Experience with sentinel node localisation in a district general hospital breast unit.

Intraoperative lymphatic mapping with identification of the first draining lymph node (sentinel node) is under investigation as a possible sole axillary staging procedure in breast cancer patients. The role of sentinel node biopsy in the district general hospital breast unit is currently unclear. We report a series of 122 patients undergoing sentinel node biopsy, using a blue dye technique. The sentinel node was identified in 113 patients, and accurately predicted the status of the axilla in 108 patients (96%). Of 39 patients who were node positive, the sentinel node was the only positive node in 11 cases (26%). There were five false negatives in patients who had a node-positive axilla. We therefore suggest that sentinel node biopsy may be a feasible alternative to formal axillary dissection in certain patients, and that lack of access to radioisotope facilities in a district general hospital need not preclude such an approach.

Intraluminal stenting in the management of adhesional intestinal obstruction.

Intraluminal stenting of the small bowel has been advocated as a method of reducing the risk of recurrent adhesional obstruction in patients requiring adhesolysis. We reviewed the complications and efficacy of this technique in 25 patients undergoing surgery for relief of intestinal obstruction due to complex, extensive and dense adhesions. Five patients developed minor and three patients major complications. Three (13%) of 23 patients alive after mean follow-up of 4 years had had episodes of recurrent intestinal obstruction, but none had required reoperation. Intraluminal stenting remains of unproven efficacy. It may find a place as an adjunct to adhesolysis in patients requiring repeated operations for the relief of obstruction due to extensive and dense adhesions; but, in view of the high rate of complications, careful case selection will be necessary.

Symptomatic pancreatic heterotopia treated by local excision.

Non-ulcer dyspepsia is a continuing problem and in many cases a precise cause is never identified. We present five patients with an allegedly uncommon condition--pancreatic heterotopia. They were managed by local excision of the tumour and after a mean (range) follow up of 42 (9-80) months all remain free of the original symptoms.

Vitamin A and its transport proteins in patients with chronic renal failure receiving maintenance haemodialysis and after renal transplantation.

Serum vitamin A, retinol binding protein, prealbumin and transferrin have been studied in chronic renal failure patients receiving maintenance haemodialysis and after renal transplantation. Vitamin A and retinol binding protein were uniformly raised in haemodialysis patients and this was unrelated to the period on dialysis. There was a molar excess of retinol binding protein to both vitamin A and prealbumin as compared with normal individuals. Renal transplantation significantly reduces serum vitamin A and retinol binding protein concentrations but has no effect on prealbumin concentrations. The reduction in vitamin A and retinol binding protein is variable in individual patients and cannot be predicted either by the allograft function or time since transplantation. Several years after transplantation, with normal serum creatinine, both serum vitamin A and retinol binding protein levels may still be greatly increased. Despite the very high vitamin A and retinol binding protein concentrations, the close correlation between the two seen in normal individuals is well maintained. The continuing high vitamin A and retinol binding protein levels in patients with satisfactorily functioning transplants is unexplained.

Bile reflux and gastric emptying in patients with combined gastric and duodenal ulceration.

Measurements of duodenogastric reflux of bile and gastric emptying of a 5 per cent glucose liquid test meal have been made in 8 patients with combined gastric and duodenal ulcers and the results compared with those found in 21 patients with a diagnosis of uncomplicated duodenal ulceration. It was not possible to demonstrate any differences between the two groups of patients in respect of these studies and it is suggested that gastric stasis and duodenogastric reflux may not be important factors in the aetiology of combined ulcer disease.

Reduced tissue content of vasoactive intestinal peptide in aganglionic colon of Hirschsprung's disease.

The colonic tissue content of immunoreactive vasoactive intestinal peptide was measured in four children with histologically proven Hirschsprung's disease. The concentration of vasoactive intestinal peptide was lower in the aganglionic bowel than in nearby normal bowel. Similar results have been described for another gastrointestinal peptide: substance P. Abnormalities of peptidergic control may contribute to the motility disorder of congenital aganglionic colon.

Does osmotic control of gastric emptying persist after truncal vagotomy?

Gastric emptying of 5 per cent and 10 per cent glucose test meals has been measured in 43 patients with a duodenal ulcer prior to surgery and in 52 patients with an unsatisfactory result following truncal vagotomy and a drainage procedure. Seventeen patients had a recurrent ulcer and incomplete vagotomy while 35 patients were symptomatic with complete vagotomy. In both the preoperative and postoperative patients the 10 per cent glucose test meal emptied significantly more slowly than the 5 per cent glucose test meal regardless of the completeness of vagotomy. Thus, osmotic control of gastric emptying persists after vagotomy.

