Jörg G. Albert

Benefit of a clipping device in use in intestinal bleeding and intestinal leakage

BACKGROUNDnThe over-the-scope clip (OTSC) system was first used to close the access route in natural orifice transluminal endoscopic surgery and is increasingly used for other indications.nnnOBJECTIVEnWe analyzed the use of the OTSC in intestinal bleeding and in closure of GI tract leaks.nnnDESIGNnAnalysis of a consecutive series of patients.nnnSETTINGnUniversity hospital.nnnPATIENTSnNineteen patients (group A: closure of GI leak site, n = 12; group B: complex GI bleeding, n = 7) were retrospectively enrolled in this study. We analyzed outcome and follow-up (6-68 weeks; group A: mean 37 weeks, standard deviation 24) in terms of treatment success (closure of the GI tract leak/durable hemostasis).nnnINTERVENTIONnEndoscopic application of OTSCs.nnnMAIN OUTCOME MEASUREMENTSnResolution of leaks, closure of fistula (group A), or stopping bleeding (group B).nnnRESULTSnIn group A, durable closure was achieved in 8 of 12 patients. Sealing a postoperative/postinterventional leak was successful in 6 patients and failed in 3. A gastrocutaneous fistula was primarily closed successfully in 2 patients, but recurred in 1 of these patients. A gastric wall dehiscence in necrotizing pancreatitis was successfully closed in another patient. Group B patients had previous endoscopic treatment failure in 4 of 7 patients (through-the-scope clips, injection of Suprarenin or fibrin glue, others) and were deemed not treatable by through-the-scope clips in 3 of 7 patients. The primary success rate was 100% (7 of 7 patients); durable hemostasis was achieved in 4 of 7 patients, whereas surgery or angiography was necessary in the remaining patients.nnnLIMITATIONSnRetrospective analysis.nnnCONCLUSIONSnLeaks and fistulae are reliably closed with OTSCs in tissue flexible enough to be sucked into the attached cap (eg, in lesions caused <1 week before). GI bleeding may be stopped by OTSCs with reliable transient hemostasis, but durable hemostasis is less frequent.

Long‐term follow‐up of endoscopic therapy for stenosis of the biliobiliary anastomosis associated with orthotopic liver transplantation

Endoscopic treatment for stenosis of an anastomotic biliary stricture (ABS) after orthotopic liver transplantation (OLT) has been proven to be effective and safe, but the long‐term outcomes and the risk factors for recurrence are unknown. All 374 patients who underwent OLT at Frankfurt University Hospital were screened for the occurrence of ABSs. ABSs were treated via the endoscopic insertion of a plastic endoprosthesis (29.8%), balloon dilation (12.8%), or a combination of the two (57.4%). The mean follow‐up time was 151 weeks, and the mean survival time was 3.4 years. ABSs were observed in 47 patients (12.6%). The mean time from OLT to an ABS was 16.25 months (medianu2009=u20093.25 months). The cumulative incidence rates for ABSs were 0.09 after 12 months, 0.10/24 m. and 0.11/36 m. In 12 cases (25.5%), ABSs were observed more than 12 months after OLT. ABSs recurred in 16 of the 47 patients (34%). The occurrence of an ABS 6 weeks or more after OLT was a significant predictor of ABS recurrence [Pu2009=u20090.04, hazard ratio (HR)u2009=u20090.235]. There was a trend of hepatitis C virus (HCV) infections being predominant in patients experiencing ABS recurrence (30% for HCV etiology versus 4% for non‐HCV etiology) in comparison with patients not experiencing recurrence (36% for HCV etiology versus 30% for non‐HCV etiology, Pu2009>u20090.05). The severity of the initial stricture predicted ABS recurrence (Pu2009=u20090.046, HRu2009=u20092.78), but it did not influence overall survival. The long‐term resolution of ABSs was observed in 45 of the 47 patients (95.7%), and ABS recurrence was treated with another attempt (nu2009=u200916 or 34%) or 2 more attempts (nu2009=u20091) at endoscopic treatment. In conclusion, the long‐term success of the endoscopic treatment of ABSs is highly probable if recurrent strictures are again treated endoscopically. ABSs might occur late (>36 months) after OLT, and lifelong follow‐up is essential for identifying OLT patients with ABSs. Liver Transpl 19:586–593, 2013.

