bluuebunny/crossref_metadata_2025 huggingface dataset:
Traumatic arteriovenous fistula: Experience with 202 patients
Authors: Robbs J V , Carrim A A , Kadwa A M , Mars M
Published: March 2007

Experience with the management of 202 patients with 210 traumatic arteriovenous fistulas is reported. Penetrating trauma accounted for 98 per cent of injuries caused mainly by stabs (63 per cent) and missile wounds (26 per cent). Seven of 15 patients with shotgun wounds had multiple lesions. Over half of all fistulas occurred in the cervicomediastinal vessels; abdominal and thoracic vessels were infrequently involved. The upper limbs were involved in 22 per cent and the lower limbs in 20 per cent. Some 133 patients were diagnosed and treated within 1 week of injury; 69 presented 1 week to 12 years later. Machinery murmur was noted in 61 per cent of the early presenters, but was an almost universal finding in those presenting late. Only three patients had cardiac failure and all had underlying cardiomyopathy. Active overt haemorrhage was not common. Arterial continuity was restored in 80 per cent of cases, usually by autogenous reconstruction. Venous injury was usually treated by ligation or lateral suture. Patients treated within 1 week of injury had a lower rate of perioperative mortality and morbidity than those treated late, due mainly to technical difficulties in controlling the vessels caused by fibrosis and massive venous dilatation. If a policy of selective exploration of penetrating trauma is to be followed, careful assessment for arteriovenous fistula must be made and the patient evaluated at regular intervals for several months. Shotgun injuries require routine angiography at the time of presentation. The earlier treatment is instituted, the better the results.
Improved survival in simulated surgical infection with combined cytokine, antibiotic and immunostimulant therapy
Authors: Gaar E , Naziri W , Cheadle W G , Pietsch J D , Johnson M , Polk H C
Published: March 2007

A study was performed to find an ideal combination and sequence of cytokines, antibiotics and immunorestorative agents to enhance survival from serious infection. The effects of combinations of granulocyte-macrophage colony-stimulating factor (GM-CSF), tumour necrosis factor (TNF) a, the immune adjuvant muramyl dipeptide (MDP) and two systemic antibiotics were studied in a validated murine model of surgical infection. A single cotton suture containing absorbed Klebsiella pneumoniae was placed into the thighs of mice to produce local and systemic infection. Control mice received a volume of subcutaneous saline equal to that of the therapeutic agent; only 18 per cent survived 9 days after infection. The survival time of mice treated with any single agent was similar to that of controls. The group given maximal combined therapy (65 mice) received GM-CSF, TNF-a, MDP, and ampicillinsulbactam or cefoxitin for 6 days. The survival rate in this group 9 days after the introduction of infection was 84–90 per cent (P< 0·0001), suggesting that specific combinations of cytokines, immunostimulants and antibiotics may be useful in combating lethal infection.
Randomized comparison of fine-needle aspiration cytology and Biopty-Cut needle biopsy after unsatisfactory initial cytology of discrete breast lesions
Authors: Carty N J , Ravichandran D , Carter C , Mudan S , Royle G T , Taylor I
Published: March 2007

In a minority of patients with a discrete breast lump the initial cytological assessment is either unsatisfactory or at variance with the results of other methods of diagnosis. A randomized comparison of repeat cytology and needle-core biopsy provided clinically useful information in 14 of 31 patients receiving repeat cytology and in 26 of 29 randomized to core biopsy. Nineteen patients had carcinoma: ten who received repeat cytology, which indicated malignancy in only three (diagnostic of malignancy in one, suspicious in two), while all nine patients who underwent core biopsy had a correct diagnosis (only suspicious of malignancy in one). The sensitivity for the definitive diagnosis of carcinoma on repeat cytology and core biopsy was 10 and 89 per cent respectively. Patients with a discrete breast lump and unclear cytology results require needle-core biopsy. This has more diagnostic value than repeat cytology.
Detection of hepatitis C virus RNA in the ultrasonic dissector irrigating solution used in liver surgery
Authors: Higashi H , Matsumata T , Hayashi J , Yanaga K , Shimada M , Shirabe K , Taketomi A , Kashiwagi S , Sugimachi K
Published: March 2007

Hepatitis C virus (HCV) RNA was detected in the irrigating solution aspirated by the ultrasonic dissector system used in liver surgery with a reverse transcription polymerase chain reaction technique and was then compared with HCV RNA in the serum to clarify the risk of viral transmission to hospital personnel. The positivity of HCV RNA in the aspirated irrigating solution was approximately equal in all patients whose serum was positive for HCV RNA. However, viral RNA was not detected in the aspirated irrigating solution of any patient who was seronegative for HCV RNA. These results indicate that it is necessary to be cautious regarding the transmission of HCV during liver surgery when using the ultrasonic dissector in HCV RNA seropositive patients, because the irrigating solution aspirated by this device appears to be highly infectious.
Complications of adjacent organs in chronic pancreatitis managed by duodenum-preserving resection of the head of the pancreas
Authors: Izbick J R , Bloechle C , Knoefel W T , Wilker D K , Dornschneider G , Seifert H , Passlick B , Rogiers X , Busch C , Broelsch C E
Published: March 2007

