Rosa Filiberti

A meta-analysis of endoscopic stenting as bridge to surgery versus emergency surgery for left-sided colorectal cancer obstruction

The best approach to resolve colonic obstruction in patients with left-sided colon cancer is not established. In this meta-analysis the efficacy of stenting as bridge-to-surgery was compared to emergency surgery for the management of left-sided colonic obstruction. Fourteen studies (randomized and non controlled studies) were identified, including 405 patients in the stent group and 471 in the emergency group. The difference between proportions was evaluated as effect size (ESi). There was large heterogeneity among the studies. Stenting offered advantages over emergency surgery in terms of increase in primary anastomosis (ES=25.1%, p<0.001), successful primary anastomosis (ES=23.7%, p<0.001), reduction of stoma creation (ES=-27.1%, p=0.03), infections (ES=-7.9%, p=0.006) and other morbidities (ES=-13.4%, p<0.001). The interventions were similar in regards to length of hospitalization, preoperative mortality and long-term survival.

Cap-assisted endoscopic mucosal resection for colorectal polyps.

PURPOSE: Cap-assisted endoscopic mucosal resection has been used to treat superficial esophageal and gastric cancers. Efficacy data in the colon are limited. The aim of the study was to evaluate the safety and efficacy of this technique in the treatment of sessile polyps and lateral spreading tumors in the colorectum. METHODS: Two-hundred and fifty-five consecutive patients with sessile polyps or lateral spreading tumors ≥20 mm were treated between January 2000 and December 2007. RESULTS: A total of 146 sessile polyps and 136 lateral spreading tumors were treated with cap-assisted endoscopic mucosal resection. Complications occurred in 22 (8.6%) patients (5.5% in sessile polyps and 10.3% in lateral spreading tumors). Intraprocedural bleeding occurred in 21 (7%) of polypectomies (6% in sessile polyps and 10% in lateral spreading tumors); all were controlled endoscopically. Postcoagulation syndrome occurred in 1 patient with lateral spreading tumor. No perforation occurred. Invasive adenocarcinoma was found in 35 patients, of whom 15 underwent surgery. Endoscopic follow-up in 200 patients with 216 adenomas for a median of 12.1 months showed recurrence in 8 (4%) who were treated with resection and/or ablation. CONCLUSIONS: Cap-assisted endoscopic mucosal resection is an effective treatment for sessile polyps and lateral spreading tumors. A disadvantage of the technique is that the resection is piecemeal. Close surveillance provides the opportunity for additional tissue ablation, when required, to achieve complete lesion removal.

Cap-assisted EMR of large, sporadic, nonampullary duodenal polyps

BACKGROUND EMR is an effective alternative to surgery for the removal of nonampullary duodenal polyps (NADPs). Cap-assisted EMR (EMR-C) has been rarely performed in the duodenum because of the risk of perforation. OBJECTIVE To evaluate the safety and effectiveness of EMR-C for the removal of large (≥ 15 mm) NADPs. DESIGN Retrospective study. SETTING Tertiary-care referral center. PATIENTS Between 2000 and 2010, 26 consecutive patients with sporadic NADPs underwent EMR-C. INTERVENTION EMR with the cap technique. MAIN OUTCOME MEASUREMENTS Complete eradication of polyps, complications, and recurrence. RESULTS A total of 14 sessile polyps (53.8%), 7 lateral spreading type nongranular tumors (26.9%), and 5 lateral spreading type granular tumors (19.2%) were treated. The median size of lesions was 15 mm. Five lesions involved one-half of the luminal circumference. Post-EMR histologic assessment showed low-grade dysplasia in 5 patients (19.2%) and high-grade dysplasia in 18 patients (69.2%). Three patients (11.5%) had well-differentiated endocrine tumors. Complete eradication was obtained in 25 of 26 (96%) patients. No perforations occurred. Three cases of intraprocedural bleeding were managed endoscopically. Median follow-up was 6 years (range 1-10 years). Residual adenomatous tissue was observed in 3 patients in lesions of 50 mm. In one of these cases, an adenocarcinoma occurred after 8 months, which was managed surgically. LIMITATIONS Retrospective design, single center. CONCLUSION This study supports the efficacy and safety of EMR-C for removing NADPs. Regular follow-up is mandatory because of the high risk of residual or recurrent adenomatous tissue and even cancer.

One-step circumferential endoscopic mucosal cap resection of Barrett's esophagus with early neoplasia.

BACKGROUND AND OBJECTIVE Focal endoscopic mucosal resection (EMR) of visible intraepithelial lesions arising within Barretts esophagus (BE) may miss synchronous lesions that are not endoscopically apparent. Stepwise radical endoscopic resection would obviate this concern by removing all BE; however, it requires repeated endoscopy which may increase the risk of complications, particularly for patients with circumferential BE. The aim of the study was to evaluate the safety and efficacy of one-step complete circumferential resection of BE by cap-assisted EMR (EMR-C) among patients with circumferential BE and high-grade dysplasia or intramucosal carcinoma. PATIENTS AND METHODS Between January 2003 and March 2010, 47 patients with circumferential BE and biopsy-proven high-grade dysplasia or intramucosal cancer underwent EMR-C. We evaluated: (1) complete eradication of neoplasia, (2) complete eradication of metaplasia, and (3) complications including bleeding and esophageal stricture. RESULTS Complete eradication of neoplasia and complete eradication of metaplasia were achieved after a median follow-up of 18.4 months in 91% (43/47) of patients. After EMR-C, two patients (one IMC, one invasive cancer) underwent esophagectomy. Histology of the resected specimens showed no residual disease and a T1bN0 lesion, respectively. Two patients had progression of neoplasia. A stenosis occurred in 18 out of 45 patients (40%). All stenoses were treated with dilations and two required temporary placement of a covered stent. CONCLUSION One-step complete EMR-C is a safe and effective technique which can be considered in patients with early neoplastic lesions. Although 40% of patients developed dysphagia, this could well be managed endoscopically.

