Achalasia or malignancy? Confirmation of the diagnosis by oesophageal manometry.

Malignancy involving the gastro-oesophageal junction can present with features very similar to those of idiopathic achalasia. Failure to identify such cases may delay effective treatment of a curable tumour. We report four patients with malignant dysphagia who were initially referred for treatment of achalasia--the diagnosis based on clinical, radiographic and endoscopic findings in each case. In all four, oesophageal manometry suggested, correctly, that the diagnosis of achalasia was incorrect, allowing early surgical exploration. We suggest that the diagnosis of achalasia should be confirmed by manometric studies--particularly in elderly patients with a short history and weight loss as these features are frequently associated with malignancy.

Prolonged survival without treatment in a patient with primary hepatocellular carcinoma.

The proportion of primary hepatocellular carcinomas which are technically operable with hope of cure is small. Recommended therapy ranges from aggressive therapy to a nihilistic approach. There is little data available on the natural history of untreated tumours and we report such a case. A review of the literature regarding survival with primary hepatocellular carcinoma shows that the prognosis of patients with this tumour may vary considerably. Such variability has important implications for those involved in the design and interpretation of trials of treatment for hepatocellular cancer.

Changes in Wolfe mammographic patterns with aging.

Mammograms of 212 women were examined at a mean interval of 15 (range 11-17) years, to determine whether there was any change in Wolfe mammographic pattern with age. The mean age of the patients at repeat mammography was 52 (range 32-75) years. The DY pattern tended to change to P2 or P1 with age. Those in whom the DY pattern remained tended to be younger (mean age 47 years) than those who changed to P2 (57 years), or P1 (55 years). Women whose pattern changed from DY to N1 had a mean age of 42 years. These findings support the hypothesis that the perilobular connective-tissue elements are the structures responsible for the dense appearance of the DY breast, as these elements would be most active between 15 and 45 years (peak reproductive period) and tend to regress later.

The efficiency of management of emergency surgery in a district general hospital--a prospective study.

In a 6-month prospective study of management of surgical emergencies in a district general hospital, we have tried firstly to determine the degree to which non-life-threatening emergencies could be managed within 'social hours' (0800-1800), and secondly to identify examples of and reasons for potentially hazardous delay in the performance of urgent procedures. Emergency referrals undergoing surgery were categorised into three groups: Group A--patients requiring surgery either immediately or at the earliest possible time (maximum 3 h after diagnosis). Group B--patients requiring urgent but not immediate surgery (within 6 h of diagnosis). Group C--patients whose operations could be delayed until social hours without detriment. The reason for delay--shortage of theatre nursing, anaesthetic or surgical staff--was recorded in each case. Of the 95 patients in Group C (elective management) 63 (65%) underwent surgery within social hours, 15 (16%) between 1800 and 2100 and 17 (18%) at night. Unacceptable delays occurred in 37 (14%) of the 260 cases and were most likely to affect patients in Group A who most needed urgent care. We conclude that our current staffing levels in theatre nursing should be increased to consistently provide two (rather than one) staffed theatres for emergencies, in addition to a theatre team dedicated exclusively to obstetrics. Anaesthetic manpower should be increased to provide four duty anaesthetists with no more than one at SHO level as obstetric and intensive care duties can be complex. General surgical staffing requires expansion in order that on-call staff have no fixed commitments during and in the session immediately after their duty periods.

Gastro-oesophageal reflux and oesophagitis before and after vagotomy for duodenal ulcer.

Fifty patients undergoing elective vagotomy for the treatment of chronic duodenal ulceration have been investigated pre-operatively and again 3 months postoperatively to determine the extent and severity of associated gastro-oesophageal reflux. Pre-operatively all patients had a normal lower oesophageal sphincter pressure but 50 per cent had symptoms of gastro-oesophageal reflux, 42 per cent had excessive reflux on 24 h pH monitoring and 30 per cent had oesophagitis on endoscopy and/or oesophageal biopsy. Postoperatively, reflux symptoms were present in only 12 per cent of patients but pH studies were still abnormal in 36 per cent and oesophagitis was observed in 32 per cent. Lower oesophageal sphincter pressure was unaffected by vagotomy. Gastro-oesophageal reflux is common in pre-operative duodenal ulcer patients and is not significantly reduced by vagotomy. Careful pre-operative oesophageal assessment is necessary to determine which duodenal ulcer patients require an anti-reflux procedure in addition to vagotomy.

