Early-stage adenocarcinoma of the esophagus with mid to deep submucosal invasion (pT1b sm2-3): the frequency of lymph-node metastasis depends on macroscopic and histological risk patterns.

The rate of lymph-node (LN) metastasis in early adenocarcinoma (EAC) of the esophagus with mid to deep submucosal invasion (pT1b sm2/3) has not yet been precisely defined. The aim of the this study was to evaluate the rate of LN metastasis in pT1b sm2/3 EAC depending on macroscopic and histological risk patterns to find out whether there may also be options for endoscopic therapy as in cancers limited to the mucosa and the upper third of the submucosa. A total of 1.718 pt with suspicion of EAC were referred for endoscopic treatment (ET) to the Dept. of Internal Medicine II at HSK Wiesbaden 1996-2010. In 230/1.718 pt, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of pT1b EAC (ER/surgery) was made. Of these, 38 pt had sm2 lesions, and 69 sm3. Rate of LN metastasis was analyzed depending on risk patterns: histologically low-risk (hisLR): G1-2, L0, V0; histologically high-risk (hisHR): ≥1 criterion not fulfilled; macroscopically low-risk (macLR): gross tumor type I-II, tumor size ≤2 cm; macroscopically high-risk (macHR): ≥1 criterion not fulfilled; combined low-risk (combLR): hisLR+macLR; combined high-risk (combHR): at least 1 risk factor. LN rate was only evaluated in pt who had proven maximum invasion depth of sm2/sm3, and who in case of ET had a follow-up (FU) by EUS of at least 24 months. 23/38 pt with pT1b sm2 lesions and 39/69 pt with sm3 lesions fulfilled our inclusion criteria. In the pT1b sm2 group, rate of LN metastasis in the hisLR, hisHR, combLR, and combHR groups were 8.3% (1/12), 36.3% (4/11), 0% (0/5), and 27.8% (5/18). In the pT1b sm3 group, rate of LN metastasis in the hisLR, hisHR, combLR and combHR groups were 28.6% (2/7), 37.5% (12/32), 25% (1/4), and 37.1% (13/35). 30-day mortality of surgery was 1.7% (1/58 pt). In EAC with pT1b sm2/3 invasion, the frequency of LN metastasis depends on macroscopic and histological risk patterns. Surgery remains the standard treatment, because the rate of LN metastasis appears to be higher than the mortality risk of surgery. Whether a highly selected group of pT1b sm2 patients with a favourable risk pattern may be candidates for endoscopic therapy cannot be decided until the results of larger case volumes are available.

[Catch me if you can: endoscopic remove of a needle from the jejunum]. / Catch me if you can: Endoskopische Bergung einer Sicherheitsnadel aus dem tiefen Dünndarm.

INTRODUCTION: The ingestion of foreign bodies is a frequently observed problem in daily clinical practice. In order to avoid complications such as perforation, endoscopic removal of potentially penetrating foreign bodies should be attempted quickly. The use of various endoscopic techniques has been reported for this purpose. However, extraction of foreign bodies from the mid gastrointestinal tract has rarely been reported. CASE REPORT: We present the case of a patient who had swallowed a safety needle which could safely be removed from the jejunum by means of double-balloon enteroscopy (DBE). The combination of a thin p-type enteroscope with a thick t-type overtube was used in order to improve the manoeuvrability of the endoscope. The needle was pulled into the overtube which served as a protective shield during the retrieval of the endoscope. CONCLUSION: Our case report describes the potential of removing foreign bodies from the deep small bowel by pulling them into the overtube of a double-balloon enteroscope. If the suspicion of foreign body impaction in the small bowel is made, it may be advisable to primarily choose a balloon enteroscopy system. Through this, quick and deep insertion can be combined with a safe removal of the foreign body.

[Detection of early neoplasia in Barrett's oesophagus: focus attention on index endoscopy in short-segment-Barrett's oesophagus with random biopsies]. / Detektion von frühen Neoplasien im Barrett-Ösophagus: Ein Plädoyer für die Wertigkeit der Indexendoskopie und 4-Quadranten-Biopsien im Short-Segment-Barrett-Ösophagus.

