bluuebunny/crossref_metadata_2025 huggingface dataset:
Lymph node metastases in early rectal cancer
Authors: Huddy S P J , Husband E M , Cook M G , Gibbs N M , Marks C G , Heald R J
Published: March 2007

Local excision of early rectal tumours is an attractive proposition, avoiding the morbidity and mortality of major resection and possible permanent stoma. This study was designed to investigate the incidence of lymph node metastases associated with tumours that are locally confined to the bowel wall. A total of 454 rectal excision specimens were reviewed. Twenty-two (20 per cent) of 109 patients with tumours locally confined to the bowel wall had metastases in local lymph nodes, although 14 of these had only one or two involved nodes. Three of 27 patients with tumours that did not penetrate through the submucosa had lymph node metastases. Less well differentiated tumours were more likely to have metastasized but there was no significant difference in the height or size of tumours or in the depth of invasion between patients with or without lymph node metastases.
Role of the leucocyte in the pathogenesis of vascular disease
Authors: Bradbury A W , Murie J A , Ruckley C V
Published: March 2007

The leucocyte plays a key role in the local and systemic tissue injury that results from peripheral arterial disease and chronic venous insufficiency. Despite the apparent dissimilarities between limb ischaemia and chronic venous ulceration, in both diseases macrovascular abnormalities lead to microvascular leucocyte trapping and activation. Activated leucocytes adhere to and damage adjacent endothelium by expressing adhesion molecules and releasing harmful moieties such as proteases and free radicals. Subsequent loss of endothelial integrity and the migration of activated leocytes outwith the circulation leads to destruction of surrounding tissue. Leucocytes and their products are also involved in the systemic manifestations of ischaemia such as multiple organ failure and coagulopathy. An overview of leucocyte biology as it pertains to peripheral arterial and venous disease is presented. The opportunities for novel therapeutic interventions based on a better understanding of this biology are also discussed.
Role of surgery and chemotherapy for peripheral lymph node tuberculosis
Authors: Subrahmanyam M
Published: March 2007

A total of 105 patients with peripheral lymph node tuberculosis were treated by either surgical excision and chemotherapy or chemotherapy alone. The cervical nodes were affected in 98 patients, axillary nodes in four and inguinal nodes in three. Biopsy of the lymph nodes confirmed the diagnosis in all cases. Thirty-five patients who had sinus, ulcer or abscess underwent excision of the lymph nodes with drainage of the abscess, or resection of the sinus or ulcer. The remaining 70 patients received only chemotherapy. Chemotherapy in all patients consisted of isoniazid and ethambutol for 18 months. Of the 35 patients treated with surgery and chemotherapy, two had gaping wounds, one infection and one cellulitis of the face and neck. After 3 months, one patient had recurrence of the lymph node mass and one recurrence of a sinus; these were excised. Of the 70 patients treated only with chemotherapy, 13 were lost to follow-up. Four had non-healing wounds at the biopsy site, six wound infection and two sinus formation. Five of these patients had persistent lymph node masses, which were excised after 3 months. The remaining 52 patients had no recurrence.
Reliability of clinical judgement in evaluation of the nutritional status of surgical patients
Authors: Lupo L , Pannarale O , Altomare D , Memeo V , Rubino M
Published: March 2007

The ability of surgeons to make a reproducible and reliable evaluation of the nutritional status of patients was assessed. Three independent observers assigned 64 patients to one of four nutritional states — normal nourishment, and mild, moderate and severe malnutrition — using a questionnaire and clinical examination. Interobserver variability was analysed using the K statistic and reliability by assessing the correlation between the assigned class and total serum protein, haemoglobin, albumin, transferrin and cholesterol levels, weight loss and the results of immunological skin tests. Concordance was observed in 49 of the 64 judgements (77 per cent) and partial agreement in the remainder (K = 0·74, P < 0·001). Clinical judgement correlated significantly with albumin, transferrin and cholesterol levels and weight loss (R2 = 0·73, P < 0·001). Surgeons are able to assess nutritional status using clinical judgement.
Prolonged normothermic ischaemia of human cirrhotic liver during hepatectomy: A preliminary report
Authors: Kim Y I , Nakashima K , Tada I , Kawano K , Kobayashi M
Published: March 2007

To evaluate the tolerance of the cirrhotic liver to extended warm ischaemia, 47 patients with cirrhosis who underwent liver resection over a 4-year period were studied retrospectively. Three groups of patients were identified. In group 1 (14 patients) liver resection was performed under conditions of portal triad occlusion ranging from 50 to 75 (mean 57·1) min. Group 2 (12 patients) was treated with portal occlusion for a period ranging from 30 to 42 (mean 33·1) min. Group 3 comprised 21 patients who underwent hepatectomy using conventional techniques. Mean blood loss was significantly reduced by portal triad occlusion (819 ml in group 1, 523 ml in group 2) compared with the conventional technique (1652 ml in group 3) (P < 0·05, group 1 versus group 3; P < 0·01, group 2 versus group 3). Hospital death occurred in three of the 21 patients in group 3 but in no patient who underwent portal triad occlusion. The morbidity rate was lower in the two occlusion groups (four of 26 patients) than in group 3 (six of 21). Bilirubin metabolism was substantially better after surgery in the occlusion groups (P < 0·05, groups 1 and 2 versus group 3 at day 14). Although the serum levels of transaminases were significantly raised until day 3 in patients undergoing long-term occlusion, the cirrhotic liver withstood the ischaemia—reperfusion insult, as assessed by changes in hepatic microcirculation, lipid peroxidation and the morphology of hepatic sinusoids. It is concluded that prolonged ischaemia during liver resection can be sustained in patients with cirrhosis and without high-risk factors.
Total pelvic exenteration: A justified procedure
Authors: Plukker J Th , Aalders J G , Mensink H J A , Oldhoff J
Published: March 2007

