bluuebunny/crossref_metadata_2025 huggingface dataset:
Prospective comparison of laparoscopic and conventional anterior resection
Authors: Tate J J T , Kwok S , Dawson J W , Lau W Y , Li A K C
Published: March 2007

A prospective comparison of laparoscopically assisted (n = 11) and conventional (n = 14) anterior resection in patients with sigmoid colon or upper rectal cancer was carried out. Patients were not randomized: age and the presence of metastases determined the type of surgery. Laparoscopic assistance was used to mobilize the tumour and minimize the abdominal incision. This was achieved in all patients and six of the 11 required only a muscle-splitting incision. The mean(s.d.) operating time was longer for laparoscopic than conventional surgery (205(31) versus 123(26) min, P = 0.01). The mean(s.d.) time to reintroduction of normal diet (2.5(0.2) versus 3.6(0.3) days, P = 0.01), postoperative analgesia requirement (2.6(0.4) versus 7.4(2.1) doses of pethidine, P = 0.01) and length of hospital stay (12.3(3) versus 14.3(6) days, P = 0.08) were less in the laparoscopic group. Histopathological examination of the resection specimens showed similar results for the two procedures. Major complications were few and occurred in a similar proportion of patients treated laparoscopically or conventionally. Laparoscopically assisted anterior resection is technically feasible, adequate tumour excision can be achieved and recovery after operation is enhanced.
Resection-line involvement in gastric cancer: A continuing problem
Authors: Hallissey M T , Jewkes A J , Dunn J A , Ward L , Fielding J W L
Published: March 2007

Surgeons are aware of the adverse effect that resection-line disease has on anastomotic leakage, perioperative mortality and long-term survival. In an attempt to assess the effect of this knowledge on surgical practice, patients entered into the second British Stomach Cancer Group adjuvant therapy trial were studied. The presence of resection-line disease was compared with the operative stage. Of 555 patients for whom complete data were available, resection-line disease was present in 105 (19 per cent). Of 424 patients undergoing what the surgeon considered to be a potentially curative operation, 55 (13 per cent) had involvement of one or both resection lines, rendering the surgery palliative. Only 9 per cent of patients with stage I–III disease and resection-line involvement survived beyond 5 years, compared with 27 per cent of those with clear lines. Despite knowledge of the adverse effects of resection-line disease, surgeons continue to perform inadequate resections. This demonstrates the need for a more aggressive approach to assessment of resection margins at operation.
Vertical banded gastroplasty for the treatment of morbid obesity
Authors: Ashley S , Bird D L , Sugden G , Royston C M S
Published: March 2007

Prospective evaluation of 114 obese patients (96 women, 18 men) undergoing vertical banded gastroplasty over a 5-year period was undertaken. The age range was 17–58 (median 37) years, median weight 119·3 (range 79–216) kg, mean(s.d.) proportion of excess body-weight 104·1(34·9) per cent and median body mass index (BMI) 44·8 (range 33·2–77·7) kg/m2. Three gastric outlet stoma circumferences were used: 5·5 cm (31 patients), 5·0 cm (28) and 4·75 cm (55). A total of 109 patients (95·6 per cent) were available for follow-up. At 1 year after operation, 54 patients (59 per cent) had lost greater than 50 per cent of excess body-weight. No patient lost less than 25 per cent of excess body-weight, and the median BMI was 32·5 (range 21·3–47·8) kg/m2. The operative mortality rate was zero, but three patients (2·6 per cent) with gastric leakage required surgical revision. Vertical banded gastroplasty is a relatively safe and simple procedure that produces significant and sustained weight reduction in the majority of morbidly obese patients.
Reoperation for biliary tract complications following orthotopic liver transplantation
Authors: Ramirez P , Parrilla P , Bueno F S , Robles R , Pons J A , Acosta F
Published: March 2007

Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in 49 patients over a 2-year period. Reconstruction of the bile duct consisted of end-to-end choledochocholedochostomy over a T tube in 47 cases and Roux-en-Y choledochojejunostomy in seven (two for sclerosing cholangitis, one for secondary biliary cirrhosis, four retransplants). The T tube was withdrawn 12–16 weeks after operation in all but two patients (2–3 weeks). There was no intraoperative mortality. Eight patients (16 per cent) died during the first month and the 1-year actuarial survival rate was 75 per cent. Early biliary complications (up to 3 months after operation) consisted of five bilomas, for which ultrasonographically guided drainage was effective in three and surgical drainage necessary in two. Late biliary complications (3 months onwards) consisted of biliary peritonitis following T tube removal (four patients; reoperation was required in all four) and necrosis of the bile duct secondary to a late arterial thrombosis (one). The incidence of reoperation as a result of early biliary complications was low (two patients), but higher for biliary peritonitis following T tube removal.
Mucosal morphology, cell proliferation and faecal bacteriology in acute pouchitis
Authors: Kmiot W A , Youngs D , Tudor R , Thompson H , Keighley M R B
Published: March 2007

