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In patients with malignant esophageal strictures within 6 cm from the upper esophageal sphincter, self-expanding metal stents placement represents a challenge because there is an increased risk of complications. The aim of this study was to assess the safety and effectiveness of large-diameter WallFlex® fully covered self-expanding metal stents for palliation of patients with proximal malignant esophageal strictures. From March 2010 to December 2012, 12 patients with proximal strictures (4-6 cm from the upper esophageal sphincter) and six with very proximal strictures (

Since its development in the 1980s, endoscopic ultrasonography (EUS) has undergone a great deal of technological modifications. EUS has become an important tool in the evaluation of patients with various clinical disorders and is increasingly being utilized in many centers. EUS has been evolving over the years; EUS-guided fine needle aspiration (FNA) for cytological and/or histological diagnosis has become standard practice and a wide array of interventional and therapeutic procedures are performed under EUS guidance for diseases which otherwise would have needed surgery, with its associated morbidities. EUS shares the risks and complications of other endoscopic procedures. This article addresses the specific adverse effects and risks associated with EUS, EUS-FNA and interventional EUS, namely perforation, bleeding, pancreatitis and infection. Measures to help minimizing these risks will also be discussed.

The aim of this paper was to evaluate the outcome of endoscopic resection (ER) for pedunculated and non-pedunculated colorectal neoplasms exceeding 4 cm in size.All patients with a colorectal neoplasms measuring 4 cm or more, who underwent ER at our institution between January 1996 and December 2008 were included in the study.In the study period, 67 ERs were carried out in 67 patients with a mean (±SD) age of 72±11 years. The mean neoplasms size was 48.2±12.5 mm. There were 32 sessile, 26 flat and 9 pedunculated neoplasms. The most frequent location (49.3%) was rectum. No perforation occurred, there were 4 procedural and 2 delayed bleeding, treated endoscopically, and 3 cases of transmural burn syndrome, managed conservatively. Pathologic examination showed 18 low-grade dysplasia, 43 high-grade dysplasia, 3 intramucosal and 3 invasive cancer. The most frequent type of neoplasm was villous adenoma (76.1%). The presence of malignancy was related to villous histology (P=0.005) and to age ≥ 80 of patients (P=0.04).During endoscopic follow-up (49.4± 26.3 months) recurrence was found in 25.8% of lesions (11 sessile and 4 flat), always treated endoscopically. Recurrence was more likely in patients with lesions larger than 60 mm (P=0.04). The three patients with invasive cancer did not undergo surgery, because of advanced age and/or severe extracolonic diseases. During follow-up no local recurrence or metastasis was found.ER is a safe and effective procedure for removing benign appearing very large colorectal neoplasms.

As it is a non-invasive method, magnetic resonance cholangiography (MRCP) has almost completely replaced endoscopic retrograde cholangiography (ERCP) in the diagnosis of pancreato-biliary diseases. The aim of this study was to evaluate sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MRCP in diagnosis of choledocholithiasis using ERCP/endoscopic sphincterotomy (ES) as gold standard.For this study 140 individuals, suspected for lithiasis of the common bile duct (CBD), were enrolled. After a clinical and biochemical evaluation, patients underwent upper abdominal ultrasonography, then MRCP and diagnostic and/or operative ERCP.Only 120 out of 140 patients completed the study. MRCP diagnosed lithiasis of CBD in 84. ERCP confirmed the lithiasis in 73/84 patients who were submitted to ES. Eleven were negative after ES. ERCP documented stones in 10 patients among the 36 negative at MRCP; stones were detected only in four patients after ES. In 26 out of 36 patients negative at MRCP, ERCP confirmed this response: only 12 out of 26 patients underwent ES. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 72%, 83%, 87%, 72%.As the MRCP diagnostic yield is still limited with small stones, the question of which patient is the best candidate to ERCP/ES is still unsolved.

In several studies, attention is needed to one specific complication, in particularly to hepatocellular carcinoma, which modifies the natural history of liver cirrhosis. Thus, we performed a retrospective cohort analysis to clarify which complications, alone or in combination, are predictive factors of mortality in patients with viral or alcoholic cirrhosis without hepatocellular carcinoma.Case records of 255 patients with decompensated viral or alcoholic cirrhosis between January 1990 and December 2000 were retrospectively analyzed. Relevant clinical and laboratory parameters, and their relationship to mortality, were studied.The mean duration of follow-up period was 29 months in which 178 patients (69.8%) died and 77 (31.8%) survived. None of the patients underwent liver transplantation. The cumulative mortality rate of patients with complicated cirrhosis was 38.8% after 1 year, 51.7% after 2 years, 61.1% after 3 years and 65.1% after 8 years. A multivariate Cox's model identified the following variables as significant: age (P=0.001), gastrointestinal bleeding (GB)-ascites combination (P=0.000), encephalopathy-GB-ascites (P=0.028), hepatorenal syndrome (HRS) (P=0.000), GB-spontaneous bacterial peritonitis (SBP) (P=0.001), alkaline phosphatase (ALP) (P=0.004) and the Child-Pugh score (P=0.000).The mortality in a group of patients with alcoholic cirrhosis is longer than in those with viral cirrhosis . Moreover, ascites in combination with other complications, HRS and hemorrage-SBP association are independent predictors of mortality in patients with complicated liver cirrhosis.