Twenty patients with advanced primary or locally recurrent pelvic tumours treated by total pelvic exenteration are described. There were no operative or postoperative deaths. The most frequent postoperative complications appeared to be related to previous irradiation. Four patients developed non-fatal intestinal complications within 30 days of operation that required further surgery. After a mean follow-up of 19 months the crude 2-year survival rate was 40 per cent. This procedure is judged to be useful in a selected group of patients.
Secondary proctectomy and ileal pouch—anal anastomosis after ileorectal anastomosis for familial adenomatous polyposis
Authors: Penna C , Kartheuser A , Parc R , Tiret E , Frileux P , Hannoun L , Nordlinger B
Published: March 2007

Conversion of ileorectal anastomosis to ileal pouch—anal anastomosis (IPAA) was indicated in 29 patients with familial adenomatous polyposis but technically impossible in three because of unsuspected pelvic desmoid tumours. There was no operative mortality and overall postoperative morbidity and late complication rates were no different from those in a group of 120 patients who underwent IPAA as a first operative procedure. Unsuspected adenocarcinoma (one invasive, three in situ) was found in four patients. The functional results in patients with IPAA did not differ from those of ileorectal anastomosis before conversion or from those obtained after IPAA as a first-choice procedure. Secondary proctectomy and IPAA can be safely offered to patients with ileorectal anastomosis and a high risk of rectal cancer.
Local recurrence of colorectal cancer: The problem, mechanisms, management and adjuvant therapy
Authors: Abulafi A M , Williams N S
Published: March 2007

Local recurrence of colorectal cancer after ‘curative’ surgery is a major clinical problem. Typically, 50–70 per cent of patients presenting to a surgical clinic will undergo apparently curative surgery for disease and of these about 10–25 per cent will develop local recurrence, in either the tumour bed or bowel wall. The wide differences in local recurrence rate both between and within institutions is probably caused by variation in surgical technique. The main causes of local recurrence are inadequate excision of the primary tumour or the draining lymph nodes, and intraoperative tumour cell implantation. The most significant single factor prognostic of local recurrence is Dukes' tumour stage. Other important factors include tumour grade and fixity, level of the tumour in the rectum, blood and lymphatic vessel invasion inadvertent perforation of the tumour during resection, and the surgeon's experience. The prognosis of patients with local recurrence is poor. Prevention of recurrence by adequate surgery and adjuvant therapy as well as its early detection offer the best prospect of improving results.
Early detection of major complications after abdominal aortic surgery: Predictive value of sigmoid colon and gastric intramucosal ph monitoring
Authors: Björck M , Hedberg B
Published: March 2007

The early detection and reversal of gastrointestinal ischaemia is thought to play a key role in minimizing the incidence of complications after abdominal aortic surgery. In an open prospective non-selective study intramucosal pH (pHi) was monitored in 27 patients undergoing elective aortic surgery and in seven submitted to emergency procedures. The pHi was monitored in the sigmoid colon in all 34 patients and in the stomach in 26. Eight patients developed major complications, four of whom had ischaemic colitis, and five died. Sigmoid acidosis (pHi below 7·10) served as an early warning; if acidosis was reversed within 2 h no major complication developed, if prolonged it was predictive of major morbidity (sensitivity 100 percent, specificity 92 per cent). A colonic pHi below 6·86 predicted endoscopically detectable ischaemic colitis. A gastric pHi below 7·20 predicted major complications with a sensitivity of 100 per cent and specificity of 81 per cent. Both monitoring procedures were considered feasible, although monitoring in the sigmoid colon was found to be superior for the patients studied.
Prospective study of 713 below–knee amputations for ischaemia and the effect of a prostacyclin analogue on healing
Authors: Dormandy J , Belcher G , Broos P , Eikelboom B , Laszlo G , Konrad P , Moggi L , Mueller U
Published: March 2007

In 51 hospitals in six European countries 713 patients requiring below–knee amputation for ischaemic disease were studied prospectively. The patients were allocated randomly to receive standard postoperative treatment or standard treatment plus intravenous infusion of the prostacyclin analogue iloprost for 6 h per day over 14–21 days. Healing of the amputation stump and the need for reamputation at a higher level were similar in the two groups. Overall at 3 months 59 per cent of stumps had healed, 19 per cent of patients had required reamputation at a higher level, 11 per cent had died and the remaining 11 per cent remained with unhealed stumps. Preoperative characteristics were analysed as possible risk factors or markers for primary healing, reamputation and death. Previous arterial reopening procedures (surgical or radiological) almost doubled the chances of primary stump healing (P<0–05). The surgeon's assessment of the likelihood of healing was wrong in 21 per cent of cases in which the operating surgeon thought that healing would probably occur and in 52 per cent of those in which it was thought healing was improbable.
Prevalence of impaired cerebrovascular reserve in patients with symptomatic carotid artery disease
Authors: Naylor A R , Merrick M V , Gillespie I , Sandercock P A G , Warlow C P , Cull R E , Griffin T M G , Ruckley C V
Published: March 2007

