[Double balloon enteroscopy. First surgical experience]. / Doppelballonenteroskopie in der Chirurgie. Ein erster Erfahrungsbericht.

INTRODUCTION: In Germany double balloon enteroscopy (DBE) has been used for about 4 years in diagnostics of the small intestine. Testing for the first time its value in daily surgical practice, we analyzed retrospectively the results of all DBE examinations from December 2004 to September 2006. MATERIAL AND METHODS: During the study period 106 enteroscopies were performed on 75 patients (42 males, 33 females, age 16-84 years). The approach was oral in 75 cases and anal in 31. Most indications were recurrent middle gastrointestinal bleeding. RESULTS: Complete small intestine inspection could be performed completely orally in seven of 106 examinations; and in most cases a combined oral/anal approach was required. Total endoscopy was completed in 21.3% of the patients studied. Pathologies were detected in 41 examinations (54.7%). These included 11 patients with angiodysplasias (14.7%) successfully treated with argon plasma coagulation (APC) and seven patients with small intestinal polyps (9.3%) that could be removed endoscopically. Further findings included diverticulum (6.7%), changes related to Crohn's disease (4.0%), small intestinal tumors (4.0%), extraluminar disorders (2.6%), stenoses (1.3%), and others (8.0%). Secondary diagnoses included colonic/rectal lesions in 5.3% of cases and pathologies of the stomach or esophagus in 4.0%. One patient had severe complications from a perforation following polypectomy. Therapies followed in 40.0% of all patients examined. Surgical interventions were indicated in six of 75 patients (8.0%), specifically five small intestinal resections and one bypass operation due to an infiltrating pancreas carcinoma. Endoscopic interventions were used in 25.3% of patients and medical treatment in 10.7%. CONCLUSION: With adequate indication, DBE shows very high diagnostic value. Immediate endoscopic therapy is possible in most cases, a considerable advantage over previous methods. Surgery was indicated for 8.0% of those examined in our study group, whereas the literature until now describes surgical indication rates of up to 22%.

Does aging influence pancreatic response in the ultrasound secretin test by impairing hydrokinetic exocrine function or sphincter of Oddi motor function?

BACKGROUND: Secretin administration induces a brief distinct dilatation of the main pancreatic duct in healthy persons, visible at ultrasonography. Several investigations have indicated that sonographic duct measurements before and after secretin injections are a useful tool in the diagnostic screening for pancreatic disease. AIMS: Aim of this study was to evaluate the influence of aging on the test results. METHODS: We examined prospectively two groups of patients with distinctly different mean age, measuring the pancreatic duct diameter sonographically before, 2, 4, 6 and 10 minutes after intravenous injection of 1 CU secretin per kilogram body weight. The examination was performed in all patients on account of abdominal complaints, and pancreatic disease could be excluded by further diagnostic procedures. Group 1 consisted of 22 patients, median age 30.5 years, Group 2: 21 patients, median age 68 years. RESULTS: The younger patients (Group 1) had a mean basal pancreatic duct diameter of 1.6 mm. After secretin injection they showed dilatation reading 3. 1 mm, corresponding to 94% of the basal duct diameter. The older patients (Group 2), with a basal diameter of 1.9 mm, showed a duct enlargement of about 84% to 3.5 mm. There was no statistically significant difference between the two groups concerning extent and temporal development of secretin-induced pancreatic duct dilatation. CONCLUSIONS: The underlying mechanisms of response to secretin stimulation - hydrokinetic pancreatic function, sphincter of Oddi motor function, and extensibility of Wirsung's duct--do not seem to be impaired by aging. Thus, the ultrasound secretin test should be suitable for application in older patients.

Pancreas and aging: a study using ultrasonography.

BACKGROUND: The pancreas undergoes a continuous aging process leading to alterations such as atrophy, fatty infiltration and fibrosis. OBJECTIVE: The aim of this study was to determine the normal ultrasonic aspect of the pancreas and any relationship to age with special regard to pancreatic echogenicity and pancreatic duct diameter. METHODS: In the study on pancreatic echogenicity 131 patients (56 male, 75 female), aged 18-92 (median 52) years, with normal weight were examined prospectively. The echogenicity of the pancreas was compared with the normal liver and divided into four different categories. The prospective investigation into any age relationship of pancreatic duct diameter was performed on 101 patients (44 male, 57 female), ages 18-91 (median 53) years, with normal weight. In both studies, the patients were split into seven age groups. For statistical analysis the chi-square test for independence was used. RESULTS: With advancing age, ultrasonography demonstrated an increasing echogenicity of the pancreas, beginning in the 4th decade of life. Most patients over 50 years, and all patients over 80 had a marked echogenicity, distinctly higher than that found in the liver. The mean pancreatic duct diameter of all patients in the second study was 1.9 mm. Younger subjects had a smaller diameter - average 1.5 mm in the group 18-29 years - but with advancing age a distinct duct enlargement was observed: mean 1. 9 mm in the group 40-49 years, mean 2.3 mm in patients over 80 years, but not exceeding 3 mm. CONCLUSION: On ultrasonography, the aging process of the pancreas leads to an increase of echogenicity. In the aged, a very high echogenicity is a normal ultrasonic finding. The pancreatic duct diameter also increases with advancing age. Even in advanced age, a diameter of more than 3 mm, however, should be regarded as a pathological finding.

Ultrasound secretin test in patients with pancreas divisum--an aid in the diagnosis of papillary or dorsal duct stenosis?

BACKGROUND: Pancreas divisum is a common anatomical variant of pancreatic ductal anatomy. Obstruction of the accessory papilla could cause pain and pancreatitis. It has been suggested that accessory papillary sphincter obstruction can be assessed by sonographic measurement of pancreatic duct diameter after secretin stimulation. METHODS: We now compared our results of sonographic pancreatic duct diameter measurements before and during 10 min after intravenous injection of 1 CU secretin per kg body weight in 32 patients with confirmed pancreas divisum and 20 healthy volunteers. RESULTS: The healthy controls showed a short-lasting duct caliber enlargement by about 93% of the basal diameter within 5 min after secretin injection. 25 pancreas divisum patients without pancreatic disease had a secretin-induced duct dilatation by about only 58%. In four patients with pancreas divisum and chronic pancreatitis no or just a slight duct dilatation was observed after stimulation. Two patients with dorsal duct stenosis as well as one patient with accessory papilla stenosis, however, showed a marked and prolonged secretin-induced duct enlargement by about 155% of the basal duct diameter. CONCLUSION: In this investigation pancreatic duct response to secretin stimulation in pancreas divisum patients without pancreatic disease was less marked than in normal individuals. Thus, a particularly distinct and long-lasting duct dilatation could support the suspicion of accessory papilla or pancreatic duct stenosis.