bluuebunny/crossref_metadata_2025 huggingface dataset:
Five-year vascular audit from a district hospital
Authors: Holdsworth J D
Published: March 2007

Vascular patients under the care of one surgeon over a 5-year period have been reviewed, from computer-based discharge records, with regard to in-hospital measures of outcome to determine whether or not surgery was being performed to an acceptable standard. Out of 466 procedures, 30 per cent of patients had at least one complication, 14 per cent had further surgery and 9 per cent died. Outcome was examined within the following treatment groups: aorto/iliac aneurysm, aortofemoral bypass, femoroproximal popliteal bypass, femorodistal popliteal bypass, femorocrural bypass, embolectomy and percutaneous transluminal angioplasty. Patients having below-knee bypass surgery were found to have an unacceptably high rate of complications, reoperations and amputations. An overall rate of reoperation for postoperative bleeding of 5 per cent was also considered to be high. With these exceptions, it was concluded that the surgery was being performed to an acceptable standard, but that comparative audit of this type remained difficult while there was a deficiency of national statistics against which the work of individual surgeons could be judged.
Vasodilatory capacity of the skin in venous disease and its relationship to transcutaneous oxygen tension
Authors: Cheatle T R , Stibe E C L , Shami S K , Scurr J H , Smith P D Coleridge
Published: March 2007

Low transcutaneous oxygen tension (Ptc,O2) values in the supramalleolar skin of patients with venous disease are often reported. This measurement involves heating the skin to 43°C to cause maximum vasodilatation and is valid only if liposclerotic and normal skin can vasodilate to the same degree. Forty-four limbs were studied, 15 with lipodermatosclerosis (LDS), 14 with uncomplicated varicose veins, and 15 controls. A Ptc,O2 electrode was modified to incorporate a laser Doppler probe. Laser Doppler flux was measured in the supramalleolar skin before and after local heating to 43°C and the relative increase in flux was measured. The Ptc,O2 was then measured at the same site and on the chest. Vasodilatory capacity was expressed as the ratio of peak:basal laser Doppler flow, and the Ptc,O2 was expressed as a leg:chest ratio. Median laser Doppler flow was higher in limbs with LDS (median 67 mV) than in normal limbs (median 40 mV) (P<0·03). Ptc,O2 was higher in control limbs (median ratio 0·94) than in limbs with LDS (median 0·53) (P < 0·006). The microcirculation in LDS had less capacity to vasodilate after heating (median factor of increase 5·4) than normal skin (median factor of increase 12·3) (P<0·001). A simple regression analysis was performed on all pairs of data, and revealed a correlation between Ptc,O2 and vasodilatory capacity (r = 0·524, P<0·001). The results indicate that low Ptc,O2 levels in venous disease reflect an inability of the microcirculation to increase its flow in response to local heating; inferences about the oxygen content of liposclerotic skin at normal temperatures cannot be drawn using this technique.
Groin wound infection after arterial surgery
Authors: Newington D P , Houghton P W J , Baird R N , Horrocks M
Published: March 2007

Fifty-six patients, 30 with superficial and 19 with deep groin wound infections, and seven with lymph fistulae with positive cultures within 30 days of arterial surgery, were identified after 661 operations (873 groins at risk) between September 1984 and August 1988. The commonest infecting organisms were Staphylococcus aureus, Pseudomonas aeruginosa and Proteus spp. In 33 patients the infection settled completely after treatment with culture specific antibiotics. These were given intravenously then orally for up to 6 weeks. Sixteen patients required debridement and excision of necrotic wound edges, including one who had an antibiotic infusion into the wound. Graft excision was performed in seven patients of whom five received an extra anatomic bypass. The need for graft excision was much greater (six versus one) for Dacron® and/or polytetrafluoroethylene than for vein. In two lymph fistulae sartorius transposition and wound resuture were used. All groins healed, though three extremities were ischaemic following occlusion of the bypass. There were two deaths, one from myocardial infarction and one from pulmonary embolism and no major amputations. These results suggest that most infective groin problems may be successfully managed conservatively and that radical graft excision is only necessary for a few intractable cases.
Clinical outcome and health care costs in renal revascularization — percutaneous transluminal renal angioplasty versus reconstructive surgery
Authors: Weibull H , Bergqvist D , Jendteg S , Lindgren B , Persson U , Jonsson K , Bergentz S E
Published: March 2007

Clinical outcome and health care costs related to investigation, treatment with either percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery, and follow-up of patients with renovascular hypertension with or without uraemia were analysed in 21 PTRA-treated and 16 operated patients. Most renal artery stenoses were atherosclerotic. Nineteen PTRAs were successful or partly successful and two failed; the patients were operated on without delay. All surgical reconstructions were successful. In the PTRA group six restenoses occurred after 4–24 months. Four were treated with re-PTRA and two were operated on. No recurrence occurred in the operated group. At the end of follow-up (median 48, range 9–84 months) primary patency in the PTRA group was 69 per cent and in the operated group 100 per cent. Secondary patency in the PTRA group was 100 per cent. With regard to hypertension, including primary and secondary results, 19 out of 21 (90 per cent) patients were improved in the PTRA group and 13 out of 16 (81 per cent) in the operated group. The diagnostic and preprocedure costs were the same in both groups, whereas the procedure and postprocedure costs were lower in the PTRA group. However, the follow-up costs were considerably higher because of recurrences and their treatment in the PTRA group. The total median cost of reconstructive surgery was 12 per cent higher than for PTRA, a non-significant difference.
Haemodynamic significance of incompetent calf perforating veins
Authors: Zukowski A J , Nicolaides A N , Szendro G , Irvine A , Lewis R , Malouf G M , Hobbs J T , Dudley H A F
Published: March 2007

