Gastrointestinal stromal sarcoma--a case report of palliative enteral stenting

We report a case of metastatic gastrointestinal stromal sarcoma (GISS) in a 33-year-old man who subsequently underwent successful palliative endoscopically-placed enteral stenting for duodenal stenosis secondary to extrinsic compression. Enteral stenting for palliative relief of malignant gastrointestinal obstruction is recommended for its safety, efficacy and cost-effectiveness.

The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort

BACKGROUND

In developed nations, increasing proportions of the population now reach advanced age. Physicians may be reluctant to refer such patients for non-critical diagnostic and therapeutic interventions, on the basis of perceived diminution of tolerance, safety and substantive benefits in these patients. We aimed to review the utility and safety of gastrointestinal endoscopy in an extremely elderly cohort.

METHODS

The study involved 214 consecutive participants aged 85 years or more, between 1995 and 1997. They were identified using a prospective database linked to the endoscopy reporting system. Procedure type, indication, use of sedation, complications, and outcomes were evaluated.

RESULTS

The median age was 87 (85-94, sigma = 2). The female:male ratio was 3:2; 185 had undergone one procedure and 29 two or more; and 65% of procedures were performed on an outpatient basis. Of the inpatient procedures, 10% of all procedures were performed emergently, predominantly for upper gastrointestinal hemorrhage. Midazolam was administered to 129 patients (60%), at a median dose of 2 mg (range 1-11); of these, 75 (35%) also received a median dose of 25 microg fentanyl (range 12.5-125). Colonoscopy (n = 95) was the most frequently performed procedure, followed by esophagogastroduodenoscopy (EGD) (n = 64) and endoscopic retrograde cholangiopancreatography (ERCP) (n = 21). There was no procedure-related mortality. The incidence of post-ERCP pancreatitis was 5%, colonic perforation 1%, and cardiopulmonary complications in sedated patients, 0.6%. The majority underwent procedures which related to active management of ongoing medical problems, and procedures were performed for palliative indications in only 15 (7%) patients.

CONCLUSIONS

Gastrointestinal endoscopy is extremely safe and well tolerated in extremely elderly patients. Age alone should not influence decisions relating to its utilization.

Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction

BACKGROUND

The endoscopically placed enteral stent has emerged as a reasonable alternative to palliative surgery for malignant intestinal obstruction. This is a report of our experience with the use of enteral stents for nonesophageal malignant upper GI obstruction.

METHODS

Data on all patients who had undergone enteral stent placement were reviewed. Those with a diagnosis of pancreatic cancer were compared with another similar cohort of patients who underwent palliative gastrojejunostomy.

RESULTS

Thirty-one procedures were performed on 29 patients (mean age 67.7 years). Thirteen (45%) were men and 16 (55%) women. The diagnoses were gastric (13.8%), duodenal (10.3%), pancreatic (41.4%), metastatic (27.6%), and other malignancies (6.9%). Malignant obstruction occurred at the pylorus (20.7%), first part of duodenum (37.9%), second part of duodenum (27.6%), third part of duodenum (3.5%), and anastomotic sites (10.3%). Twenty-nine (93.5%) procedures were successful and good clinical outcome was achieved in 25 (80.6%). Re-obstruction by tumor ingrowth occurred in 2 patients after a mean of 183 days. The median survival time for patients with pancreatic cancer who underwent enteral stent placement compared with those who underwent surgical gastrojejunostomy was 94 and 92 days, charges were $9921 and $28,173, and duration of hospitalization was 4 and 14 days, respectively (latter 2 differences with p value < 0.005).

CONCLUSION

Endoscopic enteral stent placement of nonesophageal malignant upper GI obstruction is a safe, efficacious, and cost-effective procedure with good clinical outcome, lower charges, and shorter hospitalization period than the surgical alternative.

