bluuebunny/crossref_metadata_2025 huggingface dataset:
General practice-based population screening for abdominal aortic aneurysms: A pilot study
Authors: O'Kelly T J , Heather B P
Published: March 2007

All 1195 male patients aged between 65 and 74 years on the Family Practitioner Committee register for the four group practices in Stroud, UK were invited for a health screening check. The examinations included abdominal ultrasonography to measure maximum aortic diameter, measurement of blood pressure and recording of smoking habits. An attendance rate of 76 per cent was achieved (906 patients). Seventy-one patients (7.8 per cent) were found to have aortic diameters > 2-5 cm and 14 (1.5 per cent) had aortic diameters > 4.0 cm. Aneurysms were more common in smokers and in hypertensive patients. However, restriction of screening to patients with these risk factors would have led to a number of aneurysms remaining undiscovered. We recommend therefore that ultrasound screening for abdominal aortic aneurysms should be offered to all men between the ages of 65 and 74 years.
Clinical and histological sequelae of Roux-en-Y diversion
Authors: Hollands M J , Filipe I , Edwards S , Brame K , Maisey M , Owen W J
Published: March 2007

Nine post-Polya gastrectomy patients with symptoms of reflux gastritis were studied immediately before and 6 months after Roux-en-Y diversion with a 60 cm jejunal loop. Endoscopy, histology, HIDA radionuclide studies and add secretory studies were performed to determine the effect of Roux-en-Y diversion. Symptomatic results were pleasing in that all patients were graded as Visick I or II. There was a statistically significant improvement in endoscopic evidence of mucosal damage (median score of 6 reduced to median ofl) and visible bile reflux (median score of 10.5 reduced to 0). Foveolar hyperplasia, superficial chronic gastritis and histological precursors of malignancy all improved. There was a significant decrease in the reflux of 99mTc-labelled HIDA into the gastric remnant while acid secretion remained unchanged. Roux-en-Y diversion with a 60 cm jejunal loop provides not only symptomatic relief but scintiyraphic, endoscopic and histological evidence of pancreatobiliary diversion.
Intra-abdominal lymphangioma
Authors: Roisman I , Manny J , Fields S , Shiloni E
Published: March 2007

The historical background, aetiology, clinical features, radiographic findings and treatment of abdominal lymphangiomas are reviewed. The condition may give rise to the acute surgical abdomen.
Gastric banding in the treatment of morbid obesity
Authors: Kirby R M , Ismail T , Crowson M , Baddeley R M
Published: March 2007

Gastric banding was carried out in 30 patients as a treatment for morbid obesity. The mean excess weight lost at 3 months was 32.6 per cent (27 patients) and 69.7percent at 2 years (eight patients). Fifteen patients required 22 reoperations for technical complications. Two patients underwent removal of the band and seven patients were converted to a stapled vertical Silastic® ring gastroplasty. Although gastric banding appears to be a satisfactory method of achieving weight loss, the complication and reoperation rates are unacceptable in our hands. It is recommended that this operation should no longer be used as a treatment for morbid obesity.
Yersinia infections in surgical practice
Authors: Attwood S E A , Cafferkey M T , Keane F B V
Published: March 2007

This article reviews the clinical manifestations of Yersinia bacteria emphasizing their recent rise in incidence and describing how Yersinia infection presents to the general surgeon. Geographical variations, patterns of disease, pathogenicity and the problems in diagnosis and management are discussed. This common but often unrecognized infection is usually self-limiting but the very young, the very old and the immunocompromised are at greater risk and prompt treatment is required to save lives.
Incidence of septic and thromboembolic-related deaths after splenectomy in adults
Authors: Pimpl W , Dapunt O , Kaindl H , Thalhamer J
Published: March 2007

In a review of 37012 autopsies over the last 20 years 202 deceased adults who had had a splenectomy were investigated. The incidence of infections and thromboembolic complications related to death in these patients was compared with that of a matched deceased population (n = 403) who had not undergone splenectomy. Death-related pneumonia was diagnosed frequently in the splenectomy group and to a lesser extent in the control group (57.9 versus 24.7 percent, P < 0.001). Lethal sepsis with multiple organ failure occurred in 6.9 per cent of the splenectomy group and in 1.5 per cent of the controls (P < 0.001). Purulent pyelonephritis was observed in 7.9 per cent of the splenectomy group and was significantly more frequent than in the control group with its rate of 2.2 per cent (P < 0.001). Finally, pulmonary embolism was the major or a contributory cause of death more often in the splenectomy group than in the control group (35.6 versus 9.7 per cent, P < 0.001). We conclude that splenectomy generates a considerable life-long risk of severe infection and of thromboembolism.
Controlled trial of heater probe treatment in bleeding peptic ulcers
Authors: Fullarton G M , Birnie G G , MacDonald A , Murray W R
Published: March 2007

