Dieulafoy lesion is a vascular anomaly predominantly found in the stomach, which represents a rare cause of gastrointestinal bleeding and life-threatening haemorrhages in pediatric age with few cases reported in the l...Dieulafoy lesion is a vascular anomaly predominantly found in the stomach, which represents a rare cause of gastrointestinal bleeding and life-threatening haemorrhages in pediatric age with few cases reported in the literature. We experienced a 7-year-old previously healthy boy with hematemesis endoscopically diagnosed and successfully treated for a Dieulafoy lesion in the stomach. This case report illustrates the initial diagnostic workup and the possible differential diagnosis in presence of an acute episode of hematemesis in children. It focuses on an uncommon cause of gastrointestinal bleeding that is probably underestimated because of missing diagnosis. Any unusual and acute case of upper gastrointestinal bleeding should raise the suspicion of Dieulafoy lesion also in children, especially in those who have a past medical history negative for peptic disease and varices due to portal hypertension: a promptly endoscopy can provide visual diagnostic criteria and ensure an adequate hemostasis that is generally the definitive treatment of the lesion.展开更多
Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal...Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term “idiopathic” is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.展开更多
Optical coherence tomography(OCT) is an optical imaging modality that performs high-resolution,cross-sectional,subsurface tomographic imaging of the microstructure of tissues.The physical principle of OCT is similar t...Optical coherence tomography(OCT) is an optical imaging modality that performs high-resolution,cross-sectional,subsurface tomographic imaging of the microstructure of tissues.The physical principle of OCT is similar to that of B-mode ultrasound imaging,except that it uses infrared light waves rather than acoustic waves.The in vivo resolution is 10-25 times better(about 10 μm) than with high-frequency ultrasound imaging,but the depth of penetration is limited to 1-3 mm,depending upon tissue structure,depth of focus of the probe used,and pressure applied to the tissue surface.In the last decade,OCT technology has evolved from an experimental laboratory tool to a new diagnostic imaging modality with a wide spectrum of clinical applications in medical practice,including the gastrointestinal(GI) tract and pancreatic-biliary ductal system.OCT imaging from the GI tract can be done in humans by using narrow-diameter,catheter-based probes that can be inserted through the accessory channel of either a conventional front-view endoscope,for investigating the epithelial structure of the GI tract,or a side-view endoscope,inside a standard transparent ERCP catheter,for investigating the pancreatico-biliary ductal system.Esophagus and the esophago-gastric junction has been the most widely investigated organ so far;more recently,also duodenum,colon and pancreatico-biliary ductal system have been extensively investigated.OCT imaging of the gastro-intestinal wall structure is characterized by a multiple-layer architecture that permits an accurate evaluation of the mucosa,lamina propria,muscularis mucosae,andpart of the submucosa.The technique may be,therefore,used to identify pre-neoplastic conditions of the GI tract,such as Barrett's epithelium and dysplasia,and evaluate the depth of penetration of early-stage neoplastic lesions.OCT imaging of the pancreatic and biliary ductal system could improve the diagnostic accuracy for ductal epithelial changes and the differential diagnosis between neoplastic and non-neoplastic lesions.展开更多
AIM： To investigate if high-definition （HD） colonoscope with i-Scan gave a higher detection rate of mucosal le- sions vs standard white-light instruments. METHODS： Data were collected from the computer- ized datab...AIM： To investigate if high-definition （HD） colonoscope with i-Scan gave a higher detection rate of mucosal le- sions vs standard white-light instruments. METHODS： Data were collected from the computer- ized database of the endoscopy unit of our tertiary referral center. We retrospectively analyzed 1101 con- secutive colonoscopies that were performed over 1 year with standard white-light （n = 849） or HD＋ with i-Scan （n = 252） instruments by four endoscopists, in an outpatient setting. Colonoscopy records included patients＇ main details and family history for colorectal cancer, indication for colonoscopy （screening, diagnos- tic or surveillance）, type of instrument used （standard white-light or HD＋ plus i-Scan）, name of endoscopist and bowel preparation. Records for each procedure included whether the cecum was reached or not and the reason for failure, complications during or imme- diately after the procedure, and number, size, location and characteristics of the lesions. Polyps or protruding lesions were defined as sessile or pedunculated, and nonprotruding lesions were defined according to Paris classification. For each lesion, histological