Reduced tumour growth of the human colonic cancer cell lines COLO-320 and HT-29 in vivo by dietary n-3 lipids

Seventy-five nude mice received subcutaneous inoculation with 1 X 10(7) cells of the human colonic cancer cell lines COLO-320 or HT-29. Tumour growth was assessed over 4 weeks in animals given one of three iso-caloric diets; standard diet, high saturated fat (20% coconut) diet and high n-3 fat (20% Maxepa fish oil) diet. The n-3 diet produced significant tumour growth reduction compared to the other diets for COLO-320 at 3 to 4 weeks (P less than 0.05 at least) and similarly for HT-29 at 4 weeks (P less than 0.05). Significant incorporation of n-3 fatty acids occurred in red cell membranes, adipose tissue and both neutral lipid and phospholipid fractions of tumour lipids in animals fed Maxepa (P less than 0.01 at least). This was accompanied by reduction of linoleic acid and arachidonic acid in these tissues (P less than 0.01 at least) but was most marked in the metabolically labile phospholipid fraction. There was high mitotic activity in the tumours from all the groups but there was no difference according to diet.

Effects of dietary N-3 and saturated fats on growth rates of the human colonic cancer cell lines SW-620 and LS 174T in vivo in relation to tissue and plasma lipids

Ninety nude mice were inoculated subcutaneously with 1 x 10(7) cells of the human colonic cancer cell lines, SW-620 and LS174T. Tumour growth was assessed weekly for three weeks whilst the animals were receiving one of three diets: control (4.6% fat), coconut (20% fat, saturated fatty acids) and Maxepa (20% fat; n-3 fatty acids). At the end of the study SW-620 tumour weights (mean +/- SD, gm) were: control = 0.38 +/- 0.22, coconut = 0.43 +/- 0.31, Maxepa 0.20 +/- 0.16; the LS174T tumour weights were control = 1.33 +/- 1.27, coconut = 0.47 +/- 0.74, Maxepa = 0.38 +/- 0.56 (p less than 0.001, analysis of covariance). The Maxepa diet produced significant retardation in tumour growth (p less than 0.001). This was associated with reduced levels of linoleic acid and arachidonic acid in adipose tissue and tumour lipids with incorporation of n-3 fatty acids (all p less than 0.01 at least, analysis of variance). Moreover, the Maxepa diet produced significant reductions of plasma cholesterol, phospholipids and triglycerides (all p less than 0.01).

Evaluation of herniography in the diagnosis of an occult abdominal wall hernia in symptomatic adults

Outpatient herniography as a means of confirming or refuting the presence of an occult abdominal wall hernia was performed in 50 symptomatic patients, including 13 who had previously undergone hernia repair. Altogether 30 occult hernias were detected in 27 patients, only one of which was considered to be unrelated to the presenting symptoms. On the basis of herniography, 17 patients were spared surgical exploration and, of these 17, 16 obtained a good result. One further patient with a clinically apparent hernia on one side but with contralateral symptoms was spared unnecessary surgery because the contralateral side was radiologically normal. There was one false negative and no false positive examinations. There were three minor complications: two cases of sigmoid colon puncture and one of abdominal wall haemorrhage (all managed conservatively). There were two technical failures. These results support the Scandinavian experience that herniography has a useful role in the management of patients who may have occult hernias as the underlying cause of abdominal wall symptoms.

Comparison of deoxyribonucleic acid ploidy and nuclear expressed p62 c-myc oncogene in the prognosis of colorectal cancer

A simultaneous flow cytometric assay of the nuclear expressed protein product of the c-myc oncogene p62 and deoxyribonucleic acid (DNA) ploidy in archival paraffin-embedded tumor material was undertaken in 179 patients with colorectal cancer, followed for up to 9 years. DNA ploidy showed a survival advantage for diploid tumors (chi 2(1) = 5.39, p = 0.020) and could be used to further divide patients with Dukes' A tumors (chi 2(1) = 4.87, p = 0.027) and Dukes' C tumors (chi 2(1) = 5.33, p = 0.021). By dividing patients into 2 levels of tumor expression of p62 c-myc, there was a trend for improved survival in patients with low expression (chi 2(1) = 3.65, p = 0.056). A combination of ploidy status and p62 c-myc expression improved upon survival prediction by ploidy alone in providing 3 groups (chi 2(2) = 7.86, p = 0.0197). While these results do not suggest a replacement for the Dukes' staging for prognosis (chi 2(3) = 33.82, p less than 0.00001), they strongly support the concept that enhanced expression of c-myc oncogene is associated with the progression of colorectal cancer.

