Evaluation of Gastro-Esophageal Reflux Disease (GERD), as a possible cause of Eustachian tube dysfunction in adults.

BACKDOWN: In this study, the authors, each for their own skills, on the basis of clinical, psychological, endoscopic investigations, evaluated the probable relationship between the laryngopharyngeal reflux present in gastroesophageal reflux disease, and the dysfunction of the Eustachian tube. At the end of the study, after a phase of medical therapy for GERD, they found that laryngopharyngeal acid reflux was in fact the basis of audiological symptoms and chronic dysfunction of the Eustachian tube. METHODS: We evaluated with a digestive endoscopy 60 patients with symptoms of gastroesophageal reflux, who had associated pathologies of ENT relevance, probably caused by extraesophageal reflux. Following audiometric evaluations, 40 patients treated with drug therapy for reflux were selected. RESULTS: Based on clinical, psychological, endoscopic investigations, and after medical therapy, acid reflux has been shown to underlie audiological symptoms and chronic dysfunction of the Eustachian tube. CONCLUSION: Although limited to a small number of patients, the results obtained with our study, supported by various clinical studies in the literature, confirm the hypothesis that acid reflux may underlie audiological symptoms and therefore involved in the genesis and chronic dysfunction of Eustachian tube. KEY WORDS: Dysfunction of the Eustachian tube, Esophagogastroduodenoscopy, Gastroesophageal reflux disease, Laryngopharyngeal reflux.

Could atmospheric temperature impact on adequate colon cleansing for colonoscopy? An observational, single-institution study.

PURPOSE: Several risk factors affecting the adequacy of colon cleansing have been proposed during the last decades. However, less is known about the impact that atmospheric aspects could have on adequacy of the bowel cleansing. The study aimed to investigate if the atmospheric temperature could impact on the bowel cleansing during colonoscopy. METHODS: A prospective maintained database of the colonoscopies performed since 1st August 2017 to 31st March 2020 was retrospective reviewed. The primary outcome of the study was to identify if the atmospheric temperature was associated with inadequate colon cleansing during colonoscopy. Secondary outcome was to identify the other factors associated with an inadequate colon cleansing. RESULTS: One thousand two hundred twenty patients were enrolled. High atmospheric temperature (> 25 °C) significantly influenced the colon cleansing (p < 0.0001). Adequate colon cleansing was negatively influenced by gender (female patients were associated with higher colon cleansing rate, p = 0.013), diabetes (p < 0.0001), previous pelvic surgery (p = 0.001), use of Beta-Blocker (p = 0.001), anti-platelet (p = 0.017), angiotensin converting enzyme inhibitors (p = 0.001), the adoption of 4 L Poly Ethylene Glycol solution (p = 0.009), single-dose regimen (p < 0.0001) low patients' compliance (p < 0.0001), higher age and body mass index (p < 0.0001 and p = 0.025), lower education levels (p < 0.0001). On the contrary, admission to the ward to perform bowel preparation positively impacted on colon cleansing (p = 0.002). CONCLUSION: Atmospheric temperature could play an important role in the colon cleansing during colonoscopy, being high temperature (> 25 °C) associated with lower rate of adequate bowel cleansing. However, being this relationship never studied before, these results must be confirmed by other studies.

Robotic Surgery and Functional Esophageal Disorders: A Systematic Review and Meta-Analysis.

