bluuebunny/crossref_metadata_2025 huggingface dataset:
Distal arterial bypass by composite grafting
Authors: Britton J P , Leveson S H
Published: March 2007

The use of non-autogenous prostheses for femorodistal grafting has been attended by relatively poor patency rates. We have attempted to improve on these disappointing results by fashioning a composite graft using expanded PTFE (GORE-TEX) and transposed non-reversed saphenous vein, placed between the femoral artery and anterior tibial artery. We report the early results using this technique in 25 critically ischaemic limbs. At 12 months, the cumulative graft patency for this group of patients was 65 per cent (mean follow-up of 19 months). Eighteen of the twenty-five limbs were saved and there was no mortality. This technique offers a useful alternative to other forms of distal grafting and appears superior to the results obtained using non-autogenous femorodistal conduits.
Secondary arterio-enteric fistulae: A surgical challenge
Authors: Umpleby H C , Britton D C , Turnbull A R
Published: March 2007

Ten cases of secondary arterio-enteric fistulae are described. There were nine graft enteric fistulae and one fistula involving the aortic suture line following elective resection of an infected graft. Only four of the patients initially received prophylactic antibiotics (single dose) at the original aortic reconstruction, and the vascular suture line had only been protected in two. Eight patients presented with bleeding and two with groin abscesses. One patient died before operation. Graft resection was undertaken in all patients and organisms were grown from six of eight grafts cultured. No patient died during operation but one died after 3 days. Axillofemoral bypass grafts were constructed in seven patients (four immediately after resection of prosthetic grafts and three within 4 days of operation). Only three of the eight patients who survived operation are still alive; two died of a ruptured aorta and one from a recurrent fistula. Two patients died of other causes. Four of five axillofemoral grafts in surviving patients subsequently occluded.
Assessment of perfusion in postoperative patients using tissue oxygen measurements
Authors: Jonsson K , Jensen J A , Goodson W H , West J M , Hunt T K
Published: March 2007

Subcutaneous tissue oxygen tension was measured as an index of perfusion in 44 postoperative patients. Hypoperfusion was defined as suboptimal tissue oxygen tension unresponsive to increased inspired oxygen but becoming responsive after increased fluid infusion. Twelve of thirty patients who underwent major abdominal and flank operations were found to be suboptimally perfused by this definition despite adequate fluid maintenance according to standard clinical criteria including urine output. Apparently, a significant number of postoperative abdominal surgery patients are not optimally perfused, and this state is not recognized by the present clinical criteria. Tissue oximetry may be a useful objective method of assessing tissue perfusion.
Combination fine-needle aspiration cytology and intrarenal manometry at the onset of renal dysfunction
Authors: Ubhi C S , Guillou P J , Davison A M , Giles G R
Published: March 2007

Twenty-three consecutive cadaveric renal allograft recipients immunosuppressed with cyclosporin have been monitored three times a week by fine-needle aspiration cytology and intrarenal manometry until discharge from hospital or until 30 days post-transplant. Standard criteria were used to determine the cause of allograft dysfunction. The onset of allograft rejection was marked by an elevation of the total corrected increment score by fine-needle aspiration cytology in 80 per cent of rejection episodes whereas intrarenal pressure was raised in only 46·6 per cent. However, intrarenal pressure was greater than 40 mmHg on a single occasion in 16 measurements performed on allografts showing evidence of cyclosporin nephrotoxicity. By combining fine-needle aspiration cytology and intrarenal manometry the sensitivity of these tests for allograft rejection was increased to 93·3 per cent at the onset of renal dysfunction. Our results demonstrate that fine-needle aspiration cytology is more sensitive than intrarenal manometry as a single investigation. However, the combined test may have an important role in the differentiation of allograft rejection and cyclosporin nephrotoxicity in the early management of renal allograft recipients.
Splenic injury: A prospective multicentre study on non-operative and operative treatment
Authors:   The Splenic Injury Study Group, Kirurgisk J N
Published: March 2007

One hundred and forty-seven patients with splenic injury admitted to 18 different hospitals were included in a prospective multicentre study. The spleen was saved in 64 per cent. Out of the total series, 43 per cent of patients were not operated upon, 5 per cent had exploratory laparotomy only, and in 16 per cent splenic repair was performed. Treatment is discussed with reference to the nature of the splenic lesion, concomitant injuries, amount of blood transfusion given, and age of the patient. No deaths were definitely related to the splenic injury. The frequency of serious recurrent bleeding was not higher in the splenic salvage group when compared with the splenectomy group. Delayed bleeding was detected in 4 per cent of the patients. The mode of treatment varied considerably in different hospitals in that conservative treatment was performed in 14, splenic repair in 10 and splenectomy in 12 hospitals. Splenic salvage seems safe in most patients with a splenic injury. However, meticulous surveillance of the patient is mandatory.
Spleen-saving procedures in paediatric splenic trauma
Authors: Büyükünal C , Danişmend N , Yeker D
Published: March 2007

