bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevention of anastomosis leakage: An artificial connective tissue
Authors: Marescaux J F , Aprahamian M , Mutter D , Loza E , Wilhelm M , Sonzini P , Damge C
Published: March 2007

Anastomosis leakage still causes considerable morbidity and mortality after digestive tract surgery. We report here our experience of the use of reconstituted connective tissue created from elastin, fibronectin and collagen in preventing anastomosis leakage and closing intestinal fistulas. In animal studies (56 rats), this connective tissue was used as a patch applied with fibrin sealant to the edges of a 1 cm diameter colonic defect. In a clinical evaluation, eight patients had an intestinal fistula closed by a simple sewn suture reinforced by a sealed patch and seven patients had a high risk anastomosis reinforced by a sealed patch, in most cases as an alternative to staged surgery. In animal studies, complete reconstitution of the three colonic layers was obtained without retraction and without inflammatory reaction within 40 days, while the patch was slowly resorbed. In clinical trials all 15 defects and anastomoses healed without complication. Three patients died from other causes and, at autopsy, the patch was found to have remained in place covering the suture line. If these results are confirmed by a prospective clinical trial, such biomaterial offers the possibility of reducing the occurrence of anastomosis leakage, especially in high risk circumstances.
Role of a regional register for familial adenomatous polyposis: Experience in the Northern Region
Authors: Rhodes M , Chapman P D , Burn J , Gunn A
Published: March 2007

Within 36 months of its formation the Northern Region Polyposis Registry had increased the number of identified gene carriers of familial adenomatous polyposis from 56 to 65 in a population of 3·1 million and had achieved a 15-fold increase in the number of at-risk relatives being regularly screened. Review of the surgical records at the outset of the registry revealed that the mean age at diagnosis of those patients detected by screening was 24·7 years, whereas it was 36·6 years for those detected by symptoms. Ten of the 31 in the latter group had colorectal carcinomas whilst only one of those detected by screening had a cancer and a significantly higher proportion had sphincter-saving surgery. A regional registry can provide an effective screening and counselling service to surgeons treating patients with familial adenomatous polyposis. At-risk relatives are best assessed by combining results of the different screening procedures now available but the prime requirement of a successful registry is dedicated domiciliary counselling.
Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures resulting from Crohn's disease
Authors: Williams A J K , Palmer K R
Published: March 2007

Endoscopic balloon dilatation was undertaken in seven patients who presented with obstructive symptoms resulting from Crohn's disease. Five patients had strictures from recurrent disease at the site of an ileotransverse anastomosis, one had duodenal stenosis and one a colonic stricture. The procedures were performed under intravenous sedation on one to four occasions (median 2) and were uncomplicated. Sustained improvement over an 18–24-month follow-up period was achieved in five patients, but dilatation was unsuccessful in two cases. Endoscopic balloon dilatation is a safe and effective option in selected patients with intestinal strictures resulting from Crohn's disease and may overcome the need for surgery.
Blood transfusion and recurrent Crohn's disease
Authors: Scott A D N , Ritchie J K , Phillips R K S
Published: March 2007

The effect of blood transfusion on the postoperative recurrence of Crohn's disease has been investigated. Clinical and pathological data from 197 patients treated by right hemicolectomy between 1947 and 1988 have been analysed. Symptomatic recurrences confirmed radiologically or histologically have been recorded and cumulative recurrence rates calculated for transfused and non-transfused patients. Perioperative blood transfusion does not influence the development of recurrent disease (log rank test, χ2 = 0·112).
Limited hepatic resection for selected cirrhotic patients with hepatocellular or cholangiocellular carcinoma: A prospective study
Authors: Paquet K-J , Koussouris P , Mercado M A , Kalk J-Fr , Müting D , Rambach W
Published: March 2007

From 1 January 1983 to 1 January 1989 123 cirrhotic patients with hepatocellular cancer (n = 122) or cholangiocarcinoma (n = 1) were screened using liver function tests, α-fetoprotein determination, ultrasonography with biopsy (and in selected cases computed tomography or nuclear magnetic resonance), laparoscopy and angiography, Child-Pugh classification and urea-nitrogen synthesis rate. Twenty-three patients were selected for surgical resection because the tumour was smaller than 5 cm, not centrally located and at least 1 cm away from main structures; there was no evidence of multicentricity or metastatic disease; and the Child-Pugh classification was A or B and the urea-nitrogen synthesis rate at least 6 g/day. Upper gastrointestinal endoscopy was used routinely to identify oesophageal varices which were present in 17 cases; ten patients with a history of variceal haemorrhage (43 per cent) had preoperative endoscopic sclerotherapy. In cases with recurrent haemorrhage, surgery was used to prevent intraoperative and postoperative bleeding. Tumour resection was carried out using controlled hypotension and hepatoduodenal ligament clamping. Twelve bisegmentectomies, ten segmentectomies and one atypical resection were performed. The operative mortality rate was 13 per cent with liver failure and sepsis as the causes of death. The ‘recurrence rate’ was 26 per cent and the late mortality rate for the whole group up to 1 January 1990 was 30 per cent; 13 patients were still alive. The 12-month survival rate was 77 per cent and after 5 years it was 49 per cent. Thus, surgical resection of small liver tumours is the treatment of choice in this selected group of patients.
Necrotizing fasciitis: 10 years' experience in a district general hospital
Authors: Ward R G , Walsh M S
Published: March 2007

