Endoscopic minor papilla sphincterotomy in patients with complete pancreas divisum and acute recurrent pancreatitis: a metanalysis

BACKGROUND AND AIMS

Pancreas divisum (PD) is a congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic minor papilla sphincterotomy (MiES) is the most common procedure performed in the management of PD-related ARP. The aim of this study is to perform a meta-analysis estimating the efficacy and the safety of MiES in the management of patients with PD-related ARP.

METHODS

A research was performed in Pubmed, EMBASE and Web of science, the studies were reviewed and selected according to inclusion and exclusion criteria. Evaluation of Heterogeneity and publication bias was performed, and a random effect model was used to estimate the effect size of each study.

RESULTS

One hundred and thirteen articles were selected and reviewed, 13 met the inclusion criteria. All the studies were retrospective with a mean follow-up duration of 45.9 months. A total of 323 patients with PD-related ARP treated with MiES were included in the meta-analysis. The overall clinical success rate of MiES (defined as no further episodes of ARP, reduction of episodes of ARP, or improvement in quality of life) was of 77% (95%CI: 72%-81%; p = 0.30). Evaluating only the studies with clinical success rate defined as "no further AP in the follow-up" the clinical success rate was of 69.8% (95%CI: 61.3%-77.2%; p = 0.57), while evaluating the studies with other definitions (reduction of episodes of ARP or improvement in quality of life) the clinical success rate was of 81.2% (95%CI: 75.2%-86.1%; p = 0.45). The common fixed effects model disclosed a 25.5% overall adverse events rate (95%CI: 19.3%-32.8%; p = 0.42): acute pancreatitis in 14.3% (95%CI: 9.7%-20.6%; p = 0.36), bleeding in 5.6% (95%CI: 2.9%-10.4%; p = 0.98), and other adverse events in 5.6% (95%CI: 2.9%-10.4%; p = 0.67).

CONCLUSION

MiES is an effective and relatively safe treatment in the management of PD-related ARP. The retrospective nature of the studies selected is the main limitations of this metanalysis. Prospective trials are needed to confirm these data.

Endoscopic pancreatic sphincterotomy in patients with IPMN-related recurrent pancreatitis: A single center experience

BACKGROUND

Acute recurrent pancreatitis (ARP) is a rare manifestation of Intraductal Papillary Mucinous Neoplasms (IPMN) of the pancreas; ARP is a relative indication for pancreatic surgery in the setting of IPMN. Endoscopic pancreatic sphincterotomy (EPS) has been described as a minimal invasive treatment to reduce the episodes of ARP secondary to mucus migration in IPMN.

METHODS

patients with IPMN-related ARP treated with ESP from January 2004 to December 2020 were retrospectively selected. Clinical and technical data were recorded. A clinical follow-up (minimum 12 months) was performed to assess the number of episodes of AP occurring after EPS.

RESULTS

25 patients were included. The mean follow-up after ESP was 93.4 months (SD± 56.6). The mean number of AP before and after EPS were respectively 3.29 (SD ± 1.04) and 0.51 (SD ± 0.71). A complete response (no further episodes of AP) and a partial response (>50% reduction of AP episodes) were obtained in 64% and 24% of the cases, respectively, with an overall response rate of 88%. One post-EPS bleeding and one minor-papilla stenosis were reported and were endoscopically managed. Two patients underwent pancreatic resection for the occurrence of high-risk stigmata for cancer progression.

CONCLUSIONS

EPS is a safe and effective treatment to reduce the number of episodes of AP in selected patients with IPMNs-related ARP. Prospective trials are needed to confirm these data.

Nanocomposite hyaluronic acid-based hydrogel for the treatment of esophageal fistulas

Fistulas are abnormal connections between two body parts that can impair the quality of life. The use of biological glues represents the least invasive procedure to fill the fistula; however, it is limited by the need of multiple injections, the persistence of infection and the failure in the treatment of high-output fistulas. We describe herein the use of an injectable nanocomposite hydrogel that is able to form in situ a tissue-mimicking matrix as an innovative material for the treatment of esophageal fistulas. Injectable hydrogels that have the dual advantage of being implantable with a minimally invasive approach and of adapting their shape to the target cavity, while the introduction of mesoporous silica nanoparticles opens the possibility of drug/biomolecules delivery.

The hydrogel is based on hyaluronic acid (HA), the crosslinking process occurs at physiological conditions leading to a hydrogel made of >96% by water and with a large-pore micro-architecture. The kinetic profile of the hydrogel formation is studied as a function of HA molecular weight and concentration with the aim of designing a material that is easily injectable with an endoscopic needle, is formed in a time compatible with the surgical procedure and has final mechanical properties suitable for cell proliferation. The in vivo experiments (porcine model) on esophageal-cutaneous fistulas, showed improved healing in the animals treated with the hydrogel compared with the control group.

