Bestimmung von Effektivität und Risiken bei systematischer Anwendung der Inversion im Coecum. Vergleich zwischen Endoskopen.

Background and study aims: Precut is a well-known technique that is used if repeated attempts at common bile duct (CBD) cannulation fail. Opinions on the complication rate of precut are conflicting, however. The aim of the present study was to compare the efficacy and complication rate of precut used as a primary method of CBD access with the efficacy and safety of the conventional technique.Patients and methods: During the 19-month study period, consecutive patients who were scheduled for first-time endoscopic sphincterotomy (ES) for a variety of biliary disorders were randomized into two groups: patients in group A underwent conventional wire-guided biliary cannulation followed by ES (with precut being performed only when this failed); in patients in group B precut was used as a primary technique to gain biliary access, followed by wire-guided ES. We used a specially designed, modified Erlangen type of sphincterotome for precutting.Results: A total of 291 patients (100 men, 191 women; mean +/- SD age 65 +/- 17.5 years) were recruited: 146 patients were assigned to group A (conventional approach) and 145 to group B (primary precut approach). The indications for ES were comparable in the two groups. In group A, wire-guided cannulation of the CBD failed in 42 patients. Secondary precut was successful in 41 of these patients, leading to an overall success rate of 99.3%. In group B, the ES success rate using primary precut was 100% at the first attempt. The mean time to successful deep CBD cannulation was 8.3 +/- 2.1 minutes in group A and 6.9 +/- 1.8 minutes in group B (P < 0.001). The incidence of mild to moderate pancreatitis was similar in the two groups (2.9% in group A vs. 2.1% in group B, P > 0.05). Mild bleeding occurred in only one patient (from group A) and this was controlled by epinephrine injection. None of the study patients developed severe pancreatitis or perforation.Conclusions: In experienced hands, an approach using primary precut appears to be at least as successful and safe as a conventional approach using guide-wire-based CBD cannulation followed by ES, and might also be a quicker method.

Hintergrund: Während der klinische Nutzen der Kapselendoskopie belegt ist, bleiben verschiedene Aspekte bei der praktischen Durchführung der Kapselendoskopie noch unbefriedigend gelöst. Die Wahl einer geeigneten Lesegeschwindigkeit ist schwierig und mit der zur Verfügung stehenden Software zu aufwändig anzupassen.

Most benign papillary tumors are adenomas which can potentially undergo the adenoma-carcinoma-sequence making complete removal mandatory for curative therapy. Endoscopic resection (papillectomy) of these lesions is being increasingly performed as a less traumatic alternative to surgery. Available data shows endoscopic papillectomy to be effective and safe in experienced hands with usually little morbidity and virtually no mortality. Success rates are around 80% for lesions without intraductal involvement. Selected cases of limited distal intraductal involvement accessible after sphincterotomy may also be managed curatively by endoscopic resection.Endoscopic snare resection of entire lesions should be primarily regarded as a diagnostic procedure. It allows for an accurate histological diagnosis based on examination of the entire specimen rather than forceps biopsies and thus a reliable assessment of the need for surgical therapy. Subsequent surgery in operable patients is not precluded by previous endoscopic resection. Surgery is indicated in case of incomplete removal and if malignancy is present. The curative role of endoscopic papillectomy for early invasive carcinoma needs to be established. Histological features and individual risk for surgery are factors to be considered. Inoperable patients may still benefit from palliative endoscopic stenting. After endoscopic papillectomy has been completed, regular follow-up examinations including biopsies are warranted because of the risk of local recurrence. For benign looking papillary tumors, endoscopic papillectomy serves as a diagnostic tool and should be considered as first line procedure regardless of age.The following article details the approach to patients with benign papillary tumor and the technique of endoscopic papillectomy.

Capsule endoscopy (Given Imaging, Yoqneam, Israel) allows for small-bowel assessment with little discomfort for the patient. However, evaluation is still a challenge for the investigator. Unlike flexible endoscopy where the examiner is actively involved in maneuvering the instruments, browsing more than 50 000 images in capsule endoscopy can be a monotonous procedure. We added a “jog/shuttle” control, which is a well-established tool in professional video editing, to the Given Imaging capsule endoscopy reading system.

Background: When colonic polyps are encountered during colonoscopy, polypectomy is the standard of care. Malignant potential was correlated with larger adenoma size, villous histology, and more severe dysplasia. Adenomas have classically been categorized into three size groups: <1 cm, 1-2 cm, and >2 cm. Whether the malignant potential differs among polyps >2 cm is not well defined. Aim: To correlate the size of colonic polyps with severity of dysplasia, occurrence of malignancy and histological subtype.

