I coloranti in Endoscopia digestiva - EndoscopiaDigestiva.it
I coloranti in Endoscopia digestiva - EndoscopiaDigestiva.it
I coloranti in Endoscopia digestiva - EndoscopiaDigestiva.it
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I COLORANTI<br />
IN ENDOSCOPIA DIGESTIVA<br />
Felice Cosent<strong>in</strong>o
CROMOENDOSCOPIA<br />
Ida, 1975
ENDOSCOPIA “INCOLORE”<br />
per quasi un ventennio
F<strong>in</strong>e anni ‘90 esplode l’<strong>in</strong>teresse<br />
per la<br />
CROMOENDOSCOPIA<br />
Perché ?
CROMOENDOSCOPIA<br />
1994<br />
Kudo S; J Cl<strong>in</strong> Pat 1994; 47: 880-885<br />
Colorectal Tumors and P<strong>it</strong> Pattern<br />
1977, Kariya<br />
1985, Muto<br />
Diagnosi di Early Colorectal Cancer<br />
< 1 cm<br />
1996<br />
Canto MI; Gastro<strong>in</strong>test Endosc 1996; 44: 1-7<br />
Methylene Blue selectively sta<strong>in</strong> <strong>in</strong>test<strong>in</strong>al metaplasia <strong>in</strong> Battett’s Esophagus.
CROMOENDOSCOPIA
CROMOENDOSCOPIA<br />
2001
2003<br />
Coord<strong>in</strong>atori:<br />
A. Trecca<br />
G. Galloro<br />
Componenti:<br />
M.A. Bianco<br />
F. Cosent<strong>in</strong>o<br />
E. Ricci<br />
USO DEI COLORANTI VITALI E<br />
DELLA COLONSCOPIA A MAGNIFICAZIONE<br />
D’IMMAGINE NELLA DIAGNOSI<br />
E TERAPIA DELLE NEOPLASIE DEL<br />
COLON-RETTO
CROMOENDOSCOPIA<br />
Coloranti v<strong>it</strong>ali<br />
(Lugol, Blu di Metilene, Blu di<br />
Toluid<strong>in</strong>a)<br />
Coloranti reattivi<br />
(Rosso congo)<br />
Coloranti di contrasto<br />
(Indigo carm<strong>in</strong>io)<br />
Coloranti per tatuaggio<br />
(Inchiostro di ch<strong>in</strong>a)
CROMOENDOSCOPIA<br />
Esofago<br />
(Lugol, Blu di Metilene, Blu di<br />
Toluid<strong>in</strong>a)<br />
Stomaco<br />
(Blu di Metilene, Rosso congo)<br />
Duodeno<br />
(Blu di Metilene)<br />
In tutti i distretti:<br />
Inchiostro di Ch<strong>in</strong>a<br />
Colon<br />
(Indaco di Carm<strong>in</strong>io, Blu di Metilene)
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications and Lim<strong>it</strong>ations<br />
Chromoesophagoscopy<br />
Chromogastroscopy<br />
Chromoduodenoscopy<br />
Chromocolonoscopy<br />
Endoscopic Tattoo<strong>in</strong>g
CHROMOESOPHAGOSCOPY<br />
V<strong>it</strong>al sta<strong>in</strong>s<br />
• Lugol’s solution<br />
• Methylene blue<br />
• Toluid<strong>in</strong>e blue<br />
Use<br />
• Sta<strong>in</strong>s glycogen <strong>in</strong><br />
normal squamous<br />
mucosa<br />
• Sta<strong>in</strong>s actively<br />
absorb<strong>in</strong>g ep<strong>it</strong>helium<br />
and metaplastic tissue<br />
• Sta<strong>in</strong>s nuclear material<br />
of malignant ep<strong>it</strong>helial<br />
lesions
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
V<strong>it</strong>al sta<strong>in</strong>s<br />
Cl<strong>in</strong>ical applications<br />
LUGOL’S SOLUTION<br />
Sta<strong>in</strong>s glycogen <strong>in</strong> normal<br />
squamous mucosa<br />
V<strong>it</strong>al sta<strong>in</strong><strong>in</strong>g: Dark brown<br />
Technique<br />
Removal of surface mucus w<strong>it</strong>h 15%<br />
solution on N-acetylcyste<strong>in</strong>e by<br />
