Giovanni Domenico De Palma

Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study

BACKGROUND Rapid palliation of malignant dysphagia is usually possible with endoscopic implantation of a plastic prosthesis, but this device has a high rate of complications. Recently, expandable metal stents, a new class of endoprosthesis, have become available and may reduce complication rates. METHODS Thirty nine patients affected by esophageal thoracic cancer were randomly assigned to treatment with either a plastic stent (20 patients) or expandable metal stent (19 patients). The degree of palliation (expressed as dysphagia score) and incidence of complications (short- and long-term) were compared in both treatment groups. RESULTS Technical success, as a percentage of successful intubation, was similar in both treatment groups (90% vs 94.7%, p = NS) and dysphagia scores improved significantly and similarly in both treatment groups. Nevertheless, complications and mortality related to implantation were significantly less frequent with metal stents than with plastic prostheses (complications: 0% vs 21%, p < 0.001; mortality: 0% vs. 15.8%, p < 0.001). Late complications included obstruction by food in both treatment groups (four cases with plastic stents vs four cases with metal stents), tube migration only with plastic prostheses (two cases) and tumor ingrowth only with metal stents (two cases). CONCLUSIONS Expandable metal stents can be considered an effective and safer alternative to conventional plastic prostheses in the treatment of esophageal obstruction caused by inoperable cancer.

Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study

BACKGROUND The frequency of small-bowel mucosal changes in patients with portal hypertension is not known. The objective of the study is to better define the mucosal abnormalities of portal hypertensive enteropathy (PHE) and to determine whether these findings are associated with the severity of liver disease, esophageal varices, portal gastropathy, portal colonopathy, or other clinical characteristics. METHODS We compared the medical records of 37 patients with cirrhosis and portal hypertension with 34 control patients who underwent capsule endoscopy over a 3-year period. RESULTS Mucosal changes were found to be significantly more common in the cirrhotic patients than in the control patients (67.5% vs. 0, p < 0.001). The lesions included telangiectasias or angiodysplastic-like lesions in 9 (24.3%) patients, red spots in 23 (62.2%), and varices in 3 (8.1%). Active bleeding was seen during endoscopic examinations in 4 (10.8%) patients. A comparison of patients with and those without PHE showed that grade 2+ or larger esophageal varices, portal gastropathy, portal colonopathy, and Child-Pugh class C cirrhosis were all significantly associated with PHE. There were no differences between these two groups of patients with regard to the etiology of cirrhosis, gender, or history of esophageal variceal bleeding. CONCLUSIONS Mucosal abnormalities in portal jejunopathy include edema, erythema, and vascular lesions findings. A standardized grading system to classify the endoscopic appearance and the severity of portal enteropathy is proposed. The clinical import of these changes remains to be explained.

Oral contrast-enhanced sonography for the diagnosis and grading of postsurgical recurrence of Crohn's disease.

Background: Postsurgical recurrence (PSR) is very common in patients with Crohns disease (CD) and previous surgery. Endoscopy is crucial for the diagnosis of PSR, also showing high prognostic value. Bowel sonography (BS) with or without oral contrast enhancement (OCBS) is accurate for CD diagnosis but its role in PSR detection and grading is poorly investigated. The aim was to evaluate the diagnostic accuracy of BS and OCBS for PSR compared to the endoscopical Rutgeertss grading system. Methods: We prospectively performed endoscopy, BS, and OCBS in 40 CD patients with previous bowel resection to provide evidence of possible PSR. Endoscopy, BS, and OCBS were executed 1 year after surgery, with PSR diagnosis and grading made in accordance with Rutgeerts. BS and OCBS were considered suggestive for PSR in the presence of bowel wall thickness (BWT) >3 mm. OCBS was performed after ingestion of 750 mL of polyethylene glycol (PEG). Also, a receiver operating characteristic (ROC) curve was constructed in order to define the best cutoff of BWT to discriminate mild from severe PSR (grade 0–2 versus 3–4 of Rutgeerts) for both BS and OCBS. Results: In all, 22 out of the 40 CD showed an endoscopic evidence of PSR (55%). A severe PSR was present in 14 patients (64%). Sensitivity, specificity, and positive and negative predictive values were 77%, 94%, 93%, and 80% for BS, and 82%, 94%, 93%, and 84% for OCBS. On the ROC curve a BWT >5 mm showed sensitivity, specificity, and positive and negative predictive values of 93%, 96%, 88%, and 97% for the diagnosis of severe PSR at BS, while a BWT >4 mm was the best cutoff differentiating the mild from the severe CD recurrence for OCBS, with a sensitivity, specificity, and positive and negative predictive values of 86%, 96%, 97%, and 79%, respectively. Conclusions: Both BS and OCBS show good sensitivity and high specificity for the diagnosis of PSR in CD, with a BWT >5 mm for BS and BWT >4 mm for OCBS strongly indicative of severe endoscopic PSR. Accordingly, these techniques could replace endoscopy for the diagnosis and grading of PSR in many cases.

