The current status of broncho-esophagoscopy in otorhinolaryngology

Most bronchoscopies and esophagoscopies are currently performed with flexible instruments by the respective specialist. Thus the field of bronchoesophagology is in danger of being fragmented; neither the pneumologist nor the gastroenterologist have the complete overview of the upper respiratory and digestive tract. This review shows that number of pathologic conditions in the ENT area and the mediastinum involve the upper respiratory as well as the digestive tract, and thus underscore the need for combined tracheobronchial and esophageal endoscopy. Mastering of rigid and flexible endoscopy is mandatory to be efficient in diagnostic and therapeutic broncho-esophagoscopy. The ENT specialist is in the best position to maintain an overview of this whole field. New developments in broncho-esophagoscopy are presented and discussed in terms of cost effectiveness.     

Pulmonary rehabilitation for chronic lung disease

Its is the task of each medical specialty to develop guidelines for diagnosis and therapies. Examinations done by several specialties should follow a common consensus. A randomized survey at 70 German ENT departments investigated the current position of tracheobronchoscopy and esophagoscopy at each institution. Sixty questionnaires were evaluable. Altogether 8,295 tracheobronchoscopies and 10,404 esophagoscopies were performed. Thirty-six percent of all tracheobronchoscopies and 6% of all esophagoscopies were done with a flexible system. Approximately 58% of all tracheobronchoscopies and 55% of all esophagoscopies were performed for tumor staging. Complications during tracheobronchoscopy occurred in 0.8% of cases and in 0.58% of the esophagoscopies. Using these data an interdisciplinary quality assurance concept was developed for tracheobronchoscopy and esophagoscopy. Current experience has shown that a otolaryngologists in Germany mainly perform rigid tracheobronchoscopy and esophagoscopy. Although endoscopy is mostly done in cases with varied anatomic structures, complications are very rare and comparable to flexible techniques. Greater experience with flexible systems also is to be encouraged in ENT departments.     

Laparoscopy-assisted endoscopic removal of a stromal-cell tumor of the stomach

Endoscopic resection of gastrointestinal tumors is being performed with increased frequency. Submucosal mass lesions pose a particular problem, because of the risk of malignancy and the risk of complications associated with endoscopic removal. Increased incidences of both perforation and bleeding have been reported. We report here on a case in which we used a combined approach that included gastrointestinal endoscopy, laparoscopy, and laparoscopic ultrasound to resect a gastric leiomyoma. We consider that this approach enhanced our diagnostic capabilities, provided intraoperative options for resection, and enhanced the safety of the procedure.     

Tumors of the papilla of Vater--diagnostic and therapeutic dilemmas

Benign and malignant tumors of papilla Vateri are rare diagnoses in the endoscopic practice. Sixteen patients with benign and 22 cases of malignant tumors are presented. In all of them endoscopic cholangiopancreatography with or without papillotomy followed by biopsy and operation in 13 cases was performed. Biopsy confirmed the endoscopy in 71%. Adenomyosis, supposed by endoscopy was proved by repeated histology in only 2/9 cases although invasive component of the tumor was found in 3/9 patients at operation underlying precancerous nature of this entity. Among 5 cases of villous adenoma one developed malignant alterations during 4 years of follow-up. Biopsy was not more effective after papillotomy than without it, and 5-7 days of delay for recovery of thermic lesion did not ameliorate success rate of histology. For malignant diseases surgical therapy should be considered if staging of tumor and general condition of the patient permits. In unresectable cases endoscopic palliation (papillotomy or polypectomy with or without drainage) can increase survival. In patients with benign tumors operative endoscopy followed by regular ultra-sonography and endoscopy seems to be necessary.     

