bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of recent advances in hepatobiliary imaging techniques on the preoperative diagnosis of carcinoma of the gallbladder
Authors: Chijiiwa Kazuo , Sumiyoshi Kinjiro , Nakayama Fumio
Published: May 2005

Among 26 patients with gallbladder carcinoma, 11 resected cases were studied retrospectively with respect to the preoperative imaging techniques and the operative procedures employed. Ultrasonography, endoscopic ultrasonography, and computed tomography were valuable in detecting gallbladder carcinoma preoperatively while direct cholangiography and angiography were helpful in designing operative strategy. The ultrasonographic findings were: a polypoid (fungating) mass protruding into the gallbladder lumen in 45%, abnormal thickening of the gallbladder wall in 18%, and a mass in the gallbladder invading adjacent organs in 18% of cases. Approximately 80% was diagnosed preoperatively by ultrasonography. Correct diagnosis was made by computed tomography in 60% of the cases. Endoscopic ultrasonography offered valuable information on the depth of tumor invasion. Direct cholangiography and angiography were useful in assessing the extent of the tumor spread. Recent advances in hepatobiliary imaging techniques, especially ultrasonography and computed tomography, contributed greatly to the detection and evaluation of gallbladder carcinoma at an early and resectable stage.
Radical operations for carcinoma of the gallbladder: Present status in Germany
Authors: Gall Franz Paul , Köckerling Ferdinand , Scheele Johannes , Schneider Claus , Hohenberger Werner
Published: May 2005

Despite the overall poor prognosis of gallbladder carcinoma, it appears that, in resectable lesions, an aggressive surgical approach promises improvement in survival rates. Radical treatment of gallbladder carcinoma is based on a detailed knowledge of the lymphatic, venous, direct, and intraductal modes of spread of gallbladder carcinoma. Customized therapy of gallbladder carcinoma takes staging into consideration: if one is dealing with gallbladder carcinoma with macroscopic liver infiltration (T3 or T4), or with a pre‐ or intraoperatively diagnosed gallbladder carcinoma with an unknown depth of infiltration, an en bloc resection of the gallbladder with adjacent liver segments IVb and V, perhaps including VI, as well as a dissection of the hepatoduodenal ligament should be performed. If the carcinoma is missed intraoperatively at the time of cholecystectomy for other indications, in the presence of a T2 gallbladder carcinoma in proximity to the liver bed, reoperation with dissection of the hepatoduodenal ligament and resection of liver segments IVb and V should be performed. In the presence of T1 gallbladder carcinoma, simple cholecystectomy is adequate.

This concept is based on our experience with 113 patients with gallbladder carcinoma who underwent treatment in our department from January, 1970 to June, 1989. Sixty‐seven percent of the gallbladder carcinomas were resected, 30% for cure and 37% palliatively. In 33%, the operation was limited to an exploratory laparotomy or a palliative operation, or no operation was performed. Of the curatively resected carcinomas (n=34), 7 were Stage I, 7 Stage II, 9 Stage III, and 11 Stage IV.

The average follow‐up or survival time following curative resection at first operation (n=21) was 48.1 months; survival in patients who underwent curative resection at reoperation, in the presence of distant metastases, if there was tumor spillage, and in the presence of synchronous tumor was 14.0 months; survival following palliative resection was 5.8 months, and after exploratory laparotomy, palliative operation, or no operation was 3.6 months.

Compared to palliative resection, customized therapy of gallbladder carcinoma for cure at the time of initial operation leads to a significant improvement in prognosis.
Radical operations for carcinoma of the gallbladder: Present status in Japan
Authors: Ogura Yoshifumi , Mizumoto Ryuji , Isaji Shuji , Kusuda Tsukasa , Matsuda Shinsuke , Tabata Masami
Published: May 2005

Based on the histological findings of 1,686 resected cases of gallbladder carcinoma and operative results collected from 172 major hospitals in Japan, the present status of radical operation was assessed with respect to the relationship between the depth of carcinoma invasion and the operative results. The depth of carcinoma invasion was classified into 5 groups, i.e., limited to the mucosal layer (m) in 11.9%, advanced to the proper muscle layer (pm) in 9.8%, extending to the subserosal layer (ss) in 29.6%, serosal involvement (se) in 21.8%, and carcinoma invading the adjacent organs (si) in 26.9%. Tumor extension, such as lymph node metastasis, invasion of lymphatic and venous vessels, and perineural infiltration, were observed more frequently in patients with ss, se, and si than in those with m and pm. The cumulative 5‐year survival rates were 82.6% and 72.5% in patients with m and pm, which were significantly higher than 37.0%, 14.7%, and 7.5% in those with ss, se, and si, respectively. The choice of operative procedures should depend on the depth of carcinoma invasion. Cholecystectomy alone is done only in patients with tumor limited to the mucosa, and more radical procedures such as extended Cholecystectomy should be performed in those with carcinoma invasion beyond the mucosa. Pancreatoduodenectomy is indicated in those with lymph node metastasis posterior to the head of the pancreas and with invasion to the duodenum. When the tumor directly invades the liver, major hepatic resection is recommended. Extended right hepatic lobectomy with pancreatoduodenectomy should be reserved only for those younger than 70 years of age with advanced carcinoma and in a good nutritional state because of the high postoperative morbidity and mortality.
Radical operations for carcinoma of the gallbladder: Present status in North America
Authors: Gagner Michel , Rossi Ricardo L.
Published: May 2005

