bluuebunny/crossref_metadata_2025 huggingface dataset:
Value of oral antibiotic prophylaxis in colorectal surgery
Authors: McArdle C S , Morran C G , Pettit L , Gemmell C G , Sleigh J D , Tillotson G S
Published: March 2007

A total of 169 patients undergoing colorectal surgery were randomly allocated to receive either gentamicin plus metronidazole or oral ciprofloxacin plus metronidazole as prophylaxis; they were also allocated to receive cover for 1 or 3 days. Twenty-eight patients (17 per cent) developed postoperative wound infections. The proportion of patients with wound infections and other infective complications was significantly less (P < 0·02) in those receiving oral ciprofloxacin. Cover for 3 days was no better than that for only 1 day. Oral ciprofloxacin for prophylaxis may offer advantages in efficacy and ease of administration compared with parenteral antibiotics.
Prediction of local recurrence and survival of carcinoma of the rectum by surgical and histopathological assessment of local clearance
Authors: Goldberg P A , Nicholls R J
Published: March 2007

The surgeon and histopathologist were asked to assess whether clearance of the resected primary rectal tumour was complete or not. The results of each assessment were related to survival and recurrence rates. Of 478 patients entered, full information was available for 396 who were followed to death or for at least 5 years. The surgeon and pathologist agreed on the clearance in 341 of the 396 patients. The 5-year local recurrence rate was 15 per cent in the 331 patients with complete local clearance and 62 per cent in those with incomplete clearance. There was disagreement regarding 55 patients (14 per cent) (39 pathologist ‘incomplete’/surgeon ‘complete’ 16 surgeon ‘incomplete’/pathologist ‘complete’). Local recurrence occurred later where the pathologist assessed resection to be incomplete (log rank X2 = 11·0, 1 d.f., P = 0·001). Of 321 patients without metastatic disease, the surgeon and pathologist agreed in 290 that 284 had complete and six incomplete clearance. The 5-year survival rates were 53 and 0 per cent respectively. There was disagreement regarding 31 patients (10 per cent) (11 surgeon ‘incomplete’/pathologist ‘complete’; 20 pathologist ‘incomplete’/surgeon ‘complete’). The 5-year survival rates were 18 and 10 per cent respectively (log rank X2 = 1·5, 1 d.f., P = 0·2). Surgical and histopathological assessments of local clearance are important in determining local recurrence and survival.
Ilioinguinal block dissection for malignant melanoma
Authors: Sterne G D , Murray D S , Grimley R P
Published: March 2007

A retrospective analysis of 41 patients treated for metastatic inguinal lymph node malignant melanoma is presented: 16 underwent inguinal node excision and 25 ilioinguinal node excision. The two groups were well matched for age, sex and other characteristics. The mean time in hospital (inguinal 20 days, ilioinguinal 18 days) and the complication rates (inguinal, ten of 16 patients, ilioinguinal, 13 of 25) were similar in each group. The incidence of groin relapse, defined as the development of symptomatic melanoma in the region of the inguinal or iliac node basins following block dissection, was lower after ilioinguinal block dissection (inguinal, three patients; ilioinguinal, none). Histological examination demonstrated a high proportion of iliac node involvement (13 of 25 patients), even in those with a single mobile inguinal lymph node clinically and no clinical or computed tomographic evidence of iliac node involvement. This supports the value of ilioinguinal block dissection and suggests that the associated morbidity need not be greater than that associated with inguinal clearance alone.
Exposure of the peritoneal cavity to air regulates early inflammatory responses to surgery in a murine model
Authors: Watson R W G , Redmond H P , McCarthy J , Burke P E , Bouchier-Hayes D
Published: March 2007

Factors in circulating air may play a role in immune responses after surgery through induction of gut-derived lipopolysaccharide (LPS) translocation across the gut. CD-1 mice were randomized to one of four treatment groups: controls, laparoscopy with carbon dioxide inflation, laparoscopy with air inflation and laparotomy. The peritoneal and systemic immune response was assessed by evaluating peritoneal macrophage, blood monocyte and neutrophil activity. In a second study, the effect of each of the treatments on fluorescein isothiocyanate (FITC)-LPS translocation across the gut was assessed. There were significant (P < 0·05) increases in peritoneal tissue macrophage release of superoxide and tumour necrosis factor after laparoscopy with air and laparotomy compared with control procedures and carbon dioxide laparoscopy. However, peritoneal macrophage FITC-Candida albicans ingestion was significantly decreased after air laparoscopy and laparotomy compared with controls and carbon dioxide laparoscopy (P < 0·05). These findings correlated with a significant (P < 0·05) decrease in CD11b expression. Significant translocation into the peritoneal cavity and systemic circulation occurred after air laparoscopy and laparotomy only. Factors in circulating air can induce LPS translocation and subsequent stimulation of postoperative immune responses. The beneficial effects of laparoscopic surgery may be explained by the minimal air contamination of the peritoneal cavity.
Importance of hepatovenous back-perfusion for maintenance of liver viability during the Pringle manoeuvre
Authors: Tatsuma T , Kim Y I , Kai T , Ishii T , Akizuki S , Takayama F , Egashira T , Kobayashi M
Published: March 2007

