bluuebunny/crossref_metadata_2025 huggingface dataset:
Psychomotor skills of surgical trainees compared with those of different medical specialists
Authors: Harris C J , Herbert M , Steele R J C
Published: March 2007

Forty-eight trainees in surgery, psychiatry, anaesthetics and medicine underwent objective testing of manual dexterity (Mandex test), hand-eye coordination (Gibson spiral maze test) and visuospatial ability (embedded figures task). Surgical trainees performed significantly more quickly on the spiral maze test than psychiatrists (P = 0.03) but made more errors (P = 0.02). Combining male and female subjects across all groups, women were significantly more accurate than men. When men only were compared no psychomotor differences between specialty groups could be demonstrated. There were no differences in visuospatial ability by either sex or specialty. Self-selection on the basis of such skill is therefore unlikely.
Triage by laparoscopy in patients with penetrating abdominal trauma
Authors: Fernando H C , Alle K M , Chen J , Davis I , Klein S R
Published: March 2007

Laparoscopy was performed on 33 patients with penetrating abdominal injuries to identify those with peritoneal penetration. Diagnostic or therapeutic manoeuvres were not attempted; evidence of peritoneal penetration mandated exploratory laparotomy. Twenty-two patients had gunshot wounds and 11 stab wounds. Ten patients had multiple penetrating injuries. Intraperitoneal injury was not evident by clinical assessment in any patient and all were haemodynamically stable. Twenty-three patients underwent negative laparoscopy and no intraperitoneal injury was subsequently detected. Laparoscopy demonstrated peritoneal penetration in ten patients and subsequent laparotomy detected intraperitoneal injuries in nine. No complications of laparoscopy occurred. In stable patients with penetrating trauma and no clinical evidence of intraperitoneal injury, laparoscopy effectively and safely detects those with peritoneal penetration.
Ratio of invaded to removed lymph nodes as a predictor of survival in squamous cell carcinoma of the oesophagus
Authors: Roder J D , Busch R , Stein H J , Fink U , Siewert J R
Published: March 2007

Prognostic factors that may alter the indications for primary surgical resection or that can be influenced by the extent of the procedure were analysed in a homogeneous group of 186 patients with squamous cell carcinoma of the oesophagus. All patients underwent standardized en bloc oesophagectomy and lymph node dissection with prospective documentation of the histopathological findings; follow-up was complete. Multivariate analysis identified the Union Internacional Contra la Cancrum R category (i.e. the presence of residual tumour after resection) as the most important independent prognostic factor (P< 0.001) followed by the ratio of invaded to removed lymph nodes (P< 0.001). These data suggest that only patients in whom R0 resection can be anticipated based on preoperative assessment should undergo primary resection for oesophageal cancer. Extended lymphadenectomy may improve survival in patients with a limited number of invaded mediastinal nodes.
Local anaesthetic agents in surgery for ingrown toenail
Authors: Connolly A A P , Meyer L C , Tate J J T
Published: March 2007

To determine the most effective local anaesthetic for ingrown toenail surgery, 100 procedures were performed after patients had been randomized to receive lignocaine, bupivacaine or hyaluronidase and bupivacaine. The effect of each anaesthetic was monitored and 80 patients returned a follow-up questionnaire. There was no significant difference in the time for the local anaesthetic to take effect, or in the pain caused by its injection or the procedure. Significant differences were found between treatments with respect to pain at discharge from hospital and significantly fewer patients who received bupivacaine experienced pain 24 h after surgery (P = 0.002). Bupivacaine provides quickacting and long-lasting anaesthesia and should be used in preference to lignocaine.
Prospective study of postoperative renal function in obstructive jaundice and the effect of perioperative dopamine
Authors: Parks R W , Diamond T , McCrory D C , Johnston G W , Rowlands B J
Published: March 2007

A prospective study was undertaken to assess postoperative renal dysfunction in patients with obstructive jaundice and to determine the effectiveness of dopamine in reducing its incidence. A total of 23 patients undergoing surgical relief of obstructive jaundice (serum bilirubin level above 100 μmol l−1) were randomized into two groups. Those in the control group (n = 10) received 3 litres 5 per cent dextrose intravenously during the 24 h before surgery plus a bolus of intravenous frusemide 1 mg kg−1 at induction of anaesthesia. The second group (n = 13) received a similar fluid and frusemide regimen plus an infusion of dopamine 3 μg kg−1 min−1 starting at induction of anaesthesia and continuing for 48 h after surgery. Postoperative oliguria occurred in two of the ten patients in the control group and in three of the 13 given dopamine (P = 0.74). No patient developed acute renal failure. There was no significant difference in mean levels of serum bilirubin, urea and creatinine, creatinine clearance and 24-h urinary output, on the day before and on days 1–5 after operation, between the two groups. It is concluded that, with careful preoperative resuscitation and control of fluid and electrolyte balance, the incidence of postoperative renal dysfunction in patients with obstructive jaundice is not as high as in some previous studies and is unaltered by administration of perioperative low-dose dopamine.
Biliary bile acid profiles in patients with familial adenomatous polyposis before and after colectomy
Authors: Barker G M , Radley S , Bain I , Davis A , Lawson A M , Keighley M R B , Neoptolemos J P
Published: March 2007

