Bidirectional endoscopy in patients with fecal occult blood.

BACKGROUND: Current screening protocols for colorectal cancer depend primarily on fecal occult blood testing (FOBT). However, positive test results do not always indicate the presence of a colonic neoplasm. METHODS: We reviewed the results of 100 consecutive bidirectional (upper and lower) endoscopic procedures performed to evaluate positive FOBT results. Patients were excluded if they presented with gross bleeding, a history of bowel lesions, or previous intestinal operations. There were 31 women and 69 men whose mean age was 51 years. RESULTS: Major abnormalities were found on esophagogastroduodenoscopy (n = 24), colonoscopy (n = 13), or both studies (n = 2). Active bleeding was manifested in two patients, (Barrett's ulcer, duodenal arteriovenous malformation). Two other patients had malignancy: One had a cecal adenocarcinoma and the other a gastric adenocarcinoma. Various benign lesions also were identified in the stomach including esophagitis (n = 8), ulcers/erosions (n = 8) varices (n = 5), and arteriovenous malformations (n = 2). Colonic pathology included polyps (n = 8), arteriovenous malformations (n = 3), and rectal varices (n = 1). Diverticulosis and hemorrhoidal disease were present in 29 and 16 patients, respectively, but were not considered to be likely sources of a positive FOBT. CONCLUSION: Positive FOBT results may indicate the presence of either upper or lower intestinal pathology, and bidirectional endoscopy is an efficient and accurate technique for the comprehensive evaluation of occult bleeding.

Jejunoileal causes of overt gastrointestinal bleeding: diagnosis, management, and outcome.

Major bleeding from the small intestine is uncommon and difficult to localize. We examined its etiologies and assessed available diagnostic and therapeutic approaches. The records of all adults undergoing operation for small intestinal hemorrhage over a 10-year period (1/89-12/98) were reviewed. There were eight men and four women with a mean age of 54 years. Six patients presented with arteriovenous malformations. Preoperative diagnosis was by endoscopy (three of six), scintigraphy (two of two), and/or angiography (two of six). Intraoperative panendoscopy was used for localization in 5 cases. Three other patients had tumors (leiomyoma, leiomyosarcoma, and adenocarcinoma) by CT scan (two) and/or scintigraphy (two). All were resected but one patient died of recurrence. Two patients underwent resection of a Meckel's diverticulum, one after angiographic diagnosis. Another patient with Crohn's disease had a positive angiogram and colonoscopy before resection. There were no operative deaths but major morbidity occurred in five patients (42%) and hospitalization averaged 17 days. We conclude that jejunoileal lesions are a rare cause of intestinal bleeding but can be associated with substantial morbidity. Arteriovenous malformations and tumors remain the most common causes. An accurate diagnosis and definitive management depend on selective preoperative imaging and judicious operative exploration.

Operations for peptic ulcer disease: paradigm lost.

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.

Operative management of diverticular emergencies: strategies and outcomes.

HYPOTHESIS: A selective surgical approach using either a 1- or a 2-stage resection is relatively safe and effective in the management of acute complicated colonic diverticulosis. DESIGN: A consecutive cohort study. SETTING: A university hospital. PATIENTS: Eighty-nine consecutive patients who underwent emergency operations for diverticular disease between July 1, 1984, and June 30, 1999. There were 53 male and 36 female patients (mean age, 47 years). The ethnic background was predominantly Mexican American (58 patients [65.2%]). INTERVENTIONS: Resections of the affected colon (n = 83) plus construction of a Hartmann pouch or mucous fistula (n = 72) or primary anastomosis (n = 11). MAIN OUTCOME MEASURES: Morbidity, mortality, and length of hospital stay. RESULTS: Sixty-eight operations were performed for perforation at an annual rate that has increased greater than 75% in the past 15 years. Another 14 patients underwent operations for obstruction, and 7 underwent operations to control unremitting hemorrhage. Surgical therapy included resection of the affected segment of the bowel in 83 (93%) of the 89 patients, and a Hartmann pouch or mucous fistula was added in 72 (81%). A primary anastomosis was performed in 4 (80%) of 5 right-sided lesions but in only 7 (8%) of 84 left-sided lesions. Morbidity occurred in 38 (43%) of the 89 patients, and the mortality was 4%, with 4 deaths occurring secondary to sepsis in high-risk patients with perforations (n = 3) or obstructions (n = 1). The average length of hospital stay was 19.7 days (range, 5-80 days). CONCLUSIONS: Emergency operations for diverticular disease are uncommon but may be associated with substantial morbidity and occasional mortality. Complicated diverticulosis may present at a relatively young age, and perforated forms appear to be increasing rapidly in prevalence. Most diverticular lesions can be satisfactorily managed using a selective approach based on resection with either a primary anastomosis or a temporary colostomy.

