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PubMed2005

Excisional surgery versus ablative surgery for ovarian endometriomata.

BACKGROUND: Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured for as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. OBJECTIVES: The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall, with regard to relief of pain, recurrence of the endometrioma, recurrence of symptoms and the subsequent spontaneous pregnancy rate. SEARCH STRATEGY: The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 15 Nov 2004), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966-Nov 2004), EMBASE (1980- Nov 2004) and reference lists of articles, the handsearching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world. SELECTION CRITERIA: Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata. DATA COLLECTION AND ANALYSIS: Reviewers assessed eligibility and trial quality. MAIN RESULTS: No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3cm in size were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93), reduced requirement for further surgery (OR 0.21 CI 0.05-0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15 CI 0.06-0.38), dyspareunia OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56). It was also associated with a subsequent increased rate of spontaneous pregnancy women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29). AUTHORS' CONCLUSIONS: There is some evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation, with regard to the recurrence of the endometrioma, recurrence of symptoms and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. However we found no data as to the effect of either approach in women who subsequently undergo assisted reproductive techniques.

Drainage↗
PubMed1999

An ambulant porcine model of acid reflux used to evaluate endoscopic gastroplasty.

BACKGROUND: There is a lack of suitable models for testing of therapeutic procedures for gastro-oesophageal reflux disease. Endoscopic sewing methods might allow the development of a new less invasive surgical approach to treatment of gastrointestinal disorders. AIMS: To develop an animal model of gastro-oesophageal reflux for testing the efficacy of a new antireflux procedure, endoscopic gastroplasty, performed at flexible endoscopy without laparotomy or laparoscopy. METHODS: At endoscopy a pH sensitive radiotelemetry capsule was sewn to the oesophageal wall, 5 cm above the lower oesophageal sphincter, in six large white pigs. Ambulant pH recordings (48-96 hours; total 447 hours) were obtained. The median distal oesophageal pH was 6.8 (range 6.4-7.3); pH was less than 4 for 9.3% of the time. After one week, endoscopic gastroplasty was performed by placing sutures below the gastro-oesophageal junction, forming a neo-oesophagus of 1-2 cm in length. Postoperative manometry and pH recordings (24-96 hours; total 344 hours) were carried out. RESULTS: Following gastroplasty, the median sphincter pressure increased significantly from 3 to 6 mm Hg and in length from 3 to 3.75 cm. The median time pH was less than 4 decreased significantly from 9.3% to 0.2%. CONCLUSIONS: These are the first long term measurements of oesophageal pH in ambulant pigs. The finding of spontaneous reflux suggested a model for studying treatments of reflux. Endoscopic gastroplasty increased sphincter pressure and length and decreased acid reflux.

Animals↗
PubMed2005

Small-bowel diaphragm disease: seven surgical cases.

HYPOTHESIS: Small-bowel diaphragm disease is an important source of gastrointestinal tract bleeding and subacute intestinal obstruction that may require surgical intervention. DESIGN: Case series. SETTING: Tertiary-care academic medical center. PATIENTS: Seven consecutive patients with histologically confirmed enteropathy induced by use of nonsteroidal anti-inflammatory drugs received treatment at our institution from February 2001 to February 2004. INTERVENTIONS: Laparotomy with small-bowel resection. MAIN OUTCOME MEASURES: Initial symptoms and signs, findings at diagnostic workup, type of medication and duration of use, operation performed, and intraoperative findings were evaluated. RESULTS: Patients were identified who had symptoms of subacute intestinal obstruction or signs of gastrointestinal tract bleeding and were determined to have used nonsteroidal anti-inflammatory drugs for differing periods. All 7 patients underwent extensive nondiagnostic radiologic and endoscopic examinations. The diagnosis of diaphragm disease was ultimately made at either video capsule endoscopy or laparotomy. Randomly distributed diaphragms throughout the jejunum and ileum necessitated resection in all cases. No patient has had a documented recurrence, although follow-up is short (range, 0-20 months). CONCLUSIONS: Nonsteroidal anti-inflammatory drugs are clearly linked to pathologic findings of diaphragm disease in both the upper and lower gastrointestinal tracts. Although rarely reported in the surgical literature, small-bowel diaphragm disease may be more common than thought and can manifest as gastrointestinal tract bleeding or obstruction. Diagnosis is difficult and may require laparotomy and small-bowel resection.

Aged↗
PubMed1984

A frequency-duration index (FDI) for the evaluation of ambulatory recordings of gastro-oesophageal reflux.

