Contrast-enhanced endoscopic ultrasonography in pancreatic diseases: a preliminary study

OBJECTIVE: The purpose of this study was to clarify the usefulness of contrast-enhanced endoscopic ultrasonography in pancreatic diseases. METHODS: The subjects comprised 37 patients with pancreatic diseases: 11 with ductal cell carcinoma, 10 with mucin-producing tumor, five with pseudo-cyst, four with islet cell tumor, four with chronic pancreatitis, and three with serous cystadenoma. After endoscopic ultrasonography, Albunex (0.22 ml/kg) was injected intravenously at a rate of 1 ml/s into the right median vein, and observation was continued for 10 min. The presence or absence of enhancement of the lesion was determined in each disease. Because all the patients with ductal cell carcinoma, islet cell tumor, chronic pancreatitis, and serous cystadenoma, as well as five with mucin-producing tumor and three with pseudo-cyst, underwent angiography, vascularity was compared between angiographic images and those of contrast-enhanced ultrasonography. RESULTS: Enhancement of the lesion was observed in all patients with islet cell tumor and serous cystadenoma, in eight with mucin-producing tumor, and in three with chronic pancreatitis. However, no enhancement effect was observed in the patients with ductal cell carcinoma and those with pseudo-cyst. Comparison between the images of contrast-enhanced endoscopic ultrasonography and angiographic images showed three patients in whom angiograms were hypovascular, but enhancement effect was observed on ultrasonographic images. CONCLUSION: The combined evaluation of plain and enhanced images of endoscopic ultrasonography may be useful for the diagnosis of pancreatic diseases.     

Ultrasonographic findings of diseases in peripheral lung fields using transtracheobronchial endoscopic ultrasonography (TUS)

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. The case of a 70 years-old woman with microcystic cystadenoma is reported. CT-scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An ERCP showed cephalic symmetrical stenosis (diameter 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter 6 mm). An intraoperative biopsy of the cystic wall was performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including the stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, in a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, DPPHR is a highly effective surgical procedure with a low early and late morbidity and mortality due to limited surgical resection. This technique, introduced into surgical practice by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can be performed also in case of pancreatic benign tumors, as microcystic cystadenoma. Advantages of this technique makes DPPHR an attractive alternative to Pylorus-Preserving-Pancreatico-Duodenectomy (PPPD).     

Dynamic imaging of the pancreas using real-time endoscopic ultrasonography with secretin stimulation

BACKGROUND: Tissue factor (TF) is a transmembrane glycoprotein that, after binding to factor VII/VIIa, initiates the extrinsic coagulation pathway, resulting in thrombin generation and its sequelae. Thrombin has been shown to induce TF mRNA in endothelium, monocytes, and smooth muscle cells, further perpetuating the thrombogenic cycle. This study was designed to determine the effect of specific inhibition of thrombin by recombinant hirudin (r-hirudin) on TF distribution after balloon angioplasty in the cholesterol-fed rabbit femoral artery and porcine coronary artery models. METHODS AND RESULTS: Thirty-five femoral arteries from 32 cholesterol-fed New Zealand White rabbits and 84 coronary arteries from 55 Yorkshire-Albino swine were studied by use of a recently developed in situ method of TF localization based on digoxigenin labeling of recombinant factor VIIa (Dig-VIIa), with correlative studies of TF immunoreactivity by use of anti-rabbit (AP-1) or anti-human (sTF) antibodies. At sites of balloon angioplasty in rabbit femoral or pig coronary arteries (double or single injury), TF-antibody and Dig-VIIa staining were noted in association with endothelial cells, smooth muscle cells, and foam cells and within the fibrous tissue matrix primarily of the adventitia and neointima. Staining was significantly greater after balloon angioplasty than in vessels that had not undergone angioplasty but was similar after single and double balloon injury. Animals treated with r-hirudin (rabbits, 1 mg/kg bolus plus 2-hour infusion; pigs, 1 mg/kg bolus plus 0.7 mg x kg(-1) x d(-1) infusion for 14 days with implantable pump) had diminished TF-antibody and Dig-VIIa staining 28 days after balloon angioplasty compared with controls (bolus heparin only). This effect was more prominent on the neointima and was more striking in the porcine than the rabbit model. CONCLUSIONS: TF expression, persistent 1 month after balloon angioplasty in rabbit femoral arteries and porcine coronary arteries, is attenuated by specific thrombin inhibition with hirudin. These results suggest that thrombin inhibition, in addition to its effect on acute thrombus formation and its effect on luminal narrowing by plaque in experimental animals, may result in a prolonged reduction in thrombogenicity of the restenotic plaque through this effect on TF expression.     

