James M. Becker

High prevalence of adenomatous polyps of the duodenal papilla in familial adenomatous polyposis

Eighteen consecutive asymptomatic patients with familial adenomatous polyposis (both familial polyposis coli and Gardners syndrome) were studied over a 12-month period; side-viewing upper endoscopy and biopsy were used to assess the frequency of adenomatous polyps of the duodenal papilla. Nine of the 18 patients demonstrated adenomatous polyps of the papilla, varying in size and appearance from microadenomas in normalappearing duodenal papillae (two) to a sessile polyp 3 cm in diameter. Two were tubulovillous adenomas (0.5 cm and 2 cm in diameter) and the remainder were tubular adenomas. Severe atypia and malignancy were not encountered. These findings reveal that adenomas of the duodenal papilla are common in individuals with familial adenomatous polyposis. Because of these findings and because of the known risk of periampullary adenocarcinomas and nonmalignant complications of polyps of the duodenal papilla in patients with familial adenomatous polyposis, upper gastrointestinal screening of such patients should include examination of the duodenal papilla with a side-viewing endoscope.

Transduodenal sphincteroplasty and transampullary septectomy for postcholecystectomy pain.

Ninety-two patients underwent a transduodenal sphincteroplasty and transampullary septectomy (extended papilloplasty) for chronic, incapacitating upper abdominal pain over an 11-year period. Seventy-nine had a prior cholecystectomy; 42 of 56 patients with reported pathology had documented gallstone disease. Serious morbidity included two moderately severe cases of postoperative pancreatitis and a pulmonary embolus. There were no deaths. Operative findings revealed stenosing papillitis (n = 45), transampullary septitis (n = 40), and papillary dysfunction (n = 7). Histologic examination of septa) biopsy specimens revealed inflammation in 34 cases and fibrosis in 19 cases. There were no microscopic abnormalities in 39 biopsy specimens. The results at 1 to 10 years in 83 patients is as follows: good in 36 patients (no pain—43%), fair in 27 patients (occasional pain—33%), and poor in 20 patients (unrelieved by the procedure—24%). Patients with prior sphincteroplasty (12 of 15 with a fair to good result) benefitted the most from the procedure. Those who underwent concomitant cholecystectomy responded poorly. Risk factors for failure include alcoholism, drug addiction, mental illness, and duodenal ulcer disease. The finding of papillary cholesterolosis at operation also was accompanied by a less than optimal result. Transduodenal sphincteroplasty with transampullary septectomy provides long-term benefit to carefully selected patients with chronic abdominal pain after cholecystectomy.

Functional assessment after colectomy, mucosal proctectomy, and endorectal ileoanal pull-through.

