bluuebunny/crossref_metadata_2025 huggingface dataset:
Anal endosonography in patients with anorectal symptoms after haemorrhoidectomy
Authors: Abbasakoor F , Nelson M , Beynon J , Patel B , Carr N D
Published: March 2003

Background

Anorectal symptoms after haemorrhoidectomy are common and treatment is often empirical. Because of this, an audit was carried out of the value of anal endosonography in patients with anorectal symptoms after haemorrhoidectomy.

Methods

Between May 1993 and February 1997, 16 patients (ten men and six women of median age 56 (range 35–77) years) were investigated by anal endosonography for anorectal symptoms after haemorrhoidectomy which involved anorectal incontinence (n = 10), anal pain (n = 4) and obstructive defaecation (n = 2). The findings were compared with those in a matched group of asymptomatic patients after haemorroidectomy.

Results

Anal endosonography demonstrated an abnormality in 12 symptomatic patients. Of the ten patients with anorectal incontinence, endosonography showed an internal anal sphincter defect (n = 5), a combined sphincter defect (n = 2) and an isolated external anal sphincter defect (n = 1). Normal appearances were seen in all asymptomatic patients. The endosonographic abnormalities of the four patients with anal pain included internal anal sphincter defect (n = 1), extrinsic mass (n = 1), and intersphincteric abscess (n = 1). One of the two patients with obstructive defaecation had an isolated external anal sphincter defect on endosonography.

Conclusion

These results show a high yield of endosonographic abnormalities in patients who experience symptoms after haemorrhoidectomy. In particular, occult sphincter injury as a cause of incontinence in these patients can frequently be demonstrated.
Rectal adaptation to distension in patients with overt rectal prolapse
Authors: Siproudhis L , Bellissant E , Juguet F , Mendler M-H , Allain H , Bretagne J-F , Gosselin M
Published: March 2003

Background

High recovery rates of continence are observed after surgical procedures for rectal prolapse. Increases in rectal compliance but no obvious rise in anal pressures have been reported. The authors' hypothesis was that decreased rectal adaptation to distension may contribute to incontinence in patients suffering from overt rectal prolapse.

Methods

This was a prospective study conducted in 20 consecutive incontinent patients suffering from overt rectal prolapse with no mucosal change (two men and 18 women; mean(s.e.m.) age 50(3) years). They were compared with 20 age- and sex-matched patients with incontinence without rectal prolapse and ten age- and sex-matched healthy volunteers observed during the same period. The subjects were submitted to phasic isobaric distension of the rectum with an electronic barostat. Anal pressures, perception scores and rectal volumes were recorded at six different preselected pressures.

Results

Compared with healthy subjects, maximum rectal volumes (mean(s.e.m) 98(6) versus 167(11) ml; P = 0·005), volumes related to compliance (56(5) versus 100(9) ml; P = 0·004) and tone (41(3) versus 67(4) ml; P = 0·003) were decreased significantly in the rectal prolapse group. Prolapse and incontinence groups did not differ significantly with respect to rectal adaptation for all three parameters and steps of distension considered.

Conclusion

Patients suffering from overt rectal prolapse had markedly impaired rectal adaptation to distension which may contribute to incontinence.
Controlled prospective study of positron emission tomography using the glucose analogue [18F]fluorodeoxyglucose in the evaluation of pulmonary nodules
Authors: Präuer H W , Weber W A , Römer W , Treumann T , Ziegler S I , Schwaiger M
Published: March 2003

Background

Positron emission tomography (PET) is a new imaging technique which, by measuring focal metabolic activities, can make a qualitative statement (benign or malignant) about a tumour. PET has been described in many studies to provide a high diagnostic accuracy for the evaluation of pulmonary coin lesions. However, these studies were not always supported by histological confirmation of the results. In a controlled prospective study, it was investigated whether the diagnostic accuracy of PET is sufficiently high to allow omission of diagnostic thoracotomy or thoracoscopy in the case of a negative finding.

Methods

A PET scan was carried out before operation using [18F]fluorodeoxyglucose (FDG) in 50 patients with pulmonary coin lesions (diameter 30 mm or less). All of these lesions were completely removed thoracoscopically or by a formal thoracotomy and were examined histologically. Using the histology results, the diagnostic accuracy of the PET procedure with regard to a benign or malignant diagnosis was evaluated and compared with that of computed tomography (CT).

Results

From a total of 54 coin lesions (four of the 50 patients had two lesions) there were 31 malignant (19 primary bronchial carcinomas, 12 metastases) and 23 benign diagnoses. With the PET procedure 28 of 31 malignant and 19 of 23 benign lesions were classified correctly (sensitivity 90 per cent, specificity 83 per cent). False negatives included two bronchial carcinomas and one metastasis. CT had a sensitivity of 100 per cent and specificity of 52 per cent.

Conclusion

FDG PET cannot generally be considered as a replacement for diagnostic thoracoscopy or thoracotomy at the present time. However, by combining FDG PET with radiological follow-up, clinical applications may evolve in patients at low risk for a malignant tumour or at high risk for surgical complications.
Surgical treatment and outcome in patients with a hepatocellular carcinoma greater than 10 cm in diameter
Authors: Lee N H , Chau G Y , Lui W Y , King K Ls , Tsay S H , Wu C W
Published: March 2003

Background

Hepatocellular carcinoma (HCC) over 10 cm in diameter at the time of diagnosis continues to account for a number of patients undergoing hepatic resection. This study evaluated the clinicopathological features and outcome following surgery for large HCC.

