Measurement of the internal dose to families of outpatients treated with 131I for hyperthyroidism.

OBJECTIVE: The aim of this study was to measure the internal dose received by family members from ingestion of radioactive contamination after outpatient therapy. MATERIALS AND METHODS: Advice was given to minimise transfer of radioiodine. Home visits were made approximately 2, 7 and 21 days after treatment to measure radioactivity in the thyroids of family members. A decay correction was applied to radioactivity detected assuming ingestion had occurred at the earlier contact time, either the day of treatment or the previous home visit. An effective half-life of 6 or 7 days was used depending on age. Thyroid activity was summed if activity was found at more than one visit in excess of the amount attributable to radioactive decay. Effective dose (ED) was calculated using ICRP72. RESULTS AND DISCUSSION: Fifty-three adults and 92 children, median age 12 (range 4-17) years participated. Median administered activity was 576 (range 329-690) MBq (131)I. Thyroid activity ranged from 0 to 5.4 kBq in the adults with activity detected in 17. Maximum adult ED was 0.4 mSv. Thyroid activity ranged from 0 to 11.8 kBq in the children with activity detected in 26. The two highest values of 5.0 and 11.8 kBq occurred in children aged 5 and 14 years from different families. Eighty-five children had no activity or <1 kBq detected. ED was <0.2 mSv in 86 out of 92 children (93%). Previous published data showed 93% of children received an ED

The relationship between administered radiopharmaceutical activity in myocardial perfusion scintigraphy and imaging outcome.

INTRODUCTION: Lower radiopharmaceutical activities are used for myocardial perfusion scintigraphy (MPS) in the UK than in other countries. There is no evidence to suggest that higher activities improve imaging or clinical outcome. MATERIALS AND METHODS: We undertook a multicentre study of the relationship between radiopharmaceutical activity and imaging outcome. Fifty-one patients with clinical referrals for MPS followed a 2-day protocol with an injection of 1,000 MBq (99m)Tc-tetrofosmin for each of the stress and rest images. ECG-gated acquisition was performed in three rotations occupying 25, 35 and 40% of a standard acquisition, and rotations were summed to simulate administered activities of 250, 400, 750 and 1,000 MBq. Each set of images was reported by an experienced physician who was blinded to all clinical information and to the simulated activity. Scores were assigned for image quality, low count, attenuation and reconstruction artefact, segmental tracer uptake, segmental and global defect classification, and confidence in the global classification. The images were reported twice to assess intra-observer variability. RESULTS: Positive relationships were found between administered activity and overall image quality, observer confidence and intra-observer agreement of uptake score, and a negative relationship was found with low-count artefact. For the majority of comparisons, there was no additional improvement with increasing activity from 750 to 1,000 MBq. Intra-observer agreement was found to be better in female patients and in those below average body mass index. DISCUSSION: We conclude that higher administered radiopharmaceutical activities lead to better quality images and improved surrogate parameters for clinical outcome, but that activities above 750 MBq may be unnecessary in average patients.

The nature of local recurrence after colorectal cancer resection.

OBJECTIVE: Local recurrence (LR) after rectal cancer resection has long been regarded as a particular problem, its incidence having been high. This study aims to determine the reasons why. METHOD: A prospective record was kept of all 887 cases of colorectal adenocarcinoma referred to one surgeon between 1989 and 2000. Of these, 802 underwent major resection. They were followed up for 5 years or until death. RESULTS: There was no significant difference between LR rates throughout the colorectum (P = 0.74). LR was significantly related to tumour grade (P < 0.001) and to tumour stage (P < 0.001), but not to the need to resect involved adjacent structures (P = 0.08), nor, after restorative rectal resection, to the distal margin of clearance (P = 0.97). A difference became apparent between recurrence resulting from tumour left in or implanted into the operation field and tumour resulting from pre-excision metastasis, here called, respectively, technique-related (TLR) and pre-excision metastatic (MLR) local recurrence. MLR was significantly related to tumour stage (P < 0.001), while TLR was not. Some TLR can be curatively excised. CONCLUSION: Rectal LR is no more common than colonic LR. There may be practical merit in discriminating between TLR and MLR.

A prospective study of outcome from rubber band ligation of piles.

OBJECTIVE: With the recent introduction of stapled anopexy it is timely to review the benefits of existing treatment options for piles. This study investigates the effectiveness and safety of rubber band ligation (RBL) of piles in the outpatient setting. PATIENTS AND METHODS: Two hundred and fifty-two consecutive patients referred with piles in an 18-month period were studied prospectively. In those patients deemed suitable for banding of piles, data were collected on symptoms, proctoscopic appearance and degree of piles. Short and long-term outcome data were recorded for success of treatment and complications. RESULTS: Of 203 patients considered suitable and who attended for RBL, 176 kept their follow-up appointment. One hundred and forty-eight (84%) had been rendered symptom-free. A third of patients, however, had proctoscopic evidence of persistent piles, whilst in half of those patients with continuing symptoms the anal cushions appeared normal. Six (3%) patients had suffered a complication. Long-term follow-up by questionnaire found that 44% of respondents remained asymptomatic at a median of 46 months from banding. Six (5%) of 117 responders to the questionnaire had, though previously normal, suffered a postbanding impairment of continence. CONCLUSION: Most patients with piles of any degree can be safely managed by rubber band ligation, but return of symptoms in the long term affects more than half of patients treated.

