A Simple Evaluation Tool (ET-CET) Indicates Increase of Diagnostic Skills From Small Bowel Capsule Endoscopy Training Courses: A Prospective Observational European Multicenter Study.

Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n = 2), Italy (n = 2), Germany (n = 2), Finland (n = 1), and nationally in Germany (n = 10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P < 0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P < 0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P < 0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P < 0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.

Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis.

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

Magnetic resonance cholangiopancreatography in the diagnosis of primary sclerosing cholangitis.

BACKGROUND AND STUDY AIMS: Magnetic resonance cholangiopancreatography (MRCP) is a less-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of primary sclerosing cholangitis (PSC). This study evaluated the diagnostic accuracy of MRCP in PSC compared with ERCP, and assessed the diagnostic accuracy of different T2w sequences. PATIENTS AND METHODS: 95 patients (69 PSC, 26 controls) were evaluated using both ERCP and MRCP. Exclusion criteria included secondary sclerosing cholangitis and contraindications to MRCP. The diagnosis of PSC was confirmed in 69 patients based on ERCP as the reference gold standard. MRCP was performed using a 1.5 Tesla MR unit, using breath hold, coronal and transverse half-Fourier acquisition single-shot turbo spin-echo (HASTE), coronal-oblique, fat-suppressed half-Fourier rapid acquisition with relaxation enhancement (RARE), and coronal-oblique, fat-suppressed, multisection, thin-section HASTE (TS-HASTE) sequences. The MRCP morphological criteria of PSC were evaluated and compared with ERCP. RESULTS: The sensitivity, specificity, and diagnostic accuracy were 86%, 77%, and 83%, respectively, using the MRCP-RARE sequence, and increased further to 93%, 77%, and 88%, respectively, by the inclusion of follow-up MRCP in 52 patients, performed at 6-12-month intervals. HASTE and TS-HASTE sequences showed significantly lower diagnostic accuracy but provided additional morphologic information. CONCLUSIONS: MRCP can diagnose PSC but has difficulties in early PSC and in cirrhosis, and in the differentiation of cholangiocarcinoma, Caroli's disease, and secondary sclerosing cholangitis. A positive MRCP would negate some diagnostic ERCP studies but a negative MRCP would not obviate the need for ERCP.

[Recurrent gastrointestinal bleeding and aortic valve stenosis (Heyde syndrome): need for valve replacement?]. / Rezidivierende gastrointestinale Blutungen bei Aortenklappenstenose (Heyde-Syndrom): Indikation zum Aortenklappenersatz?

UNLABELLED: Angiodysplasia are common in patients over the age of 60. Heyde syndrome describes the coincidence of aortic valve stenosis and gastrointestinal bleeding from angiodysplasia. We describe one characteristic case of aortic valve stenosis and gastrointestinal bleeding from angiodysplasia which subsided after replacement with an aortic valve bioprosthesis. We review the current literature and discuss the actual explanation approaches for this phenomenon. CONCLUSION: There seems to be a clear indication for valve replacement in the case of aortic valve-stenosis and gastrointestinal bleeding due to angiodysplasia.

Primary precutting versus conventional over-the-wire sphincterotomy for bile duct access: a prospective randomized study.

BACKGROUND AND STUDY AIMS: Precut is a well-known technique that is used if repeated attempts at common bile duct (CBD) cannulation fail. Opinions on the complication rate of precut are conflicting, however. The aim of the present study was to compare the efficacy and complication rate of precut used as a primary method of CBD access with the efficacy and safety of the conventional technique. PATIENTS AND METHODS: During the 19-month study period, consecutive patients who were scheduled for first-time endoscopic sphincterotomy (ES) for a variety of biliary disorders were randomized into two groups: patients in group A underwent conventional wire-guided biliary cannulation followed by ES (with precut being performed only when this failed); in patients in group B precut was used as a primary technique to gain biliary access, followed by wire-guided ES. We used a specially designed, modified Erlangen type of sphincterotome for precutting. RESULTS: A total of 291 patients (100 men, 191 women; mean +/- SD age 65 +/- 17.5 years) were recruited: 146 patients were assigned to group A (conventional approach) and 145 to group B (primary precut approach). The indications for ES were comparable in the two groups. In group A, wire-guided cannulation of the CBD failed in 42 patients. Secondary precut was successful in 41 of these patients, leading to an overall success rate of 99.3 %. In group B, the ES success rate using primary precut was 100 % at the first attempt. The mean time to successful deep CBD cannulation was 8.3 +/- 2.1 minutes in group A and 6.9 +/- 1.8 minutes in group B ( P < 0.001). The incidence of mild to moderate pancreatitis was similar in the two groups (2.9 % in group A vs. 2.1 % in group B, P > 0.05). Mild bleeding occurred in only one patient (from group A) and this was controlled by epinephrine injection. None of the study patients developed severe pancreatitis or perforation. CONCLUSIONS: In experienced hands, an approach using primary precut appears to be at least as successful and safe as a conventional approach using guide-wire-based CBD cannulation followed by ES, and might also be a quicker method.