diagnosis was recorded. RESULTS： Eight hundred and forty-nine colonosco- pies were carried with the standard white-light video colonoscope and 252 with the HD＋ plus i-Scan video colonoscope, The four endoscopists did 264, 300, 276 and 261 procedures, respectively; 21.6%, 24.0%, 21.7% and 24.1% of them with the HD＋ plus i-Scan technique. There were no significant differences be- tween the four endoscopists in either the number of procedures done or the proportions of each imaging technique used. Both techniques detected one or more mucosal lesions in 522/1101 procedures （47.4%）. The overall number of lesions recognized was 1266; 645 in the right colon and 621 in the left. A significantly higher number of colonoscopies recognized lesions in the HD＋ plus i-Scan mode （171/252 = 67.9%） than with the standard white-light technique （408/849 = 48.1%） （P 〈 0.0001）. HD＋ with i-Scan colonoscopies identified more lesions than standard white-light imag- ing （459/252 and 807/849, P 〈 0.0001）, in the right or left colon （mean ：1： SD, 1.62±1.36 vs 1.33±0.73, P 〈 0.003 and 1.55±0.98 vs 1.17±0.93, P = 0.033）, more lesions 〈 10 mm （P 〈 0.0001） or nonprotruding （P 〈 0.022）, and flat polyps （P = 0.04）. The cumulative mean number of lesions per procedure detected by the four endoscopists was significantly higher with HD＋ with i-Scan than with standard white-light imaging （1.82 ± 2.89 vs 0.95± 1.35, P 〈 0.0001）. CONCLUSION： HD imaging with i-Scan during the withdrawal phase of colonoscopy significantly increased the detection of colonic mucosal lesions, particularly small and nonprotruding polyps.展开更多
Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures.The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated.Providing a...Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures.The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated.Providing an adequate regimen of sedation/analgesia might be considered an art,influencing several aspects of endoscopic procedures: the quality of the examination,the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation.The properties of a model sedative agent for endoscopy would include rapid onset and offset of action,analgesic and anxiolytic effects,ease of titration to desired level of sedation,rapid recovery and an excellent safety prof ile.Therefore there is an impulse for development of new approaches to endoscopic sedation.This article provides an update on the methods of sedation today available and future directions in endoscopic sedation.展开更多
AIM： To compare the sensitivity and specificity of two imaging techniques, endoscopic ultrasound （EUS） and magnetic resonance imaging （MRI）, in patients with rectal cancer after neoadjuvant chemoradiation therapy...AIM： To compare the sensitivity and specificity of two imaging techniques, endoscopic ultrasound （EUS） and magnetic resonance imaging （MRI）, in patients with rectal cancer after neoadjuvant chemoradiation therapy. And we compared EUS and MRI data with histological findings from surgical specimens. METHODS： Thirty-nine consecutive patients （51.3% Male; mean age： 68.2 ＋ 8.9 years） with histologically confirmed distal rectal cancer were examined for staging. All patients underwent EUS and MRI imaging before and after neoadjuvant chemoradiation therapy. RESULTS： After neoadjuvant chemoradiation, EUS and MRI correctly classified 46% （18/39） and 44% （17/39） of patients, respectively, in line with their histological T stage （P 〉 0.05）. These proportions were higher for both techniques when nodal involvement was considered： 69% （27/39） and 62% （24/39）. When patients were sorted into T and N subgroups, the diagnostic accuracy of EUS was better than MRI for patients with T0-T2 （44% vs 33%, P 〉 0.05） and NO disease （87% vs 52%, P = 0.013）. However, MRI was more accurate than EUS in T and N staging for patients with more advanced disease after radiotherapy, though these differences did not reach statistical significance. CONCLUSION： EUS and MRI are accurate imaging techniques for staging rectal cancer, However, after neoadjuvant RT-CT, the role of both methods in the assessment of residual rectal tumors remains uncertain.展开更多
Whether acute recurrent pancreatitis is a chronic disease is still debated and a consensus is not still reached as demonstrated by differences in the classification of acute recurrent pancreatitis. There is major evid...Whether acute recurrent pancreatitis is a chronic disease is still debated and a consensus is not still reached as demonstrated by differences in the classification of acute recurrent pancreatitis. There is major evidence for considering alcoholic pancreatitis as a chronic disease ab initio while chronic pancreatitis lesions detectable in biliary acute recurrent pancreatitis (ARP) seem a casual association. Cystic fibrosis transmembrane con-ductance regulator (CFTR) gene mutation, hereditary and obstructive pancreatitis seem an acute disease that progress to chronic pancreatitis, likely as a consequence of the activation and proliferation of pancreatic stellate cells that produce and activate collagen and therefore fibrosis. From the diagnostic point of view, in patients with acute recurrent pancreatitis Endoscopic ultrasound (EUS) seems the more reliable technique for an accurate evaluation and follow-up of some ductal and parenchymal abnormalities suspected for early chronic pancreatitis.展开更多
Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric content.GE...Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric content.GERD can be currently treated by medical therapy,surgical or endoscopic transoral intervention.Medical therapy is the most common approach,though concerns have been increasingly raised in recent years about the potential side effects of continuous longterm medication,drug intolerance or unresponsiveness,and the need for high dosages for long periods to treat symptoms or prevent recurrences.Surgery too may in some cases have consequences such as longlasting dysphagia,flatulence,inability to belch or vomit,diarrhea,or functional dyspepsia related to delayed gastric emptying.In the last few years,transoral incisionless fundoplication(TIF)has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy.This review describes the steps of the TIF technique,using the Esophy X®device and the MUSETM system.Complications and their management are described in detail,and the recent literature regarding the outcomes is reviewed.TIF reconfigures the tissue to obtain a full-thickness gastroesophageal valve from inside the stomach,by serosato-serosa plications which include the muscle layers.To date the procedure has achieved lasting improvement of GERD symptoms(up to six years),cessation or reduction of proton pump inhibitor medication in about 75%of patients,and improvement of functional findings,measured by either p H or impedance monitoring.展开更多
AIM To investigate the relationship between pathological oropharyngeal(OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.METHODS In this prospective study we enrolled consecutive ou...AIM To investigate the relationship between pathological oropharyngeal(OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.METHODS In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease(GERD). We enrolled only patients with a reflux symptom index(RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal highresolution manometry(HRM). Patients were divided into two groups on the basis of a normal or pathological p H-metric finding(Ryan Score) and all manometric characteristics of the two groups were compared.RESULTS We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure(median 71 mmH g vs 126 mmH g, P = 0.004) and the median proximal contractile integral(median 215.5 cm·mmH g·s vs 313.5 cm·mmH g·s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mm Hg isobaric contour(38.7% vs 15.38%, P < 0.0001).CONCLUSION In patients with suspected GERD-related extraesophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.展开更多
The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pa...The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.展开更多
With the advent of linear echoendoscopes, endoscopic ultrasound (EUS) has become more operative and a new field of oncological application has been opened up. From tumor staging to tissue acquisition under EUS-guided ...With the advent of linear echoendoscopes, endoscopic ultrasound (EUS) has become more operative and a new field of oncological application has been opened up. From tumor staging to tissue acquisition under EUS-guided fine-needle aspiration, new operative procedures have been developed on the principle of the EUS-guided puncture. A hybrid probe combining radiofrequency with cryotechnology is now available, to be passed through the operative channel of the echoendoscope into the tumor to create an area of ablation. EUS-guided fine-needle injection is emerging as a method to deliver anti-tumoral agents inside the tumor. Ethanol lavage, with or without paclitaxel, has been proposed for the treatment of cystic tumors in non-resectable cases and complete resolution has been recorded in up to 70%-80%. Many other chemical or biological agents have been investigated for the treatment of pancreatic adenocarcinoma: activated allogenic lymphocyte culture (Cytoimplant), a replication-deficient adenovirus vector carrying the tumor necrosis factor-α gene, or an oncolytic attenuated adenovirus (ONYX-015). The potential advantage of treatment under EUS control is the real-time imaging guidance into a deep target likethe pancreas which is extremely difficult to reach by a percutaneous approach. To date there are no randomized controlled trials to confirm the real clinical benefits of these treatments compared to standard therapy so it seems wise to reserve them only for experimental protocols approved by ethics committees.展开更多
Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other ...Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.展开更多
AIM: To assess the rate of relapses of acute pancreatitis (AP), recurrent AP (RAP) and the evolution of endosonographic signs of chronic pancreatitis (CP) in patients with pancreas divisum (PDiv) and RAP.
