Wilfried Veltzke-Schlieker

Successful recanalization of a completely obliterated esophageal stricture by using an endoscopic rendezvous maneuver

Patients with head and neck cancer frequently develop problems with food intake and malnutrition. A common cause is non-neoplastic stricture of the proximal esophagus after radiotherapy. The proximal esophagus is known to be particularly radiosensitive; radiation-induced injury usually occurs at doses of greater than 60 Gy in about 3.4% of patientswithheadandneckcanceratamedianof6months after completion of radiotherapy. 1 Radiation-induced strictures are amenable to a single or a repeated endoscopic dilation. 2,3 Complete obliteration of the esophagus, however, poses a greater challenge. This report describes the first successful recanalization of a completely obstructed esophagus after radiotherapy by using an endoscopic rendezvous maneuver.

Prospective pilot evaluation of a new needle prototype for endoscopic ultrasonography-guided fine-needle aspiration: comparison of cytology and histology yield.

Objectives Endoscopic ultrasonography (EUS) with the adjunct of EUS-guided fine needle aspiration has become an important diagnostic modality in gastroenterologic oncology. EUS-guided fine needle aspiration mainly relies on cytology; data are scarce that compare cytology and histology. While testing a 22-gauge prototype needle, we prospectively compared the yield for both. Methods Forty-two consecutive patients (27 male, 15 female; mean age 59.2 years, range: 17–90 years) were included. In each patient we aimed to make two needle passes, and if the material acquired appeared insufficient macroscopically (no in-room cytopathology was available), further passes were done. The material was sent for cytological and histological assessment. Results A median number of two passes (range: 2–3) were uneventfully performed for pancreatic lesions (n=30), mediastinal and other lymph nodes/masses (n=8) and various other lesions (n=4) and yielded adequate material for cytology, histology or at least one of the two investigations in 62, 67 and 74% of patients, respectively. No false positive results were found (specificity 100%). Sensitivities were 58.6 and 65.5%, respectively, for cytology and histology alone; combined assessment increased sensitivity to 79.3%. When adjusted values were calculated, based only on those cases with adequate material, sensitivity was 89.5% for cytology and 85.7% for histology, and increased to 100% with combined assessment. Conclusion The new needle achieves sensitivities similar to those previously reported with no significant differences in sensitivity between cytology and histology. More effective tissue acquisition methods must be sought to improve overall results.

Secondary Sclerosing Cholangitis in Critically Ill Patients: Clinical Presentation, Cholangiographic Features, Natural History, and Outcome: A Series of 16 Cases.

AbstractSecondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an important differential diagnosis in patients presenting with cholestasis and PSC-like cholangiographic changes in endoscopic retrograde cholangiography (ERC). As a relatively newly described entity, SSC-CIP is still underdiagnosed, and the diagnosis is often delayed. The present study aims to improve the early detection of SSC-CIP and the identification of its complications.A total of 2633 records of patients who underwent or were listed for orthotopic liver transplantation at the University Hospital Charité, Berlin, were analyzed retrospectively. The clinical presentation and outcome (mean follow-up 62.7 months) of the 16 identified SSC-CIP cases were reviewed.Cholestasis was the first sign of SSC-CIP. GGT was the predominant enzyme of cholestasis. Hypercholesterolemia occurred in at least 75% of the patients. SSC-CIP provoked a profound weight loss (mean 18 kg) in 94% of our patients. SSC-CIP was diagnosed by ERC in all patients. The 3 different cholangiographic features detected correspond roughly to the following stages: (I) evidence of biliary casts, (II) progressive destruction of intrahepatic bile ducts, and (III) picture of pruned tree. Biliary cast formation is a hallmark of SSC-CIP and was seen in 87% of our cases. In 75% of the patients, the clinical course was complicated by cholangiosepsis, cholangitic liver abscesses, acalculous cholecystitis, or gallbladder perforation. SSC-CIP was associated with worse prognosis; transplant-free survival was ∼40 months (mean).Because of its high rate of serious complications and unfavorable prognosis, it is imperative to diagnose SSC-CIP early and to differentiate SSC-CIP from other types of sclerosing cholangitis. Specific characteristics enable identification of SSC-CIP. Early cooperation with a transplant center and special attention to biliary complications are required after diagnosis of SSC-CIP.

