bluuebunny/crossref_metadata_2025 huggingface dataset:
Preduodenal mechanisms in initiating gallbladder emptying in man
Authors: Ellenbogen S , Jenkins S A , Grime J S , Critchley M , Mackie C R , Baxter J N
Published: March 2007

The existence of preduodenal phases of gallbladder emptying in normal volunteers was investigated by evaluating the effect of sham feeding a sandwich (chew and spit) (n = 15), the sight and smell of food followed by sham feeding a cooked meal (n = 15), and gastric distension (intragastric balloon tube) (n = 9) on gallbladder emptying and comparing these responses with those after ingestion of a standard meal (n = 14). A control group given no intestinal stimuli were studied to determine the frequency of spontaneous emptying during fasting (n = 18). 99mTc-EHIDA (2,6 diethylphenylcarbamoylmethyliminodiacetic acid) was used as the biliary tracer. The frequency of gallbladder emptying during fasting was 0.0045/min. Thus, in any 20 min period emptying occurred spontaneously in only about 1 in 11 volunteers. Significant emptying (> 5 per cent over 20 min) occurred in 8 out of 15 volunteers after sham feeding a sandwich (P < 0.001 versus control), in 8 out of 15 volunteers after sham feeding a cooked meal (P = 1.0 versus sandwich sham feed, n.s.), in 6 out of 9 volunteers after gastric distension (P < 0.001 versus control) and in 14 out of 14 volunteers after meal ingestion. The rate of emptying was significantly greater in the gastric distension and meal ingestion groups compared with other groups (P < 0.05). However, the emptying rate after sham feeding was not significantly different from spontaneous gallbladder emptying (P > 0.05, n.s.). These was no significant difference in time to onset of emptying between the four stimulus groups (P > 0.05, n.s.). These results suggest that pre-duodenal stimuli can evoke gallbladder emptying in man, although the precise physiological significance of this phenomenon remains to be established.
Surgical treatment of hepatic hydatid disease
Authors: Dawson J L , Stamatakis J D , Stringer M D , Williams R
Published: March 2007

The results of surgery in 48 patients with hepatic hydatid disease are described. In 26 out of 32 patients with uncomplicated cysts, conservative surgery with obliteration of the cyst cavity by omentoplasty gave satisfactory results. In contrast, 16 patients with cysts complicated by pyogenic infection or cholangitis required a variety of surgical procedures, including prolonged tube drainage, exploration of the common bile duct, sphincterotomy/plasty and hepatojejunostomy to achieve a satisfactory outcome. The group with complicated cysts also had a much longer postoperative stay (median 30 days) than those with uncomplicated cysts (median 14 days). Two patients died: in one, post-mortem examination revealed carcinoma in the wall of the cyst.
Surgical glove perforation
Authors: Dodds R D A , Guy P J , Peacock A M , Duffy S R , Barker S G E , Thomas M H
Published: March 2007

In a study to investigate the incidence and significance of surgical glove perforation, bacterial contamination of surgeons' hands and gloves before and after operation was measured and the gloves tested for damage. Perforations were found in 74 of 582 gloves (12.7 per cent) and occurred in 34–5 per cent of operations. Glove perforation did not influence bacterial counts on the surgeons' hands or on the outside of their gloves. A separate clinical study of 100 adult hernia repairs gave no evidence that perforation increased wound sepsis. After standard pre-operative hand preparation, glove perforations are of no clinical significance to the patient, but their high incidence should alert surgeons to the need for protection against pathogens transmissible during surgery, such as hepatitis B and the human immunodeficiency virus. Protection of the surgeon is the main indication for peroperative change of damaged gloves.
Thrombosis prophylaxis with low molecular weight heparin in total hip replacement
Authors: Eriksson B I , Zachrisson B E , Teger-Nilsson A-C , Risberg B
Published: March 2007

In a randomized prospective trial, the efficacy of low molecular weight heparin (LMWH) (Fragmin®) and dextran 70 (Macrodex®) in preventing deep vein thrombosis (DVT) in the legs was evaluated in 98 consecutive patients undergoing elective total hip replacement. The patients were randomly allocated to receive either 2500 anti-factor Xa units LMWH twice daily for 7 days, with the first dose given 2 h before surgery; or 500 ml dextran 70 twice during the day of operation, followed by a single infusion of 500 ml on the first and again on the third postoperative day. DVT was assessed by 125I-fibrinogen test for 2 weeks postoperatively, a positive test being followed by phlebography. DVT developed in 22 (45 per cent) of 49 patients receiving dextran 70 and in 10 (20 per cent) of 49 patients in the LMWH group (P < 0.01). LMWH was thus statistically significantly better than dextran 70 in preventing DVT in the legs. It was not firmly established whether this benefit was also valid in the high ileofemoral region. Two patients with non-fatal pulmonary embolism were found in each group. Per- and postoperative blood loss and blood transfusion requirements were significantly lower in the LMWH group.
Erythrocyte membrane stearic and oleic acid ratios in breast cancer
Authors: Thomas B S , O'Dea J , Fentiman I S
Published: March 2007

A case control study has been conducted to determine the value of stearic/oleic acid ratios in the erythrocyte membranes of women at the time of presentation with breast cancer. No difference was found between the stearic/oleic acid ratio of cases and that of controls with benign breast condition or normal volunteers. Furthermore, within clinical stages of breast cancer, no differences were detected. This ratio does not appear to be of value as a marker of malignancy, or of tumour burden.
A new non-operative approach to fistula in ano
Authors: Misra M C , Kapur B M L
Published: March 2007

