Analysis of deaths occurring within the Nottingham trial of faecal occult blood screening for colorectal cancer.

OBJECTIVE: To report the causes of, and ages at, death of subjects in an English colorectal cancer screening trial. DESIGN AND SETTING: Analysis of 78 708 deaths occurring between 1981 and 2008, within the Nottingham randomised controlled trial of biennial faecal occult blood testing. MAIN OUTCOME MEASURES: Cause of death, age at death by sex and by cause. RESULTS: Significantly more subjects died from verified colorectal cancer in the trial's control group than in the intervention group (3.2% vs 2.9%). For no other major cause of death was the difference in proportion across the two groups statistically significant. Age at death was lower for cancer than for other principal causes, except for ischaemic heart disease among women. However, mean age at death was higher for colorectal cancer than for other cancers, except for prostate cancer among men. Increasing levels of material deprivation significantly lowered the expected ages at death, independently of cause. For both men and women, the mean age at death from all causes for screening participants was higher than that of controls and non-participants. Mean deprivation was lowest among participants. Of those participating in screening, and dying from colorectal cancer, subjects receiving negative test results lived significantly longer than those who received positive test results. However, if dying from other causes, they died at an earlier age. CONCLUSIONS: The age at death from colorectal cancer is higher than that of most other cancers. Those accepting a screening invitation live longer than non-participants. In part, this difference is explained by relative deprivation. Among screening participants, the receipt of a positive, as opposed to a negative, test result is associated with a later age at death.

Cefotaxime plus metronidazole appears more effective than piperacillin in the prevention of postappendicectomy wound sepsis. Preliminary results of a comparative trial.

Metronidazole suppositories have previously been shown to be superior to povidone iodine intraoperative wound spray in reducing postappendicectomy wound sepsis. In subsequent studies metronidazole suppositories and cefotaxime injections reduced the sepsis rate to 9.3%, while the same combination produced a wound sepsis rate of 7.6% compared with 17.2% for cefotaxime alone. In an ongoing study, metronidazole and cefotaxime are now being compared with piperacillin in a single-blind trial. Adult patients undergoing emergency appendicectomy in Nottingham have been included in this study, which has ethical committee approval. When the decision to perform emergency appendicectomy was made, the patient was randomly allocated a numbered pack. This contained either 3 x 1g injections of cefotaxime and 6 x 1g metronidazole suppositories or 3 x 2g injections of piperacillin and 6 placebos. 40 minutes before operation the patient received the first suppository and the remainder every 8 hours. The patient received the first injection of antibiotic by intravenous or intramuscular injection and the remaining doses 8 and 16 hours later. A wound was regarded as infected if pus discharged either spontaneously or on incision. 175 patients have been studied to date. The treatment groups were well matched for age and sex. Seven of the 77 patients in the cefotaxime/metronidazole group (9.1%) compared with 12 of the 76 in the piperacillin group (15.8%) have developed wound infections. This study confirms that the combination of cefotaxime and metronidazole seems to be more effective than piperacillin alone in the reduction of postappendicectomy wound sepsis. Currently cefotaxime plus metronidazole is the therapy of choice.

Primary B-cell immunoblastic lymphoma of pancreas.

Extranodal lymphoma may present as an abdominal mass without evidence of disease elsewhere. Predominant pancreatic involvement with lymphoma is rare. Presenting as a pancreatic mass, it may be difficult to differentiate if from carcinoma. Ultrasound-guided fine needle biopsy and immunocytochemistry are helpful in establishing a histological diagnosis. It is important to differentiate lymphoma from carcinoma, because lymphoma is treated differently and has a better prognosis.

Periampullary diverticula: consequences of failed ERCP.

Periampullary diverticula (PAD) are associated with biliary disease and contribute to failure of endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. The presence of PAD and causes of failure to cannulate the ampulla were noted in 1211 consecutive patients undergoing ERCP. Case notes of 100 consecutive patients with PAD were reviewed retrospectively. Overall prevalence of PAD was 9%. Prevalence was higher in patients > or = 75 years when compared with those < 75 years (19.2% vs 4.8%, P < 0.0001). Ampullary cannulation was successful in 62.4% of patients with PAD and 92.7% without PAD (P < 0.0001). Success rates were lower in patients with intradiverticular papillae than in those with juxtapapillary diverticula (38.1% vs 77.6%; P < 0.0001). Of 19 patients with PAD who did not have any imaging other than ultrasound, 16 were asymptomatic over a median follow-up of 20 months. Biliary surgery was performed on 35 patients, with no major complication. PAD are a major cause of failed ERCP. Failure rates are higher in patients with intradiverticular papillae than juxtapapillary diverticula. Though a large proportion of patients not imaged remain asymptomatic on follow-up, it is difficult to predict which patients may form this group. Surgery, when indicated, is safe and effective in elderly patients in whom ERCP has failed.

