bluuebunny/crossref_metadata_2025 huggingface dataset:
Regional review of blunt trauma in children
Authors: Teanby D N , Lloyd D A , Gorman D F , Boot D A
Published: March 2007

Seventy–five severely injured children (Injury Severity Score greater than 15 or death) were identified during a 1-year prospective audit of all severe trauma in a single region. Fourteen children were admitted primarily to the regional children's hospital, comprising 0–2 per cent of that accident and emergency department workload. Paediatric trauma admissions to the 15 district general hospitals averaged 3–1 children per hospital per year or 0–007 per cent of the accident and emergency department attendances. There were 38 deaths (51 per cent), of which 15 occurred before admission to hospital. Significant deficiencies in acute management were identified at both types of hospital. There is a need to improve trauma management of children at tertiary care level and district general hospitals by developing trauma management protocols. The low number of severely injured children presenting to the district general hospitals suggests the need for a regional trauma system.
Breast-conserving surgery and tumour bed positivity in patients with breast cancer
Authors: Macmillan R D , Purushotham A D , Mallon E , Ramsay G , George W D
Published: March 2007

Between March 1988 and April 1992, in 264 patients undergoing breast-conserving surgery for stage I and II cancer, the tumour bed was analysed for residual disease. After a conventional breast-conserving operation the entire wall of the cavity from which the lumpectomy specimen had been taken was excised. This was involved with disease in 38 per cent of patients. Additional random biopsies of the secondary cavity were performed in 130 patients and were involved with disease in 13 per cent. Residual disease was detected in the tumour bed of 37 per cent of patients with screen-detected tumours.
Adenocarcinoma of the duodenum: Factors influencing survival
Authors: Rotman N , Pezet D , Fagniez P-L , Cherqui D , Celicout B , Lointier P
Published: March 2007

The records of 66 patients with histologically proven adenocarcinoma of the duodenum were reviewed retrospectively to determine factors influencing survival. The parameters studied were age, sex, weight loss, jaundice, anaemia, duodenal stenosis, type of surgical procedure, tumour size and location, depth of parietal invasion, presence and location of lymph node metastases, and pancreatic invasion. These factors were assessed in a group of 46 patients who underwent curative resection of the tumour; 20 patients who received palliative procedures were excluded from statistical analysis. Survival curves were established by the Kaplan-Meier method and compared by the Mantel-Haentszel test. The actuarial 3- and 5-year survival rates of patients undergoing curative resection were 59 and 45 per cent respectively. None of the prognostic factors studied influenced survival. These results indicate that resection of adenocarcinoma of the duodenum should be performed whenever possible, even in the presence of lymph node metastasis and pancreatic spread.
Changing pattern of admission and operation for duodenal ulcer in Scotland
Authors: Jibril J A , Redpath A , Macintyre I M C
Published: March 2007

To assess changes in the pattern of admission and operation for duodenal ulcer in Scotland, data recorded on Scottish Medical Records forms for the years 1975–1990 were analysed. The overall admission rate fell by 38 per cent from 157 to 98 per 100000 population while the number of operations per year dropped by 80 per cent from 2955 to 582. There was a decline in perforation rate between 1975 and 1990 from 27 to 15 per 100000 population. This general trend conceals a significant 93 per cent increase in the incidence of duodenal ulcer perforation among women aged 65 years and above, from 21 per 100000 in 1975 to 41 per 100000 in 1990 (r=0·76, P<0·001). There was a general trend towards a decline in haemorrhage rates, although this was significant only for men aged 15–44 years (r= −0·73, P<0·01) and 45–64 years (r= −0·63, P<0·04).
Resection of hepatic and pulmonary metastases in patients with colorectal cancer
Authors: Gough D B , Donohue J H , Trastek V A , Nagorney D M
Published: March 2007

Nine consecutive patients underwent surgery for liver and lung metastases from colorectal cancer (Dukes' stage B in five, C in one and ‘D’ in three) between 1980 and 1991. A total of 21 procedures were performed: 16 thoracotomies with six lung lobectomies and 17 lung wedge resections, ten laparotomies with nine hepatectomies and six liver wedge resections. No operative or hospital deaths occurred and the mean(s.d.) postoperative hospital stay was 10(7) days per procedure. Perioperative blood transfusions for all nine patients amounted to a total of 7 units. The median survival after completion of liver and lung surgery was 27 (range 10–62) months. Median survival from resection of the first liver or lung metastasis was 30 (range 12–62) months and from excision of the primary colorectal tumour 46 (range 30–78) months. Two patients were alive and well 11 and 62 months after liver and lung resections; seven have died with metastases. This controversial aggressive treatment resulted in longer survival times than most alternative therapies in these highly selected and well motivated young patients, with no hospital mortality and only moderate morbidity.
Pancreatic transplantation as a small programme
Authors: Griffin P J A , Owens D , Krishnan H , Salaman J R
Published: March 2007