spray<strong>in</strong>g <strong>it</strong> w<strong>it</strong>h a special wash<strong>in</strong>g<br />
catheter.<br />
Next a 1-2% of Lugol’s solution is<br />
sprayed (5-10 ml)
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
V<strong>it</strong>al sta<strong>in</strong>s<br />
Cl<strong>in</strong>ical applications<br />
LUGOL’S SOLUTION<br />
V<strong>it</strong>al sta<strong>in</strong><strong>in</strong>g: Dark brown<br />
(sens<strong>it</strong>iv<strong>it</strong>y 89% - specific<strong>it</strong>y 93% )<br />
Barrett’s esophagus<br />
(non sta<strong>in</strong><strong>in</strong>g)<br />
Esophageal cancer<br />
(non sta<strong>in</strong><strong>in</strong>g)<br />
Reflux esophag<strong>it</strong>is<br />
(non sta<strong>in</strong><strong>in</strong>g)
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
V<strong>it</strong>al sta<strong>in</strong>s<br />
Cl<strong>in</strong>ical applications<br />
LUGOL’S SOLUTION<br />
Sta<strong>in</strong>s glycogen <strong>in</strong> normal<br />
squamous mucosa<br />
V<strong>it</strong>al sta<strong>in</strong><strong>in</strong>g: Dark brown<br />
Barrett’s esophagus<br />
(non sta<strong>in</strong><strong>in</strong>g)<br />
Esophageal cancer<br />
(non sta<strong>in</strong><strong>in</strong>g)<br />
Reflux esophag<strong>it</strong>is<br />
(non sta<strong>in</strong><strong>in</strong>g)
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
V<strong>it</strong>al sta<strong>in</strong>s<br />
Cl<strong>in</strong>ical applications<br />
LUGOL’S SOLUTION<br />
Sta<strong>in</strong>s glycogen <strong>in</strong> normal<br />
squamous mucosa<br />
V<strong>it</strong>al sta<strong>in</strong><strong>in</strong>g: Dark brown<br />
Barrett’s esophagus<br />
(non sta<strong>in</strong><strong>in</strong>g)<br />
Esophageal cancer<br />
(non sta<strong>in</strong><strong>in</strong>g)<br />
Reflux esophag<strong>it</strong>is<br />
(non sta<strong>in</strong><strong>in</strong>g)
LUGOL’S SOLUTION<br />
<strong>in</strong><br />
Barrett’s Esophagus
CHROMOESOPHAGOSCOPY<br />
V<strong>it</strong>al sta<strong>in</strong>s<br />
Use<br />
• Lugol’s solution<br />
• Toluid<strong>in</strong>e blue<br />
• Methylene blue<br />
• Sta<strong>in</strong>s glycogen <strong>in</strong> normal<br />
squamous mucosa<br />
• Sta<strong>in</strong>s nuclear material of<br />
malignant ep<strong>it</strong>helial lesions<br />
• Sta<strong>in</strong>s actively absorb<strong>in</strong>g<br />
ep<strong>it</strong>helium and metaplastic<br />
tissue
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
TOLUIDINE BLUE<br />
1 -2%<br />
V<strong>it</strong>al sta<strong>in</strong><strong>in</strong>g<br />
blue<br />
Squamous cell carc<strong>in</strong>oma<br />
of the esophagus<br />
Gastric metaplasia <strong>in</strong><br />
Barrett’s esophagus
CHROMOESOPHAGOSCOPY<br />
Toluid<strong>in</strong>e blue<br />
TB can sta<strong>in</strong> columnar-type mucosa <strong>in</strong><br />
Barrett’s esophagus, but <strong>it</strong> cannot discrim<strong>in</strong>ate<br />
between gastric and <strong>in</strong>test<strong>in</strong>al metaplasia<br />
(sens<strong>it</strong>iv<strong>it</strong>y 98% - specific<strong>it</strong>y 80%)<br />
Canto MI, Gastro<strong>in</strong>test Endosc 1996; 44:1-7
