bluuebunny/crossref_metadata_2025 huggingface dataset:
Colonoscopic follow-up after resection for colorectal cancer: A selective policy
Authors: Barlow A P , Thompson M H
Published: March 2007

A policy of selective colonoscopy after resection for colorectal cancer was evaluated to assess the benefit of detecting missed synchronous and metachronous tumours in patients under 70 years of age with a good prognosis, and the possible risk of missing such lesions in those not screened. With preoperative barium enema and palpation at laparotomy, synchronous cancers and adenomas were found in 2 and 28 per cent, respectively, of 275 consecutive patients undergoing resection. Eighty-five patients were selected for postoperative colonoscopy, which was repeated at least once in 32, there being a total of 60 repeat examinations. Adenomas, but no cancers, were found in 19 patients (22 per cent) on first screening, but on repeat colonoscopy early metachronous cancers were detected in three patients (9 per cent) and adenomas on 21 examinations (35 per cent). Only one of the patients followed by clinical examination developed a symptomatic tumour. This suggests that postoperative colonoscopy is unlikely to benefit the majority but may be extremely important for young fit patients with continuing polyp formation who are at high risk of developing metachronous cancer.
Pharmacological study of the internal anal sphincter in patients with chronic anal fissure
Authors: Regadas F S P , De O. Batista L K , Albuquerque J L A , Capaz F R
Published: March 2007

A pharmacological study of the internal anal sphincter (IAS) was undertaken in patients with chronic anal fissure. The sensitivity of the IAS to the contractile effect of phenylephrine and potassium chloride and to relaxation by isoproterenol was evaluated. Supersensitivity of the IAS to relaxation by isoproterenol was noted. Further research is necessary to determine the pharmacological basis of such a disturbance.
Infrainguinal vein graft stenosis
Authors: Varty K , Allen K E , Bell P R F , London N J M
Published: March 2007

Although knowledge of the biological processes involved in the development of intimal hyperplasia has increased markedly in recent years, the precise aetiology of infrainguinal vein graft stenosis remains undetermined. Current therapy is therefore directed at treatment of the established lesion rather than its prevention. There seems little doubt, however, that recent advances in understanding of the vascular biology of normal and pathological saphenous vein will eventually lead to specific targeted therapy that will allow the prevention of vein graft stenosis.
Biliary drainage in obstructive jaundice: Experimental and clinical aspects
Authors: Clements W D B , Diamond T , McCrory D C , Rowlands B J
Published: March 2007

Jaundiced patients undergoing invasive diagnostic and therapeutic procedures are at increased risk of complications and death. Despite the large number of clinical and experimental investigations carried out to identify relevant risk factors, no single parameter has been found to be consistently useful in predicting morbidity or mortality. Biliary decompression was initially employed by surgeons and subsequently by interventional radiologists. More recently, endoscopic retrograde cholangiopancreatography has provided an alternative route for decompression of the biliary tree and preliminary data using this method are encouraging. Although there are enthusiastic proponents of various therapeutic techniques, controlled trials have not been convincing in highlighting the benefits of biliary drainage or in determining the best approach. This article reviews the literature pertaining to this complex surgical problem; an attempt has been made to balance the advantages and disadvantages of biliary decompression as palliation and/or preliminary treatment for extrahepatic biliary obstruction.
Foot volumetry and duplex ultrasonography after saphenous and subfascial perforating vein ligation for recurrent venous ulceration
Authors: Bradbury A W , Stonebridge P A , Callam M J , Ruckley C V , Allan P L
Published: March 2007

Forty-three patients undergoing superficial and perforating vein ligation for recurrent venous ulceration underwent preoperative and postoperative foot volumetry and postoperative duplex ultrasonography. Patients were followed for a median of 66 (range 18–144) months. Of nine patients who developed recurrent ulceration, six had femoral vein incompetence and all had popliteal vein incompetence demonstrated by duplex ultrasonography. Of the 34 patients who remained ulcer-free, five had femoral vein incompetence and a single patient had popliteal vein incompetence on duplex scanning, giving positive predictive values for recurrent ulceration of 55 per cent (femoral vein incompetence) and 90 per cent (popliteal vein incompetence). Patients with saphenofemoral incompetence on late follow-up were also more likely to suffer recurrence. Preoperative foot volumetry with tourniquet occlusion of superficial veins showed that the median expulsion fraction of patients who developed recurrent ulcer during follow-up was 0.8 (range 0.6–2.3) per cent compared with 1.5 (range 0.4–2.9) per cent for those who remained ulcer-free (P = 0.025); the median half-refilling time of patients with recurrent ulcer was 1.5 (range 0.5–5.5) s compared with 5.0 (range 0.5–23.0)s for those without recurrence (P < 0.01). Postoperative foot volumetry showed similar differences. Deep venous incompetence, particularly of the popliteal segment, as demonstrated by duplex ultrasonography and foot volumetry, is a useful predictor of recurrent ulceration after subfascial perforator and superficial venous ligation.
Non-therapeutic operations for penetrating trauma: Early morbidity and mortality
Authors: Demetriades D , Vandenbossche P , Ritz M , Goodmann D , Kowalszik J
Published: March 2007

