Evaluation of a novel endoluminal stapling procedure to restrict the lower esophageal sphincter and reduce reflux.

BACKGROUND AND STUDY AIMS: An effective, safe, and long-lasting endoluminal treatment for gastroesophageal reflux disease (GERD) would be an attractive prospect. We developed an endoluminal technique to restrict and tighten the lower esophageal sphincter (LES), by using a transoral endoscopic stapling device in a porcine model. PATIENTS AND METHODS: Pre-interventional evaluation comprised endoscopy, manometry, and 48-hour pH measurement of the distal esophagus using the catheterless BRAVO pH capsule. By placing the endoluminal stapling device at the LES and firing a 2.5-cm staple line, a vertical plication was created. In five pilot pigs (phase 1), plications were placed in various locations at the LES. In another five pigs (phase 2), plications were placed uniformly at the mid level of the LES on the lesser curvature side. Measurements were repeated 2 weeks after the procedure. Necropsy and histological analysis were performed. RESULTS: Endoluminal stapling was successfully completed in all animals. In phase 2, the median procedure time was 15 minutes (range 10-55 minutes). LES pressure increased from 10.5 mmHg (+/- 2.5 mmHg) to 14.3 mmHg (+/- 3.8 mmHg) (P = 0.038). Median percentage of time with pH below 4 decreased from 6.6% (range 2.9%-48.8%) to 2.2% (range 0%-10.4%) (P = 0.043). Histology showed the staple line involving the muscular layer in all pigs. A gap was present in the central part of the staple line in three pigs resulting in a mucosa-muscular bridge of tissue. This bridge did not influence the results. CONCLUSION: This novel endoluminal technique is feasible and safe in a porcine model over 2 weeks. It is appealing due to its simplicity and ease of application. Further studies aimed at eliminating the gap in the staple line and investigating more animals over longer survival periods are needed.

Effect of corticotropin-like intermediate lobe peptide on pancreatic exocrine function in isolated rat pancreatic lobules.

Naturally occurring derivatives of pro-opiomelanocortin (POMC) have been identified in various extra-pituitary sites, including the endocrine and exocrine pancreas. Corticotropin-like intermediate lobe peptide (CLIP = ACTH18-39), a naturally occurring derivative of POMC, has been suggested to be an insulin secretagogue. To determine whether CLIP might also affect the exocrine pancreas, we measured its effect on amylase secretion and protein synthesis and secretion in isolated rat pancreatic lobules. Lobules were dual-pulsed with trace amounts of 14C- and 3H-leucine, both in the presence and absence of CLIP (10(-9)-10(-6) M), using a technique that permitted the labeling of both the synthetic and secretory compartments. The effect of CLIP on protein synthesis was determined by comparing 3H-leucine incorporation into lobules with and without CLIP. The secretory effect of CLIP was determined by measuring (a) secreted 14C-labeled protein as a percent of total incorporated radiolabeled protein, and (b) amylase release into incubation medium. The effect of CLIP on amylase release was compared with that of secretin, cholecystokinin-octapeptide, and carbamylcholine. To localize the biologically active region of CLIP, we similarly studied synthetic ACTH25-39. We demonstrated that CLIP stimulates amylase and protein secretion in a dose-dependent manner and is of similar potency to secretin and carbamylcholine. This effect appears to require the ACTH18-24 region of CLIP and results from stimulus-secretion coupling rather than augmented protein synthesis. We also confirmed the presence of immunoreactive-adrenocorticotropic hormone (IR-ACTH) in rat pancreatic extract using a COOH-terminally directed antibody to ACTH1-39 and demonstrated that this IR-ACTH co-eluted with synthetic CLIP. These findings suggest that CLIP might be an endogenous modulator of pancreatic exocrine function.

Is the variable-stiffness paediatric colonoscope more effective than a standard adult colonoscope for outpatient adult colonoscopy? A randomised controlled trial.

