bluuebunny/crossref_metadata_2025 huggingface dataset:
Non-radical therapy for early gastric cancer
Authors: Heesakkers J P F A , Gouma D J , Thunnissen F B J M , Bemelmans M H A , Von Meyenfeldt M F
Published: March 2007

To assess the potential benefit of R2 gastrectomy for patients with early gastric cancer, complications and long-term survival of patients who underwent conventional resection with limited lymphadenectomy (R1 gastrectomy) were analysed retrospectively. Resection margins of all 46 consecutive patients were free from tumour. Tumours were limited to the mucosa in 35 patients and infiltrated the submucosa in 11. Positive lymph nodes were found in two patients. The 30-day mortality was two patients, and cardiac and pulmonary complications occurred in five and six respectively. Anastomotic leakage developed in two patients. During 5 years of follow-up two patients died from tumour recurrence; one of these had lymph node metastases at the initial resection. Resection with limited lymphadenectomy for early gastric cancer results in a 91 per cent 5-year survival rate without the need for R2 gastrectomy with its probably higher morbidity and mortality.
Laparoscopic highly selective vagotomy
Authors: Dallemagne B , Weerts J M , Jehaes C , Markiewicz S , Lombard R
Published: March 2007

Between February 1991 and August 1992, 35 patients underwent laparoscopic highly selective vagotomy (HSV) for recurrent duodenal ulcer disease. An antireflux procedure was also performed in 25 of these patients. There was no 30-day mortality and morbidity. The mean operating time was 110 (range 85-205) min for HSV and 155 (range 100–300) min for vagotomy and antireflux repair. Follow-up is short but initial postoperative gastric acid secretion studies have demonstrated results similar to those obtained after conventional open HSV. The main advantage of laparoscopic HSV is the reduction of 70 per cent in hospital stay and 50 per cent in the overall recovery period compared with open surgery.
Effect of human leucocyte antigen matching on the incidence of acute rejection in renal transplantation
Authors: Beckingham I J , Dennis M J S , Bishop M C , Blamey R W , Smith S J , Nicholson M L
Published: March 2007

The influence of human leucocyte antigen (HLA) matching on the incidence of acute rejection and graft survival was examined in 181 consecutive patients receiving cadaveric renal transplants. Allografts with better HLA-DR and HLA-B matching showed significantly lower rejection rates than less well matched grafts on both univariate (rejection rates 25, 62 and 82 per cent for zero, one and two DR mismatches; P<0·001) and multivariate analysis. Rejection episodes occurred earlier in mismatched grafts (P<0·001). Superior matching was associated with improved graft function at 1 year after transplantation (mean serum creatinine level 137, 180 and 225 μmol l−1 for zero, one and two DR mismatches; P<0·05). No association was, however, demonstrated between the degree of matching and overall graft survival. Good HLA matching reduces the number of acute rejections episodes, producing significant savings in drug costs and hospital stay. Long-term graft function is improved and minimizing early graft damage helps to avoid later development of chronic rejection.
Radical pancreatoduodenectomy for misdiagnosed pancreatic mass
Authors: Smith C D , Behrns K E , Van Heerden J A , Sarr M G
Published: March 2007

Occasionally pancreatoduodenectomy is performed for clinically suspected pancreatic malignancy only for the surgeon to find that a benign aetiology accounts for the pancreatic mass. The aim of this study was twofold: to determine the incidence of pancreatoduodenectomy performed for a misdiagnosis of pancreatoduodenal malignancy and to identify potentially avoidable errors in preoperative and intraoperative judgement. Between 1956 and 1990, radical pancreatoduodenectomy was performed in 603 patients at the Mayo Clinic; 29 (5 per cent) underwent pancreatoduodenectomy for a diagnosis made before and during surgery of primary pancreatic or periampullary malignancy that was later proven histopathologically to be either unsuspected subacute or chronic pancreatitis (22 patients), benign fibrous common bile duct stricture (two), and penetrating duodenal ulcer, metastatic melanoma, ampullary adenoma, intrahepatic drug-induced cholestasis and pseudocyst (one each). No patient had a preoperative diagnosis of chronic pancreatitis. Weight loss, pain and/or jaundice were present in 27 of the 29 patients. Objective imaging tests, such as computed tomography, ultrasonography and/or endoscopic retrograde cholangio-pancreatography, were performed in 25 patients. Potential errors in judgement may be avoided by a more aggressive attempt at biopsy in selected patients; in others, resection for presumed malignancy may be unavoidable.
Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: A prospective study
Authors: Widdison A L , Longstaff A J , Armstrong C P
Published: March 2007

In patients with symptomatic gallstones the management of choledocholithiasis has been controversial since the introduction of laparoscopic cholecystectomy. A prospective study was made of 300 consecutive patients with symptomatic gallstones managed by laparoscopic cholecystectomy and preoperative endoscopic retrograde cholangiography (ERC) over 2 years. Fourteen patients were excluded either because urgent surgery was required or because they were unfit for laparoscopic cholecystectomy. ERC was performed on 96 patients (34 per cent) who were at risk of choledocholithiasis. The presence of bile duct calculi was confirmed in 59 patients (21 per cent of the total, 61 per cent of those undergoing ERC); stones were removed endoscopically in 53 cases (90 per cent of attempts). The remaining six patients underwent open cholecystectomy and bile duct exploration. Laparoscopic cholecystectomy was attempted in 280 patients (98 per cent); it was necessary to convert to open operation in only three (1 per cent). There were no deaths, no retained stones and no bile duct injuries, and only three patients (1 per cent) developed a significant postoperative complication. Symptomatic gallstones can be managed by preoperative ERC and laparoscopic cholecystectomy with minimal morbidity and mortality.
Abdominal wall metastases following laparoscopy
Authors: Nduka C C , Monson J R T , Menzies-Gow N , Darzi A
Published: March 2007

