Mr R C Mason.Accepted for publication 28 January 1991 The incidence of gastric stump cancer remains controversial." A large recent series, however, has shown that gastric surgery for benign disease is associated with a pronounced increase in gastric adenocarcinoma when compared with a control population from the same locality.7Studies in experimental animals have shown that gastric surgery can induce adenocarcinoma of the stomach without the use of carcinogens.8 Furthermore, the incidence of malignant change in the gastric mucosa was proportional to the degree of duodenogastric reflux. In this rat model of duodenogastric reflux the pancreaticoduodenal secretions, rather than the bile, seemed to be responsible for the tumour.9 In tissues which have a high proliferative rate the activity of the rate-limiting enzyme in polyamine biosynthesis, ornithine decarboxylase, and the concentrations of the polyamines are relatively high. Many human cancers also show high levels of ornithine decarboxylase activity in the malignancy.Since duodenogastric reflux is a reliable model for inducing gastric cancer, and since polyamine metabolism has never been studied in the gastric mucosa in this model, we examined the sequential longterm effects of duodenogastric reflux on gastric mucosal morphology, mucin histochemistry, ornithine decarboxylase activity, and polyamine concentration and correlated the results with the labelling index assessed autoradiographically, an established method of measuring tissue proliferation. Methods STUDY DESIGNAltogether, 186 male Wistar rats weighing 200-250 g were randomised to undergo either simple gastrojejunostomy or gastrotomy. Laparotomy was performed through an upper midline abdominal incision and a 7 mm gastrotomy was made 2 mm distal to the squamocolumnar junction along the anterior surface of the greater curvature. In gastrotomy rats this was closed with an all layer 6/0 Ethibond suture. In gastrojejunostomy animals a loop of jejunum 4 cm distal to the ligament of Treitz was anastomosed to the stomach using an all layer 6/0 Ethibond suture in an isoperistaltic, antecolic manner. Animals from the two groups which survived the operation (operative mortality 10-8%) were allocated to cohorts to be sacrificed at 8,16, 24, 32, 40, 48, and 56 weeks after surgery. An intraperitoneal injection of tritiated thymidine (specific activity 5 Ci/mmol, Amersham International) was given one hour before sacrifice at a dose of 1 RCi/g body weight.The rats were killed by exsanguination under general anaesthetic. The stomach was removed en bloc and opened along the greater curvature. After washing briefly in tap water, the stomach was pinned out on a cork board and the macroscopic findings noted. Some 20-70 mg samples of gastric mucosa were removed by sharp dissection from the underlying serosa and muscle immediately adjacent to the gastrotomy or to the anastomosis. The samples were stored at -70°C until analysed for polyamines and related enzymes within three months of sacrifice.The stomach was fixed in 10% f...

We are reporting on a 47-year-old man who presented with a prolongation of the activated partial thromboplastin time (APTT) prior to orthopedic surgery. An evaluation suggested an inhibitor when his plasma prolonged a normal control APTT upon 50:50 solution of patients with normal plasma. The platelet-neutralizing procedure (PNP), anticardiolipin antibody, and antinuclear antibody (ANA) were positive. Further studies revealed decreased von Willebrand factor ristocetin cofactor (vWF:RCoF), von Willebrand factor antigen (vWF:Ag), an inhibitor to vWF, and absent high-molecular-weight vWF multimeters. Assays of FVIII:C, FIX, and FXI were nonparallel to the standard curve. Intravenous immunoglobulin (IVIG) corrected the APTT, multimeric pattern, and FVIII:C by the 7th day postinfusion. This case demonstrates the efficacy of IVIG for acquired von Willebrand's syndrome (vWS) and also represents a unique combination of a lupus-like anticoagulant and acquired vWS in a patient without the full serological requirement for systemic lupus erythematosus (SLE). Whether patients with acquired vWS and lupus inhibitors are more or less susceptible to either a thrombotic complication or hemorrhage is not established. Prospective studies for the incidence of lupus inhibitor/antiphospholipid syndromes and vWF deficiencies are needed to assess this question.

Anti-CEA MAbs are excellent agents for imaging recurrent, residual, or metastatic MTC. The high lesion sensitivity in patients with known lesions, combined with the ability to detect disease, may make these agents ideal for staging patients, monitoring disease pretherapy or posttherapy, and especially for evaluating patients with recurrent or persistent hypercalcitonemia or CEA elevations after primary surgery. Analogous to radioiodine in the evaluation of patients with differentiated thyroid cancer, radiolabeled anti-CEA MAbs may achieve a similar role in diagnosing and monitoring patients with MTC.

SUMMARY The incidence of pancreatic cancer is increased in patients who have undergone gastric surgery. An animal model is described in which pancreatic hyperplasia and adenoma formation developed within 56 weeks. The effects of a simple gastrojejunostomy were compared with those after a split gastrojejunostomy, in which the jejunum was transected and the two limbs implanted separately into the greater curvature of the glandular stomach 1 cm apart. After 56 weeks no animals in the simple gastrojejunostomy group had pancreatic hyperplasia whereas all 10 animals in the split gastrojejunostomy group had generalised pancreatic hyperplasia with macroscopic nodules. Microscopy of the nodules showed that in nine animals hyperplastic nodules had developed, and four of these also had adenomatous nodules. The remaining animal had enlarged lymph nodes. Pancreatic hyperplasia was associated with jejunal hyperplasia. Jejunal morphometry showed that the villus height was doubled and the villus height:crypt depth ratio was higher in the split gastrojejunostomy group compared with those animals with a simple gastrojejunostomy. This finding represents a new model for the investigation of pancreatic neoplastic change.Recent epidemiological studies have shown an increased incidence of pancreatic cancer in patients who have undergone gastric surgery.' Until now, however, there has been no experimental model with which to study this association.A major interest in our unit has been the investigation of gastric carcinoma using an animal model which does not require the presence of carcinogens. Langhans first described the induction of gastric adenocarcinomas by duodenogastric reflux in the rat without the use of carcinogens. We confirmed these findings,4 and undertook further experiments to study the sequence of carcinogenesis. In order to determine the site of maximal histological change in the stomach, the two limbs of the gastrojejunostomy were divided and anastomosed separately to the stomach. formation. These findings were fortuitous and significant because carcinogens were not used.