New endoscopy devices to improve population adherence to colorectal cancer prevention programs

Despite recent advances in medicine, colorectal cancer (CRC) remains one of the greatest hazards for public health worldwide and especially the industrialized world. It has been well documented with concrete data that regular screening colonoscopy aimed at early detection of precancerous polyps can help decrease the incidence of CRC. However, the adherence of the general population to such screening programs has been shown to be lower than that expected, thus allowing CRC to remain a major threat for public health. Various reasons have been suggested to explain the disappointing compliance of the population to CRC screening programs, some of them associated with colonoscopy per se, which is viewed by many people as an unpleasant examination. Governments, medical societies, individual gastroenterologists, as well as the medical industry are working in order to improve endoscopic devices and/or to improve standard colonoscopy. The aim is to improve the acceptance of the population for this method of CRC screening, by providing a painless and reliable examination of the colon. This review focuses on some of the latest improvements in this field.

ERCP in the sitting position--an alternative technique with potential benefits (with video).

The authors describe a new technique of performing endoscopic retrograde cholangiopancreatography in the sitting position with special emphasis on methods of stabilization of the duodenoscope during the procedure. The article is accompanied by an instructional video. The benefits of this comfortable alternative to the standard standing position and its potential limitations are discussed.

4620 Endoscopic therapy of post-pancreatitic persistent necrosis.

Introduction: Development of PPN occurs as a severe complication of necrotising pancreatitis. PPN has to be differentiated from pancreatic pseudocysts and pancreatic abscesses. So far, treatment is performed by percutaneous or surgical drainage as well as surgical resection and necrosectomy. Endoscopic treatment offers an alternative approach to surgery. Aim:We studied the short term outcome (=30 days after initiation of endoscopic treatment) of endoscopic PPN therapy. Methods: PPN was identified by means of sonography and CT. Endoscopic treatment was adapted to the findings (MRCP, ERP) in the pancreatic duct system. Endoscopic treatment modalities comprised EST of pancreatic sphincter as well as stenting and dilation of pancreatic duct stenoses and stone extractions. Furthermore, PPN were treated by endoscopic fistulation, subsequent stenting (Amsterdam stents, 10 Fr., 2-3 cm length) and sequester extraction. Fistulation was carried out either through the gastric or the duodenal wall depending on the topographic situation. Solid sequesters and debris were extracted after enlargement of the fistula hole by multiple stenting. Liquid PPN content was washed out by irrigation through nasocystic catheters. Results: 14 patients affected with PPN (8 Women; 7 Men; mean age 47 years) were treated by endoscopic drainage. Underlying causes had been alcoholic pancreatitis (n=8), biliary pancreatitis (n=4) and idiopathic pancreatitis (n=2). All patients received endoscopic therapy as mentioned above. In 71% of patients (10 out of 14) PPN completely disappeared. In contrast, 2 patients showed no improvement and 2 further patients only partial response to endoscopic drainage therapy. 2 patients refractory to endoscopic therapy received surgery in terms of partial pancreatectomy, necrosectomy and Whipples reconstruction. 1 patient recovered soon while the other one developed septic complications and finally died. Due to endoscopic therapy, 1 patient suffered from perforation of the post-pancreatitic necrosis into the peritoneum. Discussion: We treated 14 patients which were affected with PPN due to necrotizing pancreatitis. Most patients (71%) completely recovered due to endoscopic therapy. Patients suffering from PPN are usually in reduced physical condition and therefore at high risk for surgery. Endoscopic therapy of PPN offers a minimal invasive and successful alternative to surgery. It is also suggested, that surgical resection should be restricted to patients refractory to endoscopic drainage therapy.

