bluuebunny/crossref_metadata_2025 huggingface dataset:
Simulation in surgical training using freeze dried material
Authors: Stotter Ann T , Becket A J , Hansen J P R , Capperauld I , Dudley H A F
Published: March 2007

The acquisition of manual dexterity and surgical skills is usually achieved in the operating theatre under supervision. We describe an efficient way of learning intestinal anastomosis procedures with the use of gamma irradiated, lyophilized porcine or bovine tissues together with a purpose designed holding jig. Preliminary evaluation of this method with untrained subjects showed that they were able to improve their performance. Because the tissues are sterile, health hazards are avoided and no special laboratory facilities are required. This approach has promise as an aid to evaluation as well as training.
Clearance technique for the detection of lymph nodes in colorectal cancer
Authors: Cawthorn S J , Gibbs N M , Marks C G
Published: March 2007

Lymph node metastases are an important determinant of prognosis following surgery for colorectal cancer. A xylene alcohol clearance technique has been employed in Guildford to facilitate the identification of lymph nodes in the mesorectum of rectal cancer specimens. The numbers of lymph nodes and lymph node metastases were compared with seven other centres and St. Mark's Hospital, where clearance techniques were not employed in patients undergoing a randomized trial of preoperative radiotherapy for rectal cancer. The total number of lymph nodes identified per patient in the mesorectum of patients at Guildford (mean = 23.1 ± 1.18) was significantly higher when compared with patients at St. Mark's Hospital alone (mean = 13.1 ± 0.86) and the seven combined ‘non-cleared’ centres (mean = 10.5 ± 0.6) (P < 0.001). The number of lymph node metastases per patient was significantly higher in the Guildford series (mean = 3.21 ± 0.58) when compared with the seven combined centres (mean = 1.9 ± 0.3) (P < 0.05). The numbers of lymph node metastases found in the lowest part of the specimen close to the levator ani were significantly higher in the Guildford patients (mean = 1.2 ± 0.4) compared with St. Mark's Hospital (mean = 0.13 ± 0.1) and the seven combined ‘non-cleared’ centres (mean = 0.56 ± 0.1). This clearance technique identified not only a greater number of lymph nodes but also more metastases within those nodes, particularly in the supralevator area of the mesorectum.
On-table lavage to achieve safe restorative rectal and emergency left colonic resection without covering colostomy
Authors: Thomson W H F , Carter S St C
Published: March 2007

On table orthograde colonic lavage has been used in a nearly consecutive series of 122 cases of restorative rectal resection (16 for acutely obstructing rectosigmoid lesions), and in a further 4 cases of acutely obstructing left colonic carcinoma, with the aim of both achieving safer anastomoses in these adverse circumstances and avoiding a covering colostomy. The technique was found to be safe and to be effective, only five temporary colostomies being required for management of anastomotic leakage. The incidence of clinical anastomotic leakage was 4.8 per cent.
Carcinoma of the ampulla of Vater
Authors: Knox R A , Kingston R D
Published: March 2007

Experience in treating tumours of the ampulla of Vater in the North West region of the UK is reviewed. The results of local resection, radical resection and palliative bypass in 61 cases have been compared. Local resection in this series offers a better survival than radical procedures at one, two, three and five years. The operative mortality for radical procedures was 30 per cent. There were no operative deaths in those patients having a local resection. No patient having palliative bypass surgery survived more than 18 months.
Aspirate cellularity as a rapid indicator of renal allograft rejection
Authors: Wilson R G , Shenton B K , Taylor R M R , Proud G
Published: March 2007

No rapid and unequivocal test exists to diagnose renal allograft rejection. Despite advances in immunosuppression over the last 20 years, rejection is still the major problem in clinical organ transplantation. Most transplant centres report a renal graft survival rate of about 60 per cent at 5 years and the majority of graft losses are due to rejection. An influx into the graft of various cell types has been implicated in the diagnosis of rejection but it takes up to 24 h to obtain such information histologically. We have carried out fine needle aspiration biopsy of the allografts and estimated the number of white cells in the aspirate using a fluorescence activated cell sorter. Studies were performed in 34 cases of normal allograft function, 8 of rejection, 8 of acute tubular necrosis and 8 of cyclosporin nephrotoxicity. There was a statistically significantly higher cell number in the group undergoing rejection (P < 0.01; Wilcoxon unpaired test) when compared to each of the other three groups. We believe that this technique, which takes only a few minutes to perform, could yield much valuable information. It deserves further study.
Meckel's diverticulum in the adult
Authors: Leijonmarck C-E , Bonman-Sandelin Kerstin , Frisell J , Räf L
Published: March 2007

The management of Meckel's diverticulum (MD) incidentally detected in adults remains controversial. To assess the risk involved in excision of such diverticula and the incidence of complications arising from MD in adult life, we analysed 260 cases of MD found at laparotomy in a baseline population during a 15-year period. There were 148 symptomless and 112 symptom-producing diverticula, with intestinal obstruction as the most common complication. Assuming a 2 per cent general incidence of MD, the complication rate in these adult patients was 0.03 per cent per year. The calculated lifetime risk of complication from MD was 3.7 per cent at age 16 years, falling to zero in old age. Excision of an incidentally detected MD entailed a 6 per cent rate of major complications. Twenty-eight symptomless diverticula were not excised, and follow-up revealed no complications in these cases. In adults an incidentally discovered, symptomless Meckel's diverticulum should be left in place.
Familial hypocalciuric hypercalcaemia as a differential diagnosis of hyperparathyroidism: Studies in a large kindred and a review of surgical experience in the condition
Authors: Lyons T J , Crookes P F , Postlethwaite W , Sheridan B , Brown R C , Atkinson A B
Published: March 2007