The aim of this study is to assess the advantages of ‘spleen-saving procedures’ in paediatric splenic trauma. Since January 1979, 87 children with splenic trauma were treated. Six were treated without operation. Eighty-one patients were treated surgically. Sixteen cases with type I splenic injury were subject to simple splenorrhaphy, and twenty-three cases with type II splenic injury underwent splenorrhaphy plus omentoplasty. Twenty-four cases had type III splenic injury; of these, 20 were treated by ligation of the splenic artery (the main splenic artery in 14 cases and the upper segmental artery in six cases) with splenorrhaphy and omentoplasty, and the remaining four cases were treated by partial splenectomy and omentoplasty. In 16 of the 18 patients with type IV splenic injury, splenectomy was inevitable and heterotopic splenic autotransplantation was added. In the remaining two cases, it was possible partially to preserve the spleen. No complication was observed due to any of these spleen-saving procedures. Moreover, splenic implants increased complement C3 levels and improved filtration function. Despite other injuries, the mortality rate of this group was 5·7 per cent. The splenic salvage rate was 82 per cent.
Mucosal proctectomy and coloanal anastomosis for distal ulcerative proctocolitis
Authors: Varma J S , Browning G G P , Smith A N , Small W P , Sircus W
Published: March 2007

Four patients with long-standing symptomatic ulcerative colitis confined to the left colon and rectum were treated by resection, mucosal proctectomy and colo-anal sleeve anastomosis. There was no operative mortality or anastomotic leakage. Follow-up has ranged from 12 to 66 months (mean 52 months). Loose bowel motions with urgency and frequency of defaecation were troublesome postoperative symptoms. Recurrence of the colitis in the neorectum with extension into the proximal colon occurred in all patients within 3 to 11 months (mean 6 months) of operation. This necessitated total proctocolectomy with ileostomy in three patients (mean 18 months postoperatively). In the fourth patient the recurrence is medically controlled without a stoma more than 5 years after operation. This operation is unsuitable for the treatment of segmental ulcerative proctocolitis.
Postanal repair and intersphincteric Ivalon sponge rectopexy for the treatment of rectal prolapse
Authors: Rogers J , Jeffery P J
Published: March 2007

Twenty-four consecutive patients (mean age: 74 years) with complete rectal prolapse, fifteen of whom were incontinent of solid stool, have been treated by postanal repair and intersphincteric Ivalon sponge rectopexy. There was no operative mortality, or serious morbidity. There was one recurrence of complete prolapse which occurred 14 days after operation. The other 23 patients have been followed for up to 4 years. All patients who were incontinent of solid stool pre-operatively have been rendered continent. This type of operation may be the treatment of choice in the elderly, where an abdominal procedure is considered unwise and in cases of rectal prolapse associated with faecal incontinence.
Surgery for necrotizing enterocolitis
Authors: Robertson J F R , Azmy A F , Young D G
Published: March 2007

Thirty-seven patients who had necrotizing enterocolitis and required emergency surgical intervention are reviewed. The indications for surgery were intestinal perforation (28), intestinal obstruction (7), clinical deterioration (1) and persistent rectal bleeding (1). The initial procedure was percutaneous peritoneal catheter drainage (13), intestinal diversion alone (8), intestinal resection (14), laparotomy and biopsy (1) and laparotomy alone (1). Twelve patients developed late intestinal strictures. The overall mortality rate was 35 per cent.
Epidemiology and outcome of acute pancreatitis
Authors: Thomson S R , Hendry W S , McFarlane G A , Davidson A I
Published: March 2007

Acute pancreatitis in North-East Scotland from January 1983 to December 1985 was examined. The criteria for diagnosis were a serum amylase > 1000 units/l with a consistent clinical presentation, or acute pancreatitis confirmed at laparotomy or post mortem. All serum amylase assays were performed in one regional laboratory. The commonly used diagnostic coding search for pancreatitis yielded only half the cases found. We identified 378 episodes of acute pancreatitis (196 males and 182 females). The mean annual incidence for first attacks of acute pancreatitis was 242 per million of the population. The commonest aetiology was biliary tract disease (30 per cent of males and 53 per cent of females). Alcohol related pancreatitis occurred in 26·5 per cent of males but only 3 per cent of females. Complications included 26 pseudocysts, 11 pancreatic abscesses, 9 patients with respiratory failure, 11 patients with renal failure and 6 patients with disseminated intravascular coagulation.
Value of the P3 amylase fraction as an indicator of the long-term prognosis of acute pancreatitis
Authors: Navarr S , Aused R , Casals E , Elena M , García-Pugés A M , Adrián M J , Ballesta A M , Bonet J Vilar
Published: March 2007

The value of the serum P3 amylase fraction in the prediction of the course of acute pancreatitis (AP) after the initial episode was studied prospectively. Eighty-eight patients with AP were included. Amylase, lipase, trypsin and the P3 amylase fraction were measured in serum obtained at the time of discharge. Patients were followed for 60 days after discharge and divided into two groups: 75 patients who did not have complications, of whom 22·6 per cent displayed elevation of one or more pancreatic enzymes at discharge (17·3 per cent hypertrypsinaemia, 9·3 per cent hyperlipasaemia and 6·6 per cent P3 fraction); and 13 patients who had an unsatisfactory outcome (4 died, 4 developed a pseudocyst and 5 presented with recurrent pancreatitis). All of the latter group had an increase in at least one enzyme at the time of discharge (92·3 per cent P3 fraction, 69·2 per cent trypsin, 15·3 per cent lipase, and 7·6 per cent amylase). Both the persistence of the P3 fraction and hypertrypsinaemia were significantly more frequent in patients with an unfavourable outcome than in those with an uncomplicated course (P < 0·001). On the other hand, persistent elevation of total amylase and lipase were unrelated to outcome. The hospitalization time was similar in both groups (good outcome 21·4 ± 1·9 days, unfavourable outcome 17·3 ± 5·3 days). It is concluded that the presence of P3 amylase fraction or hypertrypsinaemia at the time of discharge from hospital in a patient with acute pancreatitis suggests a risk of a later complication. Careful surveillance until enzyme levels become normal is urged. It is suggested that isoamylase P3 determination is the most sensitive assay to screen for the complications of acute pancreatitis.
Clinical implications of abnormal oesophageal motility
Authors: Bancewicz J , Osugi H , Marples Margaret
Published: March 2007

