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PubMed1992

Colonoscopy in a private hospital: continuous quality improvement in practice.

This paper documents serial audits on technical aspects of the performance of fibre-optic examination of the large intestine by a number of proceduralists, in one institution, over 7 years. The completeness of the procedure and the associated morbidity are recorded and compared with results reported in the world literature. The study provides a clear demonstration of continuous quality improvement in practice.

Clinical Competence↗
PubMed2005

Peritoneal dialysis as a plausible option in morbus Osler: case report.

At the age of 69 years, a woman with recurrent gastrointestinal bleeding underwent investigation by gastroscopy and colonoscopy. Extensive telangiectatic changes were observed in the canalis and antrum of the ventricle and in the colon. In parallel, the woman suffered from nephrotic syndrome, hypertension, and progressive renal failure attributable to chronic glomerular changes with extensive interstitialfibrosis. The progressive renal failure and recurrent gastrointestinal bleeds made frequent transfusions and erythropoietin injections necessary. Because of those complications, and because CAPD avoids the intermittent overhydration of a therapy such as hemodialysis and the risk of using anticoagulants, it was decided to perform continuous ambulatory peritoneal dialysis (CAPD) when dialysis became necessary. After CAPD was started, the woman's bleeding episodes decreased within 1 week. After 70 months of CAPD, the woman is well, without gastrointestinal bleeding. No transfusions have been necessary since the start of CAPD. For the now 77-year-old woman, data are as follows: epoetin beta dose, 12,000 U/week; body weight, 67 kg; hemoglobin, 130 g/L. The woman has experienced 1 episode of peritonitis since starting dialysis (6 months before the time of writing), because of a malfunction of the peritoneal dialysis device. No intestinal perforations have occurred. It seems worthwhile to try CAPD for dialysis in patients with morbus Osler

Aged↗
PubMed2006

Bevacizumab: new drug. Metastatic colorectal cancer: good in theory, not in practice.

(1) The prognosis for metastatic colorectal cancer is grim. The best treatment results are obtained by adding irinotecan to first-line fluorouracil + folinic acid therapy and then oxaliplatin to second-line fluorouracil + folinic acid therapy (or the reverse sequence), but median survival time still fails to exceed 2 years. (2) Bevacizumab is a monoclonal antibody directed against vascular endothelial growth factor (VEGF), a mediator involved in angiogenesis. Bevacizumab is marketed in Europe for first-line treatment of metastatic colorectal cancer, in combination with fluorouracil + folinic acid (with or without irinotecan). (3) The clinical evaluation includes 3 comparative trials. A double-blind trial involving 813 patients compared the American IFL protocol (irinotecan + fluorouracil + folinic acid) + placebo with the IFL protocol + bevacizumab. Median survival time was shorter with IFL + placebo (15.6 versus 20.3 months), but the results are difficult to extrapolate to the situation in Europe, where the FOLFIRI protocol is used (irinotecan + fluorouracil + folinic acid). This protocol is more effective than the IFL protocol. (4) Another double-blind trial, involving 204 patients, compared another American protocol, fluorouracil + folinic acid + placebo, with fluorouracil + folinic acid + bevacizumab. Median survival time did not differ significantly between the groups (12.9 and 16.6 months). (5) A combined analysis of 3 comparative trials showed an increase in median survival time of 3.3 months (17.9 versus 14.6 months) when bevacizumab was added to a fluorouracil + folinic acid combination. An indirect comparison suggests that this is no better than adding irinotecan. (6) In second-line treatment, preliminary data from a trial of bevacizumab + FOLFOX 4 (oxaliplatin + fluorouracil + folinic acid) fail to show a tangible benefit for bevacizumab. (7) Bevacizumab adjunction to current chemotherapy protocols increased the frequency of some potentially serious reactions, such as cardiovascular disorders (hypertension, arterial thrombosis); tumour haemorrhage; intestinal perforation; wound healing; and haematological disorders (severe leukopenia, etc.). (8) In practice, there is no evidence that bevacizumab is any better than current European chemotherapy protocols for first-line treatment of metastatic colorectal cancer.

