bluuebunny/crossref_metadata_2025 huggingface dataset:
Thrombosis of the superior mesenteric vein
Authors: Umpleby H C
Published: March 2007

Four patients under 45 years old presented with small bowel infarction secondary to superior mesenteric venous thrombosis. Diagnosis was not made pre-operatively in three patients and delay to operation of over 4 days occurred in two patients. In each case infarcted bowel was resected and a primary anastomosis fashioned. A further resection of infarcted small bowel was necessary in three patients. Each patient was discharged on long-term warfarin therapy. Two patients required permanent total parenteral nutrition, one of whom died of liver failure at one year. The remaining patients remain well.
Use of a lipid containing medium chain triglycerides in patients receiving TPN: A randomized prospective trial
Authors: Clarke Patricia J , Ball Madeleine J , Hands Linda J , Dennison A R , Tunbridge Anne , White K , Kettlewell M G W
Published: March 2007

Lipid emulsions which contain long chain triglycerides (LCTs) provide a valuable energy source for patients requiring total parenteral nutrition (TPN). We have investigated the use of a new lipid emulsion containing both long and medium chain triglycerides (MCTs) in a randomized prospective trial. Sixty patients received TPN including 500 ml of either 20 per cent Lipofundin S (LCT) or Lipofundin 10 per cent MCT/10 per cent LCT for at least 6 days. Patients with renal or hepatic impairment, or major trauma, were excluded from the study. The MCT/LCT emulsion was found to be as safe and as effective a source of calories as LCT but the differences in metabolic parameters did not differ significantly between the two groups of patients. A lipid emulsion containing MCTs may have important advantages for seriously ill patients, but appears to have no obvious advantages for the majority of patients receiving TPN who are not severely stressed.
Relative contribution of bile and pancreatic juice duodenogastric reflux in gastric ulcer disease and cholelithiasis
Authors: Eyre-Brook I A , Smythe Anne , Bird N C , Mangnall Yvonne , Johnson A G
Published: March 2007

Bile acid concentrations, phospholipase A2 activity and pH in the stomach were measured in the fasting state and for 2 h after a fat-containing test meal in patients with an active gastric ulcer (GU), in patients with gallstones before and after cholecystectomy and in normal subjects. Fasting and peak postprandial bile acid concentrations in the stomach were low in all normal controls. Although high concentrations were found in many patients with GU (P<0·01), similar concentrations were found in many patients with radiologically non-functioning gallbladders containing gallstones (NFG) (P<0·01) and also after cholecystectomy (AC) (P<0·01). Fasting intragastric phospholipase A2 activities were similar, and very high in GU and NFG patients compared with control subjects (P<0·01). High values were not found after cholecystectomy. There was no difference in pH profile or in postprandial phospholipase A2 between patient groups. Since patients with cholelithiasis or after cholecystectomy are not known to have an increased incidence of gastric ulceration, the significance of duodenogastric reflux in the aetiology of gastric ulcers must be questioned. If reflux does produce ulcers in GU patients then factors in addition to bile acid are probably involved. However, neither patterns of phospholipase A2 reflux nor pH profiles can explain the absence of gastric ulceration in those patients with gallstones who reflux large quantities of bile acid.
Lateral paramedian incision
Authors: Brennan T G , Jones N A G , Guillou P J
Published: March 2007

Prospective randomization of 360 patients undergoing abdominal surgery determined whether a standard lateral paramedian incision was made (group A) or one of two modifications in which the anterior sheath was incised medially and posterior sheath incised laterally (group B) or vice versa (group C), in order to determine the necessity for incising both layers laterally to provide the shutter mechanism which is held responsible for the integrity of this wound. Medial incision of the anterior rectus sheath significantly reduced the time required to perform the incision (P<0·02) and tended to reduce wound sepsis rate. However, this was achieved at the cost of a higher incisional hernia rate (0 per cent, 2·9 per cent and 4·6 per cent in groups A, B and C respectively, P<0·02). We conclude that lateral incision of both anterior and posterior rectus sheath is necessary to obviate the risk of wound hernia with the lateral paramedian incision.
Role of Enterobius vermicularis in the aetiology of appendicitis
Authors: Budd J S , Armstrong C
Published: March 2007

An evaluation was made of the histological material obtained from all 1529 appendices removed during the last 5 years at Southmead Hospital. Bristol, in order to elucidate possible relationships between the incidence of Enterobius vermicularis and the origin of inflammation in the appendix. In total, 1419 appendices were removed as cases of clinical appendicitis and 110 in the course of another surgical procedure. E. vermicularis was identified in 2·7 per cent of patients with clinical appendicitis and was most commonly seen in appendices with either chronic inflammation or where the appendix was histologically normal. E. vermicularis was rarely associated with histological changes of acute appendicitis. No cases of E. vermicularis infestation occurred in appendices removed during the course of other surgical procedures. The results suggest that, although E. vermiculans may have a causal role in appendicular pain and chronic inflammation, it is rarely related to acute appendicitis.
Comparison of the local and systemic effects of sepsis in predicting survival
Authors: Ponting G A , Sim A J W , Dudley H A F
Published: March 2007