Experience in the United States of America with the use of radical operations for carcinoma of the gallbladder was reviewed. Four studies using the Nevin clinicopathologic classification were combined for analysis. The 5‐year survival rate for patients with stage I disease was 59%; stage II disease, 40%; stage III disease, 9%; stage IV disease, 7%; and stage V disease, 1%. Only one study analyzed the results of surgical procedures according to Nevin staging. No conclusions can be drawn from retrospective studies on the value of operations more radical than simple cholecystectomy. Responses to a questionnaire sent to prominent North American surgeons emphasized the controversial management of patients with this disease.
Palliative operative procedures for carcinoma of the gallbladder
Authors: Jones R. Scott
Published: May 2005

Gallbladder cancer afflicts predominantly women, the elderly, and persons with gallstones. Despite its producing symptoms of abdominal pain, nausea and vomiting, weight loss, jaundice, and anorexia, this disease remains difficult to detect. Even with contemporary imaging techniques, most gallbladder cancers escape diagnosis until the time of laparotomy. The aggressive character of this malignancy permits an overall 5‐year survival rate of 3–5%. Although cures occur, the majority of operations performed for gallbladder cancer are for palliation. The objects of palliation include relief of pain, relief of jaundice, relief of intestinal obstruction, and the restoration of normal food intake. Resection of the tumor should be performed whenever possible; however, extensive operations including large liver resections and pancreaticoduodenectomy should be avoided in the presence of distant metastases. In the presence of large unresectable hilar masses, internal biliary bypass may relieve jaundice. Biliary‐enteric anastomosis using the segment III duct exposed via the umbilical fissure may offer satisfactory relief of jaundice in selected cases.
Intraoperative radiation therapy for carcinoma of the gallbladder
Authors: Busse Paul M. , Cady Blake , Bothe Albert , Jenkins Roger , McDermott William V. , Steele Glenn , Stone Michael D.
Published: May 2005

The recognition of a high incidence of local failure following surgical management of adenocarcinoma of the gallbladder has led to the use of adjuvant radiation therapy. In order to deliver higher doses to the gallbladder bed, intraoperative radiation therapy (IORT) has been used both with and without external beam radiation.

The experience to date is reviewed. Ten patients have been treated, all of whom had either gross residual or unresected disease. The median survival for the group was approximately 1 year. There were no long‐term survivors. The IORT did not contribute to the overall morbidity.

Because of the limited number of patients and the advanced nature of the disease, the role of IORT in the management of gallbladder carcinoma has yet to be determined. The utility of this modality will most likely reside in the treatment of minimal residual disease at the time of cholecystectomy rather than in the palliative treatment of unresectable tumors.
Resection combined with intraoperative radiation therapy (IORT) for stage IV (TNM) gallbladder carcinoma
Authors: Todoroki Takeshi , Iwasaki Yoji , Orii Kazuo , Otsuka Masaaki , Ohara Kiyoshi , Kawamoto Toru , Nakamura Kyoichi
Published: May 2005

From October 1976 to May, 1990, a total of 86 patients with stage IV (TNM) gallbladder cancer were treated at Tsukuba University Hospital. Twenty‐seven of the 86 patients underwent tumor resection; 43 patients received palliative surgery. The remaining 16 were too advanced to have surgery. Of 27 patients who had tumor resection, 9 had resection alone, 17 had intraoperative radiation therapy (IORT)±postoperative external radiotherapy (ERT), and 1 had postoperative ERT.

The procedures used were: extended right hepatic lobectomy plus hepaticobiliary resection (HBR) (n=2), hepatic segmentectomy (SIVb, SV) plus HBR (n=9), hepatic segmentectomy (SIV, V, VI) with HBR (n =1), hepatic segmentectomy (SIV, V) plus HBR with pancreaticoduodenectomy (PD) (n=3), PD plus HBR (n=1), cholecystectomy with wedge resection of the gallbladder fossa plus HBR (n=3), and cholecystectomy plus HBR (n=3), and cholecystectomy (n=4). Regional lymph node dissections were performed in every patient and 17 of 27 patients underwent additional resections of adjacent organs such as the stomach, duodenum, colon, and abdominal wall.

A single dose of 20–30 Gy was delivered intraoperatively for 17 patients. A mean total dose of 36.4 Gy (1.8/fraction) was added to IORT for 10 patients.

The three‐year cumulative survival rate was 10.1% for resection plus IORT but 0% for resection alone. The longest survivor is alive and well at 3 years and 3 patients are alive 16,13, and 4 months after tumor resection followed by IORT plus ERT.
Cecal diverticulitis: A continuing diagnostic dilemma
Authors: Schmit Paul J. , Bennion Robert S. , Thompson Jesse E.
Published: May 2005

