The role of endorectal ultrasound in therapeutic decision-making for local vs. transabdominal resection of rectal tumors.

INTRODUCTION: In rectal tumors, preoperative biopsies frequently fail to diagnose an invasive carcinoma. Endorectal ultrasound is considered a useful adjunct in preoperative staging of rectal tumors. However, feasibility of endorectal ultrasound and its role in therapeutic decision-making in presumed rectal adenomas is sparsely studied. METHODS: Endorectal ultrasound was performed in 268 tumors referred for local excision because biopsies showed tubulovillous adenoma. Feasibility of endorectal ultrasound was studied and ultrasound staging was compared with definite histopathologic findings. RESULTS: In 231 tumors, endorectal ultrasound was technically feasible (86 percent). Median distance from the dentate line was 11 cm in nonassessable tumors and 7 cm in assessable tumors (P < 0.001). In 21 tumors, endorectal ultrasound was not conclusive, mainly in tumors being recurrent or after recent endoscopic manipulation (P < 0.001). With endorectal ultrasound the rate of preoperative missed carcinomas could be reduced from 21 to 3 percent (P < 0.01). In diagnosing tubulovillous adenomas, sensitivity and specificity of endorectal ultrasound was 89 and 86 percent, respectively. CONCLUSIONS: Endorectal ultrasound is technically feasible in almost all presumed rectal adenomas, referred for local excision. Proper endorectal ultrasound interpretation is possible in 78 percent of all presumed rectal adenomas. Endorectal ultrasound is very reliable in diagnosing tubulovillous adenomas, and therapeutic decision-making regarding local excision vs. radical surgery based on endorectal ultrasound is valid.

The significance of venography in the management of patients with clinically suspected pulmonary embolism.

The accurate diagnosis of pulmonary embolism causes many problems. Clinical signs are non-specific, and ventilation-perfusion lung scanning has high sensitivity but variable specificity. In more than 90% of cases a pulmonary embolus is derived from deep venous thrombosis in the lower extremities. We have performed a prospective study to evaluate venography in the management of patients with suspected pulmonary embolism. A total of 169 patients were included in the study, and a ventilation-perfusion scan was performed in all cases. Forty-four (26%) patients had a normal scan and treatment was not given (group A). The other 125 (74%) patients, who had an abnormal scan, underwent bilateral venography. Venous thrombosis was demonstrated in 63 patients, and they were treated with oral anticoagulants for 3 months (group B). The remaining 62 patients, who showed no venous thrombosis, did not receive anticoagulant therapy (group C). During follow-up, 1 patient in group A, 3 patients in group B and 1 patient in group C developed a new deep venous thrombosis. One patient in group B suffered a pulmonary embolus. It is concluded that venography of the lower extremities can be of additional value in the management of patients with pulmonary embolism when the lung scan does not provide sufficient information.

A new computerized impedance plethysmograph: accuracy in the detection of proximal deep-vein thrombosis in symptomatic outpatients.

Because of the lack of specificity of the clinical diagnosis it is appropriate in patients with clinically suspected deep-vein thrombosis to apply an objective test before starting anticoagulant treatment. Impedance plethysmography is a highly accurate technique for the detection of proximal-vein thrombosis with a reported sensitivity and specificity of 93 and 97%, respectively. In all previous reported evaluations of impedance plethysmography an apparatus which was developed in 1971 was used. A new computerized impedance plethysmography, using a novel device to measure impedance, was blindly compared against venography in 443 consecutive outpatients with clinically suspected deep-vein thrombosis. In the first phase of the study the computerized impedance plethysmography test results of 242 symptomatic patients were used to develop a discriminant line. Subsequently, this discriminant line was validated in the second phase of the study in another 201 symptomatic patients. The combined sensitivity and specificity of these two phases for proximal-vein thrombosis was 91% [95% confidence interval (CI), 86 to 94%] and 94% and (95% CI, 90 to 96%), respectively, which compares favourably with impedance plethysmography. It is concluded that computerized impedance plethysmography is a simple, portable, non-invasive technique with a high accuracy for the detection of proximal vein thrombosis. However, before computerized impedance plethysmography can be used as the only test in the diagnosis of deep-vein thrombosis, the safety of withholding anticoagulant treatment to patients with repeated normal computerized test results should be assessed during long-term follow-up studies.

Prophylaxis of deep venous thrombosis with a low-molecular-weight heparin (Kabi 2165/Fragmin) in stroke patients.

In a group of 60 patients in the acute phase of an ischemic stroke the assumption that low-molecular-weight heparin Kabi 2165 in the dose of 2 X 2,500 anti-Xa units s.c. could prevent thromboembolic complications was tested using a double-blind, placebo-controlled, randomized trial design. Thirty patients were allocated to each group. Both treatment groups were comparable with regard to neurological status and general condition. In the Kabi 2165 group there were 6 cases of deep venous thrombosis (DVT) compared to 15 in the placebo group (p = 0.05). In the placebo group there were 4 deaths during the trial versus 9 in the Kabi-2165-treated group (NS). Cerebral bleeding complicated 2 cases in the placebo group versus 4 in the Kabi 2165 group (NS). These results indicate that in ischemic stroke patients Kabi 2165 2 X 2,500 anti-Xa units s.c./24 h reduces the frequency of DVT. Because of the small number of patients it is impossible to evaluate the safety.

The value of adding thermographic leg scanning to impedance plethysmography in the detection of deep vein thrombosis.

The clinical value of adding thermographic leg scanning to impedance plethysmography was evaluated and compared in 52 patients with clinically suspected deep venous thrombosis. Both tests were performed on the day of referral and phlebography within 72 hours. The sensitivity of thermography was 83%, the specificity 41% and the accuracy 61%. In comparison IPG had a sensitivity of 83%, a specificity of 96% and an accuracy of 90% The combination of thermography and IPG showed a sensitivity of 92%, a specificity of 41% and an accuracy of 65%. It is concluded that the addition of thermography to IPG is of no clinical value.

Vascular ectasias (angiodysplasias) of the cecum and the ascending colon.

Over a period of two years (1977-1979) the diagnosis symptomatic vascular ectasias of the colon was made in 7 patients. The authors describe 3 cases with corresponding illustrations. The diagnostic value of selective mesenteric artery angiography and fiber endoscopy for the diagnosis and treatment is stressed. The possible pathogenesis of the vascular abnormality is discussed with reference to the histology and the literature.