bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk factors in patients presenting as an emergency with colorectal cancer
Authors: Scott N A , Jeacock J , Kingston R D
Published: March 2007

Of 905 patients with colorectal cancer admitted to a single district general hospital, 272 (30 per cent) were admitted as emergencies. Emergency patients had more advanced tumours (Dukes stage B and C 96 per cent versus 88 per cent of those admitted electively, P < 0·006), a shorter history (median 3 versus 11 weeks, P < 0·001), were less likely to be fully ambulatory (44 versus 80 per cent, P < 0·0001) and more likely to have abdominal pain (74 versus 51 per cent, P < 0·001) and vomiting (40 versus 10 per cent, P <0·0001). More emergency patients were given stomas (56 versus 35 per cent, P < 0·0001) and died in hospital (19 versus 8 per cent, P < 0·0001). Of those who survived to be discharged, patients admitted as an emergency spent longer in hospital (median stay 16 versus 13 days, P <0·0001) and had a poorer overall 5-year survival rate (29 versus 39 per cent, P = 0·0001). Emergency patients were significantly older (median 74 versus 72 years, P = 0·04) and much more likely to be widowed (41 versus 27 per cent, P = 0·0002) than those admitted for elective surgery. If the personal and resource disaster of emergency colorectal cancer admission is to be reduced, screening strategies targeted by demographic characteristics require investigation.
Laparoscopic technique for small bowel biopsy
Authors: Greig J D , Miles W F A , Nixon S J
Published: March 2007

The mid-small bowel is relatively inaccessible to the endoscopist. Barium follow-through examination may present a differential diagnosis which includes Crohn's disease and lymphoma. In the past, laparotomy and small bowel biopsy were the only methods to obtain a definitive diagnosis. A laparoscopic technique for taking a full-thickness small bowel biopsy specimen is described.
Comparison of conventional Lewis-Tanner two-stage oesophagectomy with the synchronous two-team approach
Authors: Hayes N , Shaw I H , Raimes S A , Griffin S M
Published: March 2007

Twenty-seven patients with oesophageal carcinoma had subtotal oesophagectomy by the Lewis-Tanner operation (group 1, n=14) or a synchronous modification (group 2, n=13). Synchronous operations were completed more quickly (230 versus 305 min, P < 0·01), but with more time spent under single-lung anaesthesia (160 versus 120 min, P < 0·01) and a greater fall in systolic blood pressure during hiatal manipulation (60 versus 30mmHg, P < 0·01). Operative blood loss was not significantly greater in group 2, but the total volume of blood transfused in the perioperative period was greater in this group (5 versus 3 units, P < 0·01). Four patients in group 1 suffered significant postoperative complications, compared with seven in group 2; three postoperative deaths occurred in group 2. This study suggests that the synchronous two-team oesophagectomy produces a higher incidence of complications than the conventional operation. Continued use of the Lewis-Tanner two-stage oesophagectomy is recommended for patients with carcinoma of the oesophagus.
Total anorectal reconstruction
Authors: Abercrombie J E , Williams N S
Published: March 2007

Abdominal stomas carry a considerable physical and psychological morbidity. Several authors have attempted total anorectal reconstruction (TAR) to avoid a permanent stoma for patients undergoing abdominoperineal excision of the rectum (APER). The published series of TAR are reviewed. There is no evidence that TAR adversely affects survival in patients with cancer. Patients who have undergone reconstruction have variable anorectal function, most suffering from anorectal incontinence to some degree. It appears, however, that the psychological benefit of avoidance of an abdominal stoma outweighs the inconvenience of incontinence for almost all. Refinements in surgical technique, allied with novel methods of achieving neorectal emptying, make TAR a viable alternative to APER in selected patients.
The ileoanal pouch: A risk-benefit analysis
Authors: Köhler L , Troidl H
Published: March 2007

This review assesses whether the risk of ileoanal pouch construction in patients with ulcerative colitis, compared with that of ‘less dangerous’ operations, is compensated by a better postoperative outcome. Even though the mortality rate is not greater for pouch construction, the risk of pelvic sepsis and pouchitis increase morbidity. Bowel function after construction of the ileal pouch, although better than that before operation, is not as good as that of normal controls and does not, in itself, justify increased morbidity. Quality of life measurements suggest that the benefit of the ileal pouch procedure is not much greater than that of ileostomy, even though some dimensions of quality of life are improved. However, most patients wish to avoid an ileostomy and surgeons should respect this wish, remembering that the pouch procedure has some risks and that the gain for the patient may be small.
Definition of local recurrence after surgery for rectal carcinoma
Authors: Marsh P J , James R D , Schofield P F
Published: March 2007

Local recurrence rates of rectal carcinoma have been analysed among 284 patients in a prospective randomized multicentre trial of adjuvant preoperative radiotherapy for locally advanced rectal carcinoma. Wide variations in local recurrence rates are demonstrated depending on the definition of local recurrence employed and the subgroup studied. Thus after surgical operation alone, rates as high as 43.3 per cent or as low as 12.7 per cent can be calculated. After both adjuvant preoperative radiotherapy and operation the overall local recurrence rate is 12.8 per cent, although the local recurrence rate inside the radiotherapy field (true recurrence) may be as low as 2.3 per cent. It is recommended that local recurrence after operation for rectal carcinoma be defined as any detectable local disease at follow-up, occurring either alone or in conjunction with generalized recurrence, in patients who have undergone resection. A rate should be given both for all patients and for those operated on for cure, but not for the latter group alone as this could introduce bias.
Influence of a vein cuff on polytetrafluoroethylene grafts for primary femoropopliteal bypass
Authors: Raptis S , Miller J H
Published: March 2007