A total of 149 consecutive unselected patients (221 limbs) who presented with signs and symptoms of chronic venous problems (varicose veins with or without ankle oedema, skin changes and leg ulcers) have been studied by clinical examination, ascending deep to superficial venography, Doppler ultrasound and ambulatory venous pressure measurements. Of the limbs, 180 (82 per cent) had varicose veins without obstruction in the deep veins or reflux in the popliteal or femoral veins while 41 (18 per cent) had deep venous disease. Of the 180 limbs with ‘primary’ varicose veins 110 (60 per cent) did not have incompetent calf perforating veins (group A) while 70 (40 per cent) did (group B). On the basis of the ambulatory venous pressure after calf muscle exercise and the refilling time, the incompetent calf perforating veins of limbs in group B belonged to three subgroups of different haemodynamic significance. In 20 limbs (30 per cent) they were found to be of no haemodynamic significance, in 25 (35 per cent) of moderate haemodynamic significance and in 25 (35 per cent) of major haemodynamic significance. The last were, on clinical examination, indistinguishable from limbs with deep venous disease although they had patent deep veins with competent popliteal valves.
Influence of local recurrence on survival: A controversy reviewed from the perspective of soft tissue sarcoma
Authors: Barr L C , Stotter A T , A'Hern R P
Published: March 2007

The relationship between local recurrence and survival has been examined using the example of soft tissue sarcomas of the extremities. Studies that appear to indicate that local recurrence does not jeopardize survival are shown to have been inappropriately analysed, to have inadequate patient numbers, or both. A survival deficit due to local tumour recurrence cannot be excluded on present data, and clinical decisions regarding conservative versus radical surgery will therefore continue to involve an element of value judgement.
Endothelial cell seeding
Authors: Mosquera D A , Goldman M
Published: March 2007

Endothelial cell seeding is a technique that has developed over the past 15 years in response to the need for a high performance synthetic vascular graft. This review details our present knowledge of seeding and examines the various problems that have hampered its introduction into clinical practice.
Autologous transfusion: An alternative to transfusion with banked blood during surgery for cancer
Authors: Miller G V , Ramsden C W , Primrose J N
Published: March 2007

Autologous blood transfusion in surgery for cancer has been avoided because of the metastatic potential of reinfused malignant cells. This study determined whether viable tumour cells remain in the red cell concentrate after separation and whether blood transfusion filters remove these tumour cells before reinfusion. Units of banked blood were inoculated with tumour cell lines: breast cancer SKBr3; colon cancer COLO 320; lymphoma Daudi; erythroleukaemia K562. After processing with the Cell Saver®, aliquots of the red cell concentrate and waste saline wash were examined for tumour cells and cultured. Tumour cells from all four cell lines were identified in the red cell concentrate but not in the waste saline wash. All the cell lines except Daudi grew from the red cell concentrate. Experiments on two of the cell lines (SKBr3 and COLO 320) were performed in which the red cell concentrate was either unfiltered (control) or filtered with SQ40S blood transfusion filter or RC100 leucocyte depletion filter. Both cell lines were present in the control samples and after filtration with SQ40S filters, and cells from these samples grew normally in culture. No tumour cells were evident after filtration with the RC100 filters and no growth of either cell line was found after 1 week in culture. The Cell Saver in combination with RC100 filters may be suitable for use during the surgical treatment of malignant disease.
Paget's disease of the nipple
Authors: Dixon A R , Galea M H , Ellis I O , Elston C W , Blamey R W
Published: March 2007

A total of 48 women with Paget's disease of the nipple (nipple eczema containing Paget cells but without a palpable lump) presented to one surgeon over a 13-year period. Temporary healing of the nipple eczema occurred in six patients. In all, 21 of 34 patients with in situ (DCIS) or invasive ductal carcinoma had mammographic abnormalities. Treatment was by simple mastectomy (37 cases), cone excision of the nipple-areola complex (ten cases) and tamoxifen (one case). DCIS was found in 45 operative specimens (96 per cent); eight had associated invasion. The DCIS was predominantly large cell solid/comedo in type and was multifocal in seven cases (19 per cent). At a median (range) follow-up of 56 (18–96) months, four of the ten patients treated by cone excision have developed a local recurrence, two of these patients have also developed metastases. Two of the 37 patients who underwent mastectomy developed loco-regional recurrences; both had invasive foci at their first operation and remain disease free at 8 years. We no longer feel that cone excision is appropriate treatment.
Deep vein thrombosis: Effect of graduated compression stockings on distension of the deep veins of the calf
Authors: Smith Coleridge , Hasty J H , Scurr J H
Published: March 2007

