bluuebunny/crossref_metadata_2025 huggingface dataset:
Contralateral inguinal lymph node metastasis in patients with melanoma of the lower extremities
Authors: Jonk A , Kroon B B R , Mooi W J , Hoefnagel C A
Published: March 2007

A retrospective study was carried out on six patients with contralateral inguinallymph node metastasis from a melanoma of the lower extremity. All six patients were found to have had a previous homolateral groin dissection and in five patients there was intercurrent disease relapse in the leg before or at the same time as the appearance of contralateral node metastasis. Although the prognosis in these patients is unfavourable, two had a survival period of 24 and 32 months and two were still alive 27 months after contralateral groin dissection. In order to determine possible pathways of dissemination, lymphoscintigraphic studies of the leg were performed in another 16 melanoma patients who in the past had undergone a groin dissection. In 13 of them uptake in the contralateral inguinal lymph nodes was detected, indicating that groin dissection can lead to a different lymphatic flow pattern, which is often directed to the contralateral groin. Contralateral lymph node involvement may be an expression of regional disease. In such patients a contralateral groin dissection is advocated.
Lateral internal sphincterotomy in the treatment of fourth degree haemorrhoids
Authors: De Roover D M L R , Hoofwijk A G M , van Vroonhoven Th J M V
Published: March 2007

Between January 1984 and May 1988, 25 patients with fourth degree haemorrhoids were treated in the acute phase by lateral internal sphincterotomy under narcosis. Pain relief was immediate. The median hospital stay was 3 days. The median follow-up period was 26 months. For 20 patients a single lateral internal sphincterotomy alone was adequate treatment. If further therapy was required, simple band ligation was enough. There was one recurrence, which was treated with a further lateral internal sphincterotomy. In the long term, 18 patients had no complaints and seven had only minor complaints. Twenty-three patients were very satisfied and two were moderately satisfied. Nobody was dissatisfied. Lateral internal sphincterotomy is an attractive alternative in the treatment of fourth degree haemorrhoids, its major benefits being simplicity, efficiency and low morbidity.
Construction of a neorectum and neoanal sphincter following previous proctocolectomy
Authors: Williams N S , Hallan R I , Koeze T H , Watkins E S
Published: March 2007

A new operation is described in which a neorectum and neoanal sphincter mechanism have been constructed to restore gastrointestinal continuity and continence in a patient who had previously undergone proctocolectomy and a permanent ileostomy. The neorectum was constructed by forming a triplicated pouch from the distal ileum. The neoanal sphincter was fashioned from a transposed gracilis muscle and was activated electrically by an implanted stimulator. A period of chronic low frequency stimulation altered the muscle characteristics and enabled the neosphincter to contract continually without fatigue. Complete continence was achieved by the neosphincter gripping a Silastic® plug inserted within the efferent spout of the pouch. The patient was able to void completely when the stimulator was switched off and the plug removed.
Limb conservation for soft tissue sarcomas of the shoulder and pelvic girdles
Authors: Barr L C , Robinson M H , Fisher C , Fallowfield M E , Westbury G
Published: March 2007

Fifty-five patients with soft tissue sarcomas of the shoulder and pelvic girdles were treated between 1982 and 1987 with a consistent policy of limb conservation, using a wide variety of excisional and reconstructive surgical techniques and radical radiotherapy. Actuarial 5-year overall survival was 75 per cent for patients with low or intermediate grade tumours, and 38 per cent for those with high grade tumours (log rank test, P <0·05). Five-year local recurrence rates were 32 per cent for low or intermediate grade tumours, and 48per cent for high grade tumours (log rank test, not significant). Multivariate analysis of the following risk factors for overall survival was performed: age, sex, tumour site, diameter, grade, inadequate surgical margins and local recurrence. Age over 55 years and high tumour grade emerged as independent prognostic variables for survival. Forequarter or hindquarter amputations were undertaken in seven of the 55 patients for local recurrence following previous limb-conserving surgery and radiotherapy. Local failure was not always salvaged by major amputation; satisfactory proximal tumour clearance was achieved in only two of seven patients undergoing major amputation; four of the seven patients developed stump recurrence, three of whom died with uncontrolled local disease. Meticulous attention to surgical and radiotherapeutic technique is required to minimize the incidence of local recurrence while maintaining satisfactory limb function.
Combined endocrine effects of LHRH agonist (Zoladex®) and tamoxifen (Nolvadex®) therapy in premenopausal women with breast cancer
Authors: Robertson J F R , Walker K J , Nicholson R I , Blamey R W
Published: March 2007

In premenopausal women with breast cancer, the use of the luteinizing hormone releasing hormone agonist, goserelin, results in the production of serum levels of oestradiol equivalent to those after surgical oöphorectomy or in postmenopausal women. The standard first line hormonal treatment for systemic breast cancer in postmenopausal women is tamoxifen. The combination of goserelin and tamoxifen in premenopausal women has been proposed. We have treated 34 premenopausal breast cancer patients with goserelin (3·6 mg) monthly and tamoxifen (20 mg) twice daily: endocrine data are available on all 34 patients. As with goserelin alone, patients on goserelin and tamoxifen showed transient stimulation of serum follicle stimulating hormone over the first 7–10 days with subsequent low gonadotrophin levels. Serum oestradiol and progesterone levels were reduced to castrate levels in all patients studied; no peaks of serum oestradiol were detected. There is no endocrinological contraindication to the use of goserelin and tamoxifen together in premenopausal women with breast cancer either as adjuvant therapy or in treating advanced disease.
Sample size in fine needle aspiration biopsy
Authors: Kreula J , Bondestam S , Virkkunen P
Published: March 2007

