Comparison of colonic stents, stomas and resection for obstructive left colon cancer: a meta-analysis.

BACKGROUND: Emergency surgery (ES) is the standard-of-care for left-sided obstructing colon cancer, with self-expanding metallic stents (SEMSs) and diverting colostomies (DCs) being alternative approaches. The aim of this study was to review the short- and long-term outcomes of SEMS versus ES or DC. METHODS: Embase and Medline were searched for articles comparing SEMS versus ES or DC. Primary outcomes were survival and recurrence rates. Secondary outcomes were peri- and postoperative outcomes. SEMS-specific outcomes include success and complication rates. Pooled odds ratio and 95% confidence interval were estimated with DerSimonian and Laird random effects used to account for heterogeneity. RESULTS: Thirty-three studies were included, involving 15,224 patients in 8 randomized controlled trials and 25 observational studies. There were high technical and clinical success rates for SEMS, with low rates of complications. Our meta-analysis revealed increased odds of laparoscopic surgery and anastomosis, and decreased stoma creation with SEMS compared to ES. SEMS led to fewer complications, including anastomotic leak, wound infection, ileus, myocardial infarction, and improved 90-day in-hospital mortality. There were no significant differences in 3- and 5-year overall, cancer-specific and disease-free survival. SEMS, compared to DC, led to decreased rates of stoma creation, higher rates of ileus and reoperation, and led to longer hospital stay. CONCLUSIONS: SEMS leads to better short-term outcomes but confers no survival advantage over ES. It is unclear whether SEMS has better short-term outcomes compared to DC. There is a lack of randomized trials with long-term outcomes for SEMS versus DC, hence results should be interpreted with caution.

Lupus - the cold, hard facts.

Systemic lupus erythematosus (SLE) is a multisystem chronic disease with a multitude of clinical presentations. We review and synthesize how an environmental insult (exposure to extreme cold for a short duration) and endogenous (antiphospholipid antibody syndrome, SLE vasculitis) insults in a susceptible young female with lupus (peripheral arterial disease, smoking, SLE) led to a perfect storm resulting in catastrophic injuries (frostbite).

Hypoxia during upper gastrointestinal endoscopy with and without sedation and the effect of pre-oxygenation on oxygen saturation.

In Study A, the incidence of arterial oxygen desaturation was studied using pulse oximetry (SaO2) in 100 sedated and 100 nonsedated patients breathing room air who underwent diagnostic upper gastrointestinal endoscopy. Hypoxia (SaO2 92% or less of at least 15 s duration) occurred in 17% and 6% of sedated patients and nonsedated patients, respectively (p < 0.03). Mild desaturation (SaO2 94% or less and less than 15 s duration) occurred in 47% of sedated patients compared with 12% of nonsedated patients (p < 0.001). In Study B, the effects of supplementary oxygen therapy and the effects of different pre-oxygenation times on arterial oxygen saturation (SaO2) in sedated patients were studied using pulse oximetry. One hundred and twenty patients who underwent diagnostic upper gastrointestinal endoscopy with intravenous sedation were studied. Patients were randomly allocated to one of four groups: Group A (n = 30) received no supplementary oxygen while Groups B-D received supplementary oxygen at 4 1 x min(-1) via nasal cannulae. The pre-oxygenation time in Group B (n = 30) was zero minutes, Group C (n = 30) was 2 min and Group D (n = 30) was 5 min before sedation and introduction of the endoscope. Hypoxia occurred in seven of the 30 patients in Group A and none in groups B, C and D (p < 0.001). We conclude that desaturation and hypoxia is common in patients undergoing upper gastrointestinal endoscopy with and without sedation. Sedation significantly increases the incidence of desaturation and hypoxia. Supplementary nasal oxygen at 4 1 x min(-1) in sedated patients abolishes desaturation and hypoxia. Pre-oxygenation confers no additional benefit.

Common anxieties of patients undergoing oesophago-gastro-duodenoscopy, colonoscopy and endoscopic retrograde cholangio-pancreatography.

AIMS & METHODS: To investigate the anxieties of patients undergoing oesophago-gastro-duodenoscopy (OGD), colonoscopy and endoscopic retrograde cholangio-pancreatography (ERCP) in relation to their demographic features, their knowledge and understanding of the procedure, its indication, and their doctors' explanation. A standard questionnaire was filled in consecutively for 280 OGD patients, 64 colonoscopy patients and 50 ERCP patients. RESULTS & CONCLUSIONS: Majority of the anxious patients were afraid of pain. There was no difference between the "fearless" and "fearful" groups in terms of source of referral and inpatient/outpatient status. However for all 3 procedures, anxious patients were significantly younger by a mean of 10 years. Females, better educated and OGD patients undergoing the procedure for the first time were more anxious but this difference was not seen with the more complex colonoscopy and ERCP. The more sophisticated ERCP seemed to instill greater anxiety amongst Malay patients. Doctors were significantly more likely to explain the indication for OGD and colonoscopy than how it would be done. This discrepancy was not seen with ERCP where the endoscopists tend to adopt a more personal approach. Most patients prefer to be sedated.