Methods

Forty patients with a large HCC (greater than 10 cm) (group 1) resected between 1991 and 1996 were studied retrospectively. They were compared with 245 patients who had smaller HCCs (10 cm or less) (group 2).

Results

No patient in group 1 had hepatitis C infection compared with 22·9 per cent in group 2 (P =0·001). Patients in group 1 were significantly younger, had higher α-fetoprotein levels (16 750 versus 1864 ng/ml; P < 0·001), better liver function, a higher incidence of multiple tumours (27 of 40 versus 42·0 per cent; P =0·003) and venous invasion (35 of 40 versus 52·2 per cent; P < 0·001), and underwent more major resections (37 of 40 versus 26·5 per cent; P < 0·001) than those in group 2. Morbidity and mortality rates and hospital stay were comparable in the two groups. For group 1, the 1-, 3- and 5-year disease-free survival rates were 42, 30 and 28 per cent respectively. Multiple tumours, venous invasion and impaired liver function were factors associated with recurrence.

Conclusion

Large HCC had specific clinicopathological features. In selected patients, resection is safe and offers the chance of long-term disease-free survival.
Association between breast and colorectal cancers
Authors: Stoll B A
Published: March 2003

Background

The risk of breast and colorectal cancers in immigrants from non-industrialised countries is sharply increased when they adopt a Western lifestyle. In addition, epidemiological studies on Western populations show an association between the two tumours, both in the same individual and also in close relatives. Most studies agree that high energy intake, obesity and inadequate physical exercise are associated with an increased risk of both tumours.

Methods

Risk markers for each cancer are examined in order to identify causative nutritional factors or metabolic–endocrine dysfunction. The role of steroid hormones and other possible carcinogenic mechanisms is discussed, concentrating on evidence of a role for insulin and insulin-like growth factors (IGFs) in the promotion of carcinogenesis in both organs.

Results

Individuals with a genetic susceptibility to insulin resistance show triggering of hyperinsulinaemia following excessive weight gain or long-term diet high in saturated fat. Case–control studies show an association between hyperinsulinaemia and evidence of breast or colorectal carcinoma. Multiple laboratory studies show that increased activity of IGFs can stimulate the growth of human breast and colorectal cancer cells.

Conclusion

It is postulated that either insulin resistance and its concomitants promote the development of breast and colorectal cancers, or that they share common risk factors. Sex steroid metabolism and organ specificity may explain age and sex differences between the tumours in relation to the role of obesity. Recent research suggests that a diet high in n-3 polyunsaturated fatty acids may reduce the risk of developing insulin resistance. This observation may be applied to test the hypothesis that an effect on hyperinsulinaemia may modify the risk of developing breast or colorectal cancer.
Solitary rectal ulcer syndrome
Authors: Vaizey C J , van den Bogaerde J B , Emmanuel A V , Talbot I C , Nicholls R J , Kamm M A
Published: March 2003

Background

Solitary rectal ulcer syndrome is a rare disorder characterized by erythema or ulceration of the rectal wall, associated with typical histological features, and disturbed defaecatory behaviour with the passage of blood and mucus.

Methods

This is a review based on a literature search using a computer database (Medline) and manual cross-referencing.

Results

The pathogenesis is likely to vary in different patients; it includes trauma from straining, direct digital trauma and possibly primary neuromuscular pathology. The histological findings of extension of the muscularis mucosa between crypts and muscularis propria disorganization on full-thickness specimens are characteristic. Biofeedback defaecation retraining, including habit training, can lead to symptom improvement and return to work in a majority of patients. Abdominal rectopexy offers long-term symptom improvement in approximately 50 per cent of patients. Rectal ulceration may persist after any treatment, even if symptoms improve.

Conclusion

Behavioural therapy and carefully considered operations offer the best treatment results. Further work on psychological factors and neuromuscular and vascular pathology is required.
Lower limb surveillance following autologous vein bypass should be life long
Authors: McCarthy M J , Olojugba D , Loftus I M , Naylor A R , Bell P R F , London N J M
Published: March 2003

Background

The aim of the study was to investigate whether infrainguinal vein graft surveillance can be stopped at 1 year without prejudicing graft or leg survival.

Methods

Data were collected prospectively on 351 infrainguinal vein bypass grafts (326 patients) that had been entered into a vein graft surveillance programme between 1988 and 1997.

Results

Some 104 grafts (30 per cent) developed significant new vein graft stenoses, 95 (91 per cent) of which occurred within 12 months. After 1 year, the risk of developing a significant graft stenosis was 3 per cent per year. Sixty-nine grafted limbs (20 per cent) developed new arterial inflow or run-off stenoses that required intervention, but only 37 (54 per cent) occurred within the first year, after which the risk was 9 per cent per year. The overall risk of developing a new vein graft or arterial stenosis after 1 year was 10 per cent per year.

