[What to do if incompressible bleeding from a stab wound occurs in EMS and ER? Temporary control with a Foley catheter]. / Was tun bei nicht komprimierbaren Stichkanalblutungen in Rettungsdienst und Notfallraum? Temporäre Versorgung mittels Blasenkatheter.

Exsanguination plays a key role in avoidable prehospital deaths. As some bleedings from deep stab wounds cannot be stopped with direct compression, the insertion of a Foley catheter can prevent ongoing bleedings. A case report of bleeding from a stab wound in the supraclavicular region is given. The simple measure of careful insertion and blocking of a Foley catheter proved to be a key resuscitative procedure which can be done under any suitable circumstances.

Impact of miniprobe ultrasonography on planning of minimally invasive surgery for gastric and colonic tumors.

BACKGROUND: The use of minimally invasive procedures for the management of gastrointestinal cancer is increasing. The aim of this study was to investigate the role of high-frequency miniprobe endoscopic ultrasound (EUS) for therapeutic decisions making in patients with gastric or colonic tumors. METHODS: A total of 137 patients underwent EUS with a 12.5-MHz miniprobe for preoperative staging of tumors of the stomach ( n = 49) or colon ( n = 88). After resection, the surgical path was reviewed to analyze the role of preoperative staging with miniprobes. RESULTS: Miniprobe EUS enabled accurate assessment of the infiltration depth of gastric and colonic tumors. The overall accuracy rates were 88% and 87%, respectively. The lymph node status was predicted correctly in 82% of the patients (sensitivity, 61%, specificity, 94%). Based on the results of miniprobe EUS, patients with gastric cancer were accurately selected to undergo endoscopic mucosal resection, laparoscopic resection, or open surgery in 100%, 91%, and 86% of the cases, respectively. In patients with colonic tumors, the treatment decision analysis showed that the stratification was correct in 90% of the patients. CONCLUSIONS: Miniprobe EUS is a reliable method for validating treatment decisions for patients undergoing minimally invasive procedures for gastric and colonic tumors. This method is particularly valuable in the management of colon cancer, because endoscopic and laparoscopic resections can be offered to selected patients as an alternative to open surgery.

Endosonography of upper gastrointestinal tract cancer on demand using miniprobes or endoscopic ultrasound.

BACKGROUND: The aim of this study was to investigate whether endosonography on demand with miniprobes and conventional endoscopic ultrasound improves the accuracy of endosonographic staging of upper gastrointestinal tract cancer. METHODS: Altogether, 173 patients underwent endoscopic ultrasonography for preoperative staging of esophageal (n = 63) or gastric cancer (n = 110). Depending on the endoscopic appearance (i.e., size and growth pattern), tumors were examined with a linear-array echoendoscope (7.5 MHz) or with high-resolution miniprobes (12.5 MHz). The results of preoperative staging were correlated with histopathology of the resection specimen. RESULTS: The overall accuracy of miniprobe ultrasonography and endoscopic ultrasound in assessing the infiltration depth of upper gastrointestinal cancer was 87% and 81%, respectively. Miniprobe ultrasonography was superior to conventional endoscopic ultrasound in the staging of early cancers, particularly T1 tumors (accuracy, 81% vs 56%). The combined accuracy of both techniques for all tumor stages was 82%. Correct diagnosis of lymph node involvement was obtained with miniprobe ultrasonography or endoscopic ultrasound in 76% and 71% of the cases, respectively. The combined accuracy in assessing the lymph node status was 73% (sensitivity, 68%; specificity, 81%). CONCLUSIONS: Endosonography on demand using either miniprobes or conventional endoscopic ultrasound may result in more effective and less invasive staging of esophageal and gastric cancer. Selective use of high-resolution miniprobes and conventional endoscopic ultrasound offers accurate staging of all tumor stages.

The role of transrectal ultrasound-guided biopsy in the postoperative follow-up of patients with rectal cancer.

BACKGROUND: The value of endorectal ultrasound (EUS) in the diagnosis of recurrent rectal cancer is limited by the inability to differentiate between malignant and benign lesions. We have prospectively investigated the role of EUS with transrectal ultrasound-guided biopsy in the postoperative follow-up of rectal cancer. METHODS: Since 1995, patients who had undergone a sphincter-saving operation for rectal cancer (n = 312) were followed-up by a standard program including rectal palpation, carcinoembryonic antigen monitoring, computed tomography, and EUS. Transrectal EUS-guided biopsy of perirectal lesions was performed in 68 patients with perirectal lesions by using a rigid endoprobe with a 10 MHZ multiplane transducer and special targeting device. RESULTS: Overall local recurrence was observed in 36 patients. Intraluminal recurrence was diagnosed by proctoscopy in 12 patients. Transrectal EUS-guided biopsy showed pelvic recurrence in 22 of 68 patients with perirectal lesions. Biopsy specimens with benign histology were obtained from 41 patients, and the procedure failed in 5 cases (accuracy, 92%). There was a strong agreement between transrectal biopsy results and the final diagnosis (kappa = 0.84), the sensitivity and specificity being 91% and 93%, respectively. In contrast, clinical examination (kappa = 0.27), computed tomography (kappa = 0.47), or EUS (kappa = 0.42) showed only a moderate level of agreement with the histopathologic diagnosis, mainly because of the limited specificity of all 3 methods (65% vs 46% vs 57%). EUS-guided biopsy was significantly more accurate than computed tomography and EUS (P <.01). The biopsy results had a considerable impact on the management in 18 of 68 patients (26%). CONCLUSIONS: Transrectal EUS-guided biopsy is a safe and efficient method for tissue sampling of perirectal lesions. This minimally invasive and inexpensive technique improves the accuracy of endorectal ultrasound in the diagnosis of recurrent rectal cancer.

