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Guidewire technique for endoscopic transpapillary procurement of bile duct biopsy specimens without endoscopic sphincterotomy
Guidewire technique for endoscopic transpapillary procurement of bile duct biopsy specimens without endoscopic sphincterotomy Lien-Fu Lin, MD, Chuan-Pau Siauw, MD, Ka-Sic Ho, MD, Jai-Nien Tung, MD
Background: Endoscopic sphincterotomy may be required when endoscopic lxanspapillary bile duct biopsy specimens are needed for tissue diagnosis. However, endoscopic sphincterotomy has potential complications. A guidewire technique for obtaining transpapillary biopsy specimens without endoscopic sphincterotomy was evaluated. Methods: A total of 13 patients (11 men, 2 women; mean age 67.5 years) with biliary stricture or obstruction underwent endoscopic retrograde cholangiography. A guidewire was then inserted across the stricture or obstruction and into an intrehepaUc duct. Alongside the guidewire, the biopsy forceps (1.5 mm diameter) was introduced into the papillary orifice with the duodenoscope extremely close to the papilla. Observations: Tissue was obtained in 92.3% of the cases for-kistopathologic evaluation without difficulty or complication. The single failure occurred in a patient who had undergone a partial gastrectomy with BiUroth I anastomosis. Conclusions: The guidewire technique for endoscopic transpepillary procurement of biopsy specimens of the bile duct obviates the need for endoscopic sphincterotomy. Endoscopic sphincterotomy (EST) is usually needed to obtain endoscopic transpapillary biopsy specimens (ETPB), because it makes for easier insertion of the relatively stiff biopsy forceps into the biliary tract. 1-3 However, EST is associated with complications such as hemorrhage, pancreatitis, and perforation.4-7 Prior insertion of a guidewire in the biliary tract would facilitate entry of the relatively inflexible forceps into the bile duct for ETPB without EST, thus avoiding the complications of EST. PATIENTS AND METHODS
J
From January 2001 to September 2002, 18 patients with biliary stricture or obstruction underwent ETPB. Of these procedures, 3 wereperformed with a Howell biliary introducer (HBI-1; Wilson-Cook Medical, Inc., WinstonSalem, N.C.) catheter, two with a Mighty forceps (Zimmon wire-guided lateral forceps cup; Cook). Received November 4, 2002. For revision January 29, 2003. Accepted April 9, 2003. Current affiliations: Division of Gastroenterology, Department of Internal Medicine, Tung's Taichung Metroharbor Hospital, Taichung, Taiwan, Republic Of China. Reprint requests: Lien-Fu Lin, MD, No. 8, 11th Floor, Mei Tsun Road, Sea 2, Lane 168, Taichung, Taiwan, R.O.C. Copyright 9 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067 / mge.2003.329 272
GASTROINTESTINAL ENDOSCOPY
C Figure 1. A, Duodenoscopic view showing guidewire (arrow) inserted into bile duct. B, Biopsy forceps (arrow) extended from duodenoscope. C, Biopsy forceps (arrow) entering bile duct alongside guidewire with duodenoscope positioned close to papilla.
VOLUME 58, NO. 2, 2003
Guidewire technique for procurement of bile duct biopsy specimens
The biopsy procedure was unsuccessful in one case in which the HBI-1 catheter was used because of the inability to advance the forceps from the accessory channel at the tip of the duodenoscope. With the Mighty forceps, the catheter accepted only an 0.018-inch guidewire, and the guidewire became dislodged while introducing the forceps into the duct. Thus, another guidewire technique was used for ETPB in 13 patients (11 men, 2 women; mean age 67.5 years, range 54-88 years). After obtaining written consent for endoscopic cholangiography (ERC) and ETPB, ERC was performed with a duodenoscope (TJF-200 or 240; Olympus Optical Co., Ltd., Tokyo, Japan). A 0.025-inch guidewire (Jagwire; Microvasive, Boston Scientific Corp., Miami, Fla.) was introduced through the biliary stenosis or obstruction (Fig. 1A) and a 1.5-mm diameter, 220-cm-long biopsy forceps (HBIF-1.5-220, Wilson-Cook) was advanced through the accessory channel of the duodenoscope (Fig. 1B). The next, and most important step, was to deflect the tip of the duodenoscope upward to place it extremely close to the papilla, followed by insertion of the forceps alongside the guidewire (Fig. 1C). Under fluoroscopy, two to 4 biopsy specimens were taken from different portions of the biliary stricture or obstruction (Fig. 2). The specimens were fixed in 10% formalin and stained with H&E. All biopsy procedures were performed without prior EST.
