Patient satisfaction with sedation for flexible bronchoscopy

Background and objective:   Patient satisfaction with health care has increasingly been recognized as an important health outcome, but few studies have examined patient satisfaction with flexible bronchoscopy (FB). The purpose of this study was to assess patient satisfaction with FB conducted under conscious sedation and to identify the aspects of the procedure related to patient satisfaction.
Methods:   Patients' willingness to return for repeat FB was measured on a 5-point scale. Patients were asked whether they were bothered by the anaesthetic spray, scope insertion, shortness of breath, coughing, pharyngeal pain, chest pain or swallowing pain. Patients were asked to assess the quality of the physician, the institution and nursing, and their satisfaction with the privacy, waiting time and information provided about the procedure.
Results:   Of 161 consecutive eligible patients who underwent FB, 129 (80.1%) completed the questionnaire. Of the 129 patients, 65.8% reported that they would return for a repeat FB (12.4% would definitely return and 53.4% would probably return). Male gender, shorter examination time, excellent physician quality and not being bothered by coughing, pharyngeal pain or swallowing pain were related to greater patient satisfaction. The results of multiple logistic regression analysis showed that male gender was related to greater patient satisfaction.
Conclusions:   Bronchoscopists should try to recognize the factors that influence patient satisfaction and adjust their management accordingly.     

Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: Efficacy and analysis of factors that favor stone fragmentation

Background and Aim:  Difficult common bile duct stones (CBD) are those not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon. The role of extracorporeal shock wave lithotripsy (ESWL) in stone fragmentation and clearance of difficult CBD stones and the factors which favor fragmentation were prospectively evaluated in the present study.
Methods:  A total of 283 patients with large CBD stones were subjected to ESWL. A maximum of 5000 shocks was delivered per session until CBD stones were fragmented to less than 5 mm diameter. CBD was cleared by biliary endotherapy using a basket or balloon. Outcome was assessed by CBD clearance.
Results:  Total CBD clearance was achieved in 239 patients (84.4%) and partial CBD clearance in 35 patients (12.3%). Three or fewer sessions of ESWL were required in 74.6% of patients. Minor complications were seen in 45 patients (15.9%). There was no procedure-related mortality. Epidural anesthesia, shock frequency of 90/min, radiolucent calculi and presence of fluid around the calculus helped in better fragmentation.
Conclusion:  A high success rate, negligible complications and non-invasive nature of the procedure make ESWL a useful tool for removing large CBD stones.     

Endoscopic retrograde cholangiopancreatography in hepatic alveolar echinococcosis

Background and Aim:  Hepatic alveolar echinococcosis (HAE) involves both the vascular and biliary structures of the liver. Endoscopic retrograde cholangiopancreatography (ERCP) is said to be an alternative for the diagnosis and treatment of biliary complications of HAE. We present here our experience with ERCP in HAE.
Methods:  We followed 13 patients who underwent ERCP for the treatment of biliary complications of HAE in the endoscopy unit of our clinic at Ataturk University School of Medicine, Erzurum between January 2002 and June 2008.
Results:  Eight men and five women were followed up. Mean age was 43.2 (24–64 years). All patients had non-resectable HAE. Indications for ERCP were biliary fistula in seven patients, obstructive jaundice in five patients and cholangitis in one patient. Endoscopic sphincterotomy (ES) was carried out in 12 patients, and in one patient with biliary leakage, a stent was inserted into the right hepatic branch. ERCP findings were dilated common bile duct, irregular narrowing and distortion of the common bile duct and common hepatic duct, communication with the cystic cavity or biliocutaneous fistula and complete disappearance of the biliary tree above the level of the common hepatic duct or hepatic bifurcation. In patients with biliary leakage, biliary drainage decreased only in two patients after ERCP and in patients with obstructive jaundice, the high bilirubin levels decreased in only one patient.
Conclusion:  ERCP showed structural changes of the external biliary tract and ES has a limited effect on these changes and stents can be used in selected cases.     

