Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy.

Complex and lengthy endoscopic examinations like endoscopic ultrasonography and/or endoscopic retrograde cholangiopancreatography benefit from deep sedation, due to an enhanced quality of examinations, reduced discomfort and anxiety of patients, as well as increased satisfaction for both the patients and medical personnel. Current guidelines support the use of propofol sedation, which has the same rate of adverse effects as traditional sedation with benzodiazepines and/or opioids, but decreases the procedural and recovery time. Non-anesthesiologist administered propofol sedation has become an option in most of the countries, due to limited anesthesiology resources and the increasing evidence from prospective studies and meta-analyses that the procedure is safe with a similar rate of adverse events with traditional sedation. The advantages include a high quality of endoscopic examination, improved satisfaction for patients and doctors, as well as decreased recovery and discharge time. Despite the advantages of non-anesthesiologist administered propofol, there is still a continuous debate related to the successful generalization of the procedures.

Gastrointestinal stromal tumor, jejunal atresia and stenosis in a neonate.

Gastrointestinal stromal tumors could rise in different areas of the digestive tract, at any age, but very rarely in neonates. We present the case of a 5-day-old male, with intestinal stenosis and atresia (type II) operated for peritonitis. On the resected specimen, the histopathological examination revealed a small gastrointestinal tumor of 8 mm. The immunohistochemical analysis indicated a low malignant potential. He is currently at two years of oncologic follow-up with no evidence of disease.

Combined contrast-enhanced power Doppler and real-time sonoelastography performed during EUS, used in the differential diagnosis of focal pancreatic masses (with videos).

BACKGROUND: Contrast-enhanced power Doppler (CEPD) and real-time sonoelastography (RTSE) performed during EUS were previously described to be useful for the differential diagnosis between chronic pseudotumoral pancreatitis and pancreatic cancer. OBJECTIVE: To prospectively assess the accuracy of the combination of CEPD and RTSE to differentiate pancreatic focal masses. DESIGN: Cross-sectional feasibility study. SETTING: A tertiary-care academic referral center. PATIENTS: The study group included 54 patients with chronic pancreatitis (n = 21) and pancreatic adenocarcinoma (n = 33). INTERVENTIONS: Both imaging methods (CEPD and RTSE) were performed sequentially during the same EUS examination. Power Doppler mode examination was performed after intravenous injection of a second-generation contrast agent (2.4 mL of SonoVue), and the data were digitally recorded, comprising both the early arterial phase and venous/late phase. Three 10-second sonoelastographic videos were also digitally recorded that included the focal mass and the surrounding pancreatic parenchyma. Postprocessing analyses based on specially designed software were used to analyze the CEPD and RTSE videos. A power Doppler vascularity index was used to characterize CEPD videos, the values being averaged during a 10-second video in the venous phase. Hue histogram analysis was used to characterize RTSE videos, with the mean hue histogram values being also averaged during a 10-second video. MAIN OUTCOME MEASUREMENTS: To differentiate chronic pancreatitis and pancreatic cancer. RESULTS: The sensitivity, specificity, and accuracy of combined information provided by CEPD and RTSE to differentiate hypovascular hard masses suggestive of pancreatic carcinoma were 75.8%, 95.2%, and 83.3%, respectively, with a positive predictive value and negative predictive value of 96.2% and 71.4%, respectively. LIMITATION: A single-center, average size of study population. CONCLUSIONS: A combination of CEPD and RTSE performed during EUS seems to be a promising method that allows characterization and differentiation of focal pancreatic masses.

Confocal laser endomicroscopy of the colon.

Confocal laser endomicroscopy (CLE) has been recently proposed as a new technique that allows in vivo histologic assessment of mucosa during endoscopy. The most commonly used contrast agents are acriflavine hydrochloride and fluorescein sodium. For colon pathology assessment, the administration of fluorescein intravenously produces a strong staining of both surface epithelium and deeper layers of lamina propria. Confocal laser endomicroscopy is a feasible method to diagnose colon cancer in vivo. Furthermore, confirmation of neoplastic changes using CLE during colonoscopy may lead to major improvements in the clinical management of the patients with inflammatory bowel disease. Biopsies can be limited to targeted sampling of relevant lesions. Confocal laser endomicroscopy will certainly play an important diagnostic role during gastrointestinal endoscopy in the future, enabling the elimination of the diagnostic delay associated with conventional biopsy preparation and processing.

