bluuebunny/crossref_metadata_2025 huggingface dataset:
Tumour S-phase activity, nucleotide profile and RNA levels after hepatic artery occlusion and reperfusion in an experimental model of secondary liver carcinoma
Authors: Wang L Q , Roos G , Andersson B , Renfjärd E , Persson B , Stenram U
Published: March 2007

Rats with carcinoma of the colon implanted into the liver were subjected to hepatic arterial occlusion for 30–120 min. Regrowth of the tumour after reperfusion was evaluated by immunohistological determination of S-phase activity after injection of bromodeoxyuridine. Levels of RNA and nucleotides, and energy charge, were also examined. DNA synthesis was observed in the entire tumour except in necrotic areas of controls and after 30-min ischaemia with 2-h reflow. Almost all tumoral DNA synthesis was abolished by 2 h of ischaemia, except in a few cells in the tumour periphery, which after reperfusion for 22 and 40 h grew into a band-like concentric layer. Levels of energy charge, adenosine, uridine and guanosine 5′-triphosphates, and RNA were unchanged in liver tissue after hepatic arterial occlusion but decreased in the tumour. In conclusion 30 min of ischaemia did not damage the tumour cells substantially. Ischaemia for 2 h seemed able to kill the tumour cells except those in the periphery in areas nourished by the portal vein where tumour regrowth was seen. The liver tissue was not damaged.
Haemodynamic effects of pneumoperitoneum during laparoscopic cholecystectomy: A prospective comparative study using bioimpedance cardiography
Authors: Köksoy C , Kuzu M A , Kurt I , Kurt N , Yerdel M A , Tezcan Ç , Aras N
Published: March 2007

The haemodynamic effects of increased intra-abdominal pressure during laparoscopic cholecystectomy in 22 patients were compared with those in 11 patients undergoing open cholecystectomy; bioimpedance cardiography was used for monitoring at predetermined time intervals. In the laparoscopy group stroke volume, cardiac and ejection velocity indices were significantly decreased and the total peripheral resistance index was significantly increased during the insufflation period when compared with preinsufflation and corresponding values in the group undergoing open operation. Routine intraoperative parameters such as heart rate and blood pressure did not show any significant change or indicate alterations in cardiovascular performance during laparoscopic procedures. Continuous non-invasive cardiovascular monitoring by bioimpedance cardiography may be useful in patients with limited cardiac function.
Giant diverticulum of the sigmoid colon
Authors: Naber A , Sliutz A-M , Freitas H
Published: March 2007

Giant diverticulum is a rare entity and few cases have so far been reported. It is nearly always associated with diverticular disease. There are some theories about the formation of a giant diverticulum but none is conclusive. Associated symptoms are similar to those of diverticular disease but, as with the patient reported here, the lesion may sometimes be asymptomatic. Diagnosis is easy with radiological help.
Operative procedures in patients subsequently found to be human immunodeficiency virus positive
Authors: Whitfield G , Stotter A , Graham R M , Wiselka M J
Published: March 2007

This study investigated the number and range of surgical procedures performed in patients subsequently found to be human immunodeficiency virus (HIV) positive. Procedures were included if they occurred during a period when the patients were likely to have been infected with HIV but unaware of their HIV status. A total of 28 operative procedures were documented in 19 (22 per cent) of 86 patients. Several operations were major and invasive. All patients had recognized risk factors for HIV infection but these had not been elicited in the surgical records. Women and patients who acquired their disease through heterosexual intercourse were more likely to have undergone surgery before a diagnosis of HIV than homosexual men. The incidence of surgical procedures in patients with HIV infection was significantly greater than in the general population of Leicestershire; however, many of these were minor and related to the management of complications associated with HIV. Surgeons are performing operations on patients who are unknowingly infected with HIV. The risk of transmission of HIV to surgeons is remote, but surgeons must be aware of risk factors for HIV infection.
Surgical management of regional lymph nodes in primary cutaneous malignant melanoma
Authors: Stone C A , Goodacre T E E
Published: March 2007

The management of regional lymph nodes in the patient with primary cutaneous malignant melanoma remains a contentious issue. Early removal of nodes, which may harbour occult microscopic disease before the development of clinically detectable malignant lymphadenopathy, is thought by some to confer a survival advantage and/or improve locoregional tumour control. While tumour burden at lymphadenectomy has been shown to correlate with prognosis, there are conflicting reports regarding the efficacy of elective lymph node dissection (ELND) compared with a regimen of delayed therapeutic dissection for clinically detectable nodal involvement. Evaluation of arguments for and against ELND, together with consideration of surgical morbidity and the predictability of lymphatic drainage patterns, has allowed a clinical algorithm to emerge which may identify patients who may benefit from prophylactic surgery. A chronological summary of the relevant studies is presented and the overall division of opinion regarding the efficacy of ELND is discussed.
Total mesorectal excision and local recurrence: A study of tumour spread in the mesorectum distal to rectal cancer
Authors: Scott N , Jackson P , Al-Jaberi T , Dixon M F , Quirke P , Finan P J
Published: March 2007