We have studied 46 members of a large kindred with familial hypocalciuric hypercalcaemia (FHH) after a neck exploration failed to cure hypercalcaemia in an asymptomatic patient. Serum calcium, serum phosphate, plasma parathormone and vitamin D metabolites do not distinguish affected members from patients with hyperparathyroidism. Because of the continuing debate as to whether or not FHH is a variant of, or distinct from, hyperparathyroidism, we have carried out a review of surgical experience with subtotal parathyroidectomy in hyperparathyroidism secondary to parathyroid hyperplasia and in FHH. Whereas the procedure is successful in 90 per cent of the former cases only one case of FHH has been cured by it. This provides evidence for the two conditions being aetiologically distinct. Before patients with asymptomatic hypercalcaemia are referred for parathyroid surgery the calcium:creatinine clearance ratio should be measured using a 2 h urine sample collected after an overnight fast and a fasting blood sample. If this ratio is less that 0·01 then screening of first degree relations should be undertaken before any parathyroid surgery is performed. Unnecessary surgery can therefore be avoided.
Injection sclerotherapy of oesophageal varices with the freehand technique: Experience in Hong Kong
Authors: Lai E C S , Choi T K , Fok M , Wong J
Published: March 2007

A prospective study of the efficacy of injection sclerotherapy with the freehand technique for acute bleeding oesophageal varices was conducted, to evaluate its use in the control of acute variceal bleeding and to assess long-term sclerotherapy as the definitive treatment. Between July 1981 and January 1985, a total of 108 patients (96 men, 12 women with mean age of 54·4 years) had intravariceal injection of 5 per cent ethanolamine oleate. The majority had non-alcoholic cirrhosis and alcoholism accounted for only 18·5 per cent. There were 22 Child's A, 42 Child's B and 44 Child's C patients. During the 411 sessions of injection, major complications occurred in 12 patients (11·1 per cent) with 3 deaths. Of the 145 episodes of acute variceal bleeding 91·7 per cent were successfully controlled. In episodes which required more than one injection to control the bleeding, there was a high mortality of 75 per cent. Over the three and a half year period, 33 out of the 93 patients on long-term sclerotherapy had re-bled (35·5 per cent). Varices were obliterated in 27 patients with a mean of 5·4 injections. From our experience, the procedure is safe and effective. However, its status as a definitive treatment when compared with conventional surgical treatment requires further controlled evaluation.
Twenty year experience with familial polyposis coli in Cape Town
Authors: Aitken R J , Elliot M S , Torrington M , Louw J H
Published: March 2007

Forty-nine patients undergoing surgery for familial polyposis coli (FPC) over a twenty year period are presented. Forty-three patients underwent total colectomy with ileorectal anastomosis (TC + IRA) and five patients subsequently developed a rectal carcinoma. The incidence of rectal carcinomafollowing TC + IRA appears to increase with time. There were significant postoperative complications secondary to adhesive obstruction and desmoid tumour recurrence. Upper gastrointestinal pathology has been detected by endoscopy in only one of nine patients, but the importance of upper gastrointestinal pathology is now appreciated. The problem of screening a widely distributed and closely knit community has been considerable. TC + IRA remains the operation of choice for the majority of patients with FPC, but a total colectomy with ieal reservoir and ileo-anal anastomosis is appropriate in some cases.
Amylase and gut infarction
Authors: Wilson C , Imrie C W
Published: March 2007

Serum amylase has been determined on admission in 63 (52 per cent) of 122 patients with acute mesenteric infarction. Amylase levels were normal in 34 (54 per cent) and reached greater than twice normal in 15 patients (24 per cent). In 5 patients (3 on admission) amylase levels were in the diagnostic range of acute pancreatitis (> 1200 units/I) leading to inappropriate non-operative treatment in 4. Hyperamylasaemia was found in association with all aetiologies of infarction. The magnitude of the hyperamylasaemia appeared to be related to the extent of the bowel infarction, the highest levels occurring when infarction involved the small bowel and colon. The mechanism of hyperamylasaemia in acute mesenteric infarction is discussed.
Surgery for peptic ulceration associated with hypergastrinaemia
Authors: Clark C G , Chowcat N L , Lewin M R , Gilbert J M , Gelister J S K , Boulos P B
Published: March 2007

Between 1971 and 1983, 31 males and 13 females were found to have peptic ulceration associated with hypergastrinaemia. An antral G-cell lesion was present in 11 (25 per cent) and a gastrinoma in 14 (32 per cent). There were 11 patients with multiple endocrine adenomatosis (MEA) (25 per cent) and 4 (9 per cent) with primary hyperparathyroidism. Four patients (9 per cent) were unclassified. Length of history and level of gastrin did not differentiate between the groups and an average of 2·5 operations was performed per patient, while the overall mortality was 27·3 per cent. The patients with G-cell lesions were significantly younger than all the other groups (P <0·01). Partial gastrectomy adequately treated G-cell hyperplasia. Total gastrectomy was required to treat pancreatic gastrinomata but additional pancreatic resection did not improve the outcome. In MEA, parathyroidectomy did not influence the treatment of a gastrinoma. This is the first recorded experience of surgery for hypergastrinaemia in the United Kingdom and the outcome of such a retrospective study may be a guide to the future management of these conditions.
Daily salivary progesterone levels in cyclical mastalgia patients and their controls
Authors: Kumar S , Mansel R E , Wilson D W , Read G F , Truran P L , Hughes L E , Griffiths K
Published: March 2007

