bluuebunny/crossref_metadata_2025 huggingface dataset:
Duplex scanning of the internal carotid artery: An assessment of cerebral blood flow
Authors: Leopold P W , Shandall A A , Feustel P , Corson J D , Shah D M , Popp A J , Fortune J B , Leather R P , Karmody A M
Published: March 2007

Duplex ultrasound scanning (B-mode imaging and pulsed Doppler shift analysis) was used to measure internal carotid artery blood flow (ICBF) in 20 volunteers. The effect of changes in end tidal CO2 on cerebral blood flow was measured. When corrected to a Pco, of 40 torr (5.32 kPa) internal carotid artery blood flow was 286 ± 16 ml min−1 (mean ± s.e.m.). Specific CO2 reactivity (the change in flow per torr change in CO2) was 8·16±0·69 ml min−1 torr−1 which was equivalent to 2·0 ± 0·1 per cent of the flow at 40 torr per torr change in CO2 (percentage CO2 reactivity). The mean value and the CO2 reactivity compare favourably with previously reported measurements by other techniques. These data suggest that the non-invasive measurement of internal carotid artery blood flow by Doppler ultrasound scanning is an assessment of cerebral blood flow that can be used to study both normal and pathological changes within the cerebral circulation.
Orchidopexy: The effect of changing patterns of referral and treatment on outcome
Authors: London N J M , Joseph H T , Johnstone J M S
Published: March 2007

One-hundred and twenty-eight orchidopexies performed between 1979 and 1981 were reviewed in 1985, and the results compared with the results of operations performed in 1972. The age of referral has been determined for 1972, 1979–1981 and 1985. The number of unsatisfactory results has decreased from 35 per cent in 1972 to 9.4 per cent between 1979 and 1981. Five cases of the ‘ascending testicle’ were discovered, confirming the importance of this phenomenon. We suggest that the optimum age for orchidopexy is during the second year of life; however, during 1985, only 20 per cent of boys referred for orchidopexy were under 3 years of age. Doctors performing neonatal examinations should consider the possibility of cryptorchidism and ensure that affected neonates are reviewed at 1 year. The potential theoretical advantages of orchidopexy at an early age will only be converted into clinical benefit if the operation is performed by an experienced surgeon who has developed an expertise in this area of surgery.
Implantation of a pressure cuff around the subphrenic oesophagus
Authors: Miskowiak J , Burcharth F , Olesen H P , Baden H , Hald T , Aggestrup S
Published: March 2007

The possibility of implanting a pressure cuff around the subphrenic oesophagus as a barrier to reflux was tested in six pigs. The oesophagus tolerated cuff pressures from 48 to 95 cm H2O, corresponding to intra-oesophageal pressures from 27 to 75 cm H2O. The pigs with the perioesophageal cuff swallowed a solid diet without difficulty. However, dysphagia occurred in pigs kept alive for more than a month and the main reason was malfunction of the device because of surrounding fibrosis. This problem should be solved before implantation of the device in humans is attempted.
Edrophonium provocation test in the diagnosis of diffuse oesophageal spasm
Authors: Linsell Jane , Owen W J , Mason R C , Anggiansah Angela
Published: March 2007

Criteria for diffuse oesophageal spasm(DOS) are dysphagia and chest pain with oesophageal manometry showing retention of peristalsis with the presence of synchronous contractions in response to wet swallows. Because of the intermittent nature of the symptoms, edrophonium was used as a provocative agent to increase diagnostic yield. Three hundred and ninety-six patients underwent transnasal manometry using a Gaeltec system of six internal transducers arranged at 5 cm intervals from the catheter tip; the majority of these patients received 10 mg edrophonium as an intravenous bolus. Reproduction of symptoms with typical manometry of DOS indicated a positive provocation test. There were no significant side effects. DOS was diagnosed in 34 patients who had either the typical manometry or a positive provocation test. Thirty of these patients received edrophonium. Twenty patients had baseline manometry which was diagnostic and ten of this group had a positive provocation test. The remaining 10 patients, who had normal baseline manometry, had positive provocation tests following the injection of edrophonium. Without edrophonium provocation testing, about a third of patients would not have been diagnosed as having DOS.
Intracystic injection of OK-432: A new sclerosing therapy for cystic hygroma in children
Authors: Ogita S , Tsuto T , Tokiwa K , Takahashi T
Published: March 2007

Nine patients with cystic hygroma were treated with a new sclerosing therapy consisting of intracystic injection of OK-432 (group A Streptococcus pyogenes of human origin). Favourable results including complete regression in eight patients and marked regression in one were observed within 2–3 months without serious side-effects except for fever of 2–3 days' duration and local inflammatory reaction lasting for 3–4 days. Local inflammatory reaction did not cause any damage to the overlying skin and did not lead to scar formation.
Intussusception in children 5–15 years of age
Authors: Reijnen J A M , Joosten H J M , Festen C
Published: March 2007

Twenty cases of intussusception in children between the ages of 5 and 15 years were compared with intussusception in infancy and early childhood. They accounted for 18·5 percent of all 108 children treated for intussusception in two large hospitals from 1964 to 1984. Diagnosis of intussusception was delayed, probably due to an unusual presentation. Fifty-five per cent had a definite predisposing factor precipitating the intussusception and 45 per cent had a small bowel intussusception, which warranted early surgical intervention. In the absence of contraindications no child should be disqualified from an attempt at hydrostatic reduction. After hydrostatic reduction careful follow-up is required to exclude an organic lesion, possibly by a small bowel follow-through meal. Surgery is indicated after hydrostatic reduction in case of chronically recurrent abdominal complaints.
The ischaemic leg as a source of complement activation
Authors: Bengtson A , Holmberg Pia , Heideman M
Published: March 2007

