Local excision of T2 and T3 rectal cancers after downstaging chemoradiation.

OBJECTIVE: To evaluate the safety and efficacy of local excision in patients with T2 and T3 distal rectal cancers that have been downstaged by preoperative chemoradiation. SUMMARY BACKGROUND DATA: T2 and T3 cancers treated by local excision alone are associated with unacceptably high recurrence rates. The authors hypothesized that preoperative chemoradiation might downstage both T2 and T3 lesions and significantly expand the indications for local excision. METHODS: Local excision was performed after preoperative chemoradiation on patients with a complete clinical response or on patients who were either ineligible for or refused to undergo abdominoperineal resection. Local excision was approached transanally by removing full-thickness rectal wall and the underlying mesorectum. RESULTS: From 1994 to 2000, 95 patients with rectal cancers underwent preoperative chemoradiation and surgical resection for curative intent. Of these, 26 patients (28%), 19 men and 7 women, with a mean age of 63 years (range 44-90), underwent local excision. Pretreatment endoscopic ultrasound classifications included 5 T2N0, 13 T3N0, 7 T3N1, and 1 not done. Pathologic partial and complete responses were achieved in 9 of 26 (35%) and 17 of 26 (65%) patients, respectively. Two of nine partial responders underwent immediate abdominoperineal resection. The mean follow-up was 24 months (median 19, range 6-77). The only recurrence was in a patient who refused to undergo abdominoperineal resection after a partial response. There was one postoperative death from a stroke. This treatment was associated with a low rate of complications. CONCLUSION: Local excision appears to be an effective alternative treatment to radical surgical resection for a highly select subset of patients with T2 and T3 adenocarcinomas of the distal rectum who show a complete pathologic response to preoperative chemoradiation.

Captopril-associated cholestasis complicating the management of pancreatic cancer.

Cholestatic jaundice is a rare complication associated with the use of the angiotensin -converting enzyme inhibitor captopril. The severity of the disease may range from cholestasis on liver histology to overt fulminant hepatic failure. This diagnosis is seldom considered in patients with pancreatic or biliary tract malignancy. We present a patient with unresectable adenocarcinoma of the pancreas whose jaundice decreased slowly over many weeks despite establishment of adequate endoscopic biliary drainage. The presence of captopril-associated cholestasis confounded confirmation of adequate biliary drainage. The absence of observed hepatic bile secretion at duodenoscopy, as seen in this patient, is a previously unreported endoscopic feature of this syndrome.

Anaplastic and sarcomatoid carcinoma of the small intestine: an unusual tumor.

Primary malignant tumors of the small intestine are rare, and sarcomatoid carcinomas have rarely been reported at this site. Anaplastic and sarcomatoid carcinomas are well described in the upper aerodigestive tract, particularly in the esophagus and the larynx. The authors report a case of anaplastic and sarcomatoid carcinoma of the ileum presenting as gastrointestinal bleeding. Their patient and the literature suggest that these tumors are much more aggressive than other small intestinal tumors. The importance of a systematic diagnostic approach in diagnosing these tumors is also discussed.

Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy.

BACKGROUND: Gallstones are the most common cause of acute pancreatitis during pregnancy. Without intervention, gallstone pancreatitis during pregnancy is associated with an antepartum recurrence rate of 70%, which exposes the mother and fetus to an increased risk of morbidity and mortality. A safe, effective means to prevent recurrent gallstone pancreatitis during pregnancy is desirable. METHODS: Since 1991, we have managed gallstone pancreatitis in three pregnant patients with endoscopic retrograde cholangiogram (ERC), followed by spincterotomy, despite the absence of common bile duct stones. RESULTS: All patients were judged to have mild pancreatitis by modified Ranson criteria and the Multiorgan System Failure criteria. During cholangiogram, fetal shielding was employed and fluoroscopy times ranged from 36 s to 7.2 min. One patient experienced postprocedure pancreatitis of 48-h duration. None of the patients experienced further episodes of pancreatitis and none underwent predelivery cholecystectomy. CONCLUSIONS: In pregnancy-associated gallstone pancreatitis, endoscopic sphincterotomy prevents recurrence of pancreatitis and the need for cholecystectomy during gestation. We believe endoscopic sphincterotomy represents a promising management alternative for gallstone pancreatitis during pregnancy. Further investigation is warranted.