A retrospective investigation was performed to study the benefit obtained from a vein cuff inserted at the distal anastomosis of a primary femoropopliteal bypass graft with polytetrafluoroethylene (PTFE). When PTFE was preferred to vein an attempt was made to assess whether there was subsequent use for the spared vein. A series of 559 primary PTFE bypasses was studied and found to have a cumulative patency rate of 62 per cent at 36 months. Subgroups were also studied for a similar period. In the above-knee position there was no difference in the primary patency rate of PTFE with or without a cuff at 36 months (69 versus 68 per cent, P = 0.89). Below the knee, grafts with a cuff had a better 36-month patency rate than those without (57 versus 29 per cent, P = 0.01). Cuffed PTFE for claudication had a better patency rate than that for threatened limbs at 36 months (68 versus 60 per cent, P = 0.03). Thrombectomy of occluded cuffed PTFE grafts improved the 36-month patency rate from 64 to 74 per cent. The limb salvage rate at 36 months was 97 per cent for claudication and 89 per cent for threatened limbs with cuffed PTFE. Occlusion of cuffed PTFE was associated with preservation of outflow in 91 (51 per cent) of 179 cases, permitting subsequent graft thrombectomy or insertion of a new bypass. Spared vein was rarely used to salvage an occluded PTFE graft, and was associated with poor patency and a high amputation rate. Although this study does not support the use of PTFE for the primary graft, PTFE with a vein cuff interposed at the distal anastomosis is a reasonable substitute when vein is not available.
Outcome of patients with abdominal sepsis treated in an intensive care unit
Authors: McLauchlan G J , Anderson I D , Grant I S , Fearon K C H
Published: March 2007

A group of 125 patients with abdominal sepsis admitted to the intensive therapy unit between January 1990 and June 1993 were reviewed to determine outcome. Mean(s.d.) age was 66(12) years and admission Acute Physiology And Chronic Health Evaluation (APACHE) II score 23(9). The hospital mortality rate was 63 per cent. Factors associated with mortality included age, APACHE II score, occurrence of septic shock, chronic ill health, female sex, sepsis of upper gastrointestinal origin and failure to clear the source of sepsis (all P < 0.05). Delay to surgery, anastomotic leakage and presence of malignancy did not influence survival significantly. Quality of life (measured by the World Health Organization performance score) at 15 months after discharge showed 24 of 32 survivors to be independent, ambulatory and capable of self care. No patient survived to become completely disabled. The factors associated with survival did not predict subsequent quality of life. Accurately defining the characteristics of this heterogeneous group of patients is a prerequisite for improved treatment, patient selection and research.
Recurrent inguinal hernia after laparoscopic repair: Possible cause and prevention
Authors: Deans G T , Wilson M S , Royston C M S , Brough W A
Published: March 2007

Eleven patients with recurrent inguinal hernia after laparoscopic hernia repair were referred for treatment. A medial recurrence associated with a mature peritoneal sac was identified in each case. The prosthetic mesh medial to the inferior epigastric artery had rolled away from the pubic ramus to expose Hesselbach's triangle. All cases were successfully treated by insertion of a second mesh to cover the defect and overlap the original mesh. To date there have been no further recurrences. Lessons learnt from experience of such laparoscopic transperitoneal hernia repair include that: the prosthetic mesh must be placed so that it reaches or crosses the midline; at least three staples should fix the mesh to the pubic ramus; a large mesh (13 ± 9 cm) with a greater surface area should reduce the pressure tending to disrupt the mesh; and bilateral hernia is best managed by inserting a single piece of mesh (28 ± 9 cm) fully unfolded as it crosses the midline to ensure coverage of both medial direct defects (‘bikini repair’). Application of these principles may reduce the incidence of recurrence after laparoscopic inguinal hernia repair.
Androgen and oestrogen receptors in hepatocellular carcinoma and surrounding liver parenchyma: Impact on intrahepatic recurrence after hepatic resection
Authors: Nagasue N , Yu L , Yukaya H , Kohno H , Nakamura T
Published: March 2007

Seventy-eight patients in whom androgen or oestrogen receptors, or both, were assayed in hepatocellular carcinoma (HCC) and the surrounding liver were discharged from hospital after curative resection of the tumour. Intrahepatic recurrence was evaluated retrospectively after 28–128 months follow-up to determine the association with receptor status. Androgen and oestrogen receptors in HCC significantly influenced the intrahepatic recurrence rate. The recurrence-free 5-year survival rate was 55 per cent for patients who had androgen receptor-negative tumours, 24 per cent for oestrogen receptor-negative, 10 per cent for oestrogen receptor-positive and 0 for androgen receptor-positive (P = 0.0322). Recurrence-free 5-year survival in 57 patients who had both receptor assays was 75 per cent for patients who had androgen receptor-negative, oestrogen receptor-negative tumours, 50 per cent for androgen receptor-negative, oestrogen receptor-positive, but 0 for androgen receptor-positive, oestrogen receptor-positive and androgen receptor-positive, oestrogen receptor-negative (P = 0.0104). The presence or absence of androgen or oestrogen receptor in the liver, however, was not associated with intrahepatic recurrence (P = 0.7534). Thus, androgen receptors are strongly associated with intrahepatic recurrence of HCC, while oestrogen receptors are weakly associated. Receptor status in the normal liver was not related to intrahepatic recurrence.
Detrimental effects of perioperative blood transfusion
Authors: Nielsen H J
Published: March 2007