Total mesorectal excision (TME) appears to be associated with a reduced local recurrence rate following surgery for rectal cancer. Of 20 patients with rectal cancer in whom TME was performed, adenocarcinoma was found in the distal mesorectum in four. Distal mesorectal spread often extended further than intramural spread. Patients with tumour in the distal mesorectum had a worse outcome at 4-year follow-up, a greater risk of local recurrence and an increased frequency of distant metastasis. Distal tumour spread is, therefore, a marker of poor prognosis in rectal cancer. This study provides further evidence that incomplete excision of the mesorectum contributes to local recurrence in a proportion of patients with rectal cancer, particularly in those with tumours in the middle and lower third of the rectum.
Efficacy of tumoricidal agents in vitro and in vivo
Authors: Docherty J G , McGregor J R , Purdie C A , Galloway D J , O'Dwyer P J
Published: March 2007

Implantation of exfoliated tumour cells can give rise to local recurrence of colorectal cancer and it has been recommended that the bowel lumen be lavaged with a tumoricidal agent. This study identified which tumoricidal agents are currently used in Scotland and investigated their efficacy in vitro and in vivo. Cytotoxic efficacy was tested in vitro by a clonogenic assay and in vivo by a rat model with viable intraluminal tumour cells. Overall 70 per cent of surgeons used a tumoricidal agent during colorectal cancer surgery. Povidone-iodine, sodium hypochlorite and chlorhexidine-cetrimide were all effective at killing tumour cells in vitro but were all inactivated by the presence of 25 per cent whole blood in vitro. With 105 cells in vivo povidone-iodine and sodium hypochlorite significantly (P < 0·02) reduced the incidence of tumour growth while chlorhexidine-cetrimide had no significant effect. With 106 cells povidone-iodine had no effect on the incidence of tumour growth. Tumoricidal agents have effective cytotoxicity in vitro but are only weakly cytotoxic in vivo.
Total thyroidectomy in the treatment of thyroid carcinoma in childhood
Authors: Stael A P M , Plukker J Th M , Piers D A , Rouwé C W , Vermey A
Published: March 2007

Between 1974 and 1993 ten girls and six boys aged 6–16 years underwent total thyroidectomy, with therapeutic selective neck dissection in six patients. All were treated after operation with radioactive iodine (131I) for ablation of thyroid tissue remnants. Papillary carcinoma occurred in ten patients, follicular carcinoma in two and medullary thyroid lesions in four. The patients were followed for a median of 11·5 (range 1–20) years with regular determinations of serum thyroglobulin levels and 131I whole-body scanning when indicated. Only one patient had a slight increase in thyroglobulin levels without evidence of disease on further screening. In children with medullary lesions the serum levels of basal and pentagastrin-stimulated calcitonin remained normal. Currently all patients are alive and without disease. Hypocalcaemia lasting for more than 1 year was observed in one patient. Recurrent nerves were not injured accidentally, but because of tumour invasion two of 32 recurrent nerves had to be sacrificed. This surgical approach is safe and well tolerated in children.
Liver resection without blood transfusion
Authors: Gozzetti G , Mazziotti A , Grazi G L , Jovine E , Gallucci A , Gruttadauria S , Frena A , Morganti M , Ercolani G , Masetti M , Pierangeli F
Published: March 2007

A retrospective study was carried out of 522 elective liver resections to determine the impact of blood transfusion on the immediate postoperative outcome and on long-term survival. The number of liver resections without transfusion has increased in recent years, as a result of improvement in surgical technique with less blood loss during operation and more careful choice of the timing of transfusion. In resections carried out in the past 5 years, the indication for intraoperative transfusion was restricted and the decision was made jointly by the surgeon and anaesthetist, and in any case only if the haematocrit was below 25 per cent. Of resections carried out in the past 2 years, 59 per cent did not require intraoperative transfusion. Postoperative deaths and complications were related to blood transfusion, particularly in patients with cirrhosis, in whom stepwise logistic regression analysis showed that transfusion was the only factor that correlated significantly with complications. Transfusion also affected the long-term survival of patients operated on for hepatocellular carcinoma and colorectal carcinoma metastases in univariate analysis and was the only factor shown by multivariate analysis to correlate with survival for hepatocellular carcinoma in patients with cirrhosis.
Role of nitric oxide in lung injury associated with experimental acute pancreatitis
Authors: O'Donovan D A , Kelly C J , Abdih H , Bouchier-Hayes D , Watson R W G , Redmond H P , Burke P E , Bouchier-Hayes D A
Published: March 2007

This study evaluated the effect of varying the synthesis of nitric oxide with sodium nitroprusside or N-nitro-L-arginine methyl ester (L-NAME) in a pancreatitis-lung injury model. Rats (n = 45) were randomized to control or caerulein-induced pancreatitis groups, treated with saline, sodium nitroprusside (0·4 μg/kg) or l-NAME (10 mg/kg). Myeloperoxidase activity was used as a measure of neutrophil infiltration. Wet to dry (W:D) lung weight and bronchoalveolar lavage (BAL) protein concentrations were used to assess vascular leakage. Pancreatitis was shown to induce pulmonary neutrophil influx: mean(s.e.m.) myeloperoxidase activity 6·79(0·5) units/g in caerulein-treated animals versus 2·08(0·5) units/g in controls (P < 0·001). Animals with pancreatitis showed increased microvascular leakage compared with controls (mean(s.e.m.) W:D lung weight 7·01(0·5) versus 2·85(0·2), P < 0·001; BAL protein concentration 2539(222) versus 347(32) μg/ml, P < 0·001). Compared with the saline-treated pancreatitis group, these changes were reduced by sodium nitroprusside (mean(s.e.m.) myeloperoxidase activity to 2·5(0·4) units/g, P < 0·001; W:D lung weight to 3·8(0·37), P < 0·001; BAL protein concentration 1389(182) μg/ml, P < 0·05). L-NAME exacerbated the pancreatitis-induced pulmonary oedema (W:D lung weight increased to 11·96(0·6), P < 0·001), protein leakage (BAL protein concentration rose to 3707(309) μg/ml, P < 0·05) and neutrophil infiltration (myeloperoxidase activity increased to 9·01(0·3) units/g, P < 0·05). These data suggest that, in vivo, nitric oxide inhibits pancreatitis-induced lung injury, possibly in part by inhibiting pulmonary neutrophil influx.
Further experience with laparoscopy and peritoneal cytology in the staging of pancreatic cancer
Authors: Castillo C Fernández-Del , Rattner D W , Warshaw A L
Published: March 2007

