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Transanal endoscopic microsurgery (TEM) is a type of natural orifice transluminal endoscopic surgery, developed for rectal tumors and used also to treat other rectal diseases. Anastomotic complications after colorectal surgery, including stenosis, represent a challenging problem. We present the case of a 36-year-old woman with a diagnosis of Hirschsprung disease that was submitted to a modified Duhamel operation. A postoperative barium enema showed a complete stricture of the anastomosis that was impossible to resolve by flexible endoscopic approach. Then an intraoperative endoscopic approach to facilitate the localization of preanastomotic colon (proximal colon from the anastomosis) was performed by a small colotomy and the colonic recanalization was obtained by the creation of a neo-anastomosis by TEM, under fluoroscopic-endoscopic control. The patient underwent a control barium enema showing regular retrograde transit of contrast medium without evidence of stenosis. In our experience, transanal approach by TEM-colonoscopy assisted is safe and feasible and represents a model of combined minimally invasive technique.

Gastric cancer ranks sixth among the most frequently diagnosed cancers worldwide with a higher incidence in Asian countries. Endoscopic skill in the diagnosis of early-stage disease has prompted Japanese endoscopists to propose endoscopic resections as the treatment of choice for superficial neoplastic lesions in Eastern countries. Data from the National Cancer Center Hospital, Tokyo, show how complete resection of gastric cancer is around 90% only after endoscopic submucosal dissection (ESD), and for this reason endoscopic mucosal resection has no longer been used by Japanese endoscopists since 2000. The Eastern approach includes ESD even in cases of small lesions (

The correct technique for accurate upper gastrointestinal endoscopy has some key points: preparation of the patient, use of anti-peristaltic agents and mapping of the entire stomach. Systematic protocols to explore the entire gastric mucosa have been proposed to reduce the risk of missing lesions, but a worldwide standardized protocol is still lacking. For a correct diagnosis of superficial neoplastic lesions, white light imaging (WLI) together with chromoendoscopy showed a higher accuracy compared to WLI alone. High-definition endoscopy with the combination of narrow band imaging has been used to better characterize early lesions. However, biopsy specimens and histological examination remain essential for assessing the presence of pre-neoplastic lesions or early gastric adenocarcinoma and guaranteeing the correct therapeutic pathway. Moreover, due intra-tumor heterogeneity also in the case of advanced gastric cancer a biopsy protocol should be conceptualized in order to obtain the most accurate tumor representation, crucial in an era of target therapy. A well-performed endoscopy is instrumental for both an accurate diagnosis and appropriate treatment.

BACKGROUND Different surgical techniques have been proposed for rectocele repair. However, controversial aspects exist on the best approach to use. The study aims to report the early and late outcomes of the sequential transfixed stich technique (STST) for the treatment of rectocele in the absence of mucosal prolapse. METHODS One hundred patients presenting a symptomatic rectocele were treated with STST from January 2010 through August 2015. Patients with mucosal prolapse were not considered eligible for STST. After a period of 24 months from surgery, all the patients were clinically evaluated with the intent to investigate the risk of recurrence of the preoperative symptoms. RESULTS All the patients were women (median age=54.7 years; ranges=37-75). Median discharge time was 1.5 days. One-month severe complications were: hemorrhoid thrombosis (6.0%), self-solved bleeding (6.0%), urinary retention (4.0%), anal secretion (4.0%) and urinary incontinence (1.0%). No post-operative cases of fecal incontinence were observed. Two years after surgery, 76.0% of patients reported a global improvement of the preoperative symptoms, with 73 and 35% of cases showing a reduced difficulty in the evacuation and need for digitation. Only 8.0% of patients showed a recurrence of the initial symptoms. CONCLUSIONS The STST is a feasible, safe, and cost-effective technique for the treatment of the rectocele without rectal mucosal prolapse. The method does not increase the risk of postoperative anal incontinence and presents a short hospital stay. STST presents long-term results in line with other transvaginal and transanal approaches.

Robotic colonoscopy (RC) is a pneumatically-driven self-propelling platform (Endotics System®) able to investigate the colon, in order to reduce pain and discomfort. Aims: (1) to describe the progress in gaining experience and skills of a trainee in RC; (2) to show the clinical outcomes of RC. Pilot study. An experienced endoscopist started a training on RC whose progress was assessed comparing the results of 2 consecutive blocks of 27 (Group A) and 28 (Group B) procedures. CIR (Cecal Intubation Rate), CIT (Cecal Intubation Time) and Withdrawal Time (WT) were measured. Polyp Detection Rate (PDR), Adenoma Detection Rate (ADR) and Advanced Neoplasia Detection Rate (ANDR) were calculated. Possible adverse events were recorded. At the end of the procedure all patients completed a visual analog scale (VAS) to measure their perceived pain during RC and reported their willingness to repeat RC. General CIR was 92.7%, reaching 100% in Group B. Comparing the two groups, CIT significantly decreased from 55 to 22 min (p value 0.0007), whereas procedures with CIT ≤ 20 min increased (p value 0.037). WT significatively reduced from 21 to 16 min (p value 0.0186). PDR was 40% (males 62.5%, females 14.3%). ADR was 26.7% (males 27.5%, females 14.3%). Most of patients judged the procedure as mild or no distress, with high willingness-to-repeat the RC (92.7%). Our results about RC are encouraging as preliminary experience, with clear individual learning progress, accurate diagnosis in a painless or comfortable procedure and with possibility to remove polypoid lesions. Studies with larger populations are needed to confirm obtained results.

