[Operative revascularization of visceral arteries in chronic mesenteric ischemia]. / Operative Revaskularisation der Viszeralarterien bei chronisch mesenterialer Ischämie.

Chronic mesenteric ischemia (CMI) is mostly the result of atherosclerotic occlusive processes of unpaired mesenteric arteries. Operative procedures are preferred in cases of occlusion of a long vessel segments and/or highly calcified stenoses near the ostium. Frequently, bypasses are constucted from the aorta to visceral arteries and autologous veins should be preferred. Due to atherosclerotic alterations aortic bypass anastomoses are difficult and prone to complications. Based on case descriptions a surgical technique is presented that simplifies the aortovisceral artery bypass procedure. In all 6 patients the bypasses were open after 27 months and the average increase in body weight was 13 kg within the first postoperative 6 months.

German Survey on EUS-Guided Diagnosis and Management of Gastrointestinal Stromal Tumors (GISTs) - Evidence or "Gut-Feeling"?

PURPOSE: To examine practice patterns of endosonographers in diagnosing and managing gastrointestinal stromal tumors (GISTs) in Germany. MATERIALS AND METHODS: A modified published survey (Ha et al., Gastrointest Endosc 2009) was sent to endosonographic ultrasound (EUS) customers in Germany. The survey was also publicized on the homepage of an EUS interest group. To avoid duplicate opinions, participants were asked to return one survey per institution. RESULTS: 142 centers of roughly 850 German EUS centers responded. 25 % were from University hospitals and 74 % from community hospitals. 61 % performed > 2 EUS scans for suspected subepithelial lesions/week. Although 97 % of respondents believed that tissue acquisition with CD117 immunohistochemistry best predicts a GIST, 11 % do not perform EUS-FNA when suspecting a GIST, 68 % perform it occasionally and 18 % perform it regularly. The main EUS criteria used for a suspected GIST are the typical layer (85 %), hypoechoic appearance (80 %) and gastric location (51 %). 69 % would diagnose a GIST with negative CD117 if the EUS criteria and spindle cells are present. FNA was rated helpful in < 50 % by 55 % of participants. Size was the primary criterion for suspecting malignancy. 95 % of respondents would perform surveillance ≥ 1x/year of GISTs that are not resected. CONCLUSION: There is significant variability in the diagnosis and management of GISTs in Germany. Diagnostic certainty of EUS-FNA is suboptimal in many centers and EUS is frequently used for guidance. The diagnosis of a GIST is often guided by a "gut feeling" rather than evidence. Efforts should be made to unify existing guidelines.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

EUS-Guided Bile Duct Drainage (EUBD) in 95 Patients.

PURPOSE: Bile duct stenting during ERCP has long been established as the gold standard for the treatment of biliary obstruction. However, when the ampulla cannot be reached or bile duct cannulation fails, percutaneous or surgical drainage is performed. The study aimed to investigate the feasibility and long-term outcome of a potential alternative intervention, EUS-guided transluminal biliary drainage (EUBD), in a representative number of patients. MATERIALS AND METHODS: All patients undergoing EUBD were included in a prospectively collected single-center database over a 10-year period. Feasibility was characterized by technical and clinical success, including long-term follow-up data. RESULTS: From IV/2002 - XI/2012, 10 832 EUS and 8756 ERCP procedures were performed. Simultaneously, 223 PTCD and 95 EUBD were performed. Cholangiography was achieved in 93/95 patients (97.9 %). However, in one patient stone extraction was executed by means of the rendezvous technique. Therefore, drainage was not necessary. Intention to treat with EUS-guided drainage was given in 80/94 patients (86.9 %) using different techniques depending on anatomical variations and requirements. The cause of bile duct obstruction could not be cured in 77 patients (malignancy). In 18 patients, a benign (n = 15) or unknown etiology (n = 3) of bile duct stenosis was found. The complication rate was 15.7 % (mortality, 1.1 %; n = 1/95). The follow-up ranged from 3 - 60 months with reintervention in 3 patients. CONCLUSION: EUBD is a promising therapy for bile duct obstruction in patients predominantly with malignant diseases. Using EUBD, an excellent interventional approach is available for long-term internal drainage to prevent percutaneous drainage (PTCD). EUS-guided drainage is challenging and needs extraordinary interventional expertise, preferentially in tertiary gastroenterological and endoscopic centers.

