bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of proximal colostomy on the healing of a left colon anastomosis: An experimental study in the rat
Authors: Udén P , Blomquist P , Jiborn H , Zederfeldt B
Published: March 2007

The healing of an experimental left colon anastomosis protected by a proximal diverting colostomy was studied in the rat. Collagen synthesis in the anastomotic area was measured by incorporation of [3H]proline. With a defunctioning proximal colostomy, the synthesis and accumulation of collagen in the anastomosis was diminished, and the anastomotic strength development delayed and reduced. The development of anastomotic strength seems to proceed according to the level of strain from intraluminal bulk. As the healing of the anastomosis protected by a diverting colostomy was uncomplicated, these findings should not contra-indicate the use of diverting colostomy.
Consequences of blood loss on growth of artificial metastases
Authors: Sing S K , Marquet R L , de Bruin R W F , Hop W C J , Westbroek D L , Jeekel J
Published: March 2007

Previous studies have shown that lung metastases from a non-immunogenic sarcoma (LS175) in BN (homozygous for RT1n) rats were stimulated by blood transfusions. Enhanced growth was also observed after abdominal surgery combined with allogeneic blood transfusions while syngeneic blood transfusions had no effect. These experimental findings have been confirmed in retrospective clinical studies. The allogeneic blood transfusion effect may be avoided in cancer patients by autologous blood transfusions although this implies blood donation before surgery. The aim of the present study was to investigate the effect of blood loss before surgery on formation (‘take’) of lung colonies, and on the outgrowth of established metastases in the BN rat model. These aspects of tumour behaviour were also investigated in rats undergoing surgery, or receiving blood transfusion, or both, after blood loss. The results indicate that blood loss has a profound stimulating effect on the growth of established metastases, but not on the ‘take’ of tumour cells. This stimulating effect was also present when blood loss was combined with surgery, while previously surgery alone was found to have no effect. Allogeneic and syngeneic transfusions in combination with blood loss both had a strong stimulating effect on growth of established lung metastases. The results indicate that blood loss may be an important factor in determining the outcome of metastatic growth.
Prognosis of colorectal cancer in the elderly
Authors: Irvin T T
Published: March 2007

The prognosis of colorectal cancer in the elderly was examined in a study of 306 consecutive patients. The patients were divided into two groups: Group 1 included 171 patients of average age 77 years (range 70–97); Group 2 comprised 135 patients of average age 59 years (range 22–69). There was no significant difference between the two groups with regard to the mode of presentation, the location and Dukes' classification of the tumours, the incidence of palliative operations, and the perioperative mortality. The surgical mortality rates in Group 1 were 6 per cent overall, 4 per cent after elective operations, and 16 per cent after emergency surgery; the corresponding mortality rates for Group 2 were 3 per cent, 1 per cent, and 20 per cent. Emergency surgery was associated with a significantly higher incidence of perioperative death at any age (P<0.001) and most deaths resulted from complications of coexisting medical disorders or thrombo-embolic complications. Crude actuarial 5-year survival curves showed an increased death rate in Group 1 after 18 months and a significantly lower 5-year survival (P<0.05) but the age-corrected survival curves for the two groups were not significantly different, and it was concluded that the prognosis for colorectal cancer in the elderly is not significantly different from that of younger patients.
Outcome of patients with rectal cancer treated by stapled anterior resection
Authors: Belli L , Beati C A , Frangi M , Aseni P , Rondinara G F
Published: March 2007

The mortality, morbidity and long-term survival in stapled anterior resection for rectal carcinoma has been analysed in 74 patients. Twelve patients were Dukes' A, 26 B, 29 C, and 7 ‘D’ (submitted to hepatic resection). Operative mortality rate was 3 per cent. Three patients (4 per cent) had clinical anastomotic leakage. Two patients (3 per cent) developed anastomotic stenosis. Local recurrence was present in three patients (4 per cent). The mean (± s.e.m.) overall survival rate at 5 years was 67±6 per cent. There was no significant difference in survival between Dukes' B and C (70±10 per cent versus 59±10 per cent, P = 0.209). Patients with absent local spread had a significantly better 5-year survival rate than those with positive local lymph nodes (80±7 per cent versus 54±9 per cent, P<0.01). The present results confirm the satisfactory use of the EEAR stapler device for colorectal anastomoses in rectal cancer and in patients with resectable liver metastasis.
Rigid sigmoidoscopy: An evaluation of three parameters regarding diagnostic accuracy
Authors: Mann C V , Gallagher P , Frecker P B
Published: March 2007

Rigid sigmoidoscopy is the method employed for examining the rectum and sigmoid colon in most general surgical clinics. Commonly, this is performed without any prior preparation of the bowel and with the patient in the left lateral (Sims') position. This study was designed to assess three factors relating to this method: preparation of the bowel; position of the patient; and the experience of the operator. The study shows that diagnostic accuracy without preparation is adequate in only 50 per cent of cases but, by employing a preliminary disposable (Fletcher's) enema, this can be improved to 80 per cent. Employing the knee-elbow position gave only slight advantage over the usual Sims' position and operator experience did not improve diagnostic accuracy once familiarity with the use of the sigmoidoscope had been achieved. The study underlines the importance of preparation as an essential prelude to sigmoidoscopy.
Calf pump function in patients with healed venous ulcers is not improved by surgery to the communicating veins or by elastic stockings
Authors: Stacey M C , Burnand K G , Layer G T , Pattison Marion
Published: March 2007