Mesh repair of parastomal hernias--a safety modification.

INTRODUCTION: Parastomal herniation is not uncommon and numerous surgical approaches to the problem have been employed including mesh reinforcement. Bowel wall erosion is a worrying potential complication of placing an edge of mesh around bowel. To reduce this possibility a simple modification is suggested. METHOD: The polyproylene mesh repair is fashioned on the posterior rectus sheath. The required aperture for the bowel is marked appropriately on the mesh. Instead of simple removal of the marked circle, the aperture is fashioned by folding back and stitching in place the triangular flaps from the middle to form a rolled rather than sharp edge. Non-absorbable monofilament stitches reconstitute the mesh encirclement, and attach it laterally and medially to the aponeurotic tissue. A review of the case notes was conducted and each patient was contacted by a postal questionnaire. RESULTS: This technique has been used in 10 patients (7 end colostomies, 2 end ileostomies and 1 loop ileostomy) since 2000. Over a median follow-up period of 30 months (range 2 to 40 months) there have been no hernia recurrences, no infected meshes, no bowel damage attributable to the mesh and no troubles with stoma. The only complication encountered has been a segment of superficial wound breakdown in one patient. CONCLUSIONS: This technique appears to offer a safe and reliable modification for mesh repair of parastomal herniation, in being designed to obviate the possibility of erosion of the stomal bowel wall by a sharp mesh edge but at the same time providing a sound herniorrhaphy by complete encirclement.

Direct appositional (no flap) closure of deep anal fistula.

OBJECTIVE: After sphincter-sparing core fistulectomy for deep anal fistula most surgeons advance a rectal mucosal flap to reinforce closure of the internal opening. Our own method having for many years been simple appositional closure the resulting series presented an opportunity for comparison. PATIENTS AND METHODS: From November 1987 to January 2001, 44 patients underwent 46 core fistulectomies with flap-less direct appositional closure in our unit. Records were kept prospectively. Twenty-six fistulae (in 28 patients) appeared healed at two to five months follow-up and the patients had been discharged. A full review was mounted in May 2001, when 16 of the healed patients could be contacted and questionnaires completed. Two patients were excluded from the study. RESULTS: The procedure failed in 16 patients initially and was found to have done so in two more at long-term follow-up (41% overall). Three patients had died and five could not be traced. CONCLUSION: Simple appositional closure after core fistulectomy for deep anal fistula seems inferior to methods using flap reinforcement.

A study of the complications and pelvic visceral function after restorative proctocolectomy and W pouch construction.

OBJECTIVE: Aspects of ileal pouch surgery remain controversial. The authors' single practice experience of 107 operations illustrates many of them. It was hoped that its study would contribute usefully to the debate. PATIENTS AND METHODS: Details of all 107 restorative proctocolectomies carried out since the operation was started in Gloucester in 1984 until the study period ended have been kept prospectively. All patients had proctectomy by mesorectal dissection, and 106 had W pouch restoration. Four suffered functional failure requiring reversion to ileostomy and three patients have died. The remaining 99 were sent a questionnaire concerning pelvic visceral function and evidence of pouchitis. Records of all but one of the patients have been reviewed. RESULTS: Surgical morbidity was low with neither chronic pelvic sepsis, pouch related fistula, pouch haemorrhage nor pouch ischaemia. Mucosectomised patients had similar bowel control to the stapled group. The policy change from routine to selective protective ileostomy proved satisfactory. W pouch function was found to be comparable to that reported from major J pouch series, although anti-diarrhoeal usage was reduced, and was not influenced by either gender, age or time since surgery. CONCLUSION: None of the following reasonably intuitive assumptions seem supported by our findings: that mesorectal excision necessarily poses a greater danger to pelvic visceral function than close rectal dissection, that the greater capacity of W pouches will be reflected in markedly less frequency, that mucosectomy would impair anal control, or that a defunctioning ileostomy is a mandatory precaution. Pouch frequency is less if wind can be passed separately; otherwise functional outcome seems determined by other, non-technical, factors.

Radiation and pregnancy.

Irradiation of pregnant women either in the workplace or as a consequence of clinical diagnosis is often unavoidable. This paper reviews the issues relating to this topic. For clinical exposures the "missed period" rule is applied prior to most clinical studies. However normal physiological variations in the menstrual cycle may need to be understood. The possible effects of irradiation, both deterministic and stochastic, on the fetus are also described. The decision process in relation to irradiation of a pregnant or potentially pregnant patient is discussed in terms of the regulatory guidance. A different approach is needed for studies which clearly involve a low dose to the uterus compared with studies involving a high dose, including therapy. The issue of a pregnant or potentially pregnant worker in nuclear medicine is also considered. Restrictions on certain work activities may be necessary once pregnancy is declared. Other areas considered are biomedical research and also the potential for exposure of pregnant woman in the home or in the workplace as a consequence of others having a nuclear medicine study.

