Preoperative staging of colorectal cancer with a balloon-sheathed miniprobe.

BACKGROUND AND STUDY AIMS: Conventional endoscopic ultrasonography (EUS) is a valuable modality for staging the depth of invasion of colorectal cancer. However, there are difficulties with this technique in reaching as far as the cecal area, traversing tight strictures, and obtaining clear images of smaller lesions. Due to these factors, mis-staging often occurs. The literature shows that the miniprobe is superior to EUS, because of its easy manipulation and better diagnostic accuracy. We therefore conducted a prospective study using a balloon-sheathed miniprobe for colorectal cancer staging. PATIENTS AND METHODS: Eighty-six patients underwent preoperative staging using a miniprobe combined with an outer balloon sheath. Six patients were excluded from lymph-node examination due to local tumor resection. Acoustic coupling was achieved with or without water immersion. The results were compared with the histopathological findings in the resected specimens. RESULTS: The balloon-sheathed miniprobe had an overall accuracy rate of 85 % for T staging, with 100 % in T1; 78 % in T2; 90 % in T3; and 40 % in T4. Lymph-node metastasis was correctly diagnosed in 73 % of cases, with sensitivity and specificity rates of 74 % and 71 %, respectively. It was not possible to obtain clear cross-sectional images using the miniprobe in three patients. CONCLUSIONS: The balloon-sheathed miniprobe is a good alternative for evaluating colorectal tumor lesions, since it can usually obtain cross-sectional images even in markedly stenosed lesions, and the examination can be performed easily with endoscopy, with or without water-infusion techniques. One major limitation with the probe is the difficulty in evaluating deeper structures, such as lymph-node groups and contiguous organ involvement.

Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis.

BACKGROUND: Intraductal ultrasound (IDUS) as an adjunct to ERCP for detection of extrahepatic bile duct stones is technically easy, accurate, and safe. This prospective study evaluated IDUS with an "over-the-wire" catheter US probe as an adjunct to ERCP. METHODS: Sixty-five patients, highly suspected to have choledocholithiasis, underwent IDUS during ERCP. The IDUS probe was inserted by means of the duodenoscope into the bile duct without performing a sphincterotomy. All stones identified by IDUS or retrograde cholangiography were removed with either a basket or retrieval balloon after endoscopic sphincterotomy. RESULTS: The final diagnosis was choledocholithiasis in 59 patients. Bile duct diameter ranged from 0.6 to 2.3 cm and stone size from 2 mm to 2 cm. IDUS successfully identified all stones in these patients. IDUS resulted in 2 false-positive diagnoses in the remaining 6 patients without stones (overall accuracy 97%, sensitivity 100%, specificity 67%). Cholangiography detected stones in 55 of the patients with stones (accuracy 94%, sensitivity 93%, specificity 100%). CONCLUSION: IDUS, a safe, technically easy procedure, is highly accurate in the detection of extrahepatic bile duct stones regardless of the diameter of the bile ducts. The "over-the-wire" technique preserves access to the cannulated duct. IDUS is an excellent adjunct to ERCP for the diagnosis of choledocholithiasis. IDUS differentiates stones from air bubbles and prevents unnecessary sphincterotomy.

Rapid diagnosis of choledocholithiasis using biochemical tests in patients undergoing laparoscopic cholecystectomy.

BACKGROUND/AIMS: The present study was designed to identify the biochemical tests which could detect the presence of common bile duct stones in patients with symptomatic gallstones, without other invasive investigations. The usefulness of biochemical tests may reduce the necessity of endoscopic retrograde cholangiopancreatography prior to laparoscopic cholecystectomy. METHODOLOGY: 3000 patients with symptomatic laparoscopic cholecystectomy scheduled for laparoscopic cholesystectomy were included in the study. 458 patients (201 men, 257 women; mean age, 57.7 +/- 14.6 yrs) were examined with endoscopic retrograde cholangiopancreatography for suspected common bile duct stones. The serum tests for liver function, including a measurement of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin, gamma-glutamyltransferase and albumin were obtained on admission prior to the ultrasonography, and the endoscopic retrograde cholangiopancreatography. RESULTS: The six significant factors, including alkaline phosphatase, direct bilirubin, total bilirubin, aspartate aminotransferase, alanine aminotransferase and gamma-glutamyltransferase were identified by the univariate analysis and the multivariate logistic regression analysis which identified alkaline phosphatase and gamma-glutamyltransferase, as the two significant independent factors. A statistical model was developed with a formula of [formula: see text] A curve of receiver operating characteristics was constructed to identify an alkaline phosphatase level greater than 300 U/L or a gamma-glutamyltransferase level greater than 420 mU/mL which would have both higher sensitivity and specificity. CONCLUSIONS: Biochemical tests can be a significant aid to the clinician's decision-making when predicting the presence of common bile duct stones in patients with gallstones.