The impact of the multidisciplinary tumor board (MDTB) on the management of pancreatic diseases in a tertiary referral center

BACKGROUND

The implementation of multidisciplinary tumor board (MDTB) meetings significantly ameliorated the management of oncological diseases. However, few evidences are currently present on their impact on pancreatic cancer (PC) management. The aim of this study was to evaluate the impact of the MDTB on PC diagnosis, resectability and tumor response to oncological treatment compared with indications before discussion.

PATIENTS AND METHODS

All patients with a suspected or proven diagnosis of PC presented at the MDTB from 2017 to 2019 were included in the study. Changes of diagnosis, resectability and tumor response to oncological/radiation treatment between pre- and post-MDTB discussion were analyzed.

RESULTS

A total of 438 cases were included in the study: 249 (56.8%) were presented as new diagnoses, 148 (33.8%) for resectability assessment and 41 (9.4%) for tumor response evaluation to oncological treatment. MDTB discussion led to a change in diagnosis in 54/249 cases (21.7%), with a consequent treatment strategy variation in 36 cases (14.5%). Change in resectability was documented in 44/148 cases (29.7%), with the highest discrepancy for borderline lesions. The treatment strategy was thus modified in 27 patients (18.2%). The MDTB brought a modification in the tumor response assessment in 6/41 cases (14.6%), with a consequent protocol modification in four (9.8%) cases.

CONCLUSIONS

MDTB discussion significantly impacts on PC management, especially in high-volume centers, with consistent variations in terms of diagnosis, resectability and tumor response assessment compared with indications before discussion.

Laser ablation in biliary tree: analysis of the intraductal and superficial thermal effects during the treatment

The treatment of choice for the unresectable cholangiocarcinoma is based on biliary decompression procedures. Despite stent placement is the standard of care, it is related to well-known complications. Hence, alternative techniques were proposed. Ideally, they should guarantee an adequate intraductal disobstruction, without injuring the surrounding tissues.This pre-clinical study aims to investigate the thermal effects of the laser ablation (LA) in the biliary tree, in terms of intraductal and surrounding tissue temperature achieved with different laser settings. The common bile ducts (in their upper and lower portions) of two pigs were ablated for 6 minutes with a diode laser at 3 W and 5 W. A custom-made laser applicator was used to obtain a circumferential ablation within the ducts. The intraductal temperature (T_id) was monitored by means of a fiber Bragg grating (FBG) sensor, while an infrared thermal camera monitored the T distribution in the surrounding tissues (T_sup). A maximum T difference of 65 °C and 57 °C was evidenced between the two power settings for the T_id measured in the upper and lower ducts, respectively. The mean difference between T_id and the averaged T_sup values was evaluated. At 5 W, a difference of 37±3 °C and 44±10 °C were obtained for the upper and lower ducts, respectively. At 3 W, a T difference of 2±1 °C was obtained for the upper biliary duct, while a difference of 8±1 °C was documented for the lower duct. Based on the results obtained in this preliminary study, the possibility to equip the laser probe with temperature sensor can improve the control and the safety of the procedure; this solution will guarantee the monitoring of the treatment while preserving the lumen and the surrounding structures.

Back to the origins: Human brain organoids to investigate neurodegeneration

Neurodegenerative disorders represent a high burden in terms of individual, social and economical resources. No ultimate therapy has been established so far; human brain morphology and development can not be entirely reproduced by animal models, and genomic, metabolic and biochemical differences might contribute to a limited predictive power for human translation. Thus, the development of human brain organoid models holds a wide potential to investigate the range of physiological and pathological features that characterise the early onset of the degeneration. Moreover, central nervous system development has gained a crucial role in the study of the pathogenesis of neurodegenerative disorders. Premature alterations during brain maturation have been related to late disease manifestations; genetic mutations responsible for neurodegeneration have been found in genes highly expressed during neural development. Elucidating the mechanisms triggering neuronal susceptibility to degeneration is crucial for pathogenetic studies and therapeutic discoveries. In the present work, we provide an overview on the current applications of human brain organoids towards studies of neurodegenerative diseases, with a survey on the recent discoveries and a closing discussion on the present challenges and future perspectives.

Colo-rectal endoscopic full-thickness resection (EFTR) with the over-the-scope device (FTRD®): A multicenter Italian experience

BACKGROUND AND AIM

Endoscopic full-thickness resection(EFTR) with FTRD^® in colo-rectum may be useful for several indications.The aim was to assess its efficacy and safety.

MATERIAL AND METHODS

In this retrospective multicenter study 114 patients were screened; 110 (61M/49F, mean age 68 ± 11 years, range 20-90) underwent EFTR using FTRD^®. Indications were:residual/recurrent adenoma (39), incomplete resection at histology (R1 resection) (26), non-lifting lesion (12), adenoma involving the appendix (2) or diverticulum (2), subepithelial lesions(10), suspected T1 carcinoma (16), diagnostic resection (3). Technical success (TS: lesion reached and resected), R0 resection (negative lateral and deep margins),EFTR rate(all layers documented in the specimen) and safety have been evaluated.

