Sabine Bohnacker

Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract.

BACKGROUND Endoscopic ultrasound is widely used following endoscopy for evaluation of suspected submucosal lesions and may guide further management of patients. PATIENTS AND METHOD A total of 181 consecutive patients with suspected submucosal lesion in the upper gastrointestinal tract were diagnosed by endoscopic ultrasound between 1990-97. We evaluated: 1) the potential of endoscopic ultrasound criteria to predict histological type of submucosal lesions in 69 patients with available histology, 2) the ability of endoscopic ultrasound alone or with clinical presentation, to predict malignancy in 86 patients with available histology or follow-up of >12 months. RESULTS Sensitivity and specificity for diagnosing 44 gastrointestinal stromal tumours were 95 and 72%, respectively, while 25 miscellaneous lesions were diagnosed correctly in only 56% by endoscopic ultrasound. Diagnosis of malignancy, using any two of three endoscopic ultrasound criteria (heterogeneous echotexture, size >3 cm, irregular margins) showed a sensitivity of 80% and specificity of 77%, giving accurate endoscopic ultrasound diagnosis in 16/20 malignant and 51/66 benign submucosal lesion. Heterogeneous echotexture, size >3 cm, and irregular margins showed a relative risk of 7.2, 5.4 and 4.6, respectively, for presence of malignancy. The presence of symptoms, potentially suggesting malignancy (dysphagia, gastrointestinal bleeding, pain and weight loss), had a relative risk of 4.2, however this did not increase the accuracy of diagnosing malignancy based on endoscopic ultrasound criteria alone. CONCLUSION The accuracy of endoultrasound is high in diagnosing gastrointestinal stromal tumours, which show a significant potential of malignancy. Endoscopic ultrasound morphology appears to be helpful in selection of patients for surgical or conservative treatment. The accuracy of endoscopic ultrasound in differential diagnosis of non-gastrointestinal stromal tumour lesions is limited.

Advances in therapeutic endoscopic treatment of common bile duct stones

Abstract. Advances in cannulation techniques and instruments have helped in difficult bile duct cannulation and thus stone extraction. For small common bile duct (CBD) stones, endoscopic papillary balloon dilatation has been proposed as an alternative to endoscopic papillotomy (EPT). The technique must undergo further evaluation before recommending its routine use. For most patients with bile duct stones, EPT remains the method of choice. Out of 8204 patients treated in three surgical endoscopy centers (Chile, Germany, and India), 86% to 91% of all CBD stones could be extracted subsequently after EPT using a Dormia basket; 4% to 7% required mechanical lithotripsy (ML) before removal and 3% to 10% of the patients needed other sophisticated techniques, such as electrohydraulic lithotripsy (EHL), laser-induced shock-wave lithotripsy (LISL), or extracorporeal shock-wave lithotripsy (ESWL). The local expertise and availability of equipment determines the choice of method used. In general, EHL or LISL is used for impacted CBD stones including stones in Mirizzi syndrome refractory to ML. ESWL is best suited for intrahepatic stones. Permanent stenting can be offered to poor risk patients instead of extensive procedures to clear the bile duct. Using currently available nonsurgical techniques, fewer than 1% of all patients with bile duct stones still require surgical intervention.

Advances in interventional gastrointestinal endoscopy in colon and rectum

Abstract Background. Instrumental and procedural advances particularly in the therapeutic field have been achieved. Review. Endoscopes with larger working channel, additional jet-channel, or variable stiffness allow more sophisticated interventional procedures. Higher resolution in endoscopic image quality helps to identify early lesions that can be treated endoscopically at this stage. Polypectomy and mucosectomy are no longer limited by the size of the lesion. Piecemeal technique is established, and a retrieval net is available for collecting all pieces obviating repeated introductions of the endoscope. In addition to snare polypectomy and mucosectomy, laparoscopy-assisted polypectomy and full-thickness resection are discussed. Self-expandable metal stents are used to decompress malignant colonic obstruction allowing for either preoperative bowel preparation and elective surgery or for noninvasive palliation. Argon plasma coagulation is an inexpensive and effective method for the treatment of bleeding from radiation proctitis.

The use of endoscopic clips in nonvariceal gastrointestinal bleeding

Endoscopic control of nonvariceal bleeding has never been completely satisfactory, despite the availability of several methods of injection and coagulation. The hemoclip, with its ability to mechanically occlude the bleeding vessel, provides an effective tool to meet this challenge. Indications for clipping include bleeding due to gastroduodenal ulcers, Mallory-Weiss tears, Dieulafoys lesions, postpolypectomy and postpapillotomy bleeding. It is most satisfactory in the presence of active spurting bleeders or visible vessels. This article describes the clip applicator and the procedure while highlighting the technical aspects, including a few useful tips in the successful management of nonvariceal gastrointestinal bleeding.

