Delayed laparoscopic mesh infection presenting as an abdominal mass.

A 56-year-old man presented with a delayed mesh infection 8 years following an elective laparoscopic totally extraperitoneal (TEP) bilateral hernia repair. Sterile pus was drained percutaneously as a temporising measure prior to removal of the right-hand mesh; the left-sided mesh was adherent to the femoral vessels and minimally contaminated. Delayed mesh infection is a rare occurrence. This case is the fourth example and the longest following initial operation. Removal of the infected mesh is advocated.

Misplacement of dysplastic epithelium in Peutz-Jeghers Polyps: the ultimate diagnostic pitfall?

Peutz-Jeghers syndrome is characterized by multiple polyps throughout the gastrointestinal tract in association with mucocutaneous pigmentation. Small bowel polyps in the syndrome may exhibit epithelial misplacement, into the submucosa, the muscularis propria, and even the subserosa. The authors demonstrate two patients in whom there is also misplacement of dysplastic epithelium into the submucosa and muscularis propria of the small bowel. Epithelial misplacement is recognized to mimic invasive malignancy. Such mimicry is heightened substantially when the misplaced epithelium is dysplastic. Correct interpretation of the histologic changes is aided by the use of special stains, which demonstrate the associated lamina propria and the lack of a desmoplastic response, and immunohistochemistry, which shows that the misplaced dysplastic epithelium is accompanied by non-neoplastic mucosa. There is an increased prevalence of gastrointestinal malignancy in Peutz-Jeghers syndrome. However, the presence of perplexing histologic features, caused by epithelial misplacement, especially when some of that epithelium is dysplastic, in small bowel polyps at least has the potential for the overdiagnosis of malignancy in the syndrome.

Death from unsuspected colorectal cancer.

An analysis of all subjects undergoing autopsy in the Plymouth Health District over a 10-year period revealed 61 cases of unsuspected colorectal cancer. The carcinoma was the primary cause of death in 57 cases and surgical treatment for cure might have been possible in over one-half. The 61 subjects accounted for 4.1% of all cases of fatal colorectal cancer in this area. Examination by means of rectal digital palpation, rigid sigmoidoscopy and flexible sigmoidoscopy might have diagnosed 10, 24 and 41 carcinomas respectively. This study has demonstrated that a significant number of colorectal cancers remain undetected until after death. These cases should be included in future studies of colorectal cancer.

Lower gastrointestinal bleeding during anticoagulant therapy: a life-saving complication?

Warfarin is commonly used in the prophylaxis or treatment of thromboembolic disease. Haemorrhage is a recognised complication which may be life-threatening. This paper describes eight cases in which lower gastrointestinal bleeding while on warfarin therapy resulted in the discovery of previously unrecognised large bowel malignancy. Diagnosis of an otherwise asymptomatic carcinoma in this way enabled surgery to be carried out at an earlier stage and so may have resulted in a better prognosis for these patients. Bleeding while on anticoagulant therapy is caused by a specific organic lesion in 30% to 50% of cases. This may be the case even when the prothrombin time is very prolonged. It is important, therefore, that such cases are fully investigated, especially in the elderly.

Open cholecystectomy in the age of the laparoscope.

We reviewed our experience with open cholecystectomy since laparoscopic cholecystectomy became the treatment of choice for symptomatic gallstones. Over a 3 year period 35 open (6%) and 578 laparoscopic cholecystectomies (94%) were performed. Fourteen trainee surgeons performed only 16 open cholecystectomies and assisted at 19. The proportion of open cholecystectomies declined through the study period. Ten emergency cholecystectomies were performed for empyema, gallbladder perforation, severe acute cholecystitis, liver abscess, and cholangitis. In 12 patients, laparoscopic surgery was converted to an open procedure because of severe inflammation, empyema, dense adhesions, carcinoma of the gallbladder, cholecystoduodenal fistula, and perforated small bowel. Ten patients underwent open cholecystectomy and bile duct exploration after failure to clear duct stones endoscopically, and three patients had Mirizzi's syndrome. Open cholecystectomy is infrequently performed giving trainee surgeons little experience. However, such cases are occasionally inevitable and laparoscopic surgeons need to have the appropriate skills.

The presentation of malrotation of the intestine in adults.

Three cases of intestinal malrotation presenting in adults are reported. Each illustrates various aspects of symptomatology, investigation and treatment which are discussed.

