Publications by authors named "Hansjoerg Ullerich"

20 Publications

  • Page 1 of 1

Renaissance of Radiotherapy in Intestinal Lymphoma? 10-Year Efficacy and Tolerance in Multimodal Treatment of 134 Patients: Follow-up of Two German Multicenter Consecutive Prospective Phase II Trials.

Oncologist 2020 05 27;25(5):e816-e832. Epub 2020 Mar 27.

Department of Radiation Oncology, University Hospital of Muenster, Muenster, Germany.

Purpose: This article reports on the long-term impact of radiotherapy adapted to stage, histology, and previous resection in a large cohort of patients with intestinal lymphoma (iL) treated with definitive or adjuvant curative-intent radiation therapy (RT) ± chemotherapy (CHOP, MCP, or COP).

Patients And Methods: In two consecutive prospective study designs, 134 patients with indolent (stage IE-IIE) or aggressive (stage IE-IVE) iL were referred to 61 radiotherapeutic institutions between 1992 and 2003. Patients with indolent iL received extended field (EF) 30 Gy (+10 Gy boost in definitive treatment); patients with aggressive iL received involved field (IF) (EF) 40 Gy by means of stage-, histology-, and operation-adapted radiation fields.

Results: The patients had median age 58 years and were predominantly male (2:1). Histology showed aggressive prevalence (1.6:1), stage IE-to-stage IIE ratio of iL 1.04:1, and localized stages-to-advanced stages ratio of aggressive lymphoma 23:1. Median follow-up was in total 11.7 years: 10.0 years in the first study, GIT (GastroIntestinal-Tract) 1992, and 11.8 years in the second study, GIT 1996. Lymphoma involvement was predominantly a single intestinal lesion (82.1%). Decrease of radiation field size from EF to IF in stage I aggressive iL from GIT 1992 to GIT 1996 resulted in a nonsignificant partial reduction of chronic toxicity while maintaining comparable survival rates (5-year overall survival 87.9 vs. 86.7%, 10-year overall survival 77.4 vs. 71.5%) with nonsignificant difference in event-free survival (5-year event-free survival 82.6 vs. 86.7%, 10-year event-free survival 69.7 vs. 71.5%) and lymphoma-specific survival (5-year lymphoma-specific survival 90.1 vs. 91.9%, 10-year lymphoma-specific survival 87.6% vs. 91.9%). Comparative dose calculation of two still available indolent duodenal lymphoma computed tomography scans revealed lower radiation exposure to normal tissues from applying current standard involved site RT (ISRT) 30 Gy in both cases.

Conclusion: RT adapted to stage, histology, and resection in multimodal treatment of iL, despite partially decreasing field size (EF to IF), achieves excellent local tumor control and survival rates. The use of modern RT technique and target volume with ISRT offers the option of further reduction of normal tissue complication probability.

Implications For Practice: Although patients with intestinal lymphoma (iL) are heterogeneous according to histology and subtype, they benefit from radiotherapy. Prospective study data from 134 patients with indolent iL (stage IE-IIE) or aggressive iL (stage IE-IVE) show 100% tumor control after definitive or adjuvant curative-intent radiation therapy ± chemotherapy. Radiation treatment was applied between 1992 and 2003. Median follow-up in total was 11.7 years. No radiotherapy-associated death occurred. Relapse developed in 15.7% of the entire cohort; distant failure was more frequent than local (4:1). Normal tissue complication probability can be further improved using modern involved site radiation therapy techniques.
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http://dx.doi.org/10.1634/theoncologist.2019-0783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216456PMC
May 2020

Diagnosis and management of cold urticaria in cryoablation of atrial fibrillation: a case report.

Eur Heart J Case Rep 2019 Dec 16;3(4):1-5. Epub 2019 Dec 16.

Department of Cardiology II-Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, D-48149 Münster, Germany.

Background: Cold-induced urticaria is triggered by exposure to local or environmental cold and manifests as localized or systemic pruritic papules, sometimes accompanied by angio-oedema and anaphylaxis representing a life-threatening condition. Therapy options of atrial fibrillation (AF) include catheter ablation with different energy sources, of which cryoenergy may be superior to other energy sources regarding safety and efficacy.

