Surveillance of neo-squamous epithelium after ablation of Barrett's esophagus: is it better to use jumbo over standard biopsy forceps?

BACKGROUND AND AIMS: As obtaining adequate tissue on biopsy is critical for the detection of residual and recurrent intestinal metaplasia/dysplasia in Barrett's esophagus (BE) patients undergone Barrett's endoscopic eradication therapy (BET), we decided to compare the adequacy of biopsy specimens using jumbo versus standard biopsy forceps. METHODS: This is a two-center study of patients' post-radiofrequency ablation of dysplastic BE. After BET, jumbo (Boston Scientific©, Radial Jaw 4, opening diameter 2.8 mm) or standard (Boston Scientific©, Radial Jaw 4, opening diameter 2.2 mm) biopsy forceps were utilized to obtain surveillance biopsies from the neo-squamous epithelium. Presence of lamina propria and proportion of squamous epithelium with partial or full thickness lamina propria was recorded by two experienced gastrointestinal pathologists who were blinded. Squamous epithelial biopsies that contained at least two-thirds of lamina propria were considered 'adequate'. RESULTS: In a total of 211 biopsies from 55 BE patients, 145 biopsies (29 patients, 18 males, mean age 61 years, interquartile range [IQR] 33-83) were obtained using jumbo forceps and 66 biopsies (26 patients, all males, mean age 65 years, IQR 56-76) using standard forceps biopsies. Comparing jumbo versus standard forceps, the proportion of specimens with any subepithelial lamina propria was 51.7% versus 53%, P = 0.860 and the presence of adequate subepithelial lamina propria was 17.9% versus 9.1%, P = 0.096 respectively. CONCLUSIONS: Use of jumbo forceps does not appear to have added advantage over standard forceps to obtain adequate biopsy specimens from the neo-squamous mucosa post-ablation.

Circulating Vitamin D Level and Its Impact on Mortality and Recurrence in Stage III Colorectal Cancer Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Vitamin D (VD) has been implicated in several diseases, including colorectal cancer (CRC). This study aimed to determine whether there is an association between VD levels and time-to-outcome in stage III CRC patients through a systematic review and meta-analysis. METHODS: The study adhered to the PRISMA 2020 statement. Articles were searched in PubMed/MEDLINE and Scopus/ELSEVIER. Four articles were selected, with the primary objective of providing a pooled estimate of the risk of death specifically in stage III CRC patients based on pre-operative VD levels. Study heterogeneity and publication bias were analyzed using Tau2 statistics and funnel plots. RESULTS: The selected studies showed significant heterogeneity regarding time-to-outcome, technical assessments, and serum VD concentration measures. The pooled analysis of 2628 and 2024 patients revealed a 38% and 13% increase in the risk of death (HR: 1.38, 95% CI: 0.71-2.71) and recurrence (HR: 1.13; 95% CI: 0.84-1.53), respectively, for random-effects models among patients with lower levels of VD. CONCLUSIONS: Our findings suggest that a low concentration of VD has a significant negative impact on time-to-outcome in stage III CRC.

Through-the-scope large diameter self-expanding metal stent placement as a safe and effective technique for palliation of malignant colorectal obstruction: a single center experience with a long-term follow-up.

