bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of staplers on oesophagogastric varices
Authors: Cai Cheng-Ji , Wang Cheng-Pei
Published: March 2007

Thirty-five gastrofundic devascularization procedures were performed with the side-to-side CF stapler of Chinese manufacture for obliteration of oesophagogastric varices. Four patients were operated on as emergencies, six patients 2–3 weeks after control of bleeding by tamponade and the remaining twenty-five electively (including four patients who had not bled). There were two operative deaths, an operative mortality of 6 per cent. In all, 30 patients have been followed, 20 for 1–3 years and 10 for less than 1 year. Twenty-five patients had postoperative barium meal examination. The varices were ameliorated in 19, not changed in 5 and exacerbated in 1. Nine patients rebled and of these, two died. The stapler is used in devascularization to interrupt intramural varices in the oesophagocardiac region. It must be emphasized that its use is only a part of the devascularization procedure. When used alone devascularization is not complete. The side-to-side stapler appears to be a convenient, safe and rational instrument for use in devascularization.
Adjuvant treatments following curative resection for gastric cancer
Authors:   The Italian Gastrointestinal Tumor Study Group, Bonfanti G
Published: March 2007

The results of a prospective randomized trial of adjuvant treatment after curative resection for gastric cancer are reported. The study consisted of three arms: (1) surgery only; (2) chemotherapy (5-fluoro-uracil (FU) and 1-(2-chloroethyl)-3-(4-methylcyclohexil)-1-nitrosourea (Me-CCNU)) after surgery; (3) chemo-immunotherapy (FU, Me-CCNU and levamisole) after surgery. Between March 1977 and June 1981, 235 patients were included in the study by 18 co-operating institutions. Thirteen per cent of patients in arm 2 and thirteen per cent in arm 3 suffered major toxicity, necessitating interruption of treatment. Two of these patients died of marrow aplasia. Statistical analysis of survival showed that prognosis was influenced by the well-known prognostic variables, invasion of the wall, nodal status and site of tumour. The different treatments in the three arms, however, did not show any impact on prognosis, even when adjustments were made for the most relevant prognostic variables. Given the lack of effect on survival and the presence of clinically important toxicity, FU and Me-CCNU ± levamisole cannot be recommended as adjuvant therapy for resected gastric cancer.
Death from undiagnosed peptic ulcer complications: A continuing challenge
Authors: Armstrong C P , Whitelaw S
Published: March 2007

A 10-year study of all 9653 autopsies performed in the Plymouth Health District, UK from 1977 to 1986 revealed 154 patients who died from undiagnosed peptic ulcer complications. In all, 118 of these patients died suddenly at home and 36 died in hospital. Most patients were elderly although 47 were under 70 years and 2 were under 50 years of age. Anti-inflammatory drugs were being used by 81 of these patients, an incidence of 60 per cent where full drug histories were available. Women who died were much more likely to be using these drugs than men. This study emphasizes the hitherto unrecognized importance of death from undiagnosed peptic ulcer disease and further highlights the potential risk of non-steroidal anti-inflammatory drug use.
Multivariate approach for assessing the prognosis of clinical oesophageal carcinoma
Authors: Sugimachi K , Matsuoka H , Ohno S , Mori M , Kuwano H
Published: March 2007

We investigated the prognostic contribution of 15 discrete variables on the survival of 123 patients with carcinoma of the oesophagus who underwent oesophagectomy and oesophageal reconstruction. In the mulitvariate analysis, three of fifteen variables were associated with the prognosis of patients who underwent oesophagectomy. The variables are: resectability of the malignant lesion, DNA distribution pattern of the cancer cells and postoperative complications. The DNA distribution pattern proved to be one of the most reliable prognostic factors. These three variables were assigned one of two values, ‘favourable’ or ‘unfavourable’, indicative of the effect on survival. The 123 patients were classified into four groups, characterized by eight possible combinations of these three variables. The survival rate of those with two or more ‘favourable’ variables was the highest, that is about 50 per cent at 5 years after surgery. On the other hand, patients with two or more ‘unfavourable’ variables had a very poor prognosis. Therefore, early detection and postoperative care play key roles in determining the survival of patients with oesophageal carcinoma.
Management of severe intra-abdominal sepsis: Single agent antibiotic therapy with cefotetan versus combination therapy with ampicillin, gentamicin and metronidazole
Authors: Huizinga W K J , Baker L W , Kadwa H , van den Ende J , Francis A J , Francis G M
Published: March 2007

In a prospective, randomized trial involving 100 patients with severe intra-abdominal sepsis, the value of single agent antibiotic therapy with cefotetan was compared with that of combination therapy of ampicillin, gentamicin and metronidazole (AGM). All patients underwent exploratory laparotomy. The mortality rate was 3 per cent, all deaths occurring within 48 h of operation. Two-thirds of patients were considered severely ill on admission, and one-third were moderately ill. Six patients had positive blood cultures on entry into the study. The mean age was 31 years and concurrent disease was present in 14 percent of the patients. A satisfactory response was achieved in 82 per cent of patients receiving cefotetan and in 65 per cent of those receiving AGM, whereas the response was unsatisfactory in 18 per cent of cefotetan patients and 35 per cent of those receiving AGM (P = 0.075 n.s.). Significant changes in laboratory values during the study occurred in 51 per cent of patients, and 7 per cent required vitamin K administration for hypoprothrombinaemia. The results of this study suggest that antibiotic therapy with single agent cefotetan is as safe and effective as a combination of ampicillin, gentamicin and metronidazole in patients with severe intra-abdominal sepsis requiring operative management.
Splenic repair for trauma
Authors: Ghosh S , Symes J M , Walsh T H
Published: March 2007