Oesophageal pH monitoring has been undertaken in 20 symptomatic patients and 20 normal subjects for periods of 24 hours at work and in the home using a pH sensitive radiotelemetry capsule and a portable receiving system. There was no correlation between symptoms and endoscopic findings in symptomatic patients. The number and duration of reflux episodes was greater in symptomatic patients than normal subjects during 24 hour ambulatory study (P less than 0.002). A frequency-duration index for the evaluation of recordings is described which was significantly greater in symptomatic patients than in normal subjects during both day (P less than 0.002) and night (P less than 0.008) periods of recording. Discrimination between the two groups was more clearly seen using the frequency-duration index compared to either the frequency of reflux episodes or the cumulative duration of acid reflux.

Adult↗
PubMed2004

First case of isolated small bowel transplantation at the university of cologne: rejection-free course under quadruple immunosuppression and endoluminal monitoring with video-capsule.

Intestinal transplantation is the only curative form of treatment for fulminant short bowel syndrome. Results have been hampered by frequent rejection episodes as well as technical and infectious complications. We report the first case of complete small bowel transplantation performed at our institution. A 37-year-old male patient suffered from massive gut infarction due to a superior mesenteric artery embolus from a thrombus in the descending aorta resulting from hereditary protein S and C deficiency. The primary surgery resulted in a duodenocolostomy requiring total parenteral nutrition. The course was further complicated by multiple central line infections and pre-renal kidney failure induced by dehydration. After 17 months, we performed a cadaveric small bowel transplant using systemic venous drainage. The ileum was anastomosed end-to-end to the recipient ascending colon. The proximal jejunum was used to create a jejunostomy, with an end-to-side duodenojejunostomy. Immunosuppression consisted of a single-administration of antithymocyte globulin (ATG), tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone given enterally from day 1. Biopsies of the upper jejunum showed no signs of rejection. The graft was monitored via capsule video endoscopy after 9 weeks and appeared normal. The patient was discharged on day 35, completely on an enteral diet and gaining weight with a good quality of life. Oral valganciclovir was given for the cytomegalovirus prophylaxis infection (donor-positive, recipient-negative constellation), with no clinical or serologic signs of infection. The early course after small bowel transplantation using a quadruple regimen was clinically successful. The use of video-capsules allows for noninvasive visual monitoring of bowel segments that cannot be reached endoscopically.

Adult↗
PubMed2000

Soft tissue response in the rabbit larynx following implantation of LactoSorb (PLA/PGA copolymer) prosthesis for medialization laryngoplasty.

This project is designed to provide initial data regarding the use of polylactic acid/polyglycolic acid (PLA/PGA) copolymer ("LactoSorb" [Walter Lorenz Corp]), an alloplastic, resorbable material, as a prosthesis in an animal model of vocal fold medialization. Fifteen New Zealand white rabbits were utilized for left medialization laryngoplasty with LactoSorb implants after undergoing left recurrent laryngeal nerve section. At 1, 3, 6, and 9 months, the rabbits were sacrificed and their larynges were evaluated both grossly and histologically for tissue response to, and resorption characteristics of the implant, tissue cellularity, maintenance of vocal fold medialization, and airway patency. Additionally, 4 rabbits were used as controls, implanted with silicone rubber medialization implants, and sacrificed at 9 months for comparison. One rabbit underwent no surgery and was likewise used as a control. Grossly, no airway obstruction was noted, and no extrusions of the implants occurred. The LactoSorb implant maintained medialization in each group of sacrificed rabbits. Histologic findings revealed a very discrete, fibrous capsule around the implant in the 1- and 3-month rabbits, and the LactoSorb was still grossly visible. At 6 months, the thin fibrous capsule partially remained; at 9 months, the capsule was no longer evident, and the implant was no longer grossly visible. Endoscopic findings at the time of sacrifice in those rabbits implanted with silicone rubber included grossly patent airways with maintenance of medialization. In the rabbits implanted with silicone rubber, the histologic findings are similar to those described elsewhere. LactoSorb, because of its intermittent resorption rate, could offer an ideal alternative to currently utilized temporary, or resorbable, materials, and as such will hopefully prove an invaluable tool in the laryngologist's treatment planning and surgical repair of the patient with a paralyzed vocal fold.

Animals↗
PubMed2003

Microendoscopic discectomy for recurrent disc herniations.