Antibodies, Monoclonal↗
PubMed1991

Complications of CAPD in children: six years experience in Caracas, Venezuela.

Forty-three ESRD children received treatment with CAPD from November 1984 through July 1990. Mean patient age was 10 years (range 2-17 years) and total observation period (consolidated for the whole group) was 683 months. Double cuff Tenckhoff catheters were used as access. The most common complication was peritonitis with an overall rate of one episode per 5.6 patient/months. Important correlation was found between incidence of peritonitis and socioeconomic status assessed by Graffar Index (G.I.). Patients with lowest socioeconomic status (GI of IV and V) had one episode of peritonitis per 2.9 patient/months. Patients with GI of III had one episode per 5.2 patient/months and patients with the best socioeconomic status (GI of I and II) had only one episode per 11.6 patient/months. Other complications were the following: Infections: 18 exit site infection, 5 exit site granuloma and 5 tunnel abscess. Catheter malfunction: 17 obstructions, 5 migrations and 2 ruptures. Others: 3 peritoneal hemorrhages, 1 intestinal perforation, 3 eventrations, 4 inguinal hernias and 1 right pleural effusion. In this last patient, pleurodesis was unsuccessfully attempted with homologous blood. We conclude that patients with very low socioeconomic status are poor candidates for CAPD and should be considered preferably for hemodialysis.

Adolescent↗
PubMed2006

Mortality in patients with rheumatoid arthritis treated with low-dose oral glucocorticoids. A population-based cohort study.

OBJECTIVE: To evaluate mortality and causes of death in patients with rheumatoid arthritis (RA) treated with low-dose oral glucocorticoids. METHODS: Mortality was analyzed in population-based data of 604 patients with RA. In the original study in 1988, state of general health, severity of RA, and treatment including the use of oral glucocorticoids were recorded. In 1999 vital status and causes of death were evaluated. Mortality in patients with RA who had not received glucocorticoids (Group A, n = 209) was compared to that in patients treated with glucocorticoids for less than 10 years (Group B, n = 276) or for more than 10 years (Group C, n = 119). RESULTS: From onset of RA to 1999, 395 (65%) patients had been treated with oral glucocorticoids. In 1999 a total of 160 (26%) patients had died, 23% of patients in Group A, 21% in Group B, and 45% in Group C. In multivariate Cox regression analysis, male sex (hazard ratio 2.50; 95% CI 1.74-3.59), impaired functional capacity by Health Assessment Questionnaire (HR 2.11; 95% CI 1.65-2.96), heart failure (HR 1.96; 95% CI 1.36-2.84), and diabetes (HR 1.87; 95% CI 1.17-3.01) predicted increased mortality. In the same analysis glucocorticoid treatment for 1 year increased the mortality risk by 14% (HR 1.14; 95% CI 0.98-1.27, p = 0.057) and treatment over 10 years by 69% (HR 1.69; 95% CI 1.12-2.56, p = 0.011) compared to RA patients without treatment. The major cause of death was cardiovascular disease in all groups, but infections and intestinal perforations due to amyloidosis were more frequent in patients with long-lasting glucocorticoid therapy. Lymphomas were more frequent in all patients treated with glucocorticoids (Groups B and C) than in those not receiving glucocorticoids. CONCLUSION: Patients with RA treated with low-dose oral glucocorticoids for more than 10 years had increased mortality compared to those who did not receive glucocorticoids or whose duration of treatment was less than 10 years. The increased mortality was related mainly to infections and complications caused by systemic amyloidosis.

Administration, Oral↗
PubMed2006

Risk factors of abdominal surgery in patients with collagen diseases.

