Bowel obstruction due to extrinsic compression by metastatic lobular carcinoma of the breast

The commonest sites for breast cancer metastases are the bones, lungs, liver, pleura, adrenals and central nervous system. However, although other sites have been reported, solitary metastases to the gastrointestinal tract are extremely uncommon. Widely disseminated gastrointestinal metastases may be found in up to 20% of patients. Although only 15% of patients with breast cancer will have the lobular variety, these make up the majority of patients with solitary gastrointestinal metastases. Here we present three cases where solitary lobular breast cancer metastases have been demonstrated to be the cause of bowel obstruction. In two cases of duodenal obstruction was demonstrated and in the third colonic obstruction. In all cases a focal extrinsic compression was found.

Closure of transverse loop colostomy and loop ileostomy

The aim of a defunctioning stoma is to protect patients from the consequences of faecal leakage and pelvic sepsis, should it occur. A retrospective audit of 77 patients who had undergone closure of a loop stoma between 1988 and 1996 was performed. Sixty patients had either transverse loop colostomy (52) or loop ileostomy (8) to defunction distal colorectal/anal anastomoses or pathology, and 17 patients had a loop ileostomy to defunction an ileoanal pouch. Those who had restorative proctocolectomy experienced a much higher (24%) complication rate than the loop colostomy group (5%), despite similar perioperative care and surgery performed by surgeons of equivalent seniority. The complication rate of ileostomy closure in pouch patients is similar to other published series. As a result of these findings, a selective approach to the use of loop ileostomy to protect pouches has been introduced. The absence of wound infections in our series would suggest that primary closure of the stomal wound without drainage can be achieved.

Perforated diverticulitis following extra-abdominal surgery

The peritonitis of perforated diverticular disease is a life-threatening condition. We report three cases where it occurred following unrelated extra-abdominal surgery and where surgical intervention proved to be the correct course of management. All cases were treated with a Hartmann's procedure; this is probably the safest option for purulent peritonitis in patients who are a high operative risk and have recently undergone major surgery.

Clostridium difficile toxic megacolon following splenectomy

A case of toxic megacolon following splenectomy for lymphoma is presented. The aetiology of Clostridial difficile infection is reviewed and the hazards of perioperative prohylactic antibiotics are discussed.

Proximal gastric vagotomy and anterior seromyotomy with posterior truncal vagotomy assessed by the endoscopic congo red test

The completeness of vagotomy following proximal gastric vagotomy or anterior seromyotomy with posterior truncal vagotomy was assessed prospectively in 48 patients using the intraoperative congo red test. Pentagastrin (6 micrograms/kg) was given subcutaneously before the assessment. An endoscope was passed into the stomach and 180 ml congo red solution washed over the gastric mucosa. Continuing acid production was indicated by the appearance of a black colour (pH < 3) 2 min after introduction of the dye. A grading system was adopted where grades I and II showed little black discoloration and grades III and IV showed increasing areas of discoloration indicating that further denervation was required. All 20 patients undergoing anterior seromyotomy with posterior vagotomy were classified as grade I. Fifteen of an initial 23 patients receiving proximal gastric vagotomy were grade III or IV. Following division of either the right gastroepiploic nerve or the posterior vagal trunk, 22 patients improved to grade I (16) or II (six). In the subsequent five proximal vagotomies, modification of the dissection produced grade I results. Anterior seromyotomy with posterior truncal vagotomy gave consistently complete vagotomy. The congo red test highlighted major differences in the adequacy of vagotomy achieved using various dissection techniques during proximal gastric vagotomy. The test is a useful, reproducible and simple intraoperative method for assessing the completeness of denervation.

Lugol's iodine dye-enhanced endoscopy in patients with cancer of the oesophagus and head and neck

Lugol's iodine dye indicates the presence of unsuspected early oesophageal cancers during endoscopy at which such cancers fail to show the characteristic black colour change. We evaluated Lugol's iodine dye-enhanced endoscopy in 17 patients with oesophageal cancer. In a further 37 patients with head and neck cancer we examined the use of Lugol's iodine since these patients have a 29% risk of synchronous oesophageal cancer. The oesophagus was sprayed with Lugol's iodine (1.5%) during endoscopy. Any areas not turning black were biopsied. In 13 patients with oesophageal cancer discrete areas beyond the macroscopically obvious primary tumour showed no change in colour. Biopsy revealed cancer in all cases. Six synchronous cancers were found in the head and neck group, one of which was identified only by the use of Lugol's iodine. Lugol's iodine augmented the information gained about the oesophageal mucosa during endoscopy. It revealed unsuspected cancer which altered the management of patients with primary oesophageal cancer as well as those with head and neck cancer. We recommend the routine use of Lugol's iodine-enhanced endoscopy for surveillance of all 'at risk' oesophageal cases.