Are patients who undergo open-access endoscopy more anxious about their procedures than patients referred from the GI clinic?

OBJECTIVES: Our academic hospital center operates an open access endoscopy service that allows referring physicians to directly schedule patients for outpatient esophagogastroduodenoscopy and colonoscopy without having them first seen in the GI clinic. Although patients from the GI clinic have an opportunity to meet the endoscopist and discuss their procedures directly beforehand, patients who are scheduled to undergo endoscopy through our open access service receive only a brief telephone call from a GI fellow or nurse that is made to screen for contraindications to the procedure and to give instructions. Our objective was to find out whether patients who used our open access service were more anxious about their procedures than those referred from the GI clinic. METHODS: On arrival to our endoscopy center, consecutive patients from the open access service (n = 142) and the GI clinic (n = 85) completed a questionnaire that included three measures of anxiety. After completion of the endoscopic procedure, the attending endoscopist rated patient cooperation. Patients also completed a phone questionnaire on the day after their procedures assessing their experience with endoscopy. RESULTS: We found no difference between patients from the open access service and those from the GI clinic in any of the measures of preprocedure anxiety, in scores measuring cooperation during procedures, or in patient ratings of their experience with endoscopy as assessed on the day after procedures. CONCLUSIONS: Patients who used our open access service were no more anxious about their procedures or less cooperative during them than patients first seen in the GI clinic. In both groups, procedure-related anxiety was decreased in patients who had previously undergone endoscopy.

Appropriateness of referrals for open-access endoscopy. How do physicians in different medical specialties do?

BACKGROUND: Open-access endoscopy allows nongastroenterologist physicians the opportunity to directly schedule elective common endoscopic procedures for their patients without having them first examined in the gastrointestinal clinic. There are few data as to whether nongastroenterologist physicians in the United States schedule patients for appropriate indications. OBJECTIVES: To examine our practice to see whether patients undergoing open-access endoscopy were scheduled for appropriate indications and to see whether there were differences among physicians in various medical specialties. METHODS: We prospectively tracked 310 consecutive patients scheduled for open-access esophagogastroduodenoscopy (EGD) and colonoscopy by nongastroenterologist physicians over a 9-month period in our academic practice setting to determine whether the indications for performing the procedures were appropriate. The American Society for Gastrointestinal Endoscopy criteria (revised in 1992) were used as the standard for comparison. RESULTS: Primary care physicians (family practitioners and general internists) did a superior job of scheduling patients for appropriate indications for EGD and colonoscopy than did non-primary care physicians (internal medicine subspecialists and surgeons): 97.0% vs 81.3% for EGD (P = .04) and 84.9% vs 66.7% for colonoscopy (P = .02), respectively., CONCLUSIONS: Primary care physicians were significantly more likely to schedule patients for open-access EGD and colonoscopy for appropriate indications than were non-primary care physicians. The frequency of inappropriate indications for colonoscopy referrals was greater than for EGD. The reasons for the differences among primary care physicians, surgeons, and internal medicine subspecialists require further exploration.

Esophageal dilation with polyvinyl (American) dilators over a marked guidewire: practice and safety at one center over a 5-yr period.