BACKGROUND:Endoscopic papillectomy of benign papillary tumor is still not widely practiced. Intraductal growth has been considered a contraindication for endoscopic therapy. This prospective study evaluates endoscopic papillectomy for treatment of benign papillary tumors without and with intraductal growth.METHODS:Monofilament snare and monopolar electrocoagulation were used for papillectomy. A 7F stent was placed in the pancreatic duct. Patients with distal intraductal growth underwent sphincterotomy and endoscopic resection after exclusion of more proximal growth.RESULTS:Between February 1985 and April 2004, 106 patients (109 lesions), 68 women, 38 men, median age 68 years (range 29-88 years) were included. Median tumor size was 2 cm (range 0.5-6 cm) with one session (range 1-8) required for removal. Nine patients had invasive carcinoma (8%). Surgery for incomplete removal or recurrence was performed in 12% of 75 patients without and 37% of 31 patients with intraductal growth (p < 0.01), respectively. Fifteen patients had recurrence (15%); but, only 4 required surgery. Endoscopic resection was curative (median follow-up, 43 months) in 83% without and 46% with intraductal growth (p < 0.001).CONCLUSIONS:Endoscopic papillectomy is safe and effective, and may be feasible in cases of intraductal growth. Surveillance and, if required, re-treatment are mandatory because of the risk of recurrence.

Background: The major drawback of plastic stents for biliary drainage is the occlusion by sludge. Sludge is accrued due to adherent factors for glycoproteins and bacteria, such that the rate of bile flow is insufficient to remove the sludge. Neither antibiotic measures nor modification of plastic stent design (caliber >10 Fr; hydrophilic coating) reduce the rate of stent occlusion. In this study, the experience from nanotechnology to achieve clean surfaces based on soil-release characteristics is used to optimize the internal surface of plastic biliary stents. Aim: To examine sludge accumulation in relation to plastic surface characteristics (reduction of adherent factors) designed by nanotechnology. Methods: A variety of anorganic-organic sol-gel coated stents were incubated in sterilized human bile for 40 days after addition of enzyme active E.coli. The stent materials were uncoated Teflon and Teflon coated with high and low molecular epoxy resin hydrophobized by 3 different amino-fluoro-silanes. During incubation cell culture plates (each hole filled with an impacted piece of plastic stent material and 3 ml of infected bile) were inclined up and down 10x/minute to simulate bile flow. After every 48 hours 1 ml of bile was removed from each hole and replaced. Scanning electron microscopy (SEM) was performed blinded to the type of coating. The amount of sludge accumulated on the surface was determined semi-quantitatively. Results: Partially hydrophilic-hydrophobic surfaces accumulated less sludge than the hydrophobic surface of Teflon. High-molecular weight (500 M) epoxy resin performed better than low-molecular weight (190 M) epoxy resin. The lowest sludge accumulation was found on 75% hydrophobic surface using “hydrophobic modification type VI” epoxy resin. This corroborated the results of our earlier study. Discussion and Conclusion: Nanometer thin sol-gel coating is inexpensive, because very little coating material is necessary. The coating with the lowest sludge accumulation has been shown to have a superior soil-release characteristic on other surfaces (e.g. cars). Optimized soil release may be the key to prevent biliary plastic stents from clogging. More detailed studies to determine the optimal surface are warranted.

Background: Mirizzi syndrome is uncommon, but it is clinically important because of the increased incidence of bile duct injury. The traditional treatment is surgical but surgery is often difficult due to extensive pericholecystic inflammation. This study aimed to evaluate the efficacy of endoscopic therapy as first-line treatment of Mirizzi syndrome. Methods: The clinical records of patients referred to our centre for endoscopic treatment of Mirizzi syndrome during the period from August 1990 to Oct 2004 were reviewed. Endoscopic treatment was carried out using mechanical lithotripsy if the stone could be caught using a Dormia basket; otherwise electrohydraulic lithotripsy (EHL) was performed under direct vision using the “mother-baby scope” system (Olympus, Japan) and the Walz electrohydraulic lithotripter (Walz, Germany). Follow-up data were obtained from clinical records or through telephone interviews. Results: There were 83 patients (female 63) with a median age 63 years (range 14.6-94.1; 30 patients > 75 years); ASA status was 3 or 4 in 39.6% and 14.5% had previous cholecystectomy (median duration 7 years). Eighty of the cases were Mirizzi type 1; concomitant calculi were present in the gallbladder or common bile duct in 54 cases. The mean size of calculi was 2.1 cm (1.5-5). Mechanical lithotripsy was used in 9 cases, EHL in 70 cases, while 2 patients were treated with long-term biliary stenting and another 2 were treated with temporary nasobiliary drainage. Complete clearance of calculi was achieved endoscopically in 77 cases after a median of 1 session (1 to 4). Two patients did not return for re-treatment after insertion of biliary stents; one patient died of myocardial infarct 3 days after nasobiliary drainage, while another underwent cholecystectomy after nasobiliary drainage. There were no immediate procedure related complications. Nineteen patients with intact gallbladder underwent elective cholecystectomy after a mean period of 6.4 weeks (1-30); 4 had recurrent biliary symptoms before surgery. There were no cases of associated gallbladder malignancy amongst the patients with intact gallbladders. Conclusion: Endoscopic treatment of Mirizzi syndrome is effective with complete biliary clearance achieved in more than 90%. If the endoscopic expertise is available, it should be the preferred form of treatment because immediate surgery is difficult. Cholecystectomy can thus be performed electively.