The role of hepatovenous back-perfusion in maintaining hepatic viability was investigated during inflow occlusion (Pringle manoeuvre) of the pig liver. The study compared two ischaemia procedures of 60 min duration: hepatic inflow occlusion and inflow plus outflow occlusion (vascular exclusion). Each procedure was carried out in six pigs and liver tissue perfusion, energy metabolism, lipid peroxidation and 7-day survival were assessed. Although all pigs survived after inflow occlusion, five of six died after vascular exclusion (P < 0·01). Exclusion induced a significant decrease in perfusion to 15·3 per cent of the value before ischaemia compared with 32·4 per cent after hepatic inflow occlusion alone (P < 0·01). Although cellular adenosine 5′-triphosphate levels were significantly decreased by ischaemia in both groups, the fall was less in pigs with inflow occlusion alone (to 55 per cent of the preclamp value) than in those with exclusion (to 24 per cent of the preclamp value) (P < 0·01). The plasma phosphatidylcholine hydroperoxide level rose immediately after reperfusion in pigs with exclusion, while the level remained constant after inflow occlusion alone. There is a fundamental difference between the two ischaemia procedures: back-perfusion from the vena cava contributes to the maintenance of liver function during inflow occlusion.
Hereditary breast cancer and linkage analysis to BRCA1
Authors: McKinley A G , Russell S E H , Spence R A J , Odling-Smee W , Nevin N C
Published: March 2007

In this study, over 1000 women with breast cancer were contacted by questionnaire and 164 families with a strong history of breast cancer were identified. Home visits to obtain full pedigree details took place for 123 women, and members of 24 families gave venous blood samples. The extracted DNA was typed by polymerase chain reaction amplification and the derived haplotypes submitted to linkage analysis which confirmed that in 12 families breast cancer susceptibility could be traced to BRCA1. The study demonstrates the number of women at risk of breast cancer in the population, illustrates the complexity of genetic analysis for hereditary breast cancer and demonstrates the problems of predictive analysis in clinical management.
Multivariate analysis of histopathological features as prognostic factors in patients with papillary thyroid carcinoma
Authors: Moreno-Egea A , Rodriguez-Gonzalez J M , Sola-Perez J , Soria-Cogollos T , Parrilla-Paricio P
Published: March 2007

A retrospective analysis of 121 papillary thyroid carcinomas was made to assess prognostic factors including histological variants which might be related to survival. The mean follow-up period was 10 years and clinical, surgical and histopathological data were studied. The survival curves were analysed by the Kaplan-Meier method and the multivariate analysis used Cox's regression model. Eighty-seven patients had well differentiated papillary cancers. The survival rate for papillary thyroid cancer was 86 per cent at 5 years and 72 per cent at 10 years. Factors showing prognostic significance for survival were tumour size, extrathyroid extension and histological type. Disease-free survival was influenced by sex, existence of a capsule and nodal metastases. Factors showing a favourable prognosis were: age under 45 years, size less than 4 cm, no extrathyroid extension and well differentiated histological type (P < 0·001). Histological subtype was one of the most important prognostic factors.
Follicular carcinoma of the thyroid gland in Hong Kong Chinese
Authors: Lo C Y , Lorentz T G , Wan K Y
Published: March 2007

A total of 64 Chinese patients (eight men, 56 women) undergoing primary treatment for follicular thyroid cancer between 1961 and 1986 were studied retrospectively to report the local experience in treatment of this condition and to identify the risk factors for mortality. The minimum follow-up was 7 (median 14) years. The mean tumour size was 3·0 (range 0·1–11·0) cm. The majority of patients (91 per cent) underwent total or near-total thyroidectomy. Distant metastases were detected in ten patients at the time of initial diagnosis and in three during follow-up. Locoregional recurrence had developed in six patients at follow-up. There were 13 deaths, with a median survival of 45 months. The 5- and 10-year survival rates were 87 and 80 per cent respectively. Six risk factors for mortality were selected for multivariate analysis using logistic regression; the presence of distant metastasis was the only significant risk factor for survival.
Healing process of sutureless choledochojejunostomy in an experimental model
Authors: Ishizaki Y , Bandai Y , Shimomura K , Idezuki Y , Makuuchi M
Published: March 2007

The healing characteristics and morphological features of sutureless choledochojejunostomy were investigated in a rat experimental model. The common bile duct of 34 conditioned Wistar rats was exposed, divided transversely and a choledochojejunostomy constructed with only a vinyl chloride tube positioned between the common duct and jejunum. The animals were killed 4, 12 and 52 weeks after surgery. Cholangiographic evaluation of the anastomosis in all three groups showed wide openings with dilatation of the extrahepatic bile duct. Microscopic examination of the anastomosis showed hyperplastic changes of the bile duct epithelium. The epithelial defect was completely covered with proliferative epithelium 12 weeks after operation. At long-term follow-up of 52 weeks there were no biliary strictures after the sutureless technique. This surgical approach may be useful for patients in whom sutured anastomosis of the bile duct might lead to stricture, such as those with a normal thin-walled bile duct.
Selective preoperative endoscopic retrograde cholangiopancreatography in laparoscopic biliary surgery
Authors: Rijna H , Borgstein P J , Meuwissen S G M , de Brauw L M , Wildenborg N P , Cuesta M A
Published: March 2007

