Outcome, comorbidity, hospitalization and 30-day mortality after closure of acute perforations and postoperative anastomotic leaks by the over-the-scope clip (OTSC) in an unselected cohort of patients

BACKGROUND

Acute gastrointestinal (GI) wall defects contain a high risk of morbidity and mortality and may be closed endoscopically by a full-thickness over-the-scope clip (OTSC).

METHODS

Unselected consecutive patients presenting with acute non-surgical perforations or postoperative anastomotic leaks or perforations underwent attempted OTSC placement as primary closure method after interdisciplinary consensus in three tertiary referral centres. Their clinical data and intervention characteristics were evaluated in an intention to treat analysis during a 24-month period to assess closure rates, 30-day mortality, hospitalization and comorbidity.

RESULTS

In total, 34 patients (16 females, 18 males, 69.5 years) were included with 22 non-surgical perforations and 12 postoperative anastomotic leaks or perforations. Definitive closure of the perforations and leaks was achieved in 26/34 patients (76.5 %). Successful closure of the GI wall defect resulted in a significantly shorter hospital stay (8 days, p = 0.03) and was significantly correlated with comorbidity (r = 0.56, p = 0.005). In the group with OTSC failure, hospitalization was 18 days and 6 of 8 patients (75 %) required immediate surgery. Three deaths occurred in the group with successful OTSC closure due to comorbidity, while one death in the OTSC failure group was related to a refractory perforation. Favourable indications and locations for a successful OTSC procedure were identified as PEG complications, endoscopic or postoperative leaks of stomach, colon or rectum, respectively.

CONCLUSIONS

In unselected patients, OTSC was effective for closure of acute GI wall defects in more than 75 % of all patients. Clinical success and short hospitalization were best achieved in patients without comorbidity, but closure of the perforation or the anastomotic leak was found to be not the only parameter relevant for patient outcome and mortality.

Does heparin coating reduce encrustation of biliary plastic endoprostheses? A prospective randomized trial

OBJECTIVE

Common bile duct stenting is widely performed for bridging benign and malignant obstructions. A major limitation is early stent occlusion making regular stent exchange necessary. Covalent binding of glycosaminoglycanes to polyethylene stents proved to reduce encrustation in urological implants. Since development of urological and biliary stent occlusion shows parallels, the aim of the study was to evaluate the efficacy of heparin coating of biliary endoprostheses in preventing encrustation.

MATERIAL AND METHODS

In a prospective randomized trial, heparin-coated and native stents were endoscopically placed for almost 90 days on average. After removal, all stents were dried (50°C, 24 h), weighed and after longitudinal incision visible encrustation and discoloration recorded. Fifty-three patients (21 females/32 males, 70 ± 12 (42-87) years) were included; 13 patients (4 females/9 males, 58-79 years) completed the study according to the protocol.

RESULTS

After removal, mean weight of encrustation in native stents was more than double as high as of covered stents (native: 37.9 ± 19.8 (16-93) mg; covered: 17.6 ± 6.7 (9-33) mg). In 12 of 13 cases, the encrustation weight of the native stent was higher than that of the corresponding covered stent in the same patient. Premature stent explantation became necessary in 3 of 13 native stents, because of recurrent jaundice or cholangitis but only in 1 of 13 covered stents. After longitudinal incision, the three uncovered stents showed excessive encrustation whereas no significant encrustation was found in the covered prosthesis. Altogether, covered stents showed less visible accumulation of clogging material and discoloration than native stents.

CONCLUSIONS

Covalent bound heparin is highly effective in preventing encrustation of biliary polyethylene endoprostheses.

Cleaning of occluded pancreatic duct endoprostheses: a new indication for extracorporeal shock wave lithotripsy?

BACKGROUND

Pancreatic duct stenting is widely performed for bridging main pancreatic duct obstruction in patients with chronic pancreatitis. The major limitation is early stent occlusion, making regular stent exchange necessary.

OBJECTIVE

To date, no measures are available to prevent stent occlusion. The aim of this study was to evaluate the cleansing effect of shock wave application (SWA) on occluded pancreatic duct stents in vitro.

DESIGN

In vitro study.

PATIENTS

We analyzed occlusion rates of 25 plastic endoprostheses removed from 21 patients with chronic pancreatitis.

INTERVENTION

We administered 350 shock wave pulses every 10 mm along the prosthesis, which was stored in a latex balloon filled with gas-free physiologic saline solution, by using a pressure of 42 megapascals.

MAIN OUTCOME MEASUREMENTS

After SWA, the occlusion rate was measured again, and the cleansing rate was calculated in comparison with the native prosthesis.

RESULTS

The mean (± SD) occlusion rate was significantly reduced (64.7 ± 28.7 [15%-100%]) before SWA vs 9.8 ± 25.3 [0-100%]) after SWA; P = .038). In 16 of 25 prostheses (64%), cleaning was complete. Four of the remaining 9 prostheses (16%) showed satisfactory cleaning of 95%, on average. Residual clogging material was found mainly at the duodenal tip and the middle of the stent. No significant association was found between patient-related or stent-related parameters and the cleansing effect of SWA.

LIMITATIONS

In vitro study design.

CONCLUSION

SWA is effective in cleaning occluded pancreatic endoprostheses in vitro. Prolongation of stent placement seems possible if regular SWA is performed. Extracorporeal shock wave lithotripsy therefore might become a new indication for patients under treatment with pancreatic endoprostheses.

[Oxidative stress and cardiovascular diseases]

A number of diseases like hypercholesterolemia and atherosclerosis, hypertension, congestive heart failure, diabetes, ischemia-reperfusion, neurodegenerative diseases as well as acute and chronic inflammatory diseases are characterized by an increased steady-state concentration of reactive oxygen species (ROS). On a biomolecular level an enhanced oxidative stress causes damage of proteins, lipids and nucleic acids. Both the experimental and therapeutic efficiency of different antioxidative compounds (like various antioxidative enzymes) , drugs, metabolites and vitamins for the maintenance of an appropriate intracellular redox potential underline the importance of an excessive ROS-formation for these diseases. Control of excessive ROS-formation can be obtained by angiotensin converting enzyme (ACE-) inhibitors, by AT (1)-receptor blockers, by statins and other lipid lowering compounds, by improved expression of antioxidative enzymes (superoxide dismutase, catalase etc.), by compounds such as probucol, certain vitamins, pyruvate, by lipid apheresis and by physical exercise training, which displays surprising efficacy.

Pancreatic endoprostheses in chronic pancreatitis: criteria to predict stent occlusion

BACKGROUND

Good clinical results of main pancreatic duct (MPD) stent placement in chronic pancreatitis (CP) are clouded by early stent occlusion. The aim of this study was to increase knowledge about stent occlusion and its effects on clinical symptoms, and to define criteria that enable the prediction of clogging.

METHODS

A total of 100 pancreatic endoprostheses of 47 patients (32 men, 15 women; mean age, 53 years; standard deviation, 9 years) with CP were bench tested by simulating the pathophysiologically increased MPD pressure. The main study parameter was the reduction of water flow through clogged stents in comparison with native endoprostheses of identical type, length, and diameter. Major stent occlusion was defined as flow reduction by > or = 75%. The association between time to stent occlusion and stent- or patient-related variables was evaluated.

RESULTS

Occlusion took place in nearly all endoprostheses (97%). No significant association of occlusion with clinical or blood parameters was found. Multifactorial analysis proved 4 risk factors for major stent occlusion: (A) stent diameter > 8.5F, (B) stent length > 8 cm, (C) female gender, (D) exocrine pancreatic insufficiency that required regular oral enzyme supplementation. According to the relative risk, these factors were given the following scores: A, 3 points; B to D, 2 points. Stents in patients with a score sum > 5 showed a significantly higher risk of major stent occlusion within 90 days.

CONCLUSIONS

Stent clogging in CP seems to be an inevitable phenomenon. Because clinical and laboratory data do not reliably indicate clogging, stent removal or exchange should be performed in high-risk patients (score sum > 5) within 3 months.

Interventional endoscopic therapy in chronic pancreatitis including temporary stenting: a definitive treatment?

OBJECTIVE

In the past 15 years there have been tremendous advances in endoscopic management of chronic pancreatitis (CP). However, the value of endoscopic pancreatic stenting is still debatable.