Of 14 patients with necrotizing fasciitis who presented between 1979 and 1988, six (43 per cent) died. The deaths were associated with delays in diagnosis, poor surgical technique and diabetes. Prompt diagnosis, resuscitation and early radical surgery are essential to the successful management of necrotizing fasciitis.
Role of interstitial therapy in the treatment of liver cancer
Authors: Masters A , Steger A C , Bown S G
Published: March 2007

Conventional palliative management of inoperable focal hepatic tumours remains unsatisfactory. Interstitial techniques such as cryotherapy, alcohol injection, low power laser hyperthermia and interstitial radiotherapy offer alternative approaches. Cryotherapy is an effective and precise technique for inducing tumour necrosis. It can only be performed at laparotomy making it relatively invasive and retreatment impractical. Alcohol is cheap and can be injected percutaneously. However, inhomogeneous distribution produces imprecise and non-reproducible lesions. Low power laser hyperthermia produces precise and reproducible areas of necrosis that are roughly spherical in shape. At present, this technique is most effective for small tumours. Interstitial radiotherapy remains the least evaluated of all the interstitial techniques. Unlike cryotherapy and low power laser hyperthermia, the biological effect of ethanol injection and interstitial radiotherapy cannot be monitored in real time by ultrasound. With the exception of cryotherapy, all methods can be applied percutaneously with low morbidity and mortality. None of these techniques is established, but they may offer the prospect of cure in cases where all areas of tumour can be positively identified and fully treated. However, in most instances the intention is to control the growth of relatively small discrete volumes of tumour within the hepatic parenchyma.
Hereditary sacral agenesis with presacral mass and anorectal stenosis: The Currarino triad
Authors: O'Riordain D S , O'Connell P R , Kirwan W O
Published: March 2007

A family with autosomal dominant inheritance of sacral agenesis is described. Ten members were affected; four had associated presacral teratomas and anterior sacral meningoceles, giving rise to serious complications in three, including bacterial meningitis, local recurrence of teratoma and perianal sepsis. Three of those with presacral masses presented initially with anorectal anomalies. Other associated abnormalities included tethering of the cord, hydrocephalus, duplex ureter, hydronephrosis, vesicoureteric reflux, neurogenic bladder, bicornuate uterus, rectovaginal fistula and hereditary spherocytosis. Early diagnosis and surgical excision of a presacral mass is advised to prevent future morbidity and mortality.
Colon perforation during colonoscopy: Surgical versus conservative management
Authors: Hall C , Dorricott N J , Donovan I A , Neoptolemos J P
Published: March 2007

A survey of endoscopy units in the West Midlands, UK, was undertaken to ascertain the management of colonic perforation during colonoscopy. Fifteen perforations were reported from a total of 17 500 colonoscopies performed in 14 units (a rate of 0.09 per cent). In seven patients the diagnosis was suspected or diagnosed immediately and in the remaining eight 2–72 h later. Four patients with associated pathology (carcinoma, Crohn's disease, ulcerative colitis and a polyp) had resection and primary anastomosis. Seven patients had a simple oversew, four of these having had a delayed diagnosis. In four cases the site of perforation was not identified, but only one patient had conservative treatment. Three patients had drainage and a defunctioning colostomy. There was no significant morbidity following treatment. It is recommended that patients who have had a good bowel preparation should be treated conservatively unless there is a large perforation or an underlying carcinoma.
Colonic complications after toxic tribal enemas
Authors: Dunn J P , Krige J E J , Wood R , Bornman P C , Terblanche J
Published: March 2007

Tribal enemas obtained from traditional healers are used widely in Southern Africa for a variety of indications. Inclusion of injurious substances such as potassium dichromate may cause serious colonic and renal complications. Nine such patients, in seven of whom chromate use was confirmed, presented after a mean delay of 7·3 days. All patients had bloody diarrhoea and vomiting and three underwent major colonic resection, requiring a total of ten procedures. One patient suffered mechanical perforation of the rectum, with subsequent necrotizing fasciitis, necessitating rectal excision. Eight patients had acute renal failure and seven required dialysis. One patient died. At follow-up one patient has chronic renal failure and only three are completely well. Although local medical practitioners are aware of the problem, the challenge of preventing harmful cultural practices remains.
Myectomy reduces ileal motility after ileoanal anastomosis
Authors: Sagar P M , Salter G V , Holdsworth P J , King R F G J , Johnston D
Published: March 2007

The hypothesis tested was that myectomy of the distal ileum would produce a long-lasting decrease in ileal motility, and so render single-lumen ileum more suitable for use as a rectal substitute in the course of restorative proctocolectomy, without the need for a pelvic ileal reservoir. Ileal motility, both spontaneous and in response to intraluminal volatile fatty acids (VFA), was studied after procto-colectomy in 25 female adult beagles, at least 6 months after ileoanal anastomosis alone (IAA, n = 6), IAA with myectomy (n = 8), IAA with myectomy and an ileal valve (n = 5) or IAA with a duplicated (J) ileal reservoir (n = 6). VFA were found to stimulate ileal motility significantly in each group. Myectomy significantly reduced the number of ileal contractions (P < 0.01), the mean amplitude of contractions (P < 0.05) and the motility index (P < 0.01). The addition of the valve to myectomy made no significant difference.
Risks of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones
Authors: Hill J , Martin D F , Tweedle D E F
Published: March 2007

