One-step endosonography-guided drainage of a pancreatic pseudocyst: a new technique of stent delivery through the echo endoscope.

We report here the first case of a one-step endosonography(EUS)-guided pseudocyst drainage. A prototype large channel curved array echo endoscope (Pentax FG-38 UX) and a prototype delivery system for placement of an endoprosthesis was used for the procedure. The delivery system (GIP MedicinTechnik GmbH/Medi-Globe Corporation) consists of a handle part with a piston, a metal ring sheath, a plastic catheter with a diathermy needle and a double pigtail endoprosthesis (8.5 Fr). When mounted on the endoscope the endoprosthesis can be advanced out of the distal end of the endoscope. The introduction of the stent as well as the stent release can be monitored entirely by ultrasound. The procedure was tested in a 76-year-old woman with a pseudocyst measuring 60 mm in diameter located in the tail of the pancreas. The procedure was well tolerated by the patient, and there were no procedural complications. The advantage of a large channel echo endoscope and our new prototype delivery system is that the endoprosthesis can be inserted in to a pancreatic cyst guided exclusively by EUS without exchange of endoscopes, catheters or guide wires. Further studies are warranted.

Carcinoid tumour of the breast.

A case of primary carcinoid in the female breast is reported. The patient was treated by segmental mastectomy and is without local recurrence and signs of carcinoid tumour at any other site after 3 years of observation.

[Percutaneous cysto-gastrostomy of chronic cysts in the pancreas. A nine-year clinical experience]. / Perkutan cystogastrostomi af kroniske cyster i pancreas. Ni års kliniske erfaringer.

During the years 1984-1992 74 patients with chronic pancreatic cysts were treated with percutaneous cystogastrostomy. Forty-five patients (61%) were males, 29 females (39%). Pain was the indication for treatment in all patients. The catheter was successfully placed at the first attempt in 68 patients (92%). Immediate complications occurred in four patients (5.5%); they have not occurred since 1986. Abscess formation was seen in eight patients (10.8%). One patient died four days after the procedure from a myocardial infarction (mortality rate: 1.3%); no mortality has occurred since 1986. Pain disappeared or decreased in 90%, gain of weight was seen in 80%. The mean observation time was 27 months (range: 0-108 months). This method is less traumatizing than an operation, and mortality and complication rates compare favourably with those seen after surgery; the results are at least as good.

[Necrotizing pancreatitis]. / Nekrotiserende pancreatitis.

Acute pancreatitis is in the majority of patients a mild, self-limiting illness. Five to fifteen percent of the patients develop acute necrotizing pancreatitis, a severe illness with a high morbidity and mortality. Secondary infection of the pancreatic necrosis (infected pancreatic necrosis) is the main cause of death. Pancreatic necrosis is identified with a high accuracy by contrast-enhanced computed tomography. The differentiation between sterile and infected necrosis requires demonstration of bacteria or fungi isolated from the necrosis. Surgical treatment of a sterile necrosis remains controversial, but there is a tendency towards conservative non-operative treatment. Infected pancreatic necrosis is regarded as an absolute indication for surgery, untreated the mortality is approximately 100%. The aim of modern treatment is to remove the pancreatic necrosis continuously. This has successfully been done by the open packing method, with or without subsequent drainage. At present no randomized trials comparing the different treatment modalities are available. The question of prophylactic antibiotics still remains unanswered. For the present imipenem 0,5 g x 3 is recommended.

Helicobacter pylori infection in children with recurrent abdominal pain.

Helicobacter pylori was cultured and Helicobacter-like organisms (HLO) were seen in 6 (16%) of 37 children with recurrent abdominal pain. Five children had concomitant histological inflammation, but none had endoscopic changes. All 6 children demonstrated positive serology. Compared with the total group, they were more often from developing countries, larger families and lower social groups. Treatment with phenoxymethyl penicillin and colloidal bismuth subcitrate did not result in side effects or elevated serum levels of serum bismuth. Three children demonstrated metronidazole-resistant strains and the treatment of these children remained an unsolved problem. Among the 31 H. pylori/HLO negative children 8 (26%) demonstrated histological changes, 5 (16%) endoscopic changes and 11 (35%) had positive serology. In conclusion, pathological findings at upper gastrointestinal endoscopy are common in children with recurrent abdominal pain. Because of disconcordance between endoscopy, histology and culture, we recommend that biopsies should always be taken to clarify the diagnosis.

