bluuebunny/crossref_metadata_2025 huggingface dataset:
Evidence from dynamic integrated proctography to redefine anismus
Authors: Roberts J P , Womack N R , Hallan R I , Thorpe A C , Williams N S
Published: March 2007

The role of anismus in the aetiology of defective rectal evacuation was investigated by dynamic integrated proctography in 20 controls and 71 constipated patients. Normal parameters were defined and compared between 21 constipated patients with poor evacuation during proctography (<40 per cent of contrast evacuated; group 1) and 50 who evacuated fully (>90 per cent of contrast evacuated; group 2). Nine patients in group 1 failed to evacuate. Radiological abnormalities of the rectum were recorded in all groups but obstructed evacuation was not observed. Anismus (defined as a recruitment of puborectalis electromyogram (EMG) activity of >50 per cent) was significantly more common in group 1 than group 2 patients (14 of 21 versus 12 of 50, P < 0.01) and present in seven of those unable to evacuate. Eight patients in group 1 failed to raise intrarectal pressure >50 cmH2O compared with two in group 2 (P < 0.001). Six patients in group 1 demonstrated both anismus and inability to raise intrarectal pressure, which may combine to cause defective evacuation. EMG recruitment alone is insufficient to diagnose anismus. Definition should be based on three criteria: demonstration of puborectalis EMG recruitment of >50 per cent; evidence of an adequate level of intrarectal pressure (>50 cmH2O) on straining; and presence of defective evacuation.
Long-term reduction of intimal hyperplasia by the selective alpha-1 adrenergic antagonist doxazosin
Authors: Vashisht R , Sian M , Franks P J , O'Malley M K
Published: March 2007

Studies have shown that α1- adrenergic blockade reduces intimal hyperplasia in the rabbit aorta. In this study a selective α1-adrenergic antagonist, doxazosin, has been used to examine whether this effect is persistent and dose dependent. Forty-eight New Zealand White rabbits underwent endothelial denudation of the abdominal aorta using a Fogarty balloon catheter. Test rabbits were given low-dose (2 mg) or high-dose (8 mg) doxazosin daily and all animals killed at either 1 or 12 weeks after the procedure. The aortas were harvested after fixation in situ with 4 per cent glutaraldehyde and neointimal hyperplasia was measured, using an x-y digitizer, as the percentage reduction in luminal cross-sectional area. At I week after surgery, rabbits receiving the low dose had a median area reduction of 7.7 per cent and those receiving the high dose a reduction of 8.2 per cent; both had significantly less intimal hyperplasia than control rabbits, which had a median area reduction of 14.8 per cent (P < 0.01). However, at 12 weeks, when compared with the 32.6 per cent reduction in the control group, only those rabbits receiving high-dose doxazosin had significantly less intimal hyperplasia, with a reduction of 5.5 per cent (P < 0.001). It is concluded that selective α1-adrenergic blockade significantly reduces neointimal hyperplasia, that this effect is dose dependent, and that it persists for at least 3 months.
Circadian variation in unexpected postoperative death
Authors: Rosenberg J , Pedersen M H , Ramsing T , Kehlet H
Published: March 2007

Unexpected deaths still occur following major surgical procedures. The cause is often unknown but may be cardiac or thromboembolic in nature. Postoperative ischaemia, infarction and sudden cardiac death may be triggered by episodic or constant arterial hypoxaemia, which increases during the night. This study examined the circadian variation of sudden unexpected death following abdominal surgery between 1985 and 1989 inclusive. Deaths were divided into those occurring during the day (08.00–16.00 hours), evening (16.00–24.00 hours) and night (24.00–08.00 hours). Twenty-three deaths were considered to have been totally unexpected. Of 16 such patients undergoing autopsy, pulmonary embolism was the cause of death in five. In the remaining 11 patients, death occurred at night in eight (P < 0.005). Five of the seven patients without an autopsy died at night (P < 0.04); overall, 13 of 18 unexpected deaths occurred at night-time. These results suggest a need for further studies of sleep-and respiration-related effects on postoperative nocturnal cardiac function. The efficacy of monitoring during this apparent high-risk period should be evaluated.
Traumatic amputation by explosive blast: Pattern of injury in survivors
Authors: Hull J B
Published: March 2007

Explosive blast causes a pattern of injury including primary blast lung, secondary fragment injury and traumatic amputation of limbs. Major traumatic amputation is rare in survivors of bomb blast but common in those who die. The mechanism of such injury has not been previously determined, but must be established if protective measures are to be developed for members of the armed forces. The nature of 41 traumatic amputations in 29 servicemen who survived to reach medical care after blast injury was investigated to determine the anatomical level of amputation and the pattern of soft tissue damage. Joints were an infrequent site of amputation and the tibial tuberosity was a particularly frequent site of lower-limb severance. Comparison of the pattern of injury was made with that seen in ejecting fast-jet pilots, who frequently suffer major flailing injury; there appears to be a substantially different injury distribution. The accepted mechanism of traumatic amputation, avulsion by the dynamic overpressure, is challenged: it is suggested that the shockwave resulting from an explosion is capable of causing at least bone disruption in a limb.
Oesophageal cancer: A population-based study of survival after treatment
Authors: Oliver S E , Robertson C S , Logan R F A
Published: March 2007

