[Mesenchymal gastric tumor--not always GIST]. / Mesenchymaler Magentumor--nicht immer GIST.

The correct histopathological classification of a gastric mesenchymal tumor as a schwannoma is essential because in contrast to gastrointestinal stromal tumors (GIST) it is a definitive benign neoplasm which can be sufficiently treated by in sano (R0) resection. A (partial) gastrectomy is unnecessary. A clear radiological or sonographical differentiation between a schwannoma and GIST is not possible. The histomorphological and immunohistochemical features of this tumor entity are described.

Computed virtual chromoendoscopy versus standard colonoscopy with targeted indigocarmine chromoscopy: a randomised multicentre trial.

OBJECTIVE: Colonoscopy is the accepted gold standard for screening of neoplastic colorectal lesions, but the substantial miss rate remains a challenge. Computed virtual chromoendoscopy with the Fujinon intelligent colour enhancement (FICE) system is a new dyeless imaging technique that might allow higher rates of adenoma detection. METHODS: This is a prospective randomised five tertiary care centre trial of colonoscopy in the FICE mode versus standard colonoscopy with targeted indigocarmine chromoscopy (control group) in consecutive patients attending for routine colonoscopy. Histopathology of detected lesions was confirmed by evaluation of endoscopic resection or biopsy specimens. RESULTS: 871 patients were enrolled, and 764 patients (344 female, mean age 64 years) were subjected to final analysis (368 in the FICE group, 396 in the control group). In total, 236 adenomas (mean of 0.64 per case) were detected in the FICE group and 271 adenomas (mean of 0.68 per case) in the control group (p = 0.92). There was no statistically significant difference in the percentage of patients with >or=1 adenoma between the control group (35.4%) and the FICE group (35.6%) (p = 1.0). For the differential diagnosis of adenomas and non-neoplastic polyps, the sensitivity of FICE (92.7%) was comparable with that of indigocarmine (90.4%) (p = 0.44). CONCLUSIONS: At colonoscopy, adenoma detection rates are not improved by virtual chromoendoscopy with the FICE system compared with white light endoscopy with targeted indigocarmine spraying. However, FICE can effectively substitute for chromoscopy concerning the differentiation of neoplastic and non-neoplastic lesions.

Improved investigation of portal-hepatic veins by echo-enhanced Doppler sonography.

Microbubbles of air released from a galactose vehicle (Levovist) amplify the intensity of Doppler signals. They survive both pulmonary and systemic capillary passage, leading to echo enhancement in the entire vascular system. The aim of this study was to investigate this agent in patients with liver disease and insufficient Doppler signals. A total of 275 Doppler examinations were performed in 176 patients; 20 of these patients could not be studied conventionally due to bowel gas, obesity or noncompliance. They received Levovist to examine portal or hepatic veins or TIPS patency. Angiography, computed tomography (CT) scan or magnetic resonance tomographic angiography (MRTA) was performed subsequently as a control. After administration of Levovist, portal or hepatic veins and TIPS patency could be unequivocally assessed in 18 of the 20 patients. In two patients, suspected occlusion of the portal vein was disproved because the diagnosis was not confirmed later. Only minor adverse effects were encountered. Echo-enhanced Doppler sonography with Levovist is well tolerated. Further study of the value of Levovist for the assessment of portal-hepatic vessels not amenable to conventional Doppler sonography is justified.

The place of lithotripsy and surgery in the management of gallstone disease.

In summary, 10% to 20% of all symptomatic and uncomplicated gallbladder stones can be treated by ESWL under the current entry criteria. Further, ESWL is suitable for patients with bile duct stones in whom the primary endoscopic approach is not successful (about 10%). The algorithm in Figure 7 shows the therapeutic modalities that may be employed if the least invasive therapy is chosen. The different methods shown in this diagram are usually carried out by different specialists including surgeons, gastroenterologists, or radiologists. Therefore, an interdisciplinary approach is desirable. The technology of shock wave therapy of gallbladder stones will be improved in the future, for example the efficacy of stone fragmentation while maintaining a low level of discomfort for the patient. Moreover, repeated shock wave treatments may increase the success rate in patients with multiple stones and possibly in those with slightly calcified stones as well. Repeated procedures for recurrent stones appear feasible. Long-term follow-up studies are needed to define the place of ESWL in the management of gallstone disease. Surgery of the gallbladder remains the "gold standard" of curative therapy of gallbladder stones, against which ESWL and other nonsurgical techniques have to be evaluated. For the therapy of bile duct stones, ESWL is a helpful and effective nonsurgical adjunct.