Hypotension during ERCP is common but not a risk factor for post-ERCP pancreatitis

BACKGROUND

In patients undergoing cardiopulmonary bypass, hypotension is a risk factor for developing acute pancreatitis. Hypotension in animal models can also induce pancreatitis. We sought to determine whether or not relative hypotension during ERCP is a risk factor for developing acute pancreatitis.

PATIENTS AND METHODS

A nested, case-control study reviewed all cases of post-ERCP pancreatitis resulting from ERCPs performed at this institution between May 1993 and May 1998. Post-ERCP pancreatitis was defined as abdominal pain requiring hospitalisation and elevation of serum amylase or lipase more than four times the upper limit of normal 24 hours or more after ERCP. Non-invasive blood pressure measurements were recorded automatically at least every 5 min during ERCP. Hypotension was defined as any systolic blood pressure (SBP) <100 mmHg, diastolic blood pressure (DBP) <60 mmHg, or mean blood pressure (MBP) <80 mmHg. Controls were chosen randomly from ERCPs performed on the same or the nearest day as each index case.

RESULTS

In total, 1854 ERCPs were reviewed from the study period.There were 96 cases of post-ERCP pancreatitis,giving an incidence of 5.2%. The average age of cases was 48 years, while that of controls was 55 years (p < 0.003).There were no differences between the groups regarding gender, ERCP findings, need for sphincterotomy nor acinar filling on the pancreatogram (acinarisation). At least one episode of hypotension was recorded in 32% of cases and 30% of controls (p = 0.75). There were no differences between cases and controls comparing mean pre- and intra-procedure SBP, DBP and MBPs, or lowest procedure SBP, DBP and MBP.

DISCUSSION

Episodes of acute hypotension are common during ERCP but are not a risk factor for developing post-ERCP pancreatitis.

Role of Doppler US in acute peptic ulcer hemorrhage: can it predict failure of endoscopic therapy?

BACKGROUND

Recurrent bleeding after successful primary endoscopic hemostasis of acutely bleeding ulcers is a significant problem. This study evaluates endoscopic Doppler ultrasound (US) in assessing risk of recurrent bleeding in patients presenting with acute peptic ulcer hemorrhage.

METHODS

In this prospective, double-blind, nonrandomized trial, patients were enrolled from a single academic institution. Only patients with endoscopically confirmed gastric, duodenal, pyloric, or anastomotic ulcers were enrolled. The therapeutic endoscopist was blinded to the Doppler US signal from the ulcer and based treatment decisions on standard guidelines. A 16 MHz pulsed-wave, linear scanning, US probe was used through the accessory channel of an endoscope to assess for the presence of a Doppler signal.

RESULTS

Fifty-two of 139 screened patients entered the trial (55 Doppler sessions). Endoscopic therapy was performed in 42% (30-day recurrent bleeding rate of 17%). Ulcers that remained persistently Doppler positive immediately after endoscopic therapy had a significantly higher rate of recurrent bleeding than ulcers where the Doppler signal was abolished: 100% versus 11% (p = 0.003). There were no bleeding-related deaths.

CONCLUSIONS

A persistently positive Doppler US signal appears to be a marker of inadequate endoscopic therapy in patients with acutely bleeding peptic ulcers.

Pancreatic duct stents for "obstructive type" pain in pancreatic malignancy

OBJECTIVE

Obstruction of the main pancreatic duct from malignancy with secondary ductal hypertension may be an important contributor to pain. The aim of our study was to determine the efficacy and safety of pancreatic stent placement for patients with "obstructive" pain due to pancreatic malignancy.

METHODS

Pancreatic duct stents were placed in 10 consecutive patients with malignant pancreatic duct obstruction and abdominal pain. Seven patients had "obstructive" type pain and three had chronic unremitting pain. Nine had primary pancreatic ductal adenocarcinoma and one had metastatic melanoma. There were eight women and two men. Mean age was 61 yr (range, 47-80 yr). All patients had dominant main pancreatic duct strictures with proximal dilation. Tumors were unresectable. All patients took potent analgesics before endoscopic stent therapy. Polyethylene pancreatic stents, 5- and 7-French, were successfully placed in seven patients, and self-expanding metallic stents were successfully placed in three patients.