A study was performed to investigate whether acute reservoir ileitis (pouchitis) is associated with specific changes in mucosal morphology, crypt cell kinetics and faecal bacteriology in the ileal pouch. Forty-six patients were studied (ileal reservoir, 36; end ileostomy, ten) using clinical grading, sigmoidoscopy and biopsy; 24 patients with a reservoir were restudied after therapy for 1 month with metronidazole 400 mg three times daily. An index of villus atrophy and crypt cell production rate (CCPR) were determined in all biopsy material. Faecal bacteriology was assessed in 12 patients with a pouch before and after metronidazole therapy. The mucosa of patients with pouchitis was associated with a lower villus atrophy index (P = 0·052), a higher CCPR (P = 0·03) and a higher grade of acute inflammation than that in those without pouchitis. There was no difference in faecal bacterial counts between patients with and without pouchitis. A low atrophy index correlated with a high CCPR (P < 0·001), worse functional score (P < 0·001) and more severe pouch mucosal acute inflammation (P < 0·001), but not with faecal bacteriology. Following metronidazole therapy there was resolution of acute pouch inflammation, increased villus atrophy index (P = 0·049), decreased CCPR (P = 0·049) but no differences in faecal bacterial counts apart from Bacteroides species. These data show that metronidazole therapy does not specifically alter the growth of common faecal bacteria in patients with pouchitis, apart from Bacteroides species. However, metronidazole causes resolution of the typical changes in pouch mucosal morphology and crypt cell kinetics associated with pouchitis.
Cocaine ‘body packers’
Authors: Beck N E , Hale J E
Published: March 2007

Intracorporeal drug smuggling, particularly of cocaine, is increasing. The so-called ‘body packers’ present a difficult clinical problem, particularly as no coherent management policy has been formulated. The various methods of diagnosis and the treatment options available are presented and discussed.
Popliteal aneurysm: Morphology and management
Authors: Ramesh S , Michaels J A , Galland R B
Published: March 2007

Since January 1988, 32 patients have presented with 44 popliteal aneurysms (22 thrombosed, 22 non-thrombosed). Patients with thrombosed aneurysms were older (median age 72 versus 66 years), and more likely to have bilateral lesions (P < 0·02) and serious associated cardiovascular disease (P < 0·02). Nineteen aneurysms thrombosed acutely; 12 were treated with intra-arterial thrombolysis, which was at least partially successful in seven. All 12 were subsequently bypassed, as were the other seven which were associated with such severe ischaemia that they required urgent operation. One patient died and two others required major amputation. Other complications included foot-drop (two patients), renal failure (one) and wound infection (two). Two grafts thrombosed and required re-exploration. Elective bypass was carried out in 11 patients without acutely thrombosed aneurysms; there were no significant postoperative problems. Distortion within the aneurysm (P < 0·01), large size (P < 0·01) and distortion of the popliteal artery above or below the lesion (P < 0·02) were all associated with thrombosis. Stenosis within the aneurysm was more likely in patients with multiple lesions (P < 0·01) and distortion with larger aneurysms (P < 0·01). After correcting for distortion, none of the other variables was independently significant. The combination of distortion and diameter > 3 cm was present in 13 of 15 thrombosed aneurysms. Morbidity is high following acute thrombosis of popliteal aneurysm. Distortion of the aneurysm appears to be a more sensitive predictor of thrombosis than size alone. The combination of distortion with a diameter > 3 cm may help to define popliteal aneurysms that should be bypassed electively.
Physical examination and selective conservative management in patients with penetrating injuries of the neck
Authors: Demetriades D , Charalambides D , Lakhoo M
Published: March 2007

This prospective study of 335 patients with penetrating injuries of the neck examined the decision whether to operate or observe according to a protocol based mainly on physical examination. Emergency angiography was performed in only three patients. Sixty-six patients (20 per cent) were subjected to emergency operation because of signs and symptoms suggestive of significant injury (60 patients) or because of positive investigations (six). The remaining 269 patients (80 per cent) were selected for non-operative management. Two of these patients (0·7 per cent) required elective operation during the initial hospital stay. No deaths occurred in patients treated conservatively. Some 192 (72 per cent) of observed patients were available for early follow-up and 111 (42 per cent) for late follow-up. No significant complications were found. Physical examination is a reliable method for detecting significant injuries following penetrating neck trauma. Emergency angiography is rarely necessary.
Timing of extubation after oesophagectomy
Authors: Caldwell M T P , Murphy P G , Page R , Walsh T N , Hennessy T P J
Published: March 2007

Ventilatory support for 24 h after surgery is standard practice in many units after oesophagectomy, especially for patients in whom respiratory problems are anticipated. Weaning difficulties may occur, however, and there is increasing evidence that mechanical ventilation is associated with alveolar trauma. A deliberate change in policy was instituted in the authors' unit in January 1990 to make early extubation mandatory in all patients undergoing elective oesophagectomy, apart from those in whom serious perioperative problems were encountered. The present study compared two sets of patients: group 1 (n = 36) underwent oesophagectomy in the year before the policy change and group 2 (n = 45) oesophagectomy in the year after. The two groups were similar in age, sex and respiratory risk factors. Early extubation was carried out in 38 patients in group 2 compared with eight in group 1 (P < 0·001). Only two patients in group 2 required prolonged ventilation compared with ten in group 1 (P < 0·005). No patient in group 2 required reventilation compared with seven in group 1 (P < 0·005), and no patient in group 2 who had undergone early extubation required delayed ventilation. The mean ventilation time and length of stay in the intensive care unit were significantly reduced following the policy change. Early extubation after elective oesophagectomy is an attainable goal and results in a significant reduction in both the morbidity rate and cost of surgery.
Granulocyte—macrophage colony-stimulating factor inhibits tumour growth
Authors: Hill A D K , Redmond H P , Austin O M , Grace P A , Bouchier-Hayes D
Published: March 2007