The mechanisms by which graduated compression stockings prevent deep vein thrombosis are not completely understood. Recent work has suggested that venous distension plays a role in initiating the process. Our previous work has shown that the deep veins of the lower limb distend in patients undergoing surgical procedures. We have investigated 40 patients receiving surgical treatment on the abdomen or neck. A medial gastrocnemius vein was studied using ultrasound imaging during the operations. In half the patients a graduated compression anti-embolism stocking was applied to the limb under study at the start of the operation, immediately after initial measurements of vein diameter. The median vein diameter in both groups was the same at the start of the operative procedures (control, 2·6 mm, interquartile range 2·1–3·3 mm; stocking, 2·6 mm, interquartile range 2·1–3·7 mm). After application of a stocking the median diameter in this group fell to 1·6 mm (interquartile range 1·3–2·8 mm) and then decreased slightly at the end of the operation. In the control group the vein diameter increased to 2·9 mm (interquartile range 2·3–4·0 mm) during the operative procedure.
Improving survival in gastric cancer: Review of operative mortality in english language publications from 1970
Authors: Macintyre I M C , Akoh J A
Published: March 2007

In this review of English language publications from 1970, operative mortality following surgery for gastric cancer has been analysed. Operative mortality has declined in series reporting operations in successive decades to 1970, 1980 and 1990. Series reporting patients having surgery for gastric cancer in the decade to 1990 show a mean operative mortality rate of 7·8 per cent (median 4·6 per cent). This improvement may have contributed to the declining mortality rates for gastric cancer in the face of unchanging surgical workload. Results of operations for gastric cancer should be reported in a standard manner.
Statistical aspects of research methodology
Authors: Murray G D
Published: March 2007

Many reports in the medical literature are flawed through poor presentation of numerical results, or, more seriously, by the use of inadequate or inappropriate statistical methodology. This article expands on the more complex methodological issues. The main emphasis is on discussing key aspects of experimental design, and the idea of reporting results in terms of confidence intervals rather than P values.
Rebound tenderness test
Authors: Liddington M I , Thomson W H F
Published: March 2007

The usefulness of the rebound tenderness test in indicating peritonitis was prospectively assessed in 142 unselected patients admitted as emergencies with abdominal pain and tenderness. It was found to be of no predictive value.
Extracorporeal shock wave treatment of common bile duct stones: Experience with two different lithotriptors at a single institution
Authors: Den Toom R , Nijs H G T , van Blankenstein M , Laméris J S , Schröder F H , Terpstra T
Published: March 2007

Extracorporeal shock wave lithotripsy (ESWL) is a new treatment modality for retained common bile duct stones. Sixty-two patients (mean age 75 years, range 27·95 years) with retained common bile duct stones were treated with two different lithotriptors. One of the lithotriptors operated on the electrohydraulic principle (Dornier HM-3) (n = 13), the other on the electromagnetic principle (Siemens Lithostar®) (n = 49). All HM-3 patients were treated under general anaesthesia, whereas with the Lithostar one patient was treated under general anaesthesia, 43 received analgesia and sedation and five had no analgesia at all. Patients treated with the Lithostar had more sessions (mean 1·9 versus 1·3, P<0·05) and needed more shock waves (mean 8611 versus 2534, P<0·001) than patients treated with the HM-3. Fragmentation was achieved in all patients treated wih the HM-3 and in 42 (86 per cent) patients treated with the Lithostar. In this latter group ten patients underwent common bile duct exploration without complications. Eleven patients had transient haematuria after treatment with the HM-3 and two patients (one in each group) had a subcapsular haematoma of the right kidney, all without clinical sequelae. At follow-up (median: HM-3 43 months, Lithostar 18 months), none of the patients had biliary complaints. We conclude that ESWL of retained common bile duct stones is safe and effective with both lithotriptors and should be considered before surgery in the elderly or high-risk patient.
Results of surgery for duodenal ulcer: Assessment by patients
Authors: Stanton P D , Anderson J R
Published: March 2007

A questionnaire was administered to 224 patients who had undergone 246 operations for duodenal ulcer to see how well this correlated with Visick grading and to provide insight into the patients' feelings about the results of their surgery. The patients were divided into three groups by Visick grade: good (grade I, n = 70), satisfactory (grades II and IIIs, n = 104) and poor (grades IIIu and IV, n = 72). The distribution of questionnaire responses in each group was statistically different (P < 0·01). Dividing the questionnaire responses into three corresponding groups, 72 per cent of patients assigned themselves to the same group as their Visick grade. Three observations were made regarding the Visick system: recurrent ulceration is over-scored and should be included only if symptomatic; grading should acknowledge a wider range of symptoms related to ulcer disease and its treatment; only three grades are necessary.
Clinical significance of the large adrenal mass
Authors: Khafagi F A , Gross M D , Shapiro B , Glazer G M , Francis I , Thompson N W
Published: March 2007

