Critical decisions in the management of endoscopic perforations of the colon.

The ideal management of suspected colon perforation following colonoscopy remains elusive because the incidence is only 0.1 to 2.0 per cent. The patient with obvious perforation deserves immediate exploration, but the patient with equivocal findings poses a diagnostic dilemma. We propose an algorithm based on the results of water-soluble contrast enema that allows for rapid, definitive surgical decision-making. If perforation is confirmed, early operation allows for primary repair without resection or colostomy, or if no perforation is identified, medical management can be undertaken with confidence. This algorithm should ensure that the surgical management of this potentially lethal complication is not unnecessarily delayed.

Technique of esophageal dilation.

The widespread use of flexible upper gastrointestinal (GI) endoscopy has renewed interest in management of strictures of the esophagus, including dilation. The rubber Maloney dilator is the most common dilator used, usually for symmetrical strictures 1.2 cm or greater in diameter. The "through the scope" (TTS) balloon dilators usually are used in asymmetrical strictures 1.2 cm or greater in diameter and are especially valuable if fluoroscopy is not available. The new thermoplastic Savary dilators, used with a guidewire and usually with fluoroscopy, have replaced the Eder-Puestow bougies. They are especially useful in difficult strictures that are 1.0 cm or less in diameter and are fibrotic or have transmural fibrosis.

Management of foreign bodies of the upper gastrointestinal tract: update.

Management of 242 foreign bodies of the upper gastrointestinal tract are reported. Thirty-nine were in the pharynx, 181 in the esophagus, 19 in the stomach, and 3 in the small bowel. The flexible panendoscope was used 211 times (87.2%) to manage these foreign bodies, while the rigid esophagoscope was used 12 times (5.0%). Two hundred thirty-nine foreign bodies (98.8%) were successfully managed endoscopically. The surgery rate was 0.4%. There was no morbidity or mortality. Twenty-five percent of the cases were done under general endotracheal anesthesia. Coins in the esophagus are removed promptly if in the cervical or mid esophagus, and within 12 hours if in the distal esophagus. Once in the stomach, they will usually pass without difficulty. Meat impaction resulting in an obstructed esophagus is an urgent problem and the bolus should be removed within hours. Sharp and pointed foreign bodies can be very difficult to manage. Dry runs with a reproduction of the foreign body are essential to successful removal. Button batteries lodged in the esophagus represent an emergency and should be removed without delay. Once in the stomach, they will usually pass through the gastrointestinal tract without difficulty. The forward-viewing flexible panendoscope has become the instrument of choice in managing foreign bodies in most tertiary medical centers as well as in the community hospitals.

Colonoscoping the "difficult" colon.

Despite the popularity of colonoscopy, very little has been published on specific technique. There are many factors that make colonoscopy easy or difficult, but the most important one is the endoscopist himself/herself. One must have excellent manual dexterity and technical ability; and, above all, one must perform enough cases to gain the needed experience to understand the procedure and to perform it rapidly, successfully, and safely. There are only so many maneuvers that can be carried out with a colonoscope, such as pushing it in, withdrawing it, turning it to the right, left, up, or down. Therefore, decision making (options), such as changing the position of the patient or applying external pressure points, must be performed rapidly before too many repetitive false moves are made. Options for each anatomical segment of the colon are outlined, based on an experience of ten thousand colonoscopies.

Practice locations of Texas family practice residency graduates, 1979-1987.

The location of a physician's residency training is known to be a factor in selection of a practice location. In this paper, the authors analyze the practice locations of 689 family physicians who graduated from residency programs in Texas between 1979 and 1987 and who were practicing in Texas in 1988. One-third of these graduates were practicing in cities the same size as their residency program city. More than half were in counties located within 60 miles of the residency city. Both of these trends can be explained to a large degree by the fact that a high percentage of graduates remained in their residency city to practice. When these nonmobile graduates are removed from the sample, the findings show no correlation between the size of the residency city and the size of the practice city. More than two-thirds of those graduates who left their residency city were in counties beyond a 60-mile radius. Almost two-thirds were practicing in communities of less than 25,000 population. The authors conclude that state support for family practice residency training has been effective in distributing family physicians in a manner that addresses the needs of the state of Texas as a whole.

