Volume 69 - 2006 - Fasc.3 - Symposium
Rationale to integrate comprehensive geriatric assessment for older olds pre- senting gastro-intestinal disorders
The prevalence of chronic gastrointestinal symptoms is under- estimated. However, complaints consistent with functional gas- trointestinal disorders are common in the elderly, but symptoms are a poor predictor of presentation for medical care. Moreover, chronic colonic symptoms appear to interfere with daily living and quality of life in the elderly. Clinicians are questioning about the diagnostic management of frail older adults presenting these com- mon and non specific symptoms. This paper proposes a definition of the "geriatric patient" and gives an overview of recently pub- lished literature concerning the concept of comprehensive geri- atric assessment. The rationale to integrate comprehensive geri- atric assessment for older adults presenting gastro-intestinal dis- orders is pointed out. (Acta gastroenterol. belg., 2006, 69, 283-286).
Colopathies of the old adults
The increase of life-time together with the improvement of the social, sanitary and medical cares lead to the apparition of a cohort of «very old» subjects. The prevalence of symptoms com- patible with colopathies among the olders is impressive. The spec- trum of large bowel disease in the elderly is essentially similar to that found at a younger age but the incidence of some diseases increases with age. This review presents the specificity of colopathies of the olders and focuses on the following medical topics : irritable bowel disease (IBS), clostridium colitis, ischemic disease, iatrogenous disorders. The specificity of the "geriatric" patients should be integrated into diagnosis and clinical manage- ment. (Acta gastroenterol. belg., 2006, 69, 287-295).
Ageing and the liver
Age does not spare the liver. We reviewed here the essential actu- al knowledge about age related modifications of this organ. Liver volume and blood flow decrease with age. Aging is also associated with a decline in the intrinsic metabolic activity of the hepatic parenchyma, and in the gene expression of proteins involved in intermediary metabolism, mitochondrial respiration and drug metabolism. Aged hepatocytes accumulate oxydative DNA dam- age, responsible for the increase in mutations, particularly in the mitochondrial genome. Histologically, aged hepatocytes are char- acterized by accumulation of ageing pigments into the cytoplasm and by pseudocapillarization of the sinusoid. Age is also of impor- tance at the time of HCV infection : fibrosis progression is faster when the virus is acquired after 40 years. In liver transplantation, an old transplanted liver is now an identified cause of primary non-function of the graft and an independent cause of mortality after transplantation. The age of the donor is also a predictive fac- tor of the severity of recurrent liver HCV-related disease on the graft. (Acta gastroenterol. belg., 2006, 69, 296-298).
Endoscopic removal or ablation of oesophageal and gastric superficial tumours
Endoscopic mucosal resection was developed in Eastern coun- tries as a curative treatment for superficial carcinomas in the stomach and oesophagus. Experience in Western countries is more recent and limited due to less frequent diagnosis of early gastric cancers compared to the Japanese and Korean populations and to more frequent use of ablation techniques such as argon plasma coagulation and photodynamic therapy in pre-neoplastic lesions and superficial tumours. This review summarizes the respective indications, advantages, disadvantages, limitations and complica- tions of the different ablative and resection techniques in the upper gastrointestinal tract. Several methods are described such as electrocoagulation, argon plasma coagulation, photodynamic therapy, lift and cut resection, cap assisted aspiration and band ligation mucosectomy, and endoscopic submucosal dissection. Local results in more than 170 patients managed with endoscopic resection of oesophageal high grade dysplasia or squamous cell carcinoma and gastric or Barrett's epithelium high grade dyspla- sia or adenocarcinoma furthermore demonstrate the safety and effectiveness of endoscopic resection practiced in experienced cen- tres. (Acta gastroenterol. belg., 2006, 69, 304-311).
Rationale to integrate comprehensive geriatric assessment for older olds pre- senting gastro-intestinal disorders
The prevalence of chronic gastrointestinal symptoms is under- estimated. However, complaints consistent with functional gas- trointestinal disorders are common in the elderly, but symptoms are a poor predictor of presentation for medical care. Moreover, chronic colonic symptoms appear to interfere with daily living and quality of life in the elderly. Clinicians are questioning about the diagnostic management of frail older adults presenting these com- mon and non specific symptoms. This paper proposes a definition of the "geriatric patient" and gives an overview of recently pub- lished literature concerning the concept of comprehensive geri- atric assessment. The rationale to integrate comprehensive geri- atric assessment for older adults presenting gastro-intestinal dis- orders is pointed out. (Acta gastroenterol. belg., 2006, 69, 300-303).
Early esophageal and gastric cancers : surgery in the era of minimally invasive treatment
Surgery represents today the standard treatment of oesophageal and gastric cancer. Associated morbidity remain however signifi- cant in term of incisional access and functional sequels after organ resection and extended lymphadenectomy. Retrospective reviews of surgical series have defined indications for which more conser- vative treatment appears to provide similar survival without the need for lymph node resection. Endoscopic resection is now accepted for the treatment of well-differentiated tumors restricted to the mucosa. The expansion of this technique to deeper lesions or to lesions developed on a background of metaplasia is associated with an increased morbidity and significant risk of recurrence as well as a lifelong, close endoscopic surveillance. The role of surgery as primary treatment or rescue therapy to extend the resection will rely on an accurate preoperative and pathological staging of the lesion. Laparoscopy can play a central role in the management of early oesophageal and gastric cancer as it can permit from localized to extensive resection associated to lymph node dissection with the advantage of minimal invasive surgery. Its association to function-preserving operations awaits the demonstrated efficacy of targeted lymph node dissection. Those new techniques should be restricted to centres with extensive expertise and need to be validated in long-term controlled studies. (Acta gastroenterol. belg., 2006, 69, 312-316).