Case Summary: We report the case of a 60-year-old man suffering from symptomatic paroxysmal AF. The patient had a history of cold-induced urticaria without occurrence of systemic reactions to date. After successful pulmonary vein isolation (PVI) using cryoenergy, post-interventional oesophagogastroduodenoscopy and endosonography revealed newly occurred oedema in the middle oesophagus with inclusion of all oesophageal wall layers. Due to missing peri-atrial lesions, activation of cold urticaria during cryoablation rather than procedure-associated alterations was diagnosed. The patient reported no systemic or gastrointestinal symptoms after PVI.

Discussion: We could demonstrate that cold urticaria can manifest as oesophageal angio-oedema in AF patients undergoing cryoablation. Therefore, these patients should be carefully considered for an alternative energy source for PVI or premedication with antihistamines when using cryoenergy.
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http://dx.doi.org/10.1093/ehjcr/ytz221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939821PMC
December 2019

Endoscopic Radiofrequency Ablation Prolongs Survival of Patients with Unresectable Hilar Cholangiocellular Carcinoma - A Case-Control Study.

Sci Rep 2019 09 23;9(1):13685. Epub 2019 Sep 23.

Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany.

The life expectancy of unresectable hilar cholangiocellular carcinomas (CCCs) is very limited and endoscopic radiofrequency ablation (ERFA) of the biliary tract may prolong survival. Our single-center-study retrospectively analysed all CCC cases, in whom ERFAs of the biliary tract were performed between 2012 and 2017 and compared these to historical control cases who received the standard treatment of sole stent application. ERFA was performed in 32 patients with malignant biliary strictures that were mainly caused by Bismuth III and IV hilar CCCs (66%). 14 of these patients received repeated ERFAs, for an overall performance of 54 ERFAs. Stents were applied after examination of all patients (100%). Adverse events occurred in 18.5% of examinations. Case-control analysis revealed that the survival time of cases with unresectable Bismuth type III and IV hilar CCCs (n = 20) treated with combined ERFA and stent application significantly increased compared to controls (n = 22) treated with sole stent application (342 +/- 57 vs. 221 +/- 26 days; p = 0.046). In conclusion, ERFA therapy significantly prolonged survival in patients with unresectable Bismuth type III and IV hilar CCC. As an effective and safe method, ERFA should be considered as a palliative treatment for all these patients.
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http://dx.doi.org/10.1038/s41598-019-50132-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6757045PMC
September 2019

Digital single-operator video cholangioscopy in treating refractory biliary stones: a multicenter observational study.

Surg Endosc 2020 May 15;34(5):1914-1922. Epub 2019 Jul 15.

Department of Internal Medicine, Evangelisches Krankenhaus Duesseldorf, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany.

Background: Standard endoscopic treatment might fail to treat biliary stone disease. Here, we investigated the efficacy and safety of recently introduced digital single-operator video cholangioscopy (SOVC) for the treatment of difficult biliary stones.

Methods: Digital SOVC procedures, performed in two tertiary referral centers between 2015 and 2018, were retrospectively analyzed. Only patients with a previous failure of endoscopic standard treatment and a SOVC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone removal rate per procedure and per patient.

Results: In total, 75 examinations with a digital SOVC-assisted biliary stone treatment, performed in 60 patients, were identified. Biliary stones were mainly located extrahepatic (64%) and less frequently intrahepatic (36%). The median stone size was 20 mm (interquartile range [IQR]: 10-25 mm) and the median stone number was 1 (IQR: 1-2). Digital SOVC-based treatment of biliary stone disease was successful in 95% of patients and 15% needed at least two treatment sessions. Evaluated per procedure, a complete stone removal was accomplished in 67% of all examinations (including initial and repeated procedures), while an incomplete stone removal was observed in 33% of cases. The per procedure analyzes revealed that the success rates for a complete stone removal were similar between LL and EHL (66% vs. 68%; p = 0.87). Complications, such as postinterventional cholangitis and pancreatitis occurred in 16% of examinations; however, except from one case, all were mild or moderate and no procedure-associated mortality occurred.

Conclusions: Digital SOVC-assisted biliary stone treatment is highly effective even in cases with difficult biliary stones and might be considered the new standard of care for these patients. Furthermore, mild up to moderate complications were intermittently observed which might document the complexity of our included cases.
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http://dx.doi.org/10.1007/s00464-019-06962-0DOI Listing
May 2020

Time-to-isolation-guided cryoballoon ablation reduces oesophageal and mediastinal alterations detected by endoscopic ultrasound: results of the MADE-PVI trial.

