bluuebunny/crossref_metadata_2025 huggingface dataset:
Diurnal insulin and glucose profiles following transplantation of fresh and cryopreserved canine pancreatic islets
Authors: Walsh T N , Fitzpatrick J M , Alderson D , Alberti K G M M , Farndon J R
Published: March 2007

Dispersed islet autotransplants (fresh and cryopreserved) can produce normal fasting insulin and glucose concentrations. Following an intravenous glucose challenge, however, the insulin response is impaired and glucose clearance delayed. This study examines the diurnal insulin and glucose response to feeding in recipients of fresh islet autografts (n = 6), recipients of cryopreserved islet autografts (n = 3), normal unoperated controls (n = 10) and insulin treated pancreatectomized diabetic dogs (n=7). Mean fasting insulin and glucose levels were similar in all groups. After feeding, insulin profiles in both transplant groups were near normal while significant hyperinsulinaemia occurred in insulin treated diabetic dogs. Mild postprandial carbohydrate intolerance was observed in transplant recipients but glycosylated haemoglobin levels were similar (mean(s.d.)) to normals (6·88(0·86) per cent, 6·86(0·5) per cent respectively). Dispersed islet autotransplantation with portal insulin delivery produces near normal insulin and glucose profiles suggesting that this may represent a suitable treatment for insulin dependent diabetes.
Technical training in surgery: The trainee's view
Authors: Steele R J C , Logie J R C , Munro A
Published: March 2007

A questionnaire designed to investigate the technical training of general surgical trainees was distributed throughout Scotland. A total of 222 questionnaires were sent out and 179 (81 percent) were returned. Of the responders, 38 per cent felt that the overall operative workload was too small and the majority thought that there was too little emphasis on supervised operating. Two-thirds of trainees were generally satisfied with the amount of unsupervised operating, although a substantial proportion (21 per cent) sometimes felt out of their depth when performing delegated emergency operations. Few had attended craft workshops or travelled to other centres, but of those who had, most considered both activities to be very useful. Photographic atlases and videos were not generally felt to be of great value by those who had used them. The majority of trainees did not believe that research activity had interfered excessively with their technical training.
Gastrocolic fistula as a complication of benign gastric ulcer: Report of four cases and update of the literature
Authors: Soybel D I , Kestenberg A , Brunt E M , Becker J M
Published: March 2007

Four cases of gastrocolic fistula complicating benign gastric ulcer are described, bringing the total number of individually reviewed cases in the English language literature to 108. A review of 30 cases reported in the past 10 years reveals a surprisingly high percentage of young, female patients. Three-quarters of these patients used steroidal or nonsteroidal anti-inflammatory agents. The presence of such fistulae is suspected in patients complaining of weight loss, diarrhoea and faecal vomiting. Small fistulae may not be suspected when overshadowed by other complications of ulcer disease such as bleeding or perforated viscus. Medical management of benign gastrocolic fistulae may be indicated in some circumstances. Surgical treatment involves en bloc resection, including the fistula, and surrounding colon and gastric segments.
Protein electrophoresis of diagnostic peritoneal lavage in penetrating abdominal trauma: A marker of significant injury
Authors: McDonald M A , Muckart D J J
Published: March 2007

Protein electrophoresis of diagnostic peritoneal lavage fluid has been shown in experimental work to be a marker of hollow viscus injury. In order to ascertain the value of this investigation in penetrating abdominal trauma, we conducted a prospective study, over a 4-month period, involving 35 patients with stab wounds to the abdomen whose initial clinical examination was equivocal. The results of electrophoresis were compared with the standard quantitative criteria for diagnostic lavage and the operative findings. Protein electrophoresis was found to be a more sensitive and specific marker of significant intra-abdominal injury than the standard quantitative criteria.
Prospective comparison of preoperative imaging and intraoperative ultrasonography in the detection of liver tumors
Authors: Clarke Maureen P , Kane Robert A , Steele Glenn , Hamilton Edna S , Ravikumar Thanjavur S , Onik Gary , Clouse Melvin E
Published: March 2007

A prospective evaluation of the accuracy of preoperative computed tomography (CT), ultrasonography (US), and angiography was performed in 54 patients undergoing resection of hepatic neoplasms. The results were compared with surgical findings and intraoperative ultrasonography (IOUS). A total of 167 lesions was seen by means of IOUS, of which preoperative US enabled detection of 127 (76%). In 48 patients CT allowed detection of 91 of 150 lesions (61%), and in 35 patients angiography showed 56 of 107 lesions (52%). When the detection rate is analyzed according to hepatic segment, the greater overall accuracy of preoperative US may be attributed to a markedly better detection rate in lateral segment of the left lobe of the liver. Lesion size also represented a factor, with preoperative US allowing detection of a greater number of small (less than 2 cm) lesions compared with CT. In patients studied with both CT and US, the combined lesion-detection rate increased to 81% in the right lobe and 76% in the left lobe. Because of this we recommend that preoperative assessment include both CT and US evaluation of the liver. IOUS showed 25% to 35% additional lesions compared with preoperative US and CT. More importantly, 40% of the lesions demonstrated by IOUS were neither visible nor palpable at surgery. We recommend that IOUS be considered in all patients in whom resection of hepatic neoplasm is planned. (Surgery 1989;106:849-55).

