Carmela Morace

Through-the-scope large diameter self-expanding metal stent placement as a safe and effective technique for palliation of malignant colorectal obstruction: A single center experience with a long-term follow-up

Abstract Objective. The aim of this study was to evaluate the outcomes of through-the-scope (TTS) large diameter self-expanding metal stent (SEMS) placement for palliation of malignant colorectal obstruction. Material and methods. Between January 2005 and December 2009, all patients who underwent endoscopic SEMS placement for palliation of malignant colorectal obstruction were prospectively enrolled. Results. Thirty-nine patients (17M and 22F; mean age 75.9 ± 10.6 years, range 50–91) were enrolled. The most frequent location was the sigmoid colon (13 cases). The causes of obstruction were colorectal malignancy in 32 patients and extracolonic malignancy in 7. Technical success was achieved in 36/39 patients (92.3%) and clinical success in 35/39 patients (89.7%). Technical failure was related to female sex (p = 0.04) and the extracolonic etiology of the stricture (p < 0.001). There were three early complications: two procedure-related perforations successfully managed conservatively and one hemorrhage treated with APC. Early complications were related to the location of strictures at the recto-sigmoid junction (p < 0.001). Late complications occurred in 10 patients: 8 of these patients experienced occlusive symptoms (attributable to tumor ingrowth in 5 cases and stool impaction in 3 cases); the remaining 2 were one case of tumor ingrowth with sub-occlusive symptoms and hemorrhage, and one case of distal migration. There was no procedure-related mortality and all complications were managed without surgical intervention. SEMS patency duration was 236 ± 128 days (range 31–497) and mean survival of the patients was 259 ± 121 days (range, 32–511). Conclusions. In our experience, TTS large-diameter SEMS placement is a safe and effective treatment for palliation of malignant colorectal obstruction.

Cholangioscopy using a new type of cholangioscope for the diagnosis of biliary tract disease: a case series.

We present an initial report regarding the clinical usefulness of peroral cholangioscopy, using a new type of cholangioscope, the Polyscope. Peroral cholangioscopy was performed in four patients with strictures after orthotopic liver transplantation (OLT) which were suspected of being ischemic biliary lesions, in three with indeterminate biliary strictures, in three with suspected retained bile duct stones, and in two for evaluation of the intraductal spread of adenomatous tissue after an ampullectomy. In all cases peroral cholangioscopy was performed successfully without complications. On the basis of direct viewing and/or tissue sampling a correct diagnosis was reached in all cases: in all patients who underwent OLT the strictures were not ischemic; the indeterminate strictures were all benign; and, in patients with suspected stones, complete clearance was confirmed. Intraductal spread was confirmed in one patient and excluded in the other. In our experience, peroral cholangioscopy using a Polyscope is a safe and effective method for diagnosing bile duct lesions.

A comparison of uncovered metal stents for the palliation of patients with malignant biliary obstruction: nitinol vs. stainless steel.

BACKGROUND Various types of self-expandable metal stents have been introduced for the palliation of malignant biliary obstruction. AIMS To compare the outcomes of WallFlex™ and Wallstent™ uncovered biliary self-expandable metal stents (SEMSs) for the palliation of patients with malignant biliary obstruction. METHODS Between October 2008 and December 2009, all SEMSs placed for malignant biliary obstruction were WallFlex™: all patients palliated were included in the study. Before October 2008, all the SEMSs placed for malignant biliary obstruction were Wallstent™, and the patients palliated from July 2007 to September 2008 were the comparative group. RESULTS A total of 58 WallFlex™ and 54 Wallstent™ SEMSs were placed, and efficacious biliary decompression was achieved in all patients. Early complications occurred in 5 patients in the WallFlex™ group and in 3 in the Wallstent™ group (p=ns). Late complications occurred in 6 patients in the WallFlex™ group and in 16 in the Wallstent™ group (p<0.01). The overall patency of the self-expandable metal stent in the WallFlex™ and the Wallstent™ groups was similar (227 days vs. 215 days, p=ns). Mean patient survival was 242 days in the WallFlex™ group and 257 days in the Wallstent™ group (p=ns). CONCLUSIONS We found no difference in terms of overall patency between the two types of SEMSs, but there was an increased rate of late adverse events in the Wallstent™ group.

Endoscopic Tattooing of Gastrointestinal and Pancreatic Lesions

The intraoperative identification of the lesions found at endoscopic examination is often difficult, especially during laparoscopic surgery. At present, the most used technique for the intraoperative detection of pathological lesions is endoscopic tattooing. The large majority of studies carried out concern colorectal lesions; however, endoscopic tattooing has also been described for esophageal, gastric, small bowel and, more recently, pancreatic lesions. In this review, the authors evaluated indications, substances used, injection techniques, accuracy, safety and, finally, the risk of complications related to this procedure.

