Hassan Abou-Rebyeh

Prospective pilot evaluation of a new needle prototype for endoscopic ultrasonography-guided fine-needle aspiration: comparison of cytology and histology yield.

Objectives Endoscopic ultrasonography (EUS) with the adjunct of EUS-guided fine needle aspiration has become an important diagnostic modality in gastroenterologic oncology. EUS-guided fine needle aspiration mainly relies on cytology; data are scarce that compare cytology and histology. While testing a 22-gauge prototype needle, we prospectively compared the yield for both. Methods Forty-two consecutive patients (27 male, 15 female; mean age 59.2 years, range: 17–90 years) were included. In each patient we aimed to make two needle passes, and if the material acquired appeared insufficient macroscopically (no in-room cytopathology was available), further passes were done. The material was sent for cytological and histological assessment. Results A median number of two passes (range: 2–3) were uneventfully performed for pancreatic lesions (n=30), mediastinal and other lymph nodes/masses (n=8) and various other lesions (n=4) and yielded adequate material for cytology, histology or at least one of the two investigations in 62, 67 and 74% of patients, respectively. No false positive results were found (specificity 100%). Sensitivities were 58.6 and 65.5%, respectively, for cytology and histology alone; combined assessment increased sensitivity to 79.3%. When adjusted values were calculated, based only on those cases with adequate material, sensitivity was 89.5% for cytology and 85.7% for histology, and increased to 100% with combined assessment. Conclusion The new needle achieves sensitivities similar to those previously reported with no significant differences in sensitivity between cytology and histology. More effective tissue acquisition methods must be sought to improve overall results.

4620 Endoscopic therapy of post-pancreatitic persistent necrosis.

Introduction: Development of PPN occurs as a severe complication of necrotising pancreatitis. PPN has to be differentiated from pancreatic pseudocysts and pancreatic abscesses. So far, treatment is performed by percutaneous or surgical drainage as well as surgical resection and necrosectomy. Endoscopic treatment offers an alternative approach to surgery. Aim:We studied the short term outcome (=30 days after initiation of endoscopic treatment) of endoscopic PPN therapy. Methods: PPN was identified by means of sonography and CT. Endoscopic treatment was adapted to the findings (MRCP, ERP) in the pancreatic duct system. Endoscopic treatment modalities comprised EST of pancreatic sphincter as well as stenting and dilation of pancreatic duct stenoses and stone extractions. Furthermore, PPN were treated by endoscopic fistulation, subsequent stenting (Amsterdam stents, 10 Fr., 2-3 cm length) and sequester extraction. Fistulation was carried out either through the gastric or the duodenal wall depending on the topographic situation. Solid sequesters and debris were extracted after enlargement of the fistula hole by multiple stenting. Liquid PPN content was washed out by irrigation through nasocystic catheters. Results: 14 patients affected with PPN (8 Women; 7 Men; mean age 47 years) were treated by endoscopic drainage. Underlying causes had been alcoholic pancreatitis (n=8), biliary pancreatitis (n=4) and idiopathic pancreatitis (n=2). All patients received endoscopic therapy as mentioned above. In 71% of patients (10 out of 14) PPN completely disappeared. In contrast, 2 patients showed no improvement and 2 further patients only partial response to endoscopic drainage therapy. 2 patients refractory to endoscopic therapy received surgery in terms of partial pancreatectomy, necrosectomy and Whipples reconstruction. 1 patient recovered soon while the other one developed septic complications and finally died. Due to endoscopic therapy, 1 patient suffered from perforation of the post-pancreatitic necrosis into the peritoneum. Discussion: We treated 14 patients which were affected with PPN due to necrotizing pancreatitis. Most patients (71%) completely recovered due to endoscopic therapy. Patients suffering from PPN are usually in reduced physical condition and therefore at high risk for surgery. Endoscopic therapy of PPN offers a minimal invasive and successful alternative to surgery. It is also suggested, that surgical resection should be restricted to patients refractory to endoscopic drainage therapy.

