Transanorectal ultrasonography in anal carcinoma. A prospective study of 21 patients.

Twenty-one consecutive patients with anal carcinoma of squamous cell type were evaluated by transanorectal ultrasonography (Brüel & Kjaeer) prior to radiation therapy. The normal anal anatomy, with three distinct layers, was easily demonstrated both in vitro and in vivo. The middle, low echogenic layer corresponded above the dentate line to the muscularis propria and more distally to the internal and external sphincters. A hypoechoic area, representing tumour, was detected in all patients. Using the ultrasound findings, it appeared possible to classify the depth of tumour invasion into four levels with respect to whether or not invasion had reached or penetrated beyond the muscular wall or into adjacent organs. Eighteen of 21 tumours had penetrated the muscular wall. In 3 cases low echogenic, rounded structures, interpreted as enlarged lymph nodes, were identified. The ultrasonographic findings were compared with digital staging. Tumour invasion had penetrated the muscular wall in 2 out of 3 stage T1 patients and in 10 out of 11 stage T2 patients. Prospective studies will show whether estimates of tumour size and depth of invasion in relation to various normal structures, as judged by ultrasonography, are of value prognostically and for the choice of therapy.

Prognostic significance of clinical stage, histologic grade, and nuclear DNA content in squamous-cell carcinoma of the anus.

Specimens from 47 cases of anal squamous-cell carcinoma were examined in Stockholm county (1978 to 1981) with respect to clinical stage (43 cases), histologic grade (41 cases), and DNA content of the tumor cells (31 cases). Follow-up ranged from four to seven years (median, 5.5 years). The increased mortality in advanced stage and high-grade lesions was significant. Analysis of DNA content showed that most tumors were aneuploid. No statistically significant effect of DNA content on survival could be demonstrated. Thus, histologic grade and clinical stage seem to be the best predictors of patient outcome in squamous-cell carcinoma of the anus.

ERCP and serum alkaline phosphatase in pancreatic carcinoma.

In 323 patients with suspected pancreatic or bile duct disease, the investigations included measurement of serum alkaline phosphatase (S-ALP) and endoscopic retrograde cholangiopancreatography (ERCP). The targeted duct system was satisfactorily cannulated in 283 patients, including 171 referred for ERCP because of suspected chronic pancreatitis and 75 with suspected pancreatic carcinoma. The follow-up time in all 283 cases was 3 years or, in the fatal cases, until death. ERCP was false-positive for pancreatic carcinoma in one case. S-ALP was elevated in 20 of the 24 patients with pancreatic malignancy shown at ERCP and histologically verified, but in only 35 of the 108 with chronic pancreatitis and 5 of 123 with normal ERCP. S-ALP should always be checked when pancreatic affection is suspected. If the level is raised, ERCP should also be done early in the clinical investigation, as it has high sensitivity in detection of pancreatic carcinoma.

Peritoneo-venous shunting and endoscopic sclerotherapy in patients with portal hypertension.

Denver type peritoneo-venous (PV) shunting for intractable ascites was performed in 16 patients also treated with endoscopic injection sclerotherapy (ST) for variceal haemorrhage. Indications, timing and results of shunt insertion are detailed and discussed. Serial ST for eradication of varices could be completed in 10 patients a median of 7 months before PV shunting. The postoperative risk of bleeding was increased four times, i.e. the number of GI bleedings per month of follow-up, was 0.05 and 0.21 (p less than 0.05) respectively, before and after shunt operation. Two patients experienced their first variceal bleeding and 6 patients rebled during a median follow-up of 3 months after PV shunting. The Denver shunt succeeded in resolving ascites clinically in 13 patients within 7 days with a median decrease in weight of 10 kg, parallel to increased urinary output and reduced serum-creatinine. Three patients did not benefit from the shunt procedure due to terminal neoplastic disease (one patient), and severe hepatorenal failure, although the shunts were proven patent. Serious complications included clinically important consumptive coagulopathy, DIC-syndrome (two patients), myocardial infarction (one), pulmonary embolism (three), and sepsis following intervention of obstruction (one).

