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Background and study aims: Endoscopic ultrasonography (EUS) has been shown to be the most accurate test for locoregional staging of upper gastrointestinal tumors; however, recent studies have questioned its accuracy level in daily clinical application. The present retrospective study analyzes the accuracy of EUS in guiding interdisciplinary treatment decisions. Patients and methods: 123 primarily operated patients (63 % men, mean age 61.4 years) were included; only cases with tumor-free resection margins and without evidence of distant metastases were selected. EUS and histopathological findings were compared. Main outcome parameter was the distinction between tumors to be primarily operated (T1 /2N0) and those to be treated by neoadjuvant or perioperative chemotherapy (T3/4, or any N + ), based on an assumed algorithm for treatment stratification. Results: Overall staging accuracy of EUS was 44.7 % for T and 71.5 % for N status irrespective of tumor location. Overstaging was the main problem (44.9 % for T, 42.9 % for N staging). The overall EUS classification was correct in 79.7 % (accuracy), with a sensitivity 91.9 % and specificity 51.4 %; only 19 out of 37 cases with histopathological T1/2N0 were correctly classified by EUS. Positive and negative predictive values of EUS in diagnosing advanced tumor stage for assignment to neoadjuvant therapy were 81.4 % and 73.1 %, respectively. Conclusions: Whereas EUS has a high sensitivity in the diagnosis of locally advanced gastric cancer, endosonographic overstaging of T2 cancers appears to be a frequent problem. EUS stratification between local (T1 /2N0) and advanced (T3/4 or any N + ) tumors would thus result in incorrect assignment to neoadjuvant treatment in half of cases.

Aims: To determine the immediate and long-term results of endoscopic drainage and necrosectomy for symptomatic pancreatic fluid collections. Methods: The data of 80 patients with symptomatic pancreatic fluid collections (mean diameter: 11.7 cm, range 3–20; pseudocysts: 24/80, abscess: 20/80, infected walled-off necrosis: 36/80) referred for endoscopic management from October 1997 to March 2008 were analyzed retrospectively. Results: Endoscopic drainage techniques included endoscopic ultrasound (EUS)-guided aspiration (2/80), EUS-guided transenteric drainage (70/80) and non-EUS-guided drainage across a spontaneous transenteric fistula (8/80). Endoscopic necrosectomy was carried out in 49/80 (abscesses: 14/20; infected necrosis: 35/36). Procedural complications were bleeding (12/80), perforation (7/80), portal air embolism (1/80) and Ogilvie Syndrome (1/80). Initial technical success was achieved in 78/80 (97.5%) and clinical resolution of the collections was achieved endoscopically in 67/80 (83.8%), with surgery required in 13/80 (perforation: four; endoscopically inaccessible areas: two; inadequate drainage: seven). Within 6 months five patients required surgery due to recurrent fluid collections; over a mean follow up of 31 months, surgery was required in four more patients due to recurrent collections as a consequence of underlying pancreatic duct abnormalities that could not be treated endoscopically. The long-term success of endoscopic treatment was 58/80 (72.5%). Conclusions: Endoscopic drainage of symptomatic pancreatic fluid collections is safe and effective, with excellent immediate and long-term results. Endoscopic necrosectomy has a risk of serious complications. The underlying pancreatic duct abnormalities must be addressed to prevent recurrence of fluid collections.

Endoscopic ultrasound (EUS)-guided drainage has emerged as the leading treatment modality for symptomatic pancreatic fluid collections. Endoscopic ultrasound-guided endoscopic drainage is less invasive than surgery and avoids local complications related to percutaneous drainage. In addition, unlike non-EUS guided endoscopic drainage, EUS-guided drainage is able to drain non-bulging fluid collections and may reduce the risk of procedure-related bleeding. Excellent treatment success rates exceeding 90% have been reported for pancreatic pseudocysts and abscesses. In the context of infected pancreatic necrosis, adjunctive endoscopic necrosectomy is required for effective treatment. With such an aggressive approach, the treatment success rate may reach 81%-92%. The potential complications of concern for EUS-guided drainage are severe bleeding and perforation. To minimize risk, only fluid collections with a mature wall and within 1 cm of the gastrointestinal lumen should undergo endoscopic drainage. Any coagulopathy, if present, should be corrected. Patients with pseudocysts undergoing drainage should also receive prophylactic antibiotics in order to prevent secondary infection of a sterile collection.

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

Identification of dysplasia in inflammatory bowel disease represents a major challenge for both clinicians and pathologists. Clear diagnosis of dysplasia in inflammatory bowel disease is sometimes not possible with biopsies remaining "indefinite for dysplasia." Recent studies have identified molecular alterations in colitis-associated cancers, including increased protein levels of alpha-methylacyl coenzyme A racemase, p53, p16 and bcl-2. In order to analyze the potential diagnostic use of these parameters in biopsies from inflammatory bowel disease, a tissue microarray was manufactured from colons of 54 patients with inflammatory bowel disease composed of 622 samples with normal mucosa, 78 samples with inflammatory activity, 6 samples with low-grade dysplasia, 12 samples with high-grade dysplasia, and 66 samples with carcinoma. In addition, 69 colonoscopic biopsies from 36 patients with inflammatory bowel disease (28 low-grade dysplasia, 8 high-grade dysplasia, and 33 indefinite for dysplasia) were included in this study. Immunohistochemistry for alpha-methylacyl coenzyme A racemase, p53, p16 and bcl-2 was performed on both tissue microarray and biopsies. p53 and alpha-methylacyl coenzyme A racemase showed the most discriminating results, being positive in most cancers (77.3% and 80.3%) and dysplasias (94.4% and 94.4%) but only rarely in nonneoplastic epithelium (1.6% and 9.4%; P < .001). Through combining the best discriminators, p53 and alpha-methylacyl coenzyme A racemase, a stronger distinction between neoplastic tissues was possible. Of all neoplastic lesions, 75.8% showed a coexpression of alpha-methylacyl coenzyme A racemase and p53, whereas this was found in only 4 of 700 nonneoplastic samples (0.6%). alpha-methylacyl coenzyme A racemase/p53 coexpression was also found in 10 of 33 indefinite for dysplasia biopsies (30.3 %), suggesting a possible neoplastic transformation in these cases. Progression to dysplasia or carcinoma was observed in 3 of 10 p53/alpha-methylacyl coenzyme A racemase-positive, indefinite-for-dysplasia cases, including 1 of 7 cases without and 2 of 3 cases with p53 mutation. It is concluded that combined alpha-methylacyl coenzyme A racemase/p53 analysis may represent a helpful tool to confirm dysplasia in inflammatory bowel disease.

