Endoscopic submucosal resection with an endoscopic variceal ligation device for the treatment of rectal neuroendocrine tumors

Background

Endoscopic resection is recommended for rectal neuroendocrine tumors <?1 cm in diameter; the three techniques (mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device) of endoscopic resection of neuroendocrine tumor were reported; however, the optimal endoscopic technique remains unclear.

Purpose

We compared the efficacy and safety of three endoscopic rectal neuroendocrine tumor resection methods.

Methods

We retrospectively enrolled 52 patients with rectal neuroendocrine tumors treated by endoscopy at Aichi Medical University Hospital and Nagoya City University Hospital between May 2003 and June 2017. We compared clinical outcomes in three groups based on the endoscopic treatment method.

Results

Fifty-two patients underwent endoscopic rectal neuroendocrine tumor treatment (mucosal resection, 14; submucosal dissection, 19; mucosal resection with an endoscopic variceal ligation device, 19). In the endoscopic mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device groups, R0 resection occurred in 50.0, 94.7, and 89.5%, respectively (mucosal resection vs. mucosal resection with variceal ligation device, p <?0.05; mucosal resection vs. submucosal dissection, p <?0.01), while the median procedure times were 6.5, 43, and 6.0 min, respectively (submucosal dissection vs. mucosal resection with variceal ligation device procedure times, p?<?0.01; mucosal resection vs. submucosal resection procedure times, p <?0.01). Postoperative bleeding occurred after endoscopic mucosal resection (1/14) and endoscopic submucosal dissection (4/19), but not after endoscopic mucosal resection with a ligation device.

Conclusion

Endoscopic mucosal resection with an endoscopic variceal ligation device was a safe, effective treatment for rectal neuroendocrine tumors.

     

Portale Hypertension: Varizen

Background

Variceal hemorrhage is a major cause of morbidity and mortality in patients with cirrhosis. However, mortality rates have been substantially reduced in recent years due to improved diagnostic and therapeutic workup.

Therapy

Patients who present with active variceal hemorrhage require immediate hemodynamic resuscitation and early upper gastrointestinal endoscopy. Endoscopic variceal ligation (EVL) is the treatment of choice for esophageal varices, whereas cyanoacrylate injection is preferably used for the treatment of gastric varices. If endoscopic therapy fails to control bleeding, balloon tamponade or stent placement may be required. Emergency transjugular intrahepatic portosystemic shunt (TIPS) placement is a more definite option, when available.

Prophylaxis

For primary prophylaxis of variceal hemorrhage, treatment with a nonselective beta blocker or EVL is recommended whereas a combination of the two is recommended for secondary prophylaxis.

     

Incidence of food residue interfering with postoperative endoscopic examination for gastric pull-up after esophagectomy

Background

In spite of appropriate preparation, food residue that interferes with endoscopic examination is occasionally observed in an operated stomach. The present study aimed to elucidate the incidence of such food residue and determine its risk factors in gastric pull-up after esophagectomy.

Methods

A total of 116 esophagectomized patients underwent the first postoperative endoscopy to survey their gastric pull-up with a median interval of 14 months (range 6–24) after the surgery. Fasting time was 13–16 h before the examination. The amount of food residue was retrospectively classified from Grade 0 (no food residue) to Grade 4 (a large amount of food residue) by two expert endoscopists.

Results

Among the 116 patients, 73 patients were classified as Grade 0, 23 patients as Grade 1, 10 patients as Grade 2, 9 patients as Grade 3, and 1 patient as Grade 4. Food residue (≥Grade 2) that interfered with the examination was observed in 20 patients (17.2 %). There was no significant association between the food residue and patient baseline characteristics.

Conclusion

The food residue interfering with postoperative endoscopic examination was observed in 17.2 % of all surveyed gastric pull-ups.

     

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals

Background

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals.

Methods

Retrospective analysis of collected database of patients (n=18; age 40.94±8.43 years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals.

Results

Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5 cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3 ± 0.79 and time to resolution was 4.4 ± 1.3 weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2 weeks.