Laparoscopy in liver disease.

Laparoscopy was technically successful in 73 of 75 patients in whom liver disease was suspected but not accurately diagnosed after medical investigation. In 46 patients (63%) the final histological diagnosis was either diffuse parenchymatous disease (cirrhosis/hepatitis) or metastatic malignant disease; 2 had a curable medical disease (tuberculous ascites); and 6 had a curable surgical disease (5 with gallstones and 1 with an ectopic adrenal tumour). There were no deaths and no serious complications. With increasingly accurate non-invasive techniques for localising lesions in the liver, laparoscopy, with directed biopsy, should help to provide correspondingly accurate histological confirmation.

Fistulas are not always due to Crohn's disease: an unusual groin abscess.

A 38-yr-old white female with Crohn's disease was admitted for right hemicolectomy to treat an enterocutaneous fistula of 4 yr duration. At laparotomy, it was found that the fistula was related to an appendiceal diverticulum, rather than Crohn's disease, and simple appendicectomy was curative. The literature is reviewed.

Ureterosigmoidostomy complicated by polyp formation. Report of two cases.

Neoplasia associated with ureterosigmoidostomy is uncommon but important. Two patients, one of whom developed symptoms five years after the ureterosigmoidostomy had been taken down, are reported. The authors support the theory that these tumors may arise from the ureter. When ureterosigmoidostomies are dismantled, the site of implantation should be resected and the patients kept under long-term endoscopic review.

Localized giant pseudopolyposis of the colon in ulcerative colitis. Report of a case.

Localized giant pseudopolyposis of the colon is a rare complication of both ulcerative colitis and Crohn's disease. It is not regarded as being premalignant, but it may masquerade clinically as a malignancy. This report presents a case and reviews others reported in the literature.

Gallstone ileus: diagnostic pitfalls and therapeutic successes.

Gallstone ileus is a surgical emergency that occurs almost exclusively in the elderly. It is of increasing significance with current demographic changes. Clinical records and diagnostic imaging of 15 consecutive patients treated for gallstone ileus at one hospital over a 6-year period were reviewed. The median patient age was 80 years. Six plain-film diagnoses were made correctly. Contrast studies provided a diagnosis of intestinal obstruction in four patients. Abdominal X-ray findings were assessed incorrectly in two patients, with one false-positive and one false-negative result. The median preoperative hospital stay was 2 days. Three patients had Bouveret's syndrome, two of whom required a gastrostomy and enterolithotomy, and one of whom required a gastroenterostomy. The remaining 12 patients underwent enterolithotomies. Only one patient underwent a cholecystectomy. There was one postoperative death. No patient had biliary symptoms on follow-up. Gallstone ileus is a difficult clinical and radiologic diagnosis. Enterolithotomy alone is adequate treatment in the elderly, and subsequent cholecystectomy is not mandatory.

Screening for symptomless colorectal cancer by testing for occult blood in general practice.

1638 persons over the age of 45 were invited to test their faeces for occult blood, using the 'Haemoccult' method. The acceptance-rate was low (25%) in those over the age of seventy-five and was highest (56%) in those aged fifty-five to sixty. 3.8% of those using the test had at least one positive haemoccult test. Rigid sigmoidoscopy identified 2 persons with carcinoma of the rectum and 1 with adenoma of the rectum. Subsequent colonoscopy and barium enema identified two cases of adenoma of the sigmoid colon and one case of adenoma of the caecum.

Peritoneal nesothelioma.

Two patients with primary peritoneal mesothelioma are reported. They had abdominal symptoms, no symptoms referable to the respiratory system and normal chest X-rays. There was no clinical evidence of impaired respiratory function. One of the patients had a history of brief asbestos exposure over 20 years before diagnosis. The procedure for obtaining compensation is outlined and the protean uses of, and hence possible exposure to, asbestos are noted. In screening programmes consideration should be given to both pulmonary and abdominal symptoms. Laparoscopy may have a part to play in earlier diagnosis of peritoneal mesothelioma.

Effects of inhalation anaesthetic agents on the electrical and mechanical activity of the rat duodenum.

Sleep doses of halothane (4%), enflurane (2%) and diethyl ether (10%) were administered to fasting rats. Duodenal mechanical and electrical activities were recorded using miniature extraluminal strain gauges and silver/silver chloride bipolar electrodes. Halothane abolished, or significantly reduced, phase III activity of the migrating myo-electric complex whereas enflurane abolished phase II activity but failed to reduce phase III. Ether was associated with periods of intense activity throughout anaesthesia and this activity persisted after recovery of consciousness. All anaesthetic agents caused a marked slowing of the basic electrical rhythm.

A method for long-term recording of intestinal mechanical and electrical activity in the unrestrained rat.

