Rational sequence of tests for pancreatic function.
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Of 144 patients with suspected pancreatic disease in whom a 75Se-selenomethionine scan was performed, endoscopic retrograde pancreatography (ERP) was successful in 108 (75%). The final diagnosis is known in 100 patients and has been compared with scan and ERP findings. A normal scan reliably indicated a normal pancreas, but the scan was falsely abnormal in 30%. ERP distinguished between carcinoma and chronic pancreatitis in 84% of cases but was falsely normal in five patients with pancreatic disease. In extrahepatic biliary disease both tests tended to give falsely abnormal results. A sequence of tests to provide a rapid and reliable assessment of pancreatic function should be a radio-isotope scan, followed by ERP if the results of the scan are abnormal, and a Lundh test if the scan is abnormal but the findings on ERP are normal. (+info)
Reconstruction of the anterior cruciate ligament: comparison of outside-in and all-inside techniques.
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The aim of this prospective study was to compare two arthroscopic techniques for reconstructing the anterior cruciate ligament, the "outside-in" (two incisions) and the "all-inside" (one incision) techniques. The results obtained for 30 patients operated on using the "outside-in" technique (group I) were compared with those for 29 patients operated on using the "all-inside" technique (group II). Before surgery, there were no significant differences between the groups in terms of Lysholm score, Tegner activity level, patellofemoral pain score, or knee laxity. Both groups displayed significant improvements in Lysholm score after 24 months, from 69 (16) to 91 (9) in group I and from 70 (17) to 90 (15) in group II (means (SD)). There were also significant improvements in patellofemoral pain scores in both groups, from 13 (6) to 18 (5) in group I and from 14 (6) to 18 (4) in group II after 24 months. No difference was found between the groups in knee stability at the 24 month follow up. The IKDC score was identical in both groups at follow up. The operation took significantly longer for patients in group I (mean 94 (15)) than for those in group II (mean 86 (20)) (p = 0.03). The mean sick leave was 7.7 (6.2) weeks in group I and 12.3 (9.7) weeks in group II (p = 0.026), indicating that there may be a higher morbidity associated with the "all-inside" technique. It can be concluded that there were no significant differences between the two different techniques in terms of functional results, knee laxity, or postoperative complications. The results were satisfactory and the outcome was similar in both treatment groups. (+info)
A new filtering algorithm for medical magnetic resonance and computer tomography images.
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Inner views of tubular structures based on computer tomography (CT) and magnetic resonance (MR) data sets may be created by virtual endoscopy. After a preliminary segmentation procedure for selecting the organ to be represented, the virtual endoscopy is a new postprocessing technique using surface or volume rendering of the data sets. In the case of surface rendering, the segmentation is based on a grey level thresholding technique. To avoid artifacts owing to the noise created in the imaging process, and to restore spurious resolution degradations, a robust Wiener filter was applied. This filter working in Fourier space approximates the noise spectrum by a simple function that is proportional to the square root of the signal amplitude. Thus, only points with tiny amplitudes consisting mostly of noise are suppressed. Further artifacts are avoided by the correct selection of the threshold range. Afterwards, the lumen and the inner walls of the tubular structures are well represented and allow one to distinguish between harmless fluctuations and medically significant structures. (+info)
Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group.
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PURPOSE: The safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery (SEPS) for the treatment of chronic venous insufficiency were established in a preliminary report. The long-term clinical outcome and the late complications after SEPS are as yet undetermined. METHODS: The North American Subfascial Endoscopic Perforator Surgery registry collected information on 148 SEPS procedures that were performed in 17 centers in the United States and Canada between August 1, 1993, and February 15, 1996. The data analysis in this study focused on mid-term outcome in 146 patients. RESULTS: One hundred forty-six patients (79 men and 67 women; mean age, 56 years; range, 27 to 87 years) underwent SEPS. One hundred and one patients (69%) had active ulcers (class 6), and 21 (14%) had healed ulcers (class 5). One hundred and three patients (71%) underwent concomitant venous procedures (stripping, 70; high ligation, 17; varicosity avulsion alone, 16). There were no deaths or pulmonary embolisms. One deep venous thrombosis occurred at 2 months. The follow-up periods averaged 24 months (range, 1 to 53 months). Cumulative ulcer healing at 1 year was 88% (median time to healing, 54 days). Concomitant ablation of superficial reflux and lack of deep venous obstruction predicted ulcer healing (P <.05). Clinical score improved from 8.93 to 3.98 at the last follow-up (P <. 0001). Cumulative ulcer recurrence at 1 year was 16% and at 2 years was 28% (standard error, < 10%). Post-thrombotic limbs had a higher 2-year cumulative recurrence rate (46%) than did those limbs with primary valvular incompetence (20%; P <.05). Twenty-eight of the 122 patients (23%) who had class 5 or class 6 ulcers before surgery had an active ulcer at the last follow-up examination. CONCLUSIONS: The interruption of perforators with ablation of superficial reflux is effective in decreasing the symptoms of chronic venous insufficiency and rapidly healing ulcers. Recurrence or new ulcer development, however, is still significant, particularly in post-thrombotic limbs. The reevaluation of the indications for SEPS is warranted because operations in patients without previous deep vein thrombosis are successful but operations in those patients with deep vein thrombosis are less successful. Operations on patients with deep vein occlusion have poor outcomes. (+info)
Comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding.
