bluuebunny/crossref_metadata_2025 huggingface dataset:
Venous reflux: Quantification and correlation with the clinical severity of chronic venous disease
Authors: Christopoulos D , Nicolaides A N , Szendro G
Published: March 2007

Air-plethysmography has been used to measure, in ml and in ml 100 ml−1 of tissue, the blood volume that filled the leg veins on changing posture from the recumbent position to standing. The venous filling index (VFI) (average filling range) was measured in ml s−1 and in ml 100 ml−1 min−1. We studied 24 normal legs (N), 21 with primary varicose veins without chronic swelling, skin changes (liposclerosis, eczema, pigmentation) or ulceration (PVV) and 59 with chronic swelling and/or skin changes and/or ulceration; of these 59 legs, 31 had primary varicose veins (PVV/S) and 28 had popliteal reflux (PR). The classification was done according to clinical examination, Duplex scanning, ambulatory venous pressure measurements and venography. There was an increased incidence of sequelae with increasing values of VFI. The incidence of these sequelae was irrespective of whether reflux was in the deep or in the superficial veins. VFI is a practical non-invasive measurement of reflux. It should be used to study the effect of therapy and particularly to evaluate new reconstructive procedures designed to abolish reflux in the deep veins.
Evaluation of peritoneal tube grafts in the inferior vena cava of the pig
Authors: Ribbe Else B , Alm P , Hallberg E , Norgren L E H
Published: March 2007

A tube graft 2·5 or 5 cm long, was constructed from the peritoneum of the anterior abdominal wall of 12 pigs. It was anastomosed end-to-end as an interposition graft in the infrarenal vena cava. The observation period was 4 months. Three of the six short grafts were venographically patent at 2 weeks, while all the long grafts were occluded. After 4 months two short grafts had recanalized, giving a patency rate of five out of six short grafts. No long grafts recanalized. In three of the patent specimens no clear tissue changes were found with light microscopy, while in the others changes of inflammation and fibrosis were noted. Scanning electron microscopy revealed good ‘endothelialization’ in two specimens, and partial ‘endothelialization’ in the others. No dilatation or severe stenosis of the patent grafts was seen. The occluded grafts remained only as a fibrous strand with sutures.
Pulse-generated runoff: a new method of determining calf vessel patency
Authors: Beard J D , Scott D J A , Evans J M , Skidmore R , Horrocks M
Published: March 2007

A non-invasive method of determining calf vessel patency before femorodistal bypass has been developed. This pulse-generated runoff (PGR) system generates blood flow in patent calf arteries by means of a pulsatile cuff even if the existing Doppler signal is inaudible. PGR was compared with pre-operative arteriography in 95 ischaemic limbs and both were compared with the peripheral resistance measured at operation in 62 limbs. There was a highly significant correlation between the PGR and arteriogram scores (rs = 0·74, P< <0·001) but PGR tended to detect more patent vessels than arteriography. The peripheral resistance correlated better with PGR than arteriography (rs = −0·71 and −0·54 respectively, P< <0·001). PGR is a simple, non-invasive method of determining calf and foot vessel patency pre-operatively.
Dihydroergotamine and the thromboprophylactic effect of dextran 70 in emergency hip surgery
Authors: Rørbæk-Madsen M , Jakobsen B W , Pedersen J , Sørensen B
Published: March 2007

In a prospective randomized controlled trial treatment with a combination of dextran 70 and dihydroergotamine (DHE) was compared with the administration of dextran 70 alone as prophylaxis against postoperative thrombo-embolic complications in emergency hip surgery. Forty-five consecutive patients with a fractured hip entered the study. Twenty-one were randomized to prophylactic treatment with dextran 70 (group 1) and twenty-four patients received dextran 70 and DHE (group 2). Both regimens were initiated pre-operatively and the surgical and postoperative procedures were the same in the two groups. On the first and fourth postoperative day, Tc-plasmin scintigraphy of the lower extremities and pulmonary ventilation/perfusion scintigraphy were performed to detect any deep vein thrombosis (DVT) and/or pulmonary emboli. A total of 19 per cent of group 1 patients developed DVT and so did 25 per cent in group 2; this difference was not statistically significant. Of the detected DVT, 60 per cent were subclinical, and 7 per cent of the patients had minor pulmonary emboli, all of which were symptomless. No therapeutic difference could be demonstrated between the two regimens. A recent report claiming that adding DHE to the prophylactic administration of dextran 70 considerably reduces the incidence of postoperative DVT in emergency hip surgery is questioned.
Changes in plasma and buffy layer vitamin C following surgery
Authors: Vallance S
Published: March 2007

Postoperative changes in plasma and buffy layer (BL) vitamin C were studied in 107 patients receiving either 0 (37 patients), 100 mg (33 patients) or 500 mg (37 patients) vitamin C supplements daily. In patients receiving no supplement plasma vitamin C concentrations had fallen (mean 33 per cent) by the first postoperative day and thereafter changed little. The falls occurred irrespective of initial plasma concentration, were greater the higher the initial concentration, but tended to be proportional to the length of operation. In patients given supplements this loss of vitamin C was evident but modified, and from the second postoperative day the response to the supplements was as would have been expected in non-operated subjects. The most probable explanation for the loss of vitamin C from plasma was an increased urinary excretion during operation. Changes in BL vitamin C concentrations were studied in relation to changes in leucocyte and platelet counts. The previously reported postoperative falls in BL vitamin C were found to be the result of a major artefact in the methods routinely used for BL vitamin C estimation, caused by changes in the leucocyte and platelet populations, most importantly the platelet to leucocyte ratio. No true demand for vitamin C, as measured from the buffy layer cells, was evident.
Surgical care of patients over eighty: A predictable crisis at hand
Authors: Williams J H , Collin J
Published: March 2007

