A case of gastroduodenal lipomatosis

Although sporadic lipomas are not uncommon in the upper gastrointestinal tract, diffuse gastroduodenal lipomatosis is a rare clinical entity. Medical literature reveals a limited number of such cases presenting with upper gastrointestinal obstruction or bleeding. We present the management experience of a 43-year-old woman who presented with intussusception causing high small-bowel obstruction secondary to jejunal lipomatosis. Computed tomography showed diffuse fatty thickening of the gastric wall in addition to multiple lipomas in stomach, duodenum and in the jejunum with jejunal intussusception. As complete resection of the affected segment was not possible, a side-to-side jejunal bypass was made. The patient remains well on review after 18 months.

Transfusion of 28-day-old leucoreduced or non-leucoreduced stored red blood cells induces an inflammatory response in healthy dogs

BACKGROUND AND OBJECTIVES

Studies in mice suggest that rapid transfusions of red blood cells (RBCs), refrigerator stored for longer durations, induce a pro-inflammatory cytokine response. Studies in human neonates confirm these findings; however, to date, adult human studies have failed to replicate these findings. We used healthy research dogs to begin to examine the factors affecting the cytokine response to transfusion.

MATERIALS AND METHODS

In a prospective study, healthy dogs were randomized for two autologous packed RBC transfusions after 7 (i.e. 'fresh') and 28 (i.e. 'old') days of storage, or after 28 and 7 days of storage, with or without prestorage leucoreduction (LR).

RESULTS

No significant differences were observed between LR and non-LR transfusions for all circulating analytes measured following transfusion. A pro-inflammatory cytokine response, exemplified by monocyte chemoattractant protein-1, was observed 6 h after only old RBC transfusions, irrespective of infusion rate (P < 0·001). This response was accompanied by increased neutrophil counts (P < 0·001) and decreased platelet counts (P < 0·001).

CONCLUSION

In healthy dogs, old RBC transfusions induce inflammation, which is unaffected by infusion rate.

Progression of a solitary, malignant cutaneous plasma-cell tumour to multiple myeloma in a cat

An 11-year-old male domestic shorthair cat was examined because of a soft-tissue mass on the left tarsus previously diagnosed as a malignant extramedullary plasmacytoma. Findings of further diagnostic tests carried out to evaluate the patient for multiple myeloma were negative. Five months later, the cat developed clinical evidence of multiple myeloma based on positive Bence Jones proteinuria, monoclonal gammopathy and circulating atypical plasma cells. This case represents an unusual presentation for this disease and documents progression of an extramedullary plasmacytoma to multiple myeloma in the cat.

With adequate supervision, the grade of the operating surgeon is not a determinant of outcome for patients undergoing urgent colorectal surgery

INTRODUCTION

It is essential that higher surgical trainees (HSTs) obtain adequate emergency operative experience without compromising patient outcome. The aim of this study was to compare the outcomes of patients operated by HSTs with those operated by consultants and to look at the effect of consultant supervision.

PATIENTS AND METHODS

A retrospective analysis of 362 patients who underwent urgent colorectal surgery was performed. The primary outcome was 30-day mortality. Secondary outcomes were intra-operative and postoperative surgery, specific and systemic complications, and delayed complications.

RESULTS

Comparison of the patients operated by a consultant (n = 190) and a HST (n = 172) as the primary surgeon revealed no significant difference between the two groups for age, gender, ASA status or indication for surgery. There was a difference in the type of procedure performed (left-sided resections: consultants 122/190, HST 91/172; P = 0.050). There was no difference between the two groups for the primary and secondary outcomes. However, HSTs operating unsupervised performed significantly fewer primary anastomoses for left-sided resections (P = 0.019) and had more surgery specific complications (P = 0.028) than those supervised by a consultant.

CONCLUSIONS

HSTs can perform emergency colorectal surgery with similar outcomes to their consultants, but adequate consultant supervision is vital to achieving these results.

Abdominal Aortic Aneurysm Surgery in a District General Hospital: A 15-Years Experience

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.