The management of common bile duct (CBD) stones in patients subjected to laparoscopic cholecystectomy is still a subject of debate. A prospective study was performed of all 699 patients with symptomatic gallstones at risk of CBD stones between mid-1987 and 1994. Based on clinical, biochemical and ultrasonographic criteria, 119 patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) with or without endoscopic sphincterotomy. Results showed a high positive predictive value (over 85 per cent) for the presence of CBD stones in patients with acute cholangitis, persistent obstructive jaundice or in the acute phase of gallstone pancreatitis. In the other groups (increased liver enzyme levels, a wide CBD and after resolution of jaundice or pancreatitis) the positive predictive value was less than 25 per cent. The complication rate of ERCP with sphincterotomy was 14 per cent with a mortality rate of 2 per cent. These results argue for more selective use of preoperative ERCP only for patients with acute cholangitis, persistent jaundice or acute gallstone pancreatitis. Other patients at risk of harbouring CBD stones should undergo intraoperative laparoscopic cholangiography and, if stones are found, laparoscopic exploration of the bile duct or postoperative ERCP.
Digest
Authors: Castaing D
Published: March 2007

For this quarter's digest, Dr Denis Castaing of Annales de Chirurgie, chooses the best from issues three, four and five of 1995. A reciprocal digest written by our European Editor, Mr Colin Johnson, appears in the French journal.
Manipulation of the l-arginine-nitric oxide pathway in experimental colitis
Authors: Neilly P J D , Kirk S J , Gardiner K R , Anderson N H , Rowlands B J
Published: March 2007

The role of the l-arginine-nitric oxide pathway in the pathogenesis of colonic inflammation was assessed using l-arginine and its competitive analogue Nω-nitro-l-arginine methyl ester (l-NAME) in a rat model of colitis. In the first study oral l-arginine 2 per cent (control: 3.4 per cent l-glycine) was administered with and without l-NAME 100 mg/l. Orally administered l-arginine increased colonic inflammation (P = 0.004) and decreased thymic weight (P = 0.0007). Addition of l-NAME reduced the colonic inflammation and prevented loss of body-weight (P < 0.04). In the second study l-NAME was administered orally in concentrations of 100, 200 and 500 mg/l (control: no l-NAME). l-NAME 500 mg/l reduced colonic inflammation and increased thymic weight and body-weight (P < 0.01). Thymic weight and body-weight correlated positively with the concentration of l-NAME administered orally (rs≥0.3, P = 0.04). l-NAME l g/l was administered topically as an enema (control: suspension agent). Topical l-NAME reduced colonic inflammation and increased thymic weight (P < 0.05). These results suggest that the l-arginine-nitric oxide pathway mediates colonic inflammation in this model.
In vitro regulation of human breast cancer cell adhesion and invasion via integrin receptors to the extracellular matrix
Authors: Gui G P H , Puddefoot J R , Vinson G P , Wells C A , Carpenter R
Published: March 2007

The extracellular matrix consists of the interstitium and the basement membrane. Cellular interaction with fibronectin, laminin and collagen provides a possible mechanism by which cancer cells adhere, invade and metastasize. The integrins are a major family of adhesion molecules that recognize epitopes on the extracellular matrix as ligands. These include the α2β1, α3β1, αvβ1 and αvβ5 integrins, most of which were found to be expressed on MCF-7, T47D, MDA-MB-231, ZR75-1 and Hs578T breast cancer cell lines. Each cell line adhered to the matrix proteins in a dose-dependent manner and was inhibited by monoclonal antibodies against relevant integrins. Only Hs578T was significantly invasive through fibronectin but both Hs578T and MDA-MB-231 invaded through laminin and type IV collagen in an in vitro assay. The invasive potential of these cell lines could be inhibited by integrin antibodies added to cells before incubation, but the addition of antibodies after cells were allowed to adhere to the matrix failed to inhibit invasion. Inhibition of cellular adhesion to the matrix reduced the invasive potential of breast cancer cell lines. As integrin antibodies inhibit cell invasion in vitro, the integrins may be of potential value as antitumour therapeutic agents.
Gastric juice epidermal growth factor concentration and Helicobacter pylori in patients with duodenal ulcer
Authors: Tunio A M , Holton J , Hobsley M
Published: March 2007

The level of epidermal growth factor (EGF) was measured in the basal and maximally stimulated gastric juice of 20 control subjects and 20 patients each with duodenal ulcer and non-ulcer dyspepsia. Basal gastric juice was analysed for ammonia and urea concentrations, and the [ammonia]3/[urea] ratio was used to show Helicobacter pylori status, as was the [13C]urea breath test in nine controls. There was complete concordance in the nine controls between the two methods for determining H. pylori status. Twenty-five subjects were H. pylori positive (seven with duodenal ulcer, nine with non-ulcer dyspepsia, nine controls) and 35 H. pylori negative (13, 11 and 11 respectively). In H. pylori-positive subjects, the median EGF concentrations in the stimulated secretion of patients with duodenal ulcer and without (non-ulcer dyspepsia and controls combined) were 46.7 and 18.0 ng/ml (P < 0.001), and in H. pylori-negative subjects were 40.0 and 26.5 ng/ml respectively (P < 0.01). There was no difference in EGF concentration between controls and subjects with non-ulcer dyspepsia irrespective of H. pylori status. Lack of EGF is unlikely to be a cause of duodenal ulcer. The increased EGF concentration in patients with ulcer bore no relationship to the H. pylori status of the individual. If this bacterium causes duodenal ulcer, it is not via a reduction in EGF concentration.
Percutaneous transluminal angioplasty for lower-limb critical ischaemia
Authors: London N J M , Varty K , Sayers R D , Thompson M M , Bell P R F , Bolia A
Published: March 2007

