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Role of endoscopy in git cancers

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Role of endoscopy in git cancers

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Role of endoscopy in git cancers

  1. 1. Ihab Samy MD. Surgical Oncology Lecturer of Surgical Oncology National Cancer Institute- Cairo University 2013
  2. 2. Barrett’s Esophagus (BE)  BE has been defined in the United States by the presence of specialized intestinal metaplasia of the tubular esophagus and is recognized as a precursor lesion to esophageal adenocarcinoma (EAC)  It is a reparative response to reflux induced damage to the native squamous epithelium, with subsequent replacement with a metaplastic intestinalized epithelium, BE.  Metaplastic BE is associated with increased cellular proliferation and turnover that may result in progression to dysplasia. Dr. Ihab Samy 2013
  3. 3.  It was reported up a 30- to 40-fold increased risk of the development of EAC  BE is histologically graded as: 1. Nondysplastic (NDBE) 2. Indeterminate-grade dysplasia (IGD), 3. Low-grade dysplasia (LGD) 4. High-grade dysplasia (HGD) 5. Intramucosal carcinoma (IMC) 6. Invasive EAC Dr. Ihab Samy 2013
  4. 4.  BE has a characteristic appearance endoscopically, described as a salmon or pink color in contrast to the light gray appearance of esophageal squamous mucosa.  It should be emphasized that histologic examination of esophageal biopsy samples is required to confirm the diagnosis of BE. Dr. Ihab Samy 2013
  5. 5.  The sensitivity of white-light endoscopy alone for the detection and diagnosis of BE ranges from 80% to 90%.  During endoscopy, special attention and targeted biopsies should be focused on lesions such as nodules, ulcers, and other mucosal irregularities because these lesions are more likely to demonstrate dysplasia or cancer. Dr. Ihab Samy 2013
  6. 6. Surveillance of NDBE  Consider no surveillance.  If surveillance is elected, perform EGD every 3 to 5 years with 4-quadrant biopsies every 2 cm.  Consider endoscopic ablation (RFA) in select cases (family history of EAC). Dr. Ihab Samy 2013
  7. 7. Surveillance of IGD  Clarify presence and grade of dysplasia with expert GI pathologist.  Increase antisecretory therapy to eliminate esophageal inflammation.  Repeat EGD and biopsy to clarify dysplasia status. Dr. Ihab Samy 2013
  8. 8. Surveillance of LGD  Confirm with expert GI pathologist.  Repeat EGD in 6 months to confirm LGD.  Surveillance EGD every year, 4-quadrant biopsies every 1 to 2 cm.  Consider endoscopic resection or ablation. Dr. Ihab Samy 2013
  9. 9. Surveillance of HGD  Confirm with expert GI pathologist.  Consider surveillance EGD every 3 months in select patients, 4-quadrant biopsies every 1 cm.  Consider endoscopic resection or RFA ablation.  Consider EUS for local staging and lymphadenopathy.  Consider surgical consultation. Dr. Ihab Samy 2013
  10. 10. Endoscopic management of BE with dysplasia  Endoscopic therapy can be divided into therapies that ablate dysplastic mucosa and techniques that resect dysplastic mucosa.  A key element of the endoscopic therapy of dysplasia is that re-epithelialization of squamous mucosa can only be achieved in an acid-suppressed environment.  Thus, the use of antisecretory agents or antireflux surgery is a necessary adjunct to these techniques. Dr. Ihab Samy 2013
  11. 11. Endoscopic ablation  Photodynamic therapy (PDT) using 5-aminolevulinic acid or porfimer sodium as photosensitizing agents has been used effectively to eliminate HGD (77% over 5 years) and early EAC.  Disadvantages of this technique include the inability to eliminate NDBE, skin photosensitivity for as long as 1 month, and stricture formation rates of approximately 30%.  PDT has been less commonly used for dysplasia since the emergence of RFA. Dr. Ihab Samy 2013
  12. 12.  RFA involves direct application of radiofrequency energy to the esophageal mucosa.  Chest pain or discomfort is fairly common after RFA treatment, but generally subsides after 1 week.  GI hemorrhage and esophageal stricture formation were also recorded.  Surveillance every 3 months for the first year after ablation, every 6 months for the next year, and then annually. Dr. Ihab Samy 2013