Progress in the study of sepsis has been hampered by the lack of a suitable system for grading its severity. Systems suggested for scoring sepsis have been based either on its systemic effects (APACHE II) or on a mixture of local and systemic variables (sepsis score). The APACHE II and sepsis scores were applied to patients with intra-abdominal sepsis of more than 3 days' duration, to determine if local or systemic factors were more important in predicting survival. Of 45 patients studied, 14 died. The sepsis score for non-survivors (median 21·5, range 11–32) was significantly higher than for survivors (median 14, range 10–26, P<0·05). There was overlap between the two groups, such that an individual score had no predictive value. The local component of the sepsis score was not significantly increased in non-survivors (P<0·05), but the systemic component was (P<0·05). The APACHE II score for non-survivors (median 24, range 15–38) was significantly higher than for survivors (median 12, range 3–21), and correctly identified 13 of the 14 fatalities. Both the systemic and non-systemic components (age and chronic disease) were significantly higher among the latter. The APACHE II was more effective than the sepsis score in predicting survival. We conclude that any system used for scoring sepsis should be based on systemic rather than local effects. At present the APACHE II score is preferred.
Evaluating surgical risk: The importance of technical factors in determining outcome
Authors: Pettigrew R A , Burns H J G , Carter D C
Published: March 2007

A total of 113 patients having elective resection of the alimentary tract were studied prospectively to examine the relationship of pre-operative clinical and nutritional assessment to the development of major postoperative complications. In addition, the operating surgeon made a risk assessment on a linear analogue scale before and immediately after operation. Major complications developed in 28 patients (25 per cent). Age, weight loss and relative weight did not select high risk patients, but patients with a serum albumin of 29 g/l developed significantly more complications than those with higher levels (60 versus 22 per cent, P < 0·05). Clinical assessment also selected some high risk patients but patients selected by the surgeon's pre-operative assessment did not develop significantly more complications than those not selected (38 versus 21 per cent). However, the surgeon's postoperative assessment did select patients at significantly increased risk, especially when compared with his pre-operative assessment. Of 38 patients who were selected pre-operatively as high risk or who increased their risk ranking postoperatively, 20 (53 per cent) developed complications, as opposed to only 6 of 65 patients (9 per cent) who were low risk or decreased their risk ranking (P < 0·001). The surgeons changed their ranking postoperatively in 44 patients and in 36 (82 per cent) the reason given was the technical ease or difficulty of the procedure. Using receiver-operating characteristic curves, immediate postoperative assessment was superior to any pre-operative method of selecting high risk patients. Of 15 patients with normal serum albumin levels whose risk ranking increased postoperatively 6 (40 per cent) developed complications while none of the 7 patients with low serum albumin (high risk) who decreased their risk ranking developed complications. It is concluded that operative performance is the main factor in the development of postoperative complications and should be assessed in future studies of outcome.
Renal impairment following biliary tract surgery
Authors: Thompson J N , Edwards W H , Winearls C G , Blenkharn J I , Benjamin I S , Blumgart L H
Published: March 2007

Postoperative mortality has been directly attributed to renal failure in approximately 5 per cent of patients after surgery for obstructive jaundice. An analysis of 334 patients undergoing biliary tract surgery was undertaken to identify the perioperative factors associated with the development of renal impairment, and to estimate the contribution of renal failure to mortality. Thirty-eight patients (11 per cent) developed postoperative renal impairment (a two-fold increase in serum creatinine postoperatively or a rise of > 100 μmol/l). Ninety-three factors were examined in these and 196 control patients. Stepwise logistic regression analysis identified only three factors which were significantly associated with renal impairment: postoperative sepsis (P < 0·0005), pre-operative serum bilirubin (P < 0·0005), and pre-operative urea (P < 0·05). Renal impairment developed at a median 4 days after surgery and was associated with a median of two additional major postoperative complications, particularly sepsis and haemorrhage, for which 17 patients underwent reoperation. Twenty-eight (74 per cent) of the patients with renal impairment died in hospital, but in only one case was the cause of death directly related to renal failure. Twenty patients received specific therapy for renal failure, but only one of these survived. Pre-operative obstructive jaundice and postoperative infection are the major factors associated with renal impairment after biliary tract surgery. Renal impairment appears to be related to postoperative complications rather than directly to the surgical procedure itself. The development of postoperative renal impairment predicts a low chance of survival but appears to be an indicator, rather than a direct cause of a poor prognosis.
Warfarin inhibition of metastasis: The role of anticoagulation
Authors: McCulloch P , George W D
Published: March 2007

Warfarin inhibits metastasis in animal models by mechanisms that remain unclear. A better understanding of this phenomenon may clarify processes underlying metastasis in human cancer. We have studied the effects of warfarin on metastasis in a rat model by intravenous injection of Mtln3 mammary carcinoma cells and subsequent counting of pulmonary seedlings. To determine whether warfarin acts principally on the tumour cell or the host, we pretreated either cells or animals with warfarin before intravenous injection of 104 Mtln3 cells. Pretreatment of tumour cells had no effect, whilst pretreatment of the host reduced median seedlings from 67 to 4·5 per animal (P < 0·005). To determine whether warfarin was acting via its anticoagulant action, we reversed warfarin anticoagulation by intravenous injection of coagulation factors II, VII, IX and X. Restoration of coagulation for 12 h immediately after injection of cells completely reversed the warfarin effect (P < 0·001), but if the injection of factors was delayed for 12 h it had no effect (P = 0·1753). We conclude that warfarin acts principally on the host, not the tumour cell, and that it acts via its effect on coagulation. The restriction of the effect to the first 12h after tumour cell injection suggests a mechanism involving intravascular processes such as tumour cell survival or endothelial adhesion.
Gastric emptying and clinical outcome after Roux-en-Y diversion
Authors: Britton J P , Johnston D , Ward D C , Axon A T R , Barker M C J
Published: March 2007

