Surgical lateral clearance in resected rectal carcinomas. A multivariate analysis of clinicopathologic features.

BACKGROUND: Incomplete removal of the tumor is the main cause of local recurrence in rectal carcinomas; this often occurs at the lateral aspects devoid of the peritoneum. The authors examined prospectively 80 resected rectal carcinoma specimens in an attempt to discover a reliable method to detect lateral resection margin (LRM) involvement by these tumors and to identify pathologic factors that would be prognostically important. METHODS: In each of the 80 resected specimens, the whole tumor was embedded, and whole-mount sections of the entire tumor and the surrounding mesorectum were examined after serial transverse slicing. The distance from the outermost part of the tumor to the LRM (surgical clearance) was measured. RESULTS: Six (7.5%) of the 80 specimens showed LRM involvement (defined as surgical clearance < or = 1 mm) in the single slice seen macroscopically to have the deepest tumor invasion, whereas 16 specimens (20%) were found to have LRM involved after examining all slices microscopically. Surgically clearance had a strong inverse relationship with Dukes staging (P < 0.001) and depth of tumor invasion (P = 0.001). The overall local recurrence rate was 28%; it was much higher (53%) in the patients who had LRM involved by tumor. As a whole, local recurrence was related significantly to LRM involvement (P = 0.006). Survival rates were correlated with macroscopic (n = 3) and microscopic (n = 13) features of the resected specimens using Cox multivariate regression analysis. Three of the nine pathologic parameters isolated (i.e., surgical clearance, cellular differentiation, and number of involved pericolic lymph nodes) were identified as favorable independent prognostic factors. CONCLUSIONS: Local recurrence is related closely to LRM involvement. Embedding and examining the entire tumor and mesorectum is the only reliable and satisfactory means of assessing LRM. Detailed pathologic study on the resected tumor is important when assessing the prognosis.

Bleeding angiodysplasia of the gastrointestinal tract.

Bleeding angiodysplasia of the gastrointestinal tract poses frustrating challenges to clinicians because these minute vascular lesions are difficult to diagnose pre-operatively and to locate intra-operatively. During the past 12 years, 24 patients were treated for histopathologically confirmed bleeding angiodysplasia of the gastrointestinal tract. Pre-operative investigations and intra-operative localization followed a fixed protocol for patients with gastrointestinal bleeding of obscure origin. The median follow-up of these 24 patients was 51 months and the results of treatment for 22 patients were excellent. Two patients had recurrent bleeding but investigations failed to determine the bleeding source.

Obscure bleeding in the gastrointestinal tract originating in the small intestine.

In the past 12 years, we operated upon 49 patients with bleeding lesions of the small intestine. After endoscopic examination and barium studies of the upper and lower gastrointestinal tract excluded esophagogastroduodenal and lesions of the colon and rectum, preoperative examinations consisted of technetium-99m pertechnetate scan, technetium-99m labeled erythrocyte scan, barium studies of the small intestine and selective visceral angiogram. In one patient, diagnostic laparotomy had to be done before any procedure because of severe bleeding and angiosarcoma of the ileum. The results of gross examination at operation revealed bleeding lesions in 40 patients. Special intraoperative localization procedures consisting of methylene blue injection through superselectively prepositioned angiographic catheter was done on eight patients, and intraoperative enteroscopy was done on 17 patients. These two procedures were complementary, having their own indications and limitations. Our regimen of preoperative and intraoperative localization procedures was effective in the management of bleeding small intestinal lesions.

Operative choledochoscopy in patients with acute cholangitis: a prospective, randomized study.

