Jeremy Thompson

Small bowel gastrointestinal stromal tumours and ampullary cancer in Type 1 neurofibromatosis.

BackgroundType 1 neurofibromatosis (NF-1) is an autosomal dominant disorder with variable penetrance; approximately 50% of cases present as new mutationsCase reportWe report a case of a 56 year-old man with Von Recklinghausens disease, carcinoma of the ampulla of Vater and incidental benign gastrointestinal stromal tumours of the jejunum.ConclusionsCoexistence between ampullary carcinoid, ectopic pancreatic tissue in the jejunum and neurofibroma of the jejunum in NF-1 has been previously described however; the association of synchronous carcinoma of the ampulla of Vater and gastrointestinal stromal tumour of the jejunum in NF-1 has not been previously reported.

Potential of Surface-Coil MRI for Staging of Esophageal Cancer

OBJECTIVE The aim of this pilot study was to assess the feasibility of external surface-coil MRI as a new method of imaging the esophagus and esophageal cancer. CONCLUSION The results for the 10 patients investigated indicate that by using a high-resolution axial T2-weighted sequence (small field of view, thin section images), MRI provides detailed imaging of the anatomic layers of the esophageal wall and tumor. Three independent radiologists found good correlation in the morphologic appearance and extent of tumor between MRI and matched histology sections. This study illustrates the potential of the technique as an alternative form of local staging for esophageal cancer.

Pancreas-Sparing Distal Duodenectomy for Infrapapillary Neoplasms

INTRODUCTION For neoplasms that arise in the third and fourth parts of the duodenum (D(3), D(4)), a duodenectomy that preserves the pancreas can provide adequate tumour clearance while avoiding the additional dissection and risk of the common alternative, pancreatoduodenectomy. PATIENTS AND METHODS Pancreas-sparing distal duodenectomy (PSDD) was performed in 14 patients with infrapapillary duodenal neoplasms between 1991-2002, and the clinical outcome is reviewed. The operation entails careful separation of the lower pancreatic head from D(3), complete mobilisation of the ligament of Treitz and end-to-end duodenojejunal anastomosis 1-3 cm below the major duodenal papilla. RESULTS There were 9 men and 5 women of median age 56 years, who presented with iron-deficiency anaemia (n = 8), gastric outlet obstruction (n = 4), anaemia and gastric outlet obstruction (n = 1), epigastric pain or mass (1 each). There were 11 malignant neoplasms (adenocarcinoma 5, stromal tumour 4, recurrent seminoma 1, plasmacytoma 1), 2 benign neoplasms (villous adenoma, lipoma) and 1 patient with steroid-induced ulceration. In addition to D(3) and D(4), resection included the distal part of D(2) in 5 patients, while 4 required concomitant partial colectomy. Median operation time was 240 min and median blood loss 1197 ml, being greater for malignant than benign lesions (1500 ml versus 700 ml). There was one death from gangrenous cholecystitis, one early re-operation for anastomotic bleeding and one late re-operation for delayed gastric emptying secondary to anastomotic stricture, but no pancreatic complications. At a median follow-up of 47 months, three patients had died of recurrent disease while the other 10 were alive and well with no upper gastrointestinal symptoms. CONCLUSIONS Provided there is a minimum 1-cm clearance at the papilla, PSDD is a useful alternative to formal pancreatoduodenectomy in patients with unusual neoplasms arising from the third and fourth parts of the duodenum. Although a major undertaking in its own right, it avoids the extra time of a pancreatic resection and the extra risk of a pancreatic anastomosis.

Splenectomy in mantle cell lymphoma with leukaemia: a comparison with chronic lymphocytic leukaemia

Summary. We reviewed data on 63 patients with mantle cell lymphoma (MCL) with leukaemia (n = 16) and chronic lymphocytic leukaemia (CLL, n = 47), splenectomized over a 10‐year period. Primary indications for surgery were cytopenia(s) or autoimmune phenomena and progressive or refractory disease with splenomegaly. The spleens removed were on average larger in MCL (median 2·6 kg) than in CLL (1·0 kg). Splenectomy improved the blood counts in 62% of patients with MCL and 47% with stage C CLL, both with cytopenias. The MCL patients showed a decrease in the leucocytosis (medians 60·3–29·1 × 109/l before and after splenectomy), whereas there was an increase in the leucocytosis in CLL (medians 24·2–44 × 109/l). With a median follow up post splenectomy of 10 months (range: < 1–128), 18 patients (four MCL and 14 CLL) have not required further therapy for up to 66 months. We conclude that splenectomy is a useful treatment in MCL and advanced CLL for the correction of cytopenias, reducing the leucocyte count and allowing prolonged periods of clinical remission without therapy. Differences seen between MCL and CLL in spleen size, and in response of the leucocytosis suggest a central role for the spleen in the evolution of MCL with leukaemia.

Non-Occlusive Small Bowel Necrosis in Association with Feeding Jejunostomy After Elective Upper Gastrointestinal Surgery

INTRODUCTION Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals. PATIENTS AND METHODS The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ). RESULTS Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived. CONCLUSIONS The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.

Inflammatory myofibroblastic tumour of the gallbladder.

BackgroundInflammatory myofibroblastic tumour (IMT) is a benign, nonmetastasizing proliferation of myofibroblasts with a potential for local infiltration, recurrence and persistent local growth.Case reportWe report a case of a 51 year-old female, who had excision of a gallbladder tumour. Histopathology showed it to be IMT of the gallbladder.ConclusionThe approach to these tumours should be primarily surgical resection to obtain a definitive diagnosis and relieve symptoms. IMT has a potential for local infiltration, recurrence and persistent local growth.