Control of presacral bleeding in rectal surgery.

A technique for controlling life-threatening presacral bleeding is described. This consists of a sterilised metallic drawing pin pushed through the synthetic coagulant Surgicel (Johnson and Johnson) directly into the bleeding point in the sacrum. Two patients are described in which this technique was used with a successful outcome.

A radiological diary of gallstone migration in a patient with acute pancreatitis.

This case report is interesting in radiologically showing migration of stones from the gallbladder via the biliary tree and into the gastrointestinal tract.

Death from undiagnosed peptic ulcer complications: a continuing challenge.

A 10-year study of all 9653 autopsies performed in the Plymouth Health District, UK from 1977 to 1986 revealed 154 patients who died from undiagnosed peptic ulcer complications. In all, 118 of these patients died suddenly at home and 36 died in hospital. Most patients were elderly although 47 were under 70 years and 2 were under 50 years of age. Anti-inflammatory drugs were being used by 81 of these patients, an incidence of 60 per cent where full drug histories were available. Women who died were much more likely to be using these drugs than men. This study emphasizes the hitherto unrecognized importance of death from undiagnosed peptic ulcer disease and further highlights the potential risk of non-steroidal anti-inflammatory drug use.

Non-steroidal anti-inflammatory drugs and life threatening complications of peptic ulceration.

Two hundred and thirty five consecutive patients with a life threatening complication of peptic ulceration, who either died or required emergency surgery, have been studied over a 36 month period. Seventy eight of these high risk patients died; 25 at home, 19 in hospital without surgery and 34 postoperatively. Ninety eight patients had bleeding ulcers, 132 perforated ulcers and five had both bleeding and perforated ulcers. One hundred and forty one of these 235 patients (60%) were taking a non-steroidal anti-inflammatory drugs (NSAID) and the individual agents have been listed. The overall incidence of NSAID use in a hospital control group was 9.9%. The first sign of an ulcer was a life threatening complication in 58.2% of patients taking a NSAID. Nearly 80% of all ulcer related deaths occurred in patients using an anti-inflammatory agent. Patients using these drugs were older, with more pre-existing medical conditions and had larger ulcers than those not taking NSAIDs. The mortality associated with a peptic ulcer complication in patients taking a NSAID was more than twice that in patients with no such drug history. There appears to be a relationship between the development of a life threatening complication of peptic ulceration and NSAID ingestion. Much of the associated mortality and morbidity may be potentially avoidable.

Migration of gall stones.

The factors influencing the migration of gall stones are ill understood. Altogether 331 patients undergoing cholecystectomy were studied prospectively. The diameters of the cystic and common bile ducts and of stones in the gall bladder and bile ducts were measured. Increasing pressure was applied to the freshly excised gall bladder in an attempt to evacuate stones through the cystic duct. Stones passed in 33 (60.0%) of patients with choledocholithiasis, 45 (67.2%) of patients with pancreatitis, and 7 (3.2%) of patients without either pancreatitis or choledocholithiasis. Stones migrated in 6 (3.0%) who had a normal cystic duct diameter (less than or equal to 4 mm) and in 46 (32.5%) with a duct over 4 mm diameter. Common bile duct stones were often larger than the diameter of the cystic duct and when reintroduced into the gall bladder would not migrate. The passage of debris (less than or equal to 1 mm) through the cystic duct bore no relation to the presence or absence of choledocholithiasis or a dilated cystic duct. Small stones (1-4 mm diameter) must migrate to initiate and facilitate further migration; some must increase in size in the common bile duct. Increased biliary pressure consequently dilates the duct system retrogradely, allowing larger stones to follow. Patients at risk of stone migration and thereby pancreatitis and jaundice have large ducts that can be detected by ultrasound assessment.

Pancreatic-duct reflux and acute gallstone pancreatitis.

