Eliahou Shemesh

Role of endoscopic retrograde cholangiopancreatography in differentiating pancreatic cancer coexisting with chronic pancreatitis

The pancreatographic appearance and the clinical presentation of ten patients presenting with adenocarcinoma of the head of the pancreas coexisting with chronic pancreatitis were compared with those of 45 patients with chronic pancreatitis (CP), without malignancy, investigated at the same time period. All ten patients, had typical pancreatographic findings of CP, combined with an elongated narrowing of the duct of Wirsung. Marked localized irregularity of the adjacent main duct and of side branches were found in all ten patients. Such findings were not detected in the other 45 patients with CP only. Ultrasonography or computed tomography have detected a definite pancreatic mass in only five of these patients, and in six patients with CP without malignancy. It is concluded that endoscopic retrograde cholangiopancreatography is highly accurate in detecting pancreatic cancer coexisting with CP. It is primarily helpful in elderly patients having severe degrees of CP to rule out cancer.

The association of synchronous neoplasms with occluding colorectal cancer

To find and eradicate synchronous neoplasms, colonoscopy was performed before and after resectional surgery in 50 patients with “occluding colorectal cancer,” defined as encroachment of the lumen by tumor to a degree that prevented passage of a colonoscope. Synchronous, frequently multiple adenomas were found in 29 (58 percent) of these patients. Three patients (6 percent) had synchronous invasive cancer as well. None of these lesions was detected by intraoperative palpation, even though 46 percent of them measured more than 1.0 cm in diameter. Synchronous neoplasms were found significantly more often in patients with occluding cancer than in patients with non-occluding cancer, investigated concurrently at the same hospital. The former patients appear to be in double jeopardy with respect to synchronous neoplasms, these being more prevalent and less accessible than in patients with non-occluding tumors. Moreover, most of the synchronous lesions are undetectable by palpation. These findings bear out the importance of early postoperative, as well as preoperative, colonoscopy in all patients with occluding colorectal cancer.

Early Endoscopic Sphincterotomy in the Management of Acute Gallstone Pancreatitis in Elderly Patients

Eighteen elderly patients with acute attacks of gallstone pancreatitis underwent early endoscopic sphincterotomy of the papilla of Water. Eleven patients were considered to be at high risk for surgery due to chronic cardiorespiratory or renal problems. The outcome of these patients was compared with that of 20 consecutive elderly patients with gallstone pancreatitis treated at the same time by means other than endoscopic sphincterotomy. Endoscopic sphincterotomy resulted in an immediate clinical improvement in all patients, except in one patient who developed transient cholangitis; there was no mortality. In contrast, there was one death (5%) and 20% morbidity in the controls. Mean hospitalization period was shorter in patients undergoing sphincterotomy (6 compared with 9.5 days), although the patients managed by sphincterotomy were initially more seriously ill than controls. Only two of the 11 high‐risk patients underwent elective cholecystectomy; all others were well during a mean follow‐up of 22 months. It is concluded that early endoscopic sphincterotomy is highly effective and safe in acute attacks of gallstone pancreatitis in elderly high‐risk patients.

The feasibility of in vivo resection of the left lobe of the liver and its use for transplantation

The anatomical possibility of resecting the left lobe of the liver (segments II and III) in living subjects and using it for transplantation was evaluated. A group of 60 cadaveric livers were dissected at autopsy. The vascular and biliary elements of the left lobe were isolated and the lobe was resected and evaluated for possible grafting. The left lobe was 12–28% (mean 19.4%) of the liver mass. An extrahepatic segment of the left hepatic vein was isolated in 95% of specimens. Arterial blood supply to the left lobe consisted of a single artery (92%) or two arteries (8%). A single portal vein segment to the left lobe (type I) was: found in 35% livers. Portal vein branches originated from a common orifice (type II, 35%) or separately (type III, 30%) from the left portal vein, and in these instances, preparation of a portal segment necessitated partial section of the left portal vein wall. Biliary drainage was extrahepatic in 56 livers and consisted of a single duct (type I, 78%), or two ducts (type II, 15%). The resected left lobe was evaluated as satisfactory (single hepatic vein and artery, types I or II portal vein, type I bile duct) in 48% of cases, while a less-satisfactory lobe (type III portal vein or type II bile duct) was obtained in 33%. It was found anatomically difficult or impossible to resect the left lobe for possible transplantation in 11 (19%) liver specimens.

Colorectal adenomatous polyps and carcinoma in Ashkenazi and non-Ashkenazi Jews in Israel.

In Israel, the incidence of colorectal cancer among European‐American‐born Jews is approximately 2.5 times that of African‐Asian‐born Jews. To determine the risk of all colorectal tumors for the two ethnic groups, 335 patients with colorectal adenomatous polyps and 295 with colorectal cancer, diagnosed between 1980–1984 at the Sheba Medical Center, were compared to the 35,094 persons attending the outpatient clinics at the same hospital, during September and October 1984. Ashkenazi patients (European‐American‐born) had a 2.5‐fold risk (95% confidence interval 1.9–3.3) of colorectal polyps compared to non‐Ashkenazi patients (African‐Asian‐born). The risk was similar for males (odds ratios [OR] = 2.3) and females (OR = 2.8). Ashkenazis also had a significantly enhanced risk of carcinoma: OR = 3.1; 95% confidence interval 2.2–4.3. The risk ratio was slightly higher for males (OR = 3.5) than females (OR = 2.7). Age‐specific analyses demonstrated an elevated risk of both malignant and benign neoplasms among Ashkenazi patients at all ages at diagnosis. Among the polyp patients, the highest risk ratio was for patients between 30 and 49 years old, while among the cancer patients the risk was highest in the group of 60–69‐year‐olds. The distribution by size of polyps, number of polyps, as well as polyp subsite, was similar for Ashkenazi and non‐Ashkenazi patients; however non‐Ashkenazis tended to have slightly more right‐sided colon cancer. Cancer 58:1167‐1171, 1986.

