Richard S. Phillips

Forceful balloon dilation: an outpatient procedure for achalasia

The initial treatment of choice in patients with achalasia is balloon dilation. Heretofore, this procedure was performed on an in-hospital basis resulting in high patient cost. This study evaluated the safety and efficacy of pneumatic dilation as an outpatient procedure. Sixty-one procedures were performed on 50 patients at two centers. An overall treatment success rate of 95% (47 of 50 patients) was achieved. Two patients had elective surgical treatment and a third underwent surgery for perforation secondary to dilation. A total of three patients complained of post-procedure chest pain within 4 hours and were hospitalized. Two had perforations; one required surgical repair. The third patient had resolution of symptoms. We conclude that performing balloon dilation as an outpatient procedure is safe, efficacious, and cost effective.

Oxygen desaturation and changes in breathing pattern in patients undergoing colonoscopy and gastroscopy.

The respiratory effect of diagnostic colonoscopy and upper endoscopy were studied in 32 elderly patients. Twenty-two underwent colonoscopy and 10 upper endoscopy. In the group undergoing upper endoscopy, 4 of 10 patients experienced a decrease in oxygen desaturation greater than or equal to 4% during the medication period; an additional 2 patients desaturated during the procedure. In the group undergoing colonoscopy, 12 of 22 patients experienced oxygen desaturation during the medication period; 3 other patients desaturated during the procedure. Mean SaO2 for each group was lowest (p less than 0.05) during the medication period. Central apneas occurred in 13 of the patients undergoing colonoscopy during the medication period; however, only 8 of these patients with apneas experienced desaturation greater than or equal to 4% and the periods of desaturation did not correlate with the periods of apneas. Oxygen desaturation greater than or equal to 4% occurs frequently during both upper endoscopy and colonoscopy in this elderly population. This is related to the effects of sedation; the procedure itself worsened the desaturation in only 16% of the patients. Furthermore, the desaturation did not correlate with changes in the breathing patterns of the patients. Low-flow oxygen and/or close monitoring of patients during and subsequent to administration of medication is advised.

Experience with diagnostic laparoscopy in a hepatology training program

Laparoscopy is an underutilized endoscopic procedure in the United States even though it has proven to be an important diagnostic modality. Among factors that may account for the unpopularity of this procedure are lack of experience and proper training in many gastroenterology fellowship programs, a perceived notion that there is a relatively high complication rate, and the preference for radiologic imaging techniques for establishing a diagnosis. We reviewed, over an 11-month period, our experience with laparoscopy in a large teaching center to better assess its safety when performed by trainees. The major and minor complication rates were 0.9% and 2.9%, respectively, with no fatalities. These findings compare favorably with the general experience.

Standard biopsy forceps versus large-capacity forceps with and without needle

Endoscopic biopsy forceps vary in size and design. The purpose of this prospective randomized study was to compare the quality and quantity of gastric tissue obtained by needle and non-needle versions of standard biopsy forceps and newly designed large capacity forceps. Fifty consecutive patients who underwent endoscopy with gastric biopsy forceps were enrolled in the study. There was no significant difference in the presence of crush artifact between the two forceps, both with and without the presence of a needle. Both needle and non-needle versions of the large capacity biopsy forceps were found to obtain significantly larger sized specimens (p = 0.02) than needle and non-needle versions of the standard biopsy forceps. Overall, there was no significant difference in the depth of specimen obtained when comparing the large capacity forceps to standard forceps. Needle versions of each forceps were found to obtain significantly deeper biopsies than non-needle versions of each forceps. In conclusion, our study found that large capacity forceps obtained larger specimens than standard biopsy forceps. Further clinical trials with a larger study population need to be undertaken to determine the impact of these findings on the determination of diagnoses.

Systemic autoimmune disorders associated with celiac disease

Celiac disease (CD), also known as gluten-sensitive enteropathy, is the most common gastroenterological hereditary disease (1). Its variable presentations range from clinically silent disease to frank malabsorption (2). Additionally, and perhaps more important, is that there is an increased incidence of malignancy in patients with CD compared with the general population (1). Holmes et al. found as much as a fivefold increase in small bowel malignancy in patients with CD, which is decreased to the level of the general population after 5 years of maintaining a gluten-free diet (GFD). An autoimmune-related hypothesis in the genesis of CD is supported by the finding of an increased association between autoimmune disorders (AIDs) and CD (3–5). This relationship can be explained by the sharing of common HLA class II alleles including B8, DQ2, and, most commonly, DR3 (1, 3, 6). The same autoantigens proposed in CD have been found as a reticular network in many other human tissues. Several autoantibodies have been found in the sera of untreated patients with CD, including antiendomysial, antigliadin, and antireticulin antibodies (6–8). Tissue transglutaminase (TTG) is the enzyme which is felt to be the autoantigen in CD (9). TTG results in the deamidation of gliadin and, thus, facilitates the binding of gliadin to HLA-DQ2/DQ8 molecules (10, 11). This digested gliadin peptide stimulates a Th1 response causing tissue damage to the small bowel and a Th2 response resulting in the formation of autoantibodies. Additionally, TTG can also modify other external or self-antigens and generate neo-antigens which cause autoimmune reactivity outside the intestine (3). The enteropathy may allow

Bile duct perforation: a complication of large caliber endoprosthesis

Endoscopic retrograde placement of a biliary endoprosthesis has proven to be an effective noninvasive method to palliate malignant biliary obstruction. Although this technique is safer than surgical bypass or percutaneous drainage, complications may still occur. We report a rare late complication, erosion of a large diameter endoprosthesis through the common bile duct into the hepatic parenchyma, and discuss its pathogenesis and treatment.

Endoprosthetic stenting in extrinsic pyloric obstruction

Palliative treatment of obstructing esophagogastric malignancies by the placement of endoprostheses has been well described.3 These devices have also been used to restore luminal patency in patients with extrinsic compression secondary to adjacent tumor masses. Additionally, recurrent tumor at the site of a surgical anastomosis can be successfully managed by endoscopic positioning of an endoprosthesis. We describe a patient, who, after total esophagectomy and pharyngogastrostomy for esophageal carcinoma, developed partial gastric outlet obstruction due to extrinsic compression of the pyloric channel by metastatic liver disease. Endoscopic placement of a plastic prosthesis greatly facilitated gastric emptying and provided excellent short-term palliation.