[Deep sedation in gastrointestinal endoscopic interventions: safety and reliability of a combination of midazolam and propofol]

BACKGROUND AND OBJECTIVE

Midazolam (M) is well known and established in endoscopic procedures for so-called conscious sedation. Propofol (P) is given during endoscopy for deep sedation. The combination of both (M/P) in endoscopic procedures is new. In this prospective study the safety of the combination was tested, in a second prospective study the combination M/P with Propofol alone was compared.

PATIENTS AND METHODS

In the first study 143 patients undergoing 150 endoscopic procedures (expected > 30 min) were included. Deep sedation was induced by an i.v. bolus of 2.5 mg midazolam, followed by small doses of propofol. The sedation was performed by a second physician experienced in intensive care. In the second prospective study 64 patients undergoing two necessary endoscopic procedures were included: one deep sedation with propofol alone, the second one with combination of midazolam bolus followed by propofol.

RESULTS

It was demonstrated that induction of deep sedation by an i.v. bolus of 2.5 mg midazolam, followed by small doses of propofol is safe, without undesirable side effects, e.g. respiratory or circulation depression. Recovery time increased (4 to 8 minutes) with the combination M/P, costs decreased by saving 59% propofol per minute. This may be important for longer endoscopic procedures.

CONCLUSION

The combination of M/P for deep sedation during endoscopy may be useful when long procedures are expected or patients are at risk with propofol alone.

Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey

Since there are now several ways to treat symptomatic gallstone disease, one is able to select treatment on the basis of the patient's comfort, the practicability, effectiveness, and side effects of the technique, and the relative costs. In order to assess the present status of contact dissolution with methyl tert-butyl ether with regard to these aspects, the present enquiry reports the data of 21 European hospitals. Eight hundred three patients were selected for contact litholysis of cholesterol gallbladder stones using methyl tert-butyl ether. Percutaneous transhepatic puncture of the gallbladder was performed under x-ray or ultrasound guidance. Dissolution rate, side effects, and treatment times of 268 patients from one single center were compared to those of 535 patients from the other 20 centers. Two hundred sixty-four patients were followed for five years to assess stone recurrence. Physicians were asked how they assessed the expenditure of the method, the discomfort to the patients, and the staffing situation. Patients were asked to indicate their acceptance on an analog scale. Puncture was successful in 761 (94.8%) patients. Prophylactic administration of antibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludge remained in the gallbladder. The most severe complication was bile leakage, which led 12 (1.6%) patients to have elective cholecystectomy. Toxic injuries due to the ether were not reported. Method-related lethality amounted to 0%, 30-day-lethality to 0.4%. Stone recurrence rate was about 40% in solitary stones and about 70% in multiple stones over five years. Patients with multiple stones developed recurrent stones almost twice as often as those with solitary stones. The probability of stone recurrence in patients with sludge in the gallbladder after catheter removal was not statistically significantly different from those without sludge. Seventy to 90% of the centers found the puncture to be simple and not distressing for patients and the relation between expenditure and therapeutic success to be acceptable. The acceptance of contact litholysis by the patients was excellent. Contact litholysis when applied by an experienced team provides real advantages in the treatment of gallstone disease. The method is technically simple, well accepted by the patients, and can be easily applied in community hospitals. Contact litholysis may be of particular value in patients who are not suitable for anesthesia or surgery.

[Contrast medium resorption in ERCP]

During this study the absorption rates of two contrast media were measured in double-blind design. 33 patients received lopamidol (Solutrast 300), and 30 patients Meglumine iothalamate (Conray 60). A regular absorption of the contrast media during ERC, ERP and ERCP could be stated. With reference to the absorption rates a slight, but for statistically not significant advantage for the contrast medium lopamidol could be ascertained. During ERC the absorption rates ranged from 0.4 to 30%, during ERP from 2.2 to 18.8% and during ERCP from 1.0 and 30.0%. Consequently the endoscopist always has to take into account an anaphylactoid reaction due to the systemic absorption of contrast media which, compared to other examinations with contrast media, happens relatively seldom.

Splenic injury as a complication of endoscopy: two case reports and a literature review

Two cases of splenic injury - one after a difficult colonoscopy and the other after routine ERCP - are reported. Splenic injury as a complication of endoscopic procedures is relatively rare, but over the past several years this complication has been increasingly reported. Review of the literature revealed 11 cases occurring after colonoscopy and one after ERCP. Although most of the patients presented with acute abdominal symptoms, some had mild vague symptoms. In two cases the injury was overlooked entirely. Diagnosis was established at laparotomy in four cases, by CT in four, by ultrasonography in two, by chance observation in two, by angiography in one and by paracentesis in one. All patients except the most recent three reported underwent surgery, with one mortality occurring three weeks after the operation.

