Management of gastrointestinal carcinoid tumours - 10 years experience at a district general hospital.

BACKGROUND: There is paucity of guidelines regarding management of gastrointestinal carcinoid tumours in district hospitals. METHODS: This study was undertaken at a district hospital to analyse the management pathway of gastrointestinal carcinoid tumours. RESULTS: Over a period of 10 years there were 35 patients, with an estimated annual incidence of 2.5 per 100,000 population. After a median follow up of 24 months, 22 (63%) patients were alive and disease free. Only 56% patients were referred to the regional neuro-endocrine multidisciplinary team. CONCLUSIONS: Management of patients with carcinoid tumours in district hospitals needs streamling with increased utilisation of regional neuroendocrine multidisciplinary teams.

Risk factors in laparoscopic cholecystectomy: a multivariate analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS: All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS: 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION: Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

Differential antineoplastic effects of butyrate in cells with and without a functioning DNA mismatch repair.

The aim of this study was to investigate the differential antineoplastic effects of butyrate in cells with and without a functional mismatch repair and to determine the molecular mechanisms underlying these effects. SW48 colon cancer cells in which the MLH1 gene is silenced by promoter hypermethylation and demethylated SW48 cells in which the MLH1 gene is reexpressed were treated with butyrate (0-5mM) for 8 days and the effects on cell number, MLH1 gene promoter methylation, and expression of two cell cycle regulatory genes, CDK4 and GADD45A, were assessed. Butyrate suppressed viable cell number (P < 0.001) and reduced MLH1 promoter methylation (P < 0.05) in SW48 cells. However, in demethylated SW48 cells, butyrate caused an increase in viable cells (P < 0.05) and promoter methylation (P < 0.05). CDK4 expression was downregulated by butyrate exposure, but the effect was significantly greater for demethylated SW48 cells (P = 0.025). Butyrate treatment caused upregulation of GADD45A expression in SW48 cells but downregulation of GADD45A expression in demethylated SW48 cells (P = 0.045). This study supports the hypothesis that butyrate has more potent antineoplastic effects on colon cancer cells with MLH1 dysfunction. Differential expression of key cell cycle regulatory genes may explain some of the molecular mechanisms underlying these effects.

Role of self-expanding metallic stents in the management of malignant obstruction of the proximal colon.

PURPOSE: Expandable metal stents have been shown to be effective in the management of malignant large-bowel obstruction. However, right colonic lesions account for less than 5% of all reported cases of colonic stenting. This study was performed to determine the outcomes following stenting for lesions proximal to the splenic flexure. METHODS: The hospital records of patients undergoing stenting for large-bowel obstruction at a district general hospital in northeastern England from 2003 to 2008 were reviewed retrospectively. Data were analyzed to identify patient characteristics, site of obstructing lesion, intent for stenting, and outcomes measured including relief of obstruction, hospital stay, and complications. RESULTS: Stenting was attempted in 97 patients with malignant large-bowel obstruction. Of these, 16 (16.5%) patients had lesions proximal to the splenic flexure: 8 patients had lesions in the ascending colon and 8 patients had lesions in the transverse colon. Self-expanding metal stents were successful in relieving obstruction in 14 (88%) patients with proximal colonic lesions. Stenting was attempted as a bridge to definitive surgery in five patients and for palliation in nine patients. One patient had poststent bleeding that was managed conservatively, and there were no perforations or stent dislodgements. The mean postprocedure hospital stay was 1.6 days. CONCLUSIONS: Self-expanding metal stents are safe and effective in the management of malignant large-bowel obstruction proximal to the splenic flexure. The technical and clinical success rates are comparable with those reported for stenting distal colonic lesions.