E. Morandi

Distal splenorenal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. First stage of a randomized, controlled trial.

In 1984 we started a prospective controlled trial comparing endoscopic sclerotherapy (ES) with the distal splenorenal shunt (DSRS) in the elective treatment of variceal hemorrhage in cirrhotic patients. The study population included 40 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1988. These patients were drawn from a pool of 173 patients who underwent either elective surgery or endoscopic sclerotherapy during this time. Patients were assigned to one of the two groups according to a random-number table: 20 to DSRS and 20 to ES. During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS. Four ES patients suffered at least one episode of gastrointestinal bleeding: two from varices and two from esophageal ulcerations. Five ES patients developed transitory dysphagia. Long-term follow-up was complete in all patients. Two-year survival rates for shunt (95%) and ES (90%) groups were similar. One DSRS patient rebled from duodenal ulcer, while three ES patients had recurrent bleeding from esophagogastric sources (two from varices and one from hypertensive gastropathy). One DSRS and two ES patients have evolved a mild chronic encephalopathy; four DSRS and two ES patients suffered at least one episode of acute encephalopathy. Two ES patients had esophageal stenoses, which were successfully dilated. Preliminary data from this trial seem to indicate that DSRS, in a subgroup of patients with good liver function and a correct portal-azygos disconnection, more effectively prevents variceal rebleeding than ES. However no significant difference in the survival of the two treatment groups was noted.

Small bowel capsule endoscopy in clinical practice: a multicenter 7-year survey

Background and aim Data about small bowel capsule endoscopy (SBCE) come from studies involving small and highly selected populations. The study aim was to describe extent of use, indications, results, complications, and practical issues of SBCE in clinical practice in a Northern Italian Region (Lombardia). Materials and methods Twenty-three out of 29 invited centers fulfilled a specific questionnaire. Results Between 2001 and 2008, 2921 procedures were performed and both the number of centers performing SBCE (from 5 to 29) and the number of SBCE (from 7.2 to 69.2 per month) increased steadily. The main indications for SBCE were: obscure gastrointestinal bleeding (OGIB) (43.4%), unexplained anemia (23.9%), suspected Crohns disease (7.8%) and abdominal pain (5.3%). Overall, SBCE was positive in 50% of cases, negative in 36% and undefined in 14%. The highest diagnostic yields were observed in patients with OGIB (62.5%), polypoid syndromes (74.1%), known (54.8%) or suspected (47.3%) inflammatory bowel disease, while the yields were low in patients examined for chronic diarrhea (27.4%) and abdominal pain (14.9%), 61 patients (2.1%) experienced capsule retention. Thirty-two of them eventually excreted the capsule naturally while endoscopic or surgical retrieval was necessary in 29 (1%) (in two because of obstruction). Conclusion Over a period of 7 years the use of SBCE in Lombardia increased steadily confirming, in clinical practice, a high diagnostic yield and an acceptable safety profile.

Functional evaluation of the Endotics System, a new disposable self-propelled robotic colonoscope: in vitro tests and clinical trial

OBJECTIVE Currently, the best method for CRC screening is colonoscopy, which ideally (where possible) is performed under partial or deep sedation. This study aims to evaluate the efficacy of the Endotics System, a new robotic device composed of a workstation and a disposable probe, in performing accurate and well-tolerated colonoscopies. This new system could also be considered a precursor of other innovating vectors for atraumatic locomotion through natural orifices such as the bowel. The flexible probe adapts its shape to the complex contours of the colon, thereby exerting low strenuous forces during its movement. These novel characteristics allow for a painless and safe colonoscopy, thus eliminating all major associated risks such as infection, cardiopulmonary complications and colon perforation. METHODS An experimental study was devised to investigate stress pattern differences between traditional and robotic colonoscopy, in which 40 enrolled patients underwent both robotic and standard colonoscopy within the same day. RESULTS The stress pattern related to robotic colonoscopy was 90% lower than that of standard colonoscopy. Additionally, the robotic colonoscopy demonstrated a higher diagnostic accuracy, since, due to the lower insufflation rate, it was able to visualize small polyps and angiodysplasias not seen during the standard colonoscopy. All patients rated the robotic colonoscopy as virtually painless compared to the standard colonoscopy, ranking pain and discomfort as 0.9 and 1.1 respectively, on a scale of O to 10, versus 6.9 and 6.8 respectively for the standard device. CONCLUSIONS The new Endotics System demonstrates efficacy in the diagnosis of colonic pathologies using a procedure nearly completely devoid of pain. Therefore, this system can also be looked upon as the first step toward developing and implementing colonoscopy with atraumatic locomotion through the bowel while maintaining a high level of diagnostic accuracy;

Upper gastrointestinal active bleeding ulcers: review of literature on the results of endoscopic techniques and our experience with Hemospray

Abstract Introduction and objectives. Acute gastrointestinal (GI) bleeding can lead from mild to immediately life-threatening clinical conditions. Upper GI bleeding (UGIB) is associated with a mortality of 6–10%. Spurting and oozing bleeding are associated with major risk of failure. Hemospray™ (TC-325), a new hemostatic powder, may be useful in these cases. Aim of this study is to review the efficacy of traditional endoscopic treatment in Forrest 1a-1b ulcers and to investigate the usefulness of Hemospray in these patients. Patients and methods. A MEDLINE search was performed and articles that evaluated hemostatic efficacy and rebleeding rate with traditional endoscopic techniques related to Forrest classification were reviewed. Patients with Forrest 1a–1b ulcers were treated with Hemospray, either as monotherapy or in association with other endoscopic techniques. Primary outcome was immediate hemostasis, secondary outcomes were recurrent bleeding and adverse events related to Hemospray use. Results. Analysis of literature showed that mean initial hemostasis success rate in Forrest 1a–1b ulcers was of 92.8%, and mean rebleeding rate was of 13.3%. We enrolled 13 patients treated with Hemospray. Initial hemostasis was achieved in 100% and we reported three cases of rebleeding. No adverse events occurred. Conclusion. Forrest 1a–1b bleeding ulcer is very difficult to treat. Hemospray appears to be an effective hemostatic therapy for these ulcers. However, additional prospective studies are needed to validate these findings.

