A Weber

Long-term follow-up of percutaneous transhepatic biliary drainage (PTBD) in patients with benign bilioenterostomy stricture

BACKGROUND AND AIMS Anastomotic strictures are well-known complications after bilioenterostomy. Endoscopic procedures are usually not possible in patients with a bilioenterostomy. Hence, percutaneous transhepatic biliary drainage (PTBD) has become the treatment of choice for the management of these patients. The main goal of the present study was to analyze the long-term follow-up of PTBD in such patients. METHODS AND PATIENTS Between January 1996 and December 2006, 44 patients with benign anastomotic stricture after bilioenterostomy were identified by an analysis of the PTBD database, hospital charts, and cholangiograms. RESULTS In 27/44 patients the percutaneous transhepatic biliary drain was successfully removed after 19.9 +/- 16.1 months (treatment success in 61.4 %). During a mean follow-up of 53.7 +/- 28.4 months after removal of the drain, no evidence was found of recurrent strictures in these patients. Ten out of 44 patients carry permanent drains (22.6 % of patients with ongoing treatment, mean follow-up 46.4 +/- 54.7 months) without the option for further surgery owing to concomitant disease (n = 2) or because they refused further surgery (n = 8). In 7 out of 44 patients (16 %) PTBD treatment was deemed to have failed and the patients underwent repeat operation. CONCLUSIONS PTBD should be considered the treatment of choice in patients with benign anastomotic stricture after bilioenterostomy, especially after stricturing of a hepatojejunostomy.

Narrow-band imaging vs. high definition white light for optical diagnosis of small colorectal polyps: a randomized multicenter trial.

BACKGROUND AND STUDY AIM The aim of the study was to compare the latest narrow-band imaging (NBI) device with high-definition white light (HDWL) endoscopy for accuracy of real-time optical diagnosis of small colorectal polyps. PATIENTS AND METHODS We conducted a randomized, prospective, multicenter trial at three study sites in Germany. In the NBI arm, endoscopists used NBI for the prediction of polyp pathology on the basis of the NBI International Colorectal Endoscopic classification. In the HDWL arm, NBI was not used for optical classification of polyp histology. The primary outcome was accuracy of optical diagnoses (neoplastic vs. non-neoplastic) in small polyps measuring < 10 mm. Secondary end points included sensitivity and negative predictive value (NPV). RESULTS A total of 380 patients were randomized 1:1 to either the NBI or HDWL arm. A total of 421 polyps measuring < 10 mm were detected (55.8 % neoplastic, 44.2 % non-neoplastic). Accuracy, sensitivity, and NPV were 73.7 %, 82.4 %, and 75.5 %, respectively, in the NBI arm and 79.2 %, 79.8 %, and 73.4 %, respectively, in the HDWL arm (P = 0.225, P = 0.667, P = 0.765). More polyps were assessed with high confidence in the HDWL arm (82.6 %) than in the NBI arm (73.7 %; P = 0.038). The NPV of the prediction of neoplastic histology in diminutive polyps (≤ 5 mm) rated with high confidence was 90.3 % in the NBI arm. We detected significant differences between the participating study sites in the performance data of predictions. CONCLUSION The levels of accuracy for real-time prediction of polyp histology (< 10 mm) did not differ between NBI and HDWL for optical diagnosis. Variation in the performance of optical diagnosis was apparent between study centers. TRIAL REGISTRATION ClinicalTrials.gov (NCT02009774).

Patient position and hypoxemia during propofol sedation for colonoscopy: a randomized trial