A prospective study was carried out to assess the incidence and type of complications after non-therapeutic operations for penetrating trauma. A total of 372 operations were performed on 368 patients with penetrating injuries to the abdomen (240 procedures), chest (49), neck (48) and extremities (35). There were 46 negative or non-therapeutic operations. The incidence of major complications directly related to anaesthesia or operation in this group of patients was 4 per cent (two patients). The operation might have contributed to a further three major complications. The mean hospital stay for patients undergoing uncomplicated non-therapeutic operation was 4.1 days; for those with complications it was 21.2 days. It is concluded that non-therapeutic operations for penetrating trauma carry a significant morbidity rate. A policy of selective conservatism is advocated.
Use of silicone implants after wide local excision of the breast
Authors: Thomas P R S , Ford H T , Gazet J C
Published: March 2007

The appearance of the breast after wide local excision for carcinoma may be unsatisfactory. In 59 patients undergoing wide local excision a silicone prosthesis was inserted into the cavity at the time of primary surgery. Assessment of the cosmetic result was performed after 12 months by questionnaire and clinical examination. Four prostheses were removed within 1 year because of infection (two patients), wound breakdown (one) and pain (one). Seven prostheses were subsequently removed because of severe capsular contraction. Capsular contraction was more common in patients who had received radiotherapy. Only 23 patients found the results of the implant acceptable or satisfactory. The immediate use of intramammary implants after wide local excision is currently associated with a poor cosmetic result, and the problem of the distorted breast after such excision requires continued attention.
Randomized trial of laser scalpel for modified radical mastectomy
Authors: Wyman A , Rogers K
Published: March 2007

The efficacy of a contact neodymium yttrium-aluminium–garnet laser scalpel was assessed during breast surgery. Forty consecutive women undergoing modified radical mastectomy were randomized to operation performed with a conventional or laser scalpel. The laser scalpel was associated with a significant reduction in mean operative blood loss (149 versus 421 ml; 95 per cent confidence interval of difference 176–368 ml, P <0.001), but the mean operating time was longer (105 versus 80 min; 95 per cent confidence interval of difference 16–34 min, P <0.001). No significant differences were found in the volume of postoperative wound drainage, incidence of axillary seroma, postoperative pain score or time to return of shoulder mobility. Use of a laser scalpel in breast surgery cannot be recommended.
Prospective randomized comparison of teres cardiopexy and Nissen fundoplication in the surgical therapy of gastrooesophageal reflux disease
Authors: Janssen I M C , Gouma D J , Klementschitsch P , van der Heyde M N , Obertop H
Published: March 2007

Teres cardiopexy was compared with Nissen fundoplication in a prospective randomized study of surgery for gastro-oesophageal reflux disease refractory to medical treatment. Follow-up at 3 months of ten patients undergoing each procedure showed good clinical results and improvement of the mean symptom score in both groups, for cardiopexy from 7.8 to 1.1 (P <0.01) and for fundoplication from 5.7 to 0.2 to (P <0.01). After 1 year, six of the ten patients undergoing cardiopexy required a second antireflux procedure because of recurrent disease, whereas one reoperation was performed after fundoplication. The mean symptom score after 1 year was higher in patients submitted to cardiopexy than in those receiving fundoplication (3.9 versus 0.3, P <0.01). The mean endoscopic oesophagitis score after 1 year was no different from preoperative values after cardiopexy (1.9 versus 1.9) but was significantly lower after fundoplication (1.5 versus 0.3, P = 0.01). Ambulatory 24-h pH monitoring showed a significantly higher proportion of total time at pH < 4 after cardiopexy then fundoplication (24.0 versus 3.8 per cent, P <0.05). Cardiopexy is significantly less effective than fundoplication for the treatment of gastro-oesophageal reflux disease assessed at 1-year follow-up. This study does not support the use of cardiopexy either in conventional or laparoscopic antireflux surgery.
Prognostic significance of histological type in gastric carcinoma with invasion confined to the stomach wall
Authors: Iriyama K , Miki C , Ilunga K , Osawa T , Tsuchibashi T , Suzuki H
Published: March 2007

Survival was determined after resection for the two main histological types of gastric carcinoma, intestinal (n = 223) and diffuse (n = 170), in 393 patients with pT1 or pT2 tumours. Lymph node metastases were present in 94 patients. The 10-year survival rate was significantly lower for patients with intestinal-type than for those with diffuse-type carcinoma (72 versus 91 per cent, P <0.005). In patients without nodal involvement, the 10-year survival rate was still lower for those with intestinal-type cancer (70 versus 94 per cent, P <0.01). Recurrence of carcinoma was more often by haematogenous dissemination in patients with intestinal-type cancer. Although the results of resection for pT1 or pT2 gastric carcinoma can be acceptable, the introduction of adjuvant therapy based on histological findings may be necessary for patients with the intestinal type of cancer to prevent haematogenous spread of carcinoma to the liver.
Intraoperative enteroscopy in Crohn's disease
Authors: Smedh K , Olaison G , Nyström P-O , Sjödahl R
Published: March 2007