Conclusion

The incidence of vein graft stenosis decreases significantly 1 year after operation but there is still at risk of developing potentially graft-threatening arterial stenoses. Legs that have undergone infrainguinal vein bypass grafting should continue to be monitored in a surveillance programme for life.
Effect of a novel prosthetic anal neosphincter on human colonic blood flow
Authors: Hajivassiliou C A , Finlay I G
Published: March 2003

Background

An artificial anal sphincter has been developed which aimed to simulate the normal physiology of the anorectum. As a prelude to human implantation the present study reports the effect of inflation of this device on colonic perfusion in patients undergoing colectomy, which was assessed by using a laser Doppler scanner.

Methods

Eleven patients (median age 49·8 (range 24·3–78·7) years) were studied. Five patients had inflammatory bowel disease (IBD). The neosphincter was placed around the bowel and progressively inflated. The model was designed so that blood flow changes to the colon under the neosphincter would be reflected in the distal segment of the bowel, which could be scanned by the laser Doppler scanner.

Results

The blood flow in the colon distal to the device was significantly higher in patients with IBD (mean(s.e.m.) 288·6(71·9) versus 211·1(57·6) perfusion units; P < 0·001). The mean(s.e.m.) ‘biological zero’ value was 46(14) perfusion units. Blood flow distal to the neosphincter decreased progressively with increased sphincteric compression by 0·66 per cent per mmHg applied pressure in controls and 0·35 per cent per mmHg in patients with IBD (P < 0·05).

Conclusion

These results suggest that at the planned operating occlusion pressure (less than 45 mmHg) this neosphincter should not put the vascularity of the human colon at risk.
Detection of response to chemotherapy using positron emission tomography in patients with oesophageal and gastric cancer
Authors: Couper G W , McAteer D , Wallis F , Norton M , Welch A , Nicolson M , Park K G M
Published: March 2003

Background

The aim of the study was to determine whether 2-[18F]-fluoro-2-deoxy-d-glucose (FDG)-positron emission tomography (PET) could detect response to chemotherapy in patients with oesophageal and gastric cancer.

Methods

Fourteen patients underwent imaging before and after chemotherapy using FDG-PET. Computed tomography (CT), dysphagia scores and weight changes were used for comparison of evidence of response. Tumour to liver ratios (TLRs) and influx constants for FDG (K) were used for quantification purposes.

Results

Thirteen of 14 lesions were successfully imaged before therapy. Changes were seen in all follow-up scans, ranging from a complete response to a 15 per cent increase in tumour FDG uptake. Response was demonstrated by CT in four patients; all four had large reductions in FDG uptake after chemotherapy. Two patients with an increase in FDG uptake reported no improvement in dysphagia and continued to lose weight during therapy.

Conclusion

Changes in tumour FDG uptake were seen in all tumours after chemotherapy. FDG-PET may have a role to play in the assessment of patients with upper gastrointestinal malignancy receiving chemotherapy.
Cutting seton versus two-stage seton fistulotomy in the surgical management of high anal fistula
Authors: García-Aguilar J , Belmonte C , Wong W , Goldberg D W , Madoff R D
Published: March 2003

Background

The aim of this study was to compare the clinical results obtained with the cutting seton and the two-stage seton fistulotomy (TSSF) in the surgical management of high anal fistula.

Methods

The case records of 59 patients with high anal fistula of cryptoglandular origin treated with cutting seton (n = 12) or TSSF (n = 47) over a 5-year period were retrospectively reviewed. There was no difference between the groups in age, sex distribution, or estimated percentage of anal sphincter involved by the fistula. Follow-up was by a mailed questionnaire inquiring about fistula recurrence, incontinence, and degree of satisfaction. Mean follow-up was similar in both groups (27 months for cutting seton versus 33 months for TSSF). Comparisons were made by Student t and χ2 tests, as required.

Results

There were no differences in the rate of fistula recurrence between the groups treated with cutting seton or TSSF (one of 12 versus four of 47), difficulty holding gas (six of 12 versus 25 of 47), underwear staining (six of 12 versus 18 of 47), stool incontinence (three of 12 versus 12 of 27), overall incontinence (eight of 12 versus 31 of 47) and mean incontinence score (4·9 versus 4·2). The fistula healing time and degree of satisfaction with the operation were not significantly different between the groups. One-half of the patients treated by TSSF had the seton removed under general or epidural anaesthesia.

Conclusion

Both techniques are equally effective in eradicating the fistula, and both are associated with a similar rate of incontinence.
Reintervention and mortality after infrainguinal reconstructive surgery for leg ischaemia
Authors: Dawson I , van Bockel J H
Published: March 2003

Background

Progression of atherosclerosis and graft-related complications are common indications for late vascular intervention. The aim of this study was to determine the cumulative risk of late reintervention or death after infrainguinal bypass grafting.

Methods

Some 205 consecutive patients with limb-threatening ischaemia were included. All data were recorded prospectively. The principal endpoint was reintervention for a graft-related complication or recurrent leg ischaemia. Mean follow-up was 3·3 years. Life-table and multivariate analyses were employed to estimate the cumulative risk of reintervention or death during follow-up and to assess factors influencing this risk.

Results

Beyond 30 days after insertion of the infrainguinal bypass, 67 patients (33 per cent) had 112 subsequent vascular interventions in the ipsilateral extremity. The cumulative reintervention rate was 25 per cent at 1 year and 40 per cent at 5 years. Poor run-off (P < 0·005) and prosthetic grafts (P < 0·001) were significant and independent risk factors. Long-term survival was poor and affected by the presence of diabetes (P < 0·01) and renal insufficiency (P < 0·01).

