bluuebunny/crossref_metadata_2025 huggingface dataset:
The measured effect of stopping smoking on intermittent claudication
Authors: Quick C R G , Cotton L T
Published: March 2007

One hundred and twenty-four limbs in patients suffering from intermittent claudication were studied over 10 months. Changes in ankle pressure and treadmill exercise tolerance over the period were compared between two groups, one of patients who continued to smoke (group 1) and the other of those who gave up (group 2).

Resting ankle systolic pressure fell in smokers' limbs by a mean of 10·2 mmHg (t = 3·56, P < 0·001), and rose in those patients who stopped smoking by a mean 8·7 mmHg (P - n.s.). Ankle pressures after exercise and maximum treadmill walking distance did not change in smokers but significantly improved in past smokers.

Stopping cigarette smoking increased the chance of improvement in ankle pressure and exercise tolerance in intermittent claudication.
Platelet accumulation on mature Dacron grafts in man
Authors: Goldman M , Norcott H C , Hawker R J , Drolc Z , McCollum C N
Published: March 2007

Prosthetic graft occlusion is most frequent in the early postoperative period when the luminal surface is highly thrombogenic. It is generally believed that graft maturation ultimately results in a non-thrombogenic surface. The accumulation of 111-indium-labelled autologous platelets in Dacron aortofemoral grafts has been measured 1 week following surgery and at intervals of 6 months to 1 year.

Platelets from 9 patients were labelled with 111-indium oxine and re-injected. Isotope emissions over the graft and a reference site (aortic arch) were measured daily for 8 days and gamma camera images taken on alternate days. Graft thrombogenicity was calculated as the daily rise in the graft: reference ratio of emissions.

All grafts, regardless of age, accumulated platelets and were imaged by gamma camera. Mean thrombogenicity (± s.e.mean) 1 week after surgery was 0·21 ± 0·04 compared with 0·08 ± 0·03 at follow-up (P < 0·01). The platelet survival during the early study was reduced at 6·8 ± 0·6 days but recovered to a value of 8·6 ± 0·8 days (P < 0·01) at follow-up. Further grafts, 2, 5 and 9 years old, were studied and all accumulated platelets, especially near the anastomoses.

Platelet accumulation on Dacron grafts does diminish with time but persists beyond the period of altered platelet survival and perhaps indefinitely.
Operative therapy of renovascular hypertension
Authors: Stanley J C , Whitehouse W M , Graham L M , Cronenwett J L , Zelenock G B , Lindenauer S M
Published: March 2007

Three hundred and thirteen patients exhibiting renal artery occlusive disease underwent operation for renovascular hypertension. These included 34 paediatric and 144 adult patients with fibrodysplastic disease. Atherosclerotic lesions affected an additional 64 patients without and 71 patients with clinically overt extrarenal arteriosclerotic cardiovascular disease. Ischaemic kidney renin hypersecretion (renal: systemic renin index > 0·48), associated with suppressed contralateral kidney renin secretion (renal: systemic renin index approaching 0·0), predicted curability most reliably. Four hundred and fifteen operations were performed of which 356 were primary and 59 were secondary procedures. Aortorenal bypass using autogenous vein (227 cases) or prosthetic grafts (62 cases) was the most common primary operation. Nephrectomy was the initial therapy in 17 cases. Six operative deaths occurred in patients manifesting overt extrarenal arteriosclerotic disease. No operative mortality was encountered among the remaining 242 patients. Improvement was seen following operation in 97 per cent of paediatric patients and 94 per cent of adults with fibrodysplastic disease, in 91 per cent of patients with focal renal arteriosclerosis and in 72 per cent of those exhibiting overt extrarenal arteriosclerosis.
Experimental vein grafts in the rat: Re-endothelialization and permeability to albumin
Authors: Dilley R J , McGeachie J K , Prendergast F J
Published: March 2007

Intimal thickening in vein grafts is one of the major factors leading to graft failure. Studies have suggested that delayed re-endothelialization and an enhanced permeability to proliferative factors (macromolecules) in the blood are associated with the development of intimal thickening in these vessels. The aim of this study was to determine the pattern of re-endothelialization of vein grafts and the permeability of the new endothelium to a large molecule. Iliolumbar vein to iliac artery grafts 5 mm long were inserted microsurgically into 32 male albino Wistar rats. Graft re-endothelialization and permeability, at times ranging from 2 to 140 days after grafting, were studied by scanning electron microscopy and vital staining with Evans Blue dye, which binds to plasma albumin and was used as a model of a large molecule. Re-endothelialization of the graft had commenced by 2 days after grafting and in most animals was completed by 15 days. Some grafts exhibited local areas devoid of endothelium up to 4 weeks after grafting. The mechanism of re-endothelialization involved the migration of a sheet of endothelium across the anastomosis from the adjacent artery. This sheet subsequently linked up with islands of cells which developed in the centre of the graft by 5 days. Evans Blue dye was detected in all areas where endothelium had been removed by the grafting operation. Permeability of the graft to the dye was seen during the 2–4 week period after grafting, a time at which previous studies have shown that intimal thickening develops in this vein grafting model. Thus, delayed re-endothelialization and prolonged permeability to a large molecule (albumin) does occur in some experimental vein grafts. This may be the basis for intimal thickening which is known to occur in vein grafts.
Venous thrombosis after elective hip replacement—the influence of preventive intermittent calf compression and of surgical technique
Authors: Gallus A , Raman K , Darby T
Published: March 2007