Seventeen pancreatic transplantations were performed in 17 patients with diabetic renal failure over a 6-year period. Ten patients received a simultaneous kidney transplant, the other seven having undergone previous successful renal transplantation. The actuarial pancreatic survival rate at 12 months was 63 per cent and the patient survival rate 92 per cent. The kidney transplant 12-month survival rate (86 per cent) did not differ significantly from that in a group of 22 diabetic patients receiving kidney transplants alone during the same period. Patients with a successful pancreatic transplantation had an increase in quality of life but most developed one or more complications; sometimes these required prolonged hospitalization. Pancreatic transplantation should be restricted to patients with diabetic renal failure who are particularly unstable or exhibit progressive diabetic complications. A small programme can be successful in directing what is an expensive procedure towards patients who are most likely to benefit.
Major hepatectomy and pancreatoduodenectomy for advanced carcinoma of the biliary tract
Authors: Tsukada K , Yoshida K , Aono T , Koyama S , Shirai Y , Uchida K , Muto T
Published: March 2007

Seven patients with advanced carcinoma of the extrahepatic biliary tract, including two with cancer of the gallbladder, underwent major hepatectomy with concomitant pancreatoduodenectomy. The mean hepatic volume resected was 64 (range 35–81) per cent. Postoperative complications occurred in all patients and accounted for two hospital deaths. Two patients with gallbladder carcinoma survived without recurrence for 22 and 58 months. Three of five patients with bile duct cancer survived operation, although all three subsequently died from recurrent disease at 8, 10 and 27 months. Combined major hepatectomy and pancreatoduodenectomy may be appropriate in selected patients with advanced cancer of the gallbladder. Further evaluation is necessary before this approach can be recommended for those with advanced bile duct carcinoma.
Cholesterolosis in patients with chronic acalculous biliary pain
Authors: Kmiot W A , Perry E P , Donovan I A , Lee M J R , Wolverson R F , Harding L K , Neoptolemos J P
Published: March 2007

The outcome of patients with cholesterolosis was compared with that of those with chronic cholecystitis operated on for chronic acalculous biliary pain. A total of 55 patients with acalculous biliary pain with a median symptom duration of 24 (range 6–120) months were investigated by dynamic cholescintigraphy and followed for a median of 24 (range 12–60) months. Thirty-five patients underwent cholecystectomy, of whom 22 had a low gallbladder ejection fraction (under 35 per cent), with symptomatic improvement in 21 of these (P<0·01). All four patients with a normal ejection fraction (35–50 per cent) improved after cholecystectomy but only four of nine with a high ejection fraction (over 50 per cent) did so. Results of histological examination were available in 32 patients and revealed cholesterolosis in 20. A low ejection fraction was found in 16 patients with cholesterolosis, of whom 15 showed symptomatic improvement after cholecystectomy; the other four patients had a high fraction and all improved after cholecystectomy. Overall, symptoms in 19 of 20 patients with cholesterolosis improved after cholecystectomy compared with only seven of 12 with chronic cholecystitis (P=0·03).
Choledochoduodenostomy and sphincterotomy in the treatment of choledocholithiasis
Authors: Ramirez P , Parrilla P , Bueno F S , Abad J M P , Muelas M S , Candel M F , Robles R , Aguilar J , Lujan J , Sanchez J
Published: March 2007

Over a 10-year period, 2610 patients underwent operation for biliary lithiasis. Exploratory choledochotomy was indicated in 591 patients (22·6 per cent). This was followed by simple choledochorrhaphy over a T tube in 240 patients (40·6 per cent), transduodenal sphincterotomy and choledochorrhaphy over a T tube in 126 (21·3 per cent), supraduodenal choledochoduodenostomy in 216 (36·5 per cent), and choledochoduodenostomy and transduodenal sphincterotomy in nine (1·5 per cent). Choledochoduodenostomy was performed if the bile duct was more than 12 mm in diameter. The indication for transduodenal sphincterotomy was the presence of a stone impacted in the papilla and/or papillary stenosis. Six patients developed abdominal abscess and three an external biliary fistula following choledochoduodenostomy. There were four abscesses and two episodes of acute pancreatitis in patients undergoing sphincterotomy. There was no difference in mortality rate between the two groups. After a mean follow-up of 5·6 years, 71·5 per cent of patients who underwent choledochoduodenostomy and 75·2 per cent of those who received transduodenal sphincterotomy were asymptomatic. The remainder suffered from dyspepsia, colicky pain or episodes of cholangitis. Nine patients underwent reoperation for residual calculi (six choledochoduodenostomies, three sphincterotomies).
Venous and non-venous leg ulcers: Clinical history and appearance in a population study
Authors: Nelzén O , Bergqvist D , Lindhagen A
Published: March 2007

In a defined Swedish population of 270 800, all patients with current chronic leg ulcers (827) were identified and a random sample of 382 studied in detail. Ulcers of primarily venous cause comprised 54 per cent of the total, giving a point prevalence of 0–16 per cent (95 per cent confidence interval 0–15-0-18 per cent). Half of all patients experienced their first ulcer episode before the age of 65 years, a greater proportion (61 per cent, P<0·0001) in the subgroup with venous ulcers. The median duration of ulcer diathesis was significantly longer in patients with venous than in those with non-venous lesions (13·4 versus 2·5 years, P < 0·001). About half the patients with venous and non-venous ulcers had had their current lesion for longer than 1 year. Venous ulcers were more often recurrent than those of non-venous type (72 versus 45 per cent of patients, P<0·0001). Patients with venous ulcers had a significantly higher body mass index (P<0·001). The number of dressing changes performed per week was 1100 per 100000 population. The predictive value of ‘classical’ clinical indicators of venous ulcer did not exceed 0·76. To increase the accuracy of diagnosis of venous ulcer, clinical examination should be combined with non-invasive ‘objective’ haemodynamic assessment of the venous circulation.
Experimental experience with a temporary intraluminal heparin-bonded polyurethane arterial shunt
Authors: Walker A J , Mellor S G , Cooper G J
Published: March 2007

