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Competing Interests: None

Competing Interests: Vincenzo Cennamo: Olympus Italia, Olympus Europa, Euromedical, Novità Medicali.

Standard endoscopic mucosal resection (EMR) is limited with regard to lesions below or involving the ileocecal valve. We describe the treatment and outcomes when using cap-assisted EMR (EMR-C) to remove large laterally spreading tumors (LSTs) with ileal infiltration in seven patients (median age 74 years). Each LST (median size 40 mm) was successfully resected in one session (median procedure time 50 minutes). Intraprocedural and early bleeding occurred in two patients, and delayed hemorrhage in one. Circumferential resection of the ileum caused asymptomatic strictures in six patients, with regression during follow-up for five. We conclude that the novel EMR-C method is a potentially effective treatment for cecal LST involving the distal ileum. Serious complications such as perforation or symptomatic strictures of the ileocecal valve were not observed and any procedure-related bleeding was easily controlled., ((c) Georg Thieme Verlag KG Stuttgart . New York.)

Benign tumours of the biliary tree are rare. In particular, only anecdotal cases of intraductal villous adenomas have been reported. The polyp-cancer sequence has not been observed in the biliary epithelium, in contrast to the paradigm of colorectal carcinogenesis. This report presents the case of a 64-year-old woman with a past history of cholelithiasis who had two early neoplasias involving the biliary epithelium: an adenocarcinoma in situ of the gallbladder and a common bile duct (CBD) villous adenoma with high-grade dysplasia. The tumours presented 4 years apart. The clinical features and combined radiological, cytological, and surgical modalities leading to the diagnosis of intraductal villous adenoma are presented. The endoscopic ultrasound (EUS) characteristics of villous adenoma of the CBD are described. While the prognosis on both occasions appears excellent following curative resections of both tumours detected at an early stage, it is possible that further neoplasia involving the biliary tree may recur. There are currently no data on optimal surveillance modalities. It may be hypothesized that the gallbladder and biliary epithelium share a similar mechanism for carcinogenesis to that observed in the colonic adenomacarcinoma sequence.

The optimal treatment of adenomas of the papilla of Vater has still not been definitively established, and the endoscopic excision of such lesions has received little attention in the literature. We report here the cases of two patients with familial adenomatous polyposis, in whom ampullary adenomas measuring 8 and 20 mm, respectively, were treated using one-piece snare excision of the lesion together with the papilla (snare papillectomy), followed by temporary biliopancreatic drainage. Procedure-related complications were an oozing-type hemorrhage and a mild pancreatitis, easily controlled by conservative measures. During the 18-month follow-up, one patient had a small recurrence that was successfully retreated. Further endoscopic and biopsy controls were negative. Although limited, our experience and the data in the literature indicate that snare papillectomy is a viable alternative to surgery for benign ampullary adenomas. Excising both the lesion and the papilla offers good oncological debridement and, unlike laser or thermal ablation, allows a complete histological evaluation of the pathological tissue. However, snare papillectomy should always be associated with temporary biliopancreatic drainage before or after the procedure in order to prevent ductal obstruction and serious pancreatitis. This maneuver should therefore preferably be performed by experienced endoscopists trained in therapeutic endoscopic retrograde cholangiopancreatography and hemostatic techniques.

