Combined laparoscopic-endoscopic “rendez-vous” procedure in a case of gastric Schwannoma in a toddler

Introduction. Schwannomas are rare benign tumors of the gastrointestinal tract. Despite the differences in features of schwannomas located in the stomach as opposed to peripheral or soft tissue schwannomas, their immunohistochemical characteristics are the same. We present a case of a 14-month-old boy with a gastric tumor who underwent a combined laparoscopic-endoscopic resection surgery, followed by gastric schwannoma diagnosis. Case outline. The patient was admitted to our pediatric hospital with a fever of unknown origin. Endoscopy, performed after recurrent hematemesis, revealed an ulcer in the gastric antrum. At the four-week follow-up, gastroscopic and microscopic findings were normal. Two weeks later, a flank mass in the antrum was detected by an ultrasound examination. A new gastroscopy and CT scan confirmed the presence of a tumor-like mass, 5 cm in diameter. A combined laparoscopic-endoscopic polypectomy was performed with a necessary conversion for complete resection of tumor. The initial histological findings were consistent with a gastrointestinal stromal tumor. Due to this tumor?s rarity in childhood, the paraffin-embedded tissue samples were referred for a second opinion. Histological and immunohistochemical characteristics of the tumor made the gastrointestinal stromal tumor diagnosis unlikely and consistent with a completely resected gastric schwannoma. No recurrence of the disease occurred during the seven-year follow-up. Conclusion. Combined laparoscopic-endoscopic surgery is a feasible and effective treatment for large gastric tumors that cannot be excised endoscopically. Schwannoma should be included in the differential diagnostic consideration of gastric tumor lesions even in childhood.

Practice Guidelines of the Central European Hepatologic Collaboration (CEHC) on the Use of Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease Undergoing Invasive Procedures

Background: Second-generation thrombopoietin receptor agonists (TPO-RAs) are emerging as the new standard for managing thrombocytopenia (TCP) in patients with chronic liver diseases (CLDs) undergoing scheduled procedures. However, practical guidance for their routine use in CLD patients undergoing specific invasive procedures is lacking. Methods: These practice guidelines were developed by the Initiative Group for Central European Hepatologic Collaboration (CEHC), composed of nine hepatologist/gastroenterologist experts from Central Europe. Using an adapted Delphi process, the CEHC group selected ten invasive procedures most relevant to the hepatology/gastroenterology setting in the region. Consensus recommendations for each invasive procedure are reported as a final percentage of expert panel responses. Results: A consensus was agreed that TPO-RAs should be considered for raising platelet count in CLD patients undergoing scheduled abdominal surgery, high-bleeding risk dentistry, endoscopic polypectomy, endoscopic variceal ligation, liver biopsy, liver surgery, liver transplantation and percutaneous ablation, but it was also agreed that they are less beneficial or not necessary for endoscopy without intervention and paracentesis. Conclusions: Using a modified Delphi method, experts reached an agreement for TCP management in CLD patients undergoing ten invasive procedures. These practice guidelines may help with decision making and patient management in areas where clinical evidence is absent or limited.

SURGICAL TREATMENT OF PATIENTS WITH CHRONIC RHINOSINUSITIS AND NASAL POLYPS UNDER ELECTIVE DENTAL IMPLANTAT PLACEMENT WITH SINUS LIFTING SURGERY

Dental implant placement is widely used method of dentition restoration, and if necessary, is performed with subantral augmentation of bone tissue and can be associated with an increased risk of complications in cases of mucosa alterations. To the disease and patency of the ostiomeatal complex and to minimize the possible risks is the key task when preparing patients with chronic rhinosinusitis and nasal polyps for sinus lifting. The aim of the study is to investigate the effect of shaver polipectomy method in chronic rhinosinusitis and nasal polyps on the outcomes of sinus lifting and the frequency rate of complications. Materials and methods. The study was based on data obtained from 72 patients having chronic rhinosinusitis and nasal polyps, who underwent endoscopic functional sinus surgery according to the principles of sparing effect on the periosteum in the alveolar bay (periosteum-preserving technology). The patients were divided into two groups: I group included 35 patients subjected to shaver polypectomy; II group consisted of 37 individuals operated on by standard conventional method. Results. The average total Lund-Mackay (LM) score before endoscopic rhinosurgery in I group was 14.57±0.52 scores, and 13.32±0.6 scores in the II group. It went down to 4.26±0.38 in I group and to 4.61±0.39 in II group (p <0.05) 3 months after the intervention. In the 6th month of post-surgical follow up there was a significant increase in the total LM score in the patients of II group up to 6.84±0.6 that indicates a more stable result after shaver-assisted sinusotomy. The incidence of sinus lifting complications after endoscopic polypectomy was 24.32±7.05% of cases in the patients of I group compared to the individuals of II group having 2 37.14±8.17% of complicated cases (p <0.05). Sinus lifting and dental implant placement were found out to be effective in all patients of I group and in 94.29±3.92% of patients in the II group. Conclusions. Endoscopic intervention stuck to principles of preserving periosteum and providing appropriate therapeutic support to patients with chronic rhinosinusitis under control allows oral surgeons to perform safe dental implant placement with subantral bone augmentation. Applying shaver-assisted periosteum-preserving technique for surgical treatment of patients with chronic rhinosinusitis and nasal polyps provides a longer clinical effect and reduces the incidence of postoperative complications of subantral bone augmentation by 12.82%.