OBSERVATIONS The E T P B s were successfully obtained in all patients except one with a prior partial gastrectomy with Billroth I anastomosis. In the latter patient, it was difficult to obtain an optimal position for cannulation owing to the anatomical alteration as a result of the operation. The success rate was 92.3%; there was no complication, and the procedure was e a s y a n d quick. The results are s u m m a r i z e d in Table 1. O f the 13 patients, 10 subsequently underw e n t surgery, including patients with benign disease in w h o m malignancy could not be ruled out before surgery. Subsequent to the ETPB procedure, a 10F plastic stent was inserted (without EST). Selfexpandable metallic stents were not inserted in the nonoperated cases because these patients had terminal malignant disease. The key technical point in the ETPB procedure without EST was to keep the tip of the duodenoscope as close as possible to the papilla during insertion of the biopsy forceps alongside the guidewire.
DISCUSSION C a n n u l a t i o n of the bile duct is easier if the tip of the c a t h e t e r is curved. Because of its straight tip, it is u s u a l l y difficult to insert a biopsy forceps into the biliary tract. S u g i y a m a et al. 8 used a specially designed, malleable Teflon-sheathed forceps (FB-39Q; O l y m p u s ) and s u c c e s s f u l l y o b t a i n e d E T P B s w i t h o u t EST in 87% of cases. The Howell VOLUME 58, NO. 2, 2003
L-F Lin, C-P Siauw, K-S Ho, et al.
Figure 2. Retrograde cholangiogram showing open biopsy forceps (arrow) at obstructing lesion. biliary introducer (HBI-1, Wilson-Cook) catheter, is a wire-guided, 2-lumen catheter t h a t can be used for both b r u s h i n g and o b t a i n i n g a biopsy specimen. The d r a w b a c k of this device is difficulty in advancing the forceps beyond the tip of t h e duodenoscope, even w h e n the duodenoscope is kept in a short position. When a Mighty forceps (Cook) is used, it only a c c e p t e d a n 0.018-inch guidewire, which had a tendency to become dislodged as the forceps was being i n t r o d u c e d into t h e bile duct. T a m a d a et al. 9 d e s c r i b e d u s e of a r o p e w a y - t y p e bile duct biopsy forceps for ETPB w i t h o u t EST in 12 patients, b u t special m a n i p u l a t i o n s were also n e c e s s a r y to avoid dislodging the guidewire during the procedure. In two studies of ETPB without ESTS, 9 and two of ETPB with EST, 2,3 the diameter of the forceps used was 1.8 ram. The diameter of the forceps used in the present study was slightly smaller (1.5 mm), b u t still sufficient for obtaining an adequate tissue sample. The guidewire technique described herein has the following advantages: (1) it can be performed with a guidewire of any s t a n d a r d d i a m e t e r (0.018-0.035 inch); (2) it is fast, as the forceps is not inserted through a catheter (as with the H B I catheter) or t h r e a d e d over a guidewire (as with ropeway-type forceps); and (3) there is less chance of dislodgement of the guidewire. In the HBI catheter method, the c a t h e t e r (diameter 10F) is first advanced over a guidewire, followed by introduction of the forceps t h r o u g h the H B I catheter; thus, two steps are required. In the guidewire technique described herein, as long as the elevator of the duodenoscope holds the guidewire tightly, t h e small forceps can be advanced through the accessory channel quickly; whereas, in the forceps along-the-wire (ropewayGASTROINTESTINAL ENDOSCOPY 2 7 3
F Junquera, E Brullet, R Campo, et al.
Endoscopic band ligation for bleeding small bowel vascular lesions
Table 1. Data summary for study patients No.
