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Background After patients have undergone colonoscopic polypectomy, it is uncertain whether colonoscopic examination or a barium enema is the better method of surveillance. Methods As part of the National Polyp Study, we offered colonoscopic examination and double-contrast barium enema for surveillance to patients with newly diagnosed adenomatous polyps. Although barium enema was performed first, the endoscopist did not know the results. Results A total of 973 patients underwent one or more colonoscopic examinations for surveillance. In the case of 580 of these patients, we performed 862 paired colonoscopic examinations and barium-enema examinations that met the requirements of the protocol. The findings on barium enema were positive in 222 (26 percent) of the paired examinations, including 94 of the 242 colonoscopic examinations in which one or more adenomas were detected (rate of detection of adenomas, 39 percent; 95 percent confidence interval, 33 to 45 percent). The proportion of examinations in which ...

Background The adenoma–adenocarcinoma sequence in colorectal cancer suggests an increased risk of colorectal cancer in the families of patients with adenomatous polyps. Methods A random sample of participants in the National Polyp Study who had newly diagnosed adenomatous polyps were interviewed for information on the history of colorectal cancer in their parents and siblings. The risk of colorectal cancer in family members was analyzed according to the characteristics of the patients with adenomas and in comparison with a sample of patients' spouses, who served as controls. Results Among the patients with adenomas, 1199 provided information on whether they had a family history of colorectal cancer. After the exclusion of families for which information was incomplete and of 48 patients who had been referred for colonoscopy solely because they had a family history of colorectal cancer, there were 1031 patients with adenomas, 1865 parents, 2381 siblings, and 1411 spouse controls. The relative risk of colore...

Colonoscopic removal of large, sessile polyps is difficult, but can be successfully carried out by experienced endoscopists. "Piecemeal" resection with an electrocautery snare was performed at our institution in 108 patients with 132 such lesions. The mean size of the unresected polyps was 3.0 cm. Complications occurred in 3.0% of polypectomies (3.8% of patients), with bleeding necessitating transfusion in 2.3% of polypectomies (2.8% of patients), and microperforation (probable) in the remainder. No patient required emergency surgery due to a complication. In 65 patients (60%), colonoscopic resection and follow-up alone was carried out. Of these, adenomas recurred/persisted in 28%, most of which were successfully re-resected. Nearly half of all recurrent polyps occurred after at least one negative intervening examination. Carcinoma later appeared in 17% of the recurrences despite apparent initial complete resection of a previously benign polyp. Cure was ultimately achieved in 88% of endoscopically managed patients. Surgical resection was required in 27% of patients, mostly following the initial polypectomy when invasive carcinoma was found in the specimen. No residual tumor was later found in 41% of the colon specimens from these patients. Ninety-one percent of cancers were favorable stage, whether discovered early or late. Follow-up colonoscopy was achieved in 77% of patients over an average of 3.7 years. Metachronous polyps were excised in 52 patients (63%) and metachronous carcinoma was diagnosed in 3 patients (3.6%). An aggressive regimen of surveillance colonoscopy is warranted in these patients to detect and manage local recurrences and to remove subsequent adenomas. Endoscopic resection of large sessile adenomas can be safe and effective.

Mucosal spots, or "freckles," surrounding the appendiceal orifice are an endoscopic feature of the cecum. These are clusters of 1 to 2 mm round or oval slightly raised spots, each with a pale center and an erythematous border. They correlate microscopically with subepithelial and submucosal lymphoid follicles. The freckling pattern, identified in about one third of colonoscopies, was seen best with the videoendoscope and was identified more commonly in patients with systemic illness. Recognition of mucosal freckling around the appendiceal orifice helps identify the cecum and may be useful in the evaluation of cecal and appendiceal pathology.

