bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the results of oesophagectomy for oesophageal cancer
Authors: Mannell A , Becker P J
Published: March 2007

The long-term results of standard techniques of oesophagectomy were examined in 127 patients with squamous cell carcinoma of the oesophagus. A near-total oesophagectomy with a cervical anastomosis was performed in 93 patients and an oesophagogastrectomy with an intrathoracic anastomosis was carried out in 34 patients. One hundred and eight patients had a curative oesophagectomy and 19 patients had a palliative resection. Eighty patients received radiotherapy to the tumour bed. There were 15 deaths in hospital and the overall 5-year survival rate including perioperative deaths was 13·2 per cent. Survival was adversely affected by incomplete excision of macroscopic tumour (P < 0·001), positive regional lymph nodes (P < 0·05) and distant lymphatic metastases (P < 0·02). The 5-year survival rate of patients with tumour invasion beyond the oesophageal wall (T 3) and negative nodes was 20 per cent. Postoperative irradiation had no effect on the survival of patients with gross residual tumour. Complete clearance of microscopic tumour was achieved in 50 per cent of patients with T 3 tumours and this group did not benefit from adjuvant radiotherapy. Survival in patients undergoing curative oesophagectomy with residual microscopic tumour, however, was significantly improved by irradiation of the tumour bed (P < 0·01). These results suggest that the survival of patients can be increased significantly by the excision of all gross tumour and by identification of those who will benefit from local radiotherapy.
Prolonged intermittent clamping of the portal triad during hepatectomy
Authors: Elias D , Desruennes E , Lasser P
Published: March 2007

From 112 consecutive hepatectomies for malignant tumours performed with intermittent portal triad clamping, we have retrospectively selected the 20 cases in which clamping exceeded 90 min. Intermittent portal clamping of prolonged duration was used because of abnormal liver texture in 13 cases (mainly patients who had received intra-arterial chemotherapy) and/or because of technically difficult hepatectomy. The mean(s.d.) duration of intermittent portal clamping was 109(18) min and in two cases it exceeded 140 min (148 and 150 min). There was no postoperative mortality and the rate of postoperative morbidity was 35 per cent. Postoperative changes in biochemical liver tests were not major and transient hepatic failure occurred in only one patient following subtotal resection of the liver. We conclude that intermittent portal clamping is a useful manoeuvre in partial hepatectomy when resection is difficult or prolonged, or when the liver parenchyma is abnormal. Such clamping may be used for longer than 120 min without major complications.
Effect of fibrin sealant on the healing colonic anastomosis in the rat
Authors: van Der Ham A C , Kort W J , Weijma I M , Van Den Ingh H F G M , Jeekel J
Published: March 2007

Fibrin adhesives have been advocated as a protective seal in colonic anastomosis to prevent leakage. In order to assess the effect of fibrin glue sealing we compared the healing of sutured colonic anastomosis in the rat (group 1) with the addition of human-derived fibrin sealant (group 2). As a control for a possible reaction to foreign protein, in group 3 the sutured anastomosis was sealed with specially prepared rat fibrin adhesive. On days 2, 4 and 7, ten animals in each group were killed. Adhesion formation was scored and the in situ bursting pressure was measured. The collagen concentration and degradation were estimated by measuring hydroxyproline. Adhesion formation was significantly increased in groups 2 and 3 compared with the control group. On days 2 and 7 the bursting pressure was not different between the groups. On day 4 the bursting pressure in groups 2 and 3 was significantly lower than in group 1 (P < 0·001). These findings correspond with the results of collagen measurements. On day 4 the concentration of hydroxyproline was significantly reduced in groups 2 and 3. Histological examination showed infiltration of neutrophilic granulocytes into the sealant on days 2 and 4; on day 7 the sealant had vanished. From these results it is concluded that fibrin sealing of the colonic anastomosis in the rat does not improve healing, as demonstrated by bursting pressure and hydroxyproline concentration. On the contrary, it seems to have a negative influence.
Influence of methylprednisolone on the healing of intestinal anastomoses in rats
Authors: Mastboom W J B , Hendriks T , de Man B M , de Boer H H M
Published: March 2007

