Closure of a benign broncho-oesophageal fistula by endoscopic injection of bovine collagen, cyanoacrylate glue and gelfoam.

Endoscopic application of adhesives and occlusives has been used to treat both benign and malignant tracheo-oesophageal fistulae. Successful management of a large benign broncho-oesophageal fistula by endoscopic reduction of the opening with injected bovine collagen and occlusion of the lumen with gelfoam and cyanoacrylate plugs reported.

Haemorrhage due to erosion of a metal biliary stent through the duodenal wall.

Self-expanding, metal biliary stents have recently been used in malignant obstructive jaundice as their large diameter reduces the likelihood of occlusion by biliary sludge and bacterial biofilm. However, there is a significant rate of late obstruction by tumour overgrowth and infiltration through the wire mesh. Our case of stent erosion through the duodenal wall, resulting in massive haemorrhage, is a hitherto unreported serious complication of the Wallstent (Schneider). Its occurrence may be suggested by continuous upper abdominal pain, gastrointestinal bleeding or late expansion of the stent.

Successful treatment of two patients with gastric antral vascular ectasia 'watermelon stomach' using endoscopic Nd-YAG laser therapy.

Two patients with gastric antral vascular ectasia--'watermelon stomach'--successfully treated with endoscopic Nd-YAG laser are described. This condition is an uncommon cause of iron deficiency anaemia due to chronic blood loss and is usually managed by antrectomy. Endoscopic therapy with Nd-YAG laser offers an effective and safe alternative to surgery particularly in the elderly poor-risk patient.

Nd:YAG laser therapy for colorectal polyps.

Adenomatous polyps are the precursors of most colonic cancers and should be removed and recovered for histological analysis. Removal by endoscopic laser photocoagulation offers a safe alternative to surgery. We report our experience of managing selected colonic polyps by neodymium:yttrium aluminum garnet (Nd:YAG) laser.

Could activated charcoal be used to adsorb intraduodenal methyl tert-butyl ether spillage during its use in the dissolution of gallstones?

Methyl tert-butyl ether (MTBE) is becoming more frequently used in the non-surgical removal of cholesterol gallstones. However, during its introduction into the biliary tract, some spillage can occur and subsequent systemic absorption has been reported to lead to a variety of side effects. We have carried out in vitro experiments to assess the ability of activated charcoal to adsorb MTBE. A 10% aqueous suspension of activated charcoal was mixed with MTBE and its adsorption was estimated subsequently by gas chromatography. Adsorption varied from 38% at an activated charcoal: MTBE ratio of 1:1, to 96% at a ratio of 8:1. Only 3.2% of the adsorbed MTBE could be desorbed by resuspending the sedimented activated charcoal: MTBE complex in an equivalent volume of fresh distilled water. The results indicate that a single dose of activated charcoal (greater than 12 g) may be effective in minimizing systemic absorption of MTBE spilt during gallstone dissolution.

Endoscopic Nd-YAG laser therapy for palliation of upper gastrointestinal malignancy.

Endoscopic laser therapy with the neodymium-yttrium-aluminium-garnet (Nd-YAG) laser has been shown to provide good palliation of upper gastrointestinal obstruction caused by malignancy, and to be associated with a low morbidity and a low mortality rate. Fifty patients with inoperable upper gastrointestinal malignancy have been treated with this method: 22 had oesophageal carcinoma, 16 adenocarcinoma at the cardio-oesophageal junction, two carcinoma of the antrum and 10 recurrent tumours at the site of previous anastomoses. The main symptoms were dysphagia in 40 and vomiting in seven; three others had recurrent bleeding. An Nd-YAG laser was used to photocoagulate the tumours using power levels of 50-100 W and an average energy output per treatment of 10,000 J. Thirty patients (75%) with dysphagia improved with treatment but vomiting was relieved in only three of the seven patients with this symptom. Complications were infrequent--two patients (4%) developed a perforation and one had a respiratory arrest which was reversible. The 30-day mortality rate was 14% with 2% being related to the procedure. Endoscopic Nd-YAG laser therapy is an acceptable alternative to the more established methods of palliation such as surgical or endoscopic intubation.

Primary sclerosing cholangitis: clinical and immunopathological review of 21 cases.

Twenty-one patients with primary sclerosing cholangitis were seen during 1979-87. The mean age at onset of disease was 51.7 years (range: 13-78 years) with a male: female ratio of 2.5:1. Six (29%) were asymptomatic at the time of diagnosis. Eleven patients (52%) had ulcerative colitis. Cholangiography demonstrated abnormalities limited to the intrahepatic ducts in 10 cases, with both intrahepatic and extrahepatic involvement in 11. Histological features on liver biopsy included: portal tract inflammation and cholestasis in all; paucity of bile ducts in 56%; piecemeal necrosis in 19% and cirrhosis in 6%. Circulating autoantibodies and elevated serum immunoglobulins were found in half of the patients and HLA-B8 was detected in 53%. A deficiency of circulating CD3 and CD8 cells was not found in the 12 patients tested. The mean follow-up was 51 months (range: 3-180 months). Three patients died from non-hepatic causes and another has received liver transplantation. A Kaplan-Meier curve predicted 70% survival at 72 months.

Cannulation of the cystic duct and gallbladder.