Primary neuroendocrine carcinoma of the skin expresses tyrosinase mRNA: detection by a specific nested PCR technique

BACKGROUND: Local excision of selected ampullary tumors may result in the same benefit as Whipple resection with less morbidity and mortality. The purpose of this study was to determine if endoscopic ultrasonography could aid in the selection of patients for local resection and to determine if there was a significant cost difference between the two surgical procedures. METHODS: In this retrospective study of 32 patients who underwent surgery for ampullary tumors, endoscopic ultrasonography staging was performed in 18 patients. Resected specimens were used to determine pathologic staging. Local disease was defined as stage T2N0 or less. Cost data were available for 20 patients. RESULTS: The sensitivity and specificity of endoscopic ultrasonography for differentiating local from advanced ampullary tumors were both 83%. The median total cost for a local resection was $9314 versus $16,017 for a Whipple resection (p < 0.0017). CONCLUSION: Endoscopic ultrasonography is an effective tool for identifying patients with localized ampullary tumors. The cost of a local resection for ampullary tumors is significantly less than that of a Whipple resection. The use of endoscopic ultrasonography to select patients for local resection may be a cost-effective technique in the management of patients with ampullary tumors.     

Regression of childhood Barrett's esophageal mucosa by antireflux surgery and bipolar electrocoagulation

The authors report a case of a 13-year-old girl with Barrett's esophagus who underwent antireflux surgery and was subsequently treated with endoscopic thermal coagulation using bipolar electrocoagulation. Follow-up endoscopy 15 months after completion of the endoscopic therapy showed normal esophageal mucosa without intestinal metaplasia. Longer follow-up is needed to assess the long-term effects of endoscopic treatment of the Barrett's mucosa with thermal coagulation, and this procedure should still be considered under investigation.     

Haemostasis after partial hepatectomy using argon beam coagulation

The argon beam coagulator is a new device for haemostasis during and after surgery on parenchymatous organs. No data are available on its efficacy and tissue effect following hepatic resection. Blood loss, the time needed to achieve adequate haemostasis and histological findings after liver resection were assessed in 12 pigs using argon beam coagulation or suture ligation only, the mattress suture technique and tissue glue application. The treatment was randomly assigned to each of the four liver lobes in each pig. Median blood loss following argon beam coagulation was 13 (range 2-47) ml and after simple suture ligation 55 (range 2-260) ml (P < 0.02). The median time needed for adequate haemostasis following argon beam coagulation was 3 (range 2-7) min versus 14 (range 2-48) min in the control group (P < 0.005). There was no difference between argon beam coagulation and tissue glue, which were both superior to the use of mattress sutures. Argon beam coagulation resulted in less tissue damage than tissue glue or mattress suturing. The argon beam coagulator is an efficient device for achieving haemostasis following partial hepatectomy in the pig. It causes only a moderate tissue reaction.     

Bacteriology of vulvo-vaginitis in pediatrics]

The first naso-sinus laboratory has been set up in Siriraj Hospital for better training of rhinosurgeons. The specimens used for practice operation are the entire nasal cavities with all paranasal sinuses, taken from cadavers and preserved in 95% ethanol. The "Siriraj" sinus holder is specially designed and constructed to hold various sizes of specimens. It is made of plastic board and stainless steel screws; it is an inexpensive and simple device which can be afforded by every centre. With this naso-sinus laboratory, ENT residents and rhinosurgeons can achieve their skills in performing nasal endoscopy, endoscopic or microscopical sinus surgery and all kinds of sinus operations at their convenience.     

Licensure, use, and training of paramedical personnel to perform screening flexible sigmoidoscopy

