[Prospective study comparing conventional and transnasal esophagogastroduodenoscopy for routine diagnosis]. / Prospektive Studie zum Vergleich von herkömmlicher und transnasaler Osophago-Gastro-Duodenoskopie in der Routinediagnostik.

INTRODUCTION: Transnasal gastroscopy (TNG) is the result of ongoing improvements in endoscopic device development. These ultrathin endoscopes are planned to improve patient satisfaction with the endoscopic procedure. AIM: The aim of the current study was to prospectively evaluate the performance and patient acceptance of transnasal gastroscopy. PATIENTS AND METHODS: Sixty-three consecutive patients (40 males, 23 females, mean age 58.5 years) referred for routine upper gastrointestinal endoscopy to our tertiary care referral centre were assigned to one of three groups: first time transnasal gastroscopy (group 1, TNG), first time transoral gastroscopy (group 2, TOG) and transnasal gastroscopy after a previous unsedated transoral gastroscopy (group 3). All examinations were performed without intravenous sedation. Patients answered a standardised questionnaire immediately following the examination. RESULTS: The three groups of patients did not differ in age, gender or reason for gastroscopy. Investigations performed using transnasal technique were significantly shorter (TNG 8.9 min and 9.2 min vs. TOG 11.9 min, p = 0.011 and p = 0.026, respectively) than those performed in transoral technique. Nosebleeding, albeit not clinically significant, and the urge to wretch were significantly more common in the transnasal technique group (p > 0.001). Patient acceptance tended to score higher in the transnasal technique groups, however not statistically higher. A greater number of patients from group 3 (TNG after previous TOG) would prefer a repeat exam via the transnasal route. CONCLUSIONS: Transnasal gastroscopy represents a possible alternative to the conventional transoral technique. TNG entails less subjective patient discomfort, and patients experienced in both techniques prefer the transnasal route. Shorter examination times and lack of intravenous sedation result in several benefits: no sedation-related complications, shorter post-procedure observation times, and subsequently shorter time off work for patients.

[Endoscopic ultrasonography (EUS) of the upper gastrointestinal tract - prospective multicenter study to evaluate time and staff requirements]. / Endosonographie (EUS) des oberen Gastrointestinaltrakts - Prospektive Multizenterstudie zur Analyse von Zeit- und Personalbedarf.

BACKGROUND AND AIMS: Endoscopic ultrasonography is an important procedure in the diagnostic work-up of gastrointestinal and mediastinal masses. To evaluate the time and staff requirements for the examination, a prospective multicenter study was carried out. METHODS: 27 centers were asked to document their endoscopic ultrasonographic procedures over a 4-month period, using a standardized protocol comprising several parameters: time and staff requirements (overall and related to organs), time spent on informing the patients, preparation, performance and monitoring of the examination and subsequent care of patient as well as of endoscopic equipment. RESULTS: 484 examinations from 11 centers were suitable for evaluation, 25 % of the patients were out-patients. Median examination time was 20 minutes (range: 5 - 60 min) without significant differences concerning the device but with greater differences concerning the different organs (pancreas 23.5 minutes, esophagus 15 minutes). Median time of subsequent care was 35 minutes in out-patients, 25 minutes in hospitalized patients, with a great variety between different centers. In 70 % of examinations one doctor and one nurse were involved. For sedation midazolam was used in 90 % of cases, pethidin for analgesia in 30 % of cases. CONCLUSIONS: The obvious time and staff requirements for endoscopic ultrasonography are comparable to historical data for the performance of a colonoscopy. In out-patients the time required seems to be higher.

[Preparation for colonoscopy: A comparison between 3 commercially available Golytely solutions]. / Koloskopievorbereitung: ein Vergleich von 3 Fertig-Golytely-Lösungen.

The preparation for colonoscopy is essential for the results of the examination. The effectiveness of 3 commercially available Golytely solutions for colonoscopy (Original-Golytely-salt, Oralav and Delcoprep) were compared in a randomized prospective study. 310 outpatients were randomized into 3 groups. One of the above-mentioned solutions were used in these patients. Before the examination the patients were asked to drink 3 l of the given solution within 2 h. The colonoscopy was realized within 3-5 h after the end of preparation. Outcome criteria were the subjective acceptability of the solution for the patient, cleanness of the bowel and the formation of foam. In all 3 groups sufficient up to very good results could be achieved. There were no significant differences in the 3 groups. We conclude that the used procedure is absolutely sufficient to prepare for colonoscopy and that administration of liquids of more than 3 l or the use of enema or laxans on the previous day, are unnecessary. The suggested procedure can be used for children, too.

Immunological effects of therapeutic immunoadsorption with respect to biocompatibility.

The activation of the complement system leading to generation of anaphylatoxins and the membrane attack complex depends on the chemical nature of the adsorptive system and the anticoagulation used. The method of the primary separation determines the presence of cell debris in the plasma as well as the extent of platelet activation. The particular role of anticoagulation and its properties to prevent/reduce complement activation on immunadsorption material is discussed and the combined use of citrate and heparin is proposed. The quality of the reinfused plasma--as discussed on the example of LDL-apheresis--is therefore influenced by the amount of the activated split products. This determines finally the extent of cellular activation during therapeutic immunadsorption when receptor-dependent activation of cells by C3a(desarg) and C5a(desarg) can occur.

Anticoagulation-dependent inhibition of in vitro complement activation by anti-apo-B sepharose 4B CL.

During LDL apheresis, various combinations of heparin and citrate are used for anticoagulation. With an in vitro batch system we examined whether heparin/citrate combinations can be optimized in terms of complement activation inhibition without the loss of anticoagulant potency. Plasma anticoagulated by using six clinically applicable regimens was incubated with anti-apo-B antibody-coupled Sepharose 4B CL, and the anaphylatoxin content of the supernatant was investigated. A significant dose-dependent reduction of complement activation was achieved by anticoagulating whole blood with 10 U/ml heparin (p < 0.05) if compared with serum whereas citrate inhibited more effectively the generation of C5a (desarg) even at a low concentration (ACD-B 1:20) (p < 0.01). The lowest anaphylatoxin level was generated when heparin (10 U/ml) plus citrate (ACD-B 1:10) were applied, although such an approach may be of limited clinical interest. The empirically chosen heparin plus citrate ratio (2 U/ml, 1:20, respectively) provides for an optimal and almost ideal inhibition of complement activation and contributes considerably to the good tolerability of the immunoadsorbent.

Anaphylatoxin generation and distribution during in vitro LDL apheresis.

The extent of anti-apo-B IgG-Sepharose-induced complement activation in serum and plasma (heparin 2 U/ml and ACD-B 1:20) was investigated using an in vitro model of LDL apheresis. The total volume of serum or plasma loaded to the chromatography column was collected in defined aliquots. The washing, desorption and regeneration fluids were processed in the same way. From the obtained values of generated complement split products C3a (desarg), C4a (desarg), C5a (desarg) and complement proteins C3, C4, C5, the conversion rates of the precursor were calculated. In the experiments with serum, 19% of C3, 8% of C4 and 2.3% of C5 were converted by the immunoadsorbent, whereas with plasma 7, 6, and 0.6%, respectively, were found. Furthermore, only 60-74% of total anaphylatoxins were found in the effluent during the loading process. The residual 26-40% was removed from the column with the subsequent washing fluids. Therefore, in the clinical routine, only a reduced part of generated anaphylatoxins will be retransfused to the patient. The fact that C5 is converted to the most limited extent to its biologically active fragment additionally contributes to the understanding of the good clinical tolerability of the LDL apheresis.