bluuebunny/crossref_metadata_2025 huggingface dataset:
Central venous pressure and its effect on blood loss during liver resection
Authors: Jones R McL , Moulton C E , Hardy K J
Published: March 2003

Background

Any strategy to reduce blood loss in liver resection and decrease blood transfusion would be of benefit to the patient and surgeon. This study evaluates the association of central venous pressure (CVP) with blood loss and blood transfusion during liver resection.

Methods

One hundred consecutive hepatic resections in the period 1986–1996 were studied prospectively concerning CVP, volume of blood lost, and volume of blood transfused. Blood loss volume and blood transfusion were analysed for those with a CVP less than or equal to 5 cmH2O, and greater than 5 cmH2O. A multivariate analysis assessed potential confounding factors in the comparison.

Results

The median blood loss in patients with a CVP of 5 cmH2O or less was 200 ml (n = 40) and that in those with a CVP above 5 cmH2O was 1000 ml (n = 52) (P = 0·0001). Only two of 40 patients with a CVP of 5 cmH2O or less had a blood transfusion whereas 25 of 52 patients with a CVP greater than 5 cmH2O required a transfusion (P = 0·0008). A multivariate analysis did not show confounding factors.

Conclusion

The volume of blood lost during liver resection correlates with the CVP. Lowering the CVP to less than 5 cmH2O is a simple and effective way to reduce blood loss during liver surgery.
Influence of luminal obstruction on oesophageal cancer staging using endoscopic ultrasonography
Authors: Vickers J , Alderson D
Published: March 2003

Background

Endoscopic ultrasonography is technically limited in patients with obstructing oesophageal cancers if the endoscope cannot pass beyond the lesion. This problem may be overcome by preliminary endoscopic tumour dilatation, or by the use of narrower calibre ‘blind’ endoscopic ultrasonographic telescopes or fine-bore endoscopic ultrasonographic miniprobes. These alternatives are either potentially hazardous or time consuming and expensive. The aim of this prospective study was to determine the effect of oesophageal obstruction on the locoregional staging accuracy of endoscopic ultrasonography for oesophageal cancer.

Methods

Some 50 patients with oesophageal cancer underwent staging with endoscopic ultrasonography before oesophagectomy and the T and N stage determined by endoscopic ultrasonography was compared with final histology. In 11 cases of luminal obstruction no attempt was made to overcome the blockage and a limited mediastinal scan alone was performed.

Results

Malignant obstruction of the oesophagus did not greatly reduce the staging accuracy of endoscopic ultrasonography. It correctly assessed local infiltration in all patients with obstruction, and correctly predicted nodal stage in nine of 11 patients.

Conclusion

Tumours large enough to cause luminal obstruction are nearly all full thickness (T3), and frequently have mediastinal lymph node metastases (N1) at the time of examination. This can usually be detected from limited endoscopic ultrasonography within the mediastinum.
Selective management of renal gunshot wounds
Authors: Velmahos G C , Demetriades D , Cornwell E E , Belzberg H , Murray J , Asensio J , Berne T V
Published: March 2003

Background

Gunshot wounds to the kidney have been managed traditionally by surgical exploration. Concerns over increased nephrectomy rates and unnecessary explorations have placed this method under scrutiny. Selective renal exploration based on solid clinical and radiographic criteria may be a safer alternative and deserves evaluation.

Methods

The medical records of 52 consecutive patients with renal gunshot wounds, who were managed between September 1994 and August 1995 by a protocol of selective exploration, were reviewed. Renal injuries were explored only if they involved the hilum or were accompanied by signs of continued bleeding. Main outcome measures were the numbers of kidneys lost, as well as the morbidity and mortality related to the management of the renal injury.

Results

Three patients died from associated injuries shortly after admission. Fifteen patients suffered complications but only two had complications directly associated with the renal injury. Thirty-two patients underwent renal exploration and 17 of them required nephrectomy for major renovascular or parenchymal trauma (grade IV and V). Renal exploration was successfully avoided in the remaining 20 patients. No kidneys were lost unnecessarily as a result of this policy.

Conclusion

Mandatory exploration of all gunshot wounds to the kidney is not necessary. Injuries that produce stable peripheral haematomas do not require exploration.
Physiological and functional outcome following ultra-low anterior resection with colon pouch–anal anastomosis
Authors: Williams N , Seow-Choen F
Published: March 2003

Background

Low rectal cancer is usually managed by ultra-low anterior resection (ULAR) with total mesorectal excision and straight coloanal anastomosis. However, following this procedure patients often suffer from frequency, urgency of bowel action and, occasionally, faecal incontinence. To overcome such problems, a colon pouch may be fashioned and a subsequent colon pouch–anal anastomosis performed. The physiological and functional outcome following the use of a colon pouch are appraised.

Methods

All relevant papers identified from a Medline search and papers from cross-referencing were reviewed.