A total of 114 patients with pancreatic cancer and no evidence of metastatic disease by computed tomography underwent laparoscopy. Intra-abdominal spread was present in 27 patients (24 per cent). Metastases were 2·4 times more common in tumours of the distal pancreas (11 of 25, 44 per cent) than in pancreatic head tumours (16 of 89, 18 per cent) (P < 0·05). None of the 27 patients with metastases underwent further surgery. Of the 87 patients without metastatic spread, 42 were found to have vascular invasion by angiography and were offered radiation therapy. Thirty of 40 patients explored surgically were resected; two of the remaining ten had peritoneal spread that had been missed at laparoscopy (false-negative rate of 7 per cent). Cytological examination of peritoneal washings was performed in 94 patients at the time of laparoscopy; cytology was positive in 16 (17 per cent). There was a significant correlation between positive cytology and presence of visible liver or peritoneal metastases (ten of 22 with metastases versus six of 72 without, P < 0·001). Positive cytology was present in six patients (8 per cent) without visible metastases, but none had resectable disease.
Transjugular intrahepatic portasystemic stent—shunt in the treatment of variceal haemorrhage
Authors: Jalan R , Redhead D N , Hayes P C
Published: March 2007

The transjugular intrahepatic portasystemic stent-shunt (TIPSS) is a side-to-side portocaval shunt, performed by interventional radiological methods, linking the hepatic and portal veins through the liver parenchyma with an expandable metal stent. The technique can be performed successfully in over 90 per cent of patients. The procedure-related mortality rate is about 1 per cent, mainly from intraperitoneal bleeding. The main indications for TIPSS insertion are control of acute variceal bleeding in patients with cirrhosis that is refractory to sclerotherapy and recurrent variceal haemorrhage despite sclerotherapy or band ligation. TIPSS insertion is followed by variceal rebleeding in about 10–20 per cent of cases, encephalopathy in 10–20 per cent, transient deterioration of liver function in 25–35 per cent and subsequent shunt dysfunction over a 6–12-month period in 15–60 per cent. The final place of TIPSS insertion in the management of portal hypertension is being evaluated in controlled studies, but its use in the treatment of uncontrolled variceal haemorrhage seems assured.
Cardiac ischaemia induces vagally mediated lower oesophageal sphincter relaxation
Authors: Caldwell M T P , Byrne P J , Marks P , Walsh T N , Hennessy T P J
Published: March 2007

Gastro-oesophageal reflux and coronary artery disease frequently coexist. Direct stimulation of myocardial vagal receptors impairs lower oesophageal sphincter (LOS) function but the effect of cardiac ischaemia has not been examined. Eight adult mongrel dogs were studied under general anaesthesia. Each underwent occlusion of the left circumflex coronary artery before and after bilateral cervical vagotomy. Blood pressure, heart rate and LOS responses were measured. Median (range) LOS tone was significantly reduced by coronary artery occlusion, from 9 (6–14) to 6 (3–8) sphinctometer units (P < 0.01). This was accompanied by a reduction in heart rate (P < 0.05) and blood pressure (P < 0.01). After bilateral cervical vagotomy the same ischaemic insult produced no significant alteration in LOS tone or heart rate. These data suggest a direct vagal reflex to explain the high incidence of gastro-oesophageal reflux in patients with coronary artery disease.
Observer variation in assessment of quality of life in patients with oesophageal cancer
Authors: Blazeby J M , Williams M H , Alderson D , Farndon J R
Published: March 2007

Quality of life (QOL) assessment may improve the evaluation of treatment for oesophageal cancer but patient compliance using self completion questionnaires is often poor. The use of a proxy to estimate QOL might improve data collection from patients who are either unable or unwilling to complete the questionnaire. This study examined whether a doctor or patients' carers could accurately assess QOL using the QLQ-C30 questionnaire developed by the European Organisation for Research and Treatment of Cancer Study Group on Quality of Life. One doctor, 52 patients and 39 carers completed the instrument independently. Proxy and patient ratings were analysed for agreement using weighted k scores. Agreement was poor or moderate in most QOL scales and items (κ ≤60). This study demonstrates that a carer or doctor is not sufficiently accurate to postulate the patient's responses to the questionnaire. Quality of life data, therefore, should come from the patients themselves.
Abdominoperineal resection and anterior resection in the treatment of rectal cancer: Results in relation to adjuvant preoperative radiotherapy
Authors: Holm T , Rutqvist L-E , Johansson H , Cedermark B
Published: March 2007