Use of corticosteroids in the prevention of post-ERCP pancreatitis: results of a controlled prospective study

OBJECTIVE:The aim of this prospective controlled study was to determine whether prophylactic corticosteroids decrease the incidence of post-ERCP pancreatitis.METHODS:A double-blind comparison of hydrocortisone (100 mg by i.v. infusion immediately before endoscopy) with placebo (sodium chloride administered in the same fashion). A total of 535 patients (286 women and 249 men, with an average age of 58.6 yr) who were scheduled to undergo diagnostic or operative ERCP underwent randomization. Six patients were excluded from the final evaluation for various reasons. The remaining 529 patients, 263 in the hydrocortisone group and 266 in the placebo group, were analyzed. Patients were divided into subgroups with regard to high risk factors for acute pancreatitis after ERCP.RESULTS:The overall incidence of acute pancreatitis was 5.3% (28 of 529 patients). Procedure-induced pancreatitis occurred in 15 of 263 (5.7%) patients treated with hydrocortisone and in 13 of 266 (4.9%) patients treated with placebo (p= NS). The results of analysis of risk factors for pancreatitis did not evidence any significant difference between the hydrocortisone group and the placebo group.CONCLUSIONS:Hydrocortisone does not prevent acute pancreatitis after diagnostic or therapeutic ERCP.

Noninvasive diagnosis of small bowel Crohn's disease: direct comparison of bowel sonography and magnetic resonance enterography.

Background:The diagnosis of small bowel Crohn’s disease (CD) is performed by ileocolonoscopy, whereas the assessment of its extension can be achieved by radiologic studies or, noninvasively, by magnetic resonance (MR) enterography and bowel sonography (BS). However, few comparative studies exist directly comparing the diagnostic accuracy of BS and MRI. The aim of this study was to evaluate the diagnostic accuracy of BS and MRI for the diagnosis of small bowel CD. Methods:We prospectively performed a noninferiority diagnostic study including 234 consecutive subjects with suspected small bowel CD. All patients underwent IC (used as gold standard for diagnosis), BS, and MR enterography performed in random order by physicians who were blinded about the results. Results:The diagnosis of small bowel CD was made in 120 of 249 subjects (48%). Sensitivity, specificity, positive predictive value, and negative predictive value for CD diagnosis were 94%, 97%, 97%, and 94% for BS and 96%, 94%, 94%, and 96% for MR enterography, respectively. BS was less accurate than MR enterography in defining CD extension (r = 0.69), whereas the concordance in terms of CD location between the 2 procedures was high (k = 0.81). Also, MRI showed a fair concordance with BS about strictures (k = 0.82) and abscesses (k = 0.88), with better detection of enteroenteric fistulas (k = 0.67). Conclusions:BS and MR enterography are 2 accurate procedures for the diagnosis of small bowel CD, although MR seems to be more sensitive in defining its extension. BS could be used to select the patients for subsequent MRI examination.