The risks of overwhelming post-splenectomy infection (OPSI) are now well documented both in children and adults. Although the incidence of OPSI is comparatively low following splenectomy for trauma, it has a high mortality. Splenectomy is no longer the treatment of choice for splenic injury and splenic salvage is recommended whenever feasible. Since 1982, in the Isle of Wight hospitals, 13 cases of splenic injury following trauma have been treated applying various salvage procedures and are reported here.
Postoperative urinary retention in general surgical patients
Authors: Stallard S , Prescott S
Published: March 2007

A prospective study has been performed to measure the incidence of postoperative urinary retention in 280 general surgical patients. Eighteen patients (6 per cent) were catheterized after a range of operations under general anaesthesia. There was no statistical difference in the retention rate between men and women. Increasing age did not predispose to retention of urine. Of 72 patients who had either herniorrhaphy, haemorrhoidectomy or testicular operations, only 1 was catheterized, whereas 16 (23 per cent) of 70 patients undergoing laparotomy were catheterized. Most of these laparotomy patients had upper abdominal procedures carried out. Those having lower abdominal operations were usually catheterized pre-operatively and were excluded from the study. There was a significantly higher incidence of retention among patients who had long anaesthetics (>60 min). There was also a significantly higher incidence of retention among those who were ventilated, relaxed and reversed by atropine and neostigmine. Of those 193 patients who had opiate analgesia, 15 (8 per cent) developed retention of urine, compared with 3 (3 per cent) of the 87 patients who had non-opiate analgesia. There was a significantly higher retention rate among the patients who had opiate analgesia by intravenous infusion compared with those who had opiates by intramuscular bolus injection; 7 patients had painful and 11 had painless retention. This study suggests that postoperative retention of urine is a result more commonly of diminished awareness of bladder sensation, than of factors such as anxiety or local pain.
Calmodulin antagonist trifluoperazine inhibits polyamine biosynthesis and liver regeneration
Authors: Alexander R W , Saydjari R , MacLellan D G , Townsend C M , Thompson J C
Published: March 2007

Polyamines are essential for cell growth and differentiation. Trifluoperazine (TFP) is a potent, competitive inhibitor of the calcium—calmodulin complex. TFP, when given to rats after partial hepatectomy, causes a significant decrease in DNA synthesis. The purpose of this study was to examine the effects of TFP on polyamine biosynthesis and on liver regeneration after partial hepatectomy. TFP (60 mg/kg, bodyweight) or saline control was administered to 80 male Sprague-Dawley rats 2 h before, 2 h after, or at the time of hepatectomy. Polyamines (putrescine, spermidine and spermine) were measured at the time of hepatectomy, and at 6, 24, 48, and 72 h after hepatectomy. TFP, when it was administered either 2 h before or at time of hepatectomy, blocked increases in putrescine that are seen normally at 6 h after hepatectomy. When TFP was given at the time of partial hepatectomy, putrescine was increased at 24 h, and then returned to normal levels at 72 h. Spermidine was inhibited at 24 h, but not at 48 and 72 h. Spermine was not significantly altered at any time. The administration of TFP 2 h after hepatectomy did not significantly alter concentrations of polyamines. The weight of regenerating liver was decreased by TFP at 48 h (23 per cent) and 72 h (22 per cent) after hepatectomy. These findings provide evidence that the calcium—calmodulin complex is required for the synthesis of liver polyamines before liver regeneration can proceed.
Effect of continuous postoperative epidural analgesia on intestinal motility
Authors: Ahn H , Bronge A , Johansson K , Ygge H , Lindhagen J
Published: March 2007

The effect of postoperative epidural bupivacaine on intestinal motility was studied by measuring the transit time of barium contrast through the intestines in 16 patients after resection of the left colon and/or rectum. Fourteen patients served as controls and received postoperative injections of pentazocine. Mean transit time through the intestinal tract was 35 h in the epidural group and 150 h in the control group, a difference that is significant at the 0·1 per cent level. The average time before passage of flatus and faeces was different between the two groups at the 0·1 per cent level. We conclude that postoperative epidural bupivacaine constitutes an effective means of analgesia after colorectal surgery and is associated with a short duration of intestinal paralysis.
Techniques for better suturing
Authors: Seki S
Published: March 2007

Suturing techniques enhancing the accuracy of suture placement and reducing the forces on the tissue being sutured were evaluated in six surgeons, each with 6 years' surgical experience. The accuracy was assessed by the distance between the actual and designated needle exit sites. Force was expressed in terms of the torque on the needle holder using a maximum of the torques (max. F), maximum derivative (dF/dt) and integral (IF). The effects of four factors (suturing techniques) on suturing were evaluated: (1) placement of the needle holder on the needle; (2) inclining the tissue at needle entrance, as is commonly done by elevating with forceps (unnoted role of the forceps); (3) adjustment of the needle's exit during suture placement, as is unknowingly employed in practice, and (4) variation between individual surgeons. All these factors affected the accuracy and force of suturing. Gripping the needle closer to the tip strongly reduced the max. F, dF/dt, and IF per time, as did inclining the tissue. Adjustment of exit improved accuracy, but has the potential for causing avoidable tissue injuries. Differences between surgeons suggest the necessity of addressing fundamental surgical techniques and formally incorporating them into the training programme.
Treatment of Crohn's disease in relapse with cyclosporin A
Authors: Parrott N R , Taylor R M R , Venables C W , Record C O
Published: March 2007

