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Background: Currently, there is no standardized protocol for bowel preparation before small bowel capsule endoscopy (SBCE). This study aimed to investigate the effect of simethicone combined with polyethylene glycol (PEG) on the visualization quality (VQ) of the SBCE in patients with or without known or suspected Crohn's disease (CD)., Methods: This observational, prospective, single-center study included consecutive patients undergoing a SBCE between 2007 and 2008. Patients received either a standard bowel cleansing preparation of 2 L PEG and 80 mg simethicone orally 12 and 1 h before SBCE respectively (Group A) or only PEG (Group B). VQ, based on scores for luminal bubbles in frames taken from the small intestine, examination completeness, SBCE diagnostic yield, gastric and small bowel transit times were recorded., Results: Of the 115 patients finally included (Group A, n=56 and Group B, n=59) the cecum was visualized in 103 (89.6%). Simethicone overall improved the VQ in the proximal [OR: 2.43 (95%CI: 1.08-5.45), P=0.032] but not in the distal bowel segment (P=0.064). Nevertheless, this effect was not observed in patients undergoing SBCE for either known or suspected CD., Conclusion: Simethicone as an adjunct to PEG for bowel preparation in patients undergoing SBCE significantly improved the VQ in non-CD patients.

Background and Aims: Prophylactic azathioprine (AZA) is efficacious in preventing postoperative Crohn's disease (CD) recurrence. However, it is unknown whether AZA should be started immediately after surgery. We compared the efficacy of systematic vs endoscopy-driven AZA in preventing CD recurrence at week 102., Methods: This prospective, multicentre trial included CD patients undergoing curative resection with ileocolonic anastomosis and at higher risk of recurrence. Patients were randomized to systematic AZA initiated ≤2 weeks from surgery, or endoscopy-driven AZA in which therapy was only initiated in case of endoscopic recurrence (Rutgeerts' score ≥i2) at weeks 26 or 52 following surgery. The primary endpoint was endoscopic remission (i0-i1) at week 102. Secondary endpoints included complete endoscopic remission (i0) and clinical remission., Results: The study was prematurely stopped due to slow recruitment. Between 2005 and 2011, 63 patients (28 male, median age 36 years) were randomized to systematic (n = 32) or endoscopy-driven AZA (n = 31). Twenty-one patients withdrew prematurely (8 clinical recurrence, 6 adverse reactions to AZA, 7 patient's preference). In the endoscopy-driven AZA group, 14 patients had to initiate AZA (11 at week 26, 3 at week 52). Endoscopic remission was achieved by 50% in the systematic and 42% in the endoscopy-driven AZA group (p = 0.521). No difference in secondary endpoints was found., Conclusions: Systematic AZA therapy in patients at higher risk of postoperative CD recurrence is not superior to endoscopy-driven treatment. Early postoperative endoscopic evaluation between weeks 26 and 52 seems most appropriate to guide further therapy, but larger studies are warranted. (ClinicalTrials.gov NCT02247258.)., (Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Primary intraosseous cavernous hemangiomas (PICH) of the skull represent an infrequent bone tumor. Although some rare cases of PICHs located in the skull base have been published, to our concern only three cases have been reported in the English literature of PICHs arising within the clivus., Case Description: We present the case of a patient presenting an isolated abducens paresis due to a rare PICH of the clivus showing also an unusual destruction of the inner table as well as infiltration of the dura mater. Due to this uncommon infiltrative pattern of an otherwise expected intraosseous tumor, a cerebrospinal fluid (CSF)-fistula occurred while performing a transnasal biopsy. The patient recovered successfully without need of lumbar drainage or re-surgery. Additionally, intratumoral decompression was sufficient to relief the abducens paresis., Conclusions: Our case provides new and meaningful information about clinical features as well as growth pattern of these rare clival tumors. We also discuss the importance of knowing these peculiarities before surgery in order to plan the optimal operative management as well as to avoid complications while approaching PICHs localized in such a delicate cranial region.