BACKGROUND: Trials with variable-stiffness colonoscopes have yielded conflicting results regarding efficacy and patient tolerance. AIM: We compared a variable-stiffness paediatric colonoscope with a standard adult colonoscope. METHODS: Two hundred and forty consecutive adult outpatients presenting for colonoscopy were randomised to either a variable-stiffness paediatric colonoscope or an adult colonoscope. If there was difficulty in performing colonoscopy with the assigned scope, the endoscopist was given the option of switching to the alternative instrument. In the condition of a severely fixed, angulated sigmoid colon, a final 'salvage' (backup) option was that of switching to an even thinner diameter paediatric colonoscope. RESULTS: The initial frequency of total colonoscopy was similar with the variable-stiffness paediatric colonoscope and adult colonoscope (95.8% versus 96.6%, p=1.0). Factoring in scope changes, the final frequency was 98.3% versus 99.2% (p=1.0). There was no statistical difference between the two groups in terms of insertion time, doses of sedative medications, scales of procedure difficulty, or patient satisfaction. CONCLUSIONS: Adult colonoscope and variable-stiffness paediatric colonoscope are both effective instruments for routine colonoscopy. In cases when the use of the initial scope is unsuccessful, switching to the alternative scope may permit passage to the caecum. There are occasional patients with fixed, angulated sigmoid colons in whom use of an even thinner diameter paediatric colonoscope can be helpful.

Acute pancreatitis. A review with an emphasis on new developments.

The spectrum of acute pancreatitis can range from mild and self-limited to severe and fatal. A number of aspects of the condition remain poorly understood or controversial, although recent advances have improved our understanding in many areas. A substantial number of cases of "idiopathic" acute pancreatitis may be caused by occult biliary microlithiasis. The mechanism by which enzymes and bioactive substances become activated within the pancreas is a major unanswered question in acute pancreatitis; however, recent studies suggest that lysosomal enzymes within the pancreatic acinar cell may play a role. A recent refinement in computed tomography, contrast-enhanced dynamic pancreatography, has shown itself to be an extremely useful tool for detecting pancreatic necrosis and its extent, which correlates with the severity of pancreatitis and is useful in identifying patients who may have pancreatic infection and other complications. The management of acute pancreatitis includes supportive measures, observation for development of complications, and the identification of the cause of pancreatitis to prevent recurrences. Specific treatments introduced with the goal of halting the cycle of pancreatic autodigestion and benefiting the course of pancreatitis have generally proved ineffective. Early aggressive treatment of biliary pancreatitis remains controversial; however, endoscopic sphincterotomy may be helpful in more severe cases of biliary pancreatitis if there is no clinical improvement over 48 to 72 hours. Computed tomography-guided percutaneous needle aspiration appears to be a safe and reliable method for diagnosing infected pancreatic necrosis, pancreatic abscess, and infected pancreatic fluid collections.

Liver disease in mixed connective tissue disease.

Previous descriptions of mixed connective tissue disease (MCTD) have not included evidence of hepatic involvement. A patient who had MCTD also had severe chronic active hepatitis. Retrospective review of all of our cases of MCTD confirms that liver disease is an uncommon occurrence in MCTD.

Colonic telangiectasias in scleroderma.

Gastrointestinal tract involvement in progressive systemic sclerosis (PSS) is common. A 46-year-old woman with PSS and calcinosis, Raynaud's phenomenon, esophageal hypomotility, sclerodactyly, and telangiectasias with evidence of widespread intestinal tract involvement is described in whom multiple colonic telangiectasias (angiodysplasias) were found on colonoscopy, a finding not previously reported to our knowledge. The telangiectasias represent a potential cause of gastrointestinal tract bleeding.

Gastroesophageal reflux as a pathogenic factor in the development of symptomatic lower esophageal rings.

Gastroesophageal reflux (GER) has been suggested as a cause of the lower esophageal (Schatzki) ring. We looked for the presence of GER and reflux injury in a series of 20 patients with lower esophageal ring and dysphagia, using a 24-hour esophageal pH monitoring and upper endoscopy with biopsy. Abnormal GER was documented in 13 of the patients (65%), 10 of whom had erosive reflux changes in the distal esophagus. Seven patients (35%) showed no evidence of pathologic GER or reflux esophagitis. All patients also underwent esophageal manometry. Nonspecific esophageal body motor dysfunction may have contributed to dysphagia in five patients, two of whom had no evidence of abnormal GER. We conclude that GER disease is a frequent cause of the gradually progressive ring stricturing and dysphagia seen in patients with lower esophageal ring. Antireflux therapy, as an adjunct to esophageal dilatation, may be appropriate for many symptomatic lower esophageal ring patients.