Conclusion

EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

     

Long-term results of transanal endoscopic microsurgery after endoscopic polypectomy of malignant rectal adenoma

Background

There is no consensus on the treatment and prognosis of malignant rectal polyps. The aim of the present study was to determine the role of transanal endoscopic microsurgery (TEM) after endoscopic complete polypectomy of malignant rectal adenomas with long-term follow-up.

Methods

Of 105 patients with pT1 rectal carcinoma in 32 patients TEM followed complete endoscopic polypectomy while 73 had primary TEM. Local recurrence (LR), distant metastasis, overall and cancer-specific survival were determined by the Kaplan–Meier method.

Results

Median follow-up was 9.1 years. In 32 patients with TEM following complete polypectomy no residual cancer was found. LR occurred in 3/28 (11%) patients with low-risk carcinoma (pT1 G1/2/X, L0/X, R0) and in 1/4 (25%) with high-risk carcinoma (pT1 G3/4 or L1). After primary TEM with complete resection (minimal distance >1 mm) LR occurred in 6/60 (10%) with low-risk carcinoma. After incomplete TEM resection (minimal distance ≤1 mm) LR occurred in 3/8 (38%) patients with low-risk and in 1/5 (20%) patients with high-risk carcinoma. Grading was the only significant risk factor for LR after endoscopic polypectomy followed by TEM (p = 0.002). At all outcomes did not differ between postpolypectomy TEM and primary TEM.

Conclusions

Patients with malignant rectal polyps removed by endoscopic polypectomy have a substantial risk of LR even if TEM of polyp site is cancer free. Risk of LR depends on tumor characteristics. In low-risk carcinoma long-term follow-up is necessary. The high LR rate in patients with high-risk rectal carcinoma restricts the use of TEM alone.

     

Use of self-expanding metal stents for difficult variceal bleed

Background/Aim

Patients with variceal band ligation (VBL)-induced ulcer bleeding and those with persisting bleeding in spite of VBL carry a high mortality. Balloon tamponade and transjugular intrahepatic portosystemic shunt have limitations in terms of complications, cost, and availability. The aim was to evaluate the efficacy of Sx-Ella Danis stent in persistent or complicated variceal bleeding.

Methods

Twelve patients with either persistent variceal bleeding or VBL-induced ulcer bleeding were treated with the placement of Sx-Ella Danis stents. The patients were followed up for mortality, complications, and efficacy to control bleeding.

Results

Stents were inserted successfully in all 12 patients (with immediate hemostasis). There was an immediate cessation of bleeding in all 12 patients with no stent-related complication. Five out of 12 patients died during 30 days post-procedure due to worsening encephalopathy or sepsis. Enteral feeding could be started in all 12 patients 6 h after stent placement. One patient had bleeding 10 days after stent removal and was re-stented but expired 7 days later. Stents were removed in eight patients at a mean duration of 17.5 days. (range 7 to 30 days).

Conclusions

Sx-Ella Danis stent is a useful modality to control persistent variceal bleeding as well VBL-related ulcer bleeding.

     

Validation study of a health risk appraisal model and endoscopic screening for early esophageal cancer in men in specialized hospitals

Background

This study was designed to validate a health-risk appraisal (HRA) model for identifying Japanese men in specialized hospitals who were at high risk for esophageal cancer on the basis of their past and present facial flushing reactions after drinking alcohol, drinking and smoking status, and intake of vegetables and fruit.

Methods

We prospectively studied men 50 years or older with no history of head and neck cancer or esophageal cancer who presented at Kitasato University Hospital to undergo endoscopic examination from January 2011 to March 2013. The subjects responded to an HRA questionnaire before examination.

