Multicentre survey of radiologically inserted gastrostomy feeding tube (RIG) in the UK.

AIMS: To evaluate the variance in current UK clinical practice and clinical outcomes for direct percutaneous radiologically inserted gastrostomy (RIG). MATERIALS AND METHODS: A prospective UK multicentre survey of RIG performed between October 2008 and August 2010 was performed through the British Society of Gastrointestinal and Abdominal Radiology (BSGAR). RESULTS: Data from 684 patients were provided by 45 radiologists working at 17 UK centres. Two hundred and sixty-three cases (40%) were performed with loop-retained catheters, and 346 (53%) with balloon-retained devices. Sixty percent of all patients experienced pain in the first 24 h, but settled in the majority thereafter. Early complications, defined as occurring in the first 24 h, included minor bleeding (1%), wound infection (3%), peritonism (2%), and tube misplacement (1%). Late complications, defined as occurring between day 2 and day 30 post-procedure, included mild pain (30%), persisting peritonism (2%), and 30 day mortality of 1% (5/665). Pre-procedural antibiotics or anti-methicillin-resistant Staphylococcus aureus (MRSA) prophylaxis did not affect the rate of wound infection, peritonitis, post-procedural pain, or mortality. Ninety-three percent of cases were performed using gastropexy. Gastropexy decreased post-procedural pain (p < 0.001), but gastropexy-related complications occurred in 5% of patients. However, post-procedure pain increased with the number of gastropexy sutures used (p < 0.001). The use of gastropexy did not affect the overall complication rate or mortality. Post-procedure pain increased significantly as tube size increased (p < 0.001). The use of balloon-retention feeding tubes was associated with more pain than the deployment of loop-retention devices (p < 0.001). CONCLUSION: RIG is a relatively safe procedure with a mortality of 1%, with or without gastropexy. Pain is the commonest complication. The use of gastropexy, fixation dressing or skin sutures, smaller tube sizes, and loop-retention catheters significantly reduced the incidence of pain. There was a gastropexy-related complication rate in 5% of patients. Neither pre-procedural antibiotics nor anti-MRSA prophylaxis affected the rate of wound infection.

Imaging manifestations in Proteus syndrome: an unusual multisystem developmental disorder.

In this review we use images from an 11-year-old male to describe Proteus syndrome, a complex disorder with multisystem involvement and great clinical variability. Our aim is to enhance recognition of the typical imaging findings, which can aid diagnosis of this rare condition.

Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre.

AIM: To assess the technical success rate, and evaluate the clinical outcome, length of hospital stay, and cost of palliative gastro-duodenal stenting in a single-centre. MATERIALS AND METHODS: Eight-seven patients referred for insertion of a gastroduodenal stent between April 1999 and April 2004 were recruited to a non-randomized, before and after intervention study performed in a single centre. Demographic data, diagnosis and symptoms along with clinical and technical outcomes were recorded. RESULTS: The technical success rate was 84/87 (96.6%), with inability to traverse the stricture in three patients. No immediate complications were demonstrated. There was marked improvement after stent placement with resolution of symptoms and commencement of dietary intake in 76 patients (87%). Stenting resulted in improved quality of life as reflected by an increase in Karnofsky score from 44/100, to 63/100 post-procedure. Late complications included perforation (n=1), migration (n=1) and stent occlusions due to tumour ingrowth/overgrowth (n=7; mean 165 days). Mean survival was 107 days (range 0-411 days). Median hospital stay post-stent placement was 5.5 days, (range 1-55 days) with a majority of patients (75%) discharged home. The mean cost of each treatment episode was 4146 pounds ($7132 $US, 6,028 EUROS). CONCLUSION: The present series confirms that combined endoscopic and radiological gastroduodenal stenting is a highly favourable treatment for patients with inoperable malignant gastric outlet obstruction. The results suggest that this minimally invasive procedure has a very high technical success rate, whilst at the same time providing excellent palliation of symptoms with improved quality of life in the majority of patients.

Computed tomographic colonography for colorectal screening.

Computed tomographic colonography (CTC) is a specialized computed tomographic examination that has been optimized for the detection of colorectal polyps. The technology has undergone major advances in recent years and there is emerging consensus that state-of-the-art CTC results in performance characteristics comparable to those of optical colonoscopy for polyps > or = 8 mm in size. Effective polyp detection rests on the quality of several components of the examination, which must all be optimized in order to maintain appropriate sensitivity and specificity, including adequate bowel preparation, good colonic distension, sufficient scanning parameters, and appropriate interpretation. The emergence of CTC provides another method of colonic evaluation for colorectal cancer screening and prevention. In contrast to a mutually exclusive approach to screening, the availability of both optical colonoscopy and CTC should hopefully improve overall compliance rates for colorectal screening. The ultimate role of this technique in the screening program continues to evolve. There is currently considerable variability in the materials and methods used in CTC. This article describes the approach used at the University of Wisconsin, which has been validated in a large multicenter screening trial and which is currently used for an active CTC-based colorectal cancer screening program.