Current clinical teaching indicates that large (>5 cm in diameter) adrenal masses are often malignant. In a retrospective analysis of patients studied between 1977 and 1988 with computed tomography (CT), adrenal scintigraphy, and when available, magnetic resonance imaging (MRI) 45 were found to have adrenal masses greater than 5 cm (range 5–19 cm) in diameter. Thirty were benign (16 phaeochromocytomas, six adrenocortical adenomas, four adrenal cysts, two myelolipomas, an adrenal hematoma and a ganglioneuroma). Of 15 malignant masses, there were seven adrenocortical carcinomas, five adrenal metastases and three adrenal lymphomas. With the exception of the adrenal myelolipomas, cysts, and the ganglioneuroma neither CT nor MRI demonstrated sufficient diagnostic specificity to distinguish benign from malignant lesions. Functional scintigraphy with 131I-6-β-iodomethyl-19-norcholesterol for suspected adrenocortical lesions and 131I-metaiodobenzylguanidine for suspected phaeochromocytomas frequently provided useful information.
Time trends in incidence rates of acute, non-traumatic extremity ischaemia: A population-based study during a 19-year period
Authors: Ljungman C , Adami H-O , Bergqvist D , Berglund A , Persson I
Published: March 2007

Time trends in the occurrence of acute limb ischaemia were studied from 1965 to 1983 in a defined geographical area in Sweden. Data were obtained from a computerized register which covers all instances of inpatient care for a population of 1·3 million. Analysis based on 5394 first admissions for acute arterial occlusion revealed that the annual number increased by 2·7 per cent yearly in women and 3·9 per cent in men whereas the age-adjusted incidence remained stable for women and increased by 2·6 per cent yearly for men. A study of 1189 patients who underwent surgical procedures showed that the annual number of embolectomy procedures increased 7·6 per cent for females and 8·6 per cent for males. The corresponding age-adjusted incidence rose annually by 3·0 per cent for women and by 7·5 per cent for men. The introduction of the Fogarty catheter and an increasing interest in vascular sugery may have contributed to the increasing rates of operations during the period of study.
Effects of two methods of endothelial cell seeding on cell retention during blood flow
Authors: Budd J S , Allen K E , Bell P R F
Published: March 2007

The potential benefits of endothelial cell seeding depend not only on effective cell attachment, but also on the ability of the cells to resist the stresses of blood flow. We have investigated the effect of different blood flow rates on immediately seeded grafts (SHORT) and also on preformed confluent monolayers formed by overnight incubation (LONG). Cells were labelled with indium and then exposed to either 100 or 200 ml/min of pulsatile blood flow. Cell retention was measured up to 120 min. At both flow rates the LONG seeding procedure gave significantly better cell retention than the SHORT method (P<0·01 at all times). There was no difference in cell retention between the two flow rates in the LONG group, but more cells detached at the higher flow rate in the SHORT group (P<0·01). We conclude that the new seeding method, using preformed confluent monolayers, significantly improves cell retention during blood flow.
Therapeutic aspects of radio-isotopes in hepatobiliary malignancy
Authors: Novell J R , Hilson A , Hobbs K E F
Published: March 2007

Liver tumours frequently present at a late stage and only a minority of patients are likely to benefit from resection or transplantation. Inoperable tumours carry a grave prognosis. External beam irradiation of the liver is dose-limited by the radiosensitivity of hepatocytes, particularly in the presence of cirrhosis, but internal radiation using radio-isotope sources can achieve more selective irradiation of the chosen field. Sealed sources are dose-limited by their effects on surrounding tissues, whereas with unsealed sources the dose of radio-isotope administered is limited by bone marrow suppression. Iridium-192 wires are most frequently employed as a sealed intracavitary source. They may be inserted surgically, transhepatically or endoscopically. Doses of up to 60 Gy can be delivered to a malignant biliary stricture without damage to the surrounding parenchyma. The incidence of cholangitis is low if treatment is administered after insertion of an endoprosthesis. Unsealed radio-isotope sources may be injected directly into the tumour, administered embolically via the hepatic artery in the form of microspheres or lipid droplets, or given via parenteral infusion attached to tumour-specific antibodies. Of these vehicles, the lipid agent Lipiodol appears to be the most effective and can deliver a potentially lethal dose of radiation to small tumours. Host reaction to the injected antibody remains a major drawback to the use of monoclonal antibodies as targeting agents. Iodine-131 is a β and γ emitter, producing a local tumoricidal effect and allowing accurate dosimetry by means of external scintigraphy. Yttrium-90 is a pure β emitter with a greater maximum β energy and cytotoxic range; however, it is retained in bony tissues, resulting in a dose-related risk of marrow suppression. Bone absorption cannot be measured by external imaging owing to the absence of γ emission. This lack of accurate dosimetry, coupled with the toxic side-effects of yttrium treatment, make iodine-131 the current isotope of choice.
Clinical and functional results of abdominal rectopexy for complete rectal prolapse
Authors: McCue J L , Thomson J P S
Published: March 2007

Between 1977 and 1987, 53 patients underwent polyvinyl alcohol sponge rectopexy for complete rectal prolapse. The mean follow-up period was 36·7 months. Full thickness prolapse recurred in two patients (3.8 per cent). Infection around the prosthesis and faecal impaction developed in two patients each. Continence improved significantly after operation, particularly in those under 70 years of age (P = 0·028, ξ2 test) and nulliparous women (P = 0·026, ξ2 test). Bowel function was generally unchanged after rectopexy; in particular only eight patients (15 per cent) had significant postoperative constipation.
Emergency laparotomy in patients with AIDS
Authors: Davidson T , Allen-Mersh T G , Miles A J G , Wastell C , Gazzard B , Vipond M , Stotter A , Miller R F , Fieldman N R , Slack W W
Published: March 2007

