bluuebunny/crossref_metadata_2025 huggingface dataset:
Proliferation characteristics of human colorectal carcinomas measured in vivo
Authors: Rew D A , Wilson G D , Taylor I , Weaver P C
Published: March 2007

The cell proliferation kinetics of 100 human colonic and rectal adenocarcinomas have been studied in vivo by bromodeoxyuridine infusion and multiparameter flow cytometry. A total of 97 patients, three with synchronous tumours, consented to receive a single bolus dose of 250 mg between 2·4 and 16 h before curative or palliative surgery. By this method, the ploidy pattern, the total and aneuploid labelling indices (LI), the S phase duration (Ts) and the potential doubling time (Tpot) can be estimated. Of the tumours 48 were diploid and 52 were aneuploid. The mean and median total LI of 100 tumours were 9·0 per cent (range 0·7–-22·2 per cent). The mean aneuploid LI was 12·1 per cent (median 12·0 per cent, range 2·0–25·5 per cent), and was significantly higher than the total LI (P = 0·01). The labelling index alone is not a sufficient indicator of proliferation, because the Ts also varies within and between tumours. The intertumour range of the Ts varied from 4·0 to 28·6 h. The mean was 14·1 h and the median was 13·1 h. The mean Tpot was 5·9 days (median 3·9 days) with a range of 1·7–21·4 days. No correlation was found between any kinetic parameters and the Dukes' classification or histological classification. The correlation between proliferation and prognosis will be established in due course.
Stools containing altered blood - plasma urea: Creatinine ratio as a simple test for the source of bleeding
Authors: Olsen L H , Andreassen K H
Published: March 2007

The plasma urea:creatinine ratio (U:C ratio) is known to be elevated in cases of upper gastrointestinal bleeding. Almost all patients with haematemesis have upper gastrointestinal (or generalized) bleeding so that in this study we characterized the diagnostic power of the U:C ratio in patients with stools containing altered blood without haematemesis in the hope that this simple laboratory test (used in conjunction, perhaps, with clinical data) might reduce the number of patients subjected to an unrewarding gastroscopy or colonoscopy. Of 76 cases seen in a provincial and a metropolitan hospital, 42 and 34 patients had upper and lower gastrointestinal bleeding, respectively. Fifty-four per cent of those with upper gastrointestinal bleeding and none of those with lower gastrointestinal bleeding had U:C ratios above 110 on admission. However, a discriminating level of 90 is considered to be more suitable, judged by the quadratic uncertainty score. At this level the odds for upper gastrointestinal bleeding were 15:1.
Double-blind randomized trial of perioperative fibrinolytic enhancement for femoropopliteal bypass
Authors: Berridge D C , Frier M , Westby J C , Hopkinson B R , Makin G S
Published: March 2007

Patients with rest pain or acute peripheral arterial thrombosis are known to have impaired endogenous fibrinolysis, which is associated with an increased risk of early vascular graft thrombosis. This risk is exacerbated by the fibrinolytic shutdown which is known to occur after major surgery. Stanozolol, which has been demonstrated to enhance endogenous fibrinolysis, was therefore used in an attempt to prevent this perioperative fibrinolytic shutdown and so enhance graft patency. Twenty-seven patients were randomized to receive either 50 mg stanozolol or placebo intramuscularly 24 h before operation, followed by a 6 week course of either 5 mg stanozolol or placebo orally, twice daily. On the second day after operation, 10–11 MBq of autologous 111indium-labelled platelets were injected, with scanning over the graft on the 3 following days. Despite using a large depot of stanozolol, significant effects, such as raised plasminogen (P < 0·001), reduced fibrinogen (P < 0·001) and reduced euglobulin lysis time (P < 0·001), were not seen until the seventh day after operation, with maximum benefit at 6 weeks. This was reflected in the 111indium-labelled platelet deposition studies. The placebo group had a progressive increase in platelet deposition on all 3 days. In contrast, those receiving stanozolol showed a lower, static picture of deposition. However, these changes did not attain statistical significance. Three patients experienced early graft thrombosis, two in the placebo group and one in the stanozolol group. Only an incomplete inhibition of the perioperative fibrinolytic shutdown was achieved. Much longer preoperative courses are thus required to allow the maximum effect to be present at the most crucial time. At present, perioperative fibrinolytic enhancement does not appear to be a practical proposition, and we must await the development of new safer and more potent agents.
Protein status and metabolic expenditure determine the response to intravenous nutrition - a new classification of surgical malnutrition
Authors: Hill G L , Witney G B , Christie P M , Church J M
Published: March 2007

