[Pharmacologic markers predictive of neutropenia chemically induced by cisplatin (CDDP)]. / Marqueurs pharmacologiques prédictifs de la neutropénie chimioinduite par le cisplatine (CDDP).

The aim of this study was to demonstrate the value of the level of platinum in lymphocytes, plasma and saliva, in order to predict neutropenia during the same cycle after cisplatin chemotherapy. Plasma and lymphocytes samples were obtained from 14 patients receiving 100 mg/m2 cisplatin in different combination. Saliva samples were obtained from 3 other patients. We found that platinum plasma concentration at the Cmax and 1 hour after the end of the infusion were significantly higher in the grade 4 neutropenia cycles (respectively 2.60 vs 2.05 and 2.55 vs 2.00 mg/l p < 0.05). Platinum DNA-adduct were not detectable by ICPMS. Maximum concentrations in saliva ranged between 0.05 to 0.08 mg/l at the end of the infusion. The ratio of platinum levels in plasma and saliva varied between 2 and 3%. Saliva seems to be useful for therapeutic drug monitoring of cisplatin because it can be obtained by non invasive and patient-friendly-means. However, new studies are required to demonstrate the relationship between these two biological fluids.

Colonoscopy: the initial test for acute lower gastrointestinal bleeding.

Despite literature showing safety, accuracy, and therapeutic capability of emergency colonoscopy for acute lower gastrointestinal (LGI) bleeding, surgical literature suggests that this examination is difficult to perform in the acute setting. In contrast to currently accepted protocols, we believe that unprepared colonoscopy within 24 hours of presentation can be performed safely with a high rate of success in localizing and often treating the specific cause of LGI bleeding. We report results over a 7-year period in our institution using early colonoscopy as the primary investigative method for the diagnosis and treatment of LGI bleeding. We analyzed 85 consecutive patients suspected of LGI bleeding referred to the surgical service between 1989 and 1996. LGI bleeding was defined as the passage of blood per rectum, distal to the ligament if Trietz. We excluded patients who were only hemoccult positive or had an upper gastrointestinal source by nasogastric aspirate or upper gastrointestinal endoscopy. All patients underwent urgent unprepped colonoscopy by surgical endoscopists relying on the cathartic effect of blood and liberal suction/irrigation to cleanse the colon. Therapeutic maneuvers included Nd:YAG laser or BICAP coagulation. Studies in which active bleeding was found or lesions with endoscopic evidence of recent hemorrhage were considered positive. A total of 126 colonoscopies were performed in 85 patients, 44 males and 41 females, with a median age of 75 years (range, 12-91 years). Fifty-three patients (62%) had hematocrit drops of greater than 5 per cent. Thirty-four patients were transfused an average of 4.5 units of blood per patient. The source of bleeding was correctly identified in 82 of 85 (97%) patients. Ninety-one per cent of sources were colonic, and 9 per cent were small bowel. Fecal residue prevented initial adequate examination in only two patients. Diverticulosis (20%), ischemic colitis (18%), hemorrhoids (14%), and arteriovenous malformations (11%) were the predominant sources of bleeding. Spontaneous cessation of bleeding occurred in 58 (68%) patients. Control of active hemorrhage was achieved endoscopically in 17 of 27 acutely bleeding patients. Significant therapeutic interventions were performed in 26 additional patients, including fulgration, polypectomy, relief of obstruction, and removal of foreign body. One patient with asymptomatic free air was observed nonoperatively, for a complication rate of 0.8 per cent. In-hospital mortality was 3.5 per cent (three patients), all secondary to multisystem organ failure and underlying disease. In-hospital rebleeding rate was 3.5 per cent (three). We conclude that, using colonoscopy, it is possible to identify the source of acute LGI bleeding in more than 95 per cent of cases. Diagnostic and therapeutic capability with colonoscopic intervention to control active hemorrhage is especially appealing. Additionally, the pattern, amount, and location of blood in the unprepared colon all give clues as to source and rate of bleeding. In experienced hands, morbidity and mortality of emergent colonoscopy is very low. High accuracy, safety, and therapeutic capability makes colonoscopy the initial diagnostic test of choice for acute LGI hemorrhage.

Endoscopic Nd:YAG laser therapy for villous adenomas of the colon and rectum.

