PubMed Health⌕ Search

Biomedical subjects

S L Raltz

Publications and source records attributed to S L Raltz.

At least 19 recordsLinked to original sources
PubMed2001

In vitro study and in vivo application of a reusable double-channel sphincterotome.

BACKGROUND AND STUDY AIMS: Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been deemed to be a "cost-prohibitive" procedure, based upon the cumulative costs of one-time-use accessories and current reimbursement plans. One-time-use sphincterotomes comprise a significant component of that cost and, accordingly, we evaluated the disability and clinical usefulness of a recently introduced reusable double-channel sphincterotome. MATERIALS AND METHODS: We studied a reusable 6-Fr sphincterotome at baseline and following contamination with 10(6) Bacillus stearothermophilus. Reprocessing included a unique 30-minute ultrasonic cleaning step in lieu of manual cleaning, followed by steam sterilization. Parameters evaluated included sphincterotome function, electrical integrity, and our ability to sterilize the devices for three in vitro trials. In vivo studies included patient demographics and outcomes, procedural findings, and success rates, and the mean number of times the sphincterotome was used, functional grading at time of use, and reasons for sphincterotome malfunction. RESULTS: Ten out of ten sphincterotomes maintained form, function, and electrical integrity in vitro, and all cultures were negative after sterilization. In the initial in vivo study, ten sphincterotomes were used in 50 patients (mean, 5 uses) with a 94% success rate. Reasons for sphincterotome failure included leak or breakage of the accessory port in 70%, wire fracture in 10%, incorrect wire bow in 10%, and clogged injection port in 10%. Following reconfiguration of the insertion-port polymer, an additional ten sphincterotomes were used in 110 patients (mean, 11 uses). Mechanical failure occurred primarily at the wire-insertion port, resulting in progressive friction with reuse. There were neither electrical nor infectious complications associated with reuse. CONCLUSIONS: A reusable double-channel sphincterotome is available which can theoretically be reprocessed and sterilized without the manual cleaning step of the reprocessing process. Contingent upon both provider and patient, multiple reuse can be anticipated, and contingent upon purchase price and reprocessing costs, the potential for procedural cost savings is significant.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2001

Reusable biopsy forceps: a prospective evaluation of cleaning, function, adequacy of tissue specimen, and durability.

BACKGROUND: Recent studies have indicated that reusable biopsy forceps remain contaminated after reprocessing and can only be used a mean of 12 to 25 times without malfunction. Because this contradicts traditional endoscopic practice, our study investigated the ability to sterilize a type of commercially available biopsy forceps and prospectively evaluated their function in vivo until malfunction and/or breakage. METHODS: Thirty reusable biopsy forceps were studied, 15 of which were contaminated for 5 trials each with 10(6) Bacillus stearothermophilus, and 15 of which were prospectively evaluated clinically over an 18-month period (9/98-3/00). Contaminated forceps were reprocessed by using a standard protocol and placed in a sterile bag containing soy broth. The latter was passed through a 0.2 micron filter and was subsequently cultured. In vivo data included biopsy site, size, adequacy, problems obtaining a biopsy specimen, and reasons for ultimate forceps failure. RESULTS: After contamination, all biopsy forceps yielded a heavy growth of B stearothermophilus. No forceps, including 5 that were piecemeal dismantled with a wire cutter, had residual bacteria after reprocessing. In the in vivo study, 1507 biopsy sessions were undertaken in 1339 procedures. Forceps were categorized as new or like-new in 1259 of 1339 (94%) procedures, some loss of function but usable in 72 of 1339 (5.4%), and inadequate function or broken at use in 8 of 1339 (0.6%). Histologically, 1501 specimen sets were adequate (99.6%) and mean specimen size was 2.7 +/- 0.1 mm. Mechanical problems were noted in only 38 of 1507 (3%) sessions to include such things as sticky forceps, and the mean number of uses to malfunction or breakage was 91 +/- 15 (SEM) (range 19-132). CONCLUSIONS: This reusable biopsy forceps can be sterilized and used a mean of 91 times with adequate tissue sampling. Mechanical problems were minor to time of breakage. Contingent on acquisition and reprocessing costs as well as the number of procedures performed, this reusable forceps has the potential for significant cost savings.