Europace 2019 Sep;21(9):1325-1333

Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.

Aims: Cryoballoon ablation is safe and efficient for achieving pulmonary vein isolation (PVI) in atrial fibrillation. Structural oesophago-mediastinal lesions, which seem to be associated with an increased risk of the lethal complication of an atrio-oesophageal fistula, have been described. MADE-PVI (Mediastino-oesophageal Alterations Detected by Endosonography after PVI) aimed at evaluating safety of cryoballoon PVI in relation to two different freeze protocols. As time-to-isolation-(TTI)-guided protocol has been reported to be as effective as conventional 'two freeze protocol', we hypothesized a TTI-guided protocol causes less oesophago-mediastinal lesions.

Methods And Results: Seventy consecutive patients were scheduled for cryoballoon (2nd generation) PVI employing either a conventional protocol (n = 35: 2 × 180 s per vein) or a TTI-guided approach (n = 35: TTI + 120 s per vein or 1 × 180 s in case TTI could not be measured). Oesophagogastroduodenoscopy and endoscopic ultrasound, assessing oesophago-mediastinal alterations (e.g. ulceration, oedema) were performed blinded prior and post-ablation. Post-interventional mediastinal oedematous alterations were detected in 70% with a mean diameter of 14 mm (±0.9 mm), while only 15% revealed large mediastinal oedema >20 mm. Oesophageal lesions due to PVI occurred in 5%. Freeze protocols had a distinct impact on oesophago-mediastinal alterations as mean diameter and frequency of large oedema were significantly increased in patients after conventional protocol PVI (17 mm vs. 11 mm; 26% vs. 6%). Furthermore, every oesophageal lesion was detected in patients with conventional protocol (9%). No major complication occurred in either group.

Conclusion: The present prospective study demonstrates a significant impact of freeze protocol on oesophago-mediastinal alterations. A TTI-guided protocol reduces mediastino-oesophageal lesions and may reduce short- and long-term complications of cryoballoon PVI.
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http://dx.doi.org/10.1093/europace/euz142DOI Listing
September 2019

The ambiguous role of microRNA-205 and its clinical potential in pancreatic ductal adenocarcinoma.

J Cancer Res Clin Oncol 2018 Dec 22;144(12):2419-2431. Epub 2018 Sep 22.

Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.

Purpose: Early treatment of pancreatic ductal adenocarcinoma (PDAC) is significantly delayed due to the lack of liquid biopsy markers for early diagnosis at surgically resectable tumor stages. Recent studies suggest that microRNA-205 (miR-205) is involved in PDAC progression by post-transcriptional regulation of epithelial-to-mesenchymal transition (EMT). However, the clinical potential of miR-205 as diagnostic and prognostic marker remains undefined and its exact role in PDAC is still ambiguous. This retrospective study is a substantial contribution to this on-going scientific discussion.

Methods: Expression analysis of miR-205 and its molecular targets in PDAC cell lines (n = 5), human tissue (n = 73), and blood serum samples (n = 85) by qRT-PCR, tissue microarray immunohistochemistry, and western blot. Descriptive and explorative statistical analysis of miR-205's clinical potential for diagnosis and prognosis of PDAC.

Results: The expression of miR-205 differs more than 2000-fold (p < 0.001) between epithelial and mesenchymal-like human PDAC cell lines correlating with EMT-marker expression of E-cadherin, vimentin, fibronectin, and ZEB-1. Expression of miR-205 is significantly upregulated in carcinoma tissue (eightfold, p = 0.028) and serum (2.3-fold, p = 0.023) of PDAC patients compared to age-matched healthy controls. In our patient collective circulating miR-205 in combination with CA.19-9 outperforms the diagnostic accuracy of CA.19-9 alone with an AUC of 0.890 (p < 0.001), sensitivity of 0.867, and specificity of 0.933. Though non-significant, low expression of circulating miR-205 is more frequent in advanced tumor stages combined with a worse overall survival (6.9 vs. 11.9 months, p = 0.176).

