bluuebunny/crossref_metadata_2025 huggingface dataset:
Bile acid and lysolecithin concentrations in the stomach of patients with gastric ulcer: Before operation and after treatment by highly selective vagotomy, Billroth I partial gastrectomy and truncal vagotomy and pyloroplasty
Authors: Dewar E P , King R F G , Johnston D
Published: March 2007

Bile acid and lysolecithin concentrations in the stomach were measured in normal subjects and in patients with gastric ulcer (GU) before operation and more than 1 year after highly selective vagotomy, Billroth I partial gastrectomy (PG) and truncal vagotomy and pyloroplasty. Before operation, patients with GU had significantly (P<0·001) higher bile acid concentrations in the stomach than normal people. After highly selective vagotomy, bile acid concentrations were significantly lower than in preoperative GU patients and were also significantly lower than in patients after PG, but were still higher than in normal people. Postprandial and peak lysolecithin concentrations after highly selective vagotomy were significantly lower than after partial gastrectomy. The therapeutic effect of highly selective vagotomy in the surgical treatment of GU may be due not only to reduced acid-peptic ‘attack’ on the gastric mucosa, but also to reduced duodenogastric reflux of ‘bile’.
Lymphadenopathy as a primary presenting sign: A clinico-pathological study of 228 cases
Authors: Anthony P P , Knowles S A S
Published: March 2007

A total of 228 cases of lymphadenopathy as a primary presenting sign are reported. Tissue diagnoses were divided into: metastatic carcinoma (41 per cent), lymphoma (19 per cent), a specific non-neoplastic condition (10 per cent) and non-specific hyperplasia and inflammation (30 per cent); thus the overall yield of positive tissue diagnosis was 70 per cent. Just 5 primary sites: breast, lung, gastrointestinal and genito-urinary tracts and skin (mainly melanomas) accounted for all but one case. Hodgkin's and non-Hodgkin's lymphomas were evenly distributed. In those with generalized malignant lymphadenopathy a surprisingly even proportion of 1 to 1·5 was found between carcinoma and lymphoma. In those with localized malignant disease metastatic carcinoma predominated. The overall incidence of primary lymphadenopathy increased with age, due to an increase in malignancy. Less than half of patients with carcinomatous lymphadenopathy had symptoms and these tended to be organ specific, whereas three-quarters of patients with lymphoma had symptoms which were usually non-specific. A haematological screen, liver function tests and chest X-ray were frequently abnormal but were not diagnostic.
Aortocaval fistula associated with ruptured aortic aneurysm
Authors: Burke A M , Jamieson G G
Published: March 2007

Seven cases of rupture of an abdominal aortic aneurysm into the inferior vena cava are reported. In the management of this rare condition it is important to make the diagnosis preoperatively. Most cases show evidence of a large arteriovenous fistula which can, on occasions, dominate the clinical picture, e.g. cyanosed lower extremities or cardiac failure, but abdominal pain is the major feature. Careful examination of all patients with a ruptured aneurysm, particularly listening for an abdominal bruit, will usually allow the diagnosis of aortocaval rupture to be made.
Abdominal aortic aneurysm with retroperitoneal fibrosis and ureteric entrapment
Authors: Sethia B , Darke S G
Published: March 2007

Eleven of 157 patients undergoing surgery for abdominal aortic aneurysm, with features of both aneurysm and periaortic retroperitoneal fibrosis, are presented. The clinical details, implications and management are reported. The possibility that this association may present with differing relative severity of these two conditions is discussed. Aortic replacement is advocated as the treatment of choice because the risk of rupture still exists and this procedure seems to halt, or even reverse, the inflammatory process. Synchronous ureterolysis is reasonably safe and can be undertaken if obstruction is present. Steroids represent an alternative option, where aortic replacement is too hazardous.
Fluorescent cytochemical oestrogen receptor assay: Is it valid in breast cancer?
Authors: Furnival C M , Chong K C , Watson L R , Visona A
Published: March 2007

The performance of a fluorescent cytochemical oestrogen receptor (ER) assay has been compared with an established dextran-coated charcoal ER assay in 85 cases of primary breast cancer. Both assays were performed on tissue samples from the same tumour, by independent observers in different laboratories. A good qualitative correlation between the two methods was found, with agreement in 92 per cent of cases (P < 0·0005). Criticisms of the fluorescein-labelled oestrogen methods are discussed. It is concluded that such methods should be validated in each laboratory by comparison with a conventional, quantitative ER assay before being used for clinical decisions.
Management of faecal incontinence and results of surgical treatment
Authors: Keighley M R B , Fielding J W L
Published: March 2007

Ninety-five patients have been referred for the assessment and treatment of faecal incontinence. Incontinence was associated with previous anal trauma in 49 cases: 13 occurred after vaginal delivery, 32 were associated with anal operations and in 4 severe perineal trauma occurred after road accidents. Other causes were: idiopathic incontinence in 18, persistent incontinence despite successful rectopexy for prolapse in 10, diabetic neuropathy in 5 and in 13 the cause was not identified. Conservative treatment by control of diarrhoea, physiotherapy or electrical therapy was often successful in patients with minor incontinence. Fifty-six patients have been treated surgically. Complete continence was achieved in 67 per cent of patients treated by postanal repair and in 61 per cent by sphincter reconstruction. We believe that postanal repair is the treatment of choice for idiopathic incontinence and incontinence after rectopexy or anal dilatation. Sphincter repair should only be performed with a covering colostomy and is the treatment of choice for recent or long standing division of the external sphincter ring.
Prognostic factors in locally recurrent rectal carcinoma treated by radiotherapy
Authors: James R D , Johnson R J , Eddleston B , Zheng G L , Jones J M
Published: March 2007

