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Endoscopic management of gastrointestinal leaks and fistulae: Whatoption do we have?

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World Journal of Gastroenterology 2020年第29期26卷 4198-4217页

作者： Fabrizio Cereatti roberto grassia Andrea Drago Clara Benedetta Conti Gianfranco Donatelli Digestive Endoscopy and Gastroenterology Unit Cremona HospitalCremonaCremona 26100Italy Department of Interventional Endoscopy Hospital Prive PeupliersRamsay SantéParis 75013France

Gastrointestinal leaks and fistulae are serious, potentially life threateningconditions that may occur with a wide variety of clinical presentations. Leaks aremostly related to post-operative anastomotic defects and are responsible for animportant share of surgical morbidity and mortality. Chronic leaks and longstanding post-operative collections may evolve in a fistula between twoepithelialized structures. Endoscopy has earned a pivotal role in the managementof gastrointestinal defects both as first line and as rescue treatment. Endotherapyis a minimally invasive, effective approach with lower morbidity and mortalitycompared to revisional surgery. Clips and luminal stents are the pioneer ofgastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closuredevices and techniques, such as endoscopic internal drainage, suturing systemand vacuum therapy, has broadened the indications of endoscopy for themanagement of GI wall defect. Although several endoscopic options are currentlyused, a standardized evidence-based algorithm for management of GI defect isnot available. Successful management of gastrointestinal leaks and fistulaerequires a tailored and multidisciplinary approach based on clinical presentation,defect features (size, location and onset time), local expertise and the availabilityof devices. In this review, we analyze different endoscopic approaches, which weselected on the basis of the available literature and our own experience. Then, weevaluate the overall efficacy and procedural-specific strengths and weaknesses ofeach approach.

关键词： Leak Fistula Endotherapy Over-the-scope clip Suturing system Endovacuum therapy Endoscopic internal drainage Self-expandable metal stent

Neuroendocrine carcinomas arising in ulcerative colitis:Coincidences or possible correlations?

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World Journal of Gastroenterology 2009年第33期15卷 4193-4195页

作者： roberto grassia Paolo Bodini Paolo Dizioli Teresa Staiano Elena Iiritano Guglielmo Bianchi Federico Buffoli Digestive Endoscopy and Gastroenterology Unit A.O. "Istituti Ospitalieri di Cremona"

Patients with inflammatory bowel disease （IBD） are at increased risk of colorectal malignancies. Adenocarcinoma is the commonest type of colorectal neoplasm associated with ulcerative colitis （UC） and Crohn＇s disease, but other types of epithelial and non-epithelial tumors have also been described in inflamed bowel. With regards to non-epithelial malignancies, lymphomas and sarcomas represent the largest group of tumors reported in association with IBD, especially in immunosuppressed patients. Carcinoids and in particular neuroendocrine neoplasms other than carcinoids （NENs） are rare tumors and are infrequently described in the setting of IBD. Thus, this association requires further investigation. We report two cases of neoplasms arising in mild left-sided UC with immuno- histochemical staining for neuroendocrine markers： a large cell and a small cell neuroendocrine carcinoma of the rectum. The two patients were different in age （35 years vs 77 years） and disease duration （11 years vs 27 years）, and both had never received immunosuppressant drugs. Although the patients underwent regular endoscopic and histological follow-up, the two neoplasms were locally advanced at diagnosis. One of the two patients developed multiple liver metastases and died 15 mo after diagnosis. These findings confirm the aggressiveness and the poor prognosis of NENs compared to colorectal adenocarcinoma. While carcinoids seem to be coincidentally associated with IBD, NENs may also arise in this setting. In fact, long-standing inflammation could be directly responsible for the development of pancellular dysplasia involving epithelial, goblet, Paneth and neuroendocrine cells. It has yet to be established which IBD patients have a higher risk of developing NENs.

关键词： Colorectal cancer Large cell carcinoma Neuroendocrine carcinoma Small cell carcinoma

Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate

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World Journal of Gastroenterology 2016年第48期22卷 10609-10616页

作者： roberto grassia Pietro Capone Elena Iiritano Katerina Vjero Fabrizio Cereatti Mario Martinotti Gabriele Rozzi Federico Buffoli Digestive Endoscopy and Gastroenterology Unit "ASST di Cremona" Department of Surgery "ASST di Cremona" Department of Radiology "ASST di Cremona"

AIM To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane(NBCA + MS)] to treat nonvariceal upper gastrointestinal bleeding(NV-UGIB).METHODS In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy's lesions, and 1 had duodenal diverticular *** Of the 45 patients treated endoscopically without initialhemostasis or with early rebleeding, 33(76.7%) were treated with modified cyanoacrylate glue, 16(37.2%) underwent surgery, and 3(7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS(23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients(78.8%): 19 out of 24(79.2%) during the first endoscopy and in 7 out of 9(77.8%) among early rebleeders. Two patients(22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were *** Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.

