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Hassan C.,Digestive Endoscopy Unit | Pickhardt P.J.,University of Wisconsin - Madison
Nature Reviews Gastroenterology and Hepatology | Year: 2013

The advent of CT colonography (CTC) has generated conservative policies for the management of diminutive (<5 mm) and small (6-9 mm) polyps to prevent inefficient duplication of screening tests. The effect of not referring subcentimetric polyps for polypectomy on the efficacy of colorectal cancer screening is still uncertain but depends on the natural history of diminutive and small polyps, as well as on the distribution of advanced neoplasia within these lesions. Simulation modelling enables the efficacy and cost-effectiveness of conservative strategies for the management of subcentimetric lesions to be tested (such as nonreferral to polypectomy for diminutive polyps and early CTC surveillance for small polyps). These policies might be further refined by the inclusion of patient and polyp-related predictive factors for advanced neoplasia, enabling a patient-tailored approach for the management of these lesions. © 2013 Macmillan Publishers Limited. All rights reserved. Source

Repici A.,Digestive Endoscopy Unit | Hassan C.,Gastroenterology and Digestive Endoscopy | Sharma P.,University of Kansas | Conio M.,Unit of Gastroenterology | Siersema P.,University Utrecht
Alimentary Pharmacology and Therapeutics | Year: 2010

Treatment of refractory or recurrent benign oesophageal strictures is demanding and surgery may be the only available option. The role of self-expanding plastic stents (SEPS) in the treatment of these strictures is still controversial because of the conflicting results of various studies. Aim To analyse with regard to SEPS: technical and clinical success, factors associated with outcome, and safety. Methods Pooled-data analysis of a systematic review of the literature. Clinical success was defined as no need for further endoscopic or surgical treatment after SEPS removal. Results Data of 10 studies with 130 treated patients were included. SEPS insertion was technically successful in 128 of 130 patients (98%, 95% CI = 96-100%). Clinical success was achieved in 68 patients (52%, 95% CI = 44-61%) and this was found to be lower in those with a cervical localization of the stricture (33% vs. 54%; P < 0.05). Early (<4 weeks) migration of the stent was reported in 19 (24%, 95% CI = 14-32%) cases, while post-insertion endoscopic re-intervention was required in 25 (21%, 95% CI = 14-28%). Major clinical complications occurred in 12 patients (9%, 95% CI = 4-14%), resulting in death of one (0.8%) patient. Conclusions Our pooled-data analysis showed a favourable risk/benefit ratio when SEPS are applied in patients with recurrent or refractory benign oesophageal strictures. This supports the use of SEPS before referring patients to surgery, and they are a valuable alternative to repeat endoscopic dilation. © 2010 Blackwell Publishing Ltd. Source

Hassan C.,Digestive Endoscopy Unit | Pickhardt P.J.,University of Wisconsin - Madison | Pickhardt P.J.,Uniformed Services University of the Health Sciences | Rex D.K.,Indiana University
Clinical Gastroenterology and Hepatology | Year: 2010

Background & Aims: A "resect and discard" policy has been proposed for diminutive polyps detected by screening colonoscopy, because hyperplastic and adenomatous polyps can be distinguished, in vivo, by using narrow-band imaging (NBI). We modeled the cost-effectiveness of this policy. Methods: Markov modeling was used to compare the cost-effectiveness of universal pathology evaluations with a resect and discard policy for colonoscopy screening. In a resect and discard approach, diminutive lesions (≤mm), classified by endoscopy with high confidence, were not analyzed by a pathologist. Base case assumptions of an 84% rate of high-confidence classification, with a sensitivity and specificity for adenomas of 94% and 89%, respectively, were used. Census data were used to project outputs of the model onto the US population, assuming 23% as the current rate of adherence to a colonoscopy screening. Results: With universal referral of resected polyps to pathology, colonoscopy screening costs an estimated $3222/person, with a gain of 51 days/person. Endoscopic polypectomy accounted for $179/person, of which $46/person was related to pathology examination. Adoption of a resect and discard policy for eligible diminutive polyps resulted in a savings of $25/person, without any meaningful effect on screening efficacy. Projected onto the US population, this approach would result in an undiscounted annual savings of $33 million. In the sensitivity analysis, the rate of high-confidence diagnosis and the accuracy for endoscopic polyp determination were the most meaningful variables. Conclusions: In a simulation model, a resect and discard strategy for diminutive polyps detected by screening colonoscopy resulted in a substantial economic benefit without an impact on efficacy. © 2010 AGA Institut. Source

Parodi A.,General Hospital | Repici A.,Digestive Endoscopy Unit | Pedroni A.,General Hospital | Blanchi S.,General Hospital | Conio M.,General Hospital
Gastrointestinal Endoscopy | Year: 2010

Background: Through-the-scope endoclips have been used to manage small perforations in the GI tract, but they have limitations. A new over-the-scope clip system, OTSC (Ovesco Endoscopy, Tuebingen, Germany), may be suitable for the closure of larger GI leaks. Objective: To evaluate the clinical outcomes of patients with GI perforations of up to 20 mm, treated with OTSC. Design: Prospective, single-arm, pilot study. Setting: General hospitals referral centers for endotherapy. Patients: This study involved 10 patients (median age 58.5 years [range 27-82 years], 7 men) with GI leaks from perforations, fistulas, and anastomotic dehiscence. Two gastric, 2 duodenal, and 6 colonic leaks were treated with OTSC. The diameter of leaks ranged between 7 and 20 mm. Interventions: OTSC devices were used to seal the GI leaks. Then Gastrografin (Bayer AG, Germany) was introduced via the endoscope and complete sealing confirmed under fluoroscopy. Patients underwent a second endoscopic examination 3 months later. Main Outcome Measurement: Complete sealing of the leak. Results: Complete sealing of leaks was achieved by using OTSC alone in 8 of 10 patients. For one patient, successful endoscopic management was completed by placing two additional covered stents. Only one patient required surgical repair of the leak. Endoscopic examination 3 months after treatment confirmed that leaks in 8 of 9 endoscopically treated patients were healed, and the patients did not have recurrence of the leaks or complications from the OTSC devices. One patient died from neoplastic progression before the second endoscopy could be performed. Limitations: Uncontrolled study. Conclusions: The OTSC system appears to be a useful device in the management of larger GI leaks in a variety of clinical scenarios. © 2010 American Society for Gastrointestinal Endoscopy. Source

Benatta M.A.,Digestive Endoscopy Unit
Pan African Medical Journal | Year: 2016

Iatrogenic pharyngoesophageal perforations represent serious problems that are difficult to diagnose and manage. We report a case of pharyngoesophageal diverticulum formation due to perforation after external transcervical polypectomy. The patient was referred to our endoscopy unit by otorhinolaryngologist 9 days after a surgical cervical polyp resection. He was in stable general condition, without sepsis. A nonoperative management was attempted with percutaneous endoscopic gastrostomy placement and broad-spectrum antibiotics. Nine weeks later esophagography demonstrated a complete regression of both the perforation and the diverticulum. © Mohammed Amine Benatta et al. Source

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