An analysis has been made of the symptomatic response and survival of 143 patients following radiotherapy for locally recurrent rectal cancer. Computerized tomography (CAT) was performed on 45 patients. Of 119 evaluable patients, 54 had a good response to radiotherapy, 29 a moderate response and 36 no apparent response. Median response was 9 and 3 months respectively in the good and moderate groups. Median survival was 15, 9 and 5 months for the three groups. Latent interval between surgery and radiotherapy appeared to be of prognostic importance. When this exceeded 2 yr median survival was 12 months compared with 7 months for patients with a latent interval of less than 2 yr. Tumour volume measured by computed tomography may have prognostic importance. Radiotherapy should be considered for most patients with symptomatic recurrence. Surgery might be combined with radiotherapy for selected groups of patients with good prognosis.
Randomized trial of truncal vagotomy with either pyloroplasty or pyloric dilatation in the surgical management of chronic duodenal ulcer
Authors: Pringle R , Irving A D , Longrigg J N , Wisbey M
Published: March 2007

A randomized trial of 41 patients undergoing truncal vagotomy with pyloroplasty (TV + P) or truncal vagotomy with graded pyloric dilatation (TV + PD) for chronic duodenal ulcer is reported after mean follow-up of 34 months. There was no evidence of gastric stasis in patients who did not have a pyloroplasty. Liquid gastric emptying studies showed an increased rate of gastric emptying postoperatively in patients both with and without pyloroplasty. Overall clinical gradings at review were similar in both groups although there were more patients who were completely symptom free in the group with pyloric dilatation accompanying vagotomy.
Recurrent gastrointestinal bleeding of obscure origin: Report of 17 cases and a guide to logical management
Authors: Spiller R C , Parkins R A
Published: March 2007

Seventeen patients with chronic obscure gastrointestinal bleeding presenting over a 5-year period are described. While representing only 6 per cent of the total number of admissions due to gastrointestinal haemorrhage they required a disproportionate amount of medical attention, including 67 admissions, 73 radiological and 56 endoscopic procedures and transfusion of a total of 198 units of blood. The diagnoses included 5 cases of recurrent acute upper gastrointestinal erosions, 7 small bowel abnormalities and 4 colonic lesions, with 1 patient undiagnosed. Eight arteriovenous malformations (AVM) were demonstrated angiographically and one Meckel's diverticulum identified by a 99Tcm pertechnetate scan. There were 5 cases in which laparotomy yielded the final diagnosis and in one of these peroperative endoscopy of the small bowel was required. On the basis of our experience and a review of other series, a logical plan of investigation is described for such difficult cases.
Non-surgical management of post-cholecystectomy haemobilia
Authors: Kelley C J , Hemingway A P , McPherson G A D , Allison D J , Blumgart L H
Published: March 2007

Therapeutic embolization of the hepatic artery was performed in two patients actively bleeding from aneurysms resulting from previous surgical damage to the artery at cholecystectomy. The advantages of embolization over surgical ligation of the hepatic artery are discussed.
A definition of arteriomegaly and the size of arteries supplying the lower limbs
Authors: Callum K G , Thomas M Lea , Browse N L
Published: March 2007

A study has been made of the size of normal arteries supplying the lower limbs by measuring their circumferences at fixed points in cadavers and their diameters and lengths on aortographs. The arteriographs of a group of patients with dilated and elongated arteries have also been studied and a definition produced for the arteriographic condition known as arteriomegaly.
Prediction of risk in biliary surgery
Authors: Blamey S L , Fearon K C H , Gilmour W H , Osborne D H , Carter D C
Published: March 2007

To identify individual risk factors and to establish an index of risk in biliary tract surgery, data on 16 potential predictive factors were compiled from a series of 186 biliary tract operations excluding simple cholecystectomy. Eight factors had a significant association with postoperative mortality. Linear discriminant analysis showed that serum creatinine, serum albumin and serum bilirubin levels in the week before surgery had independent significance in predicting postoperative mortality. The discriminant function derived identified a high risk group of patients and the predictive value was confirmed in an independent series of 54 biliary tract operations carried out in another surgical unit. The discriminant function derived for patients jaundiced before surgery also defined a high and low risk group and was similarly validated. Identification of high risk patients undergoing surgery for obstructive jaundice may be useful in defining a group of patients to be considered for trials of preliminary biliary drainage.
Intramuscular pressure after revascularization of the popliteal artery in severe ischaemia
Authors: Qvarfordt P , Christenson J T , Eklöf B , Ohlin P
Published: March 2007

