Impact of endoscopic assessment and treatment on operative and non-operative management of acute oesophageal perforation.

BACKGROUND: Surgeons have not typically utilized an endoscopic approach for diagnosis and management of acute oesophageal perforation, mainly due to fears of increased mediastinal contamination. This study assessed the evolution of endoscopic approaches and their effect on outcomes over time in acute oesophageal perforation. METHODS: All patients with documented acute oesophageal perforation between 1990 and 2009 were enrolled prospectively in an Institutional Review Board-approved database. RESULTS: Of 81 patients who presented during the study period, 52 had upper gastrointestinal endoscopy for diagnosis alone (12 patients; 23 per cent) or as a component of acute management (40 patients; 77 per cent). Use of endoscopy increased from four of 13 patients in the first 5 years of the study to 20 of 24 patients in the final 5 years. Endoscopy was used in conjunction with surgery in 28 patients, of whom 21 underwent primary repair, three had resection, and one a diversion; 12 patients in this group had hybrid operations (combination of surgical and endoscopic management). Primary endoscopic treatment was used in 15 patients (29 per cent), most commonly involving stent placement (7). Of those having endoscopy, complication rates improved (from 3 of 4 to 8 of 20 patients), as did mean length of stay (from 21·8 to 13·4 days) between the initial and final 5 years of the study. There were two deaths (4 per cent). Of 21 patients who had both endoscopic assessment and management in the operating room, endoscopy identified additional pathology in ten, leading to a change in management plan in five patients. CONCLUSION: Endoscopy is a safe and important component of the management of acute oesophageal perforation. It provides additional information that modifies treatment, and its wider use should result in improved outcomes.

Pancreatic ERCP.

Like biliary endoscopy, pancreatic endoscopic retrograde pancreatography (ERCP) has evolved from being a diagnostic procedure to a therapeutic one. The advent of magnetic resonance cholangiopancreatography and endoscopic ultrasonography have limited the need for anatomic definition and transpapillary tissue sampling, respectively. This review is therefore limited to studies published during the past year concerned either with efforts to limit the incidence of post-ERCP pancreatitis or with critical reviews of therapeutic pancreatography, including the treatment of strictures, stones, and ductal disruption.

Therapeutic pancreatic endoscopy.

Over the past decade, endoscopic retrograde cholangiopancreatography (ERCP) has developed from being a diagnostic tool to become one that is primarily used to provide therapy. This development occurred first for biliary disorders and more recently for primary diseases of the pancreas. Not only can new-generation computed tomography (CT), magnetic resonance imaging, and magnetic resonance cholangiopancreatography procedures suggest a diagnosis in the majority of individuals with pancreatic diseases today; in addition, ERCP-related complications can be minimized or avoided altogether in conjunction with positron-emission tomography or directed cytology or biopsy, either using ultrasound or CT guidance, or with tissue obtained during endoscopic ultrasonography. It is against this background that papers on therapeutic pancreatic endoscopy published during approximately the last year are reviewed here. Despite these developments, however, the following three issues concerning current advances in pancreatic endotherapy should be emphasized: firstly, most of the techniques reviewed here affect only a small number of patients; secondly, most of the techniques have been reported only by expert centers; and thirdly, most of the studies concerned have lacked control groups, and there is still a paucity of studies investigating endoscopic techniques on a randomized basis in comparison with surgery or medical therapy for the treatment of most benign and malignant pancreatic disorders.

Endoscopic palliation of esophageal malignancy.

Historically, the development and marketing of the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser was associated with the insertion of markedly fewer conventional prostheses for the palliation of malignant dysphagia. Subsequently, the introduction of self-expandable metal stents (SEMS) has, in turn, led to a diminished role not only for laser therapy but also for other ablative modalities, including bipolar cautery, argon plasma coagulation (APC), and the injection of caustics. Two ablative modalities deserve ongoing consideration, but not because they have been proven to be better or more cost-effective than SEMS. These include photodynamic therapy (PDT), because of its potential to ablate large areas of low-grade malignancy, and injection of chemotherapeutic agents or T-lymphocytes sensitized to an individual malignancy. The latter, while theoretically promising, will require considerably more study before widespread clinical application.

