Liposarcoma of the colon

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Bile acids and the increased risk of colorectal tumours after truncal vagotomy

An association between colorectal cancer and previous peptic ulcer surgery is reported. In a prospective screening study, 100 asymptomatic patients (80 men and 20 women) who had undergone truncal vagotomy at least 10 years previously were investigated by barium enema, colonoscopy and gallbladder ultrasonography. Control data were obtained from forensic autopsy subjects. The incidence of neoplasms greater than or equal to 1.0 cm in the vagotomized group was 14 per cent (11 adenomas, 3 carcinomas) and 3 per cent in controls (P = 0.01). Duodenal bile obtained at endoscopy from 21 vagotomized patients with normal gallbladders and from 21 control patients undergoing endoscopy was analysed by high performance liquid chromatography. The mean percentage of cholic (CA), chenodeoxycholic (CDCA), deoxycholic (DCA) and lithocholic (LCA) acids in the bile of vagotomized patients was 32.3, 45.6, 20.7 and 1.4 per cent respectively compared with 45.3, 36.2, 17.9 and 0.7 per cent respectively in controls. The increased proportions of CDCA and LCA and decreased proportions of CA in the duodenal bile of vagotomized patients were significant (P less than 0.001; P = 0.02; P = 0.007). Abnormalities in bile acid metabolism may help to explain the increased risk of colorectal neoplasia 10 years after truncal vagotomy.

Pancreatic carcinoma presenting as bleeding from segmental gastric varices: pitfalls in diagnosis

Splenic vein occlusion leading to gastric variceal haemorrhage should be considered in cases of obscure upper gastrointestinal bleeding. We report an unusual case in which the underlying pathology was a resectable carcinoma of the pancreatic tail.

Wound sepsis in 10,000 surgical patients

A twelve year prospective wound audit was undertaken in an academic surgical unit. Data from 10,000 operations were analysed. Overall, wound infection rates decreased during this time. Infection rates in contaminated wounds in particular fell from 19.2% to 4.7%. This decrease in wound infection may be related in part to a change in the antibiotic prophylactic regimen and in part to the institution of the wound sepsis audit which provided regular information on the unit infection rates. This audit permitted early detection of adverse trends, and may have had a direct influence on surgical techniques.

Cholecystectomy and colorectal cancer

This review examines the evidence for and against an association between cholecystectomy and colorectal cancer.

Cholecystectomy and the development of colorectal neoplasia: a prospective study

One hundred asymptomatic patients over 60 years of age who had cholecystectomy carried out at least 10 years earlier underwent double contrast barium enema and sigmoidoscopy. The incidence of colorectal adenomas and carcinomas was compared with age and sex matched controls undergoing routine post mortems. In the post-cholecystectomy group 12% had tumours (8 adenomas greater than 1 cm in diameter, 4 carcinomas). In the control group 3% had tumours (3 adenomas); P = 0.02. This study confirms that patients with a history of cholecystectomy have an increased risk of developing colorectal adenomas and carcinomas.

Relationship between duodenal bile acids and colorectal neoplasia

To investigate a possible relationship between bile acids and colorectal neoplasia duodenal bile acids were analysed in 50 patients with colorectal adenomas and 14 with carcinoma. Using gas liquid and high performance liquid chromatography a small, but significant increase in the proportion of chenodeoxycholic acid was found in the bile of adenoma patients compared with controls (mean % +/- SD 31.0 +/- 10.8, 26.4 +/- 8.3, p = 0.01). The difference in the proportions of chenodeoxycholic acid correlated with increasing malignant potential of the adenomas as determined by increasing size, histological type, degree of dysplasia and number present. In carcinoma patients an increase in the proportion of chenodeoxycholic acid was also observed compared with controls (mean % +/- SD, 47.2 +/- 9.6, 28.0 +/- 4.5, p less than 0.01). The proportions of other bile acids in those with adenoma or carcinoma were normal.

Auditing perioperative mortality

An audit of mortality following operation was performed over ten years classifying deaths into those that were 'expected' and 'unexpected'. 'Unexpected' deaths were defined as those in which, after careful consideration of the prevailing clinical circumstances at the time of operation, the probability of death following operation was felt to be low. This definition is a more helpful assessment of surgical performance than overall perioperative mortality as it highlights cases where improvements in surgical management might be achieved. In audits involving surgical mortality, the classification of deaths into 'expected' and 'unexpected' is recommended.

