Juergen Hochberger

Management of difficult common bile duct stones

More than 80% of all CBD stones can be effectively treated by endoscopic sphincterotomy and stone extraction using baskets or balloon catheters. For stones up to 2.5 cm in diameter, mechanical lithotripsy is the method of choice as a next step. Very large, impacted, or very hard concretions, however, often make mechanical lithotripsy cumbersome or even impossible. For these stones laser lithotripsy, EHL, and ESWL are nonoperative options, especially for elderly patients and patients with an elevated surgical risk. Because these methods are often only available at endoscopic centers, stenting is a treatment modality for immediate stone therapy, but as a definitive treatment it should be restricted to selected cases. ESWL, EHL, and laser lithotripsy yield similar success rates of 80% to 95% and may be used complementarily in endoscopic centers. ESWL is the preferred therapy in intrahepatic lithiasis. Laser lithotripsy shows the best results in CBD stones. Electrohydraulic lithotripsy is rarely used because of its high potential for tissue damage and bleeding. Laser lithotripsy using smart laser systems such as the rhodamine 6G dye laser and the FREDDY laser system can simplify the treatment of these difficult bile duct stones. The rhodamine 6G-dye laser allows blind fragmentation of these stones by exclusive insertion of a 7-F metal marked standard catheter into the bile duct by standard duodenoscopes using intermittent fluoroscopy. An oSTDS safely cuts off the laser pulse if contact with the stone is lost, thus preserving the bile duct from potential damage. Unfortunately the system is no longer produced. The new FREDDY laser lithotriptor with a piezoacoustic stone/tissue discrimination system offers an alternative to the rhodamine 6G dye laser system at less than half the financial investment. Effective stone fragmentation is accompanied by only low tissue alteration. The holmium:YAG laser is an effective multidisciplinary lithotriptor, but it can be used only under cholangioscopic control, limiting its use to gastroenterologic centers.

Endoscopic photodynamic diagnosis: oral aminolevulinic acid is a marker of GI cancer and dysplastic lesions☆☆☆★★★

BACKGROUND Dysplasia and early cancer of the upper gastrointestinal (GI) tract often are undetected at white-light endoscopy. We describe oral administration of 5-aminolevulinic acid for the in vivo photodynamic diagnosis of premalignant and malignant lesions during endoscopy. METHODS Four patients with known gastric adenoma (n = 1), macroscopically undetected but histologically proven esophageal squamous cell cancer (n = 1), suspected early cancer of the esophagus (n = 1), and multiple duodenal adenomas (n = 1) were sensitized with 5-aminolevulinic acid administered orally (15 mg/kg body weight). Photodynamic diagnosis was conducted after a retention time of 6 to 7 hours with a special light source capable of delivering either white or violet-blue light. Red fluorescence was detected through the gastroscope with an image-intensifying camera. RESULTS All malignant lesions exhibited red or bluish fluorescence during photodynamic diagnosis. Fluorescence-negative mucosal areas proved to be histologically benign. CONCLUSION Fluorescence induced with 5-aminolevulinic acid might be useful for the endoscopic detection of dysplasia and early carcinoma in the upper GI tract. Further investigations are needed to evaluate the sensitivity and specificity of photodynamic diagnosis for different tumor entities.

One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas

AIM To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip (OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas. METHODS From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients (48.8%) presented with severe upper-gastrointestinal (GI) bleeding, 3 (3.6%) patients with lower-GI bleeding, 7 patients (8.3%) underwent perforation closure, 18 patients (21.4%) had prevention of secondary perforation, 12 patients (14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection (ESD) and 3 patients (3.6%) had an intervention on a chronic fistula. RESULTS In 78/84 patients (92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients (89.28%). The overall mortality in the study patients was 11/84 (13.1%) and was seen in patients with life-threatening upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41 (85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases (57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18 (100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen (2%). CONCLUSION This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.

Triluminal Hybrid NOS as a Novel Approach for Colonic Resection With Colorectal Anastomosis

Background: Minimal invasive surgery has led to a significant decrease in surgical trauma, pain, recovery time and improved cosmesis compared with open surgery. However, scar development and the risk of hot spots for infections and hernias are still present. Natural orifice surgery (NOS) promises to offer even further reduction in invasiveness and thus may lead to even faster recovery. The goal of this study was to establish a NOS colonic resection by using commercially available standard surgical instruments avoiding major abdominal incisions. Methods and Results: This article reports a new triluminal hybrid NOS approach for sigmoid and colonic resection (Tri-Port-NOS-SIG), established using rigid laparoscopic instruments through the umbilicus, the vagina, and the rectum, without any major abdominal incision. The specimen was retrieved through the anus avoiding dilatation of the vagina. In an early series of 5 patients the first patient was a 37-year-old woman with a 10-year history of recurrent diverticulitis. She recovered quickly and was discharged on postoperative day 2. She returned to sports activity on day 12 postoperatively and to her heavy-duty job on day 16. The following 4 patients also recovered well and were discharged on postoperative days 7 (2 patients), 8, and 11, respectively. One patient experienced a temporary, mild paresthesia of the left lower dorsal leg, most likely because of intraoperative positioning. No major complications occurred. Conclusion: Tri-Port-NOS-SIG offers a feasible scarless approach for abdominal resections using commercially available surgical instruments in experienced hands.