Evidence suggests that perioperative allogeneic blood transfusion increases the risk of infectious complications after major surgery and of cancer recurrence after curative operation. This has been attributed to immuno-suppression. Several authors have suggested that filtered whole blood and/or red cell concentrate, or leucocyte-and buffy coat-reduced red cells in artificial medium or their own plasma, may reduce postoperative immuno-suppression. It was also anticipated that the use of autologous blood might minimize the risk of perioperative transfusion, but studies have unexpectedly shown similar postoperative infectious complications and cancer recurrence and/or survival rates in patients receiving autologous blood donated before operation and those receiving allogeneic blood. Future studies should identify common risk factors associated with blood storage.
Indium-111 platelet scintigraphy in vascular disease
Authors: Smyth J V , Dodd P D F , Walker M G
Published: March 2007

Indium-111 labelled platelet scintigraphy permits simple, accurate evaluation of platelet kinetics and sites of deposition. The most meaningful results are obtained from serial scans, although these are clinically useful in only a few of the many applications that have been suggested, principally in studies of acute thrombosis, prosthetic graft thrombogenicity and antiplatelet medication. Key pitfalls are associated with selection of regions and patient variation.
New grade-related prognostic variable for rectal cancer
Authors: Gagliardi G , Stepniewska K A , Hershman M J , Hawley P R , Talbot I C
Published: March 2007

The effect of microacinar growth patterns on survival after radical surgery for rectal cancer was assessed in 138 consecutive patients. All had Dukes and Jass staging and a median follow-up of 95 (range 11–180) months. Tumour acini were classified according to size (microacinar, 28; macroacinar, 110). Patients with microacinar tumours had a significantly reduced 5-year survival rate compared with those with macroacinar lesions (43 and 68 per cent respectively, P = 0.004). When examined in the presence of other histological factors, acinar size had independent prognostic value (relative risk 2.37, P = 0.006). This was true even when the Dukes and Jass classifications were included in the model (relative risk 2.08, P = 0.02 and 1.95, P = 0.03 respectively). Histological classification of rectal tumours into microacinar and macroacinar types adds prognostic value to the Dukes and Jass classifications and may be a more objective criterion than conventional histological grading.
Prospective randomized trial comparing J colonic pouch-anal anastomosis and straight coloanal reconstruction
Authors: Seow-Choen F , Goh H S
Published: March 2007

Twenty patients (13 men) with low rectal cancer, median (range) age 64.5 (38–83) years were prospectively randomized to undergo ultra-low anterior resection with a J colonic pouch-anal anastomosis (median (range) distance of anastomosis from the anal verge 3 (1–4) cm). Another 20 patients (15 men), median (range) age 62.5 (44–86) years) with low rectal cancer were randomized to a straight coloanal anastomosis (median (range) distance of anastomosis from the anal verge 3.25 (2–5) cm). There were no significant differences in operative time or complications between the two groups. There was significantly better postoperative anal function in patients who underwent pouch-anal anastomosis at 1, 6 and 12 months after ileostomy closure. At 12 months all patients (19 of 19) with a pouch reconstruction had regained normal continence compared with 14 of 20 of those who had a straight coloanal anastomosis. No patient complained of severe constipation requiring enema or intubation to evacuate.
Colonic J pouch-anal anastomosis after rectal excision for carcinoma: Functional outcome
Authors: Mortensen N J M , Ramirez J M , Takeuchi N , Humphreys M M Smilgin
Published: March 2007

A consecutive series of 23 patients with colonic J pouch-anal anastomosis for low rectal cancer (17 men; mean age 64.4 (range 44–76) years) was studied prospectively. The mean distance from the pouch-anal anastomosis to the anal verge was 3.5 (range 2.0–4.5) cm. During follow-up one patient died from an unrelated cause and four developed metastases, two local and two hepatic. In 19 surviving patients a mean of 7 months after ileostomy closure mean bowel frequency was 2.1 (range 1–4) per day, five patients had urgency and four had mild faecal seepage up to three times per week, and seven patients had some degree of incomplete evacuation. In 13 patients there were no manometric differences before and after surgery with respect to maximum tolerated volume or maximum resting pressure, but maximum squeeze pressure was significantly lower after surgery (mean 189 versus 132 cmH2O before and after surgery respectively, P < 0.05). Colonic pouch reconstruction should be considered as an alternative to straight coloanal anastomosis in patients undergoing very low anterior resection.
Bile acid absorption from ileoanal pouches using enema scintigraphy
Authors: Bain I M , Mostafa A B , Harding L K , Neoptolemos J P , Keighley M R B
Published: March 2007