From the Departments of Radiology and Surgery, New England Deaconess Hospital, Boston, Mass.
Role of pyloroplasty in the retrosternal stomach: Results of a prospective, randomized, controlled trial
Authors: Mannell A , McKnight A , Esser J D
Published: March 2007

A prospective, randomized, controlled trial comparing clinical outcome and emptying of a solid meal from the retrosternal stomach, with and without pyloroplasty is described. Forty consecutive patients with oesophageal cancer undergoing retrosternal gastric reconstruction of the oesophagus were studied. In 20 patients the pylorus was left intact (group 1) and 20 patients underwent an Aust1 pyloroplasty (group 2). Nine patients in group 1 suffered postoperative symptoms of gastric stasis compared with only one patient in group 2 (P = 0·0106). Three patients in group 1 died from aspiration pneumonia before discharge from hospital. A gastric emptying test was performed on 24 patients between 1 and 3 months after surgery. By this time, most survivors had recovered from symptoms attributed to gastric stasis and no significant difference in gastric emptying could be demonstrated between the two groups. Selection of patients, a wide range of emptying times and improvement in gastric emptying on follow-up may explain the lack of correlation between postoperative symptomatology and the gastric half-emptying times. A pyloroplasty is advised to prevent the potentially lethal effects of gastric stasis in the early postoperative period following retrosternal reconstruction of the oesophagus.
Intragastric balloons for morbid obesity: Results, patient tolerance and balloon life span
Authors: Mathus-Vliegen E M H , Tytgat G N J
Published: March 2007

Sixty morbidly obese patients were treated with 88 intragastric balloons. An air-filled intragastric balloon was used, which was permanently connected to an inflation catheter exiting through the nose. Patients were evaluated for loss of body weight and tolerance of the balloon; the balloon was inspected for efficacy and safety. A mean total loss of body weight of 21 kg was obtained after a mean of 39 weeks in 15 men (mean age 37·7 years) and 45 women (mean age 36·2 years), with a mean initial weight of 127·9kg. The maximum rate of weight loss occurred in the first 6 months, with a steady decrease of 1 kg per week; thereafter the rate declined. Subjective complaints were infrequent and consisted of nasal discomfort or abdominal symptoms. Intolerance in 12per cent of patients was due to enhanced hunger (one patient), nasal pulling sensation (four patients) and symptomatic ulcer (two patients). Fifteen patients asked for removal of the well functioning balloon after a mean of 169 days; 14 of the 15 balloons were still airtight. Forty balloons failed prematurely. Nine were retrieved orally and 31 were passed per anum, of which 28 passed with mild abdominal cramping, two patients required transabdominalpuncture undone neededlaparotomy. Even the 40 prematurely removed balloons remained in situ for a mean of 108 days; only one-third showed leakage. As yet, 33 well functioning balloons have been in situ for a mean of 167 days. Well functioning balloons deflated at a rate of 2·3 ml per day. Malfunctioning of the balloon was due to leakage in 12 cases and to clogging of the inflation catheter in three cases. Major complications (8per cent) included two gastric ulcers and three cases of mild ileus. One ileus patient required surgery (2per cent). The reported intragastric balloon model is effective and safe. We recommended this type of balloon as a weight reducing adjuvant therapy before bariatric surgery.
Electrically stimulated sartorius neosphincter: Canine model of activation and skeletal muscle transformation
Authors: Hallan R I , Williams N S , Hutton M R E , Scott M , Pilot M A , Swash M , Koeze T H , Watkins E S
Published: March 2007

The sartorius muscle was transposed into the abdominal cavity of six dogs, passed around a Thiry–Vella loop and sutured to itself to form a neosphincter. The muscle was activated by electrical stimulation and on contraction the neosphincter stopped or reduced the flow of saline through the Thiry–Vella loop in all animals until the onset of muscle fatigue. Continuous low frequency stimulation was used to transform the skeletal muscle, and when studied after a mean of 8 weeks of stimulation (range 6–11 weeks) the neosphincter stopped the flow for a significantly longer period of time (P = 0·027). Associated with the improved neosphincter function was a significant decrease in the fusion frequency (P = 0·003) and prolongation of the stimulus–peak tension time as assessed by a strain gauge sutured to the neosphincter muscle (P = 0·002). The changes in the contraction properties of the skeletal muscle suggest that continuous low frequency stimulation transformed the muscle fibres from type 2 to type 1, resulting in improved fatigue resistance and potential for continuous sphincter activity.
Pouch size: The important functional determinant after restorative proctocolectomy
Authors: Öresland T , Fasth S , Nordgren S , Åkervall S , Hultén L
Published: March 2007

Sixty-seven patients with a J-shaped ileoanal pouch were studied over a 2-year period with regular recording of sphincter and pouch characteristics and analysis of their role in functional outcome. Although there was a 27 per cent permanent reduction in resting anal pressure (RAP) (P<0–001), two-thirds of the patients still had a RAP within the normal range. The mean(s.d.) pouch volume increased during the first year from 132(46) ml to 282(85) ml. RAP was not related to functional outcome and preoperative RAP was not predictive of subsequent function. Large pouch volume and compliance correlated with low defaecation frequency (range of r = 0·27–0·36; P <0·05) and good overall function (r = 0·37·0·56; P<0·01). The initial pouch volume was predictive of subsequent overall function. The Heal length used for pouch construction predicted subsequent pouch volume (r = 0·48; P < 0·001) and to some extent functional outcome (r = 0·28·0·37; P<0·05). However, the studied variables accounted for only 21 per cent of the total variance of functional outcome.
Double contrast barium enema and flexible rectosigmoidoscopy: A reliable diagnostic combination for detection of colorectal neoplasm
Authors: Jensen J , Kewenter J , Asztély M , Lycke G , Wojciechowski J
Published: March 2007

