Delayed presentation of familial intestinal malrotation with volvulus in two adult siblings

Intestinal malrotation is an uncommon cause of abdominal pain and normally presents during infancy. Familial cases of malrotation are extremely rare in the absence of other congenital malformations. We present the case of a 22-year-old woman with undiagnosed chronic abdominal pain and her previously well 16-year-old brother who presented within 18 months of each other with acute midgut volvulus secondary to intestinal malrotation. Clinicians should be aware of this rare but serious cause of abdominal pain.

Role of mammography in the triple assessment of single-quadrant breast symptoms

Background

Most women over the age of 35 years referred to a breast clinic have single-quadrant symptoms and undergo mammography (MMG) as part of the triple assessment of these. A proportion of these women has no abnormality clinically or on ultrasonography (P1 U1). The aim of this study was to assess the additional contribution of MMG in diagnosing cancer in patients with P1 U1 findings and to consider whether it is safe to be more selective when requesting MMG.

Methods

Over a 2-year interval the clinical and radiological details of women whose single-quadrant breast symptoms were assessed as P1 U1, and who were then sent for MMG, were entered into a database. The results of further investigations initiated by a non-benign MMG report were recorded, and the patients reviewed to establish how many cancers were diagnosed purely by MMG and whether these were located at the site of symptoms.

Results

There were 454 women in the study group, representing 17·5 per cent of all new referrals. Twenty-one patients (4·6 per cent) were recalled following a non-benign MMG result, ten of whom required image-guided biopsy. Cancer was diagnosed in three patients (0·7 per cent of the study group), located in the contralateral breast in two women and a different ipsilateral quadrant in one.

Conclusion

MMG in this subset of patients did not increase the cancer detection rate at the site of symptoms and therefore constituted screening. The rationale for requesting MMG in these patients, and indeed for applying the triple assessment rule, should be reconsidered.

The results of a structured diagnostic pathway designed to minimise the chance of breast cancer misdiagnosis

AIM

To describe results from a structured clinic pathway designed to minimise inaccuracies and diagnostic delays in the diagnosis of breast cancer.

METHODS

Patients referred to our breast clinic undergo clinical, imaging and biopsy assessment according to a standard protocol. Over 4 years, patients who were discharged with a benign diagnosis and later found to have breast cancer were reviewed.

RESULTS

A total of 4366 new referrals were seen in the symptomatic breast clinic and 571 (13%) new cancers were diagnosed. Fourteen of the new cancer patients had been seen in the clinic previously (range 7-48 months) and discharged with a benign diagnosis. None of these tumours appeared to result from misdiagnosis of a lesion previously assessed to be benign. The rate of development of cancer in the cohort discharged with a benign diagnosis was closely similar to that in the normal United Kingdom population.

CONCLUSIONS

A structured breast clinic pathway can produce a rate of diagnostic accuracy closely approaching 100%.

Core biopsy vs fine needle aspiration cytology in a symptomatic breast clinic

AIM

The adequacy of physical examination, mammography and fine needle aspiration cytology (FNAC) (conventional triple assessment) in the diagnosis of breast cancer has been questioned. We have performed a prospective study directly comparing FNAC and core biopsy in our symptomatic breast clinic.

METHOD

Between 15/5/00 and 17/1/01, 330 consecutive patients with breast lumps were assessed by physical examination, ultrasound, and mammography if over 35 years, and FNAC and core biopsy with or without ultrasound guidance.

RESULTS

Three hundred and forty four specimens yielded the following FNAC and core biopsy results: C1-109, C2-144, C3-6, C4-17, C5-68; B1-97, B2-150, B3-7, B4-3, B5-87. The FNAC results corresponding to the 87 B5 samples were as follows: C1-5, C2-2, C3-0, C4-12, C5-68. All C5 samples were associated with a corresponding B5 result. All except one cancer in this series was diagnosed at a single clinic visit.

CONCLUSION

In this series, core biopsy diagnosed symptomatic breast cancer more accurately than FNAC.

An unusual case of metastatic post-irradiation breast sarcoma

A 71-year-old lady developed a left breast angiosarcoma 10 years after a wide local excision and external beam radiotherapy for invasive breast cancer. Three years after a left simple mastectomy for the angiosarcoma, she presented with metastatic angiosarcoma in the contralateral axilla. There were no local or distant metastases. This is the first reported case of isolated contralateral axillary metastases from post-irradiation angiosarcoma of the breast. A previous study has reported ipsilateral axillary metastases in relation to secondary breast angiosarcoma. Contralateral axillary metastases have always been associated with extensive distant metastases. We present a review of the available literature on radiation-associated breast angiosarcomas.

