bluuebunny/crossref_metadata_2025 huggingface dataset:
Total sphincter conservation in high fistula in ano: Results of a new approach
Authors: Matos D , Lunniss P J , Phillips R K S
Published: March 2007

An intersphincteric approach has been developed that allows complete sphincter preservation in some patients with high fistulas. This operation in 13 patients (eight trans-sphincteric, five suprasphincteric tracks) has resulted in complete success in seven, partial success (ultimate sacrifice of the internal anal sphincter) in two and failure in four. When the operation is successful continence is better than after failed procedures.
Recurrent varicose veins: Correlation between preoperative clinical and hand-held Doppler ultrasonographic examination, and anatomical findings at surgery
Authors: Bradbury A W , Stonebridge P A , Ruckley C V , Beggs I
Published: March 2007

A consecutive series of 118 patients (148 legs) presenting with recurrent varicose veins underwent preoperative clinical and hand-held Doppler ultrasonographic examination by a single observer. The presence of saphenofemoral, mid-thigh perforator and saphenopopliteal reflux was noted. Ultrasonography markedly improved the accuracy of clinical assessment at all three potential sites of reflux compared with operative findings. Of 71 patients undergoing repeat groin dissection, only 20 (28 per cent) had a tied saphenofemoral junction, 31 (44 per cent) had intact major tributaries and 52 (73 per cent) had an intact long saphenous vein (LSV) in the thigh. There was a positive association between mid-thigh perforator reflux giving rise to recurrent varices and the presence of an intact LSV in the thigh. Of 45 legs with saphenopopliteal reflux, only four had previously undergone saphenopopliteal ligation, suggesting that most short saphenous varicosities had either appeared after or had not been recognized at the time of primary surgery. This study indicates that even an experienced vascular surgeon can have difficulty in assessing the presence or absence of recurrent deep to superficial reflux by means of clinical examination alone and that Doppler ultrasonographic examination is mandatory. Recurrence continues to be associated with persistent or recurrent incompetence at the site of previous inadequate surgery.
Cytodiagnosis of breast disease using a liquid suspension medium
Authors: Ross D A , Cunningham S C , Vincenti A C , Rainsbury R M
Published: March 2007

Fine-needle aspiration cytology specimens from 187 breast lesions were processed using conventional slide cytology. Results were compared with those from 201 lesions prepared using a liquid suspension medium (Cytospin) for specimen collection, to assess the clinical utility of each technique. The frequency of diagnostic groups was similar for each method. No significant difference was found in sensitivity (conventional slide cytology 86 per cent versus Cytospin 82 per cent), specificity (72 versus 82 per cent) or diagnostic accuracy (88 versus 91 per cent). The Cytospin technique compares favourably with conventional slide cytology and can be recommended for ease of use in breast cytodiagnosis.
Erythromycin improves emptying of the denervated stomach after oesophagectomy
Authors: Hill A D K , Walsh T N , Hamilton D , Freyne P , O'Hare N , Byrne P J , Hennessy T P J
Published: March 2007

Oesophagectomy, necessitating vagotomy, is associated with delayed gastric emptying. Cisapride and erythromycin have prokinetic effects and improve emptying of the innervated stomach. Their effect on the denervated stomach following oesophagectomy is unknown. The effect of pyloroplasty, cisapride and erythromycin on the rate of gastric emptying after oesophagectomy was studied using a radiolabelled meal. Oesophagectomy was associated with a marked delay in gastric emplying (56 per cent of the test meal remaining after 4 h) compared with age- and sex-matched normal controls (16 per cent; P <0.001). Erythromycin improved the rate of gastric emptying to preoperative control values (18 per cent). Cisapride had no significant effect on gastric emptying. After pyloroplasty, 32 per cent of the label remained at 4 h (P = 0.065). The mean(s.e.m.) half-emptying time in patients receiving erythromycin was 94(29) min, which was similar to control values, 55(3) min (P = 0.26). Erythromycin may have a role in the treatment of gastric stasis following oesophagectomy or truncal vagotomy.
Pattern and surgical treatment of gastric cancer in Singapore
Authors: Ti T K
Published: March 2007

A personal series of 150 patients with gastric cancer operated on over an 11-year period in Singapore is reviewed. Cancer occurred in the antrum and/or body of the stomach in 117 patients and in the cardia in 33. Gastric tumours were well or moderately differentiated adenocarcinoma in 50 patients and poorly differentiated or signet ring cell carcinoma in 100. Surgical resection was performed on 115 patients, in whom it was palliative in 47. Attempted cure by R2 radical resection was performed in 68 patients: 14 with stage I, 12 with stage II and 42 with stage III disease. There was no operative death in these 68 patients. In 82 patients operated on more than 5 years ago, five patients with carcinoma of the cardia and 28 with cancer of the gastric antrum and/or body underwent curative resection. There were 12 known 5-year survivors among the latter 28 patients; 16 of the 28 had stage III disease, six of whom survived 5 years. These results compare favourably with those of an earlier report from Singapore in which there were no 5-year survivors. The improved results probably accrue from earlier diagnosis and the current policy of radical resection.
Orthotopic liver transplantation for hepatic complications of Wilson's disease
Authors: Rela M , Heaton N D , Vougas V , McEntee G , Ganet E , Farhat B , Chiyende J , Mieli-Vergani G , Mowat A P , Portmann S , Williams R , Tan K C
Published: March 2007