The efficiency of double contrast barium enema and flexible rectosigmoidoscopy (to 60 cm) in the assessment of patients with a positive Hemoccult II® test in a randomized screening study for colorectal neoplasms was evaluated. A positive test was present in 625 patients, of whom 530 had a complete enema and rectosigmoidoscopic assessment. A carcinoma was diagnosed in 26 and an adenoma ⩾ 1 cm in diameter in 71. As a control, 323 patients with a negative assessment repeated the Hemoccult II test and of these 67 had a positive second test, of whom 55 underwent colonoscopy. One carcinoma (Dukes' A) and two adenomas ⩾ 1 cm in diameter were diagnosed. The efficiency of the assessment was also checked by rescreening the whole group 1–2 years after the first study and by continuing follow-up. It was found that two more carcinomas and one adenoma ⩾ 1 cm in diameter had been overlooked at the primary assessment. The sensitivity for neoplasms ⩾ 1 cm in diameter at the primary assessment was 72 per cent for double contrast barium enema and 86 per cent for rectosigmoidoscopy. The sensitivity for the combined methods was 94 per cent and the specificity was 99 per cent. The combination of double contrast barium enema and rectosigmoidoscopy in the primary assessment of patients with a positive Hemoccult II test gives an acceptable result and immediate retesting of those with a negative assessment is not necessary.
Indications for conservative management of acute scrotal pain in children
Authors: Hastie K J , Charlton C A C
Published: March 2007

Forty-three boys who presented with acute scrotal pain were studied retrospectively. Of these, 40 had torsion of scrotal contents. Torsion of testicular appendages, a self limiting condition, tended to present later than testicular torsion (P = 0·002). The testis was saved in all 11 cases of testicular torsion explored within 12 h of the onset of pain but orchidectomy was required in four who presented later. In 11 cases, a torted testicular appendage diagnosed as a tender nodule was found on examining the upper pole of the testis. The remaining 14 cases of torted appendage were diagnosed at operation because testicular torsion could not be excluded due to scrotal swelling. Most (12) of this operated group were not seen until 3 days after the onset of pain. This study suggested that urgent operation was unnecessary in those in whom a tender nodule was found (pathognomonic of a torted appendage) and in those presenting after more than 24 h of pain with scrotal erythema and oedema. The likely diagnosis in the latter case is a torted appendage and in cases of torsion of the testis there is no prospect of salvage at this stage. These guidelines were applied to a group of 20 boys studied prospectively. In eight, all with less than 24 h of pain, immediate exploration was undertaken and testicular torsion was confirmed in six. The remaining 12 fulfilled the criteria for conservative management and were observed. All had normal testes at late review. Careful clinical assessment in boys with scrotal pain indicates which cases may be treated by non-operative management without fear of losing a salvageable testis.
Effect of low dose recombinant interleukin 2 plus indomethacin on mortality after sepsis in a murine burn model
Authors: Morgan P G , Mannick J A , Dubravec D B , Rodrick M L
Published: March 2007

Under anaesthesia, 129 8-week-old male A/J mice were subjected to a 25 per cent scald or sham burn and then resuscitated. They were divided at random into two groups. Mice from the first group were allocated into two groups. Mice from the first group were allocated into four subgroups to receive 6 days intraperitoneal (I.P.) injections as follows: (i) recombinant human interleukin 2 (rhIL-2) (250 units day−1); (ii) saline; (iii) indomethacin (5 µg−1 day−1); or (iv)rhlL-2 (250 units) + indomethacin (5 µg). Sham burned mice served as no treatment controls. All animals were subjected to peritonitis induced by caecal ligation and puncture 10 days after the burn and mortality was assessed. Mice from the second group were allocated to two subgroups to receive 6 days intraperitoneal injections of: (i) rhIL-2 + indomethacin; or (ii) saline. Animals in this group did not undergo septic challenge. They were randomly killed on days 7, 9 or 10 after the burn. Their splenocytes were harvested and assayed for response to the mitogens phytohaemagglutinin (PHA) and concanavalin A (Con A), and for production of interleukin 2. Mortality rate in animals subjected to burn and septic challenge without treatment was 75 per cent; in mice receiving rhIL-2 alone it was 68 per cent, in mice receiving indomethacin alone it was 62 per cent (no significance) and in mice receiving rhIL-2 + indomethacin it was reduced to 38 per cent (P < 0·02). Splenocytes from animals receiving combination therapy had markedly improved responses to PHA on days 7 (P = 0·01), 9 (P = 0·02), and 10 (P = 0·008), and to Con A on days 7 (P = 0·001), 9 (P = 0·002) and 10 (P = 0·001), after burn injury. Interleukin 2 production was also significantly (P = 0·004) improved by therapy with rhIL-2 + indomethacin. These data suggest that low dose rhIL-2 in combination with indomethacin may have potential use in the therapy of burn victims.
Quantification of duodenogastric reflux in gastroduodenal peptic ulcer and in gastric operation patients, using a 24-h gastric pH measurement as a quantification technique
Authors: Campos R Robles , Paricio P Parrilla , Mompeán J A Luján , Albasini J L Aguayo , Bueno F Sánchez , González J M Rodríguez , de Haro L F Marténez
Published: March 2007