Conclusion

Late reinterventions are common after infrainguinal bypass for limb-threatening ischaemia, and contribute to morbidity and discomfort. Such information is of particular relevance to patients in high-risk groups and should be explained as an integral part of informed consent.
Prospective randomized multicentre study of laparoscopic versus open appendicectomy
Authors: Hellberg A , Rudberg C , Kullman E , Enochsson L , Fenyö G , Graffner H , Hallerbäck B , Johansson B , Anderberg B , Wenner J , Ringqvist I , Sörensen S
Published: March 2003

Background

A prospective randomized multicentre study was performed to compare the outcome of laparoscopic and open appendicectomy in patients with suspected acute appendicitis.

Methods

A total of 523 patients was randomized, but because of 23 withdrawals the outcome in 500 patients is reported, 244 in the laparoscopic group and 256 in the open group.

Results

Patients having laparoscopic appendicectomy recovered more quickly than those having open surgery (13 versus 21 days, P < 0·001). There was no significant difference in duration of sick leave after operation (laparoscopic group 11 days versus open group 14 days). Postoperative pain (at 24 h, 7 days and 14 days) was less after laparoscopic operations and a functional index 1 week after operation was more favourable in these patients (P< 0·001). Operating time was significantly longer in the laparoscopic group (60 versus 35 min, P< 0·01). Hospital stay and complications did not differ between the groups. Thirty laparoscopic procedures (12 per cent) were converted to open appendicectomy.

Conclusion

Laparoscopic appendicectomy is as safe as open appendicectomy and has the advantage of allowing a quicker recovery.
Colour–coded duplex imaging and dependent Doppler ultrasonography in the assessment of cruropedal vessels
Authors: McCarthy M J , Nydahl S , Hartshorne T , Naylor A R , Bell P R F , London N J M
Published: March 2003

Background

It has been suggested that ultrasonography could replace diagnostic arteriography in the assessment of patients who present with leg ischaemia. This study investigated a group of consecutive patients who had femorodistal bypass and who were assessed before operation with colour-coded duplex and dependent Doppler insonation alone.

Methods

Thirty-seven consecutive patients with critical lower limb ischaemia underwent surgical exploration with a view to femorodistal bypass. Results of preoperative colour-coded duplex and dependent Doppler insonation were compared with intraoperative arteriograms and surgical findings.

Results

There was very good agreement between colour-coded duplex imaging and dependent Doppler insonation with intraoperative angiography and surgical findings in the prediction of the optimal run-off vessel (κ = 1·0) and the site of the distal anastomosis (κ = 0·85; 95 per cent confidence interval 0·71–1·0). There was also very good agreement between dependent Doppler insonation and intraoperative arteriography (κ = 1·0) in predicting pedal arch patency and the predominant feeding vessel.

Conclusion

Assessment of leg arteries before femorodistal bypass can be performed accurately with non-invasive colour-coded duplex imaging and dependent Doppler insonation alone, thus obviating the need for preoperative arteriography.
Laparoscopic reoperation following failed antireflux surgery
Authors: Watson D I , Jamieson G G , Game P A , Williams R S , Devitt P G
Published: March 2003

Background

The aim was to determine the feasibility of laparoscopic revision surgery following previous open and laparoscopic antireflux operations.

Methods

The outcome was determined for 27 patients (14 men, 13 women) who had undergone attempted laparoscopic revision between 3 months and 25 years after a previous antireflux operation. Median follow-up was 12 (range 3–48) months.

Results

Thirteen patients had previously had an open antireflux procedure (Nissen fundoplication, seven; transthoracic anatomical repair, five; Belsey procedure, one) and 14 a laparoscopic procedure (Nissen, 12; anterior partial fundoplication, two). The indications for revision were: recurrent reflux, 15; paraoesophageal hiatus hernia, six; troublesome dysphagia, six. Fifteen procedures comprised construction of a new Nissen fundoplication, six conversion from a Nissen to a partial wrap, three repair of a paraoesophageal hernia and three widening of the oesophageal hiatus. Revision was successfully completed laparoscopically in 12 patients following a previous laparoscopic procedure and in nine following a previous open operation. Median operating time was 105 min after previous open surgery and 80 min after laparoscopic surgery. No perioperative complications occurred in either group and a good outcome was achieved in 25 of the 27 patients.

Conclusion

Laparoscopic reoperative antireflux surgery is feasible. Reoperation is likely to be more difficult following failure of an open procedure than a laparoscopic one.
Pathology and outcome of surgical treatment for lithium-associated hyperparathyroidism
Authors: Abdullah H , Bliss R , Guinea A I , Delbridge L
Published: March 2003

Background

Hyperparathyroidism associated with long-term lithium therapy is well described. However, few studies have clearly defined the pathological findings or looked at the outcome of surgical treatment.

Methods

The study was a retrospective review of 11 patients with bipolar affective disorder who had surgery for lithium-associated hyperparathyroidism.

Results

Twelve patients were identified who had received lithium therapy, of whom 11 (nine women and two men, aged 46–84 (mean 65) years) had prolonged treatment from 2 to 30 (mean 15·3) years. At operation a single adenoma was identified in six patients, whereas multigland disease was seen in five patients. All patients resumed lithium treatment after operation. One patient had recurrent hyperparathyroidism at 3 years, while another had an increased serum level of parathyroid hormone in the presence of a normal serum calcium level after 1 year.

