Caterina Pennacchi

Argon plasma coagulation for the endoscopic treatment of gastrointestinal tumor bleeding: A retrospective comparison with a non-treated historical cohort

Background The endoscopic use of argon plasma coagulation (APC) to achieve hemostasis for upper gastrointestinal tumor bleeding (UGITB) has not been adequately evaluated in controlled trials. This study aimed to evaluate the efficacy of APC for the treatment of upper gastrointestinal bleeding from malignant lesions. Methods Between January and September 2011, all patients with UGITB underwent high-potency APC therapy (up to 70 Watts). This group was compared with a historical cohort of patients admitted between January and December 2010, when the endoscopic treatment of bleeding malignancies was not routinely performed. Patients were stratified into two categories, grouping the Eastern Cooperative Oncology Group (ECOG) performance status scale: Category I (ECOG 0–2) patients with a good clinical status and Category II (ECOG 3–4) patients with a poor clinical status. Results Our study had 25 patients with UGITB whom underwent APC treatment and 28 patients whom received no endoscopic therapy. The clinical characteristics of the groups were similar, except for endoscopic active bleeding, which was more frequently detected in APC group. We had 15 patients in the APC group whom had active bleeding, and initial hemostasis was obtained in 11 of them (73.3%). In the control group, four patients had active bleeding. There were no differences in 30-day re-bleeding (33.3% in the APC group versus 14.3% in the control group; p = 0.104) and 30-day mortality rates (20.8% in the APC group, versus 42.9% in the control group; p = 0.091). When patients were categorized according to their ECOG status, we found that APC therapy had no impact in re-bleeding and mortality rates (Group I: APC versus no endoscopic treatment: re-bleeding p = 0.412, mortality p = 0.669; Group II: APC versus no endoscopic treatment: re-bleeding p = 0.505, mortality p = 0.580). Hematemesis and site of bleeding located at the esophagus or duodenum were associated with a higher 30-day mortality. Conclusions Endoscopic hemostasis of UGITB with APC has no significant impact on 30-day re-bleeding and mortality rates, irrespective of patient performance status.

Double-balloon endoscopy reveals sea-blue histiocytosis affecting the small bowel (with video)

1 ommentary chinococcus granulosus is the most common of the 4 species of the worldwide tapeworm Echinococcus to infect humans; the others re E multilocularis, E vogeli, and E oligarthus. The name Echinococcus probably derives from the fact that Echinococcus embryos have ultiple hooklets that give them a spiny appearance (Greek: echinos, hedgehog, sea urchin). The eggs of E granulosus are passed ith the feces of the definitive host (dogs and other canines), and it is the ingestion of these eggs by sheep, goats, swine—and umans—that leads to infection in the intermediate host. Although intermediate hosts ingest eggs to get infected, definitive hosts ust eat infected, cyst-containing organs. Ingested eggs hatch in the small intestine of the intermediate host to release oncospheres hat penetrate the intestinal wall and migrate via arteries and lymphatics to distant organs—in particular the liver and lungs—where hey develop into hydatid cysts and can survive for many years. Cysts develop 3 layers: a host-derived outer membrane that can alcify and offer a radiologic clue to diagnosis; a middle, acellular layer; and a thin, germinal epithelium from which brood capsules evelop and subsequently give rise to daughter cysts, in which protoscolices asexually develop and then eventually mature into dult worms. Think of hepatobiliary echinococcosis whenever you see a patient from an area where dogs are used in the presence f grazing livestock, and the patient has fever, tender hepatomegaly, and eosinophilia. As for cholangitis, this has been reported to esult from cyst rupture into the bile duct, bacterial superinfection of cysts, and from use of formalin to sterilize cyst contents. Surgical emoval of the cysts combined with chemotherapy (albendazole and/or mebendazole) before and after surgery is the standard herapy. For cysts in multiple organs or in high-risk locations, chemotherapy alone or PAIR (puncture-aspiration-injectioneaspiration) alone or with chemotherapy is a therapeutic option. ERCP can be used to diagnose the type and extent of disease, to xclude concomitant disease, to remove echinococcal material, to help plan surgery, and to treat postoperative complications. I am gain reminded that in the shrinking world in which we live, we are likely to see things we think we recognize but which are, in fact, utside our usual experience. We all should broaden our differential diagnoses—even when findings appear familiar. Surprise may orce quick decisions, but an appropriate and well-thought-out plan is always preferable. Lawrence J. Brandt, MD Associate Editor for Focal Points

