Nicola de’Angelis

Wireless Capsule Endoscopy for Pediatric Small-Bowel Diseases

OBJECTIVE:Although capsule endoscopy (CE) is becoming an increasingly popular procedure, only recently data on its clinical application in pediatric gastroenterology are just emerging. Our aim is to investigate the diagnostic value of CE in small intestine diseases and to determine its safety, tolerance, and applicability in a large number of pediatric patients referred to our Tertiary Center of Pediatric Gastroenterology Unit, University of Parma.METHODS:A total of 87 Italian patients, 49 of which were male with an age range from 18 months to 18 yr with a suspected small-bowel disease (inflammatory bowel disease 37%, polyps 38%, obscure gastrointestinal bleeding 24%, malabsorption 1%), were investigated with the M2A capsule (GIVEN® Imaging Ltd., Yoqneam, Israel).RESULTS:A total of 77 patients swallowed the capsule, while in 10 it was endoscopically positioned (age range 1.5–11 yr, median age 5.3 yr). Eighty patients naturally evacuated the capsule, one patient needed surgery. The capsule evidenced pathological findings in 62 patients (71%), ileal lymphoid nodular hyperplasia in four subjects (5%), it was negative in 18 subjects (21%), and technically failed in three subjects (3%). In 21 out of 28 patients with known polyposis and in all the five patients with suspected polyposis, small-bowel polyps were found. In 16 out of 22 patients suffering from known inflammatory bowel disease (Crohns disease colitis or indeterminate colitis), small intestine lesions were found. CE examination identified a possible small intestine bleeding source in 13 out of 21 patients with suspected obscure gastrointestinal bleeding. In 5 out of 10 patients with suspected small-bowel inflammatory disease, CE evidenced ileum lesions suggesting Crohns disease, which was subsequently confirmed through diagnostic procedures and the clinical history. A patient with malabsorption presented a negative capsule study.CONCLUSIONS:Our experience, which includes the largest number of pediatric patients and the youngest child reported in literature, confirms that CE is a very useful system for the clinical work in suspected small-bowel diseases in infancy. The high rate of positive examination is due to the very careful selection of the patients, obligatory to conduct a safe examination since CE is not highly tested in children.

Short- and long-term efficacy of endoscopic balloon dilation in Crohn’s disease strictures

AIM To evaluate short- and long-term efficacy of endoscopic balloon dilation in a cohort of consecutive patients with symptomatic Crohns disease (CD)-related strictures. METHODS Twenty-six CD patients (11 men; median age 36.8 year, range 11-65 years) with 27 symptomatic strictures underwent endoscopic balloon dilation (EBD). Both naive and post-operative strictures, of any length and diameter, with or without associated fistula were included. After a clinical and radiological assessment, EBD was performed with a Microvasive Rigiflex through the scope balloon system. The procedure was considered successful if no symptom reoccurred in the following 6 mo. The long-term clinical outcome was to avoid surgery. RESULTS The mean follow-up time was 40.7 ± 5.7 mo (range 10-94 mo). In this period, forty-six EBD were performed with a technical success of 100%. No procedure-related complication was reported. Surgery was avoided in 92.6% of the patients during the entire follow-up. Two patients, both presenting ileocecal strictures associated with fistula, failed to respond to the treatment and underwent surgical strictures resection. Of the 24 patients who did not undergo surgery, 11 patients received 1 EBD, and 13 required further dilations over time for the treatment of relapsing strictures (7 patients underwent 2 dilations, 5 patients 3 dilations, and 1 patient 4 dilations). Overall, the EBD success rate after the first dilation was 81.5%. No difference was observed between the EBD success rate for naive (n = 12) and post-operative (n = 15) CD related strictures (P > 0.05). CONCLUSION EBD appears to be a safe and effective procedure in the therapeutic management of CD-related strictures of any origin and dimension in order to prevent surgery.

Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis

AIM To compare the open and laparoscopic Hartmanns reversal in patients first treated for complicated diverticulitis. METHODS Forty-six consecutive patients with diverticular disease were included in this retrospective, single-center study of a prospectively maintained colorectal surgery database. All patients underwent conventional Hartmanns procedures for acute complicated diverticulitis. Other indications for Hartmanns procedures were excluded. Patients underwent open (OHR) or laparoscopic Hartmanns reversal (LHR) between 2000 and 2010, and received the same pre- and post-operative protocols of cares. Operative variables, length of stay, short- (at 1 mo) and long-term (at 1 and 3 years) post-operative complications, and surgery-related costs were compared between groups. RESULTS The OHR group consisted of 18 patients (13 males, mean age ± SD, 61.4 ± 12.8 years), and the LHR group comprised 28 patients (16 males, mean age 54.9 ± 14.4 years). The mean operative time and the estimated blood loss were higher in the OHR group (235.8 ± 43.6 min vs 171.1 ± 27.4 min; and 301.1 ± 54.6 mL vs 225 ± 38.6 mL respectively, P = 0.001). Bowel function returned in an average of 4.3 ± 1.7 d in the OHR group, and 3 ± 1.3 d in the LHR group (P = 0.01). The length of hospital stay was significantly longer in the OHR group (11.2 ± 5.3 d vs 6.7 ± 1.9 d, P < 0.001). The 1 mo complication rate was 33.3% in the OHR (6 wound infections) and 3.6% in the LHR group (1 hemorrhage) (P = 0.004). At 12 mo, the complication rate remained significantly higher in the OHR group (27.8% vs 10.7%, P = 0.03). The anastomotic leak and mortality rates were nil. At 3 years, no patient required re-intervention for surgical complications. The OHR procedure had significantly higher costs (+56%) compared to the LHR procedure, when combining the surgery-related costs and the length of hospital stay. CONCLUSION LHR appears to be a safe and feasible procedure that is associated with reduced hospitality stays, complication rates, and costs compared to OHR.

