Mario de Bellis

Tissue sampling at ERCP in suspected malignant biliary strictures (Part 2)

Part I of this review in the previous issue of Gastrointestinal Endoscopy outlined the key points of tissue sampling at ERCP and considered intraductal bile aspiration cytology, cytologic/histologic analysis of retrieved plastic biliary stents and fine needle aspiration cytology. Specimen adequacy, slide preparation, and accuracy of slide interpretation, which is often influenced by the interpretation “philosophy” of individual cytopathologists, are fundamental to the effort to optimize cancer detection by using tissue sampling techniques at ERCP. Intraductal bile aspiration is simple and inexpensive but adds little to the other methods, which have higher rates of cancer detection. Therefore, bile aspiration is recommended only when other sampling techniques cannot be used. Cytologic evaluation of material from retrieved plastic biliary stents is relatively insensitive (32%) and impractical as a firstline approach to the diagnosis of malignant biliary obstruction because diagnosis is delayed until the stent is removed. However, it can be considered in patients undergoing stent exchange when other methods of tissue sampling fail to confirm the suspected diagnosis of malignancy. Endoscopic fineneedle aspiration (FNA) cytology has a lower rate of cancer detection (33%) than initially reported and is technically difficult. It is usually used to supplement other simpler methods. Part II of this review considers the remaining tissue sampling methods for use at ERCP: brush cytology, endobiliary forceps biopsy, and the multimodal tissue sampling. Methods for improving diagnostic yield are discussed. BRUSH CYTOLOGY

Endoscopic palliation in patients with incurable malignant colorectal obstruction by means of self-expanding metal stent: Analysis of results and predictors of outcomes in a large multicenter series

OBJECTIVES To evaluate the short- and long-term efficacy of self-expanding metal stents (SEMSs) in patients with colorectal obstruction and incurable cancer and the related factors that affect outcomes. DESIGN Retrospective analysis of SEMS placement for incurable colorectal obstruction in a 3-year period. SETTING Five tertiary care endoscopic centers. PATIENTS AND INTERVENTION Consecutive patients (N = 201) undergoing stenting for incurable malignant obstruction. MAIN OUTCOME MEASUREMENTS Clinical and technical success of stenting, complications rate, and factors affecting outcomes. RESULTS Technical success was achieved in 184 of 201 patients (91.5%) and clinical success occurred in 165 of 184 patients (89.7%; 82.1% of 201 patients). Technical and clinical failures were more frequent in extrinsic and long colorectal stenoses. Overall, 165 patients had normal bowel movements during follow-up (mean [SD], 115.5 [100.3] days; range, 1-500 days), 15 developed complications, 127 had a functioning SEMS at the time of death, and 23 were alive at completion of the study. Twenty-four (11.9%) major complications occurred: 11 migrations, 12 perforations, and 1 reobstruction. Migration of SEMSs was associated with stent diameter less than 25 mm. Bevacizumab therapy increased the risk of perforation by 19.6-fold. Karnofsky performance status of 50 or less was associated with shorter survival and a 3.7-fold higher risk of death within 6 months after the stent was placed. CONCLUSIONS The use of SEMSs is safe and effective for palliation of incurable malignant colonic obstruction; approximately 75% of patients with SEMSs are able to avoid colostomy.

Role of Endoscopic Ultrasonography in the Staging of Rectal Cancer: A Retrospective Study on 63 Patients

We evaluated retrospectively the accuracy of endoscopic ultrasonography (EUS) in the preoperative staging of 63 patients with rectal cancer who were hospitalized and underwent surgery at our institution from January 1994 to December 1997. These patients, 39 men and 24 women with a mean age of 60 years, underwent preoperative EUS, which was performed in all cases using an echo-colonoscope Olympus CF UM 20, with a 7.5 MHz radial scanner. Ten patients did not undergo surgery and, therefore, were excluded from the analysis. EUS showed an overall accuracy of 81% for the T stage (including nontraversable stenotic tumors) and of 70% for the N stage. The accuracy of EUS for the T stage increased from 81 to 90% when we excluded those cases with nontraversable stenotic cancers from the analysis. Five tumors (9.4%) were understaged. while another five cases (9.4%) were overstaged. Finally, EUS was highly accurate (81%) in differentiating T1 from T24 tumors. In conclusion, our data shows that EUS is very accurate in the locoregional staging of rectal cancer and confirms the role of this imaging technique in the preoperative staging of patients with rectal cancer.

