Hans Seifert

Retroperitoneal endoscopic debridement for infected peripancreatic necrosis

Standard management of infected peripancreatic necrosis consists of open surgical debridement and lavage--a traumatic intervention with substantial morbidity and mortality. As an alternative and novel approach with minimum invasiveness, we present fenestration of the gastric wall and debridement of infected necrosis by direct retroperitoneal endoscopy. In three patients, this strategy led to rapid clinical improvement and no serious complications. Transgastric endoscopic therapy may be a less traumatic alternative to surgery and should be further assessed in prospective studies.

Transpapillary and transmural drainage of pancreatic pseudocysts

BACKGROUND Endoscopic drainage of pseudocysts using the transpapillary and transmural approaches has been reported. We evaluated endoscopic drainage in 53 patients with symptomatic pancreatic pseudocysts in whom conservative management had failed. METHODS After preliminary endoscopic retrograde pancreatography, transpapillary drainage was attempted in 33 patients with pseudocysts that communicated with the main pancreatic duct. Transmural drainage of pseudocysts in contact with the stomach or duodenal wall was attempted in the remaining 20 patients and in 4 patients selected for combined transpapillary and transmural drainage. The cause of pseudocysts was chronic pancreatitis in 92%. The median pseudocyst size was 7.0 cm (range, 2 to 16). RESULTS Endoscopic drainage was technically successful in 50 patients (94%), of whom 47 had complete pseudocyst resolution. Complications occurred in 11% and included gallbladder puncture (n = 1) and bleeding (n = 2) after transmural drainage, and pancreatitis (n = 1) after transpapillary drainage; stent clogging resulted in abscess formation in 2 patients. Mean follow-up was 22 months (range, 1 to 70); pseudocysts recurred in 11 patients (23%), of whom 7 were successfully re-treated endoscopically. CONCLUSION Both transpapillary and transmural pseudocyst drainage are highly effective in patients with pseudocysts demonstrating suitable anatomy for these endoscopic techniques.

Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study

BACKGROUND Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The short-acting anesthetic propofol offers certain potential advantages for endoscopic procedures, but controlled studies proving its superiority over benzodiazepines for ERCP are lacking. METHODS During a 6-month period 198 consecutive patients undergoing routine ERCP randomly received either midazolam (n = 98) or propofol (n = 99) for sedation. Vital signs (heart rate, blood pressure, oxygen saturation) were continuously monitored and procedure-related parameters, the recovery time and quality (recovery score) as well as the patients cooperation and tolerance of the procedure (visual analog scales) were prospectively assessed. RESULTS Patients receiving propofol or midazolam were well matched with respect to demographic and clinical data, ERCP findings, and the performance of associated procedures. Propofol caused a more rapid onset of sedation than midazolam (p < 0.01). Clinically relevant changes in vital signs were observed at comparable frequencies with temporary oxygen desaturation occurring (< 85 %) in 6 patients in the propofol group and 4 patients receiving midazolam (not significant). However, an episode of apnea had to be managed by mask ventilation via an ambu bag (lasting 8 minutes) in one of the patients receiving propofol sedation. Mean recovery times as well as the recovery scores were significantly shorter with propofol (p < 0. 01). Propofol provided significantly better patient cooperation than midazolam ( p < 0.01), but procedure tolerability was rated the same by both groups of patients (not significant). CONCLUSIONS Intravenous sedation with propofol for ERCP is (1) more effective than sedation with midazolam, (2) safe under adequate patient monitoring, and (3) associated with a faster postprocedure recovery.

Sedation with propofol plus midazolam versus propofol alone for interventional endoscopic procedures: a prospective, randomized study

Adequate patient sedation is mandatory for most interventional endoscopic procedures. Recent anaesthesiologic studies indicates that propofol and midazolam act synergistically in combination and therefore may be superior to sedation with propofol alone in terms of sedation efficacy, recovery and costs (due to a presumed lower total dose of propofol needed).

