Management of obesity with the new intragastric balloon

BACKGROUND

The introduction of an endoscopically-placed Bariatric Intragastric Balloon (BIB) provided the opportunity to reexamine weight reduction methods and also study potential weight loss without resorting to surgical intervention.

METHODS

10 severely obese patients with mean age 33 years and mean body mass index 39, underwent BIB placement, 7 as a sole weight reduction procedure and 3 requiring weight reduction before repair of large incisional hernias. All patients were followed at 2-week intervals by a nurse practitioner and dietitian for 6 months.

RESULTS

Mean weight loss was 18.6 kg (range 6.6-40.0), equivalent to 40% excess weight loss (EWL), range 10-81%. EWL was 54% (29-81%) in those patients who had two balloons placed, who lost an average of 30.3 kg (24.0-40.0 kg). In the patients who had only one balloon placed, mean weight loss was 10.4 kg (8.8-12.5), equal to an EWL of 19% (10-37%).

CONCLUSION

These results lead us to consider BIB placement as a successful short-term measure for weight loss or for patients requiring at least weight loss before other surgery.

Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents

OBJECTIVE

Gastroesophageal anastomotic leak after cancer resection has a mortality rate of up to 60% and significant morbidity, whatever the mode of treatment. We assessed the efficacy of esophageal stenting as a therapeutic option to reduce the mortality and morbidity associated with symptomatic intrathoracic anastomotic leakage.

SUBJECTS AND METHODS

During a 52-month period, 14 patients had placement of stents for clinically significant postoperative leaks: 10 patients had an esophagogastrectomy and four patients had a total gastrectomy with esophagojejunal anastomosis. Thirteen of 14 patients had tumors that were histologically staged as T3 N1 M0 or worse. Significant anastomotic leaks were revealed by a contrast-enhanced study at 3-28 days after surgery. Stents were inserted in patients in whom the leakage was debilitating or initial conservative treatment had failed. Stenting outcome in terms of clinical and radiologic healing, hospital stay, survival, and complications was assessed.

RESULTS

No procedural morbidity or 30-day mortality occurred. Immediate postprocedural leak occlusion was obtained in all patients. Clinical healing of the leak occurred in 13 (92.8%) of 14 patients, with a median healing time of 6 days. Of the 13 patients, healing occurred within 10 days in 10 patients (76.9%). Eight of these 10 early closures received a knitted nitinol stent (p = 0.02). One patient (7%) died as a consequence of leakage at 135 days. Median survival for all 14 patients was 11 months (Kaplan-Meier method). Complications included five episodes of food blockages in three patients, which required endoscopic clearance, and one case of stent-related upper gastrointestinal hemorrhage. No patients developed anastomotic stricture or occlusive epithelial hyperplasia.

CONCLUSION

Covered esophageal stenting appears to reduce the mortality and morbidity of symptomatic anastomotic leakage after surgery for gastroesophageal cancer. Knitted nitinol stents may be best suited to this purpose.

Management of acute pancreatitis: a comparative audit of clinical practice against the recommendations of the british society of gastroenterology