[EUS-guided drainage of the pancreatic duct (EUPD)--promising therapeutic alternative to surgical intervention in case of symptomatic retention of the pancreatic duct and unsuccessful ERP]. / EUS-geführte Drainage des Pankreasgangs (EUPD)--eine therapeutische Alternative zur Operation bei symptomatischer Retention des Pankreasgangs und erfolgloser ERP.

BACKGROUND: Transpapillary ERP is the gold standard in symptomatic retention of the pancreatic duct or pancreatic fistula; however, it fails in 5-10 % due to a papilla which cannot be reached or cannulated, or in postoperative changes which do not allow conventional endoscopic drainage. METHOD: Based on our clinical, endoscopic and EUS-related experience as well as a literature search, EUS-guided pancreaticography and drainage of the pancreatic duct (EUPD) are described as alternative approach i) to symptomatic retention of pancreatic duct, ii) for cases with stenoses of the pancreatic duct and anastomoses which cannot be treated with conventional endoscopy, and iii) for patients with postoperative pancreatic fistula within the diagnostic and therapeutic management, including adequate indication, performance and outcome. RESULTS: EUPD is indicated in cases with i) altered anatomy of upper GI tract (congenital; papilla or pancreaticoenteric anastomosis), ii) symptomatic retention of pancreatic duct due to changes in peripapillary region or iii) stenosis of pancreatic duct/anastomosis, and iv) if surgical intervention cannot be done with a reasonable risk-benefit ratio. EUPD can provide a success rate of 25 to 92 %, a complication rate of 14 to 40 % (bleeding, perforation, pancreatitis, pain) and long-term clinical success rate of 69 to 78 % (pain-, symptom-free). Advantages are sustained endoscopic methodological variability, minimal invasiveness, improvement in quality of life, possible endoscopic revision of complications and conventional endoscopic equipment. In contrast disadvantages include high level of expertise, only low case load, long learning curve, instruments needing further optimisation, and a still not good clinical success rate of 70 % as well as status as an experimental clinical method. CONCLUSION: With adequate experience EUPD is for carefully selected patients an uncomplicated, elegant and safe method and represents an alternative therapeutic option for the interventional endoscopist allowing more invasive procedures to be avoided. Further prospective and systematic evaluations and technical refinements of EUPD-associated results are needed in order to establish general therapeutic guidelines on indications, peri-interventional management and to define a practical guideline-relevant procedure.

[Endoscopic ultrasonography (EUS)-guided transluminal cholangiodrainage (EUCD) - a novel option of interventional endoscopy in the interdiciplinary management of obstructive jaundice]. / Endosonografie (EUS)-gestützte transluminale Cholangiodränage (EUCD) - eine neue Option der interventionellen Endoskopie im interdisziplinären Management des obstruktiven Ikterus.