The weights of biopsy specimens from bovine liver taken for fine needle aspiration cytology (FNAC) by three groups of physicians, were compared. The groups differed from each other in their extent or degree of experience in FNAC. When the physicians used their normal technique, the mean sample weight increased significantly with experience, from 4·6 mg in the least experienced group to 17·2 mg in the group with the longest experience. Thirty-six per cent of the samples taken by the group with the least experience were in the weight class 0–2 mg, whereas no such samples were encountered for the other groups. When all the physicians were advised to use the same, standard technique there were no statistically significant differences in mean sample weight between the groups or in the proportion of samples in class 0–2 mg. Sample weights correlated significantly (P<0·001) with cell counts. This study shows that differences in the technique of FNAC are responsible for differences in sample weights and cell counts, including the number of the acellular samples obtained. This could explain in some part the wide variation in the reported accuracy rates of FNAC.
Time-related changes in characteristics of prognostic significance in carcinomas of the oesophagus and cardia
Authors: Lund O , Hasenkam J M , Aagaard M T , Kimose H H
Published: March 2007

During 25 years (1960–84) 657 patients were operated on for squamous cell carcinomas (n = 230), adenocarcinomas (n = 399) or anaplastic carcinomas (n = 28) of the thoracic oesophagus or cardia. The male: female ratio was 2·8:1 and the mean age was 66 years (range 22–91 years). Oesophagogastrectomy (n = 514) was performed whenever technically possible. From the first (1960–64) to the last (1980–84) 5-year period the proportion of adenocarcinomas increased from 56 to 78 per cent (P <0·001), poorly differentiated cancers increased from 34 to 65 per cent (P <0·0001), and stage III-IV tumours increased from 72 to 88 per cent (P <0·05). Five-year cumulative rates(s.e.) were 11(3) per cent for operations during 1960–69 (n = 262), 8(2) per cent during 1970–79 (n = 256) and 3(2) per cent during 1980–84 (n = 139; P <0·05). Hospital mortality rates (·30 days) and 5-year cumulative survival rates(s.e.) were 6·5 per cent and 36(7) per cent (n = 46) for stage I, 14·0 per cent and 21(4) per cent (n = 114) for stage II, 17·8 per cent and 5(1) per cent (n = 258) for stage III and 23·8 per cent and 3(1) per cent (n = 239) for stage IV tumours (P <0·05 and P <0·001). Well differentiated (n = 70) cancers, those of medium differentiation (n = 239) and poorly differentiated cancers (n = 348) had 5-year survival rates(s.e.) of 24(5), 10(2) and 5(1) per cent, respectively (P = 0·0007). Squamous cell carcinomas had a better prognosis than adenocarcinomas, even after stratification according to location of primary tumour. The 657 patients who underwent surgery constituted 50 per cent of a total of 1316 cases with cancer of the oesophagus and cardia reported from our catchment area during the study period. Frequency of surgery decreased with age. The annual incidence (number per 100000 inhabitants aged 20 years or more) of adenocarcinomas of the lower oesophagus and cardia doubled to 5·9 in 1980–84, while that of squamous cell carcinomas tended to decrease (to 2·9). A successive worsening of long-term survival after surgery was explained by significant changes in cancer characteristics having pronounced prognostic significance. Over the 25 years the carcinomas changed towards the present pattern where poorly differentiated adenocarcinomas of the lower third of the oesophagus and cardia in stages III–IV have become predominant.
Modern aids to clinical decision-making in the acute abdomen
Authors: Paterson-Brown S , Vipond M N
Published: March 2007

Acute abdominal pain continues to provide not only a large workload for the general surgeon but also many diagnostic and management problems. Many different techniques have been introduced over the past two decades to help in the management of the acute abdomen and this review considers their relative claims to become incorporated into the process of clinical decision-making. The evidence in support of formally structured patient interview pathways with or without computer-aided diagnostic programs is now overwhelming and should become routine. Both laparoscopy and peritoneal cytology have an important role to play in the management of patients in whom the decision to operate is in doubt, and a combination of the two would be complementary. Ultrasonography has become increasingly popular for investigating the acute abdomen, and results from specialist centres are impressive. However, the problems of operator variation and the difficulties in providing a 24-h service will probably prevent it from becoming a first-line investigation in most hospitals. Although plain radiography has been available for many years, its routine use in the management of the acute abdomen remains controversial. Recent studies have confirmed that contrast radiography is an important adjunct to decision-making, particularly in the management of large bowel obstruction, and there is increasing evidence to support its use in suspected small bowel obstruction, perforated peptic ulcer and acute diverticular disease.
Acute haemorrhage from gastric malignancy
Authors: Allum W H , Brearley S , Wheatley K E , Dykes P W , Keighley M R B
Published: March 2007