Colopathies of the old adults
The increase of life-time together with the improvement of the social, sanitary and medical cares lead to the apparition of a cohort of «very old» subjects. The prevalence of symptoms com- patible with colopathies among the olders is impressive. The spec- trum of large bowel disease in the elderly is essentially similar to that found at a younger age but the incidence of some diseases increases with age. This review presents the specificity of colopathies of the olders and focuses the following medical topics : irritable bowel disease (IBS), clostridium colitis, ischemic disease, iatrogenous disorders. The specificity of the "geriatric" patients should be integrated into diagnosis and clinical management. (Acta gastroenterol. belg., 2006, 69, 304-312).
Ethical aspects of percutaneous endoscopic gastrostomy placement for artificial nutrition and hydratation
Of the many decisions that family members and physicians must make about medical care in patients with advanced disease and perceived poor quality of life, none is more heart-wrenching than the decision about artificial nutrition and hydratation. The endoscopist often is placed in a precarious position when percuta- neous endoscopic gastrostomy tube placement is requested in such patients. Clinical decision-making between the patient, the family and the physician should be consistent with legal and ethical prin- ciples.
The purpose of this article is to provide an evaluation of med- ical and ethical issues regarding the decision on placing a percuta- neous endoscopic gastrostomy tube for various indications, as well as suggesting strategies to optimize the decision-making process. (Acta gastroenterol. belg., 2006, 69, 317-320).
Ageing and the liver
Age does not spar the liver, we reviewed here the essential actu- al knowledge about age related modifications of this organ. Liver volume and blood flow decrease with age. Aging is also associated with a decline in the intrinsic metabolic activity of the hepatic parenchyma, and in the gene expression of proteins involved in intermediary metabolism, mitochondrial respiration and drug metabolism. Aged hepatocytes accumulate oxydative DNA dam- age, responsible for the increase in mutations, particularly in the mitochondrial genome. Histologically, aged hepatocytes are char- acterized by accumulation of ageing pigments into the cytoplasm and by pseudocapillarization of the sinusoid. Age is also of impor- tance at the time of HCV infection : fibrosis progression is faster when the virus is acquired after 40 years. In liver transplantation, an old transplanted liver is now an identified cause of primary non-function of the graft and an independent cause of mortality after transplantation. The age of the donor is also a predictive fac- tor of the severity of recurrent liver HCV-related disease on the graft. (Acta gastroenterol. belg., 2006, 69, 313-315).
Superficial oeso-gastric cancer and endoscopic mucosal resection : the patholo- gist's approach
Dysplasia is the earliest phase in cancer development that can be recognized by routine morphology. High grade dysplasia, intraepithelial carcinoma and in situ carcinoma are synonymous terms identifying a non invasive lesion whereas superficial (early) carcinoma is defined as a lesion confined to the mucosa or to the mucosa and sub-mucosa with or without lymph node metastasis. In the Vienna classification, proposed by a panel of Western and Japanese experts in 2000, the term "dysplasia" was replaced by the term "intraepithelial neoplasia" because this term defines more clearly the nature and the extent of the lesion, allowing rec- ommendations for further diagnostic and therapeutic measures. Intraepithelial neoplasia is divided into two groups : low grade and high grade. Superficial oeso-gastric cancer can be treated by endoscopic mucosal resection (EMR). EMR provides specimens that must be handled and reported as surgical specimens by the pathologist. (Acta gastroenterol. belg., 2006, 69, 316-320).
Early esophageal and gastric cancers : surgery in the era of minimally invasive treatment
Surgery represents today the standard treatment of esophageal and gastric cancer. Associated morbidity remain however signifi- cant in term of incisional access and functional sequels after organ resection and extended lymphadenectomy. Retrospective reviews of surgical series have defined indications for which more conser- vative treatment appears to provide similar survival without the need for lymph node resection. Endoscopic resection is now accepted for the treatment of well-differentiated tumors restricted to the mucosa. The expansion of this technique to deeper lesions or to lesions developed on a background of metaplasia is associated with an increased morbidity and significant risk of recurrence as well as a lifelong, close endoscopic surveillance. The role of surgery as primary treatment or rescue therapy to extend the resection will rely on an accurate preoperative and pathological staging of the lesion. Laparoscopy can play a central role in the management of early esophageal and gastric cancer as it can permit from local- ized to extensive resection associated to lymph node dissection with the advantage of minimal invasive surgery. Its association to function-preserving operations awaits the demonstrated efficacy of targeted lymph node dissection. Those new techniques should be restricted to centers with extensive expertise and need to be validated in long-term controlled studies. (Acta gastroenterol. belg., 2006, 69, 321-325).
Ethical aspects of percutaneous endoscopic gastrostomy placement for artificial nutrition and hydratation
Of the many decisions that family members and physicians must make about medical care in patients with advanced disease and perceived poor quality of life, none is more heart-wrenching than the decision about artificial nutrition and hydratation. The endoscopist often is placed in a precarious position when percuta- neous endoscopic gastrostomy tube placement is requested in such patients. Clinical decision-making between the patient, the family and the physician should be consistent with legal and ethical prin- ciples.
The purpose of this article is to provide an evaluation of med- ical and ethical issues regarding the decision on placing a percuta- neous endoscopic gastrostomy tube for various indications, as well as suggesting strategies to optimize the decision-making process. (Acta gastroenterol. belg., 2006, 69, 326-329).