Results and Conclusion

Creation of a colon pouch following ULAR results in reduced bowel frequency, and a lower incidence of urgency and faecal incontinence. Although there is a slightly increased incidence of evacuatory disorder and need for enemas or suppositories, this appears to be a minor problem which may possibly be overcome by using a smaller colon pouch. Compared with straight coloanal anastomosis following ULAR, the creation of a colon pouch produced a superior functional outcome.
Quality of life after treatment for rectal cancer
Authors: Camilleri-Brennan J , Steele R J C
Published: March 2003

Background

The studies on patient-reported symptoms and quality of life following the treatment of rectal cancer were evaluated; guidelines for future quality of life studies in this field are proposed.

Methods

Relevant papers in the English language were identified via Medline from January 1970 to November 1997, supplemented by a manual search for similar articles.

Results

Patients suffer various short- and long-term complications after treatment of rectal cancer, although the reported prevalence of such problems varies from study to study. Recent prospective studies have shown that, despite these problems, global quality of life scores as measured by generic questionnaires improve after surgery.

Conclusion

The methodological shortcomings of previous work must be rectified if quality of life studies are to have relevance in patient management.
Results of surgical resection of liver metastases from non-colorectal primaries
Authors: Berney T , Mentha G , Roth A D , Morel P
Published: March 2003

Background

Advances in the field of liver surgery have lowered its associated mortality and morbidity rates, and hepatic resection for metastatic disease is increasingly performed. There are few well defined guidelines for the heterogeneous group of non-colorectal metastases. This study analysed the risks and benefits of surgical resection for liver metastases from non-colorectal primaries.

Methods

A retrospective study was performed of 34 patients who underwent 37 operations over a 10-year period. Compilation of data from 141 patients from eight additional recent series was performed in order to analyse the effect of histological type on survival.

Results

There were no perioperative deaths. Complications occurred after seven of 37 procedures. Actuarial survival rates were 61, 43 and 27 per cent at 1, 2 and 5 years. Survival was significantly improved for curative versuspalliative resection (P < 0·05), and for single versus multiple metastases (P < 0·05). A strong correlation was observed between time to presentation with metastasis and length of survival (P < 0·0001). Survival was significantly better for patients with secondaries from neuroendocrine tumours (P < 0·0001), worse for those with intestinal adenocarcinomas (P < 0·0001) and similar for patients with breast carcinoma (P > 0·5) when compared with the whole group.

Conclusion

The low mortality and morbidity rates and the satisfactory survival figures reported justify this type of surgery for selected patients, in the absence of therapeutic alternatives.
Effects of loperamide on ileoanal pouch function
Authors: Herbst F , Kamm M A , Nicholls R J
Published: March 2003

Background

Opioid analogues are used to manage increased bowel frequency in patients with an ileoanal reservoir. The aim of the study was to determine the clinical efficacy of loperamide in patients with an ileoanal reservoir and to assess its effect on pouch motility.

Methods

Fourteen patients with a pouch who had normal pouch emptying and anal function were studied. Ambulatory pouch and anal motility, and stool weights, were recorded for 24 h while taking no medication and for 24 h while receiving 8 mg loperamide. In a second analysis, patients were divided on the basis of bowel frequency into those with 4 or fewer motions (good function; n = 6) and those with more than 6 per day (poor function; n = 8), to determine any differential effects of loperamide.

Results

Loperamide decreased median bowel frequency (no loperamide 5·5 versus loperamide 4·0, P = 0·03) and 24-h stool weight (610 g versus 413 g, P = 0·03) but not individual stool weights. Patients with poor function had both higher bowel frequency (8·0 versus 3·5 per 24 h, P = 0·004) and higher stool weight (728 g versus 430 g, P = 0·05) with no treatment than those with good function. High-amplitude pouch pressure waves were greater in number before defaecation in patients with poor function and did not decrease with loperamide, in contrast to patients with good function. Pouch baseline pressure decreased after defaecation to a similar extent in both groups and was not affected by loperamide.

Conclusion

Loperamide 8 mg per day reduces bowel frequency by reducing total stool weight, not individual stool weights. In patients with good function it also affects pouch motility. High bowel frequency is associated with increased pouch high-pressure waves.
Acute non-traumatic arm ischaemia
Authors: Eyers P , Earnshaw J J
Published: March 2003

Background

Much attention has been paid to the management of acute leg ischaemia. Acute arm ischaemia is perceived as less of a problem because the risk of limb loss is lower. After conservative treatment up to half the patients have late symptoms, such as forearm claudication.

Methods

This study was a review of all published English language data on acute arm ischaemia. The entire Medline database was searched and other references were derived from the material perused. There were no randomized or controlled studies.

Results

The incidence of acute arm ischaemia is one-fifth that of acute leg ischaemia. Patients with arm ischaemia tended to be older with a mean age of 74 years compared with 70 years for acute leg ischaemia. Since the development of the embolectomy catheter, embolectomy can be performed in most patients under local anaesthetic. Collected outcome included successful restoration of the circulation in 65–94 per cent of patients and amputation in 0–18 per cent. The mortality rate ranged from 0 to 19 per cent, despite the use of local anaesthesia, mostly from associated cardiac disease. Management by a vascular specialist may be beneficial, particularly in complex cases.

