Hand infections in patients with diabetes mellitus.

Fifty diabetic patients with hand infections were studied retrospectively. The cause of infection varied, and the infections were divided into two groups: superficial infections and abscesses. The amputation rate was 14%. Only patients who presented with an abscess required amputation, and of those patients with abscesses, 17.5% required amputation. Eighteen of 38 cultured infections were polymicrobial, 4 contained Enterococcus, 11 contained gram-negative bacteria, and 3 contained anaerobic organisms. Bacteriologic culture analysis initiated a two-drug protocol: ampicillin with sulbactam (Unasyn; Pfizer, New York, NY) or piperacillin with tazobactam (Zosyn; Lederle, Pearl River, NY) and gentamicin (renal adjusted).

Enteroscopy improves the clinical outcome in patients with obscure gastrointestinal bleeding.

Push enteroscopy is often performed to identify and treat the source of blood loss in patients with obscure gastrointestinal blood loss. This study was designed to determine whether enteroscopy alters the clinical outcome in these patients. This was a retrospective study of 50 patients who underwent push enteroscopy for obscure GI blood loss. Information was obtained from chart review and telephone contact with both patients and physicians. Data collected included patient demographics, days hospitalized, and packed red blood cell transfusions for 6 months pre- and postprocedure, diagnostic yield, return to premorbid function, and a global patient's and referring physician's assessment of efficacy. For analysis, patients were subgrouped by whether or not enteroscopy identified a source for the bleeding. Complete data were available for 41 of 50 patients. Sixty-seven percent were female, with a mean age of 65+/-2.1 years. Positive findings were seen in 78%. In patients with a positive finding, there was a decrease in hospitalization days (from 17.4+/-4.5 to 7.2+/-3.0) and transfusions (from 7.9+/-1.3 to 3.0+/-1.1) in the 6 months following the procedure. Patients without findings had a significant decrease in transfusions (from 13.7+/-6.7 to 8.2+/-4.9), but not hospitalization. Forty-four percent of patients returned to premorbid function. One-third of patients and half of their physicians felt that the procedure was beneficial. Push enteroscopy improves patient clinical outcome in obscure GI bleeding--especially when a diagnostic finding is obtained.

Use of botulinum toxin in the treatment of achalasia.

Achalasia is a chronic esophageal motor disorder characterized by failure of the lower esophageal sphincter (LES) to relax during swallowing, aperistalsis of the esophageal body, and, often, an elevated resting LES pressure. Pneumatic dilation and Heller cardiomyotomy have been the time-honored, accepted treatments, but each may carry significant morbidity. Recently, intrasphincteric injection of botulinum toxin has been shown to be an effective treatment for achalasia, probably by reducing the excitatory cholinergic tone of the LES. Subjective and objective improvement have been reported in many patients with few reported adverse reactions. Clinical improvement generally lasts 2-6 months with patients often requiring repeat treatment. Although studies directly comparing botulinum toxin injection with pneumatic dilation and surgical myotomy are needed, botulinum toxin injection has rapidly become another therapeutic option in the treatment of achalasia.

Nonexpandable silicone esophageal stents for treatment of malignant tracheoesophageal fistulas: complications and radiographic appearances.