The results of a new out-patient approach to fistula in ano are presented. The technique involved passing a multi-strand stainless steel wire through the fistulous tract and has been used in 56 patients with low fistulae as well as high horseshoe anal fistulae. Recurrence was seen in only 2 patients and none of the patients experienced temporary or permanent incontinence of flatus or faeces.
Total duodenal diversion in the treatment of complicated peptic oesophagitis
Authors: Perniceni T , Gayet B , Fékété F
Published: March 2007

Total duodenal diversion (TDD) has been carried out in 59 patients with complicated forms of peptic oesophagitis (acquired short oesophagus, columnar lined oesophagus, previous oesophagogastric surgery, stenosis). A standard procedure (truncal vagotomy, antrectomy and gastrojejunal anatomosis using a 70 cm Roux-en-Y loop) was performed in 41 patients, and some technical adjustments were required in 18 patients previously operated on. One patient died from postoperative pulmonary embolism. Bowel movements were resumed before the fifth postoperative day in 93 per cent of patients (54/59). Early postoperative complications (gastroparesis, 5; fistula, 1; subsequent operation, 1) occurred in 12 per cent of patients. Stabilization of the oesophagitis was achieved in less than 3 months in 95 per cent of cases (55/58). There were two cases of regression of columnar lined oesophagus. A 3-h postprandial pH assessment showed that the reflux had been controlled in 92 per cent of cases (47/51). One patient who still had an acid reflux died subsequently of a perforated oesophageal ulcer. Three anastomotic ulcers occurred in eight patients who did not have vagotomy. Digestive side-effects have been observed in nine patients, but only in one case were they crippling. Our results suggest that TDD is a suitable form of treatment for complicated forms of peptic oesophagitis.
Relaparotomy for postoperative intra-abdominal sepsis in jaundiced patients
Authors: Mäkelä J , Kairaluoma M I
Published: March 2007

During the period 1979–84, 30 abdominal re-explorations were performed for postoperative intra-abdominal sepsis and single or multiple organ failure in jaundiced patients. Postoperative sepsis was caused by intra-abdominal abscess in 16 cases (53 per cent), by suture line leakage in 9 cases (30 per cent) and by technical error in 5 cases (17 per cent). Abscesses occurred most commonly in the subphrenic space (6 cases), in the subhepatic space (6 cases) and in the lesser sac (5 cases). Sepsis was associated with single organ failure in 20 cases and with multiple organ failure in 10 cases. The overall mortality rate was 50 per cent (15/30). Factors that were statistically associated with fatal outcome were: serum bilirubin > 100 μmol/l (P<0·008), positive blood culture (P<0·013), malignant disease (P<0·02), multiple organ failure (P<0·02) and age > 60 years (P<0·031). Mortality rose with the number of failed organs. Autopsy revealed continuing sepsis in 12 of the 15 fatal cases. Because mortality was high in spite of adequate operative drainage at relaparotomy, it is concluded that earlier definitive diagnostics are needed to lower the mortality rate.
Management of symptomatic gallstones in the elderly
Authors: Irvin T T , Arnstein P M
Published: March 2007

In a study of 544 patients with symptomatic gallstones 158 subjects were aged > 70 years. Elderly patients had a significantly higher incidence of emergency presentation, jaundice, cholangitis, ductal stones, biliary drainage procedures, and acute complications requiring urgent or emergency surgery (P < 0·001); they had more than twice the incidence of postoperative complications in comparison with patients aged < 70 years. There was an increased perioperative mortality in the elderly (1·3 per cent after cholecystectomy and 2·9 per cent after bile duct exploration, P = 0·039). Conservative treatment in 11 per cent of elderly patients resulted in no mortality due to gallstones, but 3 of 17 patients had recurrent biliary symptoms. It was estimated that 38 per cent of the bile duct explorations in the elderly might have been avoided by referral for endoscopic sphincterotomy, but surgical treatment of gallstones in the district general hospital is relatively safe and specialist referral should be considered only in the relatively small number of ‘high risk’ cases.
Effect of transdermal glyceryl trinitrate on the survival of peripheral intravenous infusions: A double-blind prospective clinical study
Authors: Khawaja H T , Campbell M J , Weaver P C
Published: March 2007

Phlebitis is the commonest complication of intravenous infusion. It has been suggested that it is initiated by venoconstriction at the infusion site, hence treatment with a vasodilator may reduce its incidence. We carried out a prospective double-blind controlled study of the effect of transdermal glyceryl trinitrate on the survival of peripheral intravenous infusions in 340 patients. Fifty-five per cent (94 out of 170) of the infusions failed in the control group compared with 19 per cent (33 out of 170) in the treatment group (χ2 = 45, P < 0.0005). The commonest cause of infusion failure was superficial phlebitis: 47 per cent in the control group and 17 per cent in the treatment group (χ2 = 46, P<0.0005). The estimated median time of infusion survival was 74 h in the control group compared with 127 h in the treatment group (log rank χ2 = 143, P < 0.0001). We conclude that infusion phlebitis is a common problem in hospitalized patients and its incidence can be effectively reduced by transdermal glyceryl trinitrate.
Definitive one-stage emergency large bowel surgery
Authors: Mealy K , Salman A , Arthur G
Published: March 2007

