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BACKGROUND AND OBJECTIVE: Midazolam (M) is well known and established in endoscopic procedures for so-called conscious sedation. Propofol (P) is given during endoscopy for deep sedation. The combination of both (M/P) in endoscopic procedures is new. In this prospective study the safety of the combination was tested, in a second prospective study the combination M/P with Propofol alone was compared. PATIENTS AND METHODS: In the first study 143 patients undergoing 150 endoscopic procedures (expected > 30 min) were included. Deep sedation was induced by an i.v. bolus of 2.5 mg midazolam, followed by small doses of propofol. The sedation was performed by a second physician experienced in intensive care. In the second prospective study 64 patients undergoing two necessary endoscopic procedures were included: one deep sedation with propofol alone, the second one with combination of midazolam bolus followed by propofol. RESULTS: It was demonstrated that induction of deep sedation by an i.v. bolus of 2.5 mg midazolam, followed by small doses of propofol is safe, without undesirable side effects, e.g. respiratory or circulation depression. Recovery time increased (4 to 8 minutes) with the combination M/P, costs decreased by saving 59% propofol per minute. This may be important for longer endoscopic procedures. CONCLUSION: The combination of M/P for deep sedation during endoscopy may be useful when long procedures are expected or patients are at risk with propofol alone.

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Since there are now several ways to treat symptomatic gallstone disease, one is able to select treatment on the basis of the patient's comfort, the practicability, effectiveness, and side effects of the technique, and the relative costs. In order to assess the present status of contact dissolution with methyl tert-butyl ether with regard to these aspects, the present enquiry reports the data of 21 European hospitals. Eight hundred three patients were selected for contact litholysis of cholesterol gallbladder stones using methyl tert-butyl ether. Percutaneous transhepatic puncture of the gallbladder was performed under x-ray or ultrasound guidance. Dissolution rate, side effects, and treatment times of 268 patients from one single center were compared to those of 535 patients from the other 20 centers. Two hundred sixty-four patients were followed for five years to assess stone recurrence. Physicians were asked how they assessed the expenditure of the method, the discomfort to the patients, and the staffing situation. Patients were asked to indicate their acceptance on an analog scale. Puncture was successful in 761 (94.8%) patients. Prophylactic administration of antibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludge remained in the gallbladder. The most severe complication was bile leakage, which led 12 (1.6%) patients to have elective cholecystectomy. Toxic injuries due to the ether were not reported. Method-related lethality amounted to 0%, 30-day-lethality to 0.4%. Stone recurrence rate was about 40% in solitary stones and about 70% in multiple stones over five years. Patients with multiple stones developed recurrent stones almost twice as often as those with solitary stones. The probability of stone recurrence in patients with sludge in the gallbladder after catheter removal was not statistically significantly different from those without sludge. Seventy to 90% of the centers found the puncture to be simple and not distressing for patients and the relation between expenditure and therapeutic success to be acceptable. The acceptance of contact litholysis by the patients was excellent. Contact litholysis when applied by an experienced team provides real advantages in the treatment of gallstone disease. The method is technically simple, well accepted by the patients, and can be easily applied in community hospitals. Contact litholysis may be of particular value in patients who are not suitable for anesthesia or surgery.

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During this study the absorption rates of two contrast media were measured in double-blind design. 33 patients received lopamidol (Solutrast 300), and 30 patients Meglumine iothalamate (Conray 60). A regular absorption of the contrast media during ERC, ERP and ERCP could be stated. With reference to the absorption rates a slight, but for statistically not significant advantage for the contrast medium lopamidol could be ascertained. During ERC the absorption rates ranged from 0.4 to 30%, during ERP from 2.2 to 18.8% and during ERCP from 1.0 and 30.0%. Consequently the endoscopist always has to take into account an anaphylactoid reaction due to the systemic absorption of contrast media which, compared to other examinations with contrast media, happens relatively seldom.

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Two cases of splenic injury - one after a difficult colonoscopy and the other after routine ERCP - are reported. Splenic injury as a complication of endoscopic procedures is relatively rare, but over the past several years this complication has been increasingly reported. Review of the literature revealed 11 cases occurring after colonoscopy and one after ERCP. Although most of the patients presented with acute abdominal symptoms, some had mild vague symptoms. In two cases the injury was overlooked entirely. Diagnosis was established at laparotomy in four cases, by CT in four, by ultrasonography in two, by chance observation in two, by angiography in one and by paracentesis in one. All patients except the most recent three reported underwent surgery, with one mortality occurring three weeks after the operation.