BACKGROUND: ERCP and PTCD are considered the gold standard in the interventional treatment of biliary obstruction, in particular, with palliative intention. If ERCP and PTCD are not possible, an alternative drainage procedure such as the EUS-guided cholangiodrainage (EUCD) can be used. AIM / METHOD: By the mean of a compact review, indication, technique, variants of approach, number of treated patients and therapeutic procedures reported by various authors, success rate, spectrum and management of complications as well as recommendations for an appropriate follow-up-investigation protocol for EUCD based on our own clinical experiences and compared to published data are described. RESULTS: EUCD is an interventionally endoscopic / -sonografic procedure, which is used in case of postoperatively changed anatomy of the upper GI tract (BII gastric resection, PPPHR, Whipple procedure, [sub-]total gastrectomy, Roux-en-Y reconstruction) and, thus, if papilla of Vater (papilla) can not be reached or catheterized or if the patient denies PTCD in subjects with recurrent, advanced or metastasized tumor lesion(s) of the upper abdomen, hepatobiliary system as well as pancreas and associated obstruction of the biliary tree - / + jaundice. PRINCIPLE: EUS-guided transluminal puncture from the upper GI tract into various extra- / intrahepatic segments of the biliary system, recanalization of the tumor stenosis with stent insertion through the access site or bypassing the tumor (stent-based retro- or antegrade drainage of the biliary tree). Derived from this, there are various approaches and procedures - EUCD i) combined with rendesvouz technique, ii / iii) transhepatically with retro- (permanent hepaticoenterostomy) / antegrade internal drainage, iv) extrahepatically with antegrade drainage (permanent choledocho-enterostomy), which are distinguished according to tumor site, possible direction of translumenal puncture, insertion of a guide wire and final stent placement. Within the spectrum of complications (rateLit.: 0 - 25 %), bleeding, perforation, stent dislocation / -migration/-occlusion and slight postinterventional pain are relevant. Currently, approximately 200 cases have been published worldwide; the clinical experience of the reporting institution is based on more than > 70 interventions. DISCUSSION: With regard to the limited diffusion process, EUCD cannot be considered a standard procedure yet. The advantages comprise low tissue trauma, primary internal drainage and the possible endoscopic re-intervention in case of complications. The high technical challenge in performing EUCD is a disfavourable aspect for broader use in clinical practice. However, the disclosed treatment results demonstrating an acceptable complication rate show that EUCD can be competitively considered to ERCP und PTCD with a great chance for primary success. CONCLUSION: EUCD is an elegant, not yet fully established, but rather still experimental procedure of interventional endoscopy / EUS, which needs great expertise of the endoscopist in an interdisciplinary centre of visceral medicine as one of the main predictions. In experienced hands, a safe procedure can be provided, for which a systematic follow-up and a multicentre evaluation of periinterventional management are still needed in order to achieve a final assessment of EUCD for guideline approval.

Value of ultrasound (US)-guided percutaneous needle biopsy of detected pathological gastrointestinal (GI) tract lesions but negative or incomplete endoscopy.

PURPOSE: The study aim was to investigate the diagnostic value of US-guided percutaneous needle biopsy in the case of suspicious tumor lesion of the GI tract revealed by abdominal US but without detection with endoscopy or with incomplete or no possible endoscopy. PATIENTS AND METHODS: Over a defined time period, all consecutive patients with no appropriate endoscopic diagnostic specimen or finding were registered. The patient, diagnostic, and periinterventional characteristics were documented. RESULTS: In total, 16 patients (7 males; mean age, 63.2 [range, 43 - 90] years) were enrolled in this study representing a rare but possible constellation from endoscopic practice characterized by no detectable intraluminal tumor growth and a suspicious tumor lesion revealed with abdominal US as found in each case (n = 16) from 01 / 01 / 2003 - 12 / 31 / 2006. The main indications for needle biopsy were pathological colonic cockades (n = 7) and tumor lesions of the stomach and small intestine (n = 9). The first needle biopsy attempt was successful in all subjects (technical success rate: 100 %) using the color-coded US mode in each case (100 %). There were no postinterventional complications (rate: 0 %). CONCLUSION: Percutaneous US-guided needle biopsy can be considered a safe diagnostic tool for clarifying the differential diagnosis of suspicious tumor lesions of the GI tract (revealed originally only by abdominal US) as the next favorable diagnostic step in the rare situation that endoscopy cannot provide appropriate information, in order to shorten the diagnostic course, to achieve a therapeutic decision and to decrease effort and costs.