Chronic pancreatitis frequently generates complications through involvement of adjacent organs. Distal common bile duct stenosis and segmental duodenal stenosis, the most frequent complications, are usually treated by resection or bypass procedures. This study presents experience with duodenum-preserving resection of the head of the pancreas in the treatment of patients with chronic pancreatitis with predominant involvement of the pancreatic head and coexisting complications involving adjacent organs. This procedure preserves the structure and function of the bile duct and duodenum. Sixty-six patients with severe chronic pancreatitis underwent duodenum-preserving resection of the head of the pancreas. Thirty-eight had associated complications of neighbouring organs: 37 had distal common bile duct stenosis, seven had duodenal stenosis, ten had evidence of segmental portal hypertension and one suffered from a pancreatopleural fistula. Details of all patients were documented prospectively; mean follow-up was 4·2 years. The complications of adjacent organs were permanently eradicated in 36 of 38 patients. Two patients required endoscopic stenting for persisting bile duct obstruction. There was substantial or complete relief of all symptoms in 35 patients. Duodenum-preserving resection of the head of the pancreas is effective in the treatment of severe chronic pancreatitis with predominant involvement of the pancreatic head and provides definitive management of associated complications of adjacent organs.
Laparoscopic versus open cholecystectomy: Hospitalization, sick leave, analgesia and trauma responses
Authors: Berggren U , Gordh T , Grama D , Haglund U , Rastad J , Arvidsson D
Published: March 2007

Laparoscopic cholecystectomy has rapidly become established as the treatment of choice for cholecystolithiasis. There is very little evidence, however, to support the claimed benefit to patients. In the present study 30 consecutive patients below the age of 65 years without acute cholecystitis and with no signs of common bile duct stones were randomized to laparoscopic or conventional open eholecystectomy. Median (interquartile range) intravenous consumption of pethidine with a patientcontrolled injection device between 13 and 24 h after surgery was 125 (62–175) mg in patients who underwent the laparoscopic procedure and 200 (150–250) mg in those who had open operation. Urinary adrenaline and cortisol levels as well as those of plasma glucose, C-reactive protein and interleukin 6 were increased after surgery in both groups of patients, but without any significant difference between them. The mean(s.d.) duration of postoperative hospital stay (2·8(0·8) versus 1·8(0·6) days) and sick leave (24·0(4·4) versus 11·7(4·1) days) was significantly longer with open than laparoscopic cholecystectomy. The findings demonstrate obvious advantages of laparoscopic surgery as regards postoperative pain and convalescence, although factors reflecting the magnitude of trauma did not differ.
Colectomy and ileorectal anastomosis in patients with Crohn's disease
Authors: Chevalier J M , Jones D J , Ratelle R , Frileux P , Tiret E , Parc R
Published: March 2007

Eighty-three patients underwent colectomy and ileorectal anastomosis for Crohn's disease of the large bowel. There were two postoperative deaths and seven anastomotic leaks. Fifty-two patients retained a functioning anastomosis with a mean follow-up of 8 years. Forty had an excellent or good functional result. The cumulative proportion of patients with a functioning ileorectal anastomosis was 77 and 63 per cent at 5 and 10 years respectively. Patients presenting with perforating Crohn's disease had a significantly increased risk of failure of the anastomosis. Perianal Crohn's disease following ileorectal anastomosis was significantly related to the need to defunction or excise the rectum.
Trauma in pregnancy
Authors: Vaizey C J , Jacobson M J , Cross F W
Published: March 2007

Trauma is a major cause of maternal death in pregnancy. The pregnant woman who has been involved in an episode leading to her arrival in an accident and emergency department presents with specific problems that often require specialist attention. The correct initial management of such patients should not be beyond the capabilities of an average trauma team and such management is clearly taught as part of the Advanced Trauma Life Support course now available in the UK. This review outlines the physiological changes associated with pregnancy that become important during resuscitation and definitive care. It discusses the presentation and management of specific problems, and the safety - or otherwise - of commonly administered drugs. Only the initial resuscitation of the patient is considered; specialist obsteric care is beyond the scope of the article.
Macrolides in roles beyond antibiotic therapy
Authors: Pilot M-A
Published: March 2007

Erythromycin and other macrolides with a closely related structure are widely used antibiotics. Side-effects related to administration of such drugs are mostly gastrointestinal. The direct effect of erythromycin on gastrointestinal motility was studied; it was found to have a stimulatory effect proximally, on stomach and duodenal motility, with an apparent distal inhibition. Gastric emptying was accelerated by erythromycin via an antroduodenal coordination mechanism, an effect that has proved to be beneficial in surgical and medical conditions in which gastroparesis is a problem. Erythromycin is now used experimentally and clinically; it has been found to accelerate gastric as well as gallbladder emptying and to have an effect on the oesophagus. Analogues of erythromycin have been developed that have potent gastrointestinal activity but little or no antibacterial potential. Macrolides modulate the antibacterial action of neutrophils, with some action on the oxidative burst. Finally, two new macrolide immunosuppressants have been developed that compare favourably with traditional drugs.
Surgical workload as a consequence of screening for abdominal aortic aneurysm
Authors: Scott R A P , Gudgeon A M , Ashton H A , Allen D R , Wilson N M
Published: March 2007