It has been suggested that cyclosporin A might be of some benefit to patients with Crohn's disease. The clinical response and side-effects of cyclosporin A in Crohn's disease are described in a series of 13 adults. The majority of patients had ileal disease and all but one were started on an initial oral dose of 15 mg/kg per day. Duration of treatment ranged from 3 to 42 weeks. Of the 13 patients, 6 showed a response to therapy; the remainder showed no response or deteriorated. The commonest side-effect was hyperaesthesia, but one patient developed nephrotoxicity and one developed hepatotoxicity. Significant drug malabsorption occurred in one case. The side-effects were dose dependent and reversible. Cyclosporin A may have a part to play in the treatment of resistant Crohn's disease, and in our hands has been associated with a 46 per cent response rate; however, the precise role of cyclosporin A in the management of Crohn's disease awaits further study.
A protocol for the safe treatment of acute lower limb ischaemia with intra-arterial streptokinase and surgery
Authors: Walker W J , Giddings A E B
Published: March 2007

Over a 5-year period 70 patients, presenting with subacute ischaemia of the lower limb (more than 12 h), were treated with low-dose intra-arterial streptokinase. There were 72 infusions and effective lysis was achieved in 52 (72 per cent), with an average infusion time of 25 h. A total of 23 (32 per cent) also underwent percutaneous transluminal angioplasty when lysis showed an underlying stenosis, and a further 19 (26 per cent) required surgery to remove persistent stenosis, organized thrombus or atheromatous debris. Significant bleeding occurred in 4 patients (6 per cent) and 13 (18 per cent) underwent amputation. There were five deaths (7 per cent), one of which was directly related to the infusion, while three were due to myocardial infarction. All of the major complications occurred in the early part of the study and both the selection of patients and the technique of infusion were modified to improve safety. Complementary treatment by percutaneous transluminal angioplasty and surgery was used more frequently in the later part of the study. The technique is not recommended for the white leg of acute ischaemia (<12 h), or for lysis of clot in a retroperitoneal Dacron® graft, but may be uniquely valuable to demonstrate the cause of subacute ischaemia.
Local thrombolytic therapy of acute peripheral arterial ischaemia with tissue plasminogen activator: A dose-ranging study
Authors: Earnshaw J J , Westby J C , Gregson R H S , Makin G S , Hopkinson B R
Published: March 2007

Low-dose streptokinase has been established as an alternative to surgery in selected patients with acute peripheral arterial ischaemia. Tissue plasminogen activator (t-PA) is responsible for normal plasma fibrinolytic activity and has recently become available for clinical use owing to recombinant DNA technology. It has the theoretical advantage of fibrin specificity, which may result in enhanced thrombolytic effects with greater safety. Twenty-three patients with recent lower limb arterial occlusions received t-PA over a tenfold range of concentrations and five patients received low-dose streptokinase. One month after treatment with t-PA or streptokinase 19 (68 per cent) patients had limb salvage, five (18 per cent) had required amputations and four (14 per cent) had died. Systemic fibrinolytic effects were variable but basically dose related. Haemorrhage occurred most frequently at the highest t-PA concentration and was major in four (17 per cent) cases, including a fatal stroke. Plasma fibrinogen concentration fell below 1·2 g l−1 in five (22 per cent) patients who received t-PA and was found to be a significant risk factor for haemorrhage. t-PA was an effective thrombolytic agent at all concentrations studied. The dose currently used in clinical studies at this institution is 0·5 mg h−1.
Blood flow in diabetics with foot lesions due to ‘small vessel disease’
Authors: Irwin S T , Gilmore J , McGrann S , Hood J , Allen J A
Published: March 2007

Blood flow was measured in the feet and toes of 23 diabetics, 7 controls and 6 non-diabetic neuropathic controls, using venous occlusion plethysmography. All of the diabetics showed a characteristic flow abnormality with mild hyperperfusion of the foot at rest but impaired peak flow following arterial occlusion. When the diabetics were subdivided into those with ‘small vessel disease’, those with neuropathic ulceration and those with neuropathy but no ulceration, the groups had remarkably comparable blood flows, except that peak great toe blood flow was rather lower in small vessel disease. In small vessel disease, the combination of high resting blood flow and elevated foot venous oxygen saturation suggests that the hyperperfusion is due to arteriovenous shunting. It seems likely that the toe lesions ascribed to small vessel disease were in fact manifestations of severe diabetic neuropathy. The term small vessel disease should be avoided in the context of diabetic foot lesions.
Plasma arginine vasopressin levels and arterial pressure during open heart surgery
Authors: Woods W G A , Forsling M L , Le Quesne L P
Published: March 2007

