Use of catheter-based cholangioscopy in the diagnosis of indeterminate stenosis: a multicenter experience

BACKGROUND

Direct bile ducts visualization through cholangioscopy has gained popularity due to its better diagnostic accuracy than a standard ERCP in indeterminate biliary stricture.

METHODS

We aimed to review our catheter-based cholangioscopy interventions in patients with indeterminate biliary stenosis, using the SpyGlass Direct Visualization System (SDVS) and summarize our experience in terms of procedures and results. We collected 25 consecutive patients with indeterminate biliary stricture over 3 years.

RESULTS

The overall procedural success in our cohort amounted to 96% (24/25). If we focus on the diagnostic procedures, the ability to merely visualize the region of interest/lesion and perform biopsy of the lesion was possible in 96% (24/25) In our cohort localization in the common bile duct (P=0.03; 95% CI: 0.27-0.96) was found as positive determining factor for diagnosis. Sensitivity, specificity and accuracy for visual diagnosis by SDVS in our cohort were 100, 83.3 and 96%, respectively. The use of biopsy or obtaining a histological diagnosis to assist in identifying patients with malignant stenosis, to exclude malignancy and to correctly classify diagnosed patients resulted in a sensitivity of 100%, a specificity of 73% with an overall accuracy of 94.4%. Only a mild adverse event (cholangitis, treated conservatively) occurred.

CONCLUSIONS

Today, the SDVS should be considered essential in diagnosing indeterminate biliary strictures, since the procedure is associated with high procedural success in terms of diagnostic accuracy, alters clinical outcome in over 80% of considered insolvable cases, with an acceptable safety profile.

Efficacy of 1 L polyethylene glycol plus ascorbate versus 4 L polyethylene glycol in split-dose for colonoscopy cleansing in out and inpatient: A multicentre, randomized trial (OVER 2019)

BACKGROUND AND AIMS

Adequate bowel cleansing is essential for colonoscopy quality. A novel 1 L polyethylene glycol plus ascorbate (1 L PEG+ASC) solution has been recently introduced. Nevertheless, the efficacy of 1 L PEG+ASC as compared to that of high-volume bowel preparation in both inpatients and outpatients is still unclear.

PATIENTS AND METHODS

This single-blinded, non-inferiority study randomized patients undergoing colonoscopy to receive split-dose 1 L PEG+ASC or 4 L PEG. The primary endpoint was the overall cleansing success. Secondary endpoints were excellent cleansing and high-quality cleansing of the right colon, as well as lesions detection rate, patient compliance, tolerability and safety.

RESULTS

Overall, 478 patients were randomized to 1 L PEG+ASC (N = 236) or 4 L PEG (N = 242). The 1 L PEG+ASC showed higher cleansing success rate (91.8% vs 83.6%; P=0.01) and a high-quality cleansing of the right colon (52.3% and 38.5%; P=0.004) compared to 4 L PEG. Moreover, 1 L PEG+ASC achieved a higher cleansing success in out-patients (96.3%% vs 88.6%; P=0.018), and a similar success rate in the in-patients (84.7% vs 76.7%; P=0.18). Adenoma detection rate, tolerability and incidence of adverse events were comparable between preparations.

CONCLUSIONS

The 1 L PEG+ASC showed higher efficacy in achieving adequate colon cleansing compared with 4 L PEG, particularly in the right colon. No differences in the tolerability and safety were detected.

Digital single‑operator cholangioscopy in treating difficult biliary stones: results from a multicenter experience

BACKGROUND

In clinical practice, standard endoscopic treatment of biliary stones fails in up to 10% of patients, and more invasive procedures such as percutaneous trans-hepatic interventions or surgery might become necessary. The aim of this multi-center retrospective study, based on prospectively-collected data, was to evaluate both the efficacy and the safety of Digital-Single Operator Cholangioscopy (D-SOC) to treat difficult biliary stones, in cases with a previous failure of conventional endoscopic methods.