Assessment of ornithine decarboxylase activity in rectal mucosa as a marker for colorectal adenomas and carcinomas

We have investigated the role of ornithine decarboxylase activity in rectal mucosa as a marker for colorectal neoplasia. Biopsies of normal rectal mucosa were taken from 18 patients with adenomas greater than 1 cm diameter, 11 with carcinomas and 16 controls. The mean ornithine decarboxylase activity in normal rectal mucosa of adenoma patients, 6.52 nmol CO2 released h-1 (mg cell protein)-1, was significantly lower than that in controls, 16.8, P = 0.006. The difference in rectal ornithine decarboxylase activities between cancer patients, 3.58, and controls was also significant, P = 0.001. These preliminary results suggest that ornithine decarboxylase may be a useful marker in screening for colorectal neoplasia.

Does cholecystectomy predispose to colorectal cancer? A case control study

A case-control study of 598 patients with colorectal cancer (296 men, 302 women) admitted from January 1974 to October 1983 was undertaken. Patients were matched for age and sex, with controls admitted for unrelated conditions. All information was obtained from the hospital records. In men, there was no evidence of an increased risk of colonic cancer after cholecystectomy relative to men without cholecystectomy. There was some evidence of an increased risk in women (relative risk = 1.7; 95 percent confidence interval, 1.0 to 3.1) and this was highest when the tumor was in the right colon (P less than 0.005). This study confirms previous observations that cholecystectomy leads to an increased risk of right-sided colonic tumors in women but not in men. The apparent difference between the sexes may be explained by the low rate of cholecystectomy in the men examined.

The pelvic ileal reservoir. An experimental comparison of the 3-loop and 2-loop systems

In an experimental study the function of the 3-loop (Parks) pelvic ileal reservoir was compared with that of the 2-loop (Utsunomiya) reservoir. Both types achieved satisfactory degrees of continence and evacuation when tested in the defunctioned state. Following restoration of intestinal continuity, the stools of dogs with 3-loop pouches were usually liquid (69 percent) compared to the more formed stools (72 percent) in the 2-loop group, P less than 0.001. At postmortem the reservoirs of the 3-loop group were found to have undergone much greater dilatation (P less than 0.05). These findings suggest that construction of the 3-loop (Parks) pelvic reservoir may lead to retention with overflow if catheterization is not used. It is not clear whether the superior function of the 2-loop pouch is attributable to better motor function or the absence of an efferent limb which allows it to be placed deep in the pelvis.

Low colorectal anastomoses. An experimental assessment of two sutured and two stapled techniques

Extraperitoneal colorectal anastomoses were constructed in dogs by four methods: one layer of sutures (N = 10), two layers of sutures (N = 10), EEA staples (N = 10), and SPTU staples (N = 10). Dehiscence occurred in eight sutured and one stapled anastomosis (P less than 0.05). The four leaks following two layer sutured anastomoses caused three deaths, whereas all four leaks following one-layer sutured anastomoses were only detected radiologically (P less than 0.02). In the stapled group, the single leak followed EEA anastomosis and was fatal. Anastomotic narrowing was greater in sutured than stapled groups (P less than 0.05). Two layers of sutures produced gross narrowing compared with one layer (P less than 0.002). Two rows of staples (EEA) produced more narrowing than one row (SPTU) (P less than 0.01). Mean hydroxyproline concentrations and bursting pressures on the seventh postoperative day were higher in stapled than sutured anastomoses (P less than 0.05). Submucosal alignment, mucosal continuity, tissue viability, and stage of healing were all inferior for two-layer sutured anastomoses, reaching statistical significance for tissue viability (P less than 0.05). Stapled anastomoses were completed significantly faster (32.6 +/- 7.3 minutes) than sutured (54.1 +/- 8.4 minutes) (P less than 0.01). This experimental study has demonstrated that stapling is a fast and reliable method of colorectal anastomosis with a low complication rate. The shortcomings of the standard two-layer sutured anastomosis are discussed.