Conclusion

An active approach to the management of acute arm ischaemia is safe and effective and reduces the risk of late disabling symptoms.
Current management of acute leg ischaemia: results of an audit by the vascular surgical society of Great Britain and Ireland
Authors: Campbell W B , Ridler B M F , Szymanska T H
Published: March 2003

Background

Management of acute leg ischaemia has changed in recent years. This study aimed to elucidate current practice throughout the UK and Ireland.

Methods

Surgeons and audit departments were asked to return a questionnaire about every episode of acute leg ischaemia seen in the hospital between 1 January and 31 March 1996.

Results

A total of 539 episodes were reported in 474 patients (248 men) aged 19–96 (median 73) years. Common causes were thrombosis in situ (41 per cent), embolism (38 per cent) and graft or angioplasty occlusion (15 per cent). Vascular surgical advice was requested in 95 per cent of cases. Initial management was: immediate embolectomy in 21 per cent, anticoagulants in 13 per cent and no vascular intervention in 10 per cent. Arteriography was done in 56 per cent, followed by 186 endovascular and 165 surgical interventions. At 30 days, 70 per cent of limbs were definitely viable and 16 per cent had been amputated. The mortality rate was 22 per cent. Cases were reported by 86 of 182 hospitals contacted, but some referred no patients, and a supplementary audit of 54 cases (10 per cent size of the original sample) from non-contributing hospitals showed no important differences.

Conclusion

Patients with acute leg ischaemia are generally treated by vascular specialists, with modern methods and acceptable results. This is being achieved despite insufficient vascular surgeons and radiologists for formal emergency rotas in most hospitals.
Current surgical practice in screening for colorectal cancer based on family history criteria
Authors: Scholefield J H , Johnson A G , Shorthouse A J
Published: March 2003

Background

As awareness about colorectal cancer increases there has been a steady rise in the number of referrals of relatives of patients with colorectal cancer to colorectal surgeons for screening investigations based on family history criteria. Surgeons are generally not trained in either risk assessment of inherited colorectal cancer or genetic counselling. As this is a relatively new area of service, there is likely to be variation in the management of these individuals.

Methods

This study investigated the family history criteria used and the colonic screening practices employed by a group of consultant colorectal surgeons by means of a postal questionnaire distributed and collected through their specialist association.

Results

The results show not only wide variation in the practice of colorectal screening based on family history criteria, but also a considerable waste of resources in the provision of illogical and inappropriate investigations.

Conclusion

Given the lack of evidence on which to base this clinical practice and the current financial difficulties in the health service, the authors question whether it is appropriate for surgeons to continue to provide such a service.
Water-soluble contrast study predicts the need for early surgery in adhesive small bowel obstruction
Authors: Chen S-C , Lin F-Y , Lee P-H , Yu S-C , Wang S-M , Chang K-J
Published: March 2003

Background

Background The optimal period of conservative treatment for adhesive small bowel obstruction remains controversial. This study sought to determine whether a 24-h abdominal radiograph after oral Urografin is a reliable indicator for operation in patients with adhesive small bowel obstruction.

Methods

One hundred and sixty-one patients who suffered from adhesive intestinal obstruction without clinical evidence of strangulation or gangrene underwent a Urografin study. Some 40 ml Urografin mixed with 40 ml distilled water was administered either orally or via a nasogastric tube to each patient. Serial plain abdominal radiographs were taken 4, 8, 16 and 24 h later. If an earlier plain radiograph showed that contrast medium had reached the ascending colon, subsequent radiographs were not taken.

Results

Contrast medium reached the colon within 24 h in 112 patients (70 per cent). These patients were all treated successfully with non-operative methods. Contrast medium was not observed in the colon within the first 24 h in 49 patients (30 per cent). Operation was performed in 47 of these patients and non-operative treatment was given in two. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of Urografin reaching the colon within 24 h as an indicator for non-operative treatment were 98, 100, 99, 100 and 96 per cent respectively.

Conclusion

All patients with evidence of Urografin reaching the colon within 24 h were treated successfully with non-operative methods. The results of this prospective study suggest that patients with adhesive intestinal obstruction in whom contrast medium fails to reach the colon within 24 h should receive prompt surgical intervention.
Influence of study design on reported mortality and morbidity rates after abdominal aortic aneurysm repair
Authors: Blankensteijn J D , Lindenburg F P , Van Der Graaf Y , Eikelboom B C
Published: March 2003

Background

The mortality and morbidity rates of elective abdominal aortic aneurysm (AAA) surgery, as reported over the past 12 years, were graded and analysed by levels of evidence.

Methods

Articles on elective AAA surgery published between 1985 and 1996 were retrieved and classified into five levels of evidence. Level 1 contains prospective studies and is subdivided into population-based (level 1a) and hospital-based (level 1b) studies. Level 2 includes retrospective studies, subdivided into population-based studies (level 2a), hospital-based studies (level 2b) and hospital-based studies concerning a specified group of selected patients (level 2c). Operative mortality and systemic and local/vascular complication rates with 95 per cent confidence intervals were calculated for each level of evidence.