RESULTS

There were no procedure-related complications. One patient required a single repeat examination to replace a migrated stent. Seven patients (75%) experienced a reduction in pain. Analgesia was no longer required in five (50%). Three patients who did not improve had chronic pain rather than "obstructive" pain.

CONCLUSIONS

Pancreatic stent placement for patients with "obstructive" pain secondary to a malignant pancreatic duct stricture appears to be safe and effective. It should be considered as a therapeutic option in these patients. It does not seem to be effective for chronic unremitting pain.

Severe cholestasis related to intraconazole for the treatment of onychomycosis

We describe a case of prolonged cholestasis temporally associated with the use of itraconazole for onychomycosis. Peak bilirubin level of 32.0 mg/dl was documented approximately 2 months after discontinuation of the patient's itraconazole therapy, with symptoms of cholestasis persisting more than 1 month after the peak in bilirubin. Physicians should be aware of the potential for severe cholestasis associated with itraconazole usage.

Mucin hypersecreting neoplasms

Mucinous pancreatic neoplasms are uncommon disorders classified as either mucinous cystic neoplasms (mucinous cystadenoma or cystadenocarcinoma) or the more recently described intraductal mucin hypersecreting neoplasms (IMHN), also termed mucinous ductal ectasia. The mucinous cystic neoplasms share many common features with IMHN's but remain distinct clinico-pathologic entities. These tumors have similar histologic appearances, produce abundant mucin, are likely to masquerade as pancreatic pseudocysts, demonstrate a biologically less aggressive course compared to typical ductal adenocarcinomas, and are treated by surgical resection. Nevertheless, IMHN is characterized by intraductal tumor growth and mucin hypersecretion causing cystic transformation of the pancreatic duct and producing a distinct appearance on ERCP of mucus extrusion through a widely patent papilla and amorphous filling defects within the duct. In contrast, the mucinous cystic tumors are proposed to secrete mucin into a peripheral branch duct leading to a cyst cavity which does not communicate with the pancreatic duct and therefore is not demonstrated on pancreatography.

Role of endoscopic stenting in the duodenum

BACKGROUND

Gastric outlet obstruction may cause the presenting symptoms, or may develop during the course of pancreatic or biliary malignancy. Treatment options for malignant gastric outlet obstruction are limited. Surgical gastrojejunostomy is commonly performed, but carries significant morbidity and mortality.

METHODS

Over the past two years, we conducted a prospective study to determine the safety, feasibility and outcomes of the newly-designed Wallstent Enteral (Scneider, Minneapolis, MN) to treat a variety of malignant gastric outlet obstructions. We deployed stents 16 to 22 mm in diameter and 60 to 90 mm in length directly through the endoscope.

RESULTS

Twelve patients (10 women ans 2 men, mean age = 59.7 years) underwent the procedure. After stenting, six patients were able to eat a regular diet, and three were able to eat a pureed diet. In three patients, the procedure was unsuccessful because of multiple obstructions that were not recognized prior to stenting in one and stents that were deployed either too proximally in one or too distally in another. Three patients were discharged within 24 hours after stenting and three had the procedure as an outpatient.

CONCLUSIONS

Placement of the Wallstent Enteral through the endoscope is safe and effective palliation for a variety of malignant gastric outlet obstructions, and leads to significant improvement in many aspects of patients' quality of life.

Expandable metal stents for gastric-outlet, duodenal, and small intestinal obstruction

The treatment of patients who have malignant gastric-outlet, duodenal and small intestinal obstructions is difficult. The morbidity and mortality of palliative surgery in these patients is significant. It is not uncommon for patients to be treated with supportive therapy only, which unfortunately, neither relieves the severe nausea and vomiting, nor allows adequate food intake. Over the past few years, a number of studies have reported the safety and efficacy of self-expanding metal stents used to palliate malignant upper gastrointestinal obstruction. In this article, the authors focus on the use of self-expanding metal stents to treat malignant gastric-outlet, duodenal, and small intestinal obstructions.