Randomised double blind trial of somatostatin in the treatment of massive upper gastrointestinal haemorrhage.

In order to evaluate the effect of somatostatin in the treatment of massive upper gastrointestinal bleeding a randomised double blind trial of 95 patients has been undertaken during a 28 months period. Patients with oesophageal varices have been excluded as well as patients with diabetes. All patients were endoscoped within eight hours of admission to the hospital, whereupon the source of bleeding and types of stigmata were assessed. Forty six patients, chosen at random, were given a 72 hour infusion of somatostatin, while the remaining 49 patients received infusion of placebo. The two groups were well matched for sex, age, and source of bleeding. On the day after admission, an additional endoscopy was performed at which eight patients in the somatostatin group and 16 in the placebo group were found to have a persistent bleeding. A total of five patients in the somatostatin group and 14 in the placebo group underwent surgery (Fisher's exact test, 2-tail, p = 0.04). Rebleeding occurred in six patients in the somatostatin group, of whom five experienced rebleeding after completion of the somatostatin treatment. In the placebo group, rebleeding occurred in five patients, of whom four rebled on the day after admission. The need for blood transfusions and the mortality rate did not differ significantly between the two groups. No toxic side effects were found as a result of the infusion of somatostatin. In this study, somatostatin reduced the number of patients needing surgery with massive upper gastrointestinal bleeding.

Squamous-cell carcinoma of the anus. A follow-up study of 65 patients.

The five-year survival rate in 72 patients who underwent treatment for squamous-cell carcinoma of the anus in Stockholm County (1972 to 1978) has been studied. There were no differences in survival rates after rectum-preserving treatment (mainly consisting of irradiation +/- cytostatics +/- local excision) as compared with extensive surgery (abdominoperineal resection), even if the tumor size, location, and differentiation were taken into consideration. It therefore seems appropriate to suggest irradiation +/- cytostatics as the therapy of choice regardless of size, location, and differentiation of the tumor.

Pancreatic function in patients with hyperparathyroidism. A study with the Lundh test.

To elucidate the assumed relationship between hyperparathyroidism and pancreatitis, the pancreatic function was studied in 20 patients with hyperparathyroidism. In all cases removal of a parathyroid adenoma was followed by normalization of preoperative hypercalcemia. A modified Lundh's test with duodenal aspiration was performed before and after the operation. The volume of the aspirate and its content of electrolytes and pancreatic isoamylase were compared with findings in an age-matched control group. Preoperatively the volume of secretion was significantly less in the patients than in the controls. Carbonate levels were also decreased, but changes in enzymatic activity were slight. Postoperatively there was significant increase in aspirate volume and fall in the level of duodenal calcium. The results suggested an influence of hyperparathyroidism on exocrine pancreatic function, even when no symptoms of pancreatic disease are present.

Is glucose intolerance after pancreatitis related to pancreatic tissue damage?

Endoscopic retrograde pancreatography (ERP) was performed in 48 patients who had been hospitalized for pancreatitis. The findings were related to results of oral glucose tolerance tests. Patients with gross changes at ERP tended to have latent or manifest diabetes. In patients with latent or manifest diabetes, the increase in C-peptide after oral glucose was lower than in healthy subjects, while insulin sensitivity, estimated with euglycemic insulin clamp technique, was within the same range as in healthy subjects. It is concluded that gross changes of the pancreatic ducts after pancreatitis are often accompanied by widespread tissue damage leading to deficient B-cell function and decreased glucose tolerance.

Evaluation of the diagnosis pancreatitis.

A widely used classification of pancreatitis is the one proposed in Marseilles in 1963, which distinguishes among acute, acute relapsing, chronic relapsing, and chronic pancreatitis. The diagnostic criteria in chronic pancreatitis are permanent damage of morphology and/or function of the pancreas after clinical symptoms of pancreatitis. In clinical practice, however, it can be difficult to find the suitable and comparable diagnosis in accordance with the Marseilles classification. In the present study the exocrine and endocrine function and the morphology of the pancreas have been thoroughly investigated in 54 patients who have been treated for various diagnoses of pancreatitis. The results show that the above diagnostic criteria often are difficult to interpret. We consider that the prevailing classification of pancreatitis needs to be revised in the light of progress in investigative techniques. A proposal for a modified classification is presented.