Intraductal mucin-hypersecreting neoplasms of the pancreas. A clinicopathologic study of eight patients

Intraductal mucin-hypersecreting neoplasms of the pancreas with extreme dilatation of the main duct were studied in eight patients. They included five men and three women, aged 47-85 years. Five patients had a history of symptoms mimicking pancreatitis; four developed steatorrhea and/or diabetes. At endoscopic retrograde pancreatography, five patients showed an open ampulla filled with mucin, and six patients showed patchy filling defects in the ectatic main duct. Morphological examination showed extreme dilatation of the entire pancreatic duct in six patients and its tail segment in two patients. The duct segments filled with viscous mucin were lined by well-differentiated mucin-secreting cells, forming papillary foldings and occasionally showing cellular atypia. None of the patients had invasive tumor or metastasis. Six patients whose lesions were resected are alive and doing well (mean follow-up, 5.5 years). It is concluded that intraductal mucin-hypersecreting neoplasm is a pancreatic tumor with favorable prognosis. Because it shares many features with intraductal papillary neoplasm, a common pathogenesis of these pancreatic tumors is suggested.

Lithotripsy of urinary concrement in the sigmoid after ureterosigmoidostomy

A urinary concrement which appeared in the sigmoid of a 63-year-old man after ureterosigmoidostomy was extracted by endoscopy. The stone was situated proximal to a radiogenic stenosis. Because of the disproportion between the stone and the sigmoidal stenosis, mechanical lithotripsy had to be done before the concrement could be completely extracted.

Elimination of bacteria in biliary tract infections during ceftizoxime therapy

A transpapillary indwelling catheter was inserted to prevent stone impaction in six female patients who were suffering from choledocholithiasis. The bile withdrawn via the catheter was infected on six occasions with Escherichia coli. In one of these cases Klebsiella sp. and in another Salmonella sp. were also identified. All bacteria were sensitive to ceftizoxime (the MIC was between 0.007 and 0.06 mg/l). The bacterial counts in the bile were determined before and during treatment by means of membrane filtration. In all six cases there was a rapid decline in the colony count. The concentration of ceftizoxime in bile samples was several times higher than the MIC of ceftizoxime for the corresponding pathogens. Overall, the therapeutic results with ceftizoxime were good. Three of eight pathogens were eliminated from the bile within eight to 24 hours. In one case a change of pathogen was seen after 24 hours. Forty-eight hours after beginning treatment, four of eight pathogens had been eliminated from the bile. After 72 hours the colony count in six patients was less than 10 pathogens/ml. In two patients a change of pathogen occurred; in one patient treatment had to be stopped after the first injection because of urticaria.

[Endoscopic determination of the size of gastrointestinal ulcers (author's transl)]

A new method based on computer-assisted semi-automatic equipment for stereological analysis has been developed to measure ulcer size endoscopically. The main component is a graphic measuring table connected with a computer which is itself linked to a television monitor. The endoscopic picture is transmitted to the television monitor and the ulcer area is measured directly on the monitor using electronic overlay markers. The trace of the measuring markers remains visible on the monitor so that every lesion demonstrated is accurately outlined. The computer calculates the ulcer area by relating it to a known endoscopically inserted reference area. Numerous measurements from various distances, various angles of view and with variable reference area sizes showed the error to be 4.2 +/- 0.5%. Measurements by six different investigators showed variations of 2.9 +/- 1.2%. These results document the reliability of endoscopic planimetrics of gastrointestinal ulcers.

A new method for the endoscopic determination of gastrointestinal ulcer area

Current endoscopic measurements of gastrointestinal ulcer area using forceps or graduated probes are associated with a high degree of inaccuracy. Based on a computer-assisted, semiautomatic device for stereological analyses, we have developed a new method for the endoscopic determination of ulcer size. The basic elements are a graphical measuring tablet coupled with a computer, the later being connected to TV-monitor. The endoscopic picture is transmitted to the TV-monitor and the ulcerated area is measured directly on the TV-monitor by means of an electronic overlay marker. The trace of the marker remains visible on the screen so that any circumscribed lesion can be labelled exactly. From the relation of a known, endoscopically introduced reference area to the circumscribed ulcerated area, the latter is calculated by the computer. Multiple measurements obtained at different distances, and visual angles, and with different reference areas, revealed an error of 4.2 +/- 0.5%. Inter-observer variation among 6 different examiners was 2.9 +/- 1.2%. These results document the reliability of endoscopic planimetry of gastrointestinal ulcers.