Cerebrovascular reserve (CVR) was studied in 104 consecutive patients with symptomatic carotid territory disease and ipsilateral internal carotid artery stenosis. Overall, 30 of 104 patients (29 per cent) had impaired CVR. The frequency of CVR impairment increased with the severity of internal carotid artery stenosis: impairment was present in none of 11 patients with stenosis of less than 50 per cent, four of 24 with stenosis of 50–69 per cent, 14 of 41 with stenosis of 70–89 per cent and 12 of 28 with stenosis of 90–99 per cent. Patients presenting with a stroke were significantly more likely to have impaired CVR than those with transient ischaemic attacks and/or amaurosis fugax (odds ratio 3·7 (95 per cent confidence interval (c.i.) 1·5–9·0)), as were those with a residual neurological deficit (odds ratio 4·3 (95 per cent c.i. 1·6–11·5)) and evidence of infarction from computed tomography (odds ratio 3·8 (95 per cent c.i. 1·6–9·4)).
Insulin resistance after abdominal surgery
Authors: Thorell A , Efendic S , Gutniak M , Häggmark T , Ljungqvist O
Published: March 2007

A study was carried out to determine the time course and degree of postoperative insulin resistance in patients undergoing elective abdominal surgery. Mean(s.e.m.) insulin sensitivity was determined before and on the first (n = 10), fifth, ninth and 20th (n = 5) days after elective open cholecystectomy using the normoglycaemic (4·7(0·1) mmol/1), hyperinsulinaemic (402(12) pmol/1) glucose clamp technique. Preoperative insulin sensitivity expressed as the M value varied from 2·3 to 8·2 mg per kg per min. The relative reduction in insulin sensitivity was most pronounced on the first day after surgery, at a mean(s.e.m.) of 54(2) per cent. Thereafter, a large variation between individuals was found during the course of recovery, and insulin sensitivity returned to normal 20 days after operation. On the first day after surgery, plasma concentrations of glucose, C peptide, noradrenaline and glucagon were slightly but significantly higher than before operation (P < 0·05), whereas insulin, growth hormone, cortisol and adrenaline levels were unaltered. Marked insulin resistance thus develops after elective upper abdominal surgery and persists for at least 5 days after operation. Factors other than simultaneous changes in levels of the hormones studied seem to regulate the maintenance of postoperative insulin resistance.
Superficial parotidectomy in the treatment of cutaneous melanoma of the head and neck
Authors: Barr L C , Skene A I , Fish S , Thomas J M
Published: March 2007

The preauricular lymph nodes are frequently the first site of metastatic disease from primary malignant melanoma of the upper two-thirds of the face or the anterior scalp. For these patients, or those with adjacent metastatic nodal disease, the prognosis is poor. The median survival of 13 such patients presented was 2 years, with two long-term survivors at 4 and 6 years. Palliative surgery can, however, prevent uncontrolled locoregional disease. Patients with palpable preauricular and cervical node disease should be treated by facial nerve-preserving parotidectomy and radical neck dissection. When no cervical nodes are palpable in patients with preauricular node metastasis, peroperative jugulodigastric node biopsy and frozensection histopathological examination are useful to select patients for radical neck dissection.
Peripheral versus central intravenous nutrition: Comparison of two delivery systems
Authors: Kohlhardt S R , Smith R C , Wright C R
Published: March 2007

Forty-six surgical patients who required intravenous nutrition (IVN) were randomly allocated to receive complete IVN by a peripheral (n = 23) or central (n = 23) venous delivery system. The peripheral IVN system combined a fine-bore silicone catheter with lipid-based nutrient solutions whereas the central system used a conventional glucose-based nutrient regimen and a single-lumen central venous catheter. The incidence of catheter complications and the complication·free system function over time were compared. Problems of venous access were not observed with peripheral IVN but occurred with one central catheterization. Three patients with central venous catheters developed bacteraemia but only one incident was thought to be catheter related (bacterial translocation). There were no such episodes with peripheral IVN. Peripheral catheterization was not associated with infective phlebitis, although late-onset chemical phlebitis occurred on four occasions after a mean(s.e.m.) time of 22·8(6·1) days, representing a daily risk of phlebitis of 0·009. There was no significant difference in the probability of complication-free system function with time between peripheral and central IVN (P = 0·14). The fine-bore silicone catheter peripheral IVN delivery system resulted in long-term phlebitis-free infusion for periods that were similar to those of single-lumen central catheterization by life-table analysis.
Effect of gastric resection, Roux-en-Y diversion and vagotomy on gastric emptying in the rat
Authors: Houghton A D , Liepins P , Clarke S M , Mason R C
Published: March 2007