OBJECTIVE: The aim of this study was to evaluate the outcomes of through-the-scope (TTS) large diameter self-expanding metal stent (SEMS) placement for palliation of malignant colorectal obstruction. MATERIAL AND METHODS: Between January 2005 and December 2009, all patients who underwent endoscopic SEMS placement for palliation of malignant colorectal obstruction were prospectively enrolled. RESULTS: Thirty-nine patients (17M and 22F; mean age 75.9 ± 10.6 years, range 50-91) were enrolled. The most frequent location was the sigmoid colon (13 cases). The causes of obstruction were colorectal malignancy in 32 patients and extracolonic malignancy in 7. Technical success was achieved in 36/39 patients (92.3%) and clinical success in 35/39 patients (89.7%). Technical failure was related to female sex (p = 0.04) and the extracolonic etiology of the stricture (p < 0.001). There were three early complications: two procedure-related perforations successfully managed conservatively and one hemorrhage treated with APC. Early complications were related to the location of strictures at the recto-sigmoid junction (p < 0.001). Late complications occurred in 10 patients: 8 of these patients experienced occlusive symptoms (attributable to tumor ingrowth in 5 cases and stool impaction in 3 cases); the remaining 2 were one case of tumor ingrowth with sub-occlusive symptoms and hemorrhage, and one case of distal migration. There was no procedure-related mortality and all complications were managed without surgical intervention. SEMS patency duration was 236 ± 128 days (range 31-497) and mean survival of the patients was 259 ± 121 days (range, 32-511). CONCLUSIONS: In our experience, TTS large-diameter SEMS placement is a safe and effective treatment for palliation of malignant colorectal obstruction.

Novel frontiers of agents for bowel cleansing for colonoscopy.

The incidence of colorectal cancer (CRC) is characterized by rapid declines in the wake of widespread screening. Colonoscopy is the gold standard for CRC screening, but its accuracy is related to high quality of bowel preparation (BP). In this review, we aimed to summarized the current strategy to increase bowel cleansing before colonoscopy. Newly bowel cleansing agents were developed with the same efficacy of previous agent but requiring less amount of liquid to improve patients' acceptability. The role of the diet before colonoscopy was also changed, as well the contribution of educational intervention and the use of adjunctive drugs to improve patients' tolerance and/or quality of BP. The review also described BP in special situations, as lower gastrointestinal bleeding, elderly people, patients with chronic kidney disease, patients with inflammatory bowel disease, patients with congestive heart failure, inpatient, patient with previous bowel resection, pregnant/lactating patients. The review underlined the quality of BP should be described using a validate scale in colonoscopy report and it explored the available scales. Finally, the review explored the possible contribution of bowel cleansing in post-colonoscopy syndrome that can be related by a transient alteration of gut microbiota. Moreover, the study underlined several points needed to further investigations.

Management of Leaks Following Laparoscopic Sleeve Gastrectomy Using Specifically Designed Large Covered Metal Stents.

BACKGROUND: Leaks are the major complication associated with laparoscopic sleeve gastrectomy. OBJECTIVE: The study aimed to assess the efficacy and safety of specifically designed large covered metal stents for the management of post-laparoscopic sleeve gastrectomy leaks. METHODS: Prospectively collected databases from three Italian Endoscopy Units were reviewed. The primary outcome of the study was to evaluate the clinical success of stents placement, defined as complete resolution of clinical and laboratory signs of sepsis with radiological evidence of leak closure. Secondary outcomes were stent-related adverse events and mortality. RESULTS: Twenty-one patients (67% females, mean age 45 years) were included in the study and a total of 26 stents were placed. Technical success of stent placement was achieved in all cases (100%). Clinical success was observed in 85.5% of patients. Stent-related adverse events occurred in 9 patients (43%), with stent migration as the most frequent complication (33%). Adverse events were more frequently observed in patients who had undergone bariatric surgery prior to laparoscopic sleeve gastrectomy compared to patients without previous surgery (83% et al. 27%, p=0.018). CONCLUSION: The placement of specifically designed covered metal stents appears to be an effective and safe therapeutic approach for post-laparoscopic sleeve gastrectomy leaks. Stent migration can be a frequent complication.

Efficacy, safety and outcomes of 'inject and cut' endoscopic mucosal resection for large sessile and flat colorectal polyps.

