European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

Advanced cardiac life support training

The OMED/ESGE consensus statements of the International Symposium on Sedation in Endoscopy, Athens, September 2009, in keeping with guidelines and position statements published by other societies, underline the need for sedation providers to be adequately trained in dealing with scenarios involving patients in respiratory and/or cardiovascular distress. This training should prepare the sedation provider with the necessary acumen to prevent, recognize and remedy sedation-related emergencies. Life support training that adheres to the International Liaison Committee on Resuscitation (ILCOR) guidelines should be a mandatory component of this instruction that should be governed by formal assessment and quality assurance reappraisal.

Sedation in digestive endoscopy: the Athens international position statements

BACKGROUND

Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field.

AIM

To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy.

METHODS

Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll.

RESULTS

The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures.

CONCLUSIONS

While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.

Site-specific geometric and electronic relaxations at organic-metal interfaces

The correlation between the geometric and electronic structures of Zn-phthalocyanine (ZnPc) and F16ZnPc on Cu(111) were studied by x-ray standing wave and angle-resolved photoemission spectroscopy. We found evidence for a distortion of the planar molecules upon adsorption, with the central Zn atom in the molecule protruding towards the substrate. This modifies the energy levels of both the molecule and the substrate, which appear as interface states. The site-specific geometric and electronic relaxations are an important effect for organic-metal interface energetics.

Real-time changes in the optical spectrum of organic semiconducting films and their thickness regimes during growth

We present real-time in situ studies of optical spectra during thin film growth of several prototype organic semiconductors (pentacene, perfluoropentacene, and diindenoperylene) on SiO2. These data provide insight into surface and interface effects that are of fundamental importance and of relevance for applications in organic electronics. With respect to the bulk, the different molecular environment and structural changes within the first few monolayers can give rise to significant optical changes. Similar to interface-driven phenomena in, e.g., magnetism, spectral changes as a function of thickness d are a very general effect, decaying as 1/d in the simplest approximation. We observe energy shifts of 50-100 meV, rather small changes of the exciton-phonon coupling, and new transitions in specific systems, which should be considered as general features of the growth of organics.

Improved phylogenomic taxon sampling noticeably affects nonbilaterian relationships

Despite expanding data sets and advances in phylogenomic methods, deep-level metazoan relationships remain highly controversial. Recent phylogenomic analyses depart from classical concepts in recovering ctenophores as the earliest branching metazoan taxon and propose a sister-group relationship between sponges and cnidarians (e.g., Dunn CW, Hejnol A, Matus DQ, et al. (18 co-authors). 2008. Broad phylogenomic sampling improves resolution of the animal tree of life. Nature 452:745–749). Here, we argue that these results are artifacts stemming from insufficient taxon sampling and long-branch attraction (LBA). By increasing taxon sampling from previously unsampled nonbilaterians and using an identical gene set to that reported by Dunn et al., we recover monophyletic Porifera as the sister group to all other Metazoa. This suggests that the basal position of the fast-evolving Ctenophora proposed by Dunn et al. was due to LBA and that broad taxon sampling is of fundamental importance to metazoan phylogenomic analyses. Additionally, saturation in the Dunn et al. character set is comparatively high, possibly contributing to the poor support for some nonbilaterian nodes.

Nanoscale spectroscopic imaging of organic semiconductor films by plasmon-polariton coupling

Tip-enhanced near-field optical images and correlated topographic images of an organic semiconductor film (diindenoperylene, DIP) on Si have been recorded with high optical contrast and high spatial resolution (17 nm) using a parabolic mirror with a high numerical aperture for tip illumination and signal collection. The DIP molecular domain boundaries being one to four molecular layers (1.5-6 nm) high are resolved topographically by a shear-force scanning tip and optically by simultaneously recording the 6x10{5} times enhanced photoluminescence (PL). The excitation is 4x10{4} times enhanced and the intrinsically weak PL-yield of the DIP-film is 15-fold enhanced by the tip. The Raman spectra indicate an upright orientation of the DIP molecules. The enhanced PL contrast results from the local film morphology via stronger coupling between the tip plasmon and the exciton-polariton in the DIP film.

