Axel Eickhoff

A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding

BACKGROUNDnCapsule endoscopy enables noninvasive diagnostic examination of the entire small intestine. However, sensitivity and specificity of capsule endoscopy have not been adequately defined. We, therefore, compared capsule endoscopy by using intraoperative enteroscopy as a criterion standard in patients with obscure GI bleeding.nnnMETHODSnForty-seven consecutive patients with obscure GI bleeding (11 with ongoing overt bleeding, 24 with previous overt bleeding, and 12 with obscure-occult bleeding) from two German gastroenterologic centers were included. All patients who had a prior nondiagnostic evaluation, including upper endoscopy, colonoscopy with a retrograde examination of the distal ileum, and push enteroscopy, underwent capsule endoscopy followed by intraoperative enteroscopy.nnnRESULTSnCapsule endoscopy identified lesions in 100% of the patients with ongoing overt bleeding, 67% of the patients with previous overt bleeding, and 67% of the patients with obscure-occult bleeding. Angiectasias were the most common source of bleeding (n = 22). Capsule endoscopy showed the source of bleeding in 74.4% of all patients. The method was more effective in patients with ongoing bleeding. Compared with intraoperative enteroscopy sensitivity, specificity, and positive and negative predictive values of capsule endoscopy were 95%, 75%, 95%, and 86%, respectively.nnnCONCLUSIONSnCapsule endoscopy has high sensitivity and specificity to detect a bleeding source in patients with obscure GI bleeding. Thus, wireless capsule endoscopy can be recommended as part of the routine work-up in patients with obscure GI bleeding.

Computer-assisted colonoscopy (the NeoGuide Endoscopy System): results of the first human clinical trial ("PACE study").

OBJECTIVES:Unsedated colonoscopy is an uncomfortable procedure for most patients. Discomfort during colonoscopy is largely related to looping of the colonoscope, which displaces the colon from its native configuration and stretches attachments to the mesentery. A novel computer-assisted colonoscope utilizes a fully articulated, computer-controlled insertion tube. On manual insertion of the colonoscope, the position and angle of the scopes tip are encoded into a computer algorithm. As the colonoscope is advanced, the computer directs each successive segment to take the same shape that the tip had at a given insertion depth. The insertion tube thus changes its shape at different insertion depths in a “follow-the-leader” manner.METHODS:This initial clinical trial with this novel colonoscopy system was designed as a prospective, nonrandomized, unblinded, feasibility study. Three physicians of varying levels of experience participated in the study.RESULTS:Eleven consecutive patients (seven men, four women, age range 19–80) meeting inclusion criteria for screening or diagnostic colonoscopy were enrolled in the study. The cecum was reached in 10 consecutive patients (100%). Findings included diverticular disease in two cases and multiple colonic polyps in two cases. Postprocedure assessment at discharge, 48 h, and 30 days revealed no complications or adverse effects. Physician satisfaction and patient acceptance of this new technique were high.CONCLUSIONS:In this limited, first of its kind feasibility study, the computer-assisted colonoscope was shown to perform colonoscopy safely and effectively. The colonoscopes unique design limited loop formation during colonoscopy. Large-scale clinical trials are indicated.

Endoscopic stenting for common bile duct stenoses in chronic pancreatitis: results and impact on long-term outcome.

Objectives The overall incidence of common bile duct strictures due to chronic pancreatitis is reported to be approximately 10–30%. It remains a challenging problem for gastroenterologists and surgeons. The exact role of endoscopic stenting has not yet been clearly defined. Design and methods Thirty-nine patients with chronic pancreatitis and symptomatic common bile duct stenoses underwent endoscopic stenting and were studied retrospectively. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stents in the long term. Results Indications for endoscopic stenting were symptomatic cholestasis, jaundice or cholangitis. The initial serum bilirubin was 8.3 mg/dl and the diameter of the common bile duct was 14.2 mm before stenting. Within 3–7 days of stenting, all patients presented improvement of jaundice and cholestasis. After a median stenting time of 9 months (range 1–144 months), 46% of the patients demonstrated regression of the stricture and clinical improvement, 26% required further stenting, and 28% were referred to surgery. Five patients received a self-expandable metal Wallstent. Thirty-one per cent demonstrated complete clinical recovery of the stricture as well as 10.2% a complete, radiologically verified stricture regression in a median follow-up of 58 months. Conclusions There seems to be a therapeutic benefit for short-term endoscopic treatment but medium-term and long-term outcome remains questionable. Endoscopic stenting should be applied as an initial therapy before surgery, but it can be the definitive approach for older and morbid patients or cases with complete stricture regression after stent removal. Overall, it should not be considered as a routine procedure for symptomatic cases.

