The current role of staging laparoscopy in oesophagogastric cancer.

INTRODUCTION: Oesophagogastric cancers are known to spread rapidly to locoregional lymph nodes and by transcoelomic spread to the peritoneal cavity. Staging laparoscopy combined with peritoneal cytology can detect advanced disease that may not be apparent on other staging investigations. The aim of this study was to determine the current value of staging laparoscopy and peritoneal cytology in light of the ubiquitous use of computed tomography in all oesophagogastric cancers and the addition of positron emission tomography in oesophageal cancer. METHODS: All patients undergoing staging laparoscopy for distal oesophageal or gastric cancer between March 2007 and August 2013 were identified from a prospectively maintained database. Demographic details, preoperative staging, staging laparoscopy findings, cytology and histopathology results were analysed. RESULTS: A total of 317 patients were identified: 159 (50.1%) had gastric adenocarcinoma, 136 (43.0%) oesophageal adenocarcinoma and 22 (6.9%) oesophageal squamous carcinoma. Staging laparoscopy revealed macroscopic metastases in 36 patients (22.6%) with gastric adenocarcinoma and 16 patients (11.8%) with oesophageal adenocarcinoma. Positive peritoneal cytology in the absence of macroscopic peritoneal metastases was identified in a further five patients with gastric adenocarcinoma and six patients with oesophageal adenocarcinoma. There was no significant difference in survival between patients with macroscopic peritoneal disease and those with positive peritoneal cytology (p=0.219). CONCLUSIONS: Staging laparoscopy and peritoneal cytology should be performed routinely in the staging of distal oesophageal and gastric cancers where other investigations indicate resectability. Currently, in our opinion, patients with positive peritoneal cytology should not be treated with curative intent.

Portal hypertension and hypersplenism in a patient with a Bochdalek hernia: a case report.

BACKGROUND: A congenital diaphragmatic hernia (Bochdalek's hernia) rarely presents in adulthood. CASE PRESENTATION: We present the case of a 21-year-old woman with thrombocytopenia secondary to hypersplenism due to left-sided (sinistral) portal hypertension. This portal hypertension was caused by strangulation of the spleen within a Bochdalek's hernia. Subacute gastric volvulus compounded by portal hypertensive gastropathy resulted in her presentation with acute haematemesis. CONCLUSIONS: Congenital diaphragmatic hernias may present in the adult. Their presentation is variable, and they may produce life-threatening complications.

Combined antioxidant therapy reduces pain and improves quality of life in chronic pancreatitis.

Patients with chronic pancreatitis (CP) typically suffer intractable abdominal pain that is resistant to most analgesic strategies. Recent research indicates that the pain of CP may be in part due to oxygen free radical induced pancreatic damage. Using a randomized, double-blind, placebo-controlled crossover trial, we evaluated the efficacy of a combined antioxidant preparation in the management of CP. Patients with confirmed chronic pancreatitis (N = 36) were randomized to receive treatment with either Antox, which contains the antioxidants selenium, betacarotene, L-methionine, and vitamins C and E, or placebo for 10 weeks. Each group of patients then switched to receive the alternative treatment for a further 10 weeks. Markers of antioxidant status were measured by blood sampling, whereas quality of life and pain were assessed using the SF-36 questionnaire. Nineteen patients completed the full 20 weeks of treatment. Treatment with Antox was associated with significant improvements in quality of life in terms of pain (+17 antioxidant vs. -7 placebo), physical (+9 vs. -3) and social functioning (+8 vs. -7), and general health perception (+10 vs. -3). We conclude that treatment with antioxidants may improve quality of life and reduce pain in patients suffering from chronic pancreatitis.

The probiotic bacterium Lactobacillus plantarum species 299 reduces intestinal permeability in experimental biliary obstruction.

AIMS: Extrahepatic biliary obstruction is associated with the failure of intestinal barrier function, allowing bacteria and other substances from the intestine to enter the circulation and initiate a systemic inflammatory response, causing impairment of organ function. Probiotic bacteria have been shown to have beneficial effects on intestinal barrier function in other conditions, but their effects have never been studied in biliary obstruction. METHODS AND RESULTS: This study examined the effects of enteral administration of Lactobacillus plantarum species 299 (LP299) in oatmeal fibre compared with sterile oatmeal fibre in water or water alone in an animal model of biliary obstruction. Administration of LP299 was associated with reduced intestinal permeability compared with sterile oatmeal alone (0.262 +/- 0.105%vs 0.537 +/- 0.037%, P=0.019, percentage excretion of (14)Carbon), but there was no evidence of reduced endotoxin exposure or blunting of the systemic inflammatory response. Animals receiving sterile oatmeal fibre alone also failed to develop the hyperpermeability after biliary obstruction seen in animals receiving water only (0.512+/- 0.05%vs 0.788 +/- 0.18%), suggesting that oatmeal itself may have some beneficial effects on intestinal barrier function. CONCLUSION: Enteral administration of the probiotic bacterium LP299 reduces intestinal hyperpermeability associated with experimental biliary obstruction. SIGNIFICANCE AND IMPACT OF THE STUDY: This study provides insight to direct further work into the modulation of intestinal barrier function by probiotic bacteria.