A multicenter study on the role of direct retrograde cholangioscopy in patients with inconclusive endoscopic retrograde cholangiography.

BACKGROUND AND STUDY AIMSnDirect retrograde cholangioscopy (DRC) may improve the diagnostic and therapeutic yield of endoscopic retrograde cholangiography (ERC) but safety, feasibility, and outcome are unknown.nnnPATIENTS AND METHODSnAll consecutive patients who underwent DRC at three tertiary endoscopy centers for inconclusive findings at ERC were included in this retrospective analysis. Ultraslim endoscopes (FujiFilm EG 530NP; Olympus GIF XP180; GIF N180) were used by the peroral route for intubating all accessible bile ducts. Success rate, usefulness in diagnosis and therapy, and safety of DRC were assessed in terms of technical and clinical parameters and therapeutic vs. diagnostic indication.nnnRESULTSnDRC was performed in 130 cases (89 patients). CO2 insufflation and an anchoring balloon were used in 66.9% and 97.7% of cases, respectively. Intubation of the papilla was successful in 115 of 130 (88.5%) cases, and the aim of the DRC investigation was accomplished in 105 cases (80.8%). DRC-guided biopsies were taken in 53 cases (40.8%), and a therapeutic intervention was performed in 32 cases (24.6%). The initial diagnosis was revised by DRC in 18 of 69 patients (26.1%) with indeterminate biliary stricture. Complications were observed in 10 cases (7.7%), including cholangitis (n=2; 1.5%), bleeding (n=2; 1.5%), and pain, hypoxia, bradyarrhythmia, air embolism, and perforation of an intrahepatic and an extrahepatic bile duct (1 each; 0.8%). There was no mortality associated with DRC.nnnCONCLUSIONSnDRC was successfully performed for the diagnosis and treatment of biliary disease that had eluded diagnosis with conventional ERC. DRC impacted on clinical decision making. The complication rate was low and similar to other cholangioscopy techniques.

ERCP in elderly patients: increased risk of sedation adverse events but low frequency of post-ERCP pancreatitis

BACKGROUND AND AIMSnThe continually increasing life expectancy in man comes along with an increasing number of endoscopic interventions performed in patients with advanced or even very advanced age. Data on the feasibility and safety of ERCP in elderly patients are relatively scarce.nnnMETHODSnBy a systematic query of the University Hospital Frankfurt clinical database, patients undergoing their first ERCP procedure at our center were retrospectively identified. Patients were grouped according to age at the day of the intervention (>80 years, 61-80 years, 40-60 years, and <40 years). Demographic data, indication, outcome, and risk factors were compared among the indicated groups.nnnRESULTSnA total of 758 patients who underwent ERCP procedures at our center were identified and included in the study. Main indications for ERCP were intraductal gallstones in 345 patients (45%) and tumor obstruction of the bile ducts (distal common bile duct: n = 126 [16.5%], hilar cholangiocarcinoma: n = 89 [11.7%], tumor of papilla of Vater: n = 16 [2.1%]). Gallstones were the most common cause for ERCP in patients aged >80 years (53.8%), and normal findings indicating exclusion of relevant disease were more frequent in patients <80 years (13.4%) compared with older patients (4.3%) (P < .01). Sedation adverse events were significantly more common in individuals aged >80 years compared with younger patients (3.4% vs 0.5%; P < .01). However, post-ERCP pancreatitis was significantly less frequent in the older patients (>80 years) (0.9% vs 5.3%; P < .05). Other adverse events were equally distributed in all age groups. The ERCP success rate (>80%) was not different among age groups.nnnCONCLUSIONSnERCP is safe and efficient in patients aged 80 years or older. However, conscious sedation must be carefully monitored in older patients because risk of sedation adverse events is increased. The incidence of post-ERCP pancreatitis is lower in older patients compared with younger ones.

Indication for 'Over the scope' (OTS)-clip vs. covered self-expanding metal stent (cSEMS) is unequal in upper gastrointestinal leakage: results from a retrospective head-to-head comparison.