BACKGROUND: The purpose of this study was to assess the state board of nursing guidelines about the performance of flexible sigmoidoscopy by nurses and to determine the current use and training of paramedical personnel in flexible sigmoidoscopy at gastroenterology fellowship programs in the United States. METHODS: Separate one-page questionnaires were sent to state boards of nursing and directors of endoscopy at gastroenterology fellowship programs in the United States. RESULTS: Twenty percent (10 of 50) of state boards of nursing explicitly approve the performance of sigmoidoscopy by registered nurses, and 50% (25 of 50) explicitly approve the practice by nurse practitioners. Forty-six percent (23 of 50) of state boards of nursing have no written policy but allow nurses to use a "decision making model" to determine whether the performance of sigmoidoscopy is allowed. Fifteen percent (24 of 164) of gastroenterology fellowship programs in the United States use paramedical personnel to perform flexible sigmoidoscopy. Sixty-three percent (15 of 24) of these programs started since 1995, and 67% (16 of 24) require that the paramedical personnel perform 50 or more supervised sigmoidoscopies during their training. Forty-five percent (5 of 11) of programs with physician assistants/nurse practitioners use these personnel to perform colonoscopy or endoscopy. CONCLUSIONS: Nurses are allowed to perform flexible sigmoidoscopy in most states based on current state board of nursing guidelines. The use of paramedical personnel to perform endoscopic procedures is increasing rapidly.     

Endoscopic therapy of esophageal cancer

In the management of esophageal cancer, endoscopy has evolved from a tool used to provide biopsy confirmation of suspected tumor to an integral part of the staging and ongoing treatment of patients. Endoscopic ultrasound is currently the most accurate means for T and N staging. Improved endoscopic techniques like dye staining and aggressive biopsy protocols can identify very early stage tumors in high-risk groups and allow curative surgery. Patients with early-stage tumors who are not surgical candidates can also be treated with endoscopic mucosectomy, photodynamic therapy, or Nd:YAG laser and still have a chance of long-term cure. Palliation of advanced tumors remains the major role of endoscopy in patients with esophageal cancer. A variety of techniques have proven effective over the years, including dilatation, laser, and rigid prostheses. Newer developments like bipolar probes, injection therapy, photodynamic therapy, and brachytherapy offer potential applications. The development and continuing improvements in both coated and uncoated expandable metal stents have been perhaps the greatest recent advance in endoscopic palliation of malignant dysphagia and esophagorespiratory fistulas. With the increasing array of endoscopic treatments and palliative techniques, emphasis must be placed on considering functional status; tumor characteristics like stage, location, and shape; patient wishes; and local expertise in tailoring treatment plans for each situation.     

Endoscopic appearances of hemorrhagic peptic ulcers and efficacy of H2-receptor antagonists

BACKGROUND/AIMS: In this retrospective study, we compared the effects of histamine H2-receptor antagonists to those of antacids and anticholinergics in patients with hemorrhagic ulcers with various endoscopic appearances of bleeding. PATIENTS AND METHODS: Patients with hemorrhagic ulcers (n = 376) were examined by emergency endoscopy and were treated with 1) antacids and anticholinergic drugs or 2) H2-receptor antagonists. RESULTS: In ulcer patients with oozing or fresh red coagulation, H2-receptor antagonists ceased further hemorrhage more effectively (65.9% of the cases) than antacids and anticholinergic drugs (46.7%). In patients with projectile bleeding, both of the treatments failed to stop hemorrhage. There were no significant differences in favorable outcome in the patients only with old black coagulation between antacid and anticholinergic drugs-treated group and H2-receptor antagonists-treated group (94.4% and 93.8%, respectively). CONCLUSIONS: The results suggest that H2-receptor antagonists are more effective than antacids and anticholinergic drugs in patents with peptic ulcer with fresh coagulation or oozing, but not with projectile bleeding or old black coagulation. The results also indicate that endoscopic appearances of peptic ulcer bleeding are good predictors for the effects of medication.     

Operative fetoscopy: new perspective in fetal therapy?

