Risto Gullichsen

Staging of gastric cancer: a study with spiral computed tomography, ultrasonography, laparoscopy, and laparoscopic ultrasonography.

In this study, we evaluated and compared the value of spiral computed tomography, transabdominal ultrasonography, laparoscopy, and laparoscopic ultrasonography in staging gastric cancer in 37 patients; there was a special interest in the additional information provided by laparoscopic ultrasonography. Although laparoscopy was unreliable or hindered by adhesions in 11% of the patients, the benefit of laparoscopy for staging was evident especially for the detection of peritoneal carcinomatosis that was missed by the other diagnostic modalities. Laparoscopic ultrasonography did not change the stage of the disease nor the decision whether to proceed with laparotomy for any of the patients. The decision whether to proceed with laparotomy was correctly predicted in 95% of the cases.

The distribution of collagen types I, III, and IV in normal and malignant colorectal mucosa

OBJECTIVEnTo compare the distribution of interstitial collagens (type I and III) and basement membrane collagen (type IV) in cancerous and normal colon.nnnDESIGNnRetrospective study.nnnSETTINGnUniversity hospital, Finland.nnnSUBJECTSn13 patients with colorectal cancer of different stages and grades.nnnMAIN OUTCOME MEASURESnIndirect immunofluorescence labelling for type I, III, and IV collagens of fresh frozen tissue samples, both normal and cancerous, cut into serial sections 6 microm thick.nnnRESULTSnIn normal mucosa, the epithelial basement membrane showed an intense immunoreaction for type IV collagen. Type I and III collagens were localised to the interstitial stroma underlying it. The membrane in cancer samples was characterised by discontinuities and thinning as estimated by immunolabelling for type IV collagen. Furthermore, immediately adjacent to the membrane type I and III collagen positivity was fragmented. The cancerous stroma showed a strong positive immunosignal for type I and III collagens.nnnCONCLUSIONnBoth the epithelial basement membrane and the collagenous matrix immediately beneath it are degraded in malignant tissue. This may suggest the simultaneous activation of several degradative enzymes (as type I and III collagens are at least in part degraded by different enzymes from type IV collagen) or alterations in the expression of collagen subtypes in normal compared with malignant tissue.

Accuracy of 18F-FDG PET/CT, Multidetector CT, and MR Imaging in the Diagnosis of Pancreatic Cysts: A Prospective Single-Center Study

Accurate diagnosis of the nature of pancreatic cysts is challenging but more important than ever, in part because of the increasing number of incidental cystic findings in the pancreas. Preliminary data suggest that 18F-FDG PET/CT may have a significant influence on clinical decision making, although its role is still evolving. Our aim was to prospectively compare the accuracy of combined 18F-FDG PET and contrast-enhanced CT (18F-FDG PET/CT), multidetector CT (MDCT), and MR imaging in differentiating malignant from benign pancreatic cysts. Methods: Thirty-one consecutive patients with pancreatic cysts were enrolled in the study. They underwent a protocol including 18F-FDG PET/CT, MDCT, and MR imaging combined with MR cholangiopancreatography, all of which were evaluated in a masked manner. The findings were confirmed macroscopically at surgery or histopathologic analysis (n = 22) or at follow-up (n = 9). Results: Of the 31 patients, 6 had malignant and 25 had benign lesions. The diagnostic accuracy was 94% for 18F-FDG PET/CT, compared with 77% and 87% for MDCT (P < 0.05) and MR imaging, respectively. 18F-FDG PET/CT had a negative predictive value of 100% and a positive predictive value of 75% for pancreatic cysts. The maximum standardized uptake value was significantly higher in malignant (7.4 ± 2.6) than in benign lesions (2.4 ± 0.8) (P < 0.05). When the maximum standardized uptake value was set at 3.6, the sensitivity and specificity were 100% and 88%, respectively. Furthermore, when compared with MDCT and MR imaging, respectively, 18F-FDG PET/CT altered the clinical management of 5 and 3 patients, respectively. Conclusion: 18F-FDG PET/CT is an accurate imaging modality for differentiating between benign and malignant pancreatic cysts. We recommend the use of 18F-FDG PET/CT in the evaluation of diagnostically challenging pancreatic cysts.

