Simona Ruggiero

Staple-line leak after sleve gastrectomy in obese patients: A hot topic in bariatric surgery

Laparoscopic sleeve gastrectomy is a surgical procedure that is being increasingly performed on obese patients. Among its complications, leaks are the most serious and life threatening. The placement of esophageal, covered, self-expandable metal stents in these cases has been performed by many authors but reports on the outcome of this procedure are limited and the technical aspects are not well defined. Stent migration is the main complication of the procedure and poses a challenge to the surgeon, with a limited number of options. Here we evaluate the technical and clinical outcome of a new, dedicated, self-expanding metal stent, comparing the advantages of this stent to those traditionally used to treat staple-line leak after sleeve gastrectomy. While published data are limited, they seem support the use of this kind of new stent as the best option for the stenting treatment of a staple-line leak after sleeve gastrectomy, over other kinds of stents. Further studies based on larger series are needed to better evaluate patient outcome.

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.

Recent advances to improve the endoscopic detection and differentiation of early colorectal neoplasia

One of the primary aims of colonoscopy is to detect andresect pre-cancerous lesions, thereby preventing cancerdevelopment and early colorectal cancers, avoiding thegrowth of advanced and deep-infiltrating malignanttumours. Failure to find and remove polyps and early can-cers results in a delayed cancer diagnosis and treatment,with the potential for poor patient outcomes and the riskof litigation [1]. In recent years, industry has made manyefforts to improve the technology to enhance the perfor-mance of endoscopic examination: many of these innova-tions are included under the term ‘augmentedendoscopy’. Augmented endoscopy includes topical dyes[2,3], optical filtering [4,5], zoom-magnification [6,7]and allows for various analyses of gastro-intestinal lesions,such as minute structure of crypts on the mucosal surfaceand superficial micro-vessels. This kind of enhancedendoscopy provides new tools for identifying the abnor-malities in the size, density, and shape of crypts andvessels in either the normal colon or a tumour lesion.Today, colonoscopy is a universally accepted methodfor colorectal cancer screening and diagnosis [8]. En-doscopists may, however, miss up to 6% of advancedadenomas (≥10 mm in size) or cancer and as many as26–30% of all adenomas when using standard white-light colonoscopy [9], probably because of the locationof the lesion, the skill of the endoscopist [10] and theimage contrast of the endoscopic picture. Augmentedendoscopy, enhancing the endoscopic appearances ofcolon lesions, has the potential to improve detectionand differentiation of colon neoplasms from otherlesions [11]. Clinical trials testing the usefulness ofaugmented endoscopy for the diagnosis of colonneoplasia show conflicting results [12]. This may berelated to the limitations of each technology and varia-tion in the diagnostic skill of the participants. There-fore, as reported by Fujiya and Kohgo, ‘...two factorsrelated to the usefulness of these novel technologiesneed to be evaluated: at which step(s) is that technologyapplicable for the diagnosis of colon neoplasms (detec-tion, differentiation, or staging) and by what level(s) ofendoscopists (experts or less experienced endoscopists)can the technology be used ...’ [13].Technology alone, however, is not enough to ensureoptimal results and to achieve the best outcome. Allvariables affecting rates of detection by the endoscopistand the endoscopic method used are important. Theseinclude the operator’s experience, bowel preparation,examination technique and the use of instruments ordevices able to increase visual identification.

Auto-Modification of Poly (ADP-Ribose) Polymerase and Membrane LipidComposition as Diagnostic Tools to Measure the Physio-Pathological Stateof the Cell