关键词： Rescue treatment Glubran Non-variceal upper gastrointestinal bleeding Endoscopic treatment Cyanoacrylate

Endoscopic ultrasound-guided sampling of solid pancreatic masses:the fine needle aspiration or fine needle biopsy dilemma. Is the best needle yet to come?

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World Journal of Gastrointestinal Endoscopy 2019年第8期11卷 454-471页

作者： Clara Benedetta Conti Fabrizio Cereatti roberto grassia Digestive Endoscopy and Gastroenterology Unit Cremona Hospital

Fine needle aspiration (FNA) is currently the standard of care for sampling pancreatic solid masses by using endoscopic ultrasound (EUS).The accuracy of the technique is reported to be high,especially if coupled with the rapid on site evaluation (ROSE),and it has a high safety ***,FNA presents some limitations,such as the small amount of tissue that can be collected and the inability of obtaining a core tissue with intact histological architecture,which is relevant to perform immunohistochemical analysis,molecular profiling and,therefore,targeted ***,the presence of the ROSE by an expert cytopathologist is very important to maximize the diagnostic yield of FNA technique;however,it is not widely available,especially in small ***,the introduction of EUS fine needle biopsy (FNB) with a new generation of needles,which show a high safety profile too and a satisfying diagnostic accuracy even in the absence of ROSE,could be the key to overcome the limitations of ***,FNB has not yet shown diagnostic superiority over *** all the technical aspects of FNA and FNB,the different types of needle currently available,comparisons in term of diagnostic yield,and the different techniques of sampling,a tailored approach should be used in order to determine the needle that is most appropriate for the different specific scenarios.

关键词： Fine needle aspiration Fine needle biopsy Endoscopic ultrasound Needle performance Diagnostic yield Diagnostic accuracy Pancreatic sampling

Liver-side of inflammatory bowel diseases:Hepatobiliary and druginduced disorders

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World Journal of Hepatology 2021年第12期13卷 1828-1849页

作者： Stefano Mazza Sara Soro Maria Chiara Verga Biagio Elvo Francesca Ferretti Fabrizio Cereatti Andrea Drago roberto grassia Gastroenterology and Digestive Endoscopy Unit ASST CremonaCremona 26100Italy Gastroenterology Unit ASST Fatebenefratelli-SaccoDepartment of Biomedical and Clinical Sciences(DIBIC)Universitàdegli Studi di MilanoMilan 20157Italy

Hepatobiliary disorders are among the most common extraintestinal manifestations in inflammatory bowel diseases(IBD),both in Crohn’s disease and ulcerative colitis(UC),and therefore represent a diagnostic *** conditions include primary sclerosing cholangitis(PSC)as the main form,variant forms of PSC(namely small-duct PSC,PSC-autoimmune hepatitis overlap syndrome and IgG4-related sclerosing cholangitis)and granulomatous *** is by far the most common,presenting in up to 8%of IBD patients,more frequently in *** genetic foci have been identified,but environmental factors are preponderant on disease *** course of the two diseases is typically *** diagnosis is based mostly on typical radiological findings and exclusion of secondary *** of cholangiocarcinoma is significantly increased in PSC,as well as the risk of colorectal cancer in patients with PSC and IBD-related *** disease-modifying drugs are approved to ***,PSC management is directed against symptoms and complications and includes medical therapies for pruritus,endoscopic treatment of biliary stenosis and liver transplant for end-stage liver *** nonimmune-mediated hepatobiliary disorders are gallstone disease,whose incidence is higher in IBD and reported in up to one third of IBD patients,non-alcoholic fatty liver disease,pyogenic liver abscess and portal vein *** liver injury(DILI)is an important issue in IBD,since most IBD therapies may cause liver toxicity;however,the incidence of serious adverse events is *** and methotrexate are the most associated with DILI,while the risk related to anti-tumor necrosis factor-αand anti-integrins is *** on hepatotoxicity of newer drugs approved for IBD,like anti-interleukin 12/23 and tofacitinib,are still scarce,but the evidence from other rheumatic diseases is *** B reactivation during immunosuppressive therapy is a major