Conclusion

Hyperparathyroidism associated with lithium may be due to either parathyroid hyperplasia or adenoma. Observations in the present study supported a true cause and effect relationship. Routine bilateral neck exploration should be performed because of a relatively high frequency of multigland involvement. However, parathyroid resection should be limited to evident disease.
Respiratory complications after thyroidectomy and the need for tracheostomy in patients with a large goitre
Authors: Rahim A A Abdel , Ahmed M E , Hassan M A
Published: March 2003

Background

Thyroidectomy for a large goitre carries a relatively high risk of postoperative respiratory obstruction which may necessitate tracheostomy.

Methods

One hundred and three patients with a large goitre who underwent thyroidectomy were studied prospectively. The presence or absence of six preoperative predictive factors for the development of serious postoperative respiratory obstruction was recorded. These factors were: goitre for more than 5 years, preoperative recurrent laryngeal nerve palsy, significant tracheal narrowing and/or deviation, retrosternal extension, difficult endotracheal intubation and thyroid cancer. Tracheostomy was performed on the basis of clinical judgement.

Results

Postoperative respiratory complications occurred in 32 patients (31 per cent), and were obstructive in 24 patients and not obstructive in eight. Tracheostomy was necessary in 13 patients (13 per cent). Tracheomalacia was the most common indication (n = 5). There were no deaths. At least four of the six risk factors were present in nine of the 13 patients who underwent tracheostomy compared with two of the 90 patients who did not.

Conclusion

Multiple preoperative risk factors in a patient with a large goitre may be useful in predicting the need for planned tracheostomy following thyroidectomy.
Management of bleeding pseudoaneurysms in patients with pancreatitis
Authors: de Perrot M , Berney T , Bühler L , Delgadillo X , Mentha G , Morel P
Published: March 2003

Background

Bleeding pseudoaneurysm is a rare but frequently fatal complication in patients with pancreatitis.

Method

The medical records of ten patients who presented to this institution with a bleeding pseudoaneurysm between 1978 and 1997 were reviewed retrospectively. Six patients had chronic pancreatitis and four had acute pancreatitis. The splenic artery was involved in six cases, a pancreaticoduodenal artery in two, the gastroduodenal artery in one and the cystic artery in one.

Results

Computed tomography (CT) revealed the bleeding pseudoaneurysm in all patients (n = 6) with chronic pancreatitis but in only one of three with acute pancreatitis. Arteriography always gave the correct diagnosis. Seven patients underwent pancreatic resection as an emergency (n = 3) or within 48 h (n = 4), and survived. Three patients presenting with acute pancreatitis and massive bleeding underwent transcatheter arterial embolization. Two of them had a favourable outcome and one died from a recurrent haemorrhage 7 days later. Overall, two patients suffered significant perioperative complications and one died.

Conclusion

CT is accurate in the diagnosis of pseudoaneurysms complicating pseudocysts. Primary resection of the pseudoaneurysm, which frequently requires pancreatic resection, is the treatment of choice. Angiography followed by transcatheter embolization is effective, but should be rapidly followed by operation.
Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis
Authors: Chiou T S-M , Chen S-C
Published: March 2003

Background

This report examines the intermediate-term results of endoscopic transaxillary T2 sympathectomy for palmar hyperhidrosis.

Methods

A retrospective review was carried out of 91 consecutive patients, 38 men and 53 women, with a mean age of 23 years. Attention was focused on patient satisfaction, late complications and morbidity.

Results

After operation, no patient died or developed Horner's syndrome. Nine of 21 patients with craniofacial, five of 16 with axillary and 17 of 73 with plantar hyperhidrosis showed simultaneous improvement. Fifteen patients (16 per cent) developed recurrent sweating, but none required reoperation. The overall mean satisfaction rate was 78 per cent with a median 80 per cent improvement using a visual linear analogue scale from 0 (poor) to 100 per cent (excellent). Twelve patients (13 per cent) were dissatisfied with the operative results, mainly owing to compensatory hyperhidrosis, which occurred in 88 patients (97 per cent) within the first year.

Conclusion

The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome.
Effect of exercise on calf muscle pump function in patients with chronic venous disease
Authors: Yang D , Vandongen Y K , Stacey M C
Published: March 2003

Background

Musculoskeletal dysfunction may be associated with poor calf muscle pump function in patients with chronic venous ulceration. The aim of this study was to evaluate the effects of physical exercise on calf muscle pump function.

Methods

Twenty patients were recruited into a 6-week intensive exercise programme. Calf muscle function and calf muscle pump function were assessed using an isokinetic device and air plethysmography respectively, before and after the exercise programme.

Results

There was significant improvement in calf muscle pump function, measured as increased ejection fraction and decreased residual fraction (P < 0·05); however, venous reflux was not altered (P > 0·05). Calf muscle strength and endurance parameters all increased, but not significantly (P> 0·05).

Conclusion

Poor calf muscle pump function in patients with chronic venous ulceration can be improved by physical exercise.
Sensory and autonomic neuropathy in patients with idiopathic slow-transit constipation
Authors: Knowles C H , Scott S M , Wellmer A , Misra V P , Pilot M-A , Williams N S , Anand P
Published: March 2003

Background

Slow-transit constipation (STC) is a severe disorder of unknown aetiology, which may result from an autonomic or sensory neuropathy. This study aimed to investigate patients with STC for the presence of neural dysfunction, and relate the findings to other factors, including any familial associations.

