bluuebunny/crossref_metadata_2025 huggingface dataset:
Rectopexy for internal rectal intussusception
Authors: McCue J L , Thomson J P S
Published: March 2007

Twelve patients presented with symptomatic internal intussusception of the rectum between 1979 and 1987. All were women with a mean age of 55·5 years. Ten patients had symptoms of obstructed defaecation and only three were completely continent. Polyvinyl alcohol sponge abdominal rectopexy was performed in each patient. Over a mean follow-up period of 26·9 months there was no recurrence of internal intussusception. The functional results, however, were mixed but only one patient remained incontinent for solid stool. Rectal discomfort and defaecatory difficulties persisted; six patients continued to strain at stool and in three this was worsened by the operation. Abdominal rectopexy can be recommended for those with associated incontinence, significant rectal bleeding or solitary rectal ulcer but may not benefit those who have obstructed defaecation.
Perineal, vulval and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap
Authors: Skene A I , Gault D T , Woodhouse C R J , Breach N M , Thomas J M
Published: March 2007

Poor perineal healing is a major complication of total or partial pelvic exenteration especially when the pelvis and perineum have previously been irradiated. Perineal, vulval or vaginoperineal reconstruction was performed in five women using the inferiorly based rectus abdominis myocutaneous flap. Primary perineal wound healing occurred in all patients and no flap-related complications developed. Primary healing of abdominal wall wounds occurred in all patients without incisional hernia. Three of the patients had an anterior or total pelvic exenteration with continent urinary diversion by the Mitrofanoff technique. Two of the patients had complete vaginal reconstruction and one patient had after-loading catheters inserted for postoperative interstitial irradiation. The patients were in hospital for 42, 28, 21, 17 and 15 days respectively. The longest stays were associated with training for self-catheterization of the continent urinary diversion. Median follow-up was 9 months. One patient developed two perineal recurrences at 16 months which were resected, and she remains disease-free 6 months later.
Epidural analgesia in colonic surgery: Results of a randomized prospective study
Authors: Bredtmann R D , Herden H N , Teichmann W , Moecke H P , Kniesel B , Baetgen R , Tecklenburg A
Published: March 2007

Colonic surgery patients were studied to measure: the influence of continuous thoracic epidural analgesia (TEA) on a postoperative pain score, the time till onset of defaecation, blood loss, postoperative temperature elevations, rate of bacterial contamination of wounds and urine, and general surgical complications. Group I patients (n = 57) received general anaesthesia and TEA for the operation, followed by continuous TEA (0·25 per cent bupivacaine) for 72 h. Group IIpatients (n = 59) received general anaesthesia for the operation, followed by systemic analgesia on request. Significant beneficial effects of TEA in group I were demonstrated by lower pain scores in the first 24 h after surgery and earlier defaecation. However, there were fewer temperature elevations in group II. There was no significant difference between the groups in terms of positive bacteriological cultures, blood loss, need for postoperative mechanical ventilation and complications. However, there was a trend toward a higher rate of rectal anastomotic breakdown, increased blood replacement and intensive care therapy, and longer hospitalization in group I. These results do not suggest any significant beneficial therapeutic effect of continuous TEA in colonic surgery compared with a conventional systemic analgesic regimen. In selected patients (i.e. those with severe pain or those prone to develop postoperative ileus) continuous TEA may be beneficial.
Single layer anastomosis in the upper gastrointestinal tract
Authors: Irwin S T , Krukowski Z H , Matheson N A
Published: March 2007

A total of 466 single layer upper gastrointestinal anastomoses were made in 349 patients during an 11-year period. Six (1·3 per cent) anastomoses leaked. Radiological leakage was seen in one of 24 (4·2 per cent) oesophagogastricljejunal anastomoses. There were no leaks after 66 gastrojejunal anastomoses; one of 84 (1·2 per cent) gastroduodenal anastomoses leaked and was converted to a gastrojejunal anastomosis. Two of 121 (1·7 per cent) biliary-enteric anastomoses leaked and both were successfully managed without reoperation. Two of 171 (1·2 per cent) enteroenteric anastomoses leaked, both in patients with established intraperitoneal sepsis which proved fatal. Of the 349 patients, 13 (3·7 per cent) died in hospital or within 30 days of operation but in only two was anastomotic leakage implicated. Single layer appositional upper gastrointestinal anastomoses are simple, safe and economic.
Prediction of the delayed complications of intestinal and mesenteric injuries following experimental blunt abdominal trauma
Authors: Paterson-Brown S , Francis N , Whawell S , Cooper G J , Dudley H A F
Published: March 2007

Injuries to the intestine and mesentery are often found in patients undergoing laparotomy for blunt abdominal trauma. Although treatment of perforations is relatively straightforward, the same is not true for contusions. Few guidelines exist at present to aid the surgeon in deciding which injuries require resection in order to avoid the complications of delayed perforation and late stricture formation. The natural history of these non-perforating intestinal and mesenteric injuries has been examined in an experimental model to identify possible criteria on which future management can be based. In the immediate postinjury period peristalsis and local mesenteric pulsation were absent in the majority of injuries which went on to full recovery and these observations are thus of little predictive value in predicting outcome. The initial size of contusion (length of contusion along longitudinal axis of bowel) relative to bowel wall circumference (BWC) was related to complications as follows: contusion < BWC (n = 47) - one complication; contusion > BWC (n = 8) - three complications (P = 0·02). Similarly, six mesenteric injuries which produced an initial ischaemia (assessed by fluorescein) less than twice the BWC did not result in any complications, compared with four complications which occurred in ten cases when the initial ischaemia was greater than twice the BWC. These results go some way towards providing a better understanding of these injuries and in turn may help the emergency surgeon in deciding which injuries require resection.
Postoperative management of patients with total exocrine pancreatic insufficiency
Authors: Braga M , Zerbi A , Dal Cin S , De Franchis R , Malesci A , Di Carlo V
Published: March 2007