The development of colorectal polyps and cancer in patients with familial adenomatous polyposis (FAP) is directly linked to inactivation of the APC gene. Other, epigenetic, mechanisms may be involved in tumorigenesis and a previous study suggested that an intrinsic difference in the biliary bile acid profile of untreated patients with FAP persisted after colectomy. Gas chromatography and gas chromatography-mass spectrometry were used to examine the biliary bile acid profiles of four groups of patients with normal gallbladders: 20 patients with an intact colon comprising 12 with FAP and eight controls; and 26 patients after colectomy comprising 12 with FAP and 14 controls. Comparison of ten different bile acids from both amidate fractions (glycine and taurine) revealed a small increase in the molar percentage of a minor bile acid (12-oxolithocholic acid) in patients with FAP and an intact colon compared with the matching control group. Colectomy was associated with a dramatic reduction in levels of secondary bile acids but with little difference between patients with FAP and controls.
Double-contrast barium enema and flexible sigmoidoscopy for routine colonic investigation
Authors: Brewster N T , Grieve D C , Saunders J H
Published: March 2007

Over a 3-year period, all patients referred for barium enema examination had a double-contrast barium enema and flexible sigmoidoscopy performed on the same day. A total of 462 joint examinations were performed. Abnormalities were found in 193 patients by the use of barium enema, 164 patients by using sigmoidoscopy and 294 by the use of both methods of investigation. Sigmoidoscopy was superior to barium enema in the detection of polyps and inflammatory bowel disease but barium enema was more sensitive for diverticular disease. The presenting symptoms had no predictive value in distinguishing carcinoma, polyps and diverticular disease. Diverticular disease did not reduce the sensitivity of barium enema examination to polyps in the sigmoid colon. Fibreoptic sigmoidoscopy immediately before barium enema was well tolerated by patients. The investigations were complementary in the diagnosis of colonic polyps, inflammatory bowel disease and diverticular disease.
Population screening for colorectal cancer: Comparison between guaiac and immunological faecal occult blood tests
Authors: Robinson M H E , Marks C G , Farrands P A , Thomas W M , Hardcastle J D
Published: March 2007

There is concern about the low sensitivity of the guaiac-based Haemoccult test in mass population faecal occult blood (FOB) screening for the early detection of colorectal carcinoma. Hemeselect, an immunological FOB test, has been shown to be more sensitive for symptomatic colorectal cancer and may prove to be a more reliable screening method. In Brighton and Guildford, 4018 asymptomatic subjects aged 50–75 years were offered screening with Haemoccult and Hemeselect. A total of 1489 (37.7 per cent) completed both tests, of which 17 (1.1 per cent) were positive for Haemoccult and 145 (9.7 per cent) positive for Hemeselect (a total of 148 subjects had positive tests). Seven subjects (4.7 per cent) refused to be investigated. Colonic investigation in the remainder revealed nine cancers and 49 patients with 67 adenomas (32 tumours 1 cm or more in size). All cancers (Dukes A, six; B, one; C, two) were detected by Hemeselect (positive predictive value 6.2 per cent) but only one patient was Haemoccult positive (positive predictive value 5.9 per cent). Hemeselect detected 65 adenomas (31 of 1 cm or more) in 48 patients (positive predictive value 33.1 per cent) compared with 11 adenomas (seven of 1 cm or more) in eight patients who were positive for Haemoccult (positive predictive value 47.1 per cent). The test specificity for neoplasia was respectively 94.9 and 99.6 per cent. The Hemeselect positive rate is high but its substantial positive predictive value for cancer warrants continuing evaluation.
Cancer of the colon and rectum in Ghana: A 5-year prospective study
Authors: Naaeder S B , Archampong E Q
Published: March 2007

A prospective study of 134 patients who presented to a teaching hospital in Ghana for the first time with colorectal cancer between January 1987 and December 1991 is reported. The mean number of new patients per year was nearly three times that of a decade ago. The disease afflicts both sexes equally and the age of highest incidence is in the seventh and eighth decades. Some 65 patients had colonic cancer and 69 rectal lesions. Most patients presented with advanced disease and only four of 109 in whom disease was staged (3.7 per cent) had Dukes A tumours. Right-sided cancer of the colon was more common than that of the left. The importance of rectal examination is emphasized by the finding that 78 per cent of rectal tumours were within reach of the examining finger. ‘Curative’ resection was possible in 60 per cent of patients with colonic cancer but in only 36 per cent of those with rectal tumours. The postoperative mortality rate of patients who underwent laparotomy was 13.6 per cent and in those who had resection 5.5 per cent. Long-term follow-up was poor. These results emphasize the need for accurate data collection on colorectal carcinoma, public education on the importance of early diagnosis and follow-up after treatment. These findings also call for a study of the epidemiology and aetiology of colorectal cancer in Ghana.
Ruptured aortic aneurysm: Early postoperative prediction of mortality using an organ system failure score
Authors: Meesters R C Tromp , Van Der Graaf Y , Vos A , Eikelboom B C
Published: March 2007

Ruptured abdominal aortic aneurysm (AAA) is a personal and public health catastrophe because of the high and unimproving mortality rate, increasingly long intensive care unit (ICU) stay and rising hospital costs. Criteria are needed to identify patients with a poor prognosis so that treatment and resources may be directed to those with a better outlook. This retrospective study reviews perioperative variables, outcome and length of ICU stay for 99 consecutive patients with operated ruptured infrarenal AAA between 1985 and 1992 who reached the ICU alive. Early death (within 48 h) occurred in 20 per cent using 24 ICU days and late death (after 48 h) occurred in 29 per cent using 420 ICU days; neither type of death could be predicted before operation. Multiple organ failure, the cause of 93 per cent of late deaths, was assessed for each patient 48 h after operation using an organ system failure score. There was a strong positive correlation between organ system failure score and mortality rate (P<0.00001); all 20 patients with more than two failing organ systems died. If used in decision making the score would have saved 43 per cent of the ICU days associated with late mortality. Withdrawing postoperative treatment at an early stage in accordance with an organ system failure score may be a defensible and cost-effective option.
Vein bypass surgery to the foot in patients with diabetes and critical ischaemia
Authors: Isaksson L , Lundgren F
Published: March 2007

