bluuebunny/crossref_metadata_2025 huggingface dataset:
Anorectal function following coloanal sleeve anastomosis for chronic radiation injury to the rectum
Authors: Varma J S , Smith A N
Published: March 2007

Anorectal manometry and electrophysiological studies of the pelvic floor were performed in eight patients who had undergone anterior resection of the rectum with mucosal proctectomy and colo-anal sleeve anastomosis for radiation rectal injury. There is a severe reduction in the compliance of the neorectum and in the maximal tolerable volume. Maximum basal anal canal pressure and physiological sphincter length are also significantly reduced although the ‘squeeze’ pressure of the external anal sphincter and the latency of the pudendo-anal reflex were unaffected. Four patients had an absent rectosphincteric reflex, four patients involuntarily expelled the test balloon at the maximal tolerable volume during a proctometrogram and four patients demonstrated increased EMG activity of the pelvic floor on straining and on rectal distension. These abnormalities help to explain many of the patients' symptoms. Histological abnormalities of the myenteric plexus were a prominent feature in all the excised specimens and may be responsible for some of the functional abnormalities.
Negative effect of Metoclopramide in postoperative adynamic ileus. A prospective, randomized, double blind study
Authors: Jepsen S , Klærke Anette , Nielsen P H , Simonsen O
Published: March 2007

In a double blind controlled study including 60 patients it was found that Metoclopramide has a negative effect upon the resolution of postoperative adynamic ileus. Metoclopramide causes a delay in the time from operation to the first passage of flatus.
Intragastric bile acids and scintigraphy in the assessment of duodenogastric reflux
Authors: Houghton P W J , McC. Mortensen N J , Thomas W E G , Cooper M J , Morgan A P , Davies E R
Published: March 2007

Following endoscopic gastric juice aspiration, intragastric bile acids were measured in 105 patients undergoing routine or review gastroscopy. Subsequently, duodenogastric reflux was assessed using 99mTc butyliminodiacetic acid (BIDA) scintigraphy and intragastric bile acid levels compared with the grades of reflux assessed scintigraphically. There was a significant correlation between both free and total intragastric bile acid levels and the degree of radiological bile reflux, especially when reflux was severe. Both endoscopic measurements of bile acids and BIDA scintigraphy appear to be useful methods for determining duodenogastric reflux, but neither may be accurate enough to quantify minor degrees of reflux.
Proximal gastric vagotomy or truncal vagotomy and drainage for chronic duodenal ulcer?
Authors: Clark C G , Fresini A , Araujo J G C , Boulos P B
Published: March 2007

A comparison has been made between truncal vagotomy and drainage (TVD) and proximal gastric vagotomy (PGV) performed electively for chronic duodenal ulceration from 1968 to 1981 in 209 and 272 patients respectively. The morbidity was 23 per cent after TVD and 19·8 per cent after PGV, with a mortality of 0·5 per cent and 0·4 per cent respectively. Of 163 patients in the former group and 253 patients in the latter group the follow-up was an average of 5·7 and 6·2 years respectively; 128 patients (78·5 per cent) and 198 (78·3 per cent) respectively had a good functional result, graded as Visick I and II, but 35 (21·7 per cent) and 55 (21·7 per cent), respectively, had a poor result owing to recurrent ulceration in 23 (14·1 per cent) after TVD and 44 (17·4 per cent) after PGV. These results were not statistically different. The frequency of diarrhoea was 23 per cent and dumping 6·8 per cent after TVD which was significantly reduced to 2·0per cent (P <0·005) and 1·2per cent (P <0·025), respectively, after PGV. However, only five patients (3·0 per cent) had severe symptoms from diarrhoea and two (1·2 per cent) from dumping after TVD. Both operations seem to carry an equal incidence of unsatisfactory results, though for slightly different reasons it might be concluded that both procedures have an equal degree of acceptability.
Renal parenchymal carcinoma in children
Authors: Booth C M
Published: March 2007

A series of 14 cases of renal parenchymal carcinoma in patients under 20 years of age is presented and reviewed with the best documented case reports from the literature. Unlike its adult counterpart the tumour has an equal sex ratio and minor trauma frequently precipitates presentation, otherwise its behaviour is similar. The treatment of choice is nephrectomy but, unlike adults, there is evidence to support the value of adjunctive radiotherapy and chemotherapy in the treatment of local spread. Prognosis is particularly worsened by cellular granularity, and vascular or direct extrarenal spread. The 5 year survival rate is 52 per cent.
Local recurrence of colorectal cancer: Effect of early detection and aggressive surgery
Authors: Schiessel R , Wunderlich M , Herbst F
Published: March 2007

A prospective study was undertaken of the incidence, symptoms, diagnostic measures and therapy of local recurrences of colorectal carcinoma following radical surgical management. Out of 715 patients, 156 (22 per cent) developed recurrence of the tumour, which was local in 90 patients. In addition, 36 patients with local recurrence from other hospitals were treated. Half of the patients were symptom-free at the time of diagnosis. Out of the 126 patients, 109 were treated by surgery, a radical operation being feasible in 53 cases. Fifty per cent of these have survived for at least 17 months. The operative mortality was very low (4.6 per cent), although extensive surgery was necessary in most of the cases. The preliminary results of this study support the hypothesis that a postoperative follow-up programme for patients with colorectal cancer leads to early detection of local recurrence and improves the chance of cure by surgical treatment.
Comparison of the function of triplicated and duplicated pelvic ileal reservoirs after mucosal proctectomy and ileo-anal anastomosis for ulcerative colitis and adenomatous polyposis
Authors: Nasmyth D G , Williams N S , Johnston D
Published: March 2007

