PubMed Health⌕ Search

Biomedical subjects

M Mutignani

Publications and source records attributed to M Mutignani.

At least 19 recordsLinked to original sources
PubMed2004

Therapeutic biliary endoscopy.

Almost all biliary diseases are now amenable to endoscopic treatment. Progress in therapeutic biliary endoscopy is currently focusing on identifying the best treatment options to be used in each case in relation to the available evidence: how should a malignant stricture of the common bile duct or hilum be drained? How should an external biliary fistula be treated? What should one do with the gallbladder after extraction of common bile duct stones? Should sedation or general anesthesia be offered? Progress has been made in the technique of endoscopic ampullectomy and in developing new devices to improve the success rate of endoscopic retrograde cholangiopancreatography.

Acute Disease↗
PubMed2003

Prospective evaluation of a new self-expanding plastic stent for inoperable esophageal strictures.

BACKGROUND: High stent cost is considered the major drawback of self-expanding metal stents for dysphagia palliation in patients with inoperable esophageal strictures. We report our experience with a self-expanding plastic (Polyflex) stent, the cost of which is half that of the metal stents. METHODS: Between September 1999 and April 2001, 16 dysphagic patients (15 men; mean age, 69.4 +/- 14.5 years; range, 49-100 years; mean dysphagia score, 3.31 +/- 0.6) with esophageal strictures who underwent Polyflex stent placement (insertion device diameter, 12-14 mm; postexpansion inner stent diameter, 16-21 mm; stent length, 9, 12, and 15 cm) were studied prospectively. The strictures were caused by postsurgical recurrence of gastric/esophageal cancer at the anastomotic site in five patients, primary esophageal cancer in four patients, esophagocardia junction cancer in four patients, metastatic mediastinal lymph nodes from a primary lung cancer invading the esophagus in 1 patient, and benign peptic stricture in two elderly patients. All the patients were prospectively followed until death. RESULTS: Stent insertion was technically successful in 12 patients (75%). Stent placement failed in four patients (25%) because of failure to pass the delivery catheter across the stricture in three patients and failure of the stent to open in one patient. Early and late stent migration occurred in two patients and 1 patient, respectively. Tumor overgrowth occurred in 1 patient. The mean dysphagia score 7 days after stent placement was 1.1 +/- 0.9. Mean survival was 100.6 +/- 71.2 days (range, 8-225 days). CONCLUSION: Self-expanding Polyflex stents are safe and effective for inoperable esophageal strictures and have an acceptable technical success rate. Further experience, better selection criteria, and design improvements should improve results.

Aged↗
PubMed2003

Liver, pancreas and biliary tract enhanced lipoperoxidation products in pure pancreatic juice: evidence for organ-specific oxidative stress in chronic pancreatitis.

BACKGROUND: Oxygen-free radicalscan play a role in the development of chronic pancreatitis, altering the redox state with damage of cell constituents and decrease in antioxidant defences. AIMS: To measure levels of lipoperoxidation products, conjugated dienes and lipid hydroperoxides, in pure pancreatic juice and serum of chronic pancreatitis patients and compare them to that in controls. To investigate a possible correlation with serum indexes of pancreatic inflammation (amylase and lipase). PATIENTS: Pancreatic juice was collected during ERCP, after secretin stimulation, in 20 patients with chronic pancreatitis and 11 controls with biliary diseases. METHODS: Lipid hydroperoxide levels were determined with FOX2 method and measured as absorbance at 560 nm. Conjugated diene levels were measured using second-derivative spectroscopy. RESULTS: No substantial difference was present in serum levels of lipid hydroperoxides, conjugated dienes (in both isomeric forms) and isomer-ratio values between those of patients with chronic pancreatitis and controls. In pancreatic juice, there was a significant increase in lipid hydroperoxides and conjugated dienes levels (especially trans-trans isomers) in chronic pancreatitis patients compared with controls, with a decrease in cis-trans isomers and a significant difference in isomer-ratio values. CONCLUSIONS: Increased levels of lipid hydroperoxides and conjugated dienes in the pancreatic juice of chronic pancreatitis patients is indicative of an enhanced lipoperoxidation and antioxidants consumption in pancreatic tissue, confirmed by the decreased isomer-ratio values as an indirect index of decreased antioxidant capacity. The lack of significant difference in conjugated diene and lipid hydroperoxide levels in the serum of chronic pancreatitis patients versus that of controls suggests an oxidative stress limited to pancreatic tissue and indicative of an organ-specific pathology, confirmed by the parallel behaviour of oxidative parameters (lipid hydroperoxides and conjugated dienes) and indexes of pancreatic inflammation (amylase and lipase).

