An atypical gastric duplication cyst as a rare cause of gastric dilatation: the key role of the endoscopy ultrasound.

We have written a "letter to Editor" about a case of gastric dilatation caused by a symptomatic gastric duplication cyst with ectopic pancreas ingrowth, in a 13 years old boy. The Endoscopy Ultra Sound characterized the lesion and permitted the aspiration of the internal liquid. The patient underwent to laparoscopic excision of the mass and the histology revealed a gastric duplication cyst with ectopic pancreas ingrowth.

PEG-J replacement for duodenal levodopa infusion in Parkinson's disease patients: a retrospective study.

BACKGROUND: Reducing percutaneous endoscopic gastrostomies with jejunal extension tubes (PEG-J) related complications is vital to the long-term preservation of duodenal levodopa infusion (DLI) in advanced Parkinson's disease (APD). Here, we provide data on the frequency of complications for both the standard "pull" and the non-endoscopic, radiologic assisted, "push" replacement PEG-J techniques in APD. METHODS: We retrospectively identified all patients treated with DLI from October 2009 to January 2020 at the Movement Disorders Center. Patients features and demographics, PEG-J procedures, causes for any discontinuation, reported complications and mortality were collected. In this cohort, PEG-J replacements were performed using the standard "pull" procedure or the radiologic assisted "push" method. Descriptive statistical analysis, t-test and paired t-test with False Discovery Rate correction was performed. RESULTS: This retrospective study included 30 APD patients [median age 72 ± 5.6 years; mean disease duration 17.2 + 5.7 years]. Mean treatment duration was 35.6 (30.6) months. Overall, 156 PEG-J procedures were performed, and Nineteen patients (63.3%) had a total of 185 reported complications, 85 of which were peristomal complications. 17 (56.6%) underwent 100 replacement procedures due to complications. The most commonly reported complication for replacement was J-tube dislocation (36%). One patient discontinued treatment after 6 months, due to peripheral neuropathy. Six patients died for causes not related to DLI. PEG-J replacements performed with the "push" method had a higher turnover (5.6 vs. 7.6 mo.), but fewer reported complications (67 vs. 75%). CONCLUSION: The overall rate of complications was lower for "push" technique. This result might have been due to a higher replacement turnover that acted as a protective factor.

SpyGlass single-operator peroral cholangioscopy in the evaluation of indeterminate biliary lesions: a single-center, prospective, cohort study.

BACKGROUND: SpyGlass single-operator peroral cholangioscopy appears to be a promising technique to overcome some limitations of conventional peroral cholangioscopy. We aimed to prospectively evaluate the SpyGlass system in a cohort of patients with indeterminate biliary lesions. METHODS: Patients with indeterminate strictures or filling defects at endoscopic retrograde cholangiopancreatography (ERCP) were consecutively enrolled. After SpyGlass visual evaluation, targeted biopsies were taken with the SpyBite and histopathological assessment was made by two experienced gastrointestinal pathologists. SpyBite-targeted biopsy results were evaluated by assessing agreement with surgical specimens and by evaluation of final, clinical follow-up-based diagnosis. RESULTS: Fifty-two patients participated in the study. In 7 cases, definite diagnosis (stones, varices) was made by SpyGlass endoscopic evaluation. In 42 of the remaining 45 cases, material suitable for histopathology assessment was provided by the SpyBite. Overall, a definite diagnosis was made in 49 (7 + 42; 94 %) cases. Agreement of SpyBite biopsy results with surgical specimen diagnosis was found in 38/42 (90 %) cases; sensitivity, specificity, and positive and negative predictive values were 88, 94, 96, and 85 %, respectively. Procedure-related complications consisted of one case of mild cholangitis and one case of mild pancreatitis. CONCLUSIONS: In our series, the SpyGlass system allowed adequate biopsy sampling and definite diagnosis with high accuracy in the vast majority of patients with indeterminate biliary lesions. Its use was associated with a low complication rate. Further refinements of the technique are warranted, but the SpyGlass system has the potential to become a diagnostic standard for the assessment of indeterminate biliary lesions.

Possible Role of Carbocysteine Syrup in the Deflation of Percutaneous Endoscopic Gastrostomy Balloons.