99mTc-HIDA cholescintigraphy in Dubin-Johnson and Rotor syndromes.

99mTc-HIDA cholescintigraphy was performed in 6 patients with Dubin-Johnson syndrome and 1 patient with Rotor syndrome. In the patients with Dubin-Johnson syndrome, the cholescintigrams had a characteristic pattern of delayed visualization or nonvisualization of the gallbladder and bile ducts in the presence of intense, homogeneous, and prolonged visualization of the liver. In the patient with Rotor syndrome, the hepatobiliary system was not visualized at all. It is concluded that 99mTc-HIDA cholescintigraphy may be helpful in the diagnosis of Dubin-Johnson syndrome and Rotor syndrome and in the differential diagnosis between these two conditions.

Clinical course and autopsy findings in acute and chronic pancreatitis.

A retrospective study of 314 patients hospitalized for pancreatitis in the period 1972-1973, showed that 74 (24%) had died in the course of five years. The aim of the study was to elucidate the etiology and the course of the pancreatitis and the immediate cause of death in the 61 cases where an autopsy was performed. There were three types of histopathological findings at autopsy concerning the pancreas: acute hemorrhagic pancreatitis, chronic pancreatitis and one group with no or minimal changes in the pancreas. The last group had had typical clinical symptoms of pancreatitis with abdominal pain and elevated urine and/or serum amylase, in many patients a very marked rise. Alcoholism was the dominant predisposing factor, regardless of the type of histopathological findings, but when the first attack of pancreatitis appeared at advanced age, biliary tract disease and cancer were the dominant causes. Liver damage was a common finding in alcoholic pancreatitis.

Prognosis in acute haemorrhagic, necrotizing pancreatitis.

Acute haemorrhagic and/or necrotizing pancreatitis is a most serious condition. A retrospective account is presented of the clinical course, treatment and results in 61 patients with the diagnosis confirmed at laparotomy and/or autopsy. Forty-eight patients (79%) died while in hospital. Of the 13 surviving patients, 10 were followed up for periods ranging from 1.5 to 9 years. They were reinvestigated with respect to morphologic and exocrine and endocrine functional changes in the pancreas. The aetiology of the acute condition was biliary tract disease in 33% of the total series and alcoholism in 59%. Neither cause of the disease nor type of treatment (surgery with or without peritoneal lavage) had statistically significant effect on survival. At the follow-up examination the endocrine and exocrine pancreatic functions were satisfactory in many patients. In almost half of the surviving patients, endoscopic retrograde pancreatography showed openly minor changes.

Diagnostic criteria, classification and clinical course in pancreatitis.

1. Alcohol was the most common cause of pancreatitis, irrespective of sex or age. The acute hemorrhagic necrotizing form could arise after the consumption of no more than 100-450 g of alcohol a day for 7-10 days. Chronic pancreatitis was almost invariably caused by alcohol. 2. While alcohol predominantly (93%) among the under-60s, biliary tract disease and cancer were a major cause (53%) of pancreatitis in the over-60s. 3. Pancreatitis usually followed one of three courses: acute hemorrhagic, acute oedematous (acute pancreatitis) or chronic. 4. Patients who have been treated for alcoholic pancreatitis have a high death rate. The mean age at death was 46 years. 5. Most cases of acute hemorrhagic, necrotizing pancreatitis (92%) occurred as the patient's first attack of pancreatitis. 6. The diagnosis acute hemorrhagic, necrotizing pancreatitis can at present be established only at operation or autopsy. 7. Extensive resection of the pancreas should be avoided in acute hemorrhagic necrotizing pancreatitis because the function of the pancreas was often acceptably restituted once the disorder had subsided. 8. Disturbed sugar regulation was the most common complication in patients who had had pancreatitis. Diabetes mellitus often occurred (29%) and might do so months or years after an attack. 9. Patients with alcoholic pancreatitis were greatly disadvantaged socially (little education, poor jobs and housing) and in the event of a recurrence elicited by alcohol it is suggested that they should be cared for at a department for alcoholics. 10. It is suggested that in chronic pancreatitis the diagnosis should specify any exocrine and endocrine disturbances as well as any morphological changes that have been documented by i.e. ERCP or ultrasound. Studies of pancreatic function and morphology for the classification of pancreatitis should be made no earlier than 6 weeks after clinical signs of pancreatitis have subsided, with abstention from alcohol in the intervals. A classification of this type would contribute to a better follow-up and treatment of patients with chronic pancreatitis and improve the possibility of comparing patient materials.