The effect of preventive intermittent calf compression on the incidence, distribution and extent of venous thrombosis after elective hip replacement was examined by randomized trial in 90 patients who were screened for postoperative thrombosis with 125I-fibrinogen leg scanning and impedance plethysmography, followed by routine venography on the seventh postoperative day. Venography showed that leg compression reduced the incidence of calf vein thrombosis from 45 per cent (21/47) in untreated patients to 16 per cent (7/43) (P < 0·005), but not that of proximal (i.e. popliteal or femoral) vein thrombosis, which occurred in 23 per cent of treated and 26 per cent of untreated patients. However, proximal vein thrombosis appeared to be less extensive in treated patients. Proximal vein thrombosis was found in 40 per cent of patients who had hip replacement by a modified Charnley technique (17/43 patients), and 9 per cent of patients in whom a posterior surgical approach was used (4/43 patients) (P < 0·005), strongly suggesting that surgical technique may influence the proximal vein thrombosis rate after elective hip replacement.
Intestinal adaptation after jejunoileal bypass for morbid obesity: A possible explanation for inadequate weight loss
Authors: Miskowiak J , Andersen B
Published: March 2007

Thirty-two patients required further abdominal operations 6–77 months after jejunoileal bypass for morbid obesity. Twenty operations were needed because of inadequate weight loss, while the remaining 12 patients had lost sufficient weight but had developed complications. In all 32 patients the lengths of functioning jejunum and ileum were measured and compared with those recorded during the original operation; elongation had occurred in 29. There was a striking difference between the median increase in jejunoileal length of 44 per cent when weight loss was inadequate and 7 per cent when weight loss was adequate (P < 0·01). Similarly, intestinal circumference and mural thickness were greater in the first group. There appears to be a relationship between intestinal adaptation and the extent of weight loss after jejunoileal bypass.
The effect of sepsis on the oxidation of carbohydrate and fat
Authors: Stoner H B , Little R A , Frayn K N , Elebute A E , Tresadern J , Gross E
Published: March 2007

Oxidative metabolism has been studied by indirect calorimetry in 27 patients with sepsis and in 7 non-septic patients while they were all receiving total parenteral nutrition. Glucose oxidation was reduced in the septic patients and fat oxidation continued despite the infusion of an excess of glucose. The extent of these changes depended on the severity of the septic state as measured by the scoring system described in the preceding paper. The mechanism of these changes is not known. They were not related to an elevation of the plasma non-esterified fatty acid concentration. Alterations must have occurred in the way fat was taken up and metabolized by the cells. Here insulin resistance and the highly significant positive relationship found between the plasma cortisol concentration and the sepsis score might be important.
Total parenteral nutrition as the sole therapy in Crohn's disease—a prospective study
Authors: Müller J M , Keller H W , Erasmi Heide , Pichlmaier H
Published: March 2007

The effect of total parenteral nutrition (TPN) as sole therapy was studied in 30 consecutive cases of complicated Crohn's disease. After insertion of a Broviac-type central venous catheter patients were nourished parenterally for 3 weeks in the hospital and then for an additional 9 weeks at home. During this time no medication or oral intake was allowed. Surgery was avoided in 25 patients by TPN. These patients returned to work, ate normal meals and needed no medical support. In 5 cases it was not possible to control the acute disease and the patients were treated by resection. During TPN, catheter-related sepsis occurred in 3 patients (0·9 cases/1000 days TPN) and catheter embolism in 2. Four other patients developed intrahepatic cholestasis. A relapse of Crohn's disease was observed in 17 cases 3–48 months after the course of TPN. The cumulative recurrence rate is 60 per cent after 2 years and 85 per cent after 4 years. Compared with the results of resection, obtained from a 10-year period before TPN was instituted at our hospital, the cumulative recurrence rate after TPN is four times higher. It is concluded that TPN is not an alternative to resection in the treatment of Crohn's disease and should be reserved for patients with multifocal lesions, when surgery is not advisable because of the risk of a short bowel syndrome.
Colonoscopic polypectomy in a regional teaching hospital
Authors: Minopoulos G J , McIntyre R L E , Lee E C G , Kettlewell M G W
Published: March 2007

Five hundred and thirty-five polyps were found in 200 patients over 6 years at a regional teaching hospital. Eighty-five per cent of the patients were from the hospital area yet the presentation of the patients, the complications of polypectomy, the size, distribution and histological features of the polyps were similar to large series reported from metropolitan specialist centres of referral both in this country and the USA. However, a smaller proportion of our polyps were over 1 cm diameter. Between 25 and 53 per cent of patients had recurrent or residual polyps on the second and third colonoscopy. Patients with two or more polyps at the first endoscopy were significantly more likely (P < 0·01) to have further polyps at follow-up. We therefore recommend that patients with colonic polyps are colonoscoped annually until free from polyps for 2 years, before being placed on colonoscopic review at 5-year intervals.
Trial of maximal anal dilatation, cryotherapy and elastic band ligation as alternatives to haemorrhoidectomy in the treatment of large prolapsing haemorroids
Authors: Lewis A A M , Rogers H S , Leighton Monica
Published: March 2007