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOESOPHAGOSCOPY<br />
Toluid<strong>in</strong>e blue<br />
“as screen<strong>in</strong>g test for squamous cell carc<strong>in</strong>oma”
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOESOPHAGOSCOPY<br />
Toluid<strong>in</strong>e blue
CHROMOESOPHAGOSCOPY<br />
V<strong>it</strong>al sta<strong>in</strong>s<br />
Use<br />
• Lugol’s solution<br />
• Toluid<strong>in</strong>e blue<br />
• Methylene blue<br />
• Sta<strong>in</strong>s glycogen <strong>in</strong><br />
normal squamous<br />
mucosa<br />
• Sta<strong>in</strong>s nuclear material<br />
of malignant ep<strong>it</strong>helial<br />
lesions<br />
• Sta<strong>in</strong>s actively absorb<strong>in</strong>g<br />
ep<strong>it</strong>helium and<br />
metaplastic tissue
CROMOENDOSCOPIA<br />
Blu di Metilene<br />
(colorante v<strong>it</strong>ale)<br />
Modal<strong>it</strong>à d’azione<br />
•Concentrazione 0,1 – 1%<br />
•Colora <strong>in</strong> blu le cellule ep<strong>it</strong>eliali<br />
di tipo assorbente (piccolo <strong>in</strong>test<strong>in</strong>o, colon) e<br />
la metaplasia <strong>in</strong>test<strong>in</strong>ale a livello gastrico<br />
•Elim<strong>in</strong>azione per via renale<br />
•Non effetti collaterali
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOESOPHAGOSCOPY<br />
Methylene blue selectively sta<strong>in</strong>s<br />
<strong>in</strong>test<strong>in</strong>al metaplasia <strong>in</strong><br />
Barrett’s oesophagus<br />
Canto MI, Setrakian S, Petras RE, et al<br />
Gastro<strong>in</strong>test Endosc 1996; 44:1-7.
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Methylene blue -Cl<strong>in</strong>ical applications<br />
Barrett’s esophagus<br />
Methylene Blue 0,5-1%
Methylene blue<br />
Interpetation of Sta<strong>in</strong><strong>in</strong>g<br />
The pattern of MB sta<strong>in</strong><strong>in</strong>g may be diffuse (longsegment<br />
Barrett) or focal (short-segment Barrett).<br />
Canto MI - Endoscopy 2002; 34:330-336<br />
MB chromoendoscopy significantly <strong>in</strong>crease the<br />
detenction on IM <strong>in</strong> patients w<strong>it</strong>h suspected SSBE,<br />
especially those w<strong>it</strong>h greater than 1 cm of appear<strong>in</strong>g<br />
mucosa <strong>in</strong> the distal esophagus.<br />
P. Sharma e coll.<br />
Gastro<strong>in</strong>test Endosc 2001; 54:289-93
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOESOPHAGOSCOPY<br />
Methylene blue<br />
The accuracy and cost-effectiveness of<br />
methylene blue-directed biopsies for detect<strong>in</strong>g<br />
<strong>in</strong>test<strong>in</strong>al metaplasia and dysplasia/cancer were<br />
significantly greater than 4-quadrant, jumbo<br />
random biopsies <strong>in</strong> a randomized controlled<br />
sequential study.<br />
Canto MI, Gastro<strong>in</strong>test Endosc 1996; 43:165<br />
(1999-2001)
Methylene blue<br />
Interpetation of Sta<strong>in</strong><strong>in</strong>g<br />
Dysplastic or malignant Barrett’s esophagus results<br />
<strong>in</strong> the endoscopic appearance of focal light-blue<br />
or p<strong>in</strong>k (unsta<strong>in</strong>ed) or heterogeneously sta<strong>in</strong>ed mucosa.<br />