RESULTS

TS was achieved in 94.4% of cases. EFTR was achieved in 91% with lateral and deep R0 resection in 90% and 92%. Mean size of specimens was 20 mm (range 6-42). In residual/recurrent adenomas, final analysis revealed: low-risk T1 (11), adenoma with low-grade dysplasia (LGD) (24) and high-grade dysplasia (HGD) (3), scar tissue (1). Histology reports of R1 resections were: adenoma with LGD (6), with HGD (1), low-risk (6) and high-risk (1) T1, scar tissue (12). Non-lifting lesions were diagnosed as: adenoma with HGD (3), low-risk (7) and high risk (2) T1. Adverse clinical events occurred in 12 patients (11%),while adverse technical events in11%. Three-months follow-up was available in 100 cases and residual disease was evident in only seven patients.

CONCLUSIONS

EFTR using FTRD^® seems to be a feasible, effective and safe technique for treating selected colo-rectal lesions. Comparative prospective studies are needed to confirm these promising results.

Endoscopic treatment of chronic pancreatitis in pediatric population: Long-term efficacy and safety

Background

Chronic pancreatitis (CP) in children is an inreasingly recognized disease.

Objective

The purpose of study was to analyse the safety and long-term efficacy of endoscopic treatment in children with CP.

Methods

Records of 38 patients aged <18 years, referred to the Digestive Endoscopy Unit at Catholic University, Fondazione Policlinico "A. Gemelli" IRCCS between 1991 and 2017, were reviewed. Abdominal pain, analgesia and number of episodes of acute pancreatitis in the pre- and post- endoscopic retrograde cholangiopancreatography (ERCP) period were evaluated. Need for surgery was assessed. Therapeutic intervention data and complications were interrogated.

Results

In total 158 ERCPs were performed. Median post-ERCP follow-up was 7 years. The majority of patients had CP type IV (47%) and type Ib (37%) (Cremer's classification). Major papilla pancreatic sphincterotomy was performed in 47%, major and minor in 24% and minor in 29% of patients. Stones/plugs were removed in at least one ERCPs in 66% individuals. Eleven out of 38 patients had stricture of the pancreatic duct; these were dilated and stented in 5/11 and stented in 6/11. Five complications were recorded (3%). Severity and frequency of abdominal pain improved significantly; p < 0.001. Use of analgesia and number of episodes of acute pancreatitis decreased significantly; p < 0.001. One child required subsequent surgery.

Conclusion

Endoscopic management of symptomatic CP in children is safe and effective.

The 2018 ISDE achalasia guidelines

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

The association of pancreatic cystosis and IPMN in cystic fibrosis: case report and literature review

Pancreatic cystosis is a rare presentation of cystic fibrosis involving pancreatic gland. To date, only very few cases of pancreatic cystosis have been described in literature. Pancreatic cystosis may begin during the second decade of life and is the rarest presentation of cystic fibrosis. This disease is characterized by the presence of multiloculated cysts without ductal system communication of different sizes in all the pancreatic tissue. Herein, we report a case of a young woman affected by cystic fibrosis that was admitted to our Pancreatic Centre to evaluate a picture of diffuse multiloculated pancreatic cysts. After magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) assessment, we perform the diagnosis of the concomitant presence of the rare condition of pancreatic cystosis with Branch Duct-Intraductal Papillary Mucinous Neoplasm (BD-IPMN). To our knowledge, this is the first reported case of a cystic fibrosis patient with the combination of pancreatic cystosis and IPMN.

Tapered fiber optic applicator for laser ablation: Theoretical and experimental assessment of thermal effects on ex vivo model

Laser Ablation (LA) is a minimally invasive technique for tumor removal. The laser light is guided into the target tissue by a fiber optic applicator; thus the physical features of the applicator tip strongly influence size and shape of the tissue lesion. This study aims to verify the geometry of the lesion achieved by a tapered-tip applicator, and to investigate the percentage of thermally damaged cells induced by the tapered-tip fiber optic applicator. A theoretical model was implemented to simulate: i) the distribution of laser light fluence rate in the tissue through Monte Carlo method, ii) the induced temperature distribution, by means of the Bio Heat Equation, iii) the tissue injury, by Arrhenius integral. The results obtained by the implementation of the theoretical model were experimentally assessed. Ex vivo porcine liver underwent LA with tapered-tip applicator, at different laser settings (laser power of 1 W and 1.7 W, deposited energy equal to 330 J and 500 J, respectively). Almost spherical volume lesions were produced. The thermal damage was assessed by measuring the diameter of the circular-shaped lesion. The comparison between experimental results and theoretical prediction shows that the thermal damage discriminated by visual inspection always corresponds to a percentage of damaged cells of 96%. A tapered-tip applicator allows obtaining localized and reproducible damage close to spherical shape, whose diameter is related to the laser settings, and the simple theoretical model described is suitable to predict the effects, in terms of thermal damage, on ex vivo liver. Further trials should be addressed to adapt the model also on in vivo tissue, aiming to develop a tool useful to support the physician in clinical application of LA.

