Leukotriene receptor expression in esophageal squamous cell cancer and non-transformed esophageal epithelium: a matched case control study.

BACKGROUND: Leukotriene B4 (LTB4R and LTB4R2) and cysteinyl leukotriene receptors (CYSLTR1 and CYSLTR2) contribute to malignant cell transformation. We aimed to investigate the expression of LTB4R, LTB4R2, CYSLTR1 and CYSLTR2 in esophageal squamous cell carcinoma and adjacent non-transformed squamous epithelium of the esophagus, as well as in control biopsy samples from esophageal squamous epithelium of patients with functional dyspepsia. METHODS: Expression of LTB4R, LTB4R2, CYSLTR1 and CYSLTR2 was analyzed by immunohistochemistry (IHC) and quantitative reverse transcription-polymerase chain reaction (qRT-PCR) in biopsy samples of 19 patients with esophageal squamous cell cancer and 9 sex- and age-matched patients with functional dyspepsia. RESULTS: LTB4R, LTB4R2, CYSLTR1 and CYSLTR2 were expressed in all biopsy samples. Major findings were: 1) protein levels of all leukotriene receptors were significantly increased in esophageal squamous cell cancer compared to control mucosa (p < 0.05); 2) CYSLTR1 and CYSLTR2 gene expression was decreased in cancer tissue compared to control at 0.26-fold and 0.23-fold respectively; 3) an up-regulation of LTB4R (mRNA and protein expression) and a down-regulation of CYSLTR2 (mRNA expression) in non-transformed epithelium of cancer patients compared to control (p < 0.05) was observed. CONCLUSIONS: The expression of leukotriene receptors was deregulated in esophageal squamous cell cancer. Up-regulation of LTB4R and down-regulation of CYSLTR2 gene expression may occur already in normal squamous esophageal epithelium of patients with esophageal cancer suggesting a potential role of these receptors in early steps of esophageal carcinogenesis. Larger studies are warranted to confirm these observations.

Jackhammer esophagus: high-resolution manometry and therapeutic approach using peroral endoscopic myotomy (POEM).

We present the first report on peroral endoscopic myotomy (POEM) in the treatment of jackhammer esophagus. A 34-year-old female patient was newly diagnosed with a jackhammer esophagus. After failure of medical treatment, the patient underwent POEM procedure for myotomy of the spastic segment. Postoperatively, a mild emphysema and pneumothorax occurred that required drainage and antibiotic therapy until full recovery. Discharge was possible after 5 days. Six months later, she presented with recurrent but mild pain due to a remnant spastic segment proximal to the myotomy. Endoscopic balloon dilation was performed twice within 6 weeks with full symptomatic relief of pain and mild symptoms of dysphagia.

[Resection of small colorectal polyps using a dedicated cold resection snare]. / Abtragung kleiner Kolonpolypen mittels Kaltschlinge.

BACKGROUND: According to actual German guidelines the resection of small colorectal polyps can be performed using a biopsy forceps. The guidelines recommend surveillance colonoscopy within 2 - 6 months if complete resection cannot be prooven. Cold snare resection of polyps allows easy and complete resection of small and diminutive polyps. AIM OF THE STUDY: To develop and evaluate a snare for cold resections of colorectal polyps. METHODS: We conducted a monocentric observational trial in our university hospital to test the performance of the cold snare resection for colorectal polyps < 10 mm. Consecutive patients were enrolled in the study. No submucosal injection was performed. Polyps were grasped with the snare and after accurate positioning of the snare polyps were resected. Primary endpoint was the rate of complete resection as defined by histology. Complications such as bleeding, perforation or abdominal pain were recorded. RESULTS: In total 99 polyps were resected in 58 patients (15 female, 43 male, age 62.8 years (31 - 85 years). The mean polyp size was 5.3 mm (2 - 10 mm). Of the 99 polyps 88 were adenoma (74 tubular adenomas, 4 tubulo-villous adenoma and 2 serrated adenoma), 18/99 polys were hyperplastic polyps and one polyp revealed as a leiomyoma. In total 74 adenoma (92.5 %) were completely resected en bloc. In polyps of 1 - 4 mm of size the R0 resection rate was 90 % (27/30). In polyps of 5 - 10 mm of size the R0 resection rate was 94 % (47/50). No complications occurred. DISCUSSION: This study demonstrated a high R0 Resection rate for small colorectal polyps using a dedicated cold resection snare. Cold snare resection of small polyps helps to reduce the rate of piece meal resections in small colorectal polyps.