Swelling is known to occur after peripheral revascularization. In this study of 14 patients undergoing revascularization of the popliteal artery for severe ischaemia, leg swelling and intramuscular pressure were recorded before and after operation. Calf circumference increased with a maximum swelling of 3·9 ± 1·1 cm on postoperative day 6. There was a gradual increase in intramuscular pressure from 9±2 mmHg on the day before operation in the anterior tibial compartment to a maximum pressure on postoperative days 6–7 of 26±4 mmHg. Similar intramuscular pressure changes were seen in the superficial posterior compartment. These high intramuscular pressures may lead to a compartment syndrome and perhaps graft failure, which was actually observed in one case. Deep-vein thrombosis in the postoperative course may contribute to the high intramuscular pressures. Phlebography revealed a deep-vein thrombosis in 2 patients. In conclusion popliteal revascularization causes leg swelling and increased intramuscular pressure which may lead to a compartment syndrome and graft failure. Therefore followup of intramuscular pressure in patients with marked swelling after distal revascularization procedures and early fasciotomy may be considered on wide indications.
Risk of gastric cancer after Billroth II resection for duodenal ulcer
Authors: Fischer A B , Græm N , Jensen O M
Published: March 2007

In a follow-up study of 1000 patients, who were subjected to Billroth II resection for duodenal ulcer, the incidence and mortality of gastric carcinoma in a 22–30 year follow-up period were determined. Among the 423 survivors traced, 196 underwent gastroscopy and biopsy but carcinomas of the gastric remnant were not seen. Thus the prevalence was 0, not significantly different from the expected prevalence of 0·3. From all 1000 patients only 13 cases of gastric carcinoma were identified. This is not significantly different from the expected number of 10·6 calculated by the life table method and indirectly standardized for age, sex, place of residence and time. Even more than 15 years after operation the gastric cancer risk was only slightly increased (observed/expected = 7/4·8 ± 1·48), but this was not significant statistically. Of 522 deaths 13 were due to gastric carcinoma, which was not significantly different from the expected number of 10·2. These epidemiological data show that individuals subjected to Billroth II resection for duodenal ulcer hardly have a higher risk of gastric carcinoma than the general population within the first decades after operation. Thus proplylactic endoscopical monitoring will be unrewarding.
Management of malignant obstructive jaundice at The Middlesex Hospital
Authors: Leung J W C , Emery R , Cotton P B , Russell R C G , Vallon A G , Mason R R
Published: March 2007

A total of 180 patients with malignant obstructive jaundice have been treated by 5 different methods: surgical resection; surgical by-pass; percutaneous prosthesis; endoscopic prosthesis; and endoscopic sphincterotomy (for papillary tumours). The spectrum of patients is unusual, because many elderly and ill patients were referred for non-operative management. Operative by-pass, percutaneous and endoscopic prostheses gave similar overall results, with a mean survival of about 6 months. Patients with tumours of the papilla of Vater treated by endoscopy or surgery fared well; 11 of 18 were alive at follow-up. Median survival after resection of other tumours was 17 months. These results underline the need for randomized clinical trials, which are now in progress.
Prevention of postoperative renal failure in patients with obstructive jaundice—the role of bile salts
Authors: Cahill C J
Published: March 2007

Preoperative administration of the simple bile salt sodium deoxycholate has been shown in this study to prevent postoperative endotoxaemia and renal failure in patients with obstructive jaundice. Fifty-four per cent of jaundiced patients not given the salt were found to have systemic endotoxaemia, associated with renal impairment in two-thirds of the cases. No patient given sodium deoxycholate 500 mg 8 hourly for 48 hours before operation had portal or systemic endotoxaemia, and none had evidence of renal impairment (P < 0·02, χ2 with Yates' correction). The incidence of endotoxaemia in untreated jaundiced patients was very significantly greater than in non-jaundiced patients undergoing elective upper abdominal surgery (P < 0·005), but this difference is abolished by the prophylactic administration of the oral bile salt. The mechanism of action of bile salts in preventing endotoxin absorption from the small bowel has been investigated, and the lack of any significant alteration in the small bowel microbial flora in obstructive jaundice suggests that a direct effect on the endotoxin molecule is involved. Nearly 20 per cent of patients with obstructive jaundice still develop postoperative renal insufficiency, but preoperative prophylactic use of sodium deoxycholate should reduce this very significantly.
Mammary duct ectasia
Authors: Dixon J M , Anderson T J , Lumsden A B , Elton R A , Roberts M M , Forrest A P M
Published: March 2007

A total of 108 patients with mammary duct ectasia have been reviewed. Patients who presented with breast pain or a lump were significantly younger than those with nipple retraction. A histological review of the 88 patients who underwent biopsy showed severe periductal inflammation around non-dilated ducts occurred in younger patients and was associated with the symptom of breast pain or a lump, whereas older patients had duct dilatation as the most prominent feature, frequently associated with nipple retraction. These findings suggest periductal mastitis precedes duct dilatation and is the initial disorder in this condition. Data on parity and breast feeding for the 108 patients with duct ectasia were compared with age-matched groups of 505 patients with breast cancer, 199 with fibroadenoma, 240 with cysts and 912 ‘normals’. There were no differences in parity or breast-feeding history between the patients with duct ectasia and any other group, indicating that neither parity nor breast feeding is an important aetiological factor in this condition.
Management of acute brachial artery occlusion due to trauma or emboli
Authors: Lambert M , Ball C , Hancock B
Published: March 2007

