Clinical implantation of 92 VACStents in the upper gastrointestinal tract of 50 patients-applicability and safety analysis of an innovative endoscopic concept.

Introduction: Endoscopic vacuum therapy (EVT) has emerged as a promising treatment option for upper gastrointestinal wall defects, offering benefits such as evacuation of secretions and removal of wound debris by suction, and reduction and healing of wound cavities to improve clinical outcomes. In contrast, covered stents have a high rate of migration and lack functional drainage, while endoluminal EVT devices obstruct the GI tract. The VACStent is a novel device that combines the benefits of EVT and stent placement. Its design features a fully covered Nitinol-stent within a polyurethane sponge cylinder, enabling EVT while maintaining stent patency. Methods: This study analyzes the pooled data from three different prospective study cohorts to assess the safe practicality of VACStent placement, complete leak coverage, and effective suction-treatment of esophageal leaks. By pooling the data, the study aims to provide a broader base for analysis. Results: In total, trans-nasal derivation of the catheter, suction and drainage of secretion via vacuum pump were performed without any adversity. In the pooled study cohort of 92 VACStent applications, the mean stent indwelling time was 5.2 days (range 2-8 days) without any dislocation of the device. Removal of the VACStent was done without complication, in one case the sponge was lost but subsequently fully preserved. Minor local erosions and bleeding and one subsequent hemostasis were recorded unfrequently during withdrawal of the device (5.4%, 5/92) but no perforation or pressure ulcer. Despite a high heterogeneity regarding primary disease and pretreatments a cure rate of 76% (38/50 patients) could be achieved. Discussion: In summary, insertion and release procedure was regarded as easy and simple with a low potential of dislocation. The VACStent was well tolerated by the patient while keeping the drainage function of the sponge achieving directly a wound closure by continuous suction and improving the healing process. The implantation of the VACStent provides a promising new procedure for improved clinical treatment in various indications of the upper gastrointestinal wall, which should be validated in larger clinical studies.Clinical Trial Registration: Identifier [DRKS00016048 and NCT04884334].

[Radiofrequency ablation effectively treats chronic radiation proctitis]. / Therapie der chronischen Strahlenproktitis - Effektive Lokaltherapie durch RFA.

Chronic radiation proctitis can develop after radiation therapy of pelvic malignancies. Symptoms include haematochezia, diarrhoea, tenesmus, urgency, faecal incontinence, and rectal pain. Various therapies have been attempted with argon plasma coagulation (APC) currently being the treatment of choice, but complications such as ulceration and stricture are commonly encountered. There are limited data suggesting that radiofrequency ablation (RFA) may be an effective alternative to APC, in particular in transfusion-dependent patients. Here we report two cases of chronic radiation proctitis, one of whom was transfusion-dependent, who were safely and successfully treated with focal RFA. Haematochezia decreased significantly the day subsequent to treatment, and transfusion independence was achieved after a single session. Three to four sessions were required to eradicate the neovascular lesions. Post-therapeutic rectal re-epithelialisation occurred, and no bleeding was encountered during up to nine months of follow-up.

[Management of the buried bumper syndrome: a new minimally invasive technique--the push method]. / Management bei Buried-Bumper-Syndrom: neue endokopische minimalinvasive Push-Methode.

The so-called buried bumper syndrome is characterised by a pathological alteration of the percutaneous endoscopic gastrostomy (PEG) in the form of a tissue overgrowth of the internal bumper of the tube. A lack of mobilisation of the tube and/or continuous traction on the PEG causes the bumper to be impacted by stomach mucosa. The consequence is a local chronic inflammatory process that may result in the occlusion of the feeding tube. As of now, different therapeutic methods exist: the surgical technique based on common laparotomy, the local invasive removal by cutting along the tube and inner flange from the outside and pulling it out (pull method) and the endoscopic recovery from inside the stomach. The authors have developed and evaluated a new endoscopic, minimally invasive technique (push method). In eight of nine patients the inner bumper could be freed by cutting with a papillotome which is brought into the stomach through the shortened PEG from the outside while maintaining endoscopic control. Afterwards the bumper is pushed to the inside with a dilatator and the patients are provided with a balloon system using the persisting stoma. The subsequent healing process proved to yield no further complications.

[Gastropexy supported single-step button gastrostomy - clinical results of a new technique for percutanous feeding tube implantation]. / Einzeitige Button-Gastrostomie mittels Gastropexie - klinische Ergebnisse einer neuen Technik zur perkutanen Sondenanlage.