Features that may predict hospital admission following outpatient therapeutic ERCP

BACKGROUND

Some patients are admitted following outpatient therapeutic ERCP because of adverse events. This study aimed to identify factors that may predict such admissions.

METHODS

We prospectively studied admissions for post-ERCP adverse events in 415 consecutive patients undergoing outpatient therapeutic ERCP. Potentially relevant predictors of admission were assessed by univariate analysis and in case of significance included in a multivariate analysis.

RESULTS

Admission was necessary in 41 patients (9.9%) because of complications and in 63 (15.2%) for observation of adverse events that did not progress to definable complications. Potential predictors of admission were evaluated comparing patients who required more than an overnight admission (n = 63) with those who did not (n = 352). Multivariate analysis identified three factors that were significant: pain during the procedure (odds ratio 3.8: 95% CI [1.8, 7.9]), history of pancreatitis (odds ratio 2.3: 95% CI [1.1, 4.7]) and performance of sphincterotomy (odds ratio 2.2: 95% CI [1.1, 4.3]). The presence of all these features was associated with a 66.7% likelihood of admission, whereas the absence of pain during the procedure, history of pancreatitis and performance of sphincterotomy made admission likely in only 11.0%, 9.8% and 10.7%, respectively, of the cases.

CONCLUSIONS

The occurrence of pain during the procedure, a history of pancreatitis and the performance of sphincterotomy were independent predictors of admission following outpatient therapeutic ERCP.

Accuracy and complication rate of brush cytology from bile duct versus pancreatic duct

BACKGROUND

The accuracy and complication rates of brush cytology obtained from pancreaticobiliary strictures have not been fully defined. In this study we compared the accuracy and complications of brush cytology obtained from bile versus pancreatic ducts.

METHODS

We identified 148 consecutive patients for whom brush cytology was done during an ERCP from a database with prospectively collected data. We compared cytology results with the final diagnosis as determined by surgical pathologic examination or long-term clinical follow-up. We followed all patients and recorded ERCP-related complications.

RESULTS

Forty-two pancreatic brush cytology samples and 101 biliary brush cytology samples were obtained. The accuracy rate of biliary cytology was 65 of 101 (64.3%) and the accuracy rate of pancreatic cytology was 30 of 42 (71.4%). Overall sensitivity was 50% for biliary cytology and 58.3% for pancreatic cytology. Of 67 patients with pancreatic adenocarcinoma, sensitivity for biliary cytology was 50% versus 66% for pancreatic cytology. Concurrent pancreatic and biliary cytology during the same procedure increased the sensitivity in only 1 of 10 (10%) patients. Pancreatitis occurred in 11 (11%) patients (9 mild cases, 2 moderate cases) after biliary cytology and in 9 (21%) patients (6 mild cases, 3 moderate cases) after pancreatic cytology (p = 0.22). In 10 patients who had pancreatic brush cytology, a pancreatic stent was placed. None of these patients developed pancreatitis versus 9 of 32 (28%) patients in whom a stent was not placed (p = 0.08). Pancreatic cytology samples obtained from the head of the pancreas were correct in 13 of 18 (72%) cases, from the genu in 7 of 7 (100%) cases, from the body in 5 of 9 (55%) cases, and from the tail in 4 of 7 (57%) cases.

CONCLUSION

The accuracy of biliary brush cytology is similar to the accuracy of pancreatic brush cytology. The yield of the latter for pancreatic adenocarcinoma is similar to that of the former. Complication rates for pancreatic cytology are not significantly higher than the rates for biliary cytology. The placement of a pancreatic stent after pancreatic brushing appears to reduce the risk of postprocedure pancreatitis.

