bluuebunny/crossref_metadata_2025 huggingface dataset:
Randomized multicentre trial of the influence of recombinant human erythropoietin on intraoperative and postoperative transfusion need in anaemic patients undergoing right hemicolectomy for carcinoma
Authors: Kettelhack C , Hönes C , Messinger D , Schlag P M
Published: March 2003

Background

The possible immunosuppressive effect of blood transfusion and its influence on survival after surgery for cancer makes it worthwhile to seek methods to avoid transfusion wherever possible. Patients with right-sided colonic cancer are frequently anaemic. Such patients were entered into a study that employed erythropoietin to avoid homologous transfusion.

Methods

In a prospectively randomized double-blind placebo-controlled multicentre trial, patients with moderate anaemia (haemoglobin concentration greater than 8·5 g/dl and less than or equal to 13·5 g/dl) presenting with right-sided colonic cancer and scheduled for hemicolectomy were treated with recombinant human erythropoietin (epoetin β) 20000 units/day subcutaneously or placebo for at least 10 days over the operative period.

Results

Perioperative treatment with epoetin β was well tolerated and there were no significant differences in morbidity and mortality. Following hemicolectomy, median cumulative blood loss in the two groups was similar (epoetin β 440 ml versus placebo 345 ml). Sixteen (33 per cent) of 48 patients treated with epoetin β and 15 (28 per cent) of 54 in the placebo group received perioperative blood transfusions (P not significant). The increase in reticulocyte count between baseline and the last preoperative value was more pronounced in the epoetin β group than in those receiving placebo (P = 0·036).

Conclusion

Despite the perioperative administration of 20000 units erythropoietin per day for at least 10 days, it was not possible to reduce the intraoperative and postoperative transfusion need. None the less, a positive change in the haematological variables of treated patients was clearly discernible. The negative result may be due to the short treatment interval and to iron deficiency, which was present in the majority of patients. The general change of attitude towards allogeneic blood transfusion is demonstrated by the overall low frequency of blood transfusion in this study.
Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the left colon
Authors: Turégano-Fuentes F , Echenagusia-Belda A , Simó-Muerza G , Camuñez F , Muñoz-Jimenez F , Del Valle Hernandez E , Quintans-Rodriguez A
Published: March 2003

Background

Palliative colostomy is still unavoidable in many patients with malignant obstruction of the left colon. This report describes an initial experience and follow-up in a small series of patients with left-sided colon obstruction in whom transanal self-expanding metal stent (SEMS) placement was attempted for palliative purposes.

Methods

Palliative transanal SEMS placement was attempted in 11 patients with malignant obstruction of the rectosigmoid region. The selection criteria included patients with advanced pelvic disease, peritoneal carcinomatosis and/or multiple parenchymatous metastatic disease. Wallstent oesophageal endoprostheses were used, and the technique was carried out by interventional radiologists.

Results

The technique succeeded in relieving the obstruction in seven patients, and surgical intervention was prevented in six. Five of these six patients died with an unobstructed colon from 26 days to 7 months after SEMS placement. The technique failed in four patients, three of whom underwent emergency colostomy.

Conclusion

Transanal SEMS placement is an appealing method for the relief of obstruction in selected patients, obviating the need for palliative colostomy.
Iron metabolism and erythropoiesis after surgery
Authors: van Iperen C E , Kraaijenhagen R J , Biesma D H , Beguin Y , Marx J J M , van de Wiel A
Published: March 2003

Background

This was a prospective study comparing the effect of major and minor surgery on haematological variables concerning erythropoiesis, iron metabolism and acute-phase response proteins.

Methods

Thirty-one otherwise healthy patients, 15 having major orthopaedic surgery and 16 undergoing minor surgery, were studied. Blood samples were taken before surgery and 1, 4, 10 and 28 days after operation.

Results

Haemoglobin concentration was decreased for up to 4 weeks after surgery. Serum erythropoietin concentration and reticulocyte count were raised after major surgery only. Serum iron concentration dropped the day after major (to 23 per cent of its preoperative level) and minor (to 46 per cent of its preoperative level) surgery and remained lower for up to 28 days after major surgery. Serum transferrin concentration and transferrin saturation decreased after both types of surgery while ferritin concentration increased. Serum transferrin receptor concentration increased only 4 weeks after major surgery (P < 0·01). The interleukin 6 peak (day 1) was greater after major than minor surgery, as was the C-reactive protein peak (day 4).

Conclusion

Both major and minor surgery induce a state of hypoferraemia in the presence of adequate iron stores. The degree of this transient form of ‘anaemia of chronic disease’ is related to the extent of surgery. Iron supplementation in the first weeks after surgery (if iron stores were normal before operation) is ineffective.
An 8-year experience of hepatic resection: indications and outcome
Authors: Finch M D , Crosbie J L , Currie E , Garden O J
Published: March 2003

Background

Most reports highlighting decreasing operative morbidity and mortality rates following hepatic resection have focused on the management of metastatic disease. Information on the full range of hepatic disease is lacking.

Methods

The indications for hepatic resection in a specialist hepatobiliary unit have been reviewed and the operative morbidity and mortality rates assessed.