The functional disease of the esophago-gastric junction (EGJ) is one of the most common health problems. It often happens that patients suffering from GERD need surgical management. The laparoscopic fundoplication has been considered the gold standard surgical treatment for functional diseases of the EGJ. The aim of our meta-analysis is to investigate functional outcomes after robotic fundoplication compared with conventional laparoscopic fundoplication. A prospective search of online databases was performed by two independent reviewers using the search string "robotic and laparoscopic fundoplication", including all the articles from 1996 to December 2021. The risk of bias within each study was assessed with the Cochrane ROBINS-I and RoB 2.0 tools. Statistical analysis was performed using Review Manager version 5.4. In addition, sixteen studies were included in the final analysis, involving only four RCTs. The primary endpoints were functional outcomes after laparoscopic (LF) and robotic fundoplication (RF). No significant differences between the two groups were found in 30-day readmission rates (p = 0.73), persistence of symptomatology at follow-up (p = 0.60), recurrence (p = 0.36), and reoperation (p = 0.81). The laparoscopic fundoplication represents the gold standard treatment for the functional disease of the EGJ. According to our results, the robotic approach seems to be safe and feasible as well. Further randomized controlled studies are required to better evaluate the advantages of robotic fundoplication.

Endoscopic approach to complex or recurrent pilonidal sinus: A retrospective analysis.

Pilonidal Sinus is a benign, chronic disease that affects the hair follicles of the natal cleft of the sacrococcygeal area. Its ideal treatment is controversial, especially in complex or recurrent cases. The aim of this study is to evaluate the use of minimally invasive endoscopic approach in this setting. We enrolled patients affected by complex or recurrent sacrococcygeal pilonidal sinus from January 2015 through December 2020 who underwent Video-Assisted Ablation of Pilonidal Sinus. All patients enrolled were re-evaluated once a year with a standard physical examination. The patients included were 38. Recurrence rate at 1-, 3- and 5-years follow-ups were 28.9%, 22.2% and 38.1% respectively. Of interest, the mean (SD) distance from the most lateral orifice to the midline was higher in group of patients with recurrence and the multivariate analysis demonstrated that it was the limiting factor, which influences the recurrence rate. In complex or recurrent pilonidal sinus disease with pits off the midline the endoscopic approach should not be the first choice. This makes us think that these cases should have their own classification to be identified and guide surgeons in choosing the appropriate approach.

Laparoscopic atypical resection of subcardial gastric GIST guided by intraoperative endoscopy. A single-center study and a review of the literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They are 1% of all gastrointestinal cancer and 60% of them affects the stomach. Up to 10% to 30% of GISTs are malignant. They occur in people over the age of 50 in both sexes. The most common symptoms of gastric GIST are bleeding, dyspepsia, vague abdominal pain or discomfort, and mass palpation. Some are asymptomatic and diagnosed incidentally. The first choice of treatment for primary localized gastric GISTs is surgery. The most suitable type of resection is not yet clear and it depends on size and location of tumor, especially for difficult localizations, such as subcardial, posterior wall and less curvature GISTs. METHODS: We report a rare case of a patient with subcardial gastric GIST treated with laparoscopic atypical quadrangular resection guided by intraoperative endoscopy. Furthermore, we performed a review of the literature about this topic. RESULTS: Despite the difficult localization an atypical resection of the gastric GIST was performed without breaking the lesion but preserving the lumen of the esofagogastrich junction. CONCLUSIONS: An atypical quadrangular resection for subcardial gastric GISTs, located along the posterior wall and lesser curvature, can be a safe and reliable alternative technique. However, we believe that it should be performed by an experienced surgeon and endoscopist to decrease the risk of mass's break and the narrowing of the cardial region's lumen. In our literature's knowledge there aren't cases treated with this technique. KEY WORDS: Gastric GIST, Gastrointestinal stromal tumors, Intraoperative endoscopy, Laparoscopic resection, Minimally invasive surgery.

The Role of Indocyanine Near-Infrared Fluorescence in Colorectal Surgery.

