bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of a single layer continuous hand-sewn method and circular stapling in 580 oesophageal anastomoses
Authors: Fok M , Ah-Chong A K , Cheng S W K , Wong J
Published: March 2007

A total of 611 patients with carcinoma of the oesophagus or gastric cardia were operated on between July 1982 and December 1989. Resection was performed in 491 patients (one-stage, 483; two-stage, eight), bypass operation in 97, and 23 had exploration alone. The anastomoses of 580 patients with one-stage resection and bypass operations were evaluated. Hand-sewn anastomosis using a single layer of continuous absorbable monofilament suture was performed in 304 patients (221 resections and 83 bypasses). A stapled anastomosis was performed on 276 patients (262 resections and 14 bypasses). Following resection, there were 11 (5 per cent) anastomotic leaks in the hand-sewn group and ten (3·8 per cent) in the stapled anastomosis group (P = 0·69). Excluding anastomotic leaks, hospital mortality and anastomotic recurrence, stricture occurred in 18 of 172 hand-sewn anastomoses (10·5 per cent) and in 57 of 195 stapled anastomoses (29·2 per cent) (P < 0·001). In patients who had bypass operations there were 12 anastomotic leaks, ten in the hand-sewn group (12·0 per cent) and two in the stapled anastomosis group (14·3 per cent). Only two of the discharged patients with bypass developed anastomotic strictures, a low incidence probably because of short survival. In addition, there were 245 subsidiary anastomoses made in the abdomen by the hand-sewn method as part of the reconstructive procedure, and there was one leak. The results of this non-randomized study suggest that hand-sewn anastomosis using a single layer continuous technique for the oesophagus is as safe as the use of circular staplers; hand-sewn anastomosis is less likely to become stenotic.
Confirmation of endosonographic detection of external anal sphincter defects by simultaneous electromyographic mapping
Authors: Burnett S J D , Speakman C T M , Kamm M A , Bartram C I
Published: March 2007

Anal endosonography was performed in 13 consecutive patients with post-traumatic faecal incontinence. Thirteen acoustic defects in the external anal sphincter (two hyperechoic, four of mixed echogenicity and seven hypoechoic) were analysed electromyographically by locating under ultrasound guidance the tip of a concentric needle within the defect. The electromyographic activity in this zone was compared with ultrasonically normal muscle. Eleven of 13 sonographic defects showed no electrical activity on electromyography, there was one technical electromyography failure, and one defect was too deep to be reached by the electromyography needle. The electromyographic response was normal in each case within ultrasonically normal muscle. Anal endosonography is recommended as the initial investigation to locate defects, which may be confirmed electromyographically thereby limiting the number of painful needle insertions required for complete mapping of the external anal sphincter.
Long-term results of choledochoduodenostomy in the treatment of choledocholithiasis: Assessment of 225 cases
Authors: Parrilla P , Ramirez P , Bueno F Sanchez , Perez J M , Candel M F , Muelas M S , Robles R
Published: March 2007

During a 10-year period 2610 patients were operated on for biliary lithiasis; in 225 (8·6 per cent) cases the operation concluded with a choledochoduodenostomy. The commonest preoperative diagnosis (62·2 per cent) in these 225 patients was choledocholithiasis; 30 patients had previously had a cholecystectomy. After choledochoduodenostomy, 4·0 per cent of patients had an intra-abdominal complication; six patients developed an intra-abdominal abscess and three developed an external biliary fistula. Four patients (1·8 per cent) died, three from pulmonary complications and one from a biliary fistula. After a mean follow-up period of 4·6 years, 71·5 per cent of patients were asymptomatic. The remainder suffered from dyspepsia (15·1 per cent), colicky pain (8·7 per cent) or episodes of cholangitis (4·7 per cent). Endoscopy in the symptomatic patients allowed the following conclusions: (a) no patient with dyspepsia had a problem at the anastomosis; (b) 27 per cent of those with colic had anastomotic stenosis or the sump syndrome; and (c) all patients with cholangitis had anastomotic stenosis and residual calculi.
Selective uptake of glutamine in the gastrointestinal tract: Confirmation in a human study
Authors: Mc Anena O J , Moore F A , Moore E E , Jones T N , Parsons P
Published: March 2007

Recent animal data suggest that the gut plays a far more important metabolic role than previously thought. During critical illness, disruption in bowel barrier function may result in a chronic hypermetabolic state and contribute to multiorgan failure. Animal studies have demonstrated that enterocytes of the gastrointestinal tract use glutamine as a respiratory fuel and during critical illness the consumption of glutamine by the gut significantly increases. The selective uptake of glutamine by the gut, to date, has not been confirmed in humans. Seven patients who sustained multisystem trauma necessitating laparotomy underwent portal venous catheterization. This was done by carefully reopening the obliterated umbilical vein and facilitating access to the left branch of the portal vein using a standard central venous catheter. Portal venous and systemic blood samples were recorded for 5 days after operation. Amino acid levels in both circulations were recorded at 48 h and 5 days. Using Student's t test for related samples, the differences between individual amino acids in portal and systemic circulations were compared. At 48 h, mean(s.d.) portal venous glutamine was 85(5) per cent of the systemic levels (253(80) compared with 296(90) μmol/ml, P<0·002). At 5 days, portal glutamine was 87(3) per cent of the systemic levels (255(69) compared with 292(83) μmol/ml, P<0·003). Levels of citrulline, a breakdown product of glutamine metabolism, were elevated in the portal venous circulation at 48 h (20(4) compared with 16(3) μmol/ml, P<0·005) and at 5 days (21(5) compared with 14(3) μmol/ml, P<0·002). No significant differences between any of the other amino acids analysed were identified. This study confirms, for the first time in humans, that selective uptake of glutamine occurs in the gut. In stressed states, glutamine deficiency is associated with gut mucosal atrophy. This has significant implications as glutamine is not provided in most commercially available parenteral and enteral nutrition formulations.
Stimulation of protein synthesis in human tumours by parenteral nutrition: Evidence for modulation of tumour growth
Authors: Heys S D , Park K G M , McNurlan M A , Milne E , Eremin O , Wernerman J , Keenan R A , Garlick P J
Published: March 2007