Results

Among 129 patients undergoing 133 hepatic resections between October 1988 and September 1996, the principal indication for resection was hepatic malignancy (102 resections), metastatic in 66 cases. Other indications included contiguous tumour (n = 20), primary tumour (n = 16) and benign disease (n = 31). Some 116 procedures were classical anatomical resections. Blood transfusion was required in 40 per cent of cases but major morbidity occurred in 20 per cent. There were six deaths following surgery, five of which were due to hepatic failure and followed resection for malignancy or trauma. The 3-year survival rate in patients resected for colorectal metastases was 65 per cent.

Conclusion

This experience has demonstrated an increasing role for hepatic resection in a wide variety of hepatobiliary pathologies. Despite the low postoperative mortality rate, the significant risk of complications in the postoperative period serves to emphasize the need for careful selection of patients for such surgery, which should be undertaken in specialist centres.
Prospective randomized trial of systemic antibiotics in patients undergoing liver resection
Authors: Wu C-C , Yeh D-C , Lin M-C , Liu T-J , P'Eng F-K
Published: March 2003

Background

Systemic antibiotics are administered frequently after hepatectomy to prevent infective complications, but their effectiveness is uncertain.

Methods

A total of 127 patients with liver tumours were prospectively randomized into two groups after hepatectomy: in group 1 (62 patients) no antibiotics were given until the appearance of infective complications; in group 2 (65 patients) intravenous cephazolin 1 g every 6 h and gentamicin 80 mg every 8 h were given for 7 days. On the day before surgery all patients received bowel preparation by clear liquid diet and oral antibiotics (neomycin 1 g and erythromycin 1 g, given together in three doses).

Results

The infective complication rate was 23 per cent in both groups (P = 0·95). The hospital costs were higher in group 2 (P < 0·001). Of the group 1 patients, 51 (82 per cent) did not require antibiotic treatment. No patient in either group died after hepatectomy.

Conclusion

Postoperative systemic antibiotics cannot prevent infective complications, and their routine use after hepatectomy is unnecessary and costly. The use of antibiotics should be delayed until infective complications and persistent septic symptoms occur.
Reconstruction after total gastrectomy by the interposition of a double jejunal pouch using a double stapling technique
Authors: Ikeda M , Ueda T , Shiba T
Published: March 2003

Background

After total gastrectomy, sustaining good nutrition is extremely important for maintaining quality of life. A technique of neogastric pouch formation based on current physiological reconstructive principles is presented.

Methods

The use of a modified interpositioned double jejunal pouch following total gastrectomy in 18 patients with cancer was reviewed. This technique results in a complete pouch and uses a double stapling technique with site-specific anastomosis between the oesophagus and pouch, in which a Hisoid angle is created.

Results

There were no anastomotic leaks and pouch blood flow was within normal expected limits. Mean oesophageal pH above 7·0 for one 24-h period was 7·7 per cent. Emptying half-time was 67·8 min. After 2 years mean body-weight was 98·3 per cent of expected, mean food volume was 94·0 per cent of expected and mean meal frequency was 3·0 per day.

Conclusion

This form of gastric reconstruction is an acceptable procedure which improves the quality of life in patients undergoing total gastrectomy.
Assessment of a scoring system for breast imaging
Authors: Roche N A , Given-Wilson R M , Thomas V A , Sacks N P M
Published: March 2003

Background

Triple assessment is the standard method of assessing symptomatic breast lumps. There is an accepted format for reporting cytology but not for the reporting of mammograms or breast ultrasonographic images. This study describes a scoring system for reporting breast imaging methods.

Methods

Patients with symptomatic breast lumps seen during 1 year were included. All patients underwent triple assessment. Imaging studies were reported using a grading system from 1 to 5. The results of triple assessment were compared with the final histology.

Results

Some 127 women had both mammography and ultrasonographic imaging; the final grade was identical in 60 per cent. The positive predictive value of imaging reported as grade 5 or 4 combined with cytology of C5 or C4 was 100 per cent. All lesions with C3 cytology and benign imaging were benign on histological examination whereas if a C3 grade was combined with imaging grade 5 or 4, all the lesions were malignant.

Conclusion

Combining the imaging grade with the results of aspiration cytology and clinical examination often predicts the final histology in patients with breast disease.
Outcome following laparoscopic resection for colorectal cancer
Authors: Psaila J , Bulley S H , Ewings P , Sheffield J P , Kennedy R H
Published: March 2003

Background

A prospective comparison of laparoscopic or laparoscopically assisted colorectal resection versus open resection has been undertaken to evaluate early benefits and cost implications.

Methods

Consecutive patients with colorectal cancer underwent either elective laparoscopic (n = 25) or open (n = 29) resection.

Results

Mean hospital stay was significantly shorter in the laparoscopic group: 10·7 versus 17·8 days. Mean morphine requirements were less in patients who had laparoscopic resection and their recovery, as measured by the dynamometer hand grip and the SF-36 symptom score, was more rapid. Adequate tumour clearance was achieved in the laparoscopic group. In both groups, the number of lymph nodes harvested was similar. Port-site or wound recurrence has not been observed at a median follow-up of 28 months.

Conclusion

When laparoscopic colorectal resection is possible, there are significant early benefits for patients.
Abdominal ultrasonography in the diagnosis of colonic cancer
Authors: Richardson N G B , Heriot A G , Kumar D , Joseph A E A
Published: March 2003

Background

Colonic cancer is normally diagnosed by barium enema or colonoscopy. Neither investigation is ideal, especially in the elderly patient. This study investigates the potential role of abdominal ultrasonography in the diagnosis of colorectal carcinoma.