The accuracy of endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, computed tomography, and transabdominal ultrasound in the detection and staging of primary ampullary tumors.

BACKGROUND/AIMS: To compare the accuracy between EUS (endoscopic ultrasound), ERCP (endoscopic retrograde cholangiopancreatography), CT (computed tomography), and transabdominal US (ultrasound) in the detection and staging of primary ampullary tumors. We will also try to discuss the influence of endobiliary stent on EUS in staging ampullary tumors. METHODOLOGY: Twenty-one patients with ampullary tumors were evaluated by EUS, ERCP, CT, and US before operation. The accuracy was assessed with TNM staging and compared with the surgical-pathological findings. RESULTS: EUS was superior to CT and US in detecting ampullary tumors, but EUS and ERCP are of similar sensitivity (EUS 95%, ERCP 95%, CT 19%, US 5%). EUS was superior to CT and US in T staging (EUS 75%, CT 5%, US 0%) and detecting lymph node metastasis (EUS 50%, CT 33%, US 0%) of ampullary tumors. The accuracy of EUS in T and N staging of ampullary tumors tended to be decreased in the presence of endobiliary stent (stenting: T 71%, N 75%; nonstenting T 83%, N 100%), but there was no statistical significance. CONCLUSIONS: EUS was superior to CT and US in assessing primary ampullary tumors, but it was not significantly superior to ERCP in detecting ampullary tumors. The presence of endobiliary stent may decrease the accuracy of EUS in staging ampullary tumors.

Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy.

BACKGROUND/AIMS: This study is conducted to evaluate the feasibility of percutaneous transhepatic gallbladder drainage prior to laparoscopic cholecystectomy for the treatment of gallbladder empyema. We also determine the sonographic findings, causative organism, clinical signs and symptoms, laboratory data, associated underlying medical disorders and the complications related to both cholecystostomy and laparoscopic cholecystectomy. METHODOLOGY: One hundred and forty-five cases of gallbladder empyema were included in this study which was composed of 80 males and 65 females, aged 22-94 years with a mean age of 71-years. All patients underwent percutaneous transhepatic gallbladder drainage under ultrasound and fluoroscopic guidance, and laparoscopic cholecystectomy was carried out thereafter. We analyzed the clinical presentations (signs, symptoms, laboratory and ultrasonographic findings, concomitant medical disorders), causative organisms and the complications related to percutaneous cholecystostomy and laparoscopic cholecystectomy. RESULTS: Percutaneous transhepatic gallbladder drainage was performed successfully in all patients within 48 hours after clinical diagnosis of acute cholecystitis. Complications related to percutaneous transhepatic gallbladder drainage were bile leakage after tract dilatation noted in 2 patients (1.4%), and 20 (14%) patients had pain at the puncture site which radiated to the right shoulder during the procedure, but resolved spontaneously within an hour later. On admission, 102 (70%) patients presented as right upper quadrant pain, 39 (27%) as epigastric pain, 90 (62%) as fever, 108 (74%) patients had leukocytosis, and 33 (22.7%) patients were septic. AST and ALT were elevated in 57% and 51% of patients, respectively. Alkaline phosphatase was elevated in 56% of patients, and 34% of those patients had combined common bile duct stones. Gallbladder stones were documented in 135 (93%) patients, while the remaining 10 (7%) cases were acalculous. Five (3.4%) patients had combined gallbladder adenocarcinoma, 7 (4.8%) had liver abscess, while 13 (9%) had biliary pancreatitis. The ultrasonographic findings included gallbladder distension (93%), wall thickening (90%), pericholecystic fluid accumulation (15%), intraluminal sludge or stone (93%) and intraluminal air (13.9%). Bile culture were positive in 83% of the cases and showed gram-negative bacteria in 75%, gram-positive in 30%, anaerobes in 7%, while no growth in the remaining 17% of the cases. The common pathogens were Escherichia coli (57%), Enterococcus (27%), Klebsiella pneumonia (18%), Morganella morganii (7.6%), Pseudomonas aeruginosa (4.1%) and Salmonella (0.7%). The total postoperative complication rate was 17%, which included wound infection, bleeding, subhepatic abscess, cystic duct stump leak, common bile duct injury and pneumonia. Postoperative mortality was 2.6%. Conversion rate to open cholecystectomy was 27%. Clinical conditions improved within 48 hours after cholecystostomy in 93% of patients. Time interval between cholecystostomy and elective cholecystectomy was 2-21 days with a mean of 4 days. Total hospital stay was 5-38 days (mean: 11 days). CONCLUSIONS: Percutaneous transhepatic gallbladder drainage is a safe and effective procedure for the initial management of gallbladder empyema. We highly recommend this preoperative drainage procedure in patient with sepsis, and for those high-risk patients such as old age and with underlying medical illnesses. This procedure can stabilized the patient so that an appropriate therapeutic planning can be achieved.