Intraoperative small bowel endoscopy was performed on 33 occasions in 31 patients with Crohn's disease. The extent of mucosal inflammation was compared with that of changes in the external bowel wall: serositis, fat-wrapping and mural thickening. The influence of endoscopic findings on surgical management was evaluated. Mucosal inflammation was generally more extensive than serositis (P < 0.01), but less so than mural thickening (P < 0.001). The extent of fat-wrapping did not differ from that of mucositis. Of 23 patients undergoing reoperation or with fistula or abscess, however, eight had serositis and/or fat-wrapping in bowel segments without mucosal inflammation. Endoscopic findings influenced surgical decisions on 20 of the 33 occasions, limiting planned resection in 14, identifying strictures for repair in one, and deciding against resection in two cases and for extended resection in three. These results suggest that external inflammatory changes are unreliable guides to the extent of intestinal mucositis and requirements for resection in Crohn's disease. By visualizing the mucosa, intraoperative enteroscopy can provide information for more precise surgery, thereby limiting resection.
Extended left hepatectomy: Technical aspects of an evolving procedure
Authors: Blumgart L H , Baer H U , Czerniak A , Zimmermann A , Dennison A R
Published: March 2007

Lessons learned in an operative experience of 14 patients submitted to extended left hepatectomy for the management of liver tumours are presented. There were no deaths within 30 days of operation. Essential preoperative studies, indications and technical details of the operation are described. The importance of the morphology of the tumour and the influence of the tumour on the technique to be adopted are emphasized. Modifications of technique that allow selection of patients for the procedure, control of venous bleeding, accurate identification of the sectoral portal pedicles within the right liver and definition of the plane of parenchymal transection are addressed.
Safety of double-stapled anastomosis in low anterior resection
Authors: Redmond H P , Austin O M B , Clery A P , Deasy J M
Published: March 2007

Clinical leakage of the anastomosis follows low anterior resection for rectal carcinoma in 5–10 per cent of patients despite standard stapling techniques. A modification of this method has obviated the need for a distal purse string. A flexible transverse stapling instrument (Roticulator 55) is applied across the rectum below the tumour, and a double staggered row of staples is inserted as a substitute for the distal purse string. End-to-end stapled anastomosis is then performed with peranal insertion of a Premium CEEA stapling instrument. In 111 patients the indications for operation were colorectal carcinoma (96 patients), diverticulosis (ten), megarectum (four) and ulcerative proctocolitis (one). Three patients had clinical evidence of anastomotic leakage; all survived. The incidence of radiological leakage on Gastrografin enema 10–12 days after operation was 9 per cent. The perioperative mortality rate was 2 per cent; all deaths were from cardiovascular causes. Local recurrence of tumour occurred in eight patients (7 per cent) after a mean follow-up of 40 months. In conclusion, double-stapled end-to-end anastomosis has made low anterior resection for rectal carcinoma a safe procedure with a low mortality rate, an acceptable local recurrence rate and minimal (clinical) anastomotic leakage.
Reappraisal of radical local excision for carcinoma of the rectum
Authors: Lock M R , Ritchie J K , Hawley P R
Published: March 2007

Outcome in all 167 patients treated by radical local excision for rectal carcinoma between 1948 and 1984 at St Mark's Hospital was assessed in terms of the original tumour differentiation except for 15 patients with incomplete follow-up or ungraded tumours. Fifty-six of the 152 patients had low-grade tumours, with one death from carcinoma in this group. Of 81 patients with average-grade tumours, ten died from carcinoma of the rectum: two after early reoperation and eight following recurrence. Six of 15 patients with high-grade tumours underwent early reoperation and three of these died from carcinoma. Among the nine patients who did not undergo early reoperation there were three related deaths (two from carcinoma, one after rectal excision for recurrence). Local excision remains a valid therapy for suitable patients with low-grade tumours but is not recommended for those with average-grade lesions. The necessity for early reoperation in patients with high-grade tumours is questioned.
Multicentre study of a continent colostomy plug
Authors: Codina Cazador A , Piñol M , Marti Rague J , Montane J , Nogueras F M , Suñol J
Published: March 2007

A multicentre clinical study was carried out to assess the performance of a new disposable device, the Conseal 1-Piece, for colostomy control and continence. Forty-three patients were studied; none had any complication at the stoma. The time elapsed since surgery and the condition of the stoma and surrounding skin were recorded. The new product was compared with the patients usual colostomy bag, studying the following parameters: ease of application, reliability, leakage, confidence, ease of removal, adhesion and comfort. Thirty-seven patients completed the study. No complications arose, and complete faecal continence was obtained with 71.1 per cent of applications. The plug was kept in position for a mean of 11.5 h and a normal stoma bag was used for the remainder of the day. Of the 37 patients who completed the trial, 26 preferred the Conseal 1-Piece to a colostomy bag. In this preliminary study the device was easy to apply, involved no major complications and provided a high degree of continence. This product deserves further study because of its simplicity of use. However, research to improve the level of continence should continue.
Anorectal function after preoperative intraluminal brachytherapy and colonic J pouch-anal anastomosis for rectal carcinoma
Authors: Kusunoki M , Shoji V , Yanagi H , Kamikonya N , Sakanoue Y , Hishikawa Y , Utsunomiya J
Published: March 2007