Progesterone levels were measured in samples of saliva collected daily throughout the menstrual cycle in patients with pronounced cyclical mastalgia and breast nodularity. A control group matched for age, length of menstrual cycle and parity was also studied. No significant differences in progesterone levels were detected between the two groups for the luteal phase of the cycle. These data indicate that cyclical mastalgia is not associated with significant luteal phase progesterone insufficiency, as demonstrated by salivary levels and, by implication, serum levels of progesterone.
Parathyroid hormone levels, hyperparathyroidism and acute pancreatitis
Authors: Shearer M G , Imrie C W
Published: March 2007

Since 1971, in Glasgow Royal Infirmary 880 patients with acute pancreatitis (AP) have been prospectively studied. Only two (0·23 per cent) have been found with associated hyperparathyroidism (HPT), one of whom also had gallstones. During the period of study daily serum calcium levels were measured routinely in all patients with AP and, in addition, a consecutive series of 200 patients had daily mineral metabolism screening of blood and urine in an attempt to identify patients with hypercalcaemia as an aetiological factor. A separate group of 90 patients had sequential daily serum calcium and parathyroid hormone assays (PTH) performed for the first five days of their hospital admission and one of the patients described in this paper came from this group. She is the first patient, to our knowledge, documented in this manner. The overall pattern of the PTH and calcium response from all these patients is also recorded according to the severity of the AP. Hyperparathyroidism is uncommonly associated with AP and when it is other aetiological factors must be excluded.
Comparison of stapling and handsuture for left-sided large bowel anastomosis
Authors: Everett W G , Friend P J , Forty J
Published: March 2007

One hundred patients undergoing elective left-sided colonic or rectal resections were randomly allocated to have an anastomosis performed either with the EEA stapling gun or by hand suture using a single layer of interrupted sutures. In six patients the anastomosis could not be performed with the stapling gun. Clinical leakage occurred in two of the remaining 94 cases; both had hand-sutured anastomoses. Radiological leakage was demonstrated in 13 further cases (7 stapled, 6 sutured); there was no statistical difference in leakage rate with stapled and hand-sutured anastomoses.
Clinical results 1–10 years after highly selective vagotomy in 306 patients with prepyloric and duodenal ulcer disease
Authors: Enander L , Rydberg B , Adami H-O , Enander L K , Ingvar C
Published: March 2007

Overall clinical results were assessed 1–10 years after routinely performed highly selective vagotomy (HSV) in 326 consecutive patients suffering duodenal and prepyloric ulcer disease, operated on by 37 surgeons of varying seniority at a district general hospital. Three hundred and six (94 per cent) patients were followed up. No mortality was recorded after 326 primary and 50 reoperative procedures. Postoperative complications were few and diminished during the study period. Persistent moderate to severe dumping was found in 2.3 per cent of the patients; slight and periodic, but in no case disabling, diarrhoea in 11 per cent and gastric retention in 2.1 per cent. The overall clinical ulcer recurrence rate was 13.8 per cent, with a tendency towards better results during the second 5 year period. Significant differences were found between individual surgeons and groups of surgeons. Recurrences tended to be located more proximally than the primary ulcer. Fifty reoperations were performed in forty patients for ulcer recurrence (twenty-five), persistent ulcer-like symptoms (twelve) and gastric retention (three). When all recurrences and reoperations were classified as failures the symptomatic assessment according to Visick showed 67 per cent of the patients in grades I–II and 26 per cent in grade IV but the corresponding figures from the patients' own classification including the results of reoperations were 79 per cent and 7 per cent. It is concluded that for the time being HSV is the method of choice for the elective surgical treatment of duodenal and prepyloric ulcer disease.
Cement bezoars of the stomach
Authors: Visvanathan R
Published: March 2007

Cement ingestion resulting in the formation of concretions in the stomach is unusual in surgical practice. Cement bezoars that are retained in the stomach do not undergo degradation and attempts at chemical dissolution are not recommended. Early surgical removal is the only safe and effective method of treatment. Smaller concretions are excreted without incident but may cause intestinal obstruction which should be anticipated and surgically relieved.
Beneficial response to pituitary ablation following aminoglutethimide
Authors: Bundred N J , Eremin O , Stewart Helen J , Dale B A , Forrest A P M
Published: March 2007

Twenty-five postmenopausal women with advanced carcinoma of the breast, who were treated initially with aminoglutethimide alone (14 patients) or combined with tamoxifen (11 patients) had, on relapse or failure of treatment, a pituitary ablation performed. Initial therapy had produced a complete response in one patient, a partial response in 7, disease stasis in 6 but was without benefit in 8 patients. A further three patients were intolerant of aminoglutethimide therapy. Ten of these 25 patients benefited from subsequent pituitary ablation (1 complete response, 4 partial responses and 5 disease stasis), both local and distant sites of disease being influenced by this further therapy. Experience is also reported of 10 patients with advanced breast cancer who were treated initially by pituitary ablation and then subsequently received aminoglutethimide therapy. None responded. It is concluded that pituitary ablation should be considered for patients with progressive disease following aminoglutethimide therapy, irrespective of the therapeutic response to aminoglutethimide.
Circumumbilical incision for pyloromyotomy
Authors: Tan K C , Bianchi A
Published: March 2007

