Gastroenterology and Digestive Endoscopy

key figures 

CLINICAL SERVICES:

• Gastrointestinal Endoscopy
• Advanced Endoluminal Surgery
• Pancreaticobiliary Endoscopy
• Digestive Physiopathology
• Precision Medicine
• Inflammatory Bowel Diseases
• Outpatient Services and Consultations:
  • Oesophageal Disorders and Achalasia
  •  Precancerous Conditions of the Digestive Tract
  • Genetic Counselling for Colo-rectal, Stomach and Pancreatic Cancer
  • Functional Digestive Disorders

PROCEDURES PERFORMED PER YEAR: 11.000

The Gastroenterology and Digestive Endoscopy Unit of Ospedale San Raffaele is considered among the most important centres for research and advanced therapeutic endoscopy worldwide; it has performed the highest number of transoral fundoplication for Gastro- Oesophageal Reflux Disease (GERD) in Europe. It is a centre of excellence with the largest case series in Italy for the early diagnosis and treatment of pancreatic diseases and tumours. It is a regional reference centre for celiac disease and primary sclerosing cholangitis. The Unit also has the greatest Italian caseload of diagnostic and operative endoscopic procedures. In addition, the Precision Medicine Unit is specialized in studying and creating a preventive and personalized path of medicine dedicated to first-degree relatives of patients with cancer of the intestine, stomach and pancreas. The goal of this programme is to evaluate their risk of developing a tumour and then propose a diagnostic route aimed at prevention.

 

treatmentS

Digestive Endoscopy

The Unit performs diagnostic and operative endoscopic procedures involving oesophagus, stomach, duodenum, colon, biliary and pancreatic ductal system. Rooms with autonomous radiological equipment are used for diagnostic and operative procedures. Procedures can also be performed in deep sedation, under anaesthetic control, prior to the patient's admission.

The Unit performs the following exams and procedures:

• Diagnostic digestive endoscopy
• Operative digestive endoscopy
• Endoluminal surgery
• Video capsule enteroscopy

Endoluminal Surgery

Main Pathologies Treated:

• Colorectal and gastro-duodenal adenoma and non-invasive cancer
• Barrett's oesophagus and non-invasive oesophageal cancer
• Ampullary adenoma / early cancer
• Submucosal lesions
• Gastroesophageal reflux disease
• Achalasia and spastic oesophageal motor disorders
• Gastroparesis
• Morbid obesity
• Gastrointestinal fistulae / strictures
• Gastrointestinal angiodysplasia and bleeding

Therapeutic Procedures

Top Procedures:

• Endoscopic submucosal dissection (ESD)
• Endoscopic mucosal resection (EMR)
• Full thickness resection
• Ampullectomy
• Transoral incisionless fundoplication
• Peroral oesophageal myotomy (POEM)
• Peroral pyloro-myotomy
• Radiofrequency / argon ablation
• Bariatric therapeutic endoscopy
• Endoluminal stenting
• Regenerative medicine
• Advanced suturing techniques

Therapeutic Pancreaticobiliary Endoscopy

Main Pathologies Treated:

• Acute recurrent pancreatitis
• Complications of acute pancreatitis
• Chronic pancreatitis and complications
• Biliary stone disease and complications
• Primary sclerosing cholangitis
• Neoplastic disease      

Precision Medicine

A multidisciplinary program has been established, to evaluate predisposition to hereditary gastroenterological cancer syndromes based on clinical patterns and molecular genetics. The team includes gastroenterologists, geneticists, gastrointestinal and pancreatic surgeons, gynaecologists, urologists, medical oncologists, and pathologists. Patients are visited and counselled by a gastroenterologist and geneticist in a single session.

Anamnestic data is matched with available medical reports to confirm cancer and its histologic type, and then compared with clinical criteria.

Main Pathologies Treated:

• Lynch Syndrome
• Familial adenomatous polyposis and its variants (attenuated adenomatous polyposis, aFAP, MUTYH-associated polyposis, MAP, Gardner syndrome, Turcot syndrome)
• Familial juvenile polyposis
• Serrated polyposis syndrome
• Cowden's syndrome
• Peutz-Jeghers syndrome
• Hereditary diffuse gastric cancer
• Familial pancreatic cancer
• Hereditary pancreatic cancer
• Familial atypical multiple mole melanoma syndrome
• Hereditary breast and ovarian cancer
• Early onset intestinal, pancreatic and gastric adenocarcinoma

Lynch Syndrome risk is investigated by means of the three-questions Colorectal Cancer Risk Assessment Tool developed by Kastrinos et al. When patients answer affirmatively to any of the Kastrinos questions, then the computational model PREMM 1,2,6 is employed to estimate pre-test probability for mutations in the mismatch repair (MMR) genes, namely MLH1, MSH2, and MSH6. Available colorectal tissue undergoes immunohistochemical analysis for MMR proteins (MLH1, MSH2, MSH6, PMS2) before genetic testing, as recently recommended. Hereditary diffuse gastric cancer (HDGC) is diagnosed when appropriate criteria are present. Familial Pancreatic Cancer (FPC) is considered according to the criteria updated by Hruban et al. Genetic testing is offered to all patients who fulfil the aforementioned clinical criteria. The Unit employs next-generation sequencing (NGS)  on a MiSeq Illumina platform. Results are disclosed in a second counselling session, where personal follow-up and familial prevention strategies are discussed and agreed upon. The Unit then coordinates the recommended follow-up procedures: endoscopic, urological and gynaecological consultations, prophylactic and preventive measures, and, eventually, surgical management, always in agreement with patients’ needs.

When direct surgery is indicated, without any neoadjuvant treatments, the multidisciplinary approach provides uniquely fast genetic results, which are available within 20 days. Rapid availability of genetic results allows to explore the surgical options with patients.

Gastrointestinal motility investigation

Main Pathologies Treated:

• Gastro-esophageal reflux disease
• Barrett’s esophagus
• Achalasia
• Primary motility disorders of the esophagus
• Gastroparesis
• Functional constipation
• Fecal incontinence
• Diseases of pelvic floor      

Diagnostic and therapeutic procedures

Top Procedures:

• pH-impedance esophageal 24-h recording
• High resolution esophageal manometry
• Ano-rectal manometry
• Pelvic floor rehabilitation

 

NOTABLE ADVANCED TECHNOLOGICAL EQUIPMENT

• Advanced endoscopic imaging for early diagnosis of gastrointestinal pre-cancerous condition and early cancer:                                  
• MEDIGUS ultrasound surgical endostapler (MUSE)
• BARR X device for thermoablation of Barrett's epithelium   
• Argon plasma coagulation
• Apollo endoscopic suturing device