bluuebunny/crossref_metadata_2025 huggingface dataset:
Helicopter Emergency Medical Service operating from the Royal London Hospital: the first year
Authors: Kirk C J C , Earlam R J , Wilson A W , Watkins E S
Published: March 2007

The additional workload on the support hospital created by using a helicopter for emergency trauma has been assessed in the first year of operation. A total of 135 patients were brought to the Royal London Hospital, of whom 30 died, 34 were transferred for convalescence or rehabilitation to another hospital, and 71 discharged home. The median Injury Severity Score was 17 (range 0–75) and 82 patients (60·7 per cent) had a reduced Revised Trauma Score at the scene. Blunt injury greatly outnumbered penetrating trauma (117 versus 15 patients). Accidental injuries accounted for 77·0 per cent of the total, self-inflicted wounds 14·1 per cent and assaults 8·9 per cent. Parameters employed to assess workload were hospital bed-days used (total 2361), operations (118, occupying 287 h of theatre time) and blood transfusion (total 702 units used). The second 6-month study period showed a considerable increase in the number of patients admitted (102 versus 33) because of increased efficiency in call-out procedures.
Crohn's disease and anastomotic recurrence: microvascular ischaemia and anastomotic healing in an animal model
Authors: Osborne M J , Hudson M , Piasecki C , Dhillon A P , Lewis A A M , Pounder R E , Wakefield A J
Published: March 2007

Microvascular injury and ischaemia may be factors in anastomotic recurrence after resection for Crohn's disease. This hypothesis was explored in a ferret model of multifocal intestinal infarction. At laparotomy, isolated loops of small intestine were injected intraarterially with styrene microspheres (test loop) or saline (control). At a second laparotomy 72 h later, test and control loops were divided and an end-to-end anastomosis performed between test loops (n = 2), test and control loops (n = 9) or control loops (n = 2). Abnormalities including chronic transmural inflammation, ulceration and granuloma formation were identified 2 weeks after the second operation in ten of the 11 surviving animals; changes were confined to the test loops and were most prominent adjacent to the anastomosis. No abnormalities were seen in control loops. The combination of two self-limiting ischaemic insults can produce a pattern of intestinal inflammation similar to that seen in anastomotic recurrence in Crohn's disease.
Comparative study of abdominal incision techniques
Authors: Telfer J R C , Canning G , Galloway D J
Published: March 2007

The characteristics of surgical incisions made with an electrosurgical technique were compared with those made using conventional methods in a prospective randomized trial. In particular, the claim that the method of incision may influence postoperative pain was investigated. A total of 101 consecutive patients receiving full-length midline laparotomy incisions for gastrointestinal resection were studied. A record was kept of the time required to make the incision and blood loss as well as postoperative pain (using a linear analogue scale), ventilatory function and requirement for analgesia. There were 50 patients in group 1 (scalpel; 15 men, 35 women) and 51 in group 2 (electrocautery; 26 men, 25 women). The groups were similar in age, body-weight, diagnosis and the type of surgical procedures being performed. Incision time was similar in the two groups but median blood loss during incision was significantly less in group 2 patients than in group 1 (10 versus 25 ml, P < 0·0001). Linear analogue pain scores were not significantly different between the groups at any stage after operation. The same was true of postoperative ventilatory function and requirement for analgesia. A total value for morphine use during the entire postoperative period was derived for each group and the median was 1·55 mg/kg for group 1 compared with 1·49 mg/kg for group 2. The electrosurgical method is associated with less blood loss during incision, although this study has failed to confirm any reduction in postoperative pain or requirement for analgesia in these patients.
Porcine islet isolation: prospective comparison of automated and manual methods of pancreatic collagenase digestion
Authors: Toomey P , Chadwick D R , Contractor H , Bell P R F , James R F L , London N J M
Published: March 2007

A prospective study was undertaken to compare an automated method of porcine pancreatic digestion with a simpler manual procedure. These techniques have not previously been compared directly. After intraductal distension with collagenase, seven porcine pancreata were divided longitudinally; half of each was digested by the automated method and half by the manual technique. Islet yield and purity were measured. Compared with the manual technique, the automated method isolated a significantly greater total volume of islet tissue (median (range) 3·56 (1·39–5·30) versus 1·07 (0·46–1·92) mm3/g, P = 0·022), increased the median (range) number of 105-μm islet equivalents isolated (5875 (2294–8746) versus 1766 (759–3168) per g, P = 0·022) and improved the islet cleavage index (median (range) 92 (89–99) versus 82 (78–92) per cent, P = 0·035). It is concluded that, although the automated method is more complicated to set up, it greatly improves the yield of intact islets from the porcine pancreas.
Selective cholangiography in laparoscopic cholecystectomy
Authors: Grace P A , Qureshi A , Burke P , Leahy A , Brindley N , Osborne H , Lane B , Broe P , Bouchier-Hayes D
Published: March 2007

