Retrospective analysis of resected primary colorectal cancer revealed no correlation between node harvest and node involvement.

OBJECTIVE: To analyze the correlation between lymph nodes harvest (LNH) and lymph nodes involvement (LNI). METHODS: A retrospective analysis was done from January 2002 - August 2008 (6.5 years). The data was obtained from medical records, pathology and radiology. The patients with primary colorectal carcinoma (CRC) including synchronous or metachronous cancer, were included. These patients were treated with curative or palliative intent. Exclusion criteria was recurrent colorectal cancer, cancer not operated, cancer not resected (stoma-only, open-close) and endomucosal resection. LNH and LNI were obtained. The data was analyzed and also compared with the literature and the national audit. RESULTS: There were 177 resections (mean=28 +/- 3 per annum). Male to female ratio was 0.9:1 and median age was 71 years. There were 112 (63.3%) colonic and 65 (36.7%) rectal cancers. There were 14 Anterio-posterior resections (APRs) (21.5% of all rectal resections). Eighty four percent of resections were elective (OR=2.2 p=0.003 compared to the national audit). Metastasis was found in 14.6% at presentation. Adenocarcinoma (not otherwise specified) NOS constituted 94% of all histology results. Median lymph node harvest was 12 (mean=13.4 p=0.08). There was no significant LNH-LNI correlation (r=0.17 p=0.02). Survival figures for stages I-III CRC revealed 3-year disease-free survival of 82% (all-stage=69%). CONCLUSION: LNI as a function of tumour and host behaviour is of prognostic significance whereas LNH may be a quality assurance (QA) tool.

Predicting outcome of acute non-variceal upper gastrointestinal haemorrhage without endoscopy using the clinical Rockall Score.

BACKGROUND: The Rockall risk scoring system uses clinical criteria and endoscopy to identify patients at risk of adverse outcomes after acute upper gastrointestinal haemorrhage. A clinical Rockall score obtained using only the clinical criteria may be able to predict outcome without endoscopy. AIM: To validate the clinical Rockall Score in predicting outcome after acute non-variceal upper gastrointestinal haemorrhage. METHODS: A retrospective observational study of consecutive patients who were admitted with non-variceal acute upper gastrointestinal haemorrhage was undertaken. Medical records were abstracted using a standardised form. RESULTS: 102 cases were identified (51 men and 51 women; mean age 59 years). 38 (37%) patients considered to be at low risk of adverse outcomes (clinical Rockall Score 0) had no adverse outcomes and did not require transfusion. Patients with a clinical Rockall Score of 1-3 had no adverse outcomes, although 13 of 45 (29%) patients required blood transfusions. Clinical Rockall Scores >3 (n = 19) were associated with adverse outcomes (rebleeding in 4 (21%), surgery in 1 (5%) and death in 2 (10%)). CONCLUSIONS: The clinical Rockall Score without endoscopy may be a useful prognostic indicator in this cohort of patients with acute non-variceal upper gastrointestinal haemorrhage. This score may reduce the need for urgent endoscopy in low-risk patients, which can instead be carried out on a more elective outpatient basis.

Natural history of asymptomatic bile duct stones at time of cholecystectomy.