A controlled trial of bipolar electrocoagulation in patients with upper gastrointestinal bleeding

We have assessed the value of the BICAP electrocoagulation probe in reducing the incidence of further bleeding in patients with upper gastrointestinal haemorrhage. One hundred and twenty-nine patients were studied in a prospective randomized controlled trial. There were 85 male and 44 female patients, age range 16-92 years. Forty-five patients had stigmata of recent haemorrhage (visible vessel or spot) and were randomized during endoscopy to 24 control and 21 treatment patients. Seven control patients rebled compared with nine treated patients (Fisher's exact probability test P = 0.44). The transfusion requirements of control patients (3.9 +/- 3.2 units) was not different from that of treated patients (5.7 +/- 3.7 units): Mann Whitney U test, P = 0.06. In the treatment group there was no difference in the operation rate. Also, the number of probe applications between patients with further bleeding and those with no further bleeding was similar (11.6 +/- 5.5 and 11.0 +/- 5.75 respectively). Access with the probe was considered inadequate in 50 per cent of lesions, but this did not correlate with the incidence of rebleeding. Stigmata of recent haemorrhage were significant in predicting rebleeding (P = 0.0019 Fisher's exact probability test). Overall mortality rate of 3.2 per cent was low and was not influenced by electrocoagulation or presence of stigmata of recent haemorrhage. We have not shown that BICAP bipolar electrocoagulation reduces the incidence of rebleeding in upper gastrointestinal haemorrhage.

Ileal reservoirs: an experimental study of motility in the Kock and triplicated pelvic ileal pouches

Motor activity in the Kock ileostomy reservoir and the triplicated pelvic ileal reservoir was studied experimentally in dogs and compared with normal terminal ileum under identical conditions. Despite claims to the contrary, both reservoirs possessed significant motor activity under basal conditions and on filling. This was reduced, however, compared with normal terminal ileum. The design of the Kock reservoir does not seem to have any distinct advantages over the triplicated ileal reservoir which may be used either as an abdominal or pelvic pouch.

Bile acids and post-vagotomy diarrhoea

Cholecystectomy increases the risk of post-vagotomy diarrhoea and bile acid binding agents may relieve it, suggesting a role for bile acids in its pathogenesis. The faecal bile acid loss in 15 patients with episodic diarrhoea after vagotomy and drainage was not raised when compared with 12 normal subjects, except on days when diarrhoea occurred. This elevation was caused by an increase in stool weight rather than bile acid concentration, suggesting that the increased bile acid loss during attacks was not causally related. Asymptomatic vagotomy patients excreted normal amounts of bile acids. Seven patients with episodic diarrhoea after vagotomy and drainage with cholecystectomy continuously excreted excessive amounts of bile acids when compared with normal subjects and asymptomatic patients. The concentration of bile acid in their stools was higher than that observed in symptomatic patients after vagotomy and drainage alone. The continuous presence of excess bile acid may prime the colon to react more readily to stimuli caused by disturbed gastric emptying and rapid small bowel transit, without being the main factor in causing the condition. These findings may explain the increased risk of diarrhoea when cholecystectomy is combined with vagotomy.

The pelvic ileal reservoir: an experimental assessment of its function compared with that of normal rectum

The function of the 3-loop pelvic ileal reservoir as an alternative to total proctocolectomy and ileostomy is assessed experimentally in dogs and compared with normal rectum under identical conditions. No difference was found between the pelvic ileal reservoir and normal rectum in their ability to maintain continence. The efficiency of evacuation, however, is significantly better in normal rectum (P less than 0.01). Observations made over a prolonged period of time suggest that frequency of defecation, tenesmus and incomplete evacuation are persistent problems with an ileal reservoir. The results of the experiments concur with clinical findings that satisfactory continence may be achieved by using the ileal reservoir but that it does not possess the ability of normal rectum to evacuate completely. Hence the frequent need for self-catheterization.

Five years' experience in stapling the oesophagus and rectum

In the 5-year period from 1976 to 1980, 143 anastomoses were performed using circular stapling devices. In 2 further cases, anastomosis was attempted but failed and operation was completed by orthodox methods. There were 101 oesophageal anastomoses; 70 of these were transections in patients with oesophageal varices and 31 were either oesophagogastric or oesophagojejunal in nature, mainly following excisional cancer surgery. The remaining 42 patients had colorectal anastomoses following anterior resection of the rectosigmoid. Initial results in a follow-up period from 2 months to 5 years have been encouraging. There were 3 cases of complete anastomotic dehiscence and 4 cases of leakage. Stricture formation occurred in 10 per cent of patients but was easily controlled in the majority of cases.