To determine whether nutritional and metabolic factors affect the response to intravenous nutrition (IVN) 146 surgical patients were classified according to their protein and metabolic status using direct measurements of body protein and metabolic expenditure. The patients were grouped into four categories: category I, moderate to severe protein depletion without raised metabolic expenditure; category II, moderate to severe protein depletion with raised metabolic expenditure; category III, mild protein depletion without raised metabolic expenditure; and category IV, mild protein depletion with raised metabolic expenditure. After 2 weeks of IVN patients in category I gained a mean(s.e.m.) of 0·43(0·06) kg of body protein (P < 0·001) and had significant rises in both plasma transferrin and prealbumin (P < 0·05); patients in category II gained 0·30(0·11) kg of protein (P < 0·005) and also had significant rises in transferrin and prealbumin (P < 0·05). Patients in category III lost 0·24(0·11) kg protein (P < 0·05) and had no changes in either transferrin or prealbumin and patients in category IV lost 0·51(0·13) kg of body protein (P < 0·001) and although there was a significant rise in plasma prealbumin there was no significant change in plasma transferrin. When postoperative patients were examined separately, they did not differ significantly from preoperative patients except in category I, where their protein gain was only 0·19(0·10) kg, an amount not significantly different from that gained by patients in category II. In each of the four categories described, the changes in total body protein occurring with 2 weeks of IVN were determined by the relative effects of two competing processes; protein depletion and raised metabolic expenditure. With moderate to severe protein depletion (approximately 30 per cent depletion of body protein stores) there was a marked tendency to gain protein with IVN. When the patient had a raised metabolic expenditure or was postoperative this tendency of depleted patients to gain protein was still present but it was less. With only mild protein depletion (approximately 10 per cent depletion) increases in metabolic expenditure made it difficult, if not impossible, to prevent continuing protein loss in spite of aggressive nutritional support. The patient categories we have described determine the response to IVN and form the basis of a new clinical classification of surgical malnutrition.
Postoperative hypophosphataemia and muscle function
Authors: Andersen P T , Toft E , Hansen A K , Sinkjaer T
Published: March 2007

Muscle function tests of the triceps brachii muscle were performed before operation and on the third postoperative day in ten patients undergoing elective cholecystectomy. Electromyograms (EMGs) were recorded by surface electrodes during sustained isotonic and isometric muscle contraction with a constant force of 20 per cent of the preoperative maximal voluntary contraction. Root-mean-square of the EMG was calculated together with the neuromuscular efficiency and measures of the fatiguability. These parameters were compared with changes in the simultaneously measured serum phosphate concentrations. Mean(s.e.m.) neuromuscular efficiency measured after 32–40 s of muscle contraction decreased 14(5) per cent after operation (P < 0·01), whereas the mean fatiguability of the muscle was unchanged. Mean serum phosphate concentration was 0·87(0·06) mmol/l before operation and 0·79(0·06) mmol/l 3 days after the operation (P > 0·05). Two patients developed severe postoperative hypophosphataemia (serum phosphate concentration < 0·50 mmol/l). Postoperative muscle function deterioration was not associated with changes in the serum phosphate level (P > 0·10; r = 0·03). We conclude that patients undergoing cholecystectomy develop postoperative deterioration in skeletal muscle function, which is not associated with serum phosphate concentration.
Importance of the omentum in the development of intra-abdominal metastases
Authors: Lawrance R J , Loizidou M , Cooper A J , Alexander P , Taylor I
Published: March 2007

Areas of trauma are preferred sites for metastatic tumour growth. In extensive intra-abdominal tumour recurrence the omentum is invariably involved. The importance of the omentum in the development of tumours at sites of intra-abdominal trauma has been investigated. Colonic anastomoses were performed in Hooded-Lister rats with and without omentectomy. Animals received intraluminal or intraperitoneal injections of a syngeneic tumour. With intraluminal injection, tumour occurred at the anastomosis and in the omentum in 38 and 43 per cent of animals respectively but following omentectomy the values were 14 and 9 per cent (omental remnant). With intraperitoneal administration tumour occurred in 53 per cent at the anastomosis and in 79 per cent in the omentum compared with 16 and 29 per cent (in omental remnant) following omentectomy. In this model a reduced ability of an anastomosis to support ‘seeded’ tumour following removal of the omentum is demonstrated and the development of local recurrence from spilled tumour cells during operation may be enhanced by, or be dependent on, the proximity of the omentum.
Merkel cell tumour: Clinical behaviour and treatment
Authors: Shaw J H F , Rumball E
Published: March 2007

We have reviewed 30 reports of Merkel cell tumour and described a further five cases in order to establish a database and from this more clearly define the biology of this tumour, prognostic factors that govern outcome, and optimal management. After excision alone of the primary lesion, local recurrence occurred in 39 per cent of patients and regional failure occurred in 46 per cent. In contrast, in patients treated by excision plus prophylactic treatment (adjuvant node dissection and/or adjuvant radiation), local recurrence occurred in 26 per cent and regional failure in 22 per cent. Locoregional recurrence carried an ominous significance with 67 per cent of patients subsequently dying of the disease. For patients who either presented with regional disease or later developed regional disease, the best outcome (44 per cent survival with mean follow-up of 40 months) was obtained following treatment by therapeutic node dissection with or without radiation. In contrast, treatment of regional disease with radiation alone was associated with only a 20 per cent survival rate. Unfavourable prognostic factors included young age, lesions sited in the head and neck or trunk, male sex, and the presence of locoregional failure and/or systemic disease. We conclude that Merkel cell tumours behave in a similar manner to the aggressive variants of melanoma and that minimal treatment consists of wide surgical resection of the primary lesion (with a margin of 2.5-3 cm) coupled with resection and probably also radiation of regional disease if present. In addition, consideration should be given to prophylactic node dissection in node negative patients, especially in those patients with unfavourable prognostic factors.
Laparoscopic cholecystectomy: The dundee technique
Authors: Nathanson L K , Shimi S , Cuschieri A
Published: March 2007