Among 39 consecutive patients who underwent colectomy, mucosal proctectomy and ileo-anal anastomosis, a triplicated pelvic ileal pouch was constructed in 17, and a duplicated pouch in 22 patients. There was no mortality, but complications such as anastomotic dehiscence and pelvic sepsis led to removal of the pouch in seven patients (18 per cent). The functioning of the pouch and anal sphincter was assessed in 31 patients 6 months, and in 22 patients 12 months after closure of the diverting ileostomy. By 6 months, all patients were either completely continent or experienced only minor leakage and defaecation could be deferred for more than 15 min by 81 per cent of patients and flatus distinguished from faeces by 90 per cent of patients. No significant differences between triplicated and duplicated pouches were discernible at 6 months. At 12 months defaecation was significantly less frequent (P < 0.05) in patients with triplicated pouches (median, 5 times in 24 h) than in patients with duplicated pouches (7 times in 24 h). All patients with triplicated pouches and all except one with duplicated pouches were able to defaecate spontaneously, without needing to intubate the reservoir. Thus, provided the early postoperative problems can be overcome, most patients achieve good anal function after mucosal proctectomy combined with a pelvic ileal reservoir. No evidence was found in this study that the functional results of duplicated pouches were superior to those of triplicated pouches; in fact, the triplicated pouches proved to be slightly superior.
Pre-operative infusion cholangiography compared to routine operative cholangiography at elective cholecystectomy
Authors: Alinder G , Nilsson U , Lunderquist A , Herlin P , Holmin T
Published: March 2007

Routine operative cholangiography (group 1) was compared with pre-operative intravenous infusion cholangiography and selective operative cholangiography (group 2) in 200 patients subjected to elective cholecystectomy. All patients were examined with pre-operative intravenous infusion cholangiography. In group 1 patients, this examination was not made available to the surgeon and not used in any way except for a later analysis. Thirteen patients had to be excluded for different reasons. In group 1, normal operative cholangiograms were obtained in 82/94 cases. Choledocholithotomy was performed in 7/12 cases, choledochotomy in 2/12 and no exploration in 3/12 cases. In group 2, pathological or inconclusive infusion cholangiograms were demonstrated in 17/91 cases. Choledocholithotomy was performed in 11/17 cases. One of 17 patients was subjected to choledochotomy only. In 5/17 patients, no exploration was carried out because of normal operative cholangiography. No residual or retained stone/s have been revealed during a follow-up period of 1 year. The general clinical outcome in the two groups of patients was similar. Significantly shorter operative time was an important advantage of the strategy in group 2 patients.
Staged below-knee amputations for septic peripheral lesions due to ischaemia
Authors: Desai Y , Robbs J V , Keenan J P
Published: March 2007

Preservation of the knee joint is of paramount importance in lower limb amputation for ischaemia. Clinical predictors of healing are unreliable in patients with septic peripheral lesions due to ischaemia. Seventy-three patients in whom a below-knee amputation was considered likely to heal, based on the temperature and appearance of the skin and bleeding from skin and muscle flaps, were divided into two groups. Twenty-nine (Group A) had a primary below-knee (BK) amputation at the site of election with delayed primary skin closure, while 44 patients (Group B) initially had a guillotine BK amputation below the site of election, with elective amputation at the appropriate level once infection had been eradicated (4–5 days later). The groups were similarly matched with regard to level of occlusive arterial disease, nature of ischaemic lesions and operative risk factors. There was no significant difference in the overall operative mortality in Group A (6.7 per cent) compared with Group B (11.4 per cent) (P > 0.05). There was a significantly higher above-knee revision rate in Group A survivors (33.3 per cent) compared with Group B (7.7 per cent) (P < 0.01) due to non-viability and uncontrolled sepsis of the BK amputation site. The presence or absence of a palpable femoral or popliteal pulse had no significant influence on healing in either group.
Ruptured abdominal aortic aneurysm
Authors: Jenkins A McL , Ruckley C V , Nolan B
Published: March 2007

Between 1974 and 1984, 174 patients with ruptured abdominal aneurysms have been treated by three vascular surgeons. The 11-year period showed a dramatic increase in the number of patients presenting with ruptured aneurysms. The overall operative survival, including patients who died before a graft could be inserted, was 67 per cent with improvement from 60 per cent in the first half of the period to 69 per cent in the second. The overall survival rate for the 162 who had a completed graft was 72 per cent. Reference to data from the Lothian area surgical audit showed that there has been a transfer of responsibility from general to vascular surgeons with an increase in the proportion of patients treated by operation. Concentration of care within a single specialized unit appears to have had a favourable effect on survival.
Para-ileostomy hernia: Failure of a local repair technique
Authors: Horgan K , Hughes L E
Published: March 2007

