Endoscopic follow-up after colorectal cancer surgery. Early detection of local recurrence?

This study deals with 188 consecutive patients who had a radically resected colorectal carcinoma and who were later controlled by colonoscopy. The median interval between resection and endoscopy was 2.5 (0.5-19) years. In 20 patients, a local recurrence was found (10.6%). In 11 of these 20 patients the indication for colonoscopy was the clinical suspicion of a recurrence. The remaining nine patients were asymptomatic, and colonoscopy was done as a routine procedure. In six of nine asymptomatic patients, a potentially curative resection of the recurrent tumor was possible, which was not possible in any of the 11 symptomatic patients. Nineteen of the 20 patients with a local recurrence could be followed up. Five of the six patients with potentially curative resection of the recurrence were asymptomatic for a median time of 38 (12-72) months after surgery; in contrast, 9 of 13 patients without curative operation died after a median survival period of 8 (1-24) months. The results of this study suggest that good long-term prognosis may be expected in patients in whom local recurrence is detected at an early asymptomatic stage with the possibility of potentially curative resection. Therefore, the authors propose regular endoscopic examinations in the first years after curative colorectal cancer surgery.

[Endoscopic papillotomy in preserved gallbladder]. / Endoskopische Papillotomie bei belassener Gallenblase.

Endoscopic papillotomy was attempted in 60 high risk patients (mean age 76 years) with complications of common bile duct stones and preserved gallbladder. Successful papillotomy and bile duct clearance was achieved in 56 patients (93%). One patient died of bleeding shortly after papillotomy. In 5 patients without signs of complication, cholecystectomy was performed prophylactically. Three patients were lost to follow-up. No cholecystectomy was performed in 47 patients (mean follow-up 24 months). 35 (74%) of these cases were free of biliary symptoms; 5 (11%) complained of nonspecific dyspeptic pain and only 2 (4%) had biliary colic. Complications due to the preserved gallbladder occurred in 5 of 47 patients (11%). Two patients had a short transient bout of jaundice and cholangitis respectively. Three patients developed acute cholecystitis with subsequent empyema. Four out of five complications occurred within one month and in three of them the cystic duct was occluded at papillotomy. In summary, treatment of common bile duct stones by endoscopic papillotomy appears to be justified in high risk patients with preserved gallbladder. Gallbladder related complications are mainly to be expected early in the follow-up or in cases with cystic duct occlusion at papillotomy. Because of the risk of empyema, early cholecystectomy is indicated in cases of acute cholecystitis.

[Endoscopic papillotomy--analysis of complications]. / Endoskopische Papillotomie--Analyse der Komplikationen.

Complications were observed in 19 out of 250 patients undergoing endoscopic papillotomy. In 215 patients in whom papillotomy was successful the frequency of complications was 2.8%, in contrast to 37% in 35 patients with failed therapy (p less than 0.0001). Furthermore, the complications of successful papillotomy were observed immediately, except in one patient with gallstone ileus. The following 19 complications were observed: cholangitis (5), pancreatitis (5), bleeding (5), perforation (2), impaction of the Dormia basket (1), and gallstone ileus (1). Three patients died, all as a result of cholangitis (mortality 1.2%). All patients with pancreatitis had previously had a precutting.

[Clinical significance of pancreas divisum]. / Klinische Bedeutung des Pancreas divisum.

Pancreas divisum was demonstrated in 22 of 500 consecutive ERCP (4.4%). Among patients with otherwise normal ERCP, pancreas divisum was found in 12.8%. In contrast, only 1.8% of patients with other pathology in the ERCP exhibited pancreas divisum (p less than 0.001). In relation to the clinical indication, pancreas divisum was found in 13.3% of patients with suspected or proven pancreatitis, in 1.9% of patients with suspicion of biliary tract disease (p less than 0.001), in 1.9% of patients with suspicion of pancreatic cancer (p less than 0,05) and in 4.4% of patients with epigastric pain of undetermined origin (p greater than 0.05). In 14 patients pancreas divisum was the only pathological finding in a thorough clinical and gastrointestinal workup; 6 of the 14 patients had had typical episodes of pancreatitis, in 6 other patients there was clinical and biochemical evidence of pancreatic disease (mainly pain and hyperenzymemia), and the last 2 cases had chronic epigastric pain without biochemical abnormalities. In 2 patients of this series the pancreas divisum was misinterpreted morphologically (sonography, autopsy) as tumor of the head of the pancreas. Based upon our experience and the literature, the following practical conclusions can be drawn: 1. Pancreas divisum may cause typical episodes of acute (relapsing) pancreatitis. 2. In patients with chronic epigastric pain associated with hyperenzymemia but without typical acute pancreatitis, pancreas divisum may be the cause. 3. Morphologically pancreas divisum may mimic a pancreatic tumor (sonography, computer-tomography, autopsy).

[Endoscopic papillotomy in benign papillary stenosis]. / Endoskopische papillotomie bei gutartiger Papillenstenose.

Since 1977 endoscopic sphincterotomy has been indicated in 18 patients because of benign papillary stenosis. In 17 patients cholecystectomy had been performed some time before. The sphincterotomy was successful in 15 patients. In one patient slight bleeding occurred. In 2 of 3 patients in whom sphincterotomy did not succeed, the endoscopic procedure was complicated by cholangitis and pancreatitis respectively. 12 of the 15 patients in whom sphincterotomy was successful were symptom-free over a median period of 21 months. Therefore, endoscopic sphincterotomy appears to be an effective treatment for benign papillary stenosis and is a low-risk procedure compared with surgical sphincterotomy.

[Ultrasonically guided percutaneous fine needle aspiration biopsy of pancreatic tumours under permanent visual control (author's transl)]. / Sonographisch gesteuerte perkutane Feinnadelaspirationspunktion von Pankreastumoren unter permanenter Sicht.

Using a new method of ultrasonically guided fine needle biopsy under permanent visual control it is now possible to biopsy tumour-suspect changes of the pancreas and other abdominal organs reliably. The risk for the patient can thus be reduced to a minimum. The method leads to considerable improvement in obtaining biopsy material and is easily performed and may be repeated. The correct diagnosis could be established in all of 18 patients with pancreatic disease by cytological investigation. Sonographic interpretation of space occupying pancreatic lesions was successful in only 16 patients.

[Pancreatic cancer associated with pancreatitis and pseudocysts]. / Pankreasmalignome, assoziiert mit Pankreatitis bzw. Pseudozysten.

A discussion is presented of the diagnostic problems encountered in 27 of 153 consecutive cases of pancreatic cancer, all of which were initially misinterpreted as acute (relapsing) or chronic pancreatitis or pancreatic pseudocysts.

[Cholelithiasis as the first manifestation of cystic fibrosis of the pancreas (mucoviscidosis)]. / Cholelithiasis als Erstmanifestation der zystischen Pankreasfibrose (Mukoviszidose).

A hitherto healthy 6-year-old girl developed cholestatic jaundice, due to multiple extra- and intrahepatic cholesterol bile calculi. Cystic fibrosis of the pancreas was established as the cause of the disease and of the biliary cirrhosis. Operative treatment and the ensuing substitution with pancreatic extracts have improved the cholestasis. Pulmonary involvement became subsequently evident and is now under treatment. The pathophysiology of bile acids in cystic fibrosis as relevant to the occurrence of gall stones in these patients is discussed.

Guided puncture under real-time sonographic control.

A new method of percutaneous thin-needle biopsy is presented. The needle is guided sonographically under visual control. This method is safe, economical, and tolerated well by the patient.