Conservative management of esophageal nontransmural tears after pneumatic dilation for achalasia.

OBJECTIVE: We sought to determine the incidence and outcome with conservative management of esophageal nontransmural tears after pneumatic dilation for achalasia. METHODS: Retrospective review of 50 pneumatic balloon dilations in 30 patients with achalasia was performed at one center over an 18-month period. RESULTS: Forty-four of 50 procedures (88%) were performed without complication. Two patients (4%) developed transmural perforations requiring immediate surgical repair; both recovered uneventfully. Four patients (8%) were found to have linear mucosal tears on routine postprocedure esophagrams. One patient was asymptomatic, and three had chest pain. No patient had fever. These four patients were managed conservatively with in-hospital observation for a mean of 4.3 days (range 3-6): nothing by mouth for a mean of 1.3 days (range 1-2) and i.v. antibiotics for a mean of 3 days (range 2-5). All were discharged within 6 days and were asymptomatic and tolerating a regular diet. CONCLUSIONS: Esophageal nontransmural tears are not uncommon after pneumatic dilation for achalasia and can be safely treated with conservative medical management.

Standard biopsy forceps versus large-capacity forceps with and without needle.

Endoscopic biopsy forceps vary in size and design. The purpose of this prospective randomized study was to compare the quality and quantity of gastric tissue obtained by needle and non-needle versions of standard biopsy forceps and newly designed large capacity forceps. Fifty consecutive patients who underwent endoscopy with gastric biopsy forceps were enrolled in the study. There was no significant difference in the presence of crush artifact between the two forceps, both with and without the presence of a needle. Both needle and non-needle versions of the large capacity biopsy forceps were found to obtain significantly larger sized specimens (p = 0.02) than needle and non-needle versions of the standard biopsy forceps. Overall, there was no significant difference in the depth of specimen obtained when comparing the large capacity forceps to standard forceps. Needle versions of each forceps were found to obtain significantly deeper biopsies than non-needle versions of each forceps. In conclusion, our study found that large capacity forceps obtained larger specimens than standard biopsy forceps. Further clinical trials with a larger study population need to be undertaken to determine the impact of these findings on the determination of diagnoses.

Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology.

OBJECTIVES: Endoscopic investigation of the small intestine remains the last frontier for gastroendoscopists. We evaluated the diagnostic efficacy and safety of two different push-type, fiberoptic enteroscopes in the investigation of patients with occult gastrointestinal bleeding or suspected small bowel pathology. METHODS: Sixty-six patients (28 men, 38 women; mean age, 68) underwent push-type enteroscopy with either the SIF 10.5L (n = 17; scope length, 2495 mm) or the SIF 3000 (n = 49; length, 2995 mm) enteroscopes (Olympus America, Inc., Lake Success, New York). All patients enrolled had an indication of either occult gastrointestinal bleeding (n = 55) or suspected small bowel pathology (n = 11). Push-type enteroscopy was performed with an overtube and fluoroscopic guidance to better estimate the degree of insertion. Assessments of mucosal visualization, tip deflection, procedure tolerance, and complications were noted. RESULTS: Visualization of the small bowel mucosa and tip deflection was rated excellent in all patients. The mean length of insertion past the ligament of Treitz for the SIF 10.5L was 90 cm and 113 cm for the SIF 3000. Only one complication, a pharyngeal tear, occurred with the SIF 3000. Lesions that may explain the occult GI bleeding were found in 35 out of 55 patients (64%). Twenty-one of these 35 patients (60%) had lesions proximal to the ligament of Treitz, and 14 patients (40%) had lesions distal to the ligament of Treitz. If only distal lesions were considered, the diagnostic yield was 25% (14/55) for occult GI bleeding and 73% (8/11) for suspected small bowel pathology. The most common lesions were arteriovenous malformations (34%), which were successfully cauterized. CONCLUSION: With a relatively high diagnostic yield and therapeutic capability, push-type enteroscopy should play an important role in the investigation and treatment of lesions causing occult GI bleeding and small bowel pathology.

Occupational exposure to Helicobacter pylori for the endoscopy professional: a sera epidemiological study.

OBJECTIVES: The purpose of this prospective study was to determine if medical and nursing staff in the United States who are regularly involved in endoscopic procedures are at an increased risk of acquiring Helicobacter pylori infection. METHODS: One hundred and twenty-two gastroendoscopists and endoscopy nurses attending an advanced gastroendoscopy course (17 women, 105 men) completed a questionnaire consisting of past medical and professional history. Serum from each subject was collected and tested using a validated ELISA assay (sensitivity 99%, specificity 96%). H. pylori prevalence in the experimental group was compared to that of 510 blood donors. RESULTS: In all age groups, H. pylori positivity was significantly higher among the study subjects compared with controls. Caucasian subjects, when matched to controls for age, race, and level of education, had significantly higher rates of H. pylori positivity. Foreign-born subjects, when compared to US-born subjects, also had higher rates of H. pylori positivity. There was no statistical difference of H. pylori positivity with respect to gender, years involved in endoscopy, or number of endoscopies performed monthly. CONCLUSION: H. pylori infection is more common in gastroendoscopists and endoscopy nurses than the general population and should be viewed as an occupational hazard.