The results of 48 Roux-en-Y (RY) diversion procedures are reported: 41 were performed as secondary procedures and 7 as part of a primary operation for peptic ulcer. There was no operative mortality, but four patients developed temporary fistulae in the postoperative period and three patients required reoperation. Good clinical results were found when RY diversion was performed as a primary procedure or when the indication for operation was peptic ulceration. The overall results, however, were poor: 24 patients (50 per cent) felt that they had not benefited and 32 patients (67 per cent) remained in Visick grades 111 or IV. The main cause of failure was gastric stasis, especially of solid food. Gastric emptying studies were carried out after RY diversion in 22 patients, most of whom had symptoms of stasis. Emptying of liquids was found to be normal in most patients, but emptying of solids was delayed, the median t1/2 for solids being 160 (75–370) min compared with 67 (50–85) min in DU patients. Bilious vomiting improved significantly after RY diversion, but 18 patients (38 per cent) complained of vomiting food and 32 patients (67 per cent) experienced postprandial distress or pain. Loss of the antral mill, vagotomy of the gastric remnant and, perhaps, resistance to gastric emptying by the Roux loop itself may together explain the delay in gastric emptying of solids after RY diversion.
Multicentre clinical trial of low volume fresh frozen plasma therapy in acute pancreatitis
Authors: Leese T , Holliday M , Heath D , Hall A W , Bell P R F
Published: March 2007

Fresh frozen plasma (FFP) has been proposed as a specific therapy for acute pancreatitis. Reduced mortality encountered in an uncontrolled clinical study and a controlled experimental study may be attributable to replenishment by FFP of the naturally occurring antiprotease system. To investigate this potential therapy further, 202 patients presenting with acute pancreatitis were randomized to receive FFP (2 units daily for 3 days) or a similar volume of colloid control as part of their intravenous fluid therapy. Clinical progress was monitored and the major serum antiproteases (α1-antiprotease and α2-macroglobulin) were measured on days 1, 3 and 7. There was no significant difference between the two groups in terms of clinical outcome. α1-Antiprotease levels rose significantly from day 1 to day 3 in both groups (P < 0·0001) and remained elevated at day 7. α1-Antiprotease is an acute phase protein in man and raised serum levels would be anticipated. FFP appears to have no effect on the magnitude of this rise. Serum α2-macroglobulin levels were reduced in both groups on day 1 and continued to fall significantly from day 1 to day 3 in the colloid control group (P < 0·005) whilst remaining substantially unaltered in patients receiving FFP (P = 0·6527). α2-Macroglobulin plays a central role in the elimination of proteases during acute pancreatitis and the ability of relatively low volumes of FFP to reduce the fall in serum α2-macroglobulin levels seen during the early stages of this disease may have therapeutic implications.
Study of common bile duct exploration and endoscopic sphincterotomy in a consecutive series of 438 patients
Authors: Neoptolemos J P , Davidson B R , Shaw D E , Lloyd D , Carr-Locke D L , Fossard D P
Published: March 2007

The outcome of 438 consecutive patients who had exploration of the common bile duct and/or endoscopic sphincterotomy (ES) in a 5-year period was reviewed. Patients were analysed according to four groups: 59 patients had planned ES followed by surgery resulting in 14 major complications (23·7 per cent) including 3 deaths (5·1 per cent) (group 1); 248 patients had surgery alone with 21 major complications (8·5 per cent) including 10 deaths (4·0 per cent) (group 2); 114 patients with gallbladder in situ underwent ES alone with 22 major complications (19·3 per cent) including 9 deaths (7·9 per cent) (group 3); 17 patients with remote cholecystectomy also had ES alone with 3 major complications (17·6 per cent) including 3 deaths (17·6 per cent) (group 4). There was no difference in mortality between the groups. Compared with group 2, major complications were significantly higher in group 1 (χ2 = 11·0, d.f. = 1, P < 0·001) and in group 3 (χ2 = 8·6, d.f. = 1, P < 0·003). Patients in group 3, however, were significantly older than those in groups 1 and 2, and the former also had higher medical and total risk factor scores than the latter (all P < 0·001). The results indicate that routine pre-operative ES is of que: ionable value. ES alone is justified in elderly high risk patients; mortality in this group might be reduced by improved management of post-ES complications.
Small bowel obstruction: Computer-assisted prediction of strangulation at presentation
Authors: Pain J A , Collier D St J , Hanka R
Published: March 2007