4681 Endoscopic management of psc patients suffering from dominant bile duct strictures.

Introduction: In general, PSC patients are in good condition for many years until progressive bile duct stenoses lead to cholestasis deteriorating physical condition. Extrahepatic bile duct stenoses contributing to symptomatic cholestasis in PSC patients are referred to as dominant stenoses. So far, reported techniques and outcome of endoscopic dilation therapy of dominant stenoses are contradictory. Aim: We estimated the benefit of endoscopic dilation of dominant stenoses in patients with PSC. Methods: Our PSC patient pool of the last 9 years (Nov. 90 - Oct. /99) was studied retrospectively. Dominant stenoses were treated by balloon dilation and bouginage. Stenting of dominant stenoses was only carried out in case of unsuccessfull dilation therapy. Results: 72 patients suffering from symptomatic PSC were investigated by ERC. 40% (29/72) of all PSC patients presented dominant stenoses. The mean age was 40.9±14.2 years, 65% (19/72) were male and 35% (10/72) female. Patients suffering from dominant stenoses were treated by repeated dilation procedures (98 interventions in 29 patients, mean: 3.4 interventions per patient). Endoscopic therapy improved physical condition as well as decreased cholestatic parameters. AST, ALT, AP, gGT and bilirubin (78% from 6.1±6.4 down to 1.4±0.6 mg/dl). 98 interventions were accompanied by 8.2% of complications in terms of post-ERC pancreatitis (2.0%), CBD perforation (3.1%) and post-ERC cholangitis (3.1%). All complications were considered as mild to moderate since all disappeared within a few days following conservative therapy. Discussion: Many PSC patients suffer from extrahepatic dominant bile duct stenoses. Dilation therapy was able to widen dominant stenoses as well as to relieve cholestasis thus improving the general state of health. Conclusively, we recommend to screen symptomatic PSC patients for dominant bile duct stenoses. Dominant bile duct stenoses should be repeatedly treated by endoscopic dilation therapy since most afflicted PSC patients benefit significantly.

7264 Clinical outcome of percutaneous-duodenal bile duct stent of the yamakawa type.

Introduction: In case of obstructive jaundice and failure of endoscopic stenting percutaneous transhepatic cholangio-drainage (PTCD) as well as Yamakawa stents are able to decompress intrahepatic bile ducts. Yamakawa stents are deployed percutaneously and unlike PTCD are advanced further through the tumor stenosis into the duodenum allowing internal bile drainage. Only in case of stent dysfunction, the percutaneous Yamakawa outlet has to be opened enabling immediate percutaneous bile drainage as well as subsequent clearing of stent occlusion. Since Yamakawa stents allow intracorporal bile drainage into the duodenum collecting bags are avoided and bile loss syndrome is prevented. Aim: We studied the clinical outcome of Yamakawa stents in pat. with malignant jaundice. Methods: During the last two years (from 8/97 to 11/99) we treated 827 pat. suffering from malignant jaundice in our clinic. In 8.2% (68/827) of cases endoscopic stenting was impossible or insufficient. These pat. receive either PTCD or Yamakawa stents (8 to 14 Fr., Pflugbeil Co., Germany). Results: In 68 pat. we performed percutaneous decompression of malignant jaundice. 62 pat. received PTCD. Later on, we exchanged PTCD to Yamkawa stent in 28 (45.2%) pat.. 6 further pat. had primarily received Yamakawa stents. Finally, we managed a total of 34 Yamakawa stent patients (20 male, 14 female, mean age: 69.2 years, range: 33-94 years). Pat. with Yamakawa stents suffered from gastric cancer (n=7), pancreatic cancer (n=7), Klatskin tumor (n=9), gall bladder cancer (n=4) and 7 metastases of distant tumors. Yamakawa stenting significantly reduced cholestasis (bilirubin

6981 Endoscopic and surgical management of biliary lesions after laparoscopic cholecystectomy (lce).

Introduction: Different therapeutical strategies for treatment of biliary lesions after LCE are recommended in the literature. Therefore, it is still not established which treatment is best suited for which type of biliary lesion caused by LCE. Aim:We investigated the type, localization and frequency of post-LCE biliary lesions introducing our new classification. Moreover, we analyzed the therapeutical success of endoscopic and surgical techniques. Methods: ERC was performed whenever symptoms occurred after LCE which were suspected to be of biliary origin. The new classification considered time of diagnosis as well as type, severity, localization and functional relevance of biliary lesions. According to the findings either endoscopic or surgical therapy was carried out. Surgical techniques comprised oversewing, splinting by percutaneous bile duct tubes, end-to-end reanastomosis, hepatico-jejunostomy and even liver transplantation. Results: Starting in 1990 a total of 108 patients (mean age 54 years, 75 female, 33 male) is treated so far for iatrogenic biliary lesions following LCE. Mean follow up was 28 months. According to 77% (83/108) of patients were primarily treated by endoscopy while 23% (25/108) received initially surgical therapy. 69% (74/108) of all patients could be definitely cured only by endoscopic treatment. 82% (89/108) of post-LCE lesions were classified as early lesions (= manifestation intraop. until 1 month postop.), including 38 peripheral and 51 central lesion sites. 18% of biliary lesions occurred late (= more than 1 month postop.). Peripheral bile duct injuries (cystic duct stump insufficieny, leckage of the gall bladder region, tangential CBD lesions) could be managed mostly by endoscopic or percutaneous means. In contrast, central lesions (occlusion or cutting of extrahepatic bile ducts) required surgical reconstruction. Discussion: This newly introduced classification of post-LCE biliary lesions enables optimization of endoscopic and surgical treatment strategies. In general, biliary lesions after LCE can be successfully treated by endoscopy except that lesions causing total disconnection of bile ducts.