A small animal model has been developed to study simultaneous mechanical and electrical activity of the gastrointestinal tract in the conscious unrestrained animal. Mechanical activity is detected using miniaturized half-bridge metal foil strain-gauge force transducers. The conventional lead-wire arrangement has been modified, thereby extending the useful life of the gauge. The electrical activity is monitored by silver/silver chloride bipolar electrodes. The lead wires from the recording units are encased in a metal compression spring and are permanently joined to a ball connector positioned on top of a modified cage. This allows the animal free access to all parts of the cage. The results are monitored using a polygraph chart recorder and stored on magnetic tape for subsequent modified replay or computer analysis. This model provides an inexpensive and reliable method for monitoring gastrointestinal motility in the unrestrained small laboratory animal, enabling more comprehensive studies than have hitherto been possible only with larger species.

Outpatient flexible fibreoptic sigmoidoscopy, diagnostic yield and the value of glucagon.

One hundred patients had flexible fibreoptic sigmoidoscopy in an outpatient clinic after preparation with a phosphate enema but without sedation. Patients were randomized to receive 1 mg of glucagon intravenously or a matching placebo. The discomfort of the patients and the ease of the procedure were similar in both groups. Nine patients were excluded from the final analysis as they had low rectal or anal lesions. In the remaining 91 patients, abnormalities were found in 27 (29.6 per cent) including 16 adenomatous polyps and 1 carcinoma. Only 3 lesions were below 20 cm and might have been easily visualized using a rigid sigmoidoscope.

Circulating immune complexes in patients with benign and malignant colorectal tumours.

Circulating immune complexes were measured using a modified Clq binding assay in 100 preoperative patients with colorectal cancer and in 52 patients with benign polyps. Sixty-one per cent of the patients with cancer and 49 per cent of the patients with benign polyps had elevated levels, as did 92 per cent of those with malignant polyps. There was no relation to a, the stage of the disease, with 10 out of 13 Dukes' A tumours (77 per cent) having increased levels; b, the degree of differentiation of the cancers; c, the tumour mass. However, cancers on the right side of the colon had significantly higher levels than rectal cancers.

Periampullary diverticula and pancreaticobiliary disease.

BACKGROUND: Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients. METHODS: The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed. RESULTS: The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with beta-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres. CONCLUSION: With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.

A comparison between suction and corrugated drainage after simple mastectomy: a report of a controlled trial.

A randomized prospective trial of closed suction wound drainage compared with corrugated wound drainage after simple mastectomy for early breast cancer (lesion confined to the breast and without skin ulceration) is reported. Fifty-one patients were admitted to the study and there was no difference between the two groups with respect to local complications such as ifection, skin necrosis and collection under flaps and wound healing. Dressings require to be performed significantly less frequently with suction as opposed to corrugated drainage and suction drains were removed significantly sooner than corrugated drains. It is concluded that closed suction wound drainage should be used after simple mastectomy.

Fecal occult blood screening for colorectal cancer in the general population. Results of a controlled trial.

A total of 26,975 asymptomatic individuals were identified from family doctors' age/sex registers and randomly allocated to test or control group. The first test group (10,253) were offered 3-day fecal occult blood (FOB) testing; 3,613 (37%) completed the tests and 77 (2.1%) were found to be positive. In this group, 13 cancers were detected (3.5/1000 persons screened), of which 9 (70%) were Stage A. Of these subjects, 3349 have been rescreened at 2 years; 2799 (85%) completed the tests and 80 (2.8%) were found to be positive. Four cancers have been detected (three Stage A). In the whole test group followed for 2 years (10,462), 34 cancers have presented (17 screening detected, 3 interval cases in test responders, 14 symptomatic cancers in nonresponders), of which 14 (43%) were Stage A. In the control group (10,272 individuals), 17 patients have presented with symptomatic colorectal cancer during the 2-year follow-up, with rates of 0.9/1000 and 0.8/1000 persons/year in the first and second years of follow-up, respectively. No Stage A tumors were present. In the second test group (3,225) offered both guaiac (Hemoccult; Smith Kline Diagnostics) and immunologic (Feca EIA; Nordic) FOB tests, 1304 (44%) completed the tests, of which 126 (9.7%) were positive. Five cancers were detected (four Stage A), of which only three were positive by Hemoccult testing. In this group of test responders, one cancer has presented symptomatically at 1 year follow-up. Thus, at 2-year follow-up of the responding individuals of both cohorts of the initial screen of the test group, 5 of 21 cancers (24%) were negative by Hemoccult testing. Fecal occult blood testing has doubled the detection of colorectal cancer in the test group compared with the number presenting with symptoms in 2 years in the control group, and increased the proportion of early stage cancers (chi 2 = 8.0, P = less than 0.001).