A selected group of 112 patients with prolapsing haemorrhoids which had failed to respond to injections of phenol in oil or which required manual replacement after defecation, were randomly allocated treatment by haemorrhoidectomy, maximal anal dilation, elastic band ligation or cryotherapy. When results were assessed 5 weeks after treatment, haemorrhoidectomy and maximal anal dilatation were equally effective in reducing symptoms, although more physical signs remained after maximal anal dilatation; cryotherapy and elastic band ligation were less effective in both respects. When patients were followed up between 6 months and 5 years haemorrhoidectomy was found to be the most effective method. Patients in the other three groups developed recurrent symptoms requiring haemorrhoidectomy.
Gastric emptying after intestinal resection in Crohn's disease
Authors: Dew M J , Harries A D , Rhodes M , Rhodes J , Leach K G
Published: March 2007

Gastric emptying, using a liquid meal labelled with 99Tcm DTPA was studied in 6 patients with Crohn's disease who had diarrhoea following resection of the small intestine. Results were compared with those obtained in 6 normal subjects and 6 patients who had classic dumping symptoms following gastric surgery. The rate of gastric emptying of patients with Crohn's disease was similar to that of normal subjects, and differed markedly from gastric emptying in patients with the dumping syndrome (P < 0.001). Diarrhoea in patients with Crohn's disease who have undergone intestinal resection is not due to rapid gastric emptying and would therefore be unlikely to respond to therapeutic measures designed to improve similar symptoms in patients who have the dumping syndrome.
Tumoral calcinosis
Authors: Knowles S A S , Declerck G , Anthony P P
Published: March 2007

Tumoral calcinosis is an uncommon, usually solitary, tumour-like mass characterized by soft tissue calcification for no apparent reason. Nearly all cases have occurred in negroes, including 2 previously recorded in this country. We report 7 cases seen over a period of 3 years in English caucasian patients and suggest that the condition is not rare but goes unrecognized under a variety of guises. Three of these 7 patients, 2 of whom were on haemodialysis for renal failure, had isolated hyperphosphataemia, which is the only aetiological factor detected so far. Surgical excision appears to be the only effective treatment.
Surgical manpower, beds and output in the NHS: 1967–1977
Authors: Fowkes F G R , Page S M , Phillips-Miles D
Published: March 2007

The availability and use of surgical manpower and beds and certain measures of surgical workload were examined in the NHS in England and Wales from 1967 to 1977 using routine health statistics. Amongst the surgical specialties, there was no consistent relationship between changes in levels of manpower and beds and operating output. For example, ENT surgery and cardiothoracic surgery had more staff and fewer beds in 1977 than in 1967, but operating output in ENT surgery decreased by 18 per cent and in cardiothoracic surgery increased by 28 per cent. Although the efficiency of bed use may have improved (average length of stay was 10·5 days in 1967 and 8·8 days in 1977), the overall use of available beds in most specialties may have decreased. The number of operations performed in each specialty per consultant surgeon was less in 1977 than 1967 except for traumatic and orthopaedic surgery. Although interpretations of routine health statistics are rarely conclusive, the results of this study suggest the possibility of a less than optimum use in 1977 compared to 1967 of surgical beds and surgeons' operating potential which might be due to lack of other resources such as usable theatre time.
Current concepts in soft connective tissue wound healing
Authors: Forrest L
Published: March 2007

The strength and integrity of intact soft connective tissues are related to the forces which exist between collagen fibrils and these in turn appear to depend on collagen fibril size, density and architecture en masse. The genetic type of collagen, enzymic modifications to the collagen monomer and the proteoglycan environment all affect fibril size. Current evidence suggests that the restoration of tissue continuity and the early redevelopment of tissue strength following wounding are initially achieved by the formation of a myofibroblast–reticulin network which eventually disappears as the healing wound ages. The extent of this network defines the area in which repair tissue will be laid down and the network is equipped with the sensory apparatus to monitor the physical and chemical environment where healing is taking place and thus to direct the various facets of connective tissue synthesis outlined above. The maturation of the scar connective tissue matrix and the development of attachment between new and original connective tissues are simultaneous, related but independent processes. It takes some time before the weld is achieved by the same forces that hold connective tissue fibres together in intact tissues and the myofibroblast–reticulin network is replaced.
Prophylaxis of post-appendicectomy sepsis by metronidazole and ampicillin: A randomized, prospective and double-blind trial
Authors: Lau W Y , Fan S T , Yiu T F , Wong S H
Published: March 2007

Two hundred and eighty-three patients were admitted to a randomized, prospective and double-blind trial of the effect of the addition of ampicillin to metronidazole in the prophylaxis of post-appendicectomy wound sepsis. Nineteen out of 142 patients in the metronidazole and ampicillin group developed wound sepsis compared with 33 out of 141 patients in the metronidazole group. The difference is statistically significant. Early cases, including normal, acutely inflamed and gangrenous appendices, received 2 doses of antibiotics. In late cases with perforation and abscess formation, the antibiotics were continued for 1 week. The difference in wound infection in each of these 2 subgroups was also statistically significant. The commonest organisms isolated from the appendicular fossa and the infected wounds were Escherichia coli and Bacteroides fragilis.
Antiseptics in the treatment of bacterial peritonitis in rats
Authors: McAvinchey D J , McCollum P T , McElearney N G , Mundinger G , Lynch G
Published: March 2007

