Peri-operative radiotherapy for rectal cancer: the case for a selective pre-operative approach - the third way.

Peri-operative radiotherapy has been used widely in addition to surgery in an attempt to reduce local recurrence (LR) following surgical resection of rectal cancer. Currently different groups follow different approaches with some routinely administering one weeks pre-operative radiotherapy to all cases of operable mobile cancer with others favouring postoperative chemoradiotherapy for selected high risk groups. In this review we bring together the changes in surgery, pathology and imaging that have occurred in recent years and together with the data from recent randomized pre-operative radiotherapy trials propose a logical and optimal way of managing rectal cancer. This third way is selective and pre-operative and should ensure a low rate of LR with radiotherapy reserved for those cases that need it.

Venous thromboembolism. Prophylaxis on a Saturday morning in a district hospital.

BACKGROUND: Implementation of guidelines to prevent venous thromboembolism (VTE) is essential to help guide junior medical staff but adherence to such protocols is insufficient. This study aims to audit the use of VTE prophylaxis (Tinzaparin 3500 units and/or thromboembolic deterrent stockings (TED) in general surgical inpatients in a district hospital on a random day at the beginning (Group A) and at the end of the junior house officer's 6 monthly term (Group B). METHODS: Patients were analyzed within the subgroups elective and emergency admissions and assessed regarding the appropriate prescription of tinzaparin and TED-stockings. The presence of a significant time lag between patients arriving on the ward and VTE-prophylaxis being prescribed was documented. RESULTS: Tinzaparin was appropriately prescribed or not prescribed if contraindicated in 86% of elective admissions in Group A (versus 91% in Group B) and in 58% of emergency admissions in Group A (versus 85% in Group B). The subcutaneous injection of tinzaparin was commenced on the day of admission in 67% in Group A and in 75% of patients in Group B. CONCLUSIONS. Despite the institution of local guidelines adherence to such recommendations appears to be sub-optimal even at the end of the junior house officer's 6 monthly term when one would expect a higher vigilance.

Thrombosis within an external jugular venous aneurysm.

Jugular plebectasia is rare, and most patients present in childhood. We describe a thrombotic episode within an external jugular venous aneurysm in an adult. This has not previously been described in the medical literature.

Bilateral and recurrent obturator hernia.

Obturator hernia is a rare condition which was first described in 1722 by de Ronsil. It occurs most commonly in elderly women who have lost weight and may strangulate in 25-100% of cases. Strangulated obturator hernia has a mortality as high as 10-50%, which is partly due to delay in diagnosis. A patient who developed three obturator hernias is described.

Cell renewal in non-specific duodenitis, ulcer-related duodenitis and duodenal ulcer. Experiments in Mastomys (Praomys natalensis).

Cell renewal in the duodenal mucosa of Mastomys was studied by autoradiography 1 and 24 h after intraperitoneal injection of tritiated thymidine. Non-specific duodenitis and duodenal ulceration were produced with a continuous infusion of histamine. Mucosal renewal in the duodenum of 30 control Mastomys was compared with 30 which received histamine dihydrochloride for 5 days. No abnormality developed in the controls, but 11 of the experimental group developed non-specific duodenitis and 12 duodenal ulcers. The size of the proliferative zone was increased in the Mastomys sacrificed 1 h after injection of tritiated thymidine which received histamine, compared with controls (p = 0.004). The number of labelled nuclei (p = 0.0003) and the size of the columns of labelled nuclei (p = 0.001) were increased in the Mastomys receiving histamine and sacrificed 24 h after injection of tritiated thymidine, compared with controls. The number of labelled nuclei (p = 0.004) and the size of the columns of labelled nuclei (p = 0.01) were increased in the Mastomys with ulcers compared with the other Mastomys which had received histamine. Cimetidine prevented duodenitis and ulceration, normalising the pattern of cell renewal. There was correlation between the severity of non-specific and ulcer-related duodenitis as judged by Lance's system and the number of labelled nuclei (Spearman rank correlation coefficient 0.771, p less than 0.002). Cell renewal increased as duodenitis became more severe and duodenal ulcers were found in duodenal mucosa where cell renewal was fastest.

Non-steroidal anti-inflammatory drug ingestion: retrospective study of 272 bleeding or perforated peptic ulcers.

The ingestion of non-steroidal anti-inflammatory drugs (NSAID) in 272 patients with bleeding or perforated peptic ulcer was compared with 272 age/sex matched controls. A significantly higher proportion of patients with gastric ulcers had received NSAID than those with duodenal ulcers. Twelve of 90 (13%) patients admitted with bleeding duodenal ulcers had received NSAID compared with 11 of 26 (42%) patients with bleeding gastric ulcers (P = 0.003). Sixteen of 132 (12%) patients with perforated duodenal ulcer were taking NSAID compared with 8 of 24 (33%) patients with perforated gastric ulcer. Thirty eight percent of patients with both bleeding and perforated gastric ulcers had received NSAID compared with 13% bleeding and perforated duodenal ulcers (P less than 0.002). This study confirms the association of NSAID and complicated peptic ulcer in patients of over 65 years and highlights the particular susceptibility of the gastric mucosa to their injurious effect.