Laparoscopic cholecystectomy is now the method of choice for removing the diseased gallbladder. Asymptomatic common bile duct stones occur in approximately 6 per cent of patients. Controversy exists, however, as to whether selective or routine peroperative cholangiography should be performed during laparoscopic cholecystectomy. Over a 21-month period 300 consecutive laparoscopic cholecystectomies without routine cholangiography were attempted. There were 28 conversions. In all, 229 patients did not undergo cholangiography and in this group there were two common duct injuries. These were both identified and dealt with by open operation. Five patients underwent peroperative cholangiography, none of whom was found to have common duct pathology. Endoscopic retrograde cholangiopancreatography was performed in 38 patients. Of 27 who had this investigation performed before operation, common duct stones were diagnosed in seven (26 per cent). Two common duct stones were discovered in 11 patients who underwent the investigation after operation. Thus only two of 240 patients (0·8 per cent) who did not undergo preoperative or peroperative cholangiography subsequently had symptomatic duct stones. Peroperative cholangiography may be indicated in selected patients who have had symptoms of common bile duct stones or in those in whom the biliary anatomy is unclear. However, routine preoperative or peroperative cholangiography is unnecessary during laparoscopic cholecystectomy.
Screening practice for familial adenomatous polyposis: the potential for regional registers
Authors: Morton D G , Macdonald F , Haydon J , Cullen R , Barker G , Hultén M , Neoptolemos J P , Keighley M R B , McKeown C
Published: March 2007

Existing screening practice for familial adenomatous polyposis (FAP) was evaluated in 47 families with FAP notified to the West Midlands Polyposis Register between February 1988 and July 1990. Of these 269 individuals, 107 were known to be affected and 162 were at 50 per cent prior risk of developing FAP; 35 deceased affected individuals from living generations were included in the analysis. Of 105 individuals in the at-risk group aged between 12 and 40 years, only 55 (52 per cent) were under follow-up by bowel examination. Thirty-seven affected individuals had developed colorectal carcinoma before diagnosis; the incidence was three of 51 (6 per cent) in those diagnosed through screening compared with 34 of 53 (64 per cent) in the unscreened group (P < 0·001). A total of 28 individuals (26 per cent of the FAP population) died from advanced colorectal carcinoma; all were from the unscreened population. In 22 (59 per cent) of the cases of colorectal carcinoma and 17 (61 per cent) of the deaths from advanced colorectal cancer there was a positive family history of FAP; these tumours were therefore potentially preventable through screening and prophylactic surgery. Since establishing the register the median age at diagnosis of the affected patients has been reduced from 32 to 23 years (P = 0·0004) and the incidence of colorectal cancer has fallen from 35 to 14 per cent (P < 0·05). It is concluded that by providing more comprehensive case ascertainment a regional register can have a dramatic effect on this largely preventable form of colorectal cancer. Regional registers are recommended as an essential component of screening for this disease.
Cytokines, sepsis and immunomodulation
Authors: Molloy R G , Mannick J A , Rodrick M L
Published: March 2007

Tissue injury and infection produce significant alterations in host metabolic and immune homoeostasis. It is increasingly clear that many of these changes result from a complex cascade of mononuclear phagocyte-derived endogenous mediators. Among the more important is a group of host proteins called cytokines, which play an integral role in mediating the host response to tissue injury and infection. Of these proteins, tumour necrosis factor (TNF) and interleukin (IL) types 1 and 6 have received much attention for their pathophysiological roles in infection and trauma. Evidence is reviewed for the involvement of these cytokines in the characteristic alterations in the metabolic and immune responses to such injury. These endogenous mediators initiate an integrated fuel substrate and hormonal adjustment to trauma and sepsis, and help to provide optimal metabolic homoeostasis for systemic host defences. Widespread tissue injury, especially when associated with fulminant sepsis, may, however, precipitate massive release of TNF, IL-1 and IL-6, triggering a series of reactions involving multiple organs, and culminating in the “sepsis syndrome”. New therapies designed to downregulate this aberrant response, either by neutralizing endotoxin directly or by blocking the release or actions of these cytokines, are reviewed. Although these treatments hold much promise for the future management of severely traumatized and infected patients, careful evaluation of both the benefits and complications of therapy is needed before widespread clinical use can be recommended.
Splenectomy in human immunodeficiency virus-related thrombocytopenia
Authors: Alonso M , Gossot D , Bourstyn E , Galera M-J , Oksenhendler E , Celerier M , Clot Ph
Published: March 2007

To evaluate the efficacy and safety of splenectomy in patients with human immunodeficiency virus (HIV)-related thrombocytopenia, 30 HIV-infected patients with thrombocytopenia (platelet count <50 × 109/l) who underwent splenectomy were followed prospectively for a mean period of 42 months. There were no perioperative deaths and morbidity was minimal. Twenty-one patients had a persistent complete response, six had a partial response and were asymptomatic after splenectomy, and only three showed no response. Three patients developed acquired immune deficiency syndrome during follow-up, an incidence that was no different from that expected. Splenectomy is a safe and effective treatment in HIV-infected patients with severe symptomatic thrombocytopenic purpura resistant to medical therapy.
Percutaneous ultrasound-guided drainage of intra-abdominal abscesses
Authors: Goletti O , Lippolis P V , Chiarugi M , Ghiselli G , De Negri2 F , Conte M , Ceragioli T , Cavina E
Published: March 2007