Accuracy of endoscopic ultrasound elastography used for differential diagnosis of focal pancreatic masses: a multicenter study.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound (EUS) elastography represents a new imaging procedure that might characterize the differences of hardness and strain between diseased tissue and normal tissue. The aim of this study was to assess the efficiency of EUS elastography for the differentiation of focal masses in chronic pancreatitis and pancreatic cancer. PATIENTS AND METHODS: The study group comprised 258 patients with focal pancreatic masses included prospectively at 13 participating centers. Qualitative analysis of the diagnoses made by two expert doctors using all recorded video clips was performed in order to test the interobserver variability. A post-processing software analysis was used to examine the EUS elastography videos by calculating average-hue histograms of individual elastography images. The quantitative information was used to calculate intra-observer variability and the accuracy of the method. RESULTS: Qualitative analysis of the recorded videos revealed a kappa value of 0.72. Intra-observer variability analysis revealed that the single measure intraclass correlation ranged between 0.86 and 0.94. The average-hue histogram analysis of the data indicated a sensitivity of 93.4 %, a specificity of 66.0 %, a positive predictive value of 92.5 %, a negative predictive value of 68.9 %, and an overall accuracy of 85.4 %, based on a cut-off value of 175. Area under the receiver operating characteristic curve (AUROC) was 0.854 ( P < 0.0001) with a confidence interval of 0.804 - 0.894. CONCLUSION: The value of quantitative analysis of EUS elastography recordings was proven by good reproducibility of the videos, as well as good parameters of the AUROC analysis. (Clinical Trials.gov identifier: CT00909103).

Interventional ultrasound-guided procedures in pancreatic pseudocysts, abscesses and infected necroses - treatment algorithm in a large single-center study.

UNLABELLED: Through a time period of 5 years, all consecutive patients were documented in this prospective single centre observational clinical study to investigate feasibility and outcome of ultrasound(US)- and EUS-guided drainage of symptomatic non-infected pancreatic pseudocysts and abscesses as well as the endoscopic debridement of infected necroses. RESULTS: From 03 / 23 / 2002 to 12 / 31 / 2008, 147 patients (females:males = 49:98 [1:2.0]) with pseudocysts (n = 32), abscesses (n = 81) and necroses (n = 34) were enrolled in the study. Technical success rate in US-guided external and in EUS-guided transmural drainage was 100 % and 97.0 %, respectively, whereas that of transpapillary (ERP-guided) drainage was 92.1 %. While the complication rate in external drainage was 3.7 %, this rate in transmural and transpapillary drainage was 9.6 % and 0, respectively. Late complications (> 24 h) were observed in 6.4 % of patients after transpapillary drainage (external drainage, 5.6 %; transmural drainage, 19.1 %). Complications in 5 cases (bleeding, n = 3; perforation, n = 1; dislocation of the prosthesis with perforation of the terminal ileum, n = 1) needed to be approached surgically. After a mean follow-up period of 20.7 months, 20.9 months, and 19.4 months, the definitive therapeutic success rate was 96.2 % in average for the three diagnoses such as pseudocyst (96.9 %), abscess (97.5 %), and necrosis (94.1 %), respectively (recurrency rate, 15.4 % in average; overall mortality, 0.7 % but no intervention-related death). CONCLUSION: US- and endoscopy-based management of pancreatic lesions as reported is suitable and favorable also in daily clinical routine since it is a safe and efficacious approach in experienced hands.

Value of endoscopic ultrasonography-guided fine needle aspiration (FNA) in the diagnosis of neoplastic tumor(-like) pancreatic lesions in daily clinical practice.