MATERIAL AND METHODS

In 98 patients suffering from symptomatic CP (84 M, 14 F, 49+/-12, age range 23-83 years) endotherapy including temporary stenting of the pancreatic duct was performed. After final stent removal, indicating the primary end-point of endotherapy, 96 patients were followed for 35+/-28 (8 days-111) months. All data were assessed retrospectively.

RESULTS

As well as other endoscopic procedures, a total of 358 prostheses were inserted in the pancreatic duct and left in place for 3+/-1 (1 day-11) months. Total stent treatment time was 10+/-10 (6 days-49) months. At 46+/-27 (4-111) months after limited endotherapy, 57 patients had no need for secondary intervention, two-thirds were even without further pain sensations. In 22 patients, surgical treatment and in 17 patients further endoscopic therapy became necessary, which was significantly correlated with continued alcohol consumption.

CONCLUSIONS

Temporary stent placement as a part of interventional endoscopic therapy in CP shows a high rate of technical and long-term clinical success, with no need for secondary treatment in a remarkable number of patients. Continued cessation of alcohol consumption supports the treatment benefit significantly.

Composition of clogging material in pancreatic endoprostheses

BACKGROUND

Endoscopic management of chronic pancreatitis (CP), especially pancreatic stent placement, has made tremendous advances. However, good clinical results are hampered by rapid occlusion. The objective of this study was to understand mechanisms and materials that cause stent occlusion.

METHODS

The clogging material of 50 lyophilized pancreatic endoprostheses (length 8.5 cm, range 5-14 cm, diameter 7-11F) from patients with CP was completely removed and weighed. Protein solubilization was achieved at pH 8.0 by using sodium dodecyl sulfate (SDS) and 2-mercaptoethanol in the presence of proteasome inhibitors. Proteins were separated by using a SDS-polyacrylamide gel electrophoresis. Protein identification was performed by the Western blot technique, as well as by mass spectrometry. Insoluble components were examined by polarized light microscopy and after staining (periodic acid-Schiff [PAS]).

RESULTS

Clogging material was found in 49 prostheses, mainly at the duodenal flap (80%). More than a third of the prostheses contained visible calcium carbonate calculi. Light microscopy and PAS staining showed plant debris (80%), crystals (73.5%), and mucopolysaccharides (100%). The dry weight of clogging material (18 +/- 13 mg, range 3-72 mg) correlated significantly with the stent diameter ( p = 0.029) but not with any other stent- or patient-related criteria. Albumin, its degradation products, and lithostathine were identified as the main proteinaceous components.

CONCLUSIONS

Almost all pancreatic stents had clogging material, predominantly located at the duodenal flap, which contained plant material, mucopolysaccharides, and crystals, as well as visible calcium carbonate calculi. Albumin and lithostathine may play an important role in the development of stent occlusion.

Extracorporeal shockwave lithotripsy of gallstones in cystic duct remnants and Mirizzi syndrome

BACKGROUND

Although the efficacy of extracorporeal shockwave lithotripsy for treatment of bile duct calculi is established, there are few studies of the value of extracorporeal shockwave lithotripsy for cystic duct remnant stones and for Mirizzi syndrome.

METHODS

Patients who required extracorporeal shockwave lithotripsy for cystic duct stones were identified in a cohort of 239 patients with bile duct stones treated by extracorporeal shockwave lithotripsy between January 1989 and December 2001 at a single institution. The medical records of these patients were reviewed. Follow-up information was obtained by telephone contact.

OBSERVATIONS

Six women (age range 19-85 years) underwent extracorporeal shockwave lithotripsy for cystic duct stones after failure of endoscopic treatment measures. Three of the patients presented with retained cystic duct remnant calculi (one also had Mirizzi syndrome type I), and 3 presented with Mirizzi syndrome type I. The stones were fragmented successfully by extracorporeal shockwave lithotripsy in all patients; the fragments were extracted endoscopically in 5 patients. Endoscopy plus extracorporeal shockwave lithotripsy was definitive treatment for all patients except one who subsequently underwent cholecystectomy.

CONCLUSIONS

Gallstones in a cystic duct remnant and in Mirizzi syndrome can be successfully treated by extracorporeal shockwave lithotripsy in conjunction with endoscopic measures. Extracorporeal shockwave lithotripsy is especially useful when surgery is contraindicated.

Successful laserlithotripsy in Bouveret's syndrome using a new frequency doubled doublepulse Nd:YAG laser (FREDDY)

Gastric outlet obstruction as a result of gallstone (Bouveret syndrome) is a rare but serious complication of cholelithiasis. In many cases, surgery has been conducted for treatment. In recent years, minimal invasive treatment modalities (e.g. shockwave lithotripsy) have been shown to be effective in some of those patients. Laserlithotripsy has so far been described in two cases with a Rhodamine-6G dye laser. We present the case of a 90-year-old woman with duodenal obstruction due to a huge gallstone. The patient was referred to our hospital because attempts at endoscopic extraction and extracorporeal shockwave lithotripsy had failed. The man was treated successfully in just one session with a new cost-efficient frequency doubled doublepulse Nd:YAG laser (FREDDY) using a total of 5726 laser pulses (120 mJ pulse energy, 10 Hz pulse repetition rate) and recovered rapidly. Laserlithotripsy can be considered an effective non-invasive therapeutic alternative to surgical treatment in Bouveret's syndrome, especially in old or high-risk patients.

Comparison of tree-based methods for prognostic stratification of survival data

Tree-based methods can be used to generate rules for prognostic classification of patients that are expressed as logical combinations of covariate values. Several splitting algorithms have been proposed for generating trees from survival data. However, the choice of an appropriate algorithm is difficult and may also depend on clinical considerations. By means of a prognostic study of patients with gallbladder stones and of a simulation study, we compare the following splitting algorithms: log-rank statistic adjusted for measurement scale with (AP) and without (AU) pruning, exponential log-likelihood loss (EP), Kaplan-Meier (KP) distance of survival curves, unadjusted log-rank statistic (LP), martingale residuals (MP), and node impurity (ZP). With the exception of the AU algorithm (based on a Bonferroni-adjusted p-value driven stopping rule), trees are pruned using the measure of split-complexity, and optimally-sized trees are selected using cross-validation. The integrated Brier score is used for the evaluation of predictive models. According to the results of our simulation study and of the clinical example, we conclude that the AU, AP, EP, and LP algorithm may yield superior predictive accuracy. The choice among these four algorithms may be based on the required parsimonity and on medical considerations.

Pancreatic duct stones in chronic pancreatitis: criteria for treatment intensity and success

BACKGROUND

The aim of the study was to evaluate interventional endoscopic management of pancreatic duct stones in patients with chronic pancreatitis by describing therapeutic methods and defining factors that predict technical success.

METHODS

Records were retrospectively analyzed for 125 patients with symptoms caused by chronic pancreatitis with pancreatic duct stones (single 43, multiple 82) treated by interventional endoscopy, including extracorporeal shockwave lithotripsy.

RESULTS

Technical success was achieved in 85% of patients (11 patients by mechanical lithotripsy, 114 by piezoelectric extracorporeal shockwave lithotripsy). There were no serious complications from lithotripsy. Univariate analysis disclosed a statistically significant association between treatment success and patient age as well as prepapillary location of stones. A greater therapeutic effort was necessary in patients with stones located in the tail of the pancreas, 2 or more stones, a stone 12 mm or more in diameter, or who have had a longer duration (>8 years) of the disease. However, with exception of the last parameter, correction for multiple testing of data removed statistical significance.

CONCLUSIONS

Extracorporeal shockwave lithotripsy enhances endoscopic measures for treatment of pancreatic duct stones when mechanical lithotripsy fails. Middle-aged patients in the early stages of chronic pancreatitis with stones in a prepapillary location proved to be the best candidates for successful treatment. Unfavorable patient-related or morphologic factors can be compensated for through more intense efforts at therapy.

Pancreatic duct stones in chronic pancreatitis: criteria for treatment intensity and success

BACKGROUND

The aim of the study was to evaluate interventional endoscopic management of pancreatic duct stones in patients with chronic pancreatitis by describing therapeutic methods and defining factors that predict technical success.

METHODS

Records were retrospectively analyzed for 125 patients with symptoms caused by chronic pancreatitis with pancreatic duct stones (single 43, multiple 82) treated by interventional endoscopy, including extracorporeal shockwave lithotripsy.