[Interdisciplinary treatment of gallstones: surgery, endoscopy, lithotripsy. Report of experiences after 4 years]. / Interdisziplinäre Behandlung des Gallensteinleidens: Chirurgie, Endoskopie, Lithotripsie. Erfahrungsbericht nach 4 Jahren.

Today, several methods of treatment for gall stone disease exist besides standard surgical procedures: endoscopy, lithotripsy, litholysis or a combination of the above. During the last four years 1786 patients were treated using an interdisciplinary approach. Cholecystectomy was still the most frequent method of treatment for symptomatic cholecystolithiasis (n = 1369) with low morbidity (4.3%) and lethality (0.28%). Probably less than 20% of all cases fulfill the strict selection criteria for extracorporeal shock wave lithotripsy (ESWL). All alternative methods of treatment in which the gallbladder is preserved have an increased risk for gall stone recurrence. Only after the long-term follow-up results of ESWL are known, the recurrence rate can be assessed. In most cases, bile duct stones (n = 417) were removed by endoscopy, if necessary in combination with ESWL (n = 310, stone removal: 95%, lethality: 0.3%). However, in low risk patients with concurrent cholecystolithiasis surgery was still the method of choice (n = 107, stone removal: 96%, lethality: 0/107). It seems not so important as to who performs the non-surgical procedures in the treatment of gall stones - the surgeon, internist or radiologist. Moreover, an interdisciplinary approach should be sought.

[Surgical therapy of locally advanced and primary inoperable pancreatic carcinoma after neoadjuvant preoperative radiochemotherapy]. / Chirurgische Therapie des lokal fortgeschrittenen und primär inoperablen Pankreaskarzinoms nach neoadjuvanter präoperativer Radiochemotherapie.

INTRODUCTION: So far, surgery represents the only prospect for cure in patients with pancreatic cancer. Most patients, however, present with locally advanced pancreatic cancer at primary diagnosis. Recently, novel therapeutic regimens with preoperative radiochemotherapy have been developed that may improve long-term survival and resectability rates of patients with locally advanced pancreatic cancer. METHODS: This feasibility study evaluates the preliminary results of neoadjuvant therapy with gemcitabine and 5-fluorouracil (5-FU) or cisplatin. Twenty-six patients suffering from locally advanced pancreatic cancer were considered for preoperative radiochemotherapy. They received radiation (45 Gy) and chemotherapy with simultaneous or sequential gemcitabine and 5-FU (n = 15) or gemcitabine and cisplatin (n = 11) administration prior to surgical resection. RESULTS: Mean patient age was 62.4 +/- 2.6 years and 62% (n = 16) were male. The response rate was 69%, and 11 patients underwent curative surgical resection of the pancreatic cancer. Nine Whipple procedures and two complete pancreatectomies were carried out. In five patients a total of eight surgical complications were observed. Median overall survival was 9.8 months after primary cancer diagnosis (mean 12.0 +/- 1.2). During follow-up no local recurrent disease was detected. CONCLUSIONS: Our findings lead us to conclude that preoperative chemoradiation with 45 Gy, gemcitabine and 5-FU or cisplatin is a powerful therapeutic tool in patients with locally advanced non-resectable pancreatic cancer. Major resections, including vascular reconstructions, are nonetheless associated with increased mortality. Preoperative chemoradiation contributes to improved survival in patients with primary non-resectable pancreatic cancer.

[75-year-old patient with persistent abdominal complaints and vomiting during a cruise]. / 75-jährige Patientin mit persistierenden abdominellen Beschwerden und Erbrechen während einer Kreuzfahrt.

