Cancer of the Pancreas: Clinical Outcome in 76 Cases

A final diagnosis of pancreatic cancer was established in 76 consecutive patients during 4 years. The clinical outcome was evaluated retrospectively, as well as clinical presentation and its impact on the rate of resectability. Even though the diagnostic techniques showed a high sensitivity, only 18.4% of patients had a radical resection performed. In 77.6% of the cases a tissue diagnosis had been obtained. However, in only 1/5 of them was the tissue proof obtained preoperatively. This review confirms that the survival of patients with pancreatic cancer is poor, with slight advantages in the few resectable cases. Therefore, an earlier diagnosis should be attempted in high-risk symptomatic patients, selected by means of nonaggressive tests and evaluated by means of more accurate diagnostic techniques, when suitable.

Ca 19-9 Assay in Patients with Extrahepatic Cholestatic Jaundice

Serum concentrations of the CA 19-9 tumour marker were determined in 35 patients with histologically proven bilio-pancreatic malignancies associated with obstructive jaundice and in 35 patients with benign extrahepatic jaundice due to choledocholithiasis.

At a cut-off level of 37 U/ml the sensitivity of this assay was 82.8%, but the specificity was very low (45.7%). Thus CA 19-9 can not be employed to differentiate between malignant and benign extrahepatic jaundice.

Serial samples of CA 19-9 were achieved in 7 patients with benign and in 6 patients with malignant biliary obstruction, before and after the disappearance of jaundice. Serum concentrations of this tumour-antigen returned to normal concurrently with the bilirubin values only in patients with benign obstruction, remaining unchanged in all cases of malignancies.

The data suggest that patients with extrahepatic jaundice should be evaluated by other examinations or by collecting serial samples for this assay.

Association between coffee or tea drinking and Barrett's esophagus or esophagitis: an Italian study

BACKGROUND/OBJECTIVES

Only a few papers have treated of the relationship between Barrett's esophagus (BE) or erosive esophagitis (E) and coffee or tea intake. We evaluated the role of these beverages in BE and E occurrence.

SUBJECTS/METHODS

Patients with BE (339), E (462) and controls (619) were recruited. Data on coffee and tea and other individual characteristics were collected using a structured questionnaire.

RESULTS

BE risk was higher in former coffee drinkers, irrespective of levels of exposure (cup per day; ⩽1: OR=3.76, 95% CI 1.33-10.6; >1: OR=3.79, 95% CI 1.31-11.0; test for linear trend (TLT) P=0.006) and was higher with duration (>30 years: OR=4.18, 95% CI 1.43-12.3; TLT P=0.004) and for late quitters, respectively (⩽3 years from cessation: OR=5.95, 95% CI 2.19-16.2; TLT P<0.001). The risk of BE was also higher in subjects who started drinking coffee later (age >18 years: OR=6.10, 95% CI 2.15-17.3). No association was found in current drinkers, but for an increased risk of E in light drinkers (<1 cup per day OR =1.85, 95% CI 1.00-3.43).A discernible risk reduction of E (about 20%, not significant) and BE (about 30%, P<0.05) was observed in tea drinkers.

CONCLUSIONS

Our data were suggestive of a reduced risk of BE and E with tea intake. An adverse effect of coffee was found among BE patients who had stopped drinking coffee. Coffee or tea intakes could be indicative of other lifestyle habits with protective or adverse impact on esophageal mucosa.

Barrett's esophagus, esophageal and esophagogastric junction adenocarcinomas: the role of diet

Identification of modifiable risk factors is an attractive approach to primary prevention of esophageal adenocarcinoma (EAC) and esophagogastric junction adenocarcinoma (EGJAC). We conducted a review of the literature to investigate the association between specific dietary components and the risk of Barrett’s esophagus (BE), EAC and EGJAC, supposing diet might be a risk factor for these tumors. Consumption of meat and high-fat meals has been found positively associated with EAC and EGJAC. An inverse association with increased intake of fruit, vegetables and antioxidants has been reported but this association was not consistent across all studies reviewed. Few studies have examined the association between diet and BE. Additional research is needed to confirm the aforementioned association and clarify the mechanisms by which dietary components affect the risk of developing EAC and EGJAC. Future studies could advance our knowledge by emphasizing prospective designs to reduce recall bias, by using validated dietary intake questionnaires and biological measures and by considering important confounders such as gastro-esophageal reflux disease (GERD) symptoms, tobacco and alcohol use, biometrics, physical activity, and socioeconomic factors.

Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer

Self-expanding metal stents (SEMS) are used to treat obstructive malignancies of the esophagus or esophagogastric junction; however, a potential complication is recurrent dysphagia because of tissue in/overgrowth. The placement of a second SEMS is one strategy to re-establish patency of the esophageal lumen. We evaluated the safety and efficacy of an alternative and likely less costly approach: placing a self-expanding plastic stent (SEPS) to manage relapsing dysphagia in patients previously treated with a partially covered SEMS. From December 2007 to January 2009, 13 patients previously treated with a SEMS for malignant dysphagia underwent treatment by inserting a SEPS to palliate relapsing dysphagia, as a result of tissue in/overgrowth. Stenosis was located in the upper esophagus in one patient, in the middle in four patients, and in the lower esophagus in eight patients. Clinical evaluation was performed at the time of stent placement, after 1 week, and then, monthly until death. The SEPS was successfully placed in a single treatment session for all patients. No preliminary dilation was required, and no further treatment was necessary for any patient. Before stenting, the median dysphagia score was 4 (range 3-4), and 1 week later the score was 0 for all patients. The resolution of dysphagia persisted until patient death (from tumor progression). The mean survival after the SEPS insertion was 4 months (range 3-8). This case series supports the use of a SEPS to palliate dysphagia from tissue in/overgrowth of a SEMS. Future clinical trials with larger patient samples are warranted.

