鼻内窥镜手术治疗1500例临床分析

目的 :探讨鼻内窥镜手术治疗慢性鼻窦炎、鼻息肉的疗效、影响手术疗效的因素及并发症处理。方法 :对 1997～ 1999年完成随访的 15 0 0例鼻内窥镜手术患者进行临床分析。结果 :Ⅰ、Ⅱ、Ⅲ型治愈率分别为 96 .6 %、82 .3%及 70 .1%;各型治愈率间有显著差异 (P <0 .0 1)。结论 :鼻内窥镜手术是治疗鼻腔、鼻窦炎性疾病的有效方法 ,手术疗效与临床分型有关。

Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma

In the developed and developing countries, corrosive injury to the gastrointestinal system as a consequence of either accidental ingestion or as a result of self-harm has become a less common phenomenon compared to decades ago. This could partly be attributed to the tighter legislation imposed by the government in these countries on detergents and other corrosive products and general public awareness. Most busy upper gastrointestinal surgical units in these countries, especially in the developed countries will only encounter a small number of cases per year. Up to date knowledge on the best management approach is lacking. In this article, we present our experience of two contrasting cases of corrosive injury to the upper gastrointestinal tract in our thoracic unit in the last 2 years and an up-to-date Medline literature search has been carried out to highlight the areas of controversies in the management of corrosive injuries of the upper gastrointestinal tract. We concluded that the main principle in managing such patients requires a good understanding of the pathophysiology of corrosive injury in order to plan both acute and future management. Each patient must be evaluated individually as the clinical picture varies widely. Signs and symptoms alone are an unreliable guide to injury.

Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis

Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach,recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/ neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported,but larger studies are needed to confirm this finding. At this time,the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.

Combined endoscopic and ursodeoxycholic acid treatment of biliary cast syndrome in a non-transplant patient

A 76-year-old diabetic man underwent cholecystectomy for gangrenous calculous cholecystitis. His postoperative course was complicated by the development of Candida albicans esophagitis necessitating antifungal therapy, and total parenteral nutrition (TPN) for 15 d. Seven weeks after cholecystectomy, he presented with cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated extrahepatic filling defects. Despite endoscopic extraction of a biliary cast, cholestasis remained unchanged. Oral administration of ursodeoxycholic acid (UDCA), 750 mg/d, resulted in normalization of liver function tests. We, therefore, propose for the f irst time, combined endoscopic plus UDCA treatment for the management of biliary cast syndrome.

Removal of press-through-packs impacted in the upper esophagus using an overtube

Foreign bodies in the upper esophagus should be re-moved as soon as possible to avoid serious complica-tions. However, removals of foreign bodies in the upper esophagus are very difficult, especially if they have sharp edges, such as press-through-packs (PTPs). We expe-rienced four cases of the impacted PTPs in the upper esophagus which was successfully extracted endoscopi-cally with the overtube. Because two edges of PTPs were so firmly impacted in the esophageal wall in all cases, the PTPs were not movable in the upper esophagus. However, after insertion of the overtube, PTPs became movable and were successfully extracted and no serious complications occurred after extraction of PTPs. In one case, insertion of the overtube rapidly expanded the up-per esophagus and PTP progressed to the gastric cavity and it could be extracted with the endoscopic protector hood. The endoscopic removal with the overtube was a simple, safe and effective technique for the removal of the impacted PTPs in upper esophagus.

