Ralf Jakobs

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.

Palliation of Nonresectable Bile Duct Cancer: Improved Survival After Photodynamic Therapy

OBJECTIVES:Preliminary uncontrolled studies of photodynamic therapy (PDT) of bile duct cancer (BDC) have shown astonishingly good results in the reduction of cholestasis, improvement of life quality, and potential improvement of survival time. Therefore, we investigated the influence of PDT on survival time in advanced BDC in a randomized controlled study.METHODS:Thirty-two patients with nonresectable BDC were randomized. In the PDT group 48 h after intravenous application of 2 mg/kg body weight of Photosan-3®, light activation was performed. In the control group, patients were treated with endoprostheses but no PDT.RESULTS:PDT group and the control group were comparable due to age, gender, performance status, bilirubin level, and BDC stage (Bismuth classification). The median survival time after randomization was 7 months for the control group and 21 months for the PDT group (p = 0.0109). In half of the initially percutaneously treated patients, we could change from percutaneous to transpapillary drainage after PDT. Four patients showed infectious complications after PDT versus one patient in the control group.DISCUSSION:PDT is minimally invasive but shows a considerable postinterventional cholangitis rate. PDT has the potential to result in a changeover of current palliative treatment of BDC.

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.

Computer-assisted colonoscopy (the NeoGuide Endoscopy System): results of the first human clinical trial ("PACE study").

OBJECTIVES:Unsedated colonoscopy is an uncomfortable procedure for most patients. Discomfort during colonoscopy is largely related to looping of the colonoscope, which displaces the colon from its native configuration and stretches attachments to the mesentery. A novel computer-assisted colonoscope utilizes a fully articulated, computer-controlled insertion tube. On manual insertion of the colonoscope, the position and angle of the scopes tip are encoded into a computer algorithm. As the colonoscope is advanced, the computer directs each successive segment to take the same shape that the tip had at a given insertion depth. The insertion tube thus changes its shape at different insertion depths in a “follow-the-leader” manner.METHODS:This initial clinical trial with this novel colonoscopy system was designed as a prospective, nonrandomized, unblinded, feasibility study. Three physicians of varying levels of experience participated in the study.RESULTS:Eleven consecutive patients (seven men, four women, age range 19–80) meeting inclusion criteria for screening or diagnostic colonoscopy were enrolled in the study. The cecum was reached in 10 consecutive patients (100%). Findings included diverticular disease in two cases and multiple colonic polyps in two cases. Postprocedure assessment at discharge, 48 h, and 30 days revealed no complications or adverse effects. Physician satisfaction and patient acceptance of this new technique were high.CONCLUSIONS:In this limited, first of its kind feasibility study, the computer-assisted colonoscope was shown to perform colonoscopy safely and effectively. The colonoscopes unique design limited loop formation during colonoscopy. Large-scale clinical trials are indicated.

Endoscopic stenting for common bile duct stenoses in chronic pancreatitis: results and impact on long-term outcome.

Objectives The overall incidence of common bile duct strictures due to chronic pancreatitis is reported to be approximately 10–30%. It remains a challenging problem for gastroenterologists and surgeons. The exact role of endoscopic stenting has not yet been clearly defined. Design and methods Thirty-nine patients with chronic pancreatitis and symptomatic common bile duct stenoses underwent endoscopic stenting and were studied retrospectively. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stents in the long term. Results Indications for endoscopic stenting were symptomatic cholestasis, jaundice or cholangitis. The initial serum bilirubin was 8.3 mg/dl and the diameter of the common bile duct was 14.2 mm before stenting. Within 3–7 days of stenting, all patients presented improvement of jaundice and cholestasis. After a median stenting time of 9 months (range 1–144 months), 46% of the patients demonstrated regression of the stricture and clinical improvement, 26% required further stenting, and 28% were referred to surgery. Five patients received a self-expandable metal Wallstent. Thirty-one per cent demonstrated complete clinical recovery of the stricture as well as 10.2% a complete, radiologically verified stricture regression in a median follow-up of 58 months. Conclusions There seems to be a therapeutic benefit for short-term endoscopic treatment but medium-term and long-term outcome remains questionable. Endoscopic stenting should be applied as an initial therapy before surgery, but it can be the definitive approach for older and morbid patients or cases with complete stricture regression after stent removal. Overall, it should not be considered as a routine procedure for symptomatic cases.