A retrospective review of 200 patients with intra-abdominal abscesses treated by percutaneous ultrasound-guided drainage is reported. Abscesses were simple in 151 patients (75.5 per cent) and complex in 49 (24.5 per cent). In 12 patients the abscess communicated with the gastrointestinal tract. There were 17 critically ill patients for whom percutaneous drainage was the only therapeutic option possible. The success rate was 94.7 per cent (143 of 151 patients) for simple abscess and 69 per cent (34 of 49) for complex abscess. The overall success rate was 88.5 per cent. The mortality rate was 1.3 per cent (two patients) for simple and 16 per cent (eight patients) for complex abscess. The overall mortality rate was 5.0 per cent. Percutaneous ultrasound-guided drainage should be the initial drainage procedure in patients with a simple abdominal abscess. The presence of a complex abscess should not prevent an attempt at percutaneous catheter drainage, particularly in high-risk patients, although the risk of failure is greater in such cases.
Fully implantable venous access systems
Authors: Ramirez J M , Miguelena J M , Güemes A , Moncada E , Cabezali R , Sousa R
Published: March 2007

Central access systems are a considerable step forward in the treatment of patients with cancer. Experience with totally implantable vascular access systems is reported. Since 1986, 185 reservoir pumps have been implanted. Access was by percutaneous cannulation of the subclavian vein in 130 cases (70 per cent) and surgical exposure of the external jugular vein in 40 (22 per cent); other sites of insertion were used in 15 cases (8 per cent). The mean duration of use of the reservoirs was 276 (range 1–632) days (total 51 150 catheter-days). The mean number of injections was 390 (range 2–670). The total number of complications, mostly mechanical, was 25 (0.5 per 1000 catheter-days). Fully implantable venous access systems are safe and reliable, and their complications can be prevented with adequate management.
Oesophagectomy by a transhiatal approach or thoracotomy: A prospective randomized trial
Authors: Goldminc M , Maddern G , Le Prise E , Meunier B , Campion J P , Launois B
Published: March 2007

A prospective randomized trial of 67 patients undergoing oesophagectomy by either a transhiatal approach or right-sided thoracotomy was conducted over a 40-month period. In 32 patients the approach was transhiatal and 35 had a thoracotomy; the groups were well matched before operation. There were two hospital deaths in patients having the transhiatal oesophagectomy and three in those undergoing thoracotomy. Blood transfusion, intensive care stay and overall time of hospitalization were not significantly different between the two groups. There was no difference in the postoperative morbidity rate and, in particular, the incidences of pulmonary complications were similar (19 per cent for transhiatal oesophagectomy, 20 per cent for thoracotomy) with anastomotic fistula in 6 and 9 per cent respectively. The median (range) operating time was significantly longer in patients having thoracotomy (6 (3.5–9.5) versus 4 (3–8) h). Long-term survival was unaffected by the type of operation performed or addition of preoperative chemotherapy or radiotherapy. Nodal status was a signficant prognostic factor within but not between the two groups. It is concluded that oesophagectomy by a transhiatal route or right thoracotomy are equally effective surgical options for treatment of squamous cell oesophageal cancer.
Resection of presumed benign liver tumours
Authors: Belghiti J , Pateron D , Panis Y , Vilgrain V , Fléjou J-F , Benhamou J-P , Fékété F
Published: March 2007

The surgical treatment of benign liver tumours (focal nodular hyperplasia (FNH) and hepatic adenoma) remains controversial. From 1984 to 1990, all 51 women aged below 50 years who presented with presumed benign liver tumours and without chronic liver disease underwent tumour resection. Preoperative assessment included liver tests, ultrasonography and dynamic computed tomography in all patients, plus angiography (n = 20), magnetic resonance imaging (n = 22) and technetium–sulphur colloid liver scintigraphy (n = 19). The aims of this study were to compare preoperative and final pathological diagnosis and determine whether surgical treatment was justified. Preoperative assessment suggested FNH in 18 patients and hepatic adenoma in 11. In 22 patients, the distinction between FNH and adenoma could not be determined before operation. Operative procedures included resection of one segment or less in 22 patients, two segments in 14 and three or more segments in 15. There was no postoperative death and no serious complication. The final diagnosis after pathological examination of resected specimens was FNH in 36 patients (71 per cent), including the 18 presumed before operation to have FNH, hepatic adenoma in 12 (24 per cent) and malignant lesions in three (6 per cent): hepatocellular carcinoma (HCC) arising in normal liver, fibrolamellar carcinoma, and adenoma containing areas of HCC in one patient each. In conclusion: (1) precise preoperative diagnosis of benign liver tumours remains difficult despite new imaging methods; (2) malignant liver tumours can go unrecognized; and (3) resection of all these lesions can be carried out safely. Resection of presumed benign liver tumours should be performed in young women when a preoperative diagnosis of FNH is not firmly established.
Clinical trial of tamoxifen in patients with irresectable pancreatic adenocarcinoma
Authors: Taylor O M , Benson E A , McMahon M J
Published: March 2007

Oestrogen-binding sites are present in tissue samples of adenocarcinoma of the pancreas. Uncontrolled studies have suggested that survival of patients with this tumour may be extended by using the antioestrogen drug tamoxifen. Forty-four patients with biopsy-proven irresectable adenocarcinoma of the pancreas were recruited into a randomized placebo-controlled clinical trial of tamoxifen 20 mg twice daily. All patients were assessed at the time of diagnosis and at monthly intervals using the Karnofsky and the Hospital Anxiety and Depression scores for quality of life. Analysis of survival by life-tables and the log rank test revealed no significant difference in the duration of survival of patients treated with tamoxifen or placebo. Quality-of-life assessment revealed no significant difference between the groups. Tamoxifen does not confer significant benefit to patients with irresectable pancreatic cancer.
Suppression of macrophage function by suture materials and anastomotic recurrence of Crohn's disease
Authors: Scott A D N , Uff C , Phillips R K S
Published: March 2007