Endoscopic Removal of Embedded Self-Expanding Esophageal Metal Stents

Endoscopic Removal of Embedded Self-Expanding Esophageal Metal Stents Wilfried Veltzke-Schlieker, Andreas Adler, Rainer Hintze, Hassan Rebeye, Bertram Wiedenmann, Thomas Rosch Background: Selfexpanding metal stents have become standard treatment for obstructing esophageal cancer as well as for sealing of esophageal and anastomotic fistulas. Removal of those stents appears desirable in some malignant conditions but also for intermittent treatment of benign strictures. We present a standardized approach for endoscopic removal of these stents. Patients and Methods: During a six year period, metal stents were placed in 172 patients, and in 20 cases stents (all Ultraflex covered stents, Boston Scientific) had to be endoscopically removed. Reasons were dysfunction in 12 cases (3 dislocations, 5 intractable pain, 4 misplacements) and in 8 cases stent removal was planned after 8-12 weeks in patients with anastomotic leaks. Two methods were applied: In firmly embedded stents, the metal mesh was longitudinally dissected using a Neodym-Yag laser, followed by extraction of the middle stent body after radial dissection at both noncovered inner ends. The remaining filaments at the proximal and distal end were then partially removed as far as tissue embedding allowed. Method 2 consisted of bougienage dislocation in less firmly fixed stents, whereby the bougie traversed the distal stent ends, thus pushing the stent distally removing it from the underlying tissue, and finally extracting it. Results: In 16 patients method 1 was successfully applied, whereas method 2 led to stent removal in two cases. In the remaining patients both methods were used in combination. In all cases stents could be removed successfully and without significant complications in 1.3 session.Only in one case oesophagus dilatation was nesseary due to stenosis. Conclusions: Endoscopic stent removal is feasible and safe even in stents embedded in the esophageal wall by ingrowth of non-covered ends. This opens further possibilities of applications in benign conditions.

4681 Endoscopic management of psc patients suffering from dominant bile duct strictures.

Introduction: In general, PSC patients are in good condition for many years until progressive bile duct stenoses lead to cholestasis deteriorating physical condition. Extrahepatic bile duct stenoses contributing to symptomatic cholestasis in PSC patients are referred to as dominant stenoses. So far, reported techniques and outcome of endoscopic dilation therapy of dominant stenoses are contradictory. Aim: We estimated the benefit of endoscopic dilation of dominant stenoses in patients with PSC. Methods: Our PSC patient pool of the last 9 years (Nov. 90 - Oct. /99) was studied retrospectively. Dominant stenoses were treated by balloon dilation and bouginage. Stenting of dominant stenoses was only carried out in case of unsuccessfull dilation therapy. Results: 72 patients suffering from symptomatic PSC were investigated by ERC. 40% (29/72) of all PSC patients presented dominant stenoses. The mean age was 40.9±14.2 years, 65% (19/72) were male and 35% (10/72) female. Patients suffering from dominant stenoses were treated by repeated dilation procedures (98 interventions in 29 patients, mean: 3.4 interventions per patient). Endoscopic therapy improved physical condition as well as decreased cholestatic parameters. AST, ALT, AP, gGT and bilirubin (78% from 6.1±6.4 down to 1.4±0.6 mg/dl). 98 interventions were accompanied by 8.2% of complications in terms of post-ERC pancreatitis (2.0%), CBD perforation (3.1%) and post-ERC cholangitis (3.1%). All complications were considered as mild to moderate since all disappeared within a few days following conservative therapy. Discussion: Many PSC patients suffer from extrahepatic dominant bile duct stenoses. Dilation therapy was able to widen dominant stenoses as well as to relieve cholestasis thus improving the general state of health. Conclusively, we recommend to screen symptomatic PSC patients for dominant bile duct stenoses. Dominant bile duct stenoses should be repeatedly treated by endoscopic dilation therapy since most afflicted PSC patients benefit significantly.