OBJECTIVE: Improvements in dilator technology over the past decade have revolutionized esophageal dilation. There remains, however, a number of controversies relating to several technical aspects of wire-guided dilation, including whether or not fluoroscopy is necessary. We describe our experience with wire-guided esophageal bougienage. METHODS: We retrospectively reviewed our experience with esophageal dilation using polyvinyl (American) dilators and marked guidewires over the period 1990-1994 to assess the practice habits of our endoscopists and the safety of the technique. We did 606 wire-guided dilations on 354 adult patients. Dilations were done by six different endoscopists. RESULTS: Fluoroscopy was used in only 32/606 dilations (5.3%) and then only to pass a guidewire when the scope could not be passed through the stricture. Fluoroscopy was not used to monitor dilator passage. Peptic strictures were dilated to their maximal target size (determined by the individual endoscopist) in one session in 195 of 253 instances (77.1%). Practice differences were seen between the individual endoscopists relating to how rapidly dilation was accomplished, the number of dilators passed per session, and the maximal dilator size passed. No perforations or other serious complications occurred in our series. CONCLUSIONS: Wire-guided esophageal bougienage is a very safe procedure when careful attention to technique is observed. No perforations were seen in our series of over 600 dilations. Fluoroscopy is needed only in those cases in which a scope cannot be passed through a stricture to assist with guidewire passage. In a majority of cases, peptic strictures can be dilated to a 45-to 51-Fr size in a single session.

Efficacy and safety of combined meperidine and midazolam for EGD sedation compared with midazolam alone.

BACKGROUND/AIMS: Safety concerns have been raised about the use of the combination of an opioid and benzodiazepine for esophagogastroduodenoscopy (EGD) sedation, a common practice of American gastroenterologists. If we could show that patients in American practice settings satisfactorily tolerate EGD with midazolam alone, as is commonly done in Europe, it would provide impetus for American gastroenterologists to change practice habits. METHODS: We performed a randomized, double-blind trial to determine whether meperidine, used in addition to midazolam, improved patient tolerance to EGD compared with the use of midazolam alone in our academic practice setting. Safety parameters were also examined. One hundred twenty adult patients undergoing diagnostic EGD were randomized to receive either 50 mg of meperidine (group I) or 1 mg of midazolam (group II). Patients were then given additional midazolam in incremental doses at the discretion of the attending gastroenterologist to induce a state of conscious sedation. RESULTS: Including the study drug, patients in group I received an average of 1.8 mg less of midazolam compared with group II (mean total midazolam dose, 3.8 mg vs 5.6 mg; p = 0.037). Patients in group I showed improved tolerance for EGD compared with those in group II in terms of a physician rating of "poor" for the overall adequacy of sedation (7 vs 20%, p = 0.033), the need for supplemental narcotics or droperidol during the procedure (7 vs 20%, p = 0.033), the need for additional medication during intubation of the esophagus (12 vs 25%, p = 0.06), the need for a faculty member to accomplish esophageal intubation (7 vs 20%, p = 0.051), the presence of retching, which interfered with the procedure (21 vs 39%, p = 0.046), and premature termination of the exam (0 vs 7%, p = 0.055). No difference was seen in the degree of amnesia, in the willingness of patients to undergo another EGD in the future, or in cardiorespiratory parameters. CONCLUSIONS: In our academic practice setting, 50 mg of meperidine given i.v. at the start of the procedure improved the ability of our patients to tolerate EGD from the endoscopists' standpoint. We found no difference in cardiorespiratory parameters between the groups.

The effect of droperidol on objective markers of patient cooperation and vital signs during esophagogastroduodenoscopy: a randomized, double-blind, placebo-controlled, prospective investigation.