Endoscopic submucosal dissection (ESD) represents the standard of care for early gastric cancer in Eastern countries. Nevertheless, in the West, this procedure is not widespread. Aim of the study was to confirm the feasibility and the efficacy of ESD in the West. A total of 60 ESD were performed between January 2005 and December 2014 by two expert endoscopists. The analysis, based on a retrospective collected database, was conducted by dividing the study period in three subgroups. Clinical and technical outcomes have been compared. Rates of complete, curative and en bloc resection did not significantly change among the study periods. Three cases of perforation occurred (5%), one in each period. The operation time significantly decreased from the second to the third period (p

The authors discuss in this chapter the role of endoscopy in the diagnosis and treatment of esophagogastric junction tumors. Different trends concerning incidence and pathophysiology in the East and in the West are considered together with the current classification of the disease. Modern concepts and societies guidelines for the treatment of these tumors are discussed and compared between eastern and western approach. International collaborative studies would be helpful to improve the detection rate and the clinical outcomes in EGJ tumors.

Endoscopic submucosal dissection (ESD) is gaining popularity worldwide in the treatment of neoplastic lesions of the gastrointestinal tract. However, the experience in Western countries is quite limited and restricted to large or academic centers. Besides, this approach requires an optimal pathological assessment. The aim of this study was to report our experience with colonic ESD using a new device that allows complete handling of the resected specimens and especially of lateral margins, for pathological analysis. In a 1-year period, 14 patients (6 men, 8 women, age range 50-82 years) underwent colonic ESD in a non-academic hospital. The endoscopic procedure was carried out successfully en bloc in more than 90 % of cases. Perforation requiring surgery occurred in one patient (7 %). Pathological assessment with the new device allowed entire and complete examination of both the deep and lateral margins of the excised specimens. Colonic ESD is a viable option for non-surgical treatment of large bowel lesions even in relatively small centers and in non-academic settings. The new device allows good handling of the specimens, and it seems to be useful for the entire examination of the resection margins.

Flexible endoscopy plays a fundamental role in the clinical monitoring of surgical digestive anastomosis. Endoscopic examination is essential for the recognition and for the description of the type of anastomosis (end to end, end to side, side to side), providing both an accurate evaluation of the new digestive anatomy and the early detection of any postsurgical complications or recurrence. Close monitoring of the surgically treated disease, both neoplastic and nonneoplastic, can be realized by an accurate and scheduled follow-up which should consider all the imaging modalities nowadays available in the clinical practice, such as radiology and endoscopic ultrasonography. On the other hand, prompt detection of any pathologic pattern of the anastomosis (stenosis, dehiscence, fistula, recurrence) is the key factor for the choice of any further and appropriate treatment. Our chapter is aimed at defining the key factors of an accurate endoscopic evaluation of surgical anastomosis and at discussing the clinical criteria for an accurate follow-up.

Endoscopic submucosal dissection (ESD) has been developed as treatment for early gastric cancer (EGC) by Japanese authors. However, there are no reports about its possible implementation in the Western setting. The aim of the present work is to determine the safety and efficacy of the endoscopic treatments for EGC in an Italian cohort. Forty-five patients for a total of 48 gastric lesions were enrolled in the study. Thirty-six EMR procedures were performed with the strip biopsy technique using a double-channel endoscope. En bloc resection refers to resection in one piece, while piecemeal refers to resections in which the lesion was removed in multiple fragments. A total of 12 ESD were performed and completed with IT knife. We define as curative treatment lateral and vertical margins of the resected specimens free of cancer and repeat endoscopic finding of no recurrent disease. Out of 36 EMR procedures, 10 were piecemeal resections (28%), while 26 were en bloc (72%). ESD led to en bloc resection in 11/12 cases (92%). Histological assessment of curability in the EMR group was achieved in 56% of the cases, and in 92% of the ESD group. Mean follow-up period was 31 months (range: 12–71 months). There was no local recurrence or distant metastasis in the curative group patients. These results seem to confirm the safety and the clinical efficacy of the ESD procedure in the Western world too.

