A. Repici

Endosonography in decision making and management of gastrointestinal endocrine tumors.

OBJECTIVEngastroenteropancreatic (GEP) neuroendocrine tumors, suspected on clinical basis, are often difficult to localize. We report our experience with endoscopic ultrasonography (EUS) in the preoperative localization of pancreatic endocrine tumors (PETs), compared to other imaging modalities, and in staging and following up carcinoid tumors (CTs) of the gastrointestinal (GI) wall.nnnMETHODSn50 patients (20 males; mean age 54 years), 39 with suspected PETs and 11 with GI CTs underwent EUS (Olympus GF-UM2 or GF-UM3). EUS data could be compared with resected specimens in 25 out of the 39 PETs and five out of the 11 CTs.nnnRESULTSnin the PETs group 42 tumors (35<20 mm) were removed: 23 in the pancreas, eight in the duodenum, and 11 in the lymph nodes. EUS correctly localized 20 out of the 23 (87%) pancreatic tumors, included 11 out of the 12 (91.6%) insulinomas, three out of the eight (37.5%) duodenal gastrinomas, and ten out of the 11 (90.9%) metastatic lymph nodes. Furthermore EUS accurately evaluated the depth of parietal invasion of CTs in three out of four patients (75%) (two after and one prior to endoscopic resection). In three patients EUS was confirmed as normal on resected specimens (two pancreas and one stomach). In the PETs group, a correct localization was obtained by ultrasonography (US) only in 17.4% of cases, by computed tomography (CT) in 30.4%, by magnetic resonance imaging (MRI) in 25%, by angiography in 26.6%, and by somatostatin receptor scintigraphy in 15.4%.nnnCONCLUSIONnEUS must be considered the first-intention method in localizing PETs and is helpful in decision making and management of GEP endocrine tumors.

Preliminary experience with a new cytology brush in EUS-guided FNA

BACKGROUNDnDespite the high diagnostic yield of EUS-guided FNA, room for technical improvements remains. Recently, the EchoBrush (Cook Endoscopy, Winston-Salem, NC), a disposable cytologic brush, was introduced to the market. To date, only 1 study, limited to 10 pancreatic cyst cases, using this device has been published.nnnOBJECTIVEnTo assess the diagnostic yield of the EchoBrush in a cohort of consecutive patients, irrespective of the target lesion.nnnDESIGNnCase series.nnnSETTINGnTertiary care university hospital (Molinette Hospital, Turin, Italy).nnnPATIENTSnThirty-nine consecutive patients (12 with solid pancreatic masses, 12 with pancreatic cysts, 7 with enlarged lymph nodes, and 8 with submucosal masses) were enrolled.nnnINTERVENTIONSnThe material collected with the EchoBrush and with a standard FNA needle was double-blind evaluated by 2 cytopathologists.nnnMAIN OUTCOME MEASUREMENTSnAdequacy of the sample and sensitivity and specificity of the EchoBrush method.nnnRESULTSnAdequate material for cytologic analysis was collected in 17 of 39 patients (43.6%) with a single pass of the EchoBrush. Results were better for pancreatic lesions (for solid and cystic lesions, the adequacy was 58.3% and 50%, respectively); adequacy was low (28.6% and 25%, respectively) for lymph nodes and submucosal masses. The overall sensitivity and specificity were 57.9% and 31.2%, respectively. There were no adverse events with the procedure.nnnLIMITATIONnPreliminary study.nnnCONCLUSIONSnThis report suggests that the EchoBrush may provide adequate cellularity to diagnose solid and cystic pancreatic lesions. More extensive studies are needed to compare the EchoBrush and standard needles.

Delivery of radiofrequency energy to the gastroesophageal junction (Stretta procedure) for the treatment of gastroesophageal reflux disease

BackgroundRadiofrequency (RF) energy treatment is increasingly offered before invasive surgical procedures for selected patients with gastroesophageal reflux disease (GERD).MethodsThirty-two patients undergoing the Stretta procedure were prospectively evaluated with upper endoscopy, manometry, 24-hour pH testing, SF-36 surveys, and GERD-specific questionnaires (GERD HRQL).ResultsSignificant clinical improvement was observed in 91% of patients (29/32). Mean heartburn and GERD HRQL scores decreased (p = 0.001 and p = 0.003, respectively), and physical SF-36 increased (p = 0.05). At a minimum follow-up of 12 months, median esophageal acid exposure decreased (p = 0.79) and was normalized in eight patients. Median lower esophageal sphincter (LES) pressure was unchanged. Esophagitis healed in six of eight patients, but two patients with nonerosive disease developed asymptomatic grade A esophagitis during follow-up. At 12 months, 56% of patients were off proton pump inhibits. Morbidity was minimal.ConclusionsRF delivery to LES is safe and significantly improves symptoms and quality of life in selected GERD patients.

