Gastrointest Endosc

A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct.

Prat F. Chapat O. Ducot B. Ponchon T. Pelletier G. Fritsch J. Choury AD. Buffet C.
Service des Maladies du Fole et de l'Appareil Digestif, INSERM U292, CHU de Bicetre, Le Kremlin-Bicetre, France.
BACKGROUND: Although metallic stents remain patent longer than plastic stents, the optimal palliation of inoperable malignant biliary strictures remains controversial because of the high cost of metallic stents and short patient survival. METHODS: A total of 101 patients (mean age 72.5+/-12.9 years) with malignant strictures of the common bile duct were included in this study, after three exclusions for technical failure (n = 3) and one for noncompliance with study design. The etiology of the strictures included pancreatic cancer (65), cholangiocarcinoma (21), ampullary tumor (3), and metastatic lymph nodes (12). Patients were randomized to receive either an 11.5F polyethylene stent to be exchanged in case of dysfunction (group 1, n = 33), an 11.5F stent to be exchanged every 3 months (group 2, n = 34), or a self-expanding metallic Wallstent (group 3, n = 34). RESULTS: Endoscopic procedures were successful (including complete relief of jaundice) in 97.1 % of cases. Procedure-related morbidity was 11.9%, and mortality was 2.9%. Bilirubinemia after 48 hours (37.2%+/-21.7% decrease from the preoperative level) did not differ between groups. Patients were followed for a mean of 166 days (median 143, range 0 to 596 days). Overall survivals were not different between groups, but complication-free survival for groups 2 and 3 was longer than that of group 1 (p < 0.05). Cumulated hospital days were 7.4+/-1.5, 10.6+/-1.7, and 5.5+/-1.4 (groups 1, 2, and 3, respectively) (p < 0.05; analysis of variance). Cost analysis showed that metallic stents were advantageous in patients surviving more than 6 months, whereas a plastic stent was advantageous in patients surviving 6 months or less. CONCLUSIONS: Metallic stents and plastic stents exchanged every 3 months are valuable alternatives for increasing complication-free survival in patients with malignant strictures of the common bile duct. Metal stents are advantageous in patients with the longest life expectancy.

Plastic and metal stents for postoperative benign bile duct strictures: the best and the worst.

Dumonceau JM. Deviere J. Delhaye M. Baize M. Cremer M.
Department of Gastroenterology and Hepatopancreatology, Erasme University Hospital, Brussels, Belgium.
BACKGROUND: Endoscopic treatment of postoperative benign bile duct strictures (BBDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined. METHODS: Forty-eight cases of postoperative BBDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed. RESULTS: Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50+/-12 and 44+/-34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values. CONCLUSION: Metal stents proved to be inadequate for treating postoperative BBDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.

Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings.

Chak A. Koehler MK. Sundaram SN. Cooper GS. Canto MI. Sivak MV Jr.
Division of Gastroenterology, University Hospitals of Cleveland, Ohio 44106-1736, USA.
BACKGROUND: Push enteroscopy is indicated in patients with suspected small bowel gastrointestinal bleeding or small bowel mucosal disease. Our aim was to determine the diagnostic yield of enteroscopy, identify clinical predictors associated with findings, and measure frequency of management changes made on the basis of results. METHODS: Endoscopy reports, office charts, and hospital charts were reviewed for 164 patients who had enteroscopy performed, primarily with a video enteroscope, during a period of 2 years. Data extraction included details of comorbid illnesses, associated risk factors, and previous endoscopies. RESULTS: Indications for enteroscopy were suspected occult bleeding in 65, overt bleeding in 64, diarrhea in 20, and suspected mucosal disease in 15 patients. Diagnostic lesions, identified in 92 patients (56%), included 57 jejunal lesions (35%). In patients with overt bleeding, upper tract lesions were present more commonly in patients receiving nonsteroidal medication (54% versus 27%, p < 0.05). Jejunal vascular ectasia occurred more frequently in patients with documented vascular ectasias elsewhere in the gastrointestinal tract (34% versus 15%, p < 0.01). Missed lesions on previous upper endoscopy included large hiatal hernias with erosions in 10, peptic ulcers in 10, and vascular ectasias in 9 patients. Therapeutic interventions, made in 67 of 92 patients (73%) with diagnostic lesions, included small bowel resection in 12 (8%), endoscopic therapy in 21 (14%), and changes in medical regimen in 34 patients (22%). CONCLUSIONS: Push enteroscopy with video enteroscopes has a moderate diagnostic yield. Positive findings frequently lead to therapy changes. Large hiatal hernias remain an under-recognized etiology of anemia. Repeat upper endoscopy should be considered before enteroscopy in patients taking nonsteroidals who develop overt bleeding.

Influence of biliary drainage catheter on bile duct wall thickness as measured by intraductal ultrasonography.

Tamada K. Tomiyama T. Ichiyama M. Oohashi A. Wada S. Nishizono T. Tano S. Aizawa T. Ido K. Kimura K.
Department of Gastroenterology, Jichi Medical School, Yakushiji, Tochigi, Japan.
OBJECTIVE: To determine the influence of biliary drainage catheter placement on bile duct wall thickness, we performed intraductal ultrasonography (IDUS) in patients before and after biliary drainage. METHODS: Patients underwent IDUS before and after either short-term (n = 9, 6 to 8 days) or long-term (n = 9, 14 to 35 days) biliary drainage using a thin (2.0 mm diameter), 20 MHz probe inserted by means of a transpapillary route or a percutaneous tract. The bile duct wall thickness (mean +/- standard deviation) was retrospectively measured at the upper portion of the common hepatic duct. RESULTS: The bile duct wall thickness increased from 0.8+/-0.4 mm (predrainage) to 2.0+/-1.6 mm (post-drainage) in the long-term group (p < 0.001) but was not significantly increased in the short-term group. CONCLUSIONS: The bile duct wall thickness as measured on IDUS appears to be increased after placement of biliary drainage catheters.

Intraportal endovascular ultrasonography for assessment of vascular invasion by biliary tract cancer.

Kaneko T. Nakao A. Nomoto S. Endo T. Ito S. Takagi H.
Department of Surgery II and Radiology, Faculty of Medicine, University of Nagoya, Japan.
BACKGROUND: This study was performed to investigate the diagnostic accuracy of intraportal endovascular ultrasonography (IPEUS) in assessing vascular invasion by biliary tract cancer. METHODS: A prospective study of 31 consecutive patients with biliary tract cancer was performed. All patients underwent surgery. The sonographic criterion for right hepatic artery invasion was interruption of the hyperechoic layer or encasement by tumor. The sonographic criterion for portal vein invasion was obliteration of the echogenic band of the portal vein. IPEUS findings were confirmed by surgical exploration and pathologic examination of resected specimens. RESULTS: Right hepatic artery invasion was confirmed in resected specimens in seven patients and by operative findings in four patients. Portal vein invasion was confirmed in resected specimens in six patients and by operative findings in five patients. For diagnosis of right hepatic artery invasion, the sensitivity, specificity, and overall accuracy of IPEUS were all 100%; respective values were 63.6%, 84.2%, and 76.7% for angiography. For diagnosis of portal vein invasion, the sensitivity, specificity, and overall accuracy of IPEUS were 100%, 95%, and 96.8%, respectively. The corresponding values were 63.6%, 89.5%, and 80% for portography and 54.5%, 85%, and 74.2%, respectively, for CT. CONCLUSION: IPEUS will improve the assessment of vascular invasion at the hepatic hilum by biliary tract cancer.

Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series.

Cellier C. Cuillerier E. Palazzo L. Rickaert F. Flejou JF. Napoleon B. Van Gansbeke D. Bely N. Ponsot P. Partensky C. Cugnenc PH. Barbier JP. Deviere J. Cremer M.
Department of Gastroenterology, Laennec Hospital, Paris, France.
BACKGROUND: Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery. METHODS: Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed. RESULTS: Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001). CONCLUSIONS: This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.

Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy.

Tham TC. Lichtenstein DR. Vandervoort J. Wong RC. Brooks D. Van Dam J. Ruymann F. Farraye F. Carr-Locke DL.
Division of Gastroenterology and Gastrointestinal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
BACKGROUND: We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using "stricter criteria" to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs). METHODS: A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using "stricter criteria" (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively. RESULTS: Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying "stricter criteria" to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs. CONCLUSIONS: Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using "stricter criteria" to select patients for preoperative ERCP can avoid unnecessary ERCPs.

Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study.

Year 1998
Siersema PD. Hop WC. Dees J. Tilanus HW. van Blankenstein M.
Department of Gastroenterology, University Hospital Rotterdam-Dijkzigt, The Netherlands.
BACKGROUND: Self-expanding metal stents seem to be safer than conventional prostheses for palliation of malignant esophagogastric obstruction. However, recurrent dysphagia caused by tumor ingrowth in uncoated types remains a problem. In addition, prior radiation and/or chemotherapy may entail an increased risk of complications. METHODS: Seventy-five patients with an esophagogastric carcinoma were randomly assigned to placement of a latex prosthesis under general anesthesia or a coated, self-expanding metal stent under sedation. At entry, patients were stratified for location of the tumor in the esophagus or cardia and for prior radiation and/or chemotherapy. RESULTS: Technical success and improvement in dysphagia score were similar in both groups. Major complications were more frequent with latex prostheses (47%) than with metal stents (16%) (odds ratio 4.07: 95% CI [1.35, 12.50], p = 0.014). Recurrent dysphagia was not different between latex prostheses (26%) and metal stents (24%). Hospital stay was longer, on average, after placement of latex prostheses than metal stents (6.3 +/- 5.2 versus 4.3 +/- 2.3 days; p = 0.043). Only prior radiation and/or chemotherapy increased the risk of specific device-related complications with respect to the esophagus (12 of 28 [43%] versus 8 of 47 [17%]; odds ratio 3.66: 95% CI [1.24, 10.82], p = 0.029). CONCLUSIONS: Coated, self-expanding metal stents are associated with fewer complications and shorter hospital stay as compared with latex prostheses, and prior radiation and/or chemotherapy increases the risk of device-related complications with respect to the esophagus.

Endoscopic ultrasound-guided, 18-gauge, fine needle aspiration biopsy of the pancreas using a 2.8 mm channel convex array echoendoscope.

Year 1998
Binmoeller KF. Thul R. Rathod V. Henke P. Brand B. Jabusch HC. Soehendra N.
University Hospital Eppendorf, Department of Endoscopic Surgery, Hamburg, Germany.
BACKGROUND: Previous studies have reported on endoscopic ultrasound-guided, fine needle aspiration biopsy using 22- to 25-gauge needles. We evaluated the histologic and cytologic yield of endoscopic ultrasound-guided, fine needle aspiration biopsy of the pancreas using an 18-gauge, Menghini-type core needle. METHODS: Fine needle aspiration biopsy was performed in conjunction with a prototype 2.8 mm channel convex array echoendoscope. The core specimen was placed in formalin for cell block, and residual material was expelled on slides for cytology. Definitive diagnosis was established by surgery or clinical follow-up. RESULTS: Of 45 patients who underwent fine needle aspiration biopsy, the needle failed to penetrate indurated pancreatic lesions in five. An average of 2.6 passes were performed in the remaining patients. Sufficient material for a histologic and/or cytologic diagnosis was obtained in 40 patients (histologic and cytologic yield of 68% and 75%, respectively). Combining the results of histology and cytology, the sensitivity and specificity for detection of malignancy was 76% and 100%, respectively. Histology confirmed the cytologic findings in 35 patients, providing additional tissue specific information. In three cases histology established a diagnosis of malignancy where cytology was not conclusively malignant. However, in three cases of surgically confirmed malignancy histology failed to detect malignancy, whereas cytology showed suspicious or malignant cells. The sensitivity of histology and cytology alone in detecting malignancy was 53% and 70%, respectively. Mild pancreatitis occurred after pancreatic fine needle aspiration biopsy in one patient. CONCLUSION: Core specimens for histology can be safely obtained using an 18-gauge needle. Histology provides tissue-specific information that complements cytology, but histology is less sensitive than cytology in detecting malignancy.

Endoscopic management of biliary strictures in liver transplant recipients: effect on patient and graft survival.

Year 1998
Rizk RS. McVicar JP. Emond MJ. Rohrmann CA Jr. Kowdley KV. Perkins J. Carithers RL Jr. Kimmey MB.
Department of Medicine, University of Washington at Seattle, 98195, USA.
BACKGROUND: Biliary strictures in liver transplant recipients cause significant morbidity and can lead to reduced patient and graft survival. METHODS: Of 251 liver transplant recipients, 22 patients with biliary strictures were categorized into two groups: donor hepatic duct (n = 12) or anastomotic (n = 10). Strictures were dilated and stented. Endoscopic therapy was considered successful if a patient did not require repeat stenting or dilation for 1 year. RESULTS: Patient and graft survival did not differ significantly in the 22 patients compared with patients without strictures (relative risk of death and graft survival 1.8 and 1.3). Donor hepatic duct strictures required significantly longer therapy than anastomotic strictures (median days 185 versus 67, p = 0.02). Twenty-two months after the first endoscopic treatment, 73% of the donor hepatic duct stricture group were stent free compared with 90% of the anastomotic group (p = 0.02). The former group had significantly more (p < 0.05) hepatic artery thrombosis (58.3% versus 10%), cholangitis (58.3% versus 30%), choledocholithiasis (91% versus 10%), and endoscopic interventions. No patient undergoing endoscopic treatment required retransplantation or biliary reconstruction during a median follow-up of 35.7 months. CONCLUSION: Endoscopic therapy of biliary strictures after liver transplantation is effective and is not accompanied by reduced patient or graft survival.

Enteroscopy for the initial evaluation of iron deficiency.

Year 1998
Chak A. Cooper GS. Canto MI. Pollack BJ. Sivak MV Jr.
Division of Gastroenterology, University Hospitals of Cleveland, Ohio 44106-1736, USA.
BACKGROUND: Occult gastrointestinal blood loss is generally investigated with colonoscopy and esophagogastroduodenoscopy in patients with iron-deficiency anemia. The aim of this study was to prospectively measure the additional diagnostic yield of examining the jejunum at the time of upper endoscopy in patients with iron-deficiency anemia. METHODS: Asymptomatic patients with newly diagnosed iron-deficiency anemia who had no identifiable source of blood loss at colonoscopy underwent standard esophagogastroduodenoscopy with the Olympus SIF100L enteroscope followed by overtube-assisted enteroscopy. Upper tract and jejunal sources of blood loss were noted. Biopsy samples from the small bowel were taken when a bleeding lesion was not identified. RESULTS: Thirty-one consecutive patients (13 men, mean age 71) with no gastrointestinal symptomatology were studied. Eleven patients (35%) had a bleeding source that required only esophagogastroduodenoscopy for identification; 8 patients (26%) had a source only in the jejunum; 2 patients (6%) (one with sprue) had a source in upper tract as well as jejunum. The enteroscopy was rated as causing minimal or mild discomfort in 25 of 31 patients (81%). Using Medicare reimbursement figures, a strategy of performing esophagogastroduodenoscopy first would have cost $656 per patient, whereas the strategy of performing esophagogastroduodenoscopy with enteroscopy as the initial test in all patients costs $467 per patient. CONCLUSIONS: Performance of push enteroscopy along with esophagogastroduodenoscopy increases the diagnostic yield from 41% to 67% when evaluating the upper gastrointestinal tract of asymptomatic patients with iron-deficiency anemia and, because of a lower cost, should be the preferred initial diagnostic test.

Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current.

