Enteroscopy in small bowel Crohn’s disease: A review

Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn’s. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial’s in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.     

Management of malignant biliary obstruction: Technical and clinical results using an expanded polytetrafluoroethylene fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent after 6-year experience

To evaluate the efficacy and safety of an expanded polytetrafluoroethylene-fluorinated ethylene-propylene (ePTFE/FEP)-covered metallic stent in the management of malignant biliary obstruction. Eighty consecutive patients with malignant common bile duct strictures were treated by placement of 83 covered metallic stents. The stent-graft consists of an inner ePTFE/FEP lining and an outer supporting structure of nitinol wire. Clinical evaluation, assessment of serum bilirubin and liver enzyme levels were analyzed before biliary drainage, before stent-graft placement and during the follow-up period at 1, 3, 6, 9 and 12 months. Technical success was obtained in all cases. After a mean follow-up of 6.9±4.63 months, the 30-day mortality rate was 14.2%. Survival rates were 40% and 20.2% at 6 and 12 months, respectively. Stent-graft patency rates were 95.5%, 92.6% and 85.7% at 3, 6 and 12 months, respectively. Complications occurred in five patients (6.4%); among these, acute cholecystitis was observed in three patients (3.8%). A stent-graft occlusion rate of 9% was observed. The percentage of patients undergoing lifetime palliation (91%) and the midterm patency rate suggest that placement of this ePTFE/FEP-covered stent-graft is safe and highly effective in achieving biliary drainage in patients with malignant strictures of the common bile duct.     

男性尿道狭窄超声管腔形态与最大尿流率关系的研究

目的：探讨男性尿道狭窄超声管腔形态与最大尿流率的相关性,以丰富尿道狭窄诊断和术后疗效评价的信息。方法：80例尿道狭窄患者（除外尿道外口狭窄）,超声测量尿道狭窄段内径（D）、狭窄段近侧10mm处尿道扩张段内径（PD）、狭窄内径比率（Rd,Rd=D/PD)和狭窄长度（L）。将超声形态学量与最大尿流率（MFR）进行相关分析。结果：≤50岁组和＞50岁组中的D与MFR的相关系数r分别为0．80、0．60、Rd与MFR的相关系数r分别为0．87和0．69。将狭窄内径比率等于0．67、0．79分别定为≤50岁组和＞50岁组的临界狭窄组,并结合MFR对尿流率测定时排尿量大于200ml患者设施了初步的分型方法。结论：尿道狭窄超声和 尿流率的联合研究,能同时提供功能和 形态的信息,弥补了各自的局限性,有助于全面、准确地反映患者的排尿功能,对于指导临床进一步处理和术后疗效评价具有重要的临床实际意义。     

Fractionated stereotactic body radiation therapy for medically inoperable stage I lung cancer adjacent to central large bronchus

PurposeTo assess the body-framed stereotactic body radiation therapy (SBRT) results and toxicity for medically inoperable stage I lung cancer adjacent to central large bronchus and then compare the results with those of SBRT in peripheral lung tumor in the aspects of survival and SBRT-related pulmonary toxicities.MaterialsFrom June 1999 to May 2006, 32 patients diagnosed as stage I, T1N0 or T2N0, resectable NSCLC were treated with body-frame based fractionated SBRT. Thirty-one patients had several medical problems conflicting surgical procedure. Stereotactic body frame was used for improving setup accuracy. Doses of 10–20 Gy per fraction were delivered to the planning target volume (PTV) up to a total dose of 40–60 Gy with three to four fractions on consecutive days. Centrally located tumor was defined as the tumor within 2 cm apart from large bronchial tree, and was subdivided into bronchial (main/lobar bronchus) and peribronchial (segmental or distal).ResultsMedian follow-up was 26.5 months. The 6-month major response rate, including complete or partial response, was 53.1%. One patient showed progressive disease 1 month after SBRT. The 1- and 2-year actuarial local tumor control rates were both 85.3%. Overall survival was 70.9% at 1 year and 38.5% at 2 years, and survival was not correlated with SBRT dose. Of 9 patients with centrally located tumors, three (33%) experienced Grades 3–5 pulmonary toxicities. Eight patients showed partial or complete bronchial stricture and secondary loss of normal lung volume. Median time to bronchial stricture was 20.5 months. Overall survival did not differ by tumor location.ConclusionsSBRT in this fractionation should not be given to central lung tumors because it can cause the late major airway toxicities in some patients. More protracted hypofractionated treatment regimen may be more safe than that used usually in SBRT for central lung tumors.     

Oblique anastomosis in Soave endoanal pullthrough for Hirschsprung’s disease: a way of reducing strictures?