Calf muscle pump function was assessed in 41 limbs after venous ulcers had healed. Treatment was then randomized either to ligation of incompetent lower leg communicating veins and ablation of incompetent superficial veins combined with permanent graduated compression elastic stockings, or to graduated compression elastic stockings only. Half volume refilling time (TV1/2) and relative expelled volume (EVrel) measured on foot volume plethysmography were used to assess calf muscle pump function. This was repeated after 12 months. The initial TV1/2 and EVrel were significantly lower than for normal limbs. There was no significant improvement in TV1/2 in either treatment group (Student's t test, P = 0.78, P = 0.19). EVrel did not improve significantly in limbs treated with elastic stockings alone (P = 0.94), but there was a slight but significant improvement in EVrel in limbs treated with surgery and elastic stockings (P = 0.048); however, this was still significantly below the normal range (P<0.001). In limbs without phlebographic evidence of post-thrombotic changes, treated with the combination of surgery and elastic stockings, there was a significant improvement in EVrel (P = 0.035), but no improvement was found in limbs with post-thrombotic changes. This small but significant improvement in EVrel in limbs without post-thrombotic changes treated by surgery and elastic stockings may explain the reduced incidence of reulceration that has been found following surgical eradication of the superficial and communicating veins.
Incidence of deep vein thrombosis after major abdominal surgery in Brisbane
Authors: Reasbeck P G , Guerrini S , Harper J , Sackelariou R , McCaffrey J F
Published: March 2007

There is some evidence that postoperative deep vein thrombosis (DVT) may be commoner in cool than in warm climates. To determine whether this complication is less common in the subtropical climate of Brisbane than in more temperate locations, the incidence of DVT after major abdominal surgery was assessed by 125I fibrinogen scanning. In order to avoid overestimating the incidence of DVT, abnormal scans were accepted as diagnostic only if the DVT was confirmed by venography or if the abnormality on the scan fulfilled more stringent criteria than have previously been applied. Thirty-six of 152 patients (24 per cent) developed a DVT; this incidence was significantly lower than in one previous study from Melbourne and higher than that found in South-East Asia and East Africa, but was not significantly different from that reported from Sydney, Japan and several centres in North America and Britain. There was no apparent seasonal variation in the incidence of the complication. The geographical variation in incidence of postoperative DVT may have been overestimated in previous reports and may be at least partly due to variations in screening technique.
Clinical application of the cholecystokinin provocation test
Authors: Sunderland G T , Carter D C
Published: March 2007

This paper reviews the value of administration of cholecystokinin (CCK) in the assessment of patients thought to have acalculous biliary pain. The literature contains conflicting reports and there is no unequivocal evidence to support the use of CCK provocation tests as a basis for deciding the need for cholecystectomy.
Sphincter of oddi dysfunction: Results of treatment by endoscopic sphincterotomy
Authors: Neoptolemos J P , Bailey I S , Carr-Locke D L
Published: March 2007

From a consecutive series of 451 patients with post-cholecystectomy symptoms referred for endoscopic retrograde cholangiopancreatography (ERCP), 40 (9 per cent) were diagnosed as having sphincter of Oddi dysfunction. Eight patients were excluded from the study because of incomplete data (n=6) or additional diagnoses (n = 2). Thirty of the patients had successful ERCP and endoscopic sphincterotomy (ES); this failed in the remaining two because of severe papillary stenosis (6·3 per cent). Endoscopic biliary manometry was performed in 23 patients (77 per cent). Immediate post-ES complications occurred in eight patients (25 per cent). At a median follow-up of 46 months (range 10-88 months) 19 patients had a good outcome (63·3 per cent) and 11 patients had a poor outcome (36·7 per cent). Patients with a good outcome tended to have a delay of months or years following cholecystectomy before the development of symptoms (median 6 years versus 0 years, P = 0·0003). At ERCP, patients with a good outcome had greater common bile duct diameters (mean ± s.d. mm, 12·6 ± 3·6 versus 8·8±1·8, P = 0·0003) and delayed drainage from the biliary tree of injected contrast (13 versus 2 patients, P = 0·02). Endoscopic biliary manometry was abnormal in all 15 patients with a good outcome in whom it was performed but in only 3 out of 8 patients with a poor outcome (P = 0·003). Sphincter of Oddi dysfunction is an important, albeit uncommon, cause of post-cholecystectomy symptoms. ES provides symptomatic relief in the majority of patients but improved criteria for predicting outcome are required.
Home parenteral nutrition: A review of 100 patient years of treatment in 76 consecutive cases
Authors: Stokes M A , Almond D J , Pettit S H , Mughal M M , Turner M , Shaffer J L , Irving M H
Published: March 2007

Over the last 10 years, the Nutrition Unit at Hope Hospital has trained and looked after 76 patients on home parenteral nutrition for a total of 100 patient years. Although 40 per cent of patients have required home parenteral nutrition for 6 months or less one patient has been on treatment for 7 years. The quality of life measured on a 4 point scale was good for the majority of patients. Sepsis and superior vena caval thrombosis are the main problems encountered. Overall mortality rate was 18 per cent and the sepsis rate was 0·14 episodes per patient per year. Home parenteral nutrition is an effective and safe treatment of intestinal failure.
Dietary fibre and gastrointestinal disease
Authors: Cranston D , McWhinnie D , Collin J
Published: March 2007