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BACKGROUND AND METHODS: We compared propranolol therapy and endoscopic ligation for the primary prevention of bleeding from esophageal varices. This prospective, controlled trial included consecutive eligible patients who had large varices (>5 mm in diameter) that were at high risk for bleeding. The patients were assigned to either propranolol therapy, at a dose sufficient to decrease the base-line heart rate by 25 percent, or variceal ligation, to be performed weekly until the varices were obliterated or so reduced in size that it was not possible to continue treatment. RESULTS: Of the 89 patients, 82 of whom had cirrhosis of the liver, 44 received propranolol and 45 underwent variceal ligation. The mean (+/-SD) duration of follow-up in each group was 14+/-9 and 13+/-10 months, respectively. The mean time required to achieve an adequate reduction in the heart rate was 2.5+/-1.7 days; the mean number of sessions needed to complete variceal ligation was 3.2+/-1.1. After 18 months, the actuarial probability of bleeding was 43 percent in the propranolol group and 15 percent in the ligation group (P=0.04). Twelve patients in the propranolol group and four in the ligation group had bleeding. Three of the four in the ligation group had bleeding before their varices had been obliterated. Nine patients in the ligation group had recurrent varices, a mean of 3.7 months after the initial treatment. Five patients in each group died; bleeding from the varices was the cause of death of four patients in the propranolol group and of three in the ligation group. There were no serious complications of variceal ligation; in the propranolol group, treatment was stopped in two patients because of side effects. CONCLUSIONS: In patients with high-risk esophageal varices, endoscopic ligation of the varices is safe and more effective than propranolol for the primary prevention of variceal bleeding. (+info)
Improving information given to patients before endoscopy: a regional audit.
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To improve the information given to patients before endoscopy an audit was performed in 16 of 18 endoscopy units in Northern region. Details of current endoscopy information leaflets provided by the 16 respondents were discussed by nurses and consultants from the participating units, and a standard, including 12 separate items, was agreed. Each unit was provided with a comparison of its current leaflet with the standard, which highlighted areas for potential improvement. Six months later the participating units were again asked to provide details of the information; 13 replied, 11 of which had produced new leaflets and two which were in the process of doing so. In the initial survey only 35% (range 8-67%) of the items in the standard were included in the leaflets. Particular omissions were an indication of risks of procedures (three units), notification of follow up procedures (two), details for obtaining the results of the endoscopy (five), advice for people with diabetes (two) and providing a contact number for the endoscopy unit (four). In the repeat audit all 11 units had made changes to their leaflets and, overall, 80% of the items were included. Through this simple audit the range of information given to patients attending for endoscopy in the region has improved. (+info)
Management of coeliac disease: a changing diagnostic approach but what value in follow up?
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OBJECTIVE: To assess the management of patients with coeliac disease in relation to a change in diagnostic method from jejunal suction biopsy to endoscopic biopsy. DESIGN: 16 item questionnaire survey of consultant members of the British Society of Gastroenterology. SUBJECTS: 359 consultant physician and gastroenterologist members of the society. MAIN MEASURES: Type of routine biopsy; repeat biopsy after gluten withdrawal; gluten rechallenge; follow up measurements; screening for malignancy; and methods of follow up, including special clinics. RESULTS: 270(70%) members replied; 216(80%) diagnosed coeliac disease routinely by endoscopic duodenal biopsy, 30(11%) by jejunal capsule biopsy, and the remainder by either method. Only 156(58%) repeated the biopsy after gluten withdrawal, though more did so for duodenal than jejunal biopsies (134/216, 62% v 13/30, 43%; p < 0.02). Follow up biopsies featured more duodenal than jejunal biopsies (133/156, 82% v 23/156, 15%; p < 0.02). Regular follow up included assessments of weight (259, 96%) and full blood count (238, 88%) but limited assessment of serum B-12 and folate (120, 44%) and calcium (105, 39%) concentrations. Routine screening for malignancy is not performed, and there are few specialist clinics. 171(63%) respondents thought that patients should be followed up by a hospital specialist and 58(21%) by family doctors. CONCLUSIONS: The practice of diagnosing coeliac disease varies appreciably from that in many standard texts. Many patients could be effectively cared for by their family doctor. IMPLICATIONS: The British Society of Gastroenterology should support such management by family doctors by providing clear guidelines for them. (+info)
Impact of endoscopic biopsy surveillance of Barrett's oesophagus on pathological stage and clinical outcome of Barrett's carcinoma.
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BACKGROUND: The efficacy of endoscopic biopsy surveillance of Barrett's oesophagus in reducing mortality from oesophageal cancer has not been confirmed. AIMS: To investigate the impact of endoscopic biopsy surveillance on pathological stage and clinical outcome of Barrett's carcinoma. METHODS: A clinicopathological comparison was made between patients who initially presented with oesophageal adenocarcinoma (n = 54), and those in whom the cancer had been detected during surveillance of Barrett's oesophagus (n = 16). RESULTS: The surveyed patients were known to have Barrett's oesophagus for a median period of 42 months (range 6-144 months). Prior to the detection of adenocarcinoma or high grade dysplasia, 13 to 16 patients (81%) were previously found to have low grade dysplasia. Surgical pathology showed that surveyed patients had significantly earlier stages than non-surveyed patients (p = 0.0001). Only one surveyed patient (6%) versus 34 non-surveyed patients (63%) had nodal involvement (p = 0.0001). Two year survival was 85.9% for surveyed patients and 43.3% for non-surveyed patients (p = 0.0029). CONCLUSIONS: The temporal course of histological progression in our surveyed patients supports the theory that adenocarcinoma in Barrett's oesophagus develops through stages of increasing severity of dysplasia. Endoscopic biopsy surveillance of Barrett's oesophagus permits detection of malignancy at an early and curable stage, thereby potentially reducing mortality from oesophageal adenocarcinoma. (+info)