The usefulness of oesophageal manometry as a clinical tool has been assessed in 202 patients requiring detailed investigation for troublesome oesophageal symptoms, who first presented between June 1979 and May 1982. Only 12 were found to have specific motility disorders such as achalasia and scleroderma. A total of 147 had a variety of non-specific motility disorders and, of these, 112 (76·2 per cent) had coexistent gastro-oesophageal reflux. There was a significant association between the symptoms of dysphagia and the occurrence of predominantly non-propagated motor activity in the oesophagus. A similarly significant relationship existed between crushing chest pain and oesophageal spasm. Despite this statistical association, detection and treatment of gastro-oesophageal reflux was found to be the most useful part of clinical management. Symptoms of associated motility disorders resolved in more than 90 per cent of patients treated by Nissen fundoplication. Pre-operative assessment of motility was of no value in detecting those who might develop postoperative dysphagia. Oesophageal manometry is useful for the assessment of a small proportion of patients with oesophageal symptoms in whom gastro-oesophageal reflux has been excluded by vigorous investigation, including 24 h pH recording.
Reflux stricture of the oesophagus
Authors: Watson A
Published: March 2007

Benign oesophageal stricture remains a common problem. Following accurate diagnosis, early treatment allows dilatation in the great majority of patients. Resection can frequently be avoided and in fit patients dilatation should be combined with an anti-reflux operation plus gastroplasty where necessary. Frail elderly patients may be managed by continued dilatation and medical means to reduce and combat the effects of reflux. Resection should now be necessary in only about 5 per cent of patients and colonic interposition offers good long-term results. It must be remembered that adenocarcinoma is a small but real risk in patients with reflux stricture.
External beam radiotherapy for rectal adenocarcinoma
Authors: Taylor R E , Kerr Gillian R , Arnott S J
Published: March 2007

A series of 243 patients with adenocarcinoma of the rectum treated with radiotherapy is presented. In the early part of the study radiotherapy was combined with 5-fluorouracil (5FU). Later, radiotherapy was given alone. Seventy-four patients were treated with radical external beam radiotherapy for recurrent or inoperable rectal adenocarcinoma. One hundred and forty-five patients with advanced pelvic tumours or with metastases were treated with palliative pelvic radiotherapy. Twenty-four patients who had small-volume residual pelvic tumour or who were felt to be at high risk of pelvic recurrence following radical resection received postoperative radiotherapy. Complete tumour regression was seen in 38 per cent of radically treated patients, and 24 per cent of palliatively treated patients. Partial regression was observed in 56 per cent of radically treated patients, and 58 per cent of palliatively treated patients. Long-term local tumour control was more commonly observed for small tumours (<5 cm diameter). Fifty-eight per cent of patients treated with postoperative radiotherapy remained free of local recurrence. Survival was significantly better in patients with small tumours. The addition of 5FU did not appear to improve survival or tumour control. The value of radiotherapy in the relief of distressing symptoms related to the presence of pelvic tumour has been confirmed.
Pre-operative assessment of soft tissue sarcomas by computed tomography
Authors: Davidson T , Cooke Julie , Parsons C , Westbury G
Published: March 2007

The current trend towards limb-sparing surgery in patients with soft tissue sarcomas has increased the need for accurate pre-operative assessment of the primary tumour. Tumour site, extent and relationship to bone and neurovascular structures determine whether adequate radical surgery is feasible or whether more limited excision as a part of multimodality treatment is appropriate. Pre-operative computed tomography (CT) was compared with operative findings in 38 patients with soft tissue sarcomas. CT prediction of muscle group involvement by tumour was correct in 95 per cent and prediction of major artery or vein invasion was correct in 92 per cent and 97 per cent respectively. Assessment of tumour relationship to major peripheral nerve was accurate for thigh sarcomas but was not possible in upper limb tumours. While CT confirmed frank bony involvement in two patients, it failed to distinguish between tumours closely adjacent to periosteum and those with periosteal invasion. Detection of residual or recurrent tumour nodules is less reliable; CT is most accurate before any surgical intervention.
Effect of Roux-en-Y reconstruction on the gastric emptying of a solid meal
Authors: Donovan I A , Drumm J , Harding L K , Alexander-Williams J
Published: March 2007

The gastric emptying of a solid meal was measured in 39 patients after Roux-en-Y reconstruction and compared with that in 27 patients after truncal vagotomy and pyloroplasty and that in 22 patients after Polya gastrectomy. There were no significant differences among the groups. It is concluded that despite the disruption of the normal motor pathway produced by the Roux-en-Y reconstruction it does not lead to clinically significant delay in gastric emptying.
Restorative proctocolectomy: The four loop (W) reservoir
Authors: Nicholls R J , Lubowski D Z
Published: March 2007