RESULTS

Technical success was achieved in 85% of patients (11 patients by mechanical lithotripsy, 114 by piezoelectric extracorporeal shockwave lithotripsy). There were no serious complications from lithotripsy. Univariate analysis disclosed a statistically significant association between treatment success and patient age as well as prepapillary location of stones. A greater therapeutic effort was necessary in patients with stones located in the tail of the pancreas, 2 or more stones, a stone 12 mm or more in diameter, or who have had a longer duration (>8 years) of the disease. However, with exception of the last parameter, correction for multiple testing of data removed statistical significance.

CONCLUSIONS

Extracorporeal shockwave lithotripsy enhances endoscopic measures for treatment of pancreatic duct stones when mechanical lithotripsy fails. Middle-aged patients in the early stages of chronic pancreatitis with stones in a prepapillary location proved to be the best candidates for successful treatment. Unfavorable patient-related or morphologic factors can be compensated for through more intense efforts at therapy.

Complications of endoscopic sphincterotomy: can heparin prevent acute pancreatitis after ERCP?

BACKGROUND

An exploratory analysis of a prospective study of risk factors for acute pancreatitis after ERCP combined with endoscopic sphincterotomy showed that the frequency of acute pancreatitis was lower in patients who received heparin compared with patients not treated with heparin. The study was continued to further analyze the effect of heparin on the frequency of acute pancreatitis.

METHODS

Potential risk factors for acute pancreatitis and outcomes were evaluated prospectively for all ERCP procedures with endoscopic sphincterotomy performed between September 1994 and December 1998. The results were analyzed by univariate and multivariate methods to determine risk factors for complications. Heparin was administered to 32.9% of the patients (heparin group [HEP group], n = 268) for various clinical reasons (low-molecular-weight heparin, n = 208, unfractionated heparin n = 60). A group of 547 patients who did not receive heparin served as control patients (CON group).

RESULTS

Eight hundred fifteen patients underwent ERCP with endoscopic sphincterotomy; acute pancreatitis occurred in 6.4% (n = 52). The frequency of acute pancreatitis was significantly lower in the HEP group versus the CON group in the final multivariate model, which included significant risk factors for acute pancreatitis (HEP group: 3.4%, 9/268 vs. CON group: 7.9%, 43/547; p = 0.005). HEP did not increase the risk of hemorrhage (HEP group: 1.1%, 3/268, 2 severe, none fatal vs. CON group: 2.0%, 11/547, 3 severe, 2 fatal). HEP (p = 0.005; OR 0.3: 95% CI [0.16, 0.73]) and the number of risk factors present (p = 0.0001; OR 2.5: 95% CI [1.80, 3.50]) influenced the frequency of acute pancreatitis independently.

CONCLUSIONS

Heparin was significantly associated with an extremely low frequency of post-ERCP pancreatitis without increasing the risk of hemorrhage after endoscopic sphincterotomy. Because this effect could not be attributed to other known or suspected confounders, our conclusion was that heparin administration before ERCP reduces the risk of pancreatitis.

Abdominal actinomycosis: complication of endoscopic stenting in chronic pancreatitis?

Pancreatic endotherapy is frequently performed in patients with chronic pancreatitis and stenoses of the main pancreatic duct. In a patient with long-standing chronic pancreatitis and treatment with pancreatic stents, metastatic pancreatic head carcinoma was suspected because of infiltration of the neighboring organs and hepatic lesions. Ultrasound-guided aspiration of one liver lesion revealed grains typical for actinomycosis. In the light of this case, an extracted pancreatic stent was microbiologically investigated for actinomycetes in another patient who had a suspicious lesion of the pancreatic head. Microbiological examination of the extracted pancreatic stent revealed colonization by Actinomyces meyeri, Klebsiella oxytoca, and mixed cultures of anaerobic and saprophytic Gram-positive bacteria. In the following weeks, she developed a septic clinical picture with multiple abscesses of the liver. Actinomyces meyeri, Corynebacterium species, Candida and Enterococcae were cultivated in the aspirates. It seems possible, that treatment with pancreatic stents could have caused invasion of actinomycetes into the parenchyma of the pancreas, which was already harmed by the chronic inflammation, followed by the typical infiltrative growth and hematologic or biliary seeding into the liver.

Contrast-enhanced ultrasound improves hepatic vessel visualization after orthotopic liver transplantation

BACKGROUND

We investigated whether color-coded Doppler sonography combined with an ultrasound contrast medium would improve the assessment of liver-supplying vessels after orthotopic liver transplantation.

METHODS

Forty-seven patients after orthotopic liver transplantation participated. Examinations were done without and then with the ultrasound contrast medium Levovist. Visualization of the liver-supplying vessels was assessed with a scoring system.

RESULTS

Visualization of the portal vein was similar without and with contrast medium. Hepatic arteries were visualized in 39 patients without contrast medium and 46 patients with contrast medium. The remaining patient showed hepatic artery thrombosis, which was confirmed angiographically. With the use of Levovist, the examination took 3.7 min rather than the usual 6.4 min.

CONCLUSION

Imaging of hepatic arteries after liver transplantation improved significantly with the use of ultrasound contrast medium. These findings are important because the early detection of blood flow through the liver after transplantation affects prognosis.

Faecal elastase-1: lyophilization of stool samples prevents false low results in diarrhoea

BACKGROUND

In patients with diarrhoea, faecal elastase-1 is used to detect exocrine pancreatic insufficiency. Diarrhoea is defined as >85% stool water content.

METHODS

We analysed elastase-1 in 519 stool samples from 310 patients unprocessed as well as after lyophilization in a standard laboratory lyophilizator. Stool water content was calculated by weight difference before and after lyophilization.

RESULTS

151 stool samples were classified as 'diarrhoea' (mean stool water content 88.8%); all others had a mean water content of 75.4%. In the 'diarrhoea' samples, elastase-1 levels were considerably higher after lyophilization--with a calculated normal water content of 75% (606 +/- 359 microg/g, mean +/- s)--compared to measurement when unprocessed (279 +/- 151 microg/g; P < 0.0001). In 16 of the 151 cases (11%), the abnormally low elastase-1 level below 200 microg/g found in unprocessed stools proved normal (>200 microg/g) after lyophilization and correction for stool water content.

CONCLUSION

Diarrhoea can result in falsely decreased elastase-1 levels in a number of patients with non-pancreatogenic diarrhoea. Lyophilization is a simple measure by which to determine elastase-1 independently of stool water content. Lyophilization of stool samples can therefore help to prevent wrong positive elastase-1 test results.

Stimulation der Immunglobulin-E-Bildung bei chronischer Pankreatitis durch Alkoholaufnahme und exokrine Pankreasinsuffizienz

Many patients with chronic pancreatitis (CP) complain of several types of food intolerance despite elimination of fat and alcohol. Since there are no data on serum immunoglobulin E (IgE) concentrations in CP, IgE concentrations in serum were detected in 97 persons with CP and 50 controls. IgE was analyzed by the use of a highly sensitive fluoro-enzyme-immunoassay. In CP, a significantly raised IgE level (mean +/- SEM; 286.1 +/- 49 KU/L; p < 0.0001) was detected compared with controls (65.2 +/- 13 KU/L). CP-patients without alcohol consumption and normal exocrine pancreatic function were found to have only slightly elevated serum IgE values (120.2 +/- 54 KU/L), whereas patients with exocrine insufficiency treated with enzyme supplementation showed an IgE level of 153.7 +/- 51 and exocrine insufficient patients without treatment of 261.0 +/- 173 KU/L (p = 0.01). IgE levels were far more elevated in the corresponding groups with continued alcohol consumption (> 25 g/day). Alcohol consuming patients with CP and normal pancreatic function had a mean serum IgE of 295.0 +/- 114 KU/L, while patients with alcohol consumption and sufficiently treated exocrine pancreatic insufficiency showed a serum IgE of 393.7 +/- 147 KU/L (p = 0.03). Non-enzyme supplemented patients with CP and exocrine pancreatic insufficiency were characterized by approximately 10-fold increased serum IgE (1080.0 +/- 313 KU/L; p = 0.001). Non-allergic, alcohol consuming patients with CP have significantly increased serum IgE values. Since patients without alcohol consumption and normal pancreatic function or sufficiently treated exocrine insufficiency showed clearly lower IgE values than non-compliant patients with manifest exocrine pancreatic insufficiency, these results are compatible with the assumption that a reduced rate of antigen digestion in exocrine pancreatic insufficiency may lead to an increased intestinal antigen load, stimulating an abnormal humoral immune response with IgE production. Alcohol may further contribute to this by damaging the mucosal barrier.