7264 Clinical outcome of percutaneous-duodenal bile duct stent of the yamakawa type.

Introduction: In case of obstructive jaundice and failure of endoscopic stenting percutaneous transhepatic cholangio-drainage (PTCD) as well as Yamakawa stents are able to decompress intrahepatic bile ducts. Yamakawa stents are deployed percutaneously and unlike PTCD are advanced further through the tumor stenosis into the duodenum allowing internal bile drainage. Only in case of stent dysfunction, the percutaneous Yamakawa outlet has to be opened enabling immediate percutaneous bile drainage as well as subsequent clearing of stent occlusion. Since Yamakawa stents allow intracorporal bile drainage into the duodenum collecting bags are avoided and bile loss syndrome is prevented. Aim: We studied the clinical outcome of Yamakawa stents in pat. with malignant jaundice. Methods: During the last two years (from 8/97 to 11/99) we treated 827 pat. suffering from malignant jaundice in our clinic. In 8.2% (68/827) of cases endoscopic stenting was impossible or insufficient. These pat. receive either PTCD or Yamakawa stents (8 to 14 Fr., Pflugbeil Co., Germany). Results: In 68 pat. we performed percutaneous decompression of malignant jaundice. 62 pat. received PTCD. Later on, we exchanged PTCD to Yamkawa stent in 28 (45.2%) pat.. 6 further pat. had primarily received Yamakawa stents. Finally, we managed a total of 34 Yamakawa stent patients (20 male, 14 female, mean age: 69.2 years, range: 33-94 years). Pat. with Yamakawa stents suffered from gastric cancer (n=7), pancreatic cancer (n=7), Klatskin tumor (n=9), gall bladder cancer (n=4) and 7 metastases of distant tumors. Yamakawa stenting significantly reduced cholestasis (bilirubin

6981 Endoscopic and surgical management of biliary lesions after laparoscopic cholecystectomy (lce).

Introduction: Different therapeutical strategies for treatment of biliary lesions after LCE are recommended in the literature. Therefore, it is still not established which treatment is best suited for which type of biliary lesion caused by LCE. Aim:We investigated the type, localization and frequency of post-LCE biliary lesions introducing our new classification. Moreover, we analyzed the therapeutical success of endoscopic and surgical techniques. Methods: ERC was performed whenever symptoms occurred after LCE which were suspected to be of biliary origin. The new classification considered time of diagnosis as well as type, severity, localization and functional relevance of biliary lesions. According to the findings either endoscopic or surgical therapy was carried out. Surgical techniques comprised oversewing, splinting by percutaneous bile duct tubes, end-to-end reanastomosis, hepatico-jejunostomy and even liver transplantation. Results: Starting in 1990 a total of 108 patients (mean age 54 years, 75 female, 33 male) is treated so far for iatrogenic biliary lesions following LCE. Mean follow up was 28 months. According to 77% (83/108) of patients were primarily treated by endoscopy while 23% (25/108) received initially surgical therapy. 69% (74/108) of all patients could be definitely cured only by endoscopic treatment. 82% (89/108) of post-LCE lesions were classified as early lesions (= manifestation intraop. until 1 month postop.), including 38 peripheral and 51 central lesion sites. 18% of biliary lesions occurred late (= more than 1 month postop.). Peripheral bile duct injuries (cystic duct stump insufficieny, leckage of the gall bladder region, tangential CBD lesions) could be managed mostly by endoscopic or percutaneous means. In contrast, central lesions (occlusion or cutting of extrahepatic bile ducts) required surgical reconstruction. Discussion: This newly introduced classification of post-LCE biliary lesions enables optimization of endoscopic and surgical treatment strategies. In general, biliary lesions after LCE can be successfully treated by endoscopy except that lesions causing total disconnection of bile ducts.