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).

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.

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.

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.

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.

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.

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.

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".

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.

Accessory sphincterotomy (endoscopic and surgical) in patients with pancreas divisum.

Sixteen patients with the congenital anomaly of pancreas divisum have been treated by enlarging the orifice of the accessory papilla. Attempts to do this at duodenoscopy succeeded in only 5 of 12 patients, and only one had a good clinical result. Sphincteroplasty was performed surgically in seven patients; five had a good or fair result. Most patients with poor results have undergone pancreatic resection. One patient died post-operatively; the remaining 15 divide equally as good (5), fair (5) and poor (5) results at follow-up after periods ranging from 7 months to 5 years. Results appear to be better in patients presenting with recurrent attacks of acute pancreatitis than in those with chronic pain. The preferred management for these patients remains unclear.

Liver abscess in the tropics: experience in the University Hospital, Kuala Lumpur.

We reviewed 204 cases of liver abscess seen between 1970 and 1985. Ninety were found to be amoebic, 24 pyogenic and one tuberculous. The cause of the abscesses in the remaining 89 patients was not established. The patients were predominantly male, Indians, and in the 30-60 age group. The majority of patients presented with fever and right hypochondrial pain. The most common laboratory findings were leucocytosis, hypoalbuminaemia and an elevated serum alkaline phosphatase. Amoebic abscesses were mainly solitary while pyogenic abscesses were mainly multiple. Complications were few in our patients and included rupture into the pleural and peritoneal cavities and septicaemic shock. An overall mortality of 2.9% was recorded. The difficulty in diagnosing the abscess type is highlighted. The single most important test in helping us diagnose amoebic abscess, presumably the most common type of abscess in the tropics, is the Entamoeba histolytica antibody assay. This test should be used more frequently in the tropics.

Tuberculous liver abscess.

Tuberculous liver abscess is uncommonly seen in our experience. We report a case of a 17-year-old boy who presented with typical clinical features of liver abscess, where a diagnosis of tuberculous liver abscess was made on laparotomy and biopsy of the abscess wall.

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.

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.