  13. 13.  Cryotherapy is an ablative technique that causes cellular destruction by using freeze- thaw cycles.  During endoscopy, a spray catheter is passed through the working channel of the endoscope and either liquid nitrogen or carbon dioxide is applied to the dysplastic area.  Significant Complications are uncommon with this technique, but 1 case of perforation has been reported. Dr. Ihab Samy 2013
  14. 14. EMR / Endoscopic Submucosal Dissection  Techniques designed to remove targeted superficial tissue of the GI tract (EMR) or large en bloc strips of mucosa (ESD)  A distinct advantage of EMR/ESD over ablative therapy is the availability of large tissue specimens for pathologic examination and cancer staging. Dr. Ihab Samy 2013
  15. 15.  EMR is indicated for shorter segment dysplastic BE, nodular dysplasia, superficial (T1a) EAC, and esophageal squamous cell carcinoma (ESC).  ESD can be used in similar situations and may be preferred for extensive areas of dysplasia or IMC. Dr. Ihab Samy 2013
  16. 16. RECOMMENDATIONS of ASGE 2012 1. endoscopic screening for BE can be considered in select patients with multiple risk factors for BE and EAC, but patients should be informed that there is insufficient evidence to affirm that this practice prevents cancer or prolongs life. QOEOEOE 2. no further endoscopic screening for BE after a screening examination with negative findings. 3. No surveillance EGD 1 year after the initial diagnosis of NDBE. 4. if patients with NDBE are enrolled in an EGD surveillance program, a surveillance EGD should be performed no more frequently than every 3 to 5 years, with white-light endoscopy and targeted plus 4-quadrant biopsies at every 2 cm of suspected BE. 5. only patients with BE who are candidates for therapy if dysplasia is identified be enrolled in EGD surveillance programs. 6. patients with a diagnosis of BE IGD undergo additional evaluation to clarify the diagnosis. This may include additional pathology review, dose escalation of antisecretory therapy to eliminate confounding esophageal inflammation, and/or a repeat EGD and biopsy. 7. an expert GI pathologist should confirm the diagnosis of LGD and/or HGD. 8. patients with LGD undergo a repeat endoscopy within 6 months to confirm the diagnosis, then annual surveillance endoscopy using a standard biopsy protocol. 9. ablation should be considered in select patients with LGD. Appropriate surveillance intervals after ablation are unknown. 10. endoscopic resection of nodular dysplastic BE be performed to determine the stage of dysplasia before considering other ablative endoscopic therapy. 11. local staging with EUS FNA is an option in select patients being considered for endoscopic ablative therapy. 12. eradication with endoscopic resection or RFA should be considered for flat HGD in select cases because of its superior efficacy (compared with surveillance) and side effect profile (compared with esophagectomy). 13. NO routine endoscopic surveillance in achalasia. 14. NO endoscopic routine screening in patients with aerodigestive cancer. 15. screening for esophageal carcinoma begin at age 30 in patients with tylosis. Surveillance intervals should be every 1 to 3 years. 16. screening for esophageal carcinoma begin approximately 10 to 20 years after caustic injury and performed every 2 to 3 years. Dr. Ihab Samy 2013
  17. 17. Esophageal Carcinoma  Malignancies of the esophagus are diagnosed via upper endoscopy with mucosal biopsies.  The sensitivity for mucosal biopsies to detect esophageal carcinoma reaches 96% when multiple samples are obtained.  Strictures may prevent complete visualization and sampling of the obstructing malignancy.  In these instances, brush cytology can improve the diagnostic accuracy by 20%.  Transoral or transnasal ultrathin endoscopes also may be used for obstructing malignancies to visualize the extent and length of the tumor. Dr. Ihab Samy 2013
  18. 18. Staging of esophageal malignancies  Staging of esophageal cancer has traditionally involved EUS and FNA in conjunction with cross-sectional imaging.  Numerous studies have demonstrated the superiority of EUS in both local tumor (T) and nodal (N) staging over CT.  Accuracy for T staging approaches 90% in superficial and partially obstructing esophageal cancers. Dr. Ihab Samy 2013
  19. 19.  Dilation of malignant strictures to facilitate echoendoscope passage for EUS staging reported high complication rates.  Ultrathin US probes or wire-guided instruments may be passed through the working channel of an upper endoscope for endosonography  limited visualization of lymph node regions. Dr. Ihab Samy 2013