Twenty-four-hour gastric pH measurement was used to study duodenogastric reflux. To differentiate between gastric hyposecretion and duodenogastric reflux, we also measured bile acid concentrations in the gastric juice, and regarded pH increases to above 4 as possible episodes of reflux. The procedure was used in 60 patients, divided into the following groups: (1) control group (ten patients); (2) duodenal ulcer (ten patients); (3) type 1 gastric ulcer (five patients); (4) type 3 gastric ulcer (five patients); (5) bilateral truncal vagotomy plus pyloroplasty (ten patients); (6) truncal vagotomy plus Billroth I partial gastrectomy (ten patients); and (7) truncal vagotomy plus Billroth II partial gastrectomy (ten patients). The amount of reflux (areas of pH > 4) in the type I gastric ulcer and Billroth 1 and Billroth II groups was significantly greater than that found in the control, duodenal ulcer, type 3 gastric ulcer and truncal vagotomy plus pyloroplasty groups. The mean concentration of total bile acids was also greater in the gastrectomized patients than in the rest of the groups studied. In the type 1 gastric ulcer group the mean bile acid concentration was similar to that of the control group.
Back pain following general anaesthesia and surgery: Evaluation of risk factors and the effect of an inflatable lumbar support
Authors: Hickmott K C , Healy T E J , Roberts S P , Faraghert E B
Published: March 2007

Factors that contribute to postoperative lumbar back pain and the effect of an inflatable lumbar support on the incidence of postoperative backache were examined. The study consisted of two parts, a pilot study in which mathematical models for appropriate support pressures were produced and the main study to assess the role of an inflatable lumbar support. The use of a support reduced the incidence of back pain on the first postoperative day from 46 to 21 per cent (P = 0·007). The patient's sex, height, weight, and the presence or absence of obesity were not found to be significant factors in the incidence of postoperative back pain. Previous back pain or arthritis in any joint tended to be associated with an increase in the severity and incidence of postoperative back pain. Postoperative back pain was more severe after procedures lasting more than 40 min. Early mobilization reduced the amount of back pain. In conclusion, patients benefit from the use of an inflatable lumbar support if they have previously suffered from backache or if they are to be anaesthetized for more than 40 min.
Interaction of penetrating missiles with tissues: Some common misapprehensions and implications for wound management
Authors: Cooper G J , Ryan J M
Published: March 2007

It is apparent from review of published papers and books that misunderstanding and confusion exists in the minds of many authors describing the interaction of penetrating missiles with tissues. These misapprehensions may influence the management of wounds by suggesting didactic approaches based upon a preconceived notion of the nature and severity of the wound for different types of projectiles. This review considers the biophysics of penetrating missile wounds, highlights some of the more common misconceptions and seeks to reconcile the conflicting and confusing management doctrines that are promulgated in the literature - differences that arise not only from two scenarios, peace and war, but also from misapprehensions of the wounding process. Wounds of war and of peacetime differ both in the nature of the wound and in the propensity for wound infection. Additionally, the limitations imposed by war dictate the type of management that may be practised and result in procedures that would be considered inappropriate by some in civilian clinical practice. Many of the procedures described in civilian peacetime settings, such as reliance on antibiotics alone for the control of infection in penetrating wounds, or minimal excision and debridement, can yield good results but would herald disaster if transposed to a war setting.
Tamoxifen therapy in unresectable adenocarcinoma of the pancreas and the papilla of Vater
Authors: Bakkevold K E , Pettersen A , Arnesjø B , Espehaug B
Published: March 2007

Between 1984 and 1987, 176 Norwegian patients with histologically verified unresectable pancreatic adenocarcinoma were randomized to double-blind treatment with oral tamoxifen (30 mg daily; 48 men and 44 women) or placebo (47 men and 37 women). Analysis of oestrogen receptor activity in the carcinomas was not performed. There were no statistically significant differences between the two groups according to age, Karnofsky performance index, tumour node metastasis (TNM) stage, operative treatment or other patient characteristics. The tamoxifen or placebo treatment continued to death or to 10 months after accrual into the trial was stopped. In the tamoxifen group, the mean and median survivals were 205 and 115 days, respectively. These values did not differ statistically from the 192 and 122 days, respectively, observed in the placebo group. Additional retrospective analyses of sex and stage revealed no beneficial effect of tamoxifen upon survival. For women in stage III (any TN1 M0), mean and median survivals were 255 and 191 days, respectively, compared with values of 84 and 45 days, respectively, in the placebo group (P = 0·011). After 2·5 years, three (7 per cent) women in the tamoxifen group were still alive compared with no survivors in the placebo group. No male patients survived beyond 2·5 years. This therapeutic result in a small subgroup of women is probably incidental and not an effect of tamoxifen.
Manovolumetric and sensory characteristics of the ileoanal J pouch compared with healthy rectum
Authors: Öresland T , Fasth S , Åkervall S , Nordgren S , Hultén L
Published: March 2007