[Air rescue missions at night: Data analysis of primary and secondary missions by the DRF air rescue service in 2014]. / Einsatz der Luftrettung in der Nacht: Datenanalyse von Primär- und Sekundäreinsätzen der DRF-Luftrettung des Jahres 2014.

The advantages that are inherent to the air ambulance service are shown in a reduction in mortality of critically ill or injured patients. The air ambulance service ensures quick and efficient medical care to a patient as well as the immediate transport of patients to a suitable hospital. In addition, primary air rescue has proved to be effective as a support for the standard ground-based ambulance services in some regions of Germany during the night. Under certain conditions, such as the strict adherence to established, practiced and coordinated procedures, air rescue at night does not have a significantly higher risk compared to operations in daytime. Particular requirements should be imposed for air rescue operations at night: a strict indication system for alerting, 4-man helicopter crews solely during the night as well as pilots (and copilots) with the correct qualifications and experience in dealing with night vision devices on a regular basis. Moreover, the helicopters need to be suitable and approved for night flying including cabin upgrades and the appropriate medical technology equipment. To increase the benefits of air rescue for specific diseases and injuries, a nationwide review of the processes is needed to further develop the primary air rescue service.

Small volume acid reflux in gastroesophageal reflux disease patients with hiatal hernia is only detectable by pH-metry but not by multichannel intraluminal impedance.

Until now, it is uncertain if the so-called pH-only reflux episodes that consist of a pH drop without evidence of retrograde bolus movement in multichannel intraluminal impedance (MII) represent reflux episodes or artifacts. Hiatal hernia (HH) may allow reflux of small volumes to occur that can be detected by pH-metry but not by MII. The aim was to search for a mechanism that can explain pH-only reflux, 20 patients (12 females and 8 males, median age 52 years, interquartile range [IQR]: 40.5-60.75 years) were investigated with MII-pH off PPI. Impedance and pH-metry data were analyzed separately. The differences in detection rate of acid reflux between pH-metry and MII were correlated with the presence of HH. In an in vitro experiment, MII-pH probes were flushed with citric acid in plastic tubes of different size with capillary diameter and diameters of 2.5 mm and 4.5 mm, while recording pH values and impedance. HH was present in six patients and absent in 14 patients. In patients with HH in comparison with patients with absent HH, the difference of acid reflux detection between pH-metry and MII is significantly higher (70%, IQR: 15-88% and 3.6%, IQR: 0-31%, respectively). In vitro all simulated reflux lead to a fall in pH whereas a corresponding decrease in impedance was only recognizable in the 4.5-mm plastic tubes. Acid reflux episodes in patients with HH are more frequently detected by pH-metry than by MII. Small volume reflux that does not lead to a decrease in impedance is the likely explanation for this phenomenon.

[Modern diagnostic tools for esophageal pathologies]. / Moderne Funktionsdiagnostik bei Ösophaguserkrankungen.

Modern functional laboratories provide various techniques for the evaluation of esophageal diseases. For proton pump inhibitor (PPI) refractory reflux symptoms the differentiation of non-erosive gastroesophageal reflux disease and functional heartburn is essential for the choice of further treatment. The differentiation of the two clinical entities is based on functional diagnostic methods, such as catheter-based and catheter-free pH measurement as well as combined pH measurement and intraluminal impedance. Combined pH measurement and impedance monitoring detects individual reflux episodes and permits the diagnosis of additional functional esophageal diseases, such as supragastric belching. The technical innovation of high resolution manometry has led to a better understanding of esophageal pathophysiology and motility disorders and resulted in a new classification system of esophageal motility disorders (Chicago classification). The diagnosis of achalasia by high resolution manometry differentiates three distinct subtypes which has a direct therapeutic impact on the clinical management.