Study Design: Retrospective cohort study., Objective: To give some insight in balancing cost and effectiveness of 3 different techniques of corpectomy in destructive thoracolumbar spine disease., Summary of Background Data: Although there are several accepted methods of surgical treatment of single-level corpectomy in destructive metastatic thoracolumbar spine disease, the choice depends on the surgeon's preference. The techniques may vary in perioperative morbidity and short- and long-term outcome, but no study so far has analyzed their cost-effectiveness., Methods: Seventy-five consecutive patients, mean age of 57 years (range: 39-72 yr) with single-level destructive thoracolumbar lesion underwent surgical treatment with 3 different techniques in 2 centers from 2009 to 2013. The 3 groups were (1) mini open transpedicular corpectomy, (2) conventional open transpedicular corpectomy, and (3) the combined posterior-anterior approach. The data were collected prospectively according to our protocol and subsequently analyzed. The clinical outcome was assessed comparing visual analogue scale score of back pain and the short form 12 (SF-12) questionnaire both pre- and postoperatively. The cost analysis was done calculating the operative time, hospital stay, and the implant cost., Results: The mean follow-up period was 25 months (range: 24-30 mo). The clinical outcome in terms of visual analogue scale score of thoracolumbar pain and SF-12 physical and mental score improvement (P < 0.005) were comparable with all 3 techniques. The radiological outcome was comparable with current available data. As the intensive care unit stay (average: 7 d) and the hospital stay were longer (average: 15 d) with combined posterior-anterior approach, the total cost was maximum (average: €20,952) with this group., Conclusion: Using the posterior approach only was the most cost-effective technique, but the mini open was comparable with the conventional open transpedicular approach., Level of Evidence: 3.

Objectives: Several studies have revealed that different salvage treatments in glioblastoma multiforme patients presenting a recurrence have limited palliative treatment options. The aim of this study was to evaluate the utility and limitations of multimodal salvage treatments in recurrent glioblastoma multiforme patients combining 5-aminolevulinic acid (5-ALA) fluorescence-guided resurgery, interstitial irradiation, and dense dose temozolomide chemotherapy (ddTMZ)., Methods: Seventeen consecutive patients with recurrent globlastoma multiforme underwent a combined scheme of salvage treatments including fluorescence-guided reoperation, high dose rate (HDR) brachytherapy, and ddTMZ chemotherapy and were included in this prospective study. This multimodal treatment group was compared with a 1∶1 matched historical control group of 17 patients who have been treated with intensive temozolomide chemotherapy as the only treatment modality. All patients were previously treated with surgery of the primary pathology, concomitant, and adjuvant radiochemotherapy with temozolomide., Results: Median follow-up was 32 months (range: 28-36 months). Median survival was 9 months for the entire cohort after salvage treatment and can be translated into a 3-month improvement in survival compared to the control group of patients with glioblastoma recurrence treated with temozolomide alone (P  =  0·043). Complications rates of multimodal salvage treatment were comparable with the temozolomide control group., Discussion: Our experience suggests that a combined salvage treatment plan have the advantages of all three methods and, thus, provide additional survival benefit and can be considered in selected patients affected by recurrent high grade gliomas. Nonetheless, more cases and additional studies are necessary to further prove the advantages of this multimodal treatment.

Glioblastoma multiforme patients presenting with recurrence following multimodality therapy have limited palliative treatment options when the major modalities of therapy including surgery, radiochemotherapy and adjuvant chemotherapy have been exhausted. The authors introduce a clinical and radiological indication-solving algorithm and provide outcome rates of a glioblastoma recurrence cohort. Sixty six consecutive adult patients with recurrent glioblastoma who underwent a combined scheme of salvage treatments consisting of reoperation, high dose rate (HDR) brachytherapy and chemotherapy were included in this prospective study and were compared to a historical control group of 24 recurrent glioblastoma patients who have been treated with intensive temozolomide chemotherapy as the only treatment modality. Median follow-up was 32 months (range 28-36 months). Median survival was 9 months for the entire cohort after salvage treatment and can be translated into a 3-month improvement in survival compared to the control group of patients with glioblastoma recurrence treated with temozolomide alone (P = 0.043). Toxicity and adverse events of reoperation, HDR brachytherapy combined with chemotherapy were quite favourable compared to intensive temomozolomide chemotherapy as the only treatment. Our experience suggests that a combined salvage treatment plan appears to be both feasible and effective and can be considered in selected patients affected by recurrent high grade gliomas. The authors' clinical and radiological indication-solving algorithm may assist in providing the best possible salvage treatment for this difficult population.

