• ESOPHAGOGASTRODUODENOSCOPY

    Esophagogastroduodenoscopy (or upper GI endoscopy) is an investigation that consists in the introduction of a gastroscope through the mouth that allows direct observation of the cavity of the esophagus , stomach and duodenum. The gastroscope is a flexible instrument of about 8-12 mm in diameter, fitted with a camera at the tip. The exam is performed on patients fasted for at least eight to ten hours. With the patient liyng in left lateral decubitus position, the probe is inserted through the mouth, then is gently pushed into the esophagus, the stomach and finally into the duodenum; the examination is completed by the withdrawal of the probe, and the visualization of the same anatomical structures. Through an internal channel to the probe is also possible to take biopsy samples of tissue for histological examinations . The exam is invasive but safe and with a very low incidence of complications (0.05% of morbidity, and less than 0.006 % mortality ). Its execution duration is short (a few minutes) and not painful , although the natural swallowing reflex may lead to subsequent, slight, pharyngeal irritation; more frequently the test can cause discomfort , pain with nausea and vomiting , significantly reducible with minor conscious sedation (midazolam) and the application of topical anesthetics in the oropharynx (lidocaine or xylocaine). In some cases (usually in the presence of significant problems in the execution of the examination, or uncooperative patients), endoscopy can be performed even in deep sedation (via IV administration of propofol). Examination can also be made transnasally. The investigation may also be operative, in fact, thanks to the endoscope and special accessories such as snares, coagulators forceps and tools for dissection, it is possible to remove pieces of mucosa, precancerous lesions and malignant tumors at an early stage. In this case it is necessary to deeply sedate patients, and, as they are real mini-invasive interventions, the risk of complications is higher than the sole diagnostic investigation.

  • COLONOSCOPY

    Colonoscopy is a diagnostic test designed to explore the inner walls of the colon to detect any lesions such as ulcers , obstruction or tumor masses . The examination is carried out introducting a probe through the anus , said colonoscope , which has a diameter from about 11 to 13 mm . The probe is equipped with a micro camera that allows to see in real time the inside of the colon. To facilitate the penetration of the probe , the colon is distended by blowing air inside, a procedure which can result in some cases annoying and even painful . Recently the insufflation of gas, other than air , such as CO2 , which is rapidly absorbed into the blood, has improved endoscopic procedures and make them more acceptable , and even more safe in case of complications . This examinatin is not tolerated by all alike, in fact, previous surgeries , special internal anatomy or a particular susceptibility to pain can really make it a painful and difficult procedure to accept. For this reason, sedatives such as midazolam,in the case of conscious sedation , or real hypnotics, such as propofol in the case of deep sedation, can be administered under the supervision of an anesthesiologist who monitors the patient during the procedure. Colonoscopy is an important prevention tool , which allows you to locate and, if necessary, immediately remove small tumors at an early stage, preventing the development and degeneration . It is recommended for all subjects at risk: for example, for those with a family history of colorectal cancer; or after age 50, when an examination of the feces detects the presence of blood , even in minute traces. Recently it was shown by long term observational studies, that a screening colonoscopy reduces mortality from colon cancer. This is due to two main mechanisms: t early diagnosis , that is, at a stage when the cancer can be cured and then removed , and the removal of precancerous lesions through techniques such as polypectomy and mucosectomy . These qualities make the survey more effective than other methods such as radiological ( x-ray barium enema , virtual colonoscopy ) or with respect to endoscopic videocapsule . The main disadvantage compared to other methods is that colonoscopy is subject to a higher rate of complications related to the greater invasiveness of the procedure. Not all colonoscopies are equal, in fact endoscopist main objective should be to offer a survey of high quality, because the only way you can get all the advantages of the method . The quality of the survey depends on several factors : the experience of the operator, the technique used , the technological equipment of the instruments used and , not least, by an adequate bowel cleansing . Therefore it is crucial with regard to patients, follow the instructions provided for the intake of laxatives survey for high-tech with considerable commitment of different professionals and by patients is not thwarted by a non-optimal cleaning .

  • ENDOSCOPIC ULTRASONOGRAPHY

    Endoscopic Ultrasonography (EUS) is a technique That combines direct vision of digestive endoscopy with ultrasound. In practice , During the same procedures you can perform a traditional endoscopy and an intracavitary ultrasound . The idea to apply a small ultrasound probe at the tip of a gastroscope was in the early 80s of Prof. Di Magno, an expert in pancreatic diseases, to better visualize this organ difficult to explore with traditional ultrasound . The first prototypes, used later for many years afterwards, were radial scan instruments with sound waves generated by mechanical probes, performing scans at 360 ° with an axis perpendicular to the instrument. In practice it is possible to obtain images with sections similar to those of Computed Tomography with the advantage of bringing the probe very close to the organs to be studied and then with a higher resolving power. This allows therefore to view  better the pancreas, the gallbladder and bile ducts, the liver, the mediastinum, the perineum and some vascular structures, and, to have a detail on gastrointestinal wall unsurpassed by most other modern radiologic methods (CT and MRI). Because of these characteristics EUS has become the most accurate method for the study and preoperative locoregional staging of tumors of the intestinal wall (esophagus , stomach , duodenum , and rectum) and for the identification and preoperative staging of pancreatic tumors. It’s also one of the most accurate methods for the study of the bile ducts and gallbladder in particular for the identification of the biliary stones. More recently, in additions,  an important role in the staging of lung cancer has emerged. The most recent development of electronic probes has allowed the entry on the market of new generation tools with improved imaging and the possibility of further top applications : such doppler, elastography, harmonic tissue imaging and the use of contrast media. However, certainly the more relevant innovation has been the application of linear scanning probes placed on the same axis of the instrument. These probes allow us to follow the route of accessories that exit from the operating channel of instruments such as needles, thus allowing tissue withdrawal from gastrointestinal wall or extraparietal organs. Moreover, the characteristics of new instruments with larger working channel are giving impetus to interventional procedures: such as extraluminal drainage of fluid collections or bile ducts drainage in the event of ERCP failure. Probably the major limitation of the method is the difficulty and the long training required to become experts in the technique and to be able to maximize their benefits. Specific training of the nursing staff is also necessary  .

