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Biomedical subjects

D E Fleischer

Publications and source records attributed to D E Fleischer.

At least 19 recordsLinked to original sources
PubMed1997

A new system for defining endoscopic complications emphasizing the measure of importance.

BACKGROUND: Currently, there are no satisfactory systems for defining, classifying, and/or scoring endoscopic complications, although it would be important for quality assurance, comparative studies, and outcomes research. Recently the term "negative outcomes" was proposed rather than "complications," and an approach that incorporates "measures of importance" was added to compare negative outcomes. METHODS: A system was developed that defines, classifies, and grades negative outcomes with a scoring system based on measures of importance. Information was recorded on a Morbidity and Mortality (M & M) form, which was used at a monthly quality assurance (M & M) conference. Several measures of importance related to the immediate negative outcome (O) were quantified (effect of the complication on completion of the endoscopy, change in level of care, change in number of hospital days, necessity for new invasive procedures). The disability (D), defined as a residual or chronic negative outcome caused by the complication, was characterized and scored. Death (D) was also characterized, the value varying with circumstances. As a quantitative measure, an overall ODD score was used. RESULTS: One hundred twenty-three negative outcomes were retrospectively classified using the new M & M form and the ODD score was applied for 117 complications. Complications were ranked according to the ODD score. CONCLUSION: A system for defining, classifying, and grading negative outcomes of endoscopic procedures is proposed with a quantitative scoring system that emphasizes measures of importance. The ODD score looks at the immediate negative outcome and also the separate long-term issues of disability and death.

Documentation↗
PubMed1997

Silicone-covered Wallstent prototypes for palliation of malignant esophageal obstruction and digestive-respiratory fistulas.

BACKGROUND: Endoscopic palliation of malignant esophageal obstruction with uncovered self-expanding metal stents has been shown to have fewer complications than with conventional plastic stents. The addition of a membrane might prevent tumor ingrowth and allow treatment of digestive-respiratory fistulas. We report the clinical experience with a prototype silicone membrane-covered self-expanding metal stent. METHODS: Twenty-three silicone membrane-covered Wallstent prototypes were used in 21 patients with dysphagia due to inoperable malignant tumors involving the esophagus and cardia. RESULTS: Stent implantation was technically successful in all patients. There were no procedure-related perforations or deaths. The prototype stent was successful in sealing seven of the eight (87.5%) digestive-respiratory fistulas. As a group, the mean dysphagia grade improved significantly after stent placement (4.8 +/- 0.9 vs 3.4 +/- 1.6, p < 0.0005). However, 9 of 21 (42.9%) patients experienced no improvement in their dysphagia. Complications occurred in 13 of 21 (61.9%) patients. Tumor ingrowth was not observed in any patient. CONCLUSIONS: The prototype covered self-expanding metal stent was effective in sealing digestive-respiratory fistulas and provided palliation of dysphagia in slightly more than one half of the patients studied. A great deal has been learned from the preliminary experience, which has led to design modifications. The utility of the commercially available device should be evaluated in further prospective clinical trials.

Adult↗
PubMed1997

Colonic chromoscopy. A new perspective on polyps and flat adenomas.

A recent innovation in colonoscopy has been the use of chromoscopy. This technique allows better visualization of mucosal lesions by applying dyes to the mucosal surface. This article focuses on the principles and techniques of chromoscopy and magnification in the colon. The authors also describe the use of chromoscopy for differentiating polyps and detecting flat adenomas. The clinical significance of flat adenomas is reviewed.

Adenoma↗
PubMed1996

Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula.

BACKGROUND: Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications. METHODS: All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival. RESULTS: Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent). CONCLUSIONS: The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.

Adult↗
PubMed1996

Flumazenil reversal of psychomotor impairment due to midazolam or diazepam for conscious sedation for upper endoscopy.

BACKGROUND: Flumazenil is a competitive benzodiazepine antagonist that acts to reverse their sedative and hypnotic effects. It is indicated in the management of benzodiazepine overdose, but its role in the routine reversal of endoscopic conscious sedation has not been defined. METHODS: Patients undergoing diagnostic upper endoscopy who received sedation with either diazepam or midazolam alone were given flumazenil 0.2 mg incrementally immediately following the procedure until awake. They were then asked to repeat three psychomotor tests measuring cognitive and motor skills, with their baseline scores compared with postprocedure scores over a 3-hour period. RESULTS: Full psychomotor function was restored to baseline values within 30 minutes after flumazenil in 79% of patients, with no differences in the reversal of psychomotor skill impairment observed between diazepam and midazolam sedation. There was no evidence of rebound sedation seen for up to 3 hours. No significant anterograde amnesia was evident in 78% of individuals. CONCLUSIONS: These results demonstrate that flumazenil's effects on reversing psychomotor impairment are similar when midazolam or diazepam are used for conscious sedation. However, the potential usefulness of routine flumazenil reversal of conscious sedation will require further evaluation of specific psychomotor performance skills (such as driving a car) before we lift the admonition against leaving the endoscopic suite unattended, driving a vehicle, or operating complicated machinery for several hours.

Adult↗
PubMed1996

High-resolution chromoendoscopy for the diagnosis of diminutive colon polyps: implications for colon cancer screening.

