Management of esophageal perforations after therapeutic upper gastrointestinal endoscopy.

BACKGROUND: Esophageal perforation is one of the most dreaded complications in therapeutic gastrointestinal endoscopy. We assessed the frequency of esophageal perforation after endoscopic procedures in a highly specialized endoscopy unit and compared clinical outcomes in patients undergoing either surgical or conservative management. METHODS: From January 1985 to June 1996, 1011 instrumental endoscopic procedures (dilatation and bougienage) were performed in our department. The computerized complication database was searched to identify all patients with esophageal perforation during this same period, and their records were reviewed. RESULTS: Seventeen esophageal perforations (1.7%) occurred in the course of 1011 procedures. Four perforations resulted from balloon dilatation, and 13 were secondary to bougienage. Six patients were managed surgically (35%), all of them recovering uneventfully. Eleven patients were managed conservatively, mainly because they were unfit for surgery. Survival rate in this group was 82%; only two patients died, both of whom had underlying malignant disease. CONCLUSIONS: The current concept in management of esophageal perforations comprises surgical as well as medical treatment. In well-selected cases, non-operative treatment can be considered with favorable results.

Cholestatic jaundice due to Ormond's disease (primary retroperitoneal fibrosis).

A case of a 51-year-old man, who presented with cholestatic jaundice due to common bile duct compression produced by primary retroperitoneal fibrosis, is reported. The patient was operated on two years earlier because of hydronephrosis, when the disease was diagnosed. Cholangiopancreatography revealed a "double duct sign", disclosing another benign cause for this radiographic sign, that once was considered to be pathognomonic of pancreas cancer. The bile duct stricture was managed by the insertion of an endoscopic endoprosthesis. This is the first report of jaundice due to Ormond's disease and the third, due to retroperitoneal fibrosis.

-Bile duct stenoses and leakage after cholecystectomy: endoscopic diagnosis, therapy and treatment outcome-. / Gallengangsstenosen und -lecks nach Cholezystektomie: Endoskopische Diagnostik, Therapie und Behandlungserfolg.

Minimal invasive methods compete with surgical treatment in the therapy of complications after cholecystectomy. In this retrospective study we evaluate the efficacy of endoscopically placed biliary stents in 35 patients (25 female, ten male) with biliary strictures and/or leakage after cholecystectomy. 27 patients received a 10- or 11.5-French endoprosthesis, eight patients needed a percutaneous-transhepatic-cholangio-drainage (PTCD). Four patients (11.4%) underwent a surgical therapy. Endoscopic therapy was successfully completed in 23 patients (65.7%), at which we noticed a superior result in patients with early incidenced stenosis/leakages after cholecstectomy. During a follow-up period of 1-109 months (median 28 months) two recurrent strictures (5.7%) were observed. As a complication we have seen a prosthesis-dislocation after PTCD. None of the patients died of complications related to endoscopic therapy.

[Anastomotic recurrence with tumor stenosis after Billroth II gastrectomy for adenocarcinoma: implantation of 2 metal stents as palliative therapy]. / Anastomosenrezidiv mit Tumorstenose bei Z.n. Magenresektion nach Billroth-II wegen Adenokarzinom: Implantation zweier Metallstents als Palliativtherapie.

We report on a 70 year old patient with a great relapse in the region of the anastomosis after a palliative, subtotal gastrectomy with Billroth-II-gastrojejunostomie because of an adenocarcinoma one year before. He was unable to swallow fluids or solid food. The possibility of a sufficient gastroenteroanastomosis was certainly limited (great tumor-mass left during operation). So we implantated two metal stents in the afferent and the efferent limb, respectively. The patient's vomiting completely relieved and he was able to swallow fluid food again. After that treatment the patient's quality of live noticeably increased. Furthermore, by stenting the afferent limb a sufficient drainage out of the duodenum could be reached, thereby preventing an increasing cholestasis.

[Ultrasound-guided extracorporeal piezoelectric lithotripsy of bile duct calculi]. / Ultraschallgesteuerte extrakorporale piezoelektrische Lithotripsie (EPL) von Gallenwegskonkrementen.

AIM: Extracorporeal shock-wave lithotripsy (ESWL) with underwater spark discharge and stone localisation via x-ray has become established in the treatment of difficult bile duct stones. First results with the piezoelectric lithotripter (EPL) in our department have also been promising. METHOD: Between 1989 and 1993 we were able to treat 79 patients (mean age 76 years) with problematic bile duct stones with the EPL. Twenty-seven patients had solitary stones, 52 patients presented with multiple stones. Seventy-one patients received a nasobiliary tube to decompress the biliary system. For extracorporeal lithotripsy, we used a piezoelectric lithotripter (Piezolith 2300, R. Wolf, Knittlingen, Germany). RESULTS: Visualisation of the stones by ultrasound and ensuing treatment were possible in 71 out of 79 patients (90%), and complete stone removal was achieved in 62 patients (78.5%) after 7,595 shock-waves were applied per patient on average. In 55 patients, endoscopic extraction of fragments was performed to avoid fragment complications. Nearly all patients in whom extracorporeal lithotripsy failed were cleared of their stones by additional use of intracorporeal electrohydraulic lithotripsy. Three patients received palliatively an endoprosthesis and two patients were referred to surgery. CONCLUSION: EPL with sonographic stone localisation and mild sedo-analgesia is a valuable adjunct in the treatment of difficult biliary tract calculi. It is a worthwhile alternative especially for elderly patients who would be at high risk on general anaesthesia.