A study of plasma arginine vasopressin (AVP) levels and their relation to changes in arterial pressure was undertaken in 13 patients undergoing open heart surgery. Seven of the patients received high doses of intravenous morphine (1 or 2 mg/kg) as part of their anaesthetic, whereas the other six did not. Increases in the AVP levels during cardiopulmonary bypass (CPB) were significant in both groups, but were significantly greater in the patients not receiving morphine (median 86·1 fmol/ml) than in those who did (47·5 fmol/ml). In both groups there was a linear correlation between the natural logarithm of the plasma AVP level and the percentage fall in the mean arterial pressure, although the slope of the relationship was significantly less in the group receiving morphine than in the group not receiving morphine. These results indicate that in patients undergoing cardiac surgery the neuroendocrine reflex control of plasma AVP levels in relation to changes in arterial pressure is intact, but that the sensitivity of the reflex (i.e. the increase in plasma AVP level for a given fall in arterial pressure) is reduced by the administration of high doses of intravenous morphine.
Posterior sagittal anorectoplasty for reoperation in children with anorectal malformations
Authors: Brain A J L , Kiely E M
Published: March 2007

A prospective study was carried out in 12 consecutive patients (7 boys and 5 girls), to evaluate posterior sagittal anorectoplasty for patients incontinent of faeces after anorectal reconstruction. Examination revealed anatomical problems such as: recurrent fistula (two), massive urethral diverticulum (one), absent vagina (one), and a missed urogenital sinus (one). Preliminary electromyography showed the external sphincter to be displaced from the anus in nine patients. Posterior sagittal anorectoplasty, with correction of anatomical defects and precise reconstruction of bowel within the sphincters, was carried out after the formation of a loop colostomy. No postoperative complications were observed. Contrast studies confirmed healed suture lines before stoma closure. Follow-up, between 4 and 46 months, revealed good faecal control in only two patients, with a significant improvement in two others. The rest remained incontinent although sensation was improved. These disappointing results, at variance with other published reports, lead us to conclude that posterior sagittal anorectoplasty, when used as a secondary procedure, is good for correcting anatomical defects but not for improving faecal continence.
Paget's disease of the anus: A clinicopathological study
Authors: Armitage N C , Jass J R , Richman P I , Thomson J P S , Phillips R K S
Published: March 2007

Paget's disease of the anus is a rare disorder of controversial origin and is frequently associated with malignancy. We studied eight patients and carried out immunohistochemical studies to determine whether particular functional profiles might be indicators of a malignant association. One patient presented with synchronous carcinoma and two developed carcinomas 3 and 10 years after excision of Paget's disease. Five patients underwent wide local excision and have not developed cancer (median follow-up 6 years, range 5-13 years). However, four patients developed recurrent Paget's disease. Immunohistochemical studies showed that in general Paget cells stained positively with CAM 5·2 (a cytokeratin marker), gross cystic disease fluid protein (a marker for apocrine cells), human milk fat globule glycoprotein (HMFG 1 and 2) and carcinoembryonic antigen but negatively for PR3A5 (a marker for colonic goblet cells). Three cases had a staining profile which was quite different from that usually observed and these were associated with malignancy. One showed an antigenic profile more typical of a large bowel carcinoma. Paget's disease of the anus appears to run one of two clinical courses: to develop malignancy; or to recur locally, often on repeated occasions. Wide local excision is the treatment of choice but long-term follow-up is necessary because of the cancer risk. An immunohistochemical staining pattern which is different from usual may indicate a higher malignant risk and/or identify some cases of Paget's disease as representing a downward ‘pagetoid’ extension from a anorectal adenocarcinoma rather than a true epidermotropic apocrine neoplasm of the perianal skin.
Anorectal function after abdominal rectopexy: Parameters of predictive value in identifying return of continence
Authors: Yoshioka K , Hyland G , Keighley M R B
Published: March 2007

Posterior abdominal rectopexy was performed in 12 patients with a full-thickness rectal prolapse: 9 had faecal incontinence. The prolapse was successfully controlled in all cases and six of nine patients were rendered continent. Physiological studies in patients were compared with age- and sex-matched controls. Preoperative anal pressures were significantly lower than in controls at rest (R), during maximum pelvic floor contraction (Sq) and attempted defaecation (St) (R, P < 0·005; Sq, P < 0·005; St, P < 0·005). Anorectal angles were significantly more obtuse in patients than in controls (R, P < 0·05; St, P < 0·025). None of these parameters changed significantly after abdominal rectopexy. Median rectal emptying significantly decreased after operation (preoperative 83 per cent/min; postoperative, 58 per cent/min, P < 0·05). Median perineal descent during attempted defaecation also significantly decreased after operation (preoperative, 8·5 cm; postoperative, 7·1 cm; P < 0·025). Parameters which predicted return of continence included: delayed leakage during the saline infusion test (P < 0·025), a narrow anorectal angle during pelvic floor contraction (P < 0·025), minimal pelvic floor descent during contraction (P < 0·05), and a long anal canal at rest (P < 0·05) and during pelvic floor contraction (P < 0·025).
Somatostatin analogue SMS 201–995 (octreotide) as a possible solution to the dumping syndrome after gastrectomy or vagotomy
Authors: Primrose J N , Johnston D
Published: March 2007

