Management of Esophageal Perforations after Therapeutic Upper Gastrointestinal Endoscopy

Esophageal perforation is one of the most dreaded complications in therapeutic gastrointestinal endoscopy. We assessed the frequency of esophageal perforation after endoscopic procedures in a highly specialized endoscopy unit and compared clinical outcomes in patients undergoing either surgical or conservative management.From January 1985 to June 1996, 1011 instrumental endoscopic procedures (dilatation and bougienage) were performed in our department. The computerized complication database was searched to identify all patients with esophageal perforation during this same period, and their records were reviewed.Seventeen esophageal perforations (1.7%) occurred in the course of 1011 procedur…

Pancreatic Endoscopic Sphincterotomy in Patients with Chronic Pancreatitis: A Single-Center Experience in 171 Consecutive Patients

Background and Study Aims: In recent years, interest in endoscopic therapy techniques for pancreatic diseases has been constantly increasing. The aim of the present study was to assess the technical success, technique, and complications of endoscopic pancreatic sphincterotomy (EPS) in patients with chronic pancreatitis. Patients and Methods: A total of 171 patients with chronic pancreatitis and abdominal complaints were identified in whom at least one attempt at EPS was carried out. During the procedure, sphincterotomy was carried out using a guide-wire sphincterotome or a needle-knife papillotome. Patients were followed up after EPS for at least 24 h, including clinical symptoms and labora…

Lasso Technique for Retrieval of a Dislocated and Impacted Esophageal Stent

Inkarzeration eines Pankreassteinfragmentes im distalen Pankreasgang nach Therapie durch extrakorporale Stoßwellenlithotripsie (ESWL)

A partial or total absence of stones in pancreaticolithiasis therapy can be reached by using ESWL. We report on a patient who happened to get an incarceration of a fragment in the distal pancreatic duct after having been treated by ESWL without a previous sphincterotomy to the ductus Wirsungianus. This emphasizes the recommendation to carry out a papillotomy of the pancreatic main duct before applying ESWL to pancreatic stones.

Transvalvular enteroscopy using a mother-baby endoscope system: a new approach to the distal ileum.

In the past decade various endoscopes have been developed to examine the small bowel, with two principal procedures established: sonde-type enteroscopy and push-type enteroscopy. The main indication is gastrointestinal bleeding of obscure origin. Push-type enteroscopy has proved itselfto be useful for the investigation ofdiseases of the small intestine. 1 The mean instrumental insertion length published by different working groups varied between 50 and 90 cm past the ligament of Trei tzfl 2 The small bowel examination area is limited to the jejunum. The alternative method is sonde-type enteroscopy that allows an insertion length of 140 (30 to 200) cm. 3, 4 Disadvantages of this type of ente…

Does Cytokeratin7/20 immunoreactivity help to distinguish Barrett's esophagus from gastric intestinal metaplasia? Results of a prospective study of 75 patients

Barrett's esophagus is a recognized risk factor for the development of esophageal dysplasia and carcinoma. Unfortunately, gastric incomplete intestinal metaplasia arising in Short Segment Barrett's esophagus can be indistinguishable histologically on hematoxylin/eosin stains. Distinct patterns of CK 7 and CK 20 immunohistochemical expression have been demonstrated to be both highly sensitive and specific for Barrett's esophagus, but have not been found in gastric metaplasia. The aim of our study was to test whether immunostaining with CK 7/20 helps to distinguish between Barrett's epithelium and gastric incomplete metaplasia. Cases of long segment Barrett's esophagus, short segment Barrett'…

Incomplete Conventional Colonoscopy: Magnetic Resonance Colonography in the Evaluation of the Proximal Colon

Background and Study Aims: The purpose of this study was to evaluate dark-lumen magnetic resonance (MR) colonography prospectively in patients with incomplete conventional colonoscopy. Patients and Methods: Thirty-two patients with incomplete conventional colonoscopy underwent same-day dark-lumen MR colonography on the basis of a standard protocol. The depiction of colorectal diseases was assessed in the following colon segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The reasons for incomplete colonoscopy included high-grade stenosis in 26 patients (four with occlusive cancer, 12 with fibrotic stenosis based on recurrent sigmoid diverticuliti…

