Hollow seton for magnetic resonance imaging fistula visualization.
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Digestive System Surgical Procedures↗
Biomedical subjects
R W Talbot
Publications and source records attributed to R W Talbot.
Accuracy of colonoscopy in localisation of colorectal cancer.
An audit was performed of 77 patients with a single colorectal cancer visualised and sited before surgery by colonoscopic examination. The site of the cancer described at colonoscopy was compared with the actual site found at laparotomy. Six significant errors in preoperative localisation were encountered, when a change from the preoperatively planned resection to an alternative resection was found necessary. In two of these cases, extra morbidity was encountered as a result of these siting errors. Inaccurate localisation is a potential hazard of colonoscopy, especially when the examination is incomplete.
Colonoscopy↗
Comparison of preoperative serum CA19-9 levels with results of diagnostic imaging modalities in patients undergoing laparotomy for suspected pancreatic or gallbladder disease.
A prospective, blinded study of CA19-9 in 2,467 patients having abdominal surgery yielded 356 patients with pancreatic, gallbladder, and biliary disease who submitted coded preoperative serum specimens. In this group, there were 84 patients with pancreatic cancer and 24 patients with gallbladder-biliary cancer; the remainder had benign lesions. The recorded imaging data and marker results were merged with the patients' demographic, clinical, and surgical data and tissue diagnoses for analysis. Receiver operator character calculation suggested that a reference value of 100 U/ml for CA19-9 was appropriate rather than the 37-40 U/ml value most frequently employed and yielded a specificity of 97% in the 467 operated patients with a sensitivity of 8.3% for all nonpancreatic-biliary cancers and 62% overall for these lesions. In the more diagnostically challenging nonicteric patients, CA19-9 sensitivity was 55%, specificity was > 99%, positive predictive value (PPV) was 97%, and negative predictive value (NPV) was 88%. When CA19-9 results were combined with those from endoscopic retrograde cholangiopancreatography, ultrasound (US), or computed tomography (CT), the PPV, and especially the NPV were increased. The addition of carcinoembryonic antigen results did not affect overall results. The addition of CA19-9 results to ambiguous or indeterminant imaging interpretation clearly improved the combined specificity, sensitivity, and PPV, but the change was less impressive, albeit positive, for NPV. The combination of CA19-9 and CT (or US) is a reasonable, cost-effective, noninvasive approach to establishing the diagnosis of pancreatic, cholangitic, or biliary cancer in nonicteric patients. Although no single procedure or combination of procedures was found to detect early, small lesions, CA19-9 is clearly a clinically useful adjunct to imaging in nonjaundiced patients suspected of having these malignancies.
Adolescent↗
Comparison of portal and peripheral blood levels of carcinoembryonic antigen, CA 19-9, and CA 125 tumor-associated antigens in patients with colorectal and pancreatic cancer.
Synchronous serum specimens from the systemic and portal circulations of 43 patients with gastrointestinal cancer were assayed for levels of carcinoembryonic antigen, CA 19-9, and CA 125 tumor-associated antigens. The number of patients having a mean ratio of portal to systemic levels greater than 1 and the observed quantity of tumor-associated antigens were significant for carcinoembryonic antigen and CA 125 only in patients with colorectal cancer. No correlations were noted with the surgical stage of disease or with high or low (normal) levels of the three tumor-associated antigens. These findings suggest that peripheral concentrations of these antigens are in equilibrium with shedding from tumors and that hepatic clearance of a single pass does not significantly alter peripheral concentrations.
Antigens, Tumor-Associated, Carbohydrate↗
Conservative proctocolectomy: a dubious option in ulcerative colitis.
Conservative proctocolectomy was performed for ulcerative colitis in 19 patients, Crohn's disease in three and familial adenomatous polyposis in one. Healing was uncomplicated in only three patients (13 per cent). Eleven developed an anal discharge and nine an infected pelvic haematoma despite peranal drainage. Fourteen patients developed pelvic sepsis and, despite surgical curettage in 11, none healed. Six of these patients have had the anal sphincter divided, with healing in only one, and the anal canal has been excised in two. Eleven patients have ultimately healed at a median time of 28 months and eight have persistent sepsis after a median period of 45 months. Two patients with sepsis have had a successful ileoanal anastomosis. Conservative proctocolectomy cannot be recommended as a definitive operation for ulcerative colitis even though it may permit a subsequent restorative procedure.
Adult↗
Anal endosonography in the evaluation of perianal sepsis and fistula in ano.
Anal endosonography has been performed in 22 patients with fistula in ano and perianal sepsis and compared with the operative findings. Using a special hard cone attachment to a radial 7 MHz probe the examination was well tolerated, rapid and generally accurate, detecting two unsuspected foreign bodies and all seven complicated fistula in ano preoperatively.