Percutaneous transluminal angioplasty (PTA) alone was used to treat 54 (23 per cent) of 232 lower limbs with critical ischaemia. Technical success was achieved in 49 cases (91 per cent) with an immediate symptomatic improvement in 47 (87 per cent). There was no death or limb loss attributable to PTA and three embolic complications were successfully treated by percutaneous aspiration. Symptomatic improvement and haemodynamic patency rates at 24 months were 77 and 78 per cent respectively; 27 of 34 limbs with ulceration or gangrene had healed with minor surgery by a median of 7.5 (range 3.0–18.0) months. Patient survival and limb salvage rates at the same time interval were 76 and 89 per cent respectively. These results demonstrate that, for a selected group of patients with lower-limb-critical ischaemia, PTA can be a highly successful therapeutic option with a low associated morbidity.
Preoperative chemotherapy for stage III–IV gastric carcinoma: Feasibility, response and outcome after complete resection
Authors: Fink U , Schuhmacher C , Stein H J , Busch R , Feussner H , Dittler H J , Helmberger A , Böttcher K , Siewert J R
Published: March 2007

Despite extensive resection and systematic lymphadenectomy the prognosis of patients with locally advanced gastric carcinoma remains poor. The effect of preoperative outpatient chemotherapy with etoposide, doxorubicin and cisplatin was evaluated prospectively in 30 patients who had been shown by preoperative staging (including endosonography and surgical laparoscopy) to have gastric carcinoma stages IIIA, IIIB or IV. Haematological side-effects were common and necessitated hospitalization in 13 of 30 patients. Complete clinical response to neoadjuvant therapy was observed in eight of 27 evaluable patients. Resection was performed in 27 of 30 patients, with complete macroscopic and microscopic tumour removal in 24. There were no deaths and no major morbidity following operation. On multivariate analysis complete clinical response (P<0.01) and complete tumour resection (P<0.01) were the major independent predictors of long-term survival after neoadjuvant chemotherapy. Actuarial survival after complete tumour removal was superior with neoadjuvant therapy compared with results in an age-, sex- and tumour stage-matched control population who had primary resection (P=0.07). Recurrence occurred in 17 of 23 evaluable patients who had complete tumour removal, with relapse in the tumour bed or area of lymphatic drainage in 11. These data show that neoadjuvant therapy in patients with locally advanced gastric carcinoma is feasible and appears to increase the rate of complete tumour removal. More powerful and less toxic regimens are, however, required to improve the response rate and to delay or avoid recurrence after neoadjuvant chemotherapy.
Macroscopically node-negative but histologically node-positive gastric carcinoma
Authors: Adachi Y , Mori M , Maehara Y , Sugimachi K
Published: March 2007

The features of macroscopically node-negative but histologically node-positive (N(−) n(+)) tumours were examined in 521 patients undergoing curative surgery for gastric carcinoma. Of 240 histologically node-positive tumours, 62 (26 per cent) were N(−) n(+). The 10-year survival rate of patients with N(−) n(+) tumour at 66 per cent was worse than that of those with histologically node-negative tumour (91 per cent) (P<0.01) but better than that of patients with macroscopically and histologically node-positive tumour (40 per cent) (P<0.01). N(−) n(+) tumour was characterized by size less than 5 cm (47 per cent), invasion not beyond the muscularis propria (53 per cent), lymph node metastasis limited to group 1 nodes (76 per cent), number of positive nodes fewer than seven (90 per cent) and disease of stage II (52 per cent). The survival of patients with N(−) n(+) tumour was determined by the number of positive nodes and stage of disease. N(−) n(+) tumours are associated with a better outcome, owing to less progressive disease, and the number of positive nodes is a prognostic indicator.
Intraoperative radiotherapy for pancreatic carcinoma
Authors: Kasperk R , Klever P , Andreopoulos D , Schumpelick V
Published: March 2007

Intraoperative radiotherapy (IORT) with an electron beam is a therapeutic modality employed predominantly in tumours with a high risk of local recurrence. In this department 35 patients with proven adenocarcinoma of the pancreas underwent surgery and IORT, while 41 patients underwent surgery only. Irradiated patients suffered more serious postoperative complications (21 per cent versus 7 per cent), spent more time in hospital (32 days versus 26 days) and did not show a survival advantage (median of 326 days versus 366 days for two patients with curative resection). Anastomotic breakdown (twp patients), abscess formation (two patients) and pancreatitis in the pancreatic remnant (one patient) occurred only in this group. It is concluded that IORT may increase the risk of postoperative complications. As, on the basis of experimental data, an additional serious long-term risk is to be expected, application of IORT should be limited to well controlled study conditions.
Intraoperative risk factors associated with hepatic resection
Authors: Tanabe G , Sakamoto M , Akazawa K , Kurita K , Hamanoue M , Ueno S , Kobayashi Y , Mitue S , Ogura Y , Yoshidome N , Baba M , Aikou T
Published: March 2007