METHODS

Only patients with a previous failure of endoscopic standard treatment and a DSOC- based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone clearance rate per procedure and per patient. Out of 1258 ERCP performed at our (three?) centers, 31 cholangioscopies in 21 patients were solely performed for the treatment of difficult biliary stones using EHL or LL.

RESULTS

A complete biliary stone removal was achieved in 67.7% (21/31) of all procedures including initial and repeated examinations, while in 35.4% (11/31) of all procedures an incomplete removal was accomplished of which 36.3% had a partial stone removal. In 22 procedures EHL was adopted as techniques to fragment and remove biliary stones, while in 9 procedures LL was used. In both the techniques, the complete stone removal rate and the incomplete stone removal rate were similar (75% vs 77.7%, p>.05). Furthermore, the success rate of digital DSOC to treat difficult biliary stones was assessed per patient: overall, 100% of patients with difficult biliary stones were successfully treated using D-SOC. Only one patient experienced mild cholangitis classified ad mild adverse event following ASGE (American Society of Gastrointestinal Endoscopy) lexicon.

CONCLUSIONS

In conclusion, our data indicate that digital D-SOC assisted biliary stone treatment is highly efficient for the treatment of difficult biliary stones even in such patients in whom previous conventional endoscopic methods to treat biliary stones have failed. Therefore, D-SOC might be considered the new standard of care for these patients, being both, effective and safe.

Palliative treatment of upper gastrointestinal obstruction using self-expansible metal stents

Gastric outlet obstruction is either a late event in the natural history of bilio-pancreatic tumors or the result of recurrent gastric or pancreatic tumors. Self-expansible metal stents, inserted under endoscopic and fluoroscopic control, can be used for palliative treatment. The present study was aimed at evaluating both the feasibility and the results of stenting in patients with malignant gastric outlet obstruction; in addition, some technical suggestions are presented. A total of 33 patients, who had a metal stent positioned, were retrospectively evaluated; 20 of them were women and 13 were men, aged from 45 to 94 years, with a mean age of 75 years. Twenty-seven patients had a pancreatic adenocarcinoma, 4 had a stricture of a gastrojejunal anastomosis due to recurrent pancreatic tumor, 2 had a stricture of a gastrojejunal anastomosis secondary to gastric cancer surgery. No postoperatory complications were observed. Improvement in the quality of life was obtained in all patients. Following the stenting procedure, the median duration of hospitalization was 8 days (range: 6-20 days), and the mean survival rate was 12 weeks (range: 2-66 weeks). Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and is well tolerated by most patients. In some cases a period of enteral nutrition had to be necessarily carried out; nonetheless, the insertion of the stent improved the quality of life.

[Treatment of biliary lithiasis with the advent of new technologies in Italy in the Lazio and Abruzzo regions over the past 15 years. Comparison between the patient series in a Roman university hospital and in a number of hospitals in the Abruzzo region]

Biliary lithiasis is a disease with a high incidence in the western world and a high social cost. To evaluate the impact of new technologies--mainly laparoscopic cholecystectomy and radiological and endoscopic techniques--in the treatment of biliary lithiasis, a statistical study was conducted on the surgical interventions performed over the past 15 years in Italy in the Lazio and Abruzzo regions. From 1985 to 1999, 150,000 cases of hepatobiliary lithiasis were hospitalized every year in Italy with a mean hospital stay of 7.8 days (13,000 in Lazio and 6,000 in Abruzzo). 100,000 cholecystectomies were performed every year in Italy in public hospitals, 30% of which by conventional laparotomy and 70% laparoscopically. Ten percent of these operations on average were performed in the Lazio region and 3% in the Abruzzo region. 10,615 cases of main bile duct stones were treated in 1999, 6,502 of which by ERCP and the others with open procedures and radiologically. The mortality was 0-0.1% for laparoscopic cholecystectomy as against 0-0.5% in open procedures.

