B. C. Manegold

Complications in endoscopy of the lower gastrointestinal tract. Therapy and prognosis.

This is a report on 126 prospectively registered and controlled complications in 29,695 consecutive endoscopic procedures of the lower gastrointestinal tract. The overall complication rate is 0.4%. All endoscopic procedures were performed in our institution; no referrals “from other hospitals” are included. The therapy and prognosis of occurring complications are described. Especially after therapeutic endoscopy—above all, after polypectomy—the complication rate of 0.83% is not negligible. A serious aspect is the average interval of 30 h from endoscopically caused complication to the onset of symptoms. Bleeding could be managed conservatively in 76% of cases. Nevertheless perforation and transmural burn injuries required surgical intervention in 78% of cases. The authors conclude that in the case of transmural burn an attempt at “active conservative treatment” is justified if the patient is under close surgical control, if the symptoms improve, and if there is a possibility of immediate surgery.

Treatment of endoscopic esophageal perforation

AbstractBackground: The increasing usage of flexible endoscopy leads to a higher incidence of esophageal perforations, whose treatment strategies (conservative or operative) still are discussed controversially. We present our experiences and therapy concepts in relation to 75 iatrogenic esophageal perforations. Patients: Between 1983 and 1997, 75 patients were treated for endoscopic perforation of the esophagus. The gender distribution was 31 females (41.3%) and 44 males (58.7%), with a mean age of 64.4 years (range 2–90 years). Results: Therapeutic endoscopy was the most common cause of perforation (73 of 75 patients; 97.3%). Diagnostic endoscopy caused perforation in 2 patients (2.7%). The perforation was located in the cervical part of the esophagus in 7 patients (9.3%), the intrathoracic part in 25 patients (33.3%), and the abdominal part in 43 patients (57.3%). In this study population, 25 patients (33.3%) were treated surgically, and 50 patients (66.7%) conservatively. The overall in-hospital mortality rate was 14 of 75 patients (18.7%). In the surgically treated group the rate was 6 of 25 patients (24%) and in the conservative group 8 of 50 patients (16%). Conclusions: The decision of a treatment strategy depends on different factors such as the location and extent of the injury, the time interval between perforation and treatment onset, the preexisting diseases, and the patients general condition. In view of these factors, an individual therapy concept should be determined for every patient.

Foreign body aspiration in children.

AbstractBackground: There is still considerable controversy about the diagnostic procedure, the endoscopic approach, and the complication rate with foreign body aspiration in children. Methods: Review of our data for 98 children suspected for foreign body aspiration between January 1990 and December 1998 was performed. Results: In this data review, 78% of the children studied were younger than 2 years. A foreign body aspiration was identified in 70%, and 67% had a definite history of aspiration. Predominant clinical features were fever (46%), pneumonia (39%), and coughing (29%). Pathologic chest radiographs were found in 84% of the children Sixty-two percent of the foreign bodies were trapped in the right lung, and 87% were of organic in origin. In 93%, a single endoscopic procedure was successful in removing the foreign bodies. The mean time between aspiration and bronchoscopic extraction was 5.4 days (range, 1 h to 36 weeks). The procedure-related morbidity rate was 0.96% and the mortality 0. Conclusions: Outcome and complications were found to depend mainly on the time the foreign body stayed in the tracheobronchial system. Early bronchoscopy is paramount in any case of suspected foreign body aspiration, and it is mandatory to increase the awareness of the population and medical professionals.

Endoscopic treatment of postoperative colorectal anastomotic strictures

Background: The postoperative development of benign colorectal anastomotic stricture remains a frequent and unsolved problem. Methods: From 1996 until 2002, we analyzed 94 consecutive patients with postoperative colorectal anastomotic stenosis who were treated endoscopically. Results: Sixty-eight patients were initially resected for malignant disease, and 26 patients for benign conditions. Most frequently, hydrostatic balloon dilatation was performed; in selected cases, it was combined with a laser or argon plasma coagulation (APC) incision, or a laser incision only. Dilatation was successful in 59% of patients resected for cancer and 88% resected for a benign condition. Complications developed in 17 patients (benign restenosis, perforation, abscess); they were significantly more frequent after initial cancer resection than after resection for a benign condition (p < 0.05). Conclusion: High success and low complication rates make endoscopic dilatation the treatment of choice to avoid high-risk reoperations in patients with benign anastomotic stricture. The presence of stapler anastomosis, postoperative leakage, and/or radiotherapy does not significantly impede successful endoscopic dilatation.

Near-infrared fiber optic spectroscopy as a novel diagnostic tool for the detection of pancreatic cancer

We have investigated the application of near-infrared (NIR) fiber-optic spectroscopy for the diagnosis of pancreatic cancer. Cluster analysis of the Fourier transformed near-infrared (FTNIR) fiber-optic spectra of surgically resected pancreatic tumor tissues allowed discrimination of tumor from normal tissue with high sensitivity and specificity. The sensitivity of the method using spectral information of the CH stretching first overtone region (5951-5608 cm(-1)) was 83.3% with a specificity of 83.3%. Based on the CH stretching second overtone region (8605-7938 cm(-1)) we could achieve a sensitivity of 88.9% and specificity of 72.2%. These findings suggest that NIR spectroscopy offers the potential for minimally invasive in-vivo diagnosis of pancreatic cancer.

