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Acute recurrent pancreatitis:Etiopathogenesis, diagnosis and treatment

World Journal of Gastroenterology 2014年第45期20卷 16891-16901页

作者： pier alberto testoni Division of Gastroenterology and Gastrointestinal Endoscopy Vita-Salute San Raffaele University Scientific Institute San Raffaele 20132 Milan Italy

Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term “idiopathic” is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.

关键词： Acute recurrent pancreatitis Chronic pancreatitis Aetiopathogenesis Diagnosis Treatment

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Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus

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World Journal of Gastroenterology 2016年第40期22卷 8991-8998页

作者： Sandro Passaretti Giorgia Mazzoleni Cristian Vailati pier alberto testoni Gastroenterology and Gastrointestinal Endoscopy Division IRCCS San Raffaele Scientific Institute Vita-Salute San Raffaele University

AIM To investigate the relationship between pathological oropharyngeal(OP) acid exposure and esophageal motility in patients with extra-esophageal *** In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease(GERD). We enrolled only patients with a reflux symptom index(RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal highresolution manometry(HRM). Patients were divided into two groups on the basis of a normal or pathological p H-metric finding(Ryan Score) and all manometric characteristics of the two groups were *** We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure(median 71 mmH g vs 126 mmH g, P = 0.004) and the median proximal contractile integral(median 215.5 cm·mmH g·s vs 313.5 cm·mmH g·s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mm Hg isobaric contour(38.7% vs 15.38%, P < 0.0001).CONCLUSION In patients with suspected GERD-related extraesophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.

关键词： Esophagus Motility Oropharyngeal reflux Gastroesophageal reflux disease High resolution manometry pH-metry

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Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

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World Journal of Gastroenterology 2007年第45期13卷 5971-5978页

作者： pier alberto testoni MD Division of Gastroenterology Vita-Salute San Raffaele University Scientif ic Institute San Raffaele Milan 20132 Italy

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

关键词： Chronic pancreatitis Pancreas divisum Pancreatic pseudocyst Pancreatic fistulas Idiopathicrecurrent pancreatitis Main pancreatic duct stenting Pancreatic dorsal duct stenting

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Is acute recurrent pancreatitis a chronic disease?

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World Journal of Gastroenterology 2008年第7期14卷 995-998页

作者： alberto Mariani pier alberto testoni Division of Gastroen-terology & Gastrointestinal Endoscopy Vita-Salute San Raffaele University-Scientific Institute San RaffaeleMilanItaly

Whether acute recurrent pancreatitis is a chronic disease is still debated and a consensus is not still reached as demonstrated by differences in the classification of acute recurrent pancreatitis. There is major evidence for considering alcoholic pancreatitis as a chronic disease ab initio while chronic pancreatitis lesions detectable in biliary acute recurrent pancreatitis (ARP) seem a casual association. Cystic fibrosis transmembrane con-ductance regulator (CFTR) gene mutation, hereditary and obstructive pancreatitis seem an acute disease that progress to chronic pancreatitis, likely as a consequence of the activation and proliferation of pancreatic stellate cells that produce and activate collagen and therefore fibrosis. From the diagnostic point of view, in patients with acute recurrent pancreatitis Endoscopic ultrasound (EUS) seems the more reliable technique for an accurate evaluation and follow-up of some ductal and parenchymal abnormalities suspected for early chronic pancreatitis.

关键词： Classification of pancreatitis Acute recurrent pancreatitis Chronic pancreatitis Alcoholic pancreatitis Pancreatic stellate cells

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Sedation and analgesia in gastrointestinal endoscopy: What’s new?

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World Journal of Gastroenterology 2010年第20期16卷 2451-2457页

作者： Lorella Fanti pier alberto testoni Division of Gastroenterology and Gastrointestinal Endoscopy Vita-Salute San Raffaele UniversityScientific Institute San Raffaele20132 MilanItaly

Various types of sedation and analgesia technique have been used during gastrointestinal endoscopy *** best methods for analgesia and sedation during gastrointestinal endoscopy are still *** an adequate regimen of sedation/analgesia might be considered an art,influencing several aspects of endoscopic procedures: the quality of the examination,the patient’s cooperation and the patient’s and physician’s satisfaction with the *** properties of a model sedative agent for endoscopy would include rapid onset and offset of action,analgesic and anxiolytic effects,ease of titration to desired level of sedation,rapid recovery and an excellent safety prof *** there is an impulse for development of new approaches to endoscopic *** article provides an update on the methods of sedation today available and future directions in endoscopic sedation.