Amylases↗
PubMed2003

Real time endoscopic imaging of oxyradical generation in pig stomach during ischemia-reperfusion.

BACKGROUND: Oxygen-free radicals generation is considered to be a major cause of gastric injury during reperfusion. Chemiluminescence has been used to assess real-time free radical release on the surface of isolated organs. AIMS: To evaluate the combined use of chemiluminescence and gastroendoscopy techniques and to assess the real-time production of free radicals during ischemic damage of the gastric wall in an animal model. PATIENTS AND METHODS: For the experiment, an optical junction was set up between a fibroendoscope and a luminograph apparatus. Three pigs were submitted to gastrofibroendoscopy before, during and after 30 min of clamping of the coeliac artery. Under basal conditions, at the end of the ischemic phase and at the beginning of reperfusion, 1 mM of lucigenin, a specific superoxide enhancer, was injected in the left gastric artery of the animal. The endoscopic live images and chemiluminescence emission were recorded and successively superimposed to measure rate and spatial distribution of photon emission (photons/s). RESULTS: Free radical production was not observed under basal conditions or during the ischemic phase, but significantly increased during reperfusion reaching a maximum peak after 15 min (0.6+/-0.2 photons x 10(5)/s) and decreased progressively thereafter. The superimposition of live and chemiluminescence images allowed the determination of the regional production rate and distribution of photons. CONCLUSIONS: Preliminary observations, in an animal model, on an innovative imaging system which allows the visualization of rate and spatial distribution of reactive oxygen species formation are presented. This new endoscopic technique could be useful for the assessment of oxidative gastric mucosal injury in several gastric diseases; however, further studies remain necessary to determine the applicability of this technique in humans.

Animals↗
PubMed2003

Comparison of standard and steerable catheters for bile duct cannulation in ERCP.

BACKGROUND AND STUDY AIMS: The aim of the study was to compare two steerable endoscopic retrograde cholangiopancreatography (ERCP) catheters with regard to speed and safety in cannulating the common bile duct. PATIENTS AND METHODS: A standard cannula, a short-nosed sphincterotome, and a bendable catheter were used. At two tertiary centres, a total of 312 patients were randomly assigned to receive treatment with one of three catheters and either by a trainee or an expert endoscopist. When cannulation failed, a further attempt was made with a different catheter. If this failed, a change in operator or other manoeuvres followed. The following were assessed: time to cholangiography and deep cannulation, number of attempts and success rates of cannulation, number of pancreatic duct injections, success of catheter cross-over, and complication rates. RESULTS: Both steerable catheters were significantly better for the initial cholangiogram than the standard catheter (standard catheter 75 %, bendable catheter 84 %, sphincterotome 88 %; P = 0.038), with no significant differences between the bendable catheter and the sphincterotome. Both were also better for deep cannulation of the bile duct (standard cannula 66 %, bendable catheter 69 %, sphincterotome 78 %; P = 0.15). When the standard catheter failed, a steerable catheter succeeded in 26 % of cases. Trainees experienced greater benefit from using steerable catheters. For experts, the bendable catheter was the quickest to achieve cholangiography and deep cannulation. Further manoeuvres had an 85-90 % success rate in allowing biliary access. Twenty of 23 needle-knife papillotomies (87 %) were successful when other methods had failed. The overall ERCP success rate was 97 %. Pancreatitis occurred in 5.3 % of cases. CONCLUSIONS: Steerable catheters allow faster access and can succeed when a standard catheter fails. If cannulation is difficult, changing the catheter should be considered at an early stage. Needle-knife papillotomy is a successful technique in expert hands.