Year 1998
Elta GH. Barnett JL. Wille RT. Brown KA. Chey WD. Scheiman JM.
Department of Internal Medicine, University of Michigan at Ann Arbor, 48109-0362, USA.
BACKGROUND: Complications after endoscopic biliary sphincterotomy occur in 8% to 10% of patients when studied prospectively. It is not known whether the type of electrocautery current affects this rate. Theoretically, less edema of the ampulla after a pure cutting current sphincterotomy could decrease the risk of pancreatitis although the risk of postsphincterotomy hemorrhage might be greater. METHODS: One hundred seventy patients undergoing sphincterotomy were prospectively randomized to either a blended or pure cut current on the Valleylab electrosurgical unit. The settings were a blended three current at a power setting of 30 watts/sec for both the cut and coagulation currents or a pure cut current at a power setting of 30 watts/sec. The individual determining whether a complication occurred was blinded to the type of current used, and all patients were hospitalized for 24 hours post-procedure. Pancreatitis was defined as mild if fewer than 5 days, moderate if 5 to 14 days, and severe if more than 14 days of hospitalization were required. RESULTS: Indications for sphincterotomy were choledocholithiasis in 111 patients, sphincter of Oddi dysfunction in 36 patients, stent placement in 15 patients, and miscellaneous in 8 patients. There were a total of 16 complications in 170 patients (9%); 4 (5%) were in the pure cut current group of 86 patients (one episode of bleeding that required transfusion of 4 U and three episodes of mild pancreatitis), and 12 (14%) were in the blended current group of 84 patients (7 mild, 2 moderate, and 1 severe pancreatitis; 1 case of cholangitis; and one episode of bleeding that required transfusion of 2 U). There were significantly fewer complications in the pure cut group (p < 0.05 by chi-square). CONCLUSION: The use of pure cut current is associated with a lower incidence of pancreatitis, the most common ERCP complication, than with blended current sphincterotomy. An insufficient number of patients were studied to comment on the relative risk of hemorrhage. However, because the complication of hemorrhage is much less common than pancreatitis, pure cut current is safer overall.

Immunoscopy--a technique combining endoscopy and immunofluorescence for diagnosis of colorectal carcinoma.

Year 1998
Keller R. Winde G. Eisenhawer C. Herwig R. Terpe HJ. Domschke W. Foerster EC.
Department of Medicine B, University of Munster, Germany.
BACKGROUND: Colorectal carcinoma is a common malignant disease with a high mortality rate. It arises most frequently in adenomas of the colorectum with different grades of dysplasia. Endoscopy and biopsy are among the most reliable diagnostic tools currently available. Diagnosis of malignancy at an early stage is sometimes difficult. This study reports on a new method, "immunoscopy", that combines endoscopy and immunofluorescent diagnostic procedures; it is the first reported use of locally applied fluorescein-labeled antibodies for detection of colorectal carcinomas. METHODS: A monoclonal antibody against carcinoembryonic antigen was fluorescein labeled. In phase I, formalin-fixed tissue samples, and in phase II, postoperative fresh tissue samples from tumorous and nontumorous areas of resected colorectal carcinomas were studied. After being incubated for 10 minutes, specific fluorescence was visualized with a conventional endoscope whose range was increased by means of two narrow band filters. RESULTS: Because of high levels of autofluorescence, evaluation of immunoscopic investigations using formalin fixed tissue (phase I) was not carried out. Immunoscopic investigation with postoperative fresh tissue samples could differentiate between tumorous and nontumorous areas (p < 0.001). Immunoscopic results were compared with data from immunohistochemical investigations with anti-carcinoembryonic antigen on the same tissue samples. CONCLUSIONS: Immunoscopy can differentiate between malignant and benign mucosal areas in fresh tissue samples. The high sensitivity of immunoscopy could potentially make it a useful diagnostic complement to routine endoscopy.

Reliability of panel-based guidelines for colonoscopy: an international comparison.

Year 1998
Burnand B. Vader JP. Froehlich F. Dupriez K. Larequi-Lauber T. Pache I. Dubois RW. Brook RH. Gonvers JJ.
Institute of Social and Preventive Medicine and Division of Gastroenterology, Medical Outpatient Clinic, University of Lausanne, Switzerland.
BACKGROUND: This study examined the reliability of explicit guidelines developed using the RAND-UCLA appropriateness method. METHODS: The appropriateness of over 400 indications for colonoscopy was rated by two multispecialty expert panels (United States and Switzerland). A nine-point scale was used, which was consolidated into three categories of appropriateness: appropriate, uncertain, inappropriate. The distribution of appropriateness ratings between the two panels and the intrapanel and interpanel agreement for categories of appropriateness were calculated for all possible indications. Similar statistics were calculated for a series of 577 primary care patients referred for colonoscopy in Switzerland. RESULTS: Over 80% of all indications (348) could be directly compared. The proportions of indications classified as appropriate, uncertain, or inappropriate were 28.4%, 24.7%, 46.6% and 33.0%, 23.0%, 44.0% for the U.S. and the Swiss panels, respectively. Interpanel agreement was excellent for all the possible indications (kappa value: 0.75) and lower for actual cases (kappa value: 0.51) because of lower agreement for the most frequently encountered indications. CONCLUSIONS: Good agreement between the two sets of criteria was found, pointing to the reliability of the method. Partial disagreement occurred essentially for a few, albeit frequently encountered, indications for use of colonoscopy in cases of uncomplicated lower abdominal pain or constipation.

Local staging of anal and distal colorectal tumors with the magnetic resonance endoscope.

Year 1998
Kulling D. Feldman DR. Kay CL. Bohning DE. Hoffman BJ. Van Velse AK. Baron PL. Lahr CJ. Hawes RH.
Department of Medicine, Medical University of South Carolina, Charleston 29425, USA.
BACKGROUND: We prospectively assessed the feasibility and accuracy of endoscopic magnetic resonance (EMR) scanning in the local staging of anal and colorectal cancer as compared to endosonography. METHODS: Fifteen patients with biopsy-proven anal (n = 2), rectal (n = 11), and distal colonic (n = 2) cancer underwent endosonography followed by EMR imaging. Scans were acquired using the magnetic resonance receiver coil incorporated into the tip of the non-ferromagnetic endoscope. Blinded to endosonography results, two radiologists interpreted the EMR images using the TNM system. Staging results were compared to endosonography in all patients and to histopathology in the 13 colorectal cases. RESULTS: EMR imaging, well tolerated in all patients, correlated with endosonography in 10 of 15 and 12 of 15 cases for T- and N-staging, respectively. In the 13 colorectal patients with available histopathology, accuracy of EMR and of endosonography in T-staging was 77% and 85%, respectively; N-staging accuracy was 62% for both. CONCLUSIONS: For anal and distal colorectal neoplasms, EMR imaging is feasible and provides local staging comparable to endosonography.

The use of a detachable mini-loop for the treatment of esophageal varices.

Year 1998
Sung JJ. Chung SC.
Department of Medicine, Prince of Wales Hospital, Shatin, Hong Kong, China.
BACKGROUND: Endoscopic variceal ligation is facilitated by multiband ligating devices, but these have limitations including a fixed number of bands, occasional failure to firmly ligate a variceal column, and relatively high cost. We report the use of a mini-loop for treatment of esophageal varices. METHODS: A detachable nylon ring (mini-loop), maximum diameter 11 mm, passed through the accessory channel of a standard endoscope is opened at the rim of a transparent ligation chamber attached to the instrument. By suction, a varix is brought into the chamber, the mini-loop is maneuvered over the varix, closed, and detached. RESULTS: Five ligation sessions (four to seven loops per session) were performed in four patients with upper gastrointestinal bleeding. There were variceal stigmata of bleeding, but no active hemorrhage. Application of all mini-loops was successful and did not induce uncontrolled bleeding. Endoscopy at 1 week disclosed superficial ulcers at ligation sites. Post procedure epigastric pain occurred in one patient. CONCLUSION: Detachable mini-loop ligation of esophageal varices is simple and safe, and a comparison study with a multi-band ligator device is warranted.

Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series.

Year 1998
Longstreth GF. Feitelberg SP.
Department of Medicine, Kaiser Permanente Health Care Program, San Diego, California, USA.
BACKGROUND: Acute upper gastrointestinal hemorrhage is a common reason for hospitalization. Clinical and endoscopic characteristics predict outcome. The aim of this study was to determine the characteristics and outcome of patients with acute upper gastrointestinal hemorrhage cared for without hospitalization. METHODS: One hundred seventy-six consecutive patients in a staff-model health maintenance organization were selected for outpatient care based on absolute endoscopic and non-absolute clinical criteria. Clinical and endoscopic characteristics, British national audit "risk scores," and rates of recurrent bleeding, hospitalization, and mortality were determined. RESULTS: Mean patient age (+/- SD) was 56.4 +/- 16.0 years, and 106 patients (60%) were men. One hundred one (57%) had endoscopy within 2 days of the onset of hemorrhage. The mean initial hemoglobin concentration was 11.7 +/- 2.3 mg/dL. Ninety-seven patients (55%) had a peptic ulcer, and 57 (32%) had a British risk score greater than 2. Hospitalization, recurrent bleeding, and mortality occurred in two (1%), one (1%), and zero (0%) patients, respectively, during 16.0 +/- 10.8 months of follow-up. CONCLUSIONS: Many patients with acute upper gastrointestinal hemorrhage can be safely treated as outpatients using endoscopic and clinical guidelines.

Effects of bolus somatostatin in preventing pancreatitis after endoscopic pancreatography: results of a randomized study.

Year 1998
Bordas JM. Toledo-Pimentel V. Llach J. Elena M. Mondelo F. Gines A. Teres J.
Gastrointestinal Endoscopy Section, Hospital Clinic I Provincial, University of Barcelona, Spain.
BACKGROUND: Pancreatitis is a potential problem in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Natural somatostatin reduces pancreatic secretion and has been administered in acute pancreatitis. To establish whether an injection of a single "bolus" of natural somatostatin is useful in preventing pancreatic reactions after endoscopic pancreatography, a randomized study was carried out in 160 patients undergoing pancreatography, associated or not, with endoscopic sphincterotomy. METHODS: Pancreatitis was considered to be present when there was the simultaneous appearance of serum amylase above 600 IU/mL and serum lipase above 200 IU, upper abdominal pain with tenderness, nausea and/or vomiting, and associated ileus, not completely resolved within 18 hours after the procedure and prolonging hospital stay. RESULTS: The incidence of pancreatitis (10% vs. 2.5%, p < 0.05) was higher in the placebo group than in the somatostatin-treated group. The difference in frequency of pancreatitis was statistically significant (18% vs 0%, p < 0.05) in the ERCP plus sphincterotomy subgroup but not significant (6% versus 4%) in the ERCP subgroup. CONCLUSIONS: These results suggest that the administration of a single bolus injection of natural somatostatin just before cannulation of the papilla may be useful in preventing pancreatitis. This procedure is useful in patients undergoing sphincterotomy. Further studies should be performed to determine whether this drug is useful in cases in which cannulation of the papilla is difficult or when therapeutic procedures require prolonged and/or aggressive manipulation of the papilla.

Injection sclerotherapy for variceal bleeding in patients with hepatocellular carcinoma: cyanoacrylate versus sodium tetradecyl sulphate.

Year 1998
Sung JJ. Yeo W. Suen R. Lee YT. Chung SC. Chan FK. Johnson PJ.
Department of Medicine, The Chinese University of Hong Kong.
BACKGROUND: Patients with hepatocellular carcinoma complicated by variceal bleeding have a very limited life span. Recurrent bleeding after endoscopic injection sclerotherapy is common. Our aim was to compare the efficacy of endoscopic injection of cyanoacrylate versus sodium tetradecyl sulphate in the control of variceal bleeding in patients with hepatocellular carcinoma. METHODS: Patients known to be suffering from inoperable hepatocellular carcinoma who presented with upper gastrointestinal bleeding underwent endoscopy within 24 hours of admission. After bleeding from esophageal varices was confirmed, they were randomized to receive endoscopic injections of either cyanoacrylate (1:1 mixture with Lipoidol) or sodium tetradecyl sulphate (1.5%). Injection were given intravariceally into each visible column for up to four injections for cyanoacrylate and up to 30 mL for sodium tetradecyl sulphate. RESULTS: A total of 50 patients were recruited for this study with 25 cases randomized to each endoscopic treatment group. Control of acute bleeding failed in four patients (16%) in both treatment groups, and two patients in each group died during the index episode of bleeding. Six patients (24%) in the cyanoacrylate group and four patients (16%) in the sodium tetradecyl sulphate group developed recurrent bleeding during their hospital stay (p = 0.48). Recurrent bleeding within 30 days after the index episode of bleeding was documented in seven patients (28%) who received cyanoacrylate injection and five patients (20%) who received sodium tetradecyl sulphate injection (p = 0.51). Median survival in the cyanoacrylate group was 16 days (range 1 to 485 days) and that of the sodium tetradecyl sulphate group was 13 days (range 1 to 407 days). There was no difference in cumulative survival between the two groups as analyzed by the Kaplan-Meier method. Patients with portal vein thrombosis had a higher risk of recurrent hemorrhage. Patients with Child's C liver disease had a significantly higher mortality. CONCLUSIONS: Cyanoacrylate did not improve the outcome of hepatocellular carcinoma patients with variceal hemorrhage.

Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique.

Year 1998
Elton E. Howell DA. Parsons WG. Qaseem T. Hanson BL.
Division of Gastroenterology, Maine Medical Center, Portland, USA.
BACKGROUND: Endoscopic pancreatic sphincterotomy is less widely practiced than biliary sphincterotomy, in part because of the lack of firm data regarding its indications and safety. In addition, recent reports of ductal and parenchymal changes occurring after pancreatic stenting raise concerns about the standard practice of stent placement at the time of pancreatic sphincterotomy. We report our experience with pancreatic sphincterotomy and describe the use of a technique involving overnight nasopancreatic drainage rather than stenting. METHODS: We reviewed the records of the 164 pancreatic sphincterotomies performed on 160 patients at our institution between January 1, 1991, and October 1, 1996, comparing procedures done with overnight nasopancreatic catheter placement with those done with stenting or no drainage. We also examined the long-term clinical outcome of patients after pancreatic sphincterotomy. RESULTS: Of the 164 sphincterotomies, 98 were done with overnight nasopancreatic drainage, 50 with stent placement, and 16 with no drainage. Complications (all pancreatitis) were significantly more frequent in the group with no drainage (12.5%) as compared with those with drainage (0.7%); p < 0.003. Nasopancreatic drainage was as safe as stent placement, with no complications after 98 procedures. Pancreatic sphincterotomy was effective when used as primary therapy, with 64% of patients so treated experiencing complete and long-lasting resolution of symptoms after the procedure. CONCLUSIONS: Pancreatic sphincterotomy is safe and effective, although pancreatic drainage is required to reduce the incidence of pancreatitis. Overnight nasopancreatic drainage is the method of choice, as it carries as low a complication rate as stent placement, but without the need for a repeat procedure, and presumably without the risk of ductal and parenchymal damage.

Accuracy of CLOtest after Helicobacter pylori therapy.