OBJECT: The use of microendoscopic discectomy (MED) for the treatment of primary lumbar disc herniations has become fairly well accepted; its role in recurrent disc herniations is less clear. The reluctance of many surgeons to use this technique stems, in part, from the concern of undertaking an endoscopic discectomy in a patient in whom the anatomy is distorted from a previous operation. It appears counterintuitive to operate through a limited working area when the traditional open approach for recurrence favors wider exposure of the surgical field. Given that operating on previously exposed tissue can be associated with even greater morbidity than on virginal tissue, the authors describe their experience with performing MED for recurrent disc herniation. METHODS: Unilateral MED was performed in patients with classic symptoms of lumbar radiculopathy, a previous operation at that level, and findings of recurrent disc herniation on magnetic resonance imaging. The approach was similar to a standard MED. Aided by fluoroscopic guidance, a working cannula was docked on the laminofacet junction at the level of the nerve root, with care taken to ensure a slightly more lateral initial trajectory. A good decompression of the nerve root could then be achieved through the use of the endoscope with preservation of the paraspinous musculature and much of the remaining facet capsule. Ten consecutive patients undergoing the procedure were analyzed prospectively and compared with the previous 25 who underwent routine single-level MED. Use of the MED technique provided excellent visualization and decompression of the nerve root; no conversions to open procedures were necessary in either group. The average operative time in the experimental group was 98.5 minutes, with a mean blood loss of 33 ml and an approximate hospital stay of 7.3 hours. In this respect, there was no statistical difference between the two groups (analysis of variance, p = 0.39, 0.68, and 0.51, respectively). There was one cerebrospinal fluid leak in each group. CONCLUSIONS: Microendoscopic discectomy for recurrent disc herniation can be safely performed without an increase in surgery related morbidity.

Adult↗
PubMed1979

An endoscopic staining method for detection and operation of early gastric cancer.

The long term survival rate of gastric cancer has been much improved, and the 5-year survival rate in our institute was 42% with a significant difference between 29% in the advanced stage and 94% in the early stage. This result means that gastric cancer must be detected and treated early as possible. However, the diagnosis of early gastric cancer may remain extremely difficult even for an excellent endoscopist. Therefore, in order to clearly recognize early gastric cancer, an endoscopic staining method with methylene blue has been studied. In this method, one capsule of 150 mg methylene blue is swallowed with a small amount of proteinase solution 3 hours before endoscopy. Gastroscopy is performed routinely after this preparation. This procedure was performed on 153 gastric cancers and 137 of them (89.5%) have been successfully dyed in dark blue. In several cases, with this method, the actual borderline between the normal mucosa and the malignant extent was clearly recognized and resection line was decided. Introduction of methylene blue into the stomach could also stain the intestinalized epithelium of the gastric mucosa. Differential diagnosis of the dyed intestinal metaplasia and the dyed carcinoma seems to be very easy, because both gastric lesions have the characteristic dyed patterns. Mechanism of this phenomenon has been considered to be due to an absorption of the dye in the intestinal metaplasia, and in the gastric cancer, many factors may be involved, among which are the infiltration or diffusion of the dye into the cancerous tissue, the absorption from the abnormal epithelium, and the staining of the necrotic tissue.

Adenocarcinoma↗
PubMed2001

Phase II clinical trial on effect of the long turmeric (Curcuma longa Linn) on healing of peptic ulcer.

The study examined patients who had symptoms indicating peptic ulcer. Forty-five patients, 24 males and 21 females, aged between 16-60 years were included in the study. Twenty-five patients, 18 males and 7 females, were endoscoped, their ulcers located in the duodenal bulb and gastric (angulus). The ulcer sizes varied between 0.5 to 1.5 cm in diameter. Capsule-filled turmeric was given orally in the dose of 2 capsules (300 mg each) five times daily, one half to an hour before meals, at 16.00 hours and at bedtime continuously. The result after 4 weeks of treatment showed that ulcers were absent in 48% or 12 cases (DU 9 and GU 3). Eighteen cases (DU 13 and GU 5) had absence of ulcer after 8 weeks of treatment. Nineteen cases (76%) (DU 14 and GU 5) did not have ulcers after 12 weeks of treatment. The rest, 20 cases were not found to have ulcers and some were not endoscoped. They appeared to have erosions, gastritis and dyspepsia. They received turmeric capsules for 4 weeks of treatment. The abdominal pain and discomfort satisfactorily subsided in the first and second week. They could take normal foods instead of soft meals. Blood chemistry and hematology of all 54 patients had no significant changes in hematological system, liver and renal functions both before and after treatment.

