Depth of endoscopically placed sutures: an experimental study in a human cadaver model.

BACKGROUND: Endoscopic suturing devices offer interesting access for interventional procedures used on the gastrointestinal tract. For the time being, the main indication is endoluminal suturing at the gastroesophageal junction for the management of gastroesophageal reflux disease. There is some evidence that endoluminal endoscopic suturing offers an alternative to the closure of esophageal fistulas and to the fixation of feeding tubes and stents in the near future. A review of the literature found no anatomic data on wall layers stitched by sutures. The aim of this study was to determine the depth of sutures placed endoscopically in the esophagus of a human cadaver model. METHODS: Altogether, 62 sutures were placed in the esophagi of 10 cadavers (complete exenterative cadaver model) at three different suction levels (0.4, 0.6, and 0.8 bar) using the EndoCinch suturing machine. After preparation of the esophagus from its mediastinal bed, all sutures were fixed in formalin and stained with hematoxylin and eosin for histologic examination. RESULTS: No sutures were placed in the mucosa alone. As observed, 1.6% were placed in the submucosa, 4.8% in the circular muscularis propria, and 56.5% in the longitudinal muscularis propria, with 37% placed transmurally. At a suction level of 0.4 bar (0.6, 0.8 bar), 0% (0%, 1.6%) were placed in the submucosa, 3.2% (0%, 1.6%) in the circular muscularis propria, and 11% (25.8%, 12.9%) in the longitudinal muscularis propria, with 12.9% (6.5%, 17.7%) placed transmurally. CONCLUSIONS: This study reports, for the first time, a systematic examination of the depth of sutures placed endoscopically in the esophagus. Most of the sutures were found in the muscular wall of the esophagus at a suction level of 0.6 bar. Also, transmural placements were seen. Reduction of suction pressure may lead to a decrease in transmural sutures.

Endoscopic treatment of postoperative colorectal anastomotic strictures.

BACKGROUND: The postoperative development of benign colorectal anastomotic stricture remains a frequent and unsolved problem. METHODS: From 1996 until 2002, we analyzed 94 consecutive patients with postoperative colorectal anastomotic stenosis who were treated endoscopically. RESULTS: Sixty-eight patients were initially resected for malignant disease, and 26 patients for benign conditions. Most frequently, hydrostatic balloon dilatation was performed; in selected cases, it was combined with a laser or argon plasma coagulation (APC) incision, or a laser incision only. Dilatation was successful in 59% of patients resected for cancer and 88% resected for a benign condition. Complications developed in 17 patients (benign restenosis, perforation, abscess); they were significantly more frequent after initial cancer resection than after resection for a benign condition ( p < 0.05). CONCLUSION: High success and low complication rates make endoscopic dilatation the treatment of choice to avoid high-risk reoperations in patients with benign anastomotic stricture. The presence of stapler anastomosis, postoperative leakage, and/or radiotherapy does not significantly impede successful endoscopic dilatation.

Correlation of postoperative survival and angiogenic growth factors in pancreatic carcinoma.

BACKGROUND/AIMS: VEGF (vascular endothelial growth factor) and EGF (epidermal growth factor) are promoters of angiogenesis. It was the aim of this study to investigate a possible coexpression of both growth factors in tumor samples of pancreatic cancer patients in relation to survival after resection of the tumor. METHODOLOGY: We investigated the expression of VEGF165 and EGF in tumor specimen from 19 patients that underwent pancreaticoduodenectomy. Growth factor expression was determined using immunohistochemical methods. RESULTS: Coexpression of VEGF165 and EGF was observed in tumor samples of 9 (47%) patients. VEGF165 and EGF expression in the same tumor correlates significantly (P < 0.05, Fisher-test). UICC stage III pancreatic carcinoma patients with VEGF165 negative tumor cells had a significantly better outcome after surgery compared to UICC stage III patients with VEGF165-positive tumor cells (median survival time 19 months vs. 9 months respectively; P < 0.05, Wilcoxon-test). CONCLUSIONS: Antiangiogenic therapy after surgery for pancreatic cancer may be beneficial, especially for UICC III patients.

[A new video documentation system for rigid procto-rectoscopy]. / Ein neues Video-Dokumentationssystem für die starre Prokto-Rectoskopie.

