aportul videocapsulei endoscopice în stabilirea indicaţiei de tratament chirurgical în patologia...

7/28/2019 Aportul videocapsulei endoscopice n stabilirea indicaiei de tratament chirurgical n patologia tumoral a

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Aportul videocapsulei endoscopice n stabilirea indicaiei

de tratament chirurgical n patologia tumoral a intestinului

subire

The Contribution of the Video Capsule Endoscopy in

Establishing the Indication of Surgical Treatment in the Tumor

Pathology of the Small Intestine

Autori: Cristin Constantin Vere1, Costin Teodor Streba1, Marius Georgescu2, Camelia

Foarf3, Alin Gabriel Ionescu1

1Clinica Medical I, Spitalul Clinic Judeean de Urgen Craiova

2Universitatea de Medicina si Farmacie Craiova

3Departamentul de Anatomie Patologic, Spitalul Clinic Judeean de Urgen Craiova

1Medical Clinic I, County Clinic Emergency Hospital of Craiova

2The University of Medicine and Pharmacy Craiova

3

The Department for Pathological Anatomy, Clinic Emergency Hospital of Craiova

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REZUMAT:

Introducere Videocapsula endoscopic reprezint o metod de actualitate ce permite

explorarea sigur, neinvaziv i rapid a intestinului subire.

Material i metod Studiul a fost realizat pe 11 pacieni ce au prezentat patologie

tumoral la nivelul intestinului subire. Tumorile au fost identificate cu ajutorul capsulei

endoscopice. Diagnosticul de malignitate a fost stabilit prin examen anatomopatologic efectuat

pe piesele de rezecie chirurgical. Analiza statistic a datelor a fost fcut cu ajutorul Testului

Exact Fisher.

Rezultate Patologia tumoral a pacienilor inclui n studiu a fost reprezentat de: 3 polipi

intestinali, 2 tumori stromale benigne, 2 tumori stromale maligne, 2 adenocarcinoame, o tumor

neuroendocrin malign, un carcinom de papil duodenal. Am urmrit repartiia tumorilor maligne i

benigne n funcie de vrst. Totalitatea tumorilor maligne (n=6) au fost nregistrate la pacienii peste

60 ani, n timp ce tumorile benigne au fost observate n majoritatea cazurilor (80%, n=4) sub vrsta de

60 ani. Un singur caz cu tumor benign (polip intestinal) a avut vrsta peste 60 ani.

Discuii Dei intestinul subire reprezint cel mai lung segment al tubului digestiv,

numrul tumorilor maligne identificate la nivelul su n timpul vieii este foarte sczut. n mare

parte aceasta se datoreaz faptului c intestinul subire este greu accesibil tehnicilor de

investigaie non-invazive clasice.

Concluzii Videocapsula endoscopic reprezint un real ajutor pentru chirurg,

deocarece permite identificarea patologiei intestinului subire, furniznd informaii cu privire la

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localizarea aproximativ a leziunilor, dimensiunilor i orientnd asupra etiologiei acestora.

Patologia tumoral se ntlnete predominant la persoane de vrsta a treia i se prezint sub o

multitudine de forme. Este deci necesar o metod eficient de identificare precoce a leziunilor

i un protocol care s stabileasc malignitatea.

ABSTRACT

Introduction Capsule endoscopy (CE) represents a novel method which allows safe,

non-invasive and rapid exploration of the small bowel.

Material and Method Our study was conducted on 11 patients who presented tumoral

pathology at the small bowel level. Tumors were identified by CE. Malignancy was determined

on the surgical resection piece, by histological exam. Statistic analysis of the data was

conducted using Fishers Exact Test.

Results Tumoral pathology was represented by: 3 intestinal polyps, 2 benign stromal

tumors, 2 malign stromal tumors, 2 adenocarcinoma, one neuroendocrine malign tumor, one

duodenal papilla carcinoma. We followed the presence of malign tumors in regards to age. All

malign tumors (n=6) were recorded in patients over 60 years old, while benign tumors were

recorded in most cases (80%, n=4) in people under 60 years old. One case of benign tumor

(intestinal polyp) was observed above 60 years old.

Discussion Even though the small bowel represents the longest segment of the

digestive tract, the number of malign tumors identified at its level during the patients lifetime is

very low. This is mainly due to the fact that the small bowel is virtually inaccessible to classic

non-invasive techniques.