Appropriateness of referrals for open-access endoscopy. How do physicians in different medical specialties do?

BACKGROUND: Open-access endoscopy allows nongastroenterologist physicians the opportunity to directly schedule elective common endoscopic procedures for their patients without having them first examined in the gastrointestinal clinic. There are few data as to whether nongastroenterologist physicians in the United States schedule patients for appropriate indications. OBJECTIVES: To examine our practice to see whether patients undergoing open-access endoscopy were scheduled for appropriate indications and to see whether there were differences among physicians in various medical specialties. METHODS: We prospectively tracked 310 consecutive patients scheduled for open-access esophagogastroduodenoscopy (EGD) and colonoscopy by nongastroenterologist physicians over a 9-month period in our academic practice setting to determine whether the indications for performing the procedures were appropriate. The American Society for Gastrointestinal Endoscopy criteria (revised in 1992) were used as the standard for comparison. RESULTS: Primary care physicians (family practitioners and general internists) did a superior job of scheduling patients for appropriate indications for EGD and colonoscopy than did non-primary care physicians (internal medicine subspecialists and surgeons): 97.0% vs 81.3% for EGD (P = .04) and 84.9% vs 66.7% for colonoscopy (P = .02), respectively., CONCLUSIONS: Primary care physicians were significantly more likely to schedule patients for open-access EGD and colonoscopy for appropriate indications than were non-primary care physicians. The frequency of inappropriate indications for colonoscopy referrals was greater than for EGD. The reasons for the differences among primary care physicians, surgeons, and internal medicine subspecialists require further exploration.

The palatability of five colonic lavage solutions.

BACKGROUND: Many patients dislike the taste and saltiness of polyethylene glycol-electrolyte colonic lavage solutions. Several commercially available lavage solutions have been introduced with reduced salt content or flavouring added in an attempt to improve palatability and to encourage patient compliance. AIM: To determine which of the commercially available lavage solutions are the most palatable. METHODS: A taste test of the five commercially available lavage solutions was performed by two groups of subjects: (a) adult patients scheduled to undergo colonoscopy (n = 50) and (b) adult family members of patients scheduled to undergo colonoscopy and hospital volunteers (n = 50). Subjects sampled all five products and were asked to grade the taste and saltiness, and to rank them in their overall order of preference. RESULTS: Similar findings were observed in the two groups of subjects. Colyte-Flavored, Cherry-NuLytely, NuLytely and GoLytely had similar median taste scores and a similar frequency of taste scores labelled as 'unacceptable' (8-11%); these four products ranked ahead of plain Colyte (which had a 25% frequency of taste scores labelled as 'unacceptable'). However, in the ranking phase of the study, about three-quarters of the subjects preferred a flavoured lavage solution to an unflavoured one. Colyte-Flavored and Cherry-NuLytely rated almost equal. Twenty-two per cent of subjects rated an unflavoured lavage solution (generally NuLytely or GoLytely) as their first choice. This included a subset of subjects who disliked the flavoured solutions and greatly preferred an unflavoured product. CONCLUSIONS: Four of the five commercially available products studied received similar taste scores. However, in the direct comparison phase of the study, a majority of subjects expressed a preference for a flavoured lavage solution. On the other hand, about one in five subjects expressed a dislike for the available flavoured solutions and preferred an unflavoured one.

Short report: prospective, randomized trial comparing a single dose sodium phosphate regimen with PEG-electrolyte lavage for colonoscopy preparation.