Use of Elastic Stain Technique to Detect Histologically Occult Vascular Invasion in Resected Colorectal Carcinomas at Danbury Hospital

Introduction/Objective Colorectal carcinoma (CRC) represents a leading cause of cancer related death in the western world and is by far the most common malignancy of the gastrointestinal tract. Vascular invasion (VI), in particular extramural VI by tumor is recognized as a feature of colorectal cancer progression, and the latter is an independent prognostic indicator of disease recurrence and survival in colorectal carcinoma. The purpose of this study is to detect VI in resected colorectal tumor samples and compare sensitivity of elastic staining to routine H&E staining at Danbury Hospital. Methods/Case Report A total of 50 colorectal cancer specimens from segmental colon resection or endoscopic polypectomy performed at Danbury Hospital over a 3-year period were included. Histologic sections of each tumor were assessed for the presence of VI by routine H&E staining. Superficial recuts of each tumor were subjected to elastic Von Giesen staining and reassessed for the presence of vascular invasion. Sensitivity of routine H&E staining for the detection of VI was calculated with elastic stain serving as the “gold standard”. Results (if a Case Study enter NA) In this study, VI by carcinoma was identified by H&E stain and/or elastic stain in 17 (34%) out of 50 cases. H&E stain and elastic stain detected VI in 12 (24%) and 16 (32%) out of 50 cases, respectively. There was a single case for which H&E stain showed vascular invasion that was not confirmed by elastic stain, representing a false negative for the H&E technique. Elastic staining detected VI in 5 cases for which the corresponding H&E stain was falsely negative for VI. Overall, vascular invasion status (absent or present) was concordant in 44 (88 %) of the 50 cases. With elastic stain deemed the “gold standard” for VI detection, the sensitivity, specificity, negative predictive value, and positive predictive value of H&E stain were found to be 68.7%, 97.0%, 86.8%, and 91.6%, respectively. Conclusion Although H & E staining of colorectal carcinoma tissue sections have a very good specificity and positive predictive value for the detection of VI, this technique suffers from a suboptimal sensitivity. For these reasons, we agree with previously published literature reports that the use of elastic stain as a supplement to H & E staining should be strongly considered for the proper evaluation and prognostication of colorectal carcinoma specimens.

Sphenochoanal Polyp - "The Forgotten Element?"

Introduction The occurrence of isolated spheno-choanal polyps are not very common and can be very well confused with antro-choanal polyps or adenoids in adolescents and children. Appropriate diagnosis and prompt surgical intervention are essential for its removal. Case Report We report one such case of a 16 year old female who presented with complaints nasal obstruction and reduced hearing. Endoscopic polypectomy was done with complete removal of the polyp. Discussion Sphenochoanal Polyp is often misdiagnosed and proper investigations are thus essential for its diagnosis. Surgical Approach is the mainstay form of treatment with complete excision of the polyp.

Importance of sessile serrated lesions in a patient with familial adenomatous polyposis

A 28-year-old male visited hospital because his mother had been diagnosed with familial adenomatous polyposis (FAP) with a pathological variant of the APC gene. Total colonoscopy showed that he has more than 100 polyps distributed throughout the colorectum, and the APC gene variant was also detected. After he was diagnosed with FAP, he received information that surgery was currently the only way to prevent the development of colorectal cancer. However, he firmly declined to undergo surgical procedures and decided to have strict follow-up with frequent endoscopic polypectomy to prevent the development of colorectal cancer. At the first endoscopy, polypectomy was performed on 52 polyps. Histological analysis of the dissected polyps showed that they were all adenomas, but adenocarcinoma was not detected. The second endoscopic polypectomy was performed after 4 months later. We found a pale 20 mm wide flat, elevated type polyp in the ascending colon with an adherent mucus cap that was resistant to washing off. After endoscopic mucosal resection, histological analysis revealed that there were two lesions in the polyps, a sessile serrated lesion (SSL) and SSL with dysplasia. SSL is a high-risk lesion for colorectal cancer, but it was reported to be rare in patients with FAP, and the existence of SSL suggested another carcinogenesis pathway in patients with FAP in addition to the adenoma-carcinoma sequence. Our report may be significant not only in consideration of the pathogenesis of FAP but also useful to raise awareness of SSL for clinicians who perform endoscopic polypectomy to prevent the development of colorectal cancer in patients with FAP.