The presentation, operative management and final diagnosis were reviewed in 28 patients with AIDS (27 men and one woman) who underwent emergency laparotomy. On clinical and radiological examination, six patients showed features of toxic megacolon, five patients had small bowel obstruction, six patients had localized peritonitis and three had perforated viscus with generalized peritonitis. The most common disease processes were acute colitis in seven patients (associated with cytomegalovirus (CMV) infection in six), intra-abdominal lymphoma in five patients, acute appendicitis in five patients (associated with CMV infection in two), and atypical mycobacterial (MAI) infection in four patients. Two perioperative deaths occurred; one in a patient with acute pancreatitis and a second with generalized peritonitis. Later deaths were due to progression of AIDS, and patient survival at 1 month, 3 months and 6 months was 89 per cent, 64 per cent and 48 per cent, respectively. Lower operative mortality than in previously reported series may be due to earlier intervention in CMV toxic megacolon. Surgery, however, conferred less benefit in patients with acute abdominal pain from MAI infection or lymphoma. With careful patient selection, emergency laparotomy may achieve worthwhile palliation in patients with AIDS.
The sphinctometer: A new device for measurement of lower oesophageal sphincter function
Authors: Gotley D C , Barham C P , Miller R , Alderson D , Arnold R
Published: March 2007

Current evidence suggests that lower oesophageal sphincter (LOS) competence depends upon both pressure and length. Existing devices can measure length and pressure, but not simultaneously. This methodological problem is a fundamental drawback to understanding LOS function and its role in oesophageal disease. A ‘sphinctometer’ has been developed, consisting of an oil-filled 3-mm diameter Silastic chamber, 6 cm in length, incorporating a pressure microtransducer designed to provide an integrated pressure reading as a function of length. Its performance has been tested in vitro using human cadaver oesophagus in a specially constructed chamber in which sphincter length and pressure can be varied independently. Comparisons were made with a conventional pull-through technique. Sphinctometer response was linear throughout the LOS pressure range of 0 to 50 mmHg at a fixed LOS length (RS = 0·99; P < 0·001). Sphinctometer response was also linear at fixed LOS pressure for sphincter lengths from 1 to 6 cm (RS = 0·99; P < 0·001). This device thus appeared suitable for monitoring function of the human LOS, and has subsequently been successfully incorporated into an ambulatory system for patient use.
Chemotherapy and surgery for locally advanced cancer of the cardia and fundus: Phase II study with methotrexate and 5-fluorouracil
Authors: Plukker J Th , Verschueren R C J , Mulder N H , Sleijfer D Th , Grond J
Published: March 2007

Locally advanced cancer of the cardia and fundus might be cured by surgical resection. Poor results after surgery in stage IIIB and stage IV disease prompted a study of neoadjuvant chemotherapy. Treatment included four cycles of high doses of methotrexate (1·5 g/m2) and high doses of 5-fluorouracil (1·5 g/m2) followed by surgery in those patients with lesions then found to be resectable. Twenty patients with tumours staged as IIIB or IV were entered; 17 patients completed the four courses of chemotherapy and 14 underwent re-exploration. Eight patients achieved tumour reduction enabling resection. Five patients underwent total gastrectomy with distal pancreatectomy and splenectomy en bloc and three patients had an oesophagogastrectomy. There were no treatment-related deaths and toxicity was tolerable. Two patients were alive 54 and 41 months after chemotherapy with no evidence of disease. Locoregional recurrence developed in five patients and metastatic disease in one. Their median survival was 22 months.
Gallbladder sepsis after stent insertion for bile duct obstruction: Management by percutaneous cholecystostomy
Authors: Ainley C C , Williams S J , Smith A C , Hatfield A R W , Russell R C G , Lees W R
Published: March 2007

Of 364 patients undergoing insertion of a biliary endoprosthesis in 1989, six (1·6 per cent) developed gallbladder sepsis. Three patients had cholangiocarcinoma, two had carcinoma of the pancreas and one had a benign biliary stricture. Two of the five patients with malignancy had gallbladder stones, and the patient with a benign stricture developed stones after 3 years of stenting. Three patients developed gallbladder sepsis early after endoprosthesis insertion (< 6 days), while in the other three it occurred late (> 6 months). All six patients failed to respond to antibiotics and were successfully managed by percutaneous cholecystostomy; the patient with a benign biliary stricture also had cholecystolithotomy. The gallbladder drainage tubes were removed or became dislodged at intervals varying from 2 weeks to 6 months without complications. Percutaneous cholecystostomy is the treatment of choice for gallbladder sepsis unresponsive to antibiotics in patients with a biliary endoprosthesis in situ.
Influence of cholecystectomy on symptoms
Authors: Bates T , Harrison M , Ebbs S R , A'Hern R P
Published: March 2007

