Portal venous gas: is it a premorbid indicator?

A 72-year-old Caucasian man presented with subtle and insidious symptoms of pain in the left iliac fossa and vomiting. The first clinical impression was of diverticulitis but he did not improve with conservative management. An initial contrast tomography (CT) scan demonstrated no diagnostic features. Four days later, a repeat CT scan demonstrated intramural gas in the ascending colon and in the intrahepatic portal venous radicles. There was a thrombus in the superior mesenteric artery with infarction of the caecum and ascending colon. An urgent right hemicolectomy was carried out. Although there was resolution of the thrombus and air in the portal system, the patient died 8 days later from intestinal haemorrhage.

Metastatic carcinoid tumour mimicking cholecystitis, and a rare case of intussusception.

This report describes an acute presentation of obstructive jaundice, with a clinical picture of cholecystitis. A primary carcinoid tumour in the terminal ileum with hepatic secondaries was found to be the cause. Additionally, in the terminal ileum was a closely associated lipoma leading to an ileo-caecal intussusception. There are few such cases in the literature, particularly in the absence of any changes in bowel habit or lower abdominal pain. The majority of cases of intussusception in clinical practice occur in the paediatric population. Of the small numbers (<5%) that occur in adulthood, the underlying aetiology is most commonly a primary adenocarcinoma, with a far smaller number being attributable to lipoma, lymphoma and polyps.

Outpatient general surgical follow-up: are we using this resource effectively?

BACKGROUND: Raised patient expectations and the 2-week rule for the investigation of suspected malignancy have led to heightened demands on surgical outpatient clinics. In this context, the utility of benign post-operative or investigative follow-ups requires justification. METHODS: The surgical outpatient clinic workload of four substantive general surgeons at a typical DGH was analysed over a 4-week period. All notes were examined to identify referral source, management plan and whether that clinic attendance was justified. RESULTS: Twenty three clinics (410 patients) were examined over the period of this study. Three hundred and twenty one patient episodes were examined; 52 episodes did not occur due to patient non-attendance and 37 episodes were not accounted for ('missing/incomplete data'). Thirty three percent of the patients underwent consultant review whilst 57% were reviewed by middle grade surgeons and 9% by SHO/ST2 doctors. Forty eight percent of the consultations were new referrals: 37% of these patients were added to the elective surgical waiting list. One hundred and sixty eight follow-up consultations occurred, which included cancer patients (6%), review patients (12%), patients attending for investigative results (13%) and benign post-operative follow-ups (22%). Forty six of the 69 (66%) post-operative follow-ups were deemed unnecessary as patients were being seen after benign procedures (hernia repair, anorectal surgery or laparoscopic cholecystectomy). CONCLUSION: Over 50% attendances (21/41) for 'normal' results could have been avoided by the use of a directed informative letter. Outpatient clinics are an important resource whose usage must be optimised.

Digestive tract schwannoma.

BACKGROUND: Digestive tract schwannomas (DTS) are rare benign mesenchymal tumours usually affecting females between 30 and 60 years old. METHODS: We retrospectively reviewed 2 cases of DTS treated at our hospital. The first case is a 38-year-old female with gastric schwannoma presenting with acute upper gastro-intestinal bleeding. The second case is a 36-year-old female with mesenteric schwannoma presenting with chronic right iliac fossa pain. Both patients underwent surgical resection of the tumour. RESULTS: Histology and immunohistochemistry revealed the typical appearance of a DTS. CONCLUSION: DTS is most commonly found in the stomach. It is usually asymptomatic but can present with variable symptoms. Definitive diagnosis can only be made on the basis of immunohistochemistry. Surgical resection is the treatment of choice.

From frown lines to fissures: therapeutic uses for botulinum toxin.

INTRODUCTION: Since the pharmacological mode of action of botulinum toxin (BTX) has been elucidated, its therapeutic potential has been increasingly recognised. The aims of this review were to summarize our current understanding of the pharmacological action of this agent and to review its therapeutic uses. METHODS: An electronic literature search with Medline (January 1965 to December 2004) was carried out to identify articles related to the pharmacological mode of action and clinical uses for botulinum toxin using the keyword "botulinum toxin". RESULTS AND CONCLUSION: Botulinum toxin A is emerging as a valuable clinical tool, both for diagnostic and therapeutic purposes in a wide variety of disorders, and is already the treatment of choice for selected conditions. Better understanding of its modes of action may identify alternative targets for pharmacological intervention, and may allow development of longer acting drugs with lower immunogenicity. Therapeutic uses of BTX-A must be assessed systematically in prospective studies, and the clinical role of other subtypes requires evaluation.

A phase II study evaluating the tolerability and efficacy of CAELYX (liposomal doxorubicin, Doxil) in the treatment of unresectable pancreatic carcinoma.

BACKGROUND: Preclinical studies of liposomal doxorubicin (CAELYX) have demonstrated significant inhibition of growth of human pancreatic cancer explants in nude mice. This study evaluated the efficacy of CAELYX in chemotherapy-naïve patients with unresectable, histologically confirmed pancreatic carcinoma. Secondary endpoints were quality of life (QOL). time to progression and overall survival. PATIENTS AND METHODS: Twenty-two patients (median age 65) were enrolled. CAELYX was administered to the first five patients at a dose of 30 mg/m2 three-weekly. Two of these patients were dose escalated to 50 mg/m2 four-weekly. Subsequent patients were all treated on the latter schedule. RESULTS: Two patients died after consenting to enter the study but before treatment was commenced and are not included in the analysis. Sixteen patients were evaluable for response. No objective responses were seen. Six patients had stable disease. One patient experienced grade 4 toxicity with palmar plantar dysaesthesia (PPE), but continued treatment after dose reduction and delay. Four patients experienced grade 3 stomatitis and two grade 3 nausea. Median survival from time of starting chemotherapy was 3.2 months (range 21 days to 19 months) and one year survival was 10%. Eight patients completed at least two EORTC QLQ C-30 questionnaires. There was no significant change in either global QOL or in any functional or symptom subscale score. CONCLUSION: No objective responses were seen with CAELYX in this study. CAELYX was however associated with stable disease, but data were inconclusive with regard to clinical benefit. It warrants further investigation in the context of combination trials.

