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Multibite: A new four shot biopsy forceps compared to a standard single shot forceps. A prospective randomized study
ENDOSCOPIC TECHNOLOGY ~49 SAFETY AND EFFICACY OF PHOTODYNAMIC THERAPY (PDT) IN LARGE VILLOUS RECTAL TUMORS.JC Saurin. S Ecuer, F Descos, R Lambert. Department of Digestive Diseases. HSpital Edouard Herriot. Lyon. France. Aim : to evaluate the endoscopic response of villous rectal turnouts to PDT and the safety of this treatment modality. Methods : Seventeen patients were treated with PDT for villous noncancerous rectal tumours between 1990 and 1994. The median initial villous surface (mis), evaluated at endoscopy was 22.2 cm 2 (range 1280). Initial histology was severe dysplasia in 5 cases, and moderate dysplasia in 12. Rectal endosonography was performed in all but 2 patients before treatment. These turnouts were classified as superficials (T1N0). The PDT treatment was proposed after failure of Nd-Yag laser therapy or surgery in 7 patients and as a primary treatment in 10. The irradiation was performed 48 to 72 h after,iv administration of the photosensitizer (Photophrin II, Lederle-Cyanamid, 2 mg/kg) using a flexible quartz fibber with an annular light distributor. The laser beam had a wave-length of 630 nm and the dose delivered to the tumour surface was 60 J/min at a power of 1W. Endoscopic response was evaluated 12 month after each PDT session. The patients were informed about the risk of cutaneous photosensitization. Results : Each patient underwent 1 PDT session. The observed reduction in tumor surface was less than 20 % in 2 cases (mis 41 cm 2 ), 20-50 % in 8 cases (mis 21.2 cm2), > 50 % in 7 cases (mis 17.4 cm2). There was no early local complication but mild rectal discomfort in 5 cases. Mild cutaneous photosensitization occurred in 2 patients. Delayed non symptomatic rectal stenosis were observed in 5 patients, consecutively to PDT and Nd-Yag laser treatment, justifying rectal dilatation in 3 for later endoscopic surveillance. Tumor eradication was achieved .with PDT alone in one patient. Sixteen patients had subsequent endoscopic or surgical treatment. C o n c l u s i o n : PDT treatment of large rectal villous tumours permits a variable reduction of the tumor surface and is well tolerated. One single PDT session is not sufficient for the treatment of large villous tumours. The efficacy of repeated PDT sessions or its combination with other endoscopic treatments is to be determined prospectively.
GIF TYPE N-30 GASTROSCOPE FOR PASSAGE THROUGH ESOPHAGEAL STRICTURES: AN ALTERNATIVE TO FLUOROSCOPIC PLACEMENT OF GUIDE-WIR.ES FOR THE DILATION OF IMPASSABLE STRICTURES. DM Scheider, J Cohen, JA Dorais, AB Elfant, MJ Bourke, GA DuVall, M Abedi, GB Haber, G Kandel, P Kortan, NE Marcon. The Wellesley Hospital, Toronto, Canada Guide-wira assisted esophageal dilation with fluoroscopy is an established and safe technique for the dilation of esophageal strictures that cannot be negotiated with an endoscope. However, the requirement for its use cannot be predicted prior to index endoscopy, which may neCessitate repeated endoscopy when fluoroscopy is available. METHODS,: An Olympus GIF type N-30 gastroscope (pediatric GI fiberscope) was evaluated for passage through esophageal strictures that were impassable using a standard 9.8 mm gastroscope. The GIF N-30 has a 5.3 mm diameter with a standard 2.0 mm instrument channel. From 10/94 to 12/95 41 pts with esophageal strictures that would not allow passage of a standard 9.8 mm endoscope were evaluated. The pts ranged in age from 54 to 86 yrs (Mean 71.0, 26M). The esophageal sfficturos were neoplastic in 23 pts: adenocarcinoma- 12, squamous cell8, lung cancer- 3. In 18 pts the strictures were benign: radiation- 7, peptic8, anastomotic- 2, and lye- 1. Mean stricture length was 5.59 cm and location was proximal- 12, mid- 8, and distal- 21. .RESULTS: At index endoscopy the N-30 gestroscope successfully passed 33 of 41 strictures (80.0%) that were impassable using a standard gastroscopa. Success was achieved in 18/23 neoplastic strictures (78.2%) and in 15/18 benign strictures (83.3%). Conventional Savary dilation was then performed with the passage of standard guide-wires followed by dilators. The N-30 ~ s s f u l l y traversed strictures in 3 lOtSwho had failed fluoroscopic attempts at guidewire plaCement during index endoscopy. No complications were experienCed. In the 8 pts who had impassable strictures: 5 had repeated endoscopy that s a m e day when fluoroscopic time was available, but required resedation; 3 pts were rescheduled with fluoroscopy on another day. Fluoroscopic guide.wire placement followed by stricture dilation was successful in all 8 pts. CONCLUSIONS: (1) Th(~ N-30 gastroscope is safe and effective for passing esophageal strictures through which standard gastroscopes cannot pass. (2) The scope offers a viable alternative at index endoscopy in cases of impassable strictures and may obviate another endoscopic session when fluoroscopy is not readily available.
