Biomedical subjects
Publications and source records attributed to N J Dorricott.
We report a rare case of a non-insulin secreting malignant insulinoma of the pancreas and discuss its medical and surgical management. Surgical excision of malignant insulinoma produces good palliation and can increase survival.
PURPOSE: To clarify the clinical role of topical glyceryl trinitrate (GTN) in the management of anal fissures. PATIENTS AND METHODS: Fifty-six consecutive patients with fissure-in-ano attending a colorectal clinic from April 1997 to May 1998 included 16 acute and 40 chronic anal fissures. Patients were instructed to apply 0.2% 0.5 g of GTN to the painful area of the anus. Patients were followed-up in the clinic at 4, 8 and 12 weeks, and by telephone interviews at a median follow up of 10 months. RESULTS: Ten of 16 acute fissures (63%) were healed by 4 weeks and 13 (81%) by 8 weeks. Thirteen of 40 chronic fissures (33%) were healed by 8 weeks and 20 (50%) by 12 weeks. Seventeen patients (30%) underwent lateral sphincterotomy and all healed. There were five recurrences within 3 months of treatment with GTN. Thirty-four (61%) suffered from headaches, eight being severe headaches. None of the patients developed incontinence with GTN or lateral sphincterotomy. CONCLUSIONS: Treatment of fissure-in-ano using GTN ointment was effective in up to 50% of patients with chronic anal fissure, and has the benefit of being repeatable if the fissure recurs. Patients should be aware that treatment is likely to take some months to be effective and is associated with significant side effects in up to 15% of patients.
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We describe a case of generalised peritonitis due to sigmoid perforation caused by an unnoticed swallowed dental plate during sleep three months previously.
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A survey of endoscopy units in the West Midlands, UK, was undertaken to ascertain the management of colonic perforation during colonoscopy. Fifteen perforations were reported from a total of 17,500 colonoscopies performed in 14 units (a rate of 0.09 per cent). In seven patients the diagnosis was suspected or diagnosed immediately and in the remaining eight 2-72 h later. Four patients with associated pathology (carcinoma, Crohn's disease, ulcerative colitis and a polyp) had resection and primary anastomosis. Seven patients had a simple oversew, four of these having had a delayed diagnosis. In four cases the site of perforation was not identified, but only one patient had conservative treatment. Three patients had drainage and a defunctioning colostomy. There was no significant morbidity following treatment. It is recommended that patients who have had a good bowel preparation should be treated conservatively unless there is a large perforation or an underlying carcinoma.
Thirty-seven patients who had had either a colonoscopy or a selective mesenteric angiogram while being investigated for severe or persistent gastrointestinal bleeding of obscure origin were reviewed. Failure to make a prompt diagnosis was partly responsible for the 16% hospital mortality in the series. Colonoscopy was diagnostic on 6 out of 38 examinations but detected 43% of lesions in the colon. Angiography achieved only 3 diagnoses in 17 examinations. Fourteen patients had an exploratory laparotomy which was diagnostic in 9. We believe that early laparotomy still has an important place in the diagnosis and treatment of intestinal bleeding of obscure origin.
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The second reported case and first successful treatment of oesophageal obstruction due to a saccular aneurysm of the distal thoracic aorta is described. The patient, a 69-year-old male, presented with severe dysphagia which was thought to be due either to achalasia or a tumour. Operation, however, revealed a large aneurysm at the level of the diaphragmatic hiatus which was compressing the oesophagus against the right crus. As the anatomy of the aneurysm was unknown and there was a significant risk of damage to the spinal arteries the oesophageal obstruction was treated by transposition of the oesophagus combined with an anti-reflux repair. This has given an excellent clinical result and the aneurysm has remained unchanged over a period of eighteen months.
71 patients participated in a double-blind trial which compared proximal gastric vagotomy (PVG) with vagotomy and antrectomy (V & A). 82 percent of the patients subsequently volunteered for endoscopy 6 to 12 months after operation and 65 percent for measurement of fasting bile reflux (FBR) and peak acid output (PAO). The results of these follow-up assessments are given in this paper. None of the 36 patients who had undergone V & A had a recurrent ulcer; in contrast ulcers or fresh scars were found in 5 of 35 patients after PGV, even in 2 who had no symptoms. Erythema of the gastric mucosa was seen more commonly after V & A than PGV. Such erythema was associated with high levels of fasting bile reflux (an objective measure of reflux of bile into the stomach) and with symptoms of bile vomiting and mild epigastric pain. High levels of fasting bile reflux were not found after PGV. Histological gastritis of the proximal stomach was equally common after both operations in patients without a recurrent ulcer. Gastritis was not related to endoscopic mucosal erythema or fasting bile reflux, but did correlate with peak acid output. These results confirm that bile reflux is associated with mucosal erythema and symptoms after V & A but that significant bile reflux does not occur after PGV. However, bile reflux is not related to gastritis, which appears to be the result of an operation (either PGV or V & A) which successfully reduces peak acid output.