Effects of Nd:YAG laser for the controlled and localized treatment of early gastrointestinal tumors: Preliminary in vivo study

Endoscopic submucosal dissection (ESD) is a minimally invasive technique allowing for the removal of early gastrointestinal (GI) tumors, widely considered as a valid alternative to conventional surgery. However, ESD is technically demanding, and potentially severe complications, such as bleeding and perforation, may occur. Energy-based techniques (e.g., radiofrequency ablation) might offer a potential alternative to ESD. However, their use mandates the ability to predict the damage induced and to identify a "signature" of the complete ablation, without the need for a physical specimen. Ideally, an energy-based procedure should be tunable in order to limit the ablation to the superficial layers, namely mucosa (M) and submucosa (SM), without injuring the muscularis propria (MP), thereby minimizing GI perforation. This experimental study aims to investigate thermal damage induced by Nd:YAG laser on the gastric wall, at different laser settings such as power (P) and time (t). Laser ablation was performed on the stomach wall of 6 Wistar rats. Two powers (2.5W and 1.0W) and 3 exposure times (12s, 6s and 2s) were tested, for a total of 30 ablations. Histological analysis allowed to assess thermal damage, in terms of damage depth (DD) and identification of involved layers. The ratio (R) between DD and the total depth (TD) of target layers (M+SM) was used as an index to evaluate the effectiveness of laser settings. At P=2.5W, MP was damaged (R>1) in the majority of cases (11/15). At P=1.0W, MP was preserved in all tests (R<;1), and rarely (4/15) did the damage reach the whole SM (R=1). Histopathological analysis evidenced that tissue damage was strongly related to the variable tissue thickness. These preliminary results seem to support the fact that endoscopic tunable laser ablation is feasible with a consistent damage/power correlation. Further tests are required to optimize the settings for applications on early GI tumors.

Novel carbon fiber probe for temperature monitoring during thermal therapies

Thermal treatments are a valid clinical option in the management of several solid tumors. The difficulties to perform an accurate prediction improve the selectivity of the treatment effects represent the main hurdles in the spread of these techniques. Among other solutions, thermometric techniques are gaining acceptance in monitoring the effects of thermal treatments because they provide a clear end-point to obtain the complete removal of cancer without damaging the surrounding healthy tissue. This paper proposes a custom needle-like probe made of carbon fibers to embed seven fiber Bragg grating (FBG) sensors. This tool aims at a multiple points monitoring the tissue temperature during the thermal procedures, streamlining the FBG sensors insertion within the organ. After the description of the probe manufacturing, we reported the calibration of the seven sensors embedded within the probe, their step response, and the feasibility assessment of the probe for temperature monitoring during laser ablation on animal model (both in vivo and ex vivo). Results show that the proposed probe is easily maneuverable by the clinician, the sensors have a linear response with the temperature and a short step response; moreover, the probe allows measuring the temperature in seven points of the tissue; finally, it can be used during CTand MR-guided procedures without causing any artifact to the images. Thanks to these features the probe may be an useful solution to improve the safety and the outcomes of minimally invasive thermal ablation procedures, so to spread these procedures in the clinical field.

Multipoint temperature monitoring in liver undergoing computed tomography-guided radiofrequency ablation with fiber Bragg grating probes

In this work, we investigated the temperature increment experienced by biological tissue during radiofrequency ablation (RFA). The measurements were performed by using two custom-made thermal probes based on fiber optic sensors (fiber Bragg gratings, FBGs). The two probes embed a total of 9 FBGs. Experiments were performed during RFA of an ex vivo healthy porcine liver. The RFA heating module was equipped with 5 thermocouples. Results show that the temperature increment close to the applicator (i.e., 0.6 cm-0.7 cm) reaches the temperature which is set as a target on the RFA module (i.e., approximately 100 °C). The distance from the applicator also has an impact on the dynamics of the heating phenomenon: at short distances the tissue temperature reaches a steady state condition after a few minutes, on the other hand the sensors placed at a distance ≥2cm did not reach the steady-state conditions during the 14-minute procedure. The multipoint temperature monitoring, which uses sensors at several distances from the applicator, can provide useful information regarding the boundary of damaged volume. This approach can be combined with the monitoring temperature system embedded in the heating equipment, to better control the damaged volume, and to improve the treatment outcomes.

Temperature monitoring during radiofrequency ablation of liver: in vivo trials

Radiofrequency ablation (RFA) is a minimally invasive procedure used to treat tumors by means of hyperthermia, mostly through percutaneous approach. The tissue temperature plays a pivotal role in the achievement of the target volume heating, while sparing the surrounding healthy tissue from thermal damage. Several techniques for thermometry during RFA are investigated, most of them based on the use of single-point measurement system (e.g., thermocouples). The measurement of temperature map is crucial for the real-time control and fine adjustment of the treatment settings, to optimize the shape and size of the ablated volume. The recent interest about fiber optic sensors and, among them, fiber Bragg gratings (FBGs) for the monitoring of thermal effects motivated further investigation. In particular, the feature of FBGs to form an array of several elements, thus to be inscribed within the same fiber, allows the use of a single probe for the multi-points monitoring of the tissue temperature during RFA. Hence, the aim of this study is the development and characterization of a needle-like probe embedding an array of three FBGs, which was tested on pig liver during in vivo trials. The needle allows a safe and easy insertion of the fiber optic within the liver. It was inserted by ultrasound guidance into the liver, and monitored the change of tissue temperature during RFA controlled by the roll-off technique. Also the measurement error induced by breathing movements of the liver was assessed (less than 3 °C). Results encourage the use of the probe in clinical settings, as well as the improvement of some features, e.g., a higher number of FBGs for performing quasi-distributed measurement.