It is unclear whether bile acid absorption is affected by ileoanal pouch construction. Bile acid absorption was measured in the abdomen of 16 patients with pouches (nine with good and seven with poor pouch function based on a clinical score) and in six patients with an end ileostomy using a radiolabelled synthetic bile acid (75SeHCAT) enema and dynamic scintigraphy. The median (interquartile range) 75SeHCAT absorption was 81 (79–87) per cent in patients with ileostomy, 46 (43–53) per cent in patients having well functioning pouches, and 24 (18–38) per cent in the group with poor pouch function (P < 0.01). Log transformation of the absorption curves revealed a two-component uptake (fast component t1/2 = 1.4–7.2 min; slow component t1/2 = 16–144 min) in all patients with ileostomy, in eight of nine patients with pouches with good function, and in one of seven patients with a poorly functioning pouch (P < 0.05); in the other six patients with poorly functioning pouches, only the slow component of absorption was present. This test showed significantly reduced bile acid absorption in patients with an ileoanal pouch and gave an objective discrimination between well and poorly functioning pouches.
Laparoscopic groin hernia repair: Results of 200 consecutive herniorraphies
Authors: Kald A , Smedh K , Anderberg B
Published: March 2007

Laparoscopic hernia surgery was introduced in this unit in May 1992. Up to September 1993, 175 patients with 200 inguinal and femoral hernias were treated using this approach. This prospective study deals with intraoperative and postoperative complications, patient recovery and early operative results. The median (range) age was 58 (21–87) years and the median (range) follow–up was 12 (5–24) months. A laparoscopic transabdominal preperitoneal technique was used. The median (range) operation time was 67 (23–160) min for unilateral hernias and the median (range) hospital stay was 1 (0–27) day.

Major complications were two postoperative bowel obstructions and seven recurrences, six of these in the first 31 patients. Overall, 17 minor complications were recorded; 52 per cent of the patients were back at work within 1 week, and 94 per cent within 1 month. The value of laparoscopic hernia repair remains to be determined and randomized controlled trials will be necessary.
Malignant epithelial parotid tumours: A rational treatment policy
Authors: Ball A B S , Fish S , Thomas J Meirion
Published: March 2007

Formal parotidectomy was undertaken in 271 patients by one surgeon over 11 years. Forty patients were treated for malignant salivary tumours (nine were recurrent). Low grade tumours (45 per cent) were treated by surgery alone, untreated high-grade tumours (55 per cent) by surgery and radiotherapy, before or after operation, depending on clinical findings. The aims of surgery were to obtain tumour clearance, to preserve the facial nerve if possible, and to perform radical neck dissection for palpable malignant lymphadenopathy proven cytologically and for high-grade tumours when intraoperative jugulodigastric lymph node biopsy confirmed metastasis. Four patients sustained facial weakness as a result of surgery. At a median of 46 months follow-up two patients had developed local recurrence. Eleven patients with high-grade but none with low-grade tumours died from metastases. Patients with high-grade lesions with facial weakness from malignant infiltration and those with lymphatic metastasis have a significantly worse prognosis than those without. Locoregional control of parotid cancers can be achieved by formal parotidectomy and selective irradiation without routine sacrifice of the facial nerve.
Computed tomographic portography in preoperative imaging of hepatic neoplasms
Authors: Moran B J , O'Rourke N , Plant G R , Rees M
Published: March 2007

Preoperative selection of suitable patients for liver resection is dependent on the quality of radiological imaging. Computed tomography (CT) identifies approximately 70 per cent of lesions. Computed tomographic arterial portography (CTAP) during contrast enhancement of the liver via the portal vein may be superior to conventional CT. Preoperative CTAP was evaluated in 60 patients with hepatic neoplasm (48 having colorectal metastases) who subsequently underwent laparotomy. The preoperative images were compared with intraoperative palpation, intraoperative ultrasonography and histology of the resected liver. Fifty-six patients (93 per cent) underwent partial hepatectomy. The detection rate sensitivity for CTAP was 110 of 116 lesions in the 56 patients (95 per cent) and for intraoperative ultrasonography was 114 of 116 (98 per cent). CTAP correctly identified all lesions found at histology in 50 of 56 (89 per cent) resected specimens. At laparotomy four of 60 patients (7 per cent) were inoperable; two of these had been predicted to be so by this technique. CTAP correctly identifies and locates the majority of hepatic tumours, particularly metastases, and is the procedure of choice for selection of suitable candidates for partial hepatectomy.
Influence of laparoscopic and conventional cholecystectomy upon cell-mediated immunity
Authors: Griffith J P , Everitt N J , Lancaster F , Boylston A , Richards S J , Scott C S , Benson E A , Sue-Ling H M , McMahon M J
Published: March 2007

Surgery, trauma and anaesthesia induce a state of transient immunosuppression. Laparoscopic cholecystectomy has several well documented clinical advantages over traditional cholecystectomy and provokes a lower acute phase response, thought to be a result of the smaller wound size. The influence of laparoscopic cholecystectomy (21 patients) and conventional open cholecystectomy (13 patients) upon components of the cell-mediated immune system was investigated. Cell-mediated immunity was studied by in vitro assays of T lymphocyte proliferation to different mitogens, and by natural killer cell cytotoxicity using a standard 51Cr release assay. Blood samples were taken before and 24 h after the start of the operation. In the sample taken after operation there was significant depression of T lymphocyte proliferation to phytohaemagglutinin (stimulation index 149.4 versus 33.3, P < 0.002), staphy-lococcal enterotoxin B (85.2 versus 52.6, P = 0.01) and toxic shock syndrome toxin (48.4 versus 14.8, P = 0.08) in the group of patients who underwent open surgery, but not in the group treated by laparoscopic surgery. There was a small but statistically insignificant decrease of natural killer cell cytotoxicity in both groups of patients. These findings suggest that laparoscopic cholecystectomy causes less depression of cell-mediated immunity than open cholecystectomy.
Klippel-Trenaunay syndrome: Clinical features, complications and management in children
Authors: Samuel M , Spitz L
Published: March 2007

