Rollin W. Hughes

Balloon Dilatation of Upper Digestive Tract Strictures

The results of balloon dilatation of upper digestive tract stricture in 111 patients were evaluated. Eighty-eight patients had esophageal strictures and 23 had gastric or pyloric strictures. Thirty-six patients had strictures associated with previous operations. Twenty-two percent of the patients with esophageal strictures had malignancies. Overall, 92% were successfully dilated, with a complication rate of 3%. Follow-up information was available in 95% of patients. Eighty-seven percent of living patients experienced symptomatic improvement, which lasted for a median period of 12 mo. Forty percent required a further procedure during the period of follow-up. We found no difference between esophageal strictures and gastric or pyloric strictures in success rate, complications, or need for further dilatation, although patients with esophageal strictures were more apt to have symptomatic improvement. Postoperative strictures responded as well as nonoperative strictures. Previously dilated strictures in patients with esophageal reflux were managed as successfully as strictures never before dilated. We found balloon dilatation of upper digestive tract stricture to be a safe, effective technique.

Acute gastrointestinal bleeding: Experience of a specialized management team

The initial experience of a specialized management team organized to provide expedient care for all acute major gastrointestinal bleeding in protocolized fashion at a large referral center is presented. Of the 417 patients, 56% developed bleeding while hospitalized. Upper gastrointestinal bleeding accounted for 82%. The five most common etiologies included gastric ulcers (83 patients), duodenal ulcers (67 patients), erosions (41 patients), varices (35 patients), and diverticulosis (29 patients). Nonsteroidal anti-inflammatory drugs were implicated in 53% of gastroduodenal ulcers. The incidence of nonbleeding visible vessels was 42% in gastric and 54% in duodenal ulcers. The rates of rebleeding were 24% (20 patients) in gastric ulcers and 28% (19 patients) in duodenal ulcers. Predictive factors for rebleeding included copious bright red blood, active arterial streaming, spurting, or a densely adherent clot. The rebleeding rate for esophagogastric varices was 57%. The mortality rate overall was 6% (27 patients), with rates varying from 3% (five patients) for gastroduodenal ulcers to 40% (14 patients) for esophagogastric varices. The morbidity rate for the entire patient population was 18% (77 patients), dominated by myocardial events (34 patients). The average length of hospitalization for gastroduodenal ulcers was 5 days, for diverticulosis 8 days, and for varices 10 days. The major efforts of a specialized Gastrointestinal Bleeding Team would be best directed at both reducing the morbidity associated with acute bleeding and reducing the overall cost of care.

Treatment of Benign Esophageal Stricture by Eder-Puestow or Balloon Dilators: A Comparison Between Randomized and Prospective Nonrandomized Trials

To determine whether the natural history of strictures is affected by the type of dilator used to treat newly diagnosed peptic strictures, we designed a prospective randomized trial to compare the results after Eder-Puestow or Medi-Tech balloon dilation. We entered 31 patients into the trial. We also prospectively followed up all 92 nonrandomized patients who underwent their first dilation for a benign stricture during the same period as the prospective randomized trial. The nonrandomized patients also underwent dilation with either the Eder-Puestow or the balloon technique at the discretion of the gastroenterologist performing the endoscopy. We found no statistically significant differences in the immediate or long-term results of the two methods among the randomized, nonrandomized, and overall combined groups. All but 1 of the 123 patients had immediate relief of dysphagia. Within each group of patients, the probability of remaining free of dysphagia 1 year after the initial dilation was approximately 20%, and the probability of not requiring a second dilation was approximately 65% with either technique. Major (esophageal rupture) and minor (bleeding or chest pain) complications occurred in 1% and 5% of the patients and 0.4% and 3% of the total dilation procedures, respectively. The esophageal rupture and four of six minor complications occurred after repeated dilations. Five of the six minor complications occurred with use of the Eder-Puestow dilators. We conclude that Eder-Puestow and balloon dilations of benign esophageal strictures are associated with similar outcomes, but repeated dilations and the Eder-Puestow technique may be associated with an increased risk of complications.

Intragastric Balloons in Comparison With Standard Therapy for Obesity—A Randomized, Double-Blind Trial

Intragastric balloons are new but commonly used devices for the treatment of obesity; however, their safety and efficacy have not been established. We report our results of a small, double-blind, randomized trial in which the effectiveness of intragastric balloons was compared with that of conventional medical therapy for obesity. Twenty-two patients, who were 21 to 77% over ideal body weight, were studied. Eleven underwent insertion of an intragastric balloon, and 11 underwent sham procedures. One patient with a gastric balloon withdrew from the study after 3 days. Weight loss at 2 to 3 months in the conventional therapy group averaged 2.8 kg; in the balloon-treated group, the mean weight loss was 5.8 kg (P greater than 0.15). Of the 10 balloons, 8 spontaneously deflated, and 1 was passed in the stools. We noted gastric erosions in five patients and multiple gastric ulcers in one. We conclude that the intragastric balloon was not clearly effective in inducing weight loss, had a high rate of spontaneous deflation, and was damaging to the gastric mucosa. Controlled trials should be done before similar weight-reduction devices are used in routine clinical practice.

