Biomedical subjects
Publications and source records attributed to R Jakobs.
Potential synergistic interaction between gemcitabine (GEM) and epirubicin (EPI) in pancreatic cancer have been described previously. The maximum-tolerated dose in this trial was GEM 1000 mg m(-2) and EPI 45 mg m(-2). Median time to progression was 5.1 months and median survival time 7.4 months. This combination appears well tolerated and shows promising clinical activity.
Photodynamic therapy (PDT) is an established treatment for the ablation of dysplastic Barrett's epithelium and early esophageal carcinoma, but no data have been published on curative 5-aminolevulinic acid (5-ALA)-PDT for long-segment early esophageal cancer with infiltration of the upper sphincter. We describe successful curative treatment of an unusual early long-segment squamous cell carcinoma (uT1a,N0) of the proximal esophagus (18 - 28 cm aborally), with three sessions of 5-ALA-PDT. Endoscopic and endosonographic follow-up macroscopically showed a complete remission of the tumor, proven by biopsy showing total histological ablation. After a follow-up period of 23 months, there has been no indication of tumor recurrence. Early superficial (< 3 mm) squamous cell carcinomas of the esophagus can be ablated completely by 5-ALA-PDT. However, long-term follow-up is required in order to prove the effectiveness of endoscopic ablation therapy for early esophageal cancer.
BACKGROUND: Endoscopic screening for Barrett's esophagus is an accepted base for surveillance strategies of Barrett's esophagus; data on the natural history of erosive gastroesophageal reflux disease (ERD) are sparse. Therefore, we performed a prospective long-term follow-up examination of the course of ERD to confirm the recommendation of a once-in-lifetime endoscopy as a screening programme for Barrett's esophagus. METHODS: Patients not older than 60 years with reflux symptoms and a first time diagnosis of ERD or Barrett's esophagus at the time of inclusion were identified. Patients were followed up by a further upper GI endoscopy after at least 5 years. They were interviewed about clinical symptoms and medication use. RESULTS: One hundred and thirty-five patients were included. Follow-up data were obtained for 115 patients. Seventy-one patients (22 female, 49 male, average age: 48.3 years; range: 22-60 years) remained in the programme, 37 patients died from unrelated diseases within the follow-up period (mostly due to cardiovascluar diseases). Seven patients were excluded because of missing videoendoscopy. The average follow-up period was 78.3 (range: 60-85) months. During this time, 76 % of the patients received medical therapy. Only three patients (4.5 %) showed progression of erosive lesions, whereas two patients developed a short-segment Barrett's esophagus without intraepithealial neoplasia. These 5 patients received no medical therapy. CONCLUSIONS: Progression of ERD is an unlikely event. Once-in-lifetime endoscopy is an adequate screening tool that may serve as a basis for a Barrett's esophagus surveillance program.
BACKGROUND: The NeoGuide Endoscopy System (NES) utilizes a fully articulated, computer-controlled insertion tube that allows proximal segments of the colonoscope to follow the path taken by the tip as it is manually advanced through the colon. The system was designed to eliminate looping and scope displacement during colonoscopy. MATERIAL AND METHODS: Using in vitro testing, an inanimate flexible model of the colon incorporating four force transducers located at the key flexure points was employed to measure the axial forces on the colon wall during colonoscopy. In the second part of the study, 10 gastroenterologists performed colonoscopies, using a training latex-based simulator, with the NES and with a standard colonoscope. Colonic displacement was independently assessed by six gastroenterologists, with each evaluating endoscopist assigning a score between 0 and 5 corresponding to the maximum colonic displacement observed at any location. RESULTS: The average measured forces (in lbs) at three of the four flexure points were significantly lower ( P < 0.05) when the NES was used. The mean colonic displacement was significantly lower for procedures performed with the NES compared with the standard colonoscope (2.36 vs. 4.26, P < 0.001). Interobserver agreement regarding the degree of colonic displacement due to looping was moderate (weighted kappa = 0.45, P < 0.01). CONCLUSIONS: Colonoscopy with the NES was associated with significantly less looping and lateral force required for advancement than procedures with a standard colonoscope. The reduced amount of looping suggests that use of the NES in patients might be associated with less discomfort and thus require less sedation.