This review examines the evidence linking dietary fibre to gastrointestinal disease. Fibre increases stool weight, decreases whole gut transit time and lowers colonic intraluminal pressure. While it may be of benefit in the treatment of constipation, the irritable bowel syndrome and diverticular disease, its role in the prevention or treatment of other gastrointestinal disease has yet to be established.
Hepatic trauma: Risk factors influencing outcome
Authors: Prêtre R , Mentha G , Huber O , Meyer P , Vogel J , Rohner A
Published: March 2007

This retrospective study analyses the fate and associated risk factors of 99 patients who underwent laparotomy for hepatic trauma from 1977 to 1986. Blunt trauma (88 patients) and stab wounds (7 patients) had mortality rates of 36 and 14 per cent respectively. The overall death rate was 35 per cent. Multiple trauma patients had a significantly higher mortality for each additional system that was seriously injured. Pre-operative shock raised the mortality from 20 to 58 per cent (P < 0.001). For patients over 50 years of age, the mortality rate increased from 30 (younger patients) to 63 per cent (P = 0.028). Minor hepatic wounds required relatively simple surgical measures in 60 patients, yet 13 died (22 per cent) of other causes. More sophisticated surgical management was applied to 27 major hepatic lesions, with 10 deaths (37 per cent). Twelve patients (seven with minor and five with major hepatic wounds) died before surgical treatment of the liver injury could be undertaken. The overall mortality rate of major hepatic wounds was 47 per cent and for minor wounds 30 per cent. However, the difference was not significant (P = 0.152). Resection was resorted to in 15 patients, 5 of whom subsequently died (33 per cent). Classical hepatic lobectomy led to 4 deaths (50 per cent). Among the 35 deaths, 6 were due to the hepatic trauma itself (5 exsanguinations and 1 intra-abdominal sepsis). Isolated hepatic injury was fatal in three patients. We believe that conservative surgical measures should be used whenever possible in patients with hepatic trauma, especially when risk factors are encountered.
Pulmonary complications after subtotal oesophagectomy
Authors: Nishi M , Hiramatsu Y , Hioki K , Hatano T , Yamamoto M
Published: March 2007

The postoperative pulmonary complications in 25 patients undergoing subtotal oesophagectomy for intrathoracic oesophageal carcinoma during the 3-year period 1981–1983 were compared with those of 25 patients undergoing surgery from 1984 to 1986. Although more extensive lymphadenectomies were performed from 1984, the mortality rate caused by the postoperative pulmonary complications was zero in the later period (1984–1986) compared with a rate of 16 per cent in the earlier period (1981–1983). The incidence of postoperative pulmonary complications was lower in the later series but the difference was not statistically significant. Factors which may have contributed to the decrease in critical pulmonary complications after surgery during the later period were the selection of the posterior mediastinal route for reconstruction, the introduction of selective endobronchial intubation by a double lumen tube with combined epidural anaesthesia, fluid restriction during and after surgery, postoperative mobilization and the administration of an expectorant.
Carcinogenic potential of the non-cancerous epithelium in patients with oesophageal cancer
Authors: Maeta M , Koga S , Shimizu N , Inoue Y , Ishiguro M , Sawada T
Published: March 2007

Detailed histopathological examination of serial blocks and subserial sections of the entire resected oesophagus in 63 patients operated upon for oesophageal cancer revealed 11 associated minute superficial cancers, independent and apart from the main tumours, in 10 patients (15.9 per cent). Only one of these eleven lesions was diagnosed pre-operatively, and only three of the eleven lesions were detected macroscopically on the resected specimens. The high incidence of such coexisting independent lesions may indicate a possible increased multicentric carcinogenic potential in the non-cancerous epithelium of patients who have had an antecedent oesophageal cancer. These results emphasize the need for careful attention to the choice of margins during surgical resection of the oesophagus.
Implication of duodenogastric reflux in the pathogenesis of Barrett's oesophagus
Authors: Gillen P , Keeling P , Byrne P J , Healy M , O'Moore R R , Hennessy T P J
Published: March 2007

Fasting and postprandial intragastric bile acid concentrations have been estimated and compared in patients with complications of Barrett's oesophagus, patients with Barrett's oesophagus without complications, patients with oesophagitis and a group of normal subjects who acted as controls. There was no significant difference in fasting intragastric bile acid concentrations between the groups. Postprandial bile acid concentrations were significantly greater in the patients with complications of Barrett's than in the remaining groups at 60, 90 and 120 min. Significant concentrations of bile acids were seen in gastric juice of unaltered pH and may be undetected on intra-oesophageal pH monitoring. Duodenogastric reflux may be implicated in the pathogenesis of complications of Barrett's oesophagus.
Plain abdominal radiographs and acute abdominal pain
Authors: Campbell J P M , Gunn A A
Published: March 2007

