G.D. De Palma

Small-bowel neoplasms in patients undergoing video capsule endoscopy : a multicenter European study

BACKGROUND AND STUDY AIM Small-bowel tumors account for 1% - 3% of all gastrointestinal neoplasms. Recent studies with video capsule endoscopy (VCE) suggest that the frequency of these tumors may be substantially higher than previously reported. The aim of the study was to evaluate the frequency, clinical presentation, diagnostic/therapeutic work-up, and endoscopic appearance of small-bowel tumors in a large population of patients undergoing VCE. PATIENTS AND METHODS Identification by a questionnaire of patients with VCE findings suggesting small-bowel tumors and histological confirmation of the neoplasm seen in 29 centers of 10 European Countries. RESULTS Of 5129 patients undergoing VCE, 124 (2.4%) had small-bowel tumors (112 primary, 12 metastatic). Among these patients, indications for VCE were: obscure gastrointestinal bleeding (108 patients), abdominal pain (9), search for primary neoplasm (6), diarrhea with malabsorption (1). The main primary small-bowel tumor type was gastrointestinal stromal tumor (GIST) (32%) followed by adenocarcinoma (20%) and carcinoid (15%); 66% of secondary small-bowel tumors were melanomas. Of the tumors, 80.6% were identified solely on the basis of VCE findings. 55 patients underwent VCE as the third procedure after negative bidirectional endoscopy. The lesions were single in 89.5% of cases, and multiple in 10.5%. Retention of the capsule occurred in 9.8% of patients with small-bowel tumors. After VCE, 54/124 patients underwent 57 other examinations before treatment; in these patients enteroscopy, when performed, showed a high diagnostic yield. Treatment was surgery in 95% of cases. CONCLUSIONS Our data suggest that VCE detects small-bowel tumors in a small proportion of patients undergoing this examination, but the early use of this tool can shorten the diagnostic work-up and influence the subsequent management of these patients.

Preliminary endoscopic technical report of a new silicone intragastric balloon in the treatment of morbid obesity.

The idea of using a gastric space-occupying volume device, giving a sensation of satiety, for the control of obesity was first described in 1982.’ Since then, there have been some reports that weight loss can be achieved by the use of different kinds of freefloating intragastric balloons, built in different materials and with different floating systems.lV4 The matter is controversial but very interesting, and basic animal studies have been performed to assess the basis of this kind of therapy.5 Moreover, after a first enraptured period, we observed a very critical and sceptical position toward this problem, especially after the Garren-Edwards and Ballobes balloon failures. However, a new kind of smooth silicone radiopaque valve and sterile saline-filled intragastric balloon from Bioenteric Corporation (Bioenteric Intragastric Balloon [BIB], Bioenteric, Carpinteria, California, USA) excited new interest in the matter. The aim of this study, on the basis of our preliminary experience, is to evaluate the technical aspects of this device.

Heliosphere® bag in the treatment of severe obesity : Preliminary experience

Background: Various intragastric balloons have been used in obese patients for temporary weight loss. Recently, a new balloon, the Heliosphere® Bag, was proposed. In a preliminary study, we evaluated the safety and efficacy of this device. Methods: The Heliosphere® Bag was used in 10 patients, selected according to the guidelines for obesity surgery. The manufacturers instructions were followed in positioning the device. Heliosphere® Bag positioning was performed, after diagnostic endoscopy, under unconscious sedation. After placement, the balloon was slowly inflated with 840-960 cc of air, which gives the inflated final volume of 650-700 cc of air, as the air is compressed. On the first and second post-treatment day, intravenous saline (30-35 ml/kg/d) with omeprazole (20 mg/d), ondansetron (8 mg/d) and butylscopolamine bromide (20 mg t.i.d.) were given to all patients. All patients from day 3 after placement began liquid diet and were discharged home on day 4 on a 1000 kcal diet (carbohydrate 146 g, lipid 68 g, protein 1 g/kg ideal weight). After 6 months, the Heliosphere® Bag was removed. The patients were followed monthly, and complications and their treatment, post-placement symptoms, BMI and %EWL were recorded. Data were expressed as mean ± SD. Results: From Sept-Dec 2004, 10 patients (5M/5F) underwent Heliosphere® Bag placement, with age 35.2 ± 15.7 years (17-49), BMI 43.3 ± 8.1 kg/m2 (35-51.2), and weight 126.8 ± 23.7 kg (98.4-148). Heliosphere® Bag positioning was quite difficult in all patients due to low pliancy and large size of the bag, causing patient discomfort. System failure at time of Heliosphere® Bag positioning was observed in 5/10 patients (50%). At time of removal, the Heliosphere® Bag was not found in the stomach in one patient. In 3 other patients, the balloon was found partially deflated. At the time of balloon removal after 6 months, BMI was 37.4 ± 13.4 (28.9-42.1) and %EWL was 29.1 ± 20.1 (9.0-57.4). BMI loss was 5.2 ± 13.1 (1.9-11.2) and mean weight loss was 17.5 ± 16.2 kg (5-33). Conclusions: Although weight loss was satisfactory, this device cannot be considered an advance for the temporary treatment of morbid obesity. This balloon still has some instrumental and technical problems that need to be solved: high rate of system failure at positioning, high rate of spontaneous deflation, absence of a marker such as methylene blue, and large size with low pliability that cause significant patient discomfort.