Eighteen patients with localized colorectal carcinoma were randomized to receive intravenous nutrition or to be fasted during the 24 h before surgery. Protein synthesis, an index of tumour growth, was then measured by the incorporation of [13C]/eucine into tumour protein immediately before surgery. The mean(s.e.m.) rate of tumour protein synthesis in patients receiving nutrition (42·7(3·5) per cent per day) was 89 per cent higher than the rate in the fasted group (22·6(1·9) per cent per day) (P = 0·002). As tumours consist of a variety of different cell types, in vitro rates of protein synthesis were measured in malignant cells isolated from colorectal tumours and cultured with autologous serum obtained from the patient in either the fasted or the fed state. There was a mean increase of 81 per cent in protein synthesis when fed rather than fasted serum was used (P<0·02), indicating that the malignant cells themselves respond to nutrient supply. This increase in tumour protein synthesis provides the first evidence in vivo that the exogenous supply of nutrients can modulate the rate of growth of a human tumour.
Carbon dioxide laser ablation of cutaneous metastases from malignant melanoma
Authors: Waters R A , Clement R M , Thomas J Meirion
Published: March 2007

Multiple cutaneous and superficial subcutaneous metastases from malignant melanoma in 30 patients were treated palliatively by carbon dioxide laser ablation when lesions were too numerous, too large or recurring too rapidly for multiple local excisions. The number of lesions per patient ranged from three to 250 (median 30). Patients were treated under local or general anaesthetic and as day cases or inpatients. After a median follow-up interval of 8 months fewer than 1 per cent of lasered metastases have recurred locally. Sixteen patients have developed cutaneous metastases at other sites requiring further treatment. Approximately 2000 lesions have been treated on 64 occasions. Patients reported little or no pain after the operation and required only simple dry dressings. Wounds were completely healed in 2–6 weeks with good cosmetic results. This simple and effective treatment is becoming an alternative to isolated limb perfusion.
Acute necrotizing pancreatitis: Management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains
Authors: Sarr M G , Nagorney D M , Mucha P , Farnell M B , Johnson C D
Published: March 2007

We reviewed our recent experience with management of 23 consecutive patients with acute necrotizing pancreatitis. All patients had documented necrotizing pancreatitis with parenchymal or peripancreatic necrosis. Our method of treatment has evolved from our previous approach of controlled open lesser sac drainage (marsupialization) to staged necrosectomy I debridement with delayed primary closure over drains. With this latter approach, hospital mortality was 4 of 23 patients (17 per cent), but significant morbidity still occurred in 12 of 23 patients (52 per cent). However, recurrent intra-abdominal abscess before discharge occurred in only one patient. We believe that this operative approach toward the severely ill patient with acute necrotizing pancreatitis who requires operative intervention will minimize the occurrence of intra-abdominal sepsis.
Treatment of oesophageal perforation: A multivariate analysis
Authors: Tilanus H W , Bossuyt P , Schattenkerk M E , Obertop H
Published: March 2007

Perforation of the oesophagus was retrospectively analysed in 59 patients. Cause and extent of perforation, localization, quality of the oesophageal wall and therapeutic modes were subjected to univariate analysis. The perforations of the intrathoracic oesophagus (39) were also subjected to multivariate analysis. Perforation of the cervical oesophagus is seldom lethal and can be adequately treated conservatively in the majority of cases. Perforations of the intrathoracic oesophagus can be divided into two groups, with or without simultaneous perforation of the parietal pleura. The optimal treatment for the group with pleural perforation seems to be resection of the oesophagus and secondary reconstruction, although primary closure is indicated in selected early cases. Perforations of the intrathoracic oesophagus confined to the mediastinum can be adequately treated conservatively in most patients. Perforation of the intra-abdominal oesophagus should be treated like any other intra-abdominal visceral perforation, by closure or diversion, even if this results in resection of the oesophagus.
Pathophysiology of ischaemia reperfusion injury: Central role of the neutrophil
Authors: Welbourn C R B , Goldman G , Paterson I S , Valeri C R , Shepro D , Hechtman H B
Published: March 2007

