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OBJECTIVE: The analysis of the endoscopic and histological characteristics of all the gastric epithelial polyps diagnosed through endoscopy in our service during a period of 5 years, and the evaluation of the usefulness of the endoscopic monitoring after polypectomy. PATIENTS AND METHODS: Between January 1995 and January 2000 5,314 high digestive system endoscopies were carried out in the Gastroenterology Service of the Santa María Madre Hospital. Sixty-four gastric epithelial polyps were detected in 18 patients (10 men and 8 women) with a median age of 61.7 years. RESULTS: Sixty-three polyps were removed through endoscopic polypectomy, and one was biopsied because of its size (5 cm), 30 (46.87%) were hyperplastic polyps, 24 (37.5%) presented normal histological characteristics, 8 (12.5%) were adenomas and 2 (3.12%) were polypoid adenocarcinomas. 56.2% measured less than 6 mm and only 6.2% measured more than 11 mm. No patient presented simultaenous gastric adenocarcinoma. Only one complication was observed after the polypectomy, a hemorrhage that was treated successfully with local injection of adrenaline. During the follow-up no case of cancer was detected and the recurrence of the polyp was observed in 2/8 patients with adenoma. CONCLUSIONS: Gastric epithelial polyps are infrequent (0.33% gastroscopies); most of them (93.75%) measure less than 1 cm and they can be removed through endoscopy with safety. In our series, the most frequent histological type was the hyperplastic polyp (43.75%); polypoid adenocarcinoma constituted 3.12% of the cases, one of them with less than 6 mm. Endoscopic follow-up is considered absolutely essential after the polypectomy, especially in adenomatous polyps.
Since its introduction into clinical practice in 1980, echo-endoscopy has greatly contributed to improving our capacity to image the digestive tract and now plays a major role in management of digestive tract diseases. Echo-endoscopy is a second intention technique reserved for further investigation of lesions previously identified by endoscopy or other imaging techniques. All five layers of the wall and surroundings of the accessible structures (oesophagus, stomach, duodenum, rectum and colon) can be visualized. Evaluation of locoregional extension of cancer invasion is one of the predominant indications. For example, since the prognosis of tumours of the oesophagus are directly related to parietal and lymph node extension, echo-endoscopy would be indicated to precisely determine the tumoural stage and thus help in adapting therapeutic management. Today, it is generally accepted that echo-endoscopy is superior to computed tomography for staging tumours of the oesophagus and the cardia. For gastric and duodenal adenocarcinomas, the performance of echo-endoscopy is similar and can identify more readily superficial lesions accessible for photocoagulation. For adenocarcinoma of the rectum, echo-endoscopy can be used to identify the tumoural stage and local extension and thus help in therapeutic decision making. Other classical indications include the evaluation of submucosal tumefaction and biliopancreatic disorders (biliary lithiasis, pancreatitis, tumours). Thus for certain well-defined indications, echo-endoscopy is now the highest performing imaging technique currently available for lesions of the digestive tract. Operator experience is however a limiting factor, emphasizing the need for clinical training.
The small bowel can be successfully investigated by enteroscopy techniques. Several types of enteroscopes with different technical characteristics have been developed. In this paper we explain the respective advantages and disadvantages of the different techniques. Results of several series using these two enteroscopes are summarized and commented. The review of different series make clear that enteroscopes, especially those including an operating channel represent an attractive alternative diagnostic tool to angiography and small bowel barium studies in patients presenting obscure digestive bleeding. The series reviewed in this paper confirm the high diagnostic efficacy of this type of endoscopy. Most of the lesions found are arteriovenous malformations especially in the elderly. Small bowel tumours are more likely to be found in younger patients. New indications for enteroscopy should be evaluated carefully. Obscure digestive bleeding represents the main indication of enteroscopy. However clinical situations suggesting Crohn's disease or malabsorption syndromes may be effectively evaluated by this special endoscopic technique.
A total of 2995 patients with esophagogastroduodenal bleeding have been treated the Department of Emergency Surgery for the period 1984-1988. A significant group were patients in advanced and senile age (beyond 65--42.4 per cent). The therapeutic and surgical approach to gastroduodenal bleeding was based on the solution of the following diagnostic-tactic problems: cause, source, localization and intensity of the bleeding, temporary or definitive hemostasis patterns, severity of blood loss. Essential is also the underlying disease, patient age and accompanying diseases. Express emergency endoscopy allows early and explicit visualization of the pathologic area and enables to gain knowledge on the nature and intensity of the bleeding or the character of spontaneous hemostasis. In this respect, express endoscopy is a guiding principle in managing upper digestive tract bleeding at the Department of Emergency Surgery. Of all hospitalized patients in this study were operated 203. Operations were performed after obligatory attempt for endoscopic hemostasis. The operative case fatality rate for the study period was, as follows: in gastric and duodenal ulcer 21.6 per cent, in gastric cancer 42.0 per cent, in hemorrhagic gastritis 33.3 per cent and in Mallory-Weiss syndrome 9.1 per cent.