Forty infants with infantile hypertrophic pyloric stenosis had a Ramstedt pyloromyotomy through a circumumbilical incision. Delivery of the pylorus was relatively easy. Mild wound infection occurred in three infants and a further child developed a purulent discharge. There was one instance of abdominal wall dehiscence and all the resultant scars were hardly visible, thus achieving an apparently unscarred abdomen.
Second hepatic resection for recurrent hepatocellular carcinoma
Authors: Nagasue N , Yukaya H , Ogawa Y , Sasaki Y , Chang Y-C , Niimi K
Published: March 2007

During the last 5 years, radical hepatic resection was performed in 91 patients with hepatocellular carcinoma (HCC). Thirty-one of them had tumour recurrence in the remaining liver during the follow-up period. Second hepatic resection was carried out on nine of them 4–38 months after the first hepatectomy. The ages of these patients ranged from 39 to 65 years with an average of 53·7. There were six men and three women. Eight patients had underlying cirrhosis of the liver and one chronic active hepatitis. Six patients are alive, four being free of HCC and two with disease, for 15–45 months after the first operation. Two patients died of systemic cancer dissemination. The remaining patient had tumour recurrence in the liver again and died of hepatic failure after the third laparotomy. The survival rate of these nine patients was significantly better than that of twenty-two patients who were treated by other palliative methods. The present result shows that a second hepatic resection is a possible and meaningful method of treatment for the patients with recurrent HCCs in the liver remnant.
Randomized trial of oral adjuvant razoxane (ICRF 159) in resectable colorectal cancer: Five-year follow-up
Authors: Gilbert J M , Hellmann K , Evans Margaret , Cassell P G , Taylor R H , Stoodley B , Ellis H , Wastell C
Published: March 2007

Razoxane is one of the few agents which has shown activity in the treatment of advanced colorectal cancer. The drug has therefore been evaluated in a prospective randomized controlled trial as an adjuvant to surgery for resectable colorectal cancer. The results to median follow-up of 5 years are reported here. Accrual has ceased and a total of 272 patients entered the trial (133 control, 139 treatment). Treated patients received razoxane postoperatively on a continuous, long-term basis while control patients received identical clinical care but no adjuvant chemotherapy. Analysis of the results shows a significant prolongation of the time to recurrence for Dukes' C patients. All other groups including the overall analysis show no benefit although there is a consistent trend in favour of the treated patients except in Dukes' group ‘D’. Razoxane is tolerated well by patients and causes minimal side-effects. However acute leukaemia occurred in three patients (2·45 per cent) after prolonged exposure to the drug and further evaluation should be in patients who are at high risk of developing recurrent cancer, in whom such a risk may be acceptable. It is concluded that razoxane is suitable for further evaluation in colorectal cancer and for incorporation into combination chemotherapy regimens.
Endoscopic sphincterotomy for retained common bile duct stones in patients with T-tube in situ in the early postoperative period
Authors: O'Doherty D P , Neoptolemos J P , Carr-Locke D L
Published: March 2007

We report on thirty-nine patients who underwent endoscopic sphincterotomy (ES) and stone extraction for retained common bile duct calculi with a T-tube in situ. Sixteen of the patients had undergone unsuccessful attempts at removal by flushing or dissolution by cholesterol solvents. A total of 76 stones were present: 53 distal to the T-tube and 23 proximal to the T-tube. ES and clearance of the common bile duct was achieved in 37 patients (95 per cent) and complications occurred in three patients (7·7 per cent). This method is an effective and relatively safe method in the early postoperative period allowing rapid treatment during the same admission as for the original operation and early hospital discharge.
Changing epidemiology, diagnosis, and treatment of Clostridium difficile toxin-associated colitis
Authors: Talbot R W , Walker R C , Beart R W
Published: March 2007

One hundred and ninety patients with Clostridium difficile toxin-associated colitis (CTAC) or pseudomembranous colitis (PMC) were identified, from microbiology records, disease index and proctoscopy service records, and studied retrospectively. CTAC was associated with cephalosporin antibiotic administration in 70 per cent of the patients. CTAC developed postoperatively in 108 patients after all types of surgery with no preponderance for abdominal surgery. Identification of cytotoxin in stool samples was the primary diagnostic test in 81 per cent of patients but cytotoxin was isolated in 98 per cent of all patients. Pseudomembranes visible on proctoscopy established the diagnosis in 19 per cent of patients and were more commonly seen in severe colitis (71 per cent) than in mild colitis (23 per cent). CTAC responded similarly to oral vancomycin and metronidazole with a relapse rate of 20–23 per cent, respectively. With its association with cephalosporin administration, CTAC is likely to occur with increasing frequency in surgical practice. Oral metronidazole is an effective, cheap, alternative to vancomycin therapy.
Endoluminal ultrasound in the assessment of local invasion in rectal cancer
Authors: Beynon J , Foy D M A , Roe A M , Temple L N , Mortensen N J McC
Published: March 2007