Identifying antagonist peptides able to inhibit the abnormal immune response triggered by gliadin peptides in celiac disease (CD) is an alternative therapeutic strategy for CD. The aim of this study was to evaluate the antagonist effect of 10mer, a decapeptide (sequence QQPQDAVQPF) from alcohol-soluble protein fraction of durum wheat, assessing its ability to prevent celiac peripheral blood lymphocytes from activation by gliadin peptides. Peripheral blood mononuclear cells (PBMC) were obtained from DQ2-positive untreated coeliac children and from healthy controls and incubated with the peptic-tryptic digest of bread wheat gliadin (GLP) and peptide 62-75 from alpha-gliadin both alone and with 10mer simultaneously. PBMC proliferation, release of pro-inflammatory Th1 cytokines interferon-gamma and tumor necrosis factor-alpha, release of immunoregulatory cytokine IL-10, and analysis of CD25 expression as indexes of lymphocytes activation were carried out. Enhanced lymphocytes activation was seen after exposure to GLP and p62-75, whereas the simultaneous incubation with 10mer inhibits the lymphocytes response. These data indicate that a peptide naturally occurring in durum wheat exerts in vitro an antagonist effect against gliadin toxicity and could have a protective effect in CD disease.

Colorectal cancer mortality is decreased by endoscopic polypectomy, but conventional colonoscopy may be inadequate for detecting subtle colonic lesions.We selectively performed chromoendoscopy in all patients undergoing colonoscopy between January 1999 and December 2005 at the International Health Union of Rome. Patients with a history of colorectal polyps, inflammatory bowel disease, colorectal surgery or coagulopathy and those with poor bowel preparation were excluded from this analysis. Whenever colonoscopy revealed suspicious mucosal areas, dye-spraying with 0.2% indigo carmine solution was also performed. Findings from conventional and dyespraying views were classified morphologically, and specimens were analyzed histologically. Non-adenomatous lesions were classified as negative findings.A total of 2005 patients underwent conventional colonoscopy and in 305 cases (15%) chromoendoscopy was also performed. Conventional colonoscopy identified 508 neoplasms in 381 patients (19%). Selective chromoendoscopy found an additional 244 neoplasms in 212 patients (11%). Thus, chromoendoscopy was positive in 212 (70%) of 305 patients in whom the examination was performed. Overall, 56 large, ulcerated, advanced cancers and 696 non-advanced neoplasms were found. Of the 696 nonadvanced neoplasms, 448 (65%) were polypoid and 248 (35%) were non-polypoid. All but 4 non-polypoid lesions were only detected with chromoendoscopy. Of the 248 non-polypoid lesions, 12 (5%) were depressed and 236 (95%) were flat. Advanced histology was present in 39 non-polypoid lesions (15%) and was more common in depressed lesions than in flat ones (58% vs. 13%; p0.001).Our study confirms the existence of flat and depressed neoplasms in an Italian population. The vast majority of non-polypoid lesions were only detected by chromoendoscopy, and many lesions with advanced histology were missed by conventional colonoscopy. We therefore recommend selectively performing chromoendoscopy when conventional colonoscopy provides clues for non-polypoid lesions. Therefore, endoscopists should be trained in the detection of these subtle mucosal clues, as well as in the use of chromoendoscopy to enhance their detection.

Endoscopic follow-up (FU) after colorectal surgery is indicated mainly for patients operated on for cancer who are at risk for metachronous adenomas and/or recurrent cancer. Despite published guidelines, there is both overuse and underuse of endoscopic surveillance, and many institutions continue to have their own follow-up regimens. Therefore, endoscopic FU of colorectal cancer (CRC) survivors remains controversial, and there are several open issues regarding its appropriateness, timing, duration, and cost-effectiveness. Endoscopic FU should allow diagnosis of early anastomotic recurrences and metachronous adenomas and/or cancer in CRC patients after curative surgery. While endoscopic surveillance of the colonic anastomosis does not have any proven benefit, patients with prior rectal cancer should undergo flexible sigmoidoscopy ± endoscopic ultrasound at 3–6-month intervals for the first 3 years after resection, if not treated with neoadjuvant chemoradiation and mesorectal excision. All CRC survivors should undergo lifelong endoscopic FU to prevent metachronous CRCs, with surveillance colonoscopies at 1, 3, and 5 years after surgery and then every 5 years until the benefit is outweighed by comorbidity. Recently, it has been proposed that endoscopic FU should be tailored according to the personal risk of the individual CRC survivor, based on the presence or absence of synchronous adenomas at perioperative colonoscopy, the diagnosis of metachronous lesions during surveillance, and the features of both synchronous and metachronous adenomas. This strategy has been shown to be cost-effective, with a clear survival benefit for CRC survivors.