A comparative study of contrast agents for endoscopic retrograde pancreatography.

Pancreatitis is a major cause of morbidity and mortality secondary to endoscopic retrograde pancreatography (ERP). One factor that may cause post-ERP pancreatitis is the type of contrast media utilized during the procedure. The purpose of this prospective, double-blind, randomized study was to evaluate the effects of three contrast agents of differing osmolality and ionicity on changes between pre- and post-ERP chemical changes in serum amylase and lipase and development of clinical symptoms of acute pancreatitis. Our study of 53 patients showed that those who received Omnipaque a non-ionic, relatively iso-osmolar contrast agent, had a significantly lower serum amylase (p = 0.0038) and serum lipase (p = 0.0002) in post-ERP serological markers, compared with patients who received the ionic agents, Hypaque meglumine 60% or Hexabrix. In addition, the development of clinical symptoms of pancreatitis was less in patients who received Omnipaque than in those who received Hexabrix or Hypaque (1 vs. 3 vs. 4). No significant difference was found between patients who received ionic agents. No patient who received Omnipaque needed hospitalization, whereas one (6%) patient who received Hexabrix was hospitalized compared to three (20%) hospitalized patients who received Hypaque. When the initial cost and cost of hospitalization were compared, the non-ionic contrast medium was also found to be more cost-effective for the patient. In summary, the risk of post-ERP acute pancreatitis was significantly lower for patients who received the non-ionic contrast agent than for those who received the ionic agents.

Sandostatin for control of catheter drainage of pancreatic pseudocyst.

Primary treatment for pancreatic pseudocyst is evolving from surgical intervention to needle aspiration with catheter drainage. The latter treatment results in a similar rate of resolution but has less patient morbidity. This study evaluated the adjuvant role of Sandostatin, which inhibits basal and stimulated pancreatic secretion, in the management of three patients with pancreatic pseudocysts who had prolonged catheter drainage subsequent to percutaneous drainage. Inhibition of secretion occurred in all three patients, as evidenced by decrease in catheter output, which allowed the catheter to be removed. All three patients have remained asymptomatic for 9, 10, and 15 months, respectively. In summary, Sandostatin decreased persistent catheter drainage from chronic pancreatic pseudocysts.

Forceful balloon dilation: an outpatient procedure for achalasia.

The initial treatment of choice in patients with achalasia is balloon dilation. Heretofore, this procedure was performed on an in-hospital basis resulting in high patient cost. This study evaluated the safety and efficacy of pneumatic dilation as an outpatient procedure. Sixty-one procedures were performed on 50 patients at two centers. An overall treatment success rate of 95% (47 of 50 patients) was achieved. Two patients had elective surgical treatment and a third underwent surgery for perforation secondary to dilation. A total of three patients complained of post-procedure chest pain within 4 hours and were hospitalized. Two had perforations; one required surgical repair. The third patient had resolution of symptoms. We conclude that performing balloon dilation as an outpatient procedure is safe, efficacious, and cost effective.

The effects of morbid obesity and the Garren-Edwards gastric bubble on solid phase gastric emptying.

Rapid solid phase gastric emptying (SPGE) resulting in decreased satiety is postulated to be a contributing factor to obesity. Twenty-six morbidly obese patients with a weight range of 189-523 lb were entered into the Garren-Edwards gastric bubble program. SPGE studies were performed pre-bubble implantation and repeated within 2 wk after bubble implant. There was no significant difference between study patients pre-bubble insertion emptying time and the normal population curve. Emptying time was found to be significantly increased, post-bubble implant, compared with pre-bubble implant over five time periods of testing. The Garren-Edwards gastric bubble has been used as a method for inducing early satiety for the morbidly obese patient. It has been postulated that delay of SPGE would be associated with satiety. Our patients experienced satiety despite their more rapid SPGE. Thus, the satiety which was experienced by our subjects was not on the basis of delayed SPGE, as previously thought.

Effects of gastric bubble implant on weight change with and without compliance with a behavior modification program.

The purpose of this prospective study was to evaluate the effect of compliance versus noncompliance with a behavior modification program (BMP) for 35 patients who underwent implantation of 51 Garren-Edwards gastric bubbles (GEGB). Criteria for morbid obesity was met by every patient. Two patient groups were formed by self-selection. Compliant patients (group I) attended 75% or more of the BMP. Group II consisted of noncompliant patients, and was divided further into partially complaint and totally noncompliant. A significant difference was found in both loss of weight and loss of body mass index (BMI) between the complaint and noncompliant groups, with no significant difference in weight loss between the partially and totally noncompliant groups. Patients' compliant or noncompliant behavior had a significant effect on changes in weight (p = 0.007) and body mass index (p = 0.005). Sixteen patients had two consecutive bubble implants. The rate of compliance was significantly higher during the first implant program, with a significantly greater loss in both weight and BMI for compliant patients. Follow-up data for 28 of 35 patients revealed a continued, albeit small, average weight decrease. In summary, weight loss does not result from the gastric bubble alone. Our study demonstrates that the key factor is compliance with a behavior modification program.