Theoretical evaluation of measurements used to assess the growth of colorectal hepatic metastases.

The measurement of the growth of colorectal hepatic metastases growth provides useful information for the management of patients, and can be used both as a prognostic variable and as an objective assessment of treatment efficacy. A number of techniques have been used to quantify such growth, including measuring the change of an anatomical measure such as tumour size or the percentage hepatic replacement. Cell kinetic studies and analysis of the changes in serum tumour markers such as carcinoembryonic antigen (CEA) are other methods. Anatomical measures are unlikely to be reliable because within the liver a metastasis may change in volume as a consequence of non-neoplastic factors outside the liver. It may also be incorrect to assume that the changes observed in an abnormality identified by radiological methods are the direct result of a change in the neoplastic burden. Measurements of cell kinetics and serum tumour markers are complicated by neoplastic cell heterogeneity across the tumour and are subject to sampling errors. All techniques presently available therefore can be considered to be indirect measures and may not be truly representative of tumour growth. These limitations of growth measurements have to be recognised when applied to the assessment of tumour response.

Cholelithoptysis: an unusual complication following laparoscopic cholecystectomy.

A 75-year old lady underwent a routine laparoscopic cholecystectomy during which stones were spilled into the peritoneal cavity. Despite peritoneal lavage the patient developed chronic right upper quadrant discomfort and a pleural effusion over several months. Following the production of a pigmented bilirubin stone in her sputum the patient's symptoms resolved. Cholelithoptysis is a rare complication of laparoscopic cholecystectomy, the diagnosis should be considered in patients with prolonged chest symptoms after surgery.

The assessment of percentage hepatic replacement using planimetry of computerized tomographic images.

Percentage hepatic replacement (PHR) may be an important factor in assessing prognosis, staging and clinical trial evaluation. Most imaging techniques used to assess PHR rely on subjective interpretation. We have employed the technique of planimetry for the quantitative measurement of PHR from CT scans of patients with colorectal liver metastases. This micro-computer based system was assessed for precision by repeated estimates of CT images of livers with variable metastatic features. Precision was correlated with single and large metastases. Accuracy of CT-planimetry was assessed against cadaveric livers containing metastases for which PHR had been determined by water displacement. For the PHR range 1.2-53.5, the range of percentage error measured was between -12.8 and +8.51. Subjective assessment of PHR scans by individual surgeons and radiologists was varied and idiosyncratic. No significant difference between the two groups could be determined. The greatest errors in the subjective estimates of PHR occurred in the range 5-15%. It is concluded that quantitative methodology must be employed to estimate the percentage hepatic replacement.

Haematoporphyrin derivative--photodynamic therapy of colorectal carcinoma, sensitized using verapamil and adriamycin.

The p-glycoprotein export mechanism may have an effect on the cytotoxicity of chemotherapy or photodynamic therapy (PDT) by reducing cytotoxic drug or photosensitizer concentration within cells. In tissues over-expressing this protein, modulation with verapamil (an antagonist of p-glycoprotein) may be useful in reversing this form of treatment resistance. This study examined the bioactivity of the interaction of photodynamic therapy using Haematoporphyrin derivative (HpD), chemotherapy and the response modifier verapamil. Multicellular spheroids derived from the human colorectal cancer line HRT 18 were used in vitro and bioactivity assessed using growth retardation. Bioactivity was observed to be greatest when all three agents and light irradiation were combined. This application may be clinically useful in the treatment of colorectal carcinoma by improving the efficacy of PDT using HpD.

Efficacy of urgent thoracotomy for trauma in patients attended by a helicopter emergency medical service.

Over a 12-month period the Helicopter Emergency Medical Service underwent 1084 missions attending casualties in the London area. Sixteen patients required an emergency thoracotomy for resuscitation, nine of which were performed at the scene and seven in the emergency department. The median injury severity score of these patients was 29.9 (SIR 11.8) of which 11 had suffered blunt injuries. Medical attention at scene was administered 16.2 min (SIR 4.0) following the London ambulance service receiving the emergency call. Significantly longer time was spent attending patients who had a scene thoracotomy (35.1 min SIR 16.4) compared with those in whom the thoracotomy was performed in the casualty department. No patient in this series survived resuscitative thoracotomy. It is suggested that scene thoracotomy be abandoned and emphasis placed upon the rapid transport of patients to an emergency facility. This enables other resuscitative measures in addition to thoracotomy to be applied effectively and concentrated over a brief period by a multidisciplinary team.