In vivo characterisation of superficial colorectal neoplastic lesions with high-resolution probe-based confocal laser endomicroscopy in combination with video-mosaicing: A feasibility study to enhance routine endoscopy

BACKGROUND Recent technological advances in miniaturisation have allowed for a confocal scanning microscope to be integrated into trans-endoscopic probes enabling endoscopists to collect in vivo virtual biopsies of the gastrointestinal mucosa during endoscopy. AIMS The aim of the present study was to assess prospectively the clinical applicability and predictive power of a probe-based confocal laser endomicroscopy for the in vivo diagnosis of colorectal neoplasia. METHODS Patients with evidence of colorectal superficial neoplasia at routine endoscopy, were included prospectively in this study. Lesions were identified using white-light endoscopy followed by pCLE imaging recorded by a Coloflex UHD-type probe. The images were interpreted as either neoplastic or not according to vascular and cellular changes. pCLE readings were then compared with histopathological results from endoscopically resected lesions and/or targeted biopsy specimens. RESULTS A total of 32 lesions were identified in 20 consecutive patients. Histopathology diagnosis was of adenomas in 19 cases, hyperplastic polyps in 11 cases and adenocarcinoma in 2 cases. For the detection of neoplastic tissue pCLE had a sensitivity of 100%, a specificity of 84.6%, an accuracy of 92.3, a PPV of 90.5% and a NPV of 100%. CONCLUSIONS pCLE permits high-quality imaging, enabling prediction of intraepithelial neoplasia with a high level of accuracy.

Bowel sonography for the diagnosis and grading of postsurgical recurrence of Crohn's disease.

Background and Aims: Postsurgical recurrence (PSR) is common in patients with Crohns disease (CD) who have undergone surgery. Endoscopy is crucial for the diagnosis of PSR, showing also high prognostic value. Bowel sonography (BS) is accurate for CD diagnosis, but its role in PSR detection and grading has been poorly investigated. The aim of this study was to evaluate the diagnostic accuracy of BS compared to endoscopy in the detection of PSR. Materials and Methods: Between March 2002 and October 2005, to gain evidence of possible PSR, we prospectively performed endoscopy and BS in 45 CD patients who had undergone previous bowel resection. Endoscopy and BS were carried out 1 year after surgery, with diagnosis and grading of PSR made in accordance with Rutgeerts. BS was considered suggestive for PSR in the presence of bowel wall thickness (BWT) >3 mm. Also, an ROC curve was constructed to define the best cutoff value for BWT to differentiate mild from severe PSR (grade 1–2 vs 3–4 of Rutgeerts). Results: Of the 45 patients with CD, 24 showed endoscopic evidence of PSR (53%). Severe endoscopic PSR was present in 16 patients (66%). Sensitivity, specificity, and positive and negative predictive values of BS were 79%, 95%, 95%, and 80%, respectively, with a sensitivity of 93% for severe PSR. On the ROC curve, a BWT >5 mm showed sensitivity, specificity, and positive and negative predictive values of 94%, 100%, 100%, and 96%, respectively, in differentiating mild from severe PSR, in remarkable agreement with endoscopy (&kgr; = 0.90). Conclusions: BS shows good sensitivity and high specificity for the diagnosis of PSR in CD, with a BWT >5 mm being strongly indicative of severe endoscopic PSR. Hence, BS could replace endoscopy for the diagnosis and grading of PSR in patients who comply poorly with the endoscopic examination.

Transmural healing evaluated by bowel sonography in patients with Crohn's disease on maintenance treatment with biologics.

Background:Both thiopurines and anti-tumor necrosis factor (TNF) &agr; agents are effective for treating Crohn’s disease (CD) as they can induce clinical remission (CR) and mucosal healing (MH) in most patients. Nevertheless, data on transmural healing (TH) induced by thiopurines and anti-TNF-&agr; agents are still lacking. This study aimed to explore the rate of TH evaluated by bowel sonography in patients with CD treated with biologics and immunosuppressors and its correlation with CR and MH. Methods:We performed an observational longitudinal study evaluating TH, CR, and MH in all patients with CD attending our clinic who would complete 2 years of maintenance treatment with biologics or thiopurines. CR and MH were assessed in accordance with current literature, whereas TH was recorded using bowel sonography. All patients underwent endoscopy and bowel sonography before starting treatment and 2 years later. Results:The study included 66 patients with CD treated with biologics and 67 patients receiving thiopurines. Finally, TH was present in 17 patients on biologics and only 3 patients treated with thiopurines (25% versus 4%; P < 0.01; odds ratio = 6.2). CR was achieved in 37 patients on biologics and in 34 patients on thiopurines (59.7% versus 53%; P = not significant), whereas MH was more frequent in patients treated with anti-TNF-&agr; agents even though without statistical significance (38% versus 25%; P = not significant). Conclusions:TH can be achieved in approximately 25% of patients with CD treated with anti-TNF-&agr; agents and significantly correlates with MH. Further studies are needed to define the potential role of TH as long-term prognostic factor.