The number of people over the age of 80 in Britain will increase by around 30 per cent over the next 15 years. Little attention has been paid to the acute surgical services required to meet the surgical needs of this population. This study reviews 198 surgical admissions in 1 year of patients aged 80 years and over, of which 74·9 per cent were admitted as emergencies. The overall mortality was 10·1 per cent of all admissions and 41 per cent of admissions were accompanied by at least one serious complication. Eighty-eight patients underwent surgery with an operative mortality of 11·3 per cent. In only 63·5 per cent of cases could the patient be discharged directly home. By 2001, in Oxford, the proportion of acute surgical beds occupied by patients aged over 80 will increase to 9·2 per cent from the present 7·0 per cent. Unless additional resources are provided to meet this extra demand for acute surgical care of the old, elective surgery for younger patients will inevitably be curtailed.
Fine needle aspiration cytology: An in vitro study of cell yield
Authors: Hartley M N , Tuffnell D J , Hutton Jane L , Palmer Margaret , Al-Jafari M S
Published: March 2007

To investigate the effect of needle size and number of passes into a tumour mass on the cell yield from a fine needle aspirate, an in vitro study was undertaken in 19 consecutive tumours removed surgically for biopsy. Different needle sizes (23G, 21G, 19G) passed in random order, five, ten and fifteen times into the tumours, were compared. The type of tumour, needle size and number of passes independently and significantly influenced cell yield. A 21G(green) needle passed into the tumour at least 10 times was the most efficient in obtaining cells. This in vitro study could explain the variation in the reported accuracy of fine needle aspiration cytology from groups using different techniques and is perhaps one reason why the highest diagnostic accuracy and the lowest rate of unsatisfactory aspirates comes from a centre which uses a 21G needle and at least 10 passes through the tumour.
Operative treatment of median cervical cysts
Authors: Tetteroo G W M , Snellen J P , Knegt P , Jeekel J
Published: March 2007

Median cervical cysts are congenital anomalies arising from remaining thyroglossal duct epithelium. A major problem in the surgical treatment of these cysts is the high frequency of recurrence. Embryonic considerations indicate an important causal role for the hyoid bone in these recurrences. We studied the relationship between operative techniques and the number of recurrences in 36 patients treated in our hospital. Fourteen patients sent from other hospitals had a recurrent fistula; in thirteen cases the hyoid bone was still in place. All patients who had the central part of the hyoid bone excised were cured. In 14 patients without adequate excisions of the hyoid bone we found four recurrences. To prevent recurrence a total excision of thyroglossal duct epithelium is necessary.
No-Touch isolation technique in colon cancer: A controlled prospective trial
Authors: Wiggers T , Jeekel J , Arends J W , Brinkhorst A P , Kluck H M , Luyk C I , Munting J D K , Povel J A C M , Rutten A P M , Volovics A , Greep J M
Published: March 2007

In order to assess the effect of the no-touch isolation technique, in the treatment of large bowel cancers, on the site of first recurrence and disease-free and overall survival, 236 patients were prospectively and randomly assigned to either the no-touch isolation technique (117 patients) or to a conventional resection technique (119 patients). No patient with distant metastases or unresectable disease entered the study. The two treatment groups were comparable with regard to patient characteristics. Pre- and postoperative complications (including mortality within 30 days) were similar in both groups. After a complete follow-up of 5 years, a tendency for reduction in the number of, and time to, occurrences of liver metastases was seen in the no-touch isolation group (P = 0.14). This effect was most obvious in the sigmoid colon with angio-invasive growth. Overall (P = 0.42) and corrected (P = 0.25) survival did not differ significantly among the treatment groups although in every analysis the survival data of the no-touch isolation group were superior. The data do suggest a limited benefit of the no-touch isolation technique. This observation is important since the morbidity and mortality of surgery were equal in both groups.
Surgical treatment of colostomy complications
Authors: Allen-Mersh T G , Thomson J P S
Published: March 2007

One hundred and twenty-three patients (M:F, 0.9:1; mean age 62 years) underwent 156 operations between 1954 and 1984 for correction of late colostomy complications (stenosis 65 patients, prolapse 16 patients, paracolostomy hernia 42 patients). Sixty-three per cent of patients eventually had a good result but in some up to 5 operations were necessary. Local excision of scar tissue at the mucocutaneous junction was associated with a 61 per cent (43/71) success rate for relief of colostomy stenosis. Where local fixation failed to prevent recurrent colostomy prolapse (13/20, 65 per cent of local fixation operations), colectomy and ileostomy was the most effective second procedure (2/3,67 per cent success rate). Where local repair of a paracolostomy hernia failed (15/32,47 per cent of local operations), resiting of the stoma to the umbilicus or right side of the abdomen produced better results (3/7, 43 per cent success rate) than resiting to another trephine on the left side of the abdomen (2/14, 14 per cent success rate).
Inflow site: Its effect on femoropopliteal and distal graft patency
Authors: Najmaldin A , Clifford P C , Chant A D , Webster J H H
Published: March 2007