Percutaneous endoscopic gastrostomy is the method of choice to allow enteral access in patients requiring long-term enteral nutrition. However, although generally safe, percutaneous tube positioning may be plagued by several complications. Among these, the deterioration and/or deflation of balloons serving as internal bolster is particularly worrisome in that it may lead to gastrostomy cannulas dislocation. Of interest, such balloon deflation may occur in up to 30% of cases for apparently unexplained causes. Here, we provide a hypothesis that could explain some of these causes.

Over-the-scope Technique for Partially Covered Self-expandable Metal Stent Placement to Treat Duodenal Perforation during EUS.

BACKGROUND AND AIMS: Although endoscopic ultrasound (EUS) is generally safe, duodenal perforation may occur during the procedure. When the iatrogenic break is wide, endoscopic positioning of a covered self- expandable metal stent is indicated to avoid a more invasive surgical approach. We evaluated the efficacy of the 'over-the-scope stenting' (OTSS) technique to treat iatrogenic duodenal perforations occurred during EUS. METHODS: Data of patients with large iatrogenic duodenal perforations treated with OTSS procedure were collected in 5 centers. Technical success was defined as a correct stent placement on the perforation site, and clinical success as complete healing of the duodenal leak at stent removal 3 weeks later. RESULTS: A total of 15 (7 males; median age: 78 years, range 47-91) patients were included in this series. A correct stent positioning was achieved in all cases (technical success: 100%), and the perforation was healed in all, apart from one patient at stent removal (clinical success: 93%). This patient was successfully treated with a novel stent placement. No immediate post-procedural adverse events occurred, and no need for emergency surgery was recorded. In one (6.7%) patient, stent migration occurred 10 days after positioning, and it was spontaneously expulsed with stool movement without complications two days later. CONCLUSIONS: Our data showed that the OTTS technique for partially covered self-expandable metal stent placement is feasible, safe and effective to tread large iatrogenic duodenal perforation occuring during EUS.

Endoscopic Submucosal Dissection for Subepithelial Tumor Treatment in the Upper Digestive Tract: A Western, Multicenter Study.

Background/Aims: Endoscopic submucosal dissection (ESD) has been proposed for removal of gastrointestinal subepithelial tumors (GI-SETs), but data are still scanty. This study aimed to report a case series from a western country. Patients and Methods: Data of patients with upper GI-SETs suitable for ESD removal observed in 4 centers were retrospectively reviewed. Before endoscopic procedure, the lesion was characterized by endosonographic evaluation, histology, and CT scan. The en bloc resection and the R0 resection rates were calculated, as well as incidence of complications, and the 1-year follow-up was reported. Results: Data of 84 patients with esophageal (N = 13), gastric (N = 61), and duodenal (N = 10) GI-SETs were collected. The mean diameter of lesions was 26 mm (range: 12-110 mm). There were 17 gastrointestinal stromal tumors, 12 neuroendocrine tumors, 35 leiomyomas, 18 lipomas, and 2 hamartomas. En bloc and R0 resection were achieved in 83 (98.8%) and in 80 (95.2%) patients, respectively. Overall, a complication occurred in 11 (13.1%) patients, including bleeding (N = 7) and perforation (N = 4). Endoscopic approach was successful in all bleedings, but 1 patient who required radiological embolization, and in 2 perforations, while surgery was performed in the other patients. Overall, a surgical approach was eventually needed in 5 (5.9%), including 3 in whom R0 resection failed and 2 with perforation. Conclusions: Our study found that ESD may be an effective and safe alternative to surgical intervention for both benign and localized malignant GI-SETs.