The effect of granulocyte—macrophage colony-stimulating factor (GM—CSF) on murine antitumour responses was examined. Sixty mice received Lewis lung carcinoma implants and were then randomized to receive GM—CSF 1 μg/day, GM—CSF 0·5 μg/day or saline for 10 days and studied with regard to tumour volume, carcass weight and food intake. Macrophage antitumour mechanisms including oxygen free radical production and nitric oxide release were studied in peritoneal macrophages after co-culture with GM—CSF in vitro and in vivo. GM—CSF 1 μg/day decreased tumour growth after 5 days (mean(s.e.m.) 0·62(0·4) versus 1·24(0·19) cm3, P = 0·017). GM—CSF upregulated macrophage antitumour mechanisms by enhancing the in vivo production of superoxide radicals (mean(s.e.m.) 0·69(0·06) versus 0·45(0·10) nmol, P < 0·05) and nitric oxide (mean(s.e.m.) 48(3) versus 24(4) μmol, P < 0·01). GM—CSF functions through the enhancement of macrophage tumoricidal activity, suggesting a therapeutic potential for this cytokine in the tumour-bearing host.
Pancreatic necrosis: Assessment of outcome related to quality of life and cost of management
Authors: Fenton-Lee D , Imrie C W
Published: March 2007

Ten patients with necrotizing pancreatitis admitted consecutively between August 1990 and August 1991 were studied. They comprised eight men and two women of median age 63 (range 29–73) years. One patient died. The median length of hospital stay was 74 (range 40–150) days. The median number of operations and endoscopic procedures performed per patient was 4 (range 2–7). Investigations performed included multiple bacteriological, radiological, haematological and biochemical tests. The mean cost of management was £18 441 (range £9296–£33 796), of which hospitalization accounted for 65 per cent, operations and endoscopic procedures 20 per cent and investigations 16 per cent. Cost—utility analysis demonstrated a mean benefit per patient of 8·55 quality-adjusted life years gained at a cost of £2157 each. The management of pancreatic necrosis is expensive but justified by the excellent outcome in terms of quality of life.
Good long-term results in patients surviving severe acute pancreatitis
Authors: Doepel M , Eriksson J , Halme L , Kumpulainen T , Höckerstedt K
Published: March 2007

Thirty-seven patients treated for severe acute pancreatitis were investigated a mean of 6·2 years after the attack; 30 were found to be in good condition and 24 were working normally. Two-thirds of previously heavy drinkers had either reduced their intake considerably or become abstainers. The main complication observed on follow-up was diabetes mellitus, which affected 20 patients and required insulin treatment in nine. Of the remaining patients, four were taking oral antidiabetic agents and seven were on a strict diabetic diet. Before severe acute pancreatitis none had been diabetic. All patients who underwent resection of the pancreas developed diabetes. In 21 of 24 patients with overt or imminent diabetes, pancreatitis had been primarily alcoholic in origin. Polyneuropathy, as diagnosed by clinical signs and/or neurophysiological tests, was observed in six patients, all of them heavy drinkers. It is concluded that patients with severe acute pancreatitis have a high chance of returning to normal activity and productive work. These results serve to encourage all those involved to persist with the exacting work involved in treating such patients.
Early discharge after operation
Authors: Narayan A , Kumar S , Singh M P , Sharma L K
Published: March 2007

To assess the feasibility and advantages of short-stay surgery in India, a policy of early discharge was adopted for 386 patients undergoing various major and minor operations. The mean postoperative and total hospital stays of patients admitted for minor surgery were 1·9 and 3·7 days respectively; the corresponding figures for age- and sex-matched historical controls were 7·4 and 11·3 days. The mean postoperative and total stays of patients who had undergone major surgery were 4·1 and 8·0 days respectively; the corresponding control values were 8·9 and 12·5 days. The use of absorbable subcuticular skin sutures helped to shorten postoperative hospital stay and avoided an extra follow-up visit. The overall complication rate in the study group was 9·6 per cent and in historical controls 13·4 per cent (P > 0·05). A total of 2357 hospital bed-days were saved during the study and 95·6 per cent of patients approved of short-stay surgery.
Surgical management of perineal and metastatic cutaneous Crohn's disease
Authors: Williams N , Scott N A , Watson J S , Irving M H
Published: March 2007

Skin lesions are the commonest extraintestinal manifestation of Crohn's disease. Lesions that develop at sites remote from the gastrointestinal tract and have granulomas on histological examination are termed metastatic cutaneous Crohn's disease. Management is difficult as medical treatment is often ineffective. This report describes the use of surgical debridement of areas of perineal metastatic cutaneous Crohn's disease in five patients, all of whom had failed to improve after a variety of medical treatments. One patient had a poor result with continuing mild perineal discharge and four had a good outcome with complete resolution of symptoms and satisfactory cosmetic results.
Laparoscopic colorectal surgery: A prospective assessment and current perspective
Authors: Wexner S D , Cohen S M , Johansen O B , Nogueras J J , Jagelman D G
Published: March 2007

