Endosonographic features of primary esophageal melanoma

Malignant melanoma most commonly arises in the skin; however, primary melanomas can also arise from the mucosal epithelial lining of the gastrointestinal tract. Primary esophageal melanoma is rare and constitutes only 0.1% of primary esophageal tumors. There are only a few reports on the use of endosonography in this condition. We report here a case of a 45‐year‐old male with a history of painful deglutition and describe the endosonographic features of primary esophageal melanoma.     

胃间质瘤超声内镜检查及免疫组织化学检测的临床意义

目的 探讨超声内镜及免疫组织化学检测对胃间质瘤(GST)良恶性评估的意义.方法 回顾性分析经胃镜及超声内镜发现的胃黏膜下肿物112例,其中经内镜下切除和手术治疗的32例进行病理组织学及免疫组织化学检查(Ki-67,p53,CD34,CD117),并分析超声内镜图像(包括大小、层次、回声、有否液性暗区及分叶、边缘的声晕、倍增时间等).结果 (1)CD117和CD34在GST中的表达率分别为90.6%和81.3%;(2)Ki-67在危险度低、中、高组表达分别为7.8%,27.3%,87.5%,危险度低组与高组之间差别有统计学意义(P＜0.05);p53在危险度低、中、高组表达分别为0％,18.2%,68.5%,危险度低组与高组之间差别有统计学意义(P＜0.05);(3)13例恶性GST具有以下特征：长径＞4 cm，呈分叶、内部回声不均匀、液性暗区、边缘不规则伴有声晕、较短的倍增时间.结论 超声内镜可为临床治疗和预后评估提供参考.CD117、CD34可作为GST的免疫组织化学标志物;Ki-67,p53的检测有助于GST恶性程度的判断.     

Significance of the Thickness of the Anal Sphincters with Age and Its Relevance in Faecal Incontinence

Papachrysostomou M, Pye SD, Wild SR, Smith AN. Significance of the thickness of the anal sphincters with age and its relevance in faecal incontinence. Scand 1 Gastroenterol 1994;29:710-714.

Background: Ultrasonographic studies in healthy volunteers showed that the external anal sphincter (EAS) and internal anal sphincter (IAS) thicknesses were inversely related at rest. The functional importance of the two sphincters in continence control was demonstrated in the relationship between the sum of the thicknesses of the two sphincters and the anal canal resting pressure. The aims of the present study were to assess the morphometric appearance of the anal sphincters by endosonography in faecally incontinent patients and to contrast this with that of older healthy subjects. Methods: Twenty-eight female patients with neurogenic faecal incontinence (FI) were studied. An older group of 7 healthy women, aged 41-75 years, and a young group of 11 nulliparous healthy women, aged 20-23 years, served as control groups. Anal endosonography was performed with a radial rotating endoprobe, with the subject in the left lateral position. Conventional anal manometry was performed in all subjects. Results: The EAS in the FI group was thicker than the EAS in the old (p < 0.04) but did not differ from the EAS in the young. The IAS thickness in the FI group did not differ from that in the older group. In both these groups the IAS was thicker than in the young women (p < 0.01). The anal pressures in the FI group were reduced compared with the normal groups (p < 0.04). There was a direct relationship between the two sphincters in FI (p < 0.001). Conclusions: The increased thickness of the IAS in the FI group does not seem to compensate for function and results in a failure of the sphincter mechanism to maintain continence, whereas in healthy elderly subjects the increased IAS thickness appears to be compensatory and important for continence control.     

The impact of endoscopic ultrasonography with fine needle aspiration (EUS‐FNA) on esophageal cancer staging: a survey of thoracic surgeons and gastroenterologists

SUMMARY. Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End‐oscopic ultrasound with fine needle aspiration (EUS‐FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS‐FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS‐FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS‐capable gastroenterologists. Seventy‐six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high‐quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N‐staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case‐by‐case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS‐FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.     

超声内镜与经内镜逆行胰胆管造影联合治疗胆胰疾病

经内镜逆行胰胆管造影(ERCP)作为消化内镜主要手段,在一些胆胰疾病的微创治疗方面起到重要作用,在胆管狭窄、胰管狭窄的减压治疗、胰瘘的治疗等方面,ERCP的胆管内引流术及外引流术、胰管支架植入术等起关键的作用。近年由于介入超声内镜(EUS)技术的进步,当ERCP插管未成功,或手术后解剖结构改变而传统ERCP无法完成胆管、胰管的减压时,还可以通过EUS引导下穿刺及支架植入术完成胆胰管的减压,为其治疗开辟新的领域,同时也体现EUS与ERCP在胆胰疾病治疗中起到的互补作用。     

