Effect of submucosal epinephrine injection on local gastric blood flow. A study using laser Doppler flowmetry and reflectance spectrophotometry

Clinical studies have demonstrated the efficacy of submucosal epinephrine injection in the control of bleeding ulcers. Since endoscopic techniques for assessing gastroduodenal blood flow are limited, we employed an animal model to study the mechanism of control of bleeding. The effect of submucosal epinephrine injection on local gastric blood flow was studied in the rat using laser Doppler flowmetry and reflectance spectrophotometry. Submucosal injection of 0.1 ml of 1/10,000 epinephrine caused a significantly greater drop in local gastric blood flow (laser Doppler flowmetry) compared with vehicle (10% sodium metabisulfite) injection. The reduction persisted for up to 120 min. This vasoconstrictive effect of epinephrine was confirmed by observations with reflectance spectrophotometry, which documented a pattern of ischemia without congestion (lower index of hemoglobin concentration, lower index of oxygen saturation). The autoregulatory escape from adrenergic vasoconstriction was not evident in either instance. We conclude that, after submucosal injection of epinephrine, the absence of autoregulatory escape from adrenergic vasoconstriction and the marked and prolonged decrease in local gastric blood flow enhance the homeostatic mechanisms (eg, platelets and other coagulative factors) to effect hemostasis in bleeding ulcers.

Adenocarcinoma of the cardia: treatment by thoracoabdominal R3 radical gastrectomy

The complications and mortality rate of R3 radical gastrectomy using a left thoracoabdominal approach were studied in 38 patients with adenocarcinoma of the gastric cardia. There were two hospital deaths and two anastomotic leaks. There was a high rate of complications following surgery (subphrenic abscess, eight; severe chest infection, five; aspiration pneumonia, two; wound infection, two; and reactivation of tuberculosis, one). The hospital stay ranged from 11 to 39 days (median 21 days). Thirty-five patients had microscopic evidence of serosal involvement (S2). Thirty-three of the patients had lymph node metastases and 17 patients had involvement of N2 nodes. Four patients had histological evidence of residual suture line tumour, but only two of these returned with recurrence at the anastomosis. Follow-up (median 3 years) revealed that splenic artery nodal involvement (N2) did not worsen the prognosis after radical resection. Despite a high complication rate, thoracoabdominal radical gastrectomy is associated with an acceptable perioperative mortality rate, adequate symptom palliation and encouraging medium-term survival. The left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of this tumour.

Precut (needle knife) papillotomy for impacted common bile duct stone at the ampulla

Twenty of 510 patients with common bile duct (CBD) stone underwent needle knife precut papillotomy after conventional papillotomy failed because of impacted ampullary stone. This facilitated deep cannulation and subsequent standard papillotomy in 12 patients. In four patients, the precut papillotomy was extended, resulting in spontaneous expulsion of stone. Bleeding precluded stone extraction in three patients, and these stones were removed at a second ERCP session. Ductal clearance was achieved in all except one patient who underwent surgical removal of the impacted stone. Mild bleeding occurred in four patients and was successfully controlled by endoscopic adrenalin injection. There was no perforation, pancreatitis, or exacerbation of cholangitis following the procedure.

Bile duct size after cholecystectomy: an endoscopic retrograde cholangiopancreatographic study

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 43 patients before and 4-14 months after cholecystectomy. All patients had a normal common bile duct and were asymptomatic after the operation. Preoperative and postoperative films of adequate quality were available for scrutiny in 35 patients. The largest mean(s.d.) diameter of the common duct, after correcting for magnification, was 0.96(0.27) cm before cholecystectomy and 1.16(0.29) cm after surgery (P less than 0.0001). Thirty-one of the 35 patients showed increased duct size after cholecystectomy, and the difference was 1 mm or more in 26 patients. There was a positive correlation between the increase in bile duct size and the time interval after cholecystectomy. After cholecystectomy a small but significant increase in bile duct diameter is demonstrable on ERCP.

The effect of obstruction on the biliary excretion of cefoperazone and ceftazidime

The biliary excretion of cefoperazone and ceftazidime was studied by endoscopic cannulation of the common bile duct, in patients with complete biliary obstruction and in an unobstructed control group. Patients were given each drug prophylactically for 24 h before endoscopy and as a single dose at the time of cannulation. In unobstructed patients biliary excretion of ceftazidime was passive. At the time of cannulation bile contained 10% of the peak serum concentration, rising to 20% 90 min later. Cefoperazone excretion was active. At cannulation biliary concentrations were 200% of the serum peak, 900% at 60 min and 700% at 90 min. In obstructed patients, bile sampled immediately at decompression contained neither antibiotic. Passive excretion of both drugs occurred rapidly after relief of obstruction and biliary concentrations were 20% of maximum serum levels at 60 min. Twenty-four hours later passive excretion had further improved, but the active excretion mechanism of cefoperazone had still not recovered. We conclude that obstruction impairs active as well as passive biliary excretion of antibiotics, that drainage is essential for the control of sepsis in obstructed cholangitis, and that both cefoperazone and ceftazidime achieve similar and therapeutic concentrations in bile during the 24 h after decompression.

