Covered metal stent for tumor obstruction of efferent loop recurrence after gastrectomy

Reports the case of a 60-year-old woman who underwent R2 total gastrectomy, and subsequent palliation of painful symptom recurrence via a membrane-covered metal stent.

Endoscopic surgery of the oesophagus

Conventional surgical access to the oesophagus often requires a thoracotomy. The application of techniques borrowed from laparoscopic surgery allows transthoracic dissection of oesophagus without thoracotomy. These techniques are useful in treatment of oesophageal leiomyomas, motility disorders and iatrogenic perforations. Oesophageal resection for cancer can be accomplished using minimal access, either thoracoscopically or with the aid of an operating mediastinoscope. Whether these techniques should replace transthoracic or transhiatal oesophagectomy for most patients with cancer remains to be seen.

Stigmata of hemorrhage in bleeding peptic ulcers: an interobserver agreement study among international experts

BACKGROUND

Stigmata of hemorrhage predict rebleeding and outcome of patients with bleeding peptic ulcers. There are variabilities in reported incidences of stigmata and their respective rebleeding risks. We sought to study the interobserver agreement among experts.

METHODS

Between June 1994 and July 1994, 100 consecutive patients with bleeding peptic ulcers underwent videoendoscopy within 24 hours of their admissions. An edited videotape of these ulcers was compiled and sent to an international panel of 14 experts. They independently rated these ulcers exclusively into one of the six categories: spurting, oozing, nonbleeding visible vessel, adherent clot, flat pigmented spot, or clean based. Agreement between any two experts was expressed by a kappa estimate (kappa). Agreements over individual stigmata and a composite kappa estimate (kappa(w)) signifying overall agreement were also computed.

RESULTS

Out of the possible 91 pairwise kappa estimates among 14 experts, 35 (38.5%) were less than or equal to 0.40, indicating poor agreement. None of the kappa estimates was greater than 0.75. Composite kappa estimates for individual stigmata were as follows: spurting kappa = 0.664, oozing kappa = 0.420, nonbleeding visible vessel kappa = 0.342, adherent clot kappa = 0.426, flat pigmented spot kappa = 0.393, and clean-based ulcer kappa = 0.371. The weighted kappa estimate was 0.426.

CONCLUSION

Agreement between experts was poor in more than a third of occasions. Although the overall interobserver agreement was fair (0.4 < kappa < 0.75), agreements for nonbleeding visible vessels, flat pigmented spots, and clean-based ulcers were poor.

Large paraesophageal varices on endosonography predict recurrence of esophageal varices and rebleeding

BACKGROUND & AIMS

Recurrence of varices and rebleeding after endoscopic therapy is very common. Data on the prediction of recurrent varices after initial obliteration by endoscopic therapy are few. The aim of this study was to correlate the presence and the size of paraesophageal varices (PEVs) in patients after endoscopic variceal ligation with recurrent varices and rebleeding.

METHODS

Forty patients who underwent endoscopic banding ligation for esophageal variceal bleeding were studied by endosonography within 4 weeks after obliteration of varices. PEVs were classified as none, small, or large (maximum diameter, > or =0.5 cm). Esophagoscopy and endosonography were then repeated every 6 months for up to 1 year.

RESULTS

Two patients (5%) were not detected to have PEVs. Small and large PEVs were identified in 24 (60%) and 14 (35%) patients, respectively. During the follow-up period of 1-year, recurrent submucosal esophageal varices were detected in 24 patients, including 13 patients (93%) with large PEVs and 11 patients (46%) with no or small PEVs (P = 0.0019). Recurrent bleeding occurred in 6 patients (43%) with large PEVs and in 3 patients (12%) with small PEVs (P = 0.044).

CONCLUSIONS

Patients with large PEVs have a higher risk of developing recurrent varices and rebleeding.

Comparison of two-dimensional vs three-dimensional camera systems in laparoscopic surgery

BACKGROUND

The lack of depth perception and spatial orientation in video vision are the drawbacks of laparoscopic surgery. The advent of a three-dimensional camera system enables surgeons to regain binocular vision and may be advantageous in complex laparoscopic procedures.