Conclusion: Besides its controversial role in carcinogenesis, miR-205 shows high potential as a solid and liquid biopsy marker in PDAC. This result is an urgent call for larger confirmatory multi-center studies.
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http://dx.doi.org/10.1007/s00432-018-2755-9DOI Listing
December 2018

Circulating microRNA-99 family as liquid biopsy marker in pancreatic adenocarcinoma.

J Cancer Res Clin Oncol 2018 Dec 17;144(12):2377-2390. Epub 2018 Sep 17.

Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1 (W1), 48149, Münster, Germany.

Purpose: Recently, we identified the microRNA-99 family as unfavorable prognostic factor in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to evaluate its value as circulating biomarker for PDAC.

Methods: Tissue and corresponding preoperative blood samples of 181 patients with PDAC UICC Stages I-IV (n = 90), intraductal papillary mucinous neoplasm (IPMN, n = 11), chronic pancreatitis (n = 40), pancreatic cystadenoma (n = 20), and age-matched healthy blood serum controls (n = 20) were collected between 2014 and 2017 prospectively. Expression of microRNA-21 as confirmatory marker and the microRNA-99 family, consisting of microRNA-99a, -99b, and -100, was analyzed by qRT-PCR. Target analysis of insulin-like growth factor 1 receptor (IGF1R) was performed using tissue array immunohistochemistry and Western blotting.

Results: Expression of microRNA-99 family members was significantly increased in macrodissected tumor tissue and corresponding blood serum samples (p < 0.05) of patients with PDAC of all stages. Correspondingly, its target protein IGF1R was upregulated (p < 0.001) in carcinoma tissue. Circulating and tissue-related microRNA-100 could well discriminate PDAC from healthy samples with area under the receiver operating characteristic (ROC) curve (AUC) values of 0.81 and 0.85, respectively. Low expression of circulating microRNA-100 was associated with significantly improved overall survival (p = 0.004) and recurrence-free survival (p = 0.03) in multivariate analyses. Circulating microRNA-21 was overexpressed in PDAC with fair discrimination between PDAC and healthy controls (AUC = 0.71) and decreased overall survival (p = 0.046) and recurrence-free survival (p = 0.03) in PDAC patients.

Conclusions: Multivariate survival and ROC analyses identified circulating microRNA-100 as potential diagnostic and prognostic marker in PDAC patients.
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http://dx.doi.org/10.1007/s00432-018-2749-7DOI Listing
December 2018

Safety, diagnostic accuracy and therapeutic efficacy of digital single-operator cholangioscopy.

United European Gastroenterol J 2018 Jul 8;6(6):902-909. Epub 2018 Mar 8.

Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany.

Background: Digital single-operator cholangioscopes (digital SOCs), equipped with an improved image quality, have been recently introduced.

Objective: The aim of this study is to evaluate the safety and diagnostic and therapeutic efficacy of digital SOCs (Spyglass™ DS).

Methods: Sixty-seven digital SOC procedures performed between 2015 and 2017 were retrospectively analyzed.

Results: The most frequent indications for examination were indeterminate biliary strictures (61.2%) and biliary stone disease (23.9%). In 25 patients (37.3), visual findings predicted malignancy with a sensitivity of 88.9%, a specificity of 97.6%, a positive predictive value (PPV) of 96.0% and a negative predictive value (NPV) of 92.9%. For histological analysis, forceps biopsies were performed in 29 patients (43.2%). Compared with visual findings, forceps biopsies yield a lower diagnostic efficacy in diagnosing malignancy (sensitivity 62.5%, specificity 90.0%, PPV 90.9%, NPV 60.0%). Therapeutic interventions were performed in 19 patients with a technical success rate of 89.4%. Adverse events were observed in 17 patients (25.4%). Of these, 11 patients (16.4%) suffered from severe adverse events (pancreatitis, cholangitis or major bleeding), which led to a prolonged hospital stay.

Conclusion: Digital SOCs have excellent diagnostic and therapeutic efficacies, but are accompanied by high rates of adverse events; therefore, physicians should use digital SOCs in carefully selected cases.
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http://dx.doi.org/10.1177/2050640618764943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047284PMC
July 2018

Digital single-operator cholangioscopy: a useful tool for selective guidewire placements across complex biliary strictures.

Surg Endosc 2019 03 13;33(3):731-737. Epub 2018 Jul 13.

Department of Medicine B for Gastroenterology and Hepatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.