Protein density profile at the interface of water with oligo(ethylene glycol) self-assembled monolayers

We determined the density profile of a high-molecular-weight globular protein (bovine serum albumin, BSA) solution at the methoxy tri(ethylene glycol)-terminated undecanethiol SAM/protein solution interface by neutron reflectivity measurements. Information about the interactions between oligo(ethylene glycol) (OEG)-terminated self-assembled monolayers (SAMs) and proteins is derived from the analysis of the structure of the solid-liquid interface. The fitting results reveal oscillations of the protein density around the bulk value with decaying amplitude on a length scale of 4 to 5 nm. The amplitude, phase, period, and decay length are found to vary only slightly with temperature and the ionic strength of the protein solution. Adsorption is reversible within the limits of detection, which suggests that the hydrated ethylene glycol surface inhibits the protein from unfolding and irreversible bonding. The insensitivity of BSA adsorption toward the ionic strength of the solution contrasts with observations in surface force experiments with a fibrinogen-coated AFM tip, where electrostatic repulsion dominates theprotein/OEG SAM interaction. As reported previously, irreversible BSA adsorption takes place below 283 K, which we interpret as indicative of the presence of dynamic effects in the protein resistance of short-chain OEG-terminated surfaces.

Coverage dependent adsorption dynamics in hyperthermal organic thin film growth

We have examined the dynamics of adsorption of diindenoperylene (DIP) on SiO(2) and SiO(2) modified with an interfacial organic layer using in situ real time synchrotron x-ray scattering, focusing on the effects of coverage. On both surfaces we observe a substantial increase in the probability of adsorption with increasing coverage, which is most dramatic at the highest incident kinetic energies. On the initially uncovered surfaces, we observe a smooth decrease in the probability of adsorption with increasing incident kinetic energy, indicative of trapping-mediated adsorption. Once both surfaces are covered by DIP, the effects of incident kinetic energy are greatly reduced, and trapping is very efficient over the range of kinetic energies examined. Possible reasons for efficient trapping at high coverage and at high incident kinetic energy include more efficient momentum transfer due to mass matching, and possibly direct molecular insertion. Comparison to results on another small-molecule, pentacene, suggests that this behavior should be common to hyperthermal growth of a variety of other small-molecule thin films.

Final results of a first line multicenter phase II metastatic breast cancer trial of vinflunine monotherapy and in combination with trastuzumab in HER2+ patients

Abstract #3148

Background: Vinflunine (VFL) is a novel microtubule inhibitor agent of the vinca alkaloid class that inhibits tubulin polymerization without stabilization, resulting in cell cycle arrest in mitosis and apoptosis. Weak tubulin binding at the vinca-binding site accounts for its reduced neurotoxicity. VFL has demonstrated activity in anthracycline and taxane pretreated patients (pts) and in combination with capecitabine. This trial evaluates the activity and safety of VFL monotherapy and in combination with trastuzumab (T) in HER2+ pts as 1st line therapy metastatic breast cancer (MBC).
 Methods: Eligibility: 0 prior regimens for MBC, > 6 mo from adjuvant therapy, RECIST criteria measurable disease, ECOG PS 0-2, adequate organ function, peripheral neuropathy < G2. Treatment: HER2 unspecified: VFL 320 mg/m2 IV q3 wks; FISH HER2+ pts: VFL 280 mg/m2 plus T 6 mg/kg q3 wks. Response evaluations q9 wks; treatment continued until disease progression or toxicity.
 Results: Due to termination of VFL licensing between BMS and Pierre Fabre Medicament, the study closed prematurely with only 31 evaluable pts of a planned 48 pts in each treatment arm of VFL monotherapy or VFL in combination with T. 10 pts received VFL and 21 pts were treated with VFL + T. Median age: 59 yrs (35-78). ECOG PS 0-18 pts, 1-11 pts, 2-2 pts. 48% were ER+. Prior adjuvant anthracyclines and taxanes noted in 17 and 19 pts respectively. 4 pts presented with de novo stage IV disease, all HER2 positive. 45% had 3 or more metastatic disease sites with bone (17 pts), liver (16 pts) and lung (15 pts) predominating. Median of # cycles: 4 (range 1-19). There were 10 PRs (32%), all in VFL + T, and 9 pts (29%) with PD (VFL-4 pts, VFL + T-5pts). SD was reported in 10 pts (32%). 2 pts (7%) were unevaluable, divided equally between the two arms. G3/4 neutropenia occurred in 11 pts (35%); none with fever. G3 nonhematologic toxicity consisted of pain, attributed to treatment in 5 pts (16%) (sites: abdomen-2, chest, back, and infusion site each in 1 pt), and GI toxicity characterized by N/V 3 pts (10%) as well as abdominal pain, diarrhea, constipation, occurring each in 2 pts (6%). There were no G4 events. 10 pts were hospitalized (GI -4 pts, pain 2 pts, pulmonary 2 pts, and other 2 pts). Median PFS was 3.5 months for VFL and 6.6 months for VFL + T. Median overall survival was 9 months for VFL and has not been reached for VFL + T.
 Conclusions: The combination of vinflunine and trastuzumab is active in the first line treatment of MBC, producing a 48% response rate. Adverse events were as expected, manageable and consisted primarily of neutropenia, pain and GI toxicity. This encouraging activity compares favorably with other trastuzumab combination regimens and merits further evaluation.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3148.

