Christa Meyenberger

Alcoholic nonprogressive chronic pancreatitis: prospective long-term study of a large cohort with alcoholic acute pancreatitis (1976-1992).

140 patients with alcoholic acute (recurrent) pancreatitis were enrolled in a prospective long-term study over the last 16 years. Regular control studies regarding progression to advanced chronic pancreatitis were performed. Based on long-term outcome the patients were classified into two groups: group A (n = 109; 77.8%) with progression to advanced chronic pancreatitis (84% with calcification, 95% with exocrine insufficiency) and group B (n = 31; 22.2%) without progression (no calcification, no exocrine insufficiency). The two groups were comparable in age, sex, and mean duration of disease from onset (13.1 2 5.2 vs. 13.8 ± 4.9 years). Surgery for pseudocysts was performed in 47% of group A and in 29% of group B. In group B, no pancreatic duct dilatation occurred (in 86% >8 years from onset). However, 4 of 7 patients with adequate histology showed unequivocal chronic pancreatitis. Surprisingly, all patients of group B except two got spontaneous lasting pain relief irrespective of alcohol intake or normal pancreatic function. Our findings indicate that a subgroup of alcoholic acute pancreatitis does not progress to advanced chronic pancreatitis. This subgroup may be identical with “small duct” chronic pancreatitis. The factors responsible for progression (group A) or nonprogression (group B) remain to be elucidated.

Relationship between APC genotype, polyp distribution, and oral sulindac treatment in the colon and rectum of patients with familial adenomatous polyposis.

PURPOSE: Familial adenomatous polyposis is an inherited colorectal cancer syndrome characterized by the presence of multiple adenomatous colorectal polyps. Molecular studies have revealed that germline mutations in theAPC gene are the underlying cause of the disease. The nonsteroidal anti-inflammatory agent sulindac has been shown to reduce the number of colorectal adenomas. Most sulindac trials in the large bowel have focused on the distal colon and relatively little is known about its effect on the proximal colon. Moreover, it is unknown whether the site of theAPC mutation affects the efficacy of sulindac. METHODS: This study investigated whether there were regional differences in the effect of sulindac on the colon and whether response to sulindac was dependent on the site of mutation in theAPC gene. In an open prospective study 17 patients with familial adenomatous polyposis were treated with 300 mg oral sulindac daily for four months followed by a washout phase of six months. Ten of the patients had an intact colon and seven had rectal stumps only. The number, size, and the degree of dysplasia of the adenomas were evaluated by colonoscopy at entry, end of treatment and end of the study. RESULTS: Overall, a statistically significant decrease in the number of adenomas was observed (120±112 to 28±64,P=0.007). After cessation of sulindac treatment the number of adenomas increased to 48±44.5, but remained significantly lower than the values observed at baseline. In the ten patients with intact colons, adenomas decreased by sevenfold in the proximal colon (103±73 to 15.1±47.4,P=0.011) and twofold in the distal colon (80±52 to 29.6±37.2,P=0.005). The size of adenomas and the grade of dysplasia also decreased. No correlation could be seen between theAPC mutation site and the response to treatment. CONCLUSION: These data indicate that sulindac reduces the number of adenomas in the entire colon and that the effect seems to be more pronounced in the proximal colon.

Multipurpose use of the over-the-scope-clip system (“Bear claw”) in the gastrointestinal tract: Swiss experience in a tertiary center

AIMnTo evaluate the outcome of over-the-scope-clip system (OTSC) for endoscopic treatment of various indications in daily clinical practice in Switzerland.nnnMETHODSnThis prospective, consecutive case series was conducted at a tertiary care hospital from September 2010 to January 2014. Indications for OTSC application were fistulae, anastomotic leakage, perforation, unroofed submucosal lesion for biopsy, refractory bleeding, and stent fixation in the gastrointestinal (GI) tract. Primary technical success was defined as the adequate deployment of the OTSC on the target lesion. Clinical success was defined as resolution of the problem; for instance, no requirement for surgery or further endoscopic intervention. In cases of recurrence, retreatment of a lesion with a second intervention was possible. Complications were classified into those related to sedation, endoscopy, or deployment of the clip.nnnRESULTSnA total of 28 OTSC system applications were carried out in 21 patients [median age 64 years (range 42-85), 33% females]. The main indications were fistulae (52%), mostly after percutaneous endoscopic gastrostomy tube removal, and anastomotic leakage after GI surgery (29%). Further indications were unroofed submucosal lesions after biopsy, upper gastrointestinal bleeding, or esophageal stent fixation. The OTSC treatments were applied either in the upper (48%) or lower (52%) GI tract. The mean lesion size was 8 mm (range: 2-20 mm). Primary technical success and clinical success rates were 85% and 67%, respectively. In 53% of cases, the suction method was used without accessories (e.g., twin grasper or tissue anchor). No endoscopy-related or OTSC-related complications were observed.nnnCONCLUSIONnOTSC is a useful tool for endoscopic closure of various GI lesions, including fistulae and leakages. Future randomized prospective multicenter trials are warranted.

