Does a water soluble contrast enema assist in the management of acute large bowel obstruction: A prospective study of 117 cases

We have performed a prospective study on 117 patients in order to assess the value of a single contrast water soluble enema in acute large bowel obstruction. In 99 cases where the plain films suggested a diagnosis of mechanical obstruction, the Diodone enema confirmed its presence in 52, and relocated its site in 11. There was free flow of contrast to the caecum in the remaining 35, 11 of whom were shown to have idiopathic pseudoobstruction. The plain films suggested a diagnosis of pseudo-obstruction in 18 patients. The Diodone enema confirmed this diagnosis in 15, but revealed an unsuspected mechanical obstruction in two. The examination failed in two cases. We conclude that the water soluble single contrast enema is of value in the management of large bowel obstruction. It will confirm the diagnosis of mechanical obstruction and prevent unnecessary surgery in patients with pseudo-obstruction.

Treatment of metastatic breast cancer with liver transplantation

Resection of liver metastases is accepted as an appropriate treatment for colorectal metastases in suitable patients. Liver transplant is not often used for malignant disease as there is a high incidence of undetectable micrometastases elsewhere and recurrence is likely. The effects of immunosuppression may also enhance the growth of malignant cells at other sites. We report a case where a young patient with undiagnosed breast cancer with axillary and liver metastases underwent liver transplantation and is effectively leading a normal life 33 months after transplant.

Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy

BACKGROUND

Haemorrhoidectomy is frequently associated with postoperative pain and prolonged hospital stay. A new technique of haemorrhoidectomy using the Ligasure device suited to day-case surgery is described. This technique was compared with conventional open diathermy haemorrhoidectomy.

METHODS

Forty patients with grade III or IV haemorrhoids were randomized to Ligasure (group 1) or conventional diathermy (group 2) haemorrhoidectomy. Operative details were recorded and patients recorded daily pain scores on a linear analogue scale. Follow-up was at 1, 3, 6 and 12 weeks to evaluate complications, return to normal activity, ongoing symptoms and patient satisfaction.

RESULTS

Reduced intraoperative blood loss (median (range) 0 (0-5) ml versus 20 (12-22) ml; P < 0.001) and a shorter operating time (10 (8-11) versus 20 (18-25) min; P < 0.001) was observed in group 1 compared with group 2. More patients in group 1 were discharged on the day of operation (18 of 20 versus 11 of 20; P < 0.05) and there was a trend towards lower postoperative pain scores on day 1 (group 1 median 5 (95 per cent confidence interval (c.i.) 2.6 to 6.8) versus group 2 7 (95 per cent c.i. 4.2 to 7.7); P = 0.36). There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications.

CONCLUSION

Ligasure diathermy may be used safely in the treatment of patients with grade III or IV haemorrhoids. It reduces intraoperative blood loss and operating time, and facilitates same-day discharge.

Management of obstructing lesions of the left colon by resection, on-table lavage, and primary anastomosis

BACKGROUND

The purpose of this study was to assess the feasibility and safety of single-stage resection, on-table lavage, and primary anastomosis in patients presenting with obstruction of the left colon.

METHODS

The outcome of surgery in 73 consecutive patients presenting with obstruction of the left colon during a 5-year period was assessed in terms of perioperative complications and long-term survival.

RESULTS

Sixty-three patients (86%) underwent single-stage restorative procedures. In this group there were four clinical anastomotic leaks (6%). However, there were no deaths as a result of leakage. There were four deaths (6%) but these were not due to anastomotic leakage. Long-term survival rates compared favorably, stage for stage, with large published series of elective experience.

CONCLUSIONS

We believe that resection, on-table lavage, and primary anastomosis constitute the operation of choice for most patients with acute obstruction of the left colon.