Percutaneous endoscopic gastrostomy tube placement in a surgical training program.

BACKGROUND: This study examines the patterns of use of percutaneous endoscopic gastrostomy (PEG) and primary open gastrostomy (Gtube) performed in a residency training program in surgery. METHODS: A retrospective cohort study that assesses the indications and outcomes of 317 PEGs and 75 isolated Gtubes used for gastric access between 1987 and 1997. RESULTS: The demographics and risk factors of the patients receiving Gtube and PEG were comparable. The mean number of PEGs performed per resident is currently 13 per year (mean 5 over 10 years) with a 97% PEG success rate; an 88% success rate is demonstrated for placement of jejunal extensions. CONCLUSIONS: PEGs are generally preferable to Gtubes as primary procedures. Surgical residents should become competent in PEG placement by performing adequate numbers of procedures with fully trained staff.

Prostaglandin E1 enhances tumoricidal activity of 5-fluoro-2'-deoxyuridine in rats.

Addition of prostaglandin E1 (PGE1) to 5-fluoro-2'-deoxyuridine (FUDR) infused via the portal vein has been shown to diminish both the regional and the systemic toxicity of this chemotherapeutic agent. The effect of concomitant PGE1 infusion on tumor growth has not yet been determined. This study was designed to assess the effect of PGE1 in combination with FUDR on an established adenocarcinoma in the rat model. Fifty-gram Fischer rats underwent placement of a 3-mm3 fragment of colon carcinoma 4047 in the left thigh pad. After 6 weeks to allow for tumor growth, the animals were randomly assigned to receive a 7-day intravenous infusion of (1) saline, (2) PGE1 (0.1 microgram/kg/min), (3) FUDR (3 mg/kg/day), or (4) PGE1 + FUDR. At 10 days animals receiving PGE1 + FUDR had a significant decrease in tumor volume (mm3, log 10) (3.39 +/- 0.24 vs 3.85 +/- 0.12, P less than 0.05) compared with animals receiving FUDR alone. We conclude that PGE1 may be useful as an adjunctive cytotoxic agent.

Carcinoma of the pancreas: a retrospective review.

Eighty-five patients with adenocarcinoma of the pancreas were reviewed in order to evaluate the efficacy of our methods of diagnosis and treatment. The most useful diagnostic test was percutaneous transhepatic cholangiography (PTC) with a diagnostic rate of 96%. Pancreaticoduodenectomy (Whipple procedure) and total pancreatic resection were performed in 13 and 2 patients, respectively. The remaining 50 patients underwent various palliative drainage procedures. Twenty patients did not undergo operation for various reasons. The primary tumor was found in the head of the pancreas in 50 patients (59%), the body in 6 patients (7%), and in the tail in 8 patients (9%). Postoperative complications, including sepsis, bleeding, intra-abdominal abscesses, and anastomotic leaks, occurred in 37% of the patients. There were one operative and 9 postoperative deaths. The average survival for those patients undergoing surgical intervention was 6 months. There were no 5-year survivors.

Portal infusion of tumor necrosis factor increases mortality in rats.