Background N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported. Objective Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen. Design Retrospective. Setting Two tertiary referral centers. Patients A total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen. Interventions (1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration. Main Outcome Measurements Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate. Results Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively. Conclusion Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

BACKGROUND AND STUDY AIMS: Magnetic resonance cholangiopancreatography (MRCP) is a less-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of primary sclerosing cholangitis (PSC). This study evaluated the diagnostic accuracy of MRCP in PSC compared with ERCP, and assessed the diagnostic accuracy of different T2w sequences. PATIENTS AND METHODS: 95 patients (69 PSC, 26 controls) were evaluated using both ERCP and MRCP. Exclusion criteria included secondary sclerosing cholangitis and contraindications to MRCP. The diagnosis of PSC was confirmed in 69 patients based on ERCP as the reference gold standard. MRCP was performed using a 1.5 Tesla MR unit, using breath hold, coronal and transverse half-Fourier acquisition single-shot turbo spin-echo (HASTE), coronal-oblique, fat-suppressed half-Fourier rapid acquisition with relaxation enhancement (RARE), and coronal-oblique, fat-suppressed, multisection, thin-section HASTE (TS-HASTE) sequences. The MRCP morphological criteria of PSC were evaluated and compared with ERCP. RESULTS: The sensitivity, specificity, and diagnostic accuracy were 86 %, 77 %, and 83 %, respectively, using the MRCP-RARE sequence, and increased further to 93 %, 77 %, and 88 %, respectively, by the inclusion of follow-up MRCP in 52 patients, performed at 6 - 12-month intervals. HASTE and TS-HASTE sequences showed significantly lower diagnostic accuracy but provided additional morphologic information. CONCLUSIONS: MRCP can diagnose PSC but has difficulties in early PSC and in cirrhosis, and in the differentiation of cholangiocarcinoma, Caroli’s disease, and secondary sclerosing cholangitis. A positive MRCP would negate some diagnostic ERCP studies but a negative MRCP would not obviate the need for ERCP.

Background and Aim: Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC. Patients and Methods: The baseline incidence of bile duct injury at Gifu Municipal Hospital was 3.1% (13 patients) in 424 patients with HCC treated by percutaneous RFA. In all patients, the tumor was within 5 mm of the central bile duct on CT images. The incidence of bile duct injury was 46% among the 28 selected patients whose tumor was close to the central bile duct. To prevent complications in such high-risk patients, we placed a nasobiliary tube endoscopically before RFA, and performed ICSP during RFA. Forty consecutive patients with tumors close to the central bile duct were enrolled in this study. Results: Of the 40 enrolled patients, only one had biliary injury, whereas the remaining 39 patients were able to avoid it. The incidence of biliary injury was significantly reduced in the ICSP group (1/40, 2.5%) compared to that in the control group (13/28, 46%) (P

Background and study aims Endoscopic ultrasonography (EUS) is generally established as the most sensitive diagnostic tool for the assessment of locoregional tumor stage in esophageal carcinoma. It therefore has a crucial impact on the decision whether patients should undergo surgery as primary treatment or should receive neoadjuvant therapy. This study retrospectively evaluates the accuracy of EUS in tumor and nodal staging of prospectively evaluated patients with esophageal carcinoma in relation to tumor type, tumor grading, tumor site, and the influence of dilation. Patients and methods All 214 patients included in the study underwent surgery without neoadjuvant therapy and had tumor-free resection margins with no evidence of distant metastasis. EUS investigations were done at our Department of Interdisciplinary Endoscopy. EUS results were compared with the pathological findings. Results EUS correctly identified T status in 141 patients (65.9 %). The sensitivity and specificity in relation to T status were 68.1 % and 98.2 % respectively for T1, 40.9 % and 83.4 % for T2, 84.3 % and 64.6 % for T3, and 14.3 % and 98.8 % for T4. The overall diagnostic accuracy of EUS in relation to N status was 64.5 % (n = 138); sensitivity and specificity for the diagnosis of N1 were 93.8 % and 20 %, respectively. Sixty-eight (80 %) of 85 pN0-staged tumors were overstaged as uN1. Dilation had a significant influence on the accuracy of EUS staging in advanced tumors ( P = 0.02), whereas tumor grading impacted on EUS staging in early tumors ( P = 0.01). Tumor site and tumor type did not show any influence. Conclusions Endosonographic staging of esophageal carcinoma is still unsatisfactory. An improvement in staging accuracy may be achieved by adding fine-needle aspiration biopsy (FNA) to EUS, because FNA improves N-stage accuracy, but it has no bearing on T-stage accuracy.

