Outpatient therapeutic endoscopic retrograde cholangiopancreatography is safe in patients aged 80 years and older.

BACKGROUND AND STUDY AIM: The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort. PATIENTS AND METHODS: A total of 600 patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed. RESULTS: There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient. CONCLUSION: Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.

Video capsule endoscopy findings in subacute superior mesenteric vein thrombosis.

BACKGROUND: Subacute superior mesenteric vein thrombosis is a rare ischemic intestinal disease which is often characterized by delayed diagnosis due to obscure clinical picture. CASE REPORT: A 67-year-old woman who presented chronic abdominal pain with mild nausea due to superior mesenteric vein thrombosis was submitted to video capsule endoscopy. We describe, for the first time, the video capsule endoscopy findings in this patient. CONCLUSION: We emphasize the role of this new technology in the diagnosis of suspected ischemic intestinal diseases.

Diagnostic yield and clinical management after capsule endoscopy in daily clinical practice: A single-center experience.

BACKGROUND: Capsule endoscopy is an effective method of examining the small bowel in patients with obscure gastrointestinal bleeding, suspected inflammatory mucosal diseases and neoplasms. We herein evaluate the diagnostic yield of capsule endoscopy and its effect on clinical management in daily clinical practice. PATIENTS AND METHODS: One hundred and one capsule endoscopies performed at the Department of Endoscopy and Motility Unit of G. Gennimatas General Hospital of Thessaloniki from May 2007 to February 2009 were retrospectively reviewed. Clinical management following capsule endoscopy findings was evaluated. The most frequent indication was obscure gastrointestinal bleeding (n=56, overt=20). RESULTS: The overall diagnostic yield was 47.5%. The diagnostic yield was 88.9% in patients with overt bleeding who underwent early capsule endoscopy (within 5 days), versus 36.4% in patients who underwent late capsule endoscopy (p=0.028). Moreover, it reached 81.8% in patients with abdominal pain, with/without diarrhea and abnormal biological markers, versus 8.3% in patients with normal biological markers (p<0.0001). Capsule endoscopy was diagnostic in all patients with symptomatic celiac disease. Adenomas were found in 9 of 14 familial adenomatous polyposis patients. Capsule retention (>72 hours) occurred in two patients. Forty-three of 48 (89.6%) patients with positive capsule endoscopy findings that received intervention or medical treatment had positive clinical outcomes. CONCLUSIONS: Capsule endoscopy has an important diagnostic role and contribution in the clinical management during routine clinical practice; however, it remains to be determined which patients are more likely to benefit from this expensive examination.

Prospective randomized study comparing double layer and Tannenbaum stents in distal malignant biliary stenosis.

BACKGROUND AND STUDY AIMS: This prospective randomized study compared the patency and effective drainage rate of two stents with different materials but similar design, in the palliation of inoperable malignant biliary obstruction. PATIENTS AND METHODS: A total of 49 patients (26 women, mean age 72.55 +/- 10.75 years, range: 48-91 years) with obstructive jaundice due to inoperable malignant stricture of the distal common bile duct without previous drainage procedure, were randomly assigned to receive 10F Double Layer (DLS) (n = 24) or 10F Tannenbaum (TAN) (n = 25) biliary plastic stent. The diagnosis included pancreatic cancer (n = 33), cholangiocarcinoma (n = 8), ampullary cancer (n = 7) and metastatic lymphadenopathy (n = 1). The duration of stent patency, the effective drainage, and the adverse events were analyzed. RESULTS: Stent placement was successful in all patients with minor complications. The overall median patency rates between the two groups did not differ (107.5 days for DLS group vs. 101 days for TAN group ; p = 0.066). Effective drainage rate at the end of second week was 95.8% for DLS group and 96% for TAN group, (p = 1.00). Proximal stent migration occurred in one patient with TAN stent. CONCLUSIONS: The present study demonstrated that both DLS and TAN stents are comparable in terms of placement, overall stent patency, and complications.

Endoscopic closure of a large iatrogenic rectal perforation using endoloop/clips technique.