A prospective randomized controlled trial of endoscopic heater probe therapy in bleeding peptic ulcers was performed to determine whether probe therapy can reduce rebleeding rates. Of 630 patients endoscoped for suspected upper gastrointestinal haemorrhage over a 16-month period, 166 (26 per cent) were found to have a peptic ulcer. Either minor or no stigmata of recent haemorrhage were found in 115 patients at the time of endoscopy. A single peptic ulcer with either active haemorrhage or a visible vessel was found in 51 patients, 43 of whom were entered into the trial. There were eight exclusions: four were inaccessible, one was a torrential haemorrhage and three were excluded for non-technical reasons. Patients were randomized to receive either heater probe (n = 20) or sham (n = 23) therapy. In actively bleeding ulcers, immediate haemostasis was achieved following probe therapy in 14 of 18 patients (78 per cent) compared with none of 21 having sham treatment (P < 0·002). No rebleeding occurred in the probe therapy group (n = 20) compared with rebleeding in five of 23 sham treated patients (P = 0·05). Urgent surgery for haemostasis was required in three of the five sham treated patients who rebled. It is concluded that heater probe therapy may be effective in reducing rebleeding rates in peptic ulcers accessible to the endoscope.
Vascularization of small liver metastases
Authors: Archer S G , Gray B N
Published: March 2007

The portal vein contributes little to the blood supply of established liver metastases in the presence of a patent hepatic artery. However, its role in the perfusion of early metastatic liver disease remains controversial. We have quantified the relative contribution of the portal vein and hepatic artery to the internal circulation of small liver tumours. These studies were conducted in a new rat model of liver metastases generated by the intraportal injection of cultured tumour spheroids. A total of 633 lesions were studied in 18 animals using radioisotope tracer microspheres. Nodules ranged from 0·5 to 6·0 mm in diameter, 92 per cent being 3·0 mm or less. The ratio of radioactivity in tumour compared with normal tissue (T:N ratio) was determined after simultaneously injecting microspheres into the portal and arterial circulation of each animal. The mean hepatic artery T:N ratio was significantly greater than that of the portal vein for all tumour sizes studied (P < 0·01). Nodules 0·5 mm in diameter had a mean (s.e.m.) hepatic artery T:N ratio of 1·50 (0·12) in comparison with a mean portal vein ratio of 0·13 (0·04). Tumour nodules 2·0 mm in diameter had a mean (s.e.m.) hepatic artery T:N ratio of 1·26 (0·11) in comparison with a mean portal vein ratio of 0·06 (0·01). The overall T:N ratio for both routes decreased with increasing tumour size. These results indicate that hepatic tumours as small as 0·5 mm already have an established internal vasculature perfused predominantly by the hepatic artery. In contrast, the portal vein contributes insignificantly to the internal perfusion of these lesions. These results have significant implications for adjuvant locoregional therapy in gastrointestinal cancer.
Management of pancreatic pseudocysts
Authors: Andersson R , Janzon M , Sundberg I , Bengmark S
Published: March 2007

Between 1969 and 1987, 68 patients with pancreatic pseudocysts were treated. The median cyst size was 10 cm (range 2–25 cm). Nine patients were managed conservatively with resolution of the pseudocyst occurring in eight patients. These patients had significantly smaller (median 4 cm) cysts compared with those in both percutaneously and surgically treated patients (P < 0·01). In 22 patients the pseudocysts (median 9 cm) were punctured percutaneously under ultrasound guidance and the cyst fluid was aspirated or drained through a catheter. Complete resolution occurred in 13 patients after 1–4 (mean 2·8) punctures per patient, regression occurred in six patients after 1–4 (mean 2·0) puncture procedures per patient and three were unchanged. No complications were noted, except that two patients treated percutaneously required additional surgery. Thirty-seven patients were managed surgically (median cyst size 11 cm) with external drainage (12 patients), cystgast-rostomy (17 patients), cystduodenostomy (three patients) cystjejunostomy (three patients) and pancreatic resection (two patients). Resolution of the cyst was noted in 29 patients, regression in five and three were unchanged. Five patients required additional surgery. Twelve complications were seen in ten patients (27 per cent), most frequently after external drainage. One patient died after surgical treatment. Mean hospital stay was 13 days among patients treated conservatively and 30 days in both percutaneously and surgically treated patients. Aspiration or catheter drainage of pseudocyst fluid guided by ultrasonography seems a safe and effective treatment of pancreatic pseudocysts and should be considered as initial therapy. If surgery is required cystgastrostomy is preferred.
Management of screen detected ductal carcinoma in situ of the female breast
Authors: Carpenter R , Boulter P S , Cooke T , Gibbs N M
Published: March 2007

Thirty eight ductal carcinomas in situ of the female breast detected during the first 7 years of screening by the Guildford Breast Screening Unit have been treated by one surgeon. Twenty-eight cases were treated conservatively and ten by mastectomy. In the group treated conservatively there have been five local recurrences: four as ductal carcinoma in situ and one as node negative microinvasive carcinoma. There were no clinical or pathological features that predicted local recurrence, which was detected only by follow-up mammography. Based on these early results, an initially conservative approach to screen detected ductal carcinoma in situ is advocated.
Number and anatomical distribution of incompetent thigh perforating veins
Authors: Papadakis K , Christodoulou C , Christopoulos D , Hobbs J , Malouf G M , Grigg M , Irvine A , Nicolaides A
Published: March 2007

