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This paper deals with further experiences in endoscopy of the maxillary sinus and in possibilities of endoscopy of frontal and sphenoidal sinuses. Some coloured photographs taken during endoscopy are shown. As the result of 301 sinuscopies of maxillary sinus performed, it could be shown that in 36% of the cases x-ray findings didn't exactly correspond with the endoscopy findings. In further 22% there was no correlation at all between the x-rays and findings at operation. This shows the great importance of sinuscopy and reveals its diagnostic values. The author used the endoscopy of the maxillary sinus not only for diagnostic purposes but for the treatment of chronic purulent sinusitis as well as complete removal of the socalled solitary cysts of the mucous membrane. A therapeutic gap between the two extreme (conservative treatment on one side and radical surgery Caldwell-Luc on the other side) ist bridged using this method. Finally the indications for endoscopy of maxillary and frontal sinuses are shown clearly in a table.
A comparison of hysterosalpingography (HSG) with endoscopy in the evaluation of tubal function in 117 infertile women is presented. Results were in accord in 55% of the patients. Correction for endoscopic error and the limitations of HSG increased the positive correlation to 74%. Twenty-three patients (20%) with abnormal findings at HSG were normal with endoscopy. Ten patients (8%) had normal HSG but abnormal endoscopic findings. Fifteen patients (12%) with positive findings by HSG had different positive findings at endoscopy. Additional endoscopic findings in 47 patients are listed. Review of 26 patients with endoscopy-confirmed endometriosis revealed that 14 (54%) had a normal HSG and normal history and pelvic examination. Although HSG should be the method of choice as part of the basic evaluation, an infertile woman should undergo endoscopy before the evaluation is considered complete or final.
Gastroenterologic endoscopy has developed into a perfect diagnostic tool. All sections of the gastrointestinal tract are accessible to visual inspection. The early diagnosis of gastrointestinal cancer has become a reality. The sources of acute bleeding can be located by emergency endoscopy. The combination of endoscopy with other procedures (biopsy, radiology, ultrasonics) has opened up further essentially diagnosis possibilities. Where changes occur in polyps, small particles are not representative. Polypectomy has advanced to total biopsy. Along with this, the step from diagnostic to curative endoscopy was taken. Further milestones in this direction are endoscopic papillotomy and endoscopic hemostasis and the prevention of bleeding by the use of laser light.
The results of radiological and endoscopic examination in 1,030 patients were compared. In one third of cases there was some discrepancy relating to a significant diagnostic finding (malignant process, peptic ulcer, polyp, stenosis or deformity, abnormal folds, diverticula or normal findings). In analysing false negative and false positive radiological diagnoses, the patients were divided into two groups (with or without a double contrast technique). Conventional radiography proved ten to 38% less reliable than the double contrast technique for a variety of reasons. In view of the high diagnostic accuracy of modern radiological investigations of the stomach and duodenum, endoscopy and biopsy are recommended as complementary procedures. In addition to the high degree of accuracy of radiological methods for various pathological processes, endoscopy places considerable demands during investigation of the upper intestinal tract. At present radiology is used 19 times as frequently as endoscopy, suggesting that there might have to be a tenfold increase in the capacity of pathological departments if endoscopy is used more frequently.
Fiberoptic gastrointestinal endoscopy was performed on 52 patients between the ages of 2 months and 16 years. The procedures were safely and easily done with premedications consisting of meperidine, promethazine, and chlorpromazine, and atropine, with diazepam given at the time of the procedure. Fiberoptic endoscopy was particularly helpful in localizing the site of upper gastrointestinal hemorrhage, in retrieving foreign objects, and in removing colonic polyps. In contrast, endoscopy added little to the clinical history and roentgenographic studies in children with recurrent abdominal pain or vomiting, in whom we believe fiberoptic endoscopy is not indicated unless the symptoms or history appear inconsistent with the diagnosis of functional bowel disease.
Because of the high rate of diagnostic error with routine barium X-ray studies in detection of upper gastroesophageal lesions, a prospective investigation was undertaken to evaluate endoscopy together with brushing cytology and biopsy. Ninety-nine patients with recurrent upper gastrointestinal symptoms were examined during a two year period. Thirty-seven patients had cancer and 62 had benign ulcers as diagnosed by cytology and histopathology. All patients with diagnosis of carcinoma were correctly diagnosed by a combination of the above studies as proven by subsequent surgical exploration of all 37 patients. In the benign group, 23 patients were confirmed by exploratory laparotomy and 16 patients by following up for at least 2 years with upper GI series and/or endoscopy. The highest degree of accuracy in the diagnosis of cancer was achieved by cytology alone (92% of cases) and lowest by barium study of upper gastrointestinal tract (84% of cases). Although the accuracy of endoscopy in detecting cancer of the upper gastrointestinal tract was 86 per cent, 15 per cent of benign ulcers were falsely called neoplastic by this technique. It is concluded that endoscopy with brushing cytology and biopsy is an effective diagnostic tool in distinguishing benign lesions from malignant neoplasms and can be performed with little risk to the patient.
The possibilities and advantages of the emergency endoscopy of the upper intestinal tract are emphasized. With the help of 475 own examinations from 1971 to 1973 and from 1973 to June 1977 the improvement of the diagnostic gain by instruments with prograde optics is proved. Ulcerous diseases of the stomach and the duodenum are found as most frequent cause of haemorrhage which appear in the oesophagus or in the oesophagogastric transition. With 20% the number of the multiple findings was significantly high, the proof of which is to be regarded as an essential advantage of the emergency endoscopy. But at the same time they also emphasize the necessity not to be satisfied with the proof of a source of haemorrhage. The coloscopic emergency endoscopy is more difficult. Endoscopico-therapeutic possiblities increase the importance of the emergency endoscopy.