[Bacterial elimination and antibiotic concentration in the gall-bladder during biliary tract infections treated with mezlocillin (author's transl)]

A transpapillary indwelling catheter was placed in 15 patients with choledocholithiasis and threatened occlusion by stone. Ten of the 15 patients had marked biliary stasis, four had signs of acute cholangitis. In all patients E. coli was present in the gall-bladder in a concentration of greater than or equal to 10(5)/ml when the catheter was first inserted. The bacteria were sensitive to mezlocillin, at a minimal inhibitor concentration between 1.5 and 16 micrograms/ml. All patients received mezlocillin, 5 g twice daily, in a short-term infusion. Immediately before and regularly thereafter bile samples were taken to measure antibiotic concentration and bacterial counts (by membrane filtration). Mezlocillin was excreted in the bile in very high concentrations in patients without biliary stasis. But while the concentrations were markedly lower in those with stasis, they were still 10 to 100 times the minimum inhibitory concentration of mezlocillin against the appropriate strains. In keeping with the high mezlocillin concentration, bacterial counts fell much more quickly in the patients without stasis than in those with alkaline phosphatase concentration above 250 U/l. These differences were even more marked after two or three days. Bacterial elimination from bile was complete in two of three patients with normal alkaline phosphatase activity, but in only one of five in whom it was elevated.

[Nonocclusive mesenteric ischemia (author's transl)]

This report intends to emphasize the importance of selective angiography in nonocclusive mesenteric ischemia (NMI). In a 67-year-old male with abdominal pain and weight loss the diagnosis of NMI was made angiographically after enteroclysis had shown extensive ulcerative jejunitis. In this condition, where constriction and obliteration of vasa recta of the superior mesenteric artery are present, operation is contraindicated. Current status of still incomplete understanding of the disease is discussed.

Alternating treatment of common bile duct stones with a modified glyceryl-1-monooctanoate preparation and a bile acid-EDTA solution by nasobiliary tube

Twenty patients with bile duct stones were treated via an indwelling nasobiliary tube with a modified Capmul 8210 preparation (GMOC) and alternating with a bile salt-EDTA (BA-EDTA) solution for an average of 12 days. In vitro the dissolution capacity of GMOC and BA-EDTA for cholesterol stones was higher than that of Capmul 8210. The nasobiliary tube was tolerated well for a maximum of 84 days; this renders us independent of the T-tube. The therapeutic success rate of GMOC was 64%, even though we treated mostly old and large concrements. Side effects occurred markedly less than with Capmul 8210. In patients with acute cholecystitis or cholangitis the clinical course improved under therapy, and there was no deterioration of a chronic condition.

[Longterm controls after endoscopic papillotomy [EPT] (author's transl)]

In 117 patients who have undergone endoscopic papillotomy (EPT) long term controls have been done. 51 were controlled in the hospital and 66 did answer a questionnaire. The mean time interval to the EPT was mean = 21.6 months. Nine out of every ten patients had no complaints. One third had minimal changes of laboratory dates, which can easily be explained by second diseases. With nearly no exception there was a large orifice to the common bile duct at the upper brim of the papilla. There was no bilioduodenal pressure gradient in 75%. Duodenobiliary reflux could be demonstrated in 25% and aerobilia in 65%. Although there was a massive bacteriobilia in all cases, no signs of cholangitis could be found in any patient. As a result, no unfavourable effects of the EPT became obvious during this follow-up study.

[Resolution of cholesterol-gallstone with a modified Capmul 8210-emulsion and with an EDTA solution (author's transl)]

Cholesterol stones in the bile duct may be resolved by applying Capmul 8210 (Cholesterol-caprylic acid ester) by way of T-drain or through a gastro-biliary tube. Results of in vitro experiments and a case reported do show, that an alternating irrigation with a specially prepared solution of glycerooctonate with bile salt-EDTA-solution will yield better results than Capmul 8210 alone. The advantage of this alternating therapy results from the fact, that calcium bilirubinate may be resolved in addition to the other components of the gallstones, and that side effects are rarer and less disturbing than side effects caused by Capmul 8210.

Experiences with the long standing nasobiliary tube in biliary diseases

Specially designed longstanding nasobiliary tubes allow to reflect upon some well established therapeutic rules. The safe, decompressing effect of the tube leads to prompt relief of obstructive suppurative cholangitis. Therefore emergency of laparotomy can be avoided in high risk patients. Large common bile duct stones until now have required a large papillotomy with increased frequency of complications. The attempt to dissolve those stones with Capmul is justified on an account of a 50% success rate. Either a very small EPT or even non is necessary in order to insert the tube.

Descending sphincterotomy of the papilla of Vater through a choledochoduodenostomy under endoscopic view. Another variant of endoscopic papillotomy (EPT)

Endoscopic papillotomy required deep cannulation of the papilla of Vater. But retrograde placing of the papillotome in the distal common bile duct is not always possible. Occasionally conditions permitting a descending antegrade cannilation of the papilla are found. An existing choledochoduodenostomy can be used as access for such a cannulation from above. A papillotome, type Erlangen, introduced into the papilla from above, spontaneously adopts the correct cutting direction. With regard to its length the incision has, however, to be monitored endoscopically. Also, undesired additional burns in the duodenum only can be avoided by endoscopic control. This may require the use of a second instrument. The technique described above was successfully applied as another variant of descending papillotomy.