Effect of ursodeoxycholic acid on serum liver enzymes and bile acid metabolism in chronic active hepatitis C virus infection

Aim:  Many reports have revealed ursodeoxycholic acid (UDCA) to be effective against chronic hepatitis C virus (HCV). However, some cases resist this therapy and the mechanism of action remains unclear. In this study, UDCA was administered to patients with chronic HCV and the correlation between the bile acids of the biliary bile and serum and the drug efficacy was investigated.
Methods:  Fifteen patients were given 600 mg/day of UDCA for more than 24 weeks. The serum bile acid concentrations and biliary and serum bile acid were collected before and after 24 weeks of UDCA treatment, and composition determined by high-performance liquid chromatography.
Results:  The treatment was effective in nine cases (ALT decreased to less than twice the normal values 80 IU/L) and ineffective in six cases. There was no significant difference in the serum bile acid concentrations before and after UDCA treatment between the values of both cases. After UDCA treatment, the serum percentage of UDCA (effective, 62.5 ± 2.0; ineffective, 53.5 ± 2.5, ( P  = 0.02)) and the percentage of chenodeoxycholic acid (CDCA) showed no remarkable changes. In the biliary bile the percentage of CDCA (effective, 30.9 ± 2.0; ineffective, 20.0 ± 3.0, ( P  = 0.007)) and the percentage of UDCA showed no remarkable changes.
Conclusion:  In the effective cases, the percentage of UDCA in the serum and the percentage of CDCA in biliary bile were significantly higher than in the ineffective cases. This indicates that, when effective, CDCA decreases in hepatocytes and this reduction contributes to hepatoprotection.     

Magnetic resonance cholangiography using half-Fourier acquisition for diagnosing choledocholithiasis

Objective: Magnetic resonance cholangiography (MRC), using a half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence, noninvasively provides very rapid (1–2 s) and high-quality images of the biliary tract. We assessed the diagnostic usefulness of HASTE-MRC for choledocholithiasis.
Methods: A total of 101 patients with suspected choledocholithiasis underwent MRC, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 97 patients in whom ERCP fully depicted the common bile duct, we retrospectively analyzed the capability of MRC to image the common bile duct and to diagnose choledocholithiasis, in comparison with that of ultrasonography.
Results: In 34 patients, ERCP demonstrated bile duct stones, which were confirmed at endoscopic or surgical treatment. The common bile duct was fully delineated in 98% by MRC and in 70% by ultrasonography. MRC (91%) was more sensitive than ultrasonography (71%) for detecting choledocholithiasis (   p < 0.05  ). MRC demonstrated bile duct stones in all patients with stones ≥11 mm but missed calculi in the 29% of patients with small (3–5 mm) stones. MRC was capable of detecting choledocholithiasis regardless of bile duct caliber. The specificity of MRC (100%) was higher than that of ultrasonography (95%).
Conclusion: HASTE-MRC, a fast and noninvasive procedure, can accurately diagnose choledocholithiasis although the detectability for small stones is limited.     

Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients

BACKGROUND & AIMS: In patients with stones in their bile ducts and gallbladders, cholecystectomy is generally recommended after endoscopic sphincterotomy and clearance of bile duct stones. However, only approximately 10% of patients with gallbladders left in situ will return with further biliary complications. Expectant management is alternately advocated. In this study, we compared the treatment strategies of laparoscopic cholecystectomy and gallbladders left in situ. METHODS: We randomized patients (>60 years of age) after endoscopic sphincterotomy and clearance of their bile duct stones to receive early laparoscopic cholecystectomy or expectant management. The primary outcome was further biliary complications. Other outcome measures included adverse events after cholecystectomy and late deaths from all causes. RESULTS: One hundred seventy-eight patients entered into the trial (89 in each group); 82 of 89 patients who were randomized to receive laparoscopic cholecystectomy underwent the procedure. Conversion to open surgery was needed in 16 of 82 patients (20%). Postoperative complications occurred in 8 patients (9%). Analysis was by intention to treat. With a median follow-up of approximately 5 years, 6 patients (7%) in the cholecystectomy group returned with further biliary events (cholangitis, n = 5; biliary pain, n = 1). Among those with gallbladders in situ, 21 (24%) returned with further biliary events (cholangitis, n = 13; acute cholecystitis, n = 5; biliary pain, n = 2; and jaundice, n = 1; log rank, P = .001). Late deaths were similar between groups (cholecystectomy, n = 19; gallbladder in situ, n = 11; P = .12). CONCLUSIONS: In the Chinese, cholecystectomy after endoscopic treatment of bile duct stones reduces recurrent biliary events and should be recommended.     

