New guide wire technique for stent placement through an occluded self-expandable metal stent: The hairpin technique.

BACKGROUND AND AIMS: Self-expandable metal stents (SEMS) for malignant biliary strictures sometimes occlude, requiring the insertion of another stent. When a guide wire is advanced conventionally through the proximal portion of an occluded SEMS, the guide wire sometimes penetrates the stent mesh. The present study reports a new guide wire insertion technique that prevents this problem from occurring. METHODS: In this new method of advancing a guide wire, the tip is not straight but bent into a curve. Because the advancing end of the guidewire is rounded like a hairpin, it cannot penetrate the stent mesh. Before cannulation, the flexible tip of the guide wire is extended out of the tip of the cannula in the descending duodenum and then cannulation is carried out as the flexible tip makes a hairpin curve. The guide wire with a maintained hairpin curve is advanced through the proximal end of the SEMS. The hairpin curve pops open and the guide wire straightens out when the guide wire has passed through the SEMS. After that, a second stent can be inserted over the guide wire. This technique has been utilized 14 times for occluded SEMS in 10 patients between June 2001 and September 2003. RESULTS: In all patients the technique served to ensure access to the biliary tree and successful placement of a second stent. CONCLUSIONS: This new hairpin guide wire technique was effective in preventing the guide wire from penetrating the stent mesh and, therefore contributed to successful stent placement within occluded SEMS.

Endoscopic hemostasis: safe treatment for peptic ulcer patients aged 80 years or older?

BACKGROUND AND AIM: Recently, the number of peptic ulcer patients aged 80 years or older has been increasing. However, little information is available concerning therapeutic endoscopy for these patients. The objective of this study was to evaluate the efficacy of endoscopic hemostasis for peptic ulcer bleeding in patients aged 80 years or older. METHODS: In this 7-year study, bleeding peptic ulcer patients were divided into group A (>/=80 years old) and group B (<80 years), for which prospective data, endoscopic findings and outcomes of endoscopic treatment were compared. RESULTS: Of the 459 patients who underwent endoscopic hemostasis for peptic ulcer bleeding, the 42 patients (average age 84 +/- 3 years) in group A had a significantly higher incidence of concomitant disease, lower hemoglobin, transfusional requirement over 800 mL and lower serum albumin than the 417 patients (average age 55 +/- 13 years) in group B. Significantly more patients in group A had large gastric ulcers. More patients in group A had ulcers located at the proximal third of the stomach, which is technically difficult to treat endoscopically. Nevertheless, all patients in groups A and B underwent initial hemostasis successfully. The rebleeding rate was not significantly different between group A and B. Neither group had hospital deaths nor complications related to endoscopic procedures. CONCLUSIONS: Endoscopic hemostasis for peptic ulcer bleeding in patients aged 80 years or older is effective and safe. Increasing age may no longer be a risk factor for rebleeding and hospital death after endoscopic hemostasis for peptic ulcer bleeding.

Short-term and long-term benefits of endoscopic hemoclip application for Dieulafoy's lesion in the upper GI tract.

BACKGROUND: Dieulafoy's lesion is an important cause of GI bleeding. The results of hemoclip application as the first treatment of choice for Dieulafoy's lesions have not been reported. This study prospectively examined the short- and long-term outcomes of hemoclip application for Dieulafoy's lesions. METHODS: The study was conducted over a 7-year period beginning in January 1995 during which hemoclip application was used as the first-choice hemostatic treatment for Dieulafoy's lesions. Clinical data, endoscopic findings, and outcome of treatment were evaluated. Long-term outcome for patients was also investigated. RESULTS: A Dieulafoy's lesion was diagnosed in 34 patients (27 men, 7 women; mean age, 54 years, range 21-81 years) after a mean of 1.2 endoscopies; 79.4% of the patients had active bleeding. Initial hemostasis was attained by hemoclip placement in 94.1%. The rate of recurrent bleeding was 9.3%. No patient required additional treatment such as surgery. The 30-day mortality rate was 2.9% (1 death, unrelated). For the remaining 33 patients, median follow-up was 53.8 months (range 19 to 90 months). Another Dieulafoy's lesion developed in one patient during follow-up, but in a different location compared with the index lesion. CONCLUSIONS: Endoscopic hemoclip application for Dieulafoy's lesions was effective and safe with short- and long-term benefits.

Differential diagnosis of benign versus malignant nonfunctioning islet cell tumors of the pancreas: the roles of EUS and ERCP.

BACKGROUND: Differentiation between benign and malignant nonfunctioning islet cell tumors of the pancreas before surgery is often difficult. The roles of EUS and ERCP were evaluated in the differential diagnosis of these tumors. METHODS: Seven patients with histologically confirmed nonfunctioning islet cell tumors (4 benign, 3 malignant) underwent EUS and ERCP. OBSERVATIONS: EUS demonstrated a homogeneous hypoechoic mass or a hypoechoic mass with a regular central echogenic area in the 4 cases of benign tumor, and a hypoechoic mass with an irregular central echogenic area in all 3 cases of malignant tumor. The irregular central echogenic area corresponded to severe hemorrhage, necrosis, or fibrosis with hyalinosis (hyaline degeneration) on pathologic examination. ERCP demonstrated displacement or complete obstruction (because of ductal invasion) of the main pancreatic duct in 2 patients with malignant tumors and no abnormalities in the other 5 cases. CONCLUSIONS: In patients with nonfunctioning islet cell tumors, a hypoechoic mass with an irregular central echogenic area on EUS or complete obstruction of the main pancreatic duct on ERCP suggests malignancy.