bluuebunny/crossref_metadata_2025 huggingface dataset:
Delayed return of gastric emptying after gastroenterostomy
Authors: Woods S D S , Mitchell G J
Published: March 2007

A retrospective study of patients having gastroenterostomies was undertaken to identify predictive factors for the development of postoperative delayed return of gastric emptying (DRGE). A total of 322 consecutive patients underwent 324 gastroenterostomies; 35 experienced delayed return of gastric emptying. Regression analysis demonstrated preoperative obstruction to be the most significant factor (P < 0·001). Vagotomy was not an independent variable. Age, sex, size of stoma, anastomotic technique, albumin and experience of the operator were not significant factors. Gastroenterostomy in the presence of ‘gastric atony’ was likely to produce DRGE. In all, 86 per cent of cases resolved spontaneously. Only one case of DRGE was found to have a mechanical cause. Most patients were supported by parenteral nutrition but, with a knowledge of the identified risk factors, more thought could be given to establishing a route for jejunal feeding at the time of surgery.
Pylorus-preserving pancreatectomy: Functional results
Authors: Hunt D R , McLean R
Published: March 2007

The pylorus-preserving technique is reported as improving the functional results of pancreatectomy but it is complicated in the early postoperative period by delayed recovery of gastric function in a proportion of patients. We have examined early and late gastrointestinal function in a prospective study of 16 patients having this procedure. The late results appear better than reported results for conventional Whipple resection and the delay in early recovery does not appear to have any late sequelae, provided that it does not require gastric bypass for relief.
C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis
Authors: Wilson C , Heads A , Shenkin A , Imrie C W
Published: March 2007

In a series of patients with acute pancreatitis we have studied complement factors, antiproteases (α2-macroglobulin and α2-antiprotease) and C-reactive protein to determine the value of their sequential measurement in the prediction of outcome relative to clinical assessment and current multiple factor scoring systems. Complement factors were unhelpful in predicting the severity of an attack. α2-Macroglobulin levels were significantly lower in complicated attacks during days 3–8 and α1-antiprotease levels were significantly higher during days 4–8. C-reactive protein concentrations showed the best discrimination between mild and complicated attacks, levels rising higher and persisting for longer in complicated attacks; these differences were highly significant from day 2 (the morning after admission) to day 8. The concentrations providing the best discrimination were found to be ⩾ 210 mg/l for the peak C-reactive protein (on the second, third or fourth day) and ⩾ 120 mg/l for the C-reactive protein at the end of the first week. Analysis demonstrated both the peak or seventh-day C-reactive protein concentration to be of similar accuracy to either the Ranson or Glasgow multiple factor scoring systems and slightly better for attacks associated with gallstones. The C-reactive protein assay is simple, quick to perform, provides useful clinical information and is more likely to be of value and to be adopted into routine clinical practice than multiple factor scoring systems.
Surgical anatomy of the human spleen
Authors: Redmond H P , Redmond J M , Rooney B P , Duignan J P , Bouchier-Hayes D J
Published: March 2007

Post-splenectomy sequelae are now well recognized, and conservative splenic surgery is widely advocated. However, controversies exist regarding splenic surgical anatomy. We studied 127 human spleens using anatomical dissection and a sequential injection method involving both radiology and corrosion casting, with the primary aim of examining segmental splenic anatomy and blood supply. The existence of well-defined splenic segments was confirmed and these ranged in number from 3 to 7 with a mean of 4·3. Each segment had its own arterial supply and venous drainage. The segments were separated from each other by avascular planes. Subsegments with independent blood supply were also identified. The splenic artery was found to divide into two branches; in all cases these further divided into segmental arteries supplying the central segments of the spleen. The polar segments were supplied by segmental vessels of highly variable origin and size. This study aims to highlight the importance of identifying these segmental vessels at operation when splenic conservation is considered.
Endoscopic haemostasis for non-variceal upper gastrointestinal haemorrhage
Authors: Steele R J C
Published: March 2007

Endoscopic haemostasis can be effective in non-variceal upper gastrointestinal haemorrhage, and should be regarded as potential front-line treatment. Diverse methods are available, and although no single technique has become firmly established, current evidence favours thermal coagulation and injection therapy.
Repeat selective visceral angiography in patients with gastrointestinal bleeding of obscure origin
Authors: Lau W Y , Ngan H , Chu K W , Yuen W K
Published: March 2007

In the past 9 years, we have operated on 56 patients with gastrointestinal bleeding of obscure origin. Selective visceral angiography demonstrated the bleeding lesions in 24 of the 30 patients who underwent this investigation. Six of these 24 patients, however, had a negative angiogram initially and the lesions were only demonstrated on a repeat angiogram. The negative initial angiograms were due to: (1) slow bleeding from lesions in two patients; (2) a small bleeding tumour that caused only intermittent jejunojejunal intussusception in one patient; (3) technical fault in one patient; and (4) spasm of the bleeding vascular lesions and their feeding arteries in two patients. We advocate repeat angiography the following day in all patients in whom profuse bleeding continues, and during the next intestinal bleeding in those whose bleeding stops after the initial negative angiography. In patients who have repeated episodes of massive bleeding, and in whom full investigations fail to reveal the bleeding source, repeat angiography carried out 4 weeks after the bleeding has stopped can sometimes demonstrate the vascular lesions.
Changing pattern of admissions and operations for duodenal ulcer
Authors: Bardhan K D , Cust G , Hinchliffe R F C , Williamson F M , Lyon C , Bose K
Published: March 2007