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.

Our perspective on endoscopic resection for colorectal neoplasms

Endoscopic mucosal resection (EMR) is a minimally invasive technique for effective treatment of early stage colorectal lesions with no invasive potential. However, the high frequency of local recurrence after piecemeal EMR for large lesions is considered a serious problem. In contrast, endoscopic submucosal dissection (ESD) allows en-bloc resection, irrespective of the lesion's size. ESD has been established as a standard method for the endoscopic removal of early cancers in the upper gastrointestinal tract in Japan. Although the use of ESD for colorectal lesions has been studied clinically, ESD is not yet established as a standard therapeutic method. We define the indications for en-bloc resection, based on extensive clinicopathological analyses, as a laterally spreading tumor (LST) non-granular type (LST-NG) lesion greater than 20 mm and an LST granular (LST-G) type lesion greater than 40 mm. Both of these lesions had a high submucosal invasion rate. Especially, LST-NG type lesions greater than 20 mm are technically difficult to remove completely even by piecemeal EMR and are considered a "definite indication for en-bloc resection". The ESD procedure is undoubtedly an ideal method to achieve en-bloc resection, however, the prevalences of suitable lesions among all neoplastic lesions and among all early cancers were not high (1.0% and 5.0%, respectively). Therefore, it is crucial to master more fundamental therapeutic techniques and have knowledge of surveillance strategy after endoscopic treatment.

Systematic review: the role of self-expanding plastic stents for benign oesophageal strictures

BACKGROUND

Treatment of refractory or recurrent benign oesophageal strictures is demanding and surgery may be the only available option. The role of self-expanding plastic stents (SEPS) in the treatment of these strictures is still controversial because of the conflicting results of various studies.

AIM

To analyse with regard to SEPS: technical and clinical success, factors associated with outcome, and safety.

METHODS

Pooled-data analysis of a systematic review of the literature. Clinical success was defined as no need for further endoscopic or surgical treatment after SEPS removal.

RESULTS

Data of 10 studies with 130 treated patients were included. SEPS insertion was technically successful in 128 of 130 patients (98%, 95% CI = 96-100%). Clinical success was achieved in 68 patients (52%, 95% CI = 44-61%) and this was found to be lower in those with a cervical localization of the stricture (33% vs. 54%; P < 0.05). Early (<4 weeks) migration of the stent was reported in 19 (24%, 95% CI = 14-32%) cases, while post-insertion endoscopic re-intervention was required in 25 (21%, 95% CI = 14-28%). Major clinical complications occurred in 12 patients (9%, 95% CI = 4-14%), resulting in death of one (0.8%) patient.

CONCLUSIONS

Our pooled-data analysis showed a favourable risk/benefit ratio when SEPS are applied in patients with recurrent or refractory benign oesophageal strictures. This supports the use of SEPS before referring patients to surgery, and they are a valuable alternative to repeat endoscopic dilation.

Pretreatment endoscopy--pro & contra: endoscopy is needed before treatment in all patients with gastroesophageal reflux disease

Most current endoscopic guidelines do not recommend the use of routine esophagoscopy in the evaluation of patients with typical symptoms of gastroesophageal reflux disease (GERD), unless alarm features are present. In patients with known reflux esophagitis, esophagoscopy is considered to have no role either in the further management or follow-up. Screening of reflux patients for Barrett's esophagus is not considered to be cost-effective. On the basis of a critical review of the available literature, and of some recent papers in particular, we disagree with these suggestions. We would argue, on the contrary, that a negative esophagoscopy can provide the GERD patient with reassurance, and that esophagoscopy allows targeted therapy to be offered if it is positive for esophagitis. When Barrett's esophagus is diagnosed, it usually leads to a surveillance program being initiated. The potential benefits of endoscopy for the patient's quality of life are probably underestimated when financial issues alone are taken into account. Even if it is true that a large percentage of GERD patients do not have endoscopic abnormalities (those with nonerosive reflux disease), surrogate tests such as the proton-pump inhibitor test or symptom questionnaires do not provide a more accurate diagnosis. We would therefore suggest that, at least in the specialist setting, all patients with suspected GERD should undergo accurate symptom analysis as well as endoscopic evaluation before treatment is started.

Comparison of the main oesophageal pathophysiological characteristics between short- and long-segment Barrett's oesophagus

AIM

To assess the oesophageal manometric characteristics and 24-h pH profiles of patients with both short-segment and long-segment Barrett's oesophagus and compare them with those of patients with reflux oesophagitis and controls.

METHODS

Seventy-nine patients who had undergone upper digestive endoscopy were recruited: 16 had short-segment Barrett's oesophagus, 13 had long-segment Barrett's oesophagus, 25 had grade III oesophagitis according to the Savary-Miller classification and 25 were used as controls. The diagnosis of Barrett's oesophagus was based on the histological detection of specialized intestinal metaplasia, which extended < 3 cm into the oesophagus in patients with short-segment disease and > 3 cm in patients with long-segment disease. All subjects underwent oesophageal manometry and basal 24-h oesophageal pH monitoring.