Removal of esophageal expandable metal stents: description of technique and review of potential applications.

BACKGROUND: Expandable metallic stents (EMS) have seen wide application in patients with malignant stricture and fistulas. They have not seen wide application for benign disease because of concern over acute complications and long-term sequelae. METHODS: Between June 1999 and October 2000, six patients with EMS in place for malignant stricture (n = 3), benign stricture (n = 1), anastomotic leak (n = 1) and benign esophagorespiratory fistula (n = 1) had their stents endoscopically removed. Removal was performed secondarily to the following complications: secondary stricture (n = 1), epidural abscess (n = 1), diskitis (n = 1), resolution of fistula (n = 2), and resolution of anastomotic leak (n = 1). RESULTS: Four patients had one EMS: Ultraflex (n = 3) and Z-stent (n = 1). In two patients, two stents (Ultraflex and Z-stent) were retrieved simultaneously. No procedurally related complications occurred. Two patients with esophageal cancer required additional stents. All three patients with benign fistula and stricture recovered uneventfully. CONCLUSIONS: The safe removal of current brands of EMS may facilitate the wider application of these devices to include selective patients with benign disease.

Therapeutic pancreatic endoscopy.

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreatic diseases is continuing to evolve. This article reviews recent publications spanning a wide range of topics related to therapeutic pancreatic endoscopy: Over the last 12 months, several case series have added to the literature on the short-term and long-term effectiveness of endoscopic therapy of pseudocysts, pancreatic abscesses and fistulas. Identification of a communication between pancreatic duct and a pseudocyst has been suggested to predict response to percutaneous drainage. The importance of identifying pancreatic leaks in patients with severe pancreatitis has been stressed. In addition, endotherapy has been reported to be effective in patients with idiopathic chronic pancreatitis. Endoscopic removal of pancreatic stones after extracorporeal lithotripsy has been shown to result in long-term improvement in clinical outcomes in patients with chronic calcific pancreatitis. Other interesting publications addressed new techniques and tricks to achieve access to the difficult pancreatic duct. Finally, no review of pancreatic endotherapy would be complete without a reminder--as recently stated by a National Institutes of Health consensus panel--that there is considerable need for higher-quality and controlled trials in this and other areas of interventional endoscopy.

A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis.

BACKGROUND: The end result of leakage of pancreatic juice into the peripancreatic space can be sterile necrosis, infected necrosis, or rupture into an adjacent hollow viscus or blood vessel (eg, colon, small bowel, or pseudoaneurysm). If a pancreatic duct (PD) leak is present, should treatment be aimed at minimizing the sequela of the leakage of pancreatic juice and not just supportive observation until a necrosectomy is required? METHODS: In 144 patients with severe pancreatitis we investigated whether the presence of a PD leak was associated with necrosis and also asked if PD leak might predict other outcomes such as a length of stay (LOS), mortality, and need for surgery. Furthermore, we questioned whether the use of endoscopic retrograde cholangiopancreatography (ERCP) to search for a PD leak might worsen the clinical outcome because of the potential for introducing microorganisms into an undrained space or exacerbating pancreatitis. RESULTS: The presence of a demonstrable pancreatic duct leak was observed in 37% of patients and was significantly associated with both a higher incidence of necrosis and prolonged LOS (> or = 20 days). These patients were 3.4 times more likely to have necrosis and 2.6 times more likely to have a prolonged LOS. When treated with a combination of percutaneous drains, pancreatic duct stents, and surgery as necessary, a PD leak (even with its higher necrosis rate) was not significantly correlated with either mortality or the need for necrosectomy. The use of ERCP was not associated with LOS, mortality, or the need for necrosectomy, provided discovered PD leaks were immediately drained. CONCLUSIONS: A PD leak is common in patients with pancreatic necrosis but it is also important to locate and decompress in order to impede progression of the disease and keep mortality low.