Diagnostik und endoskopische Therapie beim zentralen Gallengangskarzinom

Klatskin-Tumore sind cholangiozelluläre Karzinome, die sich im Bereich der Hepatikusgabel manifestieren [20]. Ihre funktionelle Bedeutung für den Galleabstrom resultiert aus ihrer Lokalisation und ihrer Wachstumsform. Ihre Resektabilität hängt von der Tumormasse und der zentrifugalen Ausbreitung in die Hepatikusgänge ab [3, 5, 19, 24]. Der diagnostische Goldstandard für die exakte Ausbreitungsdiagnostik ist nach wie vor die endoskopische retrograde Cholangio-Pankreatikographie (ERCP) [7, 13, 14]. Zum Diagnosezeitpunkt sind die meisten Klatskin-Tumore nicht mehr kurativ resektabel [5, 18]. Wird die Cholestase nicht behandelt, kommt es zu einem progredienten Leberversagen. Ziel endoskopischer Therapieverfahren ist die gezielte Galleableitung mit dem Erhalt von ausreichend funktionstüchtigem Parenchym [11, 21]. Für die Therapieplanung ist eine umfassende präinterventionelle Bildgebung des gesamten Gallenwegssystems erforderlich. Hierbei spielt die Magnetresonanz-Cholangio-Pankreatikographie (MRCP) eine zunehmend wichtigere Rolle [14].Sehr hoffnungsvoll sind multimodale präoperative Therapieansätze, die zuvor inoperable Klatskin-Tumore wieder in eine kurativ resektable Situation überführen [1, 12, 30]. Neue Ansätze ergeben sich unter anderem durch die intrakavitäre photodynamische Therapie [4, 25].

Endoscopic therapy of ITBL-strictures in liver-transplanted patients

Introduction: Ischemic type biliary lesions (ITBL) in liver-transplanted patients are a difficult challenge to endoscopic therapy. ITBL has to be diffentiated by ERC from complications of choledocho-choledocho-side-toside-anastomosis and from papillary stenosis among others. Stenosis caused by ITBL as well as papillary stenosis can be treated successfully by ERC. We examined the outcome of endoscopic therapy in ITBL patients. Methods: From the beginning of the liver transplantation programme at our clinic in 1988 until now (11/1/1997) 935 orthotopic liver transplantations have been performed. Thereupon, 23 transplanted patients developed ITBL and most of them required endoscopic therapy. Therapy comprised endoscopic spincterotomy, balloon dilatation of stenoses, internal stenting and basket extraction of calculi. Results: 14 patients were treated due to progressive ITBL-induced stenoses by balloon dilatation subsequent to endoscopic sphincterotomy. In 6 out of 14 patients dilatation therapy failed due to rapid progression of ITBL. Calculi, sludge and debris could be extracted from 9 out of 14 patients. In 4 of these patients stenting was performed to treat stenoses in the donor-CBD or in the hepatic ducts. 5 patients presented a papillary stenosis requiting endoscopic sphinkterotomy. 12 of 23 ITBL patients deteriorated thus receiving retransplantation of the liver. The average time to retransplantation was 12 month. Endoscopic therapy could help many patients to survive for many month until retransplantation was possible. At the time of firstly diagnosing ITBL 3 patients presented only extrahepatic lesions (ITBL type I referring to the Neuhaus-classification) and 5 others circumscribed intrahepatic lesions (ITBL type II). These patients could by successfully treated by ERC. Further 15 patients were afflicted by multiple intraand extrahepatic stenoses (ITBL type III) thus always requiring retransplantation. Discussion: ITBL is a servere complication of liver transplantation. Endoscopic therapy is able to treat successfully many transplantationassociated stensoses. Thus, problems caused by cholestastis, cholangitis and cholelithiasis can be prevented or reduced significantly.Thereby, patients deteriorating progessively due to intraand extrahepatic stenoses (ITBL-type Ill) can be stabilized over many month to bridge the time until retransplantation. Moreover, patients with stenoses restricted to the extraor intrahepatic bile ducts (ITBL-type I and II) can be prevented from retransplantation by endoscopic measurements.