Upper gastrointestinal endoscopy (UGI) is now widely accepted as the first-line examination of the digestive tract. UGI provides the diagnosis of most oesophageal and gastroduodenal diseases such as ulcer, cancer or oesophagitis. It is also valuable in the diagnosis of chronic diarrhoea, immunodeficiencies (immunoglobulin deficiency) and in AIDS patients. Improvements in disinfection and anesthesia make UGI a safe and well-tolerated procedure. Finally, it is, of course, the gold standard for the diagnosis of upper gastrointestinal haemorrhages and in many cases requiring endoscopic therapy.
OBJECTIVE: To evaluate the number of supervised gastrointestinal endoscopic procedures required to achieve initial competency using a simple objective grading system. DESIGN: Prospective, cross-sectional study. SETTING: A gastroenterology and surgical training program at a large, university-affiliated county hospital. PARTICIPANTS: Seven gastroenterology fellows and five fourth-year surgery residents. INTERVENTIONS: Trainees were graded postprocedure using a microcomputer program. Grading criteria for esophagogastroduodenoscopy included entering the esophagus (esophageal intubation), traversing the pylorus into the duodenum, and recognizing whether the upper gastrointestinal tract was abnormal. Criteria for colonoscopy were traversing the splenic flexure, intubating the cecum, and recognizing whether the colon was abnormal. RESULTS: When presented with a case mix representative of practice, esophageal intubation did not reach 90% until more than 100 procedures had been done. Cecal intubation remained at only 84% after 100 procedures. CONCLUSIONS: More than 100 supervised upper gastrointestinal endoscopies or colonoscopies are necessary to achieve technical competence in gastrointestinal endoscopy.
BACKGROUND AND STUDY AIMS: Neoplastic lesions in the digestive-tract mucosa are termed "superficial" when the depth of invasion is limited to the mucosa and submucosa. The endoscopic appearance has a predictive value for invasion into the submucosa, which is critical for the risk of nodal metastases. MATERIALS AND METHODS: The endoscopic morphology of superficial lesions can be assessed with a standard video endoscope after spraying of a dye--an iodine-potassium iodide solution for the stratified squamous epithelium, or an indigo carmine solution for the columnar epithelium. In 2002, a workshop was held in Paris to explore the relevance of the Japanese classification. The conclusions were revised in 2003 in Osaka in relation to the definition of the subtypes used in endoscopy and the evaluation of the depth of invasion into the submucosa. In Japan, the description of advanced cancer in the digestive-tract mucosa using types 1 - 4 is supplemented by a type 0 when the endoscopic appearance is that of a superficial lesion. Type 0 is divided into three categories: protruding (0 - I), nonprotruding and nonexcavated (0 - II), and excavated (0 - III). Type 0 - II lesions are then subdivided into slightly elevated (IIa), flat (IIb), or depressed (IIc). Nonprotruding depressed lesions are associated with a higher risk of submucosal invasion. After endoscopic resection, invasion into the submucosa is an important criterion for the necessity of additional surgical resection. Micrometer analysis of the depth of invasion in the specimen is more precise, and distinct cut-off limits have been established in the esophagus, stomach, and large bowel. CONCLUSIONS: The morphology of superficial and nonprotruding neoplastic lesions is relevant to the prognosis. Following endoscopic detection, the lesions are analyzed using chromoendoscopy and assigned a subtype of the type 0 classification. The choice between endoscopic or surgical treatment is based on this description.
Primary care physicians, including family physicians, often perform flexible sigmoidoscopy in their clinical practices. It is unknown how many of these and other endoscopic procedures, such as esophagogastroduodenoscopy and colonoscopy, are performed by these physicians. Therefore, physician reimbursement by the Medicare program was documented for selected endoscopic procedures during the calendar year 1993. Family physicians and general practitioners in the United States were reimbursed for 125,821 flexible sigmoidoscopies, 21,070 upper gastrointestinal tract endoscopic procedures, and 23,841 colonoscopies. General internists performed considerably more endoscopic procedures than did family physicians. Primary care physicians performed 44% of the reimbursable flexible sigmoidoscopies, 17% of upper gastrointestinal tract endoscopies, and 15% of colonoscopies in this patient group. In 1993, primary care physicians generated a total of $175 million in allowed charges by the Medicare program for gastrointestinal tract endoscopic procedures, of which $22.6 million was to general practitioners and family physicians. Family physicians, on average, charged less for gastrointestinal tract endoscopic procedures than did other physician specialists. Primary care physicians, especially general internists, are providing substantial numbers of gastrointestinal tract endoscopic services to their patients. As Medicare does not generally reimburse physicians to perform flexible sigmoidoscopy for colorectal cancer screening, it is likely that primary care physicians performed considerably more procedures than were documented in this study.