Background & Aims: The major drawback of plastic stents for biliary drainage is the occlusion by sludge. Sludge is accrued because the stent surface allows for the adherence of proteins, glycoproteins, or bacteria and the bile flow is insufficient to clean the surface. In this study, experience from nanotechnology to achieve a clean surface by improved soil-release characteristics is used to optimize biliary stent surface. The aim of this study was to examine sludge accumulation in relation to surface characteristics designed by nanotechnology. Methods: A variety of inorganic-organic sol-gel-coated stents were incubated in sterilized human bile and enzyme-active Escherichia coli for 35 days. Materials were Teflon (DuPont, Wilmington, DE) coated with hydrophobic Clearcoat (NTC, Tholey, Germany), Teflon with sol-gel coating synthesized of organic epoxides of 190 g/mol or 500 g/mol, and propylaminosilane without or with fluorsilanes for increased hydrophobicity. Scanning electron microscopy and semiquantitative analysis, blinded to the type of coating, were used to determine the amount of sludge accumulated on the surface. Results: Sludge deposition was reduced on the designed surfaces as compared with uncoated Teflon and Clearcoat. The performance of high molecular (500 g/mol) was superior to that of low molecular (190 g/mol) epoxide ligand. However, increasing hydrophobicity by adding fluoraminosilanes resulted in increased adherence of sludge. Less than a micrometer-thin sol-gel coating is inexpensive because very little coating material is required. This is the first published data comparing systematically modified surfaces of biliary stents using nanotechnology. Conclusions: Optimized soil release by sol-gel nanocoating of plastic stents may prevent biliary plastic stents from clogging.

Barrett's oesophagus is premalignant. Oesophagectomy is traditionally regarded as the standard treatment option in the presence of high grade intraepithelial neoplasia or intramucosal cancer. However, oesophagectomy is associated with high rates of mortality and morbidity. Endoscopic ablative therapies are limited by the lack of tissue for histological assessment, and the ablation may be incomplete. Endoscopic mucosal resection is an alternative to surgery in the management of high grade intraepithelial neoplasia and intramucosal cancer. It is less invasive than surgery and, unlike ablative treatments, provides tissue for histological assessment. This review will cover the indications, techniques and results of endoscopic mucosal resection.

Background EUS-guided pancreatic pseudocyst and abscess drainage ideally requires the insertion of both a transmural stent and nasocystic catheter to ensure continuous irrigation and effective drainage. Sequential stent and nasocystic catheter insertion may be time consuming because of the difficulty in recannulating the pseudocyst after the initial stent placement. Objective Our purpose was to describe a novel one-step simultaneous double-wire technique that facilitates effective pancreatic pseudocyst and abscess drainage. Design To solve the problem of recannulating the pseudocyst cavity after the initial transmural stent placement, we developed a prototype 3-layer puncture kit that allows the simultaneous insertion of 2 guidewires at the initial puncture in one step. This puncture kit consists of a 22-gauge needle used for FNA, a 6F inner polytetrafluoroethylene (Teflon) catheter, and an outer 8.5F Teflon catheter. Setting Tertiary referral center. Patients Eight consecutive patients were treated. Interventions With use of a therapeutic linear echoendoscope and the assembled kit with the needle protruding out distally, the pseudocyst cavity was punctured by using electrocautery. The needle and the inner catheter were then withdrawn, leaving the outer catheter within the cavity. The size of this outer catheter permitted the simultaneous insertion of two 0.035-inch guidewires. Sequential insertion of a transmural stent and nasocystic catheter was then performed without a need for recannulation of the pseudocyst or abscess cavity. Main Outcome Measurements Successful endoscopic drainage. Results All patients were successfully treated without complications. Mean procedural time was 32.5 minutes (range 25-45 minutes). Conclusions With this novel technique, establishing an irrigation system for the treatment of pancreatic pseudocysts and abscesses becomes easier, faster, and safer.

Background and study aims The diagnosis of mediastinal and intra-abdominal lymphadenopathy is sometimes difficult, especially in patients who have no other primary lesions. Lymphoma is one of the main causes of this condition. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe and accurate diagnostic procedure for lesions surrounding the gastrointestinal tract. However, diagnosing lymphoma using the EUS-FNA technique remains a diagnostic challenge, due to limitations in the amount of material sampled. The aim of the present study was to evaluate the yield of EUS-FNA biopsy (EUS-FNAB) using a large-gauge needle in patients with mediastinal and intra-abdominal lymphadenopathy of unknown origin, especially in relation to subclassification of the lymphomas. Patients and methods Consecutive patients with mediastinal and intra-abdominal lymphadenopathy of unknown origin who were referred between October 2003 and March 2005 were enrolled in the study. EUS-FNAB was carried out using a 19-gauge needle, passing through the esophageal, gastric, and duodenal walls. Pathological diagnoses were made on the basis of histological findings, including immunopathological staining. Results A total of 104 patients were included in the study. The locations of the lymph nodes were mediastinal in 50 patients, intra-abdominal in 48 patients, and both mediastinal and intra-abdominal in six patients. The diagnoses made using EUS-FNAB were lymphoma (n = 48), metastasis (n = 16), and benign/reactive (n = 40). The overall accuracy of EUS-FNAB for unknown lymphadenopathy was 98 %, and it was possible to classify the lymphomas in accordance with the World Health Organization classifications in 88 % of cases. No serious complications occurred with the procedure. Conclusions Open thoracic surgery, laparotomy, and other invasive diagnostic procedures such as mediastinoscopy and laparoscopy can now be avoided, as EUS-FNAB is potentially a safe and accurate tool for diagnosing unknown lymphadenopathy, including lymphoma.