Patterns of bacterial translocation in experimental biliary obstruction.

INTRODUCTION: Biliary obstruction is associated with impaired intestinal barrier function and translocation of enteric bacteria to the systemic circulation. Traditional live culture techniques may overlook translocation of dead bacterial fragments that stimulate the inflammatory response. The aim of this study was to estimate the extent and pattern of bacterial translocation in experimental biliary obstruction. MATERIALS AND METHODS: Thirty 9-week-old male Wistar rats were randomized to undergo bile duct ligation (BDL, n = 20) or sham operation (n = 10). Seven days after operation, each animal received 1 ml of (111)indium-oxyquinolone-labeled Escherichia coli p.o. Samples of liver, spleen, mesenteric lymph nodes, and lung were harvested 4 h later and analyzed for live bacteria and (111)indium activity. RESULTS: There was significantly more live bacterial translocation detected in BDL animals than in sham-operated animals (P = 0.00008, chi(2)). Labeled bacterial fragments were detected in all locations sampled in all animals. Sham-operated animals had significantly more labeled bacterial fragments detected in the liver (P = 0.0001) and the spleen (P = 0.03) than the BDL animals. The mean total bacterial survival in the BDL group was 30 +/- 13% and 0% in the sham operated group. CONCLUSION: These results demonstrate that non-viable bacterial fragments are present in sterile extra-intestinal sites in normal animals and that translocation of live bacteria is markedly increased in experimental biliary obstruction. These results also suggest that failure of bacterial killing is an important factor facilitating bacterial translocation in the presence of established biliary obstruction.

Glutamine improves intestinal barrier function in experimental biliary obstruction.

OBJECTIVE: To determine the effects of enteral administration of glutamine on intestinal barrier function in experimental biliary obstruction. BACKGROUND: Extrahepatic biliary obstruction is associated with the failure of intestinal barrier function, allowing bacteria and other substances from the intestine to enter the circulation and initiate a systemic inflammatory response, causing impairment of multiple organs. The amino acid glutamine has been shown to improve intestinal barrier function in other conditions, but its effects in biliary obstruction have not been fully examined. METHODS: This study examined the effects of enteral administration of glutamine on intestinal permeability and on bacterial translocation from the intestine in a rodent model of biliary obstruction. RESULTS: Glutamine was shown to reduce intestinal permeability measured as percentage excretion of 14C 7 days after biliary obstruction (0.35+/-0.03 vs. 0.56+/-0.085% in controls, p=0.028), and glutamine administration was also associated with a decreased incidence of bacterial translocation to extra-intestinal sites (p=0.03). Radiolabelled bacterial studies also demonstrated reduced translocation of bacterial fragments to extra-intestinal sites in glutamine-treated animals (p=0.01). There was also some evidence of decreased exposure to endotoxin, reduced systemic inflammation and increased bacterial killing by the immune system in glutamine-treated animals. CONCLUSIONS: Glutamine modulates intestinal permeability and reduces bacterial translocation in an animal model of experimental biliary obstruction and may increase bacterial killing by the immune system.

Feeding jejunostomy: is there enough evidence to justify its routine use?

BACKGROUND AND AIM: Intraoperative placement of feeding jejunostomy is a well-established method of providing access to enteral feeding. However, some studies describe serious complications related to this procedure. A retrospective study was undertaken to look at the technical complications related to the procedure. PATIENTS AND METHODS: Patients undergoing feeding jejunostomy in the thoracic and upper gastrointestinal surgical units at the Royal Victoria Hospital between January 1998 and December 1998 were included in the study. The charts of all the patients were studied retrospectively. RESULTS: Forty-two patients underwent a feeding jejunostomy in the time period studied. Thirty-one patients had a jejunostomy as an adjunct to major oesophageal or gastric surgery. In 5 patients, feeding jejunostomy was performed in conjunction with other palliative procedures and in 6 patients, it was performed as a sole procedure. Nine (21.4%) patients had procedure-related complications. Of these, 7 (16.7%) were minor including dislodgment of the tube (n = 4), blocked tube (n = 2), and intraoperative catheter damage (n = 1). Two (4.7%) patients had major complications requiring emergency laparotomy. One of these patients died as a result of a procedure- related complication. CONCLUSION: Feeding jejunostomy is associated with high morbidity and mortality. Its routine use may not be justified in the absence of evidence to support its use.

Treatment of infantile hypertrophic pyloric stenosis in a district general hospital: a review of 160 cases.