The presentation, pathology and treatment of 30 patients with acute bleeding from gastric malignancies has been reviewed. Patients usually have a history of symptoms of less than 6 months prior to bleeding. Adenocarcinoma was the commonest type of tumour, and 74per cent were stage IV lesions. The proportion of lesions in the body of the stomach (57per cent) was greater than expected, suggesting that these are different populations of gastric tumour. Laparotomy was undertaken in 20 patients, 12 of whom had a resection. Resection was associated with a median survival of 17·0 months. Those with unresectable tumours or who were treated only by supportive measures had a median survival of only 2·5 months (P < 0·01). Evidence of peritoneal or liver involvement should contraindicate surgical intervention as these patients have a high postoperative mortality rate.
Gastrointestinal fistulas associated with large abdominal wall defects: Experience with 43 patients
Authors: Schein M , Decker G A G
Published: March 2007

Experience with 43 patients with gastrointestinal fistulas associated with a large abdominal wall defect is presented. The overall mortality rate was 60per cent; 37per cent in patients who underwent the primary procedure in the home unit and 74 per cent in those from elsewhere. An average of five operations per patient was performed. The abdominal wall defect developed spontaneously as a consequence of postoperative peritonitis in 24 patients (mortality rate, 71 per cent) and was created intentionally as apart of the ‘open management’ in 19 cases (mortality rate, 47per cent). Errors in management were identified in 63per cent of the patients and this adversely influenced the outcome. Patients with this condition should be referred early to tertiary care facilities where diversion of the intestinal leak away from the defect, prompt control of the associated intra-abdominal infection and adequate handling of the defect itself can be performed.
Evaluation of the prognostic value of triple node biopsy in early breast cancer
Authors: du Toit R S , Locker A P , Elis I O , Elston C W , Blarney R W
Published: March 2007

The prognostic information obtained by triple node biopsy (low axillary, apical axillary and internal mammary nodes) in 693 patients with early breast cancer has been reviewed. Results show that tumour site within the breast influenced which nodal groups were involved. The low axillary node contributed the most useful prognostic information. The involved apical node carried the worst prognosis. Either the internal mammary node or a low axillary node when positive alone carried the same prognostic weight. When both nodes were positive the prognosis declined to the level associated with apical node positivity. A double node biopsy of the low axillary node and either the apical or the internal mammary node gave the same maximum prognostic information as a triple node biopsy. The triple node biopsy technique can be used to divide patients into groups with vastly different prognoses.
Synthesis of prostaglandins I2 and E2 by the canine gallbladder in vitro: Studies using a new incubation chamber
Authors: England D W , Jaffe B M , Webb H , Hoover E L
Published: March 2007

Using a specially designed incubation chamber, differential synthesis and the response to added arachidonic acid (25 mm) and l-α-phosphatidylcholine (LAP; 2mM) was quantified in gallbladders from male and female dogs. Prostaglandin I2 (PGI2) was the predominant prostanoid synthesized, and tissues from females produced much more PGI2 under basal conditions than did gallbladders harvested from male dogs. Addition of arachidonic acid stimulated PGI2 synthesis by almost 100 per cent. Arachidonate-stimulated mucosal and serosal production of PGI2 were (mean(s.e.m.)) comparable, 343(178) and 375(89) pg/cm2/min, respectively. Gallbladders from female animals synthesized significantly more PGI2 than did tissue from males. Indomethacin inhibited PGI2 synthesis in a dose–response manner; at 7 × 10−5m, prostanoid synthesis was inhibited by >80 per cent. Arachidonic acid did not stimulate prostaglandin E2 (PGE2) production by gallbladder tissue. LAP similarly stimulated PGI2 biosynthesis, but in contrast to the effect of arachidonic acid, the effect was significantly greater in the serosa than the mucosa, 355(107) and 213(59) pg/cm2/min, respectively. LAP also stimulated PGE2 biosynthesis by the canine gallbladder in a pattern very similar to that of PGI2. Based on the differences in response to the two agents added, we conclude that arachidonic acid and l-α-phosphatidylcholine stimulate prostaglandin biosynthesis via independent pathways. We advocate the use of the incubation chamber for the assessment of prostanoid biosynthesis by the gallbladder in vitro.
Impact of duplex scanning on carotid endarterectomy
Authors: Chant A D B , Thompson J F , Stranks G J , Ranaboldo C , Humphries K N , Hames T K , Clifford P C
Published: March 2007

Duplex ultrasound permits safe and accurate assessment of the extracranial vasculature. This paper reports the change in patterns of referral to a specialized vascular unit following its introduction; increased referrals were seen in all specialities except neurology. A widely available and reliable duplex service has revealed more extracranial vascular disease than was previously recognized, and has increased referrals for carotid endarterectomy, thereby increasing surgical workload.
Prospective study of colorectal cancer in the West of Scotland: 10-year follow-up
Authors: McArdle C S , Hole D , Hansell D , Blumgart L H , Wood C B
Published: March 2007

Six hundred and forty-five patients presenting with colorectal cancer over a 6-year period were studied prospectively. At the time of presentation almost half the patients had clinical evidence of local tumour fixity and over one-quarter had distant metastases. The overall resectability rate was 70·8 per cent, apparently curative resection being obtained in 52·5 per cent. Overall operative mortality rate was 13·8 per cent, increasing in the elderly. Approximately 70 per cent of patients undergoing ‘curative’ resections survived for 2 years, 50 per cent survived for 5 years and 40 per cent survived for 10 years. After palliative resection approximately 10 per cent of patients survived for 5 years; only six of 133 patients (4 per cent) undergoing palliative diversion survived for 2 years. This prospective study confirms the advanced stage of colorectal cancer as it presents to a non-specialist centre. Although the poor outlook is largely a consequence of the advanced nature of the disease, there is evidence to suggest that the results of surgical intervention could be improved.
Meta-analysis of randomized, controlled clinical trials of antibiotic prophylaxis in biliary tract surgery
Authors: Meijer W S , Schmitz P I M , Jeekel J
Published: March 2007