关键词： Gastrointestinal endoscopy Analgesia Sedation Propofol

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Optical coherence tomography in detection of dysplasia and cancer of the gastrointestinal tract and bilio-pancreatic ductal system

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World Journal of Gastroenterology 2008年第42期14卷 6444-6452页

作者： pier alberto testoni Benedetto Mangiavillano Division of Gastroenterology and Gastrointestinal Endoscopy Vita-Salute San Raffaele University Scientific Institute San Raffaele Hospital Milan 20132 Italy

Optical coherence tomography(OCT) is an optical imaging modality that performs high-resolution,cross-sectional,subsurface tomographic imaging of the microstructure of *** physical principle of OCT is similar to that of B-mode ultrasound imaging,except that it uses infrared light waves rather than acoustic *** in vivo resolution is 10-25 times better(about 10 μm) than with high-frequency ultrasound imaging,but the depth of penetration is limited to 1-3 mm,depending upon tissue structure,depth of focus of the probe used,and pressure applied to the tissue *** the last decade,OCT technology has evolved from an experimental laboratory tool to a new diagnostic imaging modality with a wide spectrum of clinical applications in medical practice,including the gastrointestinal(GI) tract and pancreatic-biliary ductal *** imaging from the GI tract can be done in humans by using narrow-diameter,catheter-based probes that can be inserted through the accessory channel of either a conventional front-view endoscope,for investigating the epithelial structure of the GI tract,or a side-view endoscope,inside a standard transparent ERCP catheter,for investigating the pancreatico-biliary ductal *** and the esophago-gastric junction has been the most widely investigated organ so far;more recently,also duodenum,colon and pancreatico-biliary ductal system have been extensively *** imaging of the gastro-intestinal wall structure is characterized by a multiple-layer architecture that permits an accurate evaluation of the mucosa,lamina propria,muscularis mucosae,andpart of the *** technique may be,therefore,used to identify pre-neoplastic conditions of the GI tract,such as Barrett's epithelium and dysplasia,and evaluate the depth of penetration of early-stage neoplastic *** imaging of the pancreatic and biliary ductal system could improve the diagnostic accuracy for ductal epithelial changes and the differential diagnosis be

关键词： Optical coherence tomography Barrett'sepithelium Dysplasia Adenocarcinoma Gastrointestinal tract Pancreatico-biliary ductal system

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Outcome of endotherapy for pancreas divisum in patients with acute recurrent pancreatitis

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World Journal of Gastroenterology 2014年第46期20卷 17468-17475页

作者： alberto Mariani Milena Di Leo Maria Chiara Petrone Paolo Giorgio Arcidiacono Antonella Giussani Raffaella Alessia Zuppardo Giulia Martina Cavestro pier alberto testoni Gastroenterology and Gastrointestinal Endoscopy Unit Division of Experimental OncologyIRCCS San Raffaele Scientific Institute - Vita Salute San Raffaele University20132 MilanItaly

AIM: To assess the rate of relapses of acute pancreatitis (AP), recurrent AP (RAP) and the evolution of endosonographic signs of chronic pancreatitis (CP) in patients with pancreas divisum (PDiv) and RAP.

关键词： Endoscopic retrograde cholangiopancreatography Magnetic resonance cholangiopancreatography with secretin stimulation Minor papilla endotherapy Pancreatic stenting Endoscopic ultrasonography

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Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis

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World Journal of Gastroenterology 2008年第7期14卷 1016-1022页

作者： Maria Chiara Petrone Paolo G Arcidiacono pier alberto testoni Division of Gastroenterology & Gastrointestinal Endoscopy Vita-Salute San Raffaele University Scientific Institute San RaffaeleMillanItaly

Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.