A study was performed to evaluate the surgical workload that has resulted from screening an at-risk population for abdominal aortic aneurysm (AAA) and to forecast the likely workload from an established screening programme. Over an 8-year period 8944 people aged 65–80 years were screened; 356 were found to have an AAA of 3 cm or greater in diameter. There were 288 outpatient consultations involving 171 patients, and 43 patients (4·8 per 1000 screened) had surgery during the study period. A fully operational screening programme for a population of 250000, screening men and women at a rate of 2000 per year, would be expected to produce a surgical workload of nine or ten operations for AAA per year. Screening men only would increase this to 34 annually.
Pulse-generated run-off versus dependent Doppler ultrasonography for assessment of calf vessel patency
Authors: Currie I C , Wilson Y G , Davies A H , Micciche M , Wakeley C J , Baird R N , Lamont P M
Published: March 2007

Pulse-generated run-off (PGR) is an established technique in the assessment of calf vessel patency. Dependent Doppler ultrasonography is proposed as a fast and simple alternative. Twenty-six limbs with severe ischaemia were evaluated by PGR, dependent Doppler examination and intra-arterial digital subtraction angiography (DSA). PGR was performed and scored as previously described. Dependent Doppler ultrasonography was performed after 5 min of foot dependency and scored as for PGR. Angiograms were scored by an independent radiologist, who awarded 2 for a vessel widely patent to the ankle, 1 for a diseased vessel crossing the ankle and 0 if no vessel was visualized. Of 78 calf vessels evaluated, 59 (76 per cent) appeared patent on PGR and dependent Doppler examination but only 33 (42 per cent) appeared patent to the ankle with ïntra-arterial DSA. There was very good agreement between PGR and dependent Doppler for detection of patent calf vessels (κ = 0·93). Doppler signals were biphasic in six calf vessels on dependency and in 22 vessels with PGR. PGR and dependent Doppler ultrasonography detected 26 vessels communicating with the pedal arch compared with seven detected angiographically. There was good agreement between PGR and dependent Doppler examination for diagnosis of the most suitable vessel for distal anastomosis (κ = 0·80). The wide availability and simplicity of dependent Doppler ultrasonography mean that no patient with a critically ischaemic limb should be denied reconstructive surgery on the basis of angiographic findings alone.
Saphenous vein reflux without incompetence at the saphenofemoral junction
Authors: Abu-Own A , Scurr J H , Smith P D Coleridge
Published: March 2007

Duplex ultrasonography was used to assess patients with primary varicose veins to determine whether varicosities of the long saphenous vein (LSV) occurred without saphenofemoral junction (SFJ) incompetence. Some 167 consecutive patients with the clinical diagnosis of primary varicose veins were investigated. Of 190 limbs with LSV reflux 63 had no SFJ incompetence, of which only five had incompetent perforators; these were midthigh perforators in two limbs and medial calf perforators in three. LSV reflux, often occurs in the presence of a competent SFJ. This indicates that, in such circumstances, saphenofemoral ligation alone is unlikely to control varices associated with LSV reflux. It also suggests that the development of primary varicose veins may be an ascending rather than a descending phenomenon.
Stripping of the long saphenous vein in the treatment of primary varicose veins
Authors: Sarin S , Scurr J H , Smith P D Coleridge
Published: March 2007

Eighty-nine legs with long saphenous vein (LSV) reflux and saphenofemoral junction incompetence were treated by saphenofemoral ligation and multiple avulsions; patients were randomized to undergo additional stripping of the LSV from groin to upper calf (n = 43) or no additional treatment (n = 46). At a median of 21 months after surgery recurrence was evaluated by duplex ultrasonography, photoplethysmography, clinical examination and patient assessment. Fewer persisting incompetent LSVs in the calf were found (21 versus 38) and median (interquartile range) photoplethysmographic refilling times were longer (20 (13–27) versus 14 (11–21) s) when the LSV was stripped than after saphenofemoral ligation alone (both P<0·01). More patients were completely satisfied (65 versus 37 per cent) and were recurrence-free (65 versus 17 per cent) when the LSV had been stripped compared with saphenofemoral ligation alone (P<0·05 and P<0·001 respectively). The addition of LSV stripping to saphenofemoral ligation and multiple avulsions results in a better overall outcome.
Prediction of recurrent bleeding after endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage
Authors: Park K G M , Steele R J C , Mollison J , Crofts T J
Published: March 2007

Endoscopic haemostasis by injection of adrenaline was attempted in 135 consecutive patients with active upper gastrointestinal bleeding. Initial haemostasis was obtained in 127 patients following injection of 5–15 ml 1 : 10000 adrenaline; eight patients in whom haemostasis was not achieved underwent immediate laparotomy. There was further haemorrhage in 25 patients, which was successfully treated by further injection of adrenaline in ten. Fifteen patients had major rebleeding requiring emergency surgery. Stepwise logistic regression analysis identified three factors that, taken together, were highly predictive of the need for surgery: pulse rate on admission, the position of the ulcer and whether the patient was obese. A scoring system was derived from the logistic analysis equation that was found to predict correctly the need for emergency surgery in 84 per cent of patients. In patients with a high probability of rebleeding surgery should be considered after initial endoscopic haemostasis and stabilization. In the majority of patients endoscopic treatment alone is sufficient for permanent haemostasis.
Surgical treatment of primary duodenal carcinoma: A personal series
Authors: Scott-Coombes D M , Williamson R C N
Published: March 2007