EUS and cytological EUS-FNA prognostic factors in patients with unresectable pancreatic cancer receiving chemotherapy.

BACKGROUND/AIMS: The incidence of pancreatic cancer is increasing. It is usually diagnosed in an advanced stage despite the improvement in diagnostic techniques. The current study was designed to prospectively analyze several demographic and tumour related variables identified by EUS and EUS-FNA cytology that may affect survival in patients with unresectable pancreatic cancer receiving chemotherapy. METHODOLOGY: The study prospectively included 72 patients diagnosed with pancreatic cancer. Only patients without surgery were selected. All the patients received chemotherapy with the same drug (5-FU). They underwent power Doppler EUS followed by EUS-FNA in all cases. The following information obtained by EUS and EUS-FNA cytology were prepared for inclusion in multivariate survival analysis (tumour localization, portal vein invasion, power Doppler signals presence, collateral circulation, signs of chronic pancreatitis, T and N status, nuclear atypia, nuclear enlargement, pleomorphism, nuclear/cytoplasm ratio, and coarse chromatin). RESULTS: The entire included population was analyzed to identify factors affecting prognosis. The overall Cox model had a significance level of p = 0.032. There were three factors that had a major impact on the survival time of the patients: regional lymph node involvement (p = 0.029), nuclear pleomorphism (p = 0.037) and nuclear enlargement (p = 0.019). CONCLUSIONS: The current pre-treatment evaluation of the pancreatic cancer patients by EUS and EUS-FNA could offer some valuable information for appreciation of patients' future evolution. However, extensive studies are required for a complex prognosis scoring system.

State-of-the art endoscopic imaging in lung cancer: should specialties collide or concur?

Endoscopic ultrasound has been recently established as a routine diagnostic and staging procedure in lung cancer patients, mainly because of the possibility of tissue sampling. Transesophageal endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) represents a method which not only allows the visualization of the upper gastrointestinal tract, but also offers good visualisation of the posterior and inferior mediastinum. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) permits the assessment of the tumors in the anterior mediastinum. Based on previously published literature, it is obvious that this minimally invasive procedure now offers the possibility of tissue diagnosis in mediastinal masses including primary tumours or secondary lesions from both benign and malignant diseases.

[The role of endoscopic ultrasound-guided transesophageal fine needle aspiration and immunocytochemistry assesment of the patients with suspected lung cancer and negative bronchoscopic biopsies]. / Rolul endoscopiei ultrasonografice cu punctie fina aspirativa transesofagiana si examen imunocitochimic în evaluarea pacientilor cu suspiciune de cancer bronhopulmonar si biopsii bronsice negative.

INTRODUCTION: Endoscopic ultrasound-(EUS) guided fine needle aspiration (FNA) allows the assessment of the posterior mediastinum, as well as the diagnosis and staging of lung cancer patients. The purpose of this feasibility study was to assess the importance of EUS-FNA combined with cytology and immunocytochemistry for patients with suspected lung cancer and negative bronchoscopic biopsies. MATERIAL AND METHODS: Our study included 20 consecutive patients assessed at the Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy Craiova. The patients were initially examined by chest X-ray, computer tomography scans and bronchoscopy, without a tissue confirmation of malignancy. RESULTS AND DISCUSSION: Of the 20 patients included in our study without a tissue confirmation of malignancy, 16 patients had a positive EUS-FNA for malignancy. For 11 patients the samples were obtained from the mediastinal lymphnodes, and for 4 cases directly from the primary mediastinal tumor, some of the obtained samples being included in paraffin to obtain cell blocks. The cell blocks allowed us to accomplish imunocytochemistry for two purposes: to establish the epithelial and mesenchimal fenotype of the malignant cells, as well as the origin of the identified atypical cells. CONCLUSIONS: EUS-FNA combined with cytology, is an excellent minimal invasive technique, highly accurate for the assessment of lung cancer, showing not only the tumoral and lymph node invasion, but also offering the ideal alternative for surgical staging. Association of immunocytochemistry determined an increase in the accuracy of the method, as well as the confirmation of a tissue diagnosis of malignancy.

[Evolutive particularities of appendicular plastron in children]. / Particularitati evolutive ale blocului apendicular la copil.