Percutaneous cystogastrostomy for chronic pancreatic pseudocyst.

During the years 1984-1992, 74 patients of mean age 45 (range 6-71) years with chronic pancreatic pseudocyst were treated by percutaneous cystogastrostomy. They comprised 45 men and 29 women. A diagnosis of chronic pancreatitis was verified in 55 patients (74 per cent); pain was the indication for treatment in all cases. The catheter was successfully placed at the first attempt in 68 patients (92 per cent). Immediate complications occurred in four patients (5 per cent); there have been none since 1986. Abscess formation was seen in eight patients (11 per cent). One patient died 4 days after the procedure from myocardial infarction giving a mortality rate of 1 per cent; no death has occurred since 1986. The mean observation time was 27 (range 0-108) months. Pain disappeared or decreased in almost 90 per cent of patients and weight gain was seen in 80 per cent. The method described is less traumatic than operation, and mortality and complication rates compare favourably with those seen after surgery; the results are at least as good.

The humoral immune response to Helicobacter pylori infection in children with recurrent abdominal pain.

The systemic humoral immune response to Helicobacter pylori antigens was investigated in 36 children with recurrent abdominal pain (RAP). H. pylori was cultured and Helicobacter-like organisms (HLO) were seen in six children, three of whom had active and two inactive chronic gastritis. None of these children had endoscopic abnormalities. All sex children had increased IgG antibodies to heat-stable H. pylori antigens which were of the IgG1 and IgG3 subclasses. Using six other IgG tests, four of which were commercially available, two to five H. pylori-positive children were found seropositive. Five of six H. pylori-negative children with inactive chronic gastritis and no endoscopic abnormalities had increased IgM antibody levels in addition to increased or borderline increased IgG antibody levels to H. pylori, indicating activity in a chronic H. pylori infection. Five children without H. pylori and with no morphological changes, but with gastritis or duodenitis by endoscopy, had significantly lower IgG and IgA antibody levels compared to other groups. Six of nineteen children without H. pylori, and with no morphological or endoscopic changes had increased IgG and IgM antibody levels to H. pylori. All H. pylori-negative children were seronegative by the four commercial kits. Overall, 12 (33%) of 36 children with RAP were either H. pylori positive by culture and microscopy or had increased IgG antibody levels to H. pylori, which is significantly different from the 10-14% seropositive rate of asymptomatic children. H. pylori may therefore be a cause of RAP in one quarter to one third of the children with RAP in whom other etiologies of RAP are excluded. Further studies on a large number of children are needed for an extended evaluation of the humoral immune response to H. pylori and for further examination of commercial kits which seem to give a high number of false-negative results.

Endosonographically-guided fine needle aspiration biopsy of malignant lesions in the upper gastrointestinal tract.

A new method of endoscopic ultrasound (EUS) guided fine needle aspiration using an ultrasonic endoscope with a curved array transducer mounted in front of the optic lens was developed. As a result of the sector shaped sound field and the direction of the scanning plane it was possible to visualise ultrasonically a needle inserted through the biopsy channel. EUS guided biopsy was performed in 37 patients (with 39 lesions) using three types of needles. Based upon initial testing of several prototype needles a 160 cm long, 0.8 mm diameter needle placed in a Teflon catheter was developed after preliminary results with the first two types were unsatisfactory (positive results for malignancy in 3/11 and 4/8 cases). The third prototype was tested in seven patients with malignant tumours of the upper GI tract. In these patients EUS guided biopsy was positive for malignancy in 7 of 8 solid lesions. Problems related to the technique and criteria for a successful outcome are discussed. The preliminary results show that it is possible to advance a needle into a malignant lesion inside or outside the GI wall during EUS examination and aspirate material for cytologic examination from various lesions. Controlled studies are needed to determine the indications for use and the accuracy of the technique.