  20. 20.  Endosonographic characteristics of malignant lymph nodes include: 1. Size >10 mm, 2. Round and smooth features, 3. Proximity to the primary tumor 4. Hypoechogenicity.  The accuracy of EUS for nodal staging based solely on these acoustic criteria approaches 80%. Dr. Ihab Samy 2013
  21. 21. EUS guided FNA  FNA of lymph nodes increases nodal staging accuracy to 92%-98%.  Tissue sampling contamination may occur when the endoscope traverses the tumor  False +ve results. Dr. Ihab Samy 2013
  22. 22. EUS after neoadjuvant chemoradiation  Fluorodeoxyglucose positron emission tomography/CT appears to have better accuracy than EUS or CT to detect response to neoadjuvant chemoradiation.  The accuracy of EUS in this clinical situation may be weakened because radiation induced mucosal inflammation of the esophageal wall may not always be distinguishable from residual disease. Dr. Ihab Samy 2013
  23. 23. Endoscopic therapy for esophageal cancer  Therapy with curative intent.  Therapy to palliate symptoms. Dr. Ihab Samy 2013
  24. 24.  Distinguishing mucosal from submucosal invasion is an important factor that contributes to the success of endoscopic curative therapies.  Stage T1a malignancies include lesions confined to the mucosa: M1 (intraepithelial), M2 (lamina propria invasion), or M3 (muscularis mucosa invasion).  Submucosal or T1b malignancies are classified into Sm1 (superficial submucosa invasion), Sm2 (invasion to center of submucosa), or Sm3 (invasion to deep submucosa). Dr. Ihab Samy 2013
  25. 25.  Mucosal (T1a) malignancies have extremely low risk of local lymph node progression while submucosal invasion (T1b) markedly increases the risk of lymph node metastases. Metastatic disease is present in up to 21% of Sm1 and 56% of Sm3 cancers.  In addition, early cancers with features of lymphovascular invasion on histology or poorly differentiated cancers are generally considered to represent a higher risk for metastatic disease.  These factors emphasize the need for accurate staging via EUS or en bloc tissue sampling. Dr. Ihab Samy 2013
  26. 26.  Either resection or ablation techniques.  A distinct advantage of resection over ablation therapy is the availability of large tissue specimens for pathologic diagnosis and accurate cancer staging. Dr. Ihab Samy 2013
  27. 27. Resection  EMR and endoscopic submucosal dissection (ESD) are endoscopic techniques that permit targeted removal of superficial tissue of the GI tract.  EMR is indicated for nodular BE and T1a lesions and may be used for flat BE with high-grade dysplasia.  ESD can be used in similar situations but is preferred to EMR for large areas of dysplasia (2 cm) or T1b malignancies (ie, confined to the submucosa). Dr. Ihab Samy 2013
  28. 28.  EMR successfully eradicates 91% to 98% of T1a cancers.  Potential complications of EMR are: 1. Bleeding (Delayed bleeding is rare).Immediate, postresection bleeding can occur in 10% of patients. 2. Perforation (less than 3%.) 3. Stricture formation (depending on the circumference and length of mucosa removed by EMR, but can occur in up to 37%  successfully managed by endoscopic dilation). Dr. Ihab Samy 2013
  29. 29.  Reports from Japan of ESD for SCC of the esophagus show up to 100% en bloc resection rates and 80% curative resection rates.  A retrospective review of ESD versus EMR for the treatment of early SCC, reported higher en bloc resection and lower local recurrence rates with ESD.  ESD in the esophagus has been associated with perforation rates of 2% to 5% and stricture rates between 5% and 17.2% Dr. Ihab Samy 2013
  30. 30. Ablation 1. Photodynamic therapy (PDT) 2. Cryotherapy 3. Argon plasma coagulation (APC) 4. Heater probe treatment 5. Radiofrequency ablation (RFA)  These techniques may be used alone or in combination with mucosal resection techniques, depending on the clinical scenario. Dr. Ihab Samy 2013
  31. 31.  Patients treated with endoscopic methods had similar median cancer-free survival compared with those treated with surgery.  Equivalent survival at 3 years in patients with high grade dysplasia and intramucosal carcinoma treated with endoscopic resection and ablation compared with surgical resection.  Morbidity associated with endoscopic treatment was significantly lower than with surgery. Dr. Ihab Samy 2013