A new method for staging local invasion in rectal cancer has been assessed. Thirty-eight patients with primary rectal cancers have been examined pre-operatively with endoluminal rectal ultrasound and results compared with histological analysis of resected specimens in 33 cases. Three patients who also underwent laparotomy but not resection had good evidence of both stage T3 (1) and T4 (2) disease. The coefficient of correlation between ultrasonic and histological staging was 0·93 (P < 0·001). Invasion beyond the muscularis propria was predicted with a sensitivity of 96 per cent, specificity of 92 per cent and a predictive value of 96 per cent.
Diagnostic yield of endoscopic retrograde cholangiopancreatography in carcinoma of the pancreas
Authors: Gilinsky N H , Bornman P C , Girdwood A H , Marks I N
Published: March 2007

The results of 117 consecutive endoscopic retrograde cholangiopancreatographic (ERCP) examinations in patients with adeno-carcinoma of the pancreas, performed over a six year period, are reported. The diagnostic accuracy of this procedure (80.3 per cent) was higher than that of computed tomography (63.6 per cent) and ultrasonography (54.0 per cent). Fewer false negative diagnoses were made by retrograde cholangiopancreatography (7.7 per cent) than with the other procedures (28 per cent each). Analysis of the total ERCP experience during the study period revealed a false positive rate for malignancy of 5.6 per cent. In situations where investigations are performed by individuals with a broad spectrum of expertise, ERCP is superior to other methods in diagnosing pancreatic carcinoma, even in areas with a high prevalence of chronic pancreatitis.
Stapled ileo-anal anastomosis: A technique to avoid mucosal proctectomy in the ileal pouch operation
Authors: Heald R J , Allen D R
Published: March 2007

Ten patients have undergone abdominal proctocolectomy with the formation of an ileal reservoir anastomosed onto the anal canal using a stapling device. This technique avoids stripping of the rectal mucosa from the muscle tube (mucosal proctectomy) which is time consuming and often difficult. One patient is awaiting closure of her ileostomy. The remaining seven are continent and are passing between one and six motions a day.
Surgical management of ‘lymphangioma circumscriptum’
Authors: Browse N L , Whimster I , Stewart G , Helm C W , Wood J J
Published: March 2007

The results of surgery in 29 patients with ‘lymphangioma circumscriptum’ have been reviewed 2–8 years after operation. They show that in regard to management there are two varieties: small lesions, < 7 cm diameter, in favourable sites of the body, which are potentially curable; and large lesions, > 7 cm diameter on the skin with an even larger area of subcutaneous cysts, in which complete excision of all the skin and subcutaneous vesicles would require skin grafting. Nine patients had small lesions excised. Seven have had no recurrence. Twenty patients had large lesions treated by a radical excision of all or as much of the cyst bearing subcutaneous tissues and skin as possible, but leaving enough skin to permit a primary suture, even though it meant leaving skin vesicles. The lesion was controlled and the cosmetic appearance improved in 16 patients. Subsequent regression of many of the vesicles not excised supports the aetiological hypothesis of the skin lesions proposed by Whimster.
Oesophageal emptying in patients with gastro-oesophageal reflux
Authors: Maddern G J , Jamieson G G
Published: March 2007

A reproducible radionuclide technique for measurement of oesophageal emptying of a solid bolus has been used to study normal control subjects, patients with gastro-oesophageal reflux and a subgroup of these patients before and after fundoplication. The number of swallows to empty the oesophagus was significantly delayed in the gastro-oesophageal reflux group compared to controls (P < 0.001). As a group, patients describing dysphagia had slower oesophageal emptying than patients without dysphagia (P < 0.001). The presence or absence of pre-existing oesophagitis did not influence oesophageal emptying significantly. Following fundoplication patients did not show any significant alteration in their oesophageal emptying compared with their pre-operative studies, although individually changes were noted in two patients. The solid bolus oesophageal emptying test is easily performed, well tolerated by patients and is a useful method for studying oesophageal dysfunction.
Distal splenorenal (Warren) shunt in the management of actively bleeding oesophageal varices
Authors: Peterson K , Giles G R
Published: March 2007

Distal splenorenal shunts have been performed on 53 patients during or soon after variceal haemorrhage. In 38 patients active haemorrhage was occurring at the time of operation or was controlled by tamponade and 12 of these patients died. There was no mortality in the semi-elective group. A higher mortality was found in patients with poor liver reserve and in whom prolonged conservative management had been attempted. Rebleeding occurred in 20 per cent of patients in the early postoperative period and this was a significant factor in the death of three patients. Of 39 patients with longer term follow-up, 8 suffered minor encephalopathy. Subsequent mortality could be related to the progression of liver disease and was no worse than that seen in a population of cirrhotic patients.
A randomized clinical trial of oral ursodeoxycholic acid in obstructive jaundice
Authors: Thompson J N , Cohen J , Blenkharn J I , McConnell J S , Barr J , Blumgart L H
Published: March 2007

Forty patients with obstructive jaundice (bilirubin > 100 μmol/l) were entered into a randomized trial of oral ursodeoxycholic acid for 48 h before surgery versus no additional therapy. Pre-operative venous and operative portal total bile salt concentrations were higher in the bile salt treated patients (P < 0·001). Portal endotoxaemia during operation was reduced in ursodeoxycholic acid treated patients (P < 0·05). There was no significant difference in systemic venous endotoxaemia, renal function or postoperative morbidity or mortality. This study suggests pre-operative oral bile salt therapy may be of no clinical benefit in patients with obstructive jaundice.
Surgical aspects of pancreatic abscess
Authors: Stricker P D , Hunt D R
Published: March 2007

