D. Reggio

Levodopa/carbidopa intestinal gel infusion in advanced Parkinson's disease: a 7-year experience

Levodopa/carbidopa intestinal gel (LCIG) infusion is nowadays becoming an established therapeutic option for advanced Parkinsons disease (PD) patients with fluctuating symptoms unresponsive to conventional oral treatment. As the implementation of LCIG therapy is increasing, there is a need for safety and efficacy data from current clinical practice.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography in Patients with Post-Liver Transplant Biliary Complications: Results of a Cohort Study with Long-Term Follow-Up

Background/Aims Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach for the management of biliary complications in liver transplant patients; however, its safety and efficacy have not been established in this setting. This study was performed to evaluate the safety and long-term efficacy of ERCP in transplant patients. Methods The case reports of 1,500 liver transplant patients were reviewed. Orthotopic liver transplantation (OLT) patients were matched 1:2 with non-OLT patients and followed-up for long-term outcome (median, 7.4 years). Results Of the 1,500 liver transplant patients, 94 (6.3%) underwent 150 ERCPs after OLT. Anastomotic strictures were present in 45 patients, biliary stones in 24, biliary leaks in 7, papillary stenosis in 2, and primary sclerosing cholangitis in 1. An ERCP success rate of 90.7% was achieved; biliary stenting led to resolution of the bile leak in 7/7 (100%) patients, and biliary stones were removed in 21/24 (87.5%) patients. In addition, 34 of 45 patients with anastomotic stricture underwent endoscopic dilation. We obtained complete resolution in 22/34 (64.7%) patients. OLT patients did not show a higher probability of complications (odds ratio [OR], 1.04), of pancreatitis (OR, 0.80) or of bleeding (OR, 1.34). Conclusions ERCP is safe and effective for the treatment of post-OLT biliary complications, has a low rate of pancreatitis and results in a durable effect.

Self-expanding covered esophageal Ultraflex stent for palliation of malignant colorectal anastomotic obstruction complicated by multiple fistulas

commercially available at that time, we adapted a selfexpanding covered nitinol Esophageal Ultraflex stent (Microvasive Endoscopy, Boston Scientific Corp., Natick, Mass.) usually used for esophageal strictures. The stent was 10 cm long (7 cm covered in the central part and 1.5 cm uncovered in the distal and proximal end) and 23 mm in diameter when deployed and was compressed onto a 90 cm long, flexible, wireguided delivery catheter. The distal margin of the stricture was marked by intramucosal injection of Lipiodol. Then a 0.035-inch guidewire (Zebra, Microvasive) was inserted under fluoroscopic guidance through the stricture, and after removing the endoscope the sheath of the stent was mounted over the guidewire and inserted beyond the stricture under fluoroscopic and direct vision with the endoscope positioned alongside the stent catheter. Deployment began proximally and progressed in a distal manner. The stent was easily placed without encountering technical problems and its correct positioning with partial expansion was immediately observed by fluoroscopy. Dilations were performed to obtain full expansion. Intestinal decompression with passage of feces was observed shortly after the procedure while restoration of the normal bowel gas pattern and complete expansion of the stent were evident on a plain x-ray film obtained 48 hours later. Fecaluria, pneumaturia, and vaginal passage of feces stopped a few hours after the stent insertion. A barium enema performed 1 week later confirmed occlusion of the fistulous tracts and effective restoration of bowel patency by the covered stent (Fig. 2). The patient died 13 weeks after endoscopic palliation without recurrence of symptoms related to the obstruction or to the genitourinary fistulas. During the last 3 weeks of life she developed severe diarrhea probably due to the formation of a new neoplastic fistula between the colon and small intestine.

Successful closure of a postsurgical benign esophagomediastinal fistula by temporary placement of a polyester, expandable stent: Case report and review

Anastomotic leaks and fistulae are well-known complications of esophagogastric surgery that occur after 10% to 30% of such operations.1-4 Treatment of these complications is challenging, surgical repair may be ineffective, and the mortality rate may be as high as 60% whatever the mode of treatment.5,6 Several endoscopic methods have been proposed as alternative, noninvasive methods of fistula closure.7-9 Placement of expandable metal stents in the esophagus has become a major method of palliation for obstructing malignant lesions and fistulas.10-12 Placement of these stents, both covered and uncovered, has occasionally been described for the management of benign esophageal strictures and fistulae.13 A case is reported here of successful treatment of an anastomotic esophagomediastinal fistula, a complication of distal esophagectomy with total gastrectomy for adenocarcinoma of the cardia, by temporary placement of a new polyester, silicone-covered, expandable stent.