Adult↗
PubMed2003

A prospective, randomized multicenter trial comparing DoubleLayer and polyethylene stents for malignant distal common bile duct strictures.

BACKGROUND AND STUDY AIMS: Endoscopic biliary stenting is an established treatment for malignant obstructive jaundice. Stent clogging continues to be a major problem with plastic stents. The aim of this study was to carry out a prospective comparison of two stents with different materials and shapes: the Olympus DoubleLayer stent (DLS; perfluoro alkoxy, without sideholes) and the standard polyethylene (PE) stent (with sideholes). PATIENTS AND METHODS: A total of 120 patients (70 women; mean age 71, range 36 - 91) with jaundice due to malignant strictures of the middle to distal third of the common bile duct were randomly assigned to receive either DLS (n = 60) or PE (n = 60) biliary stents. Patients with cholangitis, hemobilia, previous biliary drainage, hilar stricture, or ampullary cancer were excluded. RESULTS: In all, 28 DLS patients (47 %) and 17 PE stent patients (29 %) died without clinical evidence of stent occlusion after a mean of 114 and 105 days, respectively ( P < 0.05). Twenty-six DLS patients (43 %) and 38 PE stent patients (63 %) had symptoms of stent clogging after a mean of 144 and 99 days, respectively ( P < 0.05). Stent dysfunction (stent orifice impacted on the bile duct or duodenal wall, stent migration) was recorded in six DLS patients (10 %) and five PE patients (8 %) (n. s.). Kaplan-Meier analysis of DLS and PE stent clogging-free survival showed a significantly longer patency period with the DLS stents (P = 0.0005). CONCLUSIONS: These results show that DoubleLayer stents have a longer patency period than PE stents. Patients who received PE stents had a higher risk of stent occlusion (relative risk 3.05; 95 % CI, 1.57 - 5.89) before death than DLS patients.

Adult↗
PubMed2002

Endoscopic treatment of extrahepatic bile duct strictures in patients with portal biliopathy carries a high risk of haemobilia: report of 3 cases.

Extrahepatic portal venous obstruction can be associated with bile duct abnormalities, the entity being called portal biliopathy. Three cases are reported of extrahepatic bile duct strictures in patients with portal biliopathy who developed haemobilia during endotherapy. Although endoscopic therapy with stent placement can be successful in patients with portal biliopathy and could also lead to permanent stricture resolution, procedure-related haemobilia is not as uncommon as previously held. Shunt surgery could be a better option in fit patients, since it could provide definitive treatment in a young patient with an otherwise normal life expectancy.

Adult↗
PubMed2002

Endoscopic palliation of unresectable malignant oesophageal strictures with self-expanding metal stents: comparing Ultraflex and Esophacoil stents.

BACKGROUND: Two types of self-expanding metal stents to palliate dysphagia in patients with unresectable malignant oesophageal strictures have been compared. METHODS: From February 1996 to October 2000, 50 metal stents (23 covered Ultraflex and 27 Esophacoil) were placed in 50 patients (40 males, mean age: 67+/-12 years, range: 33-100, mean dysphagia score: 3.18+/-0.66) with unresectable malignant oesophageal strictures. Patients were followed until death. A retrospective review has been made of a prospectively collected database. RESULTS: The two groups were comparable as far as concerns degree of dysphagia, location and stricture length. Stent placement was successful in all cases. Covered Ultraflex stent was placed in 2 patients with oesophagobronchial fistula. No procedure-related deaths were seen. Early severe complications occurred in 2 patients (perforation in 1 and tumour bleeding in 1, in the Esophacoil group). Nine patients and 1 patient complained of pain following Esophacoil and Ultraflex stent placement, respectively. Late complications were asymptomatic rupture of distal Esophacoil rings in 2 patients, symptomatic Ultraflex stent migration in 2 and tumour overgrowth in 3 (Esophacoil 1, Ultraflex 2). Mean dysphagia score at 4 weeks after stent placement was 1.9+/-0.77. Mean survival was 177+/-109 days (range: 35-603 days). There were no significant differences in technical success, dysphagia palliation, complications (except chest pain) and survival using the two types of stent. CONCLUSIONS: Self-expanding metal stents are safe with high technical success and achieve satisfactory long-term palliation for dysphagia. The covered Ultraflex and Esophacoil stents are equally effective.