Helicobacter pylori eradication with short-term therapy leads to duodenal ulcer healing without the need for continued acid suppression therapy.

OBJECTIVE: To determine whether duodenal ulcers continue to heal following successful Helicobacter pylori eradication with short-term eradication therapy without further acid suppression therapy. METHODS: Patients with endoscopically proven duodenal ulcers who were H. pylori positive were randomized to receive omeprazole 40 mg each morning and clarithromycin 500 mg three times daily or famotidine 40 mg twice daily and clarithromycin 500 mg three times daily for 2 weeks. No acid-suppressing agents nor ulcerhealing drugs such as bismuth compounds or sucralfate were prescribed after that. Patients were re-examined endoscopically at week 2 at the end of treatment, and at week 6, 4 weeks after the completion of treatment. RESULTS: Thirty of 44 (68.2%) patients from both treatment arms, in whom the bacteria were subsequently noted to have been eradicated, had healed ulcers at week 2; at Week 6, 42 of 44 (95.5%) were noted to have healed ulcers without further acid-suppressing or ulcer-healing treatment. CONCLUSION: Although a short-term acid-suppressing treatment is insufficient to heal ulcers, where an important putative factor such as H. pylori is eliminated, the ulcer healing process continues without further need for acid-suppressing or ulcer-healing agents.

Primary biliary cirrhosis--experience in University Hospital, Kuala Lumpur.

Primary biliary cirrhosis is an uncommon disease amongst Malaysians. Over a 12-year period, between 1979 and 1991, only seven patients with clinical, biochemical and histologic evidence of primary biliary cirrhosis were identified in University Hospital Kuala Lumpur. All were Chinese females between the ages of 30 to 55 years. The presenting complaint was pruritus in 5 patients. All except one patient was jaundiced when the diagnosis was made. These patients were followed up from 1 to 11 years. Three deaths were reported, one from massive hemetemesis and two from liver failure.

The prevalence of anti-HCV antibody in risk groups and blood donors.

Anti-HCV antibody was detected in 1.9% of the blood donors in University Hospital. Among the risk groups, 33.3% of the patients with post-transfusion hepatitis were tested positive for anti-HCV antibody. The anti-HCV antibody was detected in 30% of the IDU. Haemodialysis patients, patients with acute and chronic hepatitis and patients with liver cirrhosis appeared to have increased risk of Hepatitis C virus infection. The results indicate that the frequency of HCV infection increases with the exposure to blood or blood products.

Microscopic colitis: a histopathological study of nine cases.

A retrospective histological analysis of colonic biopsies received by the Department of Pathology, University of Malaya during the 4-year-period between 1990 and 1993 revealed nine cases of microscopic colitis (MC). The ages of the patients ranged from 18 to 53 years. Seven patients were females with a female to male ratio of 3.5 :1. The main clinical symptom was chronic diarrhoea of duration varying from 4 months to 5 years. None of the patients had any systemic illness or were on any prior medication. Colonoscopy and barium enema observations in all the subjects were essentially normal. Colonic biopsies showed diffuse plasmacytic infiltration of the lamina propria, intraepithelial lymphocytic infiltration and normal crypt pattern. To the best of our knowledge, this is the first documented report on MC from Malaysia. It is envisaged that better recognition of this condition by histopathologists would reduce the numbers in the often diagnosed category of "nonspecific colitis".

Omeprazole 40 mg o.m. combined with amoxycillin alone or with amoxycillin and metronidazole in the eradication of Helicobacter pylori.

OBJECTIVES: Our objectives were to determine the effect of dual therapy with omeprazole and amoxicillin and of triple therapy with omeprazole, amoxicillin, and metronidazole in the eradication of Helicobacter pylori (HP) and to study the long-term results of eradication in these patients. METHODS: A prospective, randomized, controlled trial was performed. Patients who were recruited had unequivocal evidence of HP infection based on culture, histology, rapid urease test, and Gram's stain of a tissue smear. Eradication was defined as the absence of bacteria in all tests performed on both corpus and antral biopsies. RESULTS: The infection was eradicated in 15 of 19 (78.9%) patients randomized to receive dual therapy and in 19 of 22 (86.4%) patients who received triple therapy. We followed the course of 30 patients in whom HP had been eradicated for a prolonged term (up to 12 months). All remained clear of HP. Twenty-five of 28 patients (89.3%) with duodenal ulcers in whom HP was successfully eradicated remained healed at 12 months. Fewer side effects were reported among patients who received the dual therapy. CONCLUSIONS: Combination therapy with omeprazole and amoxicillin with or without metronidazole is effective in the eradication of HP. In particular, the dual therapy regimen with amoxicillin is not only effective but is also well tolerated by patients.