Complement activation before and after surgical resection was studied in 40 patients with ischaemic legs (17 with acute and 23 with chronic ischaemia). Plasma anaphylatoxin concentrations (C3a and C5a) and anaphylatoxin inhibitor (AI) activity were studied pre-operatively, and 1h, 24 h and 1 week postoperatively. Increased plasma anaphylatoxin concentrations were found pre-operatively. Anaphylatoxin levels in plasma had returned to normal one week postoperatively. Patients with acute ischaemia had higher plasma C3a and C5a pre-operatively and during the first 24 h postoperatively than patients with chronic ischaemia. Anaphylatoxins increase vascular permeability, smooth muscle contraction and histamine release from mast cells. Their enhanced activity might be one of the explanations for respiratory, hepatic and renal insufficiency before surgical resection in patients with extensive ischaemia.
Evaluation of the prognostic factors in gastric cancer: The effect of chemotherapy on survival
Authors: Cunningham D , Hole D , Taggart D J , Soukop M , Carter D C , McArdle C S
Published: March 2007

This is a retrospective review of 328 consecutive patients with histologically confirmed gastric adenocarcinoma diagnosed in one centre between 1974 and 1984. Of these patients, 128 (39 per cent) had a curative resection, 32 (9·8 per cent) had a palliative resection, 33 (10·0 per cent) had a gastro-enterostomy, 26 (7·9 per cent) had a Celestin tube inserted, 58 (17·7 per cent) had a laparotomy alone, and 51 (15·5 per cent) had no surgical procedure. The 5 year survival was 11 per cent but all long term survivors were patients who had a curative resection. Using multivariate analysis the best predictor of survival after curative resection was the presence or absence of serosal involvement (P = 0·0004). Patients with a long history of presenting symptoms (> 6 months) survived longer than those with a short history (P = 0·001). The impact of chemotherapy on the survival of 202 patients with advanced gastric cancer was analysed by multivariate analysis. The median survival of the 50 patients receiving combination chemotherapy was better than that of the 152 who did not (median survivals 160 versus 71 days; P<0·001). When deaths occurring within 14 days of diagnosis were excluded, the significance value dropped to P = 0·02. Comparison of the groups treated between 1974 and 1979, when 8 per cent of 92 patients received chemotherapy, with 1980–1984, when 45 per cent of 110 patients received chemotherapy, showed no significant difference in survival.
Gastrointestinal haemorrhage from a second source in patients with colonic angiodysplasia
Authors: Steger A C , Galland R B , Hemingway Anne , Wood C B , Spencer J
Published: March 2007

Angiodysplasia of the colon is increasingly recognized as a cause of obscure gastrointestinal haemorrhage. On review of 71 patients with angiodysplasia, 40 came to surgery. Of these, nine (22·5 per cent) were also found to have small bowel lesions, either at the original laparotomy (7) or later when further investigations were performed for recurrent bleeding. Angiodysplasia can only be confidently diagnosed as the source of blood loss if seen to be actively bleeding. If a synchronous small bowel lesion is seen, we recommend that it should be removed at the same time as the colectomy.
Percutaneous transhepatic cholangioscopy
Authors: Chen M F , Jan Y Y , Lee T Y
Published: March 2007

Since 1983, percutaneous transhepatic cholangioscopy has been performed in 50 patients for both therapeutic and diagnostic purposes. Percutaneous transhepatic cholangioscopy was used to evaluate the nature of obstructive jaundice in 15 patients and bile duct stones were removed in 35 patients, 27 of whom also had intrahepatic duct stones. The overall success rate for stone removal was 80 per cent. Complications were few with no mortality. Emergency surgery was necessary in two patients, one for subphrenic haematoma, the other for a bile leak. Percutaneous transhepatic cholangioscopy is an effective and safe method for management of biliary stones and is a useful procedure for establishing the diagnosis of obstructive jaundice.
Loss of substance in bile ducts treated by a new surgical endoprosthesis
Authors: Sezeur A , Kracht M , Rey P , Leandri J , Malafosse M
Published: March 2007

Three cases of loss of substance of the common bile duct in patients with neoplastic disease treated by a new surgical endoprosthesis are reported. In all patients a good biliary drainage was obtained without a biliary fistula. There were no complications related to this method. Long-term follow-up showed persistence of the good immediate results. Surgical endoprostheses might be an alternative in cases with peroperative loss of substance of the common bile duct in patients with neoplastic disease to hepato-enteric anastomoses.
Fascia closure after midline laparotomy: Results of a randomized trial
Authors: Wissing Joke , van Vroonhoven Th J M V , Schattenkerk M Eeftinck , Veen H F , Ponsen R J G , Jeekel J
Published: March 2007