Clinical features and management of 47 children with Klippel-Trenaunay syndrome treated since 1970 were reviewed. Haemangiomas and soft tissue and/or skeletal hypertrophy were present in all 47 patients; venous varicosities developed in 37 (79 per cent). There was no clinical evidence of macrofistulous arteriovenous communications in any patient. Thromboembolic episodes occurred in five children (11 per cent) and 25 (53 per cent) experienced thrombophlebitis. The Kasabach-Merritt syndrome was observed in 21 (45 per cent) and six (13 per cent) presented with high-output cardiac failure. Other manifestations included haematuria in five (11 per cent), rectal or colonic haemorrhage in six (13 per cent), and vaginal, vulval or penile bleeding in six (13 per cent) children with visceral and pelvic haemangiomas. In 26 patients (55 per cent) symptomatic treatment only was required. Surgery was undertaken in selected cases for complications of the haemangioma, for cosmetic reasons and for chronic venous insufficiency. Only one of four children who underwent resection of varicose veins improved. There was no death, but significant morbidity was associated with the treatment of Kasabach-Merritt syndrome and high-output cardiac failure.
Blood flow in breast cancer and fibroadenoma estimated by colour Doppler ultrasonography
Authors: Holcombe C , Pugh N , Lyons K , Douglas-Jones A , Mansel R E , Horgan K
Published: March 2007

Blood flow was measured by colour Doppler ultrasonography in 33 fibroadenomas of size 5–31 mm and 28 malignant breast masses of 8–37 mm visible on ultrasonography. There was detectable blood flow in 11 fibroadenomas and 21 cancers (P < 0.01). The median peak systolic frequency was 1.0 (range 0.25–2.0) kHz in malignant tumours and 0.5 (range 0.2–1.25) kHz in fibroadenomas. Blood flow was not detected in the eight fibroadenomas of less than 13 mm but was present in five of seven cancers smaller than this. Five of six carcinomas with three or more detectable vessels were classified as grade III on histological examination, compared with two of 11 carcinomas with one or two vessels. Similarly, five of seven cancers with three or more detectable vessels had axillary lymph node metastases compared with two of 13 with only one or two vessels. Detectable blood flow in breast masses is more common in cancer than in fibroadenoma and is highly suggestive of malignancy if the mass is less than 13 mm in size. Malignant tumours with a larger number of vessels are more likely to be of high grade and to have associated axillary node metastases.
Non-operative management of breast masses diagnosed as fibroadenoma
Authors: Cant P J , Madden M V , Coleman M G , Dent D M
Published: March 2007

A 7–9-year study was undertaken in 99 female patients (median age 20 years), 56 of whom had single and 43 multiple fibroadenomas (total 279). Thirty-four women with 58 masses (21 per cent) were lost to follow-up. Twenty-eight women with 73 masses (26 per cent) subsequently underwent excision at a median of 10 (range 3–59) months for single and 38 (1–110) months for multiple fibroadenomas (P = 0.03), with histological confirmation in 71 and other benign disease in two cases. There was resolution of 107 masses (38 per cent of those entered into the study, 72 per cent of those not lost or excised), leaving 41 persisting masses (15 per cent of those entered into the study, 28 per cent of those not lost or excised). The actuarial probability of disappearance was 0.46 at 5 years and 0.69 at 9 years (Kaplan-Meier analysis). There was no difference in the rate of resolution when 56 single lesions were compared with 223 multiple lesions, or when 192 lesions measuring 2 cm or less in diameter were compared with 87 greater than 2 cm. Resolution was significantly more frequent in women aged 20 years or less than in those who were older (P < 0.01). Non-operative management remains a safe approach in selected women and should be followed by resolution of half of fibroadenomas at 5 years.
Regression and progression of Barrett's oesophagus after antireflux surgery
Authors: Sagar P M , Ackroyd R , Hosie K B , Patterson J E , Stoddard C J , Kingsnorth A N
Published: March 2007

The effects of antireflux surgery on Barrett's oesophagus were studied. Fifty-six patients (45 men and 11 women of median age 48.5 (range 20–78) years) with histologically confirmed Barrett's oesophagus (greater than 3 cm in length) and gastro-oesophageal reflux underwent antireflux surgery. Symptoms were noted and patients underwent manometry and pH recording before and after operation, and annual flexible endoscopy. Fundoplication resulted in a significant improvement in lower oesophageal sphincter pressure (median (interquartile range (i.q.r.) 8 (5–14) mmHg before operation versus 17 (11–22) mmHg after operation, P < 0.001). Twenty-four of the 56 patients had partial or complete regression of Barrett's oesophagus (median (i.q.r.) length 8 (3–18) cm before versus 4 (0–10) cm after operation, P < 0.001) but nine showed progression (median (i.q.r.) length 6 (3–11) cm before versus 10 (6–15) cm after operation, P < 0.01) (median follow-up 5.5 (range 2.0–10.5) years). Carcinoma developed in one patient. The length of Barrett's oesophagus was unchanged in 23 patients. Regression was more likely to occur in patients who underwent fundoplication with previous or concomitant vagotomy (x2 = 7.21, 1 d.f., P < 0.01) and in those with a good symptomatic result (x2 = 23.52, 1 d.f., P < 0.001).
Use of a feeding jejunostomy after oesophagogastric surgery
Authors: Wakefield S E , Mansell N J , Baigrie R J , Dowling B L
Published: March 2007