A totla of 61 patients was subjected to laparoscopic cholecystectomy. The procedure was completed in 60 cases and converted to open operation in one (2 per cent). The morbidity rate was lot (total 7 per cent, major 2 per cent, blood transfusion rate 5 per cent). The medium duration of the laparoscopic cholecystectomy with cholangiography was 135 min (range 65-270 min). The operation took less time to complete in patients with functioning gallbladders than in those with non-functioning fibrotic organs (median 120 versus 175 min). the majority of patients requried opiate analgesia despite infiltration of the stabh woulds with bupivacaine. The mean(s.d.) hospital stay was 2·9(1·5) days. The median time to resume work or full activity after discharge was 11 days.
Piezoelectric lithotripsy for gallstones: Analysis of results in patients with extended selection
Authors: Darzi A , El-Sayed E , O'Morain C , Tanner W A , Keane F B V
Published: March 2007

Extracorporeal shock wave lithotripsy (ESWL) is successful in fragmenting gallstones, but <28 per cent of patients with gallstone disease fulfil the conventional criteria for treatment. However, no data exist to substantiate these selection criteria. In this study, the selection criteria were broadened to include patients with radiolucent stones of any size and number, and radio-opaque stones <3 cm in diameter. To date, 108 symptomatic patients with gallstones have received treatment. All patients received up to six outpatient sessions of ESWL (6000 shock waves per session) without sedation or analgesia. The dissolution therapy consisted of combined bile salt and terpene administration. The clearance rates were 9 per cent within 2 months, 21 per cent at 2-4 months, 38 per cent at 4-8 months, 60 per cent at 8-12 months, and 78 per cent at 12-18 months. Of patients with a successful outcome only 19 (18 per cent) would have satisfied traditional selection criteria. There have been no significant complications except in one patient who developed mild acute pancreatitis, which settled on conservative treatment, and two patients who developed acute cholecystitis. This study would suggest that the previously accepted selection criteria underestimate the number of patients suitable for gallstone ESWL and dissolution therapy.
Hirschsprung's disease presenting as neonatal gastrointestinal perforation
Authors: Stringer M D , Drake D P
Published: March 2007

In the neonate, Hirschsprung's disease characteristically presents with delayed passage of meconium and/or intestinal obstruction. Intestinal perforation in this age group is more often due to necrotizing enterocolitis or a mechanical obstruction such as atresia or meconium ileus. Hirschsprung's disease, however, may present with intestinal perforation and this association must be recognized promptly if the patients are to be managed appropriately, particularly as half of them have total colonic involvement. Three neonates with Hirschsprung's disease presenting with neonatal intestinal perforation are reported.
Long-term follow-up of elderly patients with locoregional breast cancer treated with tamoxifen only
Authors: Horobin J M , Preece P E , Dewar J A , Wood R A B , Cuschieri A
Published: March 2007

One hundred and thirteen women aged 70 years or more with locoregional breast cancer were treated with tamoxifen alone as primary treatment. They were followed for a minimum of 5 years. Complete response occurred in 38 women, partial response in 17, no change in 34 and progressive disease in 24. Where progressive disease occurred, or where patients relapsed after an initial response, the most suitable conventional therapy was given. The actuarial 5-year survival rate was 49·4 per cent for all patients and was much higher (92 per cent) in those showing an initial complete response. Seventy patients (61·9 per cent) were not controlled by tamoxifen alone to death or most recent follow-up. Tamoxifen provides an alternative treatment for operable breast cancer in older women in the short term and may be particularly suitable for those with concurrent disease or who are unwilling to undergo surgery. The low morbidity rate from tamoxifen must be balanced against the need to maintain close follow-up. In the medium to long term, sole primary treatment by tamoxifen delays more definitive therapy.
Abdominal wall tenderness: A useful sign in chronic abdominal pain
Authors: Thomson W H F , Dawes R F H , Carter S S T C
Published: March 2007

The outcome in 72 patients with obscure abdominal pain and a positive Carnett's (abdominal wall tenderness) test, seen in one firm's surgical outpatient clinic between 1975 and 1983, was sought by a combination of hospital note retrieval and general practitioner questionnaire. Full follow-up data to date or death were available for 58 (81 per cent) patients and partial follow-up for 14 patients. The study showed that the patients generated a good deal of investigation and a number of surgical procedures but that seldom were their symptoms attributable to serious pathology. Familiarity with the test, taken in the context of a proper history and examination, has been found helpful in assessing such patients and saves the inconvenience, expense and occasional hazard of investigation, and even surgery.
Cytoreductive surgery in disseminated non-seminomatous germ cell tumours of testis
Authors: Kulkarni R P , Reynolds K W , Newlands E S , Dawson P M , Makey A R , Theodorou N A , Bradley J , Begent R H J , Rustin G J S , Bagshawe K D
Published: March 2007

