Causes of withdrawal of duodenal levodopa infusion in advanced Parkinson disease.

OBJECTIVE: We performed a real-life observation of patients with Parkinson disease (PD) who received duodenal levodopa infusion (DLI) to determine which adverse events caused treatment discontinuation and when such events occurred. METHODS: All consecutive patients with PD treated at the Carlo Besta Neurological Institute were included. The patients were evaluated at baseline and after DLI at regular intervals. Their motor condition was assessed and adverse events were recorded. RESULTS: Thirty-five patients with PD (15 men and 20 women) were included. They received DLI implants between October 2007 and September 2013. Four patients died of causes unrelated to the procedure. At the end of the study, 21 patients (60%) were still on treatment. DLI provided efficacious motor control in all patients. Discontinuation was most frequently caused by device- or infusion-related adverse events. Ten patients of the remaining 31 discontinued DLI. There were 2 main causes of withdrawal: stoma infection (4 patients), and worsening of dyskinesias not manageable with infusion reduction (3 patients). In most patients, discontinuations occurred during the first year after implant. Risk of discontinuation was related to age at implant, but no other demographic or clinical variables. CONCLUSIONS: We identified 2 main causes leading to DLI withdrawal during the first year postimplant and suggest adopting measures to prevent such occurrences. Elderly patients are at higher risk of treatment discontinuation.

Barrett's esophagus: ablative endoscopic techniques.

Barrett's esophagus consists of a precancerous condition in which the progression from dysplasia to adenocarcinoma is now well documented. The management of patients affected by Barrett's esophagus is still debatable, in particular for the risk of surgical treatment in the presence of small precancerous lesions or early adenocarcinoma. Furthermore, quality of life after surgical resection is often poor. Endoscopy is the main diagnostic and follow-up procedure in Barrett's esophagus: it allows the detection and treatment of severe dysplasia and invasive esophageal adenocarcinoma. Endoscopic treatment also produces reduction or disappearance of intestinal metaplasia. In these cases, the aim of the treatment is to prevent dysplastic changes. Moreover, the ideal endoscopic treatment should be safe, easy to perform and cost effective. Thermal (electrocoagulation, laser, argon-plasma coagulation), photochemical (photodynamic therapy) or ablative (endoscopic mucosal resection) procedures have been proposed alone or in combination, with the aim to completely eradicate dysplastic lesions or early adenocarcinoma as an alternative to surgical treatment. Endoscopic removal of the lesions is followed by restoration of normal epithelium. Some questions about patient selection, prevention of recurrence and best endoscopic treatment still remain unanswered.