BACKGROUND: In elderly patients with gallstone disease, a gallstone ileus must be considered for unexplained abdominal pain. This is demonstrated in the following case report. CASE REPORT: A 75-year-old female patient presented with a 72-hour history of abdominal pain, nausea and vomiting. The patient's abdomen was mildly distended, although soft and nontender with bowel sounds present. Plain radiographs and ultrasound investigation of the abdomen were compatible with small bowel obstruction. To clarify the etiology, an abdominal computed tomography scan was obtained. These examinations disclosed air in the biliary tree, dilated small bowel and an impacted intraluminal abnormality in the terminal ileum compatible with a gallstone. Operative intervention confirmed the presence of a 3 cm obstructing calculus in the terminal ileum that was removed by an enterolithotomy. A two-step cholecystectomy and closure of the cholecystoduodenal fistula were performed 8 weeks later. The patient's recovery was uneventful. CONCLUSIONS: Although rare in a general population, gallstone ileus accounts for 25% of nonstrangulated small bowel obstructions in patients over the age of 65. The radiographic picture and ultrasound of small bowel obstruction and the presence of air in the biliary tree are suggestive for the diagnosis of a gallstone ileus. In our patient, the computed tomography and ultrasound findings confirmed the diagnosis and led to a prompt and directed surgical intervention. In patients with comorbid factors a two-step approach with enterolithotomy in a first and cholecystectomy in a second operation should be the therapeutic strategy of choice.

Biliary lithotripsy by extracorporeally generated shock waves.

Shock wave lithotripsy is a noninvasive treatment for gallstone disease, suitable for about 20% of the patients, and does not require anesthesia. Clearance of the fragments depends on: stone number and size, sufficient fragmentation and bile acid dissolution therapy. Several months are required for complete fragment disappearance. The recurrence rate is relatively low.

Ursodeoxycholic acid treatment of cholesterol gallstone disease.

Bile acid dissolution therapy alone or in combination with extracorporeal shock-wave lithotripsy continues to be a safe and effective non-surgical treatment for highly selected patients with cholesterol gallstone disease. Its disadvantages are the duration of drug treatment and potential stone recurrence. Its advantages, however, are non-invasiveness, low rate of morbidity, and lack of mortality. Considering the variety of options in modern gallstone therapy, the careful selection of treatment should be tailored to the individual patient's clinical and personal situation. This will involve the patient in the decision-making process.

[Screening for prevention of colorectal carcinoma. Who, when, how?]. / Screening zur Vorbeugung des kolorektalen Karzinoms. Wer, wann, wie?

Long-term survival of patients with colon carcinoma is largely determined by the timing of the diagnosis. For the identification of early colorectal carcinoma, it is of particular importance to detect and remove local precursor lesions (polyps) by means of effective screening, before they undergo malignant degeneration. The gold standard for such screening continues to be colonoscopy, followed by sigmoidoscopy, which latter, however, leaves large segments of the proximal uninspected. Additional--though less sensitive and more complicated--current screening techniques are the test for occult blood in the stools and the barium Doppler contrast examination, and, possibly in the near future, virtual colonoscopy and genetic testing for tumor DNA in the stools. Detailed screening recommendations are to be found in the guidelines issued by the German Society for Digestive and Metabolic Diseases. A prerequisite for effective prevention of colorectal carcinoma is the provision of information to, and motivation of, both the population and the individual patient, to participate in screening measures.

[Virtual large intestine imaging with multi-level CT. Pain free coloscopy--that works!]. / Virtuelle Dickdarmspiegelung mit der Mehrschicht-CT. Schmerzfrei koloskopieren--das geht!

Provided that the bowel is carefully cleansed, virtual colonoscopy permits a safe, reliable and painfree diagnosis of the large bowel. It requires distension of the bowel with ambient air. Contraindications include pregnancy, acute inflammation of the bowel and recent surgery. Tumors and large polyps (10 mm and more) can be diagnosed with certainty, while polyps measuring 5 mm and more are detected with a high degree of sensitivity. It goes without saying that virtual colonoscopy does not allow for the taking of biopsy material or the performance of therapeutic measures, so that positive or suspicious findings must be clarified by conventional colonoscopy. In principle, virtual colonoscopy is also suitable for use as a screening procedure. Whether the radiation exposure associated with the conventional examination protocol can be considered acceptable for screening purposes is questionable. However, using mathematical means, the radiation dose can be reduced to one-tenth of the usual dose.

