Esophageal reconstitution by simultaneous antegrade/retrograde endoscopy: re-establishing patency of the completely obstructed esophagus.

Complete obstruction of the proximal esophagus is an uncommon complication of radiotherapy. Standard endoscopic dilation is not possible because no lumen exists. We describe a retrospective case series in which rendezvous endoscopy, tissue puncture, dilation, and stenting were used to restore function to a group of patients with complete esophageal obstruction. The series consisted of patients referred for complete esophageal obstruction after radiation therapy over 5 years. Ultimately, five patients underwent successful initial recanalization via rendezvous endoscopy. All patients were able to resume eating and four have been able to maintain oral alimentation with periodic dilation. One patient developed self-limited pneumomediastinum after needle puncture and cervical osteomyelitis after stenting, and another developed an anterior neck abscess after stenting. Rendezvous endoscopy can successfully treat complete esophageal obstruction resulting from radiation therapy. Temporary stenting may allow patients to swallow immediately and leave the hospital sooner but does not appear to reduce the need for subsequent dilation and may result in serious complications.

In vitro study and in vivo application of a reusable double-channel sphincterotome.

BACKGROUND AND STUDY AIMS: Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been deemed to be a "cost-prohibitive" procedure, based upon the cumulative costs of one-time-use accessories and current reimbursement plans. One-time-use sphincterotomes comprise a significant component of that cost and, accordingly, we evaluated the disability and clinical usefulness of a recently introduced reusable double-channel sphincterotome. MATERIALS AND METHODS: We studied a reusable 6-Fr sphincterotome at baseline and following contamination with 10(6) Bacillus stearothermophilus. Reprocessing included a unique 30-minute ultrasonic cleaning step in lieu of manual cleaning, followed by steam sterilization. Parameters evaluated included sphincterotome function, electrical integrity, and our ability to sterilize the devices for three in vitro trials. In vivo studies included patient demographics and outcomes, procedural findings, and success rates, and the mean number of times the sphincterotome was used, functional grading at time of use, and reasons for sphincterotome malfunction. RESULTS: Ten out of ten sphincterotomes maintained form, function, and electrical integrity in vitro, and all cultures were negative after sterilization. In the initial in vivo study, ten sphincterotomes were used in 50 patients (mean, 5 uses) with a 94% success rate. Reasons for sphincterotome failure included leak or breakage of the accessory port in 70%, wire fracture in 10%, incorrect wire bow in 10%, and clogged injection port in 10%. Following reconfiguration of the insertion-port polymer, an additional ten sphincterotomes were used in 110 patients (mean, 11 uses). Mechanical failure occurred primarily at the wire-insertion port, resulting in progressive friction with reuse. There were neither electrical nor infectious complications associated with reuse. CONCLUSIONS: A reusable double-channel sphincterotome is available which can theoretically be reprocessed and sterilized without the manual cleaning step of the reprocessing process. Contingent upon both provider and patient, multiple reuse can be anticipated, and contingent upon purchase price and reprocessing costs, the potential for procedural cost savings is significant.

Reusable biopsy forceps: a prospective evaluation of cleaning, function, adequacy of tissue specimen, and durability.