H pylori infection in patients with Behcet's disease

AIM:To evaluate endoscopic findings and the prevalence of H pylori in patients with Behcet's disease (BD) who have upper gastrointestinal symptoms. METHODS:The patients with BD diagnosed according to the International Study Group and followed up in the Department of Dermatology and other related departments and who had any upper gastrointestinal complaints,were included in this study. Forty-five patients with BD and 40 patients in the control group were evaluated by upper gastrointestinal endoscopy and two biopsied specimens were taken during endoscopy for H pylori . A two-week triple therapy for H pylori eradication was administered to H pylori positive patients. Two months after the treatment,the patients were evaluated by urea-breath test for eradication control. RESULTS:Patients with BD had a mean age of 36.2 ± 11.4 years (18-67 years). The mean follow-up time was 35 ± 14 mo (16-84 mo). Aphthous or deep ulcer in esophagus,stomach and duodenum had never been confirmed by endoscopic examination. Most gastric lesions were gastric erosion (40%) and the most duodenal lesions were duodenitis (17.5%) in two groups. H pylori was positive in 33 patients (73.3%) with BD. The two-week triple eradication therapy was successful in 75% of the patients. There was no difference between the groups in respect to prevalence of H pylori (73.3% vs 75%,P > 0.05),and eradication rate (75% vs 70%,P > 0.05). CONCLUSION:Endoscopic findings,eradication rate and prevalence of H pylori were similar in patients withBD and control group.

Risk factors for bleeding after endoscopic mucosal resection

AIM： To clarify the risk factors for bleeding after endoscopic mucosal resection （EMR）. METHODS： A total of 297 consecutive patients who underwent EMR were enrolled. Some of the patients had multiple lesions. Bleeding requiring endoscopic treatment was defined as bleeding after EMR. Odds ratios （OR） with 95% confidence intervals （CI）, calculated by logistic regression with multivariate adjustments for covariates, were the measures of association. RESULTS： Of the 297 patients, 57 （19.2%） patients with bleeding after EMR were confirmed. With multivariate adjustment, the cutting method of EMR, diameter, and endoscopic pattern of the tumor were associated with the risk of bleeding after EMR. The multivariate-adjusted OR for bleeding after EMR using endoscopic aspiration mucosectomy was 3.07 （95%CI, 1.59-5.92） compared with strip biopsy. The multiple-adjusted OR for bleeding after EMR for the highest quartile （16-50 mm） of tumor diameter was 5.63 （95%CI, 1.84-17.23） compared with that for the lowest （4-7 mm）. The multiple-adjusted OR for bleeding after EMR for depressed type of tumor was 4.21 （95%CI, 1.75-10.10） compared with elevated type. CONCLUSION： It is important to take tumor charactedstics （tumor size and endoscopic pattern） and cutting method of EMR into consideration in predicting bleeding after EMR.

Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding

AIM:To investigate glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding and to evaluate the long-term efficacy and safety of this therapy.METHODS:A total of 148 cirrhotic patients in our hospital with esophagogastric variceal bleeding(EGVB) were included in this study.N-butyl-2-cyanoacrylate was mixed with lipiodol in a 1:1 ratio and injected as a bolus of 1-3 mL according to variceal size.Patients underwent endoscopic follow-up the next week,fourth week,second month,fourth month,and seventh month after injection and then every 6 mo to determine the cast shape.An abdominal X-ray fi lm and ultrasound or computed tomographic scan were also carried out in order to evaluate the time of variceal disappearance and complete extrusion of the cast.The average follow-up time was 13.1 mo.RESULTS:The instantaneous hemostatic rate was 96.2%.Early re-bleeding after injection in 9 cases(6.2%) was estimated from rejection of adhesive.Late re-bleeding occurred in 12 patients(8.1%) at 2-18 mo.The glue cast was extruded into the lumen within one month in 86.1% of patients and eliminated within one year.Light erosion was seen at the injection position and mucosa edema in the second week.The glue casts were extruded in 18 patients(12.1%) after one week and in 64 patients(42.8%) after two weeks.All kinds of glue clumping shapes and colors on endoscopic examination were observed in 127 patients(86.1%) within one month,including punctiform,globular,pillar and variform.Forty one patients(27.9%) had glue extrusion after 3 mo and 28 patients(28.9%) after six months.The extrusion time was not related to the injection volume of histoacryl.Obliteration was seen in 70.2%(104 cases) endoscopically.The main complication was re-bleeding resulting from extrusion.The prognosis of the patients depended on the severity of the underlying liver disease.CONCLUSION:Endoscopic injection of cyanoacrylate is highly effective for gastric varices bleeding.The glue clump shape is correlated with anatomic structure of vessels.The time of extrusion was not related to dosage of the glue.