Are Tiny Polyps Important When Found on Sigmoidoscopy in Asymptomatic People

To determine the occurrence of synchronous large bowel polyps located proximal to the sigmoid, in persons undergoing screening flexible sigmoidoscopy, we examined those who had diminutive polyps (less than or equal to 0.5 cm) as the only finding in the distal colon by further colonoscopy. One hundred one asymptomatic persons (mean age 61 +/- 13 years) had 143 diminutive polyps; a single polyp was found in 76%, and 64% of all polyps were located in the rectum. Thirty (21%) were hyperplastic and 86 (60%) were neoplastic, including 14 with moderate and one with severe dysplasia. The others were inflammatory (five) or unclassified (hot biopsy changes or normal mucosa, 14 polyps), and eight were lost before processing. Colonoscopy revealed that 16 (16%) of the 101 patients had 21 additional polyps proximally, mostly less than 1 cm in diameter. These included one hyperplastic and 18 neoplastic polyps, and two specimens showed hot biopsy changes. Age, histological type, number or location of the index diminutive polyps, were not associated with proximal lesions. We question whether immediate colonoscopy is justified in asymptomatic patients with only diminutive polyps at flexible sigmoidoscopy.

A comparison between emergency and delayed endoscopic injection sclerotherapy of bleeding esophageal varices in nonalcoholic portal hypertension

To study whether or not emergency sclerotherapy was more effective than a program of stabilization and elective sclerosis, we studied 84 patients with bleeding esophageal varices. They underwent 332 sessions of endoscopic injection sclerotherapy, 134 of which were performed for acute variceal bleeding. Most patients (90.5%) had nonalcoholic portal hypertension. Emergency sclerotherapy (1–6 h after presentation) was performed in 65 bleeding episodes in 43 patients, and delayed sclerotherapy (more than 24 h from presentation) was performed in 69 episodes in 41 patients. The selection of patients was randomized. Emergency sclerotherapy arrested active variceal bleeding in all patients and resulted in an earlier eradication of varices and for a longer period than delayed sclerotherapy. Larger volumes of sclerosant (a mean of 26 ml compared to 13 ml) were more effective in arrest of bleeding and in an early eradication of varices. We conclude that emergency sclerotherapy, mainly with a large sclerosant volume, is highly effective in arresting active variceal bleeding. Such earlier arrest of bleeding was associated with reduced morbidity and mortality.

Radiologic and Endoscopic Appearance of Intrabiliary Rupture of Hydatid Liver Disease

Intrabiliary rupture of hydatid liver cyst was diagnosed in 6 patients presenting with obstructive jaundice. All patients underwent ultrasonography and endoscopic retrograde cholangiopancreatography prior to surgical drainage of the liver cyst. Hydatid debris were found in the common bile duct preoperatively in 3 patients, and postoperatively in an additional 3 patients. Accurate diagnosis was made in all patients based on combined duodenoscopic, cholangiographic and sonographic findings. It is concluded that the combination of ultrasonography and endoscopic retrograde cholangiopancreatography can accurately detect intrabiliary rupture of hydatid liver cyst and that both techniques should be performed early in the investigation of suspected ruptured hydatid liver cyst.

Is There an Association between Gastric Polyps and Colonic Neoplasms

The association between colonic neoplasms and gastric polyps (GP) was evaluated. Two hundred and sixty patients with known colonic neoplasms undergoing gastroduodenoscopy for abdominal symptoms, with or without anemia, were evaluated for the occurrence of synchronous GP. There were 100 patients with 1-4 colonic adenomas, 80 patients with multiple (5 or more) colonic adenomas and 80 patients with colorectal cancer. One hundred patients free from colonic neoplasms, investigated for abdominal pain or anemia, served as controls. The overall occurrence of GP in patients with colonic neoplasms was 18.8% compared to 1% in the control group. Hyperplastic GP were found in 4, 22.5, 18.7 and 1% of these patients, respectively, while gastric adenomas occurred in 2, 3.7, 3.5 and 0%, respectively. Patients with colorectal cancer or multiple colonic adenomas had significantly more GP than patients with 0-4 colonic adenomas. It is suggested that gastroduodenoscopic evaluation should be performed in patients with colorectal cancer or with 5 or more colonic adenomas.

Colonoscopy without prior preparation in mild to moderate active ulcerative colitis.

We evaluated the effect of different types of preparations on the diagnostic yield of colonoscopy (total or limited) in mild to moderate active ulcerative colitis. Our ability to determine the extent of disease and see the mucosa beyond the inflamed areas was assessed in patients receiving no preparation (group A, 72 examinations) and those receiving diphosphosoda enemas (group B, 181 examinations). There were three failures in group A and 11 in group B. In the majority of patients (71% of group A, 83% of group B) the scope could be passed under optimal viewing conditions at least one segment beyond the involved area. In group A the cecum was reached in 16% of the procedures and in group B in 18%. We conclude that in mild to moderate active ulcerative colitis, colonoscopy can be performed without preparation, and still achieve the same results as with preparatory enemas.