Papillary roof incision using the Erlangen-type pre-cut papillotome to achieve selective bile duct cannulation.

BACKGROUND Prior studies evaluating pre-cutting the major papilla to access the bile duct when standard cannulation falls have usually used the needle-knife papillotome. We conducted a prospective study to evaluate the efficacy and safety of an Erlangen-type pre-cut papillotome for pre-cutting. PATIENTS AND METHODS Three hundred twenty-seven patients (114 men, mean age 67 years) who underwent first-time sphincterotomy at our institution were included. Pre-cutting was performed if free and wire-guided cannulation of the bile duct failed according to an algorithm. RESULTS Pre-cutting was performed in 123 patients (38%) and selective cannulation was successful in all. Post-ERCP serum pancreatic enzyme levels were more frequently elevated in the pre-cut group (50%) than the non-pre-cut group (27%, p < 0.001); however, there was no difference in the incidence of post-ERCP pancreatitis (pre-cut = 2.7%, 95% CI: 0.66% to 7.6%; non-pre-cut = 1.6%, 95% CI: 0.3% to 4.7%). The incidence of bleeding was similar (pre-cut, 2.4%, non-pre-cut, 3.9%; p > 0.05). CONCLUSION Pre-cutting the major papilla for biliary access using the Erlangen-type pre-cut papillotome is an effective and reasonably safe procedure when performed by endoscopists with extensive experience in pancreatobiliary endoscopy.

Ultrasonic esophagoprobe for TNM staging of highly stenosing esophageal carcinoma

BACKGROUND Endosonographic staging of esophageal carcinoma may be limited in one third of cases by tumor stenoses that cannot be traversed with conventional echoendoscopes. We designed and evaluated a new endosonographic instrument (ultrasonic esophagoprobe) for TNM staging of highly stenosing esophageal carcinomas. METHODS Eighty-seven consecutive patients (64 men, mean age 61 years) with highly stenosing esophageal carcinomas were studied with the esophagoprobe (features: diameter of 7.9 mm, bougie-shaped tip, no fiber optics, insertion over a guide wire). RESULTS The esophagoprobe was successfully inserted past the stenosis without complication in all patients. Nine patients (10%) required preliminary bougienage to 33 F. The imaging quality was high and allowed for complete T and N staging in all patients. M staging was indeterminate in 15 patients because of inadequate visualization of the celiac axis region. Histopathologic correlation in 38 patients who underwent surgery showed an overall T stage accuracy rate of 89% (T2 = 80%, T3 = 95%, T4 = 87%), and N and M stage accuracies of 79% (N0 = 44%, N1 = 90%) and 91% (M0 = 94%, M1 = 75%), respectively. CONCLUSIONS The esophagoprobe enables safe passage of highly stenosing esophageal carcinomas for TNM staging. Accuracy rates are similar to those reported for conventional echoendoscopes.

Endoscopic injection of botulinum toxin in patients with recurrent acute pancreatitis due to pancreatic sphincter of Oddi dysfunction

To evaluate the technical feasibility, safety, and short‐term efficacy of botulinum toxin injection for pancreatic sphincter of Oddi dysfunction and to analyse whether the symptomatic response to botulinum toxin might be a predictor of outcome for endoscopic sphincterotomy.

Sonographic detection of perihepatic lymphadenopathy is an indicator for primary sclerosing cholangitis in patients with inflammatory bowel disease