Background Various techniques are available for EMR in the upper- and lower-GI tract. For early cancers of the esophagus, the "suck and cut" technique, which uses a transparent cap or variceal band ligator, is the most commonly practiced method. To facilitate multiple or circumferential EMR, a modified multiband variceal ligator (MBL) is introduced, which allows sequential banding and snare resection without the need to withdraw the endoscope. Objective To study the feasibility of modified MBL device in facilitating circumferential EMR of Barrett's esophagus (BE) that contains high-grade intraepithelial neoplasia (HGIN) and/or intramucosal cancer (IMC). Design To enable band delivery with a snare inserted in the therapeutic endoscope, the threading channel of the cranking device is enlarged from 2 to 3.2 mm. The 6-shooter MBL was used. Patients Ten consecutive patients (all men; median age, 62 years; range 43-82 years) with BE were treated. IMC and HGIN were found in 8 and 2 patients, respectively. Interventions EMR was performed with pure coagulating current when using a 1.5 × 2.5-cm mini hexagonal polypectomy snare. No submucosal saline solution injection was performed before resection. Results In 5 of 10 patients with circumferential BE of 2 to 9 cm in length (median, 4 cm), complete circumferential EMR was performed in 1 session by using 3 to 18 bands (median, 6). Four patients with 3- to 10-cm (median, 4 cm) long segment BE required 2 to 5 sessions (median, 3) with a total of 5 to 42 bands (median, 12). Another patient with multifocal HGIN and/or IMC in 24 of a total of 49 specimens was finally recommended for surgery because of technical difficulties caused by mural thickening after 4 sessions. No serious procedure-related complications were observed, except for 2 minor bleedings, which were controlled endoscopically. Seven patients developed strictures after circumferential EMR. All patients except 1 were successfully managed by weekly bougienage after a median of 5 sessions (range 3-11). Deep-wall tears developed in 1 patient during the fourth bougienage session, for which limited distal esophageal resection was performed with an uneventful outcome. Conclusions The novel technique of MBL-EMR described here facilitated and simplified circumferential removal of BE that contained HGIN and/or IMC. However, the method is associated with a very high stricture rate if circumferential EMR is performed in a single session. Complete removal of BE should be achieved by repeated partial EMR. Long-term follow-up is needed to observe for late recurrence and to determine the clinical impact of this method.

Most benign papillary tumors are adenomas which can potentially undergo the adenoma-carcinoma-sequence making complete removal mandatory for curative therapy. Endoscopic resection (papillectomy) of these lesions is being increasingly performed as a less traumatic alternative to surgery. Available data shows endoscopic papillectomy to be effective and safe in experienced hands with usually little morbidity and virtually no mortality. Success rates are around 80 % for lesions without intraductal involvement. Selected cases of limited distal intraductal involvement accessible after sphincterotomy may also be managed curatively by endoscopic resection. Endoscopic snare resection of entire lesions should be primarily regarded as a diagnostic procedure. It allows for an accurate histological diagnosis based on examination of the entire specimen rather than forceps biopsies and thus a reliable assessment of the need for surgical therapy. Subsequent surgery in operable patients is not precluded by previous endoscopic resection. Surgery is indicated in case of incomplete removal and if malignancy is present. The curative role of endoscopic papillectomy for early invasive carcinoma needs to be established. Histological features and individual risk for surgery are factors to be considered. Inoperable patients may still benefit from palliative endoscopic stenting. After endoscopic papillectomy has been completed, regular follow-up examinations including biopsies are warranted because of the risk of local recurrence. For benign looking papillary tumors, endoscopic papillectomy serves as a diagnostic tool and should be considered as first line procedure regardless of age. The following article details the approach to patients with benign papillary tumor and the technique of endoscopic papillectomy.

Capsule endoscopy (CE) is a new modality for obscure digestive bleeding (OBD), but little is known about its influence on management and outcome.Fifty-six patients (male/female 26/30; mean age 63 yr) with ODB, and negative upper and lower gastrointestinal (GI) endoscopy were included in this multicenter study. The diagnostic yield of CE was compared to three other tests (OT: push enteroscopy, enteroclysis, angiography), and patients were followed up for at least 6 months. Parameters were analyzed that led to major management changes such as surgical or endoscopic intervention or specific medical therapy, as well as their correlation to further bleeding.CE had a diagnostic yield higher than OT (68% vs 38%). Major management changes and an improvement in bleeding activity were observed in 21 and 44 patients, respectively. The number and type of positive findings on CE were associated with significant management changes (p0.05). The number of positive findings detected by CE as well as by OT correlated with further bleeding episodes (p0.05). However, clinical parameters (lowest hemoglobin (Hb) value, number of blood transfusions) were also significantly associated with outcome. Diagnoses of specific diseases (tumor, Crohn, NSAID ulcer) by CE led to a favorable outcome in 64% of cases, whereas negative CE cases were associated with no further bleeding in 80%.CE helps with management decisions and can replace other more complex and risky standard tests. Nevertheless, clinical parameters are equally important for predicting further bleeding and should also be used to decide on further management.