Pouch volume, motility, sensory function and integrated pouch-anal mechanisms during graded isobaric distension of the pouch were prospectively studied in 67 patients with a J pouch-anal anastomosis. The findings were related to functional outcome. Thirty-six normal controls were studied for comparison. In contrast with normal rectum, the Heal pouch exhibited pronounced motility, and pouch contractions were frequent even at a high distension pressure. The presence of high pressure motility was associated with a poor functional outcome. The threshold pressure and threshold volume for eliciting first sensation of filling and urge to defaecate were significantly higher in the Heal pouch. The pressure threshold levels were not related to the functional outcome. Sphincter inhibition on pouch distension reappeared in 25 per cent of the patients. The distension pressure required to elicit the inhibition was considerably higher than in the control subjects. The functional result was similar irrespective of whether sphincter inhibition was present or not. The motor and sensory function of this artificial setting appear to be controlled by nervous mechanisms that are different from those in the healthy anorectum.
Colon wound management and prograde colonic lavage in large bowel trauma
Authors: Baker L W , Thomson S R , Chadwick S J D
Published: March 2007

Between 1983 and 1987 prograde colonic lavage was prospectively evaluated in 389 patients with colon trauma. Predefined high risk patients had exteriorization of the primarily sutured colon. Intra-peritoneal primary closure was otherwise used. Patients received prograde colonic lavage by random allocation. The healing exteriorized colon was interiorized 5–10 days after the initial surgery. The median age was 29 years and only 28 patients were women. Injuries were due to stab (316), gunshot (54), shotgun (10) or blunt trauma (9). Exteriorization of the primarily sutured colon was carried out in 217 patients of whom 101 had prograde colonic lavage. Twenty (9 per cent) died. Of the survivors, 150 (76 per cent) had their colon successfully interiorized and this rate was unaffected by prograde colonic lavage. Intraperitoneal primary closure was performed in 172 patients of whom 91 had prograde colonic lavage. Seven (4 per cent) died. Mortality was directly related to the number of associated injuries. Prograde colonic lavage, irrespective of the type of colonic wound management used, did not reduce the mortality rate, which was 7·2 per cent for those who had such lavage and 6·6 per cent for the rest. Prograde colonic lavage cannot therefore be recommended in colon trauma.
Asymmetrical nature of the muscular anatomy of the infantile pylorus: A possible consideration in pyloromyotomy
Authors: Cass D T , Bond G
Published: March 2007

Post-mortem studies of the normal infantile pylorus have demonstrated an asymmetrical structure with the mucosa protruding under the circular muscle at the lesser curve but not on the anterior surface. In addition the circular muscle was often discontinuous at the pyloroduodenal junction with only longitudinal fibres or even fibrous tissue separating the mucosa from the serosa. In a further specimen in which a pyloromyotomy had been performed 10 weeks previously, this asymmetry was more pronounced. This anatomy suggests that inpyloric stenosis it may be safer to site the caudal part of the pyloromyotomy incision on the anterior surface, rather than on the anterosuperior surface as most authors recommend. Perforation of the mucosa is predicted to be less likely.
Failure of nutritional recovery after total gastrectomy
Authors: Curran F T , Hill G L
Published: March 2007

Malnutrition is reported to be an inevitable consequence of total gastrectomy, although there are few data to support this contention. Six patients of median age 63 years underwent total gastrectomy for malignancy. At follow-up (median 45 months, range 25–60 months) each patient was clinically tumour-free and underwent dietary assessment, faecal fat and nitrogen measurement and routine haematological testing. Protein and fat stores, measured by neutron activation analysis and the tritiated water dilution technique, were compared with the same measurements made before operation and with predicted values. Mean(s.d.) dietary intake (2224(381) kcal day−1 and 81(15)g protein day−1) met the patients' estimated requirements. Mean(s.d.) serum albumin and faecal nitrogen values were normal but there was notable steatorrhoea (21(17) g day−1). Body composition measurements revealed profound deficiencies of body-weight (P < 0·02), protein (P < 0·01) and fat (P < 0·02) before operation which were not corrected by an apparently curative total gastrectomy (P < 0·05), although further deterioration was prevented.
Bile acids and the increased risk of colorectal tumours after truncal vagotomy
Authors: Mullan F J , Wilson H K , Majury C W , Mills J O M , Cromie A J , Campbell G R , McKelvey S T D
Published: March 2007

An association between colorectal cancer and previous peptic ulcer surgery is reported. In a prospective screening study, 100 asymptomatic patients (80 men and 20 women) who had undergone truncal vagotomy at least 10 years previously were investigated by barium enema, colonoscopy and gallbladder ultrasonography. Control data were obtained from forensic autopsy subjects. The incidence of neoplasms ≥1.0 cm in the vagotomized group was 14 per cent (11 adenomas, 3 carcinomas) and 3 per cent in controls (P = 0.01). Duodenal bile obtained at endoscopy from 21 vagotomized patients with normal gallbladders and from 21 control patients undergoing endoscopy was analysed by high performance liquid chromatography. The mean percentage of cholic (CA), chenodeoxycholic (CDCA), deoxycholic (DCA) and lithocholic (LCA) acids in the bile of vagotomized patients was 32.3, 45.6, 20.7 and 1.4 per cent respectively compared with 45.3, 36.2, 17.9 and 0.7 per cent respectively in controls. The increased proportions of CDCA and LCA and decreased proportions of CA in the duodenal bile of vagotomized patients were significant (P < 0.001; P = 0.02; P = 0.007). Abnormalities in bile acid metabolism may help to explain the increased risk of colorectal neoplasia 10 years after truncal vagotomy.
Preoperative cytology and mammography in patients with single-duct nipple discharge treated by surgery
Authors: Fung A , Rayter Z , Fisher C , King D M , Trott P
Published: March 2007