The survival of patients with oesophageal cancer diagnosed during the period 1982–1985 in Nottingham has been studied. Of 496 patients identified from endoscopy, histopathology and hospital activity analysis records, 268 (171 men) lived in the catchment area and had primary oesophageal cancer. Compared with previous studies the proportion of adenocarcinoma (35 per cent) was twice that expected, although survival was similar (hazard rate ratio at 2 years 1.0 (95 per cent confidence interval (c.i.) 0.8–1.4)) whether a squamous cell carcinoma or adenocarcinoma was present. Based on the original treatment intention, surgery was attempted in 34 per cent of cases and was associated with a median survival from diagnosis of 293 (95 per cent c.i. 232–367) days, with 41, 19 and 11 per cent surviving 1, 2 and 3 years respectively. Rudical radiotherapy was attempted in 13 per cent of patients and was associated with a median survival of 190 (95 per cent c.i. 136–253) days, with 14, 6 and 6 per cent surviving 1, 2 and 3 years. Intubation alone was performed in 40 per cent of patients, of whom 44 per cent were aged over 75 years and 29 per cent had evidence of metastases, compared with 13 and 11 per cent respectively of those undergoing surgery or radical radiotherapy. The median survival for intubation alone was 100 (95 per cent c.i. 81–122) days, with 6, 3 and 0 per cent of patients surviving 1, 2 and 3 years respectively. Although patients treated surgically had the longest survival, these data indicate that overall survival after any active intervention is modest. Intubation alone is a reasonable option in those not suitable for surgery; randomized trials are needed to compare intubation with new methods of palliation.
Prospective study in adults of splenic preservation after traumatic rupture
Authors: Schweizer W , Böhlen L , Dennison A , Blumgart L H
Published: March 2007

Seventy-five adults with splenic injury were evaluated prospectively over 45 months to examine the possibility of splenic preservation. Haemodynamically unstable patients underwent surgery with the intent of splenic preservation. Stable patients received on-operative treatment regardless of the grade of splenic injury determined by ultrasonography and computed tomography. Thirty-seven patients required splenectomy and in 38 the organ was preserved (20 operative preservation, 18 non-operative treatment). Of 22 patients initially receiving non-operative treatment, there were four secondary haemorrhages after 7, 7, 10 and 13 days making surgery necessary. Three of these patients underwent splenectomy and in one the spleen was preserved by partial resection. After splenectomy four patients required reoperation because of rebleeding or for evacuation of a haematoma. Patients who had undergone splenectomy had a significantly increased infection rate (P < 0.005) compared with those in whom the spleen was preserved, even when patients were matched with respect to multiple trauma using the Injury Severity Score (P < 0.01).
Endoscopic management of postoperative bile leaks
Authors: Mortensen J , Kruse A
Published: March 2007

Thirty-two patients aged 15-89 years developed postoperative bile leakage. Twenty-eight had undergone cholecystectomy, with choledocholithotomy in 11, and four had had miscellaneous operations. Endoscopic retrograde cholangiopancreatography (ERCP) was performed 2–75 days after operation and revealed leakage from the cystic duct stump in 19 cases, from a T tube track in five, from the gallbladder and liver abscess cavity in two and from the major bile ducts in six. Major bile duct lesions were not generally amenable to endoscopic treatment, but the remaining 26 patients were treated successfully with internal stenting (22) or endoscopic sphincterotomy (four); bile secretion in all cases stopped within I week. One patient with cholangitis after an ERCP procedure was managed by antibiotics; no other complication occurred and there were no deaths related to the procedure. ERCP procedures are well tolerated in the postoperative period and may be performed under sedation. ERCP is the method of choice for dealing with bile leakage and ERCP procedures are effective for the most common causes of postoperative bile leakage; complications are rare.
Role of endoscopic retrograde cholangiopancreatography in the investigation of pain after cholecystectomy
Authors: Carlson G L , Rhodes M , Stock S , Lendrum R , Lavelle M I , Venables C W
Published: March 2007

Patients who continue to have or who develop abdominal pain after apparently successful cholecystectomy pose diagnostic difficulties. This study reports 384 such patients, investigated by endoscopic retrograde cholangiopancreatography (ERCP). There were 146 patients with abdominal pain alone with no previous history of common bile duct (CBD) exploration, of whom only 17 (11.6 per cent) had CBD stones on ERCP. Bile duct calculi were present in 76 of 140 patients (54.3 per cent) with abnormal biochemical findings (raised alkaline phosphatase and/or amylase level) and in 34 of 57 (60 per cent) with an abnormality detected on ultrasonography or intravenous cholangiography. A combination of biochemical and radiological abnormalities was present in 37 patients and was associated with CBD stones in 28 (76 per cent). Patients who had undergone CBD exploration represented a special group, of whom the majority (75 per cent) had common duct stones at ERCP even in the absence of biochemical and radiological abnormalities. ERCP is a useful investigation in patients with persistent postcholecystectomy symptoms. Other features in addition to pain or a history of CBD exploration may be relevant to the decision to perform ERCP in the investigation of these patients.
Common bile duct diameter and complications of endoscopic sphincterotomy
Authors: Wilson M S , Tweedle D E F , Martin D F
Published: March 2007