RESULTS

The lower oesophageal sphincter pressure was significantly lower in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus than in controls (P=0.0004-0.0001), but there was no difference among the three reflux groups. The peristaltic wave amplitude of patients with long-segment Barrett's oesophagus was significantly lower than that of controls (P=0.002) and patients with short-segment Barrett's oesophagus (P=0.02), but was no different from that of patients with reflux oesophagitis. The percentage of non-propagated wet swallows was significantly higher in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus when compared with that of controls (P=0.0004-0.0001). The total percentage of time the oesophagus was exposed to pH < 4.0 was significantly higher in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus (P=0.0001) than in controls, and was higher in patients with long-segment disease than in those with short-segment disease (P=0.01).

CONCLUSIONS

Long-segment Barrett's oesophagus is characterized by a greater impairment of peristaltic wave amplitude and a higher oesophageal acid exposure than is short-segment Barrett's oesophagus. However, both forms are linked to increased acid reflux.

Carditis, intestinal metaplasia and adenocarcinoma of oesophagogastric junction

Barrett's oesophagus is a precancerous condition in which the normal squamous epithelium is replaced by intestinal metaplasia (IM). IM can then progress through increasingly severe dysplasia to oesophageal adenocarcinoma (EAC). In the gastric cardia the normal gastric mucosa, when inflamed (carditis), can be replaced by IM and can then progress to gastric adenocarcinoma (GAC). The same histopathological sequence can take place on either side of the oesophagogastric junction. Since the location of that junction can be uncertain this can result in confused diagnosis between EAC and GAC. In this review, the diagnostic criteria, incidence and risk factors for Barrett's oesophagus and carditis are discussed, together with the factors determining the risk of progression to adenocarcinoma of the oesophagus or cardia. The risk factors include familial/genetic, environmental and dietary characteristics. Finally, these risk factors are discussed within the context of cancer prevention.

Endoscopic circumferential esophageal mucosectomy in a porcine model: an assessment of technical feasibility, safety, and outcome

BACKGROUND AND STUDY AIMS

Endoscopic mucosectomy has been performed for early cancers and dysplastic lesions < or = 2 cm in diameter. The feasibility and safety of mucosectomy for circumferential lesions of the esophagus is uncertain. The aim of this study was to determine the technical feasibility, as well as the short and long-term complication rates, with circumferential endoscopic mucosectomy of the distal esophagus in the pig.

MATERIALS AND METHODS

Circumferential endoscopic mucosectomy of the distal 3 cm of the esophagus was performed in four pigs, using a cap mucosectomy device. The animals were sacrificed after 30, 50, 70, and 90 days to assess mucosal regeneration and stricture formation.

RESULTS

The procedure time for circumferential endoscopic mucosectomy was 15-30 min. Circumferential endoscopic mucosectomy was technically feasible and without short-term complications. Videotapes of all resections were reviewed to ensure that complete removal of the mucosa was achieved. All mucosectomy specimens underwent histological evaluation. The specimens included the mucosa alone in three of the pigs. Some of the specimens in the fourth pig included a superficial layer of muscularis propria. This pig failed to thrive. Macroscopic examination of the dissected esophageal specimens from the healthy pigs revealed a well-healed, normal-appearing esophagus, whereas a stenosis of 4 x 10 mm was observed in the distal esophagus of the pig that failed to thrive.

CONCLUSIONS

Circumferential endoscopic mucosectomy of the porcine distal esophagus is feasible and safe. An adequate submucosal saline cushion is essential to prevent stenosis due to deep injury.

Secular trends in the epidemiology and outcome of Barrett's oesophagus in Olmsted County, Minnesota

BACKGROUND

The incidence of oesophageal adenocarcinoma has increased greatly. Barrett's oesophagus is a known risk factor.

AIMS

To identify changes in the incidence, prevalence, and outcome of Barrett's oesophagus in a defined population.

SUBJECTS

Residents of Olmsted County, Minnesota, with clinically diagnosed Barrett's oesophagus, or oesophageal or oesophagogastric junction adenocarcinoma.

METHODS

Cases were identified using the Rochester Epidemiology Project medical records linkage system. Records were reviewed with follow up to 1 January 1998.

RESULTS

The incidence of clinically diagnosed Barrett's oesophagus (>3 cm) increased 28-fold from 0.37/100 000 person years in 1965-69 to 10.5/100 000 in 1995-97. Of note, gastroscopic examinations increased 22-fold in this same time period. The prevalence of diagnosed Barrett's oesophagus increased from 22.6 (95% confidence interval (CI) 11.7-33.6) per 100 000 in 1987 to 82.6/100 000 in 1998. The prevalence of short segment Barrett's oesophagus (<3 cm) in 1998 was 33.4/ 100 000. Patients with Barrett's oesophagus had shorter than expected survival but only one patient with Barrett's oesophagus died from adenocarcinoma. Only four of 64 adenocarcinomas occurred in patients with previously known Barrett's oesophagus.

CONCLUSIONS

The incidence and prevalence of clinically diagnosed Barrett's oesophagus have increased in parallel with the increased use of endoscopy. We infer that the true population prevalence of Barrett's oesophagus has not changed greatly, although the incidence of oesophageal adenocarcinoma increased 10-fold. Many adenocarcinomas occurred in patients without a previous diagnosis of Barrett's oesophagus, suggesting that many people with this condition remain undiagnosed in the community.