The feasibility of vein bypass surgery to the arteries of the foot was studied in a diabetic population with critical ischaemia; whether or not such reconstruction leads to an independent lifestyle was assessed 1 year later. Thirty-three reconstructions were performed on 32 limbs in 31 patients. The mortality and reoperation rates within 1 month were both 6 per cent. Primary and secondary patency, limb salvage and survival rates at 1 year were 76, 89, 89 and 82 per cent respectively. Good results in the form of combined survival, patency, limb salvage, walking ability, relief of pain and residence at home were achieved in 64 per cent of patients after 1 year. Reconstructive vascular surgery to the foot in diabetics is feasible and affords two-thirds of patients an independent lifestyle 1 year after surgery.
Effect of mode of application of papaverine on the contractile response of the internal mammary artery
Authors: Chester A H , Panda R , Borland J A A , Tadjkarimi S , Schyns C J , O'Neil G S , Yacoub M H
Published: March 2007

A study was performed to investigate the duration of action of papaverine applied either intraluminally or in a combined intraluminal and extraluminal fashion in vitro, and how the reactivity of the internal mammary artery (IMA) to a range of vasoconstrictors is affected. Segments of IMA exposed to only intraluminal papaverine (10−4 mol/1) for 15 min recovered their contractile response to 90 mmol/1 potassium chloride to pretreatment levels within 2h. In contrast, combined intraluminal and extraluminal administration of papaverine resulted in a significant depression of the contractile response to 90 mmol/1 potassium chloride (P<0–001), which persisted for at least 5 h. Responses to 5-hydroxytryptamine, noradrenaline, the thromboxane mimetic U46619, histamine and dopamine were not significantly different between control tissues and those that had received intraluminal papaverine. The duration of action of papaverine is affected by its route of delivery and there are no significant short-term effects on the contractile mechanisms in the arterial wall after intraluminal administration.
Value of Nissen fundoplication in patients with gastro-oesophageal reflux judged by long-term symptom control
Authors: Grande L , Toledo-Pimentel V , Manterola C , Lacima G , Ros E , García-Valdecasas J C , Fuster J , Visa J , Pera C
Published: March 2007

A total of 160 patients treated by Nissen fundoplication for uncomplicated gastro-oesophageal reflux disease were studied over a 20-year period. Recurrent reflux and side-effects were assessed yearly after surgery. No objective tests for reflux were performed during follow-up if patients were asymptomatic. Perioperative mortality and techniquerelated morbidity rates were both 2 per cent. At the latest evaluation, 79 per cent of patients were completely relieved of reflux symptoms, 85 per cent had symptoms of Visick grade 1 or 2 and 89 per cent would be willing to undergo surgery again under the same conditions. Actuarial analysis showed that the success rate of fundoplication was 92 per cent at 20 years. Fourteen patients (9 per cent) developed side-effects after fundoplication and had continuing disability. Nissen fundoplication achieves permanent control of reflux symptoms in most patients with few complications and has a high degree of patient satisfaction.
Atrial natriuretic peptide and glucagon release in experimental intestinal ischaemia and reperfusion
Authors: Meleagros L , Ghatei M A , Bloom S R
Published: March 2007

Intestinal ischaemia and reperfusion cause changes in cardiovascular and pulmonary function. In a rat model, the plasma concentrations of atrial natriuretic peptide (ANP) and pancreatic glucagon rose on reperfusion after 20 min of intestinal ischaemia, coinciding with significant arterial hypotension: mean(s.e.m.) ANP 79(13) versus control 36(4) fmol ml−1 (P<0·01); and mean(s.e.m.) glucagon 22(2) versus control 10(1) fmol ml−1 (P<0·001). Glucagon was also released on reperfusion after 5 min of ischaemia: mean(s.e.m.) 18(2) fmol ml−1 (P<0·001 versus control). In a second experiment, pretreatment of rats with allopurinol did not prevent arterial hypotension but abolished ANP release (mean(s.e.m.) 36(2) fmol ml−1versus no pretreatment 70(7) fmol ml−1, P<0·05), while glucagon release was unaffected. The release of ANP, but not that of glucagon, is therefore mediated by oxygen free radicals and may signify cardiac and/or pulmonary injury or dysfunction. The actions of these peptides may be relevant in the pathophysiological perturbation of intestinal ischaemia–reperfusion.
Prospective randomized study of preoperative bowel cleansing for patients undergoing colorectal surgery
Authors: Wolters U , Keller H W , Sorgatz S , Raab A , Pichlmaier H
Published: March 2007