During a 30-month period, 126 operations for emergency large bowel conditions were performed: 57 were for colonic carcinoma, 26 for acute diverticulitis, 14 for colonic ischaemia, 13 for complications of inflammatory bowel disease, and 16 for other conditions. Sixty-eight patients had peritonitis. One hundred and ten patients (87.3 per cent) underwent immediate resection. Of these, 83 (65.9 per cent of the overall group) had colonic resection with primary anastomosis but without a colostomy, 56 of which were left-sided colonic resections. Excluding 9 of the 68 patients with peritonitis, who had a total colectomy, 66 per cent also underwent resection, anastomosis and no colostomy. Total group mortality was 14.3 per cent: 12.7 per cent in the immediate resection group, 9.6 per cent in those with primary anastomosis and no colostomy, 5.2 per cent in the group with peritonitis undergoing resection and anastomosis, and 25 per cent in those having non-resectional surgery. Complications included an overall wound infection rate of 10.3 per cent and a clinical anastomotic leak rate of 7.2 per cent in those who had anastomosis without colostomy. Our results suggest that resection and primary anastomosis can be performed with acceptable morbidity and mortality in a high proportion of cases of emergency large bowel conditions, irrespective of underlying pathology, site of disease or the presence of peritonitis.
Physiological changes after postanal repair and parameters predicting outcome
Authors: Yoshioka K , Hyland G , Keighley M R B
Published: March 2007

Nineteen patients have been studied before and 3 months after postanal repair. Physiological parameters have been compared with 16 age- and sex-matched controls. Twelve patients were substantially improved whereas seven obtained no clinical benefit. Pre-operative resting (P<0.005), squeeze (P<0.005) and strain (P<0.005) anal pressures at 2 cm were significantly less than controls. Similarly, pressures during all three events at 4 cm were significantly less than controls (resting P<0.05, squeeze P<0.005, strain P<0.025). Median volume of first leak during saline infusion was significantly less than controls (P < 0.005) as was the total tolerable volume (P < 0.005). Videoproctographic parameters which differed significantly from controls included pelvic floor descent at rest (P < 0.005), during contraction (P < 0.005) and straining (P < 0.05); resting and squeeze perineal descent (P < 0.005); and anal canal length at rest and straining (P < 0.005). Anorectal angles, rectal compliance, rectal sensation and emptying did not differ from controls. None of these parameters was improved by postanal repair. Patients not improved by operation could be detected pre-operatively by low resting (P < 0.05), squeeze (P < 0.025) and strain (P < 0.05) anal pressure at 2 cm as well as by videoproctographic evidence of increased pelvic floor descent at rest (P < 0.01), during contraction (P < 0.005) and straining (P < 0.005), excessive perineal descent at rest (P < 0.05), during contraction (P < 0.05) and during attempted defaecation (P < 0.05) and a short anal canal at rest (P < 0.05) and during straining (P < 0.025).
Choice of material for above-knee femoropopliteal bypass graft
Authors: Michaels J A
Published: March 2007

Autogenous saphenous vein is generally considered to be the best material for arterial bypass grafts below the inguinal ligament. Recent results have suggested that the advantage of vein over prosthesis is more pronounced in a distal situation, but it is not immediately apparent whether the difference is sufficient to justify a policy of using prosthesis for the initial above-knee graft to preserve the vein in case later surgery is required. An attempt has been made to answer this question. The literature has been reviewed to obtain estimates of the patency rates for grafts in different situations and a mathematical model has been set up using these figures to predict the outcome of different treatment policies. The model can be used to predict the result of alteration or inaccuracy in the data or to make use of the results of newly reported studies. The model predicts that the use of prosthesis for an initial graft will reduce the overall patency and substantially increase the requirement for reoperation, even if the present data give a substantial overestimate of the advantages of vein above the knee.
Risk of aortic aneurysm surgery as assessed by preoperative gated heart pool scan
Authors: Fletcher J P , Antico V F , Gruenewald S , Kershaw L Z
Published: March 2007

Gated heart pool scan measuring left ventricular ejection fraction (LVEF) was performed preoperatively in 72 patients presenting for elective repair of abdominal aortic aneurysm. Patients with a positive cardiac history were more likely to have a LVEF of ⩽45 per cent (P < 0·001). The operative mortality rate was 4 per cent. Each of three patients who died had a LVEF ⩽35 per cent and developed cardiac failure which led to renal failure. Five other patients developed cardiac failure manifested by acute pulmonary oedema during the early postoperative period. There was no statistically significant association between a positive cardiac history and the occurrence of postoperative cardiac failure or death. However, patients with a LVEF of ⩽45 per cent were more likely to develop postoperative cardiac failure (P = 0·004) while patients with a LVEF of >35 per cent had a greater chance of dying (P < 0·001). No patient died with a LVEF > 35 per cent. Preoperative evaluation of LVEF can select patients at high risk of cardiac death from repair of abdominal aortic aneurysm. Such patients could be followed conservatively if they remain asymptomatic and the aneurysm does not enlarge. If operation is considered mandatory, patients with a low LVEF should receive intensive perioperative monitoring with enhancement of ventricular performance.
Variceal haemorrhage after failed injection sclerotherapy: The role of emergency oesophageal transection
Authors: Jenkins S A , Shields R
Published: March 2007