Year 1998
Laine L. Suchower L. Johnson E. Ronca P. Neil G.
University of Southern California School of Medicine, Los Angeles 90033, USA.
BACKGROUND: The accuracy of rapid urease testing after Helicobacter pylori therapy has not been widely studied and might be diminished because of decreased numbers of organisms. We assessed CLOtest results after therapy in two randomized, double-blind trials. METHODS: A total of 233 patients (in two separate studies) with true-positive baseline CLOtests (by histology or culture) received 2 weeks of omeprazole/amoxicillin, omeprazole, or amoxicillin. In study 1, patients received an additional 2 weeks of omeprazole therapy (20 mg/day) or placebo; no additional therapy was given in study 2. Endoscopy was repeated 4 weeks after completion of therapy in both studies. A diagnosis of cure required at least two negative endoscopic biopsy tests (histology, culture, CLOtest) and no positive tests. RESULTS: After therapy, 178 patients (76%) remained positive for H. pylori by histology and/or culture for both studies combined. Post-therapy CLOtest sensitivity was 86% and specificity was 95%. Sensitivity was poorer in patients after dual therapy than after monotherapy in both study 1 (68% vs. 89%; p = 0.03) and study 2 (75% vs. 94%; p = 0.03). CONCLUSIONS: CLOtest sensitivity after therapy was lower than expected in our large group of patients with baseline true-positive CLOtests. In addition, sensitivity was lower after the use of more effective therapy (i.e., dual therapy as compared with monotherapy). Although most patients with unsuccessful treatment will be identified with the CLOtest alone, a negative result should not be taken as diagnostic of eradication.

White ball appearance in endoscopic ligation of bleeding esophageal varices.

Year 1998
Matsutani S. Maruyama H. Sato G. Suzuki T. Umebara K. Mitsuhashi O. Fukuzawa T. Mizumoto H. Saisho H.
First Department of Medicine, Chiba University School of Medicine, Japan.
BACKGROUND: Endoscopic variceal ligation is useful in the control of bleeding from esophageal varices. However, confirmation of ligation precisely at the site of bleeding is usually difficult when treating massive variceal bleeding. Characteristic endoscopic findings that appeared when ligation was performed at the site of bleeding are reported in this article. METHODS: Emergency endoscopic variceal ligation was performed in 14 patients with active bleeding from esophageal varices. Endoscopic findings after variceal ligation at the site of bleeding were compared with those at sites without bleeding. RESULTS: Active bleeding ceased just after endoscopic ligation at the site of bleeding in all patients. After ligation of the bleeding site of the varix, an unusual white-colored ball-like appearance (white ball appearance) was observed in all patients. This finding was markedly different from the purple-colored ball-like appearance that is usually observed after ligation of a varix at a site without bleeding. CONCLUSIONS: White ball appearance was a characteristic finding that appeared after ligation of a varix at the site of bleeding. This finding may be useful in the confirmation of successful ligation of a varix at its bleeding site.

India ink tattooing in the esophagus.

Year 1998
Shaffer RT. Francis JM. Carrougher JG. Root SS. Angueira CE. Szyjkowski R. Kadakia SC.
Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, USA.
BACKGROUND: Precise endoscopic measurement of esophageal landmarks is difficult and inaccurate because of the ability of the esophagus to lengthen and foreshorten. METHODS: Nineteen patients enrolled to date in a study of Barrett's esophagus had an India ink tattoo placed at the most proximal level of the squamocolumnar junction and were examined endoscopically at 3, 9, 15, 24, and 36 months. RESULTS: Eighteen of nineteen patients (94.7%) were judged to have a good to excellent tattoo persistence at 3 months. One of the 19 patients (5.3%) had poor tattoo persistence and was retattooed at the 3-month interval. Eventually, 15 of the 15 patients (100%) who remained in the study had a good or excellent tattoo persistence at 36 months. There were no complications related to India ink tattooing including chest pain, bleeding, or perforation. At follow-up endoscopy, no ulcers, inflammation, break in the mucosa, or pain were noted. CONCLUSION: India ink tattooing in the esophagus is safe and persistent and may be used as an effective method for longitudinal follow-up of lesions in the esophagus.

Palliation of malignant gastric outlet obstruction using an endoscopically placed Wallstent.

Year 1998
Soetikno RM. Lichtenstein DR. Vandervoort J. Wong RC. Roston AD. Slivka A. Montes H. Carr-Locke DL.
Division of Gastroenterology, Brigham and Women's Hospital, Harvard University Medical School, Boston, Massachusetts 02215, USA.
BACKGROUND: Treatment options for malignant gastric outlet obstruction are limited. Surgical gastrojejunostomy, commonly performed, has significant morbidity and mortality. METHODS: Over 2 years, we prospectively studied the safety, feasibility, and outcomes for use of a newly designed expandable metal stent (Wallstent Enteral; Schneider, Minneapolis, Minn.) to treat malignant gastric outlet obstruction. Stents 16 to 22 mm in diameter and 60 to 90 mm in length were deployed directly through the endoscope. RESULTS: Twelve patients (ten women, two men; mean age 59.7 years) underwent stenting. Thereafter, six patients were able to eat a regular diet; three could eat pureed food. In three patients, the procedure was unsuccessful because of multiple obstructions not recognized before stenting (one) and stents deployed too proximally (one) or too distally (one). CONCLUSIONS: Placement of a newly designed stent through the endoscope is safe and effective palliation for various types of malignant gastric outlet obstruction and significantly improves many aspects of patient quality of life.

Expandable metallic prostheses for malignant obstructions of gastric outlet and proximal small bowel.

Year 1998
Nevitt AW. Vida F. Kozarek RA. Traverso LW. Raltz SL.
Department of Radiology, Virginia Mason Medical Center, Seattle, Washington 98111, USA.
BACKGROUND: Data are limited on use of expandable metal stents for treatment of malignant gastric outlet obstruction. Accordingly, we report our experience using these stents to palliate malignant obstructions of the gastric outlet, duodenum, and proximal jejunum. METHODS: Eight patients with malignant strictures causing gastric obstruction underwent endoscopy with fluoroscopic guidance to delineate tumor borders and length followed by expandable metallic prosthesis placement (Wallstent, Z-Stent, Ultraflex, and Endocoil). RESULTS: Symptoms were relieved in seven patients, five of whom had previous surgeries (Whipple, Billroth II, esophagojejunostomy, and gastrojejunostomy) for malignancy. One patient underwent surgical resection of a presumed malignant stricture containing a previously placed Wallstent after a 45-pound weight gain. CONCLUSIONS: Expandable metallic prostheses placed in patients with malignant obstruction of the gastric outlet, duodenum, or proximal jejunum, before or after surgery, effectively palliate obstructive symptoms and may also serve to improve nutrition.

Expandable metal stents for the treatment of colonic obstruction: techniques and outcomes.

Year 1998
Baron TH. Dean PA. Yates MR 3rd. Canon C. Koehler RE.
Department of Medicine, University of Alabama at Birmingham Medical Center, 35294-0007, USA.
BACKGROUND: Acute left-sided colonic obstruction is a surgical emergency whose management is controversial. Because experience using expandable metal stents for relief of this type of obstruction is limited, we evaluated their effectiveness, feasibility, safety, and outcome. METHODS: Twenty-five patients with acute colorectal obstruction underwent placement of various metal stents under fluoroscopic and endoscopic guidance. On an intent-to-treat basis, stents were placed for decompression before one-stage surgical resection in 10 patients and palliatively in 15 patients. Two preoperative patients had unresectable malignant disease, and stents were left for palliation resulting in 17 palliative and 10 preoperative patients for analysis. RESULTS: Stent placement was technically successful in 94% of patients. Overall effectiveness in relieving obstruction was 85% (palliative 82%, preoperative 90%). In the palliative group, stent duration ranged from 2 to 64 weeks (mean 17.3 weeks). Major complications occurred in 7 patients (30%). CONCLUSIONS: Expandable metal stents are a feasible, effective adjunct and alternative to surgery for acute colorectal obstruction.

Randomized study of intracorporeal laser lithotripsy versus extracorporeal shock-wave lithotripsy for difficult bile duct stones.

