Mechanisms of human tumor metastasis studied in patients with peritoneovenous shunts.

The technique of peritoneovenous shunting for the alleviation of abdominal pain and distension in malignant ascites due to inoperable cancer, returns the fluid to the circulation via a one-way, valved, anastomosis between the peritoneum and the jugular vein. Surprisingly, although the patients treated with this technique receive direct infusions of malignant tumor cells into the blood, this study of 29 patients, 15 of whom came to autopsy, shows that they did not all develop metastases, some being completely free of such lesions despite long survival. Even when metastases do form, they are small and clinically asymptomatic, and the technique is therefore not hazardous. In some patients, inert tumor cells identifiable by natural markers were recognized in the tissues, but no growing metastases were observed. In others, the distribution of secondary deposits was unexpected in that metastases did not form in the organ containing the first capillary bed encountered, although hematogenous metastases had formed in other organs. Despite the fact that various factors such as (a) the small numbers of patients treated with the technique; (b) the sensitive nature of studies on terminally ill patients; and (c) the absence of consistency in the sample population with regard to factors such as length of survival and site of neoplasm, combine to reduce the number of suitable cases for study, the approach has unrivaled power and interest for those seeking to understand mechanisms underlying tumor metastasis in humans.

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

The incidence and Dukes' staging of colorectal cancer over 3 decades.

AIMS: Two previous studies (1966-1971 and 1979-1983) of patients with colorectal cancer (CRC) have been reported from our hospital. A large increase in the incidence of CRC was noted, and an improvement in Dukes' staging of tumours at treatment. We report a series of patients admitted with newly diagnosed CRC to evaluate this trend further. METHODS: A prospective study was made of all patients with newly diagnosed CRC admitted to the John Radcliffe Hospital, Oxford in 1995. Means of diagnosis and Dukes' staging were recorded. RESULTS: In 1 year 177 patients were admitted with newly diagnosed CRC. Previous studies had shown an increase from 52.8 to 103.4 patients per year. The number of patients diagnosed by colonoscopy doubled from 19.4% in 1979-1983 to 41% in 1995. No significant change in the proportion of patients with Dukes' A or B tumours was found. CONCLUSION: The number of patients treated annually with CRC in a stable population has more than trebled in the last 3 decades. A real increase in the incidence of CRC is likely as this rise cannot be explained solely by changing referral patterns or an ageing community. There are no significant changes in presentation patterns despite the availability of colonoscopy since 1975.

Glycine absorption from irrigation fluid during endoscopic resection of rectal tumours.

A significant rise in plasma glycine concentration was observed in nine elderly patients undergoing endoscopic transanal resection of rectal tumours using glycine solution for irrigation. Despite the obvious absorption of glycine, plasma sodium concentration and osmolality were not significantly altered, except in a patient whose rectal wall was perforated. In this case plasma sodium and osmolality fell, and the patient developed hyperammonaemia. Potentially adverse metabolic consequences may occur when there are surgical complications, but in the absence of such problems the absorption of glycine appears to cause little effect.

Liver function tests in patients receiving parenteral nutrition.

A 5-year prospective study was performed to monitor liver function tests (LFTs) in patients receiving total parenteral nutrition (TPN). A gradual and progressive rise was seen in the plasma concentration of bilirubin, aspartate transaminase, and alkaline phosphatase. The rate of rise was not increased in patients with LFT abnormalities before the start of TPN. Half of the patients had an episode of sepsis during TPN, but overall abnormal LFTs did not appear more common in these patients than in those without obvious sepsis. Patients with malignant disease, those requiring long-term TPN, and those requiring a nonstandard TPN regimen were more likely to develop raised LFTs.

Peroral pulsion intubation of malignant esophageal strictures using a fiberoptic technique.

Palliative peroral pulsion intubation of malignant esophageal strictures in 44 patients with incapacitating dysphagia is reviewed. Intubation, using a fiberoptic endoscope, the Nottingham introducer, and a modified Celestin tube was performed, usually under intravenous sedation. Intubation was successful in 93 per cent and provided satisfactory relief of dysphagia. Six deaths (14%) were the result of intubation, three from esophageal perforation, two from aspiration pneumonia, and one from hemorrhage. The overall hospital mortality was 23 per cent. Six patients required reintubation for proximal or distal migration of the prosthesis. Although mean survival was short (3.2 months), esophageal intubation by this technique is relatively safe, minimizes hospitalization, and offers reasonable palliation in most patients.

Acute colonic pseudo-obstruction after total hip replacement.

