Recent advances in gastrointestinal malignancy.
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Antineoplastic Agents↗
Biomedical subjects
A Cuschieri
Publications and source records attributed to A Cuschieri.
Cystic disease of the biliary tract.
Cystic disease of the biliary tract is rare in Western countries with an incidence of 1/2,000,000 live births. Five anatomical types are recognized. The majority (80%) become symptomatic before the age of 30 years. The cysts rarely have an intact epithelial lining and this often exhibits metaplasia. The risk of cancer developing in a choledochal cyst has been variously estimated at 2.5-28%. Malignancy is often associated with an abnormal pancreaticobiliary junction. Surgical treatment is indicated for types I-IV and is by excision rather than drainage. The treatment of Type V is difficult and should be conservative in the first instance. However, patients with severe symptomatic diffuse hepatic disease and progressive deterioration of liver function are best managed by hepatic transplantation.
Adult↗
Epithelioid haemangioendothelioma of the liver: objective response to hepatic intra-arterial 5-FU.
A case of an epithelioid haemangioendothelioma of the liver is presented. The tumour was unresectable at laparotomy because of extensive involvement of both lobes of the liver. The histological appearances of the biopsy taken at operation suggested that the lesion was at the more malignant end of the spectrum for these tumours. The patient was treated by cycles of hepatic intra-arterial 5-fluorouracil with relief of symptoms and prolonged survival. It is important to recognize this type of neoplasm which bears resemblance to other liver pathologies, in particular, to sclerosing cholangiocarcinoma.
Female↗
How informed is signed consent?
The assurance that patients fully understand the information given to them before they sign the consent form for operation has never been validated in this country. One hundred patients were interviewed by an independent medical observer in one surgical unit in a teaching hospital between two and five days after their operation. Although all the patients interviewed were fully aware that they had had an operation, 27 did not know which organ was operated on and 44 were unaware of the exact nature of the surgical procedure. A significantly higher age group was observed in the group of patients who were unaware of the basic facts relating to their operation, and the problem was encountered most commonly in patients over the age of 60. Because of the medical and legal importance the findings of this pilot study warrant further large scale investigations.
Age Factors↗
Experience with pancreatic banding: results of a simple technique for dealing with the pancreatic remnant after distal partial pancreatectomy.
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Humans↗
[Peritoneovenous shunt in the treatment of therapy-refractory ascites].
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Ascites↗
Computerized ambulatory esophageal pH monitoring in 50 asymptomatic volunteer subjects. Results and clinical implications.
Fifty asymptomatic volunteer subjects underwent prolonged computerized ambulatory distal esophageal pH monitoring to characterize acid reflux patterns. A bimodal distribution of data, which corresponded to the erect and supine positions, occurred in 45 subjects, and separate mean baseline pH values were noted for the erect and supine positions (pH 6.46 and pH 5.46, respectively, p less than 0.001). At esophageal pH 4, reflux episodes occurred more commonly in the erect position (44 percent) than in the supine position (20 percent). There were also significantly greater numbers of reflux events and longer durations when the pH was below 3 (p less than 0.02) and 4 (p less than 0.001) in the erect compared with the supine position, but prolonged events (more than 10 minutes) occurred in both positions. Postprandial reflux occurred in 78.7 percent of the subjects, with an average of 5.1 episodes. A slight but significant correlation between age and erect reflux was seen (p less than 0.04). In the pH 3 to 5 range, 18 percent of the subjects had acid exposure in excess of the group mean plus 2 standard deviations and 10 percent in excess of the mean plus 3 standard deviations. Overall, a nonnormal distribution of pH data was found with 28 subjects having less than 1.6 percent of their values below pH 4. This finding may represent either the true spectrum of normal acid reflux or a subclinical pathologic state that will become symptomatic over time.
Adult↗
Parietal cell carcinoma of the stomach: association with long-term survival after curative resection.
Following the recent identification of gastric parietal cell carcinoma (Capella et al., 1984), a histological and clinical review of 125 consecutive cases of gastric cancers treated surgically during a 9-year period was undertaken. The pathology was reviewed blind and in addition to H & E sections, staining with Luxol Fast Blue, phosphotungstic acid haematoxylin and E-M studies were performed to identify parietal cell differentiation. The surgical procedures performed were curative R2 gastrectomy (n = 56), palliative resection (n = 30), gastro-enterostomy (n = 25) and intubation (n = 14). The 30-day operative mortality was 12/125 (10%) overall and 4/56 (7%) in the curative resection group. Two parietal cell cancers were identified and a further 4 tumours showed areas of parietal cell differentiation. All occurred in male patients (mean age 55 years, range 43-62). Sixteen patients out of the 56 patients (29%) who underwent curative R2 resection have survived long-term (mean 5.5 years, range 2.5-11): 4/5 mucosal/submucosal cancers (T1N0), 5/29 intestinal cancers (T2N0-2) 2/16 diffuse cancers (T2N1) and 5/6 with parietal cell cancer/differentiation (T2-3N0-2). There were no survivors beyond 14 months in the patients who were treated by palliative resection, bypass or intubation irrespective of histology. This study suggests that gastric parietal cell carcinoma carries a good prognosis after curative resection despite the advanced stage at presentation.
