New Techniques in Gastrointestinal Endoscopy

As result of progress, endoscopy has became more complex, using more sophisticated devices and has claimed a special form. In this moment, the gastroenterologist performing endoscopy has to be an expert in macroscopic view of the lesions in the gut, with good skills for using standard endoscopes, with good experience in ultrasound (for performing endoscopic ultrasound), with pathology experience for confocal examination. It is compulsory to get experience and to have patience and attention for the follow-up of thousands of images transmitted during capsule endoscopy or to have knowledge in physics necessary for autofluorescence imaging endoscopy. Therefore, the idea of an endoscopist has changed. Examinations mentioned need a special formation, a superior level of instruction, accessible to those who have already gained enough experience in basic diagnostic endoscopy. This is the reason for what these new issues of endoscopy are presented in this book of New techniques in Gastrointestinal Endoscopy

Capsule Endoscopy in Suspected and Established Small Bowel Crohn’s Disease

Capsule endoscopy has recognized to be a very useful non-invasive tool for diagnosis and evaluation of the extension or the recurrence in Crohn’s disease (CD) patients. It has the advantage of outstanding visualization of small-bowel lesions undetectable by conventional endoscopy or radiologic studies and has a good tolerability and safety in well-selected patients. In this chapter, we would like to evaluated the significant small bowel capsule endoscopy findings that can lead to better outcomes of diagnosis, classification, therapeutic management, and prognosis of patients with CD. Moreover, we would to discuss the specificity of the CE and to determine the place of the CE in the recurrence of CD and, for example, its role in monitoring drug response

Diagnostic and therapeutic guidelines for gastro-entero-pancreatic neuroendocrine neoplasms (recommended by the Polish Network of Neuroendocrine Tumours)

Postęp w diagnostyce i leczeniu nowotworów neuroendokrynnych (NEN), opublikowanie wyników nowych randomizowanych badań klinicznych oraz powstanie nowych zaleceń ENETS skłoniło ekspertów skupionych w Polskiej Sieci Guzów Neuroendokrynnych do uaktualnienia opublikowanych w 2013 roku zaleceń dotyczących postępowania w nowotworach neuroendokrynnych. W niniejszym artykule przedstawiono zalecenia ogólne postępowania w NEN będące wynikiem ustaleń ekspertów uczestniczących w III Konferencji Okrągłego Stołu pt. „Diagnostyka i leczenie nowotworów neuroendokrynnych układu pokarmowego: rekomendacje polskie w świetle aktualnych zaleceń europejskich”, która odbyła się w Żelechowie koło Warszawy w grudniu 2016 roku. Korzystając z bogatego doświadczenia ośrodków zajmujących się tymi nowotworami, mamy nadzieję, że udało nam się wypracować najbardziej optymalny sposób postępowania u chorych z NEN, uwzględniający najnowsze osiągnięcia medycyny, który będzie mógł być skutecznie realizowany w naszym kraju. W kolejnych częściach tego opracowania przedstawiono zasady postępowania w: NEN żołądka i dwunastnicy (z uwzględnieniem gastrinoma), trzustki; jelita cienkiego i wyrostka robaczkowego oraz jelita grubego.Progress in the diagnostics and therapy of gastro-entero-pancreatic (GEP) neuroendocrine neoplasms (NEN), the published results of new randomised clinical trials, and the new guidelines issued by the European Neuroendocrine Tumour Society (ENETS) have led the Polish Network of Neuroendocrine Tumours to update the 2013 guidelines regarding management of these neoplasms. We present the general recommendations for the management of NENs, developed by experts during the Third Round Table Conference — Diagnostics and therapy of gastro-entero-pancreatic neuroendocrine neoplasms: Polish recommendations in view of current European recommenda­tions, which took place in December 2016 in Żelechów near Warsaw. Drawing from the extensive experience of centres dealing with this type of neoplasms, we hope that we have managed to develop the optimal management system, applying the most recent achievements in the field of medicine, for these patients, and that it can be implemented effectively in Poland. These management guidelines have been arranged in the following order: gastric and duodenal NENs (including gastrinoma); pancreatic NENs; NENs of the small intestine and appendix, and colorectal NENs