Endoscopic mucosal resection of early esophageal squamous cell cancer using the Duette mucosectomy kit.

BACKGROUND AND STUDY AIM: Endoscopic mucosal resection (EMR) is a less invasive alternative treatment strategy to surgery for intramucosal esophageal squamous cell carcinoma (SCC). This study described our initial experience with the newly introduced Duette Multiband Mucosectomy Kit (Cook Ireland Ltd, Limerick, Ireland) for the treatment of extensive early esophageal SCC. PATIENTS AND METHODS: Five patients with extensive early esophageal SCC, covering at least half of the circumference of the esophageal wall and measuring a mean of 2.8 cm longitudinally, underwent EMR after EUS staging. RESULTS: EMR was successfully completed in one session in five patients. Post-EMR stricture occurred in four patients but was successfully treated with bougienage. One patient did not return for follow-up after bougienage and died from ischemic heart disease 3 months later. For the remaining four patients, there was no recurrence over a mean follow up of 14.7 months. CONCLUSION: This new device obviates the need for repeated insertion of the endoscope during the process of ligation and resection and thus facilitates EMR of extensive SCC.

Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature.

PURPOSE: This study was designed to evaluate the outcome of endoscopic polypectomy of malignant polyps with and without subsequent surgery based on histologic criteria. METHODS: Consecutive patients with invasive carcinoma in colorectal polyps endoscopically removed between 1985 and 1996 were retrospectively studied. Patients with complete resection, grading G1 or G2, and absence of vascular invasion were classified as "low risk." The other patients were classified "high risk." Available literature was reviewed by applying similar classification criteria. RESULTS: A total of 114 patients (59 males; median age, 70 (range, 20-92) years) were included. Median polyp size was 2.5 (0.4-10) cm. After polypectomy, of 54 patients with low-risk malignant polyps, 13 died of unrelated causes after a median of 76 months, 5 had no residual tumor at surgery, and 33 were alive and well during a median follow-up of 69 (range, 9-169) months. Of 60 patients with high-risk malignant polyps, 52 had surgery (residual carcinoma 27 percent). Five of eight patients not operated had an uneventful follow-up of median 57 (range, 47-129) months. Patients in the high-risk group were significantly more likely to have an adverse outcome than those in the low-risk group (P < 0.0001). Review of 20 studies including 1,220 patients with malignant polyps revealed no patient with low-risk criteria with an adverse outcome. CONCLUSIONS: For patients with low-risk malignant polyps, endoscopic polypectomy alone seems to be adequate. In high-risk patients, the risk of adverse outcome should be weighed against the risk of surgery.

Association of polymorphisms and haplotypes in the elastin gene in Dutch patients with sporadic aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: A locus containing the elastin gene has been linked to familial intracranial aneurysms in 2 distinct populations. We investigated the association of single-nucleotide polymorphisms (SNPs) and haplotypes of SNPs in the elastin gene with the occurrence of subarachnoid hemorrhage (SAH) from sporadic aneurysms in the Netherlands. METHODS: We genotyped 167 SAH patients and 167 matching controls for 18 exonic and intronic SNPs in the elastin gene. A Bonferroni correction was applied for multiple comparisons with all novel associations, with a correction factor derived from the number of SNPs tested (P value after Bonferroni correction [P(corr)]). RESULTS: SAH was statistically significant associated with an SNP in exon 22 of the elastin gene (minor allele frequency was 0.000 in patients and 0.028 in controls; odds ratio [OR], 0.0; 95% CI, 0.0 to 0.7; P=0.004; P(corr)=0.05) and possibly with an SNP in intron 5 (minor allele frequency was 0.062 in patients and 0.128 in controls; OR, 0.5; 95% CI, 0.2 to 0.8; P=0.007; P(corr)=0.08). Haplotypes of intron 5/exon 22 (P(corr)=0.002), intron 4/exon 22 (P(corr)=0.02), and intron 4/intron 5/exon 22 (P=9.0x10(-9)) were also associated with aneurysmal SAH. CONCLUSIONS: Variants and haplotypes within the elastin gene are associated with the risk of sporadic SAH in Dutch patients. Gradual increase of statistical power with the inclusion of 2 or 3 SNPs in the studied haplotypes supports the validity of our conclusion that the elastin gene is a susceptibility locus for SAH.