BACKGROUND: Recent studies have indicated that reusable biopsy forceps remain contaminated after reprocessing and can only be used a mean of 12 to 25 times without malfunction. Because this contradicts traditional endoscopic practice, our study investigated the ability to sterilize a type of commercially available biopsy forceps and prospectively evaluated their function in vivo until malfunction and/or breakage. METHODS: Thirty reusable biopsy forceps were studied, 15 of which were contaminated for 5 trials each with 10(6) Bacillus stearothermophilus, and 15 of which were prospectively evaluated clinically over an 18-month period (9/98-3/00). Contaminated forceps were reprocessed by using a standard protocol and placed in a sterile bag containing soy broth. The latter was passed through a 0.2 micron filter and was subsequently cultured. In vivo data included biopsy site, size, adequacy, problems obtaining a biopsy specimen, and reasons for ultimate forceps failure. RESULTS: After contamination, all biopsy forceps yielded a heavy growth of B stearothermophilus. No forceps, including 5 that were piecemeal dismantled with a wire cutter, had residual bacteria after reprocessing. In the in vivo study, 1507 biopsy sessions were undertaken in 1339 procedures. Forceps were categorized as new or like-new in 1259 of 1339 (94%) procedures, some loss of function but usable in 72 of 1339 (5.4%), and inadequate function or broken at use in 8 of 1339 (0.6%). Histologically, 1501 specimen sets were adequate (99.6%) and mean specimen size was 2.7 +/- 0.1 mm. Mechanical problems were noted in only 38 of 1507 (3%) sessions to include such things as sticky forceps, and the mean number of uses to malfunction or breakage was 91 +/- 15 (SEM) (range 19-132). CONCLUSIONS: This reusable biopsy forceps can be sterilized and used a mean of 91 times with adequate tissue sampling. Mechanical problems were minor to time of breakage. Contingent on acquisition and reprocessing costs as well as the number of procedures performed, this reusable forceps has the potential for significant cost savings.

In vitro and in vivo evaluation of a reusable double-channel sphincterotome.

BACKGROUND: To date, one reusable, double-channel sphincterotome has been approved by the Food and Drug Administration in the United States. Whether this device can be reprocessed easily and whether it is more durable than currently manufactured disposable sphincterotomes are uncertain. METHODS: Thirty double-channel, 20 mm, braided-wire sphincterotomes approved for multiple uses were studied in vitro/in vivo with regard to durability and sterilization. A cost analysis of reusable, disposable, and reprocessed disposable sphincterotomes was also carried out. RESULTS: Three of 10 sphincterotomes evaluated in vitro broke after 3, 4, and 8 uses. Electrical integrity was preserved after 10 uses in the remaining sphincterotomes. Nine sphincterotomes remained functional for at least 3 uses, five for 6 uses, and one for 10 uses. Culture results after inoculation demonstrated contamination with surviving organisms after manual cleaning and no growth after ethylene oxide sterilization. Sixty-one procedures were performed in vivo using 20 sphincterotomes (mean number of uses 3.1). No evidence of procedurally related infection occurred with reuse. Cost per use of this reusable sphincterotome was calculated to be $62.98; it became cost effective after 2.2 and 7.9 uses when compared with disposable and reprocessed, disposable sphincterotomes, respectively. CONCLUSIONS: This reusable sphincterotome proved to be safe, easily sterilized, and electrically intact after repeated use. In vivo, however, a progressive loss of function limited the mean number of uses to 3.1. In settings that preclude reuse of reprocessed disposable accessories, this reusable sphincterotome may provide a means to decrease costs associated with endoscopic retrograde cholangiopancreatography.

Reuse of disposable sphincterotomes for diagnostic and therapeutic ERCP: a one-year prospective study.

BACKGROUND: Although previous studies have documented that single-channel sphincterotomes can be sterilized and used up to 10 times, no studies have prospectively evaluated the reuse of disposable sphincterotomes. METHODS: Five- and six-French double-channel sphincterotomes marketed as one-time-use only were manually cleaned, sterilized with ethylene oxide, and used up to 10 times. Over a 1-year period, total number of uses as a cannulation or cutting device, reason for sphincterotome dysfunction, possible infectious complications were evaluated, and cost-savings associated with reuse were evaluated. RESULTS: The mean number of times sphincterotomes could be used in our institution was 3.4; a broken or stiff cutting wire was the main reason for discard. There were two infectious complications during the study period. Both were experienced by patients with unrelieved obstruction treated with new sphincterotomes. Contingent on the method used, total savings related to sphincterotome reuse was approximately $66,000. CONCLUSIONS: Double-channel sphincterotomes marketed as one-time-use items can be reused safely when properly cleaned. Reuse was associated with significant cost savings in our institution.

Expandable stents: unusual locations.

