bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique
Authors: Uchida I , Asoh T , Shirasaka C , Tsuji H
Published: March 2007

The influence of epidural neural blockade on postoperative insulin resistance was studied using the euglycaemic insulin clamp technique. Eighteen patients undergoing elective upper abdominal surgery of moderate severity were allocated to two groups: group G patients underwent operation under general anaesthesia, and postoperative pain was relieved by systemic administration of analgesia; and group E patients received epidural analgesia during surgery and epidural morphine postoperatively. In each patient the euglycaemic insulin clamp test was performed twice: several days before surgery and on postoperative day 1. Peroperative catecholamine and cortisol responses were also measured to investigate possible endocrine mechanisms of the insulin resistance. Glucose disposal (M) decreased in both groups on postoperative day 1 at plasma insulin concentrations ranging from 1.2 to 10.0 milliunits ml−1, resulting in the downward shift of dose-response curves. However, this downward shift was significantly smaller in group E than in group G patients. Urinary adrenaline excretion increased markedly on the day of operation in group G, but was significantly inhibited in group E. Urinary noradrenaline excretion increased mainly on postoperative day 1 in group G, but was significantly inhibited in group E. Plasma cortisol response was lower in group E than in group G during and shortly after operation, and was significantly inhibited in group E on postoperative day 1. These results indicate that insulin resistance after elective abdominal surgery is due to a postreceptor deficit in glucose utilization, as indicated by the downward shift of the dose-response curves. This disturbance in glucose metabolism was reduced by epidural analgesia, the results being associated with inhibited catecholamine and cortisol responses.
Renal transplantation: The nonstarters
Authors: Lennard T W J , Parrott N R , Wilson R G , Proud G , Farndon J R , Simpson Judy M , Taylor R M R
Published: March 2007

Renal transplants do not always function immediately and this non-function may be related to poor long-term graft survival. The causes of this primary non-function (PNF) are poorly understood. The incidence of PNF in 106 consecutive renal transplants was found to be 57 per cent. Using stepwise logistic regression analysis of 20 prospectively collected variables for each transplant two have been found to be positively associated with PNF of the transplant: (1) the use of cyclosporin as an immunosuppressant and (2) a second warm ischaemia (anastomosis) time of more than 30 min. It is proposed that the use of cyclosporin be restricted in the early post-transplant period until initial function of the transplant is established. The surgical procedure of kidney transplantation should be planned to minimize the anastomosis time prior to recirculation of the graft.
Role of constipation and anal hypertonia in the pathogenesis of haemorrhoids
Authors: Gibbons C P , Bannister J J , Read N W
Published: March 2007

The hypothesis that haemorrhoids result from chronic constipation was investigated by studying bowel habit, anal pressure profiles and anal compliance in 13 men and 10 women with prolapsing haemorrhoids. 12 women with severe constipation and 14 male and 11 female control subjects. Defaecation was less frequent in women than in men (P < 0·01) but was independent of the presence of haemorrhoids. Patients with haemorrhoids and control subjects reported similar stool consistency and rarely admitted to straining. Severely constipated women complained of infrequent defaecation, straining at stool and hard motions, but none had prolapsing haemorrhoids. Haemorrhoids were associated with significantly longer anal high-pressure zones and significantly greater maximum resting pressures at all levels of anal distension (P < 0·01), but minimum residual pressure during rectal distension and maximum squeeze pressure were not significantly different from control subjects. Maximum resting pressure was increased in patients of both sexes with haemorrhoids, but this reached statistical significance only in men (P < 0·001). Constipated women had normal anal pressure profiles and maximum anal pressures. These data show that patients with haemorrhoids are not necessarily constipated but tend to have abnormal anal pressure profiles and anal compliance. Chronically constipated women do not necessarily have haemorrhoids but have normal anal pressure profiles and compliance. This casts doubt upon the hypothesis that haemorrhoids are caused by constipation.
Lateral division of the puborectalis muscle in the management of severe constipation
Authors: Kamm M A , Hawley P R , Lennard-Jones J E
Published: March 2007

Patients with severe constipation often do not ‘relax’ their pelvic floor during defaecation. Electromyography of the pelvic floor may reveal inappropriate contraction during defaecation straining, and balloon expulsion, a test of rectal evacuation, may be impaired. Fifteen patients with severe idiopathic constipation and three patients with a megarectum underwent lateral division of the puborectalis muscle and upper half of the external sphincter muscle. Twelve patients had a unilateral division and six patients had both sides divided. Surgery caused a marked reduction in the maximum voluntary squeeze pressure in the anal canal from a pre-operative mean of 90 ± 49 (s.d.) cmH2O to a postoperative mean of 40 ± 29 cmH2O (P < 0·0001). Four patients, three with idiopathic constipation and one with megarectum, experienced symptomatic improvement. Three of these patients had a bilateral division. Improvement did not correlate with a change in the puborectalis electromyography or the ability to expel a balloon. Three patients experienced mild mucus or urge incontinence, but no patient was incontinent for solid stool.
Heparin/dihydroergotamine for venous thrombosis prophylaxis: comparison of low-dose heparin and low molecular weight heparin in hip surgery
Authors: Lassen M R , Borris L C , Christiansen H M , Møller-Larsen F , Knudsen V E , Borist P , Nehen A-M , De Carvalho A , Jurik A-G , Nielsen B W , Lucht U
Published: March 2007

