Biomedical subjects
Publications and source records attributed to M Conio.
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BACKGROUND: Endoscopic laser therapy is considered an acceptable treatment of benign colorectal adenomas. The aim of our study was to evaluate the efficacy of Nd:YAG laser to ablate right-sided colonic sessile adenomas. METHODS: Between January 1990 and February 1996, 56 patients underwent laser therapy because of high operative risk or refusal of surgery. Lesions were located as follows: cecum (23), ascending, (15), and hepatic flexure (18). Six patients (10.7%) had multiple polyps in the ascending colon. Histologic examination showed a tubulovillous pattern in 20 (35.7%) and a villous pattern in 36 (64.3%). Low-grade dysplasia was detected in 44 patients (78. 5%) and high-grade dysplasia in 12 (21.4%). RESULTS: The number of laser sessions ranged between 1 and 6 (median 3) and complete ablation, histologically confirmed, was achieved in 49 cases (87.5%). Seven patients (12.5%) underwent surgery: 2 for incomplete tumor destruction, 3 because of invasive carcinoma on repeated biopsies. Two patients (3.6%) had complications (one perforation of the cecum and one hemorrhage). Follow-up ranged from 6 to 60 months and no recurrences were observed. CONCLUSION: Laser therapy is an effective method for the destruction of sessile adenomas of the right colon in selected patients.
Our purpose was to evaluate the relationship between the clinical and histological features in a cohort of patients who had gastroesophageal reflux-related lesions diagnosed after upper digestive endoscopy. In all, 589 patients scheduled for elective endoscopy in a multicentric prospective study were evaluated. Multiple biopsies from the distal esophagus showing aspects of esophagitis or metaplastic epithelium were taken. Esophagitis was histologically detected in 25.6%, gastric-type Barrett's esophagus in 36.2%, and specialized columnar epithelium in 33.1%. The frequency of esophagitis was constant across age decades. Patients with specialized columnar epithelium were significantly older (P = 0.01) and had a greater extent of metaplastic epithelium (P<0.0001). Specialized columnar epithelium was observed in 15% of patients with only distal esophagitis. In conclusion, endoscopic esophagitis was constant across age strata. The presence of specialized columnar epithelium was associated with older age and with longer segments of Barrett's esophagus. Short areas of esophagitis should be biopsied in view of their potential for holding areas of specialized columnar epithelium.
BACKGROUND AND STUDY AIMS: Hydatid disease of the liver, and its complications, causes serious morbidity and mortality. We evaluated the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatic hydatid disease. PATIENTS AND METHODS: This retrospective analysis includes 28 patients with hepatic hydatid disease who underwent ERCP. ERCP was performed preoperatively in 11 patients, for acute cholangitis (n =7), acute pancreatitis (n = 1) and right upper quadrant pain (n = 3), and in eight asymptomatic cases to search for fistulae between the cyst and the biliary tree. In a further nine patients ERCP was performed for early (< 30 days; n = 7) and late (n = 2) postoperative biliopancreatic problems. RESULTS: In all seven patients with cholangitis preoperative ERCP with EST and ductal clearance of daughter cysts and debris led to substantial clinical improvement, including four acutely ill elderly patients who stabilized and were later able to undergo surgery. EST in two of the three patients with pain who had papillary stenosis led to resolution of the abdominal pain. Six of the seven postoperative fistulae could be successfully treated endoscopically using EST. CONCLUSIONS: This study demonstrates the usefulness of ERCP in symptomatic patients with hepatic hydatid cysts; EST enables clearance of the common bile duct and allows healing of postoperative fistulae in the majority of patients. We do not, however, recommend performing routine preoperative ERCP in asymptomatic patients with the disease.
BACKGROUND: Epidemiological data on acute pancreatitis are poorly defined. AIMS: To prospectively evaluate the aetiology of acute pancreatitis and to assess the benefits of intensive investigations. METHODS: In a prospective, 1-year study all cases of acute pancreatitis in the Nice catchment area were enrolled. Subjects underwent routine (serum calcium, phosphate and triglycerides; abdominal ultrasonography and CT scan) and additional, delayed intensive investigations (ERCP with bile sampling and/or endoscopy ultrasonography). RESULTS: One hundred and twenty-one cases were included. After routine investigations, a biliary, alcoholic, miscellaneous or unknown origin was diagnosed in 43%, 31.4%, 9.9% and 15.7%, respectively. In subjects with biliary pancreatitis, 43% had no previous history of biliary disease. In the alcohol-related subgroup, pancreatitis recurred in 18.5% during 114.5 days mean follow-up. In subjects with a first episode of alcoholic pancreatitis, delayed supplemental investigations revealed underlying chronic pancreatitis in 92.8%. After routine investigations, a diagnosis of pancreatitis of unknown origin was made in 15.7% (n = 19) of subjects. Additional investigations revealed an underlying cause in 57.8% of these patients (n = 11), including malignancy (n = 3) and biliary disease (n = 4), reducing the overall rate of pancreatitis with no apparent cause to 6.6%. CONCLUSIONS: Investigative techniques, particularly ERCP, will reveal the underlying aetiology of pancreatitis in the majority of patients presenting with 'idiopathic' pancreatitis and should be considered when routine tests are negative.