We investigated the effect of droperidol on objective markers of cooperation and vital signs in 140 patients undergoing elective diagnostic esophagogastroduodenoscopy. Procedure duration and the total doses of midazolam and meperidine required during the procedure were evaluated as objective markers of patient cooperation. The droperidol group comprised 66 patients and the placebo group 74 patients. Patient and procedure characteristics were similar for both groups. Droperidol produced a 10% reduction in procedure duration. Linear multiple regression modeling revealed droperidol to be a significant predictor of procedure duration (p = .036). Droperidol significantly reduced midazolam and meperidine requirements (p < .01). Nonetheless, four patients in the droperidol group received naloxone to reverse prolonged, excessive drowsiness. Droperidol produced a significant reduction in procedure-associated increase in pulse rate but did not exacerbate procedure-associated reduction in mean arterial pressure. Droperidol favorably influences markers of patient cooperation during elective, diagnostic esophagogastroduodenoscopy. However, the clinical significance of these changes is unclear.

Prospective, randomized trial comparing a new sodium phosphate-bisacodyl regimen with conventional PEG-ES lavage for outpatient colonoscopy preparation.

BACKGROUND: Several recent trials have shown that colonoscopy preparation with sodium phosphate solution is as effective and at least as well tolerated as conventional PEG-ES lavage. These trials utilized two 1.5-fluid oz doses, one given on the evening before colonoscopy and the other early the next morning. METHODS: We devised a new sodium phosphate regimen in which the entire dose was given on the evening before examination (1.5 fl oz at 4 PM, 1.5-fl oz at 7 PM and 10 mg of bisacodyl at 10 PM) and performed a prospective, randomized trial that compared it with conventional PEG-ES lavage in terms of quality of colon cleansing, patient tolerance, and safety in an outpatient colonoscopy population with normal renal function. Seventy-two patients received sodium phosphate-bisacodyl and 75 PEG-ES lavage. RESULTS: The overall quality of colon cleansing and frequency of unsatisfactory preparations were similar with both methods. Patients found preparation with sodium phosphate-bisacodyl to be easier than PEG-ES lavage (p = 0.005). No clinically important adverse effects were seen with either method of preparation. The average cost of sodium phosphate-bisacodyl was $4.32 per patient compared with $18.15 for PEG-ES lavage preparation. CONCLUSION: Preparation with sodium phosphate-bisacodyl, given on the evening before colonoscopy, is a well-tolerated, efficacious, and cost-effective alternative to conventional PEG-ES lavage.

Early accidental dislodgement of PEG tubes.

Newer percutaneous endoscopy gastrostomy (PEG) tubes with soft internal bolsters may be prone to accidental dislodgement or removal by patients. When this occurs after a mature gastrocutaneous fistula has formed, it is of little consequence as long as a replacement tube is promptly reinserted before the track closes. Blind reinsertion of a replacement tube before the track is adequately mature may have serious consequences, as exemplified by a patient who developed peritonitis as a result of inadvertent insertion into the peritoneal cavity. We managed two other patients with early accidental PEG tube removal by a period of nasogastric (NG) suction, intravenous antibiotic drugs, and observation, with a new tube placed endoscopically 7-9 days later. We review the management of early, inadvertent dislodgement of PEG tubes.

Short report: prospective, randomized trial comparing a single dose sodium phosphate regimen with PEG-electrolyte lavage for colonoscopy preparation.

We performed a prospective, randomized trial in 52 patients to see how preparation with a single-dose sodium phosphate solution regimen (Fleet Phospho-Soda), in which the entire 89 ml dose was given on the evening prior to colonoscopy, compared with conventional polyethylene glycol(PEG)-electrolyte lavage in terms of quality of colon cleansing and ease of patient preparation. Previous trials had utilized a two-dose sodium phosphate regimen in which one dose was given on the evening prior to colonoscopy and the other on the morning of the procedure. A nurse gave a questionnaire to the patient prior to colonoscopy, assessing how well the preparation was tolerated. The attending gastroenterologist graded the quality of colon cleansing, unaware of how the patient was prepared or tolerated the preparation (1 = excellent, 2 = good, 3 = fair, 4 = unsatisfactory). Both preparations were similarly tolerated. The overall quality of bowel preparation with PEG lavage was significantly better (mean score 1.62) than with the single-dose sodium phosphate regimen (mean score 2.85) (P = 0.0002). Of 26 patients, 2 (7.7%) undergoing preparation with PEG lavage were judged to have had an unsatisfactory preparation, compared with 8 of 26 patients (30.8%) receiving the sodium phosphate regimen (P = 0.075). We conclude that the single-dose sodium phosphate regimen is suboptimal for clinical practice and its use cannot be recommended.