METHODS

We prospectively studied two groups of surgeons (with and without experiences in laparoscopic surgery) who performed a designated standardized laparoscopic task using a two-dimensional camera system (Olympus OTV-S4) vs a three-dimensional camera system (Baxter-V. Mueller VS7700) and compared their time performances.

RESULTS

The results suggested that only experience in laparoscopic surgery had significant effect on individual's performance. We could not demonstrate any superiority of the 3D system over the 2D system. However, two-thirds of the surgeons commented that the depth perception did improve.

CONCLUSIONS

With further refinement of the technology, the 3D system may improve its potential in laparoscopic surgery.

Detectability and appearance of bile duct calculus on MR imaging of the abdomen using axial T1- and T2-weighted sequences

This is a retrospective study with the objective of assessing the appearance and detectability of bile duct calculi on axial abdominal magnetic resonance imaging (MRI). Axial spin-echo (SE) T1-weighted and Turbo-spin-echo (TSE) T2-weighted images of the upper abdomen of 23 patients suffering from acute cholangitis with known bile duct calculi were retrospectively analysed. Bile duct calculi could be visualized on a T1-weighted SE sequence in 10 (47%) patients. T2-weighted TSE images identified bile duct calculi in 20 (87%) patients. On the T1-weighted sequence, eight out of 10 (80%) visualized common duct stones were slightly hyperintense compared to bile. On T2-weighted sequence, 27 out of 34 (79%) detectable common duct stones were uniformly hypointense compared to bile, but seven stones (21%) had mixed signal intensity.

Does smoking predispose to peptic ulcer relapse after eradication of Helicobacter pylori?

OBJECTIVES

To investigate whether smoking would increase ulcer recurrence after eradication of Helicobacter pylori (H. pylori) without maintenance acid-suppression therapy.

METHODS

A total of 287 patients, 256 patients with duodenal ulcers and 31 patients with gastric ulcers, were followed-up for up to 18 months after ulcer healing and successful eradication of H. pylori. There were 83 smokers (defined as smoking > or = 10 cigarettes/day) and 204 patients who never smoked or stopped smoking after the diagnosis of peptic ulcer disease. None were taking nonsteroidal anti-inflammatory drugs or receiving maintenance acid suppression therapy. Endoscopy was repeated either at the end of the follow-up period or when ulcer symptoms recurred.

RESULTS

Of the 83 smokers, 3 (3.6%) had ulcer recurrence, which included two duodenal ulcers and one gastric ulcer. Of the 204 nonsmokers, 4 (2.0%) had ulcer relapse, and all being recurrent duodenal ulcers. Four smokers (4.8%) and nine nonsmokers (4.4%) had recurrence of H. pylori infection after 10-18 months. There was no significant difference in ulcer relapse or recurrence of H. pylori infection between smokers and nonsmokers.

CONCLUSIONS

Cigarette smoking did not increase the recurrence of peptic ulcers after eradication of H. pylori.

Comparison of muscle activity and occlusal contacts during maximal and habitual clenching in varied chair positions

The activity of anterior temporal muscle, the number of tooth contacts, and total duration of closure during maximal and habitual clenching were studied in varied chair positions. Fifteen subjects were evaluated. The means for the muscle activity of anterior temporal muscle during habitual clenching were 63.5-73.5% of maximum muscle activity. The number of tooth contacts and total duration of closure were significantly increased as biting pressure was increased from habitual to maximal clenching. No significant differences were detected in all variables among varied chair positions. The above results also suggested that occlusal instability was very common. Further research is required to explain the relationship, if any, of these variables to craniomandibular disorders.