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BACKGROUND AND OBJECTIVE: The frequency of diagnostic laparoscopy performed by internists has increased for several years once again -- especially performed as minilaparoscopy. A determination of the value of diagnostic laparoscopy is possible only with knowledge of the complication rate. PATIENTS AND METHODS: We reviewed a consecutive series of 675 laparoscopies (422male, 253 female, age 15 - 85 ) from 1996 to 2003 in our clinic. Possible risk factors for complications were analyzed. RESULTS: Minor complications occurred in 35/675 (5,2 %) laparoscopies, major complications in 8/675 (1,1 %) laparoscopies. There was no significant difference between conventional and minilaparoscopies. The existence of Child C cirrhosis was the only significiant risk factor identified for the occurrence of a major complication. CONCLUSION: Both conventional and minilaparoscopy have an acceptable rate of complications. When Child C cirrhosis is present, laparoscopy should be restricted to very few patients, as the complication rate is elevated in this condition.
Barrett's esophagus is a recognized risk factor for the development of esophageal dysplasia and carcinoma. Unfortunately, gastric incomplete intestinal metaplasia arising in Short Segment Barrett's esophagus can be indistinguishable histologically on hematoxylin/eosin stains. Distinct patterns of CK 7 and CK 20 immunohistochemical expression have been demonstrated to be both highly sensitive and specific for Barrett's esophagus, but have not been found in gastric metaplasia. The aim of our study was to test whether immunostaining with CK 7/20 helps to distinguish between Barrett's epithelium and gastric incomplete metaplasia. Cases of long segment Barrett's esophagus, short segment Barrett's esophagus, and cases with a normal gastroesophageal junction, as well as specimens with gastric antral intestninal metaplasia, were examined: three patterns were defined. Barrett's pattern (superficial CK 20 staining; superficial and crypt CK 7 staining); gastric pattern (superficial and crypt staining of both markers); other patterns (different from Barrett and gastric types). Seventy-five patients were enrolled in this study, 26 with long segment Barrett's esophagus, 21 with short segment esophagus, 13 with intestinal metaplasia of the cardia, and 18 with antral intestinal metaplasia. The Barrett pattern showed a high specificity of 97%, but a sensitivity of only 30% in patients with short segment Barrett esophagus. Our results do not confirm the hypothesis that CK 7/20 immunostaining can be used for a reliable differentiation between incomplete intestinal metaplasia and Barrett's epithelium.
During the past years several endoscopic and interventional techniques have been developed for the treatment of bile duct strictures and have had a strong impact on therapeutic regimens. Benign stenoses of the bile duct are mainly caused by cholecystectomy or liver resection or by inflammatory diseases. Insertion of an endoprosthesis insertion or balloon dilation is clinically successful in 60 to 90 % of these patients and will result in adequate opening of the stricture. To date, only bile duct stenosis in chronic pancreatitis are not improved satisfactorily by endoscopy. The insertion of an endoprosthesis is a cornerstone in the treatment of malignant obstructive jaundice in patients with cancer. Several comparative studies have demonstrated the advantages of self-expanding metal stents (SEMS) over plastic prostheses in terms of patency. A selective use of SEMS is mandatory, as the costs for SEMS are high and many patients with malignant jaundice will die with their first plastic prosthesis in situ without stent occlusion. In patients with hilar cholangiocarcinoma, the combination of photodynamic therapy and endoprosthesis insertion might result in a survival advantage. The use of bioabsorbable stent materials or coating of the stent with antiproliferative drugs will improve the treatment results in the future.