The four loop (W) reservoir was developed with the aim of improving the functional results of the J reservoir and to avoid the need for catheterization often seen with the S reservoir. It is no more difficult to construct and results in better function. Sixty-four patients have undergone the procedure. There were no deaths. Mean hospital stay (including ileostomy closure) was 24 ± 8 days. The reservoir has been removed in one patient (one week postoperatively) who was found to have a Dukes' B rectal carcinoma. Function has been assessed in 51 patients (mean follow-up 18·6±8·9 months). Frequency of defaecation per 24 h is 3·3±1·0 (range 1–8) with night evacuation in 14 per cent. Antidiarrhoeal medication is required by 20 per cent of patients. Continence is normal in 92 per cent, and 8 per cent have minor leakage. All patients defaecate spontaneously.
Risk of colorectal cancer after surgery for benign peptic ulceration
Authors: Toftgaard C
Published: March 2007

A historical prospective cohort study has been conducted to determine the incidence of colorectal carcinoma following gastric surgery for benign peptic ulcer disease. A total of 4131 patients from 53 hospitals in the western part of Denmark were operated upon for gastric or duodenal ulcer from 1955 to 1960 inclusive. After exclusion of patients who were diagnosed as having a primary cancer before the ulcer operation and 0·5 per cent of the patients whose present status could not be defined, 2975 men and 943 women survived more than one month after the operation and thus formed the cohort of the study. They were followed up to their death or the end of the year 1982. Eighty-four colorectal carcinomas were observed against the expected 85·9. There was no significant difference between observed or expected number of cancers neither among men nor women.
Ultrasound-guided percutaneous drainage of intra-abdominal abscesses
Authors: Laméris J S , Bruining H A , Jeekel J
Published: March 2007

The encouraging results of percutaneous abscess drainage (PAD) in simple intra-abdominal abscesses have led us to employ this method in patients with more complex abdominal inflammatory disease, such as those with multiple enteric communicating or multilocular abscesses and patients in whom the percutaneous approach requires puncture routes traversing uninvolved organs. Cure was achieved in 74 per cent of all patients (83 of 112 patients) who underwent PAD, but in only 50 per cent of patients with multiple intra-abdominal abscesses (n = 16), 50 per cent of patients with complex pancreatic inflammatory disease (n = 8) and 57 per cent of patients with complex intraparenchymal abscesses (n = 7). PAD contributed to cure in eight of nine patients with enteric communicating abscesses. The transhepatic route to perihepatic abscesses proved to be safe. Complications occurred in nine patients (8 per cent). No relationship was noted between the severity or number of complications and the indication for PAD. Of the 29 failures of PAD, 17 patients were cured by either surgical intervention (14 patients) or a second PAD (1 patient) or a combination of the two methods (2 patients). Twelve patients (11 per cent) died, eight from sepsis due to inadequate drainage. Frequent reassessment by ultrasonography and computerized tomography (CT) in patients with prolonged sepsis after PAD is mandatory. These results justify a place for PAD in the management of the often critically ill patient with complex abdominal inflammatory disease.
Suture materials in contaminated wounds: A detailed comparison of a new suture with those currently in use
Authors: Paterson-Brown S , Cheslyn-Curtis Sarah , Biglin José , Dye J , Easmon C S F , Dudley H A F
Published: March 2007

The relationship between five different suture materials (expanded polytetrafluoroethylene (PTFE), polypropylene, polyglycolic acid, polydioxanone and polyglactin 910) and infection has been studied in 540 guinea-pig wounds contaminated with synergistic enteric organisms. The recently introduced expanded PTFE suture has been studied because, unlike the others, it has not previously been studied under these contaminated conditions. The incidence of wound infection in the control series was 26 per cent and all suture materials increased this figure significantly. The infection rate using expanded PTFE of 51 per cent was similar to all other sutures except polyglycolic acid, which produced an infection rate of 41 per cent. This difference was not statistically significant at the 5 per cent level. This confirms other studies including our own which show that the presence of most suture materials in contaminated wounds increases the incidence of infection. It further demonstrates that expanded PTFE is no different from other materials in this regard.
Fluoroscopic peroperative cholangiography: Technique and associated radiation hazards
Authors: Faulkner K , Gunn A , Harrison R M , Perry E P
Published: March 2007

The techniques specific to peroperative fluorocholangiography are discussed based on an experience of 632 cholangiograms and an estimation has been made of the associated radiation doses to staff and patients. Rapid and accurate information can be obtained during fluorocholangiography using appropriate techniques with acceptably low radiation hazards.
Heller's myotomy for achalasia: Is an added anti-reflux procedure necessary?
Authors: Andreollo N A , Earlam R J
Published: March 2007

Literature review (1970–85) indicates excellent or good results following Heller's operation in 89 per cent of 5002 patients. The overall mortality was 2·8 per cent with a reoperation rate of 2·8 per cent. When the operation was done through an abdominal incision, gastro-oesophageal reflux was almost twice as common as when it was done through a thoracic incision, regardless of whether an anti-reflux procedure was performed.
Reduced response of cerebral blood flow to hypercapnia: Restoration by extracranial—intracranial bypass
Authors: Bishop C C R , Burnand K G , Brown M , Russell R Ross , Browse N L
Published: March 2007