The admission rates for duodenal ulcer (DU) and the effect of H2-receptor antagonists (H2RA), introduced in the Trent Region of the UK in 1977, were examined. The admission rates are expressed per 106 of resident population. The use of H2RA has risen 3·7-fold (from 1978 to 1983), yet overall admission rates for perforation have changed little: 99 in 1972-76 (pre-H2RA period) compared with 103 in 1977-84 (H2RA period). Admission rates for haemorrhage have risen by 8 per cent, from 130 to 140 (P<0·01). However, the overall rates conceal large increases (P<0·01) in the admission rates for those aged ⩽ 65 years, of 33 per cent (from 264 to 352) for perforation and of 28 per cent (from 381 to 489) for haemorrhage. Emergency admissions for uncomplicated DU were unchanged: 88 in 1972-76 and 89 in 1977-84. However, the proportions operated on fell by 58 per cent (P<0·01), from 30 per cent of admissions in the pre-H2RA period compared with only 12 per cent in the H2RA period. Waiting-list admissions for uncomplicated DU fell by 43 per cent, from 187 to 106 (P<0·01), and the proportions operated on fell from 162 to 76; the combined effect resulted in a reduction of 53 per cent in the operation rates (P<0·01). In Rotherham, the use of H2RA has risen 6·2-fold (from 1978 to 1983) and they were generally used intermittently in 1976-78 and later for maintenance therapy and high-dose treatment. Yet admissions for perforation and for haemorrhage were unchanged. Emergency admissions for uncomplicated DU rose by 40 per cent, from 130 in 1972-75 to 182 in 1976-84, but the proportions operated on fell markedly, from 20 to 6 per cent (P<0·01); waiting-list admissions fell in 1976-78 by 29 per cent and in 1979-84 by 73 per cent. The proportions operated on in the three periods fell from 74 to 53 per cent and 25 per cent respectively and these two factors led to decreases in elective surgery of 50 per cent in 1976-78 and 91 per cent in 1979-84 (P<0·01). Thus, H2RA have not reduced emergency admissions in DU patients but they are associated with a reduction in waiting-list admissions and in the numbers operated on for uncomplicated DU; where the drugs have been used more intensively, the decrease has been even more marked. Much of this decline can be attributed to the changing natural history of the disease; however, when used intensively, H2RA have a significant additional effect.
A clinicopathological study of synchronous multiple gastric cancer
Authors: Mitsudomi T , Watanabe A , Matsusaka T , Fujinaga Y , Fuchigami T , Iwashita A
Published: March 2007

In a 7 1/2-year period (from 1 January 1980 to 30 June 1987), 997 patients with gastric cancer underwent gastric resection at the Department of Surgery, Matsuyama Red Cross Hospital, Japan. We studied clinico-pathologically 83 patients (182 lesions) with synchronous multiple gastric cancer and compared them with patients who had solitary cancers only in the same period. We found that elderly men had a relatively high incidence of multiple gastric cancer, and that early cancer of the elevated well differentiated type was the most common. Of the 182 lesions, as many as 42 (23·1 per cent) were missed in the preoperative examination. Eighteen of these 42 lesions were found only with the aid of a microscope in sections almost incidentally excised. Small flat lesions tended to be missed. We should always be conscious that other gastric lesions may be present when treating patients with gastric cancer.
Oesophageal transit of marshmallow after the Angelchik procedure
Authors: Robertson C S , Smart H , Amar S S , Morris D L
Published: March 2007

The oesophageal transit time of half a marshmallow was measured radiologically in 17 controls, 28 patients with gastro-oesophageal reflux pre-operatively, 36 patients soon after implantation of the Angelchik prosthesis (2–9 weeks) and in 23 patients later postoperatively (9–48 months). Sixteen postoperative patients also underwent oesophageal manometry. All control and pre-operative patients had a marshmallow transit time of less than 1 min; 67 percent of the early postoperative patients had prolonged transit and 70 per cent of the late tests were similarly abnormal. Prolonged oesophageal transit as measured by marshmallow' swallow correlated well with symptoms of solid food dysphagia. Most, but not all, patients with an abnormal marshmallow swallow had abnormal manometric findings. The oesophageal transit of solid food is significantly slowed after the Angelchik procedure and this is not a transient postoperative phenomenon.
Surgical options in traumatic injury to the extrahepatic biliary tract
Authors: Bade P G , Thomson S R , Hirshberg A , Robbs J V
Published: March 2007