Conclusions Capsule endoscopy represents a real help for the surgeon, as it allows

identification of small bowel pathology, giving information regarding the approximate localization

of lesions, their size and orienting on their nature. Tumoral pathology is encountered mainly

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with the old age population and can be presented under a multitude of forms. It is thus

necessary an efficient method for incipient detection and a protocol to establish malignity.

KEYWORDS: Capsule endoscopy, Small Bowel, Tumor, Adenocarcinoma

REZUMAT: Dei intestinul subire reprezint cel mai lung segment al tubului digestiv,

numrul tumorilor maligne identificate la nivelul su n timpul vieii este foarte sczut. n mare

parte aceasta se datoreaz faptului c intestinul subire este greu accesibil tehnicilor de

investigaie non-invazive clasice. Videocapsula endoscopic reprezint o metod de actualitate

ce permite explorarea sigur, neinvaziv i rapid a acestui segment. Ea reprezint un real ajutor

pentru chirurg, deocarece permite identificarea patologiei intestinului subire, furniznd informaii cu

privire la localizarea aproximativ a leziunilor, dimensiunilor i orientnd asupra etiologiei acestora.

Este eficient n screening, iar combinat cu tehnicile intervenionale clasice, urmate de analizarea

histopatologic i imunohistochimic a pieselor de biopsie, stabilete cu mare precizie diagnosticul de

malignitate al leziunilor.

ABSTRACT: Even though the small bowel represents the longest segment of the

digestive tract, the number of malign tumors identified at its level during the patients lifetime is

very low. This is mainly due to the fact that the small bowel is virtually inaccessible to classic

non-invasive techniques. Capsule endoscopy represents a novel method which allows safe,

non-invasive and rapid exploration of this segment. It represents a real help for the surgeon, as

it allows identification of small bowel pathology, giving information regarding the approximate

localization of lesions, their size and orienting on their nature. It is an efficient screening

method, and combined with classic interventional methods and followed by histological and

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immunohistochemical analysis of the biopsy pieces, determines the precise malignity diagnosis

for lesions.

Introducere

Progresul tehnologic actual a facut posibil introcerea de noi tehnici de explorare non-

invazive a tractului digestiv.

Videocapsula endoscopic (VCE) permite evaluarea non-invaziv a oricrui segment al

tractului digestiv, de la esofag la colon, n prezent fiind folosit n principal pentru explorarea

intestinului subire, unde poate identifica leziuni care nu pot fi detectate prin metode convenionale. (1)

Numrul de aplicaii ale acestei metode este n continu cretere. VCE poate fi folosit cu

succes n diagnosticarea sngerrilor obscure gastrointestinale, (2-5) bolii Crohn, (6, 7) bolii celiace i

complicaiilor ei, (8, 9) leziunilor vasculare intestinale (10) sau patologiei tumorale. (11, 12)

Introducerea explorrii intestinului subire cu ajutorul VCE reprezint un real ajutor pentru

chirurg, deocarece permite identificarea patologiei intestinului subire, furniznd informaii cu privire la

localizarea aproximativ a leziunilor, dimensiunilor i orientnd asupra etiologiei acestora.

Introduction

The present technological progress has made possible the introduction of new tehniques of

non-invasive exploration of the digestive tract.

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The video capsule endoscopy (VCE) allows the non-invasive evaluation of each segment of

the digestive tract, from the esophagus to the colon, presently being used mainly for the exploration of

the small intestine, where it can identify lesions that cant be detected by conventional means. (1)

The number of applications for this method is steadily rising. VCE can be succesfully used in

diagnosticating obscure gastrointestinal bleeding (2-5), Crohn disease (6, 7) celiac disease and its

complications (8, 9) intestinal vascular lesions (10) or tumor pathology (11, 12)

The introduction of the exploration of the small intestine by means of VCE represents a real

help for the surgeon, because it allows the identification of the pathology affecting the small intestine

and supplying information regarding the approximative location of lesions, their dimensions and an

orientation on their etiology.

