Use Of Endoscopic Treatment Research Articles

Closure of Gastric Perforation with a Novel Tissue Anchoring Device

Background: With the increasing use of endoscopic treatments, there is greater risk for creating an iatrogenic perforation in the GI tract. Urgent endoscopic repair with clips has been reported as well-tolerated and a therapeutic option. However, it is difficult to apply clips for secure full thickness closure of large defects Aims: To assess the ability of a tissue anchoring device to close a large iatrogenic gastric perforation in a porcine model. Methods: A dual channel therapeutic scope was used (Olympus America, NY). The prototype tissue anchoring device consisted of two flexible retractable needle catheters and a bifurcated nylon suture with two distal t-tags and one proximal sliding t-tag. Before the procedure, both ends of the suture attached with two distal t-tags were loaded inside of the retractable needle catheters. Full-thickness puncture with each needle separately place each of the two distal t-tags on each side of the perforation. the free proximal tag was then grasped and the sliding T-tag was firmly pushed to cinch the suture. Six pigs were studied under general anesthesia. Two perforations over 2 cm in size were created for each pig along the greater curvature and the anterior wall with a combination of needle knife and sphincterotome. They were each closed with 3-5 tissue anchors sets, depending on the length of the perforation. One week after the repair, follow up endoscopy and necropsy were performed to evaluate treated sites. Results: Twelve perforations were closed with 48 tissue anchors. All animals survived for one week without clinical complications. Follow up endoscopy and necropsy revealed all tissue anchors firmly in place with healed perforations. However, three of twenty four tissue anchors (12.5%) used at the anterior wall penetrated surrounding organs; two penetrated the liver and one penetrated the anterior abdominal wall. Conclusions: Full thickness closure with a new tissue anchoring device successfully repaired large iatrogenic gastric perforations. The preliminary results of this study are encouraging for providing reliable and safe endoscopic closure of iatrogenic perforations.

Endoscopic Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is a common chronic disorder which has a severe effect on the patient's quality of life. In view of the high cost of medical therapy and the limitations of surgery, a variety of endoscopic techniques have been developed for the treatment of this condition, and these have shown apparently encouraging results, at least in the short term. However, promising results have been obtained in only around two-thirds of patients over a short-term follow-up period of about 6 months. Moreover, several inconsistencies have emerged between the efficacy of this form of treatment in improving symptoms and quality of life and a lack of improvement of objective parameters, such as lower esophageal sphincter pressure and esophageal acid exposure. The authors strongly endorse the need for comprehensive evaluation of clinical evidence on this topic. After an extensive evaluation of existing literature, we suggest that controlled studies are urgently needed in order to clarify the potential of endoscopic therapy, either in terms of cost-effectiveness or in comparison with standard therapy. Meanwhile, with regard to current practice, the use of endoscopic treatment should be limited to clinical trials, which should incorporate the provision of comprehensive and unbiased information to study patients.

The Usefulness of Endoscopic Treatment Compared Hemoclipping with Band Ligation on Active Bleeding of Mallory-Weiss Syndrome

Background : Mallory-Weiss Syndrome (MWS) is considered to be the cause of 4.5% to 11% of all UGI bleedings. In most cases, MWS bleeding stops spontaneously. However, when the bleeding is active, it persists in 50% of the cases. The recent studies also shows that endoscopic methods are effective for the treatment of active bleeding caused by MWS. Nonetheless, the debate continues over what to use for endoscopic treatment. The aim of this study is to investigate the respective efficacy and safety of endoscopic hemoclip placement and endoscopic band ligation (EBL) in MWS. Method : A randomized, open-labelled study to compare the efficacy and safety of hemoclipping with those of EBL was performed from December 2001 to August 2003. 30 patients with active bleeding from MWS were treated with endoscopic hemoclipping (n=17) or band ligation (n=13). Efficacy was resulted by primary hemostasis, rebleeding rate, secondary hemostasis, permanent hemostsis after primary or secondary hemostasis, total transfusion amount, or the length of hospital stay. Safety was also assessed by observing the complication during procedure. Result : There were no significant differences between the two groups with respect to age, gender, hemoglobin level, shock rate, stigmata of bleeding, or locations of laceration. The mean number of hemoclips applied was 2.9±1.2 and the mean number of bands applied was 1.2±0.4. Primary hemostasis was achieved in all 30 patients. Recurrent bleeding was observed in 3 patients from hemoclipping group (n=1) and band ligation group (n=2). However, no significant difference was found (p=0.565). The patients with recurrent bleeding were treated by the same endoscopic procedure performed at primary hemostasis, and secondary hemostasis was achieved in all recurrent bleeding patients. Moreover, for the total transfusion amount and length of hospital stay, there was no significant difference between the two groups. No complications or bleeding related death resulted. Conclusion : Endoscopic hemoclip placement and endoscopic band ligation are equally effective and safe for the management of active bleeding in Mallory-Weiss syndrome, even in patients with shock or comorbid disease.

