Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: summary of the working group reports of the Euro-NOTES meeting 2010.

The fourth Euro-NOTES workshop took place in September 2010 and focused on enabling intensive scientific dialogue and interaction between participants to discuss the state of the practice and development of natural-orifice transluminal endoscopic surgery (NOTES) in Europe. Five working groups were formed, consisting of participants with varying scientific and medical backgrounds. Each group was assigned to an important topic: the correct strategy for dealing with bacterial contamination and related complications, the question of the ideal entry point and secure closure, interdisciplinary collaboration and indications, robotics and platforms, and matters related to training and education. This review summarizes consensus statements of the working groups to give an overview of what has been achieved so far and what might be relevant for research related to NOTES in the near future.

Non-anatomical intestinal transplantation.

INTRODUCTION: Intestinal transplantation is the only long-range treatment option for patients with intestinal failure. We report an exceptional case of isolated intestinal transplantation with the implant in a non-anatomical position. CLINICAL CASE: The patient was a thirty-eight-year-old man (60 kg weight, 180 cm height, 18.3 body mass index) with intestinal failure and home parenteral nutrition due to a short-bowel syndrome for which intestinal transplantation was indicated. The patient had a vascular malformation with the cava vein located left to the aorta, and the intestine was implanted with a 180 masculine rotation around the mesenteric axis, so that the implant s superior mesenteric artery and vein matched the recipient s cava and aorta. Postoperative follow-up was excellent and the patient was discharged after six weeks with a 10-kg gain in body weight. DISCUSSION: This non-anatomical intestinal implantation of the small bowel, previously unreported, offers technical advantages over other options. Adequate intestinal function represents a unique model to prove the viability of intestinal implants in a non-anatomical position.

Trasplante intestinal en posición no anatómica / Non-anatomical intestinal transplantation

Introducción: el trasplante intestinal es el único tratamiento eficaz a largo plazo de los pacientes con fallo intestinal. Se presenta un caso clínico excepcional de trasplante intestinal aislado en posición no anatómica. Caso clínico: se trata de un varón de 38 años de edad con fallo intestinal y nutrición parenteral domiciliaria por un síndrome de intestino corto al que se le indicó un trasplante intestinal. Fue incluido en lista de espera con un peso de 60 kg, 180 cm de altura y 18,3 de índice de masa corporal. El receptor presentaba una trasposición de los grandes vasos con la vena cava situada a la izquierda de la arteria aorta por lo que el intestino se implantó con una rotación del injerto de 180º sobre su eje mesentérico, con el objetivo de que la vena y la arteria mesentérica superior del injerto coincidieran con la vena cava y la arteria aorta del receptor. El paciente presentó excelente postoperatorio y fue dado de alta a las 6 semanas con un aumento de peso de 10 kg. Discusión: esta implantación no anatómica del intestino, previamente no referida en la literatura, ofrece ventajas técnicas sobre otras alternativas. La adecuada función intestinal constituye un modelo único que prueba la viabilidad del intestino implantado en posición no anatómica(AU)

Introduction: intestinal transplantation is the only long-range treatment option for patients with intestinal failure. We report an exceptional case of isolated intestinal transplantation with the implant in a non-anatomical position. Clinical case: the patient was a thirty-eight-year-old man (60 kg weight, 180 cm height, 18.3 body mass index) with intestinal failure and home parenteral nutrition due to a short-bowel syndrome for which intestinal transplantation was indicated. The patient had a vascular malformation with the cava vein located left to the aorta, and the intestine was implanted with a 180º rotation around the mesenteric axis, so that the implant's superior mesenteric artery and vein matched the recipient's cava and aorta. Postoperative follow-up was excellent and the patient was discharged after six weeks with a 10-kg gain in body weight. Discussion: this non-anatomical intestinal implantation of the small bowel, previously unreported, offers technical advantages over other options. Adequate intestinal function represents a unique model to prove the viability of intestinal implants in a non-anatomical position(AU)

Sedation for gastrointestinal endoscopy and intrusionism: legal aspects / La sedación en la endoscopia digestiva y el intrusismo: aspectos legales

No disponible

Preoperative detection of gastrointestinal neuroendocrine tumors using endoscopic ultrasonography.