Three different methods of preoperative bowel preparation were tested in a prospective randomized trial examining efficacy and morbidity. In all, 163 patients were treated by gut irrigation with Ringer's lactate, Prepacol or polyethylene glycol (PEG). Fluid retention, cleansing effect, postoperative complications and subjective acceptance were documented. Relevant weight gain and decrease in haematocrit indicating fluid retention were seen only after the use of Ringer's lactate. There were no significant differences in bowel cleansing. In the Prepacol group the postoperative complication rate was significantly increased. Prepacol was tolerated best, with few side-effects. PEG was better tolerated than Ringer's lactate, but vomiting occurred in 2 and 21 per cent of patients respectively. PEG is most suitable for bowel preparation in patients undergoing colorectal surgery.
Radical resection for ampullary carcinoma: Long-term results
Authors: Sperti C , Pasquali C , Piccoli A , Sernagiotto C , Pedrazzoli S
Published: March 2007

Of 36 patients with carcinoma of the ampulla of Vater who underwent surgery between 1971 and 1990, 31 had a radical operation. There was one operative death. The overall 5- and 10-year survival rates were 56 and 37 per cent respectively. Survival was significantly influenced by tumour stage (P = 0·0002), lymph node status (P = 0·006) and the degree of differentiation of the lesion (P = 0·01). Three patients developed local recurrence after local excision of the tumour. Local or hepatic recurrence was common, even 5 years after pancreatoduodenectomy (four of 18 patients who suffered relapse). Radical resection can be curative in selected patients with ampullary carcinoma but late recurrence suggests the need for careful lifelong follow-up.
Practical score to aid decision making in doubtful cases of appendicitis
Authors: Ramirez J M , Deus J
Published: March 2007

During recent years different procedures have been used to assist in diagnosis of questionable cases of appendicitis. Among these methods, there are few scoring systems that have been shown to be effective. The aim of this study was to create a scoring system and to test its accuracy in the preoperative diagnosis of acute appendicitis. Clinical data from 360 patients who had undergone appendicectomy were collected to identify attributes that distinguished patients having a negative laparotomy from those with appendicitis. Seven independent criteria were identified. Using Bayesian methodology a weight was given to each criterion and an overall score calculated. A cut-off point was identified to separate patients for surgery and those for observation. The scoring system was applied prospectively to 166 consecutive patients; 134 had appendicitis and 32 a normal appendix (19·3 per cent error diagnosis). For the 166 patients the method suggested surgery in 113, 107 (94·7 per cent) of whom were found to have appendicitis. The system suggested observation in hospital in 38 cases. For the whole group the scoring system showed a sensitivity of 80 per cent and specificity of 81 per cent. Scoring systems from a local database could become the ideal complementary method in the diagnosis of suspected acute appendicitis.
Prognostic factors and survival of patients aged less than 45 years with colorectal cancer
Authors: Heys S D , Sherif A , Bagley J S , Brittenden J , Smart C , Eremin O
Published: March 2007

Colorectal cancers in 92 patients aged 45 years and under presenting over a 20-year period (1970–1990) were studied. A delay of more than 4 months in presentation was seen in 27 per cent of patients. All underwent surgery, 14 per cent emergency and 86 per cent elective, and follow-up was available for 91 patients. Overall, 14 per cent of patients had Dukes A tumours, 32 per cent Dukes B, 36 per cent Dukes C and 18 per cent Dukes ‘D’. Local recurrence occurred in eight (9 per cent) of the 92 patients and overall 5- and 10-year survival rates were 61 and 59 per cent. Multivariate analysis identified independent risk factors for local recurrence to be mucinous carcinoma (relative effect 4·9) and the presence of intramural vascular invasion by tumour (relative effect 9·4). For overall survival, independent risk factors were involvement of the regional lymph nodes by tumour (relative effect 2·0), extramural invasion by tumour cells (relative effect 3·0), tumour size (relative effect 1·8) and the presence of metastatic disease at initial diagnosis (relative effect 3·7).
Colorectal cancer surveillance in patients with ulcerative colitis
Authors: Jonsson B , Åhsgren L , Andersson L O , Stenling R , Rutegåd J
Published: March 2007

In prospective study carried out between 1977 and 1991, 131 patients with ulcerative colitis from an area of 65 000 inhabitants were followed by clinical visits and regular colonoscopy with biopsy. At the end of the study 58 patients had had total colitis for more than 10 years, 38 had left the programme (16 after radical operations, nine because of death – one from colitis, one from carcinoma – and 13 for other reasons) and 632 colonoscopies had been performed. Colorectal carcinoma was diagnosed in four patients, of whom two were included in the programme with a diagnosis of cancer. Dysplasia was diagnosed in 24 patients, other than those with malignancy; in four this was of high grade. Carcinoma and dysplasia occurred mainly in the left colon and in patients with total colitis. The surveillance programme was resource consuming and the cost-benefit must be questioned.
Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest
Authors: Nel J H T , Warren B L
Published: March 2007

The role of thoracoscopy in assessing the status of the diaphragm in penetrating knife wounds of the left lower chest was studied prospectively in 55 patients. Those with positive thoracoscopic findings (n = 22) proceeded to exploratory laparotomy and those with an uninvolved diaphragm (n = 32) were observed. Thoracoscopy was inconclusive in one patient and two were lost to follow-up. With operative findings or 30-month follow-up data as evaluation endpoints, thoracoscopy in 52 patients was 100 per cent sensitive, 90 per cent specific and 94 per cent accurate. A projected negative laparotomy rate of 63 per cent would have occurred with a policy of mandatory laparotomy; using thoracoscopy the actual rate was 6 per cent. Thoracoscopy is a safe and reliable method of evaluating the diaphragm in patients with left lower thoracic stab wounds.
Laparoscopic cholecystectomy for biliary pancreatitis
Authors: Tate J J T , Lau W Y , Li A K C
Published: March 2007

