Towards real-time PGS range monitoring in proton therapy of prostate cancer.

Proton therapy of prostate cancer (PCPT) was linked with increased levels of gastrointestinal toxicity in its early use compared to intensity-modulated radiation therapy (IMRT). The higher radiation dose to the rectum by proton beams is mainly due to anatomical variations. Here, we demonstrate an approach to monitor rectal radiation exposure in PCPT based on prompt gamma spectroscopy (PGS). Endorectal balloons (ERBs) are used to stabilize prostate movement during radiotherapy. These ERBs are usually filled with water. However, other water solutions containing elements with higher atomic numbers, such as silicon, may enable the use of PGS to monitor the radiation exposure of the rectum. Protons hitting silicon atoms emit prompt gamma rays with a specific energy of 1.78 MeV, which can be used to monitor whether the ERB is being hit. In a binary approach, we search the silicon energy peaks for every irradiated prostate region. We demonstrate this technique for both single-spot irradiation and real treatment plans. Real-time feedback based on the ERB being hit column-wise is feasible and would allow clinicians to decide whether to adapt or continue treatment. This technique may be extended to other cancer types and organs at risk, such as the oesophagus.

Small bowel polyp resection using device-assisted enteroscopy in Peutz-Jeghers Syndrome: Results of a specialised tertiary care centre.

INTRODUCTION: Enteroscopy resection of small bowel polyps in Peutz-Jeghers syndrome has only been described in small case series. Herein, we aimed to assess the efficacy of enteroscopy resection of small bowel polyps within a specialised tertiary care centre and the impact on intraoperative enteroscopy. METHODS: This was an observational single-centre study. All adult Peutz-Jeghers syndrome patients followed in the Predisposition Digestive Ile-de-France network who underwent an endoscopic resection of at least one small bowel polyp ≥ 1 cm by enteroscopy between 2002-2015 were included. Small bowel polyps were detected under a dedicated screening programme by previous capsule endoscopy and/or magnetic resonance enterography, performed every 2-3 years. Complete treatment was defined as the absence of polyps ≥ 1 cm after conventional endoscopic resection. Intraoperative enteroscopy or surgical resection were indicated in incomplete treatments. The overall complete treatment rate including conventional enteroscopy and intraoperative enteroscopy was also considered. RESULTS: Endoscopic resection of 216 small bowel polyps (median: 8.6 per patient, size: 6-60 mm) was performed by 50 enteroscopies in 25 patients (mean age: 36 years, range: 18-71, 56% male) with small bowel polyp ≥ 1 cm. Twenty-three patients (92%) underwent 42 screening capsule endoscopies and 14 (57%) had 23 magnetic resonance enterographies during a median follow-up of 60 months. Complete treatment was achieved in 76%. Intraoperative enteroscopy and surgical resection were performed in four (16%) and two (8%) patients. Intraoperative enteroscopy improved by 16% the complete treatment rate and the overall rate was 92%. The complication rate was 6%. CONCLUSION: This long-term study confirmed the efficacy and safety of endoscopic resection of small bowel polyps in Peutz-Jeghers syndrome. Intraoperative enteroscopy can be a complementary approach in selected cases.

[Optimal Bowel Preparation for Capsule Endoscopy and Device-assisted Enteroscopy].

For improved examination of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), bowel preparation is an essential issue. Multiple factors like air bubbles, food material in the small bowel, and gastric and small bowel transit time affect the small bowel visualization quality (SBVQ), diagnostic yield (DY) and cecal completion rate (CR). Bowel preparation with polyethylene glycol (PEG) solution enhances SBVQ and DY, but it has no effect on CR. Bowel preparation with PEG solution 2 L is similar to PEG 4 L in SBVQ, DY, and CR. Bowel preparation with fasting or PEG solution combined with anti-foaming agents like simethicone enhance SBVQ, but it has no effect on CR. Bowel preparation with prokinetics is not commonly recommended. Optimal timing for purgative bowel preparation has yet to be established. However, the studies regarding bowel preparation for DAE are not sufficient. European Society of Gastrointestinal Endoscopy (ESGE) recommends 8-12 hours fasting from solid food and 4-6 hours fasting from liquids prior to the antegrade DAE. For retrograde DAE, colonoscopy preparation regimen is recommended. This article reviews the literature and ESGE, 2013 Korean published guidelines regarding bowel preparation for VCE and DAE, following suggestion for optimal bowel preparation for VCE and balloon enteroscopy.