We performed a prospective, randomized trial in 52 patients to see how preparation with a single-dose sodium phosphate solution regimen (Fleet Phospho-Soda), in which the entire 89 ml dose was given on the evening prior to colonoscopy, compared with conventional polyethylene glycol(PEG)-electrolyte lavage in terms of quality of colon cleansing and ease of patient preparation. Previous trials had utilized a two-dose sodium phosphate regimen in which one dose was given on the evening prior to colonoscopy and the other on the morning of the procedure. A nurse gave a questionnaire to the patient prior to colonoscopy, assessing how well the preparation was tolerated. The attending gastroenterologist graded the quality of colon cleansing, unaware of how the patient was prepared or tolerated the preparation (1 = excellent, 2 = good, 3 = fair, 4 = unsatisfactory). Both preparations were similarly tolerated. The overall quality of bowel preparation with PEG lavage was significantly better (mean score 1.62) than with the single-dose sodium phosphate regimen (mean score 2.85) (P = 0.0002). Of 26 patients, 2 (7.7%) undergoing preparation with PEG lavage were judged to have had an unsatisfactory preparation, compared with 8 of 26 patients (30.8%) receiving the sodium phosphate regimen (P = 0.075). We conclude that the single-dose sodium phosphate regimen is suboptimal for clinical practice and its use cannot be recommended.

Sarcoid cardiomyopathy precipitated by pregnancy with cocaine complications.

We report the case of a 27-year-old previously healthy multiparous black woman who developed congestive heart failure 5 days postpartum. It was initially diagnosed and treated as idiopathic peripartum cardiomyopathy. Five weeks later, pulmonary sarcoidosis was diagnosed by transbronchial biopsy specimen, and steroid therapy was begun. An endomyocardial biopsy specimen 1 month later indicated cardiac sarcoidosis. She responded well to steroid therapy; however, 16 months later, she had a cardiac arrest and died. Autopsy confirmed the diagnosis of cardiac sarcoidosis.

The efficacy of polyethylene glycol-electrolyte lavage solution versus traditional mechanical bowel preparation for elective colonic surgery: a randomized, prospective, blinded clinical trial.

This study documents the efficacy, safety and patient tolerance of GoLYTELY (Braintree Laboratories, Inc., Braintree, Mass.) an orally administered, nonexplosive, polyethylene glycol-electrolyte lavage solution, in elective colonic surgery. Fifty-three patients admitted for colonic surgery were randomized to either GoLYTELY or a traditional 3-day bowel preparation. Both groups received oral and perioperative antibiotics. Pre- and postpreparation weights, blood chemistries, and hematologic values were obtained. Postpreparation patient tolerance was assessed. During surgery the surgeon scored the bowel for the presence of retained air, fluid, or feces. Standardized semiquantitative aerobic and anaerobic bacterial counts were obtained from sigmoid aspirates. Postoperative infectious complications were recorded. Mechanical preparation with GoLYTELY resulted in a greater feeling of fullness, while the traditional preparation produced more hunger and abdominal cramping. The use of GoLYTELY resulted in better scores of overall quality and bowel appearance, reflecting a greater efficiency with which it removed air, fluid, and feces from the bowel. GoLYTELY also resulted in significantly fewer total aerobic and anaerobic organisms in sigmoid aspirates. This study suggests that GoLYTELY is a safe, well-tolerated, and effective orthograde lavage solution that has significant advantages over other mechanical preparations and should be considered the preparation of choice for elective colonic surgery.

A new balanced operation for complex gastroesophageal reflux disease.

Twenty-seven patients with advanced gastroesophageal reflux disease have been treated with combined transthoracic parietal cell vagotomy and Collis-Nissen fundoplication. Gastric acid analyses (n = 20) obtained preoperatively and 6 months postoperatively demonstrated a significant late reduction in gastric acid output. Twenty-six patients (96%) have experienced relief of gastroesophageal reflux disease at a mean of 13.3 months (range, 6 to 25 months) without postvagotomy symptoms. Transthoracic parietal cell vagotomy may be considered as an adjunct to mechanical surgical control of advanced gastroesophageal reflux disease.

New surgical approach to complicated gastroesophageal reflux disease: transthoracic parietal cell vagotomy.

Surgical treatment of peptic stricture of the esophagus associated with columnar (Barrett) metaplasia can be a difficult problem. Collis-Nissen fundoplication restores an intraabdominal antireflux barrier for most cases of peptic stricture; however, 20% of patients may have persistence of pathological acid reflux. By reducing acidity of postoperative reflux, parietal cell vagotomy may complement nonresectional surgical results for Barrett stricture.

Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis.

We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.