In a series of 245 vein grafts, results of 163 from the common femoral artery were compared with 82 from the proximal superficial femoral artery. Groups were comparable for risk factors, except that significantly more of the superficial femoral artery group were anastomosed to a single calf vessel (P<0.02). Early technical failure was similar in both groups (14 per cent common femoral artery, 12 per cent superficial femoral artery, P = n.s.). Cumulative life table patency rates at 1 and 3 years were 77 per cent and 72 per cent in common femoral artery grafts, and 80 per cent and 70 per cent in superficial femoral artery grafts (P = n.s.). Analysis of 92 veins in situ (65 common femoral artery and 27 superficial femoral artery) showed l-year patency rates of 75 per cent in common femoral artery grafts and 79 per cent in superficial femoral artery grafts (P = n.s.). These results suggest that the proximal superficial femoral artery is a safe inflow site for distal bypasses.
Comparison of three Glasgow multifactor prognostic scoring systems in acute pancreatitis
Authors: Leese T , Shaw D
Published: March 2007

Modifications have been proposed in an attempt to improve the clinical value of the original nine-factor Glasgow prognostic scoring system for acute pancreatitis. These include the omission of age or serum transaminase, reducing the factors to eight. Debate exists as to which system should be employed. Assessment of the individual factors in 198 attacks of acute pancreatitis treated conventionally revealed that only serum transaminase did not differ significantly between mild and severe outcome groups. Multivariate analysis demonstrated four factors (Pa,O2, white cell count, lactic dehydrogenase, and urea) with independent significance in predicting severity, while serum glucose, albumin and transaminase were least useful. Findings were similar when considering only patients with gallstone aetiology. The reduction of the prognostic factors to eight by the omission of either age or transaminase improved the predictive value of the scoring system, both when considering all attacks and those of gallstone aetiology alone. We suggest that serum transminase should be omitted because: it shows no significant difference between mild and severe outcome groups, while age has prognostic significance; the system has greater sensitivity than if age is omitted; and the number of factors requiring emergency laboratory measurement for immediate prognostication is reduced by one.
Lack of necessity for corrections for pyloric losses and duodenogastric reflux in the performance of gastric secretory studies
Authors: Ogilvie A L , Atkinson M
Published: March 2007

Gastric secretory studies are subject to considerable error owing to incomplete collections and to contamination by reflux of alkaline duodenal contents. Corrections for these sources of error have been defined, and they have been extensively applied in a research setting. In order to assess their utility in the performance of routine gastric secretory studies? the value of such corrections was assessed in 56 studies in patients with duodenal ulceration (10), previous surgical vagotomy (8), reflux oesophagitis (30) and primary oesophageal motility disorders (8). The effect of such corrections was small, and there were close correlations between uncorrected and corrected acid outputs in all four groups. The status of the vagal efferent gastric fibres was assessed by comparing the acid output after insulin hypoglycaemia with the maximal acid output after pentagastrin (insulin: pentagastrin ratio). The application of the corrections did not alter the conclusion regarding the assessment of vagal status in 55 of the 56 studies performed. It is concluded that such corrections are not necessary in the routine performance of gastric secretory studies.
Mesenteric infarction: an analysis of 83 patients with prognostic studies in 44 cases undergoing a massive small-bowel resection
Authors: Sitges-Serra A , Mas X , Roqueta F , Figueras J , Sanz F
Published: March 2007

A series is presented of 83 patients surgically explored for massive bowel infarction. Old men with previous heart disease and symptoms of peripheral atherosclerosis were primarily affected. Clinical presenting features were abdominal pain (100 per cent), peritonitis (57 per cent), shock (34 per cent) and hypothermia (26 per cent). A third-space syndrome with metabolic acidosis and uraemia was the most common physiological derangement. Age was the only factor that appeared to have influenced the surgeon's decision to perform massive bowel resection (71 years in non-resected versus 64 years in resected patients, P < 0.006). The overall mortality rate was 71 per cent. Forty-four patients underwent massive bowel resection (mean length of remaining small bowel 60 ± 40 cm) and twenty-four (54 per cent) survived the procedure. Axillary temperature was higher in survivors (36.7°C versus 36.1°C, P < 0.03). Early postoperative total plasma protein and albumin concentrations were also higher in survivors (57 versus 46 g/l, P < 0.005; 27 versus 22 g/l, P < 0.02). Patients with previous symptoms of atherosclerotic disease and high pre-operative blood urea levels also had a bad prognosis. Survivors had a mean hospital stay of 57 days and parenteral nutrition had to be maintained for a mean of 34 days. The survival rate achieved with massive resection justifies this surgical approach in selected patients with massive bowel infarction.
Improvement of renal function in azotaemic hypertensive patients after surgical revascularization
Authors: Mestres C A , Campistol J M , Ninot S , Botey A , Abad C , Guerola M , Cases A , Revert L , Mulet J
Published: March 2007

