OPPORTUNISTIC SCREENING FOR COLORECTAL CANCER IN HIGH-RISK PATIENTS IN FAMILY MEDICINE PRACTICES IN THE REPUBLIC OF CROATIA.

Colorectal cancer is a malignant neoplasm which has an increasing incidence and represents a global public health problem. The majority of patients are diagnosed after the age of 50, and the risk of developing it over lifetime is 5%. Development of preventive, diagnostic and treatment methods has resulted in a significant reduction in mortality and other negative clinical outcomes. Precisely because of the efficient method of prevention and early detection of this disease, numerous countries, including Croatia, have organized national colorectal cancer screening and monitoring programs. However, these programs are primarily organized for the population with the usual, i.e. average risk of developing colorectal cancer. High-risk groups include persons with endoscopically detected and removed colon polyps, persons surgically treated for colon cancer, persons with a positive family history of colorectal cancer, persons with inflammatory bowel diseases, individuals and families with hereditary disorders or genetic mutations that increase the risk of this disease several fold, persons with acromegaly, and patients who have undergone ureterosigmoidostomy. Recommendations for the detection and monitoring of high-risk groups are often not defined clearly, and some of the existing ones are based mostly on scarce scientific evidence. It is commonly accepted that screening in high-risk groups should start at an earlier age, with shorter intervals between follow-ups. The basic diagnostic method for screening and monitoring in these patient groups is endoscopic monitoring, or colonoscopy. The aim of this review paper is to present the characteristics of the abovementioned risk groups and provide clear screening recommendations.

Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i. e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures for both small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, where performance measures had already been identified, this is the first time that small-bowel endoscopy quality measures have been proposed.

THE OVER-THE-SCOPE-CLIP FOR THE TREATMENT OF THE DIGESTIVE TUBE LEAKS AND TEARS: A CASE-SERIES. / LIJECENJE OSTECENJA PROBAVNE CIJEVI PRIMJENOM ENDOSKOPSKE STEZALJKE: PRIKAZ SERIJE BOLESNIKA.

Digestive tube damages represent a therapeutic challenge for the gastrointestinal endoscopists. Recenty, a novel device ­ the-over-the-scope clip (OTSC) ­ has been introduced for non-surgical treatment of gastrointestinal perforations, fi stula, anastomotic leaks and refractory gastrointestinal bleeds. This study aimed to evaluate the therapeutic effi cacy of OTSC in our case series. A total of nine patients were included (six males, medain age 72 years, range 58-86). The indications were upper gastrointestinal bleeding (refractory to standard endoscopic treatment: fi ve patients, a vessel with a large caliber: one patient), fi stula in two patients, and iatrogenic perforation of the sigmoid colon in one patient. Atraumatic and traumatic versions of OTSCs with twin graspers were used. All of the patients were treated with only one OTSC, and none of the patients required additional endoscopic treatment. The OTSC procedure had 100% technical success. In a subgroup of patients with perforation and fi stulae, the clinical success was 67%, whereas in those with the bleedings it was 50%. The median follow-up was 34 days (range: 3-452). OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic effi cacy was subopimal in patients with the upper gastrointestinal bleedings possibly due to the application of the sharp-teeth OTSC.

[PREDICTORS OF POOR BOWEL PREPARATION FOR COLONOSCOPY: A SINGLE-CENTRE PROSPECTIVE STUDY]. / PRETKAZATELJI LOSE PRIPREME BOLESNIKA ZA KOLONOSKOPIJU: MONOCENTRICNO PROSPEKTIVNO ISPITIVANJE.

Adequate bowel preparation is the key of a successful colonoscopy. The aim of the study was to analyze sociodemographic and clinical characteristics in our population of patients referred for colonoscopy. Bowel cleanness was evaluated using the Boston Bowel Preparation Scale (BBPS) where values 7 were considered a criterion of successful bowel preparation. The study involved 286 subjects (61.5% male, median 61 years, interquartile range 50-71). BBPS score 7 was found in 145 subjects (50.7%). Multivariate analysis indicated that subjects with severe comorbidity (ASA status 3, OR = 0,29; 95% CI: 0.12-0.72; p = 0,008) represented a risk factor for poor bowel preparation. Regimens with polyethyleneglycol (PEG) were superior compared with other protocols (OR = 2.54; 95% CI: 1.27-5.10; p = 0.008). Timing of the colonoscopy also contributed to better bowel preparation (OR = 5.50; 95% CI: 2.07-14.67; p = 0.001). This study confirms that presence of comorbidity and non-use of PEG regimens are predictors of poor bowel preparation in our population of patients referred for colonoscopy.