OBJECTIVE: Almost 30% of gastroenteropancreatic neuroendocrine tumors (GEPET) escape preoperative identification using standard imaging techniques. The goal of this retrospective study is to present our cumulative experience in the assessment of GEPET by preoperative endoscopic ultrasonography (EUS), and to compare it with a literature review. PATIENTS AND METHODS: Thirty-seven patients with suspected specific hormonal syndromes were sequentially examined with US, CT, MRI, angiography, OctreoScan, and radial and sectorial EUS. Sixteen were males (43%) and 21 were females (57%), with a mean age of 61 years (interval: 40-84 a). Of all 37 patients, 27 had 19 endocrine tumors in the pancreas and 14 tumors in their gastrointestinal tract. No tumors were demonstrated in 10 patients, hence they were used as a control group. Of all 37 patients, 24 were operated on or had histological samples collected, with the presence of 26 GEPET (10 carcinoids) being confirmed in 22 patients. RESULTS: EUS sensitivity and diagnostic accuracy were 81% and 78%. Specificity was 80%. All these values were similar to the mean values obtained from the literature review. Three pancreatic rumors smaller than or equal to 1 cm (insulinomas) were detected, which had escaped diagnosis with previous US, CT, and MRI studies. An echoendoscopic examination of the pancreas could not be completed in two cases (5%), a pancreas carcinoid and an already gastrectomized double pancreatic gastrinoma. CONCLUSION: EUS is a good preoperative technique for GEPET detection, and may likely be superior to other imaging techniques in the assessment of small tumors. The usefulness of EUS as a primary exploration after US or HCT has been posited for tumor diagnosis and localization before surgery.

Outcome of patients with ischemic colitis: review of fifty-three cases.

PURPOSE: Ischemic colitis is a disease of elderly patients and includes a wide clinical spectrum ranging from mild to severe forms. Some patients may develop complications. Management of this disorder depends on disease severity. Our aim was to review the clinical characteristics of patients diagnosed of ischemic colitis and analyze predictive factors of poor prognosis. METHODS: This study is a retrospective analysis of 53 cases of ischemic colitis (33 men, 20 women), 35 with moderate and 18 with severe forms, respectively. Clinical characteristics, diagnostic procedures, segment of colon involved and long-term evolution after discharge were analyzed. RESULTS: Hypertension (51 percent) was the main risk factor associated with ischemic colitis. Clinical presentation did not differ between groups, except for peritonitis which was present only in the severe group. Colonoscopy and histologic studies were the most used diagnostic procedures (90 percent). Peripheral vasculopathy (P < 0.01) and right colonic involvement (P < 0.001) were risk factors for severe outcome. Five patients died during admission. Among these, the right colon was affected in four (80 percent). No patient in either group developed chronic ischemic colitis during follow-up. CONCLUSION: Ischemic colitis usually runs a benign course after acute colonic insult. Peripheral vasculopathy and right colonic involvement are associated with severe forms of ischemic colitis.

Minimal standard terminology for digestive endoscopy: results of prospective testing and validation in the GASTER project.

BACKGROUND AND STUDY AIMS: Standardization of the endoscopic report is a key issue for future research in the field of digestive endoscopy. The Minimal Standard Terminology (MST) has been proposed by the European Society for Gastrointestinal Endoscopy (ESGE) as a structured language for production of computerized endoscopic reports. The aim of this study was to validate version 1.0 of this terminology prospectively, by collecting cases in a multicenter, multilingual trial. METHODS: Endoscopic cases (esophagogastroduodenoscopy [EGD], colonoscopy, endoscopic retrograde cholangiopancreatography [ERCP]) were prospectively collected in nine university hospitals in Europe, using the same software. Reports were produced in the local language, but the software allowed comparison of reports between languages, and global analysis of the database. Outcome measures were the adequacy of terms proposed in the MST to describe "reasons for performing an endoscopy", "findings", and "endoscopic diagnoses", frequency of use and content of free-text fields, and types of lesions described. RESULTS: A total of 6,232 reports were analyzed, including 3,447 gastroscopies, 1,743 colonoscopies, and 1,042 ERCPs. Overall, terms originally contained in the MST were adequate to describe fully 91.0% of all examinations where "reasons for endoscopy" were described, 99.5 % of examinations where "findings" were described, 95.8% of all examinations containing descriptions of "endoscopic diagnosis", 98.9% of examinations containing descriptions of "additional diagnostic procedures", and 94.8 % of examinations containing descriptions of "additional therapeutic procedures". Free-text fields were only used in the other cases (less than 5% of cases in average). CONCLUSIONS: The MST appeared adequate to cover a large part of routine endoscopy reports, and could thus be used as a tool for standardization of endoscopic reports in clinical practice. The latter could be significantly improved by the use of a structured and standardized terminology for the production of endoscopic reports.

The GASTER project: building a computer network in digestive endoscopy: the experience of the European Society for Gastrointestinal Endoscopy. Gastrointestinal Endoscopy Application for Standards in Telecommunication, Education and Research.