Effect of intranasal oxygen on hypoxia and tachycardia during endoscopic cholangiopancreatography

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Two team synchronous esophagectomy

A modification of the Lewis esophagectomy for carcinoma of the intrathoracic esophagus is described herein. With the patient in the semilateral position, two surgical teams operate simultaneously. The abdominal team mobilizes the stomach while the thoracic team removes the esophagus. Esophagogastric anastomosis is performed by stapling at the apex of the thorax. The procedure was performed upon 50 patients. There were two anastomotic leaks and one death occurred in the hospital. The two team synchronous approach avoids changes in the position of the patient, shortens operating time and may contribute to lower morbidity rates for patients undergoing esophagectomy.

Peptic pyloric stenosis treated by endoscopic balloon dilatation

Twenty-five patients with proven gastric outlet obstruction secondary to peptic ulcer disease were treated by endoscopic balloon dilatation using 'through the scope' balloons. The stricture could not be negotiated in one patient. Two patients continued to have gastric outlet obstruction despite the dilatation and required surgery. Two patients have returned up to 11 weeks after treatment with signs of recurrent gastric outlet obstruction. Twenty patients (80 per cent) remained asymptomatic (follow-up: median 9 months, range 2-24 months).

Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: detection by pulse oximetry

Oxygen saturation and pulse rate were recorded using pulse oximetry during 50 consecutive endoscopic retrograde cholangiopancreatography (ERCP) examinations. Oxygen saturation dropped to below 90% in 22 patients at some point during the procedure. Multiple regression analysis revealed that increasing age and weight were the most significant variables in predicting tachycardia or hypoxia. These problems cannot be reliably predicted or detected clinically. The use of a pulse oximeter during ERCP is recommended.

Intraoperative assessment of lymph node involvement in gastric carcinoma

This study compares the assessment of lymph nodes by the surgeon, at the time of operation, with the pathologist's assessment on the resected specimen in 85 cases of total gastrectomy with extended lymphadenectomy for gastric carcinoma. There was correlation in 67% of cases, in 28% the disease was overstaged, and in only 5% was it understaged by intraoperative assessment. This has important implications for the comparison of trials and management decisions based on surgical assessment.

Intrathoracic stapled anastomosis after oesophagectomy for cancer

Fifty consecutive oesophagectomies for cancer are reported which were performed using a two-stage technique with an intrathoracic stapled anastomosis. The oesophagus was resected through a right thoracotomy. Continuity was restored using orthotopic stomach, mobilized through an abdominal incision and anastomosed to the oesophagus at the apex of the thorax. No deaths occurred within 30 days, but two patients died without leaving hospital. Routine contrast study revealed no anastomotic leaks. Major complications were: chylothorax (one), transient bilateral recurrent laryngeal nerve palsy (one), anastomotic bleed (one), respiratory failure (one) and brain abscess (one). Four upper resection margins contained tumour (all in middle third tumours). With this technique, a reliable anastomosis can be made high in the chest. The amount of oesophagus removed is comparable with that obtained with the 'three-stage' or transhiatal procedures. The problem of occult submucosal spread in oesophageal tumours remains.

Cholecystoduodenostomy in the management of complicated duodenal ulcer

The use of end-to-end cholecystoduodenostomy to close a difficult duodenal stump is described in a patient with duodenal ulcer complicated by haemorrhage, chronic perforation and penetration of the common bile-duct.

Urgent endoscopic drainage for acute suppurative cholangitis

105 patients with acute calculous cholangitis who did not respond to conservative management underwent urgent endoscopic drainage of the biliary system at a mean of 1.5 days after admission. Treatment was successful in 102 (97%) patients. 3 of the patients in whom drainage was not successful underwent emergency surgery, with 1 death. 3 patients died of uncontrolled sepsis despite successful endoscopic drainage. 1 patient died of a stroke. The overall mortality was 4.7%. Among those in shock 2 out of 4 drained after 72 h died, compared with 3 out of 38 drained before 72 h. There were no deaths in the group without shock irrespective of the timing of drainage.

Hepatic clonorchiasis--a study by endoscopic retrograde cholangiopancreatography

An endoscopic retrograde cholangiographic study of 31 consecutive cases of hepatic clonorchiasis was performed. Filamentous wavy and/or elliptical appearance of the worm is a pathognomonic finding on ERCP examination. Significant dilation of the second and third generation bile ducts, and dilation and blunting of the terminal branches of the biliary tree are also common findings.

Occupational risk of decreased plasma cholinesterase among pesticide production workers in Taiwan

To determine the influence of ventilation control and work practices on the health of workers potentially exposed to organophosphate and carbamate compounds, we examined a total of 989 employees from pesticide factories in Taiwan during 1986-1987. Each employee was examined by a physician, and a blood sample was drawn for plasma cholinesterase, complete blood count, and liver and renal function tests. Forty-one employees with medical conditions that might alter the plasma cholinesterase were excluded. Results showed that 43 of 515 production employees had decreased plasma cholinesterase as compared with four of 340 non-production employees. Production employees working under adequate ventilation control seemed to have a lower prevalence of decreased plasma cholinesterase than those under inadequate ventilation control, although the difference was not statistically significant (p = 0.242). There was a significant association between the level of housekeeping and work practices and the prevalence of decreased plasma cholinesterase (p = 0.022). We conclude that inadequate ventilation control and poor work practices may create a potential danger of pesticide poisoning among production employees in Taiwan and should be corrected immediately.