Although incompetent thigh perforating veins are considered to be a common cause of recurrence of varicose veins after high saphenous ligation, the number and distribution of such incompetent veins have not been reported. The aim of the study was to determine the number and anatomical distribution of incompetent thigh perforating veins. Sixty-five limbs in 48 patients with varicose veins who were found to have incompetent thigh perforating veins on ascending deep to superficial venography were studied. In 80 per cent of patients one incompetent thigh perforating vein was found and in 20 per cent more than one was found. Concomitant incompetent calf perforating veins were found in 92 per cent of the limbs studied. The incompetent thigh perforating veins were found to occur anywhere in the thigh, from the upper edge of the patella to a few centimetres below the saphenofemoral junction. The majority (71 per cent) were found in the middle third of the thigh. All incompetent thigh perforating veins were communicating with the long saphenous vein, including those in five patients with incomplete stripping. The surgeon should be aware of incompetent thigh perforating veins which may be multiple and occur at any site on the medial aspect of the thigh.
Clinical results of colectomy for severe constipation
Authors: Yoshioka K , Keighley M R B
Published: March 2007

Subtotal colectomy has been performed in 40 patients with severe constipation. Only one patient was male. Five patients (13 per cent) had a history of a serious psychiatric disorder. Twenty-six patients (65 per cent) could not expel a 100-ml air-filled balloon and 19 patients (48 per cent) had electromyographic evidence of abnormal puborectalls contraction during attempted defaecation before operation. Median preoperative passage of 50 radio-opaque markers over 5 days was 16 per cent. Sixteen patients had had a previous anorectal myectomy to exclude Hirschsprung's disease. Initial resections were subtotal colectomy and ileorectal anastomosis (n = 34), caecorectal (n = 5) or ileosigmoid (n = 1) anastomosis. Secondary operations included restorative proctocolectomy and ileal pouch—anal anastomosis (n = 6) and six patients eventually had an ileostomy. Median bowel frequency per week significantly increased after operation (0·3 (range 0–1) preoperatively to 21 (range 2–70) postoperatively, P < 0·005), the percentage of patients with abdominal pain fell after operation from 93 to 39 per cent but symptoms of abdominal distension remained the same (86 per cent preoperatively and 82 per cent postoperatively).
Management of infection after prosthetic abdominal rectopexy (Wells' procedure)
Authors: Ross A H McL , Thomson J P S
Published: March 2007

The management and results of treatment of eight cases of implant infection after a Wells' rectopexy for rectal prolapse are reported. Most infections presented within 3 months of the rectopexy. Fever, abdominal or pelvic pain, diarrhoea, and the passage of pus per rectum were common presenting features. Removal of the infected implant per rectum or per vaginum was successful in four of five attempts and is the recommended initial approach, particularly in cases occurring early after surgery. Despite removal of the implant early after rectopexy recurrent prolapse did not occur.
Rehabilitation after lower limb amputation: A comparative study of above-knee, through-knee and Gritti—Stokes amputations
Authors: Houghton A , Allen A , Luff R , McColl I
Published: March 2007

A study of 169 unilateral amputees under three Disablement Services Centres was performed. The study comprised 88 above-knee, 54 through-knee and 27 Gritti-Stokes amputations. Satisfactory rehabilitation occurred in 33 per cent of above-knee, 62 per cent of through-knee and 44 per cent of Gritti—Stokes patients (56 per cent overall). The better rehabilitation of through-knee versus above-knee amputees (P < 0·02) was also found in a group of patients matched for comparable age and duration of amputation as well as in a group of age-matched vascular amputees. Through-knee amputees relied significantly less on wheelchairs than above-knee (P = 0·016) and Gritti—Stokes (P = 0·05) amputees. The prosthesis used for the through-knee and Gritti—Stokes amputations was considered unsightly in 50 per cent of cases (versus 31 per cent for the above-knee prosthesis).

The superior rehabilitation with through-knee amputations should prompt us to improve both our technique for this amputation and the prostheses currently available. A through-knee amputation should be performed in preference to an above-knee amputation in the case where either is surgically possible, and a below-knee amputation not feasible.
Technical aspects of war wound excision
Authors: Coupland R M
Published: March 2007

Excision of war wounds may be performed by civilian surgeons with no previous experience of war surgery. The principles of complete excision of non-viable tissue with removal of foreign material, leaving the wound open, and delayed primary closure of skin are vitally important. A major part of the surgical approach is wound assessment and the formation of an operative plan. The extent and ease of the operation depends on the site, age and type of wound. Attention to the technique of wound excision avoids septic complications and permits skin closure when the first dressing is removed. Wounds may need re-excision at a later date. Modification of surgical management is necessary when certain difficult areas are wounded and when the patient presents after many days or has suffered inappropriate first aid.
Tumour necrosis factor and bacterial sepsis
Authors: Michie H R , Guillou P J , Wilmore D W
Published: March 2007

This review examines the evidence that tumour necrosis factor is the principal mediator of the derangements associated with severe sepsis.
Role of cholecystostomy in the management of critically ill patients suffering from acute cholecystitis
Authors: Winkler E , Kaplan O , Gutman M , Skornick Y , Rozin R R
Published: March 2007