Aged↗
PubMed2002

Therapeutic biliary endoscopy.

An analysis of the recent medical literature on therapeutic biliary endoscopy shows that the new millennium has already brought several significant developments. However, although advances continue rapidly, several new questions have also arisen, paving the way for further research. Several studies during the last year have also focused attention on cost-effectiveness.

Antibiotic Prophylaxis↗
PubMed2002

Long-term follow-up of patients after endoscopic sphincterotomy for choledocholithiasis, and risk factors for recurrence.

BACKGROUND AND STUDY AIMS: There have been growing concerns about the long-term sequelae of endoscopic sphincterotomy (ES). The aims of the study were to evaluate the long-term clinical outcome of ES for choledocholithiasis and to identify the predictors of recurrence. PATIENTS AND METHODS: A total of 529 patients (233 men, 296 women; mean age 63, range 9 - 88) who underwent successful ES for choledocholithiasis were evaluated. Follow-up data were obtained retrospectively. Statistical analyses were carried out for 334 patients who had a follow-up of at least 5 years or had recurrence. RESULTS: Immediate complications occurred in 37 patients (7 %). Follow-up data were available in 458 patients (86.6 %), of whom 280 (61.1 %) were asymptomatic, 127 (27.7 %) died from unrelated causes without recurrence, and 51 (11.1 %) had biliary symptoms and/or choledocholithiasis recurrence. Most recurrences (65 %) occurred more than 2 years following ES and were observed on multiple occasions in 13 patients (2.8 %). A bile duct diameter of 22 mm or greater was found to predict recurrence. Of 190 patients with an intact gallbladder, 11 (5.8 %) developed acute cholecystitis necessitating emergency cholecystectomy; all of these had previously documented gallstones. CONCLUSIONS: Endoscopic sphincterotomy for choledocholithiasis is found to be safe at long-term follow-up. A dilated bile duct (> or = 22 mm) is a marker for patients at increased risk of recurrence of symptoms and/or choledocholithiasis.

Adolescent↗
PubMed2002

Treatment of unresectable pancreatic carcinoma by intraluminal brachytherapy in the duct of Wirsung.

BACKGROUND AND STUDY AIMS: Our aim was to evaluate the feasibility and clinical outcome of intraluminal brachytherapy (ILBT) in the duct of Wirsung in patients with unresectable pancreatic adenocarcinoma. PATIENTS AND METHODS: Nine patients (eight men, one woman; mean age 72.4 +/- 9.1, range 52 - 80) with unresectable pancreatic adenocarcinoma of the head or body underwent ERCP for biliary and/or pancreatic stent placement and placement of a nasopancreatic drain with/without nasobiliary drain. The ILBT dose administered was 30 - 50 Gy calculated at 1 cm from the iridium-192 wire axis. Seven patients received ILBT from the duct of Wirsung whereas two patients received dual-duct ILBT (duct of Wirsung and the common bile duct). Three patients received combined-modality treatment (ILBT with external beam radiotherapy and 5-fluorouracil). The patients were prospectively followed up. RESULTS: No endoscopy-related complications occurred. No radiation-related toxicity occurred in patients treated with ILBT alone. One patient undergoing combined-modality treatment developed gastric bleeding. Intraluminal source dislodgement occurred in three patients. Obvious tumor mass reduction of greater than 50 % was seen in three patients at 8 weeks after brachytherapy. Median survival was 11 months (range 6 - 37 months) and the 1-year and 3-year actuarial survival rates were 44 % and 15 %, respectively. CONCLUSION: Intraluminal brachytherapy in the duct of Wirsung in patients with unresectable pancreatic carcinoma is safe and feasible. Further clinical trials are warranted.