BACKGROUND AND STUDY AIMS: The study examines the outcomes of the 'inject and cut' endoscopic mucosal resection (EMR), for large sessile and flat colorectal polyps. PATIENTS AND METHODS: Between January 2006 and December 2008 all patients referred to our institution for EMR of large polyps were prospectively evaluated. The accuracy of lifting sign and the rate of en bloc and piecemeal resection, complications and recurrence were analyzed. RESULTS: A total of 157 patients with 182 lesions (median size 24.7 +/- 10.2 mm) were included in the study. The most frequent location was the sigmoid colon in 30.2%. Because of non-lifting sign, 5/182 lesions were referred to surgical resection and 177 (43 flat and 134 sessile) were resected, 79 (44.6%) en bloc and 98 (55.4%) piecemeal. There were 20 procedural (11.3%) and 2 late (1.1%) bleeding, 4 post-polypectomy syndrome (2.2%) and 2 perforations (1.1%). Bleeding was related to malignancy (p = 0.01). Intramucosal cancer was observed in 5 cases (2.8%) while invasive cancer was seen in 8 (4.5%). Malignancy was related to polyp size >or=30 mm (p = 0.002). Follow-up colonoscopy was performed in 147 patients with 172 EMR for a mean of 19.8 months. Recurrence was observed in 12/172 (6.9%) polyps. CONCLUSION: Inject and cut EMR is practical and effective with a low risk of complication and local recurrence.

Endoclip-assisted resection of large pedunculated colorectal polyps: technical aspects and outcome.

BACKGROUND: The most common complication of polypectomy is hemorrhage, and various techniques have been used to prevent this complication. AIM: This study evaluates the outcomes of endoclip-assisted polypectomy in patients with large pedunculated colorectal polyps, in comparison with a historical control group of patients treated with endoloop-assisted polypectomy. METHODS: Between January and December 2007, 32 patients with 32 large pedunculated polyps (>or=15 mm) were treated with endoclip-assisted polypectomy (group A). Between January and December 2006, 35 patients with 35 large pedunculated polyps were treated; 33 with endoloop-assisted polypectomy (control, group B) and two cases with endoclips and needle knife, which were included in group A for the analysis. RESULTS: The mean (+/- standard deviation [SD]) size of polyp head was 26.8 +/- 8.1 mm (range 15-50) in group A and 22.3 +/- 4.1 mm (range 15-30) in group B (P = 0.004). In group A, six polyps had a mean (+/-SD) head size of 40.8 +/- 5.8 mm (range 35-50) and were resected with clips and needle knife. In group A, bleeding occurred in two cases (5.9%), which were associated with the presence of cancer at histology (P = 0.006) and were managed by applying new clips. No bleeding occurred in patients of group B and no perforation and post-polypectomy syndrome occurred in either group. There were three (8.8%) cancerized adenomas in group A and one (3%) in group B. Clip application was possible in all patients, while in two cases, loop placement was impossible. CONCLUSIONS: In our experience, endoclip-assisted resection is a safe alternative to endoloop for the resection of large pedunculated colorectal polyps when endoloop placement is difficult or impossible.

Depression, anxiety and anger in subtypes of irritable bowel syndrome patients.

The present study aimed to elucidate the differences in depression, anxiety, anger, and quality of life in a sample of non-psychiatric IBS patients, starting from the hypothesis that IBS subtypes may have different symptomatic expressions of negative emotions with different outcomes on quality of life measures. Forty-two constipation-predominant IBS (C-IBS) subjects and 44 diarrhea-predominant IBS (D-IBS) subjects, after an examination by a gastroenterologist and a total colonoscopy, underwent a clinical interview and psychometric examination for the assessment of depression, anxiety, anger and quality of life. IBS subtypes showed different symptomatic profiles in depression, anxiety and anger, with C-IBS patients more psychologically distressed than D-IBS subjects. Affective and emotional symptoms should be considered as specific and integral to the syndrome, and recognizing the differences between IBS subtypes may have relevant implications for treatment options and clinical outcome.

Single session versus separate session endoscopic ultrasonography plus endoscopic retrograde cholangiography in patients with low to moderate risk for choledocholithiasis.