After vascular injury, intraluminal arterial shunting may be employed if definitive surgery must be delayed. This paper describes use of a heparin-bonded polyurethane shunt to restore distal circulation after ligation of the femoral artery in sheep. In studies to determine tissue viability for 12 h after insertion into the femoral artery, five of seven shunts remained patent. In another series of experiments to study tissue viability after limb ischaemia, the femoral artery was ligated and a tight Esmarch bandage applied to the limb for 6 h before shunt insertion. The shunt remained patent for 12 h in five of six cases. Nearly all shunt failures occurred shortly after placement and were attributable to intimal damage arising from difficulties during insertion.
Audit of emergency preoperative resuscitation
Authors: McIlroy B , Miller A , Copeland G P , Kiff R
Published: March 2007

A total of 148 patients of mean age 61 years with acute gastrointestinal disease who were assessed as requiring preoperative resuscitation were studied. Overall, the mortality rate was 14·2 per cent and the morbidity rate 50·7 per cent. Resuscitation was associated with a mean(s.e.m.) improvement in predicted mortality rate of 4·2(0·8) per cent and in morbidity rate of 4·3(0·7) per cent. However, there was a group of patients in whom resuscitation was unsuccessful, despite there being no apparent difference in duration or methods of resuscitation from those of the rest of the population studied. A poor response to resuscitation was found in 28 patients; this was commoner in the elderly (P< 0·001) and in women (P< 0·05). Complications were more frequent in patients failing to improve with resuscitation (P< 0·001). In the group deteriorating despite resuscitative efforts, there was a greater proportion of patients with a perforated viscus (P< 0·001), whereas intestinal obstruction was less common (P< 0·05). This study demonstrates that resuscitation can be audited and quantified. Preoperative resuscitation appears to be beneficial, but there is a group that may benefit from synchronous surgery and resuscitation.
Impact of thymopentin on the incidence and severity of postoperative infection: A randomized controlled trial
Authors: Braga M , Costantini E , Di Francesco A , Gianotti L , Baccari P , Di Carlo V
Published: March 2007

The effectiveness of perioperative administration of thymopentin in preventing postoperative infection was evaluated in 206 patients with cancer (54 gastric, 152 colorectal) who underwent elective major surgery. Comparable subsets of patients were obtained with respect to age (proportion over 65 years) and nutritional status (patients with serum albumin level less than 30 g/l or weight loss of 10 per cent or more of usual body-weight were considered to be malnourished). Patients were then randomly assigned to a control group or to a group receiving thymopentin. All patients received perioperative short-term antibiotic prophylaxis and postoperative parenteral nutrition. Levels of CD3-, CD4- and CD8-positive T cell subsets were evaluated before and after surgery in 20 (ten elderly) patients from each group. The severity of postoperative infection was evaluated using a sepsis score. In elderly patients thymopentin prevented the postoperative drop in CD3- and CD4-positive T cell subpopulations that was observed in controls (P < 0·05). The postoperative infection rate was 17·5 per cent in the group given thymopentin and 24·3 per cent in controls (P not significant). The mean(s.d.) sepsis score was 6·7(3·1) in the group receiving thymopentin and 9·4(5·8) in controls (P not significant). Considering only elderly patients, the mean(s.d.) sepsis score was significantly lower in those treated with thymopentin than in control patients (6·9(2·1) versus 11·3(4·7)). In conclusion, administration of thymopentin did not significantly reduce the postoperative infection rate. However, it prevented the drop in number of CD3- and CD4-positive T cells after operation and reduced the severity of postoperative infection in elderly patients.
Tumour necrosis factor-mediated release of plasminogen activator inhibitor 1 by human peritoneal mesothelial cells
Authors: Whawell S A , Scott-Coombes D M , Vipond M N , Tebbutt S J , Thompson J N
Published: March 2007

Human mesothelial cells synthesize plasminogen activator inhibitor (PAI) 1 in inflamed peritoneal tissue. The role of tumour necrosis factor (TNF) in the mediation of this response was studied. Postoperative peritoneal drain fluid contained both TNF and PAI-1. Peak levels of TNF at 4 h (median 271 pg/ml) preceded a rise in PAI-1 concentration, which peaked at 18 h (median 943·1 ng/ml). Thus TNF may mediate increased PAI-1 release in inflamed peritoneum. TNF significantly increased the mean(s.e.m.) release of PAI-1 by human peritoneal mesothelial cells in vitro at 4 h (control 1·84(0·17) ng/μg versus TNF 2·37(0·17) ng/μg, P0·05), 6 h (2·53(0·09) versus 3·88(0·46) ng/μg, P<0·05), 18 h (0·50(0·02) versus 1·04(0·11) ng/μg, P<0·05) and 24 h (0·87(0·05) versus 1·35(0·11)ng/μg, P<0·05). TNF may be an important mediator of PAI-1 production by human mesothelial cells during peritoneal inflammation.
Recurrent laryngeal nerve palsy after thyroid gland surgery
Authors: Wagner H E , Seiler Ch
Published: March 2007