Different techniques of local repair of para-ileostomy herniae have been recommended by a number of authors, but without report of long-term outcome. Two patients presenting electively with symptomatic para-ileostomy herniae are reported. A local repair technique was used in each case because of severe (coexisting) medical disease, but both herniae recurred within 2 years. It is considered that local repair without stomal transposition cannot be recommended. The literature is reviewed.
Anal hypertonia in fissures: Cause or effect?
Authors: Gibbons C P , Read N W
Published: March 2007

High sphincter pressures recorded in patients with fissure-in-ano have been attributed to sphincter spasm induced by wide recording assemblies. To investigate this hypothesis, anal sphincter pressure was measured using a series of perfused probes of 0·4–2 cm diameter in six men with chronic anal fissure in whom digital examination was easily tolerated. The results were compared with those from 14 normal men. The resting pressure within the anal canal exceeded the normal range in all six patients irrespective of probe size. With the smallest (0·4 cm) probe, the resting pressure was 114 ± 17·1 cmH2O (mean ± s.d.) in patients with fissure and 73·1 ± 27·0 cmH2O (mean ± s.d.) in control subjects (P < 0·01) even 10 min after introduction of the device. The minimum residual pressure attained during inflation of a rectal balloon with 100 ml of air was higher in patients with anal fissure than controls, reaching statistical significance with the 1·0 cm probe (80·8 ± 17·7 cmH2O versus 36·9 ± 19·0 cmH2O, P <0·001). Maximum pressures recorded during a voluntary contraction of the sphincter were no higher than in control subjects. The results suggest that high resting pressures are recorded in patients with chronic anal fissures even when small probes are employed and are unlikely to be due to spasm, but probably represent a true increase in basal sphincter tone. It is proposed that elevated sphincter pressures may cause ischaemia of the anal lining and this may be responsible for the pain of anal fissures and their failure to heal.
Factors influencing bowel function after ileal pouch–anal anastomosis
Authors: Nasmyth D G , Johnston D , Godwin P G R , Dixon M F , Smith A , Williams N S
Published: March 2007

Seventeen patients were studied 3–31 months (median 6·4 months) after mucosal proctectomy and ileal pouch–anal anastomosis for ulcerative colitis (n = 15) or adenomatous polyposis (n = 2). Seven had a triplicated pouch, and ten a duplicated pouch. Clinical bowel function was determined by detailed questionnaire, and correlations sought between clinical end-points such as frequency of defaecation, urgency of defaecation and continence, and the results of laboratory investigations, comprising anal manometry, capacity and compliance of the pouch, completeness of emptying, faecal bacteriology and mucosal inflammation. Frequency of defaecation was found to be inversely correlated with both the capacity (rs = −0·66, P < 0·01) and the compliance (rs = −0·53, P < 0·05) of the pouch. Patients who could postpone defaecation for > 30 min had higher anal squeeze pressures (P < 0·05) than patients who had greater urgency of defaecation. Patients with perfect anal continence had higher resting anal pressure (P < 0·05) and emptied the pouch more completely (P < 0·07) than patients who experienced minor leakage. The faecal flora of the pouches showed a greater predominance of anaerobes (P < 0·01) and increased numbers of bacteroides (P < 0·01) compared with the faecal flora of ileostomies, but the changes in the flora did not correlate with any aspect of bowel function. The best clinical results (i.e. perfect continence, low frequency of defaecation and little urgency) were associated with high anal pressure and with large volume, high compliance and complete emptying of the pouch. The completeness of emptying was similar for both designs of pouch, but the capacity and compliance of triplicated pouches were greater than the capacity and compliance of duplicated J pouches (P < 0·05), and this was associated with a better clinical result in the triplicated pouches.
Effect of warfarin on formation and growth of pre-neoplastic lesions in chemically induced colorectal cancer in the rat
Authors: Goeting Nicola L M , Trotter G A , Taylor I
Published: March 2007

Anticoagulant drugs are known to have an effect on tumour growth. However, the mechanisms by which they act are poorly understood, and have therefore been investigated in this study. Wistar rats were given eight weekly subcutaneous injections of azoxymethane, at a dose of 10 mg kg−1 week−1. Following this they were randomized into two groups: a control group, which received no further treatment, and a warfarin treated group, which received warfarin at ‘non-therapeutic’ doses in their drinking water, for a further 8 weeks. Pairs of rats from each group were killed at 5-weekly intervals from 10 to 35 weeks after the first azoxymethane injection. At 40 weeks all remaining rats were killed. Samples of colonic mucosa from the descending colon and rectum were taken for scanning electron microscopy. The number of microadenomas per low power field was determined in both groups at each time interval. Tumour incidence and distribution were noted in animals killed at 40 weeks. The median number of microadenomas was significantly lower in warfarin treated animals than in controls at all time intervals. Tumour number was also significantly decreased by warfarin treatment (27 in azoxymethane treated animals, 10 in animals receiving azoxymethane and warfarin, P < 0·05). The distribution of tumours along the colon was similar to that seen previously, following 12 weeks of azoxymethane. These effects occurred despite the non-concurrent administration of azoxymethane and warfarin.
Venous anatomy of the lower oesophagus in portal hypertension: Practical implications
Authors: Kitano S , Terblanche J , Kahn D , Bornman P C
Published: March 2007