Low frequency of colorectal dysplasia in patients with long-standing inflammatory bowel disease colitis: detection by fluorescence endoscopy.

BACKGROUND AND STUDY AIM: Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colonic dysplasias. Dysplastic changes in flat mucosa are likely to be missed by conventional colonoscopy. Endoscopic fluorescence imaging, using 5-aminolevulinic acid (5-ALA) as photosensitizer, has evolved as a new technique to differentiate between normal colonic mucosa and dysplasia. We combined this technique with random biopsies to prospectively evaluate the occurrence of dysplasias in patients with long-standing IBD. PATIENTS AND METHODS: 52 colonoscopies were performed in 42 consecutive patients (n = 28 with ulcerative colitis, n = 11 with Crohn's colitis, n = 3 with indeterminate colitis; mean age 43 years, range 21 - 78) with long-standing IBD colitis (median disease duration 14 years, range 3 - 40). All patients were in clinical remission. Patients were examined using both conventional white light and by fluorescence colonoscopy using oral 5-ALA. Four biopsies were taken every 10 cm from mucosa of normal appearance. In addition, macroscopically suspicious and fluorescence-positive areas were biopsied. RESULTS: A total of 688 biopsies of red-fluorescent (n = 20) and nonfluorescent (n = 662) areas of mucosa were taken. Dysplasia was detected histopathologically in only two of the biopsies. These biopsies were taken from two polypoid lesions which were fluorescence-negative. CONCLUSIONS: The rate of colonic dysplasia in patients with long-standing IBD colitis may be lower than previously reported.

Gallbladder stones: shockwave therapy.

Within the past 7 years, gallbladder lithotripsy by shockwaves has been proven to be a safe and effective non-invasive therapy for selected patients with gallstone disease. While regulatory decisions prevent shockwave therapy from being used more frequently in the USA, the number of patients treated in Europe and Asia is increasing constantly. At our institution, a relatively constant number of about 250 new patients per year have been treated since 1988 (Figure 4). About 20% of patients with gallstones are suitable for shockwave therapy according to present criteria. The rate of evacuation of all fragments is determined by the initial stone number and stone size, the success at stone fragmentation, adjuvant bile acid dissolution therapy, and gallbladder contractility. In contrast to laparoscopic cholecystectomy (Dubois et al, 1989; Perissat et al, 1989; Southern Surgeons Club, 1991), shockwave therapy does not require general anaesthesia. And in contrast to direct contact dissolution therapy of gallbladder stones using MTBE (Thistle et al, 1989), lithotripsy is non-invasive. In the majority of patients, complete fragment disappearance takes several months. Preliminary analyses of the cost-effectiveness of lithotripsy have revealed that lithotripsy, including retreatments and bile acid medication for recurrent stones, costs about as much as open cholecystectomy (Rothschild et al, 1990; Bass et al, 1991). The ideal patient for gallbladder lithotripsy has a single radiolucent stone < or = 20-25 mm in diameter in a functioning gallbladder (Figure 1). In patients with such stones, nearly all studies have confirmed a favourable outcome with rapid clearance of all fragments and a relatively low rate of stone recurrence. For carefully selected patients, extracorporeal shockwave lithotripsy is therefore an attractive non-invasive therapy.

[Inflammatory bowel diseases (IBD) -- critical discussion of etiology, pathogenesis, diagnostics, and therapy]. / Chronisch entzündliche Darmerkrankungen -- Kritische Diskussion von Atiologie, Pathogenese, Diagnostik und Therapie.

