Incomplete conventional colonoscopy: magnetic resonance colonography in the evaluation of the proximal colon

BACKGROUND AND STUDY AIMS

The purpose of this study was to evaluate dark-lumen magnetic resonance (MR) colonography prospectively in patients with incomplete conventional colonoscopy.

PATIENTS AND METHODS

Thirty-two patients with incomplete conventional colonoscopy underwent same-day dark-lumen MR colonography on the basis of a standard protocol. The depiction of colorectal diseases was assessed in the following colon segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The reasons for incomplete colonoscopy included high-grade stenosis in 26 patients (four with occlusive cancer, 12 with fibrotic stenosis based on recurrent sigmoid diverticulitis, eight with Crohn's-induced stenosis, and two with nonsteroidal anti-inflammatory drug colonopathy), extreme patient intolerance in one patient, and technical challenges associated with an elongated colon in five patients. The results of MR colonography were compared with the findings of the initial conventional colonoscopy, the histopathological outcome, and follow-up colonoscopy when possible.

RESULTS

All high-grade stenoses were confirmed on MR colonographic data sets. Of the 26 patients with high-grade stenosis, 19 underwent surgery with histopathological confirmation of the initial diagnosis. Follow-up colonoscopy was carried out in 14 patients with surgically treated high-grade stenosis. In six of these 14 patients, nine polyps identified at the initial MR colonography were confirmed and removed during a postoperative conventional colonoscopy. Two polyps (5 mm and 8 mm in diameter) identified on postoperative conventional colonoscopy had not been seen preoperatively at MR colonography. One polyp seen on MR colonography was not identified in the follow-up colonoscopy.

CONCLUSION

Dark-lumen MR colonography is a feasible and useful method of evaluating the entire colon in patients with incomplete conventional colonoscopy.

Follow-up after endoscopic snare resection of duodenal adenomas

BACKGROUND AND STUDY AIMS

Premalignant duodenal polyps are considered to be rare. Recurrence after local excision is reported to be frequent, so many authors propose radical surgical treatment of these tumors. The aim of this study was to determine the long-term outcome after endoscopic resection of duodenal adenomas.

PATIENTS AND METHODS

Between January 1990 and April 2003 we retrospectively evaluated a group of patients who presented with nonampullary duodenal villous tumors but who did not have a polyposis syndrome.

RESULTS

Duodenal polyps were diagnosed in 21 patients during routine endoscopy during the study period. Of these, 18 patients (6 men, 12 women; median age 67, range 50 - 81), with a total of 20 duodenal adenomas, were enrolled into the study. The median size +/- SD of the tumors was 27.5 +/- 12 mm (range 8 - 50 mm). Of these 20 tumors, 18 adenomas were tubulovillous, one was tubulous and one was villous. Nineteen polyps were treated by snare excision and one adenoma was treated with argon plasma coagulation alone. Argon plasma coagulation was applied to polyps in six patients after snare excision during this initial treatment phase. The success rate for endoscopic adenoma removal after a 3-month interval was 55 %. After a median follow-up period of 71 months (range 22 - 151 months), 12 patients remained in remission. Local recurrences of the lesion occurred in five patients (25 %) and these were re-treated. None of the patients developed carcinoma during the follow-up period.

CONCLUSIONS

Endoscopic snare excision of duodenal adenomas is an effective mode of treatment but an endoscopic surveillance program is mandatory in order to detect and treat recurrence.

[Interventional endoscopy for benign and malignant bile duct strictures]

During the past years several endoscopic and interventional techniques have been developed for the treatment of bile duct strictures and have had a strong impact on therapeutic regimens. Benign stenoses of the bile duct are mainly caused by cholecystectomy or liver resection or by inflammatory diseases. Insertion of an endoprosthesis insertion or balloon dilation is clinically successful in 60 to 90 % of these patients and will result in adequate opening of the stricture. To date, only bile duct stenosis in chronic pancreatitis are not improved satisfactorily by endoscopy. The insertion of an endoprosthesis is a cornerstone in the treatment of malignant obstructive jaundice in patients with cancer. Several comparative studies have demonstrated the advantages of self-expanding metal stents (SEMS) over plastic prostheses in terms of patency. A selective use of SEMS is mandatory, as the costs for SEMS are high and many patients with malignant jaundice will die with their first plastic prosthesis in situ without stent occlusion. In patients with hilar cholangiocarcinoma, the combination of photodynamic therapy and endoprosthesis insertion might result in a survival advantage. The use of bioabsorbable stent materials or coating of the stent with antiproliferative drugs will improve the treatment results in the future.