Regulation of thyroid hormones in the secretion of insulin and gastric inhibitory polypeptide in male rats

The effect of thyroid hormones on glucose-induced secretion of gastric inhibitory polypeptide (GIP) and insulin was studied. Male rats were thyroidectomized (Tx) or sham Tx. Sham Tx rats were injected with either propylthiouracil ([PTU] 20 mg/kg intraperitoneally) or saline for 2 weeks. In addition, thyroid-intact rats were injected intravenously with triiodothyronine ([T3]5 microg/kg) or saline 10 minutes before an oral glucose load (3.2 g/kg). Blood samples were collected from each animal via a jugular catheter at 0, 10, 20, 30,45, 60, and 90 minutes following glucose ingestion. Plasma levels of GIP and insulin were measured by specific radioimmunoassays (RIAs). Thyroidectomy-induced hypothyroidism increased the basal level of plasma GIP, but decreased that of insulin. Insulin levels at 10, 20, and 30 minutes following oral glucose were lower in hypothyroid rats than in euthyroid rats. Conversely, GIP levels at 60 and 90 minutes following glucose ingestion in PTU-induced hypothyroid rats were higher than those in euthyroid rats. Furthermore, glucose-stimulated insulin secretion was unaltered by pretreatment with T3, whereas the glucose-induced increase in plasma GIP was completely abolished by preinjection of T3 in thyroid-intact rats. These results suggest that thyroid functions are involved in the regulation of insulin and GIP secretion in rats.

Somatostatin reduces gastric mucosal blood flow in patients with portal hypertensive gastropathy: a randomized, double-blind crossover study

Agents which decrease gastric mucosal blood flow (GMBF) are postulated to have beneficial effects in arresting gastrointestinal bleeding in cirrhotic patients with portal hypertension. Our objective was to test the hypothesis that in a dose that significantly lowers wedged hepatic venous pressure (WHVP), a bolus injection of somatostatin will significantly decrease GMBF in patients with portal hypertensive gastropathy (PHG). In this placebo-controlled, double-blind, crossover study, 20 cirrhotic patients with PHG were randomly assigned to receive either somatostatin followed by placebo (Group A) or placebo followed by somatostatin (Group B). Wedged hepatic venous pressure was monitored. GMBF in the antrum and corpus was assessed by reflectance spectrophotometry. Indices of hemoglobin concentration (IHb) and indices of oxygen content (ISO2) were recorded. Nine patients were assigned to Group A, and 11 to Group B. Mild PHG was seen in 16 patients, and severe PHG in 4 patients. Baseline WHVP, IHb, and ISO2 were similar in both treatment groups. Wedged hepatic venous pressure (WHVP) was significantly lowered [median, 17.6%; interquartile range (-27.0,-12.6%); P = 0.0008] after a 250-microg bolus injection of somatostatin. This dose of somatostatin significantly reduced IHb both in the antrum [-10.2% (-23.4, 0.4%)] and in the corpus [-5.8% (-16.6, 5.6%)] compared to placebo (P = 0.02 and 0.04, respectively). Intravenous bolus injection of 250 microg somatostatin significantly reduces WHVP and GMBF in patients with PHG. Whether this ability to decrease the GMBF in PHG makes somatostatin an effective treatment in acute gastrointestinal bleeding in PHG deserves to be studied.

High prevalence of Helicobacter pylori infection in duodenal ulcer perforations not caused by non-steroidal anti-inflammatory drugs

There has been controversy regarding the relationship between Helicobacter pylori and perforated peptic ulcer, which is known to have a high recurrence rate if only simple patch repair is performed. The aim of this study was to evaluate the association between H. pylori infection and intake of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with perforated duodenal ulcers. Of the 73 patients recruited over a 16-month period, 51 (70 per cent) had evidence of H. pylori infection by intraoperative gastroscopy and antral biopsies. The infection rate rose to 80 per cent if NSAID users were excluded. The H. pylori-infected group was significantly younger (mean 47.6 versus 62.5 years), with a male preponderance (49 of 51 versus 14 of 22 patients), and had significantly less NSAID consumption (three of 51 versus ten of 22) and more prolonged dyspepsia (40 of 51 versus ten of 22), compared with H. pylori-negative patients. H. pylori infection probably plays an important role in the causation of non-NSAID-induced duodenal ulcer perforation. Whether eradication of the bacteria can alleviate the strong ulcer diathesis in this subgroup of patients is unknown.