Between the years 1976 and 1985, 60 patients underwent cholecystostomy for acute cholecystitis in the surgical department of the Rokach hospital in Tel Aviv. The patients' average age was 73 years; 78 per cent were 70 years or older at the time of operation. The decision to perform cholecystostomy was taken before the operation which was performed as an emergency procedure for patients considered to be at high risk for cholecystectomy. Forty-six patients (77 per cent) had severe concomitant diseases, and 42 per cent of them had two or more associated diseases simultaneously. The cardiac risk index was high in most patients (90 per cent). Fifty-two patients recovered promptly after surgery. Five patients (8 per cent) developed significant postoperative complications. Three other patients (5 per cent) died of cardiovascular complications. Forty-two patients (70 per cent) underwent an elective cholecystectomy 6–8 weeks later with no further morbidity or mortality. Eleven patients who were at high risk had no further surgery. No residual stones were found in these patients and no relapse of the disease was recorded in the long term follow-up. Four patients were lost to follow-up. We conclude that cholecystostomy may still be used as an initial life saving procedure for critically ill patients with acute cholecystitis, and serves as a definitive procedure for patients considered to be at very high operative risk and who have no residual stones.
Delayed recovery of hand grip strength predicts postoperative morbidity following major vascular surgery
Authors: Griffith C D M , Whyman M , Bassey E J , Hopkinson B R , Makin G S
Published: March 2007

Forearm muscle dynamometry was performed in the non-dominant arm in 61 patients undergoing major abdominal and limb vascular surgery, before operation and then 1, 3, 5, and 7 days after surgery. Six patients died in the postoperative period and seven patients developed major postoperative complications (bronchopneumonia, two; wound infection, four; myocardial infarction, one). The preoperative grip strength, measured in kilograms, of the patients who died after major vascular surgery was not significantly lower than that of patients who had an uncomplicated postoperative course. Of the 55 surviving patients, seven developed complications after surgery. These patients had significantly reduced grip strength, expressed as a percentage of the individual preoperative value (P < 0·05), from the first to the seventh postoperative day when compared with patients without complications. The delayed recovery of grip strength preceded the clinical manifestation of complications. These data suggest that delayed recovery of voluntary muscle performance may be used to detect patients developing postoperative complications and so allow their early treatment.
Human thrombin plus 5 per cent ethanolamine oleate injected to sclerose oesophageal varices: A prospective randomized trial
Authors: Kitano S , Hashizume M , Yamaga H , Wada H , Iso Y , Iwanaga T , Sugimachi K
Published: March 2007

Fifty cirrhotic Japanese patients with oesophageal varices underwent sclerotherapy in a prospective randomized trial carried out to examine the effects of human thrombin given concomitantly with the sclerosant 5 percent ethanolamine oleate. The two groups (25 patients each) were comparable with regard to size of the oesophageal varices, and the aetiology and severity of the liver disease. Twenty-five patients, 13 and 12 in the thrombin + and - groups, respectively, had at least one episode of variceal bleeding. The remaining 25 were given prophylactic injections. There was a significantly lower rate of occurrence of bleeding from injection sites when the injection needle was removed at the initial session of sclerotherapy in the thrombin + group, where human thrombin was injected (0·2-0·3 ml, 100–150 units per injection) just before removal of the injection needle. Endoscopy at 1 week after the initial session showed a significantly (P < 0·05) higher rate of disappearance of red colour signs on varices in the thrombin + group (96 per cent) than in the thrombin - group (72 per cent). Fibrin degradation product E-fraction (FDP-E) values increased 1 h, 1 day and 6 days after the initial session of sclerotherapy in the two groups. The rate of increase in FDP-E values 1 h after sclerotherapy was significantly larger (P < 0·001) in the thrombin + than in the thrombin - group. There was no clinical sign of disseminated intravascular coagulation. Administration of human thrombin plus a sclerosant seems to be useful and efficacious, especially for patients with huge oesophageal varices.
Rigid endoscopy under general anaesthesia is safe for chronic injection sclerotherapy
Authors: Wilson R H , Campbell W J , Spencer A , Johnston G W
Published: March 2007

Injection sclerotherapy for acutely bleeding oesophageal varices has been used in Belfast since 1958. However, a chronic injection sclerotherapy programme with rigid oesophagoscopy under general anaesthesia commenced only in 1979. So far, 82 patients have entered the programme; 57 patients had already received 73 acute injections before commencing chronic sclerotherapy. Subsequently, the 82 patients received 221 chronic injections plus a further 29 acute injections for rebleeding episodes which occurred during the programme. There were 24 Child's grade A patients, 23 B and 35 C; 48 per cent had alcoholic cirrhosis. Forty-eight patients achieved variceal obliteration with a mean of four injections. During the programme 24 patients experienced 42 acute bleeds. There were only two bleeding episodes within 1 week of a chronic injection and eight within 4 weeks. In the 8-year period there have been four early deaths. One occurred 17 days after a chronic injection and three followed acute injections required for rebleeding during the programme. There were 21 late deaths, mostly due to progressive liver failure, and none from rebleeding. We conclude that chronic injection sclerotherapy using rigid oesophagoscopy under general anaesthesia is both safe and effective.
Emergency orthotopic liver transplantation in two patients using one donor liver
Authors: Bismuth H , Morino M , Castaing D , Gillon M C , Declere A Descorps , Saliba F , Samuel D
Published: March 2007

