Faculty Bibliography

N-butyl 2-cyanoacrylate monomer was injected at endoscopy in an attempt to control arterial bleeding from a duodenal ulcer crater. Segmental infarction of the duodenum and pancreatic head followed and necessitated pancreatoduodenectomy. Butyl 2-cyanoacrylate monomers have been used with angiography as embolization agents and with endoscopy to control variceal bleeding. To our knowledge, there are no reports of its use by endoscopic injection to stop arterial bleeding. Its potential for embolism in nonselective endoscopic injections may minimize the clinical application of butyl 2-cyanoacrylate monomers in the treatment of arterial gastrointestinal bleeding.

We retrospectively reviewed 137 cases of outpatient endoscopic sphincterotomy (ES) performed over a 4-year period in a single center and compared them with an equal number of inpatient ES. The indications for ES in outpatients as compared with inpatients were, respectively: choledocholithiasis, 60% and 70%; papillary stenosis, 35% and 15% (p less than 0.001); stent insertion, 3.6% and 14% (p less than 0.01); and ampullary tumor, 1.4% and 0.7%. Complications were noted within 2 to 4 hours of ES in 6.6% of outpatients, a rate similar to that of inpatients--7.3%. Outpatients with complications were immediately admitted and stayed in the hospital for a mean of 5 days. No delayed complications were noted and no deaths occurred. Thus, a policy whereby selected individuals undergo ES as outpatients, with hospitalization reserved only for those in whom a complication develops, is reasonable and safe.

Gastric balloons have been used extensively as an adjunct to diet and behavioral modification in the treatment of exogenous obesity. Small bowel obstruction occurred in a 42-year-old female after her balloon migrated through the pyloric channel. The authors describe a simple method for percutaneous deflation which permitted the balloon to pass through the gastrointestinal tract thus relieving the obstruction.

We evaluated the efficacy of endoscopically placed biliary stents as treatment for 32 benign postoperative biliary strictures in 29 patients. Five patients also had bile fistulas. Stents were inserted for a mean of 162 days and then removed. ERCPs were obtained before stent insertion and again after removal. Responses were followed and categorized as excellent, good, or poor. Stent insertion was successful in 25 patients (86%), 23 of which have a mean follow-up of 19 months (range, 2 to 42 months) after stent removal. Seventy-four percent had an excellent (48%) or good (26%) response. Early postoperative strictures and fistulas responded favorably. We conclude that benign postoperative biliary strictures can be treated successfully by endoscopic prostheses.

Over the past two decades, endoscopy has emerged as the single most important tool in the initial diagnosis and subsequent follow-up of inflammatory bowel disease. This article is an overview of the applicability of the various endoscopic procedures in the management of inflammatory bowel disease and its complications.

Endoscopic sphincterotomy (papillotomy) was performed in 289 patients for choledocholithiasis (250, of whom 223 had undergone cholecystectomy previously), papillary stenosis or spasm (32) and ampullary neoplasm (7). The complications encountered in 39 patients were hemorrhage (15 patients), perforation (4), hemorrhage and perforation (1), cholangitis (5), pancreatitis (11), impaction (1) and others (2). Laparotomy was required in seven of these patients for hemorrhage (two), perforation (two), hemorrhage and perforation (one), pancreatitis (one) and impaction (one). Bleeding required duodenotomy with an extension of the sphincterotomy incision to control hemorrhage, and a formal sutured sphincteroplasty. Perforation occurred at the junction of the distal bile duct and duodenum and was managed by mobilization of the duodenum, with T-tube drainage through the perforation, and sutured closure. A pancreatic abscess following pancreatitis required surgical drainage. An impacted Dormia basket with entrapped stone in the bile duct required duodenotomy for its removal. There was a high risk of perforation in those patients who did not have choledocholithiasis or who had had a previous Billroth II gastrectomy. There were two deaths but the overall complication rate of 2.4% is considered low, because many of the patients were elderly or debilitated.

Duodenal bile from 27 diabetes was compared with samples from healthy subjects matched for age, sex, and body mass index. Cholesterol saturation and the molar percentages of bile acids, phospholipids, and cholesterol were not significantly different. Most bile samples were supersaturated in both groups. The maturity onset diabetics who were almost all obese had more saturated bile than the slimmer juvenile onset patients. Body fatness and plasma triglyceride levels were both positively correlated with the cholesterol saturation of bile in the controls but not in the diabetics. Bile was less concentrated in female diabetics than in controls, which is consistent with impaired gallbladder emptying. It is possible that the increased prevalence of gallstones in diabetics is due not so much to diabetes itself as to the frequently associated obesity.

Ten normal subjects ingested test meals based on apples, each containing 60 g available carbohydrate. Fibre-free juice could be consumed eleven times faster than intact apples and four times faster than fibre-disrupted puree. Satiety was assessed numerically. With the rate of ingestion equalised, juice was significantly less satisfying than puree, and puree than apples. Plasma-glucose rose to similar levels after all three meals. However, there was a striking rebound fall after juice, and to a lesser extent after puree, which was not seen after apples. Serum-insulin rose to higher levels after juice and puree than after apples. The removal of fibre from food, and also its physical disruption, can result in faster and easier ingestion, decreased satiety, and disturbed glucose homoeostasis which is probably due to inappropriate insulin release. These effects favour overnutrition and, if often repeated, might lead to diabetes mellitus.