Reentrant condensation of proteins in solution induced by multivalent counterions

Negatively charged globular proteins in solution undergo a condensation upon adding trivalent counterions between two critical concentrations C and C, C <C. This reentrant condensation behavior above C is caused by short-ranged electrostatic interactions between multivalent cations and acidic residues, mechanistically different from the case of DNA. Small-angle x-ray scattering indicates a short-ranged attraction between counterion-bound proteins near C and C. Monte Carlo simulations (under these strong electrostatic coupling conditions) support an effective inversion of charge on surface side chains through binding of the multivalent counterions.

Case volume and outcome of endoscopic retrograde cholangiopancreatography: results of a nationwide Austrian benchmarking project

BACKGROUND AND STUDY AIM

In a quality assessment project for endoscopic retrograde cholangiopancreatography (ERCP), initiated in 2006 by the Austrian Society of Gastroenterology and Hepatology, benchmark data were collected on a voluntary basis. Results from the individual participating centers, both academic and community-based, were compared with pooled benchmark data, with the intention that individual problems should be identified and corrected in order to improve patient care in Austria. Success and complication rates in nonselected patients were evaluated, especially with regard to case volume.

METHODS

In Austria, with a population of 8 million, 140 sites are registered for ERCP, and it is estimated that up to 15 000 procedures are done annually. Of these sites, 28 participated in the "Benchmarking ERCP" project during the first year, reporting on 3132 procedures, or 22 % of the total number.

RESULTS

The overall complication rate in nonselected patients was 12.6 %, consisting of post-ERCP pancreatitis (5.1 %), bleeding (3.7 %), cholangitis (1.9 %), cardiopulmonary complications (0.9 %), and perforation (0.5 %); procedure-related mortality was 0.1 %. The overall therapeutic and diagnostic target was achieved in 84.8 %. High case volume (endoscopists performing > 50 vs. < 50 ERCPs per year; 21 vs. 68 endoscopists) was associated with significantly higher success (86.9 % vs. 80.3 %, P < 0.001) and lower overall complication rates (10.2 % vs. 13.6 %, P = 0.007); significance was not reached for all subgroups of complications.

CONCLUSION

Success and complication rates for ERCP in Austria are comparable to those reported elsewhere. In our study, endoscopists with a case volume exceeding 50 ERCPs per year had higher success and lower overall complication rates.

