Pre-operative gastric emptying time correlates with clinical response to gastric electrical stimulation in the treatment of gastroparesis.

BACKGROUND: Gastric electrical stimulation (GES) may be of benefit in cases of gastroparesis that fail to respond to standard medical therapy. Response to this treatment is varied and prediction of clinical improvement is difficult. METHODS: This was a retrospective review and symptom questionnaire survey for all patients who underwent GES insertion in a single institution from November 2008 until May 2010 using the gastroparesis cardinal symptom index (GCSI). RESULTS: 14 out of 17 patients who had GES insertion responded to telephone or postal questionnaire. Mean pre-operative gastric emptying time was 151 min (median 146 min, range 18-318). Median follow up was 14 months (range 7-25 months). The mean reduction in GCSI score after GES insertion was 51% (13.4 vs 6.4, Z = 0.0013). Percentage reduction in GCSI correlated with pre-operative solid gastric emptying time (p = 0.0086). Two patients who responded to questionnaire required device removal, one due to a gastric perforation and the other for discomfort related to the implant and a poor clinical response. CONCLUSIONS: GES significantly improves symptoms of gastroparesis on the GCSI score. Not all patients respond equally to GES, and response may be predicted by pre-operative solid gastric emptying times.

Validity of segmental transit studies used in routine clinical practice, to characterize defaecatory disorder in patients with functional constipation.

OBJECTIVE: Segmental colonic transit can be determined by performing regional counts of radio-opaque markers on an abdominal radiograph. It has been claimed that the pattern of markers can be used to characterize the type of constipation, with a concentration of markers seen in the rectosigmoid region in patients with defaecatory disorders. The aim of our study was to examine this hypothesis in a cohort of patients with functional constipation. METHOD: Consecutive patients presenting to a specialist constipation clinic and satisfying inclusion criteria were studied. All patients had the following assessments: radio-opaque marker study performed according to a standard protocol; proforma-based symptom assessment using Likert scoring; and radioisotope defaecating proctogram. Transit study data included total transit time, rectosigmoid transit time and geometric mean of markers. Symptom scores were recorded for straining, incomplete evacuation and digitation, together with a cumulative symptom score. Evidence of outlet obstruction from the proctogram included four previously described parameters. RESULTS: A total of 108 patients with functional constipation according to the Rome criteria with a median age of 41 years were studied. Neither rectosigmoid transit time nor the geometric centre of markers could differentiate patients with a functional defaecatory disorder (FDD). There was no correlation between the pattern of marker distribution and any of the parameters denoting outlet obstruction. CONCLUSION: Our data do not support the hypothesis that assessment of segmental transit, using standard methods applicable to routine clinical practice can determine the type of constipation. In particular, patients exhibiting evidence of FDD are no more likely to have recto-sigmoid retention of markers than those without.

Outcome of argon beam and LASER ablation of large rectal adenomas.

OBJECTIVE: Endoscopic ablation of large rectal adenomas is being increasingly used as primary treatment. Despite the avoidance of general anaesthesia and the prevention of more major procedures, patients undergoing endoscopic ablation have the disadvantage of multiple treatment sessions and the lack of adequate tissue sample for complete histological study. The aim of this study was to analyse the outcome of all patients with large rectal polyps treated with endoscopic ablation. PATIENTS AND METHODS: Between 1993 and 1998, 29 patients who underwent endoscopic ablation of large rectal adenoma were identified. All their case notes were analysed and information was collected on recurrence, treatment episodes, complications, the incidence of carcinoma and the necessity for further procedures. RESULTS: At a median 40 (range 4-67) months follow-up, 41% of patients had recurrence of their adenoma and 14% had been diagnosed with adenocarcinoma. Only 24% of patients had been discharged while 21% were clear but were still under surveillance. Seven (24%) patients had complications, 6 stenosis and one severe bleeding. All stenosis occurred in patients who had more than 10 treatment sessions. In all, 31% of patients needed further endoanal or abdominal surgery and the median time to making this decision was 28 (range 4-66) months. There were no deaths. CONCLUSION: Laser and argon ablation of large rectal adenomas has proved very disappointing. It should be reserved for patients who are unfit to undergo general anaesthesia.

Clinical, echocardiographic, and angiographic profile of patients with double-chambered right ventricle: experience with 48 cases.

Forty-eight patients with double-chambered right ventricle (DCRV) were prospectively studied over a 3-year period. Clinical, echocardiographic, hemodynamic, and angiographic studies were done in all. Three patients were studied postoperatively also. Fifteen patients underwent surgery confirming the diagnosis. Echocardiography detected anomalous muscle bundles (AMBs) in 39/41 patients in whom this study was carried out. Angiographically AMBs were best demonstrated in anteroposterior views in a systolic frame. Common associated anomalies found with DCRV were ventricular septal defects (69%), pulmonary valve stenosis (38%), and double-outlet right ventricle (10%).

Prospective audit of quality of colonoscopy in a surgical coloproctology unit.

OBJECTIVE: The aim of this study was to prospectively audit the quality of colonoscopy and patient acceptance in a Surgical Coloproctology Unit over a one-year period. PATIENTS AND METHODS: 202 consecutive colonoscopies were evaluated over a 12-month period performed by a Consultant, Specialist Registrars and Research fellows. Data where recorded for adequacy of bowel preparation, completion rate, adequacy of sedation, patient tolerance and duration of the procedure. Adequacy of bowel preparation was monitored by scoring bowel content and the percentage of bowel wall visualised. Patients completed a questionnaire to express their sedation satisfaction, discomfort during the procedure and overall satisfaction. RESULTS: The success rate of bowel preparation was 94%. Completion rate was 90% in intended full colonoscopies by the Consultant and Registrars and 74% by more junior grade endoscopists (overall 86%). The mean dose of midazolam and pethidine was higher in patients with unsatisfactory sedation than those with satisfactory sedation. The pain score was higher when trainees performed the procedure than when performed by the Consultant. Fourteen patients refused to undergo the procedure again due to procedure discomfort (n = 7), inadequate sedation (n = 2) and bowel preparation discomfort (n = 5). CONCLUSION: A high completion rate was achieved, compared with published results. However, further improvements are possible especially by improving the performance of junior endoscopists and by ensuring optimal bowel preparation. Patients' tolerance of colonoscopy was highly acceptable but may also be improved by the same methods.