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Intraductal mucin-hypersecreting neoplasms of the pancreas with extreme dilatation of the main duct were studied in eight patients. They included five men and three women, aged 47-85 years. Five patients had a history of symptoms mimicking pancreatitis; four developed steatorrhea and/or diabetes. At endoscopic retrograde pancreatography, five patients showed an open ampulla filled with mucin, and six patients showed patchy filling defects in the ectatic main duct. Morphological examination showed extreme dilatation of the entire pancreatic duct in six patients and its tail segment in two patients. The duct segments filled with viscous mucin were lined by well-differentiated mucin-secreting cells, forming papillary foldings and occasionally showing cellular atypia. None of the patients had invasive tumor or metastasis. Six patients whose lesions were resected are alive and doing well (mean follow-up, 5.5 years). It is concluded that intraductal mucin-hypersecreting neoplasm is a pancreatic tumor with favorable prognosis. Because it shares many features with intraductal papillary neoplasm, a common pathogenesis of these pancreatic tumors is suggested.

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A urinary concrement which appeared in the sigmoid of a 63-year-old man after ureterosigmoidostomy was extracted by endoscopy. The stone was situated proximal to a radiogenic stenosis. Because of the disproportion between the stone and the sigmoidal stenosis, mechanical lithotripsy had to be done before the concrement could be completely extracted.

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Endoscopic papillotomy is nine years old. During this time it obtained a well defined place in the treatment of common bile duct stones and of papillary stenosis. In about 85% this method proved to be successful without any problems. To lower the risk and to improve the results now smaller steps must be done. Within the last 4 years we have learned to manage even big stones with a reduced risk by stone dissolution and by a new lithotripsy device. Biliary pancreatitis has become an indication for an early duodenoscopy and even papillotomy. Acute obstructive suppurative cholangitis may be treated by endoscopy with a lower risk than by surgical intervention. Even the feared Dormia basket impaction in most cases is no longer an indication for an emergency operation. Mostly it can be treated by a second endoscope together with a new cutting device designed by Mr. Mori. All these small steps have improved the success rate of papillotomy from 94% to 99%, rate of definite stone management from 87% to 92%, reducing the complication rate from 8% to 4% at the same time.

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A transpapillary indwelling catheter was inserted to prevent stone impaction in six female patients who were suffering from choledocholithiasis. The bile withdrawn via the catheter was infected on six occasions with Escherichia coli. In one of these cases Klebsiella sp. and in another Salmonella sp. were also identified. All bacteria were sensitive to ceftizoxime (the MIC was between 0.007 and 0.06 mg/l). The bacterial counts in the bile were determined before and during treatment by means of membrane filtration. In all six cases there was a rapid decline in the colony count. The concentration of ceftizoxime in bile samples was several times higher than the MIC of ceftizoxime for the corresponding pathogens. Overall, the therapeutic results with ceftizoxime were good. Three of eight pathogens were eliminated from the bile within eight to 24 hours. In one case a change of pathogen was seen after 24 hours. Forty-eight hours after beginning treatment, four of eight pathogens had been eliminated from the bile. After 72 hours the colony count in six patients was less than 10 pathogens/ml. In two patients a change of pathogen occurred; in one patient treatment had to be stopped after the first injection because of urticaria.

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A new method based on computer-assisted semi-automatic equipment for stereological analysis has been developed to measure ulcer size endoscopically. The main component is a graphic measuring table connected with a computer which is itself linked to a television monitor. The endoscopic picture is transmitted to the television monitor and the ulcer area is measured directly on the monitor using electronic overlay markers. The trace of the measuring markers remains visible on the monitor so that every lesion demonstrated is accurately outlined. The computer calculates the ulcer area by relating it to a known endoscopically inserted reference area. Numerous measurements from various distances, various angles of view and with variable reference area sizes showed the error to be 4.2 +/- 0.5%. Measurements by six different investigators showed variations of 2.9 +/- 1.2%. These results document the reliability of endoscopic planimetrics of gastrointestinal ulcers.

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