Cerebral gnathostomiasis as a cause of an extended intracranial bleeding.

This is a report of a fourteen year old Thai-girl who presented with acute hemiparesis because of intracranial haemorrhage six weeks after immigrating to Germany. Marked blood eosinophilia and raised IgE in serum in comparison with her origin led to the suspected diagnosis of parasitosis. Angiography showed mycotic aneurysm typical for cerebral gnathostomiasis one of the major causes of intracranial haemorrhage in children in Thailand. This diagnosis was confirmed by detecting specific antibodies against Gnathostoma spinigerum in serum and CSF by Western blot. Therapy was started with albendazole and dexamethasone and the girl made a complete recovery. In case of intracranial haemorrhage cerebral gnathostomiasis should be considered if the patient originates from an endemic area.

Long-term results of endoscopic removal of large colorectal adenomas.

BACKGROUND AND STUDY AIMS: Endoscopic removal of large colorectal polyps has not been widely accepted. The aims of this study were to evaluate our longterm experiences justifying endoscopic resection technique as the treatment of choice. PATIENTS AND METHODS: During a period of 12 years, 288 patients with a total of 302 polyps larger than 3 cm in diameter were treated endoscopically. 224 polyps were sessile and 78 pedunculated. Sessile polyps were removed using the piecemeal technique. Surgery was recommended in patients with unfavorable histology. Patients with favorable histology were followed up at 3 - 6 month intervals in the first year and then every 1 - 2 years. RESULTS: A total of 184 patients with sessile polyps were followed up for at least 6 months. Recurrence rate of 166 benign polyps was 17 % (29/166). Only two patients had malignant recurrence. 8 of 18 patients with malignant polyps underwent surgery while 10 were unfit for surgery. 8 of these patients remained free of recurrence. CONCLUSIONS: Previous concerns about endoscopic removal of large colorectal polyps are no longer justified. The results of this study showed that endoscopic resection of large colorectal polyps is safe and effective. In patients with high operative risk, endoscopic removal may be adequate.

Variceal bleeding and portal hypertension: has there been any progress in the last 12 months?

A review of the literature on the management of esophagogastric varices published in the last 12 months shows that the data are still quite conflicting. In the primary and secondary prophylaxis of variceal bleeding, beta-blockers are still the mainstay of pharmacotherapy. Measurement of the hepatic portal venous pressure gradient is considered to be a reliable parameter for successful reduction of portal pressure using medical therapy. However, intolerance of propranolol requiring discontinuation of therapy has been observed in approximately 30 % of patients. Patients' compliance with medication may represent another drawback of medical therapy. The role of endoscopic band ligation in secondary prophylaxis is now indisputable, especially in comparison with sclerotherapy. In the primary prevention of variceal bleeding, band ligation is beginning to have a competitive edge over pharmacological therapy. Acute variceal bleeding is no longer a frequent morbid emergency. Most cases of bleeding can now be managed successfully with band ligation and N-butyl-2-cyanoacrylate obliteration. N-butyl-2-cyanoacrylate has come into increasingly widespread use in the treatment of bleeding gastric fundal varices in which surgery or transjugular intrahepatic portosystemic shunting were previously regarded as the preferred therapies.

[MRCP in primary sclerosing cholangitis]. / MRCP bei primärer sklerosierender Cholangitis.