Cecal diverticulitis is a rare entity and remains a difficult diagnostic problem. A retrospective review was undertaken of 16 patients (11 men, 5 women; average age, 33.2 years) with a pathologic diagnosis of cecal or right colon diverticulosis who received treatment from 1979 to the present. Preoperative symptoms were difficult to distinguish from appendicitis. The majority complained of right lower quadrant pain and tenderness. Diagnostic studies were not helpful. Preoperative diagnosis was appendicitis in 88% (14 of 16) and correct in 1 patient (6%). At exploratory celiotomy, the surgeon was able to make the diagnosis of cecal diverticulitis in 9 (60%) of the 15 patients in whom the correct diagnosis had not been made preoperatively. Neoplasm was suspected in 5 patients, and an appendiceal abscess was suspected in 1. Treatment was colectomy in 9 and local excision in 4 patients. In 3 patients, the inflamed diverticulum was left in situ at initial exploration; all underwent later excision, one of these urgently for sepsis. No patient died; however, one anastomotic leak requiring reoperation occurred. On the basis of this experience, we recommend excisional therapy in all cases in which the intraoperative diagnosis is certain. Suspicion of a neoplastic process continues to prompt colectomy in an emergency setting.
Pyogenic liver abscess: Multivariate analysis of risk factors
Authors: Lee King‐Teh , Sheen Pai‐Ching , Chen Jong‐Shyong , Ker Chen‐Guo
Published: May 2005

Seventy‐three patients with pyogenic liver abscess during the year 1978–1988 were studied in the Kaohsiung Medical College Hospital. The overall mortality rate was 19.2% in this study. By using univariate analysis, it was revealed that clinical jaundice, pleural effusion, bilobar abscess, profound hypoalbuminemia (<2.5 g/dl), hyperbilirubinemia (>2 mg/dl), elevated level of serum AST (>100 IU/L), alkaline phosphatase (>150 IU/L), and marked leukocytosis (>20,000 mm3) were associated with a higher mortality rate. Multivariate stepwise logistic regression analysis detected only 3 factors of marked leukocytosis (>20,000 mm3), profound hypoalbuminemia (<2.5 g/dl), and presence of pleural effusion with independent significance in predicting mortality. Meanwhile, it was also revealed that the laboratory data could not predict a risk factor to mortality unless they became markedly abnormal.
Postoperative wound infections and surgical face masks: A controlled study
Authors: Tunevall Th. Göran
Published: May 2005

It has never been shown that wearing surgical face masks decreases postoperative wound infections. On the contrary, a 50% decrease has been reported after omitting face masks. The present study was designed to reveal any 30% or greater difference in general surgery wound infection rates by using face masks or not.

During 115 weeks, a total of 3,088 patients were included in the study. Weeks were denoted as “masked” or “unmasked” according to a random list. After 1,537 operations performed with face masks, 73 (4.7%) wound infections were recorded and, after 1,551 operations performed without face masks, 55 (3.5%) infections occurred. This difference was not statistically significant (p> 0.05) and the bacterial species cultured from the wound infections did not differ in any way, which would have supported the fact that the numerical difference was a statistically “missed” difference.

These results indicate that the use of face masks might be reconsidered. Masks may be used to protect the operating team from drops of infected blood and from airborne infections, but have not been proven to protect the patient operated by a healthy operating team.
CEA and CA 15‐3 in primary and recurrent breast cancer
Authors: O'Dwyer P. J. , Duffy M. J. , O'Sullivan F. , McDermott E. , Losty P. , O'Higgins N. J.
Published: May 2005

To evaluate CA 15‐3, a new breast cancer associated antigen, and to compare it with carcinoembryonic antigen (CEA), all patients presenting with breast cancer had preoperative and serial (3‐monthly) postoperative levels measured. Of 124 patients with primary breast cancer, 23% had an elevated CA 15‐3 (>25 units/ml) while 11% had an elevated CEA (>5 ng/ml) (p=not significant). Neither marker was an indicator of spread to regional lymph nodes in primary breast cancer. In 45 recurrences of breast cancer, CA 15‐3 was elevated at the time of first recurrence in 58% while CEA was elevated in 47% (p=not significant). Of 17 patients with locoregional recurrence alone, none had a CA 15‐3 above 40 units/ml while 11 of 12 with synchronous locoregional and distant recurrence had a CA 15‐3 level greater than 40 units/ml (χ2∶ 21.36,p < 0.0001). This study shows that CA 15‐3, like CEA, is of little clinical value in primary breast cancer. CA 15‐3, however, is an accurate indicator (overall accuracy, 97%) of synchronous distant metastases in patients with locoregional recurrence from breast cancer. This information has important implications for further investigation and management of such patients.
Changing trends in surgery for acute cholecystitis
Authors: Reiss Raphael , Nudelman Israel , Gutman Chaim , Deutsch Alexander A.
Published: May 2005

Surgery for acute cholecystitis has become the most frequent abdominal surgery in most hospitals, yet aspects of its management remain controversial. The aim of this study was to focus on the recent trends by demonstrating the principal differences between 2 series of patients operated on during 10‐year intervals.

Two hundred fifty‐six consecutive operations for acute cholecystitis were performed from 1970 to 1977 (group O) and were compared to 260 cases operated from 1980 to 1987 (group N). Thirty‐six variables were recorded in each case. All data obtained were computer recorded and analyzed. Several trends were observed in group N:

The population was significantly older with a higher proportion of males and diabetics.

There was a marked increase in common bile duct stones, acalculous cholecystitis, and gangrenous changes in the gallbladder.

There was a significant increase in patients operated on within 48 hours of admission.

There was a significant increase in the number of patients without previous history of biliary symptoms.

There was a significant decrease in the rate of wound infections and no statistically significant differences in mortality (N: 3.0%, O: 2.7%).

A decrease of the average postoperative hospital stay of 3.2 days was observed.