Video-endoscopic ultrasonography in staging gastric carcinoma.

BACKGROUND/AIMS: Clinical staging of gastric carcinoma is important in designing the strategy of treatment. Early gastric carcinomas can be treated by minimally invasive therapy, whereas advanced gastric carcinomas should be treated by surgery with or without combined chemotherapy. This study was undertaken to evaluate the accuracy and limitations of video type endoscopic ultrasound in preoperative staging of gastric cancer and assessing lymph node metastasis. METHODOLOGY: Seventy-four patients with gastric carcinoma were preoperatively staged using video-endoscopic ultrasonography, performed by the same gastroenterologist. RESULTS: Sixty-three out of the 74 (85%) patients were correctly staged by endoscopic ultrasonography. The diagnostic accuracy rate was 100% for T1, 74% for T2, 87% for T3, and 86% for T4. Overstaging occurred in 11% due to peritumoral inflammation. Understaging occurred in 4% due to microinvasion of carcinomatous tissue or deeper organ invasion. The diagnosis of lymph node metastasis was confirmed in 72% of cases. Sensitivity and specificity was 74% and 86%, respectively. CONCLUSIONS: Endoscopic ultrasonography has a high accuracy rate in staging gastric carcinoma but still has its limitations in evaluating regional lymph node metastasis, despite using a new generation video-endoscopic ultrasonography.

Rectal leiomyosarcoma diagnosed by endoscopic ultrasonography.

A 67 year-old man was admitted to the Tainan Municipal Hospital due to a protruding mass, usually noted during defecation. Digital examination revealed a single, smooth, large mass over the rectum, occupying almost the entire lumen. Colonoscopy, barium enema, and computed tomography (CT) demonstrated a submucosal tumor of the rectum. Endoscopic ultrasound (EUS) study showed that the tumor originated from the muscle layer. Based on the size, margin and echogenicity of the mass, a malignant neoplasm, probably leiomyosarcoma, was diagnosed. Post-operative histologic examination confirmed that the resected tumor was leiomyosarcoma. Existing ancillary procedures like colonoscopy, abdominal CT, magnetic resonance image (MRI), and barium enema are neither reliable nor accurate in locating which layer the lesion originates. Colonoscopic biopsy is disappointing since submucosal tumor is usually inaccessible. EUS study can provide us with a more distinct image with regards to tumor origin, size, margin and echogenicity. This report emphasizes the important role of EUS in the pre-operative diagnosis of submucosal tumors of the rectum. Furthermore, this tool can aid the surgeons whether wide excision or an abdomino-perineal resection should be performed.

A potential complication of laparoscopy--the surgeon's herniated cervical disk.

Almost all operations that were traditionally performed by open laparotomy operations can be done laparoscopically; however, surgeons may experience several negative health effects. A 37-year-old gynecologic laparoscopist had a herniated intervertebral disk at C5-6 level. Due to a negative trauma history, a possible explanation may be the nonergonomic posture that he held while performing laparoscopic surgery for many hours. To reduce the risk of this complication, we recommend that surgeons' spatial orientation and hand-eye coordination for laparoscopy be improved by sequential phases of training.

Nonoperative treatment of gastric bezoars using electrohydraulic lithotripsy.

BACKGROUND AND STUDY AIMS: Bezoars are collections of indigestible foreign material that are found within the gastrointestinal tract. Nonoperative approaches such as dietary therapy, enzymatic dissolution, and endoscopic removal have been regarded as the mainstays of therapy. The purpose of this paper is to determine the efficacy of electrohydraulic lithotripsy (EHL) as an alternative form of treatment of gastric bezoars. PATIENTS AND METHODS: Between July 1988 and May 1996, 11 patients with large gastric bezoars, defined as those greater than 5 cm in diameter, received endoscopic-guided fragmentation using electrohydraulic lithotripsy. Nine of our patients had a history of ingestion of "Pho Pu Zi", (Cordia dichotoma Frost. f.), one of orange pitch, and one of ingestion of persimmon. RESULTS: The 11 patients in the study underwent EHL for the treatment of their gastric bezoars, with a 100% success rate, which was defined as the lack of residual bezoar seen on post-procedure barium study or endoscopy done 2 days after the procedure. Patients were followed-up clinically for 30-68 months, with seven of the 11 patients undergoing a barium study with no residual bezoar noted. No procedure-related complications were seen, except for pharyngeal pain which was most probably secondary to the placement of the silicon overtube. CONCLUSIONS: Endoscopically guided electrohydraulic lithotripsy is a safe, highly effective, alternative nonsurgical technique for the treatment of gastric bezoars.