Thirteen orthotopic liver transplantations were performed in 12 patients for hepatic complications of Wilson's disease between May 1988 and July 1992. Ten patients had fulminant hepatic failure and two chronic liver disease. One patient underwent retransplantation for liver abscess secondary to hepatic artery thrombosis. Nine patients survive at a median follow-up of 18 (range 6–31) months. Three patients have died: two from multiple organ failure and sepsis, one from B cell lymphoma. Postoperative complications included bleeding requiring laparotomy in two patients, renal impairment in five, bacterial septicaemia in three, fungal sepsis in two and acute cellular rejection in six. The nine surviving patients are well with normal liver function test results.
Prophylactic use of cefuroxime in biliary tract surgery: Randomized controlled trial of single versus multiple dose in high-risk patients
Authors:   Galant Trial Study Group, Meijer W S , Schmitz P I M
Published: March 2007

To assess the efficacy of a single-dose short-acting antibiotic in the prevention of septic complications after biliary surgery, a randomized controlled double-blind multicentre trial was conducted. One dose of cefuroxime before operation (1.5 g intravenously) was compared with a three-dose regimen of the drug as control (1.5 g before and two doses of 0.75 g after operation). The study group comprised 1004 patients with risk factors for infection, who were followed for 4–6 weeks after surgery. The characteristics of both treatment groups were comparable. No significant difference was found between the one- and three-dose antibiotic regimens in preventing postoperative wound infection: 6.6 versus 6.2 per cent for minor wound infection (P = 0.78) and 4.6 versus 3.8 per cent for minor wound infection (P = 0.52). The estimated difference in major wound infection rate between the two groups was 0.8 per cent (95 per cent confidence interval −1.7 to 3.3 per cent).
Pouch–vaginal fistula
Authors: Groom J S , Nicholls R J , Hawley P R , Phillips R K S
Published: March 2007

Between January 1976 and June 1991, 161 women underwent restorative proctocolectomy. Seventeen (10.6 per cent) developed pouch-vaginal fistula. There was no difference in the incidence of inflammatory (15 of 141; 10.6 per cent) and non-inflammatory (two of 20; 10 per cent) disease, the severity of colitis or the number of stages in the operation. In 15 patients the fistula involved the ileoanal anastomosis; in two it had possibly occurred at the dentate line. There was no significant difference in the proportion of hand-sewn (ten of 120; 8.3 per cent) and stapled (seven of 41; 17 per cent) ileoanal anastomosis. Of the 17 women, six had pelvic sepsis in the immediate postoperative period and five had an anastomotic complication. There was no case of Crohn's disease. Three patients developed a pouch-vaginal fistula before closure of the ileostomy. The remaining 14 fistulas occurred a median of 7 (range 1–144) months after closure, Five further patients were referred from elsewhere to give a total of 22 for analysis of treatment and outcome. The fistula developed before ileostomy closure in five patients (group 1) and after closure in 17 (group 2). Following treatment, six fistulas had healed with five patients still undergoing treatment. In group 1, three of the five fistulas healed, whereas in group 2 only three of the 17 healed. Eight patients required excision of the pouch. The prognosis appears to be worse when pouch-vaginal fistula occurs after ileostomy closure. The optimal management is not yet established.
Surgical evaluation at the crossroads
Authors: Pollock A V
Published: March 2007

Surgeons have lagged behind physicians and oncologists in embracing randomized controlled clinical trials. This paper suggests that a complete, accurate and objective comparison of the outcome of a novel intervention with that of a traditional intervention in previous years, or in another surgical group, can yield valuable information and can lead surgeons to improve their practice. There has recently been a decline in the number of randomized controlled trials published in The British Journal of Surgery; this may reflect the unwillingness of many patients to allow their surgical treatment to be decided by chance.
Venous assessment using air plethysmography: A comparison with clinical examination, ambulatory venous pressure measurement and duplex scanning
Authors: Payne S P K , Thrush A J , London N J M , Bell P R F , Barrie W W
Published: March 2007

Air plethysmography was compared with clinical assessment, ambulatory venous pressure measurement and duplex ultrasonography in 103 unselected limbs with venous disease and ten normal control limbs without such disease. Measurements of venous function obtained by air plethysmography showed considerable overlap between groups of limbs classified on the basis of clinical condition or by the presence of popliteal incompetence detected by duplex scanning. The measurement of venous refilling time using air plethysmography correlated poorly with that obtained by venous cannulation (rs = 0·58). The residual volume fraction did not correlate with ambulatory venous pressure measurement (rs = 0·04). Air plethysmography was not found to be as useful as previously reported. The residual volume fraction should not be accepted as a substitute for ambulatory venous pressure measurement, which remains the ‘gold standard’ test of venous function.
Basic fibroblast growth factor accelerates wound healing in chronically ischaemic tissue
Authors: Uhl E , Barker J H , Bondàr I , Galla T J , Leiderer R , Lehr H-A , Messmer K
Published: March 2007

The influence of subcutaneously injected recombinant human basic fibroblast growth factor (bFGF) on wound healing in normal (n = 20) and ischaemic (n = 28) skin tissue was investigated. Standardized wounds (5 mm2) were created on the ears of hairless mice and treated for the first 3 days after wound creation with total doses of 720 ng (n = 24) and 4050 ng (n = 24) bFGF. The bFGF had no effect on wound healing in non-ischaemic tissue. In ischaemic skin, mean(s.d.) wound surface area after treatment with 720 ng bFGF was 1·6(0·9), 0·5(0·6) and 0·1(0·3) mm2 compared with 2·8(1·0), 1·4(1·0) and 0·8(0·7) mm2 for control wounds on days 7 (P <0·04), 10 (P <0·03) and 13 (P <0·04) respectively. High-dose bFGF (4050 ng) reduced the mean(s.d.) wound surface area to 2·4(0·7) and 0·8(0·7) mm2 compared with 3·9(0·6) and 2·1(0·8) mm2 for control wounds on days 7 (P <0·006) and 10 (P <0·02) respectively. These results suggest that bFGF may be of use for the treatment of wounds in ischaemic tissue.
Plantar melanoma in black South Africans
Authors: Hudson D A , Krige J E J
Published: March 2007