Cap-assisted endoscopic mucosal resection of large polyps involving the ileocecal valve

Standard endoscopic mucosal resection (EMR) is limited with regard to lesions below or involving the ileocecal valve. We describe the treatment and outcomes when using cap-assisted EMR (EMR-C) to remove large laterally spreading tumors (LSTs) with ileal infiltration in seven patients (median age 74 years). Each LST (median size 40 mm) was successfully resected in one session (median procedure time 50 minutes). Intraprocedural and early bleeding occurred in two patients, and delayed hemorrhage in one. Circumferential resection of the ileum caused asymptomatic strictures in six patients, with regression during follow-up for five. We conclude that the novel EMR-C method is a potentially effective treatment for cecal LST involving the distal ileum. Serious complications such as perforation or symptomatic strictures of the ileocecal valve were not observed and any procedure-related bleeding was easily controlled.

History of cancer in first degree relatives of Barrett's esophagus patients: a case-control study.

BACKGROUND AND OBJECTIVE Familial clusters of Barretts esophagus (BE) and esophageal adenocarcinoma (EAC) have been reported. This study evaluates the history of cancer in BE patients families. METHODS In two years, patients with BE (272), esophagitis (456) and controls (517) were recruited in 12 Italian Endoscopy Units. Cancer family history in first-degree (FD) relatives was determined by a questionnaire. RESULTS Approximately 53% of BE, 51% of esophagitis, and 48% of controls had at least one relative affected by any type of malignancy. Probands with at least one esophageal or gastric (E/G) cancer-affected relative showed a BE risk which was at least eighty-five percent higher than that of probands without affected relatives. The relative risk of BE was 4.18, 95% CL=0.76-23.04 if a FD relative had early (mean age ≤ 50 years) onset E/G cancer compared to late onset E/G cancer. CONCLUSION In this sample there was no evidence that a family history of cancer was associated with the diagnosis of BE. An intriguing result was the association between the occurrence of E/G cancers at earlier ages (< 50 years) among BE relatives with respect the control group. This could suggest a genetic contribution in onset of these tumors, but the sample was too small to demonstrate a significant association. Further exploration of family history of E/G cancer and a diagnosis of BE in larger samples is warranted.

3465 The durability of different solutions injected submucosally in a porcine model.

During endoscopic mucosal resection and polypectomy of sessile lesions an injected submucosal fluid cushion isolates the tissue prior to resection and reduces thermal injury, perforation, and hemorrhage. Aim: To investigate the efficacy of five different solutions in creating a durable submucosal esophageal fluid cushion in a pig model. Methods: Five groups of 5 pigs were studied. In each pig, six submucosal injections of 5 cc of a test solution were performed within the lower third of the esophagus. The time required for the elevated mucosa to flatten completely was recorded after each injection. The solutions used were: normal saline (NS), NS+epinephrine (NSE), dextrose 50% (D50), 10% glycerine/5% fructose in NS (G), and 1% rooster comb hyaluronic acid (HA). Statistical analysis was performed using analysis of variance (ANOVA). NS was used as the standard solution for comparative analysis. Results: The mean and median times (minutes) for each solution to dissipate are provided in the table below. Conclusions: 1. This study provides important and practical information on the durability of available solutions used to create a submucosal fluid cushion during endoscopic mucosal resection and polyectomy of sessile lesions. 2. Hyaluronic acid appears to be the ideal solution for a lasting submucosal cushion during prolonged procedures. 3. Dextrose 50% is superior to normal saline and serves as a practical alternative in terms of availabilty and cost.

Alcohol consumption pattern and risk of Barrett's oesophagus and erosive oesophagitis: an Italian case-control study

Knowledge about the association between alcohol and Barretts oesophagus and reflux oesophagitis is conflicting. In this case-control study we evaluated the role of specific alcoholic beverages (red and white wine, beer and liquors) in 339 Barretts oesophagus and 462 oesophagitis patients compared with 619 endoscopic controls with other disorders, recruited in twelve Italian endoscopic units. Data on alcohol and other individual characteristics were obtained from structured questionnaires. No clear, monotonic significant dose-response relationship was pointed out for red wine. However, a generalised U-shaped trend of Barretts oesophagus/oesophagitis risk due to red wine consumption particularly among current drinkers was found. Similar results were also found for white wine. Liquor/spirit consumption seemed to bring about a 1·14-2·30 risk excess, although statistically non-significant, for current Barretts oesophagus/oesophagitis drinkers. Statistically significant decreasing dose-response relationships were found in Barretts oesophagus for frequency and duration of beer consumption. Similar, but less clear downward tendencies were also found for oesophagitis patients. In conclusion, although often not statistically significant, our data suggested a reduced risk of Barretts oesophagus and oesophagitis with a low/moderate intake of wine and beer consumption. A non-significant increased risk of Barretts oesophagus/oesophagitis was observed with a higher intake of any type of heavy alcohol consumption, but no conclusion can be drawn owing to the high number of non-spirit drinkers and to the small number of drinkers at higher alcohol intake levels.