But how many misunderstood Crohn's disease are revealed "by chance" using Capsule Endoscopy in Chronic Recurrent OGIB? Experience of a Single Italian Center and long term follow-up

OBJECTIVE

The role of capsule endoscopy (CE) in Crohn's disease (CD) has expanded with greater understanding of the technology. The ability of CE to differentiate CD from other causes of inflammation has been questioned. Longitudinal studies are required to assess the long-term impact and significance of CE findings in suspected CD. The aim of this work is to verify in how many misunderstood cases of suspected Crohn's Disease CE was able to identify precociously and "by chance" when it is performed for recurrent obscure GI bleeding (OGIB), to evaluate how many of them were later confirmed during a median 24 months follow-up. Moreover, we observed the role of the early diagnosis in changing the clinical management of these patients.

PATIENTS AND METHODS

A retrospective review was carried out on CE procedures performed for suspected OGIB. 1008 consecutive patients was enrolled and 492 included in the study. Previous investigations such as ileo-colonoscopy and/or previous small bowel imaging were documented. Only patients with at least 6 months of documented follow-up were included. A chart review was undertaken to record CE findings/correlate with subsequent diagnosis and outcome.

RESULTS

94/492 (19.1%) patients positive for suspected CD were identified. Follow-up data were available 64/94 (68%). The mean follow-up was 24 months. There was a strong positive correlation between results of CE and subsequent clinical diagnosis. The suspected CD was confirmed in 100% (94/94) of follow-up patients.

CONCLUSIONS

CE appears able to identify lesions compatible with suspected Crohn's disease otherwise unacknowledged with consequently change in treatment options for the patients.

Central and Mucosal Immunities are Modified by Non Adsorbable Antibiotic Treatment in Uncomplicated Diverticular Disease

We review our experience on Rifaximin in uncomplicated diverticular disease. Our data show that a 2 week treatment induces modifications in the immune system: local mucosal lymphocytes with TLR-4 were increased. In the peripheral blood CD103 cells, which increased before treatment, returned to normal values after Rifaximin.

Randomised clinical trial: faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection

BACKGROUND

Faecal microbiota transplantation (FMT) from healthy donors is considered an effective treatment against recurrent Clostridium difficile infection.

AIM

To study the effect of FMT via colonoscopy in patients with recurrent C. difficile infection compared to the standard vancomycin regimen.

METHODS

In an open-label, randomised clinical trial, we assigned subjects with recurrent C. difficile infection to receive: FMT, short regimen of vancomycin (125 mg four times a day for 3 days), followed by one or more infusions of faeces via colonoscopy; or vancomycin, vancomycin 125 mg four times daily for 10 days, followed by 125-500 mg/day every 2-3 days for at least 3 weeks. The latter treatment did not include performing colonoscopy. The primary end point was the resolution of diarrhoea related to C. difficile infection 10 weeks after the end of treatments.

RESULTS

The study was stopped after a 1-year interim analysis. Eighteen of the 20 patients (90%) treated by FMT exhibited resolution of C. difficile-associated diarrhoea. In FMT, five of the seven patients with pseudomembranous colitis reported a resolution of diarrhoea. Resolution of C. difficile infection occurred in 5 of the 19 (26%) patients in vancomycin (P < 0.0001). No significant adverse events were observed in either of the study groups.

CONCLUSIONS

Faecal microbiota transplantation using colonoscopy to infuse faeces was significantly more effective than vancomycin regimen for the treatment of recurrent C. difficile infection. The delivery of donor faeces via colonoscopy has the potential to optimise the treatment strategy in patients with pseudomembranous colitis.

Systematic review with meta-analysis: the incidence of advanced neoplasia after polypectomy in patients with and without low-risk adenomas

BACKGROUND

Patients with one to two tubular adenomas <1 cm in size without high-grade dysplasia (low-risk group) are considered at low risk for colorectal cancer. However, it is uncertain whether they have the same risk of subsequent advanced neoplasia as those with no neoplasia at baseline colonoscopy.

AIM

To compare incidence of metachronous advanced neoplasia between patients in the low-risk adenoma group and those without neoplasia at index colonoscopy.

METHODS

Relevant publications were identified by MEDLINE/EMBASE and other databases for the period 1992-2013. Studies comparing the incidence of post-polypectomy advanced neoplasia (adenomas ≥10 mm/high-grade dysplasia/villous or cancer) between the low-risk group and patients without colorectal neoplasia at the first colonoscopy were included. Detection rates for advanced neoplasia at endoscopic surveillance were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random-effect models. Inter-study heterogeneity was assessed using the I(2) statistic.