Background: Treatment of biliary strictures is challenging. Digital single-operator cholangioscopes (SOCs) equipped with an improved imaging quality, were recently introduced and may be useful for selective guidewire placement in difficult biliary strictures.

Methods: A total of 167 digital SOC procedures performed between 2015 and 2018 were retrospectively analyzed for successful guidewire placements across biliary strictures. Only cases with previous failed conventional guidewire placement approaches were included.

Results: In total, 30 examinations with a digital SOC-assisted guidewire placement across biliary strictures, performed in 23 patients, were identified. In 52% of all patients, the stricture was benign with post-liver-transplant strictures (75%) as the most frequent finding; in 48% of all patients the stricture was malignant with cholangiocellular carcinoma as the most frequent type (64%). Guidewire placement was successful in 21 of 30 procedures (70%). According to a subgroup analysis, digital SOC-assisted guidewire placements were significantly more successful in patients with benign strictures than those in patients with malignant strictures (88.2% vs. 46.2%; p = 0.02). Furthermore, the technical success rate tended to be increased in cases of initial examinations (78.3%) than in patients with repeated examinations (42.9%; p = 0.15). Adverse events, such as post-interventional pancreatitis or cholangitis as well as severe bleeding occurred in 16.7% of all examinations.

Conclusions: Digital SOC-assisted guidewire placements have high technical success rates, especially in benign biliary strictures. This technique can help to avoid more invasive procedures such as percutaneous transhepatic or endoscopic ultrasound-guided biliary drainage.
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http://dx.doi.org/10.1007/s00464-018-6334-6DOI Listing
March 2019

Reply to Zimmer.

Endoscopy 2017 11 26;49(11):1120. Epub 2017 Oct 26.

Department of Medicine B, University of Münster, Münster, Germany.

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http://dx.doi.org/10.1055/s-0043-120445DOI Listing
November 2017

Direct peroral cholangioscopy with a new anchoring technique using the guide probe of Kautz - first clinical experiences.

Endoscopy 2017 Sep 16;49(9):909-912. Epub 2017 May 16.

Department of Medicine B, University of Münster, Münster, Germany.

 We present the first clinical results of a new tandem technique for direct peroral cholangioscopy using a standard ultraslim upper gastrointestinal endoscope and a guide probe that was originally developed for the non-transendoscopic placement of biliary endoprostheses (guide probe of Kautz; MTW, Wesel, Germany). Twenty direct peroral cholangioscopy procedures were performed with the new anchor-assisted method using the guide probe of Kautz in a single center and were retrospectively analyzed. Indications for anchor-assisted cholangioscopy procedures included indeterminate bile duct strictures (n = 14), filling defects that remained after stone extraction (n = 4), and complex stone extractions (n = 2). Biliary access and visualization of the target region were achieved in 18/20 procedures (90 %). The interventional success rate was 85 % (11 /13 interventions). One case of postinterventional cholangitis occurred (5 %), along with one case of minor peri-interventional papillary bleeding (5 %). The anchor-assisted cholangioscopy technique is feasible and safe for direct cholangioscopy and provides reliable success rates in clinical practice. This technique represents an alternative approach for direct cholangioscopy on a single-operator basis using standard endoscopes.
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http://dx.doi.org/10.1055/s-0043-109864DOI Listing
September 2017

Solving a disaster following coronary bypass operation.

Gut 2016 10 17;65(10):1601. Epub 2016 Feb 17.

Department of General and Visceral Surgery, University of Muenster, Muenster, Germany.

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http://dx.doi.org/10.1136/gutjnl-2015-311233DOI Listing
October 2016

Perioperative chemotherapy in gastroesophageal cancer. A retrospective monocenter evaluation of 42 cases.

PLoS One 2015 9;10(4):e0122974. Epub 2015 Apr 9.

Department of Medicine, Hematology and Oncology, University of Muenster, Muenster, Germany.

Background: Perioperative chemotherapy increases the overall and progression-free survival of patients suffering from resectable adenocarcinomas of the lower esophagus, gastroesophageal junction and stomach (GEC). Comparing different chemotherapy regimens platin-based protocols with 5-fluorouracil (5-FU)/calcium folinate (CF) or oral fluoropyrimidines were favorable in terms of efficacy and side-effects. However, there is no consensus which regimen is the most efficacious.