A group of 292 consecutive patients underwent cholecystectomy for gallstones with presumed biliary pain over a 4-year period and all completed a self-assessment questionnaire before operation. Over the following 2 years 18 patients died but no others were lost to follow-up. The remaining 274 patients completed a further questionnaire 1 and 2 years after operation. Demographic characteristics and abdominal symptoms have been compared with an age- and sex-matched control group using the same questionnaire. Before operation symptoms of flatulent dyspepsia were far more frequent in patients with gallstones but operation markedly reduced these symptoms to an incidence which almost matched that of the control group. However, 1 year after cholecystectomy 34 per cent of patients still suffered some abdominal pain and of 35 patients referred back to hospital for investigation none has been shown to have a retained bile duct stone at a minimum follow-up of 5 years. A multivariate analysis indicated that preoperative flatulence together with long duration of attacks of pain are risk factors for postoperative dissatisfaction as judged by a linear analogue scale. However, both these factors are common and neither is a good discriminator of a poor outcome. The prediction of a poor symptomatic outcome after cholecystectomy from preoperative symptoms or patient characteristics had only limited success and all patients should be warned of this risk.
Non-operative management of blunt liver injuries
Authors: Hollands M J , Little J M
Published: March 2007

Over a 10-year period 281 patients with liver injuries following blunt abdominal trauma were seen at Westmead Hospital. A decision to treat the liver injury without an operation was made in 55 (20 per cent) of the 281 patients. Two of these 55 patients required a subsequent laparotomy, one for continued bleeding and one for a bile leak. No patient died from a missed intra-abdominal or retroperitoneal injury or from concealed haemorrhage. These patients were compared with 181 patients with liver injuries who were operated on. The two groups of patients could be distingushed in terms of their clinical status on arrival at the hospital, the magnitude of their injury and the sequelae of the injury. Non-operative management proved a safe alternative to an operation in appropriate patients, but a laparotomy to exclude unsuspected intra-abdominal injuries is associated with little significant morbidity and offers some reassurance in managing patients with multiple injuries.
Pancreatic pseudocysts: A proposed classification and its management implications
Authors: D'Egidio A , Schein M
Published: March 2007

Pancreatic pseudocysts in 83 patients were classified according to clinical and radiographic criteria. Group I (45 patients) had acute, ‘post-necrotic’ pseudocysts with normal pancreatic duct anatomy and rarely duct—pseudocyst communication. Percutaneous drainage was curative in all patients in whom it was used. Group II (26 patients) included ‘post-necrotic’ pseudocysts developing in patients already suffering from chronic pancreatitis. The pancreatic duct was diseased but not strictured, and duct—pseudocyst communication was often present. Percutaneous drainage is possible for such patients but it may have to be prolonged; surgical internal drainage was usually successful. Group III (12 patients) had chronic ‘retention’ pseudocysts. The pancreatic duct was grossly diseased and strictured and duct—pseudocyst communication was present in all cases. Percutaneous drainage is contraindicated and surgical internal drainage has a high recurrence rate. Operative procedures in this group should address the specific ductal pathology. An improved classification of pseudocysts could help the surgeon to choose the most appropriate form of treatment.
Controlled trial of polyglycolic acid versus catgut and nylon for appendicectomy wound closure
Authors: Wetter L A , Dinneen M D , Levitt M D , Motson R W
Published: March 2007

Six hundred and fifty patients undergoing appendicectomy were included in a prospective randomized controlled trial. At operation patients were allocated to control (chromic catgut ligatures and muscle closure, nylon skin closure) or study (polyglycolic acid ligatures and muscle and skin closure) groups. Wounds were examined by an independent observer daily in hospital and 1 month after operation. Wound infection was defined as discharge of serous or purulent material, or a grossly inflamed wound without discharging pus, or any evidence of intra-abdominal sepsis. Of the 650 patients (335 men, 315 women, age 5–80 years, median 18 years), 615 have completed follow-up. Groups were well matched for age, sex, degree of sepsis at operation, histological diagnosis and surgeon. Infection was significantly reduced in the study (polyglycolic acid) group (12·0 per cent) compared with the control (chromic catgut/nylon) group (21·2 per cent) (ξ2 = 9·3, P = 0·002). Infection was significantly reduced in the polyglycolic acid group regardless of whether the appendix was inflamed or normal. These results indicate that suture material can influence the incidence of wound infection and that this is less frequent when polyglycolic acid sutures are used.
Comparison of iliofemoral and femorofemoral crossover bypass in the treatment of unilateral iliac arterial occlusive disease
Authors: Hanafy M , McLoughlin G A
Published: March 2007

Between 1981 and 1988, 74 synthetic crossover bypass grafts were inserted for unilateral iliac arterial occlusive disease. In 32 patients the bypass procedure was iliofemoral and in 42 femorofemoral. The cumulative patency rate at a mean of 2·7 years was 79 per cent in both groups. There was no significant difference in either postoperative mortality rate or duration of hospital stay. Iliofemoral bypass may offer significant advantages over the femorofemoral approach. In particular it avoids a groin incision in the donor limb, leaving the common femoral artery intact for subsequent angioplasty or reconstruction should proximal stenotic disease develop in the donor iliac vessel.
Cervical spine injuries in patients with head injuries
Authors: Soicher E , Demetriades D
Published: March 2007