Purpose: The object of this study was to compare minimally invasive surgery (MIS) with open surgery in a severely affected subgroup of degenerative spondylolisthetic patients with severe stenosis (SDS) and high-grade facet osteoarthritis (FJO)., Methods: From January 2009 to February 2010, 49 patients with severe SDS and high-grade FJO were treated using either MIS or open TLIF. Intraoperative and diagnostic data, including perioperative complications and length of hospital stay (LOS), were collected, using retrospective chart review. Surgical short- and long-term outcomes were assessed according to the Oswestry disability index (ODI) and visual analog scale (VAS) for back and leg pain., Results: Comparing MIS and open surgery, the MIS group had lesser blood loss, significantly lesser need for transfusion (p = 0.02), more rapid improvement of postoperative back pain in the first 6 weeks of follow-up and a shorter LOS. On the other hand, we experienced in the MIS group a longer operative time. The distribution on the postoperative ODI (p = 0.841), VAS leg (p = 0.943) and back pain (p = 0.735) scores after a mean follow-up of 2 years were similar. The overall proportion of complications showed no significant difference between the groups (29% in the MIS group vs. 28% in the open group, p = 0.999)., Conclusion: Minimally invasive surgery for severe SDS leads to adequate and safe decompression of lumbar stenosis and results in a faster recovery of symptoms and disability in the early postoperative period.

Objectives: Tumour recurrence of glioblastoma multiforme (GBM) after initial treatment with surgical resection, radiotherapy and chemotherapy is an inevitable phenomenon. This retrospective cohort study compared the efficacy of interstitial high dose rate brachytherapy (HDR-BRT), re-resection and sole dose dense temozolomide chemotherapy (ddTMZ) in the treatment of recurrent glioblastoma after initial surgery and radiochemotherapy., Design: Retropective cohort study., Setting: Primary level of care with two participating centres. The geographical location was central Germany., Participants: From January 2005 to December 2010, a total of 111 patients developed recurrent GBM after initial surgery and radiotherapy with concomitant temozolomide. The inclusion criteria were as follows: (1) histology-proven diagnosis of primary GBM (WHO grade 4), (2) primary treatment with resection and radiochemotherapy, and (3) tumour recurrence/progression., Interventions: This study compared retrospectively the efficacy of interstitial HDR-BRT, re-resection and ddTMZ alone in the treatment of recurrent glioblastoma., Primary and Secondary Outcome Measures: Median survival, progression free survival and complication rate., Results: Median survival after salvage therapy of the recurrence was 37, 30 and 26 weeks, respectively. The HDR-BRT group did significantly better than both the reoperation (p<0.05) and the ddTMZ groups (p<0.05). Moderate to severe complications in the HDR-BRT, reoperation and sole chemotherapy groups occurred in 5/50 (10%), 4/36 (11%) and 9/25 (36%) cases, respectively., Conclusions: CT-guided interstitial HDR-BRT attained higher survival benefits in the management of recurrent glioblastoma after initial surgery and radiotherapy with concurrent temozolomide in comparison with the other treatment modalities. The low risk of complications of the HDR-BRT and the fact that it can be delivered percutaneously in local anaesthesia render it a promissing treatment option for selected patients which should be further evaluated.

Background: Infliximab has shown efficacy at preventing post operative recurrence (POR) of Crohn's disease (CD). This study aimed at evaluating whether adalimumab can prevent and treat POR of CD., Methods: This prospective, single-center, open-label, two-year study included 23 patients who had undergone ileocecal resection for refractory or complicated CD and were at high-risk for POR. Patients received adalimumab from post operative day 14 (Group I, n=8) or at 6 months post operatively after confirmation of endoscopic recurrence (PO-ER) despite treatment with azathioprine, infliximab, or 5-ASA (patients intolerant to infliximab and azathioprine, Group II, n=15). Symptom assessment and laboratory tests were performed at monthly visits. Endoscopic findings were graded using the Rutgeerts score (RS) at 6 and 24 months after initiation of adalimumab. Primary end-points were maintenance (group I) or achievement of mucosal healing (Group II). Secondary end-points were prevention of post operative clinical recurrence (PO-CR) (Group I) and endoscopic and clinical improvement (group II)., Results: In Group I, PO-ER (RS≥i2) was seen in one patient at 6 months PO, whereas a second patient developed PO-ER and PO-CR after 24 months of treatment. In Group II, all patients had PO-ER whereas 9 (60%) patients had PO-CR at study enrolment; after 24 months of treatment 9/15 (60%) patients achieved complete (RS-i0, n=3) or near complete (RS-i1, n=6) mucosal healing and 5/9 (56%) clinical remission. No serious adverse events were reported., Conclusions: This pilot study suggests that adalimumab may prevent PO-ER and treat PO-ER/CR in high risk patients for POR of CD., (Copyright © 2012 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.)