The outcome of treatment in 40 black patients (27 women, 13 men; mean age 62·9 years) with plantar melanoma over a 13-year period was analysed to evaluate the efficacy of wide local excision with split skin grafting. Substantial delay in seeking medical attention occurred in 35 patients. At presentation, 20 patients had stage I disease, one stage II, 15 stage III and four stage IV. Acral lentiginous melanoma (27 patients) was the most common histological type. The mean Breslow depth was 6·9 mm and 35 patients had lesions of Clark level IV or V. The mean surface area of plantar lesions was 13·3 cm2. Wide local excision with split skin grafting was used in 29 patients; four patients with neglected advanced plantar lesions had below-knee amputation and seven with metastatic disease did not undergo surgery. Graft sepsis occurred in six patients and local recurrence in two. Nine patients were alive at follow-up; the 5-year survival rate was 25 per cent. Delay in presentation and locally advanced disease may explain the poor prognosis of plantar melanoma in black South Africans.
Prognostic relevance of systematic lymph node dissection in gastric carcinoma
Authors:   German Gastric Carcinoma Study Group, Siewert J R , Böttcher K , Roder J D , Busch R , Hermanek P , Meyer H J
Published: March 2007

In a prospective multicentre study of 2394 patients with gastric carcinoma the prognostic relevance of systematic lymph node dissection was evaluated. Of 1654 patients undergoing resection, 558 had a standard lymph node dissection, defined as fewer than 26 nodes in the specimen, and 1096 underwent radical lymphadenectomy, i.e. 26 or more nodes in the specimen. Radical dissection signficantly improved the survival rate in patients with Union Internacional Contra la Cancrum (UICC) stages II and IIIA tumours. Multivariate analysis identified radical dissection as an independent prognostic factor in the subgroups of patients with UICC tumour stages II and IIIA. Radical dissection conferred no survival advantage in patients with pN2 tumours. There was no significant difference in morbidity and mortality rates between radical and standard lymph node dissection. Radical lymphadenectomy improves survival in patients with UICC gastric cancer stages II and IIIA, and should be the recommended treatment for such patients.
Surgical polypectomy of duodenal adenomas in familial adenomatous polyposis: Experience of two European centres
Authors: Penna C , Phillips R K S , Tiret E , Spigelman A D
Published: March 2007

Between 1978 and 1988, 12 patients with familial adenomatous polyposis (FAP) and severe duodenal polyposis underwent duodenotomy and duodenal polypectomy. The patients were from two separate institutions; all were women, with a mean age of 45·6 (range 25–62) years at the time of duodenotomy. Recurrent duodenal polyposis was detected at endoscopy in all 12 patients, at a mean of 13·3 (range 5–36) months after duodenotomy. All patients had moderate to severe duodenal polyposis at the time of the last endoscopic examination. Local excision of duodenal adenomas is an unsatisfactory treatment option in those with FAP. The ideal management of patients with FAP who have severe duodenal polyposis remains uncertain.
Improved glucose metabolism after subtotal pancreatectomy for pancreatic cancer
Authors: Permert J , Ihse I , Jorfeldt L , von Schenck H , Arnquist H J , Larsson J
Published: March 2007

Diabetes occurs frequently in patients with pancreatic cancer. To investigate the impact of tumour removal, seven patients were studied before and after 85 per cent subtotal pancreatectomy for adenocarcinoma of the pancreas. The frequency of diabetes was determined by the oral glucose tolerance test. Fasting levels of C peptide and insulin were measured in plasma, and insulin secretion was investigated by hyperglycaemic glucose clamp and glucagon stimulation. Six of the seven patients were diabetic before surgery and four required insulin treatment. Improvements in diabetic status and glucose metabolism were found in all seven patients after operation, as demonstrated by increased glucose metabolic capacity during hyperglycaemia. This occurred despite a postoperative reduction in insulin secretion and is explained by the observed augmentation of whole-body insulin sensitivity after surgery. A diabetogenic factor may be produced by pancreatic adenocarcinoma that may be responsible, directly or indirectly, for the high frequency of diabetes in patients with pancreatic cancer.
Effect of antitumour necrosis factor treatment on circulating tumour necrosis factor levels and mortality after surgery in jaundiced mice
Authors: Bemelmans M H A , Gouma D J , Greve J W , Buurman W A
Published: March 2007

Tumour necrosis factor (TNF) may play an important role in the increased incidence of complications after surgery in patients with obstructive jaundice. This study evaluated the effect of three different anti-TNF treatments, a monoclonal anti-TNF antibody (TN3), pentoxifylline and lactulose, on outcome after severe surgical trauma in mice with experimental biliary obstruction. Circulating serum TNF levels and mortality rate were monitored. Severe surgical trauma, such as renal ischaemia, in jaundiced mice resulted in increased levels of circulating TNF (3·5 ng/ml) and a high mortality rate (54 per cent). The three different anti-TNF treatments caused a significant reduction in postoperative levels of circulating TNF (TN3, P <0·001; pentoxifylline, P <0·01; lactulose, P <0·05). Treatment with TN3 and pentoxifylline did not lead to a significantly reduced mortality rate (36 and 44 per cent respectively). Only lactulose treatment produced a significantly reduced mortality rate (7 per cent, P <0·01). TNF is therefore not the only mediator responsible for death after surgery in jaundiced mice. Other mechanisms affected by lactulose are also involved.
Silicone gel breast implants, breast cancer and connective tissue disorders
Authors: Park A J , Black R J , Watson A C H
Published: March 2007