The dumping syndrome, which may follow partial gastrectomy or truncal vagotomy and drainage, may be refractory to treatment. The aim of this study was to determine the effect of the somatostatin analogue. SMS 201-995 (octreotide), on dumping provoked by hypertonic glucose. Ten patients with symptoms and signs of dumping were studied. After a dumping provocation test with placebo, all patients developed severe symptoms: seven patients had early dumping, two had both early and late dumping and one had late dumping alone. With either 50 or 100 μg SMS 201-995, the symptoms of early dumping were much reduced in all patients, and those of late dumping were completely abolished. The packed cell volume, pulse and systolic blood pressure changes of early dumping were significantly reduced by SMS 201-995 and the fall in blood glucose in patients with late dumping was abolished. SMS 201-995 may be a useful treatment for early and late dumping.
Reticuloendothelial failure in chronic intra-abdominal sepsis: The role of opsonic fibronectin
Authors: Cheslyn-Curtis S , Aldridge M C , Dudley H A F
Published: March 2007

Severe sepsis leads to depression of the reticuloendothelial (RE) system with delayed bloodstream clearance of particulate matter and bacteria. Fibronectin may be an important opsonin of the RE system and low fibronectin levels often accompany severe sepsis in man. We have investigated the effect of prolonged intra-abdominal sepsis on plasma fibronectin concentrations and RE function. Serial plasma fibronectin concentrations were determined in rabbits for 2 weeks after either the induction of sepsis (appendix abscess) (n = 6) or laparotomy only (n = 6). RE function was measured at 2 weeks by determining the clearance kinetics and organ distribution of low dose technetium tin colloid (TTC). There was an early transient depression in plasma fibronectin values followed by elevated concentrations at 48–72 h which were more marked in the sepsis group. There was a delay in the blood clearance with reduced hepatic and increased bone uptake of TTC. We conclude that depletion of opsonic fibronectin is unlikely to be an important factor contributing to the impairment of RE function associated with intra-abdominal sepsis and that RE depression in septic animals is due to intrinsic Kupffer cell dysfunction.
Characterization of breast cancer subgroups in an African population
Authors: Otu A A , Ekanem I -O A , Khalil M I , Ekpo D , Attah E B
Published: March 2007

A detailed prospective study of 58 consecutive breast cancer patients and contemporaneous controls, using age, duration of tumour and presence or absence of poor prognostic signs as clinical parameters, clearly showed that the patients fell into three distinct groups. Group A accounted for 30 per cent of cancers and consisted of young women (21–45 years) with advanced cancers, a short history (3 months or less) and poor prognostic signs; these patients had fast-growing tumours. Group B, to which nearly 60 per cent of patients belonged, was made up of menopausal women (46–50 years) with advanced disease, a history of from 3 months to 1 year and poor prognostic signs; their tumour growth rate was intermediate. Group C made up slightly more than 10 per cent of cases and consisted of postmenopausal women (50 years and above) who gave a long history (1 year or more), and had resectable tumours without poor prognostic signs. Thus, although advanced breast cancer in tropical Africa is due to late presentation in the majority of cases, a small but significant proportion of women have advanced disease in spite of early presentation, attributable to fast tumour growth rate.
Follow-up after treatment of primary breast cancer
Authors: Rutgers E J Th , van Slooten E A , Kluck H M
Published: March 2007

This study evaluates the usefulness of routine follow-up of breast cancer patients. In all, 416 patients who were treated with curative intent for breast cancer were followed according to a fixed follow-up schedule for a minimum of 2·5 years and a maximum of 13·5 years (mean about 5 years). During the 4533 routine out-patient visits, 41·16 chest radiographs, 3889 pelvic radiographs and about 17000 laboratory tests were carried out routinely. In the follow-up period, 148 patients were found to have distant recurrence of whom 34 (23 per cent) had asymptomatic metastases and 114 symptomatic metastases. Of the 8005 routinely performed radiographs, 24 (0·3 per cent) revealed asymptomatic metastases, and the 17000 laboratory tests led to the discovery of six asymptomatic bone and four asymptomatic liver recurrences. Screening for metastases did not result in a reduction of the lead time to the diagnosis of asymptomatic metastases; the disease-free interval was equal in both symptomatic and asymptomatic patients. Of the 46 locoregional recurrences 42 were found by physical examination during a routine follow-up visit and 37 had not been noticed by the patient. Seventeen second primary breast cancers were diagnosed, six of which were in stage I (< 2 cm). Mammography was not a part of the routine follow-up scheme. It is concluded that routine follow-up of breast cancer patients by history and physical examination is sufficient to detect local recurrence and a second primary tumour as well as giving the opportunity to track signs and symptoms of distant recurrence at an early stage. Performing annual or biannual mammography is advisable, but the use of other costly routine investigations in the follow-up is not justifiable, as no therapeutic advantages can be expected.
Intraperitoneal rupture of amoebic liver abscess
Authors: Sarda A K , Bal S , Sharma A K , Kapur M M
Published: March 2007

A retrospective analysis of 23 cases of amoebic liver abscess with intraperitoneal rupture is presented. Group I consisted of 16 patients with clinical features of generalized peritonitis. Eight of these patients were treated surgically, and four died. Group II consisted of seven patients with features of localized peritonitis and all were treated conservatively. In all cases the diagnosis of liver abscess was established by liver scan or ultrasound examination; peritonitis was established either at operation or, in the conservatively managed group, by aspiration of pus from the peritoneal cavity. Amoebiasis was diagnosed by serology. Eight group I and all group II patients were managed conservatively by aspiration of the liver abscess, antibiotics and amoebicides. There were no deaths in this group. It is suggested that, if the diagnosis can be made early, conservative treatment offers the best chance of cure for patients of amoebic liver abscess with intraperitoneal rupture.
Cholecystectomy and colorectal cancer
Authors: Moorehead R J , McKelvey S T D
Published: March 2007

