Indocyanine Green Tattooing During Colonoscopy as a Guide to Laparoscopic Colorectal Cancer Surgery: A Literature Review.

BACKGROUND: Endoscopic tattooing of colorectal lesions has been performed employing several markers. The indocyanine green (ICG) that uses near infrared fluorescence technology, has been recently adopted in laparoscopic colorectal cancer surgery. This study aims to systematically review the international literature to validate the ICG in laparoscopic colorectal surgery, in order to include the ICG in the therapeutic protocol. METHODS: Following AMSTAR 2 criteria, we performed a systematic review to evaluate the use of green indocyanine as a marker for preoperative endoscopic tattooing and for lymph nodes mapping. The study selection was conducted using the PubMed database from January 1989 to July 2022. RESULTS: We identified 25 eligible studies. 13 based on fluorescent tumor localization in laparoscopic colorectal surgery using ICG while 12 of them reported the lymphatic road mapping and sentinel node identification by ICG using a near-infrared camera system. One study analyzed both topics. CONCLUSIONS: In laparoscopic colorectal cancer surgery indocyanine green can be used to localize fluorescent tumors and mapping fluorescence lymph node. The use of ICG appears to be a valid and safe technique that helps the surgeon to achieve a better oncological radicality. However, the protocols need to be clarified by further studies.

Prevalence and Natural History of Segmental Colitis Associated With Diverticulosis.

INTRODUCTION: We assessed the prevalence and clinical outcomes of segmental colitis associated with diverticulosis (SCAD) in patients with newly diagnosed diverticulosis. METHODS: A 3-year international, multicenter, prospective cohort study was conducted involving 2,215 patients. RESULTS: SCAD diagnosis was posed in 44 patients (30 male patients; median age: 64.5 years; prevalence of 1.99%, 95% confidence interval, 1.45%-2.66%). Patients with SCAD types D and B showed worse symptoms, higher fecal calprotectin values, needed more steroids, and reached less likely complete remission. DISCUSSION: Although SCAD generally had a benign outcome, types B and D were associated with more severe symptoms and worse clinical course.

Sizzling Fat-Curative Endoscopic Resection of a Giant Lipoma Causing Colo-Colic Intussusception.

Giant colonic lipomas, tumors that infrequently occur in the gastrointestinal tract, can manifest as bleeding, abdominal pain and, in few cases, obstruction with intussusception. Surgery is usually the treatment of choice. We report the case of a 78 years-old woman with abdominal pain, constipation, and bleeding due to a giant lipoma of the sigmoid colon causing intussusception. After an initial diagnostic colonoscopy, the patient underwent an endoscopic mucosal resection (EMR) without complications. Even if surgery is traditionally the primary therapeutic approach for giant colonic lipomas, selected cases can be successfully treated with EMR.

Novel Modality of Endoluminal Anastomotic Integrity Assessment with Fluoroangiography After Left-sided Colorectal Resections.

BACKGROUND: Several methods have been described for the intraoperative evaluation of colorectal anastomotic integrity. Technological evolution has allowed to progress from basic mechanical methods to the use of more sophisticated techniques. This study describes a novel endoluminal modality of colorectal anastomotic assessment through the use of a Disposable Rigid Scope Introducer (DRSI) also allowing for intraoperative endoluminal perfusion evaluation by indocyanine green (ICG) fluoroangiography in patients undergoing left-sided colorectal resection. METHODS: The DRSI consists of an endoluminal introducer device made up of an insertion tube and port connected to an insufflation bulb to manually insufflate the sigmoid and rectum and is compatible with any laparoscopic camera, also allowing for ICG fluoroangiography for perfusion purposes. RESULTS: The DRSI was successfully used to assess anastomotic integrity after left-sided colorectal resections performed in 16 consecutive patients. The DRSI allowed to visualize by fluoroangiography the quality of tissue perfusion at the anastomotic site in all cases, contributing to the decision of avoiding loop ileostomies in low rectal resections. In 2 cases, the DRSI showed the presence of significant anastomotic bleeding which was successfully controlled by laparoscopic suture placement. No adverse event resulted from the use of this device. CONCLUSIONS: The DRSI combines direct endoluminal visualization of the anastomosis together with real-time evaluation of its blood flow. This device holds great potential for prompt intraoperative detection of anastomotic alterations, possibly reducing the risk of postoperative anastomotic bleeding or leaks related to mechanical construction/perfusion issues. Potential advantages of this device warrant larger cohort studies and prospective randomized trials.