Recent worldwide media speculation that silicone gel-filled breast implants may be linked to an increased incidence of breast and other cancers, and connective tissue disease(particularly systemic sclerosis) has caused concern to the medical profession and public alike. Until carefully controlled studies have been performed to prove the safety of these implants, the US Food and Drug Administration has restricted their use to research and breast reconstruction. Research has so far failed to prove a causative relationship between silicone implants and cancer or connective tissue disorders.
Role of surgery in patients with primary non-Hodgkin's lymphoma of the stomach: An old problem revisited
Authors: Bozzetti F , Audisio R A , Giardini R , Gennari L
Published: March 2007

The literature after 1980 dealing with the treatment of primary gastric non-Hodgkin's lymphoma (stages I and II) is reviewed. Gastrectomy is recommended for patients with acute symptoms at presentation or with complications of chemotherapy or radiotherapy. In elective cases, patients with stage I disease may be candidates for gastrectomy as a single therapy, provided that tumour-free resection margins are achieved. There is no evidence of substantial benefit from adding postoperative chemotherapy or radiotherapy after an apparently radical resection. In stage II disease, the best results are achieved with ablative surgery plus adjuvant therapy. The resection volume should be limited to macroscopically involved structures, in principle avoiding total gastrectomy and extensive lymph node dissection, since residual disease may be optimally controlled with radiotherapy or chemotherapy. Primary chemotherapy, with or without radiotherapy, represents an experimental approach; the advantages of sparing the stomach must be balanced against the toxicity of an aggressive chemotherapy regimen and the risk of emergency operation for iatrogenic complications.
Abdominal aortic aneurysm in the elderly
Authors: Chalmers R T A , Stonebridge P A , John T G , Murie J A
Published: March 2007

Thirty-five patients over the age of 80 years underwent surgery for abdominal aortic aneurysm between January 1985 and December 1990. Of these, 25 had surgery for ruptured aneurysm (mortality rate 56 per cent) and ten had surgery for symptomatic or asymptomatic aneurysm (mortality rate zero). The mortality rate for patients with rupture aged over 80 years was considerably greater than that for those under 80 years of age (56 versus 36 per cent). The mortality rate in the elderly population was zero for elective surgery but in those under 80 years it was 5 per cent. During the study period a prospective analysis of all referrals with aortic aneurysm was carried out, whether or not they underwent surgery and whether or not they were admitted to hospital. The ratio of patients accepted for operation to those not accepted for operation was 92:59 (1·56:1) in the under 80-year-old age group and 12:34 (0·35:1) in those aged over 80 years.
Posterolateral neck dissection: Technique and results
Authors: Plukker J Th , Vermey A , Roodenburg J L N , Oldhoff J
Published: March 2007

Posterolateral neck dissection, alone or combined with a modified radical neck dissection, may be an appropriate method of treating occult and clinically manifest nodal metastases of malignant epithelial tumours of the skin of the posterior scalp. The technique and results are described in 21 patients treated between February 1981 and November 1989. Transformation of nodal status from cN0 to pN+ was seen in five of 13 patients treated electively, who may benefit from such a procedure. During a mean follow-up of 47 months the disease was controlled locally in all patients. Three patients suffered regional recurrence of whom only one had a nodal recurrence within the region previously operated on. The results of this limited retrospective study confirm the value of posterolateral neck dissection in posterior scalp lesions.
Staging of supratentorial hemispheric glioma using tumour extension, histopathological grade and extent of surgical resection
Authors: Iacoangeli M , Roselli R , Prezioso A , Scerrat M , Rossi G F
Published: March 2007

A ‘TGS’ classification for supratentorial brain glioma is proposed, based on three parameters: tumour extension (T), histopathological grade (G) and extent of surgical resection (S). Two groups of patients were analysed: the first (n = 137) had tumour submitted to stereotactic biopsy; the second (n = 60) had malignant glioma operated on by craniotomy and tumour resection. All three staging parameters signficantly influenced survival. Histopathological grade was the most significant factor, and the only independent variable on multivariate analysis, followed by extent of tumour and then extent of surgical resection. The data support the applicability of the proposed parameters for a staging classfication of hemispheric brain glioma.
Graves' ophthalmopathy after subtotal thyroidectomy and radioiodine therapy
Authors: Fernández Śnchez J R , Pradas J Rosell , Martinez O Carazo , Vela E Torres , Jimenez F Escobar , Fuentes I Garbin , Thorbeck R Vara
Published: March 2007