BACKGROUND & AIMS: A visual, nonbiopsy technique that could reliably determine the histology of diminutive colorectal polyps could greatly reduce the cost of colon cancer screening. This study was designed to report our experience using a high-resolution colonoscope combined with indigo carmine dye to diagnosis diminutive colorectal polyps. METHODS: Colonoscopy using a Fujinon EC-400 HM/HL was performed in 36 patients with polyps <10mm in diameter. Polyps from the first 12 patients (phase 1) were sprayed with 10 mL of 0.2% indigo carmine dye, and a biopsy was performed or a specimen removed and submitted for histological analysis. The morphological data were used to predict polyp histology in the subsequent 24 patients (phase 2). RESULTS: Hyperplastic polyps had a characteristic surface "pit pattern" of orderly arranged "dots" that resembled the surrounding, nonpolypoid mucosa. Adenomatous polyps had surface "grooves" or "sulci." Sensitivity and specificity of our techniques in distinguishing adenomatous from nonadenomatous colorectal polyps were 93% and 95% respectively. CONCLUSIONS: High-resolution chromoendoscopy provides morphological detail of diminutive colorectal polyps that correlates well with polyp histology. If incorporated into colon cancer screening, these techniques may limit the need for biopsy and/or subsequent colonoscopy and ultimately decrease costs.

Adult↗
PubMed1996

Gastric polyps: relationship of size and histology to cancer risk.

OBJECTIVES: Management of gastric polyps based on polyp size (< or > 2 cm), and histology obtained from forceps biopsy sampling is controversial. To illuminate this subject, the 4-yr experience with endoscopic management of gastric epithelial polyps at a university hospital and a Veterans Administration medical center was reviewed with histopathologic correlation. METHODS: A computer data-base was used to recall the endoscopic diagnosis of "gastric polyp." Endoscopy reports, video, and still photography were reviewed for data on polyp appearance, size, location, and management. These data had been entered prospectively as required by the Computer-Based Management System. Histopathology was reviewed by a second, blinded, pathologist. Gastric polyps of epithelial origin, at least 0.5 cm in diameter, and not associated with polyposis syndromes, were included. RESULTS: Thirty-five gastric polyps in 23 patients met inclusion criteria. Snare polypectomy was ultimately performed on 26, and complete resection with forceps biopsy alone on 9. On histopathology 31 polyps were hyperplastic and 4 were adenomas. Six hyperplastic polyps contained focal dysplasia. Among these, carcinoma in situ was identified in three, all <2.0 cm. Furthermore, forceps biopsy in two of these did not reveal the dysplastic components. One adenomatous polyp also contained carcinoma, also <2.0 cm. CONCLUSIONS: These data emphasize that management based on polyp size or histology obtained from forceps biopsy sampling may be faulty. We recommend that gastric polyps >0.5 cm be removed in toto.

Adenocarcinoma↗
PubMed1995

Endoscopic ultrasound for staging esophageal cancer, with or without dilation, is clinically important and safe.

BACKGROUND: To fully evaluate patients with esophageal cancer by endoscopic ultrasonography (EUS), the transducer must pass through the entire tumor to the cardia to scan the celiac axis. Dilation may be necessary. Published information suggests that dilation with EUS carries a sizeable risk. METHODS: In order to assess the complication rate associated with dilation prior to EUS in patients with esophageal cancer and the clinical significance of dilation for complete EUS staging, we reviewed the records of all patients who had undergone EUS for esophageal cancer. RESULTS: Sixty-three patients underwent EUS staging of esophageal cancer. Thirty-nine (62%) had lesions through which the EUS scope was passable (Group I). Ten (16%) patients (Group II) had lesions through which an EUS scope (diameter 13 mm) was unable to pass even after dilation. Fourteen patients (22%) had lesions that were dilated to allow passage of the EUS scope (Group III). All patients in Groups II and III had confirmation of EUS staging by CT and/or surgery. In Group II, five patients had tumors defined as T4 (50%) and five as T3 (50%). In Group III, nine (64%) had T4 tumors, four (29%) had T3, and one (7.7%) had T2. No complications were encountered in any group. CONCLUSION: EUS, either alone or after dilation, is a safe procedure and the complete EUS examination with celiac node visualization adds prognostically significant information.

Adult↗
PubMed1995

Advanced training in endoscopy.

Endoscopy has revolutionized all aspects of digestive diseases and has increased the popularity of gastroenterology and minimally invasive surgery. These changes as well as improved technology and innovative applications of standard procedures call for more sophisticated endoscopic training. This article discusses what that training and curriculum should be and how it can be conducted.

Curriculum↗
PubMed1995

The critical care management of nonvariceal upper gastrointestinal bleeding.

Upper gastrointestinal hemorrhage, although accounting for more than 300,000 annual hospital admissions in the United States, continued to have about a 10% mortality rate over the past 50 years. Whether this is secondary to the increasing age of patients admitted with UGI hemorrhage, and their comorbid diseases, is unknown. The major approach to these patients includes volume and cardiovascular resuscitation, as well as surgical and gastroenterology consultation. Both clinical signs and endoscopic features in patients aid in predicting those at high risk of either rebleeding or dying, allowing for more aggressive steps, including endoscopic therapy of the bleeding site and surgery. Improved intensive care measures and endoscopic therapies for these patients may account for the signs of a recent decline in this mortality rate during the past 10 years.

Critical Care↗