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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 Vere 1, Costin Teodor Streba 1, Marius Georgescu 2, Camelia Foarf3 , Alin Gabriel Ionescu 1

Clinica Medical I, Spitalul Clinic Judeean de Urgen Craiova Universitatea de Medicina si Farmacie Craiova Departamentul de Anatomie Patologic, Spitalul Clinic Judeean de Urgen Craiova Medical Clinic I, County Clinic Emergency Hospital of Craiova The University of Medicine and Pharmacy Craiova The Department for Pathological Anatomy, Clinic Emergency Hospital of Craiova

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

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

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

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 noninvazive 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.

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.

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

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

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,

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 Women Polyps 2 1 Benigne Stromal Tumor 0 1 Maligne Stromal Tumor 3 0 Neuro-endocrine Tumor 0 1 Adenocarcinoma 1 1 Duodenal Papilla Carcinoma 0 1 Total 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 >60 years Maligne Tumors 0 6 (54,54%) Benigne Tumors 4 (27,27%) 1 (11,11%) Total 4 (27,27%) 7 (72,72%) Table 2. Tumor Pathology of the Small Intestine Table of Incidence Total 6 (54,54%) 5 (45,45%) 11 (100%)

Benigne Tumors (45,45%) Polyps <60 years >60 years 2 (18,18%) 1 (9,09%) Stromal Tumors 2 (18,18%) 0 Neuroen docrine Tumors 0 1 (9,09%)

Maligne Tumors (54,54%) Adenocarcinom a 0 2 (18,18%) Stromal Tumors 0 2 (18,18%) Duodenal papilla carcinom a 0 1 (9,09%)

Total

3 (27,27%) 8 (72,72%)

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Total

1 2 (18,18%) 2 (18,18%) (9,09%) Table 3. Tumor Pathology Repartition by Etiology and Age Groups 3 (27,27%) 2 (18,18%) Discuii

1 (9,09%)

11 (100%)

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, 2024) 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 noninvasive 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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