Massive colonic haemorrhage--the case for right hemicolectomy.

A total of 14 patients had operations for massive colonic haemorrhage. Of the seven who had a right hemicolectomy, four had the bleeding site localised, and three had only 'equivocal' indications of a right-sided source. One of these rebled 11 months later, but all survived and are well. Of the remaining patients, two had left-sided resection, one requiring an immediate second operation for rebleeding, and five, subtotal colectomy, of whom two died. A literature review confirms the suggestion that if the bleeding site has not been identified but, nevertheless, there are clues suggesting it to be right-sided, the best results will be obtained by right hemicolectomy. Left-sided resection should be used only when there is proof of left-sided bleeding, otherwise there will be an unacceptably high mortality. No clues, 'equivocal' indications of a left-sided source, or the presence of bilateral disease, should lead the operator to perform subtotal colectomy.

A paradox explained? Patients with delayed diagnosis of symptomatic colorectal cancer have good prognosis.

OBJECTIVE: To investigate the impact on outcome of delay between referral and diagnosis in colorectal cancer (CRC). PATIENTS AND METHODS: One hundred and fifty-four patients were studied after excluding from a consecutive series of 411 with CRC, those with factors known to affect the prognosis that may also have affected the speed of diagnosis. These were advanced disease, emergency admission or surgery, referral with diagnosis already made, and tumours treated by colonoscopic polypectomy alone. Possible causative factors were compared between early and late diagnosis groups. For assessment of symptom risk, the Department of Health criteria were used. RESULTS: Forty-four patients had Referral to Diagnosis Interval (RDI) > or = 50 days ('Late'), and 110 had RDI < 50 days ('Early'). In the Late group there were only 2 deaths from cancer and 93.7% cancer-specific five year survival (c5ys), compared with 22 and 65.3%, respectively, in the Early one (P = 0.007). There were more Duke's A cases in the Late group (38.6%vs 15.2%, P = 0.006), but this did not fully explain the improved survival. Comparisons for each Duke's Stage showed improved c5ys for Late Duke's B ones (100% of 16 vs 60.3% of 54, P = 0.039). Late patients had more low risk symptoms than Early ones, both overall (31.8%vs 13.7%, P = 0.013) and in Duke's B cases (56%vs 15.3%, P = 0.003). Tumours were smaller in the Late group (length 35.3 vs 41.6 mm, P= 0.04); this difference was confined to the Duke's A patients and sigmoid tumours. Late sigmoid tumours were not only shorter (32.4 vs 45.9 mm, P = 0.02) but also were all cured (c5ys 100% of 18 vs 60.3% of 23, P = 0.011). There were no differences between Late and Early groups in: age (mean 69.9 years), sex (male 57.7%), date of diagnosis (mean December 1998), ASA comorbidity index (mean 1.9), number of lymph nodes found in the operative specimen (mean 8.6), or histological grading (moderate differentiation 94.4%). CONCLUSION: In the context of modern rapid access clinics, symptomatic CRC patients with delay between referral and diagnosis (even if this is several months or occasionally more than a year) have less aggressive tumours and markedly better long-term cure rate than their earlier diagnosed counterparts. Attempts to speed up further the diagnosis would be a waste of time and resources, being unlikely to make an appreciable difference to the overall cure rate.

Towards selecting the vagotomy and avoiding diarrhoea.

A retrospective review was carried out of 148 consecutive personal truncal vagotomies and anterior pylorectomies (TV + P), median follow-up 5.0 years. The recurrent ulcer rate was 6/148 (4.1%) for suspected (SRU) and 5/148 (3.4%) for proven ones (RU). This led to one death from RU. Thirty-six patients (24.3%) developed postvagotomy diarrhoea (PVD). Two of these were graded Visick IV because their occupations made PVD particularly inconvenient. These results are similar to those for TV and pyloroplasty, despite the slightly more destructive nature of pylorectomy. There were nine patients in whom evidence of associated bowel disease had been documented before or during operation. The occurrence of such evidence was significantly more frequent in the PVD group (6/36 vs. 3/112 patients, P = 0.014), suggesting either a summation of effects due to the bowel disease and the operation or that the diagnosis of PVD was sometimes incorrect. Of the six in the PVD group, two were in Visick Grade II because of their PVD, and four in Visick grade III or IV, but in one of these SRU was the main cause of the poor result, and in two the PVD was subsidiary to vomiting or dumping. One further patient in Visick III due to PVD had diverticular disease diagnosed after operation. Thus there were identifiable factors (occupation, associated bowel disorder) which could have been used to predict seven of the unsatisfactory results due partly or completely to PVD. TV + P is an effective operation for duodenal ulcer but, as with TV + pyloroplasty (though to no greater an extent), severe diarrhoea may occasionally mar the result.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiograph measurements and contralateral renal size in primary pelvic hydronephrosis.