Background and Study Aims: In argon plasma coagulation (APC), high-frequency energy is transmitted to tissue by ionized gas, thus reducing contact with the tissue to a minimum. Successful endoscopic APC was initially reported in the palliative treatment of gastrointestinal neoplasms. The main objectives in this pilot study were to evaluate the treatment indications, efficacy and safety of the use of APC., Patients and Methods: Between September 1994 and January 1996, APC was used to treat 125 patients with various forms of gastrointestinal pathology., Results: For local palliative treatment, APC was successfully used alongside snare loop coagulation, dilation, stenting and/or radiotherapy to treat the following conditions: carcinoma of the esophagus: 15 patients, mean number of treatment sessions (MTS) 3.3; gastric carcinoma: 10 patients, MTS 4.9; rectosigmoid carcinoma: seven patients, MTS 2.7; carcinoma of the papilla of Vater: two patients, MTS 1.5. Repeated treatment was also effective for tubulovillous adenoma of the rectum (20 patients, MTS 2.5), stomach (three patients, MTS 2.0), duodenum (two patients, MTS 1.5) and papilla of Vater (two patients, MTS 3.0). In addition, APC proved helpful in coagulating the remaining tissue and achieving hemostasis after polypectomy in the colon (18 patients, MTS 1.2) and in endoscopic treatment of Zenker's diverticulum, for coagulation of the tissue bridge and hemostasis (31 patients, MTS 2.5). Finally, APC was helpful in coagulation of multiple gastric polyps (one patient, one session), hemostasis in superficial ulceration of the duodenal bulb (one patient, one session), after dilation of benign stenoses of anastomoses in the esophagus (one patient, one session) and colon (one patient, one session) and for vascular malformations in the colon (three patients, MTS 1.3), duodenum (one patient, one session), antrum (one patient, two sessions), and watermelon stomach (six patients, MTS 2.8). We recognized signs of perforation in six patients after treatment of Zenker's diverticulum (n = 3), polypectomy in the colon (n = 2) and coagulation of angiodysplasia in the cecum. Laparotomy was carried out in two patients; in one, a perforation was sutured, and in the other no focus of leakage was seen. All six patients recovered without further complications. No complications were observed in any other patients., Conclusions: These initial experiences indicate that APC seems to be effective in a number of indications, and relatively safe. Objective evaluation, a longer follow-up period, and comparative trials with other treatment modalities should follow.

Patches of hererotopic gastric mucosa located in the upper esophagus are a frequent finding at endoscopy. These lesions are thought to be of congenital origin and of low malignant potential. However, several cases of adenocarcinoma developing on inlet patches have recently been described. We report here a new case of adenoma that had developed on heterotopic gastric mucosa in the upper esophagus, associated with an area of high-grade dysplasia. This polyp was removed surgically under endoscopic guidance, after confirmation of the superficial pattern of the lesion by endoscopic ultrasonography. This report emphasizes the malignant potential of esophageal inlet patches of heterotopic gastric mucosa.

Six patients with seven small, nonampullary duodenal villous or tubulovillous adenomas, two of which showed mild dysplasia, were treated by laser photocoagulation. The mean size of the tumors was 19 +/- 16 mm. Both argon and Nd-YAG lasers were used. All tumors were destroyed in one to five sessions. Recurrences of the lesion in two cases were successfully retreated, and both patients remained free of recurrence after 33 and 48 months, respectively. After a median follow-up of 59 months, all patients remained in remission, and five of them are still alive. One died after six months from a bronchogenic carcinoma. After a total of 18 laser sessions, no serious side-effects were observed, two patients exhibiting a transient melena possibly related to the procedure. We conclude that laser therapy is a good alternative to surgery for nonampullary duodenal villous tumors, especially in high-risk patients. Endoscopic follow-up is mandatory to detect and treat recurrence.

With the water jet guided laser, a comparatively new transmission system has become available, with the aid of which the laser beam is conducted from the end of the transmission fibre of the conventional light guide system to the target tissue via a water jet. The extra costs of this modality are low. The technique is easy to apply, and is associated with a number of technical advantages, such as absence of smoke and carbonisation, reduction in organ distension, etc. The water jet guided laser brings about volume coagulation in the deeper layers of the wall, with concomitant oedema and hyperaemia in the periphery. In a randomised, prospective controlled study, 89 patients with gastroduodenal ulcers bearing a visible vessel were treated with the Nd:YAG laser (wavelength 1.064 nm), 43 with the non-contact, and 46 with the water jet guided modality. In the water jet group a smaller number of bleedings were induced (p < 0.05) and fewer failures, emergency operations and deaths occurred. The technical advantages of the method, together with the results of treatment in 20 tumour patients with adenomas (n = 6) and adenocarcinomas in the colorectum (n = 14) with readily achievable tumour debulking (n = 13) or complete eradication (n = 7), suggest that the use of the water jet guided laser might also be appropriate for the treatment of tumours.