RESULTS

Seven studies provided data on 11 387 patients. Mean surveillance periods ranged between 2 and 5 years. Altogether, 267 patients with post-polypectomy advanced neoplasia were detected in the two groups. The incidence of advanced neoplasia was 1.6% (119/7308) in those without neoplasia and 3.6% (148/4079) in those with low-risk adenoma, respectively, corresponding to a relative risk of 1.8 (95% CI: 1.3-2.6). Inter-study heterogeneity was only moderate (I(2) : 37%). No publication bias was present.

CONCLUSIONS

Patients with low-risk adenomas at baseline had a higher risk of metachronous advanced neoplasia than the group with no adenomas at baseline, though the absolute risk was low in both groups.

Endoscopic snare papillectomy: a possible radical treatment for a subgroup of T1 ampullary adenocarcinomas

Pancreaticoduodenectomy is the standard care for invasive ampullary adenocarcinomas. However, endoscopic snare papillectomy (ESP) might play a curative role in very selected patients. We studied a series of 15 patients with T1 ampullary adenocarcinoma who were treated by ESP alone and followed up for a mean of 29.6 ± 21.9 months (range 8 - 81 months). ESP was curative for eight patients (57.1 %). No tumor-related death was observed in patients with a cancer infiltration depth of ≤ 4 mm. According to this preliminary experience, we suggest that this measurable variable threshold should be considered as a possible basis for future large-scale studies.

EUS-guided fine needle tissue acquisition for the diagnosis of pleural metastases from endometrial cancer

Transesophageal EUS-FNA have become a useful tool in the evaluation of the mediastinum, especially during the staging work-up examination of patients with non-small-cell lung cancer (NSCLC) or other malignancies. We report a challenging case of a 53 years-old woman with an endometrial adenocarcinoma who subsequently presented with right pleural effusion, diffuse pleural thickening with few pleural lesions. The patient referred a long history of exposure to amiantum, this posing a differential diagnosis between primary pleural tumour (mesothelioma) and neoplastic pleural localization of the endometrial cancer. The cytological examination of the pleural effusion (sampled via thoracenthesis) was not adequate to reach a diagnosis. Although a right-video-assisted thoracoscopy was considered the gold standard in this clinical setting to achieve a tissue acquisition of the pleura, an EUS (as the least invasive procedure) was attempted to reach a definitive diagnosis. EUS-FNTA of the pleura was done using a 19-Gauge needle and the pathological and immunophenotypic features were diagnostic for a pleural metastasis of high-grade endometrial serous carcinoma. The patient received adjuvant chemotherapy with a complete regression of the pleural lesions. We take the opportunity of this challenging case to discuss the efficacy and safety of EUS-FNAT to sample the pleural lesions with the use of a large calibre needle if the lesion lies just under the EUS cursor. We may assume that, in selected patients, this technique could be presented as a viable option to the more invasive surgical procedure, which has been previously the gold standard for the pleural tissue acquisition.

Management of acute dyarrhea: current and future trends

Acute diarrhea is a very common symptom, which may recognize different causes and is basically the expression of an altered homeostasis of the bowel, which overcame current classifications. When approaching patients with acute diarrhea, we should firstly check body temperature and vital parameters and secondly provide a general medical examination mainly focused on the abdomen, in order to exclude surgical causes of diarrhea, such as acute appendicitis, diverticulitis, intestinal occlusion and others. Another important aspect is the assessment of the level of hydration in order to provide the right amount of fluids. There is no current indication for the administration of loperamide in infectious diarrhea, but there is a strong rationale for new class of drugs, which may be defined as "mucous regenerators", such as gelatin tannate. Further studies are needed on this matter in order to test the effect of gelatin tannate in adult patients with acute diarrhea.

European experts consensus statement on cystic tumours of the pancreas

Cystic lesions of the pancreas are increasingly recognized. While some lesions show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). European expert pancreatologists provide updated recommendations: diagnostic computerized tomography and/or magnetic resonance imaging are indicated in all patients with cystic lesion of the pancreas. Endoscopic ultrasound with cyst fluid analysis may be used but there is no evidence to suggest this as a routine diagnostic method. The role of pancreatoscopy remains to be established. Resection should be considered in all symptomatic lesions, in mucinous cystic neoplasm, main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm as well as in branch duct intraductal papillary mucinous neoplasm with mural nodules, dilated main pancreatic duct >6mm and possibly if rapidly increasing in size. An oncological partial resection should be performed in main duct intraductal papillary mucinous neoplasm and in lesions with a suspicion of malignancy, otherwise organ preserving procedures may be considered. Frozen section of the transection margin in intraductal papillary mucinous neoplasm is suggested. Follow up after resection is recommended for intraductal papillary mucinous neoplasm, solid pseudo-papillary neoplasm and invasive cancer.

Prevalence and risk factors of extrapancreatic malignancies in a large cohort of patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas

BACKGROUND

The objectives of this study are to estimate prevalence and incidence of extrapancreatic malignancies (EPMs) among intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, and to identify risk factors for their occurrence.