After surgical excision of bowel, Crohn's disease is likely to recur around the anastomosis. It is suggested that this may indicate a biological effect of suture materials on gastrointestinal immunology. To investigate this, the influence of six suture materials on the functiono f macrophages the influence of six suture materials on the function of macrophages obtained from the rat peritoneal cavity and human intestinal mucosa was assessed. All materials significnatly impaired macrophage function.
Diagnostic value of cytology for biliary stricture
Authors: Kurzawinski T , Deery A , Davidson B R
Published: March 2007

Over the past 20 years, bile aspiration at endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography has been developed for cytological diagnosis of biliary tract stricture. This safe and specific test has allowed a diagnosis to be reached before or without operation in about one-third of malignancies of the pancreas or bilary tree. The recent development of bilary brush cytology has produced better results. An endobiliary biopsy forceps is now available that may allow safe sampling of lesions causing extrinsic compression of the biliary tract. An endobiliary aspiration cytology needle has been produced that may permit non-ulcerating lesions to be diagnosed. A safe alternative to endobiliary methods is percutaneous fine-needle aspiration cytology; this yields a diagnosis in about half of patients presenting with obstructive jaundice and an imaged mass lesion.
Adrenal incidentaloma
Authors: Gajraj H , Young A E
Published: March 2007

Improvements in ultrasonogrpahy and computed tomography have led to the problem of ‘adrenal incidentaloma’, an asymptomatic adrenal mass discovered during investigation of some other problem. In the light of current knowledge a management rationale for patients with such an adrenal abnormality is proposed.
Perioperative blood transfusion and outcome after resection for colorectal carcinoma
Authors: Chung M , Steinmetz O K , Gordon P H
Published: March 2007

The degree of immunomodulation by perioperative blood transfusion and its effect on oncological surgery remain controversial. A major problem with previous clinical studies has been the inadequate patient population in each and the presence of confounding variables. To resolve some of the controversy, all studies published between 1982 and 1990 were reviewed using the statistical method of Mantel–Haentszel–Peto to determine a cumulative estimate of the direction and magnitude of this association. Some 20 papers were included in the analysis, representing 5236 patients. The cumulative odds ratios (95 per cent confidence interval) of disease recurrence, death from cancer and death from any cause were 1.80 (1.30–2.51), 1.76 (1.15–2.66) and 1.63 (1.12–2.38) respectively. These results support the hypothesis that perioperative blood transfusion is associated with an increased risk of recurrence of colorectal carcinoma and death from this malignancy.
Hyperaemic response in the skin microcirculation of patients with chronic venous insufficiency
Authors: Shami S K , Cheatle T R , Chittenden S J , Scurr J H , Coleridge Smith P D
Published: March 2007

The capacity of the microcirculation in the liposclerotic skin of patients with chronic venous insufficiency to vasodilate in response to pilocarpine electrophoresis was assessed using laser Doppler fluxmetry. Pilocarpine induces vasodilatation by direct action on capillaries; other methods of vasodilatation, such as heating of the skin, act by a number of pathways including a neurogenic one. Thirty patients with lipodermatosclerosis and chronic venous insufficiency and 20 control subjects were studied. There was no difference in peak vasodilatation following pilocarpine electrophoresis in the two groups. The median (interquartile range) peak flux in patients was 665 (382–1025) units and in controls 765 (452–975) units (95 per cent confidence interval of difference −270 to 150 units, P = 0.5). This suggests that the capillaries in the liposclerotic skin of patients with chronic venous insufficiency have a normal capacity to vasodilate.
Treatment of the axilla in patients with screen-detected breast cancer
Authors: Walls J , Boggis C R M , Wilson M , Asbury D L , Roberts J V , Bundred N J , Mansel R E
Published: March 2007

Management of the axillary lymph nodes in patients with screen-detected breast cancer is controversial. Optimal treatment should combine accurate determination of node status and avoidance of unnecessary morbidity. This study attempted to determine whether axillary node status could be accurately predicted using selected criteria in women with screen-detected breast cancer. Of 223 breast cancers excised in the Greater Manchester breast screening programme, 180 were invasive and 40 of these had associated lymph node metastases. The presence of involved nodes was associated with large tumour size, high tumour grade and the absence of mammographic microcalcification. Multiple logistic regression analysis revealed that each of these three factors was independently significant. Women with a screen-detected breast cancer < 1 cm in diameter or those with grade I tumours <3 cm (35 per cent of the total) could be spared axillary surgery with an expected reduction in morbidity and operating time.
Symptomatic outcome after laparoscopic cholecystectomy
Authors: Wilson R G , Macintyre I M C
Published: March 2007