In spite of the older and sicker population in group N, no significant increase in mortality occurred and the postoperative hospital stay was reduced.
Adenocarcinoma of the stomach: A review of 35 years and 1,710 cases
Authors: Breaux John R. , Bringaze Walter , Chappuis Charles , Cohn Isidore
Published: May 2005

The records of 1,710 patients with adenocarcinoma of the stomach treated at Charity Hospital over a 35‐year period were reviewed to note any trends which might help in understanding the decreasing incidence and poor prognosis of the disease.

The yearly number of gastric cancer patients has dropped from 234/100,000 in the 1950's to 195/100,000 in the 1960's to 108/100,000 patients in the last decade. The percentage of affected white males is decreasing at a rate equal to the increasing frequency of black female patients, while the ratios for black males and white females remain constant. The median age rose from 61.5 years to 66 years over the study period.

The operability rate decreased from 82.4% to 72.8% and the resectability rate was 49%. Subtotal gastrectomy was the most common procedure, but radical subtotal gastrectomy gave the best 5‐year survival.

There are fewer lesions of the antrum today, but the highest number of 5‐year survivors had antral lesions. Long‐term survival of patients with lesions of the cardia improved from zero in the first 25 years to 14% in the last decade.

For the last 2 decades, patients with stage III and IV lesions comprised one‐half of the 5‐year survivors.

Our overall 5‐year survival was 7.9%, but in the last decade it was 8.9%. Our 5‐year survival for all patients who underwent a resection was 17.9%, but increased to 24.8% for the last decade. These improvements, in combination with a decrease in incidence, have dropped the overall mortality from gastric cancer.
Dilatation of intrahepatic biliary strictures in patients with hepatolithiasis
Authors: Jeng Kuo‐Shyang , Yang Fi‐Sh , Ohta Ikuho , Chiang Hsein‐Jar
Published: May 2005

To investigate the role of balloon dilatation in the management of complicated hepatolithiasis with intrahepatic biliary stricture, 57 consecutive patients who received 208 sessions of dilatation in addition to the usual treatment were analyzed. The strictures were located in the right intrahepatic ducts (84.2%), left intrahepatic ducts (12.3%), or both (3.5%). Dilatation began 3–4 weeks after surgery. The routes of dilatation included the matured T‐tube tract (3 cases), percutaneous transhepatic biliary drainage tracts (42 cases), and both (12 cases). The immediate overall success rate of complete stone clearance increased significantly from 0% predilatation to 94.7% postdilatation. The main complications of dilatation therapy consisted of septicemia (10.5%), hemobilia (10.5%), and mild diarrhea (80%). Eight patients (14%) with long‐segment strictures received 11 postdilatation biliary stentings. Complications were 1 patient with occlusion and 2 patients with “spontaneous” hemobilia. Severe multiple strictures and coexistent secondary biliary cirrhosis were the contributing factors to complications. During the follow‐up of 3.4±1.2 years, recurrence of strictures was found in 4 patients. Two of them belonged to the stenting group. The cumulative probability of restricture was low: 4% at 2 years, 6% at 2.5 years, and 8% at 3 years. We conclude that in complicated cases of hepatolithiasis with intrahepatic biliary stricture, dilatation and stenting are good adjuvant therapies.
Previous abdominal colectomy affects functional results after ileal pouch‐anal anastomosis
Authors: Zenilman Michael E. , Soper Nathaniel J. , Dunnegan Dee , Becker James M.
Published: May 2005

We assessed the effect of previous abdominal colectomy on functional results after ileal “J” pouch‐anal anastomosis (IPAA) in patients with ulcerative colitis. Twenty‐five patients with colectomy prior to IPAA were compared with 22 patients who underwent noncolonic abdominal operations prior to IPAA. No differences were observed in pre‐ or postoperative resting anal sphincter pressure, squeeze pressure, or rectal inhibitory reflex. Previous colectomy was associated with a greater incidence of postoperative small bowel obstruction. Mean ± SEM daily stool frequency at 1 and 12 months postoperatively, respectively, was 8.9±0.8 and 5.7±0.3 for patients who had undergone previous colectomy, and 8.2±0.7 and 6.0±0.5 for the no previous colectomy group (p=not significant). At the same postoperative intervals, nocturnal stool frequency was 1.9±0.3 and 1.1±0.2 for the colectomy group and 1.5±0.3 and 0.6±0.1 for the no colectomy group (p=0.05 at 1 year). More patients in the previous colectomy group had greater than or equal to 1 nocturnal stool after 1 year (71% versus 33%,p=0.03). Although pouch capacity at 1 year was not different in the 2 groups, pouch capacity was directly related to stool frequency in the no colectomy group (r2=0.48,p=0.01), but not in the previous colectomy group (r2= 0.08,p=not significant). We conclude that previous abdominal colectomy may be associated with a higher overall incidence of small bowel obstruction. Moreover, previous colectomy is a determinant of postoperative nocturnal stool frequency after IPAA, most likely due to altered ileal pouch function. When possible, single‐stage colectomy, mucosal proctectomy, and endorectal ileal pouch‐anal anastomosis should be performed in patients requiring colectomy for ulcerative colitis.
Cervical node metastases in early squamous cell carcinoma of the floor of the mouth: Predictive value of multiple histopathologic parameters
Authors: Nason Richard W. , Castillo Nieva B. , Sako Kumao , Shedd Donald P.
Published: May 2005

