In most endoscopy institutions, the number of procedures is welle known and rather constant. The true time consumption of the procedures including preparation and after-care in times of maximal work load during the "endoscopic rush hour" is not precisely documented in the majority of endoscopy units. Staritz et al. (1992) have reported on time measurement of endoscopic procedures in 155 endoscopy units of German hospitals with more than 500 beds each (Table 2). This analysis has primarily been made for the calculation of staff requirements; therefore it cannot be used for instrument equipment planning without some reservation. However, it can give some rough orientation for institutions which have not performed any precise time measurements themselves.
The duration of procedures extremely, which is expressed by very high standard deviations (in spite of a high sample number!). The speed of endoscopy procedures in out-patient units and private pratice is much higher than in hospitals.
If Staritz's data are taken for a rough calculation of the endoscope equipment, the mean values minus standards deviation should be taken, otherwise the calculation will result in a lack of endoscopes during times of maximal work load. Own time measurements are preferable as a basis of endoscope equipment calculations.
Each endoscopy unit should balance out the advantages and disadvantages of the two organisation principles "methods mix in one procedure room" or "separate organisation of EGD and colonoscopy". The organisation of a procedure room with a mixed schedule of EGD and colonoscopy helps to limit the number of endoscopes but necessitates rigorous hygienic regulations and a very differentiated schedule planning.
A "One-room endoscopy unit" for EGD and colonoscopy requires at least two (better three) gastroscopes and one colonoscope. A separate organisation of gastroscopy, colonoscopy and ERCP need a minimal equipment with three gastroscopes, two colonoscopes, and two duodenoscopes. The restriction of endoscope number ends where the process quality is impaired ("waiting for an endoscope"). Structure specifications, the spectrum of methods, selection of patients and indications, number and qualification of staff, and quality of endoscopes define the detailled needs for the endoscope equipment and the durability of the instruments.

Friedrich Hagenmüller, MD
President of the E.S.G.E.

REFERENCES

Staritz M, Alkier R, Krozoska B, Holzer R, Grosse A: Zeitbedarf für endoskopische Diagnostik und Therapie: Ergebnisse einer Multicenterstudie, Zeitschrift für Gastroenterologie 30 (1992) 509-518.

Education and Training of Endoscopic Assistants: the Importance of Attitudes.

I have come to the conclusion that endoscopic assistants' (most of the time nurses) behaviour is one of the major factors in the perceived quality of endoscopic examinations, certainly greeter than the endoscopist's ability.
Nurses contribute to the quality (perceived by the patient or not) of the endoscopic examination in many ways.
I shall not comment on the "technical" aspects of nurses' training (such as, for example, handling of materials, disinfection, helping the endoscopist during the various manouvres, etc.) but rather concentrate on nurses' attitudes and abilities, which may make a great difference in the way an invasive procedure is perceived by the patient.
Nurses who are good at establishing rapport with the patient and good at communicating and encouraging, may even reduce the need for sedation. This is particularly interesting where it is not customary to sedate all patients before endoscopy. To a greater degree than the endoscopist, nurses may affect the patient's perception of the examination at several steps: by informing him before the procedure of what will happen during the examination, by reducing his/her anxiety during the examination (by talking, at times focusing on the physical feelings or at other times by distracting, by physical and eye contact, be it touching or holding hands, by encouranging or reassuring, etc.).
At the end of the procedure there is also need for further information, surveillance and directions which are more easily given by the nurse. Educating and training nurses in this area will not only improve patient's satisfaction, but also the overall "quality" of the examination.
Even if most endoscopists will agree that such abilities are desirable, it is my opinion that training endoscopic assistants in this area is often superficial or simply not done at all. Such training should be planned according to defined objectives and using appropriate methods.
In this case, rather than lectures and study of texts, the use of the "critical incident" technique and the development by the assistants themselves of a relevant checklist would be more effective.
This, and the feed-back from a patients' questionnaire could develop and reinforce the assitants' desirable attitudes and skills.
If there was a request for it, I am sure that the OMGE and the OMED Education Committees would be available to provide suggestions, and expertise for a training course in this area.

Alessandro Martin, MD
Chairman OMGE Education Committee
Padua, Italy

Robotic Surgery: an Improvement in Laparoscopic Surgical Skills

There is little question that laparoscopy represents a definite progress in patients' treatment. However, at present, there are a lot of drawbacks, some of which are not insignificant. For instance, the surgeon has lost all tactile sensation, he has to perform operations for only sensory input the two-dimensional picture on a video screen, and the procedure, to be done with long instruments, is seldom performed in a position for the surgeon comfortable. All this results in a reduced accuracy of the surgical act as compared to conventional surgery.
Interaction between visual and other inputs and the final output (the final surgical action) are part of a so called medical system. It is the purpose of the new developments in technology to improve first the input part and second the output or effector system.

1. The input or afferent system

It is obvious that better optical systems, including better telescopes and cameras, are needed. The ideal optical system would be one that provides a three-dimensional image. The ultimate aim being a three-dimensional high definition television picture, in order to obtain adequate 3 D perception together with visual acuity. The fact of possible integration of three-dimensional pre-operative imaging into the actual operative picture opens new perspectives and implicates the opening of virtual reality to surgery and medicine.
Reality however is not only visual. Tactile feedback must be provided to the surgeon and this can be done by sensor systems measuring static as well as dynamic pressure changes obtained by moving a probe on a surface.

2. The output or effectorsystems

In open surgery, the dexterity of the surgeon relies on a wide variability of actions, permitted by the motility of fingers, wrist, elbow and shoulder.
In laparoscopic surgery, however, the fact that long instruments are used through cannulas in our opening (trocar) in the abdominal wall, limits the degrees of freedom of the surgeon to a number of 4motions: in and out, rotation around one axis, up and down and from medial to lateral are posible. The angle to an immobile target is however fixed, moreover, the fact that the instruments are fixed inside the trocar, puts the surgeon often in an awkward and ergonomically close to unacceptable position in order to reach the target organ.
The way things have been so far, laparoscopic instruments did not allow the surgeon to carry out tasks with the same dexterity as in open surgery. An increase of the number of degrees of freedom is essential.

3. Integration of improvements of input and output into a robotic system

In order to solve the efference problems, a robot was developed by Intuitive Surgical (Mountain Vieuw, California) and was used in a laparoscopic procedure on a human (laparoscopic cholecystectomy, March 3, 1997).
The patient, a 72 year old woman with a body mass index of 42 kg. per square meter, was put under general anesthesia with endotracheal intubation.
Two "active" ports were hooked up to two fully mobile mechanical arms that were attached to the siderails of the operating table. They harbored two articulated tools (end effectors): a grasper and an electrocautery hook, that were commanded by the surgeon sitting at a working console approximately 15 feet away from the patient.
As the surgeon watched the three-dimensional image of the operative field, he manipulated two handles that transmitted impulses from and to the end effectors via a computer interface. Sensory input and downscaling of the surgeon's motions 4 to 1 were secured.
The procedure was successfully performed in 82 minutes. The patient's recovery was uneventful.
With the present master-slave system, 7 degrees of freedom were acquired, because the end effectors had an additional articulation (wrist) inside the abdominal cavity, perfectly imitating the surgeons hand motions. Moreover, the system was capable to reduce (downscale) the manipulations of the operator hereby eliminating physiologic tremor.
Additional improvements are presently being studied so as to complete more complex endoscopic operations such as micro anastomosis in the cardiovascular field. One of these improvements is motion "tracking" which will give an "immobile" picture for the surgeon to work with, while the effectors will move in accordance with the target's movements (beating heart).

G.B. Cadière, MD
J. Himpens, MD
Département de Chirurgie Digestive
Hôpital Universitaire Saint-Pierre
Brussels, Belgium

Endoscopic Enteral Metal Stents for Malignant Gastric Outlet Obstruction

Surgical gastrojejunostomy is the standard treatment for malignant gastric outlet obstruction (GOO). Unfortunately, this intervention can be associated with significant morbidity and mortality [1]. Self-expanding metallic stents designed for the biliary tract, such as the Gianturco-Rösch Z-stent (Wilson-Cook, Inc., Winston-Salem, NC) and the Wallstent (Schneider, Minneapolis, MN) have been reported to provide effective treatment alternatives with minimal morbidity [2-10]. but small caliber lumens.
Over the past two years, we have used commercially available Wallstent Enteral stents or their prototypes to treat 12 patients who had malignant gastric or duodenal stenoses. Several patients were treated before the stents were approved by the Food Drug Administration for marketing as a gastrointestinal device, but all were approved for compassionate use by the Brigham and Women_s Research Committee. We obtained informed consent from all patients prior to treatment.