Gender
Age
1 2 3 4 5 6 7 8 9 10 11 12 13
M M M M M M M M F M F M M
65 75 66 54 76 64 62 64 57 65 88 55 73
Disease Icteric hepatoma Pancreatic head cancer Icteric hepatoma Gall bladder cancer Bile duct cancer Pancreas head cancer PSC Bile duct cancer Bile duct cancer Bile duct cancer Bile duct cancer Benign bile duct stricture Bile duct cancer
Location
Histologic results
CBD, RHD CBD CBD, LHD CBD CBD, CHD CBD CHD CHD CHD CBD CBD CHD CHD, RHD
Negative Positive Positive Negative Positive Negative Negative Positive Positive Positive Negative Negative Failure (after Billroth I)
CBD, Common bile duct; RHD, right hepatic duct; LHD, left hepatic duct; CHD, common hepatic duct; PSC, primary sclerosing cholangitis.
type biopsy forceps) method, care must be taken to avoid dislodging the guidewire. Prior insertion of a guidewire in the bile duct keeps the mucosal folds of the papilla1~ 11 flat and the pathway through the bile duct straight, making deep bile duct cannulation easier. The key point is to keep the duodenoscope close to the papilla, thereby allowing easy entrance into the bile duct whil e avoiding entry into the pancreatic duct. The reason for the failure of the technique in one patient was an inability to position the duodenoscope close to the papilla, owing to anatomic changes as a result of prior surgery (partial gastrectomy with Billroth I anastomosis). Thus, the guidewire technique described above is a viable alternative for obtaining ETPBs without EST. REFERENCES 1. Aabakken L, Karesen R, Serck-Hansen A, Osnes M. TranspapiUary biopsies and brush cytology from the common bile duct. Endoscopy 1986;18:49-51. 2. Kubota Y, Takaoka M, Tani If, Ogura M, Kin H, Fujimura I~ et al. Endoscopic transpapiilary biopsy for diagnosis of patients with pancreaticobiliary ductal strictures. Am J Gastroenterol 1993;88:1700-4.
3. Schoefl R, Haefner M, Wrba F, Pfeffel F, Stain C, Poetzi R, et al. Forceps biopsy and brush cytology during endoscopic retrograde cholangiopancreatography for the diagnosis ofbiliary stenoses. Scand J Gastroenterol 1997;32:363-8. 4. Sivak MV Jr. Endoscopic management of bile duct stones. Am J Surg 1989;158:228-40. 5. Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-93. 6. Shields SJ, Carr-Locke DL. Sphincterotomy techniques and risks. Gastrointest Endosc Clin N Am 1996;6:17-42. 7. Freeman ML. Complications of endoscopic sphincterotomy. Endoscopy 1998;30:A216-20. 8. Sugiyama M, Atemi Y, Wada N, Kuroda A, Mute T. Endoscopic transpapillary bile duct biopsy without sphincterotomy for diagnosing biliary strictures: a prospective comparative study with bile and brush cytology. Am J Gastroenterol 1996;91: 465-7. 9. Tamada K, Higashizawa T, Tomiyama T, Wada S, Ohashi A, Sateh Y, et al. Ropeway-type bile duct biopsy forceps with a side slit for a guidewire. Gastrointest Endosc 2001;53:89-92. 10. Allescher HD. Papilla of Vater: structure and function. Endoscopy 1989;21:324-9. 11. Paulsen FP, Bobka T, Tsokos M, Folsch UR, TiUmann BN. Functional anatomy of the papilla Vateri: biomechanical aspects and impact of difficult endoscopic intubation. Surg Endosc 2002;16:296-301.