The outcome of patients with rectal cancer treated by abdominoperineal or anterior resection, with or without preoperative radiotherapy, was assessed to detect any differences attributable to the operative method and interactions between radiotherapy and type of surgery. The study was based on 1292 patients included in two consecutive controlled randomized trials of preoperative radiotherapy in operable rectal carcinoma. The outcome was not related to surgical method. Radiotherapy increased postoperative mortality and complications and reduced local and distant recurrence, but had no effect on overall survival. Effects of radiotherapy were similar irrespective of the type of surgery, except that the increase in postoperative mortality in irradiated patients was greater in those treated with abdominoperineal resection. Sphincter-saving procedures appear to have no adverse effects on outcome of rectal cancer, but the optimum use of radiotherapy is still to be defined.
Postocclusive hyperaemic duplex scan: A new method of aortoiliac assessment
Authors: Currie I C , Wilson Y G , Baird R N , Lamont P M
Published: March 2007

Aortoiliac duplex scanning, while accurate, is time-consuming and technically demanding. This study aimed to develop a fast, non-invasive screening test for aortoiliac disease. Colour duplex scanning was used to record common femoral Doppler ultrasonographic waveforms following 3 min of arterial occlusion using a thigh cuff in 25 patients with normal aortoiliac segments and 25 patients with significant aortoiliac disease. The latter patients had a prolonged period of postocclusive hyperaemic flow compared with the former. End diastolic velocity, 70 s after cuff release, was a significant discriminant between the two groups (sensitivity of 88 per cent, accuracy of 92 per cent). The postocclusive hyperaemic duplex (PHD) test performed well when used prospectively in a further 50 limbs (sensitivity of 86 per cent, accuracy of 84 per cent). The test was more sensitive than femoral pulse palpation and compared favourably with arteriography. The PHD test provides a simple, non-invasive assessment for aortoiliac disease that can be performed on the initial outpatient clinic visit.
Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas
Authors: Madiba T E , Mokoena T R
Published: March 2007

The records of 152 patients with pancreatic injury treated over a 5-year period were reviewed. The diagnosis was made at laparotomy in all patients. Gunshot wounds, stab wounds and blunt trauma occurred in 63, 66 and 23 patients respectively with mean ages of 28, 28 and 30 years. Multiple organ injury was most common after gunshot wounds. Intraoperative management was by drainage of the pancreatic injury site alone in the majority of patients in all aetiological groups. The rate of fistula formation was 14 per cent after gunshot wounds, 9 per cent after stab injury and 13 per cent after blunt trauma. Death occurred after 24 h in 8, 2 and 10 per cent of patients following gunshot wounds, stab wounds and blunt trauma respectively, and was attributable to other organ damage. It is concluded that gunshot injury to the pancreas may be more extensive than other injuries, but conservative management with surgical drainage of pancreatic injury is justified irrespective of the mechanism of injury.
Distal pancreatectomy for gunshot injuries of the distal pancreas
Authors: Degiannis E , Levy R D , Potokar T , Lennox H , Rowse A , Saadia R
Published: March 2007

This study comprised 57 patients with gunshot injury of the distal pancreas. There were 16 grade II, 29 grade III and 12 grade IV pancreatic injuries. The intraoperative mortality rate was 12 per cent. Patients with the most severe grade II injuries and all those with grade III and IV injuries had distal pancreatectomy and splenectomy, with a 14 per cent fistula formation rate and 2.3 per cent postoperative mortality rate directly related to the pancreatic injury. The remaining patients with grade II injuries were managed by debridement and drainage; there were no fistulas or deaths. The method of closure of the pancreatic resection margin is unrelated to fistula formation, and identification of the duct for ligation is unnecessary. Liberal use of distal pancreatectomy with splenectomy for gunshot injuries of the distal pancreas is suggested.
Incidence and management of laser-associated oesophageal perforation
Authors: Tyrrell M R , Trotter G A , Adam A , Mason R C
Published: March 2007

The incidence of oesophageal perforation in 350 patients referred for laser treatment to palliate malignant dysphagia is reported. Perforation occurred in 6 per cent of patients or 2 per cent of treatment episodes. Perforation was usually due to oesophageal dilatation undertaken before laser treatment (23 of 25 perforations). Immediate recognition and the institution of an aggressive non-operative management protocol resulted in survival in 20 of 23 patients.
Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis
Authors: Friess H , Beger H G , Sulkowski U , Becker H , Hofbauer B , Dennler H-J , Büchler M W
Published: March 2007

A randomized double-blind placebo-controlled multicentre trial was carried out in 247 patients undergoing major elective surgery for chronic pancreatitis to clarify whether the perioperative application of octreotide prevents postoperative complications. Eleven complications were defined, including death, anastomotic leakage, pancreatic fistula, abscess, fluid collection, shock, sepsis, bleeding, pulmonary insufficiency, renal insufficiency and postoperative pancreatitis. A total of 124 patients underwent pancreatic head resection, 55 left resection, 61 pancreaticojejunostomy and seven had other procedures. The overall mortality rate was 1.2 per cent (octreotide group 0.8 per cent, placebo group 0.4 per cent (P not significant)). The postoperative complication rate in the octreotide group was 16.4 per cent (20 of 122 patients) and in the placebo group 29.6 per cent (37 of 125) (P < 0.007). The perioperative application of octreotide substantially reduces the risk of postoperative complications in patients undergoing major pancreatic surgery for chronic pancreatitis.
Polyposis: The Peutz-Jeghers syndrome
Authors: Spigelman A D , Arese P , Phillips R K S
Published: March 2007