Ischaemia is a common clinical event leading to local and remote injury. Evidence indicates that tissue damage is largely caused by activated neutrophils which accumulate when the tissue is reperfused. If the area of ischaemic tissue is large, neutrophils also sequester in the lungs, inducing non-cardiogenic pulmonary oedema. Ischaemia reperfusion injury is initiated by production of reactive oxygen species which initially appear responsible for the generation of chemotactic activity for neutrophils. Later, once adherent to endothelium, neutrophils mediate damage by secretion of additional reactive oxygen species as well as proteolytic enzymes, in particular elastase. Therapeutic options for limiting ischaemia reperfusion injury include inhibition of oxygen radical formation, pharmacological prevention of neutrophil activation and chemotaxis, and also the use of monoclonal antibodies which prevent neutrophil-endothelial adhesion, a prerequisite for injury.
Results of the Duhamel operation in the treatment of idiopathic megarectum and megacolon
Authors: Stabile G , Kamm M A , Hawley P R , Lennard-Jones J E
Published: March 2007

The results of the Duhamel operation in patients with idiopathic megarectum and megacolon have been reviewed. Twenty patients (14 males, six females) underwent the Duhamel operation over a 17-year period for this condition. The mean age at operation was 25 years; the mean age of onset of constipation was 3 years; and the mean follow-up period was 4·5 years. All the resected colons were of enlarged diameter. There was agreement between the preoperative radiographs and the operative specimens with regard to which parts of the rectum and colon were dilated. Subjective feelings of well-being were generally improved by surgery, as was bowel frequency in ten patients. Soiling, straining, abdominal pain and distension were, however, common after operation. Early complications were also common and five patients required further surgery for constipation. The Duhamel operation for megarectum and megacolon is characterized by an improved sense of well-being and improved bowel frequency, but it is associated with the persistence of many symptoms and further surgery is often required.
Devine exclusion for unresectable carcinoma of the stomach
Authors: Kwok S P Y , Chung S C S , Griffin S M , Li A K C
Published: March 2007

Between July 1986 and July 1988, Devine exclusion was performed in 20 patients with unresectable carcinoma of the gastric antrum. All 20 patients presented with repeated vomiting. On endoscopy, 16 patients had complete gastric outlet obstruction while the remainder manifested significant gastric outlet stenosis. There was no hospital mortality. All except two patients could take an oral diet after surgery until their demise. Devine exclusion is safe and effective in relieving gastric outlet obstruction and is not associated with prolonged delay in return of gastric emptying.
Anismus in patients with normal and slow transit constipation
Authors: Miller R , Duthie G S , Bartolo D C C , Roe A M , Locke-Edmunds J , Mortense N J McC
Published: March 2007

This study examined differences in anorectal function, with particular reference to anismus, which might explain why some patients with intractable constipation have slow and others have normal whole gut transit times. Twenty-four patients were studied; 13 with slow transit (all female, median age 32 years, range 16–52 years) and 11 with normal transit (eight women, three men, median age 37 years, range 21–60 years). Videoproctography with synchronous sphincteric electromyography and anorectal manometry was performed. There were no differences between the two groups, suggesting that slow transit constipation is not secondary to any abnormality in anorectal function and may therefore be a primary disorder of colonic motility. There was no correlation between electromyographic evidence of anismus (pelvic floor contraction on defaecation) and the ability of the patient to evacute the rectum or symptoms of obstructed defaecation. Electromyography findings alone can be misleading and should be related to proctographic evidence of incomplete rectal evacuation before functional anismus can be said to be present.
Early abdominal complications following heart and heart–lung transplantation
Authors: Watson C J E , Jamieson N V , Johnston P S , Wreghitt T , Large S , Wallwork J , English T A H
Published: March 2007

In the first 11 years of the heart and heart–lung transplantation programme at Papworth Hospital, Cambridge, 356 patients underwent heart transplantation, and 73 patients received both heart and lungs. Out of 429 patients 41 (9·5 per cent) developed abdominal complications within the first 30 days, and 20 of the 41 required surgery. The complications included pancreatitis (10), peptic ulceration (8), and pseudo-obstruction (8), in addition to colonic perforation and small bowel obstruction. When laparotomy was performed it was well tolerated. This paper supports the view that successful management of abdominal complications following transplantation requires prompt diagnosis and treatment. Where doubt exists in the presence of an acute abdomen, laparotomy is the appropriate way to establish a definitive diagnosis.
Suture length to wound length ratio and the integrity of midline and lateral paramedian incisions
Authors: Kendall S W H , Brennan T G , Guillou P J
Published: March 2007

A total of 349 patients were randomized to undergo laparotomy through a lateral paramedian incision with layered closure (n = 137), a midline incision with mass closure (n = 104) or a midline incision using layered closure (n = 108), endeavouring to close the latter two incisions with a measured suture length to wound length ratio of greater than 4:1. After 18 months follow-up, no patient in the lateral paramedian group had developed an incisional hernia whereas 7 of 104 patients undergoing a midline incision with mass closure and 7 of 108 patients undergoing a midline incision with layered closure had incisional hernias (P<0·01). The mean suture length to wound length ratios for the three groups were 2·6 (range 1·3–6·2), 5·0 (range 3·0–8·7) and 3·7 (range 2·0–6·3) respectively (P<0·0001). The lateral paramedian incision remains superior to the midline incision closed with the mass technique and its integrity is independent of the suture length to wound length ratio.
Synthesis of collagen types I and III in reincised wounds in humans
Authors: Haukipuro K
Published: March 2007