Between August 1991 and June 1993, 74 laparoscopic and laparoscopically assisted colonic and rectal operations were performed. A variety of procedures were carried out including 32 total abdominal colectomies (group 1), 32 segmental resections (group 2) and ten constructions of a diverting stoma without formal resection (group 3). Indications for surgery were mucosal ulcerative colitis in 20 patients, carcinoma in 12, polyposis in six, Crohn's disease in seven and other conditions in the remaining 29. The 74 comprised 42 male and 32 female patients of mean age 45 (range 12–88) years. The median (range) duration of the procedure was 3·0 (1·0–6·5) h for the entire group, 3·9 (2·5–6·5) h for group 1, 2·9 (1·5–5·5) h for group 2 and 1·8 (1·0–2·5) h for group 3. The median (range) length of ileus was 3·0 (2–7) days overall; respective times for groups 1–3 were 3·5 (2–7), 3·0 (2–7) and 2·0 (1–4) days. The median (range) length of hospitalization was 7·0 (2–40) days, 8·1 (4–19) days in group 1, 7·0 (4–20) days in group 2 and 6·0 (2–40) days in group 3. Ten patients (14 per cent) developed intraoperative and 15 (20 per cent) postoperative complications; there were no deaths. These results failed to confirm any significant advantages of laparoscopic or laparoscopically assisted colorectal surgery. Specifically, neither the operating time, nor length of ileus, nor length of hospitalization was improved over standard procedures. Advances in technology and surgical technique may improve such findings in the future.
New technique for sigmoid colectomy
Authors: Lirici M M , Bueß G , Melzer A , Weinreich S , Wehrmann M , Becker H D
Published: March 2007

A combination of laparoscopic and rectoscopic procedures has enabled complete resection of the sigmoid colon and eliminated the need for minilaparotomy when constructing the anastomosis or withdrawing the specimen. This combined procedure was performed in different ways in a series of animal models until the definitive technique had been standardized. These techniques were then successfully used in 15 consecutive medium-sized pigs. Histological evaluation of the specimens, including the anastomosis (examined 2–3 weeks after operation) confirmed the efficacy and safety of the method.
Hyperamylasaemia in ruptured aortic aneurysm: Incidence and prognostic implications
Authors: Bagley J S , Tyler M P H , Cooper G G
Published: March 2007

A study was carried out to determine the incidence of increased serum amylase activity in patients with ruptured aortic aneurysm during the 48 h after presentation and to assess its clinical significance. In a prospective series of 25 patients, hyperamylasaemia occurred in ten and was significantly associated with poor outcome (P=0·005). In patients who died or had a major complication, serum amylase activity was significantly higher than in those who had an uncomplicated postoperative recovery (P<0·05). There was a correlation between preoperative serum amylase activity and length of stay in the intensive care unit after operation (rs=0·78 (95 per cent confidence interval 0·54–0·90), P<0·002). Serum amylase activity may be useful as a prognostic indicator in patients with ruptured aortic aneurysm.
Randomized controlled trial comparing Nissen fundoplication and the Angelchik prosthesis
Authors: Hill A D K , Walsh T N , Bolger C M , Byrne P J , Hennessy T P J
Published: March 2007

Sixty-one patients with gastro-oesophageal reflux refractory to medical therapy were entered into a prospective randomized trial comparing the Rossetti–Hell modification of the Nissen fundoplication (n =31) with the Angelchik prosthesis (n = 30). Mean age, sex ratio, duration of symptoms, preoperative pH profiles and manometric findings were similar in the two groups. At a mean of 84 (range 64–105) months after closure of the trial 47 patients were available for review, eight had died from unrelated causes and six were lost to follow-up. Of the patients reviewed, 28 consented to endoscopy, 25 to oesophageal 24-h pH assessment and 20 to oesophageal manometry. Both fundoplication and the Angelchik prosthesis provided lasting control of gastro-oesophageal reflux, with 20 and 17 patients respectively maintaining a satisfactory outcome. There were no significant differences in pH profile between the groups but the Angelchik prosthesis had to be removed from three patients.
Results of resection for cancer of the exocrine pancreas: A study from the French Association of Surgery
Authors: Baumel H , Huguier M , Manderscheid J C , Fabre J M , Houry S , Fagot H
Published: March 2007

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12·3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0·001). The operative mortality rate was higher after total pancreatectomy than pancreato-duodenectomy (17 versus 8 per cent, P = 0·015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.
Evaluation of the cost of laparoscopic and open cholecystectomy
Authors: Fullarton G M , Darling K , Williams J , Macmillan R , Bell G
Published: March 2007

Despite the rapid growth of laparoscopic cholecystectomy, the comparative costs of this new procedure and open cholecystectomy remain unknown. In this study the costs have been evaluated of a consecutive series of patients undergoing these procedures in a district general hospital with an established resource management centre. Fifty consecutive patients undergoing open cholecystectomy between June 1988 and July 1990 immediately before the introduction of laparoscopic cholecystectomy and 100 patients undergoing laparoscopic cholecystectomy between August 1990 and June 1992 were studied. Costs estimated prospectively for each patient were compared. The mean cost per patient of open cholecystectomy was estimated at £2102 compared with £2026 for the first 50 patients undergoing the laparoscopic procedure. The mean cost (£1744) for the second 50 patients undergoing laparoscopic cholecystectomy was less than that for either open cholecystectomy (P<<0·005) or the initial 50 laparoscopic operations (P<0·03). Operating theatre costs and equipment costs were higher in both laparoscopic groups. These were offset by the higher nursing and ward costs of open cholecystectomy. For the laparoscopic procedure the operating theatre times and duration of hospital stay were both less in the second 50 patients than in the first 50. After the initial learning period, laparoscopic cholecystectomy is less expensive than the open operation and represents a cost-effective method for treatment of the patient with gallstones.
Metabolic and inflammatory responses after open or laparoscopic cholecystectomy
Authors: Jakeways M S R , Mitchell V , Hashim I A , Chadwick S J D , Shenkin A , Green C J , Carli F
Published: March 2007