Granular cell tumour (or Abrikossoff's tumour) was first described by Abrikossoff in 1926. This is a rare benign neoplasm of unclear histogenesis that is generally believed to be of nerve sheath origin. Usually, it presents as a solitary lesion, located mainly in the subcutaneous tissue of the head, or the neck, or in the oral cavity, such as a tongue lesion, although it may develop anywhere in the body. Approximately 1-2% of granular cell tumours are malignant. Granular cell tumours are extremely rare in patients with inflammatory bowel disease. To the best of our knowledge, granular cell tumours have never been reported in association either with Crohn's disease or scheduled infliximab treatment. Herein, we report a case of a granular cell tumour that presented as a subcutaneous skin nodule of the right lumbar area without any associated local or systemic symptoms in a 41-year-old woman with Crohn's disease who was receiving scheduled treatment with infliximab (5 mg/kg every 8 weeks) for 7 years.

Background: The purpose of this work was to analyse the surgical procedure used and the outcome from patients with solitary nerve associated benign tumors of the extremities (SNABTE) >5 cm., Methods: A 15 year review was performed for all patients with SNABTE treated in our department. The surgical procedures used (complete or incomplete tumor removal, with or without nerve preservation), the needs for grafting techniques as well as the outcome were analysed., Results: Nine (9.5%) of 94 patients with SNABTE met the study requirements. The histological diagnosis revealed a schwannoma in four cases, a neurofibroma in three cases, one lipoma and one lipofibroma. Seven lesions could be completely excised. Preservation of the nerve bundles with complete neurological recovery was possible in five cases. The resection of a 22 cm neurofibroma without preservation of the nerve did not add measurable residual neurological deficits. One patient with a peroneal neurofibroma required a grafting procedure. Intentional incomplete tumor excisions were performed in two patients with well preserved nerve functions where a median nerve lipofibroma and a radial nerve neurofibroma were diagnosed. All patients showed different degrees of improved outcome., Conclusions: We conclude that the complete resection of large SNABTE, excepting lipofibromas and some neurofibromas, is always possible and associated with an improved outcome. The nerve preservation should be attempted in all cases, particularly in those with conserved functionality of a major nerve trunk.

Background: To analyze the management and outcome of patients presenting with atypical causes of intracranial subarachnoid hemorrhage (SAH)., Methods: We performed a review of our last 820 nontraumatic-SAH patients and analyzed the management and outcome of patients where the SAH origin was not a ruptured aneurysm. The Glasgow Outcome Scale (GOS) was used to assess outcome 3 months after event., Results: Thirty-two patients had atypical causes of SAH. In 15 patients with Hunt and Hess (H&H) scores from 1 to 3 without focal neurological deficit (FND), 8 perimesencephalic non-aneurysmal SAH, 4 blood coagulation disorders, 1 sinus thrombosis, 1 vasculitis, and 1 unknown-origin-SAH (UOS) were diagnosed. Fourteen (93%) of these 15 patients were conservatively treated. In 17 patients with H&H scores from 3 to 5 and FND, 8 tumors, 1 cavernoma, 1 sinus thrombosis, 1 arteriovenous malformation, 1 blood coagulation disorders, 2 UOS, and 3 dural fistulas were diagnosed. Fifteen (88%) of these 17 patients were interventionally treated. The neurological condition 3 months later was good (GOS 4 and 5) in 12 of the 15 cases (80%) admitted with low-H&H scores, as well as in 13 of the 17 cases (76%) admitted with high-H&H scores. Three patients died and four developed a severe disability., Conclusions: Patients presenting with atypical causes of SAH and high-H&H scores at admission are likely to harbor an intracranial organic process producing the bleeding. Despite this poor initial condition, their 3-month outcome can be similar to those of patients with low-H&H scores if the origin of the bleeding is properly treated.

Introduction: In the era of the new millennium, a lot of preclinical and clinical research is published. However, ethico-legal, cost-effectiveness and patient care issues are not addressed equally., Aim: To investigate whether abstracts presented at major international gastroenterology congresses refer to issues relevant to doctor-patient relationship, cost-effectiveness and care., Methods: We reviewed the abstracts on disk CD-ROMs of the United European Gastroenterology Week (UEGW) and the Digestive Disease Week (DDW), for the years 1998-2006. We used the following keywords: ethical/ethically, legal, consent, cost-effective/effectiveness, care, quality and tolerable/tolerability., Results: Over the study period, 1,612/20,018 (8.05%) and 764/45,628 (1.67%) abstracts including the above keywords were presented at UEGW and DDW congresses (p = 0.013), respectively. Statistically significant more abstracts containing separately any of the key words (apart from 'legal') were presented at the UEGW than at the DDW congress. There was a significant trend of increased referring to these key words over the study period for UEGW (p < 0.041) but not for DDW congresses (p = 0.70)., Conclusion: The abstracts presented at the UEGW refer to ethico-legal, cost-effectiveness and patient care issues more frequently than those presented at the DDW. There is a trend of increased referring to these subjects at the UEGW but not at the DDW., ((c) 2008 S. Karger AG, Basel)