AIM To evaluate the benefits of the left lateral position in avoiding hypoxemic events in patients undergoing colonoscopy. METHODS We conducted a randomized, prospective, controlled trial at two study sites in Germany. Patients undergoing colonoscopy under propofol sedation were randomized to either the supine or left lateral position. The primary outcome was oxygen desaturation (SaO2<90%). Secondary outcome measures were apneic events, hypotension, patient satisfaction, propofol dosage, cecal intubation time, and adenoma detection. RESULTS A total of 412 patients were randomized 1:1 to undergo colonoscopy in the supine or left lateral position. No severe adverse events were observed in either group. Intention-to-treat analysis revealed no significant difference in the frequency of desaturation in the left lateral arm compared with the supine arm (6.8% vs. 12.1%; P=0.064). Patients in the left lateral arm showed lower apnea rates (9.4% vs. 16.2%; P= .040), but had more episodes of hypotension (12.3% vs. 2.9%; P<0.001). The frequency of repositioning was higher in the left lateral group. No significant differences were observed in patient satisfaction and cooperation, propofol dosage, or adenoma detection rate. Patients who were repositioned to facilitate endoscope passage were excluded from per-protocol analysis. The incidence of hypoxemia was lower for the left lateral than for the supine group in per-protocol analysis (1.8% vs. 11.2%; P=0.003). CONCLUSION The positioning of patients in the left lateral position during propofol sedation for colonoscopy results in lower desaturation rates provided the position can be maintained throughout endoscopy. ClinicalTrials.gov NCT02001792.

Longer observation time increases adenoma detection in the proximal colon – a prospective study

Background and study aims  Longer observation times are associated with increased adenoma detection rates (ADR) in the entire colon. However, adenomas in the proximal colon are at risk of being missed during colonoscopy. The aim of this study was to investigate the impact of observation time on detection of adenomatous polyps in the proximal colon. Patients and methods  This was a prospective study at a university hospital in Germany. Colonoscopies were conducted using magnetic endoscope imaging (MEI) in order to determine the exact position of the scope. Exact observation times spent for the detection of polyps in the proximal and distal colon segments were assessed. The primary outcome was adenoma detection in the proximal colon. ROC curves were generated in order to test the correlation between observation time and adenoma detection. Logistic regression analysis was used to check for interfering factors. Results  A total 480 procedures with 538 polyps were available for analysis. The overall adenoma detection rate was 38.5 %. ADR in the proximal colon was 28.0 %. There was a significant association between observation time in the proximal colon and the detection of proximal adenomas ( P  < 0.001). The impact of the time factor on ADR was stronger in the proximal compared to the distal colon ( P  = 0.030). A net period of 4 min 7 sec was found to be the minimum time span for sufficient adenoma detection in the proximal colon. Conclusion  Observation time is significant in terms of adenoma detection in the proximal colon. The impact of observation time on ADR is stronger in the proximal compared to the distal colon. In the proximal colon a minimum time span of 4 minutes should be spent in order to ensure adequate adenoma detection.

Single‐day sodium picosulfate and magnesium citrate versus split‐dose polyethylene glycol for bowel cleansing prior to colonoscopy: A prospective randomized endoscopist‐blinded trial

The intake of polyethylene glycol (PEG) prior colonoscopy is frequently associated with nausea and abdominal discomfort. The aim of this study was to investigate whether sodium picosulfate and magnesium citrate (PMC) is superior to a polyethylene glycol (PEG) preparation in regard to patient acceptance. Furthermore, it investigates possible differences in efficiency and patient safety.

Management of occluded self-expanding biliary metal stents in malignant biliary disease

BACKGROUND Occlusion of self-expanding metal stents (SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients. METHODS Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS, management strategies, stent patency, subsequent interventions, survival time and case charges. RESULTS A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency (88 vs. 143 days, P = 0.069), median survival time (95 vs. 192 days, P = 0.116), median subsequent intervention rate (53.4% vs. 40.0%, P = 0.501) and median case charge (€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months, significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS (93.3% vs. 57.1%, P = 0.037). CONCLUSIONS In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.