Cerebral blood flow, estimated by the xenon clearance technique, has been used to study eight patients before and after extracranial—intracranial (EC—IC) bypass surgery. Response of cerebral blood flow to hypercapnia was also measured to estimate cerebral reactivity, an indicator of cerebral vasodilator reserve capacity. Measurements in all patients were repeated 3 months after surgery. Resting cerebral blood flow was not increased by the operation but cerebral reactivity in the ipsilateral hemisphere was significantly increased in all patients (P = 0·002). Reactivity also increased in the contralateral hemisphere in six of the eight patients (P = 0·065). The response of cerebral blood flow to hypercapnia may prove useful in the selection of symptomatic patients with carotid occlusions or inaccessible stenoses for revascularization by EC—IC bypass.
Resection in chronic pancreatitis
Authors: Williamson R C N , Cooper M J
Published: March 2007

In the absence of ductal ectasia there is no adequate alternative to pancreatectomy for severe chronic pancreatitis. A personal series of 30 such patients operated upon between 1977 and 1984 included 16 with distal pancreatectomy, 6 with proximal pancreatectomy and 12 with total pancreatectomy; 4 patients progressed from distal to total resection after an interval of 15–28 months. The mean age was 39 years with a male preponderance of 77 per cent. The main aetiological agents were chronic alcoholism (63 per cent) and previous acute pancreatitis (23 per cent). One patient died after total pancreatectomy, giving a 30-day mortality rate for all resections of 3 per cent. Postoperative complications necessitated reoperation in 10 per cent, and there have been 5 late deaths (17 per cent). Among 27 patients followed for a median of 4·5 years, pain relief has been good in 16, fair in 8 and poor in 3 (11 per cent). Proximal pancreatectomy has proved superior to distal pancreatectomy with regard to analgesia and the avoidance of diabetes. Although technically demanding, total pancreatectomy has improved symptoms substantially in 9 of 10 patients surviving for a minimum of 18 months.
Assessment of hospital workload in war surgery
Authors: Gertsch Ph
Published: March 2007

The aim of treatment of casualties in war time is to offer a chance of survival to the greatest number of patients. This goal can be approached by selecting for treatment patients who have a real chance of survival and by reducing the duration of operations as much as possible. Should the operative time be limited to an assessed predetermined duration as proposed in certain armies? Conditions for the observation of war wounded were particularly favourable in the ICRC (International Committee of the Red Cross) Hospital in Peshawar (Pakistan) because all treatments were started and completed in the same place. During the summer of 1985, a major battle took place near the Pakistan border. Analysis of 212 operated patients, of whom 68 per cent arrived at the hospital less than 48 h after the injury, showed that the operations lasted 90 min on average. Abdominal procedures were the longest. Patients stayed in the hospital for an average of 4 weeks; those with lesions of the extremities stayed longer (5·8 weeks) than those with abdominal or thoracic lesions (4·3 and 3 weeks). The results show that the long duration of an operation has not been correlated either with an unfavourable outcome or with an increased postoperative workload. As far as possible, accelerating the turnover of operations by increasing the number of operating teams should be the objective rather than the selection of patients who require short operations. Such selection would have resulted in the death of most seriously wounded patients in this series.
Case for conservative management of selected fibro-adenomas of the breast
Authors: Cant P J , Madden M V , Close Pauline M , Learmonth Genevieve M , Hacking E Anne , Dent D M
Published: March 2007

To assess the safety of a conservative approach to fibro-adenoma of the breast we prospectively studied 321 women with this clinical diagnosis, and performed aspiration cytology and excision biopsy. There was histological confirmation of fibro-adenoma in 217 (68 per cent), the remainder having various benign conditions and 4 (1·3 per cent) had carcinoma. Aspiration cytology had a sensitivity of 87 per cent and a specificity of 76 per cent for fibro-adenoma. Three cases of carcinoma were identified cytologically and the fourth was regarded as suspicious. To estimate the risk of missing carcinoma we compared the annual frequency of carcinoma with fibro-adenoma in young women and found a ratio of 1:470 between 15 and 19 years, 1:133 between 20 and 24 years and 1:9 in the 25–29 age group. To assess patients' views on non-operative treatment of benign breast masses we asked 124 women, 10 days postoperatively, whether they preferred a conservative approach for a cytologically benign lump: 26 (21 per cent) opted for conservative management in the future and 8 (7 per cent) would have preferred conservatism rather than their recent excision. A conservative approach is safe for clinically and cytologically benign breast lumps in women under 25 years, but very few will accept it.
Selection of patients for surgery following peptic ulcer haemorrhage
Authors: Brearley S , Hawker P C , Morris D L , Dykes P W , Keighley M R B
Published: March 2007