A series of 53 patients who sustained extrahepatic biliary tract trauma were analysed to define the role of the various surgical options. Of the 45 patients with gallbladder injuries, 39 were due to stab wounds. Nine of the 45 injuries were repaired by primary suture without complication. Five patients underwent cholecystostomy and all developed biliary fistulae, which resulted in prolonged hospitalization. Cholecystectomy was performed in 31 patients; in retrospect many of these gallbladders could have been preserved because on only eight occasions was the gallbladder extensively damaged. Of eight extrahepatic bile duct injuries, the three partial transections managed by primary repair had a successful outcome, while the five complete transections were managed by a variety of techniques. Delayed diagnosis, failure of operative recognition of the injury and improper management were factors that led to mortality in two patients and prolonged morbidity in another. We conclude that suture repair is the operation of choice for gallbladder stab wounds without extensive injury. Ductal injury must be recognized. Partial transections are best managed by primary repair. Complete transections should be managed by primary duct jejunal anastomosis if the expertise is available.
Contrast-enhanced abdominal computed tomography scanning and prediction of severity of acute pancreatitis: A prospective study
Authors: London N J M , Neoptolemos J P , Lavelle J , Bailey I , James D
Published: March 2007

One hundred and fifty-two patients were admitted to a single hospital with a aiagnosis of acute pancreatitis during a 31-month period. Of these, 126 patients had contrast-enhanced abdominal computed tomography (CT) scans within 72 h of admission; 92 of these attacks were clinically mild, 34 were clinically severe. A single consultant radiologist reported the scans ‘blind’ and noted whether pancreatic enhancement was normal, increased or decreased, and whether there was loss of peripancreatic tissue planes. The maximum anteroposterior measurement of the pancreatic head and body were multiplied together to produce a ‘pancreatic size index’ (cm2). Significantly more patients with severe attacks had decreased pancreatic enhancement (79 versus 58 per cent, P = 0·01) and loss of peripancreatic tissue planes (82 versus 54 per cent, P = 0·006). The median (range) pancreatic size index for clinically severe attacks was 12·8 cm2 (3·0-52·5), and for mild attacks was 6·0 cm2 (1·1-23·4), P<0·0001. Modified Glasgow criteria had a sensitivity of 85 per cent and specificity of 79 per cent for clinically severe attacks. A pancreatic size index of ⩾ 10 cm2 had a sensitivity of 71 per cent and specificity of 77 per cent for clinically severe attacks. In conclusion, although there were highly significant differences between the clinically severe and mild groups with respect to pancreatic enhancement, peripancreatic tissue planes and pancreatic size indices, these CT criteria did not improve on modified Glasgow criteria for prediction of disease severity.
Preoperative assessment of mesorectal lymph node involvement in rectal cancer
Authors: Beynon J , Mortensen N J McC , Foy D M A , Channer J L , Rigby H , Virjee J
Published: March 2007

One hundred patients with rectal adenocarcinoma were examined preoperatively with rectal endosonography (ES) and 50 were also examined with computed tomography (CT). ES predicted mesorectal lymph node involvement with an accuracy of 83 per cent, sensitivity of 88 per cent, specificity of 79 per cent, positive predictive value of 78 per cent and negative predictive value of 89 per cent. CT in comparison had an accuracy of 57 per cent, sensitivity of 25 per cent, specificity of 91 per cent, positive predictive value of 75 per cent and negative predictive value of 53 per cent. No particular histological architectural feature could be identified as responsible for false positive diagnosis though nodal size was significantly larger in the true positive and false positive group when compared with the true negatives (P < 0·001 and P < 0·01 respectively).
Value of a risk questionnaire in screening for colorectal neoplasm
Authors: Kewenter J , Haglind E , Smith L
Published: March 2007

The value of a postal questionnaire and of Hemoccult II (Smith Klein Diagnostic Inc., Sunnyvale, California, USA) testing in screening for colorectal neoplasms was compared. In the questionnaire, the subjects were asked about previous treatment for colorectal neoplasm and rectal bleeding during the previous 6 months, specified as to type. All participants were asked to perform Hemoccult II blood testing over 3 days. Of 13 759 randomly selected subjects 9040 (66 per cent) performed the test and returned the questionnaire. Three hundred and fifty-four subjects with a positive Hemoccult II test and/or a proven previous colorectal neoplasm had a full assessment including double-contrast enema and rectosigmoidoscopy to 60 cm. Eighteen carcinomas and 61 adenomas were thus diagnosed. The population was followed for from 20 to 29 months, during which time rescreening was undertaken. An additional 34 subjects with carcinomas and 90 with adenomas were identified during this period. A significant correlation between the presence of a colorectal neoplasm and a previous history of colorectal neoplasm, a positive Hemoccult II and a previous history of bright red bleeding but not dark bleeding was found. The possibility of diagnosing a neoplasm was two, four and 19 times higher in a subject with a previous history of bleeding, a history of colorectal neoplasm, or a positive Hemoccult II respectively. Screening by faecal occult blood testing, therefore, at the moment seems to bethe best and only practicable method.
Recessive mutations and chromosome deletions leading to cancer
Authors: Berne J , McColl I , Adinolfi M
Published: March 2007

This review examines the effect that a small chromosome deletion affecting a specific DNA sequence may have in producing a state of ‘hemizygosity’ for a gene or genes, and so triggering malignancy of the cells concerned. The association between such deletions and a variety of cancers will be considered and the implications for clinical practice will be outlined.
Recurrence after strictureplasty or resection for Crohn's disease
Authors: Sayfan J , Wilson D A L , Allan A , Andrews H , Alexander-Williams J
Published: March 2007