AIMS: In 1998 the British Society of Gastroenterology (BSG) published national guidelines for the management of acute pancreatitis (AP) in an attempt to improve diagnosis and reduce mortality rates. A comparative audit was undertaken of the management of AP against the BSG recommendations. METHODS: A retrospective analysis of 53 patients (median age 61 (range 24-95) years) admitted with AP during 1998 was undertaken and a comparison was made with the BSG guidelines. RESULTS: Some 70 per cent (n = 37) of the patients were admitted with mild AP and 30 per cent (n = 16) with severe AP. The BSG recommendations are shown in parentheses in the following text. The overall mortality rate was 17 per cent (less than 10 per cent), zero in mild AP and 56 per cent in patients with severe AP (less than 30 per cent). A correct diagnosis of AP was made within 48 h of admission in all patients (100 per cent). Severity stratification within 48 h using the Glasgow criteria and C-reactive protein (CRP) level, as suggested by the BSG, was done in approximately 80 per cent of patients. Table 1. CRP was measured in 51 per cent of the patients within the first 4 days (100 per cent) and at the end of the first week (100 per cent). Gallstones and alcohol counted for 72 per cent of causes of AP and the aetiology was determined in 77 per cent (75-80 per cent). All patients with severe AP were managed in a high-dependency or intensive therapy unit with central venous pressure monitoring and prophylactic intravenous antibiotics, and underwent dynamic computed tomography within 3-10 days of admission (100 per cent). Some 86 per cent of patients with suspected common bile duct (CBD) stones (jaundice, deranged liver function tests, dilated CBD) underwent endoscopic retrograde cholangiopancreatography with or without duct drainage and clearance. CONCLUSIONS: Management of AP closely mirrors the BSG guidelines, but fails to fully address severity stratification with respect to LDH, CRP and PaO2 at 48 h. A thorough analysis of patients with severe AP (i.e. extent of pancreatic necrosis, onset of infection) has been undertaken to explain the mortality rate and it is proposed to prospectively audit admissions with AP in 1999 in order to close the audit loop.

A UK training programme for nurse practitioner flexible sigmoidoscopy and a prospective evaluation of the practice of the first UK trained nurse flexible sigmoidoscopist

BACKGROUND

Flexible sigmoidoscopy is a technical skill that has been successfully performed by suitably trained colorectal nurse practitioners in the USA. However, no recognised training course exists for nurse practitioners in the UK.

AIMS

To design and evaluate a training programme for nurse endoscopists.

METHODS

A multidisciplinary committee of nurses and clinicians developed a structured programme of study and practice. This involved a staged process of observations, withdrawals, and ultimately, full procedures. Once training had been completed the nurse practitioner was permitted to practice independently. Patients with colorectal symptoms referred for flexible sigmoidoscopy were examined for the final stages of training and independent practice. A prospective evaluation of the training and practice of the first trained nurse flexible sigmoidoscopist was performed. Barium enema, video, clinical follow up, and histology were used to validate the results of the flexible sigmoidoscopies.

RESULTS

The training programme required that 35 observations, 35 withdrawals, and 35 supervised full procedures were performed prior to the development of independent practice. Subsequent to the completion of this programme 215 patients have been examined independently by the nurse practitioner. Ninety three per cent of the examinations were judged successful and pathology was identified in 51%. The nurse endoscopist successfully identified all "significant" pathology whereas barium enema failed to identify pathology in 12.5%. There were no complications.

CONCLUSION

With suitable training nurse endoscopists are able to perform flexible sigmoidoscopy safely and effectively.

The optimum bowel preparation for flexible sigmoidoscopy

With the proposed introduction of a flexible sigmoidoscopic screening programme for colorectal cancer, patient compliance is of paramount importance. Therefore, the bowel preparation providing optimum cleansing of the bowel with the least associated discomfort and inconvenience for the patient must be found. Patients were randomized to receive either Picolax the evening before the examination or self-administered Fleet enemas prior to the investigation. The endoscopist and nurse practitioner who collected data on a standard questionnaire were blinded to the preparation used. Bowel preparation was graded by the endoscopist as: excellent, good, adequate or poor. One hundred and two consecutive patients were randomized: 56 to the Fleet enema group and 46 to the Picolax group. Self-administered Fleet enemas provided a significantly superior bowel preparation with 52 (93%) being judged adequate or better, as opposed to 34 (74%) in the Picolax group. In addition, Fleet enemas were associated with significantly fewer adverse associated symptoms: 11 (20%) vs 24 (52%). Patients reported to be willing to receive Fleet enemas again in 53 (95%) vs 37 (80%) for the Picolax group. The self-administered Fleet enema is superior to Picolax in terms of bowel preparation for flexible sigmoidoscopy and the incidence of associated adverse symptoms.

