Melsungen, Germany). This technique involves isolation of the hepatic artery, portal vein, and caval vein inferior and superior to the liver, together with a temporary (60-90 min) portocaval shunt that allows blood flow rates to be maintained in both the hepatic artery and portal lines 56 After the postoperative phase, a low dose of octreotide (100 Ilgjday subcutaneously) was maintained, and the
six weeks without any
hormonally related symptoms. Both 5-HIAA and MelmAA levels were strikingly reduced (940 fimol/24 h and 7.2 mmol/mol creatinine, respectively). Thirteen months later the patient noticed slight facial flushing and diarrhoea, but computed tomography showed no obvious tumour progression. The dose of octreotide was increased and predinisone (5 mg twice daily) was added when urinary concentrations of tumour markers increased. Further episodes of dyspnoea and hypotension four months later, together with raised serum concentrations of 5-HIAA and MelmAA (2900 mol/24 h and 24-2 mmol/mol creatinine, respectively) led to an angiogram that showed occlusion of the right hepatic artery. At surgery, exploration of both the portal vein and hepatic artery were impossible because of tumour growth. Hyperthermic perfusion of the
portal vein with melphalan and cisplatinum again led to symptomatic relief and reduction of tumour markers (1200 pmol/ 24 h and 9-3 mmol/mol creatinine, respectively). Hyperthermic perfusion of the metastatic liver with cytotoxic drugs may be a suitable treatment for patients with severe foregut carcinoid syndrome. Department of Surgery, Sahlgrenska Hospital, S-413 45 Goteborg, Sweden
T. SCHERSTÉN H. AHLMAN B. WÄNGBERG
Department of Clinical Physiology, University of Linkoping
Department of Pathology, University of Uppsala
ED, Azzopardi JG. Tumours of the lung and the carcinoid syndrome. Thorax 1960; 15: 30-36. 2. Kvols LK. Metastatic carcinoid tumours and the carcinoid syndrome. A selective review of chemotherapy and hormonal therapy. Am J Med 1986; 81: 49-55. 3. Moertel CG, Rubin J, Kvols LK. Therapy of metastatic carcinoid tumour and the malignant carcinoid syndrome with recombinant leucocyte A interferon. J Clin 1. Williams
Oncol 1989; 7: 865-68. 4. Gerterud K, Tylén U, Jansson S, Stenqvist O, Tisell LE, Ahlman H. Hepatic arterial embolisation in the treatment of the midgut carcinoid syndrome and other advanced endocrine tumours metastatic to the liver. J Intervent Radiol 1990; 5: 69-76. 5. Aigner K, Walther H, Tonn J, et al. First experimental and clinical results of isolated liver perfusion with cytotoxics in metastasis from colorectal primary. Recent Results Cancer Res 1983; 86: 99-102. 6. Hafstrom LO, Rudenstam CM, Holmberg S, Scherstén T, Ehrsson H. The pharmacokinetics of melphalan in regional hyperthermic liver perfusion. Reg Cancer Treat 1990; 3: 23-25.
Blood pressure and exercise testing SIR,-Dr Akhras and Dr Jackson (April 13, p 899) report on the blood pressure (BP) response during an exercise test of patients in whom coronary artery disease was subsequently found by arteriography. They suggest that an increase in diastolic BP of 15 mm Hg or more during exercise is excessive and associated with coronary disease and ischaemic left-ventricular dysfunction. The sensitivity and specificity of exercise testing for the detection of coronary disease are less than perfect, and any additional information from the exercise test which helped to predict coronary disease would be of value. However, our experience suggests that similar rises in diastolic BP during exercise are common in healthy people. BP was recorded at rest and during maximum exercise in 1007 men aged 25-67 years (mean 42) attending a health screening clinic; none had chest pain, signs or symptoms of heart failure, or any electrocardiographic features of ischaemic heart disease at rest or on exercise. Diastolic BP rose by 5-10 mm Hg in 214 men, by 10-15 mm Hg in 104, and by more than 15 mm Hg in 197 (196%). Although we cannot exclude coronary disease with certainty because coronary arteriography was not done, the probability of coronary disease (given the absence of chest pain and of electrocardiographic abnormalities on an exercise test) must be low.
This suggests that in unselected patients, the specificity and positive predictive value of diastolic BP rise on exercise will be poor. Even in selected groups with a high pre-test probability of coronary disease, the specificity and positive predictive value are likely to be limited.
Royal Free Hospital, London NW3, UK
S. W. DAVIES* G. WANNAMETHEE D. P. LIPKIN
Health Care, London E2
T. M. EMERY M. I. L. WATLING
*Present address: Cardiac
Department, London Chest Hospital, London E2 9JX, UK
pylori SIR,-Dr Fiocca and colleagues (June 29, p 1614) report a further study showing a low recurrence rate of duodenal ulcer after eradication of Helicobacter pylori. Virtually all of the hitherto published trials of this type used bismuth as a component of the antimicrobial regimens. Since bismuth not only possesses bactericidal activity but also cytoprotective properties, the extent to which cytoprotection contributes to the low relapse rates after treatment of duodenal ulcer with combinations containing bismuth remains unclear. We have randomised 104 patients with recurrent duodenal ulcer to either amoxicillin 750 mg thrice daily plus metronidazole 500 mg thrice daily or placebo for 12 days. All patients received ranitidine 300 mg nocte for six weeks or a further four weeks if healing was not achieved. After healing, patients were seen twice monthly for one year. Endoscopies were completed at time zero, and subsequently at 6 weeks, 2 months, 6 months, and 12 months after healing or whenever symptoms suggested relapse. H pylori status was checked by culture and histology on each occasion. All patients were H pylori positive before treatment. Our study is still running and the randomisation code has not yet been broken. So far 58 patients have completed 1 year and 42 patients have been observed for more than six months. 42 recurrences have occurred. H pylori was found in 41 of these, whereas only 1 patient who relapsed was H pylori negative. The relapse rate in patients who were still H pylori positive after treatment was 79% (41/52), compared with 2% (1/50) in those who cleared H pylori. These preliminary results support the view that eradication of H pylori only, and not any additional cytoprotective effects of bismuth, is responsible for the reduced relapse rate of duodenal ulcer after successful antimicrobial treatment. Hanuschkrankenhaus, A-1140, Vienna, Austria
E. HENTSCHEL H. NEMEC K. SCHÜTZE
Hygieneinstitut der Universität, Vienna
Ambulatorium Sud, Vienna
Landeskrankenhaus Graz, Styria
G. BRANDSTÄTTER M.TAUFER
Lymphopenia in diverticulitis SIR,-Peripheral blood lymphopenia secondary to localised inflammation of the bowel has received little attention, although it has been described in gangrenous appendicitis’ and in active colitis.2 We completed a retrospective review of patients admitted to the Whittington Hospital with a primary diagnosis of diverticular disease between September, 1987, and February, 1991. Only patients with diverticula confirmed by barium enema, colonoscopy, or laparotomy were included. Of 84 diagnoses, 61 met these criteria. Admissions were classified into four groups according to the severity of the inflammatory process: perforated diverticular disease requiring emergency surgery (6 patients), acute diverticulitis treated non-operatively (28 patients), rectal bleeding attributed to diverticular disease (17 patients), and quiescent diverticular disease (10 patients). There was a significant reduction in the peripheral