Prognostic performance of the 'DICA' endoscopic classification and the 'CODA' score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study.

OBJECTIVE: To investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA). DESIGN: A multicentre, prospective, international cohort study. SETTING: 43 gastroenterology and endoscopy centres located in Europe and South America. PARTICIPANTS: 2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications. INTERVENTIONS: A 3-year follow-up was performed. MAIN OUTCOME MEASURES: To predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score). RESULTS: The 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p<0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p<0.001), respectively. The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10% and <2.5% in CODA B; >10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981). CONCLUSIONS: DICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score. TRIAL REGISTRATION NUMBER: NCT02758860.

Sheep in Wolf's Clothing: Pedunculated Colonic Lipoma with Overlying Hyperplastic and Ulcerated Epithelium.

INTRODUCTION: Lipomas are the most common non-epithelial benign tumors of the gastrointestinal tract with a reported incidence in the colon of 0.2-4.4%. These lesions are usually asymptomatic with a typical endoscopic finding of a smooth, slightly yellow, circular, polyp that is sessile in most cases, covered with normal colonic mucosa. AREAS COVERED: There are rare reported cases of alterations of the overlying mucosa such as hyperplasia, atrophy, adenomatous changes, and necrosis. EXPERT COMMENTARY: We report a rare case of pedunculated colonic lipoma of the transverse colon covered with hyperplastic and ulcerated epithelium easily misdiagnosed as an adenomatous lesion.

Procedural Anxiety, Pain Catastrophizing, and Procedure-Related Pain during EGD and Colonoscopy.

OBJECTIVES: Although sedatives and analgesic drugs defuse anxiety and relieve pain, digestive endoscopy still is uncomfortable and painful for some patients. Identifying patients who tolerate digestive endoscopy less well remains difficult. The present study evaluated the relations between procedural anxiety, catastrophizing thoughts, and pain, using a prospective design and multimodal assessments of pain. METHODS: A total of 118 consecutive patients were assessed for procedural anxiety before endoscopy. During endoscopy, a doctor rated the patients' pain behavior. Before discharge, the patients retrospectively rated endoscopy pain and related catastrophizing thoughts. RESULTS: Notwithstanding sedation, our study revealed large between-subject variability in pain. Catastrophizing thoughts mediated the relation between procedure-related pain observed by the doctor and pain intensity reported by the patient. Catastrophizing thoughts also mediated the effect of procedural anxiety. Our study showed that anxiety exacerbates endoscopy pain when the patient engages in ruminative thinking and feels unable to cope with unpleasant bodily sensations. CONCLUSIONS: This study shows that catastrophizing thoughts account for between-subject differences in endoscopy pain. Rumination and helplessness but not magnification explain how procedural anxiety may evolve in a painful endoscopy experience. To the extent that one can address catastrophizing thoughts, endoscopy pain can be mitigated, especially for patients who are difficult to sedate.

Caiman Versus LigaSure Hemorrhoidectomy: Postoperative Pain, Early Complications, Long-Term Follow-up, and Costs.

Purpose. Recently, the use of radiofrequency for hemorrhoidectomy has minimized incidence of postoperative complications. Effectiveness of LigaSure is demonstrated, but it is quite expensive. This study aims to compare LigaSure with Caiman, a cheaper instrument that uses radiofrequency for hemorrhoidectomy. Methods. A total of 35 patients were enrolled in this study between January 2015 and December 2017: 35 (Group A: Caiman) patients were matched with 35 control patients (Group B) from our historical cohort, treated with LigaSure. They were checked at 1 week after operation, at 4 weeks, and then after 2, 6, and 12 months. We considered different factors: intraoperative (operative time, number of piles removed, necessity of stiches or ligation), immediate postoperative (pain, bleeding within 4 weeks, incontinence, soiling within 4 weeks, healing time of anal wounds, return to working activities), and with a long-term follow-up. Results. There were no statistically significant differences between the 2 groups in analyzed intraoperative data: operative time (Group A 35 minutes vs Group B 33 minutes; P = .198) and stitches used. Postoperative data were comparable too, in particular pain (Group A 1 day Visual Analog Score = 6.25 vs Group B = 5.4, P = .178; Group A 1 week Visual Analog Score = 2.7 vs Group B = 1.14, P = .22) and bleeding (Group A = 2 vs Group B = 4; P = .2). Conclusions. According our initial experience, Caiman can be a safe and cheaper alternative to LigaSure for hemorrhoidectomy.