Purposes: The aim of this study was to evaluate the importance of Indocyanine Green in control of anastomosis perfusion and on anastomotic leakage rates during laparoscopic and robotic colorectal procedures. Methods: A retrospective review of patients who underwent elective minimally invasive surgery for colorectal cancer from 1 January 2018 to 31 December 2020 was performed. All patients underwent Near-Infrared Fluorescence-Indocyanine Green system in two moments: before performing the anastomosis and after completing the anastomotic procedure. Primary outcomes were the rate of intraoperative change in the surgical resection due to an inadequate vascularization and the rate of postoperative anastomotic leakage. Secondary outcomes were the postoperative complications, both medical and surgical (intra-abdominal bleeding, anastomotic leakage). Results: Our analysis included 93 patients. Visible fluorescence was detected in 100% of the cases. In 7 patients (7.5%), the planned site of resection was changed due to inadequate perfusion. The mean extension of the surgical resection in these 7 patients was 2.2 ± 0.62. Anastomotic leakage occurred in 2 patients (2.1%). Other complications included 8 postoperative bleedings (8.6%) and 1 pulmonary thromboembolism. Conclusions: The intraoperative use of Near-Infrared Fluorescence-Indocyanine Green in colorectal surgery is safe, feasible, and associated with a substantial reduction in postoperative anastomotic leakage rate.

Post-operative oncological and psychological evaluation of patients with colostomy for colorectal cancer.

BACKGROUND: The therapeutic arsenal for colorectal cancer is largely made up of surgery. In digestive tumors, ostomy devices induce loss of function and control. This medical device generates changes that affect all aspects of patients' lives. This study evaluates the postoperative follow-up from the oncological point of view and the psychological impact of colostomy on the quality of life of patients with colorectal cancer, analyzing any complications or relapses, and the high risk of self-concept disorder and social isolation. METHODS: The aim of the work was to identify all the surgeries for colorectal cancer performed in the Federico II University Hospital of Naples, from 2018 to 2021, and among them how many had been packaged a colostomy. We then analyzed how many patients had been evaluated 12 months after surgery, with a transanal endoscopy or transtomy, and the percentage of any complications or relapses. The same patients who underwent endoscopic control were also evaluated psychologically, to analyze how they lived the packaging of the ostomy and how it had affected the quality of life. RESULTS: At endoscopic control, diversion colitis phenomena and few cases of stoma stenosis and stomatitis were detected. No case of neoplastic recurrence. From the psychological point of view, the problems detected were in particular the alteration of body image, the loss of sphincter control, embarrassment and shame for the bad smell, impairment of sexuality and difficulties in the couple relationship and social contacts, anxiety, depression and loneliness. CONCLUSIONS: The post-operative evaluation of the ostomy patient following colorectal cancer requires endoscopic control to suddenly detect recurrences and complications and psychological support that improves their quality of life. KEY WORDS: Permanent Colostomy, Psychological Adjustment, Quality of Life, Temporary Colostomy.

Endoscopic clipping in non-variceal upper gastrointestinal bleeding treatment.

Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.

Endoscopic Diagnosis and Management of Barrett's Esophagus with Low-Grade Dysplasia.

Barrett's Esophagus is a common condition associated with chronic gastroesophageal reflux disease. It is well known that it has an association with a higher incidence of esophageal adenocarcinoma, but this neoplastic transformation is first preceded by the onset of low and high-grade dysplasia. The evaluation of low grade dysplastic esophageal mucosa is still controversial; although endoscopic surveillance is preferred, several minimally invasive endoscopic therapeutic approaches are available. Endoscopic mucosal resection and radiofrequency ablation are the most used endoscopic treatments for the eradication of low-grade dysplasia, respectively, for nodular and flat dysplasia. Novel endoscopic treatments are cryotherapy ablation and argon plasma coagulation, that have good rates of eradication with less complications and post-procedural pain.

Role of narrow band imaging (NBI), in the treatment of non-polypoid colorectal lesions, with endoscopic mucosal resection (EMR). A single-center experience.