It is generally believed that significant head injury after a traffic accident or fall is associated with a high incidence of concurrent cervical spine injury. This study prospectively examined 260 victims of traffic accidents or falls with significant head injury. The incidence of associated cervical spinal injury was only 3·5 per cent. There was no association between the severity of head injury and the incidence of cervical spine injury. The risk of concurrent spinal injury in head injury patients is not higher than the reported risk in patients without head injury. Although care should be taken to protect the cervical spine in patients with head injury, the results of the present investigation show that the risk of cervical spine injury is much less than previously reported.
Endothelium-derived relaxing factor and vein grafts
Authors: Komori K , Okadome K , Sugimachi K
Published: March 2007

Platelet thrombosis, intimal hyperplasia and progression of atherosclerosis are the most important factors determining the patency of vein grafts for arterial occlusive disease. Interactions between aggregating platelets and the vessel wall play an important role in all of these processes. Recently, it has become evident that the endothelium modulates the underlying vascular smooth muscle by releasing an endothelium-derived relaxing factor, a potent vasodilator and anti-aggregating substance. Little information is available, however, on such endothelial functions of autogenous vein grafts. This review focuses on vascular modulation by endothelium-derived relaxing factor in vein grafts.
Postsplenectomy sepsis and its mortality rate: Actual versus perceived risks
Authors: Holdsworth R J , Irving A D , Cuschieri A
Published: March 2007

A collective critical review of the literature on postsplenectomy sepsis from 1952 to 1987 has been undertaken. The reports cover a cohort of 12 514 patients undergoing splenectomy but of these only 5902 reports were sufficiently detailed to allow a useful analysis. The incidence of infection after splenectomy in children under 16 years old was 4.4 per cent with a mortality rate of 2.2 per cent. The corresponding figures for adults were 0.9 per cent and 0.8 per cent respectively. The present analysis of well documented patients has shown that severe infection after splenectomy for benign disease is very uncommon except in infants (infection rate 15.7 per cent) and children below the age of 5 years (infection rate 10.4 per cent). Many of these reported postsplenectomy infections may have been coincidental. It is also apparent that children contract a different type of infection after splenectomy than adults, predominantly a meningitis which is less frequently fatal. Adults, in contrast, appear to develop a septicaemic type of illness associated with a higher mortality rate. This survey has also shown that children are reported to be no more susceptible to pneumococcal sepsis than to infection caused by any other organism. Although the removal of the spleen in otherwise normal people does not appear to be associated with an increased frequency of infection, the presence of a coexistent disorder, notably hepatic disease, can increase the risk substantially.
Clinical and functional outcome after restorative proctocolectomy
Authors: de Silva H J , de Angelis C P , Soper N , Kettlewell M G W , Mortensen N J McC , Jewell D P
Published: March 2007

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has been carried out on 88 patients since 1982. Three different pouch designs (J, S and W) were used. Ten pouches had to be removed. Detailed analysis was performed on 61 patients (J = 23, S = 15, W = 23) whose pouches had been functioning for at least 6 months. There was no significant difference in surgical complications before or after ileostomy closure between pouch designs but the hospital stay was greater after construction of an S pouch (P<0.05). There were no significant differences in stool frequency, degree of continence or urgency between the three types. Twelve patients with J pouches required antidiarrhoeal medication compared with only one with S and five with W pouches. Only seven patients with S pouches could defaecate spontaneously compared with 22 with W pouches and all patients with J pouches (P<0.001). Twenty-five of 29 patients who had preservation of the anal transition zone had perfect continence compared with 23 of 32 with a mucosal proctectomy (P = n.s.). Pouchitis occurred in 13 patients, all of whom had ulcerative colitis. In a subgroup of 23 patients, pouch evacuation was assessed scintigraphically. There was no difference in pouch capacity or total volume evacuated, but spontaneous evacuation was better in J and W pouches compared with S pouches.
Surgical restraint in the management of liver trauma
Authors: Watson C J E , Calne R Y , Padhani A R , Dixon A K
Published: March 2007

Previous experience in Cambridge in the management of liver trauma has led to the evolution of a protocol for surgical intervention to secure control of haemorrhage from the injured liver. We report 80 cases of liver trauma including 12 who were initially managed non-operatively; three of these subsequently required operation. Of the 80, all but five suffered blunt abdominal trauma. Perihepatic packing was used to manage 29 patients, of whom 21 were initially treated elsewhere before being transferred to Cambridge. Six of these required a hemihepatectomy at subsequent exploration. Of the 39 patients who underwent urgent laparotomy and definitive surgery, 11 (28 per cent) died; only three out of 29 (10 per cent) died after initial packing. Only one death from hepatic complications occurred after packing and subsequent transfer.
Graft versus host disease in small bowel transplantation
Authors: Ingham Clark C L , Price B A , Malcolm P , Lear P A , Wood R F M
Published: March 2007