The problem of the biochemical quantification of long term human wound healing was approached by measuring collagen synthesis in reincisions using specific radioimmunoassays for the wound fluid concentrations of the carboxyterminal propeptide of type I procollagen (PICP) and the aminoterminal propeptide of type III procollagen (PIIINP). First-day wound fluid PICP concentration after reincising a 3 week old scar was 25 times higher than the mean value in 20 reference standard incisions but scars older than 3 months did not show this difference. Wound fluid taken in subsequent days demonstrated that the initial acceleration of synthesis disappeared by the fourth day. When wound fluid PIIINP was assessed, high concentrations were found in reincisions of wounds for up to 5 months after the previous operation. The acceleration was also lost more slowly during the first postoperative week. The duration of a high rate of type I collagen synthesis compares well with studies in experimental wounds which show increased gain of strength if they are made not more than 6 weeks after previous surgery. The longer activity of the metabolism of type III collagen related antigens could reflect their function in the regulation of collagen fibril formation.
Use of the ultrathin choledochoscope in cholecystectomy
Authors: Rooney P S , Wherry D C , Morris D L , Doran J
Published: March 2007

Use of the ultrathin choledochoscope (2 mm) was evaluated in 80 patients undergoing routine cholecystectomy. It was used successfully in 67 (84 per cent) patients. There were eight (12 per cent) explorations of the common bile duct and no negative explorations. The instrument was helpful in determining the nature of an equivocal on-table cholangiogram. The ultrathin choledochoscope may be useful in reducing the rate of negativecommon bile duct exploration.
One hundred patients with hepatic metastases from colorectal cancer treated by resection: Analysis of prognostic determinants
Authors: Doci R , Gennari L , Bignami P , Montalto F , Morabito A , Bozzetti F
Published: March 2007

One hundred patients with hepatic metastases from colorectal cancer underwent ‘radical’ liver resection from 1980 to 1989. At least 1 cm of normal parenchyma surrounded the tumour and no microscopic invasion of resection margins was evident. The disease was staged according to our own staging system. Lobectomy was performed in 50 patients and non-anatomical resection in the remainder. The postoperative mortality rate was 5 per cent and the major morbidity rate was 11 per cent. The actuarial 5-year survival rate for patients in stages I, II and III was 42 per cent, 34 per cent and 15 per cent respectively (P<0·001). The overall actuarial 5-year survival rate was 30 per cent. The prognostic importance of various patient and tumour variables was evaluated by univariate analysis and then by multivariate analysis. Age of patient, site of primary, disease-free interval between treatment of primary and of hepatic metastases, preoperative carcinoembryonic antigen levels, and number of metastases, did not relate to prognosis, while sex (P = 0·024), stage of primary (P = 0·026), extent of liver involvement (P < 0·001), distribution of metastases (P = 0·01) and type of surgery (P = 0·028) significantly affected prognosis as single factors. Multivariate analysis revealed that only the extent of liver involvement and stage of the primary tumour were independent predictors of survival. We conclude that liver resection is effective in selected patients with hepatic metastases from colorectal cancer. In resectable patients it is not yet possible to formulate a clear prognosis based on clinical factors. The extent of liver involvement and the staging system used may be significant, although not absolute, indicators of outcome.
Problems in the definition and treatment of early gastric cancer
Authors: Inoue Kazutom O , Tobe T , Kan N , Nio Y , Sakai M , Takeuchi E , Sugiyama T
Published: March 2007

Radical operation with extensive dissection of lymph nodes (R1 48 patients; R2, 196 patients; R3, one patient) was performed in 245 out of 247 patients with early gastric cancer. The 5-year survival rate was only 73.2 per cent in the 34 patients with lymph node metastases (31·8 per cent). Analysis of factors influencing recurrence revealed that not only lymph node metastases but also the depth of cancer invasion could affect prognosis in early gastric cancer. This study suggests that radical operation with complete dissection of the first and second group of lymph nodes (R2 resection) is a safe and appropriate treatment even for early gastric cancer. We propose that the definition of early gastric cancer be modified to ‘carcinoma with invasion confined to the mucosa or submucosa and without evidence of lymph node metastases’.
Surgical treatment of carcinoma of the gastric stump
Authors: Sasako M , Maruyama K , Kinoshita T , Okabayashi K
Published: March 2007

To evaluate retrospectively the surgical treatment of patients with gastric stump cancer following gastrectomy for benign disease, we reviewed 52 patients operated on at the National Cancer Centre, Tokyo, between 1962 and 1988. Resection was carried out in 47 patients (90 per cent) and with curative intent in 36 (69 per cent). Stage distribution was: stage 1, 15 patients; stage 2, 5; stage 3, 9; stage 4, 23. In 36 cases curatively resected, 32 had completion total gastrectomy and four had subtotal resection. An R1 resection was performed in 11 patients and an R2 in 25. We had two hospital deaths and a 5-year survival rate excluding hospital deaths of 39 per cent. The 5-year survival rates of resected cases, curative cases and those having metastatic nodes were 43 per cent, 57 per cent and 29 per cent respectively. Radical resection is a reasonable treatment for gastric stump cancer as it is for primary cancer of the stomach.
Fibrinolytic activity of the arms and legs of patients with lower limb venous disease
Authors: Gajraj H , Browse N L
Published: March 2007

