Dario Moneghini

High Risk of Rectal Cancer and of Metachronous Colorectal Cancer in Probands of Families Fulfilling the Amsterdam Criteria.

Objective:To investigate the risk of metachronous colorectal cancer (CRC), its impact on survival, and the risk of rectal cancer in a cohort of probands meeting the Amsterdam criteria. Background:Several determinants of decision-making for the management of CRC in patients with a putative diagnosis of Lynch syndrome are scarcely defined, and many of them undergo segmental bowel resection instead of the advised total colectomy. Methods:A retrospective cohort study was conducted on 65 probands of the Amsterdam-positive families who had surgery for primary CRC and at least 5-year surveillance thereafter. The rates of metachronous CRC and of rectal cancer were evaluated, together with their association with preoperatively available clinical predictors. Differences in overall survival between patients with and without metachronous CRC were evaluated using a time-dependent Cox model. Results:Seventeen patients (26.2%) had metachronous CRC. No clinical feature was associated with an increased risk of its development. The risk of death in patients with metachronous CRC was 6-fold increased. Neither a 2-year interval endoscopic surveillance after surgery, nor total colectomy was associated with a significant reduction in metachronous CRC. Eighteen patients (23.7%) had rectal cancer at first presentation, 5 patients of the remainder (10.6%) developed rectal cancer after primary colon resection. Two patients undergoing total colectomy developed a metachronous rectal cancer (18.2%). A first-degree family history of rectal cancer was associated with an increased risk of rectal cancer. Conclusions:Probands of families fulfilling the Amsterdam criteria carry a high risk of rectal cancer and of metachronous CRC. Total proctocolectomy, or total colectomy and a 1-year interval of proctoscopic surveillance should be advised when a high risk of rectal cancer can be predicted.

Factors affecting the treatment of multiple colorectal adenomas

BackgroundCurrently, no guidelines exist for the treatment of patients with multiple colorectal adenomas (MCRAs) (>10 but <100 synchronous nondiminutive polyps of the large bowel). This retrospective study aimed to investigate the clinical and molecular factors related to different treatments for MCRAs.MethodsPatients with MCRAs were consecutively enrolled from January 2003 to June 2011. Sequencing of their APC and MutYH genes was performed. The clinical, molecular, and family histories of the patients were collected using the Progeny database. The patient treatments were divided into three groups of increasing clinical weight: endoscopic polypectomy, segmental resection, and total colectomy. A logistic regression analysis of clinicomolecular factors related to different treatment options was performed.ResultsThe study comprised 80 patients (32 women, 40xa0%) with a median age of 53xa0years (range 13–74xa0years). The median number of polyps was 33 (range 10–90).The cases included 62 diffuse polyposis, 18 segmental polyposis coli and synchronous colorectal carcinomas (CRC; 34 cases, 43%). The pathogenetic mutations were biallelic MutYH (nxa0=xa019, 24xa0%) and APC (nxa0=xa04, 5xa0%). The mean follow-up period was 74xa0months (median 43xa0months, range 1–468xa0months). Endoscopic polypectomy was performed in 25 cases (31xa0%), segmental resection in 16 cases (20xa0%), and total colectomy in 39 cases (49xa0%). The logistics regression analysis, considering all the patients, showed that the number of polyps, the presence of CRC, and mutation were correlated with more intensive treatment. For the patients without CRC, only the number of polyps was correlated with the severity of the treatment (pxa0>xa00.0166). “On the ROC (receiver operating characteristic) curve, 25 was the number of polyps that best discriminated between surgical and endoscopic therapy.ConclusionsThe majority of patients with MCRAs undergo surgery. For patients without CRC, only the number of polyps, and not the presence of a disease-causing mutation, is correlated with increased heaviness of treatment. Patients with more than 25 polyps are more likely to undergo a surgical resection.

Lack of interference between small bowel capsule endoscopy and implantable cardiac defibrillators: an ‘in vivo’ electrophysiological study

Background Capsule endoscopy is a widely performed procedure for small bowel investigation. Once swallowed by the patient, the capsule transmits images to an external recorder over a digital radiofrequency communication channel. Potential electromagnetic interferences with implantable cardiac devices have been postulated. Clinical studies on the safety of capsule endoscopy in patients with cardiac defibrillators are lacking. Objective The aim of this study was to assess potential mutual electromagnetic interferences between capsule and defibrillators. Methods This study used the Given M2A video capsule system. Ten different types of defibrillators were tested in a clinical setting. Before capsule ingestion, defibrillator electrical therapies were switched off. During capsule endoscopy patients were monitored with cardiac telemetry. At the end of capsule endoscopy the following defibrillator’s parameters were analysed: change in device settings; inappropriate shocks; inappropriate anti-tachycardia therapy; inappropriate sensing or pacing; noise detection; device reset; programming changes; permanent electrical damages. Any technical problem related to capsule image transmission was recorded. Results Neither defibrillator malfunction nor interference in sensing or pacing was recorded; conversely, no capsule malfunction potentially caused by defibrillators was registered. Conclusion Our results suggest that capsule endoscopy can be safely performed in patients with cardiac defibrillators.

Endoscopic Therapy for Esophageal Varices

Among therapeutic endoscopic options for esophageal varices (EV), endoscopic variceal ligation (EVL) has proven more effectiveness and safety compared with endoscopic sclerotherapy and is currently co

Ulcerative colitis and the aging-related development of colonic diverticula

PurposeAim of this observational case-control study was to assess the prevalence, features, and risk factors of colonic diverticula in patients with ulcerative colitis (UC).MethodsThe data of 896 UC patients aged ≥u200930xa0years from Brescia IBD database were retrospectively analyzed. Individuals with colonic diverticula were identified and prevalence was compared with that of control patients undergoing screening colonoscopy after gender/age matching. A nested cohort study was then conducted among UC patients in order to define eventual association of diverticula with specific clinico-pathologic parameters.ResultsPrevalence of subjects with diverticula was 11.4% among 465 UC patients aged 49xa0years and older, significantly lower than 35.1% prevalence in control patients of same age and gender (pu2009<u20090.001). Advancing age was a significant risk factor for diverticula development in both groups. Among UC patients, a short duration and a late onset of UC were both significantly associated to the presence of diverticula. Moreover, UC patients with diverticula had a significantly lower frequency of flares per year, even if maximal flare severity and frequency of hospital admission were similar to those of subjects without diverticula. UC patients with diverticula had a trend toward more frequent extension of UC to the left colon, possibly because of their older age. The majority of those patients had few sigmoid diverticula without symptoms.ConclusionsDevelopment of colonic diverticula is substantially reduced in patients with UC, markedly among those with an early onset, a long history of inflammatory disease, and a high flare frequency. This study reinforces the hypothesis sustaining a protective role of UC against colonic diverticula.

Lower Gastrointestinal Endoscopy For Polyps and Polyposis

Colonoscopy has become the leading method to explore the entire colon, and is currently considered the gold standard for colorectal cancer screening. Improvements in technology have provided specific diagnostic capability, and the treatment of dysplastic and neoplastic superficial lesions is now achievable in the majority of patients, by adopting sophisticated resection techniques. Endoscopic treatment of polyps must be performed in order to both minimize the risks of the procedure and optimize the completeness of the removal, thereby reducing recurrence; therefore operators must be skilled and continuously trained, in order to perform local treatment by either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). In this way, endoscopic resection can be considered a safe and effective alternative to surgery for the treatment of colorectal polyps.