OBJECTIVES: There is little data on the natural history of asymptomatic bile duct stones and hence there is uncertainty on the management of asymptomatic bile duct stones discovered incidentally at the time of laparoscopic cholecystectomy. We retrospectively reviewed a group of patients who had previously underwent laparoscopic cholecystectomy, but who did not have a pre-operative suspicion of intra-ductal stones, to determine if any biliary complications had subsequently developed. A group of patients who had no pre-operative suspicion of intra-ductal stones, but routinely underwent intraoperative cholangiogram (IOC) at time of cholecystectomy, served as the control group. METHODS: A telephone questionnaire was completed by each patient's family practitioner in 59 of 79 (75%) patients who underwent laparoscopic cholecystectomy. In the remaining 20 patients additional information was obtained from hospital records and from the central services agency (CSA). These patients had no pre-operative suspicion of bile duct stones and therefore did not undergo an IOC or ERCP. The control group (73 patients) had no pre-operative suspicion of bile duct stones but had a routine IOC performed to define the biliary anatomy. RESULTS: 59 patients were followed up for an average of 57 months (range 30-78 months) after laparoscopic cholecystectomy. None of these patients developed pancreatitis, jaundice, deranged liver function tests (LFT's), or required ERCP or other biliary intervention. In the additional 20 patients where no information was available from the family practitioner, 11 patients had follow up appointments with no documentation of biliary complications or abnormal LFT's. 19 of 20 patients were traceable through the CSA and were all alive. Only 1 patient was untraceable and therefore unknown if biliary complications had developed. In the control group, 4 of 73 (6%) patients had intraductal stones detected and extracted. Thus the prevalence of asymptomatic bile duct stones during the time of cholecystectomy in our population was 6%. CONCLUSIONS: Asymptomatic bile duct stones discovered at the time of cholecystectomy do not appear to cause any biliary complications over a 5-year follow up. Incidental bile duct stones found in patients undergoing laparoscopic cholecystectomy may not need to be removed.

Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography.

BACKGROUND AND STUDY AIMS: Periampullary diverticula are thought to be associated with bile duct stones. However, studies to date have been inconclusive as they have not taken into account the influence of age. Our study analysed the association of diverticula with bile duct stones and with the technical success of endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS: A total of 415 consecutive patients who were undergoing ERCP were prospectively entered into a database. Of these patients, 83 (20 %; mean age 73 years; 34 men, 49 women) were found to have diverticula. The age-matched control group comprised 261 patients (mean age 72 years; 106 men, 155 women). The chi-squared test was used to analyse the results. RESULTS: In the diverticula group, 53 (64 %) had bile duct stones, compared with 86 (33 %) of the controls ( P < 0.0001), with an odds ratio of 3.6. Significantly more patients in the diverticula group had primary bile duct stones; also significantly more of them had stones in both the bile duct and gallbladder. There was no difference between the two groups with regard to previous history of pancreatitis (10 % in the diverticula group vs. 11 % in the control group). There were no significant differences found between the diverticula group and the control group in terms of successful duct cannulation (94 % in both groups), sphincterotomies (96 % vs. 98 %) or stone extraction (94 % vs. 88 %). The incidence of complications was similar in the two groups (diverticula group 5 % vs. control group 3.3 %). CONCLUSIONS: Periampullary diverticula are associated with an increased incidence of bile duct stones but not with pancreatitis. Diverticula did not cause any technical difficulties at ERCP or increase the risk of complications.

Silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography.

BACKGROUND AND STUDY AIMS: Myocardial ischaemia may occur during endoscopic retrograde cholangiopancreatography (ERCP) and this may predispose patients to ischaemic complications, although the incidence and risk factors for mycocardial ischaemia during ERCP have not been studied in detail. The aim of this study was to determine the incidence of myocardial ischaemia, as defined by ST changes on electrocardiography during ERCP, and whether or not any intervention predisposes to an increased risk of myocardial ischaemia. PATIENTS AND METHODS: Consecutive patients undergoing ERCP at a single centre were included. Continuous Holter electrocardiograph recordings were carried out during ERCP. ST depression was defined as > 1 mm lasting for longer than 1 minute. The time of interventions during ERCP was recorded prospectively and related to the Holter recordings. RESULTS: There were 41 patients in the study (14 men, 27 women; median age 66 years, range 21 - 88). Nine patients (22 %) experienced ST depression during the procedure, of whom four (10 %) showed significant ST depression (> or = - 2 mm). Of these, five had no previous cardiac history and normal electrocardiographic findings, three had no previous cardiac history but had abnormal electrocardiographic findings and one had a previous cardiac history and abnormal electrocardiographic results. ERCP interventions associated with the episodes of ST depression were administration of sedation ( n = 6, P < 0.01) endoscopic sphincterotomy ( n = 4), balloon trawl ( n = 1), basket trawl ( n = 3) and stent replacement ( n = 1) ( P > 0.05 for the rest). No cardiac complications occurred. CONCLUSIONS: Myocardial ischaemia occurred in approximately one-quarter of patients during ERCP, and over half of these had no previous cardiac history and normal baseline electrocardiography results. Myocardial ischaemia often accompanied the use of sedation and intubation of the patient, but specific therapeutic interventions were not associated with the onset of ischaemia.