In a prospective, randomized study 145 patients with duodenal ulcer have been followed 5-7 years after proximal gastric vagotomy (PGV) or truncal vagotomy with antrectomy (TVA). Postoperative complications were significantly higher after TVA (P less than 0.0005). There was one death due to anastomotic leakage after TVA. The recurrence rate was significantly higher after PGV (9.9 per cent). Postoperative symptoms were less after PGV (P less than 0.01). Due to the recurrence rate after PGV there was no overall significant difference in the Visick grading, although perfect results (Visick I) were seen significantly more often (P less than 0.01). It is concluded that better results follow PGV.
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The complications and results of rectal anastomoses carried out with the end-to-end anastomosis (EEA) stapling instrument on 50 patients by 5 consultant surgeons are recorded. There was a clinical leakage rate of 6% and a radiological leakage rate of 20% assessed by water-soluble contrast enema. The technique has advantages compared with hand-suture by allowing low anastomoses and preservation of sphincters and is accompanied by an acceptably low leakage rate. Despite the cost of disposable cartridges these advantages make the technique economical because of the avoidance of colostomies and reduction in hospital stay.
Twelve patients aged over 70 with primary hyperparathyroidism (persistent hypercalcaemia and raised serum parathyroid hormone concentrations) underwent parathyroidectomy, which was well tolerated by all. After operation serum calcium concentrations returned to normal and the commonest symptoms before operation (muscle weakness, malaise, and mild to severe dementia), although not related in severity to the degree of hypercalcaemia, improved. Mental function was greatly improved. The findings suggest that primary hyperparathyroidism should be sought in any elderly patient with hypercalcaemia and that more such patients with the diagnosis should be considered for parathyroidectomy irrespective of age.
Patients' assessment of whole gut irrigation via a nasogastric tube has been obtained by a questionnaire answered by 79 of 99 patients who received this method of bowel preparation before operation on the large bowel or colonoscopy. Abdominal pain during the irrigation was experienced by 13 patients (17 per cent) and nausea and vomiting occurred in 24 (30 per cent). Intubation with a nasogastric tube and the discomfort of prolonged sitting on a commode were considered the most disagreeable aspects of the procedure. Fifty-six patients (71 per cent) would have agreed to the irrigation being repeated if necessary and many patients preferred whole gut irrigation to previous 'orthodox' bowel preparations that they had experienced.
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In three centres, 222 patients (Birmingham 70, London 87 and Rotterdam 65 patients) with chronic duodenal ulcer were treated by proximal gastrict vagotomy (PGV) (116 patients) or truncal vagotomy and antrectomy (TVA) (106 patients) in a prospective randomized trial. After 1 year 5 recurrent duodenal ulcers (4.3 per cent) have been recorded in the PGV group, compared with 1 (1 per cent) in the TVA group. The reoperation rate was high in both groups-6 after PGV, usually for recurrent ulcer, and 7 after TVA, mostly for gastric retention. PGV showed a marked superiority in the number of patients with a good clinical result Visick I or II) at 1 year after operation, i.e. 82 per cent compared with 56 per cent for TVA.
A consecutive series of 12 patients with stenosis secondary to duodenal ulceration were treated by proximal gastric vagotomy (PGV) and duodenoplasty or PGV and dilatation of the stenosis. Three months after operation the rate and pattern of gastric emptying of a solid meal was measured in each patient and compared with 18 patients with uncomplicated duodenal ulcer treated by PGV alone. Two patients developed gastric stasis in the early postoperative period which resolved with medical treatment. All patients were asymptomatic and were eating normally three months after operation. There was no significant difference in the rate of gastric emptying postoperatively between the patients who had stenosis and those who had uncomplicated duodenal ulcers. These results indicate that despite early postoperative difficulties in some patients pyloric dilatation or duodenoplasty with PGV are both effective treatments for stenosis due to duodenal ulceration.