纤维内窥镜的结构和维修

纤维内窥镜是一种高精度、高性能的光学仪器,目前利用光学纤维束制成的各种内窥镜有食道、胃、十二脂肠、小肠、结肠、胆道,腹腔、鼻腔、支气管、膀胱、心脏大血管、脑室、椎管、榆尿管、肾盂、输卯管等,其品种规格不下50多种。它在很大程度上克服了以往硬试管型内窥镜在诊疗上的许多缺点,基本上消灭了盲区,且又可进行彩色摄影和电视录像。

Public Screening for Early Carcinoma of Gastric Cardia: Rule of Carcinogenetic Development Observed by Endoscopy

Objective： To study the rule of development of early cancer of gastric cardia in vivo in public screening. Methods： A prospective cohort study on gastric cardiac cancer was performed in the high incidence area of cancer of esophagus and stomach in china. 106 subjects had been examined regularly by endoscopy to observe the change of mucosa in high incident area of gastric cardiac carcinoma developing at the root of gastric cardiac ridge by taking biopsy specimen. All specimens were diagnosed through normal pathological process to study the prognosis of pro-cancer lesions of gastric cardia. Results： The results of 106 subjects who had been observed for 4 years were： （1） Of 8 normal persons, 3 stayed normal, 4 turned to chronic gastritis, 1 developed early gastric cardiac cancer. （2） Of 61 persons with chronic gastritis, 11 were observed to have gland atrophy, 4 mild atypical hyperplasia, and 2 highly atypical hyperplasia. （3） Of 9 subjects showing atrophic chronic gastritis, 5 revealed no change, and 4 became chronic gastritis. （4） Of 22 subjects who revealed mild atypical hyperplasia, 17 resolved, 4 showed no change, and 1 advanced to highly atypical hyperplasia. （5） One person with highly atypical hyperplasia reverted to mild atypical hyperplasia. （6） Of 5 subjects with early gastric cardiac cancer without any treatment, 1 became advanced cancer, 1 still stayed in early cancer stage, and 3 turned to atypical hyperplasia. Conclusion： The development of early cancer of gastric cardia would proceed through the stages of chronic gastritis, gland atrophy, and atypical hyperplasia. （2） The early cancer and pre-cancer lesions of gastric cardia is reversible, though possessing malignant possibility.

Review of endoscopic techniques in the diagnosis and management of cholangiocarcinoma

Cholangiocarcinoma is a rare malignancy of the biliary tract. Key factors in determining therapeutic options include knowledge of tumor extent, anatomy and obtaining tissue diagnosis. Endoscopically, there are three modalities available to make the diagnosis of cholangiocarcinoma. These include endoscopic retrograde cholangiopancreatography, endoscopic ultrasound with fine needle aspiration and cholangioscopy. Management of cholangiocarcinoma endoscopically is typically confined to stent placement for palliative purposes or as a bridge to surgery. In this article, we will review the endoscopic techniques available for the diagnosis and management of cholangiocarcinoma.

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.

Endoscopic transpapillary brush cytology and forceps biopsy in patients with hilar cholangiocarcinoma

AIM: To evaluate the sensitivity of brush cytology and forceps biopsy in a homogeneous patient group with hilar cholangiocarcinoma.METHODS: Brush cytology and forceps biopsy were routinely performed in patients with suspected malignant biliary strictures. Fifty-eight consecutive patients undergoing endoscopic retrograde cholangio-pancreatography (ERCP) including forceps biopsy and brush cytology in patients with hilar cholangiocarcinoma between 1995-2005.RESULTS: Positive results for malignancy were obtained in 24/58 patients (41.4%) by brush cytology and in 31/58 patients (53.4%) by forceps biopsy. The combination of both techniques brush cytology and forceps biopsy resulted only in a minor increase in diagnostic sensitivity to 60.3% (35/58 patients). In 20/58 patients (34.5%), diagnosis were obtained by both positive cytology and positive histology, in 11/58 (19%) by positive histology (negative cytology) and only 4/58 patients (6.9%) were confirmed by positive cytology (negative histology).CONCLUSION: Brush cytology and forceps biopsy have only limited sensitivity for the diagnosis of malignant hilar tumors. In our eyes, additional diagnostic techniques should be evaluated and should become routine in patients with negative cytological and histological findings.

Effect of music on patients undergoing outpatient colonoscopy

AIM: To evaluate the effect of relaxing music during colonoscopy under low-dose conscious sedation, on patient satisfaction, scope insertion time and procedure duration, medication doses, and the perceived adequacy of sedation and scope insertion difficulty on the part of the endoscopist. METHODS: One hundred and sixty-seven consecutive adult outpatients presenting for routine colonoscopy under low-dose conscious sedation were randomized to undergo their procedures either with music played during the procedure or no music played. RESULTS: There were no statistical differences between the two groups in terms of meperidine dose, midazolam dose, time to reach the cecum, total procedure time, endoscopist assessment of scope insertion difficulty, endoscopist assessment of adequacy of sedation, or the pain experience of the patients during their procedure. The music group did report significantly better overall procedure satisfaction as compared to the non music group on two of our three different scales. CONCLUSION: While music does not result in shortened procedure times, lower doses of sedative medications or perceived patient pain, the patients who have music playing during their procedures report modestly greater satisfaction with their procedures.