Duodenal obstruction by gallstones (Bouveret's syndrome): a review of the literature.

Bouveret's syndrome, first described in 1896, is gastric obstruction by a gallstone following a cholecystoduodenal fistula. Endoscopy is the mainstay of diagnosis, but radiographic examination such as upper gastrointestinal contrast series and abdominal radiography can also contribute to the diagnosis. Diagnosis by computed tomography and ultrasonography has also been described. The syndrome can be diagnosed and treated endoscopically, with stone extraction or mechanical lithotripsy. Extracorporeal shockwave lithotripsy has also been used successfully. Surgery is required in over 90% of cases, with mortality rates ranging from 19% to 24%. One-stage and two-stage procedures have been described, including enterolithotomy, cholecystectomy, and fistula repair, no convincing data are available to show which of these two approaches provides a better outcome. Although the condition is rare, Bouveret's syndrome should be considered in elderly patients with a history of chronic cholecystitis who present with pain, vomiting or haematemesis.

Virtual endoscopy--comparison with colonoscopy in the detection of space-occupying lesions of the colon.

BACKGROUND AND STUDY AIMS: A new technique has been described which combines abdominal helical computed tomography (CT) scanning and virtual reality computer technology, known as virtual colonoscopy (VC); the reconstructed images provide a simulation of the interior of the colon as viewed by endoscopy. We compared VC with conventional colonoscopy in patients with suspected or known colonic neoplasia. PATIENTS AND METHODS: A total of 38 patients, in whom there was a high likelihood of colonic polyps or cancer, underwent a noncontrast helical CT scan of the abdomen and pelvis after regular colonoscopy bowel preparation. The images were reconstructed into a VC presentation and compared with the subsequent conventional colonoscopy in a blinded manner. RESULTS: Conventional colonoscopy identified a total of 24 polyps 5 mm or greater. VC correctly identified five of 13 polyps 5-9 mm in size, and ten of 11 lesions greater than or equal to 10 mm in diameter. The reasons for four missed lesions were identified as being secondary to a collapsed rectum in two patients and stool in the right colon in two patients. The sensitivity and specificity per patient of VC for lesions greater than or equal to 5 mm were 66.7% and 75.0% respectively, and for lesions greater than 1 cm were 90.0% and 82.1%, respectively. CONCLUSIONS: Virtual colonoscopy is feasible, well tolerated, and capable of detecting most lesions greater than 10 mm in diameter. This technique is continuing to be developed and warrants further evaluation as a diagnostic and screening tool in colorectal neoplasia.

Recurrent pancreatitis in a child with pancreas divisum. Endoscopic therapy of a Santorinicele.

Pancreas divisum is a rare congenital anomaly of the pancreatic ducts that has been implicated in pancreatitis. In addition, the finding of a Santorinicele, which is a cystic dilatation of the dorsal duct, suggests that there is an obstruction associated with a congenital or acquired weakness of the mucosa. We used an endoscopic technique to treat a child with recurrent pancreatitis who was found to have pancreas divisum and a large Santorinicele.

The cost effectiveness of metal oesophageal stenting in malignant disease compared with conventional therapy.

Expanding metal oesophageal stents are being used more commonly to palliate patients with inoperable oesophageal carcinoma. Many reports have so far documented their clinical effectiveness, however, their high acquisition cost has caused on-going concern when compared with the cost of conventional therapies. We reviewed 64 consecutive patients with inoperable oesophageal carcinoma, half of whom had received our conventional method of palliation using a variety of techniques including, BICAP diathermy, alcohol injection and Atkinson tube insertion. The other half (32 patients) were treated with expandable metal stents -- Gianturco Z stents (Cook UK Ltd) and uncovered Ultraflex stents (Microvasive, Boston Scientific). The physical amount of resources consumed were identified and measured (number of diagnostic and support procedures, days as in patients, number of day cases or outpatient attending) and an average NHS cost was applied to this resource use. All costs were summated over the period of palliation from the date of the first intervention with palliative intent until death. Although the patients in this study were not randomized, the two groups were matched to ensure comparability in clinical manifestation (uncomplicated biopsy proven oesophageal carcinoma) and the average age of patients from each group. A difference was identified between the length of survival in both patient groups and the analysis was corrected for this by estimating a cost per day of palliative support. Patients palliated with metal stents underwent fewer procedures and spent fewer days in hospital during the time period from presentation until death even when corrected for differences in survival. Patient outcome (effectiveness of palliation) was measured by recording mean dysphagia scores which were recorded before and after palliation. Metal stents were found to lead to a significantly higher improvement in dysphagia in comparison to conventional therapy. In addition, the mortality related to metal oesophageal stents was lower than Atkinson tube insertion. The average cost of palliation was much lower in the metal stent group (mean = pound sterling 2817) compared with the cost in those palliated conventionally (mean = pound sterling 4566). However, once this was corrected for survival the difference in the cost of palliation on a per diem basis was reduced (metal stents = pound sterling 60 per day, conventional group = pound sterling 72 per day). The results of our study indicate that the initial high cost of metal stents is more than outweighed by resource savings elsewhere in the hospital by virtue of reduced need for re-intervention and shorter length of hospital in patient stay. Such cost savings taken in combination with the improved clinical effectiveness and low mortality related to metal stents provide significant support for introducing their use into clinical practice.

