- Email: [email protected]
Pancreatic and biliary Endoscopic Ultrasound (EUS): is endoscopy necessary?
ENDOSCOPIC TECHNOLOG Y "~53
I"55
PRELIMINARY ASSESSMENT OF A HEMOCLIP DEVICE FOR HEMOSTASIS. R. Miazga and J. H. McCarthy. Methodist Hospital, Lubbock, Texas. The use of a simple mechanical device such as the endoscopic hemoclip has theoretical appeal because (i) it should provide permanent hemostasis with minimal bleeding recurrence, and (2) it should be associated with less complications than techniques that employ thermal energy and sclerosing agents which can produce fu~l thickness tissue injury. Benmoeller et al (Endoscopy 25:167-170, 1993) have reported on the use of this device in patients with nonvariceal upper gastrointestinal tract bleeding. However, the technique has not gained wide acceptance in the USA. In this study, we report on the use of endoscopic hemoclips in 20 patients admitted to our institution between 1/1992 and t2/1994. The average age of the patients was 73 with a range of 58 to 92 years. Two-thirds of the patients were male. Ten patients had bleeding peptic ulcers, three patients had bleeding esophageal varices, two patients had MalloryWeiss tears, and two patients had clips applied post-polypectomy (one for perforation and one for bleeding). Three patients had clips applied to bleeding GI tumors. Hemostasis was achieved in all the ulcer patients, and all but one of the ulcer patients had a straightforward course and did well.One patient died from causes not related to his peptic ulcer disease. The Mallory-Weiss tear patients did well. The patients with bleeding gastric tumors also responded to treatment. Patients with bleeding esophageal varices were only clipped when conventional sclerotherapy failed. In these three patients, the bleeding stopped following the application of hemoclips. One patient died from hepatic encephalopathy, two patients were discharged, and one of these was readmitted at a later date with further bleeding and died after he failed to respond to further sclerotherapy. In conclusion, the results of this preliminary study are very encouraging, and hopefully this device will be used in controlled studies in the near future.
RANDOMIZED PROSPECTIVE COMPARISON OF HIGH- AND LOW-COMPLIANCE BALLOON DILATORS IN PATIENTS WITH ACHALASIA S.M. Muehldorfer, E.G. Hahn, C. Ell. Dept. of Medicine, University of Erlangen-Nuremberg, Germany. Pneumatic dilatation is the most effective nonsurgical treatment of achalasia. Esophageal perforation is the most serious complication of this procedure occuring in about 5% of cases. We compared a high-comphance latex balloon (HCB) mounted on an endoscope (Pentax FG-29X, 40 mm max. distension diameter, 6 psi inflation pressure) with a low-compliance balloon (LCB) (Microvasive Rigiflex ABD, 35 mm, 20 psi) which is said to be safer, since it increases esophageal wall tension in the stenotic zone only. Methods: We studied the complications in 25 patients after dilatation and a symptom score prior to and every 6 months up to 2 years after dilatation. A symptom score for dysphagia, regurgitation and chest pain was calculated by multiplying the frequency of a symptom (0-5) by the severity (0-4). Complications were graded for severity from none to perforation (0 3). All dilatations were performed for 3 minutes under direct endoscopic control. Patients were assigned to the two different balloon types by random. The obtained data were analysed by using Wilcoxon rank-sum test. Results: One perforation was seen in the LCB-group, which reached not statistical significance. Superficial mucosal tears appeared in 42% of all dilatations (n.s. between HCB and LCB). Initial dilatation treatment was successful in all 25 patients. There were no significant differences in the pre- and post-treatment symptom scores. Symptom score pre post 6 post 12 post 18 post 24 HCB 160 76 7.4 8.2 3.0 LCB 16.7 59 7.5 4.6 8.5 Three patients required repeated dilatations during the observation period They were treated with the competitive balloon system and showed no difference compared with the initial post-treatment symptom score. Conclusion:No significant difference concerning the complication rate and the clinical outcome could be demonstrated between the HCB- and LCB system. In consequence both systems appear equally effective, even if the scope-mounted systen (HCB) can be handled easier.