Minilaparoscopy versus conventional laparoscopy in the diagnosis of hepatic diseases

Minilaparoscopy (ML) is being used increasingly in the diagnosis of liver disease. This is a prospective study of the accuracy and safety of ML compared with conventional laparoscopy (CL) in the diagnostic workup of liver disease.One hundred four patients with suspected liver disease were randomized either to undergo CL (n = 50) or ML (n = 54). CL was performed with a standard Storz laparoscope (Ø 11 mm, Storz GmbH, Tuttlingen, Germany) according to accepted guidelines. For ML a 1.9-mm small-diameter optical telescope was used (Richard Wolf GmbH, Knittlingen, Germany). In all cases, an attempt was made to obtain a liver biopsy specimen.Laparoscopy could successfully be performed in 100 of 1…

Endoskopische ablative Verfahren bei Gallengangstumoren – Effektivität der photodynamischen Therapie und der Radiofrequenzablation

Nur etwa 20–30 % der Patienten mit hilarem cholangiozellularen Karzinom (CCC) konnen bei Diagnosestellung kurativ operiert werden, da erst bei fortgeschrittenem Tumorstadium Symptome auftreten 3 . Daher konnen den meisten Patienten mit dieser Tumorentitat lediglich palliative Therapiekonzepte angeboten werden. Die Effektivitat der photodynamischen Therapie (PDT) wurde in 2 kontrolliert randomisierten sowie in weiteren kontrollierten Studien nachgewiesen. Eine endoskopische Drainage in Kombination mit einer intraluminalen PDT stellte bislang das beste palliative Therapiekonzept dar [1, 3]. Die Radiofrequenzablation (RFA) ist ein neues endoskopisches Verfahren im Rahmen des palliativen Therap…

Kombiniertes Simulationstraining: Ein neues Kurskonzept trainiert und verbessert das Krisenmanagement der gastroenterologischen Endoskopie

Introduction Crisis management as well as realistic emergency situations can be trained in the new developed simulation workshop "Gastrointestinal Endoscopy and Crisis Resource Management" by combining a full-scale simulator and the Erlanger Endoscopy Trainer. The aim of the current study was to evaluate the efficiency of the newly developed simulation workshop. Methods Endoscopists with more than 12 months experience can train their endoscopic skills and crisis resource management with the help of different simulators. In addition, two different scenarios (GI bleeding with significant blood loss and sedation overdoses) embedded in a realistic surrounding (emergency room) have to be managed…

Long-Segment Early Squamous Cell Carcinoma of the Proximal Esophagus: Curative Treatment and Long-Term Follow-Up after 5-Aminolevulinic Acid (5-ALA)-Photodynamic Therapy

Photodynamic therapy (PDT) is an established treatment for the ablation of dysplastic Barrett's epithelium and early esophageal carcinoma, but no data have been published on curative 5-aminolevulinic acid (5-ALA)-PDT for long-segment early esophageal cancer with infiltration of the upper sphincter. We describe successful curative treatment of an unusual early long-segment squamous cell carcinoma (uT1a,N0) of the proximal esophagus (18 - 28 cm aborally), with three sessions of 5-ALA-PDT. Endoscopic and endosonographic follow-up macroscopically showed a complete remission of the tumor, proven by biopsy showing total histological ablation. After a follow-up period of 23 months, there has been …

Diagnostic Accuracy of <sup>13</sup>C-Urea Breath Test in the Diagnosis of <i>Helicobacter pylori</i> Infection in Patients with Partial Gastric Resection due to Peptic Ulcer Disease