The occurrence of maldigestion and malnutrition was studied in 14 patients who had undergone pancreaticoduodenectomy and occlusion of the Wirsung duct with Neoprene®. Before discharge patients were put on a 70 g/day dietary fat intake. Mean faecal fat excretion was 32·9 g/day without enzyme replacement and fell to 14·2 g/day with pancrelipase supplementation. At discharge all patients were underweight (88 per cent of the usual mean body-weight) and nine patients showed alteration in laboratory nutritional parameters. At the time of discharge a low-fat diet (50 g/day) was prescribed. Six months after surgery, mean faecal fat excretion decreased further to 8·3 g/day (P < 0·01) and all patients but one gained weight, reaching 93 per cent of the usual mean body-weight with normalized nutritional parameters. Our data show that the combination of enzyme replacement therapy and low-fat diet allows good correction of steatorrhoea and a significant improvement in nutritional status.
Outcome of surgery for non-palpable mammographic abnormalities
Authors: Aitken R J , MacDonald H L , Kirkpatrick A E , Anderson T J , Chetty U , Forrest A P M
Published: March 2007

Four hundred and ninety-three women underwent 515 localization biopsies for non-palpable mammographic abnormalities. The mammographic abnormality was located with a hooked wire in 509 cases. Specimen radiology was performed on all excised tissue. The mammographic abnormality was visualized in the first piece of tissue excised in 402 (78·1 per cent) cases and complete excision was achieved in 476 (92·4per cent). A palpable nodule was removed in 38 (7·4 per cent) cases and in 17 (44·7 per cent) was shown to contain a carcinoma. The mammographic abnormality was missed in 14 (2·7 per cent) cases or only partly excised in 13 (2·5 per cent). Overall 144 (28·0 per cent) localization biopsies were malignant. The mammographic abnormality was not visualized on the specimen radiograph more frequently in women aged under 55 years, in women with dense breast (Wolfe grade DM or DY) or in those whose mammographic abnormality contained only microcalcification. The 27 women in whom the mammographic abnormality was not visible on the specimen radiograph underwent repeat mammography 2 months later. Only two women required a further localization biopsy and the mammographic abnormality was recovered in the first piece of tissue excised. Women with a carcinoma underwent mastectomy or wide local excision, and residual carcinoma at the localization biopsy site was found in 64 (44·4 per cent) cases. Oestrogen receptor analysis by ligand binding assay was possible in only 71 (49·3 per cent) carcinomas. If the specimen radiograph does not show the mammographic abnormality within pieces of tissue excised and there is no palpable nodule it may be best to conclude the biopsy. In this series these missed lesions were usually benign. Only rarely is a second localization biopsy required and this is performed without difficulty.
Original communications recurrence in early gastric cancer
Authors: Ichiyoshi Yuji , Toda Tomohiro , Minamisono Yoshikazu , Nagasaki Susumu , Yakeishi Youichi , Sugimachi Keizo
Published: March 2007

In a retrospective study of 503 cases of early gastric cancer, 17 of the patients had died of a recurrence of the gastric cancer and 72 had died of unrelated causes. The cumulative recurrence mortality rates were 2.2% at 9 years for mucosal cancer and 8.4% at 8 years for submucosal cancer. The recurrence patterns of early gastric cancer were hematogenic metastasis to the liver, lung, or bone (nine cases), recurrence from lymph nodes (three cases), and recurrence in the residual stomach (five cases). Submucosal cancers with a macroscopically elevated appearance, lymph node metastasis, and evidence of vessel invasion were the high-risk cancers for hematogenic recurrence, and adjuvant chemotherapy should be prescribed. Two cases of lymph node recurrence were attributed to inadequacy of lymph node dissection. Because metastasis to the group 2 lymph nodes was noted in 1.5% of cases of early gastric cancer and a macroscopic diagnosis of nodal status was inaccurate, complete dissection should be performed regardless of identification of metastasis. Five cases of recurrence in the residual stomach were attributed to overlooked lesions of multiple carcinoma and were detected at an advanced stage. Careful and regular postoperative follow-up is required to detect these recurrences at an early stage. (SURGERY 1990;107:489–95).
Changing patterns of incidence and mortality from acute pancreatitis in Scotland, 1961–1985
Authors: Wilson C , Imrie C W
Published: March 2007