Results

Seventy-two articles describing a total of 37 654 patients could be included: two level 1a studies (692 patients), nine level 1b studies (1677 patients), 13 level 2a studies (21 409 patients), 32 level 2b studies (12 019 patients) and 16 level 2c studies (1857 patients). The mean 30-day mortality rates of the two population-based levels were similar: 8·2 (95 per cent confidence interval 6·4–10·6) per cent for the prospective (1a) and 7·4 (7·0–7·7) per cent for the retrospective (2a) series. These figures were significantly higher than the remarkably similar hospital-based mortality rates: 3·8 (3·0–4·8) per cent for the prospective (1b), 3·8 (3·5–4·2) per cent for the retrospective (2b) and 3·5 (2·8–4·4) per cent for selected patient group (2c) studies. The most frequent complication was of cardiac origin. In the population-based series the cardiac complication rates were 10·6 (8·5–13·2) and 11·1 (9·1–13·6) per cent for levels 1a and 2a respectively. This compared well with 12·0 (10·5–13·9) per cent for the prospective hospital-based series (level 1b). The cardiac complication rates in the retrospective hospital-based studies were significantly lower: 8·9 (8·4–9·5) and 6·1 (4·9–7·6) per cent for levels 2b and 2c respectively.

Conclusion

There is a clear and consistent disagreement in reported mortality rates between hospital-based and population-based studies of elective surgery for AAA. Prospective studies give the best documentation of postoperative morbidity.
Scanning laser Doppler flowmetry and intraluminal recirculating gas tonometry in the assessment of gastric and jejunal perfusion during oesophageal resection
Authors: Boyle N H , Pearce A , Hunter D , Owen W J , Mason R C
Published: March 2003

Background

The ability of the new techniques of scanning laser Doppler flowmetry and recirculating gas tonometry to measure changes in gastric serosal and mucosal blood flow respectively during oesophageal resection was assessed.

Methods

Changes in regional and total gastric blood flow were assessed in 16 patients undergoing oesophagectomy at three stages of the procedure. Laser Doppler images were analysed and perfusion expressed as mean perfusion units. Tonometric measurements of gastric and jejunal intramucosal pH (pHi) were made synchronously.

Results

There were significant falls in gastric perfusion measured with scanning laser Doppler flowmetry in all subjects between each measurement. Mean perfusion of the stomach fell 41 per cent after mobilization. There was a gradient of reduced perfusion between the antrum (mean fall 25 per cent) and the area used for the anastomosis in the fundus (mean fall 55 per cent). Before mobilization mean gastric and jejunal pHi were 7·37 and 7·46 respectively. These fell to 7·18 and 7·37 respectively after mobilization and to 7·29 and 7·38 after anastomosis.

Conclusion

These new techniques could be employed at operation, appear to overcome the limitations of single-point laser Doppler flowmetry and saline tonometry, and have measured significant changes in gastric perfusion. They may have widespread clinical application.
Changing trends in the management of phaeochromocytoma
Authors: Geoghegan J G , Emberton M , Bloom S R , Lynn J A
Published: March 2003

Background

The recent experience of a specialist endocrine surgery unit in the management of phaeochromocytoma is reviewed.

Methods

Over a 14-year period (June 1978 to June 1992) 43 patients (14 men, 29 women) with a mean age of 42 years were referred with phaeochromocytoma.

Results

Biochemical confirmation was usually by measurement of 24-h urinary vallinylmandelic acid. From 1980 venous sampling was replaced by computed tomography as the primary localizing procedure. 131I-meta-iodobenzylguanidine scintigraphy was used in all patients between 1984 and 1987, but selectively after that. With regard to the operative approach used, between 1978 and 1983 midline or flank incisions were used, and from 1984 to 1992 subcostal or posterior approaches were used predominantly. There was one operative (30-day) death. One patient died 24 months after operation from recurrent malignant phaeochromocytoma, and three patients died during follow-up from unrelated causes. The remaining patients (mean follow-up 30 months) have no evidence of recurrent phaeochromocytoma, although four remain on antihypertensive medication.

Conclusion

Improved imaging of phaeochromocytoma obviates the need for transperitoneal exploration, allowing selected phaeochromocytomas to be successfully managed using an extraperitoneal approach.
Investigation of oesophageal reflux symptoms after gastric surgery with combined pH and bilirubin monitoring
Authors: Marshall R E K , Anggiansah A , Owen W A , Owen W J
Published: March 2003

Background

Little is known about the role of bile in gastro-oesophageal reflux disease in patients with previous gastric surgery. This has partly been due to a lack of suitable techniques for identifying bile reflux objectively.

Methods

Some 28 patients with reflux symptoms and previous gastric surgery underwent oesophageal manometry, and 24-h ambulatory oesophageal pH and bilirubin monitoring.

Results

A wide variety of operations had been performed, most commonly Pólya gastrectomy (seven patients), vagotomy and pyloroplasty (six) and vagotomy and gastrojejunostomy (four). Three patients had isolated acid reflux, eight had isolated bile reflux, six had combined acid and bile reflux, and 11 patients had no reflux. Two-thirds of heartburn symptoms were not associated with reflux. However, one-quarter were associated with acid reflux and only 7 per cent with bile reflux. Erosive oesophagitis was present in five patients: two with combined acid and bile reflux, and three with isolated bile reflux.