High titers of mucosal and systemic anti-PrP antibodies abrogate oral prion infection in mucosal-vaccinated mice

Significant outbreaks of prion disease linked to oral exposure of the prion agent have occurred in animal and human populations. These disorders are associated with a conformational change of a normal protein, PrP(C) (C for cellular), to a toxic and infectious form, PrP(Sc) (Sc for scrapie). None of the prionoses currently have an effective treatment. Some forms of prion disease are thought to be spread by oral ingestion of PrP(Sc), such as chronic wasting disease and variant Creutzfeldt-Jakob disease. Attempts to obtain an active immunization in wild-type animals have been hampered by auto-tolerance to PrP and potential toxicity. Previously, we demonstrated that it is possible to overcome tolerance and obtain a specific anti-PrP antibody response by oral inoculation of the PrP protein expressed in an attenuated Salmonella vector. This past study showed that 30% of vaccinated animals were free of disease more than 350 days post-challenge. In the current study we have both optimized the vaccination protocol and divided the vaccinated mice into low and high immune responder groups prior to oral challenge with PrP(Sc) scrapie strain 139A. These methodological refinements led to a significantly improved therapeutic response. 100% of mice with a high mucosal anti-PrP titer immunoglobulin (Ig) A and a high systemic IgG titer, prior to challenge, remained without symptoms of PrP infection at 400 days (log-rank test P<0.0001 versus sham controls). The brains from these surviving clinically asymptomatic mice were free of PrP(Sc) infection by Western blot and histological examination. These promising findings suggest that effective mucosal vaccination is a feasible and useful method for overcoming tolerance to PrP and preventing prion infection via an oral route.

Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members

BACKGROUND/AIMS

Sedation rates may vary among countries, depending on patients' and endoscopists' preferences. The aim of this survey was to investigate the rate of using premedication for routine diagnostic upper gastrointestinal (UGI) endoscopy in endoscopy societies, members of the European Society of Gastrointestinal Endoscopy (ESGE).

METHODS

We evaluated a multiple-choice questionnaire which was e-mailed to representatives of national endoscopy societies, which are members of the ESGE. The questionnaire had 14 items referring to endoscopy practices in each country and the representatives' endoscopy units.

RESULTS

The response rate was 76% (34/45). In 47% of the countries, less than 25% of patients undergo routine diagnostic UGI endoscopy with conscious sedation. In 62% of the responders' endoscopy units, patients are not asked their preference for sedation and do not sign a consent form (59%). Common sedatives in use are midazolam (82%), diazepam (38%) or propofol (47%). Monitoring equipment is not available 'in most of the endoscopy units' in 46% (13/28) of the countries. Though they were available in 91% of the national representatives' endoscopy units, they are rarely (21%) used to monitor unsedated routine diagnostic UGI endoscopy.

CONCLUSIONS

In about 50% of ESGE-related countries, less than 25% of patients are sedated for routine diagnostic UGI endoscopy. Major issues to improve include availability of monitoring equipment and the use of a consent form.

Hydration of oligo(ethylene glycol) self-assembled monolayers studied using polarization modulation infrared spectroscopy

The interaction with water of protein-resistant monolayers (SAMs), self-assembled from (triethylene glycol) terminated thiol HS(CH2)11(OCH2CH2)3OMe solutions, was studied using in and ex situ polarization-modulated Fourier transform infrared spectroscopy. In particular, shifts in the position of the characteristic C-O-C stretching vibration were observed after the monolayers had been exposed to water. The shift in frequency increased when the SAM was observed in direct contact with a thin layer of water. It was found that the magnitude of the shift also depended on the surface coverage of the SAM. These findings suggest a rather strong interaction of oligo(ethylene glycol) SAMs with water and indicate the penetration of water into the upper region of the monolayer.

Muscle weakness is a significant problem in older patients receiving chemotherapy