Anastomotic dehiscence is a major complication of surgery of the digestive tract with high morbidity and mortality rate. Its management differs, depending mainly on clinical presentation. Technological improvement allowed development of endoscopic devices that can be adopted as an alternative to surgical management in selected cases of anastomotic leakage.

The endoscopic detection of Crohn’s disease (CD) is generally difficult and confined to the late stage of the disease [1]. The importance of inspecting the terminal ileum during lower endoscopy is gaining increasing acceptance in the international literature based on its ability to provide an earlier diagnosis of this inflammatory bowel disease (IBD), especially in asymptomatic patients [2]. Over the last few decades, new endoscopic imaging modalities that offer enhanced early detection of neoplastic disease have been introduced into clinical practice, although their impact on the diagnosis of IBD is still under evaluation [3]. In the following, we present an unusual case of a patient with CD that was detected by terminal ileoscopy.

The diagnosis of small bowel disease is still a mattern of concern among experts. Each imaging technique has its advantages but also its limits. This is particularly true when dealing with the management of patients with obscure gastrointestinal bleeding. In this group, the positive detection rates are in the range of 43–60% with double-balloon enteroscopy (DBE) [1, 2], 42–77% with capsule endoscopy (CE) [3], 21–24% with computed tomography (CT), and 5–25% with small bowel series [4], with the highest accuracies thus obtained with DBE and CE. Here we present a difficult case of gastrointestinal bleeding.

In the field of modern gastroenterology, ileoscopy has opened up new frontiers in the diagnosis of intestinal diseases [1]. Exploration of the terminal ileum during total colonoscopy has gained much greater acceptance among endoscopists, based on its diagnostic accuracy in patients with intestinal diseases, including neoplasms [2]. Whether a routine terminal ileoscopy should be mandatory when performing a screening colonoscopy remains to be assessed. However, many authors seem to agree that, at the very least, an ileoscopy should always be attempted, because it allows an accurate diagnosis even in asymptomatic patients [3]. Here we present a clinical case in which ileoscopy enabled the definitive treatment of a rare tumor located in the terminal ileum.

A submucosal tumor (SMT) of the stomach, which is an occasional finding during routine upper gastrointestinal endoscopy, may pose diagnostic and therapeutic challenges.To assess whether endoscopic submucosal dissection (ESD) is a feasible approach to definitively cure SMTs, the authors performed a retrospective cohort study with two endoscopic italian centers.The study consisted of 20 patients with SMTs who underwent ESD. The patients underwent ESD and were followed up by endoscopy. We analyzed complete resection rate, frequency of complications, and survival. The overall rate of R0 resection was 90 % (18/20), with two endoscopic failures, one for a submucosal tumor and one for a neoplasm deeply infiltrating the proper muscle layer. The median procedure time was 119.1 min (range 40-240 min). The median size of the resected specimens was 29 mm (range 15-60 mm). Perforation occurred in 3 patients; all were treated conservatively. There were no cases of severe bleeding. Based on histopathological findings, 6 cases of ectopic pancreas, 1 of ectopic spleen, 3 of leiomyoma, and 10 of gastrointestinal stromal tumor (GIST) were diagnosed. Complete resection was obtained in all GIST cases. Among the 10 GIST cases treated by ESD, no death occurred: the 5-year disease-specific survival rate was 100 %.The high success rate of 90 % and the low incidence of complications should indicate ESD is the correct diagnostic and definitive treatment in selected patients.

Rectocele is defined as the herniation of rectal wall due to a rectovaginal septum defect in direction of the vagina. In most of cases it is a result of vaginal delivery or repeated increases of intra-abdominal pressure due to chronic constipation. Some patients can develop rectocele as a consequence of congenital or inherited weakness of the pelvic support system. The rectopexy procedure by a single mechanical stapler allows to ablate the exceeding tissue. This surgery is performed through transanal access without laparotomy, by means of a circular stapler which simultaneously resects portion of the rectal wall and re-anastomizes it. Also the technique of sequential transfixed stitches (TSTS) represents a minimally invasive procedure for the rectocele treatment, allowing the performance of a complete plasty of rectal wall through transanal access. Hence, starting from a more effective stadiation of rectocele, the authors of this study will show the advantages of an endorectal approach for the treatment of the above-mentioned disease using both methods. A total of 25 female patients attending our colonproctology outpatient department, with an age ranging between 38 and 63 years, have been selected for our study; following a careful assessment of stadiation, they have undergone rectopexy with circular stapler first, thereafter fulfilling the surgery with TSTS. the mean duration of hospital stay was 2.5 days (range 2–3). Twelve patients out of 25 have shown early complications, and 11 patients late ones. Among the early complications, 3 patients reported pain (12 %), 3 patients urinary retention (12 %), and 2 patients bleeding (8 %). Among late complications, 5 cases of urgency defecation disorders (>4 months) (20 %), 1 intestinal flatus incontinence (4 %), 1 stenosis (4 %), 2 prolonged pain and 2 cases of persistent obstructive defecation syndrome were reported. No cases of life-threatening local or pelvic sepsis as well as of rectovaginal fistulae were reported. At the 6 months post-surgery evaluation, neither rectocele recurrence nor prolapse was observed. The association of circular stapler and TSTS in the rectopexy treatment of rectocele showed its short-term efficacy, producing an improvement of patient’s clinical conditions, without inducing further alterations of pelvic statics, of the sphincteric tone as well as of rectum emptiness deficit.

