Juergen F. Riemann

A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding

BACKGROUND Capsule endoscopy enables noninvasive diagnostic examination of the entire small intestine. However, sensitivity and specificity of capsule endoscopy have not been adequately defined. We, therefore, compared capsule endoscopy by using intraoperative enteroscopy as a criterion standard in patients with obscure GI bleeding. METHODS Forty-seven consecutive patients with obscure GI bleeding (11 with ongoing overt bleeding, 24 with previous overt bleeding, and 12 with obscure-occult bleeding) from two German gastroenterologic centers were included. All patients who had a prior nondiagnostic evaluation, including upper endoscopy, colonoscopy with a retrograde examination of the distal ileum, and push enteroscopy, underwent capsule endoscopy followed by intraoperative enteroscopy. RESULTS Capsule endoscopy identified lesions in 100% of the patients with ongoing overt bleeding, 67% of the patients with previous overt bleeding, and 67% of the patients with obscure-occult bleeding. Angiectasias were the most common source of bleeding (n = 22). Capsule endoscopy showed the source of bleeding in 74.4% of all patients. The method was more effective in patients with ongoing bleeding. Compared with intraoperative enteroscopy sensitivity, specificity, and positive and negative predictive values of capsule endoscopy were 95%, 75%, 95%, and 86%, respectively. CONCLUSIONS Capsule endoscopy has high sensitivity and specificity to detect a bleeding source in patients with obscure GI bleeding. Thus, wireless capsule endoscopy can be recommended as part of the routine work-up in patients with obscure GI bleeding.

Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study

BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive and increasingly used procedure in cases involving biliary and pancreatic diseases. However, the accuracy of MRCP in differential diagnosis between pancreatic cancer and chronic pancreatitis has never been documented in a large prospective controlled study. METHODS 124 patients were recruited for the study, selected from 141 consecutive patients with an average age of 55 years (range 19-80) who presented to our department between February, 1996, and January, 1998, with a strong clinical suspicion of pancreatic cancer. MRCP images were interpreted by a radiologist and a gastroenterologist who were unaware of the clinical diagnosis of patients. The exact diagnosis was based upon histological evidence from biopsy examination (surgical and fine needle biopsy) or a follow-up of at least 12 months. FINDINGS Of the 124 patients, 37 (30%) had pancreatic carcinoma; 17 (14%) had other neoplastic pancreatic diseases; 57 (46%) had chronic pancreatitis; 13 (10%) pancreatic ducts were clear. The sensitivity of MRCP with respect to diagnosing pancreatic cancer was 84% and its specificity 97%. The corresponding values for endoscopic retrograde cholangiopancreatography (ERCP) were 70% and 94%, respectively. INTERPRETATION MRCP is as sensitive as ERCP when detecting pancreatic carcinomas. Furthermore, it is feasible to presume that the use of MRCP may prevent inappropriate explorations of the pancreatic and common bileducts in cases of suspected pancreatic carcinomas, where interventional endoscopic therapy (ie, palliative common-bileduct drainage) is unlikely.

Management of retained bile duct stones: a prospective open trial comparing extracorporeal and intracorporeal lithotripsy

BACKGROUND Endoscopic management of common bile duct stones has become the approach of choice, especially in patients with high surgical risk. Problems are encountered if there are large stones or a duct stenosis. For these difficult stones, shock wave technology serves as an alternative to surgical intervention. METHODS A total of 125 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected and treated either by extracorporeal piezoelectric lithotripsy (ESWL, n = 79) or intracorporeal electrohydraulic lithotripsy (EHL, n = 46). The average age of our patients was 70 years. RESULTS In the ESWL group visualization of the stones by ultrasound and ensuing treatment were possible in 71 out of 79 patients (90%); stones could be fragmented in 68 patients. The biliary tree could then be completely freed of calculi in 62 of 79 patients, a success rate of 78.5%. In the EHL group, stones were successfully fragmented in 38 of 46 patients; 34 patients (74%) eventually became stone free. Thirty-day mortality was zero in both groups. Combined treatment including ESWL, EHL, and intracorporeal laser lithotripsy was finally successful in 118 patients (94%). CONCLUSIONS Endoscopic management in combination with the lithotripsy techniques described can be recommended as the method of choice for treating difficult common bile duct stones. A success rate of almost 100% and a mortality rate of 0% is now the established standard, even in elderly and unstable patients.

Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

BACKGROUND Endoscopic papillotomy is successful in more than 95% of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. AIM To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. METHODS Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful extracorporeal shock-wave lithotripsy and electrohydraulic were also performed before laser in 35% and 26% of the cases, respectively. RESULTS Laser was effective in 79.2% of 72 patients guided by cholangioscopy and in 82.4% of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,335 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7% vs. 31.9%). When the stones were in the distal bile duct, fluoroscopic control was more successful. CONCLUSION In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated proximal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.

Primary clear cell carcinoma of noncirrhotic liver: immunohistochemical discrimination of hepatocellular and cholangiocellular origin.

The incidence of hepatoce llular carcinoma (HCC) is low in Europe, particularly in noncirrhotic livers (1). HCC consists of typical cytological attribute s: the nuclear/cytoplasmic ratio is high, the cells are polyglonal, and the cytoplasm is ® ne ly granular and more basophilic than that of the surrounding live r cells. In this part of the world, clear cell carcinoma is an uncommon cytological variant of HCC that merits special attention. The tumor is predominantly or wholly composed of cells with clear cytoplasm, which is due to the presence of glycoge n and lipids that are dissolved by routine histologic pressing (2). This variant may pose a diagnostic dilemma since it resembles other clear cell carcinomas originating in the adre nals, kidne ys, ovarie s, lungs, pancreas, and other organs (3± 5). Unless speci® c feature s of hepatoce llular carcinoma can be demonstrated, the diagnosis of primary clear cell hepatoce llular carcinoma remains uncertain. We report two very rare cases of primary clear cell carcinoma in the noncirrhotic live r, in which the ® nal differential diagnosis between hepatoce llular and bile duct origin could be made by cytohistologic features from a needle aspirate , and provide diagnostic recommendations for these tumors. CASE REPORTS

Effectivity of current sterility methods for transgastric NOTES procedures: results of a randomized porcine study.

BACKGROUND AND AIM Natural-orifice transluminal endoscopic surgery (NOTES) is an emerging transluminal technique in which interventions are carried out by entering the abdominal cavity via a natural orifice such as the stomach. Infection is a potential risk of the procedure, and the potential pathogens are different from those encountered with skin incisions. Currently, available data regarding prophylactic anti-infective treatment are limited. We compared the effectiveness of topical antimicrobial lavage of mouth and stomach and proton pump inhibitor therapy with gastric cleansing with sterile saline solution in preventing NOTES-related contamination and infection. METHODS A randomized survival swine study was performed. Eight pigs underwent preparation with intravenously administered proton pump inhibitors, mouth and gastric lavage (chlorhexidine), and gastric irrigation (diluted neomycin), plus single-shot intravenous antibiotics. Control group (n = 8) underwent gastric cleansing with sterile saline solution. Peritoneal biopsy, multiple smears, and dilutions for cultures were taken and incubated. The swine were sacrificed after 14 days. Bacterial load was expressed in colony-forming units (CFU). RESULTS One pig died due to gallbladder perforation after 3 days, 2/15 swine presented minor clinical signs of infection in the 14-day follow-up (all 3 pigs were in the control group). Mean C-reactive protein levels were 5.7 +/- 2.4 g/dL (therapy group) and 12.2 +/- 3.8 g/dL (control) ( P = 0.17). Bacterial growth was seen in 1/8 swine (therapy group) and 6/8 swine (control group) ( P = 0.002). Bacterial load was 282 CFU/mL (therapy) vs. 3.2 x 10 (5) CFU/mL (control) ( P = 0.023) in the follow-up. CONCLUSION The use of intravenous antibiotics in addition to topical antimicrobial lavage of mouth and stomach and treatment with proton pump inhibitors decreased the peritoneal bacterial load to almost zero and this was associated with a significantly lower peritoneal infection rate compared with saline-only lavage.