This study attempts to define whether there is an increased need for reoperation in patients with small bowel Crohn's disease treated by strictureplasty compared with those treated by small bowel resection. Previous studies of the rate of reoperation for small bowel Crohn's disease do not distinguish between reoperation performed because of a lesion at the original operation site and that undertaken because of a lesion at a distant site. This study analyses the need for reoperation only at the original site of operation and measures operation-free intervals. The site specific operation-free intervals in 41 patients with small bowel Crohn's disease treated by strictureplasty were not significantly different from the similar intervals in 41 patients treated by a small bowel resection.
Anorectal physiology measurement: Report of a working party
Authors: Keighley M R B , Henry M M , Bartolo D C C , Mortensen N J Mcc
Published: March 2007

A 2-day meeting was held in Bristol on 5 and 6 July 1988 immediately before the Tripartite meeting of the Surgical Research Society in order to discuss methods and identify areas of agreement with regard to measurement of indices of anorectal physiology. The following report highlights our findings.
Relationship between bile colonization, high-risk factors and postoperative sepsis in patients undergoing biliary tract operations while receiving a prophylactic antibiotic
Authors:   West of Scotland Surgical Infection Study Group, Wells G R , Taylor E W , Lindsay G , Morton L
Published: March 2007

A prospective audit of 644 patients undergoing biliary tract operations has been conducted to assess the incidence of bile colonization and its association with the incidence of postoperative sepsis when all patients received the same prophylactic antibiotic. The accuracy of the determination of high-risk factors has been assessed as has the correlation between bile colonization and patients assessed as ‘high risk’. Organisms were cultured from the bile of 121 (19 per cent) patients and among these the incidence of wound or intra-abdominal sepsis was 22 per cent whereas among patients with sterile bile the incidence was only 2 per cent (P<0·0001). Although the incidence of bile colonization within the high-risk group (32 per cent) was more than twice that in the low-risk group (14 per cent), more than half (54 per cent) of the patients with positive bile cultures were in the low-risk group. It is concluded that, despite prophylactic antibiotics, bile colonization remains the major factor associated with postoperative sepsis, but that this cannot be predicted accurately by preoperative assessment of high-risk factors. Furthermore, we believe that a policy of selective administration of prophylactic antibiotics solely to high-risk patients cannot be justified.
Gallbladder carcinoma: Role of radiation therapy
Authors: Houry S , Schlienger M , Huguier M , Lacaine F , Penne F , Laugier A
Published: March 2007

Gallbladder carcinoma continues to be a discouraging disease. Prognosis after resection still remains poor. Radiation therapy has been used in an attempt to improve the prognosis but only a few series of less than ten cases have been reported. Since 1977 we have treated 20 patients with gallbladder carcinoma with postoperative radiotherapy (mean total dose 4200 radiation absorbed dose). In four patients all the tumour was resected with the intent of cure. In 12 patients, the lesion was partially resected and in four patients no resection was performed. Seven patients in whom the tumour was partially resected or not resected also had chemotherapy. Our evaluation was retrospective and we compared our results with historical control groups comparable with respect to surgical procedures and pathological staging. In patients operated on for cure, one patient is alive at 84 months, the others died at 7, 8 and 33 months. In patients in whom the tumour was partially resected the mean survival time was 8.1 months and two patients are still alive 7.0 months after treatment. According to the Nevin classification the mean survival time in stage IV and V patients was respectively 9.2 and 7.2 months. There was no difference in survival between patients treated or not treated with chemotherapy. This experience is the largest published and suggests that radiotherapy may increase survival after no resection or palliative resection of gallbladder carcinoma.
Gastric cancer: A 25-year review
Authors: Allum W H , Powell D J , McConkey C C , Fielding J W L
Published: March 2007

Between 1957 and 1981, 31716 cases of gastric cancer were registered in the West Midlands, UK. The age-standardized incidence has shown a decrease from 17·42 per 100000 population during the first quinquennium to 15·30 per 100000 in the last. There was an apparent increase in the proportion of proximal lesions with a decrease in the proportion of distal, antral cancers. The stage of disease at diagnosis remained constant with 79 per cent of patients having stage IV disease. Less than 1 per cent presented with stage I disease. As a result, the curative resection rate was 21 per cent. The operative mortality rates for curative partial gastrectomy and total gastrectomy were 13 and 29 per cent respectively. Surgeons undertaking more than nine total gastrectomies annually had an overall mean operative mortality rate of 22 per cent. Overall age-adjusted survival at 5 years was 5 per cent. Survival at 5 years for stage I, II and III disease was 72, 32 and 10 per cent respectively. There was a significant increase in survival time for those treated by curative resection between 1972 and 1981 compared with the previous decade. The implications for the management of gastric cancer are discussed.
Arm morbidity within a trial of mastectomy and either nodal sample with selective radiotherapy or axillary clearance
Authors: Aitken R J , Gaze M N , Rodger A , Chetty U , Forrest A P M
Published: March 2007