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) on the use of endoscopy simulators for training and assessing skill

t n m t s d d t The PIVI (Preservation and Incorporation of Valuable endoscopic Innovations) initiative is an American Society for Gastrointestinal Endoscopy (ASGE) program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Additionally, PIVIs may also outline the data and/or the research study design required for proving that an established threshold is met. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice, presuming the appropriate training in that endoscopic technology has been achieved. The ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds. The PIVI initiative was developed primarily to direct endoscopic technology development toward resolving important clinical issues in endoscopy. The PIVI initiative is also designed to minimize the possibility that potentially valuable innovations are prematurely abandoned due to lack of use and to avoid widespread use of an endoscopic technology before clinical studies documenting their effectiveness have been performed. The following document, or PIVI, is one of a series of statements defining the diagnostic or therapeutic threshold that must be met for a technique or device to become considered appropriate for incorporation into clinical practice. It is also meant to serve as a guide for researchers or those seeking to develop technologies that are designed to improve digestive health outcomes. An ad hoc committee under the auspices of the existing ASGE Technology and Standards of Practice Committees Chairs develops PIVIs. An expert in the subject area hairs the PIVI, with additional committee members hosen for their individual expertise. In preparing this ocument, evidence-based methodology was used, with MEDLINE and PubMed literature search to identify ertinent clinical studies on the topic. PIVIs are ulti-

Clinical experience of non-contact and contact Nd-YAG laser therapy for inoperable malignant stenoses of the oesophagus and stomach

For palliative treatment of tumours with the Nd-YAG laser, the non-contact method of applying laser energy has become established as a useful technique. However, it has certain disadvantages which include overdistension of the intestine, difficulty in calculating the amount of energy applied in each place, and the danger of destruction of the tip of the light guide if this makes contact with the tissue while the laser is being fired. The newly developed contact method of energy application by means of ceramic tips is free from such disadvantages. We report our results with the contact and the non-contact method in the treatment of stenosing inoperable tumours of the oesophagus and stomach. By the end of 1985 we had treated 76 patients with the non-contact method and 16 with the contact method. The relative advantages of the two methods in clinical use are discussed.

Difficult Cannulation and Sphincterotomy

Abstract Endoscopic retrograde cholangiopancreatography (ERCP) requires several years of dedicated training and continuous refinement of knowledge and skill. With the dissemination of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), ERCP has evolved from a diagnostic to an almost purely therapeutic procedure. General issues on cannulation have already been highlighted in Chapter 40 . This chapter concentrates on variations of standard techniques to overcome challenges to standard cannulation and sphincetrotomy, including in patients with anatomic variations, gastric outlet obstruction, and surgically altered anatomy.

⁎3367 A prospective evaluation of 10 easie team-training workshops on endoscopic hemostasis.

Introduction:The Erlangen Active Simulator for Interventional Endoscopy (EASIE®) is a new close to life training model permitting for the first time the creation of artierial spurting ulcer bleedings, varices and polyps in a specially prepared pig stomach. Overall about 25 different interventional techniques in the upper GI-tract and hepatobiliary system can be trained. Methods:10 systematically structured EASIE team-training courses (21.3.98-8.5.99) on endoscopic hemostasis were evaluated prospectively by the participants according to a questionnaire at the end of one day training. The courses were designed as a team-training for groups of 3 doctors and 3 nurses per simulator. 207 of 283 participants (73.1%) filled in the questionnaire (133 doctors, 65 nurses). As training models 4x EASIE®, 3x miniEASIE®, 3x compactEASIE® were used all equipped with the same, specially prepared pig esophago-gastro-duodenal organ package. For the training of ulcer hemostasis, vessels, polyps and submucosal varices were created. Perfusion was achieved by a roller-pump with the addition of an on demand bypass regulating the pressure of the blood surrogate. Workshop structure: 30 min. theoretical introduction on treatment of ulcer bleeding, 2 hours practical training of injection techniques (epinephrine, fibrin glue) and hemoclip application, 30 min. theoretical introduction of variceal therapy, 2 hours practical training of sclerotherapy (including cyanoacrylat) and banding techniques. Results: Most trainees rated themselves as advanced (39%) or experienced (35%) endoscopists. 19% were endoscopic novices, 7% no statement. Previous experience in endoscopic hemostasis was distributed as follows: No experience 19%, 6 years 20%, 9% no statement. Nearly all trainees assessed the training as excellent or good (83% excellent (++), 14% good (+), 0% unsatisfactory(-), 3% no statement Φ). Single techniques were evaluated as follows: Injection therapy: 73% (++), 18% (+), 0% (-), 9% Φ; Clip application: 83% (++), 9% (+), 1% (-), 7% Φ; Sclerotherapy: 60% (++), 18%(+), 1%(-), 21%Φ; Multiband ligation: 77%(++), 17% (+), 0% (-),. 6% Φ; Closeness to realitywas assessed as good, specifically: 72% (++), 22% (+), 0% (-), 6% Φ. Conclusion: EASIE team-training endoscopic hemostasis has a high acceptance by the trainees. A prospective comparison between conventional endoscopic education and practical education in interventional endoscopy using EASIE will be done soon.

Laser Lithotripsy: Clinical Applications

Since the early 1980s several teams have worked on the problem of fragmenting gallstones by laser [1–6]. The first successful endoscopic-retrograde laser fragmentation of a bile duct stone was reported in 1986 [7]. In the meantime, experiences by other teams in clinical laser lithotripsy of bile duct stones have been published [8–10] or reported on (N. Marcon and C. Haber 1989, M. Haws 1989, A.R.W. Hatfield 1989, and T. Ponchon 1989, personnal communications). However, to date, only about 50 patients have been treated with this new therapy method worldwide. The success rate (complete/partial stone removal) is estimated at 50%–80%. Complications after laser lithotripsy have so far not been reported.