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EARLY EXPERIENCE WITH A NEW METAL STENT (ENDOCOIL R) FOR BILIARY AND PANCREATIC STRICTURES: LIMITATIONS OF THE CURRENT DESIGN. DM Scheider, J Cohen, JA Dorais, P Kortan, GB Haber. The Wellesley Hospital. Toronto, Canada. Biliary metallic stents offer improved efficacy due to lower incidenCes of occlusion and migration. A new ceil design is conceptually attractive, but clinical evaluation has been limited. METHODS: The EndoCoilR (EC) [Instent Inc.] is comprised of a nicldetitanium fiat wire wound into a coil configuration with a central section of adjacent ceils (dia. 24F) and open-coiled flared ends (dia. 26F) to prevent migration. EC shorten upon release from the insertion catheter by 55%. From 9/93 to 12/95 15 biliary and 2 pancreatic EC ware inserted into 17 pts (14M, mean age 72 yr). 15 biliary stents (length 5.0 to 7.0 cm) were plaCed into common bile duct (CBD) strictures: malignant-11, benign- 4. Malignant strictures were pancreas- 5, bile duct- 3, and one each of the ampulla, metastatic stomach and colon. Benign strictures were due to chronic pancreatitis- 3 and sclerosing cholangitis- 1. Strictures location was: ampulla- 1, distal CBD- 12, and mid CBD- 2. Mean stricture length was 3.4 cm. Pancreatic EC (3.5 cm, no flared ends) were inserted into 2 pts with chronic pancreatitis and proximal PD strictures. All pts ware prospectively followed to EC occlusion, migration, or death (mean flu 73d, r: 3-331). RESULTS: Successful insertion was achieved in 13/15 biliary and in 2/2 pancreatic EC (88%). Technical problems with delivery occurred with 2 biliary EC: delivery catheter fracture during forceful removal from a partially expanded stent leaving the tip trapped above the stent and ampullary tissue embedded between open coils of the distal flared end resulting in occulsion and cholangitis 3 d later that required endoscopic removal. Other immediate problems were central section twist (straight @ 20d flu) and inCOmplete expansion in 2 (fully expanded at 5 & 21d f/u). Overall, relief of jaundiCe was achieved in 12/15 (80%): Late complications included EC migration out of the duct (3/15 biliary EC, 1/2 pancreatic EC), pancreatic EC migration into the PD requiring retrieval, and tumor ingrowth causing biliary EC occulsion in 3/15 (cholangitis-1) at a median time of 49d, range 21-150. EC mortality was zero and life-threatening complications occurred in 2/17 pts (12%). Longest EC patency was 331d. CONCLUSIONS: (1) EC are limited to use in the distal CBD due to their 55% shortening on release. (2) Tight strictures may limit initial EC expansion, thereby delaying biliary decompression. (3) The distal opencoiled end can embed ampullary tissue resulting in occlusion. (4) Flared ends for pancreatic EC are necessary to avoid migration.