In a planned sequential policy for the emergency control of continued bleeding from oesophageal varices, oesophageal transection was performed after failure of conservative treatment, including injection sclerotherapy. In 15 patients who underwent emergency oesophageal transection, bleeding was controlled by operation in the majority (87 per cent), but 11 of the 15 patients died in hospital. Mortality in patients with poor liver function (Child's C) was 100 per cent, the majority of deaths resulting from hepatic and renal failure. The results of this study suggest that emergency oesophageal transection to control acute variceal haemorrhage is associated with a poor prognosis in patients with poor liver function and questions its role in a sequential emergency treatment policy.
Timing of prophylactic antibiotics in abdominal surgery: Trial of a pre-operative versus an intraoperative first dose
Authors: Bates T , Siller G , Crathern B C , Bradley S P , Zlotnik R D , Couch C , James R D G , Kaye C M
Published: March 2007

When prophylactic antibiotics are used in abdominal surgery it is customary to give the first dose before the operation. Whilst intra-operative antibiotics may be effective in elective surgery, there may be an advantage to starting pre-operatively when there is already an infective focus such as appendicitis. Antibiotics started pre-operatively (group P) have been compared with antibiotics started after initial abdominal exploration (group T). Three intravenous doses of 500 mg metronidazole plus 1 g cephazolin were given in a randomized, double-blind study of 700 emergency and elective high-risk abdominal operations. Antibiotic plasma concentrations at the end of the operation were significantly lower in group P but lay well within the therapeutic range. Wound infection rates, which included minor and delayed infections, were similar in both groups (group P, 57 of 342, 16·7 per cent; group T, 55 of 358, 15·4 per cent; 95 per cent confidence intervals for the difference being −4·1 to +6·7 per cent. In appendicitis, wound infection rates were 12·1 and 13·9 per cent for groups P and T respectively. However, non-fatal deep sepsis was more common in group P (nine cases) than in group T (two cases) (χ2 = 4·9, P < 0·05). Postoperative infection was twice as common in obese patients whose body mass index (BMI) was ⩾ 26 (39 of 132, 30 per cent) than in thin patients whose BMI was <24 (41 of 288, 14 per cent; χ2 = 13·8, P < 0·001). This study failed to show any advantage to starting antibiotics pre-operatively, even in appendicitis.
A study of the physiological variation in anal manometry
Authors: Pedersen I Krogh , Christiansen J
Published: March 2007

The physiological variation in anal manometry using a perfused catheter with radiating sideholes was studied in 78 healthy volunteers. The maximum intraindividual variation in the length of the anal high pressure zone, resting pressure and squeeze pressure was 10 mm, 26 mmHg and 68 mmHg respectively. The median 95 per cent confidence interval for length of the pressure zone was 4 mm; for resting pressure it was 15 mmHg and for squeeze pressure it was 48 mmHg. Day-to-day variation did not exceed the intraindividual variation. Constant recording with the catheter fixed in the high pressure zone revealed slow waves and ultraslow waves with amplitudes of 6–24 mmHg which could account for most of the intraindividual variation. No sex difference was found in the length of the high pressure zone whereas resting pressure and squeeze pressure were higher in men than in women. Although a tendency towards a decrease in the length of the high pressure zone, resting pressure and squeeze pressure was observed with increasing age, no significant age-related difference could be demonstrated.
Near-total thyroidectomy for carcinoma of the thyroid
Authors: Sarda A K , Bal S , Kapur M M
Published: March 2007

There is controversy about the most appropriate treatment for patients with thyroid cancer. This study analyses our experience with 206 cases of thyroid cancer from an endemic goiterous area. There were 100 males and 106 females; patients presented at an earlier age with a short history. Thyroid cancers demonstrated an aggressive biological behaviour with an advanced stage at presentation (overt cancers in 51 per cent) and a relentless course with a mortality rate of 24·2 per cent for the well-differentiated tumours. Near-total thyroidectomy was performed in 126 patients. Multicentric foci of tumour were seen in 17·2 per cent of the well-differentiated cancers and 25·2 per cent of the cases of well-differentiated cancers who underwent near-total thyroidectomy developed loco-regional recurrence. Hemithyroidectomy was performed in 35 patients who refused completion total thyroidectomy at a second stage; 16·7 per cent of these patients developed a recurrence in the remaining contralateral lobe. Thus in our patients from an endemic goiterous area, near-total thyroidectomy is the treatment of choice particularly because of the frequent occurrence of follicular and anaplastic cancers (in 44·2 per cent) and because the course of the disease is more virulent.
Prediction of outcome in patients with acute variceal haemorrhage
Authors: Jacobs S , Chang R W S , Lee B , Al Rawaf A , Pace N C , Salam I
Published: March 2007

Prediction of outcome in 87 patients following acute bleeding oesophageal and gastric varices due to portal hypertension from chronic liver disease was studied at our hospital over a 30-month period. The overall mortality rate was 26 per cent (23/87), with the operative mortality rate (50 per cent) being more than triple the non-operative mortality rate (14 per cent). The initial prothrombin time ratio (PTR) alone was significantly different in survivors and non-survivors both in the operated and non-operated patients. The only survivor in the whole material with a PTR ⩾ 2·2 was a patient who was transferred and underwent successful liver transplantation elsewhere. Among operated intensive care unit (ICU) patients, the Glasgow predictor gave a mean probability of discharge of 0·81 (s.d. 0·15) in 13 survivors and of 0·35 (s.d. 0·35) in the 15 non-survivors (P < 0·001). In the 11 non-operative ICU patients, who had failed sclerotherapy, the Glasgow predictor could not be validated. Fourteen ICU deaths were associated with significant hypotension defined as a systolic blood pressure < 90 mmHg for > 1 h.
Cardia carcinoma considered as a distinct clinical entity
Authors: Huseman B
Published: March 2007