Data on all discharges from hospitals in Scotland have been recorded since 1961 as the Scottish Hospital In-Patient Statistics and examination of these data has permitted analysis of the incidence and mortality trends from acute pancreatitis. The number of discharges recorded has increased 11-fold in males from 69 patients/year in 1961 to 750 patients/year in 1985, and fourfold in females from 112 patients/year to 484 patients/year respectively. This increase has occurred particularly amongst young and middle-aged males (20–59 years) and in elderly females (over 60 years), the most marked increases occurring in the health boards of the ‘central belt’ area of Scotland. Mortality rate did not show a corresponding change, increasing only two-fold in males from 15 patients/year to 30 patients/year and in females from 29 patients/year to 37 patients/year. As a consequence the case mortality rate has fallen from 17·8 per cent over the period 1961–65 to 5·6 per cent over the period 1981–85. An apparent increase in the incidence of acute pancreatitis may be inferred from these data, much of which is thought to be due to improved accuracy in diagnosis.
Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochal fistula
Authors: Baer H U , Matthews J B , Schweizer W P , Gertsch P , Blumgart L H
Published: March 2007

Several methods of handling the residual choledochal defects encountered during operation for type II Mirizzi syndrome have been described. Early experience with eight patients treated by a variety of procedures including direct suture and flap techniques led to disappointingly high morbidity and mortality rates. Since 1986 a standardized surgical approach has been used in four patients without complications or mortality. Essential to management are preoperative diagnosis by ultrasonography and endoscopic retrograde cholangiopancreatography and classification of the Mirizzi syndrome into two types as proposed by McSherry. Mirizzi type I consists of an extrinsic compression of the hepatic duct by a calculus impacted in the cystic duct or in Hartmann's pouch. This is treated by cholecystectomy with or without common bile duct exploration. In the more difficult Mirizzi type II, the stone has eroded into the hepatic duct causing a cholecystcholedochal fistula. This is treated by partial cholecystectomy and a cholecystcholedochoduodenostomy. This management strategy prevents inadvertent bile duct injury and has yielded satisfactory results.
Choice of incision and pain following gallbladder surgery
Authors: Armstrong P J , Burgess R W , Macgowan W A L
Published: March 2007

A prospective randomized trial compared pain in the first 24 h after gallbladder surgery via an upper midline or a transverse incision. Pain was measured by the patients' self-administered consumption of pethidine, degree of postoperative respiratory impairment and a visual analogue pain scale. The upper midline incision group self-administered significantly more pethidine than the transverse incision group (P<0–001), but there was no difference between the groups in respiratory function or visual analogue pain scale results 24 h after operation. Length of hospital stay was not different. An upper midline incision is more painful than a transverse incision in the first 24 h following gallbladder surgery.
Truncoumbilical bypass of the portal vein in radical resection of biliary tract tumour involving the hepatic duct confluence
Authors: Kumada K , Ozawa K , Shimahara Y , Morikawa S , Okamoto R , Moriyasu F
Published: March 2007

Before combined resection of the right hepatic lobe and the hepatoduodenal ligament, an autogenous external iliac vein was interposed between the root of the portal vein trunk and the umbilical portion of the vein in four patients with biliary tract tumour. The left hepatic arterial pathway was preserved, except in one case in whom resection of this artery was followed by reconstruction. This procedure allowed successful and safe extended right hepatic lobe resection and combined en bloc resection of the hepatoduodenal ligament while preserving hepatic blood perfusion.
Reduced water and sodium intakes associated with high levels of natriuretic factor following common bile duct ligation in the rabbit
Authors: Oms L , Martínez-Ródenas F , Valverde J , Jiménez W , Sitges-Serra A
Published: March 2007

Renal failure complicating obstructive jaundice (OJ) is probably linked to reduction of the extracellular water compartment. To elucidate the mechanism by which OJ leads to isotonic water depletion we studied a group of rabbits with OJ after common bile duct ligation (n = 17) and another group of sham operated rabbits (n = 14) for 10 days. Water intake and balance for two study periods (1–4 and 7–10 days after operation) were calculated. Renal function, sodium balance and plasma atrial natriuretic factor were determined on the fourth and tenth days after operation. Water intake and balance were lower in the OJ group both in the first study period (230 versus 519 ml/days 1–4, P<0–001; and—2·4 versus 279 ml/days 1–4, P < 0·0001 respectively) and in the second study period (260 versus 865 ml/days 7–10, P< 0·0001; and 11 versus 379 ml/days 7–10, P< 0·000 7 respectively). Sodium intake was negligible in the OJ group both on day four (0·73 versus 7·75 mM/24 h, P<0·0001) and on day 10 (0·78 versus 15·78 mM/24 h, P<0·0001). As a result plasma osmolality did not change. Day 10 urine osmolality and osmolar clearance were reduced in the OJ group (653 versus 1103 mOsm/kg, P<0·0001 and 0·09 versus 0·25 ml/min, P<0·0001 respectively) together with a decreased creatinine clearance (3 versus 77 ml/min, P<0·0001). Atrial natriuretic factor was increased in jaundiced rabbits (day 4, 22·7 versus 7·5 fmol/ml, P<0·0001; and day 10, 26·5 versus 11·2 fmol/ml, P<0·02). These findings suggest that OJ leads to an isotonic volume depletion resulting from abnormalities of the extracellular volume regulating mechanisms. These appear to be secondary to an inappropriate elevation of the atrial natriuretic factor plasma concentration.
Effect of defunction on cytokinetics and cancer at colonic suture lines
Authors: Appleton G V N , Davies P W , Williamson R C N
Published: March 2007

