Efficacy of a computer-aided detection system in a fecal immunochemical test-based organized colorectal cancer screening program: a randomized controlled trial (AIFIT study).

BACKGROUND: Computer-aided detection (CADe) increases adenoma detection in primary screening colonoscopy. The potential benefit of CADe in a fecal immunochemical test (FIT)-based colorectal cancer (CRC) screening program is unknown. This study assessed whether use of CADe increases the adenoma detection rate (ADR) in a FIT-based CRC screening program. METHODS: In a multicenter, randomized trial, FIT-positive individuals aged 50-74 years undergoing colonoscopy, were randomized (1:1) to receive high definition white-light (HDWL) colonoscopy, with or without a real-time deep-learning CADe by endoscopists with baseline ADR > 25 %. The primary outcome was ADR. Secondary outcomes were mean number of adenomas per colonoscopy (APC) and advanced adenoma detection rate (advanced-ADR). Subgroup analysis according to baseline endoscopists' ADR (≤ 40 %, 41 %-45 %, ≥ 46 %) was also performed. RESULTS: 800 individuals (median age 61.0 years [interquartile range 55-67]; 409 men) were included: 405 underwent CADe-assisted colonoscopy and 395 underwent HDWL colonoscopy alone. ADR and APC were significantly higher in the CADe group than in the HDWL arm: ADR 53.6 % (95 %CI 48.6 %-58.5 %) vs. 45.3 % (95 %CI 40.3 %-50.45 %; RR 1.18; 95 %CI 1.03-1.36); APC 1.13 (SD 1.54) vs. 0.90 (SD 1.32; P  = 0.03). No significant difference in advanced-ADR was found (18.5 % [95 %CI 14.8 %-22.6 %] vs. 15.9 % [95 %CI 12.5 %-19.9 %], respectively). An increase in ADR was observed in all endoscopist groups regardless of baseline ADR. CONCLUSIONS: Incorporating CADe significantly increased ADR and APC in the framework of a FIT-based CRC screening program. The impact of CADe appeared to be consistent regardless of endoscopist baseline ADR.

A multicenter survey on endoscopic retrograde cholangiopancreatography during the COVID-19 pandemic in northern and central Italy.

Background and study aims COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19. Patients and methods We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020. Results We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP. Conclusion The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.

[Complicated diverticular disease of the colon: 5 years' experience in a provincial hospital]. / La malattia diverticolare complicata del colon: esperienza di 5 anni in un ospedale di provincia.

Colon diverticular disease presents in 10%-25% of cases when a complication arises. Helped by Hinchey's classification, the surgeon can choose from among the following therapeutic strategies: a) medical treatment; b) one-stage resection and anastomosis with or without a protective colostomy; and c) resection according to Hartmann. The increasingly widespread use of laparoscopic techniques, though generally improving surgical outcomes, has perhaps made the choice of treatment more difficult, because it has extended the range of indications, both in the elective and emergency setting. From January 1999 to December 2004 411 patients (174 men and 237 women) affected by symptomatic diverticular disease were admitted to our surgical department and 94 of these (22.8%) underwent surgery: 41 of them (43.6%) underwent a true emergency operation, while for 53 of them surgery was delayed (within one week). None of the patients undergoing resection-anastomosis had a protective colostomy. The total morbidity was 3.7% and total perioperative mortality 1% (one patient undergoing surgery with the Hartmann procedure). More than one year after the end of the research there was no need for operation of any of the non-surgical patients and no deaths due to diverticular disease were recorded. On the basis of our experience we may conclude that a one-stage resection, even in the emergency situation, is possible and yields excellent results, while preventive resection would not currently seem justified.

[Merkel cell carcinoma: a report of two cases]. / Carcinoma a cellule di due osservazioni.

The Authors report two cases of Merkel cell carcinoma and describe their diagnostic and therapeutic difficulties in the management of these tumours. The main therapeutic problem consists in establishing the size of the excision margins in relation to the neoplastic aggressiveness. The first case was characterised by major lymphophilia and by a tendency to relapse. Radical excision was achieved by low invasive surgery using a radioguided technique to search for microscopic disease. The radioguided technique takes the place of the intra-operative anatomo-pathological examination. After adjuvant ra- diotherapy and chemotherapy the patienthas remained in remission for three years. The second case is characterized by a rapid haematic diffusion with metastasis and exitus after one year. Radiotherapy and chemotherapy were ineffective. In this case surgery was limited to a bioptic approach since extirpative surgery would have been inappropriate. Our experience shows the wide biological variability of Merkel cell carcinoma and the importance of eclectic treatment to avoid ineffective extirpative surgery.