Metabolic and inflammatory responses and changes in fatigue were studied in groups of patients undergoing either laparoscopic (n = 14) or open (n = 10) elective cholecystectomy. The mean(s.e.m.) cortisol concentration was significantly (P<0·001) increased from 342(80) and 424(91) nmol l−1 before operation to 895(46) and 966(53) nmol l−1 after surgery in patients undergoing laparoscopic and open cholecystectomy respectively. There was no difference in cortisol response between the groups. Glucose concentration was increased (P < 0·02) at the end of surgery from mean(s.e.m.) preoperative levels of 5·54(0·15) and 6·16(0·15) mmol l−1 to postoperative values of 7·46(0·29) and 8·46(0·86) mmol−1 for the laparoscopic and open procedures respectively. The mean glucose concentration during the initial 12 h after surgery was significantly greater (P < 0·02) following open than laparoscopic cholecystectomy. The mean(s.e.m.) albumin concentration fell significantly (P < 0·01) during surgery by an equivalent extent from 38·9(0·77) and 38·5(1·10) g l−1 to 35·2(0·79) and 34·6(0·97) g l−1. The mean (95 per cent confidence interval) interleukin (IL) 6 concentration peaked 4 h after surgery at 57·2 (44·6–73·4) pg ml−1 following laparoscopic and 99·3 (72·8–135·4) pg ml−1 after open cholecystectomy. Mean (95 per cent confidence interval) C-reactive protein (CRP) levels at 24 h were 17·0 (12·7–21·2) and 49·0 (25·3–93·6) mg l−1 and at 48 h 28·0 (21·4–35·4) and 70·0 (36·4–133·6) mg l−1 following laparoscopic and open operations. The differences in IL-6 and CRP level between the groups were significant (P < 0·01). Mean(s.e.m.) fatigue scores were significantly (P < 0·05) increased from preoperative values of 2·4(0·24) and 2·6(0·44) to 5·5(0·56) and 6·8(0·51) at 24 h after laparoscopic and open operations. At 48 h the mean(s.e.m.) fatigue score (5·6(0·57)) remained significantly (P < 0·05) raised only after open cholecystectomy. Hand grip strength was significantly (P < 0·05) reduced only after the open procedure, to a mean(s.e.m.) of 88(6) per cent of the preoperative value. These results demonstrate that aspects of the metabolic and acute-phase responses are attenuated following laparoscopic cholecystectomy, consistent with a reduction in tissue trauma.
Current role of extracorporeal shockwave therapy in surgery
Authors: Plaisier P W , van der Hul R L , Terpstra O T , Bruining H A
Published: March 2007

In urology the introduction of extracorporeal shockwave therapy brought a revolutionary change to the management of urinary calculi. This inspired the introduction of shockwave therapy in several fields of surgery; it has been applied as a potential alternative to several operative procedures but is still experimental. So far, the major application of shockwave therapy has been lithotripsy of stones in the gallbladder, common bile duct, pancreatic duct and salivary gland ducts. Other applications are in the non-operative management of bone healing disturbances and in the inhibition of tumour growth. Steps towards selective thrombus ablation and pretreatment of heavily calcified arteries have also been made. In this review, the applications of extracorporeal shockwave therapy in several areas of surgery are discussed. It is concluded that, for selected patients, shockwave treatment may serve as a useful addition to the surgical armamentarium.
Reliability of ankle: Brachial pressure index measurement by junior doctors
Authors: Ray S A , Srodon P D , Taylor R S , Dormandy J A
Published: March 2007

Ankle: brachial pressure index (ABPI) measurements are often performed by junior medical staff with little experience of the technique. The accuracy of such measurements is unknown. Two newly qualified doctors with no training in the use of Doppler ultrasonographic flowmeters performed ABPI measurement in 38 limbs (experiment 1). Two other newly qualified doctors then underwent a formal training session before, as well as continuous instruction during, ABPI measurements in 23 limbs (experiment 2). The doctors' measurements were compared with those obtained by experienced vascular technicians. The mean difference in ABPI measurement between the doctors and technicians in experiment 1 was greater than that in experiment 2 at both the dorsalis pedis (P<0·05) and posterior tibial arteries. Nearly 30 per cent of the doctors' ABPI measurements in experiment 1 differed from those of the technicians by more than 0–15, in comparison with only 15 per cent of the measurements performed in experiment 2. Junior doctors should undergo formal training before performing ABPI measurements.
Prediction of outcome using the Mannheim peritonitis index in 2003 patients
Authors:   The Peritonitis Study Group, Billing A , Fröhlich D , Schildberg F W
Published: March 2007