This review examines the evidence for and against an association between cholecystectomy and colorectal cancer.
Direct retroperitoneal approach to necrosis in severe acute pancreatitis
Authors: Fagniez P-L , Rotman N , Kracht M
Published: March 2007

From 1981 to 1987, 40 patients with severe acute pancreatitis were operated on using a direct retroperitoneal approach, 22 primarily and 18 after a first operation performed through another incision. The severity of the disease was assessed by Ranson's bioclinical and computed tomography scan scoring systems. The retroperitoneal approach consisted of a left lateral incision, just anterior to the 12th rib, allowing direct access to the pancreas and a complete manual exploration of the gland and peripancreatic spaces. All patients but one were operated on for infected necrosis. The overall mortality rate was 33 per cent but was lower in the patients operated on primarily through a direct retroperitoneal approach (18·2 per cent). Twenty patients (50 per cent) developed a local complication (haemorrhage, colon fistula and/or necrosis). The direct retroperitoneal approach permits the removal of necrosis and several reoperations without the risk of large wound dehiscence and does not preclude the extension of the incision to a subcostal incision when necessary.
Proctocolectomy and ileoanal pouch anastomosis without conservation of a rectal muscular cuff
Authors: Chaussade S , Verduron A , Hautefeuille M , Risleight G , Guerre J , Couturier D , Valleur P , Hautefeuille P
Published: March 2007

The technique of proctocolectomy and formation of an ileal reservoir with ileoanal anastomosis is well described. It is believed that the conservation of a rectal muscular cuff is necessary for continence but no data are available to support this contention. The aims of this study were to describe the clinical and physiological aspects of continence after proctocolectomy and ileal J pouch anastomosis without conservation of a rectal muscular cuff. Eighteen consecutive patients (mean age 37·3 years, 16 ulcerative colitis, two familial polyposis) who underwent proctocolectomy and ileoanal anastomosis on the dentate line were studied 6 months after closure of the loop ileostomy. The 18 patients and eight controls underwent: (a) anal manometry; (b) determination of maximum tolerable volume (MTV); (c) liquid continence test (infusion of NaCl at 60 ml/min for 25 min) with simultaneous measurement of ileal reservoir pressure. The volume evacuated during 5 min after the continence test was also measured. The frequency of bowel actions was (mean ± s.e.m.) 5·3 ± 0·4 per 24 h (nocturnal 1·14 ± 0·26). Seventeen of 18 patients (94 per cent) had normal continence and defaecation; one patient was incontinent. A decrease in resting anal canal pressure (102·5 ± 4 versus 47·5 ± 6 cmH2O) was observed after ileoanal anastomosis. A rectoanal inhibitory reflex was elicited in one of the 18 patients (6 per cent). Patients were able to retain 1023 ± 68 ml saline during the liquid continence test. The percentage evacuation of the ileal reservoir was 61 ± 4·5 per cent. Correlations were found (P = 0·05) between daily stool frequency and the volume of saline retained during the liquid continence test. It is concluded that conservation of a rectal muscular cuff is not necessary for the achievement of good clinical results.
A common pathophysiology for full thickness rectal prolapse, anterior mucosal prolapse and solitary rectal ulcer
Authors: Sun Wei Ming , Read N W , Donnelly T Carmel , Bannister J J , Shorthouse A J
Published: March 2007

Anorectal pressures at rest, during conscious contraction of the external sphincter, during serial distension of the rectum and during straining to inflate a balloon were measured in 56 patients (21 patients with full thickness rectal prolapse, 24 patients with anterior mucosal prolapse, 11 patients with solitary rectal ulcer) and in 30 normal subjects. Both basal and squeeze pressures were significantly lower in the three groups of patients compared with matched normal controls (P < 0·05). During increases in intra-abdominal pressure, anal pressure remained above maximum rectal pressure (P < 0·05) in normal controls, with the highest anal pressures being recorded in the most caudal anal channels. In contrast, anal pressures tended to be lower than rectal pressures during this manoeuvre in patients with rectal prolapse, anterior mucosal prolapse and solitary rectal ulcer, and the highest pressures were recorded in the channels nearest the rectum. During serial distension of the rectum, 64 per cent of patients with solitary rectal ulcer, 75 per cent with anterior mucosal prolapse and 76 per cent with rectal prolapse, but only 10 per cent of controls, showed repetitive rectal contractions. The highest anal pressure always remained higher than rectal pressure during rectal distension in normal subjects (P < 0·05) but not in patients. The threshold rectal volume required to cause a desire to defaecate and the maximum tolerable volume were significantly lower (P < 0·05) in each of the patient groups, compared with normal subjects. The similarity in the results from patients with rectal prolapse, anterior mucosal prolapse and solitary rectal ulcer support the hypothesis that they share a common pathophysiology. In each of the groups, the rectum is hypersensitive and hyper-reactive, and weakness of the anal sphincter creates the conditions for prolapse of the rectum to occur into or through the anal canal.
Thigh length versus knee length stockings in the prevention of deep vein thrombosis
Authors: Porteous M J Lef , Nicholson E A , Morris L T , James R , Negus D
Published: March 2007