Digestive endoscopy is currently the main diagnostic procedure for investigation of the digestive tract whenever a digestive disease is suspected. From 1970 to 1985, digestive endoscopy was performed with endoscopes equipped with fiberoptic bundles, whereas the last decade was marked by the development of electronic endoscopes, characterized by the presence of a CCD (charge coupled device) at the tip of the endoscope. Thus the physician looks at a TV screen to control the procedure and examine in detail the gut wall. Endoscopes examine the foregut until the duodenum and the hindgut, up to the three last intestinal loops. When the endoscopic workstation comprises a computer, it is possible to acquire electronic images during the endoscopy and use these images as support of the information about the results of the procedure. These numeric images can then be stored in databases containing text attached to them. Starting with these images, one may expect many developments in the near future that will change the management of the patient with digestive diseases. Physicians will become able to exchange images and text related to one patient or one procedure, although they are equipped with different workstations. Therefore, it is obvious that the information exchanged must be written in a standard format that makes it understandable by all systems. The European Society of Gastrointestinal Endoscopy is a scientific society that groups most of the gastroenterologists in Europe. This society has initiated a research program to develop standards for the exchange of images and text. The Gastrointestinal Endoscopy Applications for Standards in Telecommunication, Education, and Research (GASTER) project intends to implement a multimedia database of endoscopic images based on a standard format of images and a standard terminology for descriptive terms. These standards must be validated by use in different endoscopy units. The database will collect images from these centers that will be linked to the coordinating center through a network based on an integrated services digital network (fast electronic connection). This database will then be used for the development of computer applications. The output of the GASTER project will bring advances at three levels: (1) The physicians will be able to exchange images about the procedures their patients have undergone and will thus obtain more complete information, improving quality of care. They will also benefit from help-to-decision applications based on validated reference images from the database. (2) At the patient level, the quality of care will be improved through a better dissemination of information between the physicians in charge of the patient, thus there is better follow-up of the patient and a decrease in redundant examinations. (3) At the level of national health care systems, the benefit will be a decrease in cost of care due to a better follow-up of the patients, a decrease in redundant examinations, and a faster decision made to treat the patient. The possibility of consulting a database of a scientifically validated images used as reference material will also improve quality control in digestive endoscopy.

[The diagnosis and preoperative location of digestive endocrine tumors by endoscopic ultrasonography]. / Diagnóstico y localización preoperatoria de los tumores endocrinos digestivos mediante ultrasonografía endoscópica.

UNLABELLED: Around 30% of the gastroenteropancreatic endocrine tumors (GPET) cannot be preoperatively identified by the common diagnostic imaging techniques. The aim of this retrospective study was to present our experience in the diagnosis and localization of GPET by endoscopic ultrasonography (EUS) performed prior to surgery and compare this with a review of the literature. PATIENTS AND METHODS: Twenty patients suspected of having specific hormonal syndromes were correlatively explored with US, CT, MR, angiography, octreoscan and radial EUS with Olympus GFUM3/EUM3 and GF-UM20/EUM 20 and 30. Eleven cases were males (55%) and 9 (45%) females with a mean age of 60 years (range: 40-80 years). Of the 20 patients, 14 had endocrine 16 tumors in the pancreas and 6 tumors in the gastrointestinal tract. In 6 patients no tumors were found and were therefore used as a control group. Of the 20 patients, 14 underwent surgery confirming the existence of GPET in 12 cases. RESULTS: The diagnostic sensitivity and precision of the EUS were of 75 and 78%, respectively, with these percentages being higher to those obtained with other imaging techniques. The specificity was 83%. All these values were slightly lower than the mean obtained on review of the literature. Two pancreatic tumors of less than or equal to 1 cm were detected which had not been previously diagnosed with US, CT and MR. In two cases the exact situation was not determined. Echo-endoscopic exploration of the pancrease could not be completely performed in two cases (10%), one pancreatic carcinoma and one double pancreatic gastrinoma which was gastrectomized. Endoscopic ultrasonography is a good preoperative technique for detecting GPET and in the evaluation of small sized tumors it may surpass other imaging techniques. The usefulness of EUS as a second exploration following US has been suggested for the diagnosis and localization prior to surgery.

The role of therapeutic endoscopy associated with extracorporeal shock-wave lithotripsy and bile acid treatment in the management of Caroli's disease.