Clearance of subcutaneous 125I-labelled fibrin was prolonged from the legs but not from the arms of patients with uncomplicated varicose veins and patients with healed ulcers, compared with controls. The euglobulin clot lysis time (ECLT) of blood from the arms and legs of those with healed ulcers was prolonged; venous congestion significantly shortened the ECLT of blood from all limbs except legs with healed ulcers. The clearance of interstitial fibrin of both legs and arms correlated with the response of the ECLT to venous congestion (P < 0·05). The clearance of interstitial 125I-labelled albumin in five patients with healed ulcers was faster from the legs than from the arms, whereas the clearance of interstitial 125I-labelled fibrin was faster from the arms in all cases. These results suggest that there is a defect in interstitial fibrinolytic activity as well as vein wall production of plasminogen activator in legs with chronic venous insufficiency.
Tropic role of enteroglucagon in pancreatic adaptation to subtotal enterectomy
Authors: Watanapa P , Williamson R C N , Beardshall K , Calam J
Published: March 2007

Proximal small bowel resection causes pancreatic hyperplasia, presumably via a humoral mechanism. Although cholecystokinin can stimulate pancreatic growth, its proximal distribution in the gut makes it an unlikely intermediary after proximal small bowel resection. The potential roles of neurotensin and enteroglucagon were studied, since these hormones are mainly secreted from the ileum and proximal colon. Male Wistar rats (n = 50) weighing 200–250 g were randomized to receive 90 per cent proximal small bowel resection or jejunal transection and resuture (control). Rats were killed at 1 week or 1 month, when plasma was obtained for hormone assay and the pancreas was excised for protein and nucleic acid measurement. Proximal small bowel resection increased circulating enteroglucagon levels by 150 per cent at 1 week (P < 0.002) and by 83 per cent at 1 month (P < 0.005); neurotensin levels were unchanged. Pancreatic wet weight was 21 per cent greater 1 month after proximal small bowel resection (P < 0.001). Proximal small bowel resection increased protein, RNA and DNA contents of the pancreas both at 1 week and at 1 month. Since plasma enteroglucagon correlated with these indices of pancreatic mass, enteroglucagon may have a pancreatotropic role (in addition to its enterotropic role).
Distal pancreatectomy with and without splenectomy
Authors: Aldridge M C , Williamson R C N
Published: March 2007

Splenectomy is performed routinely during distal pancreatectomy, yet the spleen has an important role in host defence and can often be preserved. A personal series of 100 distal pancreatectomies undertaken for pancreatic disease between 1978 and 1990 included 23 patients undergoing total pancreatic resection. The remaining 77 patients, who form the basis of the present report, underwent primary distal pancreatectomy and comprised 34 women and 43 men with a median age of 41 years (range 17–78 years). Conventional distal pancreatectomy including splenectomy was performed in 42 patients (55 per cent) for chronic pancreatitis (34 patients), pancreatic neoplasia (six patients), suspected pancreatitis (one patient) or pancreatitic trauma (one patient). Conservative resection with splenic preservation was performed in 35 patients (45 per cent) for chronic pancreatitis (12 patients), suspected pancreatitis (13 patients, including eight patients with pancreas divisum), pancreatic neoplasia (six patients), recurrent acute pancreatitis (two patients) and pancreatic trauma (two patients). There were no postoperative deaths in either group. Early complications followed conventional resection in 10 patients (24 per cent) and conservative resection in seven patients (20 per cent). In five patients the splenic vessels were ligated away from the splenic hilum and the spleen was left in situ, but subsequent isotope scans and haematological indices showed no hyposplenism. The spleen can safely be preserved in many distal pancreatic resections, including those for inflammatory disease, and we now prefer a retrograde technique for dissecting the pancreas off the splenic vessels.
Value of duplex scanning compared with angiography and pressure measurement in the assessment of aortoiliac arterial lesions
Authors: Legemate D A , Eikelboom B C , Teeuwen C , Hoeneveld H
Published: March 2007

To detect haemodynamically significant lesions in the aortoiliac arteries, invasive tests such as angiography and intra-arterial pressure measurement (IAPM) are considered valuable diagnostic tools. The value of duplex scanning as a direct non-invasive examination technique was prospectively compared with intra-arterial digital subtraction angiography (IADSA) and IAPM at rest, and after the administration of papaverine in 60 patients. Excellent agreement, as assessed by the K statistic, was shown between duplex scanning and IADSA (K = 0·81). A fair agreement was shown between duplex scanning and IAPM (K = 0·63), and between IADSA and IAPM (K = 0·63). Duplex scanning and IADSA both missed some less haemodynamically critical lesions if IAPM was considered the ‘gold standard’. It is concluded that duplex scanning detects haemodynamically significant lesions as effectively as angiography and so may be considered a new and valuable diagnostic tool. IAPM remains necessary to detect some lesions of borderline haemodynamic significance. However, with future developments, duplex scanning has the potential to replace the need even for IAPM.
Necrotizing enterocolitis following operation in the neonatal period
Authors: Shanbhogue L K R , Tam P K H , Lloyd D A
Published: March 2007

Over a 16-year period, 33 newborn infants developed necrotizing enterocolitis (NEC) following some form of operation (accounting for 19 per cent of all neonates with NEC), including repair of myelomeningocele, intestinal atresia, gastroschisis and congenital diaphragmatic hernia. The neonates with postoperative NEC had a median birth-weight of 3.05 (range 1.0–4.4) kg, and median gestational age of 40 (range 27–41) weeks. Twenty patients were treated non-operatively. The remaining 13 required operation for complications of NEC. Twenty-three patients are alive and have been followed for a median of 66 (range 3–168) months. If a neonate deteriorates following any operation NEC must be included in the differential diagnosis.
Penetrating missile injuries in the Gulf war 1991
Authors: Spalding T J W , Stewart M P M , Tulloch D N , Stephens K M
Published: March 2007