关键词： Acute recurrent pancreatitis Endoscopic ultrasound

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Transoral incisionless fundoplication for gastro-esophageal reflux disease: Techniques and outcomes

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World Journal of Gastrointestinal Pharmacology and Therapeutics 2016年第2期7卷 179-189页

作者： pier alberto testoni Giorgia Mazzoleni Sabrina Gloria Giulia testoni Division of Gastroenterology and Gastrointestinal Endoscopy Vita-Salute San Raffaele University San Raffaele Scientific Institute

Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric *** can be currently treated by medical therapy,surgical or endoscopic transoral *** therapy is the most common approach,though concerns have been increasingly raised in recent years about the potential side effects of continuous longterm medication,drug intolerance or unresponsiveness,and the need for high dosages for long periods to treat symptoms or prevent *** too may in some cases have consequences such as longlasting dysphagia,flatulence,inability to belch or vomit,diarrhea,or functional dyspepsia related to delayed gastric *** the last few years,transoral incisionless fundoplication(TIF)has proved an effective and promising therapeutic option as an alternative to medical and surgical *** review describes the steps of the TIF technique,using the Esophy X®device and the MUSETM *** and their management are described in detail,and the recent literature regarding the outcomes is *** reconfigures the tissue to obtain a full-thickness gastroesophageal valve from inside the stomach,by serosato-serosa plications which include the muscle *** date the procedure has achieved lasting improvement of GERD symptoms(up to six years),cessation or reduction of proton pump inhibitor medication in about 75%of patients,and improvement of functional findings,measured by either p H or impedance monitoring.

关键词： Gastro-esophageal reflux disease Transoral incisionless fundoplication Anterior fundoplication with ultrasonic surgical endostapler Esophy X MUSE Surgical fundoplication

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High-definition colonoscopy with i-Scan:Better diagnosis for small polyps and flat adenomas

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World Journal of Gastroenterology 2012年第37期18卷 5231-5239页

作者： pier alberto testoni Chiara Notaristefano Cristian Vailati Milena Di Leo Edi Viale Division of Gastroenterology and Gastrointestinal Endoscopy Vita-Salute San Raffaele UniversityScientific Institute San Raffaele

AIM： To investigate if high-definition （HD） colonoscope with i-Scan gave a higher detection rate of mucosal le- sions vs standard white-light instruments. METHODS： Data were collected from the computer- ized database of the endoscopy unit of our tertiary referral center. We retrospectively analyzed 1101 con- secutive colonoscopies that were performed over 1 year with standard white-light （n = 849） or HD＋ with i-Scan （n = 252） instruments by four endoscopists, in an outpatient setting. Colonoscopy records included patients＇ main details and family history for colorectal cancer, indication for colonoscopy （screening, diagnos- tic or surveillance）, type of instrument used （standard white-light or HD＋ plus i-Scan）, name of endoscopist and bowel preparation. Records for each procedure included whether the cecum was reached or not and the reason for failure, complications during or imme- diately after the procedure, and number, size, location and characteristics of the lesions. Polyps or protruding lesions were defined as sessile or pedunculated, and nonprotruding lesions were defined according to Paris classification. For each lesion, histological diagnosis was recorded. RESULTS： Eight hundred and forty-nine colonosco- pies were carried with the standard white-light video colonoscope and 252 with the HD＋ plus i-Scan video colonoscope, The four endoscopists did 264, 300, 276 and 261 procedures, respectively; 21.6%, 24.0%, 21.7% and 24.1% of them with the HD＋ plus i-Scan technique. There were no significant differences be- tween the four endoscopists in either the number of procedures done or the proportions of each imaging technique used. Both techniques detected one or more mucosal lesions in 522/1101 procedures （47.4%）. The overall number of lesions recognized was 1266; 645 in the right colon and 621 in the left. A significantly higher number of colonoscopies recognized lesions in the HD＋ plus i-Scan mode （171/252 = 67.9%） than with the standard white-light technique （4

关键词： Colonoscopy High-definition+ with i-Scancolonoscopy White-light colonoscopy Colonic polyps Nonprotruding lesions Adenoma detection rate With-drawal time Surface enhancement Contrast enhance-ment Tone enhancement

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