Endoscopic treatment of benign ureteral strictures

BACKGROUND: The traditional choice of procedure for treatment of ureteral stricture is open surgical repair. Advances in endourology have provided the urological surgeon with an alternative to open surgery for the treatment of benign ureteral stricture. METHODS: Twenty-seven benign ureteral strictures in 24 patients were treated by the endourological method. Twelve endoureterotomies were performed using a cold knife via a 9.5Fr Storz ureteroscope and 15 high pressure balloon dilations were performed. The ureters were stented with 7 Fr double-J stents for 6 weeks. RESULTS: The success rate was 9/12 (75%) in the endoureterotomy group and 9/15 (60%) in the balloon dilation group after follow-up for more than 6 months. CONCLUSIONS: Endoscopic treatment of ureteral strictures appeared to be a safe and reasonably effective modality for the treatment of ureteral strictures, especially for the short type that are non-ischaemic in origin and not associated with radiation therapy. Endourological treatment of ureteral strictures is the procedure of choice for initial management of benign ureteral strictures and has high success rates and fewer complications.     

Endoscopic laser stricturotomy and balloon dilatation for benign colorectal strictures

Background : A fibrous stricture may develop at the site of a colorectal anastomosis or as a complication following abdominal aortic surgery. A major resection may be necessary if the stricture cannot be released. The authors’ experience with endoscopic stricturotomy using neodymium:yttrium–aluminium–garnet laser, together with balloon dilatation, as a conservative method of treating such strictures, is reported here. Methods : The case notes of all patients referred for laser treatment of benign distal large bowel strictures at Concord Hospital were reviewed. Results : Ten patients had endoscopic laser treatment combined with endoscopic balloon dilatation between October 1991 and July 1999. An anastomotic stricture had developed in eight patients and two patients had a fibrous stricture of the upper rectum after abdominal aortic aneurysm surgery. Nine of the 10 patients had their stricture treated successfully without complication or recurrence (median follow up 82 months; range: 14–104 months). The remaining patient re‐presented with a large bowel obstruction at the site of his stricture 6 years following initial treatment. Conclusion : A protocol combining laser stricturotomy with balloon dilatation appears to be a safe and effective treatment of such strictures.     

Endoscopic electrosurgical section of benign esophageal strictures

The work presents material on the treatment of patients with benign strictures of the esophagus by means of the method of electrosurgical endoscopic cutting. The results obtained made it possible to shorten the periods of treatment considerably and avoid an operative intervention.     

Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with diathermy

Background: Initially, treatment for anastomotic strictures was surgical. Currently. however, endoscopic techniques are preferred. This study aimed to investigate the efficiency and safety of endoscopic treatment using argon plasma coagulation in combination with diathermy. Methods: From 1995 to 2000, 49 patients with postsurgical anastomotic strictures of the esophagus or colon were referred for endoscopic treatment. In all cases, radiologic and endoscopic examination showed membranous or short strictures (diameter, 3–8 mm). Under direct endoscopic control, the scar tissue at the anastomotic line was incised radially with a polypectomy snare. The scar tissue between the incisions then was reduced carefully by argon plasma coagulation. Results: All 49 patients were treated successfully with this combined endoscopic technique. Only for four patients was more than one endoscopic session (mean, 3.5; range, 2–6) needed to guarantee long-term success. No complications were encountered. Conclusions: Endoscopic argon plasma coagulation in combination with diathermy is a safe and effective technique for the treatment of short postsurgical gastrointestinal anastomotic strictures.     

Endoscopic sphincterotomy and temporary internal stenting for bile leaks following complex hepatic trauma

BACKGROUND: Biliary leak secondary to blunt or penetrating hepatic trauma and damage to the intrahepatic biliary tree remains a challenging problem. The role and safety of endoscopic retrograde cholangiopancreatography (ERCP) and stenting in this setting were studied. METHODS: All trauma victims who developed a bile leak secondary to hepatic trauma were included. Bile leak was defined as the appearance of bile in a surgical wound or intra-abdominal drain after surgery, following percutaneous drainage of a perihepatic bile collection, or evidence of a leak on hepatobiliary scintigraphy. ERCP was performed within 24 h of diagnosis and included biliary sphincterotomy and internal stenting. Recovery was defined as cessation of leakage. RESULTS: Between 1996 and 2004, six patients with penetrating injuries and five with blunt abdominal injuries were treated according to the study protocol. Eight underwent surgery to control bleeding or for additional intra-abdominal injuries. All bile leaks resolved completely within 10 days of ERCP. One patient died from pulmonary sepsis; ten recovered without hepatobiliary sequelae. CONCLUSION: ERCP, biliary sphincterotomy and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represent a safe and effective strategy for the management of bile leaks following both blunt and penetrating hepatic trauma.     

Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage

Endoscopic haemostasis can be effective in non-variceal upper gastrointestinal haemorrhage, and should be regarded as potential front-line treatment. Diverse methods are available, and although no single technique has become firmly established, current evidence favours thermal coagulation and injection therapy.     

Endoscopic approaches to upper gastrointestinal bleeding

Treatment for most patients with upper gastrointestinal bleeding has shifted from the operating room to the endoscopy suite. Endoscopic treatment has resulted in substantial benefit for patients with bleeding from peptic ulcer. Ulcers associated with high-risk stigmata of recent hemorrhage (SRH) not treated endoscopically have 40 per cent to 100 per cent risk of continued or recurrent bleeding and up to a 35 per cent chance of requiring surgical control of bleeding. Endoscopic therapy has reduced the risk of recurrent bleeding to 10 per cent to 20 per cent and the need for surgery to 5 per cent to 10 per cent. These improvements translate to shorter hospital stays, fewer transfusions, lower costs, and less morbidity. Similar progress has been made for patients bleeding from esophageal varices. Mortality for a first variceal bleed is now approximately 20 per cent as compared with 40 per cent to 60 per cent in past decades. Rebleeding after initially successful endoscopic hemostasis is often best treated by a second attempt at endoscopic control. The decision regarding management of recurrent bleeding should be made at the time initial endoscopic control is achieved. Local factors such as experience of the endoscopic team, availability of interventional radiologists, and individual patient characteristics should guide these decisions. Failures of endoscopic control and patients with massive hemorrhage still require operative intervention.     

Endoscopic control of upper gastrointestinal bleeding

One important objective in managing patients with upper gastrointestinal hemorrhage is to control the bleeding until the patient's condition is stable and definitive therapy can be carried out. Endoscopic techniques are now available to attain this goal. Endoscopic sclerosis has become an accepted treatment for bleeding esophageal varices, especially in patients with Child's class B or C cirrhosis. Control of nonvariceal bleeding by endoscopic techniques is now feasible and involves laser photocoagulation and electrocoagulation. Clinical experience with endoscopic laser photocoagulation has demonstrated that it can successfully arrest bleeding in gastric and duodenal ulcers. Endoscopic electrocoagulation has been successful in stopping bleeding from Mallory-Weiss tears, acute gastric erosions, and gastric, duodenal and stomal ulcers. Use of an endoscopic heater probe, now in the development stage, to control bleeding gastric and duodenal ulcers will be an important addition.     

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

Background The utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB. Methods All patients who underwent LRYGB at the authors’ institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated. Results This study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%). Conclusions According to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.     

Endoscopic diagnosis and treatment of upper gastrointestinal bleeding

Considerable progress has been made in endoscopic hemostasis. Several methods are available. Sclerotherapy of esophageal varices is the procedure of choice for the control of active variceal hemorrhage and for the prevention of recurrent bleeding. For endoscopic treatment of nonvariceal gastrointestinal bleeding, the nonerosive contact probes (heater probes and BICAP) and injection sclerotherapy are preferred. Several hemostatic modalities should be available and applied depending on the anatomic location and type of bleeding lesions. Advanced endoscopic hemostatic techniques seem to be decreasing the mortality rates in patients with upper gastrointestinal bleeding.     