BACKGROUND: The superiority of laparoscopy with guided biopsy over biopsy alone is established. It is still uncertain if this is also true for midi-/ and mini-laparoscopy. AIM: The aim of this study was to determine the diagnostic gain of laparoscopic-guided biopsy for standard laparoscopy and the use of midi-/mini-laparoscopies. Characteristics of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis. METHODS: In a consecutive series of 425 patients clinical, laparoscopic and histological findings were investigated. The length and fragmentation of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis. RESULTS: The sensitivity of laparoscopy in the diagnosis of cirrhosis was 96 %, that of histology 68 %. The sensitivity of histology alone was especially low in macronodular cirrhosis. The sensitivity of both laparoscopy and histology improved from Child A to C. When cirrhosis was apparent, liver biopsies were shorter and more frequently fragmented. However, the diagnosis of cirrhosis was independent of these parameters. CONCLUSION: Mini-laparoscopy may replace standard laparoscopy and appears to be superior compared with histology alone.
Each diagnostic procedure needs to be viewed in the context of all the other available diagnostic tools, and therefore has to be reevaluated periodically. This is also true of diagnostic laparoscopy, whether performed by gastroenterologists in patients under sedoanalgesia or by surgeons in patients under general anesthesia. Publications during the previous year have shed light on many important issues. Despite its greater expense, fluorescence laparoscopy may have advantages over white-light laparoscopy in the diagnosis of small tumor seeding. The unchanged superiority of laparoscopy over other imaging modalities for detecting small superficial liver metastases and peritoneal seeding has been clearly demonstrated. Whether cytological investigation of peritoneal washing can add relevant information to laparoscopy remains a matter of debate. Diagnostic laparoscopy before surgery has proved to be effective in many fields, including traumatology. The use of diagnostic laparoscopy in certain clinical circumstances, such as the early postoperative period after major cardiac surgery using extracorporeal circulation, appears promising. A transgastric approach to the peritoneal cavity for diagnostic and therapeutic purposes, the feasibility of which has been demonstrated in a porcine model, is an exciting innovation with as yet unforeseeable implications.
BACKGROUND: Endoscopic stenting with self-expanding metal stents (SEMS) has proved to be an efficient palliative endoscopic therapy option in treating malignant dysphagia. Different types of SEMS have been examined previously in small randomized clinical trials. METHODS: A total of 150 consecutive patients (from 1/1995-1/2004; 35 females, 115 males) with a median age of 66 years (range 43-94 years) were evaluated. Three different types of SEMS were examined: Group A: Gianturco Z Stent n = 59 pts.; Gruppe B: Ultraflex Stent n = 49 pts.; Gruppe C: Flamingo Wallstent n = 42 pts.). Dysphagia was categorized into grade 0 (no dysphagia) to grade 4 (total obstruction). RESULTS: Stent insertion was successfully evaluated in 55/59 (93 %) of the patients in group A, in 47/49 (96 %) of the patients in group B and in 40/42 (95 %) of the patients in group C (p = 0.78). After stent insertion, a reduction in the dysphagia score from 2.77 to 0.99 was observed in group A, from 2.58 to 0.72 in group B and from 2.62 to 0.81 in group C (p = 0.37). The median time to dysphagia recurrence was 78 days in group A, 90 days in group B and 70 days in group C (p = 0.45). The median overall survival time was 96 days in group A, 118 days in group B and 108 days in group C (p = 0.18). The incidence of high grade complications was 34 % in group A, 16 % in group B and 17 % in group C (p = 0.04). CONCLUSIONS: The 3 types of SEMS examined in this study showed similar efficacies in treating malignant dysphagia. However, the major complication rate of the Gianturco Z stent was significantly higher when compared to the complication rate of the Ultraflex stent and the Flamingo Wallstent.