Methods

Fifty-four patients with known or suspected colonic carcinoma were referred for abdominal ultrasonography. A single radiologist performed scans on these patients and the site of any colonic mass or wall thickening considered to be consistent with a colonic carcinoma was reported. All carcinomas were confirmed by histology on tissue obtained at colonoscopy or surgery against which the ultrasonographic diagnosis was compared. Colonic masses detected in patients undergoing routine abdominal ultrasonography for abdominal symptoms were also reported.

Results

Forty-five of the 54 patients referred had colonic carcinoma and abdominal ultrasonography detected 43 of the tumours and correctly identified the site of 41. The sensitivity, specificity and accuracy of abdominal ultrasonography in the detection of colonic tumours considered to be consistent with a colonic carcinoma was 96, 67 and 91 per cent respectively. Seven tumours were identified in patients referred before any other investigation had been carried out.

Conclusion

Abdominal ultrasonography may detect a colonic mass or wall thickening consistent with a colonic carcinoma with a high degree of accuracy and may be useful when barium enema or colonoscopy is not possible.
Ruptured hepatocellular carcinoma as a complication of transarterial oily chemoembolization
Authors: Liu C-L , Ngan H , Lo C M , Fan S T
Published: March 2003

Background

Transarterial oily chemoembolization (TOCE) is frequently employed as a non-operative treatment for hepatocellular carcinoma (HCC). Serious complications of TOCE are well known but ruptured HCC as a fatal complication of TOCE has not been reported previously.

Methods

A retrospective study was performed on all patients who received TOCE for treatment of HCC from January 1989 to October 1996; the complication of ruptured HCC within 2 weeks from the procedure was recorded.

Results

During the study period, 391 patients received a total of 1443 sessions of TOCE (mean 3·7 sessions per patient) for the treatment of HCC, with an overall median survival of 10·4 months. Six patients developed ruptured tumour within 2 weeks after TOCE, resulting in an overall incidence of 1·5 per cent per patient or 0·4 per cent per procedure. All except one patient died 1–25 days after tumour rupture. Factors common to these six patients included: (1) male sex; (2) large tumour size (range 8–17 cm in diameter); (3) tumour located in the right lobe of the liver; (4) tumour ruptured after the first session of TOCE; and (5) TOCE performed as primary treatment without previous hepatic resection.

Conclusion

Ruptured HCC is a serious complication of TOCE although the incidence is low. It occurred predominantly in men after the first session of TOCE for a large irresectable tumour of the right lobe.
Experimental study of a novel phospholipase A2 inhibitor in acute pancreatitis
Authors: Uhl W , Schrag H-J , Schmitter N , Aufenanger J , Nevalainen T J , Büchler M W
Published: March 2003

Background

In acute pancreatitis, two different types of secretory phospholipase A2 (PLA2) have been found: pancreatic type I PLA2 and non-pancreatic type II PLA2. In this study a potent new PLA2 inhibitor effective against type II PLA2 was used in an experimental model of acute pancreatitis.

Methods

In 70 rats the efficacy of the compound was analysed in two experimental models of acute pancreatitis: cerulein- and taurocholate-induced acute pancreatitis, imitating mild and severe disease respectively. Serum rat type I PLA2 protein concentration and type I and type II PLA2 catalytic activities were measured while giving the inhibitor therapeutically. In a prophylactic protocol the effect on histology was analysed.

Results

In the taurocholate model, type II PLA2 activity was found to be nine-fold higher than in the cerulein model (P < 0·002), whereas the activity of type I PLA2 was not increased. The inhibitor significantly decreased serum type II PLA2 activity in the taurocholate model of acute pancreatitis (P < 0·05) but type I PLA2 protein concentration and type I PLA2 activity were not affected. The inhibitor also reduced histological tissue damage, with significant differences at 3 and 12 h (P < 0·01).

Conclusion

The PLA2 inhibitor significantly reduced type II PLA2 activity and was able to protect the pancreas against tissue damage. PLA2 inhibition offers the possibility of a treatment for acute pancreatitis.
Pancreatic cancer resection in elderly patients
Authors: Di Carlo V , Balzano G , Zerbi A , Villa E
Published: March 2003

Background

Pancreatic cancer resection is considered a high-risk procedure in patients aged 70 years or older.

Methods

Some 398 patients with pancreatic adenocarcinoma, observed between 1990 and 1995, were reviewed. Operative outcome and survival of 33 patients aged 70 years or more were compared with findings in 85 younger patients who underwent resection.

Results

Resectability was not significantly different between the elderly and younger patients; neither were mortality or overall morbidity. However, patients aged 70 years or more had more relaparotomies (P < 0·01) and more haemorrhagic complications (P < 0·001). Nutritional recovery after resection was satisfying even for elderly patients (body-weight gain and increase in serum albumin concentrations, P < 0·05). Univariate analysis showed a moderately poorer survival in the elderly (P = 0·09). Multivariate analysis demonstrated that tumour diameter, grading and Union Internacional Contra la Cancrum stage were independent prognostic factors, whereas age was not.