The venous anatomy of the lower oesophagus and upper stomach in man was studied using high resolution resin casts obtained from ten fresh cadavers. Four layers of veins were identified in the oesophagus of both normal and portal hypertension patients. Intra-epithelial channels drained into a superficial venous plexus which connected to larger deep intrinsic veins. Both the superficial plexus and the deep intrinsic veins communicated directly with their counterpart veins in the stomach. Perforating veins connected the deeper veins with the adventitial plexus, the fourth layer. In patients with portal hypertension all of these veins were significantly dilated. Typical large oesophageal varices arose from the main trunks of the deep intrinsic veins which communicated directly with gastric varices. This study clarifies the anatomy of oesophageal varices and may explain why sclerotherapy is usually effective. The venous communications are probably partly responsible for the recurrence of varices after sclerotherapy.
Impact of vascular surgery on community mortality from ruptured aortic aneurysms
Authors: Ingoldby C J H , Wujanto R , Mitchell J E
Published: March 2007

The workload of aortic surgery in a district increased fourfold over 10 years as the incidence of aneurysm rupture rose from 7 to 17/100 000. Of 260 patients with ruptured aneurysms 101 reached hospital alive (38 per cent) of which 52 (52 per cent) survived, an overall survival rate of 19.8 per cent. Despite increasing experience, mortality after emergency surgery did not improve, suggesting outcome was largely determined by the patient's condition and age. Only 5 of 90 patients aged over 75 survived aortic rupture at home. In consequence overall community mortality did not improve in the period studied. Survival after elective surgery was 95 per cent, suggesting that efforts to improve survival should be directed towards identifying and treating the disease before rupture occurs. The commonly stated figure of 50 per cent survival for ruptured aortic aneurysms is an overestimate, due to neglect of patients dying at home.
Abdominal aneurysms in a black population: Clinicopathological study
Authors: Costa M , Robbs J V
Published: March 2007

With exclusion of vascular trauma 2182 patients (1302 black and 880 white) have been treated in our Vascular Service over a period of 3 years. Sixty black patients (4.6 per cent) and 260 white patients (29.5 per cent) presented with aneurysms of the aorta and its abdominal branches. The aneurysms in the black group were distributed as follows: 50 aortic (9 suprarenal, 41 infrarenal), 6 common iliac artery, 2 superior mesenteric and 2 renal artery aneurysms. None of the 260 aneurysms seen in white patients involved arteries other than the aorta (16 suprarenal, 244 infrarenal). In the black group there was an almost equal distribution among sexes, whereas in the white group there was a male to female ratio of 2:1. The mean age was 49.4 years among the black patients, and 67.1 years among the white patients. Surgery was performed on 47 black patients and 245 white patients. Among the black patients 16 aneurysms were atherosclerotic (34 per cent), 22 were of non-atherosclerotic origin (47 per cent) and 9 were of uncertain nature (19 per cent). Of the 22 non-atherosclerotic aneurysms 14 were due to non-specific aorto-arteritis, 4 were due to tuberculous arteritis, 2 were due to intimomedial mucoid degeneration, 1 was due to syphilitic aortitis and 1 was a mycotic aneurysm. In the white group 243 aneurysms were atherosclerotic and 2 had changes of intimomedial mucoid degeneration. All aneurysms were treated along standard surgical lines, antituberculous treatment was initiated when appropriate. It was concluded that abdominal aneurysm is an uncommon disease in black patients. When it occurs a more heterogeneous pathology can be expected with an unusually high prevalence of aorto-arteritis compared with the white population.
Risk of lymphoedema following the treatment of breast cancer
Authors: Kissin M W , Della Rovere G Querci , Easton D , Westbury G
Published: March 2007

The incidence of lymphoedema was studied in 200 patients following a variety of treatments for operable breast cancer. Lymphoedema was assessed in two ways: subjective (patient plus observer impression) and objective (physical measurement). Arm volume measurement 15 cm above the lateral epicondyle was the most accurate method of assessing differences in size of the operated and normal arm. Arm circumference measurements were inaccurate. Subjective lymphoedema was present in 14 per cent whereas objective lymphoedema (a difference in limb volume > 200 ml) was present in 25.5 per cent. Independent risk factors contributing towards the development of subjective late lymphoedema were the extent of axillary surgery (P < 0.05), axillary radiotherapy (P < 0.001) and pathological nodal status (P < 0.10). The risk of developing late lymphoedema was unrelated to age, menopausal status, handedness, early lymphoedema, surgical and radiotherapeutic complications, total dose of radiation, time interval since presentation, drug therapy, surgery to the breast, radiotherapy to the breast and tumour T stage. The incidence of subjective late lymphoedema was similar after axillary radiotherapy alone (8.3 per cent), axillary sampling plus radiotherapy (9.1 percent) and axillary clearance alone (7.4 per cent). The incidence after axillary clearance plus radiotherapy was significantly greater (38.3 per cent, P < 0.001). Axillary radiotherapy should be avoided in patients who have had a total axillary clearance.
Is operative cholangiography always necessary?
Authors: Wilson T G , Hall J C , McK Watts J
Published: March 2007