Diagnosis of superficial-type early carcinoma of the gallbladder by endoscopic ultrasonography--comparison with ultrasonography

The detectability of superficial-type carcinoma of the gallbladder by ultrasonography (US) and endoscopic ultrasonography (EUS) were investigated. Eight patients with such carcinoma of the gallbladder were reviewed. They had undergone both US and EUS previous to surgery. The tumor was detected in 3 patients by US, 2 patients with IIa + IIb-type carcinoma and 1 patient with IIa-type carcinoma. Those lesions were visualized as localized thickening of the gallbladder wall or as broad-based tumor. In 2 patients, lesions were not initially detected by US, but were shown by US after the examination by EUS. The tumor was detected by EUS also in 1 case of IIb + IIa-type carcinoma besides those 3 patients mentioned above. All four of these lesions were visualized as broad-based tumor by EUS. It was difficult to detect pure IIb-type or small IIa-type carcinoma even by EUS. In patients with concomitant acute cholecystitis or gallbladder stone, it was difficult to evaluate the abnormal findings of the gallbladder wall.     

Percutaneous endoscopic gastrostomy (PEG)

In the form of a case study that illustrates the procedure of percutaneous endoscopic gastrostomy (PEG), this article examines the implications of feeding patients by identifying the professional, legal, and moral issues that are involved.     

Short communication: detection of early scirrhous carcinoma of the stomach by endoscopic ultrasonography

The endoscopic ultrasonography (US) characteristics of early scirrhous carcinoma of the stomach (ESS) were evaluated in four patients. ESS was defined as the presence of poorly differentiated carcinoma cells spreading through the submucosa and muscularis propria in association with a marked desmoplastic reaction without serosal invasion. ESS was characterized by localized irregular hypoechoic enlargement of the third (submucosal) and the fourth (muscularis propria) layers. The fifth (serosal) layer was normal. The third and fourth layers showed a threefold increase in thickness compared with the thickness of these layers in healthy subjects. Our results suggest that endoscopic US is useful for diagnosis of ESS.     

A complication of T-fasteners in percutaneous endoscopic gastrostomy (PEG) placement

Two patients with sinus tracts from retained T-fasteners following PEG tube placement are reported. Both patients had the PEG tubes subsequently removed and presented with purulent discharge and granulations near well-healed gastrostomy sites. The management of this complication and a possible method of prevention are discussed.     

Magnetic resonance cholangiopancreatography (MRCP) versus endoscopic retrograde cholangiopancreatography (ERCP): diagnostic usefulness

Human stem cell growth factor (SCGF) produced by a myeloid cell line, KPB-M15, exhibits species-specific hematopoietic activities. However, KPB-M15-conditioned medium induced colony formation of mouse bone marrow cells. KPB-M15-derived colony-stimulating activity (CSA) was purified through Butyl-Toyopearl 650c and Cu2+ chelating-Sepharose 6B chromatography. TSK-G3000SW gel filtration of the purified preparation presented 3 distinct peaks around Vo, 150 kD and 85 kD. Gel fractions extracted from SDS-PAGE had macrophage colony-stimulating factor (M-CSF)-specific amino acid sequences. PCR, Northern hybridization and ELISA demonstrated that KPB-M15 cells secreted a significant amount of M-CSF and IL-6. Anti-M-CSF but not anti-IL-6 antibody abrogated CSA in KPB-M15-CM. IL-6 hardly synergized with M-CSF to enhance colony formation. Collectively, M-CSF is a sole CSA for murine hematopoietic progenitor cells in KPB-M15-CM. This is the first report of a human myeloid cell line, KPB-M15, constitutively producing M-CSF in addition to SCGF and IL-6. It can be useful in investigating the mechanism of production of M-CSF.     

A new HF current generator with automatically controlled system (Endocut mode) for endoscopic sphincterotomy--preliminary experience

Although the precise definition of multiple system atrophy has been difficult, a recent consensus in diagnostic criteria for multiple system atrophy has been achieved. This should lead to progress in defining the underlying pathophysiology of the neuroendocrine, autonomic and motor deficits characteristic of multiple system atrophy. Hopefully, these developments will lead to effective treatment.     