Quantities of organized lymphoid tissue in small bowel allografts may cause graft versus host disease (GVHD) following transplantation. This study examines the effect of graft mesenteric lymphadenectomy on development of GVHD following small bowel transplantation in rats. GVH reactivity was assessed by measuring the degree of graft cell emigration to the host. In the PVG to DA strain combination, graft mesenteric lymphadenectomy led to a significant reduction in graft cell colonization of host lymphoid tissues from 40–50 per cent to 25–35 per cent. Transplantation from PVG to (PVG × DA)F1 hybrids caused fatal GVHD within 21 days whereas when DA donors were used survival was over 30 days. When mesenteric lymphadenectomy was performed on PVG donors, host survival increased by only 3–4 days. Mesenteric lymphadenectomy in DA donors led to long-term recipient survival with no GVHD. Intensity of GVHD following rat small bowel transplantation is a strain-dependent phenomenon and graft mesenteric lymphadenectomy does not always prevent GVHD. The mucosa may have an important immunological role.
Injection sclerotherapy for bleeding varices: Risk factors and complications
Authors: McKee R F , Garden O J , Carter D C
Published: March 2007

Risk factors for complications after injection sclerotherapy were studied in 163 patients undergoing 667 treatments for bleeding oesophageal varices. The overall mortality rate was 7 per cent per injection sclerotherapy session; 16 per cent per acute session and 2.4 per cent per elective session. Acute variceal bleeding was controlled by injection sclerotherapy in 91 per cent of patients. Complications occurred after 16 per cent of injection sclerotherapy sessions. Deaths and complications were significantly associated with poor modified Child's grading (P<0.001), the first variceal bleed (P<0.001), acute injection sclerotherapy (P<0.001) and the use of the rigid oesophagoscope (P<0.001).
Perineal injuries in children
Authors: Jones L W , Bass D H
Published: March 2007

Over a 12-year period, 463 children under 13 years of age were treated for perineal injuries. The most common cause of injury was a fall astride, but motor vehicle trauma and rape were responsible for most of the severe and multiple injuries. Physical or sexual abuse was evident in 178 (38 per cent) of children, and four sustained injuries from forceful enema. Minor abrasions or first degree tears (88 per cent) and second degree tears (6 per cent) were sutured primarily or allowed to granulate with sepsis rates of 1.2 per cent and 14 per cent respectively. Twenty-nine (6 per cent) children sustained third degree lacerations; one died from secondary pelvic haemorrhage. In the 28 survivors, the outcome of primary (18) or delayed (ten) surgical repair was related to whether or not early defunctioning colostomy had been performed.
Ruptured aortic aneurysm: A proposed classification
Authors: Callam M J , Haiart D , Murie J A , Ruckley C V , Jenkins A McL
Published: March 2007

There is a wide variation in reported operative mortality rates for ruptured abdominal aortic aneurysm, ranging from 14 to 70 per cent. Although many factors influence this variation, such as the expertise and facilities available at an individual institution, considerable differences could be due to variations in the pattern of referral and the proportion of cases accepted for operation. In this paper a classification applicable to all patients with ruptured aortic aneurysm is proposed; it has been applied prospectively to 100 consecutive patients with ruptured abdominal aortic aneurysm referred to the Edinburgh Vascular Surgical Unit. The classification illustrates how surgical mortality rates ranging from 29 to 52 per cent may be reported using the same mortality data. Two major benefits may derive from the use of such a standard reporting system. Firstly, it allows management deficiencies to be identified easily and, secondly, it should facilitate comparison of results reported from different centres.
Surgical training: A report to the Association of Surgeons of Great Britain and Ireland
Authors: Jones P F
Published: March 2007

During the author's tenure (1990–1991) of the British Journal of Surgery Travelling Fellowship of the Association of Surgeons of Great Britain and Ireland, a study was made of surgical training in this country and abroad. This report outlines certain beneficial changes which may be made in UK training programmes.
Frequency of familial colorectal cancer
Authors: Stephenson B M , Finan P J , Gascoyne J , Garbett F , Murday V A , Bishop D T
Published: March 2007

Familial clustering of cancer is not uncommon. The frequency of familial colorectal cancer was estimated by taking family histories from 100 patients presenting with apparently sporadic colorectal cancer. Compared with controls, the relative risk of a positive family history for colorectal cancer was 4·6. Life-table methods were used to examine the observed to expected mortality from colorectal cancer. Overall there was a fourfold increase in mortality rate (P < 0·0001), which was greatest in female relatives of patients with colonic cancer (P < 0·001). Three families with dominant inheritance of colorectal cancer and one family with Lynch type II syndrome were identified. Nine per cent of patients had siblings who had developed colorectal cancer a median of 4 years before the diagnosis of the index patient (range 1–17 years). It is recommended that a careful family history should be obtained from all patients with colorectal cancer. Where a positive history is obtained a geneticist may determine empirical risks for the development of colorectal cancer and the appropriate method of surveillance may be selected.
Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy
Authors: Joyce W P , Keane R , Drumm J , Egan T J , Delaney P V , Burke G J , Daly M
Published: March 2007

To identify patients with common bile duct stones, all patients considered for laparoscopic cholecystectomy in this unit undergo intravenous cholangiography (IVC) with tomography and, more recently, operative cholangiography. To date 100 consecutive patients with symptomatic gallstones have undergone laparoscopic cholecystectomy with no specific exclusion criteria. Eight patients of 100 were found to have duct stones on IVC with one false-positive. These IVC data were compared with data from 52 patients who also had operative cholangiograms performed. One stone was detected on operative cholangiography that was not identified on IVC. No additional information was gained from operative cholangiography. These data suggest that preoperative IVC is adequate for the detection of duct stones in patients considered for laparoscopic cholecystectomy.