  32. 32. Endoscopic palliative therapy  Endoscopic options for palliation include: 1. Dilation. 2. Stenting. 3. Chemical or Laser debulking. 4. Enteral feeding. Dr. Ihab Samy 2013
  33. 33.  Dilation of obstructing esophageal masses rarely provides sustained relief of symptoms and is complicated by a high perforation rate.  More durable symptom relief can be obtained by esophageal stenting.  Self-expandable metal stents (SEMS) have been used since the 1990s to palliate malignancies.  An overall improvement in quality of life in patients treated with stents was noted. Dr. Ihab Samy 2013
  34. 34.  Stent complications include 1. Intolerable chest pain 2. Perforation 3. Migration 4. Tumor ingrowth 5. Bleeding 6. Fistula formation Dr. Ihab Samy 2013
  35. 35.  A tracheoesophageal fistula can develop from tumor penetration or as a complication of radiation therapy.  SEMS can be used to palliate malignant tracheoesophageal fistulae by sealing the esophagus from the airway and preventing aspiration of luminal contents.  Successful closure of tracheoesophageal fistulae has been reported in up to 86% of patients with SEMS placement. Dr. Ihab Samy 2013
  36. 36.  Successful restoration of luminal patency by using laser ablation (Nd:YAG) has been reported in up to 97% of patients, but multiple sessions are required.  Endoscopic placement of enteral feeding tubes (eg, gastrostomy tube) bypasses obstructing lesions of the upper GI tract in order to permit delivery of nutrition.  Gastrostomy tube placement can complicate esophagectomy and gastric pull-up procedures.  Malignant metastases at stoma sites have been reported Dr. Ihab Samy 2013
  37. 37. Evaluation and treatment of patients with biliary neoplasia  CT, magnetic resonance imaging (MRI), and magnetic resonance cholangiography (MRC), are useful for confirming dilation of the biliary and/or pancreatic ducts and staging more advanced disease but are inferior to side-viewing endoscopy and EUS for detecting small ampullary lesions.  Duodenoscopy by using a side-viewing endoscope permits direct visualization of the ampulla and tissue acquisition and EUS permits diagnosis as well as staging via FNA tissue sampling  EUS and intraductal US (IDUS) can assess the depth of invasion in relation to the muscularis propria as well as intraductal extension and periampullary nodal involvement, facilitating selection of patients who can undergo surgical ampullectomy instead of pancreaticoduodenectomy.  Although not endorsed for routine clinical management, endoscopic ampullectomy has been described for the removal of early ampullary adenocarcinomas. Dr. Ihab Samy 2013
  38. 38. ERCP  ERCP is important in the diagnosis and management of cholangiocarcinoma because tissue confirmation can be achieved with this technique.  Brushings for cytology and biopsy samples for histology can confirm the diagnosis of cholangiocarcinoma. Dr. Ihab Samy 2013
  39. 39.  If the level of obstruction is located below the level of the bifurcation (Bismuth type I lesions), surgical resection should be considered in medically stable patients without metastatic disease.  If the patient is a poor surgical candidate, palliation with plastic or metal stents should be considered. Dr. Ihab Samy 2013
  40. 40. Bismuth classification of cholangiocarcinoma Dr. Ihab Samy 2013
  41. 41.  If the level of obstruction is at or above the hilum, Unilateral endoscopic biliary stent placement directed by prior imaging has been shown to achieve palliation of jaundice equal to that of bilateral stent placement, but with a lower risk of cholangitis and lower cost.  In patients in whom ERCP is unsuccessful, interventional EUS techniques or percutaneous transhepatic cholangiography with stent placement can be considered where expertise is available. Dr. Ihab Samy 2013
  42. 42. Biliary stents  Biliary stents are made of plastic or metal.  Plastic stents are less expensive, but they occlude by a median of 3 to 6 months because of the deposition of bacterial biofilm.  Self-expandable metal stents may remain patent longer than plastic stents.  Although it has been suggested that the use of self expandable metal stents be reserved for patients whose estimated survival is longer than 3 to 6 months the choice of stent type should be individualized. Dr. Ihab Samy 2013