Risk factors associated with complications following hepatic resection were investigated retrospectively in 121 patients between January 1987 and April 1992. Fifty-seven patients recovered uneventfully, but 64 suffered postoperative complications and 15 died within 3 months. All those who died had suffered from hyperbilirubinaemia or bleeding and/or coagulopathy, which were considered critical complications after hepatic resection. Risk factors following hepatic resection were investigated statistically. Stepwise logistic regression analysis showed that serum levels of cholinesterase, the histology of the remaining liver and the volume of intraoperative blood loss were significantly associated with major complications (odds ratio 0.02, 5.14 and 4.97 respectively). Coexisting liver cirrhosis, deterioration of liver protein synthesis and massive intraoperative blood loss are important risk factors following hepatic resection.
Prospective evaluation in 121 consecutive unselected patients undergoing laparoscopic treatment of choledocholithiasis
Authors: Millat B , Fingerhut A , Deleuze A , Briandet H , Marrel E , De Seguin C , Soulier P
Published: March 2007

Laparoscopic common bile duct (CBD) exploration was attempted in 115 of 121 consecutive unselected patients with choledocholithiasis (mean age 69 (range 21–92) years) found during routine intraoperative cholangiography. The CBD was successfully cleared of all stones in 100 patients (87 per cent). Ten of 11 patients referred for surgery after failure of endoscopic sphincterotomy had complete laparoscopic choledocholithiasis. Eleven patients (10 per cent) required conversion to open CBD exploration, and laparoscopic exploration was not attempted in six (5 per cent) because of inflammation or fibrosis. Postoperative endoscopic sphincterotomy was required in four patients (4 per cent) for retained stones after laparoscopic exploration. There were no postoperative deaths (39 per cent of patients were aged 75 years or more). Routine intraoperative cholangiography, and when required laparoscopic CBD exploration, should be compared in randomized trials with preoperative endoscopic retrograde cholangiography in patients with suspected choledocholithiasis.
Non-surgical trauma to the extrahepatic biliary tract
Authors: Parks R W , Diamond T
Published: March 2007

Non-surgical trauma to the extrahepatic biliary tract is uncommon and encountered only rarely by surgeons outside specialist hepatobiliary centres. Such injury often results in significant morbidity and mortality. This review outlines the incidence, classification, mechanisms of injury, presentation, diagnostic techniques and management options. Depending on the type of biliary injury identified, an optimal method of repair is suggested. Recommendations are made for surgeons who encounter this type of injury and do not have the appropriate expertise for definitive management.
Der Chirurg
Authors: Herfarth Ch , Lehnert Th
Published: March 2007

For this quarter's digest Professor Christian Herfarth and Dr Thomas Lehnert have selected the best from the April to June 1995 issues of Der Chirurg. A digest of the BJS for the same period, written by Mr Colin Johnson, appears in the German journal.
Use of lightguide spectrophotometry to quantify skin oxygenation in a variable model of venous hypertension
Authors: Hanna G B , Newton D J , Harrison D K , Belch J J F , McCollum P T
Published: March 2007

A variable model of venous hypertension was used to examine the immediate effect on skin oxygenation and blood flow. Measurements were carried out using laser Doppler flowmetry, transcutaneous oximetry and both macro- and micro-lightguide spectrophotometry to measure haemoglobin saturation (So2). Assessments were performed on 20 normal subjects and in ten patients with deep venous insufficiency lying supine with a pressure cuff left uninflated (P0), then inflated to 40 mmHg (P40), 60 mmHg (P60) and 80 mmHg (P80). All measurements were performed at the gaiter area of the leg. In normal subjects median Doppler values fell significantly at P40 (P<0±001) but further pressure increases had no more effect. Mean values of transcutaneous partial pressure of oxygen (Pteo2) fell steadily (P<0±001), although the initial fall at P40 was small. Median So2 fell with increasing occlusion pressure with both macro- and micro-lightguide spectrophotometry (P<0±001), although the main reduction occurred predominantly at lower occlusion pressures. Higher levels of So2 were obtained with local heating up to 44°C, with a pattern similar to that of Ptco2. In patients, the same pattern of response to increased venous pressure occurred in areas of clinically normal skin. These data suggest that small increases in venous hypertension have an immediate and profound influence on skin blood flow and oxygen availability in normal skin.
Critical limb ischaemia in patients over 80 years of age: Options in a district general hospital
Authors: Humphreys W V , Evans F , Watkin G , Williams T
Published: March 2007