8545

Background: Accurate prediction of toxicities from chemotherapy in the elderly could lead to improved decision making and supportive care. Methods: A large prospective multicentric cohort study of older cancer patients undergoing chemotherapy is underway to document the occurrence of chemotherapy toxicity and to develop a predictive score: the CRASH score (Chemotherapy Risk Assessment Score for High Age patients). Toxicity, including muscle weakness, is assessed using the Common Toxicity Criteria v.3.0. Results: An analysis of the first 200 patients entered in the study revealed an infrequently highlighted side effect: muscle weakness. Twenty patients were not evaluable for this analysis. Muscle weakness was reported by 22 patients. This represented 12.2% of the patients, of whom 13 (7.2%) had grade 3 muscle weakness. There was no grade 4 muscle weakness. This side effect appears to be independent from fatigue: only 4/22 patients reported concomitant severe (grade 3–4) fatigue, and among the 24 patients with severe fatigue, only 4 reported any muscle weakness. Muscle weakness occurred fairly early during the treatment: median 30 days (range 6–126 days). The muscle weakness was predominantly of two types: a generalized muscle weakness, or a weakness affecting the lower extremities. It was accompanied by falls in two patients. That weakness was present across tumor types, chemotherapy types, individual physicians, and oncology centers. Like the rest of the study population, the majority of these patients had advanced disease. Other frequent severe side effects were: grade 4 neutropenia 31.7%; grade 3–4: hypokalemia 8.8%, hyperglycemia 8.3%, hyponatremia 7.2%, febrile neutropenia 7.2%, diarrhea 7.2%, infection with neutropenia 6.7%. Conclusion: Muscle weakness is a frequent and clinically significant side effect of chemotherapy in the elderly, distinguishable from fatigue. This could be targeted by a preventive physical therapy intervention to prevent muscle deconditioning.

[Table: see text]

Real-time observation of structural and orientational transitions during growth of organic thin films

We study kinetically controlled orientational and structural transitions of molecular thin films during growth in situ and in real time, using diindenoperylene (DIP) as an example. By time-resolved surface-sensitive x-ray scattering (out of plane and in plane), we follow the organic molecular beam deposition of DIP on silicon oxide, on stepped sapphire, and on rubrene as an organic model surface. We identify transitions for the few-monolayer (ML) regime, as well as for thick (several 10's of ML) films. We show that the differences in the interaction of DIP with the substrate change the thickness as well as temperature range of the transitions, which include (transient) strain, subtle changes of the orientation, as well as complete reorientation. These effects should be considered rather general features of the growth of organics, which, with its orientational degrees of freedom, is qualitatively different from growth of inorganics.

Anomalous roughness evolution of rubrene thin films observed in real time during growth

We study the growth and structure of thin films of the organic semiconductor rubrene during organic molecular beam deposition (OMBD) on silicon oxide in situ and in real time using X-ray scattering. Using in situ grazing incidence diffraction (GID) we find a small degree of local order but an otherwise largely disordered structure, consistent with out of plane scans. Monitoring the surface morphology in real time during growth, we find relatively smooth films (surface roughness sigma below approximately 15 A for thicknesses up to at least 600 A) and a significant delay before the onset of roughening. This anomalous roughening in the beginning and crossover to normal roughening later during growth may be related to conformational changes of rubrene in the early stages of growth.

Mucosal vaccination delays or prevents prion infection via an oral route

In recent years major outbreaks of prion disease linked to oral exposure of the prion agent have occurred in animal and human populations. These disorders are associated with a conformational change of a normal protein, PrP(C) (prion protein cellular), to a toxic and infectious form, PrP(Sc) (prion protein scrapie). None of the prionoses currently have an effective treatment. A limited number of active immunization approaches have been shown to slightly prolong the incubation period of prion infection. Active immunization in wild-type animals is hampered by auto-tolerance to PrP and potential toxicity. Here we report that mucosal vaccination with an attenuated Salmonella vaccine strain expressing the mouse PrP, is effective at overcoming tolerance to PrP and leads to a significant delay or prevention of prion disease in mice later exposed orally to the 139A scrapie strain. This mucosal vaccine induced gut anti-PrP immunoglobulin (Ig)A and systemic anti-PrP IgG. No toxicity was evident with this vaccination approach. This promising finding suggests that mucosal vaccination may be a useful method for overcoming tolerance to PrP and preventing prion infection among animal and potentially human populations at risk.

Optimized preparation of cross-sectional TEM specimens of organic thin films

We present a route for the preparation of cross-sectional TEM specimens of crystalline organic thin films which minimizes the mechanical, chemical and thermal load of the organic film during preparation and allows to take TEM images with molecular resolution. A typical example of a thin film of diindenoperylene capped with a thin layer of gold is shown to demonstrate the application of the technique for the investigation of metal-organic interfaces.

