Digestive diagnostic and surgical endoscopy programme

The work of the unit for Digestive Diagnostic and Surgical Endoscopy ( EDDI) is characterized by clinical-healthcare activities and  advanced pre-clinical research (clinical, investigative and translational in nature), focused on early diagnosis and therapy of  gastrointestinal diseases and tumours, and those of  the pancreas and bile ducts.

Digestive diagnostic and surgical endoscopy programme

 

The unit performs procedures aimed at out-patients and also in-patients (Day Hospital and standard hospitalization). These procedures differ in levels of complexity, from diagnostic investigations, to surgical procedures, responding to the extreme diversification in clinical demand technological supply.

Digestive endoscopy plays a key role in the identification of early lesions in the context of the prevention of  cancers of the oesophagus, of the stomach and of the colon-rectum. Our centre is able to provide advanced diagnostic endoscopy and minimally-invasive endoscopic therapies for pathologies which, in other centres, are treated surgically.

This routine endoscopic activity ensures high diagnostic standards for all patients, by guaranteeing the use of state-of-the-art instrumentation, equipped with advanced imaging technology with endoscopes :

 

1. with high definition, magnification

2. contrast enhancement, by means of chromoendoscopy with vital or electronic staining

 

The unit offers highly-specialized diagnostic and surgical endoscopy procedures, through constant research in the field in new technologies and the constant training of all staff involved.

 

 

Multidisciplinarity

 

The unit interacts through multidisciplinary meetings with all the clinical and surgical departments in the Institute. The complexity of the oncological condition is conducive to  a diagnostic and therapeutic approach which is shared by more specialists than in other centres, whether the focus is clinical (surgical and medical) or experimental. Teamwork permits the unit to blaze trails in excellence for the diagnosis, follow-up and the endoscopic treatment of the individuals suffering from neoplastic pathologies and otherwise.

A multidisciplinary group with the involvement of the Oncologist, Surgeon, Endoscopist, Pathologist, Radiologist and Radiation Therapist makes an improvement possible in patient management  during the patient’s journey within the centre, discussing the therapeutic choices collegially, synchronizing diagnostic and therapeutic procedures with an optimization of procedure times. Thus healthcare plans for diagnosis, care and follow-up are defined and personalized for each individual  Patient in a way that the competencies, professional skills and experience of the different specialists become integrated.

 

Research: Translational approach to diagnosis and therapy

Highly significant is clinical activity and that of research into tumours of the gastrointestinal tract, the pancreas and the bile ducts. The objective of the research consists in transferring scientific knowledge into clinical care. The study of the mechanisms behind the formation of the cancer, the development of optimized instruments for targeted treatment and early diagnosis have a significant influence on the possibilities of care. These therefore require  continuous exploration of new strategies(diagnostic molecular, etc) to determine the individual risk of cancer and relevant prevention (tests for early diagnosis, study of  proteomics and genomics, molecular therapies…). Innovative clinical studies, then, are necessary if we are to convert  knowledge acquired into maximum development of innovative preventive, diagnostic and therapeutic technologies. The development of  clinical/translational study protocols is promoted hrough  research activities, supporting educational activities and the dissemination of knowledge.

 

Diseases

 

The carcinoma of the colon-rectum represents in Italy the neoplasia in second place in terms of mortality for tumours (10% males and 12% females). Neoplasms of the oesophagus are in eighth place in the world, with an overall incidence of 3-4 cases/100,000. The gastric carcinoma represents the fourth cause of death by tumour in Europe, and the second in the world. In Italy the mortality rate is roughly 5-10 cases for every 100,000 inhabitants. In the last few decades there has been a declining trend in incidence and in mortality for these types di tumours. This is thanks to the prevention offered by early diagnosis through screening tests and improvements in the results obtained with therapeutic strategies. In this sense,  endoscopy plays a pivotal role both from a diagnostic-preventive point of view and a therapeutic-operative one, also preserving its indispensability in post surgical/therapeutic follow-up.

Our centre guarantees:

• Prevention and early diagnosis of neoplasms of the oesophagus, stomach, duodenum and colon-rectum

• curative treatments for precancerous lesions and early-stage malignant neoplasms of the oesophagus, stomach, duodenum and colon-rectum with cutting-edge endoscopic surgery and result monitoring;

• Diagnosis, treatment and palliation of the preneoplastic conditions, neoplastic lesions of the pancreas and of the bile ducts

• Preoperative staging of the neoplasms of the oesophagus, stomach, rectum, mediastinum and pancreas by means of ultrasound endoscopy

• curative endoscopic procedures for post-surgical complications (fistulas; stenosis) in close collaboration with the Surgery Division.