Above-knee graduated compression stockings are effective in preventing postoperative deep vein thrombosis, but are more expensive and less acceptable than below-knee stockings. One hundred and fourteen patients undergoing major abdominal surgery were randomly allocated to wear above-knee or below-knee graduated compression stockings. Deep vein thromboses were diagnosed by isotope uptake in three of 56 patients (5·4 per cent) in the above-knee group and one of 58 patients (1·7 per cent) in the below-knee group. These differences are not statistically significant. Results suggest that below-knee stockings are as effective as above-knee in the prevention of postoperative deep vein thrombosis.
Ten-year experience of strictureplasty for obstructive Crohn's disease
Authors: Dehn T C B , Kettlewell M G W , Mortensen N J Mcc , Lee E C G , Jewell D P
Published: March 2007

Strictureplasty is controversial in the management of obstructive Crohn's disease. Only a small proportion of patients undergoing surgery for obstructive Crohn's disease are suitable for strictureplasty. Lesions which are most amenable for this procedure are short, fibrous strictures. Over a 10-year period 24 patients have undergone 30 operations at which 86 strictureplasties were performed. The median follow-up has been 40 (range 4–112) months. No leaks or fistulae arose from the stricture-plasties. The median weight gain 3 months postoperatively was + 4·0 kg. Four patients subsequently required a further 13 strictureplasty procedures, between 12 and 36 (median 18) months after the initial operation; all but one of the previous strictureplasties were patent. Thirteen patients have been symptom free following surgery, four have required further medical therapy for recurrent Crohn's disease and three have sustained episodes of self-limiting intestinal colic. Strictureplasty is a safe and effective procedure in selected patients undergoing surgery for obstructive Crohn's disease.
Psychiatric screening for patients with faecal incontinence or chronic constipation referred for surgical treatment
Authors: Fisher S E , Breckon K , Andrews H A , Keighley M R B
Published: March 2007

Fifty patients attending for surgical treatment of chronic constipation (n = 21) or faecal incontinence (n = 29) were studied using two psychiatric screening tests: the Hospital Anxiety and Depression (HAD) scale and the General Health Questionnaire (GHQ). Each patient was assessed preoperatively and 6–12 months postoperatively. Results were compared with age and sex-matched controls (n = 50). Constipated patients had significantly higher HAD depression scores compared with controls (median and range): 6 (2–12) versus 4 (0–8), P < 0·05. Constipated patients who were improved by operation (n = 13) had significantly lower preoperative HAD anxiety scores compared with those who were not improved (n = 8): 8 (3–14) versus 15 (10–19), P < 0·01; they also had significantly lower HAD depression scores: 4 (2–12) versus 7 (5–11), P < 0·05. Using these parameters incontinent patients did not differ from controls, but patients who had a bad result after operation (n = 15) had significantly higher HAD anxiety scores than those who obtained clinical benefit (n = 14): 10 (2–15) versus 6 (2–12), P < 0·05; HAD depression scores were also greater: 5 (2–15) versus 3 (0–9), P < 0·05; and GHQ scores were greater: 12 (0–47) versus 4 (0–41), P < 0·05.
Splenectomy for massive splenomegaly
Authors: Shaw J H F , Clark M
Published: March 2007

Twenty-four patients who underwent resection of giant spleen (spleen weight > 1·5 kg) have been reviewed to determine the difficulties and benefits of the procedure and, in particular, whether the use of adrenaline injection into the splenic artery could safely reduce technical difficulty. Although morbidity was higher in patients with giant spleens compared with those undergoing resection of smaller spleens the incidence of serious complications was small, and there were no operative or in-hospital deaths. In addition, virtually all patients benefited either on the basis of minimized haematological defect, or palliation of symtoms. Further, the injection of 1 ml of 1:10000 adrenaline into the splenic artery before splenic mobilization reduced the splenic volume by approximately 40 per cent on average, and resulted in improved exposure, thereby facilitating the procedure.
Surgery in patients with von Willebrand's disease
Authors: Blombäck M , Johansson G , Johnsson H , Swedenborg J , Wabö E
Published: March 2007

The risk of bleeding complications in the surgical treatment of patients with von Willebrand's disease has been evaluated. Sixty-four major surgical procedures were performed in 51 patients with various forms of von Willebrand's disease. In 18 cases, the bleeding disorder was unknown at the time of surgery, resulting in bleeding complications in 12 cases (67 per cent). Forty-five operations were carried out in patients in whom the diagnosis of von Willebrand's disease was known at the time of surgery. In these patients, the following haemostatic preparations were given: factor concentrate, fresh plasma, tranexamic acid and desmopressin. Haemostatic complications occurred in three of these operations (6·7 per cent); all were managed easily. No mortality was observed. It is concluded that patients with von Willebrand's disease do not carry an increased operative risk if appropriate precautions are taken.
Plasma eicosanoids, platelet function and cold sensitivity
Authors: Wilkinson D , Vowden P , Gilks L , Latif A B , Rajah S M , Kester R C
Published: March 2007