Endoscopic treatment of pancreatico-biliary malignancies

Biliary obstructions, due to pancreatic cancer and cholangiocarcinoma, have an ominous prognosis. At the time of diagnosis, most patients are beyond any curative treatment. Palliative therapies, such as transhepatic biliary drainage, bypass surgery, and endoscopy, have an established role in the management of such patients. Endoscopic retrograde cholangio-pancreatography (ERCP) plays a key role, allowing diagnosis, collection of cytologic and bioptic specimens, and insertion of large-bore biliary stents. The major drawback of plastic stents is the high rate of clogging, requiring frequent stent exchange. In the 1990s, self-expanding metal stents (SEMS) were developed and randomized studies have shown their superiority over plastic stents. SEMS can be successfully used in patients with hilar tumors. Duodenal obstruction due to biliopancreatic neoplasms can also be managed endoscopically. ERCP can be performed on an outpatient basis in selected patients, reducing costs related to hospitalization. A team approach is mandatory to obtain the best results.

Postpolypectomy lower GI bleeding: descriptive analysis

BACKGROUND

Postpolypectomy hemorrhage may warrant intensive care monitoring, transfusions, and surgery. We sought factors predicting significant bleeding requiring blood transfusion and the benefits of critical care monitoring.

METHODS

Patients with postpolypectomy bleeding between April 1989 and November 1996 were identified from a comprehensive GI bleeding database. Data included age, gender, medical history, medications, polyp characteristics, and polypectomy technique. Outcomes assessed included bleeding cessation, transfusion requirements, recurrent bleeding, length of stay, and death.

RESULTS

There were 83 patients with a median age of 73 years (range 18 to 88 years; 56 men, 27 women). Comorbid conditions were common (71.1% cardiovascular, 43.4% musculoskeletal, 14.5% hematologic, 6.0% renal). Within 3 days of presentation, 32.5% had taken aspirin, 10.8% nonsteroidal anti-inflammatory drugs, 12.0% warfarin, and 12.0% corticosteroids; and within 1 day, 10.8% intravenous heparin, 7.2% subcutaneous heparin, and 7.2% dipyridamole. Fifty-seven percent of patients were hemodynamically stable. Sessile cecal polyps greater than 2 cm in diameter bled more commonly. The median number of units transfused was equal between critical care and noncritical care patients. Using age in the logistic regression model, no other variable was predictive of transfusion. Eighty patients (96.4%) received endoscopic therapy, 1 required embolization and 2 hemicolectomy. There was no significant difference in outcomes for patients managed in an intensive care unit versus a general medical floor.

CONCLUSIONS

Postpolypectomy bleeding appears to have a predictable presentation and outcome. Advanced age seems to be predictive of transfusion requirement. Patient monitoring in an intensive care setting is not absolutely necessary.

Gastroesophageal reflux disease: relationship between clinical and histological features. GOSPE. Gruppo Operativo per lo Studio delle Precancerosi dell'Esofago

Our purpose was to evaluate the relationship between the clinical and histological features in a cohort of patients who had gastroesophageal reflux-related lesions diagnosed after upper digestive endoscopy. In all, 589 patients scheduled for elective endoscopy in a multicentric prospective study were evaluated. Multiple biopsies from the distal esophagus showing aspects of esophagitis or metaplastic epithelium were taken. Esophagitis was histologically detected in 25.6%, gastric-type Barrett's esophagus in 36.2%, and specialized columnar epithelium in 33.1%. The frequency of esophagitis was constant across age decades. Patients with specialized columnar epithelium were significantly older (P = 0.01) and had a greater extent of metaplastic epithelium (P<0.0001). Specialized columnar epithelium was observed in 15% of patients with only distal esophagitis. In conclusion, endoscopic esophagitis was constant across age strata. The presence of specialized columnar epithelium was associated with older age and with longer segments of Barrett's esophagus. Short areas of esophagitis should be biopsied in view of their potential for holding areas of specialized columnar epithelium.

Extensive aetiological investigations in acute pancreatitis: results of a 1-year prospective study

BACKGROUND

Epidemiological data on acute pancreatitis are poorly defined.

AIMS

To prospectively evaluate the aetiology of acute pancreatitis and to assess the benefits of intensive investigations.

METHODS

In a prospective, 1-year study all cases of acute pancreatitis in the Nice catchment area were enrolled. Subjects underwent routine (serum calcium, phosphate and triglycerides; abdominal ultrasonography and CT scan) and additional, delayed intensive investigations (ERCP with bile sampling and/or endoscopy ultrasonography).

RESULTS

One hundred and twenty-one cases were included. After routine investigations, a biliary, alcoholic, miscellaneous or unknown origin was diagnosed in 43%, 31.4%, 9.9% and 15.7%, respectively. In subjects with biliary pancreatitis, 43% had no previous history of biliary disease. In the alcohol-related subgroup, pancreatitis recurred in 18.5% during 114.5 days mean follow-up. In subjects with a first episode of alcoholic pancreatitis, delayed supplemental investigations revealed underlying chronic pancreatitis in 92.8%. After routine investigations, a diagnosis of pancreatitis of unknown origin was made in 15.7% (n = 19) of subjects. Additional investigations revealed an underlying cause in 57.8% of these patients (n = 11), including malignancy (n = 3) and biliary disease (n = 4), reducing the overall rate of pancreatitis with no apparent cause to 6.6%.