The Soave endorectal pullthrough is a commonly performed procedure for the definitive management of children with Hirschsprung’s disease (HD). Anastomotic stricture is a recognised complication of this procedure [1–5]. There are multiple causes for these strictures, circular anastomosis being one of them. There are techniques described which alter the shape of the anastomosis of the pulled through bowel to decrease the incidence of strictures. These are oblique [6] and heart-shaped [7] anastomoses. We describe a new technique of oblique anastomosis where the pulled through bowel is anastomosed posteriorly 0.5 cm from the dentate line, and anteriorly 1.5 cm above this point. This oblique anastomosis is designed to lower the stricture rate. If a stricture does occur, an anastomosis near the anocutaneous junction on the posterior aspect also faciltates Y–V anoplasty. We present our experience using this technique. Seventeen consecutive children underwent the procedure at our institution between 2003 and 2006. Only one child developed an anastomotic stricture requiring anal dilatation.     

腔内冷刀切开及瘢痕电切治疗后尿道狭窄

目的探讨腔内冷刀切开及瘢痕电切治疗后尿道狭窄,提高后尿道狭窄腔内手术成功率.材料与方法回顾分析76例外伤性后尿道狭窄行尿道内切开及尿道瘢痕电切术治疗.后尿道狭窄长度0.3～2.5cm,平均1.7cm.结果72例(94.7%)手术成功,其中68例一次成功,4例因狭窄复发而行2次腔内手术成功;4例失败原因均为术中尿道出血多视野不清晰而改为开放手术治疗.患者术后均定期行尿道扩张,术后6～12月复查尿流率,最大尿流率16～34(21.2±8.9)ml/s,平均尿流率10～25(14.1±5.6)ml/s.结论腔内冷刀切开及瘢痕电切治疗后尿道狭窄,方法简单、安全、疗效好、可反复治疗、费用低、创伤小,我们认为腔内冷刀切开及瘢痕电切术是后尿道狭窄的最佳选择.     

经胃粘膜下层食管胃粘膜单层吻合的临床研究

目的：探讨预防食管胃吻合术吻合口瘘、吻合口狭窄以及反流性食管炎的手术方法。方法：按根治要求切除恶性肿瘤，关闭残胃断端，在保留胃的前壁分别置作3cm宽的隧道出、入口，出、入口间距为3cm，经胃粘膜下层打通出、入口，构成胃壁“隧道”。游离食管粘膜3cm，由隧道入口至出口，距出口远端胃浆肌层断缘0．5cm处，横行切开胃粘膜3cm作为吻合口，行食管胃粘膜单层吻合，关闭出、入口，置游离的食管粘膜于隧道内。结果：本组300例术后无1例早期死亡和发生吻合口瘘，吻合口狭窄和反流性食管炎各2例。结论：经胃粘膜下层食管胃粘膜单层吻合可以预防吻合口瘘、吻合口狭窄和反流性食管炎。     

Changing trends in the minimally invasive surgery for corrosive esophagogastric stricture

Esophagogastric stricture is the troublesome long-term complication of corrosive ingestion with a significant adverse impact on the quality of life. Surgery remains the mainstay of therapy in patients where endoscopic treatment is not feasible or fails to dilate the stricture. Conventional surgical management of esophageal stricture is open esophageal bypass using gastric or colon conduit. Colon is the commonly used esophageal substitute, particularly in those with high pharyngoesophageal strictures and in patients with accompanying gastric strictures. Traditionally colon bypass is performed using an open technique that requires a long midline incision from the xiphisternum to the suprapubic area, with adverse cosmetic outcomes and long-term complications like an incisional hernia. As most of the affected patients are in the second or third decade of life minimally invasive approach is an attractive proposition. However, minimally invasive surgery for corrosive esophagogastric stricture is slow to evolve due to the complex nature of the surgical procedure. With advancements in laparoscopic skills and instrumentation, the feasibility and safety of minimally invasive surgery in corrosive esophagogastric stricture have been documented. Initial series have mainly used a laparoscopic-assisted approach, whereas more recent studies have shown the safety of a total laparoscopic approach. The changing trend from laparoscopic assisted procedure to a totally minimally invasive technique for corrosive esophagogastric stricture should be carefully disseminated to preclude adverse long-term outcomes. Also, well-designed trials with long-term follow-ups are required to document the superiority of minimally invasive surgery for corrosive esophagogastric stricture. The present review focuses on the challenges and changing trends in the minimally invasive treatment of corrosive esophagogastric stricture.     

Negotiating the ‘difficult’ oesophageal stricture

Very narrow oesophageal strictures, although visible on contrast examination, may not be amenable to safe prograde dilatation. A technique used in four recent cases where attempts at prograde dilatation had failed is described. The strictures were easily negotiated from below via a gastrostomy and the distal oesophagus using an Arrow Duoflex guide wire for subsequent string-guided dilatation. Access to the lower oesophagus was easily achieved using a Portex blue-line endotracheal tube. This method appears quick, safe, and reliable. Correspondence to: A. J. W. Millar