The classical pigmentation of Peutz-Jeghers syndrome distinguishes it immediately from the other polyposis syndromes. Less widely appreciated than this most obvious manifestation are the pitfalls in management presented by the risk of cancer and by the performance of multiple laparotomies that also characterize this condition. An outline of these risks and an approach that minimizes them is presented.
Continent colonic conduit for the treatment of faecal incontinence associated with disordered evacuation
Authors: Hughes S F , Williams N S
Published: March 2007

A transverse colonic conduit incorporating an intussusception valve and skin-flapped cutaneous aperture was constructed in nine patients with combined faecal incontinence and disordered evacuation. Intestinal continuity was restored with a colocolonic anastomosis. Median follow-up was 4 (range 2–15) months and daily irrigation with a median of 1·2 (range 0·3-2·0) litres of water resulted in evacuation in less than 1 h. At 1 month after operation there was no leakage of solid or liquid faeces from the anus between irrigations. The valve was continent to faeces and irrigation fluid, and no stoma appliances were required.
Defunctioning colostomy for low anterior resection: A selective approach
Authors: Grabham J A , Moran B J , Lane R H S
Published: March 2007

Seventy-seven consecutive low anterior resections of the rectum were performed with a selective approach to the use of a defunctioning colostomy. A defunctioning colostomy was performed in seven patients (9 per cent) where there was concern about the anastomosis due to difficult dissection (three), incomplete doughnuts (three) and tension on the anastomosis (one). The mean level of the tumour in the defunctioned group was 7±6 cm. Clinical anastomotic leakage occurred in two patients (3 per cent) in the non-defunctioned group, both of which were controlled with subsequent transverse colostomies. There were no perioperative deaths. Selective defunctioning of low colorectal anastomoses can produce low rates of anastomotic dehiscence while reducing the morbidity associated with a temporary stoma.
Detection of circulating tumour cells with the magnetic activated cell sorter
Authors: Wong L S , Bateman W J , Morris A G , Fraser I A
Published: March 2007

A technique has been developed for the detection of tumour cells in blood with the magnetic activated cell sorter (MACS). Colonic carcinoma cell lines and disaggregated primary tumours were used to establish optimal conditions of separation. A murine monoclonal antibody specific for epithelial cells was added to the suspension of leucocytes and tumour cells, followed by magnetic labelled goat antimouse antibody. The labelled tumour cells were retrieved by passing this suspension through a MACS separation column in a strong magnetic field. Tumour cells were detected at a dilution of 10 cells per ml blood. Tumour cells were identified in mesenteric blood in three of 24 patients undergoing surgery for colorectal cancer. This study supports the use of the MACS to detect circulating tumour cells.
Lateral subcutaneous sphincterotomy for treatment of anal fissure in children
Authors: Cohen A , Dehn T C B
Published: March 2007

Twenty-three children, aged between 8 and 168 months, underwent lateral subcutaneous sphincterotomy. All fissures healed by 8 weeks after operation. Two children had recurrent proctalgia and defaecating difficulties after surgery despite a healed fissure. Requirement for stool softener was reduced or abolished in 17 children. The parent-child satisfaction score after operation was more than 70 per cent in 19 of 23 cases. Lateral subcutaneous sphincterotomy is an effective procedure in children.
Single-centre prospective study of isolated limb perfusion with melphalan in the treatment of subungual malignant melanoma
Authors: Lingam M K , McKay A J , Mackie R M , Aitchison T
Published: March 2007

Subungual melanoma is rare and experience in treating this condition with isolated limb perfusion is limited. Between 1985 and 1990, 24 patients were treated by digital amputation and isolated limb perfusion with melphalan and mild hyperthermia. The disease was staged according to the M.D. Anderson classification: stage I (17 patients), stage IIIA (one), stage IIIB (two) and stage IIIAB (four). Thirteen lesions were on the foot and 11 on the hand. Seven patients have developed locoregional recurrence. The estimated overall 2- and 5-year probabilities of survival were 77 and 46 per cent respectively, while for disease-free survival the rates were 58 and 51 per cent. When these results were compared retrospectively with those in 111 patients treated by amputation alone, no significant difference in survival was demonstrated. This experience suggests that isolated limb perfusion with melphalan and mild hyperthermia confers no additional survival benefit over appropriate surgery.
Presentation of endometriosis to general surgeons: A 10-year experience
Authors: Singh K K , Lessells A M , Adam D J , Jordan C , Miles W F A , MacIntyre I M C , Greig J D
Published: March 2007

The presentation and management of 24 patients with endometriosis (median age 34 (range 21–68) years) presenting to general surgeons over a period of 10 years (1985–1994) was reviewed. Patients presented with an abdominal wall swelling related to a previous Pfannenstiel incision (seven patients), umbilical swelling (four), inguinal canal swelling (two), incidentally following appendicectomy (five), terminal ileal obstruction (two), rectal bleeding (two) and urinary symptoms (two). Endometriosis was not suspected in most patients but was confirmed by surgical excision or resection with minimal morbidity. No recurrence occurred during a median follow-up of 53 (range 9–113) months. Endometriosis is a disease rarely seen by general surgeons and is often diagnosed incidentally or on histological examination. Cyclical symptoms associated with menstruation are present in 50 per cent of patients and should suggest the diagnosis in those presenting with scar-related and/or subcutaneous swellings. Simple excision or resection of the presenting lesion provides adequate treatment but, since pelvic endometriosis may be present, referral to a gynaecologist is recommended in every case.
Lobular carcinoma of the breast can be managed by breast-conserving therapy
Authors: Holland P A , Shah A , Howell A , Baildam A D , Bundred N J
Published: March 2007