Year 1998
Neuhaus H. Zillinger C. Born P. Ott R. Allescher H. Rosch T. Classen M.
Medizinische Klinik, Evangelisches Krankenhaus, Dusseldorf, Germany.
BACKGROUND: Endoscopic treatment modalities are well established for the removal of bile duct stones. For the small percentage of stones that are difficult or impossible to extract by conventional means, more sophisticated endoscopic techniques or associated modalities such as intracorporeal laser lithotripsy (ILL) and extracorporeal shock wave lithotripsy (ESWL) have to be applied. Little is known, however, about the relative value of these different techniques. We therefore compared endoscopic ILL with ESWL in patients with difficult bile duct stones in a prospective randomized study. METHODS: The study included 60 patients (35 women; mean age 70+/-15 years) with bile duct stones in whom standard extraction failed (n=33) or in whom the papilla was not accessible, thus requiring percutaneous access (n=27). They were randomized to receive ESWL under fluoroscopic targeting (maximum discharge number per session: 6000) or ILL using a pulsed dye laser with an automatic stone recognition system, which was mostly performed (28 of 30 cases) under cholangioscopic control. Endoscopic removal of fragments was attempted within the subsequent (ESWL) or the same (ILL) session. Failure was defined as failure to remove all ductal stones/fragments after a maximum of three lithotripsy sessions. RESULTS: There were no statistical differences in background variables between the two groups. Bile duct clearance was achieved in 22 of 30 patients (73%) in the ESWL group and in 29 of 30 patients (97%) in the ILL group (p < 0.05). The number of treatment sessions (ESWL 3.0+/-1.3; ILL 1.2+/-0.4; p < 0.001) and the duration of treatment (ESWL 3.9+/-3.5 days; ILL 0.9+/-2.3 days; p < 0.001) were also significantly different in favor of ILL. Two minor complications occurred in each group; there was no 30-day mortality. Crossover therapy to ILL led to stone removal in seven of the eight cases in which ESWL failed, whereas ESWL fragmented the stone in the single patient in whom ILL failed. CONCLUSIONS: ILL is more effective in the treatment of difficult bile duct stones than ESWL in terms of stone clearance rate and treatment duration.

EUS-guided, fine-needle aspiration biopsy using a new mechanical scanning puncture echoendoscope.

Year 1998
Binmoeller KF. Brand B. Thul R. Rathod V. Soehendra N.
University Hospital Eppendorf, Department of Endoscopic Surgery, Hamburg, Germany.
BACKGROUND: A new mechanical sector scanning echoendoscope designed for EUS-guided, fine-needle aspiration biopsy (FNAB) was prospectively evaluated. The technical feasibility, safety, and histocytologic FNAB results are reported. METHODS: Eighty-six patients underwent 106 FNAB procedures. The new echoendoscope has a 2.8 mm accessory channel and an elevator. Target sites: pancreas 58, lymph nodes 43, and miscellaneous lesions 5. Lesions were punctured with a 0.7 mm needle and submitted for cytologic and histologic examination. Definitive diagnosis was by surgery or clinical follow-up. RESULTS: The wide scanning field (250 degrees) enabled easy sonographic orientation for FNAB. Longitudinal needle visibility was "good" in 93% and 71% of transesophageal and transgastric procedures, respectively, but were compromised during most transduodenal procedures. Needle penetration of indurated pancreatic lesions failed in two patients, and in four additional patients pancreatic sampling succeeded only after a second attempt using an automated spring-loaded device. The mean number of passes was three. Ten percent of FNAB specimens were "inadequate"; excluding these, the diagnostic accuracy rate was 97%; sensitivity for malignancy was 88.5% and specificity was 100%. CONCLUSION: EUS-guided FNAB is feasible, safe, and accurate using the new mechanical puncture echoendoscope. Needle visibility needs to be improved, particularly for transduodenal FNAB.

Characterization of biliary strictures using intraductal ultrasonography: comparison with percutaneous cholangioscopic biopsy.

Year 1998
Tamada K. Ueno N. Tomiyama T. Oohashi A. Wada S. Nishizono T. Tano S. Aizawa T. Ido K. Kimura K.
Department of Gastroenterology, Jichi Medical School, Tochigi, Japan.
BACKGROUND: We determined the accuracy of intraductal ultrasonography (IDUS) in distinguishing between bile duct cancer and benign bile duct disease. METHODS: Patients (n=42) who required bile duct biopsy using percutaneous transhepatic cholangioscopy (PTCS) to evaluate bile duct strictures or filling defects were studied. A thin-caliber ultrasonic probe (2.0 mm diameter and 20 MHz frequency) was inserted into the bile duct, and its images were prospectively reviewed before PTCS. RESULTS: Disruption of the bile duct wall structure, seen on IDUS, was associated with malignancy in 25 of 26 patients. When IDUS demonstrated a lesion with normal bile duct structure, six of nine patients were found to have no malignancy. IDUS demonstrated no intraductal lesion in seven patients, and bile duct biopsy also did not indicate cancer in any of these patients. The accuracy, sensitivity, and specificity of IDUS for diagnosing bile duct cancer were 76%, 89%, and 50%, respectively. When used in tandem with IDUS, the sensitivity of bile cytology (64%) and PTCS (93%) improved to 96% and 100%, respectively. CONCLUSIONS: The accuracy of IDUS for diagnosing bile duct cancer was less than that of PTCS (95%). However, the sensitivity for bile cytology, or bile duct biopsy improved when performed in combination with IDUS.

Utility of preoperative fiberoptic flexible sigmoidoscopy in the evaluation of patients with suspected gynecologic malignancy.

Year 1998
Lawitz E. Kadakia SC.
United States Army Medical Corps, Gastroenterology Service, Brooke Army Medical Center, Fort Sam Houston, Texas 78234-6200, USA.
BACKGROUND: Fiberoptic flexible sigmoidoscopy (FFS) is routinely requested preoperatively as part of evaluation of pelvic masses to exclude colonic involvement by the tumor or concurrent colonic neoplasm. The aim of our study was to evaluate the utility of preoperative FFS in patients with suspected gynecologic malignancy. METHODS: FFS, performed using a 60 cm sigmoidoscope, evaluated (1) presence of bowel involvement by the tumor, (2) extrinsic compression by the tumor, and (3) presence of colonic neoplasms. FFS findings were correlated with surgical findings. RESULTS: A total of 107 women underwent preoperative FFS and subsequent surgery. Eleven patients (11%) had lower gastrointestinal symptoms. At surgery, 63% of pelvic tumors were malignant and 37% were benign. The most common abnormality at FFS was colonic polyps in 23 patients (21%). Colonic adenomas were found in 11 patients (10%). Extrinsic compression by the tumor without mucosal abnormalities was seen in 15 patients (14%). The most common intraoperative finding was tumor adhering to the bowel in 18 patients requiring dissection, but only 1 patient required bowel resection. Eight of these 18 patients had preoperative lower gastrointestinal symptoms. All 15 patients with extrinsic compression at FFS had tumor adhering to the bowel. CONCLUSIONS: Pelvic masses cause extrinsic compression at FFS in 14% of patients. This is suggestive of tumor adherent to the bowel at surgery. However, bowel resection is rarely required because of tumor involvement. Most patients with bowel adherence by tumor have lower gastrointestinal symptoms. Colonic adenomas are found in one tenth of patients, mostly in patients older than 50 years of age. Preoperative FFS does not change the surgical management of pelvic tumors. Screening FFS is indicated in all patients with pelvic tumors over age 50, as in persons with average risk, but is otherwise unnecessary in evaluation of pelvic masses.

Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage.