BACKGROUND: Detecting early neoplasias in Barrett's oesophagus (BE) is challenging. Recent publications have been focusing on improving the detection of such lesions during Barrett's surveillance. However in a recently published Danish register study calculating the risk for cancer-development in BE two-thirds of the diagnosed tumors were identified during the first examination or in the first year. This means that index endoscopy might be more effective than surveillance in detecting early neoplasia in BE. METHODS: In the period from January 2010 to April 2011, all patients who consecutively presented with a diagnosis of early neoplastic changes in BE were recorded prospectively. ANALYSIS: The analysis included data for 121 patients. In patients with short-segment BE (SSBE), neoplasia was only diagnosed in 6 % of cases in the surveillance examination, compared with 44 % of cases in long-segment BE (LSBE). The neoplastic lesion was identified visually in 43 patients (36 %) during the external EGD. Type II tumours were detected in 40 % (39/98) and were correctly assessed as neoplastic in 25 % of cases (24/98). CONCLUSIONS: 1. in patients with SSBE almost all early tumours are diagnosed by index endoscopy and not by Barrett's surveillance; 2. around 40 % of all early neoplasias are endoscopically invisible and are only diagnosed using four-quadrant biopsies; 3. the macroscopic tumour type has a substantial influence on the detection rate for neoplasia. If efforts to increase the detection rate for early neoplasia in BE are focused solely on the Barrett's surveillance method, then only a minority of patients - 20 % in the present group - will benefit from the measure. German clinical trials register, DRKS00 004 168.

[Acute complications after endoscopic resection of duodenal adenomas]. / Akutkomplikationen nach endoskopischer Resektion von Duodenaladenomen.

With the increasing technological development of endoscopy in recent years the diagnosis of and endoscopic therapy for duodenal adenomas has gained in importance. Due to its potentially malignant transformation an effective and safe therapy is necessary. The endoscopic resection has been shown to be safe and effective, even in cases of resection of large duodenal adenomas. Several studies have supported this thesis but are based on relatively small numbers of patients. In our clinic we have performed endoscopic resections of 178 duodenal adenomas over a period of 14 years, including sporadic duodenal adenomas as well as adenomas in familial polyposis syndromes. The aim of this retrospective analysis was to determine the acute complications associated with this technique. The rate of severe complications such as major bleeding or perforations was 9%. Further complications were minor bleeding (15.7%), pain needing treatment with analgesia (6.7%), fever (2.8%) and pancreatitis (0.6%). Summing up our experience with the endoscopic resection of adenomas of the small bowel we also consider the endoscopic resection of duodenal adenomas in most cases as a safe and effective alternative to surgical therapy. Because of the potential complications and their management especially in the resection of large adenomas with a size more than 2 cm, the endoscopic resection should be performed on an inpatient basis in experienced centres.

[Esophageal precancerous lesions: early diagnosis, treatment, and preservation of quality of life]. / Präkanzerosen im Ösophagus: Früherkennung, sichere Behandlung und Erhalt der Lebensqualität.

Modern high-resolution video endoscopes allow detailed examination of the esophageal mucosa and diagnosis of early neoplastic changes in the gastrointestinal tract. Whereas Barrett's esophagus is a precancerous condition that can develop into adenocarcinoma, there is no defined precancerous lesion for squamous cell carcinoma. Various diseases are associated with the development of esophageal squamous cell carcinoma. Chromoendoscopy has become an established method in the diagnostic work-up for better visualization of early neoplasia. If Barrett's esophagus is present, acetic acid spraying or virtual chromoendoscopy can be used to accentuate the display of superficial gyriform structures in the mucosa. The gold standard for detecting squamous cell carcinoma is still the use of Lugol solution. When early neoplasia is suspected, diagnostic endoscopic resection should be performed. This allows precise histological assessment of the tumor. Early diagnosis of neoplastic changes in the esophagus provides patients not only with the option of curative therapy but also with a good quality of life through preservation of the esophagus.

How is early Barrett's cancer currently diagnosed and treated in Western Europe? Results of a survey at 52 university hospitals in eight Western European countries.