BACKGROUND AND AIM: Endoscopic ultrasonography (EUS) is a minimally invasive diagnostic tool for common bile duct stones (CBDS) and may be used to select patients for therapeutic endoscopic retrograde cholangiography (ERC). The aim of this trial is to compare, in patients with non-high-risk for CDBS, the clinical and economic impact of EUS plus ERC performed in a single endoscopic session versus EUS plus ERC in two separate sessions. METHODS: During an 11-month period, all adult patients admitted to the emergency department with suspicion of CBDS were categorized into either high-risk or non-high-risk groups, on the basis of clinical, biochemical, or transabdominal ultrasound findings. Patients in the non-high-risk group were randomized to receive EUS plus ERC in one single or in two separate sessions. RESULTS: Eighty patients were recruited and randomized. Forty patients underwent EUS plus ERC in a single session and 40 patients underwent EUS plus ERC in two separate sessions. Negative EUS examination for CBDS avoided unnecessary ERC to 33 patients. Out of 47 patients with positive EUS (25 from the single session group and 22 from the double session), ERC confirmed the presence of CBDS in 46 cases (EUS sensitivity 100% and specificity 98%). Average time of procedure and hospitalization were significantly shorter in the single session group compared to the two session group. The single session strategy was also less expensive. CONCLUSION: Endoscopic ultrasonography plus ERC with sphincterotomy and stone extraction performed during the same endoscopic session was safe and efficacious with a reduction of procedure time, hospitalization and costs.

Hem-o-Lok clip migration into the duodenum after laparoscopic digestive surgery: a systematic review.

INTRODUCTION: The wide use of hemoclips during laparoscopic surgery has led to a variety of unusual complications, among these, there is the migration of Hem-o-Lok clip into the duodenum. We performed a literature review of all cases of Hem-o-Lok clip migration into the duodenum after laparoscopic digestive surgery reported in literature. EVIDENCE ACQUISITION: All relevant articles were extracted up to June 2019 based on the results of searches in MEDLINE, PubMed, Scopus, Web of Science and Google Scholar. EVIDENCE SYNTHESIS: At the time of this review, a total of seven cases have been described. The mean age was 49 years and the majority of these patients were women (57%). Previous laparoscopic surgery was performed for cholecystectomy (four patients), cholecystectomy with common bile duct exploration (one patient), right hemicolectomy (one patient) and distal gastrectomy (one patient). Symptoms occurred from 3 months to 2 years after laparoscopic surgery. The majority of patients developed symptoms of bowel occlusion and abdominal pain. Three patients remained asymptomatic. In many cases the Hem-o-Lok wedged into the wall of the first or second portion of the duodenum. In all cases, esophageal gastroduodenoscopy was the primary modality to make the diagnosis. Initial treatment was conservative with watch-and-wait strategy or proton pump inhibitors followed by endoscopic removal, while surgical treatment was required in two cases. CONCLUSIONS: The application of Hem-o-Lok clip during laparoscopic surgery is safe and effective. Postoperative Hem-o-Lok migration into the duodenum is rare. The treatment could be conservative in the majority of cases.

"Wandering spleen" as a rare cause of recurrent abdominal pain: a systematic review.

INTRODUCTION: Wandering spleen (WS) is a rare and generally acquired condition, resulting from abnormal ligamentous laxity failing to fixate the spleen in its normal location in the left upper quadrant, thus leading to its migration to the pelvis due to gravity. Such migration leads to an elongated vascular pedicle, which is prone to torsion causing splenic infarction; thus, a prompt surgical intervention is recommended. Since this adverse event affects childbearing women or children, it is crucial to choose the most appropriate surgical strategy, such as splenectomy or splenopexy, both effective and widely diffused options. The aim of this paper is to perform a literature review on WS reports treated by surgery. We also present a case of symptomatic WS migrated in pelvis in a young female treated by splenectomy. EVIDENCE ACQUISITION: All relevant articles from 1895 up to December 2017 were identified by literature searches in PubMed, Scopus and Google Scholar. EVIDENCE SYNTHESIS: A total of 376 patients treated with surgical approach for WS were identified. The most common presentations were abdominal pain and abdominal mass, and approximately half of the patients had an acute clinical onset. Radiology is essential for the diagnosis. Surgical strategy changed over the time; splenectomy is the most reported treatment although in the last years there is an increasing trend towards a more conservative strategy, preferring splenopexy or a laparoscopic approach. CONCLUSIONS: Surgery is the gold standard strategy, and laparoscopic approach is recommended, for the treatment of wandering spleen. Both splenopexy or splenectomy are effective and safe surgical options.