Risk factors for recurrent laryngeal nerve (RLN) lesions after thyroid gland surgery were evaluated retrospectively in 1026 patients. RLN palsy occurred in 5·9 per cent; the incidence of permanent palsy was 2·4 per cent as 59 per cent of paralyses were transient. For euthyroid nodular goitre, Graves' disease, chronic lymphocytic thryoiditis, recurrent goitre and thyroid carcinoma, permanent nerve damage occurred in 1·7, 4, 5, 3·8 and 8 per cent of patients respectively. In relation to the number of nerves at risk, the incidence of permanent RLN palsy was 1·1 per cent for subtotal lobectomy and 4·0 per cent for total lobectomy. The overall incidence of permanent RLN palsy was 1·8 per cent of nerves at risk. There was no statistically significant difference between the number of RLN paralyses occurring after nerve exposure and that occurring after non-exposure in subtotal lobectomy, but in total lobectomy the permanent palsy rate increased from 3·8 to 7 per cent when the nerve was not exposed or identified (P<0·01). Underlying thyroid disease, the extent of resection and exposure of the nerve in total lobectomy are risk factors for both transient and permanent RLN palsy.
Right thoracoscopically assisted oesophagectomy for cancer
Authors: McAnena O J , Rogers J , Williams N S
Published: March 2007

Thoracoscopic mobilization was performed in nine patients with oesophageal cancer. Five principles emerged as essential for successful dissection: (1) the selection of patients with mobile oesophageal tumours without evidence of local invasion; (2) double-lumen anaesthesia and complete collapse of the right lung during surgery; (3) simultaneous use of a flexible gastroscope; (4) high-quality illumination; and (5) minimal blood loss during dissection. The surgeon should have adequate training in thoracic operations. Further experience should permit mediastinal lymph node dissection. Postoperative pulmonary complications were common, requiring prolonged intensive care management. Widespread adoption of the technique cannot be recommended.
Distal splenorenal shunting for bleeding gastric varices
Authors: Thomas P G , D'Cruz A J
Published: March 2007

In patients with bleeding gastric varices from causes other than splenic vein thrombosis, endoscopic sclerotherapy and ablative surgery have yielded poor results. Over a 3-year period starting in June 1989, a total of 30 distal splenorenal shunts were performed prospecdvely on 19 paediatric and 11 adult patients with bleeding gastric varices and good liver function. The mean(s.d.) age was 17(12) (range 6–50) years; there were 20 male and ten female patients of whom six had cirrhosis, four non-cirrhotic portal fibrosis and 20 portal vein thrombosis. Two patients died and two more had shunt thrombosis; all four were considered failures of treatment. Hypersplenism was present in 15 patients but reverted to normal in 13. In 26 patients the gastric varices disappeared. Concomitant oesophageal varices were present in 22 patients and showed marked regression, with no rebleeding over a mean(s.d.) follow-up of 21(10) (range 7–39) months. A distal splenorenal shunt was effective in controlling gastric variceal haemorrhage in 26 of 30 patients in whom liver function was well preserved.
Compartment syndrome in experimental chronic obstructive pancreatitis: Effect of decompressing the main pancreatic duct
Authors: Karanjia N D , Widdison A L , Leung F , Alvarez C , Lutrin F J , Reber H A
Published: March 2007

Chronic pancreatitis is characterized by persistent and severe pain, which can be relieved by decompression of the main pancreatic duct (MPD). Both ductal and interstitial pressures have been shown to be increased in chronic pancreatitis in patients. A study was carried out of pancreatic interstitial pressure and pancreatic blood flow in normal cats and those in which chronic obstructive pancreatitis had been induced 5 weeks earlier to determine the effect of decompression of the MPD. In the normal pancreas, median (interquartile range (i.q.r.)) basal interstitial pressure was 0·05(1·2) mmHg and median (i.q.r.) basal pancreatic blood flow 58·3(24·3) ml per min per 100 g. Secretory stimulation did not change the interstitial pressure significantly, but was associated with a 40 per cent increase in median(i.q.r.) blood flow to 81·8(45·8) ml per min per 100 g. In contrast, in chronic obstructive pancreatitis, the median(i.q.r.) basal inteistitial pressure was 2·0(1·5) mmHg, which was significantly higher than in the normal gland, and median(i.q.r.) pancreatic blood flow was 38·3(9·8) ml per min per 100 g, significantly lower than in the normal pancreas. Furthermore, secretory stimulation was associated with a significant increase in median(i.q.r.) interstitial pressure to 3·3(1·6) mmHg and a simultaneous decrease in median(i.q.r.) blood flow to 31·5(13·7) ml per min per 100 g. After decompression of the MPD in cats with chronic obstructive pancreatitis, the median(i.q.r.) basal interstitial pressure was 2·0(1·4) mmHg and on secretory stimulation 1·8(1·5) mmHg. Decompression thus prevented the increase in interstitial pressure seen in the animals with obstruction. In contrast, ductal decompression improved the median(i.q.r.) basal pancreatic blood flow to 45·9(38·4) ml per min per 100 g and, furthermore, this increased significantly on secretory stimulation to a median(i.q.r.) of 81·4(47·8) ml per min per 100 g. Decompression thus restored the normal pattern of secretory hyperaemia. Within the confines of this model, these observations demonstrate that chronic obstructive pancreatitis exhibits a compartment syndrome that is relieved by duct drainage.
Motor determinants of incontinence after ileal pouch–anal anastomosis
Authors: Ferrara A , Pemberton J H , Grotz R L , Hanson R B
Published: March 2007