54
~56
A BLINDED CONTROLLED COMPARISON OF HIGH RESOLUTION ENDOLUMINAL SONOGRAPHY TO VIDEO ENDOSCOPY IN THE DETECTION AND EVALUATION OF ESOPHAGEAL VARICES. L.S, Miller, T. Schiano, J.B. Liu, H. Ter, S. Bellary, M. Dabezies, M. Black. Temple University School of Medicine, Phila., PA Introduction: In light of the fact that high resolution endoluminal sonography (HRES) has been found to be the most sensitive imaging modality for the detection of gastric varices,* HRES was used to detect and grade esophageal varices in patients with known cirrhosis. Methods: 9 normal controls and 33 patients with known cirrhosis underwent HRES with a 20 MHz ultrasound transducer (Endosound, Microvasive) passed through a 34 Fr endoscope. The lumen of the esophagus was maximally distended with water. Endoscopy (EGD) was performed immediately after ultrasonography and the esophageal lumen was maximally distended with air. Both procedures were videotaped. An investigator blinded to both procedures reviewed the videotapes to determine the presence and size of varices in the distal 5cm of the esophagus above the diaphragmatic hiatus. The reviewer graded the largest varix in each patient based on a 4 point grading system: Grade I = n o vat'ices; Grade II =varices 0-30% of the radius of the lumen; Grade III =30-60% of the radius of the lumen; Grade IV=6fl-100% of the radius of the lumen. The number of patients in each grade was determined for each procedure and a Spearman correlation coefficient was calculated between HRES and EGD2 Results: All 9 of the control patients were correctly identified by both HRES and EGD as Grade I (no varices). The number of cirrhotic pts. with each grade of varices were graded as follows: Grade I II III IV EGD 5 15 9 4
PANCREATIC AND BILIARY ENDOSCOPIC ULTRASOUND (EUS): IS ENDOSCOPY NECESSARY? B Napoldon, B Pujol, O KerivenSouquet, JC Souquet. Clinique Saint Jean, 30 Rue Bataille, 69008 Lyon, HSpital E Herriot, Lyon, France.
HRES compared to EGD overestimated the grade of esophageal varices in 18 pts, underestimated the grade of esophageal varices in 3 pts and graded 12 pts the same. The correlation between the grade of HRES and EGD was i'=0.8. EGD failed to identify 4 of 9 patients (44%) with varices that were identified as grade II by HRES. Conclusions: HRES is a more sensitive imaging morality than EGD for the detection of small (grade II) esophageal varices. There is a good correlation between the size of varices measured by HRES and the size measured by EGD. Detection of esophageal varices by HRES at a less advanced stage in the development of portal hypertension may make earlier therapeutic intervention feasible. *Radiology 1993;187:363-366
VOLUME 41, NO. 4, 1995
Blind ultrasound probes have been used for the exploration of the esophagus and upper part of the stomach. For the biliary tree or the pancreas, exl~lorations were always performed wit h echoendoscopes, larger in diameter, more fragile, and more expensive. Indeed endoscopy was considered as mandatory to insert the probe into the second duodenum. With experience however, the probe can be pushed only under echo guidance. Therefore we prospectively compared the 2 methods of probe insertion. Methods: 40 consecutive patients submitted to biliary or pancreatic EUS (Olympus G UM20) under anesthesia, were randomized in 2 groups: in the first group (n=20), EUS was performed as usually using endoscopy to pass the pylorus, while in the second (n=20), EUS was performed without endoscopic vision (light off). The time necessary to push the probe from the mediastinum (aortic arch) to the second duodenum (scan with the aorta and the inferior vena cava) was measmed. Then the exploration of the pancreas through the duodenum and the stomach was recorded. The tapes were reviewed by 2 independant operators different from the 2 who performed the examinations: the quality of duodenal and gastric explorations were graded from 1 to 5 according to the presence or absence of artefacts. Results: The 2 groups were similar for age, sex, indications of EUS, number of previous cholecystectomy (respectively 9 and 5 patients). No complications were noted. In each group, exploration was incomplete in one case due to duodenal stenosis. Then the change of method did not allow a better exploration. Group
n
Endoscopy Echography
20 20
Median time sec 54-+7 35+-5 p<0.05
Quality (sum of 2 reviewers) duodenum stomach 6.9+0.2 5.9+0,4 7.1+0.3 6,7+-0,4 NS NS
Conclusions: Insertion of the ultrasonic probe into the duodenum could be :done safely under echoguidance, ie without endoscopic vision. It was even quicker, perhaps by avoiding air insufflation and pylorus visualization Transgastric exploration quality was slightly decreased after air insuffiation. Thus blind ultrasonic probe, potentially cheaper and less fragile could be .used for bi!iary and pancreatic examinations.