Efficacy of Sedation by Midazolam in Association With Meperidine or Fentanyl and Role of Patient Distress During Elective Colonoscopy.

Meperidine and fentanyl are opioids currently used in addition to midazolam for sedation and analgesia during colonoscopy in Italy. The aim of the study was to assess the impact of patients' psychological state before elective colonoscopy on the efficacy of the sedation regimens. Eighty outpatients who underwent an elective colonoscopy were included in our study. The Hospital Anxiety and Depression Scale questionnaire was self-administered to evaluate basal anxiety and depression state. The rate of baseline discomfort was evaluated by a standard 100-mm visual analog scale. Sedation was obtained alternatively with a midazolam-meperidine or midazolam-fentanyl combination. There were no statistically significant differences between the fentanyl and meperidine groups on body mass index, age, and gender composition. Patients in the meperidine group reported less pain during colonoscopy than patients in the fentanyl group. There were statistically significant positive correlations in the meperidine group with the distress, anxiety, and depression. Our study has pointed out greater effectiveness of the midazolam plus meperidine regimen, equal recovery times, and no significant differences in the duration of the endoscopic examinations. The evaluation of patients' psychological status seems to predict the efficacy of sedation when the nociceptive component of pain is well controlled.

Helicobacter pylori infection: antibiotic resistance and eradication rate in patients with gastritis showing previous treatment failures.

Forty patients infected by Helicobacter pylori were studied. The treatment was based on the positivity or negativity of cultures (tailored therapy or empiric therapy). The eradication rate was 68% and 82% respectively. Genotypic susceptibility testing proved very useful in case of heteroresistance or mixed infections that represent a real problem possibly leading to a resistance underestimation. Real-time PCR detected the resistant population at a very low concentration not detectable by phenotypic tests. Bismuth quadruple therapy (PPI, bismuth, metronidazole, tetracycline, PBMT) was effective in the Hp eradication rate consistent with a high level of clarithromycin resistance.

Management of concomitant hyperparathyroidism and thyroid diseases in the elderly patients: a retrospective cohort study.

BACKGROUND: Thyroid disease and hyperparathyroidism are the most common endocrine disorders. The incidence of thyroid disease in patients with hyperparathyroidism ranges in the different series from 17 to 84%, and thyroid cancer occurs with an incidence ranging from 2 to 15%. AIM: The aim of our study was to analyze the management of elderly patients with concomitant thyroid and parathyroid disease in order to define the best surgical therapeutic strategy and avoid reoperations associated with a higher risk of complications. METHODS: All consecutive patients (64 patients, age range 60-75 years), undergoing surgery for hyperparathyroidism, from January 2011 to June 2014, were retrospectively evaluated. Enrolled patients were divided into two study groups of patients affected by hyperparathyroidism with or without a concomitant thyroid disease. RESULTS: Out of 64 patients enrolled in our study (24 men, age range 60-75 years), affected by hyperparathyroidism, 34 had an associated thyroid disease and were treated with total thyroidectomy and parathyroidectomy. The group, who underwent parathyroidectomy associated with thyroidectomy, had no greater complications than the group receiving only parathyroidectomy. CONCLUSIONS: Thyroid disease must be excluded in patients affected by hyperparathyroidism. It is difficult to determine whether hyperparathyroidism can be considered a risk factor for thyroid disease, but an accurate preoperative study is essential for a surgery able to treat both thyroid and parathyroid disease. In this way, we avoid the elderly patient, with associated morbidity and increased surgical risk, to undergo a reoperation for thyroid disease, burdened with major complications.

Endoscopic mucosal resection in elderly patients.

BACKGROUND: Endoscopic mucosal resection (EMR) of early superficial colorectal carcinomas is nowadays accepted as the gold standard treatment for this type of neoplasia. AIM: This study aims to evaluate the efficacy and safety of mucosectomy in elderly patients considering the predictive value of submucosal infiltration. METHODS: A retrospective study of all patients referred for EMR of sessile colorectal polyps classified IIa by the Paris classification between April 2013 and April 2015. A total of 50 patients (30 males (60 %); age range = 44-86; mean age = 67.7) were enrolled. Patients were divided in two groups considering 65 years as cutoff to individuate the elderly patients. RESULTS: EMR was performed in 53 lesions: 39 were performed en bloc and 14 by piecemeal technique. 30 % of lesions were in the rectum; 11 % in the sigmoid colon; 15 % in the descending colon; 6 % in the transverse colon; 24 % in the ascendant colon; and 14 % in the cecum. The mean size of the resected specimens was 20 mm (range 8-80 mm). The rate of complete resection was 79.2 %, incomplete 13.2 %, not estimable 7 %. Ten patients underwent surgery because of an incomplete resection and/or histological evaluation. CONCLUSIONS: Colon EMR is safe and effective in elderly patients. Endoscopy is still helped in the correct indication for surgery in high-risk surgical patients.

Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient.

BACKGROUND: Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long. AIMS: The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients. METHODS: A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique. RESULTS: Success rate was 97.7% with a healing time of 4 weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed. DISCUSSION: Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed. CONCLUSIONS: Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.

Anti-transglutaminase immunoreactivity and histological lesions of the duodenum in coeliac patients.

Coeliac disease (CD) is characterized by several markers, including anti-transglutaminase auto-antibodies (tTGAb) directed against multiple epitopes of the gliadin protein. We aimed to investigate the correlation among CD duodenal lesions, tTGAb titres and the immunoreactivity against tTG constructs. A total of 345 CD patients (209 females, 136 males, overall median age: 7.3 years) were tested for full-length (fl) tTGAb with a fluid-phase radioimmunoassay. Out of the total, 231 patients were also tested for immunoreactivity against tTG fragments (F1: a.a. 227-687 and F2: a.a. 473-687). Patients were classified according to diffuse (D), patchy (P) or bulb (B) histological lesions. All sera were found fltTGAb positive. Patients with D, P and B lesions had a mean Ab index of 0.84±0.39, 0.57±0.39 and 0.45±0.24, respectively. Mean tTGAb titre varied between D and localized (P+B) patients (0.84±0.39 versus 0.52±0.34, P < 0.0001). Overall, 86.1% of patients were F1 auto-antibody (F1Ab) positive (D: 89%, P: 75%, B: 40%; D versus P+B: P = 0.004) and 49% of patients were F2 auto-antibody (F2Ab) positive (D: 53%, P: 19%, B: 10%; D versus P+B: P = 0.0006). Of the D patients 50.7% showed combined F1Ab-F2Ab (D versus P+B: P = 0.001), whereas 60% of B patients were negative for both F1Ab and F2Ab (B versus D: P < 0.0001). Coeliac-specific tTGAb immunoreactivity correlates with the grading and extension of histological duodenal lesions in CD patients at diagnosis. The immunoreactivity against single and combined tTG fragments is significantly higher in patients with D lesions. This is the first evidence of a distinct coeliac-specific immunoreactivity in patients with different duodenal involvement.

Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment.

PURPOSE: Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically. Rectal instillation of formalin solution has been described as a successful treatment for chronic radiation-induced hemorrhagic proctitis resistant to medical treatment. We present our results in patients undergoing treatment with application of 4 % formalin for radiation-induced injury to the rectum. METHODS: All patients were treated under anesthesia by direct application of 4 % formalin solution to the affected rectal areas. Patient gender, initial malignancy, grade of proctitis, need for blood transfusion, previous therapy, number of applications and response to treatment with formalin, complications, and length of follow-up were reviewed. RESULTS: A total of 15 patients with a mean age of 68.9 (range, 48-77) years were followed for 31.3 (range, 18-51) months. The mean interval from the conclusion of radiotherapy and the onset of symptoms was 6.9 months. The mean duration of hemorrhagic proctitis before formalin application was 7.9 months. Ten patients had only one formalin application and five patients required a second application because of the persistent bleeding. Thirteen patients (87 %) had complete cessation of bleeding. No complications related to the formalin treatment were observed. CONCLUSIONS: According to a revision of the literature and our experience, despite the small number of patients in our trial, we can state that the application of 4 % formalin solution is an effective, safe, and well-tolerated treatment for chronic radiation-induced hemorrhagic proctitis with minimal discomfort and no severe complications.

A case report of a colouterine fistula treatment: when the patient chooses the steeplechase.

Colouterine fistula is a rare disease that is primarily treated using surgical approaches. Although invasive surgery is controversial in terms of techniques and results, minimally invasive endoscopic treatments have not been widely described. However, because it is rare for these fistulas to close spontaneously, surgical treatment is often mandatory. Appropriate management of colouterine fistula is complicated, especially when the patient refuses surgery. In this case study, we provide the first description of a minimally invasive endoscopic treatment of an iatrogenic colouterine fistula using a self-expandable metallic stent after an over-the-scope clip malposition.

