H. Juergen Nord

Foreign bodies of the upper gastrointestinal tract.

This is a retrospective review of our experience with fiberendoscopic management of 40 separate episodes of foreign body ingestion. Eighteen patients swallowed a food bolus which impacted in the esophagus. Seventy-eight percent of these patients had an esophageal stenosis. Sixteen patients were involved in 22 episodes of true foreign body ingestion. Fiberendoscopic management was successful in 92% of food impactions and 76% of true foreign bodies. In our experience, fiberendoscopic removal is a safe procedure with an 83% overall success rate. It is the method of choice in the management of esophageal and gastric foreign bodies.

Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: Extended follow-up of an expanded randomized prospective trial

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a “bridge to transplantation.” All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child’s class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P<0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P <0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P <0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.

Palliative bipolar electrocoagulation therapy of obstructing esophageal cancer

In a multicenter pilot study, a prototype bipolar electrocoagulation tumor probe was employed for palliation of obstructing circumferential esophageal cancer in 20 patients. Mean number of initial treatment sessions was 1.7. Dysphagia and tumor channel size improved significantly after treatment. Mean treatment interval before repeat treatment was 7.6 weeks. Major complications included delayed hemorrhage (two patients) and esophageal-pulmonary fistula (two patients). This new device may provide a less expensive alternative to laser or surgery for palliation of malignant esophageal obstruction.

Are hyperplastic rectosigmoid polyps associated with an increased risk of proximal colonic neoplasms

Diminutive polyps are frequent findings on screening flexible sigmoidoscopy. To determine the significance of distal diminutive polyps, we conducted a prospective study of 162 asymptomatic, average-risk subjects who were 50 years of age or older. Subjects were divided into four groups: 42 control subjects with no polyps in the rectosigmoid, 66 subjects with at least one diminutive adenoma in the rectosigmoid, 12 subjects with a mixed hyperplastic-adenomatous polyp in the rectosigmoid, and 42 subjects with only hyperplastic polyps in the rectosigmoid. Total colonoscopy was performed on all subjects. The prevalence of proximal adenomas was 42% in the adenoma group, 25% in the mixed group, 14% in the hyperplastic group and 12% in the control group. The prevalence of proximal adenomas was significantly higher (p = 0.006) in the adenoma group as compared with the control and hyperplastic groups. Increasing age was associated with an increased prevalence of proximal adenomas. Nearly two thirds of those over 65 years of age with distal diminutive adenomas had proximal colonic neoplasms. These results indicate that diminutive rectosigmoid adenomas are good markers for proximal neoplasms. Rectosigmoid hyperplastic polyps are not associated with an increased prevalence of proximal neoplasms. Total colonoscopy is not indicated if hyperplastic polyps are the only finding on flexible sigmoidoscopy.

Esophageal Perforation Following Use of the Esophageal Obturator Airway

Four cases of esophageal rupture associated with the use of the esophageal obturator airway are presented and added to the fifteen cases already in the literature. The incidence of this complication may be greater than previously suspected since a systematic search for this complication has not been made in cardiac arrest patients. The mechanism of rupture of the occluded esophagus may be similar to that seen in postemetic rupture. Endotracheal intubation remains the procedure of choice in airway control of cardiac arrest patients, although the modified esophageal obturator airway with gastric tube may prevent the occurrence of esophageal rupture by allowing decompression of the esophagus.

Granular cell tumor of the esophagus: natural history, diagnosis, and therapy

Five cases of granular cell tumor of the esophagus are reported. In four cases, the tumor was an asymptomatic, incidental finding. In one case, a larger granular cell tumor presented with dysphagia and required local surgical excision. Long-term follow-up in three cases revealed no evidence of tumor progression. Esophageal granular cell tumors are benign lesions which can frequently be diagnosed by endoscopic biopsy. Asymptomatic, smaller lesions require observation only. Larger, symptomatic lesions can be treated with local surgical excision.