PURPOSE:This study was designed to evaluate the outcome of endoscopic polypectomy of malignant polyps with and without subsequent surgery based on histologic criteria.METHODS:Consecutive patients with invasive carcinoma in colorectal polyps endoscopically removed between 1985 and 1996 were retrospectively studied. Patients with complete resection, grading G1 or G2, and absence of vascular invasion were classified as "low risk." The other patients were classified "high risk." Available literature was reviewed by applying similar classification criteria.RESULTS:A total of 114 patients (59 males; median age, 70 (range, 20-92) years) were included. Median polyp size was 2.5 (0.4-10) cm. After polypectomy, of 54 patients with low-risk malignant polyps, 13 died of unrelated causes after a median of 76 months, 5 had no residual tumor at surgery, and 33 were alive and well during a median follow-up of 69 (range, 9-169) months. Of 60 patients with high-risk malignant polyps, 52 had surgery (residual carcinoma 27 percent). Five of eight patients not operated had an uneventful follow-up of median 57 (range, 47-129) months. Patients in the high-risk group were significantly more likely to have an adverse outcome than those in the low-risk group (P < 0.0001). Review of 20 studies including 1,220 patients with malignant polyps revealed no patient with low-risk criteria with an adverse outcome.CONCLUSIONS:For patients with low-risk malignant polyps, endoscopic polypectomy alone seems to be adequate. In high-risk patients, the risk of adverse outcome should be weighed against the risk of surgery.

PURPOSE:To compare the performance of helical computed tomography (CT) and endoscopic ultrasonography (US) in the preoperative staging of gastric cancer.MATERIALS AND METHODS:Fifty-one consecutive patients with a primary malignant gastric tumor (stage T2-T4) were preoperatively evaluated with both helical CT and endoscopic US within 3 days. Each tumor was staged according to the TNM classification system with both modalities. All patients subsequently underwent surgery. Results of CT and endoscopic US were compared with histologic staging of tumor invasion depth and regional lymph node metastasis. For comparison of CT and endoscopic US data, the marginal homogeneity test was used, and a P value of less than.05 was determined to indicate statistical significance.RESULTS:In comparison with histologic results, CT achieved correct T staging in 39 patients (76%) and correct N staging in 35 patients (70%). The corresponding results for endoscopic US achieved correct T staging in 44 patients (86%) and correct N staging in 45 patients (90%). There was no significant difference between T staging (P =.55) and N staging (P >.99). Because of challenging detection of wall layers, correct T staging was difficult for CT and endoscopic US in the differentiation of T2 and T3 lesions.CONCLUSION:Compared with endoscopic US, helical CT focused on the stomach provides valuable results regarding T and N staging in patients with gastric cancer.

Background and Study Aims: Endoscopic removal of large colorectal polyps has not been widely accepted. The aims of this study were to evaluate our longterm experiences justifying endoscopic resection technique as the treatment of choice.Patients and Methods: During a period of 12 years, 288 patients with a total of 302 polyps larger than 3 cm in diameter were treated endoscopically. 224 polyps were sessile and 78 pedunculated. Sessile polyps were removed using the piecemeal technique. Surgery was recommended in patients with unfavorable histology. Patients with favorable histology were followed up at 3-6 month intervals in the first year and then every 1-2 years.Results: A total of 184 patients with sessile polyps were followed up for at least 6 months. Recurrence rate of 166 benign polyps was 17% (29/166). Only two patients had malignant recurrence. 8 of 18 patients with malignant polyps underwent surgery while 10 were unfit for surgery. 8 of these patients remained free of recurrence.Conclusions: Previous concerns about endoscopic removal of large colorectal polyps are no longer justified. The results of this study showed that endoscopic resection of large colorectal polyps is safe and effective. In patients with high operative risk, endoscopic removal may be adequate.