As abnormal eicosanoid (prostaglandin) metabolism has been suggested as a factor in the aetiology of vasospastic diseases we have measured levels of stable eicosanoid metabolites using a radioimmunoassay in 30 normal subjects and 31 patients with Raynaud's phenomenon. There were 13 patients with primary Raynaud's, ten with Raynaud's secondary to scleroderma and eight men with vibration white finger (VWF) disease. We have also measured platelet aggregation to adenosine diphosphate (ADP), collagen and adrenaline in 19 normal subjects, 22 patients with primary Raynaud's, 12 with Raynaud's secondary to scleroderma and 14 men with VWF. When compared with our normal subjects, patients with VWF have an elevated thromboxane B2 level, with a normal 6-keto-prostaglandin F1α (6-keto-PGF1α) level. Their platelets are less sensitive to ADP and collagen. Patients with primary and secondary Raynaud's have elevated thromboxane B2 levels but this is much more marked in the secondary group. Patients with primary Raynaud's have a normal 6-keto-PGF1α level but in patients with secondary Raynaud's the 6-keto-PGF1α level is markedly raised. The platelets from both groups are more sensitive to ADP and collagen and this is more marked in the secondary group. Whether these phenomena are a cause or an effect of vasospasm remains unknown.
Obstacles to organ donation
Authors: Wakeford R E , Stepney R
Published: March 2007

Attitudes towards transplantation were investigated in national surveys of the general public (n = 1471), the medical profession (n = 590) and key clinical staff in units referring potential organ donors (n = 380). A clear majority of doctors would like to see more transplants. Only 16 per cent of doctors opposed them on cost grounds, and a 50 per cent 5-year survival rate is seen as more than adequate clinical justification. However, doctors are less supportive of liver and heart grafts than of kidney and cornea grafts. Few lay people would refuse donation of specific organs, but 30 per cent worry that doctors might be pressured into removal of organs when they are not sure the patient is dead. Religious or moral objection is rare. Intensive care unit staff felt the most important factor restricting organ harvest in their own units was dislike of adding to relatives' distress, followed by lack of training in approaching relatives and adverse media publicity. Only 11 per cent thought reservations on brain stem death a likely or possible influence. Enhanced public awareness of the need for transplants was seen as the most important means of increasing organ harvest. Required request would be controversial and perhaps impossible to implement. We conclude that the time, effort and expense involved in potential organ donation do not play a substantial part in limiting referral. Neither do reservations about brain stem death. Increased training of staff (both in communication skills and in the professional responsibility to encourage donation) and greater public awareness are seen as the twin foundations of a realistic approach to enhancing referral.
Long-term follow-up after choledochojejunostomy for bile duct stones with complex clearance of the bile duct
Authors: Gouma D J , Konsten J , Soeters P B , von Meyenfeldt M , Obertop H
Published: March 2007

In this retrospective study, the long-term follow-up of patients undergoing choledochojejunostomy (Roux-en-Y) for bile duct stones with complex clearance of the bile duct is evaluated. Bile duct exploration and subsequent choledochojejunostomy (Roux-en-Y) was performed in 43 patients (median age 67 years) in the period 1976–82. There was no mortality and only one patient had a major complication. Twenty patients died during follow-up (median follow-up period 5 years); the median follow-up period for the remaining 23 patients was 8 years. Good long-term results were found in 98 per cent of cases. No signs or symptoms could be related to bile duct obstruction or to cholangitis. Nearly all liver function tests and serum bilirubin levels were normal in the 21 patients who were tested. We conclude that patients with bile duct stones with complex clearance of the bile duct can be safely treated by means of a choledochoenterostomy (in this study a choledochojejunostomy Roux-en-Y).
Endoscopic endoprosthesis insertion following failure of cholecystojejunostomy in pancreatic carcinoma
Authors: Dowsett J F , Cairns S R , Vaira D , Polydorou A A , Hatfield A R W , Russell R C G
Published: March 2007

Sixteen patients in whom malignant biliary obstruction recurred after failure of cholecystojejunostomy had attempted relief of obstruction by endoscopic insertion of an endoprosthesis. This treatment was successful in 13 patients, although one required percutaneous insertion because of duodenal distortion and one required a combined percutaneous-endoscopic approach. Median survival after stenting was 3.5 months (range from 2 weeks to 16 months). Of the three treatment failures, two patients had external drainage only and one succumbed before further treatment could be attempted. There were two complications associated with the procedure (one small bile leak and one episode of cholangitis) but the 30-day mortality rate of 12.5 per cent was related to disease progression rather than the procedure. Endoscopic stent insertion may achieve further worthwhile palliation of jaundice after the failure of surgery to relieve malignant biliary obstruction.
Gallstone lithotripsy with the pulsed dye laser: In vitro studies
Authors: Murray A , Basu R , Fairclough P D , Wood R F M
Published: March 2007

The use of a pulsed dye laser to fragment human gallstones is reported. Laser energy was delivered by a 320 μm quartz fibre at wavelengths of 440,480,504,560,590, and 635 nm, in 1 μs pulses at energies of 5–60 mJ per pulse, producing peak powers of the order of 105 W. Cholesterol, pigment and mixed stones were fragmented. The shorter wavelengths were most efficient, using significantly less energy at 440 and 480 nm than at the longer wavelengths. Pigment stones were fragmented with significantly less energy than those in which cholesterol predominated. Thermal imaging during laser treatment showed no significant rise in temperature in the bulk of the stone. Absorption spectroscopy of bile revealed a peak at 450 nm, coinciding with the known absorption characteristic of bilirubin. Bile strongly attenuated light at shorter wavelengths, even at dilutions as great as 1:20 and protected samples of biliary epithelium from laser damage except when the optical fibre was in direct contact. The pulsed dye laser may offer significant advantages over current methods of biliary stone fragmentation.