Pancreatic pleural effusion associated with oncocytic carcinoma of the pancreas.

A pancreatic pleural effusion is an uncommon presenting feature of pancreatic malignancy. A case is described where such an effusion was associated with an oncocytic carcinoma of the pancreas, a tumour which itself has been reported on only one previous occasion.

Gastric emptying: a study to compare the effects of intrathecal morphine and i.m. papaveretum analgesia.

Gastric emptying was studied in two groups of 10 patients who underwent elective cholecystectomy. The groups were comparable for age, weight and duration of operation. Gastric emptying was measured with a radioisotopic technique using Tc99m-DTPA (diethylene triamine pentaacetic acid) before, and 24 h after, surgery. Analgesia was provided by intrathecal morphine 0.8 mg alone (group A) or by i.m. papaveretum 10 mg, administered as required, plus one additional dose 1 h before the postoperative measurement (group B). Control gastric emptying rates were not significantly different in the two groups (mean +/- SD: A = 76.6 +/- 23.0 ml; B = 81.8 +/- 16.3 ml in 30 min). After surgery, gastric emptying was significantly greater in group A (42.9 +/- 35.6 ml) than in group B (11.0 +/- 27.9 ml) (P less than 0.05).

Effect of intrathecal morphine on the adrenocortical and hyperglycaemic responses to upper abdominal surgery.

Changes in plasma cortisol concentration and serum glucose concentration were measured in a group of 10 patients given intrathecal morphine 0.8 mg before cholecystectomy and the results compared with those from a control group of 10 patients receiving papaveretum i.v. during the operative procedure. Intrathecal morphine had no effect upon the hyperglycaemic response to surgery, but attenuated the increase in serum cortisol concentration.

When do patients given intrathecal morphine need postoperative systemic opiates?

A prospective, randomised study has compared the requirements for intramuscular papaveretum after cholecystectomy in patients given either 0.8 mg intrathecal morphine preoperatively or intravenous papaveretum peroperatively. Patients given intrathecal morphine required significantly less papaveretum during the first 48 hours after operation, but no significant difference in analgesic requirements was observed by 72 hours due to a continuing demand for papaveretum by these patients.

Demonstration of carcinoembryonic antigen in bone marrow from patients with carcinoma.

Primary and secondary tumour and bone marrow trephine biopsies from 20 patients with carcinomas were stained for carcinoembryonic antigen by the three stage immunoperoxidase method. Six marrow biopsies contained tumour deposits, five of which were positive for carcinoembryonic antigen. A further five marrow biopsies contained single carcinoembryonic antigen positive cells of uncertain origin. Carcinoembryonic antigen staining may be a useful adjunct to conventional histology in the diagnosis of marrow metastases.

Palliation of malignant ascites by the Denver peritoneovenous shunt.

Five out of 8 Denver peritoneovenous shunts placed in 7 patients provided excellent palliation of malignant ascites. Subclinical consumptive coagulopathy was detected after placement of 6 shunts, but no patient developed overt bleeding.

The use of a rigid choledochoscope in exploration of the common bile duct.

In 62 consecutive explorations of the common bile duct during a 2-year period, a Storz rigid choledochoscope was used to visualize the lumen of the duct before its closure over a T tube. All patients had radiological abnormalities on cholangiography: 45 had stones and 17 apparent strictures. In those with stones, the instrument was introduced after apparent removal of the stones to confirm the completeness of the manoeuvre. This examination showed that 11 patients (25 per cent) still had stones present and needed further manipulation. When the duct was seen to be clear, a T tube was inserted and the validity of the choledochoscopic findings checked by postoperative T-tube cholangiography. This confirmed the visual accuracy in all but one patient, an accuracy of 98 per cent. Of the 17 patients explored for other radiological abnormalities, choledochoscopy correctly determined the aetiology or excluded abnormalities in all cases. No complications of the procedure were encountered.

Traumatic renal artery occlusion producing hypertension.

Traumatic renal artery occlusion is relatively rare. Prior to 1974 there were only 38 cases reported in the literature (1). The true incidence, however, is greater and the diagnosis is frequently missed at the time of the original injury. Less than 50 per cent of cases will develop hypertension. Early diagnosis is essential if this complication is to be avoided. Two cases of traumatic renal artery occlusion producing hypertension are described.