Introdução/objetivos: A dissecção endoscópica da submucosa (ESD) tem sido proposta para a exérese de tumores subepiteliais gastrointestinais (GI-SETs), embora a literatura seja escassa. Este estudo teve como objetivo reportar uma série de casos de um país ocidental. Métodos: Coorte retrospectiva incluindo doentes com SETs do tubo digestivo superior submetidos a ESD em 4 centros (1 ano de follow-up). Antes do procedimento, a lesão foi caracterizada por ecoendoscopia, histologia e tomografia computadorizada. Foram avaliadas as taxas de ressecção em bloco e R0, bem como a incidência de complicações. Resultados: Incluídos 84 doentes com GI-SETs esofágicos (N = 13), gástricos (N = 61) e duodenais (N = 10). O diâmetro médio das lesões foi de 26 mm (intervalo 12­110 mm) ­ 17 tumores do estroma gastrointestinal, 12 tumores neuroendócrinos, 35 leiomiomas, 18 lipomas e 2 hamartomas. A resseção foi em bloco e R0 em 83 (98.8%) e em 80 (95.2%) doentes, respectivamente. Globalmente, ocorreram complicações em 11 (13.1%) doentes, incluindo hemorragia (N = 7) e perfuração (N = 4). A terapêutica endoscópica foi eficaz em todas as hemorragias exceto em 1 doente que necessitou de embolização radiológica e em 2 perfurações (submetidas a cirurgia). No geral, a abordagem cirúrgica foi necessária em 5 (5.9%) ­ 3 doentes com resseção R1 e 2 com perfuração. Conclusões: A ESD pode ser uma alternativa eficaz e segura à intervenção cirúrgica para GI-SETs benignos e malignos localizados.

Upper Gastrointestinal Endoscopy Quality in Italy: A Nationwide Study.

BACKGROUND AND AIMS: International guidelines advise improving esophagogastroduodenoscopy (EGD) quality in Western countries, where gastric cancer is still diagnosed in advanced stages. This nationwide study investigated some indicators for the quality of EGD performed in endoscopic centers in Italy. METHODS: Clinical, endoscopic, and procedural data of consecutive EGDs performed in one month in the participating centers were reviewed and collected in a specific database. Some quality indicators before and during endoscopic procedures were evaluated. RESULTS: A total of 3,219 EGDs performed by 172 endoscopists in 28 centers were reviewed. Data found that some relevant information (family history for GI cancer, smoking habit, use of proton pump inhibitors) were not collected before endoscopy in 58.5-80.7% of patients. Pre-endoscopic preparation for gastric cleaning was routinely performed in only 2 (7.1%) centers. Regarding the procedure, sedation was not performed in 17.6% of patients, and virtual chromoendoscopy was frequently (>75%) used in only one (3.6%) center. An adequate sampling of the gastric mucosa (i.e., antral and gastric body specimens) was heterogeneously performed, and it was routinely performed only by 23% of endoscopists, and in 14.3% centers. CONCLUSIONS: Our analysis showed that the quality of EGD performed in clinical practice in Italy deserves to be urgently improved in different aspects.

Hood colonoscopy in trainees: a useful adjunct to improve the performance.

BACKGROUND: The use of a transparent hood to improve colonoscopic performance has recently been proposed. AIMS: The purpose of this study was to evaluate whether using the hood might improve the cecal intubation rate, cecal intubation time, number of attempts needed to intubate the ileo-cecal valve, and polyp detection rate in trainees. METHODS: Patients undergoing colonoscopy (n = 378) were randomized in two groups, one studied with hood colonoscopy (n = 179) and the other (n = 199) with standard examination. RESULTS: No differences were found between hood and standard colonoscopy with respect to cecal intubation rate (95 vs 92 %), whereas hood colonoscopy significantly shortened the cecal intubation time, the number of attempts needed to intubate the ileo-cecal valve, and the overall polyp detection rate (p < 0.01 for all these variables). CONCLUSIONS: Hood colonoscopy might represent a useful adjunct to standard colonoscopy, especially improving the performance of endoscopic trainees.

Transabdominal self-expandable metal stent placement as a rescue therapy for drainage of walled-off necrosis.

Video 1CT scan of a walled-off necrosis in the right pararenal space extended to the iliac area.

Endoscopic ultrasonography-guided biliary drainage for malignant jaundice by using electrocautery-enhanced lumen-apposing metal stents (Hot-SPAXUS stent).

Background: Biliary drainage with endoscopic retrograde cholangiopancreatography (ERCP) for tumoral jaundice fails in a certain percentage of patients. In these patients, endoscopic ultrasonography-guided lumen-apposing metal stents (LAMS) with electrocautery-enhanced (ECE) technology allows a single-step, radiation-free palliative treatment. Methods: We reviewed the data of patients who underwent choledochoduodenostomy with placement of ECE-LAMS (Hot-SPAXUS stent) after ERCP failure in a single tertiary center. Technical and clinical success rates were calculated and adverse events recorded. Results: Data of 15 patients (8 male, median age 72 years) were collected. The procedure was technically successful in all patients, whilst clinical success was achieved in 14 (93.3%) patients. One (6.7%) patient presented delayed bleeding treated endoscopically. At follow up, stent occlusion with recurrence of jaundice occurred in 2 (13.3%) patients, due to food impaction (n=1), or neoplastic ingrowth (n=1). Conclusion: Our results suggest that the Hot-SPAXUS procedure is effective and safe for palliative treatment in patients with distal biliary malignant obstruction after failure of ERCP.