Conclusion

Patients aged 70 years or more can benefit from pancreatic cancer resection similarly to younger patients.
Survey of changes in the provision of vascular surgical services in the Oxford Region over 5 years
Authors: Galland R B , Magee T R
Published: March 2003

Aim

This study aimed to examine changes in the provision of vascular services in the Oxford region over 5 years.

Methods

A questionnaire was sent to all general surgeons in the region asking of their involvement in vascular surgery. Data were obtained from the Department of Health concerning vascular procedures and inpatient codes for each district in the Oxford Region from 1990–1991 to 1994–1995. Office of Population Censuses and Surveys (OPCS) data for abdominal aortic aneurysm repair and femoral artery reconstruction were validated against data collected prospectively for West Berkshire.

Results

Eighteen of 45 surgeons who replied to the questionnaire carried out elective and emergency arterial work. All were members of the Vascular Surgical Society of Great Britain and Ireland (VSS). All but one took part in the general surgical rota. Eight surgeons carried out emergency arterial surgery only; only two of these were members of the VSS. Of 19 surgeons undertaking no arterial surgery, 15 operated on primary and 11 on recurrent varicose veins. The number of arterial reconstructions rose from 20·8 per 100000 population to 28 per 100000 throughout the study. The greatest increase occurred in districts where a new vascular consultant had been appointed. Similar results were obtained with endovascular procedures. The number of major amputations remained fairly constant at approximately 11 per 100000 population. The number of inpatient episodes for arterial disease also rose, from 35·7 to 47·6 per 100000. In validating OPCS codes against prospectively collected data, discrepancies for individual years were noted but the annual trend was reflected fairly accurately by the codes.

Conclusion

There has been an increase in vascular activity in the region, but variations still exist between different districts.
Endoprostheses for colonic strictures
Authors: Akle C A
Published: March 2003

Background

Patients who present with large bowel obstruction often undergo emergency surgical intervention with its attendant risk of morbidity and death. A colostomy may be inevitable and this detracts from the patient's quality of life, especially when palliation is the only option.

Methods

This review examines the possibility of a more conservative approach using metallic stents to relieve colonic obstruction, either as the first stage of a curative surgical procedure or for palliation without surgery. The various stents available are examined.

Results

Case reports show that relief of obstruction can be achieved in over 80 per cent of patients, allowing subsequent elective surgery or achieving palliation for several months. Complications are rare but include colonic perforation, particularly when predilatation of the stricture has to be performed. Such complications are generally recognized early and patients can proceed to surgery and colostomy, as would previously have been conventional treatment; on occasion a small leak may be treated conservatively with success. The advent of newer endoprostheses which do not require active dilatation may improve the rate of successful deployment and lessen the risk of perforation.

Conclusion

The development of new endoprostheses has allowed their adaptation for use in the colon and, perhaps, the distal small bowel. The technology is evolving rapidly and warrants serious consideration in selected patients with large bowel obstruction before embarking on surgery. There is an urgent need for a controlled trial to establish whether such intervention for malignant strictures, potentially curable by surgery, leads to an increased risk of metastatic disease.
Non-operative management of blunt hepatic trauma
Authors: Carrillo E H , Platz A , Miller F B , Richardson J D , Polk H C
Published: March 2003

Background

Non-operative management is currently considered the treatment of choice in over 50 per cent of adult patients with blunt liver injury. This report reviews the criteria for non-operative management and its potential downside.

Methods

English language publications were reviewed.

Results

Most reports from major trauma centres in the USA support the non-operative treatment of patients with blunt liver injury if well established criteria are met. Using such criteria, non-operative treatment is successful in 50–80 per cent of cases. Adjunctive radiological techniques may be helpful in managing some complications of non-operative treatment.

Conclusion

Non-operative management is safe in haemodynamically stable patients with blunt liver injury. Computed tomography (CT) of the abdomen is extremely useful to document the extent of the damage and the presence of associated injuries, but it is not possible, based on CT alone, to predict failure; careful physiological monitoring in selected patients is indicated to avoid catastrophic complications.
Extrafascial excision of the rectum for rectal cancer
Authors: Hill G L , Rafique M
Published: March 2003

Background

The fascia propria of the rectum is an upward capsular projection from the superior fascia of the pelvic floor which surrounds the rectum and its mesorectum posteriorly and the fat, blood vessels, nerves and lymphatics in front and laterally. It is postulated that if rectal cancer is contained within the fascia propria and extrafascial excision of the rectum is performed then it would be exceptional for the cancer to recur locally.

Methods

A total of 122 consecutive patients with rectal cancer underwent extrafascial excision of the rectum. The operation involved mobilizing the rectum outside its fascia propria and removing not only the rectum and its mesorectum posteriorly but also the fat, blood vessels, nerves and lymphatics in front and laterally. Resection was considered curative unless there were distant metastases or the tumour had involved the resection margins.

Results

There was one postoperative death. The cumulative cancer-free survival rate at 5 years was 68 per cent. In 100 patients in whom the operation was considered to be curative, the cumulative cancer-free survival rate was 81 per cent. Eighty-four of these patients were available for a minimum follow-up of 24 (median 73, range 24–193) months. Three (4 per cent) developed local recurrence. In two patients this was at the anastomosis.