Results

Among the 164 patients enrolled, 157 were eligible for analysis. The median HRA score was 3 in patients aged 70–90 years and 6 in those aged 50 to 69 years. Early esophageal cancer was diagnosed on endoscopic examination in 3 subjects (1.9%, 3/157). Among 70 patients 70–90 years of age, 18 (25.7%, 18/70) had an HRA score of 7 or higher, and early esophageal cancer was detected in 2 (11.1%, 2/18) of these patients. Early esophageal cancer was not detected in 87 patients 50–69 years of age. Early esophageal cancer was detected in a 70-year-old patient with an HRA score of 2 who had no history of drinking alcohol or smoking.

Conclusions

Our results suggest that an HRA questionnaire is useful for identifying persons 70 years or older who are at high risk for alcohol-related esophageal cancer in specialized hospitals.

     

Comparison of continuous versus intermittent infusions of terlipressin for the control of acute variceal bleeding in patients with portal hypertension: An open-label randomized controlled trial

Background

Continuous infusion of terlipressin causes more stable reduction in portal venous pressure than intermittent infusion. The aim of the study was to compare the efficacy of continuous infusion vs. intermittent boluses of terlipressin to control acute variceal bleeding (AVB) in patients with portal hypertension.

Methods

Eighty-six consecutive patients with portal hypertension and AVB were randomized to receive either continuous intravenous infusion (Group A, n?=?43) or intravenous boluses of terlipressin (Group B, n?=?43). Group A received 1 mg intravenous bolus of terlipressin followed by a continuous infusion of 4 mg in 24 h. Group B received 2 mg intravenous bolus of terlipressin followed by 1 mg intravenous injection every 6 h. Upper gastrointestinal (UGI) endoscopy was done within 12 h of admission. Endoscopic variceal ligation (EVL) was done using a multi-band ligator. In both groups, treatment was continued up to 5 days. The primary endpoint was rebleeding or death within 5 days of admission.

Results

Patients in group A had lower rate of treatment failure (4.7%) as compared to patients in group B (20.7%) (p?=?0.02). Within 6 weeks, four and eight patients died in group A and B, respectively (p?=?0.21). Model for end-stage liver disease sodium (MELD-Na) score and continuous infusion of terlipressin showed significant relationship with treatment failure on multivariate analysis.

Conclusions

Continuous infusion of terlipressin may be more effective than intermittent infusion to prevent treatment failure in patients with variceal bleeding. There is significant relationship between MELD-Na score [Odd ratio = 1.37 (95% CI-1.16 - 1.62), p-value < 0.001] and continuous infusion of terlipressin [Odd ratio = 0.18 (95% CI-0.037 - 0.91), p-value - 0.04] with treatment failure.

     

RETRACTED ARTICLE: Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy

Background/Purpose

The prevention of pancreatic fistula is still a major problem in distal pancreatectomy (DP). We have recently adopted preoperative endoscopic pancreatic stenting with the aim of preventing the leakage of pancreatic juice from the resection plane of the remnant pancreas after DP. We reviewed ten patients who underwent this intervention.

Methods

One to 6 days before surgery, the patients underwent an endoscopic transpapillary pancreatic stent (7 Fr., 3 cm) placement. The perioperative short-term outcomes were assessed.

Results

Preoperative endoscopic pancreatic stenting was successfully performed in all ten patients. Two (20%) patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the ten patients developed pancreatic fistula. The pancreatic stent was removed 8–28 days (mean, 11 days) postoperatively.

Conclusions

Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP.

     

Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement

Background

Left atrial appendage (LAA) obliteration is a proven stroke-preventive measure for patients with nonvalvular atrial fibrillation (AF). However, the efficacy of LAA obliteration for patients with AF after bioprosthetic mitral valve replacement (MVR) remains unclear.

Aim

This study aimed to estimate the efficacy of LAA obliteration in preventing embolism and to investigate the predictors of thromboembolism after bioprosthetic MVR.

Methods

We retrospectively studied 173 AF subjects with bioprosthetic MVR; among them, 81 subjects underwent LAA obliteration using an endocardial running suture method. The main outcome measure was the occurrence of thrombosis events (TEs). The mean follow-up time was 40?±?17 months.