BACKGROUND AND STUDY AIMS: Endoscopic treatment is increasingly being accepted for early Barrett's cancer (EBC), as it is associated with few complications, excellent long-term results, and almost no mortality. This study investigated current standards and treatment strategies for EBC in eight countries in Western Europe. METHODS: A standardized questionnaire with questions on the endoscopic diagnosis, staging, and treatment of EBC was developed and sent to 107 university gastroenterology departments. The data were analyzed anonymously. RESULTS: The response rate was 49 % (52/107). For work-up of early Barrett's neoplasia, 67 % of hospitals use high-resolution endoscopes, with routine four-quadrant and targeted biopsies of visible lesions in 94 % of the cases. Narrow-band imaging and chromoendoscopy are used in 67 % of the cases, and other advanced imaging and staining techniques in 65 %. Before treatment, 63 % of the respondents recommended conventional endosonography, 6 % miniprobe endosonography, and 19 % both. Endoscopic resection is carried out at 98 % of the hospitals. Argon plasma coagulation is used for ablation in 52 % of the cases and radiofrequency ablation in 27 %. An 80-year-old patient with localized mucosal EBC would be treated endoscopically in all of the hospitals. Endoscopic therapy was recommended for 50-year-old patients with mucosal EBC by 87 % of the hospitals; esophageal resection was recommended for multifocal EBC by 15 % in 80-year-old patients, by 63 % in 50-year-old patients and by 44 % in patients with incipient submucosal infiltration. CONCLUSIONS: About two-thirds of the university hospitals use high-resolution endoscopy and advanced imaging. Endoscopic therapy is the accepted standard for treating localized mucosal Barrett's cancer in Western Europe; esophageal resection is recommended by the majority (63 %) for a young patient with multifocal EBC.

Prospective, cross-over, single-center trial comparing oral double-balloon enteroscopy and oral spiral enteroscopy in patients with suspected small-bowel vascular malformations.

BACKGROUND AND STUDY AIMS: Spiral enteroscopy is a new, promising rapid enteroscopy technique. A prospective cross-over study was carried out to compare this new method with the established technique of double-balloon enteroscopy (DBE). PATIENTS AND METHODS: From an initial group of 18 patients with suspected mid-gastrointestinal bleeding due to vascular malformations but no previous history of small-bowel or colonic surgery, 10 patients (mean age 69 years) completed the study. Patients underwent both enteroscopy techniques with an oral approach, in a randomized sequence. The deepest point reached during advancement in the first enteroscopy was marked with India ink. The primary end point of the study was the total examination time. RESULTS: For spiral enteroscopy, the mean examination time was significantly shorter than with DBE (43 minutes vs. 65 minutes; P = 0.007), as was the mean time required for advancement of the enteroscope to the deepest point (24 minutes vs. 43 minutes; P = 0.03). However, the median maximum insertion depth was greater in the DBE group than in the spiral enteroscopy group (310 cm vs. 250 cm; P = 0.004). In all cases in which DBE followed spiral enteroscopy, DBE passed the India ink mark by a mean of over 100 cm. When DBE was performed first, spiral enteroscopy was either unable to reach the mark or else unable to advance deeper into the small bowel. No severe complications occurred. CONCLUSIONS: The results confirm that the new spiral enteroscopy technique reduces the examination time, although the insertion depth with DBE is at present superior.

Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: Vascular malformations are the most common sources of bleeding in the small bowel. They can be treated with argon plasma coagulation (APC) during double-balloon enteroscopy (DBE). This study aimed to evaluate the long-term follow-up of the effectiveness of APC for small-bowel bleeding by means of a single-center retrospective study. PATIENTS AND METHODS: Between June 2003 and December 2005, APC treatment for small-bowel lesions was carried out during DBE in 63 patients with known or suspected mid-gastrointestinal bleeding. Fifty patients were included in the analysis. Main outcome measurements were comparison of hemoglobin values and blood transfusion requirements before and after APC, and rebleeding rates. RESULTS: Twenty-nine patients (58%) had only oral DBE, whereas 21 patients (42%) underwent combined oral and anal approaches. The most frequent bleeding sources treated with APC were angiodysplasias in 44 patients (88%). Hemoglobin levels increased distinctly and stabilized after APC during a mean long-term follow-up of 55 ± 7 months, with mean levels of 7.6 g/dL before APC and 11.0 g/dL afterwards. Blood transfusion requirements substantially declined, from 30 patients (60%) before APC to 8 (16%) afterwards. However, small-bowel bleeding recurred in 21 patients (42%), particularly in patients with Osler disease (6 of 8 patients, 75%). CONCLUSIONS: Bleeding sources in the small bowel can be effectively treated with APC using DBE, and long-term follow-up data show a clear increase in hemoglobin levels and reduced blood transfusion requirements after APC. Further efforts are needed to reduce the rebleeding rate, possibly through more intensive initial treatment.