Effect of the diameter of the common bile duct on the incidence of bile duct stones in patients with recurrent attacks of right epigastric pain after cholecystectomy.

OBJECTIVEnTo study the relationship between the diameter of the common bile duct and the incidence of bile duct stones in non-jaundiced patients with recurrent attacks of right epigastric pain after cholecystectomy.nnnDESIGNnRetrospective study.nnnSETTINGnUniversity hospital, Finland.nnnSUBJECTSn57 consecutive, non-jaundiced patients admitted for elective endoscopic retrograde cholangiopancreatography (ERCP) because of attacks of right epigastric pain after cholecystectomy.nnnINTERVENTIONSnMeasurement of maximum diameter of the common bile duct and presence or absence of bile duct stones.nnnMAIN OUTCOME MEASURESnDiameter of bile duct (10 mm or less was regarded as normal) and presence or absence of stones.nnnRESULTSn33 patients had normal-sized bile ducts and in 24 they were widened. Only 2/33 patients with normal-sized ducts (6%) had stones, compared with 11/24 (46%) with wide ducts (p = 0.0008). However, the degree of ductal dilatation did not seem to have any influence on the presence or absence of stones.nnnCONCLUSIONnBile duct stones are unlikely after cholecystectomy in patients who are not jaundiced and have a normal-sized common bile duct. However, nearly half of the patients with a wide common bile duct had stones, but the degree of dilatation was not important.

Feasibility of ERCP Procedures in Patients 90 Years of Age and Older

To the Editor: According to the web pages of Statistics Finland, the proportion of the elderly of the Finnish population will grow 2-fold during the next quarter century. As our population ages, the challenge for expedient miniinvasive treatment modalities in older age groups will become more and more significant, particularly in diseases common in the elderly such as pancreato-biliary diseases. With advances in equipment and expertise, the role of endoscopic procedures as mini-invasive treatment modalities has proved pivotal in the treatment of pancreato-biliary diseases during the last 2 decades. In the literature, there are numerous reports on endoscopic retrograde cholangiopancreatography (ERCP) procedures performed in the elderly including octogenarians, but only few surveys on very old patients undergoing ERCP. Here, we report our 11-year experience of ERCP procedures performed in patients aged 90 years or older.

A non-icteric cholecystectomized patient with recurrent attacks of right epigastric pain and dilated common bile duct--do liver function tests predict bile duct stones?

Abstract Cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct are a clinical challenge. In a number of these patients dilatation of the common bile duct is explained as a normal postoperative state following cholecystectomy and the recurrent pain attacks are of origin other than bile disorder, but in some cases dilatation of the common bile duct and attacks are caused by bile duct stones. The aim of the present work was to study the value of common plasma liver function tests in predicting bile duct stones in the group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. The study population comprised 24 consecutive non-icteric cholecystectomized patients admitted for elective endoscopic retrograde cholangiopancreatography because of attacks of right epigastric pain and dilated common bile duct in ultrasonography. All the liver function tests seemed to assist in separating patients with bile duct stones (n=11) from those without (n=13). Alanine aminotransferase levels were significantly higher (p=0.05) in patients with bile duct stones than in those without, but also alkaline phosphatase (p=0.07), γ-glutamyl transferase (p=0.09) and bilirubin (p=0.09) levels seemed to be higher in patients with bile duct stones than in those without, although the differences in these values did not reach statistical significance. In conclusion, common plasma liver function tests assist in separating patients with bile duct stones from those without in this small but clinically important group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. However, the actual value of these measurements is limited in clinical decision making since overlapping of values occured.

Angled- or straight-tipped hydrophilic guidewire in biliary cannulation: a prospective, randomized, controlled trial.

