C. Ell

Shockwave lithotripsy of salivary duct stones

Surgical extirpation of the affected gland has been necessary for cases of sialolithiasis in which the stone cannot be removed by dilatation or dissection of the salivary duct. The ability of the piezoelectric lithotripter to deliver shockwaves to a small focus makes extracorporeal shockwave lithotripsy of salivary gland stones potentially safe. Its safety and efficacy have been assessed in 51 patients with symptomatic solitary salivary stones that could not be removed by conservative measures. The stones had a median diameter of 8 (range 4-18) mm and were located in the submandibular gland in 69% of patients and in the parotid gland in 31%. A total of 72 shockwave treatment sessions (maximum 3 per patient) were given under continuous sonographic monitoring. In 45 patients (88%) complete fragmentation (fragments less than or equal to 3 mm) of the concrements was achieved. No patient needed anaesthesia, sedatives, or analgesics. The only untoward effects were localised petechial haemorrhages after 10 (13%) out of 72 treatments and transient swelling of the gland immediately after delivery of shockwave in 2/72 (3%) sessions. 20 weeks after the first session 90% (46/51) of patients were free of discomfort, and 53% (27/51) were stone free. Stone-clearance rate was higher among patients with stones in the parotid gland (81%) than among those with stones of the submandibular gland (40%). Auxiliary measures such as dilatation or dissection of the salivary duct were required only in patients with stones in the submandibular gland (20%). No long-term damage to the treated salivary gland or to adjacent tissue structures was noted during the median follow-up of 9 (1-24) months. Extracorporeal piezoelectric shockwave therapy seems likely to be safe, comfortable, and effective minimally-invasive, non-surgical treatment for salivary stones.

Accuracy of endoscopic ultrasound in preoperative staging of esophageal cancer: results from a referral center for early esophageal cancer

BACKGROUND AND STUDY AIM Endoscopic ultrasound (EUS) has been regarded as the most accurate staging tool in esophageal cancer. Staging results have a strong impact on the decision as to whether a patient should undergo endoscopic treatment, surgery alone, or neoadjuvant therapy. This retrospective study was conducted to analyze the accuracy of esophageal cancer staging using EUS. METHODS All patients who received EUS for staging of esophageal cancer before esophagectomy from February 2003 to December 2007 at a high volume academic tertiary care center were included. RESULTS 179 consecutive patients (mean age 64.4 +/- 9.5 years; 142 men) underwent esophageal resection for Barretts adenocarcinoma (n = 134) and squamous cell cancer (n = 45). Postoperatively, 99 patients were staged as having T1 cancers (55 %), 30 patients T2 (17%), 46 patients T3 (26%), and four patients T4 (2%). The sensitivity and specificity of EUS relative to the T stage were 82% and 91%, respectively, for T1; 43% and 85% for T2; and 83% and 86% for T3. The overall accuracy for EUS in identifying the correct T stage was 74% (95%CI 66-80). Positive lymph nodes were diagnosed histologically in 68 patients (38%). The sensitivity, specificity and accuracy of EUS for the diagnosis of N1 were 71%, 74% and 73% (95%CI 65-79), respectively. CONCLUSIONS The diagnostic accuracy of EUS in patients with esophageal cancer is still unsatisfactory. T2 cancers in particular are frequently overstaged, with a significant effect on the subsequent treatment strategy.

Prospective, cross-over, single-center trial comparing oral double-balloon enteroscopy and oral spiral enteroscopy in patients with suspected small-bowel vascular malformations

BACKGROUND AND STUDY AIMS Spiral enteroscopy is a new, promising rapid enteroscopy technique. A prospective cross-over study was carried out to compare this new method with the established technique of double-balloon enteroscopy (DBE). PATIENTS AND METHODS From an initial group of 18 patients with suspected mid-gastrointestinal bleeding due to vascular malformations but no previous history of small-bowel or colonic surgery, 10 patients (mean age 69 years) completed the study. Patients underwent both enteroscopy techniques with an oral approach, in a randomized sequence. The deepest point reached during advancement in the first enteroscopy was marked with India ink. The primary end point of the study was the total examination time. RESULTS For spiral enteroscopy, the mean examination time was significantly shorter than with DBE (43 minutes vs. 65 minutes; P = 0.007), as was the mean time required for advancement of the enteroscope to the deepest point (24 minutes vs. 43 minutes; P = 0.03). However, the median maximum insertion depth was greater in the DBE group than in the spiral enteroscopy group (310 cm vs. 250 cm; P = 0.004). In all cases in which DBE followed spiral enteroscopy, DBE passed the India ink mark by a mean of over 100 cm. When DBE was performed first, spiral enteroscopy was either unable to reach the mark or else unable to advance deeper into the small bowel. No severe complications occurred. CONCLUSIONS The results confirm that the new spiral enteroscopy technique reduces the examination time, although the insertion depth with DBE is at present superior.