Endoscopic ultrasonography findings in autoimmune pancreatitis

Endoscopic ultrasonography is an established diagnostic tool for pancreatic masses and chronic pancreatitis. In recent years there has been a growing interest in the worldwide medical community in autoimmune pancreatitis (AIP), a form of chronic pancreatitis caused by an autoimmune process. This paper reviews the current available literature about the endoscopic ultrasonographic findings of AIP and the role of this imaging technique in the management of this protean disease.

Interobserver agreement in contrast harmonic endoscopic ultrasound

Background and Aim:  Contrast harmonic endoscopic ultrasound (CH‐EUS) was recently introduced to clinical practice; its reproducibility among endosonographers is unknown. Our aim was to assess the interobserver agreement (IA) in CH‐EUS.

Safety of propofol in cirrhotic patients undergoing colonoscopy and endoscopic retrograde cholangiography: results of a prospective controlled study

Background and aims Safety of propofol sedation in patients with liver cirrhosis undergoing colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP) remains to be studied. The aim of this study was to investigate whether the use of propofol is safe for endoscopic procedures more complex than gastroscopy in patients with liver cirrhosis in a prospective controlled study. Methods Two hundred and fourteen consecutive patients, with or without cirrhosis, who underwent colonoscopy or ERCP with propofol sedation were recruited between January and June 2009. Administration of sedation was performed by anesthesiologists and outcome measures were recorded. Main outcomes were complication rates and recovery times. Results Sixty-one (28.5%) cirrhotic patients and 153 (71.5%) noncirrhotic patients were included. The incidence of sedation-related complications did not significantly differ between the two populations (11.5 vs. 17.0%, respectively, P=0.31). The mean (±SD) dose of propofol administered (213±86 vs. 239±100 mg, P=0.07), the mean time to achieve adequate sedation (3.3±1.1 vs. 3.0±1.2 min, P=0.21), the mean total duration of the endoscopic procedure (24.5±10.6 vs. 27.4±11.8 min, P=0.08), the mean time to reach Observer’s Assessment of Alertness and Sedation Scale 5 (17.2±4.4 vs. 18.4±5.6 min, P=0.15), the mean time from completion of the procedure to release (9.0±2.5 vs. 9.1±3.2 min, P=0.86), and the mean time to full recovery (42.2±7.3 vs. 42.3±7.8 min, P=0.88) were very similar between the two groups. The limitation of this study was lack of randomization, and a control group of cirrhotic patients using standard sedation with benzodiazepines and opioids. Conclusion Propofol deep sedation administered by an anesthesiologist with appropriate monitorings seems to be a safe procedure during colonoscopy or ERCP in cirrhotic patients.

Narrow band imaging vs. high definition colonoscopy for detection of colorectal adenomas in patients with positive faecal occult blood test: A randomised trial

BACKGROUND The impact of narrow band imaging in improving the adenoma detection rate in a screening scenario is still unclear. AIM To evaluate whether narrow band imaging compared with high definition white light colonoscopy can enhance the adenoma detection rate during screening colonoscopy. METHODS Consecutive patients presenting for screening colonoscopy were included into this study and were randomly assigned to the narrow band imaging group (Group 1) or standard colonoscopy group (Group 2). Primary end point was the adenoma detection rate and secondary aim was the detection rate of advanced adenomas. RESULTS Overall, 117 patients were allocated to Group 1 and 120 to Group 2. Both the adenoma detection rate and the detection rate of advanced adenomas were not significantly different between the two groups (respectively, 52.1% vs. 55%, RR=0.95, 95% CI 0.75-1.20; 32.5% vs. 44.2%, RR=0.74, 95% CI 0.53-1.02). No significant difference between the proportions of polypoid and flat adenomas was found. Male gender, no prior history of screening, and endoscopists adenoma detection rate were independent predictive factors of higher advanced adenoma detection rate. CONCLUSIONS In a screening scenario, narrow band imaging did not improve the adenoma nor advanced adenoma detection rates compared to high definition white light colonoscopy.