Conclusion

Acid and/or bile reflux can be present after a wide variety of gastric operations. Symptoms are more frequently associated with acid reflux than with bile reflux. Erosive oesophagitis can occur in the presence of isolated bile reflux. Combined pH and bilirubin monitoring determines the nature of the refluxate, and may help in the management of these patients.
Assessment of potential donors for living related liver transplantation
Authors: Baker A , Dhawan A , Devlin J , Mieli-Vergani G , O'Grady J , Williams R , Rela M , Heaton N
Published: March 2003

Background

Living related liver transplantation has been developed as an important potential source of organs for treatment of children with acute and chronic liver disease. A single UK centre performing living related liver transplantation was established in 1993.

Methods

Parents who were potential donors for their children for living related liver transplantation were assessed for suitability according to a protocol based on one developed and published by the University of Chicago Transplant Group. Records kept by the transplant coordinators were retrieved and data were extracted.

Results

Of 64 potential donors for 32 potential recipients ten were excluded at a preliminary stage. Fourteen ultimately became donors. Of 54 parents who began evaluation 23 were finally considered to be suitable. There were 19 non-disease-related reasons for unsuitability: blood group mismatch (eight cases), size discrepancy (six), pregnancy (two), oral contraceptive medication (one), vascular anatomy variant (one) and age (one). Sixteen were unsuitable because disease was found, namely fatty liver (four), thyroid disease (two), hepatitis B positivity (two), cardiac murmur (one), anaemia (one), glucose-6-phosphate dehydrogenase deficiency (one), diabetes mellitus (one) and psychological problems (one), and three parents were affected by the same disorder as the child (Alagille syndrome, one; mitochondrial disorder, one; recurrent cholestasis, one). Three parents were rejected for more than one reason. Both parents were unsuitable for donation in 21 per cent of cases.

Conclusion

Parents approach living related liver transplantation with enthusiasm. They should be advised of the high chance of unsuitability, including the finding of significant pathology. The limitation of living related liver transplantation as the major source of organs for children is recognized.
Indicators of recurrence following cryotherapy for hepatic metastases from colorectal cancer
Authors: Seifert J K , Morris D L
Published: March 2003

Background

This retrospective review aimed to assess the incidence of local recurrence at the cryosite, hepatic and extrahepatic recurrence and the corresponding disease-free intervals. Prognostic indicators following hepatic cryotherapy were also identified.

Methods

Eighty-five patients underwent complete cryotreatment of colorectal liver metastases between April 1990 and May 1997. Possible prognostic indicators were tested for their impact on the disease-free interval at the cryosite, liver disease-free survival and overall disease-free survival with univariate and multivariate analysis.

Results

At a median follow-up of 22 months 66 patients developed tumour recurrence: 18 in the liver only; 15 in the liver and lung; 22 in the liver and extrapulmonary areas; and 11 at extrahepatic sites only. Local recurrence at the cryosite occurred in 28 patients. Cryotreated metastases larger than 3 cm were associated with a shorter disease-free interval at the cryosite and liver disease-free survival; persistently raised serum carcinoembryonic antigen (CEA) levels after operation were associated with shorter liver disease-free and overall disease-free intervals in multivariate analysis.

Conclusion

Improvements in probe placement and monitoring of the freezing process are required to allow successful treatment of large liver metastases. A failure in complete postoperative CEA response indicates that hepatic or extrahepatic disease was not detected before operation, which may be avoided with better staging procedures.
Differences in contractile properties of anorectal smooth muscle and the effects of calcium channel blockade
Authors: Cook T A , Brading A F , Mortensen N J McC
Published: March 2003

Background

Pharmacological manipulation of the anal sphincter is hampered by a lack of specificity. This study aimed to determine differences in the role of intracellular and extracellular calcium in the development of tone and agonist-induced contractions between internal anal sphincter (IAS) and rectal circular muscle which might allow targeted manipulation.

Methods

Smooth muscle strips from the IAS and rectal circular muscle of 24 Large White pigs were mounted for isometric tension recording in a superfusion organ bath in the presence of different perfusates.

Results

IAS developed tone and spontaneous activity that were abolished by nifedipine, which also reduced contractions to noradrenaline to 72 per cent of control values. Rectal smooth muscle developed spontaneous activity but no tone. Nifedipine abolished the activity and reduced contractions to carbachol to 17 per cent of control. Contractile activity was abolished in both tissues in calcium-free solution. Transient exposure to a high calcium concentration reloaded the stores, and the ability of agonists to release stored calcium was tested after 3 min in calcium-free solution. In IAS, noradrenaline contraction was 76 per cent of control and in rectal circular muscle carbachol contraction was 57 per cent of control. Store loading was prevented by nifedipine in rectal smooth muscle but not IAS. Cyclopiazonic acid reduced store filling in both tissues.