Impact of fluoroscopy on oral double-balloon enteroscopy: results of a randomized trial in 156 patients.

BACKGROUND AND STUDY AIMS: The routine utility of fluoroscopy during double-balloon enteroscopy (DBE) via the oral route has been not prospectively evaluated. Up to now, there have been no prospective randomized trials to assess whether fluoroscopy improves outcomes. The aim of this study was to assess the value of fluoroscopy during oral DBE. PATIENTS AND METHODS: A total of 156 patients (88 men, 56.4 %) of mean (standard deviation [SD]) age 56 (19) years were randomly assigned to undergo oral DBE either with or without fluoroscopy. The majority of the patients had obscure gastrointestinal bleeding (n = 96, 62 %). The primary target criteria for the study were postpyloric insertion depth and time required to reach the deepest insertion point. A secondary target criterion was the diagnostic yield achieved. RESULTS: The results in the fluoroscopy and nonfluoroscopy groups did not differ significantly with respect to the mean (SD) insertion depth (fluoroscopy, 284 [89] cm, range 70 - 470 cm; nonfluoroscopy, 256 [86] cm, 40 - 430 cm), the mean time required to reach the deepest point of insertion, or the diagnostic yield achieved. In patients with previous abdominal surgery and during difficult procedures, the mean insertion depth was significantly lower. CONCLUSIONS: Fluoroscopy during DBE via the oral route does not provide a significant gain in insertion depth, advancement time, or diagnostic yield in comparison with nonfluoroscopically guided procedures. In experienced hands, fluoroscopy does not have to be used routinely during oral DBE.

Prevention of feeding tube dislodgement with the Wiesbaden rein: a case series.

We describe initial experience with the use of a new fixation method (Wiesbaden rein), which has been developed to prevent dislodgement of feeding tubes in the gastrointestinal tract. The Wiesbaden rein has been used in three patients without complication. In none of the patients was dislodgement or malfunction of the feeding tube observed. Therefore, the use of the Wiesbaden rein might prevent dislodgement of feeding tubes. Clinical trials are required before this new method can be recommended for general use.

Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.

OBJECTIVE: Endoscopic therapy is increasingly being used in the treatment of high-grade intraepithelial neoplasia (HGIN) and mucosal adenocarcinoma (BC) in patients with Barrett's oesophagus. This report provides 5 year follow-up data from a large prospective study investigating the efficacy and safety of endoscopic treatment in these patients and analysing risk factors for recurrence. DESIGN: Prospective case series. SETTING: Academic tertiary care centre. PATIENTS: Between October 1996 and September 2002, 61 patients with HGIN and 288 with BC were included (173 with short-segment and 176 with long-segment Barrett's oesophagus) from a total of 486 patients presenting with Barrett's neoplasia. Patients with submucosal or more advanced cancer were excluded. INTERVENTIONS: Endoscopic therapy. MAIN OUTCOME MEASURES: Rate of complete remission and recurrence rate, tumour-associated death. RESULTS: Endoscopic resection was performed in 279 patients, photodynamic therapy in 55, and both procedures in 13; two patients received argon plasma coagulation. The mean follow-up period was 63.6 (SD 23.1) months. Complete response (CR) was achieved in 337 patients (96.6%); surgery was necessary in 13 (3.7%) after endoscopic therapy failed. Metachronous lesions developed during the follow-up in 74 patients (21.5%); 56 died of concomitant disease, but none died of BC. The calculated 5 year survival rate was 84%. The risk factors most frequently associated with recurrence were piecemeal resection, long-segment Barrett's oesophagus, no ablative therapy of Barrett's oesophagus after CR, time until CR achieved >10 months and multifocal neoplasia. CONCLUSIONS: This study showed that endoscopic therapy was highly effective and safe, with an excellent long-term survival rate. The risk factors identified may help stratify patients who are at risk for recurrence and those requiring more intensified follow-up.

"Dry biopsies" with spraying of dilute epinephrine optimize biopsy mapping of long segment Barrett's esophagus.