Microdochectomy has been the routine management for single-duct nipple discharge. Our review of 176 consecutive patients surgically treated between 1975 and 1988 revealed eight patients with in situ carcinomas and seven with infiltrative carcinomas. Seventeen patients had multiple papillomas, two had atypical hyperplasia and two had atypical epitheliosis. Case selection for surgery has recently been advocated. In our study, nipple discharge cytology was helpful in 67 per cent of cases with underlying malignant pathology. Mammography was found to be unreliable, alerting suspicion in only two of 15 cases.
Direct measurement of collagenase in colonic anastomosis
Authors: Chowcat N L , Savage F J , Lewin M R , Boulos P B
Published: March 2007

Collagenase has been implicated in colonic anastomotic dehiscence but the enzyme has not previously been specifically measured in colonic healing. A 72 h tissue culture method for colonic tissue and a radio chemical assay for collagenase were adapted to measure the enzyme in healing rabbit colon, with specificity of the assay confirmed by sodium dodecylsulphate polyacrylamide gel electrophoresis. Normal and postoperative colon secreted collagenase, predominantly in a latent form, in the first 24 h of culture. Total activity reached a plateau after 48 and 72 h in culture, when 50–70 per cent of the enzyme was in an active form. At these times in culture, activity was significantly higher than after 24 h (P < 0.001). One day after anastomosis the total amount of collagenase secreted in culture was higher than normal but the increase did not achieve significance. Three days after anastomosis the colon secreted more collagenase than explants from 1 day postoperative tissue (P < 0.002). The proportion of active enzyme in the first 24 h in culture was also increased. Since active collagenase can be measured in culture medium from both normal and postoperative colon, the tissue may be secreting plasminogen activator which allows plasmin to activate the enzyme. The increase in collagenase after operation coincided with a decrease in collagen concentration in the colon wall, measured by hydroxyproline. This supports previous suggestions that collagenase contributes to anastomotic dehiscence. However, the findings must be interpreted with caution as the variance of the results was shown to be predominantly due to time in culture, suggesting this could be a bigger influence than the operation itself. In addition, our previously reported immunohistochemical study of this system indicated that collagenase only occurred in a localized region, restricted to the everted portion of the anastomosis, with the activity being tightly controlled by its inhibitor, tissue inhibitor of metalloproteinases.
Epidermal growth factor receptor expression in colorectal cancer
Authors: Steele R J C , Kelly P , Ellul B , Eremin O
Published: March 2007

Epidermal growth factor (EGF) receptor expression was estimated in 50 invasive human colorectal cancers using immunohistochemistry and the degree of expression was quantified from integrated optical density measurements on the stained sections. All tumours stained positively, but Dukes' C tumours exhibited significantly higher levels of receptor than either Dukes' A or B tumours. In addition, histologically high grade cancers expressed receptors more strongly than those of low grade. It is concluded that a high EGF receptor concentration is associated with poor prognostic factors in colorectal malignancy.
Effect of vaginal delivery on the pelvic floor: A 5-year follow-up
Authors: Snooks S J , Swash M , Mathers S E , Henry M M
Published: March 2007

We have studied the pelvic floor musculature and its innervation in 14 of 24 (58 per cent) multiparous women who had been recruited into a study of the effect of childbirth on the pelvic floor as part of a prospective investigation that began in 1983. These 24 women had all delivered by the vaginal route without forceps assistance. Five of the 14 had developed clinical symptoms of stress incontinence 5 years later; two of them had had a further uncomplicated vaginal delivery during this time. There was manometric and neurophysiological evidence of weakness because of partial denervation of the pelvic floor striated sphincter musculature, with pudendal neuropathy, which was more marked in those women with incontinence. These findings provide direct evidence for the hypothesis that pudendal neuropathy due to vaginal delivery persists and may worsen with time.
Primary papillary carcinoma of a thyroglossal duct cyst: Report of a case and literature review
Authors: Weiss S D , Orlich C C
Published: March 2007

Thyroglossal duct cysts are the most common anomaly in thyroid development. They are twice as frequent as branchial cleft abnormalities and, in children, are second only to enlarged cervical lymph nodes as the cause of neck mass. Generally, duct cysts are benign, but 1 per cent of cases may be malignant. From the world literature, 114 cases of malignant thyroglossal cysts were available for review. With the addition of our own case, we discuss 115 instances of duct cysts. The different types of neoplasia described included thyroid papillary carcinoma in 81·7 per cent, mixed papillary-follicular carcinoma in 6·9 per cent, squamous cell carcinoma in 5·2 per cent, follicular and adenocarcinoma in 1·7 per cent each, and malignant struma, epidermoid carcinoma and anaplastic carcinoma in 0·9 per cent each. Of the 115 cases surveyed, 35 thyroid glands were examined microscopically; of these, four (11·4 per cent) contained malignant foci. Whether these are primary malignancies of the thyroglossal duct cysts or metastases is discussed.
Surgical strategies in the treatment of pancreatic necrosis and infection
Authors: D'Egidio A , Schein M
Published: March 2007