To assess the relationship between distal common bile duct (CBD) diameter and the incidence of an immediate complication following endoscopic sphincterotomy (ES), all patients undergoing ES between January 1986 and October 1990 were studied. The overall risk of an immediate complication following ES in 655 patients was 5.6 per cent (37 patients). Patients with calculi were at greater risk if the distal CBD was dilated (P <0.001); the complication in those with stones was most likely to be haemorrhage (81 per cent). The relative risk of a complication increased ten times if the distal bile duct diameter was >0.8 cm. Patients with stricture of the distal CBD did not have a significantly greater risk of complication than those with stones (9.7 versus 4.9 per cent). There was no significant difference between the mean distal CBD diameter of those with stricture and controls (0.61 versus 0.44 cm).
Psychological screening for non-specific abdominal pain
Authors: Fraser S C A , Smith K , Agarwal M , Bates T
Published: March 2007

Non-specific abdominal pain (NSAP) may have a detectable psychological component that could be used to predict outcome. To test this hypothesis, 131 patients aged 14–40 years admitted with acute abdominal pain were assessed using the General Health Questionnaire (GHQ) and Hospital Anxiety and Depression (HAD) scale, and a structured interview. Of 61 patients with NSAP, more had a psychosocial problem identified by the admitting registrar (P < 0.01) and marginally more had high questionnaire scores. The risk of having NSAP was high if an abnormality on interview accompanied high questionnaire scores (relative risk 1.93 (95 per cent confidence interval (c.i.) 1.35–2.77)) or if prodromal pain had lasted > 7 days (relative risk 2.13 (95 per cent c.i. 1.55–2.92)). After 2 years, patients with continuing pain had higher HAD and Spielberger Anxiety Trait scores (both P < 0.02); NSAP was associated with persisting pain (relative risk 2.22 (95 per cent c.i. 1.10–4.48)). Psychosocial factors are implicated in NSAP and in chronic pain, but the sensitivity and specificity of questionnaire assessment are too low to be useful in diagnosis.
Anovaginal and rectovaginal fistula in patients with Crohn's disease
Authors: Scott N A , Nair A , Hughes L E
Published: March 2007

Between 1971 and 1991, details of 67 women with perianal Crohn's disease were recorded prospectively using the Cardiff classification. Two groups were identified according to the presence (n = 29) or absence (n = 38) of anorectal Crohn's fistula involving the vagina. Patients in both groups were of a similar age and had had Crohn's disease for a similar period before diagnosis of perianal involvement. The incidence of associated perianal lesions, superficial ulcers, cavitating ulcers, other fistulas and strictures was not significantly different between the two groups. A greater proportion of patients with anorectal-vaginal fistulation (n = 15) had distal intestinal Crohn's disease (rectal or contiguous colorectal) compared with women with no vaginal fistulation (n = 14). A range of therapies was used to manage women with perianal Crohn's disease, from local surgery to a defunctioning stoma and/or proctectomy. Only 13 of 38 women with perianal Crohn's disease but no vaginal fistula required a defunctioning stoma or proctectomy, whereas 18 of 29 with anorectal-vaginal fistulation underwent these procedures (P ≤ 0.05). A vaginal fistula has a considerable adverse effect on the outcome of perianal Crohn's disease.
Manual dilatation of the anus
Authors: Macdonald A , Smith A , McNeill A D , Finlay I G
Published: March 2007

A group of 100 consecutive patients undergoing manual dilatation of the anus between 1980 and 1983 were reviewed retrospectively by examining the clinical presentation, diagnosis, treatment and outcome. Anal fissure was diagnosed in 46 patients, 22 had either first-or second-degree haemorrhoids, and stenosis of the anal canal was identified in seven. Manual dilatation of the anus was performed on 25 patients in the absence of a diagnosis. Dilatation failed to treat 26 anal fissures successfully. Where it was employed alone in ten cases of haemorrhoids and seven of anal stenosis, manual dilatation failed to cure seven and five patients respectively. Of the patients with no diagnosis, 23 were relieved of their symptoms following dilatation. Episodes of incontinence occurred in 27 patients, 21 of whom were female. There should be a reduced role for manual anal dilatation in the treatment of common anorectal disorders.
Medullary thyroid carcinoma
Authors: Dunn J M , Farndon J R
Published: March 2007

Medullary thyroid carcinoma accounts for 5–10 per cent of thyroid malignancies and occurs sporadically, and in three familial settings with autosomal dominant inheritance. Calcitonin, a 32 amino acid 3.5-kDa protein, is a biochemical marker of the tumour. Serum levels correlate with disease burden. Treatment initiated by screening allows disease removal at a premalignant phase: C cell hyperplasia. Genetic linkage studies locate the multiple endocrine neoplasia type 2A gene near the centromere of chromosome 10. Flanking genetic markers may allow polymorphic probes to examine DNA from a once-only blood sample to identify affected individuals. At what age thyroidectomy should be carried out in these patients is unclear.
Contemporary management of the appendiceal mass
Authors: Nitecki S , Assalia A , Schein M
Published: March 2007

An appendiceal mass is the end result of a walled-off appendiceal perforation and represents a pathological spectrum ranging from phlegmon to abscess. Over the past decade, improved imaging and interventional radiological techniques have allowed a more accurate definition of pathology and thus a more specific and less invasive management than was previously possible. A management policy should be possible that allows over 80 per cent of patients presenting with an appendiceal mass to be safely spared an open operation.
Autotransfusion in aortic surgery: The Haemocell System 350 cell saver
Authors: Kalra M , Beech M J , Al-Khaffaf H , Charlesworth D
Published: March 2007