Safety of ERCP during pregnancy.

OBJECTIVES: There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy. METHODS: We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential. RESULTS: The mean patient age was 28.9 yr (15-36 yr). The mean duration of gestation was 25 wk (12-33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD +/- 1.8). An estimated fetal radiation exposure was 310 mrad (SD +/- 164) which is substantially below the accepted teratogenic dose. CONCLUSIONS: ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

Differences in the diagnostic yield of upper gastrointestinal endoscopy in dyspeptic patients receiving proton-pump inhibitors and H2-receptor antagonists.

BACKGROUND AND STUDY AIMS: Patients attending for diagnostic oesophagogastroduodenoscopy (OGD) for dyspeptic symptoms are often receiving acid-suppression therapy that has not been discontinued prior to endoscopy, and this may reduce the diagnostic yield of endoscopy. The aim of this study was to compare the diagnostic yield of OGD in uncomplicated dyspepsia in patients receiving no medication, those receiving acid-suppression therapy, and those receiving nonsteroidal anti-inflammatory drugs (NSAIDs) at the time of endoscopy. PATIENTS AND METHODS: A total of 6825 diagnostic OGDs performed in our unit between 1993 and 2001 were analysed. Patients were excluded if they had sinister symptoms, were receiving NSAIDs, or were undergoing repeat or surveillance endoscopy. RESULTS: A total of 4233 OGDs (62 %) fulfilled the criteria for uncomplicated dyspepsia. Of the patients examined in these procedures, 1367 (32 %) were receiving acid-suppression therapy. A total of 724 patients (53 % of those on therapy) were receiving proton-pump inhibitors (PPIs), 393 of whom (54 %) had positive endoscopic findings (oesophagitis 31 %, gastritis 16 %, duodenal ulcer/duodenitis 16 %). A total of 643 (47 % of the patients on therapy) were receiving H 2 -receptor antagonists, 443 of whom (69 % of this group) had positive endoscopic findings (oesophagitis 30 %, gastritis 21 %, duodenal ulcer/duodenitis 31 %). A total of 2866 patients were not receiving acid-suppression therapy, 1805 of whom (63 %) had endoscopic findings (oesophagitis 37 %, gastritis 14 %, duodenal ulcer/duodenitis 24 %). The endoscopic yield was significantly lowest in the PPI group, except for the diagnosis of oesophagitis. Overall, 17 carcinomas were detected in patients referred with simple dyspepsia, and in five of these cases the patients were receiving acid suppression. CONCLUSIONS: The widespread use of acid suppression in the treatment of simple dyspepsia prior to endoscopy leads to a reduction in the endoscopic recognition of mucosal lesions caused by acid-peptic disease, but not to a high healing rate for these lesions, and it may mask malignancy.

Duodenal stents for malignant duodenal strictures.

Duodenal obstruction may be caused by inoperable malignant disease. Symptoms of nausea and vomiting have been traditionally palliated by surgery. The aim of the study was to determine the efficacy of the endoscopic placement of metal self expanding duodenal stents for the palliation of malignant duodenal obstruction. Four patients with malignant gastric outlet obstruction are described. One patient had a history of oesophagectomy for oesophageal adenocarcinoma and presented with further dysphagia. At endoscopy the recurrent oesophageal tumour and an adenocarcinoma involving the pylorus were both stented. In the other three patients there was a previous history of colonic carcinoma, cholangiocarcinoma and oesophageal adenocarcinoma respectively. All four patients were successfully stented with good palliation of their symptoms. Duodenal Wallstents are a useful alternative to surgery in patients with inoperable malignant duodenal obstruction or those who are unfit for surgery.

Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic.

Unkept outpatient appointments are a drain on resources. In a prospective study we asked non-attenders at a gastroenterology clinic why they had missed their appointment. 103 patients missed their appointment (14% of the total invited); 3 had died. The remaining 100 were asked to complete questionnaires, 68 by mail (43 returned) and 32 by telephone (30 successful); the response rate was thus 73%. 49 of the respondents were new patients, 6 of them with urgent referrals. The explanations for non-attendance by the 73 patients were: forgot to attend or to cancel (30%); no reason (26%); clerical errors (10%); felt better (8%), fearful of being seen by junior doctor (3%); inpatient in another hospital (3%); miscellaneous other (20%). 13 (27%) of the review patients had not kept one or more previous appointments. The non-attendance rates for different clinics ranged from 10% to 25% (average 14%). A substantial number of non-attenders claimed to have forgotten their appointment or to cancel it. If, as we surmise, this reflects apathy, no strategy to improve attendance is likely to have great impact. Since the non-attendance rate is reasonably constant, it can be taken into account when patients are booked.

Does prophylactic endoscopic sphincterotomy prevent recurrent biliary problems in patients with gallstones and a normal cholangiogram?

BACKGROUND: Endoscopic sphincterotomy (ES) is indicated in patients with confirmed bile duct stones at endoscopic retrograde cholangiopancreatography (ERCP). The role of ES in patients with suspected bile duct stones but a normal cholangiogram, in the prevention of recurrent biliary symptoms, when cholecystectomy is not planned, is unclear. AIM: To determine if prophylactic ES prevents further biliary problems in such patients. METHODS: Patients were identified with gallbladder stones presenting with jaundice, abnormal liver function tests (LFTs) or dilated bile ducts on ultrasound, in whom cholecystectomy was not planned and who had a normal cholangiogram at ERCP. Patients were followed-up to determine the frequency of recurrent biliary problems or repeat investigations. RESULTS: Forty-one patients were included, of whom 20 had an ES. The frequency of pre-ERCP features did not differ between the two groups. Median follow-up was 32 months (range 15-66). Post-ERCP recurrent abdominal pain (5 vs 3; p=0.39), jaundice (3 vs 1; p=0.28), pancreatitis (0 vs 1; p=0.32), and repeat ultrasound (2 vs 1; p=0.52), ERCP (1 vs 1; p=0.97) or cholecystectomy (2 vs 3, p=0.82) did not differ between the two groups. CONCLUSIONS: Patients with gallstones, suspected common bile duct (CBD) stones and a normal cholangiogram need not have a prophylactic sphincterotomy since there is no reduction in recurrent biliary problems and this potentially increases the morbidity.

Radiation doses to patients during ERCP.

BACKGROUND: There is a scarcity of data regarding the radiation dose and associated risks to patients during ERCP. Dose area product (DAP) measurements can be used to estimate an effective dose (ED) to patients undergoing ERCP. This measure allows radiation risk associated with such procedures to be quantified. The aim of this study was to evaluate the ED to patients undergoing ERCP. METHODS: A DAP meter was fitted to the x-ray tube before each ERCP. DAP reading (Gy-cm(2)), fluoroscopy time, average screening kVp, number of films, and kVp per film were recorded. Mean ED was estimated by using DAP readings and Monte Carlo computer software to model radiation exposure conditions. RESULTS: Data were recorded on 20 subjects. Average DAP was 13.5 Gy-cm(2) (6.8-23.9) for diagnostic and 66.8 Gy-cm(2) (28.7-108.5) for therapeutic ERCP (p < 0.05). Average fluoroscopy time was 2.3 minutes (1.1-5.3) for diagnostic and 10.5 minutes (5.9-16.6) for therapeutic ERCP (p < 0.05). DAP showed a linear relationship with fluoroscopy time (R(2) = 0.928). Mean number of diagnostic and therapeutic films was 2.8 and 3.7, respectively. Fluoroscopic exposure represented 69% of the DAP for diagnostic ERCP and 90% of the DAP for therapeutic ERCP. Average ED was 3.1 mSv for diagnostic and 12.4 mSv for therapeutic ERCP. CONCLUSIONS: Therapeutic ERCP is associated with significantly higher radiation exposure than diagnostic ERCP. ED in therapeutic ERCP is a result largely of fluoroscopy time as opposed to number of films.