Diffuse increase in renal uptake of technetium 99m methylene diphosphonate in association with disseminated cholangiocarcinoma

A 48-year-old woman presented with disseminated cholangiocarcinoma and diffuse joint pain. A technetium 99m methylene diphosphonate bone scan revealed no bony abnormality, but intense bilateral renal uptake was seen. There was temporary renal impairment following imaging, but the cause of this is uncertain. An association between cholangiocarcinoma and 'hot kidneys' on bone imaging scanning has not been previously reported.

Erythrocyte membrane stearic acid: oleic acid ratios in colorectal cancer using tube capillary column gas liquid chromatography

Erythrocyte fatty acids were measured in 32 patients with colorectal cancer (four with recurrent disease), four patients with large colorectal adenomas, and 42 hospitalised patients without cancer. No significant differences were found with respect to any of the fatty acids between these groups. In particular there was no difference between the erythrocyte stearic acid: oleic acid ratios (mean +/- SD) between the cancer cases (1.07 +/- 0.31) and the control cases (1.09 +/- 0.31, 2-tailed Mann-Whitney U test). No difference in this ratio was observed with respect to age or sex and in the case of colorectal cancer, to the Dukes' stage, degree of tumour differentiation, or recurrence. A significant correlation was found between stearic acid concentrations in plasma and erythrocytes from fasting individuals (r = 0.477, n = 24, P less than 0.05). This study provides further evidence that the erythrocyte stearic acid: oleic acid ratio is of no value for diagnosing primary or recurrent colorectal cancer.

Methyl-tert-butyl-ether for treating bile duct stones: the British experience

Methyl-tert-butyl-ether (MTBE), infused via a nasobiliary catheter, was used to treat 33 patients with bile duct stones in nine units around Britain. MTBE contributed to success in 12 (36 per cent) cases: seven passed stones spontaneously during MTBE infusion and five had partial stone dissolution allowing subsequent endoscopic extraction. MTBE was non-contributory in 21 (64 per cent) cases: four passed stones after MTBE was stopped, six were treated by subsequent endoscopic techniques without evidence of dissolution, seven underwent surgery, and four were treated conservatively (with one death). In at least ten of the 21 cases in which MTBE was non-contributory, pigment stones were present. Forty-two complications occurred in 26 (79 per cent) patients. The efficacy of MTBE for treating bile duct stones might be improved by better methods of instillation and, since success may be related to technique, the use of MTBE should be restricted to units familiar with this chemical.

Advantages of nonsurgical treatment of bile duct stones

A variety of effective nonsurgical forms of treating bile duct stones have emerged to challenge the traditional role of surgery. Four distinct philosophies have evolved upon which to base treatment: the partisan, supermarket, combination, and deductive philosophies. Adopting the latter, it is argued that surgery remains the gold standard for the great majority of patients. Surgery should, however, give way to non-operative forms of treatment in those who are at high surgical risk because of concomitant medical problems, acute cholangitis and severe gallstone pancreatitis. These newer treatments should increase the proportion of symptomatic patients amenable to treatment.

The theory of 'persisting' common bile duct stones in severe gallstone pancreatitis

There have been uncertainties as to the role of common bile duct (CBD) stones in severe gallstone pancreatitis. In order to resolve this, ERCP findings in 131 patients with acute pancreatitis were compared with predicted severity, clinical course and final outcome. Significant associations were found between 'persisting' CBD stones, coincidental acute cholangitis, predicted severity and actual outcome. There was evidence for acute obstruction of both the CBD and the pancreatic duct by CBD stones. The theory was therefore proposed that small migrating stones tend to initiate the attack, whereas larger 'persisting' stones tend to convert a mild attack into a severe attack. This hypothesis resolves previously irreconcilable theories and lends support to the use of urgent endoscopic sphincterotomy for treatment, but only in cases predicted to be severe.