Transperineal excision of malignant peripheral nerve sheath tumors of the ischiorectal fossa: Case report of a rare tumor in a frequently forgotten anatomical region.

INTRODUCTION AND IMPORTANCE: Malignant peripheral nerve sheath tumor is an aggressive tumor that arises from peripheral nerves. Frequently associated with neurofibromatosis, its common localization is in the extremities, trunk (with paravertebral regions), neck and head. Some cases have been found in the pelvis or uterus. In this case report we illustrate one of the rarest localization of this type of tumor in the ischiorectal fossa, with the full recovery of the patient after surgical excision and radiotherapy. CASE PRESENTATION: A 61-year-old woman showed a lump near the anus which was initially diagnosed as a lipoma of the right ischiorectal fossa, by Computed Tomography scan. The tumor was completely removed with a minimal skin incision, and the patient had a complete recovery. Only the pathological examination determined the diagnosis of malignant peripheral nerve sheath tumor, in this unusual localization. In consideration of its high aggressiveness the patient underwent radiotherapy. After more than two years of follow-up there is no sign of recurrence. DISCUSSION: In sites far from branches of nerves, malignant peripheral nerve sheath tumors can be considered episodic. Ischiorectal fossa is a rare localization, and the differential diagnosis from benign mesenchymal cell tumors can be challenging. When possible, a biopsy should be performed before surgery. CONCLUSION: Surgical excision of tumors in ischiorectal fossa should be always complete, in consideration of possible histological surprise.

Endocuff Vision-Assisted Resection for Difficult Colonic Lesions-Preliminary Results of a Multicenter, Prospective Randomized Pilot Study.

Background-Screening programs for colorectal cancer are implemented due to their ability to reduce mortality. The Endocuff Vision is a new endoscopic device that significantly improves the adenoma detection rate. The primary outcome was to assess the efficacy of ECV in improving stability and reducing operation time during difficult colon polypectomies in a multicenter randomized prospective study. Methods-In a randomized multicenter pilot study, two groups of patients who underwent difficult polypectomies with and without the assistance of Endocuff Vision were compared. Demographics and clinical characteristics of patients were obtained, and polyps' size, morphology, site, and access (SMSA); polypectomy time; and endoscope stability were evaluated. Results-From October 2016 to April 2020, 32 patients were enrolled. In total, 12 patients underwent Endocuff Vision polypectomy, and 20 patients underwent standard polypectomy by using a computer-generated random number table. No statistical differences were found in clinical characteristics, SMSA, and polypectomy time. The most interesting findings were the positive correlations between shaking and SMSA (r = 0.55, p = 0.005) and shaking and polypectomy time (r = 0.745, p < 0.0001). Conclusion-Endocuff Vision seems to be adequately stable during difficult endoscopic resection procedures. The new parameter proposed that shaking is strongly correlated to the stability of the endoscope, the difficulty of the resection (SMSA), and the polypectomy time.

Diverticular Disease Worsening Is Associated with Increased Oxidative Stress and Gut Permeability: New Insights by Circulating Biomarkers.

Diverticular disease (DD) management is impaired by its pathogenesis, which is still not completely defined, with an unmet clinical need for improved therapies. Ex vivo DD human models demonstrated the presence of a transmural oxidative imbalance that supports an ischemic pathogenesis. This study aimed to assess, with the use of circulating biomarkers, insights into DD pathogenesis and possible therapeutic targets. Nox2-derived peptide, H2O2, antioxidant capacity, isoprostanes, thromboxanes, TNF-α, LPS and zonulin were evaluated by ELISA in healthy subjects (HS) and asymptomatic and symptomatic DD patients. Compared to HS, DD patients presented low antioxidant capacity and increase in sNox2-dp, H2O2 and isoprostanes paralleled to a TNFα increase, lower than that of oxidative markers. TxB2 production correlated to Nox2 and isoprostanes, suggesting platelet activation. An increase in zonulin and LPS highlighted the role of gut permeability and LPS translocation in DD pathogenesis. The increase of all the markers statistically correlated with DD severity. The present study confirmed the presence of a main oxidative imbalance in DD and provides evidence of platelet activation driven by LPS translocation. The use of circulating biomarkers could represent a new clinical tool for monitoring disease progression and validate therapeutic strategies never tested in DD as antioxidant supplementation.