Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

[Colorectal Carcinoma with Suspected Lynch Syndrome: A Multidisciplinary Algorithm]. / Kolorektales Karzinom bei V. a. Lynch-Syndrom: ein interdisziplinärer Algorithmus.

Lynch syndrome is the most frequent hereditary cancer syndrome, accounting for approximately 3-5 % of all colorectal cancers. In addition, it is the most frequent predisposing hereditary cause of endometrial cancer and is also associated with gastric cancer, ovarian cancer, cancer of the urinary tract as well as several other cancers. In clinical practise Lynch syndrome is frequently not detected and many clinicians admit uncertainties regarding diagnostic procedures. Also, counselling of patients is considered difficult regarding therapeutic - especially prophylactic surgical and chemopreventive options and recommendations. Based on a review of available literature we discuss optimized strategies for improved detection of suspected Lynch syndrome patients. The aim of this review is to establish a clinical algorithm of how to proceed on a diagnostic level and to discuss surgical options at the time of a colorectal cancer. In order to identify patients with Lynch syndrome, family history should be ascertained and evaluated in regards to fulfilment of the Amsterdam-II- and/or the revised Bethesda criteria. Subsequently immunohistochemical staining for the mismatch-repair-genes, BRAF testing for MLH1 loss of expression, as well as testing for microsatellite instability in some, followed by genetic counselling and mutation analysis when indicated, is recommended. Pathological identification of suspected Lynch syndrome is readily feasible and straightforward. However, the need of performing these analyses in the tumor biopsy at the time of (gastroenterological) diagnosis of CRC neoplasia is essential, in order to offer patients the option of a prophylactically extended surgery and - as recommended in the German S3 guidelines - to discuss the option of a merely prophylactical hysterectomy and oophorectomy (if postmenopausal) in women. Close cooperation between gastroenterologists, pathologists and surgeons is warranted, so that patients may benefit from options of extended or prophylactically extended surgery at the time of diagnosis of a colorectal primary. Patients nowadays must be involved in informed decision-making regarding prophylactic or extended prophylactic surgery at the time of a colorectal primary. To date, however, limitations in daily clinical practise, the failure to assess family history and the lack of awareness of this important hereditary syndrome is the major asset leading to severe underdiagnosis and putting to risk the indexpatients themselves and their families to (metachronous) CRC and the associated extracolonic cancers. If at all tumors of patients fulfilling Bethesda criteria will be analysed for MSI in the surgical specimen and therefore Lynch syndrome patients are not given the opportunity to opt for extended surgery. In clinical experience the postoperative MSI-analysis is inconsistently performed - even if the Bethesda criteria are fulfilled - and in case of suspected Lynch syndrome genetically counselling is not consistently recommended. Therefore affected cancer patients are left unaware of their increased genetic risk and in average 3 high-risk gene carriers per family miss the opportunity to actively engage in the recommended screening program.

[Transcutaneous sonography of the gastroesophageal junction in prospective comparison with endoscopy]. / Die transkutane Sonographie des gastroösophagealen Uberganges im prospektiven Vergleich mit der Endoskopie.

BACKGROUND AND OBJECTIVE: Despite its practical value, few data exist on assessing the gastrooesophageal junction by transcutaneous sonography (TS). A prospective study was undertaken to compare TS and endoscopy (ES) of this region. PATIENTS AND METHODS: Between 1 September, 1994 and 31 May, 1995 TS of the lower oesophagus was followed by ES of this region in 211 patients (116 women, 95 men; mean age 58.9 [14-90] years). None had previously been examined by ES or radiological contrast study of the oesophagus and stomach. Endoscopist and sonographer were blinded to each other's findings. The ability to visualize the abdominal oesophagus by TS and to recognize abnormalities were compared with ES results, both quantitatively and descriptively. RESULTS: The diaphragmatic course of the terminal oesophagus or (where present) a gastric hernia were well visualized by TS in all 211 patients. In 78 patients with normal results on TS and ES the visible length of the oesophagus was 3.3 +/- 0.8 cm, with a wall thickness of 4.5 +/- 1.0 mm (mean +/- standard deviation). In seven of eight patients with echo-poor wall thickness between 9 and 27 mm, suspected of being malignant, ES revealed neoplasm of the terminal oesophagus or cardia (six T2 to T4 carcinomas; one MALT lymphoma). One patient had involvement of the oesophagus and cardia as part of Crohn's disease. No case of malignancy remained unrecognized by ES. 64 of 77 hiatal hernias diagnosed by ES were also recognized by TS. Hiatal hernia was falsely diagnosed by TS in four patients. Oesophageal varices were correctly identified by TS in three of eight patients, as was one case of achalasia. CONCLUSION: Transcutaneous sonography is a good screening method with a high sensitivity for changes in wall architecture and it provides indications for further selective diagnostic procedures.