Little is known about the mucosal microflora of the colon and rectum at the time of elective surgery. Our objective was to determine the concentrations of anaerobic and aerobic bacteria associated with the mucosa of the mechanically prepared large bowel. Ten patients were studied after a standard polyethylene glycol-electrolyte lavage preparation. No patient had taken antibiotics in the preceding four weeks. Sterile wire brushes passed through the colonoscope during advancement were used to culture the rectal, transverse colon, and cecal mucosa. Total anaerobic, aerobic, Gram-positive, and enteric bacterial counts were determined along with specific cultures for Bacteroides fragilis, Clostridium difficile, Escherichia coli, Pseudomonas aeruginosa, enterococcus, and staphylococcus species. The results showed that there was a significant increase (P0.01) in aerobes, anaerobes, enterics, Gram positives, B. fragilis, and E. coli mucosal counts with proximal progression. Aerobes showed a steady gradient, while anaerobes demonstrated an increase from the rectum to the transverse colon but no change between the transverse colon and cecum. We conclude that, in the prepared bowel, there is an increase in the mucosal bacterial counts in the more proximal portions of the bowel. The results may serve as a baseline for future studies on the mucosal-associated bacteria of the large intestine.

Background. Prolonged enteral feedings are required occasionally in seriously burned individuals. We have employed percutaneous endoscopic gastrostomy (PEG) in selected patients who require particularly prolonged access, thus prompting this review. Methods: The PEG procedure was performed under general anesthesia in combination with another surgical procedure using a variety of commercially available needle and guidewire kits in 14 patients. Results. These 14 patients had an average age of 55.2 ± 6.6 years and a burn involving 38 ± 8% of the body surface. Eleven of these patients had suffered an inhalation injury. The tubes were placed an average of 57 ± 10.5 days after injury through unburned and unharvested skin in four patients (28%), healed donor sites in five patients (35%). healed burn in one patient (1%), and grafted burn in four patients (28%). One patient, whose catheter was placed through a grafted fascial excision, developed moderate local wound erosion. Tubes were known to have been left in place as long as 155 days. However, most were removed in rehabilitation hospitals, and we were unable to determine how long most were left in place. We are unaware of any problems with the tubes occurring after discharge from the acute care setting. Conclusions. In selected patients, PEG can provide more comfortable access for prolonged enteral feedings than nasogastric tubes and can be placed with minimal morbidity.

Survival of major burn injuries has improved markedly from an expected survival of 10% to 20% in both children and adults to an expected survival of 60% in children with burns greater than 70% BSA. Increased survival for adults after similar burn injuries has been less dramatic than in children because of the profound influences of advancing age and the coexistent processes of aging upon survival after a major injury. Consecutive admissions of patients with massive burn injuries (greater than or equal to 70% BSA) to the Massachusetts General Hospital Adult Burn Unit from 1974 to 1986 were analyzed statistically using univariate and multiple logistic regression analysis to identify factors associated with survival and to identify patient characteristics associated with increases in expected survival. Survival of adults with massive burn injuries has improved markedly, from 24% of adults admitted to the Adult Burn Center in 1974-75 to 48% of adults admitted in 1984-86. An increased likelihood of survival was shown to be associated with the use of artificial skin. Improved survival rates in these massive burn injuries were attributed to multiple factors including wound management of prompt eschar excision and immediate wound closure.

Mortality at the Adult Burn Center of the Massachusetts General Hospital (MGH) has declined from 24% in 1974 to an average of 7% for 1979-1984. From 1974 to 1976, prompt eschar excision and immediate wound closure therapy was initiated and standardized. After 1976, this therapy was the standard treatment. Detailed statistical analysis is necessary to determine the influence of this treatment on the improved survival. Therefore, logistical regression analysis was used to examine the influence of variables such as burn size, age, and treatment on mortality for 1103 patients during 1974-1984. Survival rates during the treatment development phase (1974-1977) were compared to the survival rates of the last 5 years of standardized excisional treatment (1979-1984). Survival rates for the standardized excisional treatment were also compared to the results of previously published studies from this hospital that were probit analyses of burn mortality for 1939-1955 and 1955-1970. This latter comparison provided 45 years' experience with burn mortality at a single institution. Results of the statistical analysis of the survival data from 1974 to 1984 indicate that mortality strongly depends on burn size, age, and treatment (p less than 0.001 for each independent variable). In addition, length of stay (LOS) for the total group decreased significantly from 32 to 22 days. The improved survival for 1974-1984 occurred independently of changes in the annual distributions of burn size, age, or sex. Comparison of survival rates shows improved survival during standardized excisional treatment when compared to the treatment development phase. The most extensive increases in survival during 1974-1984 were seen in the treatment of elderly patients and patients with massive burn injuries. Survival for the period 1974-1984 was markedly improved as compared to the 1939-1970 published experiences.