Methods: 42 consecutive patients with resectable GEC (UICC II and III) were treated with 3 pre- and postoperative chemotherapy cycles each consisting of epirubicin, oxaliplatin and capecitabine (EOX). We analyzed the overall survival, progression-free survival and toxicity retrospectively in comparison to published data.

Results: The median overall survival in our cohort was 29 months and the progression-free survival was 17 months. The most frequent grade 3 and 4 toxicities during preoperative chemotherapy were diarrhea (16.7%), leukocytopenia (9.5%) and nausea (9.5%); overall 38.1% of our patients suffered from grade 3 or 4 toxicity. Surgery was carried out in 83% of our patients, 69% of those achieved R0 resection.

Conclusion: Comparing our data with the results of previously published randomized trials EOX is at least non-inferior with regard to overall survival, progression-free survival and toxicity. In conclusion, EOX is an appropriate perioperative therapy for patients with resectable GEC.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0122974PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4391860PMC
December 2015

Endocuff-assisted colonoscopy: a new accessory to improve adenoma detection rate? Technical aspects and first clinical experiences.

Endoscopy 2014 Jul 13;46(7):610-4. Epub 2014 May 13.

Department of Medicine B, University of Muenster, Muenster, Germany.

Background And Study Aims: The Endocuff is a new colonoscopy accessory that has been designed to improve both the adenoma detection rate and endoscope tip control.

Patients And Methods: A total of 50 Endocuff-assisted colonoscopies were analyzed retrospectively with regard to safety, procedural success, and complications.

Results: The cecal intubation rate was 98 %, and the mean intubation time was 6.0 minutes (95 % confidence interval 5.3 - 6.6 minutes). The ileal intubation rate was 76 %. In 30 % of patients, the Endocuff caused small, superficial, "scratch-like" mucosal lesions. In all other patients, no Endocuff-associated complications were observed. A total of 36 adenomas were detected in 50 patients. The adenoma detection rate was 34 %.

Conclusions: Endocuff-assisted colonoscopy showed good procedural success rates in terms of cecal intubation rate and time, and a promising adenoma detection rate. Endocuff seems to improve endoscope tip control, especially during polypectomy. Endocuff may be a useful device for colorectal adenoma screening, and should be investigated in larger trials.
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http://dx.doi.org/10.1055/s-0034-1365446DOI Listing
July 2014

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography in patients with surgically altered anatomy: higher failure rate in malignant biliary obstruction - a prospective single center cohort analysis.

Scand J Gastroenterol 2014 Jun 3;49(6):766-71. Epub 2014 Apr 3.

Department of Medicine B, University of Muenster , Muenster , Germany.

Introduction: The performance of endoscopic retrograde cholangiopancreaticography (ERCP) in patients with post-surgically altered anatomy is technically ambitious. Our study aimed at comparing a cohort of patients having successfully undergone single-balloon enteroscopy (SBE)-assisted ERCP to those in whom SBE-ERCP failed.

Methods: This trial is a prospective single center cohort study. Participants included 30 patients (median age 69.5 years, range 20-86 years) with previous pancreaticobiliary surgery. First, a conventional ERCP approach was attempted in all patients. Additionally, those patients in whom prior conventional ERCP had failed underwent SBE-ERCP (n = 26). Patients' baseline characteristics were retrieved and patient cohorts with and without successful SBE-ERCPs were compared and analyzed. Statistical analysis was applied. Univariate analysis was performed to detect possible risk factors of SBE-ERCP failure.

Results: The overall success rate of SBE-ERCP, including two patients with percutaneous transhepatic cholangiography- assisted rendezvous technique was 65.4% (17/26). Patients with malignant obstructive cholestasis had a significantly higher failure rate compared to those with benign strictures (84.2% vs. 14.2%, p < 0.001).

Discussion: SBE-ERCP is a promising tool for diagnostic and therapeutic procedures in the pancreaticobiliary system of selected, previously operated patients with failure of conventional ERCP. However, higher failure rates in malignant biliary obstruction should be taken into account.
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http://dx.doi.org/10.3109/00365521.2014.904397DOI Listing
June 2014

CO2 insufflation during single-balloon enteroscopy: a multicenter randomized controlled trial.

Endoscopy 2014 Jan 18;46(1):53-8. Epub 2013 Dec 18.