Stimulation of gastric acid secretion and suppression of VIP-like immunoreactivity by bombesin in the Atlantic codfish, Gadus morhua.

Cods were equipped with cannulae for drainage of the stomach and for separate perfusion of the stomach (pure sea-water) and intestine (diluted sea-water). Acidity and volume of gastric effluence were measured. Plasma immunoreactive gastrin and vasoactive intestinal polypeptide (VIP) were assayed in some experiments. The high rate of "basal" acid secretion was further elevated by i.m. administration of bombesin, but not by pentagastrin. Exogenous VIP inhibited acid secretion. Following 5 h of bombesin infusion, plasma gastrin-IR was unaffected while VIP-IR was depressed compared to saline-treated controls. The possibility that bombesin stimulates acid secretion by inhibiting VIP-release is discussed.

Effect of VIP infusion in water and ion transport in the human jejunum.

Infusion of vasoactive intestinal polypeptide (VIP) is known to cause intestinal secretion in animal models. The present study was designed to answer the question whether VIP has a similar effect on the human intestine. Pure porcine VIP was administered by constant i.v. infusion to healthy subjects while their jejunum was perfused with a plasma-like electrolyte solution. At the lowest VIP infusion rate (100 pmol/kg/hr), plasma VIP levels rose two- to four-fold, and there was an increase in the transmucosal potential difference but no change in sodium chloride absorption. At higher VIP infusion rates (200 and 400 pmol/kg/hr), VIP plasma concentrations rose to levels commonly observed in patients with pancreatic cholera syndrome. At these levels VIP caused a dose-dependent decrease of water and sodium absorption. Chloride absorption changed to secretion, while bicarbonate movement remained completely unaffected. Chloride secretion was active, since it occurred against an electrical and chemical gradient. All changes induced by VIP were reversible after discontinuance of VIP infusion. Our observations suggest that elevated levels of circulating VIP are capable of affecting water and ion movement in the human jejunum. They lend support to the hypothesis that high levels of circulating VIP may be a mediator of secretory diarrhea in some patients with pancreatic cholera syndrome.

Hepatic and pulmonary clearance of exogenous vasoactive intestinal peptide in the rat.

1125-labeled vasoactive intestinal peptide (VIP) has been injected into the portal and systemic circulations of rats in an attempt to identify the distribution and fate of the circulating peptide. When VIP I125 was introduced into the portal circulation radioactivity was concentrated in the liver (415.5% +/- 57.2 at 10 min--counts per minute (cpm) per gram of tissue as percentage cpm per milliliter of plasma). Radioactivity in kidney and lung was 346.6% +/- 37.4 and 136.4% +/- 11.4, respectively. In contrast, if the liver was bypassed by performing a portacaval shunt or by injecting into the inferior vena cava, radioactivity was maximal in the lung (2,454.3% +/- 302.3 10 min after IVC injection) with activity in the liver of only 89.3% +/- 10.6. Analysis of the pattern of radioactivity in plasma and tissue extracts by gel filtration chromatography showed the presence of a number of fragments of smaller molecular weight than VIP with a progressive diminution of the amount of VIP-like radioactivity. Both liver and lung have the capacity to concentrate VIP from the circulation. Vasoactive intestinal peptide released into the portal circulation is probably taken up initially by the liver, and this may prevent subsequent uptake by pulmonary tissue. There is some evidence to suggest that the liver and the lung may handle VIP in different ways. If this is so, the enhanced pulmonary extraction of VIP when the liver is bypassed may have some significance for the cardiovascular complications of fulminant liver failure.

Improved diagnostic accuracy of a modified oral pancreatic function test.

The oral pancreatic function test (PFT) depends upon urinary recovery of p-aminobenzoic acid (PABA) released by chymotrypsin hydrolysis of orally administered N-benzoyl-L-tyrosyl-p-aminobenzoid acid. The diagnostic value of the test is limited because falsely abnormal results frequently occur in patients with bowel or liver disease in whom PABA recovery is impaired by abnormal absorption or hepatic conjugation, even though pancreatic function is normal. To overcome this problem, we have modified the oral PFT to correct for impaired PABA absorption and conjugation. Results of the oral PFT have been compared with urinary recovery of an equivalent dose of free PABA in order to derive a PABA excretion index (PEI). When the modified oral PFT is used, the PEI clearly distinguished patients with pancreatic disease from normal subjects. In patients with small-bowel or liver disease and normal exocrine pancreatic function, the PEI results were similar to those of normal subjects, although a previous oral PFT had been falsey abnormal. The modified test can therefore distinguish abnormal results due to pancreatic disease from the falsely abnormal results found in liver and small-bowel disease.