Results

AF rhythm was observed in 136 patients postoperatively. The incidence rate of TEs was 13.97?% for postoperative AF subjects; a dilated left atrium (LA; >?49.5 mm) was identified as an independent risk factor of TEs (OR?=?10.619, 95?% CI?=?2.754–40.94, p?=?0.001). For postoperative AF patients with or without LAA, the incidence rate of TEs was 15.8?% (9/57) and 12.7?% (10/79; p?=?0.603), respectively. The incidence rate of TEs was 2.7?% (1/36) and 4.2?% (2/48) for the subgroup patients with a left atrial diameter of <?49.5 mm, and 38.1?% (8/21) and 25.8?% (8/31) for those with a left atrial diameter of >?49.5 mm (p?=?0.346).

Conclusion

Surgical LAA obliteration in patients with valvular AF undergoing bioprosthetic MVR did not reduce TEs, even when the CHA₂DS₂-VASc score (a score for estimating the risk of stroke in AF) was ≥?2 points.

     

Insulated-tip knife endoscopic polypectomy for difficult pedunculated colorectal polyps: a prospective pilot study

Background

Endoscopic polypectomy is widely used for colorectal polyps. However, for giant pedunculated colorectal polyps (≥3 cm), conventional techniques are so difficult with en bloc resection that patients had to be transferred to surgery. We had firstly reported our first experience with an insulated-tip knife to successfully remove a giant pedunculated polyp in the sigmoid colon. In this study, our aim was to explore safety and feasible of insulated-tip knife endoscopic polypectomy (IT-EP) for difficult pedunculated colorectal polyps.

Methods

A total of seven consecutive patients with giant pedunculated colorectal polyps (≥3 cm) were prospectively enrolled. IT-EP was conducted with the help of clips for all the seven patients, and data of them was recorded and analyzed.

Results

Of seven patients, five were men and two were women with a mean age 61 years (49–72 years). The mean diameter of polyp head and stalk was 36.4 ± 4.9 mm (30–42 mm) and 14.6 ± 3.6 mm (10–20 mm), respectively. All the polyps were successfully removed with IT-EP, with a mean operation time of 14.9 ± 3.5 min (11–20 min). No serious bleeding or perforation was experienced, and no surgery was needed. There was no recurrence or residual of polyps at a mean 8.1-month follow-up.

Conclusions

Insulated-tip knife endoscopic polypectomy is a safe and feasible alternative for difficult pedunculated colorectal polyps.

     

Endoscopic ultrasound-guided coil or glue injection in post-cyanoacrylate gastric variceal re-bleed

Background and Aims

N-butyl-cyanoacrylate injection is recommended in bleeding/recently bled gastric varices. However, cyanoacrylate injection is associated with re-bleed in 25% to 50% of patients. Endoscopic ultrasound (EUS)-guided coil application is an emerging treatment modality for bleeding gastric varices. The aim of this study was to compare EUS-guided coil application combined with or without cyanoacrylate glue injection to injection alone in post-glue gastric variceal re-bleed.

Methods

A retrospective analysis of a prospectively maintained database was performed. Thirty patients who re-bled after cyanoacrylate injection and who had EUS-guided coil application to gastric varices were included. The comparison was done with data of 51 patients who had only repeat cyanoacrylate injection. Both groups had a follow up for 12 months. EUS-guided coil application was done under endosonographic guidance. A single coil was placed in 7, two coils in each of 13 patients, three in 5, four in 3, five in one, and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 15 patients. Eight patients had repeat EUS-guided coil application 1 month later. Re-bleed and mortality were assessed.

Results

Coilng: Six out of 30 (20%) patients re-bled during follow up of 9 to 365 days. Three out of 30 (10%) died. One patient died 9 days after the procedure due to acute respiratory distress syndrome, one died 4 months after the procedure due to a re-bleed and one 5 months after the procedure due to spontaneous bacterial peritonitis. Glue only: 26/51 (51%) re-bled during follow up of 45 to 365 days. EUS-guided coil application resulted in significantly less re-bleed than glue-only (Kaplan-Meir survival analysis with log-rank test, z?=?5.4, p?<?0.001). Two out of 51 (4%) died 59 and 186 days after the procedure.