Out of 37 patients requiring emergency surgery for upper limb ischaemia, 9 were due to spontaneous embolus, 7 to arterial laceration and 21 followed cardiac catheterization. Eleven of the initial operations (30 per cent) failed to relieve ischaemic symptoms though 6 were corrected by further operations. Success at the initial operation was associated with (i) repair with end-to-end anastomosis after resection, saphenous vein bypass or interposition graft, or generous vein patch, (ii) exposure of the radial/ulnar bifurcation, (iii) instillation of heparinized saline locally or (iv) restoration of the radial pulse at the end of the operation. In the cases studied in whom all the above recommendations were followed, the operation was entirely successful and all patients have a radial pulse and are currently symptom free.
An assessment of long saphenous venography to evaluate the saphenous vein for femoropopliteal bypass
Authors: Mosley J G , Manhire A R , Raphael M , Marston J A P
Published: March 2007

A long saphenous venogram was performed on a consecutive series of 42 patients (5 bilateral) though in 4 the vein was not satisfactorily demonstrated. In all cases the long saphenous vein was dissected out and its suitability for use for a femoropopliteal bypass compared to the radiological findings. Eleven veins were unusable for a bypass and radiologically these were narrower (mean diameter 2·8 mm) than the veins which functioned satisfactorily (mean diameter 5·0mm), and had more tributaries (mean 5) than the suitable veins (mean 2). Preoperative venography is a useful technique to identify veins that will be unsuitable for a femoropopliteal bypass and thereby save an unnecessary dissection.
Glutamine
Authors: Hall J C , Heel K , McCauley R
Published: March 2007

Glutamine is the most abundant free amino acid in the circulation. It is a primary fuel for rapidly dividing cells and plays a key role in the transport of nitrogen between organs. Although glutamine is absent from conventional regimens aimed at nutritional support, glutamine deficiency can occur during periods of metabolic stress; this has led to the reclassification of glutamine as a conditionally essential amino acid. Experiments with various animal models have demonstrated that the provision of glutamine can result in better nitrogen homoeostasis, with conservation of skeletal muscle. There is also considerable evidence that glutamine can enhance the barrier function of the gut. This review concludes by discussing the clinical evidence that supports the inclusion of stable forms of glutamine in solutions of nutrients.
Role of cytokines and growth factors in promoting the local recurrence of breast cancer
Authors: Reid S E , Scanlon E F , Kaufman M W , Murthy M S
Published: March 2007

The pathogenesis of local recurrence in breast cancer is not well understood. Breast-conserving surgery is particularly prone to local recurrence as it leaves behind breast tissue that may harbour occult cancer, and lends itself to enhanced intraoperative shedding of cancer cells due to narrower resection margins and transection of lymphatic channels. A review of clinical breast cancer studies as well as experimental research strongly suggests that these persisting cancerous cells are unlikely to develop into clinically evident disease if their environment remains unstimulated. However, an inordinately high local recurrence rate occurs at the surgical scar, and such recurrence must be triggered by the release of growth factors and cytokines into the healing wound. These factors can stimulate any available cancer cells which express the proper growth factor receptors. Perioperative strategies to neutralize this tumour cell-growth factor interaction should maximize local control.
Long-term outcome after surgery for asymptomatic small hepatocellular carcinoma
Authors: Lee C-S , Sheu J-C , Wang M , Hsu H-C
Published: March 2007

The subjects of this study were 48 asymptomatic patients who had surgery for small hepatocellar carcinoma (HCC). There were 42 men and six women with mean(s.d.) tumour size of 3·31(1·46) cm and age 55·0(7·4) years. Follow-up was for a minimum of 10 years. The main concern of this study was a univariate analysis of factors that might affect long-term survival after surgery, which was 50 per cent at 5 years and 31 per cent at 10 years. A high incidence of recurrent HCC (37 of 48 patients) was observed but reoperation further prolonged life in some cases. The significant prognostic factors detected by multivariate analysis were: histological classification, functional liver reserve and histology of the resection margin. Tumour size, gross appearance of tumour, presence of liver cirrhosis, serum α-fetoprotein level, age or sex did not affect the prognosis.
Serum concentrations of inflammatory mediators related to organ failure in patients with acute pancreatitis
Authors: de Beaux A C , Goldie A S , Ross J A , Carter D C , Fearon K C H
Published: March 2007

Leucocyte activation and proinflammatory cytokine release (tumour necrosis factor (TNF) and interleukin 6 (IL-6)) are thought to contribute to the induction of a systemic inflammatory response, an acute-phase response and multiple organ failure in patients with acute pancreatitis. The serum concentration of TNF, soluble TNF receptors (sTNFR55 and sTNFR75), IL-6 and Creative protein (CRP) in 58 patients with acute pancreatitis was assessed during the first 2 days of admission. Thirty patients had mild disease and 28 severe disease, of whom 18 developed local pancreatic complications alone (Atlanta classification) and ten developed organ failure (a Goris score of 1 or more). TNF was detected in only 17 patients on the first day of admission, while soluble TNF receptors were detected in all patients and IL-6 in 34. On the first and second days of admission there was a progressive and significant (P < 0·03) increase in the median concentration of sTNFR55, sTNFR75 and IL-6 in patients eventually classified into those with mild disease, a local pancreatic complication alone, or organ failure. This pattern was also evident in CRP levels from the second but not the first day of admission. These findings suggest that proinflammatory cytokines or their soluble receptors may be more accurate early predictors of outcome than CRP. Moreover, markers of inflammation in the sera of patients with acute pancreatitis are highest in those who subsequently develop organ failure.
Randomized study of antibiotic prophylaxis for general and gynaecological surgery from a single centre in rural Africa
Authors: Reggiori A , Ravera M , Cocozza E , Andreata M , Mukasa F
Published: March 2007