Accuracy of computed tomography in predicting adrenal tumor size

We undertook a multi-institutional, retrospective study of 51 patients with adrenal tumors (pheochromocytomas, functioning and nonfunctioning cortical adenomas, cysts and carcinomas). All patients had computed tomography (CT) with a maximum of 5 millimeter cuts the week before undergoing complete adrenalectomy. Pathologists were asked to measure the tumor to the nearest 0.1 centimeter. Tumor size obtained from pathologic reports (actual size) and CT reports (estimated size) were compared. Adrenal tumors were divided into two groups on the basis of size--tumors with actual size of 6 centimeters or greater and tumors with actual size of less than 6 centimeters. Statistical analysis was performed with Newman-Keuls analysis of variance. After controlling for tumor type and for the institution at which the measurement was made, we found that CT consistently underestimated adrenal tumor size in both tumor groups. Moreover, the average, underestimated difference for tumors 6 centimeters or greater was 32 percent, but 47 percent for tumors less than 6 centimeters (p = 0.060). CT seemed to underestimate the size of small adrenal tumors more than large tumors. Because the decision to operate on solid, nonfunctioning adrenal tumors is based on tumor size and because CT is currently the standard technique used to estimate size, our findings need to be considered before undertaking surgical treatment.

Effects of different lipid emulsions on lymphocyte function during total parenteral nutrition

A prospective randomized study of the immunological effects of three total parenteral nutrition (TPN) regimens in patients undergoing preoperative parenteral nutrition was conducted. In one regimen the calories were derived solely from glucose. The others were identical except that 50 per cent of the calories were provided as lipid emulsion, in one as long-chain triglycerides (LCT) only while the other contained half the fat as medium-chain triglycerides (MCT) and half as LCT (MCT/LCT). Natural killer (NK) activity and lymphokine-activated killer (LAK) activity were significantly higher after TPN with the MCT/LCT solution. A significant fall in LAK activity occurred after TPN with the LCT solution. The interleukin 2 content in supernatants from activated T lymphocytes was significantly higher after TPN with the LCT-containing solution. Solutions containing LCT and those containing MCT perturb cytokine interactions, but this is less with MCT-containing solutions, which may augment certain responses. These observations may have implications for the design of TPN regimens.

Cholecystectomy is safer without drainage: the results of a prospective, randomized clinical trial

Drainage after cholecystectomy remains routine despite the lack of scientific supportive data. Numerous clinical studies in the past have attempted to address this controversy but have failed to resolve the issue for different reasons. These include retrospective design, inclusion of only selected cases, and randomization before surgery. In this study 479 patients undergoing cholecystectomy were randomly allocated to a drainage group (a high-pressure suction drain in Morison's pouch for 48 hours) or a nondrainage group. Randomization was performed at the time of peritoneal closure. All patients undergoing cholecystectomy, both elective and urgent, were included and the operations were performed by all grades of surgeons. There were two deaths from cardiopulmonary causes, both in the drainage group. No patient required reoperation in either group. The incidence of both wound infections (15 vs 5; p less than 0.05) and chest infections (56 vs 19, p less than 0.02) was significantly higher in the drainage group. Three hundred fifty-six patients underwent abdominal ultrasonography 72 hours after surgery. The number of subhepatic fluid collections thus detected was significantly higher in the patients who received a drain (17 vs 6, p less than 0.05). None of these collections was clinically significant. The postoperative hospital stay was longer in the patients with drains (10.3 vs 9.1 days), but this difference failed to reach statistical significance. We conclude from this study that the use of a drain after cholecystectomy serves no useful purpose and is potentially harmful. This practice should be abandoned.

Suture length to wound length ratio and the integrity of midline and lateral paramedian incisions

A total of 349 patients were randomized to undergo laparotomy through a lateral paramedian incision with layered closure (n = 137), a midline incision with mass closure (n = 104) or a midline incision using layered closure (n = 108), endeavouring to close the latter two incisions with a measured suture length to wound length ratio of greater than 4:1. After 18 months follow-up, no patient in the lateral paramedian group had developed an incisional hernia whereas 7 of 104 patients undergoing a midline incision with mass closure and 7 of 108 patients undergoing a midline incision with layered closure had incisional hernias (P less than 0.01). The mean suture length to wound length ratios for the three groups were 2.6 (range 1.3-6.2), 5.0 (range 3.0-8.7) and 3.7 (range 2.0-6.3) respectively (P less than 0.0001). The lateral paramedian incision remains superior to the midline incision closed with the mass technique and its integrity is independent of the suture length to wound length ratio.