Background Intestinal perforation or leakage increases morbidity and mortality of surgical and endoscopic interventions. We identified criteria for use of full-covered, extractable self-expanding metal stents (cSEMS) vs. ‘Over the scope’-clips (OTSC) for leak closure. Methods Patients who underwent endoscopic treatment for postoperative leakage, endoscopic perforation, or spontaneous rupture of the upper gastrointestinal tract between 2006 and 2013 were identified at four tertiary endoscopic centers. Technical success, outcome (e.g. duration of hospitalization, in-hospital mortality), and complications were assessed and analyzed with respect to etiology, size and location of leakage. Results Of 106 patients (male: 75 (71%), female: 31 (29%); age (mean ± SD): 62.5 ± 1.3 years, 72 (69%) were treated by cSEMS and 34 (31%) by OTSC. For cSEMS vs. OTSC, mean treatment duration was 41.1 vs. 25 days, p<0.001, leakage size 10 (1-50) vs. 5 (1-30) mm (median (range)), and complications were observed in 68% vs. 8.8%, p<0.001, respectively. Clinical success for primary interventional treatment was observed in 29/72 (40%) vs. 24/34 (70%, p = 0.006), and clinical success at the end of follow-up was 46/72 (64%) vs. 29/34 (85%) for patients treated by cSEMS vs. OTSC; p = 0.04. Conclusion OTSC is preferred in small-sized lesions and in perforation caused by endoscopic interventions, cSEMS in patients with concomitant local infection or abscess. cSEMS is associated with a higher frequency of complications. Therefore, OTSC might be preferred if technically feasible. Indication criteria for cSEMS vs. OTSC vary and might impede design of randomized studies.

Pan-intestinal capsule endoscopy in patients with postoperative Crohn's disease: a pilot study

Abstract Background: Patients are at increased risk of disease recurrence after surgical treatment of Crohn’s disease. Endoscopic detection of postoperative, ileo-colonic inflammation is well established, but the potential of pan-intestinal endoscopy is yet unknown. Methods: This prospective multicenter pilot study assessed the value of pan-intestinal capsule endoscopy using a colon capsule endoscope for the detection of inflammatory recurrence of Crohn´s disease. Patients who had been operatively treated for Crohn´s disease were included. Colon capsule endoscopy was performed 4–8 weeks (d1) and 4–8 months (d2) postoperatively together with ileo-colonoscopy at d2 using a modified Ruttgeerts index for evaluating disease activity. Results: Twenty-two patients were included into this study. At d1, significant disease activity (Ruttgeerts index ≥2) was detected in 3/16 (19%) of the patients. At d2, half of the patients (6/12) showed active disease, whereas ileo-colonoscopy revealed significant inflammation in 5/15 (33%). All patients rated as having active disease by ileo-colonoscopy had been revealed by PICE as well. These findings influenced the medical treatment in every case. Conclusion: Pan-intestinal capsule endoscopy seems to be feasible in the postoperative surveillance of Crohns disease. Disease activity is reliably detected. Especially, the findings in the small bowl might be a significant advantage in comparison to ileo-colonoscopy, as they can have significant impact on clinical management. Further studies with a larger number of patients are needed to confirm these findings and might lead to a replacement of the flexible ileo-colonoscopy with pan-intestinal capsule endoscopy in this indication in the future.

Intraductal biopsies in indeterminate biliary stricture: Evaluation of histopathological criteria in fluoroscopy- vs. cholangioscopy guided technique

BACKGROUNDnDifferentiating malignancy from benign disease in indeterminate biliary stricture by imaging modalities is limited. Definite diagnosis relies on histopathological diagnosis.nnnAIMSnTo assess accuracy of histopathological diagnosis of fluoroscopy-guided vs. cholangioscopy-directed intraductal biopsies in indeterminate biliary stricture.nnnMETHODSnAll patients with indeterminate biliary stricture and fluoroscopically (n=68) or cholangioscopy-directed (working channel 2mm, n=38) biopsies were included. Histopathological results of biopsies were classified into inflammatory lesion (class 1), dysplasia/intraepithelial neoplasia (class 2) and malignancy (class 3) and results as well as macroscopic diagnosis were compared with final diagnosis.nnnRESULTSnSensitivity and specificity of fluoroscopy-guided vs. cholangioscopy-directed biopsies were 22.9% and 100% vs. 25.0% and 100% for class 1+2 vs. class 3 lesions, respectively. Sensitivity for class 1 vs. class 2+3 lesions was 45.7% (p=0.044) vs. 58.3% (p=0.214) for fluoroscopy-guided vs. cholangioscopy-directed biopsies, respectively, while specificity was 100% in both. There was no difference in size of the obtained sample (p=0.992). True positive diagnosis rate increased with the number of biopsies taken (p=0.028).nnnCONCLUSIONnFluoroscopy-guided and cholangioscopy-directed intraductal biopsies are equally limited in establishing the diagnosis of malignancy in indeterminate biliary stricture. Categorizing dysplasia or intraepithelial neoplasia as malignancy increases sensitivity without decrease in specificity. By taking more biopsies, diagnostic yield is increased.