Acute colonic pseudo-obstruction is a poorly recognised and potentially fatal complication of hip surgery. Between 1991 and 1994 six patients were observed who required laparotomy after failure of medical management. In three the indication was signs of peritonism, while in the other three exploration was required to exclude segmental ischaemia and to decompress the bowel. In all, there was no evidence of mechanical obstruction. Patients having total hip replacement are at risk of developing pseudo-obstruction due to their age, comorbidity, high doses of analgesics and the nature of the operation. If postoperative ileus persists for more than 48 hours acute colonic pseudo-obstruction should be suspected and confirmed by plain radiography. Prompt recognition and treatment with early referral to a colorectal unit are indicated. Laparotomy appears to carry less risk than that for patients with idiopathic pseudo-obstruction, but should be performed only if colonic ischaemia is suspected.

Restorative proctocolectomy in children and adolescents.

Children and adolescents with colitis present specific problems for surgeons. There has been a fashion, particularly in North America, for restoring continuity after colectomy by a direct ileo-anal anastomosis. The authors reviewed their experience with restorative proctocolectomy with ileal reservoir (RPC) in patients under 18 years of age to evaluate the outcome and to discuss the problems and challenges associated with the procedure in this age group. Fifteen patients (6 boys, 9 girls) were operated on between 1984 and 1995. The diagnoses included 12 patients with ulcerative colitis (UC), two with familial adenomatous polyposis (FAP), and one with total colonic neuronal dysplasia. The median age of the patients at the time of ileal pouch formation was 15 years, and follow-up data were available for all patients at a median of 43 months. Ten patients with UC underwent pouch surgery 4 to 14 months after initial total abdominal colectomy (7 for acute severe disease, 3 for chronic disease). Four patients (2 with chronic UC, 2 with FAP) underwent primary RPC. There were no deaths in this series. Three (20%) patients suffered serious early morbidity (pouch hemorrhage, pelvic sepsis, severe psychological crisis). Late morbidity included three patients who had small bowel obstruction, one who required laparotomy, two who required pouch revision, and five of 12 (42%) patients with UC who presented with a documented episode of pouchitis between 2 and 72 months after ileostomy closure. All patients had acceptable bowel frequency and quality of continence. This experience suggests that RPC provides an important surgical option for children and adolescents with UC or FAP.

Colonoscopy following intraoperative lavage in the management of severe colonic bleeding.

Intraoperative lavage of the colon through a catheter inserted into the caecum provides a rapid means of cleansing the bowel of blood and clots to enable thorough colonoscopy in cases of severe colonic bleeding. This permits diagnosis of the site and cause of haemorrhage in those cases in which neither arteriography, conventional colonoscopy, nor laparotomy alone are helpful. Four cases are presented in which the technique of colonoscopy following intraoperative lavage allowed diagnosis and treatment in massive large bowel bleeding.

Changing patterns of colorectal cancer in a regional teaching hospital.

A study was performed of all patients who underwent either surgery or endoscopic polypectomy for colorectal cancer in Oxford between 1979 and 1983 to ascertain whether any changes had occurred in presentation, diagnosis, treatment or outcome since a previous study from the same centre undertaken between 1966 and 1971. The average number of patients treated annually had increased from 52.8 to 103.4. The growth of the population of the health district was 6.7%. A similar proportion (25%) continued to present as emergencies. There was an improvement in the proportion of cases presenting with Dukes' A and B lesions (54% vs 41%) (P < 0.001), and a decrease in the number of patients with extranodal disease (from 30.4% to 13.3%) (P < 0.001). Only 13.9% of patients underwent colonoscopy before surgery and 14 patients were treated by endoscopic removal alone. In a health district with a slowly growing population, the number of patients presenting with colorectal cancer had increased dramatically over a decade. Colonoscopy has so far made little impact on making an earlier diagnosis. The increase in colorectal cancer has important implications for resource allocation.

The total parenteral nutrition service: an update.

A total parenteral nutrition (TPN) service was established in Oxford in 1978 and the results of the first 3 years were published in 1983. Since then the service has provided intravenous nutritional support to an increasing number of patients, representing a considerable and increasing financial burden on the constrained hospital budget. To assess whether this expansion is justified, and whether regular review has improved the care given to patients, a further audit has been performed for the period 1983 to 1986. Despite an increase of approximately 60% in the numbers of patients parenterally fed, line associated morbidity was less and there were no serious metabolic problems or deaths. Patient selection has improved, as judged by fewer patients fed for periods less than a week. Regular audit appears to improve the selection and treatment of patients but there remains a need to identify subgroups of patients for whom this costly form of nutrition is essential.

