Successful use of biliary accessories in antegrade dilation of complex upper esophageal stricture due to chemoradiation and surgery.

Endoscopic management of complete or near complete upper esophageal strictures is challenging. Current methods such as retrograde esophageal access are high risk and may require additional abdominal surgery. A biliary cannulation technique with a 0.035 inch guidewire was utilized to obtain antegrade esophageal access in a patient with near complete high esophageal stricture due to chemo radiation and surgery for head and neck cancer. Biliary accessories including bougie and balloon dilators were used for the initial dilation of the esophageal stricture, followed by the traditional approach of stricture dilation using over-the-wire dilators. The procedure was successfully performed in a patient with near complete upper esophageal stricture due to chemo radiation and surgery for recurrent laryngeal cancer. The dysphagia of this patient was resolved following serial esophageal dilations and his esophageal stricture was wide open on the last upper endoscopy. Biliary accessories can be safely used for obtaining antegrade esophageal access and dilation of near complete upper esophageal strictures. This approach should be considered in patients with complex esophageal strictures, especially after chemo radiation or surgery for head and neck cancer and prior to seeking other more complex alternatives involving retrograde esophageal access.

Ampullary carcinoid tumor presenting as acute pancreatitis in a patient with von Recklinghausen's disease: case report and review of the literature.

A patient with von Recklinghausen syndrome presented with multiple attacks of pancreatitis. Evaluation using computed tomography, endoscopic retrograde cholangiopancreatography, and endosonography revealed an ampullary carcinoid. The patient underwent a pylorus-sparing Whipple resection, and is doing well after 30 months of follow-up. This is the second reported case of ampullary carcinoid presenting with pancreatitis in a patient with von Recklinghausen syndrome.

Nonmalignant obstruction is a common problem with metal stents in the treatment of esophageal cancer.

BACKGROUND: The use of metal stents for the treatment of dysphagia due to esophageal malignancy is an important advance because of ease of delivery and their self-expandable property. Obstruction due to tumor overgrowth is a recognized complication, but nonmalignant obstruction in patients with metal stents is rarely reported. METHODS: Database records of patients who had esophageal cancer and underwent metal stent insertion were reviewed. RESULTS: A total of 116 patients were seen between October 1993 and October 1997. Four types of metal stents had been used (Ultraflex, Z Stent, Wallstent, and Esophacoil). Detailed follow-up information was available for 81 patients, who constitute the study sample. Forty-nine (60%) stent obstructions were reported, 26 of the 49 (53%) were due to tumor overgrowth and 23 (47%) were not associated with malignancy. Histologic analysis of the nonmalignant obstructing tissue showed granulation tissue (56%), reactive hyperplasia (22%) and fibrosis (22%). CONCLUSIONS: Nonmalignant obstruction is a common although infrequently reported complication after placement of metal stents for esophageal cancer. The tissue response of the esophageal mucosa occurred with all 4 types of stents used. No specific characteristic of the stent or prior treatment seems to be related to obstruction of the stent in patients with either nonmalignant obstruction or tumor overgrowth.

Needle-knife papillotomy: a helpful and safe adjunct to endoscopic retrograde cholangiopancreatography in a selected population.

BACKGROUND AND STUDY AIMS: Needle-knife papillotomy (NKP) has been shown to be a useful alternative when standard techniques fail to provide access during ERCP. A retrospective review was conducted to reevaluate the indications, efficacy, and complications of NKP at a tertiary referral center. PATIENTS AND METHODS: A total of 1205 therapeutic endoscopic retrograde cholangiography procedures (ERCPs) were reviewed. Sixty-eight patients (5.6%) had undergone NKP after an established algorithm of techniques had failed to provide access. The NKP results were analyzed in two periods, including initial experience with 470 ERCPs (group 1, NKP n = 22) and later experience with 735 patients (group 2, NKP n = 46). RESULTS: Immediate free cannulation in group 1 was achieved in 14 of 22 patients (64%), vs. 34 of 46 (74%) in group 2. The delayed cannulation rate was five of eight patients in group 1 (62.5%) vs. 11 of 12 in group 2 (92%). The success rate was 19 of 22 patients in group 1 (86%) vs. 45 of 46 in group 2 (98%). The overall success rate was 64 of 68 (94%). Successful cannulation led to a therapeutic intervention in 94% of these patients. A complication rate of 6%, without mortality, was noted. CONCLUSIONS: NKP is a valuable tool that allows a high success rate for cannulation, with a low complication rate. The success rate increases with operator experience. NKP should be carried out by experienced endoscopists after standard maneuvers fail to provide access, and when cannulation is likely to be followed by a therapeutic intervention.