文摘Dieulafoy lesion is a vascular anomaly predominantly found in the stomach, which represents a rare cause of gastrointestinal bleeding and life-threatening haemorrhages in pediatric age with few cases reported in the literature. We experienced a 7-year-old previously healthy boy with hematemesis endoscopically diagnosed and successfully treated for a Dieulafoy lesion in the stomach. This case report illustrates the initial diagnostic workup and the possible differential diagnosis in presence of an acute episode of hematemesis in children. It focuses on an uncommon cause of gastrointestinal bleeding that is probably underestimated because of missing diagnosis. Any unusual and acute case of upper gastrointestinal bleeding should raise the suspicion of Dieulafoy lesion also in children, especially in those who have a past medical history negative for peptic disease and varices due to portal hypertension: a promptly endoscopy can provide visual diagnostic criteria and ensure an adequate hemostasis that is generally the definitive treatment of the lesion.
文摘Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term “idiopathic” is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.
文摘Optical coherence tomography(OCT) is an optical imaging modality that performs high-resolution,cross-sectional,subsurface tomographic imaging of the microstructure of tissues.The physical principle of OCT is similar to that of B-mode ultrasound imaging,except that it uses infrared light waves rather than acoustic waves.The in vivo resolution is 10-25 times better(about 10 μm) than with high-frequency ultrasound imaging,but the depth of penetration is limited to 1-3 mm,depending upon tissue structure,depth of focus of the probe used,and pressure applied to the tissue surface.In the last decade,OCT technology has evolved from an experimental laboratory tool to a new diagnostic imaging modality with a wide spectrum of clinical applications in medical practice,including the gastrointestinal(GI) tract and pancreatic-biliary ductal system.OCT imaging from the GI tract can be done in humans by using narrow-diameter,catheter-based probes that can be inserted through the accessory channel of either a conventional front-view endoscope,for investigating the epithelial structure of the GI tract,or a side-view endoscope,inside a standard transparent ERCP catheter,for investigating the pancreatico-biliary ductal system.Esophagus and the esophago-gastric junction has been the most widely investigated organ so far;more recently,also duodenum,colon and pancreatico-biliary ductal system have been extensively investigated.OCT imaging of the gastro-intestinal wall structure is characterized by a multiple-layer architecture that permits an accurate evaluation of the mucosa,lamina propria,muscularis mucosae,andpart of the submucosa.The technique may be,therefore,used to identify pre-neoplastic conditions of the GI tract,such as Barrett's epithelium and dysplasia,and evaluate the depth of penetration of early-stage neoplastic lesions.OCT imaging of the pancreatic and biliary ductal system could improve the diagnostic accuracy for ductal epithelial changes and the differential diagnosis between neoplastic and non-neoplastic lesions.
