Nicola Gennarelli

Confocal laser endomicroscopy in breast surgery: a pilot study

BackgroundBreast neoplasms include different histopathological entities, varying from benign tumors to highly aggressive cancers. Despite the key role of imaging, traditional histology is still required for a definitive diagnosis. Confocal Laser Endomicroscopy (CLE) is a new technique, which enables to obtain histopathological images in vivo, currently used in the diagnosis of gastrointestinal diseases. This is a single-center pilot feasibility study; the main aim is to describe the basic morphological patterns of Confocal Laser Endomicroscopy in normal breast tissue besides benign and malignant lesions.MethodsThirteen female patients (mean age 52.7, range from 22 to 86) who underwent surgical resection for a palpable breast nodule were enrolled. CLE was performed soon after resection with the Cellvizio® Endomicroscopy System (Mauna Kea Technologies, Paris, France), by using a Coloflex UHD-type probe; intravenous fluorescein was used as contrast-enhancing agent. The surgical specimen was cut along the main axis; dynamic images were obtained and recorded using a hand-held probe directly applied both to the internal part of the lesion and to several areas of surrounding normal tissue. Each specimen was then sent for definitive histologic examination.ResultsHistopathology revealed a benign lesion in six patients (46%), while a breast cancer was diagnosed in seven women (54%). Confocal laser endomicroscopy showed some peculiar morphological patterns. Normal breast tissue was characterized by a honeycomb appearance with regular, dark, round or hexagonal glandular lobules on a bright stroma background; tubular structures, representing ducts or blood vessels, were also visible in some frames. Benign lesions were characterized by a well-demarcated “slit-like” structure or by lobular structures in abundant bright stroma. Finally, breast cancer was characterized by a complete architectural subversion: ductal carcinoma was characterized by ill-defined structures, with dark borders and irregular ductal shape, formingribbons, tubules or nests; mucinous carcinoma showed smaller cells organized in clusters, floating in an amorphous extracellular matrix.ConclusionsThis is the first pilot study to investigate the potential role of confocal laser imaging as a diagnostic tool in breast diseases. Further studies are required to validate these results and establish the clinical impact of this technique.

Bacterial stimuli activate nitric oxide colonic mucosal production in diverticular disease. Protective effects of L. casei DG® (Lactobacillus paracasei CNCM I-1572)

Background Micro-inflammation and changes in gut microbiota may play a role in the pathogenesis of diverticular disease (DD). Objective The objective of this article is to evaluate the expression of nitric oxide (NO)-related mediators and S100B in colonic mucosa of patients with DD in an ex vivo model of bacterial infection. Methods Intestinal biopsies obtained from patients with diverticulosis, symptomatic uncomplicated diverticular disease (SUDD) and SUDD with previous acute diverticulitis (SUDD+AD) were stimulated with the probiotic L. casei DG® (LCDG) and/or the pathogen enteroinvasive Escherichia coli (EIEC). S100B, NO release and iNOS expression were then evaluated. Results Basal iNOS expression was significantly increased in SUDD and SUDD+AD patients. Basal NO expression was significantly increased in SUDD+AD. No differences in S100B release were found. In all groups, iNOS expression was significantly increased by EIEC and reduced by LCDG. In all groups, except for SUDD+AD, EIEC significantly increased NO release, whereas no increase was observed when LCDG was added to biopsies. EIEC did not induce significant changes in S100B release. Conclusions Colonic mucosa of patients with DD is characterized by a different reactivity toward pathogenic stimuli. LCDG plays a role in counteracting the pro-inflammatory effects exerted by EIEC, suggesting a beneficial role of this probiotic in DD.

In vivo assessment of tumour angiogenesis in colorectal cancer: the role of confocal laser endomicroscopy.

Tumour neoangiogenesis is a key factor in tumour progression and metastatic spread and the possibility to assess tumour angiogenesis might provide prognostic information. The aim of this study was to establish the role of probe‐based confocal laser endomicroscopy (p‐CLE) in the identification of vascular architecture and specific morphological patterns in normal colorectal mucosa and malignant lesions during routine endoscopy.

Recovery after intracorporeal anastomosis in laparoscopic right hemicolectomy: a systematic review and meta-analysis