CONCLUSIONS

Investigative techniques, particularly ERCP, will reveal the underlying aetiology of pancreatitis in the majority of patients presenting with 'idiopathic' pancreatitis and should be considered when routine tests are negative.

Endoscopic Nd:YAG laser therapy for villous adenomas of the right colon

BACKGROUND

Endoscopic laser therapy is considered an acceptable treatment of benign colorectal adenomas. The aim of our study was to evaluate the efficacy of Nd:YAG laser to ablate right-sided colonic sessile adenomas.

METHODS

Between January 1990 and February 1996, 56 patients underwent laser therapy because of high operative risk or refusal of surgery. Lesions were located as follows: cecum (23), ascending, (15), and hepatic flexure (18). Six patients (10.7%) had multiple polyps in the ascending colon. Histologic examination showed a tubulovillous pattern in 20 (35.7%) and a villous pattern in 36 (64.3%). Low-grade dysplasia was detected in 44 patients (78. 5%) and high-grade dysplasia in 12 (21.4%).

RESULTS

The number of laser sessions ranged between 1 and 6 (median 3) and complete ablation, histologically confirmed, was achieved in 49 cases (87.5%). Seven patients (12.5%) underwent surgery: 2 for incomplete tumor destruction, 3 because of invasive carcinoma on repeated biopsies. Two patients (3.6%) had complications (one perforation of the cecum and one hemorrhage). Follow-up ranged from 6 to 60 months and no recurrences were observed.

CONCLUSION

Laser therapy is an effective method for the destruction of sessile adenomas of the right colon in selected patients.

The role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease

BACKGROUND AND STUDY AIMS

Hydatid disease of the liver, and its complications, causes serious morbidity and mortality. We evaluated the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatic hydatid disease.

PATIENTS AND METHODS

This retrospective analysis includes 28 patients with hepatic hydatid disease who underwent ERCP. ERCP was performed preoperatively in 11 patients, for acute cholangitis (n =7), acute pancreatitis (n = 1) and right upper quadrant pain (n = 3), and in eight asymptomatic cases to search for fistulae between the cyst and the biliary tree. In a further nine patients ERCP was performed for early (< 30 days; n = 7) and late (n = 2) postoperative biliopancreatic problems.

RESULTS

In all seven patients with cholangitis preoperative ERCP with EST and ductal clearance of daughter cysts and debris led to substantial clinical improvement, including four acutely ill elderly patients who stabilized and were later able to undergo surgery. EST in two of the three patients with pain who had papillary stenosis led to resolution of the abdominal pain. Six of the seven postoperative fistulae could be successfully treated endoscopically using EST.

CONCLUSIONS

This study demonstrates the usefulness of ERCP in symptomatic patients with hepatic hydatid cysts; EST enables clearance of the common bile duct and allows healing of postoperative fistulae in the majority of patients. We do not, however, recommend performing routine preoperative ERCP in asymptomatic patients with the disease.

Self-expanding metal stents in the palliation of neoplasms of the cervical esophagus

BACKGROUND/AIMS

Self-expanding metal stents (SEMS) represent a major advancement in the palliative treatment of dysphagia caused by neoplasms of the esophagus. Malignant cervical stenoses are a challenge for palliative techniques, due to their close relationship with the cricopharynx.

METHODOLOGY

Six patients with a malignant stricture of the upper esophagus, within 2 cm of the cricopharyngeal muscle, were treated with a self-expanding metal stent. All patients had a circumferential squamous cell carcinoma histologically proven. Patients were intubated under general anesthesia, and the procedure was carried out under simultaneous endoscopic and fluoroscopic control.

RESULTS

All patients had a remarkable improvement of dysphagia and none of them reported a foreign body sensation. In 3 patients, an insufficient expansion of the stent, detected 24 hours later, required a balloon dilation in two of them, whereas, for the third patient, it was necessary to introduce a second stent. Neoplastic in- and overgrowth occurred in 4 (67%) patients after 1, 2, 4 and 8 months, respectively. These complications were managed by placing a second stent in 3 patients; in the fourth patient, a neoplastic involvement of the cricopharynx did not allow for an endoscopic examination. Improvement of dysphagia was observed only in the patient who received a covered Cook-Z stent. In the other 2 patients, a percutaneous endoscopic gastrostomy was performed. The only major complication occurred in the patient who received three metal stents, as he complained of severe cervical pain.

CONCLUSIONS

Our experience shows that uncovered self-expanding metal stents provide a good palliation in this subgroup of patients. Tumour ingrowth, overgrowth, and the progressive impairment of the swallowing mechanism due to a proximal submucosal infiltration remain complications difficult to solve.

Vascular disorders of the small bowel

Approximately 5% of all patients with gastrointestinal hemorrhage, and up to 38% of subjects with iron deficiency anemia without overt gastrointestinal bleeding, do not have a bleeding site identified after routine evaluation by esophagogastroduodenoscopy and colonoscopy. The source of bleeding in these subjects is often the small intestine. Most vascular lesions of the small bowel present as chronic gastrointestinal bleeding, which may severe in some cases. Depending on the underlying disease, other systemic signs and symptoms may be present. The diagnosis and often therapy are heavily dependent upon endoscopic techniques, and in some cases nonendoscopic methods.