In a prospective, double-blind controlled study we have compared the prophylactic efficacy against deep vein thrombosis of low-dose heparin + dihydroergotamine (A), low molecular weight heparin + dihydro-ergotamine (B) and placebo (C). A total of three hundred and fifty-six patients undergoing total hip replacement were randomized into three groups and 316 patients were analysed. All thrombi were verified by ascending phlebography. One-third of the patients developed deep vein thrombosis in group A and B, differing significantly from group C. The operative blood loss in group B was higher than that in groups A and C. However, the number of patients transfused and their transfusion requirements did not differ. Severe bleeding occurred in one patient in each group. No deaths were registered during the study. Our study indicates that prophylactic treatment against postoperative deep vein thrombosis with low molecular weight heparin + dihydroergotamine once daily is as effective and safe as conventional low-dose heparin + dihydroergotamine twice daily in patients undergoing total hip replacement. The once-daily regimen has the advantage of better patient acceptance and less nursing time.
Screening for breast cancer: some clinical aspects
Authors: Stockdale A D , Last P , Tucker A K , Thomas J Meirion
Published: March 2007

There is little doubt that screening by palpation and mammography will reduce the mortality from breast cancer. Most of the studies have been designed to test survival difference and, following diagnosis, patients were treated by a variety of surgeons and methods. We present clinical and pathological data on 32 asymptomatic patients who were screened and found to have breast cancer. Investigation and treatment was performed by one surgeon according to a defined protocol. We confirm that mammography is a more sensitive diagnostic tool than palpation and describe how a review of the patient with the suspicious mammogram will increase the incidence of palpable tumours. We stress the importance of fine-needle aspiration cytology as a diagnostic and localization method. The low incidence of axillary node metastasis in patients with invasive carcinoma is described. More importantly, no patient in this series required treatment by mastectomy. In our experience patients with breast cancer detected by screening are eminently suitable for treatment by breast conservation.
Role of adhesive wraps in the pathogenesis of complicated amoebic colitis
Authors: Luvuno F M
Published: March 2007

Ischaemic foci within the abdomen attract omental and peritoneal adhesions with neovascularization. Previously it has been shown that transmural amoebic colitis is an ischaemic process. An intra-operative evaluation of the peritoneal barriers in response to necrosis was undertaken during laparotomy in 82 patients with clinical transmural amoebic colitis. At operation the ischaemic colon was covered by adhesive wraps in all patients; peritonitis subsequently was absent in 23 patients (28 per cent), serous in 43 patients (52 per cent), purulent in only 9 patients (11 per cent) and faeculent in another 7 patients (9 per cent). The author regards wrapping as mechanically protective. Wrapping is also a source of neovascularization which was demonstrated on 10 angiograms of resected specimens with transmural disease. This is further supported by clinical finding of subsequent necrosis of colons in three patients whose wraps were disturbed at laparotomy without resection of the colons. Therefore, for both mechanical and vascular reasons, these wraps should not be disturbed.
Reproducibility of reactive hyperaemia test in the measurement of peripheral arterial disease
Authors: Fowkes F G R , Housley E , Macintyre C C A , Prescott R J , Ruckley C V
Published: March 2007

The reproducibility and sources of variation in ankle and brachial systolic pressures were determined for a reactive hyperaemia test used to assess peripheral arterial disease in the lower limbs. Thirty-six subjects had repeat measurements taken by four observers on two separate days using a Doppler probe and random zero sphygmomanometer. Ankle pressures were measured before and after 4 min of arterial occlusion above the knee. The 95 per cent confidence limits for a postocclusion reduction in pressure was approximately ±25 mmHg and for the postocclusion ankle-brachial ratio was ±20 per cent. The corresponding figures for the mean of four measurements taken by two observers on 2 days was approximately ±17 mmHg and ±13 per cent. In patients with vascular disease analysis of variance showed that the greatest sources of variation in the postocclusion ankle-brachial ratio were the ‘biological’ variations between subjects and between legs. But for postocclusion reductions in pressure, variability due to observers and repeat readings was as important as the ‘biological’ differences between subjects and legs. Thus, in respect of variability, the ratio may be a better parameter to detect differences between subjects.
Benign disease of the common bile duct
Authors: Saxena R , Pradeep R , Chander J , Kumar P , Wig J D , Yadav R V S , Kaushik S P
Published: March 2007

The incidence of common bile duct (CBD) pathology in a group of patients with benign biliary disease (n = 505) was found to be 23.2 per cent. The spectrum included 111 patients (90.2 per cent) with CBD stones, 37 of whom (33.3 per cent) had no symptoms or findings pre-operatively indicating CBD involvement. Five patients had papillary stenosis, three had postoperative CBD strictures, one had a choledochal cyst and one had an external biliary fistula. Of the 100 CBDs measuring more than 10 mm in diameter, 90 harboured calculi. In the remaining 23 CBDs measuring less than 10mm, calculi were present in 21. The presence of CBD calculi was demonstrated by intra-operative cholangiography in 49 patients. In the remaining patients (n = 74), the diagnosis of CBD pathology was made either by percutaneous transhepatic cholangiography, endoscopic retrograde cholangio-pancreatography, T-tube cholangiography or peroperative palpation. The surgical procedures performed included choledochotomy and T-tube drainage (n = 74), transduodenal sphincteroplasty (n = 27) and choledochoduodenostomy (n = 18). The overall mortality and morbidity of CBD exploration was 3.3 per cent and 24.4 per cent respectively, which was significantly greater than that for cholecystectomy alone (0.3 per cent and 8.6 per cent respectively). Transduodenal sphincteroplasty carried a much higher mortality (11 per cent) and morbidity (52 per cent) when compared with other procedures.
Standardization of the surgical technique in breast-conserving treatment of mammary cancer
Authors: Aspegren K , Holmberg L , Adami H-O
Published: March 2007