In a personal series, 22 patients (11 men, 11 women) of median age 60 (range 25–81) years with primary duodenal adenocarcinoma underwent operation between 1979 and 1993. Tumours arising from bile duct, ampullary or pancreatic tissue were excluded. Principal presenting symptoms were jaundice (12 patients), pain (seven), anaemia (six) and vomiting (six). A pre-existing villous adenoma was seen in 11 patients and adjacent duodenal dysplasia in 13. Sites of origin were mostly the second part of the duodenum (18 patients) but also the third and fourth parts (two each). Seventeen patients underwent ‘curative’ resection with one hospital death at 25 days; the 5-year survival rate thereafter was 40 per cent. Five patients who received palliative surgery survived for a median of 7 months. Primary duodenal carcinoma is a distinct entity with a better prognosis than pancreatic cancer after radical resection. It favours the descending duodenum and is closely linked with villous adenoma and epithelial dysplasia.
Reconstructive abdominal operations after laparostomy and multiple repeat laparotomies for severe intra-abdominal infection
Authors: Scripcariu V , Carlson G , Bancewicz J , Irving M H , Scott N A
Published: March 2007

Between 1980 and 1993, 18 patients underwent formal laparotomy after laparostomy and healing of the peritoneal cavity by granulation. The majority (12 patients) were men and the median age was 47 (range 22–67) years. Intra-abdominal infection following surgery for Crohn's disease (four patients) and necrotizing pancreatitis (six) was the most common primary condition requiring laparostomy. A total of 23 reconstructive operations were carried out on the 18 patients a median of 6 (range 1–18) months after laparostomy. The indication for surgery was for closure and/or resection of an enteric fistula in 13 patients. The site of the fistula included three gastric, two duodenal, 11 small bowel and seven colonic. A further four patients required operation for closure or refashioning of a stoma. Five patients subsequently required a second laparotomy: two for elective restoration of bowel continuity, two for recurrent fistula and one for an acute abdomen. After reconstructive surgery following laparostomy 16 patients were discharged home alive and well, one requiring home parenteral nutrition for short boweksyndrome. In contrast, the two oldest patients in the series died from multiple organ failure immediately after initial reconstructive surgery. Both had pre-existing medical problems and in neither was there evidence of further intra-abdominal infection after reconstruction.
Randomized trial of modified Bassini versus Shouldice inguinal hernia repair
Authors: Paul A , Troidl H , Williams J I , Rixen D , Langen R
Published: March 2007

Between 1986 and 1992, 265 men of mean age 51 (range 16–75) years with a primary inguinal hernia were randomized to undergo surgery by staff surgeon or surgical resident and further randomized to receive a modified Bassini operation (transversalis fascia not divided but included in the repair) or Shouldice procedure. The follow-up rate was 92·1 per cent with a mean follow-up of 3·3 years. Recurrence developed in 12 of 125 patients with a Bassini procedure and two of 119 after a Shouldice repair (9·6 versus 1·7 per cent, P = 0·006). The recurrence rate was no different for staff surgeons and trainees (5·9 versus 5·6 per cent, P not significant). Multivariate analysis identified the presence of a direct hernia (P = 0·003) as the additional main factor for the development of recurrence.
Blood flow measurement in extremity soft tissue sarcoma with technetium-99m hexamethyl-propyleneamineoxime and single photon emission computed tomography
Authors: Hill S , Heary T , Flower M A , Cronin B , McCready V R , Thomas J M
Published: March 2007

Blood flow measurements were made in 28 patients with soft tissue sarcoma of the extremities to investigate the prognostic significance of tumour vascularity. Four patients with benign tumours also underwent blood flow measurement. Mean and maximum tumour blood flow was calculated from technetium-99m hexamethyl-propyleneamineoxime uptake measured using single photon emission computed tomography (SPECT), tumour volume measured from SPECT transaxial image reconstructions and cardiac output assessed with Doppler ultrasonography. Twenty-seven malignant lesions and one benign tumour showed increased uptake of isotope relative to surrounding tissues. Mean sarcoma blood flow varied between 1 and 33 ml per 100 ml tumour per min, and maximum flow between 5 and 57 ml per 100 ml per min. Fourteen patients developed progressive disease during the first year of follow-up. Eight of 11 patients with a high isotope uptake ratio, eight of 12 with a high mean blood flow and eight of 14 with a high maximum blood flow relative to the respective medians for the series showed disease progression.
Intraoperative assessment of nodal status in the selection of patients with breast cancer for axillary clearance
Authors: Hadjiminas D J , Burke M
Published: March 2007

Axillary node status was assessed by intraoperative contact cytology of four sampled nodes in each of 114 consecutive patients with operable breast cancer treated by wide local excision or mastectomy. At a mean follow-up of 18·7 months, 43 node-positive patients who underwent immediate axillary clearance had two locoregional and six distant recurrences with two deaths; four had arm oedema and one shoulder stiffness. There were no recurrences or arm and shoulder morbidity in 71 node-negative women who had no clearance or radiotherapy. The mean hospital stay was 4·3 days for patients having wide local excision versus 7·2 days for those undergoing excision and axillary clearance (P < 0·001), and 8·9 days for patients receiving a mastectomy versus 9·1 days for those having mastectomy and clearance (P not significant). Selective axillary clearance based on intraoperative contact cytology of four sampled nodes reduces hospital stay in patients treated by wide local excision and may lead to a reduction in arm morbidity without impairing disease control.
Chronic obscure groin pain is commonly caused by enthesopathy: ‘Tennis elbow’ of the groin
Authors: Ashby E C
Published: March 2007