There is controversy concerning the subsequent clinical course of patients whose gallbladder is left in situ following successful endoscopic removal of stones from their common bile ducts. A total of 191 patients (median age 76 years) were reviewed between 12 and 100 months (mean 38 months) after endoscopic sphincterotomy. Ten patients (5·2 per cent) had symptoms requiring cholecystectomy which was uneventful, nine in the first year. Cholangitis at presentation or failure to fill the gallbladder by endoscopic retrograde cholangiography were not helpful in identifying these patients. Forty-nine (25·6 per cent) patients died during the review period from non-biliary pathology (usually cardiovascular). Elective cholecystectomy is not required in elderly patients with symptomatic bile duct stones if the common bile duct can be cleared of stones after endoscopic sphincterotomy.
Combined surgical and interventional radiological approach for complex benign biliary tract obstruction
Authors: Schweizer W P , Matthews J B , Baer H U , Nudelmann L I , Triller J , Halter F , Gertsch P , Blumgart L H
Published: March 2007

In patients with complicated high benign biliary strictures surgical technique alone cannot exclude the possibility of recurrent problems, and hepatic atrophy/hypertrophy, portal hypertension and intrahepatic stones may all complicate surgical management. A multidisciplinary approach to these complex cases, which minimizes the need for repeated surgical interventions, has been pursued. Roux-en-Y hepaticojejunostomy was performed and an extended limb of the jejunum brought to the abdominal wall to allow access for later radiological intervention. Over a 30-month period 58 biliary-enteric anastomoses for benign disease were performed. Seventeen of these 58 patients were managed using the combined approach. Ten of these 17 patients had complex postcholecystectomy strictures and seven had strictures resulting from inflammatory disease, hepatic resection or congenital problems. A new classification of results of management of bile duct strictures is proposed. Seven patients were classified as ‘excellent’, six ‘good’, two ‘fair’ and two ‘poor’. Results were obtained at a mean follow-up of 16 months and it seems likely that in some patients major surgical reinterventions were avoided.
Effects of relief of biliary obstruction on mononuclear phagocyte system function and cell mediated immunity
Authors: Megison S M , Dunn C W , Horton J W , Chao H
Published: March 2007

Obstructive jaundice causes depression of immune system function but it is unclear at present how rapidly immune function recovers after relief of biliary obstruction. To address this issue, we studied 218 Sprague-Dawley rats with common bile duct obstruction. Mononuclear phagocyte function, cell mediated immune function, portal-systemic shunt fraction, liver function tests, and liver histology were evaluated in normal (sham) rats, obstructed rats, and at weekly intervals after relief of biliary obstruction. Hepatic uptake of radiolabelled bacteria was 82 per cent in sham rats and 66 per cent in rats 21 days after CBD obstruction (P < 0–05). Phagocytic activity returned to normal within 7 days after choledochoduodenostomy. Cell mediated immunity, measured by skin graft rejection, was significantly prolonged in the obstructed group (P < 0–05) but had returned to normal 7 days after biliary diversion. Return of hepatocellular function, as measured by liver function tests, paralleled recovery of immune function. This study demonstrates prompt recovery of the immune system after internal biliary drainage for obstructive jaundice. This finding is in contrast to previous studies that demonstrated persistent immune suppression months after biliary diversion. These data may have implications concerning the usefulness of internal biliary drainage before surgery in patients with obstructive jaundice.
Chylothorax after oesophagectomy
Authors: Bolger C , Walsh T N , Tanner W A , Keeling P , Hennessy T P J
Published: March 2007

Chylothorax is an uncommon complication of oesophagectomy. In a review of 537 oesophageal resections there were 11 cases ofchylothorax, an incidence of 2·0 per cent. There was no correlation with site, size, penetration, lymph node status, length or type of tumour but there was a significant correlation between chylothorax and the type of operative procedure carried out. The incidence in 95 transhiatal resections was 10·5 per cent. The incidence following 442 transthoracic procedures was 0·2 per cent (P < 0·001) with one chylous fistula occurring after a three-stage oesophagectomy. Initial management was conservative with chest drainage and total parenteral nutrition. Thoracotomy and duct ligation was subsequently carried out in three patients and was successful in two. The third patient died. Conservative management alone was successful in four out of eight patients, with closure of the fistula at a median of 35 days (range 14–42 days). Four patients treated conservatively died. Transhiatal oesohagectomy greatly increases the risk of chylothorax, a condition that carries a high mortality rate (46 per cent in this series) whether managed conservatively or by surgical intervention.
Preoperative localization of parathyroid tumours does not reduce operating time
Authors: Serpell J W , Campbell P R , Young A E
Published: March 2007

Accurate preoperative localization of abnormal parathyroid glands might be expected to result in a reduction in operating time. To test this hypothesis the duration of surgery was recorded in a consecutive series of 50 patients who underwent neck exploration after preoperative localization by thallium-201 and technetium-99m subtraction scanning and were found to have parathyroid tumours. A total of 34 patients had accurate localization by the scan, and these patients had a median operating time of 90 min. When the tumour had not been localized before operation, the median operating time was not significantly different (80 min). Accurate preoperative localization of parathyroid tumours does not reduce operating time.
In situ venous valve construction
Authors: Wilson N M , Rutt D L , Browse N L
Published: March 2007