BACKGROUND: Skin-level gastrostomy devices have been established to maintain enteral nutrition in clinical practice. Unfortunately there is still a need for a second intervention to place the secondary system. The combination of a new introducer technique with endoscopic controlled gastropexy for PEG and the primary placement of a button system leads to a safe stomal fixation of the balloon device. The aim of this study was to evaluate for the first time the safety of this combined approach. METHODS: Between 2000 and 2005 five patients were treated with this new technique and received a single-step button gastrostomy. All patients were followed with a standardised protocol. RESULTS: No major complications were seen during follow-up. The system could be removed within 6 - 18 weeks without any problems. CONCLUSIONS: On the basis of our first experience we conclude that by combination of the three techniques, introducer PEG with gastropexy, Seldinger wire, and balloon-type button, a single-step button gastrostomy can be safely performed.

[A 76-year-old male patient with iron deficiency anaemia - first experience with single-balloon enteroscopy]. / 76-jähriger Patient mit chronischer Eisenmangelanämie - erste Erfahrungen mit dem Single-Ballon-Enteroskopiesystem.

Diagnosis of and therapy for small bowl disease is a new challenge for modern endoscopy. Following the development of capsule endoscopy it is possible to inspect the whole small intestine. Therefore one needs adequate endoscopes in order to take tissue samples and perform the corresponding therapeutic measures. Today, the technical procedure of double-ballon enteroscopy is established and is available for routine clinical use. Double-ballon enteroscopy is usable both perorally and peranally, and can be used to inspect the entire small intestine. However, there are a few difficulties with the handling, which are time-consuming. Recently, the new single-ballon enteroscopy system SIF-Q180 was introduced which consists of a dedicated endoscope without an attached balloon, an overtube with a balloon, and an air controller to inflate or deflate the balloon of the overtube. We report the case of a patient admitted to our hospital in order to to detect the reason for an iron deficiency anaemia.

[Duodenal ileus due to an intramural duodenal haematoma. Conservative therapy using a multiple lumen intestinal probe]. / Duodenalileus bei Darmwandhämatom. Konservative Therapie mit einer mehrlumigen Intestinalsonde.

HISTORY AND ADMISSION FINDINGS: A 68-year-old woman was admitted with upper abdominal symptoms, epigastric fullness and nausea, eight days after initiation of heparin anticoagulation for deep-vein thrombosis. There were no other clinical abnormalities. INVESTIGATIONS: Abdominal ultrasound and computed tomography showed an intramural duodenal haematoma. Endoscopy revealed a stenosing lesion in the duodenum. TREATMENT AND COURSE: Instead of conventional parenteral nutrition, a triple-lumen feeding tube was placed, one lumen in the jejunum for feeding, the other for gastric decompression. Six months later the symptoms had completely disappeared and ultrasound, endoscopy and computed tomography no longer detected any lesion. CONCLUSION: Intrajejunal feeding and gastric decompression via a multi-lumen tube provided effective conservative treatment of duodenal ileus together with gastric decompression.

[Skin-level gastrostomy -- long-term results from a prospective trial in gastric and jejunal application]. / Button-Gastrostomie -- Langzeitergebnisse einer prospektiven Untersuchung bei gastraler und jejunaler Anwendung.

OBJECTIVE: The usefulness of skin-level gastrostomy tubes (button systems) for maintaining nutrition support after primary insertion of percutaneous endoscopic gastrostomy (PEG) is widely accepted. After first promising experiences with newly developed skin-level gastrostomy system (Freka-Button Gastrostomy) the safety and long-term stability of this new tube was not defined. MATERIAL AND METHODS: In a cohort study we prospectively evaluated from 2.1998 until 12.2001 for ease of use, complications, time to failure and long-term follow-up of 61 Freka button gastrostomies inserted in 50 patients (mean age 57.6 years, range 6 - 78 years, 44 men, 6 women). Mean time after primary PEG placement was 6.3 months (range 1 - 30 months). RESULTS: Correct application of all buttons (48 gastric, 2 jejunal) was easy and fast (median time 11 minutes) to perform. In 56 % we used a new Seldinger guide wire technique to improve stomal passage. Within the first ten days and during long-term follow-up (median 248, range 2 - 593 days) no major complication was seen. 11 systems had to be replaced mainly due to balloon failure (median 352, range 186 - 593 days). The total observation time were 15,128 days with a system failure rate of 0.26 per year. CONCLUSION: The Freka-button systems provides an easy-to-use, safe, and feasible alternative for long-term use of skin-level gastrostomy. First jejunal application of this new device was promising but needs further evaluation.

Endoscopic palliation and nutritional support in advanced gastric cancer.

Most of the patients with advanced gastric cancer have incurable disease at presentation and require palliative treatment to reduce symptoms as vomiting, nausea and inability to eat. Treatment options are palliative surgery and endoscopic techniques. Insertion of self-expanding metal stents is nowadays a well-established method of treating biliary and esophageal strictures and is also effective in gastric tumors. The indication and application technique are described in this review. In addition, enteral nutrition is indicated if the gastrointestinal tract functions but swallowing or mastication is compromised by disease or if it is needed to pass an obstructed area, especially in gastric tumor patients. This article reviews the enteral nutrition techniques and their clinical value for patients with advanced gastric cancer.