First report of colonoscopic closure of a gastrocolocutaneous PEG migration with over-the-scope-clip-system.

Percutaneous endoscopic gastrostomy (PEG) is a common practice for long-term nutrition of patients who are unable to take oral food. We report of an 85-year old man with a history of recurrent larynx carcinoma and hemicolectomy many years ago due to unknown reason. Laryngectomy was indicated. Preoperatively a PEG was inserted endoscopically after an abdominal ultrasonography without abnormal findings. Few months after PEG insertion, the patient was evaluated for diarrhea and insufficient feeding without signs of infection or peritonism. An upper endoscopy and computed tomography scan confirmed a buried bumper syndrome with migration of the PEG tube into the colon as a rare complication. He underwent successful colonoscopic removal of the internal bumper and closure of the colonic orifice of the fistula with the over-the-scope-clip system (OTSC). OTSC is an endoscopic device for treatment of bleeding, perforation, leak and fistula in the gastrointestinal tract. To the best of our knowledge, this is the first report of the use of OTSC for colonoscopic closure of a gastrocolocutaneous fistula due to a buried bumper syndrome with transcolonic PEG tube migration.

Perception of preference and risk-taking in laparoscopy, transgastric, and rigid-hybrid transvaginal NOTES for cholecystectomy.

QUESTIONS UNDER STUDYnFew data are available regarding patients perceptions of new cholecystectomy (CC) techniques, in the context of the patients risk behaviours. We investigated patients preferences for transgastric pure natural orifice translumenal endoscopic surgery (NOTES; transgastric NCC) and rigid-hybrid transvaginal NOTES CC (tvNCC) compared with the standard laparoscopic CC (SL-CC), and patients risk behaviours.nnnMETHODSnA total of 140 inpatients scheduled for elective laparoscopic CC were enrolled in this prospective single-centre study, from January 2009 to January 2010. Patients judged the potential advantages and disadvantages of transgastric NCC and tvNCC compared with SL-CC. The individuals risk behaviour was analysed by means of the validated 40-item Domain-Specific Risk Attitude Scale (DOSPERT).nnnRESULTSnOf the 140 recruited patients, 57 (65% females; mean age 51.5 years) were analysed. Twenty-five percent of males opted for transgastric NCC and 75% opted for SL-CC. Among females, 10.8%, 37.8% and 51.4% opted for transgastric NCC, tvNCC and SL-CC, respectively. Faster convalescence was graded as the primary potential advantage of transgastric NCC, whereas the potential risk of long-term stomach injuries was considered a primary disadvantage. Females graded the reduction of hospital-acquired morbidity as the primary advantage of tvNCC. The risk assessment showed significantly more risk-taking behaviour in the recreational domain of life among patients who opted for innovative surgical techniques than among those opting for conventional surgery.nnnCONCLUSIONSnTransgastric NCC is rarely accepted by females but accepted by a quarter of males. Females consider rigid-hybrid tvNCC and SL-CC similarly attractive. Despite promising new techniques, three-quarters of male and one half of female patients still prefer the standard laparoscopic CC.

Endoscopic dilation of complete oesophageal obstructions with a combined antegrade-retrograde rendezvous technique

AIMnTo investigate the combined antegrade-retrograde endoscopic rendezvous technique for complete oesophageal obstruction and the swallowing outcome.nnnMETHODSnThis single-centre case series includes consecutive patients who were unable to swallow due to complete oesophageal obstruction and underwent combined antegrade-retrograde endoscopic dilation (CARD) within the last 10 years. The patients demographic characteristics, clinical parameters, endoscopic therapy, adverse events, and outcomes were obtained retrospectively. Technical success was defined as effective restoration of oesophageal patency. Swallowing success was defined as either percutaneous endoscopic gastrostomy (PEG)-tube independency and/or relevant improvement of oral food intake, as assessed by the functional oral intake scale (FOIS) (≥ level 3).nnnRESULTSnThe cohort consisted of six patients [five males; mean age 71 years (range, 54-74)]. All but one patient had undergone radiotherapy for head and neck or oesophageal cancer. Technical success was achieved in five out of six patients. After discharge, repeated dilations were performed in all five patients. During follow-up (median 27 mo, range, 2-115), three patients remained PEG-tube dependent. Three of four patients achieved relevant improvement of swallowing (two patients: FOIS 6, one patient: FOIS 7). One patient developed mediastinal emphysema following CARD, without a need for surgery.nnnCONCLUSIONnThe CARD technique is safe and a viable alternative to high-risk blind antegrade dilation in patients with complete proximal oesophageal obstruction. Although only half of the patients remained PEG-tube independent, the majority improved their ability to swallow.

