M. Goss

Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures

BACKGROUND Benign, refractory esophageal strictures are an important therapeutic challenge. Metal stents occasionally have been used, but results have been disappointing. The present study assessed the safety and the efficacy of temporary placement of the new expandable polyester silicone-covered stent for management of problematic esophageal strictures. METHODS Fifteen patients with benign esophageal strictures were treated by temporary (6 weeks) placement of an expandable polyester silicone-covered stent. All patients had previously been treated, unsuccessfully, by repetitive endoscopic dilation. RESULTS Stent placement was successful in all patients. There was no procedure-related complication. Dilation with over-the-guidewire polyvinyl dilators was required before stent placement. With the stent in situ, dysphagia completely resolved in all patients. Six weeks after placement, one stent was found to have migrated into the stomach. In the remaining patients, the stent was easily removed with a foreign body forceps. The pretreatment dysphagia score was 3 (range 2-4); the post-treatment score was 1 (range 0-1) (p < 0.0005). Long-term resolution (mean follow-up 22.7 [2.6] months) of the stricture was achieved in 12 patients (80%). The treatment failed in 3 patients, all of whom continue to require periodic dilation. CONCLUSIONS In patients with benign esophageal strictures refractory to conventional dilation, temporary placement of a removable expandable polyester silicone-covered stent may lead to long-term relief of dysphagia with minimal morbidity.

The Natural History of Gastrointestinal Subepithelial Tumors Arising From Muscularis Propria: An Endoscopic Ultrasound Survey

Aim The majority of lesions originating from muscularis propria of stomach, duodenum, and colon are gastrointestinal stromal tumors (GISTs). Surgery is indicated when endosonographic criteria of malignancy are met, but little is known about the natural history of lesions with benign endosonographic features. Aim of this study was to evaluate the natural course of benign-appearing lesions originating from muscularis propria in organs where GISTs significantly overcome leiomyomas. Materials and Methods A total of 49 asymptomatic patients with hypoechoic lesions originating from the fourth layer of the gastrointestinal tract entered a follow-up program by means of endoscopic ultrasonography. All lesions were nonulcerated, <3 cm in maximal diameter, with regular margins, and cystic spaces of <3 mm. Results After a mean follow-up of 31±20.8 months and a median of 2 (range, 1 to 5) endosonographies/patient, no change in echostructure or dimensions was seen in 44 subjects whereas in 5, an increase of at least 25% in 1 diameter occurred. Surgical removal was proposed to all: 1 patient refused (she is still alive and symptom-free after 4 y), 3 of the 4 lesions removed proved to be GISTs with very low or low risk of malignancy and 1 lesion was classified as a glomus tumor with no malignant appearance. Conclusions Even small and benign-appearing lesions from muscularis propria may increase in size over time but this increase cannot be considered as an index of malignancy. As most of these lesions are GISTs, a policy of surveillance is advisable.

The sentinel node in anal carcinoma.

Aims and Background Anal cancer is a rare condition. The inguinal lymph nodes are the most common site of metastasis in this neoplasm. The inguinal lymph node status is an important prognostic indicator and the presence of metastases is an independent prognostic factor for local failure and overall mortality. Depending on the primary tumor size and histological differentiation, metastasis to superficial inguinal lymph nodes occurs in 15-25% of cases. Methods and Study Design To evaluate the inguinal lymph node status we performed a search for the sentinel node in a female patient affected by squamous anal carcinoma. Results Identification and examination of the sentinel node was positive and postoperative histology showed the presence of bilateral lymph node metastases. Conclusions We suggest that examination of the sentinel node in anal cancer could be an efficient way to establish the inguinal lymph node status, which would help the clinician to plan and perform adequate treatment.

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.