Subjects

The mean (_ SD) age of the patients whom we treated (10 women and 2 men) was 59.7 _ 13.2 years. Eleven patients had nausea and vomiting and/or were unable to take adequate calories orally. One patient with pancreatic cancer and GOO had associated recurrent cholangitis because of episodes of food impaction into a biliary wallstent placed through a choledochoduodenostomy that had been created 20 years previously because of stone disease. The most common malignancy was pancreatic cancer (three patients). Nine patients had GOO due to a variety of primary duodenal (two) or metastatic cancer (two ovarian, one gallbladder, one cholangiocarcinoma, one colon, one breast, and one pseudomyxoma peritonei). Of the twelve patients, one with gallbladder cancer presented with both jaundice and GOO and four patients had had biliary Wallstent stents placed for treatment of malignant biliary stenoses. Most patients were too ill or were otherwise unsuitable for surgical treatment as assessed by their primary care physicians, gastroenterology consultants, and, in some cases, surgical consultants. Patients were followed for their symptoms by us or their primary-care physicians.


Equipment

We used self-expanding metallic stents (Wallstent Enteral) 16 to 22 mm in diameter and 60, 83 or 90 mm in length. These stents are constructed from a woven stainless steel superalloy and have a larger diameter than the commonly used biliary Wallstent. Prior to deployment, these stents are constrained by a transparent plastic membrane (Unistep System) onto a delivery system of outer diameter of 10 Fr (3.3 mm) and overall length of 230 cm. This slim and long delivery system allowed us to insert and deploy the stents through the biopsy channel of therapeutic upper endoscopes or duodenoscopes (Fujinon, Inc, Wayne, NJ).


Technique

We placed all stents under endoscopic and fluoroscopic guidance. After identification of the stricture, we passed standard 0.035 inch Glidewire or Zebra guidewire (Microvasive, Watertown, MA) through it using a standard ERCP catheter . We determined the length of the stricture by the distance the catheter traveled over the guidewire while observing fluoroscopically. We used stents that were at least 2 cm longer than the stricture although early prototypes were not available in all sizes. We did not dilate any stricture prior to stent deployment. We advanced the Wallstent Enteral over the guidewire such that the ends of undeployed stent were equidistant from the ends of the stricture. In a few cases where an endoscope could be passed through the stricture, we marked the distal end of the stricture by injecting Renografin contrast submucosally for additional guidance. During deployment, we repositioned stents frequently because there was a tendency for them to move away from the endoscope. We assessed the adequacy of stent placement at the conclusion of each procedure using endoscopy and fluoroscopy.


Results

The mean follow-up period for the group was thirteen weeks (range 2 to 40 weeks). One patient was lost to follow-up at 40 weeks, another patient who underwent gastrojejunostomy was lost to follow-up at seven weeks. Nine patients died after the procedure from progression of their cancer unrelated to the stent implantation.
Fourteen Wallstent Enteral was implanted for the 12 patients. All stent deployments were technically successful. There were no major short or long-term complications, such as bleeding from the cancer, perforation, or stent migration. Placement of enteral stents in the second portion of the duodenum in patients who had biliary Wallstents did not cause obstruction of the biliary outflow. In at least three patients, the stent protruded approximately 1 to 2 cm into the normal antrum and did not cause any gastric obstruction or any new symptom.
Six patients were able to eat a regular diet, and three others were able to eat a pureed diet within 24 hours of stent placement. Three patients developed recurrent symptoms of obstruction at two, four, and 21 weeks after stent placement. Of these three patients, one patient was found to have the stent deployed too distally and another patient was found to have tumor ingrowth into the stent. Both patients underwent successful restenting two and 21 weeks after the initial stent placement. The third patient had supportive therapy only. Stenting did not relieve the symptoms of three patients. One patient was found to have multiple distal small-bowel strictures that were not recognized prior to stent insertion and two patients had stents that were deployed suboptimally: one stent expanded too distally, and this patient subsequently underwent gastrojejunostomy, another stent was too proximal, and this patient was given supportive therapy only. Both technical failures occurred when one-size prototypes only were available. As we gained experience in stent placements, we were able to discharge patients earlier after stenting such that three patients were discharged within 24 hours after stent placement. Three patient had the procedure performed as an outpatient. Another patient had both biliary and enteral Wallstents placed during the same setting and was discharged two days later. Two other patients were also discharged within 48 hours after stenting. One patient was hospitalized for six days after stent placement to receive supportive care.


Discussion

The treatment of malignant gastroduodenal stenoses is difficult. Many patients have advanced malignant disease and are too ill to undergo surgical gastrojejunostomy, which is associated with significant morbidity and mortality [1]. It is not uncommon for patients to be treated with only supportive therapy, which, unfortunately, does not relieve nausea and vomiting or allow adequate food intake. Other treatment options have been tried. Treatment with chemotherapy or radiation therapy is typically unhelpful. A surgically-placed jejunostomy for feeding combined with percutaneous endoscopic gastrostomy has been used in patients with gastroduodenal stenoses [5], but this combined therapy is often unsatisfactory. Other endoscopic modalities to dilate or ablate the stenoses have been used infrequently, because they provide only a transient response and are associated with a significant risk of perforation.
Our prospective study found that endoluminal treatment of malignant GOO with the self-expanding metallic Wallstent Enteral is a safe and effective alternative to surgery. TTS deployment facilitates accurate and safe stent insertion. The slim and flexible delivery systems permit stent placements into the angulated lumen of the gastrointestinal tract without prior dilation of the stenoses. The large diameter of these stents allows patients to eat regular food and perhaps prevents early occlusion due to tumour ingrowth. With experience, we found that placements of Wallstent Enteral were associated with minimal morbidity, allowing us to discharge patients shortly after stenting.
The design of the stents that we used differed from those of the stents used in previous reports [2-10]. In 1992, Kozarek and colleagues, successfully placed Z-stents in the afferent limb of a patient who had had a Whipple resection for pancreatic carcinoma and in the efferent limb of a patient who had Bilroth II anastomosis for gastric carcinoma with good results [6]. Following this report, Maetani and associates, treated three patients who had malignant gastric and duodenal stenoses with Z-stents and reported similar results [7,8]. The delivery system of the Z-stent was large: thus, direct TTS placement was not possible. Keymling and colleagues used the endovascular Wallstent as palliative treatment for malignant duodenal stenoses [5], but as this stent had short delivery system, it was placed through a gastrostomy. The stents that we used had delivery system long enough to allow TTS placement (230 cm). Howell and others [4]. used the biliary Wallstent as palliation for GOO. Although the biliary Wallstent allowed TTS placement, its diameter was small (10 mm) and thus limited patients_ diets to clear liquids or soft foods. In comparison, the diameter of Wallstent Enteral is much larger (18, 20 or 22 mm), potentially allowing patients to eat a regular diet. Despite shortcomings in the design and delivery systems of the stents used previously, these reports indicate that self-expandable metal stents can be used safely to treat malignant gastric or duodenal obstruction. In the era of cost containment, the cost effectiveness of the Wallstent Enteral to treat malignant gastrointestinal obstruction must be considered. Although our study evaluated only feasibility and outcomes, our experience suggests that use of the Wallstents would be cost effective. The overall cost of treatment with the Wallstent is likely to be lower than the overall cost of treatment with gastrojejunostomy, because stent placement does not require costly use of operating room and hospitalization for post-operative recuperation. In addition, stenting can be expected to provide more quality and quantity of life. Patients who receive stents require less time to recuperate than do patients who undergo surgery and stent placement is associated with minimal morbidity. In contrast, surgery is associated with significant mortality. In the future, we expect placement of the Wallstent to become the preferred treatment because it may improve quality and quantity of life and use fewer resources.
In conclusion, our initial experience with use of Wallstent Enteral to treat patients with malignant GOO is favorable. Stent deployment is technically feasible and in some patients allows effective palliation of obstructive symptoms and the ability to take food orally.

David L. Carr-Locke, MD, FRCP
Director of Endoscopy - Brigham and Women's Hospital
Associate Professor of Medicine - Harvard Medical School
Boston, Massachusetts, USA

REFERENCES

1. Weaver D, Winczek R, Bowman D, Walt A. Gas- trojejunostomy: is it helpful for patients with pancreatic cancer? Surgery 1987; 107: 608-613.
2. Topazian M, Ring E, Grendell J. Palliation of obstructing gastric cancer with steel mesh, self-expanding prostheses. Gastrointest Endosc 1992; 38(1): 58-60.
3. Holstege A, Gross V, Lock G, Mebmann H, Vogt W, Scholmerich J. Self-expanding metallic stent placement in the palliation of inoperable malignant gastric outlet obstruction (abstract). Gastrointest Endosc 1995; 41(4): A38.
4. Howell D, Bosco J, Muggia R, Biber B. Endoscopic double bypass: duodenal metal expandable stenting in late stage malignancy (abstract). Gastrointest Endosc 1994;140:A38.
5. Keymling M, Wagner H, Vakil N, Knyrim K. Relief of malignant duodenal obstruction by percutaneous insertion of a metal stent. Gastrointest Endosc 1993; 39(3): 439-441.
6. Kozarek R, Ball T, Patterson D. Metallic self-expanding stent application in the upper gastrointestinal tract: caveats and concerns. Gastrointest Endosc 1992; 38: 1-6.
7. Maetani I, Ogawa S, Hoshi H, Sato M, Yoshioka H, Igarashi Y, Sakai Y. Self-expanding metal stents for palliative treatment of malignant biliary and duodenal stenoses. Endoscopy 1994; 26: 701-714.
8. Maetani I, Inoue H, Sato M, Ohashi S, Igarashi Y, Sakai Y. Peroral insertion techniques of self-expanding metal stents for malignant gastric outlet and duodenal stenoses. Gastrointest Endosc 1996; 44: 468-471.
9. Raijman I, Roddey G. Treatment of malignant duodeno-biliary obstruction with double-endoscopic stenting (abstract). Gastrointest Endosc 1995; 41(4): A466.
10. Buto S, Tsang T, Crampton A, Berlin G. Nonsurgical bypass of malignant duodenal and biliary obstruction. Gastrointest Endosc 1990; 36(5): 518-520.