Methods

Thirty-three patients with STC were studied using standard neurophysiological tests and a range of quantitative sensory and autonomic tests. The findings were compared with those of 20 matched control subjects and nine diabetic patients with gastrointestinal symptoms.

Results

Twenty of the 33 patients with STC gave a family history of constipation, including an affected identical twin and Hirschsprung's disease (n = 3). None had abnormalities on neurological examination or nerve conduction studies. Fifteen of the 33 patients had abnormalities on quantitative tests, including all six who required a colectomy. Eleven patients with STC had reduced axon-reflex sweating in the presence of normal sweat gland responses (P< 0·001, all patients with STC versus controls). Twelve patients with STC had small sensory fibre dysfunction, with significantly increased thermal thresholds (cool, P< 0·05; warm, P< 0·01); these included six of nine patients with STC and rectal hyposensation. There were similar findings on quantitative testing in diabetic patients.

Conclusion

Quantitative tests in patients with STC provide evidence of a small fibre neuropathy. The high incidence of a positive family history, particularly a possible association with Hirschsprung's disease, suggests a genetic basis, which deserves further investigation.
Preoperative staging of rectal carcinoma
Authors: Heriot A G , Grundy A , Kumar D
Published: March 2003

Background

The development of treatment modalities for rectal cancer, including local excision, total mesorectal excision and preoperative radiotherapy, has increased the importance of accurate preoperative staging to allow the optimum treatment to be selected.

Methods

A literature review was undertaken of methods of preoperative staging of rectal carcinoma and the evidence for each was evaluated critically.

Results

Clinical assessment of rectal carcinoma may give an indication of fixity but is not accurate for staging. Endoanal ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), radioimmunoscintigraphy and positron emission tomography have all been used for staging. The extent of tumour spread through the bowel wall (T stage) is most accurately assessed by endoanal ultrasonography, although this technique is poor at assessing tumour extension into adjacent organs for which both CT and MRI are more accurate. No method accurately determines lymph node involvement, but endoanal ultrasonography is the best available. Liver metastases may be assessed by abdominal ultrasonography, CT, MRI and CT portography (with increasing sensitivity and cost in that order).

Conclusion

Endoanal ultrasonography is the most effective method of local tumour staging, with the addition of either CT or MRI if adjacent organ involvement is suspected. Abdominal ultrasonography or CT is recommended for routine preoperative assessment of the liver.
Results of repeat anal sphincter repair
Authors: Pinedo G , Vaizey C J , Nicholls R J , Roach R , Halligan S , Kamm M A
Published: March 2003

Background

Patients with a poor outcome from anterior sphincter repair may be candidates for dynamic graciloplasty, artificial bowel sphincter implantation or a secondary repair. This study examines the outcome of repeat overlap repairs in these patients.

Methods

Twenty-six of 235 patients undergoing a sphincter repair (median age 43 (range 23–63) years) underwent repeat repair from May 1994 to April 1997. Twenty-three patients were available for follow-up. Clinical evaluation included a satisfaction scale from 1 to 10, the patient's assessment of percentage improvement, ability to defer defaecation before and after operation, and Wexner continence scores before and after operation. Manometric studies were performed in 21 patients before and 17 patients after operation, and anal ultrasonography was undertaken in 17 patients before and 14 patients after operation. External sphincter defects were present on all preoperative scans.

Results

At a median follow-up of 20 (range 5–42) months, 15 patients felt that they were 50 per cent or more improved after operation. On the satisfaction scale of 1–10 the median score was 7 (range 1–10). There was a significant improvement in the Wexner continence score from 19 (range 17–20) before operation to 12 (range 1–20) after operation (P < 0·001). Ability to defer defaecation improved significantly from less than 5 min in all patients before operation to greater than 15 min in six patients after operation. Ultrasonography showed good overlap of the external sphincter muscle in eight of 14 patients. All patients who failed to improve showed a residual defect on ultrasonography.

Conclusion

Repeat anterior repair produces a significant improvement in continence score and ability to defer defaecation in patients with obstetric sphincter damage. Clinical improvement correlates closely with an improvement in the appearance on endoanal ultrasonography.
Digest
Authors: Lehnert T
Published: March 2003

For this quarter's digest, Professor Christian Herfarth and Dr Thomas Lehnert have selected the best from the April to June 1998 issues of Der Chirurg. A digest from the BJS for the same period, written by Mr Colin Johnson, appears in the German journal.
Sequential hepatic and pulmonary resections for metastatic colorectal cancer
Authors: Lehnert T , Knaebel H P , Dück M , Bülzebruck H , Herfarth C
Published: March 2003

Background

Resection of pulmonary or hepatic colorectal metastases is associated with a 5-year survival rate of 25–40 per cent. This report analyses outcome following sequential resection of colorectal metastases to both organs.

Methods

Seventeen patients with histologically confirmed colorectal adenocarcinoma and resection of liver and lung metastases were identified from a prospective database.

Results

The median interval between resection of the primary tumour and first metastasis was 21 (range 0–64) months. The interval between resection of the first and subsequent metastases was 18 (range 1–74) months. No patient died in the postoperative period and there were two perioperative complications. The overall survival rate in 17 patients was 70 per cent at 2 years from resection of metastasis to the second organ, but the disease-free survival rate at 2 years was only 24 per cent.