BackgroundDeep biliary cannulation is the key for successful endoscopic retrograde cholangiopancreatography (ERCP) procedures. Guidewire-assisted cannulation is associated both with a higher success rate and a reduced risk of post-ERCP pancreatitis compared with standard catheter cannulation. However, to our knowledge there are no prospective, randomized studies comparing the use of different guidewires in biliary cannulation. The goal of this study was to compare the performance of an angled-tipped guidewire (AGW) with a straight-tipped guidewire (SGW) in achieving successful deep biliary cannulation.MethodsPatients with intended biliary cannulation of an intact papilla were prospectively randomized to angled- or straight-tipped hydrophilic guidewire arms in a tertiary, referral, university hospital setting. Randomized cannulation method was applied either until successful cannulation of the bile duct or until 2xa0min had passed. Crossover was not included in the study protocol. The main outcome measurements were the cannulation success rate and duration of cannulation.ResultsOf the 239 consecutive patients, 155 patients were randomized: in the final analysis 70 patients were included in the AGW arm and 83 patients in the SGW arm. Cannulation time [median; seconds (s)] was shorter with the AGW compared with the SGW (20 vs. 63xa0s, pxa0=xa00.01). There was no difference in the cannulation success rate or the complication rate between the two study groups.ConclusionsAGW may facilitate biliary cannulation in ERCP.

Subjective results and symptomatic outcome after fundoplication revision

Objective. In a small proportion of patients, fundoplication fails and a reoperation is required. However, there are few reports on the symptomatic outcome after reoperative antireflux surgery. The aim of this study was to evaluate the results after fundoplication revision. Material and methods. All patients (n=71) undergoing fundoplication revision between 1997 and 2005 were included in this study. The follow-up data were collected both from the hospital records and during postoperative control visits, including a personal interview using a structured questionnaire; follow-up was completed by 61 patients (88.4%). Results. The primary fundoplications included both open (n=21) and laparoscopic (n=40) approaches; 92% (n=56) of the reoperations were open procedures. The morbidity rate was 21% and the reoperation rate 16%. Fifty-six percent (n=34) of the patients regarded the result of their reoperative surgery as excellent, good or satisfactory at a mean follow-up of 51 months; 66% of the patients had no significant reflux symptoms after refundoplication. With the benefit of hindsight, 77% of the patients would again choose to undergo refundoplication, but only 48% of the patients would again primarily choose surgical treatment. Mortality rate was 1.4% (n=1) and in three patients the reoperative treatment required total gastrectomy. Conclusions. These suboptimal results show that surgical treatment for gastro-oesophageal reflux disease in general is far from being perfect and this is even more marked after reoperative antireflux surgery, as fundoplication revision can result in severe complications. This emphasizes the importance of proper patient selection for both initial and reoperative antireflux surgery.

Female gender and post-ERCP pancreatitis: Is the association caused by difficult cannulation?

Abstract Objective. Female gender is a well-known risk factor for the development of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the underlying mechanism for this increased risk has remained unknown. We hypothesize that cannulation difficulty might play a part in this association. The aim of the current study was to determine whether the female papilla is more difficult to cannulate than the male papilla. Material and methods. Prospective data collection with emphasis on cannulation was conducted in 364 consecutive biliary ERCP procedures performed by very experienced ERCP endoscopists through native papilla in a tertiary referral university hospital. Results. Although the cannulation times seemed to be longer and alternative cannulation techniques seemed to be needed more frequently for successful cannulation in female than male patients, no statistically significant differences (p = 0.061 and 0.054, respectively) in the cannulation process could be found between the genders. Conclusions. The study was not able to confirm that the cannulation of the female papilla is more troublesome than the cannulation of the male papilla.

Endoscopic treatment of internal gastrointestinal fistulas with fibrin glue.

Objective: Gastrointestinal fistulae are a heterogenous entity originating from various etiologies. When occurring, these fistulae are associated with considerable morbidity and even mortality. One third of the fistulae heal spontaneously and the rest have traditionally required major revisional surgery at a later stage. Even after surgery, the healing rate remains at a level of 75% to 90%. During the last years, gastrointestinal fistulae have been successfully treated endoscopically with fibrin glue. Methods: All (n=8) consecutive patients with diagnosed internal upper or lower gastrointestinal fistula treated endoscopically with fibrin glue. Results: During the minimum follow-up of 11 months, 7 of 8 patients (87.5%) were successfully treated endoscopically, and in only 1 case (12.5%) with a major diagnostic delay, a reoperation was required. Conclusions: Our results support the view that endoscopic treatment with fibrin glue may be considered as a first-line therapy to treat small caliber gastrointestinal fistulas.