M. R. Lane

Two hundred and ten patients with coeliac disease previously reported from this unit were reviewed at the end of 1985 after a further 11 years of follow up. The initial review at the end of 1974 could not demonstrate that a gluten free diet (GFD) prevented these complications, probably because the time on diet was relatively short. The same series has therefore been kept under surveillance with the particular aim of assessing the effects of diet on malignancy after a further prolonged follow up period. Twelve new cancers have occurred: of which one was a carcinoma of the oesophagus and two lymphomas. Thirty nine cancers developed in 38 patients and of 69 deaths, 33 were the result of malignancy. A two-fold relative risk (RR) of cancer was found and was because of an increased risk of cancer of the mouth and pharynx (RR = 9.7, p less than 0.01, 95% confidence interval (CI) = 2.0-28.3), oesophagus (RR = 12.3, p less than 0.01, CI = 2.5-36.5), and of non-Hodgkin's lymphoma (RR = 42.7, p less than 0.001, CI = 19.6-81.4). The results indicate that for coeliac patients who have taken a GFD for five years or more the risk of developing cancer over all sites is not increased when compared with the general population. The risk is increased, however, in those taking a reduced gluten, or a normal diet, with an excess of cancers of the mouth, pharynx and oesophagus (RR = 22.7, p < 0.001), and also of lymphoma (RR = 77.8, p < 0.001). A significant decreasing trend in the excess morbidity rate over increasing use of a GFD was found. The results are suggestive of a protective role for a GFD against malignancy in coeliac disease and give further support for advising all patients to adhere to a strict GFD for life.

BACKGROUND: The traditional management of pyloroduodenal obstruction is open gastrojejunostomy (OGJ). More recently laparoscopic gastrojejunostomy (LGJ) and endoscopic stenting (ES) have been introduced. The aim of this study was to evaluate the three approaches to the palliation of malignant pyloroduodenal obstruction. METHODS: All patients who underwent surgery (open and laparoscopic) for malignant pyloroduodenal obstruction at Auckland City Hospital between 1989 and 2002 inclusive were identified from International Classification of Diseases (ICD) 10 codes and from the Otago Surgical Audit Database. Patients who had an endoscopic stent were identified from the Endoscribe database. A review of medical records was conducted and data recorded in a structured pro forma. There were 181 patients with malignant pyloroduodenal obstruction of whom 56 patients had OGJ, 14 had LGJ and 16 had ES. Patients in the LGJ and ES groups were matched with those who underwent OGJ with respect to American Society of Anesthesiologists (ASA) grade (I-V), age (within 10 years) and level of obstruction (pylorus, first part of duodenum D1, D2, D3 and D4). The primary outcomes compared between the groups were time to starting free oral fluids and light diet, length of stay and survival. RESULTS: There were no significant differences in age, sex, ASA grade and level of obstruction between the matched OGJ (n=16), LGJ (n=14) and ES (n=16) groups. There was a significant reduction in time to starting free oral fluids and light diet, and length of stay after the procedure, in the ES group. Patients who underwent surgical palliation of the obstruction had significantly more complications than those who underwent stenting (P=0.016). There were no significant differences in requirement for biliary drainage either before or after the procedure between the three groups. Survival was shortest in the ES group. CONCLUSION: This matched study showed significant advantages for ES compared with OGJ and LGJ in the palliation of malignant pyloroduodenal obstruction.

Two patients with neurofibromatosis and somatostatinoma are described, one patient in addition having a parathyroid adenoma diagnosed post mortem. The other patient had a partial somatostatinoma syndrome with diabetes, abdominal pain and cholelithiasis. The tumour was diagnosed preoperatively and metabolic studies demonstrated mild diabetes mellitus apparently due to suppression of insulin secretion by somatostatin, since oral glucose tolerance returned to normal post-operatively despite hemipancreatectomy. The tumour also secreted gastrin. There are now 18 reported cases of neurofibromatosis and duodenal carcinoid tumours which makes a genuine association between these two conditions very likely. With the present two cases, seven of the carcinoid tumours in this group have been positively identified as somatostatinomas. The histological finding of psammoma bodies is important in the diagnosis of duodenal somatostatinomas.