To determine whether operative cholangiography could be performed on a selective basis, 272 consecutive patients undergoing cholecystectomy and routine operative cholangiography were studied prospectively. Appropriate clinical, biochemical and operative data were recorded and the surgeon was asked to estimate the likelihood of common bile duct stones. These factors were correlated with the subsequent cholangiographic and operative findings. From this information, four criteria were selected as indications for performing an operative cholangiogram: an abnormal common bile duct, a wide cystic duct, or elevated levels of alkaline phosphatase or bilirubin documented in the previous six months. Operative cholangiograms would have been indicated by the presence of one or more of these criteria in only 139 of the 272 patients in the study (51 per cent). Only one unsuspected stone would have been missed. It is concluded that a policy of selective cholangiography could have been safely adopted in this series of patients.
Pancreatoduodenectomy with pylorus preservation for adenocarcinoma of the head of the pancreas
Authors: Grace P A , Pitt H A , Longmire W P
Published: March 2007

For many years, the classical Whipple procedure has been the standard operative treatment for resectable periampullary cancer. Recently, the pylorus preservation operation has also been applied to periampullary tumours. This newer procedure has potential advantages in terms of ease of performance and postoperative physiology, but has yet to be proved as an adequate cancer operation. We, therefore, undertook the present retrospective analysis to compare the outcome following the pylorus preservation operation (n = 13) with that of the classical Whipple resection (n = 13) in 26 patients with histologically proved adenocarcinoma of the head of the pancreas. The two groups of patients were comparable for age, sex, pre-operative laboratory data, and resected margins free from tumour. More patients undergoing the classical Whipple resection had Stage I disease (10 versus 4, P < 0.05). However, this difference would not be significant if the two patients in the pylorus preservation group with carcinomas in situ were considered to have stage I disease. Mean tumour diameter in the pylorus preservation patient group (3·2±0·6 cm) was smaller (P <0·05) than in the classical Whipple group (4·1±1·0 cm) but more patients in the pylorus preservation group also had metastases to the regional lymph nodes (54 versus 23 per cent). Overall operative morbidity (31 per cent) and mortality (4 per cent) was acceptable and did not differ between the two groups. Five year actuarial survival for pylorus preservation (25 per cent) was comparable to that observed for the Whipple procedure in this and other series.
Perineal and pelvic morbidity following perimuscular excision of the rectum for inflammatory bowel disease
Authors: Berry A R , De Campos R , Lee E C G
Published: March 2007

One hundred and fifteen patients who were treated by a proctocolectomy in Oxford between 1972 and 1984 for inflammatory bowel disease have been studied. All the patients had the rectum removed by the technique of perimuscular dissection which was introduced in 1972 in an attempt to overcome the problems associated with the previous types of proctectomy. The method has been shown to be safe; the operative mortality was 1·7 per cent. The most worrying potential complications due to permanent autonomic nerve damage (i.e. impotence and urinary incontinence), which previously have been recorded as occurring in a significant percentage of patients, were completely prevented by the method of dissection. One man suffered transient impotence which responded to psychiatric treatment. There were no long term urinary tract or sexual problems. Postoperative complications occurred in 37 per cent of patients, perineal wound infections being the most common (25·7 per cent). Perineal healing, however, was achieved in 75 per cent of patients by the time of their discharge from hospital. The mean length of postoperative hospital stay was 19 days in patients with ulcerative colitis and 15 days in patients with Crohn's disease. Our rate of perineal healing is better than has been recorded using other operative techniques.
Changing pattern of lower limb amputation for vascular disease
Authors: Sethia K K , Berry A R , Morrison J D , Collin J , Murie J A , Morris P J
Published: March 2007

In 1980 a review of lower limb amputation over a 3.5 year period between 1974 and 1978 was reported from our centre. More recently 193 amputations were performed for peripheral vascular disease over a similar 3.5 year period, representing an increase of 33 per cent in the amputation rate during the last 6 years. This cannot be explained by the increasing age of the population alone. Fewer below-knee amputations (BKA) (33.0 per cent) and more Gritti—Stokes amputations (GSA) (32.0 per cent) were performed and the overall incidence of re-amputation for stump breakdown was 13.5 per cent. Twenty-eight per cent of below-knee amputation stumps required re-amputation at higher levels, but when successful were associated with a 75 per cent incidence of rehabilitation with an artificial limb. Eight per cent of GSA stumps required re-amputation and were associated with a twenty-eight per cent incidence of successful rehabilitation. Thirty-seven per cent of patients had undergone reconstructive vascular surgery before amputation. Of the 26 patients requiring re-amputation 58 per cent had undergone arterial reconstruction in an attempt to salvage the limb (χ2 = 5.65, P < 0.02) and in 26.9 per cent of cases this was performed within the week before amputation. We feel that injudicious attempts at arterial reconstruction, when amputation appears inevitable, may adversely affect the subsequent level of amputation and jeopardize rehabilitation.
Ischiopagus tetrapus conjoined twins
Authors: Somasundaram K , Wong K S
Published: March 2007

Two sets of ischiopagus conjoined twins were successfully operated on at the University Hospital, Kuala Lumpur in 1981 and 1982. The anatomy of the organ and system malformations are discussed which determined the technique of reconstruction after surgical separation to obtain optimum cosmetic and functional results. Permanent colostomy was not required in any of the four twins and in only one twin was there a need for urinary diversion.
Survival patterns in hormone treated advanced breast cancer
Authors: Williams M R , Todd J H , Nicholson R I , Elston C W , Blamey R W , Griffiths K
Published: March 2007