Choledochocele imaged with magnetic resonance cholangiography

Choledochal cysts are rare developmental malformations of the biliary tree. Percutaneous and endoscopic ultrasound, as well as endoscopic retrograde cholangiopancreatography, are recommended diagnostic tools. Magnetic resonance cholangiography may also contribute to the workup and treatment plan of patients with choledochal cysts. We report a 25-yr-old white woman with episodic nausea and moderate epigastric dyscomfort. Magnetic resonance cholangiography showed a rather spherical, cyst-like, fluid-filled structure in continuity with the prepapillary segment of the common bile duct, thus making a choledochocele (type III choledochal cyst) likely. The patient was treated by endoscopic sphincterotomy and, after a 6-month follow-up, is without complaints.

The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer

Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.

Risk factors for symptomatic stone recurrence after transpapillary laser lithotripsy for difficult bile duct stones using a laser with a stone recognition system

Background Laser-induced shock-wave lithotripsy (LISL) is successfully used for the treatment of difficult bile duct stones. The aim of this study was to assess the long-term risk for a symptomatic bile duct stone recurrence after LISL and to detect risk factors predicting recurrence. Methods Between 1993 and 2001, 80 patients with difficult bile duct stones were successfully treated by intracorporeal LISL through the papilla of Vater. Seventy-one of these patients [median age, 65.8 years; 51 women (71.8%)] were followed for a median (range) period of 58 (1–114) months. Results Eleven patients (15.5%) had a symptomatic stone recurrence. The median (range) period between laser lithotripsy and recurrence was 40 (5–85) months. The presence of a bile duct stenosis (P=0.032) and a body-mass index below 25 (P=0.025) were significantly associated with an increased risk for stone recurrence. A gallbladder in situ, the presence of gallbladder stones, dilation of the bile duct, or a peripapillary diverticulum was not associated with stone recurrence. Conclusions The presence of a bile duct stenosis is significantly related to bile duct stone recurrence after treatment with LISL. The impact of the body mass index on stone recurrence is interesting. The gallbladder status did not predict stone recurrence in our study.

Endoscopic resection of "giant" colorectal lesions: long-term outcome and safety.

BACKGROUND Today, endoscopic resection is a standard procedure for the resection of colonic polyps. Before the establishment of endoscopic techniques, the surgical approach was a clearly preferred method for removal of polyps with a size larger than three centimeters. The safety and effectiveness concerning endoscopic resections of colorectal polyps also with a size of more than 3 cm have been demonstrated in numerous studies. PATIENTS AND METHODS Data from 165 patients (age: 68 +/- 10.4 years) harboring 167 polyps with a minimum diameter of 3 cm were retrospectively evaluated. Objects of interest were macroscopic morphology and histopathology of the polyps, their localization in the colon, the modality of endoscopic resection and follow-up. In those cases with macroscopic signs of malignancy the patients were excluded. RESULTS Successful endoscopic resections were obtained in 72.5 %. Therefrom, resection in the piecemeal-technique was necessary in 73.6 %. Recurrence polyps after endoscopic complete resections occurred in 26.3 % after a mean follow-up of 16 +/- 12.5 months. We registered a complication rate of 19.2 %. Relevant bleeding and perforation were registered as early complications in 18.6 %. We observed no intervention-related mortality. CONCLUSION Endoscopic mucosal resection is a safe and efficient method even for removing giant colorectal polyps. Controls are recommended at defined intervals for detecting polyp recurrence.