There has been a reluctance to treat patients with invasive lobular carcinoma by breast-conserving therapy because of the possibility of increased rates of local recurrence. This study is a retrospective review of 226 patients with pure invasive lobular carcinoma 4 cm or less treated by breast conservation therapy or mastectomy. Local relapse occurred in four of 52 patients (8 per cent) after breast conservation compared with 21 of 174 (12 per cent) after mastectomy. Breast conservation for invasive lobular carcinoma did not result in a higher incidence of local relapse and patients with invasive lobular and ducta carcinomas may be managed in a similar fashion.
Prospective evaluation of ultrasonography and liver function tests for preoperative assessment of the bile duct
Authors: Welbourn C R B , Haworth J M , Leaper D J , Thompson M H
Published: March 2007

Current means of predicting the presence of bile duct stones are sensitive but produce a large number of false-positive results, potentially leading to added morbidity from unnecessary invasive investigation. This study prospectively assessed 545 patients with gallbladder stones, including 55 patients with bile duct stones, to refine criteria for further investigation of the bile duct. The sensitivity, specificity, and positive and negative predictive values were calculated for bile duct dilatation (diameter abnormal if larger than 5 mm below age 50 years, normal value increasing by 1 mm per decade) and elevation of three liver function tests, singly or in combination. Depending on the number of abnormalities used the sensitivity ranged from 46 to 96 per cent and the positive predictive value from 35 to 77 per cent. All groupings gave at least 96 per cent negative predictive value for the absence of stones but none combined both high sensitivity and positive predictive value. The specificity was improved if the tests were done on the working day before operation. Refining criteria for predicting bile duct stones allows the selective use of cholangiography and may reduce the number of negative cholangiograms.
Laparoscopic ‘bikini mesh’ repair of bilateral inguinal hernia
Authors: Deans G T , Wilson M S , Royston C M S , Brough W A
Published: March 2007

Laparoscopic hernia repair using a single piece of mesh was performed in 150 patients with bilateral inguinal hernia. The median operating time was 43 (range 30–90) min with a median hospital stay of 1 (range 1–10) days. In all, 138 patients were discharged within 24 h of operation. The median time for return to normal activity was 7 (range 2–60) days and that for return to work 14 (range 2–60) days. One patient required surgery for a port-site hernia and another for a Veress needle injury to the small bowel. Additional complications included bruising in nine patients, cord seromas in seven and urinary retention in two. There have been no recurrences after a median follow-up of 18 (range 1–38) months. The cost benefits of a short hospital stay and rapid return to work afforded by laparoscopic bilateral hernia repair warrant further evaluation.
Mortality, endotoxaemia and cytokine expression after intermittent and continuous hepatic ischaemia
Authors: Hewitt G , Halliday I , McCaigue M , Campbell G , Rowlands B , Diamond T
Published: March 2007

This study compared mortality rates, endotoxaemia, systemic tumour necrosis factor (TNF) and interleukin (IL)-6 concentrations after continuous and intermittent hepatic ischaemia. Two groups of rats were subjected to continuous or intermittent left hepatic inflow occlusion for a total period of 120 min in each group. Intermittent ischaemia was associated with significantly lower mortality rates than continuous ischaemia (four of 20 versus 15 of 20; P = 0±0015). In a separate study, again following 120 min continuous or intermittent ischaemia, systemic blood was sampled at 0 min, 1 h, 3 h and 5 h after final clamp release for measurement of endotoxin, TNF and IL-6 concentrations. Endotoxin concentrations were significantly lower at 1 h, as were TNF and IL-6 concentrations at 3 and 5 h, after final clamp release in the group having intermittent ischaemia (P<0±05). Intermittent ischaemia is associated therefore with significantly reduced mortality rates and lower systemic endotoxin, TNF and IL-6 concentrations when compared with continuous ischaemia.
Mesenteric ischaemia: A multidisciplinary approach
Authors: Bradbury A W , Brittenden J , McBride K , Ruckley C V
Published: March 2007

Mesenteric ischaemia may result from a wide range of pathological processes, each possessing unique clinical features, diagnostic difficulties, management strategies and outcome. Regardless of aetiology, prognosis depends crucially on rapid diagnosis and institution of treatment to prevent, or at least to minimize, bowel infarction. Progress in understanding the pathophysiology of mesenteric ischaemia has led to novel methods of treatment, so that in some circumstances therapy may be purely medical. More often surgery is required and is frequently life saving. Percutaneous transcatheter techniques are increasingly employed in both diagnosis and treatment. Close cooperation between radiologists, physicians and surgeons is therefore necessary if clinical outcome is to be optimized. This paper reviews the modern interdisciplinary management of mesenteric ischaemia in the light recent advances.
Manipulation of local and systemic host defence in the prevention of perioperative sepsis
Authors: Windsor A C J , Klava A , Somers S S , Guillou P J , Reynolds J V
Published: March 2007