In this study all available clinical trials of antibiotic prophylaxis in biliary tract surgery, published from 1965 to 1988, were examined. Results of 42 randomized, controlled trials (4129 patients), in which a group of patients treated with antibiotics was compared with a group of patients not treated with antibiotics, were pooled. Wound infection rates in the control groups range from 3 to 47 per cent and are 15 per cent overall. The overall difference in infection rates is 9 per cent in favour of antibiotic treatment (95 per cent confidence interval 7–11 per cent), while the common odds ratio is 0·30 (95 per cent confidence interval 0·23–0·38). Subgroup meta-analysis showed a significant stronger protective effect in high risk patients, while the timing of wound inspection (i.e. early in hospital or late at follow-up) markedly influenced the treatment effect reported. Comparison of wound infection rates in patients treated with first generation versus second or third generation cephalosporins (11 trials, 1128 patients), as well as single-dose versus multiple-dose regimens (15 trials, 1226 patients) did not reveal any significant effect (P > 0·05) in each trial separately as well as in the overall comparison. The results indicate that there is evidence against further use of no-treatment controls and that the choice of treatment regimen can largely be made on the basis of cost.
Progressive pneumoperitoneum in the management of giant incisional hernias: A study of 41 patients
Authors: Caldironi M W , Romano M , Bozza F , Pluchinotta A M , Pelizzo M R , Toniato A , Ranzato R
Published: March 2007

Forty-one patients (17 men and 24 women) were treated with progressive pneumoperitoneum before repair of giant incisional hernias. The pneumoperitoneum was induced using nitrous oxide gas and a laparoscopic insufflator, and was topped up every other day for a mean of 5·5 days with a total injection of 23·2 litres of nitrous oxide. The pneumoperitoneum was well tolerated in 30 patients, caused a mild temporary pain in 10 patients and a sharp pain in one patient; no serious side-effects occurred. All the patients underwent surgery to repair their hernias, 40 patients were available for follow-up for a mean of 25·3 months, only two hernias recurred both within 4 months of the operation.
Skeletal muscle enzyme activities and metabolic substrates during exercise in patients with postoperative fatigue
Authors: Christensen T , Nygaard E , Stage J G , Kehlet H
Published: March 2007

Subjective fatigue was quantified before and 20 days after uncomplicated elective abdominal surgery in 12 patients and compared with changes in heart rate, enzyme activities and skeletal muscle substrates before and after bicycle exercise for 10 min at 65per cent of patients' preoperative maximum work capacity. Fatigue increased from a mean(s.e.m.) preoperative level of 2·5(0·5) arbitrary units to 4·6(0·5) on postoperative day 20 (P<0·01). Body-weight, triceps skinfold thickness and arm circumference decreasedpostoperatively (P<0·02). Postoperative values of muscle enzyme activities indicative of oxidative phosphorylation capacity (citrate synthase and 3-OH-acyl coenzyme A dehydrogenase) were lower than preoperative values (P<0·05). Lactate dehydrogenase was unaltered and resting values of muscle glycogen and adenosine triphosphate were higher after operation (P<0·05). In response to exercise, heart rate, muscle glucose, glucose-6-phosphate and lactate increased (P<0·05), while muscle glycogen and creatine phosphate decreased (P<0·05). Increase in postoperative fatigue correlated with the increase in heart rate (P<0·05), while no significant correlations were found between fatigue and muscle parameters. Our results suggest that lack of exercise and malnutrition may be of importance in the decrease in work capacity and in fatigue after operation.
Asymptomatic gallstones
Authors: Gibney E J
Published: March 2007

The increasing detection of asymptomatic gallstones leads to difficult decisions for the surgeon and patient about whether the stones should be managed expectantly or surgically. This review examines the evidence currently available upon which such decisions must be based. Gallstones may present as biliary pain, acute cholecystitis, biliary obstruction or pancreatitis, but it is not clear who will develop symptoms and what are the commonest initial symptoms. Studies of the natural history of silent gallstones suggest that a large majority of patients with such stones will remain asymptomatic. However, diabetics are at increased risk, as are patients whose stones are detected initially at laparotomy. Incidental cholecystectomy is usually safe, and preoperative detection by ultrasonic screening is an advantage in planning the operation. Prophylactic cholecystectomy is not indicated to prevent gallbladder carcinoma (except in cases of porcelain gallbladder) and there is conflicting evidence about whether cholecystectomy predisposes to colorectal carcinoma.
Non-invasive estimation of peripheral resistance using Pulse Generated Runoff before femorodistal bypass
Authors: Scott D J A , Vowden P , Beard J D , Horrocks M
Published: March 2007