Between 1977 and 1988, 67 patients underwent surgical removal of residual metastatic deposits following an aggressive chemotherapy regimen (cisplatin, vincristine, methotrexate and bleomycin alternating with etoposide, actinomycin D and cyclophosphamide) for disseminated germ cell tumours of the testis (stage IIB or above). Ninety-one surgical procedures were performed. There were 63 (69 per cent) retroperitoneal lymph node dissections, 16 (18 per cent) thoracotomies, three (3 per cent) hepatic resections, three (3 per cent) craniotomies, five (5 per cent) delayed orchidectomies and one anterolateral decompression of the vertebral column. Nine (13 per cent) patients required a repeat retroperitoneal node dissection and one patient needed a repeat thoracotomy to remove recurrent metastatic deposits during the period of follow-up. Multivisceral resections and vascular reconstruction procedures were required in 20 (30 per cent) patients undergoing retroperitoneal node dissection. Fifty-five (82 per cent) patients remain in complete remission with a mean follow-up period of 49·6 months (range 2–121 months). Nine (13 per cent) patients died with metastatic disease between 2 months to 4 years after operation. There were three deaths in the perioperative period (4 per cent). The histology of the resected metastases revealed undifferentiated active tumour in 20 (30 per cent) patients, differentiated mature teratoma in 29 (43 per cent) patients and fibrosis/necrosis in 18 (27 per cent) patients. Twelve (60 per cent) patients with undifferentiated elements and 15 patients (60 per cent) with raised preoperative tumour markers (poor prognostic categories) are in complete remission. Cytoreductive surgery in patients with metastatic germ cell tumours offers the best chance of remission following chemotherapy even in poor prognostic group categories.
Long-term survival in patients operated on for benign peptic ulcer disease
Authors: Lundegårdh G , Holmberg L , Krusemo U B
Published: March 2007

Survival rate was analysed in a cohort of 6459 patients who had undergone partial gastrectomy for benign ulcer disease and who had survived the first year after operation. The cohort was followed for 27–35 years. There was a slight but significant decrease in relative survival rate to 92 per cent (95 per cent confidence interval 87–97 per cent) 35 years after operation. No decrease in relative survival rate was observed during the first 20 years after operation. There was no difference by gender or surgical procedure, but patients operated on for gastric ulcer, compared with duodenal ulcer, and patients operated on at younger ages had a poorer relative survival rate. The effects of partial gastrectomy on survival, both overall and by diagnosis or age at operation, are probably attributable to confounding factors linked with the peptic ulcer disease rather than to the surgical procedure itself. We conclude that partial gastrectomy seems to have very little impact on survival once the patient has survived the first year after operation.
Effects of cardiac surgery and intraoperative hypothermia on energy expenditure as measured by doubly labelled water
Authors: Taggart D P , McMillan D C , Preston T , Richardson R , Burns H J G , Wheatley D J
Published: March 2007

Total energy expenditure (TEE) was measured over two 10-day periods, before and after operation in 16 patients undergoing coronary artery surgery and randomized to have cardiopulmonary bypass with an intraoperative blood temperature of either 28 or 20°C. TEE was measured with doubly labelled water containing stable isotopes of hydrogen and oxygen to allow calculation of TEE over fixed periods from the differential rate of excretion of the two isotopes. Results were available for eight patients in the 28°C group but for only seven in the 20°C group (one patient in this group was excluded as the temperature allocated was not achieved). The groups were similar with respect to body-weight and lean body mass. The 20°C group received more grafts than the 28°C group, resulting in an increase in cross-clamp and bypass times. Mean preoperative TEE was similar in both groups. The mean difference in fractional turnover rates of hydrogen and oxygen was not significantly different in the postoperative period. There was a non-significant increase in the mean 10-day postoperative TEE, calculated in total calories, of 4·7 per cent in the 28°C and 5·1 per cent in the 20°C group. When changes in postoperative TEE were calculated according to lean body mass, the mean increases were respectively 3·7 and 3·2 per cent. Cardiac surgery utilizing cardiopulmonary bypass and intraoperative hypothermia results in only a modest increase in postoperative TEE. In this study a more profound level of intraoperative hypothermia did not influence the change in postoperative TEE.
Thrombolytic therapy in the management of acute limb ischaemia
Authors: Earnshaw J J
Published: March 2007

Acute limb ischaemia poses a threat to both the limb and life of a patient. Until recently, attempted revascularization by thrombo-embolectomy or vascular reconstruction held the best chance of limb salvage. Thrombolytic techniques afford an alternative method of management for this condition and are effective in selected patients. Low-dose intra-arterial streptokinase is the most established method of thrombolysis, although the recently developed tissue plasminogen activator offers a promising alternative. Intra-arterial thrombolysis is not an easy option, being labour intensive and requiring close co-operation between surgeon and radiologist. Thrombolytic and surgical techniques are not mutually exclusive but are best used to complement each other. Ideally patients with acute limb ischaemia should be managed by surgeons with knowledge of, and access to, optimal current surgical and non-surgical techniques.
Randomized study on the effect of collagen impregnation of knitted Dacron® velour aortoiliac prostheses on blood loss during aortic reconstruction
Authors: De Mol Van Otterloo J C A , van Bockel J H , Ponfoort E D , van den Akker P J , Hermans J , Terpstra J L
Published: March 2007