The records of all (5080) patients presenting to a district general hospital with acute abdominal pain over a 4-year period were examined. The contribution of abdominal radiographs to the assessment of patients with suspected appendicitis, urinary tract infection, and non-specific abdominal pain was evaluated, these conditions accounting for 48 per cent of patients with abdominal pain and 32 per cent of those with abdominal radiographs. Any positive information from these radiographs was less likely to be helpful than incidental or inconsistent (and hence potentially misleading). Because of this high ‘false positive’ rate it is suggested that if the initial diagnosis is suspected appendicitis, urinary tract infection, or non-specific abdominal pain, there is little value in the routine use of abdominal radiographs.
Tuberculous cervical abscess: comparing the results of total excision against simple incision and drainage
Authors: Cheung W L , Siu K F , Ng A
Published: March 2007

In 40 patients with tuberculous cervical abscesses a prospective study was undertaken to determine the results of surgical treatment by either total excision or incision and drainage, together with 6 months of chemotherapy in both groups. While both procedures were well tolerated, the results showed that 17/22 (77 per cent) of those having a simple drainage procedure required a second operation to excise the residual infected lymph glands because of persistent sinus discharge, recurrent abscesses or enlarging lymphadenopathy. In contrast, 17/18 (94 per cent) of those having total excision as the primary procedure had no local ward problem afterwards. Most of the patients remained asymptomatic after completion of the chemotherapy but small painless lymph nodes might still be palpable during follow-up at 2 years.
Traumatic retroperitoneal venous haemorrhage
Authors: Smith S R G
Published: March 2007

Vena caval injury is rare in the UK, but changes in society suggest that it may become more frequent. The problem is always unexpected and presents a major surgical challenge. Modern techniques have led to a substantial improvement in survival so that most patients with an infrarenal injury should now survive but only with prompt, effective treatment. In this review the problems and techniques of surgical management are illustrated by three cases of traumatic injury and two of peroperative accidents.
Operative mortality rate and surgery for colorectal cancer
Authors: Brown S C W , Walsh S , Sykes P A
Published: March 2007

Different authors use different definitions of operative mortality rate when reporting results of their operations. Four definitions used in current literature were applied to our own series of 578 patients with colorectal carcinoma. The operative mortality rate was found to vary from 7·3 per cent to 12·2 per cent, depending on the definition used. ‘Death within 30 days of the last operation’ was the definition which best reflected true operative deaths. We urge that this definition of operative mortality rate be adopted as a standard for all operations.
Natural history and treatment of anorectal strictures complicating Crohn's disease
Authors: Linares L , Moreira L F , Andrews H , Allan R N , Alexander-Williams J , Keighley M R B
Published: March 2007

Forty-four patients seen between 1975 and 1985 with anorectal strictures complicating Crohn's disease have been reviewed to determine the natural history and outcome of surgical treatment. Proctitis was present in 98 per cent, and 93 per cent of patients had severe perianal disease. The site of strictures was rectal in 22, anal in 15 and anorectal in 11 (4 patients had a stricture at 2 sites). Initial treatment was by rectal excision alone in 6, dilatation in 33, and 5 needed no treatment at all. Single dilatation was effective in 15, 8 required two dilatations and in 10 repeated dilatation was necessary. Proctocolectomy was eventually required in 19 patients, 2 have a loop ileostomy and I has an ileostomy with a rectal stump in situ. Only 21 remain asymptomatic while 3 continue to need dilatation. Perineal wound healing was delayed in 9 of 19 patients having a proctocolectomy and in 3 the perineal wound has never healed.
The task of a statistical referee
Authors: Murray G D
Published: March 2007

The results are presented of an audit of the statistical standard of papers published in The British Journal of Surgery. A number of deficiencies are highlighted, many of which stem from an over-emphasis on statistical significance at the expense of any assessment of the clinical relevance of research findings. The flaws in the design of published studies, and in particular the many instances of inadequate sample sizes, emphasize that statistical input should be sought at the beginning of a research project rather than at the end.
Hydroxyethyl starch: an alternative to plasma for postoperative volume expansion after cardiac surgery
Authors: Munsch C M , Maclntyre E , Machin S J , Mackie I J , Treasure T
Published: March 2007

Hydroxyethyl starch (HES) is a recently developed synthetic volume expander. Forty patients undergoing coronary artery surgery were randomized to receive either HES or plasma protein fraction (PPF) as non-blood volume replacement according to standard haemodynamic criteria. The two groups were comparable in all respects. The median colloid use in the first 24 h was 950 ml (range 500–1500) in the HES group and 975 ml (350–2000) in the PPF group (not significant). There was no difference in blood use, urine output or blood loss between the two groups. Tests of coagulation showed the postoperative changes usual in cardiac surgical patients. There was no difference between the two groups in thrombin time, prothrombin time, activated partial thromboplastin time, or fibrinogen concentration. Similarly, tests of platelet function and Factor VIII and von Willebrand Factor activity showed no difference between the two groups. We conclude that HES is a safe and effective volume expander, and its relative lack of expense and ease of availability make its routine use after cardiac surgery an attractive proposition.
Effect of surgery on neutrophil functions, superoxide and leukotriene production
Authors: Utoh J , Yamamoto T , Utsunomiya T , Kambara T , Goto H , Miyauchi Y
Published: March 2007

