Endoscopic ultrasound, endoscopic sonoelastography, and strain ratio evaluation of lymph nodes with histology as gold standard.

BACKGROUND AND STUDY AIMS: Accurate lymph node staging is essential for the selection of an optimal treatment in patients with upper gastrointestinal cancer. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are considered to be the most accurate method for locoregional staging. Endoscopic sonoelastography (ESE) assesses the elasticity of lymph nodes and has been used to differentiate lymph nodes with promising results. The aim of this study was to evaluate the use of EUS, EUS - FNA, ESE, and ESE-strain ratio using histology as the gold standard. PATIENTS AND METHODS: Patients with upper gastrointestinal cancer who were referred for EUS examination were enrolled if surgical treatment was planned and the patient had a lymph node that was accessible for EUS - FNA and EUS-guided fine-needle marking (FNM). The lymph node was classified using EUS, ESE, and ESE-strain ratio. Finally, EUS - FNA and EUS - FNM were performed. The marked lymph node was isolated during surgery for histological examination. RESULTS: The marked lymph node was isolated for separate histological examination in 56 patients, of whom 22 (39 %) had malignant lymph nodes and 34 (61 %) had benign lymph nodes. There were no complications of EUS - FNM. The sensitivity of EUS for differentiation between malignant and benign lymph nodes was 86 % compared with 55 % - 59 % for the different ESE modalities. The specificity of EUS was 71 % compared with 82 % - 85 % using ESE modalities. CONCLUSION: The use of the EUS - FNM technique enabled the identification of a specific lymph node and thereby the use of histology as gold standard. ESE and ESE-strain ratio were no better than standard EUS in differentiating between malignant and benign lymph nodes in patients with resectable upper gastrointestinal cancer.

Endoscopic ultrasound-guided fine-needle marking of lymph nodes.

BACKGROUND AND STUDY AIMS: No previous studies have evaluated the ability of endoscopic ultrasonography to describe the anatomic location of lymph nodes on the basis of a node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new endoscopic ultrasound (EUS)-guided fine-needle technique for marking lymph nodes. PATIENTS AND METHODS: Twenty-five patients with suspected or confirmed malignancies of the upper gastrointestinal tract were prospectively included. EUS-guided fine-needle marking (EUS-FNM) was performed with a silver pin with a diameter that allowed it to fit into a 19-gauge needle. The position of the pin was verified by EUS. End points were the ability to identify and isolate the marked lymph node during surgery and a comparison between the location of the pin as suggested by EUS and the actual location found in the resected specimen. RESULTS: Twenty-three lymph nodes were marked. Nineteen intended surgical isolations were performed. The lymph nodes were isolated in the resection specimens in 18 patients (95 %). In 2 out of 20 cases the pin was not localized by laparoscopic ultrasonography. In 89 % of the cases the marked lymph node was in the same location as described by EUS. One pin (5 %) was not retrieved. In three cases, a small hematoma was observed. There was no sign of long-term complications. CONCLUSION: EUS-FNM with a silver pin in lymph nodes is feasible and safe. EUS-FNM seems to be a suitable tool for evaluating lymph nodes on the basis of a node-to-node comparison.

A new method for three-dimensional laparoscopic ultrasound model reconstruction.

BACKGROUND: Laparoscopic ultrasound is an important modality in the staging of gastrointestinal tumors. Correct staging depends on good spatial understanding of the regional tumor infiltration. Three-dimensional (3D) models may facilitate the evaluation of tumor infiltration. The aim of the study was to perform a volumetric test and a clinical feasibility test of a new 3D method using standard laparoscopic ultrasound equipment. METHODS: Three-dimensional models were reconstructed from a series of two-dimensional ultrasound images using either electromagnetic tracking or a new 3D method. The volumetric accuracy of the new method was tested ex vivo, and the clinical feasibility was tested on a small series of patients. RESULTS: Both electromagnetic tracked reconstructions and the new 3D method gave good volumetric information with no significant difference. Clinical use of the new 3D method showed accurate models comparable to findings at surgery and pathology. CONCLUSIONS: The use of the new 3D method is technically feasible, and its volumetrically, accurate compared to 3D with electromagnetic tracking.