BACKGROUND AND STUDY AIMS: For surveillance of Barrett's esophagus random stepwise four-quadrant biopsy (4QB) is recommended for detecting macroscopically occult neoplasias. Thorough performance of the systematic protocol is commonly hampered by poor visibility due to oozing from biopsy sites. Topical application of dilute epinephrine may prevent bleeding by vasoconstriction of superficial microvessels and might therefore enable "dry biopsy" sampling. The aim of this study was to examine the safety and efficacy of spraying dilute epinephrine for optimal 4QB mapping of Barrett's esophagus. PATIENTS AND METHODS: In this prospective, double-blind trial 40 patients with known long segment Barrett's esophagus were randomly allocated to undergo spraying with either dilute epinephrine (1 : 20 000) (epinephrine group; n = 20) or saline (control group; n = 20) before 4QB sampling. During endoscopies patients received continuous monitoring of vital parameters. Endoscopists blinded to randomization assessed visibility scores during biopsy sampling. Additionally, electronically stored images of the Barrett's esophagus segment after 4QB sampling were evaluated by blinded assessors. RESULTS: The mean length of Barrett's segments was 5.5 +/- 1.8 cm and the mean number of 4QBs was 12.5 +/- 3.6 with no statistically significant differences between control and epinephrine groups. Epinephrine spraying did not affect patients' vital parameters. Visualization ratings by endoscopists on site and by the assessors of the stored images were significantly better in the epinephrine compared with the control group (P < 0.05). Moreover, epinephrine spraying reduced the time for 4QB sampling (P = 0.015) and the mean number of saline flushes needed to maintain visibility (P = 0.0003). CONCLUSIONS: The novel "dry biopsy" technique with spraying of dilute epinephrine is safe, and facilitates thorough performance of systematic 4QB mapping of Barrett's esophagus by improvement of visibility.

Invisible gastric carcinoma detected by random biopsy: long-term results after photodynamic therapy.

BACKGROUND AND STUDY AIMS: Gastric cancer diagnosed from routine gastric biopsies without any evidence of a visible lesion and negative repeated biopsies is an infrequent but serious clinical problem for which gastrectomy has usually been recommended, even if operative specimens do not show cancer either. We report on a series of 22 such patients undergoing long-term follow-up after attempted treatment with photodynamic therapy (PDT). PATIENTS AND METHODS: 22 patients with invisible gastric cancer (IGC) who presented during a 10-year period (10 men, mean age 56 +/- 15 years) were prospectively included. Initial histopathological findings confirmed by second opinion included 10 well-differentiated adenocarcinomas and 12 signet ring cell carcinomas. After two negative state-of-the art endoscopic reassessments, a single session of PDT using 5-delta-aminolevulinic acid (ALA) was performed in the area from which the biopsy was taken, and patients were followed up regularly. RESULTS: After a mean follow-up period of 56.2 +/- 27.6 months, three patients had died of causes unrelated to gastric cancer, four had developed mucosal cancer that was successfully treated endoscopically after 4 - 38 months, and the remaining 15 patients remained without evidence of recurrent gastric cancer, lymph-node involvement, or metastases during a follow-up period of 54 +/- 26 months. CONCLUSIONS: Our results suggest that gastrectomy may not be the only option for IGC, which might follow an uneventful natural course provided careful follow-up is scheduled. The role of PDT in this setting remains unclear and should be studied further.

Prospective multicenter trial of capsule endoscopy in patients with chronic abdominal pain, diarrhea and other signs and symptoms (CEDAP-Plus Study).