Celiac disease is a permanent autoimmune enteropathy that is triggered, in genetically determined individuals, by the ingestion of gluten, an alcohol-soluble protein storage compound present in wheat. The mucosal lesions characteristic of celiac disease can be detected by upper gastrointestinal endoscopy, which also enables biopsy sampling. Definitive diagnosis is based on the findings of villous atrophy, hyperplasia of the crypts, and T-cell infiltration of the lamina propria, along with an increase of intraepithelial lymphocytes. Imaging of celiac disease is nowadays carried out by capsule endoscopy, a non-invasive procedure that enables the study of the entire surface of the gut. In celiac disease, capsule endoscopy demonstrates the extent of the affected bowel segments. New endoscopic modalities that include enhancement of the intestinal mucosa can help the endoscopist to better define the appearance of celiac disease in a particular patient and to appropriately target biopsy sampling. This chapter discusses the use of the main imaging modalities in the diagnosis of celiac disease.

The visualization and exploration of the terminal ileum was first described by Nagasako in 1972. Terminal ileoscopy (TI) is currently the only in best evidence of a well-performed total colonoscopy and the ability to perform the procedure is an essential step in becoming a proficient colonoscopist. TI also allows the diagnosis of many diseases of the gut. The published success rate of TI during colonoscopy is 74–100% in different series. The question whether it should be performed routinely or only in case of certain clinical conditions is still a matter of debate. The contribution of TI in diagnosing a wide spectrum of inflammatory bowel and infectious diseases is particularly important, such as in clinical conditions manifesting as diarrhea, right lower abdominal quadrant pain, anemia, suspicious imaging findings, or a family history of inflammatory bowel disease. In addition, TI plays an important role in the decision whether to perform other imaging procedures, such as capsule endoscopy or enteroscopy, for a definitive diagnosis when there is evidence of bowel disease. While the results obtained with emerging technologies have been promising, they remain to be validated in clinical practice. A well-performed ileoscopy represents the best method to correctly select those patients who would most benefit from further investigation, and it offers a fast-track approach to diseases of the gut.

Rectocele and haemorrhoidal prolapse are two pathologies that in all cases entail partial excision of anorectal tissue possibly with less invasive surgical procedures. For these pathologies, the authors have recently improved their treatment procedures, introducing the sequential transfixed stitch technique (STST) for rectocele and the transfixed stitch technique (TST) for haemorrhoidal prolapse, and thereby obtaining a significant technical and clinical improvement in terms of both outcomes (complete correction of rectal prolapse and haemorrhoidal prolapse) and discomfort and quality of life in the postoperative period. Moreover, in the present study the authors propose a subsequent innovation of the technique developed recently for the treatment of rectocele and haemorrhoidal disease using a new curved siliconate needle, thinner than the traditional lanceolate needles, with a longer, more rigid needle-thread junction in order to achieve less invasiveness and mucosal trauma, enabling the surgeon to perform sutures in a simple, easy manner. Ten consecutive patients with a clinical and instrumental diagnosis of rectocele--6 type II and 4 type III--were treated with TSTS and 20 patients with third (12 patients) and fourth degree (8 patients) haemorrhoidal disease were treated with TST. The surgical procedures were the same for all patients, although patients were divided into two groups. To the first group (A) were allocated patients treated with traditional stitches with a cylindrical, half circle needle, (Hr 25.9 mm). To the second group (B) were allocated, for the same objective, patients treated with the new siliconate needle, with an ultrafine tip, manufactured by Assut Europe S.p.A. The mean duration of the TST surgical procedures was 16 minutes using the new siliconate needle, whereas the mean duration using the traditional lanceolate needle was 17 minutes (p = ns). The surgical team judged the TST performed with the siliconate needle to be easier in 90% of cases in comparison to 70% of cases treated with the traditional lanceolate needle (p0,05). In patients treated with TSTS using the traditional lanceolate needle the mean duration of the surgical procedures was 20 minutes as against 18 minutes in the cases treated with the siliconate needle (p = ns). The surgical team judged the TSTS performed with the siliconate needle to be easier in all cases, while in two cases treated with the traditional lanceolate needle there were technical difficulties related to the use of the needle. The use of the ultrafine siliconate siliconate needle is more effective for the treatment of rectocele with TSTS and for haemorrhoidectomy with TST, particularly with a view to improving the surgical procedures and limiting the extent of mucosal damage related to suture oedema.

