Enrico Fiori

Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial

BACKGROUND Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. METHODS In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. RESULTS There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125-612 days) in patients who had stents and 280 days (range, 135-591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. CONCLUSIONS Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

Unusual breakage of a plastic biliary endoprosthesis causing an enterocutaneous fistula.

OBJECTIVE The objective of our study was to illustrate a case of endoscopically placed biliary stent breakage. METHODS A72-year-old woman with a prolonged history of cholangitis following laparoscopic cholecistectomy was referred to our institution 8 years ago. Dilatation of the intra- and extrahepatic biliary tree and a benign stricture at the cystic confluence were observed at US and endoscopic retrograde cholangiopancreatography (ERCP). A 12-F gauge plastic endoprosthesis was placed. In the absence of any symptoms, breakage of the stent was revealed 18 months later at plain radiology. Eight years later an enterocutaneous fistula occurred originating from a jejunal loop containing the indwelled distal part of the stent. Surgery was undertaken and the distal part of the stent removed with the perforated jejunal loop. The proximal part was successively endoscopically removed. CONCLUSIONS Disruption of a biliary endoprosthesis is observed in patients in whom the stent is kept in situ for a long period or consequent to exchange. The removal and exchange is mandatory when the stent disruption is followed by cholangitis. In the current case, because of the absence of any symptoms the removal of the stent was not attempted. Immediate endoscopic removal of the prosthetic fragments seems to be the treatment of choice for replacement of a new stent.

Isolated intestinal neurofibromatosis of colon. Single case report and review of the literature

Isolated intestinal neurofibromatosis of the colon is a most unusual disease: from 1937 to 1999 only 12 cases have been reported. The differential diagnosis and treatment of this lesion are very difficult. A review of the literature is made and personal experience in the diagnosis and treatment of a case in a 68-year-old female is described.

Endoscopic placement of self-expanding stents in patients with symptomatic anastomotic leakage after colorectal resection for cancer: long-term results.

Anastomotic leak after colorectal resection for cancer is a challenging clinical problem. The postoperative quality of life in these situations is significantly impaired. We prospectively analyzed the effect of placing a self-expanding metal stent (SEMS) at the level of the leak, with or without proximal diverting ileostomy, in 22 patients with symptomatic anastomotic leakage after colorectal resection. The stents were placed successfully in all 22 patients. An proximal ileostomy was created in 15 patients under general anesthesia. The anastomotic leak healed, without evidence of residual stricture or major incontinence, in 19 patients (86 %). In 3 patients, the leak did not heal; in 2 patients with recurrent rectovaginal fistula, the size of the leak decreased significantly, allowing successful flap transposition; and only 1 patient required a permanent stoma. SEMS placement is a valid adjunct to the treatment of patients with symptomatic anastomotic leakage after colorectal resection.

Self expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer

To evaluate the use of self‐expandable metallic stents to treat patients with symptomatic benign anastomotic stricture after colorectal resection.

A Study on Metals Content in Patients with Colorectal Polyps

Data on metals involvement in colorectal polyps are scarce and fragmentary. The aim of this study was to examine whether the level of metals could be associated with risk of colorectal polyp development. The concentration of 15 chemical elements (Al, Ba, Ca, Cd, Co, Cr, Cu, Fe, Hg Mg, Mn, Pb, Se, Sr, and Zn) in 17 colorectal biopsies of healthy individuals, in 15 polypotic and corresponding nonpolypotic biopsies taken from the same individual, was evaluated. Concentration in polyps of metals such as Al, Ca, Mg, Mn, Pb, Sr, and Zn was unchanged both in unpaired and paired samples; elements such as Ba, Cd, and Hg were significantly lower and Fe was significantly higher both in individual and paired tissues. Cobalt, Cr, and Cu were significantly different only between polyps and the adjacent normal tissue area; Se showed a significant accumulation comparing polyps versus healthy tissues. The difference found in some elements between polyps and a control tissue provides an indication about the role of essential and nonessential elements in the early stage (polyps) in the colon carcinogenic process and encourages further studies to confirm the involvement of such elements in neoplastic processes.