From 1 January 1969 until 31 December 1985, gastric resections were performed in 937 patients with carcinoma of the stomach and 422 patients with carcinoma of the cardia. During this period, the general frequency of cardia carcinoma increased continuously from 6·6 per cent (1969–71) to 37·5 per cent (1984–85) and a corresponding decrease of carcinomas in other sites was observed. Early carcinomas (pT1) of the oesophageal margin (n = 10, 2·4 per cent) were diagnosed less often than early carcinomas in other sites (n = 177, 18·9 per cent). Whereas 51·4 per cent of all resected carcinomas of the stomach showed no lymph node metastases (pN0), only 14·1 percent of cardia carcinomas belonged to this category. With respect to operative treatment. Lauren's classification which defines the required margin of clearance according to diffuse type (frequency in cardia carcinoma 43 per cent, in other stomach sites 51 per cent), is of great significance. We believe that extensive oesophageal resection is necessary for patients with such difficult tumours. The pattern of metastasis in cardia carcinoma is similar to that of cancer in other stomach sites, the preferred area is the regional lymph nodes on the lesser curve (83 per cent). Histological classification and metastasis pattern show that cardia carcinoma is a type of carcinoma of the stomach which must be treated according to the criteria of stomach cancer surgery.
Branched chain amino acids as the protein component of parenteral nutrition in cancer cachexia
Authors: Hunter D C , Weintraub M , Blackburn G L , Bistrian B R
Published: March 2007

A prospective randomized trial was conducted to determine the effects of branched chain amino acids (BCAA) as the protein component of total parenteral nutrition (TPN) on protein kinetics in patients with intra-abdominal adenocarcinoma. Nine malnourished patients were given both conventional TPN containing 19 per cent BCAA (AA) and isocaloric, isonitrogenous TPN containing 50 per cent BCAA (BCAA-TPN), in random order. Both [13C]leucine and [14C]tyrosine were employed as tracers to avoid the potential bias due to the different amino acid composition of the two TPN solutions. With BCAA-TPN, leucine and tyrosine flux increased significantly from (mean ± s.d.) 158·0 ± 37·2 to 243·5 ± 75·8 μmol kg−1 h−1 (P < 0·025) and from 35·0 ± 8·4 to 42·6 ± 11·0 μmol kg−1 h−1 (P < 0·05) respectively. Leucine oxidation was significantly higher on BCAA-TPN (24·1 ± 6·3 on AA versus 68·3 ± 37·1 μmol kg−1 h−1, P < 0·025) while tyrosine oxidation was significantly lower (3·7 ± 1·8 μmol kg−1 h−1 on AA versus 2·5 ± 2·0 μmol kg−1 h−1 on BCAA-TPN, P < 0·05). Whole body protein synthesis and breakdown was significantly higher on BCAA-TPN by the tyrosine tracer (31·3 ± 7·3 on AA versus 40·1 ± 9·3 μmol kg−1 h−1, P < 0·025 and 33·0 ± 8·4 on AA versus 41·3 ± 11·1 μmol kg−1 h−1, P < 0·05) respectively. Using the leucine tracers both synthesis and breakdown were increased, but not significantly, from 133·8 ± 40·0 to 175·3 ± 65·1 μmol kg−1 h−1 and from 127·9 ± 33·6 to 167·7 ± 71·2 μmol kg−1 h−1 respectively. The fractional albumin synthetic rate increased significantly on BCAA-TPN from 4·3 ± 2·9 on AA to 8·0 ± 5·1 per cent per day (P < 0·05). The reduction in tyrosine oxidation, suggesting improved protein utilization, coupled with an increase in protein and albumin synthesis, strongly support a positive benefit from BCAA-TPN in cancer cachexia.
Isotopic studies during surgical convalescence
Authors: Humberstone D A , Shaw J H F
Published: March 2007

We have performed paired isotopic studies in four patients undergoing resection of early colorectal cancer and four having removal of parathyroid adenomas. Kinetic measurements of protein and glucose metabolism were made before resection and at home 10 weeks after surgery. During convalescence there were major changes in both groups in glucose metabolism and the hormonal milieu despite no alterations in protein kinetics or metabolic rate. In particular, the rate of glucose production doubled from (mean±s.e.m.) 14·8 ± 1·3 to 28·1 ± 2·5 μmol kg−1 min−1 (P < 0·01), the percentage of available glucose undergoing oxidation decreased from 35·5 ± 3·9 to 21·5 ± 2·9 per cent (P < 0·05) and the percentage of glucose undergoing recycling to lactate increased from 20·1 ± 10·0 to 52·9 ± 2·3 per cent (P < 0·05). During convalescence the basal plasma insulin concentration was significantly higher (P < 0·05) and there was a proportionately smaller response to glucose infusion. The convalescent state was also associated with an elevation in serum cortisol from 291 ± 54 to 496 ± 75 nmol litre−1 (P < 0·05). The values for resting energy expenditure were not significantly different from the predicted energy expenditure in either the preoperative or the convalescent groups. We conclude that (a) there is a marked increase in both glucose production and glucose recycling to lactate in convalescence from clean uncomplicated surgery, and this is associated with a decrease in the percentage of glucose uptake oxidised; (b) a relative hyperinsulinaemia is seen in convalescent patients and is associated with decreased responsiveness to a glucose load; (c) the plasma cortisol level is significantly elevated after 10 weeks of convalescence; and (d) convalescent patients do not have elevated rates of protein catabolism or energy expenditure.
Anergy in patients with biliary lithiasis
Authors: Caínzos M , Potel J , Puente J L
Published: March 2007