BACKGROUND: In this study, the authors evaluated the role of narrow band imaging endoscopy in the early detection of infiltration of the colon wall by flat and depressed lesions, highlighted during colonoscopy, to confirm the possibility of removal with Endoscopic Mucosal Resection (EMR). METHODS: 67 patients (37 males and 30 females) with non-polypoid colorectal lesions were included in this study. The location of the lesions, the size and possible infiltration of the colon wall were performed with a colonoscopy with NBI. Lesions without massive invasion were treated with an EMR. RESULTS: NBI was found to be a sensitive, specific, and accurate technique in assessing any infiltration of the colon wall. Endoscopic resection of the mucous membrane was successfully performed in 62 patients, it was not possible to perform it in 5 patients, due to the lack of dissection, and they underwent surgery. CONCLUSIONS: Non-polypoid colorectal lesions and early tumors can be treated with EMR. Certainly, early detection with Narrow Band Imaging endoscopy and subsequent endoscopic resection can reduce colorectal cancer mortality. Many studies have confirmed that these two methods have achieved important results comparable with surgical procedures. KEY WORDS: Endoscopic Mucosal Resection, Narrow Band Imaging, Therapy.

Histopathological Examination and Endoscopic Sinusectomy: Is It Possible?

Introduction: Although carcinomatous degeneration is a rare occurrence, some authors support the need for a histopathological examination after pilonidal cyst excision. Today, minimally invasive techniques are widely spread for the treatment of pilonidal sinus disease but opposed to standard procedures, these techniques could not allow to perform a histopathological examination because of the absence of a specimen. The aim of this two-institutions study is to evaluate whether histopathological examination of the pilonidal sinus excision material can be successfully performed after an endoscopic ablation of the cyst. Materials and Methods: We identified all consecutive patients from January 2021 to September 2021 with diagnosis of pilonidal sinus disease who underwent Video Assisted Ablation of Pilonidal Sinus (VAAPS) followed by histopathological examination. Results: A total of 45 patients were included in the study. All patients were Caucasians and aged below 50 years. Nine of them underwent surgery due to recurrence of PSD. No evidence of malignancy was detected in the histopathological examination of the pilonidal sinus sampling material. Discussion: We were able to send pilonidal sinus sampling material for a histopathological examination in all patients who underwent minimally invasive technique for the treatment of pilonidal sinus disease. No evidence of malignancy was found in any of the 45 samples. Our findings prove that minimally invasive ablation of pilonidal sinus does not preclude histopathological examination of the cysts.

Oncological and psychological evaluation of laryngectomized patients, pre and post implantation of voice prostheses. A single center experience.

BACKGROUND: In our study we evaluated from an oncological and psychological point of view, a group of patients who had previously undergone total laryngectomy and candidates for the placement of a vocal prosthesis, which allows to recover the voice using the air that passes from the trachea to the esophagus, thus vibrating a segment of the cervical esophagus. For the placement of the prosthesis and the oncological follow-up, we used the support of videoendoscopy, to exclude any recurrence or secondary tumors. At the same time, we subjected patients to a psychological evaluation before and after the implantation of the prostheses, to understand the behavioral changes in the two phases, and the possible achievement of the result of total autonomy, social reintegration, and recovery of oral communication, in the post-surgical phase. METHODS: We performed a complete esophagogastroduodenoscopy and psychological evaluation on 42 patients who had previously undergone a total laryngectomy, before proceeding to the creation of a tracheoesophageal fistula and the placement of a phonatory prosthesis. After six months, we re-evaluated the same patients, both from an oncological and psychological point of view. RESULTS: At the preimplantation control of the prosthesis, in endoscopy we detected three neoplastic relapses that did not allow the placement of a prosthesis, and four patients who had grade B esophagitis according to the Los Angeles classification, in the remaining 35 patients there were no complications. At the psychological evaluation, most of the patients had psychosocial disorders, with phenomena of anxiety and depression. At the check-up six months after implantation, none of the patients had relapses, and the voice prosthesis was not fully functional in a single patient. From a psychological point of view, voice recovery has significantly improved relationships both in the family and in the social sphere. CONCLUSIONS: Our experience has confirmed the interesting and advantageous use of videoendoscopy in patients undergoing total laryngectomy and candidates for the placement of a tracheoesophageal vocal prosthesis, in the evaluation of neoplastic relapses and secondary lesions of the esophagus. The role of the psychologist both in the pre and post prosthetic phase is fundamental in assessing the discomfort of these patients by helping them solve some problems such as isolation and anxiety. KEY WORDS: Anxiety, Depression, Total laryngectomy, Voice prosthesis.