Canto MI - Endoscopy 2002; 34:330-336
Classification<br />
of Barrett,s<br />
ep<strong>it</strong>helium by<br />
magnify<strong>in</strong>g<br />
endoscopy<br />
T. Endo<br />
Gastro<strong>in</strong>test Endosc 2002; 55:641-7
Chromogastroscopy<br />
Methylene Blue<br />
Congo Red<br />
Indigo carm<strong>in</strong>e
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOGASTROSCOPY<br />
Methylene Blue<br />
“Sta<strong>in</strong>s actively absorb<strong>in</strong>g ep<strong>it</strong>helium and<br />
metaplastic tissue”<br />
It has been used to pos<strong>it</strong>ively sta<strong>in</strong> metaplastic absorptive<br />
ep<strong>it</strong>helium, such as <strong>in</strong>test<strong>in</strong>al -type metaplasia <strong>in</strong> the<br />
stomach.<br />
The technique of MB sta<strong>in</strong><strong>in</strong>g was orig<strong>in</strong>ally described<br />
by Japanese <strong>in</strong>vestigators for improv<strong>in</strong>g the diagnosis of<br />
early gastric cancer.<br />
Fennerty MB, Gastro<strong>in</strong>tes Endosc. 1992; 38:696-8<br />
Tatsuta M, Endoscopy 1984; 16: 131-134
Intest<strong>in</strong>al metaplasia<br />
A. Grassi
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CONGO RED<br />
0,3%<br />
Reactive sta<strong>in</strong><strong>in</strong>g<br />
(pH <strong>in</strong>dicator)<br />
turns red to dark blue or<br />
black<br />
• Acid-secret<strong>in</strong>g<br />
gastric mucosa<br />
(<strong>in</strong>clud<strong>in</strong>g ectopic<br />
locations)<br />
• Gastric cancer<br />
(non sta<strong>in</strong><strong>in</strong>g)
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOGASTROSCOPY<br />
Congo Red<br />
“To def<strong>in</strong>e acid-secretion area”<br />
Tatsuta M, Endoscopy, 1984; 16:131-134
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOGASTROSCOPY<br />
Congo Red<br />
M. Mar<strong>in</strong>i
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOGASTROSCOPY<br />
Methylene Blue-Congo Red<br />
The comb<strong>in</strong>ation of MB and CR has been<br />
described as be<strong>in</strong>g useful for detection of<br />
m<strong>in</strong>ute or synchronous gastric cancer<br />
Tatsuta M, Endoscopy, 1984; 16:131-134
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
INDIGO CARMINE<br />
0,1 -1%<br />
Contrast Sta<strong>in</strong><br />
blu (<strong>in</strong>digo)<br />
• Colon, gastric,<br />
duodenal, esophageal<br />
lesions<br />
• Barrett’s esophagus
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMOGASTROSCOPY<br />
Indigo carm<strong>in</strong>e 0,1 -1%<br />
“For contrast topography”<br />
M. Mar<strong>in</strong>i
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications and Lim<strong>it</strong>ations<br />
Chromoesophagoscopy<br />
Chromogastroscopy<br />
Chromoduodenoscopy<br />
Chromocolonoscopy<br />
Endoscopic Tattoo<strong>in</strong>g
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications<br />
CHROMODUODENOSCOPY<br />
Methylene Blue/Indigo carm<strong>in</strong>e<br />
Both dyes were used for v<strong>it</strong>al sta<strong>in</strong><strong>in</strong>g and<br />
surface sta<strong>in</strong><strong>in</strong>g.<br />