Endoscopic management of choledocholithiasis

The first description of endoscopic sphincterotomy 25 years ago spearheaded the widespread use of endoscopic treatment of choledocholithiasis. It is largely accepted that common bile duct stone removal should be endoscopic rather than surgical in patients who have undergone previous cholecystectomy, in the high-risk surgical patient when the gallbladder is still present, in patients with severe acute cholangitis, in selected patients with acute biliary pancreatitis, and in special circumstances for the average risk surgical patient with suspected choledocholithiasis before laparoscopic cholecystectomy. We have summarized a number of endoscopic techniques that are used in the management of bile duct stone disease.

Management of occluded biliary Wallstents

BACKGROUND

Wallstents (Schneider Stent, Inc., USA) used for the palliation of malignant biliary strictures, although associated with prolonged patency, can occlude. There is no consensus regarding the optimal management of Wallstent occlusion.

AIMS

To evaluate the efficacy of different endoscopic methods for managing biliary Wallstent occlusion.

METHODS

A multicentre retrospective study of patients managed for a biliary Wallstent occlusion.

RESULTS

Data were available for 38 patients with 44 Wallstent occlusions, all of which had initial endoscopic management. Twenty four patients had died and 14 were alive after a median follow up of 231 (30-1095) days following Wallstent occlusion. Occlusions were managed by insertion of another Wallstent in 19, insertion of a plastic stent in 20, and mechanical cleaning in five. Endoscopic management was successful in 43 (98%). Following management of the occlusion, bilirubin decreased from 6.0 (0.5-34.3) to 2.1 (0.2-27.7) mg/100 ml (p < 0.05). No complications occurred. The median duration of second stent patency was 75 days (95% confidence interval 43 to 107) after insertion of another Wallstent, 90 days (71 to 109) after insertion of a plastic stent, and 34 days (30 to 38) after mechanical cleaning (NS). The respective median survivals were 70 days (22-118), 98 days (54-142), and 34 days (30-380) (NS). Incremental cost effective analysis showed that plastic stent insertion is the most cost effective option.

CONCLUSION

Although all three methods are equally effective in managing an occluded Wallstent, the most cost effective method appears to be plastic stent insertion.

Palliation of malignant gastric outlet obstruction using an endoscopically placed Wallstent

BACKGROUND

Treatment options for malignant gastric outlet obstruction are limited. Surgical gastrojejunostomy, commonly performed, has significant morbidity and mortality.

METHODS

Over 2 years, we prospectively studied the safety, feasibility, and outcomes for use of a newly designed expandable metal stent (Wallstent Enteral; Schneider, Minneapolis, Minn.) to treat malignant gastric outlet obstruction. Stents 16 to 22 mm in diameter and 60 to 90 mm in length were deployed directly through the endoscope.

RESULTS

Twelve patients (ten women, two men; mean age 59.7 years) underwent stenting. Thereafter, six patients were able to eat a regular diet; three could eat pureed food. In three patients, the procedure was unsuccessful because of multiple obstructions not recognized before stenting (one) and stents deployed too proximally (one) or too distally (one).

CONCLUSIONS

Placement of a newly designed stent through the endoscope is safe and effective palliation for various types of malignant gastric outlet obstruction and significantly improves many aspects of patient quality of life.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts

OBJECTIVE

To provide current information on the risks of endoscopic sphincterotomy for stone.

SUMMARY BACKGROUND DATA

In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients.

METHODS

Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria.

RESULTS

Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm.

CONCLUSION

Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Endoscopic management of acute gallstone pancreatitis

Urgent management of acute biliary pancreatitis has increasingly included early endoscopic intervention. Endoscopic intervention allows effective removal of the offending stone(s) and reestablishment of biliary drainage. Four randomized controlled trials involving more than 800 patients in Western and Asian countries have been completed. This article summarizes the findings of these studies and proposes a preferred approach to the management of acute biliary pancreatitis.

Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy

BACKGROUND

We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using "stricter criteria" to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs).

METHODS

A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using "stricter criteria" (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively.

RESULTS

Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying "stricter criteria" to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs.