Cold agglutinin related acrocyanosis and paroxysmal haemolysis

The clinical features of severe cold agglutinin related paroxysmal agglutination and haemolysis could be confused with a number of conditions. A 61-year old lady presented with features of acute peripheral ischaemia who had recently been started on treatment for Raynaud's disease. Haematological investigations revealed the presence of potent cold haemagglutinins to be the cause of her symptoms but no definite cause for the raised titres were found. She was managed conservatively by keeping her hands and feet warm and regular chlorambucil for a suspected underlying lymphoproliferative disorder. It is important to differentiate the features of Raynaud's disease from those of severe haemagglutination so that identification of any underlying disorder can be made and appropriate treatment instituted.

MR imaging of hemorrhagic brain lesions: a comparison of dual-echo gradient- and spin-echo and fast spin-echo techniques

OBJECTIVE

Our objective was to assess the usefulness of the dual-echo gradient- and spin-echo (GRASE) technique in revealing acute hemorrhagic brain lesions and compare GRASE and fast spin-echo techniques for revealing acute hemorrhagic lesions and image artifacts.

MATERIALS AND METHODS

Thirty-two consecutive patients with acute intracranial hemorrhage underwent dual-echo GRASE (TEeff1/TEeff2, 35/85) and fast spin-echo (25/110) imaging. The techniques were matched for TR (3032 msec), spatial resolution, and acquisition time. Two neuroradiologists reviewed the images independently, documenting the number, size (<1, >1, or 1 cm in diameter), location, and signal characteristics (hypointense versus hyperintense compared with brain) of detectable lesions. These observers also compared matched T2- and proton density-weighted GRASE and fast spin-echo images for paramagnetic lesion conspicuity, diamagnetic susceptibility artifacts, chemical shift artifacts along the phase- and frequency-encoding directions, and artifactual CSF hyperintensity in the thin curvilinear cortical sulci and the Virchow-Robin spaces on only the proton density-weighted images.

RESULTS

The average number and conspicuity of dark (paramagnetic) lesions were significantly greater on GRASE than on fast spin-echo images (p < .05 and p < .001, respectively). We found no significant difference in the average number of bright lesions revealed by either technique (p > .1). Chemical shift artifacts along the phase-encoding directions were more prominent on GRASE than on fast spin-echo imaging. Chemical shift artifacts along the frequency-encoding directions and artifactual CSF hyperintensity were more prominent on fast spin-echo than on GRASE imaging. No visually apparent difference was found in the degree of diamagnetic susceptibility artifacts seen with the two techniques.

CONCLUSION

Dual-echo GRASE imaging can be helpful in the examination of patients with suspected acute brain hemorrhage.

Circulating soluble adhesion molecules in inflammatory bowel disease

OBJECTIVE

To determine levels of soluble forms of the cell adhesion molecules (CAM), ICAM-1, E-Selectin and VCAM-1 in relation to prevalence, treatment and disease activity in inflammatory bowel disease.

PATIENTS AND METHODS

Plasma was obtained from patients with ulcerative colitis (n = 49), patients with ulcerative colitis who had undergone restorative proctocolectomy (n = 32, eight of whom had a clinical pouchitis), Crohn's disease patients (n = 34) and 24 healthy controls.

RESULTS

Plasma soluble ICAM-1 levels [medians (ranges in ng/ml)] were significantly higher in patients with active ulcerative colitis [270 (90-510)], pouchitis [415 (310-670)] and active Crohn's disease [305 (200-630)] than in those with inactive ulcerative colitis [225 (140-425), P = 0.031], non-inflamed ileoanal pouch [260 (140-380), P = 0.0004] and inactive Crohn's disease [245 (90-520), P = 0.045], respectively, and controls. The soluble E-Selectin levels were also significantly higher in patients with active ulcerative colitis [55 (40-140)], pouchitis [90 (45-145)], and active Crohn's disease [78 (30-115)] than in those with inactive ulcerative colitis [45 (20-80, P = 0.003], non-inflamed ileoanal pouch [45 (20-90), P = 0.001] and inactive Crohn's disease [48 (25-90, P = 0.020], respectively, and controls.

CONCLUSIONS

The present study suggests that increased levels of soluble ICAM-1 and soluble E-Selectin occur during active inflammatory bowel disease and pouchitis, which may be used as sensitive markers of continuing inflammation.