Metastatic colon carcinoma to the biliary tract mimicking choledocholithiasis.

This case is reported because of its rarity and in order to demonstrate that, using ERCP, it can be difficult at times to differentiate not only primary from metastatic diseases of the common duct, but also both of these malignant conditions from benign choledocholithiasis.

Esophageal dilation: personal experience with current instruments and techniques.

The popularity and widespread use of flexible panendoscopy has produced a dramatic change in the management of benign strictures of the esophagus. Most are now managed medically. Two new esophageal dilators, the balloon and Savary, have made a major impact on the endoscopist's armamentarium. The Maloney dilator is still used 56% of the time, in the author's experience with strictures that are symmetrical and greater than 1.2-1.4 cm in diameter. Hydrostatic balloon dilators are used 24% of the time with strictures that are asymmetrical and 1.2 cm or more in diameter. The Savary thermoplastic dilators have replaced Eder-Puestow dilators and are used 20% of the time in strictures 1.2 cm or less in diameter. Morbidity and mortality rates should be under 1% with all dilators and are 0.1% and 0.05%, respectively, in the author's last 2000 dilations.

Management of foreign bodies of the upper gastrointestinal tract.

In the United States, 1500 people die yearly of ingested foreign bodies of the upper gastrointestinal tract. The flexible esophagogastroduodenoscope has had a major impact on the treatment of these foreign bodies. The following discussion includes the management of coins, meat impaction, sharp and pointed objects, button batteries, and cocaine packets; and it reflects both a personal experience and a review of the literature. The uses of the rigid and the flexible endoscopes, the Foley catheter, glucagon, papain, and gas-forming agents are presented. The cost-effectiveness impact of the flexible endoscope is also detailed, and morbidity and mortality rates for foreign body management are included.

Patient management after endoscopic removal of the cancerous colon adenoma.

The subject of management of patients after endoscopic removal of cancerous adenomas is controversial. A retrospective review of 126 lesions in 121 patients who had had colonoscopic polypectomy of malignant lesions between 1971 and 1985 was used to determine the criteria for colon resection. Invasive cancer was identified in 80 patients, while 41 patients had carcinoma in situ. A synchronous colon cancer was found in five of the 121 patients. The patients who had carcinoma in situ had no evidence of residual tumor or metastatic disease on subsequent follow-up (colon resection in three patients and endoscopic surveillance in 38 patients). Of the 80 patients with invasive cancer, 44 had subsequent colon resection, and 34 of these had no evidence of tumor in the resected bowel or mesenteric lymph nodes. Ten patients had residual tumor, metastatic cancer to regional lymph nodes, or both. Each of the 10 had at least one of the following indications of inadequate resection or dissemination of disease to local lymph nodes (the first indication is a macroscopic evaluation, while the remaining four are all microscopic): incomplete excision, poorly differentiated tumor, invasion of the line of resection, invasion of the polyp stalk, and invasion of venous or lymphatic channels. Present recommendations for patient management after endoscopic removal of an invasive malignant adenoma should include colon resection with regional lymphadenectomy for patients with one or more of these five criteria. Patients without any of these risk factors should have early repeat endoscopic examination 3 months after initial polypectomy to evaluate the polypectomy site. Total colonoscopic examination is repeated at 1 year to ensure the surveillance program is begun with a colon without neoplasms.

Endoscopic criteria for malignancy in colon adenomas. The dunce cap adenoma.

Histologic criteria for malignancy in colonic adenomas have been well established, but little has been written regarding the gross or macroscopic appearance of malignant adenomas. The following nine criteria, listed in order of most to least importance, were used to endoscopically evaluate polypoid lesions of the colon: friability, ulceration, firmness, the dunce cap sign, lobulation, asymmetry, size, macroscopic growth pattern, and color. Three cases of the dunce cap adenoma are reported in detail. In evaluating 121 consecutive colonic lesions, 87 percent were resected endoscopically. Eleven carcinomas, three villous adenomas, and two lipomas were not removed via the endoscope.