  43. 43. RECOMMENDATIONS of ASGE 2012 1. EUS should be performed in patients with suspected ampullary adenocarcinoma or cholangiocarcinoma if the EUS findings or positive FNA results would change management. 2. MRC to assess for resectability if a CT scan suggests cholangiocarcinoma, particularly of the bifurcation. If the lesion is unresectable, endoscopic palliation of jaundice should be performed by using MRC as a guide for unilateral drainage to minimize the risk of cholangitis. 3. ERCP to obtain tissue or facilitate further evaluation of indeterminate strictures. 4. Symptomatic patients with GBP undergo cholecystectomy. 5. Asymptomatic patients with a GBP larger than 10 mm undergo cholecystectomy. 6. Asymptomatic patients with a GBP 6 mm to 10 mm in size and without other risk factors for GB cancer (60 years of age and older, coexistence of gallstones, sessile morphology) be followed by TUS every 12 months. 7. The presence of any GBP should prompt cholecystectomy in patients with PSC. Dr. Ihab Samy 2013
  44. 44. Gastric epithelial polyps  The majority of gastric epithelial polyps found during endoscopy are incidental and frequently either of hyperplastic or fundic gland histology (70%-90%).  Fundic gland polyps may develop in association with long-term proton pump inhibitor use but have not been associated with an increased risk of cancer.  Adenomatous polyps have malignant potential, and this risk correlates with size and older patient age. Dr. Ihab Samy 2013
  45. 45.  Patients with adenomatous polyps should have complete excision and surveillance endoscopy to ensure no recurrence.  Polyp histology cannot be reliably distinguished by endoscopic appearance, and therefore either biopsy or polypectomy is warranted in any suspicious lesion.  Hyperplastic polyps may have an increased risk of cancer (dysplastic elements being present in up to 19% of hyperplastic polyps) Dr. Ihab Samy 2013
  46. 46.  Polypoid defects of any size detected radiographically should be evaluated endoscopically, with biopsy and/or removal of the lesions.  If endoscopic polypectomy is not possible, a biopsy of the polyp should be performed, and if adenomatous or dysplastic tissue is detected, referral for surgical resection should be considered.  If representative biopsy samples are obtained and the polyp is nondysplastic, no further intervention is necessary.  If it is felt that endoscopic biopsy cannot sufficiently exclude the presence of dysplastic elements, referral for surgical resection is reasonable in polyps that cannot be removed endoscopically. Dr. Ihab Samy 2013
  47. 47.  Surveillance endoscopy 1 year after removing adenomatous gastric polyps is reasonable to assess recurrence at the prior excision site, new or previously missed polyps, and/or supervening early carcinoma.  If the results of this examination are negative, repeat surveillance endoscopy should be repeated no more frequently than at 3- to 5-year intervals.  Follow-up after resection of polyps with high-grade dysplasia and early gastric cancer should be individualized.  No surveillance endoscopy is necessary after adequate sampling or removal of nondysplastic gastric polyps. Dr. Ihab Samy 2013
  48. 48. Gastric intestinal metaplasia and dysplasia  Gastric intestinal metaplasia (IM) is recognized as a premalignant condition that may be the result of an adaptive response to environmental stimuli such as H pylori infection, smoking, and high salt intake.  Patients with IM may have a 10-fold increased risk of developing gastric cancer, which may be highest in certain geographical areas (e.g, Japan) and in patients infected with H pylori. Dr. Ihab Samy 2013
  49. 49.  Endoscopic surveillance for gastric intestinal metaplasia has not been extensively studied and therefore cannot be uniformly recommended.  Patients at increased risk for gastric cancer due to ethnic background or family history may benefit from surveillance.  Endoscopic surveillance should incorporate a topographic mapping of the entire stomach.  Patients with confirmed high-grade dysplasia are at significant risk for progressing to cancer and should be considered for gastrectomy or local (eg, endoscopic) resection. Dr. Ihab Samy 2013
  50. 50. FAMILIAL ADENOMATOUS POLYPOSIS AND HEREDITARY NONPOLYPOSIS COLORECTAL CANCER  Patients with FAP should undergo upper endoscopy early in the third decade of life.  If no adenomas are detected, another exam should be performed in 5 years because adenomatous change may occur later in the course of the disease.  For patients with duodenal and periampullary adenomas, surveillance endoscopy and biopsy should be performed at intervals every 6 months for a minimum of 2 years, with endoscopy thereafter at 3-year intervals. Dr. Ihab Samy 2013
