[Initial results using extracorporeal low energy shockwave therapy ESWT in muscle reflex-induced lock jaw]. / Erste Erfolge unter Anwendung der extrakorporalen niederenergetischen Stosswellentherapie ESWT bei muskelreflektorischer Kieferklemme.

BACKGROUND: Post-traumatic reflex-mediated temporomandibular joint (TMJ) locking is one of the complications frequently observed after sophisticated and long dentoalveolar operations. Its severity can be up to 90%. Usually, therapy consists of mouth-opening exercises using tongue depressors. In difficult cases, the treatment regularly extends for weeks, often with only moderate improvement of this painful limitation. USE OF ESWT: In three cases, it was shown that supportive treatment utilizing low-energy shock waves (ESWT) is significantly effective in the therapy of limited opening of the mouth. The patients reported relief of their complaints, especially over the mandibular angle region, through the daily application of ESWT and felt their condition improved after the fifth therapy course. DISCUSSION: This in particular improved the patient's ability to eat, speak, and maintain good oral hygiene. Great physiotherapeutic benefit is imparted by the use of ESWT in the clinical management of these and other cases of dentomaxillofacial practice.

Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis.

OBJECTIVE: Therapeutic endoscopy may be effective in selected patients with chronic calcific pancreatitis (CCP). We prospectively evaluated the early outcome of extracorporeal shockwave lithotripsy (ESWL) in combination with interventional endoscopy, using broad inclusion criteria. METHODS: A total of 48 consecutive patients (35 male, 13 female) were recruited for ESWL and endoscopic therapy of symptomatic CCP. Symptoms, quality of life, pancreatic morphology and function were assessed before and after. RESULTS: Multiple stones (n = 43), strictures (n = 34), and pancreas divisum (n = 11) were found. A median of 13 ESWL sessions (range 2-74) with a median of 22,100 shockwaves (1,700-150,900) were required. Endoscopic pancreatic sphincterotomy (n = 48), stricture dilation (n = 12), and/or stenting (n = 27) were performed. After therapy, drainage of the pancreatic duct system was achieved in 36, complete stone clearance in 21 patients. Follow-up (n = 38) at 7 months (range 5-9) showed a significant decrease in pancreatic duct diameter (p < 0.001) and pain score (p < 0.0001) whereas complete pain relief was observed in 45% of cases. Several quality of life scores improved significantly. Weight gain occurred in 68% of patients. Normalization of fasting blood glucose and HbA1c levels were observed in four patients, without modifying their treatment. Improvement in pain score correlated with weight gain and decrease in pancreatic duct diameter. Nonalcoholic etiology was associated with a better chance for improvement in pain score and decrease in pancreatic duct diameter. The presence of strictures did not deteriorate the clinical outcome. CONCLUSIONS: Besides pain relief, ESWL in combination with interventional endoscopy resulted in pancreatic ductal decompression, weight gain, and improvement in quality of life in a considerable number of patients with advanced CCP.

[Endoscopic therapy in chronic pancreatitis]. / Endoskopische Therapie bei chronischer Pankreatitis.

In chronic pancreatitis obstruction of the pancreatic ductal system by strictures, stones or pseudocysts seems to play an important part in pathogenesis. Therefore, therapeutic efforts are directed mainly towards reestablishing a free flow of pancreatic secretion. Endoscopic techniques allow decompression of the organ by stenting or stone extraction, as well as evacuation and drainage of pseudocysts. Thus, interventional endoscopy offers safe and long lasting therapy for many patients suffering from chronic pancreatitis. This paper gives a review of the literature and reports on own clinical data.

Pulverisation of calcified and non-calcified gall bladder stones: extracorporeal shock wave lithotripsy used alone.