A technique of in situ deep venous valve construction based on vein wall intussusception is described. The technique has been used to construct a size-matched, autogenous valve in the femoral vein of the dog. Forty-one valves have been constructed. Immediately after construction, all 41 were patent at ascending phlebography and Harvey's test showed them to be competent. Descending phlebography demonstrated competence in 38 valves. Hydrostatic testing was performed on 27 valves in the vertical position at pressure gradients in the range 0·2–250 cmH2O. Of these, 24 valves were fully competent. Six valves were studied at intervals between 1 and 112 days after construction. All six were competent by Harvey's test and five were competent at descending phlebography. There was no evidence of thrombosis in any valve. This technique may be suitable for replacement of deep venous valves in patients with the calf pump failure syndrome caused by deep venous reflux.
Comparison of duplex ultrasonography and venography in the diagnosis of deep venous thrombosis
Authors: Mitchell D C , Grasty M S , Stebbings W S L , Nockler I B , Lewars M D , Levison R A , Wood R F M
Published: March 2007

Sixty-five patients with suspected deep venous thrombosis (DVT) in 68 limbs were entered consecutively into a study to compare venography with duplex ultrasonography scanning. Both tests were performed on 64 limbs, venography being contraindicated in four. Overall, duplex scanning correctly identified 86 per cent of DVTs diagnosed on venography and correctly excluded 80 per cent with negative venograms. Nearly all errors arose in the diagnosis of calf DVT. In the femoral vein duplex scanning had a specificity of 100 per cent and a sensitivity of 95 per cent. In addition, duplex scanning provided data on the limb not undergoing venography. Of 55 limbs that underwent bilateral duplex scanning, five had thrombus in the femoropopliteal segment and a negative contralateral venogram. In addition, three Baker's cysts were diagnosed. Duplex scanning can be used in patients in whom venography is contraindicated and may also provide information about the contralateral limb. We regard femoropopliteal duplex scanning as sufficiently accurate that treatment can be initiated on the basis of the scan. Duplex scanning should replace venography as the standard method of diagnosing femoropopliteal DVT; radiographic studies should now be required only when the scan result is in doubt.
Limitations of ultrasonography in surveillance of small abdominal aortic aneurysms
Authors: Ellis M , Powell J T , Greenhalgh R M
Published: March 2007

The repeatability, observer bias and instrument bias of aortic diameter measurement by ultrasonography, were investigated in ten patients with small (3–6 cm by computed tomography) infrarenal abdominal aortic aneurysm. The repeatability of maximum aortic diameter measurement by ultrasonography was much better for anterior—posterior than transverse diameter, with coefficients of repeatability 3·0–7·5 mm and 10–15 mm respectively. The repeatability of suprarenal aortic diameter measurement was poor. Surprisingly, maximum diameter using ultrasonography was larger than that using computed tomography, the difference being least for anterior—posterior measurements. At best a single, experienced observer, using the same instrument may provide aortic diameters using ultrasonography accurate to within 5 mm, but more commonly such aortic diameter is only accurate to within 8 mm.
Intraoperative localization of colorectal cancers using radiolabelled monoclonal antibodies
Authors: Davidson B R , Waddington W A , Short M D , Boulos P B
Published: March 2007

Radiation detectors may allow the intraoperative localization of small cancer deposits following administration of radiolabelled tumour-associated antibodies. This technique was evaluated in 16 patients with colorectal tumours (14 cancers, one adenoma, one lipoma) with the 111In-labelled monoclonal antibody (MAb) ICR2 which recognizes the tumour-associated epithelial membrane antigen (EMA). At operation counting was carried out (3 × 20 s per site) using a hand-held radiation probe over the primary lesions and any palpable lymph nodes in the mesocolon. The tumour to normal colon (T/NC) ratio of counts recorded at operation was more than 1·5:1 in eight of the 14 patients with cancer (mean(s.d.), 1·54(0·41):1) and 0·91:1 and 1·06:1 respectively in the two patients with benign tumours. Node to normal colon ratios were higher in lymph nodes containing metastases. The uptake of radiolabelled antibody (T/NC ratio) was higher in EMA-expressing cancers than in those not expressing the target antigen (mean(s.d.), 2·45(0·65):1 versus 1·40(0·20):1, P = 0·019). An abdominal tumour model was also developed. Radioactively filled containers of 0·5–10 ml representing tumour deposits were suspended in a tank of 111In solution representing the background activity found in normal tissues. The ratio of radioactivity in the ‘tumour’ to that of background varied from 2:1 to 8:1. The ‘tumour’ was considered to be detectable if the mean counts recorded over the ‘tumour’ exceeded the mean of counts recorded over background by three standard deviations. At a ratio of 2:1 only ‘tumours’ greater than 5 ml could be detected with a sodium iodide probe and those over 10 ml could be detected with a cadmium telluride (CdTe) probe. At a ratio of 8:1, ‘tumours’ of 0·5 ml could be detected with either probe. At all ratios and counting periods the Nal probe was more sensitive than the CdTe.
Strategy for management of distal ileal Crohn's disease
Authors: Andrews H A , Keighley M R B , Alexander-Williams J , Allan R N
Published: March 2007