OBJECTIVES: Expandable metallic prostheses have been used widely for malignant biliary stenoses and are being used increasingly for malignant dysphagia and esophago-airway fistulas. Potentially, such prostheses can be placed for gut neoplasms obstructing beyond the esophagus or gastric cardia. This series reports our experience with expandable metallic stents in the stomach, jejunum, and colon. METHODS: All patients with expandable gastrointestinal stents (other than biliary tree or esophagus) were reviewed. Indications for stent placement, type and location of prosthesis, patient demographics, procedural problems, and data with regard to outcome were defined. RESULTS: Over a 6-yr period, expandable prostheses (Z stent, Esophacoil, and Ultraflex) were placed in nine patients with widespread malignancy (afferent loop obstruction, three; colon obstruction, three; gastric outlet obstruction, two; and esophagojejunal interposition stricture, one). There was one colon perforation as a consequence of dilation prior to placement of the prosthesis. Subsequent problems included migration (one), occlusion by food bolus (one), and tumor overgrowths/ingrowths (three) which were treated with laser. Median survival approximated 9 months. CONCLUSIONS: Expandable metallic prostheses have the potential to palliate malignant gastrointestinal stenoses that have traditionally been treated with surgical bypass or comfort care measures only.

Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems.

BACKGROUND: Although expandable esophageal endoprostheses may be easier to insert and are associated with fewer procedure-related perforations, data comparing clinical results with these stents to those obtained with conventional prostheses are sparse. METHODS: We reviewed the records of all patients undergoing esophageal stent placement at our institution between October 1983 and July 1995 to define relative risks, clinical results, and need for reintervention prior to death, contrasting conventional to a variety of expandable esophageal endoprostheses. RESULTS: Over the period of review, 47 patients had conventional prostheses (CP) and 38 had expandable prostheses (EP) placed. Fifteen of 44 patients with CP and 14 of 38 with EP for malignancy also had esophago-airway fistulas. Insertion complications, prestent and poststent dysphagia scores, and complete fistula occlusion rates were comparable. Subacute complications were higher in the patients receiving EP (80%) than in those receiving CP (60%), possibly related to the prospective accumulation of data in patients receiving EP. Survival data were virtually identical and approximated 3 months for either group. CONCLUSIONS: Although both CP and EP improve dysphagia and occlude tracheoesophageal fistulae, patients ill enough to require a prosthesis do poorly regardless of prosthesis design. Moreover, although EP may be easier to insert than CP, stent- and patient-related problems persist and may require additional intervention.

Endoscopic approach to pancreas divisum.

Pancreas divisum has been claimed to be a harmless congenital variant or to occasionally cause acute relapsing pancreatitis (ARP), chronic pancreatitis (CP), or a chronic abdominal pain (CAP) syndrome. Both surgical and endoscopic approaches to accessory papilla decompression have been promulgated and widely disparate results reported in the literature. We retrospectively reviewed a five-year experience with dorsal pancreatic duct decompression at our institution utilizing a variety of endotherapeutic techniques. Data collected included procedural complications; patient interpretation of pre- and posttherapy pain, frequency, and intensity graded on an analog pain scale; frequency of hospitalization; and patient perception of "global" improvement to endotherapy. At a mean follow-up of 20 months, there was a statistically significant decrease in pancreatitis incidence in 15 patients with ARP (P = 0.016) and 19 patients with CP (P = 0.025). The frequency and intensity of chronic pain was also significantly improved (P < 0.001) in the latter group. In contrast, only one of five patients with CAP and normal dorsal pancreatography and secretin tests experienced global improvement, and there was no improvement utilizing an analog pain scale (P = 0.262) in the group as a whole. There was a 20% incidence of mild procedure or subsequent stent-related pancreatitis and an 11.5% accessory papilla restenosis rate. It is concluded that a subset of carefully selected patients with pancreas divisum may respond to endotherapy but that long-term follow-up will be required to define its ultimate place in the management of symptomatic patients with this anomaly.

Presentation and treatment of annular pancreas in an adult population.