An intestinal suture line potentiates experimental carcinogenesis in its vicinity, probably due to adaptive hyperplasia. By contrast, a defunctioning colostomy causes distal hypoplasia, and fewer tumours develop. Male Sprague-Dawley rats (n = 160) were used to study adaptation (assessed by a stathmokinetic technique) and carcinogenesis (induced by azoxymethane) at an end-to-end anastomosis that was raised in either functioning or defunctioned left colon. Controls had no procedure and other rats had proximal colostomy alone. Defunction had a profound antitropic effect on the colon, reducing bowel length and weight and crypt cell production rate (CCPR) by 22–56 per cent. Anastomotic CCPR was increased by a factor of 2–6 over controls: mean(s.e.m.) values of 12·71(2–85) versus 4·87(0·41) cells/crypt/h (P<0·01), but defunction reduced this by 76per cent to a mean(s.e.m.) value of 3·00(0·52) cells/crypt/h below that in the intact colon. In the left colon, 39–50 per cent of tumours were sited at the anastomosis. Compared with controls there were 77 per cent fewer tumours in defunctioned colon, but they still favoured the site of anastomosis. Neoplasms at the colostomy site accounted for 74–77 per cent of all right-sided tumours. Anastomosis and defunction have powerful but contrasting effects on colonic adaptation and carcinogenesis; when combined they tend to cancel each other out.
Constipation: Another indication for restorative proctocolectomy
Authors: Hosie K B , Kmiot W A , Keighley M R B
Published: March 2007

We have extended our experience of restorative proctocolectomy and ileoanal anastomosis to include 13 patients with functional bowel disorders. Eight had recurrent constipation after colectomy for slow transit constipation and five had constipation and overflow incontinence associated with megarectum and megacolon. In all cases the only alternative was a permanent stoma. Despite a high complication rate, 11 patients (85 per cent) felt that the operation had been worthwhile with improvement of their symptoms and quality of life. The operation led to a mean frequency of defaecation of 4·8 times (range 2–8) during the day, and 1·2 times (range 0–4) during the night. There was no frank incontinence and, while only one patient experienced soiling during the day, six patients suffered from night-time soiling. Two patients have had the pouch converted to an ileostomy due to persistent complications and a poor functional result.
Coeliac artery compression syndrome: The effect of decompression
Authors: Geelkerken R H , van Bockel J H , De Roos W K , Hermans J
Published: March 2007

The effects of operation to decompress the coeliac artery were evaluated in 11 consecutive patients with coeliac artery compression syndrome. Immediately after the operation all patients were free of symptoms. Three months later three of the 11 had recurrent abdominal pain. Long-term follow-up between 15 and 23 years, obtained by questionnaire, was available for eight patients. All eight had return of symptoms similar to those before surgery. These unsatisfactory results suggest that operation should not be undertaken in patients with vague upper abdominal complaints and compression of the coeliac artery by the median arcuate ligament, who do not otherwise have pathological conditions which might explain their symptoms.
The role of interventional radiology for complications of cholecystectomy
Authors: van Sonnenberg Eric , Casola Giovanna , Wittich Gerhard R , Christensen Ross , Varney Robert R , Neff Courtney C , D'Agostino Horacio B , Moossa A R
Published: March 2007

This report summarizes diagnostic and therapeutic radiologic procedures in 45 patients who suffered major complications from cholecystectomy. Complications were divided into (1) bile duct injury or ligation and (2) a variety of pathologic fluid collections. Specific lesions were bile duct injury (n = 6), accidental bile duct ligation (n = 12), ductal stricture (n = 12), abscess (n = 11), biloma (n = 7), hematoma (n = 5), infected pancreatic pseudocyst (n = 3), and stones (n = 2). Presenting problems were sepsis, jaundice, and intermittent cholangitis. The patients underwent 104 interventional radiologic procedures including 29 percutaneous transhepatic cholangiograms, 21 percutaneous biliary drainages, 12 balloon dilatations of strictures, drainage of 11 abscesses, 8 bilomas, 5 hematomas, and 3 pancreatic pseudocysts. Stones were removed by baskets in 2 patients; 12 pressure and perfusion studies were performed. One hundred of 104 procedures were successful; there was one failed biliary drainage, one unsuccessful stricture dilatation, one unsuccessful hematoma drainage, and one recurrent biloma. Thirty patients were spared another operation. The percutaneous procedures were beneficial although not curative in 14 of 15 patients who underwent reoperation; in those patients the procedures helped to establish a diagnosis, improve the patient's preoperative status, or serve as a landmark for the surgeon to locate and repair the ligated or injured duct. One patient died after reoperation, a 2.2% mortality rate. Sectional imaging studies combined with interventional radiologic procedures help to diagnose promptly and effectively treat major complications of cholecystectomy. These interventional procedures either cure the complication and obviate reoperation or aid the surgeon by relieving sepsis and jaundice before reoperation and providing an intraoperative guide for bile duct reconstruction. (SURGERY 1990;W7:632–8.)
Percutaneous endoscopic gastrostomy
Authors: Moran B J , Taylor M B , Johnson C D
Published: March 2007

The many variations of surgical gastrostomy for nutritional support or for long-term gastric decompression all have a significant morbidity and mortality. An ‘incisionless’ technique under local anaesthesia, namely percutaneous endoscopic gastrostomy, was described in 1980. A review of the literature shows that the percutaneous technique is safer for the patient, easier and faster to perform and considerably cheaper than surgical gastrostomy. As the few complications usually require surgical management, percutaneous endoscopic gastrostomy should be considered a surgical technique. Few patients are unsuitable for the percutaneous endoscopic technique and this route should be considered for all patients referred for a gastrostomy.
Surgical management of anorectal disease in HIV-positive homosexuals
Authors: Miles A J G , Mellor C H , Gazzard B , Allen-Mersh T G , Wastell C
Published: March 2007