Solid and liquid gastric emptying studies were conducted in 61 male Wistar rats. In 20 animals a two-thirds Póya-type gastric resection was performed and 21 had a similar resection with a 10-cm Roux-en-Y diversion. In nine of the Roux diversions truncal vagotomy was also carried out. Twenty animals acted as controls: ten unoperated and ten that received laparotomy only. Body-weight and gastric emptying were measured weekly for 4 weeks and monthly for 4 months after surgery. Animals subjected to gastrectomy revealed a weight loss of approximately 16 per cent after operation. Weight gain was slower after Roux reconstruction than after Pölya-type anastomosis and slowest in animals with vagotomy and Roux drainage (P < 0·05). Gastric emptying was unchanged in unoperated controls. Animals in which a laparotomy was performed had delayed solid and liquid emptying for the first 4 weeks after operation (P < 0 · 05). Following Pölya-type gastrectomy, liquid emptying was delayed for 4 months. Solid emptying was unchanged, with no evidence of the delay present in animals with a laparotomy. Animals subjected to Roux-en-Y diversion showed a greater delay in liquid emptying than those with a Póya resection; solid emptying was also delayed (P < 0 · 05). Severe gastric retention of liquids and solids occurred in the early postoperative phase when vagotomy was added to the Roux diversion (P < 0 · 01). Emptying of solids adopted a relatively normal linear pattern after this initial retention. Emptying of liquids, however, remained abnormal, appearing to adopt a biphasic pattern.
Testicular atrophy as a consequence of inguinal hernia repair
Authors: Reid I , Devlin H B
Published: March 2007

Testicular atrophy is an uncommon but well recognized complication of inguinal hernia repair and one that frequently results in litigation. A series of ten cases of testicular atrophy occurring after hernia repair in nine patients is presented. Identifiable risk factors were present in eight instances. Surgeons should make careful enquiries as to previous groin or scrotal surgery and, when indicated, warn the patient before surgery of the increased risk of testicular atrophy. Overzealous dissection of a distal hernia sac, dislocation of the testis from the scrotum into the wound and concomitant scrotal surgery should all be avoided.
Prospective study of open cholecystectomy for calculous biliary disease
Authors: Moreaux J
Published: March 2007

Data of 5000 consecutive patients with biliary lithiasis operated on between 1970 and 1990 were recorded prospectively. There were 476 emergency procedures and 125 reoperations. Concomitant abdominal operations were performed in 504 patients. The mean(s.d.) age was 54·7(14·2) years. Cholecystectomy was performed in 4872 patients (97·4 per cent) and intraoperative cholangiography in 4400 (88·0 per cent). There were 612 operations for acute cholecystitis, 579 for common bile duct stones, 50 for acute pancreatitis and 29 reoperations following injury to the bile duct. Complications occurred in 527 patients (10·5 per cent). There was one injury (0·02 per cent) to the hepatic duct. The complication rate was 7·0 per cent following elective cholecystectomy and 17·4 per cent after emergency surgery. The mortality rate was zero after elective procedures and 0·8 per cent after emergency surgery; the mortality rate after concomitant abdominal operations (1·0 per cent) was unrelated to the biliary procedure. The mean(s.d.) hospital stay was 12·8(5·2) days.
Laparoscopic versus open appendicectomy: A prospective assessment
Authors: Lujan Mompean J A , Robles Campos R , Parrilla Paricio P , Soria Aledo V , Garcia Ayllon J
Published: March 2007

A prospective study of 200 consecutive patients with suspected acute appendicitis was performed to compare open and laparoscopic appendicectomy. Formal randomization was precluded by instrument availability. Some 100 patients underwent laparoscopic appendicectomy (conversion to laparotomy was carried out in five) and 100 had conventional surgery. The groups were similar in sex ratio, age, degree of appendiceal inflammation and antibiotic treatment. The mean duration of open appendicectomy was 46 min and of the laparoscopic procedure 51 min (P not significant). Postoperative complications in patients who underwent laparoscopic appendicectomy included: intraabdominal abscess (two patients), wound infection (one), early bowel obstruction (four all resolved with medical treatment) and umbilical haematoma (two). There were no reoperations in the immediate or late postoperative period. Complications after open operation were: wound infection (seven patients) (P < 0·05), early bowel obstruction (five; three resolved with medical treatment, two required surgery) and haematoma of the Surgical wound (one). The mean hospital stay was 4·8 days for laparoscopic appendicectomy and 6·0 days for the open operation (P < 0·05). There were no deaths.
Laparoscopic prosthesis fixation rectopexy for complete rectal prolapse
Authors: Cuschieri A , Shimi S M , Velpen G Vander , Banting S , Wood R A B
Published: March 2007

Five women aged 64–81 years with complete rectal prolapse and incontinence were treated by laparoscopic mobilization of the rectum and posterior fixation to the presacral fascia using Marlex mesh. Mobilization was carried out with standard straight laparoscopic instruments in the first two patients (operating times 3·5 and 4·5 h) and with coaxial curved instruments and ultrasonic dissection in the succeeding three (operating times 2·5, 2·0 and 2·5 h). Restoration to full continence (grade 1) was observed in two patients and to grade 2 in a further two. No recurrence of the prolapse occurred during follow-up of 4–27 months.
Long-term results of postanal repair for neurogenic faecal incontinence
Authors: Setti Carraro P , Kamm M A , Nicholls R J
Published: March 2007