Intraductal chilled saline perfusion to prevent bile duct injury during percutaneous radiofrequency ablation for hepatocellular carcinoma

Background and Aim:  Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC.
Patients and Methods:  The baseline incidence of bile duct injury at Gifu Municipal Hospital was 3.1% (13 patients) in 424 patients with HCC treated by percutaneous RFA. In all patients, the tumor was within 5 mm of the central bile duct on CT images. The incidence of bile duct injury was 46% among the 28 selected patients whose tumor was close to the central bile duct. To prevent complications in such high-risk patients, we placed a nasobiliary tube endoscopically before RFA, and performed ICSP during RFA. Forty consecutive patients with tumors close to the central bile duct were enrolled in this study.
Results:  Of the 40 enrolled patients, only one had biliary injury, whereas the remaining 39 patients were able to avoid it. The incidence of biliary injury was significantly reduced in the ICSP group (1/40, 2.5%) compared to that in the control group (13/28, 46%) ( P  < 0.0001). Moreover, the liver function 6 months after RFA was also better preserved in the ICSP group according to Child–Pugh grading, thus resulting in a better clinical outcome.
Conclusions:  ICSP through a nasobiliary tube is a potential intervention method to prevent biliary injury by percutaneous RFA.     

Brief Intervention for Problem Drinkers in a Chinese Population: A Randomized Controlled Trial in a Hospital Setting

Background:  Alcohol is a legal and accessible substance in Taiwan. As excessive alcohol has been linked to health and social problems, it is necessary to develop a brief, rapid, and low-cost tool to help health care providers deal with persons in Taiwan whose alcohol consumption has become hazardous or harmful to their health.
Methods:  A randomized controlled clinical trial with 6- and 12-month follow-ups was designed. Eighteen medical/surgical units at a medical center in northern Taiwan were randomly assigned to 2 groups: experimental ( n  = 9) and control ( n  = 9). Inpatients on the units were enrolled if they met the following criteria: were older than 18 years, had no severe psychiatric illness, and were not pregnant. The experimental group ( n  = 138) received the intervention, a 15-minute counseling visit in which nurses screened participants using the Alcohol Use Disorders Identification Test (AUDIT), provided a health promotion booklet for adults, and individually discussed the booklet contents with patients based on their drinking level (AUDIT score). The control group ( n  = 137) received no treatment. Patterns of alcohol consumption were determined by AUDIT scores at baseline, 6, and 12 months later.
Results:  Alcohol use disorders identification test scores decreased significantly in both groups at 6 months after the intervention, but did not differ significantly between the 2 groups. However, 12 months after the brief alcohol intervention, experimental subjects' AUDIT scores were significantly better than those of the control group.
Conclusions:  Our brief alcohol intervention provided a 12-month benefit for problem drinkers in Taiwan.     

Does magnifying endoscopy improve the diagnosis of erosive esophagitis?

Background and Aims:  Low-grade erosive esophagitis (i.e. Los Angeles grade A) is the most predominant type of esophagitis in Japan. It is unclear whether all the mucosal breaks detected by conventional endoscopy are indicative of esophageal mucosal erosion. Hospital-based, cross-sectional, cross-over, observational study was assigned to investigate the value of magnifying endoscopy for diagnosis of erosive esophagitis.
Methods:  From August to December 2006, 178 consecutive patients with upper gastrointestinal symptoms were enrolled at three university hospitals and one national medical center in western Japan. Before endoscopy, all participants were requested to answer questionnaires concerning their symptoms. Experienced endoscopists performed an endoscopic diagnosis of each patient first with a conventional standard view and then with a magnifying view. Endoscopic diagnostic concordance between conventional and magnifying endoscopic view for erosive esophagitis was calculated. Relationship between a variety of symptoms and erosive esophagitis was also evaluated.
Results:  Erosive esophagitis was identified using conventional and magnifying endoscopy in 14.6% and 17.4% of patients, respectively. Eleven false-negative and six false-positive diagnoses using conventional endoscopy occurred among the 178 enrolled patients. The weighted kappa value of diagnostic concordance for erosive esophagitis between the two endoscopic views was 0.76. The prevalence of erosive esophagitis in patients with reflux-, dysmotility-, and ulcer-like symptoms was 20.7%, 24.1%, and 15.2%, respectively.
Conclusions:  Magnifying endoscopy did not significantly improve the diagnostic sensitivity of erosive esophagitis over non-magnifying, conventional endoscopy. Erosive esophagitis was frequently identified in patients that did not have reflux symptoms.     