PURPOSE: To investigate the value of EUS-guided FNA in the diagnosis of solid and cystic pancreatic tumor(-like) lesions as well as metastatic tumor growth within peripancreatic lymph nodes and its impact on therapeutic decision-making. The results of the cytologic and pathohistological investigation were compared with i) each other and ii) the detection rates of various imaging procedures. PATIENTS AND METHODS: Overall, 153 patients (mean age, 56.9 years) underwent EUS-guided FNA from I/ 2000 - III/ 2003. RESULTS: Comparing various imaging procedures such as CT scan (80 %), MRI (57.1 %) and abdominal US (88.8 %), EUS achieved the highest diagnostic accuracy: 100 %. For EUS-based T-staging in 26 patients with malignant tumor lesions undergoing surgical intervention, there was a sensitivity of 73.3 % (specificity, 85.9 %; PPV, 69.2 %; NPV, 84.4 %), while the parameters for N-staging (n = 25) were: sensitivity, 61.5 %; specificity, 75 %; NPV, 64.3 %; PPV, 72.7 %. While the sensitivity of EUS-guided FNA in the group of patients who underwent surgical intervention (n = 55) was 81.4 % (specificity, 75 %; PPV, 92.1 %; NPV, 52.9 %), the parameters were as follows in the subgroup of individuals with chronic pancreatitis (n = 30): sensitivity in detecting a malignant pancreatic tumor lesion, 50 %; specificity, 91.7 %; PPV, 60 %; NPV, 88 %. Based on preoperative characteristics such as suspected diagnosis, TNM stage and tumor entity, a surgical intervention could be avoided in 29 / 153 patients (19 %). CONCLUSION: EUS-guided FNA allows more precise diagnosis clarification (malignant tumor growth and tumor entity) in solid and cystic pancreatic tumor(-like) lesions, which may assist in early and sufficient therapeutic decision-making.

[Jejunobronchial fistula as a complication after an alloplastic diaphragm substitute]. / Jejunobronchiale Fistel als Komplikation nach alloplastischem Zwerchfellersatz--Ein Fallbericht.

CASE REPORT: In a 60-year-old patient with an inflammatory pseudotumour due to a penetrating gastric ulcer, extended gastrectomy and partial diaphragm resection were carried out 7 years ago. The diaphragmatic defect was closed with a prosthetic patch (polytetrafluoroethylene, PTFE). The patient currently complains about cough during eating, fever and weight loss. By means of fluoroscopy after barium swallow, an enterobronchial fistula was detected. Intraoperatively, a 10-cm long, dead-end piece jejunum was found after end-to-side oesophagojejunostomy. The torn-out PTFE patch was seen in a subphrenic empyemic cavity, which communicated with the dead-end length of jejunum and the peripheral bronchi of the lower lobe via a fistula. After resection of the dead-end length of jejunum and extensive debridement of the residual parts of the diaphragm as well as oversewing of the bronchial fistula, the diaphragmatic defect was covered with a distally pedicled flap of the latissimus dorsi muscle. There were no postoperative complications. CONCLUSION: In case of potential infections the implantation of alloplastic material must be excluded. The reversed latissimus dorsi muscle flap proved to be ideal autologous material for reconstruction of the hemidiaphragm. The dead-end length of jejunum in the end-to-side oesophagojejunostomy should be short to prevent any retention of food. Pulmonary resection is not absolutely necessary in the case of enterobronchial fistulation.

Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study).

BACKGROUND: As with endoscopic transmural drainage of peripancreatic fluid collections, the same transluminal access can be expanded to introduce an endoscope through the gastrointestinal wall into the retroperitoneum and remove infected pancreatic necroses under direct visual control. This study reports the first large series with long-term follow-up. METHODS: Data for all patients undergoing transluminal endoscopic removal of (peri)pancreatic necroses between 1999 and 2005 in six different centres were collected retrospectively, and the patients were followed up prospectively until 2008. The initial patient and treatment outcome data were recorded, as were long-term results. RESULTS: Ninety-three patients (63 men, 30 women; mean age 57 years) underwent a mean of six interventions starting at a mean of 43 days after an attack of severe acute pancreatitis. After establishment of transluminal access to the necrotic cavity and subsequent endoscopic necrosectomy, initial clinical success was obtained in 80% of the patients, with a 26% complication and a 7.5% mortality rate at 30 days. After a mean follow-up period of 43 months, 84% of the initially successfully treated patients had sustained clinical improvement, with 10% receiving further endoscopic and 4% receiving surgical treatment for recurrent cavities; 16% suffered recurrent pancreatitis. CONCLUSIONS: Direct transluminal endoscopic removal of pancreatic necroses is associated with good long-term maintenance of the high initial efficacy; complications can occur, with an associated mortality of around 7.5%. Further studies are necessary in order to optimise endotherapy and define its role in relation to surgery in the clinical management of such patients.