Forty-five patients with Graves' ophthalmopathy were studied prospectively. Twenty-one patients (42 orbits; group 1) were treated surgically by subtotal thyroidectomy and 24 (48 orbits; group 2) received radioiodine therapy. All patients underwent tests of thyroid function, ophthalmological examination, and axial and coronal computed tomography before and 12 months after treatment. Patients in group 1 showed significant improvement in the Feldon score (P < 0·001), in proptosis as estimated by Hertel exophthalmometry (P < 0·001) and in proptosis (P < 0·001), maximum diameter of the medial rectus (P < 0·01), lateral rectus (P < 0·05), superior group (P < 0·05) and inferior rectus (P < 0·001) muscles as estimated by computed tomography. Patients in group 2 showed significant improvement only in the Feldon score (P < 0·05). The ophthalmopathy of Graves' disease improves to a greater extent after subtotal thyroidectomy than after radioiodine therapy.
Penetrating external injuries of the oesophagus and pharynx
Authors: Hatzitheofilou C , Strahlendorf C , Kakoyiannis S , Charalambides D , Demetriades D
Published: March 2007

Fifty-one instances of oesophageal perforation were discovered when the records of 18 588 patients with external penetrating injuries of the neck, chest and abdomen were reviewed. Of these, 33 resulted from stab wounds, 17 from bullets and one from hyperextension of the neck. There were 15 perforations of the pharynx and 36 of the oesophagus. Oesophagography in a lateral decubitus position demonstrated the perforation in all 16 patients in whom it was used. In 45 patients simple repair within 24 h of injury was performed (mortality rate 11 per cent). In six patients with a delay of more than 24 h in the repair of the thoracic oesophagus, special techniques were preferred. In two patients an oesophageal diversion-exclusion method was used; one such patient died. In four patients repair over a large-bore T tube was carried out with one death. The main cause of mortality was associated spinal injury (four deaths).
Survival following microscopically confirmed radical resection of N0 gastric cancer
Authors: Brems-Dalgaard E , Clausen H V
Published: March 2007

In a series of 128 patients operated on for gastric cancer, 27 satisfied microscopic criteria for radical resection. The median age of these patients was 72·3 (range 36-84) years at operation; the median hospital stay after surgery was 12·9 days. The median observation time was 3·8 years and the crude 5-year survival rate 48 per cent. Older patients did remarkably well. No significant difference was found in the number of survivors, survival-observation time or hospital stay in the age groups 55–64, 65–74 or 75–84 years. Thus, age alone should not be considered a barrier to curative surgical treatment. When the study was ended, 12 of the 27 patients who underwent microscopically confirmed radical resection were still alive; six had died from recurrent gastric cancer and nine from other causes. At 5 years after microscopically confirmed radical resection for gastric carcinoma, the gastric cancer-specific mortality rate was 23 per cent.
Factors associated with early discharge after inguinal hernia repair in 500 consecutive unselected patients
Authors: Millat B , Fingerhut A , Gignoux M , Hay J-M
Published: March 2007

The feasibility of discharge within 48 h of surgery was evaluated in 500 consecutive men with unilateral uncomplicated non-recurrent inguinal hernia. Fifty-nine patients were unsuitable for short-stay Surgery on medical or social grounds. Of 411 patients suitable for early discharge, 107 stayed longer than 48 h. Early discharge was declined by 84 otherwise suitable patients and contraindicated because of local or general complications in 42. A total of 304 patients were discharged within 48 h; 1-day surgery was performed in 51 patients. Employment, low physical requirements, a lower age and fewer than two medical risk factors were associated with feasible and successful short-stay surgery. These factors may not be independent variables.
Liver resection with normothermic ischaemia exceeding 1 h
Authors: Hannoun L , Borie D , Delva E , Jones D , Vaillant J-C , Nordlinger B , Parc R
Published: March 2007

A retrospective study was made of 34 patients who underwent major liver resection with a single period of vascular occlusion exceeding 60 min. The liver remnant was normal in all cases. Vascular occlusion was achieved by continuous portal trial clamping (15 patients), hepatic vascular exclusion (15) or a sequential combination of both procedures (four). Liver cooling was not used. The mean(s.e.m.) duration of continuous normothermic liver ischaemia was 73·6(2·5) (range 60–127) min. The mean(s.e.m.) amount of blood transfused during operation was 5·3(0·8) units packed red cells. There were no deaths after surgery and the postoperative course was uneventful, or limited to asymptomatic pleural effusion, in 18 patients. Three patients suffered postoperative bleeding necessitating further surgery and one of these required reintervention for a prolonged bile leak. Four patients had transient liver failure that resolved spontaneously within 15 days. There was a 13-fold increase in serum transaminase activities and the proaccelerin level was 45 per cent that of normal on day 1 after operation. These changes were returning to normal levels within 15 days. Continuous vascular occlusion during major liver resection is a useful manoeuvre that may be performed safely on normal hepatic parenchyma for up to 90 min.
Morphological studies of graft pancreatitis following pancreas transplantation
Authors: Büsing M , Hopt U T , Quacken M , Becker H D , Morgenroth K
Published: March 2007

Morphological findings in the initial stages of graft pancreatitis were studied systematically in sequential biopsies of 16 human pancreatic allografts. In 14 patients clinical and morphological signs of graft pancreatitis developed in the early postoperative period. In all cases disturbances in the integrity of structures within acinar cells occurred during ischaemia. In ten cases activation of autophagocytosis occurred following reperfusion, with acceleration of cellular metabolism. After reperfusion a marked leucocyte reaction occurred with a later single acinar cell necrosis in six cases. At the same time, high serum pancreatic enzyme concentrations were observed in all patients following transplantation. Exocrine secretion from the allografts via the pancreatic duct was reduced, correlating with the severity of graft pancreatitis. Studies in this clinical situation might complement analyses of the cascade of morphological and pathophysiological reactions during the early stages of other types of acute pancreatitis.
Percutaneously placed Wallstent endoprosthesis in patients with malignant distal biliary obstruction
Authors: Stoker J , Laméris J S , Jeekel J
Published: March 2007