In a limited number of conditions in utero surgery may be life-saving, such as some cases of congenital diaphragmatic hernia, cystic adenomatoid malformation of the lung, sacrococcygeal teratoma and lower urinary tract obstruction. Postoperative premature labour and its extreme invasiveness have been major drawbacks for open fetal surgery. More recently the merger of fetoscopy and advanced video-endoscopic surgery has been the basis of the concept of endoscopic fetal surgery. In order to evaluate the opportunities of 'fetendo' surgery, animal models have been developed to test the safety of the endoscopic approach, and the feasibility of surgical manipulations on the fetus. In the non-human primate, a lesser invasiveness of endoscopy over open surgical approach was demonstrated, by a significant decrease in uterine activity in comparison with hysterotomy. The main application of fetoscopy today is the surgical treatment of complicated or abnormal monochorionic twin gestations. Fetoscopic laser coagulation of chorionic plate vessels is suggested as a causal therapy for severe feto-fetal transfusion syndrome. Survival rates are around 55 per cent with an incidence of five per cent of neurological morbidity. Fetoscopic cord ligation is associated with a 66 per cent survival rate, but unfortunately also with a risk of 30 per cent for PPROM prior to 32 weeks. Although still in its early experimental phase, endoscopy seems to offer new hope for surgical fetal therapy. Though conceptually very tempting, the development of endoscopic fetal surgery should follow the formal guidelines, as earlier formulated for open surgery by the International Fetal Medicine and Surgery Society. The prospective registration of worldwide experience is advocated and a randomized trial of laser therapy versus amniodrainage is announced.     

Role of nasosinusal endoscopic surgery in the treatment of headache and facial pain of rhinogenic origin

Headaches and facial pain are common complaints. In many cases patients are referred to an otolaryngologist to determine if head pain is sinus related. In the absence of other nasal or sinus symptoms, some rhinogenic headaches can be overlooked or misdiagnosed. A complete history and thorough ENT examination, including nasal endoscopy, with or without coronal CT scans, is the key to the correct diagnosis. Subtle exploratory findings such as minimal inflammatory changes or anatomic abnormalities of the ostiomeatal complex area may cause pressure resulting in facial pain. When medical treatment fails to produce sustained relief, surgery may be considered. Current worldwide thinking firmly supports the endoscopic endonasal approach as a safe and effective form of treatment in patients with nasal and sinus disease. We prospectively assessed 67 patients who underwent FESS for rhinogenic facial pain in the absence of other nasal or sinusal symptoms. The overall success rate was 93%. Only 5.9% of our cases had some minor complications. No major complications occurred.     

T-cell response to HIV in natural infection: optimized culture conditions for detecting responses to gag peptides

We report a case of successful laparoscopic resection of a solitary schwannoma of the gastric fundus performed on emergency. The patient was a 52-year-old man who presented with an upper gastrointestinal hemorrhage. At admission, the endoscopy and hydro-CT scan showed a submucosal tumor, 2.5 cm in maximum diameter, with an area of central ulceration arising from the anterior wall of the gastric fundus. A wedge laparoscopic resection of the gastric wall was performed under endoscopic guidance. The defect in the anterior wall was repaired in part by linear stapler and in part using a continuous suture. The postoperative recovery was uneventful and the patient was discharged on the 4th postoperative day. Laparoscopic approach represents a safe and efficient approach for the treatment of benign tumors of the stomach, also on emergency basis.     

Endosonographic features of esophageal granular cell tumors

BACKGROUND AND STUDY AIMS: Granular cell tumors of the esophagus are rare tumors. A definite diagnosis is achieved by endoscopic biopsies in only 50% of cases. Endoscopic ultrasonography (EUS) is the best procedure in the evaluation of upper gastrointestinal tract submucosal tumors. The aim of this study was to describe the endosonographic findings of esophageal granular cell tumors. METHODS: From January 1989 to March 1994, 15 patients with 21 granular cell tumors which had negative biopsies were examined by EUS (Olympus GF UM3 or GF UM20,7,5 and 12 MHz). In five cases, the tumor was also studied with a 20 MHz Olympus miniprobe. The final histological diagnoses were obtained by subsequent endoscopic snare resection in 20 cases and surgically in one case. RESULTS: The endosonographic features (with the GF UM3 or GF UM20) of esophageal granular cell tumors were: a) a tumor size of less than 2 cm in 95% of cases; b) an hypoechoic solid pattern in 100% of cases; c) a tumor arising in the inner layers in 95% (second echo-poor layer n=15; third echo-rich layer n=5). In one case, the endosonographic finding was transmural malignant infiltration of the esophageal wall (histologically confirmed). CONCLUSION: When a granular cell tumor of the esophagus is suspected, EUS can show the inner layer location of the tumor and thus contribute to planning the endoscopic resection or follow up. When the tumor also invades the outer layers, EUS can contribute to planning the surgical resection.     

