Search

Background: Extramedullary plasmacytoma is an uncommon tumor that most often involves the nasopharynx or upper respiratory tract. Extramedullary plasmacytoma is a type of plasma cell neoplasm that can present as a primary tumor or secondary to another plasma cell neoplasm, such as multiple myeloma. Secondary extramedullary plasmacytoma is usually noted in the advanced stages of the disease. Involvement of the gastrointestinal tract occurs in approximately 10% of cases., Case Presentation: A 71-year-old Caucasian woman with known diverticular disease of the colon and multiple myeloma diagnosed 3 years previously, with monoclonal bands of immunoglobulin A, lambda light chains, and multiple osteolytic lesions, presented to our hospital with abdominal pain, abdominal discomfort, and pneumoperitoneum. She underwent left colectomy for diverticulitis with perforation, and an extramedullary secondary colonic plasmacytoma was found in histopathological examination of the sigmoid colon., Conclusions: Plasmacytoma is known to occur in extraosseous sites. The stomach and small intestine are the most commonly involved sites in the gastrointestinal tract. Secondary extramedullary plasmacytoma of the colon is rare. Colonic plasmacytoma may have varying clinical presentations, such as inflammatory bowel disease and multiple colonic strictures. Although these cases are rare, treating physicians as well as radiologists, pathologists, and surgeons should be aware of this entity.

Introduction: Neck pain and torticollis are common symptoms in the pediatric population that rarely requires further investigation. However, in case symptoms persist, then a more meticulously approach should be considered. Underlying conditions such as infections, neck injury, autoimmune disorders or even cervical spine cancer should be excluded from diagnosis. Cervical spine cancer is a rare neurosurgical entity in the pediatric population and even rarer is atlantoaxial Ewing's sarcoma. In this report, we present a rare case of primary Ewing's sarcoma of the axis., Case Report: A 3.5-year-old female with progressive neck pain and intermittent episodes of torticollis was referred to our outpatient clinic. Imaging studies revealed a malignant tumor located on C2 vertebra. Diagnosis of Ewing's Sarcoma was confirmed via open biopsy and the patient was treated with Euro-EWING 99 chemotherapy., Conclusion: Pediatric neck pain and/or torticollis should raise high suspicion for malignancy of cervical spine. Modern diagnostic means and techniques can assist in the screening and diagnosis of these tumors., (Copyright © 2018 Polish Neurological Society. Published by Elsevier Sp. z o.o. All rights reserved.)

1  ESGE recommends cold snare polypectomy (CSP) as the preferred technique for removal of diminutive polyps (size ≤ 5 mm). This technique has high rates of complete resection, adequate tissue sampling for histology, and low complication rates. (High quality evidence, strong recommendation.) 2  ESGE suggests CSP for sessile polyps 6 - 9 mm in size because of its superior safety profile, although evidence comparing efficacy with hot snare polypectomy (HSP) is lacking. (Moderate quality evidence, weak recommendation.) 3  ESGE suggests HSP (with or without submucosal injection) for removal of sessile polyps 10 - 19 mm in size. In most cases deep thermal injury is a potential risk and thus submucosal injection prior to HSP should be considered. (Low quality evidence, strong recommendation.) 4  ESGE recommends HSP for pedunculated polyps. To prevent bleeding in pedunculated colorectal polyps with head ≥ 20 mm or a stalk ≥ 10 mm in diameter, ESGE recommends pretreatment of the stalk with injection of dilute adrenaline and/or mechanical hemostasis. (Moderate quality evidence, strong recommendation.) 5  ESGE recommends that the goals of endoscopic mucosal resection (EMR) are to achieve a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques. (Low quality evidence; strong recommendation.) 6  ESGE recommends careful lesion assessment prior to EMR to identify features suggestive of poor outcome. Features associated with incomplete resection or recurrence include lesion size > 40 mm, ileocecal valve location, prior failed attempts at resection, and size, morphology, site, and access (SMSA) level 4. (Moderate quality evidence; strong recommendation.) 7  For intraprocedural bleeding, ESGE recommends endoscopic coagulation (snare-tip soft coagulation or coagulating forceps) or mechanical therapy, with or without the combined use of dilute adrenaline injection. (Low quality evidence, strong recommendation.)An algorithm of polypectomy recommendations according to shape and size of polyps is given (Fig. 1)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Endoscopic papillary large balloon dilation with biliary sphincterotomy (EPLBD + EBS) is safe and effective in patients with large common bile duct (CBD) stones. However, data on long-term outcomes after EPLBD + EBS remain limited. We sought to prospectively evaluate the long-term recurrence of CBD stones after EPLBD + EBS and to identify the associated factors., Methods: We conducted an extended follow-up of a previous randomized trial (2009-2011) comparing the outcomes of 30- versus 60-s large balloon dilation. A total of 106 trial participants undergoing successful CBD stone clearance by EPLBD + EBS were prospectively followed up for up to 4 years (range 19-48 months). Various risk factors were analysed to assess predictors of long-term recurrence of stones., Results: Recurrent CBD stones appeared in 8/106 (7.5 %) patients during a mean follow-up of 30.5 ± 5.5 months. The mean diameter of CBD was significantly higher in the recurrence versus non-recurrence group (2.0 ± 4.9 vs 1.6 ± 0.9 cm, p = 0.008). Multivariate analysis revealed that CBD diameter was the only predictor significantly associated with the long-term recurrence of stones (odds ratio 1.2, p = 0.01)., Conclusions: EPLBD + EBS is associated with a low rate of long-term CBD stone recurrence. However, the risk is significantly higher in patients with a more dilated CBD.