A number of designations—for example excision, wide excision, lumpectomy, tylectomy, extended tylectomy, partial mastectomy, tumorectomy, segmental resection and quadrantectomy—have been applied to operative procedures aimed at treating mammary carcinoma with preservation of the breast. None of them, however, has been explicitly linked to a defined surgical technique and there is no consensus about the terminology. We propose a simple classification system for breast-conserving procedures, which can facilitate the communication between surgeons and the interpretation and exchange of scientific data. We also describe a strictly defined and locally radical partial mastectomy—a sector resection—which has been used at several centres in Sweden for more than 5 years with a favourable outcome so far in terms of local tumour control and the cosmetic result.
Pyogenic liver abscess: An improvement in prognosis
Authors: Farges O , Leese T , Bismuth H
Published: March 2007

Forty-six patients with pyogenic liver abscess have been treated at Paul Brousse Hospital between 1966 and 1986. The overall mortality was 24 per cent, all 11 deaths occurring in 24 patients seen prior to 1978 when there was often a considerable delay in the diagnosis of liver abscess (mean 90 ± 71 days). In seven patients the diagnosis was not made until post-mortem examination. The mainstay of treatment was surgical drainage. Since 1978 high resolution imaging techniques for the liver, and in particular ultrasound, have been available. The diagnostic delay has been significantly reduced (mean 28±20 days, P < 0·01). Patients are receiving definitive treatment at an earlier stage in the evolution of the disease process, with fewer established complications prior to treatment (P < 0<05). Percutaneous drainage under ultrasound control is the preferred initial drainage procedure in high-risk patients. There have been no deaths in 22 patients treated for pyogenic liver abscess since 1978 (P < 0·001).
Endoscopic removal of retained stones after biliary surgery
Authors: Lambert M E , Martin D F , Tweedle D E F
Published: March 2007

Seventy-three patients with retained stones in the common duct after biliary surgery underwent attempted endoscopic removal at a mean interval of 39 days after surgery. Endoscopic extraction was successful in 63 patients (86 per cent). Complications occurred in 14 patients (19 per cent). The most frequent complication was haemorrhage which occurred in nine patients, four of whom required surgery: two other patients required surgery for complications. The complication rate of endoscopic sphincterotomy in recently operated patients may be higher than in the non-operated patient. Less invasive methods, such as dissolution therapy or T tube track extraction, may be preferable as they are associated with less risk. Endoscopic sphincterotomy should be reserved for patients in whom these alternative techniques fail or are inappropriate.
Comparison of absorbable materials for surgical haemostasis
Authors: Blair S D , Backhouse C M , Harper R , Matthews J , McCollum C N
Published: March 2007

The haemostatic effect of two new materials has been compared with surgical gauze and oxidized cellulose using a standardized liver laceration in New Zealand White rabbits. Following excision of a 3 cm2 disc of tissue from the liver, 42 rabbits were randomized to the use of gauze swabs (n = 6), oxidized cellulose (Surgicel®) (n = 12), porcine collagen (Medistat®) (n = 12) or calcium alginate (Kaltostat®) (n = 12) to control the resulting haemorrhage. Blood loss and time to haemostasis were accurately recorded. The absorbable materials were left in situ and animals killed between 2 weeks and 6 months later to examine speed of absorption and resulting adhesions. Calcium alginate stopped bleeding in <3 min in all animals compared with a mean (±s.e.m.) of 5.7 ± 0.75 min for porcine collagen, 12.5 ± 0.9 min for oxidized cellulose and > 15min with gauze (P < 0.001). Oxidized cellulose and calcium alginate reabsorbed within 3 months leaving a fibrous scar, but a vigorous foreign body reaction was seen with porcine collagen which caused intestinal obstruction in 5 out of 12 animals within 3 months.
Endocrine basis for the clinical presentation of hidradenitis suppurativa
Authors: Harrison B J , Read G F , Hughes L E
Published: March 2007

Clinical assessment of 134 patients with hidradenitis suppurativa revealed clinical evidence supporting an androgen-based endocrine disorder underlying the condition. Such features included postpubertal onset maximal during the third decade; female preponderance (13:5); premenstrual flare in 57 per cent of women; absence of this flare associated with irregular or anovulatory menstrual cycles; and an increased incidence of obesity and acne. Detailed hormone profiles in 36 female patients and 14 controls showed evidence of relative androgen excess and decreased progesterone levels in those patients without a premenstrual flare. Obesity and enhanced peripheral androgen conversion by apocrine tissue are possible explanations for normal serum androgen profiles in patients with a flare. Precise elucidation of the hormonal abnormality is a prerequisite for effective medical treatment of early disease.
Effects of low dose perioperative interferon on the surgically induced suppression of antitumour immune responses
Authors: Sedman P C , Ramsden C W , Brennan T G , Giles G R , Guillou P J
Published: March 2007