A prospective study was carried out in 428 subjects (212 controls and 216 patients) to evaluate the delayed cell-mediated immune response preoperatively in patients with biliary lithiasis. The delayed hyper-sensitivity response was assessed by a Multitest and subjects were classified as immunocompetent, relatively anergic or anergic. Significant differences were found between control subjects and patients with cholelithiasis compared with those with acute cholecystitis (P < 0·01), non-icteric choledocholithiasis (P < 0·01) and choledocholithiasis with jaundice (P < 0·05). There were also differences between patients with icteric and non-icteric choledocholithiasis (P < 0·02). Seven possible causative factors for anergy were evaluated: a haemoglobin concentration of ⩽ 12 g/l and a haematocrit of ⩽ 35 per cent were related to the appearance of anergy and relative anergy in patients with acute cholecystitis. Bilirubin levels ⩾ 34 μmol/l were found in 60 per cent of patients with choledocholithiasis and relative anergy and in 80 per cent of those who were anergic (P < 0·001). These results show a high incidence of failure of the cell-mediated immune response in patients with acute cholecystitis (71 per cent) and icteric choledocholithiasis (82 per cent). In the latter, jaundice appears to be associated with this failure. A close correlation between relatively anergic and anergic state and the development of postoperative septic complications was found.
Residual tumour after biopsy for non-palpable ductal carcinoma in situ of the breast
Authors: Wobbes Th , Tinnemans J G M , van der Sluis R F
Published: March 2007

In a group of 40 patients with non-palpable ductal carcinoma in situ (DCIS) of the breast, 41 breast specimens were available for studying residual tumour after biopsy. In one group of ten patients seen before 1977, simple histological examination revealed a 9 per cent incidence of residual tumour. However, after thorough examination residual foci of DCIS were found in 77 per cent of a subsequent group of 30 patients. This means that the majority of patients would have had to undergo reoperation if a breast-saving procedure had been performed. This fact must be taken into account when planning treatment of patients with non-palpable DCIS.
Prior renal transplantation does not facilitate subsequent canine islet allograft survival
Authors: Guy A J , Griffin S M , Alderson D , Farndon J R
Published: March 2007

Successful islet allografts can be established in rats bearing long surviving renal allografts, without additional immunosuppression, when kidney and islet donor animals are of the same strain. The applicability of such a scheme to clinical practice has been investigated in a large animal model of diabetes: the pancreatectomized dog. Eight dogs with previously established renal allografts and immunosuppressed with cyclosporin A received islet allografts from their respective original kidney donors. The median islet graft functional survival was only 10·5 days, significantly less than for six similarly immunosuppressed dogs receiving islet allografts alone (48·5 days, P < 0·05). Three of the sequentially transplanted dogs had had no renal graft rejection episodes before islet transplantation, yet their islet grafts were all rejected within 19 days. In the pancreatectomized dog, prior donor specific renal transplantation has an adverse effect upon subsequent islet graft survival.
Need for surgical wound dressing
Authors: Chrintz H , Vibits H , Cordtz T O , Harreby J S , Waaddegaard P , Larsen S O
Published: March 2007

The need for dressings on clean and clean contaminated surgical wounds was investigated. A total of 1202 patients with 1202 clean or clean contaminated surgical wounds were randomized into two groups: 633 wounds were covered by dressings up until the time of suture removal, and 569 wounds were treated without dressings after the first postoperative day. In the group characterized by long dressing time, the rate of postoperative wound infections was 4·9 per cent. The rate was 4·7 per cent in the group represented by short dressing time. Using short dressing time not only reduces the number of nursing hours but also limits the need for costly dressing material. In addition, both wound observation and patients' personal hygiene are made easier.
Mortality and perforated peptic ulcer: A case for risk stratification in elderly patients
Authors: Irvin T T
Published: March 2007

In a consecutive series of 284 patients with a perforated peptic ulcer (229 pyloroduodenal, 55 gastric) there was a 26 per cent hospital mortality rate, and patients aged ⩾ 70 years (n = 176) had a significantly higher mortality rate (34 per cent) than patients aged <70 years (14 per cent, P < 0·001). Multiple clinical variables were significantly more common in the elderly group of patients (65 per cent), in those having non-steroidal anti-inflammatory drugs or steroid therapy (56 per cent), in patients where there is an absence of a previous dyspeptic history (69 per cent), and when risk factors such as delayed presentation (33 per cent) and the presence of shock on admission to hospital (27 per cent) are present. Definitive operations (vagotomy or gastrectomy) had an increased mortality rate in the elderly (P = 0·018). Risk scores based upon the presence of shock, delayed presentation or concurrent medical illness could have predicted 87 per cent of postoperative deaths in elderly subjects, and it is suggested that risk stratification and greater caution in the use of definitive operations for perforated ulcer may result in a reduction in the high mortality rate in elderly subjects.
Determinants of gastro-oesophageal reflux and their inter-relationships
Authors: Johnsson F , Joelsson B , Gudmundsson K
Published: March 2007