• palliative treatment of advanced neoplastic diseases obstructing the digestive tract for the purpose of restoring intestinal canalization and thus permitting feeding (prosthesis, laser therapy, gastrostomy)

• palliative/pre-operative treatment for neoplastic stenosis of the bile ducts.

 

 

Activities

 

Diagnostic Endoscopy:

• Oesophagogastroduodenoscopy +/- biopsies (EGDs)

• EGDs + magnification +  vital and/or virtual computerized staining (NBI)

• Transnasal oesophagogastroduodenoscopy (EGDs – T)

• Colonscopy (+/- biopsies ) +/- retrograde ileoscopy

• Enteroscopy with single balloon

• Videoenteroscopy with videocapsule

• Endoscopic ultrasound, (EUS) digestive ( upper digestive tract, rectum), biliopancreatic, diagnostic

 

Operational Endoscopy ( endoscopic therapy):

• Endoscopic mucosal resection (EMR)(oesophagus, stomach, duodenum, colon-rectum)

• Endoscopic submucosal resection (ESD) (oesophagus, stomach, colon-rectum)

• Full thickness resection

• Endoscopic ultrasound, or EUS, operative (Fine Needle Aspiration, prothesis positioning) digestive

• Dilatation (mechanical/pneumatic) of enteral stenoses (oesophagus, stomach, colon-rectum)

• Positioning enteral prostheses (oesophagus, stomach, duodenum, colon-rectum)

• Radiofrequency thermal ablation treatment (RFA) of Barrett's oesophagus

• Endoscopic conservative treatment (with various techniques and modern devices) of complications of surgery (haemorrhages;dehiscence, fistulas, stenosis)

• mechanical or thermal treatment (APC/RF) of haemorrhagic pathologies (e.g.: actinic proctopathy; GAVE; vascular malformations (telangiectasia;MAV), neoplasms)

• Haemostasis of bleeding lesions (injective, thermal or mechanical)

• Endoscopic treatment of the nutritional pathologies ( endoscopic positioning of: nasojejunal probe ; decompression probe; positioning, replacement and removal  percutaneous gastrostomy and jejunostomy,PEG and PEJ)

• Endoscopic treatment of gastric and/or oesophageal varices : ligation, sclerosis, cyanoacrylate

 

Interventional biliary and pancreatic pathways

 

• ERCP(Endoscopic Retrograde Cholangiopancreatography) + sphincterotomy

• Dilatation of bile (post-transplant stenosis) or pancreatic ducts

• Drainage - nasobiliary or nasopancreatic

• Positioning of biliary or pancreatic prostheses (plastic and metallic) in the neoplastic pathology (cholangiocarcinoma, carcinoma of the pancreas), and benign

• Endoscopic therapy for post surgery complications: fistulas ; stenosis

• Drainage of pancreatic cysts (retrograde or EUS guided)

• EUS + Fine-needle aspirates (FNA)

• Cholangioscopy (Spyglass DS) diagnostic and operative (intraductal biopsies, lithotripsy)

• Papillectomies

• Extraction of stones from the bile and/or pancreatic ducts; mechanical endoluminal lithotripsy

• Intraductal brushing

 

Endoscopic mucosal resection (EMR) and submucosal (ESD)

The Endoscopic mucosal resection (EMR) and submucosal dissection (ESD) make the removal of many surface neoplasms of the gastrointestinal tract possible with curative and/or staging intents. These are considered highly-advanced techniques of minimally-invasive endoscopic endoluminal surgery thanks to which it is possible to ensure  treatment and  palliation of  advanced oncological disease, without the need to resort to surgery and preserving the integrity and function of the organ involved.

Our service is able to provide the patient with such therapeutic support. This is fully in keeping  with the foundation's mission to improve of the technical and professional skills  and to introduce operational methods which guarantee the patient optimal management of his neoplastic pathology.