Today there is a low <strong>in</strong>terest for the duodenal<br />
chromoscopy.<br />
Kohli Y, Endoscopy, 6: 105-110, 1974
Sta<strong>in</strong><strong>in</strong>g <strong>in</strong> Gastro<strong>in</strong>test<strong>in</strong>al Endoscopy<br />
Cl<strong>in</strong>ical applications and Lim<strong>it</strong>ations<br />
Chromoesophagoscopy<br />
Chromogastroscopy<br />
Chromoduodenoscopy<br />
Chromocolonoscopy<br />
Endoscopic Tattoo<strong>in</strong>g
Cromocolonscopia<br />
I <strong>coloranti</strong><br />
Blu di Metilene<br />
Indaco di carm<strong>in</strong>io<br />
Crystal Violet – Cresyl violet<br />
Inchiostro di Ch<strong>in</strong>a<br />
(Blu di Metilene)
Impiego cl<strong>in</strong>ico<br />
CROMOCOLONOSCOPIA<br />
Blu di Metilene<br />
Valutazione del grado di funzional<strong>it</strong>à dell’ep<strong>it</strong>elio<br />
<strong>in</strong> corso di Malattia Infiammatoria Cronica<br />
Diagnosi precoce di lesioni neoplastiche<br />
nella RCU cronica<br />
Kiesslich R, Gastroenterology 2003; 14:880-888
CROMOCOLONOSCOPIA<br />
Indaco di Carm<strong>in</strong>io<br />
(colorante di contrasto)<br />
Modal<strong>it</strong>à d’azione<br />
•Concentrazione 0,1 – 0,4%<br />
•Colora (blu) le normali aree di depressione della mucosa e<br />
le zone patologiche migliorando la visione endoscopica<br />
•Effetto molto breve - Elim<strong>in</strong>azione per via renale<br />
•Non effetti collaterali<br />
Impiego cl<strong>in</strong>ico<br />
Studio della superficie mucosa<br />
Studio delle formazioni polipose
Modal<strong>it</strong>à d’impiego<br />
CROMOCOLONOSCOPIA<br />
Indaco di Carm<strong>in</strong>io<br />
Elim<strong>in</strong>azione muco e residui fecali dalla zona da esam<strong>in</strong>are<br />
Diffusione del colorante mediante<br />
catetere spray …oppure<br />
Diffusione del colorante mediante sir<strong>in</strong>ga collegata al canale operatore<br />
ATTENZIONE: non eseguire con forza il lavaggio sulla lesione !
CROMOCOLONOSCOPIA<br />
Indaco di Carm<strong>in</strong>io<br />
Impiego cl<strong>in</strong>ico<br />
Studio della superficie mucosa
Impiego cl<strong>in</strong>ico<br />
CROMOCOLONOSCOPIA<br />
Indaco di Carm<strong>in</strong>io<br />
Valutazione estensione delle formazioni polipose<br />
e caratteristiche della loro superficie (“P<strong>it</strong> pattern”)
G.Gizzi<br />
The p<strong>it</strong>s of the normal mucosa are round<br />
and regular <strong>in</strong> size and arrangement<br />
The p<strong>it</strong>s of non-neoplastic, hyperplastic<br />
polyps are larger than the normal p<strong>it</strong>s, and<br />
star-shaped but regularly arranged<br />
In polypoid adenomas the p<strong>it</strong>s often<br />
look elongated<br />
“P<strong>it</strong> Pattern”<br />
Classification<br />
Lesions w<strong>it</strong>h compactly arranged p<strong>it</strong>s smaller<br />
than normal ones are characteristically<br />
depressed and tend to be early cancers.<br />
In polypoid adenomas the p<strong>it</strong>s sometimes<br />
look branched<br />
The p<strong>it</strong> pattern <strong>in</strong> <strong>in</strong>tramucosal cancer or<br />
<strong>in</strong>vasive cancer range from the fairly<br />
Irregular to non-structural pattern.
