BACKGROUND: Self-expandable metal stents (SEMS) palliate malignant dysphagia but may embed in tissue, produce granulation tissue, and prevent removal. OBJECTIVE: Our purpose was to evaluate in a porcine model the tissue response induced by a new esophageal SEMS completely coated internally rather than externally. DESIGN: Eight Yucatan pigs were studied. Each animal underwent placement of 2 stents: 1 study stent and 1 control stent. SEMS were placed proximally or distally by random assignment. Follow-up endoscopy was performed 1, 2, 3, and 4 weeks after implantation. Ease of stent removal was assessed at 2 weeks and 4 weeks after placement. SETTING: Animal laboratory. INTERVENTIONS: Endoscopic placement of study stents (Alveolus ES-STS, Alveolus, Inc, Charlotte, NC; 18 mm diameter, fully covered internally) and control stents (Ultraflex stent, Boston Scientific, Natick, Mass; microvasive, 18 mm midbody, subtotally covered externally). MAIN OUTCOME MEASUREMENTS: Extent of granulation tissue and stent-induced esophageal injury. RESULTS: The tissue hyperplasia response of the study stents was endoscopically graded as mild to moderate. All study stents were endoscopically removed easily and atraumatically. Control stents produced severe granulation tissue formation with complete embedding of the uncovered stent ends; endoscopic removal was possible but resulted in trauma and endoscopically visible bleeding. Histopathologic findings revealed minimal tissue response at the ends of the study stents and severe pseudopolyps in the embedded portion of the control stent. Stent migration occurred in 7 of 8 study stents and 4 of 8 control stents. LIMITATIONS: Animal model lacks stricture. CONCLUSIONS: Fully internally lined SEMS may resist tissue embedding and hyperplasia and may be removable. Human studies are needed to assess applicability to treatment of benign and malignant esophageal disease.

Animals↗

PubMed2006

Endoscopic management of radiation-induced complete upper esophageal obstruction with an antegrade-retrograde rendezvous technique.

BACKGROUND: Esophageal strictures occur in 3% to 4% of patients with head and neck cancer who undergo radiation therapy. Some patients develop complete obstruction of the upper esophagus. Antegrade dilatation is often unsuccessful and many of these patients require surgery. OBJECTIVE: To describe the outcomes and complications of an endoscopic antegrade-retrograde rendezvous procedure to restore esophageal patency. DESIGN: Retrospective review of 8 cases treated with an endoscopic rendezvous procedure between August 2001 and April 2005. Medical records of consenting patients were abstracted for clinical history, procedural success, complications, and follow-up. SETTING: A large tertiary referral center. PATIENTS: Eight patients with head and neck or upper esophageal cancer and complete upper esophageal obstruction from radiation stricturing who underwent an attempted rendezvous procedure. MAIN OUTCOME MEASUREMENTS: Clinical procedural success, reported adverse events. RESULTS: Seven patients were men, and median age was 65 years. The median interval between radiation and the rendezvous procedure was 11 months. In 7 of 8 cases esophageal patency was restored and no major complications occurred. Two esophageal microperforations resolved without intervention. Most patients responded well to subsequent serial dilations and many discontinued gastrostomy tube use. LIMITATIONS: Retrospective, selection bias. CONCLUSIONS: An antegrade-retrograde rendezvous technique with subsequent dilation appears to be safe and effective for endoscopic management of complete upper esophageal obstruction induced by radiotherapy and can obviate the need for esophageal resection.

Aged↗

PubMed2006

Double-balloon enteroscopy to facilitate retrograde PEG placement as access for therapeutic ERCP in patients with long-limb gastric bypass.

Explore the source record for details and available documents.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2006

The role of endoscopy in ampullary and duodenal adenomas.

Explore the source record for details and available documents.

Adenoma↗

PubMed2006

Palliation of malignant obstructive jaundice.

Palliation of obstructive jaundice can be achieved in most patients using various approaches. The method chosen should be individualized to the patient and based upon performance status, patient preferences, and available expertise. The best approach ideally should be determined by a multi-discipline approach with endoscopists, interventional radiologists, oncologists, and surgeons.

Endoscopy, Gastrointestinal↗

PubMed2006

Endoscopic treatment of an impacted pancreatic duct stone using a balloon catheter for electrohydraulic lithotripsy without pancreatoscopy.