Although steroids are generally thought to impair intestinal anastomotic healing, this effect has never been proven unequivocally in either clinical or experimental studies. We have investigated the influence of methylprednisolone (2·5 or 10·0 mg kg−1 day−1) given from 2 days before operation onwards, on 3-day-old and 7-day-old ileal and colonic anastomoses in rats. Anastomotic abscesses occurred more frequently in the ileum, but not in the colon, after steroid medication. However, methylprednisolone did not lower anastomotic bursting pressures in either of the bowel segments. Comparison of the hydroxyproline content of the anastomotic segment yielded no significant difference between control and methylprednisolone groups in either small or large bowel. Thus, healing of experimental colonic anastomoses remains unaffected by short-term administration of this corticosteroid.
Influence of local hyperthermia on the healing of small intestinal anastomoses in the rat
Authors: Shimizu T , Maeta M , Koga S
Published: March 2007

Peritoneal hyperthermia may have a role in limiting serosal metastatic disease. When applied to the peritoneal cavity immediately after surgery, it is important to know the optimum temperature, and to investigate the subsequent healing of intestinal anastomoses. To study the first problem, local hyperthermia was applied to the intestinal loop of rats for 30 min. Treatment at 46·0°C or 45·0°C resulted in 100 per cent and 90 per cent mortality respectively, but 100 per cent survival was obtained at 44·0°C. To study the second problem rats with intestinal anastomoses were studied in three groups: group A, local hyperthermia (44·0°C < 30 min) applied to the intestinal loop containing the anastomosis; group B, local hyperthermia (44·0°C × 30 min) applied using saline supplemented with mytomycin C (10 mg/l); group C (controls) no thermal treatment was applied. Anastomotic healing was assessed by breaking strength and histological examination. On the third day after operation, the breaking strength of anastomoses decreased to the lowest values in each group, but no statistically significant differences were noted. On the seventh and 14th day, increased resistance to breaking developed in all three groups and was greatest in the thermally treated groups. Histological findings supported these results. Local hyperthermia up to 44·0°C × 30 min had no adverse effects on the healing of intestinal anastomoses.
Correlation between laboratory findings and clinical outcome after restorative proctocolectomy: Serial studies in 20 patients with end-to-end pouch-anal anastomosis
Authors: Sagar P M , Holdsworth P J , Johnston D
Published: March 2007

Clinical function and anorectal physiological function were assessed and correlated in 20 patients with ulcerative colitis before restorative proctocolectomy and 3, 7, and 12 months after operation. The entire anal sphincter was preserved by means of a stapled pouch-anal anastomosis. Before operation, the median resting anal pressure was 79 cmH2O (interquartile range 70–89 cmH2O), the rectoanal inhibitory reflex was present in all patients and anorectal ‘sampling’ was noted in 16 of 20 patients. Three months after operation, resting anal pressure was 68 cmH2O (range 50–87 cmH2O) (P < 0·001), the reflex was present in only three patients (P < 0·001) and sampling was observed in one patient. After 7 months, resting anal pressure was 76 cmH2O (range 64–89 cmH2O), the reflex was present in 11 patients and sampling was observed in nine patients. At 12 months, resting anal pressure was 84 cmH2O (range 66–94 cmH2O), the reflex was present in 19 patients and sampling was observed in 17 patients. The compliance and capacity of the reservoir increased significantly. Ability to discriminate flatus from faeces was associated with return of the rectoanal reflex and sampling.
Changes in anal canal sensation after childbirth
Authors: Cornes H , Bartolo D C C , Stirrat G M
Published: March 2007