Choleretic effect of inchinkoto, a herbal medicine, on livers of patients with biliary obstruction due to bile duct carcinoma

Aim:  To investigate the choleretic effects of inchinkoto (ICKT) on livers of patients with biliary obstruction due to bile duct carcinoma.
Methods:  Twenty-seven patients with bile duct carcinoma who were due to undergo biliary drainage and subsequent major hepatectomy were randomly assigned to preoperative ICKT ( n  = 13) or untreated ( n  = 14) groups. ICKT was administered from the day of admission until one day before surgery. Changes in bile constituents, expression of multidrug resistance-associated protein (MRP) 2, MRP3 and MRP4 in the liver, and the incidence of postoperative complications were included as end-points.
Results:  The biliary concentration of total bilirubin was significantly increased after administration of ICKT (23.7 ± 2.8 mg/dL before ICKT; 34.0 ± 4.0 mg/dL after ICKT, P  < 0.05). The biliary concentration of total bile acids was also significantly increased. Protein levels of MRP2 and MRP3 in the crude plasma membrane fraction of livers of treated patients were significantly higher than those without treatment. MRP2 staining in the livers of patients without ICKT treatment was weak and diffuse around the bile canaliculi, whereas staining in patients with ICKT treatment was strong and restricted to the bile canaliculi.
Conclusion:  ICKT exerts a choleretic effect on the livers of patients with biliary obstruction. This beneficial effect was associated with increased expression of MRP2. ICKT thus has therapeutic potential for treatment for obstructive cholestasis due to bile duct carcinoma.     

Comparison of one-week and two-week empirical trial with a high-dose rabeprazole in non-cardiac chest pain patients

Background:  In patients with non-cardiac chest pain (NCCP), the optimal duration of an empirical trial with a high-dose proton pump inhibitor (PPI) is unclear. We aimed to compare the efficacy of one-week and two-week PPI trial in patients with weekly or more than weekly NCCP and to determine its optimal duration for diagnosing gastroesophageal reflux disease (GERD)-related NCCP.
Methods:  Forty-two patients with at least weekly NCCP were enrolled. The baseline symptoms were assessed using a daily symptom diary for seven days. Also, esophago-gastro-duodenoscopy and 24 h esophageal pH monitoring were performed for the diagnosis of GERD. Then, patients were treated with rabeprazole 20 mg twice daily for 14 days. To assess NCCP improvement during the PPI trial, the first week and the second week symptom diary were kept for 1–7 and 8–14 days. The PPI test was considered positive if a symptom score improved (50% compared to the baseline.
Results:  There was no significant difference for a positive PPI test between GERD-related NCCP group ( n  = 8, 50%) and non GERD-related NCCP group ( n  = 6, 23%) during the first week of the PPI test. However, during the second week, GERD-related NCCP had a higher positive PPI test ( n  = 13, 81%) than non GERD-related NCCP ( n  = 7, 27%) ( P  = 0.001) with a sensitivity and specificity of 81% and 62%, respectively.
Conclusions:  The rabeprazole empirical trial was diagnostic for patients with GERD-related NCCP, and its optimal duration was determined to be at least two weeks.     