Autotransfusion was performed during elective abdominal aortic reconstruction in ten patients using the recently developed Haemocell System 350. A mean of 60 per cent of total blood loss was salvaged, and during operation each patient was autotransfused 1 unit. Good preservation of cellular components, including platelets, was seen after processing with the device, which uses a vortex mixing filter for cell separation. There was no evidence of coagulopathy; mean free plasma haemoglobin levels were slightly raised (17 mg/dl) and plasma heparin concentration was negligible (0·10 units/ml) 4 h after surgery. A transient drop in plasma fibrinogen levels and the appearance of fibrin degradation products in low concentrations (mean 1·5 mg/l) were seen. Oxyhaemoglobin dissociation curves showed the salvaged red blood cells to have a normal affinity for oxygen. Renal and hepatic function remained unaltered and there were no complications attributable to autotransfusion. The device was easy to handle and a trained operator was not required.
Transit disorders of the gastric remnant and Roux limb after Roux-en-Y gastrojejunostomy: Relation to symptomatology and vagotomy
Authors: van der Mijle H C J , Beekhuis H , Bleichrodt R P , Kleibeuker J H
Published: March 2007

Patients after Roux-en-Y gastrojejunostomy frequently complain of upper abdominal pain, fullness, nausea and vomiting. This study was performed to clarify the relationship of this Roux-en-Y syndrome to transit disorders in the gastric remnant and Roux limb, and to vagal status. Using a questionnaire, 35 of 66 patients operated on between 1976 and 1987 were judged to suffer from the Roux syndrome. Gastrojejunal transit was studied by scintigraphy with a solid test meal in 61 patients, 34 of whom were symptomatic. The median (interquartile range) gastric half-emptying time was longer in symptomatic than in asymptomatic patients (79 (43–146) versus 56(27–79) min, P < 0·05), and in patients with a bilateral vagotomy than in those without a vagotomy (94 (43–225) versus 59 (31–77) min, P < 0·05). Stasis in the Roux limb was observed in 18 of 28 symptomatic and in only three of 27 asymptomatic patients (P < 0·01). The median (interquartile range) fraction of activity emptied from the stomach and remaining in the Roux limb at 60 min was 54 (39–60) per cent in symptomatic patients and 33 (21–40)per cent in those without symptoms (P < 0·01). Stasis in the Roux limb was not related to vagal status. No relationship between slow gastric emptying and Roux-limb stasis was found. Slow gastric emptying, Roux-limb stasis or a combination of both was found in 30 of 34 symptomatic and in only nine of 27 asymptomatic patients (P < 0·01). It is concluded that both slow gastric emptying and Roux-limb stasis can be interpreted as causing the Roux syndrome. Vagotomy seems to be the major cause of slow gastric emptying, but it is not related to stasis in the Roux limb.
Assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography in patients with acute pancreatitis
Authors: Neoptolemos J P , London N J M , Carr-Locke D L
Published: March 2007

The integrity of the main pancreatic duct (MPD) was evaluated by endoscopic retrograde pancreatography (ERP) in a retrospective study of 105 patients with acute pancreatitis presenting over an 11-year period (1980–1991). The findings were compared with clinical outcome and the need to operate for local pancreatic complications. Patients were divided into two groups. Group 1 (n = 89) had either clinically mild pancreatitis or severe disease but no surgery for local complications, and <25 per cent necrosis on contrast-enhanced computed tomography (CT) (n = 48). Group 2 patients (n = 16) had clinically severe pancreatitis and underwent surgery for local complications and/or had ≧ 25 per cent necrosis on CT (n = 12), at surgery or post mortem. All 89 patients in group 1 had an intact MPD at ERP, which was performed a median of 6 (range 0–30) days after onset of pancreatitis; the median age was 63 (range 20–88) years and there were no deaths. The median age of patients in group 2 was 59 (range 26–85) years. ERP in this group was performed in four patients <5 days after onset and all had an intact MPD; one died with necrosis and another from a cerebrovascular accident. ERP was performed ≧ 5 days after onset in the other 12 patients: five had an intact MPD and two required surgery for pseudocyst drainage only; seven had a disrupted MPD and all required surgery for pancreatic necrosis (one death). It is concluded that an intact MPD was a feature of mild pancreatitis, whereas disruption occurred >4 days after onset in patients with necrosis necessitating surgery.
Long-term follow-up after open cholecystectomy
Authors: Konsten J , Gouma D J , von Meyenfeldt M F , Menheere P
Published: March 2007

The long-term outcome of open cholecystectomy was investigated. Follow-up data at a median of 10 years were obtained from physicians' records on 325 (92·6 per cent) of 351 patients treated for symptomatic gallbladder stones by open cholecystectomy between 1978 and 1980. One 79-year-old patient died after operation, from a pulmonary complication. Of the 325 patients, 81·5 per cent were currently asymptomatic or had not had symptoms during follow-up until death. Sixty patients (18·5 per cent) had complaints after 10 years. Stone recurrence was found in five patients (1·5 per cent); ten others (3·1 per cent) had biliary tract-related complaints during follow-up. Blood samples were obtained in 67·3 per cent of surviving patients with biliary complaints. There were no laboratory findings associated with biliary obstruction. Patients with typical symptoms of gallstone disease before surgery had significantly fewer complaints during follow-up than those with typical as well as atypical symptoms (14·8 versus 26·5 per cent, P < 0·02). However, most of these complaints were not related to the procedure. It is concluded that the majority of patients reported no complaints or postcholecystectomy symptoms 10 years after surgery.
Plasminogen activator inhibitor 2 reduces peritoneal fibrinolytic activity in inflammation
Authors: Whawell S A , Vipond M N , Scott-Coombes D M , Thompson J N
Published: March 2007