Year 1998
Chang WH. Kortan P. Haber GB.
Division of Gastroenterology, The Wellesley Hospital, University of Toronto, Ontario, Canada.
BACKGROUND: There is much controversy as to the importance of establishing drainage of both liver lobes in malignant hilar obstruction. The purpose of the present study was to compare survival data in patients with malignant hilar obstruction, stratified according to the Bismuth classification, who had cholangiography with filling of one or both hepatic ducts and subsequently endoscopic or percutaneous drainage of one or both ducts. METHODS: A retrospective review was performed for the time period from July 1990 to July 1995, and 224 patients were identified with a presumed diagnosis of a bifurcation tumor. All x-ray films were reviewed and 150 patients finally diagnosed as hilar tumor were classified according to Bismuth type I, II, or III. Type II and III patients were further subclassified with respect to contrast injection into a single or both hepatic duct systems and whether one or both sides were eventually drained. RESULTS: Data were obtained in 141 patients (4 patients still alive); there were 43 type I, 58 type II, and 40 type III. Type II and III patients were divided into three groups: group A, one lobe opacified with same lobe drained; group B, both lobes opacified with both lobes drained; and group C, both lobes opacified with one lobe drained. Overall median survival for type I, II, and III patients was 160, 131, and 62 days, respectively. Among type II and III patients the median survivals of groups A, B, and C were 145, 225, and 46 days, respectively. Survival was significantly longer in group A vs. group C (p < 0.001), group B vs. group C (p < 0.001, and group A + B (165 days) vs. group C p < 0.001). There was no difference in group A + B versus type I (p=0.90). In addition, when comparing single drain only (group A + C, 80 days) versus double drains (group B, 225 days), there was a significant survival advantage (p < 0.0001). CONCLUSION: In bifurcation tumors the best survival was noted in those with bilateral drainage, and the worst survival in those with cholangiographic opacification of both lobes but drainage of only one.

Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results.

Year 1998
Etzkorn KP. Diab F. Brown RD. Dodda G. Edelstein B. Bedford R. Venu RP.
Therapeutic Endoscopy Services, University of Illinois at Chicago, 60612-7323, USA.
BACKGROUND: Conscious sedation is usually used during endoscopic retrograde cholangiopancreatography (ERCP). Little is known about the indications and outcomes for ERCP in patients who cannot undergo conscious sedation and therefore require general anesthesia. We retrospectively evaluated the indications and outcome for patients undergoing ERCP who required general anesthesia at four teaching hospitals over a 2-year period. METHODS: Of 1200 ERCPs performed over a 2-year period, 65 patients required general anesthesia. Retrospective chart analysis was undertaken to determine indications and outcomes of ERCP performed under general anesthesia. Eleven patients underwent sphincter of Oddi manometry. RESULTS: The major indication for general anesthesia was substance abuse. Therapeutic intervention was successful in 45 of 48 patients; 6 of the 63 patients had complications, all mild and not related to the anesthesia. Sphincter of Oddi manometry was normal in 7 patients; 4 patients had elevated basal pressures. CONCLUSIONS: ERCP under general anesthesia may be considered when conscious sedation fails to achieve a satisfactory level of sedation for a successful and safe ERCP. Procedure-related complication rates appear to be comparable if not lower with general anesthesia.

Emergency endoscopic retrograde cholangiopancreatography in critically ill patients.

Year 1998
Ramirez FC. McIntosh AS. Dennert B. Harlan JR.
Department of Medicine, Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Arizona 85012, USA.
BACKGROUND: The aim of this study was to assess the frequency, indications, yield, and outcome of emergency endoscopic retrograde cholangiopancreatography (ERCP) in critically ill patients. METHODS: Records of all intensive care unit patients undergoing emergency ERCP were reviewed over a 40-month period. Indications, findings, therapeutic interventions, and survival were analyzed. Those requiring mechanical ventilation at the time of ERCP were in group A and those who did not were in group B. RESULTS: Of 1781 ERCPs, 32 (1.80%) were performed on intensive care unit patients. Fifteen patients belonged to group A (46.87%) and 17 (53.13%) to group B. The common bile duct was the duct of interest in 30 patients (94%) and was cannulated in 97%. Indications included possible biliary sepsis (68.75%), gallstone pancreatitis, and jaundice (12.5% each). The most common finding was choledocholithiasis (34%), followed by failure to fill the cystic duct (16%) and common bile duct stricture (9%). A normal examination was present in 18.75% of cases. Endoscopic therapy was required in 66.6% of patients in group A and 70.5% of group B. The overall 30-day mortality was 25% (33% for group A and 17.6% for group B) and not related to the ERCP. CONCLUSIONS: Two percent of all ERCPs performed were on intensive care unit patients (47% requiring mechanical ventilation) primarily to evaluate for possible biliary sepsis. Technical success was not compromised by mechanical ventilation. Therapeutic intervention was required in more than two thirds of patients and the overall 30-day mortality was 25%.

Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope.

Year 1998
Zaman A. Katon RM.
Department of Medicine, Oregon Health Sciences University, Portland 97210, USA.
BACKGROUND: The use of push enteroscopy to evaluate patients with obscure gastrointestinal bleeding has increased in recent years, and diagnostic yield has been reported to be 50% to 65%. This yield may be an overestimate of accuracy, as some lesions found during enteroscopy are within reach of a standard endoscope. METHODS: Ninety-five patients underwent push enteroscopy for obscure gastrointestinal bleeding. There were 58 men and 37 women with a mean age of 67 years (range 32 to 93 years). Diagnostic yield and patient outcome were assessed. RESULTS: A suspected source of bleeding was found in 39 of 95 patients (16 of these patients had endoscopic treatment of their lesions). Proximal lesions (at or above the main duodenal papilla) accounted for 25 of 39 sources (64%), including Cameron ulcers and arteriovenous malformations of the stomach/proximal duodenum. Distal lesions accounted for 14 of 39 sources (36%) with arteriovenous malformations (n=0) being most common. Patients who underwent some form of treatment (medical, surgical, or endoscopic) because of an enteroscopic finding had a statistically better outcome than patients without a lesion (73% vs. 47%, p < 0.05). CONCLUSIONS: Push enteroscopy identified a presumed bleeding source in 41 % of patients with obscure gastrointestinal bleeding. However, 64% were within reach of a standard endoscope. Repeat standard endoscopy should be considered before push enteroscopy for obscure gastrointestinal bleeding, and during enteroscopy meticulous attention should be given to the proximal gastrointestinal tract in addition to the distal duodenum and jejunum.

Effectiveness of premedication with pronase for improving visibility during gastroendoscopy: a randomized controlled trial.

Year 1998
Fujii T. Iishi H. Tatsuta M. Hirasawa R. Uedo N. Hifumi K. Omori M.
Department of Nursing, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan.
BACKGROUND: Minute early gastric cancers can be removed with endoscopic mucosal resection techniques. However, early detection of these minute cancers with endoscopy is still difficult. For this purpose, use of a dye is helpful. To increase visibility further, gastric mucus should be removed before endoscopic examination. In this study, the effectiveness of premedication with pronase for improving visibility during gastroendoscopy was investigated. METHODS: From January through July 1996, outpatients scheduled for gastroendoscopy were randomly assigned to oral premedication with the antifoam agent dimethylpolysiloxane alone (n=34), with dimethylpolysiloxane plus sodium bicarbonate (n=32), or with dimethylpolysiloxane, sodium bicarbonate, and pronase (n=34). All were given about 10 minutes before the start of endoscopy. After inserting the endoscope, the endoscopist gave visibility scores at conventional endoscopy and after methylene blue spraying. RESULTS: Premedication with pronase significantly improved visibility before and after methylene blue spraying as compared with the two other groups pretreated without pronase. Pronase also significantly shortened the times for chromoendoscopic examination. Pronase had no significant effect on the culture of Helicobacter pylori. CONCLUSION: Premedication with pronase improved endoscopic visualization during conventional endoscopy and chromoendoscopy. Its routine use at gastroendoscopy is therefore recommended.

Subumbilical midline vascularity of the abdominal wall in portal hypertension observed at laparoscopy.