BACKGROUND AND STUDY AIMS: Caroli's disease causes relapsing episodes of cholangitis due to the presence of intrahepatic lithiasis. Strategies for cholangitis prevention are still widely debated. Ursodeoxycholic acid, hepaticojejunostomy, partial hepatectomy, or transplantation, have all been proposed as therapeutic options. The aim of this study was to evaluate the role of therapeutic endoscopy, and especially endoscopic sphincterotomy (ES), in the management of Caroli's disease. PATIENTS AND METHODS: Between 1983 and 1995, six patients with Caroli's disease (mean age 52, range 17-75) underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. Sphincterotomy was performed if common bile duct stones were present. Extracorporeal shock-wave lithotripsy, (ESWL) or intraductal electrohydraulic lithotripsy (IEL) were performed if necessary. RESULTS: The mean number of endoscopic sessions per patient was four (range three to seven). Sphincterotomy was performed in five patients and cholangioscopy in three. ESWL was performed twice in each of four patients. A Strecker expandable metal stent was placed in one patient to maintain sphincterotomy patency. In one patient, two sessions of IEL and pulsed laser were carried out. Complete clearance of intrahepatic stones was achieved in four of the six subjects (66.6%) and partial clearance in two patients. No morbidity or mortality was observed. During the follow-up (mean 6.2 years; range: 2.1-16.3), only two patients had acute cholangitis at nine months and three years, respectively, after the endoscopic treatment. Both had residual intrahepatic stones left after the initial endoscopic attempt at clearance. CONCLUSION: ERCP is a necessary diagnostic procedure which should always be carried out in patients with Caroli's disease. Our experience shows that ES does not result in an increased incidence of cholangitis and that therapeutic endoscopy allows complete clearance of intrahepatic stones in the majority of patients with unresectable symptomatic Caroli's disease. Nevertheless, the oncological risk in these patients remains unchanged, and they still have an increased risk of cholangiocarcinoma.

The minimal standard terminology for digestive endoscopy: introduction to structured reporting.

The wider use of computers for the management of endoscopic data and the use of electronic endoscopes for the production of high quality endoscopic images has made the standardization of terminology and images formats necessary in digestive endoscopy reports. The European Society for Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy have combined their efforts to propose a Minimal Standard Terminology for Computerized Databases in Endoscopy. This terminology is based on the following principles: no term describing findings less frequent than 1%, of the daily practice, and no term based on subjective impressions. The Minimal Standard Terminology has been developed according to the natural process of constructing an endoscopic report in natural language and deals with the following: reasons for performing the examination, endoscopic findings, endoscopic diagnosis, additional therapeutic and diagnosis procedures (biopsies, etc.). It is subdivided according to the main organs examined with an endoscopy. Until now, the Minimal Standard Terminology was tested in many centers and was shown to accurately cover 95% of routine examinations for the upper gastrointestinal tract, colonoscopy and cholangio-pancreatography. It is currently being tested in an a prospective way in several centers in Europe (with a grant from the European Commission DGXIII-C4) and in the USA (with grant from the AHDHF).

[Changes in the epidemiology of gastric cancer in the last 15 years]. / Cambios en la epidemiología de la neoplasia gástrica en los últimos 15 años.

AIM: To determine whether the epidemiological profile of gastric cancer is changing in our patient referral area. EXPERIMENTAL DESIGN: We have compared the incidence rates of gastric cancer in our Hospital in two three year periods (1975 to 1977 and 1990 to 1992). Gastric cancer was diagnosed by endoscopy or surgery and confirmed histologically. Incidence rate was obtained calculating the ratio (cases of gastric cancer)/ (patients assisted at the hospital) for each period. RESULTS: 522 patients were identified in the first period, and only 255 in the second. Then, the overall incidence fell from 96 x 10(5) to 37 x 10(5). In both periods a male predominance, with a sex ratio male/ female of 1.9 in the first period and 1.6 in the second, was observed. The mean age was also similar in both periods: 61 years (range 20-89) and 65.5 (range 28-90) respectively. Adenocarcinoma was the predominant neoplasm in both periods (98% and 95% respectively). There was also a predominance of antral tumors with a slight decrease of their incidence in the later series (ratio antrum/other gastric sites) from 1.6 to 1.1 respectively (p = 0.07). CONCLUSIONS: Although gastric cancer is still very common, its incidence in our referral area is decreasing. In addition, the characteristic antral predominance also seems to be decreasing. It remains to be established whether the changing pattern we have observed is related to environmental variation.

Gastric ulcer perforation into the heart.

Penetration of the pericardium and heart is a very rare complication of benign peptic ulcer. The case is reported here of a 76-year-old woman with advanced senile dementia, who was admitted due to melena. Endoscopy revealed a large gastric ulcer located in a giant hiatal hernia. The ulcer base was protruding and strongly pulsatile, and seemed to be mobile and free in relation to the ulcer margins. This effect was particularly obvious during the pulsatile movements. Endoscopic findings suggested ulcer perforation to the pericardium. The patient's relatives denied consent to surgery. She was therefore treated with conservative measures, including parenteral nutrition, ranitidine, and antibiotics. The patient remained in a relatively stable condition, and she was discharged three weeks later. One month later, however, she was admitted with massive bleeding and hypovolemic shock. In spite of resuscitation measures, she died. The autopsy study showed a gastric ulcer penetrating through the pericardium and myocardium into the left ventricle.