Successful jejunal nutrition therapy in a pregnant patient with apallic syndrome.

A 41-year-old woman was admitted in the 8th pregnancy week as a consequence of a left-sided media infarction. After alloprothetic aortic valve replacement, she had discontinued deliberately the mandatory anticoagulation treatment. Following an initial clinical stabilisation, a second insult with right-sided media total infarction occurred 3 weeks after admission. In the further course, she developed an apallic syndrome and required respirator therapy. The initial enteral nutrition therapy via naso-gastric tube, was continued via percutaneous endoscopic gastrostomy (PEG). Due to recurrent vomiting from the 24th pregnancy week, the PEG was changed into a PEG with jejunal position of the tube (JET-PEG). Via this access and simultaneous body impedance analysis (BIA) control, the further nutrition therapy could be continued uneventfully. In the 27th pregnancy week, the patient gave birth to a female newborn (birth weight: 820 g) by Caesarean section in pre-eclampsia. The foetal development was in accordance with the gestational period and uncomplicated in the further course. The mother could be released into ambulatory care where the above nutrition therapy was continued. Reports on a successful nutrition therapy of pregnant comatose patients are rare. To the best of our knowledge, this is the first case where JET-PEG and monitoring by repeated BIA measurement were used for the control of the enteral nutrition.

Palliation of esophageal carcinoma with a new self-expanding plastic stent.

BACKGROUND AND STUDY AIMS: Self-expandable metallic covered stents (SEMS) are widely used for the palliation of esophageal cancer. In the long term, a drawback of these stents is the occurrence of nontumoral occlusion at their proximal or distal parts. New self-expanding plastic stents (SEPS) may combine the advantages of SEMS with those of previously used plastic stents. Our aim was to study prospectively the implantation of such stents in a series of patients with fairly long life expectancy, focusing on safety, feasibility and long-term effectiveness. PATIENTS AND METHODS: Between June 1999 and December 2000, in a prospective cohort study, 33 patients were treated with Polyflex stents for palliation of esophageal stenoses, and were followed up until death. The inclusion criteria demanded the presence of a nonresectable or nonoperable, histologically proven, malignant stricture of the esophagus causing significant dysphagia. RESULTS: Stent insertion was successful in all cases. The mean duration of follow-up of the patients was 149.7 days (range 25 - 469). A complete follow-up until death was documented for all patients (n = 33). During the entire follow-up, no stent occlusion was observed which was caused by either nontumoral or tumoral ingrowth, or by nontumoral overgrowth. Stent occlusions were caused only by tumoral overgrowth, and occurred at a rate of 12.1 % (n = 4). The stent migration rate was 6.0 % (n = 2), and the re-intervention rate overall was 21.1 % (n = 7). CONCLUSIONS: These results show that SEPS are effective for the palliation of dysphagia in patients with esophageal malignancies. The immediate results are similar to those observed with SEMS, and the observed low rate of late obstruction suggests that their long-term efficacy might be superior to that of SEMS. This device warrants evaluation in a controlled prospective trial.

[Tube feeding - who, how and when]. / Sondenernährung - Wer, Wie, Wann?

Summary. The concept of enteral nutrition is well established for a long time. During the past twenty years different percutaneous tube feeding techniques have been established. The most popular method is the percutaneous endoscopic gastrostomy (PEG) which is applied as a pull-through technique in Germany. In some patients this approach is not successful and alternative techniques must be used (e. g. introducer method). In some patients nasal or percutaneous feeding tube have to be placed directly into the intestine. There are different systems available for this approach which have to be clearly indicated. As a second step after initiation of enteral nutrition therapy quality of life can be improved by implanting secondary systems (e. g. button gastrostomy).A standardized technique for inserting tubes is essential to have a successful long-term outcome in enteral nutrition and care after has to be integrated into the regimen. The aim of this article is to demonstrate different enteral nutrition tube techniques their indication, contraindication and long-term follow-up.

Endoscopic techniques for enteral nutrition: standards and innovations.

Enteral nutrition has been increasingly used in clinical practice during the past decades. Today, nasogastric, nasoenteric, and transcutaneous gastric or enteral feeding tubes are well established as a routine endoscopic intervention. After clinical introduction of percutaneous endoscopic gastrostomy (PEG) in 1980, the sutureless 'pull' PEG has become a widespread endoscopic technique for transcutaneous gastric long-term nutrition. Multiple new techniques have been introduced since then, and today even long-term jejunal nutrition can be achieved with modified techniques. The introducer PEG (first reported in 1984) has not become an established procedure, but new techniques with an endoscopic gastropexy might be a more effective approach. To increase the quality of life of the patients, skin-level devices were designed and successfully introduced in 1984. A new development has been the one-step feeding tubes which provide the patients with a permanent tube. The standard techniques for long-term enteral feeding, new developments of feeding tubes, and future concepts are discussed in this review.