Fibrinolysis in peritoneal tissue may play a role in the development of intra-abdominal adhesions. The plasminogen-activating capacity of human peritoneum results largely from the presence of tissue plasminogen activator (tPA). Inflammation reduces peritoneal plasminogenactivating activity and leads to the appearance of plasminogen activator inhibitor (PAI) type 1. The role of PAI-2 in the inhibition of peritoneal fibrinolysis during inflammation was investigated in this study. The plasminogen-activating activity of peritoneal biopsy homogenates (seven inflamed, seven normal), measured using a fibrin plate technique, was reduced in inflamed compared with normal tissue (median <0·07 versus 13·9 units/cm2, P < 0·01); tPA antigen levels were not significantly different (median 1·02 versus 1·34 ng/ml). PAI-1 and PAI-2 antigens were not detected in normal human peritoneum but were present in inflamed peritoneum (median concentration 8·8 ng/ml for PAI-1, 26·7 ng/ml for PAI-2). These inhibitors may be important factors in adhesion formation by contributing to the abolition of peritoneal plasminogen-activating activity.
Controlled trial of wound infiltration with bupivacaine for postoperative pain relief after appendicectomy in children
Authors: Wright J E
Published: March 2007

A double-blind controlled trial was performed to assess the effectivene, of wound infiltration with bupivacaine for postoperative pain relief after appendicectomy in children. Sixty children entered the trial and 52 completed it; they were randomized to receive bupivacaine or placeb Assessment of postoperative pain using a numerical scoring system was made by the child, the recovery sister and the ward sister, and 52 measurement of the time between the end of the operation and the need for narcotic injection. Analysis revealed significantly less pain (P < 0·03) in the immediate postoperative period in the treated ground The use of bupivacaine wound infiltration as a supplement to other current methods of pain control is recommended.
Ischaemia—reperfusion injury in the rat kidney: Effect of a single dose of sodium bicarbonate
Authors: Lennon G M , Ryan P C , Fitzpatrick J M
Published: March 2007

The protective effect of intravenous 8·4 per cent sodium bicarbonate on renal function after ischaemia was evaluated in rats subjected to 45 or 90 min warm unilateral renal ischaemia. Two groups of control animals received normal or 3 per cent saline. All solutions were given by bolus injection 3 h before ischaemia. Renal function was significantly protected in animals receiving bicarbonate. Vascular congestion of the inner stripe of the renal medulla was prevented. The survival rate in the group undergoing 90-min ischaemia was 70 per cent for animals receiving bicarbonate and nil in those given saline. Preoperative alkalinization confers significant functional and morphological protection in the ischaemic kidney.
Simultaneous dynamic electromyographic proctography and cystometrography
Authors: Thorpe A C , Williams N S , Badenoch D F , Blandy J P , Grahn M F
Published: March 2007

The rectum and bladder share a common origin and work in harmony; disturbance in one may lead to a similar problem in the other. The two have, however, not previously been investigated dynamically and simultaneously. A new system has been devised allowing dynamic integrated electromyographic proctography to be performed simultaneously with cystometrography in 41 patients (28 women and 13 men). Of 16 women with chronic constipation who underwent the combined study, ten were shown to have obstructed micturition. Eight of these ten women exhibited an inappropriate contraction of the puborectalis muscle during micturition, compared with one of the six with normal micturition (P = 0·02). Of the patients with obstructed micturition, seven of eight women with a rectocele also had anismus, compared with none of four women with a rectocele among those who were able to micturate normally (P = 0·02). Eight of the ten women with obstructed micturition thus had a proctological abnormality that explained the urological symptoms. Of 12 women with idiopathic faecal incontinence who underwent the combined study, eight were shown to have genuine stress incontinence of urine. In seven of these the severity was shown to be of type 2a or greater, indicating that pelvic floor dysfunction may be the causal factor of both rectal and urinary symptoms. The combined study shows abnormalities in one system that could explain similar symptoms in the other.
Carotid endarterectomy improves haemodynamics on the contralateral side: implications for operating contralateral to an occluded carotid artery
Authors: Markus H S , Harrison M J , Adiseshiah M
Published: March 2007

The importance of the patency of the contralateral carotid artery on the haemodynamic effect of a carotid stenosis was investigated. The breath-holding index was used to estimate cerebral perfusion reserve. The percentage rise in middle cerebral blood flow velocity, measured by transcranial Doppler ultrasonography, occurring during breath-holding was divided by the time of breath-holding. In study 1, ten subjects with no carotid stenosis, 13 with unilateral and eight with bilateral stenosis were studied. For unilateral stenosis the breath-holding index was reduced on the stenosed side compared with normal (0·85 versus 1·34 per cent per s, P <0·05). For bilateral disease, in the presence of severe stenosis on the side contralateral to that being examined, even a moderate stenosis (30–50 per cent) resulted in a much greater reduction in the breath-holding index. In study 2, the breath-holding index was measured before and after carotid endarterectomy in ten patients. The index increased significantly following operation, not only on the operated side (1·31 versus 0·79 per cent per s, P <0·01), but also on the contralateral side (1·23 versus 0·87 per cent per s, P <0·05). In three of four patients with contralateral stenosis >90 per cent or occlusion, operation improved the breath-holding index markedly (>90 per cent) on the non-operated side above the stenosis or occlusion. These results demonstrate the importance of patency of the contralateral carotid artery in determining the haemodynamic effect of a carotid stenosis. In addition, operating contralateral to an occlusion may improve haemodynamic status above the occlusion. Implications in selecting patients for carotid endarterectomy are discussed.
Critical leg ischaemia: an appraisal of clinical definitions
Authors:   Joint Vascular Research Group, Tyrrell M R , Wolfe J H N
Published: March 2007