Does Cytokeratin7/20 immunoreactivity help to distinguish Barrett's esophagus from gastric intestinal metaplasia? Results of a prospective study of 75 patients

Barrett's esophagus is a recognized risk factor for the development of esophageal dysplasia and carcinoma. Unfortunately, gastric incomplete intestinal metaplasia arising in Short Segment Barrett's esophagus can be indistinguishable histologically on hematoxylin/eosin stains. Distinct patterns of CK 7 and CK 20 immunohistochemical expression have been demonstrated to be both highly sensitive and specific for Barrett's esophagus, but have not been found in gastric metaplasia. The aim of our study was to test whether immunostaining with CK 7/20 helps to distinguish between Barrett's epithelium and gastric incomplete metaplasia. Cases of long segment Barrett's esophagus, short segment Barrett's esophagus, and cases with a normal gastroesophageal junction, as well as specimens with gastric antral intestninal metaplasia, were examined: three patterns were defined. Barrett's pattern (superficial CK 20 staining; superficial and crypt CK 7 staining); gastric pattern (superficial and crypt staining of both markers); other patterns (different from Barrett and gastric types). Seventy-five patients were enrolled in this study, 26 with long segment Barrett's esophagus, 21 with short segment esophagus, 13 with intestinal metaplasia of the cardia, and 18 with antral intestinal metaplasia. The Barrett pattern showed a high specificity of 97%, but a sensitivity of only 30% in patients with short segment Barrett esophagus. Our results do not confirm the hypothesis that CK 7/20 immunostaining can be used for a reliable differentiation between incomplete intestinal metaplasia and Barrett's epithelium.

Die Diagnose einer Leberzirrhose: Ein Vergleich der Wertigkeit von Standardlaparoskopie, Minilaparoskopie und Histologie

BACKGROUND

The superiority of laparoscopy with guided biopsy over biopsy alone is established. It is still uncertain if this is also true for midi-/ and mini-laparoscopy.

AIM

The aim of this study was to determine the diagnostic gain of laparoscopic-guided biopsy for standard laparoscopy and the use of midi-/mini-laparoscopies. Characteristics of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis.

METHODS

In a consecutive series of 425 patients clinical, laparoscopic and histological findings were investigated. The length and fragmentation of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis.

RESULTS

The sensitivity of laparoscopy in the diagnosis of cirrhosis was 96 %, that of histology 68 %. The sensitivity of histology alone was especially low in macronodular cirrhosis. The sensitivity of both laparoscopy and histology improved from Child A to C. When cirrhosis was apparent, liver biopsies were shorter and more frequently fragmented. However, the diagnosis of cirrhosis was independent of these parameters.

CONCLUSION

Mini-laparoscopy may replace standard laparoscopy and appears to be superior compared with histology alone.

Patient acceptance of diagnostic laparoscopy

PURPOSE

To assess patient acceptance of diagnostic conventional laparoscopy and minilaparoscopy under sedoanalgesia.

MATERIALS AND METHODS

120 consecutive patients undergoing diagnostic laparoscopy were enrolled prospectively in this study. Within the first week after diagnostic laparoscopy the patients were asked to answer a total of eight questions with regard to the acceptance of the procedure.

RESULTS

The inconvenience of laparoscopy was assessed with a mean of 1.6 on a scale from 0 to 10 (0 = no inconvenience, 10 = very unpleasant). The discomfort in the two days following laparoscopy were graded with a mean of 2.1 on a scale from 0 to 10 (0 = no inconvenience, 10 = very unpleasant). There was no difference between conventional laparoscopy and minilaparoscopy. Only 10% of the patients described laparoscopy more inconvenient in comparison to diagnostic gastroscopy, whereas 29% of the patients assessed diagnostic gastroscopy more inconvenient.

CONCLUSIONS

Diagnostic laparoscopy under sedoanalgesia is a very well tolerated procedure. There is no difference between conventional laparoscopy and minilaparoscopy.

Diagnostic laparoscopy

Each diagnostic procedure needs to be viewed in the context of all the other available diagnostic tools, and therefore has to be reevaluated periodically. This is also true of diagnostic laparoscopy, whether performed by gastroenterologists in patients under sedoanalgesia or by surgeons in patients under general anesthesia. Publications during the previous year have shed light on many important issues. Despite its greater expense, fluorescence laparoscopy may have advantages over white-light laparoscopy in the diagnosis of small tumor seeding. The unchanged superiority of laparoscopy over other imaging modalities for detecting small superficial liver metastases and peritoneal seeding has been clearly demonstrated. Whether cytological investigation of peritoneal washing can add relevant information to laparoscopy remains a matter of debate. Diagnostic laparoscopy before surgery has proved to be effective in many fields, including traumatology. The use of diagnostic laparoscopy in certain clinical circumstances, such as the early postoperative period after major cardiac surgery using extracorporeal circulation, appears promising. A transgastric approach to the peritoneal cavity for diagnostic and therapeutic purposes, the feasibility of which has been demonstrated in a porcine model, is an exciting innovation with as yet unforeseeable implications.