Year 1998
Oelsner DH. Caldwell SH. Coles M. Driscoll CJ.
The University of Virginia, Department of Internal Medicine, Charlottesville, USA.
BACKGROUND: Large volume paracentesis is a common treatment of ascites. Injury to abdominal wall collateral veins during this procedure can lead to hemoperitoneum. Because of this concern, the midline below the umbilicus is often recommended as a site for paracentesis because of its presumed avascularity. METHODS: We examined the subumbilical peritoneal surface in 20 consecutive patients with liver disease undergoing diagnostic laparoscopy. This area was visualized by table tilting and confirmed by external finger compression. Nineteen patients had cirrhosis of various etiologies, and one had advanced fibrosis with evidence of portal hypertension. RESULTS: In these 20 patients, only 7 had avascular midlines below the umbilicus. Seven had small but definite veins running along the path of the urachus (median umbilical fold), and 6 had more prominent veins in this region. The internal landmarks in this region (median and medial folds) were frequently asymmetric with regard to the external appearance of the midline. CONCLUSION: The subumbilical midline in patients with portal hypertension is commonly vascular. When using this site for paracentesis, care should be exercised to identify venous structures with the narrow-gauge needle used to inject local anesthetic agent before placement of larger paracentesis needles.

Usefulness of laparoscopy with liver biopsy in the assessment of liver involvement at diagnosis of Hodgkins and non-Hodgkins lymphomas.

Year 1998
Sans M. Andreu V. Bordas JM. Llach J. Lopez-Guillermo A. Cervantes F. Bruguera M. Mondelo F. Montserrat E. Teres J. Rodes J.
Liver Unit and Hematology Department Hospital Clinic i Provincial, Barcelona, Spain.
BACKGROUND: Staging of lymphoma at diagnosis determines therapeutic strategy and disease prognosis. Hepatic involvement, demonstrated by laparotomy or laparoscopy, is frequent in Hodgkin's and non-Hodgkin's lymphoma. However, it is unclear whether these procedures are still necessary or whether they should be replaced by less invasive techniques. METHODS: Laparoscopy-assisted liver biopsies, as well as laboratory studies, bone marrow biopsy, and thoracic and abdominal computed tomography, were performed as an initial staging evaluation in 112 consecutive patients who were diagnosed with Hodgkin's or non-Hodgkin's lymphoma. RESULTS: Hepatic lymphomatous involvement was demonstrated in 18 patients (16%). It was more frequent in non-Hodgkin's (24%) than in Hodgkin's (8%) lymphomas (p < 0.04) and among stage III and IV (24%) than stage I and 11 (10%) patients (p < 0.05). The laparoscopic finding of white spots or nodules on the liver surface had a 100% specificity in the diagnosis of lymphomatous liver involvement. Conversely, hepatomegaly on both laparoscopy and computed tomography, as well as laboratory studies, had a low sensitivity and specificity. CONCLUSIONS: Laparoscopy-assisted liver biopsy was a useful technique to establish hepatic lymphomatous involvement, which was not identified by either computed tomography or laboratory studies.

Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy.

Year 1998
Fogel EL. Sherman S. Lehman GA.
Indiana University Medical Center, Indianapolis, USA.
BACKGROUND: Selective biliary cannulation is often difficult when there is a periampullary diverticulum, especially when the papilla is within the diverticulum. We report eight such cases in which a new technique was used to achieve biliary access. METHODS: Among 4138 ERCPs, there were 246 cases (5.9%) with periampullary diverticula. Biliary cannulation initially failed in eight patients (3.3%), five of whom had previously undergone six failed attempts at other institutions. A technique was used whereby the papilla was kept out of the diverticulum by placement of a pancreatic duct stent. Needle-knife sphincterotomy was then performed followed by attempts to achieve biliary access. RESULTS: Biliary entry was immediately successful in five patients and successful at a second ERCP in two (overall success 87.5%). Two patients developed post-ERCP pancreatitis. CONCLUSIONS: When the papilla is within the periampullary diverticulum, placement of a main pancreatic duct stent keeps the papilla out of the diverticulum, thereby facilitating pre-cut needle-knife sphincterotomy and selective biliary cannulation.

Emergency endoscopic ligation of actively bleeding gastric varices with a detachable snare.

Year 1998
Cipolletta L. Bianco MA. Rotondano G. Piscopo R. Prisco A. Garofano ML.
Servizio di Gastroenterologia ed Endoscopia Digestiva, Ospedale A. Maresca, Torre del Greco, Italy.
BACKGROUND: Bleeding gastric varices (BGV) is a challenging condition whose management remains controversial and often empirical. METHODS: Over the past 6 months, emergency ligation of BGV was performed in seven cirrhotic patients (five men, two women; age range 47 to 70 years) using a detachable snare. Child's grade was B in two and C in five patients. Two patients had a concurrent hepatocellular carcinoma. Three patients had been previously treated with either balloon tamponade or injection sclerotherapy for bleeding esophageal varices. RESULTS: Hemostasis was achieved in all patients. Morbidity consisted of fever in one case. Six snares passed spontaneously, one was removed from the stomach on follow-up examination. Post-ligation ulcers were detected in all patients after treatment (mean diameter 7.4+/-2.1 mm) with no stigmata of recurrent hemorrhage. No early rebleeding was observed during hospital stay. On a mean follow-up of 3.8 months (range 2 to 6 months), no digestive hemorrhage was recorded. Ligated gastric varices were significantly 'reduced in size in four patients. CONCLUSIONS: Emergency ligation with detachable snare is feasible and may be an alternative life-saving method of endoscopic hemostasis in BGV.

Usefulness of videoduodenoscopy and vital dye staining as indicators of mucosal atrophy of celiac disease: assessment of interobserver agreement.

Year 1998
Niveloni S. Fiorini A. Dezi R. Pedreira S. Smecuol E. Vazquez H. Cabanne A. Boerr LA. Valero J. Kogan Z. Maurino E. Bai JC.
Clinical Department, Salvador University, Buenos Aires, Argentina.
BACKGROUND: The present study was designed to determine the diagnostic usefulness of videoduodenoscopic inspection alone and the addition of vital dye staining in the detection of celiac disease. We additionally sought to evaluate interobserver agreement for specific duodenoscopic markers of mucosal atrophy. METHODS: One hundred sixty-seven consecutive subjects who underwent duodenoscopy for intestinal biopsy were included in a prospective controlled study. Endoscopic examination was performed by experienced endoscopists according to a set protocol using methylene blue (1%) dye. All procedures were recorded on videotape, but only 20 (10 with atrophy and 10 normal) were used in a blinded, independent, randomized analysis by five reviewers to evaluate interobserver agreement. Endoscopic signs indicative of mucosal atrophy were as follows: reduction in the number or loss of Kerkring's folds, "scalloped" folds, "mosaic pattern," and visualization of the underlying blood vessels. RESULTS: Eighty-seven patients had celiac disease (57 newly diagnosed, 30 when treated). Seven treated patients had nonatrophic mucosa. In 80 patients the final diagnosis excluded celiac disease. Videoendoscopic inspection alone correctly identified 75 of 80 patients with complete mucosal atrophy and 86 of 87 with normal mucosa. False-negative diagnoses occurred in treated celiac patients with mild atrophy. Mosaic pattern (89%) and scalloped folds (86%) were the most useful endoscopic signs. Vital dye staining, as assessed by experienced endoscopists, provided identical results to those obtained by inspection alone. Sensitivity, specificity, and positive and negative predictive values for the presence of one or more than one feature were 94%, 100%, 100%, and 96%, respectively. The agreement (kappa statistics) among observers was excellent for the mosaic pattern (kappa: 0.76 for both the videoendoscopic inspection alone and dye staining) and the scalloped folds (kappa: 0.83 and 0.76, respectively) and was fair (kappa: 0.41 and 0.59, respectively) for the reduction in the number or loss of duodenal folds. CONCLUSION: This study confirms that videoduodenoscopy is useful in the detection of intestinal atrophy. Dye staining produces a better delineation of scalloped folds and mosaic pattern in the atrophic mucosa, but did not provide additional information to the expert endoscopist. Finally, interobserver agreement was excellent for the most prevalent signs.