Efficacy, risk factors and complications of endoscopic polypectomy: ten year experience at a single center.

AIM: To examine the efficacy and complications of colonoscopic resection of colorectal polypoid lesions. METHODS: We retrospectively reviewed 1354 polypectomies performed on 1038 patients over a ten-year period. One hundred and sixty of these were performed for large polyps, those measuring > or = 20 mm. Size, shape, location, histology, the technique of polypectomy used, complications, drugs assumption and associated intestinal or extra intestinal diseases were analyzed. For statistical analysis, the Pearson chi2 test, NPC test and a Binary Logistic Regression were used. RESULTS: The mean patient age was 65.9 +/- 12.4 years, with 671 men and 367 women. The mean size of polyps removed was 9.45 +/- 9.56 mm while the size of large polyps was 31.5 +/- 10.8 mm. There were 388 pedunculated and 966 sessile polyps and the most common location was the sigmoid colon (41.3%). The most frequent histology was tubular adenoma (55.9%) while for the large polyps was villous (92/160 -57.5%). Coexistent malignancy was observed in 28 polyps (2.1%) and of these, 20 were large polyps. There were 17 procedural bleeding (1.3%) and one perforation. The statistical analysis showed that cancer is correlated to polyp size (P < 0.0001); sessile shape (P < 0.0001) and bleeding are correlated to cardiac disease (P = 0.034), tubular adenoma (P = 0.016) and polyp size. CONCLUSION: The endoscopic resection is a simple and safe procedure for removing colon rectal neoplastic lesions and should be considered the treatment of choice for large colorectal polyps. The polyp size is an important risk factor for malignancy and for bleeding.

Abnormal nuclear structures (micronuclei, nucleoplasmic bridges, and nuclear buds) in a pleomorphic giant cell carcinoma of the stomach.

A rare case of pleomorphic giant cell carcinoma of the stomach in a 70-year-old man is reported. Characteristic microscopic findings included a general lack of architectural cohesiveness, aggregates of mononucleated or multinucleated giant cells, extensive areas of coagulative necrosis, and numerous mitoses. Immunohistochemically, tumor cells displayed cytoplasmic immunoreactivity for cytokeratin AE1/AE3 as well as overexpression of p53 and Ki-67. Electron microscopy revealed paranuclear tonofilaments bundles in giant cells confirming their epithelial nature. Furthermore, giant cells contained two or more nuclei with heterogeneous size, nucleoplasmic bridges, nuclear buds, and micronuclei. Similar abnormal nuclear structures have been closely related to breakage-fusion-bridge type of mitotic disturbances in tumor cell lines, and have not been previously reported in a human tumor.

Performance of the over-the-scope clip system in the endoscopic closure of iatrogenic gastrointestinal perforations and post-surgical leaks and fistulas.