文摘AIM： To investigate if high-definition （HD） colonoscope with i-Scan gave a higher detection rate of mucosal le- sions vs standard white-light instruments. METHODS： Data were collected from the computer- ized database of the endoscopy unit of our tertiary referral center. We retrospectively analyzed 1101 con- secutive colonoscopies that were performed over 1 year with standard white-light （n = 849） or HD＋ with i-Scan （n = 252） instruments by four endoscopists, in an outpatient setting. Colonoscopy records included patients＇ main details and family history for colorectal cancer, indication for colonoscopy （screening, diagnos- tic or surveillance）, type of instrument used （standard white-light or HD＋ plus i-Scan）, name of endoscopist and bowel preparation. Records for each procedure included whether the cecum was reached or not and the reason for failure, complications during or imme- diately after the procedure, and number, size, location and characteristics of the lesions. Polyps or protruding lesions were defined as sessile or pedunculated, and nonprotruding lesions were defined according to Paris classification. For each lesion, histological diagnosis was recorded. RESULTS： Eight hundred and forty-nine colonosco- pies were carried with the standard white-light video colonoscope and 252 with the HD＋ plus i-Scan video colonoscope, The four endoscopists did 264, 300, 276 and 261 procedures, respectively; 21.6%, 24.0%, 21.7% and 24.1% of them with the HD＋ plus i-Scan technique. There were no significant differences be- tween the four endoscopists in either the number of procedures done or the proportions of each imaging technique used. Both techniques detected one or more mucosal lesions in 522/1101 procedures （47.4%）. The overall number of lesions recognized was 1266; 645 in the right colon and 621 in the left. A significantly higher number of colonoscopies recognized lesions in the HD＋ plus i-Scan mode （171/252 = 67.9%） than with the standard white-light technique （408/849 = 48.1%） （P 〈 0.0001）. HD＋ with i-Scan colonoscopies identified more lesions than standard white-light imag- ing （459/252 and 807/849, P 〈 0.0001）, in the right or left colon （mean ：1： SD, 1.62±1.36 vs 1.33±0.73, P 〈 0.003 and 1.55±0.98 vs 1.17±0.93, P = 0.033）, more lesions 〈 10 mm （P 〈 0.0001） or nonprotruding （P 〈 0.022）, and flat polyps （P = 0.04）. The cumulative mean number of lesions per procedure detected by the four endoscopists was significantly higher with HD＋ with i-Scan than with standard white-light imaging （1.82 ± 2.89 vs 0.95± 1.35, P 〈 0.0001）. CONCLUSION： HD imaging with i-Scan during the withdrawal phase of colonoscopy significantly increased the detection of colonic mucosal lesions, particularly small and nonprotruding polyps.
文摘Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy procedures.The best methods for analgesia and sedation during gastrointestinal endoscopy are still debated.Providing an adequate regimen of sedation/analgesia might be considered an art,influencing several aspects of endoscopic procedures: the quality of the examination,the patient’s cooperation and the patient’s and physician’s satisfaction with the sedation.The properties of a model sedative agent for endoscopy would include rapid onset and offset of action,analgesic and anxiolytic effects,ease of titration to desired level of sedation,rapid recovery and an excellent safety prof ile.Therefore there is an impulse for development of new approaches to endoscopic sedation.This article provides an update on the methods of sedation today available and future directions in endoscopic sedation.
文摘AIM： To compare the sensitivity and specificity of two imaging techniques, endoscopic ultrasound （EUS） and magnetic resonance imaging （MRI）, in patients with rectal cancer after neoadjuvant chemoradiation therapy. And we compared EUS and MRI data with histological findings from surgical specimens. METHODS： Thirty-nine consecutive patients （51.3% Male; mean age： 68.2 ＋ 8.9 years） with histologically confirmed distal rectal cancer were examined for staging. All patients underwent EUS and MRI imaging before and after neoadjuvant chemoradiation therapy. RESULTS： After neoadjuvant chemoradiation, EUS and MRI correctly classified 46% （18/39） and 44% （17/39） of patients, respectively, in line with their histological T stage （P 〉 0.05）. These proportions were higher for both techniques when nodal involvement was considered： 69% （27/39） and 62% （24/39）. When patients were sorted into T and N subgroups, the diagnostic accuracy of EUS was better than MRI for patients with T0-T2 （44% vs 33%, P 〉 0.05） and NO disease （87% vs 52%, P = 0.013）. However, MRI was more accurate than EUS in T and N staging for patients with more advanced disease after radiotherapy, though these differences did not reach statistical significance. CONCLUSION： EUS and MRI are accurate imaging techniques for staging rectal cancer, However, after neoadjuvant RT-CT, the role of both methods in the assessment of residual rectal tumors remains uncertain.