Report of the Education Committee OMED

The Education Committee consists of the following members:
Nestor A. Chopita, MD
Daldiyono, MD
Rikiya Fujita, MD
Glaciomar Machado, MD
Alessandro Martin, MD
Jesus Y. Perez, MD
Herman Espejo Romeo, MD
Laszlo A. Simon, MD
Jerome D. Waye, MD (Chairman)
Christopher B. Williams, MD.

The Education Committee has applied itself over the past four years to several areas with the purpose of bringing information concerning various aspects of endoscopy to endoscopists throughout the world. The major thrust of the Education Committee is not in the training of endoscopists in a formal fellowship program, but rather is focused on bringing information to physicians who already perform endoscopy and educating doctors about endoscopy in countries where there is a need for further endoscopic expertise.
Videotapes from the past two World Congresses of Gastroenterology (Australia, 1990 and USA, 1994) are now available as a package. The price for the entire package is US$100. This is available in either PAL or NTSC format, and is available upon request form Prof. Massimo Crespi, President of OMED. Constituent member societies of OMED may acquire a copy of these videotapes free of charge providing that they agree to show these videotapes at national meetings of their endoscopic societies. The Education Committee has arranged for a live demonstration endoscopy course to be held in Moscow on April 23-24, 1998. This course will be presented in conjunction with the Olympus Corporation, who will supply equipment and arrange for video transmission.
The Education Committee currently has a list of constitutions and by-laws which is available on request. These constitutions and by-laws had been submitted by member endoscopic societies of OMED three years ago. The Education Committee is currently seeking information from every constituent endoscopic society as to the availability of educational aids for gastrointestinal endoscopy. The aids would include slide series, brochures, written material, and videotapes. A letter has been sent to every president of each constituent endoscopic society throughout the world seeking such information.If any individual members have knowledge of educational material which contain information concerning gastrointestinal endoscopy, please contact Dr. Waye with a listing of this information.
The Education Committee is currently working on developing a brochure for the performance of live courses in endoscopy. Live tele-endoscopic courses are of great benefit in the education of large numbers of physicians in the performance of endoscopic procedures. A section of this brochure will address small, focused endoscopy courses. OMED desires to establish standards for patient safety, patient selection, the performance of such live courses, and patient privacy. The Education Committee is also concerned with the selection of "experts" in endoscopic procedures, and desires to eliminate any risk to the patient from being a subject in a "live" endoscopic course. Most physicians who agree to produce such a course, are, in general, not knowledgeable about the various forms of transmission to a nearby or remote location, and would benefit by having a "primer" on the conduct of these courses. Anybody with a special expertise in the development or production of live courses or is knowledgeable about the video requirements should contact Dr. Waye with such information.
Stimulated by an excellent response from the Research Committee on a previous questionnaire, the Education Committee is collaborating with the Research Committee to distribute a questionnaire worldwide to collect further information on endoscopic practices. The questionnaire is currently in the development phase, and will be distributed during 1998.

Jerome D.Waye, MD
Chairman OMED Education Committee
New York, USA

Activities of Research Committee of OMED

In association with Dr. Jerome Waye, Chair of the Education Committee of OMED, the Research Committee has been working over the past several months to develop a comprehensive questionnaire on endoscopic priorities throughout the world. This has now been finalized and is about to be distributed to the constituent national societies of OMED. This questionnaire will address several areas, including what endoscopic procedures are performed, who performs them and what has been their training. The purpose is to develop a database on endoscopic practice, training and facilities throughout the world, to provide a basis for further education, training and research initiative in this area. We look forward to the active participation of the constituent national societies in this process and we hope that all of you will complete this questionnaire and, also, that you will communicate with either Dr. Waye or Dr. Quigley regarding any comments or criticisms on the questionnaire. We believe that this is a vital prerequisite to developing short- and long-term strategies for OMED throughout the world.

Eamonn M.M. Quigley, MD, FRCP
Chairman OMED Research Committee
University of Nebraska, USA

6^th World Congress of Endoscopic Surgery Rome '98

The 6th World Congress of Endoscopic Surgery and the 6th European Congress of the European Association of Endoscopic Surgery, will take place in Rome from May 31 to June 6, 1998.
These two events, the former promoted by IFSES and the latter promoted by EAES will be held together in order to unite in one spirit the actual State-of-the Art of Minimally Invasive Surgery.
A World Expo of Surgical Technologies will also be organised for the evaluation of the real impact of these technologies on surgical practice. The exhibition who will display the latest progresses in the field, will gather a very large number of companies from all over the world. The Opening Ceremony of the World Expo will be held on Wednesday June 3, in the morning.
The Organising Committee wishes to thank all sponsors who have shown such wide interest and specially the Major Sponsors who have proved to be substantial to realise this event.
The Core meeting will be preceded by a Nurses' Seminar and a Post-Graduate Course.
While the importance of the Nurses' Seminar has been particularly stressed, since it will be a very qualifying event, the Post-Graduate. Course has been designed to create a forum where the role of flexible endoscopy, interventional radiology and endoscopic surgery is discussed, focusing on those areas where they are competing or complementary. All the sessions will be run as Round Table with comments on the most interesting steps of the ongoing live surgery session with a teleconference link with the course venue to North (Milan) and South (Catania) of Italy, and probably to Krakow (Poland), Vladimir (Russia) and San Salvadore de Bahia (Brasil).
The following have been appointed within the Post-Graduate Coordinating Council: A. Cuschieri and J.J. Jakimowicz (EAES), J.R. Armengol Mirò and M. Crespi (OMED), J.Ponsky and G. Van Stiegmann (SAGES).
The organisation of the event is well in progress and the Scientific Committees have met several times and have finalised the scientific programme, having screened the more than 1800 abstract from almost 90 different countries which have been presented (of which over 1272 have been selected and will be published on the journal Surgical Endoscopy), witnesses of the wide interest for this congress shown by the world scientific community.
A plenary session will be devoted to Karl Storz EAES, ELSA, Poster and Video Congress Awards. Live demonstrations of telesurgery and robotic will be organised.
One of the difficulties which the Organising Committee faces is represented by the low interest shown for Specialty Seminars until now, even though these benefit of a reduced registration fee and cover fields of high scientific level such as: Coelioscopic Gyn Surgery, Interventional and Intraoperative MRI, Spine Surgery, Minimal Invasive Heart Surgery, Minimal Invasive Vascular Surgery, Arthroscopic Surgery,Minimal Access Plastic and Reconstructive Surgery and Urology. A Consensus Conference on Lap Surgery for Benign Diseases of the Colon is included in the scientific programme and the relevant experts have already been appointed.
The Opening Ceremony of the World Congress will be held in the evening of June 3 at the Campidoglio, whose square designed by Michelangelo represents the Congress logo. A show will be organised staging a historical excursus from Ancient Rome to our days.
A Clinical Congress Journal will be published on a daily basis, it will highlight the major events of the day and introduce the most interesting features of the following day.
Organising the Conference has proved a very difficult task, given the many aspects that have to be faced, among which the economic necessities of such an important event but every effort is being made towards attracting the widest participation possible in order to render this event a very meaningful one for Minimally Invasive Surgery at the end of the second Millennium. All roads lead to Rome and I welcome all of you to the Eternal City.

Alberto Montori, MD
President

Twenty Years Anniversary of the OMED Terminology Committee

The evolution of endoscopic terminology and nomenclature has been mentioned in previcus reports (1) but a 20 years anniversary of the committee gives the opportunity to recall the story shortly.
In the seventies the need for a standardized endoscopic terminology became more and more apparent and with the advent of computers was urgent. One of the first innovations which I introduced after being elected President of the European Society for Gastrointestinal Endoscopy (ESGE) in 1976 was founding the Terminology Committee. A round table conference was organized at the IV World Congress of Digestive Endoscopy in Madrid (1978) which aroused unexpected interest and incited inviting representatives of the other zones to participate in future activities. Thus the ESGE Committee was raised to an OMED Committee and since then bore the name Committee for Terminology and Computerization in Digestive Fndoscopy of the World Society of Digestive Endoscopy (OMED).The achievements of this committee during its 20 years existence can be summarized as follows.
First it was necessary to establish basic rules for endoscopic terminology. Three essential requirements were put forward:

1. Endoscopic terminology must be based on visual perception and denomination of macroscopic features as seen through the scope.
2. Accepted terms must be classified and arranged in a system according to the character of the finding; OMED's classification distinguished nine categories of findings referring to lumen, contents, wall, peristalsis, mucosa, hemorrhage, flat changes, protrusions and depressed/excavated lesions. The list of all terms belonging to the discipline represents a comprehensive database: the OMED nomenclature.
   