The effects of preoperative intraluminal brachytherapy on bowel function after anoabdominal rectal resection and colonic J pouch-anal anastomosis were studied. The patients included eight not receiving irradiation (group 1), eight who received 30 Gy (group 2) and eight who received 80 Gy (group 3). Stool frequency and the incidence of soiling were significantly greater in group 3 than in the other groups. Anal resting pressure was lower in group 3 during the study period but J pouch distensibility was not reduced. The maximum tolerated volume, threshold volume and squeeze pressure were significantly lower in group 3 than in the other groups in the early postoperative period. These results suggest that high-dose brachytherapy affects the anal sphincters and colonic J pouch. A moderate dose of 30 Gy may be more suitable before restorative anorectal surgery.
Risberg retroperitoneal approach to the abdominal aorta
Authors: Butler P E M , Grace P A , Burke P E , Broe P J , Bouchier-Hayes D
Published: March 2007

In a study of the best approach to the infrarenal abdominal aorta, 47 patients were compared retrospectively: 15 underwent a standard transperitoneal incision, 15 a retroperitoneal left flank incision and 17 a new modified lateral pararectus incision, the Risberg approach. Operating time, length of postoperative intubation and hospital stay, mortality rate, morbidity rate and cost were assessed. There was a significant reduction (P <0·05) in mean(s.d.) operating time (141(21) versus 198(41) min), intraoperative cross-clamping time (74(13) versus 104(46) min) and postoperative intubation time (6·5(8·0) versus 13·3(7·3) h) associated with the Risberg retroperitoneal incision compared with the left flank retroperitoneal route. There was also a significant decrease (P <0·02) in mean(s.d.) postoperative intubation time (6·5(8·0) versus 17·5(12·0) h), time after operation to discharge (11·0(2·4) versus 17·3(7·6) days) and hospital cost (£4885(670) versus £7732(580)) associated with the Risberg incision compared with the transperitoneal approach. The Risberg incision gives better access to the infrarenal abdominal aorta while maintaining the advantages of other retroperitoneal approaches. This technique is recommended as the incision of choice for the retroperitoneal approach to the aorta.
Preoperative coagulopathy in ruptured abdominal aortic aneurysm predicts poor outcome
Authors: Davies M J , Murphy W G , Murie J A , Elton R A , Bell K , Gillon J G , McL. Jenkins A , Ruckley C V
Published: March 2007

In a prospective study of 50 consecutive patients undergoing operation for ruptured abdominal aortic aneurysm, a coagulation screen was performed on admission to hospital. Twenty patients with either a platelet count <100 × 109/l or a prothrombin time >1·5 times the control value had a mortality rate of 65 per cent (95 per cent confidence interval 45–85 per cent); a further 23 patients with normal screen results had a mortality rate of 9 per cent (95 per cent confidence interval 0–20 per cent) (P <0·001). Seven patients, of whom three died, did not have an admission coagulation screen performed. Patient age in the study group did not have independent statistical predictive power. This study indicates that coagulopathy at the time of admission predicts poor outcome in patients with ruptured aortic aneurysm. Current management strategies are inadequate for the treatment of these patients, who can be rapidly identified on admission by means of platelet and prothrombin counts.
Computed tomography in the management of blunt abdominal trauma in children
Authors: Turnock R R , Sprigg A , Lloyd D A
Published: March 2007

Sixteen children with suspected abdominal injury were reviewed. All underwent plain abdominal radiography and computed tomography (CT). Fifteen CT scans showed an abnormality, and the abdominal radiograph was abnormal in seven cases. Eight patients also underwent abdominal ultrasonography, and six scans failed to demonstrate an abnormality. Only two patients required laparotomy, one for a ruptured left diaphragm and one for a major renal injury. These results support the use of CT as the optimal method for assessing the stable child following blunt abdominal trauma.
Transatlantic perspectives of trauma systems
Authors: McNicholl B P , Fisher R B , Dearden C H
Published: March 2007

The need for centralized management of acute trauma was evaluated in a 1-year prospective study in Northern Ireland. All patients with an Injury Severity Score >15 who reached hospital alive were included. The sample population was approximately 1 million people. A total of 239 patients entered the study, of whom 74 died. An audit panel considered that 3–15 per cent of deaths were preventable. There was no significant difference in the preventable mortality rate between any hospital or groups of hospitals. There was a high level of consultant involvement, especially in small hospitals. A system in which patients with acute trauma bypass the nearest hospital to reach a trauma centre may be neither beneficial nor cost-effective in Northern Ireland. Upgrading of the present system with stabilization of the patient and emergency surgery at the nearest hospital before transfer is recommended.
Prognostic signs in the evaluation of patients with minor head injury
Authors: Duus B R , Boesen T , Kruse K V , Nielsen K B
Published: March 2007

To assess signs that might be used in the decision whether or not to admit a patient with minor head injury, the records of 713 female and 1163 male patients were reviewed. Skull radiographs were not obtained routinely; all patients were able to walk and talk when they reached medical contact. Nine patients developed an intracranial complication. The risk of developing such a complication was 16·7 per cent when the patient was agitated, 3·4 per cent in the presence of impaired consciousness and 2·1 per cent when positive neurological signs were observed at the time of examination. Based on the medical history, amnesia for >5 min and vomiting were associated with a risk of 3·3 and 1·2 per cent respectively; the risk increased considerably in the presence of both. It is recommended that all patients presenting themselves with one or more of the above symptoms or signs, or with alcohol intoxication, after a minor head injury be admitted for observation. If these guidelines had been used, all patients with an intracranial complication would have been detected, and 44·5 per cent of the bed-days used would have been saved.
Low-dose tumour necrosis factor α and melphalan in hyperthermic isolated limb perfusion
Authors: Hill S , Fawcett W J , Sheldon J , Soni N , Williams T , Thomas J M
Published: March 2007

