Giuliano Bedogni

Antioxidant vitamins or lactulose for the prevention of the recurrence of colorectal adenomas

Colonic adenomas represent the natural precursor lesions of most colorectal cancers. The treatment of choice is endoscopic polypectomy. However, after endoscopic removal, polyps recur in a large fraction of cases. Thus, we evaluated the effect of antioxidant vitamins or lactulose on the recurrence rate of adenomatous polyps. After polypectomy, 255 individuals were randomized into three groups. Group 1 was given vitamin A (30,000 IU/ day), vitamin C (1 g/day), and vitamin E (70 mg/day); Group 2 was given lactulose (20 g/day); Group 3 received no treatment. Forty-six subjects had to be excluded because the histologic diagnosis was not consistent with adenoma. The remaining 209 individuals were included in the analysis according to the “intention to treat” criterion, though 34 did not adhere to the scheduled treatment or were lost during the follow-up. Subjects were followed at regular intervals for an average of 18 months. Polyps recurring before one year from index colonoscopy were considered missed by the endoscopist. In the 209 evaluable subjects, the percentages of recurrence of adenomas were 5.7 percent, 14.7 percent, and 35.9 percent in the vitamins, lactulose, and untreated groups, respectively. The fraction of subjects remaining free of adenomas, estimated by Kaplan-Meier survival curves, was significantly different among the three groups (log-rank chisquared =17.138;P< 0.001). Using Coxs regression analysis, treatment was the only variable that significantly contributed to the model (regression coefficient=0.905;P<0.001). In conclusion, either antioxidant vitamins or, to a lesser extent, lactulose lower the recurrence rate of adenomas of the large bowel and can be proposed as chemopreventive agents, at least in high-risk individuals.

Colonoscopic excision of large and giant colorectal polyps. Technical implications and results over eight years.

Large polyps are sessile or pedunculated lesions that are larger than or equal to 3 cm in size. Sixty-six colonoscopic piecemeal excisions of large pedunculated and sessile polyps (75 percent of 88 recognized large polyps) were performed over eight years. The macroscopic feature of the lesions and the result of an extensive snare biopsy were the deciding factors for endoscopic as opposed to surgical removal. Only three complications (4.5 percent) were recorded (two hemorrhages and one colonic wall burn syndrome), none of which required surgery. Fifty patients with 52 adenomatous lesions had colonoscopic follow-up (range, 3 to 85 months). Of 36 sessile ademonas, two cases of residual (5.5 percent) and four of recurrent disease (11 percent) were observed. Colonoscopic removal is an alternative to local surgical excision of large benign colorectal polyps, and often can be an alternative method to elective colectomy in elderly and high-risk patients.

Generalized juvenile polyposis with mixed pattern and gastric cancer

Generalized gastrointestinal juvenile polyposis is a rare form of diffuse polyposis in which cancer infrequently develops. A clinical case is described in which gastric polyps showed a variety of histological features, including both in situ and invasive adenocarcinoma. Many mixed lesions were observed, confirming a morphological sequence already documented in colorectal tumorigenesis but still undefined in gastric tumors. The patient seems strongly predisposed to gastric cancer, presumably on a genetic basis, because he developed a malignancy in a hyperplastic juvenile polyp, usually not considered a precancerous lesion. There is no doubt that cases like this may be important for accurate genetic evaluation and biological characterization.

A simple latex protector hood for safe endoscopic removal of sharp-pointed gastroesophageal foreign bodies

The large majority of ingested foreign bodies (FBs) pass through the gastrointestinal tract spontaneously without complications. Thus, treatment has traditionally included an initial period of observation. 1 The overall rate of perforation from foreign objects is estimated at less than 1%. 2, 3 However, when considering sharp objects as a separate group, the rate of perforation increases to 15% to 35%, 4, 5 so that early extraction is usually advocated. After the advent of fiberoptic endoscopy, a wide variety of ingested FBs have been successfully removed from the gut. Nevertheless, a number of severe complications can occur during extraction, especially of sharp objects. 1, 6, 7 Several techniques for safe endoscopic retrieval have been proposed, 7-2° most of which can, however, be used only for the extraction of FBs of fixed size and form. We previously described our preliminary experience in adults and children with a new, commercially available protector device specially designed for the endoscopic removal of sharp FBs of the upper gastrointestinal tract. 21, 22 We report herein our 5-year experience with this device in removing a wide variety of large, sharp-pointed g astroesophageal objects.