Using a modified electromagnetic lithotripter (Siemens), extracorporeal shock wave lithotripsy (ESWL) was performed in 260 patients with gall bladder stones. Exclusion criteria for treatment were a non-functioning gall bladder, subcostal gall bladder location, and multiple stones occupying more than three quarters of the gall bladder volume. Stone pulverisation was the end point of ESWL. The number of shock wave discharges and sessions was not limited. Pulverisation was achieved in 250 patients (96.1%) after a median of three ESWL sessions (range 1-21). The number of sessions required depended upon stone composition and burden. More than three sessions were required in 60.2% of patients with calcified stones compared with 35.9% of patients with non-calcified stones (p < 0.001). 65.8% of patients with stones measuring more than 30 mm in total diameter required more than three sessions compared with 42.9% of patients with a stone burden less than 30 mm (p < 0.01). At 18-24 (8-12) months follow up, stone clearance was achieved in 94.3% (80.4%) of patients with non-calcified stones, compared with 89.5% (76.8%) in patients with calcified stones and in 75% (71.4%) of patients with a total stone diameter more than 30 mm compared with 95.7% (80.4%) for patients with a total stone diameter less than 30 mm (p < 0.05). ESWL related complications (gross haematuria) occurred in three patients. Thirty six (13.8%) patients experienced biliary colic; four had cholecystectomy, and five endoscopic papillotomy because of common bile duct obstruction. Stone recurrence was seen in 5.3% of patients over a follow up period of up to two years (median 16.6 months).

Endoscopic sclerotherapy--personal experience.

Over the last 12 years, treatment of bleeding esophageal and gastric varices has improved considerably. By the use of new techniques and with increased experience the results of endoscopic sclerotherapy have been optimized. Acute variceal bleeding, esophageal or gastric, can now be reliably and definitively stopped using the tissue adhesive Histoacryl Blau. This is also applicable to all patients irrespective of their liver status at presentation. As expected, the mortality of acute variceal bleeders has decreased considerably, no death from bleeding occurring in the last 5 years. This has obviated the need for emergency surgery, balloon tamponade or vasopressin infusion. Using an aggressive sclerotherapy technique in the bleeding-free interval, varices of all grades can now be effectively eliminated within an average of 3 sessions covering 3-4 weeks. With the intra- cum peri-variceal injection technique not only are the visible veins eradicated, but also fibrosis of the inner esophageal wall is achieved at the same time. If careful attention is paid to certain details of the technique and instruments, and with close follow-up, patients of portal hypertension can now live well in terms of liver function, without the danger of further variceal bleeding.

Experience with a transnasally fixed endoprosthesis for treating esophageal anastomotic leakage.

Eight patients suffering from leakage around the esophagus were treated with a transnasally fixed Celestin tube. All of the subjects had exhibited an anastomotic dehiscence after having undergone esophageal resection, cardia resection or total gastrectomy. Following treatment, in all cases the anastomoses healed quickly with no complications.

A new technique for replacing an obstructed biliary endoprosthesis.

We report on a new method of stent exchange using a threaded device that enables removal of the clogged stent while simultaneously maintaining the original pathway without withdrawing the endoscope. With this method stent replacement has become more reliable, safer, simpler and quicker. This technique is also suitable for removal of stents dislodged inside the duct.

ESWL and gallstone dissolution with MTBE via a naso-vesicular catheter.

Endoscopic placement of a naso-vesicular catheter was successful in 90% (45/50) of patients with cholecystolithiasis. The first 7 patients were treated by MTBE dissolution alone. Dissolution was discontinued after a maximum of 14 days, as only two patients were rendered stone free. In one patient, 3 tiny pigment stones were sucked out through the catheter, and in another inoperable patient a pigtail endoprosthesis was finally inserted into the gallbladder. In the remaining 36 patients, combined ESWL and MTBE dissolution therapy was carried out. Treatment was broken off by one patient after one week, and interrupted in another due to catheter dislodgement. After an average of 10 days with 1-9 ESWL sessions (average: 3) complete stone clearance was achieved in 60% (20/34) of patients. Fourteen of the patients who completed treatment, and the one with catheter dislodgement still have sludge in the gallbladder, which is being treated with oral bile acids. The procedure-related complication rate was 10% (3 pancreatitis, 1 cystic duct perforation and 1 guidewire impaction). The mortality rate was zero. There was no evident complication due to either ESWL or MTBE dissolution.

Endoscopic treatment of a pancreatic abscess originating from biliary pancreatitis.

We present a case report of a patient with two large pancreatic abscesses and an associated colonic fistula originating from acute gallstone pancreatitis, which we treated endoscopically. The common bile duct stones were extracted after a papillotomy. The abscess in the pancreatic head was drained into the duodenum and the one in the pancreatic tail irrigated through a nasopancreatic catheter using normal saline mixed with gentamycin. The colonic fistula was finally obliterated using a two-component fibrin glue.

