Effect of thoracic epidural anaesthesia on splanchnic blood flow.

BACKGROUND: Thoracic epidural anaesthesia (TEA) is used widely in colorectal surgery. However, there is increasing concern that epidurals are associated with postoperative hypotension, mediating a potential reduction in splanchnic flow. The aim was to review the literature on the effects of TEA on splanchnic blood flow. METHODS: PubMed and Cochrane databases were searched. Search terms used were: English language, 'thoracic epidural splanchnic flow', 'thoracic epidural gut blood flow', 'thoracic epidural intestinal blood flow' and 'thoracic epidural colonic blood flow'. Abstracts were reviewed by two independent researchers and irrelevant studies excluded. The full text of the remaining articles was then retrieved. RESULTS: Twenty-two abstracts were reviewed and three excluded. Nineteen papers were reviewed in full and seven irrelevant articles excluded. Five human studies investigated the effects of TEA on splanchnic flow. Two studies measured splanchnic flow directly and found an epidural-mediated fall in flow, unresponsive to intravenous fluids and requiring vasopressors or inotropes to restore baseline flow. The remaining three studies had inconsistent findings and haemodynamic stability was maintained. The seven animal studies identified were heterogeneous in both methodology and findings. Three suggested a protective role for thoracic epidurals in septic shock and pancreatitis. CONCLUSION: These findings are inconsistent; however, the two studies that investigated the effects of vasoconstrictors on splanchnic blood flow directly both found a significant epidural-mediated reduction in splanchnic blood flow that was unresponsive to fluid therapy.

Stapled diverticulectomy for solitary caecal diverticulitis.

Caecal diverticulitis is an uncommon phenomenon in western countries. The clinical diagnosis is often difficult as it mimics other acute abdominal conditions like appendicitis, colitis or neoplasia. Diagnosis is often made at operation. Operative strategy has been controversial and there is no broad consensus emerging. We report the case of a 71-year-old woman, known to have chronic obstructive pulmonary disease, who presented acutely with right iliac fossa pain. A clinical diagnosis of appendicitis was made. At laparoscopy, a solitary, inflamed, gangrenous caecal diverticulum was found. A laparoscopic stapled diverticulectomy was performed. The patient made a steady post-operative recovery. Histology confirmed diverticulitis. We conclude that stapled diverticulectomy for solitary caecal diverticulitis is a safe and effective surgical strategy when confronted with this scenario.

Antibodies reactive with the protein core of MUC1 mucin are present in ovarian cancer patients and healthy women.

Antibodies reactive with peptide epitopes on the core protein of MUC1 epithelial mucin have been demonstrated in some patients with adenocarcinomas. Because these epitopes can be exposed on MUC1 in the serum of healthy women, we measured concentrations of MUC1-reactive antibodies in the serum of healthy pregnant and non-pregnant women, and in patients with benign and malignant ovarian tumours. Antibodies were measured in an enzyme-linked immunosorbent assay utilising a synthetic peptide corresponding to a 105-amino-acid segment of the MUC1 tandem repeat region (5.25 repeats). MUC1-reactive antibodies were always of an IgM isotype and concentrations were highest in young healthy women and declined progressively with age (P=0.0006) concomitantly with increasing serum MUC1 levels (P=0.003). Regardless of age, antibody levels were lower in cancer patients than in healthy women (P<0.0001), but MUC1 levels were much higher in cancer patients (P<0.0001). Although high antibody levels were associated with greater survival in ovarian cancer (P=0.015), multivariate regression analysis showed that this was not a significant independent prognostic indicator after consideration of the International Federation of Gynaecology and Obstetrics (FIGO) stage, histological type, serum MUC1 levels and age. Serial measurement of MUC1 and MUC1 antibodies during treatment in 18 patients with ovarian cancer and throughout pregnancy in 10 women showed a negative correlation between alterations in MUC1 and MUC1 antibodies. These results show that MUC1-peptide-reactive antibodies are present in the serum of healthy women and women with cancer and that they probably form immune complexes with MUC1, but provide no evidence for an augmentation of the humoral immune response to MUC1 in ovarian cancer