Conclusion

Agonist-induced contraction of IAS is largely due to release of stored calcium and L-type calcium channels are not needed for store filling. Rectal circular smooth muscle depends more on extracellular calcium and uses L-type calcium channels for agonist-induced contraction and store filling. These differences suggest that targeted manipulation may be possible in patients with anorectal disorders.
Day-case haemorrhoidectomy
Authors: Hunt L , Luck A J , Rudkin G , Hewett P J
Published: March 2003

Background

Ligation excision haemorrhoidectomy is usually performed on an inpatient basis. This study was designed to assess the feasibility of day-case haemorrhoidectomy.

Methods

Patients fulfilling criteria for day surgery underwent ligation excision haemorrhoidectomy with the intention of a same-day discharge from hospital. A standardized protocol for anaesthesia, perioperative analgesia and antiemesis was followed. Patients received daily home nursing visits until they felt both comfortable and confident. Staff recorded pain and nausea scores on a visual analogue scale (range 1–10) until the first bowel action. Patient satisfaction was assessed independently after operation.

Results

Fifty-one patients underwent planned day-case haemorrhoidectomy. Forty-two (82 per cent) were discharged on the day of surgery. All patients were discharged within 26 h of surgery. Four patients required readmission, two with reactive bleeding, one with urinary retention and one for pain control. Pain and nausea were well controlled. Forty-four patients (86 per cent) were totally or very satisfied with their overall care.

Conclusion

Ligation excision haemorrhoidectomy can be performed successfully as a day-case procedure.
Value of magnetic resonance cholangiopancreatography in demonstrating major bile duct injuries following laparoscopic cholecystectomy
Authors: Yeh T-S , Jan Y-Y , Tseng J-H , Hwang T-L , Jeng L-B , Chen M-F
Published: March 2003

Background

Conventionally, recognition of bile duct injuries after laparoscopic cholecystectomy largely relies on endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). However, these invasive procedures are not without risk. Preliminary experience with use of magnetic resonance cholangiopancreatography (MRCP) to identify these injuries is reported.

Methods

The medical records of five patients who had undergone laparoscopic cholecystectomy and had suspected major bile duct injuries were reviewed. All five patients underwent MRCP, followed by conventional cholangiography: either ERCP or PTC, or both. The findings of MRCP and conventional cholangiography were compared.

Results

Four patients had proven bile duct injuries. The remaining patient had gallstones dislodged into the common bile duct (CBD) during laparoscopic cholecystectomy, which presented as transient jaundice mimicking a bile duct injury. The MRCP images were of higher diagnostic value than conventional cholangiographic images in four patients with frank bile duct injury. For these patients, ERCP showed only the cut-off sign of the CBD, and PTC was needed to visualize the upper biliary system. MRCP, however, demonstrated the entire biliary system proximal and distal to the amputated or stenotic sites simultaneously. In the remaining patient with dislodged gallstones, the two techniques yielded similar diagnostic information.

Conclusion

This preliminary study suggests that MRCP is an ideal diagnostic test whenever bile duct injury following laparoscopic cholecystectomy is suspected.
Gastrointestinal stromal sarcomas
Authors: Lev D , Kariv Y , Issakov J , Merhav H , Berger E , Merimsky O , Klausner J M , Gutman M
Published: March 2003

Background

Gastrointestinal stromal sarcomas are a rare group of malignancies originating in the bowel wall.

Methods

The treatment of 12 patients with gastrointestinal stromal sarcoma who underwent operation between 1994 and 1998 was reviewed.

Results

Eight tumours originated in the stomach; others were in the small bowel or rectum. Five of the tumours were of myogenic origin, two were gastrointestinal autonomic nerve tumours, one was a mixed neural–myoid tumour, and four could not be differentiated. Complete resection was possible in ten patients; in two of the ten en bloc resection of adjacent organs was required to ensure adequate margins. The tumours in the remaining two patients were irresectable because of diffuse intra-abdominal metastatic disease. All patients who underwent complete resection were alive after 4–48 (median 14) months. Two of the ten patients developed recurrence, which was reresected completely. The patients with metastatic disease died less than 1 year after operation.

Conclusion

Aggressive surgical resection, achieving complete resection, can lead to prolongation of life and may be a potential cure for patients with gastrointestinal stromal sarcoma.
Anocutaneous advancement flap closure of high anal fistulas
Authors: Jun S H , Choi G S
Published: March 2003

Background

Fistula-in-ano may be treated by closing the internal fistulous opening. An anocutaneous flap was developed to facilitate this closure.

Methods

From October 1995 to April 1997, 40 patients with high trans-sphincteric or suprasphincteric anal fistulas were treated. The important components of the procedure are excision of the internal opening, excision or curettage of the tract, closure of the internal opening by an anocutaneous flap, and external drainage.

Results

In two patients (5 per cent) the flap separated and the sutured internal opening was exposed. One of the two was healed 4 weeks later. In the remaining 38 patients, complete healing occurred 2–3 weeks after operation. No patient was incontinent of gas or stool.

