Secondary colonic stent insertion in acute large bowel obstruction following primary stent failure.

INTRODUCTION: Colonic stent insertion has been shown to be an effective treatment for patients with acute large bowel obstruction, either as a bridge to surgery or as definitive treatment. However, little is known of the role of secondary stent insertion following primary stent failure in patients considered inappropriate or high risk for emergency surgery. METHODS: Fourteen patients presenting with acute large bowel obstruction who had previously been treated with colonic stent insertion were studied. All underwent attempted placement of a secondary stent. RESULTS: Technical deployment of the stent was accomplished in 12 patients (86%) but only 9 (64%) achieved clinical decompression. Successful deployment and clinical decompression of a secondary stent was associated with older age (p=0.038). Sex, pathology, site of obstruction, duration of efficacy of initial stent and cause of primary failure were unrelated to outcome. No procedure related morbidity or mortality was noted following repeated intervention. CONCLUSIONS: Secondary colonic stent insertion appears an effective, safe treatment in the majority of patients presenting with acute large bowel obstruction following failure of a primary stent.

Ileal MALT lymphoma causing massive gastrointestinal haemorrhage revealed on computed tomography angiography.

Primary MALT lymphomas affecting the ileum are rare, and their presentation with massive haemorrhage exceptional. This report describes such a case. The patient presented with melaena and haemodynamic instability, but normal upper gastrointestinal endoscopy. Subsequent imaging with multi-detector row computed tomography angiography both localised the bleeding source to the ileum and identified the underlying tumour, resulting in considerably earlier introduction of appropriate management. The patient made an excellent recovery and remains in remission.

Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision?

INTRODUCTION: Local excision is considered inappropriate treatment for T3-T4 rectal adenocarcinomas, as it cannot provide prognostic information regarding lymph node involvement and has a high risk of pelvic recurrence. Preoperative chemoradiation (CRT) studies in rectal cancer suggest that a pathological complete response (pCR) in the primary tumour provides an excellent long-term outcome. If downstaging to stage pT0 predicts a tumour response within the perirectal and pelvic lymph nodes, this may allow local excision to be performed without increased risk of pelvic recurrence. This retrospective study aimed to determine the incidence of involved lymph nodes following pCR (ypT0) after preoperative CRT and total mesorectal excision. METHOD: The outcome and treatment details of 211 patients undergoing preoperative CRT for clinically staged T3-T4 unresectable rectal adenocarcinomas between 1993 and 2003 at Mount Vernon Hospital were reviewed. RESULTS: Data were recorded from the 143 patients who completed treatment with a median follow-up of 25 months. Twenty-three patients (18%) were found to have had a pCR. Four out of 23 patients (17%) had involved lymph nodes. No pelvic recurrences developed after a ypCR. Overall survival was similar for patients with ypT0 or residual tumour. CONCLUSION: Pathological complete response in the primary tumour failed to predict a response in the perirectal lymph nodes (p=0.08). The degree of response predicted a lymph node response (p=0.02). The detection of ypCR identified patients with a low rate of pelvic recurrence. This may in the future allow selection of patients for whom local excision can be performed without a higher risk of local relapse.

The reliability of lymph-node staging in rectal cancer after preoperative chemoradiotherapy.

AIMS: To determine the prognostic significance of the nodal stage and number of nodes recovered in the surgical specimen after preoperative synchronous chemoradiation (SCRT) and surgery for locally advanced or unresectable rectal cancer. MATERIALS AND METHODS: One hundred and eighty-two consecutive patients with locally advanced or unresectable (T3/T4) rectal carcinomas were entered on a prospective database and treated in this department with preoperative chemoradiation, followed 6-12 weeks later by surgical resection. Most patients received chemotherapy in the form of low-dose folinic acid and 5-fluorouracil (5-FU) 350 mg/m2 via a 60-min infusion on days 1-5 and 29-33 of a course of pelvic radiotherapy delivered at a dose of 45 Gy in 25 fractions over 33 days to a planned volume. After resection, patients with a positive circumferential margin (< or = 1 mm), extranodal deposits or Dukes' C histology received adjuvant 5-FU-based-chemotherapy (n = 40). RESULTS: After SCRT, 161 patients underwent resection. Twenty-one patients remained unresectable or refused an exenterative operation. Median follow-up is 36 months. Down-staging was achieved in most patients, with 19 having a complete pathological response (pT0). The median number of lymph nodes recovered for all patients was five (range 0-21). The 3-year survival rate for node-positive patients is 47%, for node-negative patients with less than three lymph nodes recovered is 62% and for node-negative patients with three or more lymph nodes recovered is 70%. Compared with node-positive patients, simple regression models revealed a reduced hazard ratio (HR) of 0.72 (0.36-1.43) for node-negative patients with less than three nodes recovered and 0.48 (0.26-0.89) for node-negative patients with three or more lymph nodes recovered. In a multivariate model, including nodal status, excision status, age and sex only positive excision margins significantly predicted a poor outcome: HR = 3.05 (1.55-5.97). CONCLUSIONS: The number of nodes found after preoperative chemoradiation is a significant prognostic factor by univariate analysis. In this study, patients with node-negative histology, and at least three nodes recovered, had better long-term survival than patients in whom two or less nodes were recovered or with positive nodes. This effect was attenuated by the inclusion of excision status in multivariate models.