Tumor necrosis factor (TNF) is a protein found in the serum of mice presensitized with BCG following injection of endotoxin. Although TNF has been shown to cause hemorrhagic necrosis of certain tumors, the marked toxicity of recombinant human TNF has limited the clinical usefulness of this compound. This experiment was designed to determine whether hepatic metabolism would reduce the systemic toxicity of TNF delivered by the portal circulation. Twenty male Fischer rats received a continuous infusion of recombinant human TNF (100 micrograms/kg/day), 10 through a portal venous branch, and 10 through a branch of the inferior vena cava. Control animals received an infusion of carrier solution by the same route. After 7 days the animals were sacrificed and their organs weighed and sectioned. Mortality in the portal TNF group was 100%. The animals followed the clinical pattern seen with lethal TNF injection. Histologic sections revealed significant gastric and small intestinal mucosal injury, pulmonary edema, and acute tubular necrosis. Animals receiving TNF systemically lost more weight per day of infusion than controls, but followed a relatively benign course. Systemically infused animals had evidence of mild pulmonary edema, and a periportal mononuclear infiltrate in the liver, but no obvious renal or gastrointestinal injury. In a second experiment the effect of escalating doses of portal TNF infusion on liver enzymes was assessed. TNF was infused intraportally at 10, 50, or 100 micrograms/kg/day for 3 days. Control animals received a carrier solution. Mortality was dose-related with 100% mortality in animals receiving 100 micrograms/kg/day, and 40% mortality in the 50 micrograms/kg/day group.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunocytochemical analysis of estrogen receptors in human breast carcinomas. Evaluation of 130 cases and review of the literature regarding concordance with biochemical assay and clinical relevance.

An estrogen receptor-immunocytochemical assay (ER-ICA) was performed on frozen sections of 130 samples of human breast carcinoma. A standard dextran-coated charcoal assay (DCCA) was performed on the same samples. Concordance of results between the tests was 91%. The sensitivity and specificity of the ER-ICA, compared with the DCCA, were 92% and 89%, respectively. We describe the ER-ICA technique and review the literature regarding the use of the ER-ICA in evaluating breast cancer with respect to the agreement of results with the DCCA, the nature of discordant results, the ability to predict the clinical response to hormone therapy, and the ability to predict disease-free survival. The combined experience of many studies has shown that the ER-ICA is a highly specific and sensitive method for measuring the level of ERs in breast tumors with a high level of agreement with the DCCA. Early experience has suggested that the ER-ICA can predict the response to hormone therapy and disease-free survival, as well as or better than the DCCA. The evaluation of receptor heterogeneity, made possible by the ER-ICA, may enhance our ability to discriminate ER-positive tumors with a relatively high risk of recurrence.

Great expectations: stress and the medical family. 1987 Committee on Issues, Association for Academic Surgery.

The high divorce rate and significant stress experienced by families of academic surgeons stimulated the Committee on Issues of the Association of Academic Surgery to choose medical family stress as the topic for the 1987 Committee presentation at the annual meeting. The Committee hoped to provide insight into the cause of this stress and new strategies for coping with this pervasive problem. Forty-three percent of the 505 surgeons who entered the Association from 1981 through 1984 and 38% of their spouses responded to a questionnaire covering issues of time management, response to stress, child rearing, financial security, and spouse career. A panel consisting of Shirley P. Levine, M.D., Hiram C. Polk, Jr., M.D., and Lane A. Gerber, Ph.D., after discussing the questionnaire results, recommended realistic goal setting, specific prioritization of activities, recognition of the considerable contributions of the spouse, and insight into personal limitations as mechanisms for improving family function.

Single-dose cefmetazole versus multiple dose cefoxitin for prophylaxis in abdominal surgery.

One hundred and ninety-five patients undergoing abdominal surgical procedures completed a multicentre, randomized, open-label study comparing the safety and efficacy of cefmetazole and cefoxitin for the prevention of postoperative wound infection. Cefmetazole was administered iv in a single 2 g dose given within 90 min of the operation. Cefoxitin was administered in a single 2 g, similarly timed, preoperative dose and two additional doses given at 6 h intervals after surgery. For operations that exceeded 2-4 h duration an additional dose of each agent was administered. Patients undergoing colorectal operations received oral neomycin and erythromycin as bowel preparation. Colorectal operations were performed most frequently (49% of patients) followed by cholecystectomies (26%) and gastroduodenal procedures (21%). The operative site infection rate was 6.5% for cefmetazole and 7.7% for cefoxitin (P greater than 0.05). Serious drug related adverse effects were not observed. This study demonstrates that administration of single-dose cefmetazole is as effective as a standard three dose regimen of cefoxitin for prophylaxis with abdominal operations.

A randomized prospective study of antibiotic prophylaxis during abdominal surgery.