Department of Medicine B, University of Münster, Münster, Germany.

Background And Study Aims: Carbon dioxide (CO2) insufflation has previously been shown to have advantages over air insufflation in terms of procedure-related pain and oral insertion depth during double-balloon enteroscopy. The aim of this prospective study was to evaluate the performance of CO2 vs. air insufflation during single-balloon enteroscopy.

Patients And Methods: This study was a randomized European multicenter trial (ClinicalTrials.gov: NCT01524055). Patients and endoscopists were blinded to the type of insufflation gas used. Patient discomfort during and after the procedure was scored using a visual analog scale.

Results: A total of 107 patients were enrolled in the study (52 in the CO2 group and 55 in the air group). Patient characteristics were comparable in both groups. The mean (±SD) oral intubation depth was not significantly deeper in the CO2 group vs. the air group (254±80 vs. 238±55 cm; P=0.726). However, in patients with previous abdominal surgery, oral intubation depth was significantly higher in the CO2 group compared with the air group (258±84 vs. 192±42 cm; P<0.05). In patients undergoing SBE via the anal approach, CO2 showed no significant difference in intubation depth compared with air insufflation (86±67 vs. 110±68 cm; P=0.155). The diagnostic yield was comparable (CO2 67%; air 73%). Procedure times, dosage of sedation, and therapeutic interventions did not differ between the two groups. Patients in the CO2 group reported less pain than those in the air group.

Conclusions: This study demonstrated an advantage of using CO2 insufflation during single-balloon enteroscopy in patients with a history of previous abdominal surgery. Overall, single-balloon enteroscopy was a well-tolerated procedure that may benefit from the use of CO2 insufflation to reduce post-procedural pain.
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http://dx.doi.org/10.1055/s-0033-1359041DOI Listing
January 2014

Detection and differentiation of inflammatory versus fibromatous Crohn's disease strictures: prospective comparison of 18F-FDG-PET/CT, MR-enteroclysis, and transabdominal ultrasound versus endoscopic/histologic evaluation.

Inflamm Bowel Dis 2012 Dec 22;18(12):2252-60. Epub 2012 Feb 22.

Department of Medicine B, University of Muenster, Muenster, Germany.

Background: Differentiation between inflammatory and fibromatous strictures in Crohn's disease (CD) is difficult but crucial for therapeutic decisions. The aim of this study was to assess the best noninvasive imaging method for the detection and differentiation of inflammatory and fibromatous stenoses in CD in comparison to endoscopic and histologic evaluation.

Methods: Patients with suspected CD strictures were included. According to a formalized endoscopic and histologic protocol, strictures were classified as inflammatory, mixed, and fibrostenotic. Strictures were further analyzed using fluorine 18-labeled fluoro-2-deoxy-D-glucose ((18) FDG) / positron emission tomography (PET) low-dose computed tomography (CT), magnetic resonance (MR) enteroclysis and transabdominal ultrasound using standardized scoring systems.

Results: Thirty patients with 37 strictures were evaluated (inflamed n = 22; mixed n = 12, fibromatous n = 3). (18) FDG-PET/CT detected 81%, MR-enteroclysis 81%, and ultrasound 68% of the strictures. Correct differentiation rates of strictures were 57% for MRE, 53% for (18) FDG-PET/CT, and 40% for ultrasound. Differences of detection rates and differentiation rates were not statistically significant. When combining transabdominal ultrasound with (18) FDG-PET/CT or MR-enteroclysis all strictures that required invasive treatment were detected.

Conclusions: Detection rates of the strictures were not significantly different between (18) FDG-PET/CT, MR-enteroclysis, and ultrasound. Despite good stricture detection rates relating to our gold standard, (18) FDG-PET/CT nor MR-enteroclysis nor ultrasound can accurately differentiate inflamed from fibrotic strictures. A combination of MR-enteroclysis and ultrasound as well as a combination of (18) FDG-PET/CT and ultrasound resulted in a 100% detection rate of strictures requiring surgery or endoscopic dilation therapy, suggesting the combination of these methods as an alternative to endoscopy at least in the group of patients not able to perform an adequate bowel preparation.
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http://dx.doi.org/10.1002/ibd.22930DOI Listing
December 2012

Single-step versus multi-step transmural drainage of pancreatic pseudocysts: the use of cystostome is effective and timesaving.