This study was designed to evaluate the outcome of endoscopic polypectomy of malignant polyps with and without subsequent surgery based on histologic criteria. Consecutive patients with invasive carcinoma in colorectal polyps endoscopically removed between 1985 and 1996 were retrospectively studied. Patients with complete resection, grading G1 or G2, and absence of vascular invasion were classified as “low risk.” The other patients were classified “high risk.” Available literature was reviewed by applying similar classification criteria. A total of 114 patients (59 males; median age, 70 (range, 20–92) years) were included. Median polyp size was 2.5 (0.4–10) cm. After polypectomy, of 54 patients with low-risk malignant polyps, 13 died of unrelated causes after a median of 76 months, 5 had no residual tumor at surgery, and 33 were alive and well during a median follow-up of 69 (range, 9–169) months. Of 60 patients with high-risk malignant polyps, 52 had surgery (residual carcinoma 27 percent). Five of eight patients not operated had an uneventful follow-up of median 57 (range, 47-129) months. Patients in the high-risk group were significantly more likely to have an adverse outcome than those in the low-risk group (P < 0.0001). Review of 20 studies including 1,220 patients with malignant polyps revealed no patient with low-risk criteria with an adverse outcome. For patients with low-risk malignant polyps, endoscopic polypectomy alone seems to be adequate. In high-risk patients, the risk of adverse outcome should be weighed against the risk of surgery.

Background The diagnostic yield and safety of trans-gastric EUS-guided FNA of the left adrenal gland are not well defined. Methods All patients with an enlarged left adrenal gland on abdominal imaging and known or suspected malignancy referred to two EUS centers over a 3-year period were included in this study. EUS-guided FNA was performed on an outpatient basis by one of 4 experienced endosonographers. Results Thirty-one consecutive patients (21 men, 10 women; mean age 64.8 years) were evaluated. Tissue adequate for interpretation was obtained in all patients; no attempt to obtain tissue was unsuccessful. The median number of needle passes was 4.5 (range 1-8). No immediate complications were encountered. EUS-guided FNA confirmed malignant left adrenal involvement in 42% (13/31) of the patients. Patients with malignant left adrenal masses were more likely to have known cancer at another site (OR 12.0: 95% CI[1.6, 87.9]). Patients with benign masses were more likely to have preservation of the normal sonographic appearance of the adrenal gland ("seagull" configuration) compared with those with malignant masses (OR 9.8: 95% CI[1.9, 51.0]). The accuracy of EUS imaging based on size (≥3 cm) alone was 81%: 95% CI[63, 93]). Of the patients with malignant adrenal masses, 85% (11/13) died or their clinical condition deteriorated during follow-up, while 15% (2/13) were being treated and were stable clinically. Conclusions EUS-guided FNA of the left adrenal gland is a minimally invasive, safe, and highly accurate method that confirms or excludes malignant adrenal involvement in patients with thoracic or GI malignancies.

Die akute Osophagusvarizenblutung ist eine wichtige Komplikation der portalen Hypertension bei Patienten mit Leberzirrhose und mit einer hohen Mortalitatsrate assoziiert. Der Erfolg der Therapie hangt ganz entscheidend von der Erstversorgung und der anschliesenden definitiven Blutstillung in der Klinik ab. Vor Ort muss der Notarzt fur den Erhalt der Vitalfunktionen sorgen; uberbruckend kann die Blutung mit Substanzen wie Terlipressin oder Octreotid reduziert werden. Die derzeitige Therapie der Wahl zur definitiven Blutstillung ist die endoskopische Intervention. Es ist daher zu fordern, dass der Patient in die nachste Klinik mit endoskopischem Notdienst verlegt wird. Der schwierige und gefahrliche Einsatz der Ballontamponade kann hierdurch vermieden werden. Endoskopisch kann der Ort der Blutung sicher identifiziert und entweder durch Gummibandligatur oder Applikation des Gewebeklebers N-Butyl-2-Cyanoacrylat gestillt werden. Wahrend der Untersuchung werden Blut und Koagel mit einem groslumigen Endoskop aus dem Magen entfernt; so wird eine wirksame Komaprophylaxe eingeleitet. Trotz der Fortschritte in der endoskopischen und medikamentosen Therapie der Varizenblutung wird die Prognose des Patienten durch die Leberfunktion determiniert. Die Lebertransplantation ist die damit einzige Therapieoption, die den Verlauf der Erkrankung positiv beeinflussen kann.

Background: There is no study of circumferential EMR in patients with Barrett's esophagus containing early stage malignant lesions. This study investigated the effectiveness and safety of circumferential EMR by using a simple snare technique without cap. Method: Patients with Barrett's esophagus containing multifocal high-grade intraepithelial neoplasia or intramucosal cancer, and patients with endoscopically nonidentifiable early stage malignant mucosal changes incidentally detected in random biopsy specimens were included in the study. A 30 × 50-mm polypectomy snare made of monofilament 0.4-mm steel wire was used without any additional device or submucosal injection. Results: Twelve patients (10 men, 2 women; median age 63.5 years, range 43-88 years) underwent circumferential EMR; 5 had multifocal lesions, and 7 had no visible lesions. Segments of Barrett's epithelium were circumferential (median length 5 cm) and completely removed. The median number of EMR sessions was 2.5. The median number of snare resections per EMR session was 5. The medial total area of mucosa in resected specimens per session was 3.8 cm 2 . Two patients developed strictures that were successfully treated by bougienage. Minor bleeding occurred during 4 of 31 EMR sessions. During a median follow-up of 9 months, no recurrence of Barrett's esophagus or malignancy was observed. Conclusions: Circumferential EMR with a simple snare technique is feasible, safe, and effective for complete removal of Barrett's epithelium with early stage malignant changes. (Gastrointest Endosc 2003;57:854-9.)

