Crypt cell carcinoma of the appendix.
A case of crypt cell carcinoma of the appendix is reported detailing its characteristic histological and immunohistochemical features and outlining current view on management.
Appendiceal Neoplasms↗
Biomedical subjects
I P Linehan
Publications and source records attributed to I P Linehan.
Swallowed button batteries: is there a consensus on management?
The optimum management of ingested button batteries was ascertained by postal questionnaire sent to 608 members of the endoscopic and paediatric sections of the British Society of Gastroenterology. Some 312 returns were suitable for analysis: 36.2% of the respondents were not concerned about ingested button batteries and gave no treatment, 6.4% used medical treatment, 48.4% removed them under certain circumstances, and 9% did not know how to manage the problem. Emetics and H2 antagonists or antacids were often used for batteries in the oesophagus, stomach, and duodenum and laxatives were commonly prescribed for batteries in the small and large bowel. Of the 48.4% who felt batteries should be removed under certain circumstances, 78%, 72%, and 48% extracted them from the oesophagus, stomach, and duodenum respectively within 24 hours of ingestion. The main reason for operative removal from the small and large bowel was failure of the battery to progress. Current management is therefore variable. Heavy metal poisoning may be occurring more frequently than is suggested in the published reports.
Antacids↗
Total pancreatectomy for chronic pancreatitis.
The operation of total pancreatectomy is performed rarely. Its role in the management of patients with chronic pancreatitis remains to be elucidated. We have reviewed our series of 29 total pancreatectomies for benign disease [14 women median age 39 years; 15 men median age 34 years]. Twelve underwent standard total pancreatectomy, in 17 duodenum preserving total pancreatectomy (DPTP) was performed. There was one death (mortality 3.4%). In no patient was the total pancreatectomy the first operative procedure. The patients were compared with age and sex matched diabetic control subjects selected on a best fit basis from the diabetic clinic database. The aetiology of the pancreatitis was idiopathic nine, pancreas divisum nine, alcohol eight and other causes three. The indication for surgery was pain 27, acute pancreatitis one and cholangitis with pancreatitis one. The complications of the procedures were mainly caused by infection [wound three, chest six and central line sepsis four] and in two there was a leak from the duodenum; no patient required re-operation. The postoperative stay [standard total, median 21 days (range 13-98) DPTP median 31 days (range 17-49)] has lengthened over the period due to greater attention to analgesic, diabetic and enzyme deficiency control before discharge. In standard total pancreatectomy there were five major hypoglycaemic episodes with only two in 17 DPTP patients. The per cent ideal body weight, the insulin requirement and the HbAl compared less well in standard total pancreatectomy group compared with controls than did DPTP. With both groups large doses of enzyme replacement were required, and this proved of importance in diabetic control. Our experience with total pancreatectomy suggests that pain will be improved in over 80% of patients and that the results of surgery will improve with prolonged follow up provided attention is given to analgesic abuse, enzyme deficiency and diabetes.
Adult↗
The dumping syndrome after pancreatoduodenectomy.
Some patients have postoperative nutritional problems after a pancreatoduodenectomy. These problems have been attributed without objective evidence to the partial gastrectomy that is performed at the time of the pancreatoduodenectomy. The dumping syndrome has been implicated, and the results of this study determine, for the first time, the role of the dumping syndrome in pancreatic surgical procedures. Sixty-four dumping provocation tests have been performed upon patients with pancreatic disease or after pancreatic surgical treatment. Three patients had the dumping syndrome, and in eight, the result of the test was equivocal. Results of the present study demonstrate an incidence of dumping syndrome after pancreatoduodenectomy of 10 per cent; however, in none of these patients, was the dumping syndrome a significant problem. There was no instance of the dumping syndrome after pylorus-preserving or duodenum-preserving pancreatectomy. It is concluded that, contrary to previous assumptions, the dumping syndrome does not contribute to long term postoperative problems after pancreatic surgical procedures.
Diagnosis, Differential↗
Duodenum-preserving total pancreatectomy for end stage chronic pancreatitis.
