Volume 86 - 2023 - Fasc.1 - Reviews
Colorectal endoscopic submucosal dissection: a review on patient selection and indications
Background: The development of ‘third-space’-endoscopy has paved the way towards en-bloc resection of early gastrointestinal neoplasia. Endoscopic submucosal dissection (ESD) has improved the endoscopic management of colorectal lesions by facilitating R0-resection, improving histological assessment and preventing recurrence.
Methods: The purpose of this review is to provide an evidence-based overview of indications for which ESD should be considered within colorectal endoscopy.
Results: The development of ESD has partially bridged the gap between endoscopy and surgery, but depends heavily on adequate pre-resection visual evaluation, ruling out potential deep submucosal invasion. ESD should be considered for large colorectal polyps (≥20mm) and/or lesions diagnosed as harbouring high-grade dysplasia, in-situ carcinoma or superficial submucosal invasion. Not only has it found its way into our guidelines for the treatment of neuroendocrine neoplasms, ESD also seems a promising alternative for the controlled resection of large pedunculated lesions. ESD can also be applied in more challenging situations, such as in pre-treated lesions, post-surgical context and in patients with IBD, although this requires a high level of skill and expertise.
Conclusions: In this review we have described the different indications for ESD and attempted to define its place within our current endoscopic armamentarium. For both non-expert and expert endoscopists, knowledge about ESD indications, patient selection and therapeutic alternatives, remains crucial in the care for patients with colorectal neoplasia.
Neuromodulating agents in functional dyspepsia: a comprehensive review
Background and study aims: Functional dyspepsia is a common
chronic condition with upper abdominal symptoms in the absence
of an organic cause. The first line treatment consists of protonpomp
inhibition or Helicobacter pylori eradication. However,
this approach often does not provide enough symptom relief.
Neuromodulating agents are commonly used in clinical practice but
only tricyclic antidepressant (TCAs) are mentioned in European
and American and Canadian guidelines.
Methods: We performed a comprehensive review of the
literature in Pubmed for full-text randomized controlled trials in
English with adult participants (>18 years) who met the Rome II,
III or IV criteria or were diagnosed by a physician with a negative
upper endoscopy and that compared a neuromodulating agent with
placebo.
Results: The search strategy identified 386 articles of which 14
articles met the eligibility criteria. TCAs like amitriptyline and
imipramine have been shown to be effective in the treatment of
functional dyspepsia whereas other neuromodulating agents like
tetracyclic antidepressants, levosulpiride and anxiolytics might
be beneficial but conclusive evidence is lacking. serotonin and
noradrenaline reuptake inhibitors (SNRI) and selective serotonin
reuptake inhibitors (SSRI) have not shown benefit in patients with
functional dyspepsia.
Conclusion: Selected neuromodulators have an established
efficacy in functional dyspepsia. The best supporting evidence
is available for TCAs with a potential role for tetracyclic
antidepressants, levosulpiride and anxiolytics.
Secondary anal fissures: a pain in the a**
An anal fissure is a painful tear of the sensitive anoderm, distally from the dentate line. It is a prevalent disorder and impairs quality of life dramatically. Typical or primary fissures are associated with constipation and mostly located at the posterior midline. About 1% of fissures are atypical in appearance and are generally secondary in nature. These secondary fissures should arouse attention and require further exploration for underlying conditions, such as Crohn’s disease, malignancy, trauma or venereal infections. The aim of this manuscript is to provide a comprehensive review on the clinical aspects, evaluation and treatment of secondary anal fissures.