General surgical procedures are followed by a period of generalized immunosuppression that may favour the deposition of metastases seeded at operation in patients with malignant disease. In an attempt to prevent the suppression of host-antitumour immune mechanisms following surgery we have studied the immunological effects of low-dose perioperative interferon-α (r-HuIFNα). Patients were randomly allocated pre-operatively to the control (n = 15) or treatment group (n = 15). Patients in the treatment arm received a 1-week course of subcutaneous recombinant human interferon-α 2a (Roferon-A) at a dose of 2 megaunits daily starting on the evening before surgery. Natural killer cell, lymphokine activated killer cell cytotoxicities and endogenous interleukin 2 production were measured 1 day before surgery and on the first, third, fifth and tenth postoperative days. Treatment with r-HuIFNα did not prevent the postoperative impairment of interleukin 2 production or lymphokine activated killer cell cytotoxicity. However it prevented the fall in natural killer cell activity normally observed following surgery. This may have important consequences in controlling metastatic dissemination of tumour in this vulnerable period.
Cystic change and neoplasia in isolated thyroid swellings
Authors: Cusick E L , McIntosh C A , Krukowski Z H , Matheson N A
Published: March 2007

During a 6-year prospective study of clinically isolated thyroid swellings (ITS), 148 (37 per cent) of 395 swellings were cystic as defined by the aspiration of fluid during fine needle aspiration cytology (FNAC). In the 106 (72 per cent) patients operated upon, 47 per cent of the cystic swellings were neoplastic and 14 per cent were malignant. In men 29 per cent of cystic swellings were malignant and 11 percent in women. Only twelve cystic ITS were permanently abolished by aspiration and FNAC was inaccurate in predicting neoplasia. The incidence of malignancy in cystic ITS is higher than generally accepted and most cysts not abolished by aspiration should be removed.
Physiological parameters influencing function in restorative proctocolectomy and ileo-pouch-anal anastomosis
Authors: Keighley M R B , Yoshioka K , Kmiot W , Heyen F
Published: March 2007

Ileo-pouch-anal function has been assessed in 30 patients after restorative proctocolectomy and compared with age- and sex-matched controls. Median resting anal canal pressure was only 42 cmH2O (7–113 cmH2O) compared with 100 cmH2O (46–114 cmH2O) in controls (P < 0.005). Maximum squeeze anal pressures were also significantly lower in pouch patients: 87 cmH2O (25–180 cmH2O) than controls: 143 cmH2O (114–171 cmH2O) (P < 0.01). The recto-anal inhibitory reflex was absent in all pouch patients but was present in all controls. Maximum pouch or ileal pressures exceeded resting anal canal pressures in three patients. Median volume at first leak during saline infusion was 320 ml (60 ml-no leak) in pouch patients whereas the majority of controls had no leakage (median, none; 450 ml-no leak; P < 0.05). Threshold pouch sensation (median, 50ml (0–250 ml)) did not differ from rectal sensation in controls (50 ml (0–180 ml)) but pouches were less compliant than a normal rectum, median 6.8 ml/cmH2O (2.1–17 ml/cmH2O) and 11.6 ml/cmH2O (4.7–16.2 ml/cmH2O) respectively (P < 0.05). In patients who had an episode of pelvic sepsis (n = 8) the average number of abnormal physiological indices per patient was 3.8, compared with 1.3 in those with no sepsis (P < 0.05). There was no difference in the number of abnormalities per patient with a J pouch (2.0; n = 19) or a W pouch (1.9; n = 11).
Sensory discrimination and dynamic activity in the anorectum: Evidence using a new ambulatory technique
Authors: Miller R , Lewis G T , Bartolo D C C , Cervero F , Mortensen N J McC
Published: March 2007

The anal canal in health is extremely sensitive to thermal stimuli. If temperature sensation plays a part in sensory discrimination two conditions must be fulfilled: there must be a temperature gradient along the anorectum and rectal contents must be able to come into contact with the sensitive anal mucosa. In a study of 53 normal subjects we demonstrated this temperature gradient with a median temperature difference between the rectum and lower, mid and upper anal canal of 0.4, 0.2 and 0.1°C respectively. The second condition was examined in 15 normal ambulatory subjects by measuring mid-anal sphincter (SP) and rectal pressures (RP) with a microtransducer catheter. The signals were digitalized and recorded in a portable electronic memory for later computer display, and analysis. Marked spontaneous sphincter relaxation resulting in equalization of RP and SP occurred 7 times per hour (1–4). The conscious sensation of the presence of flatus was associated with an SP reduction of 30 mmHg (20–50 mmHg) and an RP increase of 7 mmHg (0–15 mmHg), such that RP ⩽ SP in 80 per cent of 144 recorded events. Using this new technique we have demonstrated the highly dynamic nature of the anal sphincter. Several times an hour the sphincter relaxes with subsequent equalization of rectal and anal pressures, allowing entry of rectal contents into the anal canal so that its presence and nature can be determined.
Abdominoperineal and anterior resection of the rectum with retrocolic omentoplasty and no drainage
Authors: Smith S R G , Swift I , Gompertz H , Baker W N W
Published: March 2007