OBJECTIVE: To describe a series of adult patients with annular pancreas, their presentation, and treatment modalities. METHOD: A retrospective chart review of patients seen at a multispecialty referral center from 1977 to 1994. RESULTS: Seven adult patients (ages ranging from 33 to 77 yr, four females and three males) presented with various symptoms and signs: abdominal pain (six patients) gastric outlet obstruction (two), pancreatitis (two), pancreatic mass (two), gastric/duodenal ulcer (one), and/or postoperative obstructive jaundice (one). The duration of symptoms ranged from 1 wk to 16 yr before diagnosis (median 18 months). Upper GI radiography was consistent with annular pancreas in two cases, CT scan in two cases (neither of which actually depicted the annulus), and four of six successful endoscopic retrograde cholangiopancreatographies. Three patients were diagnosed during operative procedures. Five of the seven patients required therapeutic operative procedures that included transduodenal sphincteroplasty, duodenojejunostomy, gastrojejunostomy, subtotal gastrectomy, or Whipple procedure. Four of the five had significant symptomatic relief. In one case, endoscopic sphincterotomy and biliary stent placement was therapeutic. CONCLUSIONS: 1) Annular pancreas occasionally presents in the adult population. 2) Although gastric outlet obstruction was seen in two of seven patients, a plethora of additional presentations included pancreatic mass, pancreatitis, peptic ulcer disease, and post-operative obstructive jaundice. 3) Diagnosis of annular pancreas was most commonly suggested by upper GI series or endoscopic retrograde cholangiopancreatography. However, fully 40% of diagnoses required surgery for confirmation. 4) In contrast to the pediatric population in whom gastrojejunostomy or duodenojejunostomy is the treatment of choice, a variety of surgical as well as interventional endoscopic procedures were utilized for effective treatment in adults with annular pancreas.

Esophageal dilation can be done safely using selective fluoroscopy and single dilating sessions.

Maxims for safe esophageal dilation have included recommendations to use fluoroscopy in all instances and to limit dilation sessions to 2-mm increments. We reviewed a 34-month experience of all esophageal dilations undertaken at a large multispecialty clinic to define adherence to these recommendations and to delineate whether deviation was associated with significant complications. Four hundred thirty-two patients underwent 716 courses of esophageal dilation during this time, 92% of whom had benign disease. Eighty-nine percent of patients were dilated with polyvinyl dilators (Savary/American) and only 8% of these patients required fluoroscopic monitoring for the bougienage. Seventy-eight percent of the dilating sessions for patients without achalasia were undertaken using either a single large dilator (> or = 45 Fr) or employed incremental dilator sizes > 2 mm (6 Fr) in a single session. There was a single perforation in 662 nonachalasia dilations and this was a consequence of attempted placement of an esophageal endoprosthesis. We conclude that use of guide wire technology and newer dilating techniques do away with the need for routine fluoroscopic control. Moreover, single large dilators or dilator increments > 2 mm may be safely used, contingent on endoscopic stricture assessment.

Successful treatment of bleeding pseudoaneurysms of chronic pancreatitis.

A ruptured pseudoaneurysm is the most rapidly fatal complication encountered in patients with chronic pancreatitis, with a reported mortality rate of 12.5% in treated patients to > 90% in those untreated. Although reportedly a rare complication of chronic pancreatitis, a pseudoaneurysm is encountered in 6-9.5% of patients with chronic pancreatitis and as many as 17% of all patients operated on for chronic pancreatitis. Timely diagnosis and treatment seems to result in markedly reduced mortality. Four patients with bleeding pseudoaneurysms associated with chronic pancreatitis and pseudocysts were encountered recently at Virginia Mason Medical Center. These patients' charts, as well as the English literature, were reviewed in detail. All of our cases occurred in alcoholic males. Pseudocysts with pancreatic ductal or pseudocyst rupture were seen in three cases. All had a history of crescendo-decrescendo pain episodes and had evidence of bleeding or were bleeding at presentation. Splenic vein occlusion was identified in 50% of the cases. A pseudoaneurysm was documented by angiography in all patients. Embolization was successfully attempted without complication in two patients. Three patients were ultimately treated with a pylorus-sparing (2) or standard (1) pancreaticoduodenectomy. These three are alive and doing well at 16, 26, and 52 months from the time of their procedure. A fourth patient was treated nonoperatively, because of severe comorbid disease and aberrant anatomy, with successful embolization of the pseudoaneurysm and biliary and pancreatic stenting. The pseudocyst resolved and he is asymptomatic 12 months after therapy. We advocate preoperative arteriography in all patients with suspected or known arterial pseudoaneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)