Photodynamic therapy for gastrointestinal tumors using three photosensitizers--ALA induced PPIX, Photofrin and MTHPC. A pilot study

Photodynamic therapy (PDT) produces localized necrosis with light after prior administration of a photosensitizing drug. As PDT lesions in the gastrointestinal tract heal well, the technique is suitable for repeated endoscopic use. In this study we used PDT to treat benign and malignant gastrointestinal tumors in esophagus, duodenum and rectum in 22 patients, who refused or were not suitable for surgery. Patients were sensitized with 0.15 mg/kg of body weight with mesotetrahydroxyphenylchlorin i.v. m-THPc (2 patients), with 2.0 mg/kg Photofrin i.v. (4 patients) or 60 mg/kg 5-aminolevulinic acid orally ALA (which is converted in vivo to active derivate protoporphyrin IX-PRIX) in fractionated doses (16 patients). Laser treatment was performed 2 days after Photofrin, 2 and 4 days after mTHPc and 4 hours after ALA, using a metal vapour laser (628 nm, 50-150 J/cm2 for ALA and Photofrin, 650 nm and 10-15 J/cm2 for mTHPc). Using ALA, the necrosis was only superficial (up to 1.8 mm depth). Four patients treated with Photofrin showed deeper necrosis, in one case of 8 mm colon cancer complete response, in three cases 1-1.5 cm adenomatous polyps involving the ampulla Vateri 50% longer term reduction in size-seen endoscopically. Two patients with rectal villous adenomas treated with mTHPc showed 60-80% reduction in size (observed endoscopically) within few days after PDT, with better effects for treatment carried out 4 rather than 2 days after the sensitization. In all patients the healing was without any complications. Photofrin and mTHPc work better, but cause cutaneous photosensitivity lasting 12 and 5 weeks, respectively. Better results with ALA are possible when using higher drug doses or modified light dosimetry. PDT is a promising treatment for small localized tumors in patients unsuitable for surgery, but further work is required to optimize the treatment conditions.

The role of therapeutic endoscopy associated with extracorporeal shock-wave lithotripsy and bile acid treatment in the management of Caroli's disease

BACKGROUND AND STUDY AIMS

Caroli's disease causes relapsing episodes of cholangitis due to the presence of intrahepatic lithiasis. Strategies for cholangitis prevention are still widely debated. Ursodeoxycholic acid, hepaticojejunostomy, partial hepatectomy, or transplantation, have all been proposed as therapeutic options. The aim of this study was to evaluate the role of therapeutic endoscopy, and especially endoscopic sphincterotomy (ES), in the management of Caroli's disease.

PATIENTS AND METHODS

Between 1983 and 1995, six patients with Caroli's disease (mean age 52, range 17-75) underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. Sphincterotomy was performed if common bile duct stones were present. Extracorporeal shock-wave lithotripsy, (ESWL) or intraductal electrohydraulic lithotripsy (IEL) were performed if necessary.

RESULTS

The mean number of endoscopic sessions per patient was four (range three to seven). Sphincterotomy was performed in five patients and cholangioscopy in three. ESWL was performed twice in each of four patients. A Strecker expandable metal stent was placed in one patient to maintain sphincterotomy patency. In one patient, two sessions of IEL and pulsed laser were carried out. Complete clearance of intrahepatic stones was achieved in four of the six subjects (66.6%) and partial clearance in two patients. No morbidity or mortality was observed. During the follow-up (mean 6.2 years; range: 2.1-16.3), only two patients had acute cholangitis at nine months and three years, respectively, after the endoscopic treatment. Both had residual intrahepatic stones left after the initial endoscopic attempt at clearance.

CONCLUSION

ERCP is a necessary diagnostic procedure which should always be carried out in patients with Caroli's disease. Our experience shows that ES does not result in an increased incidence of cholangitis and that therapeutic endoscopy allows complete clearance of intrahepatic stones in the majority of patients with unresectable symptomatic Caroli's disease. Nevertheless, the oncological risk in these patients remains unchanged, and they still have an increased risk of cholangiocarcinoma.

Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy

AIM

Endoscopic retrograde cholangiopacreatography and associated therapeutic procedures are widely used in routine clinical practice. The changes in the upper gastrointestinal anatomy after a Billroth II anastomosis may present technical difficulties at endoscopic retrograde cholangiopacreatography.

METHODS AND PATIENTS

The case records of all patients who underwent endoscopic retrograde cholangiopacreatography at our Unit from January 1985 to December 1995 were reviewed. All patients who had had a previous Billroth II anastomosis or gastroenteroanastomosis were included in this analysis. Of the 5994 procedures performed, 124 patients with Billroth II surgery and 10 with a gastroenteroanastomosis were identified.

RESULTS

In these patients, the papilla was located in 89% of cases from 1985 to 1990 and in 100% of cases from 1991 to 1995. Overall, the success rates for pancreatography, cholangiography, and endoscopic sphincterotomy were 94%, 97.7%, and 100%, respectively. The morbidity and mortality rates were 7.4% and 0%, respectively.

CONCLUSIONS

The success rate for endoscopic retrograde cholangiopacreatography in patients with Billroth II gastrectomy is similar to that of a normal population.

[Acute inoperable cholecystitis treated by endoscopic naso-vesicular drainage. Study of 15 patients]

OBJECTIVES

Cystic duct cannulation during endoscopic retrograde cholangiography is now possible, due to advances in endoscopic equipment and methodology. The aim of this study was to assess the role of endoscopic transpapillary cholecystostomy in inoperable patients with acute cholecystitis.