3. The endoscope findings designated by appropriate terms specific for the endoscopic method are interpreted in terms of clinical diagnosis by means of accessory methods like biopsy, if necessary.
   

Developing a consistent endoscopic terminology was considered to be the primary goal of endeavor. A draft was prepared and repeatedly circulated to the members of the Committee and relevant experts to insure the greatest possible consensus. At all international Congresses symposia and round table conferences were held and the present state of the document was discussed and comments respected.
In 1984 the first publication appeared and gained wide acceptance; it was quickly translated in other languages and updated in further editions (2). At present the forth English edition is ready-to-print. In addition to the book, an atlas (3) and videos (4) were published. A CD-ROM in 5 languages presenting gastroenterology as a discipline viewed by the eyes of the endoscopist and using the OMED nomenclature was published under the name Normedia-Gastro (5). All this work was accomplished thanks to sponsoring by pharmaceutical and endoscopic industry companies as well as by perfect collaboration with Normed Verlag, Bad Homburg.
The OMED nomenclature aims at being a possibly complete list of terms used in digestive endoscopy organized in a hierarchical system and provided by definitions and diagnostic criteria. Being such it should represent a fundamental database. For practical purposes this exhaustive list can be tailored to suit different computer programs, e.g. Minimal Standards for a computerized endoscopic database (6) facilitating a correct formulation of endoscopic records. Customized databases of this kind, however, should use the standardized nomenclature and should not depart from agreed categorization and terminology.
It has been a privilege to chair the OMED Terminology Committee for these 20 years and to see its achievements being accepted by the endoscopic community and further developed by the ESGE Committee for Minimal Standards for Tenninology and Documentation in Digestive Endoscopy.

Zdenek Maratka, MD
Prague,Czech Republic

REFERENCES

1. ESGE News Letter No.11 (1978) p.7; No.15 (1989) p. 1,5; No. 17 (1983) p. 8; ESGE News- Acta Endoscop. 15 (1987) p. 5; 20 (1988) p. VI; Bulletin OMED III. (1986) p.13; V. (1994) p. 25; OMED News Letter No. 1 (1993) p. 21.
2. Maratka Z. et al. Terminology, Definitions and Diagnostic Criteria in Digistive Endoscopy, Scandinavian Journal Gastroenterology 19 (1984) Suppl. 103, Normed Verlag, Bad Homburg. English 1984, 1989, 1994; German 1984, 1989; Italian 1986, 1989; Spanish 1986, 1994; Portuguese 1986, 1994; Czech 1989, French 1990; Russian 1996; Norwegian 1996; Brazilian 1995.
3. Maratka Z. et al. Illustrated Terminology, Definitions and Diagnostic Criteria in Digestive Endoscopy, Normed Verlag, Bad Homburg, English 1992, French 1992, German 1993.
4. Cosentino F. et al. 5 Videos OMED nomenclature. Normed Verlag, Bad Homburg. English; Italian; German; 1991. 5. Maratka M., Armengol Mirò J.R. et al. Normedia-Gastro CD-ROM, Normed Verlag, Bad Homburg, 1996.
5. Crespi M., Delvaux M., Schapiro M. et al. Minimal Standards for a Computerized Endoscopic Database, Am J Gastroenterol 89 (1994) p. 144-153, ESGE Committee for Minimal Standards for Terminology and Documentation in Digestive Endoscopy: Minimal Standard Terminology for Databases in Digestive Endoscopy, Normed Verlag, Bad Homburg, English 1995, Italian 1998.

Push Enteroscopy: Clinical Applications and Open Issues

Endoscopic evaluation of the small bowel has rapidly evolved over the last years, marking an important milestone in the diagnosis and treatment of small bowel diseases. Gradual progress in endoscopic techniques and development of new instruments with full therapeutic capabilities have facilitated and spread the use of enteroscopy. The two areas in which small bowel endoscopy is most useful are obscure gastrointestinal bleeding (OGIB) and suspected small bowel disease on the basis of clinical criteria. Today, push enteroscopy is available for widespread use and provides full therapeutic capabilities. This technique has now come of age (1-3), however, some issues concerning its correct use in clinical practice remain to be solved.


Obscure gastrointestinal bleeding:
the importance of lesions missed at esophagogastroduodenoscopy (EGD)

Obscure gastrointestinal bleeding is most commonly defined as acute or chronic blood-loss, intermittent or continuous, with iron-deficiency anemia and heme-positive stool. The source of bleeding remains undetected in 3-5% of patients even after thorough upper and lower endoscopy. In evaluating the source of obscure bleeding, it is mandatory that the small bowel be endoscopically investigated. In the literature, push enteroscopy reveals site or probable cause of bleeding in about 50% of cases. However, it is striking that, in most studies reported, the lesions discovered using push enteroscopy are actually within reach of a skillfully-employed standard gastroscope; the extent of the pathology missed during previous gastroscopic examinations, perfomed several times in many of these patients, is about 50% of positive findings at push enteroscopy Jensen et al. (4) investigated a group of 58 patients with recurrent OGIB using push enteroscopy, in order to evaluate the possible causes for which gastroenterologists had failed to make a diagnosis previously. The reasons for such failure were:

1. jejunal location (34.5%);
2. lesions in the postpapillar duodenum (25.8%);
3. upper gastrointestinal (UGI) lesions such as gastroduodenal vascular malformations, large hiatal hernias with Cameron's lesions, gastroduodenal ulcers, and watermelon stomach, not diagnosed in 39.6% of cases, because they were either not recognized or were missed on EGD.

The evanescent character of vascular malformations may explain why investigation sometimes remains non-diagnostic; nevertheless, proper clinical interpretation of abnormalities seen in patients with OGIB is of primary importance. Since push enteroscopy is an intensive and costly procedure, patients should be more carefully selected for submission to enteroscopy. It would therefore be prudent to repeat a thorough EGD before referring the patient for enteroscopy. In general, such "proximal lesions" should be properly evaluated during EGD, and treated if they are clinically relevant. If symptoms do not resolve after treatment, the patient should undergo push enteroscopy.


Outcomes studies

The diagnostic yield obtained by enteroscopy in patients with OGIB is variable; in any case, the ultimate impact of diagnostic and/or therapeutic enteroscopy on the actual clinical outcome for the patient remains to be determined. The key issue is, does enteroscopic therapy really improve longterm outcome in patients with OGIB? With the jejunal limitation of enteroscopic therapy, the main treatment studied in these patients has been ablation of small bowel angiodysplasia, using a heater probe, a BICAP probe, a hot-biopsy forcep or a laser fibre passed via the biopsy channel of the enteroscope. Presently, only few studies have specifically evaluated the long-term effectiveness of push enteroscopy in controlling gastrointestinal bleeding from small intestinal angiodysplasias. The Waye' group (5) report that, in 55 of 83 patients with OGIB, cauterization of an actively bleeding angiodysplasia decreases the requirement for blood transfusions compared to no treatment on similar patients. Schmit et al. (6) treated 25 patients with small bowel angiodysplasias either by electrocoagulation, or by hormonal therapy, or both. Only 50% of patients achieved a good outcome. Incidentally, the use of Octreotide appears to be effective during its administration in reducing episodes of bleeding and limiting transfusion requirement (3).
More recently, Morris et al. (7) prospectively studied 11 transfusion dependent patients with significant bleeding from small bowel angiodysplasia who were subjected to enteroscopy and heater-probe ablation of lesions.
There was a reduction in blood-transfusion requirements and an improvement in anemia. In addition to measuring clinical and physiological endpoints, outcomes research in enteroscopy should also assess the effect of treatment on the health-related quality of life, functional status, patient satisfaction, survival and costs. In this sense, Vakil et al. (8) prospectively studied 29 patients with OGIB. Although only thirteen patients had electro-coagulation of angiodysplasia at enteroscopy (45%), the authors concluded that enteroscopy alters the outcome of some patients with OGIB, by reducing or eliminating bleeding and improving functional status. On the whole, though push enteroscopy is relatively expensive and somewhat time-consuming, it seems that, when applied appropriately, it can positively impact on medical care and reduce the cost of recurrent investigations and hospital admissions. On the other hand, if it makes sense to use a therapeutic modality for cauterizing bleeding lesions, we should also bear in mind, however, that the natural history of small bowel angiodysplasia is largely unknown, and that some studies suggest that, in about 50% of patients with angiodysplasias, bleeding stops spontaneously. Despite the difficulties of a placebo-controlled study in patients with bleeding (not to treat potential bleeding lesions may be a difficult decision), in our opinion further investigation with a randomized prospective multicenter trial is warranted, in order to elucidate the effect of treatment, and justify repeated treatments, in a disease that is regarded to be a diffuse intestinal disease.