Intraoperative blood loss is an important factor in reconstructive surgery for aortoiliac disease because it is clearly associated with an increase in the operative morbidity and mortality rates. To minimize intraoperative blood loss, a blood-tight vascular prosthesis has been developed by impregnating a knitted Dacron™ prosthesis with bovine collagen. To study a potential reduction of intraoperative blood loss using these collagen-impregnated prostheses, we conducted a prospective randomized trial involving the collagen-impregnated prosthesis and its non-impregnated substrate, the Dacron knitted non-impregnated prosthesis. During a 2·5-year period, 123 consecutive patients (undergoing 81 procedures for aneurysmal disease and 43 procedures for occlusive disease) were admitted for elective aortic reconstructive surgery. Equal numbers of the two prostheses were randomly implanted. Various parameters were monitored: intraoperative blood loss before aortic cross-clamping (phase 1), during implantation of the prosthesis (phase 2) and after release of aorta cross-clamping (phase 3); the number of intraoperative and postoperative blood transfusions; and, finally, all preoperative and intraoperative factors that might contribute to intraoperative blood loss. A significant overall difference in intraoperative blood loss between the collagen-impregnated (2425 ml) and the non-impregnated (1907 ml) group was found (P = 0·003). However, this difference could not be attributed to collagen impregnation because no statistically significant difference in blood loss was found in the relevant period of operation (phase 3). Similar results were observed in patients operated on for both aneurysmal and occlusive disease (2600 versus 2195 ml and 2105 versus 1344 ml respectively).
Gastrointestinal complications in 4473 patients who underwent cardiopulmonary bypass surgery
Authors: Huddy S P J , Joyce W P , Pepper J R
Published: March 2007

Thirty-nine gastrointestinal complications occurred in 35 of 4473 patients (0·78 per cent) who underwent surgery involving cardiopulmonary bypass during an 8-year period. The mortality rate when one of these complications occurred was 22 (63 per cent) representing 11·5 per cent of the 191 deaths from all causes in the series. The relative risk of developing a gastrointestinal complication was 1:249 when the heart was not opened, 1:66 when it was and 1:5 after cardiac transplantation. Gastrointestinal bleeding (n = 20) was the most common complication of whom nine (45 per cent) died, followed by intestinal infarction (n = 12) with eight (67 per cent) deaths and acute pancreatitis (n = 6) all of whom died. There was one death after surgery for gastrointestinal bleeding (n = 7). No patient survived bowel infarction without operation but resection was possible in five of the eight who underwent surgery, four of whom survived. The results demonstrate that surgical intervention is not associated with undue mortality but inappropriate conservative therapy is poorly tolerated in this high-risk group.
Isotopic study of the effects of platelets on development of intimal thickening in autologous vein grafts in dogs
Authors: Yukizane T , Okadome K , Eguchi H , Muto Y , Sugimachi K
Published: March 2007

The effects of platelets on the development of intimal thickening of arterially transplanted autologous vein grafts was investigated using canine poor run-off models. A new apparatus consisting of a shielding lead block to measure in vivo platelet adherence only on the intima of the vein graft was developed. In 23 dogs, 51Cr-labelled platelets (20 μCi/kg) were injected and isotope emission over the grafts was counted. Platelet adherence was expressed as the thrombocyte accumulation index (TAI), i.e. the ratio of counts over the graft under an abnormal flow condition in the poor run-off model to those over the graft under normal flow conditions of the contralateral leg. The TAI of the total graft (TTAI) was significantly high immediately and on the first and third days after implantation. The TAIs of the proximal (PTAI) and distal (DTAI) portions of the vein graft were also high at these same times. At 7, 10, 14 and 21 days, the TAI was almost equal to 1·0, a time at which endothelial regeneration was complete as confirmed by scanning electron microscopy. Thus, the prominent intimal thickening of arterially transplanted autologous vein grafts in dogs, induced under an abnormal flow condition, correlates well with the enhanced platelet adherence on the intima of the vein grafts in an early period after implantation.
POSSUM: A scoring system for surgical audit
Authors: Copeland G P , Jones D , Walters M
Published: March 2007

POSSUM, a Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, is described. This system has been devised from both a retrospective and prospective analysis and the present paper attempts to validate it prospectively. Logistic regression analysis yielded statistically significant equations for both mortality and morbidity (P < 0·001). When displayed graphically zones of increasing morbidity and mortality rates could be defined which could be of value in surgical audit. The scoring system produced assessments for morbidity and mortality rates which did not significantly differ from observed rates.
Repair and replacement of deep vein valves in the treatment of venous insufficiency
Authors: Wilson N M , Rutt D L , Browse N L
Published: March 2007

Venous insufficiency is a widespread condition, the prevalence of venous ulceration being 0·5–1·0 per cent in Western populations. A principal abnormality causing venous insufficiency is deep venous reflux, usually resulting from post-thrombotic valve destruction. Patients undergoing treatment for venous insufficiency should have all venous abnormalities investigated, defined and corrected where possible. Although treatment for superficial and communicating vein incompetence is available, correction of deep vein reflux has been neglected until recently. Deep vein valve physiology, the selection of patients for deep vein valve surgery and methods of valve repair and replacement are reviewed.
Watermelon stomach
Authors: Park R H R , Russell R I
Published: March 2007

The typical and atypical appearances of watermelon stomach (gastric antral vascular ectasia) during endoscopy, along with the treatments for it, are reviewed.
Carotid endarterectomy in Great Britain and Ireland: Trends and current practice
Authors: Murie J A , Morris P J
Published: March 2007