Mesh hernioplasty using a stapler

BACKGROUND

The recent development of laparoscopic hernioplasty has evoked extensive re-examination of the safety and effectiveness of using synthetic mesh materials in hernia surgery. We have investigated the efficacy of anterior stapling mesh repair in the treatment of inguinal hernia.

METHODS

From July 1993 to June 1994, a modified open mesh hernioplasty using staples for anchorage has been performed in 127 patients.

RESULTS

The mean age of patients was 61.4 +/- 13.0 years. Over 90% of them were operated on under local anaesthesia. The operation time ranged from 30 to 95 min with a median of 39 min. Only sixteen patients (12.6%) required postoperative parenteral analgesics and the median time for resuming daily activities was 7 days. Apart from two patients with reactionary haemorrhage, there was no other significant complication observed. Only one recurrence was encountered over the 26-month median follow-up period.

CONCLUSIONS

We conclude that the modified mesh hernia repair with a stapling device is a feasible, inexpensive and safe procedure that is well tolerated under local anaesthesia by most patients.

An overview of laparoscopic and thoracoscopic vagotomy

The development of laparoscopic surgery in the past few years has been truly explosive. Techniques developed in laparoscopic cholecystectomy are also applied to other operations in the abdomen. Vagotomy can be performed expediently laparoscopically. However, the advent of effective ulcer drugs has decreased the demand for elective surgery, especially since ulcer disease can now be cured with a short course of anti-Helicobacter treatment. We review the role of laparoscopic and thoracoscopic vagotomy in the light of these developments.

Endoscopic drainage aborts endotoxaemia in acute cholangitis

Forty patients with acute calculous cholangitis had successful endoscopic drainage. Bile from nasobiliary drains and venous blood was collected at 0, 12, 24, 36 and 48 h after endoscopy. Endotoxin levels were measured by the chromogenic Limulus Amoebocyte Lysate assay. There was a significant reduction in both bile and serum endotoxin levels after endoscopic drainage (P < 0.001). Endotoxaemia occurred when bile endotoxin reached 10(3) EU/ml and rose exponentially beyond this threshold. Significant association was demonstrated between both bile and serum endotoxins to the clinical features of cholangitis (P < 0.05). No correlation was evident between serum endotoxin and the parameters of white cell count, serum bilirubin and alkaline phosphatase (r = 0.53, 0.00 and 0.00 respectively). Endoscopic drainage is effective in lowering bile and serum endotoxin levels and clinical signs and symptoms reliably predict endotoxaemia.

A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique

OBJECTIVE

This study compares laparoscopic versus open repair and suture versus sutureless repair of perforated duodenal and juxtapyloric ulcers.

BACKGROUND DATA

The place of laparoscopic repair of perforated peptic ulcer followed by peritoneal toilet of the peritoneal cavity has been established. Whether repair of the perforated peptic ulcer by the laparoscopic approach is better than conventional open repair and whether sutured repair is better than sutureless repair are both undetermined.

METHODS

One hundred three patients were randomly allocated to laparoscopic suture repair, laparoscopic sutureless repair, open suture repair, and open sutureless repair.

RESULTS

Laparoscopic repair of perforated peptic ulcer (groups 1 and 2) took significantly longer than open repair (groups 3 and 4; 94.3 +/ 40.3 vs. 53.7 +/ 42.6 minutes: Student's test, p < 0.001), but the amount of analgesic required after laparoscopic repair was significantly less than in open surgery (median 1 dose vs. 3 doses) (Mann-Whitney U test, p = 0.03). There was no significant difference in the four groups of patients in terms of duration of nasogastric aspiration, duration of intravenous drip, total hospital stay, time to resume normal diet, visual analogue scale score for pain in the first 24 hours after surgery, morbidity, reoperation, and mortality rates.