Perioperative changes of neutrophil function were investigated in 28 patients who underwent major surgery, particularly focusing on the potential capacity for superoxide and leukotriene production, which seem to be important in host defence. The superoxide-producing capacity of neutrophils, which was examined using N-formyl-peptide or phorbol myristate acetate as an attractant, significantly decreased postoperatively to 55 and 69 per cent of the pre-operative values, respectively. The leukotriene-producing capacity of neutrophils, which was stimulated with calcium ionophore A23187 in the presence of arachidonic acid, significantly changed postoperatively. The leukotriene B4 (LTB4) production increased together with an increment of production of 6-trans 6-trans LTB4, however, increased postoperatively to 1·2 times the (LTC4) production decreased postoperatively. The total production of leukotriene A4 (LTA4) metabolites consisting of LTB4, LTC4, and 6-trans LTB4, however, increased postoperatively to 1·2 times the pre-operative values. This indicates that neutrophils in the postoperative period have a higher capacity for LTA4 production but a lower capacity for superoxide production than those in the pre-operative period.
Enterostomy as an adjunct to treatment of intra-abdominal sepsis
Authors: Hesp W L E M , Lubbers E J C , De Boer H H M , Hendriks T
Published: March 2007

In 60 patients a small bowel enterostomy was constructed as part of the treatment of various intra-abdominal infectious and obstructive conditions. Eleven patients (18 per cent) died in the immediate postoperative period from continuing sepsis. In one patient closure of the stoma was not considered because of disseminated malignancy. In the remaining 48 patients continuity of the gut was subsequently restored. In 22 patients (46 per cent) complications occurred, 12 (25 per cent) of which were intra-abdominal septic complications. The occurrence of intra-abdominal complications was found to be linked to premature (i.e. within 3 months) closure of the stoma. Reasons for premature closure were stomal difficulties and prerenal azotaemia. Stomal closure was attended by a 10 per cent mortality rate.
Abdominal aortic aneurysm
Authors: Thomas P R S , Stewart R D
Published: March 2007

Between 1981 and 1986, 282 cases of abdominal aortic aneurysm were diagnosed in Waltham Forest. Rupture had occurred in 183, 15 underwent urgent operation for intact aneurysm, and 84 had elective surgery. The incidence of rupture increased from 13 to 21 per 100000 population during the 6-year period. Operative mortality for patients with rupture was 54.7 per cent, but the mortality overall was 81.4 per cent. In 59 per cent of patients with rupture no operation was performed, and 35.0 per cent of all deaths occurred in the community. The mortality for rupture in women was significantly higher than in men, although the operative mortality was comparable. Fifty patients (27 per cent) were found to have attended hospital within 2 years of rupture and many had documented evidence of an aneurysm. One-third of all patients admitted with rupture were undiagnosed. This study complements the previous small number of community studies and suggests that the incidence of rupture is increasing nationally particularly in women, where the mortality was exceptionally high. Early elective surgery is the key to the problem and improved clinical awareness could save many patients without elaborate and expensive programmes to screen the ‘at risk’ population.
Femorodistal vein bypass graft stenoses
Authors: Grigg M J , Nicolaides A N , Wolfe J H N
Published: March 2007

Eighty femorodistal in situ vein bypass grafts have been evaluated at 3-monthly intervals clinically, with ankle:brachial pressure indices (ABI), by intravenous digital subtraction angiography (IV DSA) and by Duplex scanning. Five grafts (6 per cent) failed in the perioperative period. Nineteen (25 per cent) of the remaining 75 grafts subsequently developed stenoses on IV DSA during the first 12 months. All angiographic stenoses were detected by Duplex scanning using velocity ratio criteria before the development of symptoms or a measurable decline in ABI, i.e. while non-haemodynamically significant. This technique involves scanning the entire length of the graft but allows even minor stenoses to be detected and progression of stenoses can be determined. At a mean follow-up of 12 months (3–18 months), four (7 per cent) of the fifty-six grafts without stenoses occluded. Eight (42 per cent) of the nineteen stenosed grafts either occluded or developed symptoms. None of the occluded grafts in this series could be salvaged. Non-haemodynamically significant vein stenoses can be detected non-invasively, occur frequently and are associated with graft failure.
Endoscopic sclerotherapy in the treatment of gastric varices
Authors: Sarin S K , Sachdev G , Nanda R , Misra S P , Broor S L
Published: March 2007

Of 309 patients with portal hypertension, gastric varices were found in 48 (16 per cent). While the majority (88 per cent) of the patients had gastric varices in association with oesophageal varices, 6 (12 per cent) patients had ‘isolated’ gastric varices. Gastric varices were seen significantly (P < 0.01) more often with grade 4 than with grade 3 varices. In 11 (28 per cent) of the 40 patients who completed sclerotherapy for oesophageal varices, gastric varices disappeared concurrently on eradication of oesophageal varices or during the following 6 months. Of the initial five patients with gastric varices who received direct intravariceal injections, four rebled; this technique was therefore replaced by combination (paravariceal + intravariceal) gastric variceal sclerotherapy. Emergency combination sclerotherapy successfully controlled bleeding from gastric varices in six of the eight treated patients. Thirty-two patients entered a programme of elective combination gastric variceal sclerotherapy. Variceal obliteration was achieved in 12 cases (38 per cent) and reduction in size was noted in another 7 patients (22 per cent) after a minimum of four courses. There were 11 (23 per cent) deaths, 8 due to uncontrolled bleeding from gastric varices and 3 due to hepatic coma. The other complications of gastric variceal sclerotherapy were minor and included retrosternal pain, fever and dysphagia. It is concluded that gastric varices often coexist with large oesophageal varices. If they persist for 6 months after eradication of oesophageal varices, a combination of paravariceal and intravariceal sclerotherapy should be attempted for their obliteration.
Value of endoscopic surveillance in the detection of neoplastic change in Barrett's oesophagus
Authors: Robertson C S , Mayberry J F , Nicholson D A , James P D , Atkinson M
Published: March 2007