<i>Aims:</i> We investigated the diagnostic properties of the <sup>13</sup>C-urea breath test (<sup>13</sup>C-UBT) prospectively. These are well validated in nonresected patients before and after treatment of <i>Helicobacter pylori</i> infection but not in patients with partial gastric resection due to peptic ulcer disease. <i>Methods:</i> Hospitalized patients with previous gastric resection and indications for upper gastrointestinal endoscopy were recruited for the study. Biopsy specimens were obtained from the fundus mucosa and the gastric remnant adjacent to the gastroenteric anastomosis for histological examination and rapid u…

Laser fragmentation of pancreatic duct stones using a rhodamine laser with an automatic stone-tissue detection system. Basic in-vitro studies

OBJECTIVES The aim of our study was to examine the suitability of a rhodamine 6G laser with an integrated stone-tissue detection system (STDS) for fragmenting pancreatic stones. METHODS A total of 64 pancreatic duct stones were measured for weight, diameter, main chemical components and in some cases for their computerized tomography density. Recognition of all stones was checked with the standard STDS or a prototype version. Number of fragmentation pulses, total fragmentation energies and correlation with the individual stone parameters were determined. The quality of the tissue-detection mode was evaluated in postmortem pancreata. RESULTS The standard STDS detected only 45% of the pancrea…

Management of retained bile duct stones: a prospective open trial comparing extracorporeal and intracorporeal lithotripsy.

Abstract Background: Endoscopic management of common bile duct stones has become the approach of choice, especially in patients with high surgical risk. Problems are encountered if there are large stones or a duct stenosis. For these difficult stones, shock wave technology serves as an alternative to surgical intervention. Methods: A total of 125 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected and treated either by extracorporeal piezoelectric lithotripsy (ESWL, n=79) or intracorporeal electrohydraulic lithotripsy (EHL, n=46). The average age of our patients was 70 years. Results: In the ESWL group visualization of the stones by ultra…

In vitro evaluation of forces exerted by a new computer-assisted colonoscope (the NeoGuide Endoscopy System).

Background: The NeoGuide Endoscopy System (NES) utilizes a fully articulated, computer-controlled insertion tube that allows proximal segments of the colonoscope to follow the path taken by the tip as it is manually advanced through the colon. The system was designed to eliminate looping and scope displacement during colonoscopy. Material and methods: Using in vitro testing, an inanimate flexible model of the colon incorporating four force transducers located at the key flexure points was employed to measure the axial forces on the colon wall during colonoscopy. In the second part of the study, 10 gastroenterologists performed colonoscopies, using a training latex-based simulator, with the …

Capsule Endoscopy versus Push Enteroscopy in Patients with Occult Gastrointestinal Bleeding

Background Wireless capsule endoscopy is a new method enabling non-invasive diagnostic endoscopy of the entire small intestine. In this study we prospectively examined the diagnostic precision of capsule endoscopy compared with push enteroscopy in patients with occult gastrointestinal bleeding. Methods Between July 2001 and October 2002 we examined 48 patients with suspected disorders of the small intestine using capsule endoscopy. 33 patients with obscure bleeding (19 men, 14 women, mean age 58 +/- 23 years) were prospectively examined using capsule endoscopy and push enteroscopy. Results On average, the patients had been suffering from chronic gastrointestinal bleeding for 30 +/- 36 (1-12…

THE ROLE OF ENDOSCOPY IN ACUTE RECURRENT AND CHRONIC PANCREATITIS AND PANCREATIC CANCER

Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.

Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms.

Abstract Background: The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms. Methods: Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners. Results: The procedure was successful in…

Colorectal Polyps: Detection with Dark-Lumen MR Colonography versus Conventional Colonoscopy

To prospectively compare dark-lumen magnetic resonance (MR) colonography with conventional colonoscopy in the detection of colorectal polyps.Local ethical committee approval and informed consent were obtained. One hundred consecutive patients (56 men, 44 women; mean age +/- standard deviation, 67.7 years +/- 14.7; range, 25-82 years) who were referred for conventional colonoscopy from January 2003 to January 2004 underwent MR colonography and conventional colonoscopy after standard precolonoscopic bowel cleansing. Colonoscopy was performed immediately after MR colonography. For MR colonography, the colon was filled with approximately 2000 mL of tap water. Imaging was performed with a 1.5-T …

Endoscopic laser palliation for rectal cancer-- therapeutic outcome and complications in eighty-three consecutive patients.