During the recent Gulf war 63 patients with penetrating missile injuries (including 29 Iraqi prisoners of war) underwent operation in a British Army Field Hospital. Their injuries and initial operative management are reported. Fifty-one casualties (81 per cent) suffered an average of nine wounds (range 1–45) due to fragmentation weapons, and 12 casualties sustained bullet wounds. All wounds were explored following the established principles of war surgery. The extremities were involved in 48 patients (76 per cent). Eight compound long bone fractures were managed with external skeletal fixators applied at the time of initial operation. Laparotomy was performed on seven patients, one of whom died. The average duration of operation was 77 min for shrapnel wounds and 85 min for bullet wounds.
Routine examination of the vocal cords before and after thyroid and parathyroid surgery
Authors: Järhult J , Lindestad P-Å , Nordenström J , Perbeck L
Published: March 2007

A prospective study of the value of routine examination of the vocal cords in 239 patients before and after thyroid or parathyroid surgery is presented. From the patient's history and voice the surgeon assessed before and after operation whether vocal cord examination was necessary or not. The surgeon's judgement was compared with the phoniatrician's* report. All except one of the documented recurrent laryngeal nerve palsies were suspected by the surgeon. No additional important clinical information was gained by the laryngologist's examinations. Routine vocal cord examination in connection with thyroid and parathyroid surgery is probably not necessary.
Prevalence of abdominal aortic aneurysm in Western Australia
Authors: Norman P E , Castleden W M , Hockey R L
Published: March 2007

The prevalence of abdominal aortic aneurysm (AAA) in Western Australia was studied using health department mortality data. Age-standardized and age-specific mortality rates related to the disease were calculated for the period 1980–88. The mortality rate has risen by 36 per cent for men and 24 per cent for women. Most of this rise was due to an increase in non-hospital and emergency admission hospital deaths. The number of elective and emergency operations has also risen. Despite two decades of elective surgery, the mortality rate for AAA continues to rise. This rise is highly suggestive of an increasing prevalence. This contrasts with the decline in deaths from other manifestations of arteriosclerosis and provides support for a policy of screening for aneurysm.
Abdominal aortic aneurysm in 4237 screened patients: Prevalence, development and management over 6 years
Authors: Scott R A P , Ashton H A , Kay D N
Published: March 2007

An ultrasonography screening programme for detecting abdominal aortic aneurysm (AAA) in the community is described in which 7200 men and women aged between 65 and 80 years were contacted by letter. Of these, 4237 were screened; the aorta was visualized in 4122 and 179 AAAs of 3 cm or more in diameter were detected (4.3 per cent). Criteria for surgery are suggested and the results of their application prospectively over 6 years are discussed. Using these criteria, under 10 per cent of patients with ultrasonographically-detected AAA should require surgery for this condition provided ultrasonography follow-up is used.
Detection and characterization of arterial thromboses using a platelet-specific monoclonal antibody (P256 Fab')
Authors: Berridge D C , Perkins A C , Frier M , Lonsdale R J , Ballantyne K C , Wastie M L , Makin G S , Hopkinson B R
Published: March 2007

Arteriography does not reliably distinguish between acute and chronic arterial occlusions. Seventeen patients with acute lower limb ischaemia were investigated by arteriography and by imaging with a platelet-specific monoclonal antibody (P256 Fab'); 20 MBq 111In-labelled P256 Fab' was administered intravenously and patients were imaged at intervals of between 20 min and 24 h. Thirteen patients were subsequently treated with intra-arterial thrombolysis. In six the images showed foci of increased uptake of 111In-labelled P256 Fab' and the corresponding arterial segment was recanalized. Patency to 30 days was maintained in four cases. Seven patients had negative scans, only four of whom achieved lysis, and two of these suffered early rethrombosis. The remaining four patients were excluded from thrombolysis by the arteriographic appearances. 111In-labelled P256 Fab' imaging can identify sites of acute arterial thrombosis and may have clinical applications in the management of peripheral vascular disease. Further studies are required to test whether the technique has a role to play in patient selection for thrombolysis.
Treatment perspectives in locally advanced unresectable pancreatic cancer
Authors: Jeekel J , Treurniet-Donker A D
Published: March 2007

Locally advanced unresectable pancreatic cancer is sometimes encountered without manifest distant metastases. Twenty patients with histologically proven unresectable pancreatic cancer without distant metastases were treated with radiotherapy and 5-fluorouracil (5-FU). Radiotherapy consisted of 50 Gy external upper abdomen radiation in two courses, concomitant with intravenous 5-FU 375 mg/m2 given as a bolus injection 4–6 h before radiation on the first 4 days of each treatment course. The treatment protocol was completed in 18 patients without complications. The median survival time was 10 months which compares favourably with a 3–5 months median survival time when treatment is withheld. Nine patients (45 per cent) were alive at 1 year, two patients at 2, 3 and 4 years. A second-look operation was performed in four patients 6, 11, 12 and 22 months after completion of radiotherapy. In two patients the tumour could be resected. It appears that treatment with radiotherapy and 5-FU may benefit patients with locally advanced unresectable pancreatic cancer.
Histopathological study of oesophageal mucosa in patients with varices: A comparison between bleeders and non-bleeders
Authors: Hirata M , Kawasaki S , Sanjo K , Idezuki Y
Published: March 2007