Experience with 1000 colonoscopic polypectomies.

Experience with 1000 consecutive polypectomies in 591 patients, from December 1975 to October 1982, is reviewed. There were 633 adenomas, 292 hyperplastic, and 75 miscellaneous polyps. While eight minor bleeding episodes (0.8%) occurred, there were no major complications (perforations or bleeding requiring transfusion). The polyp retrieval rate was 97.9%. Of the 633 adenomas, seven (1.1%) had in situ carcinoma and ten (1.6%) invasive. Eight of the invasive group underwent colon resection with no positive nodes present. Anatomic location demonstrated a shift to the right side of the colon. Three hundred thirty-six (53.1%) were in the rectosigmoid; 134 (21.3%) were in the left colon; 79 (12.3%) were in the transverse colon; and 84 (13.3%) were in the right colon and cecum. Patients who have undergone benign polypectomy are colonoscoped again in 1 year, and, if negative, every 3 years thereafter. Postpolypectomy patients with malignant adenomas require closer observation. Endoscopic polypectomy, with its lower morbidity and mortality, has revolutionized the treatment of the colon polyp. It is also more cost-effective, with outpatient polypectomy being 29 times less expensive and inpatient polypectomy four times less expensive than transabdominal polypectomy.

The distribution of an oil-based corticosteroid following intralymphatic infusion.

Following infusion of tritium labeled clobetasol propionate in Ultrafluid Lipidol (UFL) into a right hind limb lymphatic of rabbits, the radioactivity levels in various tissues at intervals up to 28 days were determined by liquid scintillation counting. There was a rapid decline in activity in the right popliteal node over the first three days due to early bloodstream absorption. From three to 28 days radioactivity levels were consistently higher in the right popliteal node and lung than in other tissues sampled. This distribution suggests that there is an affinity between clobetasol and the lipidol vehicle which retards (but does not prevent) free diffusion of this agent out of lymphatic tissues. Thus, while permitting generalized perfusion of tissues by clobetasol propionate, intralymphatic infusion maximizes its initial concentration and duration of activity within specific node groups and, therefore, may be useful in certain patients with primary lymphedema where lymph nodes affected by fibrosis constitute a major site of obstruction.

Foreign bodies of the upper gastrointestinal tract: current management.

The popularity of the flexible esophagogastroduodenoscope prompted us to reevaluate our management of foreign bodies. In this paper we report our experience and update treatment guidelines. In our series (from December 1975 to May 1982), 74 foreign bodies were removed: 12 with the rigid endoscope, 60 with the flexible endoscope, and two surgically. There was no morbidity or mortality. In the age group 1 to 10 years, there were 15 patients, while the age group 11 to 88 years had 59 patients. Although the rigid endoscope is less expensive and has a larger operating channel, the advantages of the flexible instrument are numerous. Foreign bodies of the pharynx and at the level of the cricopharyngeus muscle are best managed with a rigid endoscope; foreign bodies of the esophagus can be managed with rigid or flexible instruments, but are more easily managed with the latter. Foreign bodies of the stomach and duodenum that require removal can be managed only with the flexible panendoscope.

The use of endoscopy in assessment and treatment peptic strictures of the esophagus.