A controlled mixed peritoneal infection was produced by inoculation of bacteria into the peritoneum and peritonitis was allowed to become established. A laparotomy was performed and peritoneal toilet with a variety of agents was carried out. Local povidone-iodine in the inflamed peritoneum proved to be not only of no benefit but, in fact, to be toxic. In the standard concentrations recommended it proved lethal. Noxythiolin 2·5 per cent also had no beneficial effect. There was a significant difference between the effect of povidone-iodine when instilled into an inflamed peritoneum and instillation into the intact peritoneal cavity. We would advise caution in the use of these antiseptics in any situation in which local defence mechanisms have been compromised as a result of established infection.
The use of graduated compression stockings in the prevention of postoperative deep vein thrombosis
Authors: Allan A , Williams J T , Bolton J P , Le Quesne L P
Published: March 2007

The efficacy of graduated compression stockings in the prevention of postoperative deep vein thrombosis was studied in a randomized, prospective, controlled trial of 200 patients, aged 40 years and over, undergoing abdominal surgery (100 for benign disease, 100 for malignant conditions). Deep vein thrombosis was diagnosed by the 125I-fibrinogen test. The incidence of deep vein thrombosis was 35·9 per cent in the control group (103 patients) and 15·5 per cent in the stockinged group (97 patients) (P < 0·025). In the patients with benign disease, deep vein thrombosis developed in 24·5 per cent of the control limbs and 6·1 per cent of stockinged limbs (P < 0·005); in patients with malignant disease the similar figures were 27·9 and 11·5 per cent (P < 0·05). Increasing age did not alter the efficacy of the stockings. It is concluded that graduated compression stockings provide a safe and effective method of prophylaxis against deep vein thrombosis.
The conservative treatment of fissure-in-ano
Authors: Gough M J , Lewis A
Published: March 2007

A randomized clinical trial assessed the value of regular anal dilatation in combination with a topical local anaesthetic in the treatment of 82 patients with a posterior fissure-in-ano. One month after treatment the fissure had healed in 43·6 per cent of patients using 2 per cent lignocaine gel alone and in 41·9 per cent of patients who also used a St Mark's Hospital anal dilator. Thus the regular use of such a dilator did not contribute to the success of conservative therapy in patients with a posterior anal fissure. A review of patients who presented with anterior or lateral anal fissures during the trial period revealed that healing was achieved in 73·3 per cent of patients without operation within 1 month of diagnosis.
Cicatrial cancer in the South-West of England: A regional plastic surgery unit's experience over a 20-year period
Authors: Nancarrow J D
Published: March 2007

Historical aspects of cicatrial cancer are presented and 18 cases of cicatrial cancer reviewed. The incidence of cicatrial cancer is increasing, paralleling other skin tumours. Survival is better than many series have suggested. Prevention and treatment is discussed in relation to the biological behaviour of scars and their tumours. A high index of suspicion for chronic non-healing lesions in scarred areas will increase survival.
Neurological deficit and injuries involving the neck arteries
Authors: Robbs J V , Human R R , Rajaruthnam P , Duncan H , Vawda I , Baker L W
Published: March 2007

The management of 85 patients with penetrating injuries involving the external (n = 19), internal (n = 6) and common carotid (n = 46), vertebral (n = 10) and brachiocephalic (n = 4) arteries over a 5-year period in one hospital is reviewed. Sixty-three patients had no peroperative neurological deficit; 22 presented with localizing neurological signs. Where there was no deficit, the external carotid (n = 19) and vertebral (n = 10) arteries were ligated without adverse sequelae. Arterial reconstruction was performed of the internal carotid (n = 2), common carotid (n = 25) and brachiocephalic (n = 4) which resulted in a temporary neurological deficit in 7 patients and death in 3. Among the 22 patients with a preoperative neurological deficit, arterial reconstruction was performed in 18, which involved the common carotid in 17 patients and the internal, carotid in 1 patient. There was complete neurological recovery in 11 patients and 2 patients died. Four comatose patients had cerebral revascularization performed without fatality and with complete recovery in 3 of them. CT head scanning was not routinely employed for logistic reasons but has proved of limited value. No intraluminal arterial shunts were used in this series. It would seem that arterial reconstruction is not harmful and may well be beneficial to the young patient with extracranial cerebral arterial injury associated with a neurological deficit. Shunts are probably unnecessary for routine use.
Two methods of skin closure in abdominal operations: A controlled clinical trial
Authors: Pickford I R , Brennan S S , Evans Mary , Pollock A V
Published: March 2007

Operative bacterial contamination of surgical wounds is common. The ability of the host to eradicate these bacteria and prevent subsequent wound infection is affected by a number of factors; one of these has been shown experimentally to be the presence of suture material in the subcutaneous tissues. In a prospective randomized controlled clinical trial in 341 abdominal operations we compared the primary infection rates after two methods of skin closure: either vertical mattress monofilament nylon sutures (182 patients) or steel clips which penetrated only the dermis (159 patients). All patients received a single dose of a cephalosporin intravenously at induction of anaesthesia and neither sutures nor drains were placed in the subcutaneous plane. The overall wound infection rate in the sutured wounds was 17·0 per cent, compared with 6·3 per cent in those closed by clips (χ2 = 9·26, P < 0·01). We conclude that skin closure with clips reduces the incidence of wound infection in patients in whom operative parietal contamination has occurred.
Endogenous prostaglandin F2α in the hyperdynamic state of severe sepsis in man
Authors: Oettinger W K E , Walter G O , Jensen U M , Beyer A , Peskar A
Published: March 2007