A total of 114 reconstructions were performed in 82 octogenarian patients and the results compared with those of 33 patients who had primary amputation. The operative mortality rate was higher after amputation (45 versus 11 per cent) and the mean survival less (25 versus 34 months). Quality of life assessment using a Rosser scale suggested that, although there was no improvement in the 38 per cent with a failed reconstruction, there was a significant improvement in the 62 per cent whose reconstruction remained patent. There was minimal improvement in quality of life after primary amputation and this was due to relief of pain. Costs (including the costs of revisions and community costs) were assessed in detail. Although the mean total operative costs of reconstruction were higher than those of amputation (£10222 versus £6475) this was more than offset by teh high community costs of amputation. The total cost of reconstruction was £13546, compared with £33095 for amputation. Following reconstruction 66 per cent of those patients independent before critical limb ischaemia occurred were able to return to their own home; only 33 per cent of amputees were able to do so.
Symptomatic outcome 1 year after laparoscopic and minilaparotomy cholecystectomy: A randomized trial
Authors: McMahon A J , Ross S , Baxter J N , Russell I T , Anderson J R , Morran C G , Sunderland G T , Galloway D J , O'Dwyer P J
Published: March 2007

In a randomized controlled trial, 299 patients were sent a symptoms questionnaire 1 year after laparoscopic (n = 151) or minilaparotomy (n = 148) cholecystectomy for symptomatic cholelithiasis. The response rate to the questionnaire from contactable patients was 86 per cent. In both groups, at least 90 per cent of patients reported that their symptoms were improved, and at least 93 per cent rated the success of their operation as ‘excellent’, ‘good’, or ‘fair’. However, over half the patients reported abdominal pain, a quarter reported flatulence, and a quarter dyspepsia. The only difference between treatment groups was that a higher proportion of patients who underwent minilaparotomy reported heartburn (35 per cent versus 19 per cent, P = 0±005). Patients who reported a ‘poor’ outcome were more likely to have suffered a postoperative complication, had lower quality of life scores, and higher anxiety and depression scores. Both laparoscopic and minilaparotomy cholecystectomy result in symptomatic benefit in at least 90 per cent of patients with symptomatic cholelithiasis.
Clinical and physiological evaluation of anorectal eversion during restorative proctocolectomy
Authors: Williamson M E R , Lewis W G , Miller A S , Sagar P M , Holdsworth P J , Johnston D
Published: March 2007

Fifty patients had a restorative proctocolectomy with stapled end-to-end ileoanal anastomosis by the eversion technique. Median (interquartile range) maximum resting anal pressure was 90 (73–116) cmH2O before restorative proctocolectomy and 71 (51–88) cmH2O 1 year after surgery (P<0±001). Median maximum squeeze pressure was 141 (110–185) cmH2O before surgery and 146 (118–186) cmH2O 1 year after surgery (P not significant). Median thresholds for sensation in the lower third of the anal canal before and 1 year after surgery were 5±3 and 7±1 mA, respectively (P=0±006). One year after restorative proctocolectomy, all patients were continent, although two experienced leakage of mucus requiring a pad. Forty-two patients (84 per cent) could discriminate between faeces and flatus. Eversion of the anorectum during restorative proctocolectomy impairs the motor and sensory functions of the anal sphincter. Most patients achieved satisfactory anal continence, however, despite these physiological changes.
Role of total pancreatectomy in the treatment of patients with end-stage chronic pancreatitis
Authors: Fleming W R , Williamson R C N
Published: March 2007

Forty patients underwent total pancreatoduodenectomy for end-stage chronic pancreatitis. There were 34 men and six women of median age 39 (range 21–66) years. Alcoholism was the major aetiological agent (30 patients), and five patients had had previous acute idiopathic pancreatitis. The overwhelming indication for operation was severe abdominal pain, complicated by failing exocrine and endocrine function. Resection was performed in one (17 patients) or two (23) stages, following previous proximal (seven) or distal (16) pancreatectomy; progression from partial to total pancreatectomy occurred over an interval of 8–96 (median 15) months. A further six patients had undergone previous pseudocyst or duct drainage procedures. The pylorus was preserved in 28 patients and the spleen in ten. Median operating time was 6 (range 2±5–8±5) h and median blood loss 2000 (range 500–16000) ml. There were two hospital deaths and three patients required reoperation. Of 38 survivors, 30 obtained complete or substantial relief of pain. There were 15 late deaths at 2±5–120±0 months after operation, 13 in the alcohol group and 11 disease-related. Total pancreatectomy can relieve the intractable pain of chronic pancreatitis at the cost of possible premature death from continuing alcohol abuse.
Randomized, double-blind phase II trial of Lexipafant, a platelet-activating factor antagonist, in human acute pancreatitis
Authors: Kingsnorth A N , Galloway S W , Formela L J
Published: March 2007