Quantitative testing of liver function in patients with cirrhosis due to chronic hepatitis C to assess disease severity

BACKGROUND/AIMS

Quantitative testing of liver function (QTLF) may allow a prognostic assessment of patients with various liver diseases. However, there are insufficient data about patients with liver cirrhosis due to hepatitis C.

PATIENTS/METHODS

86 consecutive patients (58 males, 28 females, age: 48.3 +/- 11.7 years) with chronic hepatitis C (HCV RNA pos.) underwent sonographically guided liver biopsy to confirm the diagnosis of cirrhosis. QTLF included aminopyrine breath test (microsomal liver function), galactose elimination capacity (cytosolic liver function), sorbitol clearance (liver plasma flow) and indocyanine green clearance (liver perfusion). Values were correlated with the Child-Pugh classification.

RESULTS

55% of the patients (n=47) had cirrhosis of Child-Pugh grade A, 28% of grade B (n=24) and 17% of grade C (n=15). QTLF showed a steady decrease from Child-Pugh grade A to grade B and to grade C. Contrary to markedly reduced tests of metabolic liver function in Child-Pugh grade patients, surrogate tests of hepatic perfusion were at the lower normal limit. All QTLF were significantly reduced in Child-Pugh grade B and C patients compared to healthy controls. Differences between the three Child grades were significant.

CONCLUSION

In patients with cirrhosis due to hepatitis C, QTLF correlated inversely with Child-Pugh grades. Since in cirrhosis of grade A, surrogate tests of hepatic perfusion remained at the lower normal limit, whereas those of metabolic function were decreased, QTLF may be a tool to predict prognosis or complications in early cirrhosis due to chronic hepatitis C.

Adverse drug reactions in patients with gastroenterological diseases: does age increase the risk?

BACKGROUND

It has been claimed that the risk of adverse drug reactions increases with age. However, only limited data exist for disease-group specific risks and none for patients with liver and gastrointestinal diseases.

AIMS

To determine the incidence and characteristics of adverse drug reactions and the physicians' awareness of adverse drug reactions.

METHODS

During a 7-month period, a prospective survey of 532 male patients (158 aged 65 years or older; 30%) was conducted on a hepatogastroenterological ward of a tertiary-care university hospital, using intensive bedside and computer-assisted drug surveillance methods.

RESULTS

No difference was found in the overall rate of adverse drug reactions between older and younger patients (25.9% vs. 24.2%) during 6213 treatment days. However, a significantly higher risk for developing adverse drug reactions could be shown for the elderly with biliary tract diseases (P < 0.01). Independently of age, patients suffering from gastric ulcers, acute episodes of pancreatitis, cholangitis or inflammatory bowel diseases were at high risk of adverse drug reactions. Adverse drug reaction-associated mortality was encountered in four elderly and none of the younger patients. Secondary pharmacological effects and drug toxicity were the main types of adverse drug reactions for both age groups. Although 75.3% of the adverse drug reactions were predictable, only 37.5% of all adverse drug reactions were recognized by the staff physicians.

CONCLUSION

In hepatogastroenterological patients, advancing age was not associated with an overall increased risk of adverse drug reactions except for patients with biliary tract diseases. In the elderly, adverse drug reactions were more severe and carried higher mortality. Guidelines and educational programs should be developed to increase the awareness of adverse drug reactions and their prevention, especially in high risk patients and, thus, to improve patient outcomes.

Risperidone-induced cholestatic hepatitis

Risperidone, a widely used atypical and potent neuroleptic drug, is assumed to induce fewer hepatic side-effects than phenothiazine anti-psychotics. Recently, we observed a case of risperidone-induced cholestatic hepatotoxicity. A 37-year-old male developed a rapid increase in liver enzymes and cholestatic parameters after starting treatment with risperidone for paranoid psychosis. Work-up for other potential aetiologies was negative. The results of a percutaneous liver biopsy were consistent with drug-induced liver injury and cholestasis. Over the course of one month after the discontinuance of all anti-psychotic agents, the liver function test results returned to near-normal values. This observation supports the need to monitor cholestatic parameters in addition to liver function enzymes during initiation and the first weeks of risperidone intake.

Changes in hepatic hemodynamics after orthotopic liver transplantation: color Doppler sonography

BACKGROUND

Liver perfusion has an influence on therapy results in patients undergoing orthotopic liver transplantation (OLT). The objective of the present study was to investigate changes in hepatic hemodynamics in patients after OLT with color-coded Doppler sonography (CCDS).

METHODS

Forty-five consecutive patients were included. The examinations were done before, on postoperative day 1, and then weekly until the patients were discharged. Mean velocity of the portal (PV-V) and splenic (SV-V) veins and the maximum velocity and resistance index of the hepatic artery were determined.

RESULTS

After OLT a significant increase in PV-V and SV-V was observed. Twenty-five patients had normal perfusion of the hepatic artery, whereas 16 patients had abnormal flow patterns. In these patients prostaglandin I(2) was used until flow rates normalized. In four patients, CCDS could not detect perfusion of the hepatic artery.

CONCLUSIONS

CCDS is a suitable method for evaluating hepatic hemodynamics before and after OLT. Changes in blood flow velocities in the liver-supplying vessels are detectable, but perfusion of the hepatic artery is seldom detectable. These observations are of special interest after OLT, where liver circulation has an influence on therapy results.

Parameters of microsomal and cytosolic liver function but not of liver perfusion predict portal vein velocity in noncirrhotic patients with chronic hepatitis C

Our aim was to compare color-coded Doppler sonography (CCDS) and quantitative testing of liver function (QTLF) in patients with chronic hepatitis C. In all, 74 patients with chronic hepatitis C and mild fibrosis underwent QTLF, which included aminopyrine breath test (ABT), galactose elimination capacity (GEC), sorbitol clearance (SC), and indocyanine green clearance (ICG). Hepatic artery velocity and resistance index (HA-V, HA-RI) as well as portal vein velocity (PV-V) were measured by CCDS. ABT, GEC, and PV-V were significantly reduced, whereas SC1, ICG, HA-V, and HA-RI showed normal levels. There was a significant correlation between reduction in PV-V only with GEC and ABT. QTLF did not correlate with HA-V and HA-RI. In conclusion, in hepatitis C patients with liver fibrosis, ABT and GEC are decreased significantly, which was paralleled by a reduction of PV-V. Unexpectedly SC1 and ICG, the classical hepatic perfusion parameters, do not correlate with the parameters measured by CCDS.

Is endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date?

OBJECTIVE

Common bile duct (CBD) stenoses often complicate chronic pancreatitis (CP). Although endoscopic drainage is employed as a standard procedure in malignant CBD stenoses, it is not yet the approved standard therapy of CBD stenosis in CP.

METHODS

The records of 31 patients with CBD stenosis in CP who had undergone endoscopic placement of plastic endoprostheses into the bile duct between January 1991 and February 1997 were analyzed retrospectively. In all, 18 patients suffered from jaundice and 13 patients exclusively showed serological cholestasis. Upstream dilation of the CBD (19 +/- 6.6 mm, 12-35 mm) was detected by ERCP in all patients. In total, 101 endoprostheses were implanted endoscopically, exchanged after 3 +/- 2 months, and removed after 10 +/- 8 months.

RESULTS

All jaundiced patients showed immediate improvement of cholestasis after drainage. At the time of last exchange or after stent removal, prestenotic CBD dilation was reduced in 55% of all patients. Complete regression of stenosis and prestenotic dilation was accomplished only in 13%; dilation remained unchanged in 10%, and even showed progression in 22%. A total of 29 patients were followed-up over 24 months. Cholestatic parameters remained normal in all patients with complete normalization of the CBD, and were only moderately increased in another 10 patients, 7 and 28 months after stent removal, respectively.

CONCLUSIONS

Technical and immediate clinical success of CBD stenting in patients with CBD stenoses due to CP is high; however, long-term complete normalization of the bile duct is rare. Endoscopic drainage of CBD-stenosis in patients with CP can be recommended to alleviate acute cholestasis, but not yet as a definite treatment.

Incidence and costs of adverse drug reactions during hospitalisation: computerised monitoring versus stimulated spontaneous reporting

OBJECTIVE

To implement a computer-based adverse drug reaction monitoring system and compare its results with those of stimulated spontaneous reporting, and to assess the excess lengths of stay and costs of patients with verified adverse drug reactions.