[Successful use of a button system in "buried bumper" syndrome]. / Erfolgreicher Einsatz eines Buttonsystems bei Buried Bumper-Syndrom.

HISTORY AND CLINICAL FINDINGS: A 65-year-old patient had a fracture of the skull with resulting swallowing disorder and underwent percutaneous endoscopic gastrostomy (PEG) 9 months previously. A specific home care and maintenance of the PEG was not provided. The patient was referred to our hospital because of haematemesis on the suspicion of upper gastrointestinal bleeding. He was in a generally reduced condition with the clinical signs of anaemia and with a positive shock index. INVESTIGATIONS: The laboratory tests revealed an anaemia. The gastroscopy showed an active bleeding ulcer under the migrated internal bumper of the PEG (buried bumper syndrome). The bleeding activity was classified as Forrest lb. In addition, the chest X-ray and the bronchoscopy showed bilateral pneumonia. DIAGNOSIS, TREATMENT AND COURSE: Summarizing the diagnoses there was an active bleeding ulcer in the sense of a buried bumper syndrome in combination with bilateral pneumonia caused by aspiration. After releasing the bumper the bleeding was stopped by local injection therapy. As additional treatment of the lesion it was aimed to lower pressure on the affected mucosal area. This was achieved by the use of a button gastrostomy with a liquid-filled retention balloon that was placed through the preexisting stoma. The pneumonia was treated with antibiotics. Follow-up gastroscopies revealed good healing of the ulcer and the patient was discharged. CONCLUSIONS: The complication of a buried bumper syndrome with ulcer bleeding can effectively be treated by the use of a button gastrostomy. Treatment is based on sufficient pressure relief in the affected mucosa area. Advantages can be seen in the maintenance of the stoma and in the opportunity for an early continuation of enteral feeding.

[Ulcerative esophagitis and colitis as rare manifestations of Adamantiades-Behcet disease]. / Ulzeröse Osophagitis und Kolitis als seltene Manifestationen bei Morbus Adamantiades-Behçet.

We report the case of a 39-year-old German women who suffered from chronic inflammatory bowel disease which had not been exactly classified for 6 years. In the course of the disease she developed recurrent iritis, nodular skleritis, oral and genital ulcer, erythema nodosum and axillary folliculitis. For the first time retrosternal pain occurred. Endoscopy of the upper gastrointestinal tract showed mid esophageal ulcer formation. Colonoscopy demonstrated ulcerative colitis with no involvement of rectal mucosa. Histologically a cutaneous vasculitis in the lower limb was seen and diagnosis of Adamantiades-Behçet disease with marked gastrointestinal involvement and rare manifestation in the esophagus was established. A therapy with prednisolone, azathioprine and mesalazine was started. Under this regimen stomatitis, esophagitis and cutaneous vasculitis resolved, while the colitis showed partial remission now for up to one year.

Self-expanding metallic stents for continuous dilatation of benign stenoses in gastrointestinal tract - first results of long-term follow-up in interim stent application in pyloric and colonic obstructions.

The use of self-expandable metallic stents (SEMS) is an established palliative treatment of malignant stenosis in the gastrointestinal tract. There is wide experience with the palliation of malignant esophageal obstruction and fistulae, but the application of stents in benign stenosis is rarely reported and exclusively deals with obstruction of the esophagus. No data has been available for benign gastric outlet and rectosigmoid obstruction until now. For the first time we report about 4 cases, in which we temporarily implanted a SEMS (Ultraflex(R) stent, Boston Scientific Microvasive(R)) in benign stenosis of the pylorus or rectosigmoid between 09.97-07.98. The indications for stent implantation were failure of established dilatation therapy and/or refusal of surgical treatment, and/or surgical high-risk patients. Our idea was to prolong the duration of the dilatation by interim implantation (range 8 days - 12 weeks) of a SEMS. There where no peri-interventional complications or dislocations. In one case endoscopic removal was not possible, peranal surgical approach allowed the removal of the stent. During follow-up (range 34-39 months) 2 patients needed one bougienage directly after stent removal. Endoscopic examinations showed no recurrence of any stenosis in all patients. We conclude that interim application of SEMS in benign stenosis of the gastrointestinal tract may be a possible therapeutic tool in selected patients. Further trials with greater numbers of patients dealing with the questions of duration of stay of SEMS and choice of stent type are needed.