Transgastral retroperitoneal endoscopy in septic patients with pancreatic necrosis or infected pancreatic pseudocysts.

OBJECTIVE: Peripancreatic fluid collections are common complications of acute pancreatitis or acute exacerbations of chronic pancreatitis. Surgery is required when these fluid collections become infected or cause obstruction or pain. However, morbidity and mortality after surgery in these cases are still too high, therefore minimally invasive approaches have been encouraged. The aim of this study was to evaluate the feasibility of endoscopic ultrasound-guided transmural drainage with intracystic endoscopy and necrosectomy. MATERIAL AND METHODS: From 2000 to 2006 30 patients (age: 57 +/- 10 years, range: 34 - 74 years) with an infected pancreatic pseudocyst or infected pancreatic necrosis were included in the study. The diagnosis of infection in patients who had fever despite an adequate antibiotic regime was confirmed by endoscopic fine needle aspiration with a positive bacterial or mycological result. The mean C-reactive protein value before treatment was 202 +/- 58 mg/L and the mean leukocyte count was 13.25 +/- 4.75 GPt/L. Transgastric cyst drainage was performed using a therapeutic endoscopic ultrasound probe (Pentax 38 UX or Olympus GF UCT 140) with insertion of an 8-Fr double pigtail prosthesis. After balloon dilatation (12 mm) a normal gastroscope was inserted into the cavity and all the fluid and easy removable necrosis were removed. The prosthesis was removed 4 weeks after the end of the endoscopic treatment. Clinical and ultrasound follow-up were carried out 3 and 6 months after removal of the prosthesis. The mean follow-up was 60 weeks. RESULTS: The technical success of the procedure was 96.7 %, the long-term success was 83.4 %. On average 2.7 (range: 1 - 16) procedures were necessary for complete removal of necrosis and the remaining fluid. Major complications (bleeding, perforation, fistulation) occurred in 10 %. In 10 % a secondary operation was necessary. The overall mortality rate was 6.6 %. DISCUSSION: Endoscopic treatment of infected pseudocysts and infected postacute pancreatic necrosis using transgastral retroperitoneal endoscopy with fluid and necrosis removal is a minimally invasive and effective procedure in patients with acute pancreatitis or acute exacerbation of chronic pancreatitis. However, the mortality rate of 6.6 % has to be taken into account.

Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding-the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006.

BACKGROUND: Adjustable silicone gastric banding (ASGB) is an effective treatment in morbid obesity. Band migration is a long-term complication. Causes, clinical symptoms, timing and incidence are investigated in single centres only. In Germany, since January 1st, 2005, practice in bariatric surgery has been investigated in German prospective multicenter trial for quality assurance in obesity surgery. MATERIALS AND METHODS: All patients underwent ASGB in two centres of bariatric surgery in Germany were prospectively registered using a computer-based data form. Patients with band migration were retrospectively evaluated, in particular, causes and characteristics of its management. The results were correlated with data obtained from the German prospective multicentre trial. RESULTS: In total, 493 patients were enrolled in the study from February 1995 to February 2007. The follow-up rate was 79.9% (mean follow-up time period, 78.7 months; range, 2-148 months). Fifteen patients (3.0%) developed migration. In 14 cases, migration occurred within the range of 30-86 months after implantation. In one case, migration occurred 10 months after repositioning of the band. In the German multicentre trial, 629 patients underwent surgery during 2005 and 827 patients in 2006. In both periods, 74.4% of the patients were female and 25.6% male. The most frequently performed operation was ASGB (46.8%) followed by Roux-en-Y gastric bypass (38.5%). CONCLUSION: Band migration requires band removal. Different symptoms and complications influence the kind of band removal. Multicentre data were evident in the case of high long-term complication rate after ASGB. Data of the German multicentre trial show the trend from restrictive bariatric procedures to malabsorptive approach.