A semiquantitative assessment of multiple histological parameters was applied retrospectively to 66 patients with stage I and II squamous cell carcinoma of the floor of the mouth to determine if prognostic information relative to cervical node metastases could be obtained. Three parameters relating to the tumor cell population and 5 describing the tumor‐host interface were evaluated on a point scale from 1 to 3 with the highest score going to the most threatening characteristic. Twenty of the 66 patients had either occult metastases identified by elective lymphadenectomy (n=11) or developed metastases to the neck (n=9). There was no correlation between traditional histological grading as recorded at the time of presentation and the frequency of cervical metastases (p> 0.05). Histological reevaluation defined 3 groups of patients with low (<14), moderate (14–16), and high scores (>16) with an incidence of cervical metastases of 5/39 (12.8%), 6/17 (35.3%), and 9/10 (90%), respectively (p<0.001). The results suggest that microscopic grading could be a useful adjunct to the present TNM staging system in selecting patients likely to benefit from elective treatment of the neck.
Multifactorial analysis of survival in primary extremity liposarcoma
Authors: Chang Helena R. , Gaynor Jeffrey , Tan Claire , Hajdu Steve I. , Brennan Murray F.
Published: May 2005

The treatment of extremity soft tissue sarcoma is now directed at limb preservation with the addition of various adjuvant therapies to improve treatment results. To achieve this goal, a knowledge of prognostic factors for extremity soft tissue sarcoma becomes increasingly critical. The object of this study was to analyze prognostic factors for survival in patients with extremity liposarcoma.

Eighty‐three patients with primary localized extremity liposarcoma, admitted from 1968 to 1978, were retrospectively reviewed. Surgical resection was the primary mode of treatment. Eleven prognostic factors were analyzed. Tumor factors included: histologic subtype, tumor grade, size, depth, invasion of vital structures, and site; operative factors included: type of operation, and surgical margins; and patient factors included: symptoms, age at diagnosis, and sex. Kaplan‐Meier survival curves, and univariate and stratified log‐rank tests of association were performed. Independent factors for predicting survival were identified using the Cox model stepwise regression technique.

In univariate analysis of the entire group of patients, 5 factors were significant for tumor mortality: tumor grade (p=0.00005), histologie subtype (p=0.00025), tumor size s≥5 cm (p=0.005), type of surgery/ margin (p=0.0001), and invasion of vital structures (p=0.008). When associations among all factors were analyzed, it was found that many factors were interdependent. The independent prognosticators were, therefore, determined according to the Cox model technique. For the multivariate analysis, well‐differentiated and lipoblastic liposarcomas were excluded because of lack of survival variation within each group. The former group had no tumor‐related deaths and the latter group showed 80% tumor mortality. The remaining patients with myxoid, high‐grade fibroblastic and pleomorphic liposarcoma were subjected to multivariate analysis. Three factors emerged as independent prognostic predictors: high‐grade tumor (p=0.013), inadequate resection/amputation (p=0.003), and tumor≥cm (p=0.04).
The “Kergin pneumonectomy”
Authors: Gozzetti Giuseppe , Mastrorilli Mario , Bragaglia Romano B. , D'Abruzzo Giulio Cipolla , Romualdi Anna , Villani Silvia , Liberatore Gian Luca , Spolaore Renato
Published: May 2005

Out of a series of 211 stage III (A and B) lung cancers radically resected with routine lymphadenectomy from 1971 to 1987, a total of 11 were squamous cell carcinomas invading the right main bronchus and lateral portion of the trachea. These patients were managed using a particular technique that we have always arbitrarily called, “Kergin pneumonectomy, ” after the Toronto surgeon who described it in 1952. These patients, today, are staged III B. There was no operative mortality and only 2 minor complications. Two patients survived 3 years and 1 is alive and free of disease 7 years from surgery. This technique should be considered before embarking on more perilous surgery such as “sleeve pneumonectomy,” a procedure which still carries high mortality and morbidity rates and requires special equipment and intensive postoperative care.
Suppression of the human mucosal‐related colonic microflora with prophylactic parenteral and/or oral antibiotics
Authors: Smith Mark B. , Goradia Vipool K. , Holmes James W. , McCluggage Samuel G. , Smith Jeffrey W. , Nichols Ronald Lee
Published: May 2005

The purpose of this investigation was to assess the effects of preoperative administration of parenteral antibiotics with or without concomitant preoperative administration of oral antibiotics on the colonie mucosal‐related microflora. Thirty‐one patients were studied in a prospective fashion. Group A patients (n=8) had colonoscopic mucosal biopsies performed after mechanical bowel preparation. Group B patients (n=5) received neomycin and erythromycin (NE), 1 g each following mechanical bowel preparation, at 1,2, and 11 p.m. the evening prior to either elective colon resection (n=2) or prior to colonoscopic biopsy (n=3). Emergent trauma patients who had left colon or sigmoid perforations due to gunshot wounds requiring segmental resection comprised group C (n=7). These patients received cefoxitin or cefotetan 2 g intravenously preoperatively. Individuals in group D (n=11) all had elective left hemicolectomies or sigmoid resections due to nonobstructing malignancies. These patients underwent the same regimen as group B patients in addition to receiving intravenous cefoxitin perioperatively. Quantitative and qualitative bacterial cultures as well as scanning electron microscopy (SEM) were used to study the mucosa‐associated flora. Tissue for culture and SEM were obtained from the pathologic specimen immediately after removal. The interval between the dosage of parenteral antibiotics to tissue removal was 3 hours in both groups. Anaerobic and aerobic counts were suppressed the greatest in patients receiving both oral and parenteral antibiotics (p=0.0001). Mean anaerobic counts decreased from 3.4×107 in group A to 1.8×102 (mean cfu/g) in group D patients. Mean aerobic counts in group A decreased from 3.7×106 to 64 (mean cfu/g) in group D. This study documents the effectiveness of oral NE to suppress the mucosa‐associated flora when administered preoperatively and suggests that parenteral antibiotics suppress the mucosa‐associated bacteria in addition to providing therapeutic serum levels.
Evaluation of effectiveness of mass screening for colorectal cancer
Authors: Fujita M. , Sugiyama R. , Kumanishi Y. , Ota J. , Horino T. , Nakano Y. , Taguchi T.
Published: May 2005