Phytobezoar: an uncommon cause of small bowel obstruction

Phytobezoars are an unusual cause of small bowel obstruction. We report 13 patients presenting with 16 episodes of small bowel obstruction from phytobezoars. Eleven patients had previously undergone surgery for peptic ulceration (eight truncal vagotomy and pyloroplasty). A history of ingestion of persimmon fruit was common and the majority of cases presented in the autumn when this fruit is in season. One phytobezoar causing obstruction at the third part of the duodenum was removed by endoscopic fragmentation, while an episode of jejunal obstruction was precipitated by endoscopic fragmentation of a gastric bezoar. Twelve patients underwent surgery for obstruction on 15 occasions, with milking of the phytobezoar to the caecum performed in ten, enterotomy and removal in four and resection in one patient. Associated gastric phytobezoars were found in two cases and multiple small bowel bezoars in two other cases. These were removed to prevent recurrent obstruction. Phytobezoar should be considered preoperatively as a cause of obstruction in patients with previous ulcer surgery. Wherever possible milking of a phytobezoar to the caecum should be performed. Careful assessment for other phytobezoars should be made. Prevention of phytobezoars is dependent upon dietary counselling of patients by surgeons after gastric resection or vagotomy and drainage for peptic ulcer.

Multiple primary cancers in Hong Kong Chinese patients with squamous cell cancer of the head or neck

BACKGROUND

The risk of multiple primary tumors in the head and neck area is higher than that in other areas of the body.

METHODS

A total of 573 patients with squamous cell carcinoma of the head or neck were studied prospectively during a 4.5-year period to determine the incidence of associated synchronous and metachronous second primary carcinoma.

RESULTS

Multiple primary carcinoma was found in 2.4% of these patients (69% with synchronous primary tumors). Sixty-three percent of all second primary tumors occurred in the esophagus.

CONCLUSIONS

This report emphasizes the importance of esophagoscopy in the initial assessment of patients with squamous cell carcinoma of the head or neck.

Is antibiotic penetration compromised in the ischaemic tissues of patients undergoing amputation?

Antibiotic prophylaxis is indicated for patients undergoing amputation for severe ischaemia or gangrene. However, the adequacy of tissue levels of antibiotics in ischaemic tissue is not known. In this study the serum and tissue antibiotic levels were measured after intravenous administration of metronidazole (15 mg/kg body weight) and cephradine (20 mg/kg body weight). In 11 patients, venous samples were taken at time 0 (induction of anaesthesia) 10, 30 and 60 min. Samples of 2 g each of fat and muscle were collected from the amputation site and three distal sites. Metronidazole and cephradine levels were measured and the degree of limb ischaemia estimated preoperatively by an isotope limb blood flow method. Our results indicate that both metronidazole and cephradine penetrate ischaemic tissues to levels equivalent of a Mean Inhibitory Concentration (MIC) 50 for most organisms encountered in vascular surgery, and that the degree of ischaemia does not alter this.

Alcohol injection: a treatment for ruptured hepatocellular carcinoma

Nine patients with bleeding from a ruptured hepatocellular carcinoma had absolute alcohol injection. Laparotomy and alcohol injection stopped the bleeding in seven patients. Injection under laparoscopic visualization was attempted in two patients and in one patient haemostatis was achieved initially. He rebled, however, 4 h later and laparotomy failed to control the bleeding. He died 2 days later because of coagulopathy and renal failure. In the second patient, bleeding was not controlled laparoscopically and immediate laparotomy and alcohol injection stopped the bleeding. The eight patients who survived left hospital between 8 and 21 days after surgery (median 10 days). In our experience, laparotomy and alcohol injection achieved good results in bleeding hepatocellular carcinoma.