关键词： Inflammatory bowel diseases Hepatobiliary disorders Primary sclerosing cholangitis Drug-induced liver injury Biological drugs Viral hepatitis

Gastric per-oral endoscopic myotomy:Indications,technique,results and comparison with surgical approach

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World Journal of Gastrointestinal Surgery 2022年第1期14卷 12-23页

作者： Maria Chiara Verga Stefano Mazza Francesco Azzolini Fabrizio Cereatti Clara Benedetta Conti Andrea Drago Sara Soro Biagio Elvo roberto grassia Gastroenterology and Digestive Endoscopy Unit ASST CremonaCremona 26100Italy Gastroenterology and Digestive Endoscopy Unit Ospedale San Raffaele IRCCSMilano 20132Italy Digestive and Interventional Endoscopy Unit ASST MonzaMonza 20800Italy

Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying,without the presence of a *** 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining *** with EndoFLIP,a device that assesses pyloric distensibility,increased the knowledge about *** on this data,several pyloric-targeted therapies were developed to treat refractory gastroparesis:Surgical pyloroplasty and endoscopic approach,such as pyloric injection of botulinum and pyloric ***,the success of most of these techniques is still not *** 2013,the first human gastric per-oral endoscopic myotomy(GPOEM)was *** was inspired by the POEM technique,with a similar dissection method,that allows *** results of GPOEM are similar to surgical approach in term of clinical success,adverse events and post-surgical *** the last 8 years GPOEM has gained the attention of the scientific community,as a minimally invasive technique with high rate of clinical success,quickly prevailing as a promising therapy for *** surprisingly,in referral centers,its technical success rate is 100%.One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.

关键词： Gastric per-oral endoscopic myotomy Pyloroplasty Gastroparesis EndoFLIP Pyloromyotomy Gastroparesis cardinal symptom index

SARS-CoV-2 in inflammatory bowel disease population:Antibodies,disease and correlation with therapy

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World Journal of Gastrointestinal Endoscopy 2022年第3期14卷 153-162页

作者： Clara Benedetta Conti Elsa Mainardi Sara Soro Sophie Testa Annalisa De Silvestri Andrea Drago Fabrizio Cereatti roberto grassia Department of Gastroenterology and Digestive Endoscopy ASST CremonaCremona 26100Italy Department of Laboratory Medicine Haemostasis and Thrombosis CenterASST CremonaCremona 26100Italy Department of Clinic Epidemiology and Biometric Scientific DirectionFondazione IRCCS Policlinico San MatteoPavia 27100Italy

BACKGROUND Guidelines recommend to cease inflammatory bowel disease(IBD)biologic therapy during coronavirus disease 2019(COVID-19).AIM To investigate severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)antibody positivity in an IBD cohort,COVID-19 disease severity and to evaluate the correlation with clinical/therapeutic *** Prospective observational cohort *** patients were tested for SARS-CoV-2 *** on COVID-19 disease,demographics/therapeutics and clinical features of the IBD population were ***≥7 was set for SARS-CoV-2 antibody *** swab was performed in cases of IgG *** between antibody positivity or COVID-19 symptoms and therapeutic/clinical data were *** In total,103 IBD patients were *** them,18.4%had IgG≥*** analysis of antibody positivity correlated only with IBD *** IgG≥7,the odds ratio was 1.44 and 0.16 for azathioprine and mesalazine,respectively,vs biologic drugs(P=0.0157 between them).COVID-19 related symptoms were reported in 63%of patients with IgG *** but one patient with COVID-19 symptoms did not require ceasing IBD treatment or hospitalization. IBDtreatment and body mass index correlated with COVID-19 disease development with *** IBD population does not have a higher risk of severe COVID-19. The relative risk of havingSARS-CoV-2 antibodies and symptoms was higher for patients taking azathioprine, then biologictherapy and lastly mesalazine. None of the patients under biologic therapy developed severeCOVID-19.