Anal canal pressure gradient and ileal pouch motor activity were studied in continent and incontinent patients after ileal pouch-anal anastomosis. A multichannel microtransducer catheter was positioned in eight continent and eight incontinent patients 15 months or more after operation and 24-h ambulatory motor activity recorded. Resting anal pressures were significantly lower for incontinent patients during the day and night. The frequency of high-pressure waves was identical in both groups, but peak pressures were higher for incontinent patients. For continent patients, each high-pressure wave was accompanied by a rapid increase in anal canal pressure such that pressure in the pouch was always less than that in the anal canal. For incontinent patients this response was often absent. Incontinent patients had lower resting pressure, more prolonged anal canal relaxation, higher amplitude high-pressure waves and a non-responsive anal canal; the anal canal pressure gradient was therefore frequently reversed.
Lateral lymph node dissection for rectal carcinoma below the peritoneal reflection
Authors: Moreira L F , Hizuta A , Iwagaki H , Tanaka N , Orita K
Published: March 2007

Lateral lymph node dissection has been advocated for advanced low rectal tumours. However, its benefit is debatable because of the possibility of postoperative bladder and sexual impairment. To assess the role of lateral lymph node dissection 95 patients who underwent the procedure between 1981 and 1991 were reviewed and compared with 83 who had resection of rectal cancer without lateral node dissection. Only ten (11 per cent) of the 95 patients had lateral lymph node involvement; all had Dukes'C tumours. Lymphovascular invasion was present in 50·6 per cent of all patients and neural invasion in 27 per cent of 65 examined specimens. Local recurrence, distant metastasis and overall 5-year survival rates were 7, 9 and 76 per cent respectively in patients undergoing extended lymphadenectomy and 16, 7 and 72 per cent respectively in those who had resection alone. There were no statistically significant differences in survival between the two groups for any Dukes' stage. Recurrence, metastasis and survival were related more to venous or neural invasion and tumour spread than to node dissection. These results demonstrate that patients with Dukes' A tumours do not benefit from latera lymph node dissection, and that local recurrence rates in those with Dukes' B and C lesions are not significantly decreased. It is concluded that extended lymphadenectomy is unlikely to provide significant benefit to patients with low rectal cancer.
Abdominal resection rectopexy with pelvic floor repair versus perineal rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse
Authors: Deen K I , Grant E , Billingham C , Keighley M R B
Published: March 2007

A randomized trial was performed to compare abdominal resection rectopexy and pelvic floor repair (n = 10) with perineal rectosigmoidectomy and pelvic floor repair (n = 10) in elderly female patients with full-thickness rectal prolapse and faecal incontinence. There were no recurrences of full-thickness prolapse following resection rectopexy but one after rectosigmoidectomy. Continence to liquid and solid stool was achieved in nine patients, with faecal soiling reported in only two, after resection rectopexy and in eight, with soiling in six, following rectosigmoidectomy. The median (range) frequency of defaecation was only 1 (1–3) per day following resection rectopexy compared with 3 (1–6) per day after rectosigmoidectomy. There was an increase in the mean(s.d.) maximum resting pressure after resection rectopexy (19·3(15·28) cmH2O) compared with a reduction following rectosigmoidectomy (– 3·4(13·75) cmH2O) (P = 0·003). Mean(s.d.) compliance was also greater after resection rectopexy than following rectosigmoidectomy (3·9(0·75) versus 2·2(0·78) ml/cmH2O, P<0·001). Abdominal resection rectopexy gives better functional and physiological results than perineal rectosigmoidectomy.
Peritonitis impairs intestinal absorption of proline and leucine in the rat
Authors: Gardiner K R , Gardiner R E , Barbul A
Published: March 2007

Systemic sepsis is associated with reduced mesenteric blood flow and impairment of metabolic and barrier functions of the small intestine. A study was performed in the rat to investigate the effect of sepsis induced by caecal ligation and double puncture on intestinal absorption of leucine and proline in vivo. Absorption was studied 24 h after caecal ligation and puncture by measuring intestinal disappearance and circulatory appearance of intraluminal 3H-labelled amino acid over a 60-min study period.

Peritonitis resulted in a significant increase relative to controls in the mean(s.e.m.) percentage of leucine (67.2(3.6) versus 18.0(3.5), P<0.001) and proline (64.7(6.0) versus 15.1(3.7), P<0.001) remaining within the small intestine. There were significant decreases in portal venous and femoral arterial concentrations of leucine and proline in animals with sepsis. Intestinal amino acid absorption is impaired in this model.
Surgical assessment of acute anorectal sepsis is a better predictor of fistula than microbiological analysis
Authors: Lunniss P J , Phillips R K S
Published: March 2007

Twenty-two patients with acute anorectal sepsis were examined prospectively to compare surgical assessment with microbiological analysis as predictors of the aetiology of the sepsis. Culture of gut organisms was a sensitive method of detecting an underlying fistula but was not particularly specific (80 per cent). Demonstration of sepsis in the intersphincteric space in association with an anorectal abscess was 100 per cent sensitive and 100 per cent specific for detection of an underlying fistula. The demonstration was facilitated by a radially placed incision.
Provision of vascular surgical services in the Oxford Region
Authors: Michaels J A , Browse D J , McWhinnie D L , Galland R B , Morris P J
Published: March 2007