Fifty-six patients with Barrett's oesophagus diagnosed between 1977 and 1986 were prospectively studied by 6-monthly endoscopic surveillance and biopsy. During follow-up to-date, four patients have developed high-grade dysplasia and three have adenocarcinoma of the oesophagus. Two of the adenocarcinomas were preceded by progressively severe dysplastic changes but in the third no dysplasia had been previously detected. The incidence of adenocarcinoma was 1 per 56 patient-years of follow-up. Changes in symptomatology or gross endoscopic appearances were usually absent, even after adenocarcinoma had developed, indicating that biopsy is essential for early diagnosis. The high risk of malignant change makes endoscopic surveillance advisable in all patients with Barrett's oesophagus.
Reconstruction after excision of soft tissue sarcomas of the limbs and trunk
Authors: Stotter A , McLean N R , Fallowfield M E , Breach N M , Westbury G
Published: March 2007

From a retrospective analysis of 180 surgical interventions for soft tissue sarcoma of the limbs and trunk, it was concluded that complete excision of the tumour can usually be achieved without sacrifice of major artery, vein, nerve or bone. In this series five major arteries were resected but only one required reconstruction. None of six resected major veins or seven resected nerves were reconstructed. Bone resection in the limb required plating in only two of eleven patients who had limb-sparing resection (there were nine amputations). Both in the limbs and the thorax, resection of bone often involved such a wide excision of the superficial soft tissues as to require a flap repair: four were used in the limbs and three in five chest wall resections. In the majority of operations (140/180) primary wound closure was possible. After 15 procedures for tumour predominantly involving the superficial tissues, split skin grafts were used. These were generally successful (13/15), even occasionally when high-dose radiotherapy had been given. In 16 cases earlier radiotherapy influenced the decision to use a flap repair. A total of 18 flap repairs were performed. In various situations Mersiline mesh (Ethicon, Ltd., UK), Silastic implants and omental swings were used. Wound breakdown in heavily irradiated tissues presented a major challenge for reconstruction. Although major reconstruction was required in only 27 operations (15 per cent), a thorough knowledge of the available methods of reconstruction and repair is essential to allow uninhibited resection with an optimal aesthetic and functional result.
Assessment of the analgesic efficacy of nefopam hydrochloride after upper abdominal surgery: A study using patient controlled analgesia
Authors: McLintock T T C , Kenny G N C , Howie J C , McArdle C S , Lawrie S , Aitken H
Published: March 2007

A randomized, double-blind, placebo-controlled study was performed to assess the analgesic efficacy of intramuscular nefopam hydrochloride after upper abdominal surgery. Patients received either 20 mg nefopam (n = 23) or matching placebo (n = 26), 90 min before surgery, immediately after surgery, and 6, 12 and 18 h after the end of surgery. The 24-h morphine requirements were measured using a patient-controlled analgesia system delivering on-demand intravenous bolus doses of morphine. Pain was assessed using visual analogue scales. Patients receiving nefopam had a mean (± s.e.m.) cumulative morphine consumption of 4.1 ± 0.8 mg in the first hour, compared with 8.5 ± 0.8 mg in the control group (P < 0.01). After 24 h the consumptions were 44.1 ± 7.2 mg and 62.5 ± 6.9 mg respectively (P < 0.05). The pain scores in both groups were similar. This study confirms that nefopam hydrochloride has significant analgesic effects and would be a useful supplement to morphine in the management of postoperative pain.
Influence of pancreatic resection on systemic complications in acute necrotizing pancreatitis
Authors: Teerenhovi O , Nordback I , Isolauri J
Published: March 2007

The influence of pancreatic resection on early systemic complications of acute necrotizing pancreatitis was evaluated in 84 patients. The aetiology of pancreatitis was alcohol 71 per cent, gallstones 13 per cent, alcohol plus gallstones 2 per cent, trauma 1 per cent and idiopathic 12 per cent. A total of 26 of 81 patients (32 per cent) had greater than 50 per cent pancreatic necrosis and 9 patients (11 per cent) considered to have parenchymal necrosis at operation had none shown histologically. The overall mortality was 38/84 (45 per cent) and mortality during the first postoperative week was 15/84 (18 per cent). The outcome after early and delayed operation did not differ significantly. Pancreatic resection had no beneficial effect on shock or respiratory or renal failure (respective pre-operative incidence 12 per cent, 11 per cent and 14 per cent).
Gallbladder non-filling: An indication for cholecystectomy after endoscopic sphincterotomy
Authors: Worthley C S , Toouli J
Published: March 2007