Between 1974 and 1986, 17 patients (16 men and I woman) with renal insufficiency (serum creatinine > 1.5 mg/dl, mean 3.75 mg/dl), with a mean age of 51.3 years, underwent surgical renal revascularization. Two of them were on maintenance haemodialysis. All were severely hypertensive in spite of antihypertensive drugs. Atherosclerosis was the cause of renal stenosis in 14 cases and fibromuscular dysplasia in 3. Operative procedures included splenorenal shunt (5), autotransplantation (3), aortorenal bypass (3), hepatorenal bypass (1), bilateral renal endarterectomy (1), renal ostial closure (1) and nephrectomy (3). Mean serum creatinine showed a decrease from 3.76 to 1.65 mg/dl (P < 0.005). Mean arterial pressure dropped from 161 mmHg to 103 mmHg (P < 0.001). Systolic and diastolic pressures also showed significant decreases. Two patients died. Four patients required a second operation and the renal function and blood pressure then improved. Renovascular disease must be ruled out in patients with renal insufficiency associated with hypertension, including those patients on haemodialysis. We conclude that renal revascularization surgery is a reliable and efficient form of treatment in selected cases of renal failure of renovascular origin.
Bile acid concentrations in the refluxate of patients with reflux oesophagitis
Authors: Gotley D C , Morgan A P , Cooper M J
Published: March 2007

Although reflux of bile acids has been implicated in the pathogenesis of reflux oesophagitis, attempts to document this in vivo have failed to detect more than trace amounts of bile acid in the oesophagus. To determine the bile acid composition of oesophageal reluxate, 45 patients with abnormal acid gastro-oesophageal reflux with oesophagitis and 10 controls had a size 14 Fr Salem sump tube positioned 5 cm above the lower oesophageal sphincter. Oesophageal contents were continuously aspirated and collected in aliquots every 2 h over 16 h. Fasting, postprandial, upright and supine (nocturnal) periods were assessed and total conjugated bile acids were measured by high pressure liquid chromatography with a sensitivity of 8 μmol/l. Conjugated bile acids were detected in 2 of 10 controls (maximum 40 µmol/l) and in 39 of 45 patients (87 per cent). Eleven patients had peak conjugated bile acid levels > 200 µmol/l, and these levels occurred exclusively during the supine (nocturnal) period. Median conjugated bile acid levels during daytime reflux were < 20 µmol/l which was significantly lower than during nocturnal reflux (median 51 µmol/l, P < 0.001). Conjugated bile acids are detected in the oesophagus of most patients with oesophagitis and may play a role in the pathogenesis of oesophagitis in some patients with nocturnal gastro-oesophageal reflux.
Variations in surgical practice: welcome diversity or disturbing differences
Authors: Jennett B
Published: March 2007

The review examines the variations in surgical practice and assesses the value of surgical audit in quality control and allocation of surgical resources.
Management of major colonic haemorrhage
Authors: Berry A R , Campbell W B , Kettlewell M G W
Published: March 2007

Major colonic haemorrhage remains a difficult diagnostic and therapeutic problem. We propose that those patients who continue to bleed after resuscitation are best served by immediate laparotomy. High flow antegrade irrigation and intra-operative colonoscopy can then be used to localize the site of bleeding and allow appropriate excisional surgery rather than blind colonic resection.
Intravenous digital subtraction angiography and Duplex scanning in the detection of late human umbilical vein degeneration
Authors: Nevelsteen A , Smet G , Wilmst G , Marchal G , Suy R
Published: March 2007

To define the exact incidence of late degeneration, 32 patients underwent intravenous digital subtraction angiography (IVDSA) and/or a Duplex scan more than 3 years after human umbilical vein (HUV) grafting. IVDSA (n = 26) showed a 23 per cent aneurysmal degeneration rate which increased to 40 per cent with Duplex scanning (n = 25). Although the differences obtained in those patients receiving both examinations (n = 19) were statistically not significant, Duplex scanning appeared to be more sensitive, demonstrating two additional cases of aneurysmal degeneration not detected by IVDSA. Since, moreover, Duplex scanning proved able to detect anastomotic stenosis, it appears to be the examination of choice in long-term follow-up of the HUV graft. Despite this relatively high degeneration rate, the authors consider continued use of the HUV graft in selected patients to be justified, especially when the long-term patency rates, the available alternatives, and the less favourable long-term survival after femoropopliteal reconstruction are taken into consideration.
Clinical observations on the wound healing properties of honey
Authors: Efem S E E
Published: March 2007

Fifty-nine patients with wounds and ulcers most of which (80 per cent) had failed to heal with conventional treatment were treated with unprocessed honey. Fifty-eight cases showed remarkable improvement following topical application of honey. One case, later diagnosed as Buruli ulcer, failed to respond. Wounds that were sterile at the outset, remained sterile until healed, while infected wounds and ulcer became sterile within 1 week of topical application of honey. Honey debrided wounds rapidly, replacing sloughs with granulation tissue. It also promoted rapid epithelialization, and absorption of oedema from around the ulcer margins.
Human gastric perfusion: Evidence for non-uniformity of blood flow
Authors: Allen P I M , Chesner I , Wheatley K , Goldman M
Published: March 2007

Post-mortem injection studies have demonstrated marked differences in the course and distribution of arterioles in the stomach, but evidence of differential perfusion in man is lacking. Using the non-invasive laser Doppler technique, we studied 38 patients referred for gastroscopy for dyspeptic symptoms. Flux measurements were made at nine sites: distal oesophagus, cardia, mid-body and antrum on lesser and greater curves, and pre- and post-pylorus. In all cases the stomach was macroscopically normal. Flux in the proximal stomach was significantly greater than that in the antrum, (P < 0.001, Student's t test). This in vivo study demonstrates a flow gradient related to the previously demonstrated anatomical differences.
DNA ploidy pattern and tumour spread in gastric cancer
Authors: de Aretxabala X , Yonemura Y , Sugiyama K , Kamata T , Konishi K , Miwa K , Miyazaki I
Published: March 2007