CONCLUSIONS

Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using "stricter criteria" to select patients for preoperative ERCP can avoid unnecessary ERCPs.

Therapeutic ERCP in outpatients

BACKGROUND

We evaluated the safety of outpatient therapeutic ERCP since most complications are apparent within a few hours.

METHODS

We reviewed 190 patients undergoing planned outpatient therapeutic ERCP from a cohort of 409 consecutive therapeutic ERCP procedures. Patients were selected for outpatient therapeutic ERCP based on relative good health and overnight accommodation near our institution.

RESULTS

Outpatient therapeutic ERCPs included plastic biliary stent insertion (n = 71), biliary sphincterotomy (45), pancreatic stent insertion (28), Wallstent insertion (19), biliary balloon or catheter dilation (10), pancreatic balloon or catheter dilation (8), biliary stone extraction with prior sphincterotomy (7), pancreatic sphincterotomy (5), and duodenal ampullectomy (1). Admission was necessary in 31 (16%) because of complications in 22 (11.6%) and observation of post-ERCP symptoms in 9. Twenty-six (13%) of these patients were admitted directly from the endoscopy unit recovery room and 5 (3%) from home after a median interval of 24 hours following discharge (range 5 to 48 hours). Reasons for admission were pancreatitis in 17, hemorrhage in 3, cholangitis in 3, endoscopic but not clinical hemorrhage in 4, pain in 4, and vomiting in 1. Of the patients who were admitted from home, 3 had pancreatitis (following sphincterotomy in 1, pancreatic stenting in 1, pancreatic balloon dilation in 1) and 2 had hemorrhage (postsphincterotomy in 1 and ampullectomy in 1). In comparison, of the 219 consecutive inpatients undergoing therapeutic ERCP, 28 (13%) developed complications with 1 (0.4%) death.

CONCLUSIONS

A policy of selective outpatient therapeutic ERCP, with admission reserved for those with established or suspected complication, appears to be safe and reduces health care costs.

Intraductal mucin-hypersecreting neoplasm "mucinous ductal ectasia": endoscopic recognition and management

OBJECTIVES

Intraductal mucin-hypersecreting neoplasm (IMHN), also termed mucinous ductal ectasia, is a rare disorder of the pancreas characterized by distension of the pancreatic duct with mucus. This study attempted to clarify the clinical, radiographic, histological, and treatment approaches to this entity.

METHODS

The medical records, radiological imaging studies, and pathology specimens of eight patients with IMHN seen during a 3-yr period were reviewed. The diagnosis of IMHN was established by findings during ERCP, which included mucin plugging of the papilla, mucin extrusion from the papillary orifice after intraductal injection of contrast medium, mucinous filling defects in the main pancreatic duct, and dilated main and branch pancreatic ducts in the absence of obstructing ductal strictures.

RESULTS

All patients presented with an initial clinical diagnosis of acute or chronic pancreatitis, suspected cystic neoplasm, or biliary obstruction. Noninvasive imaging studies such as transabdominal ultrasonography or CT and laboratory evaluation did not seem to help in defining the disease. Five patients underwent Whipple resection; pathology included papillary ductal hyperplasia in one, dysplastic mucinous epithelium in two, and mucinous cystadenocarcinoma in two. All five patients had associated histological evidence of chronic pancreatitis. All patients are alive and well after 21-53 months without evidence of residual disease.

CONCLUSIONS

IMHN has a wide spectrum of clinical, radiological, and histological features. The indolent biologic behavior and favorable prognosis of IMHN suggest that it is one of the most curable forms of pancreatic malignancy.

Endoscopic cystgastrostomy: role of endoscopic ultrasonography

We report a case of successful endoscopic cystgastrostomy guided by endoscopic ultrasound after an unsuccessful attempt of "blind" drainage. Endoscopic drainage of pseudocysts without endoscopic ultrasonography is an appropriate initial approach by experienced endoscopists in carefully selected patients. In cases in which an intraluminal impression by the pseudocyst is not well visualized, or the conventional approach has not established drainage, endoscopic ultrasound provides excellent localization for the therapeutic maneuver.