"Hemosuccus pancreaticus"--primarily ultrasound-guided successful intervention using transcutaneous fibrin glue application and histoacryl injection.

There is a broad spectrum of causes for upper gastrointestinal (GI) bleeding that can be stopped by various approaches. On the basis of the report of an extraordinary case, the favorable minimally invasive approach of applying fibrin glue and histoacryl/lipiodol to the vascular basis of a bleeding pseudoaneurysm leading to "Hemosuccus pancreaticus" as a rare cause of recurrent bleeding in the upper GI tract and dangerous complications in the case of chronic pancreatitis is described. There were recurrent bleeding episodes within the upper GI tract in a 40-year-old female patient. Her medical history was significant for chronic pancreatitis and pseudocyst. Abdominal ultrasound plus duplex ultrasonography revealed a pseudoaneurysm within the tail of the pancreas as the cause of "Hemosuccus pancreaticus". Ultrasound guidance was used to repeatedly apply 2 ml of fibrin glue and 2 x 2 ml of the mixture of lipiodol and histoacryl to the basis of the pseudoaneurysm which led to complete and permanent cessation of the bleeding. Immediate and follow-up control duplex ultrasonographies (up to one year) demonstrated sufficient exclusion of the pseudoaneurysm but a preservation of the lienal artery with no disturbance of the blood perfusion in the splenic parenchyma. In conclusion, this is one of the first reports of the successful cessation of recurrent bleeding into a pseudocyst out of pseudoaneurysm ("Hemosuccus pancreaticus") by an ultrasound-guided transcutaneous fibrin glue and histoacryl/lipiodol application, which 1. is recommended as an alternative but feasible and safe therapeutic tool, 2. can provide sufficient and permanent cessation of bleeding but preserve the perfusion of the natural vessel as an initial step in the possible therapeutic algorithm, and 3. can avoid, in case of success, more invasive approaches such as angiography-guided embolization with coils or implantation of a prosthesis and even open surgical intervention, in particular, in high-risk patients.

[Therapeutic endosonography]. / Schwerpunkte der interventionellen Endosonografie.

Endoscopic ultrasonography (EUS)-guided interventions are an essential tool for complex (such as combined or subsequent) therapeutic measures and are, in current as well as future endoscopy, an indispensable part of modern gastroenterology. Longitudinal EUS scanners allow one to puncture transluminally both mediastinal and abdominal lesions which cannot be approached with other techniques. Using the EUS-guided puncture of such pathological lesions, it becomes possible to perform further, more advanced endoscopic interventions which thus become safer as well as more efficient and are associated with a lower complication rate compared with conventional endoscopic or even surgical interventions. A crucial aspect in interventional EUS is the adequate, less traumatic treatment of pancreatic pseudocysts. The transluminal route for interventions spanning from the approach to the placement of a drainage for abscesses and/or necroses is considerably easier under EUS-guidance, including better outcomes. Novel approaches and interventions are the internal EUS-guided insertion of a transluminal (from the upper GI tract) I) cholangiodrainage in patients with malignant obstruction of the bile duct but no option to achieve sufficient conventional cholangiodrainage with ERC or PTC, II) pancreaticodrainage in symptomatic patients with enlarged pancreatic duct -/+ pancreatic fistula postoperatively or in patients with chronic pancreatitis, which may be considered new therapeutic strategies with non-operative intentions and/or low invasiveness.

Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation.