CONCLUSIONS

Laparoscopic repair of perforated peptic ulcer is a viable option. Sutureless repair is as safe as suture repair and it takes less time to perform.

Risk of further ulcer complications after an episode of peptic ulcer bleeding

To identify the risk factors for developing recurrent ulcer complications after recovery from an episode of peptic ulcer bleeding 611 patients admitted with peptic ulcer bleeding were studied. Some 557 (91 per cent) were discharged without operation. A total of 22 patients were lost to follow-up and five were excluded as maintenance H2 blockers were required. Of the remaining 530 patients at risk, 169 (32 per cent) developed another complication (166 bleeding, three perforations) over a median follow-up period of 36 months. Patients with duodenal ulcers at the time of bleeding, previous history of peptic ulcer, previous bleeding, history of dyspepsia longer than 3 months, and a short interval between previous ulcer complications and the index bleed were more likely to develop further complications. Sex, age, smoking, coexisting illness, non-steroidal anti-inflammatory drugs intake and time taken to achieve ulcer healing had no predictive value.

Epinephrine or epinephrine plus alcohol for injection of bleeding ulcers: a prospective randomized trial

BACKGROUND

Rebleeding following epinephrine injection of bleeding peptic ulcers occurs in 10% to 20% of all cases. The addition of a sclerosant has the theoretical advantage of inducing vessel thrombosis and permanent hemostasis.

METHODS

A prospective randomized controlled trial was conducted to compare injections with epinephrine alone or epinephrine plus absolute alcohol in patients with actively bleeding ulcers at endoscopy. Repeat endoscopy was performed 24 hours later; treatment was repeated in the presence of endoscopic signs of rebleeding. Surgery was performed when arterial bleeding could not be controlled endoscopically, clinical rebleeding with hematemesis or shock occurred, or the transfusion total exceeded 8 units.

RESULTS

One hundred sixty patients were enrolled (epinephrine alone, 81; epinephrine and absolute alcohol, 79). They were matched in age, sex, location of ulcers, hemoglobin on admission, shock, and severity of bleeding. Initial hemostasis was comparable: 79 of 81 with epinephrine alone (97.5%) versus 75 of 79 with epinephrine and absolute alcohol (94.9%). No difference was observed between the two with respect to either rebleeding (9 vs 6), need for emergency operation (12 vs 9), transfusion requirement (median, three units vs two units), hospital stay (median, 5 days vs 4 days), mortality (4 vs 7) and ulcer healing at 4 weeks (50 vs 46).

CONCLUSIONS

The additional injection of absolute alcohol after endoscopic epinephrine injection confers no advantage.

Laparoscopic truncal vagotomy and gastroenterostomy for pyloric stenosis

BACKGROUND

Gastric outlet obstruction secondary to chronic duodenal ulceration is an indication for surgery as conservative management with balloon dilatation frequently fails. The standard operation is truncal vagotomy and a drainage procedure. However, development of minimally invasive surgery has revolutionized the surgical approach to this clinical problem.

METHODS

Twelve male patients with pyloric stenosis secondary to duodenal ulceration underwent laparoscopic truncal vagotomy and gastrojejunostomy. The perioperative and long term outcome of this group of patients were analyzed.

RESULTS

The median operating time was 210 (range 180 to 240) minutes. Median postoperative stay was 6 (range 4 to 41) days. Conversion to laparotomy was necessary in one patient. Delayed gastric emptying occurred in two patients but resolved on conservative measures. At a median postoperative followup of 6 (range 1 to 12) months all patients had a good symptomatic outcome (Visick grades I or II).

CONCLUSIONS

Laparoscopic truncal vagotomy and gastrojejunostomy is a feasible technique. Intermediate followup shows good symptomatic results when used for pyloric stenosis.