Nine patients with soft tissue tumours of the lower limb not amenable to treatment other than by isolated limb perfusion or amputation underwent hyperthermic isolated limb perfusion at the level of the superficial femoral vessels, using a combination of recombinant tumour necrosis factor (TNF) α and melphalan. In seven patients with superficial tumours, necrosis and sloughing was apparent within 48 h of perfusion. All patients experienced a complete tumour response. There were no systemic side-effects associated with the use of TNF-α although local side-effects, particularly oedema, were pronounced. Three patients ultimately required amputation because of the large soft tissue defects that resulted from necrosis of the tumour and overlying skin.
Management of malignant melanoma of the head and neck
Authors: Orr D J A , Hughes L E , Horgan K
Published: March 2007

A total of 91 patients with melanoma of the head and neck treated between 1973 and 1991 were studied prospectively with regard to prognostic features, treatment and outcome. Other than Breslow thickness, the only important prognostic feature was the less aggressive nature of lentigo maligna melanoma. A policy of selective excision margins, 1 cm for impalpable and 2 cm for palpable lesions, was found to be safe, although preliminary biopsy should be used if there is diagnostic uncertainty or where the expected extent of surgery entails a mutilating procedure. Local recurrence rates were not affected by the method of wound closure, which should be determined by the best functional and cosmetic outcome. These results support the trend against prophylactic neck dissection. Such dissection, when indicated for lesions of the face, pinna, anterior scalp and parotid area, should routinely include superficial parotidectomy. Uncontrolled symptomatic locoregional recurrence is an uncommon complication that may occur despite radical primary surgery. The role of preoperative radiotherapy for high-risk melanoma in this situation warrants investigation.
Specimen-orientated radiography helps define excision margins of malignant lesions detected by breast screening
Authors: Dixon J M , Sekar O Ravi , Walsh J , Paterson D , Anderson T J
Published: March 2007

Eighty patients with impalpable breast lesions detected by mammographic screening underwent hookwire-guided wide local excision. Excision specimens were orientated with Ligaclips and submitted to radiography; if on the specimen radiograph, the mammographic lesion crossed any visible margin, further tissue was excised. Clear histological margins were obtained on the initial excision in 52 (68 per cent) of 77 carcinomas. After inspection of the orientated specimen radiograph, further tissue was excised from 22 patients; this significantly increased the rate of complete excision to 86 per cent (P <0·01). Significantly more patients with invasive cancer had a complete excision than those with ductal carcinoma in situ (52 of 57 versus 14 of 20, P <0·02).
Effects of surgery on the generation of lymphokine-activated killer cells in patients with breast cancer
Authors: McCulloch P G , Macintyre A
Published: March 2007

Natural killer (NK) cell activity and the capacity to generate lymphokine-activated killer (LAK) cell activity were studied in 43 patients with operable breast cancer before and after surgery. Results were compared with those from ten healthy subjects. Patients with breast cancer had normal LAK and NK cell activity before surgery. A subgroup of patients with stage III disease had depressed LAK cell activity (P < 0·013). NK cell activity decreased by over 50 per cent on the first day after surgery and did not return to preoperative levels by day 7 (P <0·0005). Generation of LAK cell activity was unaffected by surgery. The addition of 10 per cent autologous plasma to the culture medium during the induction of LAK cell activity in vitro did not suppress LAK cell activity in patients with breast cancer. These results suggest that perioperative adjuvant immunotherapy based on interleukin 2 and LAK cells is not ruled out by systemic suppressive effects from either cancer or surgery.
Method for diagnosing rejection in small bowel transplantation
Authors: Grover R , Lear P A , Ingham Clark C L , Pockley A G , Wood R F M
Published: March 2007

Diagnosis of rejection in small bowel transplantation by the identification of a host-cell infiltrate is hampered by the physiological trafficking of host lymphocytes to the ‘gut-associated lymphoid tissue’ of the graft. This study compared physiological host-cell infiltration of small bowel grafts with that occurring in rejection and stable immunosuppression. Physiological host-cell infiltration, where the graft does not present an immune stimulus to the host, was assessed by transplanting bowel from DA to (DA × PVG) F1 hybrid rats. The extent of host-cell infiltration was determined by immunohistochemical analysis. In the lamina propria, considerable infiltration by host cells was seen, although it was significantly less than that in rejection or stable immunosuppression. By contrast, host cells were seen in the intraepithelial compartment only in rejection. Host-cell infiltration in the absence of an allogeneic stimulus suggests that histological identification of host cells in the lamina propria is not necessarily indicative of rejection. However, the presence of host cells in the intraepithelial compartment is specific for rejection in small bowel transplantation.
Pattern of recurrence after hepatic resection for colorectal metastases
Authors: Sugihara K , Hojo K , Moriya Y , Yamasaki S , Kosuge T , Takayama T
Published: March 2007