Self-expanding metal stents versus plastic prostheses in the palliation of malignant dysphagia: long-term outcome of 153 consecutive patients.

Background: Malignant dysphagia due to esophagogastric cancer is associated with poor overall prognosis. Placements of self-expandable metal stents or plastic tubes are established methods as palliative treatment options. As an alternative and/or complementary therapy, radiologic techniques (external beam radiation/brachytherapy) and locally endoscopic techniques (laser, APC-beamer, PDT) are often used. Study and Goals: Retrospective trial of 153 patients treated in our department between 1993 and 2001. Forty-five patients received a plastic tube (Group A) and 108 patients were treated with metal stents (Group B). Both groups were compared for improvement of dysphagia score, survival, recurrent dysphagia and complications. Results: Stent placement was successful in 41 of 45 (93%) patients of Group A and 107 of 108 (99%) of Group B. The median dysphagia score improved significantly in Group A (from 3.03 to 1.55, P = 0.010) and Group B (from 2.77 to 1.44, P = 0.009). Recurrent dysphagia was noted in 12 of 45 (27%) patients of Group A and 27 of 108 (25%) patients of Group B. Median survival time after stent insertion was 78 days (Group A) and 113 days (Group B). Overall complications occurred in 15 of 45 (33%) patients of Group A and 28 of 108 (26%) patients of Group B. However, significantly (P = 0.05) more major complications were seen in Group A than in Group B (22% vs. 9%). Conclusions: Our results indicate a marginal clinical benefit for metal stents versus plastic tubes in malignant dysphagia in the long run. However, metal stents seem to be safer and associated with a prolonged improvement of dysphagia score.

Diagnosis of liver cirrhosis : A comparison of modified ultrasound and laparoscopy in 100 consecutive patients

Background/Goals: Liver cirrhosis, the final stage of chronic liver disease, is characterized by an unfavorable prognosis and an increased risk of hepatocellular carcinoma and also requires an appropriate management. Laparoscopy, the gold standard in the diagnosis of cirrhosis, is hampered by its invasiveness. Therefore, a noninvasive method for diagnosing liver cirrhosis would be of great benefit. Study: A consecutive series of 100 patients, sent to our gastroenterological unit for diagnostic laparoscopy, underwent a standardized ultrasonographic examination prior to laparoscopy. Results: Conventional ultrasonographic examination revealed a sensitivity of 55% and a specificity of 86% in the diagnosis of cirrhosis. Considering the assessment of the transmission of heart pulsation on the liver surface, the corresponding values improved by increasing to 85% and 93%. Conclusion: Evaluating the transmission of heart pulsation on the liver surface improves the ability of ultrasound to diagnose liver cirrhosis; therefore, it should be an integral part of routine sonographic examination of the liver.

Determining scope position during colonoscopy without use of ionizing radiation or magnetic imaging: the enhanced mapping ability of the NeoGuide Endoscopy System.

BackgroundKnowledge of the position and shape of the endoscope could overcome many challenges of performing colonoscopy, e.g., loop formation. A novel computer-assisted colonoscope (NeoGuide Endoscopy System) delivers a real-time, three-dimensional map of the tip position and insertion tube shape in addition to the video image of the colon lumen. The aim of this study is to evaluate the mapping capabilities of the NeoGuide Endoscopy System in terms of colonic looping, insertion depth, tip position, and tip angle formation.MethodsTen endoscopists with various levels of experience were each shown 70 map images generated by the NeoGuide endoscopy system in a benchtop anatomical colon model. First endoscopists were asked to determine the tip angle based on the map image and the system’s corresponding tip positioning aid (20 images). In the second part they had to identify the scope-tip position in the colon model (40 images). In the third part ten images were presented for identification of colonic loops.ResultsThe tip angle was correctly identified in 99% (198/200) of images. Using only the map images the scope position was accurately determined in 87.5% (350/400). Identification of colonic looping of the scope was appropriate in 99% (99/100). Overall accuracy was 92.4%, and overall positive predictive value was 94.9%.ConclusionThree-dimensional map images generated by the NeoGuide endoscopy system provide accurate information regarding tip position, insertion tube position, and colonic looping.

Endoscopic stenting for postoperative biliary strictures due to hepatic hydatid disease: effectiveness and long-term outcome.