A multivariate computer analysis has been performed on the presenting data of patients with simple small bowel obstruction that settled with conservative treatment (n = 120) and of patients with viable strangulation small bowel obstruction (n = 38) and non-viable strangulation small bowel obstruction (n = 39) found at operation. Initially only 66 per cent of patients with viable strangulation and 46 per cent of those with non-viable strangulation had been treated by immediate surgery after resuscitation. The remainder had been treated conservatively for a median of 3·8 and 2·2 days respectively before undergoing surgery. The computer predicted on the basis of presenting symptoms and signs that 82 per cent of patients with viable strangulation and 97 per cent of those with non-viable strangulation had or would develop strangulation and should have undergone immediate surgery. We advocate that the computer can assist in the management of patients with small bowel obstruction.
Long-term effect of carotid endarterectomy on carotid sinus baroreceptor function and blood pressure control
Authors: Dehn T C B , Angell-James J E
Published: March 2007

In order to assess whether carotid endarterectomy had any long-term hypotensive effect, by altering the function of the carotid sinus baroreceptors, blood pressure and carotid sinus baroreceptor function were recorded in 25 patients undergoing carotid endarterectomy. No overall change in blood pressure was recorded 6 months after surgery. Sinus function was shown to decrease in 2 (8 per cent), to remain unchanged in 15 (60 per cent) and to increase in 8 (32 per cent) patients 6 months postoperatively. There was no relationship between changes in sinus function and changes in blood pressure over the 6 months period. Thus, carotid endarterectomy has no long-term hypotensive effect.
Reduction of the surgical excision rate in benign breast disease using fine needle aspiration cytology with immediate reporting
Authors: Dixon J M , Clarke P Jane , Crucioli V , Dehn T C B , Lee E C G , Greenall M J
Published: March 2007

Patients attending a breast clinic in two different periods were studied. In the first period fine needle aspiration cytology (FNAC) was not available and in the second it was used on all discrete solid breast lumps and reported immediately in the clinic. With the use of FNAC the overall surgical excision rate for discrete solid lumps was reduced from 83 percent to 41 percent and the excision rate in patients with benign disease was reduced from 74 per cent to 23 per cent (P<0·001). All patients with breast cancer in the second period had malignant cytology and no patient with benign or acellular cytology has been shown, after a minimum follow-up period of 18 months, to have breast cancer. Using FNAC with immediate reporting, the number of operations performed in patients with benign breast disease can be safely reduced.
Insulin resistance in patients with colorectal cancer
Authors: Copeland G P , Leinster S J , Davis J C , Hipkin L J
Published: March 2007

The euglycaemic glucose clamp technique has been used to assess insulin resistance in patients with colorectal adenocarcinoma. Ten cancer patients were studied and compared with control subjects matched for age, sex and nutritional status. Forty-one euglycaemic clamps were performed at one of five different insulin infusion rates (20, 30, 40, 100 or 200 milliunits min−1 m−2). Glucose disposal was significantly decreased in the cancer group at all insulin infusion rates, whilst attained insulin levels and metabolic clearance rates of insulin were comparable in the control and cancer groups. Analysis of dose-response data allowed assessment of sensitivity (insulin concentration of half maximal glucose disposal) and responsiveness (maximal glucose disposal). Responsiveness was significantly reduced in the cancer group (40·3 versus 71·5 μmol kg−1 min−1; P<0·001), whilst sensitivity was similar (93·7 milliunits l−1 in controls versus 90·8 milliunits l−1 in cancer patients), suggesting a postreceptor defect in insulin action in the cancer group.
Exfoliated cells and in vitro growth in colorectal cancer
Authors: Skipper D , Cooper A J , Marston Jane E , Taylor I
Published: March 2007

Cells exfoliated from colorectal cancers may only be implicated in local recurrence if they are proven to be viable and capable of growth. Thirty patients with primary colorectal cancer were studied. Cells were obtained from primary tumour, uninvolved mucosa, mesorectum, lumen of the bowel, luminal mucus, serosal surface of the bowel and from washings of the tumour bed after dissection. Colonies grew in vitro in monolayer culture from 21/30 primary tumours; 11/41 mesorectum specimens; 11/27 luminal washings; 14/29 luminal mucus specimens; 1/27 serosal surface washings and 3/13 post-dissection washes. Colonies stained positively for the epithelial markers cytokeratin and desmosomes and also for carcinoembryonic antigen. Cells capable of in vitro growth are present in these various sites and, if spilled at operation, may well be implicated as one of the factors leading to local recurrence.
Non-invasive endoscopic technique to assess gastrointestinal perfusion
Authors: Allen P I M , Gourevitch D , Goldman M
Published: March 2007

Changes in mucosal blood flow may occur in many gastrointestinal disorders, but assessment is impossible without a non-invasive in vivo technique. We have compared endoscopic laser Doppler (LD) with oxygen electrode (OE) measurements in a dog isolated colon preparation, using variable perfusion measured with an electromagnetic flow probe. At maximum flow, LD measurements were made at three sites to compare mucosal with serosal readings. Flow rate was varied (1-38 ml/min) and measurements of microcirculatory flux obtained using LD, and of oxygen tension using a serosal OE. A progressive trend towards increasing flux was demonstrated from caecum to rectum—serosa: 46·8 ± 18·7 V (caecum), 52·6 ± 17·9 V (mid-colon) and 61·3 ± 17·6 V (rectum). A parallel trend was observed in mucosal values: 41·1 ± 18·2 V (caecum), 45·7 ± 15·2 V (mid-colon) and 54·1 ± 15·1 V (rectum). At all sites, serosal and mucosal values were not significantly different (Student's t test). LD serosal values correlated significantly with EM flow (r = 0·544, 0·01 > P > 0·001). A similar linear correlation was found between OE and EM flow (r = 0·65, P<0·001). Oxygen tension measurements varied as expected with microcirculatory flux (r = 0·441, 0·02 > P > 0·01). Endoscopic LD assessment of colonic microcirculation accurately reflects changes in blood flow.
Prospective 14- to 18-year follow-up study after parietal cell vagotomy
Authors: Hoffmann J , Olesen A , Jensen H-E
Published: March 2007