Vascular surgical practice across an entire health region was studied. There was a mean of 115.9 inpatient episodes and 46.9 vascular reconstructions per 100000 population, with considerable variation between districts. Vein utilization for infrainguinal grafts was greater in the teaching hospital and few femorodistal grafts or carotid endarterectomies were carried out elsewhere; there were few tertiary referrals of elective vascular cases. Only two districts have formal arrangements for emergency vascular ‘on-call’. There is marked inequality of provision of vascular surgical services across the region.
Incidence and management of catheter-related sepsis in patients receiving home parenteral nutrition
Authors: Williams N , Carlson G L , Scott N A , Irving M H
Published: March 2007

Fifty patients, comprising 24 male and 26 female of median age 43 (range 15–67) years, received a total of 2620 patient-months of home parenteral nutrition (median 48 (range 2–130) months). There were 13 episodes of bacterial catheter sepsis (of which the catheter was successfully salvaged by an antibiotic-fibrinolytic ‘lock’ technique in four cases) and ten of exit-site sepsis (all managed by elective catheter replacement), representing an incidence of 1 septic complication per 113 patient-months of parenteral nutrition. This low incidence of catheter-related sepsis was achieved by strict adherence to established protocols of catheter management.
Oesophageal perforation: Primary suture repair reinforced with absorbable mesh and fibrin glue
Authors: Bardaxoglou E , Campion J P , Landen S , Manganas D , Siriser F , Chareton B , Launois B
Published: March 2007

Despite major advances in the management of intrathoracic oesophageal perforation, morbidity and mortality rates remain high1,2. Currently accepted management3 includes early thoracotomy, cleansing of the mediastinum, oesophageal suture and pleural space drainage. Even when performed at an early stage, primary oesophageal suture repair remains precarious, however. Experience of oesophageal primary suture reinforced with absorbable mesh and fibrin glue is reported.
Laparoscopic Nissen fundoplication: Technique and preliminary results
Authors: Cadière G B , Houben J J , Bruyns J , Himpens J , Panzer J M , Gelin M
Published: March 2007

Between May 1991 and November 1992, 80 consecutive patients with gastro-oesophageal reflux disease underwent laparoscopic Nissen fundoplication. The technique used was exactly the same as for the conventional open approach. There were no deaths but there were four peroperative complications: one gastric perforation, two pleural perforations and one hepatic laceration. Three conversions to laparotomy were necessary, one because of a defective needle holder and two as a result of left hepatic lobe hypertrophy. The duration of operation ranged from 40 to 300 (median 150) min. The median postoperative stay was 3 days, but increased to 10 days in two patients who developed pulmonary infection. One major postoperative complication (necrosis of the wrap) required a laparotomy on day 8 after operation. No recurrence of heartburn has been observed and there were no instances of long-term dysphagia after surgery. These findings indicate that laparoscopic Nissen fundoplication can be performed safely if the team is well trained.
Prognostic significance of the number of positive lymph nodes in gastric carcinoma
Authors: Adachi Y , Kamakura T , Mori M , Baba H , Maehara Y , Sugimachi K
Published: March 2007

A total of 195 patients with node-positive gastric carcinoma who were treated by curative gastrectomy and lymphadenectomy were studied to evaluate the prognostic significance of the number of metastatic lymph nodes. Univariate analysis showed that the number and level of positive nodes, tumour size and depth of invasion, and type of gastrectomy were significantly related to patient survival. Multivariate analysis indicated that the number of positive nodes (up to six versus seven or more; relative risk 2.91), depth of invasion (three levels; relative risk 1.83) and histological type (well versus poorly differentiated; relative risk 0.63) were independently correlated with survival. The results indicate that the total number of positive nodes is the most significant prognostic factor in patients with node-positive gastric carcinoma.
Should general surgeons treat gastric carcinoma? An audit of practice and results, 1980–1985
Authors: McCulloch P
Published: March 2007

An audit of treatment of gastric carcinoma was conducted in a major general hospital unit in the UK over a 5-year period. In all, 206 patients (114 men, 92 women) with a mean age of 68 years were treated. Operation was performed in 150 patients; 87 underwent gastrectomy with 31 procedures appearing potentially curative. Most tumours were advanced at diagnosis: 92 were stage IV and 34 stage IIIB, with 42 tumours at earlier stages. After the 87 gastrectomies anastomotic leakage occurred in 16 patients (18 per cent) and there were 14 deaths (16 per cent). The rates of resectability, inadequate resection, anastomotic leakage and postoperative mortality varied considerably between surgeons. The 5-year survival rate was 5 per cent overall, 11 per cent after gastrectomy and 32 per cent following curative resection. The results of treatment of gastric cancer by general surgeons are poor and show marked variation between operators. The declining incidence of the disease makes prospective audit difficult. Treatment by fewer surgeons specializing in this area might improve the outcome.
Abdominal ultrasonography for the diagnosis of strangulation in small bowel obstruction
Authors: Ogata M , Imai S , Hosotani R , Aoyama H , Hayashi M , Ishikawa T
Published: March 2007