We have determined the outcome of a defined policy for the management of distal ileal Crohn's disease using a prospective computer-based analysis of 139 patients diagnosed between 1970 and 1988 with a mean follow-up of 10 years. The policy in outline consists of conservative treatment for acute obstructive episodes, resection or strictureplasty for recurrent obstructive episodes, surgical treatment for abscess and fistula formation and specific medical treatment (corticosteroids, immuno-suppressive therapy or metronidazole) for symptomatic non-obstructive disease. Twenty-nine patients had a benign course without resection. The remainder were treated surgically at some time but only 28 of these patients had specific treatment before operation. Thirty-three needed more than one resection and five needed more than three surgical procedures. Immediate, early or delayed surgical treatment did not affect the reoperation rates or the long-term outcome. Eleven patients died, ten of causes unrelated to Crohn's disease. Of the 128 living patients, 114 are fit and well, and only two are currently taking specific medication. Fourteen are unwell of whom six either need or have refused further surgery which could restore them to good health. This management policy has achieved excellent long-term results in nearly all patients, and our findings suggest that the timing of surgery and its nature are more important in determining outcome than specific medical therapy.
Perineal excision of the rectum for prolapse in the elderly
Authors: Finlay I G , Aitchison M
Published: March 2007

A perineal operation is described for the treatment of rectal prolapse. The surgery improves functional outcome by correcting the anatomical anomalies associated with the condition. In 17 elderly women, there was one perioperative death and one recurrence. At a median follow-up of 24 months, 13 patients were able to control solid stool and three were profoundly incontinent. The operation may be an alternative to the more invasive abdominal procedures for the treatment of the majority of patients with prolapse.
Relationship between outlet obstruction constipation and obstructed urinary flow
Authors: MacDonald A , Shearer M , Paterson P J , Finlay I G
Published: March 2007

Ten women with symptoms and radiological features of outlet obstruction constipation underwent urodynamic bladder studies. The results were compared with ten age- and sex-matched controls. The mean(s.e.m.) peak flow rate for patients was 19·4(6·4) ml/s compared with 32·1(7·2) ml/s for controls (P<0·05). The mean(s.e.m.) voiding time for patients was 62·9(23·7) s against a corresponding value of 15·6(6) for controls (P<0·05). The mean(s.e.m.) bladder volume in patients was 482(80) ml compared with a control value of 254(112) ml (P<0·03). The mean residual volume was raised in patients at 45 ml (range 10–150 ml). The mean(s.e.m.) detrusor pressure during the voiding phase was 53·3(12) cmH2O. These results demonstrate that patients with outlet obstruction constipation have a generalized pelvic floor disorder resulting in obstructed urinary flow.
Evaluation of diagnostic peritoneal lavage in suspected penetrating abdominal stab wounds using a dipstick technique
Authors: Muckart D J J , McDonald M A
Published: March 2007

The total protein content (g/l) and white blood cell count (cells/mm3) of diagnostic peritoneal lavage was assessed using a urine dipstick in 46 patients with suspected penetrating abdominal stab wounds and equivocal physical examination. Those patients with a protein content ⩾ 1 g/l and white blood cell count of >500 cells/mm3 were submitted to laparotomy while those with lower values underwent observation and repeat physical examination. In all, 26 patients had a positive lavage and significant injuries were found in 23 of these. Of 18 patients with a negative lavage, 17 were managed successfully without operation while one patient died from complications related to central venous catheterization. In two patients the lavage results were equivocal. One underwent a negative laparotomy and the remaining patient recovered uneventfully. The test has a 100 per cent sensitivity and 86 per cent specificity and provides an accurate, cheap, and rapid means of diagnosis of intra-abdominal injury in penetrating trauma.
Severe late postsplenectomy infection
Authors: Cullingford G L , Watkins D N , Watts A D J , Mallon D F
Published: March 2007

In all, 1490 patients underwent splenectomy in Western Australia between 1971 and 1983, giving 7825 person years exposure. Thirty-three patients developed severe late postsplenectomy infection (septicaemia, meningitis or pneumococcal pneumonia requiring hospitalization) and three developed overwhelming postsplenectomy infection. The incidence and mortality rates of severe late postsplenectomy infection were 0·42 and 0·08 per 100 person years exposure respectively and for overwhelming postsplenectomy infection the incidence and mortality rates were 0·04 per 100 person years exposure. There were 628 splenectomies after trauma, giving 3922 person years exposure. Eight patients developed severe late postsplenectomy infection of whom one had overwhelming postsplenectomy infection. Following trauma, the incidence of severe late postsplenectomy infection was 0·21 per 100 person years exposure, with the incidence and mortality rates of overwhelming postsplenectomy infection being 0·03 per 100 person years exposure. Patients undergoing splenectomy have a 12·6-fold increased risk of developing late septicaemia compared with the general population. Splenectomy following trauma gives an 8·6-fold increased risk of late septicaemia. The majority of severe late postsplenectomy infections did not occur within the first 2 years and 42 per cent of severe late postsplenectomy infections occurred > 5 years after splenectomy. The low incidence of severe late postsplenectomy infection and overwhelming postsplenectomy infection makes statistical evaluation of the effectiveness of prophylactic antibiotics, vaccination and splenic repair most difficult.
Combined portal vein and liver resection for carcinoma of the biliary tract
Authors: Nimura Y , Hayakawa N , Kamiya J , Maeda S , Kondo S , Yasui A , Shionoya S
Published: March 2007