Material i metod

Din totalul de pacieni investigai cu ajutorul VCE n perioada iunie 2008 martie 2009 n

cadrul Clinicii 1 de Medicin Intern i Gastroenterologie a Spitalului Clinic Judeean de Urgen

Craiova, 11 pacieni au prezentat patologie tumoral a intestinului subire, stabilindu-se indicaia de

tratament chirurgical.

Criteriul de includere n studiu a fost reprezentat de suspiciunea prezenei de tumori ale

intestinului subire, dup excluderea localizrii la nivelul altor segmente ale tractului digestiv prin

endoscopie digestiv superioar sau colonoscopie total.

Lotul a fost compus din 6 brbai (54,54%) i 5 femei (45,45%), cu vrste cuprinse ntre 54 i 79 ani,

media fiind de 63,72 ani; deviaia standard 7,11, interval de ncredere (CI) 95% 4,77.

Material and Method

From the total number of patients investigated by VCE in the June 2008 - March 2009 period

within Internal Medicine and Gastroenterology Clinic 1 of the County Clinic Emergency Hospital of

Craiova, 11 patients presented tumor pathology of the small intestine, establishing the

indication of surgical treatment.

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The study inclusion criterion was represented by the suspicion of presence of tumors of

the small intestine , after excluding their localisation at the level of other segments of the

digestive tract by upper digestive endoscopy or total colonoscopy.

The study group was made up of 6 men (54.54%) and 5 women (45.45%), aged between

54 and 79 years of age, the average being 63.72 years; standard deviation 7.11, confidence

interval (CI) 95% 4.77.

Fiecrui pacient i s-a administrat videocapsula dup o pregtire prealabil. Pregtirea

standard a constat n restricie alimentar 12-16 ore nainte de nceperea explorrii, asociat cu lavajul

intestinal cu soluie de polietilenglicol (PEG) (2 l) administrat n preziua explorrii cu 12-16 ore nainte

de nceperea nregistrrii. Nu am folosit n mod obinuit pregtirea intestinului subire cu prokinetice,

deoarece informaii recente au artat c astfel de tehnici nu sunt ntotdeauna necesare (13). Pacienii

au putut consuma lichide limpezi la 2 ore dup ingestia capsulei i un prnz lejer la 4 ore dup

ingestia videocapsulei (13, 14). Pacienii au fost monitorizai timp de 8 ore.

Videocapsula endoscopic (VCE) este un dispozitiv de 11/26 mm, cntrind 3.7 g. Este

capabil s trimit dou imagini pe secund, n sistem radio (o nregistrare obinuit de 8 ore

cuprinznd peste 50.000 de imagini), cmpul de vizibilitate fiind de 140 grade, cu o rat de mrire de

1:8 i un cmp de profunzime de la 1 la 30 mm. Permite vizualizarea leziunilor cu dimensiuni de

minim 0.1 mm. Principalele sale componente sunt un dom optic i un sistem de lentile, ase LED-uri

(light emitting diodes) pentru iluminare, modulul de camera CMOS (complementary metal oxide

silicone), un circuit special ASIC (application specific integrated circuit) i o anten care ajut la

transmiterea imaginilor ctre electrozii ataai de corp, n timp ce permite totodat nregistrarea datelor

pe un mic dispozitiv portabil de stocare. (15)

Each patient was administered the video capsule after a preliminary preparation. Standard

preparation consisted of alimentary restrictions for 12-16 hours before the exploration, associated with

intestinal lavage with a solution of polietylenglycol (PEG) (2 l) administered the day before exploration

12-16 hours before starting the recording. We did not usually use the preparation of the small intestine

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with prokinetics because recent information has shown that such techniques are not always necessary

(13). Patients were able to consume clear liquids 2 hours after ingesting the capsule and a light lunch

4 hours after ingesting the capsule (13, 14) Patients were monitored for 8 hours.

The video capsule endoscopy (VCE) is a 11/26 mm device that weighs 3.7 grams. It is

capable of sending 2 images per second on a radio system (an average 8 hour recording containing

over 50 000 images), the visibility field being of 140 degrees, with a zoom rate of 1:8 and depth of field

of 1 to 30 mm. It allows the visualisation of lesions with dimensions of a minimum of 0.1 mm. Its main

components are an optic dome and a lens system, 6 LEDs (light emitting diodes) for illumination, the

CMOS camera module (complementary metal oxide silicone), a special ASIC circuit (application

specified integrated circuit) and an antenna that helps transmitting images to the electrodes attached

to the body, while also permitting the recording of data on a small portable storage device. (15)

n fiecare caz s-a intervenit chirurgical, practicndu-se enterectomie segmentar n 10 cazuri

(91%) i duodenopancreatectomie cefalic ntr-un caz. Piesele operatorii au fost trimise ctre

Departamentul de Patologie al Spitalului Clinic de Urgen Craiova, unde au fost pregtite i

prelucrate histopatologic.