Because of its anatomy, the liver can be divided into two hemilivers suitable for use as two grafts for liver transplantation. The line of division is the main scissure, giving the right hemiliver (segments 5–8) and the left hemiliver (segments 2–4). Segment 1 (caudate lobe) has to be resected. The vessels are divided between the two grafts: the vena cava remains on the right; on the left, the left hepatic vein is sutured into the vena cava of the recipient, which is retained intact. The left graft retains only the left branch of the portal vein, the bile duct and the hepatic artery. The right graft retains the portal trunk, the common bile duct and the right branch of the hepatic artery. This procedure was used for emergency grafting of two patients with fulminant hepatitis when only one donor was available. Both recipients recovered from coma and regained normal liver function. However, both died from causes not specifically related to the operative technique, one from multiple organ failure on the 20th day and the other from diffuse cytomegalovirus infection on the 45th day.
Timing of strangulation in adult hernias
Authors: McEntee G P , O'Carroll A , Mooney B , Egan T J , Delaney P V
Published: March 2007

This retrospective study aimed to determine why the incidence of strangulated hernias in adults remains high. Seventy-nine patients presented with clinical evidence of hernia strangulation which required urgent surgery during the period 1979–87. Forty-six patients (58 per cent) had noted a hernia present for at least 1 month before strangulation: 18 (23 per cent) had not reported it to their family doctor, 19 (24 per cent) were known by family practitioners or non-surgical medical personnel to have a hernia but had not been referred for surgical opinion, and nine (11 percent) had been previously assessed surgically with a view to elective repair. Of these nine, five were considered unfit, three were on waiting lists for operation and one had refused surgery. Thirty-two patients (40 per cent) presented primarily with strangulation within days of developing a hernia. The duration of hernia before strangulation in one patient was unknown. Although an unavoidable number of patients will continue to present with strangulation within days of developing a hernia, the overall incidence could be significantly reduced by greater public awareness of the risks of hernia strangulation and by a policy of immediate patient referral and prompt elective repair.
APACHE II score in massive upper gastrointestinal haemorrhage from peptic ulcer: Prognotic value and potential clinical applications
Authors: Schein M , Gecelter G
Published: March 2007

This study examined the prognostic value of the APACHE II scoring system in patients undergoing emergency operations for bleeding peptic ulcer. There were 96 operations for gastric ulcers and 58 for duodenal ulcers. The mean scores in survivors and in patients who died were 10.8 and 17.5 respectively. None of the 66 patients with a n APACHE II score < 11 died, whiel the mortality rate in those scored > 10 was 22 per cent. In patients scored > 10 non-resective procedures carried less risk of mortality than gastectomy. The APACHE II score is useful when measuring the severity of the acute disease and predicting the outcome in these patients. If used in daily practice it may assist the surgeon in stratifying patients into a low-risk group (score < 11) in which major operations are well tolerated and outcome is favourable and a high-risk group (scor < 10) in which the risk of mortality is high and the performance of procedures of lesser magnitude isprobably more likely to improve survival.
Multivariate analysis of factors influencing the results of restorative proctocolectomy
Authors: Keighley M R B , Winslet M C , Flinn R , Kmiot W
Published: March 2007

Univariate and multivariate analyses have been used to assess the influence of 14 variables on the results of 65 consecutive ileoanal pouch procedures over 5 years. There were nine failures requiring intubation, ileostomy or pouch excision. There was a significant association between failure and pelvic sepsis (P <0·05, n = 8), endoanal mucosectomy (P <0·05, n = 7), preservation of a long rectal cuff (P <0·05, n = 5) and lack of experience with the operation (P <0·05, n = 8). Of 49 patients with preoperative evidence of ulcerative colitis, three are now known to have Crohn's disease. Functional outcome was significantly impaired in patients who developed pelvic sepsis (P <0·01) or a postoperative fistula (P <0·05), and who had an endoanal mucosectomy (P <0·05). Success with ileoanal pouch reconstruction increases with experience. Avoidance of sepsis is associated with a lower failure rate, improved functional results and reduced hospital stay. Preliminary colectomy is also advised to exclude Crohn's disease if the diagnosis is in question.
Anal endosonography in the evaluation of perianal sepsis and fistula in ano
Authors: Law P J , Talbot R W , Bartram C I , Northover J M A
Published: March 2007

Anal endosonography has been performed in 22 patients with fistula in ano and perianal sepsis and compared with the operative findings. Using a special hard cone attachment to a radial 7 MHz probe the examination was well tolerated, rapid and generally accurate, detecting two unsuspected foreign bodies and all seven complicated fistula in ano preoperatively.
Clinicopathologic study of early stage esophageal carcinoma
Authors: Sugimachi Keizo , Ohno Shinji , Matsuda Hiroyuki , Mori Masaki , Matsuoka Hideo , Kuwano Hiroyuki
Published: March 2007

As part of a consecutive series of 370 patients who underwent subtotal esophagectomy because of carcinoma of the thoracic area of the esophagus, between January 1965 and July 1988, in the Second Department of Surgery, Kyushu University Hospital, 42 patients (11.4%) with early stage esophageal carcinomas confined to the intraepithelium, mucosa, or submucosa were studied clinicopathologically. Of these 42, 26 (61.9%) had symptoms; slight dysphagia or chest discomfort was the most common symptom. The remaining 16 (38.1%) had no subjective symptoms. Endoscopic examination proved to be more useful than barium studies. Lugol-combined endoscopy was most effective in detecting the presence and spread of small malignant lesions of the esophagus. At the time of surgery, six patients with submucosal carcinoma of the esophagus had lymph node metastasis, and five died of recurrence. Described herein are the diagnostic features, clinicopathologic characteristics, and long-term results of these 42 patients with early stage, and 328 patients with advanced, carcinomas of the esophagus, detected and surgically treated in our clinics.
Aids in the diagnosis of acute appendicitis
Authors: Hoffmann J , Rasmussen O Ø
Published: March 2007