Surgery remains the only widely available and well-proven means of stopping haemorrhage from peptic ulcers and preventing its recurrence but carries an unavoidable morbidity. If surgery is to be used to maximum effect with minimum morbidity, an accurate means of predicting which patients will suffer further haemorrhage is needed. Although over 80 per cent of patients who rebleed have the endoscopic stigmata of haemorrhage, a policy of operation in all patients with stigmata would lead to a very high operation rate and a high proportion of unnecessary operations, as one-half of the patients with stigmata do not rebleed. Clinical data were collected prospectively from 278 cases of peptic ulcer haemorrhage. The data from a randomly selected 75 per cent of the cases were analysed by stepwise logistical regression. Patients who had the endoscopic stigmata of haemorrhage and who had a probability of further haemorrhage, calculated from the regression equation, of more than 0·2 were identified as a high risk group. This definition was validated using the 25 per cent of cases not used in the initial analysis. Eighty-four per cent of patients in the high risk group suffered further haemorrhage and all such patients therefore require early surgery: such a policy would have resulted in an operation rate of 28 per cent. Thirty per cent of the patients who had further haemorrhage were not identified as being at high risk but none of them had a severe rebleed. The regression equation greatly enhanced the value of stigmata in guiding surgical decision making and merits further evaluation.
Importance of cellular DNA content in pre-malignant breast disease and pre-invasive carcinoma of the female breast
Authors: Carpenter R , Gibbs N , Matthews Joyce , Cooke T
Published: March 2007

The-risk of malignant change in pre-invasive breast disease such as proliferative atypia (PA) or the risk of invasive carcinoma arising from ductal carcinoma in situ (DCIS) remains uncertain in individual women because of the absence of any prognostic criteria. In order to clarify this, the cellular DNA content (ploidy) of 51 screen-detected lesions has been investigated. Cellular DNA measurements were made by static cytometry following Feulgen staining of disaggregated tissue sections and the resulting histograms classified as either diploid or aneuploid. Thirteen cases of PA and twelve of DCIS were compared with twenty-six biopsies showing DCIS with adjacent invasive carcinoma (DCIS + Ca). In the latter group, ploidy of the invasive carcinoma was compared with the associated DCIS in 16 cases. Aneuploid cells were found in approximately 30 per cent of PA and DCIS lesions but in 23 of 26 cases of DCIS + Ca. Of 16 assessable cases of co-existing DCIS and micro-invasive carcinoma both were aneuploid in 11, both diploid in 1, and in 4 cases the DCIS was aneuploid whereas the invasive carcinoma was diploid. These results suggest that aneuploidy may be of value in predicting the most biologically aggressive of these pre-invasive lesions.
Total pancreatectomy for chronic pancreatitis
Authors: Cooper M J , Williamson R C N , Benjamin I S , Carter D C , Cuschieri A , Linehan I P , Russell R C G , Torrance H B
Published: March 2007

A survey of six British centres collected data on 83 patients undergoing total pancreatectomy (TP) for chronic pancreatitis between 1977 and 1986. There were 57 men and 26 women with a median age of 38 years (range 19–61 years). Half were alcoholics and half had had previous acute pancreatitis. Besides jaundice (14 per cent) severe pain was the indication for the operation; regular opiates had been needed in 82 per cent of patients and 37 per cent were addicted to these drugs. All but 12 had had previous pancreatic or biliary surgery, with a median of two operations and a maximum of six. TP was a one-stage procedure in 32 patients, 42 had had distal resections and 9 proximal resections in the past; the pylorus was preserved in 30. Median operation time was 4 h (range 2–18 h) and median blood loss was 3 units (1–21 units). Intra-operative complications in 11 patients included haemorrhage in 9. Four deaths occurred within 30 days from bleeding (2), respiratory failure (1) and Roux-loop infarction (1). All but one of the 79 survivors required full pancreatic supplementation and 38 per cent had difficulties in endocrine control. At a median follow-up of 1·5 years (range 0·25–10 years), 57 patients (72 per cent) were pain-free and 9 (11 per cent) needed only occasional analgesia. Though 13 (17 per cent) still took regular analgesics, all were symptomatically improved. There have been 10 late deaths (13 per cent), all but one of which are attributable to the operation.
Urological complications in 600 consecutive renal transplants
Authors: Jaskowski A , Jones R M , Murie J A , Morris P J
Published: March 2007

The results of 600 consecutive renal transplant operations (540 cadaver and 60 living related donor) in 491 patients were assessed with respect to urological complications. In nearly all cases the ureter was inserted into the bladder using a Leadbetter-Politano ureteroneocystostomy technique. The bladder was drained by Foley catheter for 5 days and the operation site by vacuum drain for a variable period. After 26 operations in 26 patients, 27 episodes of ureteric obstruction were identified (one re-obstruction). These occurred between 1 day and 45 months after transplantation and involved the lowest third of the ureter 19 times, the middle third 3 times and the proximal third 4 times. They were due to stricture (11), pelvic collection (7), redundant or twisted ureter (3) or other cause (5). An anatomical predisposing factor in either patient or graft was identified in 31 per cent of these caes. After 18 operations in 18 patients, 21 episodes of urine leakage were identified (three re-leakages). These occurred between 1 day and 6 months after transplantation and an anatomical predisposing factor in either patient or graft was present in 59 per cent. Thus, overall, 7 per cent of patients developed a urological complication in this series. This rate has declined in recent years in parallel with a general reduction in steroid dose for immunosuppression. This last feature, combined with the surgical technique described, has resulted in a low incidence of urological complication after transplantation, being now between 1 and 2 per cent.
Treatment and outcome in 52 consecutive cases of ampullary carcinoma
Authors: Neoptolemos J P , Talbot I C , Carr-Locke D L , Shaw D E , Cockleburgh R , Hall A W , Fossard D P
Published: March 2007