Only 18 cases of recurrence at the sites of cannula insertion after laparoscopy have been reported in the literature, ten of them in the past year. The period between laparoscopic surgery and presentation of wound metastasis varies widely, from 7 days to 10 months; the lesions are typically hard, craggy and painful. The most likely mechanism is direct implantation of viable exfoliated tumour cells but three aspects specific to laparoscopy may also be important. First, there may be increased exfoliation of tumour cells following manipulation by laparoscopic instruments of an unsuspected malignancy. Second, there may be repeated close contact between tumour-laden instruments and the port. Third, the passage of resected tissue through a small incision may coat the wound with potentially malignant cells.
Variation in outcome of surgical procedures
Authors: Houghton A
Published: March 2007

Evidence regarding the relationship between outcome and the number (volume) of patients treated at individual hospitals or by individual surgeons is reviewed and the interplay of other factors such as hospital characteristics, population profiles and referral preferences examined. An inverse relationship between mortality rate and hospital volume has repeatedly been found and, while there have been similar findings for surgeon volume, these results have been less consistent. What is certain is that wide variation in outcome does occur. What is less clear is whether the relationship to volume is a causal one or whether it is due to other factors such as those mentioned above. Despite there being a great deal that we do not understand about these relationships, considerable action has been taken as a result of the studies reported here, in the USA in particular. This has taken the form of rationalization of services, publication of hospital mortality rates and the setting of minimum numbers of specific procedures that should be performed each year by individual surgeons. Understanding of this area should be much greater before rationalization is considered in the name of higher quality and before mortality rates according to hospital or surgeon are published.
Intestinal anastomosis with a skin stapler: A safe and efficient method in humans
Authors: Fraser I
Published: March 2007

A method of intestinal anastomosis with a skin stapler has been used successfully in 39 patients to form 40 anastomoses. The method has been employed in elective and emergency surgery, in small and large intestine, for a variety of pathological conditions and in the presence of obstruction, sepsis and soiling. Bowel anastomosis with a skin stapler is safe, simple and efficient in time and materials.
Repeated reconstruction for recurrent benign bile duct stricture
Authors: Kozicki I , Bielecki K , Kawalski A , Krolicki L
Published: March 2007

Since 1965, 101 operations for benign bile duct stricture have been performed, including 51 Roux-en-Y end-to-side hepaticojejunostomies. Complete follow-up to a mean of 12·5 years has been achieved. Nine patients required reoperation for stricture; the total cumulative late patency rate was 90 per cent, including successful repair. Seven of the nine patients who underwent a second operation had a favourable outcome. Early hepaticojejunostomy is a satisfactory treatment for recurrent biliary stricture.
Endoluminal ultrasonography in the follow-up of patients with rectal cancer
Authors: Ramirez J M , McC Mortensen N J , Takeuchi N , Humphreys M M Smilgin
Published: March 2007

One principal aim in follow-up after curative surgery for colorectal cancer is to identify recurrent disease at an early and possibly treatable stage. The major problem for patients with rectal carcinoma is local recurrence, which occurs in 3–30 per cent of cases and carries a 5-year survival rate of less than 5 per cent. Since 1989, in addition to digital and sigmoidoscopic examination, endorectal ultrasonography has routinely been used in the follow-up of patients with rectal cancer. Sixty-six patients (40 men) who had undergone attempted radical surgery for mid- and lower-third rectal cancer were included in the study. The mean age was 68 (range 43–87) years. A total of 190 scans were performed, with a mean of 3 (range 1–9) for each patient. Thirteen (20 per cent) of the 66 patients developed local recurrence; in all cases this was suggested by rectal ultrasonography. Digital examination and rigid sigmoidoscopy failed to detect recurrence in three patients. Four detected recurrences were treated radically; the remaining patients received radiotherapy, palliative transanal resection or laser management because of advanced age or refusal to undergo surgery. Six patients were alive a mean of 21 (range 4–50) months after recurrence. Of these six patients, four were free from disease (three had undergone salvage surgery and one radiotherapy). Postoperative rectal ultrasonography can detect some local recurrences at an early treatable stage. The method is more accurate than digital examination and sigmoidoscopy, and should be used as part of a regular follow-up programme.
Inappropriate neutrophil activation in venous disease
Authors: Whiston R J , Hallett M B , Davies E V , Harding K G , Lane I F
Published: March 2007