BACKGROUND: The aim was to evaluate the radiologic appearances and complications that occurred after placement of nonexpandable silicone stents used as palliative therapy for patients with malignant tracheoesophageal fistulas (TEFs). METHODS: Records of 11 patients (6 males, 5 females) who underwent placement of esophageal stents for malignant TEF between 1988 and 1994 were reviewed. Nine patients had esophageal carcinoma and two patients bronchogenic carcinoma. A TEF was documented radiographically in all patients. Silicone stents were placed in all patients under endoscopic guidance. A chest radiograph was obtained for each patient immediately following stent placement to confirm proper positioning and to assess complications. A contrast study was performed within 24 hours after the procedure to evaluate the function of the stent and its efficacy for occluding the fistulous tract. The patients were followed until January 1995 or until their death (range 1.5-24. 0 months). RESULTS: Seven of the patients developed stent-related complications. Within the first 24 hours after stent insertion (which was successful in 100% of cases), 2 of the 11 patients developed minor complications. One patient had pooling of contrast around the proximal portion of the stent leading to aspiration of contrast, and one patient experienced transient, asymptomatic, idiopathic, esophagovenous intravasation. Delayed (>24 hours) complications related to stent placement occurred in five of the patients: one patient each had pooling at the proximal end of the stent with aspiration, worsening esophageal dysphagia causing reflux through the stent, caudad stent migration, superior stent migration, epithelial hyperplasia causing obstruction of the stent, and pressure necrosis. There were no cases of hemorrhage. Two patients were lost to long-term follow-up, and eight patients died of their disease, all unrelated to the stent placement. CONCLUSION: Silicone esophageal stents provide successful short-term palliation for most patients with malignant TEF but are not without associated complications. These complications, however, can usually be detected early using radiographic imaging, permitting remediation.

Laparoscopic resection of gastric leiomyosarcoma.

Wedge resection with a normal margin of stomach is generally considered adequate therapy for gastric leiomyosarcoma. We report here four patients with gastric leiomyosarcoma managed laparoscopically. The technique is described. There were no operative complications and all patients have been followed for 7 to 56 months. Three patients are free of disease and one patient with a high grade tumor is alive with liver metastases at 2 yars postoperatively. From this experience we conclude the following: 1) Laparoscopic wedge resection of gastric leiomyosarcoma is straightforward and easily accomplished without violation of standard surgical oncologic principles. 2) Intraoperative endoscopy is helpful in locating and manipulating the tumor, and aids in ensuring lumenal adequacy and staple line integrity. 3) Preoperative localizing studies may be misleading and should not discourage laparoscopic evaluation and treatment.

Helicobacter pylori infection. The importance of eradication in patients with gastric disease.

Discovery of Helicobacter pylori infection in patients with peptic ulcer disease has completely transformed the approach to the disease. Implications of this discovery for healthcare in general and for medical economics are only now being appreciated. Noninvasive and invasive methods of establishing the presence of infection are currently available, and clinical introduction of the recently approved urea breath test in the near future will add another method for documenting both active infection and successful eradication. Patients with initial presentation or recurrence of gastric or duodenal ulcer disease and those with previous disease who are receiving maintenance therapy should be treated for H pylori infection. Treatment regimens, which consist of combinations of antibiotics, bismuth salts, and proton pump inhibitors, can result in cure rates of 90%, with prevention of recurrence. Understanding of the infection continues to grow rapidly, and current recommendations regarding diagnosis and treatment will evolve as new methods are developed.

Treatment of symptomatic nonachalasia esophageal motor disorders with botulinum toxin injection at the lower esophageal sphincter.

The purpose of this study was to determine if botulinum toxin injection at the lower esophageal sphincter improves symptoms in patients with nonachalasia spastic esophageal motility disorders. Fifteen patients with nonachalasia spastic esophageal motility disorders (diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction) unresponsive to medical therapy underwent endoscopic injection of botulinum toxin at the level of the gastroesophageal junction. Symptoms were scored (0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe and 4 = very severe) before treatment, at seven days and every 30 days after treatment. There was significant improvement in chest pain, dysphagia, and regurgitation at 7,30,60 and 90 days after treatment. At one month after treatment, 11 of 15 (73%) patients had a good or excellent response to treatment. At the last patient interview (mean follow-up of 10.6 months), five (33%) patients continued to have a good to excellent response, whereas 10 (67%) underwent subsequent treatment with repeat botulinum toxin, pneumatic dilation, or bougienage. We conclude that botulinum toxin injection at the gastroesophageal junction leads to significant symptom improvement in patients with nonachalasia esophageal motility disorders. These results suggest that botulinum toxin may be an effective treatment option in some of these patients not responsive to conventional medical therapy.

Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter.