One thousand and ninety human immunodeficiency virus (HIV)-positive homosexual or bisexual males were seen in one hospital for management of HIV disease over a 9-year period. One hundred and fifty-five patients were referred by acquired immunodeficiency syndrome (AIDS) physicians for general surgical management. The most frequent reason for surgical referral (64 patients) was anorectal disease which occurred in 5·9 per cent of all HIV-positive patients. One or more diagnoses were reached in 61 of the 64 patients referred with anorectal disease: warts (38 per cent of diagnoses), anorectal ulceration (26 per cent), perianal sepsis (15 per cent), neoplasia (14 per cent) and haemorrhoidal disease (8 per cent). Anorectal symptoms were relieved in 68 per cent of patients and the median survival of those treated was 17·5 months from the time of surgical referral. Both warts and perianal sepsis were associated with in situ neoplasia, but no case of progression from in situ to invasive anal squamous carcinoma was detected. The aetiology of anorectal ulcers was not clear, but surgical excision of anal ulcers and skin tags can produce healing. Palliation of anorectal symptoms in HIV-positive homosexual patients is possible but some conditions are unusual and surgeons should be familiar with their presentation and management.
Mutagenicity of bile and duodenal adenomas in familial adenomatous polyposis
Authors: Spigelman A D , Crofton-Sleigh C , Venitt S , Phillips R K S
Published: March 2007

Duodenal adenomas occur almost inevitably in patients with familial adenomatous polyposis (FAP) whereas gastric adenomas are rare. FAP patients are also at high risk of duodenal cancer. Within the duodenum, adenomas cluster around the ampulla of Vater, as do the majority of duodenal cancers, suggesting that bile plays a role in tumour development. We therefore tested duodenal bile from 29 postcolectomy FAP patients (27 of whom had duodenal adenomas) and 24 non-FAP patients for mutagenicity, using techniques that detect point mutations in bacteria. Results which appeared to show that FAP bile was more mutagenic than control bile could be accounted for by a feeding effect, elimination of which also eliminated ‘mutagenicity’. Under the conditions of our assays we conclude that if bile is an important factor in genesis of duodenal tumours, it does not act by inducing point mutation.
Fistulotomy without external sphincter division for high anal fistulae
Authors: Kennedy H L , Zegarra J P
Published: March 2007

Thirty-two patients with high trans-sphincteric or suprasphincteric fistulae underwent fistulotomy without external sphincter division. Fifteen patients had posterior fistulae involving the deep postanal space and 17 patients had anterior fistulae. Primary healing, after removal of the seton, occurred in 25 of the 32 patients (78 per cent). Primary healing in patients with posterior fistulae occurred in 66 per cent and in 88 per cent of patients with anterior fistulae. Following surgery, eight patients (33 per cent) reported problems controlling flatus, six patients (25 per cent) reported mucous discharge and one patient (4 per cent) complained of occasional incontinence for liquid stool. No patient experienced problems controlling solid stool nor did any patient require the use of a protective pad. These results have encouraged us to use this method as the initial procedure of choice for these more difficult fistulae. A significant number of patients can be cured of their fistula while preserving the external sphincter, thereby minimizing the impact of surgical therapy on continence.
Penetrating visceral injuries of the neck: Results of a conservative management policy
Authors: Ngakane H , Muckart D J J , Luvuno F M
Published: March 2007

A study of the conservative treatment of 109 patients with penetrating neck injuries was carried out over 3 years. Patients with clinical or radiological evidence of injury to the oesophagus or trachea were included in the study while nine patients with major vascular trauma were explored immediately and excluded. Three late vascular operations were performed. The remaining 106 patients were treated conservatively. There were two deaths, both from associated injuries. The remaining 104 patients were treated successfully with only three cases of minor wound sepsis. We conclude that oesophageal and tracheal injuries after stab injuries and low velocity gunshot wounds can be treated successfully by non-operative treatment.
Unremarkable parotid tumours that prove to be malignant
Authors: Nnochiri C C , Watkin G T , Hobsley M
Published: March 2007

Of 539 patients with clinically unremarkable lumps treated by formal parotidectomy, subsequent histological examination indicated that 20 of these lesions were malignant. After a follow-up of 1–18 years, only one patient has suffered a recurrent tumour and none has died from disease related causes. The results indicate that formal parotidectomy is an acceptable means of treating the small number of malignant tumours presenting in this way, and strengthen the argument that attempts to obtain a histological diagnosis before treatment are contraindicated.
Effect of branched chain amino acid enrichment of total parenteral nutrition on nitrogen sparing and clinical outcome of sepsis and trauma: A prospective randomized double blind trial
Authors: von Meyenfeldt M F , Soeters P B , Vente J P , van Berlo C L H , Rouflart M M J , De Jong K P , van der Linden C J , Gouma D J
Published: March 2007