PurposeAlthough intracorporeal anastomosis (IA) appears to guarantee a faster recovery compared to extracorporeal anastomosis (EA), the data are still unclear. Thus, we performed a systematic review of the literature with meta-analysis to evaluate the recovery benefits of intracorporeal anastomosis.Materials and methodsA systematic search was performed in electronic databases (PubMed, Web of Science, Scopus, EMBASE) using the following search terms in all possible combinations: “laparoscopic,” “right hemicolectomy,” “right colectomy,” “intracorporeal,” “extracorporeal,” and “anastomosis.” According to the pre-specified protocol, all studies evaluating the impact of choice of intra- or extracorporeal anastomosis after right hemicolectomy on time to first flatus and stools, hospital stay, and postoperative complications according to Clavien-Dindo classification were included.ResultsSixteen articles were included in the final analysis, including 1862 patients who had undergone right hemicolectomy: 950 cases (IA) and 912 controls (EA). Patients who underwent IA reported a significantly shorter time to first flatus (MD = − 0.445, p = 0.013, Z = − 2.494, 95% CI − 0.795, 0.095), to first stools (MD = − 0.684, p < 0.001, Z = − 4.597, 95% CI − 0.976, 0.392), and a shorter hospital stay (MD = − 0.782, p < 0.001, Z = −3.867, 95% CI − 1.178, − 0.385) than those who underwent EA. No statistically significant differences in complications between the IA and EA patients were observed in the Clavien-Dindo I-II group (RD = − 0.014, p = 0.797, Z = − 0.257, 95% CI − 0.117, 0.090, number needed to treat (NNT) 74) or in the Clavien-Dindo IV-V (RD = − 0.005, p = 0.361, Z = − 0.933, 95% CI − 0.017, 0.006, NNT 184). The IA procedure led to fewer complications in the Clavien-Dindo III group (RD = − 0.041, p = 0.006, Z = − 2.731, 95% CI − 0.070, 0.012, NNT 24).ConclusionsAlthough intracorporeal anastomosis appears to be safe in terms of postoperative complications and is potentially more effective in terms of recovery after surgery, further ad hoc randomized clinical trials are needed, given the heterogeneity of the data available in the current literature.

Confocal laser endomicroscopy in ulcerative colitis: beyond endoscopic assessment of disease activity

AbstractBackground The aim of this study was to investigate the role of confocal laser endomicroscopy (CLE) in the assessment of disease activity in ulcerative colitis (UC).Methods Consecutive patients with UC referred to our inflammatory bowel disease unit for colonoscopy were enrolled. Patients without UC were used as controls. UC activity was evaluated by white light endoscopy and classified according to the Mayo Ulcerative Colitis Endoscopic Score of Severity. Endoscopic biopsies were also taken for histological assessment of disease activity and then assessed with CLE. Three parameters were evaluated; crypt architecture (crypt diameter, inter-crypt distance, presence of fused crypts, crypts regularity), microvascular pattern (regular, dilated, irregular and deformed), fluorescein leakage.ResultsFifty patients with UC and 10 controls were enrolled. At colonoscopy, 11 patients (22%), 19 patients (38%), 12 patients (24%) and 8 patients (16%) presented a Mayo score of 0, 1, 2 and 3, respectively. At CLE, fused crypts were present in all the patients with UC and absent in controls. Crypt diameter and inter-crypt distance showed a parallel increase with the Mayo score. Fluorescein leakage and irregular vessels were more frequently found in case of a high level of endoscopic severity, but were also identified in about 20% of UC patients with normal mucosa. Biopsies also demonstrated the presence of histological activity in 4 patients with endoscopically inactive colitis.ConclusionsCLE might be a useful tool to determine inflammatory activity in UC. Fused crypts appeared to be a CLE marker of UC, while other abnormalities, like microvascular alteration and fluorescein leakage, have also been identified in patients with mucosal healing at endoscopy. Larger series are required to validate these results and the advantages of a CLE-based assessment of UC activity.

Pulmonary Complications after Surgery for Rectal Cancer in Elderly Patients: Evaluation of Laparoscopic versus Open Approach from a Multicenter Study on 477 Consecutive Cases

Aim To evaluate the impact of open or laparoscopic rectal surgery on pulmonary complications in elderly (>75 years old) patients. Methods Data from consecutive patients who underwent elective laparoscopic or open rectal surgery for cancer were collected prospectively from 3 institutions. Pulmonary complications were defined according to the ACS/NSQUIP definition. Results A total of 477 patients (laparoscopic group: 242, open group: 235) were included in the analysis. Postoperative pulmonary complications were significantly more common after open surgery (8 out of 242 patients (3.3%) versus 23 out of 235 patients (9.8%); p = 0.005). In addition, PPC occurrence was associated with the increasing of postoperative pain (5.04 ± 1.62 versus 5.03 ± 1.58; p = 0.001) and the increasing of operative time (270.06 ± 51.49 versus 237.37 ± 65.97; p = 0.001). Conclusion Our results are encouraging to consider laparoscopic surgery a safety and effective way to treat rectal cancer in elderly patients, highlighting that laparoscopic surgery reduces the occurrence of postoperative pulmonary complications.

Recurrent abdominal pain in 52‐year‐old male

Intussusception of the appendix is a rare condition. Symptoms vary widely, whereas some patients are asymptomatic. Diagnosis is generally challenging and few cases have been diagnosed by colonoscopy. It is important to recognize the endoscopic appearance of this entity in order to avoid the potential hazard of an inadvertent “polypectomy”.

Endoscopic retrograde cholangiopancreatography in the elderly: a review of most recent personal experience

It is well documented that the incidence of biliary tract pathologies increases with age, and as life expectancy is rising, it is expected that the prevalence of advanced age patients with bile duct pathologies will correspondingly increase leading to an increase in the demand for endoscopic retrograde cholangiopancreatography (ERCP) interventions. Our aims are to assess the outcomes, safety and complications associated with ERCP performed in an elderly population.

A retrospective analysis of elective lower gastrointestinal endoscopy in patients 80 years of age and older

Colonoscopy is the standard investigation for colonic disease. However, clinicians often are reluctant to refer elderly for the procedure because of a perception of a greater risk of complications and high failure rates. Our aims are to assess the success rate, safety and complications associated with colonoscopy performed in patients 80 years of age and older.