A cardiac evoked response algorithm providing automatic threshold tracking for continuous capture verification: a single-center prospective study.

BACKGROUND: The AutoCapture algorithm as implemented in Regency and Microny pacemakers (Pacesetter Inc., Sylmar, CA, USA) provides beat-by-beat monitoring of capture based on proper detection of the evoked response, provides high output back-up pulse when loss of capture occurs, performs periodic threshold evaluations and acquires the capture threshold data in a time-based event counter for later retrieval. The safety and efficacy of this algorithm was prospectively evaluated at a tertiary care hospital of north India. METHODS AND RESULTS: Fifty-four patients (38 males, mean age 66+/-13 years) received a ventricular pacemaker model Regency SC+ with low polarization bipolar lead for high-grade atrioventricular block (n=42) and sick sinus syndrome (n=12). Evoked response and polarization signal were assessed initially at 24 hours postimplant, and follow-up measurements were systematically conducted at week 1 and months 1, 3 and 6. Further evaluation of eligible patients was performed at 6-monthly intervals. Lead implantation parameters were optimum in all patients. At 6 months, the algorithm was functional in 51 patients. The pacing threshold increased to 0.89+/-0.36 V (p<0.001) in the first month and stabilized thereafter. Significant saving of energy was accomplished by a constant output safety margin of 0.3 V instead of the traditional 100%. While the evoked response signal remained stable throughout the study period, the potential signal increased significantly from 0.6+/-0.7 mV to 1.0+/-0.6 mV (p<0.001) in the first month and remained steady subsequently. Back-up pacing in the event of exit block was confirmed in all 25 patients who underwent a 24-hour Holter test. Based on the suggested sense margins, ventricular undersensing was observed in 7 (28%) patients, the majority of whom had competitive cardiac rhythms. An elderly patient with pneumonic illness succumbed to pulmonary embolism at 6 months. CONCLUSIONS: This large single-center experience on AutoCapture demonstrates the success of this algorithm in low-energy ventricular pacing without compromising the patient's safety.

Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis.

OBJECTIVE: To evaluate the feasibility and safety of laparoscopic cholecystectomy in severe acute cholecystitis. DESIGN: Analysis of data collected prospectively from a consecutive series of 350 laparoscopic operations. SETTING: Two general surgical units in a teaching hospital. SUBJECTS: 31 patients with a diagnosis of severe acute cholecystitis based on clinical examination, investigation results, and operative findings. INTERVENTIONS: Initial intravenous fluids and broad spectrum antibiotics followed by laparoscopic cholecystectomy within 72 hours of presentation. MAIN OUTCOME MEASURES: Failure to complete the operation laparoscopically, length of postoperative stay in hospital, early postoperative morbidity, interval from operation to full activity, and return to work. RESULTS: Laparoscopic cholecystectomy was attempted in 19 patients with empyema of the gall bladder and 12 who had severe cholecystitis which failed to settle on medical management. A total of 29 operations were successfully completed with two conversions to open surgery. Two minor postoperative complications occurred, and one case of retained common bile duct stones with jaundice was treated by endoscopic retrograde cholangiopancreatography and papillotomy. Median postoperative hospital stay was two days, with return to normal activity in seven days and to work in two weeks. There were no deaths related to the operation. CONCLUSIONS: In the presence of severe acute cholecystitis laparoscopic cholecystectomy is feasible in most patients, with minimal risk of injury to surrounding structures and considerable benefits. It is recommended that laparoscopic cholecystectomy should be attempted in these patients when appropriate surgical skill is available.

Acute chylous ascites with carcinoid of the pancreas.

Acute chylous ascites is of idiopathic origin in 50 per cent of cases, the remainder being accounted for by trauma and intestinal obstruction. It usually presents with acute abdominal pain. Neoplastic disease is much more common in chronic cases, and lymphomas comprise about half of these. Chronic chylous ascites usually presents without pain but with inanition and hypoproteinaemia. This report describes acute chylous ascites following trauma in a patient who was subsequently found to have a pancreatic carcinoid, the lymphangiographic findings being of particular interest.

Subacute pulmonary hypertension and systemic tumour embolism from cervical cancer.

Venous tumour embolization is not unusual in malignant disease (1-3) usually in the form of individual cells or small clumps. Malignant cells in the pulmonary vasculature are therefore not an uncommon finding, especially in patients with abdominal neoplasms (4-7). Arterial emboli from a malignant tumour are, however, rare (8, 9), particularly peripheral ones (9, 10) and those sufficiently large to cause organ infarction. An unusual case of pulmonary and widespread systemic tumour embolization from carcinoma of the cervix is described in which systemic dissemination of tumour emboli had apparently resulted from transpulmonary passage, without the development of pulmonary metastases.

Diarrhea and Fecal Incontinence.

In brief Two endurance athletes developed diarrhea and fecal incontinence each time they exercised strenuously. Such gastrointestinal difficulties are usually benign, but physicians determined that the disorders were an unusual presentation of lumbar spondylolisthesis in a runner and of jejunal diverticulosis in a cyclist. The runner's diarrhea and incontinence resolved when she avoided activities that precipitated her symptoms, and the cyclist's condition resolved with oral tetracycline.