The increased invasiveness of endoscopic procedures and complex surgical interventions has resulted in an increased number of gastrointestinal iatrogenic defects, such as perforations, leak and fistulas. The conventional treatment for these gastrointestinal defects is surgery, with considerable risks especially in emergency situations and in patients with comorbidities. The Ovesco over-the-scope clip (OTSC) system (Ovesco Endoscopy AG, Tübingen, Germany) and more recently, the Padlock Clip™ (Aponos Medical, Kingston, NH, USA) have shown promising results in the treatment of gastrointestinal defects. Several case reports and case series have demonstrated the efficacy of the OTSC system for the closure of full-thickness defects. Clinical success is best achieved in patients undergoing closure of a perforation or a leak. Closure of fistulas remains a clinical challenge since fibrosis or necrotic and inflamed tissue surrounding lesions may cause clip failure. Over-the-scope clips are a less invasive endoscopic option for managing patients with gastrointestinal defects before a more invasive surgical approach is attempted. Moreover, a failed attempt of OTSC deployment does not preclude subsequent surgical treatment.

Elective endoscopic variceal ligation is not a risk factor for bacterial infection in patients with liver cirrhosis.

BACKGROUND: Patients with cirrhosis are at high risk of bacterial infections. Invasive procedures are generally believed to increase this susceptibility. AIMS: We investigated the incidence of bacterial infections in cirrhotic patients undergoing elective endoscopic variceal ligation (EVL). METHODS: We enrolled 60 consecutive cirrhotic patients who underwent a total number of 112 elective EVL procedures. One to seven bands were applied at each session until variceal eradication. Markers of inflammation/infection and blood cultures were obtained before and 24 h after EVL. RESULTS: Aetiology of liver disease was metabolic in 27 (45%), viral in 21 (35%), alcoholic in 12 (20%) patients. Child-Pugh class A/B/C distribution was 29/26/5, respectively, 23 (38%) patients had ascites and 15 (25%) had hepatocellular carcinoma. Blood cultures were negative in all samples before EVL, whereas 3/112 (2.7%) cultures tested positive after endoscopy. Streptococcus mitis and Staphylococcus epidermidis were isolated in 1 and 2 cases, respectively. None of these three patients developed any features of clinically relevant infection, suggesting that the positive cultures were an expression of a transient bacteraemia with no clinical sequelae. CONCLUSIONS: Bacterial infection is an uncommon occurrence after elective EVL in cirrhotic patients, and antibiotic prophylaxis is not necessary in this clinical setting.

Colonic acute malignant obstructions: effectiveness of self-expanding metallic stent as bridge to surgery.

BACKGROUND/AIMS: Bowel obstruction is a frequent event in patients with adenocarcinoma, affecting, in some series, almost one-third of the patients. In the last decades, in addition to surgery, self-expanding metallic stents (SEMSs) are available both as a bridge to surgery (BTS) or palliation. The aim of our study was to demonstrate the safety and efficacy of the use of SEMSs as BTS in selected patients with acute colonic malignant obstructions. MATERIALS AND METHODS: In total, 125 patients with malignant colonic obstruction who underwent emergency surgery or stent insertion were retrospectively enrolled in our study; 62 patients underwent surgery initially, whereas 62 were subjected to stenting as BTS. The 6-month and 1-year survival rates after the procedure (stenting or surgery) and short-term and long-term complication rates were considered as primary endpoints; the recanalization rate after Hartmann's procedure and the length of hospitalization were considered as secondary endpoints. RESULTS: On comparing the surgery group (SG) and the BTS group (BG), we observed a lower short-term complication rate (p<0.05) and a reduction in the mean hospital stay (16.1±7.7 vs. 13.5±3.0, p<0.05) in the latter. No differences in long-term complications were found. The recanalization rate after Hartmann's procedure was higher in BG than in SG, although this was not statistically significant. CONCLUSION: Our experience shows that SEMS insertion is a safe and effective technique in selected patients with colonic malignant obstruction; the reduction in hospital stay and short-term complications in BG is an important cost-saving aim.

Endoscopic ultrasound core needle for diagnosing of solid pancreatic lesions: is rapid on-site evaluation really necessary?