In a district rural hospital in Uganda, 850 surgical patients were evaluated prospectively over a 3-year period to compare the clinical efficacy of conventional postoperative penicillin therapy with single-dose ampicillin prophylaxis for hernia repair and ectopic pregnancy, and with single-dose ampicillin-metronidazole prophylaxis for hysterectomy and caesarean section. The high rate of postoperative infection usually encountered in African hospitals after conventional treatment with penicillin for 7 days was significantly reduced with the new regimen: from 7·5 to 0 per cent in hernia repair and from 10·7 to 2·4 per cent in ectopic pregnancy; from 20·0 to 3·4 per cent in hysterectomy and from 38·2 to 15·2 per cent in caesarean section. Length of hospital stay and postoperative mortality rates were also significantly reduced. Single-dose ampicillin prophylaxis with or without metronidazole, although rarely used in developing countries, is more cost effective than standard penicillin treatment.
Perineal excision of the rectum
Authors: Poppen B , Svenberg T , Bark T
Published: March 2007

An intersphincteric and perimuscular approach was employed for perineal excision of the rectum in 33 patients who had previously undergone total colectomy with preservation of the rectum. Laparotomy was avoided in 28 of the 29 patients who had had closure of the rectal stump with ileostomy. Of the lour patients (two with ileorectal anastomoses and two with sigmoid mucous fistulas) for whom laparotomy was planned, this was considered to be much less extensive than would otherwise have been required. It is concluded that in patients who have previously undergone total colectomy for inflammatory bowel disease, subsequent perineal excision of the rectal stump without laparotomy is frequently possible.
Salvage surgery for ileal pouch outlet obstruction
Authors: Herbst F , Sielezneff I , Nicholls R J
Published: March 2007

Sixteen patients with ileal pouch outlet mechanical obstruction had major abdominal revision of the ileoanal anastomosis. Before operation all had severe difficulty in evacuation which required catheterization in 11. Eleven patients had a long efferent limb and/or long anorectal cuff, and five had a persistent stricture at the ileoanal anastomosis. None had pouchitis. The pouch was fully mobilized abdominally and the obstructing lesion resected. A new handsewn ileoanal anastomosis was formed. In two cases pouch volume was increased by incorporating an additional loop of ileum. All anastomoses but one were covered by a loop ileostomy. There were no deaths. Major complications occurred in two patients. Function was assessed in 15 patients; in one the ileostomy had not been closed. Median (interquartile range) frequency of defaecation per 24 h fell from 15 (7·3–19·5) to 6 (4·5–6·0) (P = 0·0033). Of the 11 patients who required a catheter before operation six evacuated spontaneously, three were improved but intubated on some occasions and two were unchanged after revisional surgery. Of the ten incontinent patients, five became continent, four were improved and one remained unchanged. There was a new continence disturbance in four (minor nocturnal in three) of the remaining five patients. One patient underwent further abdominal salvage surgery and another required establishment of an ileostomy because of poor function. Combined abdominoanal salvage surgery for outlet mechanical obstruction was successful in averting an ileostomy in 13 of 16 patients, and significantly improved pouch function in 12 of 15.
Randomized controlled trial of lateral internal sphincterotomy with haemorrhoidectomy
Authors: Mathai V , Ong B C , Ho Y H
Published: March 2007

A prospective trial was conducted to compare haemorrhoidectomy alone (control, group 1) with haemorrhoidectomy plus lateral internal sphincterotomy (group 2) for prolapsed piles. Some 33 patients (18 men, 15 women) of mean(s.e.m.) age 40(2·3) years were randomized, 16 to group 1 and 17 to group 2. There were no significant differences in postoperative pain scores. Mean resting and maximum anal squeeze pressures, studied 6 weeks and 3 months after operation, were generally lower in group 2, but were not significantly different. Two patients in group 2 were distressed by incontinence to liquid faeces which persisted in one after 1 year. There were no other complications in either group after a mean(s.e.m.) follow-up of 11(0·4) months. The addition of lateral internal sphincterotomy to routine haemorrhoidectomy is unnecessary and carries the added risk of incontinence.
Adrenalectomy for metastatic disease to the adrenal glands
Authors: Lo C Y , Van Heerden J A , Soreide J A , Grant C S , Thompson G B , Lloyd R V , Harmsen W S
Published: March 2007

A policy of supportive treatment is frequently adopted for patients with metastatic disease to the adrenal glands. This study reports an experience with adrenalectomy for adrenal metastasis. Between 1983 and 1993, adrenalectomy was performed in 52 patients for metastasis to the adrenal glands. Survival was calculated by the Kaplan- Meier method and compared with the log rank test. Primary tumour sites included kidney (n = 15), lung (n = 11), colon (n = 7), unknown (n = 5), stomach (n = 3), melanoma (n = 3) and other (n = 8). Adenocarcinoma (69 per cent) was the most common histological cell type. Thirty-two patients were asymptomatic on initial evaluation. Symptomatic adrenal pain relief was achieved in 11 of 13 patients. Overall survival rates were 73 per cent at 1 year and 40 per cent at 2 years. Patients with potentially curative resection had better survival than those who had a palliative procedure. Patients with adrenal metastases due to adenocarcinoma had improved survival compared with that in those with other histological cell types. Although long-term survival is generally poor, highly selected patients with adrenal metastasis (symptomatic disease or adenocarcinoma) may benefit from surgical resection.
Early postoperative plasma calcium concentration as a predictor of the need for calcium supplement after parathyroidectomy
Authors: Wong W K , Wong N A C S , Farndon J R
Published: March 2007