METHODS

Between October 1993 and February 1996, cystic duct cannulation was performed in 15 patients with acute cholecystitis (9 men and 6 women; mean age 74.8 years. Acute calculous cholecystitis was associated with cholangitis in 4 cases, with pancreatitis in 2 cases, and with perforation of the gallbladder in 1 case.

RESULTS

Cystic duct cannulation was successful in 13 patients (86.6%), and resulted in remission of cholecystitis by nasovesicular drainage associated with antibiotherapy in all cases. No morbidity and mortality due to this method was observed at one month. No recurrence was observed after a mean follow-up of 8 months (range: 6 weeks-14 months).

CONCLUSION

This study suggests that endoscopic nasovesicular drainage is a good alternative treatment to percutaneous cholecystostomy in inoperable patients.

Is biliary lithogenesis affected by length and implantation of cystic duct? Study of 270 patients with endoscopic retrograde cholangiopancreatography

The gallbladder seems to play an important role in lithogenesis. Moreover, the morphology and the implantation of the cystic duct may also influence this process. Our purpose was to evaluate if the length and the implantation of the cystic duct may affect the formation of gallstones. Between April 1992 and March 1994, 270 patients who underwent endoscopic retrograde cholangiopancreatography were included in the study, and the radiological length of the cystic duct was carefully recorded. Patients were divided into two groups: I, absence of lithiasis: 113 patients (65 men, 48 women); and II, gallbladder lithiasis or lithiasis in the common bile duct with or without gallbladder lithiasis: 157 patients (73 men, 84 women). A statistically significant difference was observed among the two groups regarding the insertion of the cystic duct: implantation on the left side of the common bile duct represented a risk factor of lithiasis. The length of the cystic duct was not directly implicated. Hypokinesis of the gallbladder is currently recognized as being a major factor in the initial steps of lithogenesis, but the implantation of the cystic duct can play an important role by increasing cystic duct resistance and causing a reduced washout effect of the gallbladder contents, including cholesterol crystals.

Abdominal tuberculosis involving hepatic hilar lymph nodes. A cause of portal vein thrombosis and portal hypertension

Abdominal tuberculosis is a rare disease. Involvement of lymph nodes at the hepatic hilum responsible for jaundice is exceptional. We describe a 59-year-old woman in whom jaundice was the presenting feature, complicated by portal vein thrombosis and portal hypertension.

Incidence of Barrett's adenocarcinoma in an Italian population: an endoscopic surveillance programme. Gruppo Operativo per lo Studio delle Precancerosi Esofagee (GOSPE)

BACKGROUND

Barrett's oesophagus is a premalignant condition leading to adenocarcinoma. The incidence of adenocarcinoma of the oesophagus and the gastrooesophageal junction is rapidly increasing in the USA, northern and central Europe. Data from southern Europe are still unavailable.

OBJECTIVE

To evaluate the incidence of oesophageal adenocarcinoma in a large cohort of Italian patients with Barrett's oesophagus.

METHODS

A total of 344 patients (253 males and 91 females, age range 19-75 years) with histologically proven Barrett's oesophagus (length of metaplasia > or = 3 cm) were enrolled from November 1987 to June 1995. Endoscopic and histological examinations were scheduled at yearly intervals.

RESULTS

One hundred and eighty-seven patients complied with the follow-up. The mean duration of the follow-up period was 36 months (total follow-up 562 patient-years; range 12-90 months). Low grade dysplasia was found in five patients at the initial examination. During the surveillance period, dysplasia increased in frequency as well as in severity and was found exclusively in the intestinal type of Barrett's oesophagus. In all, dysplastic changes were found in seven patients (five low grade and two high grade) and adenocarcinoma developed in three patients during the follow-up. In a single case, both adenocarcinoma and specialized columnar epithelium developed without any evidence of dysplasia or intestinal metaplasia at the previous follow-up examination. This prospective study shows an incidence of adenocarcinoma in Barrett's oesophagus of 1/187 patient-years. When only patients with specialized columnar epithelium were considered, the risk of adenocarcinoma was 1/88 patient-years.

CONCLUSION

The present report shows that the incidence of adenocarcinoma in Italian Barrett's oesophagus patients is in the range of that reported from other Western countries.

Combined treatment with lasertherapy (Nd:YAG) and endocavitary radiation in the palliation of rectal cancer

BACKGROUND/AIMS

The ideal treatment for patients with advanced rectal cancer and who cannot undergo a radical therapy is still undefined. The association between lasertherapy (LT) and internal radiotherapy (IRT) could affect both technical results and quality of life. This study was aimed at evaluating the association of LT and IRT in the palliative treatment of rectal cancer.

MATERIAL AND METHODS

Between January and April 1994, 9 patients (2 males, 7 females) with rectal cancer underwent a combined treatment modality in order to control their symptoms. All patients were unfit for surgery and EUS showed an invasion of the whole muscular layer. After laser recanalization, brachytherapy was applied at a one week interval from last laser session. Two fractions of 10 Gy were administered at one week intervals.

RESULTS

The mean number of laser sessions to obtain a complete recanalization was 3 (range:2-5) and no complications occurred. After IRT, we obtained a good result in 7/9 patients (79%) and 2 patients required further LT. The mean follow-up was 146 days (range:74-240): during this period no laser treatment was performed. Four patients complained of acute perineal pain and tenesmus after brachytherapy: in one patient, a colostomy was performed.