One hundred and thirty-five patients underwent elective parietal cell vagotomy- for duodenal, pyloric or prepyloric ulcers. The patients were followed prospectively at intervals of 1-3 years in order to detect postvagotomy symptoms and recurrent ulcers; 14-18 years after surgery 106 patients were studied with regard to recurrent ulceration and 84 concerning postvagotomy symptoms. Thirty-two patients (30 per cent) had developed proven recurrent ulcers and a further 9 per cent were suspected of having recurrences. Two patients were reoperated for gastric outlet obstruction and one for bile reflux gastritis. Four patients had severe dyspeptic symptoms and four severe dyspepsia plus dumping. No patient had severe diarrhoea. Forty-three patients were regarded as failures after parietal cell vagotomy. After treatment of these failures 88 per cent of the patients available for subsequent follow-up had satisfactory results. The alternatives to parietal cell vagotomy are discussed. It is concluded that although parietal cell vagotomy has a high long-term recurrence rate, this disadvantage is outweighed by the low incidence severe postvagotomy symptoms.
Vascular trauma
Authors: Blacklay P F , Duggan E , Wood R F M
Published: March 2007

Civilian vascular trauma is not uncommon. Prompt treatment with modern vascular surgical techniques produces good results.
Effects of fundoplication on the antireflux mechanism
Authors: Johnsson F , Joelsson B , Gudmundsson K , Florén C-H , Walther B
Published: March 2007

Forty patients with a diagnosis of gastro-oesophageal reflux disease established by 24-h ambulatory pH monitoring were treated by a short 360° fundoplication. Results of postoperative evaluation at 6 months were compared with those from 50 normal volunteers. The amount of gastro-oesophageal reflux at pH monitoring decreased significantly and was less than the reflux in the normal subjects. The pressure and the intra-abdominal length of the distal oesophageal high-pressure zone increased significantly. The pressure was similar to that in the normal subjects while a significantly longer intra-abdominal part of the high-pressure zone was created. The clinical results of the operation were evaluated in 38 patients by an independent gastro-enterologist, and were considered to be excellent in 22 patients, good in 13, fair in 2 and poor in 1 patient. The antireflux procedure provided good control of the gastro-oesophageal reflux in our patients by restoring the major components of the antireflux mechanism.
Factor X-activating activity in patients with colorectal carcinoma
Authors: Dover R , Goeting Nicola L M , Taylor I , Roath O S , Francis J L
Published: March 2007

The ability of malignant tissue from 50 patients with colorectal carcinoma to activate blood coagulation factor X directly was compared with samples of adjacent, macroscopically normal colonic mucosa from the same patients, and tissue from four patients with non-malignant bowel disease. The resected tissue was homogenized and incubated with purified factor X and calcium ions. The subsequent generation of activated factor X was measured spectrophotometrically with a chromogenic substrate. Results were expressed as absorbance units, and as the ratio of tumour and normal activities. Factor X-activating activity (FXAA) was present in all normal and malignant tissues tested. FXAA was significantly greater (P<0·001) in the tumour homogenates than in the uninvolved tissue. The tumour:normal ratio was significantly (> 1·2) elevated in 38 patients (76 percent). FXAA was not correlated with the degree of differentiation of the tumour, the Dukes' classification of the disease or the exact site of the tumour. There was no difference between the FXAA content of non-involved tissue from the colorectal cancer group and colonic mucosa from patients with non-malignant bowel disease. It is concluded that colorectal carcinomas contain significantly more FXAA than adjacent, non-malignant colonic mucosa from the same subject, but there is no direct evidence for a relationship between procoagulant levels and the extent of malignancy in these patients.
Randomized trial comparing anorectal myectomy and controlled anal dilatation for outlet obstruction
Authors: Yoshioka K , Keighley M R B
Published: March 2007

A randomized controlled study has compared anorectal myectomy (n=13) with anal dilatation (n=10) using Park's anal retractor for patients with constipation. No patient was able to defaecate spontaneously more than three times a week before the operation. Of the 13 patients, 7 were able to defaecate spontaneously more than three times a week after anorectal myectomy, compared with none after anal dilatation (P<0·05). None of the patients in either group became incontinent. There was a significant fall of anal canal pressure after anorectal myectomy at rest, during maximum pelvic floor contraction, and attempted defaecation: median, 100 (range, 21-200) to 43 (20-133) cmH2O, P<0·01; 140 (79-238) to 86 (43-153) cmH2O, P<0·01; 127 (79-208) to 86 (29-167) cmH2O, P<0·005. A significant improvement in rectal emptying occurred after anorectal myectomy (median, 0 percent/min (range, 0-83) to 50 (0-100) per cent/min, P<0·025). On the other hand, anal dilatation was not associated with any significant change in rectal emptying or anal pressure. Pre-operative anal pressures during attempted defaecation in patients who achieved a good result after anorectal myectomy were significantly higher than those that did not (median, 136 (range, 120-208) versus 114 (79-129) cmH2O, P<0·025). Patients having a good result after anorectal myectomy had a significantly shorter history of constipation (median, 4 (range, 2-14) versus 38 (4-72) years, P<0·01) and normal colonic transit (median, 100 (range, 4-100) versus 10 (0-90) years, P<0·05) compared with those who had no benefit after operation.
Growth rate of human tumour xenografts measured in nude mice by in vivo cast modelling
Authors: Fiennes A G T W
Published: March 2007

