Robert I. Goldberg

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.

Pancreatic carcinoma is associated with delayed gastric emptying

Fifteen patients with histologically confirmed pancreatic carcinoma, without evidence of gastroduodenal invasion or obstruction, were prospectively studied to determine the frequency of gastric emptying disorders as determined by a solid-phase gastric emptying study. Nine of these (60%) had gastric emptying curves more than two standard deviations below normal mean values. The majority of patients did not have symptoms of gastric stasis. Nausea and/or vomiting was present in 33% of patients with abnormal gastric emptying and in none of those with normal emptying. Abdominal and/or back pain was present in 8/9 with delayed gastric emptying and in 3/6 with normal emptying. Disordered gastric emptying did not correlate with tumor stage, histology, location, or hyperbilirubinemia. Delayed solid-food gastric emptying may be responsible for the nonspecific abdominal complaints that occur during the course of pancreatic carcinoma, although more frequently, gastroparesis exists on a subclinical level.

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.

Dysphagia as the presenting symptom of recurrent breast carcinoma

Esophageal obstruction secondary to recurrent breast carcinoma is not widely recognized. Frequently, the esophageal narrowing is attributed to a benign process, resulting in delays of diagnosis and treatment. Such a case prompted this report and review of the literature.

Benign Small Bowel Thickening and Lymphadenopathy: A Manifestation of Celiac Disease

Celiac disease (CD) is the most common familial gastrointestinal (GI) disorder with an overall prevalence of 1:250 [1]. Small bowel lymphoma with lymphadenopathy is a welldocumented complication of patients with CD [2]. It accounts for one-half to two-thirds of malignancies complicating CD [3, 4]. However, small bowel thickening with lymphadenopathy does not always represent malignancy. Several case reports suggest lymphadenopathy representing benign disease in patients with CD, as there was subsequent regression on a gluten-free diet in the majority of patients [5–14]. We report three patients with small bowel thickening with biopsy-proven CD and lymphadenopathy with subsequent regression after appropriate treatment for CD.

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.

Endoscopic resection for early esophageal cancer complicated by esophageal varices

Purpose: Perioperative morbidity is a substantial problem in the surgical treatment of esophageal carcinoma. Endoscopic mucosal resection offers a therapeutic alternative to esophagectomy for early esophageal cancer.

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.