[COLONIC MUCO-SUBMUCOSAL ELONGATED POLYP: A CASE REPORT AND LITERATURE REVIEW]. / IZDUZENI SLUZNICNO-PODSLUZNICNI POLIP DEBELOG CRIJEVA: PRIKAZ BOLESNIKA I PREGLED LITERATURE.

Recently a new entity has been described--a colonic muco-submucosal elongated polyp (CMSEP)--that did not fall into traditional classification of colorectal polyps. The CMSEP is endoscopically characterised by elongated, worm-like appearance with a normal overlying mucosa. Histologic characteristics of the CMSEP comprise mucosa and expanded submucosa with dilated vasculature and lymphatics. Herein, we report a case of CMSEP, that to the best of our knowledge, has not been previously described in our literature. With regard to the on-going National colorectal cancer screening programme, our intention is to draw attention of gastrointestinal pathologists and endoscopists to this distinctive and very rare phenomenon.

[Clinical characteristics of patients with a double pylori]. / Klinicke karakteristike bolesnika s dvostrukim pilorusom.

Double pylorus (DP), is a form of gastroduodenal fistula, which consists of a short accessory canal from the gastic antrum to the duodenal bulb, and mostly occrus in the background of peptic ulcer disease. Prevalence, as well long-term follow-up of patients with DP is less elucidated in western countries. Aim of our study was to analyse demografic, clinical and endoscopic characteristics in our case-series. During 2008-2013. a total of 23836 upper endoscopies were performed in 16759 patients. DP was diagnosed in 6 patients (prevalence of 0.04%). The follow-up period was f 8 to 72 months. In 87% DP was a complication of the upper gastrointestinal bleeding. In 83% cases opening of the fistula was on lesser curvature of gastric antrumu. During follow-up period the fistula healing did not occur in any of our patients. DP is a very rare entity, with a benign course of the disease Associated comorbidity and use of ulceriform medications plays important role in persistence of DP, wheras possible eradication of Helicobacter infection in this background remains elusive.

Endoscopic ligation ("Loop-And-Let-Go") is effective treatment for large colonic lipomas: a prospective validation study.

BACKGROUND: Colonic lipomas (CL) are rare benign adipose tumours usually found incidentally during colonoscopy. Endoscopic resection of symptomatic large CL remains controversial, since significant rates of perforation have been reported. In recent years, a novel technique for removal of large CL has been described, consisting of looping and ligating the lipoma with a nylon snare. The aim of our study was to evaluate the safety and efficacy of the "loop and let go" technique for large colon lipomas in a large case series. METHODS: Consecutive patients referred to our institution for colonoscopy were eligible for the study. The diagnosis of CL was confirmed endoscopically by "pillow" and "naked fat" signs. Following diagnosis, lipomas were looped and ligated by endoloop. Follow-up colonoscopies were scheduled at 1- and 3-months interval. RESULTS: A total of 11 patients with large CL were enrolled in study. The indications for the colonoscopy included altered bowel habits (7 patients, 64%), screening for colorectal neoplasm (3 pts, 27%) and lower gastrointestinal bleeding (1 pts, 9%). The median lesion size was 3 cm (range 2,5-6 cm). Lesions were located at the hepatic flexure in 4 patients (36%), cecum and ascending colon (4 pts, 36%), rectosigmoid (2 pts, 18%) and transverse colon (1 pts, 9%). There were no immediate and late complications. On follow-up (median follow-up time 11.9 months, range 8-24), there was one small residual lipoma (<1 cm). CONCLUSION: The results of this study confirm that "loop-and-let-go" technique is safe and efficacious treatment of large colonic lipomas.

[Intraductal papillary mucinous neoplasm of the pancreas: case report and review of the literature]. / Intraduktalna papilarna mucinozna novotvorina gusterace: prikaz slucaja i pregled literature.