Caliper measurement of xenograft tumour volume incurs shape-dependent errors of up to 230 per cent. A more sensitive and accurate method is described for repeated in vivo measurement of tumour volume by cast modelling. The technique can provide electronic data for further analysis and its accuracy and limitations can themselves be determined. Week-on-week changes in tumour volume may be detected with up to 99 per cent confidence.
Prognostic significance of DNA ploidy in colorectal cancer: A prospective flow cytometric study
Authors: Jones D J , Schofield P F , Moore M
Published: March 2007

A prospective study of prognostic factors has been carried out in a group of 123 consecutive patients with colorectal cancer. The fate of all patients is known at 3 years after operation. Clinical and pathological data were recorded at the time of presentation and operation, and the patients have been subject to regular postoperative review. DNA ploidy status was determined by flow cytometry. In all, 39 (33 per cent) patients had DNA diploid tumours and 80 (67 per cent) patients had DNA aneuploid tumours. In four cases, tumour material was not obtained. The patients with DNA aneuploid tumours had a worse prognosis than those with DNA diploid tumours, but this was only seen in those patients classified as Dukes' B. In a Cox's regression analysis, the surgeon's assessment of operability was the strongest predictor of survival, followed by the pathological classification and the patient's age. After these factors had been considered, the DNA ploidy status conferred no independent survival value.
Prospective study of the effects of postanal repair in neurogenic faecal incontinence
Authors: Womack N R , Williams N S , Morrison J F B
Published: March 2007

The most important factor associated with a good result in the surgical treatment of neurogenic faecal incontinence by postanal repair is considered to be restoration of the obtuse anorectal angle. Sixteen patients (14 F:2 M; median age 59 years) with neurogenic faecal incontinence confirmed by a raised fibre density in the external anal sphincter underwent postanal repair. Pre- and postoperative manometric assessment was performed in 16 and radiological assessment in 12. Normal ranges for these parameters were established in age and sex matched control subjects. Continence was improved in 14 (88 per cent) patients, 6 (38 per cent) of whom regained normal continence, at a minimum of 15 months follow-up. A successful outcome was associated with no significant change in basal (pre-operative 35 (10–85) cmH2O, postoperative 44 (12–105) cmH2O; n.s.) or voluntary (pre-operative 43 (5–150) cmH2O, postoperative 32 (12–180) cmH2O; n.s.) components of anal canal pressure. There was a small but significant increase in sphincter length (pre-operative 2 (0–3) cm, postoperative 2·5 (0–3·5) cm; P < 0·01). There was no significant change in the anorectal angle at rest (pre-operative 96 (90–110) degrees, postoperative 107 (79–118) degrees; n.s.) in the patients in whom continence was restored and five of these patients had resting anorectal angles within the normal range (75–94 degrees). Thus postanal repair need not be restricted to patients with widening of the anorectal angle since its beneficial effects do not appear to be related to reduction of this angle.
Maximal isokinetic muscle strength in patients with primary hyperparathyroidism before and after parathyroid surgery
Authors: Joborn Charlotte , Joborn H , Rastad J , Äkerström G , Ljunghall S
Published: March 2007

Primary hyperparathyroidism (HPT) is associated with symptoms of generalized fatigue and muscle weakness. The purpose of this study was to investigate muscular function in HPT quantitatively and to evaluate the effect of parathyroid surgery in this respect. The maximal isokinetic muscle strength (peak torque) of knee extension and flexion was measured with a Cybex-II dynamometer in 16 patients with primary HPT (mean serum calcium 2·81 ± 0·14 mmol/l), four of whom had subjective impairment of strength, and in nine control patients submitted to hemithyroidectomy due to atoxic thyroid adenoma. Before surgery there was no significant difference in muscle strength between the two groups, neither was there any consistent relationship between the subjective feeling of muscular weakness and the measured peak torque. Seven months after surgery the HPT patients had increased their muscle strength by 8 per cent (P<0·05). The improvement was correlated with the pre-operative serum calcium levels (r = 0·56, P = 0·02) and was particularly seen in patients with pre-operative subjective muscular weakness. Patients with only slightly raised calcium values and without subjective muscular symptoms did not benefit clearly from surgery, compared with the controls. The study demonstrates that HPT patients, especially those with neuromuscular symptoms, can improve their muscle strength after parathyroid surgery.
Small bowel volvulus complicating intestinal ascariasis in children
Authors: Wiersma R , Hadley G P
Published: March 2007