Isoamylases and their thermolability in serum and cyst fluid from patients with pancreatic pseudocysts.

The isoamylase pattern in serum and the amylase thermolability have been suggested as screening tests for the development of pancreatic pseudocysts. To study whether serum reflects the contents of pseudocysts, we have investigated the isoamylases and their thermolability in cyst fluid and in serum from 13 patients with pancreatic pseudocysts. No significant correlation was found between the contents in serum and cyst fluid with regard to total amylase and isoamylase P2 and P3 or with regard to the thermolability of total amylase and isoamylase P2 and P3. Thus, serum does not reflect the cyst contents of isoamylases or their thermolability. Therefore these serum amylase determinations can hardly be expected to be useful in distinguishing patients developing pseudocysts among patients with pancreatitis.

Upper gastrointestinal hemorrhage associated with pancreatitis.

In a two-year period from June 1981, two cases of acute upper gastrointestinal bleeding caused by pancreatitis were observed. In both cases the bleeding was caused by erosion of the gastric mucosa contiguous to, respectively, a pseudocyst and an abscess of the pancreas. Both patients were successfully treated with cystogastrostomy. Erosive bleeding from gastrointestinal mucosa adjoining pancreatic lesions may be a more common source of upper gastrointestinal bleeding than has hitherto been assumed.

Metastases to the breast from extramammary carcinomas.

Metastases to the breast from extramammary carcinomas are rare. Only about 200 cases are reported in the literature. Fifteen additional cases are presented here and the literature is reviewed. Two of the patients has primary thyroid carcinoma, two adenocarcinoma of the colon, three bronchogenic carcinoma, four malignant melanoma, one a squamous cell carcinoma of the oesophagus, one an adenocarcinoma of the stomach, one a renal cell carcinoma and one a carcinoid of the terminal ileum. In three cases the breast lesion was the first manifestation of an extramammary cancer. Six of the patients died of disseminated cancer shortly after the breast metastasis was diagnosed. Although breast metastasis may be suspected clinically, exact histological diagnosis is important in order to avoid unnecessary surgical treatment and to guide further therapy.

Prospective controlled vagotomy trial for duodenal ulcer: primary results, sequelae, acid secretion, and recurrence rates two to five years after operation.

In a prospective, controlled clinical trial, vagotomies for duodenal, pyloric, and prepyloric ulcers were performed on 259 patients. Eighty-three patients were randomly selected for truncal vagotomy and drainage (TV + D), 93 patients were randomly selected for selective gastric vagotomy and drainage (SV + D) and 83 patients were randomly selected for parietal cell vagotomy without drainage (PCV). This interim report deals with the primary results, reduction in acid secretion, sequelae, and recurrence rates two to five years after the operation. One patient died after the operation. Postoperative complications were evenly distributed between the three operations. No differences in spontaneous acid secretion (BAO), peak acid output after pentagastrin stimulation (PAOP), or peak acid output after insulin stimulation (PAOI) were found. Patients with recurrent ulcers ahd smaller reductions in BAO than patients without ulcer recurrences, although not significantly. Patients with ulcer recurrences after TV + D had, in contrast to ulcer recurrences after SV + D and PCV, a significantly smaller reduction in PAOP than patients without recurrences. The overall recurrence rate was 13%: 10% after TV + D, 14% after SV + D and 16% after PCV. The risk of ulcer recurrence within the first three years, calculated by an actuarial method, was found to be significantly higher after PCV (0.52% per month) than after TV + D (0.32% per month), but not different from SV + D (0.42% per month). In contrast to TV + D and SV + D, no recurrences after PCV occurred after three years--25% of the patients were followed for five years. It is concluded that the trial, at present, does not point to any evident superiority of PCV.