Early prognostic evaluation of abdominal sepsis is desirable to select high-risk patients for more aggressive therapeutic procedures and to provide objective classification of the severity of disease. The reliability of the Mannheim peritonitis index was assessed and its predictive power for different populations examined in a study of 2003 patients from seven centres in three European countries. The prevalence of risk factors varied considerably between the groups. For a threshold index score of 26, the sensitivity was 86 (range 54–98) per cent, specificity 74 (range 58–97) per cent and accuracy 83 (range 70–94) per cent in predicting death. For patients with a score less than 21 the mean mortality rate was 2·3 (range 0–11) per cent, for score 21–29 22·5 (range 10·6–50) per cent and for score greater than 29 59·1 (range 41–87) per cent. The mean index score and mean mortality rate correlated in the different groups, reflecting a homogeneous standard of therapy for peritonitis. The Mannheim peritonitis index provides an easy and reliable means of risk evaluation and classification for patients with peritoneal inflammation.
Timing of surgery in relation to the menstrual cycle in premenopausal women with operable breast cancer
Authors: Saad Z , Bramwell V , Duff J , Girott M , Jory T , Heathcote G , Turnbull I , Garcia B , Stitt L
Published: March 2007

Recent studies have suggested that the timing of surgery in relation to the menstrual cycle might influence survival of premenopausal women with operable breast cancer. The data of 96 premenopausal patients who underwent primary surgery for operable breast carcinoma between 1975 and 1988 were analysed. At 10 years, disease-free and overall survival rates of patients whose initial surgery was 1–12 days after the starting date of the last menstrual period (follicular phase) were significantly poorer compared with survival of those who underwent operation more than 12 days after the last menstruation (luteal phase) (disease-free survival rate 40 versus 72 per cent, P = 0·002; overall survival rate 40 versus 79 per cent, P = 0·001). These differences in survival remained significant in a second analysis based on the menstrual phase at the time of both initial and definitive operation. Menstrual phase had the greatest impact on the survival of patients with positive axillary nodes (P = 0·009). Prospective studies are required to elucidate the relationship between the timing of all surgical procedures during the menstrual cycle and survival.
Stereotactic cytology in a regional breast-screening programme
Authors: Kerin M J , Williams N N , Cronin K J , Dervan P , Ennis J , Dowling M , Fitzpatrick J M , Gorey T F
Published: March 2007

Stereotactic localization and fine-needle aspiration are new procedures for the management of non-palpable mammographic abnormalities. In this prospective study, stereotactically guided cytology with immediate reporting was performed before biopsy in a consecutive series of 166 patients with screen-detected non-palpable abnormalities. All specimens were obtained by multiple stereotactically guided passes with a 22–G Franzén needle and graded as: 1, acellular or inadequate; 2, benign; 3, atypical, probably benign; 4, probably malignant; or 5, malignant. After definitive surgery all tumours were staged according to the Union Internacional Contra la Cancrum classification. Of 71 patients with malignancy, 56 were correctly diagnosed by cytology before operation. Twelve patients with malignancy had grade 1 cytology and 50 of the 52 with grade 2 cytology had benign disease. This study confirms that stereotactic cytology is a valuable diagnostic test in a breast-screening programme.
Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer: A randomized controlled trial
Authors: Izbicki J R , Thetter O , Habekost M , Karg O , Passlick B , Kubuschok B , Busch C , Haeussinger K , Knoefel W T , Pantel K , Schweiberer L
Published: March 2007

The value of radical systematic lymphadenectomy in the treatment of bronchial carcinoma is controversial. In a randomized controlled clinical trial, radical lymphadenectomy was compared with conventional node dissection in 182 patients with non-small cell lung cancer. Comparison of short-term results revealed a significantly longer operating time in those undergoing systematic lymphadenectomy, but overall morbidity and mortality rates were comparable between groups. However, there were complications associated with radical lymphadenectomy such as prolonged air leakage and haemorrhage. Interim analysis of results at a median follow-up of 26·8 months showed no significant influence of radical lymphadenectomy on local recurrence-free interlval, metastasis-free interval or cancer-related survival. In conclusion, radical systematic lymphadenectomy is a safe operation that leads to a better staging of non-small cell lung cancer, but its prognostic benefit is questionable.
Implications of upright gastro-oesophageal reflux
Authors: Gillen P , Thornton J , Byrne P J , Walsh T N , Hennessy T P J
Published: March 2007

The presentation, oesophageal profile and management of 27 symptomatic patients with daytime (upright) gastrooesophageal reflux only is reported. Oesophagitis was a presenting feature in 11 patients and its development was most closely correlated with postprandial reflux, which was characterized by cumulative acid exposure rather than by clearance abnormalities. Upright reflux was not associated with a hypotensive lower oesophageal sphincter or with oesophageal dysmotility. Antireflux surgery is indicated when conservative measures fail and was not associated with gas-bloat syndrome after operation.
Highly selective devascularization for bleeding oesophagogastric varices
Authors: Yassin Y M , Eita M S , El-Mirghani M
Published: March 2007