Circadian entrainment and phase shifting in mammals with melatonin

BACKGROUND: Diathermy procedures are indispensable in interventional endoscopy. Argon beam coagulation is an innovative no-touch electrocoagulation technique in which high-frequency alternating current is delivered to the tissue through ionized argon gas. METHOD AND PATIENTS: Before clinical application, we conducted in-vitro studies to investigate the depth and diameters of tissue coagulation in fresh operative specimens from the stomach, small intestine and colon. Five different power/gas flow settings between 40 and 155 W and 2 and 7 l/min were used. The impact time (1-10s) and the incident angle of the probe (45 degrees and 90 degrees) were also varied. The maximum depth of necrosis was 2.4 mm, the maximum diameter 1.1 cm. No perforation occurred even in critical areas such as the colon and duodenum. We therefore performed argon beam coagulation in 66 consecutive patients. Two power/gas flow settings of 40 and 70 W and 2 and 3 l/min, respectively, were used. The impact time and incident angle were varied individually. RESULTS: In 49 of the 50 patients with oozing haemorrhage from angiodysplastic lesions, polypectomy sites, erosions or ulcers or oozing of blood due to vascular penetration by tumours, definitive haemostasis was achieved in one to two sessions. In all 11 patients with residual sessile adenoma tissue, complete removal was possible. Oesophageal patency was restored in all five patients with stenosing tumours. In one patient with angiodysplasia of the caecal pole, an asymptomatic accumulation of gas in the submucosa was observed which resolved spontaneously. In two patients with extensive oesophageal carcinoma, there was a transitory--also asymptomatic--accumulation of gas in the mediastinum and peritoneal cavity but no evidence of perforation. CONCLUSION: Argon plasma electrocoagulation is an effective and relatively low-cost alternative to laser therapy in gastrointestinal endoscopy.     

Endoscopic treatment of major bleeding from advanced gastroduodenal malignant lesions

OBJECTIVE: To summarize the results of endoscopic therapy for acute hemorrhage from gastroduodenal malignant lesions. DESIGN: The 3-year experience (1989 through 1991) of a specialized gastrointestinal (GI) bleeding team in the endoscopic treatment of acute upper GI bleeding from gastroduodenal malignant tumors was retrospectively reviewed. MATERIAL AND METHODS: Of 1,083 consecutive patients with acute major upper GI hemorrhage, 21 (1.9%) were found to have advanced tumors of the stomach and duodenum, 15 of whom received endoscopic therapy. In this study group of 15 patients, the tumors were gastric in 11 and duodenal in 4. Endoscopic treatment consisted of injection of epinephrine, heater probe coagulation, neodymium:yttrium-aluminum-garnet laser coagulation, or injection of sodium tetradecyl sulfate. RESULTS: Initial endoscopic hemostasis was achieved in 10 of the 15 patients (67%); however, bleeding recurred in 8 of 10 (80%), and all 5 in whom endoscopic hemostasis was not achieved continued to bleed. Mean transfusion requirements for the 30 days before and the 30 days after the first endoscopic treatment were 7.6 and 6.4 units of packed erythrocytes, respectively (P > 0.10). Five major procedure-related complications occurred, two of which were fatal. The median duration of survival after the first endoscopic treatment was 39 days (range, 1 to 1,414). CONCLUSION: In patients with major bleeding from advanced gastroduodenal malignant lesions, endoscopic therapy seems to provide limited benefit.     