Adenocarcinoma↗
PubMed2001

Endoscopic treatment of postsurgical external pancreatic fistulas.

BACKGROUND AND STUDY AIMS: External pancreatic fistulas (EPFs) are managed primarily by conservative treatment with a success rate of 40-90%. Failures of conservative therapy have traditionally been dealt with using surgery; however, major morbidity and mortality are associated with operative treatment. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic treatment in the closure of EPF. PATIENTS AND METHODS: A total of 16 consecutive patients with EPF (12 men, four women; median age 50, range 21-66) underwent an attempt at endoscopic management after failure of conservative therapy. Four patients had chronic pancreatitis. All patients had EPFs occurring after open abdominal surgery. The mean interval between the onset of the fistula and our intervention was 108 days (range 27-365 days). The mean output volume of the fistula was 205 ml/d (range 50-600 ml/ d). The aim of treatment was to lower the pancreatic duct pressure and to bypass the ductal disruption by placement of drains and/or stents to induce fistula healing. RESULTS: In all, 13 biliary and nine pancreatic sphincterotomies were performed in order to gain access to the pancreatic duct. Access through the minor papilla was required in one patient. Complete visualization of the main pancreatic duct as well as of the fistulous tract was obtained in 12 patients (75%). Treatment consisted of placement of a nasal pancreatic drain (NPD) across the pancreaticojejunal anastomosis in one patient after duodenopancreatectomy. In 11 of the remaining 15 patients (73%) a NPD could be placed in the pancreatic duct across the ductal leakage (n = 9) or nearby (n = 2). One patient died 24 hours after endoscopic treatment from severe sepsis and massive pulmonary embolism. Endoscopic drainage was effective in healing the EPF in all patients in whom NPDs had been successfully placed, except one. The fistula in this patient healed completely after insertion of an 8.5-Fr pancreatic stent. The mean interval between endoscopic treatment and fistula closure was 8.8 days (range 2-33 days). No complications related to the endoscopic treatment were recorded in this series. In the 12 successfully treated patients, fistulas did not recur in any of the 11 surviving patients after a mean follow-up of 24.7 months (range 3-63 months). CONCLUSIONS: Endoscopic pancreatic drainage, when feasible, is safe and effective for EPF and should be considered as a first-line therapy when EPFs do not respond to conservative therapy.

Adult↗
PubMed2001

Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents.

BACKGROUND: Endoscopic dilation with stents has been proposed as an alternative to hepaticojejunostomy for management of postoperative biliary strictures. Good long-term results with double 10F plastic stent insertion for 1 year have been reported in 74% to 90% of cases. This is a review of our experience with a more aggressive approach. METHODS: The technique, short-term results, and long-term results of placement of increasing numbers of stents until complete disappearance of the biliary stricture are reported. At each exchange, the maximum possible number of stents in relation to the tightness of the stricture and diameter of the bile duct were inserted. All stents were removed at the end of treatment. RESULTS: The records of 45 of 55 patients with postoperative biliary strictures treated in this manner and observed consecutively were reviewed retrospectively. By intention-to-treat analysis the success rate was 89% (40/45). Early complications developed in 4 (9%) patients (3 cholangitis, 1 pancreatitis) and stent occlusion that required early exchange occurred in 8 (18%) patients. There was 1 death caused by a stroke 2 months after a stent exchange. Forty-two patients completed the protocol (mean number of stents 3.2 +/- 1.3; range 1-6). Mean duration of treatment was 12.1 +/- 5.3 months (range 2-24 months). Two patients died of unrelated causes during follow-up. Among the remaining 40 patients there was no recurrence of symptoms caused by relapsing biliary stricture at a mean follow-up of 48.8 months (range 2-11.3 years). One patient sustained 2 episodes of cholangitis but without stricture recurrence. CONCLUSIONS: This more aggressive approach to endoscopic treatment with stents may improve long-term results for patients with postoperative biliary strictures.