Treatment of Helicobacter pylori infection.

Since acceptance of the association between Helicobacter pylori and peptic ulcer disease, eradication of H. pylori has become the standard of care in the treatment of peptic ulcer disease. Unfortunately, eradication therapy is no easy task, especially when one is faced with a myriad of drug combinations with varying degrees of efficacy and tolerability. The following is a review of the literature regarding the drugs and drug combinations used to eradicate H. pylori and their effectiveness both as single agents and in combination.

TNM staging of pancreatic carcinoma using helical CT.

OBJECTIVE: The purpose of this study was to determine the accuracy of helical CT scanning in predicting the stage of carcinoma of the exocrine pancreas using TNM staging guidelines and in predicting resectability of carcinoma of the exocrine pancreas. MATERIALS AND METHODS: Twenty-six patients with proven adenocarcinoma of the pancreas underwent uniphasic or biphasic helical CT scanning. Two observers unaware of the patient's surgical stage evaluated the CT examinations using the TNM system (with specific assessment and description of disease sites). In addition, the two observers rated confidence of nonresectability using a 5-point scale (ranging from 1, definitely resectable, to 5, definitely not resectable). Observer results and preoperative interpretations were compared with surgical findings. RESULTS: Nineteen of 26 patients had nonresectable disease. The combined observer scores showed correct determination of T stage in 77% of patients, of N stage in 58%, and of M stage in 79%. The overall accuracy in determining lack of resectability was 96% and 84% for the two observers. All errors in determining resectable versus nonresectable disease occurred when the observer was not maximally confident of his or her diagnosis. CONCLUSION: Helical CT is an effective screening technique for assessing T and M stages of pancreatic carcinoma. However, helical CT is poor at detecting regional lymph node involvement. In patients with equivocal T-stage findings (such as questionable venous involvement), other studies such as endoscopic sonography may be of value.

A new system for defining endoscopic complications emphasizing the measure of importance.

BACKGROUND: Currently, there are no satisfactory systems for defining, classifying, and/or scoring endoscopic complications, although it would be important for quality assurance, comparative studies, and outcomes research. Recently the term "negative outcomes" was proposed rather than "complications," and an approach that incorporates "measures of importance" was added to compare negative outcomes. METHODS: A system was developed that defines, classifies, and grades negative outcomes with a scoring system based on measures of importance. Information was recorded on a Morbidity and Mortality (M & M) form, which was used at a monthly quality assurance (M & M) conference. Several measures of importance related to the immediate negative outcome (O) were quantified (effect of the complication on completion of the endoscopy, change in level of care, change in number of hospital days, necessity for new invasive procedures). The disability (D), defined as a residual or chronic negative outcome caused by the complication, was characterized and scored. Death (D) was also characterized, the value varying with circumstances. As a quantitative measure, an overall ODD score was used. RESULTS: One hundred twenty-three negative outcomes were retrospectively classified using the new M & M form and the ODD score was applied for 117 complications. Complications were ranked according to the ODD score. CONCLUSION: A system for defining, classifying, and grading negative outcomes of endoscopic procedures is proposed with a quantitative scoring system that emphasizes measures of importance. The ODD score looks at the immediate negative outcome and also the separate long-term issues of disability and death.