A review of the literature on the management of esophagogastric varices published in the last 12 months shows that the data are still quite conflicting. In the primary and secondary prophylaxis of variceal bleeding, beta-blockers are still the mainstay of pharmacotherapy. Measurement of the hepatic portal venous pressure gradient is considered to be a reliable parameter for successful reduction of portal pressure using medical therapy. However, intolerance of propranolol requiring discontinuation of therapy has been observed in approximately 30 % of patients. Patients' compliance with medication may represent another drawback of medical therapy. The role of endoscopic band ligation in secondary prophylaxis is now indisputable, especially in comparison with sclerotherapy. In the primary prevention of variceal bleeding, band ligation is beginning to have a competitive edge over pharmacological therapy. Acute variceal bleeding is no longer a frequent morbid emergency. Most cases of bleeding can now be managed successfully with band ligation and N-butyl-2-cyanoacrylate obliteration. N-butyl-2-cyanoacrylate has come into increasingly widespread use in the treatment of bleeding gastric fundal varices in which surgery or transjugular intrahepatic portosystemic shunting were previously regarded as the preferred therapies.

Background and study aims Endoscopic ductal decompression therapy has become an established method of treating patients with painful obstructive chronic pancreatitis. Smaller series, mostly with a medium-term follow-up period, have reported encouraging results. The present analysis presents long-term follow-up data from a large multicenter patient cohort. Patients and methods Patients with painful chronic pancreatitis and with ductal obstruction due to either strictures and/or stones treated endoscopically at eight different centers underwent follow-up after 2 - 12 years (mean 4.9 years). The patients' clinical data, the rate of technical success, and complications were recorded from the charts. Follow-up data were prospectively obtained using structured questionnaires; the main parameter for evaluating treatment success was a significant reduction in pain (no pain or only weak pain). Results Follow-up data were obtained from 1018 of 1211 patients treated (84%) with mainly strictures (47%), stones (18%), or strictures plus stones (32%). At the long-term follow-up, 60% of the patients had their endotherapy completed, 16% were still receiving some form of endoscopic treatment, and 24% had undergone surgery. The long-term success of endotherapy was 86% in the entire group, but only 65% in an intention-to-treat analysis. There were no significant differences between the patient groups with regard to either strictures, stones, or both. Pancreatic function was not positively affected by endoscopic therapy. Conclusions Endoscopic ductal decompression therapy offers relief of pain in two-thirds of the patients when it is used as the only form of treatment. One-quarter of the patients have to undergo surgery.

Background. Endoscopic ultrasound is widely used following endoscopy for evaluation of suspected submucosal lesions and may guide further management of patients. Patients and Method. A total of 181 consecutive patients with suspected submucosal lesion in the upper gastrointestinal tract were diagnosed by endoscopic ultrasound between 1990-97. We evaluated: 1) the potential of endoscopic ultrasound criteria to predict histological type of submucosal lesions in 69 patients with available histology, 2) the ability of endoscopic ultrasound alone or with clinical presentation, to predict malignancy in 86 patients with available histology or follow-up of > 12 months. Results. Sensitivity and specificity for diagnosing 44 gastrointestinal stromal tumours were 95 and 72%, respectively, while 25 miscellaneous lesions were diagnosed correctly in only 56% by endoscopic ultrasound. Diagnosis of malignancy, using any two of three endoscopic ultrasound criteria (heterogeneous echotexture, size >3 cm, irregular margins) showed a sensitivity of 80% and specificity of 77%, giving accurate endoscopic ultrasound diagnosis in 16120 malignant and 51/66 benign submucosal lesion. Heterogeneous echotexture, size >3 cm, and irregular margins showed a relative risk of 7.2, 5.4 and 4.6, respectively, for presence of malignancy. The presence of symptoms, potentially suggesting malignancy (dysphagia, gastrointestinal bleeding, pain and weight loss), had a relative risk of 4.2, however this did not increase the accuracy of diagnosing malignancy based on endoscopic ultrasound criteria alone. Conclusion. The accuracy of endoultrasound is high in diagnosing gastrointestinal stromal tumours, which show a significant potential of malignancy. Endoscopic ultrasound morphology appears to be helpful in selection of patients for surgical or conservative treatment. The accuracy of endoscopic ultrasound in differential diagnosis of non-gastrointestinal stromal tumour lesions is limited.

We present a case of a 73-year-old male patient with Korsakow's disease who was admitted with upper gastrointestinal bleeding and recurrent vomiting. He had received partial gastric resection with Billroth II reconstruction 39 years before for recurrent ulcer disease. At gastroscopy erosive gastritis with no active bleeding and a structure-resembling necrotic mucosa suspicious for intussuscepted small bowel was seen. At exploratory laparotomy jejunogastric intussusception of 50 cm of small bowel through Braun's enteroanastomosis into the gastric remnant was found. After reposition the bowel recovered well and resection was unnecessary. As prophylaxis the bowel was partially attached by sutures in terms of a partial Noble's Operation. The patient's recovery was uneventful after surgery. Jejunogastric intussusception is a rare cause of upper gastrointestinal bleeding and ileus.

A new mechanical puncture video echoendoscope (GF-UMD-240P, 270° image field parallel to the endoscope axis) has been used for puncture and drainage of a symptomatic pancreatic pseudocyst. It is equipped with a 2.8 mm working channel and an elevator, allowing single step drainage with passage of a 7F nasocystic catheter.

Well- to moderately differentiated early cancer limited to the mucosal layer and high-grade intraepithelial neoplasia, which have no or minimal risk of distant metastases, can be treated with curative intent using the technique of endoscopic resection. This paper will describe the technique of endoscopic mucosal resection using the multiband ligation technique.