The authors report on the position of the endoscopy of oesophagus, stomach and duodenal bulb within the diagnostic endoscopy. The therapeutic endoscopy including polypectomy remains widely not taken into consideration. They particularly deal with the endoscopic-bioptic diagnosis of the stenoses of the oesophagus, the gastric ulcers and the early carcinoma of the stomach. It is referred to the importance of the endoscopy for the diagnostics of varicose veins of the oesophagus and of duodenal ulcers. For the clinician references to the clinical elaboration of the endoscopic and bioptic findings are given.
A total of 416 patients had been admitted to hospital for acute upper gastrointestinal bleeding, about half of them before the introduction of endoscopy. There was a highly significant decrease in total mortality rate by 18 percent since the introduction of endoscopy. The reason for this is probably largely the much higher number of correct identification or localisation of bleeding points by endoscopy (98 percent) when compared with conventional radiological examination.
An open-access general-practitioner referral service for endoscopy of the upper gastrointestinal tract was established in a district general hospital, and the impact of the service over three years was assessed. The reason for referral, duration of symptoms, and amount of disease detected were the same in patients referred by general practitioners and those attending from hospital outpatient departments. Despite a steady increase in the number of patients referred for endoscopy, the number of barium-meal examinations performed did not correspondingly decrease. The number of ulcers and cancers detected in each six-month period of the study did not increase, and the combined overall pick-up rate for these two conditions fell from 25% to 13%. All general practitioners in the area were sent questionnaires. Most thought that clinic referral had been reduced and patient management helped as a result of the introduction of the service. While the value of negative endoscopic findings cannot be assessed, there is little objective evidence of benefit. Hence the large increase in numbers of endoscopies performed as a result of the introduction of the service cannot be justified.
The development of fiber endoscopy has made possible routine endoscopic bioptic examination of the upper (including the duodenum) and lower digestive tract (with the terminal ileum). Biopsy material can be obtained in the necessary quantities with forceps or a loop. In many centers endoscopy is already the basic method for the diagnosis of diseases of the upper digestive tract. A similar tendency is also becoming apparent in colo-ileoscopy. The increase in the frequency of endoscopic investigations is accompanied by a decrease in the number of complications. The increasing importance and dissemination of gastrointestinal fiber endoscopy demands greater and better training facilities and adequate control of qualifications together with an integrated cooperation with the pathologists.
In about 90% of cases of active gastrointestinal hemorrage, sources and nature of bleeding can be identified exactly by means of emergency endoscopy. With time passing from the beginning of hemorrhage, diagnosis established by endoscopy is getting less precise. The most common cases of bleeding are peptic lesions, either esophageal, gastric, or duodenal; the most common site of hemorrhage is the stomach. Different potential points bleeding at the same time have to be take in account. A case report of Mallory-Weiss syndrome (13 episodes of hemorrhage) illustrated the method's value in establishing diagnosis of acute gastrointestinal bleeding. Special applications of emergency endoscopy in mental patients are described.
In a number of diseases, operative or therapeutic endoscopy permits an effective therapy without the necessity to open up the abdominal wall and the digestive organs themselves. Included here are the removal of foreign bodies, haemostasis, papillotomy with concrement dislodgement, polypectomy and the obliteration of the excretory pancreas. The evaluation of the achieved results and the examination of operative endoscopy in respect of its clinical value cooperation with the pathologisz should not be neglected. The refined endoscopic methods and the highly developed technology can only be applied successfully, when it is possible to get enough skillful endoscopists and to prevent an everyman's endoscopy by which the new methods could be brought into discredit.
In 11 years experience (67-78) we studied the importance of endoscopy in HDA. Were carried out 8300 esophagogastroduodenal endoscopies of which 2837 were HDA. The main reasons to follow these studies were: 1) Diagnostic of the HDA location; 2) Diagnostic of type of injury; 3) Injury intensity. Referring to the findings 30% were duodenal ulcer; 27% hemorrhagic gastritis; 17% gastric ulcer and 10% were due to VE. From the remaining 10% the most frequent were the esophagitis and gastric cancer. It is most important to show that aspiring added to alcohol in the most common cause of hemorrhagic gastritis. We have to point out that in 42 endoscopies performed in Intensive Care Service 10 of them were due to non-digestive causes. Through this method of diagnosis the Endoscopist has an important role to play in defining the prognosis and conduct to be followed.
In selected chapters of the therapeutic endoscopy we tried to represent secure knowledge, actual tendencies and partly future prognoses. Hereby completeness cannot be expected. However, it became clear that numerous physical principles became useful for the therapy with the endoscope. Chemical techniques, such as the litholysis of gall-stones are only at present used in our field. With all scepticism against the own field of interest one may say that the operative therapeutic endoscopy, as it is seen at the instance of the classification of polyps, has led to an improvement of the diagnostics, Its advantages in the therapeutic field are based on the fact that it substitutes larger operations. In the polypectomy- the intervention, avoiding laparotomy and colotomy, is reduced on the minimum given by the size of the polyp. The risk of endoscopic operations is small, compared with the alternative surgical interventions. Shortening of the duration of the disease and hospitalisation leads to lower expenses. Methods, such as the endoscopic haemostypsis or the obliteration of the pancreatic duct, need further detailed examinations. There is no doubt that the modern endoscopy has a strong technical fascination for many young physicians. It gets the greatest value in the hands of a clinically experienced physician.