As the first step in the epidemiological evaluation of the effectiveness of mass screening for colorectal cancer, we compared clinicopathological features and survival rates of patients with cancer detected by mass screening (screened group) with those for patients treated in our outpatient clinic in the same period (outpatient group). The screened group consisted of 53 patients with colorectal cancer detected by 2‐day or 3‐day screening for fecal occult blood by guaiac slides. Their background factors were comparable to those of 120 patients of the outpatient group in regard to age, sex ratio, location of cancer, and histological type of cancer.

In the screened group, 90% of patients had no complaints, and positive occult blood tests led to the detection of cancers. More than 60% of the patients had Dukes' A and B1 early cancers while only about 30% had advanced cancers. In the outpatient group, nearly 90% of patients were symptomatic, most commonly from rectal bleeding. Early‐stage cancers made up only 20%, and large, advanced‐stage cancers accounted for 80%. The 5‐year survival rate of the screened group was 91.5%, being significantly higher than the 60% survival rate for the outpatient group.

It is anticipated that mass screening for colorectal cancer by guaiac fecal occult blood testing will significantly reduce the mortality due to this neoplasm.
West Germany: Still an underdeveloped country in the diagnosis and early treatment of primary hyperparathyroidism?
Authors: Dotzenrath Cornelia , Goretzki Peter Erich , Röher Hans‐Dietrich
Published: May 2005

Early diagnosis of asymptomatic patients with primary hyperparathyroidism (primary HPT) has been achieved in Scandinavia, the United States of America, and the United Kingdom during the last 20 years. Comparable results have been reported from some medical centers from West Germany; however, clinical manifestations were pronounced and patient symptoms were high in our population with primary HPT (N=128) operated on at the University of Düsseldorf from April, 1986 to July, 1989. Only 19 patients (14.8%) were asymptomatic while the others suffered from nephrolithiasis (39%), osteopathy (32%), gastrointestinal disturbances (28.9%), and depression (11.7%). In 46 (35.9%) of our patients, the duration of these clinical symptoms exceeded 10 years, in 27 patients (21%) 15 years, and in 12 patients (9.3%) even 25 years.

We, therefore, conclude that primary HPT is still a grossly underdiagnosed illness in parts of West Germany, presently, with patients suffering from severe clinical symptoms for more than 1–2 decades before definitive treatment.
Acquired and congenital clotting syndromes
Authors: Blaisdell F. William
Published: May 2005

Although Virchow postulated 100 years ago that hypercoagulability states exist, it has only been in recent years that methods of documenting hypercoagulability have been developed. These clotting tendencies can be acquired or congenital. The common causes of acquired clotting tendencies include conditions which result in tissue and cellular damage, shock, transfusion reactions, and tissue necrosis. Certain drugs and drug reactions, and certain disease states which include blood dyscrasias and cancer are also associated with clotting problems. In certain diseases such as homocystinuria, hyperlipidemia, and lupus erythematosus, abnormal clotting tendencies may also develop.

Important advances in the recognition of hypercoagulability have come with the documentation that congenital clotting abnormalities exist. Moreover, these abnormalities are proving to be more common than are congenital bleeding syndromes. Patients who appear to have spontaneous clotting manifestations and are under 40 years of age should be screened for one of these abnormalities.

These congenital clotting tendencies can be classified as defects in thrombosis inhibitors, dysfibrinogenemias, or defects in fibrinolysis. The first thrombotic inhibitor defect recognized was antithrombin III deficiency which was reported in 1965. Subsequently, Protein C, Protein S, and Heparin cofactor II deficiencies have been recognized as contributing to thrombotic tendencies.

Dysfibrinogenemias are relatively rare and most are associated with bleeding problems; however, 11% of the abnormal fibrinogens are associated with a clotting tendency. The reason appears to be that these fibrins are resistant to fibrinolysis.

The most common defects which are associated with thrombotic tendencies appear, at the present time, to be due to defects in fibrinolysis. These include hypoplasminogenemia, decreases in plasminogen activator, increases in plasminogen activator inhibitor, and Factor XII deficiency.
Prophylaxis of venous thromboembolism
Authors: Kakkar Vijay V. , Stringer Mark D.
Published: May 2005

The objective of prophylaxis in venous thromboembolism is, first, to prevent fatal pulmonary embolism and, second, to reduce the morbidity associated with deep vein thrombosis (DVT) and the postphlebitic limb. This should now be standard practice for most patients over 40 years of age undergoing major surgery and for younger patients with a history of venous thromboembolism. Particularly high‐risk groups include patients over 60 years of age undergoing major surgery, those with malignancy, and those requiring hip operations.

