Filippo Catalano

The Italian Research Group for Gastric Cancer (GIRCG) guidelines for gastric cancer staging and treatment: 2015

This article reports the guidelines for gastric cancer staging and treatment developed by the GIRCG, and contains comprehensive indications for clinical management, including radiological, endoscopic, surgical, pathological, and oncological paths.

Treatment for Retrieved Common Bile Duct Stones During Laparoscopic Cholecystectomy: The Rendezvous Technique

OBJECTIVE To determine the feasibility and efficacy of the laparoscopic intraoperative rendezvous technique for common bile duct stones (CBDS). DESIGN Case series. SETTING Verona University Hospital, Verona, Italy. PATIENTS A total of 110 patients were enrolled in the study; 47 had biliary colic; 39, acute cholecystitis; 19, acute biliary pancreatitis; and 5, acute biliary pancreatitis with associated acute cholecystitis. INTERVENTIONS In all patients, CBDS diagnosis was reached by intraoperative cholangiography. Intraoperative endoscopy with rendezvous performed during laparascopic cholecystectomy for confirmed CBDS; for such a procedure, a transcystic guide wire was positioned into the duodenum. Intraoperative endoscopy with rendezvous was performed for retrieved CBDS during a laparoscopic cholecystectomy. MAIN OUTCOME MEASURES Laparoscopic rendezvous feasibility, morbidity, postprocedure pancreatitis, and mortality. RESULTS The laparoscopic rendezvous proved to be feasible in 95.5% (105 of 110 patients). The rendezvous failed in 3 cases of successfully performed laparoscopic cholecystectomy, and a conversion of the laparoscopy was needed in 2 cases of successful rendezvous. Two major complications and 2 cases of bleeding were registered after sphincterotomy was successfully performed with rendezvous, and severe acute pancreatitis complicated a traditional sphincterotomy performed after a failed rendezvous. CONCLUSIONS Rendezvous is a feasible option for treatment of CBDS; it allows one to perform only 1 stage of treatment, even in acute cases such as cholecystitis and pancreatitis. Positioning of the guide wire may allow reduced complications secondary to papilla cannulation but not those of the endoscopic sphincterotomy.

Endoscopic and Surgical Treatment of Early Gastric Cancer

Early gastric cancer (EGC) is defined as a tumor confined to the mucosa/submucosa, irrespective of the presence of lymph node metastases. Only high-quality endoscopic evaluation with chromoendoscopy and biopsy can increase the number of detected EGCs. As the presence of lymph node metastases has a strong adverse influence on patient prognosis, selected criteria must be used to identify the subset of lesions with no risk of lymphatic spread, as these are eligible for endoscopic resection. Conventional endoscopic mucosal resection has gained worldwide consensus for the treatment of selected EGC types but curative resection cannot be always guaranteed for lesions with a diameter > 15 mm. In these patients, a new technique, endoscopic submucosal dissection, allows successful en bloc resection. When conditions for endoscopic treatment cannot be met and lymphatic diffusion cannot be excluded, patients must be treated surgically. Gastrectomy with a clear margin of 2 cm from the lesion and D2 dissection is generally recommended as the treatment of choice. To define radicality and prognosis, the correct application of histological parameters is essential.

Preoperative Work-up: EsophagoGastroDuodenoScopy, Tracheobronchoscopy, and Endoscopic Ultrasonography

Patients with esophageal squamous cell carcinoma (ESCC) frequently describe “alarm” symptoms, such as as dysphagia, bleeding, and weight loss. In these cases, endoscopy of the upper gastrointestinal (GI) tract is the first diagnostic examination usually performed. In a series of 4018 patients, Bowrey et al. [1] identified 123 cases of esophagogastric carcinoma (3%), and in 85% of these patients “alarm” symptoms were present. A comparison of this subgroup with the entire series showed that in the former the tumors were significantly more advanced (47% vs. 11%); there were fewer indications for surgery (50% vs. 95%) and a worse survival (median 11 vs. 39 months).

Endoscopic and Surgical Palliation of Unresectable Gastric Cancer

Chemotherapy is the standard treatment in patients with unresectable gastric cancer, but is not an option for those with malignant gastric outlet obstruction. Instead, in these cases gastrojejunostomy is the most commonly used palliative treatment. Recently, endoscopic stent placement has been introduced as an alternative, safe, and effective procedure for palliative treatment of malignant strictures involving the gastroduodenal region. The results of different studies suggest that gastrojejunostomy is associated with better long-term results and is therefore the optimal treatment in patients with good performance status and relatively long life expectancy. However, in patients with a relatively short life expectancy and poor performance status, endoscopic stent placement is the treatment of choice.

Role of Endoscopy in Palliative Treatment

Approximately 50% of patients with esophageal squamous cell carcinoma (ESCC) have metastatic disease at presentation and are candidates for palliative therapy. The median age of these patients is 65 years such that palliative surgery has a high morbidity and mortality. The main goal of endoscopic therapy in patients with advanced cancers is the palliation of dysphagia, which contributes to improved nutritional status and quality of life. Bleeding and esophago-respiratory fistulas may also be palliated. Several endoscopic palliative treatments are available for ESCC patients, as summarized in Table 18.1.