Continuous versus intermittent infusion of fat emulsions during total parenteral nutrition: clinical trial

It is now generally accepted that fat emulsions are an efficient energy source during total parenteral nutrition (TPN). However, there is debate about how this fat should be prescribed. Some authorities prescribe fat as an intermittent infusion, alternating fat and carbohydrate, whereas others prefer a continuous infusion, giving fat simultaneously with carbohydrate. This 6-day crossover study examined the substrate-hormonal profiles of 10 patients in response to two isocaloric and isonitrogenous TPN regimens. In regimen A (intermittent), equicaloric volumes of 25% glucose and 10% Intralipid as energy sources were alternated every 12 h. During regimen B (continuous), the total nonprotein calories given each day was the same as in regimen A, but glucose and fat were infused simultaneously over every 24-h period. Amino acids were infused continuously throughout the study period in all patients. Blood samples were taken every 12 h. Wide fluctuations in insulin and all substrates occurred during regimen A. Persistent hyperinsulinemia throughout regimen A may have impaired the oxidation of exogenous fat. The substrate-hormonal profiles observed during regimen B approximated the normal postabsorptive state and were stable throughout the infusion period. The results of this study suggest that exogenous fat should be administered as a continuous infusion.

Pharmacological concentrations of lipid emulsions inhibit interleukin-2-dependent lymphocyte responses in vitro

Most immunological functions are accomplished by means of interactions between mediator molecules (cytokines or lymphokines) and their specific receptors on the lymphocyte surface. One particular lymphokine, Interleukin-2 (IL-2) is central to the generation of most immune responses including those with antitumor activity. Prompted by two clinical trials which have suggested distinct but apparently opposite effects of lipid emulsions on the production of and lymphocyte responses to IL-2 we have examined the effects of pharmacological concentrations of three lipid emulsions currently in clinical use on IL-2 related interactions in vitro. Mitogen-stimulated and IL-2 activated human lymphocyte proliferation were both inhibited in a dose-dependent manner in the presence of all three lipid emulsions although the effects were less marked with the solution in which 50% of the calories are present as medium-chain triglycerides (MCT) rather than long-chain triglycerides (LCT). Similarly the LCT, but less so the MCT-containing solutions inhibited the generation of cytotoxic lymphokine-activated killer cells. These solutions did not inhibit the proliferation of cell lines which are not growth-factor dependent but did inhibit the growth of an IL-2-dependent cell line. We conclude that lipid emulsions can upset IL-2-dependent lymphocyte responses. These observations may lead to parenteral feeding regimens which are less immunocompromising for the tumor-bearing patient.

Total parenteral nutrition adversely influences tumour-directed cellular cytotoxic responses in patients with gastrointestinal cancer

The effects of total parenteral nutrition (TPN), using a lipid-based regimen, on non-specific lymphocyte function and tumour-directed cellular cytotoxicity was studied in 30 patients suffering from gastrointestinal (GI) cancer. After 7 days of TPN, augmented lymphocyte blastogenesis and production of the helper T-lymphocyte lymphokine Interleukin-2 were observed. However, over the same time period, significant impairment of basal natural killer (NK), and IL-2 activated NK activity were observed. Furthermore, lymphokine-activated killer (LAK) cell responses towards the NK resistant cell line DAUDI and the colorectal tumour cell line COLO 320, were markedly depressed. These findings have important implications for the use of this TPN regimen in GI cancer patients who might be considered for either surgical adjuvant or primary treatment with immunotherapy protocols.