Myelofibrosis presenting as chronic cholecystitis

A 61 year old man presented with abdominal pain typical of chronic cholecystitis of one month's duration. Pallor was noted on examination and investigation uncovered myelofibrosis and a small gallstone. Cholecystectomy relieved the pain and pathological examination of the gall bladder showed widespread myeloid metaplasia. This is the first reported case of myelofibrosis presenting as chronic cholecystitis.

Non-tumour morbidity and mortality after modified radical mastectomy

From 1985 to 1987 148 patients underwent mastectomy for breast cancer, of whom 91 underwent modified radical mastectomy. Of these patients (median age 60 years (range 31-86 years)), 89 have been assessed for early (< 30 days) and late (> 30 days) non-tumour morbidity and mortality. A total of 41 patients had nodal metastases. Adjunctive therapy used was tamoxifen in 70 patients and radiotherapy in 20. Overall, 47 patients (53%) developed a total of 75 complications, and there was one 30-day mortality. Of the patients, 26 developed one complication, 14 had two complications and 7 three complications. Early complications were lymphocoele/seroma (n = 22), wound infection (n = 9) and cardiopulmonary problems (five deep vein thrombosis, two pulmonary embolus (1 death), one myocardial infarct). Late complications were lymphoedema (n = 10), pectoralis major wasting (n = 6), frozen shoulder (n = 7), intercostobrachial neuralgia (n = 4), and a small number of self-limiting wound problems (n = 9). There were two late deaths (myocardial infarcts). Early complications were not related to nodal status, and late complications were related to neither nodal status nor radiotherapy. Significant morbidity is attached to radical surgery for breast cancer. Most complications are minor and self-limiting, but there are a small number of late complications which may affect quality of life.

Anal canal stenosis and pseudo-obstruction

Mechanical large bowel obstruction and pseudo-obstruction can be difficult to differentiate because clinical symptoms and signs are often misleading. Although plain abdominal radiographs showing diffuse gaseous distension, no shut-off point and gas in the rectum are very suggestive of pseudo-obstruction, incomplete clinical examination with over-reliance on the abdominal radiographs may lead to large bowel mechanical obstruction being misdiagnosed as pseudo-obstruction. We report a rare case of large bowel obstruction occurring secondary to anal canal stenosis.

Clostridial cholecystitis--the need for early recognition and treatment

There remains some controversy regarding the timing of cholecystectomy after an attack of acute cholecystitis. Opinions vary between early operation within two and seven days and delayed operation readmitting the patient eight to twelve weeks later. There is, however, a small group of patients who require prompt emergency cholecystectomy. This group includes patients presenting with cholecystitis complicated by gas-forming organisms where the plain abdominal gas-forming organisms where the plain abdominal radiograph can establish the diagnosis.

Iatrogenic gastrocolic fistula associated with non-steroidal anti-inflammatory drug administration

An unusual case is presented of a benign gastrocolic fistula occurring in a 70-year-old man treated with piroxicam for arthritis for a period of only two months. This report illustrates that significant upper gastrointestinal complications can occur, even with short-term treatment, with non-steroidal anti-inflammatory drugs (NSAIDs).

Pancreatic duct pressure, duct permeability and acute pancreatitis

The relationship between pancreatic duct pressure, duct permeability to macromolecules and the development of acute pancreatitis was studied in a cat model. Perfusion of the pancreatic duct with 15 mM glycodeoxycholic acid, ethanol administration, or secretagogue-stimulated pancreatic secretion against greater than 50 per cent duct obstruction resulted in an increase in peak pancreatic duct pressure in all animals. Duct permeability to 20,000 molecular weight dextran molecules was increased in 22 of 29 experimental animals compared with two of 22 control animals (P less than 0.01). Perfusion of the pancreatic duct with activated pancreatic enzymes resulted in acute pancreatitis in 24 of 29 experimental animals compared with three of 22 control animals (P less than 0.01). These results suggest that pancreatic ductal hypertension, resulting in increased ductal permeability to large molecules, may be a common early event in gallstone and alcoholic pancreatitis.