Diagnosticul de malignitate a fost dat de examenul histopatologic. Orientarea probelor a

reprezentat cel mai important pas, implicnd evaluarea rapid a vilozitilor intestinale imediat dup

recoltarea probelor. Fixarea s-a fcut cu formol 10%. Deshidratarea i includerea n blocuri de

parafin a fcut posibil conservarea pieselor importante. Colorarea final a fost fcut cu colorani

obinuii Hematoxilin-Eozin, Van Gieson, acid periodic Schiff, Gmri (folosit n special pentru

fibrele de reticulin).

Prelucrarea statistic a rezultatelor i descrierea loturilor au fost efectuate folosindu-se

metode de statistic descriptiv i Testul Exact al lui Fisher (test pentru verificarea semnificaiei

statistice folosit pe eantioane de mici dimensiuni). (16)

Surgical intervention was made in each case, practicising a segmentary enterectomy in 10

cases (91%) and cephalic duodeno-pancreatomy in one case. The surgically prelevated samples were

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sent to the Pathology Department of the Clinic Emergency Hospital of Craiova, where they were

histopathologically prepared and processed.

The malignancy diagnosis was given by the histopathological exam. The orientation of

samples represented the most important step, implicating a rapid evaluation of the intestinal vilosities

immediately after prelevating samples. 10 % formol was used to FIX SAMPLES. Dehydration and

inclusion in paraffin blocks made the conservation of important samples possible. Final coloration was

made with standard colorants Hematoxylin-Eosin, Van Gieson, Periodic Acide Schiff, G mri (used

especially for reticulin fibers).

Statistical processing of results and description of groups were made using the methods of

descriptive statistics and the Fishers Exact Test (test for verifying the statistical significance which is

used on small size groups)

Rezultate

Lotul a cuprins 11 pacieni ce au prezentat patologie tumoral, investigai cu ajutorul VCE i

supui interveniei chirurgicale. Lotul a fost structurat astfel: 54,54% brbai (n=6) i 45,45% femei

(n=5), cu vrste cuprinse ntre 54 i 79 ani, media fiind de 63,72 ani; deviaia standard 7,11, interval

de ncredere (CI) 95% 4,77. Pentru efectuarea testelor statistice lotul a fost mprit n funcie de sex,

vrst i patologie.

Patologia tumoral a pacienilor inclui n studiu a fost reprezentat de: 3 polipi intestinali, 2

tumori stromale benigne, 2 tumori stromale maligne, 2 adenocarcinoame, o tumor neuroendocrin

malign, un carcinom de papil duodenal. (vezi tabel 1)

Results

The group was made up of 11 patients suffering from tumor pathology, investigated by VCE

and surgically intervened on. The structure of the group was: 54.54% men (n=6_ and 45.45% women

(n=5), ages between 54 and 79 years of age, average being 63.72 years; standard deviation 7.11,

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confidence interval (CI) 95% 4.77. The group was divided according to sex, age and pathology for

statistical testing.

Tumor pathology of patients included in the study was made up of: 3 intestinal polyps, 3

benigne stromal tumors, 2 maligne stromal tumors, 2 adenocarcinoma, 1 neuroendocrine maligne

tumor, 1 duodenal papilla carcinoma. (see table 1)

Men WomenPolyps 2 1Benigne Stromal Tumor 0 1Maligne Stromal Tumor 3 0Neuro-endocrine Tumor 0 1Adenocarcinoma 1 1Duodenal Papilla Carcinoma 0 1Total 6 5

Table 1. Repartition by Sex of Tumor Pathology

Tumorile benigne au reprezentat 45,45% din total (polipi 27,27%; tumori stromale benigne

18,18%), patologia tumoral malign fiind repartizat astfel: 18,18% tumori stromale maligne, 18,18%

adenocarcinoame, 9,09% tumori neuroendocrine, 9,09% carcinoame de papil duodenal.