Ultrasound-guided extracorporeal shock wave lithotripsy of pancreatic ductal stones: six years' experience.

Extracorporeal shock wave lithotripsy (ESWL) and endoscopic sphincterotomy (EST) was performed in 35 patients suffering from pancreatic duct stones. Calculi disintegration and resolution of obstruction were achieved in all cases. Completely stone-free ducts were achieved in 16 patients (46%) while some peripheral asymptomatic stone material remained in 19 (54%). Dilation of the main pancreatic duct was reduced in 29 patients (83%). Twelve patients (34%) became completely asymptomatic and 17 (49%) reported a marked reduction of pain. Pancreatogenic steatorrhea ceased and 18 patients (51%) gained weight. Pathological glucose tolerance returned to normal in one patient. No major complications were observed. The combination of ESWL and EST is a successful, nonoperative, new treatment in pancreatic stone disease.

[Extracorporeal shockwave lithotripsy (SWL) of common bile duct calculi without previous endoscopic papillotomy]. / Extrakorporale Stosswellenlithotripsie (ESWL) von Gallengangsteinen ohne vorherige endoskopische Papillotomie.

In 17 patients (8 men, 9 women; mean age 61.5 years) with problematic bile-duct stones (papilla endoscopically inaccessible, residual bile-duct stones after recent laparoscopic cholecystectomy or age below 25 years) the chances of successful treatment by ESWL without sphincterotomy were examined. In 15 patients with solitary stones measuring up to 14 mm "pulverization-ESWL" produced complete freedom from stones after spontaneous migration of fragments through the intact papilla. Only two patients with two ductal stones measuring up to 15 mm still had residual fragments in the bile duct after treatment. The ideal stone for ESWL without sphincterotomy is thus the solitary bile-duct stone measuring up to 14 mm. Before performing a high-risk sphincterotomy, before re-operation and in young patients one should therefore always examine whether ESWL without sphincterotomy is indicated.

[Endoscopic therapy in acute hemorrhage caused by duodenal diverticula]. / Endoskopische Therapie einer akuten Blutung aus einem Duodenaldivertikel.

HISTORY AND CLINICAL FINDINGS: A 70-year-old previously healthy woman had been feeling nauseous for one day and had passed several liquid tarry stools. A barium meal previously done as an out-patient had shown a duodenal diverticulum 3.5 cm in diameter with marked contrast-medium retention. Her general condition was impaired, her skin pale and cold, while heart rate and blood pressure were normal. Rectal examination confirmed tarry stool and thus suggested upper gastrointestinal bleeding, the contrast-medium retention pointing to the duodenal diverticulum as a likely site. INVESTIGATIONS: Haemoglobin concentration was 9.1 g/dl, the haematocrit 26.6%. Total protein was reduced to 4.4 g/dl. Esophagogastroduodenoscopy (performed about 10 hours after the barium meal) showed erosion at the duodenal bulb and contrast retention in the juxtapapillary diverticulum, but no acute bleeding was discovered. TREATMENT AND COURSE: Repeat endoscopy on the following day revealed acute bleeding (Forrest stage Ia) from an arterial stump in the diverticulum. It was stopped with local injection of adrenaline (6 ml of 1:10,000 solution) and fibrin glue, but the injections had to be repeated twice. Another endoscopy 30 days after the first showed merely a mucosal scar. CONCLUSION: Early endoscopy enables one to make the diagnosis and to provide minimally invasive treatment of bleeding from a duodenal diverticulum.