Outcomes of Radiofrequency Ablation for Dysplastic Barrett's Esophagus: A Comprehensive Review

Barretts esophagus is a condition in which the normal squamous lining of the esophagus has been replaced by columnar epithelium containing intestinal metaplasia induced by recurrent mucosal injury related to gastroesophageal reflux disease. Barretts esophagus is a premalignant condition that can progress through a dysplasia-carcinoma sequence to esophageal adenocarcinoma. Multiple endoscopic ablative techniques have been developed with the goal of eradicating Barretts esophagus and preventing neoplastic progression to esophageal adenocarcinoma. For patients with high-grade dysplasia or intramucosal neoplasia, radiofrequency ablation with or without endoscopic resection for visible lesions is currently the most effective and safe treatment available. Recent data demonstrate that, in patients with Barretts esophagus and low-grade dysplasia confirmed by a second pathologist, ablative therapy results in a statistically significant reduction in progression to high-grade dysplasia and esophageal adenocarcinoma. Treatment of dysplastic Barretts esophagus with radiofrequency ablation results in complete eradication of both dysplasia and of intestinal metaplasia in a high proportion of patients with a low incidence of adverse events. A high proportion of treated patients maintain the neosquamous epithelium after successful treatment without recurrence of intestinal metaplasia. Following successful endoscopic treatment, endoscopic surveillance should be continued to detect any recurrent intestinal metaplasia and/or dysplasia. This paper reviews all relevant publications on the endoscopic management of Barretts esophagus using radiofrequency ablation.

Circulating progenitor cells in hypertensive subjects: Effectiveness of a treatment with olmesartan in improving cell number and miR profile in addition to expected pharmacological effects

CD34+ circulating progenitor cells (CD34+CPCs) are a population of multipotent cells which can delay the development of atherosclerosis and cardiovascular disease (CVD) in conditions of increased CV risk. MicroRNAs (miRs) 221 and 222 modulate different genes regulating angiogenesis and inflammation; moreover, miR221/22 have beenshown to participate in differentiation and proliferation of CD34+CPCs, inhibiting cell migration and homing. miR221/222 in CD34+CPCs from hypertensive subjects are also increased and associated with CD34+cell number and reactive oxygen species (ROS). We evaluated CD34+CPC number, intracellular miR221/222 and ROS levels, arterial stiffness (AS)and echocardiography indices at baseline (T0).Then, after a six-month treatment with olmesartan, 20 mg/day (T1), in 57 hypertensive patients with left ventricular hypertrophy (LVH) and with no additional risk factor for CVD, and in 29 healthy controls (baseline),fibrinogen, C-reactive protein (CRP), glucose and lipid profiles were also evaluated.At T1, blood pressure values, CRP and fibrinogen levels, ROS and miR221/222 were significantly decreased (all p <0.001), as were AS indices and LV mass index (p<0.001), while cell number was increased (p<0.001). Olmesartan is effective in reducing miR and ROS levels in CD34+CPCs from hypertensive subjects, as well as in increasing CD34+CPC number, providing multilevel CV protection, in addition to its expected pharmacological effects.

CD34+ cell count predicts long lasting life in the oldest old

Circulating progenitor cells (CPCs) represent a pool of cells capable of differentiating into mature cells of different organs and systems, promoting tissue maintenance and repair. Among CPCs, CD34+cells (CD34+CPCs) seem to predict outcome in CV disease, also in elderly people. A decline in CD34+CPCs was reported with advancing age. Moreover, aging is associated with a state of chronic inflammation, influencing life expectancy. Our purpose was to investigate a 10-year predictive ability of CD34+CPCs, inflammatory marker levels, classic CV risk factors (CVRFs), and Framingham Risk Score (FRS) in a population of healthy, self-sufficient octogenarians. We found that baseline CD34+CPCs was strongly associated with mortality, showing a significant difference in CD34+CPC numbers between deceased and living patients. Moreover, by dividing our patients into tertiles based on age reached, this difference was more remarkable the higher the age reached. Regressive analyses suggested that the chances of reaching an older age depend on higher CD34+CPCs at baseline and are not significantly affected by inflammatory markers levels, FRS, CVFRs, or HDL-C levels. We found that higher CD34+CPCs predict longer life also in the oldest old, providing additional insights on the predictive role of CD34+CPCs in subjects aged 80 years or more.