Prospective, randomized trial comparing sodium phosphate solution with polyethylene glycol-electrolyte lavage for colonoscopy preparation.

We performed a prospective randomized trial in a predominantly outpatient colonoscopy population to see how preparation with oral sodium phosphate solution compares with polyethylene glycol-electrolyte lavage in terms of the quality of colon cleansing, ease of preparation, and gastrointestinal intolerance. Before colonoscopy, a nurse administered a questionnaire to the patient to assess how well the preparation was tolerated (scale from 1 to 5:1 = easy, to 5 = unable to finish) and about the presence of four symptoms: abdominal pain, nausea, vomiting, and dizziness. The quality of colon cleansing was graded by the attending gastroenterologist, who was unaware of how the patient was prepared or tolerated the preparation (1 = excellent, 2 = good, 3 = fair, 4 = poor). The overall quality of bowel preparation with polyethylene glycol lavage was slightly better than with sodium phosphate (mean score, 1.93 vs 2.07); however, the difference was not statistically different. No statistical difference was seen in the frequency of patients with poor preparations (14.2% for sodium phosphate, 9.6% for polyethylene glycol lavage). Patients found preparation with sodium phosphate to be somewhat easier than polyethylene glycol lavage (mean score, 2.07 vs 2.41; p = 0.05). No difference was seen in the incidence of abdominal pain, nausea, or vomiting. Dizziness was more common with sodium phosphate but was mild and not believed to be clinically important. We conclude that the quality of colon cleansing is similar with polyethylene glycol lavage and oral sodium phosphate solution, with satisfactory preparation seen in 85% to 90% of patients. Patients found preparation with sodium phosphate to be slightly easier to tolerate.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective evaluation of optimal number of biopsy specimens and brush cytology in the diagnosis of cancer of the colorectum.

We prospectively studied the diagnostic accuracy of endoscopic biopsy and cytology in the diagnosis of colorectal cancer and sought to ascertain the optimal number of biopsy specimens that should be taken. Seventy consecutive patients with colorectal masses or polypoid lesions that could not be removed by endoscopic polypectomy and which were referred for surgery were studied. Lesions were first brushed for cytology. A series of 10 biopsies were then obtained from each lesion; the first four were placed into the first container, and two were placed into each of three other containers. Cytology and biopsies were read blindly by one pathologist. Findings were compared with the resection specimen results. Ten lesions were benign; all had negative biopsies and cytology. Sixty lesions were malignant: cytology was positive in 77.2% and biopsies in 78.3%. The yield was increased to 91.7% when both were done (cytology plus six biopsies). Cytology detected seven cancers that were missed by biopsy. Biopsy detected eight cancers not diagnosed by cytology. Five cancers were missed by both. Of the 47 cancers detected by biopsy, the first four biopsies made the diagnosis in 41 cases. Taking two more biopsies (six total) identified six more cancers. No additional cancers were identified by taking more biopsies (eight or 10 total). When six different biopsy-cytology strategies were examined: 1) cytology alone, 2) four biopsies (Bx), 3) six Bx, 4) 10 Bx, 5) cytology + four Bx, and 6) cytology + six Bx, the yield was 77.2%, 68.3%, 78.3%, 78.3%, 90.0%, and 91.7%, respectively. We conclude that biopsy and cytology are complementary in the diagnosis of colorectal cancer. The combination of cytology and four to six biopsies is recommended. There appears to be little additional yield to taking more than six biopsies. Even combined biopsy and cytology will miss 8-10% of cancers.