PURPOSE: There is currently no imaging procedure that allows precise differentiation between inflammatory and malignant lesions of the papilla of Vater (papilla) in a satisfying manner. The aim was to study whether endoscopic ultrasonography (EUS) as an initial diagnostic step 1. may have the potential to distinguish between different tissue characteristics, such as tumor growth or inflammation of the papilla, because of its high resolution capacity and 2. is superior to the accuracy of histologic investigations of mucosal biopsies by means of a prospective collection and retrospective evaluation of the data. PATIENTS AND METHODS: Between 1995 and 2002, a significant pathologic finding in the papilla and the peripapillary region was revealed using EUS in 311 patients (overall, 4,832 EUS investigations); the comparison of this suspicion with the results of histologic investigation was only possible in 183 subjects. In 133/183 patients, a biopsy for histologic investigation was not able to be obtained prior to the use of EUS. Diagnosis was set up using EUS, which tried to differentiate between benign or malignant lesions of the papilla. Histologic investigation of the 133 tumor lesions of the papilla became possible by taking deep transpapillary biopsies following papillotomy, papillectomy or by obtaining specimens from surgical resections. RESULTS: Using EUS, differentiation between inflammatory and neoplastic lesions of the papilla or the peripapillary region was correct in 109 of 133 cases (82%), while suspected EUS-based diagnosis "papillitis stenosans" (inflammatory lesions of the papilla of Vater) in 4 subjects (3%) was corrected to adenoma and carcinoma, respectively (n=2 each) by histologic investigation. In 20 of 133 patients with suspected neoplastic lesions, inflammatory lesion of the papilla of Vater was detected resulting in an overall sensitivity of 92.3% and specificity of 75.3%. CONCLUSIONS: EUS makes it possible to detect small intraampullary tumors and segmental thickening of the wall of the prepapillary biliary duct, which cannot be revealed by conventional imaging. In patients with biliary symptoms, EUS can reliably visualize and characterize a malignant lesion as a first diagnostic tool (detection rate, 82%) and may be considered the basis for subsequent diagnostic steps for verifying diagnosis correctly, e. g., using histologic investigation.

Contrast-enhanced ultrasound for the characterization of focal liver lesions--diagnostic accuracy in clinical practice (DEGUM multicenter trial).

PURPOSE: To evaluate the diagnostic benefit of contrast-enhanced ultrasound for the differential diagnosis of liver tumors in clinical practice. MATERIALS AND METHODS: From May 2004 to December 2006 1349 patients (male 677, female 672) with a hepatic tumor lacking a definite diagnosis based on B-mode ultrasound and power Doppler ultrasound were examined at 14 hospitals by contrast-enhanced ultrasound using a standardized protocol (pulse/phase inversion imaging, mechanical index < 0.4). The Tumor status was assessed based on the vascularity pattern and contrast enhancement seen in focal lesions during the arterial, portal, and late phase. The diagnosis established after contrast-enhanced ultrasound was compared to histology (> 75% cases) or in some cases to CT or MRI. RESULTS: The final diagnosis of hepatic tumors included 573 benign hepatic tumors (hemangiomas n = 242, focal nodular hyperplasia n = 170, hepatocellular adenoma n = 19, other benign lesions n = 142) and 755 malignant hepatic tumors (metastases n = 383, hepatocellular carcinoma n = 279, other malignant lesions n= 93). The overall diagnostic accuracy of contrast-enhanced ultrasound in comparison to the correct final diagnosis based on the combined gold standard was 90.3%. Contrast-enhanced ultrasound was able to correctly assess 723/755 malignant lesions (sensitivity 95.8%) and 476/573 benign lesions (specificity 83.1%). The positive predictive value of contrast-enhanced ultrasound for the diagnosis of a malignant tumor was 95.4% and the negative predictive value of contrast-enhanced ultrasound was 95.7%. CONCLUSION: Contrast-enhanced ultrasound clearly improves the differential diagnosis of hepatic tumors and is very helpful in clinical practice when B-scan or power Doppler morphological criteria are missing.