Extracorporeal shock-wave lithotripsy and endoscopy: combined therapy for problematic bile duct stones

SummaryEndoscopic treatment of bile duct stones is currently successful in 86% of patients. We prospectively studied the efficacy and complication rate of extracorporeal shock-wave lithotripsy (ESWL) of problematic bile duct stones combined with endoscopy. When stone removal was not possible, patients were subjected to ESWL, Fragmented stones were removed endoscopically. During 1 year, 220 patients presenting with choledocholithiasis were diagnosed and 188 were successfully treated endoscopically. In all, 3 subjects received alternative treatmenl and the remaining 29 (13%) constituted our study group: 19 (65%) were women and the mean age was 76.7 years. Overall, 22 (76%) were high-risk patients; 23 (79%) were jaundiced and 9 (31%) had cholangitis at admission. The most frequent indication for ESWL was stone size. Stone fragmentation was achieved in 80% of cases. Complications were mild and were managed conservatively. No patient died. Complete stone clearance was possible in 23 (80%) cases. The association of ESWL and endoscopy enhanced the success rate of endoscopic stone clearance from 86% to 96%. During the same period, open surgery was performed in 4 cases for residual common bile duct (CBD) stones and in 32 cases in association with simultaneous cholecystectomy.

Intraoperative colonoscopy in the detection of nonpalpable colonic lesions — how to identify the affected bowel segment

SummaryThe development and widespread use of the colonic fiberscope has led to the identification of early colonic cancers which, being small and flat, are not palpable by intraoperative examination of the exterior of the intestine. Standard operation for cancer is required when snare polypectomy is insufficient, or when it is considered that the lesions would be resected incompletely by electrocautery. We report on the use of intraoperative colonoscopy in 11 patients to identify small lesions and to maintain an adequate distance from the lesions. Intraoperative colonoscopy allows lesions to be detected rapidly, safe operations, and a decrease in operation time.

Lap simulator, animal studies, and the Laptent

SummaryIn an effort to ensure proper training and to establish a routine amongst the surgical team right from the start, we began practicing laparoscopic techniques with the lap simulator. After having acquainted ourselves with the fundamentals of this minimal-invasive method, we applied our newfound experience to the animal model. Even though the subsequent studies with pigs were the best learning model in which to practice different surgical techniques — e.g., ureter clipping and renal vessel triple stapling with the Endo-GIA — various problems can arise in a true clinical situation since anatomical diversity exists between an animal and human situs. We found that a compromise could be reached by simulating laparoscopic conditions during open surgery without endangering the safety of the patient during any point of the operation. After open surgical exposure of the Gerota fascia was carried out, the operative site was completely covered with the Laptent. From this moment on, all operative steps were performed with laparoscopic instruments under continuous video monitoring.Our step-by-step training program has exposed the surgeon and OR staff to the complexity of this new surgical technique. The use of the Laptent has successfully bridged the gap between open and laparoscopic surgery. Most important of all, those surgical centers without access to extensive experimental studies will realize that Laptent-assisted surgery can be of benefit and facilitate the clinical introduction of this minimal-invasive method.

Peutz-Jeghers-Syndrom Beobachtungen am klinikum mannheim über 25 jahre

Observations in our clinic and others reviewed in the literature result in a new picture of the Peutz-Jeghers syndrome. It turns out to be a hereditary polypose syndrome which is hard to define. The tendency to malignant degeneration of polyps and development of associated neoplasms is almost impossible to forecast. In addition operations frequently involve complications and often need to be repeated more than once. Radical removal of all polyps must be the aim of treatment; the patients must then be closely followed up by clinical examination, endoscopy and radiology to avoid complications of regrowth and to make sure degeneration and associated neoplasms are detected at an early stage.ZusammenfassungAn Hand eigener Beobachtungen sowie einer Literaturübersicht wird ein neues Bild des Peutz-Jeghers-Syndroms entworfen. Es stellt sich als ein schwer abgrenzbares, hereditäres Polyposesyndrom mit einer kaum einschätzbaren Neigung zu Entartung und Entwicklung assoziierter Neoplasmen einerseits und wiederholten komplikationsträchtigen Operationen andererseits dar. Deshalb ist therapeutisch eine möglichst vollst↭dige Entfernung der Polypen zu fordern. Die Patienten müssen engmaschig klinisch und endoskopisch bzw. radiologisch kontrolliert werden, um polybedingten Komplikationen vorzubeugen und Entartungen und assoziierte Neoplasmen rechtzeitig zu erkennen.

Organerhaltung durch Rekonstruktion des Ductus Wirsungianus bei kompletter Pankreasruptur

SummaryBlunt abdominal traumas with pancreatic injuries often cause partial or subtotal resection of the organ, especially when the pancreatic duct is damaged. A reconstructive method for anastomosis of the duct is reported in a case of a 9-year-old boy with complete pancreatic rupture in which the whole organ could be salvaged.ZusammenfassungTraumatische Pankreasläsionen beim stumpfen Bauchtrauma stellen hdufig eine Indikation zur partiellen bis subtotalen Organresektion dar, insbesondere bei Verletzungen des Ductus pancreaticus. Anhand einer Kasuistik eines 9jährigen Jungen mit totaler Pankreasruptur wird ein Verfahren zur Gangrekonstruktion dargestellt, durch das eine vollständige Organerhaltung möglich war.