Between 1975 and 1984, 419 patients with bleeding oesophagogastric varices were subjected to the simplified operation of highly selective devascularization. All but three were available for follow-up at 5–10 years. The overall mortality rates for urgent and elective operation were 8 and 2 per cent respectively. The overall recurrent bleeding rates at 1, 5 and 10 years were 8 per cent, 13 per cent (15 per cent of survivors) and 17 per cent (24 per cent of survivors). The overall survival rates at 1,5 and 10 years were 87,76 and 57 per cent. Recurrent bleeding was usually controlled by endoscopic sclerotherapy and less often by reoperation. Highly selective devascularization controlled bleeding in emergency and elective situations without compromising hepatic function.
Use of Marlex mesh in the repair of recurrent incisional hernia
Authors: Liakakos T , Karanikas I , Panagiotidis H , Dendrinos S
Published: March 2007

Recurrent incisional hernia remains a major problem for the general surgeon. The rate of recurrence of hernia repaired by primary closure using nylon sutures or with knitted monofilament polypropylene (Marlex) mesh was studied. A total of 102 repairs were performed over a 19-year period. Marlex mesh was used in 49 cases and primary closure in 53. All except two patients were followed from 1 to 15 (mean 7·6) years or to death. The incidence of recurrence was 8 per cent when Marlex was used and 25 per cent after primary closure. In both groups the majority of the recurrences were in the first 16 months after repair. The use of Marlex mesh should be considered in the management of recurrent incisional hernia.
Improved sensitivity of colour Doppler flow imaging of colorectal hepatic metastases using galactose microparticles: A preliminary report
Authors: Leen E , Angerson W J , Warren H W , O'Gorman P , Moule B , Carter E C , McArdle C S
Published: March 2007

The clinical application of ultrasonographic contrast agents in colour Doppler flow imaging of hepatic tumours is receiving increasing attention. Levovist is a suspension of galactose microparticles that provides reproducible concentrations of stabilized air bubbles with transpulmonary stability. Its effect on colour Doppler imaging was assessed in 26 patients with colorectal cancer and histologically proven hepatic metastases. Colour Doppler flow imaging was performed before and after intravenous injection of 10ml Levovist 300mg/ml. At 5–10 s after injection there was significant enhancement of the hepatic lesions with colour Doppler signals in 23 patients, lasting for a mean(s.d.) of 180(45) s. A consistent pattern of colour Doppler signal was observed, with increased enhancement predominantly around the tumour periphery and little or no central enhancement. These data suggest that Levovist may increase the sensitivity and specificity of colour Doppler flow imaging of colorectal hepatic metastases.
Efficacy of octreotide in the prevention of complications of elective pancreatic surgery
Authors:   The Italian Study Group, Pederzoli P , Bassi C , Falconi M , Camboni M G
Published: March 2007

A placebo-controlled double-blind multicentre study, with randomization into parallel groups, was performed to determine whether perioperative subcutaneous administration of octreotide 0·1 mg every 8 h reduces the rate of complications specifically related to pancreatic surgery. In all, 252 patients were evaluated (153 men, 99 women; mean(s.e.m.) age 53·1(0·8) years) who had pancreatic or periampullary tumour or other duodenal disease (157 patients) or chronic pancreatitis (95) and were undergoing elective pancreatic resection (100 Whipple's procedure, 60 distal resection, 12 others), pancreaticojejunostomy (66) or enucleation of pancreatic lesions (14). The proportion of patients with complications was significantly lower in the group treated with octreotide than in the placebo group (15·6 versus 29·2 per cent, P = 0·01). Octreotide thus appears to reduce substantially the risk of complications related to elective pancreatic surgery. Moreover, treatment acceptability was high.
Postoperative immunological function and jaundice
Authors: Regan M C , Keane R M , Little D , Bouchier-Hayes D
Published: March 2007

The effects of operative trauma and obstructive jaundice on systemic immunity were studied in a rat model, using the delayed-type hypersensitivity response to 2,4-dinitro-1-fluorobenzene as a measure of systemic immune responsiveness. Midline laparotomy caused a significant decrease in the mean(s.e.m.) delayed-type hypersensitivity response 1 week after operation (4·6(1·3) versus 19·0(2·2) per cent for controls). The response returned to control leyels by 2 weeks (14·6(3·1) per cent). Common bile duct ligation and division resulted in a significantly depressed hypersensitivity response at 2 and 3 weeks (6·8(2·0) and 8·4(1·6) per cent respectively). The expected decrease in the response at 1 week in these animals was not observed (mean(s.e.m.) 12·7(2·7) per cent), suggesting a possible role for the normal liver in the induction of postoperative immune depression. Impaired function of the reticuloendothelial system was induced in non-jaundiced animals by Kupffer cell ablation following intraportal infusion of λ-carrageenan. A similar prevention of postoperative immune hyporesponsiveness was observed (mean(s.e.m.) 10·4(1·0) versus 10·4(1·6) per cent for controls). Hepatic Kupffer cells play an important role in the induction of postoperative immune depression.
Peritoneal aspiration cytology as a diagnostic aid in acute appendicitis
Authors: Caldwell M T P , Watson R G K
Published: March 2007

A total of 110 consecutive patients presenting to one surgical firm with suspected acute appendicitis underwent peritoneal aspiration cytology. Aspiration was successful in 108 patients and 44 were positive. Patients with a positive result underwent emergency surgery; 42 had histologically proven acute appendicitis and two peritonitis of other causes. Seven patients with a negative result underwent appendicectomy; four had acute appendicitis and three a normal appendix. Peritoneal aspiration cytology had a sensitivity for acute appendicitis of 91 per cent and a specificity of 94 per cent. The positive predictive value of the test was 95 per cent and the negative predictive value 94 per cent. The negative appendicectomy rate was 10 per cent overall and 11 per cent in women of reproductive age. Peritoneal aspiration cytology is a useful diagnostic test in the management of patients with suspected acute appendicitis.
Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis
Authors: Sun W M , Read N W , Katsinelos P , Donnelly T C , Shorthouse A J
Published: March 2007