Biopsy, Needle↗
PubMed2000

Overview of the problem: reprocessing versus disposal of endoscopic accessories.

The decision to reuse or not reuse endoscopic accessories appears simple on the surface. Further reflection, however, reveals that the decision to purchase reusable accessories or reuse disposable accessories is complex and controversial. This article clarifies key issues surrounding the use of disposable and reusable endoscopic accessories. Discussion includes the advantages and disadvantages of disposable and reusable accessories, the issues surrounding reprocessing of reusable equipment, and the issues surrounding the reuse of disposable accessories.

Disposable Equipment↗
PubMed1999

Recurrent pancreatitis in Gardner variant familial polyposis: etiology, diagnostic approach, and interventional results.

HYPOTHESIS: Pancreatitis arising from an obstructing ampullary neoplasm in patients with Gardner variant familial polyposis is an infrequently described clinical entity. We reviewed all patients with Gardner variant polyposis presenting with pancreatitis during a 12-year period in our institution, hoping to better define etiology and the appropriate diagnostic and interventional approach. METHODS: A retrospective record review (1986-1998) defined patient demographics, presenting features, initial and subsequent endoscopic retrograde cholangiopancreatography (ERCP) findings, subsequent treatments, and both immediate and long-term outcomes. Particular consideration was given to initial post-ERCP diagnosis and to endoscopic interventions undertaken at that time. We also looked at those patients who eventually required surgical intervention after long-term failure of medical and endoscopic therapy, the indications for surgery, final pathological characteristics, and follow-up results. RESULTS: Eight patients (6 women and 2 men), with a mean age of 42 years at initial presentation, were found. Each patient was known to have Gardner variant familial polyposis at the time of the initial bout of pancreatitis. All had undergone prior colectomy and 4 of 8 had undergone prior cholecystectomy. None were known to be taking medications or ingesting pancreatoxic substances. Five of 8 patients had obstructing focal or diffuse adenomatous disease involving the ampulla. Two of 8 patients had pancreatitis attributed to other causes (divisum, stones) and a single patient had no clear etiology. Three of 5 patients with ampullary adenomatous disease underwent pancreaticoduodenectomy for recurrent adenomatous encroachment and ampullary stenosis, despite repetitive snare resection and papillotomy. All of these patients had ampullary and other duodenal adenomas, and none had malignant disease. CONCLUSIONS: Patients presenting with pancreatitis in the setting of Gardner variant familial polyposis will frequently have an obstructing ampullary neoplasm, although additional etiologies should be sought. Initial endoscopic therapy affords transient relief but may not be definitive. The abnormal scarring and fibrosis (keloid formation, desmoid reaction) that characterize this disease likely play a large role in endoscopic or subsequent surgical failure. A significant number of these patients will go on to require surgical referral and intervention.

Adult↗
PubMed1999

In vitro and in vivo evaluation of a reusable double-channel sphincterotome.