Radiographic, manometric, and clinical techniques were used to assess the functional results after colectomy, mucosal proctectomy, and endorectal ileoanal pull-through (IAP). In 40 patients with ulcerative colitis, Gardners syndrome, or familial polyposis, anorectal manometry was performed before IAP and 2 months and 1 year afterward. At 4 weeks after IAP, a standardized water contrast radiograph allowed an estimation of the dimensions of the ileal pouch and the integrity of the ileoanal anastomosis. Radiographically, the mean ± SE length, width, and depth of the ileal pouch were 10.9±0.6 cm, 4.5±0.6 cm, and 3.9±0.2 cm, respectively. No anastomotic leaks were identified; however, 2 patients were incontinent to the contrast material. The mean maximal anal sphincter resting pressure decreased from a mean ± SEM of 87.1±3.2 mmHg preoperatively to 68.1±3.1 mmHg 8 weeks after operation, but by 1 year resting pressure increased to 72.3 ±4.9 mmHg. The change in sphincter pressure with voluntary squeeze was greater 8 weeks after IAP than before the operation (114.0±8.2 mmHg versus 97.7±6.2 mmHg) and increased further by 1 year. No patient experienced major episodes of incontinence. Mean ± SEM stool frequency per 24 hours decreased from 7.5±0.5 at 1 month after ileostomy closure to 6.4±0.7 at 12 months. Ileal pouch capacity increased with time and was inversely related to stool frequency. It was concluded that endorectal pull-through of an ileal J pouch, by providing an adequate intestinal reservoir and preserving nearly normal anal sphincter function, results in anal continence and acceptable stool frequency.RésuméDes méthodes cliniques, manométriques et radiographiques ont été employées pour apprécier les résultats fonctionnels postopératoires après la colectomie associée à la protectomie muqueuse et à labaissement iléal transanal. Chez 40 malades qui présentaient une colite ulcéreuse, un syndrome de Gardner ou une polypose familiale, la manométrie anorectale fut pratiquée avant lintervention puis respectivement 2 mois, 1 an après lintervention. Quatre semaines après celle-ci une exploration radiographique standard permis dapprécier les dimensions du réservoir iléal et lintégrité de lanastomose iléo-anale. En moyenne sur les radiographies la longueur, la largeur, la profondeur moyenne étaient respectivement 10.9± 0.6 cm 4.5±0.6 cm et 3.9±0.2 cm. Aucune fuite au niveau de lanastomose ne fut constatée mais deux patients présentèrent une continence lors du lavement. La pression au repos du sphincter anal (moyenne de la maximale) décru de 87.1±3.2 mmHg à 68.1±3.1 mmHg 8 semaines après lopération mais après un an elle se relèva jusquà 72.3±4.9 mmHg. La modification de la pression sphinctérienne lors de la contraction volontaire fut plus grande après lintervention quavant lopération (114.0±8.2 mmHg versus 97.7±6.2 mmHg) et saccrut progressivement pendant un an. Aucun malade ne présenta dépisodes importants dincontinence. La fréquence moyenne des selles pendant 24 heures décrus de 7.5. ±0.5 un mois après la fermeture de liléostomie à 6.4 ±0.7 après 12 mois. La capacité du réservoir iléal augmenta avec le temps cependant que la fréquence des selles diminua. De ces faits, on peut conclure que ce type dopération avec un réservoir iléal en J abouti à la constitution dun réservoir intestinal adéquat tout en conservant une fonction sphinctérienne anale normale, une continence satisfaisante et un nombre acceptable de selles.ResumenSe utilizaron técnicas radiográficas, manométricas y clínicas para evaluar los resultados funcionales después de colectomía, protectomía mucosal y del descenso (“pull-through”) endorrectal ileoanal (PEI). La manometría anorrectal fué realizada en 40 pacientes con colitis ulcerativa, síndrome de Gardner o poliposis familiar, antes y 2 meses y 1 año después de la PEI. A las 4 semanas después de la PEI un estudio radiográfico estandarizado con agua permitió estimar las dimensiones de la bolsa ileal y la integridad de la anastomosis ileoanal. Radiográficamente el promedio de la longitud, ancho y profundidad de la bolsa ileal fué de 10.9± 0.6 cm, 4.5±0.6 cm y 3.9±0.2 cm respectivamente. No se identificaron escapes anastomóticos; sin embargo, dos pacientes aparecieron incontinentes con el material de contraste. La presión màxima promedio del esfínter anal en reposo disminuyó de un promedio de 87.1±3.2 mmHg a 68.1±3.1 mmHg ocho semanas después de la operación, pero al final de un año la presión en reposo había aumentado a 72.3±4.9 mmHg. El cambio en la presión esfinteriana al hacer una contracción voluntaria fué mayor ocho semanas después de la PEI que antes de la operación (114.0±8.2 mmHg vs 97.7±6.2 mmHg) y aumentó aún más después de un año. Ningún paciente exhibió episodios mayores de incontinencia. La frecuencia promedio de defecaciones diarias disminuyó de 7.5±0.5 al mes después del cierre de la ileostomía a 6.4±0.7 a los 12 meses. La capacidad de la bolsa ileal aumentó con el paso del tiempo y se halló en relación inversa a la frecuencia de las defecaciones. Se llegó a la conclusión de que el descenso (“pull-through”) endorrectal de una bolsa ileal en “J”, al proveer un adecuado reservorio intestinal y preservar una función casi normal del esfínter anal, resulta en continencia anal y en una aceptable frecuencia del número de defecaciones diarias.