Hydrogen peroxide-enhanced transanal ultrasound in the assessment of fistula-in-ano

Appropriate classification of the fistulous tracts in patients with fistula-in-ano may be of value for the planning of proper surgery. Conventional transanal ultrasound has limited value in the visualization of fistulous tracts and their internal openings. Hydrogen peroxide can be used as a contrast medium for ultrasound to improve visualization of fistulas. PURPOSE: This prospective study evaluates hydrogen peroxide-enhanced ultrasound in comparison with physical examination, standard ultrasound, and surgery in the assessment of fistula-in-ano. METHODS: Twenty-one consecutive patients (4 women; mean age, 42 years) with fistula-in-ano were evaluated by local physical examination (inspection, probing, and digital examination), conventional ultrasound, and hydrogen peroxide-enhanced ultrasound before surgery. Ultrasound was performed using a B&K Diagnostic Ultrasound System with a 7-MHz rotating endoprobe. Hydrogen peroxide (3%) was infusedvia a small catheter into the fistula. The results of physical examination, ultrasound, and hydrogen peroxide-enhanced ultrasound were compared with surgical data as the criterion standard. The additive value of standard ultrasound and hydrogen peroxide-enhanced ultrasound compared with physical examination was also determined. RESULTS: At surgery, 8 intersphincteric and 11 transsphincteric fistulas and 2 sinus tracts (without an internal opening) were found. During physical examination, probing was incomplete in 13 patients, the diagnosis being correct in the other 8 patients (38%) as a low (intersphincteric or transsphincteric) fistula. With conventional ultrasound, the assessment of fistula-in-ano was correct in 13 patients (62%); defects in one or both sphincters could also be found (n=8). With hydrogen peroxide-enhanced ultrasound, the fistulous tract was classified correctly in 20 patients, the overall concordance with surgery being 95%. The internal opening was found at physical examination in 15 patients (71%), with hydrogen peroxide-enhanced ultrasound in 10 patients (48%), and during surgery in 19 patients (90%). Secondary extensions, confirmed during surgery, were found in five cases. In two patients, a secondary extension with hydrogen peroxide-enhanced ultrasound was not confirmed during surgery. Both patients developed a recurrent fistula. CONCLUSION: Hydrogen peroxide-enhanced ultrasound is superior to physical examination and standard ultrasound in delineating the anatomic course of perianal fistulas. It makes accurate preoperative assessment of the fistula possible and may be of value for the surgeon in planning therapeutic strategy.Dr. Poen was supported by a grant from Janssen-Cilag B.V., The Netherlands.Presented in part at the United European Gastroenterology Week, Birmingham, United Kingdom, October 18 to 21, 1997.     

Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients

Aim Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined. Method Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI. Results Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC‐curve was 0.84 (P < 0.001; 95% confidence interval, 0.80–0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure. Conclusion Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.     

经腹肠道超声诊断小肠克罗恩病并发症

目的 评估经腹肠道超声（TBUS）诊断小肠克罗恩病（SBCD）并发症的价值。方法 回顾性分析25例确诊SBCD患者10年42例次超声检查,包括活动期26例次（活动期组）、缓解期16例次（缓解期组）的声像图特征,观察超声评估病变活动度结果与Harvey-Bradshaw指数（HBI）的一致性。结果 TBUS与HBI评估病变活动度的一致性较高（Kappa=0.897）。瘘、脓肿、炎性包块均见于活动期组;活动期组狭窄、爬行脂肪征、淋巴结炎、腹腔积液等发生率均明显高于缓解期组（P均<0.05）,肠壁及爬行脂肪厚度明显大于缓解期组（P均<0.01）。42例次超声检查中,15例次见肠管狭窄,8例次见瘘;31例次病变肠壁周围脂肪组织炎性增生,20例次见多发肠系膜淋巴结炎;腹腔积液16例次,腹部包块9例次,其中5例次伴脓肿,穿孔1例次,炎性息肉8例次,憩室形成3例次。结论 TBUS能准确显示SBCD腹部并发症,可作为评估SBCD并发症的常规影像学检查手段。     

Unique usage of a partially covered metal stent for drainage of a pancreatic pseudocyst via endosonography-guided transcystgastrostomy

Pancreatic pseudocysts are frequent complications of pancreatitis episodes. The current therapeutic modalities for drainage of pancreatic pseudocysts include surgical, percutaneous, and endoscopic drainage modalities. Endosonography-assisted endoscopic drainage of these pseudocysts with the placement of multiple plastic or fully covered self-expanding biliary metal stents is becoming more commonly carried out. The present case report discusses the unique and successful drainage of a pancreatic pseudocyst with the placement of a partially covered self-expanding metal stent.