Neutrophil oxygen radical production was studied in 18 limbs with class 2 or 3 venous disease and compared with that of nine normal limbs. Neutrophils were isolated from arm and leg venous samples. Free radical production was determined using chemiluminescence after stimulation with the chemotactic peptide formyl-methionyl–leucyl–phenyl-alanine (FMLP) or the ester phorbol myristate acetate (PMA). The ratio of leg to arm luminescence was greater after FMLP stimulation in patients with venous disease median 1·52 (95 per cent confidence interval (c.i.) 1·27–2·60)) than in controls (median 0·97 (95 per cent c.i. 0·70–1·12); P < 0·01). These changes were not observed with PMA (venous disease 1·16 (95 per cent c.i. 1·05–1·40); controls 0·95 (95 per cent c.i. 0·78–1·24)). There were fewer FMLP receptors on activated leg neutrophils (median 20·19 (95 per cent c.i. 3·58–51·42) fluorescence units) than arm neutrophils (median 36·03 (95 per cent c.i. 13·00–65·28) fluorescence units; P < 0·05), indicating an amplification of signal transduction. Intracellular calcium imaging demonstrated a larger release of calcium after stimulation of leg neutrophils (median 25·0 per cent (95 per cent c.i. 15·7–43·9 per cent)) compared with neutrophils from the arm (median 8·0 per cent (95 per cent c.i. 5·6–16·1 per cent); P = 0·04), demonstrating calcium-dependent activation. Neutrophils in patients with chronic venous disease inappropriately produce more oxygen free radicals as a result of amplification of a calcium-dependent signal pathway.
Mortality rates associated with operative treatment of infrarenal abdominal aortic aneurysm in The Netherlands
Authors: Akkersdijk G J M , van der Graaf Y , van Bockel J H , de Vries A C , Eikelboom B C
Published: March 2007

Information on surgery for non-ruptured and ruptured infrarenal abdominal aortic aneurysm (AAA) in all hospitals in The Netherlands in 1990 was obtained from the Dutch National Medical Registration Foundation. The operation rate in the population over the age of 50 years was 30·3 per 100000 for non-ruptured AAA and 16·8 per 100000 for ruptured aneurysm. The hospital operative mortality rate for non-ruptured AAA surgery was 6·8 per cent in 1289 patients and for ruptured aneurysm 43·6 per cent in 709. For non-ruptured AAA the mortality rate almost doubled per age group of 10 years, whereas the influence of age was less significant for ruptured lesions. The operative mortality rate for non-ruptured aneurysm in university hospitals exceeded that in other hospitals, but no difference was found for emergency surgery on ruptured AAA. Nationwide results give a more representative picture of the true mortality rate associated with operation for aortic aneurysm. Such data are important for planning future treatment strategy and for evaluating the efficacy of screening.
Splenic autotransplantation after splenectomy: Tuftsin activity correlates with residual splenic function
Authors: Zoli G , Corazza G R , D'Amato G , Bartoli R , Baldoni F , Gasbarrini G
Published: March 2007

This study set out to determine the relationship between splenic function (as assessed by the percentage of pitted red cells) and tuftsin activity, and to confirm the return of effective splenic function after splenectomy for trauma. Twenty-three patients (13 men) took part. Ten of mean age 48·5 (range 30–74) years had had the spleen removed for traumatic rupture and 13 of mean age 49·7 (range 23–66) years had undergone elective splenectomy. At the time of the study all patients had had the spleen removed a minimum of 1 year previously (mean 6·1 (range 1–15) years). Fifty healthy volunteers matched for sex and age were also studied. In each subject, residual splenic function was evaluated by counting the percentage of pitted red cells. Tuftsin activity was also determined. A highly significant negative correlation was found between pitted red cell percentage and tuftsin activity (rs = −0·80, P 0·001). Compared with healthy controls (mean 21·6 (range 13–37) per cent), tuftsin activity was significantly reduced both in patients who had undergone splenectomy for trauma (mean 4·4 (range 0·9) per cent; P < 0·0001) and in those who had had elective splenectomy (mean 0; P < 0·0001). Tuftsin activity was significantly (P < 0·001) more depressed after elective than traumatic splenectomy. These data confirm a decrease in tuftsin activity following splenectomy and show that this deficit is significantly greater after elective than emergency removal. These observations confirm that residual splenic function is often present after traumatic splenectomy.
Influence of total colectomy on serum antineutrophil cytoplasmic antibodies in inflammatory bowel disease
Authors: Patel R T , Stokes R , Birch D , Ibbotson J , Keighley M R B
Published: March 2007

Perinuclear antineutrophil cytoplasmic antibodies (pANCAs) have previously been demonstrated in patients with various forms of vasculitis and more recently in those with inflammatory bowel disease (IBD) by an indirect immunofluorescence technique. Sera from 194 patients were tested for pANCAs: 101 with ulcerative colitis (43 with varying grades of disease severity, 19 after subtotal colectomy, 39 following restorative proctocolectomy), 40 with Crohn's disease, five with indeterminate colitis, 24 patients without IBD and 24 healthy volunteers (controls). The overall prevalence of pANCAs in patients with ulcerative colitis was 70·3 per cent (71 of 101). These antibodies were still present in 29 of 39 patients after restorative proctocolectomy, in whom the median follow-up after surgery was 2 years. All five patients who had pouchitis after restorative proctocolectomy were pANCA positive. By contrast, only ten of 40 patients with Crohn's disease had pANCAs, nine of whom had Crohn's colitis. No pANCAs were detected in Controls. These results show that pANCAs are more prevalent in colonic IBD, especially ulcerative colitis. The persistence of pANCAs in the sera for 2 years after restorative proctocolectomy suggests that the antigens are not fully eradicated and, therefore, that it is not just the colon that is targeted immunologically in ulcerative colitis.
Prognosis of elderly patients with large bowel cancer
Authors: Mulcahy H E , Patchett S E , Daly L , O'Donoghue D P
Published: March 2007

