Erythromycin stimulates gastric emptying after esophagectomy with gastric replacement: a randomized clinical trial.

UNLABELLED: Delayed gastric emptying after esophagogastrectomy can pose a significant early postoperative problem. Because erythromycin, which stimulates the gastric antral and duodenal motilin receptor, has been shown to significantly increase gastric emptying in patients with diabetic gastroparesis, we decided to evaluate its effect on gastric emptying after esophagogastrectomy. METHODS: Twenty-four patients (18 men and six women, age range 41 to 79 years, median 66 years) were randomized to receive either erythromycin lactobionate (200 mg in 50 ml normal saline solution intravenously) (n = 13) or placebo (50 ml normal saline solution intravenously (n = 11) 11 days after esophagogastrectomy (with pyloric drainage procedure). After erythromycin or placebo had been infused over a 15-minute period, patients ingested a solid meal (scrambled egg with bread) labeled with technetium 99m sulfur colloid (500 microCi) over approximately 15 minutes. Dynamic images of the stomach were then acquired over 90 minutes in the supine position by gamma imaging. Results were expressed as percentage of counts retained in the stomach (percent gastric retention) over time. RESULTS: There were no side effects of erythromycin. In the placebo group, the mean percent of radiolabeled meal retained in the stomach after 90 minutes was 88%, which was significantly greater than in the erythromycin group, 37% (p < 0.001). In addition, analysis of covariance demonstrated that the rate of gastric emptying (slope of the line) was significantly greater in the erythromycin-treated group than in the placebo group (p < 0.0001). CONCLUSION: Early satiety after esophagogastrectomy may be due to delayed gastric emptying and not due to a decrease in the gastric reservoir. Intravenous erythromycin significantly improves gastric emptying in patients after esophagogastrectomy by stimulating gastric motility.

Computed tomographic enteroclysis: one methodology.

RATIONALE AND OBJECTIVES: Computed tomography (CT) is limited in the assessment of partial small bowel obstruction (SBO). Enteroclysis is preferred but gives little direct information about the bowel wall, mesentery, or remote findings. Preliminary results of a combined CT enteroclysis (CT-E) methodology are reported. METHODS: Forty-eight patients with suspected partial SBO underwent a water soluble contrast enteroclysis followed immediately by CT. Pump rates at fluoroscopy and CT were 75 to 100 cc/min unless a high-grade obstruction was encountered at fluoroscopy. Shrake's criteria for complete, high-grade or low-grade partial SBO were used. RESULTS: The calculated dose per patient was 27 rad for CT-E as opposed to 32 rad with traditional enteroclysis. Site specific sensitivity and specificity for low-grade partial SBO, were 82.1% and 87.5%. One death was encountered in a patient with diffuse abdominal metastatic disease and complete obstruction. This was caused by vomiting and aspiration secondary to tube placement alone, CT-enteroclysis having been aborted. CONCLUSIONS: Computed tomographic enteroclysis is a diagnostic option for evaluation of low-grade partial SBOs. Pitfalls with this technique are encountered in decompressed torsions and hernias.

The changing role of amputation for soft tissue sarcoma of the extremity in adults.

The role of amputation in soft tissue sarcoma of the extremity has decreased at Memorial Sloan-Kettering Cancer Center during the last 20 years. In an attempt to determine the reasons for this change in therapy, an analysis of two separate databases involving 1,057 patients compiled during the periods of 1968 to 1978 and 1982 to 1990 was performed. The patients requiring amputation for soft tissue sarcoma of the extremity in the two databases (n = 233) were compared in an attempt to determine any significant differences between the two time periods. The groups were specifically compared for differences in risk factors, indications for amputations and the effect a decreasing incidence of amputation in the 1982 to 1990 group had on local recurrence and overall survival between the two groups. Despite similarity of risk factors and indications for amputation, the decreased incidence of amputation during the 1982 to 1990 period was associated with a significant decrease in local recurrence after amputation and no significant change in overall survival compared with the 1968 to 1978 group. Absence of local recurrence was associated with significant improvement in survival. Possible reasons for the shift in therapy, as well as the present and future role of amputation in soft tissue sarcoma of the extremity, are discussed.

Comparison of amputation with limb-sparing operations for adult soft tissue sarcoma of the extremity.

The use of amputation in extremity soft tissue sarcoma has been decreasing at Memorial Sloan-Kettering Cancer Center (MSKCC) over the last 15 years. In an attempt to define the efficacy and future role of amputation in extremity soft tissue sarcoma, a prospective sarcoma database compiled at MSKCC from July 1982 to January 1990, consisting of 649 patients, was analyzed in a retrospective fashion. Ninety-two patients underwent amputation, and 557 had a limb-sparing procedure. Patients selected for amputation were those who had large (T greater than or equal to 5 cm) high-grade tumors that invaded major vascular or nervous structures. The amputation group achieved significantly better local control than the limb-sparing group (p = 0.007). No survival benefit could be demonstrated, however, in the groups selected for amputation (i.e., large, high-grade tumors) when compared with patients undergoing a limb-sparing procedure with similar tumors. Prevention of local recurrence by amputation also did not improve survival in this group compared with similar patients undergoing limb-sparing surgery who did develop a local recurrence. The group of patients with high-grade tumors 10 cm or larger who received chemotherapy did have a significant improvement in survival (p = 0.01) compared with a similar group of patients who did not receive chemotherapy, regardless of the type of operation. The prognosis of patients most likely to undergo an amputation for extremity soft tissue sarcoma (those with high-grade, large tumors) is not related to their local disease, but rather to the risk of distant metastases. Therefore, amputation in this cohort of patients can be recommended only when a limb-sparing procedure cannot achieve gross resection of tumor while still preserving a useful extremity, because amputation improves only local control and does not address distant disease. Further improvement in survival in this group of patients will be dependent on better systemic treatment for extremity soft tissue sarcoma, and not on more radical surgery.

Atypical hyperplasia in the era of stereotactic core needle biopsy.

BACKGROUND AND OBJECTIVES: To characterize both atypical hyperplasia (AH) and the malignancies typically present at open surgical biopsy in women diagnosed with AH by stereotactic core needle biopsy (SCNB). METHODS: Patients with AH diagnosed by SCNB were advised to undergo surgical biopsy to rule out an associated malignancy. Mammography findings, pathology reports and follow-up data were analyzed. RESULTS: AH was identified by SCNB in 38 of 893 (4.3%) patients. Carcinoma was identified in 12 of 33 (36.4%) patients who went on to surgical biopsy. Ductal carcinoma in situ (DCIS) was present in 11 of the 12 patients with malignancy. There were no characteristic mammographic findings which would identify patients with carcinoma. CONCLUSIONS: When SCNB returns a diagnosis of AH there is a substantial risk of an associated malignancy in the breast. There appear to be no definitive criteria to distinguish which patients harbor a malignancy, and surgical biopsy should always serve as an adjunct diagnostic procedure.