Blood patch treatment of chylothorax following transthoracic oesophagogastrectomy: a novel technique to aid surgical management.

Chylothorax is a well-recognised complication of oesophagectomy, occurring in around 3% of cases. If managed conservatively, the mortality rate can be over 50%. We describe our experience of managing a patient with a chylothorax following oesophagectomy, and the use of a blood patch (a novel technique) to overcome persistent leakage following re-operation. The authors feel that this technique has the potential for a wider application in the treatment of chyle leak, especially if combined with minimally invasive or radiological techniques.

Further observations on LKB1/STK11 status and cancer risk in Peutz-Jeghers syndrome.

Germline mutations in the LKB1/STK11 tumour suppressor gene cause Peutz-Jeghers syndrome (PJS), a rare dominant disorder. In addition to typical hamartomatous gastrointestinal polyps and pigmented perioral lesions, PJS is associated with an increased risk of tumours at multiple sites. Follow-up information on carriers is limited and genetic heterogeneity makes counselling and management in PJS difficult. Here we report the analysis of the LKB1/STK11 locus in a series of 33 PJS families, and estimation of cancer risks in carriers and noncarriers. Germline mutations of LKB1/STK11 were identified in 52% of cases. This observation reinforces the hypothesis of a second PJS locus. In carriers of LKB1/STK11 mutations, the risk of cancer was markedly elevated. The risk of developing any cancer in carriers by age 65 years was 47% (95% CI: 27-73%) with elevated risks of both gastrointestinal and breast cancer. PJS with germline mutations in LKB1/STK11 are at a very high relative and absolute risk of multiple gastrointestinal and nongastrointestinal cancers. To obtain precise estimates of risk associated with PJS requires further studies of genotype-phenotype especially with respect to LKB1/STK11 negative cases, as this group is likely to be heterogeneous.

Spotlight on a distant mirror - colorectal cancer surgery in a 20-year period at a general hospital.

BACKGROUND: A published audit of the management of colorectal cancer at a general hospital in the 1970s was available for comparison with a later audit at the same hospital in the 1990s. METHODS: Case note analysis. RESULTS: In the later audit, more cases were treated annually by an unchanged surgical team. The incidence of synchronous combined excision of the rectum, for rectal cancers suitable for resection, was halved, and that of anterior resection of the rectum (sphincter sparing, without a permanent stoma) increased almost threefold. The incidence of local recurrence in cases suitable for rectal surgery dropped from 17% to 9%, in spite of the change in the principal operation undertaken for this population. Outcomes associated with critical care improved as resources in this discipline became available. Overall survival figures were only improved by 6% in the20-year period, reflecting a diagnosis of Dukes C tumours or worse in at least 45% of the stable population studied in both audits. CONCLUSION: More resources are necessary in Great Britain to increase survival figures in this common cancer. Earlier diagnosis and more specialist management of the disease may allow us to emulate American and Swedish survival figures.

Emergency surgery: atavistic refuge of the general surgeon?

A prospective audit of emergency soft-tissue surgery for an eight-week period revealed that general surgical emergency operations were more than twice as common as those undertaken in other soft-tissue specialties. The audit reveals that emergency general surgery needs an increase in resources, an increase in available staff and an increase in the role of the consultant general surgeon on call. An alternative solution would be to admit soft-tissue emergencies by specialty and develop specialist emergency services.

Surgical palliation for pancreatic cancer: will biliary bypass alone suffice?

Because a number of options are available to relieve the obstructed bile duct, stomach or both in patients with irresectable carcinoma of the pancreatic head, palliative surgery for this condition was reviewed retrospectively between 1971 and 1981 at the Royal United Hospital, Bath. One hundred and sixty-five patients underwent a biliary bypass procedure with (n = 37), or without (n = 128) gastric drainage. Thirty patients had a prophylactic gastroenterostomy to avoid gastric outlet obstruction: tumour encroachment made gastroenterostomy essential in seven others. After biliary bypass alone, operative mortality was 14%. After a concomitant gastroenterostomy, mortality was 27% (P less than 0.04). Within a year of biliary bypass alone, there was a 9% incidence of gastric outlet obstruction requiring gastric drainage, with an associated mortality rate of 18%. Survival after biliary bypass or biliary bypass with gastroenterostomy was equal (7-8 months). Except where gastric outlet obstruction is imminent, palliation for irresectable pancreatic head carcinomas should be by biliary bypass alone, because the addition of a gastroenterostomy almost doubles the mortality without any advantage in survival time.

Noninvasive assessment of portosystemic shunting in extrahepatic portal hypertension in rats.

A simple reproducible animal model of extrahepatic portal hypertension (EHPHT) has been developed in weanling Wistar rats using a two-stage ligation of the portal vein. This model consistently produces substantial collaterals, both portosystemic (hepatofugal) and portoportal (hepatopetal). Using dynamic hepatic scintigraphy (DHS) with 99mTechnetium sulphurcolloid, hepatopetal collateral flow was measured as the mesenteric fraction (MF) of total hepatic blood flow and compared with measurement of hepatofugal collateral flow (portosystemic shunting) following intraportal injection of radiolabeled microspheres. Strong and significant correlation between the two assessments was found with reduction in MF denoting increased portosystemic shunting (PSS). The technique of DHS has been used successfully in adults to assess compromised portal venous flow and is a simple noninvasive test to aid diagnosis, assessment, and follow-up of children with EHPHT.