Are there other clinically relevant indications to enteroscopy?

Endoscopic examination of the small bowel may be of prime importance in a number of clinical situations different from OGIB, such as unexplained diarrhoea or malabsorption, in locating proximal Crohn's sites and thus for differential diagnosis between Crohn's and other diseases, for further endoscopic exploration and tissue diagnosis of radiographically suspected disease, inherited polyposis syndromes (1-3). In a prospective study, we evaluated a large group of patients with unexplained diarrhoea or malabsorption in order verify whether push enteroscopy improves the diagnostic yield in comparison to an exploration restricted to the descending duodenum by routine EGD (3). Taking the jejunal biopsy as diagnostic standard, the sensitivity of the duodenal biopsy fell to 72%, with specificity at 100%. Our preliminary experience suggests (9): - with regard to diseases that usually affect the small bowel diffusely, such as celiac disease, "routine" EGD with duodenal biopsies is sufficient to make the diagnosis in most patients already suspected of having the disease and push enteroscopy, which is a more expensive procedure, should be reserved for selected patients in whom endoscopic/histological duodenal findings are inconclusive; push enteroscopy may also be employed to verify correlations between the severity of the clinical picture in celiac disease and the extent of lesions. Moreover, this technique may be useful to diagnose complications such as ulcerative jejuno-ileitis or small bowel neoplasia. - when a segmental disease such as lymphoma, Crohn's disease, lymphangiectasia, or parasitic infections, is suspected, endoscopic duodenal biopsies might not be diagnostic; push enteroscopy could thus be proposed as first-choice endoscopic examination.
It is well-known that various forms of polyposis syndrome may be associated with small intestinal polyps. Upper gastrointestinal cancer has become an increasingly common cause of death in familial adenomatous polyposis (FAP), after proctocolectomy. Although duodenal and jejunal adenomas, whose incidence is high in FAP, are regarded as a significant risk factor for the development of cancer, it is unknown how many patients with polyps ultimately develop cancer, thus the value of surveillance of the upper digestive tract is still uncertain. We and others have found that push enteroscopy appears to be useful and sufficient for complete UGI surveillance in FAP patients, once front and side-view duodenoscopy has established the presence of periampullary or proximal duodenal adenomas (2,3). This technique, therefore could become the screening procedure of choice for the UGI tract in FAP patients. However, it should be stressed that the jejunal area thought to be at highest risk of adenoma can also be adequately investigated with a less cumbersome and less costly procedure, for example with a 118 cm-long gastroduodenoscope (personal observation). However, several years' experience using push enteroscopy in large series of patients will be necessary before its effect on the incidence and mortality of UGI cancer in FAP patients can be known. Moreover, since endoscopic treatment of duodenal or jejunal polyps is quite risky, future studies should evaluate whether the potential gain in life expectancy outweighs the morbidity of endoscopic examination.
Patients with Peutz-Jeghers syndrome suffer from anemia and small bowel obstruction with intussusception. Polyps in the small bowel can be eliminated with intraoperative enteroscopy and polypectomy; this technique, however, has still unacceptable morbidity and entails prolonged hospitalization. In the near future, more innovative applications of enteroscopy, such as laparoscopic assisted enteroscopy, may allow complete examination of the small bowel to be associated with an immediate means of minimally-invasive therapy, thus avoiding the undesirable aspect of open laparatomy. In a prospective study carried out at our Unit we have found that push enteroscopy may help patients in whom at small bowel barium imaging, limited number of more proximally located polyps have been revealed (3). Thus, push enteroscopy surveillance with removal of metachronous jejunal polyps could prolong the intervals between laparotomies (10). In conclusion, push enteroscopy should be considered an essential tool of gastrointestinal clinical endoscopy. We are convinced that most of the issues discussed in this article can be resolved with more widespread use of this technique, especially in large hospitals and large gastroenterology units; this will provide an opportunity to carry out multicentre studies of a large number of patients. Future studies should always include cost-benefit and outcome analysis.

F.P.Rossini, MD
Dept of Oncology - Endoscopy Service
S.Giovanni AS Hospital
Turin, Italy

M. Pennazio, MD, Senior Registrar
Dept of Oncology - Endoscopy Service
S.Giovanni AS Hospital
Turin, Italy

Surgical Digestive Department: the Practical and Scientific Value of a Digestive Endoscopic Unit in a Surgical Surrounding

Many surgical and endoscopic journals have been recently discussing the subject of a role which endoscopy plays in general surgery (2,3,4). Some authors limit the term only to laparoscopy procedures while others, utilising video techniques as a visualisation method for endoscopic images, go further and are already creating a new branch of surgery: video-surgery. The latter tend to forget, however, that video techniques, as a visualisation tool, have been widely used in numerous other disciplines, both theoretical and practical.
My impression is that still too few surgeons can see the advantages of endoscopy, applied in day-to-day surgical practice, as one of several available examination and treatment methods utilising either flexible or rigid endoscopes which common feature is possibility to diagnose and surgically treat in a minimally invasive way (5). The best example of such approach is gastroenterological surgery in which endoscopy improved conventional diagnostic and surgical techniques and resulted in more efficient and minimally invasive surgical treatment. Endoscopy is not an alternative for surgery: it represents its immanent part. This statement was clearly understood by Prof. Jan Mikulicz-Radecki, a prominent surgeon who performed in 1881 the first endoscopic examination of the upper GI tract. Just two years later, he described a macroscopic image of stomach cancer and, in the same 1883, removed with the use of endoscope a foreign body from oesophagus (6,7). His contemporaries, however, underestimated this achievement. Even nowadays still too many surgeons are satisfied with only lower GI tract viewing, i.e. rectoscopy. Their prevailing belief is that endoscopic examinations of the remaining GI tract parts should rather be performed by internists and gastrologists, and not by surgeons.
Endoscopy Unit of First Surgery Department at Jagiellonian University in Krakow was established only in 1972, ninety years after the period in which Prof. Mikulicz had been serving as Head of this very Department (1882 - 1887). Wide use of endoscopy in daily surgery practice has definitely changed our approach to the surgery of GI tract and abdominal cavity. In time, owing to our accumulating experience in endoscopic applications and the constant development of endoscopy modern tooling generations, also the range of endoscopic methods has rapidly been broadening, and in addition to diagnostic and treatment aspects, has allowed to enhance research work on certain diseases of GI tract, bile ducts and pancreas (9,11,12).
Our Endoscopy Unit of First Surgery Department enjoys the same status as the Operating Theatre, i.e. is a Department's part, and each employed surgeon has to learn endoscopic examinations and perform them just as any other surgical procedure. It is worth mentioning that the same level of expertise is required in the field of intra-operative and endorectal ultrasonography. It is not possible nowadays to accept a surgeon who treats diseases of GI tract without the knowledge and actual use of endoscopic and USG tools. At present, one can hardly think of proper treatment without endoscopy in such cases as GI tract bleeding, cholecystolithiasis, choledocholithiasis, upper and lower GI tract polyps, nutritic gastric fistula or palliative operations of advanced GI cancer. As far as this matter is concerned, a full consensus has already been reached on the superiority of endoscopic methods to conventional procedures. Nonetheless, still too few GI surgery centres have been successfully performing endoscopic sphincterotomy of acute biliary pancreatitis inflammation or intra-operative cholangioscopy. Moreover, intra-operative colonoscopy seems to be the only diagnostic examination, which allows for a proper surgical treatment of patients for whom, due to advanced cancer, it is impossible to exclude pre-operatively multifocal colon cancer or polyps. Also such methods as intra-operative control of radical HSV or detection of acid antrum with the Congo Red test are still not widely applied (13).
Endoscopy plays a particular role in the examination of post-operative complications, understanding of surgical treatment failures, evaluation of surgical methods that have been used or, most of all, in early detection of local recurrence after the surgical treatment of GI tract cancer diseases (8,10).
Over 25 years of our own experiences with modern endoscopic equipment (Tab.1) do allow us to look forward to furthering the rapid development of diagnostic and surgical endoscopy in the nearest future. The said development is going to result from both new ideas in construction of endoscopic equipment, e.g. the new generation of lens systems, and its better tooling but, most of all, from joint utilisation of endoscopic techniques and ultrasonography, laser, CT or MR system capabilities. It shall be mentioned here that our Department has been using for some time now the new generation endoscopes, which have a USG head installed in their tips or provide special USG probes inserted via a biopsy lumen of both flexible and rigid endoscopes. Such equipment is not widely used by surgeons yet. Its actual utilisation in clinical practice requires from us not only to learn new disciplines but to acquire expertise in interpretation of images which are not available while using standard USG imaging. The same applies to implementing this method for intra-operational procedures. Only a surgeon who possesses sufficient practical experience is able to properly and fully utilise all image interpretation possibilities that are offered by endoscopy and intra-operative ultrasonography.
One can expect considerable profits from the introduction of latest computer-based or aided systems for processing, collecting and presentation of endoscopic images. Technical solutions and computer software which have been already widely applied in digital X-ray imaging equipment - such as DSA, CT or MR, e.g. 2D or 3D reconstruction, zoom or colour-mapping - are only now being introduced to endoscopy. As per today, we can hope that endoscopic images, processed digitally even many hours after an examination, will provide us with new, now unforeseeable diagnostic capabilities. Furthermore, standardisation and unification of DICOM (Digital Imaging and Communication in Medicine) systems, offered by various manufacturers, will not only allow for wider endoscopy applications, but shall enable to instantly transmit endoscopic images via tele-media lines to a reference centre, even hundreds of kilometres away, in order to consult with other specialists and finally diagnose a patient (1,14).
We have presented above only such trends in modern endoscopy development, which either have solid theoretical background or have been preliminarily tested and implemented in real environments. Further mastering of endoscopic methods shall depend also upon surgeons' active participation in this process in a critical and free of fascination manner, so that patient's well-being and health are always prioritised in light of both the merits and safety of modern endoscopic applications to be introduced. Finally, it is imperative to re-evaluate surgeons' approach towards broader utilisation of all already available endoscopic methods in their daily surgical routine. Overall surgery development to implement minimally invasive methods while improving treatment effectiveness, shall be conditional upon the level of surgeons self-engagement and adapting for their treatment ranges all the latest endoscopy, USG and radiology achievements, as well their support with the modern computer-aided techniques and telecommunication tools.