This study evaluated early postoperative serum calcium concentration as a predictor of hypocalcaemic symptoms and the need for calcium supplements. A total of 64 consecutive patients undergoing curative para- thyroidectomy for primary hyperparathyroidism were studied. Twenty patients (31 per cent) developed hypocalcaemic symptoms requiring calcium supplements. Plasma calcium levels in the preoperative and early postoperative periods were similar in patients who required calcium supplements and those in whom they were not necessary. There was no significant difference in the percentage decrease in early calcium levels after operation between the two groups. In those undergoing reoperative surgery and subtotal parathyroidectomy the percentage decline was significantly higher in patients who required calcium supplements (12.8 versus 5.6 percent, P <0.005). A fall of 10 per cent or more was consistently followed by hypocalcaemic symptoms. Calcium determination in the early postoperative period is of little value in predicting the onset of hypocalcaemic symptoms.
Ultrasonographic carotid plaque morphology in predicting stroke risk
Authors: Geroulakos G , Hobson R W , Nicolaides A
Published: March 2007

A number of new studies have provided evidence which suggests that carotid plaque surface characteristics and internal structure, as seen on ultrasonography, contribute to the development of cerebrovascular endpoints. This review is a critical presentation of the evidence that has emerged so far supporting the hypothesis that the ultra-sonographic morphology of the carotid plaque may be an independent variable in predicting the risk of stroke. It is concluded that Ultrasonographic plaque morphology should be used together with other local risk factors in prospective natural history studies which aim to identify a subgroup of patients at high risk of stroke.
Adhesion molecules as determinants of disease: From molecular biology to surgical research
Authors: Menger M D , Vollmar B
Published: March 2007

Cellular adhesion is mediated by distinct cell surface receptors (adhesion molecules) and plays a pivotal role in the biological processes of morphogenesis, cell migration and cell-cell communication. During the past decade many adhesion molecules have been identified and structurally analysed. This has allowed an understanding of their role in the pathophysiology of disease, including inflammation and sepsis, ischaemia and reperfusion, transplant rejection, atherosclerosis and thrombosis, angiogenesis and wound healing, as well as carcinogenesis and tumour metastasis. Understanding of the molecular mechanisms of cellular communication is not only vital for advances in surgical pathophysiology, it also has the potential to widen the spectrum of diagnosis and therapy of disease. Analysis of expression of individual surface molecules may help in the diagnosis of transplant rejection and allow a prognostic determination of tumour progression and metastasis formation. Moreover, manipulation of adhesion molecule function by monoclonal antibodies, antisense oligonucleotides or single gene products may open the door for novel therapeutic regimens to prevent transplant rejection and ischaemia-, sepsis- and shock-induced tissue injury.
Spontaneous rupture of hepatocellular carcinoma
Authors: Zhu L X , Wang G S , Fan S T
Published: March 2007

Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening condition; the mechanism is not clear but it is suggested that rupture is usually preceded by rapid expansion of the tumour secondary to bleeding from within its substance. Diagnosis may be made by abdominal paracentesis, ultrasonography, computed tomography or angiography; the positive rates of diagnosis are 86, 66, 100 and 20 per cent respectively. Prognosis is poor. Based on treatment results reported in the literature, the mean survival time for patients who underwent hepatectomy, transcatheter arterial embolization (TAE) and conservative therapy were 247, 98 and 13 days respectively. Judging from the reported results the first choice for emergency treatment of haemostasis is TAE. If laparotomy is undertaken, hepatic artery ligation, preferably of the branch supplying the liver lobe bearing the tumour, should be considered, together with haemostasis of the rupture site by various means (suture plication, packing, argon beam coagulation, use of microwave or absolute ethanol). Emergency hepatectomy should be reserved for patients with an easily resectable lesion who are in a stable cardiovascular condition. Conservative therapy may be used for selected patients in extremely poor condition. The rational treatment for the majority of patients with ruptured HCC is TAE, followed by hepatectomy if the lesion is resectable.
Immune function early in acute pancreatitis
Authors: Widdison A L , Cunningham S
Published: March 2007

Circulating lymphocyte numbers and activation together with granulocyte function were measured in 20 patients in the early stages of an attack of acute pancreatitis and in 20 healthy controls. Circulating lymphocytes, T lymphocytes, and CD4 and CD8 T lymphocyte subsets were decreased in both mild pancreatitis (67–80 per cent of controls) and severe pancreatitis (22–40 per cent of controls). CD4: CD8 ratios were unchanged and median (interquartile range) interleukin 2 receptor expression was increased from less than 1 per cent in controls to 14(6) per cent in severe pancreatitis, suggesting lymphocyte activation. Median granulocyte chemiluminescence was increased to 293 per cent of controls in severe pancreatitis and random motility was reduced to 77 per cent of controls, indicating increased metabolic activity. Complement-mediated antibody-independent opsonization and chemotaxis toward endotoxin were normal. Immune function is not reduced early in acute pancreatitis. Granulocyte hyperactivity may be important in the development of multiple organ failure.
Role of segmental colonic transit time studies to select patients with slow transit constipation for partial left-sided or subtotal colectomy
Authors: de Graaf E J R , Gilberts E C A M , Schouten W R
Published: March 2007