Thirty-six patients with oesophageal varices underwent a non-shunting operation including oesophageal transection. Of these, 16 had an emergency or elective operation (bleeders) and the remaining 20 had prophylactic surgery (non-bleeders). A comparative study was performed between the bleeders and non-bleeders in terms of preoperative endoscopic findings and histopathology of the oesophagus. The severity of red colour sign showed no significant difference between the two groups. The venous dilatation in each of the three layers of the oesophageal mucosa was demonstrated histologically to be of the same degree in bleeders and non-bleeders. In addition, the hepatic venous pressure gradient in cirrhotic patients did not differ between the two groups; for bleeders this was a mean(s.d.) of 15.2(6.1) mmHg and for non-bleeders 14.4(2.9) mmHg. We were unable to find any factors differentiating bleeders from non-bleeders, although these results do not justify prophylactic surgery for oesophageal varices.
Above-knee prosthetic grafts do not compromise the ipsilateral long saphenous vein
Authors: Budd J S , Langdon I , Brennan J , Bell P R F
Published: March 2007

Prosthetic graft materials are used preferentially by a number of surgeons for above-knee femoropopliteal bypasses. Using B-mode ultrasonography we have assessed the ipsilateral long saphenous vein in patients undergoing such bypasses to determine its suitability for future use in more distal bypasses. A total of 137 above-knee prosthetic grafts were performed over a 10-year period. Of the patients, 74 were available for further assessment. Overall, 97 per cent of veins were suitable for future bypass surgery if required. Above-knee prosthetic bypasses do not appear to jeopardize the ipsilateral long saphenous vein.
Management of the perineal wound following abdominoperineal resection: prospective study of three methods
Authors: Robles Campos R , Ayllon J Garcia , Paricio P Parrilla , Tebar J Cifuentes , Mompean J A Lujan , Ruiz R Liron , Martinez J A Torralba , Martinez J Molina
Published: March 2007

A prospective study was made of three procedures for treating the perineal wound and presacral cavity in 102 patients undergoing abdominoperineal excision for cancer of the rectum: (1) packing of the presacral space after suture of the pelvic peritoneum; (2) suture of the pelvic peritoneum and perineal wound, leaving two drains through the perineum; and (3) no suture of the pelvic peritoneum, and primary closure of the perineal wound, leaving drains through the abdomen for physiological saline irrigation. The parameters analysed were incidence of infection, primary healing of the perineum, extraperineal complications and mean hospital stay. Primary healing of the perineum was best with method 3, and overall incidence of infection highest with method 2. There were no differences between the methods with regard to extraperineal complications. Hospital stay was shortest with method 3.
Temporary loop ileostomy following restorative proctocolectomy
Authors: Hosie K B , Grobler S P , Keighley M R B
Published: March 2007

A retrospective study compared the outcome of restorative proctocolectomy in patients who had a covering ileostomy (n = 53) with those who had no proximal stoma (n = 32). Those who had a loop ileostomy had a higher incidence of anastomotic leakage (21 per cent), pelvic abscess (32 per cent) and postoperative fistula (28 per cent) than those with no covering ileostomy (6, 12 and 12 per cent respectively). Intestinal obstruction occurred in 23 per cent of those with an ileostomy, compared with 6 per cent in those who had no stoma. The functional outcome was identical.
‘Natural history’ of hepatectomy
Authors: Suc B , Panis Y , Belghiti J , Fékété F
Published: March 2007

The aim of this study was to describe biochemical and liver function test changes after hepatectomy in 33 patients with the following characteristics: absence of underlying liver disease, no blood or plasma transfusion during the perioperative period, uneventful postoperative course. Resection with a temporary pedicle inflow occlusion (10–45 min) consisted of unisegmentectomy or less in 15 patients and bisegmentectomy or more in 18. Blood tests showed: a correlation between aminotransferase rise and duration of ischaemia, and a fall in prothrombin time and factor V levels correlating with the weight of resected specimen at day 1; a moderate γ-glutamyl transpeptidase and alkaline phosphatase elevation and a rise in fibrinogen level correlating with the extent of resection at day 7. Changes in haemoglobin level, white cell count, platelet count, prothrombin time, factor V level and serum bilirubin level tended to return to preoperative levels by day 7. For γ-glutarnyl transpeptidase and alkaline phosphatase, increased levels persisted for 8–12 weeks after resection. These results, in this selected group of patients, allow a description of the ‘natural history’ of hepatectomy. The knowledge of these ‘natural’ changes may contribute to the early detection of postoperative complications.
Hepatic transplantation in children using reduced size allografts
Authors: Badger I L , Czerniak A , Beath S , Tisone G , Deakin M , Sherlock D J , Kelly D A , McMaster P , Buckels J A C
Published: March 2007

