Role of endoscopy in the bariatric surgery of patients

Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett’s esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett’s esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.

Quality of life in rectal cancer surgery:What do the patient ask?

Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision(TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques(pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.

Minimally invasive treatment of cholecysto-choledocal lithiasis:The point of view of the surgical endoscopist

The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%,depending on the patient's age.Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones.At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include:single-stage laparoscopic treatment,perioperative endoscopic treatment and endoscopic treatment alone.Published data evidence that,associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay.However,current data does not suggest clear superiority of any one approach with regard to success,mortality,morbidity and cost-effectiveness.Considering the variety of therapeutic options available for management,a critical appraisal and decision-making is required.endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis,i.e.,in patients with acute obstructive suppurative cholangitis,severe biliary pancreatitis,ampullary stone impaction or severe comorbidity.In a setting where all facilities are available,decision in the selection of the therapeutic option depends on the patients,the number and size of choledocholithiasis stones,the anatomy of the cystic duct and common bile duct,the surgical history of patients and local expertise.

Confocal laser endomicroscopy in the “in vivo” histological diagnosis of the gastrointestinal tract

Recent technological advances in miniaturization have allowed for a confocal scanning microscope to be integrated into a conventional flexible endoscope,or into trans-endoscopic probes,a technique now known as confocal endomicroscopy or confocal laser endomicroscopy.This newly-developed technology has enabled endoscopists to collect real-time in vivo histological images or "virtual biopsies" of the gastrointestinal mucosa during endoscopy,and has stimulated significant interest in the application of this technique in clinical gastroenterology.This review aims to evaluate the current data on the technical aspects and the utility of this new technology in clinical gastroenterology and its potential impact in the future,particularly in the screening or surveillance of gastrointestinal neoplasia.

In-vivo characterization of DALM in ulcerative colitis with high-resolution probe-based confocal laser endomicroscopy

Recently,the use of confocal laser endomicroscopy(CLE) in the diagnosis of chronic ulcerative colitis(CUC) was reported.In this brief report we aimed to assess the application of probe-based CLE to characterize colonic mucosa and dysplasia in CUC.The study involved a patient presenting long-standing CUC.Confocal imaging of both the inflamed mucosa,a circumscribed lesion(dysplasiaassociated lesional mass),and adjacent colonic mucosa are demonstrated and the correlation between the CLE and histological images.Inflamed mucosa and dysplasia showed specific alteration of crypt architecture,cellular infiltration,and vessel architecture with an excellent correlation between CLE and standard histological examination.

Endoscopic papillectomy: Indications, techniques, and results

Endoscopic papillectomy (EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size (up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings (ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound (EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a ‘‘high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early (pancreatitis, bleeding, perforation, and cholangitis) and late (papillary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis (FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.

Management strategies of Barrett's esophagus

Barrett's esophagus is a condition resulting from chronic gastro-esophageal reflux disease with a documented risk of esophageal adenocarcinoma. Current strategies for improved survival in patients with Barrett's adenocarcinoma focus on detection of dysplasia. This can be obtained by screening programs in high-risk cohorts of patients and/or endoscopic biopsy surveillance of patients with known Barrett's esophagus (BE). Several therapies have been developed in attempts to reverse BE and reduce cancer risk. Aggressive medical management of acid reflux, lifestyle modifications, antireflux surgery, and endoscopic treatments have been recommended for many patients with BE. Whether these interventions are cost-effective or reduce mortality from esophageal cancer remains controversial. Current treatment requires combinations of endoscopic mucosal resection techniques to eliminate visible lesions followed by ablation of residual metaplastic tissue. Esophagectomy is currently indicated in multifocal high-grade neoplasia or mucosal Barrett's carcinoma which cannot be managed by endoscopic approach.

Endoscopic treatment of esophageal achalasia

Achalasia is a motility disorder of the esophagus characterized by dysphagia, regurgitation of undigested food, chest pain, weight loss and respiratory symptoms. The most common form of achalasia is the idiopathic one. Diagnosis largely relies upon endoscopy, barium swallow study, and high resolution esophageal manometry(HRM). Barium swallow and manometry after treatment are also good predictors of success of treatment as it is the residue symptomatology. Short term improvement in the symptomatology of achalasia can be achieved with medical therapy with calcium channel blockers or endoscopic botulin toxin injection. Even though few patients can be cured with only one treatment and repeat procedure might be needed, long term relief from dysphagia can be obtained in about 90% of cases with either surgical interventions such as laparoscopic Heller myotomy or with endoscopic techniques such pneumatic dilatation or, more recently, with per-oral endoscopic myotomy. Age, sex, and manometric type by HRM are also predictors of responsiveness to treatment. Older patients, females and type Ⅱ achalasia are better after treatment compared to younger patients, males and type Ⅲ achalasia. Self-expandable metallic stents are an alternative in patients non responding to conventional therapies.

Confocal laser endomicroscopy in inflammatory bowel diseases:Dream or reality?

Confocal laser endomicroscopy(CLE)is a newly introduced procedure that provide real-time,high-resolution imaging of the gastrointestinal mucosa during endoscopy,allowing the visualization of the pathology of the mucosal epithelium with its cellular and subcellular structures.Recently,the use of CLE was reported in the study of colonic mucosa in patients with inflammatory bowel diseases and in particular in patients affected by ulcerative colitis.CLE has the potential to have an important role in management of inflammatory bowel diseases(IBD)patients as it can be used to assess the grading of colitis and in detection of microscopic colitis in endoscopically silent segments.Moreover,CLE can be used in surveillance programs especially in highrisk patients.Finally,CLE has been effectively used in diagnosing a biliary dysplasia/neoplasia in patients with primary sclerosing cholangitis,a pathological condition frequently associated with IBD,with a coexisting bile duct stricture.