The aim of this study was to assess upper limb morbidity following treatment for operable breast cancer. Patients were randomized to either mastectomy and axillary clearance (40 women: 12 with axillary nodal metastasis and 28 without axillary metastasis) or mastectomy and axillary sampling (54 women). Adjuvant radiotherapy was delivered to those in whom the sample revealed axillary nodal metastasis (28 women) but not to those with no axillary nodal metastasis (26 women). A subjective assessment of the state of the arm was made using a standard questionnaire. Objective assessment included upper and forearm circumference, shoulder joint mobility and assessment of power in the pectoralis muscle. The mean age was 56·8 years (range 33–77 years) and the mean elapsed time from treatment was 5·72 years (range 4·0–7·5 years). Subjective limb oedema was greatest in those who had axillary lymph node metastasis but there was no objective difference. Subjective joint mobility was reduced in the women who received radiotherapy and this was confirmed by objective assessment (P < 0·05). The objective reduction in arm mobility was related to the treatment rather than the axillary lymph node status. There was no difference in power. In this study women receiving adjuvant radiotherapy had significantly reduced shoulder mobility. This may have implications for current conservation studies using adjuvant radiotherapy.
Capsular penetration and perforation in pleomorphic adenoma of the parotid salivary gland
Authors: Lawson H H
Published: March 2007

Both penetration and perforation of the capsule were seen on the superficial aspect of pleomorphic adenomas. Only penetration was noted on the deep aspect, where the tumour was adjacent to the facial nerve. In terms of local recurrence this may explain why it appears to be safe to separate the deep aspect of the tumour from the facial nerve without a wide margin of normal parotid tissue.
Conservative proctocolectomy: A dubious option in ulcerative colitis
Authors: Talbot R W , Ritchie J K , Northover J M A
Published: March 2007

Conservative proctocolectomy was performed for ulcerative colitis in 19 patients, Crohn's disease in three and familial adenomatous polyposis in one. Healing was uncomplicated in only three patients (13 per cent). Eleven developed an anal discharge and nine an infected pelvic haematoma despite peranal drainage. Fourteen patients developed pelvic sepsis and, despite surgical curettage in 11, none healed. Six of these patients have had the anal sphincter divided, with healing in only one, and the anal canal has been excised in two. Eleven patients have ultimately healed at a median time of 28 months and eight have persistent sepsis after a median period of 45 months. Two patients with sepsis have had a successful ileoanal anastomosis. Conservative proctocolectomy cannot be recommended as a definitive operation for ulcerative colitis even though it may permit a subsequent restorative procedure.
Endoscopic balloon dilatation of colonic anastomotic strictures
Authors: Aston N O , Owen W J , Irving J D
Published: March 2007

Nine postoperative colonic and rectal strictures were treated using dilatation balloons passed over a guide-wire introduced endoscopically. Six strictures resolved after a single dilatation. The method is simple, safe, effective and avoids further surgery.
Effect of nutritional supplementation on protein synthesis in tumour and host tissues of rats with colonic cancer
Authors: Emery P W , Ward M W N , Lewin M R
Published: March 2007

Rats with colonic cancer were given a palatable liquid diet which enabled them to gain weight while those fed on stock diet, either ad libitum or in restricted amounts, lost weight. Protein synthesis was measured in vivo using a flooding dose technique. Increased nutrient intake caused increases in the rate of protein synthesis in muscle, liver and non-diseased parts of the colon, but had no effect on protein synthesis in the tumours. These data suggest that enteral hyperalimentation may be safely employed in the preoperative management of patients with cancer, as it is likely to stimulate nitrogen retention in the host tissues without increasing the growth rate of the tumour.
Management of thyroglossal cysts in children
Authors: Athow A C , Fagg N L K , Drake D P
Published: March 2007

Forty children with a suspected thyroglossal cyst were operated on by one paediatric surgeon receiving primary and secondary referrals in an 8-year period. Nine patients (22 per cent) proved to have other pathology. Multiple operations were required in eight of 17 patients (47 per cent) who had infected thyroglossal cysts but in only one of 14(7 per cent) with uninfected cysts. In the infected group preliminary incision and drainage was necessary in five cases and cyst recurrence occurred in four (24 per cent), whereas in the uninfected group there was only one recurrence (7 per cent) in a patient with double pathology. Infection and recurrent cysts were the chief reasons for multiple operations. Recurrence was caused by inadequate performance of the correct operation (Sistrunk's) or choice of the wrong operation. Two of our own three recurrences were due to the latter, other pathology being suspected intraoperatively. Histological study of the specimens showed that thyroglossal ducts were frequently multiple and widely spaced. In children any lesion whose presentation is typical of a thyroglossal cyst should be treated with an early Sistrunk's operation. The operation in children who have other pathology has no complications and is justified.
Surgical management of neutropenic enterocolitis
Authors: Koea J B , Shaw J H F
Published: March 2007

Three cases of histologically confirmed neutropenic enterocolitis, each presenting as an acute abdomen in patients with leukaemia are presented. All three patients presented with fever and abdominal pain within 14 days of completing a course of chemotherapy. Signs of peritonitis localized to the right iliac fossa developed in each patient, in spite of aggressive antibiotic therapy and bowel rest. All three patients were found, to have non-viable caecum at laparotomy and were treated by right hemicolectomy. Primary ileocolic anastomosis was performed in one patient, who recovered following a stormy postoperative course owing to sepsis. Two patients underwent formation of an ileostomy with distal mucous fistula and each recovered with minimal postoperative complications; secondary anastomosis was performed electively in both cases. The difficulty in diagnosing neutropenic enterocolitis pre-operatively is discussed and the place of non-operative management is reviewed but we recommend surgical intervention as a means of ensuring removal of a localized septic focus until marrow regeneration occurs.
Additional value of fine-needle aspiration biopsy in a mammographic screening trial
Authors: Frisell J , Eklund G , Nilsson R , Hellström L , Somell A
Published: March 2007