Pre-operative staging of recto-sigmoid colon carcinoma by upper gastrointestinal endoscopic ultrasonography.

BACKGROUND/AIMS: To assess the accuracy of a new generation endoscopic ultrasonography (EUS)(GF-M200) in pre-operative staging of recto-sigmoid colon carcinoma invasion and lymph node metastasis. METHODOLOGY: Seventy-three patients with biopsy proven colon cancer were included in this study. These comprised 60 patients with rectal carcinoma and 13 patients with sigmoid carcinoma. All patients were pre-operatively examined by EUS. Pathological findings of the depth of tumor invasion and presence of lymph node metastasis were correlated with EUS. RESULTS: EUS has an overall accuracy rate of 89% in staging of recto-sigmoid cancer. The diagnostic accuracy rate was 83% for T1, 83% for T2, 93% for T3, and 71% for T4. Understaging and overstaging occurred in 6% and 6%, respectively. In determining lymph node metastasis, the overall accuracy rate was 77%, with a sensitivity and specificity rate of 77% and 76%, respectively. CONCLUSIONS: EUS is a valuable staging modality in the staging of the depth of tumor invasion, not only for rectal carcinoma but also for tumors located at the sigmoid colon.

Thoracoscopic T2-sympathetic block by clipping--a better and reversible operation for treatment of hyperhidrosis palmaris: experience with 326 cases.

Although thoracoscopic sympathectomy or sympathicotomy is the best treatment for hyperhidrosis palmaris, a new approach of clipping only without transection of T2-sympathetic trunk is just as effective. Aside from the guaranteed cure of hyperhidrosis, this new method has fewer complications and has the advantage of recovery of the sympathetic tone in the hands if the procedure is reversed by the removal of the clips. Between March 18 and September 30 of 1996, 326 patients (190 female and 136 male with a mean age of 20.5 years) underwent thoracoscopic T2-sympathetic block by clipping to treat hyperhidrosis. Good results and few complications were noted during follow up six months to one year postoperatively. Five of the 326 patients, all female, had the operation reversed because of intolerable compensatory sweating. Three recovered from the compensatory sweating within two months and had less palmar sweating than before their sympathetic block; the fourth achieved relief of compensatory sweating after nine months, and the fifth reported no improvement.

Percutaneous cholangiofiberscopic endoluminal forceps biopsy of intrabile duct diseases.

BACKGROUND/AIMS: The aim of the present study was to determine the usefulness and sensitivity of percutaneous cholangiofiberscopic guided forceps biopsy in patients suspected of intrabile duct diseases. This study also emphasized the use of a video monitor system in which the field of view is magnified; thus, even a small lesion can easily be detected. Furthermore, coordination of both the operator and assistant is easier because both can observe the image together on the video monitor. METHODOLOGY: Percutaneous cholangio-fiberscopic forceps biopsy was performed in 27 patients (14 men, 13 women, aged 37-81 years with a mean age of 61 years). A mature T-tube tract was used as an access for cholangioscopy in 17 cases while the remaining 10 patients underwent percutaneous transhepatic biliary drainage and gradual tract dilatation from 7-French to 16-French. A flexible fiberoptic choledoscope was gently inserted into a mature tract and once an abnormal mucosal lesion was identified, a forceps biopsy was inserted into a working channel of the scope, and 3-5 specimens were taken for histological examination. RESULTS: A histological diagnosis was obtained in 24 cases of the 27 patients (sensitivity 89%) and included cholangiocarcinoma (n=8), papillomatosis (n=3), ampullary adenoma (n=1), ampullary adenocarcinoma (n=1), hepatoma with intrabile duct invasion (n=1), and chronic inflammation (n=10). Post-procedural bleeding was noted in 1 patient. CONCLUSIONS: Percutaneous cholangiofiberscopic-guided forceps biopsy is a safe and easy to perform procedure. It yielded a high sensitivity rate for definitive diagnosis of very small or early intrabile duct lesions; thus, a curative therapeutic modality can be appropriately applied. The use of a video monitor system, which magnified the field of view without distorting the quality of the image, plays a crucial role in this technique. Mucin substance is commonly seen in cholangiocarcinoma. The association between bile duct stones and neoplasm needs further evaluation.