Over a 5-year period, 58 patients with oesophageal or gastric malignancy underwent surgical resection with oesophagogastric or oesophagojejunal anastomosis. All were fed temporarily with a catheter feeding jejunostomy placed at the time of surgery. All patients tolerated the feeding well. There were no catheter-related deaths and only one serious complication, formation of an abscess following catheter dislodgement. Experience with this technique suggests that it is a safe and cheap method of feeding patients after oesophagogastric surgery. Such patients are particularly suitable for a feeding jejunostomy as they are frequently malnourished, rarely have prolonged postoperative ileus and may develop complications that delay the onset of oral intake.
Laparoscopic repair of perforated peptic ulcer
Authors: Lau W Y , Leung K L , Zhu X L , Lam Y H , Chung S C S , Li A K C
Published: March 2007

A total of 100 consecutive patients with perforated duodenal or juxtapyloric ulcers were treated by: laparotomy and omental patch repair (group 1, n = 44); laparoscopic suture patch repair (group 2, n = 35); and laparoscopic fibrin glue repair (group 3, n = 21). The three groups were comparable in Acute Physiology And Chronic Health Evaluation II score and in other known operative risk factors such as shock on admission, delayed presentation and associated underlying medical illness. Operative mortality and morbidity data were identical in all groups. The mean operating time was 52.1, 101.3 and 61.1 min respectively in the three groups (group 1 versus group 2, group 2 versus group 3, and group 1 versus groups 2 and 3 combined, P < 0.001). The median number of doses of analgesia required after operation was 4, 3 and 1 respectively (group 1 versus groups 2 and 3, P < 0.05). Conversion to laparotomy was necessary in six patients in group 2 and in one in group 3 (P not significant). The median hospital stay was 5 days in all three groups. Patients who underwent laparoscopic repair of perforated peptic ulcer required fewer postoperative doses of analgesia than those who had open repair. Laparoscopic glue repair has the additional advantage over laparoscopic suture of being technically simpler; it also takes less time to perform.
Pancreatitis associated with choledochal cyst and other anomalies in childhood
Authors: Okada A , Higaki J , Nakamura T , Fukui Y , Kamata S
Published: March 2007

Fifty-one children with anatomical anomalies of the pancreatic duct developed pancreatitis associated with either congenital dilatation of the bile duct (choledochal cyst; n = 48) or other rare causes (n = 3). Among those with choledochal cyst, 41 underwent primary surgical resection of the dilated bile duct, while five of the remaining seven patients receiving cystenterostomy underwent secondary resection of the cyst.
New concepts in the pathophysiology of oxygen metabolism during sepsis
Authors: Vlessis A A , Goldman R K , Trunkey D D
Published: March 2007

Sepsis is an intriguing pathological condition associated with many complex metabolic and physiological alterations. In this review a novel hypothesis in the pathophysiology of oxygen metabolism during sepsis is explored. It is proposed that the hypermetabolic response to sepsis results from enhanced reactive oxygen generation by phagocytes. Reactive oxygen detoxification by host enzyme systems subsequently leads to alterations in oxidative metabolism. The similarities between the metabolic consequences of reactive oxygen metabolism and the metabolic changes observed during sepsis are outlined. A unified concept is presented to help explain the pathophysiological changes in oxygen metabolism during sepsis.
Lothian and borders large bowel cancer project: Immediate outcome after surgery. The consultant surgeons and pathologists of the lothian and borders health boards
Authors: Carter D C
Published: March 2007

A prospective audit of all large bowel cancer resections is being conducted in the adjacent Health Boards of Lothian and Borders. The results of surgery in 750 consecutive patients recruited during the first 2 years are presented. In this time, 249 (33.2 per cent) patients presented as an emergency, 490 (65.3 per cent) had resection of a colonic cancer, and 36 (4.8 per cent) patients died within 30 days. Abdominal resection was performed in patients and intestinal continuity was restored in 646 (87.2 per cent). Of all anastomoses performed, 31 (4.8 per cent) leaked (15 of 467 (3.2 per cent) and 16 of 179 (8.9 per cent) after resection of colonic and rectal cancers, respectively). Of the patients presenting with a rectal cancer, 251 (96.5 per cent) underwent abdominal resection and intestinal continuity was restored in 179 (71.3 per cent). Five of 28 consultants were responsible for half of these patients. Patients treated by these five consultants were no more likely to undergo anastomosis, but when an anastomosis was performed it was less likely to leak (four of 95 (4.2 per cent) versus 12 of 84 (14.3 per cent) (χ2 = 4.63, P<0.05)). The overall outcome of surgery appears to be improved when compared to previous similar audits. Considerable intersurgeon variation remains in the results of resection of rectal cancer.
Colectomy as treatment for constipation in selected patients
Authors: Piccirillo M F , Reissman P , Wexner S D
Published: March 2007