Dintre cei ase brbai inclui n lot, 33,3% (n=2) au prezentat tumori benigne (polipi intestinali), restul

fiind diagnosticai cu tumori maligne (trei tumori stromale maligne i un caz cu adenocarcinom).

Dintre cele cinci femei incluse n studiu, 40% (n=2) au prezentat tumori benigne (un polip

intestinal i o tumor stromal benign), restul fiind diagnosticate cu tumori maligne (o tumor

neuroendocrin, un adenocarcinom i un carcinom de papil duodenal).

Benigne tumors represented 45.45% of the total (polyps 27.27%; benigne stromal tumors

18.18%), while maligne tumor pathology was represented thus: 18.18% maligne stromal tumors,

18.18% adenocarcinoma, 9.09% neuroendocrine tumors, 9.09% duodenal papilla carcinoma. Of the

six men included, 33.3 % (n=2) presented benigne tumors (intestinal polyps), the others being

diagnosed with maligne tumors (3 stromal maligne tumors and 1 case of adenocarcinoma).

Of the five women included, 40 % (n=2) presented benigne tumors (one intestinal polyps, one

benigne stromal tumor), the others being diagnosed with maligne tumors (one neuro-endocrine tumor,

one adenocarcinoma and one duodenal papilla carcinoma).

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Am urmrit repartiia tumorilor maligne i benigne n funcie de vrst, pornind de la ipoteza c

patologia malign se ntlnete predominant peste 60 de ani, n timp ce tumorile benigne sunt

predominant ntlnite sub aceast vrst. Vrsta de 60 ani a fost luat ca punct de referin n

divizarea lotului, fiind apropiat de vrsta medie a acestuia. Pentru aplicarea Testului Exact al lui

Fisher, lotul a fost submprit n dou subloturi, sub i peste 60 de ani. Totalitatea tumorilor maligne

(n=6) au fost nregistrate la pacienii peste 60 ani, n timp ce tumorile benigne au fost observate n

majoritatea cazurilor (80%, n=4) sub vrsta de 60 ani. (vezi tabel 2 i 3) Un singur caz cu tumor

benign (polip intestinal) a avut vrsta peste 60 ani. Aplicnd testul Fisher s-a obinut o valoare

p=0,01515 2-Tail (CI 95% valoare prag 0,05), rezultat semnificativ statistic ce verific ipoteza iniial.

We tracked the repartition of maligne and benigne tumors by age, starting from the hypothesis that

maligne pathology appears predominantly over 60 years of age, while benigne tumors appear

predominantly before this age. The age of 60 years was taken as a referrence point in dividing the

group, since it is close to the average age of the group. For the application of Fishers Exact Test, the

group was subdivided in two subgroups, over and under 60 years. All the maligne tumors (n=6) were

observed on patients over 60 years, while the majority of benigne tumors (80%, n=4) were observed

under 60 years. By applying Fishers Exact Test a p value of 0.01515 2-Tail (CI 95% threshold value

0.05) was obtained, a statistically significant result which verifies the initial hypothesis.

60 years TotalMaligne Tumors 0 6 (54,54%) 6 (54,54%)Benigne Tumors 4 (27,27%) 1 (11,11%) 5 (45,45%)

Total 4 (27,27%) 7 (72,72%) 11 (100%)Table 2. Tumor Pathology of the Small Intestine Table of Incidence

Benigne Tumors (45,45%) Maligne Tumors (54,54%) Total

PolypsStromalTumors

NeuroendocrineTumors

Adenocarcinoma

StromalTumors

Duodenalpapilla

carcinoma

60years

1 (9,09%) 0 1(9,09%)

2 (18,18%) 2 (18,18%) 1(9,09%)

8 (72,72%)

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Total 3 (27,27%) 2 (18,18%) 1(9,09%)

2 (18,18%) 2 (18,18%) 1(9,09%)

11 (100%)