Anorectal manometry and electromyography were studied in 17 patients before and after restorative proctocolectomy with stapled pouch-anal anastomosis, in ten patients before and after low anterior resection with stapled coloanal anastomosis, and in 35 normal controls. More than 80 per cent of patients in both groups developed abnormal oscillation of anal pressure after operation (amplitude 15–60 (median 25) cmH2O, frequency 4–10 (median 8) per min) and showed no anal relaxation in response to intermittent neorectal distension. All patients lost discriminative rectal sensation and none could perceive a normal desire to defaecate. Patients with postoperative soiling had a greater amplitude of anal pressure oscillation and lower minimum basal pressure, although those who underwent coloanal anastomosis had a greater risk of incontinence because of large asynchronous oscillations in neorectal pressure. The common pathophysiological features after restorative proctocolectomy and coloanal anastomosis probably relate to damage to the autonomic and enteric nerve supplies. The presence of an unstable internal anal sphincter may be an important cause of postoperative nocturnal incontinence.
Postanal repair for faecal incontinence persisting after rectopexy
Authors: Carraro P Setti , Nicholls R J
Published: March 2007

Eleven patients (nine women) with persistent faecal incontinence after rectopexy for rectal prolapse were treated by postanal repair. Follow-up data, including clinical and anorectal physiology, at 5–8 years (median 76 (range 64–95) months) were available for nine patients. At long-term follow-up, seven of the nine patients had improved continence (two were continent to solid and liquid stools, and five to solid stool). One patient required a colostomy. Median (range) physiological findings before and after postanal repair in the nine patients were: anal canal length 2·3 (1·5–3·0) versus 3·5 (2·0–5·5) cm (P<0·05); resting anal pressure 20 (0–49) versus 35 (10–55) cmH2O (P<0·05); perineal descent 2 (1–3) versus 0 (3 to –0·2) cm; and mean pudendal nerve terminal motor latency 2·35 (2·0–3·1) versus 2·85 (2·3–3·4) ms.
Pelvic ileal reservoirs: The options
Authors: Sagar P M , Taylor B A
Published: March 2007

Restorative proctocolectomy has become an established surgical option for patients with chronic ulcerative colitis and familial adenomatous polyposis. However, despite a large number of different reservoir designs there is so far no acknowledged ideal configuration. This paper reviews the advantages and disadvantages of the different types of pelvic ileal reservoir so far studied.
Coronary artery disease in patients with peripheral vascular disease
Authors: Gajraj H , Jamieson C W
Published: March 2007

For patients requiring peripheral vascular surgery, coronary artery disease is the major determinant of perioperative mortality and long-term survival. The management of coronary artery disease in these patients is controversial as no randomized blinded prospective studies have been conducted. Data on the prevalence, diagnosis and management are reviewed.
Management of advanced rectal cancer
Authors: Baigrie R J , Berry A R
Published: March 2007

If possible, palliative resection should be undertaken for advanced rectal cancer as it provides good relief of local symptoms; there is, however, little evidence that it prolongs survival. If palliative excision is not possible, endoscopic transanal resection may be used for obstructing lesions at or below the peritoneal reflection. Laser therapy is an alternative in the frail. Both procedures allow quick and effective relief of symptoms. These methods and other options for treating advanced rectal cancer are described in this review.
Prevalence of anal human papillomavirus infection and intraepithelial neoplasia in renal allograft recipients
Authors: Ogunbiyi O A , Scholefield J H , Raftery A T , Smith J H F , Duffy S , Sharp F , Rogers K
Published: March 2007

A study was performed to test the hypothesis that renal allograft recipients are at high risk of developing anal human papillomavirus (HPV) infection and anal intraepithelial neoplasia (AIN). A total of 133 renal allograft recipients and 145 control patients underwent anoscopy and biopsy. A polymerase chain reaction was used to detect HPV16 DNA in biopsy samples. A histological diagnosis of anal HPV infection or AIN was made in 32 allograft recipients (HPV infection, five; AIN I, 20; AIN II, three; AIN III, three; AIN III and anal cancer, one). One subject with AIN was detected in the control group. HPV16 DNA was detected in 47 and 12.4 per cent of anal biopsies in the allograft and control groups respectively. Renal allograft recipients are at high risk of developing anal HPV infection and neoplasia (P<0.05). Further studies are required to determine whether screening anal examination is required in organ allograft recipients.
Low-dose intra-arterial thrombolysis in the treatment of phlegmasia caerulea dolens
Authors: Wlodarczyk Z K , Gibson M , Dick R , Hamilton G
Published: March 2007

Three patients with phlegmasia caerulea dolens treated successfully by low-dose intra-arterial thrombolysis are presented. In all patients a rapid improvement was observed and amputation avoided. The risk of pulmonary embolus was reduced by the use of a retrievable vena cava filter in one patient and thrombolytic therapy in the presence of a previously inserted cava filter in the other two.