Administration of extra branched chain amino acids (BCAA) has been associated with a nitrogen sparing effect in septic and traumatized patients. Whether nitrogen sparing is associated with decreased morbidity and mortality rates is unknown. We therefore undertook a prospective, randomized, double blind trial investigating the effects of BCAA enrichment of a total parenteral nutrition (TPN) regimen on nitrogen balance, 3-methylhistidine excretion, morbidity as evidenced by disturbances in organ function, severity of sepsis and mortality. One hundred and one patients entered the study; 52 received a standard TPN solution and 49 a BCAA-enriched solution. Both groups received 30 kcal kg−1 body-weight, 15 per cent fat calories and 0·17g nitrogen kg−1 body-weight. In the BCAA-enriched group, patients received 0·56 g BCAAkg−1 body-weight (50·2 per cent BCAA). Standard group patients received 0·18g BCAA kg−1 body-weight (15·6 per cent BCAA). Nitrogen balances and 3-methylhistidine excretion were not significantly different between groups. Although morbidity scores tended to decrease during the study, no difference was observed between groups. Mortality (early or late), sepsis or stress-related, did not differ significantly between groups. We were not able to confirm the reported beneficial effects of BCAA-enriched TPN solutions for use in septic and traumatized patients.
Adenocarcinoma of the cardia: Treatment by thoracoabdominal R3 radical gastrectomy
Authors: Griffin S M , Chung S C S , Woods S D S , Li A K C
Published: March 2007

The complications and mortality rate of R3 radical gastrectomy using a left thoracoabdominal approach were studied in 38 patients with adenocarcinoma of the gastric cardia. There were two hospital deaths and two anastomotic leaks. There was a high rate of complications following surgery (subphrenic abscess, eight; severe chest infection, five; aspiration pneumonia, two; wound infection, two; and reactivation of tuberculosis, one). The hospital stay ranged from 11 to 39 days (median 21 days). Thirty-five patients had microscopic evidence of serosal involvement (S2). Thirty-three of the patients had lymph node metastases and 17 patients had involvement of N2 nodes. Four patients had histological evidence of residual suture line tumour, but only two of these returned with recurrence at the anastomosis. Follow-up (median 3 years) revealed that splenic artery nodal involvement (N2) did not worsen the prognosis after radical resection. Despite a high complication rate, thoracoabdominal radical gastrectomy is associated with an acceptable perioperative mortality rate, adequate symptom palliation and encouraging medium-term survival. The left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of this tumour.
The “Right Stuff”: Five nobel prize–winning surgeons
Authors: Morris Jon B , Schirmer William J
Published: March 2007

Alfred Nobel's will specified that his estate be placed in a fund, the interest of which was to be distributed on an annual basis “to those who during the preceeding year had conferred the greatest benefit on mankind.” The first Nobel Prize in Physiology or Medicine was awarded in 1901, and its receipt is widely regarded as one of the highest accolades in science. This article reflects upon five surgeons who have been recognized as worthy of this honor. They are Emil Theodore Kocher, Alexis Carrel, Frederick Grant Banting, Werner Theodor Otto Forssman, and Charles Brenton Huggins. By winning this coveted prize these men have elevated the discipline of surgery to the summit of the scientific world. We review their legacy as an inspirational reminder of what we, the future of surgery, are capable. (Surgery 1990;108:71–80.)

There is a most intimate interdependence of physiology, pathology and surgery. Without progress in physiology and pathology, surgery could advance but little, and surgery has paid its debt by contributing much to the knowledge of the pathologist and physiologist, never more than at the present time.1—William Stewart Halsted, 1904.
Surgical aspects of malaria
Authors: Gibney E J
Published: March 2007

The spread of drug-resistant organisms and increased international travel makes malaria a disorder of ever-increasing importance. This report reviews those aspects of malaria of surgical relevance. The importance of the spleen in host defence against malaria and other infections makes splenic preservation desirable whenever possible after rupture of the spleen. Tropical splenomegaly is caused by an abnormal immune response to malaria and is best managed medically. Careful selection of blood donors is essential to prevent transfusion malaria, and routine antimalarial prophylaxis is indicated for blood recipients in many endemic areas. The risk of postoperative malaria may justify chemoprophylaxis in certain patients.
Pylorus preserving pancreatoduodenectomy: An overview
Authors: Grace P A , Pitt H A , Longmire W P
Published: March 2007

Pylorus preserving pancreatoduodenectomy (PPPD) was reintroduced 12 years ago. Since that time, over 400 patients have undergone PPPD with approximately 41 per cent having chronic pancreatitis and 54 per cent having pancreatic and other periampullary malignancies. Reported 5-year survivals in this latter group have been comparable to those achieved by the classic Whipple procedure. The postoperative mortality rate in 339 reported patients has been 3·8 per cent. Postoperative morbidity, including delayed gastric emptying, has been similar to that of the classic Whipple operation. However, PPPD has been associated with fewer late problems with dumping, diarrhoea, delayed gastric emptying (8·6 per cent), and marginal ulceration (3·6 per cent). Moreover, most patients undergoing PPPD have been able to return to their preoperative and preillness weight. The additional advantage of decreased operative time makes PPPD an attractive alternative to the classic pancreatoduodenectomy.
Operative choledochoscopy: Common bile duct exploration is incomplete without it
Authors: Motson R W , Wetter L A
Published: March 2007

This paper reviews the reported experience of operative choledochoscopy. Development of choledochoscopes to the currently available rigid and flexible instruments is described. The collected results of both rigid and flexible choledochoscopy are reported. Retained stones occurred in 97 of 2712 stone-positive explorations with the rigid choledochoscope (3·6 per cent) and in 35 of 1726 stone-positive explorations with the flexible choledochoscope (2·0 per cent). Choledochoscopy should now be a mandatory part of common bile duct exploration.
Mucosal intussusception to avoid ascending cholangitis
Authors: Yeh T-J , Chin T-W , Tsai W-C , Weim C-F
Published: March 2007