The safety and efficacy of intravenous cefmetazole for prophylaxis before abdominal operations were compared with those of intravenous cefoxitin in a randomized, prospective clinical study. Eighty-nine evaluable patients were enrolled. These patients underwent primarily clean/contaminated (56%) and contaminated (39%) operations. A total of three (3%) patients developed postoperative wound infections. Two patients (2%) developed non-life-threatening adverse drug reactions. There were no life-threatening adverse drug reactions. There were no significant differences between the cefmetazole and cefoxitin study groups. Cefmetazole appears to be as safe and as efficacious as cefoxitin antibiotic in prophylaxis for intra-abdominal operations.

Needle aspiration biopsy of palpable breast masses.

One hundred fifteen patients underwent needle aspiration biopsy of palpable breast masses prior to open biopsy. Aspirates were obtained by surgical residents, prepared by a cytotechnologist present at the procedure, and evaluated by a single pathologist. Cytologic findings were interpreted as positive or highly suspicious for malignancy, normal or benign, or insufficient. All patients underwent open biopsy. Patients with positive or highly suspicious cytologic findings who preferred partial mastectomy and radiotherapy were offered a segmental mastectomy. No patient was offered total mastectomy based on cytologic findings alone. There were two false-positive and two false-negative results, for a 92 percent sensitivity and 97 percent specificity. The value of needle aspiration biopsy lies in its ability to identify patients at high risk for malignancy. Total mastectomy cannot be recommended based on cytologic findings alone. The setting of a surgical residency program does not adversely affect the reliability of the technique.

Continuous infusion of tumor necrosis factor: mechanisms of toxicity in the rat.

UNLABELLED: This study was designed to assess the toxicity of continuous infusion of tumor necrosis factor (TNF) in the rat model. The effect of TNF on cell membranes was assessed by diffusion of radiolabeled inulin (RI). The effect of concomitant administration of the cytoprotectant prostaglandin E1 (PGE1) was also assessed. Eighty rats were anesthetized and two osmotic pumps were implanted in the peritoneal cavity of each rat. One pump contained either TNF (0.1 mg/kg/day) or vehicle and the other either PGE1 (0.1 mcg/kg/min) or vehicle. Four groups resulted: vehicle alone, PGE1 alone, TNF alone, and TNF + PGE1. After 5 days, half of each group received intravenous RI and organ/blood radioactivity ratios were compared at sacrifice 7 min later. Remaining animals had serum drawn for CBC and electrolyte determination. Organ weights were determined in all animals. The effects of TNF and PGE1 were assessed by two-way ANOVA. Mortality in animals infused with TNF was 20%. One animal in the control group died. TNF infusion increased lung weight by 38% (697 +/- 49 vs 937 +/- 77 mg; P less than 0.05). Liver weight was also increased in animals infused with TNF (6.7 +/- 0.2 vs 7.0 +/- 0.3 g; P less than 0.05). TNF infusion increased blood urea nitrogen and decreased serum bicarbonate compared to controls. TNF had no effect on RI diffusion. PGE1 did not alter the response to TNF. CONCLUSIONS: Continuous infusion of TNF does not affect membrane permeability as assessed by inulin diffusion. PGE1 does not cytoprotect against the toxicity of TNF. Evidence of direct hepatic toxicity suggests that regional therapy via the hepatic artery or portal vein is contraindicated.

Intraportal prostaglandin E1 ameliorates the toxicity of intraportal 2'-deoxy-5-fluorouridine in rats.

This study was designed to see whether intraportal infusion with prostaglandin E1 (PGE1) could reduce mortality associated with high-dose intraportal infusion of 2'-deoxy-5-fluorouridine (FUDR). Thirty anesthetized male Sprague-Dawley rats underwent laparotomy and placement of osmotic pumps (Alzet 2ML1) infusing a branch of the portal vein. Animals were weighed and infused for 1 week with buffer (control), FUDR (3 mg/kg/day), or FUDR (3 mg/kg/day) + PGE1 (0.1 microgram/kg/min). Blood was then obtained for liver functions and white blood cell count. The body and liver were weighed. No animals died in the control group. Five animals in the FUDR group died during the fourth (n = 1), sixth (n = 2), and seventh (n = 2) days of infusion. Only one animal in FUDR + PGE1 group died during the sixth day of infusion. Weight loss was greater in both treated groups than in controls. Animals receiving PGE1 lost significantly less weight than animals receiving FUDR alone. These data suggest that intraportal PGE1 ameliorates the hepatic toxicity of intraportal FUDR. The effect of PGE1 on the tumoricidal properties of FUDR infused by either the portal vein or the hepatic artery remains to be studied.