[Gastroschisis and omphalocele. Treatment and results]. / Gastroschisis og omphalocele. Behandling og resultater.

Between 1976 and 1988, 28 neonates with gastroschisis and 44 with omphalocele were treated. In 44 patients primary closure was achieved, while silastic prostheses were used in 23 patients, and dura implant in three patients. Two patients were not treated. The mortality rate was 8% (4/52) among the patients without serious congenital defects and birth weights over 1,800 g. This mortality was mainly caused by bowel infarction and, in infants with birth weights below 1,800 g, by the respiratory distress syndrome. Our experience suggests that ventilatory assistance with total paralysis is mandatory per- and postoperatively. The handling of these abdominal wall defects demands transport in an incubator with a nasogastric tube in place, a sterile bowel bag and replacement of fluid loss. Bowel stretch at the edge of the defect should be minimized in order to reduce the risk of bowel infarction. The favorable results of treatment of these malformations depend less on birth weight than on the presence of other serious congenital defects which are decisive for the mortality.

[Rectoscopy and Hemoccult II in irritable colon. A prospective study]. / Rektoskopi og Hemoccult-II ved colon irritabile. En prospektiv undersøgelse.

It was investigated whether Hemoccult-II test (H-II) could reduce the number of colonic examinations in patients with the irritable bowel syndrome, with normal rigid proctoscopic findings. A negative H-II was obtained in 299 patients from general practice and a positive test in nine. Colonoscopy was done in 157 and double contrast barium enema in 142 after random allocation. The nine patients with positive H-II all had colonoscopy. Among the 299 with negative H-II, colonic adenomas were detected in ten and an early cancer in an adenoma in the sigmoid colon; overlooked rectal adenomas were found in three, rectal cancer in one, rectal carcinoid in another and a coecal cancer, which could be palpated, in a third patient. Two patients with colonic cancer and one with adenoma were detected among those with positive H-II. All patients were followed by clinical examination after one year. In conclusion, colonic examination should carry a low priority in patients with symptoms of irritable bowel, negative Hemoccult-II and normal rigid proctoscopic findings performed by an experienced examiner. The investigation confirmed the recommendation of total colonoscopy in patients with a positive H-II and added support for increasing number of endoscopy services in contrast to those of diagnostic radiology, which should be reduced.

[Pre-therapeutic assessment of resectability in patients with upper gastrointestinal cancer. Combined use of endoscopic ultrasonography and laparoscopy]. / Praeterapeutisk resektabilitetsvurdering af patienter med øvre gastrointestinal cancer. Kombination af endoskopisk ultralydskanning og laparoskopi.

The combined use of endoscopic ultrasonography (EUS) and laparoscopy for the assessment of resectability in patients with upper GI tract cancer was prospectively evaluated in 57 patients. Laparoscopy was able to fill the informational gap in all the patients (n = 6) where EUS failed to give a complete assessment of resectability. This study suggests that the combination of EUS and laparoscopy can reduce the need for "necessary" laparoscopies to about 10%.

[Preoperative laparoscopic evaluation of patients with upper gastrointestinal cancer]. / Laparoskopisk operabilitetsvurdering af patienter med øvre gastrointestinal cancer.

Nineteen consecutive patients with adenocarcinoma of the stomach or pancreas, in whom preoperative ultrasonography and computed tomography were unable to assess the possibility of surgical resection, had a diagnostic laparoscopy performed. In 16 cases the operability could be established from the findings at laparoscopy. All laparoscopies were carried out without major morbidity and with a short postoperative hospital stay. It is concluded that patients belonging to this category should have a diagnostic laparoscopy performed in order to avoid futile laparotomies, which in cases that are unsuitable for surgical treatment are associated with emotional stress, physical morbidity and a prolonged hospital stay.

[Laparoscopic ultrasonography. A review and authors' own experiences]. / Laparoskopisk ultralydskanning. Oversigt og egne erfaringer.