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Approximately 5% of all patients with gastrointestinal hemorrhage, and up to 38% of subjects with iron deficiency anemia without overt gastrointestinal bleeding, do not have a bleeding site identified after routine evaluation by esophagogastroduodenoscopy and colonoscopy. The source of bleeding in these subjects is often the small intestine. Most vascular lesions of the small bowel present as chronic gastrointestinal bleeding, which may severe in some cases. Depending on the underlying disease, other systemic signs and symptoms may be present. The diagnosis and often therapy are heavily dependent upon endoscopic techniques, and in some cases nonendoscopic methods.
BACKGROUND AND STUDY AIMS: Caroli's disease causes relapsing episodes of cholangitis due to the presence of intrahepatic lithiasis. Strategies for cholangitis prevention are still widely debated. Ursodeoxycholic acid, hepaticojejunostomy, partial hepatectomy, or transplantation, have all been proposed as therapeutic options. The aim of this study was to evaluate the role of therapeutic endoscopy, and especially endoscopic sphincterotomy (ES), in the management of Caroli's disease. PATIENTS AND METHODS: Between 1983 and 1995, six patients with Caroli's disease (mean age 52, range 17-75) underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. Sphincterotomy was performed if common bile duct stones were present. Extracorporeal shock-wave lithotripsy, (ESWL) or intraductal electrohydraulic lithotripsy (IEL) were performed if necessary. RESULTS: The mean number of endoscopic sessions per patient was four (range three to seven). Sphincterotomy was performed in five patients and cholangioscopy in three. ESWL was performed twice in each of four patients. A Strecker expandable metal stent was placed in one patient to maintain sphincterotomy patency. In one patient, two sessions of IEL and pulsed laser were carried out. Complete clearance of intrahepatic stones was achieved in four of the six subjects (66.6%) and partial clearance in two patients. No morbidity or mortality was observed. During the follow-up (mean 6.2 years; range: 2.1-16.3), only two patients had acute cholangitis at nine months and three years, respectively, after the endoscopic treatment. Both had residual intrahepatic stones left after the initial endoscopic attempt at clearance. CONCLUSION: ERCP is a necessary diagnostic procedure which should always be carried out in patients with Caroli's disease. Our experience shows that ES does not result in an increased incidence of cholangitis and that therapeutic endoscopy allows complete clearance of intrahepatic stones in the majority of patients with unresectable symptomatic Caroli's disease. Nevertheless, the oncological risk in these patients remains unchanged, and they still have an increased risk of cholangiocarcinoma.
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Photodynamic therapy (PDT) produces localized necrosis with light after prior administration of a photosensitizing drug. As PDT lesions in the gastrointestinal tract heal well, the technique is suitable for repeated endoscopic use. In this study we used PDT to treat benign and malignant gastrointestinal tumors in esophagus, duodenum and rectum in 22 patients, who refused or were not suitable for surgery. Patients were sensitized with 0.15 mg/kg of body weight with mesotetrahydroxyphenylchlorin i.v. m-THPc (2 patients), with 2.0 mg/kg Photofrin i.v. (4 patients) or 60 mg/kg 5-aminolevulinic acid orally ALA (which is converted in vivo to active derivate protoporphyrin IX-PRIX) in fractionated doses (16 patients). Laser treatment was performed 2 days after Photofrin, 2 and 4 days after mTHPc and 4 hours after ALA, using a metal vapour laser (628 nm, 50-150 J/cm2 for ALA and Photofrin, 650 nm and 10-15 J/cm2 for mTHPc). Using ALA, the necrosis was only superficial (up to 1.8 mm depth). Four patients treated with Photofrin showed deeper necrosis, in one case of 8 mm colon cancer complete response, in three cases 1-1.5 cm adenomatous polyps involving the ampulla Vateri 50% longer term reduction in size-seen endoscopically. Two patients with rectal villous adenomas treated with mTHPc showed 60-80% reduction in size (observed endoscopically) within few days after PDT, with better effects for treatment carried out 4 rather than 2 days after the sensitization. In all patients the healing was without any complications. Photofrin and mTHPc work better, but cause cutaneous photosensitivity lasting 12 and 5 weeks, respectively. Better results with ALA are possible when using higher drug doses or modified light dosimetry. PDT is a promising treatment for small localized tumors in patients unsuitable for surgery, but further work is required to optimize the treatment conditions.