Complications of percutaneous endoscopic gastrostomy (PEG)

Percutaneous endoscopic gastrostomy (PEG) is a simple technique for the endoscopic placement of a permanent feeding access. The procedure is relatively safe and the technique well established. PEG can, however, be associated with serious complications and death. Following the rare PEG-related complication of an abdominal dislocation we review technique, indications and complications of this sixteen year old method.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Percutaneous endoscopic gastrostomy (PEG) in cancer patients

Ninety-nine cancer patients underwent PEG placement attempt at Rosewell Park Cancer Institute between January 1, 1985, and December 1, 1987. Ninety-eight of these were successful and were retrospectively reviewed to determine if cancer patients constitute a high-risk group for PEG placement. Procedure-related mortality was 2% and morbidity was 19%. Morbidity of 17% was noted at less than 30 days and 2% had late complications. Six complications were considered serious with peritonitis in 3 and tube loss in 3 patients; an additional 4 patients had a failure of adequate GI tract decompression which was the indication for their PEG placement. Ascites was a major factor in morbidity with 4 of 5 patients with ascites having complications including the 2 deaths. Overall major morbidity was not increased in cancer patients without ascites including a group of patients with carcinomatosis (18 patients) and 22 patients requiring preoperative dilatation and/or tumor ablative procedures. We conclude that morbidity in cancer patients is not increased if one excludes those with ascites from the procedure.     

Assessment of endoscopic aspiration cytology and endoscopic retrograde cholangi-pancreatography (ERCP) in patients with cancer of the pancreas. Part I

The level of serotonin (5-HT) was increased in the whole rat brain as well as in the hypothalamus plus midbrain region at 0.5 hr after the fifth or sixth daily dose of delta9-tetrahydrocannabinol (THC), 20.0 mg/kg, i.p., respectively. A decreased rate of 5-HT synthesis was also observed. A slight development of tolerance was indicated by the fact that elevation of 5-HT was smaller than that seen after a single dose (1).     

A prospective randomized trial evaluating endoscopic Nd:YAG laser prostate ablation with or without potassium titanyl phosphate (KTP) laser bladder neck incision

OBJECTIVE: The purpose of this investigation was to study the correlation between diagnostic delay and the stage of the lung cancer at the time of operation. A second objective was to study differences in symptoms between the patients grouped according to stage. METHODS: A total of 172 patients consecutively admitted for surgery between 1 January 1994 and 1 June 1995 at the Department of Thoracic and Cardiovascular Surgery of Rigshospitalet National Hospital of Denmark were included in the retrospective study. Two groups of patients were compared, one group with good prognosis (patients in Stages I and II) and one group with poor prognosis (patients in Stages III and IV). The time-spans studied were: (1) interval from the patient's perception of the first symptom to operation; and (2) the time from first contact with the healthcare-system to operation. The median delay between the patient-groups was compared using the Mann-Whitney U-test. To compare the symptoms which brought the patients in contact with the healthcare-system, the chi2-test was used. RESULTS: In the time interval between appearance of the first symptom and operation, a significantly shorter median delay was found for patients with Stages I and II compared to Stages III and IV (P = 0.037). Concerning the interval from first contact with the healthcare system to operation a significantly shorter median delay was found for the group of patients in Stage I and II compared to the patients-group in Stage III and IV (P = 0.017). It was found that the cancer was an accidental finding, significantly more often in patients in Stages I or II compared to patients in Stages III or IV (P = 0.0002). CONCLUSIONS: A few months delay before final treatment of a non-small-cell lung cancer seems to have an impact on the perioperative stage of the cancer, and thereby on the patients prognosis. A screening of asymptomatic risk-group patients will result in recognition of early lung cancer.     

Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy

BACKGROUND: Adrenalectomy is not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. METHODS: Some 54 videoendoscopic adrenalectomies performed on 52 patients by five surgical teams between October 1993 and December 1996 were prospectively evaluated. RESULTS: Indications for endoscopic adrenalectomy were pheochromocytoma (n = 17), primary hyperaldosteronism (n = 15), Cushing's adenoma or disease (n = 7), nonsecreting adenoma (n = 7), single metastasis from adenocarcinoma (n = 2), adenoma with dehydroepiandrostenedione (DHEAS) hypersecretion (n = 3), and ACTH-secreting metastases from a thymoma (n = 1). Of the 54 adrenalectomies performed, 31 were of the left gland, 19 of the right and two bilateral. Laparoscopic adrenalectomy was successful in 50 patients (96%). Median tumor size was 4 cm (range 1.5-12), median operation duration was 80 min (range 59-360), and median postoperative stay was 4 days (range 2-13). One patient required blood transfusion. CONCLUSIONS: Endoscopic adrenalectomy can safely be performed-even sporadically-by surgeons well versed in adrenalectomy techniques for endocrine disorders and trained in endoscopic surgery.