The Stockholm breast cancer screening trial used single-view mammography as the sole screening method. A majority (63 per cent) of the mammographic selected cases from the first two screening rounds had uncertain mammograms, coded as 3 on an ordinal scale from 1 to 5, where 1 and 2 are dismissed as normal mammograms and 5 stands for a typical cancer. In this group of uncertain mammograms 30 cases were malignant and 431 were non-malignant. The aim of this study was to examine whether surgical biopsy in this group could be replaced by fine-needle aspiration (FNA) biopsy, combined with the information from the mammogram and clinical examination, and whether this diagnostic' strategy could select the malignant cases with a high sensitivity. FNA biopsy selected 25 of the 30 mammary carcinomas as definite malignancy or atypia, with a sensitivity of 83 per cent (95 per cent confidence interval: 69–96 per cent), and combined with the information from the mammogram and clinical examination 29 of the malignancies were selected with a sensitivity of 97 per cent (95 per cent confidence interval: 83–100 per cent). In 398 of 431 non-malignant cases the diagnosis was established with the triple diagnostic approach without needing a surgical biopsy. In a clinical follow-up study, up to 64 months after the first screening round, only one false negative case was found, included in the group of 30 malignancies described above. With this strategy the rate of negative surgical biopsies was reduced by 90 per cent in the group with uncertain mammograms and without considerably impairing the reliability of the results.
Anastomotic aneurysms of the femoral artery: Aetiology and treatment
Authors: Clarke A M , Poskitt K R , Baird R N , Horrocks M
Published: March 2007

The aetiology and treatment of 35 femoral false anastomotic aneurysms in 29 patients presenting over the 4-year period 1984–88 were reviewed retrospectively. The mean interval between primary anastomosis and false aneurysm repair was 6 years (range from 2 weeks to 16 years). Twenty-two (63 per cent) false aneurysms had occurred after previous aortobifemoral bypass grafting for occlusive aortoiliac disease. Seven (20 per cent) presented as acute surgical emergencies. Review of the records of the initial operations revealed that superficial wound infections with positive bacteriological cultures had been present in eight cases (23 per cent) and a further two (6 per cent) had lymph fistulae. Thirty-two false aneurysms were repaired, by simple reanastomosis in 14 cases, interposition grafting in 17 cases and in one case by complete revision to an aortobifemoral bypass graft. The risk of a further operative repair was less (P < 0.05) following interposition grafting, than after simple revision. False aneurysm repairs, when compared with primary reconstructions done during the same period, were associated with more superficial wound infections (37 versus 10 per cent) and more explorations for haemorrhage within 30 days (19 versus 7 per cent).
Abdominal aortic aneurysm repair in the over eighties
Authors: Robson A K , Currie I C , Poskitt K R , Scott D J A , Baird R N , Horrocks M
Published: March 2007

Between January 1980 and September 1988, 34 octogenarians underwent aortic aneurysm repair. There were 26 men and eight women with a median age of 83 years (range 80–88 years). Twenty underwent ‘emergency’ repair after presenting with pain and/or collapse: 11 with a retroperitoneal rupture, three with an intraperitoneal rupture and six with an expanding aneurysm. The mortality rate for this group was 35 per cent. During the same period 14 patients had an elective repair and there were no deaths within 30 days. The mean hospital stay for the elective group was 14.2 days compared with 17.0 days for survivors in the emergency group. There was no significant difference in terms of risk factors between those who developed postoperative complications and those who did not. These mortality rates compare favourably with our overall mortality results for elective (4.6 per cent) and emergency (31 per cent) surgery. Those patients over 80 years of age with infrarenal abdominal aortic aneurysms should not be refused surgery on the basis of age alone; each patient should be judged individually.
Differential effects of low-dose tissue plasminogen activator and streptokinase on platelet aggregation
Authors: Berridge D C , Burgess-Wilson M E , Westby J C , Hopkinson B R , Makin G S
Published: March 2007

Despite increasing success with low-dose intra-arterial thrombolysis, early rethrombosis still occurs. Platelet aggregation is thought to play a major part in this process. We have therefore investigated the effects of recombinant tissue plasminogen activator (rt-PA) and streptokinase on platelet function at doses currently used for peripheral arterial thrombolysis. Platelet-rich plasma was stirred at 37°C, with either streptokinase (100, 300 or 1000 units ml−1) or rt-PA (10 (T10), 30 (T30) and 100 (T100) mg l−1), with immediate addition of an agonist for platelet aggregation (thrombin, collagen, adenosine diphosphate (ADP) or adrenaline) at a predetermined threshold dose. Significant inhibition of collagen-induced and adrenaline-induced platelet aggregation was produced with rt-PA at all doses used (P < 0.05). With adrenaline as the agonist, T100 produced disaggregation to a mean(s.d.) level of 26 (11) per cent. Thrombin-stimulated platelet aggregation was significantly reduced by T100 (P < 0.001) and T30 (P < 0.01) only, disaggregation being dose-dependent and complete with T100. Using ADP as the agonist, T100 produced a significant reduction in maximum platelet aggregation (P < 0.01), and disaggregation was achieved to a mean(s.d.) level of 48(13) per cent. Streptokinase did not produce any significant changes in any parameter of aggregation.
Complications of parotid surgery: The need for selectivity
Authors: Owen E R T C , Banerjee A K , Kissin M , Kark A E
Published: March 2007