Conclusion

Although few long-term survivors were observed in this small series, sequential resection of hepatic and pulmonary metastases is warranted in a highly selected group of patients.
Surveillance for Barrett's oesophagus in the UK
Authors: Smith A M , Maxwell-Armstrong C A , Welch N T , Scholefield J H
Published: March 2003

Background

Endoscopic screening for Barrett's oesophagus is being offered without evidence of efficacy Barrett's oesophagus is not an ideal candidate for a screening programme, as the natural history is unclear, uncertainties surround the indication for intervention and the treatment is associated with high morbidity and mortality rates.

Methods

To determine the practices that clinicians employ in the management of Barrett's oesophagus in the UK, postal questionnaires were sent in May 1997 to 297 randomly selected members of the British Society of Gastroenterology asking for details of their current practice.

Results

Of 152 respondents, 106 (70 per cent) performed surveillance for Barrett's oesophagus; 46 (30 per cent) did not carry out screening. There was no difference in the practices carried out by physicians or surgeons, teaching or acute general hospital clinicians, or those with an upper gastrointestinal interest. There was a wide disparity in screening interval: just over half (52 per cent) screen at yearly intervals. Only nine (8 per cent) took four quadrant biopsies per 2 cm of Barrett's oesophagus. Nearly half (49 per cent) manage mild dysplasia by increasing the frequency of endoscopy; only seven (7 per cent) prescribed patients a proton pump inhibiting agent. Faced with severe dysplasia, 33 (31 per cent) offered surgery immediately; 22 (21 per cent) simply followed the patient by endoscopy. Those not choosing to perform screening most frequently cited lack of evidence of efficacy as the reason behind their decision.

Conclusion

There is wide variation in surveillance practices for Barrett's oesophagus. Some methods are ineffectual. The recommendations made by the Barrett's Oesophagus Working Party in 1991 are not followed, possibly because they are not practical. New workable guidelines based on available evidence and a consensus of expert opinion should be established; this was suggested by 38 per cent of respondents who performed screening.
Liver metastases after curative resection in patients with distal bile duct cancer
Authors: Takao S , Shinchi H , Uchikura K , Kubo M , Aikou T
Published: March 2003

Background

Curative resection cannot ensure long-term survival for patients with distal bile duct cancer. The aim of this study was to determine the most frequent mode of recurrence after curative resection and to analyse its risk factors.

Methods

Clinical details for 64 consecutive patients with distal bile duct cancer who underwent surgical resection between 1980 and 1997 were reviewed. Modes of recurrence and clinicopathological findings were analysed based on the residual tumour (R) classification.

Results

The overall actuarial 5-year survival rate was 32 per cent. Of 42 patients undergoing R0 resection 10 were alive at 5 years, of 17 having R1 resection one was alive at 5 years, and none of the five patients having R2 resection survived for 5 years (R0versus R1, P = 0·02). In the R0 group, the incidence of liver recurrence (14 of 42 patients) was similar to that in the R1 resection group (six of 17), although there were fewer lymph node and peritoneal recurrences than in patients who had R1 resection (P < 0·05). The high-risk factor for liver metastasis was microscopic vascular involvement. Important factors for survival were lymph node metastasis, microscopic vascular involvement and age. In addition, microscopic vascular involvement was the only independent factor for survival in the R0 group.

Conclusion

R0 resection provided significant survival benefit but had no effect on liver recurrence. Therefore, new agents or strategies to prevent liver metastasis are necessary for improvement of survival.
Mechanism of action of antireflux procedures
Authors: Rydberg L , Ruth M , Lundell L
Published: March 2003

Background

To define the clinical role of antireflux surgical procedures a proper understanding of their mode of action is required. The aim of this study was to investigate the impact of total or posterior partial fundoplication on the function of the lower oesophageal sphincter (LOS) in the basal state as well as during stimulation.

Methods

Patients with chronic reflux (n = 24) were randomized either to a total fundic wrap or to a posterior partial (Toupet) fundoplication. Basal LOS function was investigated as well as the response to inhibitory stimuli 4 years after operation. Inhibitory stimulation was elicited by water swallows and by gas distension (750 ml air insufflation into the stomach).

Results

Basal LOS tone was substantially higher (P = 0·01) after a total than a partial wrap, as was the nadir pressure after water swallows (10·1 versus 3·4 mmHg). Body position did not affect this difference. Transient LOS relaxations occurred only occasionally in the basal state. The frequency of transient LOS relaxation increased somewhat during the first 10 min of stomach distension with more occurring in patients who underwent a Toupet procedure. Common oesophagogastric cavities were more often seen in this latter group of patients after gas distension of the stomach.

Conclusion

These physiological observations on the LOS after total and posterior partial fundoplication explain the observed clinical differences in favour of the latter operation. The partial fundoplication seems to restore the physiology of the gastro-oesophageal junction more adequately, allowing air to be vented from the stomach without jeopardizing the antireflux barrier.
Topographical distribution of blood supply to the anal canal
Authors: Lund J N , Binch C , McGrath J , Sparrow R A , Scholefield J H
Published: March 2003

Background

It has been suggested that anal fissure is an ischaemic ulcer caused by a combination of poor blood supply to the posterior midline of the anal canal and spasm of the internal anal sphincter. This study investigated the topographical distribution of blood supply to quadrants of the anal canal above and below the dentate line.