INTRODUCTION: Crisis management as well as realistic emergency situations can be trained in the new developed simulation workshop "Gastrointestinal Endoscopy and Crisis Resource Management" by combining a full-scale simulator and the Erlanger Endoscopy Trainer. The aim of the current study was to evaluate the efficiency of the newly developed simulation workshop. METHODS: Endoscopists with more than 12 months experience can train their endoscopic skills and crisis resource management with the help of different simulators. In addition, two different scenarios (GI bleeding with significant blood loss and sedation overdoses) embedded in a realistic surrounding (emergency room) have to be managed by the participants. Vital parameters, endoscopic skills, as well as personal interactions were recorded and graded. RESULTS: 100 participants took part in the newly developed workshop (between June and December 2003). The participants showed a significantly better endoscopic performance and a significantly better crisis management after the standardized training program. CONCLUSIONS: Simulation training plays an essential role in aviation and minimizes the risk for human errors. In the current study it is clearly shown that simulation training is also useful in gastrointestinal endoscopy. The newly developed workshop may thus be of crucial importance to improve personal crisis management. Simulation also leads to an improvement of endoscopic and emergency skills. Accordingly, simulation training should be recommended or offered as an education option in gastrointestinal endoscopy.
BACKGROUND AND STUDY AIMS: Premalignant duodenal polyps are considered to be rare. Recurrence after local excision is reported to be frequent, so many authors propose radical surgical treatment of these tumors. The aim of this study was to determine the long-term outcome after endoscopic resection of duodenal adenomas. PATIENTS AND METHODS: Between January 1990 and April 2003 we retrospectively evaluated a group of patients who presented with nonampullary duodenal villous tumors but who did not have a polyposis syndrome. RESULTS: Duodenal polyps were diagnosed in 21 patients during routine endoscopy during the study period. Of these, 18 patients (6 men, 12 women; median age 67, range 50 - 81), with a total of 20 duodenal adenomas, were enrolled into the study. The median size +/- SD of the tumors was 27.5 +/- 12 mm (range 8 - 50 mm). Of these 20 tumors, 18 adenomas were tubulovillous, one was tubulous and one was villous. Nineteen polyps were treated by snare excision and one adenoma was treated with argon plasma coagulation alone. Argon plasma coagulation was applied to polyps in six patients after snare excision during this initial treatment phase. The success rate for endoscopic adenoma removal after a 3-month interval was 55 %. After a median follow-up period of 71 months (range 22 - 151 months), 12 patients remained in remission. Local recurrences of the lesion occurred in five patients (25 %) and these were re-treated. None of the patients developed carcinoma during the follow-up period. CONCLUSIONS: Endoscopic snare excision of duodenal adenomas is an effective mode of treatment but an endoscopic surveillance program is mandatory in order to detect and treat recurrence.
BACKGROUND AND STUDY AIMS: The purpose of this study was to evaluate dark-lumen magnetic resonance (MR) colonography prospectively in patients with incomplete conventional colonoscopy. PATIENTS AND METHODS: Thirty-two patients with incomplete conventional colonoscopy underwent same-day dark-lumen MR colonography on the basis of a standard protocol. The depiction of colorectal diseases was assessed in the following colon segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The reasons for incomplete colonoscopy included high-grade stenosis in 26 patients (four with occlusive cancer, 12 with fibrotic stenosis based on recurrent sigmoid diverticulitis, eight with Crohn's-induced stenosis, and two with nonsteroidal anti-inflammatory drug colonopathy), extreme patient intolerance in one patient, and technical challenges associated with an elongated colon in five patients. The results of MR colonography were compared with the findings of the initial conventional colonoscopy, the histopathological outcome, and follow-up colonoscopy when possible. RESULTS: All high-grade stenoses were confirmed on MR colonographic data sets. Of the 26 patients with high-grade stenosis, 19 underwent surgery with histopathological confirmation of the initial diagnosis. Follow-up colonoscopy was carried out in 14 patients with surgically treated high-grade stenosis. In six of these 14 patients, nine polyps identified at the initial MR colonography were confirmed and removed during a postoperative conventional colonoscopy. Two polyps (5 mm and 8 mm in diameter) identified on postoperative conventional colonoscopy had not been seen preoperatively at MR colonography. One polyp seen on MR colonography was not identified in the follow-up colonoscopy. CONCLUSION: Dark-lumen MR colonography is a feasible and useful method of evaluating the entire colon in patients with incomplete conventional colonoscopy.