The DNA ploidy pattern of gastric cancer was studied in 58 patients to investigate the heterogeneity between primary tumour and metastases. In both primary tumours and lymph node metastases, diploid patterns accounted for 33 per cent, whereas all liver metastases were aneuploid. The percentage of polyploid cells was higher in the liver metastases than in primary tumours and lymph node metastases. When the heterogeneity of DNA ploidy pattern between primary tumour and metastasis was evaluated, diploid tumours had a significantly lower rate of lymph node metastasis heterogeneity than aneuploid tumours. When the DNA ploidy pattern and survival were evaluated, the patients who had a diploid pattern in both primary tumour and metastasis had a significantly higher survival rate than the patients who had an aneuploid pattern in the primary tumour and metastasis (57 per cent versus 26 per cent at 5 years). These data suggest that cell heterogeneity is a common phenomenon in gastric cancer, and this may be important in the evolution of the disease. Furthermore, the role of the DNA ploidy pattern as a prognostic factor is emphasized.
Delayed external sphincter repair for obstetric tear
Authors: Laurberg S , Swash M , Henry M M
Published: March 2007

In some patients with faecal incontinence due to an obstetric tear of the external anal sphincter there is additional weakness of the anal sphincter muscles from damage to the innervation of these muscles during delivery. Of 19 patients who required surgical repair of an obstetric sphincter tear some months or years after injury, 9 (47 per cent) had evidence of pudendal nerve damage at pre-operative anorectal physiological investigation. The result of surgical repair was excellent or good in eight of the ten patients in whom there was no evidence of nerve damage, while this was the case in only one of the nine patients with nerve damage. These results are significantly different (P = 0.018). Thus the functional result of delayed anal sphincter repair after obstetric lesions is partly dependent upon whether the nerve supply is intact. Pre-operative physiological evaluation can give information on the probability of a successful surgical result.
Blood transfusion and infectious complications following colorectal cancer surgery
Authors: Tartter P I
Published: March 2007

Blood transfusion has been linked to clinical phenomena attributable to immune suppression. We prospectively studied the relationship between perioperative blood transfusion and postoperative infectious complications in 343 consecutive patients undergoing surgery for colorectal cancer. Of the 134 patients who received transfusions 33 (24.6 per cent) developed infectious complications compared with 9 (4.3 per cent) of the 209 patients who did not receive blood (P < 0.0001). The mean number of units of blood received by patients who developed infectious complications significantly exceeded the number for patients without infectious complications (2.31 versus 0.74, P < 0.0001). The association of transfusion with infections was highly significant (P < 0.0001) after controlling for age, sex, blood loss, procedure, tumour differentiation, stage, admission haematocrit, duration of surgery, length of the specimen and tumour size. Blood transfusion appears to be an independent risk factor for postoperative infectious complications.
Ten-year computerized audit of infection after abdominal surgery
Authors: Krukowski Z H , Matheson N A
Published: March 2007

A prospective audit of the frequency of infective complications after all abdominal operations was carried out between January 1977 and December 1986. A total of 3100 abdominal procedures (2041 elective; 1059 emergency) were performed in 3056 patients. There were 50 (1·6 per cent) in-hospital and 66 (2·1 per cent) late wound infections (overall 3·7 per cent). Fifty-four (1·8 per cent) patients developed postoperative intraperitoneal sepsis. Ninety-eight patients died (overall mortality 3·2 per cent) and introperitoneal sepsis was a related factor in twelve (0·4 per cent). Wound infection, peritoneal sepsis and mortality were related to the degree of operative contamination and to reoperation. The results support the traditional, although sometimes inadequately stressed, teaching that technique is an important factor in preventing infection. Infection is also reduced by peroperative antibiotic lavage. The limited value and the potential difficulties of the unstructured introduction of computerized audit should be recognized.
Anterior lesser curve seromyotomy and posterior truncal vagotomy for chronic duodenal ulcer: The results at five years
Authors: Siriwardena A K , Gunn A A
Published: March 2007

In one surgical unit, 241 patients have undergone anterior gastric seromyotomy and posterior truncal vagotomy for chronic duodenal ulcer. The postoperative mortality rate was 0·4 per cent. Four patients (1·6 per cent) required a drainage procedure for gastric stasis. The first 66 patients (Group A) were followed prospectively and 58 were available for assessment at 5 years. Eight patients (14 per cent) had developed a recurrent ulcer. In seven of these patients this responded to conservative treatment with H2 receptor antagonists. One patient has required Polya partial gastrectomy for recurrent ulceration. At 5 years 47 patients (81 per cent) were placed in the Visick I or II categories. In the next 175 patients (Group B), the ulcer recurrence rate was 3 per cent, suggesting a learning curve in mastering the procedure. We conclude that the immediate and 5-year results of the first 66 patients are at least comparable with those of highly selective vagotomy. Anterior gastric seromyotomy with posterior truncal vagotomy is an easy and rapid procedure and may be more widely applicable than highly selective vagotomy.
Highly selective vagotomy: A 14-year experience
Authors: Byrne D J , Brock B M , Morgan A G , McAdam W A F
Published: March 2007