We reviewed 34 villous tumors of the colon and rectum treated endoscopically with neodymium:YAG laser therapy from 1983 to the present. Twenty-three tumors were benign, and 11 contained carcinoma in situ. Invasive carcinomas were excluded. Treatment locations included cecum (6), descending colon (1), sigmoid colon (2), and rectum (25). Fourteen males and 20 females with a mean age of 70 years (31-93) completed an average of 3.3 total treatments per patient under no sedation (9), intravenous demerol (24), or general anesthesia (1). Treated tumors ranged between 2-12 cm in greatest dimension, and one fourth were 50 to 100 per cent circumferential. Four patients presented with recurrent tumors subsequent to transanal excisions, done elsewhere. Five patients suffered complications of mild stricture (2), self-limited bleeding (2), and one pinhole colovaginal fistula. There was one incomplete treatment and one recurrence in the cecum that was carcinoma in situ at resection. There were no missed cancers during follow up that ranged from 1-120 months (average 32 months). The average total cost for the entire treatment per patient was $3627. Endoscopic neodymium:YAG laser therapy of villous tumors of the colon and rectum is a safe and effective outpatient procedure. The complication rate is lower than most reported series of operatively treated patients, and sphincter dysfunction, incontinence, or fecal fistula is avoided. With close follow up and repeated biopsy, invasive carcinoma can be ruled out. We believe this is the procedure of choice for management of these tumors.

Long-term follow-up of a kindred with multiple endocrine neoplasia type IIA.

A kindred with multiple endocrine neoplasia type IIA was studied. In four of five fully documented cases, patients presented with adrenal medullary disease during the second or third decade; in three cases, medullary thyroid carcinoma was not diagnosed until the fourth decade. This kindred seems to have an aggressive variant of adrenal medullary disease in which clinical presentation is early, metastasis occurs, and oncological cure is uncommon. Early detection and operation were important, and symptoms were controlled with operations and alpha- and beta-adrenergic blockade in uncured members.

Postgastrectomy phytobezoars--endoscopic diagnosis and treatment.

Thirty-three consecutive patients with 38 bezoars were identified since 1975. Twenty-nine patients (87.8%) had undergone previous gastric surgery. The average interval between surgery and bezoar diagnosis was 7.7 years. There were 14 men and 19 women (mean age, 61.5 years). Epigastric distress (84%) and weight loss (31%) were the most common complaints. Twenty-two (75.9%) of 29 barium studies were falsely negative. Attempts at prior enzymatic dissolution had failed in three patients. Three (13.6%) of 22 patients available for follow-up had multiple episodes of bezoar formation. All patients underwent esophagogastroduodenoscopy for diagnosis and concomitant fragmentation and "flushing" of the bezoar for resolution. The success rate was 100%; no complications occurred.

Idiopathic perforation of the colon in a newborn.

Although infrequent, idiopathic perforation of the colon in the newborn is a surgical emergency. Etiology remains obscure. Diagnosis of a pneumoperitoneum, prompt operative intervention, and the use of antibiotic therapy are essential to the survival of these infants.

Cerebral blood flow, cerebral metabolism and cerebrospinal fluid biochemistry in brain-injured patients after exposure to hyperbaric oxygen.

A series of head-injured patients, in coma, were treated with hyperbaric oxygen (OHP) at 2.5 atm. Cerebral blood flow (CBF), cerebral metabolic rates of oxygen (CMRO2), glucose (CMRGL), and lactate (CMRL act), and various cerebrospinal fluid (CSF) parameters were measured before and 2 h after the treatment. Pre-OHP and post-OHP average values of arterial blood and CSF lactate, and CMRL act were higher than normal, while CBF, CMRO2 and CSF oxygen pressure (PO2) were lower. CBF tended to increase after OHP in some patients and to decrease in others. This discrepancy and the conflicting results of the literature can be tentatively explained in assuming that there is a different effect of OHP on normal brain circulation as compared to impaired brain circulation. Changes of cerebral metabolic rates were inconsistent and did not relate to changes of CBF, except with repeated studies of the same patient. A correlation was found between the variations of CMRGL and those of arterial blood and CSF glucose content. CSF PO2, CSF acid-base balance, and CSF lactate content did not vary, and arterial PO2 showed a consistent fall. In two patients who were neurologically improved after OHP exposure, the CBF and metabolic changes were not the same.