The role of endoscopy after vertical banded gastroplasty

Since 1984, a total of 99 patients underwent vertical banded gastroplasty (VBG) through protocol (pouch 8 ml in size, band 4.3 cm in circumference) to treat morbid obesity. Follow-up was obtained in 95 patients. Thirty upper gastrointestinal endoscopies were performed post-operatively in 17 patients. Indications were nausea/vomiting in 11, epigastric pain in 4, acute obstructive symptoms in 4, and miscellaneous in three. Findings included food impaction in 10, distal esophagitis in 8, gastritis in 4, and a normal examination in 2. Only 4 of 10 food impactions were associated with an excessively narrowed gastroplasty outlet. Eight patients had an excessively narrowed gastric stoma: two became asymptomatic with dietary modification only and six underwent dilation therapy (dilator range from 8 to 18 mm in diameter) with immediate resolution of symptoms in four of six. One of the two patients unresponsive to dilation was lost to follow-up, and the other required surgical revision after multiple dilation sessions.

Diagnostic laparoscopy guidelines for clinical application.

Abstract This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for the appropriate use of endoscopy are based on a critical review of the available data and expert consensus. Controlled clinical studies are needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical considerations may justify a course of action at variance from these recommendations.

Laparoscopy--a historical perspective: are gastroenterologists going to reclaim it?

Laparoscopy is one of the oldest GI endoscopic procedures. September 21, 1901, is considered the birth date of laparoscopy, when Georg Kelling, a surgeon from Dresden, Germany, described his new technique ‘‘coelioscopy’’ and use of pneumoperitoneum to create a visual intraabdominal space. Over the years, laparoscopy has seen multiple rediscoveries, coming full circle with its current dominance by surgeons with minimally invasive surgery, while in the interval primarily practiced by gastroenterologists as diagnostic laparoscopy with an emphasis on diseases of the liver and peritoneum. Von Ott in St Petersburg, Russia, independently described ‘‘ventroscopy’’ in 1901, mainly with an emphasis on gynecology. In 1910 Jacobaeus in Stockholm, Sweden, unaware of previous reports, published an article about use of a cystoscope to inspect the abdominal cavity in humans. He coined the term laparoscopy. Kalk, an internist in Frankfurt, Germany, who ‘‘reinvented’’ laparoscopy for the fourth time in the 1920s, ushered in the era of modern laparoscopy, which was dominated by gastroenterologists for more than 6 decades. Kalk developed the modern instrumentation, foroblique optics (135-degree side-viewing) which, through rotation, allowed a panoramic view of the abdominal cavity and its organs. Laparoscopy became an important diagnostic tool, especially in the differential diagnosis of liver disease with guided biopsy and staging of intra-abdominal malignancies. With the emergence of noninvasive imaging studies such as US, CT, and magnetic resonance imaging, laparoscopy by gastroenterologists declined dramatically in the 1980s in spite of its superiority in focal hepatic lesions and the staging of malignancies. At the same time, laparoscopy was rediscovered by surgeons, initially for cholecystectomy and then for a wide array of abdominal procedures, ushering in the era of minimally invasive surgery. Gynecologists, who had valued diagnostic laparoscopy for years, were the first to widely embark on operative laparoscopy, primarily tubal sterilization. It was actually a gynecologist who performed the first nongynecologic operative laparoscopy. Semm, in Kiel, Germany, who also developed the insufflator for pneumoperitoneum, reported the first

Endoscopic ambulatory surgery centers in the academic medical center: We can do it too!

A freestanding ambulatory surgery center (ASC) at an academic institution is an exception rather than the rule. It is a major challenge to the concept of the traditional academic medical center. Advantages and disadvantages are discussed, as well as the detailed planning process beginning with a well executed feasibility study, the hiring of consultants, and financing of the facility. Construction, opening of the facility and operation are not different from other ACSs. However, the integration of teaching and research presents new opportunities. Lessons learned and advice to others are detailed on how the ASC benefitted one specific institution and how it may add value and revenue to other academic medical centers.