Conclusion

EUS-guided coil application with/without cyanoacrylate injection for the obliteration of gastric varices is effective for post-cyanoacrylate gastric variceal re-bleed.

     

A novel endoscopic treatment for anastomotic leakage post anterior resection: Padlock over the scope clip

Background

Anastomotic dehisense is a serious complication of anterior resections. We have had success in our centre utilising Endosponge therapy to salvage anastomotic leaks but this requires multiple endoscopic sessions and can take around 6 weeks to heal in some cases. This can delay further management such as chemotherapy.

Aim

We describe the novel use of Padlock over the scope clips to manage patients with anastomotic dehisense post anterior resection.

Method

Padlock over the scope clips were used to manage three patients who presented with anastomotic breakdown post laparoscopic anterior resection between February 2016 and July 2017.

Results

These patients were initially managed conservatively with IV antibiotics and fluids. One case was first managed with Endosponge treatment before a Padlock clip was utilised to bridge a narrow defect. The other cases were managed initially with CT-guided percutaneous drains before clip deployment. Patients were followed up with regular clinic and sigmoidoscopies. All three cases demonstrated anastomotic salvage and satisfactory healing. This allowed the patients to be fit for their chemotherapy in less than 4 weeks from presentation. There were no complications from utilising the Padlock clips in these cases.

Conclusion

Utilising over the scope endoclips previously has been thought to be limited by the size of defect. Our experience details novel combination techniques that allow for quick resolution and the expeditious commencement of further management such as chemotherapy. These clips also proved to be cost-effective in our centre, utilising less inpatient and outpatient resources than alternative management plans.

     

Risk of complications and long-term functional alterations after local excision of rectal tumors with transanal endoscopic microsurgery (TEM)

Introduction

Transanal endoscopic microsurgery (TEM) is a consolidated technique for the excision of rectal tumors. However, many aspects relating to its morbidity, risk of functional alterations, and therapeutic outcomes are still unclear. The aim of this study was to assess the rate of morbidity and fecal incontinence after TEM, and to identify associated risk factors.

Methods

We prospectively recorded the clinical data of 157 patients who underwent TEM from 1996 to 2013. Among these, 89 patients answered a questionnaire for the assessment of fecal continence at a median follow-up time of 40 months.

Results

Intraoperative and postoperative TEM complication rates were 3.8 and 20.4 %. The mortality rate was 0.6 %. A distance from the anal verge of more than 6 cm correlated with a higher risk of perforation, while patients with cancer were more likely to have postoperative bleeding. Incontinence was reported by 32 (36 %) patients, of which 7 (8 %) experienced transitory symptoms only, while 25 (28 %) reported persistent symptoms. We found a correlation between patients receiving preoperative radiotherapy (RT) and the development of fecal incontinence. The recurrence rate was 3 % (1/32) in pT1, 80 % (4/5) in pT2, and 100 % (1/1) in pT3. After radiotherapy, 7 % (1/9) showed a good response (pT0-1), and 18 % (2/7) showed no response (pT2-3).

Conclusions

TEM is associated with low morbidity but the risk of developing functional alterations is not negligible and should be discussed with the patient before the operation. Good oncological outcomes are possible for early invasive cancers and for selected advanced cancers following a good response to preoperative RT.

     

Incidence and risk factors of advanced neoplasia after endoscopic mucosal resection of colonic laterally spreading lesions

Purpose

To investigate advanced neoplasia (AN) after endoscopic mucosal resection (EMR) of colonic laterally spreading lesions (LSLs).

Methods

A retrospective study of patients who underwent injection-assisted EMR of colonic LSLs ≥?10 mm was performed. Primary outcome was overall rate of AN at initial surveillance colonoscopy. Secondary outcomes were the rates of residual AN (rAN) at the EMR site and metachronous AN (mAN), and analysis of risk factors for AN, including effect of surveillance guidance.

