Colonoscopy: why are general surgeons being excluded?

BACKGROUND

The role of surgeons as endoscopists has been extensively debated in the literature, with conflicting studies published regarding the safety and efficacy of surgeons performing colonoscopies. A multitude of medical federations and societies have set various standards for granting endoscopy privileges, many with a bias against general surgeons [1, 3]. We reviewed the colonoscopy experience at our institution to evaluate differences between gastroenterologists (GI) and general (GS) and colorectal surgeons (CRS) in procedure times and complication and cecal intubation rates.

METHODS

Between January 2000 and July 2002, 5237 colonoscopies were performed at our institution. The data for procedure times, completion, and complication rates were collected in a prospective database. Complications were defined as perforation, bleeding, and postpolypectomy syndrome. Incomplete colonoscopies due to colitis, poor bowel preparation, or tumor obstruction were excluded. Chi-squared test was used to compare complication and cecal intubation rates between the three groups. Median procedure times were compared using the Kruskall-Wallis and Dunn's pairwise tests. A significant p-value was defined as <0.05.

RESULTS

No differences in the complication rate was noted between the three groups: GI (0.12%), CRS (0.15%), and GS (0.11%) ( p = 0.99). There was a trend toward a lower incomplete colonoscopy rate in the GS group compared to CRS and GI: 0.32% vs 0.84% and 0.36%, respectively ( p = 0.07). The median colonoscopy times for GS (29 min), however, were shorter than for GI (34 min, p < 0.001) or CRS (31 min, p < 0.001).

CONCLUSION

General surgeons perform colonoscopies expeditiously, with as low a morbidity rate and as high a completion rate as their gastroenterology or colorectal surgery colleagues. As the results of this study confirm, general surgeons should not be excluded from endoscopy suites.

Screening colonoscopy in the asymptomatic 50- to 59-year-old population

BACKGROUND

In an effort to decrease the death rate from colorectal cancer, a multitude of medical societies and task forces recommend routine screening for colorectal cancer beginning at age 50. Yet, there is no consensus as to the best and most cost-effective screening method. Medicare now pays for screening colonoscopies for its average risk beneficiaries [3]. Many insurance companies, however, will not cover this test in younger patients. We therefore reviewed our institution's colonoscopy experience with asymptomatic 50- to 59-year-olds, with negative fecal occult blood tests and negative family histories.

METHODS

Between January 1999 and January 2002, 4779 colonoscopies were performed at our institution. The charts for 619 persons 50-59 years of age were retrospectively reviewed, with 91 patients meeting the strict requirements of this study. We defined polyps with high-grade neoplasias as those with villous or tubulovillous components, and cancerous lesions included those with carcinoma in situ. The distal colon was defined as the rectum and sigmoid colon.

RESULTS

There was a 58% incidence of neoplastic polyps in this younger asymptomatic population. More than 4% of our subjects had high-grade neoplasias or cancerous lesions. In the absence of any distal findings, flexible sigmoidoscopy would have missed up to 38% of these polyps.

CONCLUSIONS

The findings generally support the recommendations by the American College of Gastroenterology for average-risk patients to preferentially undergo a screening colonoscopy at age 50 in lieu of other methods.

Managing heartburn at the 'base' of the GERD 'iceberg': effervescent ranitidine 150 mg b.d. provides faster and better heartburn relief than antacids

BACKGROUND

Many individuals with heartburn self-medicate with antacids for relief of their symptoms.

AIM

To compare efficacy of effervescent ranitidine to as-needed calcium carbonate antacids in subjects who self-treat heartburn.

METHODS

A total of 155 subjects with frequent antacid-responsive heartburn were randomized to receive effervescent ranitidine 150 mg tablets b.d., or as-needed calcium carbonate 750 mg for 12 weeks. Endoscopic oesophagitis severity and mucosal histology were assessed at baseline, and at weeks 6 and 12. Heartburn frequency, severity, and antacid consumption were recorded daily, and quality of life was assessed at baseline, and at weeks 6 and 12.

RESULTS

Heartburn frequency and severity were significantly decreased after 1 day of ranitidine (P < 0.02). By week 6, ranitidine had significantly decreased rescue antacid consumption (7.3 tablets, P < 0.001) vs. antacids (14.1 tablets). Endoscopic oesophagitis healing (</= grade 1) was significantly better with ranitidine (55%, P=0.022) vs. antacids (29%). Quality of life was improved by both treatments; however, ranitidine was numerically superior for all quality of life parameters, statistically superior for several quality of life indices at week 6 and for the pain-related index by week 12 (P < 0. 05).

CONCLUSIONS

For subjects self-administering antacids for chronic heartburn, effervescent ranitidine 150 mg b.d. is more effective than antacids in reducing heartburn, healing erosive oesophagitis, alleviating pain, and improving quality of life.

Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities

Ambulatory 24-hr esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease (GERD). The current approach is to encourage patients to pursue their everyday activity in order to obtain near-physiological recordings. However, the effect of the test itself on reflux-provoking activities has never been evaluated. Thus, the aim of our study was to assess daily food consumption, habits, symptoms, sleep, and perceived experience of patients undergoing pH testing as compared to an off test (normal) day. Patients reported type and time spent in each activity pursued, food ingested and length of each meal, habits, frequency and severity of GERD and other related symptoms, sleep disturbances, side effects, and overall perceived experience during pH testing and four weeks later, during a normal day. Fifty-four patients enrolled. pH testing significantly reduced time spent being active, number of meals and cups of coffee consumed, and frequency of GERD symptoms. Almost half of the patients reported having dysphagia during the test. Most patients experienced side effects and stated that the test bothered them most of the time. In conclusion, pH testing has a significant effect on decreasing reflux-provoking activities-patients tend to assume a more sedentary lifestyle. This may influence the reliability of the test as a physiologic measure of acid reflux.

Heartburn requiring frequent antacid use may indicate significant illness

BACKGROUND

Many otherwise healthy individuals with episodic heartburn self-medicate with over-the-counter antacids. We evaluated clinical characteristics of subjects who had never been medically diagnosed as having any upper gastrointestinal tract disorder and who used antacids for symptomatic relief of heartburn.

SUBJECTS AND METHODS

Subjects with at least 3 months of frequent heartburn relieved by antacids, and with heartburn on at least 4 of 7 days during the week prior to study entry, had their medical history and gastrointestinal pathological characteristics recorded. Tests included esophagogastroduodenoscopy, esophageal motility and sensitivity studies, and 24-hour pH monitoring.

RESULTS

Of 178 subjects screened, 13 were excluded on the basis of other gastrointestinal diseases at baseline, including diffuse esophageal spasm, peptic ulcer disease, dysplastic columnar metaplasia of the esophagus (Barrett's esophagus), and adenocarcinoma. Ten subjects were ineligible because of insufficient baseline heartburn. The remaining 155 eligible subjects had heartburn for an average of 11 years. Forty-seven percent had daily symptoms and 70% described heartburn severity as moderate, even though on endoscopy most (53%) had normal-appearing esophageal mucosa (grade 0 or 1). Esophageal acid sensitivity was present in 86% of subjects. Mean lower esophageal sphincter pressures and esophageal contractile amplitudes were at the lower limits of normal and total esophageal acid contact time was slightly increased.

CONCLUSIONS

Chronic heartburn can reflect a wide range of diagnostic findings, including important underlying pathological features, and may warrant a full medical examination to detect such abnormal conditions and to permit selection of appropriate therapy.

Clinical presentation and management of iatrogenic colon perforations

BACKGROUND

Because iatrogenic colonic perforation is uncommon, surgical management of this complication has been based on the civilian trauma experience. In this study, we determine the incidence, clinical presentation, and management of colonic perforations resulting from colonoscopy or barium enema.

PATIENTS AND METHODS

The medical records of all patients with colorectal perforations due to barium enema or colonoscopy seen over a 5-year period were reviewed.

RESULTS

Twenty-one patients, 12 males and 9 females aged 66 +/- 16 years, undergoing evaluation for polyps and bleeding (11), diverticulosis (4), diarrhea (2), or miscellaneous indications (4) sustained colonic perforation from colonoscopy (18; 0.20%) or barium enema (3; 0.10%). Abdominal pain, 66% (13), and fever, 24% (5), were the most frequent symptoms encountered and extraluminal air, 67% (14), the most common radiologic finding. The site of perforation was the rectosigmoid in 62% (13) of patients. Eighteen patients underwent surgery; 11 within 24 hours (group I) and 7 patients within 6.0 +/- 4 days (group II). Fifty percent (9 of 18) had primary repair or resection with anastomosis without mortality. Of the 6 patients initially treated nonoperatively, 3 subsequently underwent surgery. Both deaths, one in group I and one in group II, occurred in patients who had colonic diversion for perforation following colonoscopy.

CONCLUSION

We conclude that in the absence of significant contamination either primary repair or resection and anastomosis can be performed with acceptable morbidity for iatrogenic perforations of the colon.

Experience with a catheter-based ultrasound probe in the bile duct and pancreas

BACKGROUND AND STUDY AIMS

Complete examination of the biliary tree and pancreatic duct may be difficult or unsuccessful using conventional imaging instruments. The purpose of this study was to evaluate the cannulation success rate, clinical utility, and safety of a new catheter-based ultrasound probe (CBUSP) used in the biliary tree and pancreas.