Patients with collagen diseases have been reported to demonstrate a greater risk when undergoing surgical operations. To determine the risk factors in abdominal surgery for patients with collagen diseases, 32 patients with collagen diseases who underwent abdominal surgery were analyzed for their clinical features and surgical results by comparing 26 cases from the favorable prognosis group (Group A) and 6 cases resulting in hospital death (Group B). The analysis revealed that emergent operations tended to result in worse outcomes (P = 0.011) than elective operations and that cases undergoing operations for collagen disease-related problems, including intestinal perforation and acute pancreatitis, also showed a worse postoperative course than those who underwent operations for problems unrelated to collagen diseases, such as carcinomas and cholelithiasis (P = 0.0006). The dose of steroids administered at the time of operation was also significantly higher in Group B than in Group A (P = 0.03). These results suggested that the patients with collagen diseases should be followed periodically not only for the primary disease but also for any potential surgical diseases to identify such diseases at an early stage and to avoid an emergent operation, and that patients treated with high doses of steroids also need intensive care after abdominal surgery.

Abdomen↗
PubMed2006

Non-Hodgkin's lymphomas of the colon.

BACKGROUND: Non-Hodgkin's lymphoma of the colon is a rare and consequently poorly studied extranodal lymphoma. Most of the previous publications used old pathologic classifications and old diagnostic and treatment approaches. OBJECTIVE: To examine the clinical presentation, pathologic classification, treatment and outcome of patients with NHL of the colon. METHODS: A retrospective study was performed of all patients with NHL and involvement of the colon in two medical centers. The patient group consisted of 17 patients over a 13 year period. RESULTS: Fourteen patients had primary involvement and 3 secondary. The ileocecal region and cecum were the most frequent sites of involvement, occurring in 76% of patients. Most patients had bulky disease: three had a diameter >5 cm and eight a diameter >10 cm. Aggressive histology was found in 12 patients: diffuse large B cell lymphoma in 11 and peripheral T cell lymphoma in 1. Three patients had mantle cell lymphoma and two had indolent lymphomas: mucosa-associated lymphoid tissue (n=l) and small lymphocytic (n=l). Eleven patients underwent hemicolectomy: right sided in 9 and left sided in 2, and 5 DLBCL patients required emergency surgery for intestinal perforation. The median overall survival was 44 months (range 1-147). Disease stage influenced prognosis; six of seven patients with limited-stage DLBCL who received aggressive chemotherapy achieved complete remission and enjoyed prolonged survival, whereas patients with aggressive disseminated disease had resistant disease and poor survival (median 8 months). CONCLUSIONS: Most colonic lymphomas are aggressive B cell lymphomas. Diagnosis is often delayed. Early diagnosis may prevent perforation. Those with limited-stage disease when treated with aggressive chemotherapy may enjoy prolonged survival. The role of elective hemicolectomy to prevent perforation should be examined in prospective trials.

Adult↗
PubMed1991

[Peritoneal lavage in the diagnosis of blunt injuries of hollow intra-abdominal organs].

In some cases of blunt abdominal trauma lesions of gastrointestinal tract are occasionally found. The difficulty with these injuries lies in establishing the diagnosis. Clinical examination alone does not reliable evidence, particularly if the patient is unconscious and therefore unable to respond subjectively. Although abdominal sonography ist becoming increasingly important in the diagnosis of blunt abdominal trauma lesions of the gastrointestinal tract frequently remain undetected or are diagnosed to late where this method of examination is used exclusively. In the retrospective analysis of our patients we have encountered serious complications such as peritonitis and even cases resulting in death. On the other hand when peritoneal lavage was employed, no false negative results occurred. Consequently the value of this method in the diagnosis of blunt abdominal trauma and possible lesions of the gastrointestinal tract is indisputable.

Abdominal Injuries↗
PubMed1991

[Hartmann's procedure. Indications, results. Apropos of 105 cases].