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AIM: Endoscopic retrograde cholangiopacreatography and associated therapeutic procedures are widely used in routine clinical practice. The changes in the upper gastrointestinal anatomy after a Billroth II anastomosis may present technical difficulties at endoscopic retrograde cholangiopacreatography. METHODS AND PATIENTS: The case records of all patients who underwent endoscopic retrograde cholangiopacreatography at our Unit from January 1985 to December 1995 were reviewed. All patients who had had a previous Billroth II anastomosis or gastroenteroanastomosis were included in this analysis. Of the 5994 procedures performed, 124 patients with Billroth II surgery and 10 with a gastroenteroanastomosis were identified. RESULTS: In these patients, the papilla was located in 89% of cases from 1985 to 1990 and in 100% of cases from 1991 to 1995. Overall, the success rates for pancreatography, cholangiography, and endoscopic sphincterotomy were 94%, 97.7%, and 100%, respectively. The morbidity and mortality rates were 7.4% and 0%, respectively. CONCLUSIONS: The success rate for endoscopic retrograde cholangiopacreatography in patients with Billroth II gastrectomy is similar to that of a normal population.
The gallbladder seems to play an important role in lithogenesis. Moreover, the morphology and the implantation of the cystic duct may also influence this process. Our purpose was to evaluate if the length and the implantation of the cystic duct may affect the formation of gallstones. Between April 1992 and March 1994, 270 patients who underwent endoscopic retrograde cholangiopancreatography were included in the study, and the radiological length of the cystic duct was carefully recorded. Patients were divided into two groups: I, absence of lithiasis: 113 patients (65 men, 48 women); and II, gallbladder lithiasis or lithiasis in the common bile duct with or without gallbladder lithiasis: 157 patients (73 men, 84 women). A statistically significant difference was observed among the two groups regarding the insertion of the cystic duct: implantation on the left side of the common bile duct represented a risk factor of lithiasis. The length of the cystic duct was not directly implicated. Hypokinesis of the gallbladder is currently recognized as being a major factor in the initial steps of lithogenesis, but the implantation of the cystic duct can play an important role by increasing cystic duct resistance and causing a reduced washout effect of the gallbladder contents, including cholesterol crystals.
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Abdominal tuberculosis is a rare disease. Involvement of lymph nodes at the hepatic hilum responsible for jaundice is exceptional. We describe a 59-year-old woman in whom jaundice was the presenting feature, complicated by portal vein thrombosis and portal hypertension.
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BACKGROUND: Barrett's oesophagus is a premalignant condition leading to adenocarcinoma. The incidence of adenocarcinoma of the oesophagus and the gastrooesophageal junction is rapidly increasing in the USA, northern and central Europe. Data from southern Europe are still unavailable. OBJECTIVE: To evaluate the incidence of oesophageal adenocarcinoma in a large cohort of Italian patients with Barrett's oesophagus. METHODS: A total of 344 patients (253 males and 91 females, age range 19-75 years) with histologically proven Barrett's oesophagus (length of metaplasia > or = 3 cm) were enrolled from November 1987 to June 1995. Endoscopic and histological examinations were scheduled at yearly intervals. RESULTS: One hundred and eighty-seven patients complied with the follow-up. The mean duration of the follow-up period was 36 months (total follow-up 562 patient-years; range 12-90 months). Low grade dysplasia was found in five patients at the initial examination. During the surveillance period, dysplasia increased in frequency as well as in severity and was found exclusively in the intestinal type of Barrett's oesophagus. In all, dysplastic changes were found in seven patients (five low grade and two high grade) and adenocarcinoma developed in three patients during the follow-up. In a single case, both adenocarcinoma and specialized columnar epithelium developed without any evidence of dysplasia or intestinal metaplasia at the previous follow-up examination. This prospective study shows an incidence of adenocarcinoma in Barrett's oesophagus of 1/187 patient-years. When only patients with specialized columnar epithelium were considered, the risk of adenocarcinoma was 1/88 patient-years. CONCLUSION: The present report shows that the incidence of adenocarcinoma in Italian Barrett's oesophagus patients is in the range of that reported from other Western countries.