Forty-nine patients with chronic obscure groin pain, bilateral in four, presented to one general surgeon in a 12-month period. Inflammation (‘enthesopathy’) at the pubic insertion of the inguinal ligament was the cause in 30 patients (32 groins). This has not previously been recognized as a cause of chronic groin pain, possibly because the exact site of tenderness can be obscured by the pubic pad of fat. Enthesopathy also occurred in five rectus and one adductor longus tendons (one patient had inflammation in both). Infiltration with long-acting steroid (1 per cent triamcinolone) and local anaesthetic (2 per cent lignocaine) was offered to all patients with localized tenderness of tendon or ligament. A questionnaire survey 3–15 months after injection showed a better outcome after treatment than when injection was declined. Other causes of pain included nerve entrapment (five cases), spinal referred pain (five in four patients) and ureteric stones (two). Inguinal hernia is sometimes coincidental rather than causative of the pain. In three patients the pain had subsided and no diagnosis was made. Simple diagnostic and therapeutic measures may relieve chronic groin pain and spare patients elaborate investigation or unnecessary operation.
Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery
Authors: Santos J C M , Batista J , Sirimarco M T , Guimarães A S , Levy C E
Published: March 2007

A total of 149 patients admitted for elective colorectal surgery were randomly allocated to receive preoperative mechanical bowel preparation (group 1) or no mechanical bowel preparation (group 2). All patients received antimicrobial prophylaxis with cephalothin and metronidazole. The overall incidence of wound infection was 17·4 per cent (24 per cent for group 1, 12 per cent for group 2) and that of dehiscence 7·4 per cent (10 per cent for group 1, 5 per cent for group 2). The incidence of wound infection was significantly higher in group 1 (P<0·05) but that of anastomotic dehiscence did not differ significantly between groups. Mechanical bowel preparation is unnecessary and may be harmful in terms of preventing wound infection and anastomotic dehiscence in patients undergoing elective colorectal surgery.
Experimental colonic healing in relation to timing of 5-fluorouracil therapy
Authors: Weiber S , Graf W , Glimelius B , Jiborn H , Påhlman L , Zederfeldt B
Published: March 2007

In an experimental study resembling clinical use of adjuvant 5-fluorouracil (5-FU) treatment of colorectal carcinoma, 97 male Wistar rats were operated on with a standardized left colonic resection. Treatment was given as a daily intraperitoneal injection. The animals were randomized to one of four groups: early treatment with 5-FU 20 mg/kg or saline 0·1 mol/l from the third day after operation to the day 7 after operation, and delayed treatment with 5-FU 20 mg/kg or saline 0·1 mol/l from the third day after operation to the day before killing. The animals were killed in groups on day 7 or 10 after operation. In the group receiving early 5-FU treatment there was an increased rate of anastomotic complications (seven of 26) compared with none in the control or delayed 5-FU groups. The anastomotic breaking strength in animals having early 5-FU treatment (day 7, median 1·45 (range 0·20–2·95) N; day 10, median 1·80 (range 0·95–3·20) N) was significantly lower than that in controls on both day 7 (median 3·20 (range 2·50–3·80) N) and day 10 (median 3·20 (range 2·20–3·60) N). In the delayed 5-FU treatment group anastomotic breaking strength did not differ from that in controls. Colonic healing was not impaired when intraperitoneal 5-FU treatment was started on day 3 after operation, whereas immediate postoperative administration of 5-FU had a detrimental effect on wound healing.
Delorme operation for rectal prolapse
Authors: Tobin S A , Scott I H K
Published: March 2007

A consecutive series of 49 elderly patients of mean age 73 years with full-thickness rectal prolapse underwent the Delorme operation between 1986 and 1990. A standard technique was used, or supervised, by one surgeon. In this prospective series, 43 patients were reviewed clinically. The Delorme operation abolished rectal prolapse in 32 patients. Half of the 40 with faecal incontinence were rendered continent. Failure was related to previous anorectal surgery and/or psychiatric illness. Of the 11 patients in whom the first procedure failed, four were improved by a second Delorme operation. The Delorme operation is a suitable procedure for elderly and/or medically unfit patients with rectal prolapse. Good results have also been demonstrated for younger patients, suggesting that the operation may have wider application.
Surgical aspects of Behçet's disease
Authors: Bradbury A W , Milne A A , Murie J A
Published: March 2007

Behçet's disease is an uncommon condition that is managed primarily by medical therapy. Nevertheless, the widespread manifestations of the disease mean that surgeons from many different subspecialties may be involved in the care of patients. This is especially so for the treatment of life-threatening complications. For this reason the surgeon needs to consider Behçet's disease in the differential diagnosis of many conditions and to be aware of the general principles underlying the surgical care of affected patients.
Digest
Authors: Frileux P , de Chirurgie Annales
Published: March 2007

The Editors are delighted this month to publish the first digest from Annales de Chirurgie, written by Dr Pascal Frileux of that journal. Dr Frileux has chosen from the sixth, seventh and eighth issues of 1994. A reciprocal digest written by our Editor, Professor John Farndon, appears in the eleventh issue of the French journal published in December.
Multi-agent therapy in the treatment of sepsis-induced microvascular injury
Authors: Carey P D , Windsor A C J , Walsh C J , Fowler A A , Sugerman H J
Published: March 2007