A comparison of right versus left hepatic duct endoprosthesis insertion in malignant hilar biliary obstruction

Endoscopic endoprosthesis insertion plays an increasingly important role in the palliation of jaundice in patients with unresectable malignant hilar biliary obstruction (HBO). Drainage of both obstructed lobes in Types II and III HBO is not necessary to achieve adequate palliation, providing 25% of the liver volume is drained by a single endoprosthesis. The anatomy of the main hepatic ducts suggests some benefit may accrue from preferential drainage of the left hepatic duct. We have reviewed a consecutive series of 151 patients with Type II and III HBO over a 4-year period to compare the outcome of endoprosthesis placement in either the right (RHD) or left (LHD) hepatic duct, to test this hypothesis. No significant difference was found in terms of successful drainage, complications, 30-day mortality, number of endoprosthesis changes and survival between patients with right system drainage compared with those with left sided drainage (chi 2-test and Mann Whitney U test). When dealing with a patient with a Type II or III HBO, we would recommend single endoscopic endoprosthesis insertion into the technically most accessible obstructed system. This would achieve adequate palliation in 84% of the patients.

The relationship between plasma pharmacokinetics and tissue metabolites of 5-fluorouracil (5-FU) in patients with colorectal cancer

To assess the relationship between the plasma pharmacokinetics of 5-Fluorouracil (5-FU) and the levels of intracellular 5-FU metabolites, we have studied eight patients presenting with primary carcinomas of the colon and rectum. Serum 5-FU levels and fluorinated metabolites within normal and malignant tissue were estimated using chromatographic methods. An analysis of the total fluorinated products against plasma halflife, plasma clearance and maximum plasma concentration failed to demonstrate any significant correlation. Furthermore the differing levels of 5-FU metabolites in normal and malignant tissue could not be correlated with the pharmacokinetic parameters studied. It is concluded that the cellular levels of active 5-FU metabolites reflect local cellular activity rather than the handling of the drug in vivo.

Post-mastectomy breast reconstruction using the inflatable tissue expander

Breast reconstruction following mastectomy has previously relied on the insertion of a silicone gel implant or the use of a myocutaneous flap. We report the use of an innovation, the inflatable tissue expander, for both immediate and delayed breast reconstruction in 26 patients where soft tissue cover was inadequate to permit the use of the silicone implant. By serial inflation of the tissue expander with saline, sufficient tissue cover was achieved for a second operative placement of a silicone prosthesis of appropriate volume to match the normal breast. To date, 10 patients undergoing delayed reconstruction and 5 of 16 patients with immediate reconstruction have had their final prosthesis inserted, while 3 women are satisfied with the result of the expandable implant and desire no further surgery. Only two technical complications have arisen with loss of the expander in one patient who had had recent radiotherapy and in another the tissue expander was placed much too high on the chest wall. Mechanical failure occurred in three cases where disruption of the seam led to sudden deflation in two and a slow leak from the injection port developed in one. One patient also attempted self-inflation leading to deflation of the tissue expander. The cosmetic results were subjectively and objectively very good with capsular distortion present in only one case. We feel that the inflatable tissue expander is simple and safe to use, may be used for immediate reconstruction without compromising the ablative surgery and should be a choice available to general surgeons for providing safe and cosmetically acceptable reconstructive surgery.

Incorporation of intermediary products of 5-FU anabolism into colorectal cancer

In 18 patients intermediary anabolic metabolites of 5-FU were measured in normal colonic mucosa and colorectal cancer tissue of intravenous bolus injection or continuous infusion. Higher total concentrations of 5-FU products were found in the cancers when compared with normal colonic tissue. There appeared to be no evidence, however, that some patients had a selectively increased ability to incorporate 5-FU into their tumours. Overall higher concentrations of tumour incorporation of 5-FU were found after bolus injection rather than the infusion method, although this difference is statistically not significant.

The role of a questionnaire and four biochemical markers to detect cancer risk in a symptomatic population