Background. Endoscopic ultrasound is widely used following endoscopy for evaluation of suspected submucosal lesions and may guide further management of patients,Patients and Method, A total of 181 consecutive patients with suspected submucosal lesion in the upper gastrointestinal tract were diagnosed by endoscopic ultrasound between 1990-97. We evaluated: 1) the potential of endoscopic ultrasound criteria to predict histological type of submucosal lesions in 69 patients with available histology, 2) the ability of endoscopic ultrasound alone or with clinical presentation, to predict malignancy in 86 patients with available histology or follow-up of > 12 months,Results. Sensitivity and specificity for diagnosing 44 gastrointestinal stromal tumours were 95 and 7256, respectively, while 25 miscellaneous lesions were diagnosed correctly in only 56% by endoscopic ultrasound. Diagnosis of malignancy, using any two of three endoscopic ultrasound criteria (heterogeneous echotexture, size >3 cm, irregular mat-gins) showed a sensitivity of 80% and specificity of 77%, giving accurate endoscopic ultrasound diagnosis in 16/20 malignant and 51/66 benign submucosal lesion. Heterogeneous echotexture, size >3 cm, and irregular margins showed a relative risk of 7.2, 5.4 and 4.6, respectively, for presence of malignancy. The presence of symptoms, potentially suggesting malignancy (dysphagia, gastrointestinal bleeding, pain and weight loss), had a relative risk of 4.2, however this did not increase the accuracy of diagnosing malignancy based on endoscopic ultrasound criteria alone.Conclusion. The accuracy of endoultrasound is high in diagnosing gastrointestinal stromal tumours, which show a significant potential of malignancy Endoscopic ultrasound morphology appears to be helpful in selection of patients for surgical or conservative treatment. The accuracy of endoscopic ultrasound in differential diagnosis of non-gastrointestinal stromal tumour lesions is limited.

BACKGROUND:A new mechanical puncture-echoendoscope was evaluated by comparing it with conventional linear and radial echoendoscopes. The new instrument has a 300 degrees image field parallel to the axis of the echoendoscope, which could potentially improve accuracy and facilitate assessment of suspected pancreatic lesions before needle puncture.METHODS:Twenty consecutive patients with suspected pancreatic lesions were evaluated endosonographically, including fine needle aspiration (FNA). The initial assessment was performed by random selection of either the new instrument or the standard linear echoendoscope. After completing the assessment including FNA, the procedure with FNA was repeated with the other puncture echoendoscope. The findings with these 2 instruments were compared to those with the conventional radial scanning echoendoscope.RESULTS:FNA was performed in 17 patients with pancreatic head lesions. In 3 patients without a visible pancreatic mass lymph, nodes greater than 10 mm in diameter were aspirated. The ability to image the needle, number of punctures, and material obtained were comparable for both puncture echoendoscopes. There were no significant differences with regard to time required for FNA with both puncture echoendoscopes or in the assessment of surrounding structures with all 3 instruments. The results of cytopathologic evaluation of material obtained by FNA were similar in 15 cases. The new instrument could not be passed into the esophagus in 1 patient because of an esophageal stricture.CONCLUSIONS:The performance of the new mechanical puncture echoendoscope was satisfactory for assessment and FNA of pancreatic lesions. The additional use of the conventional radial scanning echoendoscope provided no advantage with regard to any parameter assessed.

BACKGROUND AND STUDY AIMS:Optical coherence tomography (OCT) is a novel technique for performing high-resolution, cross-sectional tomographic imaging in human tissue, which allows resolution of up to 10 microm. The short depth of penetration allows assessment of the superficial 2 mm of the gastrointestinal tract, an area that is difficult to appraise even with high-frequency ultrasound. This is the first report on in vivo OCT of the human biliary system. The aim was to assess the feasibility of the technique.PATIENTS AND METHODS:Four cases of intraductal OCT are presented. The probe was inserted through the working channel of a duodenoscope.RESULTS:The connective tissue layer and the underlying retroperitoneal tissue, with less backscattering, could be clearly demonstrated. The images showed a layer architecture which was similar to that found histologically.CONCLUSIONS:OCT of the biliary system is feasible in patients with biliary pathology. Interpretable images were obtained, and clinical use needs further assessment. As current OCT probes and processors do not yet provide optimal resolution, further generations of equipment with improved image quality are required.