Localization of lower gastrointestinal bleeding using in vivo technetium-99m-labelled red blood cell scintigraphy

Technetium-99m-labelled red blood cell scintigraphy was used in the investigation of 41 patients with major rectal haemorrhage. Red cells were labelled in vivo with technetium-99m pertechnetate and serial scans (0-36 h) were taken using a large field gamma camera. Twenty-two men and 15 women, mean age 71.3 years (range 32-91 years), and four children were studied. Forty-three scans were performed in all and there were 31 positive and 12 negative results. In each case the accuracy of the scan in localizing the bleeding site was checked either by independent investigations or at laparotomy. A definite bleeding site was identified in 30 cases and red cell scintigraphy correctly localized 29 of these (sensitivity 97 per cent). In the remaining 13 cases a bleeding site was not identified by any of the independent investigations and in this group there were two false positive scans (specificity 85 per cent). The investigation had a high predictive value when both positive (94 per cent) and negative (92 per cent). These data suggest that technetium-99m-labelled red cell scintigraphy should be used more widely in the investigation of patients with suspected lower gastrointestinal haemorrhage.

Contrast-enhanced abdominal computed tomography scanning and prediction of severity of acute pancreatitis: a prospective study

One hundred and fifty-two patients were admitted to a single hospital with a diagnosis of acute pancreatitis during a 31-month period. Of these, 126 patients had contrast-enhanced abdominal computed tomography (CT) scans within 72 h of admission; 92 of these attacks were clinically mild, 34 were clinically severe. A single consultant radiologist reported the scans 'blind' and noted whether pancreatic enhancement was normal, increased or decreased, and whether there was loss of peripancreatic tissue planes. The maximum anteroposterior measurement of the pancreatic head and body were multiplied together to produce a 'pancreatic size index' (cm2). Significantly more patients with severe attacks had decreased pancreatic enhancement (79 versus 58 per cent, P = 0.01) and loss of peripancreatic tissue planes (82 versus 54 per cent, P = 0.006). The median (range) pancreatic size index for clinically severe attacks was 12.8 cm2 (3.0-52.5), and for mild attacks was 6.0 cm2 (1.1-23.4), P less than 0.0001. Modified Glasgow criteria had a sensitivity of 85 per cent and specificity of 79 per cent for clinically severe attacks. A pancreatic size index of greater than or equal to 10 cm2 had a sensitivity of 71 per cent and specificity of 77 per cent for clinically severe attacks. In conclusion, although there were highly significant differences between the clinically severe and mild groups with respect to pancreatic enhancement, peripancreatic tissue planes and pancreatic size indices, these CT criteria did not improve on modified Glasgow criteria for prediction of disease severity.

Serial computed tomography scanning in acute pancreatitis: a prospective study

One hundred and two patients with acute pancreatitis had abdominal computed tomography (CT) scans within 72 hours of admission, at one week and at six weeks. Twenty eight attacks were clinically severe, 74 clinically mild. Ninety three (91%) admission scans, 85 (84%) one week scans, and 52 (51%) six week scans were abnormal. The aetiology of the pancreatitis could be inferred from 28 (27%) of admission scans, the CT sign of fatty liver having a sensitivity of 21% and specificity of 100% for alcoholic aetiology. The sensitivity of CT for gall stone aetiology was 34%, specificity 100%. The pancreatic size indices (max anteroposterior measurement of head x max anteroposterior measurement of body) of those patients with severe attacks were significantly greater than those with mild attacks on admission, at one week and at six weeks (p less than 0.004). Fourteen pseudocysts were detected by CT, five (36%) of which were clinically apparent. The pseudocyst size indices (max anteroposterior x max transverse measurement) of the pseudocysts which were clinically apparent were significantly greater than those which were not apparent (p less than 0.01) and only those pseudocysts with a size index greater than or equal to 15 cm2 required treatment.