    EUS indications

    • locoregional staging of digestive tract tumors ( esophageal carcinoma , gastric carcinoma and lymphoma , rectal cancer ). From the staging of these tumors depend both the prognosis, both therapeutic choices . After excluding the presence of distant metastases (M) performing EUS allows accurate assessment of parietal extension of the tumor (T).  The visualization of the structures that surround the digestive tract also allows you to suspect the presence of metastases to regional lymph nodes (N) and carry out  a cytological confirmation of this obtaining tissue (FNA). This assessment can also be useful for testing the down- staging after neoadjuvant therapy. The refinement of the staging of  digestive neoplasms allows you to address each patient to the most appropriate therapy , be it endoscopic , surgical , oncology or palliative care; this results in the execution of surgery only in patients with operable neoplasms (minimizing the thoracolumbar / exploratory laparotomy , for the presence of tumors too extensive to obtain a radical resection ), whilst reserving palliative care or oncology in more advanced cases.

    • differential diagnosis of subepithelial lesions of the digestive tract . On the basis of sonographic appearance and the parietal layer of origin , you can assume the type of tumor under examination ( leiomyoma , stromal tumors , neuroendocrine tumor , lipoma , ectopic pancreas , cysts, varicose veins ); in doubtful cases the evaluation of the Doppler signal and performing the FNA allows you to get a more accurate differential diagnosis.

    differential diagnosis of solid pancreatic lesions (carcinoma , focal chronic pancreatitis , neuroendocrine tumors , lymphoma, metastasis). Using ultrasound evaluation and cytological confirmation (FNA) ; locoregional staging (after excluding distant metastases) in the case of malignant tumors, to undertake a choice between surgery and palliation .

    • differential diagnosis of pancreatic cystic lesions ( serous cystadenoma , mucinous cystadenoma , cystadenocarcinoma , intraductal papillary mucinous tumor , neuroendocrine tumors , or metastases with liquid component , pseudocysts ) by ultrasound evaluation, cytology and biochemistry of cystic fluid analysis ; subsequent evaluation of the indications for surgery, endoscopic (drainage of pseudocysts ) or just follow up.

    research of early changes associated with chronic pancreatitis

    • search of bile duct stones of even small dimensions , especially in the case where , in the light of the framework clinical, laboratory and trans-abdominal ultrasound, the probability of such pathology appears not sufficiently high to justify the immediate execution of an ERCP ( from only perform therapeutic purposes ) .

    diagnosis and locoregional staging of neoplasms of the extrahepatic biliary, with the possibility of a FNA confirmation , especially after brushing transpapillary not diagnostic .

    staging of non-small cell lung cancer. The display and the ability to perform FNA of mediastinal lymph nodes (also stations can not be reached by bronchoscopy ) is making EUS an indispensable tool for determining treatment decisions to be taken, even after neoadjuvant radio-chemotherapy. The easy approach to the mediastinum makes EUS FNA also useful in the study of other kinds of lymphadenopathy (TB, sarcoidosis, Hodgkin’s disease ).

    EUS interventional: drainage of pancreatic pseudocysts (procedure easier and safer than done blindly) celiac plexus neurolysis (for pain from chronic pancreatitis and pancreatic cancer ).

  • ERCP (Endoscopic Retrograde Cholangiopancreatography)

    This endoscopic procedure, consists in performing real diagnostic-operative interventions on the biliary tract and main pancreatic duct . In particular, the examination is carried out by using a special endoscope that has a side view and not forward view like normal gastroscopes. This particular angle helps to view properly the papilla of Vater (outlet point of the bile ducts and the main pancreatic duct ) placed in II portion of the duodenum and allows, with the help of guide wires and specific probes the cannulation of these tiny ducts. The subsequent injection of contrast and combination with the radiological method allow to make high quality diagnostic imaging on the bile ducts and pancreas . Thanks to the development of the methodology and accessories such as the “sphinterotome ” it is possible to make real operational procedures, how to make a small section of the papilla of Vater in order to allow the extraction of stones using balloon catheters or baskets , or placement of prosthesis for drainage in the event of obstruction. This method is not free from adverse events such as: acute pancreatitis ( 1.6-15.7 %), hemorrhage, especially after sphincterotomy (2-5 %), cholangitis (< 1%), cholecystitis ( 0.2-0.5 % ) , cardiopulmonary complications ( 1 % ), perforations ( 0.1-0.6 % ). There is also a certain mortality associated with the procedure that has been reported in rates of about 0.2% for diagnostic and up to 0.4-0.6 % for operative ERCP. The development of Magnetic Resonance Imaging and Endosonography that allow a satisfactory diagnostic performance but with fewer complications than ERCP relegated its role purely to operational one, reducing its indications during time.

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