DESIGN

A prospective cohort study was used to assess the efficacy of computer-based monitoring, and case-matching was used to assess excess length of stay and costs.

SETTING

This was a study of all patients admitted to a medical ward of a university hospital in Germany between June and December 1997.

PATIENTS AND PARTICIPANTS

379 patients were included, most of whom had infectious, gastrointestinal or liver diseases, or sleep apnoea syndrome. Patients admitted because of adverse drug reactions were excluded.

METHODS

All automatically generated laboratory signals and reports were evaluated by a team consisting of a clinical pharmacologist, a clinician and a pharmacist for their likelihood of being an adverse drug reaction. They were classified by severity and causality. For verified adverse drug reactions, control patients with similar primary diagnosis, age, gender and time of admission but without adverse drug reactions were matched to the cases in order to assess the excess length of hospitalisation caused by an adverse drug reaction.

RESULTS

Adverse drug reactions were detected in 12% of patients by the computer-based monitoring system and stimulated spontaneous reporting together (46 adverse reactions in 45 patients) during 1718 treatment days. Computer-based monitoring identified adverse drug reactions in 34 cases, and stimulated spontaneous reporting in 17 cases. Only 5 adverse drug reactions were detected by both methods. The relative sensitivity of computer-based monitoring was 74% (relative specificity 75%), and that of stimulated spontaneous reporting was 37% (relative specificity 98%). All 3 serious adverse drug reactions were detected by computer-based monitoring, but only 2 out of the 3 were detected by stimulated spontaneous reporting. The percentage of automatically generated laboratory signals associated with an adverse drug reaction (positive predictive value) was 13%. The mean excess length of stay was 3.5 days per adverse drug reaction. 48% of adverse reactions were predictable and detected solely by computer-based monitoring. Therefore, the potential for savings on this ward from the introduction of computer-based monitoring can be calculated as EUR56 200/year ($US59 600/year) [ 1999 values].

CONCLUSION

Computer monitoring is an effective method for improving the detection of adverse drug reactions in inpatients. The excess length of stay and costs caused by adverse drug reactions are substantial and might be considerably reduced by earlier detection.

Analysis of the risk factors associated with endoscopic sphincterotomy techniques: preliminary results of a prospective study, with emphasis on the reduced risk of acute pancreatitis with low-dose anticoagulation treatment

BACKGROUND AND STUDY AIMS

The aim of the present study was to analyze the risk factors associated with complications of endoscopic sphincterotomy (ES).

PATIENTS AND METHODS

In all consecutive endoscopic sphincterotomies carried out between September 1994 and December 1996, the possible risk factors (12 patient-related factors and 12 procedure-related ones), as well as the concomitant medical treatment, indications, techniques, and success of endoscopic sphincterotomy were evaluated prospectively. Risk factors were analyzed on an exploratory basis using univariate methods. "Potential risk factors" (univariate, P<0.1) underwent multivariate analysis to determine independent "risk factors" (multivariate, P<0.05). In addition, the complication rate was calculated according to the number of potential risk factors present.

RESULTS

A total of 438 patients who underwent ES were analyzed. Complications occurred in 7.5% (n = 33; acute pancreatitis 4.3%, hemorrhage 2.3 %, cholangitis 0.9%, technical 0.2%). Statistical analysis of the complications identified three independent risk factors (coagulopathy, patient age (< or =60 years, pancreas divisum), and one protective factor (pancreatic duct obstruction). The frequency of acute pancreatitis was increased by two independent risk factors (pancreas divisum, ES frequency <40 procedures/year) and was reduced if low-dose anticoagulation (unfractionated heparin or low molecular weight heparin) was administered (0.9%, one of 115 vs. 5.8%, 18 of 313; P<0.05). The effect of anticoagulation was not confounded by the presence or absence of other potential risk factors for acute pancreatitis. Neither the risk nor the severity of hemorrhage were increased by low-dose anticoagulation. Due to the low number of events, only potential risk factors for hemorrhage were identified (coagulopathy, intensive-care treatment). The overall complication rate and the incidence of pancreatitis and hemorrhage increased significantly depending on the number of simultaneous potential risk factors present (P<0.0001).

CONCLUSIONS

Patients at risk for complications after endoscopic sphincterotomy can be identified by risk factor analysis. These data suggest the hypothesis that low-dose anticoagulation prior to endoscopic sphincterotomy reduces the risk of acute pancreatitis after sphincterotomy.

Acute hepatitis induced by greater celandine (Chelidonium majus)

The hepatotoxic potential of conventional drugs is well known, but herbal medicines are often assumed to be harmless. In the last 2 years, we have observed 10 cases of acute hepatitis induced by preparations of greater celandine (Chelidonium majus), which are frequently prescribed to treat gastric and biliary disorders. The course of hepatitis was mild to severe. Marked cholestasis was observed in 5 patients, but liver failure did not occur. Other possible causes of liver disease (viral, autoimmune, hereditary, alcohol, and secondary biliary) were excluded by laboratory tests and imaging procedures, and liver biopsy specimens were consistent with drug-induced damage. After discontinuation of greater celandine, rapid recovery was observed in all patients and liver enzyme levels returned to normal in 2-6 months. Unintentional rechallenge led to a second flare of hepatic inflammation in 1 patient. Greater celandine has to be added to the list of herbs capable of inducing acute (cholestatic) hepatitis. A significant proportion of unexplained cases of hepatitis may be caused by greater celandine.

Impact of skill and experience of the endoscopist on the outcome of endoscopic sphincterotomy techniques

BACKGROUND

Our aim was to assess the influence of the skill and experience of the endoscopist on the success and risk of endoscopic sphincterotomy techniques.

METHODS

The outcome of all endoscopic sphincterotomies (n = 1335) carried out between 1988 and 1995 were retrospectively analyzed with respect to the endoscopist performing the procedure. Endoscopists were differentiated according to whether they had previous experience with endoscopic sphincterotomy techniques (n > 100) and the frequency of endoscopic sphincterotomy during the study period (>40, 26 to 40, 10 to 25, <10 per year).

RESULTS

Indications for endoscopic sphincterotomy techniques and technical execution had only a minor influence on the results of endoscopic sphincterotomy and were comparable for the individual endoscopists. The overall success rate of endoscopic sphincterotomy was 94.4% and did not significantly differ among the endoscopists. The overall complication rate of endoscopic sphincterotomy was 7.3%. Endoscopists learning endoscopic sphincterotomy techniques with a case frequency of less than 10 procedures per year had a consistently high complication rate (10.5%). Those learning endoscopic sphincterotomy techniques with a case frequency of more than 25 procedures per year had an above-average complication rate for their first 40 endoscopic sphincterotomy procedures and a significant decrease in complication rate as the number of procedures increased. The complication rate for experienced endoscopists was 7.7%. There were distinct and, in one case, significant differences in complication rates between individual endoscopists (11.5% vs. 4.8%, p = 0.01). However, when corrected for multiple testing, there were no significant differences at the p < 0. 05 level. The endoscopic sphincterotomy frequency of the endoscopist was the only significant risk factor for complications. Endoscopists with a frequency of more than 40 procedures per year had a significantly lower complication rate (5.6%) than endoscopists with a lower case frequency (9.3%, p < 0.05).

CONCLUSIONS

A low endoscopic sphincterotomy frequency is, even for endoscopists with previous experience with the procedure, a risk factor for complications after endoscopic sphincterotomy. The learning of endoscopic sphincterotomy techniques requires a minimum of 40 procedures, but also after 100 procedures a further decrease of the complication rate can be expected.

Retrospective analysis of the frequency and recognition of adverse drug reactions by means of automatically recorded laboratory signals

AIMS

To estimate the frequency of adverse drug reactions (ADRs) identified through the use of automatic signals generated from laboratory data (ALS) in hospitalised patients. To determine the frequency of spontaneous recognition of these ADRs by the attending physicians and to assess the potential value of ALS for detection of ADRs.

METHODS

Laboratory results of patients hospitalised in a nine bed medical ward were automatically recorded over a period of 17 months. Values exceeding defined boundaries were used as ALS. Charts of every third patient were analysed retrospectively with regard to adverse drug related reactions and causality was evaluated as well as whether the ADR had been recognised during the period of hospitalisation.