Since August 1971, 244 highly selective vagotomies were performed for pyloric and duodenal ulceration by one surgeon (W.A.F.M.). There was one postoperative death. Twenty (8 per cent) patients were lost to follow-up. The remaining 223 patients were followed up for 1 to 14 years (mean 4·2 years). On the modified Visick grading system 83·4 percent were Visick 1 or 11 and 16·6 per cent were Visick III or IV. The failures were mainly recurrences. The recurrence rate was 11·2 percent. Certain factors were examined to try to elucidate those influencing recurrence rate but no significant prognostic indicator was found. Acid studies were analysed and no significant relationship between these and the development of a recurrence could be found. The second 100 vagotomies were better than the first as judged by the results of studies of insulin-stimulated acid. Finally, we question whether all recurrences should automatically be regarded as treatment failures and the patients classified as Visick IV.
Hyperparathyroidism after neck irradiation
Authors: Christmas T J , Chapple C R , Noble J G , Milroy E J G , Cowie A G A
Published: March 2007

A retrospective review of 1550 cases of hyperparathyroidism (HPT) treated surgically over a 30-year period reveals a past history of exposure to neck irradiation in 10 cases (0·7 per cent). The indication for radiotherapy was benign disease in nine and papillary thyroid carcinoma in one case. The mean interval between radiation exposure and the detection of HPT was 32 years (range 3–63 years). Patients treated with radioactive iodine alone developed HPT after a mean of 5 years while the interval for those treated with external beam therapy alone was a mean of 44 years. The parathyroid histology was adenoma in six cases, carcinoma in three cases and nodular hyperplasia in one case. All patients had coincident benign thyroid disease apart from one that had previously had papillary carcinoma and another with follicular carcinoma. Neck irradiation has been shown to confer an increased risk of HPT due to parathyroid adenoma and carcinoma. Radiotherapy for benign disease has generally been abandoned and these cases demonstrate a further contra-indication for the use of neck irradiation.
Resting energy expenditure in the critically ill: Estimations versus measurement
Authors: Hunter D C , Jaksic T , Lewis D , Benotti P N , Blackburn G L , Bistrian B R
Published: March 2007

A prospective trial was conducted in 20 surgical intensive care unit patients receiving mechanical ventilation to compare estimates of resting energy expenditure (REE) with the measured values. The 12 women and 8 men (mean age 61·7±2·8 (s.e.m.) years) underwent a full nutritional assessment before measurement of their REE by indirect calorimetry using the MGM II metabolic cart (Utah Medical). Their REE was estimated by the Harris-Benedict formula (mean 1324±53 (s.e.m.) kcal/day) as well as an empirical formula (where empirical formula = 22 × body weight in kg) (1370 ± 68 (s.e.m.) kcal/day). Results by either estimate were not statistically different from the measured resting energy expenditure (MREE) (1382±130 (s.e.m.) kcal/day), by one-way analysis of variance. No multiplication factors were needed to relate the Harris–-Benedict formula to MREE in this critically ill population and the estimate by the empirical formula was as good and simpler to perform. Although values by the Harris—Benedict formula and empirical formula correlated significantly with MREE (P < 0·05) the correlation coefficients were low: 0·48 and 0·45 respectively. Thus, mean estimates were excellent for the group but less predictive for the individual. Multiple linear regressions did reveal that body composition and metabolic stress were of greater predictive value, since an equation relating weight (P <0·003), sex (P <0·003), white blood cell count (P < 0·003) and 24-h urinary creatinine excretion (P < 0·05) could predict 76 per cent of the variation (r = 0·87) in the MREE with an overall significance of P = 0·0002. Given the importance of matching energy intake to needs in many critically ill patients who are mechanically ventilated, accurate measurement of the REE is recommended now that instrumentation is equal to the task.
Grip strength: A measure of the proportion of protein loss in surgical patients
Authors: Windsor J A , Hill G L
Published: March 2007

Measurements of voluntary hand grip strength (GS) are a sensitive predictor of postoperative complications. The loss of body protein is thought to be important in the development of these postoperative complications, but the relationship between GS and body protein status has not been studied. We have measured GS (by hand dynamometry), total body protein (indirectly by mid-arm muscle circumference, and directly by in vivo neutron activation analysis) and the proportion of protein loss (protein index) in 80 patients with gastrointestinal disease and 87 normal volunteers. Using regression analysis, a matched study and clinical decision analysis, it has been demonstrated that GS is a sensitive measurement of the degree of protein loss. The results support more widespread use of GS measurements in the identification of patients at high risk of postoperative complications and in the monitoring of patient response to nutritional intervention.
Choledochal cyst: A 14-year surgical experience with 36 patients
Authors: Tan K C , Howard E R
Published: March 2007

The presentation and management of 36 patients with cystic dilatation of the biliary tree seen over a 14-year period is reviewed. There were 28 females and 8 males, a ratio of 3·5:1. The classic triad of jaundice, pain and an abdominal mass was seen in only seven cases. Twelve patients suffered recurrent pancreatitis. There were three cases of variceal haemorrhage from portal hypertension secondary to biliary cirrhosis, and one case of biliary peritonitis from a ruptured cyst. Internal drainage (cystenterostomy) was performed in nine patients but five of these eventually needed cyst excision. Cysts have been excised primarily in the last 21 consecutive patients without mortality. Preliminary external drainage with T tubes was used before cyst resection in three patients who presented with complications of choledochal cysts. Cyst excision and hepaticojejunostomy is now the definitive treatment of choice.
New technique of anastomosis after resection of left colon and rectum
Authors: Korepanov V I , Sh. Chuntua R , Sugrobov S P
Published: March 2007