Obstructing main pancreatic duct (PD) stones represent a challenge for endoscopic removal because they are frequently impacted within the duct, are hard, and process sharp edges. Multiple series have been published demonstrating that removal of obstructing stones in the main PD can improve symptoms in the majority of patients with chronic pancreatitis. Extracorporeal shock wave lithotripsy (ESWL) has become an accepted technique to facilitate stone clearance when standard endoscopic methods fail. More recently, direct contact lithotripsy with the use of smaller caliber endoscopes has been described as an alternative to ESWL. Limited experience suggests that intraductal electrohydraulic lithotripsy under direct endoscopic visualization with a small caliber pancreatoscope results in successful fragmentation of PD stones that have been refractory to standard endoscopic methods or ESWL. Herein, we report the use of intraductal electrohydraulic lithotripsy to fragment a large obstructing PD stone guided only by fluoroscopy without the utilization of a pancreatoscope.

Adult↗

PubMed2006

Endoscopic palliation of cholangiocarcinoma.

PURPOSE OF REVIEW: The current endoscopic palliative modalities for unresectable cholangiocarcinoma are reviewed, focusing on the emergent methods of endoscopic palliation. RECENT FINDINGS: Cholangiocarcinoma is a rare malignant tumor arising from biliary epithelium. Endoscopic retrograde cholangiopancreaticography can provide histological diagnosis through brush cytology of the bile duct, and newer cytologic techniques such as digital image analysis and fluorescent in-situ hybridization may improve the cytologic accuracy for diagnosing cholangiocarcinoma. Endoscopic ultrasonography can play an adjunctive role in the diagnosis and staging by facilitating tissue acquisition through fine needle aspiration of the tumor and surrounding lymph nodes. Most patients present with unresectable disease and features of biliary obstruction. This has led to an emphasis on the role of palliative care. Biliary stent placement is an effective method of palliating obstructive jaundice. Newer modalities such as photodynamic therapy, intraluminal brachytherapy, and high-intensity ultrasound therapy may result in improved survival and play a future role as an adjunctive therapy to surgical resection. SUMMARY: Several endoscopic palliative modalities have recently emerged. Among these, photodynamic therapy in addition to biliary stent placement appears to be a promising step towards the management of locally unresectable cholangiocarcinoma. Randomized, controlled trials are required, however, to further evaluate these therapies.

Bile Duct Neoplasms↗

PubMed2006

Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding.

INTRODUCTION: Endoscopic obliteration of esophageal varices by endoscopic variceal ligation (EVL) is an effective form of secondary prophylaxis. However, there is no consensus regarding the technical aspects of EVL for secondary prophylaxis. The present study compares the technical aspects of EVL (frequency of sessions, number of sessions and number of bands used) in patients who rebled following secondary prophylaxis of esophageal varices by EVL compared to those who did not rebleed. METHODS: All patients who underwent EVL for treatment of acute variceal bleeding followed by EVL for secondary prophylaxis and who subsequently developed recurrent variceal bleeding at Mayo Clinic, Rochester between January 1995 and May 2003 were identified. A control group of patients undergoing EVL for secondary prophylaxis who did not rebleed was identified. RESULTS: During the study period, 216 patients with acute esophageal variceal hemorrhage underwent emergent EVL treatment with follow-up EVL for secondary prophylaxis, of whom 20 (9.3%) subsequently rebled. Both rebleeding and non-rebleeding patient groups were well-matched with respect to liver function (Child-Pugh class), number and size of variceal trunks, endoscopic stigmata of hemorrhage and beta-blocker usage. The median interval between EVL sessions in the rebleeding group (2 weeks, interquartile range 0-2 weeks) was significantly shorter compared to the non-rebleeding group (5 weeks, interquartile range 3-7 weeks; P = 0.004). Adjusting for age, gender, and Child-Pugh class, interbanding interval >/= 3 weeks was associated with increased likelihood of not rebleeding, hazard ratio 3.84 (95% confidence interval: 1.69-11.79; P = 0.0007). CONCLUSIONS: These findings demonstrate the importance of technical aspects of EVL on patient outcome, suggesting the benefit of longer interbanding intervals. Future prospective studies are required to define the optimal intersession interval. Standardizing procedural aspects of EVL will aid in objectively evaluating the benefit of this procedure when compared to other modalities such as medical treatment.

Acute Disease↗