OBJECTIVES: The aim of this study was to assess the long term clinical outcome of patients with achalasia after treatment with botulinum toxin. METHODS: Sixty five patients with achalasia (60 idiopathic, five secondary) were treated with injection of botulinum toxin at the gastroesophageal junction. Dysphagia, chest pain, and regurgitation were scored (0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe, 4 = very severe), with the sum representing the total symptom score, at 0, 7, 30, 120, 240, and 365 days posttreatment. Responders were defined as patients with a 50% decrease in total symptom score at 1 month posttreatment. RESULTS: The 60 patients with idiopathic achalasia had significant improvement in symptoms of dysphagia, chest pain, and regurgitation at 1 and 4 wk posttreatment. At 1 month posttreatment, 42 of 60 patients (70%) were classified as responders. Of 33 patients with at least 1 yr follow-up, 36% continued to have a good or excellent response, whereas 39% underwent a subsequent treatment with botulinum toxin, pneumatic dilation, or myotomy. When symptoms recurred after an initial response, patients responded to a second injection of botulinum toxin in six of seven cases. In four of five patients with secondary achalasia, there was no response to botulinum toxin. CONCLUSIONS: Botulinum toxin injection at the gastroesophageal junction significantly improved symptoms in 70% of patients with idiopathic achalasia at 1 month. Recurrent symptoms responded to repeat botulinum toxin treatment in initially responsive patients. In contrast, most patients with secondary achalasia did not improve after botulinum toxin injection.

Comparison of high-resolution endoluminal sonography to video endoscopy in the detection and evaluation of esophageal varices.

High-resolution endoluminal sonography (HRES) was used to image and measure esophageal varices in control subjects and patients with portal hypertension and compared with endoscopic findings. Nine control patients and 68 patients with known cirrhosis or noncirrhotic portal hypertension underwent videotaped HRES and videotaped esophagoscopy (EGD). Two blinded investigators reviewed the videotapes to determine the presence and size of the largest esophageal varix in each patient. The largest varix by HRES was measured with the esophagus at rest at a point where the varix appeared most circular. The largest varix seen on EGD was graded on a 5-point scale. All nine of the control patients were correctly identified by both EGD and HRES as grade I (no varices). Eight of the 10 patients with no varices seen on EGD had varices identified by HRES. The interobserver correlation for HRES was r = .88 and for EGD was r = .79. The correlation between EGD and HRES was r = .50. High resolution endoluminal sonography allows quantitative measurement of variceal size, is a more sensitive and reproducible imaging modality than esophagoscopy for the detection and sizing of esophageal varices. There is poor correlation between monographic measurement and endoscopic grading of esophageal varices. Assessment of esophageal variceal presence and the measurement of variceal size by high resolution endoluminal sonography is an accurate, reproducible method of determining the size of esophageal varices.

Use of high-resolution endoscopic ultrasonography to assess esophageal wall damage after pneumatic dilation and botulinum toxin injection to treat achalasia.

OBJECTIVE: The purpose of this study was to utilize high-resolution endoscopic ultrasonography to assess esophageal wall damage in patients with achalasia treated by either pneumatic dilation or botulinum toxin injection and to compare their symptomatic response. METHODS: Twenty-nine patients were treated with pneumatic dilation (11) or botulinum toxin injection (18) in a nonrandomized, controlled manner. An achalasia balloon dilator inflated at the gastroesophageal junction was used for dilation. Botulinum toxin was injected during endoscopy into the gastroesophageal junction. Endoscopic ultrasonography was performed at the level of the diaphragm before, immediately after, and 24 hours after treatment. Symptoms were assessed before and 7, 30, 60, and 90 days after therapy. RESULTS: The mucosal-submucosal thickness increased significantly immediately after pneumatic dilation, but normalized by 24 hours. No significant change in mucosal-submucosal thickness occurred after botulinum toxin injection. No significant alteration in muscularis propria thickness was observed after either procedure. Dysphagia and regurgitation improved significantly at 7, 30, 60, and 90 days after both procedures. CONCLUSIONS: Pneumatic dilation produced transient thickening of the mucosa-submucosa, but no thickening or breaks in the muscularis propria. This transient wall damage suggestive of edema was not seen after botulinum toxin injection. Over a 3-month period, botulinum toxin was equivalent to pneumatic dilation in relieving dysphagia and regurgitation in patients with achalasia.