Between 1984 and 1986, 54 patients underwent postanal repair for neurogenic faecal incontinence. Forty-two (41 women) were available for follow-up 5–8 (median 6·2) years after operation. Of these, 34 women attended for clinical and anorectal physiological assessment. Anal endosonography was also performed in 30 patients. In the 34 patients examined, continence categories (Browning and Parks' classification) of C (n = 12) and D (n = 22) before surgery became A (n = 2), B (n = 12), C (n = 16) and D (n = 1) at 6 months and A (n = 4), B (n = 5), C (n = 21) and D (n = 4) at 5–8 years. Nine patients therefore had continence for solids and liquids, five of whom were incontinent to flatus, in the long term. Assessment of outcome by patients revealed long-term improvement in 28 and no change in six. Two of the 34 patients assessed were housebound because of incontinence. Of the total of 54 patients, only one required a stoma. The length of the anal canal increased significantly from a preoperative median (range) of 2·0 (1·5–4·0) cm to 3·8 (1·8–5·5) cm 5–8 years after surgery. Perineal descent at rest decreased markedly. Progression of neuromuscular damage was demonstrated by prolongation of the pudendal nerve terminal motor latency from a median (range) 2·38 (1·80–3·35) ms to 2·80 (2·20–4·25) ms and increasing median (range) fibre density in the external sphincter, from 1·86 (1·76–2·40) to 3·63 (2·03–6·20). The pudendal nerve terminal latency was the only preoperative physiological variable that correlated significantly with long-term outcome (A and B 2·20 ms versus C and D 2·65 ms, P < 0·05). At long-term assessment, maximal anal squeeze pressure was the only physiological variable that correlated significantly with clinical outcome. Anal endosonography revealed a clinically undetected sphincter defect in 19 of 30 patients examined but the presence of a defect did not relate to clinical outcome.
Femoropopliteal angioplasty for severe limb ischaemia
Authors: Currie I C , Wakeley C J , Cole S E A , Wyatt M G , Scott D J A , Baird R N , Horrocks M
Published: March 2007

Fifty patients undergoing 51 percutaneous transluminal angioplasties of the femoropopliteal segment for severe limb ischaemia were reviewed regularly. They comprised 30 men and 20 women of median age 70 (range 56–85) years. There were two deaths within 30 days. At 2 years the cumulative patient survival rate was 60 per cent. Eleven angioplasties were technical failures, 25 failed in the first 6 months and 14 were successful at 6 months' follow-up; in addition one patient died from myocardial infarction within 30 days of technically successful angioplasty. Subsequent vascular procedures were successful in 11 limbs following failed angioplasty. The primary limb survival rate was 42 per cent at 2 years. There were eight major complications after angioplasty, requiring amputation in five instances. Of the 23 long occlusions (greater than 5 cm) that were recanalized and dilated, 22 procedures failed within 6 months. The run-off score and diabetic status did not predict outcome. In this group of patients angioplasty had a low durability. Dilatation of long occlusions is associated with high rates of reocclusion and, on the basis of these results, should not be performed.
Ultrasonography as a method of measuring breast tumour size and monitoring response to primary systemic treatment
Authors: Forouhi P , Walsh J S , Anderson T J , Chetty U
Published: March 2007

Accurate measurement of change in tumour size is a prerequisite for the use of response-based regimens of primary systemic therapy for breast cancer. This study evaluated the accuracy of clinical assessment, mammography and ultrasonography in measuring tumour size and in monitoring response to treatment. Size was determined during the week preceding surgery and actual size measured from resected specimens. Sequential measurements were performed in 35 patients undergoing primary systemic treatment. There was moderate correlation between pathological and clinical size (n = 51, r2 = 0·68, P<0·0001). Close correlation with pathological tumour size was observed for mammographic (n = 45, r2 = 0·84, P<0·0001) and ultrasonographic (n = 52, r2 = 0·89, P<0·0001) tumour size. Response was correctly evaluated by clinical assessment in 31 of 35 patients, by mammography in 20 of 35 and by ultrasonography in 31 of 35. Actual tumour size can be measured accurately by available imaging techniques but ultrasonography is the most practical and accurate method for monitoring response.
Resection of ‘recurrent’ colorectal metastases to the liver
Authors: Que F G , Nagorney D M
Published: March 2007

Hepatic resection is the only treatment for patients with colorectal cancer metastatic to the liver that has resulted in long-term survival. This apparent efficacy of hepatectomy has prompted efforts to expand the surgical approach for disease progression within the liver. A review of personal experience and of the literature was performed in an attempt to define the role of surgery for disease progression. Twenty-one patients who underwent hepatic resection between 1983 and 1991 for isolated disease progression in the liver were retrospectively reviewed. The median follow-up of patients still alive was 1·7 years (range 4 months to 4·5 years). The median survival from the date of repeat hepatic resection was 3·4 years with an estimated actuarial survival rate of 43 per cent at 4 years. These patients experienced no significant morbidity and the mortality rate was 5 per cent. Hepatic resection of metastatic colorectal carcinoma can produce long-term survival without prohibitive risk. These findings support an aggressive surgical approach for metastatic progression in the liver from colorectal carcinoma.
Anorectal myotomy combined with anterior resection in the treatment of Hirschsprung's disease
Authors: Scobie W G
Published: March 2007