Thoracoscopic resection of oesophageal diverticulum: a case report

The introduction of video-assisted surgery has revolutionized thoracic surgery. The main attraction is the avoidance of a large thoracotomy incision and its associated morbidity. We present the case of a 55-year-old woman with an oesophageal diverticulum presenting with troublesome dysphagia. A thoracoscopic assisted oesophageal diverticulectomy was performed. Post-operative recovery was uneventful, and only two doses of intramuscular opiate analgesic were required. The patient remained asymptomatic at a follow-up of 3 months.

Short communication: oesophageal tumour volume measurement using spiral CT

A CT technique for measuring oesophageal cancer tumour volume in the monitoring of local disease response following radiotherapy or chemotherapy is described. Patients with newly diagnosed oesophageal carcinoma were referred for pre- and post-chemotherapy CT scans. IV Buscopan was given to abolish peristalsis. Patients were scanned in prone position. Effervescent gas granules and Calogen (a negative contrast of fat density) were given. Spiral scanning was performed. The area of tumour on each 1 cm slice was measured. The sum of these areas gave tumour volume in cubic centimetres. The accuracy of the method was tested on patients who had had surgery. The volume of the segment of oesophagus containing tumour was measured by its weight and water displacement. Lumenal distention proximal and distal to the tumour was achieved in all patients. 10 gross surgical specimens were available for comparison with pre-operative CT. The correlation coefficient was 0.95. In conclusion, accurate tumour volume assessment was achieved with our technique.

Dual therapy versus triple therapy for Helicobacter pylori-associated duodenal ulcers

We compared the ulcer healing effect and eradication of H. pylori by one-week triple therapy of bismuth, metronidazole, and tetracycline with two-week dual therapy of amoxicillin and omeprazole. One hundred twelve patients with confirmed H. pylori infection and duodenal ulcers were recruited in a prospective, randomized, single-blinded trial. Ulcer healing, eradication of H. pylori in the stomach six weeks after randomization and side effect reported by patients during the therapy. Duodenal ulcers were healed in 44 of 49 (89.8%, 95% CI, 81.3-98.3 %) patients receiving triple therapy and in 44 of 53 (83.0%, 95% CI, 72.9-93.1%) patients receiving dual therapy (P=0.32). H. pylori was successfully eradicated in 41 of 49 (83.6%, 95% CI 73.4-94%) patients and in 40 of 53 (75.5%, 95% CI 63.9-87.1%) patients in the triple therapy group and the dual therapy group respectively (P=0.31). Side effects experienced by patients who received triple therapy were significantly more frequent than those who received dual therapy (P=0.0076). In conclusion, a two-week course of omeprazole and amoxicillin achieves a comparable rate of H. pylori and ulcer healing with fewer side effect.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in laparoscopic cholecystectomy

BACKGROUND

The management of possible common bile duct (CBD) stones in patients scheduled for laparoscopic cholecystectomy remains controversial.

METHODS

Prospective evaluation of 609 patients who underwent laparoscopic cholecystectomy was carried out in relation to the use of selective preoperative ERCP for detection of common duct stones. Preoperative ERCP was performed if there is or has been (1) cholangitis, biliary pancreatitis, or jaundice; (2) abnormal serum liver tests or (3) ultrasonogram showing a dilated CBD or ductal stones.

RESULTS

A total of 139 patients underwent preoperative ERCP, and cannulation of CBD was successful in 133 patients (96%). CBD stones were found in 60 patients (45%) and extracted after sphincterotomy. High prevalence of CBD stones was noted in patients with acute cholangitis and CBD stones on ultrasonogram. There were six endoscopic sphincterotomy-related complications (complication rate, 4.5%): bleeding (2), pancreatitis (3), retroduodenal perforation (1). No patient required surgery as the result of a complication. The prediction of the occurrence of ductal stones was further analyzed using stepwise logistic regression. Acute cholangitis and CBD stones on ultrasonogram were shown to be independent significant risk factors with odds ratios of 8.9 and 13.5, respectively.

CONCLUSIONS

With selective preoperative ERCP, suspected CBD stones can be identified and removed prior to laparoscopic cholecystectomy.