The measurement of peripheral resistance (PR) is a useful technique for predicting the outcome of femorodistal bypass. In an attempt, non-invasively, to predict PR, Pulse Generated Runoff (PGR) was used to assess 35 consecutive patients undergoing femorodistal non-reversed vein bypass for critical ischaemia. The PGR subscores (anterior tibial, posterior tibial, peroneal, pedal arch status were correlated against the measured PR. Using multiple linear regression three resistance values were derived for runoff at different levels: (1) a single calf vessel (R1); (2) distal popliteal artery (R3); (3) irrespective of the level (R0). There was good agreement between the predicted resistances RO, R1 and R3 and the measured PR. In the single calf vessel group (R1) the limits of agreement (−0·41 to +0·39) and 95 per cent confidence interval (−0·16 to +0·14) with the measured PR were better than in the R0 and R3 groups. These levels of agreement are small enough to replace the measured PR with the predicted PR method. Using the appropriate resistance equation in a further prospective series of 14 cases, there was agreement between the predicted and measured PR (limits of agreement −0·67 to +0·41; 95 per cent confidence interval −0·26 to +0·15). These results confirm the value of PGR in the assessment of critically ischaemic limbs particularly with a single calf vessel. Calf vessel continuity with the pedal arch appears to be a major determinant of PR, particularly in the isolated calf vessel group. A non-invasive resistance value can be derived which will predict the intraoperative peripheral resistance and should help predict subsequent graft outcome.
Urine acid output as a test of completeness of vagotomy
Authors: Johnson C D , Rai A S
Published: March 2007

Peak acid output in response to sham feeding and changes in urine acid output 2 and 3 hours after a test meal have been measured in 20 normal volunteers, 17 asymptomatic patients after vagotomy, six patients with recurrent duodenal ulcer after vagotomy and ten normal subjects given a 48-h course of ranitidine, 150 mg 12-hourly. Gastric peak acid output in normal volunteers ranged from 6·9 to 22·1 mmol/h. All asymptomatic patients after vagotomy had a peak acid output < 7 mmol/h, consistent with complete vagotomy. Five patients with recurrent ulcer had a peak acid output > 8 mmol/h, suggesting an incomplete vagotomy. Urine acid output after a test meal, expressed as the change from the basal rate of acid output, was always in a negative direction in normal subjects (fall in acid output = postprandial alkaline tide. This change was abolished in patients with complete vagotomy, in whom urine acid output increased after a meal. In five patients with incomplete vagotomy (and one other with recurrent ulcer and unknown vagal status) the urine acid output changed in a negative direction after a test meal. The relationship of urine acid output to gastric secretion was confirmed by the abolition of the postprandial alkaline tide in normal subjects given ranitidine. The results in patients with incomplete vagotomy did not overlap with those from patients with complete vagotomy. This suggests that this test could be used for the routine postoperative assessment of completeness of vagotomy.
Continuous 99mTc-HIDA infusion as a method for measuring duodenogastric reflux
Authors: Mompeán J A Luján , Paricio P Parrilla , Campos R Robles , Jímenez T Fuente , Gomez D Martínez
Published: March 2007

The continuous 99mTc-HIDA infusion test is presented as a method for measuring duodenogastric reflux as well as for studying biliary elimination of the compound when it is administered by constant intravenous infusion. Thirty patients were studied: (a) ten patients with a T tube placed in the biliary tree were used to study the elimination of 99mTc-HIDA in the bile; (b) ten normal subjects were used as a control group; and (c) ten patients were studied who had undergone Billroth I gastrectomy for peptic ulcer ation. Studies of subjects in groups (b) and (c) were used to assess duodenogastric reflux by this test, correlating it with the measurement of bile acids in gastric juice. When 99mTc-HIDA was administered by constant intravenous infusion it resulted in an increased elimination in bile for the first 80–100 min, and the concentration in bile then remained relatively constant for the rest of the test. With respect to the duodenogastric reflux study group, reflux rates in the patients who had been operated on were higher than those in the control group, with statistically significant differences. Minimum reflux rates were found in the normal subjects. Assessment of reflux by 99mTc-HIDA correlated closely with the results of bile acid concentrations in Billroth I patients (r = 0·75, P < 0·001) and control subjects (r = 0·85, P < 0·001). Our results demonstrate that continuous 99mTc-HIDA perfusion is a useful, accurate and objective method for measuring duodenogastric reflux.
Primary hepatic malignancy: The role of liver transplantation
Authors: Ismail T , Angrisani L , Gunson B K , Hübscher S G , Buckets J A C , Neuberger J M , Elias E , McMaster P
Published: March 2007

Between January 1982 and April 1989, 134 patients with a suspected liver neoplasm were referred to the liver unit, Queen Elizabeth Hospital, Birmingham. In 105 (78 per cent), a primary hepatic neoplasm was historically confirmed, and 47 patients (45 per cent) proved to have primary hepatocellular carcinoma. Twenty-nine orthotopic liver transplants were performed in 28 of these patients (27 per cent). Twenty patients (71 per cent) survived 30 days or longer (median 11·5 months; range 2–87 months), of whom nine are currently alive. We retrospectively analysed our data to determine the influence of preoperative evaluation, histological type and staging on outcome. Computed tomography proved to be superior to intraoperative assessment (86 versus 58 per cent) in diagnosing tumour positive nodes. Patients with tumour negative lymphadenopathy had a better prognosis. Postoperative stage I/II had a median survival of 16 months (range 3–87 months) compared with 7·5 months (range 2–20 months) for stage III. Non-cirrhotic patients with hepatocellular carcinoma had the best prognosis; cholangiocellular carcinoma and cirrhotic patients with hepatocellular carcinoma had the worst outcome with no survivors beyond 1 year. Because of the advanced stage of disease at the time of presentation, the value of liver transplantation in primary liver cancer is limited. For those presenting with advanced disease confined to the liver (stage I/II) in whom conventional hepatic resection is not possible, significant benefit can be achieved in selected cases.
Differing effects of pethidine and morphine on human sphincter of Oddi motility
Authors: Thune A , Baker R A , Saccone G T P , Owen H , Toouli J
Published: March 2007