The place of endoscopic sphincterotomy in the treatment of common duct stones leaving the gallbladder in situ remains controversial. Over a 3-year period, 20 elderly high-operative-risk patients with stones in the common duct and intact biliary tree were treated by endoscopic sphincterotomy leaving the gallbladder in situ. Two patients underwent cholecystectomy for persistent symptoms after endoscopic sphincterotomy, and 18 patients were discharged from hospital, with the gallbladder intact. Of the 18 patients, 6 developed recurrent gallbladder problems, with 3 of the 6 dying as a result of these problems. On review of our data, these six patients were in a group of eight who, at the time of original endoscopic retrograde cholangiography (ERC), were shown to have an obstructed cystic duct. The other 10 patients, with a patent cystic duct and discharged with gallbladder in situ, remained symptom free over a median follow-up period of 9 (range 2–42) months. We conclude that if the gallbladder does not fill at ERC (indicating probable cystic duct obstruction), cholecystectomy is warranted. When the gallbladder fills, regular follow-up alone is justified in the absence of symptoms.
Application of mammary serum antigen assay in the management of breast cancer: A preliminary report
Authors: Tjandra J J , Russell I S , Collins J P , Stacker S A , McKenzie I F C
Published: March 2007

A monoclonal antibody (3E1.2) based serum test using an enzyme immunoassay has been used to determine circulating levels of the breast cancer associated antigen—mammary serum antigen (MSA). Of 157 patients with early breast cancer (stage I and II) and 199 patients with advanced breast cancer (stage III and IV), 73 per cent and 87 per cent respectively had elevated MSA levels (i.e. > 300 inhibition units (IU). Furthermore, 40 of 44 patients (91 per cent) had a significant fall of MSA levels with reduction in tumour load by mastectomy. In addition, there was a correlation of MSA levels with the clinical course: changes in MSA levels correlated with changes in disease status (progressive disease, stable disease, disease regression) in 54 of 61 patients and antedated disease progression or recurrence by up to 8 months in some patients; and in 32 of 36 patients (89 per cent) with no clinical evidence of recurrence MSA levels did not vary by more than 25 per cent of the original MSA value over a period of 2–15 months. MSA is therefore a useful tumour marker in the diagnosis and staging of breast cancer. There is also evidence that serial estimations of MSA levels may be used to detect subclinical recurrence and the fluctuations in MSA levels might be useful in assessing response to therapy. Furthermore, it was also noted that surgical procedures such as fine needle aspiration biopsy or incisional biopsy could lead to a rise in MSA levels.
Bilateral spontaneous descent of the testis after the age of 10: Subsequent effects on fertility
Authors: Rasmussen T Bremholm , Ingerslev H J , Høstrup H
Published: March 2007

Fertility after late spontaneous descent of the testes in 45 men with previous bilateral undescended testes was evaluated on the basis of seminal analysis and concentrations of follicle-stimulating hormone (FSH) in serum. Only 15 (33 per cent) were found to have a normal fertility as estimated from the results of the total semen analysis, whereas 21 (47 per cent) were classified as being sterile or having severely reduced fertility. Elevated serum FSH concentrations in the majority of men with subnormal sperm densities supported the results of the semen analysis, indicating impaired spermatogenesis. These findings suggest that the expectant attitude in the treatment of cryptorchidism does not seem to be justified in terms of fertility and combined with recent histomorphological studies favour a more active and early treatment of undescended testes.
Penetrating injuries of the diaphragm
Authors: Demetriades D , Kakoyiannis S , Parekh D , Hatzitheofilou C
Published: March 2007

This study involved 163 patients with penetrating injuries of the diaphragm (knife, 139; bullet, 24). Intra-abdominal injuries were present in 122 patients (75 per cent) and this resulted in early diagnosis and treatment of the associated diaphragmatic injury (mortality 3.2 per cent). In the remaining 41 patients (25 per cent) the injury was confined to the diaphragm, and the diagnosis was missed during the initial admission in 10 patients who returned at a later stage with diaphragmatic hernia. A diaphragmatic hernia was found in 24 cases (14.7 per cent). Fourteen of these were diagnosed during the initial admission (mortality 7.1 per cent) and the remaining ten were diagnosed during a subsequent admission (mortality 30 per cent). The initial chest radiograph was diagnostic of diaphragmatic injury in 13 per cent, abnormal but not diagnostic in 76 per cent, and completely normal in 11 per cent. The importance of early diagnosis in reducing mortality, morbidity and hospital stay is emphasized. A high index of suspicion, careful clinical examination, and serial chest radiographs remain the best way of making the diagnosis.
Use of fine needle aspiration cytology with immediate reporting in the diagnosis of breast disease
Authors: Nicholson S , Sainsbury J R C , Wadehra V , Needham G K , Farndon J R
Published: March 2007