Natural history of a randomized trial comparing distal spleno-renal shunt with endoscopic sclerotherapy in the prevention of variceal rebleeding:A lesson from the past

AIM: To compare endoscopic sclerotherapy (ES) with distal splenorenal shunt (DSRS) in the prevention of recurrent variceal bleeding in cirrhotic patients during a long-term follow-up period. METHODS: In 1984 we started a prospective, controlled study of patients with liver cirrhosis. Long-term follow-up presents a natural history of liver cirrhosis complicated by advanced portal hypertension. In this study the effects of 2 types of treatment, DSRS or ES, were evaluated. The study population included 80 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1991. These patients were drawn from a pool of 282 patients who underwent either elective surgery or ES during the same period of time. Patients were assigned to one of the 2 groups according to a random number table: 40 to DSRS and 40 to ES using polidocanol. RESULTS: During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS and another patient suffered duodenal ulcer rebleeding. Eight ES patients suffered at least one episode of gastrointestinal bleeding: 4 from varices and 4 from esophageal ulcerations. Eight ES patients developed transitory dysphagia. Long-term follow- up was completed in all patients except for 5 cases (2 DSRS and 3 ES patients). Five-year survival rates for shunt (73%) and ES (56%) groups were statistically different: in this follow-up period and in subsequent follow-ups this difference decreased and ceased to be of statistical relevance. The primary cause of deathbecame hepatocellular carcinoma (HCC). Four DSRS patients rebled due to duodenal ulcer, while eleven ES patients had recurrent bleeding from esophago-gastric sources (seven from varices, three from hypertensive gastropathy, one from esophageal ulcerations) and two from unknown sources. Nine DSRS and 2 ES patients developed a chronic encephalopathy; 13 DSRS and 5 ES patients suffered at least one episode of acute encephalopathy. Five ES patients had esophageal stenoses, which were successfully dilated. CONCLUSION: In a subgroup of patients with good liver function, DSRS with a correct portal-azygos disconnection more effectively prevents variceal rebleeding than ES. However, this positive effect did not influence the long-term survival because other factors (e.g. HCC) were more important in deciding the fate of the cirrhotic patients with portal hypertension.

Endoscopic treatment and follow-up of gastrointestinal Dieulafoy's lesions

AIM: To investigate retrospectively the clinical and endoscopic features of bleeding Dieulafoy's lesions and to assess the short- and long-term effectiveness of endoscopic treatment.METHODS: Twenty-three patients who had gastrointestinal bleeding from Dieulafoy's lesions underwent endoscopic therapy. Demographic data, mode of presentation, riskfactors for gastrointestinal bleeding, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, recurrence of bleeding, and mortality rates were collected and analyzed retrospectively.RESULTS: Hemostasis was attempted by dextrose 50% plus epinephrine in 10 patients, hemoclipping in 8 patients,heater probe in 2 patients and ethanolamine oleate in 2 patients. Comorbid conditions were present in 17 patients (74%). Overall permanent hemostasis was achieved in 18 patients (78%). Initial hemostasis was successful with no recurrent bleeding in patients treated with hemoclipping, heater probe or ethanolamine injection. In the group of patients who received dextrose 50% plus epinephrine injection treatment, four (40%) had recurrent bleeding and one (10%) had unsuccessful initial hemostasis.Of the four patients who had rebleeding, three had unsuccessful hemostasis with similar treatment. Surgical treatment was required in five patients (22%) owing to uncontrolled bleeding, recurrent bleeding with unsuccessful retreatment and inability to approach the lesion. One patient (4.3%) died of sepsis after operation during hospitalization. There were no side-effects related to endoscopic therapy. None of the patients in whom permanent hemostasis was achieved presented with rebleeding from Dieulafoy's lesion over a mean long-term follow-up of 29.8 mo.CONCLUSION: Bleeding from Dieulafoy's lesions can be managed successfully by endoscopic methods, which should be regarded as the first choice. Endoscopic hemoclipping therapy is recommended for bleeding Dieulafoy's lesions.