Surface neoplastic lesions (precancerous lesions and tumours in the initial phase (Tis; T1 sm1) for which this therapeutic approach is viable are:

 

• oesophagus: superficial Squamous Cell Carcinoma (SCCs, m1 – m2); Barrett's oesophagus with HGD ( high grade dysplasia) or intramucosal adenocarcinoma (m1, m2, m3; sm1 ≤ 500μm); GIST
• stomach: both intramucosal and submucosal neoplasms (sm1 ≤ 500μm) : adenoma or well-differentiated adenocarcinoma  (G1, G2) or papillary carcinoma ; GIST
• duodenum: intramucosal neoplasms: adenomas with low / high degree of dysplasia
• colon-rectum: intramucosal or submucosal neoplasia (sm1 ≤ 1000μm) (adenoma or adenocarcinoma G1 G2); GIST

 

With this technique it is possible to verify the section profile  with precision and to remove lesions above two centimetres in a single fragment. This, in the presence of a tumour, makes it possible to assess with the microscope whether or not the lesion has been removed completely and the degree of infiltration.

Endoscopic resection is performed in day surgery, with admission time being from 7 a.m. To  5 p.m., or with standard hospitalization of 48/72 hrs. For lesions of the upper tract deep sedation is generally used with anaesthesiological assistance. For rectal and  colon procedures sedation depends on the type of lesion and  on the time required for its removal.

 

Full thickness resection (FTR)

This endoscopic resection technique permits full-thickness resection and radical treatment of a wide range of lesions otherwise requiring non-curative surgical or endoscopic removal (carcinomas T1; neoplastic submucosal lesions; partially resected lesions in the course of previous endoscopic procedures)
It also allows for an optimization of anatomical-pathological assessment of the tissue ( full-thickness diagnostic resection).
The removal a full thickness of the lesions by means of the FTRD system offers notably reduced operating times when compared to EMR and ESD techniques. The system makes it possible to work safely (lower rate of complications due to perforation and early and late haemorrhages),  swiftly (shortening of hospitalization times) and with excellent results.

 

Ecoendoscopy

In the diagnostic–staging phase, a key role is played by endoscopic ultrasound. Endoscopic ultrasound, or EUS, is an advanced endoscopy technique which makes it possible to obtain an accurate pre-operative assessment of neoplasms of the gastrointestinal tract and of the lung. This method is, in addition, an aid, in combination with other advanced endoscopic imaging techniques, to assessing  early-stage gastrointestinal neoplasms which permit a minimally invasive endoscopic approach. Among the diagnostic endoscopic ultrasound procedures for oncological purposes, the most frequently indicated ones include staging of tumours of the oesophagus, stomach, duodenum, rectum, the pancreas and of the bile ducts. In particular, endoscopic ultrasound is today a highly important method in the characterization of the solid and cystic neoplasms of the pancreas, as well as in  pre-operative assessment of tumours of the bilio-pancreatic area in which correct staging is fundamental before undertaking a highly-complex surgical path. The tumour diagnosis and staging phase in many cases necessitates the acquisition of a biological sample of the tumour itself. Cytological and/or histological definition of the disease, and also its molecular characterization, is indeed today essential in setting the best course of therapy. To this end, during an EUS investigation, in minimally-invasive fashion, with fine needle and under ultrasound guidance, samples of a part of the tumour may be taken, whether the tumour is gastrointestinal, hepatic, abdominal-mediastinal lymphonodal, bilio-pancreatic, and more generally, of the retroperitoneal region provided that the lesion is adjacent to the upper or lower gastrointestinal tract. Lastly, and again on the subject of Endoscopic ultrasound diagnostics, and thanks to the availability of ultrathin instruments  which make it possible to perform the ultrasonography of the mediastinum through the trachea and the bronchi, procedures of EUS staging of tumours of the lung may be performed in which the combined trans-bronchial and trans-oesophageal approach may replace more invasive surgical techniques such as mediastinoscopy. Of more recent development are the operative EUS techniques which, in combination with other surgical endoscopy procedures, make it possible to reach, in minimally-invasive fashion, therapeutic and palliative targets otherwise pursuable only through operations putting the patient at greater risk. Procedures can be performed for the drainage of pancreatic collections, post-surgical collections, and those of the bile ducts, as well as EUS-guided operations for stenosis of the digestive system.

 

More

 

• Clinical gastrointestinal examinations
• Screening  for colorectal cancer (The EDDI is the regional Centre of reference for the screening programme for the prevention and  early diagnosis of colorectal cancer)

 

Staff

 

Surgical Endoscopy: Teresa Staiano (MD), Cristiana Laudi (MD)
Surgical Team: Dario Ribero (MD), Alfredo Mellano (MD), Domenico Lo Conte (MD)