Is Helicobacter pylori the Infectious Target to Prevent Gastric Cancer? An Interdisciplinary Point of View

Gastric carcinogenesis, which may well extend over decades, is characterized by a slow stepwise evolution from superficial gastritis to glandular atrophy, intestinal metaplasia, dysplasia, and finally, adenocarcinoma. This sequence provides an excellent opportunity for the prevention or early detection of the events preceding development of the neoplasm. In 1994, the International Agency for Research on Cancer defined Helicobacter pylori (H. pylori) as a group I carcinogen for gastric cancer (GC). Evidence supporting a causal association has been demonstrated by epidemiological data as well as by experimental animal models. A meta-analysis has shown an higher risk (odds ratio: 1.92) of progression to GC in infected compare to uninfected subjects, that increased to a value > 8 considering the surveys having a follow-up of more than 8 years. A crucial question remains whether and when precancerous lesions can reverse after H. pylori eradication. While several prospective studies have cast doubts about this reversibility others obtained opposing results. Currently, H. pylori is recognized as a necessary but insufficient cause of GC. The most accepted model of gastric carcinogenesis provides, like for other cancers, a multifactorial pathogenesis, linked with a number of initiators and other continuator agents. This review presents a multidisciplinary point of view to approaching the relationship between H. pylori infection and GC, focusing on the potential benefits of bacterial eradication in slowing down or in inducing regression of precancerous lesions.

Is pregnancy a predisposing factor for Dieulafoy's duodenal lesion or only a coincidence?

Dieulafoy’s lesion (DL) is a rare vascular abnormality of a submucosal artery, associated with a minute mucosal defect, that can be the cause of a massive, potentially lifethreatening, gastrointestinal (GI) hemorrhage [1]. Although such lesions may develop anywhere throughout the entire GI tract, they most often develop in the proximal stomach [1]. Safety and efficacy of endoscopic management for DLs have been widely recognized. Various endoscopic techniques, including injection therapy, thermal probes, laser therapy, endoscopic band ligation and hemoclipping have been used with high rates of successful hemostasis [2]. To date, no cases of bleeding DL in pregnant woman have been described in literature. We describe a case of a 35-years-old, ninth week pregnant woman referred to our Emergency Department because of melena in the previous 2 days, sickness and syncopal episode. Blood examination showed red blood cells 2.9 × 106/ L (normal range: 4.0—5.2); hemoglobin 7.1 g/dL (normal range: 12.0—16.0); mean cell volume 75.9 fL (normal range: 80.0—100.0). Heart rate was 130 bpm; blood pressure 100/70 mmHg; SatO2 100%. No blood was encountered after nose-gastric tube placement. We started red blood cells transfusion, while performed ultrasonography showed intra-uterine normal gestational sac, with a living fetus, crown rump length 24.8 mm, corresponding to predicted gestational age. The performed esophagogastroduodenoscopy under deep sedation showed blood in the second duodenal portion but no hemorrhagic lesion was observed. We decided to change the gastroscope with the colonoscope reaching the third duodenal portion where a Dieulafoy’s spurting lesion was observed (Fig. 1) and the bleeding was stopped with four metallic clips placement (Fig. 2). Patient was submitted to a second look upper GI endoscopy 2 days later showing the clips correctly placed and no evidence of rebleeding. At 1 month followup, patient still does not have any sign of GI bleeding, and pregnancy is physiologically going on. Figure 2 Placement of four metallic clips on the bleeding lesion.

Negative Emotions in Irritable Bowel Sindrome: which differences among IBS Subtypes?

There are conflicting data on peculiar negative emotional patterns in Irritable Bowel Syndrome subtypes. Our study was aimed to determine possible differences in depression, anxiety and anger in patients suffering from Irritable Bowel Syndrome constipation, diarrhoea and mixed subtypes. The sample underwent a psychometric examination for the assessment of depression (Hamilton Rating Scale Depression), anxiety (Hamilton Rating Scale Anxiety), and anger (State-Trait Anger Expression Scale 2). Differences among groups were assessed using the Analysis of variance with Bonferroni post hoc comparisons, or the χ²-test if requested. 111 subjects ( diarrhoea subtype =37; constipation subtype =34; mixed subtype =40) were included in the study. The severity of depressive symptoms was “moderate” in patients with constipation subtype and “mild” in patients with diarrhoea and mixed subtypes (17.15±6.7 vs 14.24±6.6 vs 12.50±4.9); no statistically significant differences were documented among subtypes. Severity of anxiety symptoms was “mild to moderate” in patients with constipation subtype (mean = 18.53 ± 7.7), and mild in patients with diarrhoea (mean = 13.35 ± 7.1) and mixed subtypes (mean = 13.25 ± 4.7); statistically significant differences among subgroups were found (Constipation vs D iarrhoea : p=0.004; Constipation vs Mixed : p=0.003). Regarding anger, significant differences among subgroups emerged at State Anger Feeling Angry and Anger In variables, both higher in constipation subtype group than in mixed subtype group (State Anger Feeling Angry: p=0.002; Anger In: p=0.001). P atients with constipation subtype constitute a subgroup characterized by a discrete burden of negative emotions, mainly anxiety and anger.