Hepatic portal venous flow in patients undergoing tricuspid valve surgery.

OBJECTIVE: To determine the changes of flow in the hepatic artery and portal vein of patients undergoing tricuspid valve repair together with mitral valve replacement. DESIGN: Non-randomised parallel group study. SETTING: Tertiary referral centre. PATIENTS: 18 patients with mitral valve disease with or without tricuspid regurgitation (age range 46-73; six men) and six patients with coronary artery disease and normal left ventricular function (women age range 39-78; four men). INTERVENTIONS: Mitral valve replacement with or without modified De Vega repair of the tricuspid valve or coronary artery bypass surgery. MAIN OUTCOME MEASURES: Flow in the hepatic artery and portal vein as measured by duplex Doppler flowmetry before and two to four weeks after operation. RESULTS: Preoperative hepatic artery flow was less in patients with mitral valve disease than in patients with coronary artery disease (162.7(13.1) ml.min-1 v 242.5(6.6) ml.min-1, p < 0.05). Portal vein perfusion was significantly reduced only in patients with associated tricuspid regurgitation compared with (844(83) ml.min-1 v 1422(64) ml.min-1 p < 0.05). Hepatic perfusion was unaltered after operation in patients undergoing coronary artery bypass surgery (p > 0.05). Flow in the hepatic artery and portal vein was improved only in patients undergoing mitral valve replacement with associated tricuspid valve repair (p < 0.05). CONCLUSION: Abnormalities of hepatic perfusion can be measured non-invasively in all patients with mitral valve disease but especially in those with associated tricuspid regurgitation needing valve repair. These abnormalities improved two to four weeks after mitral valve surgery and tricuspid valve repair, suggesting that measurement of portal flow might be a useful means of assessing the severity of tricuspid regurgitation.

Squamous carcinoma of the oesophagus. Surgery alone or combined with perioperative radiotherapy?

A retrospective comparison of surgery alone and surgery combined with pre- and post-operative radiotherapy was performed for the treatment of squamous carcinoma of the mid and upper oesophagus. Twenty-five ostensibly curative resections for squamous carcinoma of the oesophagus were performed in the period 1974-1987 by the Lewis oesophagectomy. Patients were well matched for histological stage, sex (14F 11M) and age (range 23-69 years). Five year survival for patients receiving surgery alone was 54.5%. Survival for patients who in addition received adjunctive pre- and postoperative radiotherapy of 5700 cGY was not significantly different. Adjunctive pre- and post-operative radiotherapy was considered to facilitate surgical resections but long term survival was not improved.

Decision making in surgery: a pilonidal sinus.

Pilonidal sinus is an unglamorous surgical condition, often left to juniors, that is difficult to treat. Correct decisions in management may influence the prognosis of the condition by avoiding recurrence and continued sepsis.

Growth rate and percentage hepatic replacement of colorectal liver metastases.

The growth of 32 untreated colorectal liver metastases and hepatic parenchymal volume in 11 patients were studied using planimetry of computed tomographic images. The median percentage hepatic replacement (PHR) of metastases was 0.49 (range 0.09-18.2). At subsequent assessment a median of 72 (range 14-235) days later, metastases were significantly larger with a median PHR of 1.78 (range 0.10-22.9) (P < 0.001). To compare the growth of metastases with variable PHR, logarithmic changes of PHR over 100 days were studied. This parameter was shown to be reduced in metastases of larger volume. The median (interquartile range) non-neoplastic hepatic parenchymal volume was found to increase from 1839 (1647-1997) to 2200 (1590-2401) cm3 (P = 0.005) as metastatic burden increased. These findings suggest that the growth of colorectal hepatic metastases is more complex than a simple process of hepatic replacement.

Sternal fractures.