Obstetic trauma predisposes to faecal incontinence. Anal canal sensation is impaired in incontinent patients. To assess the effect of childbirth on anal canal sensation anal mucosal electrosensitivity was measured in 122 primiparous patients in the immediate postnatal period and in 74 at 6 months postpartum. There were 35 normal vaginal deliveries, 36 forceps deliveries, 20 ventouse extractions, ten vaginal breech deliveries and 21 caesarean sections. Sensation was impaired in the lower, mid and upper anal canal immediately after delivery in those patients who had a normal vaginal delivery or a forceps delivery when compared with controls or with those delivered by caesarean section. Women who had ventouse deliveries had impaired sensation immediately after delivery in the mid anal canal compared with controls and those undergoing caesarean section. By 6 months there were no differences between any group. Patients who sustained a division of the external anal sphincter at delivery had impaired sensation which persisted in the upper anal canal at 6 months.
Role of the protease-antiprotease balance in peritoneal exudate during acute pancreatitis
Authors: Wilson C , Shenkin A , Imrie C
Published: March 2007

The peritoneal exudate formed during experimental pancreatitis is toxic when administered intraperitoneally or intravenously to other animals. Overwhelming of the peritoneal antiprotease defences by proteolytic enzymes released from the pancreas may be a key factor responsible for this toxicity and is examined in the current study. Human pancreatitis exudates possessed tryptic amidase activity indicating trypsinogen activation. The trypsin inhibitory capacities of exudates were reduced indicating a degree of consumption of the peritoneal antiproteases. Of 21 exudates examined, three showed marked reduction of their trypsin inhibitory capacity indicating almost complete consumption of their antiproteases. All three patients were shocked at the time of sampling, two dying of fulminant pancreatitis within 24 h. Overwhelming of the peritoneal antiproteases was not confirmed, but may occur in a few instances where proteolytic enzyme release or zymogen activation continues. Intraperitoneal administration of exogenous antiproteases prolongs survival in rats with pancreatitis and has been suggested as a therapy in man. The current data suggests that few patients are likely to benefit from such an approach.
Neonatal small bowel atresia, stenosis and segmental dilatation
Authors: Paterson-Brown S , Stalewski H , Brereton R J
Published: March 2007

In 8 years, 44 neonates were treated for small bowel atresia, stenosis or segmental dilatation by one surgical team. There was a single lesion in 30 infants and 14 had two or more sites of intestinal obstruction. Associated gastrointestinal abnormalities were found in 23 (52 per cent) patients. Resection of the atresia(s) and primary anastomosis were performed in 34 infants and staged procedures were carried out in ten patients with complicated lesions. Patients undergoing staged procedures had a higher complication rate than those having primary repair (six out of ten and 11 out of 34 respectively). The overall initial survival rate was 93 per cent, rising to 100 per cent in those without associated anomalies or prenatal complications, but more than a quarter (27 per cent) of survivors have long-term disabilities.
Solitary thyroid nodule: A prospective evaluation of nuclear scanning and ultrasonography
Authors: Cox M R , Marshall S G , Spence R A J
Published: March 2007

The aim of this study was to assess prospectively the value of thyroid nuclear scans and ultrasound examination in the preoperative investigation of patients with a solitary thyroid nodule. Total thyroid lobectomy for a solitary thyroid nodule was performed in 68 cases. Each patient had a thyroid isotope scan (except two women who were pregnant) and thyroid ultrasound examination. There were 10 (15 per cent) malignant nodules, 11 (16 per cent) benign neoplastic nodules and 47 (69 per cent) benign non-neoplastic nodules. All of the patients with malignant nodules who were scanned had a solitary cold nodule on thyroid scan, as did 40 (69 per cent) of those with benign solitary nodules. Ultrasound examination of the thyroid suggested correctly that one of 16 (6 per cent) cystic lesions, four of 16 (25 per cent) complex solid-cystic lesions and three of 18 (17 per cent) of solid lesions were malignant. One lesion reported as multinodular on ultrasonography and one reported as normal also turned out to be malignant. Thyroid isotope scans and ultrasound do not accurately differentiate between benign and malignant conditions and their routine use in the investigation of a solitary thyroid nodule should be abandoned.
DNA aneuploidy in follicular thyroid neoplasia
Authors: Cusick E L , Ewen S W B , Krukowski Z H , Matheson N A
Published: March 2007