This review addresses some of the immunological issues surrounding the complex problem of perioperative sepsis. It identifies an immunological paradox between the relative immunosuppression of the immediate postoperative period and the relative immune activation of established sepsis, in addition to discussing current knowledge of the mechanisms surrounding these phenomena. Much remains unknown about perioperative immunoregulation; there are a number of potential mechanisms, however, whereby local and systemic immune defences can be modified or enhanced. Provided patients at risk can be identified, such manipulations may find application in preventing infection and sepsis after surgery.
Endotoxaemia and cytokine production in experimental colitis
Authors: Neilly P J D , Gardiner K R , Kirk S J , Jennings G , Anderson N H , Elia M , Rowlands B J
Published: March 2007

Systemic endotoxaemia is a well recognized feature of inflammatory bowel disease but its pathogenic role remains uncertain. This study examined plasma endotoxin and cytokine concentrations and the acute-phase protein response in a hapten-induced model of experimental colitis. On days 2, 8 and 14 after induction of colitis with trinitrobenzenesulphonic acid in ethanol (TNBS-E), plasma endotoxin, immunoglobulin (Ig) G and IgM endotoxin-core antibody (EndoCAb), tumour necrosis factor (TNF), interleukin (IL) 6 and α2-macroglobulin (α2M) concentrations and colon macroscopic inflammation score were determined. At all time points there was significant colonic inflammation when compared with control values (P<0·0001). Animals treated with TNBS-E had raised concentrations of endotoxin at all time points (P<0·04). In TNBS-E-treated animals EndoCAb concentrations were reduced on day 2 (P<0·0001) and later increased. There were increases in IL-6 and α2M concentrations in TNBS-E-treated animals but no significant change in TNF concentrations. Endotoxin concentrations correlated with macroscopic inflammation score, IL-6 and α2M concentrations. There was a less consistent correlation between EndoCAb concentrations and these parameters. These results suggest that endotoxin is a mediator of the systemic response in this model of experimental colitis.
Intraoperative measurement of colonic anatomy and attachments with relevance to colonoscopy
Authors: Saunders B P , Phillips R K S , Williams C B
Published: March 2007

This study examined the variations in colonic length and mesenteric attachments in 118 patients undergoing laparotomy. Measurements were taken according to a set protocol with the bowel pulled medially, or towards the pubic symphysis or the xiphisternum, mimicking the possible displacements that may occur during colonoscopy. A free sigmoid loop was not present in 20 patients (17 per cent) because of adhesions. A descending mesocolon of 10 cm or more in length was recorded in ten patients (8 per cent) and an ascending mesocolon 10 cm or greater in 11 (9 per cent). Some 24 patients (20 per cent) had mobile splenic flexures and in 34 (29 per cent) the mid-transverse colon reached the symphysis pubis or lower when pulled downwards. Mean (range) total colonic length was 114.1 (68–159) cm. This study helps define anatomical variations that may affect the facility, or otherwise, of colonoscopy.
Cusum as an aid to early assessment of the surgical trainee
Authors: van Rij A M , McDonald J R , Pettigrew R A , Putterill M J , Reddy C K , Wright J J
Published: March 2007

Tests of knowledge, aptitude and psychomotor skills have been used to assess and select surgical trainees but none of these is reliable in the long term. The industrial quality-control method of the cusum was used to assess performance progress in 17 surgical trainees. Trainees were assessed on their ability to perform, independently, selected surgical operations using the criterion of procedure duration. Cusum profiles were compared with scores from at least four independent assessors using a modified Royal Australasian College of Surgeons' mentor form. The cusum identified all trainees who were considered either satisfactory or less able by their mentors. This objective evaluation was reliable after 25 procedures, whether for appendicectomy or combined with herniorrhaphy and cholecystectomy. Evaluation of surgical performance using the cusum may prove to be a more objective tool for assessing surgical trainees than early impressions or less clinically oriented tests.
Impact of fine-needle aspiration cytology, ultrasonography and mammography on open biopsy rate in patients with benign breast disease
Authors: Green B , Dowley A , Turnbull L S , Smith P A , Leinster S J , Winstanley J H R
Published: March 2007

The management of breast disease has been influenced by breast imaging and fine-needle aspiration cytology (FNAC) for preoperative diagnosis. To investigate the impact of introducing an in-clinic FNAC service on patient management, the pathology records of patients presenting before and after introduction of the service were studied. Four management changes emerged. The number of patients investigated by histology and/or cytology increased (from 266 to 503), as did specimen numbers (392 to 728). The use of pathological services changed, with more cytology specimens (39 to 554), fewer needle-core biopsies (62 to three) and fewer excision biopsies (245 to 118). The number of patients admitted for surgery fell, especially those with a benign histological diagnosis (174 to 49). These figures demonstrate a change in the management of benign breast disease, from surgery with histopathological diagnosis to cytological diagnosis with surgery only if indicated clinically or from imaging.
Palliation of irresectable hilar cholangiocarcinoma with biliary drainage and radiotherapy
Authors: Kuvshinoff B W , Armstrong J G , Fong Y , Schupak K , Getradjman G , Heffernan N , Blumgart L H
Published: March 2007