Vasoactive drugs, microvascular permeability, and hemorrhagic pancreatitis in cats

We investigated the mechanisms by which 16,16-dimethyl prostaglandin E2 and histamine induced pancreatic hemorrhage in an experimental model of acute pancreatitis in cats. In normal animals, when large molecular weight dextran molecules were infused into the systematic circulation, they were recovered in secretin-stimulated pancreatic juice in low concentrations. Both 16,16-dimethyl prostaglandin E2 (in a dose that increased splenic artery blood flow and microvascular permeability) and histamine (in a dose that increased permeability only) increased the amount of dextran recovered in pancreatic juice. Isoproterenol, in a dose that produced the same increase in blood flow as 16,16-dimethyl prostaglandin E2 but which did not increase microvascular permeability, did not alter the amount of dextran recovered. This suggested that the increase in dextran output after 16,16-dimethyl prostaglandin E2 was primarily due to the increase in microvascular permeability caused by the drug. In other experiments, a combination of H1- and H2-receptor antagonists (mepyramine and cimetidine) protected against the development of pancreatic hemorrhage in both the prostaglandin- and histamine-treated animals. Indomethacin (a cyclooxygenase inhibitor) protected against the development of hemorrhage in the histamine-treated animals. Our results support the hypothesis that changes in microvascular permeability may be important in the pathogenesis of parenchymal hemorrhage in this model.

Treatment of acute pancreatitis with beta-adrenergic agonist drugs

An increase in microvascular permeability may be important in the pathogenesis of acute pancreatitis. beta-adrenergic receptor agonist drugs are known to inhibit the increase in microvascular permeability induced by histamine and related vasoactive substances. These inflammatory mediators have been shown to be released during the course of experimental and human pancreatitis. We investigated the effect of isoproterenol and terbutaline sulfate on the development of acute edematous (AEP) and acute hemorrhagic (AHP) pancreatitis in a feline model of biliary pancreatitis. When given at the time of pancreatic insult, isoproterenol prevented the development of both AEP and AHP. Both isoproterenol and terbutaline sulfate reduced the severity of pancreatic inflammation, even when given up to 12 hours after the onset of AEP. Although neither drug was effective in treating established AHP, our findings suggest that, if given early in the course of the disease, they may be useful in preventing the progression of AEP to AHP.

Effects of oral agents on pancreatic duct permeability. A model of acute alcoholic pancreatitis

The main pancreatic duct can be made permeable to molecules of up to 20,000 daltons by oral pretreatment with aspirin and ethanol. Because pancreatic enzymes have similar molecular weights, we hypothesized that activated pancreatic enzymes would leak from a permeable duct and produce pancreatitis. Four groups of cats were pretreated with either milk, aspirin, ethanol, or aspirin and ethanol for 48 hr. Then pancreatic juice (either activated by enterokinase or nonactivated) was perfused along the duct from tail to duodenum. Twenty-four hours later the animals were examined. Animals pretreated with aspirin, ethanol, or both, and in which ducts were perfused with activated juice, developed acute edematous pancreatitis. Animals that had perfusion with nonactivated enzymes had pancreases indistinguishable from control animals. Morphological studies on ductal permeability in animals pretreated with ethanol and aspirin showed electron-dense material (believed to be dextran) between the basal plasma membrane and basal lamina, and in the basal intercellular space.