Results

Three hundred seventy-four patients underwent successful EMR for 388 LSLs. AN occurred in 66/374 (17.6%) patients on initial surveillance colonoscopy at median follow-up of 364.5 days. Two patients had both rAN and mAN, for a total of 68 instances of AN, including 30/374 (8.0%) cases of rAN and 38/374 (10.2%) cases of mAN. On multivariate analysis, use of piecemeal resection was associated with increased likelihood of residual AN (P?=?0.003, OR 9.2, 95% CI 2.1–33.3). Twenty-nine out of thirty cases (96.7%) of rAN were successfully endoscopically managed at surveillance colonoscopy.

Conclusions

AN occurred in 17.6% of all patients at initial surveillance colonoscopy at a median of 1 year after EMR. Roughly half of the instances of AN were metachronous lesions. Our data support a 1-year surveillance interval after EMR of LSLs ≥?10 mm with careful inspection of the entire colon, not just the prior resection site.

     

Non-variceal upper gastrointestinal bleeding in cirrhotic patients in Nile Delta

Background and Study Aims

Acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients occurs mainly from esophageal and gastric varices; however, quite a large number of cirrhotic patients bleed from other sources as well. The aim of the present work is to determine the prevalence of non-variceal UGIB as well as its different causes among the cirrhotic portal hypertensive patients in Nile Delta.

Methods

Emergency upper gastrointestinal (UGI) endoscopy for AUGIB was done in 650 patients. Out of these patients, 550 (84.6 %) patients who were proved to have cirrhosis were the subject of the present study.

Results

From all cirrhotic portal hypertensive patients, 415 (75.5 %) bled from variceal sources (esophageal and gastric) while 135 (24.5 %) of them bled from non-variceal sources. Among variceal sources of bleeding, esophageal varices were much more common than gastric varices. Peptic ulcer was the most common non-variceal source of bleeding.

Conclusions

Non-variceal bleeding in cirrhosis was not frequent, and sources included peptic ulcer, portal hypertensive gastropathy, and erosive disease of the stomach and duodenum.

     

Postoperative complications in the treatment of rectal neoplasia by transanal endoscopic microsurgery: a prospective study of risk factors and time course

Purpose

Transanal endoscopic microsurgery (TEM) is a safe and efficient minimally invasive treatment for rectal benign and early malignant neoplasia, but postoperative complications may be severe. We aimed to evaluate the risk factors related to the incidence, severity, and time course of postoperative complications of TEM.

Methods

This is a prospective study of postoperative complications in 53 patients (>18 years old) with benign or early rectal neoplasia who underwent TEM with curative intention or, for higher stages, palliation. Outcome measures included age, sex, American Society of Anesthesiologists score, neoadjuvant chemoradiotherapy, lesion height and size, pathologic margins, tumor histology, and suture type.

Results

Overall morbidity was 50 %. Temporary fecal incontinence was the most frequent complication (17.3 %). Complication rates of Clavien–Dindo grades I and II were 21.1 % and those of grades III and IV 3.8 %. Of patients with complications, more had lesions under the first rectal valve than over the first valve (61.54 % vs 38.46 %, p?=?0.04). Patients submitted to chemoradiotherapy had a 24-fold greater chance of presenting grade II complications (p?=?0.002). When the surgical defect was treated using the TEM device to perform the suture, the chance of having grade III complications was reduced 16-fold (p?=?0.04). Fifty-three percent of complications occurred in the first 10 days and 95 % within 20 days.

Conclusions

Postoperative complications after transanal endoscopic microsurgery for the treatment of rectal neoplasia are frequent, acceptable, and usually controllable with pharmacologic treatment. Over time the nature of complications is continuous, centered on the first 20 days after surgery.

     

Anesthesia in per-oral endoscopic myotomy: A large tertiary care centre experience

Background and Objectives

Per-oral endoscopic myotomy (POEM) is safe and efficacious for the management of achalasia cardia (AC). POEM is usually performed under general anesthesia in an endoscopy suite or operating theatre. The current study was conducted with the aim to analyse anesthetic management of patients with AC who underwent POEM at our institution.