Performance of a multicompounds nutraceutical formulation in patients with symptomatic uncomplicated diverticular disease.

BACKGROUND: Symptomatic uncomplicated diverticular disease (SUDD) is a recognized clinical condition characterized by abdominal pain and changes in bowel habits, attributed to diverticula but without macroscopic signs of diverticulitis. There is no consensus about the management of these patients. Enteroflegin®, an association of natural active ingredients, could be effective in the treatment of those patients. METHODS: We conducted a retrospective observational study to evaluate the performances of Enteroflegin® in patients with SUDD. Patients were treated with Enteroflegin® 2 cp/day for 10 days per month for 6 months. Primary endpoint was the clinical remission rate, defined as the absence of any symptoms; secondary endpoints were the impact of the treatment on reduction of symptoms, on fecal calprotectin (FC) expression, and the prevention of acute diverticulitis. RESULTS: Three hundred and fifty patients were retrospectively enrolled (183 males, median age 64 years, IQR 54-70). Enteroflegin® was effective in inducing remission in 9.34% and 17.64% of patients at 3 and 6 months respectively (P<0.001). Reduction of symptoms occurred in 92.3% and in 85.3% of patients at 3 and 6 months respectively (P<0.001), and symptoms' recurrence or worsening was recorded in only 1.71% of patients during the follow-up. FC expression dropped from 181.3 µg/g at baseline to 100.2 µg/g (P<0.001) and to 67.9 µg/g (P<0.001) at 3 and 6 months of follow-up respectively. No adverse event was recorded during the follow-up. Finally, acute diverticulitis occurred in just 2% of patients during the follow-up. CONCLUSIONS: Enteroflegin® seems to be an effective nutraceutical compound in obtaining remission and symptom relief in SUDD patients. Further randomized, placebo-controlled clinical trials are needed to confirm these preliminary data.

A rare case of polypoid primary anorectal melanoma with subsequent giant stomach metastasis: A gastrointestinal involvement of both primary and metastatic mucosal melanoma.

Melanoma can involve the gastrointestinal apparatus as both primary and metastatic lesions. Primary anorectal mucosal melanoma (ARMM) and metastatic gastric melanoma are rare entities and usually resulted in a poor prognosis. We presented a case of a 61-year-old man who after the complete excision of an ARMM developed a gastric metastasis after almost three years form the complete tumour excision. Upon esophagogastroduodenoscopy, a giant ulcered mass resulted in melanoma metastasis. The patient underwent a near-total gastrectomy. After five months of follow-up, the patient is disease-free. The incidence of ARMMs is increasing, highlighting the necessity of new prevention and treatment strategies in order to achieve a better prognosis for these patients. There are no known risk factor for ARMMs but surgery, together with the combination of anti-CTLA-4 and anti-PD-1 antibodies, are promising therapeutic options. Early and aggressive treatments are required, together with a strict multidisciplinary approach.

Timing of endoscopic therapy for acute bilio-pancreatic diseases: a practical overview.

Diseases of the pancreas and hepatobiliary tree often require a therapeutic approach with endoscopic retrograde cholangiopancreatography (ERCP), generally following noninvasive imaging techniques. Appropriate indications and the correct timing for urgent ERCP would benefit both patients and clinicians and allow optimal utilization of health resources. Indications for urgent (<24 h) ERCP include severe acute cholangitis, acute biliary pancreatitis with cholangitis, biliary or pancreatic leaks, in the absence of percutaneous drainage, and severe acute cholecystitis in patients who are unfit for surgery and do not respond to conservative management. In patients who have severe acute biliary pancreatitis with ongoing biliary obstruction but without cholangitis, early (<48-72 h) ERCP is indicated. This overview aims to provide decisional flowcharts that can be easily used for managing patients with acute bilio-pancreatic disorders when they are referred to the Emergency Department.