Nine surgical patients underwent haemodynamic and respiratory monitoring during the course of severe sepsis. Endogenous PGF2α levels in mixed venous and arterial plasma were measured. Results indicate pulmonary net release of PGF2α, since arterial levels (1252±119pg/ml) are significantly higher than mixed venous ones (824 ± 89 pg/ml) in full-pronounced hyperdynamic septic shock. By contrast, the inactive metabolite KH2PGF2α was found in lowest concentrations during shock (368±72pg/ml) which suggests impaired pulmonary degradation. It is concluded that circulating PGF2α is a marker of stimulated prostaglandin production in severe human sepsis.
Acute emphysematous thyroiditis
Authors: Gigot J F , Mannell Aylwyn
Published: March 2007

Acute emphysematous thyroiditis is a severe pyogenic infection of the thyroid gland characterized by the production of gas. Although earlier writers of the pre-antibiotic era had referred to ‘gangrene of the thyroid with gas formation’ (1–3), only 5 cases of gas-forming or emphysematous thyroiditis have been specifically documented.

In this report, the sixth case of acute emphysematous thyroiditis is presented and the clinical features of this rare but potentially lethal infection of the thyroid gland are described. The pathogenesis and management of the disease are discussed.
A Silastic stent for palliation of extrinsic tracheal compression or unresectable tracheobronchial obstruction
Authors: Westaby S
Published: March 2007

A silicone rubber stent has been used successfully in the treatment of patients with unresectable major airways obstruction. Silicone rubber does not generate secretions in the tracheobronchial tree and may be left in situ for long periods without complications. With effective relief from asphyxia, radiotherapy can be employed safely.
Radical surgery following radiotherapy for advanced parotid carcinoma
Authors: Corcoran M O , Cook H P , Hobsley M
Published: March 2007

We have reviewed the surgical treatment of 12 consecutive patients with advanced carcinoma of the parotid gland at this hospital. Ten patients received immediate preoperative radiotherapy to a mean total dose (TD) of 4000 cGy (rad), range 2600–6500 cGy. Two patients with recurrent carcinoma had previously been treated with local radiotherapy (TD 6500 cGy) at 1 year and 2 years respectively prior to referral. A radical parotidectomy with block dissection of the neck was performed on all 12 patients. After a follow-up period ranging from 6 months to 8 years, 6 patients have remained disease free including 3 patients who have died from unrelated causes within this period. Three patients have developed local recurrent disease (interval 9 months–3 years), 3 further patients with residual microscopic disease have been observed postoperatively (follow-up interval 6 months–2 years) without developing overt local recurrence.
The influence of ultrasonic duplex scanning on the management of carotid artery disease
Authors: Breslau P J , Knox R A , Greep J M , Strandness D E
Published: March 2007

In order to assess the influence of a non-invasive test such as Duplex scanning on the management of patients with suspected carotid artery disease, we reviewed the data on all new referrals (n = 491) during a year. The patients were grouped according to the reason for the referral: 1, patients with focal neurological symptoms lasting less than 24 h (n = 156); 2, patients with focal neurological symptoms lasting longer than 24 h (n = 107); 3, patients with non-focal neurological symptoms (n = 147); 4, patients with asymptomatic bruits (n = 81). For all four groups there was a statistically significant relationship (χ2; P < 0·005) between the reporting of the presence of a high grade stenosis (more than 50 per cent diameter reduction) and the likelihood that the patient would undergo arteriography. The finding of a high grade stenosis on the arteriogram resulted in a greater number of patients undergoing carotid artery surgery. The results of this study indicate that the report of the non-invasive test influenced the decision-making process in the management of patients with suspected carotid artery disease.
Effect of postoperative total parenteral nutrition (TPN) as an adjunct to gastrectomy for advanced gastric carcinoma
Authors: Yamada N , Koyama H , Hioki K , Yamada T , Yamamoto M
Published: March 2007

Clinical staging and immune reactivity were correlated in 39 patients who underwent gastrectomy for primary gastric cancer. Cellular immunity was depressed as the stage of cancer advanced, whereas humoral immunity was unaffected. Gastrectomy for advanced cancer in stage 3 and 4 suppressed cellular immunity.

The cellular and humoral immune systems in relation to total parenteral nutrition (TPN) versus non-TPN were evaluated in 57 patients who underwent gastrectomy for stage 3 and 4 advanced cancer. Cell-mediated immunocompetence was restored in all 29 patients who received postoperative TPN, while serum immunoglobulins were unaffected by TPN. Improvement of impaired cell-mediated immunity was also obtained in patients treated with a TPN–5-FU combination as an adjunct to surgery. Treatment with TPN during 5-FU administration restored immunocompetence, increased tolerance for 5-FU and gave a satisfactory 3-year survival rate. There were significant differences in the 3-year survival rates of patients who underwent non-curative gastrectomy (54 per cent for TPN–5-FU v. 0 per cent for non-TPN–5-FU; P < 0·05).