Prolapsing gastric polyp, an unusual cause of gastric outlet obstruction: a review of the pathology and management of gastric polyps

Gastric polyps are rare and largely asymptomatic, but attract importance because of their strong potential to progress to carcinoma. Rarely, pedunculated polyps arising in the antrum may prolapse through the pylorus, causing intermittent gastric outlet obstruction. We describe here our experience of four cases collected over a ten-year period, each presenting dissimilarly with this phenomenon. We review the literature referring to the pathogenesis of gastric polyps and their association with malignancy and other disorders. We proceed to discuss the efficacy of barium studies versus gastroscopy in detecting these lesions, the relative roles and merits of endoscopic polypectomy and surgery, and the importance of prolonged follow-up of patients harbouring gastric polyps.

Urinary trypsinogen activation peptides (TAP) are not increased in mild ERCP-induced pancreatitis

Acute pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) occurs in 3-18% of patients undergoing either diagnostic or therapeutic ERCP. We prospectively measured urinary trypsinogen activation peptides (TAP) by an automated anti-TAP enzyme-linked immunoassay among 107 patients 4 h after ERCP to determine whether this measurement helps in the early diagnosis of ERCP-induced pancreatitis. Pancreatitis was documented in 10 of 107 patients (9.3%). All episodes were graded as mild. Urinary TAP was not significantly increased. We conclude that measurement of urinary TAP 4 h after ERCP is not helpful in documenting mild ERCP-induced acute pancreatitis.

Sphincterotomy techniques and risks

Endoscopic sphincterotomy has revolutionized the approach to numerous biliary and pancreatic diseases. The indications, technique, and complications of endoscopic sphincterotomy are covered in detail in this article.

Pancreatic duct stricture caused by islet cell tumors

We report three cases of pancreatic islet cell tumors causing stricture of the main pancreatic duct. The clinical presentation was consistent with episodes of acute pancreatitis or biliary colic. One patient in whom the diagnosis was delayed died of metastatic disease. Islet cell tumors are an important clinical entity that must be considered in the differential diagnosis of pancreatic duct strictures.

Postsurgical bile leaks: endoscopic obliteration of the transpapillary pressure gradient is enough

OBJECTIVES

Bile leaks are a well documented complication of biliary surgery, occurring more frequently with laparoscopic procedures. Endoscopic therapy with a long biliary endoprosthesis traversing the site of the leak is effective. We have evaluated the hypothesis that equalizing biliary and duodenal pressures with a short transpapillary stent is an equally effective therapy for bile leaks.

METHODS

Thirty one consecutive patients presenting over a 52-month period with postsurgical bile leaks were evaluated. Patients had been treated with long endoprostheses (stents or nasobiliary tubes), sphincterotomy, or short transpapillary stents. The success, complication rate, need for additional therapy, and hospitalization time of each therapeutic approach were determined.

RESULTS

Endoscopic therapy was successful in all 25 patients in whom a bile leak could be documented. The clinical success, need for radiological drainage, length of hospitalization, and incidence of pancreatitis were similar for all methods of treatment.

CONCLUSIONS

These results confirm that endoscopic therapy is highly successful in the treatment of postoperative bile leaks and suggest that the mechanism of healing is the equalization of bile duct and duodenal pressures, allowing flow of bile into the duodenum. The endoscopic placement of short transpapillary stents without sphincterotomy is a temporary, effective, and technically simple method of pressure equalization. This should be considered as the primary therapy for most postoperative bile leaks.

Technology assessment status evaluation: balloon dilation of gastrointestinal tract strictures. American Society for Gastrointestinal Endoscopy

Balloon dilation is an acceptable modality for the dilation of stenoses at various sites in the gastrointestinal tract. In the esophagus its reported efficacy and safety is similar to bougienage; in other sites it offers an alternative to surgical treatment, in most cases as the definitive therapy.