Rectal mucosal prolapse is characterised by protrusion of the rectal mucosa alone in the anal lumen. To correctly establish the intraoperative stage of rectal mucosal prolapse the authors performed a test based on the intrarectal introduction of a large-sized hydrophilic plug, to be extracted later from the anal canal. A total of 40 patients with proctological symptoms and with a diagnosis of rectal mucosal prolapse were submitted, in the outpatient setting, to a minimally invasive test with a small plug and later, in the preoperative stage, in patients under anaesthesia, using a plug entirely inserted into the rectal lumen and extracted via the anus. The same procedure was performed after surgery to verify the results of the excision. In all cases the plug test used in the preoperative stage permitted the perfect surgical evaluation of the extent of the prolapse. The plug test revealed a mucosal prolapse occupying 25% of the anal circumference in 10 patients, up to 50% in 20 patients and more than 50% in 10 patients. The first 30 patients were treated with the transfixed stitch technique, while for the others the Longo surgical technique was preferred. The plug test for the preoperative and postoperative evaluation of rectal mucosal prolapse is an effective tool for obtaining a more precise indication as to the optimal surgical intervention and for verifying the radicality of the surgical excision. The plug test, moreover, proved to be a minimally invasive and easily performed test for evaluating rectal mucosal prolapse.

Rectal mucosal prolapse is characterised by the protrusion of the mucosa alone in the rectal lumen. The authors, after an experience conducted in ambulatory patients, have produced a score to classify the extent of rectal mucosal prolapse based on evaluation of qualitative and quantitative factors that should help in the correct management of proctological patients. A total of 30 patients with proctological symptoms during outpatient visits were submitted to a minimally invasive test in comparison to the traditional ones, using a simple gauze plug connected to the end of a suture thread, inserted in the rectal lumen and removed via the anus. The score designed by the authors made it possible to classify 96.6% of patients accurately. In 4 patients the score was equal to zero. In 12 patients there was a mucosal prolapse of less than 25% with a reduction score equal to 2.4 and therefore these were treated with a single rubber ligature (7 patients with classes a and b) and 5 patients were treated with the transfixed stitch technique (TST) (class c). In 10 patients a 50% mucosal prolapse of the anal circumference and a mean reduction score of 5.6 were found. In 5 of these patients (classes a and b) it was possible to perform a multiple ligature while the other 5 (class c) were treated with TST. In 3 patients a prolapse ranging from 50 to 75% with a mean reduction index of 8.1 was found. The therapeutic procedure preferred for these patients was TST. In one patient a circumferential prolapse was diagnosed with a reduction score of 11 treated with Longo's surgical technique. The mucosal prolapse score seems to be useful to stratify patients more precisely in the choice of surgical intervention and during follow-up. The plug test is a minimally invasive test, useful for the application of the rectal mucosal prolapse score.

Less severe histological changes have sometimes been reported in the terminal ileum (TI) of coeliac patients. The aim of this work was to assess whether magnified ileoscopy and the corresponding biopsy could be used when diagnosing coeliac disease (CD). This would be of clinical value in coeliac patients who show predominant abdominal symptoms and who undergo colonoscopy with ileoscopy as first clinical examination.All patients underwent conventional and magnified ileoscopy, along with histological examination of macroscopic mucosal abnormalities, if present. Patients whose ileoscopy with biopsy suggested CD underwent a blood test for quantitative determination of anti-transglutaminase antibodies and upper gastrointestinal endoscopy with corresponding duodenal biopsy.Out of 143 patients enrolled, 21 had a TI mucosal lesion, and 10 of these showed villous atrophy at ileoscopy only after magnification. Six showed a count of intra-epithelial lymphocytes (IELs)25/100 enterocytes and upper intestinal lesions, confirming the diagnosis of CD. Finally, of four patients diagnosed with Crohn's disease, TI mucosal aftoid lesions were seen in two only in magnified view.Magnified ileoscopy reliably recognizes the presence of mucosal villous subtotal or total atrophy at TI. This finding, even if not specific to CD, can address the diagnosis of CD. Magnification in the course of ileoscopy could also be useful in the diagnosis of Crohn's disease.