Cystic duct leaks in laparoscopic cholecystectomy.

BACKGROUND: Cystic duct leak (CDL) appears to complicate laparoscopic cholecystectomy (LC) more often than open cholecystectomy (OC). No mention of CDL was found in a literature review that covered 48,822 OCs and their complications. PATIENTS AND METHODS: Fifty-four patients who developed biliary tract injuries following LC were reviewed for: the time from LC to presentation, presenting symptoms, method of diagnosis, treatment, outcome, and follow-up. RESULTS: Seventeen of 54 biliary tract complications (31%) were CDLs. The CDLs presented at a median of 4 days after LC with pain (76%) and nausea and/or vomiting (35%). Endoscopic retrograde cholangiopancreatography (ERCP) defined the diagnosis and the anatomy of the leak in 11 patients (65%). Biliary endoprosthesis placement was employed in 8 patients, with concomitant sphincterotomy in 5 (63%), and resolved CDL in every case. Seven (88%) of these patients were asymptomatic at a median interval of 10 months after stent retrieval. Six patients (35%) underwent reoperation. Five had laparotomy with ligation of the cystic duct stump and 1 underwent laparoscopic examination with reclipping of the cystic duct stump. Five (83%) were asymptomatic at a median follow-up of 26 months. CDLs may result from inaccurate clip placement, perforations proximal to the clips, and stump necrosis, as documented at reoperation. CONCLUSIONS: CDLs occur more frequently in LC than in the OCs reported in the literature. Most leaks require intervention. ERCP with stent placement is the diagnostic and therapeutic procedure of choice and has a high success rate of resolving leaks. To forestall CDLs, it is important to place clips accurately and avoid electrocautery in the vicinity of the cystic duct.

Endoscopic pancreatic duct sphincterotomy: indications, technique, and analysis of results.

Fifty-six patients, 54 of whom had chronic pancreatitis, underwent endoscopic pancreatic duct sphincterotomy during a 4-year period from 1988 to 1992. Acute complications noted in 10% of patients included exacerbation of pancreatitis (4) and cholangitis (2). Chronic complications included induction of asymptomatic ductal changes in 16%, thought to be related to endoprosthesis placement, and stenosis of the sphincterotomy site in 14%, requiring repeated endoscopic or surgical sphincter section. When combined with a number of ancillary procedures, including removal of obstructing ductal calculi and stent placement for ductal disruption or stenosis, pancreatic duct sphincterotomy was associated with amelioration of chronic pain or decreased number of clinical attacks of pancreatitis in a subset of patients. The authors conclude that endoscopic pancreatic duct sphincterotomy enlarges our endotherapeutic armamentarium and deserves additional evaluation.

Endoscopic treatment of biliary injury in the era of laparoscopic cholecystectomy.

During a 2-year period in which the application of laparoscopic cholecystectomy became widespread in the Pacific Northwest, 33 patients with surgically related bile duct injury were seen by the gastroenterology section of a large multi-specialty clinic. Twenty-nine of these patients had anatomy amenable to endoscopic approach, and 25 of the 29 are symptom-free, with normal ultrasonography and serum liver function tests, at a minimum of 1 year of follow-up after undergoing a variety of endotherapeutic procedures. The authors conclude that endoscopic therapy, in conjunction with percutaneous drainage of large bilomas, is effective treatment for cystic duct leak and minor damage to the common bile duct. Further data and prolonged follow-up are required in patients with more significant biliary injury who undergo endoscopic endoprosthesis and/or dilation therapy.