Preoperative ECF chemotherapy in gastro-oesophageal adenocarcinoma.

Epirubicin, cisplatin and continuous 5-fluorouracil (5-FU) infusion (ECF) has been reported to result in high clinical response rates in advanced gastro-oesophageal adenocarcinoma and is currently the 'gold standard' chemotherapy regimen for this tumour site. Despite this, its role as preoperative (neoadjuvant) treatment is unproven and therefore remains under investigation. We report our experience using ECF (intravenous epirubicin 50 mg/m2 and cisplatin 60 mg/m2 every 3 weeks, with continuous infusion of 5-FU 200 mg/m2 per day) as preoperative treatment in locally advanced adenocarcinoma of the lower oesophagus, gastro-oesophageal junction and stomach. Of the 23 patients treated (median age 54 years), 19 had potentially resectable disease, four were unresectable and seven had radiological evidence of lymph node involvement. A median of four cycles of ECF was delivered (range 1-6). Ten of 12 patients (83%) with dysphagia reported improvement of symptoms. Clinical disease progression occurred in six patients (26%) during chemotherapy. WHO grade 3 or 4 toxicity occurred in six patients (26%): four haematological, one mucositis, one vomiting. Seventeen patients (74%) proceeded to surgery; 14 (61%) were resected and three were unresectable. There were two (12%) postoperative deaths from respiratory failure. Major pathological response was seen in three patients (13%): one pathological complete response, two microscopic residual disease. Two patients had Stage II (T2N(0-1)) disease and nine were Stage III (T(3-4)N(0-1)). None of the patients with initially unresectable disease was rendered resectable. After a median follow-up interval of 33 months (range 26-53), the overall median survival was 12 months and 2-year survival was 30%. All patients who were initially unresectable or had radiological evidence of lymph node involvement have died. Therefore, despite good symptomatic response rates, ECF chemotherapy given in the preoperative setting did not appear to improve the outcome of patients with unresectable or radiologically lymph node-positive gastro-oesophageal adenocarcinoma. The role of ECF chemotherapy in resectable tumours is unclear and is currently under investigation in the randomized MRC Adjuvant Gastric Infusional Chemotherapy (MAGIC) study.

Radiofrequency tissue volume reduction of the soft palate in simple snoring.

BACKGROUND: Snoring is common and often associated with social morbidity. Current therapies are generally unsatisfactory, but radiofrequency tissue volume reduction (RFTVR) palatoplasty offers a new approach. OBJECTIVE: To assess the outcomes and morbidity associated with RFTVR palatoplasty. DESIGN: Open, prospective trial. SETTING: Tertiary referral center. PATIENTS: 20 adults with loud habitual snoring without clinically significant obstructive sleep apnea. INTERVENTIONS: Three treatments with RFTVR to the middle, distal, and proximal thirds of the midline of the soft palate. MAIN OUTCOME MEASURES: Clinical assessment (visual analog scores) before and after each treatment, polysomnography (with sound intensity measurements), and lateral cephalometry performed prior to the first treatment and 2 months following the final treatments. RESULTS: After treatment, there was a significant overall improvement in the snoring visual analog score (7.5+/-1.5 to 4.6+/-2.5; P<.001), a small reduction in the proportion of sleep spent snoring at 50 to 60 dB (P = .03), and mild pain that was controlled with simple analgesia. There were no long-term adverse effects. Individual response could not be predicted by demographic, polysomnographic, or cephalometric data. Treatment of the proximal third of the soft palate was associated with fewer adverse effects but also seemed less effective than at the other sites. CONCLUSIONS: (1) The RFTVR palatoplasty is well tolerated with very low morbidity. (2) It is associated with subjective improvement in snoring in most patients. (3) Placement of lesions seems to influence outcome. (4) The improvement is accompanied by a marginal change in objective measurements, suggesting either an acoustic change independent of sound intensity or a placebo effect. (5) A randomized controlled trial is needed to further evaluate this therapy.

An approach to ear, nose and throat assessment.

An approach is described for assessing ear, nose and throat problems, which may be of assistance to general practitioners in diagnosing common ENT problems. Making an ENT diagnosis requires your well honed skills of history taking and examination. This is aided by a few examination tools.

Detection of mycobacterial rRNA in sarcoidosis with liquid-phase hybridisation.