Einfluss einer elektromagnetischen Endoskopvisualisierung (Scope Guide®) auf den Propofolbedarf in der Koloskopie – Ergebnisse der Mexico Studie

Einleitung: Eine Sedierung mit Propofol hat zu einer verbesserten Patienten-Akzeptanz der Koloskopie gefuhrt. Nebenwirkungen des Medikaments treten dosisabhangig auf und betreffen vor allem die Atmung und das Kreislaufsystem. Schlingenbildungen, welche durch das Koloskop hervorgerufen werden, konnen beim Patienten Schmerzen verursachen. Dies kann eine gesteigerte Propofoldosierung zur Folge haben. Eine Moglichkeit die Untersuchungsbedingungen zu vereinfachen, ist die Verwendung einer elektromagnetischen Endoskop Darstellung (EME). Diese ermoglicht es die Lage des Koloskops auf einem Monitor dreidimensional darzustellen. Schlingen konnen damit leichter erkannt und beseitigt werden, was zur Vermeidung von Schmerzen fuhren kann. Ziele: Ziel dieser Studie war es zu uberprufen, ob durch den Einsatz von EME eine Reduktion der Propofoldosierung in der Koloskopie erreicht werden kann. Methodik: Wir fuhrten eine prospektive randomisierte Studie an einem Universitatsklinikum in Deutschland durch. 16 Endoskopeure nahmen an der Studie teil. Patienten > 18 Jahre mit Indikation zur Koloskopie unter Sedierung konnten rekrutiert werden. Bei Randomisierung in den Studienarm erfolgte die Spiegelung unter Verwendung von EME. In der Kontrollgruppe wurde EME zu keiner Zeit der Untersuchung verwendet (Standardarm). Propofol wurde in beiden Armen nach festen Kriterien appliziert. Primarer Endpunkt war die Gesamtdosis an Propofol. Sekundare Endpunkte waren Patientenzufriedenheit (Numerischen Analogskala, 0 – 10 Punkte), Zokum-Intubationszeit und Adenom-Detektionsrate. Ergebnisse: Insgesamt 334 Patienten wurden 1:1 in beide Studienarme randomisiert. Es traten keine schwerwiegenden Komplikationen auf. Die mediane Propofoldosierung war im EME-Arm niedriger als im Standardarm (150 mg vs. 180 mg; p = 0.044). Die Patientenzufriedenheit war im EME-Arm signifikant hoher als im Standardarm (9.0 vs. 8.5 Punkte; p = 0.028). Die Patientenkooperation (aus Sicht der Endoskopiker) unterschied sich zwischen den Gruppen nicht. Schlussfolgerung: Die Verwendung einer elektromagnetischen Endoskop Visulalisierung konnte hilfreich sein um die Propofoldosierung bei Koloskopien zu senken und somit das Patientenrisiko zu verringern. Eine Beeintrachtigung der Patientenzufriedenheit ist dadurch nicht zu erwarten.

Endoskopische und perkutane Interventionen in der Langzeitbehandlung benigner Gallengangstenosen@@@Endoscopic and percutaneous intervention in the long-term treatment of benign biliary stenosis: 71-jähriger Patient mit Cholestase nach Radiatio@@@A 71-year-old patient with cholestasis following radiotherapy

Benign biliary stenosis can have various causes and requires differentiation from disorders caused by malignant disease. Treatment of benign stenosis is often difficult and includes treatment modalities such as endoscopic, percutaneous or surgical interventions. Exact knowledge of the etiology and localization of the stenosis is essential when selecting the appropriate method of treatment. Here we present the case of a 71-year-old patient admitted to our hospital with cholangitis 13 years after undergoing radiotherapy of the renal bed due to hypernephroma of the right kidney. The patient was diagnosed with common bile duct stenosis due to the secondary effects of radiation, which is rarely reported in the literature. Our case covers a total treatment period of 15 years, enabling us to also discuss a viable sequence of treatment modalities in the treatment of benign bile duct stenosis.

Reliability of the continuous cardiac index measurement using the pulse contour analysis of the PiCCO system

Reliable continuous hemodynamic monitoring of critically ill patients is essential for effective volume management and adequate administration of vasoactive drugs. The PiCCO system allows continuous measurement of the cardiac index using arterial pulse contour analysis. Calibration of this system by transpulmonary thermodilution is recommended every 8 hours. In this study we compared the difference of the continuous measurement of the cardiac index using the arterial pulse contour analysis (CIpc) with the cardiac index acquired by the transpulmonary thermodilution (CItd) when calibrating the system.