The aim of this study was to evaluate the effects of morphine and pethidine on human sphincter of Oddi motility. The action of these opioids on the sphincter of Oddi was evaluated by means of intraoperative manometry in 36 patients undergoing elective cholecystectomy. Both opioids were given in intravenous cumulative equipotent doses up to a maximum of 10 μg/kg morphine or 100 μg/kg pethidine. At these doses, morphine increased the mean(s.d.) frequency of contractions from 2·4(1·0) to 7·9(1·6) (P < 0·001); this effect was reduced by naloxone (0·04 mg bolus, P < 0·05). Pethidine inhibited the frequency of contractions from 1·5(0·8) to 0·8(0·5) (P < 0·05); this response was blocked by atropine (0·6 mg bolus, P < 0·01). Pretreatment with atropine or naloxone reduced the frequency of contractions significantly (P < 0·05). The results illustrate different responses to pethidine and morphine of the sphincter of Oddi, and provide a pharmacological explanation for the suitability of pethidine over morphine as the analgesic of choice in patients experiencing biliary pain.
Experimental study of starch-induced intraperitoneal adhesions
Authors: McEntee G P , Stuart R C , Byrne P J , Leen E , Hennessy T P
Published: March 2007

The effects of starch on the development of postoperative adhesions were examined in 144 Sprague Dawley rats. Groups of rats were injected intraperitoneally with suspensions of washings from starched gloves, starch-free gloves and starch-poor washed gloves, and after operative manipulation of the bowel. The incidence of adhesions was greatest (78 per cent) after laparotomy and injections of starch-rich washings and least when starch-poor (33 per cent) or starch-free glove suspensions (37 per cent) were used, confirming an advantage for washing gloves or switching to starch-free products.
Pancreatic ischaemia in experimental acute pancreatitis: Mechanism, significance and therapy
Authors: Klar E , Messmer K , Warshaw A L , Herfarth C
Published: March 2007

Much clinical and experimental evidence suggests that pancreatic ischaemia in the early phase of acute pancreatitis is important in the development of pancreatic necrosis. While depletion of intravascular volume has often been assumed to be the main circulatory defect, an additional disturbance of pancreatic microcirculation has been demonstrated experimentally. Possible contributory mechanisms include chemical-induced vasoconstriction, direct injury of vessel wall, intravascular coagulation and increased endothelial permeability resulting in pancreatic oedema, haemoconcentration and impaired venous drainage. Pancreatic ischaemia as a consequence of these local effects seems to be responsible for the transition of mild pancreatitis to parenchymal necrosis. In experimental models the beneficial effect of various drugs and of sympathetic blockade has been ascribed to an improvement in pancreatic perfusion. Although effective volume therapy is generally accepted as the mainstay of conservative treatment in acute pancreatitis, the efficacy of different fluid preparations is still controversial, and simple fluid resuscitation has not been shown to prevent the development of parenchymal necrosis. The specific impairment of pancreatic microcirculation cannot be prevented merely by replenishment of intravascular volume with crystalloids, albumin or plasma despite normalization of macrohaemodynamics. In contrast, partial replacement of blood by dextran preparations has been shown to increase pancreatic perfusion by improving blood fluidity. Isovolaemic haemodilution in conjunction with conventional fluid therapy may provide a new and effective means of protecting the pancreas from secondary injury due to the early ischaemic phase of acute pancreatitis.
Effective intraperitoneal antiprotease therapy for taurocholate-induced pancreatitis in rats
Authors: Wilson C , Imrie C W
Published: March 2007

In canine pancreatitis, irreversible hypotension and death follow saturation of the antiprotease molecules in peritoneal exudate by activated proteolytic enzymes which are released from the pancreas. This study has examined, in rats with taurocholate-induced pancreatitis, the efficacy of removal of the peritoneal exudate by aspiration and a single lavage, followed by instillation of an exogenous antiprotease solution. Instillation of human fresh frozen plasma, containing α2-macroglobulin and α1-antiprotease, was associated with the longest median survival. Aprotinin, although possessing a much greater trypsin inhibitory capacity, just failed to significantly improve the median survival time compared with the control group. Intraperitoneal antiprotease therapy is simple to perform, has a beneficial effect on survival time in this model and merits investigation in man.
Value of retesting subjects with a positive Hemoccult® in screening for colorectal cancer
Authors: Kewenter J , Engarås B , Haglind E , Jensen J
Published: March 2007

Within a prospective randomized screening study for early detection of colorectal cancer with rehydrated Hemoccult II® test, the possibility of increasing the specificity of the test by retesting patients with an initially positive Hemoccult II test was investigated. Of those offered the test 3561 (62·6 per cent) returned it and it was positive in 210 cases (5·9 per cent). The repeat test was performed by 184 patients and was positive in 68 (1·9 per cent). All those with a positive initial test had rectosigmoidoscopy to 60 cm and a double contrast enema. A carcinoma was found in one in seven patients with a positive retest but in only one in 100 patients with a negative retest (P < 0·001). The specificity of the test was, therefore, increased from 95 per cent to 98 per cent and the sensitivity was unchanged. Rescreening was offered at a later date and increased numbers were available: 7147 patients returned the test and 369 (5·2 per cent) were positive. The test was repeated in 360 patients and 118 (1·7 per cent) were positive. A colorectal neoplasm was found in one in three of those with a positive repeat test, compared with one in seven of those with a negative repeat test. In conclusion, screening for early detection of colorectal cancer with a rehydrated Hemoccult II test may be followed by investigation of only those patients with a positive retest. Such a procedure will reduce the work-load by 60 per cent without reducing sensitivity.
Paraileostomy hernia: A clinical and radiological study
Authors: Williams J G , Etherington R , Hayward M W J , Hughes L E
Published: March 2007