Is endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date?

OBJECTIVE:Common bile duct (CBD) stenoses often complicate chronic pancreatitis (CP). Although endoscopic drainage is employed as a standard procedure in malignant CBD stenoses, it is not yet the approved standard therapy of CBD stenosis in CP.METHODS:The records of 31 patients with CBD stenosis in CP who had undergone endoscopic placement of plastic endoprostheses into the bile duct between January 1991 and February 1997 were analyzed retrospectively. In all, 18 patients suffered from jaundice and 13 patients exclusively showed serological cholestasis. Upstream dilation of the CBD (19 ± 6.6 mm, 12–35 mm) was detected by ERCP in all patients. In total, 101 endoprostheses were implanted endoscopically, exchanged after 3 ± 2 months, and removed after 10 ± 8 months.RESULTS:All jaundiced patients showed immediate improvement of cholestasis after drainage. At the time of last exchange or after stent removal, prestenotic CBD dilation was reduced in 55% of all patients. Complete regression of stenosis and prestenotic dilation was accomplished only in 13%; dilation remained unchanged in 10%, and even showed progression in 22%. A total of 29 patients were followed-up over 24 months. Cholestatic parameters remained normal in all patients with complete normalization of the CBD, and were only moderately increased in another 10 patients, 7 and 28 months after stent removal, respectively.CONCLUSIONS:Technical and immediate clinical success of CBD stenting in patients with CBD stenoses due to CP is high; however, long-term complete normalization of the bile duct is rare. Endoscopic drainage of CBD-stenosis in patients with CP can be recommended to alleviate acute cholestasis, but not yet as a definite treatment.

Value of high-frequency miniprobes and conventional radial endoscopic ultrasound in the staging of early Barrett's carcinoma

BACKGROUND AND AIMS High-frequency miniprobes (HFPs) and conventional radial endoscopic ultrasonography (crEUS) are considered valuable tools in the staging of early Barretts cancer. However, there is some controversy on whether HFPs are superior in the T staging of Barretts cancer or whether the same level of accuracy can be achieved by the sole use of crEUS. PATIENTS AND METHODS Patients referred for endoscopic treatment for Barretts cancer were included in this prospective crossover trial and were randomly assigned to either HFPs or crEUS as the initial diagnostic method. Afterwards, all of the patients were re-examined with the alternative procedure. The staging results obtained with each method were documented prospectively. RESULTS A total of 43 patients (median age 66 years [interquartile range: 58 - 73]; 34-male) were included. A total of 23 mucosal and 16 submucosal Barretts cancers were confirmed at histology. Histological confirmation was not possible in four patients. Assessment of the T category was not possible with HFPs in 7 % of patients, compared with 33 % with crEUS ( P < 0.0001) due to positioning problems. T category was correctly assessed with HFP in 64 % of patients and with crEUS in 49 %. CONCLUSIONS HFPs are significantly superior to crEUS for local staging of Barretts cancer. However, the accuracy of assessment of the T category was unsatisfactory with both techniques.

Impact of fluoroscopy on oral double-balloon enteroscopy: results of a randomized trial in 156 patients

BACKGROUND AND STUDY AIMS The routine utility of fluoroscopy during double-balloon enteroscopy (DBE) via the oral route has been not prospectively evaluated. Up to now, there have been no prospective randomized trials to assess whether fluoroscopy improves outcomes. The aim of this study was to assess the value of fluoroscopy during oral DBE. PATIENTS AND METHODS A total of 156 patients (88 men, 56.4 %) of mean (standard deviation [SD]) age 56 (19) years were randomly assigned to undergo oral DBE either with or without fluoroscopy. The majority of the patients had obscure gastrointestinal bleeding (n = 96, 62 %). The primary target criteria for the study were postpyloric insertion depth and time required to reach the deepest insertion point. A secondary target criterion was the diagnostic yield achieved. RESULTS The results in the fluoroscopy and nonfluoroscopy groups did not differ significantly with respect to the mean (SD) insertion depth (fluoroscopy, 284 [89] cm, range 70 - 470 cm; nonfluoroscopy, 256 [86] cm, 40 - 430 cm), the mean time required to reach the deepest point of insertion, or the diagnostic yield achieved. In patients with previous abdominal surgery and during difficult procedures, the mean insertion depth was significantly lower. CONCLUSIONS Fluoroscopy during DBE via the oral route does not provide a significant gain in insertion depth, advancement time, or diagnostic yield in comparison with nonfluoroscopically guided procedures. In experienced hands, fluoroscopy does not have to be used routinely during oral DBE.