Prospective evaluation of costs of disposable accessories in diagnostic and therapeutic ERCP.

Procedural (room fee) reimbursement from insurance payers is usually fixed for individual endoscopic procedures and may not include the costs of disposable equipment. This study estimated costs of disposable items used in ERCP procedures and calculated the percentage of total reimbursement spent on such equipment. A total of 248 ERCPs were performed in a 5-month study period, 192 (77%) of which were therapeutic. Total reimbursement was estimated to be $112,262 ($452 per procedure) and total disposable equipment costs were $47,195 ($190 per procedure), or 42% of total reimbursement. Disposable instrument costs in diagnostic ERCP approximated 13% of those associated with therapeutic ERCP, and the latter costs in turn utilized more than 60% of Medicare/Medicaid room fee reimbursement. This reimbursement may be inadequate to cover both disposable instrument costs and other procedural expenses, such as admit-recovery costs, nursing assistance, expenses related to endoscope purchase and capitalization, and equipment cleaning or sterilization. Our data suggest the need for either re-usable endoscopic accessories or adequate compensation to cover disposable instrument costs.

Endoscopic repair of bile leaks after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has quickly eclipsed open cholecystectomy as the standard approach to symptomatic gallstones and acalculous biliary disease. Procedure-related morbidity and mortality continue to be defined, but a higher incidence of bile duct injuries has been reported to date using present technology and procedure. Key principles in the management of these problems include definition of the anatomy, relief of any impedance to biliary-enteric flow, and drainage of significant extrahepatic fluid collections. A cooperative, multispecialty approach involving surgeons, radiologists, and gastroenterologists is critical to successful outcomes. Future studies will help streamline the management of bile duct injuries and aid physicians in their selection of the best approach for each individual patient.

Endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy.

We assessed the use of endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy (LC) at our hepatobiliary referral center. This assessment included patients from outside institutions with post-LC problems. Between May 1990 and September 1992, we performed 522 LCs and 1,723 ERCP examinations. There were 78 patients who underwent 143 ERCP examinations after LC, 65% of whom were referred. ERCP findings were categorized as follows: normal results (8%), problems inherent to stone disease (65%), and iatrogenic injury (27%). The types of inherent problems were common bile duct (CBD) stones, pancreatitis, and papillary stenosis/microlithiasis. Within the CBD stone group, 5 of 26 patients also had papillary stenosis, and, within the pancreatitis group, 9 of 11 patients also had papillary stenosis, making papillary stenosis the most frequent observation (55%). Almost all of these patients (96%) required endoscopic papillotomy for successful treatment. The iatrogenic injury group was comprised of 21 patients, 16% of whom had cystic duct leak and 84% of whom had CBD injury. These patients required a variety of endoscopic procedures including endoscopic papillotomy (67%), CBD endoscopic stenting (76%), percutaneous drainage of biloma (29%), and percutaneous transhepatic biliary drainage (24%). Open surgical procedures after endoscopic assessment or treatment were required in only three patients in the iatrogenic group and in none in the inherent group. At this time, long-term follow-up is not possible with regard to biliary stricture. We conclude that the majority of problems after LC are either due to papillary stenosis/microlithiasis with or without CBD stones or to biliary injury. Both can be successfully diagnosed and treated with endoscopic techniques.

Nonoperative versus operative treatment of obstructive jaundice in pancreatic cancer: cost and survival analysis.

Pancreatic carcinoma is complicated by malignant obstructive jaundice in 40-70% of cases. Patients frequently are old, debilitated, unresectable, and faced with a dismal prognosis. Invasive endoscopic and radiologic procedures in the inoperable patient can provide palliation without the need for surgery, in most cases. Few studies have compared nonoperative palliation with conventional surgical biliary enteric bypass procedures. In a retrospective study of patients with pancreatic carcinoma, we found no difference between operative and nonoperative treatment in survival, total hospitalization, or morbidity and mortality. Cost analysis revealed significant savings with nonoperative treatment.