Photodynamic therapy for palliation of nonresectable bile duct cancer—preliminary results with a new diode laser system

OBJECTIVES:Preliminary results of photodynamic therapy (PDT) of bile duct cancer have shown astonishingly good results in the reduction of cholestasis, improvement of quality of life, and even prolongation of the survival time. Unfortunately, the existing dye laser systems are large and costly, and their maintenance is expensive. Therefore, we investigated the feasibility of a diode laser system for PDT of nonresectable bile duct cancer.METHODS:Eight patients with nonresectable bile duct cancer were treated. Forty-eight hours after i.v. application of 2 mg/kg body weight of Photosan-3, light activation was performed by a transpapillary (four patients) or percutaneous (four patients) access. We used a cylindrical diffusor tip and illuminated using a wavelength of 633 ± 3 nm and a total energy of 200 J/cm2. All patients were additionally provided with bile duct endoprostheses after PDT.RESULTS:Four weeks after initial PDT all patients showed a marked reduction of bile duct stenosis. The median serum bilirubin value declined from 5.8 mg/dl (2.0–10.1) to 1.0 mg/dl (0.8–4.4). The median survival time at the time of writing is 119 days (52–443). Five patients are still alive. In four patients we could change from percutaneous to transpapillary drainage after PDT, two patients showed infectious complications.CONCLUSION:PDT with the diode laser system seems to be effective in reducing malignant bile duct stenosis. This treatment is minimally invasive and has a low specific complication rate. Randomized, controlled studies comparing PDT with the insertion of endoprostheses and long term follow-up of results are needed to confirm the promising short term results.

Management of Esophageal Perforations after Therapeutic Upper Gastrointestinal Endoscopy

BACKGROUND Esophageal perforation is one of the most dreaded complications in therapeutic gastrointestinal endoscopy. We assessed the frequency of esophageal perforation after endoscopic procedures in a highly specialized endoscopy unit and compared clinical outcomes in patients undergoing either surgical or conservative management. METHODS From January 1985 to June 1996, 1011 instrumental endoscopic procedures (dilatation and bougienage) were performed in our department. The computerized complication database was searched to identify all patients with esophageal perforation during this same period, and their records were reviewed. RESULTS Seventeen esophageal perforations (1.7%) occurred in the course of 1011 procedures. Four perforations resulted from balloon dilatation, and 13 were secondary to bougienage. Six patients were managed surgically (35%), all of them recovering uneventfully. Eleven patients were managed conservatively, mainly because they were unfit for surgery. Survival rate in this group was 82%; only two patients died, both of whom had underlying malignant disease. CONCLUSIONS The current concept in management of esophageal perforations comprises surgical as well as medical treatment. In well-selected cases, non-operative treatment can be considered with favorable results.

Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up

AIMS To compare the efficacy and the complication rate between endoscopic snare resection of adenomas of Vaters papilla and endoscopic palliation. METHODS In a retrospective, non randomized manner, we compared long-term results of our endoscopic strategies in 36 patients with histologically confirmed adenoma of Vaters papilla submitted either to local endoscopic snare resection (n=18) or to simple endoscopic palliation (n= 18), respectively. RESULTS Between 1985 and 1998 results were reviewed. Median age was 76.5 (range 42-89) years in the palliation, and 64.0 (23-89) years in the endoscopic snare resection group. Median duration of follow-up was 33 (6-135) and 75.0 (27-123) months, respectively. The incidence of adenocarcinoma of Vaters papilla was 1 per 52.8 patient-years after endoscopic snare resection and 1 per 15.5 patient-years in the group treated with endoscopic palliation. Compared to the results of endoscopic palliation (prosthesis, sphincterotomy), we found a significant reduction of carcinoma-related death (p=0.0045, McNemar) and adenoma carcinoma-sequence (p=0.007, McNemar) after snare resection. CONCLUSIONS This retrospective study suggests that complete endoscopic snare resection of adenomas of Vaters papilla will lead to a lower rate of adenoma-carcinoma sequence, to a lower carcinoma-related death rate and probably improves patient survival. These results should be proven prospectively.