Aspects of fetal thyroid dose following iodine-131 administration during early stages of pregnancy in patients suffering from benign thyroid disorders.

Detrimental effects on the thyroid of the developing fetus as a result of iodine-131 treatment for thyrotoxicosis of the mother in the first trimester of pregnancy are discussed. Dose estimations under typical clinical circumstances yield a fetal thyroid dose of 100- 450 Sv. This dose may increase considerably if the blood concentration of (131)I in the mother remains high. Under such circumstances there may be fetal thyroid dysfunction, which can lead to severe abnormalities.

Radiation exposure of the families of outpatients treated with radioiodine (iodine-131) for hyperthyroidism.

Patients who receive radioiodine (iodine-131) treatment for hyperthyroidism (195-800 MBq) emit radiation and represent a potential hazard to other individuals. Critical groups amongst the public are fellow travellers on the patient's journey home from hospital and members of the patient's family, particularly young children. The dose which members of the public are allowed to receive as a result of a patient's treatment has been reduced in Europe following recently revised recommendations from ICRP. The annual public dose limit is 1 mSv, though adult members of the patient's family are allowed to receive higher doses, with the proviso that a limit of 5 mSv should not be exceeded over 5 years. Unless the doses received during out-patient administration of radioiodine can be demonstrated to comply with these new limits, hospitalisation of patients will be necessary. The radiation doses received by family members (35 adults and 87 children) of patients treated with radioiodine at five UK hospitals were measured using thermoluminescent dosimeters mounted in wrist bands. Families were given advice (according to current practice) from their treatment centre about limiting close contact with the patient for a period of time after treatment. Doses measured over 3-6 weeks were adjusted to give an estimate of values which might have been expected if the dosimeters had been worn indefinitely. Thirty-five passengers accompanying patients home after treatment also recorded the dose received during the journey using electronic (digital) personal dosimeters. For the "adjusted" doses to infinity, 97% of adults complied with a 5-mSv dose limit (range:0.2-5.8 mSv) and 89% of children with a 1-mSv limit (range: 0.2-7.2 mSv). However 6 of 17 children aged 3 years or less had an adjusted dose which exceeded this 1 mSv limit. The dose received by adults during travel was small in comparison with the total dose received. The median travel dose was 0.03 mSv for 1 h travel (range: 2 microSv-0.52 mSv for 1 h of travel time). These data suggest that hyperthyroid patients can continue to be treated with radioiodine on an out-patient basis, if given appropriate radiation protection advice. However, particular consideration needs to be given to children aged 3 years or younger. Admission to hospital is not warranted on radiation protection grounds.

Controlled digital anal dilatation under total neuromuscular blockade for chronic anal fissure: a justifiable procedure.

BACKGROUND: There is widespread antipathy to digital dilatation of the anus (DDA) for medically resistant anal fissure. A retrospective study was therefore undertaken to test the validity of the criticism of this technique. METHODS: Some 273 patients who underwent DDA for fissure between November 1982 and July 1997 were sent a questionnaire and/or telephoned. Those with impaired control were offered investigation. In addition, routine clinic follow-up data were scrutinized in the 302 available notes of the 307 patients who had undergone DDA for fissure to determine its efficacy. RESULTS: Some 241 patients (88.3 per cent) were contacted successfully a median of 7.8 years after operation. Follow-up records showed the fissure to have healed in 89.1 per cent of 302 patients. No patient was rendered incontinent. Fifteen patients indicated persistently impaired control in the questionnaire, nine (3.8 per cent) as a result of the DDA and six preceding it. All 23 patients who had experienced either temporary or permanent impairment, whether or not pre-existing, were invited to attend for ultrasonography and manometric measurements, of whom 18 accepted. No sphincteric fragmentation was seen, and resting and squeeze pressures did not differ from normal. CONCLUSION: A single DDA appears to heal 89 per cent of chronic anal fissures. Consequent impairment of control is infrequent and minor if the procedure is performed carefully and with the patient paralysed.

Tube caecostomy to protect rectal anastomoses.

BACKGROUND: Low rectal anastomoses are associated with a substantial risk of anastomotic leakage. Tube caecostomy offers a potentially simple method of anastomotic protection. METHODS: Some 226 patients undergoing restorative rectal resection with on-table colonic lavage and tube caecostomy over an 11-year period were reviewed. Endpoints selected included clinical anastomotic leakage, requirement for a subsequent formal stoma and complications of tube caecostomy. RESULTS: Overall, clinical anastomotic leakage occurred in 25 patients with a caecostomy (11.1 per cent). All leaks were noted among patients in whom caecostomy protection had been used after low anterior resection, giving a leak rate of 14.9 per cent (25 of 168) for this group of whom 17 (10.1 per cent) required reoperation and a formal stoma, and five (3.0 per cent) died. Complications of caecostomy or prolonged drainage after tube removal occurred in ten (4.4 per cent) and 15 (6.6 per cent) patients respectively. There were two cases of life-threatening invasive infection. CONCLUSION: Tube caecostomy provides inadequate protection of rectal anastomoses; complications are common and may be life threatening.