Between 1978 and 1989, 159 patients with liver metastases from colorectal cancer underwent hepatic resection. Of 134 patients in whom metastases were confined to the liver, 109 had tumours removed completely with histologically negative resection margins. Two patients died in hospital. Ultrasonographically guided partial resection was performed in 80 patients, lateral segmentectomy in seven and lobectomy in 22. The 5-year survival rate of patients undergoing potentially curative resection was 47·9 per cent. Patients with metachronous tumours showed a significantly better prognosis than those with synchronous lesions in both univariate (P <0·01) and multivariate (P = 0·01) analysis. During a median follow-up of 35·4 months, 64 patients developed recurrence, including 34 in the liver, 20 in the lung and 12 in the abdominal cavity. Of those with hepatic recurrence, ten patients developed tumours at the initial resection bed, seven in the same lobe, five in the contralateral lobe and 12 in both lobes. Ultrasonographically guided partial liver resection did not increase the risk of hepatic recurrence.
Growth rate and percentage hepatic replacement of colorectal liver metastases
Authors: Purkiss S F , Williams N S
Published: March 2007

The growth of 32 untreated colorectal liver metastases and hepatic parenchymal volume in 11 patients were studied using planimetry of computed tomographic images. The median percentage hepatic replacement (PHR) of metastases was 0·49 (range 0·09–18·2). At subsequent assessment a median of 72 (range 14–235) days later, metastases were significantly larger with a median PHR of 1·78 (range 0·10–22·9) (P <0·001). To compare the growth of metastases with variable PHR, logarithmic changes of PHR over 100 days were studied. This parameter was shown to be reduced in metastases of larger volume. The median (interquartile range) non-neoplastic hepatic parenchymal volume was found to increase from 1839 (1647–1997) to 2200 (1590–2401) cm3 (P = 0·005) as metastatic burden increased. These findings suggest that the growth of colorectal hepatic metastases is more complex than a simple process of hepatic replacement.
Role of serum endotoxin and antiendotoxin core antibody levels in predicting the development of multiple organ failure in acute pancreatitis
Authors: Windsor J A , Fearon K C H , Ross J A , Barclay G R , Smyth E , Poxton I , Garden O J , Carter D C
Published: March 2007

It has been proposed that endotoxin contributes to the development of multiple organ failure (MOF) in acute pancreatitis. Endotoxaemia is transient and may not be detected by intermittent blood sampling. By contrast, not only can changes in the patient's endogenous antiendotoxin core antibody pool persist for many days, but depletion of this pool may be a key event in determining the physiological significance of endotoxaemia. A series of 33 patients with acute pancreatitis had daily measurement of Acute Physiology Score (APS) and levels of C-reactive protein, interleukin 6, endotoxin, immunoglobulin (Ig) G and IgM antiendotoxin core antibodies, and prospective documentation of complications. Endotoxin was detected in the serum of 13 patients, while a significant change in levels of endogenous antiendotoxin core antibodies was detected in all those with severe pancreatitis and in 28 overall. MOF developed in seven patients, five of whom died. The combination of a rising APS over the first 48 h of admission and a significant fall in endogenous IgG antibody level was observed in all patients who developed MOF (seven of seven), but in only one of 16 without MOF (P = 0·00003; overall predictive value 91 per cent). This study suggests that measuring the initial trend in APS and the concentration of endogenous IgG antiendotoxin core antibody provides a means of identifying patients with acute severe pancreatitis who are at high risk of developing MOF. This group might benefit from passive immunotherapy with antiendotoxin antibodies.
Probability of rejection predicted from ultrasonographic measurement of renal transplant swelling
Authors: Nicholson M L , Bell A , Burton P R , Donnelly P K , Veitch P S , Bell P R F
Published: March 2007

Serial ultrasonographic measurements of renal transplant crosssectional area were used to quantify allograft swelling as a diagnostic test of acute rejection. Eighty consecutive episodes of acute allograft dysfunction (rise in creatinine level ⩾ 10 per cent or ⩾ 30 μmol l−1) were investigated. Needle core biopsy was performed in all cases to diagnose acute rejection. Rejecting transplants demonstrated a median (interquartile range) swelling of 16·2 (12·1–25·5) per cent compared with 2·2 (−2·0 to 8·4) per cent for non-rejecting organs (P < 0·001). A ⩾ 10 per cent increase as the diagnostic threshold for rejection yielded a sensitivity of 80 per cent, specificity of 77 per cent, positive predictive value of 85 per cent, negative predictive value of 71 per cent and overall accuracy of 79 per cent. Using a logistic regression model, predictive probabilities of rejection for individual changes in cross-sectional area were calculated. A 20 per cent increase was associated with a predicted probability of rejection of 87 per cent (95 per cent confidence interval 75–94 per cent). There was a significant correlation between the functional severity of rejection and the degree of transplant swelling (rs = 0·63, P < 0·001). Ultrasonographic measurement of renal transplant cross-sectional area is a simple non-invasive test for the diagnosis of acute rejection.
Fistula complicating restorative proctocolectomy
Authors: Keighley M R B , Grobler S P
Published: March 2007