Calculation of Metabolic Expenditure and Substrate Utilization from Gas Exchange Measurements

At least nine different equations have been published for calculating metabolic expenditure by indirect calorimetry. This study examined the differences between equations when they are used for the nutritional assessment in an intensive care unit (ICU). Oxygen consumption and carbon dioxide production were measured in 36 ICU patients and used to calculate metabolic expenditure with the nine equations. The equations produced differences in metabolic expenditure which averaged from 0.8-96 kcal/day. The largest difference produced by any two of the nine equations was 189 kcal/day. Although differences in original stoichiometric data have resulted in numerous different equations for the calculation of metabolic expenditure, these differences are not clinically important. It makes little difference which equation is used for nutritional assessment in an ICU.

Superior results of ileoanal pullthrough (IAPT) in polyposis coli vs ulcerative colitis patients

Colectomy, mucosal proctectomy, and ileoanal pull through (IAPT) have replaced proctocolectomy as the operation of choice in most patients with the colorectal mucosal diseases ulcerative colitis and polyposis coli. This study was conducted to determine whether there is any difference in postoperative morbidity and long-term functional results when IAPT is performed for polyposis coli than when it is performed for ulcerative colitis patients. Between 1982 and 1989, 277 IAPT procedures were performed at the University of Utah Medical Center, 239 for ulcerative colitis and 38 for polyposis coli syndromes. A prospective study compared polyposis and colitis patients after IAPT with regards to age, family history, preoperative findings, operative findings, postoperative complications, and long-term complications. Functional results were compared including day and night stool frequency, incidence of nighttime incontinence, and incidence of pouchitis. The incidence of postoperative complications was lower in the polyposis group than in the colitis group, but the numbers were low enough in both diseases that significant differences were not detected. However, the incidence of pouchitis (0% vs 19%), day (4.2 vs 6.0) and night (0.4 vs 0.9) stool frequency, and nighttime incontinence (5% vs 25%) was significantly lower in the polyposis group when compared to the colitis group. We conclude that IAPT performed for polyposis conditions is associated with superior results when compared with results from patients who undergo the procedure for ulcerative colitis.

Quantitation of colonic injury from argon laser, neodymium: YAG laser and monopolar electrocautery applied to flat mucosa and small sessile polyps of the canine colon

This study determined the optimum laser energy for ablation of colonic mucosal lesions and small sessile polyps in the canine colon. Neodymium (Nd):YAG laser, argon laser, and monopolar electrocautery were applied to exposed canine colonic mucosa for various application times at various power settings. At the minimum energy level necessary to ablate mucosa, the Nd:YAG laser caused greater muscularis injury than the argon laser and monopolar electrocautery. At higher energy levels, monopolar electrocautery and Nd:YAG laser caused greater muscularis injury than argon laser. Small surgically created polyps in the canine colon were ablated endoscopically with the three energy sources. Single-session complete polyp ablation occurred most frequently with Nd:YAG laser and least frequently with argon laser. The depth of tissue injury beneath polyp ablation sites was least with argon laser and greatest with Nd:YAG laser. This study suggests that the argon laser is safer than the Nd:YAG laser or monopolar electrocautery for coagulation of flat colonic mucosal lesions. Although the argon laser is safer for the coagulation of small sessile colonic polyps, it may be less effective than monopolar electrocautery or the Nd:YAG laser for the single-session fulguration of polyps greater than 5 mm in diameter.

Effect of alcohol on cyclical myoelectric activity of the opossum sphincter of Oddi