First choice for total parenteral nutrition: the peripheral route.

Historically, total parenteral nutrition (TPN) has been administered by the central venous route because of the rapid development of thrombophlebitis when TPN solutions are administered into peripheral veins. The insertion and placement of central venous catheters is, however, associated with morbidity and mortality and is the main cause of TPN-related complications. By avoiding central venous catheterization, TPN can be made safer. Current awareness about the pathophysiology of peripheral vein thrombophlebitis and the use of a number of techniques that prevent or delay onset of peripheral vein thrombophlebitis mean it is now possible to administer TPN via the peripheral route. These techniques and changes in the practice of TPN in recent years (eg, reduction of caloric loads and use of lipid emulsions) mean peripheral parenteral nutrition is a technique that is now applicable to the majority of hospitalized, nutritionally compromised patients for whom intravenous feeding is anticipated for less than 10 to 14 days.

Transdermal glyceryl trinitrate to allow peripheral total parenteral nutrition: a double-blind placebo controlled feasibility study.

Seventy-two consecutive patients requiring total parenteral nutrition (TPN) were randomized to two groups. Group A received daily a peripheral intravenous regimen which provided 10 g nitrogen and 1400 non-nitrogen kcal (5.9 MJ). Group B received daily a peripheral intravenous regimen which delivered 9.4 g nitrogen and 1900 non-nitrogen kcal (8.0 MJ). Each group was further randomized to receive a self-adhesive patch of transdermal glyceryl trinitrate (GTN) or an identical placebo. Infusion survival was the main end-point. For group A, the median time of infusion survival was 74 h (range: 58-100) in the control group compared with 108 h (range: 68-156) in the group that received transdermal GTN (P less than 0.001). For group B, the median infusion survival was 67 h (range: 46-92) in the control group compared with 103 h (range: 66-151) in the treatment group (P less than 0.001). TPN is feasible via peripheral veins and the incidence of infusion failure can be effectively reduced by transdermal GTN.

The effect of surgery and nutritional regimen on plasma lipoproteins and fat metabolites in man.

Plasma lipoproteins and fat metabolites were measured before and during the first five post-operative days in patients undergoing elective abdominal surgery of moderate severity. They received nutrition as total parenteral nutrition (TPN) or 4% dextrose saline (D S ) or isotonic aminoacids (IAA). Surgery caused an immediate fall in total and very low density lipoprotein triglyceride and total high density lipoprotein cholesterol but a rise in the high density lipoprotein subfraction 2 cholesterol. The increase in total triglyceride after 5 post-operative days was due principally to changes in triglyceride not carried by very low density lipoprotein and was related to the type of nutrition provided. There was no evidence of impaired intra-vascular lipolysis.

An economic evaluation of transdermal glyceryl trinitrate in the prevention of intravenous infusion failure.

A common cause of peripheral intravenous infusion failure is due to the patient developing phlebitis or extravasation. Recent clinical trials indicate that the use of transdermal glyceryl trinitrate (GTN patches) can reduce the incidence of infusion failure and hence the costs of re-infusion. In this study we conduct an economic evaluation of this new pharmaceutical application to determine whether the use of such patches results in hospital resource cost savings. Time-to-first infusion failure probabilities from a placebo-controlled trial are used to model the sequential failure problem as a Markov process. Using estimated staff and materials costs for first and subsequent infusions, we calculate the expected cost per infused patient to time t for treatment and control groups. Using this simple comparative cost method, results indicate that the net impact on hospital resources from patch usage is dependent upon the total required length of infusion time. Analysis of infusion time thresholds indicates that for patients requiring long-term (t greater than 50 hours) periods of infusion the use of patches is likely to generate resource savings. We conclude that to realize such resource savings clinical decisions to infuse with GTN patches should incorporate the prior probability that the total required length of infusion time exceeds 50 hours.

Podophyllin versus scissor excision in the treatment of perianal condylomata acuminata: a prospective study.

Thirty-seven patients with previously untreated perianal condylomata acuminata were randomly treated by application of 25 per cent podophyllin or scissor excision. The result of treatment was assessed by an independent observer. At 6 weeks, scissor excision completely cleared the warts from 16 of 18 patients (89 per cent) compared with 15 of 19 patients (79 per cent) treated with podophyllin. Following complete clearance by surgery, two patients had recurrent warts at 18 weeks and a further single patient at 42 weeks, giving a cumulative recurrence rate of 19 per cent. In contrast, five of 15 patients whose warts were cleared by podophyllin had recurrent warts at 18 weeks and a further four at 42 weeks representing a cumulative recurrence rate of 60 per cent (X2 = 3.95, d.f. = 1, P = 0.05). At 42 weeks six patients (32 per cent) were free of disease in the podophyllin group compared with 13 (72 per cent) in the scissor excision group (X2 = 4.6, d.f. = 1, P = 0.03). Scissor excision is therefore preferable to podophyllin application in the treatment of perianal condylomata acuminata.