Four techniques to close the fascia after midline laparotomy were compared in a prospective randomized multicentre trial. The four techniques were: interrupted closure with polyglactin; continuous closure with polyglactin; continuous closure with polydioxanone-s, and continuous closure with nylon. The early postoperative results in 1491 patients revealed an incidence of wound infection of 8·6 per cent and of wound dehiscence of 2·3 per cent with no statistically significant differences between the four techniques. We reviewed 1156 patients after 1 year. Wound pain was present in 9·7 per cent of the patients, statistically significantly more in the group closed with nylon (16·7 per cent). Suture sinuses developed in 3·5 per cent of the patients, statistically significantly more frequently in the nylon group (7·7 per cent). The total number of incisional hernias detected 1 year postoperatively was high (15·2 per cent) (interrupted polyglactin 16·9 per cent, continuous polyglactin 20·6 per cent, continuous polydioxanone 13·2 per cent and continuous nylon 10·3 per cent). The difference between nylon and continuous polyglactin is statistically significant. The results of this trial indicate that although nylon has the lowest incidence of incisional hernia it also is associated with more wound pain and suture sinuses.
Salvage autotransfusion in aortic surgery: Initial studies using a disposable reservoir
Authors: Clifford P C , Kruger A R , Smith A , Chant A D B , Webster J H H
Published: March 2007

Transmission of disease by allogeneic transfusion can be avoided using several techniques by which a patient receives his own blood. Sixty patients undergoing aortic surgery consented to salvage interoperative autotransfusion. A mean of 895 ml shed blood was reinfused under full heparinization, representing 12-74 per cent of total blood loss. Bank blood requirements fell from 4·9 units to 3·4. No important haematological or clinical complications were noted (including coagulation studies) but haemolysis was detected 4 h postoperatively by plasma haemoglobin levels of 0·05 ± 0·03 g/dl. This preliminary study confirms the applicability of salvage autotransfusion during elective vascular surgery by demonstrating an appreciable saving in bank blood transfusion (70 per cent).
Node dissection in gastric cancer
Authors: De Aretxabala X , Konishi K , Yonemura Y , Ueno K , Yagi M , Noguchi M , Miwa K , Miyazaki I
Published: March 2007

Three hundred patients who underwent absolute and relative curative gastrectomy and lymph node dissection for gastric cancer were reviewed with respect to postoperative mortality; proportion of patients with node involvement according to the extent of dissection; number of metastatic nodes dissected according to the extent of dissection; accuracy of macroscopic evaluation of node involvement and microscopic node involvement according to tumour location. If more nodes were dissected the proportion of patients with node involvement and the total number of metastatic nodes increased; conversely within R0 and R3 the extent of dissection did not affect postoperative survival. Finally when the presence and extent of node involvement was only macroscopically evaluated, the patients were classified incorrectly in 9·5 per cent of the N0 group and 20·2 per cent of the N1 group. The data suggest that lymph node dissection may be useful in the treatment of gastric cancer, and within the extent studied the employment of this procedure does not affect the postoperative mortality.
Barrett's oesophagus: pH profile
Authors: Gillen P , Keeling P , Byrne P J , Hennessy T P J
Published: March 2007

Twenty-four patients with a columnar-lined (Barrett's) oesophagus underwent oesophageal manometry and 24 h ambulatory oesophageal pH monitoring. The results were compared with 25 patients with oesophagitis studied in the same fashion. No significant difference in lower oesophageal sphincter pressure was demonstrated between the two groups. The Barrett's patients demonstrated significantly greater acid exposure in the distal oesophagus than oesophagitis patients. Clearance of refluxed acid was poorer in Barrett's patients than oesophagitis patients. Twelve of the Barrett's patients presented with complications of the condition, i.e. ulceration or stricture. No significant difference in acid exposure was demonstrated between Barrett's patients with or without complications. These results suggest that patients with columnar-lined (Barrett's) oesophagus have greater acid exposure than patients with oesophagitis. The development of complications of a Barrett's oesophagus may not be dependent on acid reflux alone.
Late results of mesocaval interposition shunting for bleeding oesophageal varices
Authors: Terpstra O T , Ausema B , Bruining H A , Laméris J S , Reuvers C B , Schalm S W , van Urk H , Wilson J H P
Published: March 2007

Survival, encephalopathy and shunt patency were studied in 64 consecutive patients who underwent mesocaval shunting with a wide-calibre Dacron® prosthesis. Half of the patients were operated as emergency cases. Operative blood loss in patients who had emergency procedures was significantly higher than during elective operations. Overall, 30-day mortality was 27 per cent. Survival was 61 per cent after 1 year and 39 per cent after 5 years. Serious encephalopathy requiring hospital admission occurred in 5 patients (11 per cent of patients surviving more than 1 month). Shunt patency was assessed by scintisplenoportography and ultrasonography. Cumulative shunt occlusion rate was 16 per cent after 1 year, 33 per cent after 5 years and 52 per cent after 8 years of follow-up. Out of 17 patients with an occluded shunt, 9 had persistent or recurrent bleeding, while 3 patients had recurrent bleeding despite a patent shunt. We conclude that the mesocaval Dacron interposition shunt should not be recommended as the procedure of first choice for portosystemic shunting.
Bilateral ankle skin temperature as a predictor of early vascular graft patency
Authors: Jansson I G , Thomsen M B , Elfström J L
Published: March 2007