Background Postoperative strictures due to hepatic hydatid disease caused by Echinococcus surgery is considered to be a rare cause of benign bile duct strictures, especially in the Western world. Goals The aim of this retrospective study is to demonstrate possible characteristics of the strictures as well as the effectiveness of long-term endoscopic stenting. Study Between 1994 and 2001, we treated 10 of these cases in our clinic. All patients had surgery for hepatic Echinococcus disease one or more times. These types of benign biliary strictures, secondary to surgery of hepatic hydatid disease, were multiple and located in the proximal common bile duct. Endoscopic stent therapy was carried out in all cases containing transpapillary approach with plastic prostheses (7.5–11 French) or transhepatic approach with Yamakawa ® prostheses (16 French). Nine patients were available for follow-up. Results In 6 patients (66%), the stents were removed after a median period of 22.5 months with radiologic and clinical signs of improvement. Three patients required prolonged dilatation therapy because of stricture-recurrence. There was low overall morbidity and we recognized no therapy-associated mortality. Conclusions Endoscopic stent therapy is a safe nonoperative method for the treatment of postoperative benign biliary strictures due to hepatic hydatid disease.

Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy

BackgroundArgon plasma coagulation (APC) is a thermal coagulation technique that uses ionized argon for contact-free transmission of high-frequency electrical current to tissue. Prospective data on complications with the new APC-2 (VIO) system are lacking.MethodsA prospective trial was conducted with 152 patients treated for various gastrointestinal diseases using three modes of the APC-2. The study aimed to assess complications, focusing on the pain and neuromuscular stimulation (NMS) experienced during and after treatment. Patients reported pain and NMS using a scale ranging from 0 to 10 and were interviewed for symptoms such as tingling, paresthesia, muscle pain, and cramping or twitching. The endoscopists also graded NMS using a separate questionnaire.ResultsA total of 85 males and 67 females (median age, 66xa0years) were enrolled in the study. All APC therapies were completed successfully. Two peri-interventional perforations were recorded. Of the 152 patients, 26 (17%) reported pain sensation during or after APC. The median pain sensation reported by the patients on the standardized scale was 3.7. The findings showed NMS in 14 (9.2%) of the 152 patients. Significantly more NMS events were seen with pulsed APC than with forced or precise APC. Additional risk factors for NMS were gender (female) and type of sedation (combination midazolam and pethidine). No complications were noted among patients with intracardiac defibrillators or cardiac pacemakers.ConclusionsAccording to the findings, APC may be associated with minor complications such as pain sensation and NMS. These complications were rarely seen, but occurred more often with pulsed APC than with forced or precise APC. Physicians should be aware of these complications.

Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients.

Background/Goals Diagnostic laparoscopy under sedoanalgesia is a valuable tool in the work-up of liver diseases and is helpful as a staging procedure. The rate of bacteremia caused by this procedure is unknown, in particular when performed as minilaparoscopy. Study A 100 consecutive patients having undergone diagnostic laparoscopy carried out either conventionally (group I, n=50) or as minilaparoscopy (group II, n=50) were prospectively enrolled in this study. Blood cultures were drawn before and within 5 minutes after the procedure. Risk factors for bacteremia were evaluated. Results Bacterial growth occurred in 4 blood cultures drawn immediately after laparoscopy. No patient developed fever or other signs of infection in the follow-up. Risk factors predisposing to bacteremia could not be identified. Conclusions Conventional diagnostic laparoscopy under sedoanalgesia and minilaparoscopy are associated with a low rate of bacteremia as in diagnostic upper endoscopy.

Papillenadenom/Papillenkarzinom: Endoskopisch-interventionelle Möglichkeiten

Eine Vielzahl verschiedener Tumorentitäten kann im Bereich der Papilla Vateri auftreten. Im Vergleich zu anderen peripapillären Tumoren weisen diese Läsionen eine deutlich bessere Prognose auf. Die Methode der Wahl zur Detektion von Papillentumoren ist die Endoskopie. Erst die Kombination mehrerer, sich ergänzender diagnostischer Verfahren (Seitblick-Duodenoskopie mit Biopsie, Endosonographie, endoskopisch retrograde Cholangiopankreatikographie, intraduktaler Ultraschall) erlaubt eine zuverlässige Aussage über das lokale Tumorwachstum und die Dignität. Liegen keine Zeichen der lokalen Tiefeninfiltration, histologische Hinweise für ein Karzinom oder Fernmetastasen vor, so ist die lokal endoskopische Resektion in spezialisierten Zentren heute die Therapieoption der ersten Wahl. Eine Vielzahl von Studien und unsere eigenen Ergebnisse zeigen, dass die endoskopische Behandlung von Papillenadenomen sicher und effektiv ist. Bei Papillenfrühkarzinomen kann in ausgewählten Einzelfällen, sollten Kontraindikationen gegen eine Operation vorliegen und die Tumorinfiltration auf die Mukosa beschränkt sein, die lokal endoskopische Resektion erwogen werden.