Endoscopic Submucosal Dissection for Visible Dysplasia Treatment in Ulcerative Colitis Patients: Cases Series and Systematic Review of Literature.

BACKGROUND AND AIMS: Ulcerative colitis [UC] patients are at an increased risk of developing colorectal cancer due to chronic inflammation. Endoscopic submucosal dissection [ESD] allows removal of non-invasive neoplastic lesions in the colon, but few data are available on its efficacy in UC patients. METHODS: Data from consecutive UC patients diagnosed with visible dysplastic lesions in the colon who underwent ESD were evaluated. The en bloc removal, R0 resection and complication rates were calculated. Local recurrence and metachronous lesions during follow-up were identified. A systematic review of the literature with pooled data analysis was performed. RESULTS: A total of 53 UC patients [age: 65 years; range 30-74; M/F: 31/22] underwent ESD. The en bloc resection rate was 100%, and the R0 resection rate was 96.2%. Bleeding occurred in seven [13.2%] patients, and perforation in three [5.6%] cases, all treated at endoscopy. No recurrence was observed, but two metachronous lesions were detected. Data from six other studies [three Asian and three European] were available. By pooling data, en bloc resection was successful in 88.4% (95% confidence interval [CI] = 83.5-92) of 216 lesions and in 91.8% [95% CI = 87.3-94.8] of 208 patients. R0 resection was achieved in 169 ESDs, equivalent to a 78.2% [95% CI = 72.3-83.2] rate for lesions and 81.3% [95% CI = 75.4-86] rate for patients. No difference between European and Asian series was noted. CONCLUSIONS: This pooled data analysis indicated that ESD is a suitable tool for safely and properly removing non-invasive neoplastic lesions on colonic mucosa of selected UC patients.

A simplified method for anal ultrasonography: preliminary report.

BACKGROUND: Anal endosonography (AES) is able to reliably visualize and identify anal sphincter abnormalities. However, dedicated probes are quite expensive. AIM: We describe a simple and less costly method to perform AES in a unit that already has echoendoscopes available by inserting the endoscope through a disposable anoscope filled with standard ultrasound gel. PATIENTS: Subjects without anal abnormalities and patients with anal disease (abscesses, fistulas) were evaluated. RESULTS: Good-quality images were obtained in both controls and patients, with optimal visualization of the anatomic structures and pathologic features. The latter (abscesses, fistulas) were always confirmed by magnetic resonance imaging. CONCLUSIONS: This simple and less costly method allows to perform good-quality AES in units having echoendoscopes availability, without the need of a more expensive dedicated probe.

Colonic propulsive and postprandial motor activity in patients with ulcerative colitis in remission.

BACKGROUND: Although it is known that colon motility is abnormal in ulcerative colitis, data are still scarce with regard to the underlying mechanisms. Recent evidence suggests that the propulsive activity is highly increased during the active phase of the disease, probably contributing to the diarrhoea. However, data are even scarcer in the quiescent phase of the disease. AIMS: To assess the colonic high-amplitude and low-amplitude propulsive activity and the colonic motor response to eating in patients with ulcerative colitis in remission. PATIENTS AND METHODS: Fourteen patients were recruited, all with the disease in remission as documented by clinical and endoscopic criteria. Twenty-four hour manometric recordings were obtained in these patients, and compared to those of 16 healthy controls. RESULTS: The high-amplitude propagated contractions were similar in both groups (5.8+/-2.6 events in ulcerative colitis patients and 5.5+/-0.8 in controls (P=0.13)), whereas patients tended to display a higher number of low-amplitude propagated events (134.4+/-34 vs. 60.9+/-16 in controls (P=0.058)). No differences were found in the colonic motor response to eating between patients and controls. CONCLUSIONS: Colonic propulsive activity in ulcerative colitis in remission is almost normal, even though the low-amplitude propagated activity tends to be similar to that observed in patients with the irritable bowel syndrome, thus possibly contributing to the persistence of abdominal symptoms in a subgroup of patients.

Clinical management of patients with gastric neuroendocrine neoplasms associated with chronic atrophic gastritis: a retrospective, multicentre study.