Renal size was estimated from the radiographs in 47 cases of primary pelvic hydronephrosis. The area of functioning renal tissue of the side opposite to the disease was greater in patients with severe hydronephrosis treated by pheloplasty, compared with those with moderate disease (P less than 0.05). This suggests that compensatory hypertrophy had occurred in the contralateral kidney. This finding did not appear to affect the outcome of pyeloplasty. It is suggested that the finding of compensatory hypertrophy in the kidney opposite to a severe hydronephrosis is not a contra-indication to conservative surgery.

Is a fat stitch necessary?

Two hundred and eight consecutive patients undergoing surgery were allocated randomly in a trial of the use of a plain catgut subcutaneous fat stitch, compared with no fat suture. There was no appreciable difference between the two trial groups in wound infection rate following either clean (4 out of 74 with and 1 out of 68 without a fat stitch) or contaminated operations (4 out of 27 with and 4 out of 41 without). Likewise, there were no differences in haematoma rates. There is therefore no appreciable benefit to be derived from the use of this stitch.

Parenteral nutrition in Crohn's disease.

A retrospective study of 50 consecutive patients admitted to hospital with Crohn's disease has been undertaken in order to assess the place of parenteral nutrition in our management of this disease. Following treatment, median weight, hemoglobin, and plasma albumin were the same in three treatment groups--parenteral nutrition (12), low-residue diet (9), and normal diet (29). Of 13 courses of parenteral nutrition used in 12 patients, 10 were for periods of less than 14 days (median four days). Most patients with nutritional problems associated with Crohn's disease can be treated successfully by one or other form of enteral nutrition. Parenteral nutrition, if required, is usually only necessary for periods of less than two weeks, to support patients over a critical period in their illness. Occasionally prolonged parenteral nutrition is required for short-bowel syndrome or advanced fistulous disease. In these cases, training the patient to infuse himself with nutrients at home has much to recommend it.

Benign thyroid inclusions within cervical lymph nodes: an alarming incidental finding.

Small clusters of microscopically normal thyroid follicles within cervical lymph nodes are very occasionally encountered during histological examination. We support the view that provided the thyroid gland is not palpable and a technetium thyroid scan is normal, these should be regarded as benign thyroid inclusions and do not represent small metastatic lesions from thyroid carcinoma. We report an example of these inclusions in a cervical lymph node which was removed incidentally during the excision of a branchial cyst in a 25-year-old woman. The inclusion was too small to be noticed macroscopically and consisted of a small aggregation of histologically normal thyroid follicles situated in the subcapsular region of the lymph node.

N tau-Methylhistidine excretion and myofibrillar protein breakdown in patients receiving intravenous or enteral nutrition.

1. N tau-Methylhistidine, nitrogen and creatinine were measured in the urine of 10 volunteers on normal and meat-free diets and in 10 vegetarians, and compared with the results from the urine of eight patients with intestine fistulae on intravenous or enteral nutrition containing no meat. The values obtained were used to calculate fractional breakdown rate of myofibrillar protein. 2. There was a significant fall in the excretion of N tau-methylhistidine and creatinine and in apparent fractional breakdown rates after 2 days on a meat-free diet. 3. One of the patients had lower, and two of the patients had higher, fractional breakdown rates compared with the vegetarians. 4. N tau-Methylhistidine and creatinine excretion may be a useful and non-invasive measurement of myofibrillar protein degradation in patients on meat-free diets. Firm conclusions cannot, however, be drawn without confirmatory, direct measurement of the breakdown rates of muscle protein in vivo.

Intracellular free amino acids in undernourished patients with or without sepsis.

1. Thigh muscle samples for analysis were obtained from 35 control subjects and 12 severely ill patients, of whom five had disease-induced undernutrition and seven had associated sepsis. An improvement in the Bergström technique for analysing muscle needle biopsy samples was used. 2. Muscle water, chloride and DNA were increased in both groups of ill patients, indicating an increase in the extracellular component and loss of muscle protein. 3. Falls in the concentrations of glutamine, glutamate, arginine, histidine, ornithine and lysine and rises in those of glycine, serine, asparagine, tyrosine, valine, leucine, isoleucine, phenylalanine, methionine and tryptophan were observed in the group of ill patients compared with those in the control subjects. The changes were present mainly in the patients with sepsis, significant differences between these and the undernourished ones without associated sepsis being observed in glutamine, lysine, tyrosine, valine, leucine, isoleucine, phenylalanine and methionine. The changes were either absent or slight in plasma. 4. The increased concentrations observed in six essential amino acids in the septic patients, but not in those with undernutrition, is consistent with the increased catabolic rate of sepsis. 5. However, the branched-chain amino acids, and lysine, threonine, arginine, and histidine, were present in lower concentrations than might be expected from catabolism, presumably due to utilization. It is suggested therefore that septic patients might benefit from increased proportions of these amino acids in their feeding regimen.