This study investigates a series of factors, all recordable by the time of presentation of distant metastases from primary breast cancer and relates these to survival after the initiation of endocrine therapies. One hundred and ninety-one patients have received endocrine therapy as initial treatment for distant metastases. In all patients both the histological grade and oestrogen receptor (ER) status of primary tumour tissue; the lymph node stage and menopausal status at mastectomy and the disease-free interval and sites of initial metastases are available for analysis. Four of these factors have been found to contribute independently towards prolonged survival after the initiation of treatment: tumour grade, ER status, disease-free interval and sites of metastases. Employing a multivariate analysis incorporating these four factors, three groups of patients have been identified with survivals of 67, 37 and 0 per cent at 18 months on therapy. These three groups of patients contain 37, 41 and 22 per cent of the patient population respectively.
Experimental and clinical study of lactulose in obstructive jaundice
Authors: Pain J A , Bailey M E
Published: March 2007

The role of lactulose in preventing endotoxaemia in obstructive jaundice has been investigated. A prospective study was performed on 24 consecutive patients with obstructive jaundice undergoing surgery. Twelve patients were given oral lactulose before operation and were compared with twelve controls. Endotoxaemia was reduced in peroperative portal (P < 0·05) and postoperative systemic (P < 0·05) blood samples in the lactulose treated group, and a significant fall (P < 0·05) occurred in the postoperative 24 h creatinine clearances in controls compared with the lactulose treated group. Results from animal experiments in which oral lactulose reduced endotoxin related mortality in obstructive jaundice (P < 0·05), and the in vitro demonstration of a direct anti-endotoxic action of lactulose suggest that its beneficial action is due in part to an inactivation of endotoxin.
Effect of early blood transfusion on gastrointestinal haemorrhage
Authors: Blair S D , Janvrin S B , McCollum C N , Greenhalgh R M
Published: March 2007

The effect of citrated stored blood on coagulation was studied initially in a pilot study where 25 patients with acute severe gastrointestinal haemorrhage had their whole blood coagulation measured using the Biobridge Impedance Clotting Time (ICT). This demonstrated that there is a hypercoagulable response to haemorrhage which was partially reversed by blood transfusion. Similar changes were noted in Kaolin Cephalin Clotting Times (KCCT). A further 50 patients were then randomized to receive, during the 24h after admission, either at least 2 units of blood or no blood transfusion unless the haemoglobin fell below 8 g/dl or they were shocked. In the transfused group nine patients re-bled compared with only one in the non-transfused group (P < 0·01, χ2 with Yates' correction). Early blood transfusion appears to reverse the hypercoagulable response to haemorrhage thereby encouraging rebleeding and hence the need for an operation.
Fluid sequestration: An early indicator of mortality in acute pancreatitis
Authors: Sauven P , Playforth M J , Evans Mary , Pollock A V
Published: March 2007

Complete daily intake and output charts were available for 218 patients with acute pancreatitis. The patients were divided into three groups according to the relation between fluid intake and output. In 105 patients in whom there was negligible fluid sequestration (daily output within 2 litres of intake) there were six deaths (5·8 per cent). In 69 patients the daily fluid intake exceeded the output by 2 litres or more but this imbalance lasted for 48 h or less; six patients died (8·7 per cent). The remaining 44 patients sequestered 2 litres or more of fluid per day for more than 48 h or until death. Thirty-eight patients in this group died (86·4 per cent). Fluid sequestration of 2 litres or more per day, and lasting longer than 48 h, is an accurate and simple predictor of mortality in acute pancreatitis. In this study it had a sensitivity of 76 per cent and a specificity of 96 per cent. The predictive value of a positive result was 86 per cent and of a negative result 93 per cent (efficiency 92 per cent).
Sialography in salivary gland disease
Authors: McEntee G P , Manners A R , Peel A L G
Published: March 2007

Ninety-six consecutive patients underwent sialography over a 10 year period at North Tees District General Hospital; there were 68 parotid and 28 submandibular examinations. Patients were divided into two groups: group 1, patients with symptoms but no clinical signs (n = 27); group 2, patients with swelling of the salivary gland (n = 69). Results showed that sialography was of considerable value in group 1 patients demonstrating pathology in 33 per cent (9/27 patients). In patients with a suspected, but unusually situated, parotid tumour (n = 20) sialography was confirmatory in 10 patients but the technique failed in four, gave a false negative result in four and would seem to be of limited value. In the remaining patients in group 2 with diffuse glandular swelling (n = 49) the main contribution of sialography was in demonstrating sialectasia (9), duct strictures (4) and non-opaque parotid calculi (2), but even in this group of patients 35 per cent (17/49 patients) of the examinations were normal. When submandibular calculi were demonstrable on plain radiography sialography contributed no further relevant information.
Outpatient varicose vein surgery under local anaesthesia
Authors: Bishop C C R , Jarrett P E M
Published: March 2007