In vitro study and in vivo application of a reusable double-channel sphincterotome.

BACKGROUND AND STUDY AIMS: Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been deemed to be a "cost-prohibitive" procedure, based upon the cumulative costs of one-time-use accessories and current reimbursement plans. One-time-use sphincterotomes comprise a significant component of that cost and, accordingly, we evaluated the disability and clinical usefulness of a recently introduced reusable double-channel sphincterotome. MATERIALS AND METHODS: We studied a reusable 6-Fr sphincterotome at baseline and following contamination with 10(6) Bacillus stearothermophilus. Reprocessing included a unique 30-minute ultrasonic cleaning step in lieu of manual cleaning, followed by steam sterilization. Parameters evaluated included sphincterotome function, electrical integrity, and our ability to sterilize the devices for three in vitro trials. In vivo studies included patient demographics and outcomes, procedural findings, and success rates, and the mean number of times the sphincterotome was used, functional grading at time of use, and reasons for sphincterotome malfunction. RESULTS: Ten out of ten sphincterotomes maintained form, function, and electrical integrity in vitro, and all cultures were negative after sterilization. In the initial in vivo study, ten sphincterotomes were used in 50 patients (mean, 5 uses) with a 94% success rate. Reasons for sphincterotome failure included leak or breakage of the accessory port in 70%, wire fracture in 10%, incorrect wire bow in 10%, and clogged injection port in 10%. Following reconfiguration of the insertion-port polymer, an additional ten sphincterotomes were used in 110 patients (mean, 11 uses). Mechanical failure occurred primarily at the wire-insertion port, resulting in progressive friction with reuse. There were neither electrical nor infectious complications associated with reuse. CONCLUSIONS: A reusable double-channel sphincterotome is available which can theoretically be reprocessed and sterilized without the manual cleaning step of the reprocessing process. Contingent upon both provider and patient, multiple reuse can be anticipated, and contingent upon purchase price and reprocessing costs, the potential for procedural cost savings is significant.

Reusable biopsy forceps: a prospective evaluation of cleaning, function, adequacy of tissue specimen, and durability.

BACKGROUND: Recent studies have indicated that reusable biopsy forceps remain contaminated after reprocessing and can only be used a mean of 12 to 25 times without malfunction. Because this contradicts traditional endoscopic practice, our study investigated the ability to sterilize a type of commercially available biopsy forceps and prospectively evaluated their function in vivo until malfunction and/or breakage. METHODS: Thirty reusable biopsy forceps were studied, 15 of which were contaminated for 5 trials each with 10(6) Bacillus stearothermophilus, and 15 of which were prospectively evaluated clinically over an 18-month period (9/98-3/00). Contaminated forceps were reprocessed by using a standard protocol and placed in a sterile bag containing soy broth. The latter was passed through a 0.2 micron filter and was subsequently cultured. In vivo data included biopsy site, size, adequacy, problems obtaining a biopsy specimen, and reasons for ultimate forceps failure. RESULTS: After contamination, all biopsy forceps yielded a heavy growth of B stearothermophilus. No forceps, including 5 that were piecemeal dismantled with a wire cutter, had residual bacteria after reprocessing. In the in vivo study, 1507 biopsy sessions were undertaken in 1339 procedures. Forceps were categorized as new or like-new in 1259 of 1339 (94%) procedures, some loss of function but usable in 72 of 1339 (5.4%), and inadequate function or broken at use in 8 of 1339 (0.6%). Histologically, 1501 specimen sets were adequate (99.6%) and mean specimen size was 2.7 +/- 0.1 mm. Mechanical problems were noted in only 38 of 1507 (3%) sessions to include such things as sticky forceps, and the mean number of uses to malfunction or breakage was 91 +/- 15 (SEM) (range 19-132). CONCLUSIONS: This reusable biopsy forceps can be sterilized and used a mean of 91 times with adequate tissue sampling. Mechanical problems were minor to time of breakage. Contingent on acquisition and reprocessing costs as well as the number of procedures performed, this reusable forceps has the potential for significant cost savings.