Colonic perforation is the most severe complication of lower gastrointestinal endoscopy. Recently successful closure with endoscopic clips has been reported. However large (10 mm) perforations and perforations occurring during diagnostic colonoscopy are considered a contraindication to endoscopic closure.We retrospectively reviewed our own experience with endoscopic closure of colonoscopic perforations. The size of the perforations was determined by comparison with the maximal opening of the clipping device. In addition we reviewed all cases of colonoscopic perforation published in the English language literature.From January 2006 we performed closure of three large colonoscopic perforations in three patients. One perforation occurred after en-bloc endoscopic mucosal resection of two polyps in the descending colon. The other two perforations occurred during diagnostic colonoscopy. All three cases were promptly diagnosed and successfully repaired with TriClips. Patients were kept on intravenous antibiotics and a clear liquid diet until bowel movement and were discharged between the 2nd and the 8th day after the procedure. A review of the literature, including our series, revealed 75 reported cases of colonoscopic perforations repaired with endoclips. Of these, four perforations were larger then 10 mm and four occurred during diagnostic colonoscopy. Of the perforations occurring during therapeutic colonoscopy, clip closure was carried out in 55-96% of the immediate perforations and was successful in 69-93% of cases.Nonsurgical management of colonoscopic perforations with endoclips is a highly feasible option. From our initial experience large perforations and perforations occurring during diagnostic colonoscopy are not a contraindication to endoscopic repair, but due to the small number of patients these data must be interpreted with caution.

BACKGROUND Celiac disease (CD) is a Th1-driven autoimmune permanent enteropathy that is triggered by dietary gluten. Molecules able to shift the immune response from a Th1- to a Th2-type response have been suggested as therapeutic agents for Th1 autoimmune diseases. OBJECTIVE We sought to investigate the possibility that a decapeptide from durum wheat (p10mer, QQPQDAVQPF), which was previously shown to prevent the activation of celiac peripheral lymphocytes, may promote a shift from a Th1- to a Th2-type immune response in gluten-specific intestinal T cells of CD patients. DESIGN Intestinal T lymphocyte lines derived from 8 children with CD were incubated with gliadin peptides both alone and simultaneously with p10mer. Cell proliferation and the production of interferon-gamma and interleukin-10 by these T cells were measured. RESULTS The incubation of celiac intestinal T cells with deamidated gliadin peptides resulted in a significant (P < 0.008) increase in cell proliferation and interferon-gamma release, whereas the simultaneous exposure to p10mer totally abolished the cell proliferation and cytokine release. Moreover, incubation with p10mer maintained an elevated release of interleukin-10, whereas exposure of the cells to culture medium only did not. The replacement of the residues of aspartic acid in position 5 or those of alanine in position 6 in the sequence of p10mer resulted in peptides with no activity in the activation experiments. CONCLUSION In vitro, p10mer showed the ability to shift the pathogenic immune response of a CD patient from a Th1- to a Th2-type response.

As the increase in lifespan brings to light diseases that were previously not clinically detectable, osteoporosis has become an issue of worldwide significance. The disease is marked by a loss of bone mass; the bones become less dense, fragile and more prone to fracturing. Because it is regulated by endocrine and environmental factors, osteoporosis presents a multifactorial etiopathogenesis, with the genetic component accounting for 70% of an individual variation in bone mass density (BMD), the principal determinant, with age, of fracture risk. Pathological conditions such as celiac disease (CD) exacerbate the process of bone loss, so that the occurrence of osteoporosis in celiac subjects is of particular note: indeed, the screening of osteoporosis patients for this disease is advisable, since it may be the only sign of undiagnosed CD. An increase in interleukin IL-1beta, of the IL-1 system, in the relatives of celiac patients confirms the genetic predisposition to osteoporosis and its presence is evidence of an association between the two conditions. The direct effect on the bones of CD is secondary to poor absorption of calcium and vitamin D. In women osteoporosis is indirectly associated with early menopause and amenorrhea, and it may follow prolonged breast-feeding and frequent pregnancies, while in men it is associated with hypogonadism and GH deficit. These endocrine and non-endocrine factors exert their effects on bones by modulating the RANK/RANK-L/OPG system. An appropriate lifestyle from adolescence onwards, together with early diagnosis of and treatment for CD and primary and secondary endocrine pathologies are important for the prevention of damage to the bones.

Dilatation of the anal sphincter with anal dilators for the treatment of acute anal fissure is efficacious, economic and safe but not always correctly executed with a negative repercussions on the technical results. Our study was aimed at comparing the efficacy of new graduated dilator with a progressively graduated diameter, using a standard treatment schedule, or a free schedule in comparison with the use of multiple classic dilators currently available for the resolution of anal fissures. A series of 60 patients, 35 female and 25 male, with a clinical diagnosis of acute anal fissure in the absence of a hypotonic anal sphincter, abscess or perianal fistula, hemorrhoidal thrombosis, chronic inflammatory bowel diseases or lower gastrointestinal neoplasms were preliminarily evaluated with the solid sphere test and randomly divided into three groups: the first was treated with the new graduated dilator with a standard treatment schedule (20 patients); the second was treated with multiple anal dilators (20, 23, 27 mm) (20 patients) using a standard treatment schedule, and the third group (20 patients) was treated with the new graduated dilator according to a free treatment schedule. After four weeks of treatment, 91% of all patients showed resolution of the anal fissure. Patients treated with new graduated dilator and those treated with multiple dilators according to the standard schedule showed similar 90% rates of fissure healing in comparison to the 92% treated with the graduated dilator according to the free schedule. The tolerability and manageability of the new single graduated dilator was judged positively by all patients in the treated groups. The use of the graduated anal dilator according to a free treatment schedule seems to induce lasting resolution of acute anal fissures with similar results to those achieved using traditional multiple dilators, while proving better tolerated by the patients.

