Biomedical subjects
D J Leaper
Publications and source records attributed to D J Leaper.
Malignant neuroendocrine tumour of pancreas, Salmonella enteritidis cholangitis and pseudomembranous cholecystitis.
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Carcinoma of the gallbladder: a diagnostic challenge.
Since the introduction and availability of abdominal ultrasound and computed tomography, 38 patients have been admitted to the Department of Surgery, Queen Mary Hospital, University of Hong Kong with a subsequently confirmed histological diagnosis of carcinoma of the gallbladder. The majority of patients presented with abdominal pain, anorexia or weight loss, jaundice, and anaemia or an abdominal swelling. Abnormal liver function tests were found in 70-90%. Cholangiography, ultrasound and particularly computed tomography helped to confirm clinical suspicion when performed but 23 patients (61%) had an inaccurate diagnosis made before surgery. Operative intervention was only of benefit when the carcinoma was confined to the gallbladder (median survival after cholecystectomy alone 13 months; other procedures 2 months; P less than 0.01). Carcinoma of the gallbladder carries a poor prognosis but ultrasound and computed tomography can help select patients for appropriate treatment (surgery, endoscopic stenting, radiotherapy, chemotherapy) if clinical suspicion is raised.
Hypoxia and hypotension during endoscopy and colonoscopy.
Sixty-three patients undergoing oesophagogastroduodenoscopy (OGD) (n = 24) or proctosigmoidocolonoscopy (PSC) (n = 39) had continuous monitoring of arterial oxygen saturation (SaO2), pulse and mean blood pressure (BP). The degree of patient distress, duration, dose of sedative and details of the endoscope and operator were recorded. Marked hypotensive (greater than 40% fall in BP) and hypoxic (greater than 8% fall in SaO2) changes occurred in 13% and 17% of the overall group, respectively. There were no significant differences in fall in BP, SaO2 or pulse between the OGD and PSC groups. The dose of sedative was significantly related to the fall in SaO2 (P less than 0.001) but not to the fall in BP. The falls in both SaO2 and BP were related to the duration of the procedure (P less than 0.001, P = 0.03, respectively). There were no correlations between the degree of hypoxia or hypotension and the patient's age or previous medical history. Hypotension and hypoxia occur in both colonoscopy and OGD and are neither predictable nor usually recognizable clinically. Pulse oximetric and BP monitoring throughout gastrointestinal endoscopy are recommended for maximal safety.
Antiseptic toxicity to breast carcinoma in tissue culture: an adjuvant to conservation therapy?
Of 50 patients who had scrape cytology of the excision cavity after conservative surgery for breast carcinoma, 10 (20%) had malignant cells remaining in the cavity recognised by cytology. Of these patients, 18 had histological evidence of tumour at the resection margin, giving an accuracy of the cytology of 84%, a sensitivity of 56%, and a specificity of 100%. When assayed for cytotoxicity against a breast tumour cell line (MCF7) or human fibroblasts, chlorhexidine gluconate was the most effective of eight antiseptics or antitumour agents (100% cytotoxicity at a 1/10,000 dilution) in killing breast tumour cells and had 70% toxicity to human fibroblasts at the same dilution. Hydrogen peroxide appeared to be the most useful agent overall with 94% cytotoxicity to breast tumour cells with only a 12% cytotoxicity to human fibroblasts at a dilution of 1/1,000,000. We suggest that free malignant cells left in the cavity after conservative surgery for breast cancer may be a cause of local recurrence. They can be recognised by scrape cytology at operation and the topical use of antiseptics as cytotoxic agents may be beneficial and warrants further investigation.
Bowel preparation or not for elective colorectal surgery.
The importance of bowel preparation in elective colorectal surgery has often been stressed. We have surveyed the current practice of bowel preparation and chemoprophylaxis amongst surgeons in Wales and the south-west of England. From this we identified one surgeon who used no preoperative preparation and his results are reported in detail. One hundred consecutive colorectal cases were studied from one surgeon (J.M.P-T.). There was a 7% incidence of wound infection and one anastomosis leaked. None of these patients had mechanical bowel preparation but all had antibiotic chemoprophylaxis. Mechanical bowel preparation is usual in the UK. These results demonstrate that its importance as a factor in wound infection and anastomotic dehiscence may be overstated.
Colour lymphography in clinical surgery.
In 38 patients undergoing femoral artery profundaplasty and in 18 having simple mastectomy with pectoral node biopsy, a 6.2 per cent solution of sodium sulphan blue was injected peripherally to outline the lymph nodes in the groin or axilla. Nodes and vessels were easily seen and the technique is now in routine use.
Breast cancer and prostaglandins: a new approach to treatment.
The effect of the non-steroidal inhibitor of prostaglandin synthesis, flurbiprofen, has been studied on a transplanted mouse mammary tumour of spontaneous origin. Daily administration of 2.5 mg/kg flurbiprofen signficantly reduced the growth of this NC adenocarcinoma transplanted subcutaneously into the right flank of WHT/Ht mice. Histological examination showed that primary tumours excised at 3 weeks from treated mice tended to have a more prominent lymphocytic infiltration. There was a non-significant tendency for mice treated with flurbiprofen alone to survive longer after tumour excision and to develop less local metastases, although scar recurrences seemed unaffected. The effect of adjuvant chemotherapy and local radiotherapy on local metastases and survival time tended to be greater when flurbiprofen was also given. This work supports and extends the basis for prospective clinical trials to evaluate the role of prostaglandins in human cancer and the value of prostaglandin synthesis inhibitors in cancer therapy.