The authors report in this retrospective study, 105 cases of patients operated with Hartmann's technic since 1979 to 1990. There were 55 men and 50 women with average age of 70 years (34-90 years old), 71 patients were strucked down by malign disease, 34 by benign disease. 42 surgical operations were performed immediately, 63 were delayed, 26 operations were immediately performed for serious sepsis, 11 for occlusives syndromes. Delayed surgical operations were performed for malignant diseases in 50 cases, elsewhere, there were 6 sigmoiditis with malignant aspect. The upper half rectum was resected at a rate of 38%, the original technic was performed at a rate of 65%. Post operatory mortality was at a rate of 13% (14 died) concerning 25% of immediately operated patients and 6% of delayed operations. Post operatory mortality was at a rate of 15.4% for malignant disease and 8.8% for benign disease. Post operatory results were complicated with 4 occlusives syndromes, 3 fistula from the rectum, 1 cholecystis, 1 small intestine perforation. There were 10 parietal complications and 10 general complications with 7 urinary infections, 4 lung infections and 2 venous thrombosis. The colon anastomosis was performed in a manual way in 23.4% of cases, in a mechanical way in 23% of cases (with EEA or PCEA forceps) with a 8 month average interval between the 2 surgical operations. The mortality rate of this surgical operation is high because patients are old and have heavy deficiencies and are immediately operated for serious diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

[Treatment of gastric cancer patients with peritoneal metastasis by continuous hyperthermic peritoneal infusion with mitomycin C and cisplatin].

Following the resection of its primary lesion, continuous hyperthermic peritoneal perfusion (CHPP) with anticancer drug (mitomycin C, cisplatin) containing warmed physiological saline was performed on gastric cancer having peritoneal dissemination, and the effect of CHPP was examined by second look operation (SLO). The subjects were 41 cases of gastric cancer with peritoneal dissemination but without hepatic metastasis, which we have experienced in the past 7 years. The prognosis of these CHPP-treated cases was such that 50% survival period, 3 year survival rate and 5 year survival rate were 398 days, 28.5 and 12%, respectively. Comparison of the effects of CHPP by SLO revealed remarkable diminution of the peritoneal dissemination in 7 (44%) of 16 cases and disappearance of the ascites with a single course of CHPP in 7 of ascitic cases. Long-term survival (greater than 3 years) was noted in 4 of the CHPP-treated cases. Side effects were renal insufficiency, leukopenia and small intestinal perforation in 2(5), 2(5) and 1 cases (2%), respectively. The above results suggested the effectiveness of CHPP for the treatment of gastric cancer having peritoneal dissemination.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1990

Acute abdomen in childhood leukemia.

With the continuing advancement in the treatment of childhood leukemia and the lengthened survival of these patients, an increased incidence of abdominal complications has been observed. A retrospective analysis of 364 patients with leukemia treated at the National Taiwan University Hospital from January 1977 through April 1988 was undertaken. Eleven patients (3.0%) developed abdominal complications during their course of disease, including acute appendicitis, intussusception, intestinal perforation, ovarian cyst rupture, etc. All of these patients had abdominal complications during the initial presentation or relapse of leukemia, and 9 (82%) of them had just received chemotherapy. Ten patients (91%) had thrombocytopenia and 7 (64%) had leukopenia. Blood cultures were positive in 5 patients (45%), and gram-negative enteric bacilli were isolated in 4 of them. All 5 septicemic patients had leukopenia or neutropenia. The clinical manifestations were nonspecific and were often masked. Most of the complications occurred in the right lower abdominal structures. Of the 7 children treated surgically, 3 had long term survival. Among the 4 patients who did not receive an operation, only 1 survived for more than 4 weeks. The mean length of survival tended to be longer in patients with additional surgical treatment. Prompt diagnosis and early aggressive treatment, under modern supportive facilities, appear to offer a more favorable outcome.

Abdomen, Acute↗
PubMed1991

[Atypical giant cell arteritis].