We describe a case of a long-standing, untreated achalasia with a huge sigmoid esophagus in a 58-year-old Caucasian man who declined surgery. All means of classical endoscopic approach for pneumatic dilation, including the use of an overtube, were impossible because any attempt to propel the balloon dilator made the guide wire pull back out of the stomach because of the large loops and the tortuosity of the esophagus. For this reason, we used, for the first time, a combined approach of percutaneous gastrostomy and endoscopy in order to fix the guide wire at two points, achieving a pneumatic dilation in this way. A few months later, a significant improvement in the symptoms and nutritional status of the patient were observed.

Minimal invasive techniques (MIT) like microscopy, stereotaxy, endoscopy and neuronavigation facilitate and improve neurosurgical results and reduce the operative trauma. We report the combined employment of these techniques and the results obtained in our department during the last 7 years in 95 consecutive patients with supratentorial deep located intracerebral haematomas (ICHs). Thirty-six deteriorating patients with deep ICHs under 30 cm (3) volume associated to intraventricular bleeding, were treated early (first 24 hours after bleeding) with neuronavigation guided stereotactic lysis, using multiplanar targets (1 to 3). Microsurgical clot aspiration through an enlarged burr-hole was frequently combined with endoscope- or neuronavigation-assisted evacuation within the first 6 hours after bleeding for the rest of the deteriorating patients with ICHs larger than 30 cm (3). A 1.2 cm narrow surgical corridor assured the least injury to vital cortical areas, tracts and blood vessels. In 86 cases the clots were adequately removed (non-measurable rest) with a reduced morbid mortality (13.8 and 8.6 as well as 23.3 and 16.9 for stereotactic and microscopic MIT, respectively). In our experience, the use of combined MIT adapted to the surgical urgency of the individual patient reduces the operative trauma and improves the accuracy for the access to the clot allowing an adequate haematoma evacuation and a satisfactory outcome in most of the cases.

Objective: The aim of this prospective study was to assess whether the coadministration of azathioprine (AZA) and olsalazine is superior to AZA monotherapy in maintaining remission of steroid-dependent ulcerative colitis (UC)., Methods: Patients with steroid-dependent UC in remission were randomized to receive AZA alone (2.2 mg/kg) or in combination with olsalazine (0.5 g tid). Remission was defined as steroid withdrawal, an Ulcerative Colitis Clinical Activity Index (UCCAI) score of <2, an Ulcerative Colitis Disease Activity Index (UCDAI) score of 0, and a negative colonoscopy and histology. Patients were followed in the outpatient clinic every month for 2 yr. The study protocol included 1) monthly clinical examination, assessment of UCCAI, hematological and biochemical tests, and compliance with treatment; 2) a sigmoidoscopy and completion of inflammatory bowel disease quality-of-life questionnaire (IBD-Q) and UCDAI every 3 months; and 3) total colonoscopy with biopsies at the end of the first and second year of the trial., Results: Seventy patients were randomized to receive AZA alone (n = 34) or with olsalazine (n = 36). Three patients in each group developed side effects or could not comply with treatment and were withdrawn from the study. Three patients receiving AZA relapsed after the first year of the study and three after the second year of the study (19%). In the combination therapy group four patients relapsed after the first year of study and two after the second year of the study (18%). Relapse rates were not significant whether analyzed by intention-to-treat or per protocol. There were no significant differences between groups in time to relapse or discontinuation of treatment, UCCAI, UCDAI, or IBD-Q scores. However, the number of adverse events and the cost of treatment were significantly higher, whereas compliance with treatment was poorer in the combination therapy., Conclusion: Patients with steroid-dependent UC successfully maintained in remission on AZA are not in need of 5-aminosalicylic acid compounds.

Primary melanoma is a rare neoplasm of the oesophagus, with dismal outcome in most cases. We report a case of primary melanoma of the oesophagus treated endoscopically, as coexisting illness prohibited surgical resection of the tumour. A review of the literature is made.