Cyclo-oxygenase inhibition (with ibuprofen) combined with histamine (H1, H2) receptor antagonism (with diphenhydramine and cimetidine) attenuates microvascular leak injury in sepsis syndromes. Ibuprofen reduces microvascular injury by limiting oxygen radical production by neutrophils. Histamine is known to inhibit this oxygen radical production, an effect antagonized by cimetidine. In the present study neutrophils isolated from pigs made septic with Pseudomonas organisms exhibited a significant (P < 0.05) increase in the production of the oxygen radicals, superoxide anion (O-2, 133 per cent) and hypochlorous acid (HOCl, 38 per cent). Ibuprofen used alone attenuated this sepsis-stimulated overproduction. Addition of the antihistamines cimetidine and diphenhydramine produced a significant increase in oxygen radical production (P < 0.05), by 122 per cent (O2−) and 47 per cent (HOCl), equivalent to that in untreated septic animals. This coincided with a significant deterioration in pulmonary compliance (P < 0.05) compared with that found in control animals and those treated with ibuprofen alone, and a significant accumulation of extravascular lung water (P < 0.05) at 240 and 300 min versus baseline. Histamine receptor antagonism may inadvertently enhance microvascular injury in sepsis.
Bacterial translocation during peroperative colonic lavage of the obstructed rat colon
Authors: Horgan A F , Stuart R C , O'shaughnessy E M , Cryan B , Kirwan W O
Published: March 2007

Peroperative antegrade colonic lavage is often performed before primary anastomosis in emergency colonic surgery. The influence of colonic lavage on bacterial translocation from the obstructed colon was determined. Forty female Wistar rats were studied in four groups: (1) control; (2) non-obstructed with lavage; (3) obstructed; and (4) obstructed with lavage. Ligature obstruction of the rectum was performed in groups 3 and 4. Some 4 days later 35S-radiolabelled Escherichia coli was inoculated into the colon of all animals. Groups 2 and 4 underwent colonic lavage. Lavage in the group 4 animals with left-sided colonic obstruction significantly increased the levels of E. coli in regional nodes, liver, spleen, lung, kidney and blood (as assessed by organ culture and scintillation counting) compared with those in groups 1, 2 and 3 (P < 0.05). These results suggest that peroperative lavage of the obstructed colon significantly increases the level of bacterial translocation.
Juvenile polyposis
Authors: Desai D C , Neale K F , Talbot I C , Hodgson S V , Phillips R K S
Published: March 2007

Juvenile polyposis is an uncommon condition characterized by the development of multiple juvenile polyps, predominantly in the colon but also in the rest of the gastrointestinal tract. The condition usually presents in childhood; only 15 per cent of patients present as adults. The rarer and often fatal form, namely, juvenile polyposis of infancy, is typified by diarrhoea, protein-losing enteropathy, bleeding and rectal prolapse. The more common form of juvenile polyposis (affecting the colon, stomach and small bowel) occurs in the first or second decade with rectal bleeding and anaemia. A family history of the condition is found in 20–50 per cent of patients with apparently an autosomal dominant trait. The gene for juvenile polyposis has not yet been identified. Epithelial dysplasia is common and the cumulative risk of colorectal cancer is > 50 per cent. Various extracolonic abnormalities may also occur. Most patients are treated surgically for colonic polyps, although endoscopic polypectomy is also an option. The rest of the gastrointestinal tract should be screened as should asymptomatic first-degree relatives.
Influence of temporary faecal diversion on long-term survival after curative surgery for colorectal cancer
Authors: Meleagros L , Varty P P , Delrio P , Boulos P B
Published: March 2007

Experimental carcinogenesis is enhanced at colorectal anastomoses, inhibited by proximal faecal diversion and promoted by the closure of a defunctioning stoma. The clinical relevance of these observations was investigated in a retrospective study of curative restorative resection for colorectal carcinoma. The 5-year disease-free survival rate (95 per cent confidence interval) in 122 patients with a temporary stoma (50·4 (41·1–59·7) per cent) was significantly reduced (P <0·01) compared with that in 218 with no stoma (66·8 (59·4–73·5) per cent). In patients with Dukes B tumours early stoma closure (within 3 months of resection) was associated with a worse survival (P < 0·005) and a higher tumour recurrence rate (P <0·05) than in those with no stoma. Survival rates after late stoma closure were no different from those in patients with no stoma. Multivariate analysis revealed Dukes stage (P <0·0001), tumour differentiation (P = 0·02) and tuning of stoma closure (P = 0·02) as independent predictors of survival. In curative surgery for colorectal cancer temporary faecal diversion confers a survival disadvantage that can be prevented by delayed closure of the stoma.
Restoration of intestinal continuity following Hartmann's procedure: The Lothian experience 1987–1992
Authors: Wigmore S J , Duthie G S , Young I E , Spalding E M , Rainey J B
Published: March 2007