Methods used to improve the accuracy of diagnosis of acute appendicitis are reviewed. Laparoscopy, barium enema, ultrasonography and computer assistance have all been shown to improve accuracy, but no one method is of proven superiority. Such diagnostic aids or intensive in-hospital observation must be used to reduce the 15–30 per cent negative laparotomy rate when acute appendicitis is suspected, without increasing the incidence of appendiceal perforation.
Hypoplasia of defunctioned rectum
Authors: Appleton G V N , Williamson R C N
Published: March 2007

The adaptive response of the large bowel to surgical defunction in man is essentially unknown, although in the rat there is progressive hypoplasia and a reduced propensity to experimental carcinogenesis. Mucosal biopsies were taken from the upper rectum completely defunctioned by a proximal stoma from 2 months to 5 years earlier in 11 patients and from 14 controls without abdominal operations or disease. Samples were established in organ culture and, after 16 h, crypt cell production rate (CCPR) was determined by a stathmokinetic technique. Crypt morphometry was also undertaken. CCPR in defunctioned large bowel was less than half that of controls: (mean (s.d.) 1.96 (0.68) versus 4.65 (0.54) cells crypt−1 h−1, P <0.0001). Likewise, crypt length was 24 per cent lower (0.34 (0.05) versus 0.44 (0.04) mm, P <0.0001) and crypt width was 38 per cent lower (0.04 (0.01) versus 0.07 (0.01) mm, P <0.0001). Rectal defunction causes profound and persistent hypoplasia in man.
Collagen changes around intestinal anastomoses in germ-free rats
Authors: Mastboom W J B , Hendriks T , de Boer H H M
Published: March 2007

The changes in collagen, measured as hydroxyproline, concentration around both ileal and colonic anastomoses in germ-free and control rats have been investigated and compared with each other. The germ-free rats were raised, operated on and maintained under completely pyrogen-free conditions. Animals were killed 2, 3 or 7 days after operation. There was a significant reduction in the lowering of hydroxyproline concentrations around the colonic anastomosis of germ-free rats compared with control rats both in the anastomosis at days 2 and 3 (P = 0.04 and P = 0.006 respectively) and in the proximal segment at day 3 (P = 0.03). In ileal anastomoses, significant differences between control and germ-free rats were only found at 7 days. Here the increase in hydroxyproline concentration observed in control rats was significantly reduced in germ-free rats. These data are taken to support the hypothesis that bacteria affect colonic anastomotic healing by contributing to postoperative collagen degradation.
Pelviureteric junction obstruction and recurrent abdominal pain in childhood
Authors: Ward H C , Brereton R J
Published: March 2007

Three cases of recurrent abdominal pain due to pelviureteric junction obstruction in childhood are presented. Ultrasound is useful in confirming the diagnosis and pyeloplasty is recommended.
Abdominal aortic aneurysms: A review of current problems
Authors: Cheatle T R , Scurr J H
Published: March 2007

This review examines the aetiology and possible methods of prevention of abdominal aortic aneurysm. The natural history of the lesion is discussed. Given its poor prognosis, surgery should be considered even when the patient is over 80 years of age, has stable cardiovascular disease and has a small aneurysm. The case for population screening is reviewed and potential areas of advance in management are outlined.
Clinical, radiological and cytological diagnosis of breast cancer in young women
Authors: Ashley S , Royle G T , Corder A , Herbert A , Guyer P B , Rubin C M , Taylor I
Published: March 2007

In women over the age of 35 years, an accurate diagnosis of breast cancer can be made in over 95 per cent of patients using a ‘triple assessment’ system collating information from clinical examination, mammography, sonomammography, and fine-needle aspiration cytology. These methods have not been specifically evaluated in women aged 35 years or less, hence a study was undertaken on 30 such patients. Clinical examination was unreliable in predicting malignancy with a sensitivity of only 37 per cent. Thirty per cent of patients presented with a lump which had the clinical features of a fibroadenoma. Radiological methods were less sensitive in detecting malignancy in this age group than in older patients. The sensitivity of aspiration cytology was 78 per cent which was higher than that for breast cancer at all ages. Histology showed that there were fewer low grade tumours and fewer scirrhous tumours in this age group than in a control group of women aged over 35 years. This study indicates that cytological confirmation of apparently benign focal breast lesions in young women is essential, especially when these are managed conservatively.
Adverse effects of preoperative hepatic artery chemoembolization for resectable hepatocellular carcinoma: A retrospective comparison of 138 liver resections
Authors: Nagasue Naofumi , Galizia Gennaro , Kohno Hitoshi , Chang Yu-Chung , Hayashi Takafumi , Yamanoi Akira , Nakamura Teruhisa , Yukaya Hirofumi
Published: March 2007