INTRODUCTION: Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) has a crucial role in the diagnosis of solid pancreatic lesions and rapid on-site evaluation (ROSE) can increase its diagnostic yield. Rapid on-site evaluation is not always available and after EUS-FNA provides a cytology specimen with scant cellularity. Fine needle biopsy (FNB) specimens containing core tissue may theoretically overcome the limitations of EUS-FNA sampling. It could be hypothesized that EUS-FNB without ROSE could achieve the same adequacy and accuracy of EUS-FNB with ROSE. The aim of this review is to evaluate the evidence on the role of ROSE in the setting of EUS-guided tissue acquisition with core needles in patients with solid pancreatic lesions. EVIDENCE ACQUISITION: All relevant articles were extracted up to February 2017 based on the results of searches in PubMed, Scopus and Google Scholar. EVIDENCE SYNTHESIS: A total of 21 pertinent articles were finally included. Among the included studies, 11 were performed without ROSE, 8 with ROSE, and 2 were performed both with and without ROSE. In the ROSE group we found a sensitivity, specificity, overall diagnostic adequacy and overall diagnostic accuracy of 96%, 100%, 86.5%, 85.5%, respectively, while in the no-ROSE group 86.6%, 100%, 89.5%, 86.1% were found, respectively. Mild pancreatitis (mean rates, 3.43%) and abdominal pain (mean rates, 3.6%) were reported as most frequent adverse events. CONCLUSIONS: Endoscopic ultrasound guided-FNB without ROSE offers similar results in terms of adequacy and accuracy as in the presence of an on-site cytopathologist.

Outcomes of Radiofrequency Ablation for Dysplastic Barrett's Esophagus: A Comprehensive Review.

Barrett's esophagus is a condition in which the normal squamous lining of the esophagus has been replaced by columnar epithelium containing intestinal metaplasia induced by recurrent mucosal injury related to gastroesophageal reflux disease. Barrett's esophagus is a premalignant condition that can progress through a dysplasia-carcinoma sequence to esophageal adenocarcinoma. Multiple endoscopic ablative techniques have been developed with the goal of eradicating Barrett's esophagus and preventing neoplastic progression to esophageal adenocarcinoma. For patients with high-grade dysplasia or intramucosal neoplasia, radiofrequency ablation with or without endoscopic resection for visible lesions is currently the most effective and safe treatment available. Recent data demonstrate that, in patients with Barrett's esophagus and low-grade dysplasia confirmed by a second pathologist, ablative therapy results in a statistically significant reduction in progression to high-grade dysplasia and esophageal adenocarcinoma. Treatment of dysplastic Barrett's esophagus with radiofrequency ablation results in complete eradication of both dysplasia and of intestinal metaplasia in a high proportion of patients with a low incidence of adverse events. A high proportion of treated patients maintain the neosquamous epithelium after successful treatment without recurrence of intestinal metaplasia. Following successful endoscopic treatment, endoscopic surveillance should be continued to detect any recurrent intestinal metaplasia and/or dysplasia. This paper reviews all relevant publications on the endoscopic management of Barrett's esophagus using radiofrequency ablation.

Biliary and pancreatic stenting: Devices and insertion techniques in therapeutic endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography.

Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fully-covered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.

A Lower Gastrointestinal Bleeding Due to a Post-Traumatic Splenosis: "Wait and See" Represents a Feasible Attitude: A Case Report.

Splenosis represents a benign condition due to an ectopic localization of splenic tissue caused by pathologic or traumatic spleen rupture. Generally, it is asymptomatic and incidentally diagnosed during imaging performed for other reasons. Occult gastrointestinal bleeding due to an extraperitoneal localization is a rare occurrence. Differential diagnosis may be very hard and includes benign and malignant neoplasms.We describe the case of a 68-year-old Caucasian man that was admitted for an increasing lower gastrointestinal bleeding associated to a vague abdominal pain.He was assessed by means of laboratory tests, as well as by endoscopic and radiological examinations, and successfully treated with an exclusive medical approach.The patient was discharged on the ninth day and currently he is doing well.This case shows that wait and see could prove a feasible attitude for the management of clinically stable patients.