Non-operative management of malignant intestinal obstruction

Intestinal obstruction is a relatively common clinical problem in patients with advanced cancer, particularly those with colorectal and ovarian tumours. A proportion of patients have a non-malignant cause for their obstruction, but in the remaining patients obstruction will be caused by advanced malignancy itself. In the past, most patients were either managed surgically or by nasogastric intestinal decompression and intravenous hydration. Surgery in patients with advanced cancer is associated with high mortality and morbidity. Effective surgical decompression is difficult. We have managed 24 patients with advanced abdominal malignancy and previous operative or radiological evidence of intestinal obstruction without operation. The technique is only appropriate for patients in whom a solitary or correctable obstructing lesion can be excluded. The patient is encouraged to take free fluid and a diet low in fibre. Intestinal colic is managed with morphine, the dose required being titrated for each individual patient against background pain and colic. Vomiting is controlled by the parenteral administration of antiemetic drugs. To simplify drug administration, morphine and metoclopramide are mixed in the same syringe and infused subcutaneously simultaneously. In our 24 patients the mean survival rate after the onset of complete obstruction was 29.2 days. The mean dose of morphine infused was 9.2 mg/h, and the mean dose of metoclopramide was 6.9 mg/h. The case of an 82-year-old male patient is presented. We commend the technique to surgeons contemplating surgery in these very difficult patients. It is simple, relatively non-invasive and saves the patients the pain, discomfort and complications of unproductive surgery.     

Inpatient management of piles: a surgical audit.

A retrospective study was performed on 160 patients admitted to the University Surgical Unit between July 1975 and November 1989 with haemorrhoidal disease. Patients' records were analysed with respect to predisposing factors, inpatient management, postoperative analgesia, hospital stay and post-management complications. One hundred and nineteen patients had haemorrhoidectomy (low ligation combined with an anal stretch). Of these, 1.6% developed urinary retention and 4.2% bled postoperatively but did not require surgical intervention. Ten patients were found to have tight anal canals post surgery and required outpatient anal dilatation. In no case was dilatation necessary for more than 3 months. Three patients required a therapeutic course of antibiotics. Of the 119 patients, 60 required narcotic analgesia for less than 24 hours. Hospital stay was 1-4 nights.     

Failure of intramuscular antivenom in Red‐back spider envenoming

Four cases of Red‐back spider envenoming are reported in which there was minimal response to intramuscular antivenom. Intravenous antivenom was then administered in each case with almost complete resolution of symptoms. All cases were followed up to confirm the effect of treatment. This failure of intramuscular Red‐back antivenom raises the question of its efficacy. There has been no controlled trial to prove that intramuscular Red‐back antivenom is effective and animal work with other antivenoms has demonstrated the intramuscular formulation to have delayed and incomplete effects. Controlled studies should be undertaken to establish the effectiveness of intravenous and intramuscular Red‐back antivenom.     

Colorectal cancer below age 40 in the Kingdom of Saudi Arabia.

This study compares colorectal cancer from the King Faisal Specialist Hospital and Research Center (KFSHRC) Tumour Registry in patients under and over 40 years and contrasts the data with registry data from New Zealand (NZ). Between 1975 and 1989 622 patients were registered at KFSHRC and 528 were Saudi. Three hundred and twenty-one were male and 207 were female. The average ages were 55.3 and 49.6. One hundred and nineteen were less than 40 years. More patients with proximal lesions were less than 40 years. Of the young patients 8.3% had small tumours (less than 4 cm) compared with 24.9% of patients over 40. Mucinous and signet ring carcinomata were more common in the young. Tumours were less well differentiated in younger patients. There were more young patients with 'localized' disease and nodal involvement. Older patients had more distant metastases. Of patients registered in NZ 5.5% were young compared with 23% of Saudi patients. In both countries localized disease was more common in the young. Nodal involvement was more frequently seen in the young in the Kingdom of Saudi Arabia (KSA) whereas the opposite was true in NZ. Distant metastases were more common in the old in the KSA but there were more young patients with metastases in NZ. In both countries young females with rectal tumours were more common but this ratio was reversed in the old. This study suggests that colorectal cancer may be more aggressive in the young in KSA but there was no evidence that the disease was more aggressive in young New Zealanders. Differences in the epidemiology of the disease in the young and old were found in both countries.     

Cross-neutralisation of Australian brown and tiger snake venoms with commercial antivenoms: Cross-reactivity or antivenom mixtures?

Recently it has been suggested that the Australian snake antivenoms made by CSL Ltd. are in fact not truly monovalent and may contain antibodies to other snake venoms because the horses are injected with multiple snake venoms. It is unclear to what extent various monovalent antivenoms can neutralise the effect of other venoms, whether this is due to a mixture of antibodies or true cross-reactivity, and whether this has any clinical significance. We aimed to study the immunological and functional properties of brown snake (Pseudonaja spp.) antivenom (BSAV) and tiger snake (Notechis spp.) antivenom (TSAV) against their respective venoms using enzyme immunoassays (EIA) and in vitro clotting studies. There was significant overlap between the two antivenoms with both TSAV and BSAV being detected by EIA on brown snake venom (BSV)-coated and tiger snake venom (TSV)-coated wells, respectively. In a competition EIA, increasing amounts of immunoaffinity-purified hen anti-brown antibodies (IgYp) mixed with TSAV reduced TSAV measured on TSV-coated wells. Both BSAV and TSAV prevented the clotting activity of both venoms. IgYp also prevented the clotting activity of TSV, suggesting true cross-reactivity. The cross-reactivity of TSAV and BSAV with BSV and TSV, respectively, was likely due to each being a mixture of anti-brown and anti-tiger antibodies, but there was partial cross-reactivity demonstrated by the effect of IgYp. Single-polyvalent antivenom for brown snake and tiger snake may be feasible in the future.     

COLONOSCOPY: HOW FAR IS ENOUGH?

Total colonoscopy is arguably the best method available for examination of the colon and rectum. Colonoscopy costs are high and rising and it may be that in the future practitioners will be unable to afford to colonoscope all of the patients presently being examined. This retrospective study was undertaken in an attempt to examine the cost, in terms of lesions missed, of a limited endoscopy programme. During a 15 year period, 1426 colonoscopies were performed at Wellington Hospital, New Zealand. Total colonoscopy was possible in 79% of all patients. Three perforations occurred. Nine patients bled and two required blood transfusion after biopsy or ‘snaring’ of polyps. After exclusion of patients with continuous inflammatory bowel disease (IBD) 75% of all lesions were found in or distal to the descending colon. More cancers were found in patients colonoscoped because of bleeding. Thirty-two of 93 cancers diagnosed were proximal to the descending colon but 18 presented with bleeding. A further seven had a radiological abnormality. Only 7.5% of colorectal cancers would be missed by flexible sigmoidoscopy (65 cm) and 758 of the costs of total colonoscopy would be avoided if only patients presenting with bleeding and IBD were offered total colonoscopy and patients with radiological abnormalities were treated according to the abnormality. This compromise, based on the data presented, may represent a rational way to reduce colonoscopy costs.