The reliable prediction of imminent limb death remains a clinical problem. The International Vascular Symposium and European working parties each produced similar definitions of “critical ischaemia”, but this is the first attempt to address the issue with prospectively collected data. Complete 3-year follow-up data were available for 213 patients. In addition to the above two definitions, a simplified modification has been evaluated, after review of the data 1 year into this study. All three definitions were able to identify patients likely to require amputation in the absence of successful reconstruction. The sensitivity, specificity and positive predictive values with which they were able to do so was, however, poor. None of the definitions was able to predict which diabetic patients would require amputation. Diabetics were more likely to undergo amputation than non-diabetics. There was, however, no significant difference in the initial ankle artery pressures between the diabetic and non-diabetic patient subgroups. None of the definitions reliably predicted which grafts would occlude, in which event the 3-year mortality rate was approximately 35 per cent. Critical ischaemia by any of these definitions is associated with a high mortality rate. Arterial reconstruction is associated with a reduction in both mortality and amputation rates These data do not support the hypothesis that critical ischaemia is associated with a greater graft occlusion rate than lesser degrees of severe ischaemia.
Femoral hernia: intestinal obstruction is an unrecognized source of morbidity and mortality
Authors: Chamary V L
Published: March 2007

A total of 180 consecutive femoral hernia repairs, consisting of 100 emergency and 80 elective admissions between January 1979 and December 1986, were reviewed. Morbidity was greater in the emergency than in the elective group (P <0·01) and was significantly related to intestinal obstruction (P <0·001), a feature not previously highlighted. Intestinal obstruction also had an important association with mortality, which was confined to patients undergoing emergency surgery. Patients with intestinal obstruction are a high-risk group and require careful perioperative management. Wound infection predisposed to recurrence of femoral hernia (P <0·01). Repair of recurrent hernia in patients treated electively was associated with an increased incidence of chest infection (P <0·001). Prophylactic measures, including antibiotics, may help to reduce recurrence and its associated morbidity. Patients referred with an inguinal lump or hernia, as opposed to a femoral hernia, had a later outpatient appointment and consequently a later operation date (P <0·02). All elderly patients referred with any groin lump should receive an early outpatient appointment.
Life quality and psychological morbidity with an ileostomy
Authors: Awad R W , El-Gohary T M , Skilton J S , Elder J B
Published: March 2007

The recent introduction of restorative proctocolectomy for the treatment of ulcerative colitis has reopened the debate about the effects of ileostomy on quality of life. This study analysed life quality and psychological morbidity in 113 patients with an ileostomy using a postal questionnaire which included questions about their opinion of the pouch operation. Of the questionnaires, 73 per cent were suitable for analysis. A total of 93 per cent of those responding were happy with the ileostomy and appeared to have adapted to a normal life with it. Some 87 per cent stated that they would keep the ileostomy in preference to an ileoanal pouch. In addition, psychological morbidity as assessed by the General Health Questionnaire occurred in only 5 per cent of patients.
Emergency laparoscopic surgery
Authors: Paterson-Brown S
Published: March 2007

The acute abdomen continues to demand a large proportion of the general surgeon's workload. Recent studies have demonstrated that management errors can be significantly reduced using selective laparoscopy and this should now become routine practice. The continuing advances in laparoscopic surgery that permit many emergency procedures to be performed by this route provide increased impetus for a combined approach using diagnostic and therapeutic laparoscopy for the management of the acute abdomen. Results of current studies must be awaited before the exact role of emergency laparoscopic surgery can be defined, but early reports suggest several advantages in using laparoscopy to manage conditions such as acute appendicitis, perforated peptic ulcer and gynaecological emergencies.
Elective lymph node dissection in the management of malignant melanoma
Authors: Scott R N , McKay A J
Published: March 2007

The surgical management of regional nodes in patients with cancer has been controversial for many years. This paper reviews the role of elective lymph node dissection in the management of malignant melanoma. The evidence for and against elective lymphadenectomy is discussed and a policy of therapeutic, rather than elective, lymph node excision recommended.
Splenectomy for splenomegaly exceeding 1000 grams: Analysis of 47 patients
Authors: Letoquart J-P , La Gamma A , Kunin N , Grosbois B , Mambrini A , Leblay R
Published: March 2007