CONCLUSION

We deem that the administration of two fractions of 10 Gy is not advisable, particularly for the treatment of non-circumferential lesions, due to the severe side effects we observed.

p53 is frequently mutated in Barrett's metaplasia of the intestinal type

Barrett's Esophagus (BE) is a complication of gastroesophageal reflux in which the normal squamous epithelium of the lower esophagus is replaced by metaplastic tissue. The clinical significance of this condition is the associated predisposition to adenocarcinomas (ADCs). Three types of BE have been characterized: the gastric fundic (F) type, the gastric cardial (C) type, and the intestinal (I) type. The latter is the most closely associated with the development of ADCs; the causes of this bias remain unknown. To determine whether p53 and/or K-ras gene alterations (a) are present in preneoplastic lesions and (b) are associated with a specific histotype, we performed PCR-based denaturing gradient gel electrophoresis (DGGE) analysis of exon 1 (codons 12-13) of K-ras gene and of exons 5-8 of the p53 gene in biopsies obtained from 30 patients with BE of the I type (9 patients), combined I type (I + C +/- F; 10 patients) and non-I type (C, F, or C + F; 11 patients). None of the cases under study revealed K-ras mutations, whereas biopsies from 12 patients showed at least one p53 DGGE variant. Four patients showed the exact same variants in leukocytes also (polymorphisms), whereas eight cases revealed specific DGGE variants only in biopsies. The molecular characterization of these variants revealed that four of them showed a single base pair substitution, and four showed multiple mutations. Of 17 somatic mutations, all but 1 were base pair substitutions located mainly in exons 7 and 8. The majority of these mutations were GC targeted (13 of 16; 81%), 54% (7 of 13) of which were transitions occurring at CpG sites. All somatic mutations were found in BE with at least one I component. The association with the histotype was statistically significant (P < 0.03; pure I type versus non-I type; P < 0.04, combined I type versus non-I type; Fisher's exact test). Loss of heterozygosity in the vicinity of the p53 locus was evaluated by PCR using a highly polymorphic variable number of tandem repeats marker on 25 out of 30 cases. Ninety-two % of the cases analyzed were informative, and none of them showed LOH. In conclusion, we showed that p53 mutations are frequently observed in specimens from BE patients of the I-type, whereas no involvement of K-ras (exon 1) mutational activation was observed. In light of the key roles that the p53 protein plays in controlling cell cycle and cell diploidy, this result may suggest why this type of metaplasia is the most closely associated to the development of ADCs.

[Hemorrhagic pancreatic cystadenocarcinoma with colonic fistula. An unusual mode of manifestation]

We report a case of a cystadenocarcinoma of the pancreatic tail, in a 85-year-old man. This tumor was successively revealed by a wirsungorrhagia and a hemorrhagic pancreatico-colic fistula. To our knowledge, it's an exceptional revelation of a pancreatic cystadenocarcinoma and the first case reported in the literature.

Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study

BACKGROUND

Nonsurgical pathologic confirmation of malignant bile duct strictures is desirable for defining subsequent treatment and prognosis. Endoscopic retrograde cholangiopancreatography is frequently performed in patients suspected of having pancreaticobiliary obstruction, but there exists no standardized method for defining the nature of obstructing lesions by ERCP.

METHODS

We prospectively evaluated the yields of endoscopic retrograde brush cytology and biopsy for the diagnosis of malignant bile duct strictures. Fluoroscopically guided endobiliary biopsy and brush cytology (52) or cytology alone (42) were performed during endoscopic retrograde cholangiopancreatography in 94 consecutive patients, 64 with malignant strictures and 30 with benign strictures. A single cytopathologist classified the results of these studies as positive or negative for malignancy.

RESULTS

The sensitivities of the two procedures were identical (53%) and the gain achieved by combining the two techniques (61%) was small. Specificity proved excellent for both methods. One major complication that occurred was perforation of the common hepatic duct with leakage of bile, which was managed by surgical oversewing. This complication was ascribed to biopsy and untimely removal of the nasobiliary drain by the patient herself.

CONCLUSIONS

This study indicates that endoscopic retrograde brush cytology alone may be sufficient in daily practice, at least in centers that have access to experienced cytopathologists. We recommend use of forceps biopsy in selected cases where brush cytology is negative.

Photodynamic therapy for polyps in familial adenomatous polyposis--a pilot study

Photodynamic therapy (PDT) produces localised necrosis with light after prior administration of a photosensitising drug. As PDT lesions in the gastrointestinal tract heal so well, the technique is suitable for repeated endoscopic use. In this study, PDT was used to treat large polyps (four duodenal and two colorectal) unsuitable for surgery in 6 patients with familial adenomatous polyposis (FAP). Patients were sensitised with 60 mg/kg 5-aminolaevulinic acid (ALA) orally or intravenous (i.v.) 2.0 mg/kg Photofrin. Laser treatment was performed 6 h after ALA or 48 h after Photofrin using a gold vapour laser. Necrosis was only superficial (up to 1.8 mm) using ALA but much deeper using Photofrin. The one malignant polyp (8 mm diameter in the colon) showed a complete response using Photofrin. All healed safely with no complications. Photofrin worked better, but caused cutaneous photosensitivity lasting up to 3 months. ALA cleared within 2 days, but its use is limited by the superficial effect. Better results with ALA may be obtained using higher drug doses or modified light dosimetry. Fluorescence microscopy showed no evidence of selectivity of photosensitisation between neoplastic and normal tissue. PDT is a promising treatment for inoperable polyps in patients with FAP, but further work is required to optimise the treatment conditions.