The efficacy of abdominal ultrasonography for the recognition of strangulation was evaluated prospectively in 231 patients with adhesive small bowel obstruction. The diagnosis based on ultrasonographic criteria was accurate in 35 of 39 patients with strangulation and in 176 of 192 with simple obstruction. Abdominal ultrasonography revealed the presence of strangulation in 13 of 15 patients with strangulation who were clinically diagnosed as having simple obstruction, and ruled it out in 28 of 36 with simple obstruction who were clinically suspected to have strangulation. An akinetic dilated loop observed on real-time ultrasonography proved to have high sensitivity (90 per cent) and specificity (93 per cent) for the recognition of strangulation; however, its positive predictive value for strangulation was only 73 per cent. The presence of peritoneal fluid was sensitive for strangulation. Compared with clinical judgement based on conventional parameters, abdominal ultrasonography proved to be useful for the early recognition of strangulation.
Cystic dilatation of the common bile duct: Surgical treatment and long-term results
Authors: Benhidjeb T , Münster B , Ridwelski K , Rudolph B , Mau H , Lippert H
Published: March 2007

Twelve patients (11 female) with an extrahepatic biliary cyst (six type I, three type II and three type III according to the classification of Todani) are reviewed with emphasis on aetiology, clinical features and long-term results at follow-up of 3–10 years. The clinical manifestations were abdominal pain, cholestasis with jaundice, fever and episodes of pancreatitis. The diagnosis was established before surgery in all cases by ultrasonography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and computed tomography. An abnormally long common channel was found in four patients. Three patients had had cysts drained internally in the 1970s. Of these three patients, one developed carcinoma of the cyst 23 years later. Radical excision of the dilated bile duct and reconstruction by Roux-en-Y hepaticojejunostomy was performed in nine cases. Two patients, each with a small choledochocele, were treated successfully by endoscopic sphincterotomy and stone extraction. There were no serious postoperative complications. All nine patients operated on remained in good health for 3–10 years. These results support radical excision of the cystically dilated bile duct with reconstruction by end-to-side Roux-en-Y hepaticojejunostomy for types I and II cyst. Endoscopic treatment of type III choledochocele should be limited to the management of smaller lesions.
Local recurrence of rectal adenocarcinoma after ‘curative’ surgery with and without preoperative radiotherapy
Authors: Holm T , Cedermark B , Rutqvist L-E
Published: March 2007

The natural history of locally recurrent rectal cancer was analysed to assess whether preoperative irradiation altered the clinical course of the disease. In a randomized controlled trial of 849 patients, the value of preoperative radiotherapy in those with operable rectal adenocarcinoma was examined. After a minimum follow-up of 4 years, 156 patients who developed local recurrence were studied retrospectively. There were no differences concerning symptoms and the site of local recurrence between irradiated and non-irradiated patients. Curative treatment was rarely possible and median survival was only about 1 year, irrespective of adjuvant treatment. Local recurrence was the only manifestation of disease in 30–50 per cent of patients. An earlier and more aggressive surgical approach might improve survival.
Canine model for treatment of faecal incontinence using transposed and electrically stimulated sartorius muscle
Authors: Konsten J , Baeten C G M I , Havenith M G , Soeters P B
Published: March 2007

A neosphincter was successfully created around each end of a Thiry-Vella loop in five dogs using transposed sartorius muscle to study new treatments for faecal incontinence. One of these dynamic neosphincters in each dog was electrically trained for 8 weeks while the other served as a control. Muscle biopsies demonstrated an increase in type 1 fatigue-resistant fibres from a median of 49 (range 37–54) per cent before electrical stimulation to 78 (range 53–99) per cent 8 weeks later in the stimulated sartorius neosphincters (P<0.05), whereas the percentage of type 1 fibres in control neosphincters increased only slightly.

Retention times of saline increased from a median of 10 (range 5–50) s before to 340 (range 100–470) s after electrical stimulation (P< 0.05) but also increased in control neosphincters (to 370 (range 330–1200) s); this may indicate that electrical stimulation immediately increases acute retention times. It is concluded that construction of a neosphincter is technically feasible with preservation of muscle morphology and that stimulation induces morphological and functional changes towards the characteristics of the external anal sphincter.
Short bowel syndrome: Metabolic and surgical management
Authors: Shanbhogue L K R , Molenaar J C
Published: March 2007

The management of short bowel syndrome requires long-term nutritional support and monitoring, medication, and occasionally additional surgical procedures. Constant attention is required to ensure adequate adaptation of the gut. This article reviews the normal function of the small bowel, adaptation following resection, total parenteral and enteral nutrition, and the role of adjunctive surgical procedures in the management of short bowel syndrome.
Malignant anal tumours
Authors: Deans G T , McAleer J J A , Spence R A J
Published: March 2007

Anal tumours represent 5 per cent of anorectal cancers and exist as two clinical entities: tumours of the anal canal and those of the anal margin. Smoking and sexual behaviour, particularly homosexual anal intercourse, are important aetiological factors. This association is related to anal warts and human papillomavirus infection, notably type 16, which is found in around 70 per cent of warts. Symptoms are non-specific and are frequently attributed to benign conditions. Rectal examination reveals a characteristically infiltrating lesion and any suspicious anal area should be biopsied. There are two histological types. Squamous carcinoma comprises approximately 95 per cent of anal tumours and includes the 35 per cent of tumours derived from the anal transition zone (cloacogenic tumours), containing a mixture of squamous and mucinous elements. The remaining 5 per cent of anal tumours are adenocarcinoma. Squamous cell tumours of the anal canal are probably best treated using radiotherapy (with chemotherapy) as complete response rates, 5-year survival rates, and incidences of normal sphincter function and significant toxicity are around 80, 70, 75 and 20 per cent respectively. Treatment failures may be salvaged by surgery. The 5-year survival and local recurrence rates for radical surgery are around 60 and 25 per cent respectively; there are few indications for local excision. In contrast, 60 per cent of anal margin tumours are suitable for local excision, the 5-year survival rate being in excess of 80 per cent. Combining radiotherapy with surgery may give additional benefit. Current randomized controlled trials should further clarify the relative merits and demerits of the treatment options.
Treatment and outcome of severe lower-limb ischaemia
Authors: Sayers R D , Thompson M M , Hartshorne T , Budd J S , Bell P R F
Published: March 2007