AimPrimary sclerosing cholangitis (PSC) is a frequent complication in patients with inflammatory bowel disease (IBD). While hyperplasia of the perihepatic lymph nodes has been described in patients with PSC, its prevalence and cause in IBD patients remains obscure. In the present study we address the question of whether ultrasound (US) examination is useful to detect perihepatic lymphadenopathy and improve the diagnostic accuracy for PSC in patients with underlying IBD.MethodsA total of 310 consecutive IBD patients were prospectively evaluated by US for enlarged perihepatic lymph nodes, as well as serologic testing for cholestasis-indicating enzymes. In patients with positive test results, viral or autoimmune liver disorders were excluded by serum testing. Next, the presence of PSC was confirmed/excluded by endoscopic retrograde cholangiography (ERC).ResultsPerihepatic lymphadenopathy was detected by US in 27 of 310 (9%) patients. In 9 (33%) of those, serologic testing identified an underlying autoimmune or viral hepatitis. In the remaining 18 patients, ERC confirmed PSC in 17 (94%) and excluded it in 1. Elevated cholestasis parameters were found in 43 of 310 (14%) patients and 5 (12%) of those were diagnosed with autoimmune or viral hepatitis. In the remaining 38 patients, ERC confirmed PSC in 15 (39%) and excluded it in 23 (61%). Therefore, when autoimmune or viral hepatitis was excluded, enlarged lymph nodes in US predicted PSC more accurately than conventional serum parameters alone (PPV 94 and 39%, respectively [ P<0.001]), and the sensitivity ratio increased by a factor of 1.13 in favor of the US examination.ConclusionIn patients with IBD, detection of enlarged perihepatic lymph nodes is a highly predictive indicator for the presence of PSC. Alternative causes of perihepatic lymphadenopathy have to be excluded.

Endoscopic botulinum toxin injection into the minor papilla for treatment of idiopathic recurrent pancreatitis in patients with pancreas divisum

BACKGROUND In some patients with pancreas divisum, obstruction to the flow of pancreatic juice into the duodenum is the presumptive cause of acute recurrent pancreatitis. However, identification of those patients who may benefit from minor papilla sphincterotomy or stent placement is difficult. METHODS Five patients with acute recurrent pancreatitis and pancreas divisum were therefore treated by endoscopic injection of 50 units of botulinum toxin into the minor papilla in an outpatient setting. RESULTS Botulinum toxin injection was successfully performed on six occasions in 5 patients and no adverse effects were noted. Two patients relapsed after 9 and 10 months, respectively, but had definite relief of symptoms after needle-knife sphincterotomy. One patient relapsed 7 months after botulinum toxin injection but became symptom free again after a second botulinum toxin injection. Another patient is still in clinical remission 4 months after botulinum toxin administration, and 1 patient did not respond to either botulinum toxin administration or to sphincterotomy and stent placement. CONCLUSIONS Endoscopic injection of botulinum toxin into the minor papilla in patients with pancreas divisum and acute recurrent pancreatitis is a safe procedure that is easy to perform and provides short-term relief in some patients. Response to botulinum toxin injection may predict whether patients with pancreas divisum and acute recurrent pancreatitis will benefit from other forms of endoscopic therapy.

Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities

BACKGROUND This prospective study evaluated whether extraductal catheter probe EUS as an adjunct to endoscopic retrograde cholangiography can detect or rule out choledocholithiasis and other pathologic conditions of the distal common bile duct. METHODS A total of 119 patients referred because of suspected choledocholithiasis or other bile flow obstruction for endoscopic retrograde cholangiography and papillotomy were included in this prospective study. Extraductal EUS of the distal common bile duct with a radial-scanning catheter probe was followed immediately by endoscopic retrograde cholangiography and papillotomy by a second examiner who was blinded to the EUS findings. Extraductal EUS and endoscopic retrograde cholangiography findings were compared. RESULTS Extraductal EUS detected 33/34 bile duct stones and all papillary adenomas (16 patients). In 8/34 patients, stones were missed on cholangiography but were seen after papillotomy and stone extraction. Extraductal EUS missed 10 peripheral lesions, one pancreatic tumor, and two distal bile duct stenoses. Overall, the sensitivity of EDUS was 78% and specificity was 98%. CONCLUSIONS Extraductal EUS accurately detects abnormalities involving the distal common bile duct, especially small stones. The use of catheter probe EUS imaging during interventional endoscopy can help to avoid unnecessary papillotomy and can influence therapeutic strategy.