Conclusion

If the cancer is contained within the fascial tube surrounding the rectum and complete extrafascial excision has been performed, local recurrence will be minimal.
Role of arteriography in the selection of patients for carotid endarterectomy
Authors: Bain D J , Fergie N , Quin R O , Greene M
Published: March 2003

Background

Duplex ultrasonography is used increasingly to select patients for carotid endarterectomy. This study aims to clarify whether arteriography is still required.

Methods

A total of 272 patients in whom duplex imaging indicated significant disease of the internal carotid artery underwent arteriography and the results were compared. Regarding the arteriogram as the ‘gold standard’, three aspects were considered: the accuracy of duplex ultrasonography in detecting significant stenosis, the ability of duplex imaging to identify patients who should have arteriography and whether the arteriogram provided important additional information that might influence a decision to operate.

Results

Three patients (1 per cent) suffered a permanent neurological deficit as a result of arteriography. Of the 272 patients with significant stenosis identified by duplex ultrasonography, 241 (89 per cent) were confirmed as significant on arteriography. Duplex imaging was not able to predict accurately which arteriograms would provide useful additional information (sensitivity 59 per cent, specificity 65 per cent), whereas 89 arteriograms (33 per cent) contained information that might have influenced subsequent management.

Conclusion

Duplex imaging is unable to detail the anatomy or determine the extent of carotid disease and may therefore lead to an inappropriate decision to perform carotid endarterectomy. Duplex imaging alone is not adequate before carotid endarterectomy.
Laparoscopy and laparoscopic ultrasonography in staging of oesophageal and cardial carcinoma
Authors: Romijn M G , van Overhagen H , Spillenaar Bilgen E J , Ijzermans J N M , Tilanus H W , Laméris J S
Published: March 2003

Background

The ideal method for staging tumours of the oesophagus and gastric cardia is not known. This paper was designed to assess the value of laparoscopy and laparoscopic ultrasonography in the staging of oesophageal and cardial carcinoma.

Methods

From October 1993 to January 1996, 60 patients in whom no metastases were seen on gastroscopy, ultrasonography of the abdomen and supraclavicular region, helical computed tomography of the chest and abdomen or endosonography were scheduled for laparoscopy and laparoscopic ultrasonography.

Results

Some 40 patients had carcinoma of the oesophagus, in one of whom liver metastases were found at laparoscopy and proven histologically. On laparoscopic ultrasonography metastases were found in four patients but were impossible to biopsy. These lymph node metastases were confirmed at exploratory laparotomy. Twenty patients had carcinoma of the gastric cardia; distant metastases were found in four at laparoscopy. On laparoscopic ultrasonography metastases were present in four further patients, all proven by biopsy.

Conclusion

In this study laparoscopy was not an effective staging technique for oesophageal carcinoma. The inclusion of laparoscopic ultrasonography was of little benefit. A problem that was encountered was biopsy under laparoscopic guidance. In carcinoma of the gastric cardia, laparoscopy was more effective; adding laparoscopic ultrasonography doubled the number of patients seen to have metastatic disease.
Sentinel node localization in patients with breast cancer
Authors: Flett M M , Going J J , Stanton P D , Cooke T G
Published: March 2003

Background

Intraoperative lymphatic mapping and identification of the first draining lymph node (the sentinel node) may allow some patients with breast cancer to avoid the morbidity of formal axillary clearance. The aim of this pilot study was to establish the reliability of the technique in predicting axillary node status.

Methods

Sixty-eight consecutive patients with breast cancer, 38 undergoing mastectomy and 30 wide local excision, were included. Some 2–4 ml of 2·5 per cent Patent Blue dye was injected into adjacent breast tissue on the axillary side of the primary tumour. After 5–10 min, the axilla was explored. Blue-stained lymphatics were dissected to the sentinel node, which was removed for frozen-section examination, followed by routine histology. Formal axillary dissection was then completed.

Results

A sentinel lymph node was identified successfully in 56 (82 per cent) of 68 patients. Histology of the sentinel node accurately predicted axillary node status in 53 (95 per cent). There were three false negatives (5 per cent). In each case, only a single non-sentinel node was tumour positive. Sensitivity and specificity were 83 and 100 per cent respectively.

Conclusion

This technique would allow a selective policy of formal axillary dissection in only node-positive patients; however, further experience and refinement are needed.
Laparoscopy in the management of the impalpable undescended testis
Authors: Humphrey G M E , Najmaldin A S , Thomas D F M
Published: March 2003

Background

This study evaluates the role of laparoscopy for managing the intra-abdominal testis.

Methods

Over 30 months, 48 children (six with previous groin explorations) underwent laparoscopy for a unilateral impalpable undescended testis. The patients' age ranged from 1 to 9 years.

Results

Eleven children required insertion of ‘working ports’ for mobilization of obscuring colon before the diagnosis could be established. Twenty-eight children had an absent testis. In nine, vas and vessels entered the internal ring. In 19, vas and vessels ended blindly above the internal ring. Twenty children had an intra-abdominal testis. Ten underwent a laparoscopic single-stage orchidopexy (eight without and two with ligation of vessels); at a minimum follow-up of 2 years, one testis in this group had atrophied, three were located in the lower half of the scrotum and six in the upper half. The remaining ten children underwent a laparoscopic two-stage Fowler–Stephens operation. At a minimum follow-up of 6 months, eight of these testes were palpable in the lower half and two in the upper half of the scrotum.