[Ultrasound of the larynx, hypopharynx and upper esophagus]. / Ultraschall des Larynx, Hypopharynx sowie des oberen Ösophagus.

Sonography is an integral part of the routine diagnosis of diseases of the head and neck area. Ultrasound plays an important role in particular in the diagnosis, treatment and follow-up of head and neck cancer. Sonographic imaging of the larynx, hypopharynx and upper esophagus is often difficult due to the anatomical conditions. Therefore, CT and MRI are performed as the imaging techniques of first choice for diseases of these organs. In addition to the well-established transcutaneous ultrasound, endoscopic endoluminal ultrasound has developed as a promising new technique in recent years. Hollow organs can be displayed in high resolution transcutaneously and endoluminally. Thus, the attending otolaryngologist can use endoscopy and ultrasonography for accurate surgical planning. The aim of the present paper is to present the possibilities and limitations of ultrasonography of the larynx, hypopharynx and upper esophagus.

[Palliative treatment in gastroenterology at the border to (abdominal) surgery]. / Palliativtherapie im Grenzgebiet zwischen Gastroenterologie und (Viszeral-)Chirurgie.

BACKGROUND: In the management of gastrointestinal tumour lesions, palliative treatment has attained an increasing role. As also in curative treatment, an interdisciplinary cooperation between gastroenterologists and surgeons has to be aimed for. AIM: The aim of this study is to illustrate the diagnostic and therapeutic management of frequently occurring diseases in palliative medicine from a gastroenterological point of view. METHODS: Complementary short overviews on clinical experience and selectively searched references from the current scientific literature were evaluated. RESULTS: The symptomatic complex is very heterogeneous and requires an adequate approach taking into account the differential diagnosis. The palliative gastroenterological approach is characterised by the competent care on ascites, management of "malignant intestinal obstruction and obstipation" (MIO) as well as appropriate nutrition and analgetic therapy. The surgical approach is indicated after sequential exhaustion of medical, interventional endoscopic and (eventually) image-guided radiological measures; it comprises creation of a peritoneovenous shunt (ascites), bypass procedures (gastroenteral, biliodigestive, enteroenteral) as well as, in extraordinary cases, resection in addition to the implantation of an i. v. port-a-cath or surgical revision of a PEG / stent complication; in particular, in case of recurrent and massive haemorrhage and perforation (absolute indication), surgery becomes necessary. DISCUSSION: A lack of appropriate studies, absence of adequate study results including the difficult initiation of medical studies with palliative intention aggravate a competent evidence-based approach. Therefore, the management is considerably affected by clinical experience. CONCLUSION: Efficacious care in palliative visceral medicine requires relevant clinical expertise and interdisciplinary action because of the occurrence of clinical cases in gastroenterology at the border to surgery.

Multichannel intraluminal impedance and pH-metry for investigation of symptomatic gastroesophageal reflux disease.

BACKGROUND: Combined multichannel intraluminal impedance and pH-metry (MII-pH) is a technique that enables monitoring of gastroesophageal reflux independent of its acidity. AIM: To investigate the utility of MII-pH in the clinical investigation of patients with gastroesophageal reflux disease (GERD) symptoms. METHODS: 32 consecutive patients underwent 24-hour ambulatory MII-pH. 16 patients were on PPI (PPI+) therapy and 16 were taking no acid-suppressive medication (PPI-). We investigated the pattern of reflux by means of acid and nonacid reflux and the relation to typical and atypical symptoms. In addition, we investigated the symptom association by using the symptom index. RESULTS: Symptom-related acid reflux was higher in the PPI+ group (33 vs. 25%) and symptom-related nonacid reflux was higher in the PPI- group (36 vs. 21%). The association between type of symptoms and the association to reflux is highly significant (p < 0.001) in the PPI- group. In this group the association of acid reflux is more likely to correlate with typical symptoms and the association of nonacid reflux is more likely to be associated with atypical symptoms. CONCLUSIONS: These data show that nonacid reflux can be associated with symptoms in patients with GERD symptoms. The diagnostic value of MII-pH is independent of PPI therapy.