Forty consecutive patients scheduled for either low anterior resection or abdominoperineal resection of the rectum have been studied. After standard procedures, carried out by all grades of surgeons, the omentum was mobilized as a pedicle graft based on the left gastro-epiploic arcade and transposed to the pelvis or perineum. All wounds were closed primarily without drainage. Twenty-six patients had anterior resection, 11 abdominoperineal resection and 3 an extended Hartmann's operation. Patients were assessed clinically and radiographically by Gastrografin® enema and ultrasound for evidence of anastomotic leakage, pelvic collections and wound healing. After anterior resection there were three radiological leaks and no overt clinical leaks. One patient had a collection related to a leak. Of 11 perineal wounds 8 healed primarily in 2 weeks and all healed by 4 weeks. There was no frank wound breakdown. The three patients who had Hartmann's operations all healed without complication. There were no unavoidable complications of the procedure. Retrocolic omentoplasty is a simple, safe and effective adjunct to rectal surgery. The additional time taken (15–20 min) is well rewarded by sound healing of these operations.
Endoluminal ultrasound and computed tomography in the staging of rectal cancer
Authors: Holdsworth P J , Johnston D , Chalmers A G , Chennells P , Dixon M F , Finan P J , Primrose J N , Quirke P
Published: March 2007

Pre-operative staging of rectal cancer might define patients with disease confined to the rectal wall without lymph node metastases, in whom local excision might be appropriate, or patients with extrarectal spread, who might benefit from pre-operative radiotherapy. With these objectives, 36 consecutive patients with rectal cancer were studied by endoluminal ultrasound: 17 of them also underwent computed tomography (CT) of the pelvis. The results were correlated with the findings at operation and subsequent pathological examination. Endoluminal ultrasound correctly predicted invasion of the tumour through the rectal wall in 86 per cent of patients, with a sensitivity of 96 per cent and specificity of 50 per cent, but correctly identified lymph node metastases in only 61 per cent of patients (sensitivity 57 per cent; specificity 64 per cent). CT correctly predicted invasion through the rectal wall in 94 per cent of cases, with a sensitivity of 100 per cent and specificity of 67 percent and correctly identified lymph node metastases in 70 per cent of patients (sensitivity 25 per cent; specificity 85 per cent). These findings indicate that both endoluminal ultrasound and CT may be helpful in selecting patients for pre-operative radiotherapy. Neither technique, however, can reliably identify lymph node metastases and therefore cannot be used to select patients who would be suitable for local excision.
Preventing wound infection after appendicectomy: A review
Authors: Krukowski Z H , Irwin S T , Denholm S , Matheson N A
Published: March 2007

An exponential increase in the number of published prospective studies reflects both a continuing interest in, and a lack of consensus on, the optimal prophylaxis of wound sepsis after appendicectomy. Review of the literature over the last 25 years leads us to emphasize both the importance of adequate study size and of stratification of the severity of the sepsis found at operation. For critical comparison of prophylactic regimens the high percentage of wound infections disclosed after discharge from hospital must be taken into account. Antibiotics reduce the frequency of wound sepsis and although low wound sepsis rates have been reported with systemic antibiotics active against only anaerobes, the cumulative evidence favours a spectrum of antibacterial activity against both aerobic and anaerobic organisms. Topical antiseptics have no significant effect but topical antibiotics are beneficial. Wide variations in outcome for similar antibiotic regimens reflect the importance of technical factors in determining the frequency of wound sepsis.
Murine monoclonal antibodies in breast cancer: An overview
Authors: Tjandra J J , McKenzie I F C
Published: March 2007

Monoclonal antibody technology has been an important development in breast cancer research. Monoclonal antibodies do not detect ‘breast cancer specific’ antigens but, rather, they react with normal or modified tissue antigens which are either preferentially or inappropriately expressed upon malignant cells. Thus far a number of monoclonal antibodies that have a preferential reaction with breast cancer tissue have been developed. They have a potential value in immunohisto-pathology as diagnostic tools and in the recognition of small quantities of malignant cells, in the development of serum assay for tumour markers in breast cancer and in the radio-immunodetection of metastases. There has been success in effecting selective targeting of anticancer agents (cytotoxic drugs, toxins, radionuclides) to tumour deposits and encouraging results are obtained in preclinical in vivo studies. Various clinical studies are now in progress to evaluate the role of monoclonal antibodies in the management of breast cancer.
Temperature gradient between the rectum and the anal canal: Evidence against the role of temperature sensation as a sensory modality in the anal canal of normal subjects
Authors: Rogers J , Hayward M P , Henry M M , Misiewicz J J
Published: March 2007

Temperature difference between the rectum and anal canal is a fundamental requirement for the hypothesis that temperature sensation is of physiological importance in discrimination of anorectal contents occurring during the ‘sampling reflex’. The temperature gradient between the rectum and the anal canal was measured in 47 normal subjects (mean age 51.6 years ± 16.8 s.d., 24 men). The maximum mean difference in temperature between the rectum and the anal canal was 0.13°C (0.06-0.19, 95 per cent confidence intervals) and occurred 4 cm from the anal verge. This difference is too small to be detected by the anal canal mucosa. Under normal physiological circumstances the conscious appreciation of temperature of faeces passing from the rectum to the anal canal is impossible during the anorectal sampling reflex.
Faecal incontinence associated with reduced pelvic sensation
Authors: Lubowski D Z , Nicholls R J
Published: March 2007