Effects of low dose perioperative interferon on the surgically induced suppression of antitumour immune responses

General surgical procedures are followed by a period of generalized immunosuppression that may favour the deposition of metastases seeded at operation in patients with malignant disease. In an attempt to prevent the suppression of host-antitumour immune mechanisms following surgery we have studied the immunological effects of low-dose perioperative interferon-alpha (r-HuIFN alpha). Patients were randomly allocated pre-operatively to the control (n = 15) or treatment group (n = 15). Patients in the treatment arm received a 1-week course of subcutaneous recombinant human interferon-alpha 2a (Roferon-A) at a dose of 2 megaunits daily starting on the evening before surgery. Natural killer cell, lymphokine activated killer cell cytotoxicities and endogenous interleukin 2 production were measured 1 day before surgery and on the first, third, fifth and tenth postoperative days. Treatment with r-HuIFN alpha did not prevent the postoperative impairment of interleukin 2 production or lymphokine activated killer cell cytotoxicity. However it prevented the fall in natural killer cell activity normally observed following surgery. This may have important consequences in controlling metastatic dissemination of tumour in this vulnerable period.

Cytosolic retinoic acid binding protein in the human pancreas

Cytosolic retinoic acid receptor in carcinoma, chronic pancreatitis, and normal pancreatic tissue were examined using sucrose density gradient centrifugation, isoelectric focussing on agarose gel and saturation analysis. Thirteen patients were studied. Cytosolic retinoic acid binding protein (cRABP) was detected in all the samples with chronic pancreatitis and pancreatic carcinoma, but not in the normal tissue. Using sucrose gradient centrifugation, the highest concentrations of cRABP were found in pancreatic carcinoma tissues, ranging from 5.5-23.9 pmol/mg protein. These concentrations were markedly different than in chronic pancreatitis tissue (0.7-2.7 pmol/mg protein). Saturation analysis of cRABP showed a mean dissociation constant of 21.5 nM and maximum binding sites of 5.2 pmol/mg protein. Cytosolic retinoic acid binding protein was separated at an isoelectric point of 4.5 on agarose gel. The presence of cRABP suggest that retinoic acid may have a role to play in the function of the pancreas.

Augmentation of lymphokine-activated killer cell activity in patients with gastrointestinal cancer

Adoptive cellular immunotherapy with lymphokine-(interleukin 2) activated killer (LAK) cells is not as successful in patients with gastrointestinal cancer as with other tumour types. This may be because the cytotoxic capacity of LAK cells from such patients is suboptimal. In this study we have sought to augment this activity by stimulating the lymphocytes with recombinant human interferon-gamma (r-HuIFN-gamma) in addition to interleukin 2 or by depleting the lymphocytes of adherent suppressive mononuclear cells. Both procedures augment LAK activity in gastrointestinal cancer patients but adherent cell depletion results in fewer cells being available for adoptive cellular immunotherapy. No further augmentation of LAK activity of adherent cell depleted cells could be accomplished by addition of r-HuIFN-gamma. Co-stimulation of unfractionated peripheral lymphocytes with r-HuIFN-gamma is the preferable procedure for the generation of LAK cells for adoptive cellular immunotherapy in patients suffering from gastrointestinal cancer.

Lymphokine activated killer (LAK) cells in patients with gastrointestinal cancer

Lymphokine activated killer (LAK) cells are a recently described cellular immune phenomenon with exciting potential for the treatment of tumours arising from solid organs. A comparison of some aspects of LAK cell precursors and LAK cell function was undertaken in 44 control subjects and 44 preoperative patients suffering from gastrointestinal cancer (20 localised and 24 advanced). Lymphokine activated killer cell precursor (natural killer (NK) cell) activity was significantly diminished in patients with advanced tumours (p less than 0.02) as was fully mature LAK cell activity against an NK resistant target cell (p less than 0.012). T-lymphocyte responses were not significantly different between the three groups. The reduced LAK cell generation was associated with a significantly diminished proliferative response of LAK precursors to stimulation with high dose IL-2 in vitro (p less than 0.012). Impaired LAK cell generation may explain the failure of adoptive cellular immunotherapy with LAK cells in some patients with advanced gastrointestinal cancer and prompts the search for means of augmenting this activity in such patients.