This paper analyses the experience of the Paediatric Surgery Department from the Emergency Hospital in Craiova regarding the clinical and therapeutical evaluation of 55 cases with appendicular plastron admitted in our department between 1997-2006. We analyse both the evolution and the complications in managing these cases, together with particular aspects of differential diagnosis related to this group of age. These 55 cases were children aged between 2 and 15 years with a 15 days average hospitalization period. Applying a standard treatment we had favorable results in 85% of cases with 15% cases underwent surgical treatment from the first admission. Comparative to a study realised in our dept. between 1975-1996, which registered 30 cases with a mortality of 6.70%, the present one revealed in the latest years an important increase of the number of appendicular plastron with a significant low mortality.

[The gastroschisis: clinical and therapeutic considerations]. / Laparoschizisul: consideratii clinico-terapeutice.

Gastroschisis is a severe congenital malformation of the abdominal wall, with relative low incidence. The authors are analysing different therapeutic methods, in a group of 17 cases, hospitalised and operated in Department of Pediatric Surgery, Emergency Hospital of Craiova. They are underlining the importance of the ultrasound prenatal diagnosis of the malformation, close related to different therapeutic methods applied in this period of time and also are advising secondary closure of the abdominal wall, using a synthetic material (Silo-bag) for temporary coverage of the intestine developed outside the peritoneal cavity. This method helped with the decreasing of mortality in gastroschisis but with high costs of treatment.

[Update in diagnosis and treatment of esophageal atresia]. / Actualitfati în diagnosticul si tratamentul atreziei de esofag.

The paper present a number of 17 cases of esophageal atresia, hospitalised and operated in a period of 4 years (2001-2004). The authors are underlining the importance of the prenatal diagnosis, preoperative and postoperative care, the chance for primary anastomosis for type III A of the disease, complications and prognosis related to the type of atresia. Esophageal atresia is a success of a complex team where the role of the neonatologist and anesthesiologist, next to the surgeon, is very important.

[Bowel intussusception on the child: clinical therapeutical study]. / Invaginatia intestinala la copil. Studiu clinico-terapeutic.

Intussusceptions is the most common cause of bowel obstruction in children between 5 months and 1 year of age. Intussusceptions occurs when a portion of the bowel folds like a telescope, with one segment slipping inside another segment. This study refers to a group of 72 children, with intussusceptions diagnosis between 1975-2000 in our clinic. The authors are also analyzing these cases from the point of view of frequency on years, seasons, age, sex, residence, clinical forms, time since the intussusceptions occurred until the treatment begun.

[Elements of gynecology pathology in girls before and during puberty age]. / Elemente de patologie ginecologica la fetite înainte si la vârsta pubertatii.

PURPOSE: The annexial pathology in little girls is representing a more and more frequent form of acute and chronic abdomen, especially in girls around the age of puberty with dysfunction of the menstrual cycle correlated with disturbance of growing and the occurrence of secondary sexual characters. If this kind of pathology is frequent in the period of puberty, there are cases diagnosticated at small ages. MATERIAL & METHODS: The authors are communicating a number of 25 cases with anexial pathology some of them manifesting the symptoms of the acute abdomen (most of them with torsion of the normal or pathological annexes) others having a chronic aspect. The clinical examination correlated with the imagistic investigations were the main elements for the diagnosis. RESULTS & CONCLUSIONS: The results were good, the follow-up of the patients is including social therapy with the girls and their families, for integration in the family, evaluating the chance of giving birth. The occurrence of some forms of acute abdomen was frequent on a pathologic annexes (malformated annexes), causing sometimes the excision of it, extended to the uterus. The presence of a malign tumour can be related with different malformations, also caused by exposure to some risk factors: radiation, pollution, chemical agriculture, deficitary alimentation, stress etc.).

[Errors and difficulties in the diagnosis and management of acute and chronic abdomen in children]. / Intre dificultati si confuzii de diagnostic în abdomenul acut si cronic la copil.

The authors are reviewing on a lot of 2844 cases between 1996 and 2000 the difficult problems of differential diagnosis between acute surgical abdomen in children and intestinal tuberculosis, abdominal tumors and inflammatory diseases such as acute osteomielitis. They are presenting 13 particular cases in which the acute abdomen diagnosis was difficult or even omitted.