Eight patients with faecal incontinence associated with high threshold of rectal sensation are described. All had a normal anal sphincter on clinical and physiological assessment including anal manometry, pudendal nerve latency estimation and single fibre electromyography. In each case however rectal sensation was abnormal. The threshold of rectal sensation was 143 ± 33 ml (range 110–200 ml) compared with control values of 39 ± 14 ml (range 25–65 ml) (P < 0.005) in 12 normal age-matched individuals. The degree of rectal distension required to initiate the recto-anal reflex was no different in the incontinent patients (19 ml, range 15–25 ml, compared with 22ml, range 15–30 ml, in the controls). There was also no difference in the maximal tolerated volume of rectal distension between the groups (291 ± 87 ml and 279 ± 91 ml respectively). These observations may have defined a small group of patients with incontinence in whom an abnormality of rectal sensation rather than sphincter incompetence could be a part of the pathophysiological disorder.
Paget's disease of the anal margin
Authors: Jensen S L , Sjolin K E , Shokouh-Amiri M H , Hagen K , Harling H
Published: March 2007

A follow-up study of 22 patients with Paget's disease of the anal margin was conducted to determine the prevalence of invasive disease and coexisting visceral carcinomas, cure and survival rates. Seventy-three per cent of the patients suffered from persistent pruritus ani. Seven (32 per cent) patients had malignancy (invasive Paget's disease (n = 5) and coexisting visceral carcinoma (n = 2)) and six (27 per cent) developed malignancy (invasive Paget's disease (n = 4) and coexisting visceral carcinoma (n = 2)) during follow-up, giving an overall occurrence of malignancies of 59 per cent (95 per cent confidence limits: 36–79). The median follow-up period was 9 (range 0.5–25) years. No difference in length of history could be found between patients with or without malignancy. The estimated cure rate by actuarial analysis among radically treated patients was 64 per cent (95 per cent confidence limits: 43–91) at 1 year and 45 per cent (95 per cent confidence limits: 18–72) at 8 years after primary treatment. The 5- and 10-year crude survival rates of 54 per cent and 45 per cent, respectively, were significantly lower than the corresponding values of 84 per cent and 60 per cent for the normal population (P<0.01). Patients with persistent pruritus ani and a perianal skin lesion should be biopsied frequently. If Paget's disease is diagnosed, physical examination of the patient and anorectal region must be done carefully and repeatedly.
Surgical aspects of a district hospital combined gastroenterology clinic
Authors: Holmes K M , Cole T P , Salter R H
Published: March 2007

The surgical aspects of 12 years' involvement with a combined consultative gastroenterology clinic at a district general hospital are reviewed. In this time the overall number of patients subjected to surgery has gradually fallen and the average age of patient referral has gradually increased and the logistical implications are considered. Trends for the common diagnoses encountered are discussed and the educational benefit of the clinic is stressed.
Surgical treatment of acute necrotizing pancreatitis
Authors: Wilson C , McArdle C S , Carter D C , Imrie C W
Published: March 2007

Between January 1980 and June 1986, 21 patients required surgery for acute necrotizing pancreatitis. Four patients had been transferred from other hospitals: the remaining 17 patients had been treated from the outset at Glasgow Royal Infirmary, representing 3.7 per cent of the 456 patients treated for acute pancreatitis during this time. Necrosectomy was performed on 14 patients and 7 patients were treated by pancreatic resection, with 4 deaths in each group; thus 8 patients (38 per cent) died at a median time of 22 days from onset of their attack. Three of the four patients transferred to our care died, giving a mortality in our own patients of 29 per cent. Of the survivors, all but three had a prolonged and complicated hospital course. Our data confirm that acute necrotizing pancreatitis is still associated with a considerable mortality and morbidity. Early multi-organ failure, advanced age, underlying medical illness and the presence of infected necrosis were associated with a poor outcome. Necrosectomy delayed until the second or subsequent week appeared to be a suitable procedure for the majority of our patients, but shortcomings were apparent with the traditional methods of closed drainage of the pancreatic bed postoperatively. The many demands imposed by this small group of patients suggests that their management is best undertaken in centres in which there is special expertise and this should contribute to a further reduction in the mortality from this condition.
Hepatocellular pseudotumour (regenerating nodule) in the cirrhotic liver mimicking hepatocellular carcinoma
Authors: Nagasue N , Yukaya H , Chang Y-C , Kimura N , Ota N , Nakamura T
Published: March 2007

During a recent 6-year period we have encountered 10 patients with ‘hepatocellular pseudotumour in the cirrhotic liver’ (regenerating hyper-plastic nodule). The patients were all male, aged 40–82 years. Seven were chronic alcohol consumers. None was positive for HBs-Ag but seven had either anti-HBs or anti-HBc. Serum AFP level ranged from 4 to 28 ng/ml in six patients who did not have hepatocellular carcinoma at the time of the diagnosis of the pseudotumour. The lesions were depicted by ultrasonography in seven, by computed tomography in two, and by angiography in one case. Liver scan was negative in all five cases investigated. The pre-operative diagnosis was definitely or highly suspicious of hepatocellular carcinoma in three, of pseudotumour in the cirrhotic liver in three, and of recurrent carcinoma in one. In another three patients, pseudotumour was coincidentally discovered in resected specimens with hepatocellular carcinoma. The histopathological and follow-up studies demonstrated synchronous or metachronous development of carcinoma in seven patients. Whether or not these lesions in the cirrhotic liver are premalignant remains to be elucidated.
Parotid tumours: A review of parotid tumour surgery in the Northern Regional Health Authority of the United Kingdom 1978–1982
Authors: Gunn A , Parrott N R
Published: March 2007