Low‐dose subcutaneous heparin 5,000 IU commencing 2 hours preoperatively and continuing 12 hourly until the patient is fully mobile is unequivocally effective in preventing DVT in medical and surgical patients and, most importantly, significantly reduces the incidence of fatal postoperative pulmonary embolism and total mortality. Such prophylaxis, in the presence of established DVT, also limits proximal clot propagation, which is the precursor of major pulmonary embolism. Low‐dose heparin prophylaxis is associated with a small risk of bleeding complications, evidenced mostly by an increased frequency of wound hematoma rather than major clinical hemorrhage.

Low molecular weight heparin fragments (e.g., Fragmin®, Choay®, Enoxaparine®) are emerging as useful alternative agents, having the advantage of once daily administration and yet providing similar efficacy in the prevention of DVT. Mechanical methods of prevention which counteract venous stasis, such as graduated elastic compression stockings, are also useful in protecting against DVT but have not been shown to prevent fatal postoperative pulmonary embolism. They are recommended particularly for patients in whom heparin prophylaxis is best avoided (e.g., neurosurgery) and possibly in combination with heparin in very high‐risk patients.
Surgical treatment of acute deep venous thrombosis
Authors: Lord Reginald S. A. , Chen Frank C. , Devine Terence J. , Benn Ian V.
Published: May 2005

In patients with venous thrombotic disease and in whom anticoagulation or thrombolytic therapy is inappropriate, ineffective, or even contraindicated, insertion of vena caval filters or venous thrombectomy must be considered.

The primary indication for the placement of vena caval filters is in patients who have developed a pulmonary embolus and in whom anticoagulation is either contraindicated or in whom anticoagulation must be discontinued because of the development of bleeding complications. At the present time, either the Greenfield filter placed through a jugular, femoral, or axillary venotomy or the bird's nest filter are appropriate and appear to be the most effective and least fraught with complications.

The use of venous thrombectomy has waxed and waned over the last several decades. At the present time, the procedure is advocated mainly for lower limb venous thrombosis which is extensive enough to threaten limb viability. On occasion, it may be appropriate to extend the indications for venous thrombectomy to include femoral thrombosis of less than 10 days duration or iliac thrombosis of less than 3 weeks duration with floating thombi at that level. Technical modifications which improve the patency of the obliterated veins which are predisposed to rethrombosis include the creation of a temporary arteriovenous fistula and meticulous care in removing the entire clot. The patient should be treated with anticoagulants postoperatively to prevent a recurrence of the problem.

The main theoretical advantage of venous thrombectomy is a reduced incidence of postthrombotic syndrome. Objective data to support this contention do not exist.
Cooper ligament repair: An update
Authors: Barbier Jacques , Carretier Michel , Richer Jean P.
Published: May 2005

This study had 4 objectives: first, to define the place of the Cooper ligament in hernial repairs by recalling its anatomic importance within the inguinal region; second, to describe our technique using the Cooper ligament, a technique based on suture of the conjoined tendon to the Cooper ligament without a relaxing incision into the rectus sheath and also to describe other authors' variants; third, to report the results obtained for 1,040 patients operated on by our technique from 1970 to 1978; fourth, to define the value and limits of these herniorrhaphy methods in repairs of groin hernias. These methods are inexpensive and virtually exclude the risk of serious infections because no foreign material is used. The procedures can be used in most patients. The only limits are suture tension during the repair and the presence of parietal deterioration. In such situations, it is necessary to perform a prosthetic repair or to reinforce the herniorrhaphy with prosthetic mesh.
Preperitoneal herniorrhaphy: A historical review
Authors: Read Raymonnd C.
Published: May 2005

From ancient times, both the transabdominal (posterior) and the groin (anterior) approach have been used either singly or in combination in the management of inguinofemoral herniation. Development accelerated in the nineteenth century after Lister introduced antisepsis. Although Bassini and Halsted conducted their classic procedures in the preperitoneal plane, it was Cheatle, in 1920, who first performed transabdominal preperitoneal herniorrhaphy. In 1950, McEvedy described the lateral approach, which was made popular by Nyhus and Condon in the 1960's. The problem of relaxing incisions and the importance of prosthetic repair through this exposure are substantiated along with the anatomy of the preperitoneal fatty layer and the results of sutureless bilateral herniorrhaphy.
The recurrent groin hernia: Therapeutic solutions
Authors: Nyhus Lloyd M.
Published: May 2005

Attention to the problem of groin hernia problems has focused on the primary type of operative repair. Because of this, major advances have been made in the surgical cure of these entities. It is important in the primary operation to individualize the type of operative procedure to the specific hernial problem.

The results of treatment of recurrent groin hernia range from very poor to excellent. It appears that the use of prosthetic mesh, particularly if placed in the preperitoneal space, has markedly improved the cure rate for these difficult recurrent groin hernias.
The treatment of complicated groin and incisional hernias
Authors: Stoppa René E.
Published: May 2005