Twenty-nine patients in whom small bowel volvulus complicated intestinal ascariasis are reported. Attention is drawn to the varied clinical and radiological presentation and the relationship of volvulus to the use of vermifuge. The mortality of 17 per cent was contributed to by delay in diagnosis and failure of pre-operative resuscitation. Early diagnosis is dependent upon clinical vigilance and repeated radiological assessment of those patients with simple ascaris obstruction who fail to improve rapidly with conservative treatment. The instillation of intraluminal vermifuge intra-operatively has minimized postoperative worm migration through suture lines and anastomoses.
Wound healing response in surgical patients: Recent food intake is more important than nutritional status
Authors: Windsor J A , Knight G S , Hill G L
Published: March 2007

We have recently found that an impairment of the wound healing response (WHR) occurs in surgical patients with protein-energy malnutrition before there are any measurable changes in body fat and protein stores. The hypothesis of this study was that the patients' recent food intake is more important in determining the WHR than the patients' overall nutritional status. We have measured the recent food intake (by dietary recall), the WHR (by hydroxyproline accumulation in subcutaneous GORE-TEX implants), the pre-operative weight loss (per cent), and body fat and protein stores (by in vivo neutron activation analysis) in 83 patients awating a major elective gastrointestinal resection, and divided them into two groups: adequate recent food intake (n = 59) and inadequate recent food intake (n = 24). There was no significant difference between these two groups for age, sex, diagnosis, surgical procedure, weight loss (per cent), or the amount of body fat and protein stores but there was a significant difference in the WHR (1.81 ± 0.16 s.e.m. versus 1.04 ± 0.22 s.e.m. nmol hydroxyproline/mg GORE-TEX, P<0.005). These results show that pre-operative food intake has a greater influence over the wound healing response than absolute losses of protein and fat from body stores and they suggest that the maintenance of a normal food intake up until the time of surgery is of importance in preventing an impairment of the wound healing response.
Urgent and early cholecystectomy for acute gallbladder disease
Authors: Addison N V , Finan P J
Published: March 2007

A retrospective study of 645 cholecystectomies performed in a surgical unit over a 10-year period is presented, of which 236 were carried out during an acute admission. of these 236 cholecystectomies, 195 were performed for acute cholecystitis and 41 for acute gallstone pancreatitis. In the acute cholecystitis group the proportion of patients over 70 years of age was significantly higher (35 per cent) than the corresponding elective group (10.3 per cent). of those patients presenting with complications (empyema, gangrene, perforation, and biliary peritonitis) 51 per cent were over the age of 70 years. The most valuable investigation in the diagnosis of acute cholecystitis was ultrasound carried out within the first 48 h, with positive results in 83 per cent of those examined. The mortality for elective cholecystectomy was 0.5 per cent rising to 4.7 per cent in the urgent/early cholecystectomy group. The mean age of the 11 patients who died was 76 years, 8 of these patients being over the age of 70 years. The mortality in the subgroup of patients over 70 years was 10 per cent rising to 20 per cent in the over-80 age group. There were no deaths in the acute gallstone pancreatitis group. We conclude that emergency or early cholecystectomy is a safe procedure in patients under 70 years of age. However, patients over 70 years present with more serious complications of acute gallbladder disease which necessitate urgent surgery. We therefore recommend early cholecystectomy in patients over 70 years despite the high attendant mortality.
Pancreatic trauma: Acute and late manifestations
Authors: Leppäniemi A , Haapiainen R , Kiviluoto Tuula , Lempinen M
Published: March 2007

A retrospective analysis of 47 patients with pancreatic trauma is presented. A total of 43 patients presented with acute pancreatic injury, 32 after blunt abdominal trauma. Isolated blunt pancreatic injuries were a considerable diagnostic problem with a mean delay from trauma to operation of 9.4 days. At operation peripancreatic drainage in mild injuries and distal resection in cases of ductal injury were the commonest procedures. The overall mortality was 19 per cent, but only three of the eight deaths were attributable to the pancreatic injury. The overall complication rate was 63 per cent and the pancreatic complication rate was 33 per cent. Four patients presented with chronic pancreatitis resulting from previously untreated blunt abdominal trauma 0.5-21 years earlier. Clinically, they did not differ from the manifestations of chronic pancreatitis of other aetiological origins.
Aggressive treatment of severe diffuse peritonitis: A prospective study
Authors: Schein M , Saadia R , Freinkel Z , Decker G A G
Published: March 2007

In a prospective study of 22 patients with diffuse peritonitis managed by the method of electively staged multiple laparotomies, the abdomen was left open in 9 patients. The patients were selected on the basis of the severity of their intra-abdominal infection: only massive faecal peritonitis, postoperative peritonitis and pancreatic abscesses were included. These amounted to only 9 per cent of all patients with intra-abdominal infection treated over a 2-year period. Up to seven re-operations were required per patient. In view of a high mortality rate of 32 per cent, the superiority of this aggressive management strategy over conventional methods is not fully established.
Effect of splenectomy on Gram-negative bacterial clearance in the presence and absence of sepsis
Authors: Cheslyn-Curtis S , Aldridge M C , Biglin J E J , Dye J , Chadwick S J D , Dudley H A F
Published: March 2007