Background and Study Aims: The results of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in focal pancreatic lesions are less impressive than those in the mediastinum. The aim of this prospectively randomized study was to compare two commercially available needle assemblies with regard to handling and cytopathological yield. Patients and Methods: A total of 30 patients (19 men, 11 women; mean age 61) with focal pancreatic lesions underwent EUS-FNA with each of the two needles (GIP, Wilson-Cook). The sequence was randomized for the examiner and blinded for the cytologist. Three patients had to be excluded because of the impossibility of sample assignment or patient follow-up. EUS-FNA was performed using the standard technique with linear echo endoscopes. Results: None of the characteristics evaluated by the examiner differed significantly between either of the needles. Inadequate results were obtained in 11 % using the GIP needle, but in none with the Wilson-Cook needle. GIP needle cytology revealed malignancy in 11 patients (sensitivity, specificity, and accuracy were 55%, 100%, and 65 %, respectively, including inadequate results). The aspirates obtained with the Wilson-Cook needle identified malignancy in 16 patients (sensitivity, specificity, and accuracy were 85 %, 100 %, and 89 %, respectively). Conclusions: No statistically significant differences were detected in the handling of either of the two needle assemblies. No complications were reported using the GIP needles. However, in four procedures breakages of the outer Teflon sheath of the Wilson-Cook needle occurred, and in another four cases re-insertion of the stylet was impossible. Nevertheless, cytopathologic results were significantly better with the Wilson-Cook needle.

Background and Study Aims: We prospectively studied the outcome of endoscopic sphincterotomy in symptomatic patients with elevated liver enzyme levels but no clear evidence of biliary pathology on transabdominal ultrasound and diagnostic endoscopic retrograde cholangiography (ERC). Methods: 29 consecutive patients with biliary-type pain (two or more out of eight criteria), elevated liver enzyme levels and no evidence of gallstones or significant common bile duct dilatation were evaluated. Elevated bilirubin levels (up to 7.2 mg/dl) were found in 18 patients. The majority of patients (n = 21) had a gallbladder in situ. The findings from bile duct exploration following sphincterotomy were recorded, and pain (as measured by visual analogue scale) as well as laboratory findings was assessed. Results: Wire-guided sphincterotomy was successful in all patients while uncomplicated pancreatitis occurred in one instance. In 16 patients (55 %) there was macroscopic evidence of small stones (n = 2), sludge (n = 12) or both (n = 2) following bile duct exploration. In addition, microscopy showed bile crystals in all four patients who had no macroscopic findings. All four patients with elevation of pancreatic enzymes prior to treatment, and four of those eight patients with previous cholecystectomy, showed evidence of biliary pathology. The initial median pain intensity was 8 (range 1-10); 26 patients became pain-free within 3 months following endoscopic sphincterotomy. While 26 of 28 patients (93 %) remained asymptomatic over a median follow-up period of 19 months (range 12-26), one died of an unrelated malignancy 6 months after therapy. Conclusions: Endoscopic sphincterotomy may be acceptable in patients with typical clinical presentation suggesting a papillary or biliary origin of pain without further diagnostic work-up. Contrary to expectations, diagnostic ERC was insensitive in detection of the biliary etiology of symptoms in this selected group of patients.

La ligature endoscopique de varices (LEV) s’est averee etre un traitement efficace des hemorragies par rupture de varices œsophagiennes avec un faible taux de complications. En cas d’hemorragie massive de varices œsophagiennes ou gastriques, l’injection de N-butyl(2)-cyanoacrylate est consideree comme le traitement le plus efficase aussi bien pour obtenir l’hemostase primaire que pour obtenir une reduction du taux de recidives.

Background: Improved methods of tissue diagnosis for obstruction at the hilum of the liver (porta hepatis) have contributed substantially to the preoperative diagnosis of cholangiocarcinoma. Endoscopic brushing during endoscopic retrograde cholangiopancreatography (ERCP), with sensitivity of 20% to 100%, is the preferred technique for obtaining accurate pathologic results. Extensive hepatic resection with curative intent as well as modern approaches to palliative treatment are based on definitive diagnosis. This is a study involving endosonography-guided, fine-needle aspiration (EUS-FNA) for cytodiagnosis of potentially operable hilar cholangiocarcinoma when brush cytology was negative or unavailable. Methods: Ten consecutive patients (7 men, 3 women; age 47 to 78 years, median 59 years) with bile duct strictures at the hepatic hilum, diagnosed by CT and/or ERCP, underwent EUS-FNA using linear echoendoscopes and 22-gauge needles. Results: Adequate material was obtained in nine patients. Cytology revealed cholangiocarcinoma in seven and hepatocellular carcinoma in one. One benign inflammatory lesion identified on cytology proved to be a false-negative finding by frozen section. Metastatic locoregional hilar lymph nodes were detected in two patients, and in one patient the celiac and para-aortic lymph nodes were aspirated to obtain tissue proof of distant metastasis. There were no complications. Conclusions: When standard methods of tissue diagnosis are inconclusive, EUS-guided FNA may have a potential role in the diagnosis of primary cholangiocarcinoma of the hepatic hilum. As a new, minimally invasive approach, it proved to be technically feasible without significant risks.

■■■■■■■■■■ ■■■■■■■■■■■ ■■■■ ■ ■■■■■■■■■■ ■■■■■■■■■■■ ■■■■ ■ Background and Study Aims: We studied the feas ibility of endoscopic optical coherence tomography imaging in esophageal disorders, including Barrett’s esophagus and Barr ett-related adenocarcinoma. Optical coherence tomograph y is a high-resolution cross-sectional imaging technique with a resolution of almost 10 µm. Patients and Methods: The mucosal architecture of reflux esophagitis (n = 9) and Barrett’s esophagus (n = 9) including Barrett-related esophageal cancer (n = 6) was studied by optical coherence tomography imaging. Results: In differ ent stages of reflux esophagitis edema, fibrin oid deposits, or loss of the epithelial layer w ere observed. Optical coherence tomography images of Barrett’s esophagus substantially differed from normal esophagus, reflux esophagitis, and esophageal carcinoma. A stratified structure of the mucosa was still preserved in Barrett’s esophagus. However, images of Barrett-related cancer lacked the regu lar structure of the esophagus. Conclusions: The high consistency of the first optical coherence tomograph y findings, the resolution of up to 10 µm, and the distinct pattern of normal, inflammatory, premalignant and malignant tissues make optical coherence tomography a promising method for endoscopically obtained optical biopsy.