Lateral paramedian incision

Prospective randomization of 360 patients undergoing abdominal surgery determined whether a standard lateral paramedian incision was made (group A) or one of two modifications in which the anterior sheath was incised medially and posterior sheath incised laterally (group B) or vice versa (group C), in order to determine the necessity for incising both layers laterally to provide the shutter mechanism which is held responsible for the integrity of this wound. Medial incision of the anterior rectus sheath significantly reduced the time required to perform the incision (P less than 0.02) and tended to reduce wound sepsis rate. However, this was achieved at the cost of a higher incisional hernia rate (0 per cent, 2.9 per cent and 4.6 per cent in groups A, B and C respectively, P less than 0.02). We conclude that lateral incision of both anterior and posterior rectus sheath is necessary to obviate the risk of wound hernia with the lateral paramedian incision.

Breast reconstruction by tissue expansion

The techniques of tissue expansion for use in breast reconstruction is described, together with the results of its use in 33 patients. The advantages and disadvantages of tissue expansion in relation to other currently favoured techniques are discussed. It is concluded that tissue expansion represents a major advance in the field of breast reconstruction.

Influence of intraperitoneal drains on subhepatic collections following cholecystectomy: a prospective clinical trial

In this prospective randomized study, the influence of an intraperitoneal drain on the incidence and clinical significance of subhepatic collections occurring in patients after acute or elective cholecystectomy was assessed by ultrasound examination. A total of 112 patients entered the study, of whom 54 received a drain. There was no significant difference between the drainage and the non-drainage groups with respect to mean age or sex distribution, the number of patients in whom the gallbladder bed was formally closed (27 versus 21) nor in the number of acute cholecystectomies performed in either group (12 versus 13). Ultrasound detected 10 (18 per cent) collections in the drainage group and only one (1.8 per cent) in the non-drainage group (P less than 0.01, chi 2 test). None of the collections required any further treatment and no morbidity occurred that was directly attributable to the presence of the retained fluid. These results suggest that rather than preventing fluid collections, suction drains may predispose to the development of subhepatic collections after cholecystectomy.

Immunorestorative effect of lipid emulsions during total parenteral nutrition

This prospective in vivo cross-over study investigated the effect of Intralipid on immune responses. Twenty-three patients were randomly allocated to receive one of two alternative total parenteral nutrition (TPN) regimens for the first 7 days and the other regimen for the second 7 days. Only one of the regimens included a fat emulsion to provide 50 per cent of the calorific requirement. Immunological studies were performed on days 0, 7 and 14. These included peripheral blood T cell subsets, antibody dependent cellular cytotoxicity and basal and maximal Interleukin 2 production. All immunological parameters were significantly augmented during total parenteral nutrition using the lipid based regimen. No such change was seen during intravenous feeding with carbohydrate based TPN. It is concluded that, far from being immunosuppressive, the incorporation of a fat emulsion into a TPN regimen has immunostimulatory properties.

Post-mastectomy breast reconstruction using the inflatable tissue expander

Breast reconstruction following mastectomy has previously relied on the insertion of a silicone gel implant or the use of a myocutaneous flap. We report the use of an innovation, the inflatable tissue expander, for both immediate and delayed breast reconstruction in 26 patients where soft tissue cover was inadequate to permit the use of the silicone implant. By serial inflation of the tissue expander with saline, sufficient tissue cover was achieved for a second operative placement of a silicone prosthesis of appropriate volume to match the normal breast. To date, 10 patients undergoing delayed reconstruction and 5 of 16 patients with immediate reconstruction have had their final prosthesis inserted, while 3 women are satisfied with the result of the expandable implant and desire no further surgery. Only two technical complications have arisen with loss of the expander in one patient who had had recent radiotherapy and in another the tissue expander was placed much too high on the chest wall. Mechanical failure occurred in three cases where disruption of the seam led to sudden deflation in two and a slow leak from the injection port developed in one. One patient also attempted self-inflation leading to deflation of the tissue expander. The cosmetic results were subjectively and objectively very good with capsular distortion present in only one case. We feel that the inflatable tissue expander is simple and safe to use, may be used for immediate reconstruction without compromising the ablative surgery and should be a choice available to general surgeons for providing safe and cosmetically acceptable reconstructive surgery.