关键词： Inflammatory bowel disease SARS-CoV-2 COVID-19 Biologic treatment SARS-CoV-2 antibody Inflammatory bowel disease therapy

Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholang-iopancreatography in defining etiology of idiopathic acute pancreatitis

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World Journal of Gastrointestinal Endoscopy 2022年第6期14卷 376-386页

作者： Stefano Mazza Biagio Elvo Clara Benedetta Conti Andrea Drago Maria Chiara Verga Sara Soro Annalisa De Silvestri Fabrizio Cereatti roberto grassia Gastroenterology and Digestive Endoscopy Unit ASST CremonaCremona 26100Italy Gastroenterology and Endoscopy Unit Federico Ⅱ UniversityNapoli 80131Italy Interventional Endoscopy Unit ASST MonzaMonza 20900Italy Biometry and Clinical Epidemiology Scientific DirectionIRCCS San Matteo Hospital FoundationPavia 27100Italy Department of Gastroenterology and Digestive Endoscopy Castelli HospitalAriccia(Rm)00040Italy

BACKGROUND About 10%-30%of acute pancreatitis remain idiopathic(IAP)even after clinical and imaging tests,including abdominal ultrasound(US),contrast-enhanced computed tomography(CECT)and magnetic resonance cholangiopancreatography(MRCP).This is a relevant issue,as up to 20%of patients with IAP have recurrent episodes and 26%of them develop chronic *** data are available on the role of EUS in clarifying the etiology of IAP after failure of one or more cross-sectional *** To evaluate the diagnostic gain after failure of one or more previous crosssectional *** We retrospectively collected data about consecutive patients with AP and at least one negative test between US,CECT and MRCP,who underwent linear EUS between January 2017 and December *** investigated the EUS diagnostic yield and the EUS diagnostic gain over different combinations of these crosssectional imaging techniques for the etiologic diagnosis of *** and frequency of EUS diagnosis were also analyzed,and EUS diagnosis was compared with the clinical *** EUS,patients were followed-up for a median of 31.5 mo to detect cases of pancreatitis *** We enrolled 81 patients(63%males,mean age 61±18,23%with previous cholecystectomy,17%with recurrent pancreatitis).Overall EUS diagnostic yield for AP etiological diagnosis was 79%(20%lithiasis,31%acute on chronic pancreatitis,14%pancreatic solid or cystic lesions,5%pancreas divisum,5%autoimmune pancreatitis,5%ductal abnormalities),while 21%remained ***,CECT and MRCP,taken alone or in combination,led to AP etiological diagnosis in 16(20%)patients;among the remaining 65 patients,49(75%)obtained a diagnosis at EUS,with an overall EUS diagnostic gain of 61%.Sixty-eight patients had negative US;among them,EUS allowed etiological diagnosis in 59(87%).Sixty-three patients had a negative CECT;among them,47(74%)obtained diagnosis with ***-four had a negative MRCP;among them,20(83%)had EUS diag

关键词： Endoscopic ultrasound Idiopathic acute pancreatitis Diagnostic gain Computed tomography Magnetic resonance cholangiopancreatography

Large symptomatic gastric diverticula:Two case reports and a brief review of literature

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World Journal of Gastroenterology 2013年第36期19卷 6114-6117页

作者： Luigi Marano Gianmarco Reda Raffaele Porfidia Michele grassia Marianna Petrillo Giuseppe Esposito Francesco Torelli Angelo Cosenza Giuseppe Izzo Natale Di Martino 8~(th) General and Gastrointestinal Surgery Department of Internal Medicine Surgical Neurological Metabolic Disease and Geriatric Medicine Second University of Naples

Gastric diverticula are rare and uncommon *** gastric diverticula are *** symptoms arise,they are most commonly upper abdominal pain,nausea and emesis,while dyspepsia and vomiting are less ***,patients with gastric diverticula can have dramatic presentations related to massive bleeding or *** diagnosis may be difficult,as symptoms can be caused by more common gastrointestinal pathologies and only aggravated by *** appropriate management of diverticula depends mainly on the symptom pattern and as well as diverticulum *** is no specific therapeutic strategy for an asymptomatic *** some authors support conservative therapy with antacids,this provides only temporary symptom relief since it is not able to resolve the underlying *** resection is the mainstay of treatment when the diverticulum is large,symptomatic or complicated by bleeding,perforation or malignancy,with over two-thirds of patients remaining symptom-free after surgery,while laparoscopic resection,combined with intraoperative endoscopy,is a safe and feasible approach with excellent ***,we present two cases of uncommon large symptomatic gastric diverticula with a discussion of the cornerstones in management and report a minimally invasive solution,with a brief review of the literature.

关键词： Gastric diverticulum Laparoscopic gastric diverticulectomy Abdominal pain Dysphagia Gastric Diverticulum