A consecutive series of 614 operative cholangiograms was studied prospectively to determine the relationship of pancreatic-duct reflux to a previous history of acute gallstone pancreatitis. Of 53 patients who had previously had pancreatitis, 33 had pancreatic-duct reflux on their cholangiogram (62.3%), whereas, of 561 patients with no history of pancreatic disease, pancreatic-duct reflux was seen in only 82 (14.6%). In patients with a history of pancreatitis, reflux occurred into a wider pancreatic duct, at a greater angle between the bile and pancreatic ducts, and was associated with a longer functioning common channel. The wider cystic duct, wider common bile duct, and multiple small stones seen in patients with previous pancreatitis and pancreatic-duct reflux were suggestive of gallstone migration being associated with reflux. There was no correlation between pancreatic-duct reflux and the presence of choledochal calculi. Two patients developed recurrent severe pancreatitis after pancreatic-duct reflux of infected bile. Patients with gallstone pancreatitis appear to have an increased tendency for pancreatic-duct reflux that is mechanically facilitated by differences in the choledocho-pancreatic duct anatomy.

Factors influencing prognosis in carcinoma of the stomach.

Prognostic factors were prospectively sought in a consecutive group of 223 patients with carcinoma of the stomach observed for a minimum of seven years. Age, race and mode of presentation did not influence survival time. Statistically improved seven year survival rates were observed in females (p less than 0.01) and patients with several features: symptoms lasting more than six months (p less than 0.01); absence of an abdominal mass (p less than 0.01); T1 versus T3 Stage of disease (p less than 0.001); absence of nodal involvement (p less than 0.01) and when curative resection was possible (p less than 0.01).

Synchronous upper and lower gastrointestinal endoscopy is an effective method of investigating iron-deficiency anaemia.

BACKGROUND: The investigation of iron-deficiency anaemia is often inadequate. Synchronous upper and lower gastrointestinal endoscopy under the same sedative episode (bidirectional endoscopy; BDE) has been proposed for all such patients. METHODS: The value of this strategy has been examined prospectively. Eighty-nine patients with iron-deficiency anaemia underwent BDE using local anaesthesia of the throat and intravenous midazolam. RESULTS: A cause for gastrointestinal blood loss was found in 75 patients (84 per cent) after BDE alone. Twenty-five patients (28 per cent) had upper gastrointestinal pathology alone, 24 (27 per cent) had lower gastrointestinal pathology alone and 26 (29 per cent) had dual pathology. Forty-five patients (51 per cent) had gastrointestinal malignancy. Twenty patients (22 per cent) had further investigations and these yielded a diagnosis in five. No cause for the anaemia was found in nine patients (10 per cent). Treatment of the bleeding source(s) resolved the anaemia in all but one patient. CONCLUSION: BDE is an effective investigation for patients with iron-deficiency anaemia and its use should be encouraged.

The fractured scapula: importance and management based on a series of 62 patients.

A prospective analysis of 62 patients with 64 fractured scapulas is presented. Most cases are caused by severe injury, especially motor vehicle accidents. Of the total number of patients, 87.1 per cent had other injuries, with thoracic injury being especially common. Six patients died--a mortality rate of 9.7 per cent. The combination of a fracture of the scapula and the underlying first rib appears to be a particularly severe injury. Good results can be obtained with conservative therapy in fractures of the body, spine, coracoid and acromion. Less favourable results follow fractures of the neck and glenoid. In young and fit patients open reduction may be indicated in fractures of the neck and glenoid.

Pre-incisional intraparietal injection of cephamandole: a new approach to wound infection prophylaxis.

Pre-incisional injection of cephamandole has been studied. Wound tissue levels of cephamandole have been found to be extremely high throughout the operation. Serum levels were compared to those obtained with parenterally administered antibiotic. The use of a pre-incisional injection of antibiotic therefore offers major theoretical advantages over the use of either conventional parenteral or topical antibiotics in the prevention of postoperative sepsis.

Effects of bile, infection and pressure on pancreatic duct integrity.

Ionic flux, potential difference and mucosal ultrastructure have been studied in the rat bile-pancreatic duct and the effects of pressure, bile and infection on the duct evaluated. The duct remained stable after perfusion with control solution under low pressure and high pressure produced widening of intercellular spaces only. Perfusion with a bacterial solution of Escherichia coli did not effect significant changes. Sterile human bile disturbed the integrity of the duct by increasing ionic flux, altering potential difference and producing reversible ultrastructural changes of cell oedema. High pressure increased these changes. Infected human bile under high or low pressure was by far the most toxic substance tested. Perfusion with infected bile led to irreversible duct damage and complete loss of duct integrity. Pressure and infected bile may have a role in damaging duct integrity and could thus play an integral part in the genesis of acute gallstone pancreatitis.