Laparoscopic ultrasound scanning has long been available, but interest in and reports of the technique have until the last few years been sporadic. The rapid development and growing interest in laparoscopic surgery as well as the advent of commercially available systems designed for laparoscopic ultrasound have resulted in renewed interest in the technique. The available published reports lack prospective, controlled clinical studies with respect to where and when laparoscopic ultrasound would be indicated. A favourable picture is given as concerns the use of laparoscopic ultrasound in the diagnosis and evaluation of primary liver and pancreas tumours as well as liver metastases. Laparoscopic ultrasound is also mentioned as a reliable alternative to cholangiography in laparoscopic cholecystectomy. Our own preliminary experiences with two laparoscopic ultrasound systems and a simple system using an ultrasound finger-probe are described. A laparoscopic ultrasound scanning system consisting of a stiff instrument with a convex (linear) transducer mounted on a flexible support and with the possibility of ultrasound-guided biopsy and colour-Doppler seems optimal. Prospective studies are being carried out to identify areas of utilization and limitations of laparoscopic ultrasound.

[Endoscopic ultrasonography of malignant tumors in the upper abdomen]. / Endoskopisk ultralydskanning af maligne tumorer i øvre abdomen.

Endoscopic ultrasonography (EUS) of the upper gastrointestinal tract is a newly developed, non-invasive investigational method. It combines the direct optical picture of the endoscope with a simultaneous ultrasonographic image of the whole wall of the oesophagus, stomach and duodenum as well as organs and other structures with anatomical relations to the upper gastrointestinal tract. EUS is evaluated for its capacity with respect to cancer of the oesophagus, stomach, pancreas, biliary tree and neuroendocrine tumours, the emphasis being laid on TNM-classification, assessment of resectability and comparison with other imaging techniques. It is concluded that EUS is well-suited for assessing tumour infiltration and thereby also the resectability of these cancer types. Judging whether lymph nodes visualized by EUS are malignant or not is difficult when operating solely from endosonographic and quantitative criteria, and while the sensitivity of EUS for detecting lymph node metastases is in most situations superior to other investigational methods, the specificity and ability to visualize distant metastases is poor. For these purposes the optimal solution appears to be a combination of EUS with CT and/or ultrasound scanning. Future possibility of EUS-guided biopsy will strengthen the method's position in the diagnostic armoury concerning malignant disease in the upper gastrointestinal tract.

[Curative treatment of ventricular cancer]. / Kurativ behandling af cancer ventriculi.

Extended lymphadenectomy on connection with the surgical treatment of gastric cancer is gaining access in western centres especially since Japanese centres have shown an ever increasing rate of survival over several decades, coupled with the fact that operative procedures have become more sophisticated. The latest prospective studies in the west seem to confirm the value of lymphadenectomy in some patients. Furthermore, correct staging demands extended lymphadenectomy. For patients with gastric cancer, adjuvant preoperative chemotherapy is probably an asset.

Vagotomy.

Peptic ulcer disease was for years a common indication for surgery in Danish hospitals and considerable experience in partial gastrectomy was gained. In spite of an unquestionable mortality rate and a number of patients having postgastrectomy complaints, results were generally recognized as acceptable. Danish surgeons were for long reluctant to take up vagotomy and drainage as a primary ulcer operation, but when they did start a large number of procedures were performed. In fact, the use of this treatment culminated during two to three decades. However, on a basis of experiences from these years, Danish research contributed actively to the international evolution of the surgical vagotomy technique, the evaluation of clinical results and the studies of postoperative alterations in gastric physiology. References are selected from an extensive literature and are in no way complete.

Adrenergic influence on gastric mucosal blood flow in gastric fistula dogs.