Seventy-five patients with malignant distal biliary obstruction were treated by percutaneously placed self-expandable Wallstent endoprostheses for palliative drainage. The stent diameter was I cm and its length 3·5 – 10·5 cm. Early complications occurred in 16 patients (21 per cent); they were related to the endoprosthesis in five (7 per cent) and serious in six (8 per cent). The 30-day mortality rate was 15 per cent, with a 1 per cent procedure-related mortality rate. Sixty-five patients died 6–365 (median 87) days after stent insertion and four had recurrence of obstruction after 21–341 (median 152) days. Reobstruction was the result of tumour ingrowth in one patient, angling of the stent in one and an unestablished cause in two. Ten patients were alive without obstruction 31–383 (median 65) days after stent insertion. Percutaneous use of the Wallstent endoprosthesis allows easy insertion; reobstruction is rare.
Role of early and extensive surgery in the treatment of severe necrotizing soft tissue infection
Authors: Voros D , Pissiotis C , Georgantas D , Katsaragakis S , Antoniou S , Papadimitriou J
Published: March 2007

Forty-two patients with necrotizing soft tissue infection are reviewed. Bacterial culture revealed between two and seven types of micro-organism in each patient. All patients were treated with radical surgical debridement and a combination of antibiotics. In 30 patients, early diagnosis and treatment resulted in only two deaths. Delayed surgical intervention in 12 patients transferred from outside hospitals was followed by nine deaths. Predisposing factors and site of infection did not affect outcome. Of 26 patients with systemic manifestations of sepsis, 16 survivors responded well to initial surgical debridement.
Synchronous abdominoperineal resection without transfusion
Authors: De Cannière L , Rosiére A , Michel L A
Published: March 2007

Blood loss and hypovolaemic shock affect the immune system significantly, and perioperative blood transfusion has been shown to be associated with a higher rate of tumour recurrence in patients with cancer and increased susceptibility to infectious complications. Data obtained from patients undergoing synchronous abdominoperineal excision of the rectum were analysed to assess whether such surgery is feasible without transfusion. Twenty-two consecutive unselected patients were studied. There were 16 men and six women of median age 66 (range 48–80) years. The tumour stage was Dukes' B in 11 patients and Dukes' C in 11. Six patients were severely obese according to body mass index. Four patients required blood transfusion (1, 1, 2 and 2 units). There was no hospital mortality and all perineal wounds healed primarily with no wound infection. Fifteen patients received radiation therapy 6 weeks after surgery. Abdominoperineal resection with minimal blood transfusion is feasible in unselected patients.
Imipenem prophylaxis in elective colorectal surgery
Authors: Karran S J , Sutton G , Gartell P , Karran S E , Finnis D , Blenkinsop J
Published: March 2007

In a randomized controlled study of 411 patients undergoing elective colorectal surgery, the efficacy and safety of two different regimens of imipenem were compared with those of a control regimen of cefuroxime plus metronidazole. Surgical infections occurred in 92 (26·4 per cent) of 349 evaluable patients. There were no major differences between the three treatment groups. It is concluded that imipenem is as effective as cefuroxime plus metronidazole in the prevention of sepsis after elective colorectal procedures.
Infrainguinal revascularization in the diabetic patient
Authors: Stonebridge P A , Murie J A
Published: March 2007

This article reviews the epidemiological, anatomical and physiological background to infrainguinal arterial reconstruction in the diabetic patient. There is no firm evidence in the literature for the existence of a surgically significant occlusive ‘small-vessel’ disease in diabetic patients, either as an aetiological component in the pathogenesis of diabetic foot lesions or as a factor limiting the success of infrainguinal bypass grafting. Recent published results of infrainguinal vascular reconstruction in patients with diabetes are reviewed. These are encouraging; early aggressive treatment of lower-limb occlusive disease may be warranted in the diabetic patient.
Concurrent hyperthyroidism and thyroid carcinoma
Authors: Terzioǧlu T , Tezelman S , Onaran Y , Tanakol R
Published: March 2007

Between 1986 and 1991, thyroidectomy was performed on 138 patients with hyperthyroidism. Thyroid carcinoma was found in eight patients (5.8 per cent). Eighty (58.0 per cent) of the 138 patients had toxic nodular goitre, 33 (23.9 per cent) toxic diffuse goitre and 25 (18.1 per cent) toxic adenoma. Concurrent carcinoma was more frequent in patients with toxic adenoma (8 per cent) than in those with Graves' disease (6 per cent) and toxic nodular goitre (5 per cent). Papillary carcinoma was found in seven patients and follicular carcinoma in one. Three papillary carcinomas were occult with a diameter less than 1.5 cm. Five patients received 100 mCi 131I after operation. There was no morbidity. During follow-up of 10–45 months, there was neither death nor recurrence.
Thyroid neoplasia coexistent with chronic lymphocytic thyroiditis
Authors: McKee R F , Krukowski Z H , Matheson N A
Published: March 2007