BACKGROUND: To date, one reusable, double-channel sphincterotome has been approved by the Food and Drug Administration in the United States. Whether this device can be reprocessed easily and whether it is more durable than currently manufactured disposable sphincterotomes are uncertain. METHODS: Thirty double-channel, 20 mm, braided-wire sphincterotomes approved for multiple uses were studied in vitro/in vivo with regard to durability and sterilization. A cost analysis of reusable, disposable, and reprocessed disposable sphincterotomes was also carried out. RESULTS: Three of 10 sphincterotomes evaluated in vitro broke after 3, 4, and 8 uses. Electrical integrity was preserved after 10 uses in the remaining sphincterotomes. Nine sphincterotomes remained functional for at least 3 uses, five for 6 uses, and one for 10 uses. Culture results after inoculation demonstrated contamination with surviving organisms after manual cleaning and no growth after ethylene oxide sterilization. Sixty-one procedures were performed in vivo using 20 sphincterotomes (mean number of uses 3.1). No evidence of procedurally related infection occurred with reuse. Cost per use of this reusable sphincterotome was calculated to be $62.98; it became cost effective after 2.2 and 7.9 uses when compared with disposable and reprocessed, disposable sphincterotomes, respectively. CONCLUSIONS: This reusable sphincterotome proved to be safe, easily sterilized, and electrically intact after repeated use. In vivo, however, a progressive loss of function limited the mean number of uses to 3.1. In settings that preclude reuse of reprocessed disposable accessories, this reusable sphincterotome may provide a means to decrease costs associated with endoscopic retrograde cholangiopancreatography.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1999

Use of a double-channel duodenoscope for diagnostic and therapeutic ERCP.

BACKGROUND: A double-channel duodenoscope has the potential to shorten ERCP procedure time or improve procedure success rates because tasks can be done in parallel through variably situated accessory channels. METHODS: We prospectively evaluated a prototype double-channel duodenoscope in 102 patients, recording findings, procedural success, and potential advantages or problems associated with the instrument. RESULTS: Both channels were used in 79 cases (77%) and a single-channel in the remainder. Ninety-nine percent (101 of 102) of diagnostic and 95% (87 of 92) of therapeutic ERCPs were successful. Instrument advantages included decreased procedure time (23%), cannulation/procedural ease (16%), and miscellaneous (6%). Disadvantages were noted in 15% of the patients and were related to instrument diameter and diameter of the accessory channels. CONCLUSIONS: Additional study of second generation dual-channel duodenoscopes appears warranted.

Bile Duct Diseases↗
PubMed1999

Reuse of disposable sphincterotomes for diagnostic and therapeutic ERCP: a one-year prospective study.

BACKGROUND: Although previous studies have documented that single-channel sphincterotomes can be sterilized and used up to 10 times, no studies have prospectively evaluated the reuse of disposable sphincterotomes. METHODS: Five- and six-French double-channel sphincterotomes marketed as one-time-use only were manually cleaned, sterilized with ethylene oxide, and used up to 10 times. Over a 1-year period, total number of uses as a cannulation or cutting device, reason for sphincterotome dysfunction, possible infectious complications were evaluated, and cost-savings associated with reuse were evaluated. RESULTS: The mean number of times sphincterotomes could be used in our institution was 3.4; a broken or stiff cutting wire was the main reason for discard. There were two infectious complications during the study period. Both were experienced by patients with unrelieved obstruction treated with new sphincterotomes. Contingent on the method used, total savings related to sphincterotome reuse was approximately $66,000. CONCLUSIONS: Double-channel sphincterotomes marketed as one-time-use items can be reused safely when properly cleaned. Reuse was associated with significant cost savings in our institution.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1999

In vitro evaluation of integrity and sterilization of single-use argon beam plasma coagulation probes.

OBJECTIVE: Argon plasma coagulation probes (APC) are currently marketed in the United States as single-use items, and may constitute a significant per-procedure expense. It is unknown whether these probes can be sterilized after endoscopic use and if electrical integrity can be maintained after reprocessing. METHODS: Ten probes (2.3 mm diameter, 220 cm length) manufactured by ERBE Inc., (Marietta, GA) were studied using the ERBE APC 300 at 60 watts. Baseline coagulation depth was measured by coagulating a piece of beefsteak for 60 s. Probes were contaminated with 10(6) Bacillus subtilis spores, cultured, and manually cleaned. Culturing involved introducing 10 cc sterile water through the probes; water was filtered, plated onto blood agar, and incubated for 48 h. After ethylene oxide (ETO), the probes were cultured to determine sterilization. Finally, the per-procedure cost of each probe was assessed. RESULTS: Ten of 10 probes completed 10 testing sessions. One probe split at the proximal end but remained functionally intact. Electrical integrity remained intact for all 10 sessions. All probes grew too numerous to count colonies of B. subtilis after inoculation and no B. subtilis was detected after ETO sterilization. Assuming 10 uses clinically, a total per-procedure equipment cost would approximate $24.00, whereas per-procedure probe cost would equal $42.66 if only five uses were obtained in vivo. CONCLUSIONS: The combination of manual cleaning and ETO sterilization consistently sterilized APC probes. Ninety percent of the probes showed no sign of physical deterioration and 100% maintained their electrical activity after 10 uses. APC probes can potentially be safely and effectively reused up to 10 times, and a significant procedural savings is possible with reuse.