A prospective study was undertaken to assess the technical difficulty of early laparoscopic cholecystectomy for acute biliary pancreatitis. Patients underwent early endoscopic retrograde cholangiography (ERC) and laparoscopic cholecystectomy was performed after signs of clinical improvement. Five steps were assessed during surgery using a visual analogue score. These patients were compared with a control group undergoing elective surgery for chronic symptomatic gallstones. Of 24 patients aged 28–83 (median 60) years, eight had three or more positive signs according to Ranson's criteria. Twenty-three patients underwent successful ERC; seven had choledocholithiasis and were managed endoscopically. Laparoscopic cholecystectomy performed 3–24 (median 7) days after admission was successful in 21 of the 24 patients. The mean(s.d.) operative difficulty score was significantly increased in patients with acute biliary pancreatitis compared with that in the 40 controls (5·4(1·8) versus 3·6(1·4), P < 0·002), particularly for dissection of Calot's triangle (6·5(1·5) versus 3·0(1·6), P < 0·001). A dilated cystic duct was present in over 50 per cent of patients and in seven could not be safely closed with a clip; this finding was not predicted by ERC. Biliary pancreatitis is a further indication for laparoscopic cholecystectomy. Early surgery is safe but technical difficulty is increased. Cystic duct dilatation must be anticipated; an externally tied ligature in continuity is recommended.
National audit of complicated diverticular disease: Analysis of index cases
Authors: Tudor R G , Farmakis N , Keighley M R B
Published: March 2007

Details of 300 patients with complicated diverticular disease from 30 hospitals between 1985 and 1988 were entered into a national audit organized by the Surgical Research Society. Complications present on admission included acute phlegmon (n=104), pericolic abscess (n=34), purulent peritonitis (n=40), large bowel obstruction (n=31), faecal peritonitis (n=23), pericolic abscess complicated by fistula (n=28) and lower gastrointestinal bleeding (n=40). The overall mortality rate was 11·3 per cent (acute phlegmon, 4 per cent; purulent peritonitis, 27 per cent; pericolic abscess, 12 per cent; faecal peritonitis, 48 per cent; large bowel obstruction, 6 per cent; bleeding, 2 per cent; fistula, 4 per cent). Acute phlegmon was treated without operation in 78 patients (75·0 per cent) and by resection in 24 (23·1 per cent). Management of purulent peritonitis generally involved Hartmann's procedure (62 per cent) or resection and primary anastomosis (15 per cent). Similarly, patients with pericolic abscess usually underwent Hartmann's procedure (38 per cent) or resection and primary anastomosis (35 per cent). The principal operation for faecal peritonitis was Hartmann's resection (83 per cent). Large bowel obstruction was managed conservatively in four patients (13 per cent), by Hartmann's procedure in nine (29 per cent), and by resection and primary anastomosis with or without a proximal stoma in 13 (42 per cent). Most patients (82 per cent) with fistula associated with an abscess were managed by resection and primary anastomosis; 90 per cent with acute gastrointestinal bleeding were treated without operation.
The 5-year natural history of complicated diverticular disease
Authors: Farmakis N , Tudor R G , Keighley M R B
Published: March 2007

The natural history of complicated diverticular disease based on details of 300 patients entered into a national audit between 1985 and 1988 is reported. Questionnaires were sent to the general practitioners of 176 patients with this condition 5 years after hospital admission; 120 responded. Of these 120 patients, ten died from recurrent complicated diverticular disease, 29 died from other disorders and 81 remain alive. Forty of 110 patients (excluding those who died from recurrence) are still symptomatic or were so at the time of unrelated death. Thirty-nine patients developed a severe complication after the index admission, 14 of whom had the same complication initially. Of the 77 patients who had initially been managed by sigmoid resection, only two developed recurrent complications compared with 37 of 43 managed conservatively. Of the ten patients who died from recurrent diverticular disease, nine had not undergone sigmoid colectomy at or after the original admission. These data argue for interval sigmoid colectomy in most patients who initially present to hospital with complicated diverticular disease to prevent later development of potentially lethal complications.
Unconjugated faecal bile acids in familial adenomatous polyposis analysed by gas-liquid chromatography and mass spectrometry
Authors: Barker G M , Radley S , Davis A , Imray C H E , Setchell K D R , O'Connell N , Donovan I A , Keighley M R B , Neoptolemos J P
Published: March 2007

Previous studies have suggested reduced formation of secondary bile acids in patients with familial adenomatous polyposis (FAP). Developments in the collection, extraction and analysis of faecal bile acids as well as in the accurate diagnosis of FAP by DNA markers prompted reinvestigation of this hypothesis. The median (interquartile range (i.q.r.)) faecal bile acid concentration (3·69 (1·66–5·36) μmol per g dry weight) and daily excretion rate (60·5 (29–149) μmol per g per 24 h) in ten patients with FAP were similar to those of nine control subjects (3·31 (0·65–8·38) μmol per g dry weight and 30·1 (7·9–228) μmol per g per 24 h). Although the median (i.q.r.) concentration of only one bile acid (12-oxo-lithocholic acid) was significantly different between patients with FAP and controls (49 (34–70) versus 0 (0–20) nmol per g dry weight, P=0·006), the derivatives of chenodeoxycholic acid (3·35 (1·76–5·32) versus 0·51 (0·13–2·37) μmol per g dry weight, P=0·02) and cholic acid (1·63 (0·42–2·34) versus 0·80 (0·13–3·57) μmol per g dry weight, P=0·006) were increased in those with polyposis. These results show increased bacterial biotransformation of faecal bile acids in patients with FAP.
Increased gut permeability after multiple trauma
Authors: Pape H-C , Dwenger A , Regel G , Auf'm'Kolck M , Gollub F , Wisner D , Sturm J A , Tscherne H
Published: March 2007