A prospective, randomized evaluation of operative choledochoscopy was carried out during emergency surgery in patients with acute cholangitis or acute suppurative cholangitis when conservative management had failed. After common bile duct exploration, 79 patients were randomized to have choledochoscopy and 78 patients to the control group. Laboratory and clinical parameters showed that choledochoscopy did not increase the incidence of septicaemia, acute pancreatitis, persistent cholangitis, postoperative wound sepsis, intraperitoneal sepsis and hospital mortality. The incidence of retained common bile duct stones detected by T tube cholangiography performed in the second postoperative week was significantly reduced (P less than 0.01) after choledochoscopy. Choledochoscopy detected stones missed by conventional common bile duct exploration in ten patients. It is concluded that choledochoscopy is a safe and effective technique in patients with acute cholangitis and acute suppurative cholangitis.

Reducing meal-stimulated acid secretion versus reducing nocturnal acid secretion for healing of duodenal ulcer.

Both meal-stimulated and nocturnal acid secretions have been shown to be abnormally increased in patients with duodenal ulcer. The relative efficacy of an acid-reducing regimen aimed specifically at controlling postprandial acid secretion compared with one that controls nocturnal acid secretion is, however, not known. The endoscopic healing rates at weeks 2, 4, 6, 8, 10, and 12 of three cimetidine regimens with identical total daily dose--bedtime (1200 mg), mealtime (400 mg three times a day with meals), and reference (200 mg three times a day with meals and 600 mg at bedtime)--were compared in a randomized study on 141 patients with endoscopically proven duodenal ulcer. Evaluating endoscopists were blinded to patients' form and duration of treatment and their clinical progress; patients were unaware of the comparative design of the study. Life-table analysis for the 12 weeks of observation revealed that the mealtime regimen resulted in significantly (P less than 0.05) better healing rates than either the bedtime or the reference regimen. The differences were accounted for largely by the significantly (P less than 0.04) better healing rate at two weeks with the mealtime regimen (68%) than with either the bedtime (47%) or the reference (45%) regimen. These findings indicate that a regimen that aims at controlling meal-stimulated acid secretion achieves a faster healing rate than one that aims at controlling nocturnal acid secretion in the treatment of duodenal ulcer, and they suggest that postprandial acid secretion plays a greater role than nocturnal acid secretion in the pathophysiology of this condition.

Omeprazole and ranitidine in duodenal ulcer healing and subsequent relapse: a randomized double-blind study with weekly endoscopic assessment.

To investigate the efficacy of standard and low dosage of omeprazole in the healing of duodenal ulcer, 270 patients with endoscopically active duodenal ulcer were randomized to receive omeprazole, 10 mg or 20 mg every morning, or ranitidine, 150 mg twice daily, using the double-dummy technique. Forty-six potential prognostic factors for healing including clinical, acid-secretory, and endoscopic characteristics were prospectively obtained and healing was assessed by endoscopy at weekly intervals for up to 4 weeks. The cumulative healing rates in the 4 weeks were 43%, 77%, 94% and 95% for omeprazole, 10 mg (n = 83); 49%, 86%, 93%, and 96% for omeprazole, 20 mg (n = 87); and 29%, 63%, 83% and 93% for ranitidine (n = 84), respectively. Life-table analysis showed P less than 0.03 for omeprazole, 10 mg versus ranitidine and P less than 0.002 for omeprazole, 20 mg versus ranitidine. Life-table analysis also showed that in the omeprazole groups, healing rates were lower in smokers than in non-smokers (P less than 0.001), in late- than in early-onset patients (symptoms starting after or before the age of 30 years, respectively, P less than 0.02), in those with less than 5 months than in those with more than 5 months of remission (P less than 0.05), and in those with increased maximal acid output than in those with normal output (P less than 0.05). Patients with healed ulcer were interviewed at 2-month intervals and endoscoped at 4-month intervals or whenever symptoms recurred. The cumulative ulcer relapse rates in 1 year were not significantly different between omeprazole and ranitidine groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylactic antibiotics in elective colorectal surgery.