Twenty-seven patients developed a fistula after 168 restorative proctocolectomies. Thirteen fistulas were enterocutaneous (two with communication to the bladder); their origins were from the pouch (three patients), the ileoanal anastomosis (three), the pouch appendage (three), a previous loop ileostomy (two) and iatrogenic small bowel injury (two). Two patients had Crohn's disease. The pouch was removed in four patients, one of whom died from chronic small bowel obstruction; the remaining nine have satisfactory pouch function after fistula excision. Ten pouch–vaginal fistulas occurred, all from the ileoanal anastomosis; four were extrasphincteric. Four of these patients had underlying Crohn's disease. Only two patients, with Crohn's disease and indeterminate colitis, required pouch excision; the remainder have good pouch function after treatment of the fistula. There were three pouch–perineal fistulas, all from the ileoanal anastomosis; these were successfully managed by seton fistulotomy. There was one pouch–vesical fistula, successfully treated by excision of the fistula and pouch appendage.
Relationship between intra-abdominal and intrarectal pressure in the proctometrogram
Authors: MacDonald A , Paterson P J , Baxter J N , Finlay I G
Published: March 2007

During normal defaecation the intrarectal pressure increases but, in the absence of a reference catheter in the pelvis, the contribution of abdominal straining and rectal contraction to this rise is unclear. Anorectal manometry was performed in ten consecutive women with no gastrointestinal symptoms in an attempt to measure intrapelvic pressure using a catheter in the bladder. During filling the mean(s.e.m.) rectal pressure increased from 2(1) to 18(4) cmH2O. The mean(s.e.m.) intravesical pressure remained unchanged at 2(1) cmH2O. Evacuation of the rectal balloon produced an increase in mean(s.e.m.) intrarectal pressure from 18(4) (end-filling pressure) to 68(15) cmH2O. The mean(s.e.m.) intravesical pressure increased from 2(1) to 51(18) cmH2O. The true intrarectal pressure (intrarectal minus intravesical) did not rise during defaecation. The rise in intrarectal pressure during rectal evacuation occurs by increased intrapelvic pressure alone.
Idiopathic slow-transit constipation
Authors: Macdonald A , Baxter J N , Finlay I G
Published: March 2007

Until recently, the surgical management of idiopathic slow-transit constipation had remained unchanged since the condition was first described by Arbuthnot Lane in 1908. Although colectomy and ileorectal anastomosis is a successful treatment for the majority of patients, symptoms persist or are worse in some cases following such surgery. The previously inaccessible colon is now an area of interest in both health and disease; recent observations on aetiology, clinical investigation, neuropathology and surgical outcome lead us to question the rationale of colectomy for all patients with severe constipation.
Systemic leakage during isolated limb perfusion for melanoma
Authors: Klaase J M , Kroon B B R , Van Geel A N , Eggermont A M M , Franklin H R
Published: March 2007

A hazard of regional perfusion for melanoma is incomplete isolation, resulting in leakage of the cytostatic drug into the systemic circulation. Data were analysed retrospectively on 438 melphalan perfusions performed for melanoma of the extremities during the period 1978-1990; continuous isotopic measurement of systemic leakage was carried out. The cumulative systemic leakage after 60 min perfusion was 0·9 per cent (95 per cent confidence interval 0·7-1·1 per cent). Systemic leakage of ≧ 1 per cent was detected in 12·6 per cent of perfusions, ≧ 5 per cent in 6·2 per cent and ≧ 10 per cent in 1·4 per cent. In 2·3 per cent of patients, systemic side-effects in the form of mild transient bone marrow depression occurred. Six variables related to the perfusion technique were assessed by multivariate analysis for their influence on systemic leakage. The level of isolation and diameter of the venous cannula emerged as significant factors. In addition, ligation of the internal iliac vein provided optimal isolation during iliac perfusion.
Pathophysiology, recognition and management of pneumoretroperitoneum
Authors: Prêtre R , Robert J , Mirescu D , Witzig J-A , Rohner A
Published: March 2007

The medical records of 15 patients found to have pneumoretroperitoneum in a 10-year period were reviewed. The cause of retroperitoneal emphysema was infection in six patients, trauma in five and iatrogenic in four. Emphysema was confined to the retroperitoneum in 11 patients, and extended to the mediastinum in four and to the soft tissue of the neck in three. Failure to diagnose pneumoretroperitoneum resulted in delayed intervention in two patients. One patient with pneumoretroperitoneum and pneumoperitoneum secondary to a lung lesion underwent unnecessary laparotomy. Outcome was favourable in these three patients. The presence of air in the retroperitoneum is not dangerous but its early recognition and detection of the source are important as septic conditions may be involved.
Venous thromboprophylaxis in oesophageal cancer surgery
Authors: Rakićc S , Peško P , Jagodić M , Dunjić M S , Maksimović Ž
Published: March 2007