Gut permeability was studied in multiply injured patients with respect to the development of multiple organ failure (MOF). Two groups were defined according to MOF score (threshold 10 points) as to whether MOF developed (group 1; n = 11, four deaths) or did not (group 2; n = 21, no death). Gut permeability was determined from the ratio of urinary excretion of enterally administered lactulose and mannitol. Serum elastase concentrations were also determined. Mean(s.e.m.) gut permeability was abnormal during the entire study (day 1: group 1 5·1(2·1) versus group 2 10·6(4·1) (P not significant; P < 0·001 versus normal volunteers, 0·56(0·24)). An increase on days 3 and 5 correlated with serum elastase levels only in patients in group 1 (rs = 0·71, P < 0·01). Severe injury leads to increased intestinal permeability, which is related to a systemic inflammatory response.
Comparison of radioligand assay and immunostaining for epidermal growth factor receptor in human breast cancer
Authors: Hastrich D J , Dunn J M , Nicholson S , Newcomb P , Farndon J R
Published: March 2007

Epidermal growth factor (EGF) receptor status is a useful prognostic indicator in women with breast cancer. Lack of standardization and correlation of methodology for the detection of EGF receptor has hampered its further evaluation. EGF receptor status was ascertained by immunohistochemistry and radioligand assay in 120 breast cancers. Of 52 tumours negative for EGF receptor on radioligand assay, 47 were negative on immunohistochemistry and, of 68 tumours positive for the receptor on assay, 52 were positive on immunohistochemistry. If the more widely evaluated radioligand assay is assumed to be the ‘gold standard’, immunohistochemistry has a sensitivity of 81 per cent and a specificity of 91 per cent.
Perioperative and postoperative tranexamic acid reduces the local wound complication rate after surgery for breast cancer
Authors: Oertli D , Laffer U , Haberthuer F , Kreuter U , Harder F
Published: March 2007

A randomized double-blind trial has shown that, in 160 women with breast cancer undergoing lumpectomy or mastectomy with axillary clearance, perioperative and postoperative administration of tranexamic acid 1 g three times daily resulted in a significant reduction in the mean postoperative drainage volume compared with patients given placebo (283 versus 432 ml, P < 0·001). The frequency of postoperative seroma formation was also decreased by tranexamic acid administration (27 versus 37 per cent, P = 0·2). Haematoma formation was infrequent in both groups and was not altered by administration of tranexamic acid. No infectious complications occurred. Age over 60 years was a significant risk factor for overall wound complications but tumour size and regional lymph node metastases were not. Tranexamic acid may be used to reduce the frequency of postoperative wound complications following surgery for breast cancer.
Prediction of pulmonary complications after transthoracic oesophagectomy
Authors: Nagawa H , Kobori O , Muto T
Published: March 2007

Postoperative pulmonary complications are often fatal in patients with oesophageal cancer. The influence of various preoperative and perioperative risk factors in the prediction of such complications was analysed. Some 170 oesophageal resections performed through a thoracotomy between January 1977 and December 1991 were reviewed. Twenty-two parameters generated from various medical risk categories were studied. Six variables were significant (P < 0·05) on univariate analysis: vital capacity, serum albumin level, partial pressure of carbon dioxide in arterial blood, presence of liver cirrhosis, presence of chronic obstructive airway disease and clinical stage of the tumour. Multivariate discriminant analysis of these six factors identified three as significant, namely vital capacity (P < 0·0001), liver cirrhosis (P = 0·01) and tumour stage (P = 0·01), yielding an equation for assessment of the risk of postoperative pulmonary complications. Calculation of the risk score showed that 42 of 53 patients with pulmonary complications had scores of 0 or more and that 74 of 102 without had scores below 0. The mean risk score was 0·34 for patients with complications and −0·26 for those without. The equation predicted pulmonary complications after transthoracic oesophagectomy with 74·8 per cent accuracy, 79·2 per cent sensitivity and 72·5 per cent specificity. It is concluded that the risk of postoperative pulmonary complications can be accurately assessed in individual patients by calculation of a risk score based on vital capacity, liver cirrhosis and tumour stage.
Surgical management of intrathoracic oesophageal rupture
Authors: Sabanathan S , Eng J , Richardson J
Published: March 2007

Intrathoracic oesophageal rupture is a life-threatening condition that requires early diagnosis and effective treatment if death or serious prolonged illness is to be avoided. Six consecutive patients with intrathoracic oesophageal rupture were treated by debridement and irrigation of the mediastinum and primary suture closure with reinforcement of the suture line by pedicled omentum. The cause of the rupture was Boerhaave's syndrome in five patients and compressed air injury to the oesophagus in one. All but one patient presented more than 24 h after onset of symptoms, with a mean of 38 (range 12–72) h. All the patients recovered well with no postoperative oesophageal leakage. The mean hospital stay was 11·5 (range 9–15) days. Irrespective of the duration of the oesophageal rupture, aggressive resuscitation and prompt primary suture closure with reinforcement of the suture line with a well vascularized pedicled tissue flap is required for optimal results.
Effect of intraoperative manipulation and anaesthesia on lower oesophageal sphincter function during fundoplication
Authors: Johnsson F , Ireland A C , Jamieson G G , Dent J , Holloway R H
Published: March 2007