Gastric Polyps: A 10-Year Analysis Of 18496 Upper Endoscopies

Background/Aims: Gastric polyps (GPs) are usually asymptomatic lesions of the upper gastrointestinal tract observed in 1-3% of esophagogastroduodenoscopies (EGD). The majority of polyps are benign. The aim of this study was to precise the frequency of different types of gastric polyps in our population, and to analyze their possible association with other factors.Materials and Methods: A total of 18496 consecutive patients undergoing EGD over a ten-year period (between 2007 and 2018) in a tertiary hospital were retrospectively reviewed. Eighty-six patients diagnosed with gastric polyps were analysed. Demographics, medical history of the patients, and indication for gastroscopy were collected. Morphological, histological characteristics of polyps, and therapeutic management data were also collected.Results: GPs were found in 86 out of 18496 (0.46%) reviewed EGD, corresponding to a total of 141 polyps. There were 64 female (74.4%) and 22 male patients (25.6%) with a sex ratio (M/F) of 0.34. The average age was 58.1 years. One hundred and forty one polyps were included, and histopathology was obtained on 127 GPs. The most common location was the fundus (59.6%) and 48.9% were smaller than 5 mm. The polyp was unique in 75.6% of cases. According to Paris classification, 80% of the polyps were sessile (Is). Hyperplastic polyps were the most common (55.9%) were hyperplastic polyps, followed by sporadic fundic gland polyps in 23 patients (18.1%), 7 (5.5%) were adenomas, and 4 (3.1%) were neuroendocrine tumors type 1. The following factors were associated with hyperplastic polyps: anemia (p= 0.022), single polyp (p= 0.025) and size ≥ 5mm (p= 0.048). Comparing hyperplastic polyps biopsies to resected polyps, no difference was found in the evolutionary profile of the 2 groups. A size less than 10 mm (p=0.013) was associated with fundic gland polyps. Sixty polyps (47.2%) were treated by cold forceps, 19 (15%) treated by a mucosal resection and 15 (11.8%) with diathermic snare. Five procedural bleeding incidents were observed (3.9%). Only the use of anticoagulant treatment was associated with a high bleeding risk (p= 0.005). The comparative histological study between specimens of biopsied GPs and endoscopic polypectomy led to an overall agreement of 95.3%.Conclusion: In our study, the GPs frequency was 0.36%. Hyperplastic polyps and fundic gland are the most common gastric polyps in our country. The high frequency of Helicobacter pylori infection in our patients and in our area may explain the high frequency of HP.

BLADDER FUNCTION AFTER CONSERVATIVE SURGERY AND HIGH-DOSE-RATE BRACHYTHERAPY FOR BLADDER-PROSTATE RHABDOMYOSARCOMA.

Background: Conservative-surgery (CS) brachytherapy (BT) techniques for local therapy in bladder-prostate rhabdomyosarcoma (BP-RMS) seeks to retain organ function. We report bladder function after high-dose-rate (HDR) BT combined with targeted CS for any vesical component of BP-RMS. Procedure: Prospective cohort of all BP-RMS patients between 2014-19 receiving HDR-BT (Iridium-192, 27.5Gy in 5 fractions) with/without percutaneous endoscopic-polypectomy (PEP) or partial cystectomy (PC). Functional assessment included frequency-volume-chart, voided volumes, post-void residual, flow studies, continence status and ultrasound scanning; abnormalities triggered video-urodynamics. Results: Thirteen patients (10 male), aged 9 months to 4 years (median 23 months), presented with localised fusion-negative embryonal BP-RMS measuring 23-140mm (median 43mm) in cranio-caudal extent. After induction chemotherapy, local treatment consisted of PC+BT in three, PEP+BT in four and BT alone in six. At a median 3½ years (range 1¾-7 years) follow up, all were alive without relapse. At a median age of 6 years (4-9 years), the median bladder capacity was 86% (47%-144%) of that expected for age, including 75% (74-114%) after PC. There was no relation to radiation dose to the bladder. Complications occurred in two: one urethral stricture and one vesical decompensation in a patient with pre-existing high-grade VUR. The remaining patients are dry by day; five with anticholinergic medication for urinary urgency. Three patients are enuretic. Conclusions: Day-time dryness at a median 3½ years after CS-HDR-BT was achieved in 92%, with 85% voiding urethrally, and 62% attaining day-and-night continence aged 4-9 years. We report reduced open surgery, with minimally-invasive percutaneous surgery with HDR-BT or brachytherapy alone being suitable for many.