Endoscopic YAG-laser treatment in massive upper gastrointestinal bleeding. Report of a controlled randomized study.

In patients with massive upper gastrointestinal bleeding the results of endoscopic control by coagulation with YAG-laser have been compared with the results of an active surgical approach with early operation in a controlled randomized study. The laser coagulation was done at admission in patients in whom an actively bleeding lesion was diagnosed at endoscopy. Of the 66 patients belonging to the laser group, 23 were bleeding at admission and endoscopy, and in 15 of these coagulation was attempted and initial haemostasis was achieved in 14. Seven of the latter rebled and five of them were then operated upon with on postoperative death. Two patients died from bleeding oesophageal varices and hepatic failure. In the patient in whom haemostasis was not achieved, an operation was done for a duodenal ulcer. She died postoperatively. Of the 43 patients belonging to the laser group and not bleeding at endoscopy, nine patients rebled and three of them were operated upon, the with on postoperative death. An additional four patients died in this group, three of bleeding oesophageal varices in combination with hepatic failure and one of bleeding from an unknown source. Sixty-nine patients belonged to the control group and in 19 of these patients bleeding lesions were diagnosed at endoscopy. Five of these were operated upon, with two postoperative deaths. An additional three patients died of bleeding oesophageal varices and hepatic failure. Of the 50 patients belonging to the control group and not bleeding at endoscopy, eight later showed signs of recurrent bleeding. Four of them had oesophageal varices and two died. The other four with recurrent bleeding were operated upon with no postoperative mortality. Thus nine patients (five with oesophageal varices) died in the laser group and seven (five with oesophageal varices) in the control group. There was no statistically significant difference between the two groups regarding mortality, need of blood transfusion or time of treatment in the hospital. However, the material is too small to make any definite conclusions, and further studies are necessary in which laser treatment is compared with an aggressive surgical policy with early operations.

Percutaneous fine-needle aspiration biopsy during endoscopic retrograde cholangio-pancreatography.

In 12 non-icteric patients, changes in the pancreatic duct indicative of carcinoma were found during endoscopic retrograde cholangio-pancreatography (ERCP). Percutaneous fine-needle biopsy was positive for cancer in six cases. Nine of the 12 patients were later proved to have carcinoma of the pancreas. There was one falsely negative biopsy but no false positives. In two cases no pancreatic cells were found in the smear. It seems that percutaneous fine-needle aspiration biopsy during ERCP is a feasible procedure and can be recommended in ductal changes indicative of carcinoma.

Intussusception of the rectum-internal procidentia: treatment and results in 90 patients.

A series of 90 patients with intussusception of the rectum (internal procidentia) has been studied. In 11 per cent of the patients there was also an enterocele and in 3 per cent, a large proctocele. Forty patients were operated upon by the Ripstein procedure. Indications for operation were, in most cases, incontinence for gas and/or feces. Seventy-five per cent of the preoperatively incontinent patients were, at follow-up 2 to 10 years after operation, continent. When indications for surgery were pain and or a sensation of obstruction, the results were poor; most of these patients had unchanged symptoms postoperatively, and some even had increased symptoms. There was one postoperative death. Of 50 patients treated conservatively during a period of 2 to 10 years, only two had to be operated upon: one due to the development of a rectal prolapse and the other due to severe pain and an increased sensation of obstruction.