Heartburn, oesophagitis and Barrett's oesophagus in self-medicating patients in general practice

A postal questionnaire on heartburn sent to 6760 randomly selected subjects yielded 3971 replies suitable for analysis. Heartburn had never been experienced by 1665 (42%) respondents. Significant symptoms of more than three months' duration that had occurred at least once a month in the preceding 12 months were reported by 1337 (34%) respondents. Of these, 875 had not consulted their general practitioner and were invited to attend for a structured interview with questionnaire and upper gastrointestinal endoscopy. A total of 177 were interviewed, and 143 underwent upper gastrointestinal endoscopy. Of those endoscoped, 106 (74%) experienced symptoms at least once a week. These were relieved by alginate consumption in 97 (68% of) cases. Just nine (6%) patients had been taking H2-receptor antagonists. Macroscopic appearances of oesophagitis were seen in 46 cases [13 (6%) grade 1, 24 (11%) grade 2, five (2%) grade 3, two (1%) grade 4, and two (1%) grade 5]. Three patients had mild strictures and six patients had Barrett's oesophagus. There were no appearances suggestive of malignancy. Biopsies were taken in 122 cases, including all those in which abnormalities had been seen. Histological evidence of oesophagitis was seen in 47 cases. Gastric metaplasia was found in six cases and dysplasia seen in three. Patients who self-medicate for reflux symptoms have a low prevalence of pre-neoplastic and neoplastic pathology. A substantial proportion, however, have histological evidence of oesophagitis and a small number have metaplasia.

Administrative aspects of a general surgical firm: an audit of accuracy of operation lists and timeliness of discharge summaries

A one-year audit of operation lists and discharge summaries of one surgical firm showed only 1.4 percent of operation lists contained errors or omissions and only 5 percent contained abbreviations. 74.2 percent of discharge summaries were dictated within one week of discharge. A high proportion of day cases allowed 44.7 percent of the discharge summaries to be dictated on the day of operation. Close consultant and secretarial involvement in the preparation of operating lists can ensure a high degree of accuracy. Day case operation notes should be combined with a discharge letter to optimise communication with general practitioners.

Adjuvant treatment with tamoxifen. Multicentre trial should be welcomed

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Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum

Over 14 years 276 patients with rectal cancer underwent surgery; 219 who underwent low anterior resection of the rectum with total mesorectal excision were studied. There were 24 (11.0 per cent) major anastomotic leaks associated with peritonitis or a pelvic collection and 14 (6.4 per cent) minor leaks that were asymptomatic and detected by contrast enema. All major leaks occurred at an anastomotic height of less than 6 cm (P = 0.08). The abdominoperineal excision rate was 9.1 per cent. Major leaks were associated with failure to defunction in 11 of 62 patients and with a defunctioning colostomy in 13 of 157 (P = 0.03). Of the 24 patients with major leaks seven developed peritonitis, one with a defunctioned anastomosis (P = 0.002), and three died (P = 0.02). Use of the sigmoid colon led to major leakage in seven of 32 patients compared with 17 of 187 when the splenic flexure was employed (P = 0.05). There was no increase in the local recurrence rate but only nine patients with major leakage and a temporary stoma have had these closed. Key technical factors include: a clean dry pelvic cavity, pulsatile colonic blood supply, suction drainage started during closure and mobilization of ample tissue to fill the pelvic space.

The timing of breast cancer surgery within the menstrual cycle

The effects of the timing of surgery, fine needle aspiration cytology (FNAC) and mammography within the menstrual cycle were investigated retrospectively in 211 premenopausal breast cancer patients. The day of surgery within the menstrual cycle was known for 157 women whose menstrual cycles were regular. Recurrence and survival were closely similar whether surgery was performed during days 3-12 or at other times (days 0-2 or 13-32) in the cycle. Outcome was also unrelated to the timing of mammography which was known in 101 cases. There were no significant differences in recurrence or survival associated with the timing of FNAC when all patients were considered. In the subset of lymph node negative patients (n = 32), however, FNAC outside days 3-12 was associated with a significantly decreased rate of relapse (RR = 0.25, 95% CI = 0.07-0.9) and death (RR = 0.10, 95% CI = 0.02-0.9). These patients, however, also had significantly smaller tumours (median = 2 cm, interquartile range = 2-3 cm) than patients having FNAC on days 3-12 of the cycle (median = 3, interquartile range = 2-4) (Mann-Whitney: z = 2.11, P = 0.04). We have not confirmed that surgery or FNAC during days 3-12 of the cycle is associated with a poorer outcome than interventions during other parts of the cycle.

What are the benefits of routine breast cancer follow-up?

