Francesco Lombardo

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.

Rendez-vous Technique

The so-called Rendez-vous technique refers to a combined surgical, either laparoscopic or open, endoscopic approach to common bile duct stone treatment. The term Rendezvous (a French word meaning appointment) was adopted when the surgeon and the endoscopist met one other at the level of the duodenum, the former by the way of a trans-cystic guidewire and the latter with his lateral view endoscope for biliary procedures, as originally ideated by radiologists through percutaneous trans-hepatic access.