The potential value of DNA aneuploidy, in distinguishing benign from malignant follicular thyroid neoplasms, was studied. The nuclear DNA content of 65 follicular thyroid neoplasms (52 adenomas and 13 carcinomas) was determined by flow cytometric analysis of paraffin embedded material; in 58 cases preparations were technically satisfactory. In 22 follicular neoplasms DNA analysis was also performed on fresh material obtained by fine needle aspiration of surgical specimens. Cell cycle analysis was performed on both fresh and fixed specimens. An aneuploid DNA profile was found on analysis of fixed tissue in eight of 45 (18 per cent) follicular adenomas and four of 13 (31 per cent) follicular carcinomas. DNA aneuploidy was also found in six of the 22 (27 per cent) fresh preparations from follicular adenomas. The frequency of DNA aneuploidy in apparently benign and malignant follicular neoplasms was similar. Follicular thyroid neoplasia are best regarded as a single entity with a low incidence of local and distant spread. All follicular neoplasia are therefore best excised.
Further evaluation of radical surgery following radiotherapy for advanced parotid carcinoma
Authors: Gallegos N C , Watkin G , Cook H P , Sanders R , Hobsley M
Published: March 2007

A series of 30 patients who have been treated for advanced carcinoma of the parotid gland using radiotherapy followed by radical surgery is presented. Three patients deteriorated during preoperative radiotherapy and remained unfit for surgery; the remaining 27 underwent radical parotidectomy with block dissection of the neck. Twelve patients received additional radiotherapy after operation. Of those patients undergoing surgery, three have been lost to follow-up, 17 have died and seven remain alive; the period of follow-up ranges from 3 to 133 months. Fourteen patients remained free of recurrent disease at death or when last seen, and six patients developed a local recurrence at a median period of 10·5 (range 3–36) months after surgery. For all 30 patients, the cumulative proportion surviving for 5 years was 30 per cent.
Role of phenytoin in healing of large abscess cavities
Authors: Lodha S C , Lohiya M L , Vyas M C R , Bhandari Sudha , Goyal R R , Harsh M K
Published: March 2007

The promotion of healing of large abscess cavities attained with topical phenytoin was evaluated in controlled studies of clinical and experimental wounds. In the clinical abscess cavities, phenytoin application in 20 patients compared with conventional treatment in 20 patients resulted in earlier separation of slough, decrease in oedema, control of pain and overall enhanced healing. The mean(s.d.) rate of reduction of wound area was 2·02(0·48) cm2/day in the phenytoin group versus 1·58(0·51) cm2/day in controls (P < 0·05) on day 10, and 1·8(0·32) cm2/day versus 1·19(0·21) cm2/day (P < 0·01) on day 20. The mean volume reduction rates at both the 10th and 20th day were 0·48(0·01) cm3/day for phenytoin versus 0·32(0·04) cm3/day for controls; (P < 0·005). By day 20, 17 of the patients treated with phenytoin were rated as having healed completely, compared with only one of the controls. In a standardized guinea-pig model of the clinical abscess cavity, which included inoculation of the wound with Bacillus proteus and Klebsiella pneumoniae, an enhanced healing rate was also observed (at 7 days 0·40(0·05) cm2/day with phenytoin versus 0·21(0·08) cm2/day in controls; P < 0·005). All eight of the animals treated with phenytoin healed by day 21, compared with one of the eight controls. Biopsies of wounds treated with phenytoin showed less inflammation, no necrosis, and enhanced neovascularization, collagen deposition and fibroblast proliferation compared to controls. Bacterial colonies also decreased more rapidly with the use of phenytoin.
New trends in gallstone management
Authors: Cheslyn-Curtis S , Russell R C G
Published: March 2007