Percutaneous endoscopic gastrostomies: attitudes of general practitioners and how management may be improved.

Percutaneous endoscopic gastrostomy (PEG) has replaced surgical gastrostomy in patients requiring long-term enteral nutrition. Increasing numbers of patients are being referred for PEG placement. Concern has been raised about patient selection and subsequent follow-up of these patients in the community. We report the views of Northern Ireland GPs to PEGs and how management may be improved.

Pancreatic duct stents for "obstructive type" pain in pancreatic malignancy.

OBJECTIVE: Obstruction of the main pancreatic duct from malignancy with secondary ductal hypertension may be an important contributor to pain. The aim of our study was to determine the efficacy and safety of pancreatic stent placement for patients with "obstructive" pain due to pancreatic malignancy. METHODS: Pancreatic duct stents were placed in 10 consecutive patients with malignant pancreatic duct obstruction and abdominal pain. Seven patients had "obstructive" type pain and three had chronic unremitting pain. Nine had primary pancreatic ductal adenocarcinoma and one had metastatic melanoma. There were eight women and two men. Mean age was 61 yr (range, 47-80 yr). All patients had dominant main pancreatic duct strictures with proximal dilation. Tumors were unresectable. All patients took potent analgesics before endoscopic stent therapy. Polyethylene pancreatic stents, 5- and 7-French, were successfully placed in seven patients, and self-expanding metallic stents were successfully placed in three patients. RESULTS: There were no procedure-related complications. One patient required a single repeat examination to replace a migrated stent. Seven patients (75%) experienced a reduction in pain. Analgesia was no longer required in five (50%). Three patients who did not improve had chronic pain rather than "obstructive" pain. CONCLUSIONS: Pancreatic stent placement for patients with "obstructive" pain secondary to a malignant pancreatic duct stricture appears to be safe and effective. It should be considered as a therapeutic option in these patients. It does not seem to be effective for chronic unremitting pain.

A prospective randomised trial of a "test and treat" policy versus endoscopy based management in young Helicobacter pylori positive patients with ulcer-like dyspepsia, referred to a hospital clinic.

BACKGROUND: Management of dyspepsia remains a controversial area. Although the European Helicobacter pylori study group has advised empirical eradication therapy without oesophagogastroduodenoscopy (OGD) in young H pylori positive dyspeptic patients who do not exhibit alarm symptoms, this strategy has not been subjected to clinical trial. AIMS: To compare a "test and treat" eradication policy against management by OGD. PATIENTS: Consecutive subjects were prospectively recruited from open access OGD and outpatient referrals. METHODS: H pylori status was assessed using the carbon-13 urea breath test. H pylori positive patients were randomised to either empirical eradication or OGD. Symptoms and quality of life scores were assessed at baseline and subsequent reviews over a 12 month period. RESULTS: A total of 104 H pylori positive patients aged under 45 years were recruited. Fifty two were randomised to receive empirical eradication therapy and 52 to OGD. Results were analysed using an intention to treat policy. Dyspepsia scores significantly improved in both groups over 12 months compared with baseline; however, dyspepsia scores were significantly better in the empirical eradication group. Quality of life showed significant improvements in both groups at 12 months; however, physical role functioning was significantly improved in the empirical eradication group. Fourteen (27%) in the empirical eradication group subsequently proceeded to OGD because of no improvement in dyspepsia. CONCLUSIONS: This randomised study strongly supports the use of empirical H pylori eradication in patients referred to secondary practice; it is estimated that 73% of OGDs in this group would have been avoided with no detriment to clinical outcome.