To evaluate the symptomatic outcome after laparoscopic cholecystectomy, a standard symptom questionnaire was sent to three patient groups at least 1 year after surgery: 115 patients had undergone laparoscopic cholecystectomy; 200 had undergone open cholecystectomy; and 200 had had inguinal hernia repair. Return of questionnaires was higher after laparoscopic cholecystectomy (100 of 115; 87.0 per cent) than the open procedure (167 of 200; 83.5 per cent) or hernia repair (163 of 200; 81.5 per cent). There was no difference in the number of patients who considered the operation to have cured or improved their preoperative symptoms after laparoscopic cholecystectomy (94 of 100; 94.0 per cent), open cholecystectomy (157 of 167; 94.0 per cent) or hernia repair (154 of 163; 94.5 per cent). Similar numbers considered their operation to have been a success (94.0, 95.2 and 94.5 per cent respectively). The prevalence of abdominal pain, nausea, flatulence, food intolerance and heartburn was similar in all groups of patients following operation. Diarrhoea occurred more often following laparoscopic (6.0 per cent) and open (4.2 per cent) cholecystectomy than hernia repair (1.2 per cent). Patients who underwent laparoscopic cholecystectomy tended to have a higher incidence of nausea or vomiting than those undergoing the open procedure, and consumed significantly more antacids (23.0 versus 12.0 per cent, P < 0.02). Laparoscopic cholecystectomy achieved the same rate of patient satisfaction as open cholecystectomy, with no apparent symptomatic advantage.
Reoperation for suspected primary hyperparathyroidism
Authors: Järhult J , Nordenström J , Perbeck L
Published: March 2007

A retrospective analysis of 93 patients undergoing 128 re-explorations for persistent or recurrent hypercalcaemia is presented. Seventy-six patients (82 per cent) became normocalcaemic after between one and five reoperations. Nine patients had hypercalcaemia caused by sarcoidosis, familial hypocalciuric hypercalaemia or metastatic disease, and two had parathyroid carcinoma. Fifteen patients (16 per cent) developed permanent hypoparathyroidism requiring vitamin D and/or calcium therapy and nine had permanent recurrent laryngeal nerve paralysis. Undetected adenomas (41 cases) and inadequate resection in hyperplastic disease (28) were the predominant causes of initial failure. Reoperation for persistent or recurrent hyperparathyroidism restored normocalcaemia in the majority of patients. This ‘cure’ was achieved at the cost of considerable morbidity and a careful risk-benefit analysis of each patient is recommended before performing reoperative parathyroid surgery.
Detection and significance of occult metastases in node-negative breast cancer
Authors: Hainsworth P J , Tjandra J J , Stillwell R G , Machet D , Henderson M A , Rennie G C , McKenzie I F C , Bennett R C
Published: March 2007

The clinical value of lymph node immunohistochemistry was assessed in 343 consecutive patients with apparently node-negative breast cancer using antimucin monoclonal antibodies BC2, BC3 and 3E1.2. Occult metastases were detected in 41 patients (12 per cent). Although most of these were micrometastatic (< 2 mm in diameter), larger or diffuse deposits were found in ten patients. Blind assessment of repeat haematoxylin and eosin stained sections detected metastases in ten of the 41 patients with occult metastases. After a median follow-up of 79 months, patients with occult metastases had a shorter time to disease recurrence (P < 0.05) but not to death. After adjustment for other prognostic factors, the presence of occult metastases in two or more nodes was the most significant predictor of both disease recurrence (P < 0.01) and death (P < 0.01). When the ten patients with positive haematoxylin and eosin sections were excluded from the analysis, the presence of occult metastases in two or more nodes was still associated with a reduced disease-free interval (P < 0.05) and survival (P < 0.05). Lymph node immunohistochemistry is a simple technique affording more accurate definition of nodal involvement than conventional methods.
Antibiotic prophylaxis is indicated for chest stab wounds requiring closed tube thoracostomy
Authors: Cant P J , Smyth S , Smart D O
Published: March 2007

To determine the role of antibiotic prophylaxis for stab wounds of the chest requiring intercostal tube drainage, a double-blind study was conducted comparing cefazolin, given to 57 patients at 500 mg every 8 h for 24 h, with placebo, given to 56. Differences were detected in the rate of thoracotomy for sepsis (antibiotic nil versus placebo 9 per cent, P < 0.05) and in the frequency of sputa positive for pathogens (12 versus 34 per cent respectively, P < 0.05), but the incidence of pyrexia, raised white cell count, positive cultures from pleural drainage or intercostal catheter tips and volume of chest drainage was similar. The mean hospital stay and costs consequent on morbidity were greater in patients receiving placebo, supporting the conclusion that antibiotic prophylaxis is indicated.
Vagal system involvement in changes in small bowel motility during restraint stress: An experimental study in the dog
Authors: Muelas M S , Ramirez P , Parrilla P , Ruiz J M , Perez J M , Candel M F , Aguilar J , Carrasco L
Published: March 2007