Cancer growth, response to treatment and survival time in mice: beneficial effect of the prostaglandin synthesis inhibitor flurbiprofen.
Adult mice were injected subcutaneously with cells from a syngeneic metastasizing mammary cancer. Daily treatment with flurbiprofen starting before injection of the cancer cells reduced tumour growth and lengthened the survival of mice whose tumours were excised at 3 weeks. When low doses of radiotherapy and chemotherapy were given, additional treatment with flurbiprofen starting 25 days after injecting the cancer cells substantially inhibited tumour growth.
Toxicity of oral adjuvant chemotherapy in breast cancer.
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The role of antibacterial preparation of the intestine in the reduction of primary wound sepsis after operations on the colon and rectum.
A consecutive series of 320 patients undergoing operations on the colon and rectum, under the care of one surgeon, was studied to determine the influence of oral antibacterial preparation of the intestine on the incidence of postoperative wound sepsis. Thirty patients were excluded from the analysis, and the rates of major wound sepsis in the remaining 290 patients were 21.7 per cent when no antibacterial preparation was used; 18.6 per cent when the intestine was prepared with phthalylsulfathiazole and neomycin, and 1.6 per cent when the intestine was prepared with phthalysulfathiazole, neomycin and tetracycline. Other important determinants of the rate of wound sepsis were obesity and the use of cephaloridine prophylaxis. Results of bacteriologic studies showed the effectiveness of triple antimicrobial preparation of intestine against gram-negative aerobes and Bacteriodes species.
Tumour growth and response to treatment: beneficial effect of the prostaglandin synthesis inhibitor flurbiprofen [proceedings].
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Multimodal therapy for stage-II breast cancer.
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Single dose intra-incisional antibiotic prophylaxis of surgical wound sepsis: a controlled trial of cephaloridine and ampicillin.
In a series of 410 consecutive potentially contaminated operations, we have compared the relative efficacy of intra-incisional cephaloridine and ampicillin in single doses of 1 g in 2 ml of water. In high risk operations (ileocolorectal surgery, perforated appendicitis, or when the patient has 2-5 cm or more of subcutaneous fat at the site of the incision) cephaloridine prophylaxis resulted in a primary sepsis rate of 14 per cent compared with 36 per cent for ampicillin. In all other patients the two antibiotics were equally effective. Secondary sepsis, following discharge from the wound of a substance other than pus, was equally common in the two groups.
Abdominal wound closure: a trial of nylon, polyglycolic acid and steel sutures.
Failures after abdominal wound closure (early dehiscences and late incisional hernias) are due to breakage of sutures, slippage of knots or tearing out of sutures from the tissues. The suture-holding capacity of the entire thickness of muscle and aponeurosis is nearly twice that of the anterior rectus sheath, and deep bites (1-0 cm from the cut edges) are nearly twice as secure as bites of 0-5 cm. In a random controlled clinical trial of 357 major laparotomies, closure with either layered monofilament nylon or mass polyglycolic acid or steel resulted in 2 burst abdomens (0-56%), 10 incisional hernias due to suture failure (3-4%) and 8 incisional hernias caused by deep sepsis (2-7%). There were no statistically significant differences among the treatment groups, but 1 patient in the nylon and 3 in the steel groups had persistent sinuses until their sutures were removed.
Diuresis and clot retention after prostatectomy.
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A clinical index for selection of breast cancer patients for adrenalectomy.
Selection of patients with disseminated breast cancer for endocrine surgery has not been facilitated by sophisticated biochemical techniques. The present study was designed to produce a method of prognosis based exclusively on clinical data. Eighteen features were studied in 95 patients who underwent adrenalectomy and oophorectomy, and correlated with their degree of response to produce predictive variables. In a further group of 90 patients a prognostic score (the sum of the predictive variables) was calculated. There were 17 patients who scored less than 0 and in no case was a good response to endocrine surgery achieved. There were 40 who scored over 10, 29 of whom had a good response. The remaining 33 scored between 0 and 10 and there was no correlation between score and response. This predictive system offers significant advantages over accepted methods of clinical assessment (chi2 = 6-61, P less than 0-02). When patients with a score between 0 and 10 are excluded, its advantages are even more obvious (chi2 = 11-26, P less than 0-001). Patients who are likely to respond to endocrine surgery can be selected by clinical parameters alone, and total failure to respond can be forecast with complete accuracy. Between these two there is a third group whose response is unpredictable.
Computer-aided diagnosis of lower gastrointestinal tract disorders.
This paper reports a survey of human and computer-aided diagnosis in a prospective consecutive series of 301 patients admitted to the hospital with lower gastrointestinal tract disease. At initial outpatient contact (at which time endoscopy was customarily performed), the clinicians' diagnostic accuracy was 64.5%. After biopsy, radiology, and other investigative procedures, the clinicians' preoperative diagnostic accuracy rose t0 82.7%. When data from the house surgeon's case notes were fed into the computer, its diagnostic prediction proved accurate in 77% of the 301 patients, and when details of the outpatient endoscopy were added to the house surgeon's case notes, the computer's diagnostic accuracy rose to 84.7%. It is suggested that computer-aided analysis may have a limited part to play in discriminating between the common causes of lower gastrointestinal disorders in routine clinical practice.