The atypical clinical course of giant-cell arteritis in the elderly (who may develop a clinical picture of severe consumptive disease) is illustrated by two observations with histologically confirmed temporal arteritis. In addition to fever and loss of weight, the inflammatory vascular process in a 78-year old female was reflected in arrhythmias (atrial fibrillation and atrial flutter), probably due to involvement of the coronary arteries, and occlusion of the left axillary artery. Similar general symptoms and various neurological deficits comprising amaurosis, mononeuritis multiplex, polyneuropathy, myopathy and finally subarachnoid hemorrhage characterized the disease in a 72-year-old man. The picture was further complicated by intestinal perforation. In both patients steroids brought considerable improvement and the disease process came to a standstill.

Aged↗
PubMed1991

[Injuries of the small and large intestine in the traumatized abdomen].

Between 1973 and 1989 a total of 388 patients underwent laparotomy because of abdominal trauma. In 98 cases, injuries of the small bowel, the colon or the mesentery were found. The injuries were caused by motor vehicle accidents in 55 patients; 12 had gunshot or stab wounds and 12 committed suicide. There were 78 patients who had sustained a blunt abdominal trauma and 20 patients with a penetrating trauma. Only 21 patients had suffered a solitary injury of the gastrointestinal tract. In 41 patients there were also lesions to other intraabdominal organs, in 11 patients, thoracic injuries and in 24 patients, a craniocerebral trauma. Combined injuries of skull, thorax and abdomen were present in 24 patients. Neither ultrasound nor peritoneal lavage allows reliable prediction of injuries of the gastrointestinal tract. In 51 cases a defect of the mesentery or serosa was repaired. In 54 patients there was a rupture of the small or large intestine: in 20 of these cases primary repair without resection was performed and in 34, resection and anastomosis. Ileostomy or colostomy was done in only 8 patients. An anastomotic leak developed in 2 patients. Lethality is correlated to the extent of concomitant injuries. Solitary injury of the small bowel or colon was followed by lethality of only 4.1%, increasing to 50% in patients with combined injuries of skull, thorax and abdomen.

Abdominal Injuries↗
PubMed1990

[Intestinal metastasis of pulmonary cancers. Apropos of 2 cases].

We report 2 new cases of intestinal metastases from lung cancer. Such metastases are not exceptional, but their clinical manifestations are rare and their diagnosis during evaluation of lung cancer is difficult. This diagnosis could be suggested by the presence of iron deficiency anaemia or melena in a patient being investigated for lung cancer. Other metastases are often present, and the prognosis is fatal at short term.

Adult↗
PubMedDate not supplied

[Percutaneous cholangioscopy. An alternative in the treatment of retained stones].

We report our experience in the use of percutaneous cholangioscopy for extraction of retained stones in the biliary tract, at the Oncology Hospital, Centro Médico Nacional, IMSS, between July 1984 and January 1990. Ninety seven patients were evaluated; the endoscopic manipulation was successful in 82 patients (84.5%). The main causes of failure were: narrow fistula, impacted stone, very small stones and false way. There were minor complications on 13 patients, but in two cases intestinal perforation indicated laparotomy. No death was reported. The main disadvantage of cholangioscopy was the waiting period, necessary to obtain a strong fistula. Nevertheless, the endoscopist can also relay on other techniques, such as sphincterectomy; the choice depends of each particular case.

Cholelithiasis↗
PubMed1990

[Changes in the diagnosis and therapy of invagination].

The alterations in diagnosis and therapy of intussusception in infants is described in 155 cases from 1978-1989. The primary diagnostic procedure is the abdominal sonography. It is followed to 1988 the attempt of hydrostatic reduction by barium enema and now the pneumatic reduction. The rate of success with conservative treatment was finally over 80%. Primary operative treatment is only necessary in the rare cases with signs of perforation of intestine or of peritonitis.

Air↗