The capsule endoscopy “suspected blood indicator” (SBI) for detection of active small bowel bleeding: no active bleeding in case of negative SBI

Abstract Objective. Capsule endoscopy (CE) is the gold standard to diagnose small bowel bleeding. The “suspected blood indicator” (SBI) offers an automated detection of active small bowel bleeding but validity of this technique is unknown. The objective was to analyze specificity and sensitivity of the SBI using the second small bowel capsule generation for the detection of active bleeding. Methods. This is a retrospective analysis of all patients (199) who attended our clinic for CE from June 2008 through March 2013. The second-generation PillCam SB 2 capsule was used for detection of (1) luminal blood content and (2) potentially responsible small bowel lesions. The findings of an independent investigator were correlated to SBI findings and a number of SBI markings were analyzed by a receiver operating characteristic (ROC). Results. In 157/199 cases, no sign of active bleeding or altered blood was detected. One hundred and thirty-seven of these 157 cases provided at least one SBI marking and a mean of 18.4 positive SBI markings per record were found. In 20 cases, neither SBI nor the human investigator detected abnormalities. Thirteen patients showed investigator-detected minor bleeding with mean SBI findings of 36 positive screenshots per record. When major bleeding was diagnosed by the investigator (n = 29), SBI detected a mean of 46.6 SBI-positive markings. SBI turned positive in 179 patients, whereas the investigator detected active bleeding in 42 cases. All patients with active bleeding were detected by SBI (sensitivity 100%, specificity 13%). ROC analysis revealed 51.0 SBI markings being the optimal cutoff for active versus no bleeding (sensitivity 79.1%, specificity 90.4%, misclassification of 15.3%). Conclusion. The new SBI software is a reliable tool to exclude active bleeding and/or major lesions but analysis of the CE video by a trained investigator is still important for the detection of lesions responsible for past bleeding.

Health care for osteoporosis in inflammatory bowel disease: Unmet needs in care of male patients?

BACKGROUND AND AIMSnOsteoporosis is a frequent complication of inflammatory bowel disease (IBD). It may be related to IBD itself or to its therapy. In this study, the quality of care regarding diagnosis and treatment of osteoporosis was examined.nnnMETHODSnIn this retrospective, monocentric study 293 consecutive patients with IBD (98 ulcerative colitis, 195 Crohns disease) were included. Information on age, gender, weight, nicotine abuse, course, disease pattern and medication was assessed, results of dual X-ray absorptiometry (DEXA-scan) were evaluated.nnnRESULTSnDEXA-scan was performed in 174 patients (59 male, 115 female). Bone mineral density (BMD) was impaired in 38.5% of these patients. Male patients were diagnosed more often with osteopenia or osteoporosis than females (55.9% vs. 29.6%, p=0.03) and had a risk of bone disease comparable to postmenopausal women. Additionally, duration of corticosteroid treatment and IBD were identified as risk factors for osteoporosis. Follow up DEXA-scan demonstrated an overall deterioration of BMD in patients with normal baseline results.nnnCONCLUSIONSnWhile in general, women are considered at higher risk for osteoporosis, male patients had a higher risk of impaired BMD, especially when under treatment with corticosteroids. The high incidence of reduced BMD supports the recommendation to screen patients with IBD at an early stage of disease, although a possible bias has to be considered for patients at a tertial referral centre for IBD. Patients with normal baseline DEXA-scan were still at risk to develop bone disease and it seems advisable to monitor patients with IBD for reduced BMD continually.

Role of CD15 expression in dysplastic and neoplastic tissue of the bile duct – a potential novel tool for differential diagnosis of indeterminate biliary stricture

CD15 is expressed by various cancer types; among these are intrahepatic and perihilar cholangiocarcinoma (CCA). The aim of this study was to elucidate CD15 expression in distal CCA as well as in dysplastic biliary tissue and to determine its prognostic significance.