In the 1960s, evaluation of peptic strictures of the esophagus was a significant and difficult clinical problem. The use of rigid esophagoscopes and general anesthesia resulted in high complication rates. Most peptic esophageal strictures were managed surgically. The 1970s brought a dramatic change in the management of peptic strictures of the esophagus. With the introduction and widespread use of the forward-viewing, flexible panendoscope for upper gastrointestinal (GI) endoscopy, general anesthesia is no longer needed; evaluation of the peptic stricture has become one of the most common procedures in GI endoscopy. From December 1975 to October 1982, 1000 dilations were performed with a morbidity of 0.2 per cent and a mortality of 0.1 per cent. Initially, radiographic evaluation proximal to, distal to, and at the stricture is conducted. Endoscopic evaluation of the same three areas is then performed with emphasis on determining whether the stricture is benign or malignant. Malignancy can be determined visually in more than 90 per cent of the patients and in more than 95 per cent of the patients with multiple biopsies and cytology. Immediate dilation, using rubber (Maloney) dilators (Pilling Medical Co., Fort Washington, PA) or Eder-Puestow dilators (Eder Instrument Co., Chicago, IL), is then performed. The personality of the stricture determines which dilator can be used with greatest safety.

Endoscopic evaluation of dysphagia in two hundred and ninety-three patients with benign disease.

A total of 538 dilations were performed upon 293 patients evaluated at our unit. Of these, 4.8 per cent had cervical webs, 3.0 per cent had cricopharyngeal dysfunction, 9.2 per cent had undetermined cause, 3.4 per cent had achalasia, 65.5 per cent had peptic strictures, 3.8 per cent had Schatzki's ring, 2.4 per cent had esophagitis, 6.1 per cent had postoperative strictures, 0.3 per cent had caustic stricture and 1.4 per cent had extrinsic compression. True dysphagia should always be investigated through a careful history, physical examination, barium study, endoscopy and, infrequently, esophageal manometry.

Endoscopic evaluation of 125 cases of upper gastrointestinal bleeding.

The fiberoptic panendoscope has been shown to be superior to the UGI series in diagnosing the site(s) of upper gastrointestinal bleeding (UGIB). Recent data has shown that gastritis has replaced peptic ulcer disease (PUD) as the leading cause of UGIB since the diagnosis can now be made with the endoscope. Our clinical experience differs from this. One hundred twenty five cases of UGIB from December 1975 to December 1978 were reviewed. The patients ranged in age from 11 to 91 years. There were 83 males and 42 females included in the study. Twenty-four per cent of the patients were actively bleeding at the time of endoscopic examination, and 62% received two or more units of blood. Endoscopic examination was technically successful in all patients, and there were no deaths or complications. One hundred twenty three lesions were found in 117 patients for a diagnostic accuracy of 93.9%. In eight patients, no bleeding site was found, resulting in a failure rate of 6.1%. PUD accounted for 74.9% of the bleeding sites, while gastritis accounted for only 0.8%. Mallory-Weiss tears of the esophagus accounted for 9.8% and esophageal varices for 4.9%. Thirty-five per cent of the patients had associated lesions, with gastritis and esophagitis being the most common. Eighteen patients (14.4%) required surgical intervention. Seventeen patients had PUD. There was one death, for a mortality rate of 5.5%. The medical mortality rate was 0.9%. The benefits of endoscopy in UGIB are still controversial. An important subgroup of patients with the "visible vessel" in the ulcer bed has been identified recently by others. If not bleeding at the time of endoscopy, 70% will rebleed. It is our opinion that it is important to identify this patient, as well as to know if one is treating gastritis, PUD, or varices. Finally, electrocoagulation of bleeding points, as well as the development of the laser and application of adhesives or clotting agents through the endoscope, will change the management of UGIB.

Chain saw injuries: review of 330 cases.

Three hundred thirty chain saw injury patients arriving at the emergency clinic of a community hospital in the southeast United States between 1972 and 1979 were reviewed. Forty-eight patients were admitted to the hospital with severe injuries requiring extensive repair; another was dead on arrival at the emergency clinic. The retrospective study reveals a typical pattern in chain saw injuries as injuries caused by other power tools have typical patterns: the majority of the injuries occur on the left side. Most injuries are caused by saw kickback, upward or downward; the face (not usually eyes), neck, hands and feet are most frequently injured. The findings suggest that many of these extensive, expensive injuries can be prevented by proper equipment and training, and by operator compliance with safety procedures. An automatic motor brake is now being installed on many saws, and laws are being prepared to make its use mandatory.