Serum hepatitis B virus DNA: relationship with the e-antigen and anti-e status in chronic carriers.

The relationship between serum Hepatitis B virus DNA (HBV-DNA) and the Hepatitis B e-antigen/ anti-Hepatitis Be (HBeAg/anti-HBe) serological status in Malaysians was studied. 212 cases of asymptomatic HBV carriers were recruited for this study. 92 cases were positive for the HBeAg at the point of recruitment. 85 (92.4%) of these patients tested positive for HBV-DNA, of whom 55 (64.7%) had levels over 100pg/ml of serum. Three of the remaining 7 HBeAg positive cases who were negative for HBV-DNA subsequently seroconverted. The other 4 cases remained negative for HBV-DNA for periods of 6-12 months. Out of 113 cases who were anti-HBe positive, 12 (10.6%) gave a positive HBV-DNA result. 2 of these 12 patients were recent seroconverters; the remaining cases had transiently increased viral replicative activity which later subsided. 7 out of the 212 carriers were in the e-window period; all 7 tested negative for HBV-DNA. Our data confirm a high frequency of HBV-DNA in HBeAg positive carriers and a negative correlation between HBV-DNA and anti-HBe. An atypical profile of anti-HBe associated with HBV-DNA was observed in 10.6% of the carriers. An inverse relationship between serum HBV-DNA levels and age was also observed.

The rapid urease test in the diagnosis of Helicobacter pylori infection.

With the increasing recognition of the importance of H. pylori in gastrointestinal disease, there is a need for a reliable, efficient and yet inexpensive diagnostic test. The performance of the rapid urease test (RUT) as an endoscopy suite diagnostic test was compared to the established methods of culture, histology and Gram stain of tissue smear, in 274 gastric biopsy samples. Histology had the highest sensitivity of 99.3% followed by the RUT (96.6%). Culture and Gram stain of tissue smear had 100% specificity, while the rapid urease test had 99.2% specificity. The RUT had a positive predictive value of 99.3% and a negative predictive value of 96.2%. The RUT is an inexpensive, rapid and reliable diagnostic test of H. pylori infection.

Wilson's disease--a review of cases at University Hospital, Kuala Lumpur.

The clinical course of 18 patients with Wilson's disease is reported. There were 13 males and five females of whom one is Malay. The prevalence of Wilson's disease in Malaysia is probably the same as elsewhere. Being a genetic syndrome, the genetic carrier rate for Wilson's disease is probably lower amongst the Malays. At diagnosis, the clinical signs were predominantly hepatic in 10 patients, neurological in five patients with three asymptomatic cases. All patients were commenced on penicillamine but poor compliance was observed in many patients. Two patients defaulted follow-up and seven patients died. Out of the nine surviving patients, only four are well with no clinical symptoms.

Survival in hepatitis-B cirrhosis compared to alcoholic cirrhosis in patients with Child's C liver disease: a prospective study of endoscopic sclerotherapy for bleeding oesophageal varices.

A prospective comparative study was carried out on thirty-seven consecutive patients presenting with bleeding oesophageal varices at University Hospital, Kuala Lumpur. All patients received injection sclerotherapy if active bleeding was seen at the time of initial endoscopy, followed by repetitive courses of sclerotherapy to obliterate the varices. Predominant aetiological factors were hepatitis-B cirrhosis (43%) and alcoholic cirrhosis (30%). Chinese ethnic group accounted for 62.5% of hepatitis-B cirrhotics and Indian 73% of alcoholic cirrhotics. After excluding patients lost to follow-up, analysis of the remaining thirty-four patients showed reduced long-term survival in patients with Child's C disease. Log-rank analysis of survival curves between hepatitis-B cirrhosis and alcoholic cirrhosis in patients with Child's C liver disease showed no significant difference in long-term survival (p = 0.07). However, six deaths were seen in hepatitis-B cirrhosis compared to one death in alcoholic cirrhosis in the first eight months of follow-up. Most patients died from progressive liver failure. Median survival for Child's C hepatitis-B cirrhosis was 7.5 months whereas this had not been reached for Child's C alcoholic cirrhosis (median follow-up 11.6 months). We conclude that variceal haemorrhage in Child's C hepatitis-B cirrhosis is a bad prognostic sign and is associated with reduced survival with a median survival of 7.5 months despite control of the variceal bleed.

Helicobacter pylori infection and non-ulcer dyspepsia: the effect of treatment with colloidal bismuth subcitrate.