Sternal fractures have become more common since the introduction of seat belt legislation. However, the injury often heals well with minimal or no sternal deformity. Morbidity and mortality in patients with fractures of the sternum are usually due to other organ injuries.

In vitro modulation of haematoporphyrin derivative photodynamic therapy on colorectal carcinoma multicellular spheroids by verapamil.

Photodynamic therapy has possible applications in the treatment of colorectal carcinoma. The photosensitizer haematoporphyrin derivative (HpD) is selectively retained by tumours. Agents which block p-glycoprotein, an export protein expressed to increased levels in a high proportion of colorectal carcinomas, may modulate photodynamic therapy by reducing HpD efflux from cells. Multicellular spheroids derived from the colorectal cell lines HRT18 and HT29 were incubated for 24 h with 1 microgram ml-1 HpD and 0, 1, 2 and 4 microM verapamil. Bioactivity demonstrated a dose-dependent potentiation of HpD-photodynamic therapy growth retardation. Clonogenic survival of cells disaggregated from spheroids treated with HpD-photodynamic therapy was reduced when spheroids were coincubated with verapamil. The mean(s.e.m.) efflux of HpD from spheroids into fresh medium assessed by fluorimetry was greater in spheroids treated with HpD alone (93.2(18.8) arbitrary units ml-1) than in those treated with verapamil (18.1(2.8) arbitrary units ml-1), P = 0.003. Flow cytometry demonstrated increased HpD fluorescence in cells derived from spheroids coincubated with verapamil over a range of HpD incubation concentrations. Verapamil can potentiate the bioactivity of HpD-photodynamic therapy and HpD may be a substrate for p-glycoprotein.

Accurate method to measure the percentage hepatic replacement by tumour and its use in prognosis of patients with advanced colorectal cancer.

The natural history of patients with colorectal hepatic metastases was studied following resection of the primary tumour. Patients were stratified according to the presence of extrahepatic disease and the percentage hepatic replacement (PHR) measured by planimetry of computed tomographic images. The median(semi-interquartile range (s.i.r.)) PHR of patients without extrahepatic disease was 15.0(10.5) and for those with extrahepatic disease 5.4(2.2) (P less than 0.02). The median(s.i.r.) PHR of all patients was 8.7(8.5). The median(s.i.r.) survival of all patients was 125(85.5) days, 92(114) days for patients with extrahepatic disease and 175(133.5) days for patients with disease confined to the liver (P less than 0.02). A linear correlation between the natural logarithm of PHR and survival was demonstrated (p = -0.76, P less than 0.001) for patients without extrahepatic disease. Extrahepatic disease in patients with colorectal hepatic metastases is a major determinant of survival; PHR has a direct association when extrahepatic disease is absent.

Oesophageal erosion of an Angelchik prosthesis: surgical management using fundoplication.

Complications following insertion of the Angelchik prosthesis are becoming increasingly recognised. We report a 35-year-old patient with both mediastinal migration and intraluminal oesophageal erosion of a prosthesis. Successful management included transthoracic removal combined with a modified onlay fundoplication over the oesophageal defect to prevent gastro-oesophageal reflux.

Assessment of residual urine in men following catheterisation.

There is a certain volume of urine left within the bladder which cannot be drained by a catheter. A dilutional method was used to calculate this residual volume in 15 men; 10 had acute retention secondary to benign prostatic hyperplasia and 5 had permanent indwelling catheters for neurogenic urinary incontinence. The mean catheterised residual volume was 98.53 ml for patients with acute retention and 14.48 ml for patients with long-term catheters. The explanation for higher post-catheterisation volumes in the acute retention group is probably multifactorial; bladder sacculation and diverticula, detrusor tone and reflux may all play a role.

Motorcycle injuries in Bermuda.

Tourists who hire mopeds or motorcycles for personal use have a risk for accident. The incidence of tourist accidents in Bermuda was 1.57 accidents/1000 tourists evaluated over a 6-month period. The accident incidence increased as the tourist population got larger. Tourists of more than 40 years of age had the greatest increase in incidence for accident during this period. The risk of an injury requiring hospital stay was one patient for every 16,000 tourists visiting the island, and usually involved the fracture of an extremity. All accidents, major or minor, resulted in some form of skin injury.