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a relatively rare clinical entity with a main characteristic being mucus production. Extension of IPMN along pancretic ducts and mucus production lead to ductal obstruction and dilatation, resulting in recurrent episodes of acute pancreatitis. Molecular background of IPMN-a comprises several aberrations, with the K-ras gene mutation being the likely trigger that initiates further genetic changes. Due to its indolent nature, IPMN is most commonly diagnosed in the 7th decade of life. Depending on the histology type, IPMN has a malignant potential. Therefore, surgical therapy remains a "gold standard" of treatment. Insidious, slow progression of the disease and absence of symptoms in a certain number of patients makes diagnostic approach to this entity difficult. In this paper we present a patient with IPMN of the pancreas, in whom the episodes of acute pancreatitis had been present for 22 years.

[Endoscopic mucosal resection of sessile polypoid colorectal lesions: a two-year retrospective study, technique description, indications and complications]. / Endoskopska mukozna resekcija sesilnih polipoidnih lezija debelog crijeva: dvogodisnja retrospektivna analiza, prikaz tehnike, indikacija i komplikacija.

INTRODUCTION: Endoscopic mucosal resection (EMR) is a therapeutic method for removal of sesile premalignant lesions and intramucosal carcinoma of the gastrointestinal tract. No reports on EMR data in Croatia have been published yet. MATERIALS AND METHODS: All patients included in the study were managed at the University Hospital Centre Zagreb between December 2006 and December 2008. EMR was performed using strip technique with submucosal injection of epinephrine (dilution with saline 1:5000-10000). RESULTS: EMR of sessile polypoid colorectal lesions was performed in 95 patients. The most common localisation of the disease was rectum (52 pts - 54.7%). In most patient size of the lesion was between 16-25 mm (43 pts - 45%). En-bloc resection was performed in 75 patients and piecemeal resection in the rest. Bleeding occurred immediately during the EMR in 5 pts (5.3%). Patohistological diagnosis revealed tubulovillous adenoma in 67 pts (70%). Invasive carcinoma was observed in 6 pts (6.3%) and intramucosal carcinoma in 20 pts (21%). On follow up, 73 pts (77%) did not show and sign of disease recurrence. Surgery was needed in 6 pts (6.3%) due to the diagnosis of invasive carcinoma. CONCLUSION: EMR is safe and reliable method with low risk of serious complications and acceptable recurrence rate.

[Narrow band imaging: new paradigm in gastrointestinal video-endoscopy]. / Prikaz uskim spektrom: nova paradigma u gastrointestinalnoj videoendoskopiji.

Novel technologies in gastrointestinal endoscopy, such as magnification and high resolution endoscopy, have a clear aim in improving diagnostic accuracy of mucosal abnormalities. Narrow band imaging encompasses both of these by endoscopic display of gastric mucosa with bands of blue and green light. This enhances mucosal architecture and adjacent vasculature. Combined with optical magnification NBI enables recognition of subtle mucosal abnormalities, such as dysplasia in Barrett's oesophagus, early morphological changes of vasculature in inflammatory and malignant diseases of esophagus, stomach and colon. Before NBI becomes a routine diagnostic procedure, further investigations are needed especially in regard to standardisation and validation of findings, as well as their correlation with histopathological findings.

Self-expandable metal stent for dysphagia caused by mediastinal masses in patients with lung cancer.

BACKGROUND AND STUDY AIMS: We intended to evaluate the role of self-expandable metal stents (SEMS) for palliation of malignant dysphagia in patients with lung cancer. PATIENTS AND METHODS: During the period between May 2015 and September 2017, 42 SEMS have been placed for malignant dysphagia in patients with lung cancer. Stents have been placed under combined fluoroscopic and endoscopic guidance. RESULTS: Data from 42 patient were analysed. 35 patients (83%) were males and the mean age was 68,4 years (range 52-80 y). In 26 patients (61%) cause of dysphagia was extraluminal mediastinal lymphadenopathy and in others direct tumour infiltration of the oesophagus. A tracheo-oesophageal fistula (TEF) was seen in 8 patients (19%). Most of the patients (32 patients; 76%) had stage 3 dysphagia (able to swallow liquids only) and the rest (10 patients; 24%) stage 4 (unable to swallow saliva). Thirty stents (71%) were partially covered and 12 (29%) were fully covered. Five (12%) stents have been placed across the oesophagogastric junction due to infiltration of the cardia. There were no immediate complications except for aspiration pneumonia in 3 (7%) and minor bleeding in 2 (5%) patients which resolved spontaneously. Dysphagia score improved in all patients to stage 1 (dysphagia with certain solid food in 16 patients-38%) or stage 2 (able to swallow semi solid in 26 patients-62%). In 3 (7%) patients during the follow-up we encountered tumour overgrowth and in 1 patients the TEF was not sealed so they have been referred for gastrostomy. No other long term complications were recorded. Most of the patients (30 patients- 71%) died during the follow-up, with mean survival of 4 months (range 2-9) after the stent placement. CONCLUSION: Placing SEMS in patients with lung cancer is safe and highly effective in relieving dysphagia with significant improvement in quality of life.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

Polypectomy techniques for difficult colon polyps.