The effect of age on the presentation, diagnosis, management and survival of patients with colorectal cancer was studied prospectively in 512 patients admitted to a single institution. In all, 225 patients were aged 70 years or more and 287 less than 70 years. Older patients had a significant excess of emergency presentations (18 versus 11 per cent). Methods of diagnosis, proportion of curative operations performed, stage and histological grade were similar in the two age groups. The postoperative mortality rate was 6 per cent in the elderly group and 3 per cent in younger patients. The postoperative mortality rate rose to 15 and 12 per cent respectively in those undergoing emergency surgery. The relative 5-year survival rate standardized for age and sex was 52 per cent for older patients and 45 per cent for younger patients; for those undergoing curative surgery it was 68 and 59 per cent respectively. The behaviour of colorectal carcinoma changes little with age and, allowing for population mortality, age has no effect on the long-term survival of elderly patients with large bowel cancer.
Hypercoagulable states in patients with leg ischaemia
Authors: Ray S A , Rowley M R , Loh A , Talbot S A , Bevan D H , Taylor R S , Dormandy J A
Published: March 2007

Hypercoagulable states are found in up to 10 per cent of patients with a history of unexplained venous thrombosis. To investigate the prevalence in arterial thrombosis, thrombophilia screening was performed on 124 patients who had previously undergone lower-limb revascularization, 45 claudicants and 27 controls. Of the patients who had undergone revascularization 40 per cent had a hyper-coagulation abnormality (low levels of protein C, protein S and antithrombin III or presence of the lupus anti-coagulant) in comparison with 27 per cent of claudicants and 11 per cent of controls (P < 0·01). Furthermore, patients who had suffered reocclusion after revascularization were significantly more likely to have a hypercoagulation abnormality than those who had not (P < 0·05), even if the occlusion had occurred more than 6 months previously. Lupus anticoagulant was the abnormality most frequently detected and, like low protein C levels, was found only in patients with peripheral vascular disease. It appears that hypercoagulable states are common in patients with arterial disease and may predispose to failure of revascularization.
Platelet activation during hand vibration
Authors: Kent P J , Williams G A , Kester R C
Published: March 2007

The level of β-thromboglobulin, the circulating platelet aggregate ratio and platelet sensitivity to aggregation with adenosine 5′-diphosphate (ADP) and collagen were assessed in 12 control subjects, 16 patients with vibration white finger (VWF) and 15 patients with primary Raynaud's disease; this was done before and after a 1-min exposure to hand vibration. The β-thromboglobulin level increased significantly in controls, from a median (interquartile range) of 35·5 (22–47) to 47·5 (27–52) ng/ml, and in the VWF group from 44·0 (39–60) to 47·5 (42–109) ng/ml (P < 0·005). Vibration had no effect on circulating platelet aggregate ratio in any group. The platelets of normal subjects tended to be more sensitive to aggregation with low-dose ADP (1 mmol/l) than those of patients with VWF or primary Raynaud's disease. Significant change occurred in the lag phase of the aggregation response to vibration in the control group at an ADP concentration of 2 and 5 mmol/l. These results indicate that intravascular platelet aggregation occurs as a result of exposure to vibration. Platelet sensitivity to aggregation with ADP may be decreased in patients with VWF or established Raynaud's disease.
Carotid endarterectomy in Great Britain and Ireland: Practice between 1984 and 1992
Authors: Murie J A , John T G , Morris P J
Published: March 2007

Of 356 questionnaires on carotid endarterectomy sent to all vascular surgeons in Great Britain and Ireland likely to undertake this procedure, 326 (92 per cent) were returned. Of those who replied 131 (40 per cent) performed at least one carotid endarterectomy in 1992; 57 (44 per cent) of these carried out ten or fewer operations and 74 (56 per cent) more than ten. The 131 surgeons were collectively responsible for 2628 operations in 1992, twice as many as were undertaken in either 1984 or 1989, years for which similar survey data are available. This sharp rise in the number of operations was accounted for by increased activity on the part of experienced operators, rather than any rise in the number of ‘occasional’ carotid surgeons. In 1992, although the neurologist remained a major source of patient referral, general practitioners (and others) were also referring patients in large numbers direct to the vascular surgeon; this represents a change in practice compared with previous years. Many of the technical aspects surrounding carotid endarterectomy remained unchanged over the years surveyed (1984, 1989, 1992) but by 1992 duplex scanning, intra-arterial (but not intravenous) digital subtraction angiography and transcranial Doppler ultrasonography had become established as clinically useful techniques.
Trends in vascular surgery since the introduction of percutaneous transluminal angioplasty
Authors: Pell J P , Whyman M R , Fowkes F G R , Gillespie I , Ruckley C V
Published: March 2007

Lower-limb percutaneous transluminal angioplasty (PTA) has been used increasingly over the past decade, either alone or in conjunction with arterial reconstructive surgery. However, its impact on operation rates has not been evaluated properly. Rates of vascular operations and PTAs performed per referral for peripheral arterial disease to the regional vascular service at The Royal Infirmary, Edinburgh, were calculated for the years 1986-1992. The overall rate of PTA for peripheral arterial disease increased ninefold over this period; that for critical ischaemia increased fivefold. Rates of aortic and femoral reconstruction for all peripheral arterial disease increased by 40 and 100 per cent respectively, but rates for critical ischaemia remained static. The major amputation rate rose by 47 per cent between 1986 and 1990, and thereafter reached a plateau. Increased use of PTA was not associated with a reduction in the number of vascular operations.
Outcome in patients who require renal support after surgery for ruptured abdominal aortic aneurysm
Authors: Gordon A C , Pryn S , Collin J , Gray D W R , Hands L , Garrard C
Published: March 2007