The morbidity rate following 112 operations on the parotid gland is reported. Facial nerve palsy (temporary, 38 per cent; permanent, 9 per cent) and Frey's syndrome (11 per cent) were common following superficial parotidectomy. For pleomorphic adenoma and malignant lesions this procedure is justified. Benign conditions, which can be diagnosed preoperatively, should be treated by more limited surgery which has a lower complication rate.
Appendicectomy and carcinoma of the caecum
Authors: Armstrong C P , Ahsan Z , Hinchley G , Prothero D L , Brodribb A J M
Published: March 2007

A total of 519 patients presenting with carcinoma of the caecum in the Plymouth Health District between 1975 and 1987 were reviewed. The clinical course was determined in relation to patients with and without a history of previous appendicectomy. There was no difference in the incidence of previous appendicectomy between patients with carcinoma of the caecum and an age and sex matched control group. The presence of synchronous carcinomas and/or adenomas was unrelated to previous appendicectomy. Ten patients presented with appendicitis and 11 with a mucocele of the appendix as the first sign of carcinoma of the caecum. Previous appendicectomy was associated with a higher incidence of local fixity, invasion of the abdominal wall, metastatic spread and poor differentiation. These differences were reflected in a significantly lower resection rate for carcinomas in patients who had previously undergone appendicectomy. The survival of patients who had previously had appendicectomy was significantly reduced. Four independent prognostic factors for survival were identified using multivariate discriminant analysis. These were Dukes' classification, local invasion, tumour differentiation and previous appendicectomy. Local recurrence was more common in patients who had previously had appendicectomy and was often in the old appendicectomy wound itself. Appendicectomy does not increase the risk of carcinogenesis in the caecum. In this study a history of appendicectomy was an independent risk factor for survival and significantly worsened the prognosis for patients who subsequently developed carcinoma of the caecum.
Anterior sphincter plication and levatorplasty in the treatment of faecal incontinence
Authors: Miller R , Orrom W J , Cornes H , Duthie G , Bartolo D C C
Published: March 2007

The surgical treatment of faecal incontinence has been traditionally divided into sphincteroplasty for sphincter disruption and postanal repair for idiopathic cases. However, many studies have failed to show a correlation between outcome and change in the anorectal angle. This study was carried out to determine the effectiveness of anterior sphincteroplasty and levatorplasty in the treatment of faecal incontinence, regardless of aetiology. Thirty consecutive patients underwent surgery, 14 with traumatic sphincter injuries and 16 with idiopathic faecal incontinence. A satisfactory clinical result was obtained in ten (71 per cent) patients in the traumatic group and in ten (62 per cent) in the idiopathic group. This was associated with a significant increase in maximum voluntary contraction pressure in the traumatic group and in those patients who had a good result in the idiopathic group (traumatic: preoperative median 80 cmH2O (range 50–115 cmH2O) versus postoperative 115 cmH2O (75–290 cmH2O), P<0.005; idiopathic: preoperative 105 cmH2O (45–190 cmH2O) versus postoperative 120 cmH2O (45–230 cmH2O), P<0.05; Wilcoxon paired signed ranks test). There was also a significant improvement in anal sensation in the upper anal canal in both groups (traumatic: preoperative mean 17 mA versus postoperative 11 mA, P<0.05; idiopathic: preoperative 24 mA versus postoperative 9 mA, P <0.02). The anorectal angle increased in the idiopathic group at rest (preoperative median 105° (range 86–152°) versus postoperative 118° (95–180°), P<0.05). In conclusion, the type of approach (anterior or posterior) and the anorectal angle are irrelevant to the outcome of surgery for idiopathic faecal incontinence. Success appears to be related more to improved sphincter pressure and anal sensation.
Declining indications for abdominoperineal resection
Authors: Kirwan W O , O'Riordain M G , Waldron R
Published: March 2007

In 126 consecutive patients operated on for carcinoma of the lower two-thirds of the rectum, a consistent policy of sphincter preservation resulted in 100 (79 per cent) having anterior resection and 22 (17 per cent) abdominoperineal resection. Perioperative complications in the anterior resection group were: death (two patients), clinical leakage (three patients), pulmonary embolism (five patients), pelvic haematoma (one patient), small bowel obstruction (one patient) and wound sepsis (six patients). Of 55 patients who had a potentially curative anterior resection with follow-up of at least 2 years, one developed local recurrence. Five per cent of patients had significant continence problems. Low anterior resection for carcinoma is associated with low perioperative morbidity, satisfactory functional results and acceptable local recurrence rates.
Differential diagnosis of subungual melanoma from a surgical point of view
Authors: Shukla V K , Hughes L E
Published: March 2007

