Endoscopic Laser Coagulation Research Articles

Inter‐twin membrane folding in monochorionic pregnancies

This study examines the value of assessing inter-twin membrane folding in monochorionic twin pregnancies in the prediction of twin-to-twin transfusion syndrome. In 83 monochorionic twin pregnancies ultrasound scans were carried out at 10-14, 15-17 and 19-21 weeks to investigate folding of the inter-twin membrane as an early sonographic feature of inter-twin discrepancy in amniotic fluid volume. There were 23 (28%) cases of membrane folding, which was first observed in one case at 10-14 weeks, in 21 cases at 15-17 weeks and in another case at 24 weeks. In 12 (52%) of the 23 cases the pregnancy progressed to severe twin-to-twin transfusion syndrome and 10 of these were treated by endoscopic laser coagulation of the placental vascular anastomoses. In the other 11 cases there was a moderate syndrome with large discrepancies in amniotic fluid volume and fetal size, persisting throughout pregnancy. In the severe group, five pregnancies resulted in live birth of both babies, three in live birth of one and intrauterine death of the other twin and in four cases there were no survivors. In the moderate group, all babies survived and the inter-twin disparity in birth weight was more than 20%. Similarly, all 60 pregnancies with no membrane folding resulted in live births. In all three groups there was an increase in inter-twin disparity in fetal size with gestation and the greatest inter-twin disparities were in those with moderate twin-to-twin transfusion syndrome from as early as the 10-14 week scan. These findings demonstrate that folding of the inter-twin membrane occurs in about one-quarter of monochorionic twins and in about half of these there is subsequent development of severe twin-to-twin transfusion syndrome.

Endoscopic laser coagulation in the management of severe twin-to-twin transfusion syndrome.

To assess the clinical effectiveness of endoscopic laser coagulation of placental vessels in the treatment of severe transfusion syndrome. Prospective study. Three referral centres for the management of twin-to-twin transfusion syndrome. One hundred and thirty-two pregnancies complicated by severe twin-to-twin transfusion syndrome, reflected by polyhydramnios and enlarged bladder of one twin and oligoanhydramnios and collapsed bladder of the other twin, presenting before 28 weeks of gestation. Prospective collection of data on pre-procedure assessment, the procedure and the follow up were collected prospectively. Laser coagulation of placental vessels crossing the intertwin membrane on the chorionic surface under sono-endoscopic guidance, followed by amniodrainage. Maternal and pregnancy complications, perinatal death and morbidity were assessed over the last five years with follow up of survivors. Endoscopic laser was carried out at a median gestation of 21 weeks. The total number of surviving infants was 144 (55%) and there was at least one survivor in 97 cases (73%). At a minimum age of one year neurological handicap was suspected in six survivors (4.2%). The results of this multicentre study are similar to those in our original report on the first 45 cases. In comparison with serial amniodrainage, the survival rate may be similar, but the handicap rate in survivors appears much lower. This study stresses the need for a prospective study comparing these two techniques.

レーザー療法が有効であった慢性腎不全透析患者における胃前庭部毛細血管拡張症の2例

A 48-year-old man was admitted to our hospital complaining of tarry stool. Laboratory data revealed marked anemia (Hgb 4.7g/dl) . Endoscopic examination revealed diffusely erythematous spots and Oozing hemorrhage at the gastric antrum. Endoscopic biopsy specimen taken from those areas demonstrated dilated vessels with fibrosis in the proper gastric mucosal layer. A 68-year-old man was admitted to our hospital complaining of general fatigue. Laboratory data revealed marked anemia (Hgb 6.0g/dl) . Endoscopic examination revealed longitudinal stripes, resembling the stripes of a watermelon at the gastric antrum. Endoscopic laser coagulation was performed for our two cases, under the diagnosis of gastric antral vascular ectasia (GAVE) . After the therapy, the vascular ectasia disappeared, and there was remarkable improvement in anemia. We consider that the endoscopic laser coagulation is an effective therapeutic method for gastric antral vascular ectasia, and should be the treatment first choice for this disease.

-Interruption of umbilical blood flow in an acardiac twin by endoscopic laser coagulation-.