Intrasphincteric botulinum toxin type A for the diagnosis of sphincter of Oddi dysfunction: a case report.

Biliary-type pain from sphincter of Oddi dysfunction is not uncommon after cholecystectomy. An increased basal pressure of sphincter of Oddi manometry establishes the diagnosis and treatment is usually by endoscopic sphincterotomy. Both procedures carry a significant complication rate. A few patients with elevated sphincter pressure do not respond to therapy; the source of their pain may be elsewhere. This case report describes the use of intrasphincteric botulinum toxin injection for the diagnosis of sphincter of Oddi dysfunction in a patient after repeated attempts at manometry had failed. This may provide a safe and easy method of determining whether sphincter of Oddi dysfunction may be the cause of biliary pain in post/ cholecystectomy patients and help select patients who would benefit from subsequent sphincter ablation, without the risks of sphincter of Oddi manometry. Prospective studies are first needed.

Supine and upright radionuclide esophageal transit before and after treatment for achalasia.

The authors hypothesized that radionuclide esophageal transit (RET) studies performed in the upright position and aided by gravity would provide better objective evaluation of achalasia than supine scanning and would correlate better with the degree of symptomatic relief after treatment. Radionuclide esophageal transit studies were prospectively performed in both the supine and upright positions in four symptomatic patients before treatment, after simple dilation, and after pneumatic dilation in patients who did not respond to simple dilation. After simple dilation, two patients reported near resolution of symptoms. Supine RET revealed little improvement, but upright esophageal emptying was markedly improved at 2, 5, and 10 minutes. In the two patients who had no relief after simple dilation. RET failed to show improvement while they were in either the supine or the upright position. These patients subsequently underwent pneumatic dilation that resulted in resolution of symptoms and marked improvement in upright RET only. In the supine position, the esophageal emptying at 2 minutes in the four patients after successful dilation improved from 0% baseline to a mean of 14% (+/- 18%). However, in the upright position, esophageal emptying improved from 3% (+/- 3%) to 73% (+/- 17%) and better correlated with symptomatic relief. The difference in improvement in esophageal emptying in the upright versus the supine position was statistically significant (P = 0.0033). The authors conclude that only upright esophageal emptying provides objective evidence that correlates well with symptomatic relief.(ABSTRACT TRUNCATED AT 250 WORDS)

Finding the cause of ascites. The importance of accurate fluid analysis.

Diagnostic paracentesis with ascitic fluid analysis is critical to the accurate diagnosis and management of ascites. Recent advances have improved the evaluation of ascitic fluid, among them the serum-ascites albumin difference for discriminating between ascites caused by liver disease and ascites due to malignancy. The ascitic fluid polymorphonuclear leukocyte concentration is the best index for the rapid presumptive diagnosis of spontaneous bacterial peritonitis. Familiarity on the part of the clinician with ascitic fluid interpretation and with ascitic fluid characteristics in various diseases will increase the chances of controlling ascites early.

How to make consultations work.

The consultation process exists to improve patient care in an era of medical complexities, but breakdowns in the process are common because of poor communication and inadequate physician education on the subject. The referring physician and the consultant both need to assume important responsibilities if quality patient care is to be ensured. The referring physician has to establish the reasons for and urgency of the consultation, communicate them to the consultant, and supply appropriate clinical information. The consultant has to determine the questions being asked, evaluate the patient, and communicate the findings and recommendations back to the referring physician. Whenever possible, the patient should be included in the decision-making process.

Chronic constipation in adults. How far should evaluation and treatment go?

In all patients who present with constipation, a history should be taken and physical examination and proctosigmoidoscopy performed. Structural evaluation of the entire colon by barium enema should be considered when constipation is of recent onset, is severe, or does not resolve with simple measures. A colonic transit study should also be considered in the latter two situations. Anorectal manometry, defecography, and electromyography are helpful in patients with diagnosed or suspected outlet delay. Treatment is most often empirical. Simple, helpful measures include education, dietary fiber supplementation, adequate fluid intake, and regular physical activity. When laxatives are necessary, they should be used sparingly. Pelvic floor retraining may be helpful in the management of patients with outlet delay. Select patients with intractable constipation may benefit from surgery, although results are variable.