C. Paul Swain

NATURE OF THE BLEEDING VESSEL IN RECURRENTLY BLEEDING GASTRIC-ULCERS

An unselected consecutive series of 826 patients admitted for acute upper gastrointestinal bleeding underwent urgent endoscopy. Peptic ulcers were found in 402 (49%). Of the 329 ulcer craters that could be fully examined, visible vessels were identified in 156 (47%), other stigmata of recent hemorrhage in 66, and no stigmata of recent hemorrhage in 107. One hundred twenty-nine patients with stigmata of recent hemorrhage (93 of whom had visible vessels) randomly allocated to no endoscopic treatment were observed for evidence of further bleeding. Fifty-four of the 93 patients (58%) with visible vessels rebled, compared with 2 of 36 (6%) with other stigmata of recent hemorrhage. No patient without stigmata of recent hemorrhage rebled. Twenty-seven patients in whom a visible vessel in a gastric ulcer was identified at endoscopy underwent urgent partial gastrectomy because of recurrent bleeding. The vessel identified at endoscopy was found in 26 of 27 resection specimens (96%). The arterial vessel wall protruded above the surface of the ulcer crater in 10 specimens, and clot in continuity with a breach in the vessel wall protruded in a further 10 specimens. Postoperative angiography, when technically possible, showed that the breached artery ran across the base of the ulcer in all of these specimens. Pathological changes were common in the bleeding artery and included arteritis in 24 of 29 (83%) eroded arteries found in these specimens, with aneurysmal dilatation in 14 of 27 (52%) bleeding points that could be fully examined. The ulcer had penetrated to serosa in 13 specimens (45%). The bleeding artery had a mean external diameter of 0.7 mm with a range of 0.1-1.8 mm. This study provides new information about the nature of the bleeding vessel in gastric ulcers, and some of this information is relevant in planning studies of endoscopic therapy for bleeding peptic ulcers. It validates the endoscopic identification of a visible vessel, and confirms that such identification has a high predictive value for the development of recurrent hemorrhage.

Endoscopic full-thickness resection with sutured closure in a porcine model

BACKGROUND Some early gastric cancers might be advantageously staged and treated by full-thickness resection if secure methods for closing the defect were available. The aim of this study was to test the feasibility of full-thickness gastric resection. METHODS Full-thickness gastric resections were performed by using a ligating device without submucosal injection in survival studies in pigs (n = 8). The defects were closed by using new methods for suturing, locking, and cutting thread through a 2.8-mm accessory channel. Stitches (n = 2-4) were placed close to the target area before resection. OBSERVATIONS Full-thickness resections (n = 8) were performed. The pigs survived without incident for 21 to 28 days. Healing of the suture site was evident at follow-up endoscopy. Suture sites were water tight. The pull-out force with stitches by using this new sewing method was significantly higher than with endoscopic clips (20.3 N +/- 0.94 vs. 2.2 N +/- 0.42, p < 0.05). CONCLUSIONS Endoscopic full-thickness resection with sutured defect closure was feasible and appeared safe in these survival experiments.

Antireflux operations at flexible endoscopy using endoluminal stitching techniques: an experimental study

BACKGROUND Three antireflux operations-gastroplasty, fundoplication, and anterior gastropexy-were developed for performance at flexible endoscopy without laparotomy or laparoscopy. METHODS An endoscopic sewing machine mounted on a standard gastroscope, endoscopic knotting devices, overtube, and nylon thread were used to perform these operations in adult beagle dogs. RESULTS Gastroplasty (n = 10) was accomplished by suturing the anterior and posterior wall of the stomach to create a gastric tube (neoesophagus) along the lesser curve. An anatomic arrangement similar to fundoplication (n = 6) was achieved by invaginating the esophagus and fixing it to the stomach 2 cm distal to the cardioesophageal junction. Anterior gastropexy (n = 6) was performed using a technique similar to that used in creating percutaneous gastrostomies. There was no mortality. Ninety percent of sutures were seen at repeat endoscopy at 4 to 8 week intervals. The gastroplasty group was selected for more extensive evaluation. Manometry using a three-channel perfused catheter system before and after the procedures showed an increase in the lower esophageal sphincter pressure (preoperative median 4.6 mm Hg; post-operative median 13.33 mm Hg, p = 0.008) and cardiac yield pressures (preoperative median 10 mm Hg; postoperative median 19 mm Hg, p = 0.007). CONCLUSIONS This study demonstrates the feasibility of performing antireflux operations at flexible endoscopy, without laparoscopy or laparotomy, by use of endoluminal suturing techniques.