A novel technique of ‘autorecanalizing’ anastomosis has been developed experimentally to reduce the risk of anastomotic failure when resection of the left colon or rectum is performed in the face of suboptimal bowel preparation. The method has been used in nine patients who presented with large bowel obstruction. One patient developed a low output faecal fistula that closed spontaneously within 19 days of operation. No leakage was detected in the remaining eight patients. The delay between operation and recanalization ranged from 8–13 days and the caecostomy used for intubation closed spontaneously within 24 days of surgery.
Diagnosis and management of graft—enteric fistulae
Authors: Tilanus H W , Terpstra O T , de Smit P , van Urk H , Veen H F
Published: March 2007

During a 7-year period 20 patients underwent operation for a graft-enteric fistula after implantation of an intra-abdominal vascular prosthesis months or years before. Eighteen patients had gastrointestinal blood loss as their first symptom; 12 were in shock on admission. Fourteen patients had a fistula between the proximal anastomosis and the duodenum. Graft excision followed by axillobifemoral bypass was performed in 10 patients and four patients underwent local repair. A fistula between the distal anastomosis and the bowel was found in the remaining six patients and a local repair was carried out. Proximal graft-enteric fistula carries a particularly high postoperative mortality rate of more than 50 per cent.
Cholecystokinin (CCK) provocation test: Long-term follow-up after cholecystectomy
Authors: Rhodes M , Lennard T W J , Farndon J R , Taylor R M R
Published: March 2007

Over a 6-year period 264 cholecystokinin (CCK) provocation tests have been performed in 174 patients with undiagnosed right upper quadrant pain. All were carried out by one person (T.W.J.L.) as part of a prospective placebo-controlled crossover study. Following infusion of CCK but not saline, 103 patients developed pain (CCK + ve). These patients were offered cholecystectomy and 90 accepted. Seventy patients developed no pain during either infusion (CCK − ve), and one patient experienced pain with both CCK and saline infusions. Of the 90 patients who underwent cholecystectomy, 81 (90 per cent) have been followed up for a mean of 35 months (range 12 months to 5½ years), 67 percent have had complete resolution of symptoms and a further 24 percent have had a marked improvement in symptoms. Only 9 per cent of patients did not benefit from cholecystectomy. This compares well with patients undergoing cholecystectomy for uncomplicated calculous gallbladder disease, 88 per cent of whom, in our study, were improved by surgery. Patients with a positive CCK test have an excellent chance of symptomatic improvement following cholecystectomy.
ERCP findings and the role of endoscopic sphincterotomy in acute gallstone pancreatitis
Authors: Neoptolemos J P , Carr-Locke D L , London N , Bailey I , Fossard D P
Published: March 2007

A total of 131 patients with acute pancreatitis (of whom 100 had gallstones) underwent endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Urgent ERCP (<72 h) was performed in 68 cases and early ERCP (3–30 days) in 63 cases; 47 had predicted severe attacks and 84 had predicted mild attacks (modified Glasgow criteria). The highest incidence of common bile duct stones occurred in those with predicted severe attacks and those who had urgent ERCP. Highly significant correlations were found between age and common bile duct and pancreatic duct diameters. Significant correlations were also found between the common bile duct and pancreatic duct (correcting for age) and between these and the admission serum bilirubin. The common bile duct diameter was greatest in those with common bile duct stones and predicted severe attacks. A considerably lower incidence of pancreatic duct filling occurred in those with predicted severe attacks and common bile duct stones; in predicted mild attacks the pancreatic duct diameter was greater in those with common bile duct stones. In gallstone patients complications were highest in those with predicted severe attacks but more significantly in those with common bile duct stones. Endoscopic sphincterotomy was undertaken in 37 patients with common bile duct stones without mortality. The overall complication rate in gallstone patients was 19 per cent and the mortality rate was 2 per cent. These findings suggest that common bile duct stones cause acute common bile duct and pancreatic duct obstruction and are closely associated with complications. Urgent ERCP for detection of common bile duct stones, and endoscopic sphincterotomy for treatment, is strongly recommended for patients with predicted severe attacks due to gallstones and should also be considered for others who fail to show clinical improvement.
A prospective comparison of the effects of placebo, ranitidine and highly selective vagotomy on 24 h ambulatory intragastric pH in patients with duodenal ulcer
Authors: Rogers M J , Holmfield J H M , Primrose J N , Gledhill T , Johnston D
Published: March 2007