Restoration of intestinal continuity following Hartmann's procedure is associated with high morbidity (anastomotic leak rates 4–16 per cent) and mortality (0–4 per cent) rates. A total of 178 patients, under the care of seven different surgical units, underwent reversal of Hartmann's procedure during a 5-year period, representing the largest series yet reported. The mortality rate of the study group was 0·6 per cent, the anastomotic leak rate was 3·9 per cent and the incidence of anastomotic stricture was 6·7 per cent. The median time interval between resection and reversal was 92 days and no relation was found between timing and complications. Anastomotic stricture occurred significantly more commonly in stapled than in sutured anastomoses (P <0·05); however, leaks were equally common in both types. The mean age of the patients who developed major complications was not statistically different from that of the rest of the study group and there was no difference in premorbid state. The authors believe that the low complication rates reported in this series may be attributable to the high level of operator experience in performing this technically difficult procedure, which was done by a consultant in 66 per cent of cases and by a senior registrar in 33 per cent.
Fate of the non-operated carotid artery after contralateral endarterectomy
Authors: Naylor A R , John T , Howlett J , Gillespie I , Allan P , Ruckley C V
Published: March 2007

The long-term fate of the non-operated internal carotid artery (ICA) in 219 patients undergoing contralateral carotid endarterectomy was studied; 151 patients underwent serial postoperative imaging of the vessel. Cumulative freedom from stroke in the non-operated hemisphere was 99, 96 and 86 per cent at 1, 5 and 10 years respectively, giving a mean incidence of stroke of 1 per cent per annum. Only one stroke was preceded by a transient ischaemic attack and no stroke was associated with severe (70 percent or greater) stenosis of the ICA. Ten patients (7 per cent) with initially mild or moderate disease of the non-operated ICA progressed to severe stenosis during follow-up, but only three became symptomatic and, in each case, the onset of symptoms preceded recognition of disease progression. The long-term risk of stroke in the non-operated ICA territory is very small. Of practical importance is that none of the observed strokes could have been prevented by postoperative surveillance of this type.
Effect of ‘antiembolism’ compression hosiery on leg blood volume
Authors: Sparrow R A , Hardy J G , Fentem P H
Published: March 2007

Blood volume in the legs of healthy volunteers and the ability of graduated compression hosiery to reduce that volume were investigated with γ scintigraphy. Changing posture from supine to upright, or pneumatic thigh cuffs inflated to either 20 or 40 mmHg with the subject supine, significantly increased leg blood volumes; the mean increase was: upright 126 ml, 20 mmHg cuff 44 ml, and 40 mmHg cuff 113 ml. A significant trend in reducing these volumes was noted in three brands of commercially available stockings, with the subject supine and without thigh cuffs (Page's L trend 132·5, P <0·01) and when cuffs were applied at 20 mmHg (Page's L trend 128, P = 0·05). Few of the commercially available stockings delivered the ‘standard’ compression profile of 18 mmHg at the ankle, 14 mmHg at the calf and 8 mmHg at the upper thigh. The effects of other compression profiles were assessed, using custom-made stockings, and pneumatic cuffs inflated to 20 mmHg applied to the upper thighs to impede venous return. There was no consistent reduction of blood volume in the popliteal region, although decreases were seen in the upper and lower calf. The major determinant of performance was compression at the calf; the ankle to calf compression gradient was not important. Stockings with a profile of 16·8 mmHg at the ankle, 14·5 mmHg at the calf and 64 mmHg at the upper thigh performed best.
Effect of high-lipid high-nitrogen intravenous nutrition on total body nitrogen, visceral protein synthesis and nitrogen balance
Authors: Kohlhardt S R , Smith R C , Rose A , Allen B
Published: March 2007

The impact of high-lipid intravenous nutrition (IVN) on selected indices of nitrogen retention following major surgical resection was studied. Twenty-two patients, randomly allocated to two equal well matched groups, received either high-lipid IVN (75 per cent non-protein calories supplied as lipid) or isocaloric isonitrogenous glucose IVN (100 per cent non-protein calories supplied as glucose). Total body nitrogen (assessed by in vivo neutron activation analysis), nitrogen balance and levels of circulating proteins were measured. Mean(s. d.) total body nitrogen and fat-free mass decreased (P = 0·04) in patients receiving high-lipid IVN, −109(36) gN and −1·7(0·4) kg respectively, but not in those given glucose-only IVN, 8(43) gN and 01(1·0) kg. This small loss of body protein does not appear to be clinically significant because postoperative hospital stay, complication rates and the acute-phase protein response (immunological and visceral) were similar in the two groups.
Ceiling-mounted radiographic equipment for trauma management in the emergency room
Authors: Bhagat K K , Earlam R J , Hately W , McAvinchey R , Brown I W , Blakeney C G
Published: March 2007

Use of ceiling-mounted radiographic equipment in an emergency room for management of the multiply injured patient is described. The protocol of the Advanced Trauma and Life Support manual is followed and three plain radiographs (lateral cervical spine, anteroposterior views of the chest and pelvis) are obtained by the radiographers, who are members of the trauma team. Abnormalities were diagnosed on 7 per cent of the cervical radiographs, 31 per cent of the chest and 28 per cent of the pelvis in 108 patients during the first year of use. With full integration of the radiographers into the trauma team these three initial films are obtained within 10 min. Subsequent films can be taken of skeletal injuries found clinically or incidentally on the first three plain radiographs. It is recommended that all emergency rooms should have a ceiling-mounted radiographic unit with an automatic daylight processor to provide the best service for patients with major trauma.
Concentrations of soluble vascular cell adhesion molecule-1 and E-selectin in breast cyst fluid and their relation with cyst type
Authors: Lai L C , Siraj A K , Kadory S , Lennard T W J
Published: March 2007