Over a 3-year period haemofiltration and dialysis was provided for 18 patients who developed renal failure after operation for ruptured abdominal aortic aneurysm (AAA). Four of the patients underwent operation elsewhere and were transferred when renal failure was diagnosed. The median duration of renal support in the 11 survivors was 24 days, while the seven patients who died received support for a median of 11 days. By 3 months after operation eight of the 11 survivors were independent of dialysis. Renal support was life saving in eight of 91 patients operated on in Oxford for ruptured AAA and reduced the 30-day operative mortality rate from a potential 47 per cent to an actual 38 per cent. Haemofiltration and haemodialysis for acute renal failure after surgery for ruptured aortic aneurysm is clinically justified and results in the long-term survival of most patients.
Venous function and clinical outcome following deep vein thrombosis
Authors: Milne A A , Stonebridge P A , Bradbury A W , Ruckley C V
Published: March 2007

The severity of post-thrombotic symptoms in 111 limbs (107 patients) with previous phlebographically proven deep vein thrombosis (DVT) was correlated with superficial and deep venous function as determined by foot volumetry (n = 90) and duplex ultrasonography (n = 62). The median delay between DVT and assessment was 8 (range 1–34) years. Symptoms were mild (group 1) in 31 limbs (28 per cent), moderate (group 2) in 41 (37 per cent) and severe (group 3) in 39 (35 per cent). There was no significant relationship between the site of DVT, or the time since DVT, and the severity of symptoms. Without tourniquet occlusion of superficial veins, limbs in group 3 had a significantly shorter half-refilling time than those in groups 1 and 2 (P = 0–01). Although a similar trend was observed after tourniquet occlusion of superficial veins, this was not statistically significant. There was no significant difference in the expelled volumes between the three clinical groups. On duplex scanning, deep and superficial venous reflux was detected in just over half of the limbs in each group. Eight patients had entirely normal scans and none of them had severe symptoms (P = 0·04). This study identifies a strong association between severe postphlebitic syndrome and venous reflux, such that it may be considered that venous reflux is necessary for the development of severe post-thrombotic symptoms. However, many patients with severe reflux have only mild symptoms and additional factors must therefore contribute to the development of severe postphlebitic syndrome.
Randomized trial of adrenaline injection and laser photocoagulation in the control of haemorrhage from peptic ulcer
Authors: Carter R , Anderson J R
Published: March 2007

Forty-nine consecutive patients with bleeding from peptic ulcers that would conventionally have required surgical intervention were randomized to receive endoscopic injection of adrenaline (1:10000) or laser photocoagulation. Patients were included only if they had a visible vessel at endoscopic examination. Five patients proceeded directly to surgery and, of the remaining 44, 21 received laser photocoagulation and 23 injection therapy. Haemostasis was achieved initially in all patients. There was one rebleed in the group of patients who received laser treatment and four in those treated by injection. All five patients underwent further endoscopic haemostasis according to the initial randomization. Haemostasis was again achieved in all cases, but the patient who had undergone laser treatment suffered recurrent haemorrhage after a further 48 h and subsequently died. Overall, one of the 21 patients receiving laser treatment died compared with none of the 23 injected with adrenaline. Injection of adrenaline achieves similar results to laser photocoagulation for bleeding peptic ulcer.
Endoscopic drainage of traumatic pancreatic pseudocyst
Authors: Funnell I C , Bornman P C , Krige J E J , Beningfield S J , Terblanche J
Published: March 2007

Pancreatic pseudocyst following trauma is usually caused by a major duct injury and may present late. The outcome of endoscopic treatment in five patients with post-traumatic pseudocyst is described. Diagnosis was made from 3 weeks to 1 year after injury by ultrasonography and computed tomography. A distinct bulge was visible in the stomach or duodenum using endoscopic retrograde cholangio pancreatography, and a cyst enterostomy was established with a knife or standard papillotome. Successful drainage was achieved without complications. One patient developed a recurrence, which was redrained endoscopically, but surgical intervention was required for persistent pain. Early results suggest that endoscopic drainage for selected pancreatic pseudocysts is feasible and safe.
Chemotherapy prolongs survival in inoperable pancreatic carcinoma
Authors: Palmer K R , Kerr M , Knowles G , Cull A , Carter D C , Leonard R C F
Published: March 2007

Forty-three patients with irresectable advanced pancreatic cancer were randomized to receive chemotherapy using a combination of 5-fluorouracil, Adriamycin and mitomycin or no chemotherapy. Groups were well matched with regard to age, extent of disease and performance status on entry. Chemotherapy was well tolerated and, although common, side-effects were usually mild. Psychological measurements based on the Hospital Anxiety and Depression score were made in 31 patients. These showed significantly less depression but not anxiety in the treated group immediately after randomization and following 2 months of chemotherapy. Median survival in the treated group was 33 (range 9–80) weeks compared with 15 (range 1–62) weeks in the untreated group (P < 0·002). Chemotherapy should be considered in all patients presenting with advanced inoperable pancreatic cancer.
Intra-abdominal sepsis and survival after surgery for colorectal cancer
Authors: Varty P P , Linehan I P , Boulos P B
Published: March 2007