Local anaesthesia has been used for 186 varicose vein operations performed in a day surgical unit. The long saphenous vein was stripped in 87 legs using a femoral nerve block. All patients went home on the day of operation and none required readmission. Complications were minimal and included six wound infections, six episodes of thrombophlebitis and one case of saphenous neuritis; 35 patients had minor residual varices at 6 weeks of which 29 required injection sclerotherapy. The technique has been shown to be both safe and acceptable to patients, and reduced the waiting time for surgery to a mean of 3·1 months during the period studied.
Haemodynamics of the interposition vein cuff
Authors: Beard J D , Benveniste G L , Miller J H , Baird R N , Horrocks M
Published: March 2007

It has been suggested that the use of an interposition vein cuff for anastomosing PTFE grafts to small calibre arteries confers a haemodynamic advantage. Pulsatile blood flow through a standard anastomosis was compared, in vitro, to that incorporating a vein cuff. 6 mm PTFE was anastomosed end-to-side to 10 pairs of cadaver internal mammary arteries matched for length and internal diameter (median 1·8 mm, range 1·6–2·4). Blood flow was significantly higher through the vein cuff anastomosis than the standard anastomosis (comparison of regression analysis, P < 0·001) when the arterial diameter was < 2·0 mm (five pairs). These results suggest that the vein cuff does confer a significant haemodynamic advantage when PTFE is anastomosed to arteries < 2·0 mm diameter and this may be because the compliant vein cuff allows more distension of the anastomosis thus reducing anastomotic resistance.
Diagnosis and surgical management of intractable constipation
Authors: Roe A M , Bartolo D C C , Mortensen N J McC
Published: March 2007

Seventy-four patients with intractable constipation, of whom thirty-three had slow and forty-one normal intestinal transit, were investigated to determine the aetiology of their disorder and plan treatment. Patients with slow transit had a greater incidence of abdominal pain and distension (P < 0·001) and only 9 per cent had a normal call to stool compared with 71 per cent of those with normal transit (P < 0·001). Internal anal sphincter function as assessed by sphincter pressures, length and the recto-anal inhibitory reflex did not reveal any difference between the groups and normal controls; similarly anal sensation and rectal compliance were normal. However, those with normal transit had a higher threshold of rectal sensation than controls (P < 0·05), Slow transit patients failed to show a postprandial increase in rectosigmoid motility compared with controls (P < 0·05). Whilst the majority failed to inhibit the external sphincter on bearing down, half of those with normal transit produced either partial or complete inhibition. Both groups were able to increase the anorectal angle on straining. Twenty-two normal transit patients had abnormal perineal descent compared with controls (P < 0·0005). Patients with perineal descent exhibited abnormal rectal morphology. Rectal intussusception was observed in 13 of 35 evacuation proctograms. On the basis of the data presented, we could not justify internal sphincterotomy of puborectalis division. Our policy in severe slow transit constipation was to offer colectomy and ileorectal anastomosis. In five out of seven to date, a successful result has been achieved. Eight patients with rectal intussusception have undergone an abdominal rectopexy with significant improvement in three. In our hands, the evacuation proctogram and transit studies were the most useful preoperative investigations.
Results of surgical treatment for iliofemoral venous thrombosis
Authors: Swedenborg J , Hägglöf R , Jacobsson H , Johansson J , Johnsson H , Larsson S , Nilsson E , Zetterquist S
Published: March 2007

The long-term results after venous thrombectomy combined with a temporary arteriovenous fistula were evaluated in 19 patients. Clinical status, isotope phlebography, venous occlusion plethysmography and foot volumetry were performed after a mean follow-up time of 38 months (range 13–75). The primary operation was successful in 17 of the 19 patients; the 2 remaining had chronic occlusions of their iliac veins. At the time of closure of the arteriovenous fistula, i.e. 3 months after thrombectomy, 14 patients had a patent iliac vein. At follow-up eight patients were considered to have a patent iliac vein, eight had a partial restitution and three had an occluded iliac vein. The group as a whole had no impaired venous emptying of the leg, but the small group of patients with occlusion at follow-up according to isotope phlebography seemed to have an impaired venous emptying. Foot volumetry showed only minor signs of valvular insufficiency, mainly in limbs with distal extension of the initial thrombus or only partial restitution of venous patency. A good long-term result can be expected after venous thrombectomy with a temporary arteriovenous fistula particularly in younger patients where the thrombosis is limited to the iliofemoral segment. This emphasizes the importance of early operation before distal extension of the thrombus occurs.
Carcinoma of the thyroid: Differential behaviour in solitary and multinodular tumours
Authors: Kapur M M , Sarda A K , Bal S , Sood S
Published: March 2007

One hundred and sixty-three cases of thyroid carcinoma were treated between 1979 and 1983. The cancers were classified as solitary nodules or carcinomas in multinodular goitres according to their clinical presentation. Analysis revealed a significantly higher incidence of T0/T1 in the solitary nodular carcinoma group (P < 0·001) and a lower incidence of metastatic disease (P < 0·05) compared with multinodular carcinoma. Survival for the T0/T1 subgroup of solitary nodular carcinoma was significantly better compared with the same subgroup of multinodular carcinoma (P < 0·05).
Insulin infusion (GIK) in the treatment of type 2 (non-insulin dependent) diabetes during the perioperative period
Authors: Thomas D J B , Platt H S , Alberti K G M M
Published: March 2007