Bacillus subtilis↗
PubMed1998

Risk of contamination of sterile biopsy forceps in disinfected endoscopes.

BACKGROUND: Previous studies have shown that pathogens may persist within bacterial biofilms in endoscope accessory channels despite high-level disinfection. Breaching the gastrointestinal mucosa with biopsy forceps contaminated at time of passage has the potential to cause cross-infection between patients. METHODS: We studied contamination risk of sterilized biopsy forceps passed through endoscopes after high-level disinfection. For each trial, five video colonoscopes, duodenoscopes, and gastroscopes were used. All endoscopes had been previously processed and stored for 10 or more hours. Sterile biopsy forceps were inserted and retrieved followed by vortexing the tips in 15 mL of soy broth. Under a laminar flow hood, the broth was filtered through a 0.2 microm millipore membrane and plated. Because of minimal bacterial growth resulting from the above, soy broth (> 20 mL) was flushed through two video colonoscopes, duodenoscopes, and gastroscopes on two occasions and collected. The effluent was plated using a sample of 0.1 mL dilution. The remaining suspension was passed through a millipore filter, and the filter was cultured. All cultures were incubated more than 48 hours. RESULTS: Biopsy forceps underwent a total of 24 anaerobic and 75 aerobic cultures. Microbacterial growth occurred on 17 plates: 7 from gastroscopes, 5 from colonoscopes, and 5 from duodenoscopes. Fifteen plates grew staphylococcus for a total of 21 colonies, 1 plate grew 1 colony of propionibacter, 2 plates grew diphtheroids for a total of 4 colonies, and 1 plate grew a single colony of lactobacillus. Cultures from soy broth flushed through the various endoscopes grew on 5 plates: 3 from gastroscopes and 2 from duodenoscopes grew a total of 8 colonies of staphylococcus. CONCLUSIONS: With proper cleaning technique, a 20-minute soak in 2% glutaraldehyde is effective in disinfecting endoscopes. Although current procedures for endoscope disinfection remain imperfect, we found that in this clinical setting, infection of pathogenic gastrointestinal flora is unlikely when using sterile biopsy forceps.

Bacterial Infections↗
PubMed1998

Expandable metallic prostheses for malignant obstructions of gastric outlet and proximal small bowel.

BACKGROUND: Data are limited on use of expandable metal stents for treatment of malignant gastric outlet obstruction. Accordingly, we report our experience using these stents to palliate malignant obstructions of the gastric outlet, duodenum, and proximal jejunum. METHODS: Eight patients with malignant strictures causing gastric obstruction underwent endoscopy with fluoroscopic guidance to delineate tumor borders and length followed by expandable metallic prosthesis placement (Wallstent, Z-Stent, Ultraflex, and Endocoil). RESULTS: Symptoms were relieved in seven patients, five of whom had previous surgeries (Whipple, Billroth II, esophagojejunostomy, and gastrojejunostomy) for malignancy. One patient underwent surgical resection of a presumed malignant stricture containing a previously placed Wallstent after a 45-pound weight gain. CONCLUSIONS: Expandable metallic prostheses placed in patients with malignant obstruction of the gastric outlet, duodenum, or proximal jejunum, before or after surgery, effectively palliate obstructive symptoms and may also serve to improve nutrition.