Gastro-oesophageal reflux was measured by 24-h ambulatory oesophageal pH monitoring in 220 patients with symptoms suggestive of gastro-oesophageal reflux disease. By multiple regression analysis it was found that the pressure in the distal oesophageal high pressure zone, the presence of a hiatal hernia, the intra-abdominal length of the high pressure zone, the amplitude of the contraction waves in the distal oesophagus and age all significantly participated in the determination of the amount of gastro-oesophageal reflux. The pressure in the distal oesophageal high pressure zone was the single variable that correlated most strongly to the amount of reflux. Although the amount of reflux increased significantly with increasing weight as measured by Broca's index, this variable did not participate in the determination of reflux by the multiple regression test. The study emphasizes the role of the pressure and intra-abdominal length of the distal oesophageal high pressure zone as the primary antireflux barrier. It also shows that a hiatal hernia plays a role in generating gastro-oesophageal reflux through a mechanism other than affecting the pressure and the intra-abdominal length of the high pressure zone.
Alcohol sclerotherapy of non-parasitic cysts of the liver
Authors: Andersson R , Jeppsson B , Lunderquist A , Bengmark S
Published: March 2007

Between 1980 and 1987, nine patients with non-parasitic cysts of the liver were treated with computed tomography-guided percutaneous puncture and evacuation of the cyst contents followed by injection of absolute alcohol as a sclerosing agent. During the same period only one patient was treated with surgery. The patients included seven women and two men with a mean age of 62 years. Three patients had a single cyst and six patients had multiple cysts. The size of the largest cysts varied between 5 and 20 cm (mean 10 cm). Patients with multiple liver cysts had repeated punctures and sclerosing procedures (up to eight times); 50–3100 ml of cyst fluid (mean 650 ml) was drained per procedure. One patient had symptoms of moderate alcohol intoxication; otherwise no complications were noted. Follow-up was performed with computed tomography or ultrasonography for 8–54 months (median 18 months). The results have been considered successful in eight out of nine patients who had cyst regression and reduced symptons. Two patients, however, required additional surgical treatment due to residual and multiple cysts. Computed tomography-guided alcohol sclerotherapy of non-parasitic liver cysts appears to be a safe and effective initial therapy.
The role of thrombolytic therapy in surgical practice
Authors: Moran K T , Jewell E R , Persson A V
Published: March 2007

The ability of streptokinase and urokinase to lyse intravascular fibrin-based clots is firmly established. However, there is a lack of enthusiasm for these agents because of serious haemorrhagic complications and a lack of controlled randomized studies indicating their efficacy. Thrombolytic therapy is suitable in only 15 per cent of patients with acute deep venous thrombosis. It restores the venous circulation to normal in up to 95 per cent of these patients if therapy is instituted within 5 days of the onset of symptoms. These patients have significantly fewer symptoms on follow-up than patients treated with heparin although the ability of thrombolytic therapy to preserve venous valvular function and to prevent the post-phlebitic syndrome is now in question. Thrombolytic therapy is as effective as heparin in preventing pulmonary embolism and may be superior in its treatment. Pulmonary haemodynamics are rapidly improved, diffusion capacity is restored and, although the evidence is inconclusive, long-term pulmonary hypertension may be prevented. Although the mortality rate is not decreased, controlled studies show that thrombolytic therapy may be beneficial in massive pulmonary embolism with clinical shock. Thrombolytic therapy is indicated for acute arterial and acute bypass graft occlusion when the surgical alternative is associated with a higher morbidity and mortality. Partial thrombolysis is achieved in up to 90 per cent of cases and the need for further therapeutic intervention is eliminated in one-third of the patients treated. New thrombolytic agents with greater specificity and potentially greater efficacy and fewer complications are being developed. Tissue plasminogen activator has been successfully used. Prourokinase, fibrin-seeking urokinase and acetylated streptokinase—plasminogen complex may expand the role of thrombolytic therapy in surgical practice.
Role of B-mode venous mapping in infrainguinal in situ vein—arterial bypasses
Authors: Leopold P W , Shandall A , Kupinkski A M , Chang B B , Kaufman J , Shah D M , Leather R P
Published: March 2007

Two hundred and eighty patients underwent B-mode mapping (B-map) of their saphenous vein over a period of 3 years (1984–1987) before lower limb revascularization. B-map deemed that 229 veins were suitable for bypass, 26 were questionable and 25 were unsuitable. A successful bypass was achieved in 97·8 per cent of the suitable group (all in situ), 85 per cent of the questionable group (in situ and composite vein), and 80 per cent of the unsuitable group (composite vein). At a minimum follow-up period of 1 year the overall patency rate was 95·0 per cent with a revision rate of 15·8 per cent. There was no correlation between revision rate and vein complexity or calf vein diameter. Calf vein diameter > 2·5 mm was correlated with a successful bypass (P < 0·001). It is concluded that B-map is the investigation of choice for saphenous vein assessment before infrainguinal bypass surgery.
Localization of lower gastrointestinal bleeding using in vivo technetium-99m-labelled red blood cell scintigraphy
Authors: Nicholson M L , Neoptolemos J P , Sharp J F , Watkin E M , Fossard D P
Published: March 2007

Technetium-99m-labelled red blood cell scintigraphy was used in the investigation of 41 patients with major rectal haemorrhage. Red cells were labelled in vivo with technetium-99m pertechnetate and serial scans (0–36 h) were taken using a large field γ camera. Twenty-two men and 15 women, mean age 71·3 years (range 32–91 years), and four children were studied. Forty-three scans were performed in all and there were 31 positive and 12 negative results. In each case the accuracy of the scan in localizing the bleeding site was checked either by independent investigations or at laparotomy. A definite bleeding site was identified in 30 cases and red cell scintigraphy correctly localized 29 of these (sensitivity 97 per cent). In the remaining 13 cases a bleeding site was not identified by any of the independent investigations and in this group there were two false positive scans (specificity 85 per cent). The investigation had a high predictive value when both positive (94 per cent) and negative (92 per cent). These data suggest that technetium-99m-labelled red cell scintigraphy should be used more widely in the investigation of patients with suspected lower gastrointestinal haemorrhage.
High volume lesser sac lavage in acute necrotizing pancreatitis
Authors: Teerenhovi O , Nordback I , Eskola J
Published: March 2007