RESULTS

The charts and ALS of 98 patients were analysed. In 18 cases a drug-related adverse reaction was probable. Awareness to the reaction by the treating physicians was evident in 6 out of these 18 ADRs. Approximately 80% of the ADRs were considered predictable. Three ADRs were regarded as serious.

CONCLUSIONS

Adverse drug reactions are common and often preventable. Only one third of ADRs which could have been detected through ALS were recognised by the attending physicians. An increased doctor's awareness of the frequency of drug related abnormal laboratory results by means of ALS is likely to increase the recognition rate of ADRs and might help to prevent them.

Effect of substance P on histamine secretion from gut mucosa in inflammatory bowel disease

BACKGROUND

Mast cell hyperplasia in the gut is a feature of inflammatory bowel disease (IBD), but the role of mast cells in this disease is still unclear. Since mast cell-nerve interactions might have some impact on intestinal inflammation, the present study investigated whether the neuropeptide substance P causes histamine secretion from human gut mucosal mast cells.

METHODS

Four hundred and eighteen colorectal endoscopic samples from 20 patients with IBD and 10 controls were studied. Colorectal biopsy samples were cultured in an oxygenated medium for spontaneous histamine release or were stimulated with substance P, anti-human immunoglobulin E, and a combination of substance P and anti-human immunoglobulin E. Histamine release was measured using a highly sensitive and specific radioimmunoassay.

RESULTS

Substance P failed to induce mast cell activation in histologically normal mucosa from controls. In contrast, mucosal specimens taken from inflamed IBD tissue or from uninvolved Crohn disease tissue showed a considerably enhanced rate of histamine secretion towards substance P, alone or in combination with anti-IgE. Unaffected mucosa with ulcerative colitis appeared insensitive towards substance P.

CONCLUSIONS

The neuropeptide substance P was shown to preferentially enhance mucosal mast cell mediator secretion in active IBD. Thus, it appears likely that mast cell-nerve interactions are involved in as yet uninvestigated neurovegetative histamine-releasing processes of the gut in IBD.

[Optimized extracorporeal shockwave lithotripsy of gallbladder calculi: a prospective randomized therapy comparison]

Is "pulverization" or "fragmentation" the best endpoint of extracorporeal shock wave application in ESWL of gallbladder stones? Has gallbladder motility a potential for the prevention of stone recurrence?

METHODS

Prospective, monocentric study with randomization between the conventional treatment strategy (endpoint of shock wave application: fragments < or = 4 mm, concomitant oral chemolitholysis) and an intensified treatment strategy (endpoint of shock wave application: Pulverization, no chemolitholysis). Prevention of stone recurrence: At least once per month for one hour after a meal standardized position (back position, lowered chest).

RESULTS

34 patients, age 46 +/- 14 years (27 women, seven men) were included (F-ESWL: n = 18; P-ESWL: n = 16). Gallbladder motility, number, size and CT-measured calcifications of stones were comparable for both groups. P-ESWL patients received more shock wave pulses than F-ESWL patients and more treatment sessions. P-ESWL resulted in a better fragmentation and pulverization of stones was reached significantly more often (p < 0.05). The time period for stone clearance was significantly depending on the fragmentation result (pulverization: 0.7 months vs. fragments < or = 4 mm: 6.6 months vs. fragments > or = 4 mm: 8.0 months; p < 0.01). The stone free rate after twelve months was 87.5% for P-ESWL and 72.2% for F-ESWL (n.s.) and correlated significantly with the fragmentation result (p < 0.01). Pain sensations during stone clearance were significantly reduced by P-ESWL. Stonefree patients were followed up for 30 +/- 13 months, the total recurrence rate was 7.1%.

CONCLUSIONS

Aiming for pulverization of gallbladder stones by means of intensified extracorporeal shock wave application is at least equal or in tendency superior compared to disintegration to fragements < or = 4 mm. Gallbladder motility might be useful to prevent gallstone recurrence after successful ESWL.

25 years of endoscopic sphincterotomy in Erlangen: assessment of the experience in 3498 patients

BACKGROUND AND STUDY AIMS

The aim of the study was to investigate the evolution of endoscopic sphincterotomy (EST) over a period of 25 years at its birthplace in Erlangen, Germany.

PATIENTS AND METHODS

A total of 3498 consecutive ESTs between 1973 and the end of 1997 were reviewed with respect to indications, technology, success, complications, therapy of complications and mortality. In order to demonstrate changes in the course of time, the results have been compiled separately for four time periods (A-D).

RESULTS

During the 25 years' practice of EST in Erlangen the frequency of ETSs has increased constantly and significant changes have been observed concerning the spectrum of indications: Bile duct stones (total 55.1%) decreased continuously from 91.1% (period A) to 35.7% (period D). In contrast, the proportion of ESTs applied for malignant obstruction (total 22.1%) rose successively from 1.1% (period A) to more than 25% (periods B-D). Chronic pancreatitis as an indication for EST was established in period B (1.0%) and accounted for 20.2% of all procedures in period D (total 8.0%). Several new indications (summarized as "others") increased from 1.8% in period A to 11.9% in period D (total 6.7%) whereas biliary pancreatitis and scarred papillary stenosis remained constantly below 5%. Whereas the "Erlangen sphincterotome" was the only sphincterotome used in period A, it was almost completely replaced by guide-wire sphincterotomes in period D. With the introduction of the needle knife the precut technique became popular and was used with increasing frequencies: period B 31.9%, period C 34.1%, period D 41.9%. The success rate in total was 95.2%. For each time period the highest success rate of EST was obtained for bile duct stones (96-98%), whereas EST appeared to be more difficult in case of malignant obstruction (93.3%) or chronic pancreatitis (90.2%), but for both indications growing experience resulted in an increase in the success rates (85.7% to 94.9% and 90.9% to 94.0%, respectively). Complications occurred in 7.9% of cases. The complication rate declined significantly from 10.5% in period A over 7.6% in period B to 6.3% in period C. Prospective data acquisition in period D revealed a significant increase in the detection of mild forms of acute pancreatitis, resulting in a slight increase of the complication rate (8.4%). Needle-knife papillotomy did not significantly increase the complication rate. Whereas in period A 41% of all complications were managed by surgery, this value dropped over 28% (period B) and 7.5% (period C) to ultimately 1.6% in period D. The method-related mortality was nearly constant over the whole period of time (0.6%).

CONCLUSIONS

Despite a continuous shift of indications and a changing mixture of learning endoscopists and EST experts over 25 years, the practice of EST at its birthplace in Erlangen has shown a constantly high success rate, a decreasing complication rate and an acceptable but mainly unchanged mortality rate. Currently, nearly all complications can be successfully managed nonoperatively.

Photodynamic ablation of early cancers of the stomach by means of mTHPC and laser irradiation: preliminary clinical experience

BACKGROUND

Radical surgical treatment has been the first choice for early gastric cancer, but high resolution endosonography allows in situ diagnosis with a high sensitivity and specificity and in consequence the option of local endoscopic treatment.

AIMS

To evaluate photodynamic therapy (PDT) using meso-tetrahydroxyphenyl-chlorin (mTHPC) as the photosensitiser in superficial gastric cancer.

METHODS

Twenty two patients with superficial early gastric cancer received mTHPC (0.075 mg/kg intravenously) and were treated 96 hours later with red light at 652 nm (20 J/cm2). Tumour response was assessed by endoscopy and extensive biopsy.

RESULTS

Endoscopies performed two to three days after PDT showed a haemorrhagic fibrinoid necrosis of the mucosal layer. Complete remission was achieved in 16/22 (73%) patients: 13/16 (80%) with intestinal type cancer and 3/6 (50%) with a diffuse Lauren's carcinoma. The mean follow up period was 12 months and 20 months, respectively. An average of 1.8 treatment sessions was required. Severe side effects were not observed. Seven patients had mild to moderate skin photo-sensivity reactions; 12 had local pain after PDT for 1-10 days.

CONCLUSION

PDT using mTHPC as the photosensitiser represents a safe and efficient method for topical treatment of early gastric cancer, especially of Lauren's intestinal carcinoma. If the preliminary results can be verified in larger patient series and during long term follow up, local treatment of early cancers of the stomach by PDT could be considered as a therapeutic option for selected patients.

Safety and efficacy of pancreatic sphincterotomy in chronic pancreatitis

BACKGROUND

Endoscopic pancreatic sphincterotomy (EPS) is being performed with increasing frequency as a prerequisite to interventional measures in the pancreatic duct. The aim of this study was to evaluate EPS with regard to technique, success, complications, and mortality in patients with chronic pancreatitis.