Changes in small intestinal motility were studied during restraint stress in fasting animals and after food; the involvement of the vagal system in the pathophysiology of these changes was assessed. Small intestinal motility was recorded in 40 dogs using electromyography with monopolar electrodes and manometry with submucosal microballoons. Twenty animals underwent bilateral truncal vagotomy. Stress increased intestinal motility (percentage of slow waves followed by action potentials in 1 min), both in fasting conditions (P < 0.001) and postprandially (P < 0.001). It also completely abolished the migrating motor complex–interdigestive myoelectric complex periodicity characteristic of the normal fasting pattern. In dogs subjected to vagotomy, restraint stress increased motility during fasting (P < 0.001) but decreased it after feeding (P < 0.01). Restraint stress thus increases small intestinal motility, both during fasting and after food. The vagal system is partially involved in this hypermotility response.
Graft size assessment by preoperative computed tomography in living related partial liver transplantation
Authors: Higashiyama H , Yamaguchi T , Mori K , Nakano Y , Yokoyama T , Yamamoto N , Yamaoka Y , Tanaka K , Kumada K , Ozawa K
Published: March 2007

The size of segmental liver grafts assessed by preoperative computed tomography (CT) volumetry was evaluated in relation to surgical outcome in 14 living related partial liver transplantations (LRLTs). The aim was to show that graft size can be accurately assessed before operation and to estimate the lower safety limit of graft size in assessing subsequent graft function and survival. The relationship between calculated CT volume and weight of the liver was linear in the recipient (r = 0.97) and donor (r = 0.98). The mean (s.e.m.) modified liver weight ratio (MLWR; ratio of graft weight to recipient's expected liver weight based on body-weight) was 0.59(0.07) (range 0.27–1.09). Surgical complications related to an oversized graft and primary graft failure caused by a small-for-size graft were not observed. The lowest MLWR of any survivor was 0.27. These results suggest that a partial liver graft reduced to about 30 per cent of the recipient's expected liver weight can tolerate LRLT well.
Treatment of perforated sigmoid diverticulitis: A prospective randomized trial
Authors: Kronborg O
Published: March 2007

A prospective randomized trial was carried out on 62 patients with diffuse peritonitis from perforated diverticulitis of the left colon, comparing acute transverse colostomy, suture and omental covering of a visible perforation with acute resection without primary anastomosis. For purulent peritonitis the postoperative mortality rate was significantly higher after acute resection (six of 25) than after colostomy (none of 21). In those treated by acute resection, the mortality rate was not significantly higher after Hartmann's procedure (five of 15) than after exteriorization of both lumens (one of ten). The postoperative mortality rate in patients with faecal peritonitis did not differ significantly between colostomy (six of ten) and acute resection (two of six). Stomas became permanent in four of 25 patients with diverticulitis surviving acute colostomy and in seven of 22 surviving acute resection. Suture and transverse colostomy is superior to resection for purulent peritonitis because of the lower postoperative mortality rate and in spite of the shorter hospital stay in those surviving acute resection.
Radiological investigation in acute diverticulitis
Authors: McKee R F , Deignan R W , Krukowski Z H
Published: March 2007

Optimal management of acute sigmoid diverticulitis depends on evaluation of the severity of the inflammatory process, in which radiological investigation is a useful but probably underutilized adjunct to clinical assessment. Plain abdominal radiography shows abnormalities in 30–50 per cent of patients but these tend to be non-specific and more accurate information is obtainable from a contrast enema. Although the quality of images produced by a water-soluble contrast agent is inferior to that with barium, the former is less hazardous in the presence of perforation and provides sufficient information to permit rational management decisions to be made. Ultrasonography and computed tomography (CT) are particularly useful in visualizing abscesses. They may be helpful in following the progression or resolution of suppuration and in guiding percutaneous aspiration when appropriate. Despite early reports to the contrary, CT is no more specific than a contrast enema in the diagnosis of acute diverticulitis. Radionuclide scans have little role in the routine assessment of acute diverticulitis and magnetic resonance imaging has not been adequately evaluated. Water-soluble contrast enema is safe, widely available and probably the most useful early supplementary investigation.
Gene transfer therapy in cancer
Authors: Dorudi S , Northover J M A , Vile R G
Published: March 2007

Gene transfer techniques have now achieved clinical realization in the wake of recent advances in recombinant DNA technology, together with increased understanding of the molecular biology and immunology of cancer. These novel treatments, and their applications and limitations merit intensive study.
Tissue and urokinase plasminogen activators in the environs of venous and ischaemic leg ulcers
Authors: Stacey M C , Burnand K G , Mahmoud-Alexandroni M , Gaffney P J , Bhogal B S
Published: March 2007

Urokinase plasminogen activator (uPA) and tissue plasminogen activator (tPA) were assayed in biopsies from the base, edge and adjacent skin of ischaemic and venous ulcers using a functional bioimmunoassay and a standard immunoassay. Two series of 14 biopsies were examined: from seven venous and seven ischaemic ulcers in the first series, eight venous and six ischaemic in the second. It was found that tPA was detected in only four samples of ulcer edge using the bioimmunoassay and in no sample by the standard immunoassay. By contrast, uPA was detected in all but one ulcer edge biopsy and at a significantly lower median concentration in the adjacent skin (16.9 units/g) than the ulcer edge (26.1 units/g) or base (32.3 units/g) (both P < 0.01). Levels of uPA were greater in the edge and base of venous compared with ischaemic ulcers. The predominant plasminogen activator in chronic leg ulcers is uPA; this activator may play an important role in wound healing.
Prognostic significance of cell culture in carcinoma of the oesophagus
Authors: Shimada Y , Imamura M
Published: March 2007