Many methods have been devised to prevent ascending cholangitis following Kasai's hepatic portoenterostomy for biliary atresia. To investigate the effectiveness of mucosal intussusception in preventing ascending cholangitis, 20 mongrel dogs were randomized to undergo Roux-en-Y cholecystjejunostomy and common bile duct ligation with or without mucosal intussusception. Aeromonas hydrophila was instilled into the gastrointestinal tract. Bacterial cultures were grown from samples taken from the gallbladders and lower jejunum, and blood chemistry and barium studies were performed. The barium studies showed satisfactory lack of reflux in all ten dogs with mucosal intussusception. Only two of them had positive cultures for Aeromonas from the gallbladder 3 days after bacterial instillation into the jejunum. All ten dogs in the control group had positive cultures for Aeromonas from the gallbladder. Our results showed that the mucosal intussusception group had a significantly lower rate of recovery of organisms from the gallbladder compared with the control group when the organisms were instilled into distal intestine (P < 0·05). The method is worthy of clinical trial as a means of preventing or treating ascending cholangitis.
Papillary cystic neoplasm of the pancreas: Radiological and pathological characteristics in 11 cases
Authors: Yamaguchi K , Hirakata R , Kitamura K
Published: March 2007

Clinical charts, radiological features, macroscopic and microscopic findings, and clinical follow-up data were retrospectively reviewed in 11 patients with papillary cystic neoplasm of the pancreas (PCNP). The patients were nine women and two men, aged from 13 to 51 years with a mean age of 25 years. The greatest diameter of the PCNPs ranged from 2·5 cm to 14·0 cm with a mean size of 7·5 cm. Six tumours were located in the tail of the pancreas, two in the body and three in the head. Most patients complained of abdominal pain or a mass. Ultrasonographic and/or computed tomography findings showed five solid, four mixed (solid and cystic) and two cystic types of tumour. Angiographically, PCNP was either a hypovascular or mild hypervascular mass with a displacement of the surrounding vessels. No vascular encasement was seen. Macroscopically all 11 tumours consisted of a well defined solid mass with degenerative change of various widths, including haemorrhage, necrosis or dystrophic calcification, and were represented by three radiological types of PCNP. The 11 patients with PCNP survived for from 3 to 253 months after curative resection without any signs of local recurrence or remote metastasis. PCNP usually affects the distal portion of the pancreas of young women. Despite its huge size, PCNP should be explored with aggressive surgical intent because of the inherently good prognosis.
Choice of emergency operative procedure for bleeding duodenal ulcer
Authors: Hunt P S , McIntyre R L E
Published: March 2007

In a consecutive series of 201 emergency operations in patients with bleeding duodenal ulcer the size of the ulcer was the only factor that showed a significant correlation with the procedure chosen. Vagotomy, pyloroplasty and underrunning of the bleeding point was performed in 101 cases with ten deaths (10 per cent), partial (Billroth II) gastrectomy in 81 cases with ten deaths (12 per cent), and vagotomy and antrectomy in 16 cases with one death (6 per cent). A patient was more likely to be treated by partial gastrectomy if a giant ulcer with an internal diameter of ⩾ 2 cm was found. The results suggest that while vagotomy and pyloroplasty, combined with a direct attack on the bleeding point or excision of an anterior ulcer is an acceptable standard emergency operation for bleeding duodenal ulcer, gastric resection proved to be a satisfactory alternative procedure and should be considered in the technically difficult case with a very large ulcer. A giant ulcer was present in 37 per cent of cases coming to surgery.
Feeding regimens after pyloromyotomy
Authors: Wheeler R A , Najmaldin A S , Stoodley N , Griffiths D M , Burge D M , Atwell J D
Published: March 2007

In a prospective randomized study three different feeding regimens after operation were compared in 74 babies with infantile hypertrophic pyloric stenosis: gradual regrading of feeds over 48 h (regimen J), rapid regrading of feeds over 16 h (regimen 2), and initial starvation followed by full normal feeds at 24 h (regimen 3). No significant difference between the treatment groups was found either in episodes of vomiting after operation (regimen 1, 2·9 episodes in 21 patients; regimen 2, 3·6 episodes in 28 patients; regimen 3, 3·6 episodes in 25 patients) or in the mean duration of postoperative hospital stay (regimen 1, 59·3 h; regimen 2, 47·8 h; regimen 3, 56·7 h). We conclude that vomiting following pyloromyotomy is self-limiting and independent of the timetable or composition of the postoperative dietary regimen.
Resympathectomy of the upper extremity
Authors: van Rhede van der Kloot E J H , Jörning P J G
Published: March 2007

Resympathectomy was performed in 27 patients (eight bilaterally) with ischaemic hand phenomena. An extended operative technique, resecting parts of the second and third intercostal nerves and their surrounding tissue, was used. In all 35 procedures the posterior extrapleural approach was used. Follow-up was from 3 to 12 years. Only the sympathetic ganglia had been removed during the previous surgery by the axillary approach (67 per cent of these patients had had a transient response for between 6 months and 2 years; 33 per cent had had no response at all). A direct subjective improvement was seen after 27 of the 35 reoperations (77 per cent). In 14 patients continuous wave Doppler ultrasound studies were available and showed a significant increase in peak forward frequency after operation (P < 0·001). From these data it may be concluded that it is possible to obtain a resympathectomy effect, but reoperation should be reserved for special cases for whom survival of digits is essential.
Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis
Authors: Byrne J , Walsh T N , Hederman W P
Published: March 2007