[10 years' experience with endoscopic sclerotherapy of esophagogastric varices]. / 10-Jahres-Erfahrung mit der endoskopischen Sklerotherapie von oesophagogastrischen Varicen.

We report on our 10 years' experience in endoscopic sclerotherapy. A total of 1054 patients (90% of them with liver cirrhosis) were treated. During the first seven years (1978-1985) the hospital mortality of the bleeders was 31.5%. During the last three years after the introduction of tissue adhesive the mortality rate has falling to 14.5%. The rate of patients with late recurrent hemorrhages sank from 16.6 to 7.8%. This improvement of the results is in our opinion due to the more sufficient control of bleeding and treatment of fundic varices. The sclerotherapy in the interval has an overall hospital mortality of 5-6% (for all patients regardless the Child-classification). Perforations occurred in less than 1% and stenoses requiring bougienage in 2-3%. The cumulative survival curve shows that after 10 years about 40% of the patients are still alive.

New modalities for treating chronic pancreatitis.

Over the last few years, a new method, neither medical nor surgical, has been developed for treating often difficult-to-treat chronic pancreatitis. In the case of obstructive pancreatitis, endoscopy permits both drainage and calculus extraction. Even encrusted concrements and calcifications can be removed from the pancreatic duct with the aid of extracorporeal shockwave lithotripsy. The first aim is to relieve pain by restoring a free flow of secretion. Perhaps the use of endoscopic treatment in the early stages will break the vicious circle of chronic inflammation and ultimate gland destruction.

Malignant jaundice: results of diagnostic and therapeutic endoscopy.

Direct cholangiography plays an important role in the diagnosis of malignant obstructive jaundice. Endoscopic retrograde cholangiopancreatography is gradually gaining ground over percutaneous transhepatic cholangiography. Endoscopy can determine the exact location and extent of the obstruction. Typical changes of the ducts are often helpful in interpreting the causes of obstructive jaundice. Representation of the bile and pancreatic duct systems is successful in 95% of cases in the hands of an expert. Acute pancreatitis is a complication occurring in about 1% of cases. Immediate drainage can usually prevent septic complications. Endoscopic drainage is a palliative measure for inoperable patients. Compared to biliodigestive anastomoses, catheters are subject to clogging in the less-risky, nonsurgical method. Blockage causes late cholangitis which can only be recognized and remedied by regular after-care of the patient. Endoscopic placement of the prosthesis has an 85% rate of success. The rate of complications related to the procedure is 2%. The mortality rate is 1%.

Transnasal fixation of the esophageal prosthesis.

We present a simple technique for the fixation of esophageal tubes. The endoprosthesis is anchored to a thin polyethylene catheter which is passed transnasally and attached to the ear. This method of treatment effectively prevents dislodgement. It is also suitable for placing a tube into the esophagus when the stenosis essential for anchorage is absent, for example in large fistulae, perforations, or suture dehiscence.

N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy.

We report on our two years' experience with the tissue adhesive n-butyl-2-cyanoacrylate. During this period 202 patients suffering from esophagogastric varices were treated endoscopically. With the aid of the tissue adhesive the conventional sclerotherapy with Polidocanol 1% has been clearly improved. Problems concerning early recurrent bleeding and fundic varices are satisfactorily solved. The endoscopic hemostasis of severe variceal bleedings has become safer and surer. The overall hospital mortality of these patients has sunk from 31.5 to 17.5%. Cyanoacrylate is a very useful substance for obliterating large esophagogastric varices. However, the complete elimination of esophageal varices, which is the guarantee for a long-term freedom from recurrent bleeding, can only be achieved by using a genuine sclerosing agent.

Endoscopic dilatation and papillotomy of the accessory papilla and internal drainage in pancreas divisum.

In the case of pancreas divisum the minute orifice of the minor papilla has offered a special challenge to endoscopic diagnosis and therapy. Here we describe a method for easy cannulation of the minor papilla and drainage of the pancreatic duct. By means of a flexible guide wire and a dilator, the tiny papilla can be simply dilated, enabling papillotomy to be successfully accomplished. This method has been used in six cases without any major complications, and should pave the way for diagnosis and therapy of pancreas divisum.

Endoscopic obliteration of large esophagogastric varices with bucrylate.

We report on three patients with severe recurrent bleeding from large esophagogastric varices which could not be controlled by conservative treatment or sclerotherapy. In these cases the bleeding was successfully arrested by intravascular injection of Bucrylate.