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A study of 57 patients admitted to the Department of Emergency Surgery at the Ospedale Maggiore in Milan between 1980 and 1992 following the recent ingestion of a caustic substance is presented herein. Through this study, an aggressive diagnostic and therapeutic approach has been employed, including early surgery which plays a fundamental role in the prevention of acute hemorrhagic or perforative complications as well as in the development of scar tissue and neoplastic strictures over time. The criteria for early emergency surgery were the presence of endoscopic grade 3 and 4 lesions as well as those on the borderline between grades 2 and 3 with clinical symptoms. In 11 patients with lesions of moderate severity, the treatment of choice was medical therapy, which required subsequent surgical intervention for strictures in 5 patients. In 13 patients with severe lesions, an early surgical approach was performed with a mortality rate of 23%.
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BACKGROUND: Many practicing surgeons claim that hernias after previous lower abdominal surgery should be treated by transabdominal preperitoneal repair (TAPP). Moreover, previous radical prostatectomy contraindicates the laparoscopic approach for hernia repair. This prospective study was designed to examine the feasibility and to evaluate the surgical outcome of laparoscopic totally extraperitoneal (TEP) hernia repair in patients who had undergone previous lower abdominal surgery or radical prostatectomy, and to compare this group to all patients who underwent laparoscopic TEP without previous surgery during the study period. METHODS: Patients undergoing elective inguinal hernia repair, by one staff surgeon, in the Department of Abdominal Surgery at the Institute of Laparoscopic Surgery (ILS, Bordeaux) between September 2003 and December 2004 were prospectively enrolled to this study. Three groups were defined--patients with previous radical prostatectomy, patients with previous lower abdominal surgery, and patients without previous surgery--and their data were analyzed and compared. RESULTS: A total of 256 laparoscopic inguinal hernia repairs were performed in 202 patients. Of these, 148 patients had unilateral hernia (143 right and 113 left) and 54 patients had bilateral hernias. There were 166 male patients and 36 female patients with a mean age of 61 +/- 16 years. Of these, 10 patients had inguinal hernia after prostatectomy and 15 patients had inguinal hernia after previous lower abdominal surgery. The mean operative time was significantly longer in the patients with previous prostatectomy than in the two other groups. Two patients after prostatectomy were converted to TAPP due to surgical difficulties. There were no major intraoperative complications in all patients except for three cases of bleeding arising from the inferior epigastric artery: two in the postprostatectomy group and one in a patient without previous surgery. Both ambulation and hospital stay were similar for all groups. Only one patient without previous surgery had postoperative bleeding and was reoperated on several hours after the hernia repair. During the follow-up period of 8 +/- 4 months, there was no recurrence of the hernia in any group. CONCLUSIONS: Laparoscopic TEP for inguinal hernia repair in patients after previous low abdominal surgery has good results, similar to those in patients without previous surgery. Despite a longer operative time, TEP repairs can be performed efficiently and safely in patients after prostatectomy by skilled and experienced laparoscopic surgeons.
The management of hilar strictures is dependent upon their resectability and may therefore require a multidisciplinary approach. However, resectability rates for such tumors are reported to be in the region of 15%-20%, and, therefore, palliative therapy will be the mainstay of treatment for most patients. With the presenting symptoms being those of obstructive jaundice and the consequences of cholestasis, a significant improvement in morbidity can be obtained by achieving biliary drainage. A number of options are available, including the placement of Teflon or expandable metallic endoprostheses by either the endoscopic or percutaneous route. Some considerable debate exists as to which route of stent placement is best, and in many circumstances the decision will depend on the availability of local services. Some have suggested that success rates with percutaneous stenting are superior to those for endoscopic placement, but the latter technique may be associated with fewer complications. In competent hands, endoscopic placement does achieve a high rate of success and it should be remembered that a combined approach may further improve success rates. The debate over the use of plastic versus metallic stents is centered around the higher rates of stent occlusion/migration for plastic stents seen in some studies, although a stent change is usually possible. An additional advantage of metallic stents is that they may provide drainage of the side branches of the biliary tree through the mesh. However, possible drawbacks may be a greater difficulty in placement of a second stent where a first provides inadequate drainage, and cost issues often have to be taken into consideration. Considerable debate exists over the optimum number of stents required to achieve adequate drainage and minimize the risks of cholangitis. There is good evidence that if overfilling of the biliary tree with contrast is avoided with only the segments to be drained visualized, a single stent may be all that is required, while others argue that placement of more than one stent may improve survival. In the following review we discuss these issues, and conclude by considering success rates and complications following endoprosthesis insertion; we also discuss the prognosis of patients treated in this way.