Sclerosing peritonitis due to practolol: a report on 9 cases and their surgical management.

Nine patients with an unusual and serious intraabdominal complication of the beta-adrenergic blocking agent practolol seen since 1973 are reported. The striking and bizarre peritoneal changes induced by the drug have distinctive features that are not shown by other forms of peritoneal disease. The cases presented with small bowel obstruction, usually chronic in type and often associated with profound weight loss and an abdominal mass. Characteristic radiological features were present. The abnormalities at laparotomy were impressive, with a gross proliferation of the visceral peritoneum which formed a dense white cocoon which encased, constricted and markedly shortened the small bowel, usually from the duodenojejunal flexure to the ileocaecal valve. The obstruction was relieved by mobilizing the small bowel from the ensheathing tissue. Restoration of alimentary function after surgery was delayed but the long term result was satisfactory with full relief of symptoms and the absence of recurrent obstruction during the follow-up period. This complication may arise after treatment with the drug has been stopped, and although long term oral therapy has been discontinued, further cases will almost certainly present for some time to come.

Management of acute intestinal ischaemia.

The acute abdomen due to a vascular catastrophe affecting the major splanchnic vessels is often a life-threatening condition that can be very difficult to diagnose. In this article the pathological and physiological changes found in large- and small-intestinal ischaemia are related to the clinical features of the illness. Radiological, biochemical, and haematological aids to diagnosis are discussed. The treatment of large- and small-bowel ischaemia and of their specific complications, such as malabsorption and gastric hypersecretion, is outlined.

Flatulent dyspepsia in patients with gallstones undergoing cholecystectomy.

The incidence of flatulent dyspepsia and its relationship to gallbladder function has been studied in 100 consecutive patients with gallstones undergoing cholecystectomy. Thirty-three per cent of patients suffered significant flatulent dyspepsia of whom 80 per cent were cured or improved by operation. In 15 patients gastric function was studied pre- and postoperatively and it was noted that there was no difference in gastric emptying times between patients with flatulent dyspepsia who were cured by operation and those who remained symptomatic. Bacteriological studies on gallbladder bile from 39 patients suggested that infection within the gallbladder may be a factor in the causation of flatulent dyspepsia.

Duodenal inhibition of gastric secretion by osmotic agents in normal subjects and patients with duodenal ulcer.

Gastric secretion in man is inhibited by the presence in the duodenum of hyperosmolar and hypoosmolar solutions. Both acid and pepsin outputs are affected. There is no change in hydrogen, sodium, or potassium ion concentration in the gastric juice. Pepsin concentration, however, is reduced by all inhibitory stimuli. Inhibition is thought to act directly upon parietal and chief cells, and a possible basis for this mechanism is discussed. The response is similar in control subjects and duodenal ulcer patients; there is in particular no evidence of impaired inhibition in the ulcer group. An anomalous feature is the relatively small inhibition of acid output after hypertonic saline in control subjects compared with the duodenal ulcer patients.

Gastric secretion after massive small bowel resection.

This paper confirms that gastric hypersecretion can occur in man and dogs after massive intestinal resection. The assumption, made by others, that hypersecretion in the clinical situation is similar to that observed in dogs is challenged. An acute hypersecretory state occurred in eight of 19 patients after massive intestinal resection. This was apparent as an increased rate of basal secretion. It was usually transient and unrelated to the length of intestine resected. A correlation was noticed between hypersecretion and jaundice in the immediate postoperative period. Histamine release after acute hepatic injury was postulated as the cause of the hypersecretion. By contrast a chronic gastric hypersecretory state was demonstrated in dogs after massive intestinal resection. The rate of basal secretion was not significantly altered. The increased daily acid output was shown to be due to prolonged and enhanced response to food. The cause was thought to be loss of inhibitory agents, such as enterogastrone, normally released by the small intestine when in contact with food. The rationale of performing vagotomy and pyloroplasty at the same time as the intestinal resection is questioned.