[Papillary tumors - therapeutic concepts]. / Papillentumoren - therapeutische Konzepte.

Papillary tumors originate from the various structures of the ampulla of Vater; therefore, these rare tumors represent a heterogeneous group of tumor entities. Intestinal differentiated adenomas are the most common benign lesions, whereas intestinal differentiated papillary carcinomas are the most common malignant tumors. Carcinomas with pancreaticobiliary differentiation have a poorer prognosis. Mesenchymal and neuroendocrine tumors are among the least frequent papillary tumors. Diagnosis is performed by side-view upper endoscopy and biopsy. In cases of suspected malignancy a complete staging with computed tomography (CT) and endoscopic ultrasound scanning is indicated to determine local tumor spread.Adenomas are removed by endoscopic snare papillectomy whereas the therapy of choice for papillary carcinomas is pancreatic head resection with systematic lymphadenectomy. Patients with papillary carcinomas are most likely to benefit from adjuvant therapy, which should be determined in an interdisciplinary consensus conference considering the histological differentiation of the tumor.

[Biliary leaks after liver resection. Prevention and treatment]. / Gallenleckage nach Leberresektion. Vermeidung und Behandlung.

The surgical treatment of primary and secondary liver pathologies is nowadays standard practice. Since the first major resections performed by Langenbruch in 1888 there have been significant developments in the surgical technique. In addition to the surgical technique, the diagnostics and patient selection, perioperative care and anesthetic management as well as knowledge of liver anatomy and physiology have also shown significant developments. The proportion of complex operations, even within the framework of multimodal concepts has also increased. Despite this increasing complexity, the morbidity (< 45 %) and mortality (< 5 %) of liver surgery could be clearly reduced; however, the incidence of postoperative biliary leaks in large published series currently lies between 0 % and 30 % and has only shown a minimal reduction in recent years. The management of bile leakage requires an interdisciplinary management involving endoscopic and radiological, interventional or operative therapy. Most leakages (69-94 %) persist under conservative treatment (drainage and if necessary antibiotic therapy). For high volume fistulas and persistent biliary leakage endoscopic retrograde cholangiography (ERC) with stent placement represents the therapy of choice. Infections with biliary peritonitis and failure of interventional strategies often require revision surgery, possibly consisting of suturing if a leakage is identifiable, replacement of drainages or application of a bile duct drainage (e.g. T-drain or transhepatic external biliary drainage).

Histomorphological differentiation of non-erosive reflux disease and functional heartburn in patients with PPI-refractory heartburn.

BACKGROUND: Proton pump inhibitor (PPI)-refractory heartburn may be due to persistent gastro-oesophageal reflux, oesophageal hypersensitivity or functional heartburn (FH). The differentiation between non-erosive reflux disease (NERD) and FH may be very difficult. However, this differentiation is important for appropriate therapeutic management. Dilated intercellular spaces (DIS), papillary elongation (PE) and basal cell hyperplasia (BCH) can be all assessed by light microscopy. Whether these mucosal abnormalities allow the differentiation of NERD from FH in PPI-refractory patients is uncertain. AIM: To assess histopathological findings by light microscopy in patients with refractory heartburn to differentiate NERD from FH. METHODS: Sixty-two patients with PPI-refractory symptoms underwent EGD and MII-pH after pausing PPI medication for 2 weeks before investigation. Twenty-five subjects without upper gastrointestinal symptoms were included as controls. Symptom assessment was based on the reflux disease questionnaire (RDQ). Biopsies were taken 3-5 cm above the gastro-oesophageal junction. DIS, PE, BCH and infiltration of immune cells were evaluated and a sum score was calculated. RESULTS: Based on endoscopy and MII-pH, GERD was diagnosed in 43 patients (NERD: 20; ERD: 23) and FH in 19 patients. There was no difference in symptoms between the groups. Each individual histopathological item was different between the groups (P < 0.0001). Between NERD and FH, the most significant difference was found for DIS and the histopathological sum score (P < 0.001). CONCLUSIONS: These findings suggest that oesophageal biopsies are useful to differentiate NERD from FH. Increased DIS and a histological sum score are the most significant histopathological abnormalities in NERD as compared with FH.