MULTIBITE : A NEW FOUR SHOT BIOPSY FORCEPS COMPARED TO A STANDARD SINGLE SHOT FORCEPS. A PROSPECTIVE RANDOMIZED STUDY. JA See 1, M Sibony2, P Callard2, F Bodin t . Services de Gastroent6rologie ~ et d'Anatomopathologie 2 , H6pital Tenon, Paris, France. Multiple biopsies for G1 lesions such as gastric ulcers is a time consuming procedure. In order to reduce the time needed to perform the biopsies, Multibite (Microvasive, Natick, Mass) a new forceps allowing 4 biopsy samples to be taken in a single intubation of the operating channel of the endoscope was developped. The aim of this study was to compare Multibite to one of the most widely used conventional biopsy forceps : FB 24 U (Olympus, Japan). Twelve patients were included in the study. They all had a macroscopically normal antrum and were biopsied 4 times with each forceps in a randomized order. Time needed to perform the biopsies was measured with each forceps. Than, biopsy samples were labeled and sent for pathological examination. The largest diameter was measured, the deepest layer involved was identified using a score from 1 to 4 (epithelium to submucosa). Presence of crush artefacts was specified. Time needed to perform 4 biopsies and put them in the fixative was 81 + 15 sec for muhibite and 132 + 18 sec for the one shot forceps (p<0.01). The largest diameter of each biopsy sample was 2.8 + 1.1 nun with muhibite and 2.8 • mm with the standard forceps (NS). The deepest layer involved using our score was 2.9 + 0.9 with muhibite and 24 • 0.6 with the other forceps (p
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY 303
GIF TYPE N-30 GASTROSCOPE FOR PASSAGE THROUGH ESOPHAGEAL STRICTURES: AN ALTERNATIVE TO FLUOROSCOPIC PLACEMENT OF GUIDE-WIR.ES FOR THE DILATION OF IMPASSABLE STRICTURES. DM Scheider, J Cohen, JA Dorais, AB Elfant, MJ Bourke, GA DuVall, M Abedi, GB Haber, G Kandel, P Kortan, NE Marcon. The Wellesley Hospital, Toronto, Canada Guide-wira assisted esophageal dilation with fluoroscopy is an established and safe technique for the dilation of esophageal strictures that cannot be negotiated with an endoscope. However, the requirement for its use cannot be predicted prior to index endoscopy, which may neCessitate repeated endoscopy when fluoroscopy is available. METHODS,: An Olympus GIF type N-30 gastroscope (pediatric GI fiberscope) was evaluated for passage through esophageal strictures that were impassable using a standard 9.8 mm gastroscope. The GIF N-30 has a 5.3 mm diameter with a standard 2.0 mm instrument channel. From 10/94 to 12/95 41 pts with esophageal strictures that would not allow passage of a standard 9.8 mm endoscope were evaluated. The pts ranged in age from 54 to 86 yrs (Mean 71.0, 26M). The esophageal sfficturos were neoplastic in 23 pts: adenocarcinoma- 12, squamous cell8, lung cancer- 3. In 18 pts the strictures were benign: radiation- 7, peptic8, anastomotic- 2, and lye- 1. Mean stricture length was 5.59 cm and location was proximal- 12, mid- 8, and distal- 21. .RESULTS: At index endoscopy the N-30 gestroscope successfully passed 33 of 41 strictures (80.0%) that were impassable using a standard gastroscopa. Success was achieved in 18/23 neoplastic strictures (78.2%) and in 15/18 benign strictures (83.3%). Conventional Savary dilation was then performed with the passage of standard guide-wires followed by dilators. The N-30 ~ s s f u l l y traversed strictures in 3 lOtSwho had failed fluoroscopic attempts at guidewire plaCement during index endoscopy. No complications were experienCed. In the 8 pts who had impassable strictures: 5 had repeated endoscopy that s a m e day when fluoroscopic time was available, but required resedation; 3 pts were rescheduled with fluoroscopy on another day. Fluoroscopic guide.wire placement followed by stricture dilation was successful in all 8 pts. CONCLUSIONS: (1) Th(~ N-30 gastroscope is safe and effective for passing esophageal strictures through which standard gastroscopes cannot pass. (2) The scope offers a viable alternative at index endoscopy in cases of impassable strictures and may obviate another endoscopic session when fluoroscopy is not readily available.