BACKGROUND: On the basis of the published data, capsule endoscopy cannot be recommended in patients whose only symptom is chronic abdominal pain. The present study therefore focused on the diagnostic yield of capsule endoscopy in patients with chronic abdominal pain who were also suffering from additional symptoms. PATIENTS AND METHODS: A total of 50 patients with chronic abdominal pain, plus other symptoms singly or in combination were enrolled in this prospective multicenter trial. The "plus" symptoms or signs consisted of weight loss (> 10 % of body weight), inflammation shown by laboratory tests, chronic anemia, or suspected mid-gastrointestinal bleeding. Chronic diarrhea was recorded if present, but patients did not qualify for the study if they had pain and diarrhea alone. Capsule endoscopy was carried out following a defined previous diagnostic work-up that had not revealed the cause of the patient's symptoms. The capsule videos were assessed by two independent blinded investigators. The findings were classified as relevant, potentially relevant, or not relevant for explaining the symptoms, or else classified as normal. RESULTS: The capsule reached the cecum in 84 % of the patients (42 of 50). Relevant findings were discovered on capsule endoscopy in 36 % and 40 % of patients by the two investigators, and potentially relevant findings in 14 % and 24 % of patients. The additional symptom or sign of inflammation was associated with the highest diagnostic yield (odds ratio 3.2). The presence of more than one additional symptom did not increase the yield in our patient group. Two capsules (4 %) entrapped at previously unrecognized stenoses were removed endoscopically using push-and-pull enteroscopy (n = 1) or surgery (n = 1). CONCLUSIONS: Strict patient selection on the basis of additional symptoms or signs is the key to increasing the yield of capsule endoscopy in patients with chronic abdominal pain. Inflammation seemed to be the additional sign with the highest value.

Argon plasma coagulation for flexible endoscopic Zenker's diverticulotomy.

BACKGROUND AND STUDY AIMS: The increasing use of flexible endoscopy to treat symptomatic Zenker's diverticulum is only partially supported by data on safety and benefits. This retrospective study reports the mid-term results of argon plasma coagulation (APC) for flexible endoscopic therapy of Zenker's diverticulum. PATIENTS AND METHODS: Between January 2002 and July 2006, 41 patients (27 men, 14 women, mean age +/- standard deviation [SD] 73 +/- 11 years) were treated by means of APC flexible endoscopic Zenker's diverticulotomy. Technical and immediate clinical success (on a 3-month control examination) was assessed for the entire group. Mid-term follow-up data were obtained for patients treated until December 2005 (n = 34) with a mean +/- SD follow-up period of 16 +/- 5 months. RESULTS: Technical success was achieved in all 41 patients, with a mean +/- SD of 3 +/- 2 treatment sessions during one or two hospitalizations (1-3 sessions for 78% patients, > 3 sessions for 22% patients). Immediate clinical success was achieved in 95% of cases. Fever occurred in seven patients (17%), lasting less than 24 hours in three patients (7%) and associated with clinical infections in four (10%); one perforation occurred, which was managed conservatively. In the patients for whom we had mid-term follow-up data, 5/34 experienced recurrence and achieved a successful clinical outcome after retreatment with APC. CONCLUSIONS: APC treatment of Zenker's diverticulum is safe and effective in the short term, with a mean of three treatment sessions. Recurrence rates of around 15% have to be expected on mid-term follow-up. The relative value of APC vs. needle-knife techniques can only be clarified in a prospective randomized study.

Prospective evaluation of the macroscopic types and location of early Barrett's neoplasia in 380 lesions.

BACKGROUND AND STUDY AIMS: The macroscopic appearance of early gastric cancers, classified according to the Japanese criteria, has been shown to be an important prognostic factor for local endoscopic therapy. No prospective data about the distribution of macroscopic types and their location in early Barrett's neoplasia are available, however. The present study was conducted to evaluate the clinical applicability of this macroscopic classification and to analyze the relative proportions of the different gross types in early Barrett's neoplasms and the correlation between the macroscopic classification and the stage or grade of differentiation. PATIENTS AND METHODS: A total of 344 patients with 380 Barrett's neoplastic lesions who were referred between October 1996 and September 2005 for endoscopic therapy of early Barrett's high-grade intraepithelial neoplasia and carcinoma were prospectively included in the study. Routine endoscopy prior to endoscopic resection in our center included assessment of the macroscopic type (according to the Japanese classification) and documentation of the radial location of the neoplastic lesions. Images were recorded which were later assessed by six independent reviewers; intra- and interobserver agreement for the assessment of the macroscopic type were calculated using kappa statistics. RESULTS: The distribution of the lesions by gross type was as follows: type I, n = 49 (13 %); type IIa, n = 139 (37 %); type IIb, n = 106 (28 %); type IIc, n = 17 (4 %); type IIa + c, n = 62 (16 %); type III, n = 7 (2 %). Type IIb lesions seem to be the most favorable type with regard to differentiation and T category ( P < 0.05). The mean kappa value for the interobserver agreement was 0.86 and the mean kappa value for the intraobserver agreement was 0.89. Most lesions were found at the 12 o'clock and 3 o'clock positions. CONCLUSIONS: Assessment of the macroscopic type may provide important information about the possibility of endoscopic treatment. The harder-to-detect flat lesions are by far the most frequent macroscopic type of neoplastic lesion in Barrett's esophagus.