Non-cardiac chest pain: Prevalence of reflux disease and response to acid suppression in an Asian population

Background:  Gastroesophageal reflux disease is thought to be the commonest cause of 'non-cardiac chest pain'. The use of proton-pump inhibitors resulting in improvement in the chest pain symptom would support this causal association.
Objectives:  To determine the prevalence of gastroesophageal reflux disease in non-cardiac chest pain and the response of chest pain to proton-pump inhibitor therapy.
Methods:  Patients with recurrent angina-like chest pain and normal coronary angiogram were recruited. The frequency and severity of chest pain were recorded. All patients underwent esophagogastroduodenoscopy and 48-h Bravo ambulatory pH monitoring before receiving rabeprazole 20 mg bd for 2 weeks.
Results:  The prevalence of gastroesophageal reflux disease was 66.7% (18/27). The improvement in chest pain score was significantly higher in reflux compared to non-reflux patients ( P  = 0.006). The proportion of patients with complete or marked/moderate improvement in chest pain symptoms were significantly higher in patients with reflux (15/18, 83.3%) compared to those without (1/9, 11.1%) ( P  < 0.001).
Conclusion:  The prevalence of gastroesophageal reflux disease in patients with 'non-cardiac chest pain' was high. The response to treatment with proton-pump inhibitors in patients with reflux disease, but not in those without, underlined the critical role of acid reflux in a subset of patients with 'non-cardiac chest pain'.     

Factors enabling home death of the elderly in an institution specializing in home medical care: Analysis of apprehension of the bereaved family

Aim:   To determine the factors enabling home death despite caregiver apprehension about home medical care.
Methods:   This study was an anonymous mailed survey of bereaved family members (the caregiver) of patients who died in a home medical care setting provided by an institution specializing in home medical care in Japan (home death rate, ∼80%). We analyzed the relationships between caregiver apprehension about home medical care, overall satisfaction with home medical care and the place of death.
Results:   Higher caregiver apprehension about home medical care and lower overall satisfaction with home medical care were significantly associated with dying in a hospital. In addition, the home death group with apprehension about home medical care significantly rated higher overall satisfaction with home medical care than the hospital death group. Meanwhile, there was no difference in the overall satisfaction with home medical care between those with or without apprehension about home medical care in the home death group. Factors influencing overall satisfaction with home medical care in the home death group with apprehension about home medical care were: (i) being free from pain or symptoms (partial regression coefficient: 0.83); and (ii) fulfilled medical care service system (partial regression coefficient: 0.40).
Conclusion:   These results suggest that caregiver satisfaction with home medical care is an essential factor to enable home death of the patient despite the caregiver apprehension about home medical care.     

Factors influencing patient satisfaction with GI endoscopy

BACKGROUND: A modified Group Health Association of America-9 survey (mGHAA-9) was recently proposed for measurement of patient satisfaction with endoscopy. It is unknown whether the mGHAA-9 addresses the issues most important to this outcome. METHODS: A 15-item survey of factors potentially important to patient satisfaction with endoscopy was developed, including the 6 core mGHAA-9 items. Respondents were asked to rank the factors from 1 to 15 (1 = most important to l5 = least important to satisfaction). Two groups were surveyed: (1) patients with prior endoscopy experience and (2) physician endoscopists. Item rank distributions overall and by patient age, gender, and procedure experience were examined. RESULTS: Of 559 outpatients surveyed, 437 (78%) provided complete responses. The mean patient age was 59 years (48.7% female, 45.3% male, 6% not stated). The number 1 ranked factor was the endoscopist's technical skills (median ranking (mr) = 1), an item included in the mGHAA-9. Pain control, a factor not assessed by the mGHAA-9, was second (mr = 4), and ranked number 1 by 16% of patients. Item rankings were consistent across patient subgroups. Relative to patients, endoscopists underprioritized preprocedure and postprocedure communication. CONCLUSIONS: The mGHAA-9 has inadequate content validity for measurement of patient satisfaction with endoscopy because it does not assess pain control. However, endoscopy satisfaction measurement with a single, universally applied instrument appears feasible.     