High prevalence of adenomas and microadenomas of the duodenal papilla and periampullary region in patients with familial adenomatous polyposis

Background: Patients with familial adenomatous polyposis (FAP) are traditionally considered to be at high risk for duodenal-papillary and periampullary adenomas and cancer. Aim: To evaluate prospectively the prevalence, histology and clinical significance of ampullary and periampullary macroscopic and microscopic lesions in our population of affected patients. Setting: Three gastroenterological departments of northern Italian hospitals. Patient and methods: Twenty-five affected patients were carefully investigated over a 24-month period by end-viewing and side-viewing upper panendoscopy. Biopsies were performed on representative macroscopic lesions and randomly on normal-appearing papillary and periampullary mucosa. Results: Seven patients had macroscopic adenomas of the duodenal papilla, three of the periampullary region and five at both sites (cumulative prevalence 40%). An additional six patients had macroadenomas in the rest of the duodenum (overall prevalence 64%). Microscopic adenomas were identified in nine and two patients in the papilla and periampullary region, respectively, and in three at both sites (overall prevalence 44%). Thus, a total of 17 (68%) patients presented macro- or microadenomas at these locations. The prevalence rose to 72%, when a further patient with macroadenomas in the rest of the duodenum only was included. Malignancy was not encountered and severe dysplasia was observed only in a macroadenoma of the second duodenal portion. A higher frequency of macroadenomas in the papilla and periampullary region was significantly correlated with the presence and number of such lesions in the rest of the duodenum (P=0.04). No other significant association was detected either between micro- or macroadenornas at different sites or with the demographic, clinical and pathological features. Conclusion: This study confirms that the duodenal papilla and periampullary region are sites with high prevalence of macro- and microscopic adenomas in patients with FAP. However, our data do not seem to support a higher frequency and malignancy potential of such lesions as compared to polyps in the rest of the duodenum. Nevertheless, these findings warrant a periodic, careful examination of the duodenum with either end-viewing or side-viewing endoscopy, the need for random biopsies of the papilla and periampullary region and the removal of any larger or rapidly growing lesions detected. European Journal of Gastroenterology & Hepatology 1996, 8:1201–1206

Jejunal polyps in familial adenomatous polyposis assessed by push-type endoscopy.

Cancer of the upper gastrointestinal tract is a leading cause of death in patients with familial adenomatous polyposis who have previously undergone total colectomy. The prevalence and the degenerative risk of gastric and duodenal adenomas has been well documented, but little is known about the occurrence of jejunal polyps in these patients. We evaluated 21 (16 affected and five high-risk) subjects in nine families prospectively in order to assess the frequency of polyps in the upper jejunum. With the push-type technique, it has been possible to insert a standard gastroduodenoscope or a longer fiberscope 15-80 cm beyond the ligament of Treitz. Eight out of 16 (50%) affected patients and none of the nonaffected subjects had polyps. All lesions were adenomas, including a 4-cm tubulovillous adenoma with severe dysplasia, and were almost exclusively located in the first 20 cm of jejunum. The depth of insertion obtained with gastroduodenoscopes was significantly smaller than that obtained with longer endoscopes (pediatric colonoscope or experimental enteroscope). However, the jejunal area thought to be at the highest risk of adenoma (the proximal 20 cm) was usually investigated even with standard 105-cm long gastroduodenoscopes. This study confirms that the upper jejunum has a high prevalence of adenomas in patients affected by familial adenomatous polyposis and that proximal jejunoscopy is a worthwhile, not excessively uncomfortable procedure that should be added to the usual follow-up protocols.

First observation of microadenomas in the ileal mucosa of patients with familial adenomatous polyposis and colectomies

