Bernhard Rieder

The response of Crohn’s strictures to endoscopic balloon dilation

Aliment Pharmacol Ther 31, 634–639

Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy

BACKGROUND Pancreatic fistula (PF) is the most common postoperative complication after distal pancreatectomy (DP). Endoscopic pancreatic sphincterotomy and drainage have been shown to be an effective treatment for PF. Recently, preoperative endoscopic pancreatic stenting was proposed to prevent PF, but there are no controlled trials so far. OBJECTIVE We investigated whether preoperative pancreatic sphincterotomy and stenting could prevent the development of PF in patients with DP. DESIGN Nonrandomized cohort study with a prospective endoscopic intervention group and a retrospective control group. SETTING Single-center academic teaching hospital. PATIENTS Preoperative endoscopic pancreatic sphincterotomy and stenting were intended to prevent PF after DP in 25 patients between July 2004 and October 2008. The incidence of PF was compared with that in a control group of 23 patients who underwent DP between January 2001 and March 2004 without preoperative endoscopic intervention. INTERVENTIONS Pancreatic sphincterotomy and stenting. MAIN OUTCOME MEASUREMENT PF rate. RESULTS Overall, a cohort of 48 patients underwent DP between January 2001 and October 2008. In all 25 patients who underwent preoperative endoscopic pancreatic intervention, sphincterotomy was successfully performed, and stenting of the pancreatic duct was successful in 23 patients. PF developed in none of the 25 patients in the endoscopic intervention group. In the 23 patients without preoperative endoscopic intervention, a PF developed in 5 patients (22%) (P = .02). LIMITATIONS Nonrandomized design, retrospective control group. CONCLUSIONS Preoperative pancreatic sphincterotomy and stenting were a feasible and safe procedure in this series. Prophylactic preoperative endoscopic intervention may decrease PF rates after DP.

Endoscopic Treatment of the Buried Bumper Syndrome

Endoscopic Treatment of the Buried Bumper Syndrome Bernhard Rieder, Albrecht Pfeiffer Introduction: The buried bumper syndrome is a rare but serious complication in patients with percutaneous endoscopic gastrostomy (PEG). While a variety of non-operative techniques have been used to manage buried bumper syndrome, in most cases surgical intervention is necessary to rectify the problem. We report on an endoscopic method using a Savary dilator over a guidewire for the treatment of the buried bumper syndrome. Method: 8 patients (4 females, 4 males, 60-90 years) were admitted to our gastroenterology unit with buried bumper syndrome. The PEG-tubes had been placed 4 (2-6) years earlier. The manifestations of the buried bumper syndrome included inability to infuse feeding solutions and swelling, pain and leakage above the PEG tube. All attempts to grasp the bumper with a snare or to dislodge it by applying pressure on the PEG tube externally proved futile. The PEG tube was cut 2 to 3 cm above the skin level. Under endoscopic visualization, a Savary dilator guidewire was inserted through the gastrostomy tube into the lumen of the stomach. The guidewire was grasped with a snare and withdrawn through the mouth. The endoscope was reinserted into the stomach. In 4 patients, where the bumper was overgrown by gastric mucosa, endoscopic incision using a needle knife was necessary. Savary dilators (24 F) were passed over the guidewire to displace the bumper together with the remnant of the tube into the stomach. The bumper was snared and removed endoscopically. Results: The buried bumpers could be removed in all 8 patients. In 7 patients, the procedure was tolerated without any incident. In one patient, a bleeding episode induced by the needle knife procedure was treated endoscopically. A new PEG was placed in all 8 patients within 6 days. Conclusion: The described endoscopic method using Savary dilators over a guidewire allows safe removal of embedded PEG bumpers and might replace surgery in the treatment of the buried bumper syndrome.

An Adult Man With Acute Dysphagia and Systemic Inflammation

944 Question: A 45-year-old man was admitted to the hospital with increasing dysphagia and retrosternal pain of 2 weeks’ duration. He denied any weight loss or B-symptoms. The patient had no history of alcohol or nicotine consumption. He was afebrile and the blood pressure was 110/ 60 mmHg. The physical examination of the oropharynx and thyreoidea was unremarkable. Auscultation revealed decreased breath sounds basal on the patient’s left side. Laboratory studies showed leukocytosis (15.8 10/ mL) and an increased C-reactive protein level of 67.9 mg/L; troponin and heart enzymes were negative. The esophagogastroduodenoscopy showed esophageal obstruction by an impression of the right and anterior wall of the lower third of the esophagus at 30–36 cm ab ore. The mucosal aspect was normal (Figure A). Contrast-enhanced computed tomography (CT) was performed, revealing a paraesophageal mass (5 4.5 1.5 cm) adjacent to the lower third of the esophagus (asterisk) and a pleural effusion on the left side (Figure B). After a severe coughing attack on the second day after admission there was a short exacerbation of pain and an increase of temperature. The dysphagia improved promptly. Correlating his clinical and imaging findings, what is your diagnosis? Look on page 1166 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Acknowledgments: The authors thank W. Hofmann for providing the pathologic images and J. Stollfuss for the radiologic images.