Nonsteroidal antiinflammatory drugs and upper gastrointestinal hemorrhage in an urban hospital.

Aspirin and nonsteroidal antiinflammatory drugs have been implicated in the pathogenesis of gastrointestinal hemorrhage. To evaluate their impact on inpatients, charts from Temple University Hospital with a discharge ICD-9 code which included upper gastrointestinal hemorrhage during a one-year period were reviewed. Aspirin and/or nonaspirin nonsteroid antiinflammatory drug (NSAID) use was identified in 34 patients (19 daily users and 15 intermittent users). Sixty-seven patients who bled, but did not use these agents, served as controls. Daily NSAID users were older than intermittent users and controls (P < 0.05). A higher frequency of bleeding ulcers was associated with NSAID use. Patients using NSAIDs spent more time in intensive care than controls (median 1 day vs 0 days). Daily users had a higher transfusion requirement (4 units) than non-users (0 units; P < 0.05). This study suggests that NSAID use has a substantial impact on health care resource utilization in patients admitted to an urban hospital for upper gastrointestinal hemorrhage.

Endoscopic evaluation of penetrating esophageal injuries.

There are few objective data evaluating the role of flexible endoscopy in the management of penetrating esophageal and neck injuries. A retrospective analysis was performed on 13 trauma patients who had undergone emergent esophagogastroduodenoscopy for the evaluation of potential esophageal injuries. Endoscopy resulted in one true positive (esophageal injury detected), 10 true negatives (normal esophagus), two false positives, and no false negatives. This yielded a sensitivity of 100% and specificity of 83%. There were no complications of endoscopy. We conclude that urgent flexible esophagogastroduodenoscopy is a useful diagnostic procedure in the evaluation of penetrating wounds possibly involving the esophagus.

A multicenter, randomized, controlled trial to evaluate the effect of prophylactic octreotide on ERCP-induced pancreatitis.

Eight-four patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were randomized to receive 100 micrograms of octreotide intravenously immediately prior to ERCP, and 100 micrograms subcutaneously 45 min after the initial dose, or placebo. Amylase, lipase, and glucose were measured and clinical assessment was performed before, and 2 and 24 h after, ERCP. We define clinical pancreatitis as the combination of elevated amylase or lipase with abdominal pain and tenderness. Interim analysis in 84 patients revealed an 11% incidence of clinical pancreatitis in the control group and 35% in the treatment group (p < 0.01). There were no differences in either group with respect to sphincterotomy, gender, age, duration of ERCP, number of cannulations of the pancreatic duct, degree of duct injection, or the volume of contrast injected. Analysis of group differences stratified by sphincterotomy revealed the following: 1) In patients who did not undergo a sphincterotomy, there was a significantly higher rate of pancreatitis in the treatment group [10/17 (59%) versus 1/17 (6%) RR 10.0 (95% CI 1.4-69.8)]. 2) Sphincterotomy reduced the rate of pancreatitis in patients who received octreotide from 10/17 (59% no sphincterotomy), to 3/20 (15% sphincterotomy) (p = 0.01), which equals the rate in patients who received placebo and underwent sphincterotomy [4/25 (16%)]. 3) Although the incidence of pancreatitis was higher in the treatment group, octreotide may reduce the severity of pancreatitis measured by the number of days NPO (Wilcoxon rank sum, p = 0.02), length of stay after ERCP (p = 0.13), the number of days of pain (p = 0.11), and the degree of amylase elevation (p = 0.04). We conclude that: 1) Octreotide appears to increase the incidence of pancreatitis when given prophylactically for diagnostic ERCP. 2) Although pancreatitis was more common in the octreotide group, it was less severe than the placebo group. 3) Sphincterotomy may afford protection against pancreatitis in patients who received octreotide. 4) We cannot recommend the use of prophylactic octreotide during diagnostic or therapeutic ERCP.