The roles of a self-completed symptom questionnaire and four biochemical markers of disease were assessed to determine risk for gastric and colorectal cancer from within a hospital population and a random population. Eight-six patients with cancer, 168 subjects with benign conditions of the stomach and large bowel and 720 individuals from the community at large were investigated. Multivariate analyses of the questionnaire and biochemical data were performed individually and in combination using a data set comprising 54 cancer subjects, 80 patients with benign disease and 200 random individuals. The most favourable predictive equation derived was then applied to the remaining data set to determine its efficacy. In the primary analyses the questionnaire data identified 32 (60%) cancers successfully and using the biochemical markers alone 36 (67%) patients were also correctly classified as cancer bearing. However, the combination of the questionnaire and marker data improved the sensitivity for cancer to 50 cancers detected (92%) (P less than 0.02). Using the predictive equation from this combination of data to identify risk in the second data set 28/32 (88%) cancers were correctly identified with only an 11% false positive rate. An 18 month follow-up for the non-cancer group has to date revealed only one cancer (ca. pancreas). In this limited study, multivariate analysis of questionnaire and biochemical marker data does successfully identify individuals at "high risk' of harbouring gastric or colorectal cancer within a symptomatic population and may have a role in determining priority for investigation for a symptomatic individual.

Hypothesis testing in the polychotomous logistic model with an application to detecting gastrointestinal cancer

We discuss the use of the trichotomous logistic model to discriminate between patients with gastrointestinal (GI) cancer, patients with benign GI disease and 'normal' subjects, using symptoms and the concentrations of some serum proteins that are potentially indicative of malignancy as covariates. A parsimonious model can be obtained by invoking an indistinguishability hypothesis which is appropriate when a covariate is considered to have no predictive value between categories. It is shown that the polychotomous model can be re-parameterised under the null hypothesis to give a 'reduced form', which can be fitted by maximum likelihood. The validity of the use of the same methods for retrospective sampling is discussed. The approach is illustrated by the development of a logistic model to identify symptomatic and asymptomatic subjects with a high risk of GI cancer.

Validation of a self administered questionnaire to elicit gastrointestinal symptoms

Self administered questionnaires are becoming popular investigative tools in medical research, yet few reports state the extent of methods used to validate these questionnaires before their general use. A pilot study was therefore carried out to validate a 41 item questionnaire for use in a population screening study for gastrointestinal disease. Participants in the study comprised 69 population controls, 40 patients with benign disease, and 35 patients with gastrointestinal cancer. Acceptability, ease of completion, reliability, and reproducibility of the questionnaire were all assessed. Only one subject refused to complete the questionnaire. Ninety six per cent of the questions were completed by each subject and only one response in 1440 was altered in the reproducibility study. The questionnaire disclosed symptoms similar to those elicited by a clinician and highlighted unreported gastrointestinal symptoms in the control group. Three questions were found to be unreliable and were altered before the questionnaire was put into general use. It is concluded that a pilot study to validate a new questionnaire is simple to perform and necessary to identify unreliable questions.

The impact of computed tomography on the management of testicular teratoma

A comparison has been undertaken between conventional radiographic imaging and computed tomography (CT) in 35 patients with testicular teratoma as part of an audit of our investigative approach to staging and follow-up. The CT examination included alternate cuts from the carina of the trachea to the lung bases as the thoracic assessment as well as the standard examination of the abdomen. Lymphangiography appeared to detect Stage IIa lesions better than did CT; however, CT was able to define the volume of abdominal disease more accurately. During the follow-up of Stage I patients, CT detected progressive disease in the absence of tumour marker elevation. Such progressive disease presented within 4 months in the majority of cases. The selective thoracic CT scanning conferred no advantage over whole-lung tomography, only one additional lesion being detected in 123 examinations. It is recommended that CT should be reserved for examining the area above the renal hila, for cases where lymphangiography is equivocal or positive, and that CT scanning of the abdomen in Stage I patients not receiving therapy should be repeated every 3 months following orchidectomy for the first year, irrespective of clinical status.

Priorities for computed tomography in the management of testicular seminoma

A study to assess the role of computed tomography (CT) in the management of testicular seminoma showed that CT was of value in defining the extent of bulky abdominal disease at initial staging. After radiotherapy for Stage IIc disease, relapse by 1 year was common and predominantly extra-abdominal. Mediastinal relapse was detected by CT in the absence of raised serum tumour markers or changes on the chest radiograph. It was concluded that CT should be used at initial staging only to assess the volume of bulk disease shown by lymphangiography, that no benefit seemed to accrue from CT scanning of Stage I and IIa patients and that the follow-up of Stage IIb and IIc patients requires regular CT surveillance in the first year, irrespective of clinical status.

Cross-leg fasciocutaneous flaps

Twelve patients with cross-leg fasciocutaneous flaps are reported. Of the 12 flaps, 11 healed without loss, with satisfactory cover of the recipient area, and without trouble in the donor area.