Quality of bowel cleansing in hospitalized patients undergoing colonoscopy: A multicentre prospective regional study.

BACKGROUND: Quality of bowel cleansing in hospitalized patients undergoing colonoscopy is often unsatisfactory. No study has investigated the inpatient or outpatient setting as cause of inadequate cleansing. AIMS: To assess degree of bowel cleansing in inpatients and outpatients and to identify possible predictors of poor bowel preparation in the two populations. METHODS: Prospective multicentre study on consecutive colonoscopies in 25 regional endoscopy units. Univariate and multivariate analysis with odds ratio estimation were performed. RESULTS: Data from 3276 colonoscopies were analyzed (2178 outpatients, 1098 inpatients). Incomplete colonoscopy due to inadequate cleansing was recorded in 369 patients (11.2%). There was no significant difference in bowel cleansing rates between in- and outpatients in both colonic segments. In the overall population, independent predictors of inadequate cleansing both at the level of right and left colon were: male gender (odds ratio, 1.20 [1.02-1.43] and 1.27 [1.05-1.53]), diabetes mellitus (odds ratio, 2.35 [1.68-3.29] and 2.12 [1.47-3.05]), chronic constipation (odds ratio, 1.60 [1.30-1.97] and 1.55 [1.23-1.94]), incomplete purge intake (odds ratio, 2.36 [1.90-2.94] and 2.11 [1.68-2.65]) and a runway time >12h (odds ratio, 3.36 [2.40-4.72] and 2.53 [1.74-3.67]). CONCLUSIONS: We found no difference in the rate of inadequate bowel preparation between hospitalized patients and outpatients.

A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series.

BACKGROUND: Staple-line leak is the most serious complication of laparoscopic sleeve gastrectomy (LSG) occurring in .5-7% of cases. Patients with this complication are often managed with an esophageal covered, self-expandable metal stent positioned at endoscopy. Unfortunately, migration of these stents has been reported in 30-50% of cases. A novel fully-covered, self-expanding metal stent (Megastent), specifically designed for post-LSG leaks is now available. The objective of this study was to describe the first case series of patients with a staple-line leak after LSG who were endoscopically managed with such a novel stent. METHODS: Four patients who developed a staple-line leak after LSG were treated by positioning a Megastent at endoscopy. The stents were removed after 8 weeks. RESULTS: A complete leak repair was achieved in all patients. No stent migration occurred. Prokinetic therapy was needed to treat vomiting episodes during stent presence. At endoscopic evaluation after stent removal, a decubitus lesion at the distal part of the duodenal bulb was observed. CONCLUSION: These preliminary results would suggest the use of the Megastent as an option for stenting of a staple-line leak after LSG. Further studies are still necessary.

Endoscopic repair of post-surgical gastrointestinal complications.

Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.

Diagnosis and therapeutic management of cystic dystrophy of the duodenal wall in heterotopic pancreas. A case report and revision of the literature.

CONTEXT: Cystic dystrophy in heterotopic pancreas is a rare and serious condition. Diagnosis is difficult because of non-specific clinical manifestations and radiologic and endoscopic imaging are pivotal. Therapeutic management is still under debate. CASE REPORT: We describe a case of cystic dystrophy of the duodenal wall in heterotopic pancreas complicated with chronic pancreatitis and pancreatic cystadenoma. DISCUSSION: Computed tomography and magnetic resonance are very useful in demonstrating the presence of cysts in a thickened duodenal wall but, for the most part, endoscopic ultrasonography is the most useful imaging examination. The choice of different therapeutic options is still under debate; although some authors have proposed a medical approach using octreotide or endoscopic treatment for selected patients, a pancreaticoduodenectomy is usually proposed for symptomatic patients. CONCLUSION: When surgery is needed, a pancreaticoduodenectomy is preferred, reserving by-pass procedures for high risk patients. Because of the non-specific clinical manifestation and the very difficult diagnosis and therapeutic management, these patients should be studied and treated in specialized and dedicated centers.

Pancreaticoduodenectomy as the primary therapeutic choice in cystic dystrophy of the duodenal wall in heterotopic pancreas.

On the basis of a review of the literature and description of a clinical case, the aim of this paper was to evaluate the role of pancreaticoduodenectomy as the primary therapeutic choice in a rare, serious condition such as cystic dystrophy of the duodenal wall in heterotopic pancreas. The diagnosis is difficult because of the non-specific clinical manifestations, and radiological and endoscopic imaging are decisive. Computed tomography and magnetic resonance are very useful for demonstrating the presence of cysts in a thickened duodenal wall but endoscopic ultrasonography is the most useful imaging examination. The choice of therapeutic option is still debated. Although some Authors have proposed a medical approach using octreotide or endoscopic treatment for selected patients, pancreaticoduodenectomy is usually proposed for symptomatic patients. When surgery is needed, pancreaticoduodenectomy should be preferred, reserving by-pass procedures for high-risk patients. Because of the non-specific clinical manifestations and the very difficult diagnostic and therapeutic management, these patients need to be studied and treated in specialised, dedicated centres.

New technique for endoscopic removal of intragastric balloon placed for treatment of morbid obesity.

BACKGROUND: Placement and removal of the intragastric balloon for obesity are performed endoscopically often under general anesthesia. We propose a safer and faster technique for endoscopic removal of the intragastric balloon using standard sedation. METHODS: In 87 obese patients, we performed 3 removal techniques: 1) standard gastroscope and foreign body forceps, 2) standard gastroscope and retrieval snare, 3) double-channel gastroscope and foreign body forceps plus symmetrical "shark model" polypectomy snare. Balloon retrieval time, number of times the grasping devices lost the balloon, amount of antispasmodic drug, symptoms cumulative score and VAS score for discomfort were evaluated. RESULTS: The technique by double-channel gastroscope and foreign body forceps plus symmetrical polypectomy shark retrieval snare showed a significantly lower balloon retrieval time, number of lost balloons, total number of ampoules used, symptoms cumulative score and VAS score compared to the other two techniques (Dunn's P<0.05). Number of lost balloons was positively associated with number of antispasmodic ampoules used, balloon retrieval time and VAS score. CONCLUSIONS: Technique by double-channel gastroscope and foreign body forceps plus symmetrical polypectomy shark retrieval snare, allows balloon removal safely, quickly and easily, avoiding loss of the balloon, with good patient endurance.

Duodenal epithelioid angiosarcoma: immunohistochemical and clinical findings. A case report.

Angiosarcomas are uncommon malignant tumors of vascular endothelium that represent less than 1% of all sarcomas. The epithelioid variant of angiosarcomas is exceptionally rare, and the gastrointestinal tract is rarely involved. Angiosarcomas mainly involve skin and soft tissue and rarely occur in breast, liver, bone, and spleen. We present the case of a 30-year-old man who underwent an upper gastrointestinal endoscopy for melena. A duodenal reddish polypoid lesion was found, which on microscopic examination turned out to be an epithelioid angiosarcoma. The immunohistochemical features of the lesion supported this diagnosis. The patient died eight months after the diagnosis. Epithelioid angiosarcoma is an aggressive variant of angiosarcoma and must be considered in the differential diagnosis of gastrointestinal tumors.