Controversy still surrounds the management of necrotic and septic complications of acute pancreatitis. A review of the literature of the past decade dealing with the surgical treatment of pancreatic necrosis, pancreatic abscess and infected pancreatic necrosis has been undertaken. Three main patterns of management could be identified: (1) ‘conventional treatment’, consisting of pancreatic resection or necrosectomy with drainage; (2) ‘local lavage’, consisting of necrosectomy followed by regional lavage; and (3) ‘open management’, with resection or necrosectomy followed by planned multiple re-explorations. From this review it appears that local lavage and open management offer better survival prospects than conventional treatment. Open abdomen techniques, however, are associated with an increased risk of complications, such as colonic necrosis, intestinal fistula, and intra-abdominal bleeding. Excellent results can be achieved in specialized centres with any of the three methods, provided adequate debridement and prompt reoperations are undertaken if the septic state persists.
Conventional Versus laparoscopic cholecystectomy and the randomized controlled trial
Authors: Neugebauer E , Troidl H , Spangenberger W , Dietrich A , Lefering R
Published: March 2007

We considered using a randomized trial to assess the value of laparoscopic cholecystectomy in the treatment of symptomatic gallstones. The pros and cons for the timing of such a trial were in favour of not beginning the trial until surgeons learned to use the new procedure safely and effectively, and until key endpoints and outcome indices could be identified and assessed using valid measures. Instead an observational study was implemented to monitor the learning curve of surgeons as they mastered the laparoscopic equipment and procedures, and to assess the responses of the patients to the procedure. In the first 100 patients, the procedure proved to be as safe and feasible to use as conventional surgery, and there were strong benefits in terms of quicker recovery of the patients with less pain, discomfort, and a reduced length of hospital stay. The responses of the surgeons and the patients to the new procedure now place ethical constraints on the planning of a randomized controlled trial. Currently, comprehensive surveillance and monitoring of laparoscopic cholecystectomy is the only realistic method with which to assess the impact of this new technology in our clinic.
Population-based study of surgery in juvenile onset ulcerative colitis
Authors: Sedgwick D M , Barton J R , Hamer-Hodges D W , Nixon S J , Ferguson A
Published: March 2007

A geographically based cohort of 37 children with ulcerative colitis has been derived by sampling from Scottish Hospital In-patient Statistics. Surgical histories were examined and analysed by actuarial methods, and the major operations performed were compared with operations for ulcerative colitis in the Lothians' Surgical Audit. Fourteen of the 37 patients had a total of 26 operations (15 major, 11 minor). Sixteen per cent had major surgery within 5 years of onset of symptoms, and the types of operation were similar to those recorded in Lothians' Surgical Audit. Operation rate was significantly lower than that for a parallel cohort of patients with Crohn's disease. With a mean follow-up of 7.4 years, seven (19 per cent) patients have a permanent stoma and there has been one death.
Natural history of indeterminate colitis
Authors: Wells A D , McMillan I , Price A B , Ritchie J K , Nicholls R J
Published: March 2007

The long-term outcome of patients with a pathological diagnosis of indeterminate colitis on a colectomy specimen was investigated. The case records of 46 such patients operated on for inflammatory bowel disease between 1960 and 1983 were reviewed. Using the preoperative clinical information, pathological and radiological reports, it was possible to divide the patients into three groups: group 1, probable Crohn's disease (19 cases); group 2, probable ulcerative colitis (11 cases); and group 3, indeterminate colitis (16 cases). The patients were followed for a minimum of 2.5 years (median 10, range 2·5–28 years). During this period the probable diagnosis changed in five cases only. One patient in group 1 (Crohn's disease) was subsequently considered to have ulcerative colitis (group 2). The other four patients were all in group 3. Three were reclassified as ulcerative colitis and the fourth as Crohn's disease on the finding of a single granuloma in a rectal biopsy. No case in group 3 required subsequent small bowel surgery. These data suggest that patients continuing with a diagnosis of indeterminate colitis in spite of careful preoperative and postoperative assessment are unlikely to show features of Crohn's disease in the long term. This may be important when considering a subsequent restorative proctectomy.
Outcome after emergency surgery for cancer of the large intestine
Authors: Runkel N S , Schlag P , Schwarz V , Herfarth C
Published: March 2007

The data for 77 patients with colorectal cancer who underwent emergency surgery for acute intestinal obstruction (57 patients) or perforation (20 patients) within 24 h of admission were evaluated. The patients were older and had more advanced disease than patients undergoing elective surgery for colorectal cancer. Emergency surgery for carcinoma of the right colon consisted of primary resection in 95 per cent of cases and was followed by a 28 per cent mortality rate. Perforated tumours of the left colon and rectum were managed by primary resection in 82 per cent of cases with a 22 per cent mortality rate. In contrast, obstructing tumours of the left colon and rectum were treated by primary resection in 38 per cent of cases with a 6 per cent mortality rate, and by primary decompression in 62 per cent of cases with a 25 per cent mortality rate. The overall postoperative mortality rate was 23 per cent and increased with advanced tumour disease, perforation and peritonitis. Cardiac decompensation and intraabdominal sepsis were the major causes of death. Although the long-term survival rate following emergency surgery was worse than after elective surgery, improvements in outcome should be achieved by better management of the initial emergency situation.
Reoperations for late complications following abdominal aortic operation
Authors: Haiart D C , Callam M J , Murie J A , Ruckley C V , Jenkins A Mcl
Published: March 2007