Hemospray for treatment of acute bleeding due to upper gastrointestinal tumours

BACKGROUND Hemospray is a new endoscopic haemostatic powder that can be used in the management of upper gastrointestinal bleedings. AIMS To assess the efficacy and safety of Hemospray as monotherapy for the treatment of acute upper gastrointestinal bleeding due to cancer. METHODS The endoscopy databases of 3 Italian Endoscopic Units were reviewed retrospectively and 15 patients (8 males; mean age 74 years) were included in this study. RESULTS Immediate haemostasis was achieved in 93% of cases. Among the successful cases, 3 re-bled, one case treated with Hemospray and injection had a good outcome, while 2 cases died both re-treated with Hemospray, injection and thermal therapy. No complications related to Hemospray occurred. Finally, 80% of patients had a good clinical outcome at 30days and 50% at six months. CONCLUSION Hemospray may be considered an effective and safe method for the endoscopic management of acute neoplastic upper gastrointestinal bleedings.

An ‘omental patch’ created during over-the-scope clipping completely sealed a duodenal perforation after endoultrasonography

Perforation of the inferior knee of the duodenum is a rare complication during endoscopic maneuvers and, in particular, during endoscopic ultrasonography (EUS). A recent study by Carrara and colleagues reported a duodenal perforation rate of 0.09% in a series of 3296 patients who underwent EUS with fine-needle aspiration [Carrara et al. 2010]. The data in the literature on surgical management of these perforations are not currently comforting. An 82-year-old woman was referred to our center after computed tomography had shown a 7 cm diameter pseudocyst and a suspected malignant neoplasia of the proximal third of the common bile duct, causing jaundice. The patient underwent EUS with a linear echoendoscope (Pentax Hamburg, Germany). During retraction of the scope in the duodenum, we observed a full-thickness break of about 12 mm diameter, at the inferior duodenal knee (Figure 1). With an operative gastroscope we immediately placed a sharp-toothed, 10 mm/6 diameter over-the-scope clip (OTSC; OVESCO, Endoscopy, Tubingen, Germany) on the perforation. We preferred a therapeutic endoscope instead of the standard one because of the possibility of mounting a bigger diameter OTSC. During the aspiration we placed the omentum inside the cap. After releasing the OTSC we obtained immediate closure of the perforation, creating an ‘omental patch’ (Figure 2). The correct positioning of the OTSC and the complete closure of the perforation were subsequently confirmed by X-ray, the day after, when the patient underwent transhepatic biliary drainage (percutaneous transhepatic cholangiography). After releasing the drainage across the papilla, contrast was injected to check the correct closure of the defect. CO2 was not used in this case. Figure 1. Perforation of the inferior duodenal genu by endoscopic ultrasonography (EUS). Figure 2. Duodenal perforation sealed by OTSC creating an “omental-patch”. The patient developed peritonitis and died 12 days later of respiratory failure despite fasting, antibiotic therapy, nasogastric tube placement and parenteral nutrition support. As shown in a few reports in the literature [Donatelli et al. 2013; Meduri et al. 2014; Diez-Redondo et al. 2012], given the high rate of morbidity and mortality associated with post-surgical treatment of iatrogenic duodenal perforations, the OTSC should be considered the first option for immediate resolution of this adverse event, taking into account the possible risk of failure. OTSC may play a part in the armamentarium for the acute management of perforations and other such conditions [Bingener and Ibrahim-zada, 2014].

Brunner’s Glands Hyperplasia: Diagnosis with EUS-FNA for Suspected Pancreatic Tumor Involving the Duodenum

CONTEXT Brunners gland hyperplasia is a rare, benign, proliferative disorder of the duodenum. Large masses may cause obstructive and compressive symptoms which may depend upon the location of the tumour. Owing to its rarity, these lesions can be mistaken for malignancy on radiological and endoscopic examinations. Symptomatic Brunners gland hyperplasia associated with pancreatitis is very rare and the literature is limited to a few case reports endoscopic ultrasound may be useful to obtain a correct diagnosis. CASE REPORT We describe an unusual case of diffuse Brunners gland hyperplasia of duodenum mimicking a malignancy involving the pancreas, in which EUS-FNA avoided a possible major surgery. CONCLUSION Brunners gland hyperplasia imaging is very similar to malignant pancreatic mass; EUS with FNA is mandatory to reach a correct diagnosis, avoiding surgery.

Didactic Potential of Videoendoscopy

Electronic videoendoscopy has only recently been introduced into clinical practice. The first endoscopes became available in Europe at the end of 1984, and in our Digestive Endoscopy Unit we were the first in Italy to employ this new equipment for outpatient endoscopy in May 1985. Since then we have performed examinations with all types of electronic systems. We have compared the traditional endoscopic television systems and have found the results with these poorer than those obtained with videoendoscopy; using a television camera reduces brightness and color by 25%. Furthermore, the electronic image can be modified, magnified, and manipulated, none of which is possible with traditional systems. Videoendoscopy is therefore an excellent means for endoscopic training.