Influence of Hepatic Reserve and Cause of Esophageal Varices on Survival and Rebleeding Before and After the Introduction of Sclerotherapy: A Retrospective Analysis

Esophageal variceal sclerotherapy has been enthusiastically accepted as the procedure of choice for patients with variceal hemorrhage. Because the relationships among liver function, different causes of varices, survival, and rebleeding rates have not been well established in sclerotherapy trials, this enthusiasm may be unjustified. We studied these relationships in 80 patients with bleeding esophageal varices who were admitted to hospitals affiliated with our clinic between 1978 and 1980 and who did not receive sclerotherapy and in 162 patients admitted between 1980 and 1982 who received sclerotherapy with ethanolamine oleate. In both groups of patients, survival and bleeding-free intervals were significantly related (P less than 0.005 and P less than 0.01, respectively) to hepatic reserve (Childs class). In addition, patients with nonalcohol-related liver disease and poor hepatic reserve (Childs class C) had reduced survival and bleeding-free intervals compared with patients in class C with alcohol-related liver disease. Similar probabilities of survival and bleeding-free intervals were noted for Childs class subgroups and etiologic subgroups in the sclerotherapy and nonsclerotherapy groups, although a formal comparison was not made because of the retrospective nature of this study. Indications that sclerotherapy increases survival and reduces rebleeding may be due to different distributions of Childs classes and causes of varices within sclerotherapy and nonsclerotherapy groups in published control trials.

Endoscopic variceal sclerosis: a one-year experience

Our first years experience with endoscopic variceal sclerosis (EVS) performed with a cuffed balloon fiberoptic endoscope is presented. Seventy-five patients have been treated with EVS without requiring the use of general anesthesia. All but one patient had endoscopically documented variceal hemorrhage and underwent EVS while bleeding or shortly thereafter. Ninety-two per cent of the patients were discharged from the hospital after initial treatment with the current overall survival rate being 89.3%. Complications resulting in a prolonged hospitalization were infrequent, but two deaths occurred in which EVS complications may have been a contributing factor. Based on these results, EVS is recommended for managing variceal hemorrhage and is a reasonable alternative for shunt surgery in the management of variceal bleeding.

Imaging of complications of laparoscopic cholecystectomy

Laparoscopic cholecystectomy has gained widespread acceptance for treatment of cholelithiasis. Because radiologists have aprimary role in recognizing and treating complications of this surgical technique, we reviewed the clinical records and imaging studies of 29 patients with complications after laparoscopic cholecystectomy. Complications included bile duct injuries (15 cases), retained common bile duct stones (seven cases), cystic duct stump leak (four cases), bowel perforation (two cases), abdominal abscess (two cases), intraperitoneal gallstones (2), and failure to diagnose malignant bile duct obstruction (one case). Twenty-two patients required reoperation, and one patient with bowel perforation died. Eleven of 15 bile duct injuries were imaged prior to hepaticojejunostomy. Nine of 11 were proximal bile duct injuries within 2 cm of the junction of the right and left bile ducts. Endoscopic retrograde cholangiography (ERC) identified the distal extent of injuries, but transhepatic cholangiography (THC) was necessary to fully evaluate the proximal extent of the bile duct abnormalities. ERC was used for diagnosis and treatment of the seven patients with choledocholithiasis. Abdominal films showed intraperitoneal gas in one patient with bowel perforation, intraperitoneal stones in a second patient, and intraabdominal abscess in one of two patients in whom abdominal films were performed. Computed tomography (CT), done in three patients with bowel perforation or abscess, showed the one duodenal perforation, and the two abscesses. CT also showed bilomas, intraperitoneal gallstones, and unsuspected malignancy. Imaging studies detected and defined complications after laparoscopic cholecystectomy in all cases.

Anatomic, motor, and clinical assessment of vertical banded gastroplasty

The aim of this study was to assess gastric anatomy, motility, and emptying after vertical banded gastroplasty and to correlate the anatomic and physiologic results with clinical outcome. Eleven patients were studied at least 7 mo after operation, by which time they had lost 31% +/- 4% (mean +/- SEM) of their excess body weight. Stomal diameter, volume, and distensibility of the proximal gastric pouch were determined by a balloon distention technique. Gastric emptying was monitored scintigraphically both with and without distention of the proximal pouch. Stomal diameters ranged from 10 to 15 mm (mean +/- SEM = 11 +/- 1 mm), and pouch capacity ranged from 20 to 150 ml (76 +/- 9 ml). Mean intrapouch pressure was 13 mmHg before distention, increased to 22 mmHg with distention to half-maximal capacity, and then changed little with further distention to maximum capacity. Near maximal pouch distention during gastric emptying of a 300-ml test meal decreased antral contractile activity and speeded the initial rate of emptying (t25 with distention = 14 +/- 3 min vs. 24 +/- 3 min without distention, p less than 0.03), but did not alter the later rate of emptying. No clear-cut relationship was present between weight loss and stomal diameter, pouch volume, or gastric emptying. The conclusion was that distention of the proximal gastric pouch created by vertical banded gastroplasty inhibited antral contractions and increased the initial rate of gastric emptying, but no clear-cut correlation was found in this cohort between weight loss after the operation and stomal diameter, pouch size, and gastric emptying.

The use of prosthetic stents in tracheobronchial, gastrointestinal, and genitourinary diseases.

The concept of using a stent to maintain patency of a lumen is not new. As early as 1969, stents were being investigated in the peripheral arterial system as a means of preventing restenosis after dilatation by balloon angioplasty (Dotter, 1969). Since then, numerous reports have demonstrated the use of stents in both the peripheral and coronary artery systems (Maass et al., 1982; Dotter et al., 1983; Wright et al., 1985; Palmaz et al., 1987). Concomitant with the investigation of expandable endovascular metal prosthesis has been the development of prosthetic devices for management of tracheobronchial, gastrointestinal, and genitourinary diseases. We will review the use of endoscopically placed prosthetic devices in the management of diseases affecting these systems.

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