PATIENTS AND METHODS

We conducted multicentric cohort study in Italy from January 2010 to January 2011 including 390 IPMN cases. EPMs were grouped as previous, synchronous (both prevalent) and metachronous (incident). We calculated the observed/expected (O/E) ratio of prevalent EPMs, and compared the distribution of demographic, medical history and lifestyle habits.

RESULTS

Ninety-seven EPMs were diagnosed in 92 patients (23.6%), among them 78 (80.4%) were previous, 14 (14.4%) were synchronous and 5 (5.2%) were metachronous. O/E ratios for prevalent EPMs were significantly increased for colorectal carcinoma (2.26; CI 95% 1.17-3.96), renal cell carcinoma (6.00; CI 95% 2.74-11.39) and thyroid carcinoma (5.56; CI 95% 1.80-12.96). Increased age, heavy cigarette smoking, alcohol consumption and first-degree family history of gastric cancer are significant risk factors for EPMs, while first-degree family history of colorectal carcinoma was borderline.

CONCLUSION

We report an increased prevalence of EPMs in Italian patients with IPMN, especially for colorectal carcinoma, renal cell and thyroid cancers. A systematic surveillance of IPMN cases for such cancer types would be advised.

Evaluation of gastric and small bowel transit times in coeliac disease with the small bowel PillCam®: a single centre study in a non gluten-free diet adult Italian population with coeliac disease

BACKGROUND

The mechanisms underlying bowel disturbances in coeliac disease are still relatively unclear. Past reports suggested that small bowel motor abnormalities may be involved in this pathological condition; there are no studies addressing small bowel transit in coeliac disease before and after a gluten-free diet.

AIM

The objective of this study was to determine whether capsule endoscopy (CE) could serve as a test for measurement of gastric and small bowel transit times in a group of symptomatic or asymptomatic coeliac patients at the time of diagnosis with respect to a control group.

PATIENTS AND METHODS

Thirty coeliac untreated patients and 30 age-, sex- and BMI-matched healthy controls underwent CE assessment of whole gut transit times.

RESULTS

All subjects completed the study per protocol and experienced natural passage of the pill. No statistical significant differences between gastric emptying and small bowel transit times both in coeliac and control group were found (p = 0.1842 and p = 0.7134; C.I. 95%, respectively). No correlation was found in coeliac patients and control group between transit times and age, sex and BMI. By using the Pearson's correlation test, significant correlation emerged between gastric emptying time and small bowel transit times in coeliac disease (r = 0.1706).

CONCLUSIONS

CE reveals unrecognized gender differences and may be a novel outpatient technique for gut transit times' assessment without exposure to radiation and for the evaluation of upper gut dysfunction in healthy patients suffering from constipation without evidence of intestinal malabsorption. Nevertheless, CE does not seem to be the most suitable method for studying gut transit times in untreated coeliac patients; this might be ascribed to the fact that CE consists of inert (non-digestible, non-absorbable) substances.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Complete transmural gastric migration of PTFE mesh after surgery for a recurrent hiatal hernia

Complications directly associated with the use of prosthetic materials in large hiatal hernia repair are rarely cited events in the literature. We herein report a case of a 47 year-old woman who came to our attention for a subacute onset of severe dysphagia and weight loss. She previously underwent laparotomic Nissen fundoplication with PTFE dual-mesh cruroplasty for a large recurrent hiatal hernia. With the clinical suspicious of "Tight Nissen", an endoscopy was performed and revealed a circular stenosis in the lower esophagus, a rotation of the stomach and, surprisingly, the presence of PTFE mesh free-moving in the gastric lumen With the use of rattooth forceps, the foreign body was removed and, after few days, the patient underwent a surgical debridement of hiatal scar tissue and a gastropexy procedure. In conclusion, dysphagia may manifest during the early postoperative period after mesh repair antireflux surgery, but such dysphagia usually resolves; if it doesn't or if it worsens, mesh migration must be excluded.

Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

BACKGROUND AND AIMS

Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic pancreatitis.

METHODS

Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline.

SUMMARY OF SELECTED RECOMMENDATIONS

For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones ≥ 5 mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B). For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e. g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D).For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A).For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).

Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy about endoscopic biliary stenting. The present Clinical Guideline describes short-term and long-term results of biliary stenting depending on indications and stent models; it makes recommendations on when, how, and with which stent to perform biliary drainage in most common clinical settings, including in patients with a potentially resectable malignant biliary obstruction and in those who require palliative drainage of common bile duct or hilar strictures. Treatment of benign conditions (strictures related to chronic pancreatitis, liver transplantation, or cholecystectomy, and leaks and failed biliary stone extraction) and management of complications (including stent revision) are also discussed. A two-page executive summary of evidence statements and recommendations is provided. A separate Technology Review describes the models of biliary stents available and the stenting techniques, including advanced techniques such as insertion of multiple plastic stents, drainage of hilar strictures, retrieval of migrated stents and combined stenting in malignant biliary and duodenal obstructions.The target readership for the Clinical Guideline mostly includes digestive endoscopists, gastroenterologists, oncologists, radiologists, internists, and surgeons while the Technology Review should be most useful to endoscopists who perform biliary drainage.