The efficacy of postoperative bilateral ankle skin temperature as a predictor of early graft patency was prospectively evaluated in 138 consecutive cases of femoropopliteal bypass surgery. The difference between ipsilateral and contralateral ankle temperature (hourly registrations) was significantly greater in the patients with patent graft on postoperative day 1 than in those with an occluded graft. In measurements 8 h postoperatively, highest sensitivity (84 per cent) and specificity (93 per cent) of the test were obtained when the difference was + 0·4°C. The overall accuracy of prediction with this simple method was 89 per cent.
Selective conservative and routine early operative treatment in acute limb ischaemia
Authors: Jivegård L E , Arfvidsson B , Holm J , Scherstén T
Published: March 2007

Arterial thrombo-embolectomy is often unsuccessful in those patients with acute limb ischaemia that have peripheral arteriosclerosis. During this study, conservative heparin treatment and, when needed, delayed surgery was employed in acute limb ischaemia when the ischaemia was less severe as judged by assessment of distal motor and sensory functions, regardless of the presumed aetiology of the acute ischaemia. The results are compared with those during a preceding period, when the routine treatment was emergency thrombo-embolectomy. The emergency operation rate was reduced to 49 per cent. There were overall fewer deaths with gangrene (8 per cent versus 18 per cent). In acute arterial thrombosis, more good results were obtained (76 per cent versus 47 per cent), whereas results were unchanged in embolic cases despite the reduced emergency operation rate. This study suggests that the choice of initial treatment of patients with acute limb ischaemia may be based on the severity of the ischaemia, and that patients with less severe acute ischaemia benefit from initial conservative heparin treatment.
Pre-operative albendazole therapy for hydatid cyst
Authors: Morris D L
Published: March 2007

Surgical management of hydatid cyst is associated with recurrence in 10 per cent of patients. The role of perioperative chemotherapy in prevention of recurrence has not been extensively explored. Sixteen patients with Echinoccus granulosus were treated with albendazole 10 mg kg−1 before operation; of fourteen patients who received albendazole for 1 month or more before operation only one (with doubtful therapeutic compliance) had viable protoscoleces, in contrast both of the two remaining patients who received only 1 and 3 weeks therapy had live disease at the time of operation. A 1 month pre-operative course of albendazole kills most if not all protoscoleces within hydatid cysts in man. This may allow pre-operative ‘sterilization’ of cysts and a reduction in the risk of recurrence.
Management of periampullary carcinoma
Authors: Robertson J F R , Imrie C W , Hole D J , Carter D C , Blumgart L H
Published: March 2007

Forty-one patients presented to our hospital between 1959 and 1983 with periampullary carcinoma. Twenty-six (63 per cent) underwent radical surgery, eight (20 per cent) local excision of the tumour, six (15 per cent) had bypass procedures and one was treated by endoscopic sphincterotomy (2 per cent). Potentially curative resection was performed in 83 per cent of the 41 patients. The operative mortalities for radical, local and bypass surgery were 7·7 per cent, 25 per cent and 16·6 per cent respectively. The degree of tumour differentiation significantly affected survival while local spread did not significantly affect survival in patients treated radically. The 5 year survival rates (calculated actuarially) for radical, local and bypass surgery were 34,44 and 0 per cent respectively.
Circumumbilical versus transumbilical abdominal incision
Authors: Paes T R F , Stoker D L , Ng T , Morecroft J
Published: March 2007

One hundred and fifteen patients were entered into a prospective randomized trial to establish whether midline abdominal incisions through the umbilicus produced any differences in the incidence of wound infection or failure when compared with the more conventional midline incision skirting around the umbilicus. No significant difference was shown between wound infection rates in 58 transumbilical and 51 circumumbilical incisions. Follow-up of surviving patients for at least one year showed no difference in incisional hernia rate between the two groups of patients. No problems were encountered in making the incisions through the umbilicus, but skirting the umbilicus was felt to cause problems with slewing of the scalpel blade, and asymmetry of the scar in 13 circumumbilical incisions. This study has shown that the practice of avoiding the umbilicus in midline abdominal surgery serves no useful purpose.
Appraisal of hepatic resection in the treatment of minute hepatocellular carcinoma associated with liver cirrhosis
Authors: Nagasue N , Yukaya H , Chang Y C , Ogawa Y , Ota N , Kimura N , Nakamura T
Published: March 2007

During the last 6 years, 205 patients with primary hepatocellular carcinoma (HCC) were admitted to our surgical departments. Thirty-eight had HCC smaller than 3 cm in diameter. There were 34 men and 4 women with an average age of 56·5 years. All patients had underlying hepatic disease: liver cirrhosis in 35 patients and chronic active hepatitis with fibrosis in the remaining 3. Pre-operative complications included: oesophageal varices in ten, cholelithiasis in five, peptic ulcer in two, gastric cancer in one, and severe hypersplenism in one instance. A radical resection was performed in 32 cases and palliative resection in 6. Simultaneous operations were carried out for the above mentioned associated conditions: distal splenorenal shunt in six, Hassab's devascularization procedure in one, splenectomy in one, cholecystectomy in four, cholecystolithotomy in one, and partial gastrectomy in one. Four patients had postoperative complications: liver failure, rebleeding, right haemothorax, and upper gastrointestinal bleeding from acute mucosal lesion of the stomach. One patient with liver failure died in coma within 1 month. The operative and in-hospital mortality rates were 2·6 and 7·9 per cent, respectively. Survival rates during the first 4 years in 32 patients with radical hepatic resection were 89·9, 67·2, 58·8, and 58·8 per cent, respectively. We suggest that hepatic resection should be the first choice of treatment for minute HCC even in the presence of liver cirrhosis.
Role of surgery in the treatment of primary carcinoma of the liver: A 31-year experience
Authors: Lin T-Y , Lee C-S , Chen K-M , Chen C-C
Published: March 2007