Endoscopic transthoracic electrocautery of the sympathetic chain has been the preferred treatment for palmar or axillary hyperhidrosis in this unit since 1980. A retrospective study was carried out of the first 112 patients with case material derived from a postal questionnaire, chart review and outpatient assessment. Eighty-five patients undergoing bilateral transthoracic electrocautery who replied to the questionnaire (76 per cent response rate) form the basis of this study. There were 65 females and 20 males with a mean age of 24·3 years (range 15–40 years). The hands alone were affected in 20 patients (24 per cent), the axillae alone in 17 (20 per cent) and both areas in 48 (56 per cent). Mean hospital stay was 3·1 days (range 1–7 days). Outcome was assessed by 92 per cent of patients immediately after operation as ‘very much improved’ or ‘moderately improved’, and this assessment persisted in 85 per cent after a mean follow-up of 43 months (range 3–95 months). Cosmetic results were rated as satisfactory by 95 per cent. Apart from pain after operation, morbidity was limited to transient Homer's syndrome in three patients, surgical emphysema in three, and pneumothorax requiring a chest drain in one. A repeat procedure was needed in one patient because of an inadequate first operation. Some compensatory hyperhidrosis occurred in 54 (64 per cent) patients. As a minimally invasive procedure, endoscopic transthoracic electrocautery should be considered the treatment of choice for palmar and axillary hyperhidrosis.
Transcutaneous oxygen tensions in assessing the treatment of healed venous ulcers
Authors: Stacey M C , Burnand K G , Layer G T , Pattison M
Published: March 2007

Transcutaneous oxygen tension (Ptc,O2) was assessed as an indicator of risk of reulceration in 68 limbs with healed venous ulcers. Ptc,O2 was also used to assess two methods of ulcer prophylaxis. Measurements were made over the gaiter skin, the healed ulcer and the upper arm. The results were expressed as a ratio of the lower limb readings over those taken from the arm. Patients were randomized, after the ulcer had healed, to elastic stockings and stanozolol, or elastic stockings and surgical ligation of incompetent superficial veins. Patients who declined to participate in the study were prescribed elastic stockings only. Those limbs remaining healed at 12 months had Ptc,O2 ratios remeasured. The Ptc,O2 ratios from limbs that reulcerated were not significantly lower than those from limbs remaining healed. The Ptc,O2 ratio was significantly increased in limbs treated by stanozolol and elastic stockings (P < 0·05) and by surgery and elastic stockings (P < 0·05). There was no significant increase in Ptc,O2 in limbs treated by elastic stockings alone. In those treated by surgery and elastic stockings, there was a significant improvement in limbs with normal deep veins (P < 0·07), but not in limbs with post-thrombotic changes on ascending phlebography. Although these two methods of ulcer prophylaxis improve the Ptc,O2 ratio, a high ratio has not been shown to be beneficial in preventing ulcer recurrence.
Venous stasis and vein lumen changes during surgery
Authors: Coleridge-Smith P D , Hasty J H , Scurr J H
Published: March 2007

The mechanisms underlying the development of postoperative deep vein thrombosis remain to be fully elucidated. Previous studies have suggested that peroperative venous distension may be a factor associated with venous thromboembolism. In this study we have obtained high resolution ultrasound images of gastrocnemius and posterior tibial veins in 62 patients undergoing a range of general surgical procedures. From these we determined the changes in vein diameter occurring during the operative procedures, in response to induction of anaesthesia, and after completion of surgery. Veins showed no evidence of dilatation in response to the induction of anaesthesia, but by the end of the operative procedure showed distension of 22–28 per cent. Distension was most prominent in the gastrocnemius veins, and lesser distension was observed in the posterior tibial veins. In a series of patients who received an infusion of 1 litre of saline in addition to basal requirements, distension was 57 per cent compared with 22 per cent in the corresponding control group. Intraoperative venous distension is associated with factors that lead to deep vein thrombosis and may be involved in the mechanisms which result in the commencement of deep vein thrombosis.
Human Kupffer cells are cytotoxic against human colon adenocarcinoma
Authors: Roh Mark S , Wang Leslie , Oyedeji Caroline , LeRoux M Elena , Curley Steven A , Pollock Raphael E , Klostergaard Jim
Published: March 2007

Colorectal liver metastases are a common clinical problem and require more effective therapy. Kupffer cells (KC) perform many important homeostatic functions within the liver and may also possess the ability to mediate tumor cytotoxicity. We investigated the ability of human KC to mediate cytotoxicity against human colon adenocarcinoma targets (HT 29) in vitro. Unstimulated human KC were cytotoxic against the HT 29 targets at all effector/target ratios tested. This cytotoxicity was increased significantly (p < 0.05) when the KC were stimulated with interferon-γ and lipopolysaccharide. Human KC produced tumor necrosis factor (TNF), and KC stimulation significantly (p < 0.05) increased secretion of this monokine. The addition of anti-TNF antibody to the KC-HT 29 cocultures completely neutralized all of the available TNF yet cytotoxicity was not affected, suggesting the participation of a membrane-bound form of TNF or other mechanisms.