Endoscopic submucosal dissection for stomach neoplasms

Recent advances in techniques of therapeutic endoscopy for stomach neoplasms are rapidly achieved. One of the major topics in this field is endoscopic submucosal dissection （ESD）. ESD is a new endoscopic technique using cutting devices to remove the tumor by the following three steps： injecting fluid into the submucosa to elevate the tumor from the muscle layer, pre-cutting the surrounding mucosa of the tumor, and dissecting the connective tissue of the submucosa beneath the tumor. So the tumors are resectable in an en bloc fashion, regardless of the size, shape, coexisting ulcer, and location. Indication for ESD is strictly confined by two aspects： the possibility of nodal metastases and technical difficulty, which depends on the operators. Although long-term outcome data are still lacking, short-term outcomes of ESD are extremely favourable and laparotomy with gastrectomy is replaced with ESD in some parts of therapeutic strategy for early gastric cancer.

Role of endoscopy in the management of acute diverticular bleeding

Colonic diverticulosis is one of the most common causes of lower gastrointestinal bleeding. Endoscopy is not only a useful diagnostic tool for localizing the bleeding site, but also a therapeutic modality for its management. To date, haemostatic methods have included adrenaline injection, mechanical clipping, thermal and electrical coagulation or combinations of them. The results of all published data are herein reviewed.

Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection

AIM:To investigate endoscopic and histopathological findings in the duodenum of patients with Strongyloides stercoralis(S.stercoralis)hyperinfection. METHODS:Over a period of 23 years(1984-2006),we investigated 25 patients withS.stercoralis hyperinfection who had had an esophagogastroduodenoscopy before undergoing treatment for strongyloidiasis.The clinical and endoscopic findings were analyzed retrospectively. RESULTS:Twenty-four(96%)of the patients investigated were under immunocompromised condition which was mainly due to a human T lymphotropic virus type 1(HTLV-1)infection.The abnormal endoscopic findings,mainly edematous mucosa,white villi and erythematous mucosa,were observed in 23(92%) patients.The degree of duodenitis including villous atrophy/destruction and inflammatory cell infiltration corresponded to the severity of the endoscopic findings. The histopathologic yield for identifying larvae was 71.4% by duodenal biopsy.The endoscopic findings of duodenitis were more severe in patients whose biopsies were positive for larvae than those whose biopsies were negative(Endoscopic severity score:4.86±2.47vs 2.71 ±1.38,P<0.05). CONCLUSION:Our study clearly demonstrates that,in addition to stool analysis,endoscopic observation and biopsies are very important.We also emphasize that S.stercoralis and HTLV-1 infections should be ruled out before immunosuppressive therapy is administered in endemic regions.

Gastrointestinal bezoars: A retrospective analysis of 34 cases

AIM: Bezoars (BZ) are the most common foreign bodies of gastrointestinal tract. Clinical manifestations vary depending on the location of BZ from no symptoms to acute abdominal syndrome. When located in small bowel, they frequently cause small bowel obstruction (SBO). We aimed to present our experience by reviewing literature.METHODS: Thirty-four patients with gastrointestinal BZ were presented. The data were collected from hospital records and analyzed retrospectively. Morbidity and mortality rates were statistically analyzed between the subgroups according to SBO and endoscopic or surgical treatment modalities.RESULTS: The 34 patients had phytobezoars (PBZ). Two patients with mental retardation and trichotillomania had trichobezoars (TBZ). More than half of them (55.88%) had previous gastric surgery. Also most of them had small bowel bezoars resulting in obstruction. Surgical and endoscopic morbidity rates were 32.14% and 14.28% respectively.The total morbidity rate of this study was 29.41%. Four patients in surgically treated group died. There was no death in endoscopically treated group. The total and surgical mortality rates were 11.76% and 14.28% respectively. The differences in morbidity and mortality rates between the subgroups were not statistically significant.CONCLUSION: BZ are commonly seen in stomach and small intestine. SBO is the most common complication.When uncomplicated, endoscopic or surgical removal can be applied easily.