During the 31 year period 1954 to 1985, 225 major hepatic resections have been performed for symptomatic primary carcinoma of the liver, of which right hepatic lobectomy was performed in 115, extended right hepatic lobectomy in 11, trisegmentectomy in 2, left hepatic lobectomy in 94, and middle hepatectomy in 3. In addition there were 107 partial hepatic resections for 89 asymptomatic small hepatocellular carcinomas. In the 225 patients undergoing major hepatic resection, the operative mortality was 8·0 per cent. In the 107 patients undergoing partial hepatic resection, the operative mortality was 5·6 per cent. Of the total of 314 hepatic resections for primary carcinoma of the liver, 309 were undertaken for hepatocellular carcinoma and the remaining 5 were carried out for cholangiocarcinoma. All hepatic resections in this series were performed with the finger fracture technique without controlling the hepatic hilar vessels, hepatic ducts or hepatic veins outside the liver, although hepatic clamping and the Pringle manoeuvre were also used in selective cases. Of 207 cases who survived major hepatic resection, 119 cases died within one year after the operation, mainly due to recurrence of cancer in the remaining residual lobe, lung metastasis or late hepatic failure. The 5 year survival rate is 18·0 per cent, 12 patients are still alive and well after more than 5 years and the longest survival is 23 years. Of the 89 patients with small asymptomatic hepatocellular carcinomas, 28 died within one to four years of surgery because of a second new growth.
Biliary lithiasis in the over seventyfive group: A new therapeutic strategy
Authors: Duron J J , Roux J M , Imbaud P , Dumont J L , Dutet D , Validire J
Published: March 2007

Sixty-four gallstone patients aged 75 or more (mean age 83 ± 5.1 years) were divided prospectively into two groups. They were mostly high-risk patients (average number of major risk factors, 2.2±0.9). Thirty-three showed one or several signs of lithiasis of the common bile duct and were treated with endoscopic sphincterotomy (ES) (31 successful cases, two technical problems) followed by early cholecystectomy (33 cases). Choledocholithiasis was present in 26 cases and stones were extracted in 25 cases. Two patients (6 per cent) died. ES caused no complications. Thirty-one other patients showed no sign of choledocholithiasis and were treated by cholecystectomy with operative cholangiography. Choledocholithiasis was found in two of these patients and treated by extraction and external drainage. Five of these patients (16 per cent) died. I n 30 cases acute cholecystitis was found at operation, 15 in each group. E S is therefore an eficient procedure in highksk patients, which facilitates operation, especially in cases of acute cholecystitis, and it is recommended in all cases of complicated biliary lithiasis. Early cholecystectomy is justified for these patients by the high frequency of associated acute cholecystitis.
Effect of vagal denervation on canine gallbladder motility
Authors: Traynor O J , Byrne P J , Keegan B , Hennessy T P J
Published: March 2007

There is an increased incidence of gallstones after truncal vagotomy but the mechanism is unknown. Our aim was to study the early effects of vagotomy on fasting and postprandial gallbladder motility. A chronic model was constructed in 10 dogs to correlate gallbladder motility and emptying with interdigestive and postprandial duodenal motility both before and after selective hepatobiliary vagotomy (five dogs) and truncal vagotomy (5 dogs). During each study recordings were made for one complete interdigestive motor complex (IDMC) and for 90 min after a standard meal of (a) gallbladder and duodenal motility, (b) gallbladder emptying (by a dual radioisotope marker technique) and (c) duodenal output of bilirubin. In control studies the gallbladder contracted at the start of phase II of the interdigestive motor complex and ejected 20–25 per cent of its contents into the duodenum; after meals the gallbladder contracted within 5 min and emptied almost 80 per cent of its contents within 90 min. After both selective hepatobiliary vagotomy and also truncal vagotomy there was no significant difference in the pattern of contraction or emptying of the gallbladder either during fasting or postprandially. We conclude that gallbladder motility and emptying are entirely normal in the early period after vagal denervation.
Length of stay for common surgical procedures: Variation among districts
Authors: Morgan Myfanwy , Paul Elizabeth , Devlin H B
Published: March 2007

Lengths of stay for appendicectomy, inguinal hernia repair and cholecystectomy for the 16 districts in the Northern Regional Health Authority (NRHA) and 15 districts in the South East Thames Regional Health Authority (SETRHA) are examined using data recorded in the Hospital Activity Analysis. Considerable variations exist among districts, with the three longest stay districts for each procedure in NRHA having an age-adjusted length of stay of 113 per cent of the regional average for appendicectomy, 125 per cent for hernia and 115 per cent for cholecystectomy. This resulted in > 2000 additional bed days per year being occupied in the three longest stay districts in the NRHA compared with the regional average. The age adjusted length of stay for the three shortest stay districts for each procedure is 83 per cent of the regional average for appendicectomy, 75 per cent for hernia and 85 per cent for cholecystectomy. Similar differences are seen in the SETRHA, and derive from differences in the length of both pre-operative and postoperative stay. Explanations for the observed variations are considered in terms of population, organizational and clinical variables.
Pre-operative assessment of fitness score
Authors: Playforth M J , Smith G M R , Evans Mary , Pollock A V
Published: March 2007