This prospective study investigated the value of segmental colonic transit time studies in the surgical treatment of slow transit constipation. Overall, 346 patients with chronic constipation were analysed; slow transit constipation was diagnosed in 86 (25 per cent). Based on the results of segmental colonic transit time studies, 18 patients underwent partial left-sided colectomy and 24 subtotal colectomy. Recurrent constipation was seen in three of 18 patients and seven of 24 respectively. Severe abdominal discomfort was noted in six of 18 and 15 of 24 respectively. Disabling diarrhoea and faecal incontinence developed in two of 14 and five of 20 patients with an anastomosis respectively. Although these results indicate that segmental colonic transit time studies are useful in selecting patients with slow transit constipation for partial left-sided or subtotal colectomy, both procedures should be performed with prudence.
No obvious advantages for thoracoscopic two-stage oesophagectomy
Authors: Robertson G S M , Lloyd D M , Wicks A C B , Veitch P S
Published: March 2007

Thoracoscopically assisted Ivor-Lewis oesophagectomy potentially combines the pulmonary advantages of transhiatal oesophageal dissection, with the visibility and control permitted by thoracotomy. This study reviewed 17 patients who underwent this procedure with an intrathoracic anastomosis. Five patients required conversion to thoracotomy, four because of technical difficulties with the anastomosis. After operation 13 patients had radiological evidence of atelectasis, six developed a left pleural effusion and five had clinically significant pneumonia. Three patients developed an anastomotic leak, two of whom died giving an in-hospital mortality rate of 12 per cent. Median postoperative hospital stay was 12 days. Four patients developed benign anastomotic strictures requiring dilatation. The 1- and 2-year survival rates were 73 per cent (11 of 15 patients) and 63 per cent (five of eight) respectively. The use of minimal access techniques in this context does not appear to reduce the postoperative incidence of either pulmonary or anastomotic complications.
Strategies to decrease the incidence of intra-abdominal recurrence in resectable gastric cancer
Authors: Averbach A M , Jacquet P
Published: March 2007

Two main approaches are suggested to improve treatment results in resectable gastric cancer: extended lymph-adenectomy and adjuvant antitumour therapy. Progress is to some extent stalled by the perception of gastric cancer as a pathophysiologically uniform disease; it has been demonstrated, however, that there are variants of gastric cancer associated with predominantly intra-abdominal spread or with haematogenous metastases. Recent clinicopathological studies have provided information about the mechanisms of this metastatic diversity. A review of clinical trials suggests that no single method of treatment can efficiently address all variants of gastric cancer spread, but new treatment strategies may be based on defining the pathophysiological variant of gastric cancer and selecting adjuvant therapy according to the most probable mode of tumour spread. Treatment should start with surgery which includes a ‘reasonably’ extended lymphadenectomy aimed at achieving an increased rate of curative resection and more accurate staging. Risk factors for peritoneal spread of tumour require the perioperative use of intraperitoneal chemotherapy. Subsequent adjuvant therapy may be indicated in patients at high risk of further cancer spread or occult metastases, as determined by pathological examination of the resected specimen.
Resection of hepatocellular carcinoma in patients with cirrhosis
Authors: Balsells J , Charco R , Lazaro J L , Murio E , Vargas V , Allende E , Margarit C
Published: March 2007

Between 1987 and 1993, 53 hepatic resections for hepatocellular carcinoma (HCC) were performed in 51 patients with cirrhosis. Limited hepatic resection was performed in 66 per cent of patients. The postoperative mortality rate was 13 per cent. The tumours recurred in 27 patients (53 per cent), and the cumulative recurrence rate at 1 and 4 years was 41 and 89 per cent, respectively. Mean time to recurrence was 11·7 months and the most frequent site was the liver (21 patients). The only significant risk factor for recurrence was symptomatic tumours. The recurrence rate of HCC in patients with cirrhosis with surgical resection alone is high and actuarial survival at 4 years is very low. Other approaches to the treatment of HCC in patients with cirrhosis require consideration.
Use of glyceryl trinitrate ointment in the treatment of anal fissure
Authors: Lund J N , Armitage N C , Scholefield J H
Published: March 2007

Anal fissure is often treated surgically by sphincterotomy. There is growing concern over the effects of this procedure on continence. Nitric oxide donors such as glyceryl trinitrate are thought to cause a reversible ‘chemical sphincterotomy’, capable of healing the fissure. Twenty-one consecutive patients with chronic anal fissure (13 women, mean age 36 years) were treated for 4–6 weeks with 0·2 per cent glyceryl trinitrate ointment applied to the fissure twice daily. Maximum anal resting pressure (MARP) was measured before and after application of the ointment at the first visit. There were 16 posterior and five anterior fissures. Mean(s.d.) MARP fell from 118·7(45·0) to 70·3(34·1) cmH2O over 20 min after application of the ointment (P<0·001). Healing was complete in 11 patients at 4 weeks and in 18 at 6 weeks. The fissure recurred in four patients after cessation of treatment; three were successfully treated by further glyceryl trinitrate. Mild headache occurred in four patients. Anal fissure can be successfully treated with 0·2 per cent glyceryl trinitrate ointment applied topically.
Prospective audit of discharge summary errors
Authors: Macaulay E M , Cooper G G , Engeset J , Naylor A R
Published: March 2007

