Provocation poliomyelitis: vaccine associated paralytic poliomyelitis related to a rectal abscess in an infant.

OBJECTIVE: . To describe a case of vaccine associated paralytic poliomyelitis (VAPP) and relate this to current UK immunization policy. METHOD: A case report in which the clinical course and factors leading to the diagnosis are described and then related to reports of paralytic poliomyelitis in the literature. RESULTS: The child in this case was left severely disabled by paralytic poliomyelitis. The pathological process was related to a pararectal abscess needing urgent drainage shortly after immunisation. CONCLUSION: The skeletal muscle damage due to the presence of the pararectal abscess may have acted as the 'provocation' in the development of poliomyelitis. Adoption of a policy of initial vaccination by the parenteral route as in the USA and European countries has been shown to greatly reduce this risk. The UK could adopt this policy which would minimise the risk of VAPP, as all recorded paralytic poliomyelitis in the UK in the last decade has been vaccine related.

Diverticulitis of the right colon--experience from Hong Kong.

Diverticulitis affects the right side of the colon more commonly than the left side in the Far East. A consecutive series of 35 patients (mean age 44 years) with right sided diverticulitis seen at this hospital is presented. All had localised pain in the right iliac fossa but systemic upset was uncommon. All but one were thought to have acute appendicitis. Thirty one were explored through a right iliac fossa incision but in more than half this had to be closed and a full laparotomy performed. A correct diagnosis was then made at the time of surgery in 28 (80%). Five patients underwent simple diverticulectomy, the remainder having a right hemicolectomy. On histological analysis most (26) had a single false diverticulum. All patients made a satisfactory recovery from surgery.

Selective regional chemotherapy of unresectable hepatic tumours using lipiodol.

Over a 30 month period from 1987 to 1990, selective hepatic cannulation under fluoroscopic control was performed in 57 consecutive patients with primary and secondary malignancies of the liver. Fifty-three patients were subsequently treated using intra-arterial Lipiodol emulsified with epirubicin. The tumours treated were hepatocellular carcinoma (n = 35), metastatic adenocarcinoma (n = 14), intrahepatic cholangiocarcinoma (n = 3) and leiomyosarcoma (n = 1). For hepatocellular carcinoma the cumulative survival was 38% at one year; the median survival was 12.2 months for Stage I, 6.3 months for Stage II and 0.9 months for Stage III tumours. In metastatic disease the cumulative survival was 63% at one year. These data suggest that targeted intra-arterial chemotherapy with Lipiodol-epirubicin is a useful palliative therapy for patients with Stage I and II HCC, and that a controlled trial of this treatment should be undertaken.

New hope in irresectable hepatoma?

Primary hepatocellular carcinoma (HCC) is mostly irresectable and the survival time is short. Treatment can be palliative but hardly improves survival. Some promising future aspects that should be considered include continuous intra-hepatic chemotherapy (fraught with difficulties but nevertheless worth pursuing), direct percutaneous injection of alcohol into the tumor tissue under ultrasound guidance, as well as cryotherapy of "occult" tumors. Monoclonal technique may help to target toxic therapy to the tumors whereas monoclonal antibodies raised in humans may possibly obviate the imminent dangers of antibody formation that would be an obstacle. Although all this may still smack a little of "Zukunftsmusik" ("music of the future") that would require considerable perseverance and effort before it could be translated into reality, every avenue must of course be explored. Chemical techniques that give rise to new hopes feature radio-labelled lipids selectively retained in foci of hepatocellular carcinomas; research has already gone into the question of retention within the tumor microvasculature, within the extracellular space, and the uptake by tumor cells. The oily anticancer agent SMANCS has already been combined with ethiodol (Lipiodol), an iodine addition product of the ethyl esters of saturated and unsaturated fatty acids, and selectively infused, resulting in a reduction in tumor size, and the survival time also seems to be improved following the use of Lipiodol combined with SMANCS or with other cytotoxic agents. After an encouraging pilot study, we treated 16 patients suffering from HCC, with a combination of Lipiodol and epirubicin, a cytotoxic agent having an enhanced activity against HCC as compared with its parent drug doxorubicin.(ABSTRACT TRUNCATED AT 250 WORDS)

Autotransplantation for renovascular hypertension with complete renal artery occlusion.

We report a personal series of 13 autotransplantation procedures in 12 patients who suffered from severe renovascular hypertension. In all of these cases preoperative investigation demonstrated a viable kidney, despite complete occlusion of the affected renal artery. One-half the patients had stenosis of a milder degree affecting the contralateral kidney. In eight of these patients the operation was considered successful. One patient died due to postoperative superior mesenteric artery thrombosis and two had infarction of the transplanted kidney. A fourth patient lost the autotransplant because of postoperative haemorrhage. It is suggested that if medical treatment fails then autotransplantation should be considered in place of nephrectomy for cases of renovascular hypertension with complete occlusion of the renal artery.

The value and significance of the limited barium enema examination following restorative resection for carcinoma of the rectum.

The results of limited barium enema examinations from a consecutive series of 143 patients who underwent restorative resections for carcinoma of the rectum were studied. An assessment was made of the value of the investigation both in terms of clinical management decisions and also to see whether radiologically detected anastomotic leakage was associated with a higher incidence of tumour recurrence. A study was also made of the incidence of leakage with respect to tumour size, length of the distal resection margin, Dukes' grading and histological differentiation. Results showed that there was a greater incidence of tumour recurrence following anastomoses which leaked, although due to small numbers the figures did not reach statistical significance. There was no relationship between tumour size, grade, differentiation, or length of the distal resection margin, and radiological leakage. We consider that the limited ten day barium enema examination does not contribute significantly to surgical management of these patients, except to define the extent of a leak and in the assessment of new anastomotic techniques. However, we suggest that a larger series may demonstrate a statistically significant increase in pelvic recurrence in patients who developed leakage from the anastomosis. This could dramatically alter the application of the postoperative limited barium enema.

Oncogenes and human cancer--a surgeon's perspective.

Amongst the most significant of the advances that have occurred in molecular biology in the last decade has been the development of our understanding of oncogenes, genes that would seem to be responsible for causing cancer. Subtle genetic differences between tumour cells and their normal counterparts have now been discovered, and there is much excitement being generated as new light is shed on the very roots of malignant change. Much of the technology is complicated and confusing, yet the subject should be one with which practising surgeons have a background understanding, for clinicians will possibly soon be able to utilise the results of this basic scientific research in everyday practice. This review article attempts to explain the background to the discovery of oncogenes, how they act, and how the technology may be able to be clinically used in the future in the battle to overcome cancer.