[Standards and innovations in the diagnosis of gastroesophageal reflux disease]. / Standards und Innovationen in der Diagnostik der gastroösophagealen Refluxkrankheit.

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases in the world. This article gives an overview about diagnostic procedures for GERD. Standard procedures such as pH-metry, Bilitec and manometry and also new diagnostic tools such as combined multichannel intraluminal impedance (MII) and pH-metry and Bravo Capsule are described in detail. Established endoscopy criteria as well as innovative techniques such as magnification, narrow band imaging and computed virtual chromoendoscopy are also presented. Not all of these procedures need to be used in every patient. Therefore, it is important to know the technical aspects, indications, advantages and disadvantages of each method in order to appropriately use any of these tests. The final goal is to characterise GERD and provide the patient with an appropriate therapy.

Diagnostic and therapeutic impact of double-balloon enteroscopy.

BACKGROUND AND STUDY AIMS: Double-balloon enteroscopy (DBE) is a new endoscopic method for examining the small intestine. Most reports of DBE have been from Japan, and very few data on this new technique have been reported by centers outside Japan. The aim of the present study was to determine the diagnostic yield of DBE, measure the frequency of management changes made on the basis of the results, and evaluate the clinical outcome for patients undergoing the procedure. PATIENTS AND METHODS: All patients undergoing DBE using a Fujinon enteroscope (length 200 cm, diameter 8 mm) during a 11-month period were studied. All of the patients had previously undergone esophagogastroduodenoscopy and colonoscopy. They underwent small-bowel cleansing on the day before the procedure using a standard colon lavage solution. RESULTS: Seventy DBE procedures were carried out in 53 patients (34 men, 19 women; mean age 60 years, range 24 - 80) by the oral route in 46 cases and the anal route in 24. The indications for the examination were gastrointestinal bleeding (n = 29), suspected Crohn's disease (n = 6), abdominal pain (n = 4), polyp removal or evaluation in polyposis syndromes (n = 6), chronic diarrhea (n = 4), and surveillance or tumor search (n = 4). The mean duration of the procedure was 72 min (range 25 min - 3 h). The mean radiation exposure was 441 dGy/cm (range 70 - 1462), and the mean depth of small-bowel insertion was 150 cm (range 1 - 470 cm). It was possible to evaluate the entire small bowel in four patients (8 %). A new diagnosis was obtained in 26 of the 53 patients (49 %). The findings in the 70 procedures were angiodysplasia (n = 13), ulcerations or erosions (n = 5), jejunitis or ileitis (n = 5), tumors (n = 5), stenosis (n = 4), polyps (n = 5), lymphangiectasias (n = 4), Crohn's disease (n = 4), and normal (n = 17). DBE resulted in a therapeutic intervention (endoscopic, medical or surgical, excluding blood transfusions) in 57 % of the patients (30 of 53). The only complication (1.4 %) observed was one case of intraprocedural postpolypectomy bleeding, which resolved with injection of epinephrine. CONCLUSION: In almost two-thirds of the patients examined, DBE was clinically useful for obtaining a new diagnosis and starting new treatments, changing existing treatments, carrying out surgical intervention, or providing therapeutic endoscopy. DBE is a useful and safe method of obtaining tissue for diagnosis, providing hemostasis, and carrying out polypectomy.