[Traumatic rupture of the pancreatic isthmus complicated by concomitant rupture of the duodenum and right kidney]. / Rottura traumatica dell'istmo pancreatico complicata da rotture concomitanti del duodeno e del rene destro.

The Authors describe a case of complete traumatic transection of the pancreatic isthmus associated with complete transection of the first portion of the duodenum and the isthmus of a horseshoe kidney. The treatment of the pancreatic lesion was intestinal drainage of the distal portion of the pancreas and closure of the proximal one. The authors stress the advantages and good outcome of the conservative operation, performed at an early stage, with the clinical indications and adequate surgical techniques.

[Gastrin-secreting neuroendocrine carcinoma: two cases identified and treated surgically with a radio-guided technique]. / Carcinoma neuroendocrino a secrezione gastrinica: due casi identificati e trattati chirurgicamente con tecnica radioguidata.

The authors present two cases of gastrin-producing carcinoma demonstrated by scintigraphy with In-111 pentetreotide. The possible malignant evolution of such tumours and the good results that can be achieved with surgical therapy suggest the usefulness of a radio-guided intraoperative strategy to locate the lesions and minimise invasive procedures. This approach enabled us to detect a lymph-node metastasis concealed in the adipose tissue in the first case and to exclude any other gastrin-producing tumour localisations in the second. We recommend that the radio-guided strategy should be included among the guidelines for the treatment of gastrinomas and believe that the procedure can also be used in other functioning endocrine tumours.

[Colonic perforation after colonoscopy: our experience]. / Perforazioni del colon a seguito di colonscopia: nostra esperienza.

The authors describe 6 cases of perforation during colonoscopy, occurring over the period from 1981 to 2001, out of a total of 7358 endoscopic examinations performed. Five of these perforations were found as complications of operative colonoscopy. In one case the endoscopic view of the omentum immediately revealed the perforation. Four patients underwent surgical treatment and in two cases medical therapy was implemented. In agreement with the literature, the authors stress that the management of iatrogenic colon perforations is quite difficult and depends upon the clinical features. While conservative treatment is indicated in minimal perforations in patients in good general condition with no signs of peritoneal irritation, surgery must be performed in all uncertain situations. A delay in performing surgical treatment may sometimes prove fatal.

[Bleeding small bowel angiodysplasia: unusual form of conservative treatment]. / Angiodisplasia sanguinante del tenue: un insolito trattamento conservativo.

The authors report a case of gastrointestinal bleeding caused by angiodysplasia of the small bowel. They stress the rarity of the lesion and consider the difficulties involved in obtaining a preoperative diagnosis. Intra- or pre-operative enteroscopy seems to be the most suitable method for identifying the source of occult small-bowel bleeding. The optimal management is uncertain and depends on the severity and rate of the bleeding. A conservative medical approach is indicated for many patients, while surgery constitutes definitive treatment in cases of massive haemorrhage or recurrent bleeding. The authors describe a case in which the diagnosis was reached only at intra-operative enteroscopy and an unusual conservative surgical treatment was performed based on ligation of the vascular elements of the angiodysplasia. This method makes it possible to avoid an intestinal resection and yields good results.

[Complicated diverticular disease of the right colon. Diagnostic and therapeutic difficulties: our experience]. / Malattia diverticolare complicata del colon destro. Difficoltà diagnostico-terapeutiche: nostra esperienza.

Right colon diverticulitis is an uncommon disease in Western countries. Often the disease is congenital and the clinical manifestations presenting at onset simulate the signs and symptoms typical of other diseases, such as acute appendicitis, appendicular abscess or caecal carcinoma. Since the diagnosis is usually intraoperative, diverticulectomy is recommended only in particular cases, with no complications resulting from inflammatory reactions. In the other cases, right hemicolectomy or segmental resection are the elective surgical treatments, depending on the patient's clinical condition and on the local anatomical situation. The authors describe 8 cases of complicated right colon diverticulitis, one of which with haemorrhagic complications, observed over the period from January 1999 to March 2003. The rareness and diagnostic and therapeutic difficulties of this disease are emphasised.

[Acute torsion of the greater omentum: a case report]. / Torsione acuta del grande omento: descrizione di un caso.

Taking as their starting point a case of greater omental torsion recently observed in their surgical department, the authors carefully review the relevant literature data and the aetiological, pathogenetic, clinical and diagnostic aspects which make this rare disease hard to identify preoperatively. They stress that resorting to laparotomy is a rational course of action even if laparoscopy today constitutes an effective diagnostic and therapeutic option.