The value of follow-up after potentially curative treatment of breast cancer remains controversial. Recurrence-free women (n = 402) attending a breast clinic over a 3 month period were studied. The women attended 423 appointments, 412 of which were routine. Eleven were requested by the patient or general practitioner (interval appointments). All 11 interval and 19 of the routine appointments resulted in investigations for possible recurrence. Three (27%) interval appointments and four (1%) routine appointments resulted in the diagnosis of a recurrence (P < 10(-5). The attitudes of 285 patients to follow-up were investigated by questionnaire. Two hundred and twenty-three (78%) questionnaires were completed. Regular follow-up in the breast clinic was preferred to attendance only when symptomatic by 190 (85%) women and 169 (76%) preferred regular breast clinic visits to general practitioner follow-up. Most women (n = 174) (81%) said they felt reassured and less anxious having attended the breast clinic. Routine follow-up after potentially curative treatment of breast cancer is inefficient in the detection of recurrence. It is, however, highly rated for providing reassurance and reducing anxiety. Reassurance rather than detection of recurrence may be the most important function of the breast cancer follow-up clinic.

Which surgeons avoid a stoma in treating left-sided colonic obstruction? Results of a postal questionnaire

There is now good evidence to indicate that the majority of patients with large bowel obstruction can be safely managed by resection and immediate anastomosis, but have surgeons embraced this policy? A postal survey has been performed to ascertain the opinions of consultant general surgeons within the Wessex region regarding the management of left-sided large bowel obstruction. Of 47 questionnaires sent, 42 replies could be analysed. In patients of good anaesthetic risk, 90% would perform resection with primary anastomosis if the lesion was at the splenic flexure, and 62% would adopt this policy for a rectosigmoid obstruction. In patients of higher anaesthetic risk these figures fell to 71% and 31%, respectively. Surgeons with a gastrointestinal interest were more likely to recommend resection with primary anastomosis. However, this trend reached statistical significance only for splenic flexure and descending colon lesions in good-risk patients. Most surgeons would avoid a stoma in the presence of liver metastases, and only three would be more likely to create a stoma in this situation.

Flush aortic tie versus selective preservation of the ascending left colic artery in low anterior resection for rectal carcinoma

The effects of two methods of colonic vascular ligation were studied in 143 consecutive patients who underwent low anterior resection with total mesorectal excision and full mobilization of the splenic flexure. Either the ascending left colic artery (ALCA) was selectively preserved (n = 52) or a flush aortic ligation was performed (n = 91). In those with a protective colostomy, the radiological leak rate was 12 per cent when the ALCA was preserved (n = 41) and 10 per cent when a flush aortic tie was performed (n = 60) (P greater than 0.95; 95 per cent confidence interval (c.i.) for difference -10 to +15 per cent). In those without a colostomy, the clinical leak rates of 9 per cent when the ALCA was preserved (n = 11) and 19 per cent when a flush aortic tie was performed (n = 31) were not significantly different (P greater than 0.10; 95 per cent c.i. for difference -12 to +32 per cent). Proportional hazards analysis showed no association between the method of vascular ligation and the risk of tumour recurrence and death. Anastomotic leak rates, tumour recurrence and survival were not related to the method of vascular ligation.

The diagnosis of femoral hernia

The accuracy of diagnosis of femoral hernia in referrals to a district general hospital over a period of 5 years has been studied and related to clinical outcome. A correct diagnosis was made in only 36 of 98 cases (60 urgent, 38 routine) before admission to hospital. A correct pre-operative diagnosis was ultimately made in 85 cases. Four patients, all urgent admissions with incarcerated bowel, died within 30 days of operation. In none of these cases was a correct diagnosis made before admission to hospital. The median length of post-operative stay of urgent admissions was 7 days (range 4-50) when a correct initial diagnosis was made and 10 days (range 4-50) when the initial diagnosis was incorrect (P = 0.07, Mann-Whitney test). When strangulated small bowel was found at operation, 70% of those with an incorrect initial diagnosis (n = 23) required resection, as compared with 20% of those with a correct initial diagnosis (n = 10, P = 0.014, chi 2 with Yates' correction). Femoral hernias are frequently incorrectly diagnosed before hospital admission and this is associated with worsened outcome in urgent cases.

A randomized prospective study to compare ceftizoxime with cephradine as single dose prophylaxis in elective cholecystectomy

This study compares the efficacy of ceftizoxime with that of cephradine as single agent prophylaxis in elective cholecystectomy. The incidence of purulent wound infection was low in both groups (ceftizoxime 1/99; cephradine 2/92). No adverse reactions to the trial antibiotics occurred in either group. Ceftizoxime is a safe, effective, convenient and well-tolerated antibiotic for use as single agent prophylaxis in elective cholecystectomy. However, because it has no demonstrable advantage over cephradine and is three times as expensive, its routine use is not justified.