Forty-seven patients who underwent splenectomy for splenomegaly ⩾1000 g were studied retrospectively. There were 29 men and 18 women of mean age 56 (range 19–87) years. Haematological malignancy was the most common disorder (42 patients). The main indications for splenectomy were cytopenia (20 patients), diagnosis (14), initial treatment of leukaemia (eight), pain (four) and spontaneous rupture (one). Thirteen patients underwent an associated surgical procedure. One patient died (mortality rate 2 per cent) and 12 (26 per cent) had postoperative complications. The advantages of splenectomy included histopathological diagnosis in 13 of 14 patients with splenomegaly of unknown origin, effective initial treatment in prolymphocytic and hairy cell leukaemia, definitive relief of pain in all affected patients, and long-term improvement of cytopenia in most.
Repeat liver resection for recurrent colorectal metastases
Authors: Vaillant J-C , Balladur P , Nordlinger B , Karaitianos I , Hannoun L , Huguet C , Parc R
Published: March 2007

Sixteen patients underwent 18 repeat liver resections for recurrence of colorectal hepatic metastases that had been previously resected. Only minor liver resection had been undertaken at the first operation; three were palliative. The second operation was major hepatectomy in ten patients, minor resection in five and orthotopic liver transplantation in one. In one patient, lung metastases were resected before the second operation. One repeat hepatectomy was palliative. After partial liver resection, there were no deaths and complications were observed in six of 15 patients. One patient died 2 weeks after liver transplantation. After the second resection, 2-, 3- and 5-year survival rates were 67, 57 and 30 per cent; the mean survival time was 33 (range 8–93) months. Tumour recurrence was observed in 11 of 14 patients 4–32 (mean 13) months after a second curative liver resection; two patients received a third curative operation for recurrent liver metastases. After the second curative hepatectomy, seven patients died from disease after a mean of 36 (range 14–61) months and seven are currently alive at a mean of 33 (range 8–93) months. Four of these patients are free from disease 26–93 months after resection and three are alive with recurrence. Repeat hepatectomy for recurrent colorectal metastases can prolong survival in selected patients and has low operative risk.
Intragastric bile acid and symptoms in patients with an intrathoracic stomach after oesophagectomy
Authors: Chattopadhyay T K , Shad S K , Kumar A
Published: March 2007

Bile acid concentration and symptoms were evaluated in 24 patients after total oesophagectomy and gastric pull-up. Patients were randomly allocated to receive pyloroplasty or not. After operation all were followed for a minimum of 6 months. Bile acid concentration in the gastric juice was estimated. The mean(s.d.) bile acid concentration 6 months after surgery was similar in patients with and without pyloroplasty (34.9(30.1) and 25.0(24.2) mg/dl respectively). Postprandial discomfort and bilious eructations were the two most commonly observed symptoms in both groups. Other features noted were vomiting, anaemia and anorexia. These did not however seem to be related to intragastric bile acid concentration of individual patients in either group and occurred irrespective of whether pyloroplasty was performed or not.
Increasing incidence of carcinoma of the gastric cardia in Sweden from 1970 to 1985
Authors: Hansson L-E , Sparén P , Nyrén O
Published: March 2007

Several American, Japanese and European centres have reported an increase in carcinoma of the gastric cardia, contrary to the general trend in the incidence of gastric cancer. The aim of this nationwide population-based study was to describe trends in the incidence of tumours of the gastric cardia in Sweden over the 16-year period from 1970 to 1985. The Swedish cancer register, which is more than 95 per cent complete, was used to identify cases. There were 1514 men and 481 women with cancer of the gastric cardia. The age-standardized rates increased in men from 1.9 per 105 population in 1970–1973 to 3.0 per 105 in 1982–1985, corresponding to a mean annual increase of 2.5 per cent (95 per cent confidence interval (c.i.) 1.6–3.4 per cent). In women, the age-standardized rates increased from 0.5 per 105 in 1970–1973 to 0.8 per 105 in 1982–1985, the mean annual increase being 0.9 per cent (95 per cent c.i. 0.0–1.8 per cent). The highest incidences were found in southern Sweden, contrary to the geographical distribution of gastric cancer in general, which shows a south-to-north gradient. The disparate epidemiological features of cancer of the cardia and gastric cancer at other sites suggest that the aetiologies may also be different. Since little is known about the aetiology of cancer of the cardia, and the incidence seems to be rising rapidly, analytical studies are urgently needed.
Gastric cancer and Helicobacter pylori infection
Authors: Buruk F , Berberoglu U , Pak I , Aksaz E , Celen O
Published: March 2007

Gastric adenocarcinoma can be divided into two histopathological types: intestinal and diffuse. In addition to the role of environmental factors, an association between gastric cancer and Helicobacter pylori has been suggested. A retrospective study was therefore carried out among 46 patients who had gastric cancer. As a control group, 40 patients with non-malignant disorders were selected (11 patients with peptic ulcer, 12 with chronic superficial gastritis, 17 with chronic atrophic gastritis). Twenty-six cancers were classified as intestinal type and 20 as diffuse type. H. pylori was found in 23 (88 per cent) of the intestinal type and 11 (55 per cent) of the diffuse type (P < 0.05). Patients with the intestinal-type gastric cancer had a higher prevalence of H. pylori infection than those with gastric ulcer (55 per cent) and chronic superficial gastritis (50 per cent) (P < 0.05). These findings suggest that there is a possible association between the intestinal type of gastric cancer and H. pylori infection.
Intraoperative assessment of nodal status in the selection of patients with breast cancer for axillary clearance
Authors: Fisher C J , Boyle S , Burke M , Price A B
Published: March 2007