A review of inpatients treated for parotid tumours during the 5-year period 1978 to 1982 in the Northern Regional Health Authority of the United Kingdom revealed 376 new parotid tumours and 28 recurrent tumours. The incidence of new parotid tumours was 2.4 per 100000 and of pleomorphic adenomas 1.5 per 100000 per annum. Local excision was the most common operation and was employed to remove 156 (67.2 per cent) of the 232 pleomorphic adenomas but there was evidence of incomplete excision in 60 (38.5 per cent) of these tumours. Incomplete excision also occurred in 12 (15.8 per cent) of the 76 pleomorphic adenomas removed by conservative parotidectomy. Global temporary facial nerve palsy was more common after conservative parotidectomy for benign tumours (21.8 per cent) than after local excision (3.7 per cent) but global permanent nerve palsy only occurred after local excision (0.9 per cent). The widespread use of local excision resulted in its use in 12 (27.3 per cent) of the 44 malignant tumours. The low incidence of parotid tumours and their treatment by a relatively large number of surgeons resulted in limited experience for surgeons and few opportunities for training in parotid surgery.
Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: A randomized trial
Authors: Shepherd H A , Royle G , Ross A P R , Diba A , Arthur M , Colin-Jones D
Published: March 2007

A total of 52 jaundiced elderly patients who had malignant obstruction of the distal common bile duct and who required palliative biliary decompression were randomized to receive either an endoscopically placed biliary endoprosthesis (10 French gauge) or conventional surgical bypass. Patients within the two treatment groups were well matched and 51 were followed until their death. Patients treated with endoprosthesis had a significantly shorter initial hospital stay than those treated surgically. In the long term, overall survival in the two groups was similar and jaundice was relieved in over 90 per cent of patients. Despite more re-admissions to hospital for those patients treated endoscopically, the total time spent in hospital still remained significantly shorter in this treatment group compared with those subjected to surgery. The endoscopically placed biliary endoprosthesis is a valuable alternative to conventional surgical bypass in the palliation of extrahepatic biliary obstruction.
Current practice in biliary surgery
Authors: Cahill C J , Pain J A
Published: March 2007

A questionnaire enquiring about current practices in biliary surgery was sent to over 25 per cent of consultant general surgeons in the UK; 90 per cent replied. Only 56 per cent use antibiotic prophylaxis for elective cholecystectomy, and 84 per cent for emergency cholecystectomy. Duration of use, choice of agent and absence of prophylaxis for high-risk cases were inappropriate in up to 20 per cent of cases. Of the respondents 84 per cent routinely perform operative cholangiography and use T tubes, and 75 per cent routinely place a peritoneal drain after cholecystectomy. Despite controversies in the literature, most UK surgeons still follow traditional practices in biliary surgery.
Amputation for peripheral vascular disease: The case for level selection
Authors: McCollum P T , Spence V A , Walker W F
Published: March 2007

One hundred major lower limb amputations were performed for end stage peripheral vascular disease over a 15-month period. Selection of amputation level was made on the basis of laboratory criteria using skin blood flow and infrared thermography data. Eighty-one amputations were performed at the below-knee level with six failures. This resulted in a final below-knee:above-knee amputation ratio of 3:1. It is clear that there are still many centres in the UK where above-knee amputation is the accepted operation, despite the inherent drawbacks to this procedure. We recommend that more attention is given to achieving higher below-knee amputation rates to improve the chances of amputee mobility and therefore quality of life.
Complications of intravenous feeding catheters
Authors: Mughal M M
Published: March 2007

Complications of intravenous nutrition are uncommon but may prove problematic in patients requiring long-term nutritional support. This article reviews the complications associated with intravenous catheters with particular emphasis on problems associated with insertion, catheterrelated sepsis, venous thrombosis, catheter occlusion, endocarditis and intracardiac thrombus formation.
Carotid body tumours and other cervical paragangliomas: Diagnosis and management in 25 patients
Authors: McPherson G A D , Halliday A W , Mansfield A O
Published: March 2007

This report of a series of 25 patients with cervical paragangliomas reviews the experience of one surgeon over a period of 13 years. A total of 26 resections were performed with no mortality and no hemiplegia. Two patients required carotid reconstruction. Eight patients had a permanent cranial nerve palsy but in seven this was due to involvement of the nerve by the tumour. Lymph node involvement occurred in two patients. Only one patient has developed recurrent tumour. These tumours are locally malignant and resection offers a chance of cure.
Viscoelastic properties and collagen content of the long saphenous vein in normal and varicose veins
Authors: Psaila J V , Melhuish J
Published: March 2007

