Uwe Seitz

Circumferential EMR and complete removal of Barrett's epithelium: a new approach to management of Barrett's esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma.

BACKGROUND There is no study of circumferential EMR in patients with Barretts esophagus containing early stage malignant lesions. This study investigated the effectiveness and safety of circumferential EMR by using a simple snare technique without cap. METHOD Patients with Barretts esophagus containing multifocal high-grade intraepithelial neoplasia or intramucosal cancer, and patients with endoscopically nonidentifiable early stage malignant mucosal changes incidentally detected in random biopsy specimens were included in the study. A 30 x 50-mm polypectomy snare made of monofilament 0.4-mm steel wire was used without any additional device or submucosal injection. RESULTS Twelve patients (10 men, 2 women; median age 63.5 years, range 43-88 years) underwent circumferential EMR; 5 had multifocal lesions, and 7 had no visible lesions. Segments of Barretts epithelium were circumferential (median length 5 cm) and completely removed. The median number of EMR sessions was 2.5. The median number of snare resections per EMR session was 5. The medial total area of mucosa in resected specimens per session was 3.8 cm(2). Two patients developed strictures that were successfully treated by bougienage. Minor bleeding occurred during 4 of 31 EMR sessions. During a median follow-up of 9 months, no recurrence of Barretts esophagus or malignancy was observed. CONCLUSIONS Circumferential EMR with a simple snare technique is feasible, safe, and effective for complete removal of Barretts epithelium with early stage malignant changes.

Papillary roof incision using the Erlangen-type pre-cut papillotome to achieve selective bile duct cannulation.

BACKGROUND Prior studies evaluating pre-cutting the major papilla to access the bile duct when standard cannulation falls have usually used the needle-knife papillotome. We conducted a prospective study to evaluate the efficacy and safety of an Erlangen-type pre-cut papillotome for pre-cutting. PATIENTS AND METHODS Three hundred twenty-seven patients (114 men, mean age 67 years) who underwent first-time sphincterotomy at our institution were included. Pre-cutting was performed if free and wire-guided cannulation of the bile duct failed according to an algorithm. RESULTS Pre-cutting was performed in 123 patients (38%) and selective cannulation was successful in all. Post-ERCP serum pancreatic enzyme levels were more frequently elevated in the pre-cut group (50%) than the non-pre-cut group (27%, p < 0.001); however, there was no difference in the incidence of post-ERCP pancreatitis (pre-cut = 2.7%, 95% CI: 0.66% to 7.6%; non-pre-cut = 1.6%, 95% CI: 0.3% to 4.7%). The incidence of bleeding was similar (pre-cut, 2.4%, non-pre-cut, 3.9%; p > 0.05). CONCLUSION Pre-cutting the major papilla for biliary access using the Erlangen-type pre-cut papillotome is an effective and reasonably safe procedure when performed by endoscopists with extensive experience in pancreatobiliary endoscopy.

Capsule Endoscopy versus Standard Tests in Influencing Management of Obscure Digestive Bleeding: Results from a German Multicenter Trial

BACKGROUND:Capsule endoscopy (CE) is a new modality for obscure digestive bleeding (OBD), but little is known about its influence on management and outcome.PATIENTS AND METHODS:Fifty-six patients (male/female 26/30; mean age 63 yr) with ODB, and negative upper and lower gastrointestinal (GI) endoscopy were included in this multicenter study. The diagnostic yield of CE was compared to three other tests (OT: push enteroscopy, enteroclysis, angiography), and patients were followed up for at least 6 months. Parameters were analyzed that led to major management changes such as surgical or endoscopic intervention or specific medical therapy, as well as their correlation to further bleeding.RESULTS:CE had a diagnostic yield higher than OT (68% vs 38%). Major management changes and an improvement in bleeding activity were observed in 21 and 44 patients, respectively. The number and type of positive findings on CE were associated with significant management changes (p < 0.05). The number of positive findings detected by CE as well as by OT correlated with further bleeding episodes (p < 0.05). However, clinical parameters (lowest hemoglobin (Hb) value, number of blood transfusions) were also significantly associated with outcome. Diagnoses of specific diseases (tumor, Crohn, NSAID ulcer) by CE led to a favorable outcome in 64% of cases, whereas negative CE cases were associated with no further bleeding in 80%.CONCLUSION:CE helps with management decisions and can replace other more complex and risky standard tests. Nevertheless, clinical parameters are equally important for predicting further bleeding and should also be used to decide on further management.

Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate

BACKGROUND The treatment of pancreatic fistula can be difficult. A novel endoscopic approach to sealing pancreatic fistulas by using N-butyl-2-cyanoacrylate is described. METHODS Twelve patients with pancreatic fistulas underwent endoscopic injection of N-butyl-2-cyanoacrylate into the fistulous tract, in addition to endoscopic drainage. RESULTS Fistulas were closed successfully in 8 of 12 patients. A single treatment session was successful in 7 patients; a second session was required in one patient. In two patients, closure was temporary, and, in one patient, the treatment failed. One patient died 24 hours after treatment. He developed a pulmonary thromboembolism from a left popliteal vein thrombosis and died from complications of surgical thromboembolectomy. At autopsy, a pulmonary embolus was found, but there was no evidence of N-butyl-2-cyanoacrylate in the lungs. No procedure-related complication occurred over a median follow-up of 20.7 months (range 9-51 months). CONCLUSIONS In this preliminary study, occlusion of pancreatic fistulas by using N-butyl-2-cyanoacrylate glue was safe and effective, and obviated the need for surgery in a substantial proportion of patients. Further studies of the use of N-butyl-2-cyanoacrylate for closure of pancreatic fistula are warranted.

Endoscopic treatment of biliary leakage with n-butyl-2 cyanoacrylate

BACKGROUND Biliary leakage is a problematic complication of hepatobiliary surgery. A novel alternative method is described that can obviate the need for reoperation for refractory biliary fistula. METHODS Nine patients with large biliary leaks unresponsive to endoscopic drainage underwent N-butyl-2-cyanoacrylate glue occlusion at ERCP. RESULTS In 7 patients, occlusion was successful with prompt control of the fistula in a single session, averting reoperation. In 1 patient there was a partial response and in another the treatment was unsuccessful. No procedure-related complication occurred over a median follow-up of 35 months (range: 1.6-160 months). CONCLUSION N-butyl-2-cyanoacrylate glue occlusion is a safe and effective endoscopic method for control of refractory bile leaks that eliminates the need for surgical reintervention.

Ultrasonic esophagoprobe for TNM staging of highly stenosing esophageal carcinoma

BACKGROUND Endosonographic staging of esophageal carcinoma may be limited in one third of cases by tumor stenoses that cannot be traversed with conventional echoendoscopes. We designed and evaluated a new endosonographic instrument (ultrasonic esophagoprobe) for TNM staging of highly stenosing esophageal carcinomas. METHODS Eighty-seven consecutive patients (64 men, mean age 61 years) with highly stenosing esophageal carcinomas were studied with the esophagoprobe (features: diameter of 7.9 mm, bougie-shaped tip, no fiber optics, insertion over a guide wire). RESULTS The esophagoprobe was successfully inserted past the stenosis without complication in all patients. Nine patients (10%) required preliminary bougienage to 33 F. The imaging quality was high and allowed for complete T and N staging in all patients. M staging was indeterminate in 15 patients because of inadequate visualization of the celiac axis region. Histopathologic correlation in 38 patients who underwent surgery showed an overall T stage accuracy rate of 89% (T2 = 80%, T3 = 95%, T4 = 87%), and N and M stage accuracies of 79% (N0 = 44%, N1 = 90%) and 91% (M0 = 94%, M1 = 75%), respectively. CONCLUSIONS The esophagoprobe enables safe passage of highly stenosing esophageal carcinomas for TNM staging. Accuracy rates are similar to those reported for conventional echoendoscopes.

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.

EUS-guided drainage of hepatic abscess

macroscopic type; as the polyp grows larger and becomes semipedunculated or pedunculated, adenomatous or dysplastic foci appear first, followed by the cancerous lesion. Most adenocarcinomas found within HPs are well differentiated. The occurrence of poorly differentiated adenocarcinoma in an HP is rare. The typical hyperplastic morphology of HP, characterized by ‘‘sawtooth’’ glands and no detectable dysplasia, usually is seen predominantly at the surface. Therefore, biopsy specimens from these polyps may not reveal underlying adenomatous tissue or cancer. The association of cancer and HP is not as clearly established as is the case with adenoma. Nevertheless, we believe and recommend, on the basis of available data that demonstrate that most cases of carcinoma in HP occur in larger polyps, that all gastric HPs larger than 1 cm be resected endoscopically in toto.

Endoscopic appendectomy in a case of appendicular intussusception due to endometriosis, mimicking a cecal polyp

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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.