Methods

We retrospectively analysed the data of patients with AC who underwent POEM at our institution from January 2013 to September 2016. All cases were performed in an endoscopy suite under supervision of an anesthesia management team. Pre-procedure endoscopic evacuation of esophagogastric contents was done in all cases. Management strategies used for gas-related adverse events and outcomes were assessed.

Results

Four hundred and eighty patients (median age 40 years, range 4–77 years) underwent POEM during the study period. The sub-types of AC were type I (163), type II (297), and type III (20). POEM was successfully completed in 97.5% patients. Gas-related events were noted in 30.6% cases including-capno-thorax in 1%, capno-peritoneum in 12.3%, retroperitoneal air in 16.5%, capno-mediastinum in 0.2%, and capno-pericardium in 0.4% patients. Significant rise in end tidal CO2 (> 45) and peak airway pressure were observed in 8.1% and 5.4% cases, respectively. Drainage was required in 12.3% patients. There was no occurrence of aspiration during or after POEM.

Conclusions

POEM could be safely performed in an endoscopy suite under supervision of an expert anesthesia management team. Gas-related adverse events were common during POEM and could be managed with a standardized approach.

     

Characteristics of meningitis following transsphenoidal endoscopic surgery: a case series and a systematic literature review

Background

Meningitis occurs in 0.8–1.5% of patients undergoing neurosurgery. The aim of the study was to evaluate the characteristics of meningitis after endoscopic endonasal transsphenoidal surgery (EETS) comparing the findings retrieved to those highlighted by literature search.

Materials and methods

Patients treated by EETS during an 18-year period in the Department of Neurosurgery of ‘Federico II’ University of Naples were evaluated and included in the study if they fulfilled criteria for meningitis. Epidemiological, demographic, laboratory, and microbiological findings were evaluated. A literature research according to PRISMA methodology completed the study.

Results

EETS was performed on 1450 patients, 8 of them (0.6%) had meningitis [median age 46 years (range 33–73)]. Endoscopic surgery was performed 1–15 days (median 4 days) before diagnosis. Meningeal signs were always present. CSF examination revealed elevated cells [median 501 cells/μL (range 30–5728)], high protein [median 445 mg/dL (range 230–1210)], and low glucose [median 10 mg/dL (range 1–39)]. CSF culture revealed Gram-negative bacteria in four cases (Klebsiella pneumoniae, Escherichia coli, Alcaligenes spp., and Haemophilus influenzae), Streptococcus pneumoniae in two cases, Aspergillus fumigatus in one case. An abscess occupying the surgical site was observed in two cases. Six cases reported a favorable outcome; two died. Incidence of meningitis approached to 2%, as assessed by the literature search.

Conclusions

Incidence of meningitis after EETS is low despite endoscope goes through non-sterile structures; microorganisms retrieved are those present within sinus microenvironment. Meningitis must be suspected in patients with persistent fever and impaired conscience status after EETS.

     

Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer

Background

The treatment of flat rectal adenomas is challenging. The technical difficulty and the potential of malignancy in suspected benign lesions are the factors in question. Surgical and interventional endoscopic techniques are implemented in Europe without a clear strategy. To minimize recurrent adenoma and unclear histopathological work up en bloc excision is desirable.

Methods and results

We demonstrate in this article the transanal endoscopic microsurgical submucosa dissection (TEM-ESD) procedure as a feasible method for en bloc excision of rectal adenomas and early rectal cancer. The surgical technique is demonstrated in detail with the help of a video of the operation that is available online. The results of a consecutive series of 78 patients are presented.

Conclusion

TEM-ESD is a safe procedure for resection of rectal adenomas and low risk carcinomas. It offers the possibility of organ preservation and minimizes functional disturbances. In case of a necessary salvage operation, the preserved integrity of the rectal muscle tube grants maximal oncological safety.