The aims of the study were to determine whether the platelet-activating factor antagonist Lexipafant could alter the clinical course and suppress the inflammatory response of human acute pancreatitis. In a double-blind, placebo-controlled study 83 patients were randomized to receive Lexipafant 60 mg intravenously for 3 days, or placebo. Clinical progression was assessed by daily Acute Physiology And Chronic Health Evaluation (APACHE) II score and organ failure score (OFS). The magnitude of the inflammatory response on days 1–5 was assessed by serial measurement of interleukin (IL) 8, IL-6, E-selectin, polymorphonuclear elastase-alpha1-antitrypsin (PMNE-α1-AT), and C-reactive protein (CRP). At entry, patients receiving Lexipafant (n = 42) or placebo (n = 41) were matched for age and sex, aetiology, APACHE II score and OFS. The disease was classified as severe in 29 patients (APACHE II score eight or more). There was a significant reduction in the incidence of organ failure (P = 0±041) and in total OFS (P=0±048) at the end of medication (72 h). During this time seven of 12 patients with severe acute pancreatitis who had Lexipafant recovered from an organ failure; only two of 11 with severe acute pancreatitis who had placebo recovered from an organ failure and two others developed new organ failure. Lexipafant treatment significantly reduced serum IL-8 (P = 0±038), and IL-6 declined on day 1. Plasma PMNE-α1-AT complexes peaked on day 1; the gradual fall to baseline over 5 days observed in controls did not occur in patients given Lexipafant. No effect was observed on serum CRP. This study provides a rationale for further clinical trials with the potent PAF antagonist Lexipafant in human acute pancreatitis.
Physiological changes after Delorme's procedure for full-thickness rectal prolapse
Authors: Plusa S M , Charig J A , Balaji V , Watts A , Thompson M R
Published: March 2007

Anal sphincter pressures, rectal compliance and sensation in 19 women of mean age 77 (range 57–94) years were studied before and after Delorme's procedure for full-thickness rectal prolapse. No patient had significant problems with defaecation after operation. There were no significant changes in anal sphincter pressures but the volume of first rectal sensation decreased from a median of 140 ml before surgery to 65 ml after the procedure (P = 0·01) and the maximum tolerated rectal volume declined from a median of 249 ml to 120 ml (P = 0·001). Rectal compliance was reduced from a median of 142.9 ml/kPa to 12.2 ml/kPa (P = 0·002). Improved rectal sensation and lowered compliance are associated with a reduced incidence of defaecatory problems after Delorme's procedure.
The Edinburgh randomized trial of axillary sampling or clearance after mastectomy
Authors: Forrest A P M , Everington D , McDonald C C , Steele R J C , Chetty U , Stewart H J
Published: March 2007

Between January 1980 and October 1983, 417 patients were randomized for mastectomy followed by axillary node sampling or full axillary clearance. The aim of the study was to determine whether a standard ‘four-node’ axillary sample, followed by careful dissection of removed tissue, could accurately indicate the extent of local treatment required. Axillary radiotherapy was given only to patients with histological involvement of sampled nodes and not to any having axillary clearance. The incidence of involved nodes was similar for both groups, as were distant relapse and survival rates. Currently 62.6 per cent are alive after clearance and 65.0 per cent after sampling. A non-significant increase in the rate of locoregional relapse was observed for those treated by axillary node clearance, this being due mainly to increased relapse on the unirradiated chest wall (clearance 21 per cent versus sampling 12 per cent in patients with node-positive disease). There was only a minor difference in axillary relapse, favouring axillary clearance (3.0 versus 5.4 per cent). In patients with operable breast cancer, mastectomy with axillary node sampling gives equal control to mastectomy with axillary node clearance but, as morbidity is greater, surgical clearance of the axilla is the preferred option.
Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ
Authors: Hammarström L-E , Holmin T , Stridbeck H , Ihse I
Published: March 2007

Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 per cent (11 of 39) and 5 per cent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 per cent (12 of 39) and 10 per cent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2–42 (median 13) days and 6–36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.
Clinical biology of nitric oxide
Authors: Davies M G , Fulton G J , Hagen P-O
Published: March 2007

Nitric oxide is a pluripotential molecule that acts as both an autocrine and paracrine mediator of homoeostasis, and derangement of its metabolism can be linked with many pathophysiological events. This review provides a broad overview of the basic and clinical scientific aspects of nitric oxide.
Digest
Authors: Frileux P
Published: March 2007

For this quarter's digest, Dr Pascal Frileux, Editor of Annales de Chirurgie, chooses the best from issues six and seven of 1995. A reciprocal digest written by our European Editor, Mr Colin Johnson, appears in the French journal.
Single-stage treatment for malignant left-sided colonic obstruction: A prospective randomized clinical trial comparing subtotal colectomy with segmental resection following intraoperative irrigation
Authors:   The SCOTIA Study Group, Ross S , Krukowski Z H , Munro A , Russell I T
Published: March 2007

This multicentre study is the first prospective randomized trial to compare subtotal colectomy with segmental resection and primary anastomosis following intraoperative irrigation for the management of malignant left-sided colonic obstruction. Of the 91 eligible patients recruited by 12 centres, 47 were randomized to subtotal colectomy and 44 to on-table irrigation and segmental colectomy. Hospital mortality and complication rates did not differ significantly, but 4 months after operation increased bowel frequency (three or more bowel movements per day) was significantly more common in the subtotal colectomy group (14 of 35 versus four of 35, χ2 = 6·06, 1 d.f., P = 0·01). More patients in the subtotal colectomy group reported that they had consulted their general practitioner with bowel problems than did those in the segmental resection group (15 of 37 versus three of 35, χ2 = 8·17, 1 d.f., P = 0·004). Segmental resection following intraoperative irrigation is the preferred option except when there is caecal perforation or if synchronous neoplasms are present in the colon, when subtotal colectomy is more appropriate.
Experience with ileostomy and colostomy in Crohn's disease
Authors: Post S , Herfarth Ch , Schumacher H , Golling M , Schürmann G , Timmermanns G
Published: March 2007