METHODS

Between January 1989 and September 1996, the results of all consecutive EPSs in patients with chronic pancreatitis were documented in a standardized form. Patients were followed by clinical investigation and blood sample analysis at 4, 24, and 48 hours after EPS. Complications were classified according to commonly accepted criteria.

RESULTS

EPS was performed in 118 patients with chronic pancreatitis (men 75%, women 25%, 48+/-10 years). Ninety-four patients (80%) underwent guidewire-assisted EPS, and 24 patients (20%) underwent needle-knife EPS. Seventy-seven EPS procedures (65%) were primarily successful (guidewire EPS: 60 of 94, 64%; needle-knife EPS: 17 of 24, 71%). Additional endoscopic cutting techniques (needle-knife papillotomy, biliary endoscopic sphincterotomy) were required in 41 patients (35%). In total, EPS was successful in 116 patients (98%). The complication rate was 4.2% (4 cases of moderate pancreatitis, 1 severe bleeding, no deaths). All complications were managed nonoperatively.

CONCLUSIONS

In patients with chronic pancreatitis, EPS with a standard sphincterotome or with a needle-knife offers an effective and reliable approach to the pancreatic duct system. Additional cutting techniques may be necessary in approximately one third of cases before an EPS can be successfully performed. The complication rate of EPS in patients with chronic pancreatitis appears to be lower than the complication rate of biliary sphincterotomy for other indications.

[Diagnostic procedure in cholecystolithiasis. Diagnostic approach, repeat examinations and (incidental) findings]

If non-surgical methods are to be taken into account in the therapeutic decision-making process in cholecystolithiasis, an expanded diagnostic work-up including not only stone parameters but also gallbladder function, is needed. In 2270 patients (1649 women, 621 men; age: 47.2 +/- 14 years) with (suspected) "cholecystolithiasis" attending the special gallstone outpatient clinic at a university medical department within a period of 5 years the diagnostic procedures most commonly used in both the doctor's office and hospital were abdominal ultrasonography (52%/78%), laboratory investigations (28%/39%) and plain films of the biliary tract (27%/39%). In the doctor's office gallbladder function testing took the form of an cholecystogram (17% of the patients); in the hospital ultrasonography to determine gallbladder contractility (38%). With decreasing frequency, the following additional procedures were carried out (office/hospital): CT 3%/19%, esophagogastroduodenoscopy 7%/3%, intravenous cholegram 6%/0.6%, abdominal X-ray 1%/0.4%, ERCP 1%/0.4%, chest X-ray 0.8%/1.6%. Duplicated examinations showed a relevant frequency only for ultrasonography (39% of the cases), laboratory investigations (18%) and plain films of the gallbladder (4%). Pathologic secondary findings were established in 22% of the cases.

[Changes in and acceptance of surgical and noninvasive therapy procedures in cholecystolithiasis]

BACKGROUND

The treatment of cholecystolithiasis has changed fundamentally in recent years due to the development of non-surgical techniques (extracorporeal shockwave lithotripsy [ESWL], oral litholysis) and the implementation of laparoscopic cholecystectomy.

PATIENTS AND RESULTS

Retrospective analysis of 2270 patients (1649 women, 621 men; age: 47.2 +/- 14 years) presenting with gallstone disorders in a university medical outpatients department between 1988 and 1992 in order to be instructed as to the most suitable therapy method bear witness to the rapid change in therapeutic procedure. Laparoscopic removal of the gallbladder has virtually supplanted conventional cholecystectomy, and within 5 years the proportionate role of ESWL has declined from 21 to 12%. Over the years, the proportion of patients requiring no therapeutic intervention remained constant (at about 20%). The therapeutic recommendations of the "experts" were implemented in almost 80% of cases. The majority of patients were satisfied with the chosen therapeutic approach (surgery: 93.0%, ESWL: 77.6%), although 44% of ESWL-patients and 36% of surgically managed patients reported complaints which persisted even after completion of therapy. Despite unsuccessful ESWL (residual fragments or recurrent stones) 58/95 (61%) of interviewed patients would again give preference to this non-invasive modality in the event of a renewed therapeutic decision.

CONCLUSION

Only a few years after its introduction, laparoscopic cholecystectomy has asserted itself as the predominant treatment option. But as far as acceptance and preference by the patient are concerned extracorporeal shockwave lithotripsy--as a non-invasive treatment modality--also enjoys high popularity and can be recommended as an alternative to surgery in suitable patients chosen according to the currently established stringent selection criteria.

[Tsutsugamushi fever. Rare rickettsiosis after a stay in the Philippines]

HISTORY AND CLINICAL FINDINGS

After returning to his native Germany from a holiday in the Philippines a 37-year-old man was admitted because of high fever, cervical lymphadenopathy, pharyngitis and conjunctivitis, transient skin rash, nausea and vomiting, leukocytosis with shift to the left, atypical lymphocytes, as well as increased transaminases, LDH and cholestasis-indicating enzymes.

INVESTIGATIONS

Stool, sputum and urine cultures were negative. The chest radiogram showed bilateral mild interstitial infiltration. Antibody titres against Rickettsia tsutsugamushi were markedly raised (IgG 1:128, IgM 1:2048).

DIAGNOSIS, TREATMENT AND COURSE

Empirical antibiotic treatment with ciprofloxacin (200 mg twice daily intravenously) had no effect. As the mild signs of interstitial pneumonia progressed, clarithromycin (500 mg twice daily orally) was substituted with rapid fall in fever and gradual improvement. Tsutsugamushi infection was diagnosed serologically and the antibiotic changed to doxycycline (100 mg twice daily orally), continued for 14 days. Full remission occurred.

CONCLUSIONS

Tsutsugamushi fever should be included in the differential diagnosis if, in addition to a history of a visit to an endemic area, there is the clinical triad of skin necrosis at the site of a mite bite, regional lymphadenopathy and skin rash (in this case, no skin lesion). The infection can be lethal without adequate treatment. Tetracyclines and possibly also macrolide antibiotics are effective against the causative organism.

Benefits and risks of needle-knife papillotomy

BACKGROUND

The objective of the present investigation was to assess the risks and benefits of pre-cutting with the needle knife at the papilla of Vater and to compare the findings with the results of classic endoscopic sphincterotomy.

METHODS

From January 1973 to December 1993, 2752 endoscopic cutting procedures-biliary or pancreatic sphincterotomy (EST) or needle-knife papillotomy (NKP)-were performed. Since 1981 the pre-cut technique with the needle knife has been used alone or in combination with standard sphincterotomy. Indications, success, and complications of NKP and EST were analyzed retrospectively. To demonstrate changes in indications and technique, the study period was divided into two time periods: period A, 1981 to 1987; and period B, 1988 to 1993.

RESULTS

Between 1981 and 1993, diagnostic or therapeutic access to the biliary or pancreatic duct system was attempted in 2105 patients by means of EST or related procedures (period A 1093 patients; period B 1012 patients). The overall success rate was 95.1% (2001 of 2105). In 694 of 2105 cases (33.0%) an EST was not possible or not attempted and an NKP was performed (period A 31.9%; period B 34.1%). This was successful in 590 of 694 cases (85.2%). The rate of NKP in relation to EST varied depending on the different indications for EST: 22.8% NKP in classic indications like choledocholithiasis and over 40% in newer indications such as chronic pancreatitis. In these novel indications NKP alone was often sufficient, and EST to complete the procedure was not necessary (151 patients). In period B, NKP (63 patients) and EST (23 patients) were also used to achieve endoscopic retrograde imaging of the biliary or pancreatic duct system when primary cannulation was not possible. Visualization was achieved in 81.4% (70 of 86) and pathologic findings were noted in 68.6% (59 of 86). The total complication rate of primary EST was 6.8% (96 of 1411) and 7.3% (51 of 694) for all procedures in which NKP was involved (NS). In period B the complication rate was 4.6% for NKP without subsequent EST and 7.6% for NKP in combination with EST. Compared with the complication rate of primary standard EST (6.1%) there was no statistically significant difference.

CONCLUSIONS

Needle-knife papillotomy increases the success of diagnostic and therapeutic procedures at the papilla of Vater. This pre-cut technique is safe and does not increase the overall complication risk of sphincterotomy.