An endoscopic stapling device: the development of a new flexible endoscopically controlled device for placing multiple transmural staples in gastrointestinal tissue.

Figure 2. The mechanism of the endoscopic stapling device. A, A fold of tissue is sucked into the cavity of the stapler. B, The tissue is compressed to an optimal thickness prior to stapling. C, The staple rammers force the staples through the tissue onto shaped anvils that bend the staples into a B configuration. 0, A spring opens the cavity to allow the stapled tissue to slide out of the stapling device. Note: This diagram has been simplified to show the closure of only two staples. In the device, the staples were arranged in an overlapping double layer forming a semicircle 1 mm from the outer circumference of the stapler. Received October 14, 1988. Accepted December 24, 1988. From the Departments of Medical Physics and Bioengineering, University College Hospital, and Gastroenterology, The London Hospital, London, England. Reprint requests: C. Paul Swain, MD, Department of Medical Physics and Bioengineering, University College Hospital, Shropshire House, 11-20 Capper Street, London WC1E 6JA, England. DESCRIPTION OF THE STAPLER AND ITS MECHANISM

Randomized Comparison of Nd YAG Laser, Heater Probe, and No Endoscopic Therapy for Bleeding Peptic Ulcers

Of 550 patients admitted with acute upper gastrointestinal hemorrhage, 143 with peptic ulcers containing stigmata of recent hemorrhage accessible to endoscopic therapy were included in a randomized comparison of neodymium yttrium aluminum garnet laser, heater probe, and no endoscopic therapy. The rebleeding rate in laser-treated patients (20%) was significantly less than in controls (42%; p less than 0.05), but in heater probe-treated patients (28%) it was not significantly different from either of the other two groups. The mortality rate in the laser group (2%) was not significantly different from either the heater probe (10%) or the control (9%) group. This trial has confirmed the efficacy of the Nd YAG laser but not that of the heater probe in the prevention of rebleeding from recently bleeding peptic ulcers.

Medium-term outcome of endoluminal gastroplication with the EndoCinch device in children.

Objective: Endoluminal gastroplication (EG) is emerging as a minimally invasive procedure for the treatment of gastroesophageal reflux disease (GERD). The aim of this study is to evaluate the medium-term outcomes after EG in a pediatric patient population. Patients and Methods: Seventeen children with a median age of 12.4 years (range 6.1–15.9 years) with GERD underwent EG using a flexible endoscopic sewing device (EndoCinch) over a period of 3 years. Three plications were placed in the gastric tissue below the lower esophageal sphincter. Drug dose requirement, pH measurements, symptom severity and frequency, and validated Quality of Life in Reflux and Dyspepsia (QOLRAD) scores were compared before EG and 1 and 3 years after EG. Statistical analysis was performed using a Wilcoxon rank-sum test and P < 0.05 was the threshold for significance. Results: All patients showed an immediate posttreatment improvement in symptom severity, symptom frequency, and quality of life scores. Completed 1- and 3-year data were obtained from 16 patients. Four cases (25%) required a repeat procedure as a result of recurrence of symptoms after 2 to 24 months. Fourteen patients (88%) at 1 year and 9 patients (56%) at 3 years remained without a need for any antireflux medication. A sustained improvement in heartburn (P = 0.004), regurgitation (P = 0.017), and vomiting (P = 0.018) was seen at 3 years. The total QOLRAD score (maximum of 175) improved from a median of 87 (range 69–142) to 156 (range 111–175) at 1 year (P < 0.0001) and 153.5 (range 55–174) at 3 years (P = 0.002). Conclusions: EG is an effective and safe procedure in children. It is a viable option for the treatment of GERD refractory to or dependent on antireflux medications.