OBJECTIVE The treatment of advanced rectal cancer is still a challenge. We analysed the short-term success, treatment-related complications and the long-term outcome after laser palliation for rectal cancer. METHODS Over a ten-years period eighty-three consecutive patients (median age 81 (46-94) yrs; 43 female) were treated mainly for obstructive symptoms or tumour bleeding. Laser palliation was performed using a Neodymium:Yttrium-Aluminium-Garnet (Nd:YAG) laser. RESULTS The immediate overall-success rate was 96.4 % (80 of 83 patients) and only one female received a diverting colostomy because of an inaccessible high-grade rectal stenosis, initially. During follow-up, eight additional patie…

Diagnosis of Liver Cirrhosis

Background/goals Liver cirrhosis, the final stage of chronic liver disease, is characterized by an unfavorable prognosis and an increased risk of hepatocellular carcinoma and also requires an appropriate management. Laparoscopy, the gold standard in the diagnosis of cirrhosis, is hampered by its invasiveness. Therefore, a noninvasive method for diagnosing liver cirrhosis would be of great benefit. Study A consecutive series of 100 patients, sent to our gastroenterological unit for diagnostic laparoscopy, underwent a standardized ultrasonographic examination prior to laparoscopy. Results Conventional ultrasonographic examination revealed a sensitivity of 55% and a specificity of 86% in the d…

Impact of Gallbladder Status on the Outcome in Patients with Retained Bile Duct Stones Treated with Extracorporeal Shockwave Lithotripsy

BACKGROUND AND STUDY AIMS The use of endoscopic therapy in combination with lithotripsy techniques has become increasingly common in patients with complicated common bile duct stones. In many units, although this is controversial, cholecystectomy is then performed, because of possible subsequent cholecystitis and recurrence of choledocholithiasis. The aim of this study was to investigate whether gallbladder status influences the long-term outcome in patients after extracorporeal shockwave lithotripsy (ESWL) of common bile duct stones. PATIENTS AND METHODS Recruited for the study were 120 patients with an average age of 68 years (range 28 - 86). They were selected from 137 consecutive patien…

Hemosuccus pancreaticus--a rare cause of gastrointestinal bleeding: diagnosis and interventional radiological therapy.

Hemorrhage from the pancreatic duct, i.e. hemosuccus pancreaticus (HP), is a rare cause of gastrointestinal bleeding. Pancreatic hemosuccus is usually due to the rupture of an aneurysm of a visceral artery, most likely the splenic artery, in chronic pancreatitis. Other causes of HP are rare. We present a case of HP in a female patient with no history but with positive findings of chronic calcifying pancreatitis upon ultrasonographic investigation, computed tomography scan, and endoscopic retrograde cholangiopancreatography. With detectable fresh blood in the descending duodenum, angiography of the celiac artery revealed an aneurysm of the splenic artery as the suspected cause of intermitten…

Long term follow up of patients with chronic pancreatitis and pancreatic stones treated with extracorporeal shock wave lithotripsy

BACKGROUNDThere have been conflicting reports as to whether pancreatic ductal drainage achieved by endoscopy and lithotripsy improves the clinical outcome of patients with chronic pancreatitis.AIMSTo determine the clinical outcome in patients with chronic pancreatitis who received extracorporeal shock wave lithotripsy (ESWL), and were followed up for two to eight years.METHODSEighty patients with severe chronic pancreatitis and endoscopically unretrievable obstructive stones underwent ESWL with a piezoelectric lithotripter between 1989 and 1996. Clinical status, relief of symptoms, further endoscopic or surgical interventions, and mortality were defined.RESULTSForty three (54%) patients wer…

Value of magnetic-resonance cholangio-pancreatography (MRCP) after unsuccessful endoscopic-retrograde cholangio-pancreatography (ERCP).