7160 Usefulness of endoscopic treatment for persistent biliary leak due to hepatectomy.

[Aim] Biliary leak is one of the major causes of morbidity after hepatectomy. To resolve this problem, we evaluated the efficacy of endoscopic treatment for biliary leak after hepatectomy using technique of endoscopic retrograde cholangiopancreatography (ERCP). [Subjects and Methods] From 1996 to 1999, eight patients (6 men and 2 women, mean age 48 years old) were diagnosed as having biliary leak after hepatectomy in Kyoto University Hospital. Original disease were hepatocellular carcinoma in 6 cases, traumatic liver injury in one case, donor for living related liver transplantation in one case. Five patients received right lobectomy, 2 left lobectomy and one segmentectomy. [Results] The biliary tract was clearly visualized on ERCP images in all patients. The leaking point was well defined with accuracy at the level of the hepatic duct in 7 patients and common bile duct in one. Seven of 8 patients had strictures of the biliary tract.We performed endoscopic treatment in all 8 patients [a combination of endoscopic sphincterotomy (EST) and placement of nasobiliary drainage (NBD) in 6 patients, and NBD placement alone in 2]. Successful drainage was achieved in all the patients without any complications. The biliary leak ceased after drainage in all the patients (mean duration of drainage, 18 days). However, one patient resulted in the recurrence of a bile leak after the removal of NBD, and subsequently received percutaneous transhepatic biliary drainage. This patient was discharged after 90 days. [Conclusion] Endoscopic management is very useful in not only accurate diagnosis but also treatment for biliary leak. Therefore, this procedure should be attempted as a first line of therapy for bile leak occurred after hepatectomy.

Endoscopic management of choledocholithiasis.

The first description of endoscopic sphincterotomy 25 years ago spearheaded the widespread use of endoscopic treatment of choledocholithiasis. It is largely accepted that common bile duct stone removal should be endoscopic rather than surgical in patients who have undergone previous cholecystectomy, in the high-risk surgical patient when the gallbladder is still present, in patients with severe acute cholangitis, in selected patients with acute biliary pancreatitis, and in special circumstances for the average risk surgical patient with suspected choledocholithiasis before laparoscopic cholecystectomy. We have summarized a number of endoscopic techniques that are used in the management of bile duct stone disease.

Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for the National Audit of Acute Upper Gastrointestinal Haemorrhage.

Most patients with acute upper gastrointestinal haemorrhage are managed conservatively or with endoscopic intervention but some ultimately require surgery to arrest the haemorrhage. We have conducted a population-based multicentre prospective observational study of management and outcomes. This paper concerns the subgroup of 307 patients who had an operation because of continued or recurrent haemorrhage or high risk of further bleeding. The principal diagnostic group was those with peptic ulcer. Of 2071 patients with peptic ulcer presenting with acute haemorrhage, 251 (12%) had an operative intervention with a mortality of 24%. In the non-operative group mortality was 10%. The operative intervention rate increased with risk score, ranging from 0% in the lowest risk categories to 38% in the highest. Much of the discrepancy between operative and non-operative mortality was explainable by case mix; however, for high-risk cases mortality was significantly higher in the operated group. In 78% of patients who underwent an operation for bleeding peptic ulcer there had been no previous attempt at endoscopic haemostasis. For patients admitted to surgical units, the operative intervention rate was about four times higher than for those admitted under medical teams. In patients with acute upper gastrointestinal haemorrhage operative intervention is infrequent and largely confined to the highest-risk patients. The continuing high mortality in surgically treated patients is therefore to be expected. The reasons for the low use of endoscopic treatment before surgery are not revealed by this study, but wider use of such treatments might further reduce the operative intervention rate. Physicians and surgeons have not yet reached consensus on who needs surgery and when.