Death within 30 days or survival after a major operation depends on three things: the severity of the disease and the operation, the technical proficiency of the surgeon and the ability of the patient to withstand both disease and operation. The first of these can be estimated by reference to published figures, the second can only be guessed at and the third has in the past been a matter of subjective judgement. With the aim of producing an objective assessment of the likelihood of survival, we have constructed a score system comprising 26 items including age, chronic disease and acute presenting disease. These items are each given a weight of 1 to 4 and the total fitness score for any patient ranges from 0 (fit) to 10 (unlikely to survive). We have validated this score prospectively in 1517 consecutive patients undergoing emergency or elective major abdominal operations (excluding appendicectomies and hernia repairs). In 492 operations in which the patient scored 0 or 1, one patient died (0·2 per cent); in 290 with scores of 2 or 3, one died (0·3 per cent); in 313 with scores of 4 or 5, five died (1·6 per cent). It was when the score rose to 6 or over that the chances of survival progressively declined: 16 died of the 105 patients who scored 6 (15·2 per cent) as did 74 of the 191 who scored 7 or 8 (38·7 per cent) and 70 of the 126 who scored 9 or 10 (55·6 per cent). We now use the score as part of our audit and enquire particularly closely into the death of any patient with a pre-operative score of less than 6.
Effect of the pre-operative response to H2 receptor antagonists on the outcome of highly selective vagotomy for duodenal ulcer
Authors: Goodman A J , Kerrigan D D , Johnson A G
Published: March 2007

From 1979 to 1984, 141 consecutive patients (110 men, 31 women) underwent highly selective vagotomy (HSV) for duodenal ulcer (DU). All patients had received pre-operative treatment with full dose H2 receptor antagonists (H2RA). Indications for surgery were: persistent relapse on withdrawal of H2RA, 107 (75·9 per cent); no response to H2RA, 30 (21·3 per cent); intolerance of H2RA, 1 (0·7 per cent); acute DU bleed, 2 (1·4 per cent); duodenal stenosis, 1 (0·7 per cent). Follow-up with a median of 47 months (24–85 months) revealed six patients (4·4 per cent) with endoscopically proven recurrence, three of whom were on non-steroidal anti-inflammatory drugs (NSAIDs). Only one patient with recurrent DU was a non-responder to H2RA pre-operatively. Twenty-five patients remained symptomatic after HSV without ulcer recurrence, of which a highly significant proportion (41 per cent) were non-responders (P < 0·001). The pre-operative response to H2RA does not indicate the likelihood of ulcer recurrence after HSV. However, non-responders are more likely to continue with dyspeptic symptoms despite the successful healing of their ulcers. The DU recurrence rate in patients taking long-term NSAIDs is disappointingly high (33 per cent), putting the use of HSV in these patients into question.
Experience with the ‘skew flap’ below-knee amputation
Authors: Harrison J D , Southworth S , Callum K G
Published: March 2007

A review of 353 lower limb amputations over the last 7 years has been performed to assess the results of the skew flap myoplastic below-knee amputation which was introduced in April 1983 because of reported advantages in terms of wound healing and earlier ambulation. Comparing the first 3½ year period with the second, the total number of amputations decreased by 31 per cent. The number of above-knee amputations remained similar in the two periods (82, 62), whilst the number of Gritti-Stokes amputations fell from 79 to 21 (0·001 > P > 0·01). The proportion of below-knee (BK) amputations increased from 50 (23·7 per cent) to 59 (41·5 per cent) (0·01 > P > 0·025). The groups were comparable in terms of previous vascular surgery and co-existing medical conditions. The time to full stump healing was significantly shorter in the skew flap group compared with the earlier Burgess type BK amputation (P = 0·001), and there was a trend to fewer stump failures in the skew flap group. We therefore feel that the skew flap amputation gives superior results to the Burgess BK amputation in terms of healing and a lower complication rate, allowing a higher proportion of BK amputations to be performed. A prospective randomized trial of the two techniques is in hand to determine the accuracy of this hypothesis.
Changes in the apparently normal limb in unilateral venous ulceration
Authors: Stacey M C , Burnand K G , Pattison Marion , Thomas M Lea , Layer G T
Published: March 2007

Forty-seven patients with unilateral venous ulceration have been investigated to determine if any abnormalities were present in the contralateral limbs which had not had lipodermatosclerosis or ulceration. Ascending phlebography in the non-ulcerated limbs showed post-thrombotic changes in 28 per cent and incompetent lower leg communicating veins in 19 per cent. This incidence was not significantly different to the limbs with healed ulceration (45 and 23 per cent respectively, χ2 test, P = 0·10). Half volume refilling time measured by foot volumetry suggested that 79 per cent of the non-ulcerated limbs had evidence of deep vein incompetence or incompetent lower leg communicating veins, which was again similar to the incidence in the previously ulcerated limbs (85 per cent). Transcutaneous oxygen readings, expressed as a ratio of a reading at a standard site in the gaiter region of the leg over a reading from the upper arm, were significantly lower in non-ulcerated limbs (mean 0·84 ± 0·26 s.d.) than in a cohort of age and sex matched controls (mean 1·02 ± 0·14, Student's t test, P < 0·001), and significantly higher than in previously ulcerated limbs (mean 0·68 ± 0·31, P < 0·01). Abnormalities in venous anatomy and function have been shown, in conjunction with evidence of reduced oxygen diffusion, through the gaiter skin before overt skin changes develop.
Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: A pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis
Authors: Johnston D , Holdsworth P J , Nasmyth D G , Neal D E , Primrose J N , Womack N , Axon A T R
Published: March 2007

