Luca Magno

A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series

BACKGROUND Staple-line leak is the most serious complication of laparoscopic sleeve gastrectomy (LSG) occurring in .5-7% of cases. Patients with this complication are often managed with an esophageal covered, self-expandable metal stent positioned at endoscopy. Unfortunately, migration of these stents has been reported in 30-50% of cases. A novel fully-covered, self-expanding metal stent (Megastent), specifically designed for post-LSG leaks is now available. The objective of this study was to describe the first case series of patients with a staple-line leak after LSG who were endoscopically managed with such a novel stent. METHODS Four patients who developed a staple-line leak after LSG were treated by positioning a Megastent at endoscopy. The stents were removed after 8 weeks. RESULTS A complete leak repair was achieved in all patients. No stent migration occurred. Prokinetic therapy was needed to treat vomiting episodes during stent presence. At endoscopic evaluation after stent removal, a decubitus lesion at the distal part of the duodenal bulb was observed. CONCLUSION These preliminary results would suggest the use of the Megastent as an option for stenting of a staple-line leak after LSG. Further studies are still necessary.

Endoscopic repair of post-surgical gastrointestinal complications

Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.

Quality of bowel cleansing in hospitalized patients undergoing colonoscopy: A multicentre prospective regional study

BACKGROUND Quality of bowel cleansing in hospitalized patients undergoing colonoscopy is often unsatisfactory. No study has investigated the inpatient or outpatient setting as cause of inadequate cleansing. AIMS To assess degree of bowel cleansing in inpatients and outpatients and to identify possible predictors of poor bowel preparation in the two populations. METHODS Prospective multicentre study on consecutive colonoscopies in 25 regional endoscopy units. Univariate and multivariate analysis with odds ratio estimation were performed. RESULTS Data from 3276 colonoscopies were analyzed (2178 outpatients, 1098 inpatients). Incomplete colonoscopy due to inadequate cleansing was recorded in 369 patients (11.2%). There was no significant difference in bowel cleansing rates between in- and outpatients in both colonic segments. In the overall population, independent predictors of inadequate cleansing both at the level of right and left colon were: male gender (odds ratio, 1.20 [1.02-1.43] and 1.27 [1.05-1.53]), diabetes mellitus (odds ratio, 2.35 [1.68-3.29] and 2.12 [1.47-3.05]), chronic constipation (odds ratio, 1.60 [1.30-1.97] and 1.55 [1.23-1.94]), incomplete purge intake (odds ratio, 2.36 [1.90-2.94] and 2.11 [1.68-2.65]) and a runway time >12h (odds ratio, 3.36 [2.40-4.72] and 2.53 [1.74-3.67]). CONCLUSIONS We found no difference in the rate of inadequate bowel preparation between hospitalized patients and outpatients.

Comparison between tungsten and steel polypectomy snares: evaluation of depth of colonic thermal wall injury in a pig model.

BACKGROUND AND STUDY AIMS Thermal injury of the colonic wall during polypectomy may induce complications such as bleeding and perforation. To date, the role of the snare material in these injuries has not been examined. The aim of this study was to evaluate the depth of colonic post-polypectomy thermal wall injury induced by tungsten and steel endoscopic snares, in an effort to reduce electrosurgery-related complications. MATERIALS AND METHODS This was a single tertiary center experimental study in a porcine model. A total of 90 polypectomies where performed in three live pigs under general anesthesia, using both steel and tungsten snares by cut, coagulation, and blend current modes. The pigs were then euthanized and their colons examined histologically. RESULTS Steel snares induced significantly deeper tissue injury than tungsten snares in the pure cut mode (Pearson χ2 = 6.136, P = 0.013). The ordinal logistic regression analysis showed that the current mode and snare material were significantly associated with the ordinal score for the depth of injury. Thus, cut mode was positively associated with a lower score and coagulation mode with a higher score. In addition, tungsten was significantly associated with a lower depth of tissue injury. CONCLUSIONS Due to its inherent electrical properties, tungsten is very well suited for manufacture into electrosurgical endoscopic devices. Thus, tungsten snares may be advantageous for routine use in endoscopic polypectomy, although further studies are needed to confirm these promising findings in human patients.

DUODENAL EPITHELIOID ANGIOSARCOMA: IMMUNOHISTOCHEMICAL AND CLINICAL FINDINGS. A CASE REPORT

Angiosarcomas are uncommon malignant tumors of vascular endothelium that represent less than 1% of all sarcomas. The epithelioid variant of angiosarcomas is exceptionally rare, and the gastrointestinal tract is rarely involved. Angiosarcomas mainly involve skin and soft tissue and rarely occur in breast, liver, bone, and spleen. We present the case of a 30-year-old man who underwent an upper gastrointestinal endoscopy for melena. A duodenal reddish polypoid lesion was found, which on microscopic examination turned out to be an epithelioid angiosarcoma. The immunohistochemical features of the lesion supported this diagnosis. The patient died eight months after the diagnosis. Epithelioid angiosarcoma is an aggressive variant of angiosarcoma and must be considered in the differential diagnosis of gastrointestinal tumors.

Contribution of New Technologies to Endoscopic Imaging

A thorough endoscopic visualization of the small-bowel mucosa is essential for reaching an accurate diagnosis and treating the respective disease. Standard white-light endoscopes permit gross examination of the small-bowel mucosa. The introduction of magnification or zoom endoscopy has increased our ability to analyze the mucosal details. With the application of dyes and zoom-magnification endoscopy, further architectural features of the mucosa can be elucidated. New techniques, especially computed virtual chromoendoscopy (NBI, FICE, i-Scan), have enhanced the optical capabilities for the evaluation of gut mucosal lesions. Recently, confocal endomicroscopy was proposed for the study of the small-bowel mucosa.

Multiple Primary Malignancies: Role of Advanced Endoscopy To Identify Synchronous and Metachronous Tumors of the Digestive Tract

The development of new endoscopy systems represents a significant advance in the diagnosis of tumors. The prognosis for patients is strictly dependent on the early detection of malignant lesions, because early lesions of the digestive tract can be removed endoscopically by several techniques (e.g., polypectomy, endoscopic mucosal resection, submucosal endoscopic dissection).