Table 3. Tumor Pathology Repartition by Etiology and Age Groups

Discuii

Dei intestinul subire reprezint 75% din lungimea i 90% din suprafaa de absorbie a

tractului intestinal, tumorile maligne prezente la nivelul su reprezint mai puin de 5% din totalul

cancerelor gastrointestinale. (17, 18) Ele reprezint de asemenea mai puin de 0,3% din totalul

neoplasmelor i sunt deseori prost diagnosticate sau descoperite n stadii foarte trzii (18,19) Studii

recente au artat o cretere a incidenei tumorilor intestinului subire pe tot cuprinsul globului. (18, 20-

24) Hurst RD aproximeaz c anual n Statele Unite se diagnosticheaz aproximativ 140.000 de

cazuri de cancer colorectal, 22.000 de cazuri noi de cancere gastrice, comparativ cu doar 4.500-5.000

de cazuri de cancer ale intestinului subire (25).

Discussions

Although the small intestine represents 75 % of the length and 90 % of the absorbtion surface

of the intestinal tract, maligne tumors present at its level represent less than 5 % of the total of

gastrointestinal cancers. (17, 18) They also represent less than 0.3 % of the total of neoplasms and

are often poorly diagnosed or discovered in very late stages (18, 19) Recent studies have shown an

increase in incidence of small intestine tumors all over the globe. (18, 20-24) Hurst RDs

approximations of annual diagnostics in the United States, are of approximatively 140 000 cases of

colorectal cancer, 22 000 new cases of gastric cancers, compared to only 4.500 5000 cases of small

intestine cancer (25).

ntr-un studiu retrospectiv recent, Karl Y. Bilimoria i colab. (26) au descris caracteristicile unui lot de

65.843 de pacieni inclui in perioada 1985-2005 n National Cancer Data Base (NCDB) i in

programul Epidemiology and End Results (SEER, 19732004). Dintre acetia, 25.339 (37.4%) au

fost diagnosticai cu tumori carcinoide, 25.053 (36,9%) cu adenocarcinoame, 11.711 (17,3%) limfoame

i 5.740 (8,4%) adenocarcinoame. Repartiia pe sexe a relevat o uoar predominan a brbailor

(54% vs 46%), n timp ce vrsta medie a fost 67 ani (cu vrste cuprinse ntre 56 i 76 ani). S-a

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observat o cretere a incidenei de la 11,8 cazuri la milion n 1973, la 22,7 cazuri n 2004. De remarcat

c studiul nu a inclus cazurile diagnosticate la autopsie.

Incidena total n anul 2005 a fost de 8,4/100.000 locuitori, dintre care 85-90% au fost descoperite

ntmpltor la autopsie. (27)

In a recent retrospective study, Karl Y. Bilimoria and collaborators (26) described the characteristics of

a group of 65.843 patients included in the 1985-2005 period in the National Cancer Data Base

(NCDB) and in the Epidemiology and End Results program (SEER, 1973-2004). Of these, 25.339

(37.4%) were diagnosed with carcinoid tumors, 25.053 (36.9%) with adenocarcinoma, 11.711 (17.3%)

with lymphoma and 5.740 (8.4%) with adenocarcinoma. Repartition by sex showed a slight

predominance of men (54% vs 46%), while the average age was 67 years (ages between 56 and 76

years). An increase in incidence from 11.8 cases per million in 1973 to 22.7 cases per million in 2004

was noticed. It is worthy of note that the study did not include cases diagnosed by autopsy.

Total incidence in 2005 was of 8.4/100 000 people, of which 85%-90% were discovered by chance

when autopsied. (27)

Datorit numrului mare de cazuri nregistrate post-mortem, este suficient de clar c o metod

eficient de descoperire incipient a acestei patologii tumorale este necesar. Modalitile clasice de

diagnostic pentru tumori ale intestinului subire cuprind endoscopia digestiv superioar (pentru leziuni

ale dudenului i jejunului proximal), metode radiografice (tomografie computerizat sau seriografii).

Leziunile localizate dincolo de ligamentul Treitz pun probleme majore datorit lungimii intestinului

subire. (28)

Astfel s-a impus gsirea unor modaliti diagnostice noi, sigure i eficace, cu tolerabilitate bun.