Forty-six patients who underwent colectomy with end ileostomy for ulcerative colitis (n = 33) or Crohn's disease (n = 13) have been reviewed for paraileostomy hernia (PIH) formation 1–16 years after surgery. PIH developed in 13 of these patients (28 per cent) and was not related to the original disease or excessive weight gain. Twenty-eight patients underwent limited computed tomography (CT) scanning of the stomal region. Eight of these had a clinically detectable PIH, which was demonstrated on CT. A further two patients had PIH demonstrated on CT which was not detected by clinical examination. The rate of PIH was similar where the stoma emerged lateral to the rectus abdominis muscle (six out of 16 patients, 37 per cent) to where the stoma emerged through the rectus (four out of 12 patients, 33 per cent). Recurrence following operative repair of PIH was common. PIH occurs more frequently than previously supposed. CT can detect PIH and may be useful in evaluating a patient with stoma-related symptoms for occult PIH formation.
Role of fine catheter peritoneal cytology and laparoscopy in the management of acute abdominal pain
Authors: Baigrie R J , Saidan Z , Scott-Coombes D , Hamilton J B , Katesmark M , Vipond M N , Paterson-Brown S , Thompson J N
Published: March 2007

Laparoscopy and fine catheter peritoneal cytology (FCPC) have been advocated as aids in the assessment of acute abdominal pain. In all, 411 patients admitted to a district general hospital during a 10-month period were managed using a standard protocol incorporating these techniques. After initial assessment by a surgical registrar, 151 patients were excluded from further progress through the protocol (age less than 16 years, definite diagnosis made or contraindication to FCPC. The remaining 260 patients were placed in one of four management groups: (A) urgent operation (23 patients); (B) ‘look and see’ (40 patients); (C) ‘wait and see’ (59 patients); (D) urgent operation not indicated (138 patients). Eighty-eight of 99 patients (88 per cent) in groups B and C, where the need for operation was uncertain, underwent successful FCPC and 39 patients (39 per cent) underwent laparoscopy. In these patients the initial registrar management decision proved to be incorrect in 33 cases (33 per cent), but by following the protocol the number of management errors actually made was reduced to 13 (13 per cent, P < 0·001). This would have been reduced to 8 per cent if the protocol had not been violated in five patients. This study demonstrates the effectiveness of a protocol using FCPC and laparoscopy to improve the management of patients with acute abdominal pain.
Population-based study of surgery in juvenile onset Crohn's disease
Authors: Sedgwick D M , Barton J R , Hamer-Hodges D W , Nixon S J , Ferguson A
Published: March 2007

A geographically based cohort of 68 children with Crohn's disease was derived by sampling from Scottish Hospital In-patient Statistics. Surgical histories were examined and analysed by actuarial methods, and the nature of major operations performed was compared with operations for Crohn's disease in the Lothians' Surgical Audit. Fifty-four of the 68 patients were treated surgically, with a total of 135 operations (71 major, 64 minor). Fifty per cent of the cohort had a major operation within 5 years of onset of symptoms; median time to a second operation was 4 years. The types of major operation performed in juvenile onset patients differed significantly from those recorded in the Lothians' audit, with a high rate of exploratory laparotomy in younger patients (12 cases). With a mean follow-up of 7 years, 12 patients (18 per cent) have a permanent stoma. There were five deaths, three postoperative. This study highlights the frequency of surgical intervention in young people with Crohn's disease.
Massive incisional hernia: Abdominal wall replacement with Marlex ™ mesh
Authors: Molloy R G , Moran K T , Waldron R P , Brady M P , Kirwan W O
Published: March 2007

Marlex™ (polypropylene) mesh was used to replace the abdominal wall in massive incisional herniation in 50 patients. Seventeen unsuccessful attempts at primary repair had previously been made on nine patients. Patient follow-up ranged from 6 to 120 months (mean = 45 months). There was minor hernia recurrence in four (8 per cent) patients. In each instance it was due to partial detachment of the peripheral fixation of the patch. Complications were: wound infection, four (8 per cent); wound seroma, two (4 per cent); wound haematoma, one (2 per cent); and wound sinus, six (12 per cent). Complications did not necessitate removal of the patch in any case. Inadequate peripheral attachment of the patch has been the only cause of hernia recurrence and should be avoidable.
Changes in hepatic haemodynamics and hepatic perfusion index during the growth and development of hypovascular HSN sarcoma in rats
Authors: Hemingway D M , Cooke T G , Grime S J , Nott D M , Jenkins S A
Published: March 2007