[Non-contact argon gas coagulation in flexible endoscopy of the gastrointestinal tract: in vitro studies and initial clinical experiences]. / Kontaktlose Argon-Gas-Koagulation in der flexiblen Endoskopie des Gastrointestinaltraktes: In-vitro-Untersuchungen und erste klinische Erfahrungen.

Diathermocoagulation is indispensable in interventional endoscopy. The argon beam coagulation represents an innovative electrocoagulation method, where high-frequency alternating current is conducted to tissues by ionized argon gas without contact. Before clinical application we performed in vitro studies to evaluate depth and diameter of tissue coagulation of fresh resectations from stomach, small intestine and colon. Power and gas flow were graduated in five steps from 40 to 155 W and from 2 to 7 l/min respectively. Coagulation time (1 s-10 s) and angle of the probe in relation to tissue surface (45 degrees, 90 degrees) were varied. The maximal depth of necrosis was 2.4 mm, the maximal diameter 1.1 cm. There was no perforation found, even in critical areas like colon and duodenum. Accordingly argon beam coagulation was performed in 41 consecutive patients. The power and gas flow were varied in two stages between 40 and 75 watts and 2 and 3 l/min respectively. Coagulation time and angle of the probe were handled individually. In 32 of the 33 patients with bleeding from angiodysplastic lesions or polypectomy sites, with oozing of blood from erosions or ulcers or with bleeding due to vascular penetration by tumors definitive hemostasis was achieved in one to two sessions. In all of the four patients with residual sessile adenoma tissue complete removal was possible. Esophageal patency was restored in all four patients with stenosing tumors. In one patient with angiodysplasia of the cecal pole an asymptomatic accumulation of gas in the submucosa was observed which cleared spontaneously. In two patients with extensive esophageal carcinoma there was a transitory--also asymptomatic--accumulation of gas in the mediastinum and peritoneal cavity but no reference to perforation. The non-contact argon electrocoagulation is in gastrointestinal endoscopy an effective and non-expensive alternative to laser-technique.

[ESWL-therapy of pancreatic duct calculi]. / ESWL-Therapie von Pankreasgangsteinen.

In 23 patients suffering from pancreatic duct stones, extracorporeal shock wave lithotripsy (ESWL) was performed in combination with endoscopic sphincterotomy (EST). Calculi-disintegration and resolution of obstruction was achieved in all cases. Completely stone-free ducts were achieved in 7 patients, some peripheral asymptomatic stone material remained in 16. 8 patients became completely asymptomatic, 11 reported a marked reduction of their pain. 15 patients gained weight. No major complications were observed. ESWL combined with EST is a successful non-operative new treatment option in pancreatic stone disease.

[Chronic mesenteric ischemia--a rare differential diagnosis of Crohn disease]. / Chronische Mesenterialischämie--eine seltene Differentialdiagnose des Morbus Crohn.

A 59-year-old patient was treated for six years assuming Crohn's disease. Recurrent segmental colitis, spontaneous perforation of the jejunum and chronic weight loss were suggestive of this diagnosis despite a missing typical histology, even in the resected part of jejunum. Only unspecific inflammatory changes were found. Typical angina abdominalis occurred late. Angiography showed a complete occlusion of the coeliacaxis and both mesenteric arteries. Only the slow progress of occlusion of the visceral arteries with extensive collateral circulation from iliacal arteries explains the absence of severe bowel infarction. After aortomesenteric bypass operation the patient is without any complaint.

[Extracorporeal shockwave lithotripsy of gallbladder calculi]. / Extrakorporale Stosswellenlithotripsie von Gallenblasensteinen.

Shockwave disintegration of gallbladder stones with lythic therapy of residual fragments is successful when all criteria of patient- and stone-selection, shockwave application and lysis are fulfilled. The "Four-S-stones" proved to be the best candidates: solitary, symptomatic, sonolucent in a sufficiently contractile gallbladder. The rate of complications is low. Stone recurrence rate (10 to 15% after three years) is much lower as in previous studies using lythic therapy only. The new therapeutic approach to gallbladder stone disease with fragmentation, spontaneous fragment-clearance and lysis of residual fragments is--as the only truly non-invasive procedure--for 10 to 20% of the patients an alternative equal to operation.

[Extracorporeal shockwave lithotripsy of bile duct calculi]. / Extrakorporale Stosswellenlithotripsie von Gallengangsteinen.