A reliable detachable balloon that prevents abdominal cavity contamination during transrectal natural orifice transluminal endoscopic surgery.

OBJECTIVE: To evaluate the efficacy and safety of a detachable endoluminal balloon in the prevention of abdominal cavity contamination during transrectal natural orifice transluminal endoscopic surgery (NOTES). METHODS: The efficacy and safety of a detachable endoluminal balloon to maintain disinfection in the distal colon of the pigs were evaluated. The bacterial loads and colonic cleanliness were monitored. Additionally, the device was applied to another nine pigs that underwent a cholecystotomy by transrectal NOTES. Necropsy and pathological examination were performed after 28-day follow-up. RESULTS: All animals exposed to the device and one of the seven pigs not exposed to the device scored three points on the bowel cleanliness scale (P < 0.001). After 30 min bacterial loads of the test (with balloon occlusion) and control (without balloon occlusion) groups showed a significant difference (0.8 × 103 CFU/mL vs 186.8 × 103 CFU/mL, P < 0.01). Cholecystotomy by transrectal NOTES with the device was successfully performed. The mean intraperitoneal procedure time was 102.9 ± 37.7 min. There were no procedure-related adverse events. During the follow-up, all animals presented normal behavior and appetite. No peritoneal infection or adhesion was detected at autopsy. Cholecystotomy and rectal incision were histologically healed and no histological abnormalities were detected in the colon related to balloon placement. CONCLUSIONS: The detachable balloon provides a reliable solution for preventing peritoneal contamination during transluminal operations. The technique may assist in future transrectal NOTES.

Severe Biliary Stricture Dilation Using the Soehendra Stent Retriever with a Short-Type Balloon Enteroscope in Patients with Surgically Altered Anatomies.

BACKGROUND: Balloon enteroscopy (BE) can be used for endoscopic retrograde cholangiography (ERC) to treat biliary strictures in patients with surgically altered anatomies. However, biliary strictures, including bilioenteric anastomotic strictures, are often very severe and dilation catheters cannot pass through them. The Soehendra stent retriever (SSR) is like a screw drill and can be useful for dilating severe strictures, but the utility of SSR during BE-assisted ERC (BE-ERC) is unclear. This study aimed to examine the efficacy and safety of a dilation technique using the SSR during BE-ERC. METHODS: Between 2014 and 2018, 28 patients with surgically altered gastrointestinal anatomies and severe biliary strictures underwent BE-ERC, and the SSR was used for the dilation procedures. We evaluated the technical success, therapeutic success, and adverse event rates associated with SSR dilation. RESULTS: The technical success rate was 93% (26/28). The procedures undertaken on two patients with non-anastomotic strictures failed technically because the SSR was not long enough to reach the strictures. The therapeutic success rate was 96% (25/26) for the patients whose procedures were technically successful. The adverse event rate was 7% (2/28), and the adverse events were mild and improved with conservative management. No bleeding or duct perforations occurred. CONCLUSIONS: Although the indications for using the SSR in patients with non-anastomotic strictures should be considered based on the distance between the tip of the scope and the stricture's location, SSR dilation may be a useful option during BE-ERC if a biliary stricture is very severe.

Endoscopic treatment for patients with gastric outlet stricture and biliary obstruction in the absence of endoscopic ultrasound: a retrospective study.