Delorme's operation: the first choice in complete rectal prolapse?

The Delorme operation has been used to treat 27 consecutive patients with complete rectal prolapse. The mean age in this group was 74 years and the average length of the prolapse was 12 cms. There was no postoperative mortality or morbidity. The follow-up ranges from 11 months to 64 months (mean 35 months) and so far there have been two recurrences. One of these has been successfully treated by a second Delorme operation. The second patient has declined further surgery. This low recurrence rate combined with the minor nature of the procedure suggests that the Delorme operation should be considered in all patients presenting with complete rectal prolapse.

The lateral paramedian incision--experience with 850 cases

We present our experience in 850 consecutive patients who had a laparotomy through a lateral paramedian incision during the period 1977-1981. These patients underwent both elective and emergency procedures covering a wide range of intra-abdominal conditions, and had a high incidence of factors known to predispose to wound dehiscence and incisional hernia formation. Follow-up in each case for at least 1 year revealed no wound dehiscences and 3 incisional hernias (0.37 per cent). We conclude that the lateral paramedian incision is inherently strong and that this strength is due to the splintage of the wound by the rectus abdominis muscle and the wide shutter mechanism that this provides.

Does the type of suture material contribute to the strength of the lateral paramedian incision?

A prospective randomized trial was carried out on 231 consecutive laparotomies in which the lateral paramedian incision was used in all cases. Closure of the wound was identical except for the anterior rectus sheath where closure was randomized to (a) chromic catgut, (b) polyglycolic acid or (c) polypropylene. Follow-up for 1 year has revealed no wound dehiscences and only one incisional hernia (in the catgut group). We conclude that the lateral paramedian incision is inherently strong, and that this strength is due to splintage of the wound by the rectus abdominis muscle itself and is unrelated to the type of suture material used.

Lymphomatoid granulomatosis with multiple intracranial lesions. Care report

✓ A case of lymphomatoid granulomatosis with multiple intracranial lesions is reported. Important aspects of this vasculitis are discussed, including its propensity for lymphomatous transformation, its similarity to Wegener's granulomatosis, its predilection for certain sites, and its resistance to treatment. A correlation is described between the computerized tomography scan and the autopsy findings.

The value of laparoscopy under local anaesthesia in 250 medical and surgical patients

This study reports our experience of laparoscopy under local anaesthesia in 250 patients; the procedure was safe, quick and easy to perform with minimal inconvenience to the patient. We advocate the early use of laparoscopy in patients with ascites and when there is difficulty in the diagnosis of patients with jaundice and hepatomegaly, an accurate histological diagnosis being obtained in the majority. In patients with intra-abdominal malignancy, in whom surgery is planned, laparoscopy can detect disseminated disease and so avoid an unnecessary laparotomy. Laparoscopy may also provide a diagnosis in patients presenting with a variety of vague symptoms such as abdominal pain, weight loss, lethargy etc. We have found laparoscopy an excellent investigation if positive but, as if only allows the surface inspection of viscera, when negative, we recommend caution in its interpretation.

Computed tomography in the postoperative patient

Nine cases of patients in whom intracranial infection was suspected after operation are presented. Lesions with ring enhancement were seen in all of these patients. The differentiation of enhancement, seen as a normal postoperative phenomenon, from residual neoplasia and cerebral abscess can be difficult. This can be resolved by serial and sequential-delayed CT, and thus unnecessary re-exploration may be prevented.

Vertical abdominal incisions--a choice?

A prospective randomized trial was carried out on 207 patients undergoing laparotomy using three different vertical abdominal incisions--midline, 'medial' paramedian incision and 'lateral' paramedian incision. The lateral paramedian incision is slightly more time-consuming to perform than the other two incisions but there is a statistically greater incidence of incisional hernia in midline and medial paramedian wounds than with the lateral paramedian incision. It is suggested that when a vertical abdominal incision is being considered the lateral paramedian should be the incision of choice.