Adrenaline plus cyanoacrylate injection for treatment of bleeding peptic ulcers after failure of conventional endoscopic haemostasis

BACKGROUNDnEndoscopic therapy is a safe and effective method for treating non-variceal upper gastrointestinal bleeding. However failure of therapy, in terms of continuing bleeding or rebleeding, is seen in up to 20%. Cyanoacrylate is a tissue glue used for variceal bleeding that has occasionally been reported as an alternative haemostatic technique in non-variceal haemorrhage.nnnAIMnTo retrospectively describe personal experience using cyanoacrylate injection in the management of bleeding ulcers after failure of first-line endoscopic modalities.nnnPATIENTS AND METHODSnBetween January 1995 and March 1998, 18 [12 M/6 F, mean age 68.1 years) out of 176 patients, referred to our Unit for non-variceal upper gastrointestinal bleeding, were treated with intralesional injection of adrenaline plus undiluted cyanoacrylate. Persistent bleeding after endoscopic haemostasis or early rebleeding were the indications for cyanoacrylate treatment.nnnRESULTSnDefinitive haemostasis was achieved in 17 out of 18 patients treated with cyanoacrylate. One patient needed surgery. No early or late rebleeding occurred during the follow-up. No complications or instrument lesions related to cyanoacrylate were recorded.nnnCONCLUSIONSnIn our retrospective series, cyanoacrylate plus adrenaline injection was found to be a potentially safe and effective alternative to endoscopic haemostasis when conventional treatment modalities fail in controlling bleeding from gastroduodenal ulcers.

Lymphocytic gastritis and protein-losing gastropathy

Lymphocytic gastritis is a histopathological entity of unknown aetiology which is characterized by dense surface and foveolar epithelial T-cell infiltration. We report here an uncommon clinical presentation in a young female presenting with unexplained recurrent weight loss and peripheral oedema. Endoscopic and histological features before and after successful therapy with omeprazole are described.

ENDOSCOPIC ULTRASOUND FINE‐NEEDLE ASPIRATION IN THE DIAGNOSIS OF INTRAPANCREATIC ACCESSORY SPLEEN

Intrapancreatic accessory spleens represent a potential pitfall in the diagnosis of pancreatic lesions by mimicking pancreatic neoplasms, in particular, neuroendocrine tumors. We report two cases of intrapancreatic accessory spleen discovered in patients with a previous history of neuroendocrine tumors. Case 1. A 39-year-old woman with a history of welldifferentiated pancreatic neuroendocrine tumor with liver metastases underwent follow-up endoscopic ultrasound (EUS) (Olympus GF-UCT140AL5; Olympus America, Melville, NY, USA) revealing a well-defined, homogeneous, hypoechoic lesion in the tail (Ø13 mm), suggesting a neuroendocrine localization; echo-Doppler showed arterial and venous supply. EUS-fine-needle aspiration (FNA) was carried out with a 22-G needle (Wilson-Cook, WinstonSalem, NC, USA), (Fig. 1). A dedicated cytopathologist carried out a rapid on-site evaluation (ROSE): two slides were smeared and remaining material preserved for cellblock preparation. Smears showed tangles of small blood vessels and a population of heterogeneous lymphocytes, intermixed with neutrophils, histiocytes and plasma cells (Fig. 2). Flow cytometry showed a polyclonal B and T cell population. Immunocytochemistry for cytokeratin AE1/AE3 on cell-block sections was negative.These findings were diagnostic for accessory spleen. Case 2. A 71-year-old man with a diagnosis of a welldifferentiated, somatostatin-producing neuroendocrine tumor underwent a pancreasectomy plus splenectomy in 2007. Follow-up EUS revealed a mass of 2 cm in the pancreatic head, hypo-isoechoic with smooth margins. EUS-FNA was carried out and ROSE smears showed mostly lymphocytes interspersed with other inflammatory cells. Cell-block sections showed characteristic features of both white and red pulp (lymphoid tissue with traversing vascular structures, lined by elongated, flat endothelial cells with typical beanshaped nuclei having a longitudinal cleft) and immunocytochemistry confirmed the previous findings: AE1/AE3, chromogranin and synaptophysin were CD68 KP-1 and CD8 stained the sinus endothelial lining cells, resulting in a diagnosis for accessory spleen. We confirm that EUS-FNA is a safe and sensitive test that allows an accurate diagnosis of intrapancreatic accessory spleen, ruling out neuroendocrine tumor and avoiding unnecessary surgery.

Place de l'échoendoscopie en Italie

RésuméL’échoendoscopie a fait ses débuts en Italie en 1981 grâce au travail d’un groupe de pionniers de l’Université de Bologne. A compter de cette date, l’échoendoscopie italienne a fait de considérables progrès en termes de technique et d’organisation tant sur le plan quantitatif que qualitatif, mais beaucoup de travail reste à faire surtout en ce qui concerne la ponction guidée sous écho-endoscopie (EUS-FNA) à visée diagnostique et thérapeutique. Dans ce domaine, une collaboration active entre le Groupe de Travail Italien pour l’échoendoscopie et les Clubs Français et Belge est largement souhaitable.SummaryEndoscopic Ultrasound in Italy started in 1981 thanks to the work of a pioneeristic group at the University of Bologna. In the following years endoscopic ultrasound in Italy has made good progress in terms of number of examinations, quality of the technique and organization, but a huge quantity of work still remains to be done particularly in the field of diagnostic and therapeutic EUS-FNA. For this purpose an active collaboration between the Italian Group of Work for Endosonography and the French and Belgian Clubs would really be highly desirable.