Adolescent↗
PubMed2000

Combined modality treatment in unresectable extrahepatic biliary carcinoma.

PURPOSE: Cancers of the extrahepatic biliary tract are rare. Surgical resection is considered the standard treatment, but is rarely feasible. Several reports of combined modality therapy, including external beam radiation, often combined with chemotherapy and intraluminal brachytherapy, have been published. The purpose of this study was to evaluate the effect of chemoradiation plus intraluminal brachytherapy on response, local control, survival, and symptom relief in patients with unresectable or residual extrahepatic biliary carcinoma. METHODS AND MATERIALS: From February 1991 to December 1997, 20 patients (14 male, 6 female; mean age 61 +/- 12 years; median follow-up 71 months) with unresectable (16 patients) or residual (4 patients), nonmetastatic extrahepatic bile tumors (common bile duct, 8; gallbladder, 1; Klatskin, 11) received external beam radiation (39.6-50.4 Gy); in 19 patients, 5-fluorouracil (96-h continuous infusion, days 1-4 at 1,000 mg/m(2)/day) was also administered. Twelve patients received a boost by intraluminal brachytherapy using (192)Ir wires of 30-50 Gy, prescribed 1 cm from the source axis. RESULTS: During external beam radiotherapy, 8 patients (40%) developed grade 1-2 gastrointestinal toxicity. Four patients treated with external-beam plus intraluminal brachytherapy had a clinical response (2 partial, 2 complete) after treatment. For the total patient group, the median survival and time to local progression was 21.2 and 33.1 months, respectively. Distant metastasis occurred in 10 (50%) patients. Two patients who received external beam radiation plus intraluminal brachytherapy developed late duodenal ulceration. Two patients with unresectable disease survived more than 5 years. CONCLUSION: Our data suggest that chemoradiation plus intraluminal brachytherapy was relatively well-tolerated, and resulted in reasonable local control and median survival. Further follow-up and additional research is needed to determine the ultimate efficacy of this regimen. New chemoradiation combinations and/or new treatment strategies (neoadjuvant chemoradiation) may contribute, in the future, to improve these results.

Adult↗
PubMed2000

Hydrophilic hydromer-coated polyurethane stents versus uncoated stents in malignant biliary obstruction: a randomized trial.

BACKGROUND: Hydromer-coated polyurethane stents (HCPS) have a low coefficient of friction that may reduce sludge formation and potentially increase stent longevity. METHODS: Eighty-three patients (39 men, mean age 69.3 years) with malignant mid or distal bile duct strictures were prospectively randomized to receive either 10F HCPS (n = 40) or standard polyethylene stents (n = 43). RESULTS: Fifteen patients (18.1%) underwent surgery after stent insertion. Six patients were lost to follow-up (7.2%), whereas 34 died of the underlying disease without evidence of stent occlusion (15 HCPS group and 19 polyethylene group). Median survival was 75 days (range 15 to 372 days) and 108 days (range 25 to 325 days) in the HCPS and polyethylene stent groups, respectively (p = not significant). Stent occlusion was observed in 25 patients (42%), 16 with HCPS stents and 9 with polyethylene stents, with a median patency of 103 days (range 40 to 280 days) and 68 days (range 32 to 175 days), respectively (p = not significant). CONCLUSIONS: HCPS do not appear to provide significant clinical advantages in terms of stent longevity over standard plastic prostheses.

Aged↗