Granular cell tumors of the colon: Report of a case and review of the literature

Granular cell tumors are uncommon, usually benign tumors that can be located anywhere in the body. They commonly occur in the oral cavity and in subcutaneous tissue. In the gastrointestinal tract, granular cell tumors are uncommon and are quite rare in the colon. To date, 55 patients diagnosed with granular cell tumors of the colon have been reported in the literature, only 15 had multiple tumors. We describe the case of a 38-year-old man with a family history of colon cancer who was diagnosed with multiple colonic granular cell tumors after a screening colonoscopy. This seems to be the first report of this type. However, in our patient, the diagnosis of colonic granular cell tumors was incidental and there is no data that correlates adenomas or colorectal cancer with granular cell tumors of the colon. Finally, since granular cell tumors are usually benign, we suggest a conservative approach to patients with multiple granular cell tumors of the colon by means of endoscopic resection and a strict endoscopic follow-up.

Ischemic colitis associated with paclitaxel.

Systemic chemotherapy can be complicated by colonic toxicity, which usually determines the onset of pseudomembranous colitis and, rarely, of ischemic colitis in patients with cancer. This report describes the case of a 49-year-old woman with liver metastases from a neuroendocrine tumor of unknown origin who developed mild ischemic colitis after chemotherapy with carboplatin and paclitaxel. The patient developed symptoms of gastrointestinal toxicity with abdominal pain and bloody diarrhea, which resolved in about 10 days. She had a normal white blood cell count throughout her illness; the assay of stool specimens for Clostridium difficile toxins and the stool cultures were both negative. A sigmoidoscopy showed a mild, transient ischemic colitis, which was confirmed by pathologic examination of the biopsy specimens. Although carboplatin is not related to severe colonic cytotoxicity, it has been previously reported that paclitaxel induces necrosis of the gastrointestinal mucosa and inhibits angiogenesis. Pseudomembranous colitis is the most frequent complication in patients with cancer who undergo paclitaxel-based chemotherapy and develop gastrointestinal toxicity. Once C. difficile infection has been excluded, a diagnosis of ischemic colitis should be considered, especially in patients with cancer who have normal white blood cell counts.

Percutaneous Ablation Therapy of Hepatocellular Carcinoma With Irreversible Electroporation: MRI Findings

OBJECTIVE Irreversible electroporation is a new ablation modality. Our purpose was to describe the MRI findings after irreversible electroporation treatment of hepatocellular carcinoma (HCC). SUBJECTS AND METHODS In an 18-month period, we treated 24 HCC lesions in 20 patients who were not candidates for surgery. MRI was performed before and 1 month after irreversible electroporation. We used the liver-specific contrast medium gadoxetic acid. We evaluated the size, shape, signal intensity (T1-weighted, T2-weighted, and diffusion-weighted imaging), dynamic contrast enhancement pattern, and signal behavior during the liver-specific phase. Changes in the perilesional parenchyma, perfusion abnormalities, and complications were also recorded. RESULTS According to the modified Response Evaluation Criteria in Solid Tumors system, 22 of 24 lesions had a complete response, and two lesions showed a partial response and were retreated. The lesions showed a mean size increase of 10%, with a round or oval shape. On the T1-weighted images, we observed a hyperintense core and a hypointense rim. On the T2-weighted sequences, the signal was heterogeneously hypointense. On diffusion-weighted images, 83% of lesions showed restricted diffusion, with b values of 0-800 s/mm(2), whereas in 17% of the lesions, the signal was not clearly discernible for different b values. The apparent diffusion coefficient values did not show statistically significant differences between the baseline (800-1020 × 10(-3) mm(2)/s) and the reassessment after 1 month (900-1100 × 10(-3) mm(2)/s). The necrotic area did not show a signal increase after contrast material injection. Perfusion abnormalities, such as areas of transient hepatic intensity difference, were present in the tissue adjacent to six treated lesions. In two patients, a reduced or absent concentration of the contrast medium was observed during the liver-specific phase around the ablation zone. One patient had an arteriovenous shunt and another had biliary duct dilatation. CONCLUSION MRI detects characteristic morphologic and functional changes after irreversible electroporation treatment.

Complications of Biliary and Gastrointestinal Stents: MDCT of the Cancer Patient

OBJECTIVE The goal of this article is to discuss and show the common complications of biliary and gastrointestinal stents as depicted by MDCT in cancer patients. Major complications include stent misplacement or displacement, bleeding, obstruction, perforation, stent fracture or collapse, and infection. This topic encompasses several relevant issues, including interpretative difficulties, therapeutic decisions, and potential malpractice concerns. CONCLUSION Awareness and methodical assessment of stents could allow detection of stenting complications, potentially sparing the patient from associated morbidity and mortality.

Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery? §

OBJECTIVES Flexible bronchoscopy is recommended to confirm correct placement of double-lumen tubes used for thoracic anesthesia. However, there is still controversy over routine bronchoscopic confirmation of their position. This study aimed to verify the usefulness of flexible bronchoscopy for confirming the position of double-lumen tubes after blind intubation. METHODS During a 9-month period, consecutive patients undergoing elective oncologic thoracic surgery were prospectively enrolled in the study. All patients were intubated with a left disposable polyvinyl chloride double-lumen tube. Immediately after intubation, clinical verification was made by the anesthesiologist. Then, the endoscopist performed flexible bronchoscopy with a 2.8-mm diameter Olympus(®) video bronchoscope, and verified the position of the double-lumen tube, before positioning the patient. The double-lumen tube was in optimal position, if the bronchial cuff was immediately below the tracheal carina, and there was a clear view of the left subcarina, with unobstructed left upper and lower bronchi. Misplacement of the double-lumen tube was diagnosed when the tube had to be moved (in or out) for more than 0.5 cm to correct its position. Critical malposition meant a double-lumen tube dislocated in the trachea or in the right bronchi, requiring immediate re-intubation under bronchoscopic guidance. RESULTS A total of 144 patients (44 women (42%) and 60 men (58%), with a mean age of 51 years (range 25-77 years)) were enrolled in the study. Surgical procedures included 37 right-sided and 31 left-sided thoracotomies, 22 video-assisted thoracoscopic surgeries (VATSs) (16 right-sided and six left-sided), one median sternotomy, six mediastinotomies, and seven miscellaneous procedures. In 66 (63%, 95% confidence interval 53.2-71.8%) cases, there was complete agreement between the anesthesiologist and the endoscopist. The latter diagnosed misplacement of the double-lumen tube in 33 (32%, 95% confidence interval 22.8-40.7%) patients and critical malposition in five (5%, 95% confidence interval 0.7-8.9%) cases. CONCLUSIONS After blind intubation, 37% of double-lumen tubes required repositioning by means of flexible bronchoscopy, despite positive evaluation made by the anesthesiologist. Our data suggests that initial bronchoscopic assessment should be made with the patient still in the supine position, and confirms that flexible bronchoscopy is useful in verifying the correct position of double-lumen tubes or adjusting possible misplacements, before starting thoracic surgery.

Role of endoscopic ultrasonography in the loco-regional staging of patients with rectal cancer

The prognosis of rectal cancer (RC) is strictly related to both T and N stage of the disease at the time of diagnosis. RC staging is crucial for choosing the best multimodal therapy: patients with high risk locally advanced RC (LARC) undergo surgery after neoadjuvant chemotherapy and radiotherapy (NAT); those with low risk LARC are operated on after a preoperative short-course radiation therapy; finally, surgery alone is recommended only for early RC. Several imaging methods are used for staging patients with RC: computerized tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound (EUS). EUS is highly accurate for the loco-regional staging of RC, since it is capable to evaluate precisely the mural infiltration of the tumor (T), especially in early RC. On the other hand, EUS is less accurate in restaging RC after NAT and before surgery. Finally, EUS is indicated for follow-up of patients operated on for RC, where there is a need for the surveillance of the anastomosis. The aim of this review is to highlight the impact of EUS on the management of patients with RC, evaluating its role in both preoperative staging and follow-up of patients after surgery.

Multicenter Randomized Trial of 10-French versus 11.5-French Plastic Stents for Malignant Biliary Obstruction

Background. There is little prospective data on whether bigger plastic stents are better for patients with malignant biliary obstruction with jaundice. Goals. Multicenter prospective study to compare technical success, clinical response, stent occlusion, and patient survival in patients with malignant biliary obstruction randomized to 10-French or 11.5-French plastic stent. Study. Patients with malignant biliary obstruction were randomized to 10-French or 11.5-French biliary stents. Patients were prospectively assessed for stent occlusion, stent-related interventions, hospital stay, and change in bilirubin. Main outcome measurements included technical success, clinical response, rates of stent occlusion, and survival. Results. 234 patients (47 hilar and 187 common bile duct strictures) were randomized. Outcomes were similar for the 10-French and 11.5-French groups (technical success 99.1% versus 97.4%, P = 0.37). Overall, median stent survival was 213 days, but there was no statistically significant difference in stent survival between 10-French and 11.5-French stents (149 versus 258 days, P = 0.16). Stent survival was significantly longer when placed for common bile duct versus hilar strictures (231 versus 115 days, P = 0.049). Conclusions. The theoretical advantage of improved bile flow for the 11.5-French stent does not translate into more prolonged patency, better clinical response, and longer patient survival than the 10-French stent.