The results of treatment and outcome in 52 consecutive patients presenting to Leicester from 1972 to 1984 are presented. The number of patients diagnosed increased from two per year before the introduction of duodenoscopy to nearly five per year afterwards. Endoscopic drainage (ED) was attempted in 21 patients with a success rate of 81 per cent. In eight cases ED was used pre-operatively and in the remainder as definitive treatment. Twenty-four patients had a Whipple's resection (12·5 per cent mortality), four patients had a local resection (no deaths), ten patients had surgical bypass (60 per cent mortality) and thirteen patients had ED alone (23 per cent mortality). The major risk factor score was significantly greater in patients undergoing surgical bypass compared with Whipple's resection. Age and risk factor scores were significantly greater in patients who had ED drainage alone than in surgical patients. The 5 year survival rate for resection was 56 per cent versus 13 per cent for drainage procedures (P < 0·001). Survival in resection cases was directly related to the degree of tumour differentiation and a new staging system. It is proposed that all patients with ampullary tumours should have endoscopic biopsy followed by ED; Whipple's resection remains the surgical treatment of choice.
Postoperative intra-abdominal sepsis
Authors: Rogers P N , Wright I H
Published: March 2007

Postoperative intra-abdominal sepsis carries a high mortality. Diagnosis by clinical examination is often difficult, and imaging techniques may be helpful. Diagnostic laparotomy should be considered early, even in the absence of localizing signs. The use of aggressive surgical techniques may improve prognosis. The timing of surgical intervention is as important as the technique. Early diagnosis and treatment is particularly crucial in critically ill patients.
Current spectrum of intestinal obstruction
Authors: McEntee G , Pender D , Mulvin D , McCullough Majella , Naeeder S , Farah S , Badurdeen M S , Ferraro V , Cham C , Gillham N , Matthews P
Published: March 2007

In a 12-month prospective study incorporating four neighbouring district general hospitals, 228 patients required a total of 236 admissions with intestinal obstruction. The aetiological factors included adhesions 75 (32 per cent), malignant disease 61 (26 per cent), strangulated hernias 59 (25 per cent), volvulus 10 (4 per cent), acquired megacolon 6 (3 per cent), pseudo-obstruction 4 (2 per cent), faecal impaction 6 (3 per cent) and miscellaneous 15 (6 per cent). The peak incidence for obstruction due to adhesions, malignant disease and strangulated hernias each occurred in the eighth decade. Surgery was performed within 48 h of admission in 29 per cent adhesive obstructions (22), 30 per cent obstructions due to malignant disease (18) and 68 per cent strangulated hernias (40) - bowel resection rates in these three groups were 13·5, 50 and 29 per cent, respectively. The overall mortality was 11·4 per cent (26 deaths) and postoperative mortality was 12·3 per cent (19 deaths). During the 12-month study period, 228 patients required a total of 2993 impatient hospital days as a result of intestinal obstruction. Postoperative adhesions have become the commonest cause of intestinal obstruction but strangulated hernias and intra-abdominal malignant disease still account for 50 per cent of all cases and mortalities. Obstruction due to strangulated hernias and intra-abdominal malignant disease typically occurs in the elderly age group where a more aggressive policy of elective surgical intervention is likely to be associated with increased postoperative morbidity and mortality.
Subclavian vascular injuries
Authors: Demetriades D , Rabinowitz B , Pezikis A , Franklin J , Palexas G
Published: March 2007

This study comprises 228 patients with penetrating injuries of the subclavian vessels. The vein alone was involved in 44 per cent, the artery alone in 39 per cent, and both vessels in 17 per cent. The majority of the victims (61 percent) did not reach the hospital alive, and in those who were operated on the mortality was 15·5 per cent (overall mortality 66 percent). The overall mortality of venous injuries was significantly higher than the arterial ones (P<0·01), probably because of the dangerous complication of air embolism. Physical examination is reliable in the diagnosis of these injuries and there is no need for an emergency angiogram. The clavicular incision was the preferred approach. Repair was performed in 94 per cent of those with arterial injury. Vein injuries were treated by suture in 60 per cent and ligation in 40 per cent. A selective conservative approach is advised.
Transluminal angioplasty versus conventional operation in the treatment of haemodialysis fistula stenosis: Results from a 5-year study
Authors: Dapunt O , Feurstein M , Rendl K H , Prenner K
Published: March 2007

In this retrospective study we have used life table analysis to compare the results of 37 transluminal angioplasties with those of 37 conventional operations (thrombectomy, thrombendarterectomy with/without grafting, bypass) in the treatment of stenoses and occlusions of haemodialysis fistulae. There was no difference between the groups in terms of lesion morphology or the patients' age and sex. Cumulative patency rates for angioplasty and surgery, respectively, were 94·5 and 78·1 per cent after 1 week, 72·3 and 64·1 per cent after 1 month, 41·2 and 28·9 per cent after 5 months and 31·3 and 19·3 per cent after 1 year (χ2 test, P<0·001). The difference is due mainly to a high percentage of early occlusions in the first week after surgery. When transluminal angioplasty of haemodialysis fistula stenoses is possible it achieves results which are at least as good as those of operation.
Pathophysiology of acute obstructive cholecystitis: Implications for non-operative management
Authors: Jivegård L , Thornell E , Svanvik J
Published: March 2007

