Intestinal transplant for recurring mesenteric desmoid tumour

progression. The increased risk of developing secondary gastric cancer after Hodgkin’s disease has been reported.l,2 No information is available about histological type. In the present series, there was a low mean age (38-8) at diagnosis, compared with patients with primary linitis plastica (50-5); and all gastric cancers developed in fields previously irradiated with a high dose per fraction, which suggests that a high fractional dose should be regarded as a risk factor for secondary tumours.

P Y Dietrich, S

Bellefqih,

M

Henry-Amar, J M Cosset, M Hayat

Department of Medicine, Haematology Unit, and Departments of Pathology, Biostatistics and Epidemiology, and Radiotherapy, Institut Gustave Roussy, 94805 Villejuif, France

1

Tucker MA, Coleman CN, Cox RS, Varghese A, Rosenberg SA. Risk of second cancers after treatment for Hodgkin’s disease. N Engl J Med

2

Zarrabi MH, Rosner F. Second neoplasms in Hodgkin’s disease: current controversies. Hematol Oncol Clin North Am 1989; 3: 303-18.

1988; 318: 76-81.

Intestinal transplant for recurring mesenteric desmoid tumour MR—A j /-year-oiu man, who had been on total parenteral nutrition for 2!years after excision of his small bowel for a mesenteric desmoid tumour, found this regimen unacceptable and sought a small bowel allograft. The tumour had recurred and he had four previous operations, ending up with anastomosis of duodenum to midtransverse colon. He worked full time but had to spend most of the rest of his life feeding himself intravenously. He took food by mouth but passed 5-8 motions a day and probably absorbed little of it. On examination he appeared healthy but thin (46 kg). There was a firm 6 x 4 cm swelling to the right of the midline scar in the adbomen which was presumed to be the recurrent tumour. His feeding catheter was tunnelled under the skin and entered the right atrium via the right subclavain vein. He was tissue typed (A2, A9/24; B5, B17;

Bw4; DR3, DR7). The whole of the small bowel with mesentery and mesenteric vessels were removed from a 15-year-old female accident victim who had been certified brain-stem dead. Her tissue type was A 1, A2; B7, B 17, Bw4, Bw6; DR4, DR7. Antibiotics were administered through the nasogastric tube and parenterally before organ removal. The specimen was cooled externally by perfusion through the superior mesenteric artery with cold University of Wisconsin preservation solution. The two ends of the bowel were closed with staples without irrigation. The operation was done through the midline scar and the recurrent tumour was removed from the right upper rectus together with surrounding unaffected tissue. Dissection was tedious because of multiple adhesions. The colon distal to the duodenal anastomosis was dilated and thick-walled, having adapted to the flow of duodenal contents. The liver appeared normal but access to the portal vein was difficult so the infrarenal inferior vena cava and aorta were prepared for anastomosis. The duodenocolic anastomosis was clamped and divided, and the donor specimen was oriented anatomically. A Carrel patch of donor aorta was anastomomosed to an anterior incision in the infrarenal recipient aorta, and the portal vein draining the superior mesenteric vein of the graft was anastomosed end-to-side to the 58

Figure: Operative procedure

recipient inferior vena cava. The arterial released, venting the initial flow through the splenic clamp vein of the specimen which was then tied, and the caval clamp removed. Perfusion was excellent and peristalsis was observed within a few minutes. The proximal duodenum was anastomosed to the recipient duodenum end-to-end with a running all-coats layer and interrupted seromuscular sutures. A similar technique was used to anastomose the side of the terminal anterior wall of the was

ileum some 10 cm from its end to the end of the transverse colon. The distal end of the ileum was brought out as an ileostomy and sutured to the skin with interrupted stitches (figure). A large feeding tube was inserted into the stomach via a gastrotomy and threaded through the duodenum past the anastomosis. The patient made a satisfactory recovery from surgery.

For immunosuppression we used a Pittsburgh type regimen with intravenous FK506 (5 mg/day intravenously over 24 h with epoprostenol at 8 ng/kg/min), azathioprine (5 mg daily), and prednisolone 200 mg daily reducing to 40 mg per day. On day 6 the ileostomy became dusky red and biopsy revealed early cellular rejection without loss of epithelium. There was strongly positive uptake by the entire graft on a labelled white cell scan. A 10-day course of antithymocyte globulin reversed the changes completely, with rapid improvement seen on a

repeat scan. During the second postoperative week there was transient lymphocyte chimaerism in the peripheral blood and serum alkaline phosphatase rose, with no clinical evidence of graftversus-host disease. Two courses of ganciclovir were given for serological evidence of cytomegalovirus reactivation after 5 weeks and 4 months. Serial intestinal permeability and absorption studies have shown no abnormal permeability to 51Cr-EDT A and a steady increase in 14C-labelled mannitol of the oral dose absorbed). absorption to normal (> 10% Barium follow through examination showed a normal mucosal pattern in the graft. The patient was weaned off parenteral nutrition by the end of the second month and the stoma was closed after 5 months. He is now in excellent health and back at work, maintained on 6 mg per day oral FK506 and 5 mg

prednisolone. His current weight is 54 kg. Experience with intestinal transplantation until recently has been disappointing, because of inability to control rejection with cyclosporin, mucosal necrosis, and graft-versus-host disease. There were only two long-term survivors of intestinal transplant alone.2,3 In 1990 Grant and co-workers4 started a programme of transplanting liver together with intestine, and three of their five patients are still alive (2 months, 2 years, and 3tyears); the other two patients died from lymphoma. The Pittsburgh experience with FK506 as the main immunosuppressive drug is now fifty cases (fifteen small bowel alone and thirty-five with liver allografts). The results after small bowel grafting alone have been encouraging. Development of lymphoma in 15% of patients may indicate excessive immunosuppression. Although our patient is only 6 months post-transplantation he has had a remarkably trouble free postoperative course, and immunosuppression with FK506 has probably contributed to this good early result. R Y Calne, S G Pollard, N VJamieson, P J Friend, A Rasmussen, G Neale, D G D Wight, VJoysey, E P Wraight