PURPOSE: Evaluation of MR-cholangiopancreaticography (MRCP) for the diagnosis of primary sclerosing cholangitis (PSC) in correlation with endoscopic retrograde cholangiopancreaticography (ERCP) and in comparison to the diagnostic accuracy of various T2-weighted sequences. METHODS AND MATERIALS: Fifty-five patients (34 males, 21 females; mean age 40 years, range 16 to 65 years) with suspected PSC were examined in a 1.5 T MR unit (Magnetom Vision, Siemens, Erlangen), using breath-hold transverse and coronal HASTE, paracoronal RARE and thin-sliced HASTE (TS-HASTE) sequences. Applying a five-point-scale, two blinded investigators assessed the image quality for ROC analysis. Morphologic criteria of PSC were documented and correlated with ERCP, which served as the gold standard, and sensitivity, specificity and diagnostic accuracy were calculated. RESULTS: PSC was confirmed in 40 of 55 patients (ERCP 55 of 55, liver biopsy 37 of 55), with concomitant chronic ulcerative colitis in 27 and Crohn's disease in 6 of the 40 patients. Qualitative analysis of the image quality showed no significant difference between RARE, HASTE and thin-sliced HASTE sequences (3.4/3.5/3.2). The RARE sequence had the highest sensitivity (97 %), specificity (64 %) and accuracy (84 %) for the detection of PSC. The difference between HASTE and thin-sliced HASTE was statistically significant (p < 0.01). Of the 40 patients with confirmed PSC, 29 were followed by MRI and 3 underwent a liver transplantation within the follow-up period. A Klatskin tumor, which was misdiagnosed by MRCP, was diagnosed by brush biopsy in 1 of the 40 patients. Interobserver variability was adequate to good (kappa 0.4 to 0.7), depending on the chosen sequence. CONCLUSION: MRCP seems to be a reliable non-invasive imaging method to diagnose and follow PSC. The RARE sequence showed the highest diagnostic accuracy of the T2-weighted sequences.

Biventricular pacing for successful weaning from extracorporal circulation in an infant with complex tetralogy of fallot.

Biventricular pacing therapy is an innovative therapy for improving cardiac output in adult patients with severe heart failure. However, this technique is not yet used in infants with congenital heart disease. We present a six month old infant with tetralogy of fallot and atresia of the left pulmonary artery in which biventricular stimulation led to improved left ventricular function and successful weaning from extracorporeal circulation.

First in vivo optical coherence tomography in the human bile duct.

BACKGROUND AND STUDY AIMS: Optical coherence tomography (OCT) is a novel technique for performing high-resolution, cross-sectional tomographic imaging in human tissue, which allows resolution of up to 10 microm. The short depth of penetration allows assessment of the superficial 2 mm of the gastrointestinal tract, an area that is difficult to appraise even with high-frequency ultrasound. This is the first report on in vivo OCT of the human biliary system. The aim was to assess the feasibility of the technique. PATIENTS AND METHODS: Four cases of intraductal OCT are presented. The probe was inserted through the working channel of a duodenoscope. RESULTS: The connective tissue layer and the underlying retroperitoneal tissue, with less backscattering, could be clearly demonstrated. The images showed a layer architecture which was similar to that found histologically. CONCLUSIONS: OCT of the biliary system is feasible in patients with biliary pathology. Interpretable images were obtained, and clinical use needs further assessment. As current OCT probes and processors do not yet provide optimal resolution, further generations of equipment with improved image quality are required.

Correction of simple congenital heart defects in infants and children through a minithoracotomy.

BACKGROUND: Minimally invasive surgical techniques in pediatric cardiac surgery have evolved throughout the last 10 years. Advantages of minimally invasive procedures include excellent cosmetic results and superior postoperative outcome. However, safety of minimally invasive techniques has to be proven. METHODS: In 21 female infants and children, a right anterolateral thoracotomy was performed. Mean age was 7.1 years (0.5 to 16.6 years) and mean body weight was 20.8 kg (8.3 to 56 kg). The following defects were repaired: atrial septum defect type II (n = 14); partial atrioventricular septum defect (n = 3); partial anomalous pulmonary venous connection (n = 2); ventricular septum defect (n = 2); mitral valve insufficiency (n = 1); and resection of an embolized atrial septum defect occluder (n = 1). In two cases, aortic cross-clamping was performed by using a transthoracic clamp. In 5 patients, femoral cannulation was performed. Skin incisions were limited to 4 to 7 cm. RESULTS: There was no operative or late mortality. Mean operation time, bypass time, and aortic cross-clamp time were 138 (95 to 275), 72 (32 to 179), and 35 (12 to 120) minutes, respectively. Mean postoperative mechanical ventilation time, mean intensive care unit stay, and mean hospital stay were 3.9 hours (1 to 12 hours), 1.4 days (1 to 3 days), and 12 days (8 to 18 days), respectively. Postoperative complications included hemorrhage in 1 patient requiring surgical intervention. Mean follow-up period was 13.3 months (1 to 36 months). All patients were in New York Heart Association class I postoperatively. Trivial mitral insufficiency was evident in 1 patient operated for partial atrioventricular septum defect. CONCLUSIONS: A small right anterolateral thoracotomy as a minimally invasive technique in pediatric cardiac surgery is a safe and suitable alternative in the operative management of simple congenital heart defects. Cosmetic results are superior, however, improved postoperative outcome has to be proven.