A total of 42 patients with biopsy-proven Hirschsprung's disease were treated by anorectal myotomy or myectomy, alone or combined with anterior resection. Myotomy is a simple and complication-free procedure. The results compare favourably with those of other operative procedures for this condition.
Comparison of emergency and elective haemorrhoidectomy
Authors: Eu K-W , Seow-Choen F , Goh H S
Published: March 2007

A total of 704 patients with symptomatic prolapsed haemorrhoids were operated on over a 24-month period. Overall, 500 underwent elective haemorrhoidectomy for symptomatic prolapsed haemorrhoids and 204 emergency haemorrhoidectomy for acutely prolapsed, thrombosed or gangrenous haemorrhoids. The mean age was 43 (range 16–80) years in patients undergoing elective surgery and 42 (range 20–86) years in those receiving emergency procedures. After elective surgery 27 patients (5·4 per cent) had an episode of secondary haemorrhage; ten (2·0 per cent) required blood transfusion and six (1·2 per cent) needed surgical haemostasis. After emergency surgery, ten patients (4·9 per cent) developed secondary haemorrhage; four (2·0 per cent) required blood transfusion and two (1·0 per cent) surgical haemostasis. Twelve patients (5·9 per cent) developed anal stenosis after an emergency procedure compared with 15 (3·0 per cent) after elective operation. None of the patients in either group developed portal pyaemia. After elective surgery 26 patients (5·2 per cent) developed a degree of incontinence (eight to flatus, 15 to liquids, three to solids) as did nine patients (4·4 per cent) after emergency procedures (three to flatus, five to liquids, one to solids). Recurrent haemorrhoids were found in 38 patients (7·6 per cent) after elective surgery and in 14 (6·9 per cent) after an emergency procedure.
Circulating intact parathyroid hormone levels in acute pancreatitis
Authors: McKay C , Beastall G H , Imrie C W , Baxter J N
Published: March 2007

Serum levels of parathyroid hormone (PTH), calcium and albumin were measured daily for 5 days in 41 selected patients with moderate to severe acute pancreatitis. The PTH level was measured by means of a two-site immunoradiometric assay specific for the intact polypeptide. A rise in PTH level was observed more commonly in patients with a complicated or fatal outcome than in those with an uncomplicated course (14 of 16 versus six of 25 patients, P < 0.001). Although PTH levels were variable in the presence of hypocalcaemia, raised concentrations were found more frequently in patients with complications (seven of eight versus two of seven without complications, P = 0.035). This study confirms that an appropriate rise in PTH level occurs in response to the hypocalcaemic stimulus in patients with acute pancreatitis.
Recurrent varicose veins: Assessment of the saphenofemoral junction
Authors: Bradbury A W , Stonebridge P A , Callam M J , Walker A J , Allan P L , Beggs I , Ruckley C V
Published: March 2007

Thirty-six consecutive unselected patients, who had apparently previously undergone saphenofemoral ligation for primary uncomplicated long saphenous varicosities and who had then re-presented with recurrent thigh varices emanating from the groin, underwent preoperative clinical assessment, hand-held Doppler and duplex ultrasonographic examination and varicography to establish the presence or absence of saphenofemoral incompetence as the cause of recurrence. All patients underwent re-exploration of the saphenofemoral junction (SFJ) via a lateral approach. Twenty-six patients had an intact SFJ (type I recurrence) and ten had varices arising from either a thigh perforator, or from abdominal or perineal veins (type II recurrence). Clinical examination alone was poor at distinguishing type I from type II recurrence. Doppler ultrasonography was sensitive (88 per cent) but non-specific (40 per cent). In contrast, duplex scanning was insensitive (42 per cent) but extremely specific (100 per cent) and accurate, with a positive predictive value of 100 per cent. Varicography also had a specificity and positive predictive value of 100 per cent, a sensitivity of 73 per cent and in addition provided a precise anatomical ‘road-map’. A combination of clinical examination and hand-held Doppler ultrasonography seems to be the most appropriate first-line method of preoperative assessment in these patients. Duplex ultrasonography, if available, will provide additional useful information about both the SFJ and the presence of thigh perforators. Contrast examination may be reserved for patients who have equivocal results on non-invasive investigations, who have had more than one previous groin operation or who have, in addition, deep venous disease.
Accuracy of ultrasonographic measurement of infrarenal abdominal aortic aneurysm
Authors: Akkersdijk G J M , Puylaert J B C M , Coerkamp E G , De Vries A C
Published: March 2007

The ultrasonographic measurement of abdominal aortic aneurysm (AAA) must be accurate as the decision on elective repair will usually be based on such results. To detect expansion, measurements must be comparable. The interobserver variation of ultrasonographic measurement of infrarenal aortic aneurysms under standardized conditions is described.
Local recurrence after simple mastectomy
Authors: O'Rourke S , Galea M H , Morgan D , Euhus D , Pinder S , Ellis I O , Elston C W , Blamey R W
Published: March 2007