CROMOCOLONOSCOPIA<br />
Crystal violet - Violetto di genziana<br />
(Colorante v<strong>it</strong>ale)<br />
Impiego cl<strong>in</strong>ico<br />
Studio <strong>in</strong> associazione alla magnificazione<br />
nei casi di difficoltà nella valutazione del<br />
“p<strong>it</strong> patternes”<br />
Modal<strong>it</strong>à d’azione<br />
• Concentrazione 0,2% -Effetto cromatico entro 2-3 mn<br />
• Colora (viola) lo sbocco delle ghiandole del Lieberkuhn<br />
• Probabili effetti c<strong>it</strong>otossici
Indaco di Carm<strong>in</strong>io + Crystal violet<br />
1. <strong>Endoscopia</strong> convenzionale<br />
2. Lavaggio<br />
3. Indaco di Carm<strong>in</strong>io (0.2%)<br />
4. Magnificazione<br />
5. Crystal violet (0.2%)<br />
6. Magnificazione<br />
1<br />
2<br />
Conventional endoscopy<br />
3<br />
4<br />
5
VISIONE ORDINARIA<br />
BASSA MAGNIFICAZIONE<br />
INDACO CARMINIO<br />
ALTA MAGNIFICAZIONE<br />
INDACO CARMINIO<br />
ALTA MAGNIFICAZIONE<br />
CRISTAL VIOLETTO
CROMOCOLONOSCOPIA<br />
Indaco di Carm<strong>in</strong>io<br />
Altro utilizzo ….<br />
Impiego nella tecnica di “mucosectomia”
CROMOCOLONOSCOPIA<br />
… ma una volta rimossa la lesione ricordiamoci<br />
di marcarla con l’INCHIOSTRO DI CHINA !!!<br />
Impiego <strong>in</strong> tutti i distretti. Ch<strong>in</strong>a sterile dilu<strong>it</strong>a 1:10<br />
<strong>in</strong> fisiologica. Utilizzata (<strong>in</strong>filtrazione con ago)<br />
per marcare <strong>in</strong> modo permanente un segmento <strong>in</strong>test<strong>in</strong>ale
Chromoendoscopy<br />
High Resolution Endoscopy<br />
Zoom Endoscopy<br />
Magnification Endoscopy<br />
Mucosectomia<br />
Curios<strong>it</strong>à per gli addetti ai lavori<br />
o metodica di rout<strong>in</strong>e?
Chromoendoscopy<br />
High Resolution Endoscopy<br />
Zoom Endoscopy<br />
Magnification Endoscopy
L’evoluzione<br />
nella tecnologia<br />
1980<br />
Fibroendoscopia<br />
ENDOSCOPIA<br />
1990<br />
Videoendoscopia (convenzionale)<br />
CCD con 100/300 K pixels<br />
2000<br />
Videoendoscopia (Alta risoluzione)<br />
CCD con 450/800 K pixels
Chromoendoscopy<br />
High Resolution Endoscopy<br />
Zoom Endoscopy<br />
Magnification Endoscopy
Zoom Endoscopy<br />
Alcuni endoscopi ad “alta risoluzione” sono dotati di uno zoom<br />
ottico che consente, modificando la distanza focale, un particolare<br />
<strong>in</strong>grandimento della visione endoscopica (150x).<br />
Successivamente l’immag<strong>in</strong>e viene registrata sul CCD.