Palliative treatment for malignant jaundice: endoscopic vs surgical approach

In this retrospective, comparative study a total of 107 patients, presenting with malignant inoperable strictures of common bile duct, due to a pancreatico-biliary malignancy, underwent palliative treatments. In a group, consisting of 82 patients (76.64%), endoscopic stenting procedures were performed; polyethylene stents or self-expanding metal stents were applied in 37 and 45 patients, respectively. The prerequisites for a successful endoscopic stenting were a) accuracy of diagnosis and b) exclusion of patients presenting with tumors potentially treatable by a curative resection. In the other group, consisting of 25 patients (23.36%), biliary-enteric bypass procedures were performed. Endoscopic treatment was successful in 97.5% of the cases (80/82); complication rate was 7.3% (6 patients on 82), and mortality rate was 3.6% (3 patients on 82). Median hospital stay was 13.4 and 7.3 days in patients treated with plastic stents and metallic stents, respectively. Bypass surgery was successful in 99% of the cases (24/25); complication rate was 24% (6 patients on 25), and mortality rate was 16% (4 patients on 25). Median hospital stay was 26 days. For the patients in whom a curative resection could not be performed, both the above mentioned methods resulted in a high rate of immediate technical and therapeutic success. However, the surgical approach showed a significantly higher rate in procedure-related mortality and morbidity; in addition, the hospital stay lasted longer in surgically treated patients. The patients who are definitely unsuitable for curative resection are better managed by positioning a stent. The use of metal stents should be preferred in those less serious patients who may supposedly survive longer.

ERCP and acute pancreatitis

Acute biliary pancreatitis (ABP) is a serious complication of biliary stones disease and is associated with significant morbidity and mortality. The role of ERCP in the management of ABP has been the focus of discussion in recent years. In this report, we evaluated a protocol of emergency Endoscopic retrograde Cholangiopancreatography (ERCP) (within 24 hours) and early ERCP (within 72 hours). From July 1997 to July 2000, were observed 45 patients (19 man and 26 women) with acute biliary pancreatitis. Mean age of patients was 63.4 years (range 21-87 years). Diagnosis of ABP was based on anamnesis and clinical assessment and was confirmed by specific laboratory data (hyperamylasemia, hyperlipasemia, total and fractionated bilirubinemia, gamma-GT, transaminase, alkaline phosphatase, hypocalcemia, hyperglycemia, leukocytosis). Ultrasound scanning within 24 h of admission was performed in 45 patients (100%) and it revealed gallbladder stones and muddy bile in 39 patients (87%). Computed tomography (CT) performed in all patients, showed a severe acute pancreatitis in the second or subsequent week following admission. The severity of acute pancreatitis was established by Glasgow's criteria and by clinical details of patients. ERCP and Endoscopic Sphinterotomy (ES) was performed in all 45 patients with acute biliary pancreatitis. Twenty-six patients (57%) were classified as having a severe attack (> 4) 19 as having a mild attack by Glasgow's criteria. ERCP associated with ES was performed within 24 hours in 22 patients (49%), 11 (50%) showed a severe attack and 11 (50%) showed a mild attack. A total of 2 complications (4%) occurred and the mortality was of 2 patients (4%). In 23 patients (51%) ERCP and ES was performed within 72 hours after conservative therapy, 8 (35%) showed a mild attack and 15 (65%) showed a severe attack. A total of 5 complications (9%) occurred and the mortality was of 3 patients (6%). Our study showed that ERCP with endoscopic sphincterotomy can be performed safely by skilled endoscopist, without adverse consequences soon after the onset of acute biliary pancreatitis even within the first 24 hours and it showed that is better than ERCP within 72 hours after conservative therapy.

Thienopyrimidine derivatives prevent cartilage destruction in articular disease

The effects of a series of thienopyrimidine derivatives on the prevention of cartilage destruction in articular disease were investigated. Anti-degenerative activity was assayed on culture of nasal pig cartilage in the presence or in the absence of interleukin 1beta (IL-1beta). The amount of glycosaminoglycans (GAGs) and the production of nitric oxide (NO) in the culture medium were determined. Some thienopyrimidine derivatives, in the presence of IL-beta, blocked the cartilage breakdown by inhibiting both the NO production and GAGs release in a dose-dependent manner.