Of 309 questionnaires on carotid endarterectomy sent to all surgeons in Great Britain and Ireland who might use this technique, 298 (96 per cent) were returned. In all, 110 (37 per cent) of 298 surgeons performed at least one carotid endarterectomy in 1989; 67 performed < 10 and 43 >10. In total, these 110 surgeons performed 1417 operations in 1989, a situation that has changed little over 5 years since the previous survey. Transient ischaemic attack and minor stroke remain the main indications for carotid endarterectomy; the operation was hardly ever performed for asymptomatic stenosis. By 1989 almost all surgeons initially assessed prospective patients using a technique less invasive than conventional angiography; duplex scanning was used ‘always’ or ‘sometimes’ by 70 per cent of surgeons. While 72 per cent of surgeons in 1984 ‘always’ required conventional angiograms before operation, by 1989 only 21 per cent did so, most now relying on less invasive techniques. During operation there was an increasing use of shunts, carotid sinus nerve blockade and patch closure of the arteriotomy. The overall number of carotid endarterectomies performed annually in Great Britain and Ireland has remained steady over the past 5 years and is relatively low for a population of 60 millions. An increase in the number of surgeons performing the operation is almost entirely accounted for by an increase in those performing < 10 carotid endarterectomies per year.
Prevention of perioperative deep vein thrombosis in general surgery: A multicentre double blind study comparing two doses of Logiparin and standard heparin
Authors: Liezorovicz A , Picolet H , Peyrieux J C , Boissel J P
Published: March 2007

A total of 1290 patients were enrolled in a randomized multicentre double blind study in order to investigate the use of two doses of a new low molecular weight heparin, Logiparin®, in the prevention of deep vein thrombosis (DVT) in general surgery. Patients who were included had no contraindication to heparin therapy and had at least one of the recognized risk factors for DVT. Patients were randomized to receive unfractionated heparin (UH) 5000 units b.d., Logiparin 2500 units daily or Logiparin 3500 units daily. Each treatment was given subcutaneously 2h before surgery and continued for 7–10 days. Daily 125I-labelled fibrinogen uptake tests (FUTs) were performed from day 2 to day 7 to detect DVT, and phleboangiography was used to confirm the diagnosis. The wound was examined on a daily basis to check for haematoma formation, and all patients were followed up for 1 month after operation. All three treatment arms were well matched for age, sex, weight, diagnosis and type of operation performed. The three major inclusion criteria in the trial were malignancy, age over 60 years and a history of varicose veins. Positive FUTs (UH=4·2 per cent, Logiparin 2500 units daily = 7·9 per cent, Logiparin 3500 units daily = 3·7 per cent) and positive angiograms (UH=3·0 per cent, Logiparin 2500 units daily = 5·6 per cent, Logiparin 3500 units daily = 2·3 per cent) were significantly more common in the Logiparin 2500 units daily group than in the UH and Logiparin 3500 units daily groups. The rates of major complications (severe haemorrhage, death, pulmonary embolism, reintervention) were similar in the three groups.
Peritoneal adhesion formation after lysis: Inhibition by polyethylene glycol 4000
Authors: O'Sullivan D , O'Riordain M , O'Connell R P , Dineen M , Brady M P
Published: March 2007

Peritoneal adhesions cause much long-term postoperative morbidity. This study evaluates the efficacy of polyethylene glycol (PEG) 4000 in reducing adhesion reformation after lysis. Adhesions were induced, by abrasion, in 111 Sprague-Dawley rats at a first laparotomy. At a second operation, 10 days later, these adhesions were graded and lysed, after which the animals received one of the following solutions intra-peritoneally: 5 per cent PEG 4000 (n = 21), 25 per cent PEG 4000 (n = 23), 32 per cent dextran 70 (n = 22) or isotonic saline (n = 25), or were left as an untreated control group (n = 20). When the reformed adhesions were graded after a further 10 days 5 per cent PEG 4000 was found to be the only solution that inhibited adhesion reformation. The adhesions that reformed in the other four test groups were significantly worse than when they were first graded (P ≦0·033 for all groups). Therefore 5 per cent PEG 4000 may be useful in clinical practice for the reduction of adhesion formation after lysis.
Comparison between anal endosonography and digital examination in the evaluation of anal fistulae
Authors: Choen S , Burnett S , Bartram C I , Nicholls R J
Published: March 2007

A prospective trial was performed comparing the accuracy of digital examination and anal endosonography in defining the anatomy of anal fistulae. Before operation 38 consecutive patients were assessed by the consultant in charge of the case, by a research fellow and by anal endosonography involving two radiologists. These findings were compared with the operative findings. Consultants correctly identified 26 of 33 internal openings, 29 of 34 primary tracks and 15 of 21 secondary tracks. The research fellow correctly identified 26 internal openings, 24 primary tracks and 10 secondary tracks. There was no significant difference between the accuracy of consultants and the research fellow. Anal endosonography identified 10 internal openings based on initial criteria. This rose to 24 when revised ultrasonographic criteria were applied. There was no statistical difference between consultant assessment and anal ultrasonography in correctly identifying intersphincteric and transphincteric tracks. Ultrasonography is unable to assess primary superficial, suprasphincteric and extrasphincteric tracks or secondary supralevator and infralevator tracks. Consultant assessment of secondary supralevator and infralevator tracks was correct in 78 per cent of cases.
Management of bleeding liver tumours in Hong Kong
Authors: Dewar G A , Griffin S M , Ku K W , Lau W Y , Li A K C
Published: March 2007