Veins taken from patients undergoing surgery for varicose veins were compared with those obtained from patients undergoing other surgical procedures (‘normals’). Varicose veins had a lower breaking strength and breaking energy than normal veins. Elastic stiffness was less in normals (tan θ = 41 (24)) than in varicose veins (tan θ = 55 (18); P < 0·01). There was no difference in viscoelastic behaviour between samples taken above, at, or below the valve leaflet insertion. In normals, perivalvular vein wall exhibited a 50 per cent lower breaking strength and elastic stiffness than vein from other sites. Collagen content was significantly higher in normal vein specimens in all sites examined (mean collagen content = 70 (21) μg/mg, versus 51 (20) μg/mg for varicose veins; P < 0·001). We conclude that significant structural changes are seen in varicose veins. In normal veins, the perivalvular vein wall has distinct viscoelastic features when compared with vein wall from other sites. This difference was not found in veins which became varicose.
111In-labelled leucocyte imaging in vascular graft infection
Authors: Berridge D C , Earnshaw J J , Frier M , Perkins A C , Wastie M L , Hopkinson B R , Makin G S
Published: March 2007

Twelve patients with a clinical diagnosis of possible vascular graft infection have been studied over the last 3 years. All patients had their leucocytes labelled with indium-111 and γ-camera imaging after 24 and 48h. Subsequent management was according to established surgical techniques. Eight patients proved to have vascular graft infection and indium uptake was seen along the length of the graft in six. Two patients with open wound infections and synthetic grafts had localized uptake only on leucocyte scanning. Four patients, all of whom had negative scans were not thought to have infected grafts after further investigation using digital subtraction angiography and computed tomography scanning. These patients have been followed up for a median period of 19 months (range 5–25 months) and have remained symptom free. Initial experience with 111In-labelled leucocyte scanning has been encouraging, both in diagnosis and in planning the management of patients with graft infections.
Air-filled microballoon manometr for use in anorectal physiology
Authors: Miller R , Bartolo D C C , James D , Mortensen N J McC
Published: March 2007

Manometry is fundamental to anorectal physiology but the water-filled manometric systems commonly used have several disadvantages. to investigate the ‘new’ air-filled microballoon system, we compared it with a standard water-filled equivalent by measuring sphincter length, maximum resting pressure (MRP) and maximum voluntary contraction pressure (MVC) in 44 patients using the station pull-through technique. A good correlation was found for all three parameters (Spearman correlation coefficient rs: sphincter length = 0·86, MRP = 0·86 and MVC = 0·94, P < 0·001). Repeat studies in 15 patients showed excellent reproducibility (rs: sphincter length = 0·97, MRP = 0·96 and MVC = 0·97, P < 0·001). Air-filled microballoon manometry gives results similar to a water-filled microballoon system and has many advantages.
Experience of restorative proctocolectomy with ileal reservoir
Authors: Everett W G
Published: March 2007

The experience gained with restorative proctocolectomy and ileal reservoir in 60 patients is presented. Fifty-two patients had W reservoirs and the operative technique of the procedure is described in detail. Forty patients had a defunctioning ileostomy and 20 had a single stage procedure. There was no perioperative mortality. The main complications were sepsis (28 per cent), intestinal obstruction (18 per cent) and reservoir ileitis (20 per cent). There was a significant improvement in sepsis rate (from 20 to 4 per cent) and hospital stay (from 31·8 to 15·6 days) with increased experience. The functional results of 48 patients with W reservoirs was assessed. The mean number of evacuations per 24 h (±s.d.) was 3·8 ± 0·2. Sixty-five per cent of patients did not evacuate at all, or rarely, at night and none evacuated more than once at night. Forty-four per cent of patients took antidiarrhoeal agents. Continence was normal in 50 per cent of patients. Minor leakage occurred in 46 per cent of cases, frequent leakage in 4 per cent and incontinence in none. Sexual function in 29 men was normal. Ninety-four per cent of patients considered the result of their operation to be good or excellent.
Metabolic response to sepsis and trauma
Authors: Douglas R G , Shaw J H F
Published: March 2007

This review examines current knowledge regarding the metabolic responses to trauma and sepsis. The factors which may mediate the responses are discussed and the potential value of pharmacological or nutritional manipulation is reviewed.
Anastomotic leakage: An avoidable complication of Lewis-Tanner oesophagectomy
Authors: Paterson I M , Wong J
Published: March 2007

Data were collected prospectively from 159 patients undergoing Lewis-Tanner oesophagectomy for carcinoma of the lower two-thirds of the oesophagus and analysed with regard to anastomotic leakage. The 30-day mortality rate was 3·8 per cent and none of these deaths was due to anastomotic leakage. In hospital, mortality was 7·5 per cent. Six patients (3·8 percent) had evidence of a leak. In four patients this was from the suture line, but in the remaining two it was due to patches of gangrene in the fundus of the transposed stomach and was separate from the anastomosis. Two patients died with an unhealed leak. Anastomotic leaks were minor in three instances and healed with conservative treatment but the fourth required exploration. Gangrene of the oesophageal substitute resulted in gross leakage with mediastinitis and required exploration in both cases. An apparent predisposing cause was evident in five of the six cases with leakage and some of these might have been avoidable. Transthoracic oesophagectomy can be performed with acceptably low mortality and leak rates and may therefore be considered as the treatment of choice for most patients with oesophageal cancer.