Adolescent↗
PubMed1979

Endoscopic duodenal biopsies in coeliac disease and duodenitis.

Endoscopic duodenal biopsies were taken from 27 patients with suspected coeliac disease and compared with intubation capsule jejunal biopsies. The specimens were reported without knowledge of the patients' names or symptoms. In 24 patients (89%), coeliac disease could either be diagnosed or excluded with 100% accuracy, despite the inability to orientate the biopsies correctly. Six biopsies were considered technically unsatisfactory, but only in three (11%) was it impossible to exclude coeliac disease. Duodenal biopsies were also taken from 118 consecutive patients attending for routine upper gastrointestinal endoscopy, and 1 patient with coeliac disease was discovered. We conclude that endoscopic duodenal biopsies are a reliable and worthwhile screening test for coeliac disease in certain patients attending for routine upper gastrointestinal endoscopy.

Celiac Disease↗
PubMed1993

[Reevaluation of impotence following TURP].

Impotence following transurethral prostatectomy is one of the main complications that still has a controversial origin. Many authors, reporting their experience, have demonstrated that this complication is due both to psychological problems and to organic causes. We review retrospectively 68 patients submitted to TURP. All patients (53 to 65 years old) were asked about their sexual efficiency before and after TURP, 6-12 months after surgery. Those who complained of erectile failure have been studied using this diagnostic protocol: plasmatic dosage of FSH, LH, Testosterone and Prolactin; penile Doppler ultrasound, polysomnographic recording of nocturnal tumescence test (NPT Test); angiography of the pudenda arteries has been performed in only one patient with pathological penile Doppler ultrasound (IPP < 0.7). The examinations demonstrated an organic impotence not secondary to vascular damage in 10 patients following surgery (incidence 15.6%). Our high incidence of this complication is, according to us, significant even if it should be considered in excess since in our study we used anamnestic criteria alone in the evaluation of sexual efficiency before surgery. In 1984 T. Lue demonstrated, through accurate histological preparations, that cavernous nerves run contiguously to the prostatic capsule at 5 and 7 hours in correspondence of the glandular apex. He suggested that impotence following TURP is due to iatrogenic lesions of these nervous structures during endoscopic resection. Similarly, we have conducted an anatomopathological study on prostate specimens taken from autopsies. We demonstrated the presence of nervous structure contiguously to the prostatic capsule in correspondence with the glandular apex. Thus, impotence following TURP probably occurs after an iatrogenic heat lesion of the periprostatic plexus caused by resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1979

Treatment of duodenal ulcer with carbenoxolone sodium: a double-masked endoscopic trial.

In a double-masked trial, 43 patients with an endoscopically confirmed, symptomatic duodenal ulcer were allocated at random to treatment with either carbenoxolone sodium or placebo, both provided in identical "positioned-release" capsules. The 40 patients who satisfactorily completed the trial were evenly distributed between the two treatment groups. The groups were well matched with regard to clinical features and initial ulcer size. Endoscopic review of ulcer healing after six weeks' treatment showed that 12 patients (60%) receiving carbenoxolone had healed ulcers, compared with five (25%) receiving placebo (P = 0.05). Symptomatic remission occurred by the fourth week in 17 patients (85%) receiving carbenoxolone, compared with six (30%) receiving placebo (P less than 0.001). The mean (geometric) serum carbenoxolone level in patients with healed ulcers was 31.11 microgram/mL compared with 17.75 microgram/mL in those with unhealed ulcers (P less than 0.005). Side effects of carbenoxolone therapy were observed, but they did not necessitate withdrawal of the drug and were readily controlled in every instance. These results confirm the therapeutic efficacy of carbenoxolone sodium in duodenal ulcer. In addition, a relationship between serum carbenoxolone levels and the occurrence of ulcer healing was observed.

Carbenoxolone↗
PubMed1986

[Subrenal capsule assay for testing the effectiveness of anticancer drugs].