Background: Endoscopic submucosal dissection (ESD) requires special skills and a long procedure time for a quality-controlled procedure. A universal training system remains to be established. Hands-on courses in animal models before advancing to the human colon appear to be essential, especially in Europe. The learning curve is a prerequisite in ESD, in order to improve technical outcomes and decrease the rate of procedural adverse events., Methods: In the experimental research center of ELPEN Pharmaceuticals, 18 European endoscopists, inexperienced at ESD, performed gastric ESDs in porcine models. The course lasted two days and was conducted under the supervision of experts., Results: A total of 72 of 76 ESDs were completed en bloc (94.7%). The procedural time and cutting speed differed significantly between the first and second day: 48±4.4 vs. 43±4.8 min (P=0.0045), and 1.38±0.20 vs. 1.63±0.23 cm 2 /min (P=0.0033), respectively. The complications were not significantly different between the two groups: five (13.88%) vs. four (11%) episodes of bleeding (P>0.05). The perforation rate was similar, at two episodes per day (5.55%). We documented an acceptable rate of en bloc resections and complications., Conclusion: ESD demands a new level of endoscopic skills in Europe. A formal sequential training program, using porcine models, may benefit countries with a low volume of cases., Competing Interests: Conflict of Interest: None

The main objective of this study was to determine the preliminary Diagnostic Reference Levels (DRLs) in terms of Kerma Area Product (KAP) and fluoroscopy time (Tf) during Endoscopic Retrograde Cholangio-Pancreatography (ERCP) procedures. Additionally, an investigation was conducted to explore the statistical relation between KAP and Tf. Data from a set of 200 randomly selected patients treated in 4 large hospitals in Greece (50 patients per hospital) were analyzed in order to obtain preliminary DRLs for KAP and Tf during therapeutic ERCP procedures. Non-parametric statistic tests were performed in order to determine a statistically significant relation between KAP and Tf. The resulting third quartiles for KAP and Tf for hospitals (A, B, C and D) were found as followed: KAPA=10.7Gycm(2), TfA=4.9min; KAPB=7.5Gycm(2), TfB=5.0min; KAPC=19.0Gycm(2), TfC=7.3min; KAPD=52.4Gycm(2), TfD=15.8min. The third quartiles, calculated for the total 200 cases sample, are: KAP=18.8Gycm(2) and Tf=8.2min. For 3 out of 4 hospitals and for the total sample, p-values of statistical indices (correlation of KAP and Tf) are less than 0.001, while for the Hospital A p-values are ranging from 0.07 to 0.08. Using curve fitting, we finally determine that the relation of Tf and KAP is deriving from a power equation (KAP=Tf(1.282)) with R(2)=0.85. The suggested Preliminary DRLs (deriving from the third quartiles of the total sample) for Greece are: KAP=19Gycm(2) and Tf=8min, while the relation between KAP and Tf is efficiently described by a power equation., (Copyright © 2016 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)

Purpose: There are conflicting views regarding preoperative biliary drainage in patients undergoing pancreatectomy. The aim of this study was to evaluate the effect of jaundice resolution on postoperative outcomes., Methods: Patients who underwent pancreatectomy in a single institution since 2010 were retrospectively analyzed. They were divided into two groups, depending on the presence or not of preoperative biliary drainage. Postoperative morbidity and mortality were evaluated., Results: Ninety-nine patients underwent biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) (PBD group), while 105 patients had no biliary drainage (non-PBD group). No significant difference between the two groups could be identified in terms of overall complications (p = 0.121) or mortality (p = 1). There was no significant difference regarding pancreatic fistula (p = 0.554), delayed gastric emptying (p = 0.127), hemorrhage (p = 0.426), number of reoperations (p = 1.000) or readmissions (p = 1.000). The only significant difference was found in the hospital stay, where patients who underwent preoperative biliary drainage had a prolonged length of stay of more 3 days (15.52 vs. 11.31) (p < 0.001)., Conclusion: Preoperative biliary drainage in patients undergoing pancreatectomy does not increase the rates of postoperative morbidity or mortality, but has a negative effect on hospital stay.