Retroflexion to evaluate the rectal vault provides significant additional information compared with standard forward view of the rectum. The procedure is easily performed with rare complications and is well tolerated by patients. We describe the first case of a large oval rectal perforation after retroflexion of the colonoscope in a healthy rectum during a follow-up colonoscopy, immediately closed with the endoloop/clips technique. The patient had an uneventful course and was discharged after 5 days. At his 2-month follow-up visit he remained asymptomatic and endoscopy revealed complete healing of the perforation.

Should inspection of the laryngopharyngeal area be part of routine upper gastrointestinal endoscopy? A prospective study.

BACKGROUND: Examination of the laryngopharyngeal area is not always performed during routine upper gastrointestinal (UGI) endoscopy although initial studies reported pathological findings in 0.9-3.5% of cases. The aim of this study was to prospectively evaluate the accuracy of screening the laryngopharyngeal area during routine UGI endoscopy, before insertion of endoscope into the oesophagus, to avoid a misinterpretation of trauma-related hyperaemia or erythema as signs of laryngitis. METHODS: The study included 1297 patients undergoing elective UGI endoscopy, asymptomatic in the laryngopharyngeal area, who underwent a carefully structured examination of the laryngopharyngeal area, videotaped for later blinded review. If pathological findings were suspected, patients were referred to otorhinolaryngologists for additional evaluation. In all cases the DVDs were reviewed by two ear, nose, and throat (ENT) specialists blinded to the endoscopic findings. RESULTS: In 1130 (87.12%) patients the examination was performed successfully before insertion of the endoscope into the oesophagus. Gastro-oesophageal reflux disease (GORD) symptoms were present in 254 (22.5%) patients, and erosive oesophagitis was documented in 89 (7.9%) patients. In 44 (3.89%) patients the pathology was suspected by the endoscopist and confirmed by the otorhinolaryngologists. Moreover, 8 (0.71%) patients were found to have laryngeal pathology in the DVDs reviewed by the ENT specialists, further confirmed by laryngoscopy. Sensitivity, specificity, positive, and negative predictive values were 84.61%, 100%, 100%, and 99.26%, respectively, for detecting laryngeal abnormalities by the endoscopist. The most important findings were leukoplakia (n=4), posterior laryngitis (n=16), Reinke's oedema (n=2), and hyperkeratosis of arytenoid folds (n=2). A strict correlation emerged between GORD and posterior laryngitis (75%) and between GORD and Reinke's oedema (100%), documented by pHmetry. A significant association was also observed between heavy smoking and leukoplakia (75%), and hypertrophy of pharyngeal tonsils (100%), respectively. All other findings were lesions without clinical significance. CONCLUSIONS: Screening examination of the laryngopharyngeal area should be part of each UGI endoscopy revealing important laryngeal pathology.

Fatal acute acalculous cholecystitis as an early complication after radiation therapy..

Acute acalculous cholecystitis (AAC) is a life-threatening condition whose incidence is steadily increasing, although it is still very much lower than that of the corresponding calculus form. The severity of the disease is due to the rapid course towards gallbladder necrosis and biliary peritonitis. Traditionally, it has been thought that AAC is associated with recent trauma, overeating or major surgical procedures. We describe a patient who presented acute cholecystitis, two days after completion of radiation therapy for metastatic lymphadenopathy along the hepatoduodenal ligament and distal common bile duct. He underwent exploratory laparotomy but he died from uncontrolled sepsis three days later. Histological study of the resected gallbladder showed findings of acute acalculous cholecystitis.

Synchronous occurrence of a primary colon adenocarcinoma and a gastric stromal tumor. A case report.

Gastrointestinal stromal tumors are currently the object of a great clinical and experimental interest. We are presenting the case of a 69-year-old patient, who was presented with lower gastrointestinal bleeding and dyspeptic symptoms over the last six months. The colonoscopy showed a large tumor of the sigmoid and the gastroscopy a large gastric tumor of the antrum, which were histologically diagnosed as colonic adenocarcinoma and gastric stromal tumor respectively. The patient underwent a sigmoidectomy and a partial gastrectomy. Six months after surgery were the clinical condition, abdominal CT, gastroscopy and colonoscopy without pathological findings. To our best knowledge, this is the second report of a synchronous gastric stromal tumor and a colonic adenocarcinoma in medical literature.