Abscess↗
Temporary elevation of CA 125 after abdominal surgical treatment for benign disease and cancer.
Analyses of preoperative and one to seven day postoperative determinations of CA 19-9, carcinoembryonic antigen (CEA) and CA 125 levels in 873 patients indicate that postoperative CA 19-9 and CEA serum levels were within the expected technical variance of the preoperative assay values in patients who were considered to have negative findings (below the reference value) from these tests preoperatively. If the test results were preoperatively positive in patients with cancer, they decreased postoperatively to or below normal reference values, unless the operation was palliative and significant tumor removal was not possible. For patients with a preoperative positive CA 125 level (greater than 35 units per mililiter), the postoperative serum levels were comparable with the CEA and CA 19-9 result. However, when the preoperative CA 125 level was within normal limits, 62 per cent of the patients had postoperative elevations, often to levels of less than 35 units per milliliter. Sequential postoperative determinations of CA 125 in 21 patients revealed that maximum levels of CA 125 were seen about two to four hours after the operation and that elevations persisted for as long as three months. Inferential evidence suggests that postoperative increases in serum CA 125 occur from incision and healing of the peritoneum and omentum by de novo synthesis of this antigen rather than shedding from tissues. Patients with CA 125 negative results and with carcinoma of the ovary having postoperative increases of this antigen within two months of the operation may pose a difficult problem in interpretations, and such patients require further investigation.
Antigens, Tumor-Associated, Carbohydrate↗
Bone metastases in carcinoma of the rectum: a clinical and pathological review.
Bone metastases were confirmed in 48 patients after treatment of rectal cancer and occurred predominantly in the lumbar spine and pelvis. Most of the deposits were lytic and coexisted with widespread metastatic disease. Correspondingly, the median survival from diagnosis was only 4 months. The new prognostic classification for rectal cancer was applied to the original tumour specimens and categorized 23 of these tumours into group IV which confidently predicts a poor outcome compared with only eight by the method of Dukes.
Adult↗
Changing nature of anal cancer.
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Anus Neoplasms↗
Dysplasia of the colon after jejuno-ileal bypass.
Colonoscopic biopsies were performed on 38 patients, 10-13 years after jejuno-ileal bypass. No significant dysplasia or premalignant change was seen in 371 biopsies. In one patient two tubulovillous adenomata were found in an otherwise normal colon, which is likely to be a chance finding. Although it will take another 10-20 years to establish whether jejuno-ileal bypass is associated with an increased risk of large bowel cancer in humans, there is at present no indication for regular colonoscopic surveillance.
Colon↗
A sabbatical year in the United States: planning and preparation.
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Financing, Personal↗
Changing epidemiology, diagnosis, and treatment of Clostridium difficile toxin-associated colitis.
One hundred and ninety patients with Clostridium difficile toxin-associated colitis (CTAC) or pseudomembranous colitis (PMC) were identified, from microbiology records, disease index and proctoscopy service records, and studied retrospectively. CTAC was associated with cephalosporin antibiotic administration in 70 per cent of the patients. CTAC developed postoperatively in 108 patients after all types of surgery with no preponderance for abdominal surgery. Identification of cytotoxin in stool samples was the primary diagnostic test in 81 per cent of patients but cytotoxin was isolated in 98 per cent of all patients. Pseudomembranes visible on proctoscopy established the diagnosis in 19 per cent of patients and were more commonly seen in severe colitis (71 per cent) than in mild colitis (23 per cent). CTAC responded similarly to oral vancomycin and metronidazole with a relapse rate of 20-23 per cent, respectively. With its association with cephalosporin administration, CTAC is likely to occur with increasing frequency in surgical practice. Oral metronidazole is an effective, cheap, alternative to vancomycin therapy.
Adolescent↗
Vascular complications of inflammatory bowel disease.
During an 11-year period from January 1970 to December 1980, 7,199 patients at our institution had chronic ulcerative colitis or Crohn's disease. Thromboembolic complications developed in 92 (1.3%) of these patients. An additional 4 patients had cutaneous vasculitis, and 17 had an arteritis-associated diagnosis. Of the thromboembolic complications, 61 were deep vein thromboses or pulmonary emboli. The mortality among patients with thromboembolic complications was high (25%). Sixty percent of the patients had a thrombocytosis unaffected by sulfasalazine or corticosteroid therapy. In 73% of the patients, the erythrocyte sedimentation rate was increased, and when measured, fibrinogen and factor VIII were commonly elevated. Peripheral arterial thrombosis, coronary thrombosis, and mesenteric and portal vein thrombosis were predominantly postsurgical complications, but 77% of peripheral venous thromboses occurred spontaneously. The role of anticoagulation and surgical intervention in the management of hypercoagulation in patients with inflammatory bowel disease is discussed.