T. Popiela, MD
Ist Dept of General and Gastrointestinal Surgery
Jagiellonian University
Krakow, Poland

REFERENCES

1. Buess G.: Update on clinical aspects and technology in endoscopic surgery. Endoscopy, 1995, 27,6, 449.
2. Donahue P.D., Sugitani A.: Gastrointestinal endoscopy and general surgical practice. Surgical endoscopy versus surgeon endoscopists. Am Surg, 1991,57, 330.
3. Forde K.A.: Minimal access and open surgery. Surg Endosc, 1997, 11, 1063.
4. Greene F.L.: Surgical endoscopy - a worldwide phenomenon. Surg Endosc, 1993, 7, 479.
5. Hirschowitz B.I.: Development and Application of Endoscopy. Gastroenterology, 1993, 104, 337.
6. Mikulicz J.: Przyczynki do chirurgii. Resekcja odzwiernika z powodu raka. Uwagi nad pierwszym objawem raka zoladka za pomoca gastroskopu spostrzegac sie dajacym. Przegl. Lek., 1883, 14, 171.
7. Mikulicz J.: Uber Gastroskopie und Oesophagoskopie. Centralblatt Chirurgie, 1881, 8, 43.
8. Montori A., Viceconte G., Cipriani S., Viceconte G.W.: Follow-up of patients undergoing surgery of the digestive system, using endoscopy. Ann Ital Chir, 1979, 51, 1,27.
9. Montori A., Viceconte G., Viceconte G.W., Bogliolo G.: ERCP and EPT: Italian experience. Endoscopy, 1979, 11, 2, 142.
10. Popiela T.: The Present State and Future of Endoscopic Surgery. Int Surg, 1995, 80, 341.
11. Popiela T., Karcz D., Kulig J.: Significance of intraoperative fiberocholangioscopy in the diagnosis of biliary tract disorders. Endoscopy, 1978, 10, 275.
12. Popiela T., Karcz D., Marecik J.: Endoscopic sphincterotomy as a therapeutic measure in cholangitis and as prophylaxis against recurrent biliary tract stones. Endoscopy, 1987, 19, 14.
13. Popiela T. i wsp.: Long-term results of highly selective vagotomy in the treatment of duodenal ulcer patients using the intraoperative endoscopic Congo Red test to the identify the parietal cell antrum-corpus borderline. Hepato-Gastroenterology, 1993, 40, 267.
14. Satava R.M.: Virtual endoscopy. Diagnosis using 3-D visualization and virtual representation. Surg Endosc, 1996, 10, 173.

Pan American Congresses of Gastroenterology "Gastro Santo Domingo '97"

In Santo Domingo on November 17-21, 1997 were held the Biennial Pan American Congresses of Gastroenterology. The President of the Gastroenterology Conference area was Dr. Plutarco Restituyo whilst of the President of the Endoscopy Congress was Dr. Ariel Ortega.
The Meeting and Post-Graduate Course were sponsored by AIGE and SIED together with the Sociedad Domenicana de Gastroenterologia. Over 1.300 Physicians attended the Meeting thanks to the extremely wide array of topics in Gastroenterology and Hepatology presented by the International Faculty, in fact the Congress was a great success from both the scientific and attendance point of view.
The live demonstration, perfomed by Doctors J.R. Armengol-Mirò, J. Sahel, M. Cremer, J. Way, N. Guelrud, J. Echavarria, P. Restituyo and A. Ortega, highly satisfied the audience.
Dr. Melvin Schapiro, Los Angeles, past President of ASGE, assumed the presidency of SIED from outgoing President Dr. Nestor A. Chopita, Argentina.
Doctor Luis de Paula Castro was elected as President of the Interamerican Gastroenterology Society.
The main goals of Dr. Schapiro will be to fortify SIED's structure as well as forming a local zone concordat with the industry in order to financially strengthen the Society. He will actively collaborate with OMED and its next President Doctor Glaciomar Machado, Brazil, in order to work closely together for the benefit of both endoscopic societies. Ties will also be in increased between SlED and ASGE.
We look forward to the next Pan American Congress to be held in Vancouver, British Columbia, Canada from August 30 to September 2, 1999 where current SIED Treasurer Dr. Segal, Argentina, will become President of SIED, succeeding Dr. Schapiro.

Dr. Plutarco Restituyo - Dr. Ariel Ortega
Presidents

The Multicenter Intestinal Metaplasia/Dysplasia Study

Under the auspices of OMED and its Research Committee, an international multi-center endoscopic epidemiologic research project entitled "A Comparative Study of Intestinal Metaplasia/Dysplasia at the Gastro-esophageal Junction" has been initiated. Conceived during an invited lectureship of the author to Warsaw ad Posnan, Poland in 1996, the study attempts to explain differences between Central Europe and the United States and Western Europe in proximal gastric and esophageal adenocarcinoma. Poland has the highest prevalence of distal gastric cancer in Europe, but reputedly a relatively low incidence of adenocarcinoma of the cardia, the esophagus, and of Barrett's Esophagus. This is felt to be true of most areas of central and Eastern Europe, South America, and Asia. In contrast, the West is experiencing an unprecedented rate of increase of these cancers. In the past two-three decades there has been a dramatic increase in adenocarcinomas of the esophagus (10%/year) and gastric cardia (4-5%/year) in North American and Western Europe making these the most rapidly increasing cancers in these regions. Over one half of esophageal cancers now are adenocarcinoma and over one half of gastric cancers occur in the cardia. These cancers appear to arise in specialized columnar epithelium with goblet cell hyperplasia which is felt to result from gastro-esophageal reflux of gastric and duodenal contents. Since intestinal metaplasia is felt to be the premalignant condition leading to adenocarcinoma of both the cardia and esophagus it seems reasonable to test whether differences in the occurrence of intestinal metaplasia exist or whether a trigger to dysplasia and neoplasia is lacking in Central Europe.
The progression from intestinal metaplasia to increasing degrees of dysplasia and then neoplasia is stepwise and allows endoscopic surveillance.
In the West, intestinal metaplasia at the grastro-esophageal junction is relatively common (15-20%) making recommendations regarding surveillance controversial. To demonstrate: although the cancer risk is greater the longer the segment of Barrett's mucosa, short segment Barrett's is sufficiently more common than long (20 times) that cancer is more likely to occur in short segment Barrett's. Over one-half (1/2) of esophageal cancers are adenocarcinomas and over half of these arise in short segment Barrett's. Gastric cancer is twice (2 times) as common as esophageal cancer and cardia cancer (related to intestinal metaplasia) is over half of gastric cancers. Therefore, surveillance only of long segment Barrett's will miss the large majority of cancers in these areas.
It is hypothesized that reflux esophagitis and the development of intestinal metaplasia are equally as common in other areas as in the West, but that the stimulus to progression to dysplasia/neoplasia is lacking or less common. It is further hypothesized that this stimulus may be the result of chronic medication usage, especially potent acid suppressing compounds which are little used in low prevalence areas for a variety of reason, including financial constraints.
This association between use of acid suppressing drugs and the increasing incidence of esophageal and junctional carcinoma is supported by the closely parallel curves over the past 2-3 decades of rising cancer rates, increased availability and usage of more potent acid secretion inhibitors, and by the reduced cancer risk if medications can be discontinued after effective anti-reflux surgery.
Patient studies by Dr. Svoboda have shown that: 1) non-neoplastic gastric polyps develop in a significant percentage (15%) of Barrett's patients during chronic acid suppression, especially with proton pump inhibitors; 2) that polyps disappear or get smaller with drug discontinuation or dose reduction; 3) most importantly that a high percentage (83%) of Classic Barrett's patients that develop these polyps will also develop dysplastic changes. The importance of determining the role of acid suppressing medications is underscored by recommendations in GERD patients for empirical and prolonged use of these medications often without endoscopic evaluation. With increasing financial constraints in health care, empiric therapy is recommended initially and there is an increasing literature suggesting this early therapeutic intervention should be with a PPI. Successful treatment of Helicobacter pylori increases the risk of GERD and therefore of Barrett's Esophagus. Treatment with PPIs in the presence of Helicobacter pylori increases the risk of gastric atrophy and, by extension, of gastric cancer. Treatment of Barrett's with PPIs may increase the risk of dysplasia.
The study will evolve in two phases. An initial pilot study will involve 50 consecutive admissible patients who are scheduled for upper gastrointestinal endoscopy. Questionnaires include information regarding symptoms, life style, and medication usage. According to protocol, biopsies are obtained from the stomach, the gastroesophageal junction and any abnormal areas. A second cohort of patients from a population excluded because of age, known Barrett's or cancer, have the same information recorded and tissue sampled. Material from both groups are sent to the principal investigator for separate analysis of each cohort. If warranted by the results of the pilot study, the number of admissible patients will be expanded to 300 from each site. With 28 sites in 20 different countries, there is the potential for up to 10,000 patients for analysis and comparisons.
The current study will show the incidence of intestinal metaplasia at the gastro-esophageal junction, the prevalence of long and short segment Barrett's and associated dysplasia, the prevalence of gastric and esophageal cancers in widely disparate endoscopic populations around the world collected from the practices of some of the world's leading clinicians and investigators.