Ethyl alcohol may adversely affect pancreatic function by perturbing sphincter of Oddi (SO) or duodenal motor activity. The aim of this study was to identify the effect of ingested alcohol on the SO, duodenal, and gastric myoelectric activity in conscious opossums. In five adult opossums bipolar stranded stainless-steel wire electrodes were implanted on the SO, gastric antrum, and duodenum. After a 2-week recovery period, each animal underwent eight 8-hr recording sessions while fasted and awake. After two fasting cycles of the migrating myoelectric complex, animals were randomly fed either 10 ml of a 30% ethyl alcohol solution or 10 ml of water via an esophageal tube, and recordings continued for 4-6 hr. During the control state, cyclical myoelectric spike activity was recorded from the SO, gastric antrum, and duodenum with a mean +/- SD cycle length of 7.35 +/- 15.0 min, 74.3 +/- 10.1 min, and 94.8 +/- 8.7 min, respectively. With alcohol, SO and duodenal cycle lengths were unchanged while gastric cycle length decreased. However, alcohol effected a significant increase in peak SO spike burst frequency with no corresponding change in gastric or duodenal spike burst frequency. An equivalent volume of water had no influence on sphincter of Oddi myoelectric activity. It is concluded that ingested alcohol induces increased myoelectric activity from the opossum SO, independent of changes in activity of the duodenum or stomach. Since the SO plays a major role in metering bile and pancreatic flow into the duodenum, this may be a factor in alcohol-induced pancreatitis.

Colonic mucosal dissection following electrocautery or laser polypectomy

Mucosal proctectomy and ileoanal anastomosis is being increasingly performed on patients with familial polyposis, many of whom have undergone previous subtotal colectomy followed by endoscopic surveillance and polypectomy with monopolar electrocautery (MPEC) or, more recently, argon laser (AL). Our aim was to compare the ease of mucosal dissection following polypectomy with MPEC or AL in the canine colon. At celiotomy, two groups of fifteen 5- to 7-mm sessile polyps were surgically created in the descending colon of five mongrel dogs. Six weeks later, each animal underwent flexible colonoscopy and polyp fulguration with MPEC (15 polyps) and AL (15 polyps). Fulguration was performed weekly for 2-3 weeks until all polyps had been obliterated. Ten weeks later, mucosal dissection was performed with the operating team unaware of prior treatment. Mucosal dissection was scored for dissectability (1 to 4; 1 = facile, 4 = difficult), blood loss, operating time, and number of mucosal perforations with the last three parameters normalized to 100 cm2 of mucosa. AL and MPEC were equally effective at polyp obliteration; however, more AL-treated polyps required retreatment than MPEC-treated polyps (P less than 0.05). After AL treatment, mucosal dissection was more facile [dissectability index (mean +/- SEM): 1.4 +/- 0.2 vs 2.6 +/- 0.2; P less than 0.05] and could be performed more quickly (15.1 +/- 2.4 min vs 23.6 +/- 2.7 min; P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Postprandial sphincter of Oddi myoelectric activity and gallbladder emptying

Feeding initiates gallbladder emptying and bile delivery into the duodenum. It is not yet defined how the sphincter of Oddi regulates flow of bile into the duodenum during gallbladder emptying. The aim of this study was to assess postprandial spike burst activity in the sphincter of Oddi, while quantitating gallbladder emptying with noninvasive radioisotope imaging. Six adult opossums were prepared with bipolar electrodes in the sphincter of Oddi. After 2 weeks of recovery the animals were fasted overnight and positioned under a gamma camera, and myoelectric recordings were begun. After two cycles of the migrating motor complex (MMC), 2 mCi 99Tc-HIDA was infused intravenously and permitted to concentrate in the gallbladder for a period of 30 min. Subsequently, a 30-ml liquid meal, containing 0.9 g protein, 3.5 g carbohydrate, and 3.3 g fat, was instilled into the stomach. Sphincter of Oddi myoelectric activity (spike bursts/min) and gallbladder emptying (expressed as percentage of original 99Tc counts in the gallbladder) were measured at intervals for 120 min following feeding. Feeding resulted in prompt gallbladder emptying. Sphincter of Oddi spike burst activity was not altered significantly in the first 30 min after feeding, suggesting that motor activity in the sphincter of Oddi does not initially influence bile flow. Subsequently, spike burst activity increased progressively, suggesting that sphincter of Oddi motor activity may accelerate bile delivery into the duodenum during later phases of gallbladder emptying.

Improved Survival for Patients with Pancreatic Abscess

Twenty-three consecutive patients with pancreatic abscess were reviewed. Preoperative CT scanning accurately visualized the abscess in all patients examined (19/23) and also detected 12 recurrent absc