INTRODUCTION: Disadvantages of rigid procto-rectoscope systems are the lack of sufficient visual documentation, data processing and the insufficient demonstration for educational purposes. Therefore a video documentation system for rigid procto-rectoscopy (Endovision Telecam SL) was developed. METHOD: For evaluation of the Endovision Telecam SL, the system was compared to the conventional technique over a 6-month period. RESULTS: The Endovision Telecam SL offers the advantage of flexible video-endoscopy and displays an excellent quality of documentation for rigid procto-rectoscopy. The handling of the system is slightly more time-consuming and difficult and the use is limited to cases without severe bleeding and stool contamination. CONCLUSIONS: The Endovision Telecam SL combines the advantages of flexible video-endoscopy in documentation, demonstration and data processing with the practibility of rigid instruments for procto-rectoscopy. In the present set-up the system is still limited to special indications and should be combined with conventional procedures.

[Cavernous hemangioma of the rectum--a rare cause of peranal hemorrhage]. / Das cavernöse Hämangiom des Rectums--eine seltene Ursache peranaler Blutung.

We report the case of a 34-year-old woman with severe rectal bleeding since the age of 17. The cause of the bleeding was a cavernous haemangioma of the rectum. The extent of the disease was not realised for many years. Sclerosing injections, laser coagulation and even suture ligation were helpful in acute bleeding episodes but did not result in definitive healing. Finally cure was achieved by resection of the rectum and colo-anal sleeve anastomosis. The clinical presentation and the management are described and discussed.

[Endoscopic hemostasis in stomach and duodenum]. / Endoskopische Blutstillung im Magen und im Duodenum.

Endoscopic hemostasis in cases of acute upper gastrointestinal bleeding may be achieved by various methods with comparable initial results, nevertheless the frequency of re-bleeding is different in regard to the techniques. The frequency of re-bleeding may be reduced by the application of fibrin tissue sealant, the eradication of Helicobacter pylori and by daily endoscopic controls. The use of big channel endoscopes makes intragastral survey easier, and beyond that endoscopic doppler-ultrasound may reveal visible and not visible arterial vessels on the bottom of the ulceration, so indicating the greater risk of re-bleeding. The progress of endoscopic hemostasis combined with specific pharmaco-therapy is on the way to relieve laparotomy in favour of intraluminal minimal invasive techniques in a larger scale.

[Evaluation of stents in treating childhood benign esophageal strictures]. / Evaluation von Stents zur Behandlung der benignen Osophagusstenose im Kindesalter.

BACKGROUND: Esophageal stenting is a popular of treatment of esophageal strictures in adults. It has also been described for children with benign strictures who did not respond to standard dilatation therapy. The aim of the study was to evaluate weather esophageal stents could be used safely and effectively in the treatment of benign esophageal strictures in children. PATIENTS: From 1993 to 2005 stenting therapy was performed in 12 children with complicated esophageal strictures. Etiologies of the strictures were caustic burns in 9 patients, postoperative strictures due to complicated esophageal atresia in 2 patients and iatrogenic esophageal injury in 1 patient. METHOD: Esophageal silicon tubi, covered retrievable expandable nitinol and plastic stents were placed endoscopically. The clinical course and the long term follow up were evaluated retrospectively RESULTS: The stents and tubi were placed in all patients without complications and were later removed successfully. 6 patients were treated with a self expanding plastic stent. The plastic stents showed a distinct tendency to migrate but in 5/6 patients esophageal stricture was treated successfully. 3 patients were treated by a covered self expanding nitinol stent. No migration occurred. One patient was asymptomatic after therapy, one required further dilatation therapy and the third had esophageal resection. 3 patients were treated by esophageal tubi. 2 patients required surgery in the follow up, one patient is asymptomatic. CONCLUSION: The use of stenting devices in children to treat benign esophageal strictures is safe and efficient. The self expanding plastic stents had the best long term results but required high compliance of parents and children due to the tendency of stent migration. Self expanding nitinol stents are more traumatic at the extraction procedure and are useful in patients with low compliance. Recurrence of strictures occurred most often after esophageal tubi possibly due to the lack of radial expansion.

[Obstructive jaundice of benign and malignant origin: endoscopy in diagnosis and therapy]. / Der Verschluss-Ikterus aus benigner und maligner Ursache: Endoskopie in Diagnostik und Therapie.

Laparoscopy and laparoscopic cholecysto-cholangiography for diagnosis of obstructive jaundice have been superseded by ERCP. ERCP is indicated in all patients with bilirubinaemia over 2 mg%. Surgery for obstructive jaundice should be abandoned in favour of surgery for common bile duct concretion, benign or malignant stenosis or periampullary neoplasia, as diagnosed by ERCP. Endoscopic sphincterotomy (EST) for recurrent common bile duct concretion is preferred in patients more than 60 years old. Biliary drainage techniques for litholysis or palliative tumour therapy have widely enlarged the spectrum of endoscopic surgery.