Endoscopic therapy for infected pancreatic necrosis using fully covered self-expandable metal stents: combination of transluminal necrosectomy, transluminal and percutaneous drainage.

BACKGROUND/AIMS: Endoscopic transluminal therapy has become the standard of care as a less invasive alternative to surgery. In a retrospective case series of two tertiary referral centers we report on an individualized concept combining EUS-guided drainage with self-expanding metal stents, direct transluminal debridement und percutaneous drainage. METHODS: We treated 13 patients with infected pancreatic necrosis. Initially in all patients an EUS-guided drainage with plastic stents was performed under antibiotic protection (transduodenal: 2, transgastral: 11). After clinical consolidation (after 9.6 ±â€Š9.4 days) a covered self-expanding metal stent (Niti-S, Taewoong medical Co., Seoul, Korea) was inserted by performing direct endoscopic necrosectomy in 2.9 ±â€Š1.7 sessions through the stent. In cases of disrupted duct syndromes a pancreatic plastic stent was inserted (5 of 13 patients). In 5 of 13 cases additional percutaneous drainage was applied because of extended necrosis. In one patient percutaneous endoscopic drainage using the percutaneous access was needed. RESULTS: A sustained clinical success was achieved in 12 of 13 cases (CRP before therapy 23.5 ±â€Š14.4 mg/L, after 3.1 ±â€Š2.6 mg/lL). Discharge occurred after 2.5 ±â€Š22.4 days. The self-expanding metal stent was extracted after 82.5 ±â€Š56.6 days. Mean follow up was 8.5 ±â€Š5.9 months. CONCLUSION: Our concept of combining transluminal drainage, direct endoscopic necrosectomy and percutaneuos drainage offers a safe and reliable alternative to surgery, even in case of extended necrosis.

[The role of peroral endoscopic myotomy (POEM) in achalasia]. / Die Rolle der peroralen endoskopischen Myotomie (POEM) bei der ösophagealen Achalasie.

Achalasia is a rare motility disorder of the oesophagus. Classic achalasia is characterised by a lack of propulsive peristalsis of the distal oesophagus and incomplete relaxation of the lower oesophageal sphincter (LES). Traditionally achalasia is treated either endoscopically by pneumatic balloon dilatation or laparoscopically by Heller's myotomy. Both therapeutic procedures show a comparable effectiveness. Recently, peroral endoscopic myotomy was introduced as a new definitive treatment option. So far, this minimally invasive therapy was evaluated in a few clinical studies only. In this survey, peroral endoscopic myotomy is presented and compared to the well established surgical treatment. The diagnosis of achalasia is based on the patient's medical history and analysis of symptoms and particularly on oesophageal manometry. In addition, a barium swallow (oesophagram) and upper endoscopy are performed to rule out other reasons causing dysphagia. The patient's complaints should be recorded by use of a symptoms score. The POEM procedure starts with an incision of the mucosa at the level of the mid-oesophagus. Then, a submucosal tunnel is created distally passing approximately 2 cm over the oesophagogastric junction. After this step, myotomy of (at least) the circular muscle bundle of the distal oesophagus is performed and should be extended to a distance of 2 cm over the cardiac. Finally the mucosal entry site at the level of the mid-oesophagus is closed with endoscopic clips. First results of this technique are very promising with significant symptom relief and reduction of the mean LES pressure. In conclusion, POEM is a new, minimally invasive therapeutic option for the treatment of oesophageal achalasia. First results are very promising; long-term results and results of comparative clinical trials with established treatment methods must be awaited.

A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD.

BACKGROUND AND STUDY AIMS: Unsedated esophagogastroduodenoscopy (EGD) has advantages over sedated EGD - e. g., prevention of side effects related to sedation, less patient monitoring, and less expense. This study compared the feasibility and tolerance of transnasal small-caliber (TSC-EGD) and peroral small-caliber EGD (PSC-EGD) with conventional EGD (C-EGD). PATIENTS AND METHODS: A total of 150 patients referred for diagnostic EGD were randomly allocated to undergo either TSC-EGD, PSC-EGD, or C-EGD under local anesthesia if they agreed to receive sedation only on demand or in case of intolerance. Patients, endoscopists, and nurses completed questionnaires on the tolerability and quality of the examinations using a visual analogue scale (VAS), ranging from 1 (best/nonexistent) to 10 (worst/unbearable) after EGD. Small-caliber EGD and C-EGD were performed with 5.9-mm and 9.8-mm video endoscopes (Olympus), respectively. RESULTS: The patients' age, sex, experience with EGD, and anxiety before EGD did not differ significantly between the three groups, each consisting of 50 patients. TSC-EGD failed in four of the 50 patients (8 %) because of a narrow nasal tract; they underwent PSC-EGD. Complete examinations, including the second part of the duodenum and biopsy sampling, were possible in all patients. Patients examined with an ultrathin instrument required sedation significantly less often (TSC-EGD 6 %, PSC-EGD 18 %, C-EGD 44 %; P < 0.01) and consequently spent less time in the recovery room. TSC-EGD was initially more painful on insertion, but caused less gagging (P<0.01) than peroral EGD during the whole procedure. TSC-EGD caused mild epistaxis in one case. CONCLUSIONS: TSC-EGD was carried out safely and completely in 92 % of the patients. TSC-EGD and PSC-EGD were better tolerated and required sedation less often than conventional EGD. Transnasal diagnostic EGD appears to be a promising alternative to peroral EGD, as it is associated with less gagging and a high level of patient satisfaction.

Cellular and subcellular localization of the 2B-subunit of the NMDA receptor in the adult rat telencephalon.

NMDA receptors (NR) are encoded by a family of genes including those of the NR1 and NR2A-D subunits. In situ hybridization has revealed that NR1, comprising eight splice variants, is ubiquitously expressed in the central nervous system (CNS) while the expression of NR2 isoforms is restricted to particular CNS regions. We report on the cellular and ultrastructural distribution of the NR2B polypeptide in rat telencephalon. In the telencephalon, the hippocampus represented the most intensively immunolabeled region. Here, predominantly the CA pyramidal neurons were heavily stained. Intense immunoreactivity (IR) was also detected in cortical neurons, in particular in pyramidal-like ones of layers II/III and V. On the ultrastructural level, the NR2B subunit was present not only in synaptic complexes where it usually was present in postsynaptic sites but in addition could be located at extrasynaptic sites. Furthermore, preliminary evidence indicates a presynaptic location of NR2B in some rare cases. NR2B antigen distribution is consistent with that of corresponding transcripts. Indeed, NR2B immunoreactivity coincides largely with that for NR1, indicating that both subunits are coexpressed in numerous cortical and hippocampal neurons.