Of 361 patients who survived curative left colonic or sphincter-saving rectal resection for cancer, 44 developed significant postoperative intra-abdominal sepsis and 317 did not. The two groups were well matched for age, sex, site of tumour, Dukes stage, tumour differentiation and timing of operation. There was no significant difference in the 5-year overall actuarial survival rate (P = 0·25) or in the 5-year disease-free survival rate (P = 0·23). Stepwise regression analysis of prognostic variables including age, sex, site of tumour, Dukes stage, tumour differentiation, timing of operation, grade of surgeon and postoperative intra-abdominal sepsis identified Dukes stage, age at operation and tumour differentiation as predictors of survival. These results suggest that postoperative intraabdominal sepsis is not a prognostic factor for long-term survival in colorectal cancer as has been previously reported.
Pathogenesis of abdominal aortic aneurysm
Authors: MacSweeney S T R , Powell J T , Greenhalgh R M
Published: March 2007

The pathogenesis of abdominal aortic aneurysm involves many factors acting over time. However, destruction of elastin in the aortic wall is a key event that shifts the load produced by blood pressure on to collagen. This is exacerbated in the presence of hypertension. Smoking and age are further important factors, as is the site; elastic lamellae are relatively less common in the abdominal aorta. Once the shielding effect of elastin is lost, further dilatation and rupture of the aorta depend on the physical properties of the collagen present.
Laparotomy in patients infected with human immunodeficiency virus: Indications and outcome
Authors: Lowy A M , Barie P S
Published: March 2007

Four distinct disease processes account for the majority of surgically correctable intra-abdominal pathologies associated with human immunodeficiency virus (HIV) infection: cytomegalovirus infection, Kaposi's sarcoma, non-Hodgkin's lymphoma and mycobacterial infection. Affected patients may also develop acute cholecystitis and appendicitis with significant frequency. Thorough investigation, when possible, will obviate the need for laparotomy in most HIV-infected patients with abdominal symptoms and signs. In those who require surgical intervention, the outcome varies greatly according to the nature of the diagnosis.
Randomized placebo-controlled double-blind study of three aprotinin regimens in primary cardiac surgery
Authors: Bailey C R , Kelleher A A , Wielogorski A K
Published: March 2007

The serine proteinase inhibitor aprotinin significantly reduces postoperative blood loss in patients requiring cardiac surgery using cardiopulmonary bypass. This study compared two low-dose regimens with administration of high-dose aprotinin and a control protocol to determine whether the dose of aprotinin could be greatly decreased but still maintain efficacy after primary cardiac surgery. Some 100 patients were randomly assigned to one of four groups: control group (0·9 per cent saline placebo, n = 25); high-dose group (aprotinin 2 × 106 kallikrein inactivator (KI) units intravenous patient bolus and 0·5 × 106 KI units h−1 plus 2 × 106 KI units into pump prime, n = 25); prime group (aprotinin 2 × 106 KI units added to the pump prime, n = 24); and patient group (aprotinin 106 KI units intravenous patient bolus plus 106 KI units added to the pump prime, n = 26). Only patients from the high-dose and patient groups had reduced intraoperative blood loss, but patients from all three aprotinin-treated groups demonstrated a significant decrease in median postoperative blood loss compared with the control group (high-dose 350 ml, prime 420 ml, patient 340 ml versus control 780 ml; P <0·001). There was an even greater reduction in measured median postoperative haemoglobin loss within the chest drains in the treated compared with the control patients (high-dose 15 g, prime 24 g, patient 14 g versus control 47 g; P <0·001). These decreases were statistically the same for all the treated groups; it is possible to lower the dose of aprotinin to approximately one-third of the currently recommended dosage and still obtain significantly reduced postoperative blood loss in primary cardiac surgery.
Role of thromboxane A2 in muscle injury following ischaemia
Authors: Homer-Vanniasinkam S , Crinnion J N , Gough M J
Published: March 2007

The effect of a thromboxane A2 receptor antagonist (GR32191) on gastrocnemius muscle blood flow, oedema and viability was assessed in a rodent model of 6-h unilateral hindlimb ischaemia and 4-h reperfusion, and the results compared with those in control and normal groups, and in animals undergoing 6-h ischaemia alone. Control animals demonstrated reduced muscle blood flow throughout reperfusion (at 10 min, P <0·01 versus normal, P not significant versus ischaemia; at 120 min, P <0·5 versus normal and ischaemia; at 240 min, P <0·01 versus normal, P not significant versus ischaemia), and the development of muscle oedema (P <0·01 versus normal and ischaemia) and muscle necrosis (P <0·01 versus normal and ischaemia). In contrast, the thromboxane A2 receptor antagonist enhanced muscle blood flow (at 10 min, P <0·01 versus control; at 120 min, P <0·05 versus control; at 240 min, P <0·01 versus control) and preserved muscle viability (P <0·01 versus control; P not significant versus normal and ischaemia). These results indicate that thromboxane A2 is an important mediator of skeletal muscle reperfusion injury and suggest that administration of a thromboxane A2 receptor antagonist may improve limb salvage rates after surgery for acute ischaemia.
Introduction of a population-based vascular registry: Validity of data and limitations of registration
Authors: Lepäntalo M , Salenius J-P , Luther M , Ylönen K
Published: March 2007