GASTROINTESTINAL ENDOSCOPY
309
I"55
PRELIMINARY ASSESSMENT OF A HEMOCLIP DEVICE FOR HEMOSTASIS. R. Miazga and J. H. McCarthy. Methodist Hospital, Lubbock, Texas. The use of a simple mechanical device such as the endoscopic hemoclip has theoretical appeal because (i) it should provide permanent hemostasis with minimal bleeding recurrence, and (2) it should be associated with less complications than techniques that employ thermal energy and sclerosing agents which can produce fu~l thickness tissue injury. Benmoeller et al (Endoscopy 25:167-170, 1993) have reported on the use of this device in patients with nonvariceal upper gastrointestinal tract bleeding. However, the technique has not gained wide acceptance in the USA. In this study, we report on the use of endoscopic hemoclips in 20 patients admitted to our institution between 1/1992 and t2/1994. The average age of the patients was 73 with a range of 58 to 92 years. Two-thirds of the patients were male. Ten patients had bleeding peptic ulcers, three patients had bleeding esophageal varices, two patients had MalloryWeiss tears, and two patients had clips applied post-polypectomy (one for perforation and one for bleeding). Three patients had clips applied to bleeding GI tumors. Hemostasis was achieved in all the ulcer patients, and all but one of the ulcer patients had a straightforward course and did well.One patient died from causes not related to his peptic ulcer disease. The Mallory-Weiss tear patients did well. The patients with bleeding gastric tumors also responded to treatment. Patients with bleeding esophageal varices were only clipped when conventional sclerotherapy failed. In these three patients, the bleeding stopped following the application of hemoclips. One patient died from hepatic encephalopathy, two patients were discharged, and one of these was readmitted at a later date with further bleeding and died after he failed to respond to further sclerotherapy. In conclusion, the results of this preliminary study are very encouraging, and hopefully this device will be used in controlled studies in the near future.
RANDOMIZED PROSPECTIVE COMPARISON OF HIGH- AND LOW-COMPLIANCE BALLOON DILATORS IN PATIENTS WITH ACHALASIA S.M. Muehldorfer, E.G. Hahn, C. Ell. Dept. of Medicine, University of Erlangen-Nuremberg, Germany. Pneumatic dilatation is the most effective nonsurgical treatment of achalasia. Esophageal perforation is the most serious complication of this procedure occuring in about 5% of cases. We compared a high-comphance latex balloon (HCB) mounted on an endoscope (Pentax FG-29X, 40 mm max. distension diameter, 6 psi inflation pressure) with a low-compliance balloon (LCB) (Microvasive Rigiflex ABD, 35 mm, 20 psi) which is said to be safer, since it increases esophageal wall tension in the stenotic zone only. Methods: We studied the complications in 25 patients after dilatation and a symptom score prior to and every 6 months up to 2 years after dilatation. A symptom score for dysphagia, regurgitation and chest pain was calculated by multiplying the frequency of a symptom (0-5) by the severity (0-4). Complications were graded for severity from none to perforation (0 3). All dilatations were performed for 3 minutes under direct endoscopic control. Patients were assigned to the two different balloon types by random. The obtained data were analysed by using Wilcoxon rank-sum test. Results: One perforation was seen in the LCB-group, which reached not statistical significance. Superficial mucosal tears appeared in 42% of all dilatations (n.s. between HCB and LCB). Initial dilatation treatment was successful in all 25 patients. There were no significant differences in the pre- and post-treatment symptom scores. Symptom score pre post 6 post 12 post 18 post 24 HCB 160 76 7.4 8.2 3.0 LCB 16.7 59 7.5 4.6 8.5 Three patients required repeated dilatations during the observation period They were treated with the competitive balloon system and showed no difference compared with the initial post-treatment symptom score. Conclusion:No significant difference concerning the complication rate and the clinical outcome could be demonstrated between the HCB- and LCB system. In consequence both systems appear equally effective, even if the scope-mounted systen (HCB) can be handled easier.