Aged↗
PubMed1997

Complications associated with laparoscopic anti-reflux surgery: one multispecialty clinic's experience.

BACKGROUND: The records of all patients with significant complications of laparoscopic anti-reflux surgery (LARS) seen at our institution between June 1993 and September 1996 were reviewed. Specifically excluded were patients who had mild perioperative complications or postoperative dysphagia that either did not require bougienage or responded to one to two dilations. Data collected included patient demographics; type of surgery; complication and its presentation; response to medical, endoscopic, and/or surgical therapy; and outcomes. RESULTS: Nine patients (five men and four women, mean age 59 years) presented at a mean of 4 months post-LARS (seven Nissen fundoplications and two Hill posterior gastropexy repairs). Symptoms included refractory dysphagia (4), intractable gas bloat (5), various degrees of chest or abdominal pain (4), and incapacitating diarrhea (3). Findings included tight repair (4), vagal nerve injury with gastroparesis (4) and/or diarrhea (3), and esophageal or gastric perforation (3). Additional findings included proximal gastric ulcers (3), volvulus (1), and incarcerated intrathoracic hernia (1). Patients with dysphagia had moderate improvement after a mean of 3 +/- 0.6 (standard error of the mean) additional dilations, whereas four patients required five reoperations to date. Seven of the nine patients had clinical improvement, whereas two had refractory symptoms at a mean follow-up of 10 months. CONCLUSIONS: Although LARS has supplanted open surgery in many centers, refractory complications occur in a subset of patients and require reoperation in approximately one half of those referred to a multispecialty clinic.

Catheterization↗
PubMed1997

In vitro evaluation of wire integrity and ability to reprocess single-use sphincterotomes.

BACKGROUND: Sphincterotomes are currently marketed as one-time-use items and constitute considerable cumulative expense in a busy endoscopy unit. It is uncertain whether these accessories can be safely reprocessed without loss of form and function. METHODS: We studied disposable sphincterotomes (five 5F, five 6F) in vitro as to their durability, electrical integrity, and ability to be adequately cleaned both manually and with ethylene oxide after contamination with 10(5) to 10(6) Mycobacterium chelonei. RESULTS: Seven of the 10 sphincterotomes withstood the rigors of reuse; three 6F sphincterotomes developed wire fracture between four and eight uses. Electrical integrity, as measured by an electrosurgical analyzer, remained intact up to time of breakage in all sphincterotomes. Manual cleaning followed by glutaraldehyde soak resulted in residual mycobacterial colonies in five 6F sphincterotomes and a single 5F sphincterotome. No instrument had residual organisms cultured following manual cleaning and ethylene oxide sterilization. CONCLUSIONS: The authors conclude that one-time-use sphincterotomes have the potential for safe reuse.

Electric Conductivity↗
PubMed1997

Expandable stents: unusual locations.

OBJECTIVES: Expandable metallic prostheses have been used widely for malignant biliary stenoses and are being used increasingly for malignant dysphagia and esophago-airway fistulas. Potentially, such prostheses can be placed for gut neoplasms obstructing beyond the esophagus or gastric cardia. This series reports our experience with expandable metallic stents in the stomach, jejunum, and colon. METHODS: All patients with expandable gastrointestinal stents (other than biliary tree or esophagus) were reviewed. Indications for stent placement, type and location of prosthesis, patient demographics, procedural problems, and data with regard to outcome were defined. RESULTS: Over a 6-yr period, expandable prostheses (Z stent, Esophacoil, and Ultraflex) were placed in nine patients with widespread malignancy (afferent loop obstruction, three; colon obstruction, three; gastric outlet obstruction, two; and esophagojejunal interposition stricture, one). There was one colon perforation as a consequence of dilation prior to placement of the prosthesis. Subsequent problems included migration (one), occlusion by food bolus (one), and tumor overgrowths/ingrowths (three) which were treated with laser. Median survival approximated 9 months. CONCLUSIONS: Expandable metallic prostheses have the potential to palliate malignant gastrointestinal stenoses that have traditionally been treated with surgical bypass or comfort care measures only.