A study was performed to assess the validity of the data in a nationwide vascular registry, Finnvasc, initiated in 1991. Data recorded during the first year were of 3507 procedures (immediate reoperations were excluded); 2436 (69 per cent) were surgical and 1071 (31 per cent) endovascular in nature. The Finnvasc data were compared with 2325 hospital records and re-registration of a random sample of 233 patients treated during October 1991 in nine centres was also carried out. In all, 21 per cent of patients from hospitals participating in Finnvasc were not registered and so it was calculated that about 4500 vascular procedures, 3125 surgical and 1375 endovascular, were performed in Finland in 1991. This represents an average of 900, 625 and 275 procedures per million population per year respectively. The non-registration rate in October was 17 per cent. Apart from operation classification, and function and patency at 1 month, all simple binary and code data at re-registration were in agreement in at least 92 per cent of cases; checklist and numerical data did not show such good conformity. During the first year of the registry many data were either missing or inadequately recorded, emphasizing the need for cross-validation and reregistration of a random sample of cases. Furthermore, the non-uniformity of coding between hospital records and the Finnvasc registry illustrated deficiencies in the current coding system.
Emergency oesophageal transection for uncontrolled variceal haemorrhage
Authors: Willson P D , Kunkler R , Blair S D , Reynolds K W
Published: March 2007

Continued haemorrhage from oesophageal varices despite adequate injection sclerotherapy and tamponade has a high mortality rate. Such patients are usually referred for surgery. Over a 10-year period, 30 patients (21 men and nine women of median age 52 (range 21–70) years) with acute variceal haemorrhage uncontrolled by initial treatment underwent early emergency oesophageal transection. Portal hypertension was caused by alcoholic cirrhosis in 22 patients; other forms of cirrhosis were present in seven and portal vein thrombosis in one. Hepatic function immediately before operation was Pugh grade A in two patients, B in six and C in 22. Deterioration between admission and transection from grade A to B occurred in one patient and from B to C in five. Oesophageal transection stopped variceal haemorrhage in 29 of the 30 patients. Rebleeding from gastric varices within 35 days of surgery occurred in five patients. Postoperative haemorrhage also occurred from perioesophageal vessels (two patients), a gastrotomy (one) and oesophageal ulceration (two). Hepatic failure developed in seven patients, renal failure in five and both hepatic and renal failure in four. Mortality at 30 days occurred in neither of the two patients with liver function of grade A, in one of six of grade B and in 18 of 22 of grade C. The overall 30-day mortality rate was thus 63 per cent. Mortality was related to the preoperative Pugh grade (hazard ratio 3·95 per grade; P = 0·013) and preoperative blood transfusion (hazard ratio 1·37 per unit; P = 0·035). Four of six patients with grade B liver function died within 3 months and 21 of 22 with grade C disease within 1 year. Oesophageal transection is effective at stopping variceal bleeding but does not modify the underlying disease. Caution is urged for patients with grade C hepatocellular impairment proceeding to acute oesophageal transection after initial sclerotherapy. Such patients may benefit more from treatment with somatostatin or an intrahepatic portasystemic stent shunt while awaiting definitive therapy.
Predictors of upper gastrointestinal bleeding in patients with schistosomal periportal fibrosis
Authors: Eltoum I A , Taha T E , Saad A M , Suliman S M , Bennett J L , Nash T E , Homeida M M
Published: March 2007

A case–control study was conducted between 1985 and 1987 in the Gezira-Managil area of central Sudan to assess the major predictors of haematemesis. Eighty-four patients who had suffered at least one attack of oesophageal bleeding and had schistosomal periportal fibrosis demonstrated by ultrasonography were compared with 173 subjects without bleeding but with ultrasonographic evidence of periportal fibrosis. A splenic longitudinal dimension of more than 11 cm, periportal fibrosis worse than grade I and varices more than grade I were independently associated with a significant risk of variceal bleeding. Age, sex, presence of a palpable liver and portal vein diameter were not associated with a significant risk of bleeding after adjustment for potential confounding variables. Factors identified in this study could be helpful in the prophylactic management of patients with complicated schistosomiasis.
Gastrointestinal bezoars
Authors: Robles R , Parrilla P , Escamilla C , Lujan J A , Torralba J A , Liron R , Moreno A
Published: March 2007

Of 99 patients with 117 gastrointestinal bezoars, 69 had undergone previous surgery, the most common operation being bilateral truncal vagotomy with pyloroplasty (55 patients). An excessive intake of vegetable fibre was found in 38 patients and poor mastication in 27. Thirty bezoars presented with gastric symptoms and patients had endoscopy as the diagnostic technique; 87 caused symptoms of intestinal obstruction with the diagnosis made by plain abdominal radiography. Medical treatment by enzymic or endoscopic fragmentation was used for 17 of 30 gastric bezoars; surgery was required in the remainder. Intestinal bezoars causing obstruction can be fragmented and ‘milked’ to the caecum. The stomach should be explored for associated gastric bezoars.
Xanthogranulomatous cholecystitis
Authors: Houston J P , Collins M C , Cameron I , Reed M W R , Parsons M A , Roberts K M
Published: March 2007