To provide data regarding clinical presentation, pathological features, management, and response to different treatments of patients with type I gastric neuroendocrine tumors in stages 0-2A. The study design consist of an Italian multicentre, retrospective analysis of patients with type I gastric neuroendocrine tumors managed with different therapeutic approaches: surgery, endoscopic surveillance, endoscopic resection, or somatostatin analog therapy. Among the 97 patients included, 3 underwent surgery, 45 (46.4%) radical endoscopic resection of the neoplastic lesions, 13 (13.4%) follow-up with upper endoscopy, and 36 (37.1%) somatostatin analog therapy. At the end of the follow-up, all patients were alive and there was no evidence of metastatic disease. Somatostatin analog therapy resulted in a complete response in 76.0% of the patients and stable disease in 24.0%. A prolonged period of therapy, the use of a full dose of somatostatin analogs and higher gastrin levels at diagnosis were related to a complete response to the therapy. The recurrence rate was 26.3% in patients treated with somatostatin analog therapy and 26.2% in patients treated with endoscopic resection, without a statistically significant difference in terms of disease-free survival. Regarding recurrence of the disease, no statistical difference was found according to type of therapy, number of neoplastic lesions, and 2010 WHO classification. The only risk factor for tumor recurrence was a short period of medical treatment. In conclusion, our study suggested that endoscopic surveillance, endoscopic resection and somatostatin analog therapy represent valid options in the management of patients with type I gastric neuroendocrine tumors in stages 0-2A.

Pre-operative Diagnosis of Pancreatic Neuroendocrine Tumors with Endoscopic Ultrasonography and Computed Tomography in a Large Series.

BACKGROUND AND AIMS: Diagnosis of pancreatic neuroendocrine tumors (p-NETs) is frequently challenging. We describe a large series of patients with p-NETs in whom both pre-operative Computed Tomography (CT) and Endoscopic Ultrasonography (EUS) were performed. METHODS: This was a retrospective analysis of prospectively collected sporadic p-NET cases. All patients underwent both standard multidetector CT study and EUS with fine-needle aspiration (FNA). The final histological diagnosis was achieved on a post-surgical specimen. Chromogranin A (CgA) levels were measured. RESULTS: A total of 80 patients (mean age: 58 +/- 14.2 years; males: 42) were enrolled. The diameter of functioning was significantly lower than that of non-functioning p-NETs (11.2 +/- 8.5 mm vs 19.8 +/- 12.2 mm; P = 0.0004). The CgA levels were more frequently elevated in non-functioning than functioning pNET patients (71.4% vs 46.9%; P = 0.049). Overall, the CT study detected the lesion in 51 (63.7%) cases, being negative in 26 (68.4%) patients with a tumor

S-equol, a potent ligand for estrogen receptor beta, is the exclusive enantiomeric form of the soy isoflavone metabolite produced by human intestinal bacterial flora.

BACKGROUND: The discovery of equol in human urine more than 2 decades ago and the finding that it is bacterially derived from daidzin, an isoflavone abundant in soy foods, led to the current nutritional interest in soy foods. Equol, unlike the soy isoflavones daidzein or genistein, has a chiral center and therefore can occur as 2 distinct diastereoisomers. OBJECTIVE: Because it was unclear which enantiomer was present in humans, our objectives were to characterize the exact structure of equol, to examine whether the S- and R-equol enantiomers are bioavailable, and to ascertain whether the differences in their conformational structure translate to significant differences in affinity for estrogen receptors. DESIGN: With the use of chiral-phase HPLC and mass spectrometry, equol was isolated from human urine and plasma, and its enantiomeric structure was defined. Human fecal flora were cultured in vitro and incubated with daidzein to ascertain the stereospecificity of the bacterial production of equol. The pharmacokinetics of S- and R- equol were determined in 3 healthy adults after single-bolus oral administration of both enantiomers, and the affinity of each equol enantiomer for estrogen receptors was measured. RESULTS: Our studies definitively establish S-equol as the exclusive product of human intestinal bacterial synthesis from soy isoflavones and also show that both enantiomers are bioavailable. S-equol has a high affinity for estrogen receptor beta (K(i) = 0.73 nmol/L), whereas R-equol is relatively inactive. CONCLUSIONS: Humans have acquired an ability to exclusively synthesize S-equol from the precursor soy isoflavone daidzein, and it is significant that, unlike R-equol, this enantiomer has a relatively high affinity for estrogen receptor beta.