Preliminary axillary node sampling with intraoperative reporting of imprint cytology to detect positive nodes was assessed in 50 consecutive patients with T1 or T2 breast cancer undergoing axillary clearance, 21 of whom were histologically node positive. A mean of 3.5 (range 1–4) nodes were sampled. Axillary clearance yielded a mean of 11.7 (range 4–32) nodes. Of node-positive patients, sampled nodes detected 18 of 21 on immediate processing, one on subsequent paraffin sections, and failed to detect two (one of ten and one of 17 positive nodes). If the technique had been used during operation to select patients for axillary clearance, 29 of 50 would have avoided the operation, one of two node-positive patients would have required delayed axillary treatment and two of 21 with minimal axillary disease would not have received further axillary treatment or adjuvant therapy. The technique may be useful in reducing the morbidity of breast cancer surgery without increasing the risk of locoregional or distant recurrence.
Incidence and management of benign anastomotic stricture after cervical oesophagogastrostomy
Authors: Pierie J P E N , de Graaf P W , Poen H , van der Tweel I , Obertop H
Published: March 2007

Benign anastomotic stricture after transhiatal oesophagectomy and gastric tube reconstruction constitutes a major problem. From August 1988 to April 1991, 81 patients were followed after cervical oesophagogastrostomy. Twenty-four patients (30 per cent) developed a benign anastomotic stricture 3–23 (median 8) weeks after operation. Poor vascularization of the gastric tube, determined during operation, and postoperative anastomotic leakage were statistically significant risk factors for stricture formation. Symptoms related to stricture were often typical and were confirmed by endoscopy and/or radiography. Radiography did not yield information additional to that obtained from endoscopy. Strictures were treated in the outpatient clinic by dilatation with Savary dilators. Repeated dilatation completely alleviated dysphagia in 20 of the 24 patients (83 per cent). In ten patients dilatations could be discontinued after a median of 8 (range 1–17) sessions. Dilatation was continued until the end of follow-up in nine patients or until death from recurrent disease in five. No complications of dilatation were seen.
Ultrasonography during liver resection for hepatocellular carcinoma
Authors: Lau W Y , Leung K L , Lee T W , Li A K C
Published: March 2007

Seventy-nine consecutive patients underwent elective laparotomy for symptomatic hepatocellular carcinoma between 1986 and 1992. In the first 4 years, 51 patients received liver resection without intraoperative ultrasonography. In the subsequent 2 years, ultrasonography was performed during operation on 28 patients; three were found to have inoperable tumours. The technique located tumours in two patients and changed the extent of liver resection in another two. Eight of 51 patients (16 per cent) who had the parenchymal transection plane determined clinically had histological evidence of tumour infiltration of the resection margins, compared with none of 25 in whom the plane was determined by ultrasonography. This difference was significant (P = 0.034). The use of intraoperative ultrasonography improved patient survival, although this was not statistically significant. The median survival of patients with adequate resection margins was 9.2 months, compared with 3.9 months in those with inadequate margins. Intraoperative ultrasonography is useful in surgery for hepatocellular carcinoma.
Colonic bacteria and bacterial translocation in experimental colitis
Authors: Gardiner K R , Erwin P J , Anderson N H , Barr J G , Halliday M I , Rowlands B J
Published: March 2007

The indigenous intestinal flora and an intact mucosa are vital components of body defences against luminal pathogenic bacteria. Disruption of these defences in inflammatory bowel disease may permit bacterial translocation and contribute to disease severity. Support for this hypothesis comes from this study of a hapten-induced rat model of colitis. Induction of colitis was associated with a significantly increased colonic Gram-negative aerobic bacilli count. The results, expressed as log10 [colony-forming units per gram tissue] were: colitic 6.97–8.86 versus control 4.90–6.69 (P < 0.05). Colitis was also associated with a decreased Gram-positive cocci count at 4.00–8.04 versus control 6.45–8.30 (P < 0.05). Bacteria translocated to the mesenteric lymph nodes in five of eight colitic rats (P = 0.01), to the spleen in four (P = 0.04) and to the liver in five (P = 0.01) but to these organs in none of the eight control animals. There was a positive correlation between the severity of colonic inflammation and extent of bacterial translocation in colitic animals (rS = 0.86, P = 0.007).
High prevalence of unsuspected abdominal aortic aneurysm in patients with confirmed symptomatic peripheral or cerebral arterial disease
Authors: MacSweeney S T R , O'Meara M , Alexander C , O'Malley M K , Powell J T , Greenhalgh R M
Published: March 2007

A group of 561 consecutive patients with proven symptomatic peripheral or cerebral arterial disease attending a vascular clinic was screened for abdominal aortic aneurysm (AAA) using B-mode ultrasonography. An aneurysm was present in 40 of 358 men (11.2 per cent) and 13 of 203 women (6.4 per cent), a total prevalence of 9.4 per cent. Thirty-three aneurysms were 3–4 cm in diameter. The prevalence of AAA was similar in patients referred with lower-limb and with cerebral ischaemia. Physical examination for AAA was performed in 200 patients before ultrasonography. The sensitivity of physical examination in the detection of aneurysm was 43 per cent (57 per cent for AAA <4 cm in diameter, 29 per cent for AAA ⩽4 cm in diameter). Physical examination was an inadequate method of screening. Initial follow-up showed a mean aneurysm expansion rate of 0.20 cm/year. Patients with arterial disease have a high risk of AAA; routine ultrasonographic screening should be considered.