内镜在胰胆管合流异常诊疗中的作用探讨

目的探讨ERCP在胰胆管合流异常中的诊断价值,评估内镜治疗的效果。方法16例胰胆管合流异常（PBM）患者,通过ERCP造影进行PBM分型,结合临床症状,分析引起相关疾病的机制、影像特点,根据合并的其它胰胆疾病,选择适当的内镜取石、扩张或引流等治疗,观察治疗效果。结果16例胰胆管合流异常患者多伴有腹痛、呕吐、黄疸等症状,及转氨酶和／或淀粉酶水平的升高。其中,Ⅰ型（B—P型）7例,Ⅱ型（P—B型）5例,Ⅲ型（复杂型）4例;合并胆总管囊肿扩张10例,无扩张者5例,胆管癌并狭窄1例;伴有胆管结石11例（4例为蛋白栓）、胰管结石2例（1例不伴胆管结石）。9例予内镜下胆管取石,2例胰管取石,术中置入胆道支架引流7例,行鼻胆管引流3例,胰管支架置入5例,胆道金属支架置人1例。术后临床症状均明显缓解。结论ERCP是一种可靠的诊断手段,其分型与PBM相关疾病表现有明显相关,选择性、暂时性的内镜治疗在外科术前是有效的、必要的。     

Primary choledochoduodenostomy for benign obstructive biliary tract disease

Repeated surgical interventions on the biliary ductal system increase morbidity and mortality, particularly in the geriatric patient. In an attempt to prevent these complications, side-to-side choledochoduodenostomy was performed as the primary operative procedure in 54 patients, age 72 +/- 13 years. This was the patients' first surgical intervention for benign obstructive lesions of the biliary tract system. Indications for choledochoduodenostomy were: multiple or irremovable common or hepatic duct stones, doubtfulness of complete clearing of the duct, primary common bile duct stones or mud and sludge, a grossly dilated biliary duct system, and ampullary stenosis. We encountered no operative or hospital mortality among this group of 54 patients. The mean postoperative hospital stay for this aged and relatively sick group of patients was 12.3 +/- 6.2 days. Twenty-three minor postoperative complications occurred in 18 patients, none of them requiring reoperation. The patients were followed for 2-16 years. Thirteen patients (24%) were lost to follow-up. Of the 41 patients available for follow-up, 14 died, none from biliary tract associated causes--mostly from cerebrocardiovascular disease. Twenty-seven patients still alive were found to be free of biliary tract associated abdominal complaints or recurrent cholangitis for a mean period of 7.8 +/- 3.7 years. The data indicate a zero reoperation rate during long-term follow-up, zero mortality rate, and low morbidity in a group of elderly, mostly poor risk patients. This leads us to conclude that a side-to-side choledochoduodenostomy is both the best therapy as well as prophylaxis against common duct stones. This, even in this era of endoscopic papillotomy and biliary lithotripsy.     

Electrical isolation of the superior vena cava: an adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation

PV isolation at the antrum (PVAI) has improved safety and efficacy of ablation procedures for atrial fibrillation (AF). AF triggers from the superior vena cava (SVC) may compromise the outcome of PVAI.
Purpose: We evaluated the (1) incidence of SVC triggers, (2) feasibility of empiric SVC electrical isolation (SVCI) as an adjunct to PVAI, and (3) SVCI safety.
Methods and Results: Of 190  patients (group I), 24 (12%) showed SVC triggers. Following PVAI, seven patients had AT originating from the SVC and three had AF. After SVCI, all 24  patients were arrhythmia-free 450 ± 180  days post procedure. In the subsequent 217  patients (group II), empirical SVCI was performed following PVAI. Sixty-six of all 407  patients (16%) experienced recurrence of AF.  A repeat procedure in 25 of the 66  patients showed that five (20%) had AF recurrence initiated by SVC triggers, of whom four were among group I patients (4/190; 2%) and one was from group II (1/217; 0.4%), (P < 0.05). Transient diaphragmatic paralysis can be avoided by pacing at the lateral aspect of the SVC using high output (30  mA). There was no SVC stenosis on CT scans before or 3 months after the procedure. There was no sinus node injury.
Conclusions: The SVC harbors the majority of non-PV triggers of AF. SVCI is feasible, safe, and may be considered as an adjunctive strategy to PVAI for ablation of AF. The long-term favorable outcome of this hybrid approach remains to be evaluated in a larger series of patients.     

The utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with presumed sphincter of oddi dysfunction

Objectives: We sought to study the utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with Geenen class II sphincter of Oddi dysfunction.
Methods: We reviewed the clinical course and liver function test results of 24 Geenen-Hogan class II postcholecystectomy patients with biliary colic secondary to sphincter of Oddi dysfunction who did not undergo sphincter of Oddi manometry before treatment with endoscopic sphincterotomy.
Results: Twenty of the 24 patients had an average of 1.4 episodes of abnormal liver function tests associated with biliary colic; eight patients had dilated common bile duct on cholangiogram. Eighteen of the 20 patients with abnormal liver function tests (90%) were pain-free after sphincterotomy; in contrast, only one of four patients (25%) without liver function test changes responded to sphincterotomy. Fisher exact analysis showed that abnormal liver function tests was a significant predictor for favorable response to sphincterotomy with a two-tail p value of 0.018. Of the eight patients with bile duct dilatation, six (75%) responded favorably to sphincterotomy, whereas 13 of 16 patients (81%) without dilatation also responded to sphincterotomy. Analysis of common bile duct dilatation as a predictive factor showed no significance (   p = 1.00  ).
Conclusions: We conclude that the occurrence of abnormal liver function tests during biliary colic may be used to select patients for endoscopic sphincterotomy. Sphincter of Oddi manometry may not be needed in these cases.     

Is Barrett's esophagus characterized by more pronounced acid reflux than severe esophagitis?

Objective: Barrett's esophagus is related to gastroesophageal reflux disease (GERD). However, only a small fraction of patients with GERD develop Barrett's esophagus. We evaluated whether gastroesophageal acid reflux is more pronounced in Barrett's patients than in patients with moderate or severe endoscopic esophagitis.
Methods: Retrospective evaluation of results of esophageal manometry and 24 hour ambulatory pH monitoring performed between 1990 and 1996 at the Leiden University Medical Center in those patients who also underwent endoscopy ≤3 months before pH-metry. Included were 51 patients with Barrett's esophagus, 30 patients with severe esophagitis, 45 patients with moderate esophagitis, and 24 healthy control subjects.
Results: Patients with Barrett's esophagus had significantly increased acid reflux time (   p < 0.01  –0.05) compared to patients with moderate, but not compared to patients with severe esophagitis. Distal esophageal body motility and LES pressure were significantly (   p < 0.01  –0.05) reduced in patients with Barrett's esophagus compared to patients with moderate esophagitis but not compared to those with severe esophagitis.
Conclusion: Although acid reflux is increased in patients with Barrett's esophagus and esophageal motility is impaired, other factors apart from acid exposure and motility contribute to the development of Barrett's esophagus.     

Biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma with jaundice

Background and Aim:  The combination of photodynamic therapy and biliary stenting seems to be beneficial in the palliative treatment of unresectable cholangiocarcinoma. We aimed to assess the accuracy of photodynamic therapy in a single centre.
Methods:  Fourteen selected patients, with jaundice related to unresectable cholangiocarcinoma, underwent photodynamic therapy and biliary stenting (with or without chemotherapy). Photofrin was injected intravenously (2 mg/kg) 2 days before intraluminal photoactivation. In case of malignant progression, photodynamic therapy was repeated. The outcome parameters were overall survival and quality of life.
Results:  There were eight men and six women (median age: 67 [42–81]). Unresectability was related to a low Karnofski index ( n  = 2), peritoneal carcinomatosis ( n  = 4), vascular involvement ( n  = 3), invasion of the hepatoduodenal ligament ( n  = 2) and an under-sized liver remnant ( n  = 3). Biliary stenting was efficient (≥ 50% total bilirubin) in 78.5% of cases. Eight patients developed cholangitis. The mean number of photodynamic therapy procedures was two (1–4). Six (43%) patients needed ≥ 2 procedures. No severe toxicity was noted. Photodynamic therapy improved the Karnofski index in 64% of cases. Six (42.8%) patients received concomitant chemotherapy (gemcitabine). The median survival time was 13.8 [0.7–29.2] months. The 3-, 6- and 12-month survival rates were 85%, 77% and 77%, respectively.
Conclusion:  These results confirm the beneficial effect of biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma in selected patients with jaundice.