Primary double pigtail stenting as a treatment of upper urinary tract leaks

During a 5-year period 21 consecutive patients with iatrogenic or traumatic upper urinary tract leaks (nonmalignant) underwent treatment 5 to 28 days later with an indwelling double pigtail stent via an antegrade or retrograde approach. Six patients underwent initial nephrostomy drainage for relief of obstruction causing decreased renal function and/or septicemia. Stent placement was successful in 20 patients and complete healing occurred within 2 to 7 weeks in all 20. At followup 2 to 32 months later (median 3 months) no stricture formation or deterioration of kidney function was noted. There were no major complications and 85% of the patients were able to leave the hospital without any form of external drainage within 1 week after stent placement.     

Endoscopic balloon dilatation for benign fibrotic strictures after curative nonsurgical treatment for esophageal cancer

BACKGROUND : Endoscopic balloon dilatation (EBD) is performed to treat strictures after esophagectomy. However, little is known about using EBD for benign strictures that occur after nonsurgical treatments for esophageal cancer such as chemoradiotherapy (CRT) or endoscopic mucosal resection (EMR). The aim of this study was to evaluate the safety and efficacy of EBD for benign strictures after nonsurgical treatment compared with those after surgery. METHODS : We identified 823 patients with esophageal cancer who completed definitive treatments between 2004 and 2007. Of these patients, 122 were enrolled in our study, including 60 who had surgery and 62 who did not have surgery (32 CRT, 30 EMR). The indication criteria for EBD were complaint of dysphagia and the inability to pass a conventional endoscope due to benign stricture. We retrospectively analyzed the safety and efficacy of EBD, and the measured outcomes were treatment success rate, time to treatment success, and refractory stricture rate. RESULTS : Perforation occurred in 3 (0.3?%) of 1,077 EBD sessions, with no bleeding. Efficacy was evaluated in 110 of the 122 patients. While the treatment success rate was over 90?% in both the surgery and the nonsurgery group, there was a significant difference in the median time to treatment success between both groups (2.3 vs. 5.6?months, p?=?0.02: log-rank test). There was a significant difference in the median time to treatment success between CRT and surgery groups (7.0?months, p?=?0.01), with no significant difference in the EMR group (4.4?months, p?=?0.85). A significant difference in the refractory stricture rate was evident between the nonsurgery group (75?%) and the surgery group (45?%, p?相似文献   

Endoscopic management of non-variceal upper gastrointestinal haemorrhage

Endoscopy plays a central role in the diagnosis and treatment of non-variceal upper gastrointestinal haemorrhage. Advances in endoscopic techniques, supported by an increasing body of high quality data, have rendered endoscopy the first-line diagnostic and therapeutic intervention for the patient presenting with an upper gastrointestinal haemorrhage. However, endoscopic intervention must be considered in the context of the overall management of the bleeding patient, often with significant comorbidities. Although parameters such as hospitalization duration, transfusion requirements and surgery rates have improved with advances in endoscopic therapy, mortality rates remain relatively static. This review addresses the current status of endoscopic intervention for non-variceal upper gastrointestinal haemorrhage. Additionally, an overview of important periprocedural management issues is presented.     

Endoscopic ultrasonography of the upper gastrointestinal tract

Summary Endoscopic ultrasonography was used for assessment of the extent of tumour invasion of the upper gastrointestinal (GI) tract, including analysis of submucosal tumour and detection of lymph-node metastasis. The normal oesophageal and gastric wall was depicted as five layers by endoscopic ultrasonography (EUS). The outer layer invaded by cancer was defined as the depth of tumour invasion. In 173 cases of oesophageal cancer, the depth of cancer invasion was diagnosed correctly in 88%. In 146 cases of gastric cancer, it was diagnosed correctly in 79%. In submucosal tumours of the GI tract, the site of tumour in the wall was diagnosed correctly in 99% and the histological type of tumour was predicted. EUS can also be used to detect small lymph nodes. According to the criteria, used in this study, EUS had a sensitivity of 84%, a specificity of 88% and an overall accuracy of 88% for detection of lymphnode metastases. Presented at the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting

HYPOTHESIS: Although advances in endoscopic procedures have provided alternative options for relieving biliary obstructions, the overall chance of cure for patients with benign biliary stricture is the same using surgical or endoscopic treatment. DESIGN: Case-control study. SETTING: Tertiary care university hospital. PATIENTS: Of 163 patients referred for treatment with diagnoses of benign strictures of the common bile duct between January 1, 1975, and July 1, 1998, we studied 42 patients with postcholecystectomy stricture and a follow-up longer than 60 months. Twenty of these patients were treated with endoscopic stenting and 22 with surgery (hepaticojejunostomy, choledochojejunostomy, or intrahepatic cholangiojejunostomy). MAIN OUTCOME MEASURES: Postoperative mortality and morbidity and long-term outcome. The rate of restenosis was also determined. RESULTS: Morbidity occurred more frequently in patients treated with endoscopic procedures than with surgical ones (9 vs 2; P = .34). Hospital mortality was 0%. Surgery achieved excellent or good long-term outcome in 17 of 22 patients. Endoscopic biliary stenting was successful in 16 of 20 patients. Overall, excellent or good outcomes were achieved in 34 patients (81%). CONCLUSION: The ability to achieve steady, long-term results confirms hepaticojejunostomy as the best procedure in the treatment of benign biliary strictures, even if endoscopic procedures are gaining a new role in the treatment of a greater number of patients.     

Endoscopic flushing electrocoagulation for upper gastrointestinal bleeding--an alternative to surgery

Twenty-three patients, mean age of 65 years, planned for emergency surgery because of upper gastrointestinal bleeding, were electrocoagulated with an endoscopic Storz monopolar flushing electrode. Nineteen patients were managed successfully. Two out of twelve patients with gastric ulcer and both patients with gastrojejunal ulcer bleeding needed an operation. The overall success rate was 82% and the mortality was 9%. According to this study endoscopic monopolar flushing liquid electrocoagulation is a good alternative to surgery in upper gastrointestinal bleedings except gastrojejunal ulceration.     

Endoscopic injection sclerotherapy in non-variceal upper gastrointestinal bleeding

Summary To date several agents have been used to achieve haemostasis in patients with non-variceal upper gastrointestinal bleeding using endoscopic sclerotherapy techniques. Polidocanol has been widely used but local complications have been reported after treatment. We have compared the efficacy and safety of thrombin and polidocanol in 82 consecutive patients with ongoing or recent bleeding from duodenal, gastric, or anastomotic ulcers. Primary control of haemostasis from spurting vessels was achieved in 90% of cases using polidocanol and in 86.6% using thrombin. Definitive haemostasis was obtained in 80% of patients in both groups. When a non-bleeding vessel was visible, injection of polidocanol or thrombin effectively prevented rebleeding in 90.9% and 85.7% of cases, respectively. When a non-bleeding sentinel clot was present, injection of polidocanol or thrombin provided definitive haemostasis in 100% and 92.8% of cases, respectively. No statistically significant difference was evident between the two agents. In the polidocanol group, one local haemorrhagic complication was noted. No general or local complications were recorded in the thrombin group.     

Endoscopic electrohemostasis of active upper gastrointestinal bleeding.

Emergency esophagogastroduodenoscopy for active upper gastrointestinal bleeding was performed in 160 patients. Endoscopic electrocautery for control of bleeding was considered in the last ninety patients and performed in seventy-one patients. All lesions except esophageal varices were candidates for electrohemostasis. The indications for endoscopic electrocautery were active hemorrhage and precise identification of the bleeding point. The preendoscopic blood loss ranged from 1,500 to 6,000 ml. All seventy-one patients had initial hemostasis and sixty-five (92 per cent) had permanent hemostasis after one treatment. Six patients rebled, and four of these had permanent hemostasis after a second endoscopic electrocauterization. Only two of seventy-one patients had emergency operations for bleeding. There were no complications. Endoscopic electrohemostasis is still an experimental technic which requires further laboratory study and testing before broad general clinical application. This clinical trial suggests that endoscopic electrocautery is an attractive method of controlling active upper gastrointestinal bleeding because it can be safe, effective, and rapid, and is available in most medical communities.     

内镜急诊处理上消化道出血的护理

对笔者所在医院2007年2月～2011年3月应用内镜急诊止血的102例患者进行抢救护理,经入院后的常规护理,及时的心理护理,不断观察患者情况,术中急性抢救护理以及术后护理,大部份患者抢救成功,死亡1例。上消化道出血有效的止血治疗和认真细致的观察护理,可以提高抢救成功率,减少死亡风险,达到救治的目的。