A retrospective study was undertaken of 41 patients diagnosed as having suffered spontaneous liver rupture over a 4-year period to identify the clinical features, treatment and outcome of this complication in an area in which hepatocellular carcinoma is endemic. Two patients were excluded with a revised diagnosis of haemorrhagic malignant ascites. Of the remaining 39 patients, 37 bled from ruptured hepatocellular carcinoma, one from peliosis hepatis and multiple liver cell adenomas, and one from a malignant hepatic epithelioid haemangioendothelioma. Analysis showed that 59 per cent of patients were in shock on admission and that all but two of the 37 patients with ruptured hepatocellular carcinoma were men with cirrhosis. The association with cirrhosis was significantly higher than in a series of 45 patients with hepatocellular carcinoma undergoing elective resection during the same period (P<0·05). Treatment consisted of supportive care only in two patients, angiographic embolization in four, emergency liver resection in 11 of whom six died, hepatic artery ligation in 12 of whom eight died, and suture and/or packing in eight of whom six died. One patient died at laparotomy and in another patient bleeding was successfully arrested by intratumoural injection of absolute alcohol. Because of the high operative mortality of emergency surgery in these poor risk patients, prospective evaluation of emergency angiographic embolization is required.
Prevention of postoperative renal dysfunction in patients with obstructive jaundice: A multicentre study of bile salts and lactulose
Authors: Pain J A , Cahill C J , Gilbert J M , Johnson C D , Trapnell J E , Bailey M E
Published: March 2007

The role of preoperative lactulose and bile salts in the prevention of postoperative renal failure in patients with obstructive jaundice has been evaluated in a prospective randomized trial. One hundred and two patients undergoing surgery for obstructive jaundice (bilirubin > 100 μmol/l) were randomized into three groups: those receiving preoperative oral lactulose (n = 35), those receiving oral sodium deoxycholate (n = 32) and a control group of patients receiving no specific treatment (n = 35). All patients received intravenous fluids commencing the night before surgery. One patient in the control group and none in the treatment groups developed postoperative renal failure. Postoperative deterioration of renal function in patients with normal preoperative function was significantly more common in the control group than in the treatment groups (χ2 = 8·1, d.f. = 2, P<0·02). The incidence of renal failure and impairment was lower in this control group than that reported in previous studies. This may be due to the introduction of adequate preoperative hydration. Additional protection occurs by the preoperative administration of either lactulose or sodium deoxycholate.
Adrenaline injection for endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage
Authors: Steele R J C , Park K G M , Crofts T J
Published: March 2007

Over a 30-month period, 53 patients with actively bleeding non-variceal lesions of the oesophagus, stomach or duodenum were treated by endoscopic injection of 1/10000 adrenaline. Initial haemostasis was obtained in 50 cases, and permanent haemostasis in 44. Emergency surgery for bleeding was required in nine patients overall, and there were four deaths. All lesions requiring surgery were located on the posterior wall of the duodenum or the lesser curve of the stomach, and all but one had evidence of an exposed arterial vessel. Adrenaline injection is an effective, safe and simple method of endoscopic haemostasis.
Surgical implications of drug-induced rhabdomyolysis
Authors: Rutgers P H , Van Der Harst E , Koumans R K J
Published: March 2007

Four cases are described of acute non-traumatic rhabdomyolysis with subsequent development of a compartmental syndrome, requiring extensive fasciotomies. All the patients were young male alcoholics who were taking benzodiazepines as part of an addiction treatment programme. In this risk group clinicians should be aware of two serious complications of non-traumatic rhabdomyolysis: acute renal failure and compartmental syndrome.
Povidone-iodine in experimental peritoneal hydatidosis
Authors: Gökçe Ö , Gökçe Ç , Yilmaz M , Hüseyinog̈lu K , Günel S
Published: March 2007

The effect of polyvinylpyrrolidone-iodine (PVP-I) on experimental peritoneal hydatidosis was evaluated in this randomized blind controlled study. Seventy-five white, 3-month-old rats were subjected to laparotomy. After the intraperitoneal inoculation of viable scolices, the rats were randomly divided into three groups. Their peritoneal cavities were irrigated with either 1 per cent PVP-I solution (the PVP-I group), hypertonic saline (the HS group) or Ringer's lactate (the control group). Each group was assigned a separate code number; observers blind to the meaning of the code numbers noted all findings during a period of 4 months, after which the rats were killed to allow assessment of the abdominal cavity. The results were decoded after the statistical analyses were completed. The incidence of peritoneal cysts was found to be lower (8·7 per cent) in the PVP-I group compared with the HS (50 per cent) and control (90·9 per cent) groups; the mean number of hydatid cysts per animal was also lower in the PVP-I group compared with the other two groups. We conclude that the scolicidal activity of PVP-I is significantly higher than that of hypertonic saline and that it can be employed as a prophylactic agent against peritoneal hydatidosis.
Steroid receptors in breast cancer
Authors: Rayter Z
Published: March 2007