Mucosal proctectomy with endo-anal pull-through anastomosis (MP + PTA) for ulcerative colitis reduces resting anal pressure and low RAP has been found to correlate with minor leakage of faeces or mucus. Our hypothesis was that conservative proctocolectomy with an end-to-end ileo-anal anastomosis (EEA) would result in higher anal pressure and less leakage. Twelve patients were studied after EEA and 24 after MP + PTA: each was in good health several months after operation. After EEA, maximal RAP decreased from a median 90 cmH2O (60–116 cmH2O) to 70 cmH2O (25–104 cmH2O, P < 0·01), whereas after MP + PTA maximal RAP decreased from 85 cmH2O (70–125 cmH2O) to 40 cmH2O (22–80 cmH2O, P < 0·003). RAP after EEA was significantly greater than RAP after MP + PTA (P < 0·001). The pressure profile of the anal sphincter in the EEA group did not differ significantly from that of the pre-operative group at any point from 6 to 1 cm from the anal verge, and the sphincteric high pressure zone averaged 4 cm in length both before and after operation. After MP + PTA, resting anal pressure at stations 1 to 4 cm from the anal verge was significantly less than pre-operative pressure (P < 0·001) and the sphincteric high pressure zone was only 3 cm in length compared with 4 cm before operation. Anal squeeze pressures were similar in the two groups of patients. After EEA 11 of 12 patients achieved perfect continence, day and night, whereas after MP + PTA 58 per cent of patients experienced minor faecal leakage (P < 0·01). These findings suggest that the entire anal canal should be kept intact in the course of conservative proctocolectomy for ulcerative colitis.
Surgical management of posterior pharyngeal pulsion diverticula: Inversion versus one-stage excision
Authors: Bowdler D A , Stell P M
Published: March 2007

At present one-stage excision of the posterior pharyngeal pulsion diverticulum is the most popular method of treatment in the UK and the USA. We have reviewed 53 patients who have presented to this unit between 1968 and 1986, to compare the results of different surgical techniques. Of these, 21 underwent excision and myotomy, 20 inversion and myotomy, and 9 myotomy alone. The results show that the mortality for the whole group was 4 per cent, but there were no deaths in either the inversion or myotomy group. The excision group had a complication rate of 52 per cent, compared with 30 per cent for inversion, and also had more major problems such as fistula. Median hospital stay was shorter for inversion than for excision, at 7 and 10 days respectively. In summary we believe that inversion of the posterior pharyngeal pulsion diverticula is now the surgical treatment of choice.
Hazards of thrombolytic therapy in deep vein thrombosis
Authors: Meissner A J , Misiak A , Ziemski J M , Scharf R , Rudowski W , Huszcza S , Kucharski W , Wislawski S
Published: March 2007

From 1965 to 1985, 64 deep vein thrombosis (DVT) patients were treated with streptokinase (SK). In 26 cases ‘high-dose SK’ (IV 100000 units/h for 4 days) was used and in 38 patients a ‘low-dose SK’ regime (IV 250000 units every 12 h for 4 days) was employed. The clinical signs of DVT subsided in 78 per cent of treated patients within 30 days of completing SK treatment. A repeat phlebography was performed immediately after SK therapy in 29 patients (45 percent) and a total recanalization or partial thrombolysis was achieved in 80 per cent of the studied cases. In 15 patients minor and major haemorrhagic complications occurred. There were five fatalities, all in the high-dose SK group (three intracranial haemorrhages and two major bleeds). Three patients developed pulmonary embolism and none of them died. The post-treatment clinical and phlebographic evaluation did not reveal any significant difference between the two methods of SK administration, but more haemorrhagic complications (P < 0·02, χ = 5·50825) occurred in the high-dose SK patients. This report emphasizes the risk of bleeding complications during thrombolytic therapy. If SK is to be used, therefore, careful selection of patients and meticulous monitoring are mandatory.
Choice of surgery for early breast cancer: Pre- and postoperative levels of clinical anxiety and depression in patients and their husbands
Authors: Morris Jenny , Royle G T
Published: March 2007

Two groups of patients with early breast cancer were studied prospectively to assess whether being offered a choice of surgery (simple mastectomy or wide excision plus radiotherapy) influenced levels of anxiety and depression pre- and postoperatively. A significantly higher percentage of the patients not offered a choice of surgery experienced high levels of anxiety and depression pre-operatively and up to 2 months postoperatively compared with patients offered a choice; the results were also similar for the husbands of these patients. At 4 months, differences between the two groups were not statistically significant, although the trend remained the same with more patients not offered a choice of treatment showing high levels of anxiety and depression. Patients offered a choice of surgery had similar pre- and postoperative levels of anxiety and depression to patients with benign breast disease and patients undergoing surgery for non-cancerous conditions.
Use of sodium nitroprusside induced hypotensive anaesthesia for reducing blood loss in patients undergoing lienorenal shunts for portal hypertension
Authors: Sood S , Jayalaxmi T S , Vijayaraghavan S , Nundy S
Published: March 2007