We report on the successful intrauterine surgical treatment of a twin pregnancy with an acardiac fetus. At 18 weeks of gestation the patient presented with polyhydramnios and a hydropic acardius acephalus and the donor twin showed signs of congestive heart failure. Colour Doppler ultrasound allowed localisation of the communicating vessels running on the placental surface towards the umbilicus of the acardiac twin. At 20 weeks we performed endoscopic laser coagulation of the umbilical vessels of the acardiac twin. A sheath (9.8 Charriere) with a 1.9 mm diameter rigid fetoscope (field of vision 60 degrees) was introduced percutaneously under local anesthesia into the amniotic cavity of the "pump" twin. Under sonographic control the fetoscope was directed towards the communicating vessels on the placental surface. A Nd-YAG laser (0.4 mm diameter fiber) was used to coagulate two vessels, artery and vein, until interruption of the reversed arterial perfusion was accomplished. Tricuspid regurgitation of the normal twin disappeared throughout the following two weeks and no further complications occurred throughout pregnancy. At 39 weeks a healthy girl was delivered vaginally. No at the age of 3 months she is developing normally. Minimal invasive endoscopic laser coagulation of the umbilical vessels of the acardiac twin appears to be the optimal currently available treatment for the normal twin, for which otherwise a high mortality ( > 50%) and morbidity must be expected.

Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome.

In monozygotic twin pregnancies, there are placental vascular communications between the two fetuses. In 15 percent of such pregnancies there is an imbalance in net blood flow between the twins, resulting in the twin-twin transfusion syndrome. The recipient twin may have severe hydramnios during the second trimester of pregnancy, and there is a high risk of perinatal death and cerebral palsy in survivors. This condition can now be treated by endoscopic coagulation of the vascular anastomoses responsible for fetofetal transfusion with a neodymium:yttrium-aluminum-garnet (Nd: YAG) laser. We performed intrauterine surgery in 45 pregnant women carrying twins at 15 to 28 weeks of gestation (median, 21); in each case there was severe hydramnios in one fetus due to the twin-twin transfusion syndrome. With the use of local anesthesia and continuous ultrasound visualization, a rigid fetoscope 2 mm in diameter, housed in a 2.7-mm cannula, was introduced transabdominally into the amniotic cavity of the recipient twin. A systematic search was made for all vessels approaching or crossing the membrane between the twins, and these were coagulated with an Nd:YAG laser by means of a fiber in the side arm of the cannula. Coagulation of the communicating vessels was successful in all cases. The total number of fetuses who survived to delivery was 48 (53 percent), and the number of pregnancies with at least 1 survivor was 32 (71 percent). Among the live-born infants, the median gestational age at delivery was 35 weeks (range, 25 to 40), and the median birth weight was 2098 g (range, 550 to 4252). The median interval between the endoscopic laser procedure and delivery was 14 weeks (range, 0 to 21). All the survivors were developing normally at a median age of 12 months (range, 2 to 24). Our preliminary experience suggests that the twin-twin transfusion syndrome can be treated effectively by endoscopic laser coagulation of the communicating placental vessels.

Endoscopic laser coagulation of umbilical cord vessels in twin reversed arterial perfusion sequence.

In monozygotic twin pregnancies with reversed arterial perfusion (TRAP) sequence, the donor twin is ut high risk of perinatal death. This paper describes the use of endoscopic surgery in the management of this condition. In four cases of TRAP sequence presenting at 17, 20, 26 and 28 weeks' gestation, respectively, an endoscope was introduced into the uterus under local anesthesia and a Nd-YAG laser was used to coagulate the umbilical cord vessels of the acardiac twin. Laser coagulation was successful in arresting blood flow to the acardiac fetus in the cases treated at 17 and 20 weeks, and healthy infants were delivered at term. In the pregnancies treated at 26 and 28 weeks, the umbilical cords were very edematous and laser coagulation failed to arrest blood flow; healthy infants were delivered after spontaneous labor at 29 weeks. These findings suggest that, during mid-gestation, endoscopic laser coagulation of the umbilical cord vessels of the acardiac twin is an effective method of treating TRAP sequence. In later pregnancy, alternative methods of treatment are needed.

Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon.

Endoscopic laser coagulation effectively controls bleeding from radiation-induced rectal vascular lesions. To assess the outcome of endoscopic treatment of radiation-induced bleeding due to vascular lesions located proximal to the sigmoid colon. We identified 15 consecutive patients with such proximal radiation enteropathy treated at our Institution with Nd:YAG laser between 1984 and 1991. Ten patients (66%) had gastric and/or small bowel involvement, and five (33%) had colonic involvement with or without more proximal lesions. Bleeding first appeared at a mean of 21.2 +/- 12.5 months after completion of radiotherapy. Mean duration of gastrointestinal bleeding before laser treatment was 7.6 +/- 4.6 months. After completion of laser therapy, bleeding ceased in nine (60%) patients, decreased in three (20%), and persisted in three (20%). The mean hemoglobin level increased from 8.4 +/- 0.5 g/dl to 10.4 +/- 0.6 g/dl after completion of laser treatments (p < 0.02). The mean number of transfusions per patient per year decreased from 10.5 +/- 2.8 to 0.9 +/- 0.7 (p < 0.01). No treatment-related complications or deaths occurred. Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon appears to be safe and, in most cases, effective.