Endoscopic retrograde cholangiopancreatography (ERCP) and stent placement in the management of large common bile duct stones.

Management of large common bile duct (CBD) calculi is controversial. Endoscopic treatment is fraught with difficulty, particularly when stones are over one centimetre in diameter and the patient's coagulation is deranged. Between 1988 and 1993, 56 patients have been managed by endoscopic retrograde cholangiopancreatography (ERCP) and stent placement as the initial treatment for large CBD calculi. Complete follow up has been possible in 50 cases (89.3%). The median age was 73.5 years (range 29-92) and primary presenting symptoms were jaundice (n = 39), cholangitis (n = 6) or abdominal pain (n = 5). Median bilirubin was 99 mumol/L (range 7-926) and 60% of the patients had deranged clotting with a median thrombotest of 61%. Stones ranged in size from 0.9 to 4.5 cm (median 1.6 cm). Treatment was with a 7F 'pigtail' stent in 39 cases and a 10F straight stent in 11 patients. Morbidity occurred in 12% of cases with two deaths (4%). Stents remained in place for a median of 1 month (range 0.2-59). Definitive treatment of CBD stones, once the jaundice and sepsis had settled, involved surgery in 24 patients and repeat ERCP with sphincterotomy +/- mechanical lithotripsy in 17 cases. Nine patients remain alive and well with their stents still in place. Initial management of large CBD calculi by ERCP and stent placement carries a low morbidity and mortality and is a useful adjunct in the management of a difficult clinical problem.

Arteritis and venulitis in systemic lupus erythematosus resulting in massive lower intestinal haemorrhage.

A case of systemic lupus erythematosus with massive haemorrhage from the colon is described. Histological examination showed ulceration of the mucosa of the ascending colon with necrotizing vasculitis of the submucosal veins. Adjacent arteries were normal apart from one which had ruptured on the surface of an ulcer. This is the first clearly documented case of colonic venulitis in systemic lupus erythematosus and the differential diagnosis of gastrointestinal haemorrhage in this disease is discussed.

Salvage surgery for advanced local recurrence of breast cancer.

The development of myocutaneous flaps and other reconstructive procedures has made it possible to offer surgical palliation to many patients with advanced local recurrence of breast cancer who previously would have been regarded as untreatable. We present the results of excision of such recurrences in 42 patients treated from 1982 to 1986 after non-surgical measures had failed. Good palliation was achieved in all of the patients with acceptable morbidity. There was one death. Further local recurrences developed in 12 (29 per cent) patients, though none was painful or offensive. Thirteen patients remain alive and free from local disease; 17 patients remained free from local disease until they died.

Drug acetylation in breast cancer.

The acetylator phenotype was determined in 100 patients with breast cancer and 100 control female subjects using isoniazid. The proportion of fast acetylators in the breast cancer patients (43%) was not significantly different from the control group (43%). We conclude that acetylator phenotype is unlikely to be an important determinant of the risk of developing breast cancer.

Surgery for malignant melanoma: from which limb should the graft be taken?

A study of 186 melanomas requiring skin grafts and followed for 1-13 years has shown no preferential implantation in an ipsilateral donor site, despite standard surgical teaching that skin grafts for melanoma defects should not be taken from the same limb as the primary tumour. Two cases were encountered of preferential metastasis to a distant donor site outside the lymphatic drainage of the melanoma and we present a further case where ipsilateral recurrence simulated donor site recurrence. It is clear that the major mechanism of spread to distant donor sites is by the haematogenous route to an area of acute trauma. Hence it is recommended that where possible donor skin is taken from the same limb as the tumour, so that any preferential metastasis will remain within an area amenable to regional limb perfusion.