Fine needle aspiration biopsy for cytological examination (FNAC) is becoming increasingly accepted as a means of tissue diagnosis in breast disease. This study examines the feasibility and accuracy of FNAC in ‘immediate reporting’ by a consultant cytopathologist in a busy breast clinic. Over a 2-year period, 884 cytology reports were analysed. An initial clinical report and subsequent final cytological diagnosis was made. Fine needle aspiration provided adequate material for cytological evaluation in 635 of the 884 biopsies (71·6 per cent) and this proportion was greater when discrete lumps were considered (463 of 562 biopsies = 82·4 per cent). In diffuse and cystic disease, however, the adequacy of specimens was reduced: 50 per cent and 65 per cent respectively. On immediate reporting the diagnostic sensitivity for all patients was 88 per cent (discrete lumps only, 92·5 per cent) and the specificity was 99·8 per cent (discrete lumps only, 100 per cent). FNAC retains its diagnostic accuracy when immediate reporting is employed and this study demonstrates that this technique can be used in making a diagnosis in patients with breast disease.
Role of Doppler ultrasound flowmetry in the diagnosis of breast lumps
Authors: Srivastava A , Webster D J T , Woodcock J P , Shrotria S , Mansel R E , Hughes L E
Published: March 2007

One hundred and five patients with discrete breast lumps were examined with a 10 MHz Doppler ultrasonic flowmeter. Doppler flow signals were analysed on an Angioscan spectrum analyser. Recordings from the opposite normal breast were taken as controls and signals from the two sides compared. In 23 patients signals from the normal breast could not be recorded and therefore results of the remaining 82 patients are reported. These included 39 patients with carcinoma, 20 with fibroadenoma, 12 with cyclical nodularity and 11 with cysts. Malignant lumps exhibited significantly higher peak systolic (S) and minimum diastolic frequencies (D) in comparison to the control breast. Fibroadenoma also had a higher S and D than those of the opposite normal breast. Signals over cysts and cyclical nodularity showed no significant difference from the recordings over the control side. Despite significantly higher systolic and diastolic frequencies in the cancer group in comparison to benign lumps and normal breast, considerable overlap in the values was seen between cancer and other groups. Therefore the patterns on 10 MHz Doppler sonography are not sufficiently specific to discriminate benign from malignant breast lumps.
Cholelithiasis: A serious complication after total gastrectomy
Authors: Hauters P , De de Roden A Neve , Pourbaix A , Aupaix F , Coumans P , Therasse G
Published: March 2007

To establish the incidence of cholelithiasis after total gastrectomy patients operated on between 1979 and 1985 were reviewed. The study group consisted of 30 patients, all free of gallstones at the time of their gastrectomy. The median age of the patients was 56 years, the average follow-up 40 months. Cholelithiasis developed in 47 per cent of patients (14/30) and always within 2 years of total gastrectomy. The incidence of cholelithiasis was not related significantly to the sex or age of the patients. Morbidity from cholelithiasis was not negligible. Three of the fourteen patients presenting with gallstones required medical treatment in hospital and later came to cholecystectomy because of specific biliary symptoms. Cholelithiasis appears to be a significant complication after total gastrectomy. It may be related to the vagotomy which is performed at the time of gastrectomy.
Definitive radiation therapy for selected cancers of the rectum
Authors: Sischy B , Hinson E J , Wilkinson D R
Published: March 2007

During the last 15 years, over 400 patients with adenocarcinoma of the rectum have undergone a course of endocavitary irradiation for cure or palliation of Dukes' A and B disease. This treatment method makes use of an unconventional fractionation scheme, by which the tumour receives 10000–12000 cGy in approximately four fractions over a period of about 60 days. The treatments are separated by an interval of 2 or 3 weeks. This method of definitive irradiation allows suitable patients to avoid abdominoperineal resection and its drawbacks. Hospitalization is avoided and the patients maintain a normal daily life. Approximately 15–20 per cent of all rectal cancer patients may be expected to fulfil the criteria for selection, which are sufficiently strict that the local control (95 per cent) and 5-year survival rates (94 per cent) can exceed those of surgery for comparable disease.
An aetiology for fistula in ano
Authors: Pople I K , Ralphs D N L
Published: March 2007

Four cases of superficial peri-anal fistula occurring in early infancy are described. They were all successfully treated by complete excision of the fistula. Histological examination of the excised fistulae revealed a mixture of columnar, transitional and stratified squamous epithelium lining the tracts in three cases and non-specific connective tissue in the fourth. It is postulated that the presence of these inappropriate types of epithelium (columnar and transitional) along the length of the fistulous tract is evidence of a congenital origin for peri-anal fistulae presenting in the first few months of life.
Villous tumours of the large bowel
Authors: Pollard S G , Macfarlane R , Everett W G
Published: March 2007

A series of 110 patients with villous tumours of the colon and rectum treated by a single surgeon over an 18-year period is reported. Multiple lesions were present in 15 per cent of patients and 24 per cent of cases contained invasive malignancy, of which 83 per cent were Dukes' A. The major lesion was in the rectum in 84 per cent of patients and in the sigmoid colon in 12 per cent. Rectal bleeding and diarrhoea were the most common presenting symptoms; 6 per cent of patients were asymptomatic. Digital assessment proved a more reliable indicator of the presence of malignancy than either random biopsy or barium enema. In all, 70 of 76 (92 per cent) benign rectal lesions and 15 of 22 (68 per cent) malignant rectal lesions were successfully removed by peranal submucous excision or snaring and none of the malignancies so treated has developed a recurrence to date. Benign recurrence has developed in 13 per cent of all patients; the majority appeared within 4 years and were at the same level as the initial lesion. Of the 79 patients with benign tumours 7·6 per cent have subsequently developed large bowel carcinomas, after 2–16 years; all were symptomatic, half were at the same level as the previous benign lesion, and half were suitable for peranal removal.