Twenty-nine patients with advanced carcinoma of the bile duct or gallbladder underwent combined portal vein and liver resection. Segmental excision of the portal vein was performed in 16 cases and wedge resection of the vessel wall in 13. The operative mortality rate was 17 per cent. The median survival for the 24 patients who left hospital was 19·8 months. Actuarial survival rates at 1, 3 and 5 years for all 29 patients were 48 per cent, 29 per cent, and 6 per cent respectively, whereas the median survival for 46 patients with unresectable carcinoma was 3 months and the 1 and 3-year actuarial survival rates were 13 per cent and zero respectively. This difference in survival times between patients undergoing hepatectomy with portal vein resection and those with unresectable carcinoma were statistically significant (P<0·01). Combined portal vein and liver resection is recommended as a reasonable surgical approach in selected patients with advanced carcinoma of the biliary tract.
Intra-arterial streptokinase infusion in acute lower limb ischaemia
Authors: Scott D J A , Wyatt M G , Wilson Y G , Murphy P , Baird R N , Horrocks M
Published: March 2007

Between 1986 and 1988, 38 patients (29 men and nine women), median age 65 years (range 38–85 years), underwent local intra-arterial streptokinase therapy for acute lower limb ischaemia. Three patient groups were identified: 15 with acute on chronic ischaemia (group 1), 12 postangioplasty (group 2) and 11 postfemorodistal bypass (group 3). Distal arteriographic run-off was a significant discriminant between success and failure in group 1 (n = 15, χ2 = 11·5, P = 0·001) and in the overall group (n = 38, χ2 = 17·2, P<0·001). In group 2, four patients with good run-off had an unsuccessful outcome; this was due in all cases to technical problems (haemorrhage in two and intimal dissection in two). In group 3, two patients with good run-off had unsuccessful streptokinase infusions. In both cases the graft failed in the early postoperative period (<30 days). By contrast, the four patients whose grafts occluded after 30 days had successful streptokinase infusions and long-term graft patency was achieved by further surgery and balloon dilatation. In all groups, no patient with a poor run-off had a successful outcome following streptokinase administration. The role of local intra-arterial streptokinase therapy in the critically ischaemic limb remains controversial, but these results suggest that an adequate run-off is an important factor in the selection of patients for treatment.
Accuracy of endosonography in the staging of rectal cancer treated by radiotherapy
Authors: Napoleon B , Pujol B , Berger F , Valette P J , Gerard J P , Souquet J C
Published: March 2007

Endosonography is the best available method for the pretherapeutic staging of rectal cancer. The present prospective study was to determine the influence of previous radiotherapy, widely used in the management of this tumour, on the accuracy of endosonography. A complete endosonographic examination was performed just before surgery in 40 patients with rectal cancer. Endosonographic and pathological staging were compared in group A, 21 patients without previous radiotherapy, and group B, 19 patients with preoperative radiotherapy. While the endosonographic accuracy for lymph node involvement was similar in the two groups (85 per cent compared with 84 per cent), wall invasion was correctly ascertained in 86 per cent in group A but in only 47 per cent in group B (P < 0·05). After irradiation, the thickening of the rectal wall and the poor visualization of the hyperechoic layers hampered interpretation. Post-radiotherapy inflammation and/or fibrosis probably explained the echographic changes. Radiotherapy therefore altered endosonographic staging of rectal cancer. New interpretation criteria are needed for evaluation and follow-up of rectal cancer treated by radiotherapy.
Surgical anatomy of donor extended right trisegmentectomy before orthotopic liver transplantation in children
Authors: Tan K C , Malcolm G P , Reece A S , Calne R Y
Published: March 2007

Liver transplantation is now accepted as the treatment of choice for children with end stage liver disease. A major constraint has been the shortage of donor organs of appropriate size. The use of reduced size adult organs has partially alleviated this problem but the previous technique employed was limited to a donor:recipient body-weight disparity of not greater than 3:1. Recently a new technique has been described that allows safe transplantation with a donor:recipient weight ratio of greater than 10:1. This should greatly increase the paediatric donor pool. Anatomical landmarks and techniques necessary for donor reduction hepatectomy are described from the dissection of 50 adult cadaveric livers. Variations in all important biliary and vascular structures necessitated adjustments in operative technique.
Lymph node counts in the upper abdomen: Anatomical basis for lymphadenectomy in gastric cancer
Authors: Wagner P K , Ramaswamy A , Rüschoff J , Schmitz-Moormann P , Rothmund M
Published: March 2007

The number of regional lymph nodes was determined in sites relevant to lymphadenectomy in gastric cancer in 30 cadavers. Tissue was cleared by dissolving fatty tissue, thus making lymph nodes with a diameter of at least 1 mm visible. All lymph node stations indicated by the Japanese Research Society for Gastric Cancer were studied. In stations 1–11 (corresponding with R2 resection) an average of 27 nodes (range 17–44 nodes) was found, whereas stations 1–16 (corresponding with R3 resection) showed an average of 43 nodes (range 25–64 nodes). These values are higher than those usually obtained from lymphadenectomy for gastric cancer. Striking individual differences in the total number of lymph nodes and the number of single stations was observed. The number of lymph nodes in these investigations are the normal anatomical values and serve as quality control of lymph node dissection in gastric carcinoma.
Success and failure with neonatal tracheo-oesophageal anomalies
Authors: Goh D W , Brereton R J
Published: March 2007

