Endoscopic sphincterotomy complications and their management: an attempt at consensus

Background Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. Methods We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. Results Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct,...

https://www.nejm.org/doi/pdf/10.1056/NEJM199609263351301

Complications of Endoscopic Biliary Sphincterotomy

To determine whether infection with a Helicobacter pylori strain possessing cagA is associated with an increased risk of development of adenocarcinoma of the stomach, we used a nested case-control study based on a cohort of 5443 Japanese-American men in Oahu, Hawaii, who had a physical examination and a phlebotomy during 1967 to 1970 We matched 103 H pylori -infected men who developed gastric cancer during a 21-year surveillence period with 103 H pylori -infected men who did not develop gastric cancer and tested stored serum specimens from patients and controls for the presence of serum IgG to the cagA product of H pylori using an ELISA The serum IgG assay using a recombinant CagA fragment had a sensitivity of 944% and a specificity of 925% when used in a clinically defined population; serological results were stable for more than 7 years For men with antibodies to CagA, the odds ratio of developing gastric cancer was 19 (95% confidence interval, 09–40); for intestinal type cancer of the distal stomach, the odds ratio was 23 (95% confidence interval, 10–52) Age cagA -positive H pylori strain in comparison with a cagA -negative strain somewhat increases the risk for development of gastric cancer, especially intestinal type affecting the distal stomach

https://cancerres.aacrjournals.org/content/canres/55/10/2111.full.pdf

Infection with Helicobacter pylori Strains Possessing cagA Is Associated with an Increased Risk of Developing Adenocarcinoma of the Stomach

Over the past decade the Improving Outcomes Guidance (IOG) document has led to service re-configuration in the NHS and there are now 41 specialist centres providing oesophageal and gastric cancer care in England and Wales. The National Oesophago-Gastric Cancer Audit, which was supported by the British Society of Gastroenterology, the Association of Upper Gastrointestinal Surgeons (AUGIS) and the Royal College of Surgeons of England Clinical Effectiveness Unit, and sponsored by the Department of Health, has been completed and has established benchmarks for the service as well as identifying areas for future improvements.1–3 The past decade has also seen changes in the epidemiology of oesophageal and gastric cancer. The incidence of lower third and oesophago-gastric junctional adenocarcinomas has increased further, and these tumours form the most common oesophago-gastric tumour, probably reflecting the effect of chronic gastro-oesophageal reflux disease (GORD) and the epidemic of obesity. The increase in the elderly population with significant co-morbidities is presenting significant clinical management challenges. Advances in understanding of the natural history of the disease have increased interest in primary and secondary prevention strategies. Technology has improved the options for diagnostic and therapeutic endoscopy and staging with cross-sectional imaging. Results from medical and clinical oncology trials have established new standards of practice for both curative and palliative interventions. The quality of patient experience has become a significant component of patient care, and the role of the specialist nurse is fully intergrated. These many changes in practice and patient management are now routinely controlled by established multidisciplinary teams (MDTs) which are based in all hospitals managing these patients.

The original guidelines described the management of oesophageal and gastric cancer within existing practice. This paper updates the guidance to include new evidence and to embed it within the framework of the current UK National Health Service (NHS) Cancer …

https://gut.bmj.com/content/gutjnl/60/11/1449.full.pdf

Guidelines for the management of oesophageal and gastric cancer

A BSTRACT Background Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. Methods We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. Results Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct, achievement of access to the bile duct by “precut” sphincterotomy, and use of a combined percutaneous–endoscopic procedure). The overall risk of complications was not related to the patient’s age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of complications (8.4 percent vs. 11.1 percent, P 0.03). Conclusions The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patient. (N Engl J Med 1996;335:909-18.)

Complications of endoscopic biliary sphincterotomy.