AIMS: Crohn's disease and ulcerative colitis are the most frequent inflammatory bowel diseases (IBD) with a prevalence of approximately one out of 500. Cytokine research opened new and potent treatment options and thus stimulated clinical and basic research.However, the IBD still remain a challenge for patients and physicians,demanding close cooperation between gastroenterologists,radiologists and surgeons. The basic understanding of IBD,which is necessary for efficient diagnostic and therapeutic concepts is reviewed. METHODS: Based upon recent publications and our clinical experience we discuss aspects of etiology,pathogenesis,diagnostics,and therapy of Crohn's disease and ulcerative colitis. RESULTS: A genetically influenced, exaggerated and sustained immune response against the own gut flora seems to be one of the most important factors in the pathogenesis of IBD. Not less important are environmental influences. For instance, cigarette smoking had been judged to have some negative influence on the natural course of Crohn's disease.Now,however, recent studies show that smoking is even a significant independent risk factor in the pathogenesis of IBD. Since IBD and especially Crohn's disease can effect the whole body, detailed analysis of inflammatory organ involvement is necessary before therapy. For instance, the MRI enteroclysis technique adds a necessary diagnostic tool for the exploration of those parts of the small bowel that cannot been reached by routine endoscopy like the upper ileum and the lower jejunum. In terms of therapy, a change of paradigms can be observed: patients will no longer be treated only when symptoms arise, but will early be integrated into a therapeutic concept, which is determined by site and extent of the disease and adapted to the abilities and needs of the patient.Furthermore,immunosuppressive agents like azathioprine and 6-mercaptopurine will establish as central concept in the medical treatment of IBD. DISCUSSION: IBD-therapy should rather be adapted to the patient's individual inflammatory pattern than be oriented to schematic treatment rules. New endoscopic and radiologic techniques provide the necessary diagnostic tools.

[Shockwave therapy of gallstones]. / Stosswellen-Therapie von Gallensteinen.

Extracorporeal shock-wave lithotripsy (ESWL) is a helpful adjunct for those bile duct stones which cannot be extracted by routine endoscopic measures including mechanical lithotripsy. For very large or impacted stones in the bile duct or stones in the intrahepatic biliary tree, and also for stones located in proximity to a bile duct stenosis, shock-wave therapy has proven to be safe and successful. More than 85% of the patients become free of stones after this therapy; they otherwise would have had to undergo high-risk open bile duct surgery. For gallbladder calculi, the pivotal factor for complete fragment disappearance after shock-wave therapy is sufficient stone disintegration. Only if fragments not larger than 3 mm are achieved, complete expulsion and/or dissolution of these fragments may be expected in a high percentage of the patients. Optimal candidates include patients with a single, radiolucent stone in a well-contracting gallbladder. For this group, ESWL is a safe and effective noninvasive therapeutic alternative.

Three-dimensional ultrasonography in hepatobiliary and pancreatic diseases.

Three-dimensional reconstruction of ultrasonographic images was used to visualize hepatobiliary and pancreatic lesions and stones, and to measure gallbladder emptying. The initial experience shows that these reconstructions may be of some help in the identification of the extension of tumors and the invasion into surrounding tissues. Stones and stone fragments in the pancreas and in the gallbladder as well as the wall of the gallbladder were visualized well. If further studies will reveal a benefit for the patient, three-dimensional ultrasonography may be added to the noninvasive methods used in the diagnosis of several hepatobiliary and pancreatic diseases.

Extracorporeal shock wave lithotripsy of pancreatic stones.

Extracorporeal shock wave lithotripsy of pancreatic stones was performed in eight patients with chronic pancreatitis and a dilated duct system harbouring stones 5 to 20 mm (means 10 (SD) 5 mm) in diameter. After endoscopic sphincterotomy of the pancreatic orifice the stones were disintegrated by shock waves under fluoroscopic control using a kidney lithotripter (Dornier HM3). The procedure was well tolerated by all but one patient, who had a mild pancreatitic attack immediately after lithotripsy. Clearance of the pancreatic duct systems from the larger stones was achieved in seven of eight patients. Half of the patients showed no improvement in the intensity and frequency of pain. The other patients had a marked amelioration of symptoms, however, both immediately and during a mean follow up interval of 11 (eight) months. A selective combined approach by endoscopy and extracorporeal shock wave lithotripsy for the treatment of pancreatic stones seems promising.