Background and Study Aims: The present study tries to evaluate the success rate of MRCP when two attempts by experts to perform ERCP in a center failed. Patients and Methods: From March 1996 to December 1996 thirteen patients fulfilled the inclusion criteria. The MR cholangiopancreatograms were acquired using commercially available software in a clinical MR scanner (Magnetom Expert 1T-Scanner, Siemens, Erlangen, Germany). MRCP utilized heavily T2-weighted turbo-spin echo sequences with fat supression (HASTE). Maximum intensity projection (MIP) of the pancreatic duct and biliary tree was then carried out. Additionally, T1-weighted sequences were obtained using the breath-hold technique. Resu…

Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up.

Abstract Aims. To compare the efficacy and the complication rate between endoscopic snare resection of adenomas of Vater's papilla and endoscopic palliation. Methods. In a retrospective, non randomized manner, we compared long-term results of our endoscopic strategies in 36 patients with histologically confirmed adenoma of Vater's papilla submitted either to local endoscopic snare resection (n=18) or to simple endoscopic palliation (n=18), respectively. Results. Between 1985 and 1998 results were reviewed. Median age was 76.5 (range 42–89) years in the palliation, and 64.0(23–89) years in the endoscopic snare resection group. Median duration of follow-up was 33 (6–135) and 75.0 (27–123) mon…

Schwannoma of the common bile duct: a rare cause of obstructive jaundice.

The endoscopic diagnosis of bile duct lesions has improved over recent years through the introduction of cholangioscopy and intraductal ultrasound. Combining this with biopsies examined using routinely administered immunohistochemical markers, the diagnosis of tumors of the extrahepatic bile duct can be improved substantially. We report a rare case of a schwannoma of the bile duct causing obstructive jaundice.

Buprenorphine or procaine for pain relief in acute pancreatitis. A prospective randomized study.

To assess the analgesic efficacy and side effects of buprenorphine and procaine in patients with acute pancreatitis.Forty patients (average age, 50 years; 23 male) with acute pancreatitis or an acute bout of a chronic pancreatitis were prospectively randomized to receive buprenorphine or procaine for pain relief. Both analgesics were administered as constant intravenous (i.v.) infusions and additional analgesics were given on demand. Pain scores were assessed on a visual analogue scale. Close clinical control and laboratory checks were performed during the three-day study period.Patients receiving buprenorphine were significantly less likely to demand additional analgesics (1 versus 14 pati…

Prospective, randomized, single-center trial comparing 3 different 10F plastic stents in malignant mid and distal bile duct strictures.

Abstract Background: The aim of this study was to determine whether patency rates differ with respect to the material, design, and surface texture of 3 different plastic stents. Methods: A total of 120 patients (median age 70.5 years; interquartile range 62-78 years) with malignant mid or distal bile duct strictures, seen between March 1996 and May 1999, were prospectively randomized to receive a 10F polyurethane stent, a Teflon Tannenbaum stent, or a hydrophilic hydromer-coated polyurethane stent. The primary study outcome measure was the interval between stent insertion and the first episode of clogging (or the presence of jaundice at death without stent exchange). All 3 types of stent we…

High frequency of colorectal adenoma in patients with duodenal adenoma but without familial adenomatous polyposis

Abstract Background Duodenal adenomas are extremely common in patients with familial adenomatous polyposis. However, it is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis are at greater risk for colorectal neoplasia and, therefore, should routinely undergo surveillance colonoscopy. The aim of this study was to determine whether there is a correlation between non-papillary duodenal adenoma without familial adenomatous polyposis and colorectal adenoma. Methods Twenty-five patients with non-papillary duodenal adenomas without familial adenomatous polyposis, seen from January 1990 to April 2003, were retrospectively evaluated. Results Non-papillary duode…