During a 6-year period 115 patients presenting with thyroid enlargement had evidence of chronic lymphocytic thyroiditis on fine-needle aspiration cytology. Of 27 patients in whom histological analysis was carried out, 16 had neoplasms (follicular adenoma, four; follicular carcinoma, one; papillary carcinoma, four; lymphoma, seven). Assuming that neoplasia was not overlooked in the absence of histological examination, the overall incidence was 14 per cent and that of malignant disease 10 per cent. All patients with carcinoma had cytological features suspicious of neoplasia on the first or subsequent aspirates in addition to those of thyroiditis. Cytology was suspicious of lymphoma in only two of seven patients but increasing size of the thyroid swelling was a consistent feature. Evidence of chronic lymphocytic thyroiditis may lead to neoplasia being overlooked. Repeated cytological analysis is helpful in identifying coexistent carcinoma but unreliable in excluding lymphoma.
Oesophagogastrectomy for carcinoma of the oesophagus and cardia
Authors: Rahamim J , Cham C W
Published: March 2007

A retrospective review was undertaken of all oesophagectomies performed within a single unit over a 12-year period. In all, 298 patients with primary oesophageal cancer underwent resection between March 1979 and December 1991. Four patients had a three-stage oesophagogastrectomy, 27 a thoracoabdominal oesophagogastrectomy and 267 a Lewis procedure. Dysphagia was the predominant presenting symptom. The duration of symptoms was not related to the stage of disease. Before diagnosis, 52 per cent of patients tolerated symptoms for 2–4 months. Adenocarcinoma was found in 180 tumours and squamous cell carcinoma in 103. Half the patients had evidence of metastatic spread at the time of laparotomy or thoracotomy. The 30-day mortality rate was 10 per cent and the overall actuarial 5-year survival rate of all patients 23 per cent. The actuarial 5-year survival rate of patients without lymph node involvement was 39 per cent compared with 17 per cent for those with positive nodes (P < 0·05). Five of eight patients who had anastomotic leakage died. The almost unselected nature of this series, coupled with the favourable results of oesophagectomy, support the contention that resection remains the preferred mode of treatment for carcinoma of the oesophagus of all histological types.
Reduction in circulating levels of CD4-positive lymphocytes in acute pancreatitis: Relationship to endotoxin, interleukin 6 and disease severity
Authors: Curley P J , McMahon M J , Lancaster F , Banks R E , Barclay G R , Shefta J , Boylston A W , Whicher J T
Published: March 2007

The proportion of peripheral blood mononuclear cells expressing the T helper cell phenotype and levels of antiendotoxin core antibody, interleukin (IL) 6 and C-reactive protein (CRP) were determined within 48 h of admission in a group of 29 patients with acute pancreatitis (16 mild, 13 severe attacks). There was a significant decrease in the proportion of T helper cells (12·2 versus 34·9 per cent, P < 0·01) and significant increases in levels of IL-6 (69·5 versus < 10 pg/ml, P < 0·01) and CRP (119 versus 30·5 mg/l, P < 0·01) in severe compared with mild attacks. During the convalescent stage at 3 months after admission, severe attacks were characterized by a significant increase in the proportion of T helper cells compared with the acute period (22·4 versus 10·6 per cent, P < 0·01). A persistently low proportion of T helper cells was associated with residual pancreatic necrosis. The presence of circulating endotoxin was demonstrated in two mild and two severe attacks using the Limulus amoebocyte lysate assay, and abnormal levels of antiendotoxin core antibodies were found in 70 and 92 per cent of mild and severe attacks respectively. There was a strong inverse correlation between levels of CRP and the proportion of T helper cells in severe disease (r = −0·76, P = 0·004). Translocation of endotoxin from the gastrointestinal tract may partly explain the abnormal levels of T helper cells, IL-6 and CRP.
Effect of nifedipine on renal transplant rejection
Authors: Nicholson M L , Dennis M J S , Beckingham I J , Smith S J
Published: March 2007

The effect of early nifedipine therapy on acute renal allograft rejection was studied in 170 adult cadaveric transplant recipients. Acute rejection occurring in the first 3 months after transplantation was diagnosed by Tru-cut biopsy and the severity of each rejection episode assessed histologically. The incidence of acute rejection was significantly lower in patients treated with nifedipine (29 of 80; 36 per cent) than in controls (52 of 90; 58 per cent) (P < 0·01) and there was a higher proportion of histologically mild rejection episodes in the former group (P < 0·01). Multivariate analysis confirmed that nifedipine exerted a significant independent effect on the incidence of early acute rejection. Other factors identified in the multivariate model as influencing rejection were human leucocyte antigen (HLA) matching at the DR locus, blood level of cyclosporin during the first week, HLA matching at the B locus, donor age and donor sex. The 1-year graft survival rate was 88.6 per cent in patients given nifedipine and 63·8 per cent in controls (P < 0·02). These data suggest that nifedipine therapy has a useful role in human renal transplantation.
Cytokine gene transcription in renal cell carcinoma
Authors: Filgueira L , Zuber M , Merlo A , Caetano V , Schultz E , Harder F , Spagnoli G C , Heberer M
Published: March 2007

Cytokines are powerful modulators of immune responses, the local production of which could be relevant to the interaction between tumour and immune system. This study investigated the transcription of genes encoding interleukin (IL) 2, IL-4, IL-10 and interferon (IFN) γ in lymphocyte-infiltrated renal cell carcinoma biopsies from ten patients using the reverse polymerase chain reaction technique. Autologous peripheral blood mononuclear cells and healthy renal parenchyma tissue were tested in parallel. The β-actin gene, used as a positive control, was transcribed in all samples. In contrast, transcription of cytokine genes was confined to tumour biopsies: IL-2 gene transcripts were detectable in five biopsies and IL-10 transcripts in seven. IL-4 and IFN-γ gene transcripts were detectable in one biopsy each. In two patients no cytokine gene transcription could be identified. These data underline that heterogeneous patterns of cytokine gene transcription can be observed in renal cell carcinoma biopsies. Although transcription of an immunostimulatory lymphokine such as IL-2 was observed in 50 per cent of biopsies, the most frequently transcribed cytokine gene coded for an inhibitory factor, IL-10.
Delay in the diagnosis and prognosis of carcinoma of the right colon
Authors: Goodman D , Irvin T T
Published: March 2007