In seven and a half years, one surgical team treated 67 consecutive neonates with oesophageal atresia and/or tracheo-oesophageal fistula. According to Waterston's classification, 28 were in group A, 12 in group B and 27 in group C. The mortality rate during the initial admission was 10 per cent, all seven deaths being unavoidable in infants in group C with multiple anomalies. Birthweight alone had no bearing upon the chances of survival. Primary oesophageal repair, including one suture-fistula procedure and one delayed primary repair, was attempted in 54 (84 per cent) of the 64 patients with atresia and was successful in 46 (85 per cent). All three H-type tracheo-oesophageal fistulae were successfully divided in infants in group A. Recurrent tracheo-oesophageal fistula developed in four (7 per cent) infants, one of whom (group A) underwent successful repair. One disrupted anastomosis was successfully resutured (group A), so an intact oesophagus was finally achieved in 51 patients, of whom six (12 per cent) developed anastomotic strictures and 21 (41 per cent) underwent surgery for gastro-oesophageal reflux. Of the 60 early survivors, 10 (17 per cent) underwent aortopexy for tracheomalacia. Whenever possible, primary repair is advocated in all infants. Even for those in group C with multiple, severe associated anomalies, the combined early and late mortality was no greater following primary repair (7 died of 12 operated) than after staged repair (4 died of 7 operated), but major anastomotic complications were more common in infants in group C (5 out of 19) than in those in groups A and B (3 out of 38).
Necrotizing fasciitis
Authors: Asfar S K , Baraka A , Juma T , Ma'Rafie A , Aladeen T , Al Sayer H
Published: March 2007

Ten cases of necrotizing fasciitis are reviewed. Three patients died but only two of these deaths were due to uncontrolled septicaemia. All isolated organisms were sensitive to a combination of piperacillin and ampicillin which we now regard as the initial antibiotic combination of choice. Prompt and aggressive surgical debridement remains the cornerstone of management.
Effect of fibrin glues on the mechanical properties of healing wounds
Authors: Byrne D J , Hardy J , Wood R A B , McIntosh R , Cuschieri A
Published: March 2007

Tissue glues are important in clinical practice. Fibrin based glues have many advantages over non-biological adhesives. The optimum formulation of these glues measured by their effect on mechanical properties of healing wounds has not been determined. Using a model involving standard dorsal skin incisions in adult male Wistar rats various glue formulations were compared by varying the fibrinogen, thrombin and factor XIII concentrations. Calcium (40 μmol/ml) and aprotinin (3000 kallidinogenase inactivator units, KIu/ml) concentrations were kept constant. Animals were killed at 8 days and wounds excised. Standard strips of these wounds were mechanically tested using an Instron tensiometer and the stress, strain, elasticity and work required to rupture wounds were calculated. Results indicate that a fibrin glue with a fibrinogen concentration of approximately 39 g/l and a thrombin concentration of 200–600 units/ml with no added factor XIII will result in wounds with significantly increased stress, energy absorption and elasticity values.
Autopsy-verified pulmonary embolism in a surgical department: Analysis of the period from 1951 to 1988
Authors: Lindblad B , Eriksson A , Bergqvist D
Published: March 2007

A retrospective analysis was undertaken of all surgical patients in Malmö, Sweden, during the period from 1951 to 1988 in whom pulmonary emboli were found at autopsy. The analysis included a comparison with the earlier analysed and reported time period from 1951 to 1980. A continued high frequency of pulmonary embolism at autopsy was seen during the 1980s (20·3 per cent of deaths, 31·7 per cent of autopsies). Of the 391 autopsy-verified pulmonary emboli found between 1981 and 1988, 113 (28·9 per cent) were considered fatal, 104 (26·6 per cent) contributed to death and 174 (44·5 per cent) were incidental. Few patients had symptomatic deep vein thrombosis or pulmonary embolism before death. The overall frequency of major pulmonary embolism in surgical patients remained unchanged (0·3 per cent). The frequency of major postoperative pulmonary embolism showed an increase during the 1950s and 1960s (maximum 0·4 per cent) but a decrease in the last 5-year period of the 1970s (0.3 per cent), which has earlier been reported upon. This decrease continued during the 1980s (0·2 per cent) (P<0·05). An increase was found in the number of patients operated on who had autopsy-proven pulmonary embolism and who received thromboprophylaxis. Pulmonary embolism continues to be a major cause of death in surgical patients; however, postoperative major pulmonary embolism has shown a reduction in the last 15-year period.
Epidemiology of chronic venous ulcers
Authors: Baker S R , Stacey M C , Jopp-McKay A G , Hoskin S E , Thompson P J
Published: March 2007

A metropolitan population of 238000 in Perth, Western Australia, was screened for chronic ulceration of the leg. Patients with a chronic leg ulcer and a venous abnormality comprised 57 per cent of all patients with a chronic leg ulcer, giving a prevalence of 0·62 per 1000 population. There was an increasing prevalence with age; 90 per cent of patients were 60 years and older. This group comprised 16·7 per cent of the population, and had a prevalence of 3·3 per 1000. Although chronic venous ulcers were more common in women there was no difference in age related prevalence. In 36 per cent of patients with a venous abnormality, there was at least one other aetiological factor contributing to chronic ulceration of the leg; 96 per cent had either a history of deep venous thrombosis or a condition known to predispose to deep venous thrombosis.
Early computed colour echo Doppler imaging following renal transplantation
Authors: Rajaseker M R , Lodge J P A , Irving H C , Giles G R
Published: March 2007