Study Group Participants

The tissue specimens collected lend themselves to staining for genetic changes and determining any influence of Helicobacter pylori. The need for appropriate recommendations regarding surveillance in difference populations may result.
Involvement of the MED Research Committee has had several positive impacts on the study design. These include recognition of the need to involve an epidemiologist, the need for greater diversity of sites, and a willingness of members to participate and lend their support to this international effort. As a result, a number of additional sites and the prestige of their leaders have been added (M. Crespi, Italy; R. Lambert, France; J.F. Reimann, Germany; Fujino, Japan; H. Ben Khalifa, Tunisia; G. Machado, Brazil). Current sites and investigators are appended.
Biopsy slide preparation, hystopathologic interpretation, questionnaire evaluation, computer data entry, statistical analysis, epidemiologic consultation, and scientific overview are all provided at the Sansum Medical Research Foundation in Santa Barbara, CA, USA. Additional financial support has come from the Santa Barbara Cottage Hospital Research Foundation, Santa Barbara, CA.

Albert C. Svoboda Jr., MD
Senior Scientist, Sansum Medical Research Foundation
Santa Barbara, CA, USA

Homage to Professor Francisco Vilardel Madrid 3 April 1998

It is well known that Professor Francisco Vilardell is one of the leaders of worldwide Gastroenterology. Thanks to the initiative of Professor Juan Ramon Armengol-Mirò, a celebration was organised in Madrid on April 3, 1998 in honour of Professor Vilardell. Many of the most prominent clinicians and gastroenterologists were present at the celebration. All the participants emphasised the importance of the role that Professor Vilardell has covered in promoting an implementing worldwide gastroenterology and digestive endoscopy. Among his many recognitions he has been also past President of the ESGE and OMGE.
At the inaugurating ceremony many illustrious Authorities were present, such as the Spanish Minister of Health, His Excellency D. Josè Manuel Romay Beccaria, the Honourable Catalan Health Councillor D. Eduard Rius i Pay, Her Excellency the Health Councillor of CAM, D.a Rosa Posada Chapado, the President of the Health Council Professor J.M. Segovia de Arana.
Also present were Professor Ian Bouchier (President of the OMGE), Professor Massimo Crespi (Acting President of the OMED), Professor Alberto Montori (President elect of the ESGE) Professor Javier Pèrez Piqueras (President of the SEPD), Professor J. Berenguer (President of the AEED).
The celebration was honoured by the presence of Professor Constantine Arvanitakis (Chairman of UEGF), Professor Melvin Schapiro (New President of SIED), Professor Eamonn Quigley (Chairman of the Scientific Committee of OMED), Professor Meinhard Classen (Secretary General of OMGE), Professor Carrilho Ribeiro (President of the Duodenal Club), Professor W. Domschke (Secretary General of the European Gastro Club), Professor Aksel Kruse (Treasurer of the ESGE), Professor Juan Ramon Malagelada (Secretary General of UEGF).
Furthermore during the celebrating day, many scientific papers of great interest were presented by colleagues such as Professors A. Perez Mota, R. Sainz Samitier, J.M. Pajares, J. Balanzò, R. Lambert, M. Diaz Rubio, J. Potel, J. Rodés, J.P. Delmont, R. Esteban, P. Escartin, M.A.Gassul, C. Scarpignato.
The scientific topics discussed were a valid update on the most interesting diseases of gastro-intestinal tract. The celebration day was concluded by a wonderful gala dinner honoring Professor Vilardell who had around him his Colleagues, estimators and devoted pupils.
A particular mention to Professor Juan Ramon Armengol-Mirò, Chairman of the organization of the event, for his outstanding work demonstrating his attachment and esteem to Professor Francisco Vilardell.

Alberto Montori, MD, FACS
ESGE, President Elect

Report from the Second Congress of the Croatian Society of Gastroenterology with International participation

In october 1997, three years after the First, the Second Congress of the Croatian Society of Gastroenterology took place in Zagreb under the auspices of His Excellency Minister of Health of the Republic of Croatia. Scientific Committee represented by Croatian experts of the fields in gastroenterology with Prof. Boris Vucelic?, the President of the Society, as the Chairman, and Prof. Marvin H. Sleisenger, as the Honorary Chairman, tried to cover a wide range of important topics of gastroenterology and endoscopy and review the tremendeous improvement in this field between the two congresses. A great number of invited lecturers from Croatia and many countries of Europe and USA, recognized authorities in their specialties, depictured during four days the state of the art in Croatia and the world.
After the opening ceremony and introduction lectures of exceptional value (AIDS in Gastroenterology, Marvin Sleisenger, San Francisco, USA; Education in Gastroenterology, Massimo Crespi, Rome, Italy; Transplantation in Gastroenterology, Stephen Pollard, Leeds, UK) during the four days the Congress went on with the latest information on inflammatory bowel disease, diseases of the pancreas, oncology, hepatology, disorders of the gastrointestinal motility as well as on ultrasound in clinical gastroenterology.
Endoscopy Section of the Croatian Society of Gastroenterology headed by her President Asocc. Prof. Miroslava Katic?ic?, and with the great assistance of outstanding experts of European Society of Gastrointestinal Endoscopy (ESGE), organized a part of Congress concerning the most important topics of gastrointestinal endoscopy. The most recent achievements in diagnostic and interventional endoscopy method were presented by a number of European and Croatian experts. The special importance of a good education program in grastroenterology and endoscopy, training conditions for obtaining European Diploma of Gastroenterology and recognation of European Centers able to provide the whole education program, were done in the introduction lecture, held by the Italian and world leading expert in this topic, Massimo Crespi, Rome, Italy, acting-president of Organisation Mondiale d'Endoscopie Digestive (OMED). Rules and regulations in endoscopy and European standards for endoscope cleansing were presented by the General Secretary of ESGE, Jean-Francois Rey, Saint-Laurent du Var, France, and patients preparation for endoscopic examination in extenso by Ivo Rotkvic? fromn Zagreb. The methods of variceal and non-variceal gastrointestinal bleeding management were reviewed concisely and precisely by Borut Kocijancic from Ljubljana, Slovenia and Roland Pulanic from Zagreb. The possibilities of endoscopic diagnosis and therapy of small and large bowel diseases were discussed by ESGE President, Fredrich Hagenmüller, Hamburg, Germany. Percutaneous endoscopic gastrostomy and endoscopic management of benign and malignant oesophageal diseases were referred by Milorad Opac?ic? and Tomislav Brkic and laparoscopic methods in gastroenterology by the well known Croatian surgeon Zoran C?ala, Zagreb. The role of endoscoy in the management of complications of surgical procedures was discussed by Milivoj Rubinic, Rijeka, Croatia, and Sania Kolac?ek, a pediatrician from Zagreb, spoke about endoscopy in children. Endoscopic program also encompasses a round table with a theme: Endoscopic diagnostic and therapeutic procedures in pancreatobiliary disorders (moderator: Miroslava Katic?ic?, Zagreb; participants: Andrzej Nowak, Katowice, Poland, ESGE vice-president; Milano Gorens?ek, Bled, Slovenija; Aksel Kruse, Aarhus, Denmark, ESGE treasurer, and Vladimir Supanc, Zagreb). At last, Laszlo Simon, Szekazard, Hungary gave an excellent overview of endoscopic procedures complications.
In Olympus Satellite Symposium "Innovation in Gastrointestinal Endoscopy", Laurent Palazzo, Paris, France, presented current status and future of modern endoscopic ultrasound and Aksel Kruse outlined the new trends and innovation in endoscopy.
During a number of another satellite symposia a lot of gastroenterological themes, in the mid of modern interest, were discussed: Recent advance in therapy of H. Pylori infection (Pliva d.d.), Peptic ulcer disease - Omeprazole in focus (Lek), Recent advances in hepatitis C treatment (Schering-Plough), Cisapride in the treatment of gastrointestinal motility disorder (Krka arma), Therapy of peptic ulcer disease today and tomorrow (Byk Gulden), Clinical nutrition in gastroenterology (Medias-Fresenius).
Approximately 400 participants took part in Congress. Original papers were presented as posters and some of them were chosen for oral presentation.
The last day of Congress the European Association for the Study of the Liver (EASL) organized The Post-Graduate Course in Hepatology: "Complications of liver diseases" with chairmen Juan Rodes, Barcelona, Espana and Boris Vucelic, Zagreb and participants: Peter Scheuer, London, UK; Jaime Bosch, Barcelona, Espana; Andrew K. Burroughs, London, UK; Rajko Ostojic?, Zagreb; Vicente Arroyo, Barcelona, Espana; Petra Steindel, Wien, Austria; Ivo Rotkvic?, Zagreb; Massimo Colombo, Milano, Italy; Nadan Rustemovic, Zagreb; John O'Grady, London, UK; Giovanni Costa, Modena, Italy and Stephen Pollard, Leeds, UK. The main topics were portal hypertension, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatocellular carcinoma, acute liver failure, liver transplantation and artificial liver support.
This very carefully planned and effectively presented program took place in pleasant atmosphere of Sheraton Hotel. Beautiful weather in Zagreb at this time of the year permitted interesting city walking tours. The dinner in the medieval castle Brezovice, nearby Zagreb, gave the opportunity for unforgettable get-together party for all participants. We can conclude that the Second Congress, the first one in the post-war time in Croatia, fullfilled the expectations of organizators and the most of participants. Difficulties that accompany Croatian gastroenterology were pointed out, especially concerning the equipment of particular centers, the problem already known in all countries going through transition. New trends in the development of the field were outlined and hope was laid in the growing international scientific cooperation, as well as in the cooperative enhancement of education and organization in gastroenterology.