VESICOVAGINAL AND VESICOCUTANEOUS FISTULAS: TRANSURETHRAL SUTURE CYSTORRHAPHY AS A NEW CLOSURE TECHNIQUE

We assessed the usefulness of endoscopic treatment of vesical fistulas. Two bladder fistula patients underwent transurethral surgery in an attempt to close the fistula. Both patients were cured of the fistula, without undergoing an open procedure. Cystoscopically assisted suture closure of vesical fistulas can be a successful procedure in selected patients. Nontraditional instrumentation and technique allowed for transurethral closure of these fistulas.

Morphological aspects of necrosis as a guideline for treatment of necrotizing pancreatitis. A brief report about 50 patients.

In a retrospective study, 50 patients with obvious necrotizing pancreatitis (NP) were allocated in four groups according to the morphological aspects of the necrosis. Appearance of ascite (N1), extrapancreatic spread of necrosis towards neighboring organs (N2), a large amount of necrosis (N3), and infected necrosis (N4), appears to be an easy and useful guideline for the management of NP patients. Organ failures (72%) and mortality rate (36%) are higher when the process is infected. In the other groups, organic dysfunctions were frequent, but all the patients except one survived. The majority (80%) of patients were operated on. Only 20% of patients had successful nonsurgical treatment and they were in N3 group. This percentage may increase through a morphological approach to treating necrosis, with the use of endoscopic treatment for the disruption of pancreatic duct, and better accuracy in the management of patients with noninfected necrosis, whenever organ failures are present.

Follow-up 6 to 11 years after duodenoscopic sphincterotomy for stones in patients with prior cholecystectomy

One hundred sixty-three postcholecystectomy patients with retained or recurrent duct stones underwent successful duodenoscopic sphincterotomy and duct clearance between 1975 and 1980. Follow-up information was obtained on 148 patients in 1982, and on 115 of these in 1986 (at a mean of 8 yr). Fifteen patients (13%) were found to have had further biliary problems, but only 5 were known to have had sphincter stenosis and/or stones, and only 3 had not responded to endoscopic or conservative treatment. One had undergone choledochoduodenostomy for recurrent cholangitis (but continued to have problems), and 1 had died with jaundice, the precise cause of which was unknown. The third continued to have episodes of cholangitis requiring antibiotics despite the apparent lack of biliary obstruction. Bile showed significant bacterial contamination in 60% of 44 patients undergoing check endoscopy, but there was no correlation with symptoms. These long-term results are comparable with those of surgical procedures and justify the continuing use of endoscopic treatment for patients with duct stones.

New modalities for treating chronic pancreatitis.

Over the last few years, a new method, neither medical nor surgical, has been developed for treating often difficult-to-treat chronic pancreatitis. In the case of obstructive pancreatitis, endoscopy permits both drainage and calculus extraction. Even encrusted concrements and calcifications can be removed from the pancreatic duct with the aid of extracorporeal shockwave lithotripsy. The first aim is to relieve pain by restoring a free flow of secretion. Perhaps the use of endoscopic treatment in the early stages will break the vicious circle of chronic inflammation and ultimate gland destruction.

Universal ventilation laser tracheoscope.

A universal ventilation laser fiberoptic tracheoscope has been developed for use in endoscopic treatment of patients with obstructing benign and malignant lesions of the subglottis-cervicotrachea and laryngectomy tracheal stoma. This instrument features a ventilation connector for either side port or Venturi jet ventilation and a proximal connector with a sheath for delivery of a 0 degrees telescope, laser fiber, and suction catheter. Difficulties encountered with exposure and ventilation during laser treatment of the subglottis-cervicotrachea and laryngectomy stoma are overcome with this new instrument.