Usefulness of endoscopic band ligation for bleeding small bowel vascular lesions F~lix Junquera, MD, Enric Brullet, MD, Rafel Campo, MD, Xavier Calvet, MD, Valentf Puig-Divi, ME), Mercedes Vergara, Received October 31, 2002. For revision January 8, 2003. Accepted April 28, 2003. Current affiliations: Endoscopy Unit, UDIAT-CD, Corporaci5 Parc Tauli, Sabadell, Spain. Reprint requests: Enric Brullet, MD, Endoscopy Unit, UDIAT-CD, Corporaci5 Parc Tauli, Parc Tauli s / n, 08208 SabadeU, Spain. Copyright 9 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067 / mge.2003.35 7 274
GASTROINTESTINAL ENDOSCOPY
MD
Background: The optimal therapy for bleeding small bowel vascular lesions is controversial. This study investigated the efficacy and safety of endoscopic band ligation in this clinical condition. Methods: Fourteen patients bleeding from angiodysplasia and 4 bleeding from Dieulafoy's lesions located in the small bowel were included in this pilot study. VOLUME 58, NO. 2, 2003
Background: Endoscopic sphincterotomy may be required when endoscopic lxanspapillary bile duct biopsy specimens are needed for tissue diagnosis. However, endoscopic sphincterotomy has potential complications. A guidewire technique for obtaining transpapillary biopsy specimens without endoscopic sphincterotomy was evaluated. Methods: A total of 13 patients (11 men, 2 women; mean age 67.5 years) with biliary stricture or obstruction underwent endoscopic retrograde cholangiography. A guidewire was then inserted across the stricture or obstruction and into an intrehepaUc duct. Alongside the guidewire, the biopsy forceps (1.5 mm diameter) was introduced into the papillary orifice with the duodenoscope extremely close to the papilla. Observations: Tissue was obtained in 92.3% of the cases for-kistopathologic evaluation without difficulty or complication. The single failure occurred in a patient who had undergone a partial gastrectomy with BiUroth I anastomosis. Conclusions: The guidewire technique for endoscopic transpepillary procurement of biopsy specimens of the bile duct obviates the need for endoscopic sphincterotomy. Endoscopic sphincterotomy (EST) is usually needed to obtain endoscopic transpapillary biopsy specimens (ETPB), because it makes for easier insertion of the relatively stiff biopsy forceps into the biliary tract. 1-3 However, EST is associated with complications such as hemorrhage, pancreatitis, and perforation.4-7 Prior insertion of a guidewire in the biliary tract would facilitate entry of the relatively inflexible forceps into the bile duct for ETPB without EST, thus avoiding the complications of EST. PATIENTS AND METHODS
J
From January 2001 to September 2002, 18 patients with biliary stricture or obstruction underwent ETPB. Of these procedures, 3 wereperformed with a Howell biliary introducer (HBI-1; Wilson-Cook Medical, Inc., WinstonSalem, N.C.) catheter, two with a Mighty forceps (Zimmon wire-guided lateral forceps cup; Cook). Received November 4, 2002. For revision January 29, 2003. Accepted April 9, 2003. Current affiliations: Division of Gastroenterology, Department of Internal Medicine, Tung's Taichung Metroharbor Hospital, Taichung, Taiwan, Republic Of China. Reprint requests: Lien-Fu Lin, MD, No. 8, 11th Floor, Mei Tsun Road, Sea 2, Lane 168, Taichung, Taiwan, R.O.C. Copyright 9 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067 / mge.2003.329 272
GASTROINTESTINAL ENDOSCOPY
C Figure 1. A, Duodenoscopic view showing guidewire (arrow) inserted into bile duct. B, Biopsy forceps (arrow) extended from duodenoscope. C, Biopsy forceps (arrow) entering bile duct alongside guidewire with duodenoscope positioned close to papilla.
VOLUME 58, NO. 2, 2003
Guidewire technique for procurement of bile duct biopsy specimens
The biopsy procedure was unsuccessful in one case in which the HBI-1 catheter was used because of the inability to advance the forceps from the accessory channel at the tip of the duodenoscope. With the Mighty forceps, the catheter accepted only an 0.018-inch guidewire, and the guidewire became dislodged while introducing the forceps into the duct. Thus, another guidewire technique was used for ETPB in 13 patients (11 men, 2 women; mean age 67.5 years, range 54-88 years). After obtaining written consent for endoscopic cholangiography (ERC) and ETPB, ERC was performed with a duodenoscope (TJF-200 or 240; Olympus Optical Co., Ltd., Tokyo, Japan). A 0.025-inch guidewire (Jagwire; Microvasive, Boston Scientific Corp., Miami, Fla.) was introduced through the biliary stenosis or obstruction (Fig. 1A) and a 1.5-mm diameter, 220-cm-long biopsy forceps (HBIF-1.5-220, Wilson-Cook) was advanced through the accessory channel of the duodenoscope (Fig. 1B). The next, and most important step, was to deflect the tip of the duodenoscope upward to place it extremely close to the papilla, followed by insertion of the forceps alongside the guidewire (Fig. 1C). Under fluoroscopy, two to 4 biopsy specimens were taken from different portions of the biliary stricture or obstruction (Fig. 2). The specimens were fixed in 10% formalin and stained with H&E. All biopsy procedures were performed without prior EST.