Can Computed Tomography Colonography Replace Optical Colonoscopy in Detecting Colorectal Lesions?: State of the Art.

Colorectal cancer is an important cause of morbidity and mortality worldwide. Optical colonoscopy (OC) is widely accepted as the reference standard for the screening of colorectal polyps and cancers, and computed tomography colonography (CTC) is a valid alternative to OC. The purpose of this review was to assess the diagnostic accuracy of OC and CTC for colorectal lesions. A literature search was performed in PubMed, Embase, and Cochrane Library, and 18 articles were included. CTC has emerged in recent years as a potential screening examination with high accuracy for the detection of colorectal lesions. However, the clinical application of CTC as a screening technique is limited because it is highly dependent on the size of the lesions and has poor performance in detecting individual lesions <5 mm or flat lesions, which, although rarely, can have a malignant potential.

Endoscopic resection of a large polypoid gastric heterotopia of duodenum: a case report.

This report shows a rare case of gastric heterotopia in the duodenum presented as a large polypoid lesion, differently from data reported in literature, which enters into differential diagnosis with other duodenal lesions that are not always benign.

Robotic Colorectal Cancer Surgery. How to Reach Expertise? A Single Surgeon-Experience.

The complexity associated with laparoscopic colorectal surgery requires several skills to overcome the technical difficulties related to this procedure. To overcome the technical challenges of laparoscopic surgery, a robotic approach has been introduced. Our study reports the surgical outcomes obtained by the transition from laparoscopic to robotic approach in colorectal cancer surgery to establish in which type of approach the proficiency is easier to reach. Data about the first consecutive 15 laparoscopic and the first 15 consecutive robotic cases are extracted, adopting as a comparator of proficiency the last 15 laparoscopic colorectal resections for cancer. The variables studied are operative time, number of harvested nodes, conversion rate, postoperative complications, recovery outcomes. Our analysis includes 15 patients per group. Our results show that operative time is significantly longer in the first 15 laparoscopic cases (p = 0.001). A significantly lower number of harvested nodes was retrieved in the first 15 laparoscopic cases (p = 0.003). Clavien Dindo I complication rate was higher in the first laparoscopic group, but without a significant difference among the three groups (p = 0.09). Our results show that the surgeon needed no apparent learning curve to reach their laparoscopic standards. However, further multicentric prospective studies are needed to confirm this conclusion.

Diagnosis and Management of Rectal Neuroendocrine Tumors (NETs).

Rectal neuroendocrine tumors (NETs) are rare, with an incidence of 0.17%, but they represent 12% to 27% of all NETs and 20% of gastrointestinal NETs. Although rectal NETs are uncommon tumors, their incidence has increased over the past few years, and this is probably due to the improvement in detection rates made by advanced endoscopic procedures. The biological behavior of rectal NETs may be different: factors predicting the risk of metastases have been identified, such as size and grade of differentiation. The tendency for metastatic diffusion generally depends on the tumor size, muscular and lymphovascular infiltration, and histopathological differentiation. According to the current European Neuroendocrine Tumor Society (ENETS) guidelines, tumors that are smaller than 10 mm and well differentiated are thought to have a low risk of lymphovascular invasion, and they should be completely removed endoscopically. Rectal NETs larger than 20 mm have a higher risk of involvement of muscularis propria and high metastatic risk and are candidates for surgical resection. There is controversy over rectal NETs of intermediate size, 10-19 mm, where the metastatic risk is considered to be 10-15%: assessment of tumors endoscopically and by endoanal ultrasound should guide treatment in these cases towards endoscopic, transanal, or surgical resection.