The aim of this study was to examine the influence of alpha-, beta- and dopaminergic receptors on gastric mucosal blood flow during "high", "normal", and "low" vagal conditions obtained by stimulation with bethanechol and pentagastrin and by parietal cell vagotomy respectively. During pentagastrin and bethanechol stimulation, a linear relationship between gastric acid secretion and mucosal blood flow was observed. During pentagastrin stimulation, dopamine (40 micrograms/kg/min) did not change the blood flow values while a decrease in acid secretion was found. During bethanechol stimulation dopamine (10 micrograms/kg/min) induced an increase in mucosal blood flow and a similar increase in acid secretion. If the dopamine infusion was preceded by alpha-receptor blockade, a pronounced increase in mucosal blood flow was observed without a similar increase in acid secretion. beta-adrenergic stimulation (isoprenaline) reduced the pentagastrin and bethanechol stimulated gastric acid secretion without a similar decrease in mucosal blood flow. beta-blockade (propranolol) increased the pentagastrin stimulated gastric acid secretion in parietal cell vagotomized dogs. This increase in acid output was preceded by an initial increase in mucosal blood flow and in the last two periods a decrease in blood flow. alpha-Blockade (phentolamine) reduced the pentagastrin stimulated gastric acid secretion and gastric mucosal blood flow but the ratio between blood flow and acid secretion was increased, indicating a relatively increasing effect on mucosal blood flow. One may conclude that blood flow and acid secretion are not unconditionally linked and that at least two different mechanisms are involved in blood flow changes in the stomach.(ABSTRACT TRUNCATED AT 250 WORDS)

Dopaminergic and beta-adrenergic effects on gastric antral motility.

Stimulation of splanchnic nerves and application of adrenergic drugs have been shown to give variable effects on gastric motor activity depending especially on the background activity. beta-adrenoceptors and dopaminergic receptors mediate inhibitory effect on proximal gastric motor activity. The purpose of the present study was to evaluate the effects of isoprenaline, a beta 1- and beta 2-agonist, and dopamine on gastric antral motility in gastric fistula dogs. Dopamine was used alone and in conjunction with selective blockade of adrenergic and dopaminergic receptors during infusion of bethanechol or pentagastrin inducing motor activity patterns as in the phase III of the MMC and the digestive state respectively. The stimulated antral motility was dose-dependently inhibited by dopamine. The effect was significantly blocked by specifically acting dopaminergic blockers, while alpha- and beta-adrenergic blockers were without any significant effects. Dose-response experiments with bethanechol and dopamine showed inhibition of a non-competitive type. Isoprenaline was used alone and in conjunction with selective blockade of beta 1- and beta 2-receptors during infusion of bethanechol which induces a pattern similar to phase III in the migrating myoelectric complex. The stimulated antral motility was dose-dependently inhibited by isoprenaline. The effect could be significantly blocked by propranolol (beta 1 + beta 2-adrenoceptor blocker) and by using in conjunction the beta 1-adrenoceptor blocker practolol and the beta 2-adrenoceptor blocker H 35/25. The dose-response experiments showed inhibition of a non-competitive type. These studies indicate that gastric antral motility is inhibited by isoprenaline through both beta 1- and beta 2-receptors and by dopamine through specific dopaminergic receptors.

Postvagotomy acid secretion and mucosal blood flow during beta-adrenoceptor stimulation and universal chemical sympathectomy in dogs.

The aim of the present study was to examine the effect of beta-adrenoceptor stimulation, alpha blockade, and elimination of the adrenergic nerve function on mucosal blood flow and acid secretion in parietal-cell-vagotomized (PCV) gastric fistula dogs. Isoprenaline inhibited pentagastrin-stimulated gastric acid secretion via the beta 1 receptors non-competitively. The effect of isoprenaline was more pronounced after vagotomy than before vagotomy and significantly more pronounced than the effect on parasympathomimetically stimulated (bethanechol) gastric acid secretion. The animals were subjected to chemical sympathectomy with 6-hydroxy-dopamine, a false neurotransmitter that selectively destroys the adrenergic nerve terminals. Chemical sympathectomy increased the pentagastrin-stimulated gastric acid secretion and stabilized the mucosal blood flow at the level before vagotomy, but with an increased ratio between blood flow and acid secretion. One may conclude that the sympathetic nerve system influences gastric function after vagotomy.

Polyglycolic acid (Dexon) sutures in Escherichia coli infected urine.

The tensile strength, knot strength and stretch of polyglycolic acid (Dexon) was studied after emersion in physiological saline, sterile urine and infected urine. Tests were made each day under controlled conditions over a 10 day period. The results are compared with those of other earlier studies. Tensile strength, knot strength and stretch were found to be fully acceptable in all studies, and there are no grounds to advise against the use of Dexon when urine is infected.