In a retrospective study of all patients admitted with acute pancreatitis to a single hospital over the 10 year period 1975–1984, 22 patients operated upon for pancreatic abscess complicating acute pancreatitis were identified. The accuracy of the assessment by the surgeon of the extent of the abscess and the results of treatment by either local or wide drainage have been reviewed. The surgeon underestimated the extent of the abscess in 5 of the 22 patients. Four of these five patients were assessed as having a localized abscess presenting in the lesser sac and, in the other, the abscess was thought to be confined to the tail of the pancreas. Local exploration and drainage were performed in 13 patients and resulted in a high morbidity and mortality (54 per cent). Wide exploration was performed in nine patients with only two deaths, despite the greater extent of abscess formation. Improvement in outcome seen in the second 5 year period appears to be due to a more aggressive approach to exploration and drainage. The surgeon must be aware that abscesses in the lesser sac often signify more widespread abscess formation. Without wide exploration of the pancreas, assessment at laparotomy is likely to be unreliable. There appears to be additional benefit from wide drainage, even where abscess formation appears localized.
Leg ulcers: Epidemiology and aetiology
Authors: Cornwall Julia V , Doré Caroline J , Lewis J D
Published: March 2007

In a regional Health District with a population of 198900, 357 patients with 424 ulcerated legs were documented, an overall prevalence of 0.18 per cent. The prevalence of ulceration in the 92 100 aged > 40 years was 0.38 per cent. Fifty per cent of the lesions had been present for more than one year, and 62 per cent of patients had never attended any hospital. The patients were stratified by history of peripheral arterial disease. A random sample (100 patients, 193 legs) was examined by ultrasound and photoplethysmography to assess the venous and arterial circulation; 38 per cent had evidence of deep vein involvement and 43 per cent had superficial vein incompetence. An ischaemic element was present either in isolation (9 per cent) or combined with venous disease (22 per cent) in a total of 31 per cent, with a mean pressure index of 0.62 (s.d. 0.14). Simple objective methods of assessment together with dedicated community staff with ready access to specialized facilities can enhance the service provided to patients with leg ulcers.
Low molecular weight heparin plus dihydroergotamine for prophylaxis of postoperative deep vein thrombosis
Authors: Sasahara A A , Koppenhagen K , Häring R , Welzel D , Wolf H
Published: March 2007

In a prospective, double-blind investigation of the prophylaxis of deep vein thrombosis (DVT) in patients undergoing elective major abdominal surgery, 269 patients were randomized into two groups. One hundred and thirty-two patients received a fixed combination of heparin sodium 5000 units plus dihydroergotamine mesylate 0.5 mg (H/DHE) twice a day and 137 patients received a fixed combination of low molecular weight heparin 1500 units plus dihydroergotamine mesylate 0.5 mg (LMWH/DHE) once a day as well as one injection of placebo per day. Treatment was initiated 2 h pre-operatively in both groups and continued for 7–10 days. The frequency of DVT determined by the 125I-labelled fibrinogen uptake test and phlebography was 10.3 per cent in patients receiving H/DHE and 10.4 per cent in those receiving LMWH/DHE. DVT of the femoral vein was detected in four patients of the H/DHE group and in none of the LMWH/DHE group. Intra- and postoperative blood loss did not differ significantly between both groups. Also no difference in the development of wound haematoma and injection site haematoma was found. While intra-operative volume substitution was comparable in both groups, significantly more patients under H/DHE prophylaxis received volume substitution during the postoperative phase. These results show that once-daily prophylaxis with the combination of low molecular weight heparin and dihydroergotamine is equally as effective and as safe as the twice-daily regimen using a combination of unfractionated heparin and dihydroergotamine in patients undergoing elective, major abdominal surgery. The advantages of the once-daily regimen of LMWH/DHE include greater patient acceptance, less nursing time and greater cost effectiveness, provided the new combination can be sold at a cost which maintains this advantage.
Plasma fibronectin and complement activation in coronary bypass surgery
Authors: Chadwick S J D , Stanbridge R De L , Mowbray J F , Dudley H A F
Published: March 2007

In patients with severe sepsis, plasma fibronectin concentrations are reduced and complement is activated. It is not known whether complement activation interferes with plasma fibronectin. Cardiopulmonary bypass is known to activate complement. We have therefore used this operation to study the effect of complement activation on plasma fibronectin in the absence of sepsis. After 15 min of bypass the percentage changes of plasma fibronectin and haematocrit were similar (65.9 ± s.e.m. 4.8 and 67.0 per cent ± s.e.m. 2.3, respectively), but the changes in C3 and C5 (58.4 ± s.e.m. 4.8 per cent and 52.5 per cent ± s.e.m. 2.1) were significantly greater than those of the haematocrit, indicating complement consumption. During the first 60 min of bypass there was a significant increase in the neutrophil count which is compatible with complement activation. It is unlikely that complement activation alone, in the absence of sepsis, contributes to the reduction of plasma fibronectin concentrations.
Comparison of harvesting methods for islet transplantation
Authors: Griffin S M , Alderson D , Farndon J R
Published: March 2007