Conclusion

This procedure is technically simple, heals rapidly with minimal scarring, and cures anal fistulas while preserving the anal sphincter.
Follow-up of patients with a thin melanoma
Authors: Johnson R C , Fenn N J , Horgan K , Mansel R E
Published: March 2003

Background

The aim of this study was to determine the value of follow-up in two subgroups of patients with a thin melanoma less than 0·76 mm and 0·76–1·5 mm thick.

Methods

The study group comprised all patients presenting to the Cardiff Melanoma Clinic from its introduction in 1976 to the end of 1994. All patients attend follow-up according to a strict protocol, determined by the thickness of the original melanoma (less than 0·76 mm, annually; more than 0·76 mm, every 2 months for 2 years, 3 monthly for 2 years, 4 monthly for 1 year and then annually).

Results

In total there were 306 patients with a thin melanoma: 178 with a melanoma thinner than 0·76 mm (group 1) and 128 with a melanoma of 0·76–1·5 mm (group 2). The groups were well matched for age (mean 50·6 (range 8–87) versus 50·6 (range 19–89) years respectively) and length of follow-up (mean 88·6 (range 4–296) versus 80·4 (range 2–296) months). Four patients (2·2 per cent) developed recurrence in group 1 and 16 (12·5 per cent) in group 2. The mean time to recurrence was 84·5 (range 49–143) months in group 1 and 45·3 (range 2–74) months in group 2. All patients in group 1 and 14 of 16 in group 2 died from recurrent disease.

Conclusion

Follow-up of patients with a melanoma less than 0·76 mm thick is not worthwhile. All recurrences would have been detected by annual review for 7 years in patients with melanomas between 0·76 and 1·5 mm thick.
External oblique aponeurosis nerve entrapment as a cause of groin pain in the athlete
Authors: Ziprin P , Williams P , Foster M E
Published: March 2003

Background

Groin pain in sportsmen is a common management problem. The results of surgical exploration in 25 male athletes presenting with groin pain are described.

Methods

All patients had had failed non-operative management. All groins were explored via an inguinal incision and the patients were reviewed for the presence of pain, function and their own subjective opinion.

Results

Nineteen injuries were unilateral and six bilateral. One patient had an occult inguinal hernia and another had a patent processus vaginalis. In the others, defects were found in the external oblique aponeurosis through which neurovascular bundles containing terminal branches of the iliohypogastric nerve passed. These tears were repaired after division of the bundles. The mean time to referral was 29·3 weeks (range 4–79 weeks). After operation no pain or only mild pain was experienced in 28 groins. All had improved function. Twenty of 23 patients described the operation as good or excellent. The mean time to resumption of sporting activities after operation was 11·6 (range 4–20) weeks.

Conclusion

Athletes' groin pain may be due to nerve entrapment in the external oblique aponeurosis. An awareness of this injury may reduce delays in operating leading to an earlier return to sport.
Indication for and outcome of laparoscopy-assisted Billroth I gastrectomy
Authors: Shiraishi N , Adachi Y , Kitano S , Bandoh T , Katsuta T , Morimoto A
Published: March 2003

Background

Since 1991, laparoscopy-assisted Billroth I gastrectomy has been used for patients with early gastric cancer. The aim of this study was to clarify the outcome of 40 patients who underwent this operation and to examine the indications based on a retrospective histological study of 248 resected cases of early gastric cancer.

Methods

Operating time, blood loss, length of skin incision, and postoperative hospital stay and complications were examined using the operation records and medical charts. The presence or absence of lymph node metastasis, tumour size, site, gross type, histological type, depth of invasion, presence or absence of ulceration, and status of lymph node metastasis were investigated in 248 early gastric cancers.

Results

The mean operating time was 3 h and 48 min and the mean length of skin incision was 5·8 cm. Although one patient who had suffered from chronic bronchitis developed pneumonia and wound dehiscence, no other patients had a postoperative complication. The mean hospital stay after operation was 16 days and all patients were alive without recurrence at a median follow-up of 21 months. The incidence of lymph node metastasis in early gastric cancer was 2 per cent (three of 130) in mucosal cancers and 14 per cent (17 of 118) in submucosal cancers. These lesions could have been completely resected by laparoscopy-assisted gastrectomy.

Conclusion

All 40 patients were treated successfully by laparoscopy-assisted Billroth I gastrectomy without significant complications and with no recurrences to date. Pathological study of conventionally resected stomach and lymph nodes confirmed that laparoscopy-assisted Billroth I gastrectomy would be a safe and useful operation for most early gastric cancers.
Prospective evaluation of soft tissue masses and sarcomas using fluorodeoxyglucose positron emission tomography
Authors: Lucas J D , O'Doherty M J , Cronin B F , Marsden P K , Lodge M A , McKee P H , Smith M A
Published: March 2003

Background

The differentiation of soft tissue sarcoma (STS) from benign masses is difficult owing to their clinical and radiological similarities. Accurate staging is hindered by the large number of sites at which metastases may be found. This study examined the value of whole-body [18F]2-fluoro-2-deoxy-d-glucose positron emission tomography (FDG PET) in patients presenting with soft tissue masses.