A study was undertaken to determine the role of Helicobacter pylori in non-ulcer dyspepsia (NUD) and to determine the efficacy of colloidal bismuth subcitrate (CBS) in the treatment of NUD. Seventy-one patients were randomly allocated (double blind) to CBS or placebo, two tablets twice daily for 4 weeks. The severity of dyspepsia was scored and endoscopies performed before and after treatment, and antral biopsy specimens were taken for bacteriologic and histologic examination. Forty patients had H. pylori infection, and all had changes of chronic active gastritis. H. pylori was cleared from 17 to 21 patients (81%) treated with CBS, whereas none of the 19 patients treated with placebo cleared the bacteria. Improvement in histology was noted in 15 of 21 patients (71.4%) treated with CBS, whereas no improvement was noted in any of the placebo controls. Thirty-one patients were negative for H. pylori. All had either normal gastric histology or minor degrees of inflammation. Seventeen of these patients received CBS, and 14 received placebo. All groups reported improvement in the symptom score; however, the H. pylori-positive, CBS-treated group recorded a significantly higher improvement than the other groups (p less than 0.001). Relapse of H. pylori infection after initial clearance of the bacteria was high. Twelve of 16 patients evaluated relapsed 1 month after withdrawal of CBS.

Reproducible demonstration of blood flow at duodenal ulcer margins by endoscopic reflectance spectrophotometry.

Changes in gastrointestinal mucosal blood flow were evaluated by index of oxygen saturation (ISO2) and index of hemoglobin concentration (IHB) measured with a reflectance spectrophotometer. This report examined the reproducibility of endoscopic measurements of ISO2 and IHB. Study 1: The everted stomachs of three anesthetized rats provided hands-on instruction (one teacher and three learners). Six sets of readings were obtained endoscopically (the mean calculated to give the measurement) at each level of gastric mucosal perfusion when gastric blood flow was varied by withdrawing blood from the carotid artery. Study 2: Fourteen duodenal ulcer patients with ulcer bleeding were transfused and stabilized. Two endoscopists (one teacher and one learner) took turns to obtain endoscopic ISO2 and IHB measurements at the margin of the ulcer and at the adjacent normal appearing mucosa. delta ISO2 was calculated as the ulcer margin value minus adjacent mucosa value. In study 1, the correlation coefficients between the ISO2 measurements of the experienced and those of the other three observers were 0.99, 0.97, and 0.97, respectively. In study 2, the correlation coefficients between the ISO2 measurements obtained at the ulcer margin and at the adjacent normal mucosa, and delta ISO2 obtained by the experienced observer and one of the three learners were 0.94, 0.97, and 0.94, respectively. Relative to the adjacent area, 79% of the duodenal ulcers studied had increased (+delta ISO2), and 21% had decreased blood flow (-delta ISO2) at the ulcer margins. IHB measurements were less reproducible, particularly at the ulcer margin. The measurements of ISO2 and delta ISO2 were reproducible in the everted rat stomach and in duodenal ulcer patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Campylobacter pylori infection: experience in a multiracial population.

Over a 15-month period, 399 patients with dyspepsia were investigated for the presence of Campylobacter pylori infection. Half of the patients (50.6%) had Campylobacter organisms in the antrum of the stomach. C. pylori was found in 96.1% of patients with histological changes of chronic active gastritis in the antrum. Of patients with duodenal and gastric ulcers, 87.8% and 87.5%, respectively, had Campylobacter organisms, as did 39.3% of patients with non-ulcer dyspepsia. C. pylori infection was most commonly found in Chinese and Indians. Although the prevalence of infection appeared to increase with age, there was an equal distribution amongst the sexes.

Are we missing portal vein thrombosis?

We report a case of portal vein thrombosis which was misdiagnosed as tropical splenomegaly syndrome. This is the first documented case confirmed radiologically at Universiti Hospital, Kuala Lumpur. A discussion on the management of portal vein thrombosis is also described.

Omeprazole compared with ranitidine once daily in the treatment of duodenal ulcer.

A double-blind randomized study in 230 Malaysian patients with duodenal ulcer was conducted to compare the proton-pump inhibitor, omeprazole 20 mg, given once daily in the morning, with ranitidine 300 mg, administered once daily at night. After 2 and 4 weeks of treatment, 222 and 220 patients, respectively, were evaluable according to the study protocol. Omeprazole produced significantly higher healing rates than ranitidine at both 2 weeks (75% versus 46%, respectively, P less than 0.0001) and 4 weeks (97% versus 83%, respectively, P = 0.001). Ulcer symptoms were relieved more rapidly by omeprazole than ranitidine. After 2 weeks, daytime epigastric pain was reported by 30% of ranitidine-treated patients but only by 15% of omeprazole-treated patients, which is a statistically significant difference (P = 0.004). No major clinical or biochemical side effects were recorded for either omeprazole or ranitidine. In conclusion, omeprazole 20 mg was found to be superior to ranitidine 300 mg administered once daily for the treatment of duodenal ulcer as measured by ulcer healing and pain relief.