Conclusion

In the majority of cases, laparoscopy obviates the need for groin exploration. Technically a first-stage Fowler–Stephens procedure can be performed easily and effectively via the laparoscope. However, the second-stage Fowler–Stephens procedure or single-stage orchidopexy requires laparoscopic skills and may not necessarily provide sufficient length to the testicular attachment.
Geographical inequality in the provision of carotid endarterectomy in Scotland
Authors: Adam D J , Bain M , Shanks E , Bradbury A W
Published: March 2003

Background

Carotid endarterectomy (CEA) is a proven method of stroke prevention in patients with symptomatic and asymptomatic high-grade internal carotid artery stenosis. This study examined whether site of residence affects access to CEA in Scotland.

Methods

Scottish Morbidity Record hospital discharge data were collected by the Information and Statistics Division of the National Health Service in Scotland and analysed for the interval 1 January 1989 to 31 December 1995. The number of CEAs performed in the hospitals of each of the 15 regional Health Boards, and CEA rate per 100 000 population resident in each Health Board region, were determined.

Results

In 1989, 65 CEAs were performed in the hospitals of five Health Boards and in 1995, 431 CEAs were performed in nine Health Boards. In 1989, the CEA rate per 100 000 resident population varied between 0 (four regions) and 4 (one region), with one region significantly different from Scotland as a whole (P<0·01). In 1995, the CEA rate varied between 0 (two regions) and 19 (one region), with two regions significantly different from Scotland as a whole (P<0·01).

Conclusion

Despite a sixfold increase in the number of CEAs being performed, and a rise in the number of centres performing CEA, there is increasing geographical inequality in the provision of CEA in Scotland.
Management of hepatobiliary and pancreatic Ascaris infestation in adults after failed medical treatment
Authors: Beckingham I J , Cullis S N R , Krige J E J , Bornman P C , Terblanche J
Published: March 2003

Background

The roles of endoscopy and surgery in the management of Ascaris lumbricoides affecting the hepatobiliary and pancreatic system in adults were determined.

Methods

All patients undergoing endoscopic retrograde pancreatography for ascariasis of the biliary or pancreatic system unresponsive to standard medical therapy were analysed. Worms were extracted using snare, Dormia basket or biopsy forceps. Success was defined as clearance of worms and eradication of symptoms.

Results

Endoscopic extraction was performed in 25 patients with success in 19. Failures occurred in one patient with Ascaris in the gallbladder, and in five with associated strictures or stones. All six patients were treated successfully by surgery.

Conclusion

Endoscopy was successful in the treatment of Ascaris infestation resistant to medical therapy in 19 of 25 patients. Surgery remains important in the management of infestations complicated by biliary or pancreatic strictures and stones, or worms in the gallbladder.
Upper gastrointestinal disease in patients with familial adenomatous polyposis
Authors: Wallace M H , Phillips R K S
Published: March 2003

Background

Upper gastrointestinal disease has become an important aspect in the management of patients with familial adenomatous polyposis (FAP).

Methods

A review of the literature was carried out using Medline. Epidemiology, pathology and treatment options are considered.

Results and conclusion

Despite the fact that over 90 per cent of patients with FAP develop duodenal adenomas, only 5 per cent go on to develop cancer. In the absence of methods to detect who is at risk of cancer, all patients undergo regular endoscopic surveillance at present. Chemoprevention in the form of drug therapy may be the answer to controlling the disease.
Metabolic response to severe injury
Authors: Hill A G , Hill G L
Published: March 2003

Background

Severe injury is associated with a complex sequence of metabolic events. The accurate quantification of these changes and a developing understanding of their aetiology has been the product of much work by researchers over the past 60 years. An understanding of these phenomena is vital to the practising surgeon because of the plethora of new metabolic modulators threatening to become part of clinical practice.

Methods

This review describes the clinical picture of the metabolic response to severe injury and then outlines modern understanding of the underlying processes.

Results and conclusion

The need for further research before introduction of new technologies is emphasized.
Diet, reflux and the development of squamous cell carcinoma of the oesophagus in Africa
Authors: Sammon A M , Alderson D
Published: March 2003

Background

Squamous cancer of the oesophagus has reached epidemic proportions in Africa in the past few decades. There are many known associations but as yet no well established theory of causation.

Methods

Relevant literature was found by manual review of appropriate journals and literature, Medline searches and cross-referencing. Published theories of causation of endemic cancer of the oesophagus were assessed in the light of available evidence. A hypothesis based on that evidence was formulated.

Results and conclusion

A predominantly maize-based diet is high in linoleic acid, a precursor for gastric prostaglandin synthesis. In combination with low intake of other fatty acids and riboflavin, high levels of prostaglandin E2 are produced in gastric mucosa, leading to reduced gastric acid secretion, relaxation of the pylorus and a reduction in lower oesophageal sphincter pressure. These events result in combined reflux of duodenal and gastric juices low in acidity into the oesophagus. Resulting dysplasia strongly predisposes to local squamous carcinogenesis. This is now a fertile area for research, which may open the way for preventive action.
Clinical features and investigations in patients with columnar-lined oesophagus
Authors: Martínez de Haro L , Ortiz A , Parrilla P , Aguilar J , Bermejo J , Molina J
Published: March 2003

Background

It is unclear why some patients with a columnar-lined oesophagus present with intestinal metaplasia and others do not. The physiopathological and clinical implications of the length of the metaplastic segment are also controversial. The aim of the study was to determine whether the length of the metaplasia and the presence of intestinal epithelium are related to the clinical, manometric and pHmetric data in patients with columnar-lined oesophagus.

