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Twenty patients with Stage Duke B or C adenocarcinoma of the colon or rectum who have undergone radical surgical resection and demonstrated rising serum carcinoembryonic antigen (CEA) during follow-up are the subject of this study. In all cases, while there was a continuous and progressive elevation of serum CEA, CT examination of the abdomen and pelvis was performed. Abnormal CT findings were demonstrated in 19 patients and included pelvic mass, liver metastases, and periaortic or mesenteric lymphade-nopathy. There was one normal CT scan in a patient who subsequently developed metastases in the sacrum. Based on the observations in these patients, it is concluded that in routine follow-up after colorectal surgery, rising serum CEA should be considered a warning sign and warrants additional investigation by CT.

Pyoderma gangrenosum (PG) is a debilitating skin disease most often associated with inflammatory bowel disease and is a reportedly rare cause of peristomal ulceration. The lesions of PG rapidly evolve from small, erythematous pustules to deep, painful, pyogenic ulcers within hours to days of onset. Although the behavior and the appearance of the lesions of peristomal PG are diagnostic, a lack of familiarity with PG often leads to misdiagnosis and inappropriate therapy. This study reports four cases of peristomal PG and discusses the 20 previously reported cases in patients with inflammatory bowel disease. Seventy-five percent of patients were female and 67% had Crohn's disease. All patients had colitis, including all of the patients with Crohn's disease, 82% of whom had additional perineal complications. The diagnosis of peristomal PG was based on clinical appearance alone in 83% of cases. The onset of peristomal PG ranged from 2 weeks to 3 years following ostomy. The response to medical therapy was variable. All cases (17 of 17) treated with high-dose corticosteroids and local wound care responded, but five cases required additional therapy. No patient was successfully treated with stoma revision. Risk factors for the development of peristomal PG include Crohn's colitis, female gender, and perineal disease. While most patients respond well to systemic steroids and local wound care, up to one third of patients require long-term medical management.(Arch Surg. 1994;129:769-772)

• A retrospective outcome-oriented audit was conducted to determine the complications associated with percutaneous infraclavicular subclavian catheters in a university hospital. The study is unique since patients having these catheters were not under the care of a select group of physicians and the patients were not restricted to a special nursing unit. One hundred and seventeen catheters were placed in 68 patients. Seventeen types of complications were audited. There were 13 complications (11%) identified as follows: pneumothorax, seven; subcutaneous emphysema, one; subclavian artery hematoma, one; pleural effusion, one; improper position, two; and sepsis, one. No mortality was associated with catheter placement. Pattern analysis suggested physician inexperience as an important cause of complications. The difficulties of establishing a retrospective audit based on documentation errors and omissions are discussed.(Arch Surg 113:1421-1425, 1978)

Gastric partition is advocated as a better operation than gastric bypass for treatment of morbid obesity (although this is poorly documented) because it is simpler and faster to perform; has a lower complication rate; is more physiologic; and because it is possible to examine the distal stomach by endoscopy and barium contrast studies after operation. It has not been established which of the different gastric partition operations is the best. Greater curvature gastroplasty (GP) was performed upon 47 and gastrogastrostomy (GG) upon 144 patients between May, 1979, and May, 1981, at North Carolina Memorial Hospital. The techniques used in performing the operations are described and illustrated. Postoperative complications occurred in 25.5% of the GP and 10.4% of the GG patients. There were no deaths. Reoperation was required because of stomal obstruction in 14.9% of the GP compared with 1.4% of the GG patients. The percentage of excess weight lost in 12 months following GP was 60.5% and 51.3% after GG, and at 18 months was 68.7% following GP and 53.9% after GG. These differences in weight loss following GP and GG are not statistically significant. Because of the statistically significant lower incidence of stomal obstruction requiring reoperation after GG, although weight loss appeared to be better with GP, GG is currently our preferred operation for the treatment of morbid obesity. The changes in the technique of GG introduced to improve weight loss are discussed and illustrated.