A novel technique for dilating difficult malignant biliary strictures during therapeutic ERCP

Pall iat ive s ten t ing of the common bile duct or hepat ic ducts for inoperable ma l ignan t bi l iary obs t ruct ion has become a well-establ ished procedure. 1 Al though this m a y be achieved by the percu taneous approach, the endoscopic route is preferable in t e rms of pa t ien t acceptance and morbidity. 2-4 However , 7% to 11% of a t t empt s to cross a ma l ignan t s t r ic ture wi th a s ten t fail a t the init ial ERCP. 5-7 Those pa t ien ts not successfully pal l ia ted are t hen commit ted to e i ther percu taneous bi l iary dra inage wi th subsequent percu taneous or endoscopic s ten t p lacement , to ano the r a t t em p t a t the endoscopic approach alone (for example, leaving the guide wire in si tu overnight), or to surgery. There is a subgroup of init ial ERCP fai lures in which the bi l iary s t r ic ture can be negot ia ted wi th a guide wire, bu t an impasse is r eached .because att empts to dilate the s t r ic ture enough to accept a s ten t or nasobi l iary dra in fail. These are more l ikely to be Kla tsk in type II or III h i lar s tr ictures. 5 In these c i rcumstances , pa t ien ts usual ly requi re immedia te percu taneous dra inage because of the r isk of cholangitis caused by nonster i le cont ras t med ium proximal to the str icture. We have devised a me thod of di lat ing such s t r ic tures and repor t our experience us ing it.

Development and application of endoloops for the treatment of bleeding esophageal varices

BACKGROUND Endoloops are detachable nylon snares. The aims of this study were to develop an endoscopic method for repeated delivery of endoloops to arrest variceal bleeding, to compare efficacy of endoloop hemostasis with injection and band ligation in experimental models of bleeding, and to test the reliability and safety of endoloops in a pilot study in patients with varices. METHODS Technical modifications including ridged endcaps and alterations in angulation of endoloops were developed to speed delivery and improve efficacy. Hemostatic efficacy of endoloops was compared with sclerotherapy and band ligation in animal studies before studies in patients. RESULTS Modified endcap and endoloops allowed repeated applications without withdrawal of the endoscope. Right-angled endoloops ensnared more (p < 0.0001) gastric tissue and were more reliable (p < 0.05) than straight endoloops. Injection therapy and prestretched bands appeared ineffective, whereas band ligation was only effective on vessels up to 2 mm in diameter. Only endoloops achieved hemostasis on vessels of 3 to 5 mm (p < 0.05). No significant complications occurred using endoloops in animal (esophagus n = 20, stomach n = 20) or human (n = 11) studies. CONCLUSIONS Endcap and endoloop modifications simplified repeated application to varices. Endoloops were more effective than injection or band ligation in experimental hemostasis and appeared safe and effective in patients.

Neoplastic gastric outflow tract obstruction relieved at endoscopy by argon laser

In 1981, a 71-year-old man was admitted because of a 4month history of progressive gastric retention, rapid satiety, and regurgitation of partly digested foods culminating in a total inability to keep liquids down. Nine years earlier a Polya partial gastrectomy had been performed to remove an antral adenocarcinoma. Barium studies on admission revealed a tight 3-mm stenosis of the stomal outflow tract. Endoscopy and biopsy showed extensive infiltration of the gastric remnant by recurrent adenocarcinoma to within 2 em of the cardioesophageal junction. The stomal orifice was narrowed and was blocked off by a nodule of tumor that appeared to produce a ball valve effect. Clinical evidence of hepatic metastases, the presence of ascites, the extent of the primary tumor, and a previous hemiparesis ruled out surgery. Endoscopic laser treatment was undertaken since no alternative endoscopic means of relieving this obstruction was available. Following treatment this patient was able to swallow liquids and minced solids and became well enough to return home. A repeat barium meal showed that good relief of the obstruction had been achieved with an increase in stomal diameter to 10 mm. Barium passed on the first swallow into both afferent and efferent loops of the jejunum. This improvement was maintained when the barium study was repeated 3 months later. Endoscopic views of the gastric outflow tract at presentation and at the end of the last treatment session are shown in Figures 1 and 2. This patient died of pneumonia 4 months after treatment but was able to swallow liquids and solids even during his final admission.