A randomized study was performed on 18 patients to determine whether hypotensive anaesthesia, induced by sodium nitroprusside (SNP), would reduce blood loss during elective proximal lienorenal shunt operations for portal hypertension which was due to extrahepatic obstruction or non-cirrhotic portal fibrosis. Eight patients received SNP intra-operatively to reduce the systolic blood pressure to below 95 mm Hg, and there were 10 control patients. Blood loss, the number of units of blood transfused, and urine output during surgery were measured together with the postoperative drainage from the abdominal and chest tubes over the first 24 h. There was a significantly lower blood loss (mean ± s.d. 517 ± 220 versus 1286 ± 523 ml; P<0·01) and number of units of blood transfused was less (0·9 ± 0·9 versus 3·0 ± 1·2; P<0·01) in the SNP patients than in the controls. The urine output was greater in the SNP group (606 ± 211 versus 399 ± 139 ml, n.s.). Postoperative drainages from the chest and abdomen were similar. Hypotensive anaesthesia with SNP reduces operative blood loss and transfusion requirement in patients with good liver function undergoing proximal lienorenal shunts for portal hypertension.
Hyperthyroidism and hypothyroidism complicating the treatment of thyrotoxicosis
Authors: Reid D J
Published: March 2007

Three separate studies of recurrent hyperthyroidism and hypothyroidism in groups of patients treated for thyrotoxicosis by anti-thyroid drugs, surgery and radioiodine are presented. The incidence is compared in the three groups. Two hundred and fifty-three patients with primary thyrotoxicosis received a year-long course of anti-thyroid drugs: 43 per cent relapsed in the first year following the completion of treatment. Of those remaining euthyroid at the beginning of the second year after treatment a further 21 per cent relapsed during that year and in subsequent years, 21 per cent, 18 per cent and 13 per cent of those remaining euthyroid at the start of the third, fourth and fifth years relapsed. Of those followed for the full 5 years 26 per cent remained in remission and 74 per cent had relapsed over this period. After bilateral subtotal thyroidectomy for thyrotoxicosis in 146 patients, 19 per cent were hypothyroid and 1·4 per cent had relapsed 18 months after surgery. The incidence of postoperative hypothyroidism was lower in the younger patients (under 25 years). The absence of thyroid auto-antibodies pre-operatively is an indication of a favourable result. The histological recognition of lymphocytic infiltration in the gland and the presence of thyroid auto-antibodies indicated an unfavourable outcome. Radioactive iodine gave an unpredictable response at therapeutic doses with 24 per cent relapsing in the first year after treatment. With ablative doses of radioactive iodine the incidence of hypothyroidism reached 94 per cent at 5 years after treatment. Surgery gives the best long-term results of the three treatment options and is the treatment of choice for the young, the severely toxic and those with toxic multinodular goitre.
Endoscopic biliary drainage
Authors: Kiil J , Kruse A , Rokkjaer M
Published: March 2007

Endoscopic biliary drainage (EBD) has become an established method of relieving posthepatic jaundice. This study comprises 399 patients in whom 472 EBD procedures were performed during a 5 year period; 272 patients had malignant obstruction, 36 had a benign stricture, 79 had common duct stones and 12 patients had other benign conditions requiring drainage. A 7F double pigtail endoprosthesis was used in the majority of patients and was inserted with an Olympus JF-IT duodenoscope. Ninety-two percent of the prostheses were correctly positioned, and 88 per cent of these functioned well with relief of symptoms. The 30-day mortality was 22 percent and one-third of these deaths were due to the procedure, septicaemia being the dominant hazard. This was more marked if the obstruction was not relieved satisfactorily. Antibiotic cover was not used routinely and had not been prescribed in any of the fatal cases. This omission probably made a significant contribution to the septicaemia. Acute pancreatitis and haemorrhage were rare complications and both were probably related to the coincidental sphincterotomy. Prostheses intended for permanent relief of malignant obstruction remained patent for 2-3 months (median) with a wide range of 1-618 days. Survival among these patients is so short, that one or two EBD procedures will keep the majority of patients free from symptoms related to biliary obstruction, and only two patients needed more than three procedures. Fifty-one patients with pancreatic head carcinoma had EBD as a bypass before an intended operation. Only 16 patients actually had a resection. The median survival among the 51 patients was 106 days (compared with 59 days among 100 patients with a permanent prosthetic bypass). Only one patient with a very small periampullary carcinoma has survived for more than 3 years. Forty-seven patients are dead. Among the 51 patients in whom radical resection was intended two-thirds were actually treated by permanent surgical or prosthetic bypass.
Reticulo-endothelial function in obstructive jaundice
Authors: Pain J A
Published: March 2007

A study of reticulo-endothelial function was performed in 30 patients with obstructive jaundice. Reticulo-endothelial phagocytic function, measured by the clearance of intravenous human micro-aggregated albumin, was significantly depressed in jaundiced patients compared with non-jaundiced controls (P<0·001). There was a significant correlation (P<0·001) between phagocytic function and plasma bilirubin level but not with transaminase or bile salt level. Phagocytic function was not related to the presence of malignancy, but was markedly reduced in patients with cholangitis. There was no reduction in hepatic sinusoidal blood flow, opsonin levels (fibronectin, IgG, complement) or serum opsonic activity to account for the reticulo-endothelial dysfunction.