Background/aims: Endoscopic mucosal resection (EMR) of large colorectal lesions is associated with increased procedural time. The objective of this study was to evaluate the effect of double-channel gastroscope (DCG) use on the procedural time of EMRs in the rectosigmoid area., Methods: All EMRs for sessile or flat rectosigmoid lesions ≥2 cm performed between July 2011 and September 2012 were retrospectively analyzed., Results: There were 55 lesions ≥2 cm in the rectosigmoid area in 55 patients, of which 26 were removed by EMR using a DCG (DC group) and 29 by using an ordinary colonoscope or gastroscope (OS group). The mean size of the removed polyps, morphology, adverse effects, and other parameters were similar between the two groups. The mean procedural time was significantly lower in the DC group than in the OS group (24.4±18.3 minutes vs. 36.3±24.4 minutes, p=0.015). Moreover, in a subgroup of patients with polyps >40 mm, the statistical difference in the mean procedural time between the DC and OS groups was even more pronounced (33±21 minutes vs. 58.7±20.6 minutes, p=0.004)., Conclusions: Our data suggest that the use of a DCG in the resection of large nonpedunculated rectosigmoid lesions significantly reduces the procedural time.

Background: Most colonoscopic complications are polypectomy-related and occur more frequently during the removal of numerous small polyps. Therefore, it is important to have the best polypectomy approach of small polyps. The aim of the present animal study was to investigate the effectiveness and safety of cold snare polypectomy (CSP) technique combined with light pull of the snare in order to peel the mucosal and upper submucosal layer, namely pull CSP (PCSP), for the removal of polyps sized up to 12 mm in porcine models., Methods: We performed a series of polypectomies in the pig colon with a double-channel experimental gastroscope using PCSP technique., Results: Thirty cases of "polyps" larger than 7 mm and up to 12 mm were treated using PCSP technique. No sign of perforation or bleeding was observed in all cases performed with PCSP., Conclusions: According to our preliminary results in this animal model, PCSP could be a safe and effective technique for flat colonic polyp removal up to 12 mm in size consistent with the basic polypectomy principles.

Background: Endoscopic biliary sphincterotomy followed by endoscopic papillary balloon dilation is a promising method for large stones. However, there are no data on the optimal duration of papillary balloon dilation after a biliary sphincterotomy., Aims: To compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60s versus 30s after endoscopic biliary sphincterotomy., Methods: A total of 124 patients with bile duct stones, submitted for endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation, were prospectively randomized to either the 60-s dilation group (G60, n = 60) or the 30-s dilation group (G30, n = 64)., Results: The complete removal of bile duct stones was similar: group G30, 55/64 (86%) versus group G60, 51/60 (85%); p = 0.9. The rates of post-endoscopic retrograde cholangio-pancreatography pancreatitis were also similar: 2 (3.1%) in group G30 versus 2 (3.3%) in group G60, p = 0.9. Post-procedural bleeding occurred in 2 cases (3.1%) in group G30 versus 4 (6.6%) in group G60, (p = 0.17). Two perforations of moderate severity were observed, one in each group., Conclusions: 30-s papillary balloon dilation, performed after endoscopic biliary sphincterotomy for the management of bile duct stones, was equally effective to the 60-s papillary balloon dilation., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The early indicator for the subject predisposed to gastric cancer is abnormal proliferation of gastric epithelial cells, such as atrophic gastritis (AG), intestinal metaplasia (IM), and dysplasia, which have been considered as precancerous lesions of gastric cancer. To determine whether p53 protein, cyclins D1, and D3, and p27(kip1) play a role in the carcinogenesis pathway of gastric cancer, we performed an immunohistochemical study of their expression in gastric precancerous lesions., Methods: A total of 1 45 endoscopic gastric biopsy specimens of AG, IM, and gastric dysplasia were studied. These molecular markers were localized by immunohistochemistry., Results: P53 was expressed in 15% of cases with gastric dysplasia and not in the pre-dysplastic stages of the gastric mucosa. All cases were concerning high-grade dysplasia. Cyclin D1 protein was almost undetectable in the precancerous lesions of gastric cancer. Cyclin D3 protein overexpression was seen in 10% of biopsies with IM, and 50% of biopsies with gastric dysplasia. High expression of p27(kip1) protein was demonstrated in all cases of chronic gastritis. As atrophy, IM, and dysplasia develop, expression of p27(kip1) protein is suppressed. In total, 15% of dysplastic cases showed no expression of p27(kip1) protein., Conclusions: (i) P53 mutation must be a late event during the development of gastric cancer. (ii) Cyclin D1 protein overexpression may not play a role in the progression from normal to neoplastic gastric mucosa, while overexpression of cyclin D3 is an earlier event during gastric carcinogenesis, and its role must be further evaluated. (iii) Reduced expression of p27(kip1) is a rather early event in gastric tumorigenesis, before dysplastic changes occur.

