Real-time diagnosis of H. pylori infection during endoscopy: Accuracy of an innovative tool (EndoFaster).

BACKGROUND: EndoFaster is novel device able to perform real-time ammonium measurement in gastric juice allowing H. pylori diagnosis during endoscopy. This large study aimed to validate the accuracy of EndoFaster for real-time H. pylori detection. METHODS: Consecutive patients who underwent upper endoscopy in two centres were prospectively enrolled. During endoscopy, 4 ml of gastric juice were aspirated to perform automatic analysis by EndoFaster within 90 seconds, and H. pylori was considered present (>62 ppm/ml) or absent (≤62 ppm/ml). Accuracy was measured by using histology as gold standard, and (13)C-urea breath test (UBT) in discordant cases. Accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were calculated. RESULTS: Overall, 189 patients were enrolled, but in seven (3.4%) the aspirated gastric juice amount was insufficient to perform the test. The accuracy, sensitivity, specificity, PPV, and NPV were 87.4%, 90.3%, 85.5%, 80.2%, 93.1%, respectively, and 92.6%, 97.1%, 89.7%, 85.9%, 98.0%, respectively, when H. pylori status was reclassified according to the UBT result in discordant cases. CONCLUSIONS: This study found a high accuracy/feasibility of EndoFaster for real-time H. pylori diagnosis. Use of EndoFaster may allow selecting those patients in whom routine gastric biopsies could be avoided.

Endo-sponge therapy for management of anastomotic leakages after colorectal surgery: A case series and review of literature.

BACKGROUND: Endo-sponge treatment is a novel approach to manage selected patients with anastomotic leakage following colorectal surgery. However, the available data are still scanty. AIMS: To evaluate the efficacy and safety of the endo-sponge therapy in a large series, and to perform a review of the current evidence concerning such a treatment. METHODS: Consecutive patients diagnosed with partial colonic anastomotic leakage managed with endo-sponge placement were enrolled. The endo-sponge system was changed every 48-72 h as outpatient, until to cavity closure. Literature review was performed for pooled-data analysis. RESULTS: Twenty-five patients were enrolled, including 13 (52%) with diverting ileostomy. Following endo-sponge applications (median sessions: 9, range: 1-39; median treatment duration: 4 weeks, range: 1-32), a complete healing was achieved in 22 (88%) patients. Three (12%) patients developed a major complication (1 uretheric fistula, 1 ileal fistula, and 1 pararectal abscess), all successfully treated by surgery. Ileostomy closure was achieved in 11 (84.6%) patients. No mortality related to the procedure was observed. Overall, 174 patients treated with endo-sponge were reported in literature. By considering data of the larger 7 studies, a complete healing of presacral cavity was achieved in 131 (94.3%) out of 149 patients. CONCLUSIONS: Our relatively large series of patients confirmed the efficacy, tolerability, and an acceptably low complication rate of endo-sponge therapy for colorectal anastomosis leakage treatment.

Endoscopic submucosal dissection of early gastric neoplastic lesions: a western series.

OBJECTIVE: Endoscopic submucosal dissection (ESD) has been found to be effective and safe for endoscopic removal of early gastric neoplasia in large Asian series. However, few data are available on the use of ESD in western countries. We assessed the efficacy of ESD performed in patients with early gastric neoplastic lesions. METHODS: We analyzed prospectively collected data of consecutive patients who underwent the ESD procedure for gastric neoplasia at a single Italian center. Procedure-related outcomes, including complete histological resection rate (i.e. R0 resection), immediate and late complication rate, procedure-related mortality, and follow-up were evaluated. RESULTS: Forty-two patients underwent gastric ESD. The en-bloc removal of lesions was successful in all cases, whereas R0 was achieved in 39 (92.8%) patients. A bleeding episode was observed in three (7.1%) patients, which was successfully managed by endoclip positioning. No perforations and procedure-related deaths were observed. The median follow-up period was 19 months (range: 9-53). A small residue of adenomatous lesion and a recurrent dysplastic lesion were removed by endoscopic mucosal resection in two (5%) patients. CONCLUSION: Our data are comparable with those of larger Asian series. Use of ESD for removal of gastric neoplastic lesions should be implemented in western countries.

Balanced propofol sedation administered by nonanesthesiologists: The first Italian experience.

AIM: To assess the efficacy and safety of a balanced approach using midazolam in combination with propofol, administered by non-anesthesiologists, in a large series of diagnostic colonoscopies. METHODS: Consecutive patients undergoing diagnostic colonoscopy were sedated with a single dose of midazolam (0.05 mg/kg) and low-dose propofol (starter bolus of 0.5 mg/kg and repeated boluses of 10 to 20 mg). Induction time and deepest level of sedation, adverse and serious adverse events, as well as recovery times, were prospectively assessed. Cecal intubation and adenoma detection rates were also collected. RESULTS: Overall, 1593 eligible patients were included. The median dose of propofol administered was 70 mg (range: 40-120 mg), and the median dose of midazolam was 2.3 mg (range: 2-4 mg). Median induction time of sedation was 3 min (range: 1-4 min), and median recovery time was 23 min (range: 10-40 min). A moderate level of sedation was achieved in 1561 (98%) patients, whilst a deep sedation occurred in 32 (2%) cases. Transient oxygen desaturation requiring further oxygen supplementation occurred in 8 (0.46%; 95% CI: 0.2%-0.8%) patients. No serious adverse event was observed. Cecal intubation and adenoma detection rates were 93.5% and 23.4% (27.8% for male and 18.5% for female, subjects), respectively. CONCLUSION: A balanced sedation protocol provided a minimalization of the dose of propofol needed to target a moderate sedation for colonoscopy, resulting in a high safety profile for non-anesthesiologist propofol sedation.

Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma: results from a prospective Western series.

BACKGROUND: Although endoscopic submucosal dissection (ESD) is becoming accepted as an established treatment for superficial esophageal squamous cell neoplasia, the majority of data on this endoscopic modality has been provided by Japanese series. OBJECTIVE: To assess the efficacy and safety of ESD for esophageal squamous cell neoplasia in a consecutive series of patients treated in a Western setting. DESIGN AND SETTING: Single-center, prospective observational study. PATIENTS AND INTERVENTION: From January 2005 to July 2008, 20 patients with superficial esophageal squamous cell neoplasia were treated by ESD. MAIN OUTCOME MEASUREMENTS: Rates of en bloc resection, complete resection, and complications were evaluated as short-term outcomes. Overall survival, local or distant recurrence, and postoperative stricture rates were evaluated as long-term outcomes. RESULTS: ESD was performed in 20 patients (mean age 64 years, range 46-81 years; 16 men). The mean size of the lesion was 32 mm (range 15-60 mm); it was 30 mm or larger in 14 patients (70%). The mean time of ESD was 89 minutes (range 58-180 minutes). En bloc resection with resection-free margins was achieved in 18 patients (90%), whereas 2 patients presented with incomplete or indeterminate resection. Two cases (10%) of mediastinal emphysema without overt perforation and 1 case (5%) of post-ESD symptomatic stricture were reported. No local or distant post-ESD recurrence occurred in those with resection-free margins at a median follow-up of 18 months. LIMITATIONS: Small number of patients and limited follow-up. CONCLUSION: This Western series study confirms that ESD is a potentially curative treatment for superficial esophageal squamous cell neoplasia. Early and late complication rates were comparable to those of Japanese series. ESD should be probably considered as the treatment of choice in all large lesions amenable to endoscopic treatment.

Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes.

Open access endoscopy and screening programs enable detection and removal of an increased number of colon polyps in the early stages of neoplastic transformation. Unfortunately, polyps larger than 3 cm, involving more than one-third of circumference or two haustral folds, or with a flat/depressed morphology are more challenging to remove with standard polypectomy techniques. Endoscopic mucosal resection potentiates the removal, in a minimally invasive way, of certain colonic lesions that would otherwise require surgical or ablative treatment. Because the plane of resection during endoscopic mucosal resection is typically the middle to deep submucosal layer, compared with standard polypectomy, which normally provides resection at a mucosal level, endoscopic mucosal resection offers the advantage of providing en bloc resection specimens for histopathologic analysis. Indications to perform endoscopic mucosal resection are adenoma and small, well-differentiated carcinoma, confined to the mucosa or with minimal invasion to submucosa, and without any invasion to lymphatic channels or vessels. The most frequently reported major complications, such as perforation (0-5%) and bleeding (0.5-6%), may be controlled by endoscopic methods and rarely require surgical treatment. Follow-up postendoscopic mucosal resection is essential because of the risk of neoplastic recurrence.

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.

Optical coherence tomography evaluation of ulcerative colitis: the patterns and the comparison with histology.

HYPOTHESIS: The optical coherence tomography (OCT) is an imaging modality based on infrared light backscattering properties of tissues. OCT studies documented the disappearance of crypts and the alteration in light backscattering as features of ulcerative colitis (UC) in human colon. This technique should be more and more able to identify tissue microstructures with a resolution that is nearly that of histology (optical biopsy). AIM: To evaluate whether there are OCT patterns specific for UC and to compare the overall technique performance with the histology. METHODS: A total of 27 patients (20-76 yr) with UC underwent OCT imaging during a total colonoscopy. The OCT images were collected both from affected and normal sites in active UC or disease in remission. Two biopsies of the same sites were acquired. The OCT images were separately scored. Two pathologists blinded to the endoscopic and OCT patterns scored the samples. RESULTS: Three OCT patterns were identified: the mucosal backscattering alteration (MBA), the delimited dark areas (DDA), and the layered colonic wall (LCW). In colon affected segments of active and UC in remission, these patterns showed a good correspondence with the histology. Moreover, in 14/25 (56%) normal sites above the affected segment, the OCT documented the pathological features, confirmed only in 10/14 by the histology. Thus, the assessed sensitivity and specificity of OCT in normal segments of UC patients have been 100% and 69%, respectively. CONCLUSIONS: The in vivo OCT correctly detected disease features in endoscopically affected colon segments, but even in apparently normal segments of UC patients.