A retrospective study was carried out to determine the clinical significance of local recurrence after simple mastectomy and node biopsy for primary operable breast cancer, without postoperative irradiation or systemic adjuvant therapy. Local recurrence was defined as a histologically proven lesion in or deep to the mastectomy skin flaps. A total of 966 patients with a median follow-up of 7 years were reviewed. Of these, 223 (23 per cent) developed local recurrence but half the tumours were small single lesions; 70 women had multiple discrete lesions and 21 diffuse carcinomatous dermal infiltration. Local recurrence showed significant associations with tumour grade, nodal status and the presence of lymphovascular invasion in the primary tumour. A predictive index containing these three variables was constructed. Adjuvant irradiation of the flaps is recommended for patients with high scores; such women would otherwise have a 39 per cent chance of developing local recurrence by 5 years. Different types of local recurrence have different chances of responding to local therapy: 13 per cent of single local recurrences, 32 per cent of multiple spot recurrences and 70 per cent of the diffuse type failed to respond to local therapy. Local recurrence predicts reduced patient survival.
Influence of epidermal growth factor and interferon γ on healing of oesophageal corrosive burns in the rat
Authors: Berthet B , Di Costanzo J , Arnaud C , Choux R , Assadourian R
Published: March 2007

A study was performed to attempt to modify the healing response to severe oesophageal corrosive burns to prevent complications. The study was performed on four groups each of 15 Wistar rats: a control group, an untreated group and groups given epidermal growth factor (EGF) alone or EGF for 5 days and interferon (IFN) γ from the sixth to 20th day. In the last three groups an oesophageal lesion was induced with 2–5 moll−1 sodium hydroxide solution. The efficacy of treatment was assessed on days 2, 5 and 20 by measurement of weight gain, oesophageal internal lumen, stenosis index (wall thickness: lumen diameter) and collagen production. On day 5, collagen synthesis was significantly (P<0.05) higher in rats given EGF than in the untreated group. On day 20, no significant difference was seen in weight gain between the control rats and either treated group and stenoses were present in all untreated rats and in none of the treated group. The stenosis index on day 20 was lower in the groups given EGF and EGF-IFN-γ than in untreated rats (P<0.05) and collagen production was significantly (P<0.05) lower in the group given EGF and IFN-γ than in the other animals. The sequential use of EGF and IFN-γ significantly reduced the frequency of residual stenosis.
Radical transhiatal oesophagectomy under direct vision
Authors: Alderson D , Courtney S P , Kennedy R H
Published: March 2007

Modified transhiatal oesophagectomy is described for the resection of tumours affecting the distal third of the oesophagus. The operation confers the advantages of radical resection and the ability to undertake the procedure under direct vision. Forty patients with a median age of 67 years underwent this operation during a 36-month period and were followed for up to 42 months after surgery. The hospital mortality rate was one of 40 patients and the median postoperative stay 10 days. All but four patients left hospital within 2 weeks of operation. Eighteen of 30 patients were alive at 12 months and seven of 18 at 24 months after operation. Only two patients are known to have developed local recurrence in the tumour bed. This procedure confers the advantages of a radical approach under direct vision and incorporates the principles of near-total oesophagectomy and cervical anastomosis in the treatment of oesophageal cancer.
Results of major hepatectomy for large primary liver cancer in patients with cirrhosis
Authors: Capussotti L , Borgonovo G , Bouzari H , Smadja C , Grange D , Franco D
Published: March 2007

Major hepatectomy is associated with a high operative risk in patients with cirrhosis. Between June 1983 and December 1991, 33 cirrhotic patients, 31 with good liver function, underwent major liver resection for a large hepatic primary cancer. The hospital mortality rate was 3 per cent; the only death resulted from liver failure after extended right hepatectomy. None of the patients had variceal bleeding during the postoperative period. Survival rates at 1, 2 and 3 years were 66, 43 and 37 per cent respectively. Recurrence was the most common reason for late death. These results suggest that the operative risk of major hepatectomy in cirrhotic patients with a large tumour and good liver function is comparable to that of minor liver resection. Late survival is also similar to that of patients with a small tumour. Cirrhotic patients with hepatic carcinoma and good liver function are suitable for major hepatectomy.
Radical excision of sacrococcygeal tumours
Authors: Anson K M , Byrne P O , Robertson I D , Gullan R W , Montgomery A C V
Published: March 2007

Large sacrococcygeal tumours are rare and remain a difficult management problem. Chordomas are one of the most common tumours in this region and may account for 30–40 per cent of postrectal tumours. Four patients aged between 22 and 66 years, three with chordomas and one with a schwannoma, are described. Each was managed by a combined general and neurosurgical approach. Major radical excision of the tumour involving high amputation of the sacrum and lower sacral nerve root division was performed. These large lesions can be radically excised with limited postoperative morbidity and excellent preservation of neurological function, including sphincter control, provided that one S2 nerve root is left intact.
Anal endosonography for identifying external sphincter defects confirmed histologically
Authors: Sultan A H , Kamm M A , Talbot I C , Nicholls R J , Bartram C I
Published: March 2007