[Therapeutic endoscopy in the gastrointestinal tract]

In selected chapters of the therapeutic endoscopy we tried to represent secure knowledge, actual tendencies and partly future prognoses. Hereby completeness cannot be expected. However, it became clear that numerous physical principles became useful for the therapy with the endoscope. Chemical techniques, such as the litholysis of gall-stones are only at present used in our field. With all scepticism against the own field of interest one may say that the operative therapeutic endoscopy, as it is seen at the instance of the classification of polyps, has led to an improvement of the diagnostics, Its advantages in the therapeutic field are based on the fact that it substitutes larger operations. In the polypectomy- the intervention, avoiding laparotomy and colotomy, is reduced on the minimum given by the size of the polyp. The risk of endoscopic operations is small, compared with the alternative surgical interventions. Shortening of the duration of the disease and hospitalisation leads to lower expenses. Methods, such as the endoscopic haemostypsis or the obliteration of the pancreatic duct, need further detailed examinations. There is no doubt that the modern endoscopy has a strong technical fascination for many young physicians. It gets the greatest value in the hands of a clinically experienced physician.

[A comparison of percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography (author's transl)]

Results of percutaneous transhepatic cholangiography (PTC) with the Chiba needle were compared with those obtained by endoscopic retrograde cholangiopancreatography (ERCP). PTC was used in 102 cases, most often after ERCP had been inconclusive or had failed. Overall success rate of PTC was 79%. Contrast medium could be injected in only 66% of cases with normal-sized bile passages, but in 98% of those with enlarged passages. The most frequent side effect was temporary pain in the right upper abdominal quadrant. One patient had transitory severe peritoneal irritation with shock. Emergency operation was never required. PTC is technically simpler, takes less time and causes less stress to the patient, but it is less informative than ERCP. If, therefore, both methods are mastered technically, ERCP should be employed first. If it fails to provide the diagnosis, PTC can be performed at once. Biliojejunal anastomoses and pancreatic pseudocysts are absolute indications for the primary use of PTC to investigate the cause of biliary stasis. On the other hand, allergies to iodine or contrast medium and disorders of coagulation are absolute indications for ERCP.

Descending sphincterotomy of the papilla of Vater through the T-drain under endoscopic view. Variants of endoscopic papillotomy (EPT)

An indwelling T-drain is a valuable access to the common bile duct if the conventional EPT fails in the case of choledocholithiasis. It is often easier to cannulate the duodenal papilla from the common bile duct than from the duodenum. A papillotome of the Erlangen type introduced through the T-drain into the papilla spontaneously has the correct cutting direction. The incision is controlled endoscopically. If a patient has undergone Billroth II operation, the particularly difficult cannulation and incision of the papilla is make much easier by the descending technique. Two variants of the endoscopically controlled descending electropapillotomy were successfully performed.

Gas sterilization of fiber endoscopes

Excitants of disease can be transmitted by endoscopes from one patient to another. Owing to their complicated construction and the heat-sensitive material fiber glass endoscopes are difficult to disinfect or sterilize. Of the known procedures of sterilization only gas sterilization with ethylene oxide can be used. Clinical examinations and laboratory experiments demonstrate the reliable efficacy of this procedure of sterilization of fiber glass endoscopes. On account of known risks the indications for gas sterilization are compiled.

Santorini's Duct--an insignificant variant from normal or an important overflow valve?

In a retrospective examination 250 consecutive pancreatograms obtained by ERCP were controlled on the existence of a D. Snatorini. Starting from the genetic development of the pancreatic ducts the question is investigated whether a second open pancreatic duct is responsible for a better drainage of the pancreas. Thus this duct may prevent hyperamylasemia and hyperlipasemia following ERCP. From an etiological point of view the elevation of these pancreatic enzymes is insufficiently understandable. If a D. Santorini is detectable the results demonstrate a reduction of the increased pancreatic enzymes in a statistically significant manner. A valve mechanism of the D. pancreaticus minor with volume or pressure reduction is postulated.

[Retrograde endoscopic diagnosis and therapy in diseases of the bile papillae and the bile ducts (author's transl)]

Duodenoscopy with retrograde cholangiopancreatography including associated methods (cytology, manometry, endoscopic sphincterotomy, etc.) allows, with little risk, a more precise differentiation of jaundice. Considering the therapeutic consequences, the effort seems relatively small. Diagnostic improvements lead to more differentiated therapy. Therapeutic endoscopy is being substituted for classic therapeutic methods of internal medicine and surgery.