Twenty-four hour ambulatory intragastric pH (24 h IGpH) recording, a highly reproducible technique, was used to compare the effects of ranitidine and highly selective vagotomy (HSV) in 20 patients who had been referred for surgical treatment of duodenal ulcer. The 24 h IGpH was recorded when they were taking either placebo or ranitidine 300 mg at 10 pm, and again 4 to 13 weeks after elective HSV. Median 24 h IGpH and 24 h hydrogen ion activity (24 h [H+]) were calculated for each patient. Median (quartile) 24 h IGpH was 1.4 (1.3–1.6) with placebo, 2.2 (1.8–2.7) after ranitidine and 2.6 (1.8–3.7) after HSV. IGpH was significantly higher after both ranitidine (P < 0.0001) than after placebo, but IGpH after ranitidine did not differ from IGpH after HSV (0.5 > P > 0.4). HSV reduced 24h [H+] by a median 68 per cent (quartiles, 47–82 per cent) whereas ranitidine reduced it by only 50 per cent (34–69 per cent, 0.1 > P > 0.05). The 24h pH recording was then analysed as two distinct periods; ‘daytime’ (8 am to midnight) and ‘night-time’ (midnight to 8 am). HSV reduced night-time [H+] by a median 77 per cent (59–93 per cent) whereas ranitidine reduced it by only 30 per cent (13–45 per cent, P < 0.0001). HSV reduced daytime [H+] by a median 57 per cent (40–83 per cent) but ranitidine reduced it by a median 92 per cent (78–98 per cent, P < 0.01). Thus, HSV inhibits gastric acidity more during the day than at night, whereas raniditine given at 10 pm effectively suppresses night-time acidity but is much less effective in suppressing daytime acidity. However both HSV and ranitidine will heal more than 90 per cent of duodenal ulcers. Hence, contrary to Dragstedt's teaching, suppression of nocturnal acidity is not of crucial importance for the healing of duodenal ulcers.
Testicular torsion in Bristol: A 25-year review
Authors: Anderson J B , Williamson R C N
Published: March 2007

To identify changes in incidence, presentation, management and outcome, 670 patients with torsion of the spermatic cord presenting in Bristol between 1960 and 1984 have been reviewed. Among the susceptible population of 150000, the annual incidence of torsion has increased fourfold from 11.2 cases between 1960 and 1964 to 42.8 cases between 1980 and 1984. Throughout this period > 90 per cent of patients have been managed by general surgeons. Patients aged between 12–18 years comprised 62 per cent but 20 per cent were 21 years or older. Torsion was commoner in the cold months, 24 per cent of cases occurring during December and January (χ2 = 30.26, P < 0.01). When acute torsion was relieved within 12 h of the onset of symptoms only 4 per cent of affected testes were considered non-viable, but beyond this time 75 per cent of patients received orchidectomy. Overall, 238 of 624 (38 per cent) acutely twisted testes were found to be infarcted at operation, and a further 35 patients (6 per cent) had marked testicutar atrophy on review 3 months later. The testicular salvage rate has steadily improved from 45 per cent in the years 1960–64 to 67 per cent in 1980–84. Much of the increased incidence of testicular torsion is likely to reflect a greater awareness of the condition by general practitioners. It has been more than matched by an improvement in testicular salvage rate because of earlier referral.
Intra-operative inflow resistance measurement: A predictor of steal syndromes following femoro-femoral bypass grafting
Authors: Nicholson M L , Beard J D , Horrocks M
Published: March 2007

Although femorofemoral bypass grafting was originally used only as a method of limb salvage, it is now used increasingly in patients with claudication. If this trend is to be supported, the haemodynamic consequences of the operation must be carefully assessed. Fifteen patients undergoing femorofemoral grafting were studied prospectively by intra-operative measurement of the inflow resistance (IR) of the donor iliac segment. Three groups were identified by this technique. Patients with an IR<0.05 (n = 8) were uncomplicated; those with an IR ⩾0.05 but <0.10 (n = 5) developed a subclinical steal syndrome; and those with an IR >0.10 (n = 2) developed a clinical steal syndrome. High initial IR values were corrected at the time of surgery in two cases. This study demonstrates that steal syndromes can occur after femorofemoral grafting and that the cause is an unmasking of previously unrecognized disease in the donor arterial segment. The measurement of IR allows the prediction of steal syndromes and their correction at the time of surgery. Direct haemodynamic studies are recommended, especially as the availability of balloon angioplasty has made inflow disease amenable to treatment.
Natural history of the benign breast lump
Authors: Sainsbury J R C , Nicholson S , Needham G K , Wadehra V , Farndon J R
Published: March 2007

A prospective study of 112 patients with clinically discrete benign breast lumps has shown that 68 per cent of patients experienced resolution of their lumps over a period of up to 2 years. Resolution of both fibro-adenomas and discrete areas of fibro-adenosis was observed. Diagnosis was achieved by clinical examination and fine needle aspiration cytology. Four patients thought clinically to have benign disease were proven by cytology to have a carcinoma, but no patient with a cytopathological diagnosis of benign disease has developed cancer during or subsequent to this study. We recommend that patients under 35 years of age with clinically and cytologically benign breast lumps can be offered the option of non-excision in the reasonable expectation of resolution of their lesion.
Increase in pudendal nerve terminal motor latency with defaecation straining
Authors: Lubowski D Z , Swash M , Nicholls R J , Henry M M
Published: March 2007

The relationship between perineal descent and pudendal nerve damage was tested in 57 consecutive patients by measuring the left and right pudendal nerve terminal motor latency (PNTML) before and after a maximal defaecation straining effort. In 13 patients the PNTML was also measured 1 and 4 min later. The difference between the mean PNTML before and after straining (ΔPNTML) was correlated with the amount of descent (r = 0.40, P<0.005), and with the perineal position during straining (r = −0.46, P<0.001). Four minutes after the straining effort the PNTML again approached the resting value in each subject. These findings support the concept that perineal descent causes pudendal nerve damage.