The clinical effectiveness of the Gianturco oesophageal stent in malignant oesophageal obstruction.

Between January 1994 and December 1996 72 patients were treated with 76 Gianturco oesophageal stents for oesophageal obstruction or perforation. The patients were followed prospectively in order to determine the effectiveness in improving dysphagia, to establish long term patency, survival times and complications. The mean dysphagia score prior to stenting was 3, improving to a mean score of 1 after stenting. Swallowing failed to improve in three patients. No serious complications were seen at stent insertion. Patients tolerated the procedure well with no complications in 63%. The most frequent immediate complication was chest pain occurring in 15 patients (21%). This settled in all patients with appropriate analgesia, however, four patients required long-term pain relief. In no cases was the chest pain due to perforation. Re-intervention was required in 16.7% of patients, the commonest cause being tumour overgrowth, and this was seen primarily in patients with long survival. The migration rate was low, despite the fact that 45 of 76 stents had been placed with the distal end in the stomach. Only four stents (5.6%) migrated completely, all of which had been deployed across the cardia. In our series the use of the Gianturco oesophageal stents for provided effective palliation of malignant oesophageal obstruction.

Local staging of anal and distal colorectal tumors with the magnetic resonance endoscope.

BACKGROUND: We prospectively assessed the feasibility and accuracy of endoscopic magnetic resonance (EMR) scanning in the local staging of anal and colorectal cancer as compared to endosonography. METHODS: Fifteen patients with biopsy-proven anal (n = 2), rectal (n = 11), and distal colonic (n = 2) cancer underwent endosonography followed by EMR imaging. Scans were acquired using the magnetic resonance receiver coil incorporated into the tip of the non-ferromagnetic endoscope. Blinded to endosonography results, two radiologists interpreted the EMR images using the TNM system. Staging results were compared to endosonography in all patients and to histopathology in the 13 colorectal cases. RESULTS: EMR imaging, well tolerated in all patients, correlated with endosonography in 10 of 15 and 12 of 15 cases for T- and N-staging, respectively. In the 13 colorectal patients with available histopathology, accuracy of EMR and of endosonography in T-staging was 77% and 85%, respectively; N-staging accuracy was 62% for both. CONCLUSIONS: For anal and distal colorectal neoplasms, EMR imaging is feasible and provides local staging comparable to endosonography.

Local staging of esophageal cancer using endoscopic magnetic resonance imaging: prospective comparison with endoscopic ultrasound.

BACKGROUND AND STUDY AIMS: The magnetic resonance endoscope consists of a non-ferrous endoscope with a radiofrequency receiver coil incorporated into its tip. The aim of this study was to assess the accuracy of endoscopic magnetic resonance imaging for the local staging of esophageal cancer. PATIENTS AND METHODS: Prospectively, 15 patients with biopsy-proven cancer of the esophagus (n = 9) or gastroesophageal junction (n = 6) underwent endosonography followed by imaging by the magnetic resonance endoscope. The results of endoscopic magnetic resonance imaging were assessed blindly, then compared with those of endosonography, which served as the gold standard. RESULTS: Endoscopic magnetic resonance imaging of transmural tumor invasion agreed with ultrasonography in 11/15 cases and of nodal state in 12/15 cases. Endoscopic magnetic resonance images were inadequate in four cases as a result of motion artifacts. CONCLUSIONS: Endoscopic magnetic resonance imaging of esophageal cancer diagnoses local staging that is comparable to endosonography. In future, the combination of endoscopic and conventional magnetic resonance scanning may provide comprehensive staging of esophageal cancer.