THE SELECTIVE USE OF FINE CATHETER PERITONEAL CYTOLOGY AND LAPAROSCOPY REDUCES THE UNNECESSARY APPENDICECTOMY RATE

The effect of a management protocol incorporating the selective use of fine catheter peritoneal cytology (FCPC) and laparoscopy on the unnecessary appendicectomy rate was studied in adult patients (≥16 years) treated at one district general hospital over an 11 -month period. Appendicectomy was performed on 62 adult patients managed according to this protocol, six (10%) of whom had a histologically normal appendix and no other acute condition requiring surgery. A further 57 patients underwent appendicectomy after standard clinical assessment and investigation without the use of FCPC or laparoscopy. Nineteen (33%) of these patients had a histologically normal appendix removed, with no other acute condition requiring surgical treatment. The selective use of FCPC and laparoscopy significantly reduced the unnecessary appendicectomy rate from 33% to 10% (χ² = 10.0, P<0.005). The more widespread use of these techniques in patients with suspected appendicitis is therefore recommended.     

Applied potential tomography

Applied potential tomography (APT) is a new noninvasive, nonradioactive method of measuring gastric emptying, which generates profiles of emptying of liquids that are similar to those obtained simultaneously by scintigraphy and dye dilution. This study validates the ability of APT to measure emptying of a solid beefburger test meal from the stomach by comparing the results obtained with those obtained simultaneously by scintigraphy. When acid secretion was inhibited, there was a significant correlation between the two methods for the time taken for half the meal to empty from the stomach and the amount of meal emptied at different time intervals. Furthermore, the profiles of gastric emptying obtained by APT resembled those obtained by scintigraphy in most studies. If acid secretion was not inhibited, there was no correlation between values obtained by the two methods.     

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.     

The continuing challenge of exocrine pancreatic cancer

Carcinoma of the exocrine pancreas continues to have one of the poorest outlooks of any cancer. Although worthwhile gains in survival may be achieved by early diagnosis and referral to a specialist surgeon, further improvements are unlikely without reliable screening techniques and improved adjuvant therapy.     

THE CHANGING INDICATIONS FOR CAROTID ENDARTERECTOMY IN THE UK

In early series the majority of carotid endarterectomies were performed in patients with amaurosis fugax (AFx) or transient ischaemic attacks (TIAs) who were thought to have atheromatous ulcers of the carotid bifurcation or the internal carotid artery (ICA). The degree of stenosis was considered to be of secondary importance. We compared our own data with two British series undertaken in the early and late 80s/early 90s. This reflects the broadening of indications and the change of practice for carotid endarterectomy over the years, on the one hand towards including patients who are at greater risk of perioperative stroke (previous CVAs vs TIAs, crescendo TIAs and stroke in evolution), and on the other towards patients who have had no symptoms attributable to the carotid lesion (asymptomatic cases, combined carotid and cardiac procedures).     

Abnormalities of innervation of internal anal sphincter in fecal incontinence

Physiological and histological studies have shown that the internal anal sphincter is abnormal in idiopathic fecal incontinence. We have recently demonstrated that the invitro contractile response of the internal anal sphincter to the sympathetic neurotransmitter noradrenaline is decreased in incontinence. In this study we have further defined this reduced sensitivity and provided more information about the intrinsic innervation in both the normal and the incontinent sphincter muscle. Muscle strips from 12 incontinent patients undergoing post anal repair and from 11 controls undergoing rectal excision for low rectal carcinoma were studied. Responses to noradrenaline were recorded initially alone and then in the presence of phentolamine, an α-adrenoceptor blocker. In the presence of phentolamine, noradrenaline caused relaxation: there was no significant difference in the relaxation-response curves and the EC₅₀ was the same in the two groups. These results demonstrate that the previously documented reduced sensitivity to noradrenaline is due to an altered sensitivity of the α-adrenoceptors. Electrical field stimulation produced relaxations in all muscle strips, but only in the controls was the magnitude of the relaxation significantly increased in the presence of phentolamine. This indicates that there is an α-adrenergic excitatory component of the response to electrical field stimulation of the intramural nerves, which was present in tissues from control patients but which was absent in tissues from patients with idiopathic fecal incontinence.     

Changes in Esophageal Function after Vertical Banded Gastroplasty as Demonstrated by Esophageal Scintigraphy

Background: The effects of surgery for morbid obesity on the function of the upper gastrointestinal (GI) tract are of interest to bariatric surgeons. This study was undertaken to determine any changes in esophageal function, following vertical banded gastroplasty (VBG) in morbidly obese patients, as detected by esophageal scintigraphy. Methods: Ten consecutive morbidly obese patients (six female and four male) underwent preoperative esophageal scintigraphy and upper GI endoscopy. These investigations were repeated 12 months after VBG to coincide with expected appreciable weight reduction. The results were tabulated together with body mass indices, crude weights and percentage excess weight lost. Results: Before VBG one patient gave a history of mild heartburn, one had mild dyspepsia and the remaining eight patients had no GI symptoms. No patient had a hiatus hernia or endoscopic evidence of reflux esophagitis. Preoperatively all patients had abnormal scintiscans. The abnormalities were esophageal retention (all) and intraesophageal reflux (five out of 10 patients). Gastroesophageal reflux was not identified in any patient. Postoperatively scintiscans were normal or improved in six out of 10 patients and unchanged in four out of 10 patients. In three patients the scans were normal and three showed overall improvement in esophageal function, although in one of these latter patients gastroesophageal reflux was observed. Conclusions: In this series of morbidly obese patients, esophageal function as assessed by scintigraphy was abnormal. Following VBG it improved in six out of 10 patients and was unchanged in four out of 10. However, in one patient, who had shown an overall improvement in esophageal function, gastroesophageal reflux was demonstrated when it had not been seen preoperatively. This was asymptomatic. Thus, adverse changes in esophageal function after VBG were uncommon.     

TUBERCULOUS PERITONITIS PRESENTING AS COLOENTERIC FISTULA

SUMMARY Abdominal tuberculosis can present as tuberculous peritonitis with generalised or loculated ascites, lymphadenitis of the mesenteric or retroperitoneal nodes, or as intestinal tuberculosis. In the last case it could be annular mucosal ulceration, single or multiple strictures or hyperplastic tuberculosis of the bowel, usually involving the terminal ileum or ileocaecal region. Disease higher in the ileum is considered common but involvement of the appendix, stomach, duodenum, jejunum, colon and rectum is unusual. Tuberculous peritonitis presenting as a coloenteric fistula is not a common clinical entity. In this case a patient who presented with peritonitis was found to have tuberculous peritonitis with coloenteric fistula.