PATIENTS AND METHODS

The probes used in this study are manufactured by Microvasive (Watertown, MA, U.S.A.) and were 6.2 Fr in diameter, operated at 12.5 MHz. Thirty-six patients (11 with malignant bile-duct strictures, 12 with benign bile-duct strictures, two with bile duct stones, three with pancreatic duct strictures, one with a pancreatic cyst, one with pancreas divisum, three with sphincter of Oddi dysfunction, and three normal) underwent examination with a CBUSP.

RESULTS

Cannulation was successful in all 36 patients. The hepatic artery and portal vein could be visualized with the probe in the proximal bile duct in 81% and 94% of the cases, respectively. The portal vein could not be adequately visualized in any patients when the probe was in the distal bile duct. The mean thickness of the normal bile duct wall was 0.17 cm, and the mean wall thicknesses proximal to a benign and malignant stricture were 0.16 and 0.17 cm, respectively. The mean thicknesses of benign and malignant biliary strictures were 0.32 cm and 0.31 cm, respectively (not significant). Eight of 12 benign biliary strictures (67%) and five of 11 malignant strictures (45%) were symmetrical. However, no obvious differences could be identified between benign and malignant biliary strictures. There were no catheter related complications.

CONCLUSIONS

Further catheter modifications are needed, but it appears to be feasible to assess vascular invasion in cholangiocarcinoma and to characterize biliary strictures in a way that may be able to influence therapy options in some patients. The currently available CBUSP cannot distinguish between benign and malignant strictures. However, with technical modifications, this may be possible in the future. The clinical usefulness of CBUSP in the pancreas awaits further investigation, but pancreatic imaging is feasible.

Risk of nonshunt abdominal operation in the patient with cirrhosis

BACKGROUND

The hazards of operative treatment for variceal hemorrhage and intractable ascites in patients with cirrhosis are well known. Much less information is available on the morbidity and mortality in these patients after abdominal operations not directly related to the sequelae of portal hypertension.

STUDY DESIGN

We reviewed the records of 77 consecutive histologically proved cases of cirrhosis in patients undergoing 85 general surgical, abdominal procedures during a ten year period. Logistic regression analysis was done on 32 preoperative and intraoperative variables with relation to postoperative outcome.

RESULTS

There were 47 men and 30 women, with a mean age of 61 years (range of 28 to 86 years). The 30-day mortality rate was 18 percent (15 of 77 patients). Emergent operation was associated with a mortality rate of 32 percent (11 of 35 patients) compared with 8 percent (four of 50 patients) after elective procedures (p < 0.05). Extensive complications occurred in 28 percent of patients (24 patients; 14 percent after elective operative treatment and 49 percent after emergent procedures). The mortality rate was greatest after gastric procedures (38 percent). Other factors of statistical significance (p < 0.05) associated with poor postoperative outcome included cachexia, preoperative transfusion of fresh frozen plasma, and intraoperative platelet transfusion. Surprisingly, operative blood loss, presence of ascites, and operative time were not associated with increased complications or death.

CONCLUSIONS

We conclude that elective, nonshunt abdominal operations can be performed with acceptable morbidity and mortality rates in selected patients with cirrhosis.

The effects of sera from women with spontaneous abortions on the in vitro development of early somite stage rat embryos

PROBLEM

Spontaneous abortions occur in 40 to 50% of pregnancies, but the causes for some abortions, especially those that are recurrent (spontaneous), are still unknown.

METHOD

Following previous studies that demonstrated embryotoxic effects of sera from women with spontaneous abortions in preimplantation mouse embryos, we cultured 10.5-day-old rat embryos in sera from women after spontaneous abortions to look for specific teratogenic effects.

RESULTS

About 50% of the embryos cultured in sera from women after spontaneous abortions were malformed, as compared to 19.1 and 27.1% malformations in embryos cultured in sera from women after a normal delivery and during a normal second trimester of pregnancy, respectively. We divided the sera from women who had spontaneous abortions into high-risk, and low-risk sera. In the high-risk sera from one abortion, we found 74.2% malformed embryos and in the high-risk group from two or more abortions this rate was 81.0%. This is compared to a rate of 17.1 and 10.3% in the low-risk sera, respectively. We have also found lower DNA and protein synthesis in the embryos cultured in high-risk sera compared to those cultured in low-risk and control sera. Transmission electron microscopy examination of yolk sacs cultured in high risk sera showed ultrastructural damage as represented by a lower number of microvilli and a higher number of inclusions in the entodermal cells when compared to controls. Amino acid chromatography of the serum and the concentrations of folic acid and zinc were similar in control and high-risk sera.

CONCLUSION

It seems that the majority of sera from women with unexplained spontaneous abortions are teratogenic to rat embryos in culture. In about two-thirds of these sera the teratogenic factor(s) seem to be present in the IgG fraction.

A normal initial colonoscopy after age 50 does not predict a polyp-free status for life

OBJECTIVES

The prevalence of colon polyps increases with age in the general population. It is unknown whether a lack of adenomatous polyps determined at one time point after the age of 50 is predictive of a subsequent low risk of polyp development.