Endoscopic sphincterotomy of the ampulla of Vater

Fasted, anesthetized female rats were used to test the effects of sucralfate (Sc) on the response of the gastric mucosa to ethanol (EtOH) in NaCl or taurocholic acid (TcA) in HCl. The trachea was cannulated and the esophagus and pylorus were ligated. Tubes placed into the stomach permitted instillation of test solutions and determinations of transmucosal potential difference (PD). All periods were 15 min. Each test began with a baseline 150 mM HCl period followed by two treatment periods; in the first, 5600 mg Sc in NaCl or NaCl alone was placed in the stomach; in the second, neutral EtOH or acidified TcA solution was added. In the final two posttreatment test periods, the pH of the gastric contents of the animals treated with Sc was higher, the disappearance of H+ was less, and the index of mucosal damage was reduced. The results demonstrate that Sc has a protective effect on the gastric mucosa of rats. Pretreatment with Sc also reduced the net Cl-loss from the contents and produced an unexplained significant reduction in PD. Sc formed a white coating over the glandular mucosa. This coating may a play a role in its protective action.

Analytical studies on growth of human gastric cancer.

Dye spraying method was applied in colonofiberscopy; 111 cases of normal colonic mucosa and 26 cases of ulcerative colitis were examined by this method. Using indigocarmine in this method, we could recognize the fine mucosal changes more easily and clearly and get better information for differential diagnosis. Furthermore, the degree of staining of the mucosa by methylene blue, one of the ultra vital staining dye, is different according to the stage of the inflammatory process of colonic mucosa itself in ulcerative colitis. Namely the stainability of the colonic mucosa is corresponding to the healing process of the disease.

On the dye spraying method in colonofiberscopy.

Helicobacter pylori infection is causally related to chronic type-B gastritis, and may also be associated with an increased risk of gastric carcinoma Vacuolating cytotoxin, which is an 87-kDa protein secreted by H pylori, induces eukaryotic cell vacuolation in vitro To determine whether there is an association between H pylori vacuolating cytotoxin and gastric carcinoma, we investigated several characteristics of H pylori infection, ie, isolation of H pylori from gastric biopsies, antibodies specific for H pylori, detection of neutralizing activity to vacuolating cytotoxin in serum and immunological detection of cytotoxin by serum Out of 6 sera from gastric-carcinoma patients, all showed the neutralizing activity to vacuolating cytotoxin, in contrast to 3 of 5 sera from peptic-ulcer patients Normal individuals showed no neutralizing activity All sera possessing the neutralizing activity recognized an 87-kDa protein band by Western blot analysis Our results confirmed that cytotoxin-neutralizing activity in human sera was associated with immunodetection of an 87-kDa protein To further evaluate neutralizing activity in serum from gastric-carcinoma patients, we retrospectively analyzed frozen-stocked serum samples from 22 gastric-carcinoma patients Sera from 21 of these 22 patients exhibited neutralizing activity These sera were also checked for antibodies to H pylori, using an ELISA; 16 sera showed positive results Our results indicate that detection of cytotoxin-neutralizing activity in sera is strongly associated with H pylori infection, and probably with gastric carcinoma, and is also of interest in the diagnosis of H pylori infection © 1994 Wiley-Liss, Inc

High prevalence of neutralizing activity to helicobacter pylori cytotoxin in serum of gastric‐carcinoma patients

1.

There was done a case report of postbulbar duodenal ulcer of a teenager, which was recently found in our University Hospital.




2.

The double air contrast method is suggested to be most useful for discovery of postbulbar duodenal ulcer.




3.

The lesions, seen for the last ten years in our country, were summarized and investigated.

Yoshihiro Kohli

Papers

Endoscopic sphincterotomy of the ampulla of Vater

Analytical studies on growth of human gastric cancer.

On the dye spraying method in colonofiberscopy.

High prevalence of neutralizing activity to helicobacter pylori cytotoxin in serum of gastric‐carcinoma patients

X-Ray diagnosis of postbulbar duodenal ulcer by means of double air contrast method