This study involved 746 patients with Crohn's disease treated surgically within a 13-year interval in whom 227 stomas (159 primary, 68 secondary) were created. The main indication (64 per cent) for primary stoma was severe perianal or genital fistulous disease. Revisional surgery for stomal complications was more common following colostomy than ileostomy (31 versus 5 per cent, P < 0.01). Twenty years after the first symptoms of Crohn's disease the cumulative risks of receiving any stoma or a permanent stoma were 41 and 14 per cent respectively. Four parameters were shown by proportional hazards analysis to be independently associated with the risk for any stoma as well as a permanent one; increased risk coincided with rectal inflammation, perianal fistula or abscess, and absence of small intestinal involvement. In addition, long-standing symptomatic disease before the first surgical intervention reduced the risk of a permanent stoma. The long-term chances of closure following temporary stoma were 75 per cent when used for ana-stomotic protection or avoidance, 79 per cent after postoperative complications, and 40 per cent for perianal or genital fistulas or for rectal inflammation or stenosis. Rectal disease and perianal fistula were the only independent predictors of a low possibility of stoma closure during follow-up.
Non-inflammatory rectovaginal fistula
Authors: Watson S J , Phillips R K S
Published: March 2007

The results of surgical repair of straightforward rectovaginal fistula in 26 women (obstetric, 13; infection, nine; trauma, one; unknown but not radiation-induced or related to inflammatory bowel disease, three) were ultimately excellent; 23 patients were cured. However, this result obscures a high early failure rate in five of 12 patients having a transanal advancement flap and in one of eight having perineoproctotomy (lay open and repair). A temporary stoma was used in 11 patients (five of eight with a perineoproctotomy, three of 12 with an advancement flap and in three having another local procedure).
Intracaval ultrasonography in the diagnosis of tumour involvement of the vena cava
Authors: Kaneko T , Nakao A , Funahashi H , Itoh S , Endo T , Harada A , Nonami T , Takagi H
Published: March 2007

A retrospective study of 34 consecutive patients with possible tumour involvement of the vena cava was performed to assess the usefulness of intracaval ultrasonography. Twenty-five of the 34 patients were operated and resection carried out in 23, including seven with combined resection of the vena cava. The sonographic criterion for vena cava invasion was obliteration of the echogenic ring of the vena cava wall or intracaval tumour mass. The sensitivity, specificity and overall accuracy of intracaval endovascular ultrasonography in the diagnosis of tumour involvement of the vena cava were 100, 96 and 97 per cent respectively. The respective values were 91, 61 and 71 per cent for computed tomography and 82, 67 and 72 per cent for cavography. Ultrasonography is a useful technique that can precisely evaluate the vena cava for possible tumour invasion, especially when the presence or extent of tumour involvement is not definitely established by conventional imaging techniques.
Preoperative total parenteral nutrition is not associated with mucosal atrophy or bacterial translocation in humans
Authors: Sedman P C , MacFie J , Palmer M D , Mitchell C J , Sagar P M
Published: March 2007

Concerns have recently been expressed at suggestions that postoperative sepsis may be more common in patients who have received preoperative total parenteral nutrition (TPN). The mechanism suggested for this is that TPN causes intestinal mucosal atrophy leading to increased bacterial translocation from the gut as a source of systemic sepsis. This hypothesis was examined in 203 patients who had an elective laparotomy, 28 of whom required at least 10 days of preoperative TPN. Neither mucosal atrophy nor bacterial translocation was more common in parenterally fed patients than in enterally fed controls. In humans theoretical concerns about the adverse effects of TPN on intestinal integrity are unfounded.
Self-expanding metal stents for the palliation of dysphagia due to inoperable oesophageal carcinoma
Authors: Ellul J P M , Watkinson A , Khan R J K , Adam A , Mason R C
Published: March 2007

Adequate palliation of dysphagia due to inoperable oesophageal carcinoma is difficult to achieve with low morbidity. Thirty-three patients (21 men and 12 women of mean(s.e.m,) age 69(2) years) with inoperable carcinoma of the oesophagus underwent insertion of self-expanding metal stents. In 22 patients the tumours were in the lower third of the oesophagus, in eight in the middle third and in three in the upper third. A stent was inserted as primary palliative therapy in 14 patients, after failed laser therapy in 13 and after oesophageal perforation following other treatments in six. Patients presented with dysphagia of grade 3 or 4. Three types of stent were used: Wallstent, Strecker and Gianturco; stents were inserted under fluoroscopic guidance after balloon dilatation of the stricture. All attempted insertions of metal stents were successful. Dysphagia reduced from grade 3 or 4 to 0 or 1. There were no perforations related to insertion. Patients who had stents inserted to seal previous perforations left hospital a median 7 days later. Dysphagia recurred in six patients, due to migration of the stent (three), blockage by food bolus (one) and tumour overgrowth (two). These problems were easily treated. Self-expanding metal stents seem to offer excellent palliation with minimal morbidity for patients with inoperable carcinoma of the oesophagus.