A model of hemorrhagic pancreatitis in cats--role of 16,16-dimethyl prostaglandin E2

Acute edematous pancreatitis was induced in cats by perfusing activated pancreatic enzymes through their pancreatic ducts. The ducts had been made permeable to large molecules by one of two techniques. The cats either received ethanol (2 ml/kg every 8 h) and aspirin (25 mg/kg every 8 h) orally for 48 h or had their pancreatic ducts perfused for 1 h with 7.5 mM glycodeoxycholate. When the same procedure was followed, but using 16,16-dimethyl prostaglandin E2 (dmPGE2) (2 micrograms/kg X h infused intravenously for 1 h before and during ductal perfusion with activated enzymes), hemorrhagic pancreatitis developed instead. To investigate whether an increase in pancreatic blood flow or microvascular permeability (both caused by dmPGE2) was important in this phenomenon, we tested the effects of isoproterenol (which increased blood flow) and histamine (which increased microvascular permeability) in the model. Thus in similar experiments, either isoproterenol (0.3 micrograms/kg . min) or histamine phosphate (2 micrograms/kg . min) was infused instead of dmPGE2. The animals that received histamine also developed hemorrhagic pancreatitis. Those that received isoproterenol did not. These observations suggested that an increase in microvascular permeability in the pancreas converted edematous pancreatitis to hemorrhagic pancreatitis. These findings suggest also that clinical studies using prostaglandins to treat patients with pancreatitis should be approached with caution.

A prospective study of end-to-side vs. side-to-side arteriovenous fistulas for haemodialysis

In an attempt to determine the optimum configuration of arteriovenous (A-V) fistulas for haemodialysis, 71 patients were prospectively randomized to undergo either a side-to-side or end-of-vein to side-of-artery A-V fistula. Nine months after operation, the patency rates on dialysis were almost identical in the two groups (79.2 per cent and 78.6 per cent respectively). However, 7 of the 32 side-to-side fistulas developed hyperaemia of the hand, three of which required revisional surgery. Hyperaemia of the hand has not been seen with end-to-side fistulas. In addition, peroperative measurements of fistula flow appeared to have prognostic value with end-to-side but not with side-to-side fistulas. It is suggested that the end-to-side configuration is the one of choice for the formation of A-V fistulas for haemodialysis.

The use of dermal antigen testing in predicting the outcome of renal transplantation

The responses to dermal antigen testing to a variety of antigens were measured in patients on regular dialysis. Forty-eight patients have received renal allografts and graft survival was assessed at 6 months. The antigens used were mumps, monilia, streptokinase/streptodornase, tuberculin and dinitrochlorobenzene (DNCB). The responses to these antigens were recorded using standard methodology. The response failed to correlate with graft survival in these patients when compared singly or in combination. Matching at the HLA-B locus was also correlated with graft survival. Of 31 patients with a match at this locus, 22 (71 per cent) have functioning grafts at 6 months, compared with only 4 of 13 (31 per cent) of patients with no match at the B locus (P less than 0.05). When matching at the B locus and DNCB scores were taken in combination, it became evident that those patients with no match at the B locus and low DNCB reactivity all rejected their kidneys within 4 months of transplantation.

Morphogenesis in Myxococcus xanthus and Myxococcus virescens Myxobacterales

1. Myxococcus xanthus B and M. virescens V2 were compared with a view to establishing the control of their morphogenetic cycles. Both organisms are typical myxococci and on solid media with low concentrations of nutrient they form fruiting bodies, within which vegetative cells convert to myxospores. Ultrathin sections of vegetative M. virescens resembled those of M. xanthus and contained prominent heavily stained bodies, presumed to be polyphosphate granules. Shadowed preparations showed fimbriae associated with M. xanthus but not with M. virescens. 2. M. xanthus B converted to myxospores in liquid medium in response to certain alcohols. M. virescens V2 produced phase-refractile spheres, which were not viable and had an unusual ultrastructure. 3. The distributions of fruiting bodies on solid media containing 0.02% Casitone were recorded for the two species and were compared with a Poisson distribution. Cells responded to differences in cell density in a manner suggestive of a response to a chemotactic attractant. Cells growing vegetatively and also cells forming fruiting bodies produced 3',5'-cyclic adenosine monophosphate (cAMP) as measured by the incorporation of exogeneous [3H] adenosine into cAMP. 4. The significance of these findings for theories of fruiting body formation are discussed.