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.

Acute gastric anisakiasis: an Italian experience.

Anisakidosis is a parasitic disease of the human gastrointestinal tract caused by ingestion of larvae of marine nematodes such as Anisakis spp. or, rarely, Pseudoterranova spp., present in raw or undercooked fish. We report the first series of gastric Anisakis infection (anisakiasis) from a single centre in Italy. In our department, we observed 3 cases, all in women who were urgently hospitalized following intense epigastric pain and vomiting, developed after the ingestion of raw fish. The patients underwent urgent gastroscopy within a few hours. In each, a worm was extracted from the gastric mucosa by means of biopsy forceps. This was followed by prompt clinical improvement. The worm was identified by its macroscopic and microscopic characteristics as an Anisakis spp. larva (L3). In 2 cases, laboratory tests revealed marked leukocytosis and eosinophilia in the peripheral blood 3-4 days after ingestion of the raw fish. The diagnosis of anisakiasis can be made by endoscopy, radiology and abdominal ultrasound, but is often made only at surgery. In the gastric form of the disease, urgent gastroscopy has both a diagnostic and a therapeutic role, because the worm can be removed by means of biopsy forceps.

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.

Endoscopic surveillance of Barrett's Esophagus. Personal experience.

BACKGROUND: The possible progression of Barrett's Esophagus (BE) to carcinoma is well established: the incidence of cancer in BE is about 1.9-10% or 1/52-1/441 patients/year with a risk up to 30-125 times the normal population. Endoscopic surveillance can detect esophageal adenocarcinomas when they are early and curable. The purpose of endoscopic and histologic surveillance in patients with BE is to follow its evolution in order to characterize possible affiliation to a neoplastic risk group. METHODS: From 1998 to 2000 we have endoscopically identified 12 patients with EB, histologically confirmed: 9 males and 3 females, with a M/F ratio of 3:1 and an average of 45.25 years. RESULTS: During the endoscopic and histologic follow-up have observed the sequence from intestinal metaplasia with a low-grade dysplasia in one patient, confirmed after 2 months of treatment with double-dose pump inhibitor (PPI), to intestinal metaplasia with a high-grade dysplasia on biopsy samples done after vital staining with Lugol. So the patient had an endoscopic mucosal ablation, because he rejected esophagectomy. In the other patients without dysplasia, we used prokinetic drugs and PPI and we involved them in a follow-up every 2/3 years. CONCLUSIONS: Histological grading of dysplasia is currently the most important parameter used to follow-up patients with EB: the guidelines suggest a periodic endoscopic surveillance, from six months to 2 or 5 years, according to higher or lower risk of carcinoma arising, because there is no medical or surgical therapy able to decrease cancer risk.

[Colorectal cancer screening: comparison among strategies]. / Screening del cancro del colon-retto. Metodiche a confronto.

Colorectal cancer (CCR) screening is justified since CCR is 2nd leading cause of death for malignancy: most colorectal cancers arise from preexisting adenomatous polyps that remain clinically silent until presentation, often with advanced and incurable malignant disease. The merits and cost-effectiveness of screening for colorectal cancer are evident because the detection and removal of early carcinomas and adenomatous polyps reduces colorectal cancer mortality. Several screening methods are available, each of them presenting advantages and limits. Conventional colonoscopy is considered as the gold standard for the study of colon and, at present, it is the method of screening with the highest effectiveness in reducing CCR morbidity and mortality. However, the use of colonoscopy as the most important screening strategy is limited, because it causes major complications, it has a low compliance, and there are few specialized structures and few specialists to carry out a high number of colonoscopies as screening methods. The screening strategies used at present are described and their advantages and limits are compared.

[Rare causes of serious digestive hemorrhages]. / Le gravi emorragie digestive da cause rare.

The rare causes of massive hemorrhage in the gastrointestinal tract are not completely classifiable. They are characterized by high variability, as shown in several isolated reports. In our experience of 17 cases, clinical and endoscopic features were sometimes typical of a rare pathology, others were referable to common pathologies and exactly diagnosed only by angiography or surgery. Our experience points out the difficulties in the surgical prescription and timing, when the endoscopic diagnosis was lacking or unsure, or when a massive haemorrhagic recurrence forced diagnostic laparatomy. The role of endoscopy and the advantages of intraoperative enteroscopy have been compellingly demonstrated. Diagnostic and therapeutic angiography has been the main method in vascular hemorrhage.

[Hartmann's operation in acute perforated diverticulitis]. / L'intervento di Hartmann nella diverticolite acuta perforata.

Acute perforated diverticulitis of the colon is still a serious clinical event that requires an emergency treatment which is based upon clinical staging and pathological characteristics. Surgical treatment, performed in Hinchey's stages III and IV, is correlated with the presence of infection in the peritoneal cavity: it is always necessary to remove the septic focus, but there are different reconstruction strategies. The resection of the diseased colonic segment can be performed with primary anastomosis or Hartmann's operation with reconstruction in a later time. In our experience, based on 97 patients (33 of which, Hinchey's III and IV, underwent emergency surgical treatment) we preferred Hartmann's operation which carries a low risk of mortality in seriously ill patients.

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.