Biophysical effects of high-energy pulsed ultrasound on human cells

Human benign and malignant cells of different human origin (pancreas, liver, kidney, pharynx, tongue, lip) were exposed to high-energy pulsed ultrasound (HEPUS) in vitro to evaluate the effects of various physical parameters and sonication conditions on cell viability. This included the number of pulses, focal pressure, pulse repetition rate, pulse shape, cell suspension volume, water level of the basin and cell density. Cell viability was found to depend significantly on the number of pulses (exponential), the focal pressure (linear) and the pulse repetition rate (minimum at 1 Hz). Other parameters showed no marked influence. Furthermore, electron microscopy revealed intracellular damage, and proliferation rates of cells surviving sonication were normal after HEPUS exposure. The experimental piezoelectric ultrasound transducer used in the experiments generated oscillating bipolar pulses with high negative pressure amplitudes. Measurements were made of the pulse shape and ultrasonic field of the experimental device and of a conventional lithotripter for comparison.

Antiemetic Efficacy of Moderately High-Dose Metoclopramide in Patients Receiving Varying Doses of Cisplatin

In 29 patients (48 courses of chemotherapy), a randomized double-blind crossover study was undertaken to establish the antiemetic effectiveness of a combination of metoclopramide at a moderately high dose (5 mg/kg body weight) with 1 g methylprednisolone (treatment A) as compared with metoclopramide monotherapy (5 mg/kg body weight; treatment B). With cisplatin doses of 60 mg/m2, a good antiemetic effect (0-1 vomiting episodes in 24 h) was observed in 9 out of 10 patients under treatment A as well as under treatment B. With a cisplatin dose of 120 mg/m2, treatment A produced a good antiemetic effect in 9 out of 11 patients (82%), while treatment B produced such an effect in only 3 out of 11 patients (27%; p less than 0.5). The results obtained permit the following conclusions to be made: At doses of cisplatin of up to 60 mg/m2, the antiemetic effect produced by metoclopramide (5 mg/kg body weight) given alone is adequate. At doses of cisplatin of 120 mg/m2 and more, high-dose methylprednisolone has a good additive antiemetic effect vis-à-vis metoclopramide (5 mg/kg body weight). The antiemetic effect of this combination corresponds approximately to the antiemetic effect produced with high-dose metoclopramide (10 mg/kg body weight) administered alone.

Invisible gastric carcinoma detected by random biopsy: long-term results after photodynamic therapy.

BACKGROUND AND STUDY AIMS Gastric cancer diagnosed from routine gastric biopsies without any evidence of a visible lesion and negative repeated biopsies is an infrequent but serious clinical problem for which gastrectomy has usually been recommended, even if operative specimens do not show cancer either. We report on a series of 22 such patients undergoing long-term follow-up after attempted treatment with photodynamic therapy (PDT). PATIENTS AND METHODS 22 patients with invisible gastric cancer (IGC) who presented during a 10-year period (10 men, mean age 56 +/- 15 years) were prospectively included. Initial histopathological findings confirmed by second opinion included 10 well-differentiated adenocarcinomas and 12 signet ring cell carcinomas. After two negative state-of-the art endoscopic reassessments, a single session of PDT using 5-delta-aminolevulinic acid (ALA) was performed in the area from which the biopsy was taken, and patients were followed up regularly. RESULTS After a mean follow-up period of 56.2 +/- 27.6 months, three patients had died of causes unrelated to gastric cancer, four had developed mucosal cancer that was successfully treated endoscopically after 4 - 38 months, and the remaining 15 patients remained without evidence of recurrent gastric cancer, lymph-node involvement, or metastases during a follow-up period of 54 +/- 26 months. CONCLUSIONS Our results suggest that gastrectomy may not be the only option for IGC, which might follow an uneventful natural course provided careful follow-up is scheduled. The role of PDT in this setting remains unclear and should be studied further.

Endoscopic management of bile duct complications after cholecystectomy

SummaryThe introduction of laparoscopic cholecystectomy appeared to be associated in many institutions with an increased incidence of biliary injury. Therefore, over a period of one year we prospectively collected the data of all patients who were referred to our unit with a suspected bile duct problem after cholecystectomy. Between August 1992 and August 1993, 32 patients with endoscopically identified problems were included in the study. Twenty-three out of 32 had early complications (occurred within the first 30 days after cholecystectomy). Thirteen out of these 23 patients showed a bile leakage, 7 retained stones and 2 duct strictures and in 1 patient the hepatic duct was clipped. Only 10/23 early bile duct problems occurred after laparoscopic cholecystectomy. 19/23 patients (82%) were treated successfully on the endoscopic route. All 11 patients with late complications had strictures associated in 7 cases with stones. All late complications appeared after open surgery. Endoscopic or percutaneous ther...