OBSERVATIONS The E T P B s were successfully obtained in all patients except one with a prior partial gastrectomy with Billroth I anastomosis. In the latter patient, it was difficult to obtain an optimal position for cannulation owing to the anatomical alteration as a result of the operation. The success rate was 92.3%; there was no complication, and the procedure was e a s y a n d quick. The results are s u m m a r i z e d in Table 1. O f the 13 patients, 10 subsequently underw e n t surgery, including patients with benign disease in w h o m malignancy could not be ruled out before surgery. Subsequent to the ETPB procedure, a 10F plastic stent was inserted (without EST). Selfexpandable metallic stents were not inserted in the nonoperated cases because these patients had terminal malignant disease. The key technical point in the ETPB procedure without EST was to keep the tip of the duodenoscope as close as possible to the papilla during insertion of the biopsy forceps alongside the guidewire.
DISCUSSION C a n n u l a t i o n of the bile duct is easier if the tip of the c a t h e t e r is curved. Because of its straight tip, it is u s u a l l y difficult to insert a biopsy forceps into the biliary tract. S u g i y a m a et al. 8 used a specially designed, malleable Teflon-sheathed forceps (FB-39Q; O l y m p u s ) and s u c c e s s f u l l y o b t a i n e d E T P B s w i t h o u t EST in 87% of cases. The Howell VOLUME 58, NO. 2, 2003
L-F Lin, C-P Siauw, K-S Ho, et al.
Figure 2. Retrograde cholangiogram showing open biopsy forceps (arrow) at obstructing lesion. biliary introducer (HBI-1, Wilson-Cook) catheter, is a wire-guided, 2-lumen catheter t h a t can be used for both b r u s h i n g and o b t a i n i n g a biopsy specimen. The d r a w b a c k of this device is difficulty in advancing the forceps beyond the tip of t h e duodenoscope, even w h e n the duodenoscope is kept in a short position. When a Mighty forceps (Cook) is used, it only a c c e p t e d a n 0.018-inch guidewire, which had a tendency to become dislodged as the forceps was being i n t r o d u c e d into t h e bile duct. T a m a d a et al. 9 d e s c r i b e d u s e of a r o p e w a y - t y p e bile duct biopsy forceps for ETPB w i t h o u t EST in 12 patients, b u t special m a n i p u l a t i o n s were also n e c e s s a r y to avoid dislodging the guidewire during the procedure. In two studies of ETPB without ESTS, 9 and two of ETPB with EST, 2,3 the diameter of the forceps used was 1.8 ram. The diameter of the forceps used in the present study was slightly smaller (1.5 mm), b u t still sufficient for obtaining an adequate tissue sample. The guidewire technique described herein has the following advantages: (1) it can be performed with a guidewire of any s t a n d a r d d i a m e t e r (0.018-0.035 inch); (2) it is fast, as the forceps is not inserted through a catheter (as with the H B I catheter) or t h r e a d e d over a guidewire (as with ropeway-type forceps); and (3) there is less chance of dislodgement of the guidewire. In the HBI catheter method, the c a t h e t e r (diameter 10F) is first advanced over a guidewire, followed by introduction of the forceps t h r o u g h the H B I catheter; thus, two steps are required. In the guidewire technique described herein, as long as the elevator of the duodenoscope holds the guidewire tightly, t h e small forceps can be advanced through the accessory channel quickly; whereas, in the forceps along-the-wire (ropewayGASTROINTESTINAL ENDOSCOPY 2 7 3
F Junquera, E Brullet, R Campo, et al.
Endoscopic band ligation for bleeding small bowel vascular lesions
Table 1. Data summary for study patients No.