The effect of lesser sac drainage with or without lavage on some early predictors and on outcome in acute necrotizing pancreatitis was analysed. The evaluation was made prospectively for 24 patients, in a single centre study. According to Ranson's criteria and laparotomy findings, the lavage and drainage groups were comparable and the pancreatitis was severe and necrotizing in both groups. In a longitudinal analysis of the first 4 postoperative days, lavage did not show any advantage over drainage, as measured by seven prognostic signs (serum creatinine, blood glucose, base excess, haematocrit, white blood cells, C-reactive protein and immunoreactive phospholipase A2 concentration). Furthermore, the study did not find that lavage had any positive effect on the incidence of mortality (36 versus 17 per cent in the drainage group) or on septic complications in acute necrotizing pancreatitis. In the total series the extent of pancreatic necrosis was an essential predictor of the outcome.
Surgical strategy in primary retroperitoneal tumours
Authors: Serio G , Tenchini P , Nifosi F , Lacono C
Published: March 2007

Sixty-nine patients with primary retroperitoneal tumours (17 benign, 52 malignant including 4 malignant tumours of uncertain origin) were reviewed to determine the best form of surgical strategy. Total resection was performed in 88 per cent of benign cases and in 65 per cent of malignant cases. In 62 per cent of the total resections for malignant tumours, en bloc excision included adjacent organs or anatomical structures. Operative mortality rate (in terms of the total number of operations performed) was 5 per cent. Postoperative complications occurred in 14 per cent and recurrences in 35 percent. The overall 5-year survival rate was 67 per cent in patients with totally resected tumours and zero in patients whose tumours were treated by partial resection or biopsy. An aggressive surgical approach aimed at total excision of the tumour is the best form of therapy currently available. In the totally resected retroperitoneal tumour, the use of adjuvant radiotherapy and/or chemotherapy depends on the grade of the malignancy and clearance as assessed histologically. Careful follow-up based on the use of computerized axial tomography and ultrasound allows early identification of recurrence at a stage when the recurrence is amenable to total resection.
Sequelae of internal sphincterotomy for chronic fissure in ano
Authors: Khubchandani I T , Reed J F
Published: March 2007

A total of 1355 patients underwent internal sphincterotomy for chronic fissure in ano between 1980 and 1985. Surgical data were obtained for 1102 patients, and 829 patients responded to a questionnaire. Of the 1057 for whom the time of healing was recorded, 1033 (97.7 per cent) healed by a mean time of 5.6 weeks. No significant differences in satisfaction with the outcome or in deficits in continence were noted between groups undergoing lateral, bilateral or posterior midline sphincterotomy. Excision of the fissure was found to be unnecessary. According to responses on the questionnaires, deficits in continence ranging from ‘sometimes’ to ‘frequently’ included lack of control of flatus (35.1 per cent), soiling of underclothing (22.0 per cent) and accidental bowel movements (5.3 per cent). A significantly higher proportion of patients who had accidental bowel movements were aged over 40 years.
Adjuvant multimodality treatment of rectal cancer
Authors: Galloway D J , Cohen A M , Shank B , Friedman M A
Published: March 2007

It has long been recognized that curative surgery as the sole treatment for rectal cancer yields disappointing results. There is now a growing body of evidence from prospective randomized clinical trials to support the role of adjuvant therapy for patients whose primary tumour has spread through the rectal wall or has associated lymph node involvement. Carefully planned radiation therapy with adequate doses and fields can reduce the risk of locoregional failure. Chemotherapeutic agents delivered either systemically or regionally may also contribute to better disease control and survival. A number of diagnostic and therapeutic issues still need to be addressed in order to use the available adjuvant treatment methods most appropriately. Efforts to refine patient selection, to enhance therapeutic effect and to minimize toxicity are likely to improve the outlook for patients with resectable rectal cancer.
Mesoatrial shunt: A surgical option in the management of the Budd–Chiari syndrome
Authors: Stringer M D , Howard E R , Green D W , Karani J , Gimson A S , Williams R
Published: March 2007

The Budd-Chiari syndrome, arising from hepatic venous outflow obstruction, is frequently complicated by inferior vena caval occlusion or obstruction. Satisfactory decompression of the liver by either portacaval or mesocaval shunts may therefore prove impossible or be prone to failure from shunt thrombosis. The mesoatrial shunt which allows the portal vein to drain directly into the right atrium has previously been advocated in this situation. Five patients with the Budd-Chiari syndrome and caval occlusion and/or obstruction have had mesoatrial shunts constructed using externally supported polytetrafluoroethylene grafts. A single thoracoabdominal incision, incorporating a median sternotomy, was found to provide a satisfactory approach. All patients recovered well with resolution of ascites, diminution in liver size and improvement in inferior vena caval pressure gradients. Furthermore, all shunts have remained patent, as determined by Dopper flow studies and contrast-enhanced computed tomographic scanning, during follow-up periods ranging from 9 to 16 months. If these results are supported by longer term studies, the mesoatrial shunt may become the surgical treatment of choice in patients with hepatic vein occlusion and the Budd-Chiari syndrome associated with inferior vena caval obstruction.