Diagnosis and Treatment of Small Bowel Disorders

Over the last few decades, remarkable progress has been made in understanding the aetiology and pathophysiology of diseases and many new theories emphasize the importance of the small bowel ‘ecosystem’ in the pathogenesis of acute and chronic illness. Emerging factors such as microbiome, stem cells, innate intestinal immunity and the enteric nervous system along with mucosal and endothelial barriers have key role in the development of gastrointestinal and extra-intestinal diseases. Therefore, the small intestine is considered key player in metabolic disease development, including diabetes mellitus, and other diet-related disorders such as celiac and non-celiac enteropathies. Another major field is drug metabolism and its interaction with microbiota. Moreover, the emergence of gut-brain, gut-liver and gut-blood barriers points toward the important role of small intestine in the pathogenesis of common disorders, such as liver disease, hypertension and neurodegenerative disease. However, the small bowel remains an organ that is difficult to fully access and assess and accurate diagnosis often poses a clinical challenge. Eventually, the therapeutic potential remains untapped. Therefore, it is due time to direct our interest towards the small intestine and unravel the interplay between small-bowel and other gastrointestinal (GI) and non-GI related maladies

Clinical utility of capsule endoscopy in gastrointestinal bleeding

Introduction Capsule endoscopy (CE) is a first-line diagnostic tool for known or suspected small bowel bleeding (SBB), and its use has over time been expanded to include panenteric imaging. It offers advantages over conventional endoscopy in minimal invasiveness and ease of use. However several drawbacks remain including the lack of modalities other than imaging, inability to control or propel the capsule, lesser image quality compared to conventional endoscopy and labour-intensiveness of data interpretation. Aims and objectives This thesis aims to explore the ways in which use of CE can be optimised in the current clinical or “real world” context, focusing on its use in gastrointestinal bleeding and working within current resource and technological limitations. Methods A review and analysis of the existing literature was undertaken, examining the present state of CE technology and identifying current gaps in knowledge. Meta-analyses were undertaken examining the effectiveness of the two main methods of image enhancement in CE: the use of bowel preparation and currently available rudimentary computer-aided diagnosis. The following studies then looked into how to better select patients who should be prioritised for CE examination – a pertinent issue in today’s resource-stretched healthcare systems. A retrospective study was carried out to examine the effects of altering the timing of CE examination in patients referred for likely SBB, using cases carried out at our tertiary care centre over the past decade. Outcomes were compared between patients who had undergone CE following negative bidirectional endoscopies, or negative upper gastrointestinal tract endoscopy only. Furthermore, building on existing work, a second study was undertaken using a prospectively-designed database to collect multicentre data on findings and outcomes in young patients referred for CE with iron deficiency anaemia. This study investigated factors predictive of small bowel neoplasia in this patient group. Finally, the effect of image visualisation quality on diagnostic certainty was investigated. CE images were processed to alter image parameters, and the resulting images presented to an iii international group of expert CE readers in order to determine thresholds for acceptable image quality and the effects of differing image quality in the parameters examined. Results Currently-available image enhancement techniques: (1) Use of bowel preparation: Laxative use did not improve the diagnostic yield of CE with odds ratio (OR) 1.1 for both overall and significant findings when comparing laxative use with pre-procedural fast only. However, subjectively-determined small bowel visualisation quality improved with the use of laxatives (OR 1.60 (95%CI 1.08–2.06)), NNT 14. (2) Use of suspected blood indicator (SBI): The overall sensitivity of SBI for bleeding or potentially bleeding lesions was 0.553, specificity 0.578, DOR 12.354. The sensitivity of SBI for active bleeding was 0.988, specificity 0.646, DOR 229.89. (3) Use of FICE digital image enhancement: Overall, the use of the three FICE modes did not significantly improve image delineation or detection rate in CE. For pigmented lesions only, FICE setting 1 performed better in lesion delineation and detection. Patient selection and CE pathways: The earlier use of CE in inpatients with melena or IDA, no signs of lower gastrointestinal pathology and negative UGIE resulted in shortened hospital stays, significant diagnostic yield from both small bowel and upper gastrointestinal tract, and two-thirds less unnecessary colon investigations without affecting clinical outcomes. In young patients (age <50 years) with IDA and negative bidirectional GI endoscopy, the overall diagnostic yield of CE for clinically significant findings was 32.3%. 5% of our cohort was diagnosed with SB neoplasia; lower MCV and weight loss were associated with higher diagnostic yield for significant SB pathology. Effects of visualisation quality on diagnostic certainty: Poor visualisation quality in all parameters affected mostly neoplastic lesions. Software to increase contrast and sharpen images can improve visualisation quality; smart frame rate adaptation could improve the number of high-quality frames obtained. Thoroughness in small bowel cleansing was found to be most important when there is suspicion of neoplasia. Conclusions The data in this thesis show that CE could be employed earlier in the diagnostic pathway for patients presenting clinically with SBB, as an effective diagnostic and triage tool in the semi acute setting. Although the overall diagnostic yield of CE is lower in younger patients, young patients with IDA and no significant findings on bidirectional endoscopy are also more likely to have significant small bowel findings, and should perhaps be referred preferentially for CE. This would help increase the efficiency of resource utilisation. Of the currently available image enhancement techniques in CE, digital image enhancement and diagnostic tools such as SBI and FICE remain of limited validity; however they show the most promise for vascular lesions and active GI bleeding, which supports their use in the acute to semi-acute setting to improve efficiency of CE reading. Image enhancement with both laxatives and digital means is the most crucial when patients are suspected of having more subtle small bowel findings such as small bowel neoplasia