Diagnostic accuracy of confocal laser endomicroscopy in diagnosing dysplasia in patients affected by long-standing ulcerative colitis

AIM To evaluate the diagnostic accuracy of confocal laser endomicroscopy (CLE) for the detection of dysplasia in long-standing ulcerative colitis (UC). METHODS We prospectively performed a surveillance colonoscopy in 51 patients affected by long-standing UC. Also, in the presence of macroscopic areas with suspected dysplasia, both targeted contrasted indigo carmine endoscopic assessment and probe-based CLE were performed. Colic mucosal biopsies and histology, utilised as the gold standard, were assessed randomly and on visible lesions, in accordance with current guidelines. RESULTS Fourteen of the 51 patients (27%) showed macroscopic mucosal alterations with the suspected presence of dysplasia, needing chromoendoscopic and CLE evaluation. In 5 macroscopically suspected cases, the presence of dysplasia was confirmed by histology (3 flat dysplasia; 2 DALMs). No dysplasia/cancer was found on any of the outstanding random biopsies. The diagnostic accuracy of CLE for the detection of dysplasia compared to standard histology was sensitivity 100%, specificity 90%, positive predictive value 83% and negative predictive value 100%. CONCLUSION CLE is an accurate tool for the detection of dysplasia in long-standing UC and shows optimal values of sensitivity and negative predictivity. The scheduled combined application of chromoendoscopy and CLE could maximize the endoscopic diagnostic accuracy for diagnosis of dysplasia in UC patients, thus limiting the need for biopsies.

Rapid "breath-print" of liver cirrhosis by proton transfer reaction time-of-flight mass spectrometry. A pilot study.

The aim of the present work was to test the potential of Proton Transfer Reaction Time-of-Flight Mass Spectrometry (PTR-ToF-MS) in the diagnosis of liver cirrhosis and the assessment of disease severity by direct analysis of exhaled breath. Twenty-six volunteers have been enrolled in this study: 12 patients (M/F 8/4, mean age 70.5 years, min-max 42–80 years) with liver cirrhosis of different etiologies and at different severity of disease and 14 healthy subjects (M/F 5/9, mean age 52.3 years, min-max 35–77 years). Real time breath analysis was performed on fasting subjects using a buffered end-tidal on-line sampler directly coupled to a PTR-ToF-MS. Twelve volatile organic compounds (VOCs) resulted significantly differently in cirrhotic patients (CP) compared to healthy controls (CTRL): four ketones (2-butanone, 2- or 3- pentanone, C8-ketone, C9-ketone), two terpenes (monoterpene, monoterpene related), four sulphur or nitrogen compounds (sulfoxide-compound, S-compound, NS-compound, N-compound) and two alcohols (heptadienol, methanol). Seven VOCs (2-butanone, C8-ketone, a monoterpene, 2,4-heptadienol and three compounds containing N, S or NS) resulted significantly differently in compensate cirrhotic patients (Child-Pugh A; CP-A) and decompensated cirrhotic subjects (Child-Pugh B+C; CP-B+C). ROC (Receiver Operating Characteristic) analysis was performed considering three contrast groups: CP vs CTRL, CP-A vs CTRL and CP-A vs CP-B+C. In these comparisons monoterpene and N-compound showed the best diagnostic performance. Conclusions Breath analysis by PTR-ToF-MS was able to distinguish cirrhotic patients from healthy subjects and to discriminate those with well compensated liver disease from those at more advanced severity stage. A breath-print of liver cirrhosis was assessed for the first time.