Diagnostic procedures for submucosal tumors in the gastrointestinal tract

This review is part one of three, which will present an update on diagnostic procedures for gastrointestinal (GI) submucosal tumors (SMTs). Part two identifies the classification and part three the therapeutic methods regarding GI SMTs. Submucosal tumors are typically asymptomatic and therefore encountered incidentally. Advances in diagnostic tools for gastrointestinal submucosal tumors have emerged over the past decade. The aim of this paper is to provide the readers with guidelines for the use of diagnostic procedures, when a submucosal tumor is suspected. Literature searches were performed to find information on diagnostics for gastrointestinal submucosal tumors. Based on the searches, the optimal diagnostic procedures and specific features of the submucosal tumors could be outlined. Standard endoscppy, capsule endoscopy and push-and-pull enteroscopy (PPE) together with barium contrast X-ray do not alone provide sufficient information, when examining submucosal tumors. Endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI) and fluorodeoxyglucose-labeled positron emission tomography (FDG-PET) are recommended as supplementary tools.

Capsule endoscopy:Current status in obscure gastrointestinal bleeding

Capsule endoscopy (CE) is a safe, non invasive diagnostic modality for the evaluation of small bowel lesions. Obscure gastrointestinal bleeding (OGIB) is one of the most important indications of capsule endoscopy. Capsule endoscopy has a very high diagnostic yield especially if the bleeding is ongoing. This technique appears to be superior to other techniques for the detection of suspected lesions and the source of bleeding. Capsule endoscopy has been shown to change the outcome in patients with obscure gastrointestinal (GI) bleed.

Endoscopic submucosal dissection for gastrointestinal neoplasms

Endoscopic submucosal dissection (ESD) is an advanced technique of therapeutic endoscopy for superficial gastrointestinal neoplasms. Three steps characterize it:injecting fluid into the submucosa to elevate the lesion, cutting the surrounding mucosa of the lesion, and dissecting the submucosa beneath the lesion. The ESD technique has rapidly permeated in Japan for treatment of early gastric cancer, due to its excellent results of en- bloc resection compared to endoscopic mucosal resection (EMR). Although there is still room for improvement to lessen its technical difficulty, ESD has recently been applied to esophageal and colorectal neoplasms. Favorable short-term results have been reported, but the application of ESD should be well considered by three aspects:(1) the possibility of nodal metastases of the lesion, (2) technical difficulty such as location, ulceration and operator’s skill, and (3) organ characteristics.

Therapeutic procedures for submucosal tumors in the gastrointestinal tract

This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor (GIST). Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.

Biliary brush cytology:Factors associated with positive yields on biliary brush cytology

AIM: To evaluate the yield of brushing biliary strictures and the factors associated with a positive result in biliary strictures. METHODS: Data on all consecutive patients (01/02 -10/05) who were identified to have a biliary stricture and who underwent biliary brush cytology were collected. The yield of positive biliary brush cytology was evaluated and compared to results with the gold standard for diagnosis (defi ned as either defi nitive surgical histology or clinical course). Additionally,associated factors of positive results including stricture location,gender,age,mass size,length of stricture,and dilatation prior to brushing cytology were assessed. RESULTS: From 199 patients who had brushing cytology samples (10 patients were excluded due to lack of gold standard diagnosis),77 patients had positive brushing cytology (yield 41%). Variables associated with positive cytology brushing on initial endoscopic retrograde cholangiography were age 1.02 (1.00-1.05),mass size > 1 cm 2.22 (1.01-4.89) and length of stricture > 1 cm 3.49 (1.18-10.2). The sensitivity of biliary brushing was 61%,its specifi city 98%,the positive predictive value reached 99%,and the negative predictive value was 57%. CONCLUSION: Our results revealed a 41% positive yield from brushing cytology. The sensitivity of biliary brushing cytology in our center was 61% and the specif icity was 98%. Predictors of positive yield include older age,mass size > 1 cm,and stricture length of > 1 cm.

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.

Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife

AIM: To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer. METHODS: Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD. RESULTS: The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT- ESD group (57.6 ± 31.9 min vs 21.1 ± 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups. CONCLUSION: IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. Thelong-term outcome needs to be evaluated in the future.