Recent research suggests that disturbances in gallbladder mucosal functions are important in the initiation of acute cholecystitis and its progression. Prostaglandins have pathophysiological significance and prostaglandin synthesis inhibitors such as indomethacin inhibit fluid secretion by gallbladder mucosa, reduce distension and relieve pain. Nerves in the gallbladder wall are involved in disturbed mucosal function, and the benefits of opiates may derive from reduction of active fluid secretion in the inflamed and obstructed gallbladder as well as from central analgesic effects.
Surgical management of strictures of the major bile ducts in recurrent pyogenic cholangitis
Authors: Lau W Y , Fan S T , Yip W C , Wong K K
Published: March 2007

Definitive surgical procedures were performed on 46 patients with strictures of the major bile ducts: dilatation of strictures was undertaken in 6 patients, hepatotomy and plastic repair in 2, biliary-enteric anastomosis in 18, and liver resection with or without drainage for the rest of the biliary tree in 20 patients. The overall operative morbidity was 21·7 percent. Two patients died within 30 days of operation. One patient died of septicaemia after emergency dilatation of stricture while another died of sepsis from a leakage after hepatotomy and plastic repair. The median follow-up for the 44 patients who survived the operation was 43 months. All strictures reformed after dilatation within 2 months. Acute cholangitis occurred in six patients, two after dilatation of strictures (with documented recurrent stone formation in one), two after biliary-enteric anastomosis and two after liver resection. Thus, good clinical results were obtained in 38 out of 44 patients (86·4 percent).
Left-sided subtotal oesophagectomy for carcinoma
Authors: Matthews H R , Steel A
Published: March 2007

Oesophageal resection for carcinoma has been performed using a two-part left-sided approach with cervical anastomosis in 75 patients, all of whom have been followed up to death or for a minimum of 5 years. Operative mortality was 12 per cent, but long-term survival was 28 per cent for all squamous tumours and 12 per cent for all adenocarcinomas, irrespective of node status. It is suggested that this approach offers significant advantages.
Splenectomy and renal allograft survival in the rat
Authors: Cranston D , Wood Kathryn J , Morris P J
Published: March 2007

The effect of splenectomy on renal allograft survival is not clear. In the rat, spleens isolated from recipients with functioning grafts have been shown to be a major source of cells that are capable of suppressing the rejection response (suppressor T lymphocytes). Thus the removal of the spleen in these allograft recipients could be detrimental to renal allograft survival. This study investigates this hypothesis, and looks for the presence of suppressor cells in other lymphoid organs apart from the spleen. In the rat renal allograft model, donor Lewis spleen cells given to DA recipients intravenously 1 week before transplantation of a Lewis kidney leads to indefinite allograft survival (median survival time (MST) > 100 days). Splenectomy before or after pretreatment with donor spleen cells failed to abrogate this effect (MST > 100 days). Experiments were performed in which cells or serum were prepared from long-term surviving splenectomized animals which had already been pretreated and transplanted, and then were injected into untreated recipients (adoptive transfer experiments). This was done to determine if cells capable of suppressing graft rejection were present in lymphoid organs outside the spleen in these splenectomized recipients. Thus the IV transfer of 108 lymph node cells harvested from splenectomized DA recipients with a long-term surviving LEW graft (LTS), into untreated but lightly irradiated (200 rad) DA recipients resulted in indefinite survival of a fresh Lewis kidney (MST > 100 days). In contrast, adoptive transfer of normal DA lymph node cells was ineffective (MST 13 days). Thus splenectomy is not necessarily detrimental to graft survival, as cells capable of preventing graft rejection are found in other lymphoid organs, such as lymph nodes, in splenectomized recipients.
Anorectal sampling: A comparison of normal and incontinent patients
Authors: Miller R , Bartolo D C C , Cervero F , McC Mortensen N J
Published: March 2007

It has been suggested that sampling of rectal contents by the anal canal may play a role in the continence mechanism. To investigate this concept we studied 18 patients with faecal incontinence and 18 age and sex matched controls. A microtransducer catheter was positioned so that pressures were recorded from the rectum, the junction of the upper and middle thirds of the anal canal and the lower anal canal. Recordings were taken at rest and while distending the rectum with air in a balloon, and then with air injected freely into the rectum. Sampling (equalization of the rectal and upper anal canal pressures) was seen to occur spontaneously in 16 of the controls and only 6 of the incontinent group (P<0·02) and induced sampling occurred at a higher rectal volume in the incontinent group than in controls for freely injected air (P<0·002). Defective anorectal sampling may be an important contributory factor in the pathogenesis of anorectal incontinence.
Investigation of anorectal function
Authors: Felt-Bersma Richelle J F , Klinkenberg-Knol Elly C , Meuwissen S G M
Published: March 2007

Anorectal function tests were performed in 280 consecutive patients, who were referred for evaluation of different anorectal disorders. The relationship between the estimated anal sphincter pressure on digital palpation and the measured pressure on anal manometry was investigated and the interrelationship between anal manometry, rectal capacity and the saline infusion test was defined. A significant correlation (P<0·001) was found between digitally and manometrically measured anal sphincter pressure. Considering the relationship between the three specific anorectal function tests, only manometry and the saline infusion test correlated to some extent (P<0·01). This study shows that digital palpation is helpful in anorectal function investigation, but to establish the exact anal pressures, anal manometry is mandatory. Furthermore, the poor correlation observed indicates that single tests represent different aspects of anorectal function and therefore they need to be performed together.