The presence of anti-endomysial antibodies and the level of anti-tissue transglutaminases can be used to diagnose adult coeliac disease without duodenal biopsy.

The new ESPGHAN guidelines for diagnosis of paediatric coeliac disease suggest to avoid biopsy in genetically pre‐disposed and symptomatic individuals with positive anti‐endomysial antibodies (EMA) and anti‐tissue transglutaminases (a‐tTG). However, duodenal biopsy remains the gold standard in adult coeliac disease.

Gallstone ileus: Endoscopic removal of a gallstone obstructing the lower ileum

An 81-year-old presented with a 5-day history of increasng abdominal pain, distension, and vomiting. Her bowels ere not active for 2 days, but she was passing flatus. Laboratory examination showed a haemoglobin of .7 g/dL (≤14 g/dL), haematocrit of 29.7% (≥41%), leuocytes of 13.6/nl (≤10.0/nl), creatinine of 3.7 mg/dL ≤1.1 mg/dL). A plain abdominal X-ray showed small bowel distension; bdominal CT with contrast media showed a large gallstone n the lower ileum. Distended bowel loops were shown as a ign of a small intestinal ileus. Pneumobilia was not present Fig. 1). Due to the weakened state of the patient and the concurent diseases (coronary heart disease, congestive heart failure, enal insufficiency), an operation was considered unsafe and n endoscopic removal of the stone was tried. Colonoscopy revealed a large gallstone obstructing the istal ileum (about 10 cm above the ileo-cecal valve) The ucosa was diffusely edematous (Fig. 2). The stone was mobile and it was possible to grab the stone ith a Roth net device (US Endoscopy, Mentor, OH, USA), o remove it from the site of impaction and finally retrieve he stone trough the anus. The stone measured 3.5 cm× 3.5 cm× 3 cm. The patient rapidly recovered and was discharged 5 days ater. Gallstone ileus occurs almost exclusively in the elderly nd accounts for 25% of mechanical small-bowel obstrucions in patients over the age of 65, with a mortality of 15%. Early surgical intervention is the mainstay of treatment or gallstone ileus but has a mortality of 12–50%. Colonocopic retrieval may be technically possible, carries small

In vivo assessment of tumour angiogenesis in colorectal cancer: the role of confocal laser endomicroscopy.

Tumour neoangiogenesis is a key factor in tumour progression and metastatic spread and the possibility to assess tumour angiogenesis might provide prognostic information. The aim of this study was to establish the role of probe‐based confocal laser endomicroscopy (p‐CLE) in the identification of vascular architecture and specific morphological patterns in normal colorectal mucosa and malignant lesions during routine endoscopy.

Kono-type anastomosis in a patient with severe multi-recurrent Crohn's disease.