One problem preventing islet transplantation becoming a clinical reality in the treatment of insulin-dependent diabetes is the unsatisfactory, low yield processes for harvesting islets. This study was designed to find the most effective harvesting process and to examine the feasibility of obtaining more than one graft from a single pancreas. After confirming that normoglycaemia at one month could be achieved in dogs using 50 per cent of an autograft prepared by a previously established method, novel techniques were assessed using 33 per cent of the tissue obtained. An isolation process involving perfusion of the duct by enzymes allowed normoglycaemia using only one-third of the graft preparation and these animals exhibited significantly improved glucose handling and insulin output when compared with recipients of grafts prepared by the established method. A significant improvement in harvesting technique has, therefore, been demonstrated and this will exploit the potential of multiple donor grafts in islet transplantation and the method may be worthy of trial in the human gland.
Hyperalimentation of jaundiced patients on percutaneous transhepatic biliary drainage
Authors: Foschi D , Cavagna G , Callioni F , Morandi E , Rovati V
Published: March 2007

Although percutaneous transhepatic biliary drainage (PTBD) restores hepatic and renal function in patients with obstructive jaundice, it is not certain whether it reduces the rate of complications and death after biliopancreatic surgery. We studied the possibility that the operative risks of jaundiced patients are related to malnutrition and the usefulness of hyperalimentation with PTBD to reduce the incidence of complications. Sixty-four patients with obstructive jaundice and serum bilirubin > 200 μmol/l were randomized into two treatment groups (n = 32) with PTBD or PTBD + hyperalimentation. Four patients were withdrawn from the latter group, two for metastatic cancer and two for complications of PTBD. Before starting hyperalimentation, the incidence of malnutrition was assessed by biochemical, immunological and anthropometric tests: malnutrition was found in 70 per cent of the patients. All the patients had good recovery of hepatic function but patients treated with PTBD alone still had high mortality (12.5 per cent) and morbidity (46.8 per cent) after biliopancreatic surgery. When hyperalimentation was provided to patients on PTBD for a period of 20 days before the operation, the incidence of complications fell to 17.8 per cent and mortality to 3.5 per cent. These results suggest that the combined use of PTBD and hyperalimentation, improving both hepatic function tests and the nutritional status of jaundiced patients, can reduce the rate of complications after biliary and pancreatic surgery.
Determinants of survival in liver resection for colorectal secondaries
Authors: Ekberg H , Tranberg K-G , Andersson R , Lundstedt C , Hägerstrand I , Ranstam J , Bengmark S
Published: March 2007

All 72 resections for colorectal liver secondaries during the period 1971–1984 were analysed retrospectively. Liver tumours were single in 35 (49 per cent), unilateral in 55 (76 per cent) and associated with extrahepatic disease in 12 (18 per cent) patients. Operative mortality was 5.6 per cent. With respect to the disease in the liver, the presence or absence of four or more metastases was the predominant prognostic determinant with a 5 year survival rate of 20 per cent in patients with less than four liver tumours, and no 3 year survivor among patients with four or more tumours. When the number of liver tumours was less than four, the prognosis in patients with unilateral disease was not significantly better than in patients with bilateral disease (P = 0.19). No other liver disease variable seemed to play any role in the prognosis. Extrahepatic disease was associated with a poor prognosis and no 5 year survivor. The length of the tumour-free resection margin was the only treatment variable that varied with the outcome: a resection margin of < 10 mm was followed by a poor survival. Variables that did not influence survival included uni- or bilateral disease, liver tumour volume, tumour size, type of liver resection, Dukes' classification, differentiation of the primary tumour and synchronous or metachronous disease. It is concluded that resection for liver colorectal secondaries is indicated when (a) there are less than four liver tumours, even if bilateral, (b) no extrahepatic disease is present, and (c) a resection margin of at least 10 mm can be obtained. It should not be performed unless all of these requirements are met.
The use of CA-50 radioimmunoassay inhibition test in the differential diagnosis of benign and malignant liver diseases
Authors: Habib N A , Hershman M J , Smadja C , Wood C B
Published: March 2007

The value of a radioimmunoassay (RIA) in the detection of the human carcinoma-associated antigen CA-50 has been assessed in 50 normal subjects, 28 patients with various benign liver diseases and 91 patients with primary and secondary liver carcinomas. Sera from all normal subjects and 25 of 28 (89 per cent) patients with benign liver diseases had a CA-50 level below 17 units/ml. Three patients with sclerosing cholangitis and sixty (66 per cent) patients with primary or secondary liver tumours had CA-50 levels above 17 units/ml. CA-50 may therefore be a useful tumour marker for the diagnosis of liver carcinomas and for the post-treatment monitoring of patients with various liver malignancies.
Fibrin adhesive versus sutured anastomosis: A comparative intra-individual study in the small intestine of pigs
Authors: Hjortrup A , Nordkild P , Kiærgaard J , Sjøntoft E , Olesen H P
Published: March 2007

The small intestine in each of ten pigs was subjected to three anastomoses: one sutured anastomosis and two non-suture fibrin adhesive anastomoses in an intra-individual controlled comparison. There was no significant difference in the in vivo bursting strength after 7 days. Thus, the two types of anastomoses were of equal strength. It is concluded that it appears possible to achieve a safe sutureless anastomosis in the small intestine, with fibrin adhesive alone.
Somatostatin in the treatment of severe upper gastrointestinal bleeding: A multicentre controlled trial
Authors: Torres A J , Landa I , Hernández F , Jover J M , Suárez A , Arias J , Cuberes Rosa , Santoyo J , Fernández Rosa , Calleja J , Nisa Elena , Rodriguez J L , Moreno E , Balibrea J L
Published: March 2007