A multivariate analysis of preoperative risk factors in patients with common bile duct stones. Implications for treatment

A multivariate analysis of 30 preoperative risk factors was undertaken in 248 patients who underwent surgery alone for common bile duct (CBD) stones and in 190 patients who had endoscopic sphincterotomy (ES), 77 of whom subsequently also had surgery. Independently significant risk factors in those undergoing surgery were the serum bilirubin level, the use of preoperative ES, and the presence of medical risk factors; in patients undergoing ES, only the serum bilirubin and albumin, but not medical risk factors, were of independent significance. The major implications of this study are, first, that high-risk patients should be treated by ES without subsequent surgery, and second, that "fit patients should be treated by surgery alone without routine preoperative ES.

Adenocarcinoma cell invasion of an obturator artery aneurysm

Classic teaching implies that arterial walls are a resistance to tumour invasion. We report a case of tumour cell infiltration of an obturator artery aneurysm following an abdomino-perineal excision of rectum.

Dietary fat in relation to fatty acid composition of red cells and adipose tissue in colorectal cancer

Fatty acids were determined in erthrocytes in 49 patients with colorectal cancer and compared with age and sex-matched controls. Marginally increased levels of stearic acid (P = 0.057) and oleic acid (P = 0.064) and decreased arachidonic acid (P = 0.043) occurred in cancer patients. There was no difference in the stearic to oleic acid ratio between the two groups. Dietary intake, assessed by dietary recall and adipose tissue analysis was also not different. In control subjects the polyunsaturated:saturated (P:S) fatty acid ratio correlated between diet and adipose tissue (P less than 0.01, at least). In contrast cancer patients showed different correlations; in particular dietary and erythrocyte P:S fatty acid ratios correlated (P less than 0.01). These findings may indicate disturbed fat metabolism in cancer patients. The erythrocyte stearic to oleic acid ratio is of no diagnostic value.

Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones

121 patients with acute pancreatitis thought to be due to gallstones were randomised to treatment with urgent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) or with conventional treatment. They were stratified by predicted severity of the attack, according to the modified Glasgow system. ERCP was done within 72 h, and if common bileduct stones were identified, patients underwent ES immediately to extract the stones. There were fewer complications in the 59 patients who underwent ERCP +/- ES than among the 62 treated conventionally, the difference being confined to those whose attacks were predicted to be severe (6/25 ERCP +/- ES [1 death] compared with 17/28 conventional treatment [5 deaths]). Hospital stay was also shorter for patients with severe attacks who underwent ERCP +/- ES than for those who received conservative treatment (median 9.5 versus 17.0 days).

ERCP findings and the role of endoscopic sphincterotomy in acute gallstone pancreatitis

A total of 131 patients with acute pancreatitis (of whom 100 had gallstones) underwent endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Urgent ERCP (less than 72 h) was performed in 68 cases and early ERCP (3-30 days) in 63 cases; 47 had predicted severe attacks and 84 had predicted mild attacks (modified Glasgow criteria). The highest incidence of common bile duct stones occurred in those with predicted severe attacks and those who had urgent ERCP. Highly significant correlations were found between age and common bile duct and pancreatic duct diameters. Significant correlations were also found between the common bile duct and pancreatic duct (correcting for age) and between these and the admission serum bilirubin. The common bile duct diameter was greatest in those with common bile duct stones and predicted severe attacks. A considerably lower incidence of pancreatic duct filling occurred in those with predicted severe attacks and common bile duct stones; in predicted mild attacks the pancreatic duct diameter was greater in those with common bile duct stones. In gallstone patients complications were highest in those with predicted severe attacks but more significantly in those with common bile duct stones. Endoscopic sphincterotomy was undertaken in 37 patients with common bile duct stones without mortality. The overall complication rate in gallstone patients was 19 per cent and the mortality rate was 2 per cent. These findings suggest that common bile duct stones cause acute common bile duct and pancreatic duct obstruction and are closely associated with complications. Urgent ERCP for detection of common bile duct stones, and endoscopic sphincterotomy for treatment, is strongly recommended for patients with predicted severe attacks due to gallstones and should also be considered for others who fail to show clinical improvement.