4677 Endoscopic treatment of 64 patients with mirizzi`s syndrome.

Background: Mirizzi`s syndrome is defined as extrinsic compression of the common bile duct by an impacted stone in the cystic duct or the neck of the gallbladder. Surgery is often difficult due to extensive inflammation. Aim: Evaluation of endoscopic treatment of Mirizzi`s syndrome in the largest series reported yet. Methods: Retrospective evaluation of patients (pts) presenting with Mirizzi`s syndrome between 1990 and 1999.For initial stabilisation or safe transport to our center, temporary stents or nasobiliary drainage (NBD) were placed. If the stone could be caught into the Dormia basket, mechanical lithotripsy (ML) was performed. Otherwise electrohydraulic lithotripsy (EHL) using the Mother-Baby scope system (Olympus Co.,Tokyo, Japan) and the Walz lithotriptor (Fa. Walz, Rohrdorf, Germany) was performed to fragment stones under cholangioscopic view. Results: 48 f and 16 m pts with a median age of 71years (14-94y) were included. Median duration of biliary symptoms was 22 days (1 d-5 y). Patients presented with pain in 64%, obvious jaundice in 66% and painless jaundice in 22%. 19% were in poor general condition. 9 pts had undergone cholecystectomy median 3 y before (0.1-23 y). An initial endoscopic stent or NBD was placed in 30 pts (47%). Median size of stones was 2cm (0.7- 5cm). In 8 pts ML was performed. 52 pts required EHL. Complete duct clearance was achieved in 59 pts (92%). A single lithotripsy session was sufficient in 54 pts. 4 pts were treated by stenting or nasobiliary drainage only. A complicated course was observed in 4 pts: 2 pts with cystic duct leak at the site of pressure necrosis recovered conservatively.A 71y male not sent for the 2nd session of lithotripsy was treated with long term stenting in another hospital and developed small bowel perforation by the dislodged stent. A 90 y female with septicemia treated by NBD, had myocardial infarction after 2 d and died after 3 d. Subsequently, 12 pts underwent cholecystectomy. 4 of them were symptomatic after endoscopy due to cholelithiasis (3 patients had cholecystitis after 7 d, 7 d and 56 d, respectively; 1 pt had biliary colics after 2 y). 39 pts did not undergo surgery and have remained asymptomatic over a median follow up of 28 months (2-82). None of the pts developed biliary malignancy over a median follow up of 24 (0-85) months. Conclusion: Mirizzi`s syndrome, being considered a clear indication for surgical management, can be safely and effectively treated by endoscopy even in elderly and severely ill pts. Coincidence of gallbladder malignancy with Mirizzi`s syndrome was not observed.

7168 Detection of pancreatic metastases by endosonography-guided fine needle aspiration.

Background: Metastases to pancreas cannot be differentiated from primary pancreatic tumors based on imaging alone. Tissue diagnosis is imperative to plan appropriate treatment. Endosonography guided fine needle aspiration (EUS-FNA) is an alternative for cytodiagnosis of pancreatic lesions. Methods: Amongst 114 consecutive EUS-FNA from pancreatic lesions, metastases were diagnosed in 12 patients (9.5%). Longitudinal echoendoscopes and 22 gauge needles were used for EUS-FNA. Results: Mean age of patients was 61 years (36-74). Out of 6 patients with cancer in history (breast 3, renal cell 2, salivary gland 1) 4 had recurrence while two had a second carcinoma metastasizing into pancreas. In those without prior cancer, cytology revealed metastases from renal cell, colonic, ovarian and esophageal primary tumors in 4 patients, respectively. One had malignant lymphoma, while the other primary site could not be identified. The clinical outcome was poor (median survival 6 months). 8 patients received non-surgical palliation and 3 underwent surgery for their pancreatic metastases. EUS showed metastases in the head/corpus of the pancreas, measuring 1.8-4 cm with inhomogeneous hypoechoic echotexture indistinguishable from primary pancreatic cancer. Conclusion: Pancreatic metastases are one of the important causes of focal pancreatic lesions. EUS features are not characteristic for diagnosis. A simultaneous EUS-FNA enables cytodiagnosis and may avoid surgery.