The variables influencing the intraoperative measurement of lower oesophageal sphincter (LOS) pressure and a new method of assessing the effect of a fundal wrap on LOS function were investigated in 13 patients undergoing fundoplication. All patients had a 360° wrap fashioned around a 50-Fr bougie; four also underwent highly selective vagotomy. The effect of the fundal wrap, independent of LOS pressure, was assessed by inducing LOS relaxation with balloon distension. Preoperative mean(s.e.m.) LOS pressure (14·1(2·6) mmHg) did not correlate with that at the start of operation (11·5(1·5) mmHg). After mobilization of the oesophagus mean(s.e.m.) LOS pressure increased significantly (to 19·8(2·0) mmHg; P < 0·0005) and oesophageal distension elicited LOS relaxation on 16 of 33 occasions. After completion of the wrap there was no further increase in LOS pressure, but LOS relaxation occurred after only five of 33 distensions (P < 0·01). These findings indicate that anaesthesia and intraoperative manipulation during fundoplication have significant effects on LOS function that detract from the validity of intraoperative assessment. They question the rationale of current approaches to intraoperative manometry for the assessment of antireflux surgery.
Chromosome allele loss in colorectal liver metastases and its association with clinical features
Authors: Ding S-F , Delhanty J D A , Zografos G , Michail N E , Dooley J S , Habib N A
Published: March 2007

Molecular genetic changes are better characterized in colorectal carcinoma than in other common adult tumours. Consistent allele losses, or loss of heterozygosity (LOH), on chromosomes 5q, 17p and 18q have been well established. These changes are associated with the prognosis of the disease. Little is known of such changes in liver metastases of colorectal origin. The extent of allelic loss and its association with clinical features were investigated in 19 patients with colorectal liver metastases by using 24 probes to detect restriction fragment length polymorphism. A high frequency of LOH on chromosomes 5q, 17p and 18q was found in these secondary tumours. No consistent loss has so far been shown in any other chromosome. The frequency of allele loss correlated significantly with prognostic features such as the number and size of liver secondaries (P < 0·005), metastasis to the lymph nodes (P < 0·01) and curative or palliative operation (P < 0·02).
Antimicrobial treatment of pancreatic infection in cats
Authors: Widdison A L , Karanjia N D , Reber H A
Published: March 2007

An investigation examined the efficacy of antibiotics in a novel feline model of pancreatic infection in acute pancreatitis. Acute pancreatitis was induced in cats using an established technique. In control animals (no pancreatitis) and cats with pancreatitis, Escherichia coli (104 in 0·1 ml) was placed in the pancreatic duct. Reoperation was performed after 24 h in six controls and six cats with pancreatitis. E. coli was cultured from the pancreas in five control animals and five cats with pancreatitis. Reoperation was performed after 1 week in ten controls, in 11 cats with pancreatitis and in nine with pancreatitis that were treated with cefotaxime (50 mg/kg intramuscularly three times daily) started 12 h after the induction of pancreatitis and administration of E. coli. Pancreatic infection developed in eight cats with pancreatitis compared with none of the cefotaxime-treated animals and none of the controls (P < 0·05). Cefotaxime reached bactericidal levels in pancreatic tissue and juice. In conclusion, ductal administration of E. coli caused pancreatic infection only in cats with acute pancreatitis. Early administration of an appropriate antibiotic was effective in treating pancreatic infection in acute pancreatitis.
Acute scrotal pain complicating familial Mediterranean fever in children
Authors: Eshel G , Vinograd I , Barr J , Zemer D
Published: March 2007

Twenty-nine children with familial Mediterranean fever presented with 39 attacks of acute scrotal pain. Of these, 25 patients had an acute scrotum complicating familial Mediterranean fever and only four had testicular torsion. Scrotal pain was the only manifestation of a familial Mediterranean fever crisis in 36 episodes and in 15 boys scrotal involvement was the first manifestation of the condition. Fourteen patients were treated medically. Of 15 patients who underwent scrotal exploration there were no definite diagnostic findings in 11 and four had testicular torsion. Three cardinal features strongly suggest the diagnosis of acute scrotum in familial Mediterranean fever in a boy of Mediterranean origin with a relevant family history: recurrent scrotal pain or swelling; body temperature above 37·5°C; and gradual onset of pain, usually of more than 12 h duration. Conservative management can safely be undertaken in these boys without fear of losing a salvageable testis.
Histological assessment of the distal ‘doughnut’ in patients undergoing stapled restorative proctocolectomy with high or low anal transection
Authors: Deen K I , Hubscher S , Bain I , Patel R , Keighley M R B
Published: March 2007