BACKGROUND & AIMS Little data are available on the type and prevalence of mucosal changes involved in the development of ileal adenomas in patients with familial adenomatous polyposis who have undergone colectomy. However, colonic metaplasia of the ileal epithelium is thought to be an important step in the development of such adenomas. METHODS Retrograde endoscopy and biopsy of the distal ileum were performed in 17 affected patients who underwent total colectomy or proctocolectomy 3-184.1 months (mean, 80.3 +/- 13.9 months) before the study. RESULTS Macroscopic ileal polyps were identified in 14 (82.4%) patients. All polyps were sessile and 1-5 mm in size. Histological analysis showed adenomas in 9 (52.9%) patients and lymphoid hyperplasia or inflammation in the others. In 1 patient, an area of colonic-type metaplasia of the ileal mucosa was found close to an adenoma. However, in 5 (29.4%) patients, random biopsy specimens of the normal-appearing mucosa showed foci of abnormal crypts in the absence of metaplasia, with histological appearance similar to the findings described in dysplastic aberrant crypt foci of the colon. Such lesions, previously observed only in colorectal mucosa and referred to as microadenomas or oligocryptal adenomas, are considered putative preneoplastic abnormalities. CONCLUSIONS Although the hypothesized sequence normal ileal mucosa leading to colonic-type metaplasia leading to adenoma cannot be excluded, our findings support the sequence normal ileal mucosa leading to microadenoma leading to gross adenoma and possibly cancer as the main histogenetic pathway, as already suggested for the large bowel.

Endoscopic protector hood for safe removal of sharp-pointed gastroesophageal foreign bodies

SummaryEndoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract still poses technical difficulties. Overtubes may be uncomfortable to the patients and only objects fitting within a lumen of about 11–15 mm can be removed. We present here our preliminary experience with a commercially available new endoscopic end protector hood having the unique characteristic of maintaining its bell portion inverted during the progression of the scope through the gut and flipping back to its original shape during withdrawal through the lower esophageal sphincter. This prevents exposure of the esophageal and pharyngeal wall to injuries from the edges of the foreign body. We used this device to remove nine large sharp or pointed gastroesophageal foreign bodies in six consecutive patients in whom conventional techniques were considered unsafe or not technically feasible owing to the size and shape of the objects. In all cases, removal was successful and easily performed without bowel damage. We believe that this device enhances the safe removal of a wide variety of potentially dangerous gastroesophageal foreign bodies.

Clearance of irretrievable bile duct and pancreatic duct stones by extracorporeal shockwave lithotripsy, using a transportable device: effectiveness and medium-term results.

Background and Goals Extracorporeal shockwave lithotripsy (ESWL) is an established treatment of irretrievable biliary and pancreatic stones, but the cost of the shockwave generators limits its widespread use. We revised data about the effectiveness of our treatment for refractory stones using a transportable shockwave generator. Study We retrospectively evaluated the short and medium-term outcomes of patients who underwent ESWL using a transportable electromagnetic shockwave generator between 1998 and 2003 at our unit, for the treatment of irretrievable bile duct or pancreatic duct stones. All patients received intravenous conscious sedation and antibiotic prophylaxis. Results Complete stone clearance was achieved in 70/82 patients (85.4%), in 66 of the patients (94.2%) with 1 session of ESWL. Despite the insertion of a stent in the bile duct, 2 patients had moderate cholangitis, while they waited for the next ESWL session. We did not record any moderate-severe complication of ESWL, but 2 patients underwent surgery owing to perforation/bleeding during endoscopic removal of residual fragments. A symptomatic recurrence of stones was recorded in 10/69 (14.5%) patients, who had been previously cleared and whose follow-up data (median follow-up 29 mo; range 7 to 66) were available. Conclusions We obtained satisfactory stone clearance by using a transportable shockwave generator. Most patients required 1 session. Our experience confirmed the safety of the treatment, even though patients may experience cholangitis while awaiting definitive treatment. The use of a transportable ESWL generator may be a valuable option in centers, while ensuring a sufficient proficiency in biliary endoscopy.

Nasobiliary drainage following endoscopic sphincterotomy

SummaryThe authors analyze a retrospective study of 850 patients who underwent endoscopic sphincterotomy (ES). One group of patients (705) routinely had nasobiliary drainage following ES as a prophylactic measure to prevent complications, while 145 patients were not drained. Complications, mortality and the need for emergency surgery were compared in both groups. In the drained group, the complication rate was 2% vs 10.3% in the nondrained group (P<0.001), and mortality was 0.4% vs 2.7% (P=0.03). Emergency surgery was required in 0.1% in the drained patients versus 3.4% in the nondrained group (P=0.01). Based on these data within the limits of a retrospective study, the authors strongly support the routine use of nasobiliary drainage to prevent complications, which usually occur within the first 24 h, and also to facilitate the immediate treatment of the complications. This procedure is also highly recommended when ES is performed by inexperienced endoscopists and with a technically demanding ES, which is frequently followed by complications.