Portal venous gas after a failed endoscopic retrograde cholangiopancreatography attempt in a patient with a large hepatocellular carcinoma: A case report.

The cause of hepatic portal vein gas (HPVG) is variable. Good knowledge of the possible causes, combined with the clinical assessment of the patient and a good quality imaging, is required to correctly identify the underlying cause of HPVG and to best predict the prognosis.

Endorectal Ultrasonography and Pelvic Magnetic Resonance Imaging Show Similar Diagnostic Accuracy in Local Staging of Rectal Cancer: An Update Systematic Review and Meta-Analysis.

BACKGROUND: Endorectal Ultrasonography (EUS-ERUS) and pelvic magnetic resonance imaging (MRI) are world-wide performed for the local staging of rectal cancer (RC), but no clear consensus on their indications is present, there being literature in support of both. The aim of this meta-analysis is to give an update regarding the diagnostic test accuracy of ERUS and pelvic MRI about the local staging of RC. MATERIALS AND METHODS: A systematic literature search from November 2020 to October 2021 was performed to select studies in which head-to-head comparison between ERUS and MRI was reported for the local staging of rectal cancer. Quality and risk of bias were assessed with the QUADAS-2 tool. Our primary outcome was the T staging accuracy of ERUS and MRI for which pooled accuracy indices were calculated using a bivariable random-effects model. In addition, a hierarchical summary receiver operating characteristic curve (hSROC) was created to characterize the accuracy of ERUS and MRI for the staging of T and N parameters. The area under the hSROC curve (AUChSROC) was determined as a measure of diagnostic accuracy. RESULTS: Seven studies and 331 patients were included in our analysis. ERUS and MRI showed a similar accuracy for the T staging, with AUChSROC curves of 0.91 (95% C.I., 0.89 to 0.93) and 0.87 (95% C.I., 0.84 to 0.89), respectively (p = 0.409). For T staging, ERUS showed a pooled sensitivity of 0.82 (95% C.I. 0.72 to 0.89) and pooled specificity of 0.91 (95% C.I. 0.77-0.96), while MRI had pooled sensitivity and specificity of 0.69 (95% C.I. 0.55-0.81) and 0.88 (95% C.I. 0.79-0.93), respectively. ERUS and MRI showed a similar accuracy in the N staging too, with AUChSROC curves of 0.92 (95% C.I., 0.89 to 0.94) and 0.93 (95% C.I., 0.90 to 0.95), respectively (p = 0.389). CONCLUSIONS: In conclusion, ERUS and MRI are comparable imaging techniques for the local staging of rectal cancer.

Endoscopic Treatment of Pilonidal Sinus Disease: State of Art and Review of the Literature.

Background: Pilonidal sinus disease (PSD) is a chronic troublesome pathology of the natal cleft of the sacrococcygeal region, with an estimated incidence of 26 cases in every 100,000 inhabitants. The aim of this review is to give a snapshot of the current literature on the endoscopic approach to PSD. Methods: A search on endoscopic treatment of pilonidal disease was performed according to PRISMA guidelines, adopting the following search terms: (pilonidal OR sacrococcygeal) and (endoscopic OR VAAPS OR EPSiT OR minimally invasive OR video-assisted OR video assisted). Results: Thirty-four articles were included in the final analysis, among which 23 were on adults and 11 were on pediatric population. The endoscopic approach is associated with painless postoperative pain, good aesthetic results, short time off work, and high patient satisfaction. Despite these advantages in short-term outcomes, results on recurrence rate in a long-term follow up are needed to definitively confirm the importance of this technique. Conclusions: The endoscopic approach is associated with significant postoperative advantages over other standard surgical approaches, and it should be included in the surgical portfolio for the treatment of PSD. According to the Italian guidelines, this technique could be considered as the gold standard for limited PSD. However, the favorable short-term-outcomes and lack of reliable data on long-term follow-up must be a stimulus to perform further high-quality studies to give definitive conclusions on this technique.