PURPOSE: The occurrence of benign bile duct stenoses is mostly associated with prior biliary surgery, pancreatic diseases or sclerosing cholangitis. It remains a challenging problem for gastroenterologists and surgeons, especially in case the endoscopic approach is not possible. The exact role of percutaneous transhepatic stenting for these patients has not been clearly defined yet. MATERIAL AND METHODS: 36 patients with symptomatic benign bile duct stenoses or strictures after surgery underwent percutaneous transhepatic stenting and were studied prospectively. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the drainage in the long-run. RESULTS: The primary success rate of percutaneous transhepatic biliary drainage (PTBD) was 92% (33/36 patients). All patients presented improvement of jaundice and cholestasis. Relief of the stricture and clinical improvement was achieved in 72% (26/36) of patients after a median stenting time of 14.5 (6-34) months. 5.5% (2/36) required further stenting due to a persistent stricture. A clinical recovery without radiological stricture regression after stenting demonstrated 22% (8/36) of patients. Long-term failures were noted in 27% (10/36) of patients after a median follow-up of 48 months. CONCLUSIONS: Percutaneous transhepatic stenting of symptomatic benign biliary strictures is safe and highly effective in achieving adequate internal bile drainage. There seems to be a therapeutic benefit not only for short-term interventional treatment but also as a sufficient long-term therapeutic alternative to surgery with tolerable complication rates.
PURPOSE: To assess patient acceptance of diagnostic conventional laparoscopy and minilaparoscopy under sedoanalgesia. MATERIALS AND METHODS: 120 consecutive patients undergoing diagnostic laparoscopy were enrolled prospectively in this study. Within the first week after diagnostic laparoscopy the patients were asked to answer a total of eight questions with regard to the acceptance of the procedure. RESULTS: The inconvenience of laparoscopy was assessed with a mean of 1.6 on a scale from 0 to 10 (0 = no inconvenience, 10 = very unpleasant). The discomfort in the two days following laparoscopy were graded with a mean of 2.1 on a scale from 0 to 10 (0 = no inconvenience, 10 = very unpleasant). There was no difference between conventional laparoscopy and minilaparoscopy. Only 10% of the patients described laparoscopy more inconvenient in comparison to diagnostic gastroscopy, whereas 29% of the patients assessed diagnostic gastroscopy more inconvenient. CONCLUSIONS: Diagnostic laparoscopy under sedoanalgesia is a very well tolerated procedure. There is no difference between conventional laparoscopy and minilaparoscopy.
There are several diagnostic tools available in the diagnosis of bile duct cancer. Tumors of the middle and distal part of the extrahepatic bile duct are accessible to endosonography. Endoscopic retrograde cholangiopancreatography (ERC) and percutaneous transhepatic cholangiography (PTC) are the most invasive procedures for diagnosis of bile duct cancer. However, they offer the opportunity to obtain material for cytological or histological investigation. Moreover, bile flow can be assured by inserting endoprostheses during the procedure. Cholangioscopy and/or intraductal ultrasonography can be performed during ERC. They confer to the diagnosis of a malignant bile duct tumor and are the most accurate methods to diagnose the extent of longitudinal spread. Magnetic resonance imaging-cholangiography is an efficient diagnostic procedure which should be used first, if the bile duct tumor is located in the hilar region.
There are several different approaches available for the palliation of esophago-gastric cancer. The decision on which type of therapy is used should be made individually based on an interdisciplinary consensus.In case of inoperable esophageal carcinoma, it becomes the primary objective of the therapy to maintain oral nutrition. This can be achieved through the insertion of self expanding metal stents as a minimally invasive procedure which results in an immediate elimination of dysphagia. As alternative and/or complementary therapy, radiological techniques (external beam radiation, brachytherapy) can be applied. Other locally endoscopic techniques (laser, APC-beamer) are often used for treating local complications of esophageal and inoperable stomach carcinomas. For these carcinomas palliative chemotherapy with cisplatin has been established as a standard regimen.