One hundred years ago, Edoardo Bassini said: “L'ernia é una malattia meccanica.” Before that, Ambroise Paré (1598) and Joseph‐Pierre Desault (1798) asserted the mechanical nature of strangulation. Beside strangulation, the most serious of all complications even today, I have studied huge hernias, which are natural complications, and recurrent hernias, which are the complications of suboptimal repairs. In this article, I consider the general features and diagnostic and technical consequences of the repair of groin and incisional hernias. The treatment of strangulating hernias, usually an emergency operation, has not seen any recent technical progress. Huge and recurrent hernias, however, usually allow time for adequate surgical preparation. These hernias are also amenable to modern prosthetic repairs. In prosthetic repairs, large pieces of polyester mesh are inserted beneath the muscular wall outside the peritoneum. They act as artificial, nonabsorbable endoabdominal fascia, making the abdominal wall instantly and definitively pressure tight. The state of hernial surgery has advanced to the point that one must consider the systematic surgical cure of all diagnosed hernias.
The use of the preperitoneal approach for the simultaneous repair of inguinal hernia during surgery on the bladder and prostate
Authors: Schlegel Peter N. , Walsh Patrick C.
Published: May 2005

Repair of a hernia can be performed safely and expeditiously during a radical pelvic operation by the preperitoneal approach through a median longitudinal incision. We present the results of 41 preperitoneal herniorrhaphies performed simultaneously with 343 radical retropubic prostatectomies and 26 radical cystoprostatectomies. There was no evidence of hernial recurrence after a mean of 28 months and no complications attributable to the hernial repairs. We illustrate the preperitoneal anatomy, and the technique, which allows the safe and efficacious performance of a hernial repair during a urologic procedure.
Parastomal hernias
Authors: Pearl Russell K.
Published: May 2005

Parastomal hernia is a common complication of stoma formation, having an incidence of about 10%. As with many other ostomy‐associated complications, most parastomal hernias are related to inadequate preoperative planning or technical errors. Most of these hernias should be managed conservatively; only 10–20% of patients eventually require operative intervention. When an operation is indicated, relocating the stoma generally yields better long‐term results than does an attempt at local repair of the hernia.
The place for pneumoperitoneum in the repair of massive hernia
Authors: Raynor R. Winfield , Del Guercio Louis R. M.
Published: May 2005

Progressive pneumoperitoneum before the repair of massive abdominal and inguinal hernias, first introduced in 1940, remains an important technique in preparing patients for the operation. Reports of its use have appeared sporadically in the surgical literature. This article recounts the technique of progressive preoperative pneumoperitoneum, its advantages and complications, and the variety of situations in which it is useful. Surgeons treating large hernias accompanied by loss of domain of abdominal viscera should consider preoperative progressive pneumoperitoneum as a helpful and often necessary adjunct to hernial repair.
Diagnosis and treatment of genitofemoral and ilioinguinal neuralgia
Authors: Starling James R. , Harms Bruce A.
Published: May 2005

During the past 8 years, a total of 36 patients were diagnosed as having either ilioinguinal or genitofemoral neuralgia. A multidisciplinary approach (surgeon, neurologist, anesthesiologist) as well as local blocks of the ilioinguinal nerve or paravertebral blocks of L1,2 were essential to determine which nerve was likely to be entrapped. Seventeen of the 19 patients having a diagnosis of ilioinguinal neuralgia after previous inguinal herniorraphy were completely free of pain after resection of the entrapped portion of the nerve. Seventeen patients were diagnosed as having genitofemoral neuralgia after previous inguinal herniorraphy, blunt abdominal trauma, or another operation. Neurectomy of the genitofemoral nerve proximal to the entrapment controlled the persistent pain in 12 of 17 of these patients. Ilioinguinal or genitofemoral nerve entrapment neuralgias are rare complications of operations in the inguinal region. When the diagnosis is made by a multidisciplinary approach, neurectomy is frequently successful in relieving severe pain and paresthesias without serious morbidity.
Emergency endoscopy: A basis for therapeutic decisions in the treatment of severe gastroduodenal bleeding
Authors: Pimpl Wolfgang , Boeckl Oskar , Heinerman Michael , Dapunt Otto
Published: May 2005

This prospective study compares 3 different consecutive treatment protocols of gastroduodenal hemorrhage. Three hundred sixty‐one patients underwent emergency endoscopy as the basis for further treatment. Clinical and endoscopic findings, such as site and type of the bleeding source, bleeding activity and intensity, age, and concomitant diseases of the patient were scored between 0 and 6 points, the higher number indicating a higher risk. The mean values of the total score of the 7 risk factors were comparable in the 3 treatment protocols.

In period I (n=77), a total of 16 patients (20.8%) underwent emergency operations because of severe bleeding, 27 (35%) were operated on after cessation of the bleeding, and 34 (44.2%) were treated conservatively. The mortality was 16.9%.

In period II (n=116), patients with actively bleeding lesions (n=38) underwent endoscopic sclerotherapy, with a primary rate of hemostasis in 95%. As a result, the rate of emergency surgery could be reduced to 12.9% and the mortality for the entire group was reduced to 9.5%. The problem in this protocol was the rate of recurrent bleeding after primary endoscopic hemostasis: 13/116 (11.2%). Eleven of the 13 rebleeders presented with a lesion either on the back wall of the duodenum or with a visible vessel.

In period III (n=168), a total of 83 patients (50%) underwent endoscopic injection therapy with a primary success in 93%. Sixteen patients (9.5%) with lesions of high rebleeding risk (duodenal ulcer on the posterior wall or visible vessel) were scheduled for urgent elective operation after volume resuscitation within 24 hours of emergency endoscopy (mortality, 6.3%). As a result, the frequency of emergency operations and the mortality for the entire group was reduced to 9.5% and 7.1%, respectively.

It is concluded that emergency endoscopy provides superior information for selecting patients for surgery at the optimal time. Furthermore, endoscopic therapy can reduce the rate of emergency operations with the associated high mortality.