Endoscopia e chirurgia oncologica

La terapia per via endoscopica e emersa quale metodo molto efficace e minimamente invasivo per il controllo e il trattamento precoce delle neoplasie del tratto digestivo. La polipectomia ha rappresentato un progresso rilevante e, piu di recente, l’ablazione e la resezione della mucosa per via endoscopica appaiono molto efficaci nel trattamento di aree neoplastiche piatte della mucosa intestinale. L’uso dell’ecografia endoscopica (endoscopic ultrasonography; EUS) ha portato a una maggiore accuratezza nella stadiazione neoplastica e l’agoaspirato EUS-guidato e riuscito a ottenere la diagnosi istologica di formazioni poste al di fuori del lume intestinale. Nei tumori avanzati, usualmente gestiti da un team multidisciplinare di oncologi, chirurghi e radiologi, l’endoscopista gastrointestinale (GI) ha assunto un ruolo chiave non solo nella diagnosi, ma anche nella palliazione, con l’impiego di stent per superare le ostruzioni gastrointestinali, con l’ablazione e con il posizionamento di cateteri per il drenaggio o per l’alimentazione.

Endoscopy and Surgical Oncology

Endoscopic therapy has emerged as a highly effective and minimally invasive way to control and cure early neoplasia of the digestive tract. Polypectomy has been a major advance, and most recently ablation and endoscopic mucosal resection seem to be highly successful in treating flat neoplastic areas involving the gut mucosa. The use of endoscopic ultrasonography (EUS) has resulted in improved accuracy for cancer staging, and EUS-guided fine-needle aspiration has been successful in obtaining tissue diagnosis outside the gut lumen. In advanced cancer, usually managed by multidisciplinary teams of oncologists, surgeons, and radiologists, the gastrointestinal endoscopist (GI) has assumed a key role not only in diagnosis but in palliation with the use of stents to bridge GI obstruction, ablation and the placement of tubes for drainage and feeding.

Echo-endoscopic en Italie : situation en 2005

ConclusionA la lumière d’une évaluation rétrospective des données, nous pouvons dire qu’en Italie, l’activité s’accroît dans le domaine du diagnostic par PAF-EE dans un nombre suffisant de centres (Fig. 6). En revanche, les nouvelles techniques thérapeutiques interventionnelles sous contrôle EE se mettent plus difficilement en place.Les principales techniques thérapeutiques, (drainage de collections liquidiennes sous échographie guidée et neurolyse du plexus cœliaque) ne sont réalisées en routine que dans les principaux centres de référence. En 2004, tant à Bologne qu’à Turin, nous avons eu la possibilité d’utiliser et d’évaluer un nouveau prototype d’échoendoscope à balayage radiaire électronique de 360° (XGF-UE140-AL5), mis au point en octobre 2003 par la firme Olympus (Tokyo, Japan). Cet instrument procure des images radiaires de 360° du tractus gastro-intestinal et des structures avoisinantes et permet une analyse des tissus par Doppler couleur et par l’imagerie US harmonique (Fig. 7). En outre, dans certains centres, nous expérimentons le rehaussement ultrasonore par produit de contraste, un nouveau logiciel en 3D mis au point par Olympus (MAJ-1330) et également la sonoélastographie.En conclusion, en dépit de la persistance de plusieurs problèmes, nous avons assisté en Italie, au cours de ces 3 dernières années, à d’importants progrès en terme de nombre et de qualité des examens, d’amélioration dans l’organisation et la communication entre les échoendoscopistes. Dans ce contexte, le Club Italien d’EE fait preuve de son excellente vitalité et de sa capacité à apporter une réponse appropriée aux exigences de formation dans ce domaine.ConclusionsComing back to the results of our surveys we must say that in Italy the way is still uphill about an adequate spreading of the diagnostic EUS-FNA in a sufficient number of centres (Fig. 6). Even more difficult is the diffusion of the new interventional therapeutic procedures under EUS guidance.The main therapeutic procedures, i.e. EUS-guided collections drainage and celiac plexus neurolysis, are routinely performed only in the major referral centres. During 2004 in Bologna and Turin we have the opportunity of investigate and evaluate the potential of the new prototype of an ultrasound endoscope with a 360° electronic radial scanner (XGF-UE140-AL5), developed in October 2003 by Olympus (Tokyo, Japan). This instrument can provide adequate 360° radial images of the GI tract and surrounding structures also with colour-Doppler and tissue harmonic imaging capabilities (Fig. 7). Furthermore in some centres we are experiencing the contrast-enhanced EUS, the new 3D software manufactured by Olympus (MAJ-1330) and also sonoelastography.In conclusion despite several still existing problems in the last 3 years EUS in Italy showed good progress in terms of number and quality of procedures, improvement in organization and communication between endosonographers. In this environment the EUS Italian Club demonstrated a good vitality and the capability of giving adequate response to the training requirements.