  51. 51.  Biopsies of gastric polyps in patients with FAP may be performed to confirm that they are fundic gland polyps and to assess for dysplasia.  Antral polyps are usually adenomas and should be resected.  Patients with HNPCC are at increased risk for the development of gastric and small-bowel cancer.  Although there is insufficient data to show a benefit for upper endoscopic surveillance in patients with HNPCC, endoscopic surveillance should be considered. Dr. Ihab Samy 2013
  52. 52. Colorectal Cancer (CRC)  During the past decade, great emphasis has been placed on the use of colonoscopy for the early detection and the removal of adenomatous polyps to reduce the incidence and the mortality of CRC.  Once CRC has developed, colonoscopy also has an important role in the diagnosis and subsequent disease management. Dr. Ihab Samy 2013
  53. 53.  In general, polypoid lesions found at the time of colonoscopy should be removed.  Colonic lesions not amenable to endoscopic resection can be sampled with biopsy forceps.  Biopsy specimens of broad sessile lesions or of large mass lesions should be obtained from different areas, including the edges and the center of the lesion, if possible.  The addition of cytology brushings to forceps biopsies may increase the diagnostic yield, especially in the setting of obstructing tumors that cannot be traversed. Dr. Ihab Samy 2013
  54. 54.  There was no additional diagnostic yield from obtaining more than 6 biopsy specimens.  In cases where endoscopic biopsy specimens are nondiagnostic and cancer is highly suspected, clinicians should consider obtaining a second opinion from an expert pathologist and/or performing repeat colonoscopy for additional tissue sampling.  Surgery is indicated for suspicious lesions with nondiagnostic biopsy specimens. Dr. Ihab Samy 2013
  55. 55.  EMR can be selectively used in the removal of colonic lesions that may potentially be malignant or may have high-grade dysplasia (HGD).  The use of submucosal solution injection, which allows for the complete resection of the mucosa through the mid to deep submucosa.  EUS also can serve as a useful tool in the evaluation of colonic lesions before EMR by determining depth of invasion and by detecting the presence of lymph nodes that may indicate malignancy. Dr. Ihab Samy 2013
  56. 56. Localization  colonoscopy has an important role in the localization of malignant lesions for subsequent identification at the time of surgery.  Preoperative endoscopic marking can be helpful in localizing flat, small, colonic lesions that may be difficult to identify by inspection or palpation during surgery.  Marking techniques currently available include endoscopic tattooing and metallic clip placement. Dr. Ihab Samy 2013
  57. 57. Staging  The accuracy of EUS for T staging ranges from 80% to 95%.  EUS has been demonstrated to be superior to CT in determining the T stage of rectal cancer.  Magnetic resonance imaging with endorectal coils has been compared with EUS , appears to have similar accuracy for T staging except in differentiating between T1 and T2 tumors, where EUS may be superior.  Abdominal CT, in combination with EUS, appears to be the most cost-effective strategy in staging rectal cancer Dr. Ihab Samy 2013
  58. 58.  EUS-guided FNA of perirectal lymph nodes may be most helpful in the setting of T1 or T2 disease in which the presence of malignant perirectal lymph nodes would change patient management to include preoperative chemoradiation therapy.  Malignant strictures in the rectum that are not traversable may be difficult to evaluate by EUS.  The use of miniprobes advanced through the endoscope channel or rigid rectal EUS probes may be helpful in these cases. Dr. Ihab Samy 2013
  59. 59. Detection of Recurrence  EUS and EUS-guided FNA are highly sensitive methods for the detection and the diagnosis of regional recurrence.  Tumor recurrence often may present extraluminally and can be missed by routine surveillance with digital rectal examination and colonoscopy.  The early detection of local cancer recurrence may lead to potentially curative surgical re-excision. Dr. Ihab Samy 2013