The use of laparoscopy in the management of right iliac fossa pain.

Fourty-six patients with a clinical diagnosis of acute appendicitis were laparoscoped before exploration. As a result the diagnosis was revised in 10 patients (22%). With experience the laparoscopic features of appendicitis can be recognised confidently so reducing the number of normal appendices removed.

The natural history of peptic oesophageal strictures treated by dilatation and antireflux therapy alone.

A total of 195 patients with benign peptic oesophageal strictures treated by endoscopic dilatation and antireflux medication between July 1977 and July 1986 were studied prospectively to determine the effect of such treatment on the subsequent course of this disease. Of the patients, 58% were female and they were significantly older than the males at the time of initial presentation (75 years vs 68 years, P less than 0.0001). 46% of both sexes required only one dilatation but the men required more dilatations over a longer period: 31% males vs 19% females required more than 3 dilatations (P less than 0.05) and 40% males vs 27% females were being dilated 2 years or more after the initial dilatation (P less than 0.05). Dilatation combined with antireflux medication is clearly an effective method of management for most patients with peptic oesophageal strictures. The value of antireflux surgery requires evaluation for that subset of patients, predominantly males, who require long-term and repeated dilatation.

A simple system of parenteral nutrition.

The practical problems involved in the preparation and delivery of parenteral nutrition may result in such treatment being withheld from patients who would benefit from it. A simple and reliable system is described which has been developed to overcome the more common problems.

A 15-year audit of home parenteral nutrition provision at the John Radcliffe Hospital, Oxford.

BACKGROUND: Home parenteral nutrition (HPN) is an established option for patients suffering from intestinal failure, often pending definitive surgery, but sometimes for life or pending intestinal transplant. Care for patients with HPN is provided at centres other than designated intestinal failure units in the UK, but there are few data on outcomes. AIM: To audit the standard of care at one such centre using objective measures to compare with results published from other centres and intestinal failure units. DESIGN: 15-year retrospective audit of paper and computer-based records of all HPN patients (1990-2004). METHODS: Demographic data, major line and metabolic complication rates and mortality were collected and analysed. RESULTS: 88 patients received HPN for a total period of 121 patient-years (median duration 217.8 days, range 18.3-3881.2, median age 40, range 3-73). Principal reasons for HPN were Crohns' disease (35.2%), mesenteric, infarction (11.4%), surgical complications (17.0%), intestinal motility disorder (10.7%). The frequency of major complications were line sepsis (0.35 episodes/patient-year), line occlusion (0.25 episodes/patient-year), subacute bacterial endocarditis (0.02 episodes/patient-year), cholestasis (0.17 episodes/patient-year) and central venous thrombosis (0.03 episodes/patient-year). Indications and complications were all within the range of published data. CONCLUSION: HPN can be delivered effectively outside designated intestinal failure units and the current data are representative of a standard of care.

Small bowel obstruction due to an enterolith originating in a jejunal diverticulum.

A case of small bowel obstruction caused by an enterolith from a jejunal diverticulum is reported. As such diverticula are usually asymptomatic, the diagnosis was not entertained pre-operatively.

Combined horizontal and longitudinal colomyotomy for diverticular disease: preliminary report.

The operation of horizontal and longitudinal colomyotomy for diverticular disease is described and satisfactory short-term results in six patients are presented. The indications and reasons for the use of this procedure are discussed. It is suggested that the operation is a satisfactory treatment, without the risks associated with division of all the circular muscle fibers, or with resection and anastomosis. The necessity for long-term high dietary fiber intake is stressed.

Parietal wound drainage in abdominal surgery.

A prospective randomized study of wound drainage in 250 surgical abdominal wounds was undertaken to determine (a) what effect wound drains had on clean surgical wounds; (b) whether wound drains reduced infection in potentially contaminated wounds; (c) whether wound drainage was an acceptable alternative to the use of topical antibiotics in frankly contaminated wounds. Ten per cent of clean wounds which had been drained became infected, compared with 2 per cent of control wounds in the same group (P less than 0.002). Infection was also more common in potentially and frankly contaminated wounds in the presence of a drain. Skin organisms were grown from 8 drained and 2 nondrained wounds in this group (P less than 0.005), suggesting contamination by the drains. Drains were, however, associated with a lower infection rate in 23 obese patients with frankly contaminated wounds.