E. Foggi

Endoscopic treatment of colorectal benign-appearing lesions 3 cm or larger: Techniques and outcome

PURPOSE: Colonoscopic polypectomy is the preferred technique to remove the majority of polyps. The authors evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal benign-appearing polyps equal to or larger than 3 cm. METHODS: Ninety-seven patients with 104 giant polyps underwent polypectomy within a nine-year period. The majority of these procedures were performed on an outpatient basis, all on unsedated patients. Gross appearance, size, location, histologic characteristics, synchronous lesions, modality, and adequacy of removal of giant polyps were analyzed. The follow-up was achieved in 89 percent of patients during a period ranging from 6 to 96 months (median, 38). RESULTS: Of the 104 removed polyps, 75 (72 percent) were adenomatous, 2 (2 percent) were hyperplastic, and 27 (26 percent) were malignant polyps. Six patients had more than one giant polyp. Several additional smaller polyps were found in 52 patients and a synchronous cancer in 4. Twenty-one (20 percent) giant polyps were equal to or larger than 4 cm. Forty-nine were pedunculated, 20 were short-stalked, and 35 were sessile. Sixty-one polyps were excised in one piece, and forty-three were excised using a piecemeal technique. Only four complications (3.8 percent) were recorded; all cases were treated endoscopically. Fifty-eight (75 percent) adenomas and eighteen (67 percent) malignant polyps were completely excised. Surgery was performed in 7 of 27 patients (27 percent) with malignant polyps, where there was a doubtful, infiltrated margin or poorly differentiated cancer. Post-polypectomy surveillance permitted the detection and treatment of 25 metachronous or recurrent polyps and a metachronous cancer. CONCLUSIONS: This study shows that polypectomy of giant colorectal polyps, performed by an expert endoscopist, is feasible, effective, and safe, even on an outpatient basis. The authors confirm that malignant polyps with incomplete excision, lymphovascular invasion, and poor differentiation require bowel resection. Post-polypectomy surveillance is useful for all patients who have undergone colonoscopic resection of giant adenomatous or malignant polyps.

Agenesis of the Gallbladder Found at Laparoscopy in an Adult Patient with Cardiac Congenital Malformation

We report a case of gallbladder agenesis in a 30-year-old woman affected by a cardiac congenital malformation who had been operated on at the age of 12. The patient was sent for laparoscopic cholecystectomy due to a preoperative diagnosis of cholelithiasis using clinical and instrumental examinations such as ultrasonography and cholangiography. During laparoscopy, the gallbladder was not found, and laparotomy with intraoperative cholangiography and ultrasonography was performed which also resulted negative. The preoperative possibility of a diagnosis of gallbladder agenesis, the association with other malformations and the steps to be taken to discover agenesis of the gallbladder are discussed.

Syndrome du «bumper» enfoui A propos de deux cas Recommandations et traitement. Expérience personnelle

RésuméLes auteurs rapportent leur expérience concernant la survenue et le traitement d’une complication rare de la gastrostomie percutanée: le syndrome du «bumper enfoui».La solution endoscopique retenue a consisté à libérer le «bumper» interne en pratiquant deux incisions muqueuses radiales à l’aide d’une aiguille diathermique.Après avoir examiné différents facteurs déclenchants possibles, les auteurs tirent la conclusion que le système avec «bouton» est un substitut fiable et efficace pour tous les patients non cancéreux qui nécessitent une nutrition entérale sur une longue période (supérieure à 2 à 3 mois).SummaryThe Authors report their experience in the occurrence and management of an uncommon PEG complication «The Buried Bumper Syndrome».The endoscopic solution adopted in both patients was to free the internal bumper through radial incisions using a diathermic needle.Having examined the possible causative factors they conclude that the «button» device system is to be considered a more efficient and safe substitute for non-neoplastic patients needing long-term (more than 2–3 months) enteral feeding.

Duplication cystique duodénale: méthode originale de traitement endoscopique

RésuméLes auteurs rapportent une méthode de traitement endoscopique d’un cas de duplication kystique duodénale. La lésion fut révélée par des symptômes correspondant à de fréquents épisodes de subocclusion intestinale haute. Les auteurs ont analysé la littérature relative au traitement chirurgical de cette malformation. Se référant à l’opération chirurgicale dite « de porte ouverte » proposée par Anderson en 1935, les auteurs ont réalisé par voie endoscopique, une communication entre la paroi kystique et le duodénum.La manœuvre endoscopique nécessite préalablement l’exclusion de communications entre la duplication kystique et les organes voisins et l’accessibilité de la lésion aux manœuvres instrumentales.Le traitement endoscopique a été réalisé après simple prémédication. Le succès de la méthode est confirmé un an plus tard par la normalisation du transit intestinal documenté par examen radiologique, et la disparition complète des symptômes.SummaryThe authors report a case of cystic duplication of the duodenum treated endoscopically. The clinical symptoms (nausea and vomiting) were evoking an upper G.I. subobstruction. The surgical treatment of these malformations is reviewed. The « open window » operation proposed and carried out by Anderson in 1935 has been applied, using an endoscopic approach.A wide communication between the cyst wall and the surrounding duodenum after a per endoscopic opacification of the cystic cavity, has excluded a communication and/or relationship with surrounding organs.This endoscopic procedure, performed with simple sedation, has provided an excellent clinical result and the recovery of a normal duodenal transit. The duplication must be necessarily accessible to the endoscopic instruments. Thee anatomic position is the only limiting factor of this method.