Clinical, radiological and pathological findings in 31 patients with xanthogranulomatous cholecystitis have been reviewed. The spectrum of presentation was similar to that of cholelithiasis but fewer patients had biliary colic (17 per cent) and there were more complications (32 per cent). Four patients had a biliary fistula and four a perforated gallbladder with abscess formation. Patients characteristically had gallstones. Appearances often mimicked carcinoma of the gallbladder at ultrasonography and/or laparotomy, with xanthogranulomatous tissue extending to adjacent structures. Xanthogranulomatous cholecystitis and carcinoma of the gallbladder coexisted in three patients. The possibility should be considered that an ‘inoperable tumour’ of the gallbladder may in fact be xanthogranulomatous cholecystitis, a benign condition that frozen-section biopsy may confirm.
Helium pneumoperitoneum for laparoscopic cholecystectomy: Ventilatory and blood gas changes
Authors: McMahon A J , Baxter J N , Murray W , Imrie C W , Kenny G , O'Dwyer P J
Published: March 2007

Laparoscopic cholecystectomy with carbon dioxide pneumoperitoneum may result in hypercarbia and acidosis in patients with cardiorespiratory disease. The aim of the present study was to assess helium as an alternative to carbon dioxide for creating the pneumoperitoneum. Ventilation requirements and carbon dioxide levels were assessed at the beginning and end of laparoscopic cholecystectomy using helium (n = 30) and carbon dioxide (n = 30) pneumoperitoneum. Insufflation with helium did not result in an increase in ventilation requirement although, like carbon dioxide pneumoperitoneum, it was associated with a mean rise in peak airway pressure (of 7 cmH2O; P < 0·001). There was also a 3·2-kPa increase in the alveolar-arterial oxygen gradient with helium (P = 0·006). Carbon dioxide pneumoperitoneum was associated with a significant rise in arterial carbon dioxide levels, despite increasing ventilation. Four patients with helium pneumoperitoneum had surgical emphysema for 5 days. Helium may be a suitable alternative to carbon dioxide for creating pneumoperitoneum in patients with severe cardiorespiratory disease. However, because of its low water solubility helium has a lower safety margin than carbon dioxide in the rare event of gas embolism.
Cholelithiasis and bile acid absorption after truncal vagotomy and gastroenterostomy
Authors: Thompson D , Wild R , Merrick M V , Brydon G , MacIntyre I M C , Eastwood M A
Published: March 2007

Gallbladder disease in the form of gallstones demonstrated by ultrasonography or previous cholecystectomy was found in 15 of 26 women of median age 69 (range 52–82) years who had had truncal vagotomy and gastroenterostomy performed a median of 27 (range 11–30) years previously, compared with eight of 31 healthy age-and sex-matched controls drawn from the community (P < 0·02). Bile acid malabsorption identified by retention of 23-selena, 25-homotaurocholate (75SeHCAT) occurred in only two of the 26 patients after vagotomy and there was no relationship between retention and the presence or absence of gallbladder disease. The serum concentration of 7 α-hydroxycholestenone, an indicator of bile acid turnover, was significantly lower in patients with gallbladder disease after vagotomy than in controls (mean(s.e.m.) 19·1(3·7) versus 31·4(4·4) ng/ml, P < 0·05). Bile acid malabsorption does not play a significant role in the pathogenesis of gallstones after vagotomy but decreased bile acid synthesis may be important. There is no correlation between retention of 75SeHCAT and 7 α-hydroxycholestenone levels in patients after vagotomy, indicating that bile acid synthesis and absorption are uncoupled in this situation.
Taurolidine peritoneal lavage as prophylaxis against infection after elective colorectal surgery
Authors: Baker D M , Jones J A , Nguyen-Van-Tam J S , Lloyd J H , Morris D L , Bourke J B , Steele R J C , Hardcastle J D
Published: March 2007

A total of 300 patients undergoing elective colorectal surgery over a 3-year period were randomly assigned to receive intraoperative peritoneal lavage with either taurolidine or saline. Culture swabs were taken from the region of surgery before and after lavage and the development of postoperative infection monitored. Of the positive culture swabs before lavage, a significantly higher proportion were negative after lavage with taurolidine than after that with saline. However, there was no difference in the incidence of postoperative infection between groups, suggesting that taurolidine intraoperative peritoneal lavage confers no clinical benefit over that with saline.
Cancer of the colon and rectum in the West Midlands, 1957–1981
Authors: Allum W H , Slaney G , McConkey C C , Powell J
Published: March 2007

Between 1957 and 1981, 49 904 patients with large bowel cancer were registered at the Birmingham Cancer Registry. The annual incidence was 24·5 per 100 000 population for colonic cancer and 18·4 per 100 000 for that of the rectum. The annual number of patients increased by 41·9 per cent. The age-adjusted 5-year survival rate was 26·4 per cent for colonic carcinoma and 28·2 per cent for rectal cancer. Between 1977 and 1981 these rates increased significantly to 30·3 and 30·0 per cent respectively (P < 0·01). Stage for stage, colonic cancer was associated with longer survival than that of the rectum. Curative and palliative resection rates increased, especially for anterior resection. The operative mortality rate remained constant at 8 per cent. Despite increases in palliative resection rates 50 per cent of these patients required a stoma. Treatment was not undertaken in 37·4 per cent of patients. The end results of treatment are little better than those reported previously from this registry.