Colonic Neoplasms↗
PubMed1996

Disposable versus reusable biopsy forceps: a prospective evaluation of costs.

BACKGROUND: Disposable biopsy forceps have been heavily marketed as cost-effective, convenient, and safer to use than conventional forceps. METHODS: In an attempt to define whether disposable or reusable biopsy forceps were cheaper to use, we prospectively evaluated the purchase price, number of uses, repair record, and cleaning costs of all reusable biopsy forceps used in the outpatient endoscopy unit of a large multispecialty clinic. RESULTS: Over a 12-month period, 1581 biopsy sessions were undertaken. Seventeen of 119 forceps required $1890 in repairs over the study period (an average of $1.20 per biopsy session). Cleaning costs, including technician processing and steam autoclave, approximated $3.46 per use, increasing to $5.61 per use if glutaraldehyde soak was substituted for steam autoclave. CONCLUSIONS: Assuming a sixfold difference in purchase price between reusable and disposable forceps, and a per-use repair and cleaning cost of $1.20 and $3.46, respectively, reusable biopsy forceps became cost-effective after seven uses in our institution.

Biopsy↗
PubMed1995

Endoscopic approach to pancreas divisum.

Pancreas divisum has been claimed to be a harmless congenital variant or to occasionally cause acute relapsing pancreatitis (ARP), chronic pancreatitis (CP), or a chronic abdominal pain (CAP) syndrome. Both surgical and endoscopic approaches to accessory papilla decompression have been promulgated and widely disparate results reported in the literature. We retrospectively reviewed a five-year experience with dorsal pancreatic duct decompression at our institution utilizing a variety of endotherapeutic techniques. Data collected included procedural complications; patient interpretation of pre- and posttherapy pain, frequency, and intensity graded on an analog pain scale; frequency of hospitalization; and patient perception of "global" improvement to endotherapy. At a mean follow-up of 20 months, there was a statistically significant decrease in pancreatitis incidence in 15 patients with ARP (P = 0.016) and 19 patients with CP (P = 0.025). The frequency and intensity of chronic pain was also significantly improved (P < 0.001) in the latter group. In contrast, only one of five patients with CAP and normal dorsal pancreatography and secretin tests experienced global improvement, and there was no improvement utilizing an analog pain scale (P = 0.262) in the group as a whole. There was a 20% incidence of mild procedure or subsequent stent-related pancreatitis and an 11.5% accessory papilla restenosis rate. It is concluded that a subset of carefully selected patients with pancreas divisum may respond to endotherapy but that long-term follow-up will be required to define its ultimate place in the management of symptomatic patients with this anomaly.

Abdominal Pain↗
PubMed1995

Esophageal dilation can be done safely using selective fluoroscopy and single dilating sessions.

Maxims for safe esophageal dilation have included recommendations to use fluoroscopy in all instances and to limit dilation sessions to 2-mm increments. We reviewed a 34-month experience of all esophageal dilations undertaken at a large multispecialty clinic to define adherence to these recommendations and to delineate whether deviation was associated with significant complications. Four hundred thirty-two patients underwent 716 courses of esophageal dilation during this time, 92% of whom had benign disease. Eighty-nine percent of patients were dilated with polyvinyl dilators (Savary/American) and only 8% of these patients required fluoroscopic monitoring for the bougienage. Seventy-eight percent of the dilating sessions for patients without achalasia were undertaken using either a single large dilator (> or = 45 Fr) or employed incremental dilator sizes > 2 mm (6 Fr) in a single session. There was a single perforation in 662 nonachalasia dilations and this was a consequence of attempted placement of an esophageal endoprosthesis. We conclude that use of guide wire technology and newer dilating techniques do away with the need for routine fluoroscopic control. Moreover, single large dilators or dilator increments > 2 mm may be safely used, contingent on endoscopic stricture assessment.

Dilatation↗