The Kock ileostomy reservoir: an experimental study of methods of improving valve stability and competence

The performances of four valve designs which have been used in clinical practice in the Kock continent ileostomy reservoir were examined and compared to four further modifications in an experimental study on dogs. It was found that a stable valve could be consistently produced by subjecting the gut, which forms the valve, to deep seromuscular diathermy and by excluding in mesentery completely from the intussusception. Construction of the valve with the autosuture GIA Stapling device shortened the operating time considerably but did not improve on valvular stability.

The measurement of gastric emptying: a comparison of fixed scintillation detection and the double-sampling technique

The gastric emptying of a fluid meal was measured simultaneously by fixed scintillation detection and the double-sampling technique in 14 normal subjects and 15 patients who had a vagotomy and drainage procedure. In the normal subjects good correlation was obtained between the two methods but in the operated group there was poor correlation owing to difficulty in measuring the initial rapid emptying phase by fixed scintillation detection. Modification of the fixed scintillation method allows it to be used accurately in postoperative patients. The radioactivity of the meal is measured in vitro before ingestion and this reading is converted, using a constant derived from normal subjects, to a baseline value to which the subsequent in vivo readings are related. This modified technique permits the investigation of gastric emptying of fluid meals in patients with postvagotomy syndromes without the discomfort of a nasogastric tube. The equipment required is inexpensive.

Faecal bile acid concentration of patients with carcinoma or increased risk of carcinoma in the large bowel

Faecal 3-hydroxy bile acids were assayed enzymatically in patients with carcinoma, or at increased risk of developing carcinoma of the large bowel. No rise in bile acid concentration was demonstrated in patients with ulcerative colitis, previously resected adenoma, or resected carcinoma. Patients with carcinoma, before treatment, had faecal bile acid concentrations similar to control values, and surgery did not affect the mean level. These findings cast doubt on the importance of the 3-hydroxy bile acid concentration in the faeces in the pathogenesis of large bowel cancer.

The management of suspected tumours of the colon: the role of colonoscopy in general surgery

The role of colonoscopy in the management of 100 cases of suspected large bowel tumour is described. Forty out of 47 patients with an equivocal barium enema examination were satisfactorily examined and the possibility of a tumour being present was either confirmed or refuted. Examination of 30 patients with otherwise unexplained blood loss from the bowel revealed the cause in 50 per cent of them. Twenty-nine patients had pedunculated polyps which were snared and removed, thus avoiding laparotomy and colotomy. The problem of distinguishing tumours from other lesions or retained faeces by radiology arises most often in the sigmoid colon. This segment is easily examined using a short flexible endoscope. General surgeons taking up colonoscopy will find a 1-m single-channel instrument convenient to use and capable of reaching approximately 90 per cent of colonic tumours that require further investigation or endoscopic resection. Facilities for the examination of the whole colon should be available in established endoscopy units.

Colonoscopy in surgical practice

Colonoscopy is a rewarding new technique with a potential for early and more accurate diagnosis. One hundred and seventy colonoscopies carried out over the past three years showed or confirmed colonic cancer in 14 patients, and solitary or multiple colonic polyps were found in 28 cases, of which 18 were excised endoscopically. A large villous adenoma was diagnosed in one patient, and the absence of a suspected sinister lesion was shown by direct examination and biopsy in 110 cases. There were 17 examination failures, including two perforations of the bowel. Colonoscopy complements rather than supplants barium enema examination and will make diagnostic laparotomy for colonic lesions unnecessary. The use of the diathermy snare allows endoscopic removal of colonic polyps and should greatly reduce the need for formal surgery in these cases. The financial saving to the Health Service will greatly outweigh the expense of the procedure, but it should be undertaken only in well organised centres as a specialist service for selected patients. In skilled hands it is safe, but potential hazards exist for the inexperienced endoscopist.

Coeliac and hepatic nerve function following selective vagotomy

In the intact patient insulin hypoglycaemia increases the output of amylase and bile-acids despite the exclusion of acid from the duodenum. This effect is abolished by truncal vagotomy. After selective vagotomy a partial response from the pancreas occurs consistent with preservation of a direct route in the coeliac nerve and the loss of vagally released pancreatic secretagogues. A similar effect in the biliary system could not be demonstrated.