Poly(ADPribosyl)ation, catalysed by poly(ADP-ribose)polymerases, affects many cellular events and has a recognized epigenetic role. Nuclear poly(ADP-ribose)polymerases 1 and 2 are hyper activated by DNA strandbreaks. They auto-modify with large polymers of ADP-ribose and recruit DNA repair proteins. The more the DNA strand-breaks, the more poly(ADP-ribose) polymerase modifies itself. On the other hand, dietary lipids can be signaling molecules, lead to pro-(ω6)/ anti-(ω3) inflammatory compounds, and be included in biomembranes, good biomarkers of their unbalance. Here, we report the results obtained from an epidemiological study to establish whether the combination of two different analyses, i.e. detecting auto-modified poly (ADP-ribose) polymerase levels and analyzing erythrocyte membrane fatty acid composition, might help to monitor the physio-pathological state of the cell, and to correlate with lifestyle, diet or diseases. The two analyses were carried blindly on 70 subjects undergoing endoscopy. They were first interviewed, to collect anamnesis and clinical data, if present. Lymphocytes and erythrocytes were prepared from venous blood to assay poly (ADP-ribose) polymerase auto modification and membrane fatty acid content, respectively. The results were statistically evaluated. The measure of poly (ADP-ribose) polymerase automodification confirmed that its levels correlate with DNA damage extent, within the same pathology, and allowed to monitor the clinical activity of the disease, depending on ongoing therapeutic/surgical treatment. Membrane fat profile was able to evidence unbalance of lipids linked to both diet/lifestyle and inflammatory states leading to diseases. Both analyses provide possible biomarkers for sensible, non-invasive and routine monitoring.

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.

Endoscopic Surveillance After Polypectomy

Colorectal cancer (CRC) represents the second cause of cancer mortality in Western countries after lung tumors. Its incidence is increasing in Eastern countries too, because of westernization of eating habits and aging of the population. However, since the mid-80s we are seeing a CRC incidence decline in Western countries mainly due to the screening programs. Adenomatous polyps are the most commonly found neoplastic lesions during screening colonoscopy. Patients with adenomas have an increased risk for developing metachronous adenomas or cancers compared with patients without adenomas. Modern guidelines are based on the findings of a randomized trial conducted in 1993 comparing 1-year versus 3-year surveillance intervals after polypectomy (the American National Polyp Study). Likewise, several European countries developed their own guidelines thus pushing the launch of well-organized population-based screening programs. Current American, European, and Korean guidelines for endoscopic surveillance after colorectal polypectomy were published in 2012. Japanese endoscopy society, conversely, has not yet developed specific guidelines and refers to a position statement about management of colorectal polyps, published in 2015.

Endoscopic diagnosis and treatment of neuroendocrine tumors of the digestive system

Abstract The authors evaluated the role of endoscopic techniques in the diagnosis and in the potential treatment of neuroendocrine tumors (NET) localized in the gastro-entero-pancreatic system, on the basis of their experience and of the international literature. NET are rare tumors that arise from neuroendocrine cells of the gastrointestinal tract and pancreas. It is a possibility that both the digestive endoscopy and EUS play an important role in the diagnosis, staging and surveillance of this disease. In some cases, especially in the early stages, surgical endoscopy allows the treatment of such tumors.

Relationship between gastroesophageal reflux disease and Ph nose and salivary: proposal of a simple method outpatient in patients adults

Abstract Introduction The frequency of gastroesophageal reflux disease (GERD) is increasing, in part through easy inspection of the upper digestive tract, but especially for a real spread of the disease as a consequence of modernity, lifestyle, incorrect dietary rules, and stress arising from social norms. It is a common chronic gastrointestinal disorder in Europe and the United States. Materials and methods The aim of our study is to highlight a relationship between gastroesophageal reflux disease and salivary pH as evidenced by indicator strips, especially in the outpatient field. Twenty adult subjects (10 males and 10 females) aged between 18 and 50 years (GROUP A)_ were selected. How to control a homogeneous group of 20 patients without GERD, or from any type of allergies (GROUP B) was enlisted. Results This method has provided excellent results showing no difference in the measured values compared with the traditional instrumental measurement. Conclusion Our study has allowed us to observe a strong correlation between the saliva pH, nasal cavities and the interaction between the two districts, and could be the basis for a diagnosis of GERD especially in primary health care clinics and in the initial stage of the disease.

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).