A pilot study evaluating a new low-volume colon cleansing procedure for capsule colonoscopy

BACKGROUND AND STUDY AIMS Colon capsule endoscopy (CCE) offers an alternative approach for endoscopic visualization of the colon. Some of the current CCE bowel cleansing regimens use sodium phosphate, which has raised safety concerns. Therefore, the aim of the current study was to test the feasibility and efficacy of a new low-volume, sodium phosphate-free polyethylene glycol (PEG) bowel preparation. METHODS The first 26 patients (original cleansing procedure) received a colon cleansing regimen of PEG plus ascorbic acid: patients drank 1 L in the evening and 0.75 L in the morning before capsule ingestion. Patients also drank an additional 0.5 L PEG boost and an optional 0.25 L PEG boost during the capsule procedure. Following an interim analysis, the cleansing procedure of the subsequent 24 patients was modified, with the morning intake before capsule ingestion being increased to 1 L, as well as the second boost (0.25 L) being administered 1 - 2 hours earlier (modified cleansing procedure). RESULTS The overall colon cleanliness was considered to be good or excellent in 83 % (original cleansing procedure) and 82 % (modified cleansing procedure) of patients, without any significant difference between regimens (P > 0.05). In 37 /49 (76 %) of the CCE procedures, the hemorrhoidal plexus was identified and thus the examination was considered complete, with no significant differences between the two CCE cleansing procedures. The capsule sensitivity and specificity for detecting colonic polyps ≥ 6 mm were 91 % (95 %CI 70 % - 98 %) and 94 % (95 %CI 87 % - 97 %), respectively, compared with standard optical colonoscopy. CONCLUSION A colon cleansing procedure using PEG + ascorbic acid for capsule colonoscopy yielded an adequate cleansing level in > 80 % of patients, a completion rate of 76 %, and good accuracy for detecting polyps. This procedure may be considered as an alternative, particularly for patients in whom sodium phosphate-based preparations are contraindicated.

Low seroprevalence of Helicobacter pylori infection in patients with stress ulcer bleeding--a prospective evaluation of patients on a cardiosurgical intensive care unit.

Abstract. Objective: The pathogenesis of stress ulceration in seriously ill patients is uncertain and the pathogenic role of Helicobacter pylori infection is unknown. We therefore assessed the seroprevalence of patients of a cardiosurgical intensive care unit (ICU) with clinically important stress ulcer bleeding. We compared this prevalence with a control group matched for this kind of surgical intervention, missing history of peptic ulcer disease, age and gender. Design: Prospective survey. Setting: Cardiosurgical ICU in a university teaching hospital. Patients and participants: Two thousand five hundred seventy cardiosurgical patients with intravenous ranitidine stress ulcer prophylaxis were screened for clinically important stress ulcer bleeding. Helicobacter pylori seropositivity was measured in all patients with a clinically important bleeding and in a control group of 245 consecutive cardiosurgical patients, matched for the kind of cardiosurgical intervention, age and gender. Results: In 56 of 2570 (2.1%) patients signs of clinically important bleeding were seen. Endoscopical examination revealed stress ulcer bleeding in 42 cases. The incidence of stress ulcer bleeding was 1.6%. The seropositivity of the group with ulcer bleeding was 45.2% whereas 62.4% of the patients in the control group were Helicobacter pylori positive (p=0.08). Conclusions: Our results suggest that the Helicobacter pylori infection does not play a pathogenic role in stress ulcer bleeding. Prophylactic cure of Helicobacter pylori can not be recommended in this setting.