Gross cystic breast disease may be associated with a higher risk of breast cancer. There are two groups of mammary cysts: those lined by apocrine epithelium (intracystic sodium to potassium (Na:K) ratio < 3) and those lined by flattened epithelium (intracystic Na:K ratio > 3). Cell adhesion molecules may be involved in various stages of tumour metastasis. Intracystic levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble E-selectin (sE-selectin) were measured. Significantly greater concentrations of sVCAM-1 and sE-selectin occurred in the high-electrolyte ratio group than in the low (P <0·001). A positive correlation was found between sVCAM-1 and sE-selectin (rS = 0·827, P <0·001) which may be a chance observation or suggest a common mechanism of entry into mammary cysts. The significance of these soluble cell adhesion molecules in breast cyst fluid requires elucidation.
Treatment and survival in 13560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: An epidemiological study
Authors: Bramhall S R , Allum W H , Jones A G , Allwood A , Cummins C , Neoptolemos J P
Published: March 2007

The trends in treatment and outcome of 13560 patients with pancreatic cancer, and in incidence of the disease, in the West Midlands health region were determined between 1957 and 1986 using data from the West Midlands Region Cancer Registry. Patients were divided into those diagnosed in the first 20 years (19570–1976, n = 7888) and the most recent 10 years (1977–1986, n = 5672). The disease was more common in men and the incidence increased up to 1970 after which it levelled off. In the 1977–1986 period a lower proportion of patients had laparotomy alone (825 (14·5 per cent) versus 1552 (19·7 per cent)), a similar proportion had bypass surgery (2010 (35·4 per cent) versus 2760 (35·0 per cent)), while a greater proportion had supportive care (2710 (47·8 per cent) versus 3368 (42·7 per cent)) but the resection rates were the same (145 (2·6 per cent) versus 208 (2·6 per cent)). The 30-day mortality rates between the two periods unproved for resection (40 (27·6 per cent) versus 94 (45·2 per cent)), bypass surgery (436 (21·7 percent) versus 691 (25·0 per cent)) and laparotomy (372 (45·1 per cent) versus 873 (56·3 per cent)). The 12-month survival rate for bypass did not significantly differ during the study (14·9 per cent versus 12·4 per cent) but there was a significant improvement in the 5-year survival for resection (9·7 per cent versus 2·6 per cent, P < 0·015). The resection rates were low and 30-day mortality rates for surgery were high compared with those of other published series.
Liver transplantation in patients with fulminant hepatic failure
Authors: González E Moreno , García G I , Loinaz S C , Gómez S R , González-Pinto I , Hernández G-G D , Jiménez R C , Maffettone V , Pérez-Cerdáa F , Cisneros A C , Ibáñez A J
Published: March 2007

Fulminant hepatic failure without liver transplantation is associated with a high mortality rate (80–100 per cent). Some 254 liver transplantations were performed on 202 patients between April 1986 and February 1992. Of these, 26 patients had fulminant hepatic failure. The median age was 31·5 (range 3–60) years. Reduced-size grafts were used in seven patients. The peroperative mortality rate was six of 26 patients, and five patients died during follow-up. Ten patients underwent retransplantation and two a second retransplant. The overall mortality rate was 16 of 26 and actuarial survival rate was 62·7 per cent at 12 months and 48·7 per cent at 36 months. The peroperative mortality rate is relatively high but liver transplantation is currently recommended as a last-resort treatment for patients with fulminant hepatic failure in the absence of response to medical treatment.
Preoperative transcatheter arterial chemoembolization for resectable large hepatocellular carcinoma: A reappraisal
Authors: Wu C-C , Ho Y-Z , Ho W Lin , Wu T-C , Liu T-J , P'Eng F-K
Published: March 2007

Transcatheter arterial chemoembolization (TACE) improves the treatment of hepatocellular carcinoma (HCC) by causing tumour necrosis and shrinkage. Fifty-two patients with resectable large HCC (defined as a maximal tumour diameter of 10 cm or more) were prospectively randomized into two groups: group 1 comprised 24 patients who had 1–5 sessions of TACE before operation; group 2 consisted of the other 28 patients, on whom surgery was performed without delay. Tumour volume was reduced to a mean(s.d.) of 42·8(15·3) per cent in 16 patients in group 1, but remained unchanged in four and increased in size in a further four. Patients in group 1 had a slightly longer operating time (5·5 versus 4·6 h, P = 0·09), a higher rate of concomitant resection of adjacent organs (58 versus 25 percent, P = 0·03) and a higher rate of histological invasion to these organs (33 versus 4 per cent, P = 0·01). No difference was found between the two groups in operative blood loss, operative morbidity and mortality rates, and pathological staging. The disease-free survival rate in the two groups was similar, but the incidence of extrahepatic cancer recurrence was higher in group 1 (57 versus 23 per cent, P = 0·03). The actuarial survival rate was also significantly worse in group 1 when determined from the time of detection of the tumour (P = 0·03) or from operation (P = 0·01). It is concluded that preoperative TACE for resectable large HCC should be avoided because it does not provide complete necrosis in large tumours and results in delayed surgery and difficulty in the treatment of recurrent lesions, without any benefit.