The classical Whipple procedure for chronic pancreatitis has been associated with significant long term postoperative morbidity. The pylorus-preserving procedure of Longmire has reduced but not eliminated the long-term morbidity. Preservation of the whole duodenum with total pancreatectomy has been introduced for the treatment of patients with end-stage chronic pancreatitis after favourable experience with this procedure in infants for nesidioblastosis. Fourteen patients with chronic pancreatitis have had a total pancreatectomy with preservation of the duodenum and the bile duct. All patients are still alive (median follow-up 9.5 months) and none suffered major complications in the perioperative period. One patient developed a biliary stricture at 3 months, requiring biliary reconstruction. Six of the patients have returned to full-time work; nine require no analgesia. All patients require pancreatic enzyme replacement, and all patients have gained weight postoperatively. Diabetic control is satisfactory with a twice daily insulin regime. Duodenum-preserving total pancreatectomy is feasible in the adult without mortality or high morbidity; early experience suggests that preserving the duodenum improves gastrointestinal function with easier control of the diabetes.
Adult↗
Total pancreatectomy for chronic pancreatitis.
A survey of six British centres collected data on 83 patients undergoing total pancreatectomy (TP) for chronic pancreatitis between 1977 and 1986. There were 57 men and 26 women with a median age of 38 years (range 19-61 years). Half were alcoholics and half had had previous acute pancreatitis. Besides jaundice (14 per cent) severe pain was the indication for the operation; regular opiates had been needed in 82 per cent of patients and 37 per cent were addicted to these drugs. All but 12 had had previous pancreatic or biliary surgery, with a median of two operations and a maximum of six. TP was a one-stage procedure in 32 patients, 42 had had distal resections and 9 proximal resections in the past; the pylorus was preserved in 30. Median operation time was 4 h (range 2-18 h) and median blood loss was 3 units (1-21 units). Intraoperative complications in 11 patients included haemorrhage in 9. Four deaths occurred within 30 days from bleeding (2), respiratory failure (1) and Roux-loop infarction (1). All but one of the 79 survivors required full pancreatic supplementation and 38 per cent had difficulties in endocrine control. At a median follow-up of 1.5 years (range 0.25-10 years), 57 patients (72 per cent) were pain-free and 9 (11 per cent) needed only occasional analgesia. Though 13 (17 per cent) still took regular analgesics, all were symptomatically improved. There have been 10 late deaths (13 per cent), all but one of which are attributable to the operation.
Adult↗
Infective cutaneous gangrene--urgency in diagnosis and treatment.
Many descriptions of infective cutaneous gangrene have been published under a variety of names. The classification adopted by Ledingham and Tehrani is illustrated by 4 cases seen in the Stoke Mandeville Hospital. Although the incidence is high in Eastern countries, infective cutaneous gangrene is uncommon in the Western hemisphere owing to a difference in geographic pathology. Early and delayed management is described, stressing that early diagnosis and aggressive treatment is required, ideally by a team consisting of a microbiologist and plastic and general surgeons. There is a substantial risk associated with the failure to diagnose and treat this condition. Mortality rates and prognosis are reviewed.
Adolescent↗
The 15-minute dumping provocation test.
Following gastric surgery, the diagnosis of the dumping syndrome (DS) has never been precise. The importance of diagnosis is not only in deciding management, but also in comparing series of incidences. The mainstay of diagnosis has been the gastric emptying and dumping provocation test (DPT); however it requires expensive equipment and the interpretation of the results is subjective and therefore variable. In 38 DPTs the percentage plasma volume and pulse rate changes, 15 min after the ingestion of 150 ml of hypertonic glucose, were expressed as percentages of the maximum values encountered and summed to form a score. The tests were independently interpreted by the authors and where they disagreed the result was defined as equivocal. The score was used with the symptoms provoked to follow a simple algorithm to divide the patients into those with and those without DS. There were six suffering from DS on our current interpretation; the new method identified all of these. Three tests were positive on the scoring scheme only and on review the interpreters agreed that all of these patients were suffering from the dumping syndrome. An accurate test using only the baseline and 15 min samples is simple, cheap and has definite rules of interpretation; the only laboratory measurement needed is the haematocrit estimation of three blood samples.
Dumping Syndrome↗