Protoporphyrin IX occurs naturally in colorectal cancers and their metastases.

Colorectal cancers exhibit a red fluorescence. The nature of the responsible fluorophore and its eventual diagnostic potential were investigated. Thirty-three consecutive colorectal resection specimen, 32 of which with histologically confirmed cancer, and a total of 1053 palpable mesenteric nodes were fluorimetrically characterized ex vivo. Furthermore, frozen material from 28 patients was analyzed, selected for the availability of primary tumor material and metastatic tissue, e.g., lymphatic and liver metastases from the same patient. Biochemical characterization was carried out through chemical extraction and reversed phase high-performance liquid chromatography. The fluorescence spectra of tissues, tissue extracts, and standard solutions of porphyrins were determined using a pulsed solid-state laser system for excitation and an imaging polychromator, together with an intensified CCD camera for time-delayed observation. Protoporphyrin IX (PpIX) was identified as the predominant fluorophore in primary tumors and their metastases. The fluorophore occurred in the absence of necrosis and in sterile locations. In untreated cases (n = 24), PpIX fluorescence discriminates metastatically involved lymph nodes from all other palpable nodes with a sensitivity of 62% at a specificity of 78% (P < 0.0001). After neoadjuvant treatment of rectal cancer, the PpIX fluorescence level of the primary tumors was reduced and a discrimination of lymph nodes based on PpIX-fluorescence was impossible. We conclude that colorectal cancer metastases accumulate diagnostic levels of endogenous PpIX as a result of a tumor-specific metabolic alteration.

Fluorescence as a concept in colorectal lymph node diagnosis.

Fluorescence detection may constitute an appropriate means in gastrointestinal cancers to diagnose lymphatic tumor spread as opposed to gamma-scintillation methods. Photodiagnostic tracers have been shown to localize rapidly in malignant cells and may enable sensitive detection of small cell aggregates in lymph nodes. To reach a detection depth of several millimeters, a broad banded unspecific tissue autofluorescence may be controlled by so-called background subtracting techniques, generally based either on fluorescence observation at several wavelengths or on dual-wavelength fluorescence excitation. Using such comparative fluorescence detection techniques, some tumor entities can be differentiated soley based upon autofluorescence characteristics. Introducing a further enhancement in sensitivity for longer life-time fluorophores by time delayed fluorescence detection we ran a pilot trial comprising 174 lymph nodes from colorectal cancer specimen from 9 patients. Metastatically involved lymph nodes could be differentiated from all other palpable nodes in the mesenteric fat at a specificity of 85% with a sensitivity of 65%. Specific fluorescence features may be useful to preselect tissue samples for further histological analysis.

EUS-guided fine needle biopsy: minimally invasive access to metastatic or recurrent cancer.

OBJECTIVE: Endoscopic ultrasound (EUS) is a sensitive technique for preoperative staging of gastrointestinal tumors. However, the value of this technique in the diagnosis of metastatic or recurrent disease is limited by the inability to differentiate malignant and benign lesions. We have prospectively investigated the role of EUS-guided biopsy in the evaluation of peri-intestinal tumors. METHODS: EUS-guided biopsy was performed in 167 patients with thoracic, intra-abdominal or pelvic lesions. The upper gastrointestinal tract was examined with a flexible echoendoscope equipped with a 7.5 MHz curved array transducer. For transrectal EUS a rigid endoprobe with a bifocal multiplane transducer (10 MHz) was used. Both instruments allowed to observe the biopsy procedure exactly in the longitudinal scan plane. RESULTS: Real time ultrasonography guidance of the biopsy needle enabled precise tissue sampling even of small lesions with a diameter of 1 cm. Overall EUS-guided fine needle biopsy yielded tissue samples for histopathologic or cytologic analysis in of 151 of 167 patients. Histology demonstrated benign lesions in 71 of 74 patients and malignant tumors in 68 of 93 patients. EUS-guided fine needle biopsy failed to provide the correct diagnosis in 28 cases. The overall sensitivity and specificity of EUS-guided biopsy in the diagnosis of malignancy were 73 and 96%, respectively. The histopathological results changed the clinical and endosonographic diagnosis in 49 patients. No complications were observed related to the biopsy. CONCLUSIONS: EUS-guided needle biopsy is a safe and efficient method for tissue sampling of peri-intestinal lesions. This minimally invasive technique provides adequate biopsies and improves the diagnostic value of endoscopic ultrasonography considerably.