Managements of recurrent hepatocellular carcinoma after liver transplantation: A systematic review.

AIM To investigate the efficacy (survival) and safety of treatments for recurrent hepatocellular carcinoma (HCC) in liver transplantation (LT) patients. METHODS Literature search was performed on available online databases without a time limit until January 2015. Clinical studies describing survival after HCC recurrence in LT patients were retrieved for a full-text evaluation. A total of 61 studies were selected: 13 case reports, 41 retrospective case series, and 7 retrospective comparative studies. RESULTS Based on all included studies, the mean HCC recurrence rate was 16% of all LTs for HCC. A total of 1021 LT patients experienced HCC recurrence. The median time from LT to HCC recurrence was 13 mo (range 2-132 mo). The majority of patients (67%) presented with HCC extra-hepatic recurrences, involving lung, bone, adrenal gland, peritoneal lymph nodes, and rarely the brain. Overall survival after HCC recurrence was 12.97 mo. Surgical resection of localized HCC recurrence and Sorafenib for controlling systemic spread of HCC recurrence were associated with the higher survival rates (42 and 18 mo, respectively). However, Sorafenib, especially when combined with mTOR, was frequently associated with severe side effects that required dose reduction or discontinuation CONCLUSION Management of recurrent HCC in LT patients is challenging and associated with poor prognosis independently of the type of treatment.

Short-term clinical outcomes of laparoscopic vs open rectal excision for rectal cancer: A systematic review and meta-analysis

AIM To review evidence on the short-term clinical outcomes of laparoscopic (LRR) vs open rectal resection (ORR) for rectal cancer. METHODS A systematic literature search was performed using Cochrane Central Register, MEDLINE, EMBASE, Scopus, OpenGrey and ClinicalTrials.gov register for randomized clinical trials (RCTs) comparing LRR vs ORR for rectal cancer and reporting short-term clinical outcomes. Articles published in English from January 1, 1995 to June, 30 2016 that met the selection criteria were retrieved and reviewed. The Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statements checklist for reporting a systematic review was followed. Random-effect models were used to estimate mean differences and risk ratios. The robustness and heterogeneity of the results were explored by performing sensitivity analyses. The pooled effect was considered significant when P < 0.05. RESULTS Overall, 14 RCTs were included. No differences were found in postoperative mortality (P = 0.19) and morbidity (P = 0.75) rates. The mean operative time was 36.67 min longer (95%CI: 27.22-46.11, P < 0.00001), the mean estimated blood loss was 88.80 ml lower (95%CI: -117.25 to -60.34, P < 0.00001), and the mean incision length was 11.17 cm smaller (95%CI: -13.88 to -8.47, P < 0.00001) for LRR than ORR. These results were confirmed by sensitivity analyses that focused on the four major RCTs. The mean length of hospital stay was 1.71 d shorter (95%CI: -2.84 to -0.58, P < 0.003) for LRR than ORR. Similarly, bowel recovery (i.e., day of the first bowel movement) was 0.68 d shorter (95%CI: -1.00 to -0.36, P < 0.00001) for LRR. The sensitivity analysis did not confirm a significant difference between LRR and ORR for these latter two parameters. The overall quality of the evidence was rated as high. CONCLUSION LRR is associated with lesser blood loss, smaller incision length, and longer operative times compared to ORR. No differences are observed for postoperative morbidity and mortality.

Robotic Versus Laparoscopic Gastric Resection for Primary Gastrointestinal Stromal Tumors >5 cm: A Size-Matched and Location-Matched Comparison

This study compared robotic (RR) and laparoscopic resection (LR) for primary gastrointestinal stromal tumors (GISTs) of the stomach >5 cm. Twelve consecutive patients who underwent RR from 2012 to 2015 were matched for tumor size and location with 24 patients who underwent LR from 2000 to 2012. The median tumor size was 7.1 cm (range, 5.5 to 11.5). GISTs were resected by wedge resection (91.7%) or distal gastrectomy. The median RR operative time was longer than that of LR (162.5 vs. 130 min, respectively; P=0.004). Only 1 LR patient required conversion. The time to flatus and hospital stay were similar between groups. Overall, 3 patients developed minor postoperative complications that were medically treated. Mortality was nil. All resections were R0. No difference was observed in the incidence of recurrence. RR was significantly more expensive (+21.6%) than LR. RR appears to be safe and feasible for GISTs>5 cm, but is associated with longer operative times and greater costs.

Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies

Background Locally advanced rectal cancer (LARC) requires a multimodal therapy tailored to the patient and tumor characteristics. Pretreatment magnetic resonance imaging (MRI) is necessary to stage the primary tumor, while restaging MRI, which is not systematically performed, may be of interest to identify poor responders to neoadjuvant chemoradiation therapy (NCRT), and redefine therapeutic approach. The EuMaRCS study group aimed to investigate the role and accuracy of pretreatment (including pelvimetry) and restaging MRIs in predicting surgical difficulties and surgical outcomes in LARC therapy. Methods Patients with mid or low LARC who were administered NCRT, who underwent laparoscopic total mesorectal excision, and for whom pretreatment and restaging MRIs were available, were included. Results MRIs of 170 patients (median age: 61 years) were reanalyzed by the same radiologist. Pelvimetry differed significantly between males and females, but no gender difference was noted in the clinical and tumor characteristics. Tumor volume and tumor height assessed on the restaging MRI were associated, respectively, with operative time and estimated blood loss. Conversion was predicted by tumor volume, interischial distance and pubic tubercle height. The quality of the surgical resection was found to be a predictor of overall and disease-free survival. The sensitivity and specificity of tumor regression grade 1 to identify a pathologic complete response were 76.9% and 89.3%, respectively. Conclusions In LARC management, pelvimetry and restaging MRI may be useful to predict surgical difficulties and surgical outcomes. However, the main independent predictor of patient survival appears to be the achievement of a successful surgical resection.

Postoperative Infectious Complications Impact Long-Term Survival in Patients Who Underwent Hepatectomies for Colorectal Liver Metastases: a Propensity Score Matching Analysis

ObjectivePostoperative complications strongly impact the postoperative course and long-term outcome of patients who underwent liver resection for colorectal liver metastases (CRLM). Among them, infectious complications play a relevant role. The aim of this study was to evaluate if infectious complications still impact overall and disease-free survival after liver resection for CRLM once patients were matched with a propensity score matching analysis based on Fong’s criteria.MethodsA total of 2281 hepatectomies were analyzed from a multicentric retrospective cohort of hepatectomies. Patients were matched with a 1:3 propensity score analysis in order to compare patients with (INF+) and without (INF−) postoperative infectious complications.ResultsMajor resection (OR = 1.69 (1.01–2.89), p = 0.05) and operative time (OR = 1.1 (1.1–1.3), p = 0.05) were identified as risk factors of infectious complications. After propensity score matching, infectious complications are associated with overall survival (OS), with 1-, 3-, 5-year OS at 94, 81, and 66% in INF− and 92, 66, and 57% in INF+ respectively (p = 0.01). Disease-free survival (DFS) was also different with regard to 1-, 3-, 5-year survival at 65, 41, and 22% in R0 vs. 50, 28, and 17% in INF+ (p = 0.007).ConclusionInfectious complications are associated with decreased overall and disease-free survival rates.

Which method of distal pancreatectomy is cost-effective among open, laparoscopic, or robotic surgery?

Background The aim of this study was to analyze the clinical and economic impact of robotic distal pancreatectomy, laparoscopic distal pancreatectomy, and open distal pancreatectomy. Methods All consecutive patients who underwent distal pancreatic resection for benign and malignant diseases between January 2012 and December 2015 were prospectively included. Cost analysis was performed; all charges from patient admission to discharge were considered. Results There were 21 robotic (RDP), 25 laparoscopic (LDP), and 43 open (ODP) procedures. Operative time was longer in the RDP group (RDP =345 minutes, LDP =306 min, ODP =251 min, P=0.01). Blood loss was higher in the ODP group (RDP =192 mL, LDP =356 mL, ODP =573 mL, P=0.0002). Spleen preservation was more frequent in the RDP group (RDP =66.6%, LDP =61.9%, ODP =9.3%, P=0.001). The rate of patients with Clavien-Dindo > grade III was higher in the ODP group (RDP =0%, LDP =12%, ODP =23%, P=0.01), especially for non-surgical complications, which were more frequent in the ODP group (RDP =9.5%, LDP =24%, ODP =41.8%, P=0.02). Length of hospital stay was increased in the ODP group (ODP =19 days, LDP =13 days, RDP =11 days, P=0.007). The total cost of the procedure, including the surgical procedure and postoperative course was higher in the ODP group (ODP =30,929 Euros, LDP =22,150 Euros, RDP =21,219 Euros, P=0.02). Conclusions Cost-effective results of RDP seem to be similar to LDP with some better short-term outcomes.