In a retrospective study of 127 patients who underwent resection for oesophageal cancer without anticoagulant thromboprophylaxis, the incidence of clinically established postoperative deep vein thrombosis (DVT) was 1·6 per cent. In a prospective study the Sue-Ling DVT risk factor index was calculated for 53 consecutive patients with oesophageal cancer; the mean(s.d.) value was −4·4(3·5). For 29 patients who underwent resection the following policy of thromboprophylaxis was applied. Patients undergoing transthoracic oesophagectomy with risk score > − 4 (four patients) and those undergoing transhiatal resection with risk score > - 1 (four) received both anticoagulant and mechanical thromboprophylaxis; the remaining 21 patients received only mechanical thromboprophylaxis. No patient developed DVT after operation. There were no haemorrhagic complications in the group undergoing anticoagulant thromboprophylaxis. The selective approach, based on the Sue-Ling risk factor index and type of operation, spared 72 per cent of the patients operated on from undergoing anticoagulant thromboprophylaxis and produced favourable results in this small series.
Temporal relationship of acinar and microvascular changes in caerulein-induced pancreatitis
Authors: Kelly D M , McEntee G P , Delaney C , McGeeney K F , Fitzpatrick J M
Published: March 2007

A study in rats investigated the temporal relationship between acinar cell changes and alterations in the local microvasculature in oedematous pancreatitis produced by administration of caerulein, 5 μg kg−1 h−1. Samples were taken from experimental and control animals after 15 min, 30 min, 1 h and 2 h of caerulein infusion. Transmission electron microscopy showed ultrastructural acinar cell changes after 15 min whereas the earliest microvascular changes were seen after 30 min. Ultrastructural alterations in the acinar cells thus preceded local microvascular changes. Microvascular distortion appears to be a consequence and not a cause of pancreatitis in the caerulein model.
Resection for adenocarcinoma of the body and tail of the pancreas
Authors: Johnson C D , Schwall G , Flechtenmacher J , Trede M
Published: March 2007

Adenocarcinoma of the pancreatic body and tail often presents late and is widely regarded as incurable by surgical resection; long-term survivors are rare. Thirteen patients underwent left resection (n = 7) or total pancreatectomy (n = 6) in a consecutive series of 105 patients with carcinoma of the body or tail of the pancreas. Comparison was made with 17 patients with locally advanced or metastatic disease. Preoperative computed tomography predicted irresectable disease when a large perivascular lymph node mass was demonstrated. Preoperative angiography predicted irresectable disease when there was encasement or obliteration of the coeliac axis or its major branches, or of the superior mesenteric artery or vein. Splenic vessel involvement was sometimes compatible with resection. After resection, median survival was 13 (range 3–50) months, with a minimum follow-up of 2 years. Five patients survived more than 2 years, and three are still alive 30, 43 and 50 months after resection. Resection of carcinoma of the body or tail of the pancreas was possible in 12 per cent of patients and long-term survival was observed in some of these.
Laparoscopic cholecystectomy in the Netherlands
Authors: Go P M N Y H , Schol F , Gouma D J
Published: March 2007

Laparoscopic cholecystectomy was introduced into the Netherlands in the Spring of 1990. The aim of this study was to evaluate the results of the procedure in Dutch hospitals over the first 2 years to obtain some insight into its safety and efficacy in general surgical practice. A written questionnaire was sent to all 138 Dutch surgical institutions enquiring about conversion rate, complications (with emphasis on mortality rate and common bile duct injuries), operating time and hospital stay. The surgeons' opinions were also sought on possible contraindications such as previous operation, bile duct stones and cholecystitis, as were their estimations of the percentage of patients in their practice eligible for laparoscopic cholecystectomy. Data were obtained for 6076 laparoscopic cholecystectomies; the response rate was 100 per cent. Conversion to open cholecystectomy was necessary in 413 patients (6·8 per cent), mostly because of adhesions, cholecystitis, haemorrhage and unclear anatomy. Postoperative complications were reported in 260 patients (4·3 per cent). There were seven deaths (0·12 per cent) and 52 (0·86 per cent) bile duct injuries, of which 20 were recognized during laparoscopy. The mean operating time for the ten most recent patients in each institute was 70 (range 30–180) min and the mean hospital stay 4·5 (range 2–8) days. Previous lower abdominal operations were not considered to be a contraindication by 96 per cent of surgeons, whereas, previous upper abdominal procedures were regarded as a contraindication by 66 per cent. After successful clearance of the bile duct at endoscopic retrograde cholangiopancreatography, only 12 per cent would perform an open procedure. Moderate cholecystitis was not considered a contraindication to laparoscopic cholecystectomy by 71 per cent of surgeons, but severe cholecystitis was a reason for open cholecystectomy for 83 per cent. In most surgical practices 70–80 per cent of patients were considered to be eligible for the laparoscopic procedure. In conclusion, laparoscopic cholecystectomy has gained rapid acceptance in the Netherlands. Although the number of bile duct injuries is high, the findings of this general survey are similar to those from highly specialized centres and match the overall results of conventional cholecystectomy.
Palliation of biliary obstruction in patients with advanced breast cancer using endoscopic stents
Authors: Mitchell P L R , Harvey V J , Lane M R , Evans B D , Thompson P I , Hamilton I
Published: March 2007

Endoscopic insertion of a biliary endoprosthesis was successful in eight patients with extrahepatic biliary obstruction caused by breast cancer metastases. The serum bilirubin level was significanty reduced in seven patients and in four this was accompanied by marked symptomatic improvement. Endoprostheses required replacement after a median of 8 (range 3–127) weeks. Two patients responding to systemic anticancer therapy survived 27 and 43 months. Endoscopically placed stents offer effective palliation of extrahepatic biliary obstruction caused by metastatic breast cancer and long-term survival may be possible.