Gastric partition is advocated as a better operation than gastric bypass for treatment of morbid obesity (although this is poorly documented) because it is simpler and faster to perform; has a lower complication rate; is more physiologic; and because it is possible to examine the distal stomach by endoscopy and barium contrast studies after operation. It has not been established which of the different gastric partition operations is the best. Greater curvature gastroplasty (GP) was performed upon 47 and gastrogastrostomy (GG) upon 144 patients between May, 1979, and May, 1981, at North Carolina Memorial Hospital. The techniques used in performing the operations are described and illustrated. Postoperative complications occurred in 25.5% of the GP and 10.4% of the GG patients. There were no deaths. Reoperation was required because of stomal obstruction in 14.9% of the GP compared with 1.4% of the GG patients. The percentage of excess weight lost in 12 months following GP was 60.5% and 51.3% after GG, and at 18 months was 68.7% following GP and 53.9% after GG. These differences in weight loss following GP and GG are not statistically significant. Because of the statistically significant lower incidence of stomal obstruction requiring reoperation after GG, although weight loss appeared to be better with GP, GG is currently our preferred operation for the treatment of morbid obesity. The changes in the technique of GG introduced to improve weight loss are discussed and illustrated. La bipartition de l'estomac représente une opération préférable à la gastro-jéjunostomie pour traiter l'obésité morbide. Elle est plus simple, plus facile, plus physiologique. Elle présente moins de risques et elle a pour mérite de permettre l'exploration endoscopique de la poche gastrique inférieure si nécessaire. Quant à la meilleure desméthodes de bipartition gastrique elle reste à définir. De mai 1979 à mai 1981 44 gastroplasties au niveau de la grande courbure et 144 gastro-gastrostomies furent pratiquées au North Carolina Memorial Hospital. 25,5% de complications furent observées après gastroplastie et 10,4% après gastrogastrostomies. Aucune mort ne fut à déplorer. Une intervention pour traiter la sténose de la bouche de communication fut nécessaire dans 14,9% des cas après gastroplastie et dans 1,4% des cas après gastro-gastrostomies. Le pourcentage de perte de poids après un an s'est élevé à 60,5% après gastroplastie et à 51,3% après gastro-gastrostomie. Après 18 mois il était de 68,7% dans le premier cas et de 53,9% dans la seconde éventualité. Ces différences de chute pondérale en fonction des deux méthodes ne sont pas statistiquement significatives. En raison de la fréquence moins grande de la sténose ostiale après gastro-gastrostomie et malgré que la chute pondérale soit plus nette soit preference après gastroplastie notre preference se porte vers la gastrogastrostomie. Les modifications de la technique de la gastrogastrostomie apportées pour accentuer la perte de poids sont décrites et illustrées.

A method for obtaining left ventricular (LV) volume curves, synchronized with average LV pressure (LVP) curves for calculation of LV contractility, is described. Multiple gated blood pool imaging was performed to calculate average LV volume curves. Simultaneously with this acquisition, LVPs and aortic pressures were measured by indwelling catheters and recorded on an FM tape recorder. These signals were fed to the computer as image information and averaged and processed by the software developed for this purpose. Pressure resolution of the calibrated images was 4 mmHg/pixel when provision was made for a maximum pressure of 200 mmHg. A good correlation (r=0.99) was obtained between the calculated peak LVPs and mean peak LVPs read from the chart recorder. The regression equation was: digitized peak LVP=1.04xchart recording-5.11 mmHg and the standard error of the estimate was 2.9 mmHg. Similar results were obtained with the aortic pressure (AP) measurements (digitized AP=0.94 x chart recording+6.37 mmHg, the standard error of the estimate was 3.8 mmHg). The digitized data also allowed the construction of pressure-volume loops for interpretation of ventricular contractility.

Nisoldipine (BAY k 5552) like nifedipine, is a dihidropyridine compound with strong calcium blocking activity. The purpose of this study was to measure and compare the absolute hemodynamic effects of these two drugs before and at 30 min, 60 min and 120 min after oral intake in 20 ischemic heart disease patients with radionuclide gated cardiac scintigraphy. No significant change was seen in end diastolic volume index with either of the drugs. With nifedipine the stroke volume index (SVI) increased significantly from the basal value at 30 min (P=0.004) and 60 min (P=0.034) yet not significantly at 120 min. The same trend was seen in left ventricular ejection fraction (LVEF) with significant increases at 30 min (P=0.02) and 60 min (P=0.025) yet not at 120 min. The cardiac index increased significantly at 30 min (P=0.001), 60 min (P=0.002) and 120 min (P=0.025) but the latter value was significantly lower than the 30 min value indicating the maximal effect had already passed. With nisoldipine the SVI increased significantly at 60 min (P=0.004) and 120 min (P=0.001) but not at 30 min. These changes were again reflected by a significant increase in LVEF at 60 min (P=0.021) and 120 min (P=0.002) without significant increase at 30 min. The increase in CI was highly significant at 60 min (P=0.003) and 120 min (P=0.001) without significant change at 30 min. Nisoldipine proved to be a potent calcium antagonist with slower onset and longer duration of action than nifedipine.