The overall outcome of severe lower limb ischaemia in terms of limb salvage and mortality is poorly documented. A consecutive series of 232 severely ischaemic legs in 209 patients was therefore studied. An aggressive policy of revascularizaon has been pursued; this was attempted in 89 per cent of legs, with a primary amputation rate of 8 per cent. The perioperative 30-day limb salvage rate was 79 per cent with a patient mortality rate of 20 per cent. At 12 and 24 months the limb salvage rates were 74 and 71 per cent and patient survival rates 75 and 73 per cent respectively. To identify high-risk groups the effects on limb salvage and mortality of age, sex, presentation, diabetes and ankle systolic pressure of 50 mmHg or less were studied. Using life-table analysis, none of the preoperative risk factors had an effect on limb salvage and mortality. An aggressive policy of revascularization provides excellent results in the treatment of patients with severe leg ischaemia.
Penetrating injuries of the subclavian vessels
Authors: Degiannis E , Velmahos G , Krawczykowski D , Levy R D , Souter I , Saadia R
Published: March 2007

A study was made of 76 patients with subclavian vessel injury. The mechanism of trauma was stabbing in 40 patients (53 per cent) and gunshot in 36 (47 per cent). There were marked differences between the two groups in clinical presentation, operative management and outcome. The group with gunshot injury was characterized by a more immediate threat to life, and a greater need for a median sternotomy and use of interposition grafts. The mortality rate in patients with gunshot wounds was more than twice that in the group with stab injury.
Extracranial carotid artery flow measurement during carotid endarterectomy using a Doppler ultrasonographic flowmeter
Authors: Whyman M R , Naylor A R , Ruckley C V , Wildsmith J A W
Published: March 2007

A study was performed to evaluate immediate changes in carotid artery blood flow after carotid endarterectomy using a Doppler ultrasonographic flowmeter. Forty-seven consecutive patients aged 49–78 (median 64) years with symptomatic internal carotid artery (ICA) stenosis underwent carotid endarterectomy. Volume flow, resistance and pulsatility index were measured in the common carotid artery (CCA) and ICA both before and after operation. ICA flow increased by 54 per cent (P<0.01) and resistance decreased by 58 per cent (P = 0.01). CCA flow rose by 17 per cent (P = 0.1) and resistance fell by 21 per cent (P = 0.02). The pulsatility index did not change significantly. The Doppler ultrasonographic flowmeter offers a simple, non-invasive and convenient means of improving understanding of the immediate haemodynamic effects of carotid endarterectomy. It is useful in everyday practice to confirm the adequacy of endarterectomy, particularly in the absence of other methods of quality control. Duplex ultrasonography might still be necessary after surgery if the flowmeter does not demonstrate an increase in flow compared with the preoperative value.
Postoperative changes in resting energy expenditure and interleukin 6 level in infants
Authors: Jones M O , Pierro A , Hashim I A , Shenkin A , Lloyd D A
Published: March 2007

The relationship was determined between resting energy expenditure (REE) and interleukin (IL) 6 level following surgery in infants. Sixteen infants of mean(s.e.m.) weight 3.2(0.2) kg undergoing uncomplicated surgery were studied. The operative stress score was recorded and plasma IL-6 levels were measured before and 4, 8, 12 and 24 h after surgery. Respiratory gas exchange was measured by indirect calorimetry before and at 2, 4, 6, 8, 10, 12, 24 and 48 h. Urinary nitrogen excretion was measured and calculated. IL-6 levels increased significantly after surgery (P = 0.006) and were maximal at 12 h. There was a linear correlation between the increase in IL-6 level and operative severity score (r = 0.61, P = 0.012). REE increased significantly after operation (P0.001), peaking at 2–4 h, and returned to baseline levels by 12 h. The changes in REE preceded those in IL-6. IL-6 is a marker of the stress response in infants and may play a role in the subsequent modulation of this response.
Effect of surgical trauma on muscle protein synthesis in the rat
Authors: Emery P W , Ghusain-Choueiri A
Published: March 2007

The rate of protein synthesis in skeletal muscle was measured in vivo in rats at various times during the first 2 days after abdominal surgery. Protein synthesis in abdominal muscle at the site of the wound was slightly reduced 2 h after operation, had returned to normal by 24 h and was massively increased by 48 h after surgery. In contrast, there was no change at any time in the rate of protein synthesis in either the gastrocnemius muscle or abdominal muscle distant from the wound site. Surgery had no effect on the weight or protein content of the gastrocnemius muscle, although urinary nitrogen excretion was increased relative to food intake, indicating the presence of a net catabolic response. Changes in whole-body protein turnover in response to uncomplicated abdominal surgery are thus likely to reflect the anabolic processes of wound healing and repair as well as any catabolic response in uninjured tissues.