The aim of this study was to conduct a prospective assessment of the results of total abdominal colectomy and ileorectal anastomosis (TAC) in patients with colonic inertia. Overall, 416 patients were evaluated for chronic constipation. Of the patients, 54 (13 per cent) had colonic inertia, defined as diffuse marker delay during transit study without paradoxical puborectalis contraction on cinedefaecography or electromyography. All 54 patients (42 women and 12 men), with a mean age of 49 (range 17–78) years, underwent TAC. Preoperative bowel frequency was a mean of one every 8 days, requiring large doses of laxatives, enemas or both. There was no major postoperative morbidity; five patients were readmitted due to bowel obstruction, three for successful conservative management while the other two required enterolysis. After a mean follow-up of 27 (range 2–51) months these 54 patients reported a mean frequency of spontaneous bowel movements of 3.7 (range 1–10) per day. ‘Excellent’ or ‘good’ outcome was reported by 51 patients (94 per cent). TAC can be performed with acceptable morbidity and 94 per cent of patients will have satisfactory improvement in bowel habit.
Assessment of feasibility for endovascular prosthetic tube correction of aortic aneurysm
Authors: Andrews S M , Cuming R , Macsweeney S T , Barrett N K , Greenhalgh R M , Nott D M
Published: March 2007

Abdominal aortic aneurysm (AAA) can now be corrected by perfemoral introduction of a prosthetic tube graft with fixation using expandable metal stents. This technique requires a satisfactory iliac system, through which the graft can reach its destination, and suitable lengths of non-aneurysmal aorta below the renal arteries and above the aortic bifurcation for stent attachment. The feasibility for placement of endovascular grafts was assessed in 44 consecutive patients admitted for transabdominal AAA repair. The proximal and distal aneurysmal necks and the iliac arteries were assessed before operation by colour flow Doppler ultrasonography (duplex scanning), computed tomography and intravenous digital subtraction angiography, using intraoperative measurements as the ‘gold standard’. At operation 32 of 44 patients had a suitable proximal neck and five of 44 a suitable distal neck for endovascular grafting. Duplex scanning was the most accurate modality for preoperative assessment of the aneurysm necks. According to this technique 32 of 44 patients had a satisfactory iliac system for introduction of an endovascular graft. Overall only four of 44 patients were considered suitable for endovascular correction of AAA using a tube graft-stent combination.
Laparoscopic repair of penetrating intra-abdominal injuries
Authors: Gunning K A , Moont M , Sugrue M
Published: March 2007

Laparoscopy is a useful modality in the diagnosis of peritoneal penetration1, but its therapeutic potential in abdominal trauma has yet to be fully assessed. This report describes its successful use in penetrating trauma.
Prospective randomized trial of high versus low vacuum drainage after axillary lymphadenectomy
Authors: Van Heurn L W E , Brink P R G
Published: March 2007

A randomized prospective trial was performed to assess the effect of low versus high vacuum drainage after axillary lymphadenectomy. The mean(s.e.m.) volume of seroma evacuated with a low vacuum system was 386(26) ml (n = 38) compared with 537(43) ml with a high vacuum system (n = 40) (P< 0.005). Low vacuum drains were removed earlier than high vacuum drains (P = 0.02). Seroma production after removal of the drains was not significantly different. The use of low vacuum drains after axillary dissection can reduce hospital stay.
Yield pressure, anatomy of the cardia and gastro-oesophageal reflux
Authors: Ismail T , Bancewicz J , Barlow J
Published: March 2007

The yield pressure at which the cardia opens in response to gastric distension was measured in 155 subjects with and without gastro-oesophageal reflux (GOR) and after Nissen fundoplication. Yield pressure was measured by endoscopy or during oesophageal manometry. The median pressure was significantly lower in subjects with GOR than in those without (P < 0.0001). After successful Nissen fundoplication this pressure increased to supranormal values (P < 0.0001). There was a close relationship between yield pressure and the presence and size of hiatus hernia and also between yield pressure and the valvular appearance of the cardia at endoscopy. There was a significant correlation between yield pressure and oesophageal acid exposure. However, no relationship was observed between yield pressure and lower oesophageal sphincter pressure or intra-abdominal length. These results suggest that yield pressure is useful for assessment of the competence of the cardia, particularly after antireflux surgery. The competence of the cardia is greatly influenced by its anatomical structure.
Early gastric cancer: Prognostic factors in 223 patients
Authors: Folli S , Dente M , Dell'Amore D , Gaudio M , Nanni O , Saragoni L , Vio A
Published: March 2007

A retrospective study of 223 patients treated for early gastric cancer (EGC) is reported, representing 21.2 per cent of the 1051 patients with gastric cancer treated over the same period. Two main types of surgical procedure were used: subtotal resection of the stomach for EGC of the two lower thirds and total gastrectomy for lesions of the upper third. A lymphadenectomy of groups 1 and 2, according to the procedure of the Japanese Research Society for Gastric Cancer (R2 resection), was performed in all patients. The mean duration of follow-up was 7.5 years. Univariate analysis showed a significant difference in survival rates only between patients with and without involved nodes (log rank = 6.05, P = 0.0139). Other prognostic factors were not identified. A bivariate analysis was performed to evaluate the joint effect of node status and the Kodama classification: survival rates for patients with EGC of the penetrating (Pen) A type and node positive falls to around 57 per cent within 6 years. This group of patients has a tumour that should probably be considered as a ‘non-early’ lesion. To improve the survival of patients with a Pen A, node positive lesion, adjuvant chemotherapy may be appropriate.
Laparoscopic Heller's cardiomyotomy without an antireflux procedure
Authors: Robertson G S M , Lloyd D M , Wicks A C B , De Caestecker J , Veitch P S
Published: March 2007