Cost effectiveness and projected national impact of colorectal cancer screening in France

BACKGROUND

Colorectal cancer (CRC) is a major cause of morbidity and mortality in France. Only scanty data on cost-effectiveness of CRC screening in Europe are available, generating uncertainty over its efficiency. Although immunochemical fecal tests (FIT) and guaiac-based fecal occult blood tests (g-FOBT) have been shown to be cost-effective in France, cost-effectiveness of endoscopic screening has not yet been addressed.

METHODS

Cost-effectiveness of screening strategies using colonoscopy, flexible sigmoidoscopy, second-generation colon capsule endoscopy (CCE), FIT and g-FOBT were compared using a Markov model. A 40 % adherence rate was assumed for all strategies. Colonoscopy costs included anesthesiologist assistance. Incremental cost-effectiveness ratios (ICERs) were calculated. Probabilistic and value-of-information analyses were used to estimate the expected benefit of future research. A third-payer perspective was adopted.

RESULTS

In the reference case analysis, FIT repeated every year was the most cost-effective strategy, with an ICER of €48165 per life-year gained vs. FIT every 2 years, which was the next most cost-effective strategy. Although CCE every 5 years was as effective as FIT 1-year, it was not a cost-effective alternative. Colonoscopy repeated every 10 years was substantially more costly, and slightly less effective than FIT 1-year. When projecting the model outputs onto the French population, the least (g-FOBT 2-years) and most (FIT 1-year) effective strategies reduced the absolute number of annual CRC deaths from 16037 to 12916 and 11217, respectively, resulting in an annual additional cost of €26 million and €347 million, respectively. Probabilistic sensitivity analysis demonstrated that FIT 1-year was the optimal choice in 20% of the simulated scenarios, whereas sigmoidoscopy 5-years, colonoscopy, and FIT 2-years were the optimal choices in 40%, 26%, and 14%, respectively.

CONCLUSIONS

A screening program based on FIT 1-year appeared to be the most cost-effective approach for CRC screening in France. However, a substantial uncertainty over this choice is still present.

Biliary stents: models and methods for endoscopic stenting

Biliary stenting is widely used to palliate malignant obstruction or to treat benign biliary diseases. Recently, the most important changes have related to self-expandable metal stents (SEMSs), which are now available in a wide variety of designs, and to treatment techniques. This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic biliary stenting: a technology review describes the stent models and stenting techniques, and a separate clinical guideline states the evidence and recommendations regarding stenting.

A new partially covered nitinol stent for palliative treatment of malignant bile duct obstruction: a multicenter single-arm prospective study

BACKGROUND AND STUDY AIMS

Covered self-expanding metal stents (SEMSs) have proven effective for managing malignant bile duct strictures and may reduce risk of tumor ingrowth. A new nitinol partially covered biliary SEMS was prospectively evaluated.

PATIENTS AND METHODS

70 patients with inoperable extrahepatic biliary obstructions were enrolled in a prospective multicenter trial, and followed up to 6 months or death, whichever came first. Primary endpoint was adequate palliation defined as absence of recurrent biliary obstruction from partly covered SEMS placement to end of follow-up.

RESULTS

Mean age of the patients was 69 years and 52 % were men. Pancreatic carcinoma was present in 68 %. One stent was placed in 67 patients, two patients received two, and in one patient a guide wire could not traverse the stricture. In 55 % of patients the SEMS was inserted de novo and in 45 % for exchange with a plastic stent. Technical success was 97 %. At 6 months, 62 % of patients were free of obstructive symptoms; compared with baseline the mean number of symptoms per patient was significantly reduced (3.1 at baseline, 0.6 at 6 months; P < 0.0001) and total bilirubin levels dropped by 73 %. There were four cases of recurrent biliary obstruction, due to stent migration (2), tumor overgrowth (1), and sludge formation (1). Device-related complications included cholecystitis (3), right upper quadrant pain (1), and moderate pancreatitis (1). No tumor ingrowth was reported.

CONCLUSIONS

This new partially covered nitinol SEMS is easily inserted, and safe and effective in the palliation of biliary obstruction secondary to malignant bile duct strictures.

Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: summary of the working group reports of the Euro-NOTES meeting 2010

The fourth Euro-NOTES workshop took place in September 2010 and focused on enabling intensive scientific dialogue and interaction between participants to discuss the state of the practice and development of natural-orifice transluminal endoscopic surgery (NOTES) in Europe. Five working groups were formed, consisting of participants with varying scientific and medical backgrounds. Each group was assigned to an important topic: the correct strategy for dealing with bacterial contamination and related complications, the question of the ideal entry point and secure closure, interdisciplinary collaboration and indications, robotics and platforms, and matters related to training and education. This review summarizes consensus statements of the working groups to give an overview of what has been achieved so far and what might be relevant for research related to NOTES in the near future.