Methods

Thirty patients with a soft tissue mass suspected to be malignant were evaluated with FDG PET. The images were evaluated qualitatively and quantitatively for uptake of FDG to determine whether benign lesions could be differentiated from malignant tumours, and for the presence of metastases.

Results

Thirty-one masses were removed from 30 patients; 12 were benign and 19 were malignant STSs. Using qualitative assessment of the FDG PET images, all the high-grade STSs (n = 12) were correctly identified, but low-grade STS (n = 7) could not be differentiated from a benign lesion. Using a quantification assessment, there was a 95 per cent sensitivity and a 75 per cent specificity in diagnosing STS. Three patients had metastases at presentation; two were correctly identified by FDG PET.

Conclusion

FDG PET has a role in distinguishing high-grade STS from low-grade or benign STS and may have a role in staging malignant tumours.
Clinical evaluation of lymph node metastasis in gastric cancer defined by the fifth edition of the TNM classification in comparison with the Japanese system
Authors: Fujii K , Isozaki H , Okajima K , Nomura E , Niki M , Sako S , Izumi N , Mabuchi H , Nishiguchi K , Tanigawa N
Published: March 2003

Background

This study compared the classification of lymph node metastasis according to the number of involved nodes based on the new tumour node metastasis (TNM) system (fifth edition) with the classification by the Japanese Research Society for Gastric Cancer from an anatomical perspective.

Methods

The two classifications were related to long-term results in 1489 patients with gastric cancer who underwent gastrectomy with systematic extended lymphadenectomy.

Results

Both classifications performed well as prognostic indicators (5-year survival rates: pathological (p) N0, 89 per cent; pN1, 66 per cent; pN2, 34 per cent; pN3, nil; and M1, 10 per cent by the TNM classification; n0, 89 per cent; n1, 63 per cent; n2, 46 per cent; n3, 20 per cent; and n4, 8 per cent by the Japanese classification). For regional lymph nodes, the TNM classification was a better index of the prognosis. Significant survival differences were observed among patients with M1disease according to the number of involved lymph nodes (between one and six nodes, 48 per cent; seven to 15 nodes, 12 per cent; more than 15 nodes, 2 per cent), indicating that patients with distant metastatic lymph nodes (M1) should also be classified by the number of involved nodes. On the other hand, the Japanese classification has the added benefit of being a good indicator of the anatomical extent of lymphadenectomy.

Conclusion

The new TNM classification provided a better index of the prognosis of patients who underwent systematic lymph node dissection. However, both classifications have specific benefits in the surgical treatment of gastric cancer.
Case-controlled study of the epidemiological risk factors for breast cancer in Nigeria
Authors: Adebamowo C A , Adekunle O O
Published: March 2003

Background

The incidence of breast cancer is increasing worldwide, more rapidly in societies that hitherto enjoyed a low incidence of the disease, such as most African countries. Most of the epidemiological data on breast cancer from Africa have been retrospective studies with propensity for bias.

Methods

This was a case-controlled study of 250 consecutive patients with breast cancer diagnosed between April 1992 and December 1995. An age- and sex-matched control group of patients with non-oncological and non-endocrine diseases was compared.

Results

The peak age incidence of breast cancer in the sample studied was 43 years. There was a statistically significant difference in the height and weight of the patients compared with the controls. Patients also tended to be older at first pregnancy and at first lactation, and had a higher mean number of pregnancies. The patients also tended to be of an early birth order, to have lactated less often, to have used contraceptives and to have abused alcohol compared with the controls.

Conclusion

The incidence of breast cancer in this environment is increasing. This is partly a result of the changing demographic profile, acquisition of ‘western’ lifestyle, and the changing socioeconomic profile of the country.
DNA aneuploidy as a marker of premalignancy in surveillance of patients with ulcerative colitis
Authors: Lindberg J Ö , Stenling R B , Rutegård J N
Published: March 2003

Background

Patients with ulcerative colitis have an increased risk of developing colorectal cancer. Specific and sensitive markers for premalignancy are needed. The present study evaluates the status of DNA aneuploidy (abnormal stemlines) as such a marker.

Methods

A prospective surveillance programme was conducted for all patients with ulcerative colitis from a defined area. Regular colonoscopy with mucosal sampling for histological evaluation and flow cytometric DNA analysis was performed. Some 147 patients were studied from 1984 to 1997.

Results

DNA aneuploidy was found in 20 patients. All but one had total colitis. The time from onset of disease to aneuploidy ranged from 5 to 31 years. Fourteen of the patients developed morphological alterations. In the same interval 127 patients, of whom 75 had total colitis, did not develop aneuploidy. Among patients with morphological alterations and aneuploidy, aneuploidy preceded these alterations in four patients and was present at the same examination in three; in seven patients the morphological alterations preceded the aneuploidy. Aneuploidy was diagnosed before the appearance of a dysplasia- associated lesion or mass in four of five cases.

Conclusion

Flow cytometric DNA analysis has definite value as a complement to histological examinations in cancer surveillance of patients with ulcerative colitis. Aneuploidy indicates a high risk for developing severe premalignant changes. However, there is no evidence to support the use of DNA aneuploidy as a sole indication for prophylactic surgery against cancer.