Spontaneous mesenteric haematoma; diagnosis and management

Spontaneous mesenteric haematomas are rare. They have been reported to be associated with coagulopathies, connective tissue disorders, past trauma, arteriopathy and pancreatitis. However, some cases have been reported in which there is no apparent underlying aetiology. Here we report such a case and we review the literature that discusses optimal diagnosis and management. In this case, spontaneous haemostasis occurred by intra-abdominal tamponade and the regression of the haematoma was monitored with regular imaging.

Comparison of weight loss achieved after laparoscopic adjustable gastric banding between Afro-Caribbean, Caucasian and South Asian adult female patients in a London bariatric centre

INTRODUCTION It has been shown that following laparoscopic adjustable gastric banding (LAGB) procedures, Afro-Caribbeans achieve poorer weight loss compared with Caucasians. The reasons for this are multifactorial. However, studies have been based on mainly female patients from the US and none to date have been from the UK. Furthermore, South Asians have not previously been compared. The aim of this study was to compare excess weight loss percentage (%EWL) outcomes up to five years following LAGB in Afro-Caribbean, Caucasian and South Asian females in a London-based teaching hospital. METHODS An analysis was carried out of prospectively collected data of female patients aged ≥16 years of Afro-Caribbean, Caucasian or South Asian origin who underwent LAGB between October 2000 and December 2011. Data included demographics, co-morbidities and anthropometrics. RESULTS Overall, 596 females underwent LAGB; 316 Caucasians (53.0%), 64 Afro-Caribbeans (10.8%) and 27 South Asians (4.5%) formed the majority of those who disclosed ethnicities. Age and initial body mass index (BMI) were comparable between Afro-Caribbeans and Caucasians (mean BMI: 47.3kg/m²[standard deviation [SD]: 7.5kg/m², range: 37.0-78.3kg/m²] vs 45.8kg/m²[SD: 7.1kg/m², range: 24.7-79.8kg/m²], p=0.225). A non-significant trend suggested less %EWL in Afro-Caribbeans than in Caucasians at 6 months, and at 1, 2, 3, 4 and 5 years (21.4% vs 24.4%, p=0.26; 27.4% vs 31.3%, p=0.27; 33.0% vs 36.8%, p=0.15; 39.0% vs 45.8%, p=0.14; 34.2% vs 45.3%, p=0.16; 37.1% vs 47.6%, p=0.67). South Asians and Caucasians had a similar age and preoperative BMI (mean BMI: 43.6kg/m² [range: 32.5-59.1kg/m²] vs 45.8kg/m² [range: 24.7-79.8kg/m²], p=0.08). The %EWL was greatest at three and four years among South Asians although numbers were small (n=4 and n=3 respectively). CONCLUSIONS A non-significant trend suggests poorer weight loss outcomes in Afro-Caribbeans compared with Caucasians in our cohort. Discussion of realistic weight loss outcomes as well as enhanced follow-up and dietary modifications are required for Afro-Caribbean patients. Low numbers prevent definitive conclusions regarding South Asians. Multicentre studies across England are required to better define any differences between ethnicities.

Prognostic role of metastatic lymph node number and lymph node ratio in ampullary adenocarcinoma

Background: The role of the metastatic-to-resected lymph nodes ratio (LNR) and the metastatic lymph node number (LNN) in the staging of ampullary carcinoma (AC) is controversial. This retrospective study evaluates the impact on survival of LNN and LNR in resected AC. Methods: One-hundred patients who underwent pancreaticoduodenectomy with standard lymphadenectomy for AC were categorized into N1 (1-2 metastatic LNs) or N2 (≥3 metastatic LNs) and into LNR ≤0.056 or LNR>0.056 groups. Kaplan-Meier survival curves and multivariate analysis of prognostic factors were assessed. Results: Median overall survival was 90, 36 and 36 for N0, N1 and N2 (p=0.014) and 85 and 35 months for LNR≤0.056 and LNR>0.056 (p=0.006). Median DFS was Not Reached (NR), 33 and 13 months for N0, N1 and N2 (p<0.001), and NR and 17 months for LNR≤0.056 LNR>0.056 (p<0.001). Independent prognostic factors were LNR>0.056 (HR 1.99; p=0.029), R1 margins (HR 2.4; p=0.042) and adjuvant chemotherapy (HR 1.76; p=0.044) for OS; LNN (HR 3.03 and 5.03 for N1 and N2; p=0.003), LNR>0.056 (HR 2.07; p=0.048), and tumor size ≥2cm (HR 2.73; p=0.018) for DFS. Conclusions: Both LNR>0.056 and increasing LNN (1-2 and ≥3) should be considered in the staging of AC, as they are independent predictors of worse prognosis.

Formulating a surveillance strategy following surgery for oesophagogastric cancer.

153 Background: Oesophagogastric adenocarcinoma (OGA) has a poor prognosis, even for patients (pts) with operable disease. We conducted a retrospective study to assess relapse characteristics to see if these could influence follow-up strategies. Methods: We performed a retrospective review of all pts with OGA who had surgery with radical intent at the Royal Marsden between January 2001 – December 2010. Details of first relapse, including date, site, symptoms, method of relapse detection, tumour markers and treatment were recorded. Association of survival outcomes with relapse characteristics was determined by Cox regression univariate analysis. Results: 360 pts with OGA had surgery and 72.8% received neoadjuvant or peri-operative chemotherapy. After a median follow-up of 61.7 months, the median disease-free survival (DFS) was 35.6 months (95% CI 27.0 – 65.4) and median overall survival (OS) was 59.6 months (95% CI 40.7 – 81.2). 147 pts (40.8%) had disease recurrence. 51.0%, 78.9% and 91.8% of relapses occ...