Defects of the external anal sphincter have traditionally been diagnosed by palpation, anal manometry and electromyography (EMG), but anal endosonography enables clear imaging of both the internal and external sphincter muscles. A study was performed to validate the interpretation of ultrasonographic images of external sphincter defects using histology as a ‘gold standard’. In addition the accuracy of clinical examination, manometry, EMG mapping and anal endosonography in the diagnosis of sphincter defects were compared prospectively. Twelve consecutive patients with faecal incontinence (11 women, one man; mean age 46 (range 30–64) years) who required sphincter repair underwent clinical assessment, anal manometry, concentric-needle EMG mapping and anal endosonography before surgery. The endosonographer was unaware of the history or results of physiological tests and the surgeon performing the repair was blind to the ultrasonographic findings. At operation most or all of the suspected defect was excised and examined histologically. The pathologist was unaware of the endosonographic or operative findings at the time of reporting. Combined operative and histological examination identified an external sphincter defect in nine of the 12 patients. Anal endosonography correctly identified all nine defects and the three normal sphincters. The accuracy of clinical examination was 50 per cent and that of both EMG and anal manometry 75 per cent. In addition, anal endosonography identified a defect of the internal anal sphincter in eight patients. External sphincter defects identified by endosonography have not been previously verified histologically. Precise sphincter assessment is mandatory for the correct management of faecal incontinence. Anal endosonography is more accurate than clinical and conventional physiological methods and also provides information on the internal sphincter.
Management of non-palpable breast lesions detected mammographically
Authors: Allen M J , Thompson W D , Stuart R C , Gill P T , Walton E W , Karczenski K , Hoffman J , Peel A L G
Published: March 2007

A total of 212 consecutive fine-wire localization breast biopsies in 202 patients were performed on impalpable mammographically suspicious lesions. Preoperative fineneedle aspiration cytology was performed on 159 lesions and was valuable in planning the extent of the fine-wire localization biopsy. All 212 target lesions were accurately biopsied during the initial surgery. Overall, 134 lesions were malignant and 78 benign (benign:malignant ratio 1:1·72), with fewer biopsies for benign lesions performed in screened patients (benign:malignant ratio 1:2·43) than in those with symptoms (ratio 1:1). Breast conservation was achieved in 72 patients (80 per cent) with screen-detected in situ or invasive carcinoma and in 19 of 37 presenting via a symptomatic clinic. In 160 of 202 patients (79 per cent) the initial fine-wire localization biopsy was diagnostic and therapeutic.
Effects of minimally invasive surgery on hypochlorous acid production by neutrophils
Authors: Carey P D , Wakefield C H , Thayeb A , Monson J R T , Darzi A , Guillou P J
Published: March 2007

The production of chlorinated oxidants such as hypochlorous acid is a central antimicrobial and immunoregulatory function of neutrophils. Neutrophil hypochlorous acid production was compared in patients undergoing uncomplicated laparoscopic surgery (group 1) and those submitted to conventional open surgery (group 2). Preoperative peak hypochlorous acid production was similar in the two groups (mean(s.e.m.) 0·60(0·05) versus 0·69(0·06) nmol/min respectively). In group 2, mean (s.e.m.) neutrophil hypochlorous acid production fell significantly on day 1 after surgery (0·36(0·05) nmol/min; P<0·01) but this did not occur in group 1 (0·63(0·07) nmol/min). By day 6 hypochlorous acid kinetics had returned to preoperative levels in both groups. Minimally invasive surgery is less disruptive of neutrophil function than conventional open procedures.
Strictureplasty without concomitant resection for small bowel obstruction in Crohn's disease
Authors: Tjandra J J , Fazio V W
Published: March 2007

The efficacy of strictureplasty in the treatment of Crohn's disease is often attributed in part to concomitant resection of strictured small bowel segments. Fifty-four patients with obstructive Crohn's disease who underwent 215 strictureplasty procedures (Heineke-Mikulicz, 179; Finney, 36) without concomitant resection of small bowel were reviewed. The median age was 38 (range 18–66) years and the median follow-up 3 (range 1–7) years. The mean number of strictureplasties per patient was 4 (range 1–13). Twenty-four patients had undergone at least one previous small bowel resection. There was no operative death. Intraabdominal abscess and enterocutaneous fistula occurred in two patients each and reoperation for sepsis was needed in one. At 1 year after surgery the median weight gain was 4 kg; all but two patients had relief of obstructive symptoms and 26 of 37 were weaned off steroids. Symptomatic recurrence occurred in 14 patients and seven required reoperation. Rates of recurrent stricture and of new stricture or perforative disease were 2·3 per cent of strictureplasty sites and 26 per cent of patients respectively.
Evaluation of direct and indirect inguinal hernia by computed tomography
Authors: Hahn-Pedersen J , Lund L , Højhus J Hansen , Bojsen-Møller F
Published: March 2007

The importance of venous distension of the pampiniform plexus in the prevention of inguinal hernia was evaluated. Functional closure of the inguinal canal was investigated by computed tomography during a Valsalva manoeuvre in a normal individual and 12 men with unilateral inguinal herniation, one of whom had previously undergone herniorrhaphy. Thus, 13 normal canals were evaluated along with five with direct and seven with indirect hernia. In all normal canals a rise in intra-abdominal pressure increased the cross-sectional area of the part of the pampiniform plexus located in the medial end of the canal, thereby filling the empty space and preventing herniation. In the lateral part the plexus was compressed against the external aponeurosis by the fascia transversalis in a valve-like fashion. In cases of direct inguinal herniation the distended pampiniform plexus was displaced by the hernia sac during the Valsalva manoeuvre, but in indirect hernia impaired swelling of the pampiniform plexus was seen. It is suggested that this observation could help to explain the normal mechanism of closure of the inguinal canal.