Background and Study Aims: Reduced Bax protein expression has been shown to be a negative prognostic factor in patients with breast, ovarian, colorectal, esophageal and pancreatic cancer. Our aim was to immunohistochemically study Bax protein expression in gastric carcinomas and correlate its expression with clinicopathological parameters and prognosis., Patients and Methods: Immunohistochemistry was performed, using a monoclonal antibody against bax, in paraffin-embedded tumor specimens from 47 cases of gastric cancer., Results: Positive staining for the Bax protein was found in 20/47 (42.4%) adenocarcinomas examined. Negative Bax protein expression in tumour cells was correlated with lymph node metastasis (P < 0.05), and degree of differentiation (p < 0.05). Univariate analysis showed that the variables with a significant negative impact on survival were: high TNM tumour stage, depth of penetration in the gastric wall, lymph node involvement, and Bax protein expression. Multivariate analysis showed that the only variable with an impact on survival was Bax protein expression (p < 0.05, Relative Risk: 3.34). Kaplan-Meier curves showed that the 5-year survival was 36.8% in cases with positive compared with 16% in cases with negative Bax protein expression (p = 0.0427)., Conclusion: Negative Bax expression in gastric cancer is associated with de-differentiation, lymph node metastases, and poor clinical prognosis. Bax protein expression might play an important role in the development and phenotypic differentiation of gastric carcinomas and tumor progression.

Objectives: Our study sought to compare the efficacy of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps., Methods: At the time of colonoscopy, patients with at least one colonic polyp > or =2 cm were randomized to receive treatment either by the injection of a 1:10.000 solution of adrenaline and the position of a detachable snare followed by a conventional snare polypectomy (group A) or injection of adrenaline followed by a conventional snare polypectomy (group B). A total of 159 consecutive patients were randomly assigned to one of the above groups. Out of them, 84 patients (47 men, 37 women, mean age 61 yr) were assigned to group A and 75 (37 men, 38 women, mean age 64 yr) to group B. Early (<24 h) and late (>24 h-30 days) bleeding complications were assessed., Results: Overall bleeding complications occurred in 10/159 (6.2%) of the patients. There were two cases of bleeding in group A (2.3%), and eight in group B (10.6%) (P= 0.04). The number of early bleeding episodes was significantly reduced in group A patients (1 case) compared to that of group B (7 cases) (P= 0.02). In contrast, there was no significant difference between group A and B as far as late bleeding is concerned., Conclusions: Our data suggest that the use of adrenaline injection in combination with detachable snare may significantly decrease the number of early postpolypectomy bleeding episodes in patients with large colonic polyps.

The purpose of this investigation was to measure the dose-area product (DAP) and the other relevant dosimetric quantities in diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Furthermore, the dependence of patient dose and image quality on the tube potential was investigated. A DAP meter was used for dose monitoring in seven diagnostic and 21 therapeutic ERCPs. For each ERCP the DAP meter readings, fluoroscopy time, number of radiographs and exposure data were recorded. From these data the fluoroscopy and radiography contributions to DAP, the entrance skin dose and the effective dose for each examination were estimated. For the investigation of the effect of tube potential on patient dose and image quality, a water phantom containing syringes filled with diluted contrast media was used. The average DAP was 13.7 Gy cm2 in diagnostic and 41.8 Gy cm2 in therapeutic ERCP whereas the average fluoroscopy times were 3.1 and 6.0 min respectively. DAP was strongly correlated to the fluoroscopy time. Measurements in the phantom showed that a good compromise between image quality and patient dose is obtained for tube potentials around 80 kV. Therapeutic ERCPs deliver on average higher doses to patients than diagnostic ERCPs. However, for a difficult diagnostic ERCP more patient exposure may be required than for a simple therapeutic ERCP.