Rapid roughening in thin film growth of an organic semiconductor (diindenoperylene)

The scaling exponents alpha, beta, and 1/z in thin films of the organic molecule diindenoperylene deposited on SiO2 under UHV conditions are determined. Atomic-force microscopy, x-ray reflectivity, and diffuse x-ray scattering were employed. The surface width displays power law scaling over more than 2 orders of magnitude in film thickness. We obtained alpha = 0.684+/-0.06, beta = 0.748+/-0.05, and 1/zeta = 0.92+/-0.20. The derived exponents point to an unusually rapid growth of vertical roughness and lateral correlations. We suggest that they could be related to lateral inhomogeneities arising from the formation of grain boundaries between tilt domains in the early stages of growth.

Bone scintigraphy and magnetic resonance imaging in adult-onset Still's disease

Adult-onset Still's disease (AOSD) is an acute systemic inflammatory disorder of unknown origin. We report a patient whose AOSD presented with the commonly accepted diagnostic clinical signs and laboratory parameters. The painful joints distinctly demonstrated increased uptake of 99mTc-methylene diphosphonate in scintigraphy and areas of increased gadolinium-enhanced signal in MRI. Biopsies indicated bone marrow edema. AOSD in association with bone marrow edema had not been previously demonstrated. AOSD is often diagnosed after a considerable delay, bone scintigraphy, and magnetic resonance imaging may offer new imaging techniques for early diagnosis and successful therapy in follow-up examinations.

Haemoglobin O Padova and falsely low haemoglobin A1c in a patient with type I diabetes

Glycated haemoglobin (HbA1c) measured by high performance liquid chromatography (HPLC) in a 20 year old female with insulin dependent diabetes mellitus was consistently within the normal range although her daily blood glucose values were > 11.1 mmol/l. HbA1c measured by immunoagglutination and fructosamine was elevated and correlated with the patient's blood glucose values. The HPLC chromatogram showed an additional peak at HbA0. Electrophoresis of haemoglobin on citrate agar gel revealed an abnormal haemoglobin anodal of HbS. Cellulose acetate electrophoresis and isoelectric focusing demonstrated an additional haemoglobin migrating close to HbA2. Amino acid analysis and DNA sequencing revealed an alpha 30 (B11) Glu-->Lys replacement, that is, haemoglobin O Padova. Investigations of two family members without diabetes revealed the same rare haemoglobin variant. This case showed that this silent haemoglobin mutation caused an additional peak and falsely low HbA1c values when measured by HPLC, the gold standard for this evaluation.

Complications and surgical interventions during 4 years of biliary extracorporeal shockwave lithotripsy

BACKGROUND/AIMS

Extracorporeal shockwave lithotripsy (ESWL) of renal concrements, a revolutionary therapeutic concept, was introduced into clinical routine in the early 1980s. In this study, complications and surgical interventions of biliary extracorporeal shockwave lithotripsy were investigated.

MATERIAL AND METHODS

Two hundred-eighty patients with gallbladder stones underwent extracorporeal shockwave lithotripsy during a 4 year (January 1990-December 1993) investigation period. Two hundred four patients were female, and 76 patients were male with a mean age of 48 years. All patients were symptomatic. Selection was carried out following the "Munich criteria" and the selection rate was 15.3% of all referred patients (n = 1831). One hundred eighty-eight patients had solitary stones, 92 patients presented with multiple stones (maximum 3 stones), with an average of 1.7 stones and a mean stone volume of 2.4 cm3 and stone diameter of 16.5 mm. Shockwave lithotripsy was performed with a second generation electrohydraulic lithotriptor with a mean of 2.1 sessions. Mean duration of one session was 50 min, 1331 discharges were applied on average with a mean power of 22.7 kV.

RESULTS

Analgesia, with Alfetanil (mean 2.3 mg), was necessary in 68% of all treatment sessions. Fragmentation could be achieved in 81% of the cases, stone clearance was observed in 172 cases (66.4%) out of 258 patients after 12 months. Twenty-two patients were treated in 1993 and are still under observance. Side effects such as colic after treatment were observed in 88 cases (31.4%). In seven cases, severe complications such as impaction of fragments in the papilla of Vater followed by serochemical pancreatitis were seen. An urgent endoscopic sphincterotomy was necessary in these 7 cases (2.5%). Within 4 weeks after shockwave treatment in 4 cases 1.4% emergency cholecystenomy had to be performed. Elective cholecystectomy was done in 16 patients (5.7%). There were no deaths observed during the investigation period.