It is concluded that TPN during chemotherapy as an adjunct to surgery leads to diminished morbidity, and possibly to prolonged survival time, in patients undergoing gastrectomy for gastric cancer. A possible mechanism responsible for the gratifying results of TPN treatment may be the increased tolerance for 5-FU resulting from improved nutrition and increased cell-mediated immunity.
Splenectomy and infection in Hodgkin's disease
Authors: Keel Aileen , Bennett B , Sarkar T K , Forman K M , Dawson Audrey A , Jones P F
Published: March 2007

The incidence of infection in 56 patients with Hodgkin's disease who had undergone staging laparotomy with splenectomy was compared with that of 28 non-splenectomized patients with Hodgkin's disease treated concurrently. The results suggest that splenectomy does not result in a major change in the incidence of infection experienced by such patients with stage II or stage III disease. Aggressive therapy may be of greater importance in increasing the susceptibility to infection in Hodgkin's disease.
The hourly pattern of urine solute and electrolyte excretion following standard surgical trauma
Authors: Kapadia C R , Chan S T F , Johnson A W , Radcliffe A G , Dudley H A F
Published: March 2007

Although urine volume (and, less frequently, concentration) is often measured in the perioperative period, little attempt has been made to separate temporal phases of the intra- and postoperative response to surgery. In 7 patients undergoing standard severe single trauma and managed by a conventional regimen which included intraoperative Hartmann's solution, we have investigated the hourly pattern of urine solute and electrolyte excretion over the first 48 h. Contrary to expectation, in the first 5 h Na+ excretion increases in association with overall solute excretion, and thereafter progressively diminishes. K+ excretion increases 4 h postoperatively and remains elevated for 24 h, after which it returns to normal, even though Na+ excretion remains low. Free water excretion is negative for the first 24 h, though urine osmolality does not suggest a maximal antidiuretic response by the kidney—the highest concentration achieved being just below 800 mosmol/kg. In order to distinguish between the physiological adaptive changes due to starvation and those due to injury, the hourly pattern of urine solute and electrolyte excretion was further investigated in 12 healthy volunteers mimicking postoperative conditions. Apart from the early postoperative period, the hourly pattern of Na+, K+ and osmolar excretion shows no discernible difference from the operated group. These results show that, particularly in relation to Na+, the changes seen in the post-injury patient, even after major uncomplicated surgery, are largely adaptive, and this is especially striking at 24 h after surgery.
Carcinoma of the anus in Crohn's disease
Authors: Preston D M , Fowler E Fiona , Lennard-Jones J E , Hawley P R
Published: March 2007

The incidence of gastrointestinal cancer in patients with Crohn's disease may be slightly increased. We report 2 cases of squamous cell carcinoma of the anus occurring in patients with distal Crohn's disease.
A clinical evaluation of postoperative peritoneal lavage in the treatment of perforated appendicitis
Authors: Udén P , Eskilsson P , Brunes L , Mätzsch T
Published: March 2007

In a comparative investigation, 369 patients operated upon for perforated appendicitis were studied retrospectively. During the period 1973–1979 181 patients with perforated appendicitis, treated at Sundsvall Hospital, were all given postoperative peritoneal lavage, whereas 188 patients with the same diagnosis treated at Skövde Hospital received no such treatment. Appendicectomy was performed in all patients and all were given systemic antibiotic therapy. Complications recorded were postoperative deaths, intra-abdominal abscesses, wound infections, postoperative ileus and lavage catheter complications. Postoperative peritoneal lavage did not diminish the frequency of these postoperative complications.
In situ femoropopliteal and distal vein bypass for limb salvage—experience of 50 cases
Authors: Denton M J , Hill D , Fairgrieve J
Published: March 2007

The aim of this paper is to assess the in situ technique of saphenous vein femoropopliteal (and femorotibial) bypass for limb salvage, and to compare it with the reversed vein method of bypass. In our 3-year study, we have operated on 50 cases resulting in a graft patency and limb salvage rate of 78 per cent at 18 months and 72 per cent overall. There was a 2 per cent perioperative and 10 per cent overall mortality. Graft thrombosis was associated with a variety of factors, mostly notably a small vein (< 4 mm), a low calf vessel anastomosis, wound sepsis and progressive proximal (inflow) disease. However, the strongest correlation was that between graft thrombosis and the extent of distal disease, as 11 of 12 cases with thrombosed grafts had grade 2 or 3 run-off. In our experience the in situ technique offers haemodynamic and technical advantages over the reversed vein method of performing straightforward femoropopliteal bypass. Moreover, the in situ technique has wider application in that it allows a smaller vein (> 2·5 mm) to be used and also makes anastomosis to a small calf vessel easier. In this series, 16 per cent of cases would have been considered unsuitable for the reversed vein method if 4 mm was accepted as the lower limit of size for a reversed vein graft.
Dynamic preoperative assessment of cardiac reserve in elective aortic surgery
Authors: Knight D G , Lane B , McGowan S M , Metcalf M J , Walker M G
Published: March 2007

