Benign gastrocolic fistula healing with conservative management.

We report a case of gastrocolic fistula resulting from a benign gastric ulcer, diagnosed by barium meal and endoscopy. The fistula healed with conservative management and treatment with carbenoxolone sodium. To our knowledge this is the first reported case of successful conservative treatment of a benign gastrocolic fistula using carbenoxolone.

Intracorporeal laparoscopic resections for colorectal cancer: report of cases of abdominoperineal rectal excision and right hemicolectomy with 2 year follow-up.

Techniques for total intracorporeal laparoscopic abdominoperineal excision of rectum and right hemicolectomy for colorectal cancer are described in two patients with 2-year follow-up. Potential advantages over laparoscopically assisted procedures may be offset by increased operating time and expense for right hemicolectomy but the laparoscopic approach seems well suited to abdominoperineal rectal excision. The use of a secure retrieval system is advocated for specimen removal after right hemicolectomy.

Pancreatic abscess: results of prolonged irrigation of the pancreatic bed after surgery.

The mortality from pancreatic abscess may approach 70 per cent and the survivors often require repeated operations to debride the pancreas and to drain recurrent abscesses. We report the results of prolonged irrigation of the pancreatic bed after surgical débridement in 11 patients. Surgery was performed at an average of 17 days (range 8-25 days) after the onset of symptoms. The pancreatic slough was thoroughly debrided and 2-6 large drains were placed in the pancreatic bed. Irrigation with saline or Diaflex solution (2-6 l/day) was started after 2 days and continued for a mean of 25 days (range 5-54 days). There were three deaths (27.3 per cent) after surgery: one of these patients required reoperation and packing for massive postoperative haemorrhage and all three had some evidence of persisting sepsis at autopsy. Prolonged irrigation of the pancreatic bed after surgical débridement may reduce mortality and the need for repeated drainage procedures in patients with pancreatic abscess, but the detection and treatment of persisting sepsis remains the major problem.

Diagnosis of granulomatous starch peritonitis by delayed hypersensitivity skin reactions.

Intradermal skin tests were performed on 6 patients with histologically proved granulomatous starch peritonitis and on 15 control subjects. All patients with starch peritonitis developed an erythematous reaction at least 5 mm wide between 3 and 8 days after inoculation. Such a skin reaction was not seen at that time in any of the control subjects. The microscopic changes seen in the positive reactions were dense mononuclear perivascular exudates with organized giant cell or epitheloid cell granulomas in 4 patients and loose histiocytic aggregations in a fifth patient. This evidence of cutaneous delayed hypersensitivity suggests that an immunological response underlies granulomatous starch peritonitis and that intradermal skin tests are of value in its diagnosis.

Empyema of the gall bladder - reappraisal of a neglected disease.

Thirty two patients with empyema of the gall bladder were identified among 1327 cases of gall-bladder disease presenting to one hospital over a six year period. Abdominal pain had been present for a median of eight days and, in eight cases, for between one and four months. In a few cases, the disease was painless and was discovered unexpectedly at postmortem or at operation for unrelated disease. The serious nature of the complaint was belied by the often scanty physical signs. Less than half the patients had a pyrexia of more than 37.5 degrees C and the presence of sepsis was rarely suspected clinically. Eight patients (25%) died, usually from unsuspected septicaemia. This considerable mortality might be reduced by the wider use of blood culture in cases of apparent 'cholecystitis' and by greater awareness that empyema of the gall bladder is sometimes chronic, painless, and afebrile.

Indications for laparoscopic formation of intestinal stomas.

A laparoscopic technique for formation of intestinal stomas is described and reported in four cases. The procedure has a role where difficulties with trephine stoma formation are anticipated, where simultaneous laparoscopic procedures are performed, and where accurate assessment of the extent of intra-abdominal malignancy is indicated.

Operative colonoscopy.

In 12 patients with radiologically-proved lesions of the colon total retrograde fibreoptic colonoscopy was performed on the unopened bowel at laparotomy. Additional polyps were found in five patients, and in four of these the polyp was not readily palpable through the bowel wall. This procedure is indicated whenever there are reasonable grounds for suspecting the presence of multiple polypi.

The effect of wheat bran upon bile salt metabolism and upon the lipid composition of bile in gallstone patients.

When raw wheat bran was added to the diet of six subjects for 4-6 weeks, chenodeoxycholate (CDC) synthesis increased from 0.46 +/- 0.12 to 0.57 +/- 0.17 mmol/day pool increased from 1.72 +/- 0.47 to 2.19 +/- 0.74 mmol (rho less than 0.05). Deoxycholate (DC) pool size diminished from 1.20 +/- 0.29 to 0.80 +/- 0.16 mmol, but cholate synthesis and pool size were unaffected. Overall, the size of the bile salt pool did not change. In spite of this, when 10 patients with probable cholesterol gallstones took bran supplements for 4-6 weeks, their gallbladder bile aspirated from the duodenum became less saturated with cholesterol. The molar percentage of cholesterol fell from 10.1 +/- 3.1% to 8.6 +/- 2.7% (rho less than 0.01), and the saturation index of bile fell from 1.49 +/- 0.40 to 1.29 +/- 0.38 (rho less than 0.005). Bran probably operates primarily on the colon, reducing the formation or absorption of the bacterial metabolite DC, a substance which impairs CDC synthesis.

A laparoscopic technique for full thickness intestinal biopsy and feeding jejunostomy.

A laparoscopic technique is described, suitable for both full thickness intestinal biopsy and placement of a feeding jejunostomy tube. Its application in three cases is reported. The method is simple, permits full laparoscopic examination of the abdominal contents and being minimally invasive, facilitates early patients recovery.

The immunogenicity of starch glove powder and talc.

An antigen responsible for cutaneous delayed hypersensitivity to starch glove powder in guinea-pigs was found to be associated with starch grains. Talc was not immunogenic in this system, and did not cross-react in skin tests with starch glove powder. Additives and protein components in the glove powder did not appear to be antigenic.

Sclerosing peritonitis due to practolol: a report on 9 cases and their surgical management.

Nine patients with an unusual and serious intraabdominal complication of the beta-adrenergic blocking agent practolol seen since 1973 are reported. The striking and bizarre peritoneal changes induced by the drug have distinctive features that are not shown by other forms of peritoneal disease. The cases presented with small bowel obstruction, usually chronic in type and often associated with profound weight loss and an abdominal mass. Characteristic radiological features were present. The abnormalities at laparotomy were impressive, with a gross proliferation of the visceral peritoneum which formed a dense white cocoon which encased, constricted and markedly shortened the small bowel, usually from the duodenojejunal flexure to the ileocaecal valve. The obstruction was relieved by mobilizing the small bowel from the ensheathing tissue. Restoration of alimentary function after surgery was delayed but the long term result was satisfactory with full relief of symptoms and the absence of recurrent obstruction during the follow-up period. This complication may arise after treatment with the drug has been stopped, and although long term oral therapy has been discontinued, further cases will almost certainly present for some time to come.