Intestinal lymphoma--a review of the management of emergency presentations to the general surgeon.

INTRODUCTION: Intestinal non-Hodgkin's lymphoma (NHL) is uncommon but not rare. This paper aims to review the recent evidence for the management of perforated NHL of the intestine, consider when chemotherapy should be commenced and examine the likely outcomes and prognosis for patients presenting as surgical emergencies with this condition. METHODS: MEDLINE and Cochrane databases were searched using intestinal lymphoma, clinical presentation, perforation, management and prognosis. The full text of relevant articles was retrieved and reference lists checked for additional articles. FINDINGS: Emergency surgery was required at disease presentation for between 11 and 64% of intestinal NHL cases. Perforation occurs in 1-25% of cases, and also occurs whilst on chemotherapy for NHL. Intestinal bleeding occurs in 2-22% of cases. Obstruction occurs more commonly in small bowel (5-39%) than large bowel NHL and intussusceptions occur in up to 46%. Prognosis is generally poor, especially for T cell lymphomas. CONCLUSIONS: There is a lack of quality evidence for the elective and emergency treatment of NHL involving the small and large intestine. There is a lack of information regarding the impact an emergency presentation has on the timing of postoperative chemotherapy and overall prognosis. It is proposed that in order to develop evidence-based treatment protocols, there should be an intestinal NHL registry.

An old head on new shoulders.

A modified stapling technique for anterior resection is described. A pursestring suture is placed in the proximal colon after resection of the specimen; the head of a stapling gun is detached from the stapler and inserted into the proximal bowel and the pursestring suture is tied. A pursestring suture is placed in the rectal stump. A stapling device head from a previous case is autoclaved and then fitted to the stapling device to allow safe insertion per anum: this head is discarded as soon as the distal pursestring is tied. The anastomosis is then completed in the usual way. This technique has been used successfully in twenty-one cases with minimal morbidity and no mortality.

Selective decontamination of the digestive tract reduces gram-negative pulmonary colonization but not systemic endotoxemia in patients undergoing elective liver transplantation.

OBJECTIVE: To examine the effect of selective antibiotic decontamination of the digestive tract in patients undergoing elective orthotopic liver transplantation. DESIGN: Prospective, randomized, concurrent allocation to either selective decontamination or standard antibiotic prophylaxis. SETTING: Operating theater and intensive care unit at a tertiary referral, university teaching hospital. PATIENTS: Fifty-nine adult patients were recruited into the study and underwent liver transplantation. INTERVENTIONS: Thirty-two patients were randomized to standard treatment (control group) and 27 patients were randomized to receive selective decontamination. After early deaths and exclusions, 31 controls and 21 decontamination patients were available for analysis. MEASUREMENTS AND MAIN RESULTS: Portal and systemic endotoxemia, colonization and infection rates, severity of illness (organ system failures, Acute Physiology and Chronic Health Evaluation II score, Therapeutic Intervention Scoring System score), antibiotic costs, and hospital survival rates were measured. Selective decontamination significantly reduced pulmonary infections and enteric, aerobic, and Gram-negative bacillary colonization without facilitating the emergence of resistant organisms, but selective decontamination had no effect on endotoxemia or the development of organ system failures. The financial costs of the selective decontamination regimen outweighed the advantages gained from an associated reduction in antibiotic usage. CONCLUSION: The failure of selective decontamination to enhance survival rates in many studies of the regimen in critically ill patients may, in part, be related to the inability of selective decontamination to abolish endotoxemia.

Tumour necrosis factor alpha secretion in leporine endotoxaemia: role of the liver and effects of hepatic ischaemia.

A leporine model to investigate tumour necrosis factor alpha (TNF alpha) secretion after peripheral vein or mesenteric vein lipopolysaccharide injection was devised. Mesenteric vein injection provoked lower arterial concentrations after 90 minutes (median (range), 2.81, (0.75-11.96) ng/ml) than peripheral vein injection (7.00 (4.27-14.95) ng/ml (p less than 0.05)). Mesenteric vein injection after 10 minutes' warm hepatic ischaemia, which impairs hepatic clearance, provoked higher median arterial TNF alpha values at 90 minutes (7.98 (2.85-21.48) ng/ml) than in normal animals (p less than 0.05). Portal vein endotoxaemia induced less TNF alpha production than systemic endotoxaemia unless hepatic clearance was impaired, thus the major source of TNF alpha in systemic endotoxaemia is probably extrahepatic.

Hepatic transplantation in children using reduced size allografts.

The shortage of paediatric liver donors has led to the use of reduced size hepatic allografts. Between July 1987 and July 1990, 30 reduced size orthotopic liver transplantations were performed in 24 children aged between 3 months and 7 years. All patients were in advanced chronic or acute liver failure and were considered unlikely to survive for long enough for a size-matched donor to become available. The most common indication was biliary atresia. The median intraoperative blood loss was 75 (range 13-1015) ml kg-1. Nine patients have died and seven have undergone retransplantation, four successfully. Seven patients had portal vein hypoplasia with a high graft failure rate due to ischaemic infarction. There was significant morbidity from biliary tract complications, leading to further operations in four cases. The 1-year actuarial survival rate was 62 per cent.