The role of MGMT promoter methylation as a predictive factor for temozolomide-based treatment in neuroendocrine neoplasms: a prospective observational study.

Temozolomide-based treatments have been demonstrated active in advanced NETs. However, treatment selection and sequencing are based solely on clinical parameters, since no biomarker is currently available to guide clinical management. MGMT-promoter methylation status is a good predictive factor for TEM treatment response in glioblastomas and melanomas and it is currently used in clinical practice. Differently, in NET patients, evidence on MGMT-promoter methylation status role is scarce. The aim of this study was to prospectively evaluate the role of MGMT status in predicting response to TEM-based treatment in NET patients. Primary endpoint was correlation of MGMT promoter methylation with PFS; secondary endpoints were correlation with OS, ORR, DCR, safety and cost analysis. A single-center, prospective observational trial has been conducted at ENETS Center-of-Excellence Outpatient Clinic of Policlinico-Sant’Orsola (Bologna). Patients with advanced, well-differentiated NETs of gastro-entero-pancreatic and lung origin candidate to TEM-based treatment, with tissue available for MGMT-promoter methylation analysis were enrolled. MGMT-promoter methylation status was analyzed by pyrosequencing on tumor tissue. Data of 22 patients were analyzed. Five patients (23%) presented MGMT-promoter methylation. In the MGMT-methylated population, median PFS was 34 months [IQR:15-58], compared to 14 [IQR:8-38] in non-methylated patients. MGMT-promoter methylation status was the only independent variable related to PFS. Better outcomes were observed in the MGMT-methylated group, also for OS (34vs21 months), DCR (100%vs88%) and ORR (80%vs24%). TEM-based treatment resulted a safe treatment, with low rate of adverse events (G≥3<10%). The cost of MGMT-promoter methylation testing by pyrosequencing is affordable (60 euros/patient) and the test is widely available. This study has prospectively demonstrated the role of MGMT-promoter methylation status as good predictive factor for TEM-based treatment in NET patients. Due to its promising predictive role, the wide availability and low costs of the assay, this biomarker could be implemented in clinical practice to guide treatment selection in NET patients