Summary Methods have been presented of porcine preoperative maintenance, induction and maintenance of anesthesia, intraoperative heparinization and hemodilution, prophylactic buffering prior to and during surgery along with the details of hepatectomy including hazards and rationales of the phases involved. These techniques have been utilized in 30 experimental preparations for isolated ex vivo perfusion studies and in 5 clinical perfusions. In the latter situations wherein the human-ex vivo perfused porcine liver is utilized as a possible therapeutic adjunct in the treatment of terminal hepatic failure, the avoidance of the initial phase of vasoconstriction secondary to an increase in transhepatic vascular resistance3,4 in the excised liver becomes of paramount importance in maintaining adequate flow rates to support prolonged ex vivo porcine hepatic viability.

Summary Techniques of patient cannulation, isolated ex vivo porcine hepatic cannulation and flushing, and the perfusion and monitoring circuitry involved in clinical repeated short-term cross circulation between a subject and the ex vivo porcine liver are described. These methods have been applied in 9 clinical trial perfusions, the longest lasting 9 hours. Their possible continued utilization to support patients in far advanced, but reversible, hepatic failure or patients in terminal hepatic failure prior to homotransplantation, as it becomes available, is envisioned.

Carcinoma of the large bowel arises almost exclusively in neoplastic polyps, which are present in 5-10% of the population over age 40. These polyps may be of three histologic types: (a) tubular adenoma (adenomatous polyp), (b) tubulovillous adenoma (villoglandular polyp), and (c) villous adenoma. The tendency for malignant change is greatest in the villous adenoma (41%) and in tubulovillous (villoglandular polyps–23%). In tubular adenomas (simple adenomatous polyps), the incidence of malignancy is 5% over all. The tendency toward malignant change is determined by histologic type, size, and degree of atypicality of adenoma. Early detection and complete removal of neoplastic polyps of the colon are essential to the prevention of cancer of the large bowel, and this may usually be done in most cases with the colonoscope.

1.1. Hepatic periarterial neurectomy in normal dogs produces a 15 to 25 per cent increase in estimated hepatic blood flow, as measured by Au 198 colloid, which is due to a 35 per cent increase in hepatic arterial flows. 2.2. In a normal dog with an Eck fistula and with a reduced hepatic blood flow to 53 per cent of preoperative resting values by the diversion of portal flow, hepatic periarterial neurectomy produces a 132 per cent increase in hepatic arterial flow and increases total blood flow to 85 to 88 per cent of normal resting value. 3.3. Hepatic periarterial neurectomy produces increased survival in dogs with an Eck fistula during the first postoperative month, eight of ten dogs surviving compared with three of ten dogs surviving without neurectomy. This effect was most marked in the first postoperative month. 4.4. Ammonia tolerance curves in animals with an Eck fistula were markedly improved to almost normal levels by hepatic periarterial neurectomy. 5.5. The duration of effect of hepatic periarterial neurectomy is maximal in the first four to six weeks and gradually declines thereafter but may be reproduced by laparotomy and procaine block at the site of previous neurectomy.

The incidence of severe liver trauma is rising. Violence in the cities and high speed highway accidents are the most important contributing factors in civilian cases whereas penetrating, high velocity missile wounds account for the largest part of the military experience. Management of severe liver injury has traditionally been directed toward controlling exsanguinating hemorrhage and has been characterized by large isolating mattress stitches, packing with gauze or absorbent materials, and drainage. The mortality has been high (between 40 and 60 per cent) and the rate of serious complications approximately 50 per cent in the survivors [I$]. Most of the postoperative complications can be attributed to (1) continued bleeding, (2) necrosis of devitalized liver, and (3) subphrenic collections of blood and bile which become septic [3,4]. The increasing experience with elective liver resections for malignancy, both primary and metastatic, and the conviction that in many instances extensive damage to the liver from trauma may best be treated by formal hepatic resection rather than by attempts to reconstruct a badly fragmented lobe, have resulted in a growing body of clinical material which supports the concept of resection of devitalized tissues, drainage of injured areas, and vigorous postoperative metabolic support [6,6].