Metastases in the greater omentum, which otherwise would represent an unusual pathway of gallbladder carcinoma spread, lack of other regional or distant metastases, and presence of a biliary calculus in the abdominal cavity make intra-abdominal tumour inoculation during the laparoscopic procedure in this patient likely. Our case shows that, with carcinoma of the gallbladder, rupture of the gallbladder during laparoscopic cholecystectomy must be avoided by all means, even if the umbilical incision has to be sufficiently extended to facilitate easy removal of an intact specimen. Paolo Lucciarini, Alfred Raimund Margreiter

Konigsrainer, Thomas Eberl,

Department of Surgery 1, University Hospital, A-6020 Innsbruck, Austria 1

2

Collier NA, Blumgart LH. Tumours of the gallbladder. In: Blumgart LH, ed. Surgery of liver and biliary tract, vol 2. Edinburgh: Churchill Livingstone, 1988: 819-28. Pezet D, Fondrinier E, Rotman N, et al. Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy. Br J Surg 1992; 79: 230.

Departments of Surgery, Gastroenterology, and Pathology, Tissue Typing Department, and Department of Nuclear Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK

Effects of intensive 1

2 3 4

Schwartz MZ. Small intestine transplantation. In: Flye MW, ed. Principles of organ transplantation. Philadelphia: Saunders, 1989: 500-15. Deltz E, Schroeder P, Gundlach M, et al. Clinical small-bowel transplantation. Transplant Proc 1990; 22: 2501. Goulet O, Révillon Y, Jan D, et al. Small-bowel transplantation in children. Transplant Proc 1990; 22: 2499-500. Grant D, Wall W, Minnault R, et al. Successful small-bowel/liver transplantation. Lancet 1990; 335: 181-84.

Tumour inoculation

during laparoscopic

cholecystectomy SiR-Early stages of gallbladder carcinoma (Tl, T2) are usually diagnosed only at definite histological examination of cholecystectomy specimens. Cancer frequency per total number of cholecystectomies ranges from 1 to 2 % .1 We report a patient who developed multiple metastases in the greater omentum from early stage adenocarcinoma of the gallbladder, presumably because of incidental intraoperative tumour inoculation at laparoscopic cholecystectomy. This mishap may occur during laparoscopic surgery and has been described in a patient with advanced gallbladder cancer.2 A 40-year-old man was admitted with right upper abdominal pain. Ultrasonography revealed multiple gallstones, and laparoscopic cholecystectomy was done. Dissection of the gallbladder was concluded uneventfully, but during removal through the umbilical incision the specimen ruptured. Histological examination revealed adenocarcinoma (pT2). Therefore, wedge resection of the gallbladder bed and regional lymphadenectomy were done two weeks later at our institution; all specimens turned out to be tumour free. The tumour was thus classified as pT2 pNO MO. Surgery was followed by adjuvant chemotherapy with 5-fluorouracil 1000 mg/m2 weekly for five months, when the patient was readmitted with non-specific abdominal complaints. Computed tomography revealed multiple intraperitoneal tumours with a diameter up to 10 cm. During subsequent laparotomy all tumours in the greater omentum and one gallstone were removed from the abdominal cavity. Histological examination confirmed diagnosis of metastases from adenocarcinoma of the gallbladder. Eight months later, the patient is well and tumour free.

blood-glucose control

SIR-Wang and colleagues (May 22, p 1306) give a full description of the advantages of keeping close blood glucose control in insulin-dependent diabetics, but I do not think that they show a fully balanced picture about the frequency of disadvantages that diabetics encounter. As they say, hypoglycaemia is the major problem. It is not only that severe hypoglycaemic attacks cause distress for diabetics and their families-this distress can also be socially devastating. In my practice, as a general practitioner, I am aware of several diabetics who have lost their jobs and their confidence in attending public events, such that they become socially isolated. This isolation, of course, affects their family just as much. One must look at the quality of life that diabetics and their carers have. It is all very well to delay the onset of a retinopathy for a year or two, but to achieve this, is it justifiable that a diabetic has no social life and a poorer quality of life for 20 years? If a patient dies because of hypoglycaemia, particularly a child, the upset and distress this will cause to many relatives is extreme.

All doctors should consider this possibility when instituting strict blood glucose control regimens. M R Kiln Paxton Green Health Centre, 1 Alleyn Park, London SE21 8AU, UK

SiR-Wang and colleagues’ meta-analysis of intensive bloodglucose control found a significant reduction in late complications. However, the incidence of hypoglycaemia and ketoacidosis increased. At our hospital this form of intensified insulin therapy, as a base-rate bolus procedure,! was introduced more than 5 years ago together with an intensive education programme. 72 patients have been treated with this form of insulin therapy since then and only 3 with continuous subcutaneous insulin, because our patients rarely accept it. To evaluate the effect of these treatments on severe acute diabetic complications, on the hospital admission rate, and on medical care costs, we analysed the admission diagnosis of all adult diabetic patients treated at our hospital between Jan 1, 1989, and Dec 31,1992. The admission rate for diabetics fell by 26% over this four-year period, the number of patients admitted

59