A randomized prospective study was conducted on 194 patients who underwent elective colorectal surgery for carcinoma. All patients received the same mechanical bowel preparation. In addition, patients in group A received oral neomycin and erythromycin base; patients in group B received systemic metronidazole and gentamicin, while patients in group C received both oral and systemic antibiotics. Postoperative septic complications related to colorectal surgery occurred in 27.4 per cent, 11.9 per cent and 12.3 per cent respectively in groups A, B and C (chi 2 = 7; P less than 0.05). The incidence of sepsis in groups B and C was almost identical. Patients who received oral antibiotics alone (group A) had significantly higher risks of postoperative sepsis when compared with patients in either group B or group C (P less than 0.05). As there is no additional advantage of combining oral and systemic antibiotics, we recommend systemic metronidazole and gentamicin to be used with mechanical bowel preparation in elective colorectal surgery.

Healing of esophageal fistulas after surgical treatment for carcinoma of the esophagus and the upper part of the stomach.

In a series of 132 patients who had undergone surgical treatment for carcinoma of the esophagus and upper part of the stomach, anastomotic leakage occurred in 29. We retrospectively studied the factors that could influence the healing of the fistulas in the management of this condition. Despite adequate supportive treatment, including total parenteral nutrition, five patients died from unrelenting infection. Fifteen fistulas closed spontaneously after an average of about four weeks of conservative treatment and full nutritional therapy. Those patients who had persistent fistulas after similar treatment were found to have either residual tumor after palliative operation or preoperative serum albumin levels that were lower than those of the other group. Prolonged conservative treatment for persistent fistulas may not be warranted if such risk factors are identified, and surgical repair should be considered.

Limitations and dangers of gastrografin swallow after esophageal and upper gastric operations.

In a series of 135 patients who underwent esophageal and upper stomach surgery, the incidence of anastomotic leakage was 20.4 percent. One hundred four patients had either Gastrografin swallow or the methylene blue test to evaluate anastomotic integrity before resumption of oral feeding. Both tests were disappointing in that methylene blue failed to detect any case of leakage and Gastrografin swallow could only detect three cases of subclinical leakage. The high false-negative detection rate of Gastrografin swallow might be related to the inferior radiographic detail provided by this contrast medium. Aspiration of Gastrografin is potentially dangerous and could be fatal. We believe that barium sulfate, which provides better radiographic detail and is not so hazardous when aspirated, should be the contrast medium of choice.

Optimal irrigation pressures in operative choledochoscopy.

A prospective study was conducted on 20 consecutive patients who underwent elective exploration of common bile-ducts for stones to determine the optimal irrigation pressures in choledochoscopy. Ten patients had rigid choledochoscopy and 10 patients had flexible choledochoscopy. Choledochoscopic views were assessed at low irrigation pressure (irrigant delivered at hydrostatic pressure of 1 m of water or 80 mmHg) and high irrigation pressure (irrigant delivered at cuff pressure of 300 mmHg plus hydrostatic pressure of 80 mmHg). Choledochoscopic views were better with high than low irrigation pressures for rigid choledochoscopy. However, there was little difference in the views for flexible choledochoscopy. Common bile-duct pressures were measured with irrigant delivered at pressures 80-380 mmHg at intervals of 50 mmHg. With increasing irrigation pressures, the common duct pressures rose and they were consistently higher in flexible than rigid choledochoscopy. The common duct pressures in rigid choledochoscopy never exceeded the recommended safety limit, even at the high irrigation pressure of 380 mmHg. With flexible choledochoscopy, the common duct pressure was below the recommended safety limit only with low irrigation pressure of 80 mmHg. Therefore, it is recommended that a high irrigation pressure of 380 mmHg for rigid choledochoscopy and a low irrigation pressure of 80 mmHg for flexible choledochoscopy be used.

A scientific evaluation of operative choledochoscopy in acute cholangitis.