Videocapsula endoscopic ntrunete condiiile necesare pentru a fi o astfel de investigaie, uurina

folosirii, combinat cu tolerabilitatea bun, numrul minim de efecte secundare i rata diagnostic

ridicat recomandnd-o ca metod diagnostic de mare valoare n identificarea precoce a patologiei

intestinului subire. (29,30)

Due to the large number of cases recorded post-mortem, it is sufficiently clear that an efficient method

of early discovery of this tumor pathology is necessary. Classic diagnosis methods for tumors of the

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small intestine include upper digestive endoscopy (for lesions of the duoden and proximal jejunum),

radiographic methods (computerized tomography or seriography). Lesions located beyond the

ligament of Treitz are very difficult to diagnose because of the length of the small intestine. (28)

Thus, it becomes a necessity to find new means of diagnostic that are effective, well tolerated, and

sure. The video capsule endoscopy fulfills all the necessary for such an investigation, ease of use,

combined with good tolerability, a minimum number of side effects and a high diagnosis rate all

recommending it as a high value diagnostic method for early identification of small intestine pathology.

(29, 30)

Unul din posibilele neajunsuri ale tehnologiei VCE este reprezentat de contraindicaia

absolut n cazul obstruciei. Exist pericolul reteniei capsulei la nivelul stricturii, cu rezultate

catastrofale pentru pacient. Astfel, a fost introdus o metod de control, o capsul ce verific

continuitatea tractului intestinal, numit patency capsule. (31) Capsula se resoarbe dup o anumit

perioad, impactarea sa la nivelul unei posibile stenoze nereprezentnd un pericol. Conine un

emitor RFID (radio frequency identificator=identificator n spectru radio), care face posibil

detectarea locaiei exacte unde capsula se oprete. Aceast nou modalitate de control sporete

eficacitatea sistemului VCE, suplimentnd n acelai timp capacitile sale diagnostice. (31,32)

One of the possible shortcomings of the VCE technology is represented by the absolute

contra-indication in the case of obstruction. This holds the danger of capsule retention at the stricture

level, with catastrophic results for the patient. Thus, a new control method was introduced, a capsule

which verifies the continuity of the intestinal tract, called patency capsule. (31) This capsule is

absorbed after a certain period, its impact on the level of a possible stenosis being of no concern. It

contains a RFID emitter (radio frequency identificator), which makes possible to detect the exact

location where the capsule stops. This new method of control increases the efficiency of the VCE

system, while simultaneously supplementing its diagnosis capabilities. (31, 32)

A fost pus la punct un sistem endoscopic de vizualizare a intestinului subire: enteroscopia cu

un singur balon (SBE), cunoscut drept enteroscopia mpinge-i-trage . A fost proiectat n 1997

(33). n 2001, cercetrorii japonezi au dezvoltat primul sistem endoscopic specializat. Aceasta tehnic

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permite examinarea direct a intestinului subire. Poate fi folosit pentru prelevarea de biopsii, sau

pentru aplicarea tratamentului hemostatic, acolo unde este cazul. Poate fi executat de un singur

enteroscopist, spre deosebire de enteroscopia cu dublu balon, care necesit minim doi operatori.

Anestezia standard poate fi utilizat. Enteroscopia poate fi realizat fie pe cale oral sau pe cale

anal, n funcie de localizarea leziunilor, care au fost descoperite prin alte tehnici non-invazive, cum

este VCE. (34,35)

An endoscopic system of visualizing the small intestine was implemented: single-balloon

enteroscopy (SBE), known as push-and-pull enteroscopy It was designed in 1997 (33). In 2001,

Japanese researchers implemented the first specialized endoscopic system. This technique allows

direct examination of the small intestine. It can be used to prelevate biopsies or to apply hemostatic

treatment where needed. It can be executed by a single enteroscopist, unlike double-ballon

enteroscopy, which requires a minimum of 2 operators. Standard anesthesis can be used. The

enteroscopic approach can be oral or anal, depending on the localization of lesions, which were

discovered by other non-invasive techniques such as VCE. (34,35)

Pregtirea histologic a probelor de biopsie a fost cea care a furnizat diagnosticul de

certitudine. Orientarea a fost cel mai important pas, uurnd mult diagnosticarea. Prelevarea corect a

probelor de biopsie este obligatorie pentru un diagnostic de acuratee, mai ales cnd implic

evaluarea vilozitilor intestinului subire sau atunci cnd privete leziunile neoplazice sau displazice.