BACKGROUND: Ramstedt's pyloromyotomy has long been the standard operation for the treatment of infantile hypertrophic pyloric stenosis. Controversy exists over whether this procedure can be performed safely in the district general hospital setting or whether it should be restricted to specialist pediatric units only. METHODS: Retrospective analysis was performed on the medical records of a series of 160 infants treated by Ramstedt's pyloromyotomy by 2 surgeons in a district general hospital over 16 years. RESULTS: There was no perioperative mortality. Oral feeding was achieved by 24 hours in 76% of infants, and there was persistent vomiting in only 3.8%. Wound discharge was encountered in 4.4% and confirmed wound infection in 1.3%. Wound dehiscence occurred in 1.9% of infants. Inadvertent mucosal perforation occurred in 19% of cases, although all cases were recognized and repaired at once with no apparent ill effects. These results are comparable with those reported from specialist pediatric units and from pediatric surgeons working within general surgical units. CONCLUSIONS: Infantile hypertrophic pyloric stenosis can be treated safely in a district general hospital when care is provided by appropriately trained surgical, anesthetic, and pediatric staff.

Fibrosarcoma of the brachial plexus presenting in childhood.

We report a case of malignant fibrosarcoma involving the brachial plexus presenting in childhood. Primary malignant tumours of the brachial plexus are rare entities. In particular, fibrosarcoma of the brachial plexus occurring in a child has not been previously reported. Dilemmas in resolving the management and long-term consequences of this condition are discussed.

Seat-belt syndrome revisited.

This report describes a complex syndrome of injuries occurring in a young female who was a back seat passenger wearing a lap-belt restraint in a high-speed road traffic accident. As a consequence of the forced flexion distraction injury of her lumbar spine, she sustained a fracture-subluxation of the first lumbar vertebra in association with a jejunal perforation and extensive small intestinal mesenteric laceration. She also had a large traumatic hernia of the anterior abdominal wall, which was overlooked at primary laparotomy. This report highlights collectively the classical combination of injuries associated with the lap-belt syndrome and demonstrates the importance of carefully inspecting the anterior abdominal wall for deficiencies, because traumatic herniation may be easily overlooked.

Kupffer cell blockade, tumour necrosis factor secretion and survival following endotoxin challenge in experimental biliary obstruction.

BACKGROUND: Gram-negative sepsis and its sequelae frequently complicate invasive procedures in patients with obstructive jaundice. In response to endotoxin, Kupffer cells secrete tumour necrosis factor (TNF), a pivotal early mediator of sepsis. An investigation was carried out into the specific role of Kupffer cell TNF secretion following endotoxin challenge in obstructive jaundice. METHODS: Survival following intraperitoneal administration of endotoxin (2.0, 0.02 and 0.0002 mg per 100 g) was determined in rats following bile duct ligation (BDL) or sham operation. Plasma TNF concentration was quantified following endotoxin administration (0.0002 mg per 100 g) at 1, 2 and 6 h. Subsequently, the effect of Kupffer cell blockade by gadolinium chloride on survival and plasma TNF concentration was assessed. RESULTS: Jaundiced animals showed a significantly increased mortality rate following intraperitoneal injection of endotoxin 2.0 mg per 100 g (BDL 100 per cent versus sham 0 per cent) and 0.02 mg per 100 g (BDL 70 per cent versus sham 0 per cent; P = 0. 002, Fisher's exact test). Median plasma TNF concentration was significantly greater in jaundiced animals 1 h after endotoxin administration (BDL 943 (interquartile range (i.q.r.) 211-3900) pg/ml versus sham 64 (i.q.r. 47-127) pg/ml; P = 0.002, Mann-Whitney U test). Kupffer cell blockade with gadolinium chloride increased the survival rate following endotoxin administration in BDL animals (BDL-GdCl3 100 per cent versus BDL-saline 40 per cent; P = 0.0003, Fisher's exact test) and decreased median plasma levels of TNF (BDL-GdCl3 88 (i.q.r. 0-1065) pg/ml versus BDL-saline 16 550 (1255-29 360) pg/ml; P = 0.002, Mann-Whitney U test). CONCLUSION: Kupffer cell blockade improved survival and suppressed systemic TNF activity after endotoxin challenge. In obstructive jaundice, hypersecretion of TNF by Kupffer cells may supplement systemic cytokine production and be responsible for significant complications.

Crohn's disease and colorectal malignancy.

There has been much debate over the past 50 years concerning the association between colorectal carcinoma and inflammatory bowel disease. Until recently, it was widely accepted there was a higher risk in those with widespread ulcerative colitis. However, evidence now suggests an almost equal incidence in those with Crohn's disease of similar extent and duration. We present a case that underlines the important clinical and pathological features of Crohn's disease associated colorectal carcinoma (CDAC). We present a literature review and debate the role of regular colonic surveillance in patients with Crohn's disease affecting the colon.