Wound infection following high saphenous ligation. A trial comparing two skin closure techniques: subcuticular polyglycolic acid and interrupted monofilament nylon mattress sutures

A prospective, randomized trial was performed to compare the incidence of wound infection following skin closure with subcuticular polyglycolic acid and interrupted monofilament nylon mattress sutures in patients undergoing high saphenous ligation (126 patients; 75 polyglycolic acid wounds, 86 interrupted monofilament nylon mattress wounds). By 6 weeks after operation, pus had discharged from 15 (20%) polyglycolic acid wounds compared with seven (8%) interrupted monofilament nylon mattress wounds (P = 0.05), giving an overall infection rate of 13.7%. Infection occurred in 23% of the 56 procedures performed by the two surgeons with the highest infection rates compared with 8% of the 105 procedures performed by the remaining nine surgeons (P = 0.02). The excess of infections in wounds closed with subcuticular polyglycolic acid was caused by an excess of infections in operations performed by the two surgeons with the highest infection rates. The higher infection rate found with subcuticular polyglycolic acid appeared to be operator dependent.

Risk of peritonitis and fatal septicaemia and the need to defunction the low anastomosis

The aim of this study was to investigate the need to defunction the low anastomosis after anterior resection of the rectum with total mesorectal excision for rectal cancer. Two hundred consecutive patients (125 defunctioned, 75 non-defunctioned) undergoing low anterior resection for carcinoma were included in the study. Peritonitis requiring emergency laparotomy occurred in 8 per cent of the patients who did not have a defunctioning stoma compared with less than 1 per cent of those patients who had a defunctioning stoma (P less than 0.01). There was no mortality related to closure of the stoma but seven patients developed a faecal fistula and ten developed an incisional hernia. Despite current trends to avoid the defunctioning stoma, these results suggest that after total mesorectal excision the faecal stream should be temporarily diverted away from the anastomosis that is 6 cm or less from the anal verge to protect against potentially life-threatening anastomotic leakage.

Sigmoid invasion as a late complication of mucinous cystadenoma of the appendix. Report of a case

A cystic mass arising from the right iliac fossa was an incidental finding at laparotomy and was treated conservatively after a biopsy had shown no evidence of malignancy. Nine years later the patient presented with shock and colonic bleeding. A large cystic lesion arising from the vermiform appendix and invading the sigmoid colon was found and excised. Histologic examination indicated that the underlying lesion was an inflamed mucinous cystadenoma of the appendix. Frank invasion of viscera by such lesions has not previously been described. Complications of such lesions and their association with other colonic neoplasms are discussed.

Optimal operative treatment in acute septic complications of diverticular disease

There is still no unanimity regarding optimal operative treatment in acute septic complications of diverticular disease. Logistic regression analysis was used to investigate factors influencing inpatient mortality in 100 patients who underwent urgent laparotomy for such complications. Thirteen preoperative and operative factors including operation type were investigated and odds ratios (OR) were calculated to indicate the approximate risk associated with each factor. A significant advantage for excision/exteriorisation operations compared with defunctioning operations was found (OR 0.17, 95% confidence interval (CI) 0.04-0.79). Although more conservative procedures (mainly laparotomy with drainage) were associated with an increased mortality relative to defunctioning procedures, this difference just failed to reach statistical significance (OR 3.83, 95% CI 0.89-16.5). Age (OR 1.14, 95% CI 1.05-1.24), co-existing illness (OR 2.38, 95% CI 1.08-5.25) and preoperative shock (OR 4.63, 95% CI 1.00-21.5) were significant as adverse prognostic factors. A higher proportion of survivors treated by defunction than by excision/exteriorisation underwent colostomy closure, but this was in part due to the higher proportion of excision/exteriorisation operations in the latter part of the series. We conclude that in patients requiring urgent laparotomy for septic complications of diverticular disease, the septic focus should be removed from the abdominal cavity. This is most often achieved using a Hartmann's procedure and we recommend this form of treatment.

Pseudo-obstruction

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Metronidazole v. cefoxitin in severe appendicitis--a trial to compare a single intraoperative dose of two antibiotics given intravenously

In severe appendicitis, the effect of a single intravenous dose of metronidazole (500 mg) was compared with cefoxitin (1 g). The antibiotics were given by random allocation once the diagnosis had been established at operation. In the metronidazole group, 5 out of 48 patients developed a wound infection whilst in hospital compared with 13 out of 48 in the cefoxitin group (P = 0.036). However, 57% of wound infections became apparent after the patient went home and the overall infection rates were similar. The mean length of postoperative hospital stay was 5.0 days in the metronidazole group and 6.8 days in the cefoxitin group (P = 0.052), but of those who did develop a wound infection, the length of stay was almost double in the cefoxitin group. Anaerobic organisms were cultured from the wound in 7 out of 15 patients who received cefoxitin but in none of 5 patients in the metronidazole group. Whilst metronidazole only delayed the discharge of pus from the wound, it did seem to reduce the severity of infection. Cefoxitin appeared to be less effective, given as a single intravenous injection at a dose of 1 g.