Subungual lesions referred to a surgical unit over a 17-year period have been reviewed to assess problems of differential diagnosis and management of suspected subungual melanoma. Such lesions are uncommon, even in a unit with interest in melanoma. Only four melanomas were seen for primary treatment, and eight in all, during the period. We describe the clinical features of other subungual lesions seen in surgical patients which might help in their differentiation from melanoma. Differential diagnosis and a management policy to achieve early diagnosis are discussed in the light of data from this series and study of the relevant literature.
Arteriogram scoring systems and pulse generated run-off in the assessment of patients with critical ischaemia for femorodistal bypass
Authors: Scott D J A , Hunt G , Beard J D , Hartnell G G , Horrocks M
Published: March 2007

Conventional arteriography is the investigation of choice in patients with critical ischaemia to select the site for the distal anastomosis of a femorodistal bypass. Several arteriographic scoring systems have been devised in an attempt to quantify the run-off. More recently Pulse Generated Run-off and intraoperative peripheral resistance measurements have been proposed as better predictors of early graft patency. Eighty-eight consecutive femorodistal bypass grafts were studied using Pulse Generated Run-off (PGR), conventional and intra-arterial digital subtraction arteriography (DSA) and peripheral resistance measurement. Three widely used arteriographic scoring systems were used to grade the arteriographic run-off. There were significant correlations between the scoring systems and the measured peripheral resistance, although PGR correlated better with peripheral resistance than arteriography (rs = −0·59, P <0·001). Intra-arterial DSA improved the correlation between the arteriogram scoring systems and the measured peripheral resistance in the distal popliteal artery, but not in single calf vessels. In contrast, PGR correlated much better with peripheral resistance in single calf vessels (rs = −0·82, P0·001). We recommend that selection for femorodistal reconstruction be based on a combination of intra-arterial DSA and PGR. PGR will identify patent distal calf vessels not seen on arteriography and determine their continuity with the pedal arch, two features which are essential prerequisites for successful femorodistal bypass.
Serum enzymes and other laboratory tests in acute pancreatitis
Authors: Clavien P-A , Burgan S , Moossa A R
Published: March 2007

This review evaluates selective enzymes and blood tests available for the diagnosis and prognosis of acute pancreatitis. It is concluded that serum amylase and lipase measurements represent the best available diagnostic methods. Newer alternative assays still require careful evaluation.
Late complications of pancreatic trauma
Authors: Carr N D , Cairns S J , Lees W R , Russell B C G
Published: March 2007

Pancreatic trauma is rare and experience concerning its management is consequently limited. Lessons learnt in the investigation and treatment of a group of 11 patients (median age 28·0 years, range 14–44 years), who presented with the sequelae of trauma, are described. These patients were referred to a centre with an interest in pancreatic disease at a median time of 6·0 months (range 1·5–34 months) after blunt (n = 9) or penetrating (n = 2) injury to the pancreas. Ten of the 11 patients had undergone either single (n = 4) or multiple (n = 6) previous operations. Ten of the 11 patients had either strictures or disruptions of the main pancreatic duct demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) and ultrasonography (n = 8) or by exploration of the pancreas (n = 2). Satisfactory results were achieved by non-operative treatment in one patient and by distal pancreatectomy in eight. One further patient, who underwent distal pancreatectomy, later required completion resection because of unsuspected ductal injury in the head of the gland. The final patient continued with symptoms of pancreatitis after pancreaticoduodenectomy. It is concluded that the non-resolving sequelae of pancreatic trauma are associated with injury to the main pancreatic duct and that specialist investigation should be performed before surgical intervention is contemplated.
Ten-year review of non-ruptured aortic aneurysms
Authors: Mutirangura P , Stonebridge P A , Clason A E , McClure J H , Wildsmith J A W , Nolan B , Ruckley C V , Jenkins A McL
Published: March 2007

Between 1978 and 1987, 587 cases of abdominal aortic aneurysm were operated on in the Vascular Unit of the Royal Infirmary of Edinburgh. Over this ten-year period there was a dramatic increase in the number of patients treated. Rupture had occurred in 278 patients. Of the 309 patients with non-ruptured aneurysm 175 were asymptomatic, 84 were symptomatic and 50 were acutely symptomatic. Two hundred and fifty-nine patients underwent elective operation and the 50 acutely symptomatic patients were operated on as emergencies. The overall mortality for the non-ruptured series was 2·9 per cent. The mortality in patients undergoing elective surgery was 1·9 per cent (1·1 per cent in asymptomatic and 3·6 per cent in symptomatic patients) and 4·0 per cent for patients undergoing emergency surgery.
Protective effects of recombinant human tumour necrosis factor α and interferon γ against surgically simulated wound infection in mice
Authors: Hershman M J , Pietsch J D , Trachtenberg L , Mooney T H R , Shields R E , Sonnenfeld G
Published: March 2007

Tumour necrosis factor α and interferon γ have both been shown to have immunoregulatory properties, and to be able to influence several microbial infections. This study showed that tumour necrosis factor was effective in modifying surgically simulated wound infections when administered both as prophylaxis and as therapy. Two models were used; one was an intramuscular bacterial challenge, and the other involved the use of a bacteria-laden thigh suture. The test bacterium for both models was Klebsiella pneumoniae, a common surgical pathogen in our surgical service. Interferon γ was an effective biological response modifier in these models. Tumour necrosis factor was more potent than interferon γ and there was no additive or synergistic effect with interferon γ. This indicates potentially different mechanisms of action for these two cytokines.