Methods

Cadaveric anal canals were removed and 1-cm blocks were cut above and below the dentate line. Blocks were sectioned at 10 µm and every 25th section was mounted. Using the technique of systematic random sampling, fields in the subanodermal space and the internal anal sphincter in posterior, lateral and anterior quadrants of the anal canal were chosen. The numbers of small arterioles in each field were counted. Mean counts were compared for both subanodermal space and internal anal sphincter between quadrants and levels above and below the dentate line using Page's L test for trends.

Results

Anal canals from eight cadavers were examined. There was a significant trend to an increasing number of arterioles from posterior to anterior in the subanodermal space at all levels and at two of three levels in the internal anal sphincter.

Conclusion

The arteriolar density is less in the posterior quadrant throughout the anal canal. It may be that this poor blood supply predisposes to the development of anal fissures at their most common site in the posterior midline.
Inhibition of platelet-activating factor, intercellular adhesion molecule 1 and platelet endothelial cell adhesion molecule 1 reduces experimental pancreatitis-associated gut endothelial barrier dysfunction
Authors: Wang X , Sun Z , Börjesson A , Andersson R
Published: March 2003

Background

Endothelial barrier dysfunction is a critical link in the development of tissue injury and organ dysfunction, via upregulation and exposure of adhesion molecules, intercellular signals and leucocyte–endothelial cell interactions. Inhibitors of inflammatory mediators and receptors have been suggested as a means of downregulating the cascade of both local and systemic inflammation.

Methods

The potential therapeutic inhibition of platelet-activating factor (PAF), intercellular adhesion molecule (ICAM) 1 and platelet endothelial cell adhesion molecule (PECAM) 1 was investigated in pancreatitis-associated gut endothelial dysfunction in rats, by treatment with a PAF antagonist (lexipafant, BB-882) and monoclonal antibodies against rat ICAM-1 (anti-ICAM1-Mb) and PECAM (anti-PECAM1-Mb). Alterations in gut endothelial barrier dysfunction and leucocyte recruitment, and systemic levels of interleukins were evaluated.

Results

Plasma exudation measured by the albumin leakage index and tissue leucocyte recruitment in the distal small intestine and colon increased significantly 12 h after induction of pancreatitis and treatment with saline. These alterations were to varying degrees counteracted by treatment with lexipafant, anti-ICAM1-Mb or anti-PECAM1-Mb. Alterations in levels of interleukin (IL) 1 paralleled the changes in gut endothelial barrier dysfunction and leucocyte trapping.

Conclusion

Treatment with lexipafant and monoclonal antibodies against ICAM-1 or PECAM-1 reduced the severity of pancreatitis-associated gut endothelial dysfunction, and decreased systemic concentrations of IL-1 and local leucocyte recruitment.
Factors influencing survival of patients undergoing hepatectomy for colorectal metastases
Authors: Yamamoto J , Shimada K , Kosuge T , Yamasaki S , Sakamoto M , Fukuda H
Published: March 2003

Background

The extent of surgical margin is still a matter of controversy with regard to outcome after liver resection for metastatic disease. The aim of this study was to clarify the significant prognostic factors after hepatectomy for colorectal metastases, with special reference to the surgical margin.

Methods

Ninety-six patients who underwent initial hepatic resection for liver metastases from colorectal cancer between 1992 and 1994 were studied.

Results

Overall 1-, 3- and 5-year survival rates were 94, 61 and 51 per cent respectively. All of the independent factors associated with poor prognosis after hepatic resection were tumour-related factors, such as the number of tumours (four or more), presence of portal vein invasion, hepatic vein invasion and absence of a fibrous pseudocapsule. A positive resection margin was not an independent prognostic factor, because of its strong relationship with the number of tumours resected.

Conclusion

A generous surgical margin is not essential for curative hepatic resection, although positive surgical margins should be avoided. New potential risk factors which affect survival, such as the presence of portal vein or hepatic vein invasion and the absence of a pseudocapsule, may be helpful for defining the indications for postoperative adjuvant treatment.
Dietary intake after pancreatectomy
Authors: Maskell C , Daniels P , Johnson C D
Published: March 2003

Background

Nutritional intake after pancreatectomy may be impaired. The extent of the problem and the effect on intake of specific nutrients is unknown.

Methods

A 1-week weighed dietary food intake (using digital scales and a food diary) was studied in 15 patients, a median of 4 (range 1–30) months after pancreatectomy. Results were expressed as a percentage of estimated average requirement (EAR), reference nutrient intake (RNI) or lower RNI (LRNI) values.

Results

The median energy intake was 1914 (range 1154–2804) kcal/day, representing a median of 88 (56–154) per cent of EAR. Fat intake was low (72 (60–123) g/day); protein intake was adequate (139 (99–219) per cent of RNI). Deficiencies were observed in the intake of vitamin D (17 (6–56) per cent of LRNI) and, in some patients, selenium (107 (19–203) per cent of LRNI).

Conclusion

Nutritional intake in the months after pancreatectomy could be improved by increasing fat intake (with enzyme supplements as appropriate). This 7-day study also suggests that these patients may require vitamin D and possibly selenium supplementation.