To evaluate the effectiveness of somatostatin versus combined cimetidine and pirenzepine in the treatment of upper gastrointestinal (GI) bleeding of peptic origin, a multicentre controlled, prospective, randomized and double blind trial has been undertaken in 60 subjects. Strict selection criteria were followed. All subjects were diagnosed by endoscopy during the first 18 h after admission. Endoscopic stigmata of recent haemorrhage were also evaluated. Sixty-five per cent of the subjects presented with severe upper GI bleeding (blood pressure ⩽ 100 mmHg, pulse rate ⩾ 110, haematocrit ⩽ 30 per cent), and in 71·6 per cent stigmata were found. Thirty patients (Group 1) received a somatostatin infusion (250 μ/h continuously during 120 h) and 30 patients (Group 2) received cimetidine (200 mg IV every 4 h for 5 days) and pirenzepine (10 mg IV every 8 h for 5 days). Both groups were homogeneous for sex, age, backgrounds, bleeding source, grade of bleeding (moderate or severe) and presence or not of stigmata. Bleeding stopped in 27 subjects of Group 1 (90 per cent and in 20 subjects of Group 2 (66·67 per cent) (P < 0·05, χ2 test). The time until the bleeding stopped was significantly shorter in patients of group 1 (3·44 ± 0·53 h) than in patients of group 2 (8·12 ± 1·94 h) (P < 0·05, Mann–Whitney U test). The number of blood units required for Group 1 (2·26 ± 0·35) was significantly lower than the one required for Group 2 (3·90 ± 0·51) (P < 0·005, Wilcoxon test). Significant differences were not observed between the two groups regarding cross-over subjects, rebleeding, surgery (P = 0·0635, Fisher's exact test) and hospital stay. The mortality of the trial was 5 per cent. There was no toxicity during somatostatin, cimetidine or pirenzepine infusion. In conclusion, somatostatin was more effective than cimetidine plus pirenzepine in the control of severe upper GI bleeding of peptic origin, with a lower interval time to stop bleeding and reduced transfusion requirements.
Doppler ultrasound as an adjunct to the differential diagnosis of pigmented skin lesions
Authors: Srivastava A , Hughes B R , Hughes L E , Woodcock J P
Published: March 2007

One hundred and forty-one pigmented skin tumours were examined with a 10 MHz ultrasound Doppler flowmeter to investigate the value of detecting blood flow in the diagnosis of raised pigmented skin lesions. Most of the benign lesions except for those with an angiomatous basis were devoid of blood flow signals while all basal cell carcinomas and 96 per cent of thick melanomas (⩾ 0·9 mm) were associated with detectable Doppler frequency shift signals. While the characteristics of analysed Doppler waveforms are of research interest, the simple detection of blood flow by a hand held instrument gives sufficient information for clinical purposes. In practice this simple test has been sufficiently reliable to prove a useful adjunct in the diagnosis of raised pigmented skin lesions. It has been found particularly helpful in the common clinical problem of differentiation of nodular melanoma from basal cell papilloma and benign intradermal naevus. If such a lesion is thought to be benign, and has detectable flow signals, one should reconsider the diagnosis. Absence of flow signals is strong confirmation of a benign clinical diagnosis. The test should be regarded as an adjunct to clinical diagnosis since, in common with all non-invasive diagnostic techniques, false negative and false positive cases will be encountered. The technique is not appropriate to macular lesions since these are usually flow negative, irrespective of the pathology.
Surgery for malignant melanoma: From which limb should the graft be taken?
Authors: Flook D , Horgan K , Taylor B A , Hughes L E
Published: March 2007

A study of 186 melanomas requiring skin grafts and followed for 1–13 years has shown no preferential implantation in an ipsilateral donor site, despite standard surgical teaching that skin grafts for melanoma defects should not be taken from the same limb as the primary tumour. Two cases were encountered of preferential metastasis to a distant donor site outside the lymphatic drainage of the melanoma and we present a further case where ipsilateral recurrence simulated donor site recurrence. It is clear that the major mechanism of spread to distant donor sites is by the haematogenous route to an area of acute trauma. Hence it is recommended that where possible donor skin is taken from the same limb as the tumour, so that any preferential metastasis will remain within an area amenable to regional limb perfusion.
Early gastric cancer
Authors: Oleagoitia J M , Echevarria A , Santidrian J I , Ulacia M A , Hernandez-Calvo J
Published: March 2007

From 1975 to 1985, 142 patients with early gastric cancer were operated on in our service; this group comprised 14 per cent of all patients with gastric cancer operated on during this period. Epigastric pain was the most frequent symptom (75·3 per cent). The lesions were located in the lower third in 45·8 per cent, in the middle third in 31·7 per cent, in the upper third in 20·4 per cent and in the gastric stump in 2·1 per cent. Subtotal gastrectomy was performed in 116 patients and operative mortality was limited to two patients. Macroscopically 86·6 per cent of cases were included in type III, IIc and IIc–III. The five year survival rate, excluding the operative mortality, was 93·1 per cent. Tumours located in the lower third of the stomach, limited to the mucosa and of ulcerating type, had the best prognosis.