Dear Editor: Despite significant advances in medical therapy, around 70– 80 % of patients with Crohn’s disease (CD) still require surgeries in their lifetime. New drugs and biologics have also demonstrated to be crucial in reducing post-operative recurrences; nevertheless, the fact that most of them appear at the anastomotic site emphasizes the importance of surgical approach in the management of these patients. Different ileocolic anastomotic configurations have been described, none of them demonstrating to be superior in terms of recurrence prevention. Data from post-operative endoscopic follow-up shows that, in absence of medical treatment, the post-operative endoscopic recurrence rate varies from 65 to 90 % within 12 months and 80–100 % within 3 years; on the other hand, the clinical recurrence rate is around 20–25 %/year. Many studies investigate on the potential prognostic role of some factors for the onset of CD recurrence, such as the operative technique (i.e., end-to-end anastomosis vs side-to-side anastomosis), patient’s risk profile (i.e., smoking, young age of onset, penetrating CD behavior), and prophylactic medical therapy. Early (6–12 months) ileocolonoscopy is a crucial tool for diagnosing post-operative CD recurrence, also being able to predict the subsequent course of CD in terms of clinical/ surgical recurrence. In 2011, Kono and coll. [a new antimesenteric functional end-to-end hand-sewn anastomosis: surgical prevention of anastomotic recurrence in Crohn’s disease. Dis Colon Rectum 2011; 54: 586–92] developed a new combined stapled and hand-sewn antimesenteric functional end-to-end anastomosis (Kono-S anastomosis) to minimize surgical recurrence in CD. Preliminary retrospective results comparing Kono-S anastomosis with conventional surgical techniques appear interesting and encouraging. We here share the case of a severe recurrent CD, which was successfully treated with the Kono-S anastomosis after a redo ileocolic resection. In 2009, a 24-year-old-patient, smoker, with a sister suffering from severe Crohn’s disease, received the diagnosis of penetrating ileal CD complicated by abdominal abscess. For

Specific dyspeptic symptoms are associated with poor response to therapy in patients with gastroesophageal reflux disease

Introduction In patients with gastroesophageal reflux disease (GORD), co-existence of functional dyspepsia (FD) is known to be associated with poor response to proton pump inhibitors (PPIs), but the contribution of specific dyspepsia symptoms has not yet been systematically investigated. Objective We aimed to characterize the impact of dyspepsia symptoms on response to PPIs in patients with GORD. Methods The enrolled subjects were consecutive patients with a diagnosis of GORD. All patients underwent a 24 hour pH–impedance test, while on PPI therapy. Patients were divided into two groups, refractory and responders, according to the persistence of GORD symptoms. A standardized questionnaire for FD was also administered to assess presence of dyspepsia symptoms. Results In the subgroup of refractory patients FD was more prevalent than in responders, with post-prandial fullness, nausea, vomiting, early satiation and epigastric pain being significantly prevalent in refractory GORD patients. In the multivariate analysis only early satiation and vomiting were significantly associated with poor response to PPIs. Conclusion Co-existence of FD is associated with refractory GORD. We showed that only early satiation and vomiting are risk factors for poor response to therapy with PPIs. Our findings suggest that symptoms of early satiation and vomiting would help to identify the subset of PPI-refractory GORD patients.

Long-term follow-up for pilonidal sinus surgery: A review of literature with metanalysis

BACKGROUND Sacrococcygeal pilonidal sinus disease (PSD) is a common chronic inflammation of the natal cleft and presents as an abscess or a chronically discharging, painful sinus tract. The management of chronic PSD is variable, contentious, and problematic. Although many surgical procedures have been tried, the best surgical method remains controversial. The aim of this systematic review with meta-analysis of literature is to provide surgeons an objective instrument of decision through an analysis of recurrence rate of various surgical techniques in a long-term follow-up. METHODS Systematic literature searches were performed to identify all available studies. According to the pre-specified protocol, all studies reporting a surgical approach to PSD with a minimum follow-up of 5 years were included. RESULTS Fifteen studies were included in the analysis. The number of patients varied from 50 to 1165 with a mean follow-up from 58.36 to 240 months. The overall incidence of recurrence was of 0.138; the resulting incidence of open healing, midline closure and out-midline closure were of 17.9%, 16.8% and 10% respectively. CONCLUSIONS Interestingly, our data reveal a rate of relapsing disease higher than the one defined in previous studies both for the overall PSD and for each surgical procedure. A long-term follow-up of at least 5 years, should be considered the gold standard in pilonidal sinus surgery benchmarking. From our results, we can state that open healing and midline closure should not be considered effective for their high frequency of relapse disease and midline primary closure should be preferred.

In Vivo Characterization of DALM in Ulcerative Colitis with Probe-Based Confocal Laserendomicroscopy: The Expert's Approach

Abstract The term dysplasia-associated lesional mass (DALM) refers to a heterogeneous population of endoscopically visible lesions within the colitic colon, in the course of inflammatory bowel diseases, which has an associated dysplasia in the surrounding mucosa at histology. The presence of DALM is an indication for colectomy. Here the technique of probe-based confocal laser endomicroscopy is demonstrated for in vivo characterization of DALM in a patient with chronic ulcerative colitis. This article is part of an expert video encyclopedia.