Recent advances in steroid receptor structure and function now indicate that oestrogen binds to the oestrogen receptor (ER) molecule at a specific site, denoted region E. This allows binding of the oestrogen-ER complex to DNA via cysteine residues in region C of the ER molecule, which tetrahedrally co-ordinate zinc. This modulates transcription and stimulates cell growth. A number of newly discovered growth factors are also regulated by ER, as is the progesterone receptor. Steroid receptor concentrations in tissues can now be measured on smaller tissue samples using enzyme immunoassay or on cells obtained by fine needle aspiration using monoclonal antibody technology. The prognostic value of steroid receptor is limited, but still constitutes the best marker for predicting response to endocrine therapy. The role of steroid receptors in selecting patients for adjuvant therapy is discussed.
Insights gained from the management of problematical anal fistulae at St. Mark's Hospital, 1984–88
Authors: Choen Seow , Phillips R K S
Published: March 2007

Twenty-four (3·6 per cent) patients with problematical anal fistulae out of 671 with anal fistulae were analysed to assess the reasons for their recurrences and ultimate outcome. Thirteen patients (group A) had recurrent fistulae despite two definitive attempts at surgery at this hospital (median number of previous procedures before referral to this hospital was two, range 0–7; median number of definitive procedures at this hospital was three, range 3–4). In five of these patients, the reason for recurrence was missed primary (four cases) or secondary tracks (one case) at earlier operations. Five patients required multiple operations related to the use of setons. Eleven other patients (group B) required colostomy construction, eight because of severe perianal sepsis, two because of complex fistulae, and one for postrectal dermoid. Fistula healing occurred ultimately in all patients in group A afer a median of 14 months (range 4–38 months). In group B, fistula healing occurred in eight patients after a median of 7.5 months (range 2–55 months) after colostomy construction. Only one patient has had a proctectomy, and five still have their colostomy. Of the other 18 patients, continence is normal in 14, there is mucus leakage in two, flatus incontinence in one and faecal incontinence in one. In conclusion, persistent attempts to resolve anal fistulae in difficult cases are frequently successful in the long term and result in good continence.
Primary sclerosing cholangitis: Surgical options, prognostic variables and outcome
Authors: Ismail T , Angrisani L , Powell J E , Hübscher S , Buckels J , Neuberger J , Elias E , McMaster P
Published: March 2007

The natural history of primary sclerosing cholangitis (PSC) is poorly defined and its management remains controversial. Forty-eight symptomatic patients (median age 39 years, range 8–67 years; 30 male) with PSC were reviewed retrospectively. Thirty patients had inflammatory bowel disease. Four patients (8 per cent) developed or had an associated malignancy. Twenty-one (44 per cent) died; overall 5 year actuarial survival was 30 per cent. Twenty-three patients had 27 non-transplant related biliary operations (16 patients specifically for PSC) of whom 12 died. Serum bilirubin was the only parameter to improve after biliary surgery. Seventeen patients (35 per cent) underwent orthotopic liver transplanation (OLT) of whom nine are currently alive (1 year projected survival of 55 per cent). Previous biliary surgery correlated with a poor outcome (P < 0.0001) after OLT. Being male, presence of cirrhosis, duration of symptomatic disease (> 3 years) and a serum bilirubin level > 100 μmol/l at presentation, were independently associated with a poor outcome (P < 0.05). These data provide evidence that PSC is a progressive disease and conventional surgical options have little influence on the outcome. Previous biliary surgery adversely affects outcome following OLT. For progressive liver disease, liver transplantation should be considered the treatment of choice.
Effect of percutaneous interstitial thermal laser on normal liver of pigs: Sonographic and histopathological correlations
Authors: Bosman S Saskia , Phoa S S K , Bosma A , van Gemert M J C
Published: March 2007

Tumour necrosis can be induced by interstitial application of low power laser light, which causes thermal damage to the tissue. In normal pig liver the effects were studied of low power Nd: YAG laser light (continuous wave; 1·5 W, 10 min, wavelength 1064 nm), administered percutaneously via a 600 um fibre. Ultrasound images were compared with histopathological findings. Histopathology showed induction of sharply demarcated lesions with a mean diameter of 10–15 mm (days 0 and 7), consisting of coagulative necrosis. Healing of the lesion occurred by granulation, fibrosis and removal of cell debris. Lesions could not be seen by week 4, which suggests complete regeneration. Ultrasonography showed a good correlation with histopathology, especially at 1 week when different histopathological tissue layers could be discriminated by ultrasonography. It is concluded that thermal lesions in liver can be induced via a percutaneous route and that ultrasound imaging is useful in monitoring the lesions during and after the procedure.
Breast cancer in elderly women: A Cancer Research Campaign trial comparing treatment with tamoxifen and optimal surgery with tamoxifen alone
Authors: Bates T , Riley D L , Houghton J , Fallowfield L , Baum M
Published: March 2007

Three hundred and eighty-one women with operable breast cancer aged over 70 years were randomly allocated to 40 mg tamoxifen daily and optimal surgery or to tamoxifen alone. At a median follow-up of 34 months there was no demonstrable difference in survival rate or in quality of life between the two treatment groups. More patients treated with tamoxifen alone had a subsequent change of management and this was usually an operation for local treatment failure. This progression to surgery has not been shown to be disadvantageous and the study will continue. Informed consent for randomization was difficult to obtain, leading to the exclusion of eligible patients, and it is therefore proposed to include non-randomized patients in a total cohort study.