Endoscopic ultrasonography of the digestive tract provides for a precise ultrasonic study of the accessible gastrointestinal walls (esophagus, stomach, duodenum, rectum) and through the walls, of the adjacent organs (lymph node clusters, posterior mediastinum, pancreas, extrahepatic biliary ducts and perirectal environment). This method is more efficient than computerized tomography to evaluate the local and regional extension of esophageal, gastric and rectal carcinomas, producing little or no stenosis. It is the examination of choice to detect a perianastomotic recurrence of these cancers in the aetiological diagnosis of obstacles in the biliary tract and in the diagnosis and the pretherapeutic assessment of pancreatic cancers.
EUS unites two established imaging techniques and extends the range of observation into and beyond the wall of the GI tract. The close proximity of the sonographic probe to the region of interest combined with high ultrasonic frequencies of between 7.5 and 12 MHz yields images of high resolution. EUS is used in the staging of benign and malignant neoplastic disorders of the oesophagus, stomach, pancreas and extrahepatic bile ducts. It helps to establish operability, to plan surgical approach, to follow response to therapy and to search for recurrence. The predictive value in defining the T and N stages of oesophageal carcinoma lies between 80 and 90% and 65 and 85%, respectively. It is clearly superior to CT in tumour stages T1 and T2. In gastric cancer, resectability based on the TNM staging system can be correctly assessed by EUS in 85% of cases and EUS detection and staging of early gastric cancer reaches an accuracy of 90%. The EUS accuracy rate for resectability of pancreatic carcinoma is 83% and tumour infiltration into the portal and splenic vein can be correctly determined by EUS in 94% and 67%, respectively. A reliable EUS differentiation between chronic pancreatitis and pancreatic carcinoma based on the echo pattern and outer margins is not possible. The development of EUS-guided needle biopsy should improve the specificity of EUS in this regard. Experience to data suggests as well that EUS will assume an important place in the staging of bile duct tumours. EUS has expanded our endoscopic and sonographic capabilities and it is to be hoped that further technical improvement, e.g. the construction of forward-viewing endoscopes combined with radial scanning devices, will contribute to a widespread use of this technique by gastroenterologists.
Endoscopic imaging capabilities have significantly improved over the past 10 years. Improvements in fibreoptic technology have made possible the development of very thin endoscopes that can directly visualize the biliary and pancreatic ducts. The application of the CCD to endoscopy has made electronic endoscopy possible, and holds promise for stereoendoscopy. The ability to digitize endoscopic images can be developed to store, transmit, magnify, enhance and otherwise manipulate data obtained during endoscopy, and will probably be utilized routinely in the future. Laser and ultrasound technology are likely to enhance significantly our ability to examine ultrastructural aspects of gastrointestinal organs and surrounding tissues, and may play an important role in cancer surveillance programs. Vital staining techniques are likely to find widespread use in early cancer detection programmes, and may be useful to follow prospectively lesions observed or treated during endoscopy. Finally, the new developments in 'virtual imaging' may find applications in the field of gastrointestinal endoscopy and other 'minimally invasive' surgical procedures.
BACKGROUND: Percutaneous endoscopic gastrostomy is the standard for long-term enteral access. It can provide enteral nutrition or gastrointestinal decompression. Utilization of the gastrostomy for decompression has traditionally been reported in the setting of malignant obstruction. However, decompressive gastrostomy can play a role in the treatment of nonmalignant bowel dysfunction as well. METHODS: Over a 2-year period, 20 of 121 percutaneous endoscopic gastrostomies attempted by this surgical endoscopist were for gastrointestinal decompression. RESULTS: Eleven of 18 gastrostomies successfully placed for decompression were for benign conditions. In 5 patients with fistulous disease, the purpose of decompression was to divert the gastrointestinal tract until operative repair. Four of these patients have since undergone definitive surgery. CONCLUSIONS: This series presents the successful use of the percutaneous endoscopic gastrostomy for decompression of nonmalignant conditions. In such scenarios, the drainage gastrostomy can be employed as a bridge to future surgery, or as a means of long-term decompression for bowel dysfunction.