Because sarcoidosis resembles tuberculosis clinically and histologically, it has been suggested that mycobacteria might have a role in the pathogenesis of the disorder. Mycobacteria have not been found in sarcoid tissues by conventional culture techniques, so we have used a liquid-phase hybridisation method to see whether we could detect mycobacterial rRNA in such tissues. RNA was extracted from five sarcoid and five normal spleens. Extracts were assayed by liquid-phase DNA/RNA hybridisation with a DNA probe specific for the rRNA of the Mycobacterium tuberculosis complex. Hybridisation obtained with the sarcoid spleens, from which mycobacteria were neither seen on microscopy nor cultured with standard methods, was 4.8 times higher than that with normal spleens (p less than 0.001). Our demonstration of mycobacterial nucleic-acid components in sarcoid splenic tissues supports the notion that mycobacteria play a part in the cause of sarcoidosis.

Observations on the Kveim reaction using an animal model of granulomatous bowel disease.

Striking differences were observed between the visceral and cutaneous responses after tests with validated Kveim and normal spleen suspensions in a guinea pig model of granulomatous bowel disease. Five of six animals sensitised with BCG showed positive responses at the ileal Kveim test site whereas all six had negative cutaneous Kveim tests. Conversely, two of six animals sensitised with irradiated Mycobacterium leprae showed positive cutaneous Kveim tests and only one a positive response in the ascending colon. All six showed negative responses at the ileal Kveim test site. No positive visceral or cutaneous responses were observed in either group of animals after tests with normal spleen suspension. These findings are discussed in relation to the positive Kveim responses previously reported among patients with Crohn's disease, tuberculoid and lepromatous leprosy, and among seemingly healthy BCG vaccinated subjects. The findings provide further evidence in support of a possible mycobacterial aetiology for sarcoidosis and Crohn's disease.

Effect of the immune modulating agents cyclophosphamide, methotrexate, hydrocortisone, and cyclosporin A on an animal model of granulomatous bowel disease.

This study was undertaken to determine the effect of cyclophosphamide, methotrexate, hydrocortisone, and cyclosporin A on a model of granulomatous infiltration in the terminal ileum and draining lymph nodes of the guinea pig. Treatment groups of six animals were used and compared to untreated groups of 12. Epithelioid cell granulomas and primary macrophage granulomas were induced by the inoculation of BCG (Pasteur) and irradiated Mycobacterium leprae respectively into the terminal ileum of the guinea pig. The response to purified protein derivative of tuberculin was reduced in both groups of animals receiving any of these agents. Cyclophosphamide and methotrexate treated animals inoculated with BCG or M leprae showed a significant reduction of granulomatous infiltration at the inoculation site (p less than 0.05 and p less than 0.001 respectively). BCG inoculated animals treated with either hydrocortisone or cyclosporin A showed no reduction in granulomatous infiltration at either the inoculation site or the draining lymph nodes. By contrast M leprae inoculated animals receiving either of these agents showed a significant reduction of granulomatous infiltration at both the inoculation site (p less than 0.001) and in the primary draining lymph node (p less than 0.001). Ziehl Neelsen staining showed an increased proportion of animals with detectable acid fast bacilli (AFB) at the inoculation site in the groups receiving hydrocortisone (50%) and methotrexate (67%) compared to untreated controls (8%). No AFB were observed in any of the animals inoculated with M leprae. In conclusion, this model may be helpful in elucidating the mechanism of T lymphocyte response in Crohn's disease and the variable clinical response seen with the use of immunosuppressive agents in this condition.

Duplication of the vermiform appendix. Report of a case: review of the classification and medicolegal aspects.

Duplication of the vermiform appendix is uncommon; however appendicectomy is frequently performed. Failure to recognize this condition may have serious clinical and medicolegal consequences. A case is reported and the classification reviewed; medico-legal aspects are discussed. A greater awareness of the condition amongst junior surgical staff is recommended.

An experimental animal model of granulomatous bowel disease.

A study has been undertaken of the granulomatous response induced in the ascending colon and terminal ileum of the guinea pig by the direct inoculation of mycobacterial antigens. Live BCG (Pasteur) 2 x 10(7) at two weeks induced epithelioid cell granulomas in both large and small bowel and in the draining lymph nodes. The area of infiltration was significantly greater for a given inoculum in the large bowel. Acid fast bacilli were present on Ziehl Neelson stained sections of the large bowel infiltrate, but only rarely in sections from the small bowel lesions. The response to skin testing with a standardised amount of purified protein derivative was less in animals inoculated in the small bowel. Inoculation with 2 x 10(9) cobalt irradiated BCG gave rise, at five weeks, to granulomas containing lesser numbers of epithelioid cells and caseation was sometimes evident. There was a similar but smaller difference in the degree of infiltration at the two inoculation sites. Ziehl Neelson staining failed to reveal the presence of acid fast bacilli in any sections of the bowel infiltrates. Skin testing with purified protein derivative gave a response which was greater in animals inoculated in the small bowel. An identical dose of Cobalt irradiated M leprae induced at five weeks a predominantly macrophage granuloma in both the large and small bowel, with no significant difference in the degree of infiltration at the two sites. No acid fast bacilli were seen in Ziehl Neelson stained sections of the bowel and skin testing with purified protein derivative was reduced. These findings and their relevance to studies of the aetiology of Crohn's disease are discussed.