Is proliferative colonic disease presentation changing

AIM To compare the site, age and gender of cases of colorectal cancer (CRC) and polyps in a single referral center in Rome, Italy, during two periods. METHODS CRC data were collected from surgery/pathology registers, and polyp data from colonoscopy reports. Patients who met the criteria for familial adenomatous polyposis, hereditary non-polyposis colorectal cancer syndrome or inflammatory bowel disease were excluded from the study. Overlap of patients between the two groups (cancers and polyps) was carefully avoided. The χ² statistical test and a regression analysis were performed. RESULTS Data from a total of 768 patients (352 and 416 patients, respectively, in periods A and B) who underwent surgery for cancer were collected. During the same time periods, a total of 1693 polyps were analyzed from 978 patients with complete colonoscopies (428 polyps from 273 patients during period A and 1265 polyps from 705 patients during period B). A proximal shift in cancer occurred during the latter years for both sexes, but particularly in males. Proximal cancer increased > 3-fold in period B compared to period A in males [odds ratio (OR) 3.31, 95%CI: 2.00-5.47; P < 0.0001). A similar proximal shift was observed for polyps, particularly in males (OR 1.87, 95%CI: 1.23-2.87; P < 0.0038), but also in females (OR 1.62, 95%CI: 0.96-2.73; P < 0.07). CONCLUSION The prevalence of proximal proliferative colonic lesions seems to have increased over the last decade, particularly in males.

Endoscopic treatment of ganglioneuroma of the colon associated with a lipoma: a case report

IntroductionGanglioneuromas are rare benign peripheral neuroblastic tumors characterized by hyperplasia of ganglion cells, nerve fibers, and supporting cells. They are not usually localized in the colon.Case presentationA 61-year-old Caucasian man was admitted to our department for colon cancer screening. A colonoscopy revealed a lipoma of 5cm in diameter, two micropolyps of less than 1cm, and one sessile polyp of 0.6cm in diameter. The polyps were removed with hot biopsy forceps. A histological examination revealed two hyperplastic polyps and one ganglioneuroma polyp. A follow-up colonoscopy showed no signs of recurrence after 16 months.ConclusionsAlthough a few cases of lipomas associated with ganglioneuromatous syndrome have been reported, the association of an intestinal lipoma with an isolated ganglioneuroma polyp has not been described. The implications of this association are unknown.

A Retrospective Case-Control Study Evaluating the Bowel Preparation Quality during Surveillance Colonoscopy after Colonic Resection

Purpose. Bowel preparation for surveillance endoscopy following surgery can be impaired by suboptimal bowel function. Our study compares two groups of patients in order to evaluate the influence of colorectal resection on bowel preparation. Methods. From April 2010 to December 2011, 351 patients were enrolled in our retrospective study and divided into two homogeneous arms: resection group (RG) and control group. Surgical methods were classified as left hemicolectomy, right hemicolectomy, anterior rectal resection, and double colonic resection. Bowel cleansing was evaluated by nine skilled endoscopists using the Aronchick scale. Results. Among the 161 patients of the RG, surgery was as follows: 60 left hemicolectomies (37%), 62 right hemicolectomies (38%), and 33 anterior rectal resections (20%). Unsatisfactory bowel preparation was significantly higher in resected population (44% versus 12%; P value = 0.000). No significant difference (38% versus 31%, P value = ns) was detected in the intermediate score, which represents a fair quality of bowel preparation. Conclusions. Our study highlights how patients with previous colonic resection are at high risk for a worse bowel preparation. Currently, the intestinal cleansing carried out by 4 L PEG based preparation does not seem to be sufficient to achieve the quality parameters required for the post-resection endoscopic monitoring.

Endoscopic placement of self-expandable metal stents for treatment of rectovaginal fistulas after colorectal resection for cancer

is successfulwhen the tissue looks normal and is pliable, but this israrely the case. Sometimes, a flap should be transposed be-tween the vagina and the rectum, by using a muscle likethe gracilis or the labium majus (associated or not to theoverlying skin and/or to the underlying bulbo-cavernousmuscledso-called Martius flap).