Dysplasia and carcinoma in the rectal stump of total colitics who have undergone colectomy and ileo-rectal anastomosis.

From a group of 374 patients with ulcerative colitis who underwent colectomy and ileo-rectal anastomosis between 1952 and 1976, 104 presented for follow-up rectal biopsies over a 5 year period to 1986. These patients have been followed for an average of 28 years since the onset of the disease (range 11-56) and provide a unique model for the study of the development of carcinoma in colitis. A total of 443 biopsies was examined and epithelial morphology assessed according to the classification of Riddell et al. (1983). Five patients developed carcinoma of whom two showed dysplasia in biopsies taken a year or more before the diagnosis; one showed dysplasia 2 months before the appearance of cancer, another synchronous with it, and in the fifth patient dysplasia was not detected. Of 20 biopsies classified as 'indefinite for dysplasia, probably negative', 80% were associated with subsequent resolution, while of nine 'indefinite for dysplasia, probably positive' biopsies, eight (89%) were subsequently associated with either carcinoma (six) or dysplasia (two). The results emphasize the danger of absolute reliance upon dysplasia in assessing individual cancer risk in colitics, appear to demonstrate the usefulness of Riddell's classification and provide additional information on the natural history of dysplasia.

168 double J (pigtail) ureteric catheter insertions: a retrospective review.

The medical records of 116 patients who had 168 ureteric double J (pigtail) catheters inserted over a 6-year period between 1981 and 1987 were reviewed. Eighty-five patients had pigtails inserted for benign conditions and 31 for malignant disease. The pigtail catheters were inserted cystoscopically in 88 patients, percutaneously in 7 patients and by open surgery in 21 patients. Of 168 pigtail catheters used, 147 were soft (silicone, multilength) and 21 hard (polyurethane). No mortality was attributable to the use of these catheters but certain complications were commonly encountered. Loin discomfort occurred after 32 (19%) insertions; 27 of 147 (18%) soft catheters and 5 of 21 (24%) hard catheters. Trigonal irritation, confirmed cystoscopically was reported in 26 of 147 (18%) insertions of soft catheters and in 6 of the 21 (29%) with hard catheters (chi 2, P = 0.37). Urinary tract infection (confirmed by urine microscopy and culture) occurred after 46 (31%) soft catheter insertions and after 13 of 21 (61%) hard catheter insertions (chi 2 test, P = 0.01). Stent migration occurred in five patients and obstruction in two. Pigtail catheters are safe ureteric stents which are easy to insert and their use is supported by this study. The complications of associated infection, trigonal irritation and loin discomfort are relatively common and still occur even with soft catheters. Careful monitoring of all patients with pigtail catheters in position is recommended.

Cimetidine and mucosal cell renewal in the duodenum.

Cimetidine may protect gastric and duodenal mucosa by increasing cell turnover. Mucosal cell turnover in the duodenum of 7 control rats receiving intraperitoneal injections of normal saline for 6 days was compared with 8 rats receiving cimetidine for 6 days (500 mg/kg/24 h). Cell proliferation was assessed by autoradiography after injection of tritiated thymidine. The 'leading edge' was defined as the highest tritium-labelled nucleus in the crypt-villus (D/V) column expressed as a percentage of the complete C/V column. Ten C/V columns were measured in each rat. The number of tritium-labelled nuclei in 10 complete C/V columns was also counted in each rat. In the controls the median leading edge was 74.8% (25% quartile 70.6%, 75% quartile 76.2%) and in the rats receiving cimetidine 73.4% (25% quartile 72.1%, 75% quartile 75.9%). The median labelled cell counts were 2,052 (25% quartile 2,008, 75% quartile 2,173) and 1,999 (25% quartile 1,822, 75% quartile 2,041), respectively. These differences were not significant (p greater than 0.1; Mann-Whitney U test). Duodenal mucosal proliferation was assessed in 19 rats 48 h after two subcutaneous injections of 20 mg cysteamine and in another 9 after the same dose of cysteamine plus cimetidine (500 mg/kg/24 h). The median leading edge was 90.1% (25% quartile 84.4%, 75% quartile 92.8%) in cysteamine-treated rats and 76.7% (25% quartile 71%, 75% quartile 79.9%) in rats receiving cysteamine plus cimetidine.(ABSTRACT TRUNCATED AT 250 WORDS)

Rectal biopsies: inaccuracy of histological grading in carcinoma of the rectum.

In a consecutive series of 70 patients with carcinoma of the rectum, 42 had operable tumours and in these the histology of the initial biopsy was compared with that of the excised specimen. In 9 of the 42 patients the histological grading of the original biopsy was different from that of the final specimen; in 3 the carcinoma was missed despite repeated preoperative biopsies; and in 5, errors were made in the diagnosis of carcinoma in polyps. In 5 of 7 cases of poorly differentiated carcinoma the initial biopsies indicated moderate differentiation: there was therefore a 70% inaccuracy in the preoperative diagnosis of poorly differentiated carcinoma of the rectum. The implications of this inaccuracy for the surgery of rectal cancer are discussed.