Komplikationen der internistischen Laparoskopie

BACKGROUND AND OBJECTIVE

The frequency of diagnostic laparoscopy performed by internists has increased for several years once again -- especially performed as minilaparoscopy. A determination of the value of diagnostic laparoscopy is possible only with knowledge of the complication rate.

PATIENTS AND METHODS

We reviewed a consecutive series of 675 laparoscopies (422male, 253 female, age 15 - 85 ) from 1996 to 2003 in our clinic. Possible risk factors for complications were analyzed.

RESULTS

Minor complications occurred in 35/675 (5,2 %) laparoscopies, major complications in 8/675 (1,1 %) laparoscopies. There was no significant difference between conventional and minilaparoscopies. The existence of Child C cirrhosis was the only significiant risk factor identified for the occurrence of a major complication.

CONCLUSION

Both conventional and minilaparoscopy have an acceptable rate of complications. When Child C cirrhosis is present, laparoscopy should be restricted to very few patients, as the complication rate is elevated in this condition.

Long-term outcome of percutaneous transhepatic drainage for benign bile duct stenoses

PURPOSE

The occurrence of benign bile duct stenoses is mostly associated with prior biliary surgery, pancreatic diseases or sclerosing cholangitis. It remains a challenging problem for gastroenterologists and surgeons, especially in case the endoscopic approach is not possible. The exact role of percutaneous transhepatic stenting for these patients has not been clearly defined yet.

MATERIAL AND METHODS

36 patients with symptomatic benign bile duct stenoses or strictures after surgery underwent percutaneous transhepatic stenting and were studied prospectively. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the drainage in the long-run.

RESULTS

The primary success rate of percutaneous transhepatic biliary drainage (PTBD) was 92% (33/36 patients). All patients presented improvement of jaundice and cholestasis. Relief of the stricture and clinical improvement was achieved in 72% (26/36) of patients after a median stenting time of 14.5 (6-34) months. 5.5% (2/36) required further stenting due to a persistent stricture. A clinical recovery without radiological stricture regression after stenting demonstrated 22% (8/36) of patients. Long-term failures were noted in 27% (10/36) of patients after a median follow-up of 48 months.

CONCLUSIONS

Percutaneous transhepatic stenting of symptomatic benign biliary strictures is safe and highly effective in achieving adequate internal bile drainage. There seems to be a therapeutic benefit not only for short-term interventional treatment but also as a sufficient long-term therapeutic alternative to surgery with tolerable complication rates.

Predictions and associations of cholecystectomy in patients with cholecystolithiasis treated with extracorporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is effective in the treatment of symptomatic cholecystolithiasis in well-selected patients. We analyzed the predictors of cholecystectomy in a large series of gallstone patients after ESWL. This was a retrospective follow-up cohort-study of consecutive patients undergoing ESWL for symptomatic cholecystolithiasis over a 9-year period. It was possible to analyze a total of 297 patients; there were 211 women and 86 men, with a mean age of 52 years (range, 8-81 years). Patients that had been cholecystectomized after ESWL were compared to patients with their gallbladder still in situ and determinants of cholecystemctomy in terms of clinical, stone, and gallbladder parameters and symptoms analyzed. The mean duration of follow-up was 99 months (range, 27-134 months). During follow-up, 106 (36%) patients underwent a cholecystectomy at a mean of 34 months (range, 0-127 months) after ESWL. Histological data showed a normal gallbladder wall in only 4 cases; 101 examinations revealed some kind of (chronic) inflammation, which was not different from histological gallbladder results in patients without prior lithotripsy. Three gallbladder polyps were found, but no carcinoma. Cholecystectomy after ESWL of gallbladder stones was strongly associated with persitent and/or renewed biliary symtoms. Nevertheless, only three of four patients became asymptomatic after CE. Thus, ESWL proved to be a valuable organ-preserving alternative to cholecystectomy in selected patients.

[Scrotal abscess with inguinal lymph node swelling in an 86-year-old man]

HISTORY AND ADMISSION FINDINGS

An 86-year-old patient presented to our clinic with increasing redness and swelling of the right scrotum and inguinal lymphadenopathy. Five and a half years before admission carcinoma of the bladder (pT1,G2) had been diagnosed and was treated with several transurethral endoscopic resections as well as repeated instillations of Bacille Calmette-Guérin (BCG) into the bladder.

INVESTIGATIONS

Orchiectomy on the right side was performed. Histological analysis revealed a granulomatous inflammation consistent with a mycobacteriosis. Mycobacterium bovis BCG could be isolated from several sputum and urine specimens of the patient.

DIAGNOSIS, TREATMENT AND COURSE

Tuberculostatic therapy was started soon after surgery. After seven weeks of treatment no more mycobacteria could be detected in sputum and urine control specimens. At a follow up after twelve months there was no evidence of recurrent disease.

CONCLUSION

We describe the late manifestation of a BCG infection including the lungs and the urogenital tract. This is a rare complication with potentially serious consequences and requires rapid diagnosis and urgent treatment by a multidisciplinary team.