Perspective on the practical indications of endoscopic submucosal dissection of gastrointestinal neoplasms

Endoscopic submucosal dissection (ESD) is a new endoluminal therapeutic technique involving the use of cutting devices to permit a larger resection of the tissue over the muscularis propria. The major advantages of the technique in comparison with polypectomy and endoscopic mucosal resection are controllable resection size and shape and en bloc resection of a large lesion or a lesion with ulcerative findings. This technique is applied for the endoscopic treatment of epithelial neoplasms in the gastrointestinal tract from the pharynx to the rectum. Furthermore, some carcinoids and submucosal tumors in the gastrointestinal tract are treated by ESD. To determine the indication, two aspects should be considered. The first is a little likelihood of lymph node metastasis and the second is the technical resectability. In this review, practical guidelines of ESD for the gastrointestinal neoplasms are discussed based on the evidence found in the literature.

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as typeⅠ,Ⅱ or Ⅲ,according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation,usually by endoscopic sphincterotomy (ES). Patients with typeⅠSOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in typeⅠ SOD. For patients with types Ⅱ and Ⅲ the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore,there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.

Endoscopic findings in a patient with Henoch-Schonlein purpura

Henoch-Schonlein purpura (HSP) is a systemic vasculitis of the small vessels of the skin, joints, GI tract, and kidney. It preferentially affects children but may also occur in adults. We report a 60-year-old man with HSP who presented with colicky abdominal pain, bloody diarrhea, arthralgia, and skin rash. The gastrointestinal tract was viewed by upper endoscopy and colonoscopy. We found characteristic endoscopic findings in the stomach, cecum and sigmoid colon, the combination of which has rarely been demonstrated in one patient. Histologic examination of skin biopsy specimens revealed leukocytoclastic vasculitis with positive staining for IgA in the capillaries. Endoscopy appears to have substantial diagnostic utility in patients suspected of having HSP, especially when abdominal symptoms precede the cutaneous lesions.

Conventional colonoscopy and magnified chromoendoscopy for the endoscopic histological prediction of diminutive colorectal polyps: A single operator study

AIM： To accurately differentiate the adenomatous from the non-adenomatous polyps by colonoscopy. METHODS： All lesions detected by colonoscopy were first diagnosed using the conventional view followed by chromoendoscopy with magnification. The diagnosis at each step was recorded consecutively. All polyps were completely removed endoscopically for histological evaluation. The accuracy rate of each type of endoscopic diagnosis was evaluated, using histological findings as gold standard. RESULTS： A total of 240 lesions were identified, of which 158 （65.8%） were non-neoplastic and 82 （34.2%） were adenomatous. The overall diagnostic accuracy of conventional view, and chromoendoscopy with magnification was 76.3% （183/240） and 95.4% （229/240）, respectively （P〈 0.001） CONCLUSION： The combination of colonoscopy and magnified chromoendoscopy is the most reliable nonbiopsy method for distinguishing the non-neoplastic from the neoplastic lesions.

Non-invasive prediction of oesophageal varices in cirrhosis

Non-invasive predictors of varices in cirrhosis would reduce the need for screening endoscopies. Platelet count and spleen size have been shown to be useful parameters, in mixed groups of cirrhotics with different aetiologies. We evaluated this in two homogeneous groups with cirrhosis due to hepatitis C and alcohol. Non-invasive predictors appear promising in the former group, but less so in the latter group.

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.

Premedication with pronase or N-acetylcysteine improves visibility during gastroendoscopy: An endoscopist-blinded, prospective, randomized study

AIM： To assess the efficacy of premedicaton with pronase or N-acetylcysteine （NAC） at 20 min before upper gastrointestinal （UGI） endoscopy and to determine whether pronase or NAC pretreatment influences the reliability of the rapid urease test. METHODS： A total of 146 patients were prospectively and randomly assigned into the study groups according to different premedications before endoscopy. One endoscopist assessed mucosal visibility （MV） with scores ranged from 1 to 4 at four sites in the stomach. The sum of the MV scores from these four locations was defined as the total mucosal visibility （TMV） score. Identification of Hpylori was performed using CLO test, histology, and serology. RESULTS： The Group with pronase premedication had a significantly lower TMV score than did the groups with gascon and gascon water （P 〈 0.001 and P 〈 0.01, respectively）. The group with NAC had a significantly lower TMV score than the group with gascon （P 〈 0.01） and a trend of a lower MV score than the group with gascon water （P = 0.06）. The THV score did not significantly differ between the group with pronase and the group with NAC （P = 0.39 and P = 0.14, respectively）. The sensitivity and specifidty of the CLO test were 92.5% and 93.9%, respectively, in groups premedicated with pronase and NAC together.CONCLUSION： Premedication with pronase or NAC at 20 min before UGI endoscopy improves the mucosal visibility of the stomach. Neither pronase nor NAC produces any obvious interference with the CLO test for the identification of H pylori infection.