The shortage of paediatric liver donors has led to the use of reduced size hepatic allografts. Between July 1987 and July 1990, 30 reduced size orthotopic liver transplantations were performed in 24 children aged between 3 months and 7 years. All patients were in advanced chronic or acute liver failure and were considered unlikely to survive for long enough for a size-matched donor to become available. The most common indication was biliary atresia. The median intraoperative blood loss was 75 (range 13–1015) ml kg −1. Nine patients have died and seven have undergone retransplantation, four successfully. Seven patients had portal vein hypoplasia with a high graft failure rate due to ischaemic infarction. There was significant morbidity from biliary tract complications, leading to further operations in four cases. The 1-year actuarial survival rate was 62 per cent.
Outpatient treatment of non-lactational breast abscesses
Authors: Dixon J M
Published: March 2007

Eighteen consecutive patients with non-lactational breast abscesses have been treated by aspiration (ten patients), surgical drainage after application of local anaesthetic cream (seven patients) or a combination of aspiration and local anaesthetic cream drainage (one patient) combined with a 2-week course of either amoxycillin and clavulanic acid or cephradine and metronidazole. All abscesses resolved completely within 2 weeks of treatment and all 18 patients expressed satisfaction with the method of treatment used. The majority of patients with breast abscesses can now be managed as outpatients.
Breast abscesses and cigarette smoking
Authors: Bundred N J , Dover M S , Coley S , Morrison J M
Published: March 2007

An 11-year retrospective review of women with breast abscesses presenting to a district general hospital was performed. A total of 122 women were identified with a breast abscess: 85 (70 per cent) with non-lactational abscesses and 37 (30 per cent) with an abscess in the puerperium. Six of 37 lactational and 24 of 85 non-lactational abscesses recurred. Sixteen mammillary fistulae developed, all following incision and drainage of non-lactational breast abscesses. Women with non-lactational breast abscesses were more likely to smoke cigarettes (P < 0·005). Breast abscesses containing anaerobic bacteria were signlficantly more likely to occur in current cigarette smokers (P < 0·05). Women with non-lactational breast abscesses who were heavy cigarette smokers were more likely to sufer recurrent abscesses (P < 0·01). There was histological evidence of duct ectasia on biopsy in 25 women with non-lactational abscesses and 21 of 25 were current smokers. Mammillary fistulae developed more frequently in current smokers (P < 0·03). Cigarette smoking is important in the natural history of non-lactational breast abscesses and may predispose to anaerobic breast infections and the development of mammillary fistulae.
Factors influencing the healing of distal amputations performed for lower limb ischaemia
Authors: Byrne R L , Nicholson M L , Woolford T J , Callum K G
Published: March 2007

A total of 235 toes were amputated during 125 operations on 100 consecutive patients with lower limb ischaemia. The overall amputation wound healing rate for the series was 58·4 per cent and limb salvage was achieved in 66 patients. Toe amputation was performed under local anaesthesia in 57 cases and 32 (56 per cent) of these healed primarily, not significantly diflerent from the healing rate of 41 (60 per cent) of 68 under general anaesthesia. Reconstructive arterial surgery was performed in conjunction with toe amputation in 39 patients; the healing rate with reconstruction was 32 (82 per cent) of 39, significantly better than the 41 (48 per cent) of 86 patients not undergoing bypass surgery (P < 0·001). There was no difference in healing rates when comparing diabetic and non-diabetic patients. Multiple regression analysis demonstrated that reconstructive arterial surgery was the only factor which had an independent and signficant influence on toe amputation healing. The use of local anaesthesia for distal amputation has no deleterious eflects on wound healing.
Low-dose intra-arterial thrombolysis in the treatment of occluded vascular grafts
Authors: Browse D J , Torrie E P H , Galland R B
Published: March 2007

As the use of intra-arterial thrombolysis increases, its application to specific areas requires definition. The results of treatment of occluded vascular grafts are presented. Thrombolysis using streptokinase or tissue plasminogen activator was planned in the treatment of 18 occluded vascular grafts (five aortofemoral bifurcation grafts and 13 infrainguinal grafts). Two patients, both with infrainguinal occlusions, did not receive thrombolytic therapy and were considered failures of treatment. Successful lysis occurred in three of five aortofemoral grafts, in both infrainguinal vein grafts and in five of nine infrainguinal synthetic grafts. The overall success rate was approximately 60 per cent. Two-thirds of the patients required no intervention following successful lysis. Percutaneous transluminal angioplasty was not found to be a useful additional procedure. A review of the literature revealed that intra-arterial thrombolysis is significantly more successful in the treatment of suprainguinal graft occlusion than in infrainguinal occlusions, there being no difference between infrainguinal vein and synthetic grafts. Provided that the limb is viable and there are no contraindications, intra-arterial thrombolysis is a useful means of clearing occluded grafts.
Anal endosonographic findings in the follow-up of primarily sutured sphincteric ruptures
Authors: Nielsen M B , Hauge C , Rasmussen O Ø , Pedersen J F , Christiansen J
Published: March 2007

Twenty-four women with primary suture of an obstetric tear of the anal sphincter were examined with anal endosonography a median of 12 (range 3–18) months after delivery. Endosonography was normal in ten patients, of whom one was incontinent. The examination showed a defect in the external anal sphincter in 13 patients; six of these were incontinent, two of whom had normal findings on palpation. An isolated internal sphincter defect was found in a continent patient. Since anal endosonography causes no more discomfort than digital examination, it may be useful to identify patients who would benefit from surgical reconstruction of the anal sphincter.