The effect of surgery on intermediary metabolism has been studied in six non-diabetic subjects, eleven type 2 diabetic subjects untreated during surgery, and nine type 2 diabetic subjects treated by glucose–insulin–potassium (GIK) infusion during surgery. Plasma glucose results were studied in all subjects and other metabolites whenever possible. Initial glucose concentrations were similar in both groups of diabetic subjects. Four hours postoperatively the plasma glucose was lower in the GIK group (10·1 ± 1·0 mmol/l) than in untreated subjects (14·2 ± 1·3 mmol/l, P < 0·05) but still far above levels found in non-diabetic subjects. Lactate concentration was higher in the GIK treated diabetic subjects than in both non-GIK treated diabetic and non-diabetic patients 15 min after induction (1·32 ± 0·07 compared with 0·93 ± 0·09 and 0·89 ± 0·08 mmol/l, P < 0·02). Non-esterified fatty acid (NEFA) was lower one hour postoperatively in the GIK treated diabetic group than in the non-GIK diabetic patients (0·47 ± 0·09 mmol/l compared with 1·09 ± 0·22 mmol/l, P < 0·05). All NEFA concentrations were lower in GIK treated diabetic subjects than in non-diabetic subjects for the time of insulin infusion. Blood 3-hydroxybutyrate was also lower in GIK treated (0·04 ± 0·02) than in untreated diabetic subjects 4h postoperatively (0·25 ± 0·07 mmol/l, P < 0·05). The levels of non-esterified fatty acid and 3-hydroxybutyrate found in the untreated diabetic did not differ from those found in non-diabetic controls. Plasma cortisol levels had risen in all groups 4 h postoperatively (P < 0·01).
Abolition of postprandial alkaline tide after vagotomy and its use as a screening test in the assessment of vagotomy
Authors: Ahmad A
Published: March 2007

Assessment of completeness of vagotomy has always been an irksome and time-consuming affair. The commonly employed test of insulin-induced hypoglycaemia (Hollander) is tedious, risky and associated with practical limitations and theoretical objections, which have resulted in its being replaced by the modified sham feed technique in some centres. The postprandial alkaline tide is attributed to HCO3− release consequent to H+ secretion. Any procedure which reduces acid secretion is expected to affect the postprandial urinary pH. This study was performed to evaluate the effect of vagotomy on the postprandial alkaline tide by measuring prevagotomy and postvagotomy fasting and postprandial urinary pH. The results show that postprandial urinary pH falls after vagotomy and this method may be used to assess the completeness of vagotomy. The proposed test is convenient and may be used as a screening method in the assessment of vagotomy and other acid reducing operative procedures, if further validated, by comparison with already established tests.
Diagnostic accuracy of double-contrast enema and rectosigmoidoscopy in connection with faecal occult blood testing for the detection of rectosigmoid neoplasms
Authors: Jensen J , Kewenter J , Haglind Eva , Lycke G , Svensson Christina , Åhrén C
Published: March 2007

Four hundred and fifty-eight consecutive subjects with a positive faecal guaiac test when screened for early detection of colorectal neoplasms were investigated with double-contrast enemas and rectosigmoidoscopy (60 cm). The results of these two methods were compared. The radiologists and endoscopists were unaware of the result of each others' examination at the time of their own investigation. Altogether ten subjects with carcinoma in the rectosigmoid area were found. The radiologists and endoscopists each overlooked four of these ten carcinomas and only four of the carcinomas were diagnosed with both methods. Fifty-six of one hundred and seven adenomas were 1 cm or larger in diameter and located in the rectum or the sigmoid colon. Thirteen of the fifty-six adenomas were missed by double contrast enema and ten by endoscopy and only thirty-three adenomas were diagnosed with both methods. Neoplasms in the rectum and the sigmoid colon are sometimes difficult to diagnose with both radiology and endoscopy. Rectosigmoidoscopy (60 cm) should therefore be used as a complement to double contrast enemas if this method is chosen for investigation of a patient with rectal bleeding.
Laparoscopy as an adjunct to decision making in the ‘acute abdomen’
Authors: Paterson-Brown S , Eckersley J R T , Sim A J W , Dudley H A F
Published: March 2007

When patients are admitted to hospital with acute abdominal pain, clinicians, irrespective of a specific diagnosis, intuitively select three diagnostic classes: operation definitely required (Group A); operation definitely not required (Group B); need for operation uncertain (Group C). The last is followed either by a precautionary laparotomy or a variable period of observation/investigation. We have studied prospectively the influence of laparoscopy on the distribution between these classes and particularly on outcome in group C. One hundred and twenty-five consecutive patients with abdominal pain severe enough for emergency admission have been classified by one of two admitting surgeons (SHO/registrar), who also expressed in group C a view on how they would proceed – operation or observation. Group C were then laparoscoped. The procedure confirmed a provisional view that laparotomy was needed in 11 of 15 patients. In the ‘observation’ sub-group the provisional decision was confirmed in 14 of 16 and early discharge followed in most. Six inappropriate decisions were thus avoided. Seven management decisions in group A and 4 in group B proved incorrect (11/94: 12 per cent). The majority were potentially recognizable by laparoscopy. Though relatively high rates of successful decision making are achieved with conventional clinical techniques, they can be further improved by laparoscopy. This procedure is particularly applicable in the management of patients with acute abdominal pain without a definite diagnosis, or when appendicitis is regarded as an established diagnosis.