CONCLUSION

Based on the results of our series, we do not recommend biliary ESWL in patients with stone volumes exceeding 14 cm3 (3cm), the high fragment volume after sufficient fragmentation by shockwaves indicates long term oral dissolution therapy. The probability of complications will be increased by the presence of larger fragments.

Sonographically-guided extracorporeal shockwave lithotripsy for pancreatic stones in patients with chronic pancreatitis

Over a 2 year period, 10 patients with pancreatic stones due to alcohol induced chronic pancreatitis (proven by endoscopic retrograde pancreatography) underwent extracorporeal shockwave lithotripsy. Prior to shockwave therapy, all patients underwent endoscopic sphincterotomy. Targeting of shockwave lithotripsy was exclusively performed under sonographic control. All patients were treated with a second generation electrohydraulic spark gap lithotriptor and fragmentation of concrements could be achieved in all cases. Complete duct clearance was confirmed in seven patients by endoscopic retrograde pancreatography in one session, with endoscopic fragment extraction by basket and/or balloon catheter. In three patients, balloon dilation of concomitant strictures located in the head of the pancreas was performed prior to fragment extraction. All stone-free patients showed no further symptoms over the follow-up period of 12 months. Three patients in whom complete extraction of fragments was not successful experienced minor symptoms over the 12 month follow-up period.

Endoscopic intracorporeal laser lithotripsy of difficult common bile duct stones with a stone-recognition pulsed dye laser system

BACKGROUND

Endoscopic retrograde intracorporeal lithotripsy with a stone recognition laser system seems to be a promising alternative in patients with difficult bile duct stones.

METHOD

Sixteen patients with bile duct stones not suitable for endoscopic standard procedures underwent intracorporeal laser lithotripsy during a 3-month period. An average of 6800 (120 to 25000) discharges were applied with a power setting of 100 mJ. Inserting the laser fiber into a radiopaque marked catheter or into a balloon catheter guaranteed a successful location on the stone surface in 70% of all discharges. The automatic feedback/cut-off at the fiber is not in contact with the stone surface.

RESULTS

Fragmentation was achieved in all cases. Complete bile duct clearance was reached in 14/16 cases. In two cases, remaining fragments passed spontaneously through the papilla as controlled by ERCP. Minor complications were noted in two patients (hemobilia, cholangitis). Complete recovery was achieved in both patients with conservative management.

CONCLUSIONS

For a selected group of patients with difficult common bile duct stones, intracorporeal laser lithotripsy with a stone recognition laser system was found to be a highly effective and safe technique.

Endoscopic intracorporeal laser lithotripsy of difficult common bile duct stones with a stone-recognition pulsed dye laser system

BACKGROUND

Endoscopic retrograde intracorporeal lithotripsy with a stone recognition laser system seems to be a promising alternative in patients with difficult bile duct stones.

METHOD

Sixteen patients with bile duct stones not suitable for endoscopic standard procedures underwent intracorporeal laser lithotripsy during a 3-month period. An average of 6800 (120 to 25000) discharges were applied with a power setting of 100 mJ. Inserting the laser fiber into a radiopaque marked catheter or into a balloon catheter guaranteed a successful location on the stone surface in 70% of all discharges. The automatic feedback/cut-off at the fiber is not in contact with the stone surface.

RESULTS

Fragmentation was achieved in all cases. Complete bile duct clearance was reached in 14/16 cases. In two cases, remaining fragments passed spontaneously through the papilla as controlled by ERCP. Minor complications were noted in two patients (hemobilia, cholangitis). Complete recovery was achieved in both patients with conservative management.

CONCLUSIONS

For a selected group of patients with difficult common bile duct stones, intracorporeal laser lithotripsy with a stone recognition laser system was found to be a highly effective and safe technique.