Endoscopic management of a new entity-plastobezoar:A case report and review of literature

Foreign bodies and bezoars are commonly encountered in children. We describe a child aged 11 years who ingested large amounts of plastic material used for knitting chairs and charpoys. The conglomerate of plastic threads, entrapped food material and other debris, formed a huge mass occupying the whole stomach. Chronic irritation of the gastric antral mucosa led to ulceration and formation of hyperplastic polyps. We labeled this new entity as a “plastobezoar”. The entire bezoar could be removed endoscopically.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: A two-year survey

AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience.Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy.On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy

The purpose of this article is to review the evidence regarding transmission of infection during gastrointestinal endoscopy, factors important in endoscope reprocessing and infection control, areas to focus on to improve compliance, and recent developments and advances in the field.

Upper gastrointestinal endoscopy:Are preparatory interventions or conscious sedation effective? A randomized trial

AIM: The fears and concerns are associated with gastroscopy (EGD) decrease patient compliance. Conscious sedation (CS) and non-pharmacological interventions have been proposed to reduce anxiety and allow better execution of EGD. The aim of this study was to assess whether CS, supplementary information with a videotape, or presence of a relative during the examination could improve the tolerance to EGD. METHODS: Two hundred and twenty-six outpatients (pts), scheduled for a first-time non-emergency EGD were randomly assigned to 4 groups: Co-group (62 pts): throat anaesthesia only; Mi-group (52 pts): CS with i.v. midazolam; Re-group (58 pts): presence of a relative throughout the procedure; Vi-group (54 pts): additional information with a videotape. Anxiety was measured using the “Spielberger State and Trait Anxiety Scales” The patients assessed the overall discomfort during the procedure on an 100-mm visual analogue scale, and their tolerance to EGD answering a questionnaire. The endoscopist evaluated the technical difficulty of the examination and the tolerance of the patients on an 100-mm visual analogue scale and answering a questionnaire. RESULTS: Pre-endoscopy anxiety levels were higher in the Mi-group than in the other groups (P<0.001). On the basis of the patients' evaluation, EGD was well tolerated by 80.7% of patients in Mi-group, 43.5% in Co-group, 58.6% in Regroup, and 50% in Vi-group (P<0.01). The discomfort caused by EGD, evaluated by either the endoscopist or the patients, was lower in Mi-group than in the other groups. The discomfort was correlated with “age” (P<0.001) and “groups of patients” (P<0.05) in the patients' evaluation, and with “gender” (females tolerated better than males, P<0.001) and “groups of patients” (P<0.05) in the endoscopist's evaluation. CONCLUSION: Conscious sedation can improve the tolerance to EGD. Male gender and young age are predictive factors of bad tolerance to the procedure.

Diagnosis of autoimmune gastritis by high resolution magnification endoscopy

Endoscopic visualisation of gastric atrophy is usually not feasible with conven.tional endoscopy. Magnifying endoscopy is helpful to analyze the subepithelial microvascular architecture as well as the mucosal surface microstructure without tissue biopsy. Using this technique we were able to describe the normal gastric microvasculature pattern and we also identified characteristic patterns in two cases of autoimmune atrophic gastritis.

Congenital tracheoesophageal fistula successfully diagnosed by CT esophagography

Tracheoesophageal fistula （TEF） or bronchoesophageal fistula may be congenital, inflammatory, neoplastic, or secondary to trauma. Congenital TEF or bronchoesophageal fistula is usually associated with esophageal atresia and is readily diagnosed in infancy. But if it is not associated with esophageal atresia, it may persist until adulthood. Some theories have been proposed to explain this delay in diagnosis. We present a case of a 70-year-old man with congenital TEF. The TEF was successfully diagnosed by multidetector-row CT esophagography.