The diagnostic value of the oral pancreatic function test.

An oral pancreatic function test (PFT) using the synthetic peptide N-benzoyl-L-tyrosyl-p-aminobenzoic acid can assess pancreatic exocrine function, since urinary recovery of the ingested dose is an indirect index of chymotryptic activity. We have studied 34 subjects using this oral PFT, which correctly distinguished the control group (8 subjects) from the pancreatitis group (10 patients), results correlating well with Lundh test findings. However, the test was falsely abnormal on 9 out of 16 occasions in patients with bowel or liver disease. We therefore conclude that the present test cannot distinguish small-bowel disease from pancreatic disease, which is often the diagnostic problem, and is also frequently falsely abnormal in the presence of chronic liver disease.

An evaluation of viability tests of human cadaveric kidneys.

Cadaveric kidneys are sometimes unsuitable for transplantation because of possible ischaemic damage. The advent of perfusion preservation machines has enabled evaluation of perfusion characteristics and perfusate changes of organs prior to transplantation. This study has evaluated the changes in perfusate pH, lacate dehydrogenase, lactate and free fatty acid utilization in an attempt to identify those kidneys with ischaemic damage. In this investigation no single factor was discriminatory and it was not possible to predict with any degree of certainty those kidneys liable to delayed function or to non-function.

The value of profundaplasty in the management of severe femoropopliteal occlusion.

A series of 45 patients with advanced occlusive arterial disease of the femoropopliteal segment underwent profundaplasty as the sole operative procedure. The value of this technique as a salvage procedure for the severely ischaemic limb is discussed.

Treatment of advanced bladder cancer with adriamycin and 5-fluorouracil.

The cytotoxic drug combination of adriamycin and 5-fluorouracil has resulted in a 35% objective response in 20 patients with advanced bladder cancer. This has been achieved with minimal toxicity and on an out-patient basis. If the survival rate of patients with invasive bladder cancer is to be improved it seems likely that some form of systemic treatment will need to be added to the local measures currently in use. Further studies of different chemotherapeutic agents should help to define an effective and safe form of adjunvant therapy.

Effects of truncal, selective, and highly selective vagotomy on glucose tolerance and insulin secretion in patients with duodenal ulcer. Part I-Effect of vagotomy on response to oral glucose.

An oral glucose tolerance test was performed in patients who had undergone truncal vagotomy and pyloroplasty, bilateral selective vagotomy and pyloroplasty, or highly selective vagotomy without a drainage procedure at least six months earlier. The results were compared with those from patients with chronic duodenal ulcer before operation. In all three groups of patients after vagotomy more rapid rates of rise of blood glucose and higher peak concentrations were observed than in patients who were tested before operation. These differences were statistically significant only in patients who had undergone truncal or selective vagotomy with pyloroplasty and were probably due to more rapid rates of gastric emptying after these operations. Plasma insulin concentrations were lower after truncal vagotomy than after selective or highly selective vagotomy, the difference between truncal vagotomy and highly selective vagotomy being statistically significant. Truncal vagotomy resulted in a diminished insulin response to oral glucose, which could have been due to vagal denervation of the pancreas or, more probably, impaired release of small-bowel hormones which normally augment the pancreatic insulin response.

Effects of truncal, selective, and highly selective vagotomy on glucose tolerance and insulin secretion in patients with duodenal ulcer. Part II-Comparison of response to oral and intravenous glucose.

Paired oral and intravenous glucose tolerance tests were carried out in patients who had undergone truncal vagotomy and pyloroplasty, selective vagotomy and pyloroplasty, or highly selective vagotomy at least six months earlier. Intravenous glucose tolerance was similar in all three groups. Oral glucose elicited significantly higher concentrations of plasma insulin in patients who had undergone selective and highly selective vagotomy than in those treated by truncal vagotomy. When the same amount of glucose was given intravenously, however, plasma insulin concentrations were similar in all three groups of patients. The insulin secreted in response to intravenous glucose expressed as a percentage of that secreted in response to oral glucose was 112% for truncal vagotomy, 51% for selective vagotomy, and 52% for highly selective vagotomy. Truncal vagotomy thus led to a diminished insulin response to oral glucose, which was probably due to impaired release of small-bowel hormones.