Scand J Gastroenterol 2011 Jul 15;46(7-8):1004-13. Epub 2011 Apr 15.

Department of Medicine B, University of Muenster, Muenster, Germany.

Background And Aims: Pancreatic pseudocysts are a major complication of chronic and acute pancreatitis and often require endoscopic intervention. Endoscopic single-step and multi-step transmural drainage techniques have been reported in the literature. The aim of this study was to evaluate and compare technical results and clinical outcome rates of the single-step versus multi-step endoscopic ultrasonography (EUS)-guided endoscopic transmural drainage in patients with symptomatic pancreatic pseudocysts of >4 cm size.

Design: Retrospective study at an academic tertiary referral center.

Patients And Methods: A total of 38 consecutive patients comprising 42 interventions were studied: 16 patients with pancreatic pseudocysts (18 interventions) had undergone single-step EUS-guided transmural cystostome drainage between 2007 and 2010. Results were compared with a cohort of 22 patients who had submitted to multi-step EUS-guided transmural drainage of pancreatic pseudocysts in 24 cases between 2005 and 2007.

Results: The technical success rate for using the single-step procedure was 94% compared with multi-step procedure with 83% (n.s.). Primary clinical success rate was 88% for single-step drainage and 90% for the multi-step approach (n.s.). The mean procedure time was 36 ± 9 min in the single-step group compared with 62 ± 12 min for the multi-step access (p < 0.001).

Conclusions: The use of single-step cystostome appears useful in managing selected patients with symptomatic pancreatic pseudocysts as it is effective and timesaving.
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http://dx.doi.org/10.3109/00365521.2011.571709DOI Listing
July 2011

Ileal gallstone obstruction: Single-balloon enteroscopic removal.

World J Gastrointest Endosc 2010 Sep;2(9):321-4

Hauke Sebastian Heinzow, Tobias Meister, Wolfram Domschke, Hansjoerg Ullerich, Department of Medicine B, University of Muenster, Muenster D48149, Germany.

Gallstone-induced ileus is a rare complication of cholelithiasis. Since localization of gallstones impacted in the small bowel, especially in the ileum, prevents access by conventional endoscopy in most cases, the mainstay of treatment remains surgical. Recent invention of double- and single-balloon enteroscopy has added much to the ability of imaging the small bowel and enables endoscopically directed therapy. Herein, for the first time, we report a successful endoscopic calculus removal via peroral single-balloon enteroscopy in an 81-year-old woman suffering from gallstone ileus of the ileum.
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http://dx.doi.org/10.4253/wjge.v2.i9.321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999031PMC
September 2010

Double balloon enteroscopy: a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system.

Am J Gastroenterol 2008 Apr 26;103(4):894-900. Epub 2008 Mar 26.

Department of Medicine B, University of Muenster, Muenster, Germany.

Objectives: Diagnostic and therapeutic interventions in the biliary and pancreatic system in the previously operated patient by conventional endoscopic retrograde cholangiopancreaticography (ERCP) are difficult and, depending on the surgical procedure, in many cases unsuccessful. We describe our experience of ERCP performed with a double balloon enteroscope (DBE) as an alternative examination technique for these patients.

Methods: In a retrospective analysis of all DBE procedures at our department between November 2004 and June 2007, 11 patients were identified with various anatomic variations in whom ERCP was performed using a DBE.

Results: In 72% of the patients, previous conventional ERCP examinations failed (8/11). In these patients, DBE-ERCP was successful in 63%. The overall success rate of DBE-ERCP in all patients was 64% (7/11 patients). In those patients, interventions such as papillotomy, calculus extractions, as well as stent placement could be performed even though tools for DBE-ERCP are still very limited. Despite most of the DBE-ERCPs having included therapeutic interventions, no major complications occurred in our case series and minor side effects were restricted to meteorism and mild to moderate abdominal pain.

Conclusions: DBE-ERCP is an alternative method for diagnostic as well as therapeutic interventions in the biliary as well pancreatic system in the operated patient. However, it should be limited to selected patients, e.g., with contraindications for PTC, as it is a time-consuming as well as a cost-intensive procedure.
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http://dx.doi.org/10.1111/j.1572-0241.2007.01745.xDOI Listing
April 2008