A comparative study of standard ERCP catheter and hydrophilic guide wire in the selective cannulation of the common bile duct.

BACKGROUND AND STUDY AIMS: Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic guide wire (HGW) in the selective cannulation of the CBD. PATIENTS AND METHODS: A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates. RESULTS: The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality. CONCLUSIONS: The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation.

Endoscopic sphincterotomy for acute relapsing pancreatitis associated with periampullary diverticula: a long-term follow-up.

BACKGROUND AND STUDY AIMS: Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. Data concerning the association of PAD with biliopancreatic disease are inconsistent, but an association between acute pancreatitis and PAD has been reported. The aim of this retrospective study was to evaluate the outcome of endoscopic sphincterotomy (ES) in a Greek cohort of patients with acute relapsing pancreatitis associated with PAD. PATIENTS AND METHODS: A total of 344 patients who had undergone ERCP between 1994 and 2005 for investigation of acute pancreatitis were retrospectively entered into a database. Of these patients, 11 (3.19% ; median age: 69 years; range: 58-78; 3 men, 8 women) were found to have acute relapsing pancreatitis associated with PAD. All patients underwent ES and were followed for new episodes of acute pancreatitis or other complications. RESULTS: No further episodes of acute pancreatitis occurred after ES, during a long-term follow-up (median: 4.3 years, range: 1.9-10.4). Two patients (18.2%) presented post-procedure mild pancreatitis and one patient (9.1%) post-ES stenosis with two small common bile duct stones and was treated with ES and extraction of stones. CONCLUSION: ES is the treatment of choice for patients with acute relapsing pancreatitis associated with PAD.

A case of early gastric cancer with bone metastases: are bone marrow micrometastases significant?

Gastric adenocarcinoma is currently the 14th cause of death worldwide. Early gastric cancer, defined as cancer not penetrating deeper than the submucosa, is considered to carry an excellent prognosis with 5-year survival rates reaching more than 90%. Cases of bone metastases due to intramucosal gastric cancer are very rarely described. A case of a 70-year old male presenting with confirmed bone metastases 7 years after a curative resection for a mucosal gastric carcinoma is discussed. The patient was investigated with bone marrow biopsy and bone scan and showed no other signs of disease. The clinicopathologic features included poor differentiation, signet ring cells presence, no lymph node involvement and a negative second laparotomy two years after the initial surgery. Studies concerning the presence of residual disease in the form of bone marrow micrometastases are briefly reviewed emphasizing that intramucosal gastric cancer still carries the p sibility for metastasis, many years after a curative resection, mandating long term alertness from the attending physician.

A novel technique of injection treatment for endoscopic sphincterotomy-induced hemorrhage.

BACKGROUND: We prospectively investigated the efficacy and safety of double injection of dextrose 50 % plus epinephrine (D (50)+E) solution in endoscopic hemostasis of postendoscopic sphincterotomy (ES) hemorrhage. PATIENTS AND METHODS: The study included 1331 consecutive patients who underwent 1331 ES procedures between March 2002 and June 2006. Bleeding patterns (trickle, oozing, pulsatile, none) were recorded. Patients with oozing or trickle bleeding who did not respond to spray irrigation of D (50)+E solution and all the patients with pulsatile bleeding, received double injection of D (50)+E solution at 2 - 3 cm proximal and into the bleeding point with a sclerotherapy needle. Risk factors for post-ES hemorrhage were also assessed. RESULTS: ES-induced hemorrhage occurred in 63 patients (4.73 %). Visible bleeding patterns immediately following ES were: 44 trickle (69.84 %), 13 oozing (20.63 %) and six pulsatile (9.52 %). Hemostasis was achieved by spray irrigation of solution in 41 of 44 patients (93.18 %) with trickle, and in three of 13 patients (23.07 %) with ooze bleeding. Double injection was required in all patients with pulsatile bleeding, in 10 patients (76.92 %) with oozing, and in three patients (6.82 %) with trickle bleeding. Overall, successful hemostasis was achieved with double injection in 18 of 19 patients (94.74 %). The "zipper" cut was revealed to be a sole significant risk factor to the occurrence of bleeding ( P < 0.001). Five non-bleeding patients (0.37 %) presented with delayed hemorrhage. The difference in the incidence of other complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant. CONCLUSION: Double injection of the readily available and inexpensive D (50)+E solution is a safe and effective treatment and is recommended for post-ES hemorrhage.