Background and study aims Optical coherence tomography (OCT) is a new technique for high-resolution cross-sectional imaging using infrared light. It has over 10 times the resolution of the currently available ultrasonography. Although in vitro studies have suggested its potential for gastrointestinal imaging, in vivo studies have not been possible so far on account of technical limitations. Patients and methods We describe here the first clinical study of OCT during routine endoscopy obtaining high resolution images of the normal esophageal, gastric, and colonic mucosa. Portable OCT equipment and a fiberoptic-based flexible probe for endoscopic use have been developed by the authors. Results Differences in the optical properties of epithelium, lamina propria, muscularis mucosae, and submucosa enabled distinction of the mucosal architecture. Owing to the low penetration depth (1 mm) and high resolution (10 microm), OCT images may become comparable to mucosal histological findings. Image acquisition time was 1.5 seconds, and the entire procedure was completed within 5 minutes. Endoscopic OCT images of colonic adenoma and carcinoma were also studied and compared with the corresponding histology. Conclusions The newly developed portable OCT equipment and flexible fiberoptic probe makes OCT a promising method for endoscopic "optical biopsy".

Endoscopic ultrasonography-guided fine-needle aspiration cytology (EUS FNA) is established as a safe, less invasive, highly sensitive and specific method for tissue diagnosis over the last few years. It assumes particular importance in the cytodiagnosis of lymph nodes in the mediastinum, celiac axis, and peripancreatic regions because of its immense potential in therapeutic decision making. The overall sensitivity and accuracy in the diagnosis of lymph nodes ranges from 80% to 93% and 82% to 92%, respectively. Because the false-positive results are rare on cytology, the specificity of EUS FNA is almost 100%. No complications have been reported with this procedure in relation to the lymph nodal punctures. Because of the increasing potential of this procedure in gastroenterology and pulmoology, especially in lung cancer, there is a need to disseminate the knowledge of this extremely useful technique. We describe the indications and explain the actual technique of performing EUS FNA on lymph nodes and discuss the published results on the topic.

Background: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. Methods: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial which has started in September 1997. In 24 hospitals in Sweden, The Netherlands, Germany, France, Italy and Spain, 1,200 patients will be included. The primary end point of the study is cancer-free survival after 3 years. Results: Within Conclusions: Although laparoscopic surgery appears of value in colorectal malignancy, results of randomized trials have to be awaited to determine the definitive place of laparoscopy in colorectal cancer. Considering the current accrual rate, the COLOR study will be completed in 2002.

Endoscopic ultrasound is increasingly used for evaluation of pancreatic cancer. The potential of sonographic morphology to differentiate histology type and biological behaviour of pancreatic lesions is doubtful.We prospectively studied 115 patients with focal pancreatic lesions on endoscopic ultrasound. Morphology was assessed using Olympus UM3/20/200 echoendoscopes. Histologic confirmation of diagnosis was obtained in all patients.Endoscopic ultrasound correctly diagnosed 18/34 benign and 77/81 malignant lesions. Sensitivity, specificity, accuracy, PPV and NPV for diagnosing malignancy were 95%, 53%, 83%, 83% and 82%, respectively. Endosonographic diagnosis of the lesions (% correct) were: pancreatic cancer, 84 (63.3%); chronic pancreatitis, 14 (71.4%); ampullary cancer, 9 (77.8%); cystadenoma, 5 (80%); ampullary adenoma, 2 (50%); acute pancreatitis, 1 (0). In 13 patients of chronic pancreatitis, diagnosed as cancer, diagnosis was based on absence of sonographic features of chronic pancreatitis (7) or suspected involvement of adjacent structures (6). In 3 patients malignancy was missed owing to features of chronic pancreatitis. Non-suspected neuroendocrine tumours were misjudged in all 10 cases using morphologic criteria as pancreatic cancer (8), cystadenoma and chronic pancreatitis. Accuracy for prediction of metastatic lymph nodes and an advanced pancreatic cancer stage (TxN1 or T3Nx) was 61% and 75%, respectively. On retrospective analysis, a lesion2 cm, vessel ingrowth, absence of cystic spaces and absence of diffuse pancreatitis were associated with pancreatic cancer.While overall sensitivity was high, specificity of endoscopic ultrasound for diagnosis of malignancy was low, especially in presence of chronic pancreatitis. In addition, endosonography had only a limited potential to predict the histological type of lesions.

Endoscopic control of nonvariceal bleeding has never been completely satisfactory, despite the availability of several methods of injection and coagulation. The hemoclip, with its ability to mechanically occlude the bleeding vessel, provides an effective tool to meet this challenge. Indications for clipping include bleeding due to gastroduodenal ulcers, Mallory-Weiss tears, Dieulafoy's lesions, postpolypectomy and postpapillotomy bleeding. It is most satisfactory in the presence of active spurting bleeders or visible vessels. This article describes the clip applicator and the procedure while highlighting the technical aspects, including a few useful tips in the successful management of nonvariceal gastrointestinal bleeding.