A hydrophilic polymer-coated, steerable guide wire with graduated stiffness can be used to cannulate the gallbladder. A catheter can then be placed in the gallbladder. This technique was successful in 9 out of 12 patients and took less than 10 minutes from the time of introduction of the guide wire until the catheter was placed in the gallbladder. There was one episode of perforation which was managed conservatively and two failures of cannulation. This technique will open up a new era in diagnostic and therapeutic endoscopy.

Healing and relapse of severe peptic esophagitis after treatment with omeprazole.

We have studied the response of erosive or ulcerative esophagitis to treatment with omeprazole and its subsequent relapse on cessation of therapy in 196 patients. In the first phase of the study omeprazole (20 or 40 mg daily) was compared with placebo in 64 patients. After 4 wk there was endoscopic healing in 81% (25 of 31) of omeprazole-treated patients and in only 6% (2 of 32) of placebo-treated patients. Endoscopic healing of esophagitis was accompanied by symptom relief and histologic healing of ulceration. In the second (dose finding) phase a further 132 patients were randomized to omeprazole (20 or 40 mg daily) and endoscopic healing was assessed. In patients with the mildest grade of ulcerative esophagitis (grade 2), healing occurred at 4 wk in 87% receiving 20 mg and in 97% receiving 40 mg. In patients with grade 3 esophagitis, 67% (20 mg) and 88% (40 mg) were healed. Less than half the patients with grade 4 esophagitis (Barrett's ulcers or confluent ulceration) healed with either 20 mg (48%) or 40 mg (44%). Regression analysis in the 164 omeprazole-treated patients showed no evidence that healing was influenced by factors other than severity of esophagitis at entry and omeprazole dose. In phase 3 of the study the rate of endoscopic relapse was determined in 107 endoscopically healed patients after stopping omeprazole. Erosive or ulcerative esophagitis recurred in 88 of 107 (82%) by 6 mo. Neither initial dose, grade of esophagitis, nor smoking was shown to influence relapse rate. Omeprazole is a highly effective treatment for peptic esophagitis. The 40-mg/day dosage produces endoscopic healing slightly more quickly than the 20-mg/day dosage, and the initial endoscopic gradings are of prognostic value. Relapse occurs rapidly when treatment is stopped.

Transpapillary iridium-192 wire in the treatment of malignant bile duct obstruction.

Twenty four patients with malignant bile duct obstruction were treated with intraluminal radiotherapy using iridium-192 wire inserted through an endoscopically placed nasobiliary catheter. Biliary drainage after treatment was maintained by an endoprosthesis. The median dose of intraluminal radiotherapy was 6000 cGy; two patients with cholangiocarcinoma were given a second course because of disease extension; four patients with pancreatic carcinoma received additional external irradiation (3000 cGy). There was one early death from a cerebrovascular accident (30 day mortality, 4.2%). Cholangitis (30%) was the major early complication and stent blockage (40%) the major late complication; there were no complications directly attributable to radiotherapy. The median survival for patients with pancreatic carcinoma was 250 days and for cholangiocarcinoma, 300 days. This method is technically feasible and may prove safer than the transhepatic technique. The ability of intraluminal irradiation to improve palliation or lengthen survival in patients with malignant bile duct obstruction remains uncertain. Assessment by a prospective, controlled trial is essential.

Cystic fibrosis, Crohn's colitis, and adult meconium ileus equivalent.

A 23-year-old man with cystic fibrosis developed massive rectal bleeding that continued intermittently, necessitating an emergency laparotomy and total colectomy. The resected colon was shortened by fibrosis and displayed widespread excessive production of mucus, forming a carpetlike layer over the mucosa as well as segmental discrete areas of mucosal ulceration with fissures, transmural inflammation, and multiple epithelioid granulomas, which are in keeping with Crohn's disease. One case, in a seven-year-old girl, had been reported previously.

Laser photoradiation therapy for tracheobronchial amyloid.

Tracheobronchial amyloid is uncommon and has a high morbidity and mortality. In the past, progressive airways obstruction has been treated with bronchoscopic resection but benefit has been limited. We report the successful use of a laser to treat this condition and the responses of amyloid tissue to laser photoirradiation.

Subcutaneous emphysema: a rare complication of fibreoptic sigmoidoscopy.

Fibreoptic sigmoidoscopy is a commonly used technique. However, it is not without complications. We report the rare occurrence of subcutaneous emphysema, mediastinal emphysema, and pneumoperitoneum following routine sigmoidoscopy.

Randomised trial of endoscopic argon laser photocoagulation in bleeding peptic ulcers.

Emergency endoscopy on 332 patients with acute upper gastrointestinal bleeding showed that 178 had peptic ulcers; 28 of these were actively bleeding (spurting) and 108 showed stigmata of recent haemorrhage (vessels or spots in the ulcer base) suggesting a risk of rebleeding. These 136 patients were randomly allocated to Argon laser photocoagulation or to no additional therapy (controls) at the time of initial endoscopy. All patients received conventional management, and the controlling clinicians did not know whether or not the laser had been used in any individual patients. The laser system proved both simple and safe in use. Initial haemostasis was achieved by the laser in 10 of 15 'spurting vessels', but four of 13 'control' spurting vessels also stopped bleeding spontaneously. Overall, there were no statistically significant differences between the laser treated and control groups in terms of rebleeding, the need for surgical intervention, or death. These results require amplification in larger trials, and comparison with other studies using different protocols and other haemostatic methods.