Adult↗
24-hour ambulatory dual gastroduodenal pH monitoring. The role of acid in duodenal ulcer disease.
A new system for long-term, 24-hour, ambulatory dual gastroduodenal pH monitoring is described. Eighteen patients with active duodenal ulcers and ten healthy subjects were studied. Simultaneous gastric and duodenal bulb pH were measured during fasting, the ingestion of a solid meal, and for the remainder of the 24-hour period. The gastric pH profile was similar for both groups. There was no significant difference between the fasting duodenal bulb pH of the duodenal ulcer (DU) patients and controls. The daytime and nocturnal duodenal acid exposure was similar for both groups. The meal caused a similar pattern of duodenal acidification in both controls and DU patients, and acid neutralization appeared to be effective in DU patients. The role of acid in the duodenal bulb does not appear to be of primary pathophysiologic importance in duodenal ulcer disease.
Adult↗
Pharmacological manipulation of adynamic ileus: controlled randomized double-blind study of ceruletide on intestinal motor activity after elective abdominal surgery.
In a double-blind placebo-controlled trial of patients undergoing elective abdominal surgery (n = 91), a single intravenous infusion of ceruletide (2.5 ng kg-1 min-1 for 1 hour) resulted in audible bowel sounds in 42/47 patients as opposed to 30/44 receiving placebo (P less than 0.025). Excessive bowel sounds were noted in 16 patients in the ceruletide group and four receiving placebo (P less than 0.01). Significantly more patients (P less than 0.01) in the ceruletide group (22/45 versus 9/44) passed flatus per rectum between the second and third post-operative day. Ceruletide infusion was accompanied by a significant increase in the incidence of nausea and vomiting (P less than 0.005, P less than 0.0025) but these side effects were short-lived. These results indicate that ceruletide is likely to be a useful therapeutic agent for acute intestinal adynamic motility disorders.
Abdomen↗
Reflux oesophagitis and oesophageal transit: evidence for a primary oesophageal motor disorder.
Patients with reflux oesophagitis have a diminished capacity for distal oesophageal clearance. This is considered to be secondary to acid reflux damage to the oesophageal wall. We have postulated that the observed oesophageal dysmotility is a primary phenomenon. Using 24 hour oesophageal pH monitoring and the solid bolus oesophageal egg transit test, we evaluated the oesophageal transit of 55 patients, with symptomatic reflux oesophagitis, and 16 healthy volunteers. The transit for the entire oesophagus was significantly prolonged in the patient group. This delay was evident in all three segments of the oesophagus. Amongst the patients, there was significant correlation between the oesophageal transit time and the number of prolonged reflux events. No correlation was found, however, between symptom score or severity of endoscopic oesophagitis and transit time. These results would indicate that the oesophageal dysmotility is an integral part of gastrooesophageal reflux disease, and is more of a cause than an effect.
Adolescent↗
Combined cimetidine-alginate antacid therapy versus single agent treatment for reflux oesophagitis: results of prospective double-blind randomised clinical trial.
This randomised double-blind study compared the effects of cimetidine 400 mg four times daily (q.d.s.), Gastrocote (alginic acid, aluminium hydroxide gel, magnesium trisilicate, sodium bicarbonate) two tablets q.d.s. and a combination of both on ambulatory 24-hour oesophageal pH, endoscopic findings and symptoms in patients with reflux oesophagitis. Patients were treated for ten weeks with assessments at entry, after four weeks and at the end of the study. Before treatment, oesophageal pH was less than 5.0 for 25% overall of the 24 hours monitoring in all three treatment groups. After ten weeks, the percentage of time with an oesophageal pH less than 5.0 was 26% on Gastrocote, 26% on cimetidine and 14% on the combination (P less than 0.05, combined therapy versus cimetidine alone). The severity of the heartburn was reduced on all three treatments. The average number of days with heartburn per week was 5.0, 3.6 and 3.4 in the Gastrocote, cimetidine and combined groups respectively. The difference between Gastrocote and the combination was statistically significant (P less than 0.05). There was a clear trend towards improvement of endoscopic oesophagitis at ten weeks in the combined therapy group when compared to single agent treatment with cimetidine or Gastrocote although the difference was not significant due to inadequate numbers. This study indicates that combined cimetidine and Gastrocote is a more effective treatment for reflux oesophagitis than single agent therapy with either drug.
Alginates↗
Laparoscopy for pancreatic cancer: does it benefit the patient?