Experimental liver tumours were induced in the Hooded Lister rat by the intraportal inoculation of 106 HSN sarcoma cells. The hepatic perfusion index was raised 10 days after the inoculation of cells (at the micrometastatic stage) and when overt tumour was present 20 days after inoculation. Overt tumours were hypovascular compared with normal liver. Portal venous flow and portal venous inflow fell significantly when the hepatic perfusion index was increased, but hepatic arterial flow did not alter. Portal vascular resistance and splanchnic vascular resistance were both increased in tumour-bearing animals but portal pressure, arteriosystemic shunting and portosystemic shunting did not increase significantly at any stage during the growth of hepatic tumour. These findings confirm that the hepatic perfusion index can be elevated in the presence of both micrometastatic and overt hepatic tumour and that the changes are not due to either arteriosystemic shunting or mechanical portal venous obstruction.
1,25-Dihydroxyvitamin D3 receptors and human colon adenocarcinoma
Authors: Lointier P , Meggouh F , Dechelotte P , Pezet D , Ferrier C H , Chipponi J , Saez S
Published: March 2007

Epidemiological evidence suggests that dietary calcium and 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) might have a protective effect against colorectal cancers. Since the presence of receptors is required for steroid action, specific 1,25-(OH)2D3 receptors (RD3) were investigated in biopsies taken at different levels of the colon. The study involved 90 biopsies from patients operated on for colorectal adenocarcinoma. They were paired biopsies from adenocarcinoma tissue and adjacent normal mucosa. In addition, 26 normal intestinal mucosa biopsies from patients without cancer were examined. RD3 receptors were assayed in tissue extract by the dextran-coated charcoal technique and also characterized by sucrose density gradient sedimentation. Scatchard analysis showed a single class of specific high affinity—low capacity sites binding for 1,25-(OH)2D3. The incidence of RD3 was 86 per cent in normal mucosa (n = 77) and lower in carcinoma (n = 34), for which the incidence decreased significantly (P<0·001) from right colon (58 per cent) to left colon (37 per cent) and rectum (19 per cent). These data suggest that the normal colon is a potential target organ for 1,25-(OH)2D3 which might modulate calcium transport in the colon. Loss of receptivity to 1,25-(OH)2D3 is associated with malignant transformation.
Adult polycystic disease of the liver
Authors: Vauthey J-N , Maddern G J , Blumgart L H
Published: March 2007

Adult polycystic liver disease (APLD) is a rare disorder of liver parenchyma occasionally requiring surgical treatment. Its association with adult polycystic kidney disease has meant that as renal dialysis has become widely available there is an increased number of patients surviving with cystic liver changes. Although usually asymptomatic, patients with APLD may present with abdominal pain or swelling. Liver function is not usually compromised and computed tomography or abdominal ultrasonography are the most useful investigations. The complications of cyst rupture, infection, cholangiocarcinoma and compression of surrounding structures are discussed. Surgical treatment remains controversial, and the options of cyst puncture, fenestration with or without hepatic resection, and liver transplantation are reviewed.
Suture technique affects perianastomotic colonic crypt cell production and tumour formation
Authors: O'Donnell A F , O'Connell P R , Royston D , Johnston D H , Barnard R , Bouchier-Hayes D
Published: March 2007

Suture line recurrence is an important cause of failure after potentially curative resection for colonic carcinoma. Our aim was to determine whether suture technique affected the incidence of perianastomotic tumours in experimentally induced colonic cancer. Sprague-Dawley rats were randomized into three groups. A 1 cm longitudinal colotomy was repaired with four interrupted 6/0 polypropylene monofilament sutures, using either a transmural technique (n = 18) or a seromuscular technique (n = 18). Control animals (n = 18) had a sham laparotomy. All animals received nine, weekly, subcutaneous injections of azoxymethane (total dose 90 mg/kg) starting 6 weeks after laparotomy. Surviving animals were killed 32 weeks after laparotomy. Five animals from each group were given intraperitoneal bromodeoxyuridine (100 mg/kg) 1 h before being killed. At death, perianastomotic tumours occurred more frequently in animals with transmural sutures than in either controls or those with seromuscular sutures. This difference was associated with a greater mucosal bromodeoxyuridine crypt cell labelling index in the transmural suture group. We conclude that a transmural anastomotic suture technique promotes the development of experimental perianastomotic colonic tumours.
Pyoderma gangrenosum in inflammatory bowel disease
Authors: Levitt M D , Ritchie J K , Lennard-Jones J E , Phillips R K S
Published: March 2007

Since 1954, 34 patients have attended St. Mark's Hospital with pyoderma gangrenosum in association either with ulcerative colitis (22 patients) or Crohn's disease (12 patients). Lesions were multiple in 71 per cent and over half were situated below the knees. Ulcerative colitis was active in 11 patients (50 per cent) and Crohn's disease was active in nine (75 per cent) when pyoderma gangrenosum was diagnosed. Associated illnesses - most commonly a seronegative arthritis affecting large joints - were present in 55 per cent and 92 per cent of cases respectively. A diffuse pustular rash appeared in six patients, synchronously with pyoderma in five. In a further seven patients (two with ulcerative colitis, five with Crohn's disease) the onset or course of pyoderma might have been linked to the presence of non-dermatological suppuration. Pyoderma resolved without intestinal resection in two-thirds of patients. When present at the time of surgical resection (15 procedures in 13 patients), pyoderma healed promptly in six cases, only with additional therapy in four cases and very slowly or not at all in five cases. Pyoderma gangrenosum occurs in both ulcerative colitis and Crohn's disease. Healing after intestinal resection is unpredictable both with respect to timing and extent of resection.