How is the increased risk of colorectal cancer in first-degree relatives of patients communicated?

Objectives Compared with the general population, first-degree relatives (FDRs) of colorectal cancer (CRC) patients have a two-fold to four-fold higher risk of developing CRC. Little data is available regarding communication between doctors and CRC patients about risk to FDRs. We aimed to evaluate CRC patients’ knowledge of FDRs’ increased CRC risk, and FDRs’ knowledge of this risk and adherence to CRC screening. Materials and methods In this retrospective, single-center, population-based observational study, patients aged 18–80 years who underwent surgery for CRC between January 2005 and May 2010 were asked to complete a questionnaire. A questionnaire sent to the patients’ FDRs (siblings and children) asked whether they had been advised to undergo any CRC screening examination, whether they had done so, and if so, when initiated and by whom. Main outcome measurements were: CRC patients’ and their FDRs’ information status regarding the FDRs’ increased CRC risk and screening status. Results Of 343 index patients (390 contacted, 47 deceased/moved), 134 replied to the survey (39.1% response rate). Among index patients, 82.1% (110/134) were informed about FDRs’ increased CRC risk. This information was provided mainly by gastroenterologists and general practitioners (65.7 and 28.4%, respectively). Among FDRs, 85.1% (143/168) were informed about their increased CRC risk, but 69% did not undergo a screening colonoscopy. Among the FDRs more than 50 years of age, 40.8% did not undergo a screening colonoscopy. Conclusion In Switzerland, CRC patients and their FDRs are well informed about FDRs’ increased CRC risk. However, the majority of FDRs do not undergo the recommended CRC screening.

Mind the sump! - diagnostic challenge of a rare complication of choledochoduodenostomy.

Sump syndrome is a rare long-term complication of side-to-side choledochoduodenostomy (CDD), a common surgical procedure in patients with biliary tract disease in the era before endoscopic retrograde cholangiopancreatography (ERCP). Frequently only pneumobilia, serving as sign for functioning biliary-enteric anastomosis, is reminiscent of the former surgery. We present the case of an 81-year-old patient with sump syndrome who presented with clinical signs of ascending cholangitis, decades after the initial CDD procedure. Finally the detailed medical history that was taken very thoroughly in combination with the presence of pneumobilia led to the suspicion of sump syndrome. Sump syndrome was diagnosed by ERCP, and after endoscopic debris extraction and antibiotic treatment the patient recovered quickly. In the ERCP era little is known about CDD and its long-term complications, especially by young colleagues and trainees. Therefore this report provides an excellent opportunity to refresh the knowledge and raise awareness for this syndrome.

New kit on the block

Wir berichten über einen 69-jährigen Patienten mit kompensierter äthyltoxischer Leberzirrhose Child A, ohne Nachweis von Aszites und Ösophagusvarizen, mit prophylaktischer PEG-Sondeneinlage aufgrund eines Zungengrundkarzinoms mit geplanter Radiotherapie. Bei bekannter koronarer Herzkrankheit mit Status nach sechsfachem aortokoronarem Bypass und Status nach zerebrovaskulärem Insult erfolgte eine Therapie mit Azetylsalizylsäure. Ausserdem fand sich eine Thrombozytopenie mit 66 000 Thrombozyten/μl aufgrund einer Splenomegalie. Der INR war normwertig. Die PEG-Sonde konnte problemlos endoskopisch eingelegt werden. Fünf Tage später stellte sich der Patient mit einer Blutung aus der PEG-Einstichstelle nach aussen vor. Das Hämoglobin war von 100 auf 84 g/l abgefallen, mit stabilbleibender Thrombozytopenie und INR. Die dislozierte externe Halteplatte wurde zunächst fest ange zogen. Trotzdem persistierte eine signifikante Blutung aus der PEG-Einstichstelle, so dass eine Gas troskopie erfolgte. Blutkoagel waren auf der PEG-Halteplatte lokalisiert (Abb. 1 ). Nach Entfernung der Koagel und leichtem Vorschub der PEG-Sonde ins Ma genlumen

Unspecific Abdominal Symptoms and Pneumobilia: A Rare Case of Gastrointestinal Obstruction

The case of a 77-year-old woman with symptoms of gastric outlet obstruction is presented. Transabdominal ultrasonography findings were suspicious of Bouverets syndrome. Upper endoscopy confirmed this diagnosis. Bouverets syndrome is a rare complication of gallstone disease caused by a bilioenteric fistula leading to gastric outlet obstruction by a gallstone and should be suspected in any patient who presents with pneumobilia without recent endoscopic retrograde cholangiopancreatography or biliary surgery.