This study compared the histological changes induced by human bladder tumor xenografts following their implantation in the subrenal capsular space of immunocompetent mice (CDF1, 6-10 weeks age). Ten human bladder tumors were studied by light microscopic and electron microscopic methods. All materials were obtained from cold-cup biopsy using endoscopic procedure. Single fragments (1 mm X 1 mm X 1 mm) were implanted on Day 0 under the renal capsule of each mouse. Animals were serially sacrificed from day 2 to day 6 and in some cases as late as day 10. All kidneys were sectioned up to 3 levels at the xenograft and stained with appropriate histological reagents. The results of this study were; 1) infiltration of the tumor with mononuclear cells and neutrophils began on day 4, 2) pretreatment with 200 mg/kg cyclophosphamide before implantation reduced cell infiltration into the xenograft, 3) complete rejection of the tumor on day 8, 4) electron microscopic study showed minimum changes of intracellular organs on day 2, 5) but microscopic architecture was preserved in the tumor explants removed on day 4. This morphological study suggested that histological evaluation on day 4 might be a suitable method of subrenal capsule assay using immunocompetent mice. We therefore tested genitourinary carcinomas to determine their sensitivities to commonly use chemotherapeutic agents using histological criteria. Groups of tumor-bearing mice were treated daily for 3 days. Sensitivities for assays were assessed on day 4 by comparison of histological score. Of the 15 cases evaluated, 20% demonstrated significant oncolytic activity. These data also suggested that a clinically relevant chemosensitivity assay might enhance the selection of appropriate therapy.

Animals↗
PubMed2005

Investigation of the small bowel in gastrointestinal bleeding--enteroscopy and capsule endoscopy.

The last frontier in luminal endoscopy has been conquered. Bleeding lesions in the small intestine can present a frustrating clinical problem, but recent advances have made investigating the small bowel easier and less invasive. Capsule endoscopy and double balloon enteroscopy are two new technologies that promise to lower the barrier to evaluation of the entire small intestine. Recent studies show that capsule endoscopy improves outcomes in patients who have OGIB. Although outcome studies regarding double balloon enteroscopy have not been performed, the opportunity to treat lesions throughout the small bowel without resorting to surgery is a tremendous advance. These improvements suggest that the corner may have been turned in the diagnosis and management of small bowel bleeding. Perhaps to the next generation of gastroenterologists, small bowel bleeding will not be obscure.

Capsules↗
PubMed2004

Capsule endoscopy: a single-centre experience with the first 226 capsules.

BACKGROUND: Capsule endoscopy (CE) refers to a novel diagnostic method of imaging the gastrointestinal tract using a wireless capsule that transmits images to a data recorder while the device traverses the small intestine. OBJECTIVE: To review the authors' experience with CE to determine the indications, outcomes and management of positive findings. METHODS: Patients were prepared for CE with a single dose of magnesium citrate. Following an 8 h fast, a sensor array system was applied to the abdomen, the capsule was swallowed and the images were transmitted to a data recorder worn on the patient's side. Typically, the battery life of the capsule is 8 h, following which the data recorder is returned, downloaded to a computer workstation and reviewed. RESULTS: To date, 226 capsule studies have been performed in 209 patients. The indications included obscure bleeding (167 studies: 88 overt, 79 occult), anemia (14 studies), evaluation for inflammatory bowel disease (12 studies), screening for polyps (10 studies), pain (19 studies) and abnormal radiological imaging (4 studies). In the setting of obscure bleeding, a definitive source of bleeding was discovered in 85 studies. This included angiodysplasia (52 studies), mitotic lesions (10 studies) and ulcers (23 studies). A probable source of bleeding was found in another 10 capsule studies. In the setting of anemia without evidence of bleeding, the definitive findings included ulcers (three studies), angiodysplasia (two studies), mitotic lesions (one study) and celiac disease (one study). Of four patients with abnormal radiological imaging, CE demonstrated lesions in two. The results of 35 capsule studies led to laparotomy with curative surgical resection. In eight studies, the capsules became lodged within a stricture; none led to obstruction and three were managed endoscopically. CONCLUSION: The yield of CE in carefully selected patients with obscure bleeding approximates 51%. There appear to be few complications, and patient satisfaction appears high. Cost analysis and further studies of clinical outcomes are required to elucidate appropriate indications for this device.

Angiodysplasia↗
PubMed2004

Obscure gastrointestinal bleeding: a complication of radiation enteritis diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a common disorder and may account for as many as 5% of all gastrointestinal hemorrhages. It is often caused by lesions in the small intestine, which were very complicated to examine prior to the advent of wireless capsule endoscopy. Here we present the case of a 31-year-old woman with obscure gastrointestinal bleeding as a complication of radiation enteritis, which was diagnosed only after she underwent an examination with wireless capsule endoscopy. This technique has proven to be far superior to other radiographic and endoscopic methods in diagnosing obscure gastrointestinal bleeding and pathologies of the small intestine in general.

Adult↗