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EARLY EXPERIENCE WITH A NEW METAL STENT (ENDOCOIL R) FOR BILIARY AND PANCREATIC STRICTURES: LIMITATIONS OF THE CURRENT DESIGN. DM Scheider, J Cohen, JA Dorais, P Kortan, GB Haber. The Wellesley Hospital. Toronto, Canada. Biliary metallic stents offer improved efficacy due to lower incidenCes of occlusion and migration. A new ceil design is conceptually attractive, but clinical evaluation has been limited. METHODS: The EndoCoilR (EC) [Instent Inc.] is comprised of a nicldetitanium fiat wire wound into a coil configuration with a central section of adjacent ceils (dia. 24F) and open-coiled flared ends (dia. 26F) to prevent migration. EC shorten upon release from the insertion catheter by 55%. From 9/93 to 12/95 15 biliary and 2 pancreatic EC ware inserted into 17 pts (14M, mean age 72 yr). 15 biliary stents (length 5.0 to 7.0 cm) were plaCed into common bile duct (CBD) strictures: malignant-11, benign- 4. Malignant strictures were pancreas- 5, bile duct- 3, and one each of the ampulla, metastatic stomach and colon. Benign strictures were due to chronic pancreatitis- 3 and sclerosing cholangitis- 1. Strictures location was: ampulla- 1, distal CBD- 12, and mid CBD- 2. Mean stricture length was 3.4 cm. Pancreatic EC (3.5 cm, no flared ends) were inserted into 2 pts with chronic pancreatitis and proximal PD strictures. All pts ware prospectively followed to EC occlusion, migration, or death (mean flu 73d, r: 3-331). RESULTS: Successful insertion was achieved in 13/15 biliary and in 2/2 pancreatic EC (88%). Technical problems with delivery occurred with 2 biliary EC: delivery catheter fracture during forceful removal from a partially expanded stent leaving the tip trapped above the stent and ampullary tissue embedded between open coils of the distal flared end resulting in occulsion and cholangitis 3 d later that required endoscopic removal. Other immediate problems were central section twist (straight @ 20d flu) and inCOmplete expansion in 2 (fully expanded at 5 & 21d f/u). Overall, relief of jaundiCe was achieved in 12/15 (80%): Late complications included EC migration out of the duct (3/15 biliary EC, 1/2 pancreatic EC), pancreatic EC migration into the PD requiring retrieval, and tumor ingrowth causing biliary EC occulsion in 3/15 (cholangitis-1) at a median time of 49d, range 21-150. EC mortality was zero and life-threatening complications occurred in 2/17 pts (12%). Longest EC patency was 331d. CONCLUSIONS: (1) EC are limited to use in the distal CBD due to their 55% shortening on release. (2) Tight strictures may limit initial EC expansion, thereby delaying biliary decompression. (3) The distal opencoiled end can embed ampullary tissue resulting in occlusion. (4) Flared ends for pancreatic EC are necessary to avoid migration.
MULTIBITE : A NEW FOUR SHOT BIOPSY FORCEPS COMPARED TO A STANDARD SINGLE SHOT FORCEPS. A PROSPECTIVE RANDOMIZED STUDY. JA See 1, M Sibony2, P Callard2, F Bodin t . Services de Gastroent6rologie ~ et d'Anatomopathologie 2 , H6pital Tenon, Paris, France. Multiple biopsies for G1 lesions such as gastric ulcers is a time consuming procedure. In order to reduce the time needed to perform the biopsies, Multibite (Microvasive, Natick, Mass) a new forceps allowing 4 biopsy samples to be taken in a single intubation of the operating channel of the endoscope was developped. The aim of this study was to compare Multibite to one of the most widely used conventional biopsy forceps : FB 24 U (Olympus, Japan). Twelve patients were included in the study. They all had a macroscopically normal antrum and were biopsied 4 times with each forceps in a randomized order. Time needed to perform the biopsies was measured with each forceps. Than, biopsy samples were labeled and sent for pathological examination. The largest diameter was measured, the deepest layer involved was identified using a score from 1 to 4 (epithelium to submucosa). Presence of crush artefacts was specified. Time needed to perform 4 biopsies and put them in the fixative was 81 + 15 sec for muhibite and 132 + 18 sec for the one shot forceps (p<0.01). The largest diameter of each biopsy sample was 2.8 + 1.1 nun with muhibite and 2.8 • mm with the standard forceps (NS). The deepest layer involved using our score was 2.9 + 0.9 with muhibite and 24 • 0.6 with the other forceps (p
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY 303