Comparison of the pull and introducer percutaneous endoscopic gastrostomy techniques in patients with head and neck cancer

Background and study aims Percutaneous endoscopic gastrostomy (PEG) in head and neck cancer (HNC) patients is associated with higher complication and mortality rates when compared to a general patient population. The pull technique is still the preferred technique worldwide but it has some limitations. The aim of this study is to compare the pull and introducer PEG techniques in patients with HNC. Patients and methods This study is based on a retrospective analysis of a prospectively collected database of 309 patients with HNC who underwent PEG in the Cancer Institute of São Paulo. Results The procedure was performed with the standard endoscope in 205 patients and the introducer technique was used in 137 patients. There was one procedure-related mortality. Age, sex and albumin level were similar in both groups. However in the introducer technique group, patients had a higher tumor stage, a lower Karnofsky status, and presented more frequently with tracheostomy and trismus. Overall, major, minor, immediate and late complications and 30-day mortality rates were similar but the introducer technique group presented more minor bleeding and tube dysfunctions. Conclusion The push and introducer PEG techniques seem to be both safe and effective but present different complication profiles. The choice of PEG technique in patients with HNC should be made individually.

Sa1643 Self-Expanding Metallic Stents for the Treatment of Malignant Colorectal Obstruction Are Effective and Safe

Sa1642 Ascending Colon Exploration by Retroviewing: Technical Feasibility and Diagnosis Performance Alba L. Vargas*, Marco Alburquerque, Montserrat Figa, Ferran GonzaLez-Huix Endoscopy, Clinica Girona, Girona, Spain Introduction: The right colon lesions not visualized during the standard colonoscopy have been associated to interval cancer. The proximal fold side exploration of the ascending colon by retroviewing reduces the likely of losing those lesions. The shorter colonoscope diameter would make easier the cecal retroflexion with lower complication rate. Objective: To determine the technical feasibility of the cecal retroflexion, the diagnosis performance and complication rate of the ascending colon exploration by retroviewing with a shorter colonoscope diameter. Methods: Prospective study. There were included all the consecutive total colonoscopies performed by an expert endoscopist during four months. Technique: 1) Usual exploring of the ascending colon: colonoscope insertion and colonoscope withdrawal in forward view from the cecum until the hepatic flexure, 2) colonoscope reinsertion and cecal retroflexion maneuver, and 3) colonoscope withdrawal in retroviewing until the hepatic flexure. We collected the visualized and resected lesions on conventional and retroviewing colonoscopy. Exclusion criteria: incomplete endoscopies by any cause (obstruction, endoscopic therapy, right colon resection). All procedures were done with a Colonoscope PENTAX-i10L EC34 (Insert O: 11.6, Channel: 3.8, Deflection up/down: 180/180, left/right: 160/160). Results: There were included 323 colonoscopies and were excluded 20 by incomplete examination. The cecal retroflexion was feasible in 76.6% (n Z 232). In these procedures, in the right colon, were detected 42 (29.4%) polyps: 40 Paris Is (32 sessile and 8 subpedunculated) and 2 Ip; in 142 colonoscopies. Histology: 32 adenomas and 10 sessile serrated polyps without dysplasia. 14 polyps (9.8% of the total and 33.3% of the ascending colon) were detected only by withdrawal colonoscopy in retroviewing: sessile polyps Is, between 3-15 mm; 8 were resected in retroflexion. There were not complications. Conclusion: The cecal retroflexion was feasible in over 75% of colonoscopies and were not registered associated complications. Over 30% of the ascending colon polyps were detected only by colonoscope withdrawal in retroviewing. Cecal retroflexion maneuver has the potential to improve colorectal polyps detection.