Este de preferat s se treac la fixare imediat dup intervenia chirurgical. Prelevarea pieselor

biopsice poate fi fcut uor dac este folosit o lup. Trebuie efectuat rapid i cu mult grij, pentru

a nu afecta mucoasa intestinal. Protocoalele utilizate au evideniat caracteristici histologice specifice

tipurilor tumorale benigne sau maligne, furniznd suficiente informaii pentru stabilirea unui diagnostic

de precizie n ceea ce privete malignitatea.

Histologic preparation of biopsy samples was what gave the diagnostic certainty. Orientation

was the most important step, simplifying diagnosis by a great deal. Correct prelevation of biopsy

samples is mandatory for an accurate diagnosis, especially when it involves the evaluation of small

intestine vilosities or when it regards neoplasic or displasic lesions. It is prefferable to FIX immediately

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after surgical intervention. Prelevating biopsy samples can be made easier if a magnifying glass is

used. It must be made quickly and with great care, so as not to affect the intestinal mucosa. The

protocols used have shown histologic characteristics specific to the types of benigne or maligne

tumors, supplying sufficient information to establish a precision diagnosis regarding malignity.

Imunohistochimia reprezint o metod relativ nou, ce permite localizarea proteinelor

specifice, utiliznd reacia anticorp-antigen. (36) Este folosit cu success n diagnosticarea cu

acuratee a leziunilor maligne, identificnd markeri tumorali specifici fiecrui tip de neoplasm malign.

Toate aceste tehnici vin n sprijinul chirurgului, direcionnd intervenia chirurgical i

tratamentul oncologic.

Immunohistochemistry is a relatively new method, which allows the localization of specific

proteins by utilizing the antigen-antibody reaction. (36) It is successfully used in accurate diagnosis of

malignant lesions, by identifying tumor markers that are specific to each type of malignant neoplasm.

All these techniques come to the support of the surgeon, by direction the surgical intervention

and the oncologic treatment.

Concluzii

Patologia tumoral a intestinului subire este subevaluat n raport cu cea a celorlalte

segmente ale tubului digestiv, rata de detecie n timpul vieii fiind mult mai sczut dect n alte

cazuri. Se ntlnete predominant la persoane de vrsta a treia i se prezint sub o multitudine de

forme. Este deci necesar o metod eficient de identificare precoce a leziunilor i un protocol care s

stabileasc malignitatea.

Conclusions

Tumor pathology of the small intestine is under-evaluated by comparison with the other

segments of the digestive tract, detection rate during life being much lower than other cases. It is

predominantly occuring in third age persons and it presents under a multitude of forms. It is therefore

necessary to find an efficient method of early identification of lesions and a protocol which would

establish malignancy.

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Videocapsula endoscopic reprezint fr ndoial o metod modern, eficient, de

identificare a leziunilor tumorale. Ea se poate dovedi un ajutor preios pentru chirurg n toate etapele

de diagnostic. Fiind o metod neinvaziv i avnd un grad de acceptabilitate mare din partea

pacienilor, poate fi folosit cu succes n screening-ul multiplelor afeciuni ntlnite la nivelul tubului

digestiv subire. Combinat cu capsula patency i cu metodele enteroscopice moderne (SBE), i

lrgete acurateea diagnostic i uureaz munca chirurgului, ajutnd n acelai timp pacientul prin

reducerea amplorii interveniei chirurgicale.

Folosirea tehnicilor de histologie i imunohistochimie duce la un diagnostic precis de

malignitate pentru toate tumorile intestinului subire, direcionnd efortul terapeutic i evalund corect

patologia.

The video capsule endoscopy is, without doubt, a modern effective means of identifying tumor

lesions. It can prove to be of precious help to the surgeon in all steps of the diagnosis. Being a non-

invasive technique and having a high degree of acceptability from patients, it can be successfully used

in screening the multiple pathologies of the small intestine. When combined with the patency capsule

and modern enteroscopic methods (SBE), it widens its diagnosis accuracy and eases the work of the

surgeon, simultaneously helping the patient by reducing the extent of the surgical intervention.

By using histology and immunohistochemistry techniques it leads to a precise malignancy

diagnosis for all tumors of the small intestine, directing therapeutic efforts and correctly evaluating the

pathology.

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