Severe sepsis leads to depression of the reticulo-endothelial system (RES) with delayed bloodstream clearance of particulate matter and bacteria. Splenectomy results in increased susceptibility to infection with encapsulated organisms but its effect on the resistance to postoperative Gram-negative infection has been little studied. We have investigated the effect of splenectomy on RES function by measurement of plasma fibronectin concentrations and bacterial clearance in the presence and absence of sepsis. In experiment 1, rabbits underwent splenectomy (n=8) or laparotomy only (n=8) 4 weeks before a second laparotomy. In experiment 2, animals had either splenectomy (n=8) or laparotomy only (n=8) followed 4 weeks later by devascularization of the appendix (sepsis). Plasma fibronectin concentrations and the blood clearance and organ distribution of an intravenous injection of 75Se-labelled viable Escherichia coli (2–3 × 108 colony forming units (c.f.u.)) were measured 24 h after the second operation. Splenectomy resulted in: (1) a persistent reduction in plasma fibronectin concentration in the presence and absence of sepsis, and (2) a delay in the bloodstream clearance with reduced hepatic (Kupffer cell) uptake of E. coli which was exaggerated in the septic splenectomized animal. It is concluded that the spleen may be important for Gram-negative bacterial clearance, possibly related to its influence on plasma fibronectin concentration and Kupffer cell function.
Peroperative ultrasonography in the surgery of hepatic tumours
Authors: Traynor O , Castaing D , Bismuth H
Published: March 2007

This article reviews the value of peroperative ultrasonography in the detection, localization and management of liver tumours.
Pancreaticogastrostomy: The preferred operation for pain relief in chronic pancreatitis
Authors: Pain J A , Knight M J
Published: March 2007

We present the results of surgery in 53 patients with intractable pain due to chronic pancreatitis associated with pancreatic duct dilatation. Using a limited mucosal to mucosal anastomosis over a silastic T tube the main pancréatic duct was drained in 33 patients into a Roux-en-Y jejunal loop (pancreaticojejunostomy, PJ) and in 20 patients into the stomach (pancreaticogastrostomy, PG). There was one postoperative death in the PJ group and none in the PG group. All patients were followed up for a minimum of four years. There was significantly greater pain relief in the PG group both at 1 (P<0·01) and 4 years (P<0·05) after surgery. We argue that PG is the operation of choice to relieve intractable pain in most patients with chronic pancreatitis associated with duct dilatation.
Contact laser or conventional cholecystectomy: A controlled trial
Authors: Steger A C , Moore K M , Hira N
Published: March 2007

There have been claims that the use of lasers in surgery is associated with reduced operative blood loss, trauma, postoperative pain and improved postoperative mobility. With the development of sapphire probes capable of transmitting neodymium yttrium aluminium garnet (Nd:YAG) laser light, it is now feasible to perform direct-contact low-power laser surgery. In a small randomized controlled trial, we have compared cholecystectomy performed by conventional methods (n = 11) with the same operation performed by contact laser (n = 10). Operative time, blood loss, operative stability, analgesic requirement, mobility and response to the trauma of surgery were compared. The only differences between the two groups were a significantly increased wound infection rate (P = 0·051) in the laser surgery group and a significantly increased length of operating time (P = 0·001). Thus, the laser did not confer any advantage over conventional surgery.
Intra-operative localization of bleeding small intestinal lesions
Authors: Lau W Y , Wong S Y , Ngan H , Fan S T , Wong K K
Published: March 2007

We prospectively studied 12 patients to compare fibreoptic enteroscopy and methylene blue injection through superselectively prepositioned angiographic catheters in intra-operative localization of bleeding small intestinal lesions. Four patients were excluded because the lesions were easily detected by gross examination. Eight patients were subjected to study by these two methods. As methylene blue injection required a positive angiography, it was possible only in five patients. In two of these five patients, non-bleeding lesions were present outside the intestinal segments localized by this method. Enteroscopy was simple, accurate and reliable in seven patients. Complete enteroscopy was impossible in one patient with advanced lymphoma because the intestine and its mesentery were matted together. Fortunately, the bleeding ulcers were still within the reach of the endoscope. Enteroscopy localized bleeding small intestinal lesions more exactly than methylene blue injection so that the length of gut resection could be shorter. We, therefore, conclude that enteroscopy is the better intra-operative localization procedure.
Intraparotid anatomy of the facial nerve and retromandibular vein
Authors: Laing M R , McKerrow W S
Published: March 2007

Fifty-four cadaver dissections of the parotid gland and the extracranial course of the facial nerve were made. In 52 out of 54 specimens dissected (96·3 per cent) the retromandibular vein was present and of significant calibre (> 2 mm). In all specimens the main facial nerve trunk or its major divisions were in direct contact with the retromandibular vein at the level of its entry into the parotid gland. This finding is discussed in the context of new developments in body scanning techniques and put forward as a potential adjuvant in the clinical management of lumps in the parotid region.
Risk to surgeons: A survey of accidental injuries during operations
Authors: Hussain S A , Latif A B A , Choudhary A A A A
Published: March 2007

A survey was conducted with the participation of eight consultant general surgeons, two consultant urologists, four consultant orthopaedic surgeons and four surgical residents to find the incidence of accidental injuries to surgeons and their assistants during operations. Of the total of 2016 operations over a one year period there were 112 reported accidental injuries. These included 107 needle stick injuries, 4 knife cuts and 1 diathermy burn. We found that accidental injuries to surgeons during operations were inevitable.