Gender
Age
1 2 3 4 5 6 7 8 9 10 11 12 13
M M M M M M M M F M F M M
65 75 66 54 76 64 62 64 57 65 88 55 73
Disease Icteric hepatoma Pancreatic head cancer Icteric hepatoma Gall bladder cancer Bile duct cancer Pancreas head cancer PSC Bile duct cancer Bile duct cancer Bile duct cancer Bile duct cancer Benign bile duct stricture Bile duct cancer
Location
Histologic results
CBD, RHD CBD CBD, LHD CBD CBD, CHD CBD CHD CHD CHD CBD CBD CHD CHD, RHD
Negative Positive Positive Negative Positive Negative Negative Positive Positive Positive Negative Negative Failure (after Billroth I)
CBD, Common bile duct; RHD, right hepatic duct; LHD, left hepatic duct; CHD, common hepatic duct; PSC, primary sclerosing cholangitis.
type biopsy forceps) method, care must be taken to avoid dislodging the guidewire. Prior insertion of a guidewire in the bile duct keeps the mucosal folds of the papilla1~ 11 flat and the pathway through the bile duct straight, making deep bile duct cannulation easier. The key point is to keep the duodenoscope close to the papilla, thereby allowing easy entrance into the bile duct whil e avoiding entry into the pancreatic duct. The reason for the failure of the technique in one patient was an inability to position the duodenoscope close to the papilla, owing to anatomic changes as a result of prior surgery (partial gastrectomy with Billroth I anastomosis). Thus, the guidewire technique described above is a viable alternative for obtaining ETPBs without EST. REFERENCES 1. Aabakken L, Karesen R, Serck-Hansen A, Osnes M. TranspapiUary biopsies and brush cytology from the common bile duct. Endoscopy 1986;18:49-51. 2. Kubota Y, Takaoka M, Tani If, Ogura M, Kin H, Fujimura I~ et al. Endoscopic transpapiilary biopsy for diagnosis of patients with pancreaticobiliary ductal strictures. Am J Gastroenterol 1993;88:1700-4.
3. Schoefl R, Haefner M, Wrba F, Pfeffel F, Stain C, Poetzi R, et al. Forceps biopsy and brush cytology during endoscopic retrograde cholangiopancreatography for the diagnosis ofbiliary stenoses. Scand J Gastroenterol 1997;32:363-8. 4. Sivak MV Jr. Endoscopic management of bile duct stones. Am J Surg 1989;158:228-40. 5. Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-93. 6. Shields SJ, Carr-Locke DL. Sphincterotomy techniques and risks. Gastrointest Endosc Clin N Am 1996;6:17-42. 7. Freeman ML. Complications of endoscopic sphincterotomy. Endoscopy 1998;30:A216-20. 8. Sugiyama M, Atemi Y, Wada N, Kuroda A, Mute T. Endoscopic transpapillary bile duct biopsy without sphincterotomy for diagnosing biliary strictures: a prospective comparative study with bile and brush cytology. Am J Gastroenterol 1996;91: 465-7. 9. Tamada K, Higashizawa T, Tomiyama T, Wada S, Ohashi A, Sateh Y, et al. Ropeway-type bile duct biopsy forceps with a side slit for a guidewire. Gastrointest Endosc 2001;53:89-92. 10. Allescher HD. Papilla of Vater: structure and function. Endoscopy 1989;21:324-9. 11. Paulsen FP, Bobka T, Tsokos M, Folsch UR, TiUmann BN. Functional anatomy of the papilla Vateri: biomechanical aspects and impact of difficult endoscopic intubation. Surg Endosc 2002;16:296-301.
Usefulness of endoscopic band ligation for bleeding small bowel vascular lesions F~lix Junquera, MD, Enric Brullet, MD, Rafel Campo, MD, Xavier Calvet, MD, Valentf Puig-Divi, ME), Mercedes Vergara, Received October 31, 2002. For revision January 8, 2003. Accepted April 28, 2003. Current affiliations: Endoscopy Unit, UDIAT-CD, Corporaci5 Parc Tauli, Sabadell, Spain. Reprint requests: Enric Brullet, MD, Endoscopy Unit, UDIAT-CD, Corporaci5 Parc Tauli, Parc Tauli s / n, 08208 SabadeU, Spain. Copyright 9 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067 / mge.2003.35 7 274
GASTROINTESTINAL ENDOSCOPY
MD
Background: The optimal therapy for bleeding small bowel vascular lesions is controversial. This study investigated the efficacy and safety of endoscopic band ligation in this clinical condition. Methods: Fourteen patients bleeding from angiodysplasia and 4 bleeding from Dieulafoy's lesions located in the small bowel were included in this pilot study. VOLUME 58, NO. 2, 2003