During the past 8 years we have treated 268 patients with primary hepatocellular carcinoma (HCC); total extirpation of the tumor was carried out in 138. Thirty-one of the patients with resectable HCCs had already been treated with transcatheter arterial embolization (TAE) of the liver before they were referred to us. The clinical values of preoperative TAE were retrospectively evaluated for those 31 patients and for the remaining 107 patients without TAE. There were no substantial differences between the two study groups in the clinical and histopathologic backgrounds. No differences were observed in the extent of liver resection, estimated blood loss during surgery, and operation time. During surgery, however, troublesome intra-abdominal complications relevant to TAE were encountered in 15 patients, and detection of tumors was impossible, even with intraoperative ultrasonography, in five patients in the group with TAE. Such findings were not present in any of the patients without TAE. Postoperative morbidity and mortality rates were similar in the two groups. There was no significant difference in the rate of recurrence of tumor in the liver, but the recurrence time was significantly shorter in the group with TAE. TAE did not improve the long-term survival rates in patients either with or without cirrhosis. Results of our study seem to indicate that preoperative TAE is meaningless in the treatment of resectable HCCs and therefore should be avoided, particularly in patients with advanced cirrhosis of the liver.
Wide local excision as the sole primary treatment in elderly patients with carcinoma of the breast
Authors: Reed M W R , Morrison J M
Published: March 2007

Clinically localized carcinoma of the breast in 96 women was treated by wide local excision alone. The locoregional recurrence rate was 35 per cent at a mean follow-up of 47 months. There was no significant effect of recurrence on survival because of the relatively high mortality rate from unrelated conditions in these mainly elderly patients. Recurrence was successfully managed with tamoxifen in the majority of cases, with few patients requiring radiotherapy or further surgery. Recurrence in the breast was associated with significantly less systemic disease and mortality than recurrence in the axilla.
Platelet aggregability after endoscopic intravariceal injection of 5 per cent ethanolamine oleate into oesophageal varices
Authors: Yamaga H , Hashizume M , Kitano S , Higashi H , Sugimachi K
Published: March 2007

Platelet aggregability and the coagulative and fibrinolytic systems were examined in 45 patients who underwent endoscopic injection sclerotherapy for oesophageal varices. Five per cent ethanolamine oleate, the sclerosant used, was injected into the oesophageal varices. There were significant increases in the concentrations of fibrinopeptide A, fibrinopeptide B-β-15–42 and fibrin degradation products-E after the sclerotherapy. At 1 h after the sclerotherapy the mean(s.e.m.) platelet aggregation was significantly suppressed to 71·9(4·2) per cent of that before the treatment (P <0·01). There was a gradual recovery within 1 week to the same level seen before the sclerotherapy. Thomboxane B2 and 6-keto-prostaglandin F1α, both stable products of thromboxane A2 and prostacyclin respectively, showed significant temporary increases after the sclerotherapy (P <0·01). The peak increase in the level of thromboxane B2 was noted within 1 h after the sclerotherapy and earlier than that for 6-keto-prostaglandin F1α. This increased ratio of prostacyclin and thromboxane A2 may be related to the marked limitation in platelet aggregation.
Transabdominal gastro-oesophageal devascularization and oesophageal transection for bleeding oesophageal varices
Authors: Al-Kraida A , Qazi S A , Shaikh M U , Asi S A , Al-Mofarreh M A , Al-Turki M
Published: March 2007

Fifty consecutive unselected patients presenting with acute haematemesis and melaena from endoscopically confirmed bleeding oesophageal varices were treated by one-stage transabdominal oesophageal transection with gastro-oesophageal devascularization and splenectomy. According to Child's classification, 15 were Grade A, 29 Grade B and six Grade C. The mortality rate was 10 per cent. Postoperative complications included gastric fundal leak (4 per cent), pleural effusion (4 per cent), subphrenic abscess (2 per cent), atelectasis (2 per cent) and pneumothorax (2 per cent). Although five patients (10 per cent) complained of transient dysphagia during follow-up, only one (2 per cent) presented evidence of stricture at the site of oesophageal transection. Clinical encephalopathy was not present in the surviving patients in the postoperative period. No recurrence of bleeding has been recorded in the surviving patients over a follow-up period of 2–3 years.
Sham feeding for testing gastric secretory capacities before and after parietal cell vagotomy
Authors: Gilly F , Chabal J , Boulez J , Minaire Y
Published: March 2007

The usefulness of acid secretory data collected during a modified shamfeeding (MSF) test was examined in 50 patients suffering from duodenal ulcer before and after parietal cell vagotomy. In these patients basal acid output pentagastrin-stimulated acid output and MSF-stimulated acid output were measured. Preoperative MSF-stimulated acid output was found to be correlated with preoperative basal acid output, and postoperative MSF-stimulated acid output was correlated with both preoperative basal acid output and postoperative basal and pentagastrin-stimulated acid outputs. The addition of preoperative MSF-stimulated acid output to preoperative pentagastrin-stimulated acid output did not noticeably increase the close relationship between the latter and postoperative pentagastrin-stimulated acid output. It is concluded that basal and MSF-stimulated secretory rates overlap. Therefore, it is suggested that in both preoperative and postoperative conditions the addition of the sham-feeding test to the more simple basal and pentagastrin-stimulated studies could be discarded.
Anterior lesser curvature laser seromyotomy with posterior truncal vagotomy: A potential treatment of peptic ulcer disease
Authors: Hunter J G , Becker J M , Lee R G , Christian P E , Dixon J A
Published: March 2007