A non-randomized prospective study of 38 patients, 32 with ulcerative colitis and six with familial adenomatous polyposis (FAP), who underwent high or low anal transection during stapled restorative proctocolectomy was undertaken. The median (range) height of the staple line 6 months after operation was 5·2 (3·2–6·0) cm after high transection compared with 2·9 (1·8–3·6) cm after low transection. Nineteen of 20 patients after high anal transection had columnar epithelium in the distal ‘doughnut’ versus 16 after low transection. Active colitis was present in 12 of 19 ‘doughnuts’ in patients with high anal transection and columnar mucosa and in seven of 16 after low transection. Nine patients (high transection two, low transection seven; P < 0·05) had striated muscle in the stapled distal ‘doughnut’. Dysplasia was found in the resected colon in one patient with ulcerative colitis and adenocarcinoma in two colectomy specimens (ulcerative colitis, one; FAP, one). No dysplasia or carcinoma was seen in any of the ‘doughnuts’ from patients with ulcerative colitis. Four patients with FAP (high transection, two; low transection, two) had microadenoma in the distal ‘doughnut’. Despite attempts to place a stapled pouch-anal anastomosis below the anal transition zone, it was not possible to remove columnar mucosa completely from the remaining anal canal in most patients (16 of 18). High anal transection and pouch-anal anastomosis should be the preferred option in restorative proctocolectomy, as a dentate-line anastomosis may not fully eliminate columnar epithelium and may involve resection of some of the external sphincter.
Requirement for bowel preparation in colorectal surgery
Authors: Burke P , Mealy K , Gillen P , Joyce W , Traynor O , Hyland J
Published: March 2007

To determine whether mechanical bowel preparation influences the incidence of anastomotic dehiscence following colorectal surgery, 186 patients undergoing elective left colonic or rectal resection were randomized before surgery to bowel preparation (n = 89) or no bowel preparation (n = 97). Surgical technique was standardized and no patient had a defunctioning colostomy. Seventeen patients were excluded (seven with preparation, ten without). Indications for surgery in the remaining 169 patients were carcinoma (133 patients), diverticular disease (26), inflammatory bowel disease (six) and miscellaneous conditions (four). Operations performed were left colonic resection or reversal of Hartmann's procedure (26 with preparation, 28 without) and anterior resection (56 versus 59). The overall morbidity rate (18 per cent) was similar in the two groups. All seven clinical anastomotic leaks occurred after low anterior resection, in three of the 39 patients who had undergone bowel preparation and four of the 36 who had not (P > 0·9). Two deaths occurred, both of patients who had received bowel preparation, one being secondary to anastomotic leakage. Bowel preparation does not influence outcome after elective colorectal surgery.
Magnetic resonance imaging of rectal carcinoma: A prospective study
Authors: McNicholas M M J , Joyce W P , Dolan J , Gibney R G , MacErlaine D P , Hyland J
Published: March 2007

Accurate preoperative staging of rectal cancer is necessary to identify patients who might benefit from adjuvant therapy. Magnetic resonance imaging (MRI) was evaluated in 20 consecutive patients with rectal cancer undergoing ‘curative’ surgery. Detailed histopathological examination of the resected lesion was correlated with findings of MRI. MRI staging concurred with histological staging in 18 of 20 patients using the Dukes or tumour node metastasis classification but in only 14 using the modified Astler–Coller system. MRI diagnosed transmural invasion in all but one patient with microscopic mural invasion (positive predictive value, 100 per cent; negative predictive value, 80 per cent; overall accuracy, 95 per cent). MRI correctly diagnosed tumour deposits or involved lymph nodes in 12 patients. MRI overstaged one paticnt, in whom nodes that were enlarged on imaging studies were negative at histological examination (positive predictive value, 92 per cent; negative predictive value, 100 per cent; overall accuracy, 95 per cent). MRI has a role in selected cases for the preoperative assessment of rectal carcinoma.
Bowel ischaemia and organ impairment in elective abdominal aortic aneurysm repair
Authors: Soong C V , Blair P H B , Halliday M I , McCaigue M D , Hood J M , Rowlands B J , Barrosd'sa A A B
Published: March 2007

In 30 patients undergoing elective repair of abdominal aortic aneurysm the intramucosal pH (pHi) of the sigmoid colon was measured. Blood for endotoxin assay was taken at intervals before, during and after surgery. Daily measurements were made of liver transaminase activity and of arterial partial pressure of oxygen (PaO2). The mean(s.e.m.) peak systemic endotoxin concentration in those who developed intramucosal acidosis (pHi below 7·00) was 90(14) pg/ml, compared with 42(5) pg/ml in those who did not (P < 0·01). In the 14 patients whose pHi fell below 7·00, the mean(s.e.m.) postoperative rise in aspartate transaminase activity was 346(74) per cent, compared with 181(20) per cent in those whose pHi remained above this level (P < 0·05). The mean(s.e.m.) postoperative ratio of PaO2, to the fraction of inspired oxygen was 177(11) mmHg in those with intramucosal acidosis, compared with 260(24) mmHg in those whose pHi remained above 7·00 (P < 0·01). These results demonstrate a relationship between bowel ischaemia, endotoxaemia and organ impairment following elective aneurysm repair.
Elbow arteriovenous fistulas for chronic haemodialysis
Authors: Elcheroth J , de Pauw L , Kinnaert P
Published: March 2007

Arteriovenous fistulas (AVFs) were created at the elbow, rather than using prosthetic grafts, when forearm vessels were inadequate. A total of 272 such fistulas were constructed: 49 between the brachial artery and a forearm vein, 91 between the brachial artery and the elbow perforating vein, 52 between the brachial artery and the cephalic vein and 80 between the brachial artery and the basilic vein. In each case the vein was sutured end to side to the artery. The immediate failure rate was 11·8 per cent. The 1- and 4-year cumulative patency rates were 68·7 and 51·2 per cent for brachial artery-forearm vein AVFs, 80·3 and 68·0 per cent for those between the brachial artery and the elbow perforator, 74·1 and 61·3 per cent for brachial artery-cephalic vein fistulas, and 76·7 and 49·2 per cent for those between the brachial artery and the basilic vein. The elbow AVF is a reliable means of establishing vascular access for haemodialysis.