文摘Whether acute recurrent pancreatitis is a chronic disease is still debated and a consensus is not still reached as demonstrated by differences in the classification of acute recurrent pancreatitis. There is major evidence for considering alcoholic pancreatitis as a chronic disease ab initio while chronic pancreatitis lesions detectable in biliary acute recurrent pancreatitis (ARP) seem a casual association. Cystic fibrosis transmembrane con-ductance regulator (CFTR) gene mutation, hereditary and obstructive pancreatitis seem an acute disease that progress to chronic pancreatitis, likely as a consequence of the activation and proliferation of pancreatic stellate cells that produce and activate collagen and therefore fibrosis. From the diagnostic point of view, in patients with acute recurrent pancreatitis Endoscopic ultrasound (EUS) seems the more reliable technique for an accurate evaluation and follow-up of some ductal and parenchymal abnormalities suspected for early chronic pancreatitis.
文摘Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric content.GERD can be currently treated by medical therapy,surgical or endoscopic transoral intervention.Medical therapy is the most common approach,though concerns have been increasingly raised in recent years about the potential side effects of continuous longterm medication,drug intolerance or unresponsiveness,and the need for high dosages for long periods to treat symptoms or prevent recurrences.Surgery too may in some cases have consequences such as longlasting dysphagia,flatulence,inability to belch or vomit,diarrhea,or functional dyspepsia related to delayed gastric emptying.In the last few years,transoral incisionless fundoplication(TIF)has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy.This review describes the steps of the TIF technique,using the Esophy X®device and the MUSETM system.Complications and their management are described in detail,and the recent literature regarding the outcomes is reviewed.TIF reconfigures the tissue to obtain a full-thickness gastroesophageal valve from inside the stomach,by serosato-serosa plications which include the muscle layers.To date the procedure has achieved lasting improvement of GERD symptoms(up to six years),cessation or reduction of proton pump inhibitor medication in about 75%of patients,and improvement of functional findings,measured by either p H or impedance monitoring.
文摘AIM To investigate the relationship between pathological oropharyngeal(OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.METHODS In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease(GERD). We enrolled only patients with a reflux symptom index(RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal highresolution manometry(HRM). Patients were divided into two groups on the basis of a normal or pathological p H-metric finding(Ryan Score) and all manometric characteristics of the two groups were compared.RESULTS We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure(median 71 mmH g vs 126 mmH g, P = 0.004) and the median proximal contractile integral(median 215.5 cm·mmH g·s vs 313.5 cm·mmH g·s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mm Hg isobaric contour(38.7% vs 15.38%, P < 0.0001).CONCLUSION In patients with suspected GERD-related extraesophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.
文摘The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.
文摘With the advent of linear echoendoscopes, endoscopic ultrasound (EUS) has become more operative and a new field of oncological application has been opened up. From tumor staging to tissue acquisition under EUS-guided fine-needle aspiration, new operative procedures have been developed on the principle of the EUS-guided puncture. A hybrid probe combining radiofrequency with cryotechnology is now available, to be passed through the operative channel of the echoendoscope into the tumor to create an area of ablation. EUS-guided fine-needle injection is emerging as a method to deliver anti-tumoral agents inside the tumor. Ethanol lavage, with or without paclitaxel, has been proposed for the treatment of cystic tumors in non-resectable cases and complete resolution has been recorded in up to 70%-80%. Many other chemical or biological agents have been investigated for the treatment of pancreatic adenocarcinoma: activated allogenic lymphocyte culture (Cytoimplant), a replication-deficient adenovirus vector carrying the tumor necrosis factor-α gene, or an oncolytic attenuated adenovirus (ONYX-015). The potential advantage of treatment under EUS control is the real-time imaging guidance into a deep target likethe pancreas which is extremely difficult to reach by a percutaneous approach. To date there are no randomized controlled trials to confirm the real clinical benefits of these treatments compared to standard therapy so it seems wise to reserve them only for experimental protocols approved by ethics committees.
文摘Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.
文摘AIM: To assess the rate of relapses of acute pancreatitis (AP), recurrent AP (RAP) and the evolution of endosonographic signs of chronic pancreatitis (CP) in patients with pancreas divisum (PDiv) and RAP.