Thirty patients with renal allografts were monitored for 15 postoperative days by colour-coded Doppler imaging and categorized as stable, rejection, acute tubular necrosis and cyclosporine toxicity. All forms of graft dysfunction showed significantly raised resistance (P<0·01) and pulsatility (P<0·01) indices (RI and PI, respectively). It was not possible to use Doppler imaging to differentiate the cause of graft dysfunction, but stable grafts in patients with high cyclosporine levels had significantly higher RI (P<0·04) and PI (P<0·04) than similar grafts in patients with cyclosporine levels in the therapeutic range.
Preoperative clinical evaluation as a predictor of cardiac complications after infrarenal aortic reconstruction
Authors: Chadwick L , Galland R B
Published: March 2007

This paper analyses cardiac risk factors in 93 consecutive patients undergoing elective infrarenal aortic reconstruction over a 2 year period. During the perioperative or postoperative period, 26 patients sustained a total of 42 cardiac complications. Eight patients had myocardial infarction, 14 left ventricular failure and 15 arrhythmias. There were five cardiac-related deaths. Angina was the only statistically significant risk factor in predicting postoperative cardiac problems. A multivariate analysis identified a high-risk group of patients in whom cardiac complications after operation were common.
Gynaecomastia
Authors: Hands L J , Greenall M J
Published: March 2007

This paper reviews the development of excess breast tissue in the male. Gynaecomastia is a common problem and may have a physiological or pathological basis. It can be dealt with in most cases by reassurance or simple surgery.
Limitations of surgery in the treatment of retroperitoneal sarcoma
Authors: Alvarenga J-C , Ball A B S , Fisher C , Fryatt I , Jones L , Thomas J Meirion
Published: March 2007

A retrospective analysis was undertaken of 120 patients with retroperitoneal sarcoma referred to the Royal Marsden Hospital over a period of 20 years. The actuarial 5-year survival rate of all cases following referral was 29 per cent. On univariate and multivariate analysis the principal factors associated with an unfavourable prognosis were the presence of metastases, poor performance status at presentation, high tumour grade and incomplete excision of the primary tumour. The single most important factor affecting the ability to remove the primary tumour completely was multiple organ involvement. After apparently complete excision, however, the probability of local recurrence by 5 years was 85 per cent (95 per cent confidence interval 56–99). The prognosis of patients with retroperitoneal sarcoma is poor.
Healing of abdominal incisional hernia in infant rats
Authors: Tsui S , Ellis H
Published: March 2007

Incisional hernia following major laparotomy in adult humans occurs in 5 per cent of cases. Spontaneous healing of such hernias does not occur. We have devised a model for producing abdominal wall incisional hernia in the rat by dividing the linea alba subcutaneously through a small transverse skin incision. In adult rats (n = 17), an incisional hernia formed and progressively increased in size over 32 weeks. In 3-week-old infant rats (n = 17), all developed herniation immediately. In eight rats, these hernias progressively increased. In three, the hernias were healed at the third week, but recurred at the fourth, eighth and 12th weeks, respectively. In the remaining six animals, the hernias healed spontaneously at 3 weeks and remained healed. A similar observation of spontaneous healing of incisional hernias in children has been reported in one clinical paper. This animal model provides a useful means of studying the clinical difference between adult and infant with respect to incisional hernia.
Histopathological evaluation of oesophageal carcinoma: The significance of venous invasion
Authors: Theunissen P H M H , Borchard F , Poortvliet D C J
Published: March 2007

Follow-up data on 115 patients who had undergone surgical resection for oesophageal carcinoma were analysed. Histological sections were reviewed for tumour classification, grading and staging, and special stains were used to detect venous invasion. The effect of various factors on survival was statistically analysed using Cox's proportional hazards regression model. In this multivariate analysis lymph node metastasis was the most important variable in the assessment of survival (improvement ξ2 = 7·43, P = 0·006). Venous invasion, which was demonstrated with a frequency of 76·5 per cent (mostly intramural) was the second most important prognostic factor (improvement ξ2 = 2·86, P = 0·09). The relative risk for the presence of both variables was rather modest (3·09).
Oxygenation in the stomach and the effect of truncal vagotomy
Authors: Sheridan W G , Lowndes R H , Young H L , Lewis M H
Published: March 2007

A Clark polarographic oxygen electrode allowed detailed mapping of tissue oxygen (Pto2) levels on the anterior surface of the stomach in five patients undergoing cholecystectomy. No significant difference in mean Pto2 was detectable between greater and lesser curvatures. A significant difference in mean Pto2 was detected between the body of the stomach and the pylorus (Mann-Whitney, P<0.01). The effect of truncal vagotomy on Pto2 was evaluated in six patients undergoing this procedure for duodenal ulceration. Mean postvagotomy stomach Pto2 levels (46 ± 12 mmHg) were significantly lower (Wilcoxon test, P<0.001) than prevagotomy levels (59 ± 14 mmHg). Truncal vagotomy did not have any significant effect on small intestinal Pto2. This work provides the first objective evidence of the relatively diminished tissue oxygenation in the gastric antrum and pyloric region, and confirms blood flow studies of the effects of vagotomy.