Malignant esophageal strictures: treatment with a self-expanding nitinol stent.

A self-expanding esophageal nitinol stent was implanted under fluoroscopic guidance in 40 patients with malignant esophageal strictures and clinically significant dysphagia. The strictures were caused by squamous cell carcinoma (n = 14), adenocarcinoma (n = 12), recurrent anastomotic carcinoma (n = 8), and mediastinal tumors (n = 6). Eight stents were balloon dilated to maximum diameter immediately after insertion. Sixteen stents self-expanded to maximum diameter within 24 hours, and the other stents expanded to maximum diameter during further observation. There were no serious stent-related complications, and the dysphagia was reduced considerably in all patients immediately after stent insertion. Persistent tumor bleeding occurred in two patients, and ingrowth of tumor into the stent was seen in eight patients. Two stents occluded due to tumor ingrowth but were successfully recanalized with endoscopic laser coagulation. At the end of the study, 28 patients were dead with a mean survival of 2.9 months (range, 0.1-7.0 months), and 12 patients were alive with a mean follow-up of 8.8 months (range, 4.0-15.0 months).

Successful outcome after Nd : YAG laser separation of chorioangiopagus-twins under sonoendoscopic control.

Endoscopic laser coagulation of the chorioangiopagus was successfully performed at 25 weeks' gestation in a pregnancy presenting with acute polyhydramnios due to twin transfusion syndrome. Under local anesthesia, a rigid fetoscope housed in a 2.7 mm diameter cannula was introduced transabdominally into the amniotic cavity and the communicating vessels were coagulated by Nd : YAG laser through a fiber that was passed down the side-arm of the cannula. There was rapid normalization of urine output in both fetuses and resolution of the oligo- and polyhydramnios in the donor and recipient twins, respectively. Furthermore, there was normalization in both fetal circulations, as assessed by Doppler velocimetry, and there was gradual resolution of the hydrops in the recipient. Two healthy babies were born 9 weeks after the procedure.

Treatment of congenital tracheoesophageal fistula by endoscopic laser coagulation: Preliminary report of three cases

Three newborns with congenital tracheoesophageal fistula were treated by endoscopic laser coagulation. After radiologic and endoscopic diagnosis, laser coagulation of the mucosal layer of the fistula followed using Nd:YAG laser light transferred through an uncovered quartz fiber of 600 μm diameter. The successful and uneventful course in two cases contrasts with the incomplete obliteration in one case caused by inadequate energy application and/or early localized instillation of contrast medium for radiologic control examination. The advantages of this method include elimination of an operative procedure, exclusion of operative complications, and the possibility of repetition in recurrent cases. Care must be taken to prevent esophageal and tracheal damage by use of this method.

Endoscopic laser coagulation through an optical laser balloon

An endoscope was equipped with a saline-filled latex rubber balloon at its tip to displace contaminating blood, bile, or gastric contents during operative portoscopy, biliary endoscopy, or upper gastrointestinal endoscopy. A fiber with its tip inside the balloon transmitted energy from an Nd:YAG laser for coagulation of tumors in one bile duct cancer, in six portal vein growths from primary liver cancers, and in a superficially growing stomach cancer. The balloon increased the precision of irradiation by making lesions easier to identify through displacement of bile or blood and by keeping the fiber tip at a fixed position relative to the lesion. The technique, basic experimental studies, and clinical experiences are reported.

The percutaneous treatment of upper urinary tract urothelial tumours

This paper reports the management of eight upper urinary tract (UUT) transitional cell tumours (TCC) treated by percutaneous endoscopic resection (n=7) or laser coagulation. Two patients with small, solitary-low-grade TCC and negative urine cytology are free of recurrence after 2 years. Of the remainder, two died of TCC, two proceeded to nephroureterectomy for highgrade or recurrent invasive tumors, one underwent a second percutaneous resection of a recurrent superficial TCC and one was lost to follow-up. The patient who died from high-grade invasive TCC had tumour protruding from the nephrostomy track. We feel that percutaneous surgery has a very limited place in the management of UUT TCC and should be reserved for palliation of proven solitary, low-grade superficial tumours with negative cytology in patients requiring conservative treatment.