The prognostic significance of the potential of cells to grow in tissue culture was studied in 50 patients with oesophageal cancer. The ability of cell lines to grow from resected oesophageal specimens was determined; from 50 patients, 21 cell lines were established (42 per cent). The patients were divided into two groups on this basis: group 1, from whom cancer cells could be grown as continuous cell lines and group 2, from whom cell lines could not be established. The cumulative survival rate of patients in group 1 was significantly lower than that of those in group 2 (P < 0.05). There was also a significantly higher incidence of lymph node metastases in group 1 (P < 0.05). These results suggest that the potential of cancer cells for growth is a useful long-term prognostic indicator for patients with oesophageal carcinoma.
Prospective randomized study of one- or two-layer anastomosis following oesophageal resection and cervical oesophagogastrostomy
Authors: Zieren H U , Müller M , Pichlmaier H
Published: March 2007

In a prospective randomized study, one- and two-layer anastomoses were compared following subtotal oesophagectomy and gastric substitution with cervical oesophagogastric anastomosis. After 54 one- and 53 two-layer procedures the rates of anastomotic leakage were the same (19 per cent). After a mean follow-up of 44 weeks, 13 of 51 patients (25 per cent) undergoing one-layer anastomosis and 28 of 50 (56 per cent) having the two-layer procedure complained of cervical dysphagia and required dilatation. The anastomotic strictures were fibrotic in 11 of 51 patients (22 per cent) undergoing one-layer anastomosis and in 24 of 50 (48 per cent) receiving the two-layer operation. Strictures were malignant in two and four patients (4 and 8 per cent) respectively. The lower incidence of fibrotic stricture following one-layer anastomosis was significant (P < 0.01), but not that of malignant stricture. With comparable leakage rates, one-layer anastomosis is superior to the two-layer procedure because of the lower incidence of fibrotic stricture.
Incidence of haemorrhoids and anorectal varices in children with portal hypertension
Authors: Heaton N D , Davenport M , Howard E R
Published: March 2007

A prospective study of 60 children with portal hypertension showed a significant incidence of haemorrhoids (33 per cent), anorectal varices (35 per cent) and external anal varices (15 per cent). Four children (7 per cent) complained of anorectal symptoms. A comparison of extrahepatic with intrahepatic disease showed that the former was associated with a higher incidence of both haemorrhoids and anorectal varices (57 versus 26 per cent and 64 versus 26 per cent respectively). The occurrence and severity of haemorrhoids was related to the number of previous oesophageal sclerotherapy sessions (P = 0.001). Problems relating to anorectal pathology were unusual, but treatment with haemorrhoidal sclerotherapy or banding was satisfactory for the symptomatic patients.
Cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation
Authors: Tanaka K , Nishimura A , Yamada K , Ishibe R , Ishizaki N , Yoshimine M , Hamada N , Taira A
Published: March 2007

The aim of this study was to delineate clinical features and prognosis of cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation, and to determine methods for managing the disease. A retrospective study of seven patients is presented. A further 27 cases from the Japanese literature were reviewed retrospectively with regard to method of treatment and prognosis. In 11 of 18 patients in whom staging was known the tumour was stage V, representing advanced disease. In seven of 34 cases curative operation was performed; only two patients survived for < 3 years. This poor outcome was due largely to delayed diagnosis of cancer of the gallbladder. Prophylactic cholecystectomy is recommended in patients with this anomalous junction without bile duct dilatation or a malignant lesion in the gallbladder, because of the high incidence of cancer of the biliary tract.
Vibration white finger
Authors: Palmer R A , Collin J
Published: March 2007

Vibration white finger (VWF) occurs in workers who use vibrating tools. On exposure to vibration or cold, patients experience blanching, numbness and pain in the fingers due to exaggerated vasoconstriction. This may involve both central sympathetic hyper-reactivity and local vasoactive factors. In advanced cases, hypertrophy of vascular smooth muscle causes arterial occlusion and ulceration. Diagnostic tests for VWF are unreliable. In early cases, cessation of vibration exposure arrests the progression of disease and may cause symptom remission. Patients with VWF should keep themselves warm, especially their hands, which they should place in warm water at intervals during the day; they should not smoke. Vasoactive drugs may be beneficial in some patients. In the UK, Industrial Injuries Disablement Benefit and compensation are sometimes available. Improved design of tools and restrictions on their operating time have been the main factors leading to a worldwide decline in the incidence of VWF since the early 1970s.
Safe margins in the excision of primary cutaneous melanoma
Authors: Neades G T , Orr D J A , Hughes L E , Horgan K
Published: March 2007

A group of 434 patients treated for primary cutaneous melanoma over an 18-year period by a policy of selective excision margins based on clinical estimation of tumour thickness was studied prospectively. Clinical assessments of tumour as impalpable, palpable but not overtly nodular, and nodular correspond to thicknesses of ⩽ 0·75, 0·76-1·49 and ⩽ F 1.50 mm respectively. From 1971 to 1987, 330 patients were treated with excision margins of 1, 2 and 3-5 cm based on these respective ranges. During 1988 and 1989, 104 patients were treated after reduction of the maximum width of excision to 2 cm. The overall local recurrence rate was 11 of 434 patients (2·5 per cent), with no recurrence in melanoma ⩽ 0·75 mm thick and no increase in the local recurrence rate after reduction of the maximum margin from 3 to 2 cm. A policy of 2-cm clearance for palpable and nodular melanoma and I cm for impalpable lesions is recommended. Any further reduction must be tested prospectively.
Purse-string suture for stapled oesophagogastric anastomosis: Hand-sewn versus automatic
Authors: O'Riordain D S , Buckley D J , Waldron D J , Kirwan W O
Published: March 2007