  60. 60. Endoscopic management of malignant colonic obstruction  Malignant obstruction of the colon can occur in 8% to 30% of patients with colorectal cancer.  Endoscopic management of malignant obstruction with laser therapy or stent placement offers a safe and an effective alternative to surgery. Dr. Ihab Samy 2013
  61. 61.  Currently, there are two main indications for the endoscopic management of colonic obstruction: 1. Temporary colonic decompression as a bridge to surgery. 2. Palliation of patients who are deemed poor surgical candidates or who have incurable disease. Dr. Ihab Samy 2013
  62. 62.  Successful endoscopic decompression of acute obstruction allows for the stabilization of the patient and for evaluation of the patient’s extent of disease and comorbid illnesses before surgery.  In operative candidates, acute decompression avoids the need for a diverting colostomy and a second surgery for reanastomosis, because the tumor can be resected during a one-stage procedure after adequate bowel preparation. Dr. Ihab Samy 2013
  63. 63.  Laser therapy has a high success rate in the treatment of malignant colonic obstruction ranging from 80% to 90%.  The placement of self-expandable metal stents (SEMS) has recently evolved into a more widely used method of endoscopic colonic decompression.  The success rate of stent deployment and the relief of malignant colonic obstruction has been reported to range from 70% to 95%. Dr. Ihab Samy 2013
  64. 64.  SEMS placement offers a significant cost benefit in the management of malignant colonic obstruction by avoiding diverting colostomy and a two- stage operation in surgical candidates.  Dilation of the malignant stricture does not appear to be necessary before SEMS placement and may be associated with a higher risk of perforation. Dr. Ihab Samy 2013
  65. 65.  Treatment with chemotherapy and radiation therapy after SEMS placement may be associated with an increased risk of complications.  Stent obstruction can occur because of stool impaction, tumor ingrowth, or tumor overgrowth, which all require endoscopic intervention.  Patients should be advised to follow a low residue diet and to take laxatives, stool softeners, or mineral oil supplements to avoid stool impaction after SEMS placement. Dr. Ihab Samy 2013
  66. 66. Endoscopic management of malignant colonic polyps and polyps with HGD  Invasive carcinoma may be found in approximately 2% to 4% of colonic polyps removed endoscopically.  Polypectomy or EMR may be curative in selected, superficially invasive colon cancers.  A malignant polyp is defined as one containing invasive carcinoma penetrating through the muscularis mucosa into the submucosa. Dr. Ihab Samy 2013
  67. 67.  The rate of lymph node metastasis is significantly associated with the depth of tumor invasion within the submucosa, with tumors invading the upper third, middle third, and lower third of the submucosa, having 2%, 9%, and 35% rates of lymph node metastasis, respectively.  Pedunculated polyps with cancer confined to the submucosa and without evidence of unfavorable histologic factors have a 0.3% risk of cancer recurrence or lymph-node metastasis after complete endoscopic removal, whereas similar sessile polyps have a 4.8% risk. Dr. Ihab Samy 2013
  68. 68.  Unfavorable histopathologic factors of malignant colonic polyps associated with high risk of lymph- node metastases and local cancer recurrence after endoscopic resection: 1. Poorly differentiated histology 2. Vascular invasion 3. Lymphatic invasion 4. Cancer involvement of the resection margin 5. Incomplete endoscopic resection Dr. Ihab Samy 2013
  69. 69.  Pedunculated polyps confined to the submucosa, with no evidence of unfavorable histologic features, can be definitively treated with endoscopic resection, without the need for surgical resection.  In cases of pedunculated polyps harboring unfavorable histologic features, demonstrating cancer within the resection margin, or extending through the submucosa into the deeper wall layers, surgery is recommended. Dr. Ihab Samy 2013
  70. 70.  Malignant sessile polyps confined to the submucosa and demonstrating no evidence of unfavorable histologic factors have a small increased risk of lymph-node metastasis and local recurrence compared with similar pedunculated polyps after endoscopic resection.  Endoscopic resection of this subset of sessile polyps may be adequate if the resection was complete and en bloc.  However, surgical resection should be considered to ensure definitive treatment. Dr. Ihab Samy 2013