Femoral and acetabular re-alignment in slipped capital femoral epiphysis.

NEW PATHOPHYSIOLOGICAL INSIGHTS: Based on improved knowledge of the vascular supply of the proximal femur, a safe surgical dislocation of the hip joint was established allowing direct insights to the pathomorphological malfunctioning of the joint. One insight was that slipped capital femoral epiphysis (SCFE) impingement leads to substantial damage of the chondrolabral rim area, even in the presence of minor slips. A further surgical development was the extended retinacular flap allowing for correction of the deformity with calculable risk for iatrogenic necrosis. CONSECUTIVE SURGICAL CONCEPT: In 20 years of experience, a treatment concept for SCFE could be established which replaces classic pinning in situ and indirect correction of the deformity with subcapital re-alignment when the physis is still open, with true femoral neck osteotomy for hips with closed physis. Pinning in situ still has a place in minor slips but should be combined with open or arthroscopic recreation of an anterior metaphyseal waisting. UNEXPECTED COMPLICATION: Loss of joint stability is a rare complication of anatomic re-alignment. It can be disease-related when the impingement has induced severe destruction of acetabular cartilage. It can be related to the surgical procedure, especially when the neck was excessively shortened and refixation of the trochanter was not advanced. Finally, in cases with severe and long-lasting deformity, the acetabulum may undergo adaptive flattening, being the cause of joint destabilisation with the correction of the deformity. Advancement of the greater trochanter and/or peri-acetabular osteotomy may be discussed to restabilise the joint.

Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract.

BACKGROUND: The aim of this study was to analyze safety and efficacy of a new high power argon plasma coagulation system in the upper gastrointestinal tract. METHODS: Data of 215 patients treated with a high power argon plasma coagulation system in the upper gastrointestinal tract 04/2003-01/2004, using a VIO APC device (VIO 300 D with APC 2; Erbe Elektromedizin, Tübingen, Germany; pulsed argon plasma coagulation, 20-120 W), were reviewed and analyzed. Indications were as follows: additive ablation therapy in curative treatment of early Barrett's cancer (122 patients); palliative treatment of oesophageal cancer (n=27); gastric adenoma/carcinoma (n=19); Zenker's diverticulum (n=8); and other. In 190/215 patients (149 males; mean age 67 years), the data were completely analyzable. Minor and major complications were evaluated. RESULTS: Minor complications (odynophagia, pain, fever) occurred in 24/277 sessions (8.7%); major complications (stenosis) in 3/277 sessions (1.1%) using at least 50 W. No perforation or bleeding occurred. The mean number of treatment sessions required was 1.46 (1-7); in the palliative treatment of oesophageal cancer, it was 2.5 (1-5). CONCLUSIONS: The high power argon plasma coagulation system was effective and safe in various gastrointestinal conditions. Due to it's high effectiveness and a low number of sessions required in tumour debulking, this high power argon plasma coagulation system might be used as an alternative to Nd:YAG laser.

Pathomorphology and treatment of congenital anterolateral bowing of the tibia associated with duplication of the hallux.

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient.

[Endoscopic therapy in early gastric cancer]. / Endoskopische Therapie von Magenfrühkarzinomen.

Endoscopic treatment of early gastric cancer has been shown to be effective and safe. It is a minimally invasive and organ-preserving treatment approach that can safely be used as an alternative to surgical resection. A prerequisite of any endoscopic treatment with a curative intent is a very low risk of lymph node metastasis of the lesion intended to be endoscopically resected. As in high-volume surgical centers all endoscopic procedures with a curative intent should also be carried out in centers with a high expertise in the different endoscopic resection (ER) techniques available, the major techniques being suck-and-cut ER and endoscopic submucosal dissection (ESD). Because of the risk of secondary neoplasia after curative endoscopic therapy, a standardized follow-up protocol is required. The majority of secondary neoplastic lesions can again be treated endoscopically. In the present article an overview of initial staging procedures, techniques, indications, as well as follow-up strategies after endoscopic therapy for early gastric cancer is given.