A prospective study to determine the safety and effectiveness of choledochoscopy in acute cholangitis and acute suppurative cholangitis due to common bile duct stones was conducted on 70 patients. Common bile duct pressures determined on the first 20 patients showed that choledochoscopy was unlikely to cause cholangiovenous reflux. Laboratory and clinical parameters revealed that choledochoscopy did not cause septicemia, worsen cholangitis, or provoke acute pancreatitis. There was no iatrogenic injury during choledochoscopy, and the choledochoscopic views were minimally affected by cholangitis. Choledochoscopy detected overlooked stones after conventional methods of exploration of common bile ducts in 14.3% of patients and it helped to remove impacted stones in 2.9% of patients. As a result, the incidence of retained stones after choledochoscopy was 1.4%. Time spent in choledochoscopy was short, and the total postoperative septic complication rate was only 10%. There was no operative mortality. It is concluded that choledochoscopy is safe and effective in cholangitis.

Preoperative and intraoperative localisation of gastrointestinal bleeding of obscure origin.

In the past six years, 37 patients with gastrointestinal bleeding of obscure origin had their bleeding sites localised preoperatively or intraoperatively. Preoperative investigations followed a regime consisting of endoscopy, barium meal and follow through, small bowel enema, 99mTc pertechnetate scan, 99mTc-labelled red blood cell scan and selective coeliac and mesenteric angiography. Bleeding lesions were localised preoperatively in 36 patients. In one patient, diagnostic laparotomy had to be carried out immediately before any investigation because the bleeding was severe. At operation, angiosarcoma of ileum was found. Unless preoperative investigations showed the lesions to be in anatomically fixed organs like the duodenum or colon, the lesions had still to be found at operation. Palpation and transillumination detected the lesion intraoperatively in 21 patients while only some lesions were found in three patients with multiple lesions. Sigmoidoscopy through enterotomies was required in one patient. Intraoperative enteroscopy was done for small lesions not found grossly at operation in nine patients, to detect additional lesions in three patients or to rule out suspicious lesion shown on preoperative tests in one patient. In another patient with diffuse lymphoma of small bowel with bleeding from only a small segment of jejunum, injection of methylene blue intraoperatively through a previously placed angiographic catheter stained the bleeding segment of jejunum blue. This segment was identified easily and resected. These preoperative and intraoperative localisation procedures were simple and effective and we recommend them to be used more freely.

Sucralfate overcomes adverse effect of cigarette smoking on duodenal ulcer healing and prolongs subsequent remission.

A unicenter, single-blind, randomized study was conducted on 283 patients with active duodenal ulcer to compare possible factors that may affect healing and relapse in patients treated with a potent antisecretory agent, cimetidine, or a site-protective and cytoprotective agent, sucralfate. The endoscopic healing rates at 4 wk were 76% and 79%, respectively, and cross-over treatment of the failures for a further 4 wk resulted in 68% healing with cimetidine and 69% healing with sucralfate, both differences being not statistically different. Unlike cimetidine, healing by sucralfate was unaffected by cigarette smoking, reluctance to give up smoking, habitual use of alcohol, high maximal acid output, and large ulcer diameter. In particular, the healing rate of smokers treated with sucralfate (82%) was significantly greater than that of smokers treated with cimetidine (63%). Duodenal bulb deformity significantly affected healing in both groups, and was the only offsetting factor identifiable for sucralfate out of 46 factors examined. Of the patients with healed ulcers, 238 participated in a 24-mo follow-up study consisting of interviews at 2-mo intervals and endoscopy at 4-mo intervals or whenever symptoms recurred. The cumulative relapse rate was significantly (p less than 0.007) greater in patients healed with cimetidine than with sucralfate, 50% relapse occurring at 6 and 12 mo, respectively. In both, the cumulative relapse rate was significantly greater in cigarette smokers than in nonsmokers, but smokers and nonsmokers treated with cimetidine relapsed (50% at 4 and 8 mo, respectively) faster than the corresponding smokers and nonsmokers treated with sucralfate (50% at 8 and 18 mo, respectively). Furthermore, in cimetidine- but not sucralfate-healed patients, early ulcer relapse (within 6 mo) was associated with short duration of illness, short remission period, long symptomatic spell, and reluctance to give up smoking. We conclude that smoking adversely affects duodenal ulcer healing by cimetidine and hastens subsequent relapse, and that sucralfate overcomes the adverse effect of smoking on healing as encountered with cimetidine, and results in a subsequent remission period double that of cimetidine.

Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery.

In a series of 102 patients with cancer of the oesophagus or gastric cardia in whom surgery had been performed, postoperative respiratory infection, respiratory failure and mortality secondary to respiratory complication occurred in 55.8, 34.3 and 21.6 per cent respectively. The incidence of complications correlated well with the pre-operative peak expiratory flow rate when it was less than 65 per cent of the predicted normal value. However, the predictive ability of peak expiratory flow rate was much less than the patient's age, pre-operative serum albumin level, pre-operative Pa,O2 and number of surgical wounds when all risk factors were considered. Significantly more complications occurred when the patient was greater than 65 years old, Pa,O2 was less than 10 kPa, serum albumin was less than 39 g/l and when the operation required three incisions. These findings may serve as guidelines for identification of high-risk patients in the future.

Sucralfate versus cimetidine in duodenal ulcer--factors affecting healing and relapse.

An understanding of the factors affecting duodenal ulcer healing by different pharmacological agents should give some insight into the underlying pathophysiology of healing.

Conventional vs. triple rubber band ligation for hemorrhoids. A prospective, randomized trial.

Two hundred five patients with symptomatic first- and second-degree hemorrhoids were randomized to receive either conventional rubber band ligation or triple rubber band ligation. In conventional rubber band ligation, the hemorrhoids were ligated at one primary site per session at intervals of four weeks until symptoms were relieved or when all three hemorrhoids were ligated. In triple rubber band ligation, all three primary hemorrhoids were ligated in a single session. After completion of treatment, the patients were examined every three months, or earlier if symptoms recurred. Both methods were effective in the treatment of early hemorrhoids and the incidence of postligation pain and complications was similar. The advantages of having the treatment completed at the initial visit in triple rubber band ligation are obvious. Furthermore, less treatment sessions were required for triple rubber band ligation to control symptoms than for conventional rubber band ligation. Triple rubber band ligation is more cost-effective and therefore is recommended.

Chronic antral gastritis in duodenal ulcer. Natural history and treatment with prostaglandin E1.

The natural history of chronic antral gastritis in relation to the healing of duodenal ulcer and its response to treatment, if any, are unknown. We performed a double-blind controlled trial using an oral prostaglandin E1, misoprostol, in 229 patients with active duodenal ulcer randomized to receive placebo (n = 76), misoprostol 200 micrograms (n = 77), or misoprostol 300 micrograms (n = 76), q.i.d. orally. Healing of duodenal ulcer was assessed biweekly up to 12 wk by endoscopy, during which procedures at least two antral and two fundal biopsy specimens were taken. The activity and the degree of chronic inflammation of gastritis, as assessed histologically by the infiltration of polymorphs and chronic inflammatory cells, respectively, was graded blindly by two pathologists as nil, mild, moderate, or severe. Before treatment, 99% of patients had chronic antral gastritis and 1.5% had chronic fundal gastritis. In the placebo group, healed duodenal ulcer was associated with significantly (p less than 0.01, life table analysis) higher incidence of improvement of the activity of the antral gastritis (nil or mild as endpoint) than unhealed ulcer (30% vs. 4% at week 8). Irrespective of whether duodenal ulcer was healed or unhealed, significantly (p less than 0.01) more patients on misoprostol (50% at week 8) showed improvement (nil or mild as endpoint) than the placebo group. The degree of chronic inflammation of the antral gastritis showed similar significant changes in favor of misoprostol. Smoking and alcohol intake had no significant effect on the improvement of chronic antral gastritis. In conclusion, healing of duodenal ulcer was associated with improvement of the activity of chronic antral gastritis, which, as shown for the first time, could be further enhanced by a therapeutic agent--prostaglandin E1.