Nisoldipine is a newly developed calcium channel blocker with outstanding vasodilatory properties especially with regard to the coronary arteries. Thus it may find wide-spread application as a therapeutic agent in various ischemic heart disease syndromes. The purpose of this study was to evaluate the effect of nisoldipine on the diastolic function of the left ventricle (LV) in the clinical situation. A patient group on nisoldipine treatment was compared to a control group. In the nisoldipine group a maximum decrease of 17 mmHg in the mean systolic blood pressure with an increase in the mean peak ejection rate (0.78 EDV/s) and peak filling rate (0.52 EDV/s) were observed. Mean LV ejection fraction increased by 6.4% and the time to peak filling rate decreased by 36.5 ms. After eight weeks of treatment the acute effects of nisoldipine were similar to the previous study. Nisoldipine therefore tends to improve both the diastolic and systolic function of the left ventricle.

A radionuclide washout technique (WO), for calculation of the right ventricular ejection fraction (RVEF) which is independent of the exact position of the right ventricular region of interest was evaluated and results compared with first pass (FP) and equilibrium gated blood pool (GBP) values. Regression analysis between RVEF values of 24 patients obtained from FP and WO yielded a correlation coefficient (r) of 0.89, while a slightly poorer correlation coefficient was obtained when FP and GBP were compared (r=0.79) and between WO and GBP (r=0.71). No significant difference between RVEF values calculated from the three techniques was found (P<0.05) on inter- and intraobserver level. The radionuclide washout technique yields an accurate determination of RVEF without the necessity of outlining the RV accurately.

Chronically ill and neurologically impaired children may require enteric tube feedings indefinitely to maintain adequate nutrition. When transgastric feedings are not feasible, a permanent feeding jejunostomy may be required. Since 1979, we have constructed a continent feeding jejunostomy in 16 children using a shortened Maydl Roux-en-Y limb with an intussuscepted nipple-valve mechanism. The jejunostomy is matured as a stoma through the abdominal wall, while the nipple valve is stabilized in the abdominal cavity anchored to the posterior fascia and peritoneum. Bolus or drip feedings can be initiated when gastrointestinal function resumes. Between feedings, the tube is removed as the jejunostomy is continent and can be covered with a gauze pad. No deaths were attributed to the operation, although more than 50% of these children died within 2 years from complications of their primary disease. The jejunostomy functioned well and was completely continent in 14 patients. The creation of a feeding jejunostomy with an intussuscepted nipple valve assures continence, avoids the complications of chronic indwelling tubes, and decreases the risk of regurgitation. Furthermore, the continent jejunostomy permits bolus feedings and requires minimal care. The use of this procedure is advocated whenever permanent feeding jejunostomy is anticipated.

To the Editor.—Arteriovenous malformations (AVMs) are being identified more frequently as the cause of gastrointestinal tract bleeding. The preoperative localization of AVMs is dependent on selective visceral angiography or radionuclide studies. Even then, the site may be difficult to locate at operation. Recently, reports have described the localization of AVMs in the small and large intestine using intraoperative ultrasonography to detect the difference in the flow pattern of vessels supplying the AVM.1,2 This report describes the use of intraoperative Doppler ultrasonography to locate an AVM of the sigmoid colon.Report of a Case.—The patient was a 23-year-old woman who had hematochezia that occurred during a ten-month period. Selective visceral angiography revealed the early filling of a vein that drained the sigmoid colon. At surgery, a 9-MHz Doppler probe was used to identify the blood flow in the arteries supplying the colon. The arteries on the mesenteric border