Shockwave therapy of bile duct stones is not dependent on difficult preconditions concerning stone-volume and -composition or subsequent lythic therapy. Its main indication is failure of endoscopic sphincterotomy (EST). Shockwave lithotripsy of bile duct stones--which may even be carried out even instead of EST in specific cases--is with a success rate of 80 to 95% as effective as shockwave lithotripsy in urology.

[Extracorporeal shock wave lithotripsy of an impacted gallstone in cholecysto-antral fistula]. / Extrakorporale Stosswellenlithotripsie eines impaktierten Gallensteins bei cholezystoantraler Fistel.

The endoscopic examination of a patient with gastrointestinal bleeding unexpectedly revealed a cholecysto-antral fistula with incipient penetration of a gallstone into the stomach (and presumably intermittent bleeding from the fistula rim). As endoscopic extraction was not possible and the stone impacted in the fistula was visible in the ultrasound scan extracorporeal shock-wave lithotripsy was carried out. An electrohydraulic lithotripter was used and 1,913 shock waves were applied at a maximum of 26,000 volts. In a single treatment session the stone was disintegrated completely into fragments small enough for spontaneous elimination. No sedative or analgesic medication was required. There was no evidence of any complications or side-effects following the ESWL.

Ultrasonography and biliary extracorporeal shock-wave lithotripsy.

The results of shock-wave treatment of gallbladder stones depend to a very high degree on the quality and expertise of ultrasonography applied before, during, and after shock-wave disintegration of the stones. Ultrasonography is decisive in evaluating the inclusion criteria; it is the method of choice for directing the shockwave energy at the stones and monitoring the disintegration process. It is the only diagnostic modality to really demonstrate the gallbladder being free from stones.

[Extracorporeal shockwave lithotripsy of problem bile duct calculi]. / Extrakorporale Stosswellenlithotripsie von Problemgallengangssteinen (ESWL).

ESWL is a new gentle, very effective, poor-risk technique in treatment of extrahepatic problematic bile-duct stones. This method might substitute surgical choledochotomy to a great extent. ESWL is a new therapeutic alternative to achieve nonoperative freedom of stones or, at least, to treat biliary obstruction in intrahepatic bile-duct stones, which are not treatable by endoscopic operative methods.

[Sonography and biliary extracorporeal shockwave lithotripsy]. / Sonographie und biliäre extrakorporale Stosswellenlithotripsie.

Ultrasound is an indispensable tool for preliminary diagnosis ('filter function'), during treatment ('monitoring function') and in the followup examinations ('follow-up function') after shock wave lithotripsy of gallstones. It permits rapid and reliable assessment of the therapeutic outcome and early identification of complications, which experience to date has shown to be rare.

[Sonography and biliary extracorporeal shockwave lithotripsy (ESWL)]. / Sonographie und biliäre extrakorporale Stosswellenlithotripsie (ESWL).

Ultrasound is an indispensable tool for preliminary diagnosis ("filter function"), during treatment ("monitoring function") and in the follow-up examinations ("follow-up function") after shock-wave lithotripsy of gallstones. It permits rapid and reliable assessment of the therapeutic outcome and early identification of complications, which present-day experience has shown to be rare.

[Ultrasound morphology of gallstones]. / Sonographische Gallensteinmorphologie.

Using a subtile examination technique genuine information can be obtained from the interior of a gallstone--at least to a depth of 15 mm. This information should provide an indication of the homogeneous (crystalline) or inhomogeneous (non-cholesterol) structure of the stone. Further systematic use of differentiating gallstone ultrasonography could become a useful additional decision making criterion for selection of gallstones suitable for conservative treatment.

[Biliary extracorporeal shock-wave lithotripsy]. / Biliäre extrakorporale Stosswellenlithotripsie (ESWL).

Since 1985/86, more than 200 patients with problematic intra- and extrahepatic bile duct stones were treated with ESWL. Results are excellent and comparable with ESWL's success-story in urinary stone disease, abandoning widely open surgery for bile duct stones. In gallbladder-stone treatment, ESWL (always combined with bile acid litholysis) is only promising or successful in a carefully selected subset (10 to 15%) of all symptomatic patients (with good gallbladder contractility, limited stone volume and sonolucent stones).