  71. 71.  The finding of a malignant polyp in patients with ulcerative colitis or Crohn’s colitis should be considered an indication for total colectomy.  Endoscopic resection of malignant polyps with unfavorable histologic features or piecemeal resection of large malignant polyps can be considered in patients deemed poor surgical candidates because of comorbid illnesses.  Surveillance after the endoscopic removal of a malignant polyp should consist of a follow-up colonoscopy within 3 to 6 months after resection. Dr. Ihab Samy 2013
  72. 72.  Polypectomy or EMR also can be used as the primary management of polypoid lesions with HGD.  Previously known as carcinoma in situ or intramucosal cancer, HGD currently is defined as dysplastic neoplastic tissue confined within the mucosal wall layers without invasion of the submucosa.  Endoscopic removal of lesions with HGD is adequate, provided that the endoscopist is confident in the completeness of resection. Dr. Ihab Samy 2013
  73. 73.  Surveillance after the endoscopic resection of a lesion with HGD should consist of repeat colonoscopy in 3 years.  If residual tissue is identified, this should be removed and a second follow-up examination should be performed within 3 to 6 months to verify complete resection.  If a polyp cannot be removed completely within 1 to 3 examinations, surgery is recommended. Dr. Ihab Samy 2013
  74. 74. Capsule endoscopy (CE)  After the Food and Drug Administration (FDA) approval in 2001, small bowel capsule endoscopy has rapidly gained ground in the armamentarium of small bowel investigation techniques.  Small bowel endoscopy has proved to be an extremely efficient tool providing high quality images of the entire small bowel which were largely inaccessible to flexible endoscopy. Dr. Ihab Samy 2013
  75. 75.  CE is a very sensitive diagnostic technique to detect small bowel pathology.  It has a higher diagnostic yield than conventional diagnostic methods, i.e., push enteroscopy, small-bowel follow-through, conventional CT and angiography.  In 15%-20% of all CE’s the capsule does not reach the cecum within recording time.  Risk factors for incomplete CE procedures include previous small-bowel surgery, hospitalization, moderate or poor bowel cleansing, and a gastric transit time longer than 45 min. Dr. Ihab Samy 2013
  76. 76. Dr. Ihab Samy 2013
  77. 77.  For a good and complete evaluation of the small bowel, the capsule should reach the cecum within the recording time, which is eight to eleven hours depending on the manufacturer.  Therefore, some investigators use a prokinetic agent to speed up the gastric and small bowel transit.  However, the short bowel transit time (SBTT) may influence the diagnostic yield of CE. Dr. Ihab Samy 2013
  78. 78. Dr. Ihab Samy 2013
  79. 79. Colon capsule endoscopy  In 2006, Given Imaging Ltd. developed the first generation of capsule specifically designed for colon investigation.  Non-invasive techniques for colonoscopy, such as CT colonography and colon capsule endoscopy are currently being evaluated as alternatives to conventional colonoscopy in order to improve compliance to screening programs. Dr. Ihab Samy 2013
  80. 80.  PCCE was able to visualize the entire colon in 80% of cases.  The level of bowel preparation was quite high, being rated as good-excellent in 84% of the cases.  PCCE may be indicated when a patient refuses conventional colonoscopy or when colonoscopy provides inconclusive results or when the risks from colonoscopy, such as colon perforation (for example when there is a clinical suspicion of acute diverticulitis), may outweigh the benefits. Dr. Ihab Samy 2013
  81. 81.  Bowel preparation is the most challenging factor in PCCE implementation.  A reasonable balance between adequate preparation and patient satisfaction needs to be pursued, and the adoption of a split regimen of PEG is a step in this direction. Dr. Ihab Samy 2013
  82. 82. Day Time Action −5 to −2 All day Low fibre diet −2 08:00 pm 4 senna tablets (48mg) −1 All day Liquid diet only 7:00 pm–9:00 pm 2 L PEG Exam day 6:00 am–8:00 am 2 L PEG 8:45 am Domperidone (20 mg) 9:00 am PillCam ingestion 11:00 am 30 mL NaP + 1 L water 02:00 pm 15 mL NaP + ½ L water 04:00 pm 10 mg Bisacodyl (suppository) 07:00 pm Colonoscopy Dr. Ihab Samy 2013
  83. 83. Thank you Dr. Ihab Samy 2013

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