Cytokine production in pouchitis is similar to that in ulcerative colitis

PURPOSE

Controversy exists as to whether pouchitis represents a reactivation of the immunologic mechanisms that lead to ulcerative colitis (UC). The aims of this study were to determine local levels of the cytokines: interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor alpha (TNF alpha) in the mucosa of patients with "asymptomatic" ileoanal pouch (n = 25), pouchitis (n = 9), active UC (n = 20), normal ileum (n = 15), proctitis (n = 10), and normal colon (n = 15).

METHODS

Lamina propria mononuclear cells were isolated from mucosal biopsies by enzymatic dispersion and cultured for 48 hours. Proinflammatory cytokine levels were measured in the supernatants by enzyme-linked immunosorbent assay.

RESULTS

IL-1 beta, IL-6, IL-8, and TNF alpha secretions were significantly greater in pouchitis and active UC than in the noninflamed ileoanal pouch and normal controls (P < 0.001). There was significant correlation (r = 0.63, P < 0.05) between levels of cytokines expressed in pouchitis and active UC.

CONCLUSIONS

Increased cytokine expression occurs in both active UC and pouchitis and to a lesser extent in the long-standing ileoanal pouch.

Interleukin 6 is a prognostic indicator of outcome in severe intra-abdominal sepsis

Levels of plasma cytokines and circulating endotoxin were assessed in 41 patients with severe intra-abdominal sepsis. Comparison was made with the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system. Blood samples were taken within 24 h of onset of the sepsis syndrome and at serial times thereafter. Increased levels of interleukin (IL) 6 (range 50-25,500 pg/ml) were detectable in all patients with sepsis. Eighteen of the 19 deaths were attributable to sepsis and higher levels of IL-6 at the onset of the sepsis syndrome correlated with a poor outcome. The sensitivity of IL-6 concentration in predicting mortality was 86.4 per cent with a specificity of 78.9 per cent and an overall correct classification rate of 82.9 per cent. IL-6 level was a better predictor than APACHE II score (sensitivity 72.7 per cent, specificity 57.9 per cent, correct classification rate 65.9 per cent). Levels of tumour necrosis factor alpha, IL-1 beta and endotoxin did not correlate with mortality rate. Plasma IL-6 concentrations may help in planning future strategies to decrease the mortality rate associated with sepsis.

Influence of total colectomy on serum antineutrophil cytoplasmic antibodies in inflammatory bowel disease

Perinuclear antineutrophil cytoplasmic antibodies (pANCAs) have previously been demonstrated in patients with various forms of vasculitis and more recently in those with inflammatory bowel disease (IBD) by an indirect immunofluorescence technique. Sera from 194 patients were tested for pANCAs: 101 with ulcerative colitis (43 with varying grades of disease severity, 19 after subtotal colectomy, 39 following restorative proctocolectomy), 40 with Crohn's disease, five with indeterminate colitis, 24 patients without IBD and 24 healthy volunteers (controls). The overall prevalence of pANCAs in patients with ulcerative colitis was 70.3 per cent (71 of 101). These antibodies were still present in 29 of 39 patients after restorative proctocolectomy, in whom the median follow-up after surgery was 2 years. All five patients who had pouchitis after restorative proctocolectomy were pANCA positive. By contrast, only ten of 40 patients with Crohn's disease had pANCAs, nine of whom had Crohn's colitis. No pANCAs were detected in controls. These results show that pANCAs are more prevalent in colonic IBD, especially ulcerative colitis. The persistence of pANCAs in the sera for 2 years after restorative proctocolectomy suggests that the antigens are not fully eradicated and, therefore, that it is not just the colon that is targeted immunologically in ulcerative colitis.

Is immediate postmastectomy reconstruction safe in the long-term?

A prospective case-control study of 81 patients has been carried out over 10 years comparing mastectomy with immediate reconstruction to mastectomy alone. The patients were matched for age (within 5 years), TNM stage, pathologic nodal status and operative procedure. After complete 10-year follow-up we have failed to demonstrate any long term difference in tumour behaviour. We conclude that immediate reconstruction is widely applicable and technically feasible without any long term effect on the development of local recurrence or metastatic disease.