Synthesis and pharmacological screening of 1,3,4-thiadiazino[2,3-b]quinazoline derivatives

Derivatives of 1,3,4-thiadiazino[2,3-b]quinazoline 7, 9, 9a, 12, 12a, and 13 were prepared from the 3-amino-6-bromo-2,3-dihydro-2-thioxo-4-(1H)-quinazolinone (2) and its analogue without bromine. A series of the title derivatives with or without bromine was tested and the results of pharmacological screening are discussed.

[Guidelines for routine assessment of cardiologic surgical risk: electrocardiogram]

Cardiac complications are the main cause of perioperative mortality. A preoperative electrocardiogram and cardiologist's consultation are usually performed to get information about cardiac state of patients undergoing surgery and to prevent complications. In their study the Authors applied to 1715 patients undergoing surgery an evaluation schedule for the cardiac surgical risk, including an ECG as first-level test, performed systematically on the whole sample. The aim was to assess predictive value of this preoperative examination to verify its efficacy as routine test. Basing on results achieved, electrocardiogram is not routinely indicated before noncardiac elective surgery, but it should be requested for the patients having high risk of cardiac complications at an accurate clinical-anamnestic examination. Therefore, clinical judgement, that is the first level of any preoperative evaluation, should be the basis for ordering an ECG to be considered a second-level test.

Synthesis of new [1,3,4]thiadiazolo[3,2-a]thieno[2,3-d]pyrimidinone derivatives with antiinflammatory activity

New thiadiazolothienopyrimidinones were synthesized in continuation of efforts to prepare thienopyrimidine derivatives with analgesic and antiinflammatory activities. In this study, the effect of various substituents in the thiophene ring on the pharmacological activity of the compounds was investigated.

High potent and selective arylpiperazine derivatives as ligands for the 5-HT1A receptor

This paper reports the synthesis and affinities on the 5-HT1A versus the alpha1A receptors of new arylpiperazinylalkylthiothienopyrimidine and thiadiazole derivatives 16-24. Arylpiperazines 16-23 show affinities values in the nanomolar range for the 5-HT1A receptor. The compound 16 is highly potent (Ki 0.26 nM, selectivity 28), the derivatives 20 and 21 are less potent, but highly selective (Ki 9.40 and 5.06 nM, selectivity 207 and 73, respectively).

Synthesis of aminothienopyrimidine and thienotriazolopyrimidine derivatives as potential anticonvulsant agents

New aminothienopyrimidines and derivatives of the new thienotriazolopyrimidine ring system were synthesized to investigate their anticonvulsant activity. The tricyclic compounds 6a, c, e, f, m, o and p and two bicyclic derivatives 4f and 4o were tested. The pharmacological screening results are reported and discussed.

Synthesis and pharmacological properties of thieno[2',3':4,5]pyrimido [2,1-b][1,3,4]thiadiazine derivatives

A new series of 2-substituted-7,8-dimethyl-3H,9H-thieno[2',3':4,5]pyrimido[2,1- b][1,3,4]thiadiazin-9-ones 5a-d and 6a,b was synthesized through the hydrazinium(1+) salt of 3-amino-2,3-dihydro-5,6-dimethyl-2-thioxo- thieno[2,3-d]pyrimidin-4(1H)-one, 2. These derivatives and two analogs 10a,b were tested for their analgesic and antiinflammatory properties. The pharmacological results are discussed in comparison with those of related compounds previously tested.