Effect of Pentagastrin, secretin, and cholecystokinin on gastric secretion of pepsin in man.

In eight volunteers the effect of pentagastrin (0.15, 1.0 and 6.0 microgram/kg body weight/h), secretin (0.5 and 1.0 clinical units/kg b.w./h), and cholecystokinin (CCK) (0.5 and 1.0 Ivy dog units/kg b.w./h) on the gastric secretion of pepsin was investigated to ascertain whether interaction occurred. A high intraindividual variation was found, and also a significant washout of pepsin in the initial period after stimulation. Pepsin secretion was stimulated after pentagastrin (50% above basal level) and even more after secretin (75%-200% above basal level), whereas no stimulation but a tendency for depression was seen after CCK. With the doses of gastrointestinal hormones used in this investigation, no interaction between secretin and CCK on gastric secretion of pepsin in man was demonstrated.

Angiography in the diagnosis of carcinoid syndrome.

The diagnosis of carcinoid syndrome has been confirmed by selective abdominal angiography in a consecutive series of 18 patients. In eight patients the primary carcinoid tumour was removed before angiography. The primary lesion was demonstrated in eight of ten cases. Metastases from the carcinoid tumours was present in all 18 patients. All cases of mesenteric metastases and 12 of 14 cases with liver metastases were visualized by angiography. All but one of the liver metastases were highly vascularized and therefore easy to recognize, making angiography a good monitor in the control of medical therapy or in planning of surgical intervention.

Clinical diagnosis of metastatic carcinoid tumours.

Eighteen patients with metastatic carcinoid tumours were admitted to surgical gastroenterological department of Rigshospitalet during the period 1974--1978. Thirteen had primary carcinoid tumours in the terminal ileum, two in the lungs, one in the pancreas, one in the testis, and one possibly in the retroperitoneum. All patients had distant metastases, 13 in the liver. Carcinoid syndrome with flusing and diarrhoea was present in 15 patients (83%). The time elapsing from onset of symptoms until diagnosis was on an average 2 1/2 years. The most valuable screening test for carcinoid syndrome was determination of the excretion of 5-hydroxy-indol- acetic-acid. The most sensitive investigation for determination of primary tumour and/or metastases was abdominal angiography, which was positive in all cases. Other radiological investigations were less sensitive.

Serum disappearance rate of gastrin-17 after vagotomy.

Six duodenal ulcer patients were investigated before and after truncal vagotomy and pyloroplasty. Four doses of gastrin-17 were injected intravenously (15.625, 31.25, 62.5, and 125 micrograms/kg body weight); the gastric secretory response and the disappearance rate of gastrin were measured. After vagotomy the basal level of gastrin increased from 64 pg/ml to 106 pg/ml. When corrected for the basal levels of gastrin, the peak levels and disappearance rate of gastrin-17 were observed to be the same after vagotomy as before (half-life before vagotomy, 5.6 min; after, 5.8 min). This indicates that vagus does not influence the metabolism of exogenous gastrin-17. The gastric secretion of acid was reduced to 30% after vagotomy, which shows that there is a synergism between vagus and gastrin-17.

Cimetidine treatment of recurrent ulcer.

Twenty-one consecutive patients with endoscopically proven recurrent ulcer were treated continuously with cimetidine, 1 g daily for 8 weeks. After 4 weeks' treatment 18 (86%) of the patients were free of symptoms, and the ulcers had healed in 17 (81%). At the 8th-week examination symptoms had disappeared, and ulcers were healed in 19 patients (91%). Within 6 weeks after withdrawal of cimetidine six patients (28%) presented recurrence of ulcers and symptoms. This study demonstrates that recurrent ulcer patients respond to cimetidine with regard to healing of ulcers and disappearance of symptoms, as do unoperated duodenal ulcer patients. Because operation for recurrent ulcer carries an increased mortality, we suggest that cimetidine should be attempted in the treatment.