METHODS

Twenty-nine patients between ages 50 and 70 who had no prior history of polyps and had a normal colonoscopy at least 5 yr previously were recruited for follow-up colonoscopy to evaluate the incidence of neoplastic disease in this presumably low-risk group.

RESULTS

The incidence of adenomatous polyps after a mean of 5.74 yr was 41.4% (95% confidence interval: 23.5-61.1%). A total of 20 adenomatous polyps were found in 12 patients. Seven polyps were 5 mm or more in size.

CONCLUSIONS

We conclude that in patients with no history of colonic neoplasia who are 50 yr old, or older, the finding of a normal colonoscopy does not predict diminished risk of neoplasia.

An unusual blue baby

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Children's observations of violence: II. Clinical implications for children's mental health professionals

This paper discusses the clinical implications of our current knowledge about children exposed to violence. It highlights a number of typical case scenarios in which mental health professionals have responded inadequately to the issue of violence. Alternative strategies for assessing and treating children exposed to violence are offered which have both therapeutic and preventative value. Finally, a family based assessment and treatment approach, which may be appropriate in a number of cases, is suggested.

Emotional and physical health problems of battered women

The present study focused on the emotional and physical health problems of battered women by comparing a sample of residents in shelters with a group of women in the community matched for family income, length of marriage, and number of children on the General Health Questionnaire. The results indicated that battered women report a significantly higher level of somatic complaints, anxiety, and depression. These effects tended to be associated with other life stressors and children with serious behavior problems. The implications of the study are discussed in terms of assessing the needs of battered women and their children as well as being vigilant for family violence as an etiological factor for other presenting problems.

Child witnesses to violence between parents: critical issues in behavioral and social adjustment

This study examined the impact of exposure to family violence on children's adjustment. Two groups of residents of shelters for battered women (current and former residents) were compared to a nonviolent control group. All three groups of mothers completed interviews and self-report questionnaires related to both their own and their children's adjustment. Children recently witnessing violence tended to have the lowest levels of social competence ratings, and their mothers reported the most health and emotional difficulties. Former residents of shelters experienced the highest level of family/social disadvantage. The results are discussed in the context of previous research findings, and implications for intervention programs are outlined.

Family violence and child adjustment: a comparative analysis of girls' and boys' behavioral symptoms

The authors compared behavior problems and social competence in 126 boys and girls (age 6-11) from violent and nonviolent families, on the basis of maternal ratings on the Achenbach Child Behavior Checklist. Girls from violent families were reported as showing more internalizing behavior problems and a lower level of social competence than their nonviolent comparison group. Boys from violent families were reported as demonstrating both internalizing and externalizing behavior problems, in addition to having a lower level of social competence. For boys, the level of exposure to violence between parents was significantly associated with greater adjustment problems.

Toxic shock syndrome

Presenting features and clinical manifestations of six patients with toxic shock syndrome are reported. In four of the six cutaneous injury, sometimes trivial, occurred before the onset of symptoms and may have been a causal factor. All six children recovered. The need for early recognition and intensive management in this life threatening condition is discussed.

Venous pressure and exercise tolerance

Compared to the number of contractions obtained when a blood pressure cuff on the upper arm was at zero pressure, inflation of the cuff to pressures ranging between 5 and 40 mm Hg resulted in an augmentation of the number of hand contractions that could be performed prior to the development of ipsilateral severe fatigue or intolerable pain. Cuff pressures of 60 mm Hg reduced the number of contractions below the control level. These results are consistent with the concept that exercise during venous congestion facilitates the washout of the toxic catabolite presumed to be produced during muscular contraction.

Relationship between plasma cortisol and peak expiratory flow rat in exercise-induced asthma and the effect of sodium cromoglycate

1. The changes in peak expiratory flow rate (PEF) and plasma cortisol were studied in relation to a 6 min period of treadmill running in six normal and eighteen asthmatic subjects. Of the asthmatics patients, five were not receiving treatment with steroids, six were receiving low doses of steroids (under 7·5 mg of prednisone daily) and seven were receiving high doses of steroids (over 7·5 mg of prednisone daily) at the time of study.

2. All subjects were studied twice within 1 week at similar times of day, once after premedication with sodium cromoglycate (SCG) and once after a placebo.

3. Resting PEF and plasma cortisol did not differ between placebo and SCG tests.

4. No change in PEF occurred as a result of exercise in the control subjects. The asthmatic patients developed post-exercise bronchoconstriction which was partly prevented by SCG but was not affected by steroids.

5. Plasma cortisol rose after exercise in the asthmatic subjects but not in the control subjects. The rise may have been related to the stress of exercise-induced asthma. SCG had no significant effect on plasma cortisol after exercise.