Anterior lesser curvature seromyotomy combined with posterior truncal vagotomy has been suggested as an alternative to proximal gastric vagotomy in the treatment of peptic ulcer. The argon laser may be an ideal instrument for performing seromyotomy. This study compares anterior lesser curvature argon laser seromyotomy/posterior or truncal vagotomy with anterior proximal gastric vagotomy/posterior truncal vagotomy in a canine preparation. Six dogs underwent anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy and six others underwent anterior proximal gastric vagotomy/posterior truncal vagotomy. Gastric emptying and acid secretion studies were performed preoperatively and at 1 and 6 months postoperatively. Operating time and blood loss were determined. Anterior lesser curvature argon laser seromyotomy was performed with the argon laser at 10 W, continuous, delivered through a 600 μm unsheathed quartz fibre. Anterior proximal gastric vagotomy and posterior truncal vagotomy were performed in the standard fashion. Solid phase gastric emptying was slowed with both operations (P <0·05) but this was not manifest clinically. Blood loss (millilitres) was less following anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy than following anterior proximal gastric vagotomy/posterior truncal vagotomy (21(6·8) versus 95(28·1), mean (s.e.m.), P <0·05) but operating time was not significantly different between the groups. Mean basal acid secretion was reduced by 64 per cent 6 months after anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy (P <0·05) and by 53 per cent after anterior proximal gastric vagotomy/posterior truncal vagotomy (not significant). Mean stimulated acid secretion was reduced by 41 per cent 6 months after anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy (P <0·05) and by 24 per cent after anterior proximal gastric vagotomy/posterior truncal vagotomy (not significant). We conclude that anterior lesser curvature argon laser seromyotomy/posterior truncal vagotomy is an acceptable alternative to anterior proximal gastric vagotomy/posterior truncal vagotomy and may provide superior parietal cell denervation with less operative blood loss.
Comparison of digital and manometric assessment of anal sphincter function
Authors: Hallan R I , Marzouk D E M M , Waldron D J , Womack N R , Williams N S
Published: March 2007

Anal sphincter function was assessed by digital examination and anal canal manometry in 66 patients and controls. Digital scores were allotted by using visual analogue scales for basal and squeeze sphincter function and were compared with the corresponding pressures. There were good correlations between digital basal score and maximum basal pressure (Spearman rank correlation coefficient rs = 0·56, P <0·001), and digital squeeze score and maximum squeeze pressure (rs = 0·72, P <0·001). There were wide ranges of sphincter function on digital and manometric assessment with considerable overlap between patient groups. Digital scores detected differences in sphincter function between patient groups as accurately as manometry. The sensitivities and specificities of digital scores and anal canal manometry in segregating continent and incontinent patients were similar. It was concluded that digital estimation was equally as good an assessment of anal sphincter function as anal canal manometry.
Analysis of 828 servicemen killed or injured by explosion in Northern Ireland 1970–84: The hostile action casualty system
Authors: Mellor S G , Cooper G J
Published: March 2007

Death and injury due to terrorist bombings continue to exercise civilian and military surgeons alike. In this paper 828 servicemen killed and injured by explosions in Northern Ireland have been studied, using data stored in the Hostile Action Casualty System (HACS). Because of the nature of the conflict in Northern Ireland, the magnitude of each explosion and the distance of the victims from it are quite accurately known. The overpressure (blast loading) to which the victim was exposed can be estimated from the information on the HACS forms and standard tables, giving overpressures for a given charge at a known distance. Using the HACS data, the numbers of injuries due to overpressure (primary blast injury), missiles energized by the blast (secondary injury), displacement of the victim by the blast wind (tertiary injury) and flash burn can be determined. Of the 828 servicemen involved in explosions, 216 were killed, most of them before any treatment could be instituted. Of the servicemen in the survey, 90 per cent were wearing body armour. Although body armour affords considerable protection from secondary missiles, it is unlikely to reduce the number of deaths due to primary blast injury.
Acute lower limb arterial ischaemia: A role for continuous oxygen inhalation
Authors: Berridge D C , Hopkinson B R , Makin G S
Published: March 2007

Simultaneous readings of transcutaneous partial pressure of oxygen (Ptc,O2) were obtained from the left anterior chest wall, from 10 cm distal to the medial aspect of the knee joint, and from the first dorsal webspace in 16 patients with acute peripheral arterial ischaemia of the leg. Oxygen was administered at concentrations of 24, 40, 60 and 100 per cent. Mean(s.d.) initial chest Ptc, O2 (53 (17) mmHg) was significantly higher than that of the medial lower limb site (37(17) mmHg). After inhalation of 24 per cent oxygen, a statistically significant (P < 0.025) increase in chest Ptc, O2 was achieved (63(20) mmHg), but the increase in Ptc, O2 (43(19) mmHg) at the medial lower limb site was not statistically significant. Inhalation of 40 per cent oxygen resulted in significant increases at both sites (chest: 83(23) mmHg, P < 0.01; limb: 53(26) mmHg, P < 0.05). Ptc, O2 in the limb at this concentration of inhaled oxygen was equal to the initial chest level. Increasing the oxygen concentration to 60 per cent and then to 100 per cent produced further significant (P < 0.001) increases in Ptc, O2 at both sites. The use of continuous oxygen inhalation during acute ischaemia may improve tissue nutrition before, during and after definitive treatment.