A difficult polyp is any flat or raised colonic mucosal lesion that given its size, shape or location makes it difficult for the colonoscopist to remove. Although many 'difficult polyps' will be an easy target for the advanced endoscopist, polyps that are >15 mm, have a large pedicle, are flat and extended, are difficult to see or are located in the cecum or any angulated portion of the colon should be always considered difficult. Post-polypectomy complications are more common in the presence of difficult polyps. This review describes several useful tips and tricks to deal with such polyps.

Diagnostic Accuracy of NICE Classification System for Optical Recognition of Predictive Morphology of Colorectal Polyps.

The NICE classification is an international endoscopic classification of colorectal neoplasia through a narrowband spectrum that on the basis of lesion colors, vascular pattern, and structure of the surface of the mucous membrane classifies colorectal neoplasms in three categories: type 1 as hyperplastic lesions, type 2 as adenomas, and type 3 as invasive tumors. The aim of this study was to verify diagnostic accuracy of the NICE classification system compared to the reference standard: histopathological analysis. This retrospective study was conducted by ten physicians on a sequential sample of 418 patients and 735 polyps. The total diagnostic accuracy of the NICE classification system is found to be 76.7%. Optical recognition is significantly better with larger polyps, high-risk lesions (HGIEN), and neoplastic lesions. This research has shown that the NICE classification system is at the moment inferior to histopathological analysis. However, it is noticed that some physicians achieve significantly better results, with the accuracy of diagnosis ranging from 59.5% to 84.2%. These results show that with proper training of physicians and the use of endoscope enhancements to improve image quality, the NICE classification system could in the future potentially replace the histopathological diagnosis process.

Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors.

BACKGROUND AND STUDY AIMS: The choice of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) in non-ampullary superficial duodenal tumors (NASDTs) is challenging and the benefits of ESD remain unclear. The aim was to comparatively analyze the feasibility, outcomes and safety of these techniques in these lesions. PATIENTS AND METHODS: This is an observational and retrospective study. All consecutive patients presenting with NASDTs who underwent EMR or ESD between 2005 and 2017 were included. The following main outcomes were comparatively evaluated: en-bloc and complete (R0) resection rates, and local recurrence. Secondary outcomes were perforation and delayed bleeding. RESULTS: One hundred sixty-six tumors in 150 patients (age: 66 years, range: 31 - 83, 42.7 % males) were resected by ESD (n = 37) or EMR (n = 129) and included. The median procedure time (81 vs. 50 min, P  = 0.007) and tumor size (25 vs. 20 mm, P  = 0.01) were higher in the ESD group. The global malignancy rate was 50.3 %. There were no differences in en-bloc resection (29.7 % vs. 44.2 %, P  = 0.115), complete resection (19.4 % vs. 35.5 %, P  = 0.069), and local recurrence (14.7 % vs. 16.7 %, P  = 0.788) rates. Tumor size was associated with recurrence (28 vs. 20 mm, P  = 0.008), with a median follow-up of 6.5 months. Focal recurrence (n = 22, 13.3 %) was treated endoscopically in 86.4 %. En-bloc resection in the ESD group was comparable in large ( ≥ 20 mm) and small lesions (27.6 % vs. 37.5 %, P  = 0.587), while this outcome decreased significantly in large lesions resected by EMR (17.4 % vs. 75 %, P  < 0.001). Nine perforations were confirmed in 6 lesions (16.2 %) resected by ESD and 3 (2.3 %) by EMR ( P  = 0.001). Endoscopic therapy was successful in all but 1 patient (88.9 %) presenting with a delayed perforation. CONCLUSIONS: ESD may be an alternative to EMR and surgery in selected NASDTs, such as large duodenal tumors where EMR achieves low en-bloc resection rates and the local recurrence may be higher. However, this technique may have a higher risk of perforations.