The treatment of achalasia by laparoscopic Heller's cardiomyotomy may combine the minimally invasive advantages of pneumatic dilatation with the success rate and low risk of perforation of conventional surgery. The requirement for an antireflux procedure remains a contentious issue, as in conventional surgery. Nine patients underwent laparoscopic cardiomyotomy; excellent symptomatic relief was obtained in eight at follow-up between 12 and 21 months after operation. Four of these patients agreed to 24-h pH monitoring and showed no evidence of acid reflux. One patient, however, developed recurrent symptoms associated with significant acidityi on monitoring. Laparoscopic Heller's cardiomyotomy without an antireflux procedure produced effective symptomatic relief in this small group of patients.
Introduction of laparoscopic cholecystectomy in a large teaching hospital: Independent audit of the first 3 years
Authors: Steele R J C , Marshall K , Lang M , Doran J
Published: March 2007

Commencing with the introduction of laparoscopic cholecystectomy, a detailed independent prospective audit of all cholecystectomies attributable to 12 general consultant surgeons has been carried out over a period of 3 years. Of 650 operations 502 were intended laparoscopic cholecystectomies. In the first year 58 per cent were intended laparoscopic cholecystectomies; this rose to 80 per cent in the second year and to 90 per cent in the third. The conversion rate was 21 per cent in the first year, 21 per cent in the second and 15 per cent in the third. The mean operating time for laparoscopic cholecystectomy was 133 min for year 1, 123 min for year 2 and 115 min for year 3, compared with 92, 101 and 95 min respectively for open cholecystectomy. The overall complication rate was 10 per cent for laparoscopic and 21 per cent for open cholecystectomy. This included six bile duct injuries (1.2 per cent) in the patients undergoing the laparoscopic procedure and one (0.7 per cent) in those having open cholecystectomy. This unselected audit of a group of general surgeons introducing laparoscopic cholecystectomy into their practice has revealed complication and conversion rates that are higher than those reported in most of the published literature, but may be representative of practice throughout the UK.
Comparison between pylorus-preserving and Whipple pancreatoduodenectomy
Authors: Zerbi A , Balzano G , Patuzzo R , Calori G , Braga M , Di Carlo V
Published: March 2007

Between 1989 and 1993, 62 patients underwent Whipple pancreatoduodenectomy and 75 pylorus-preserving pancreatoduodenectomy (PPPD); 35 patients in the first group and 37 in the second had pancreatic adenocarcinoma while 17 and 21 patients respectively had periampullary adenocarcinoma. The aim of this retrospective study was the comparison of operative outcome, nutritional recovery and survival of patients who underwent these two operations. No significant differences were found between the two groups in operative mortality or morbidity, duration of gastric aspiration and time to start of solid meals. Patients who underwent PPPD had a better nutritional recovery: the increase of both body-weight and serum albumin level at 6 months after discharge was significantly higher for those who had preservation of the whole stomach (P < 0.001 and P < 0.05 respectively). No significant difference in survival was found between the two procedures when patients with pancreatic or periampullary adenocarcinoma were analysed separately.
Repeated liver resection for metastatic malignant schwannoma
Authors: Borrowdale R C , Rees M
Published: March 2007

Malignant Schwann-cell tumour metastatic to the liver is exceedingly rare. This paper presents the first report in the English literature of hepatic resection for metastatic schwannoma.
Budd-Chiari syndrome
Authors: Tilanus H W
Published: March 2007

Budd-Chiari syndrome is the generic term for different forms of hepatic venous outflow obstruction resulting in a clinical picture of portal hypertension and hepatomegaly. Three levels of venous outflow obstruction may be recognized, affecting respectively the small intrahepatic venules, the large hepatic veins and the inferior vena cava (IVC). Each level of obstruction is related to a different aetiology. Clinical manifestations range from mild symptoms to acute or chronic end-stage liver disease. Treatment is surgical in the great majority of patient Occlusion of the IVC may be treated by removal of the caval obstruction in selected patients. Hepatic outflo obstruction may be circumvented by different forms of shunting from the portal or upper mesenteric vein to the IVC or right atrium, depending on the level of obstruction and the difference in venous pressure. For the rare patient presenting with acute or chronic end-stage liver failure hepatic transplantation may be a life-saving procedure.
Exercise capacity in patients undergoing proctocolectomy and small bowel resection for Crohn's disease
Authors: Brevinge H , Berglund B , Bosaeus I , Tölli J , Nordgren S , Lundholm K
Published: March 2007

The effect of proctocolectomy and small bowel resection on working capacity has not been assessed objectively in previous research. Twenty-nine patients with Crohn's disease were investigated with cycle ergometry and a questionnaire, following proctocolectomy with and without small bowel resection. Maximal exercise load is known to correspond well with working capacity, particularly when account is taken of body composition and metabolic variables. Maximal exercise load was reduced marginally (by 9 per cent) in patients without small bowel resection and by 22 per cent in patients with moderate small bowel resection (15–30 per cent resection). Patients with extensive bowel resection (more than 50 per cent) had a 40 per cent reduction in the maximal exercise load. This reduction in maximal exercise load was greater than predicted when accounting for reduction in muscle mass. All patients had a normal oxygen uptake including resting energy expenditure. Urinary sodium and magnesium excretion was low in the group with moderate bowel resection, whereas the extensively resected patients were malnourished and had a reduced body cell mass. The authors conclude that the significantly reduced working capacity was of multifactorial origin secondary to malabsorption. However, the patients seemed unaware of the degree of their diminished working capacity. This reduced capacity makes it unlikely that they would be able to perform any labour involving high energy consumption at the level of 500-700 W, and this inability was reflected by a high rate of unemployment among the patients.