54
~56
A BLINDED CONTROLLED COMPARISON OF HIGH RESOLUTION ENDOLUMINAL SONOGRAPHY TO VIDEO ENDOSCOPY IN THE DETECTION AND EVALUATION OF ESOPHAGEAL VARICES. L.S, Miller, T. Schiano, J.B. Liu, H. Ter, S. Bellary, M. Dabezies, M. Black. Temple University School of Medicine, Phila., PA Introduction: In light of the fact that high resolution endoluminal sonography (HRES) has been found to be the most sensitive imaging modality for the detection of gastric varices,* HRES was used to detect and grade esophageal varices in patients with known cirrhosis. Methods: 9 normal controls and 33 patients with known cirrhosis underwent HRES with a 20 MHz ultrasound transducer (Endosound, Microvasive) passed through a 34 Fr endoscope. The lumen of the esophagus was maximally distended with water. Endoscopy (EGD) was performed immediately after ultrasonography and the esophageal lumen was maximally distended with air. Both procedures were videotaped. An investigator blinded to both procedures reviewed the videotapes to determine the presence and size of varices in the distal 5cm of the esophagus above the diaphragmatic hiatus. The reviewer graded the largest varix in each patient based on a 4 point grading system: Grade I = n o vat'ices; Grade II =varices 0-30% of the radius of the lumen; Grade III =30-60% of the radius of the lumen; Grade IV=6fl-100% of the radius of the lumen. The number of patients in each grade was determined for each procedure and a Spearman correlation coefficient was calculated between HRES and EGD2 Results: All 9 of the control patients were correctly identified by both HRES and EGD as Grade I (no varices). The number of cirrhotic pts. with each grade of varices were graded as follows: Grade I II III IV EGD 5 15 9 4
PANCREATIC AND BILIARY ENDOSCOPIC ULTRASOUND (EUS): IS ENDOSCOPY NECESSARY? B Napoldon, B Pujol, O KerivenSouquet, JC Souquet. Clinique Saint Jean, 30 Rue Bataille, 69008 Lyon, HSpital E Herriot, Lyon, France.
HRES compared to EGD overestimated the grade of esophageal varices in 18 pts, underestimated the grade of esophageal varices in 3 pts and graded 12 pts the same. The correlation between the grade of HRES and EGD was i'=0.8. EGD failed to identify 4 of 9 patients (44%) with varices that were identified as grade II by HRES. Conclusions: HRES is a more sensitive imaging morality than EGD for the detection of small (grade II) esophageal varices. There is a good correlation between the size of varices measured by HRES and the size measured by EGD. Detection of esophageal varices by HRES at a less advanced stage in the development of portal hypertension may make earlier therapeutic intervention feasible. *Radiology 1993;187:363-366
VOLUME 41, NO. 4, 1995
Blind ultrasound probes have been used for the exploration of the esophagus and upper part of the stomach. For the biliary tree or the pancreas, exl~lorations were always performed wit h echoendoscopes, larger in diameter, more fragile, and more expensive. Indeed endoscopy was considered as mandatory to insert the probe into the second duodenum. With experience however, the probe can be pushed only under echo guidance. Therefore we prospectively compared the 2 methods of probe insertion. Methods: 40 consecutive patients submitted to biliary or pancreatic EUS (Olympus G UM20) under anesthesia, were randomized in 2 groups: in the first group (n=20), EUS was performed as usually using endoscopy to pass the pylorus, while in the second (n=20), EUS was performed without endoscopic vision (light off). The time necessary to push the probe from the mediastinum (aortic arch) to the second duodenum (scan with the aorta and the inferior vena cava) was measmed. Then the exploration of the pancreas through the duodenum and the stomach was recorded. The tapes were reviewed by 2 independant operators different from the 2 who performed the examinations: the quality of duodenal and gastric explorations were graded from 1 to 5 according to the presence or absence of artefacts. Results: The 2 groups were similar for age, sex, indications of EUS, number of previous cholecystectomy (respectively 9 and 5 patients). No complications were noted. In each group, exploration was incomplete in one case due to duodenal stenosis. Then the change of method did not allow a better exploration. Group
n
Endoscopy Echography
20 20
Median time sec 54-+7 35+-5 p<0.05
Quality (sum of 2 reviewers) duodenum stomach 6.9+0.2 5.9+0,4 7.1+0.3 6,7+-0,4 NS NS
Conclusions: Insertion of the ultrasonic probe into the duodenum could be :done safely under echoguidance, ie without endoscopic vision. It was even quicker, perhaps by avoiding air insufflation and pylorus visualization Transgastric exploration quality was slightly decreased after air insuffiation. Thus blind ultrasonic probe, potentially cheaper and less fragile could be .used for bi!iary and pancreatic examinations.
GASTROINTESTINAL ENDOSCOPY
309