Gastric predominant hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is an autosomal-dominant disorder that frequently presents with epistaxis and gastrointestinal bleeding which may be a diagnostic and therapeutic challenge. We describe a 48-year-old monk with familiar history of HHT, who presented with frequent epistaxes and symptoms of ferropenic anemia. Upper gastrointestinal endoscopy revealed innumerable telangiectasias in the stomach. The patient underwent three sessions with argon plasma coagulation treatment but the results were poor. We also review the literature on the pathophysiology of the disease and discuss the suggested treatment.

Lipohyperplasia of the ileocecal valve as a cause of intussusception.

We present a case of lipohyperplasia of the ileocecal valve causing episodes of intussusception, and visualized by abdominal ultrasound and CT as a "target-like" appearance. At surgery, a large yellow soft mass was in the region of the ileocecal valve, raising the suspicion of lipohyperplasia. Resection of the fatty tissue from the ileocecal valve was performed at operation, after histologic diagnosis on frozen section. Our case suggests that limited resection removing the terminal ileum is effective and preferable to more extensive resection.

Dieulafoy-like lesion of the colon presenting with massive lower gastrointestinal bleeding.

The Dieulafoys lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. We describe an elderly patient who presented with severe lower gastrointestinal bleeding caused by a colonic Dieulafoy-like lesion. This is the third report of colonic Dieulafoys lesion treated successfully with endoscopic hemoclipping. We review the pathophysiology, clinical presentation, diagnosis, and treatment of this rare disease.

Needle-knife papillotomy: a safe and effective technique in experienced hands.

BACKGROUND/AIMS: Results from studies evaluating needle-knife papillotomy are conflicting. The aim of this retrospective study was to assess the safety and efficacy of needle-knife papillotomy as a precut procedure to achieve biliary access during ERCP. METHODOLOGY: During a period of seven years, ERCP was performed 938 times. During this time, needle-knife papillotomy was carried out in 68 patients, with complete follow-up obtained in all patients. The follow-up concentrated on the safety and efficacy of the procedure and short-term complications. RESULTS: Cannulation of the common bile duct was successful immediately after needle-knife papillotomy in 44 patients (66%), during a second ERCP in 18 patients (26%), and in a third ERCP in 2 patients (3%) achieving a total cannulation rate of 94%. There were no needle-knife papillotomy related deaths. Complications included bleeding in 5 patients (7%), and pancreatitis in 3 patients (4%). All complications were managed conservatively. CONCLUSIONS: Our experience indicates that needle-knife papillotomy is a versatile, effective and safe technique of gaining biliary access in patients in whom deep cannulation proves impossible and biliary access is considered essential.

Needle-knife suprapapillary sphincterotomy avoids postprocedure pancreatitis in patients with sphincter of Oddi dysfunction of biliary type II: a report of three cases.

We report the cases of three patients who fulfilled the criteria for sphincter of Oddi dysfunction of biliary type II and underwent needle-knife suprapapillary sphincterotomy. These patients presented with episodes of biliary-type pain after cholecystectomy and significant elevation of liver enzymes. Ultrasonography and MRI cholangiography revealed dilatation of the common bile duct, without visible stones. The patients all underwent needle-knife suprapapillary sphincterotomy because free cannulation of the common bile duct could not be achieved. Needle-knife suprapapillary sphincterotomy enabled catheterization of the common bile duct. After clearing of the common bile duct with a balloon catheter, no stones, fragments of stones, or sludge were observed to exit from the sphincterotomy. None of our patients developed postprocedure pancreatitis. When needle-knife suprapillary sphincterotomy is performed by an experienced biliary endoscopist, it is a safe and effective procedure for patients with sphincter of Oddi dysfunction of biliary type II, who otherwise constitute a high-risk group for the development of postsphincterotomy pancreatitis.