Twelve patients with irresectable or recurrent hilar cholangiocarcinoma were treated with internal biliary drainage followed by intraluminal (iridium-192) and external-beam radiotherapy. Biliary drainage was accomplished by means of a combined surgical and interventional radiological approach. Initial biliary decompression was performed surgically by tumour resection, intrahepatic biliary enteric bypass or distal biliary-enteric anastomosis with a temporary stent. Maintenance of internal biliary drainage and application of intraluminal radiotherapy were accomplished radiologically with the use of percutaneous dilatation and metallic expandable biliary endoprostheses. Median survival was 14.5 months; all 12 patients survived for at least 6 months. Early complications during radiotherapy were minor and included two patients with cholangitis and one with transient haemobilia. Jaundice was relieved in ten of 12 patients, while episodes of cholangitis were seen during long-term follow-up in 11 (median 1.5 episodes per patient). Internal biliary drainage, in conjunction with radiotherapy, appears to be safe and effective palliation of irresectable or recurrent hilar cholangiocarcinoma. Patients can maintain a reasonable quality of life with an acceptable incidence of cholangitis, without the hindrance of external drainage devices.
Delayed massive haemorrhage after pancreatic and biliary surgery
Authors: van Berge Henegouwen M I , Allema J H , van Gulik Th M , Verbeek P C M , Obertop H , Gouma D J
Published: March 2007

The purpose of this retrospective study was to determine the causes, symptoms and optimal management of massive delayed haemorrhage after pancreatic and biliary surgery. In a series of 686 patients who underwent major pancreatic and biliary surgery between 1983 and 1993, those with massive haemorrhage (necessitating more than 6 units packed cells within 24 h) more than 24 h after the initial surgery were selected. Two groups were formed, according to the aetiology of bleeding: bleeding caused by erosion of a major artery or that from the (gastro)intestinal suture line. The groups were compared with respect to bleeding parameters, symptoms, diagnostic and interventional procedures, and mortality. Massive postoperative haemorrhage occurred in 22 patients (3.2 per cent): 12 (1.7 per cent) with arterial bleeding and ten (1.5 per cent) with suture-line bleeding were identified. Patients with arterial bleeding had a longer interval between initial surgery and haemorrhage (P = 0.02), more frequent septic complications (P=0.03) and had a higher mortality rate than those with suture-line bleeding (50 versus 0 per cent respectively, P=0.02). If minimally invasive diagnostic and therapeutic techniques are not successful, early aggressive surgical intervention is mandatory, including thorough exploration of the area of the resection, ligated artery stumps and inspection of anastomoses by enterotomy.
Incidence, diagnosis and significance of multiple gastric cancer
Authors: Kodera Y , Yamamura Y , Torii A , Uesaka K , Hirai T , Yasui K , Morimoto T , Kato T , Kito T
Published: March 2007

Of 2790 patients with gastric cancer undergoing surgery between January 1978 and December 1993, 160 (with 356 neoplastic lesions) had synchronous multiple cancer. Of these lesions 271 (76 per cent) were early cancers. Only 85 (53 per cent) of the 160 patients were diagnosed before operation as having multiple cancer; 69 further patients (43 per cent) were diagnosed during the course of the operation. Small flat (IIb) and depressed (IIc) type lesions had a propensity to be missed before operation. The incidence of multiple cancer was relatively low, indicating that several microscopic lesions might have been overlooked in this series. There has, however, only been one patient (1 per cent) with subsequent cancer of the gastric remnant of 126 with multiple cancer and postoperative gastric remnants over the past 16 years. This might be because of co-resection of unrecognized lesions by distal gastrectomy in 68 per cent of the patients. Alternatively some microscopic cancers might not invariably be destined to grow into clinically significant lesions over 10 or more years.
Management of the pancreatic stump following pancreaticoduodenectomy
Authors: Sikora S S , Posner M C
Published: March 2007

Pancreaticoduodenectomy is the procedure of choice in patients with periampullary and pancreatic cancers. Dramatic improvements in morbidity and mortality rates following pancreaticoduodenectomy have been reported in the past 5 years. Consequently, the indications for pancreaticoduodenectomy are becoming more liberal, with some authors suggesting its use as a palliative procedure in pancreatic cancer and as definitive treatment for benign diseases such as chronic pancreatitis. Complications are frequently related to the pancreatic stump and can have a fatal outcome. Several methods of managing the pancreatic stump have been described, with variable results. Modifications of standard techniques have evolved over time in an effort to reduce the incidence of major complications. The results of these methods, the role of perioperative adjuncts and the long-term outcome of pancreaticoenteric anastomosis are reviewed.
Bilateral gracilis neosphincter construction for treatment of faecal incontinence
Authors: Kumar D , Hutchinson R , Grant E
Published: March 2007

Neosphincter formation with gracilis muscle is used for faecal incontinence refractory to conservative measures and after failed sphincter repair. In this study both gracilis muscles were used to create a neosphincter to determine whether this provides superior physiological and clinical results. Ten patients of median age 39 (range 18–73) years were treated. The mean resting and squeeze pressures before operation were 16 (range 0–40) and 44 (range 0–68) cmH2O respectively. The operation was covered by a defunctioning loop left iliac fossa colostomy. Nine of the ten patients have had the stoma closed and are fully continent after a mean follow-up of 24 (range 6–40) months. One patient who had an ileoanal pouch and bilateral graciloplasty has urgency of defaecation. None of the patients has to wear a pad or is taking constipating agents. All nine patients have satisfactory evacuation on isotope defaecography and are continent to artificial stool. After operation the mean resting and squeeze pressures were 78 (range 70–112) and 121 (range 90–188) cmH2O respectively. Bilateral graciloplasty provides satisfactory results for grade 4 faecal incontinence refractory to other operative and non-operative measures, and may be an alternative to stimulated dynamic graciloplasty.