511
aetiology of testicular cancer-for example, the significant rise in
this cancer in England and Wales this century has been associated
with a substantial fall in employment in agriculture.2However,
occupational studies may still provide indirect clues.
Medical Statistics Division,
Office of Population Censuses and Surveys,
London WC2B 6JP M. MCDOWALL
Medical Department,
South West Thames RHA,
and Department of Clinical Epidemiology,
St George’s Hospital Medical School,
London SW17 R. BALARAJAN
GASTRECTOMY AND CANCER OF GALLBLADDER
OR BILIARY TRACT
SIR,-Dr Caygill and colleagues suggest (Nov 19, p 1204) that
there may be a positive association between gallbladder or biliary
tract cancer and gastrectomy. Among 348 partial gastrectomy
patients they identified 3 cases of gallbladder or biliary cancer
(where only 0 - 3 cases were expected), all diagnosed more than 20
years after surgery. In our prospective cohort study, we have
followed up 8006 examined men of Japanese ancestry in Hawaii
since 1965 for cancer incidence. Our data on partial gastrectomy
status at examination (1965-68) and subsequent occurrence of
gallbladder or biliary cancer (as of December, 1983) are shown in the
table. Gastrectomy history given at examination was confirmed by a
careful review of hospital records.
RELATION BETWEEN PARTIAL GASTRECTOMY STATUS AND
SUBSEQUENT GALLBLADDER OR BILIARY TRACT CANCER INCIDENCE
The percentage of gallbladder cancer cases is lower among 407
men with a prior gastrectomy (0 cases observed; 0 -6expected). With
age-adjustment (direct method), the incidence rates of gallbladder
cancer per 1000 men among those with vs without prior
gastrectomy were 0 - 0 vs 1 - 6, respectively. For about 63% of these
407 gastrectomy men, more than 20 years have passed since their
operation, yet none of them has been diagnosed as having
gallbladder or biliary cancer. We have observed however, that the
mortality risk of lung cancer and stroke is increased among these 407
men with a prior gastrectomy.3
LANCE K. HEILBRUN
Japan-Hawaii Cancer Study,
Kuakim Medical Center, ABRAHAM NOMURA
Honolulu, Hawaii 96817, USA GRANT N. STEMMERMANN
POST-PARTUM HAEMOLYTIC URAEMIC SYNDROME
AND VEROTOXIN-PRODUCING ESCHERICHIA COLI
SIR,-The haemolytic uraemic syndrome (HUS) is most
commonly seen in young children but it occasionally presents post
partum also. An association between HUS in children and a
cytotoxin (verotoxin)-producing Escherichia coli has been
described.4 Post-partum HUS may also be linked to this cytotoxin.
A 31-year-old, single female had an uncomplicated first
pregnancy until 16 weeks’ gestation. A right ovarian cyst was
removed and was subsequently shown to be a low-grade adeno-
carcinoma. The pregnancy continued normally until premature
labour at 32 weeks. Her blood pressure and urinalyses had been
normal. Caesarean hysterectomy was done, without complications.
2. OPCS. Census reports 1911-81. London: HMSO.
3. Stemmermann GN, Heilbrun LK, Nomura A, Rhoads GG, Glober GA. Late mortality
after partial gastrectomy. IntJ Epidemiol (in press).
4. Karmali MA, Steele BT, Petric M, Lim C. Sporadic cases of haemolytic-uraemic
syndrome associated with faecal cytotoxin and cytotoxin-producing Escherichia coli
in stools. Lancet 1983; i: 619-20.
The tumour has not recurred, and subsequent cytology was
negative. Because of a history of thrombophlebitis when a teenager
she was treated with subcutaneous heparin from the immediate
postoperative period. At that time the haemoglobin was 10.44 g/dl
and the platelet count was 330 000/pl.
On that third postoperative day her temperature was 38’7°C and
she had a bloodstained vaginal discharge. Heparin was discontinued
and she was treated with ampicillin, tobramycin, and clindamycin.
On the following day the haemoglobin was 7’6g/dl, reticulocytes
5-5%, platelets 80 000/µl, and a blood film showed many
fragmented red cells. Blood cultures, a Coombs’ test, prothrombin
time, and a partial thromboplastin time were normal. She was
transfused with two units of red cells but became anuric on the
following day with a serum creatinine of 509 µmol/l. Haemodialysis
was required over the next week. A renal ultrasound and a
retrograde pyelogram showed no evidence of obstruction. A
percutaneous renal biopsy showed thrombi in afferent arterioles
and some glomerular capillaries. Immunofluorescence was positive
for fibrinogen and C3 and electron microscopy showed lucent areas
between the endothelial cell and the glomerular basement
membrane. The platelet count returned to normal after 7 days and
she voided spontaneously after 10 days ofanuria. Her renal function
gradually improved and on follow-up nine months later, she was
normotensive with a serum creatinine of 90 I-lmol/l.
Bacteriological studies from the vagina showed "normal flora"
and in the stools there was an E coli serotype 06:H12, which was
positive for vero cytotoxin. This cytotoxicity was kindly confirmed
by Dr H. Lior, Laboratory Centre for Disease Control, Ottawa.
HUS post partum closely resembles the disease in childhood,
although a "prodrome" of bloody diarrhoea is usually seen in
children. In a review of thirty-six cases, Strauss and Alexander5
found that most post-partum cases had preceding upper respiratory
or gastrointestinal symptoms. Our patient had no gastrointestinal
symptoms despite a verotoxin-producing E coli in the stool. The
significance of this association remains to be determined but we
recommend looking for verotoxin-producing E coli in other cases of
this rare complication of pregnancy. Heparin has not been ofproven
benefit in either paediatric or adult patients with HUS and did not
prevent anuric renal failure in this patient, despite being given
before the onset of symptoms.
B. T. STEELE
Departments of Pediatrics, Medicine, GOLDIE
and Laboratory Medicine, J.
McMaster University, I. ALEXOPOULOU
Hamilton, Ontario, Canada L8N 3Z5 A. SHIMIZU
IMPROVING RENAL FUNCTION IN OBSTRUCTIVE
JAUNDICE WITHOUT PREOPERATIVE DRAINAGE
SIR,—One argument for the use of preoperative percutaneous
transhepatic biliary drainage of the obstructed biliary tree has been
that impaired renal function can be improved before surgery. We
have found that renal function can be improved without
preoperative drainage.
Following a pilot study of preoperative percutaneous drainage in
the management of malignant biliary tract obstruction, where
improvement in renal function was observed after drainage before
surgery, randomised controlled trial was started in 1981 and
a
completed the end of 1983. Patients with malignant biliary tract
at
obstruction were randomised either to percutaneous transhepatic
biliary drainage plus laparotomy or to laparotomy without
preliminary drainage. Patients who did not have drainage received
preoperative management similar in all respects tc that in those who
were drained. Specifically, patients who had renal impairment on
admission (creatinine clearance 60 ml/min or less) received
intravenous rehydration before surgery.
Of the 65 patients who completed the trial 34 underwent drainage
plus laparotomy and 31 had laparotomy without drainage. 14
5. Strauss RC, Alexander RW. Post-partum hemolytic uremic syndrome. Obstet Gynecol
1976; 47: 169-73.
1 Dooley JS, Olney J, Dick R, Sherlock S. Non-surgical treatment of biliary obstruction.
Lancet 1979; ii: 1040-44.