The authors illustrate the technical characteristics and the clinical results of a new anal retractor in proctology and pelviperineology This new device, designed and produced by the authors, enables the surgeon to operate in a traditional or isostatic modality. The small external diameter and the original morphology seem to guarantee a less invasive introduction into the anal canal with minimal mechanical damage to the anal sphincter. The main indications for its use are pelvic floor surgery and patients with a diagnosis of anal incontinence or with suspected sphincter damage. Forty consecutive patients referred to our Coloproctological Unit have been operated on with the new anal retractor with no complications. The operative results obtained with the new device are defined as good in 75% and optimal in 10%. The anal retractor seems easy to use in all the surgical procedures with a much better safety profile with regard to anal sphincter.

Direct exploration of the anal mucosa always plays an essential role in the diagnosis and treatment of the main anal and perineal pathologies. The continuous need to improve coloproctological instruments, enhancing their efficacy and advantages for patients, prompted the authors to design and test a new anoscope for both diagnostic and operative purposes, suitable for simple, immediate use. This study was conducted to demonstrate the advantages and efficacy of a disposable "fenestrated" anoscope for band ligation of haemorrhoids and for performing biopsies on suspect areas of anal mucosa. The new disposable self-lit anoscope, made of inert, non-toxic plastic material tested by the authors, has been defined as "fenestrated" because it is characterised by the presence of a fenestration in the distal part of device, capable of improving visualisation of the anal canal and facilitating operative procedures. A total of 30 consecutive patients (25 with a clinico-instrumental diagnosis of grade II-III haemorrhoids and 5 with evidence of suspect lesions of the anal mucosa) were submitted to anoscopy using the new fenestrated anoscope. In the patients treated for haemorrhoids, ease of execution of band ligation was observed in all cases independently of the number and distribution of nodules. In the patients submitted to biopsy, the presence of condyloma was observed in 3 patients, and the presence of papillary hyperplasia in 2 patients. The new fenestrated anoscope proved to be a useful accessory both for diagnosis and for conservative treatment of haemorrhoids, permitting easy execution of ligation with no side effects. The anoscope was simple to use during diagnostic examinations and biopsies of suspect lesions of the anal canal, permitting accurate histological characterisation of the lesions in all cases.

In 2000 the Italian Society of Coloproctology introduced a novel system for classifying hemorrhoidal disease, PATE 2000 Sorrento, capable of assuring a better knowledge of such pathology. After several studies had established the efficacy of this classification system in comparison to anatomical criteria such as the size and dislocation of hemorrhoids in the anal canal, the need was felt to correct the limits of PATE 2000 Sorrento. Important parameters in assessing the severity of hemorrhoidal disease, such as numerical scores, symptom severity analysis and quality of life analyses, were introduced in PATE 2006 classification. The authors then tested the PATE 2006 on 500 patients with hemorrhoidal disease over a period of two years, referred to 4 different centres. The numerical scores of the PATE 2000 Sorrento factors, quality of life and the severity of symptoms introduced with this classification proved to be important parameters for evaluating hemorrhoids. In conclusions, PATE 2006 seems to be an improvement over the PATE 2000 Sorrento classification system in terms of its efficacy in establishing the more appropriate treatment for each patients with hemorrhoid disease.

Procedures involving the use of anal dilators or topical nitroderivatives for the treatment of anal fissure are efficacious, economic and safe. The aim of our study was to compare the efficacy of two conservative treatments - passive dilation with anal dilators or topical nitroderivatives - in reducing anal pressure and resolving anal fissures. A total of 40 patients with a clinical diagnosis of acute anal fissure in the absence of hypotonic anal sphincter, abscess or perianal fistula, haemorrhoidal thrombosis, chronic inflammatory bowel disease or lower gastrointestinal neoplasia were randomly assigned to treatment with dilators (20 patients) or topical nitroderivatives (20 patients). After 4 weeks of treatment, 90% of patients treated with dilators and only 45% treated with topical nitroderivatives showed complete resolution of their anal fissures and a reduction of sphincter hypertone. After 12 weeks, 2/18 patients successfully treated with dilators and 1/9 patients successfully treated with topical derivatives presented recurrence of the anal fissure. The use of anal dilators would appear to induce better resolution of acute anal fissures than topical nitroderivates, as confirmed by the low relapse rate at 12 weeks.