Methods

A comparison of clinical, endoscopic, pathological, manometric and pHmetric data was made between patients with columnar-lined oesophagus of 3–5 cm (n = 31) and those with a metaplastic segment of 5 cm or more (n = 28); the same comparison was made between patients who had specialized intestinal metaplasia (n = 37) and those who did not (n = 22).

Results

No significant difference was found in any of the variables studied except for associated inflammatory lesions above the columnar epithelium which were more frequent in patients with a shorter metaplastic segment (P < 0·05).

Conclusion

Neither the length of the metaplastic segment nor the presence of intestinal metaplasia was related to a more evolved gastro-oesophageal reflux disease, a poorer oesophageal clearing function or higher acid reflux rates.
Small bowel obstruction after total or subtotal colectomy: a 10-year retrospective review
Authors: Nieuwenhuijzen M , Reijnen M M P J , Kuijpers J H C , van Goor H
Published: March 2003

Background

The aim of this retrospective study was to determine the cumulative incidence of adhesive small bowel obstruction (SBO) after total or subtotal colectomy and to investigate the site of the obstructive adhesions in the abdominal cavity.

Methods

The records of 234 patients who underwent colectomy from 1985 to 1994 were reviewed for SBO, potential risk factors for SBO, and the site of adhesions causing obstruction. Mean follow-up, which was complete in 215 patients, was 63 months.

Results

SBO occurred in 56 patients (24 per cent) of whom 42 (18 per cent) had adhesive obstruction. The risk of SBO due to adhesions within 1 year was 11 per cent, increasing to 30 per cent 10 years after colectomy. With univariate analysis no risk factor for adhesive SBO, including previous laparotomies, septic complications and omental resection, was identified. The most common site of obstructing adhesions was the pelvis (ten of 28 patients).

Conclusion

The incidence of SBO after colectomy is high. Colectomy may be a suitable model for studies of adhesion prevention.
Prospective randomized controlled trial of preservation of the intercostobrachial nerve during axillary node clearance for breast cancer
Authors: Abdullah T I , Iddon J , Barr L , Baildam A D , Bundred N J
Published: March 2003

Background

Complications of axillary surgery occur due to severance of the intercostobrachial nerve (ICBN). The feasibility and benefit of preserving the ICBN to prevent sensory loss was studied prospectively.

Methods

Sensory symptoms and deficits were documented, and shoulder movement and arm circumference were measured at discharge and 3 months later in 120 patients randomized to either preservation or division of the ICBN.

Results

Preserving the ICBN was feasible in 39 (65 per cent) of the 60 patients randomized to the preservation group. Preserving the nerve prolonged the procedure by a median of 5 min. No difference in sensory symptoms between the groups was seen at 3 months. At 3 months 53 per cent of patients randomized to ICBN preservation had a sensory deficit compared with 84 per cent of those randomized to ICBN sacrifice (P ≤ 0·05).

Conclusion

Preserving the ICBN reduces the incidence of sensory deficit (but not symptoms) in patients after axillary clearance.
Laparotomy and laparoscopy differentially accelerate experimental flank tumour growth
Authors: Da Costa M L , Redmond H P , Finnegan N , Flynn M , Bouchier-Hayes D
Published: March 2003

Background

Surgery depresses host tumoricidal activity and may increase tumour growth. This study compared the effects of laparoscopy with laparotomy on extraperitoneal tumour growth and immune function in a murine model.

Methods

C57BL/6 female mice aged 8–10 weeks had tumours induced in the right flank (n = 45) and were randomized to undergo halothane anaesthesia only, laparoscopy or laparotomy. Flank tumour volume was assessed over 10 days. A second group of animals (n = 540) were randomized to undergo the same procedures and killed at 24, 48 and 96 h. Splenocytes were harvested for natural killer (NK) cell and lymphokine activated killer (LAK) cell cytotoxicity studies.

Results

There was a significant increase in flank tumour growth in the first 48 h after laparotomy and laparoscopy compared with controls (P<0·01). By 96 h the difference was only significant in the laparotomy group (P<0·01). Both NK and LAK cell cytotoxicities were suppressed significantly (P≤0·03) from 24 h up to 96 h following laparotomy compared with control and laparoscopy groups. There was also a significant suppression in the laparoscopy group compared with controls in the first 48 h after operation (P≤0·02).

Conclusion

Extraperitoneal tumour growth was significantly accelerated after laparotomy and correlated with significantly suppressed NK and LAK cytotoxicity for at least 4 days after operation. Laparoscopy had a shorter, less profound effect on tumour growth and immune function.
Cystic tumours of the pancreas
Authors: Martin I , Hammond P , Scott J , Redhead D , Carter D C , Garden O J
Published: March 2003

Background

Cystic pancreatic tumours may be misdiagnosed as pseudocysts.