Chromoendoscopy<br />
High Resolution Endoscopy<br />
Zoom Endoscopy<br />
Magnification Endoscopy
Magnify<strong>in</strong>g Endoscopy<br />
La Magnify<strong>in</strong>g Endoscopy sfrutta una tecnica<br />
(software di manipolazione dig<strong>it</strong>ale) <strong>in</strong> grado di<br />
<strong>in</strong>grandire un’immag<strong>in</strong>e registrata<br />
precedentemente dal CCD <strong>in</strong> dimensioni reali.<br />
Qu<strong>in</strong>di si tratta di un’immag<strong>in</strong>e ottenuta<br />
attraverso l’<strong>in</strong>grandimento dei vari pixels …<br />
…e il risultato, a forte <strong>in</strong>grandimento, è lo<br />
sgranamento dell’immag<strong>in</strong>e stessa e non<br />
l’acquisizione di maggiori particolari !
La migliore “magnificazione”<br />
viene qu<strong>in</strong>di data da…<br />
Videoendoscopi con<br />
“zoom ottico”<br />
(o zoom ottico + elettronico)<br />
Altre variabili che condizionano la qual<strong>it</strong>à dell’immag<strong>in</strong>e:<br />
caratteristiche del CCD – profond<strong>it</strong>à di colore
Magnify<strong>in</strong>g Endoscopy<br />
Tuttavia, nel gergo corrente il term<strong>in</strong>e<br />
“magnificazione” (anche se<br />
erroneamente) viene <strong>in</strong>differentemente<br />
utilizzato sia che si tratti di<br />
<strong>in</strong>grandimento ottico, elettronico o<br />
misto.
Ma perché tanto <strong>in</strong>teresse<br />
verso tali tecnologie ?<br />
Per lo studio delle<br />
lesioni precancerose …<br />
…. <strong>in</strong> quanto la prognosi dei tumori gastro<strong>in</strong>test<strong>in</strong>ali<br />
è strettamente legata alla diagnosi precoce delle<br />
lesioni precancerose e dei tumori <strong>in</strong> fase <strong>in</strong>iziale.
Il “nuovo concetto” dei tumori<br />
colo-rettali non polipoidi<br />
Fujii T, Endoscopy 2001; 33:1036<br />
Adenoma piatto<br />
Early Colorectal Cancer <strong>in</strong> Giappone<br />
dal1962 al1971<br />
3%<br />
dal1992 al1999<br />
18%
Evoluzione del cancro colorettale:<br />
“Mounta<strong>in</strong> Route and Direct Route”<br />
“de novo” carc<strong>in</strong>oma<br />
Il cancro colorettale “early” di tipo<br />
depresso ha un alto potenziale di<br />
malign<strong>it</strong>à e di <strong>in</strong>vasiv<strong>it</strong>à anche se di<br />
piccole dimensioni.<br />
Per cui vanno adottate tecniche<br />
adeguate di rimozione endoscopica<br />
per una corretta diagnosi istopatologica
Rischio di metastasi l<strong>in</strong>fonodali correlato<br />
al grado di <strong>in</strong>vasione sottomucosa<br />
PROFONDITA’<br />
TUMORE<br />
M<br />
SM 1<br />
SM 2 - SM 3<br />
MUSC<br />
%<br />
METASTAS. LINF.<br />
0 - 2<br />
0 - 3<br />
10 - 14<br />
40 - 83<br />
Kudo ‘98
Endoscopic Mucosal Resection<br />
EMR<br />
Tada, ’84<br />
Makuuchi, ‘88
Endoscopic Mucosal Resection<br />
EMR<br />
Tada, ’84<br />
Makuuchi, ‘88
Endoscopic Mucosal Resection<br />
“LIFT-AND-CUT”<br />
(strip biopsy)
Endoscopic Mucosal Resection<br />
Tori, ‘95<br />
“SUCK-AND-CUT”<br />
Colon ?
Chromoendoscopy<br />
High Resolution Endoscopy<br />
Zoom Endoscopy<br />
Magnification Endoscopy<br />
Mucosectomia<br />
Curios<strong>it</strong>à per gli addetti ai lavori<br />
o metodica di rout<strong>in</strong>e?
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