Synthesis and pharmacological properties of benzothiazole, 1,3-4-oxadiazole and 1,3,4-thiadiazole derivatives

The reaction of the 2-amino-substituted 1,3,4-oxadiazoles 9, 10 and the benzothiazoles 11, 12 with ethyl cyanoacetate is described. The obtained cyanoacetamide derivatives 13-16 gave the benzylidene derivatives 18-21 by condensation with benzaldehyde. 2-Phenyl-5-amino-1,3,4-oxadiazolo[3,2-a]pyrimidin-7-one (17) was also obtained. Moreover, the preparation of 6,7,8,9-tetraydro-5H-1,3,4-thiadiazolo[2,3-b]quinazolin++ +-5-thio-derivatives 22-25 and N-(1,3,4-thiadiazol-2-yl-5-substituted)-3,4-5,6-tetrahydro-anthran ilic acids 26-29 is also described. All above compounds and compounds, related to them, 1-8 were tested for their analgesic and antiinflammatory activities and the pharmacological screening results are reported and discussed.

New heterocyclic ring systems--V synthesis and pharmacological activity of 6H-1,3,4-thiadiazolo [3',2':1,2]-5-oxopyrimido [5,4-b] indole derivatives and of 1-phenyl-6H-1,2,4-triazolo [1',5':1,2]-5-oxopyrimido[5,4-b] indole

As a part of a study on analgesic and antiinflammatory active condensed heterocyclic compounds containing the pyrimidinic ring, a number of 6H-1,3,4-thiadiazolo [3',2':1,2]-5-oxopyrimido [5,4-b]indole and 1-phenyl-6H-1,2,4-triazolo [1',5':1,2]-5-oxopyrimido [5,4-b] indole were synthesized and tested. The results of pharmacological assays are reported and discussed.

Synthesis and pharmacological properties of benzothienothiadiazolopyrimidine derivatives. III

2-Substituted derivatives of 5H-benzothieno [3,2-d] [1,3,4]-thiadiazolo [3,2-a]pyrimidin-5-one and of 10H-benzothieno [2,3-d] [1,3,4]-thiadiazolo [3,2-a]pyrimidin-10-one have been synthesized. The analgesic, antiinflammatory and ulcerogenic activities of these derivatives were evaluated. Some derivatives showed an analgesic activity similar to or a little lower than that of indomethacin, and much higher than that of mefenamic acid, acetylsalicyclic acid and phenylbutazone, with a lower acute toxicity and a better gastric tolerance.

[A new nitrogen-containing polycyclic system. Synthesis and pharmacologic properties of benzofuran and thienothiadiazolepyrimidine derivatives. I]

A series of 5H-benzofuro[3,2-d]1,3,4-thiadiazolo[3,2-a]-pyrimidin-5-ones and 1,3,4-thiadiazolo[3,2-a]thieno[2,3-d]pyrimidin-5-ones were synthesized and their analgesic, antiinflammatory, antiexudative and ulcerogenic activities were evaluated. The analgesic and antiexudative activities of several derivatives proved to be less than that of indomethacin and much higher than that of mefenamic and acetylsalicylic acids. Acute toxicity and ulcerogenic effects were significantly lower than those of reference drugs.

[Synthesis and antimycotic activity of derivatives of 1, 3, 4-thiadiazole (3,2a) pyrimidone]

As a continuation of previous research designed to obtain derivatives of 1,3,4-thiadiazole of pharmacological interest, some derivatives of 1,3,4-thiadiazole[3,2-alpha]pyrimidin-5-one and isomeric 7-one were prepared. The fungistatic activity of the products was tested in vitro against the following: Candida albicans, Candida parapsilosis, Candida tropicalis, Cryptococcus neoformans e Trichophyton rubrum. No relevant antifungal activity was observed for any of the compounds examined.

[Synthesis of 2,6-substituted derivatives of 5H-1.3.4-thiadiazolo[3,2a]-s-triazine-5,7-dione]

The synthesis of derivatives of 5H-1,3,4-thiadiazolo[3,2-a]-s-triazine-5,7-dione substituted in position 2 and 6 is described. The compounds were subjected to pharmacological screening, and some were found to possess antiinflammatory and antipyretic properties.