[Interventional endoscopic therapy of chronic pancreatitis]

BACKGROUND AND AIM

Complications in chronic pancreatitis, such as duct occlusion due to stenosis or stones can be treated by interventional endoscopic procedures. The benefit of such procedures and the effect on the clinical course is still under debate. Therefore, it was the aim of this study to analyze the effect of endoscopic interventional procedures in more detail with respect to technical and clinical benefit.

PATIENTS AND METHODS

100 patients with chronic pancreatitis (cP) were studied retrospectively. In 58 patients an indication for interventional endoscopic therapy was given (45 +/- 12 yrs; 46 M, 12 F; cP 1 degree: n = 1, cP II degree: n = 8, cP III degree: n = 49). The patients were allocated to three groups: stenosis (n = 18), pancreatic duct stones (n = 18) and stenosis and pancreatic duct stones (n = 20). In two patients no visualization of the main pancreatic duct was performed due to cholestasis that was treated primarily. In total, 295 endoscopic procedures were performed (EPT, duct dilatation, plastic endoprothesis, ESWL, mechanical lithotripsy). Technical success was 95%. All stenoses could be dilated or bridged by plastic stents. Fragmentation of main pancreatic duct stones was achieved in 92%. The overall complication rate of all 319 endoscopies (fever, bleeding, stent dislocation) was 15.8%. Five patients had to undergo surgery, however, not as a direct consequence of complications from or unability of endoscopic procedures. 86% of the patients reported complete pain relief after the endoscopic-interventional procedures and 62% during the follow-up interval (7.4 +/- 6.3 months). 59% of the patients with weight loss and 58% of the patients with initially stable weight experienced a weight gain following endoscopic-interventional therapy. Individual patients showed improvement of endocrine or exocrine pancreatic function. 82% of the patients did not require inhouse treatment or emergency admission to the hospital whereas three admissions on average were recorded prior to endoscopic interventional treatment. Therefore, we conclude that a subset of patients does benefit from endoscopic interventional therapy of complications of chronic pancreatitis. However, a controlled prospective study is still mandatory.

[Technical and clinical success with extracorporeal shockwave lithotripsy in pancreatic duct calculi]

BACKGROUND

Chronic pancreatitis is often complicated by concrements obstructing the main pancreatic duct. Duct obstruction is discussed as potential mechanism responsible for recurrent and persistent pain.

PATIENTS AND METHODS

75 symptomatic patients (15 female, 60 male; 46 +/- 12 years) with stones in the main pancreatic duct (solitary n = 23; multiple n = 52) primarily not endoscopically extractable even after sphincterotomy of the pancreatic orifice were treated by means of a piezoelectric lithotripter (Piezolith 2500). Fragmentation and stone clearance were documented by ERP. The clinical benefit was evaluated in 35 patients (9 female, 26 male; 45 +/- 12 years) followed up meanwhile for more than 12 (29 +/- 14) months.

RESULTS

After 3 +/- 2 (1 to 10) ESWL-sessions/patient the concrements were fragmented successfully in 80% of the patients. Focussing of the stones was achieved sonographically (15%), fluoroscopically (45%) or using both imaging techniques (40%). In total, 61% of the patients became stone free, 44% spontaneously, in further 17% all remaining fragments could be removed endoscopically. In 39% of the patients only a partial extraction was achieved. Severe complications due to shockwave application did not occur. The majority of the patients (stonefree n = 22, remaining fragments n = 13) followed up > or = 12 months kept free of pain (51%) or reported on pain relief (26%). Nine patients developed 13 recurrent calculi, which were again treated successfully by interventional measures in 8/9 patients.

CONCLUSIONS

The data confirm the value of extracorporeal shockwave lithotripsy as an important tool in the interventional therapy of chronic pancreatitis. Even if recurrent calculi may occur, the majority of patients will experience at least a medium-term profit by those measures due to pain relief.

Distribution of extracellular matrix proteins in indomethacin-induced lesions in the rat stomach

INTRODUCTION

We investigated the distribution of extracellular matrix (ECM) proteins in indomethacin-induced lesions of the rat stomach.

METHOD

Twenty rats received indomethacin orally at a dose of 8 mg/kg/body weight. The animals were killed at 3, 6, 12, 24, and 48 h after administration of the drug. The stomachs were removed and frozen in liquid nitrogen. Cryostat serial sections of the lesions were immunostained with antibodies to collagen III, IV, and VI, laminin, and fibronectin.

RESULTS

Fibronectin was the dominant extracellular protein of the provisional ECM in deep gastric lesions and gastric ulcers. Collagen III was strongly positive in stromal cells under the necrotic material in gastric erosions. Basal membrane proteins (collagen IV and laminin) were found to originate from the muscularis mucosae at the ulcer edge.

CONCLUSION

There is a typical distribution of ECM proteins in erosions and ulcers of the rat stomach. Fibronectin was most prominent in the provisional matrix of gastric erosions and ulcers.

Extracellular matrix proteins in human bile and gallstones

OBJECTIVE

To investigate the presence of extracellular matrix (ECM) proteins in human bile and gallstones and to determine whether they play a role in gallstone formation.

METHODS

ECM components [procollagen-III-peptide (P-III-P), laminin, and hyaluronic acid] in bile from patients with (n = 22) and without (n = 6) gallstone disease were investigated by immunoassay. Bile, gallstones, and serum were assayed for extracellular matrix components in an additional 19 patients with gallstone disease and gallstones were analysed in a third set of 26 patients. The expression of hyaluronic acid synthetase in bile duct and gall bladder epithelia was investigated by immunocytochemistry.

RESULTS

Hyaluronic acid levels were significantly elevated in hepatic and gall bladder bile, but not in the serum of patients with compared with those without gallstone disease (137 versus 81 micrograms/l, respectively; P < 0.05). No differences were found between hepatic and gall bladder bile. Procollagen-III-peptide and laminin were detected in the hepatic bile of patients in both groups. Laminin levels were higher in gall bladder bile than in serum in all patients and measurable amounts of hyaluronic acid were found in gallstones. The amount of hyaluronic acid was inversely correlated to the volume of the gallstone, i.e., the smallest gallstones contained the highest levels of hyaluronic acid. No procollagen-III-peptide or laminin was found in the gallstones. Immunocytochemistry of the epithelial cells of bile duct and gall bladder mucosa stained strongly for hyaluronic acid synthetase.

CONCLUSIONS

Hyaluronic acid as a progenitor of ECM can be detected in bile and is significantly elevated in patients with gallstone disease. Small gallstones contain more hyaluronic acid than large stones, suggesting that hyaluronic acid may play a role in gallstone formation, particularly since it is produced by the epithelial lining of bile ducts and is found in gall bladder mucosa.

Piezoelectric shock wave lithotripsy of pancreatic duct stones

OBJECTIVES

The efficacy of extracorporeal piezoelectric shock wave lithotripsy in patients with obstructing pancreatic duct stones was investigated.

METHODS

Fifty patients suffering from chronic pancreatitis and obstructing pancreatolithiasis were treated by ESWL (Piezolith 2500). Shock wave treatment was administered, inasmuch as the stones were not extractable by initially applied endoscopic measures.

RESULTS

A total of 119 (2.4 +/- 1.4, range 1-7) lithotripsy sessions were conducted; only mild sedation/analgesia was used. Optimum targeting of the concrements in the shock wave focus was achieved in 17 (14%) treatment sessions with ultrasonography only; it was achieved in 65 (55%) cases by fluoroscopy and, in further 37 (31%) sessions by using both localization systems. Stone fragmentation was successful in 43 (86%) patients. Nineteen (38%) patients achieved spontaneous stone discharge after shock wave lithotripsy. In 11 (22%) cases, it was possible to remove all fragments endoscopically; residual fragments remained in 20 (40%) patients. Severe complications attributable to shock wave application did not occur. During follow-up, six patients had to be referred to surgery; two male patients died of specific diabetic complications and pleural mesothelioma, respectively. Thirty-five (90%) of 39 patients whose conditions were followed for 2-50 (20 +/- 14) months reported improvement of their pain sensations. Six (15%) patients required endoscopic treatment, including ESWL in five of those patients, to be repeated due to recurrent formation of calculi in the main pancreatic duct, which was again successful in five of the six patients.

CONCLUSIONS

Piezoelectric shock wave lithotripsy offers a basis for safe and effective fragmentation of pancreatic stones and facilitates endoscopic procedures. Most of the patients with obstructing pancreatic stones became stonefree and showed a significant reduction of pain.