Laser Therapy for Severe Radiation-Induced Rectal Bleeding

Four patients with chronic hematochezia and transfusion-dependent anemia from postradiation rectal vascular lesions were successfully managed by endoscopic laser coagulation. In all four patients, symptomatic, hematologic, and endoscopic improvement was evident. Laser therapy for severe radiation-induced rectal bleeding seems to be safe and efficacious and should be considered before surgical intervention.

Endoscopic Laser Coagulation with Contact Method

Endoscopic Laser Coagulation with Contact Method

Endoscopic Laser Coagulation and Local Injection of 95% Ethanol for Hemorrhagic Gastric Ulcer

Endoscopic Laser Coagulation and Local Injection of 95% Ethanol for Hemorrhagic Gastric Ulcer

Use of the neodymium-YAG laser in the treatment of ureteral tumors and urethral condylomata acuminata. Clinical experience.

The further development of endoscopic instruments has made neodymium-YAG laser irradiation of ureteral tumors possible. To date a total of 13 ureteral tumors in 10 patients have been photocoagulated. Over a mean follow-up period of 23 months, only 1 heterotopic recurrence was found after 14 months. In view of the results achieved so far, nephroureterectomy as the first therapeutic step appears to have been made obsolete. Since 1979 we have treated 48 patients with the neodymium-YAG laser. Seven patients with excessive condyloma involvement were followed postoperatively. Our experience indicates that, in view of its low complication and recurrence rates, endoscopic laser coagulation of urethral condylomata is the method of choice. A short-term ureteroscopic follow-up examination, however, is required to detect any condylomata that might have been overlooked.

高出力Nd-YAGレーザーによる消化管出血に対する内視鏡的止血法について

We explained the instruments of endoscopic high power Nd-YAG laser coagulation for acute gastro-intestinal bleedings and reported its clinical results at the University of Munich.In 618 of 663 cases (93.2%) bleeding was successfully arrested with high power (more than 70w) short pulse (0.5-1.0 sec.) Nd-YAG laser by the end of December 1979.perforation after laser coagulation was noted in 1.3% (8/618). In four cases, however, perforation resulted from low laser power (less than 50W) due to defective laser instruments or light guides. The remaining patients were those with deeply penetrating ulcers or severe coagulopathy.

Endoscopic laser coagulation of bleeding gastrointestinal lesions with report of the first therapeutic application in man

In acute and chronic experiments in animals we have shown that it is possible to effect photocoagulation with the argon-ion laser beam in any part of the gastrointestinal tract. The degree of coagulation depends upon the duration of application of the laser, power density, and the properties of the tissue treated. Hemostasis was achieved with the laser in 50 artificially induced bleeding lesions in the mucosa and 80 incised arteries and veins having a diameter of up to 1 mm and 2mm, respectively. Endoscopically controlled laser beam coagulation has since been applied successfully in the treatment of hemangiomas, angiodysplasia, intestinal angiomatosis, bleeding gastric erosions, bleeding gastric and duodenal ulcers, and iatrogenic hemorrhage in the stomach following big particle biopsy in 94 lesions.

Klinische Erfahrungen mit einer neuen Methode der Laserkoagulation

Endoscopic laser-coagulation was used 94 times in 14 patients to stop gastro-intestinal bleeding or coagulate potential bleeding sources during non-bleeding intervals. Lasting haemostasis was achieved in three cases of incomplete gastric erosion, one of gastric ulcer, one of duodenal ulcer and one of bleeding after antral rugectomy. It failed to stop severe arterial bleeding in a case of gastric carcinoma. Lasting haemostasis was achieved in six haemangiomas of the colon, one case of angiomatosis of the antrum with 62 individual sites, two of angiodysplasia of the colon, 17 lesions in Osler's disease of the oesophagus (2 cases), stomach (10) and duodenum (5). The procedure was performed in the course of diagnostic endoscopy with an argonion laser developed by the authors, which has a density of 0.7-1.3 W/mm2. No complications have been observed so far.

The First Endoscopic Laser Coagulation in the Human Gl-Tract

Preliminary report on the first endoscopic laser coagulations in the human gastrointestinal tract. The successful light coagulations were carried out on non-bleeding colonic haemangiomas and on a bleeding gastric ulcer. For the first time, a plastic light-guide that could be passed through the instrument channel of an endoscope, served as transmission system.