During an 8-month interval of prospective audit, 63 of 637 (10 per cent) vascular discharge summaries were found to contain 94 errors. These comprised 11 (12 per cent) general errors, 21 (22 per cent) diagnostic errors, 19 (20 per cent) operative data errors, 19 (20 per cent) cases of incorrect clinical text information, 14 (15 per cent) missed complications and 10 (11 per cent) concerning follow-up arrangements. Overall, 2 per cent of consultant discharge summaries contained errors compared with 7 per cent for the senior registrar, 10 per cent for registrars and 17 per cent for senior house officers. Given that the majority of discharge summaries are currently prepared by junior staff, this study suggests that verification of the accuracy of clinical and management data should be an essential component of departmental audit meetings.
Experimental application of controlled limb reperfusion after incomplete ischaemia
Authors: Ihnken K , Beyersdorf F , Winkelmann B R , Mitrev Z , Unkelbach U
Published: March 2007

Severe local and systemic complications may occur after revascularization of extremities exposed to prolonged complete or incomplete ischaemia. These complications may be reduced by controlling the reperfusate and the circumstances of the reperfusion period. Ten adult German domestic pigs were exposed to 6 h of incomplete limb ischaemia by occlusion of the left iliac artery. To simulate the clinical situation of embolectomy, the occlusive snares were released after the ischaemic period in five pigs and normal blood flow developed with systemic pressure (uncontrolled reperfusion). In the other five pigs, a controlled reperfusate was delivered at controlled pressure before establishing normal blood reperfusion (controlled reperfusion). At the end of the observation period (90 min after start of reperfusion), the group with controlled reperfusion had a lower mean(s.e.m.) tissue water content (81·8(0·7) versus 84·3(0·7) per cent, P<0·05, a greater increase in tissue adenosine 5′-triphosphate compared with values at the end of ischaemia (6·2(1·5) versus - 2·5(1·8) μmol per g protein, P<0·03), a higher tissue pH (7·2(0·1) versus 6·8(0·1), P<0·03), a smaller temperature decrease (0·3(0·2) versus 1·2(0·3)°C, P<0·05), lower concentrations of creatine kinase (355·0(87·5) versus 624·4(73·4) units/1, P<0·05) and lactate dehydrogenase (LDH) (369·5(42·5) versus 538·4(39·2 units/1, P<0·03) in the femoral vein blood and lower LDH concentrations (356·5(48·9) versus 546·0(37·8 units/1, P<0·03) in central venous blood. These data indicate that severe local and systemic damage occurs with uncontrolled (normal blood) reperfusion even after incomplete limb ischaemia, and that these changes can be reduced by delivering a controlled reperfusate under controlled conditions.
Limited operation for gastric cancer in the elderly
Authors: Tsujitani S , Katano K , Oka A , Ikeguchi M , Maeta M , Kaibara N
Published: March 2007

The relationship between operative procedures for treatment of patients with gastric carcinoma and complications was studied with special reference to the age of patients, who were divided into four groups: 50–59 years; 60–69 years; 70–79 years; and over 80 years. Preoperative risk factors that were common in patients over 70 years of age were hypertension and cardiac disease. The selected operative procedures were similar for each age group. However, neither proximal gastrectomy nor reconstruction by jejunal interposition was selected for patients of 80 years and over. In these patients, resection of the neighbouring organs was seldom performed and lymph node dissection was usually limited to the primary and secondary nodes. There was no significant difference in the rate of postoperative complications between groups. Although only limited surgery was performed for patients of 80 years and over, there was no significant difference in age-corrected cumulative survival rate between groups. Therefore, limited resection and/or lymph node dissection may allow safe surgical treatment for patients of 80 years and over with gastric carcinoma, without any negative effect on prognosis.
Incidence of clinical pulmonary embolism after laparoscopic surgery
Authors: Inderbitzin D T , Opitz I , Giger U , Kocher T , Krähenbühl L
Published: March 2007

Background

This study aimed to determine the incidence of pulmonary embolism (PE) following laparoscopic surgery and its potential risk factors.

Methods

Data concerning 44 453 patients from 114 surgical institutions were collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery. The incidence of postoperative PE despite thromboprophylaxis was evaluated and potential risk factors were assessed singly, and then in a consecutive stepwise logistic multiple regression analysis.

Results

Among 44 453 patients assessed, 55·8 per cent were female and 44·2 per cent were male. Interventions included cholecystectomy (52·8 per cent), hernia repair (17·7 per cent), appendicectomy (12·4 per cent), colonic surgery (4·6 per cent) and oesophageal surgery (5·5 per cent). Postoperative PE occurred in 86 patients (0·2 per cent), and the incidence tended to decrease during this study (P = 0·016). A total of 149 patients died (0·3 per cent) of which nine (6·0 per cent) were due to PE. Significant predictive risk factors were female sex (P < 0·001), age (P < 0·001), weight above 90 kg (P < 0·001), emergency procedure (P < 0·001) and operating time exceeding 150 min (P < 0·001).

Conclusion

The low incidence of PE after laparoscopy, with a further decrease over the past decade, suggests a tendency towards improved perioperative thromboembolic risk management.