Fifty patients were identified who, following abdominal aortic operation, developed late complications affecting the vascular graft or endarterectomy and who underwent their first reoperation between 1979 and 1989. Thrombosis was the commonest complication affecting 28 (56 per cent) patients, followed by false aneurysm in 11 (22 per cent), enteric fistula in nine (18 per cent) and graft infection in two (4 per cent). The 30-day mortality rate for reoperation was 8 per cent; longer follow-up revealed mortality rates of 22, 50 and 63 per cent at 1, 3 and 5 years respectively. Thirty-four complications required reoperation within 5 years of the original surgery. Reoperation was needed for 35 patients whose original pathology was occlusive disease and for 15 whose original pathology was aneurysm. The nature of the complication was related to initial pathology; thrombosis was far commoner in those with occlusive disease, and enteric fistula and false aneurysm were commoner in those with aneurysmal disease.
Where there is no anaesthetist…
Authors: Leppäniemi A K
Published: March 2007

In an unselected series of 254 operations representing a wide range of surgical, obstetric and gynaecological procedures carried out on the small Pacific island of Tuvalu, the majority (85 per cent) involved the lower half of the body. In all cases but one anaesthesia was administered by a non-specialist. In operations below the level of the diaphragm epidural anaesthesia was usually used with a success rate of 96 per cent. In the upper half of the body ketamine was used where local or regional block was insufficient. Only one operation was performed under general inhalation anaesthesia. The overall postoperative mortality rate was 0·4 per cent and the morbidity rate was 13 per cent. Only two minor complications were attributed to the anaesthetic method used. In situations where anaesthetists are not available, epidural and ketamine anaesthesia in the hands of non-specialists are safe and practical options to general inhalation anaesthesia and are appropriate for most surgical procedures.
Surgical management of primary hyperhidrosis
Authors: Moran K T , Brady M P
Published: March 2007

Primary hyperhidrosis, although lacking a precise definition and of unknown aetiology, disrupts professional and social life and may lead to emotional problems. A variety of treatment methods are used to control or reduce the profuse sweating which involves mainly the palms, soles and axillae. The simplest method, the application of topical agents, is usually attempted first for axillary and plantar sweating. Iontophoresis may provide relief especially in patients with plantar or palmar involvement. In severe cases operative intervention is necessary. Excision of sweat glands is successful in patients with axillary hyperhidrosis but the role of suction-assisted removal of axillary sweat glands remains to be determined. Sympathectomy remains the standard by which other treatments must be judged. For upper thoracic sympathectomy a variety of surgical approaches are used with satisfactory relief of hyperhidrosis. Complications related to the surgical approach, such as Horner's syndrome, brachial plexus injuries, pneumothorax and painful scars may occur, while following sympathectomy compensatory hyperhidrosis is usual and hyperhidrosis may recur. Plantar hyperhidrosis which may be exacerbated or ameliorated by upper thoracic sympathectomy and which fails to respond to non-operative intervention is relieved by lumbar sympathectomy.
Biliary bile acid profiles in familial adenomatous polyposis
Authors: Spigelman A D , Owen R W , Hill M J , Phillips R K S
Published: March 2007

Patients with familial adenomatous polyposis have an excess risk for adenomas and cancers of the upper and lower gastrointestinal tract. In the upper intestine these lesions occur mainly around the ampulla of Vater and they parallel mucosal exposure to bile. In view of this finding and of evidence that bile acids play a role in colorectal carcinogenesis, biliary bile acid profiles were determined in 29 patients with familial adenomatous polyposis (12 before colectomy, 17 after colectomy) and in 28 patients without familial adenomatous polyposis (all with colons in situ). Patients with familial adenomatous polyposis had a higher total biliary bile acid concentration than the others. The bile of patients with polyposis had a greater proportion of chenodeoxycholic acid and a lower proportion of deoxycholic acid than did the bile of patients without polyposis. The ratio of chenodeoxycholic acid and its metabolite lithocholic acid to cholic acid and its metabolite deoxycholic acid, which is related to subsequent bile acid profiles in the colon, was higher in patients with polyposis. Because bile acids influence cellular proliferation, these findings may be of importance with respect to intestinal adenoma and cancer growth.
Tumour necrosis factor increases hepatic cell mass
Authors: Mealy K , Wilmore D W
Published: March 2007

The effect of tumour necrosis factor (TNF) on hepatic cellularity was investigated in male Wistar rats maintained on total parenteral nutrition. Twenty-eight rats were infused with TNF (2 × 105 units TNF-α kg−1 24 h−1) or saline (controls) for 6 days. Wet and dry liver weights and nitrogen content were significantly increased by TNF (P<0·001), indicating an increase in liver mass. A further 81 rats were infused with TNF (2 or 4 × 105 units kg−1 24 h−1) or saline over 1, 3 and 6 days. Total liver DNA and protein content and counts of hepatocyte mitosis were determined. Liver DNA and protein increased with dose of TNF and time (P<0·001), suggesting that TNF increased hepatic cellularity. Histological examination demonstrated no significant inflammatory infiltrate to account for the increased cell mass. However, the number of hepatocyte mitoses increased with dose of TNF and time (P<0·05), indicating that the increase in liver cellularity was due to increased hepatocyte cell number. TNF-induced hepatic hyperplasia appears to be an additional feature of the integrated host response to injury and infection.