The findings in 73 patients undergoing laparoscopy for pancreatic cancer have been reviewed. The procedure was performed immediately prior to a proposed laparotomy which was undertaken in 51 patients. In this subgroup, 42 patients were correctly staged as having incurable/inoperable disease by laparoscopy but only four out of nine patients judged to be resectable were found to be operable at laparotomy. Laparoscopic target biopsy/fine needle cytology of the primary or its secondary deposits confirmed the diagnosis of pancreatic cancer in 61 out of 65 patients (92%). Whereas the majority of hepatic deposits visualized by laparoscopy had been detected by the prelaparoscopic imaging tests, peritoneal and omental deposits were only identified by laparoscopy. Laparoscopy is a useful procedure in the staging of patients with pancreatic cancer and establishes the diagnosis of advanced disease thereby, obviating a laparotomy in all those patients in whom surgical palliation is not indicated. The procedure should be performed in those patients in whom a laparotomy is contemplated.
Adult↗
Diagnosis of significant abdominal trauma after road traffic accidents: preliminary results of a multicentre clinical trial comparing minilaparoscopy with peritoneal lavage.
A prospective multicentre study comparing the value of the recently introduced minilaparoscopy with peritoneal lavage in patients with abdominal trauma is in progress. To date 55 patients with blunt abdominal trauma have been entered into the study. Following initial resuscitation, 26 were randomised to peritoneal lavage and 29 to minilaparoscopy performed under intravenous sedation and local anaesthesia. The two groups were comparable with respect to age, sex, incidence of multiple injuries and mortality (2 patients in the lavage group and 1 in the minilaparoscopy group). A negative test was obtained in 15 patients subjected to lavage and 12 patients who underwent minilaparoscopy. A further four patients in the minilaparoscopy group were found to have a minimal static haemoperitoneum. All these patients were treated conservatively and none required surgical intervention on the abdomen. Thus neither investigation carried a false negative rate. A positive test was obtained in 11 patients in the lavage group and significant findings were observed in 13 patients assessed by minilaparoscopy. All these patients were subjected to emergency laparotomy. Absence of significant bleeding or trauma was observed at laparotomy in 3/11 (27%) and 1/13 (8%) in the lavage and minilaparoscopy groups respectively. Although both procedures were highly sensitive for the detection of significant intra-abdominal injury (100%), the specificity was 83% for peritoneal lavage and 94% for minilaparoscopy. The predictive value of a positive minilaparoscopic examination was 92% as opposed to a positive predictive value of 72% for peritoneal lavage.
Abdominal Injuries↗
Validation of the ASEPSIS method of wound scoring in patients undergoing general surgical operations.
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Humans↗
The effect of alcohol on nocturnal gastroesophageal reflux.
The effect of 120 mL (4 oz) of scotch whiskey (40% alcohol) on nocturnal gastroesophageal reflux was studied by ambulatory esophageal pH monitoring. Seventeen healthy volunteers were studied on two occasions, using a computerized radiotelemetric esophageal pH monitoring system. The subjects were given the alcohol during the second session, three hours after the evening meal, and went to bed at their usual time. Seven of the 17 subjects had prolonged supine reflux episodes on the night of alcohol ingestion. These lasted an average of 47.1 minutes (23.2 to 91.8 minutes) and occurred on an average of 3 1/2 hours after ingestion of whiskey and 1.4 hours after lying down. None of the subjects had these episodes on the control night. There was also a significant acidic shift in the cumulative percentage of data points below a pH of 3 and a pH of 4 in the supine position on the night of alcohol ingestion compared with the control night. This study has shown that there was a significant exposure of the distal esophagus to acid and that the normal acid clearance of the esophagus in the supine position was impaired after only moderate amounts of alcohol.
Adult↗
New physiological method of evaluating oesophageal transit.
A method of measurement of oesophageal transit time in the upright posture of a chewed solid bolus has been developed and assessed in normal volunteers (n = 16) and in 32 patients with oesophageal disease: organic stricture (n = 5), oesophageal motility disorders (n = 19) and reflux oesophagitis without stricture formation (n = 8). The test involves swallowing a 10 ml poached egg white bolus labelled with 99mTc sodium pertechnetate and external scanning by a gamma camera. An on-line computer program allows detailed analysis by the condensed image technique (which demonstrates the pattern of oesophageal transit) and activity-time curves for the whole, the upper, middle and lower thirds of the oesophagus. The reproducibility of the test is good (coefficient of variation of the total transit of 14 per cent). The results on the normal volunteers have shown that oesophageal transit slows in an aboral direction with transit being faster in the upper, when compared with the middle and lower thirds. The test clearly differentiates patients with oesophageal disease from the normal. The condensed image analysis appears to be useful in outlining the pattern of transit in patients with motility disorders. Patients with reflux oesophagitis have delayed oesophageal transit.
Adult↗