Bowel function following insertion of self-expanding metallic stents for palliation of colorectal cancer.

OBJECTIVE: Self-expanding metallic stents (SEMS) are an important addition to the treatment of large bowel obstruction. The aim of this study was firstly to assess bowel function following SEMS placement and secondly to identify any potential factors which might aid in the prediction of technical failure of stent insertion. METHODS: A review of all patients undergoing attempted SEMS placement for palliation of malignant left-sided colorectal obstruction over a four-year period (1st May 2000-30th April 2004) was performed. RESULTS: Twenty-one patients (12 male) with a median age of 76 years (range 48-92 years) were included, 11 with metastatic disease and 10 severe comorbidity. SEMS insertion was technically successful in 16 (76%) of 21 cases. Contrast successfully passed through the obstructing lesion in all 16 cases where SEMS placement was technically successful. It only passed through 1 of 5 cases where stenting was not possible (P = 0.0008, Fisher's Exact test). Complications included colonic perforation (1 case), stent migration (1 case) and tumour ingrowth requiring a second stent (1 case). Median survival after SEMS was 12 months (range 1-30 months), and 9 patients died during follow-up. Median bowel frequency following SEMS was 3.5 times per day (range 1-7). Eight patients always passed a liquid stool, 3 others regularly required laxatives and one further patient with poor function after stenting requested a defunctioning stoma. CONCLUSION: Failure of contrast to pass through the obstructing lesion may predict those cases where stenting will not be technically possible. Median survival following SEMS insertion is encouraging in this series, but bowel function is often poor. Expected bowel function should be discussed fully when consenting patients for a SEMS, particularly those with metastatic disease who are otherwise fit for resectional surgery.

Short-term results of femoropopliteal subintimal angioplasty.

BACKGROUND: Subintimal angioplasty may be more successful than conventional (intraluminal) angioplasty for treatment of long femoropopliteal occlusions. This study assessed the clinical and haemodynamic outcome of subintimal angioplasty. METHODS: All patients with femoropopliteal occlusions treated by subintimal angioplasty over a 3-year period at two centres were reviewed. Clinical assessment and colour duplex imaging were carried out. RESULTS: Sixty-nine procedures were performed in 33 men and 33 women of median age 74 (range 47-92) years. Indications for treatment were intermittent claudication in 26 (38 per cent) and critical limb ischaemia in 43 (62 per cent). Median occlusion length was 10 (range 2-50) cm. Primary technical success was achieved in 51 occlusions (74 per cent). There were 11 complications (16 per cent); the majority were minor but surgical intervention was required in two patients (3 per cent). At 6 months the cumulative symptomatic and haemodynamic primary patency rates were 60 and 51 per cent respectively, analysed on an intention-to-treat basis. The symptomatic and haemodynamic patency rates for technically successful procedures were 80 and 77 per cent respectively. CONCLUSION: In this series the short-term clinical success of subintimal angioplasty was poor because of a high incidence of reocclusion and restenosis, despite a relatively high initial technical success rate.

Limitations of chest radiography in discriminating between aortic dissection and myocardial infarction: implications for thrombolysis.

It has been stated that chest radiographic features of aortic dissection are a contraindication to intravenous thrombolysis in patients with suspected acute myocardial infarction. Excluding aortic dissection could significantly delay such treatment in patients who would benefit from thrombolysis. Initial chest radiographs of 18 patients with acute aortic dissection and 25 patients with acute myocardial infarction were evaluated. The radiographs were studied by two experienced radiologists for signs of aortic dissection. No radiographic signs or combinations of signs accurately distinguished aortic dissection from myocardial infarction. Patients with chest radiographic signs suggesting aortic dissection but with clinical features suggesting myocardial infarction should not be denied the benefits of immediate intravenous thrombolysis.

Diagnosis of acute thoracic aortic dissection using combined echocardiography and computed tomography.

Acute dissection of the thoracic aorta is a life-threatening emergency requiring a diagnosis which is rapid, accurate and safe, and which will distinguish between dissections involving the ascending and descending aorta. In the absence of any general agreement on the best method of making this diagnosis we studied the use of combined echocardiography and contrast-enhanced computed tomography (CT) to diagnose acute aortic dissection. Over a 3 year period 23 patients were investigated in this way. Aortic dissection was demonstrated in 18 cases, involving the ascending aorta in 15, and the descending aorta alone in three. The diagnosis of aortic dissection was confirmed in 13 patients at surgery, in one at aortography and in one at autopsy. Three patients died without surgery or autopsy being performed to confirm the diagnosis and the subsequently which accounted for their symptoms. This combined approach has proved a valuable and safe means of investigating aortic dissection.

Effects of sleeping with the bed-head raised and of ranitidine in patients with severe peptic oesophagitis.

Sleeping with the bed-head raised is commonly recommended as treatment for patients with troublesome oesophagitis, but its effect has not been objectively tested. Ranitidine therapy is useful in oesophagitis, but it does not often produce complete relief of symptoms. The effects of each of these treatments alone and in combination have been studied in 71 patients with severe (grade III) peptic oesophagitis. Each treatment improved both symptoms and endoscopic appearances significantly more than placebo did. However, the combination of the two treatments was much better than either alone; the reduction in pain score and the area of ulceration healed were about twice those with either treatment alone. Smoking more than five cigarettes per day or drinking more than 30 g alcohol per day significantly reduced the effectiveness of ranitidine therapy, but age, sex, body weight, or the presence of a hiatus hernia had no detectable effect.