Of 152 consecutive patients with carcinoma of the right colon, 61 (40 per cent) suffered delays in treatment of more than 12 weeks from the onset of symptoms, with a mean delay of 48 weeks. The most common error was failure to initiate or complete the investigation of iron-deficiency anaemia (33 patients). False-negative barium enema investigations occurred in 16 cases. Patients with delays in diagnosis had survival rates not significantly different from those who presented early. Thirty-one patients with anaemia and no abdominal symptoms had a significantly higher survival rate than 30 presenting with abdominal symptoms, despite delays in treatment (P <0·02). Greater vigilance is required in the investigation of patients presenting with iron-deficiency anaemia.
‘Bile’ in the oesophagus
Authors: Bremner C G , Mason R J
Published: March 2007

Acid gastro-oesophageal reflux occurs when the lower oesophageal sphincter is incompetent, but oesophagitis caused by reflux of duodenal content implies incompetence of both the pyloric and gastro-oesophageal sphincters. The term ‘alkaline’ reflux oesophagitis was coined long before objective analysis was made-of bile in the stomach and oesophagus, and well before pH monitoring was introduced. Surgical procedures to divert bile from the stomach and oesophagus were developed on a clinical basis and gave encouraging results in the management of peptic oesophageal stricture. Alkaline oesophagitis is well recognized after gastric surgery and the entity ‘primary pathological duodenogastric reflux’, although contested by some, attracts growing support. Recent evidence suggests that the complications of Barrett's oesophagus may be related to duodenogastro-oesophageal reflux. Probes designed to measure gastric and oesophageal bile salts have recently been developed and may give more information in the future.
Long-term survival after endoscopic transanal resection of rectal tumours
Authors: Dickinson A J , Savage A P , McC. Mortensen N J , Kettlewell M G W
Published: March 2007

The outcome and survival of 120 consecutive patients of median age 78 years with rectal tumours who underwent endoscopic transanal resection were assessed. Thirty-eight patients (32 per cent) were treated for large villous adenoma. These patients underwent a median of 2 (range 1–5) resections and the overall 5-year survival rate was 78.2 per cent. Of 82 patients with rectal cancer, 33 (28 per cent of the 120) had tumours amenable to conventional surgery but for the patient's age or infirmity. The 5-year survival rate of these patients was 29.7 per cent. Endoscopic transanal resection was used to palliate the symptoms of 49 patients (41 per cent) with rectal cancer; the 5-year survival rate was 13.7 per cent. Excellent long-term outcome may be achieved with endoscopic transanal resection for patients with benign rectal tumours. This approach also gives acceptable results for selected patients with rectal cancer in whom age, extent of disease or concurrent. illness preclude conventional surgical resection.
Ultrasonographic screening for abdominal aortic aneurysm in an urban community
Authors: Smith F C T , Grimshaw G M , Paterson I S , Shearman C P , Hamer J D
Published: March 2007

As part of the Birmingham Community Aneurysm Screening Project, 3500 men aged 65–75 years from 20 urban general practices were invited for aortic ultrasonographic screening at their own general practitioner's surgery; 2669 (76.3 per cent) attended. Compliance rates varied between catchment areas, from 52.1 per cent for inner-city areas to 89.6 per cent for suburbs. Successful aortic imaging was achieved in 97.3 per cent of scans. Aortic diameter > 29 mm occurred in 219 patients (8.4 per cent) and 79(3.0 per cent) with a diameter > 40 mm were referred for vascular surgical assessment; 140 patients with an aortic diameter of 29–40 mm are currently undergoing follow-up by serial ultrasonographic examinations at intervals of 3 months at their doctor's surgery. Risk factor analysis revealed ischaemic heart disease in 21.9 per cent of men with aneurysm, compared with 11.6 per cent in those without (P < 0.001); 18.3 per cent of men with aneurysm had had a previous myocardial infarction and 13.2 per cent had peripheral vascular disease, compared with 7.4 per cent (P < 0.001) and 8.0 per cent (P < 0.01) respectively of those without. No association was found between aneurysm and hypertension or diabetes. Community-based aortic screening is an inexpensive, effective method of diagnosis of aneurysm, with high compliance from the at-risk cohort of an urban population. Such screening programmes may help to reduce the mortality rate from aortic aneurysm rupture.
Resting energy expenditure in patients undergoing transhiatal or transthoracic oesophagectomy for carcinoma of the thoracic oesophagus
Authors: Sato N , Kusama A , Ohkawa A , Koyama Y , Oyamatsu M , Kayama S , Yoshikawa K , Tanaka O , Muto T
Published: March 2007

Resting energy expenditure (REE) was studied in five patients undergoing transhiatal and in 14 undergoing transthoracic oesophagectomy for carcinoma. All resections were performed with an intention to cure. REE was measured by indirect calorimetry before operation and on days 1, 3, 5 and 7 after surgery. Following transthoracic oesophagectomy, REE increased significantly on days 1, 3, 5 and 7 after operation, and on day 7 the value was significantly higher (P <0·05) than that obtained after transhiatal surgery. Energy expenditure following transhiatal oesophagectomy is lower than that after transthoracic oesophagectomy; this may be a result of reduced surgical stress.