Miroslava Katic?ic?, MD
President, Section for Endoscopy
Zagreb, Croatia

Boris Vucelic, MD
Croatian Society for Gastroenterology
Zagreb, Croatia

Transanal Endoscopic Microsurgery (TEM): Technique and Possible Indications in the Treatment of Locally Advanced Rectal Cancer

In 1983 Buess developed a new technique for the endoscopic treatment of rectal tumours, called Transanal Endoscopic Microsurgery (TEM). Such a technique requested the development of dedicated technologies and stille need optimal surgical skills but allows a precise dissection and radical removal of all benign neoplasms and malignant tumours in selected cases. This new approach to local treatment of rectal tumours carries several advantages compared to other local procedures as the Mason or the Parks operations: it allows the removal of very highly located tumours (up to 20 cm from the anal verge) and in the Buess series showed a less postoperative complication and recurrence rate. The precise removal of rectal polyps is necessary both for treatment of early carcinoma or prevention of malignant evolution of an adenoma. Local excision of T1 and T2 invasive rectal carcinoma within 6 cm of the anal verge has been reported resulting in survival and local control comparable to those obtained after more radical and invasive resection. Furthermore a permanent colostomy is avoided. A complete lcoal excision of T1 tumours up to the rectosigmoid junction is nowadays considered as curative as radical surgery.
The use of specially developed technologies allows to achieve a clear view of the rectal lumen during the whole procedure and to perform different operative techniques, from mucosectomy to full tickness dissection with resection of the retrorectal fat. The indication of TEM for cancer are very restricted in the German experience and mainly represented by T1 low risk tumours (according to Hermanek classification).
According to data reported in the international literature concerning local treatment of rectal cancer, the indications of TEM in Italy have been extended to more advaced neoplasms, in association with radio- or radio-chemo-therapy.


Classical indications

Besides sessile adenomas the following classes of rectal cancer represent a referral for TEM:

1. pT1 low risk carcinoma; the operation has a high probability to be curative;
2. pT2 low risk carcinoma; the operation has a limited probability to be curative;
3. pallation in adavanced cancers;
4. unsuspected or previously undetected cancers such as small areas of malignancy in large adenomas.

Technique

Besides the routine diagnostics, the preoperative work-up usually consists of digital examination, rigid rectoscopy, barium encma, computed tomography and endoluminal ultrasound (EUS). MRI with endoluminal coil has been to better assess tumour infiltration. Bowel preparation consists in an orthograde lavage via a gastric tube with 10 1 isotonic saline or Ringer's solution or by assumption of polyethilen glicole the day before surgery. Antibiotic prophylaxis consists in a single shot of metronidazole and one second generation cephalosporin administered at surgery.
The patient is placed on te operating table, depending on the location of tumour, in a lithotomy, prone or lateral setting. The surgeon sits and operate under direct vision through the rectoscope. The assistant sits on his left following the operation on the monitor.
TEM may be performed either under general or regional anaesthesia. Because of uncontrolled movements caused by intraoperative pain sensations, time consuming interventions or operations conducted in the prone patient's setting should be performed under general endotracheal anaesthesia after placement of a urinary catheter.
The TEM procedure is performed via a single access: both the steroscopic telescope and the endoscopic instruments are inserted through the operating 40 mm rectoscope. The stereoscopic telescope allows a three-dimesional view of the operating field. Specially dedicated instruments are necessary for TEM: high-frequency knife, right and left angled graspers and scissors, suction-coagulation, probe, needle holder and clip applier.
The ideal resection line (including suitable margin of clearance) is marked perfoming several coagulation dots around the tumour with the HF knife.
The full thickness technique is only performed in the extraperitoneal part of rectum, hence it is the technique of choice for tumours of the posterior wall up to 20 cm from the dentate line, of the lateral walls up to 15-16 cm from the dentate line, of the anterior wall up to 12 cm from the anocutaneous line. The operation starts grasping the rectal mucosa over a coagulation dot. The HF knife divides in a full thickness fashion the wall with the first stroke. Division is carried on along the lower border of resection. After completion of division of the distal margin, the incision is continued along the lateral aspects and then proximally.
Hence, after lifting upward the transected margins, the tumour's base is exposed. In case of adenomas the dissection is carried on between the outer longitudinal muscle fibres and the perirectal fat. En block resection of perirectal fat is possible for carcinoma located in the posterior and lateral rectal wall. Dissection of the retrorectal fat is performed down to the fascia of Waldeyer. In such cases dissection of incluted lymph nodes is even possible. The segmental full thickness resection of rectum is possible in tumours of its middle third.
Closure of the defect is accomplished performing a transverse continuous suture. A silver clip specially designed not to damage the thread when applied, is pressed onto the thrcad itself to secure the suture at its beginning and end.


Post-operative management

In most cases the postoperative management consists of 2 days of fasting after full thickness excision when the patient is given i.v. fluids; on the third day the patient is given full liquid to house diet and from the forth day onward the discharge is possible. After mucosectomy the patient is given clear liquid on the first postoperative day and regular meals from the second day; the discharge is possible from the third day on. Patients who undergo TEM can get out of bed the same day of the operation.


Extented indications

Local surgery for rectal adenomas has been described by several authors and it is mainly carried out through the endoluminal or the transphinteric approach. Because of the possibility to perform a full-thickness resection and to reach highly located tumours, the transanal endoscopic microsurgical approach has been shown highly effective with very large adenomas which may have areas of degeneration in a high percentage of cases.
Well differentiated T1 adenocarcinomas, well differentiated T2 adeno-carcinomas in elderly patients (>75 years), T2 and T3 adenocarcinomas in high-risk patients (palliation treatment) may be the referrals to TEM for rectal malignancy. In addition to the indications proposed by Bucss and supported by other German Authors, we prefer the association of radio and/or chemo-therapy in locally advanced rectal cancers (T2 - T3, N0). The most important criterion for exclusion is the presence of positive lymph nodes.
The present trend in the Italian centres where such a treatment is mostly performed is to combine high-dose preoperative radiation therapy and full-thickness TEM excision. In these cases, surgery is usually performed 3 to 4 weeks after completion of radiation theraphy.

Marco Maria Lirici, MD
4th Dept of Surgery Università "La Sapienza",
Rome, Italy

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