Assessment of gastric mucosal ulceration by computerized image processing.

The absence of a rapid, objective, and reproducible method for assessing mucosal ulceration has long been a frustration to research in the field of gastric physiology. This study compared assessment of mucosal injury by computerized image processing with values obtained by the shed microsphere technique. An ex vivo gastric chamber model based on miniature swine was used. Five chambers were subjected to hemorrhagic shock and acid-bile solution and five chambers were maintained in normotension and exposed to normal saline (controls). After 3 hr, mucosal injury was assessed by both techniques. The chambers exposed to shock and acid-bile all developed visible ulceration ranging from 1.8 to 99.7 cm2 by computerized image processing. These values correlated well with the results obtained by the shed microsphere technique (23 to 419 mg, r = 0.99, P less than .05). No ulceration developed in the control chambers. Implementation of computerized image processing as well as its limitations is discussed.

Evaluation of gastric adenocarcinoma. Abdominal computed tomography does not replace celiotomy.

Computed tomography (CT) has been suggested as an alternative to celiotomy for predicting the stage and resectability of gastric carcinoma. Since it is the policy at our institution to explore all patients regardless of CT findings, this experience was reviewed to see if changes were warranted. Thirty-seven patients with gastric adenocarcinoma underwent preoperative CT scanning. The extent of disease found after operation was compared with the CT assessment. Nineteen patients (51%) were found to have more extensive disease than was predicted by CT. Of the six patients predicted to have widespread disease by CT, three (50%) were found at operation to have disease confined to the stomach or regional nodes. These data support a continued role for celiotomy in managing gastric adenocarcinoma of the stomach since a significant percentage of patients whose disease is believed to be unresectable after CT have potentially curable lesions.

Evaluation of nonpalpable breast lesions. Experience in a training institution.

Biopsy directed by needle localization is a safe and relatively simple method of obtaining abnormal tissue for histologic examination without sacrificing surrounding normal breast tissue. In the setting of a training institution, accurate results can be expected as technical skills are obtained by a variety of housestaff. In this series of 70 biopsies, the lesion targeted on mammography was removed on the initial attempt in all but 1 instance, for an overall accuracy of 99 percent.

Pharmacologic analysis of the ip administration of fludarabine phosphate in the swine.

Fludarabine phosphate, an investigational water-soluble adenosine analog, was administered ip to five miniature swine at doses of 10, 16, and 25 mg/m2. Blood and peritoneal fluid samples were collected for 4 hours following drug administration and were submitted to high-performance liquid chromatographic analysis for the concentrations of the dephosphorylated derivative, 2-fluoro-ara-A. Peak peritoneal fluid concentrations of 2-fluoro-ara-A ranged from 7.72 to 18.01 micrograms/ml at the doses tested; peritoneal fluid areas-under-the-curve (AUCs) ranged from 19.23 to 47.33 micrograms X hour/ml. The peak serum concentrations of 2-fluoro-ara-A ranged from 0.15 to 0.46 micrograms/ml; serum AUCs ranged from 0.51 to 1.2 micrograms X hour/ml. The ip administration of fludarabine phosphate results in a 28-62-fold peak peritoneal concentration advantage over peak serum concentrations and a 20-53-fold advantage for peritoneal over serum AUCs. Comparison of data generated in this swine study to data from pilot studies of the ip administration of fludarabine phosphate in humans will be of interest.

Civilian vascular trauma of the upper extremity.

One hundred forty-three patients with 163 upper extremity vascular injuries were reviewed. Penetrating trauma accounted for 94% of the injuries and blunt trauma for 6%. Absent pulses are not a completely reliable sign of upper extremity arterial injury. The most frequently injured upper extremity vessel is the brachial artery, followed in decreasing frequency by ulnar, radial, and axillary arterial injuries and axillary venous injuries. The most common technique of vascular repair was end-to-end anastomosis, followed by vein graft interposition. No amputations were required. Despite excellent results of vascular reconstruction, functional impairment due to associated nerve injuries was a distressingly predominant finding.