Myocardial infarction accounts for over 50 per cent of mortality following elective abdominal aortic surgery. Previous history of ischaemic heart disease and abnormal ECGs, common in vascular patients, are unreliable parameters for predicting myocardial response to stress. Exercise ECGs are often valueless, as claudication may mask myocardial insufficiency. Myocardial performance was studied preoperatively in 29 consecutive patients undergoing elective aortic bifurcation grafting, using a Swann-Ganz catheter to measure the rise in pulmonary artery wedge pressure (PAWP) produced by rapid intravenous infusion of plasma (200–400 ml). A Frank-Starling Curve was obtained by plotting LVSWI against PAWP. Two important values were obtained: (a) ‘Upslope’ or gradient of the ascending portion of the curve. Low values identify patients most at risk from cardiac complications. Six patients who suffered from postoperative cardiac complications had a mean ‘upslope’ value of 1·568 ± 0·681 (1 s.e.m.), whereas the 23 who did not, had a mean value of 7·094 ± 0·745 (1 s.e.m.), a significant difference (P < 0·001); (b) ‘PAWPmax’, the ventricular filling pressure above which work output dropped. Infusion beyond this may precipitate pulmonary oedema. PAWP was observed at levels greater than PAWPmax in all 6 patients who developed either pulmonary oedema or myocardial infarction. The myocardial performance curve can reliably identify high risk patients and permit control of intravenous therapy within individual safety limits, thereby preventing pulmonary oedema.
Cranial and cervical nerve damage associated with carotid endarterectomy
Authors: Dehn T C B , Taylor G W
Published: March 2007

Carotid endarterectomy may be complicated by damage to the adjacent cranial and cervical nerves. The true incidence and severity of these complications is rarely reported. In a prospective study of 43 carotid endarterectomies there was a 25 per cent incidence of temporary vocal cord palsy, 5 per cent incidence of hypoglossal nerve damage and anaesthesia of the greater auricular and transverse cervical nerves was found in 60 per cent and 69 per cent of patients respectively 1 week postoperatively. There was some recovery of these nerve injuries over a 6-month period.
Vascular plasminogen activator and deep vein thrombosis
Authors: de Cossart Linda , Marcuson R W
Published: March 2007

In attempts to determine the aetiology of deep vein thrombosis (DVT) it has been established that some patients with a history of lower limb DVT have a low level of vascular plasminogen activator (VPA) in their superficial hand veins and this combined with a poor VPA release is thought to predispose to thrombosis (1). Hand veins rarely develop thrombosis and so the level of VPA has been measured quantitatively in the more commonly at risk veins of the lower limb. In 6 limbs operated on for varicose veins, paired samples of vein from the groin and from the calf were examined. The median activity score for the groin veins (8138 cpm/μg) was significantly higher than the activity in the calf veins (2353 cpm/μg) (P = 0·01). In 9 limbs amputated for critical ischaemia, paired samples of calf long saphenous vein and soleal vein were examined. The VPA in the former was 1675 cpm/μg compared with 6796 cpm/μg in the soleal veins. This difference is significant at the 1 per cent level. A correlation has been shown between the VPA content of these two sets of veins (R = 0·87).

The low level of VPA in the superficial calf veins may be an aetiological factor in superficial thrombophlebitis, but the commonest site for DVT, the soleal veins of the calf, have a high level of VPA.
Adjuvant distal arteriovenous shunt with femorotibial bypass for critical ischaemia
Authors: Harris P L , Campbell H
Published: March 2007

In a series of 59 femorotibial bypass operations for critical ischaemia an arteriovenous (A-V) shunt was constructed at the distal anastomosis in 36 patients whose pedal angiograms showed an occlusion in the primary pedal arch. Mean blood flow recorded in the grafts without the shunt in the patients whose primary pedal arch was occluded was 83·6 ± 9·9 ml/min (mean ± s.e.m.) compared with 152·16·2 ml/min in those patients whose primary pedal arch was intact (P<0·01). This increased to 236 ± 20·5 ml/min with the shunt open (P<0·001). Twelve months after operation the cumulative patency rate for grafts with an A-V shunt was 46·5 per cent compared with 40·5 per cent for grafts in the better risk patients with a patent primary pedal arch who did not receive a shunt. No side effects were observed due to the presence of a shunt. The importance of the primary pedal arch and the rationale of adjuvant distal arteriovenous shunt are discussed. The results indicate that the addition of an arteriovenous shunt at the distal anastomosis of a long femorotibial bypass is of benefit when blood flow through the graft is limited by occlusive disease in the pedal arteries.
The role of pancreatico-biliary secretions in intestinal adaptation after resection, and its relationship to plasma enteroglucagon
Authors: Al-Mukhtar M Y T , Sagor G R , Ghatei M A , Bloom S R , Wright N A
Published: March 2007

Two groups, each containing 16 male Wistar rats, had either 75 per cent small bowel resection or jejunal transection; 8 animals from each group had previously been subjected to pancreatico-biliary diversion. All animals were killed 12 days after the operation, plasma enteroglucagon levels were measured and crypt cell production rate (CCPR) at different sites of the remaining small intestine was measured using a metaphase arrest technique with vincristine. In each of the resected groups there was a significant increase in the CCPR and enteroglucagon levels compared with the transected groups. Furthermore it was found that the CCPR and enteroglucagon levels were higher in the resected group without the pancreatico-biliary diversion compared with the resected group with the diversion. This study, although it confirms the importance of pancreatico-biliary secretions in intestinal adaptation, could also indicate that a humoral factor may be important in the control of intestinal cell proliferation. Our findings do not exclude the possibility that enteroglucagon could be a candidate for such a role.
The role of mammography in the evaluation of advanced breast cancer treated by initial endocrine therapy
Authors: Sauven P , Grant R , Burn I
Published: March 2007

