Endoscopy procedures

Endoscopy  means looking inside and typically refers to looking inside the body for medical reasons using an endoscope, an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ. Endoscopy can also refer to using a borescope in technical situations where direct line of-sight observation is not feasible.




The emergence of optic fibres and cold light has revolutionised the endoscopic approach to tumours. Examinations, which in the past were painful, are now easy to perform, well tolerated and allow the clear exploration of airways (laryngoscopy, bronchoscopy), digestive tract (oesophagoscopy, gastroscopy, colonoscopy, rectoscopy), urinary tract (cystoscopy, ureteroscopy), genital apparatus (hysteroscopy), under local or general anaesthesia which can be repeated if necessary.

All of these examinations enable a precise description of the tumour but, more importantly, offer the possibility of performing biopsies to obtain pathological diagnosis before any radical treatment. In combination with an ultrasonographic probe, they study the extent of tumour invasion (which is necessary for most classifications) and look for nearby satellite nodes.

Other more complex examinations require general anaesthesia and are performed to obtain a biopsy sample in a less traumatic manner than via surgical exploration: mediastinoscopy, pleuroscopy, laparoscopy, arthroscopy.

The use of a television camera allows a better description of the lesion and offers the possibility of involving several physicians in the endoscopic exploration.

Abdominal surgery through laparoscopy has not yet totally proved its worth in oncology, except for very limited tumours or in a diagnostic setting (such as lymphadenectomy by coelioscopy). It requires a very well trained surgeon and team. The risk of cancer diffusion along the puncture openings is promoted by intraabdominal hyperpressure and clear, carcinologically satisfactory surgery may be difficult to prove (cf. definition of complete carcinological surgery). The use of a robot could be of great interest for other laparoscopic surgical acts (urology, gynaecology) although its cost-effectiveness has not yet been demonstrated.

Oesophageal endoscopy,
Gastric endoscopy,
Colic endoscopy,
ORL endoscopy,
Urinary endoscopy.

Oesophageal endoscopy:

Oesophageal endoscopy has become the diagnostic cornerstone of oesophageal cancer. The macroscopic aspect discovered during endoscopy as well as the biopsy performed during this examination lead to confirmed diagnosis.

With optic fibre technology, endoscopy has become a generally well tolerated examination (with the exception of cases of very severe dysphagia) which, in most cases, does not require general anaesthesia. The patient should be fasted and may receive a light sedation.

The three images below are typical of oesophageal cancer:
 
                           malpighian cancer with complete oesophageal obstruction, 
                           another malpighian cancer,
                           cancer of oesogastric junction (Barrett's adenocarcinoma).

The use of echoendoscopy is a new development in oesophageal endoscopy; i.e. the possibility of studying the depth of tumour infiltration and detecting pathological juxtatumoral nodes, thus assisting the surgical decision.

Another important technique is the use of endoprostheses or stents (see palliative care chapter), particularly when there is a risk of (or an already confirmed) oesotracheal fistula in order to limit the invalidating coughing each time the patient swallows, as well as pulmonary infections.

Gastric endoscopy:

Gastric endoscopy is an easy and efficient diagnostic tool for gastric carcinoma. Particularly in ulcerous forms where diagnosis is revealed by ulcer like symptomes, border ulcer biopsies are very conclusive.

Histological forms other than adenocarcinoma may be observed with particular endoscopic aspects.

Endoscopic examination is generally very well tolerated by the patient, except when major vomiting occurs due to tumour stenosis (prepyloric cancer), when a major deterioration of the general status has already occurred or when intense anaemia necessitates short, intensive haematological rehabilitation before the examination.

Occasionally, endoscopy may be performed during bleeding which can obscure correct observation.
Below are a few typical images of gastric tumours:
               
Superficial gastric tumour:   Seventy-two-year-old male patient with ill-defined abdominal pains. Gastric fibroscopy showed a barely perceptible uprising of 2 to 3 cm on the posterior verge of the distal part of stomach. The picture shows antrum and pylorus. Biopsies revealed an adenocarcinoma. The patient was operated on and the final histological report confirmed an intramucous carcinoma with no muscularis mucosae invasion.
                                           

                                                                             Gastroscopy  
Malignant gastric ulcer:  Fifty-two-year-old female patient with atypical abdominal pains which might evoke a gastric ulcer. During fibroscopy, the ulcer lesion showed raised limits, the biopsy of which revealed a poorly differentiated adenocarcinoma.

                                                                         Gastroscopy

   
Undifferentiated gastric adenocarcinoma:   Eighty-two-year-old female patient suffering from precocious satiety and postprandial vomiting with massive weight loss and anaemia, suggesting a gastric obstruction. Gastric fibroscopy revealed an ulcerated mass with large folds. Histology showed an undifferentiated adenocarcinoma with signet ring cells.

                                                                                Gastroscopy  

Ulcerating malignant lesion:  Forty-six-year-old male patient who abruptly suffered from violent epigastric pain. Paraclinical analysis revealed iron deficiency and blood in the stools. Fibroscopy showed an ulcer lesion on the small bend of the stomach, with peripheral oedema. The biopsy of the ulcer edges revealed a poorly differentiated gastric adenocarcinoma.

 Linitis plastica:   Seventy-six-year-old female patient who progressively lost her appetite and consequently lost weight. The gastric walls appear thick and the stomach does not distend when air is injected through the fibroscope. Biopsies confirmed the suspected poorly differentiated infiltrating adenocarcinoma.

   
Gastric lymphoma:  Fifty-one-year-old male patient with previously treated nasopharyngeal lymphoma. The patient began to suffer from pyrosis and painful dysphagia suggesting an oesophageal pathology. The endoscopy revealed no oesophageal abnormality, but a tumour lesion infiltrating almost the entire gastric wall, with ulcerations seen in some areas (right picture) and other areas only raised (left picture). Biopsies revealed a gastric lymphoma which required a new chemotherapy regimen.
 

MALT lymphoma:  Eighty-three-year-old female patient suffering from hypochromic sideropenic anaemia with no other symptoms. Gastric endoscopy showed numerous ulcerations of the gastric wall, with slightly raised tissue around them. Biopsies revealed a lymphoid infiltrate related to a low-grade mucosa associated lymphoid tissue (MALT) lymphoma. No helicobacter pylori could be identified.