Methods

From August 1990 to January 1998, 21 patients (16 women) with a median age of 60 years underwent operation for a cystic mass in the pancreas with histological confirmation of neoplasia (six serous cystadenoma (SCA), three mucinous cystic adenoma (MCA), ten mucinous cystadenocarcinoma (MCAC), one ductal adenocarcinoma with cystic degeneration, one cystic islet cell tumour).

Results

While the lesion had been labelled as a pseudocyst in eight patients, only one patient (MCA in the pancreatic head) had had acute pancreatitis previously. In seven patients the computed tomogram (CT) lacked suspicious neoplastic features, while endoscopic retrograde cholangiopancreatography, angiography and percutaneous cyst fluid analysis were unhelpful or misleading in 16 of 18 investigations with respect to differentiating tumour from pseudocyst. Attempted operation for cure was performed in 18 patients despite diagnostic delays of up to 6 years and initial treatment with cystenterostomy in two cases.

Conclusion

Retrospective review revealed that all 21 cystic neoplasms could be diagnosed before operation by a history excluding previous pancreatitis (20 of 21 patients) or a CT suspicious for neoplasia (14 of 21). The diagnosis relies more on absence of previous pancreatitis and a suspicious clinician who errs on the side of resecting a pseudocyst rather than watching or draining a cystic neoplasm.
Pseudomyxoma peritonei
Authors: Hinson F L , Ambrose N S
Published: March 2003

Background

Pseudomyxoma peritonei is an unusual condition in which gelatinous fluid collections are associated with mucinous implants on the peritoneal surfaces and omentum. The pathological origin and ideal treatment of the condition are subjects of debate.

Methods

An unrestricted Medline search over 1986–1997 was performed for pseudomyxoma peritonei.

Results and conclusions

There is increasing evidence that pseudomyxoma peritonei is a neoplastic condition which usually arises from a primary adenoma or adenocarcinoma of the appendix. Reported series include a spectrum of pathological lesions, from entirely benign ruptured mucocele to advanced carcinoma. This, and the rarity of the condition, limit the conclusions that can be drawn regarding its treatment and prognosis. Most authorities agree that a thorough surgical debulking should be made. In most cases this will be a difficult and time-consuming undertaking, possibly requiring cooperation between two or more specialists and consideration of delivering intraperitoneal adjuvant therapy during or immediately after surgery. Treatment therefore requires a planned approach with accurate preoperative assessment of the diagnosis and the extent of the condition. There is some largely anecdotal evidence in favour of intraperitoneal chemotherapy and radioisotope treatment. Ultraradical surgery, with heated intraoperative and further postoperative chemotherapy, is strongly advocated by one group but remains contentious. The majority of patients will eventually suffer recurrence. The 5-year survival rate ranges from 53 to 75 per cent, but outcomes vary widely between relatively benign and malignant subgroups.
Marimastat inhibits neointimal thickening in a model of human vein graft stenosis
Authors: Porter K E , Loftus I M , Peterson M , Bell P R F , London N J M , Thompson M M
Published: March 2003

Background

There is now accumulating evidence that matrix metalloproteinases (MMPs), the physiological mediators of matrix deposition and degradation, play an important role in the development of intimal hyperplasia following arterial bypass. This study investigated the effect of marimastat, an orally active specific MMP inhibitor, on neointima formation in cultured human saphenous vein.

Methods

Segments of human saphenous vein obtained from ten patients undergoing arterial bypass surgery were cultured for 14 days in serum-supplemented RPMI medium (controls) or in control medium supplemented with marimastat at three different concentrations (treatment groups). Following culture, half of each segment was prepared for histological examination and MMPs were extracted from the other half for gelatin zymography.

Results

Marimastat inhibited neointimal thickening in a concentration-dependent manner; inhibition was significant at 10−5 and 10−6 mol/l (P = 0·006). This observation was paralleled by a significant reduction in the levels of MMP-2 and MMP-9 in the tissues.

Conclusion

Marimastat significantly reduced neointimal thickening in this laboratory model. MMP inhibitors may offer a potential therapeutic strategy in the prevention of intimal hyperplasia.
Emergency resection and primary anastomosis for left-sided obstructing colorectal carcinoma in the elderly
Authors: Poon R T-P , Law W-L , Chu K-W , Wong J
Published: March 2003

Background

Emergency colorectal surgery in the elderly has been associated with a high mortality rate. Although the current trend for the management of obstructing left-sided colorectal carcinoma favours primary resection and anastomosis, the safety and benefits of this approach in the elderly have not been studied.

Methods

Some 57 elderly (aged more than 70 years) and 59 younger patients underwent emergency resection of an acutely obstructing left-sided colorectal carcinoma. Postoperative results in the two groups were compared.

Results

The primary resection rate was 95 per cent in the elderly and 89 per cent in younger patients (P = 0·70), with a primary anastomosis rate of 84 per cent and 78 per cent respectively (P = 0·64). Elderly patients had a significantly higher incidence of premorbid risk factors and postoperative cardiorespiratory complications but no increase in surgical complications. Anastomotic leaks occurred in 6 per cent of the elderly and 4 per cent of younger patients (P = 0·65), and the hospital mortality rate was 9 and 5 per cent respectively (P = 0·48).

Conclusion

Emergency resection and primary anastomosis for left-sided obstructing colorectal carcinoma can be performed with favourable outcome in the elderly and should be the treatment of choice in most elderly patients.