Barrett's esophagus, high-grade dysplasia, and early adenocarcinoma: a pathological study

OBJECTIVES: In Barrett's esophagus, early adenocarcinomas are often missed on endoscopic biopsy. We therefore examined the distribution and extent of dysplasia and carcinoma in the resected esophagus for comparison with the preoperative biopsy findings. METHODS: Patients whose endoscopy showed Barrett's esophagus but no visible cancer had four-quadrant esophageal biopsies taken every 2 cm. After resection for high-grade dysplasia or early adenocarcinoma, the esophagus was mapped histologically. RESULTS: Nineteen patients had surgery for high-grade dysplasia; two of them (10.5%) had adenocarcinoma in the resected esophagus. Eleven patients had resection after a biopsy diagnosis of adenocarcinoma or suspicion of adenocarcinoma. Esophagectomy mapping confirmed carcinoma in only five of them. Median surface areas were: total Barrett's esophagus 32 sq cm, low-grade dysplasia 13 sq cm, high-grade dysplasia 1.3 sq cm, adenocarcinoma (seven cases) 1.1 sq cm. CONCLUSIONS: Areas of high-grade dysplasia and microscopic carcinoma in Barrett's esophagus are often small. Biopsy differentiation between these lesions is difficult. A systematic endoscopic biopsy protocol will reduce the chance of missing early malignancy in Barrett's esophagus.     

The effect of tissue expansion on the expression of collagen type I and type III mRNA in distinct areas of skin in the dog as an animal model

PURPOSE: To reach an optimal treatment result and to avoid damage to critical structures a homogeneous dose distribution in the tumor volume with a rapid decreasing dose to the surrounding structures is necessary. Fractionated interstitial brachytherapy of tumors in the ENT region employing needles depends on exact localization of the target volume during all fractions. Therefore reproducibility of positioning of the needle(s) plays an important role. MATERIAL AND METHODS: We used the ISG Viewing Wand system in combination with the Vogele-Bale-Hohner (VBH) head holder and a new targeting device. Point of entrance, pathway, and target point of the needle were planned and insertion of the needle simulated in advance. To date we have treated 7 patients with inoperable tumors in the ENT region. The actual position of the needle in the control CT was compared to the planned position. RESULTS: The accuracy of positioning of the needle depended on the location of the tumor. In a patient with a recurrent retroorbital adenocarcinoma the mean accuracy was 1 mm. Due to soft tissue displacement in the neck region and the resulting necessity to readjust the targeting device the needle was placed with a mean deviation of 15 mm between the planned and the actual position. CONCLUSIONS: Computer-assisted frameless stereotactic interstitial brachytherapy allows for precise, reproducible and preplanned insertion of hollow needles into target structures closely adherent to the surrounding tissue, thus avoiding damage of neighbouring structures. This technique is of great advantage in treating deeply seated tumors which are fixed to bony structures, especially at the skull base. Inaccuracy in the neck region caused by soft tissue shift requires improvement of the immobilization in this region.     

Prognosis in endoscopic perforans vein excision in postphlebitic syndrome

In the presence of leg ulcer endoscopic treatment is particularly indicated as it permits reliable diagnosis and treatment of incompetent perforator veins from a small incision away from the contaminated zone. Lately 3 surgeons have developed special instruments for this type of endoscopy. Hauer was the 1st to develop a specialized technique with the Wolf Company. He uses an angulated optic system and a double cautery clamp. It permits excellent vision. Sattler works with a Storz thoracoscope and specially built instruments controlled by a monitor. This means agreeable and motivating handling. Fischer uses direct vision through a Wolf or similar endoscope shaft and a set of instruments produced by Storz and Ulrich Co for him for swift, simple and reasonable treatment. Each surgeon will chose his method on the ground of his education, his special liking and his set up.