Intraoperative enteroscopy.

Current options for the diagnosis and management of small bowel lesions include push enteroscopy (PE), video capsule endoscopy (VCE), single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), and intraoperative enteroscopy (IOE). IOE, the ultimate diagnostic and therapeutic modality for small bowel disorders, is a major surgical and endoscopic procedure. It should be reserved for cases that cannot be managed with others modalities because of the difficulties of the procedure and significant morbidity. The indication for IOE have diminished in recent years because of the development of VCE and DBE. IOE is reserved for patients with massive mid-gut bleeding, lesions not accessible by balloon enteroscopy, and lesions difficult or impossible to treat by balloon enteroscopy. There are special indications in Crohn disease and in Peutz-Jeghers syndrome. Our own results and a review of the literature are presented.

EUS-guided FNA of solid pancreatic masses: high yield of 2 passes with combined histologic-cytologic analysis.

BACKGROUND: EUS-guided FNA (EUS-FNA) is an established tissue-acquisition technique, with most studies concentrating on cytologic analyses of specimens, with only few data existing on histologic assessment. OBJECTIVE: To assess the sensitivity of a combined analysis of histologic followed by cytologic tissue diagnosis. DESIGN: A retrospective 3-center study. METHODS: In consecutive patients undergoing FNA of solid pancreatic masses, core specimens were harvested for histology; residual tissue was examined cytologically. Only unequivocally positive results were regarded as malignant. Criterion standards were positive results from EUS-FNA or other histologic findings, or, if negative, clinical follow-up data (minimum 12 months). RESULTS: Among 192 patients (110 men; mean age 63 years) with mostly pancreatic-head masses (72.4%), overall, adequate tissue was obtained in 98.9% of all cases, with a mean of 1.88 needle passes and an overall sensitivity of 82.9% (95% CI, 76.0%-88.5%). Histology and subsequent cytology provided adequate tissue and sensitivities of 86.5% and 60%, and 92.7% and 68.1%, respectively. Excluding cases with inadequate specimens, sensitivities rose by 4% to 10%. Histology showed a trend for superiority over cytology only in characterizing nonadenocarcinoma tumor types. No differences in sensitivity were found between the centers involved. LIMITATIONS: Retrospective design, different processing of cytologic specimens. CONCLUSIONS: At EUS-FNA in pancreatic masses, combined histologic-cytologic analysis achieved a sensitivity of more than 80%, despite a low number of needle passes and may thus save time. Histology alone did not reach higher sensitivity than cytology. In particular situations, eg, rare tumors, histology may still be required.

Follow-up of patients with obscure gastrointestinal bleeding after capsule endoscopy and intraoperative enteroscopy.

BACKGROUND/AIMS: Capsule endoscopy (CE) is highly sensitive to detect the bleeding source in patients with obscure gastrointestinal bleeding compared with intraoperative enteroscopy (IOE). Long-term follow-up information of patients undergoing CE and IOE for investigation and treatment of chronic gastrointestinal bleeding is lacking. METHODOLOGY: 50 patients with obscure gastrointestinal bleeding underwent CE and IOE. Follow-up data of 47 patients (30 men, 17 women, mean age 60.9 +/- 16.8 years) were available (3 patients lost in follow-up). Clinical outcome was assessed with a standardized patient questionnaire and personal communication with referring physicians. RESULTS: Bleeding sources were detected and effective treated during intraoperative enteroscopy (argon plasma coagulation or surgical resection) in 34 patients [(angiodysplasias (n = 22), ulcers (n = 5), malignant tumors (n = 3), Meckel's diverticulum (n = 1), jejunal varices (n = 1), bleeding ileum diverticulosis (n = 1), hyperplastic polyp (n = 1)]. Mean follow-up was 346.3 days (range 253-814 days). Clinical signs of recurrent gastrointestinal bleeding occurred in 12 of 47 patients (25.5%) [positive fecal occult blood test (n = 2), anemia (n = 2), melena (n = 3), hematochezia (= 5)]. In 3 patients (6.4%) no further therapy was necessary, 9 patients (19.1%) needed blood transfusions (range 2-62 units), endoscopic or surgical interventions to control rebleeding. CONCLUSIONS: The results of the present study support the proposal that capsule endoscopy could be used as the first-choice investigation in patients with obscure gastrointestinal bleeding.

A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding.