BACKGROUND AND AIM: Endoscopic biliary drainage is difficult in patients with biliary obstruction combined with gastric outlet stricture (GOS). Endoscopic ultrasound is useful for such patients, but needs advanced technique and sophisticated equipment. This study aimed to evaluate the efficacy and safety of conventional endoscopic retrograde cholangiopancreatography (ERCP) in patients with GOS and biliary obstruction without the assistance of endoscopic ultrasound. PATIENTS AND METHODS: Seventy-four patients with GOS proximal to the ampulla and biliary obstruction, including 27 with benign GOS and 47 with malignant GOS, were retrospectively enrolled. Three conventional methods were used to pass through the stricture and allow the duodenoscope to reach the papilla: adjusting the endoscope, balloon dilation, and metal stent insertion. The uncovered metal stent insertion was applied only in patients with malignant GOS. The primary outcome evaluated was successful biliary drainage. RESULTS: No serious complications occurred during or after ERCP. The overall success rate of biliary drainage in the patients was 81.1%. The success rate of duodenoscopy insertion by endoscope adjustment, balloon dilation, and stent insertion was 44.6, 68.9, and 71.4%, respectively. Endoscope adjustment was more successful in the patients in the benign group compared with the patients in the malignant group (60.9 vs. 35.7%). Similar findings were obtained for balloon dilation (92.3 vs. 59.4%). CONCLUSION: Most GOS, encountered during ERCP, can be safely dealt with using conventional endoscopic approaches in patients with biliary obstruction. However, the efficacy of endoscope adjustment or balloon dilation is better for benign GOS than for malignant GOS.

[Use of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction].

OBJECTIVE: To explore the function of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction, and to improve the success rate of colonic stent placement in such patients.
 Methods: A total of 49 patients with colorectal cancer complicated with almost complete obstruction or colorectal cancer were enrolled for this study. The esophageal small balloon or papillary sphincter knife was used in the guide wires. The guide wires gradually crossed the tumor gap and they were placed in the contralateral intestinal cavity with balloon progression. X-ray was then used to confirm whether the guide wire was inserted in the lesion intestinal cavity, and then the metal bare stent was inserted.
 Results: The guide wires was successfully inserted with conventional methods in these 49 cases, while they were also successfully placed the guide wire and the stent in the new way.
 Conclusion: For the patients with colorectal cancer complicated with complete obstruction or colorectal cancer located in obviously angled location, the use of esophageal small balloon or papillary sphincter knife can help the guide wire insert. They greatly improve the success rate of stent implantation.

A Case Series: Outcomes of Endoscopic Biliary Self-Expandable Metal Stent for Malignant Biliary Obstruction with Surgically Altered Anatomy.

BACKGROUND: Few studies have reported the outcomes of self-expandable metal stent (SEMS) placement for malignant biliary obstruction in patients with surgically altered anatomy. AIMS: To evaluate the outcomes of biliary metal stent placement with the use of a short-type single-balloon enteroscope (working length, 1520 mm; channel diameter, 3.2 mm) in such patients. METHODS: We retrospectively studied 13 malignant biliary obstructions treated by SEMS placement. Technical success rate, functional success rate, time to recurrent biliary obstruction (RBO), and complications were evaluated. RESULTS: Technical success rate was 100 % (13/13), functional success rate was 92 % (12/13), and the median time to RBO was 247 days (95 % CI 205.6-285.5). Complications comprised mild pancreatitis in one patient. Uncovered SEMSs were placed in three obstructions, partially covered SEMS in five obstructions, and fully covered SEMSs in five obstructions. Three stents occluded (two ingrowths and one mucosal hyperplasia), and one symptomatic distal stent migration occurred after more than 30 days from placement. CONCLUSIONS: A short-type single-balloon enteroscope was useful for the placement of various SEMS in this patient population with satisfactory outcomes.

Cápsula endoscópica: quando indicar seu uso? / Endoscopic capsule: when to indicate its use?

Muito do diagnóstico e tratamento das patologias do intestino delgado tem sido discutido e estudado na última década, desde a introdução da cápsula endoscópica na prática médica. Esta importante inovação tecnológica possibilitou o rompimento da última fronteira endoscópica do trato digestivo, permitindo o acesso endoscópico a toda a extensão do intestino delgado, o qual, devido a suas peculiaridades anatômicas e extensão, permanecia acessível somente à enteroscopia intraoperatória.

Both diagnosis and treatment of small intestine pathology has been discussed and studied in last decade since the introduction of endoscocopy capsule in medical practice. This important technological innovation allowed to break the last endoscopy borderline of digestive tract permitting endoscopy access for all extent of small intestine which due its anatomical peculiarities and extent remained accessible only to intraoperative enteroscopy.