An automatic purse-string device was compared with the traditional hand-sewn method in stapled oesophageal anastomosis. Fifteen greyhound dogs underwent distal oesophagectomy with stapled. gastro-oesophageal anastomosis; a purse-string suture was used to draw the distal oesophagus around the stapling device. The animals were randomized into group 1 (n = 8), in which the automatic device was used, and group 2 (n = 7), in which the oesophageal purse string was hand-sewn. The automatic device failed to incorporate the oesophageal mucosa and submucosa reliably into the anastomotic staple line. There were five defective anastomoses in group 1 and none in group 2 (P = 0·037). Anastomotic bursting pressures were significantly reduced in group 1 compared with group 2 (median (range) 47(22-110) versus 82(68-88) mmHg, P = 0.032). Within group 1, a significant difference in bursting pressure existed between complete anastomoses and those in which the mucosa was not fully incorporated (median (range) 75 (60-110) versus 39 (22-50) mmHg, P = 0·037). Median (range) breaking strengths where anastomoses were incomplete were lower than where all layers were incorporated (1420 (1250-2220) versus 1990 (1590-2475) g/cm, P = 0·009). This study questions the safety of the automatic purse-string device for oesophageal anastomosis when used in accordance with present recommendations. Further evaluation and possibly modification of either the instrument design or the methods recommended by the manufacturer for its use are warranted.
Emergency liver resection for spontaneous rupture of hepatocellular carcinoma complicating cirrhosis
Authors: Cherqui D , Panis Y , Rotman N , Fagniez P-L
Published: March 2007

From 1983 to 1991, 42 patients were operated on for hepatocellular carcinoma (HCC) complicating cirrhosis. Five presented with spontaneous rupture of the tumour: three had posthepatitis B and two non-A non-B cirrhosis. By contrast, 65 per cent of patients with non-ruptured HCC had alcoholic cirrhosis (P < 0.01). Laparotomy was carried out on an emergency basis (four patients) or after a 12-h delay (one) because of haemodynamic instability. Liver resection was performed in four cases (two wedge resections, one segmentectomy III, one extended right hepatectomy) and in the fifth patient hepatic artery ligation was performed. Bleeding was controlled after all four resections with one postoperative death, while the patient treated by ligation died during operation. Of the three surviving patients after liver resection, two died, 6 and 12 months after surgery. One patient is alive with recurrent tumour 43 months after extended right hepatectomy. The present data, combined with analysis of 250 cases of ruptured HCC from the literature, indicate that emergency resection is the treatment of choice in patients with limited tumour and preserved liver function. Transcatheter hepatic artery embolization, if available, is the next choice for high-risk patients or before surgical resection of the tumour. More conservative surgical approaches are the last choice because of poor reported results.
Conventional versus laparoscopic surgery for acute appendicitis
Authors: Tate J J T , Chung S C S , Dawson J , Leong H T , Chan A , Lau W V , Li A K C
Published: March 2007

A total of 155 consecutive patients with suspected acute appendicitis were studied to compare laparoscopic and conventional operations. Patients were not randomized: laparoscopy was performed when a suitably trained surgeon and laparoscopic instruments were available. Laparoscopic appendicectomy was attempted in 51 patients and was successful in 46 (90 per cent); all conversions to open operation were because of marked inflammatory adhesions around the appendix. There were no intraoperative complications. Reintroduction of normal die; and discharge from hospital occurred earlier after laparoscopic than open surgery (P < 0·05). The requirement for analgesia after successful laparoscopic surgery was less than that after conventional appendicectomy, but the difference was not significant. The incidence of wound infection was reduced after the laparoscopic procedure (P = 0·06). It is concluded that laparoscopic appendicectomy is practical and may have advantages over conventional operation, although a randomized study is necessary.
Randomized trial of drainage of colorectal anastomosis
Authors: Sagar P M , Couse N , Kerin M , May J , MacFie J
Published: March 2007

A prospective randomized trial was carried out to determine whether use of a high-pressure closed-suction intraperitoneal drain was associated with a reduction in morbidity rate after colorectal resection and to examine the influence of drainage on postoperative fluid collections. A consecutive series of 148 patients who underwent colonic or colorectal resection were randomized to receive no drain (n = 51) or a high-pressure closed-suction drain for either 3 (n = 47) or 7 (n = 47) days. Three patients were excluded. All patients underwent abdominal ultrasonography on days 3 and 7 and those undergoing left-sided colorectal resection (n = 96) received a water-soluble contrast enema on day 7. The three groups of patients were similar in age, sex, diagnosis and the numbers of sutured and stapled anastomoses. The presence of a drain did not influence the postoperative morbidity or mortality rate. If the anastomosis leaked, neither faeces nor pus emerged from the drain. Ultrasonographic detection of a fluid collection was of no value: such collections bore no relationship to radiological or clinical leaks or the postoperative course. Routine use of a high-pressure suction drain after colorectal resection appears to be unnecessary.