BACKGROUND: Capsule endoscopy enables noninvasive diagnostic examination of the entire small intestine. However, sensitivity and specificity of capsule endoscopy have not been adequately defined. We, therefore, compared capsule endoscopy by using intraoperative enteroscopy as a criterion standard in patients with obscure GI bleeding. METHODS: Forty-seven consecutive patients with obscure GI bleeding (11 with ongoing overt bleeding, 24 with previous overt bleeding, and 12 with obscure-occult bleeding) from two German gastroenterologic centers were included. All patients who had a prior nondiagnostic evaluation, including upper endoscopy, colonoscopy with a retrograde examination of the distal ileum, and push enteroscopy, underwent capsule endoscopy followed by intraoperative enteroscopy. RESULTS: Capsule endoscopy identified lesions in 100% of the patients with ongoing overt bleeding, 67% of the patients with previous overt bleeding, and 67% of the patients with obscure-occult bleeding. Angiectasias were the most common source of bleeding (n = 22). Capsule endoscopy showed the source of bleeding in 74.4% of all patients. The method was more effective in patients with ongoing bleeding. Compared with intraoperative enteroscopy sensitivity, specificity, and positive and negative predictive values of capsule endoscopy were 95%, 75%, 95%, and 86%, respectively. CONCLUSIONS: Capsule endoscopy has high sensitivity and specificity to detect a bleeding source in patients with obscure GI bleeding. Thus, wireless capsule endoscopy can be recommended as part of the routine work-up in patients with obscure GI bleeding.

Endoscopic management of pancreatic cancer.

Endoscopic treatment of pancreatic malignancy can be considered as an alternative treatment option in inoperable patients. Endoscopic retrograde cholangio-pancreatography (ERCP) plays a key role, allowing diagnosis, collection of cytologic, biopsy specimens, and insertion of biliary and pancreatic stents. A major problem is the patency of plastic stents that will eventually clog on average after 3 to 4 months. Self-expandable metallic stents have longer patency, but they can also become occluded by tumor ingrowth or overgrowth. Furthermore, metallic stents are much more expensive and their uses may be considered in patients with longer life expectancy. ERCP can be performed on an outpatient basis in selected patients, reducing costs related to hospitalization. A team approach is mandatory to obtain the best results.

Low-molecular-weight heparin does not prevent acute post-ERCP pancreatitis.

BACKGROUND: Studies suggest that heparin has anti-inflammatory effects that could prevent acute post-ERCP pancreatitis. The aim of this investigator-initiated, prospective, randomized, double-blind, multicenter study was to determine whether low-molecular-weight heparin can prevent acute post-ERCP pancreatitis. METHODS: Patients at increased risk for acute post-ERCP pancreatitis based on assessment of known risk factors were randomized to receive low-molecular-weight heparin (Certoparin 3000 IU subcutaneously) or placebo (saline solution 0.3 mL subcutaneously) the day before ERCP. The drug was given 2 hours before and 22 hours after ERCP. Documentation and follow-up included patient history, risk factors for acute post-ERCP pancreatitis, procedure-related data, assessment of pain (visual analogue scale, need for pain medication), laboratory findings before and after ERCP (0, 4, and 24 hours), as well as post-ERCP complications. The two-sided Fisher exact test was used for statistical comparison, and a p value < or =0.05 was considered significant. RESULTS: A total of 458 patients were enrolled in the study. Data from 10 patients could not be evaluated, leaving 221 patients in the low-molecular-weight heparin group and 227 in the placebo group (total 448 patients; 135 men, 313 women; mean age 58 [15] years). Low-molecular-weight heparin and placebo groups were comparable with regard to risk factors for acute post-ERCP pancreatitis (gender distribution, age <65 years, history of pancreatitis, pancreas divisum, disorders of sphincter of Oddi) and procedure-related data (difficult cannulation, diagnostic or therapeutic ERCP, needle-knife papillotomy, endoscopic sphincterotomy, biliary or pancreatic procedure, pancreatic contrast injection, success and final diagnosis of ERCP). Acute post-ERCP pancreatitis occurred in 8.5% (38/448), with one death resulting from severe pancreatitis. Low-molecular-weight heparin offered no benefit compared with placebo based on the frequency of acute post-ERCP pancreatitis (low-molecular-weight heparin, 18/221 vs. placebo, 20/227; p=0.87) and the severity of acute post-ERCP pancreatitis (low-molecular-weight heparin, 14 mild, 3 moderate, one severe; placebo, 18 mild, two moderate, 0 severe). The 24-hour serum amylase values and 24-hour pain scores did not differ significantly between the low-molecular-weight heparin group and the placebo group. Bleeding complications occurred in two patients, both in the low-molecular-weight heparin group (one mild, one moderate). CONCLUSIONS: Prophylactic subcutaneous administration of low-molecular-weight heparin does not prevent acute post-ERCP pancreatitis.

Arthroscopic resection of an extra-articular tenosynovial giant cell tumor from the ankle region.

This report describes the case of a 31-year-old man with a tenosynovial giant cell tumor in the left ankle region. The tumor developed over a period of 5 months. A conservatively treated fracture of the leg in the patient's history was important. The presurgical magnetic resonance imaging (MRI) examination allowed a specific diagnosis and the exclusion of infiltrative properties of the tumor. The tumor was excised using an exclusively arthroscopic technique. The procedure included treatment of intra-articular pathologies and the removal of 2 loose bodies. The excision was complete and no recurrence or complication was seen in 5 months' follow-up. In view of the possible recurrence (in about 50% of patients) and the unknown development of malignant tumors, arthroscopic excision can be advantageous. This procedure includes small scars and lower risks of infection and necrosis. Therefore, arthroscopic treatment of soft tissue tumors near the ankle joint may by an alternative to open excision.