Adolescent↗
Intermittent sampling of portal venous blood and bile from guinea pigs.
A technique is described for intermittent collection of portal venous blood from guinea pigs through a catheter advanced from an ileal tributary of the cranio-mesenteric vein into the portal vein and for the collection of bile from a catheter in the gallbladder after ligature obstruction of the common bile duct.
Anesthesia, General↗
Catalytically active enterokinase in human bile.
Enterokinase activates trypsinogen very rapidly and is itself resistant to proteolysis and endogenous inhibitors in blood and pancreas. Using a novel one-stage specific catalytic assay capable of detecting enterokinase in the presence of trypsin inhibitors, we have positively identified catalytically active enterokinase in human bile in each of 14 patients studied. Since the presence of active enterokinase in human bile was not explicable by duodeno-biliary reflux, enterokinase must have followed the pathway from gut to blood to liver to bile, previously identified in greater detail experimentally. We suggest that entry into the pancreatic duct system of bile-borne active enterokinase from the common bile duct may trigger necrotising acute pancreatitis.
Acute Disease↗
Displacement of endogenous enterokinase into portal venous blood and bile following luminal perfusion of proximal small intestine in guinea pigs.
The displacement of endogenous enterokinase into portal venous blood or bile was studied in conscious guinea pigs both with the small intestine undisturbed and during gentle, intermittent luminal perfusion of a 25-cm segment of duodenum and proximal jejunum. Perfusates tested included water, 150 mM saline, 5% (v/v) ethanol, 0.2% (w/v) lysolecithin, and mixtures of ethanol and lysolecithin. Enterokinase activity was absent from portal venous blood of control guinea pigs with the intestine undisturbed but perfusion with luminal saline or water was consistently associated with substantial levels of active enterokinase in portal venous blood. Similar concentrations of enterokinase in portal blood were also detected in response to luminal ethanol and lysolecithin. The capacity of the normal liver rapidly to clear the enzyme from portal blood was demonstrated. Of the estimated total endogenous enterokinase displaced, 0.2-0.4% was recovered in catalytically active form from the pooled bile of luminally perfused but not control animals. The readiness with which enterokinase was displaced into the circulation in the absence of mucosal damage raises the unexpected possibility that the event may be physiological. Induced penetration of the mucosa and absorption of luminal components is clearly different from the release into portal venous blood of endogenous mucosal macromolecules.
Animals↗
Induced mucosal penetration and transfer to portal blood of luminal horseradish peroxidase after exposure of mucosa of guinea pig small intestine to ethanol and lysolecithin.
The effect of luminal 150 mmol saline, 0.05-0.2% (w/v) lysolecithin, and 5-20% (v/v) ethanol was studied on the mucosal morphology of the proximal small intestine in conscious guinea pigs as well as on the mucosal penetration and transfer to portal venous blood of luminal horseradish peroxidase (HRP). No ultrastructural evidence of mucosal damage was identified in any of the lysolecithin-perfused animals compared with saline controls. Ten and 20% ethanol (v/v) resulted in the appearance of fluid-filled spaces between enterocytes and in cytoplasmic lipid deposits and an increased number of autophagic vesicles within the cells themselves. Tight junctions remained intact. These changes after luminal 5% ethanol (v/v) were much less conspicuous. In the presence of saline, luminal HRP was largely confined to the brush border. Both lysolecithin and ethanol (5% v/v) rapidly induced mucosal penetration of HRP which was seen in cytoplasmic vesicles within enterocytes, between enterocytes, and in the lamina propria. Peak portal venous blood levels of HRP studied in multiple samples over 3 hr were one log unit greater than saline controls. Absorption of HRP was proportional to the luminal concentration of lysolecithin in the range tested. These studies show that mucosal penetration and absorption of functional exogenous macromolecules may be induced, in the absence of morphological evidence of mucosal damage, by luminal constituents which may perturb the structure of enterocyte membranes.
Animals↗
A haematuria diagnostic service in a district general hospital.
Four years experience of a haematuria diagnostic service in a District General Hospital, comprising 215 patients, has identified 42 new cases of bladder cancer, 5 of renal cell cancer and 3 of renal pelvis cancer. Urine and blood tests were non-contributory in their diagnosis but intravenous urography was diagnostic in the majority. The period of time between presentation to the general practitioner and treatment of the cancer has been reduced to less than the time normally spent on the Out-Patient waiting list.
Adolescent↗