Interhemispheric subdural empyema: neuroradiological diagnosis

A case of subdural empyema situated in the interhemispheric subdural space is described. CT scan is useful in the diagnosis and follow-up of intracranial inflammatory pathology. Selective angiography was helpful in the compartmental localization of the abscess in the interhemispheric subdural space, adjacent to the falx and tentorium by virtue of the hypertrophied tentorial meningeal arteries and vascular displacement. CT scans are also useful in follow-up of cerebral abscess after micropaque barium has been injected into the cavity as in this patient.

Case report. Tandem lesions: chromophobe adenoma and meningioma

A number of cases of multiple primary intracranial neoplasms have been reported, including tumors of neuroepithelial and mesenchymal origin. The presence of meniogioma has been reported in association with glioblastoma, oligodendroglioma, astrocytoma, and eosinophilic adenoma. This case represents a unique example of adjacent chromophobe adenoma and meningioma. The usefulness of computed tomography in the diagnosis of concomitant lesions with different density attenuations is discussed.

Computed tomography in the diagnosis of Creutzfeldt-Jacob disease

Creutzfeldt-Jacob disease manifests clinically as a form of presenile dementia. It is now known to be caused by a transmissible agent, probably a "slow virus". Rapidly progressive atrophic changes on serial computed tomograms of the brain are highly suggestive of the disease. Neuroradiographic and pathological findings in two cases of Creutzfeldt-Jacob disease are documented.

Coagulation changes in sensitized canine renal allografts

Coagulation changes within kidney homotransplants to sensitized canine recipients have been studied by assessing the arteriovenous gradients of formed blood elements and coagulation factors across the organ. It is confirmed that hyperacute rejection is accompanied by evidence of intravascular coagulation within the graft, which is maximal during the first 20 minutes after revascularization. Attempts were made to prolong the survival of the grafts by the use of cytotosine arabinoside, methylprednisolone, heparin and azathioprine. In some instances, the severity of the intravascular coagulation was reduced but it did not prove possible to extend the survival of the kidneys beyond 24 hours.

How tight should tension sutures be tied? A controlled clinical trial

In a prospective randomized trial there was no advantage in tying tension sutures flush with the wound; by tying them loosely (over three fingers of the assistant's hand) there was less wound pain and less cutting in of the tension suture into the ridge of the wound and along the suture tracks.

A study of lymph nodes draining colorectal cancer using a two-stage inhibition of leucocyte migration technique

A two-stage technique for leucocyte migration inhibition has been developed which demonstrates the sensitization of lymph node lymphocytes to colorectal tumour extract. The studies have confirmed that some lymph nodes draining colorectal carcinomata contain sensitized lymphocytes. However, the degree of lymphocyte sensitization to tumour extract does not seem greater than that seen in lymph nodes of the small bowel mesentery or of the peripheral blood.

A trial of 1-(2-chlorethyl)-3-(4-methyl-cyclohexyl)-1-nitrosourea in the treatment of patients with advanced gastro-intestinal cancer

This paper describes an uncontrolled preliminary study of a nitrosourea drug 1-(2-chlorethyl)-3-(4-methyl-cyclohexyl)-1-nitrosourea, testing its activity against advanced gastro-intestinal cancer. Used as a single agent in a single oral dose, the objective remission rate was only II per cent. Palliation of symptoms was achieved in one-third of the cases. Side-effects were commonly seen, with immediate nausea and vomiting in two-thirds of the patients and evidence of bone marrow suppression in 55 per cent. This particular nitrosourea derivative does not appear to have a significant advantage over other forms of cytotoxic therapy when used as a single agent.

The influence of the lower oesophageal sphincter pressure on the outcome of hiatus hernia repair

Thirty-six patients who had undergone a simple repair of a hiatus hernia were examined with regard to the postoperative symptomatology, persistence of reflux as judged by radiological means and the pressures of the lower oesophageal sphincter. One-third of these patients had persistent symptoms although these were usually mild. It has not been possible to correlate the persistence of symptoms with either the demonstration of radiological reflux or reduced lower oesophageal sphincteric pressures.