Fifty-five patients with locally advanced breast cancer treated with initial endocrine therapy have been followed up for periods of between 6 and 64 months (median 17 months) with regular clinical and radiological examination. The aim of the study was to evaluate the role of mammography in initial assessment, and subsequent follow-up. Fifty patients were available for evaluation and were classified by clinical, and by mammographic data independently. The clinical assessment, using UICC criteria of response, estimated 36 patients (72 per cent) as responders (complete response, partial response and no change). Mammographic assessment of response, using 8 radiological features of malignancy, agreed with the clinical estimate in 48 per cent of cases and 32 patients (64 per cent) were assessed as responders. Where clinical and mammographic assessment differed, it was usually due either to a smaller radiological reduction in tumour size, or mammography demonstrating features of progressive disease not observed clinically. Two other mammographic features studied were of prognostic significance. In 70 per cent of the responders in which microcalcifications were present, they became reduced in number but increased in size, a change not seen in non-responders. A curvilinear band, or ‘rainbow sign’, is described which is an early sign of localized skin infiltration and was associated with a poor prognosis.
Peritoneovenous shunts in the management of malignant ascites
Authors: Souter R G , Tarin D , Kettlewell M G W
Published: March 2007

Peritoneovenous shunts have been inserted into 26 patients to control malignant ascites. All benefitted and most required no further paracentesis until death from progressive malignancy. Shunt blockage, which is the major problem at present, occurred in 8 patients. Five patients suffering from far advanced malignancy died within a month of operation. There was no clinical evidence of enhanced tumour spread or disseminated intravascular coagulation. We do not consider that the procedure is the first line of management, neither has it much to offer the patient with viscous, bloodstained or loculated ascites. We suggest criteria which help to identify the patient most likely to benefit from a peritoneovenous shunt.
A comparison of highly selective vagotomy with truncal vagotomy and pyloroplasty—one surgeon's results after 5 years
Authors: Fraser A G , Brunt P W , Matheson N A
Published: March 2007

In a prospective randomized trial highly selective vagotomy (HSV) was compared with truncal vagotomy and pyloroplasty (TVP). One surgeon performed all the operations. Ninety-eight per cent of patients were reviewed by two physicians after 20–97 mth (mean 61 mth). Fifty-nine of 68 patients (87 per cent) had an excellent or very good result after HSV (Visick grades I and II) compared with 48 of 69 (70 per cent) after TVP (P < 0·05). There was 1 proven recurrence after HSV and 4 after TVP. Diarrhoea, including mild symptoms, occurred in 5 patients (7 per cent) after HSV and in 27 (39 per cent) after TVP (P < 0·001). Severe diarrhoea did not occur after HSV but was present in 4 patients (6 per cent) after TVP (P < 0·001). Flatulence, epigastric fullness and weight loss were also significantly more common after TVP. On average HSV took 72 min to perform compared with 44 min for TVP (P < 0·001). Transient dysphagia occurred in 19 patients after HSV compared with 8 after TVP (P < 0·05). HSV gave better results than TVP and was associated with a low recurrence rate (1·5 per cent at a mean of 5 yr). Although technically more demanding, HSV in our hands is a better operation than TVP for uncomplicated duodenal ulcer.
Infiltrating lobular carcinoma of the breast: An evaluation of the incidence and consequence of bilateral disease
Authors: Dixon J M , Anderson T J , Page D L , Lee D , Duffy S W , Stewart H J
Published: March 2007

A histological review of 1003 invasive breast carcinomas identified 103 patients with infiltrating lobular carcinoma, for whom clinical and survival data were collected in each case. Six patients had bilateral carcinoma at diagnosis and 14 developed a contralateral carcinoma during the period of follow-up. The major factor predicting patients at risk of developing a contralateral carcinoma was histological type. Analysis of survival data on the patients with bilateral disease showed poor survival in the group with synchronous bilateral disease, but no difference in survival between patients with metachronous bilateral and unilateral disease. This suggests that the development of a metachronous contralateral carcinoma does not necessarily reduce the probability of survival of patients with infiltrating lobular carcinoma.
The influence of disease at the margin of resection on the outcome of Crohn's disease
Authors: Heuman R , Boeryd B , Bolin T , Sjödahl R
Published: March 2007

Sixty-seven patients with Crohn's disease undergoing 81 resections followed by a restorative procedure were reviewed to evaluate the influence of microscopic disease at the margin of resection on the recurrence rate. The average follow-up after resection was 5·6 + 2·8 years. The resectional margins were classified into three groups depending on the microscopic appearance of the most involved margin. Recurrent disease developed in 36 per cent of the resections without microscopic evidence of Crohn's disease, while 38 per cent of the resections with signs of Crohn's disease developed a clinical recurrence. The recurrence rate increased with the follow-up time, but was independent of microscopical disease at the resectional margins. Therefore we recommend restricted resection of macroscopically diseased bowel. Microscopical involvement does not seem to increase the recurrence rate.
Rectosacral suture fixation for complete rectal prolapse in the elderly, the frail and the demented
Authors: Carter A E
Published: March 2007

A simple method of fixing the mobilized rectum to the sacrum by sutures is described to treat complete rectal prolapse. Its use over 12 years in 32 patients (29 women and 3 men), 17 with various forms of dementia, is reported with one recurrence for which a repeat identical procedure was successful.