Many new therapies for the management of gallstone disease have been pioneered in the past decade. The object of this review is to equip the surgeon with the answers to all of the questions a patient will ask about gallstone therapy; the review is therefore didactic as well as comprehensive.
Reduced postoperative hospitalization after laparoscopic cholecystectomy
Authors: Grace P A , Quereshi A , Coleman J , Keane R , McEntee G , Broe P , Osborne H , Bouchier-Hayes D
Published: March 2007

An initial experience of laparoscopic cholecystectomy in 50 consecutive patients was reviewed and the results compared with those of a group of 25 patients who underwent laparotomy cholecystectomy during the 3 months before the introduction of laparoscopic cholecystectomy. Laparoscopic cholecystectomy was successfully performed in 44 of 50 consecutive patients in whom it was attempted. When compared with laparotomy, laparoscopy cholecystectomy was associated with longer mean(s.d.) anaesthesia, 155(61) min versus 102(31) min (P<0·001), shorter mean postoperative hospital stay, 3·5(1·5) versus 8·8(3·2) days (P<0.001), and reduced mean cost, £895(376) versus £2210(822) (P<0.001). Perioperative morbidity was also reduced following laparoscopy cholecystectomy (9 per cent versus 16 per cent) but not significantly so. Laparoscopic cholecystectomy is a safe, effective procedure which completely removes the gallbladder. It significantly reduces hospital stay, is cosmetically satisfactory and has financial benefits. We suggest that this technique be considered for all patients having cholecystectomy.
Non-steroidal anti-inflammatory drugs and complicated diverticular disease: A case—control study
Authors: Campbell K , Steele R J C
Published: March 2007

Fifty patients with severe complications of diverticular disease were compared with two groups of 50 controls, matched for age and sex. The first control group (A) was randomly selected from all emergency hospital admissions, and the second group (B) from patients with uncomplicated diverticular disease. Of the 50 study patients, 24 (48 per cent) were taking non-steroidal anti-inflammatory drugs (NSAIDs) at the time of admission compared with nine (18 per cent) of control group A and ten (20 per cent) of control group B. Both of these differences were statistically significant, indicating a strong association between the ingestion of NSAIDs and the development of severe complications of diverticular disease.
Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin
Authors: Desa L A , Ohri S K , Hutton K A R , Lee H , Spencer J
Published: March 2007

Intraoperative enteroscopy was performed in 12 patients (median age 68 years) with obscure gastrointestinal bleeding probably of small bowel origin, six of whom were men. All the patients were evaluated by routine haematological, coagulation and biochemical profiles, upper and lower gastrointestinal endoscopies, visceral angiography and/or isotope scanning. All the patients were anaemic. Visceral angiography was useful on three of the 12 occasions on which it was used and isotope scanning was valuable on eight of the 11 occasions it was used. Nine patients had undergone previous laparotomy. Enteroscopy was performed successfully in all cases, with fresh blood and discrete vascular lesions being the chief findings (10 of 12 cases). Segmental resections (n = 8) and local resections (n = 2) were performed in ten patients, with two patients having more than one laparotomy for rebleeding. Five patients developed postoperative complications and there was an operative death and one late death. Three of the ten surviving patients experienced further rebleeding. Intraoperative enteroscopy is now an essential adjunct to laparotomy for gastrointestinal bleeding which has been localized to the small bowel before operation.
Risk of peritonitis and fatal septicaemia and the need to defunction the low anastomosis
Authors: Karanjia N D , Corder A P , Holdsworth P J , Heald R J
Published: March 2007

The aim of this study was to investigate the need to defunction the low anastomosis after anterior resection of the rectum with total mesorectal excision for rectal cancer. Two hundred consecutive patients (125 defunctioned, 75 non-defunctioned) undergoing low anterior resection for carcinoma were included in the study. Peritonitis requiring emergency laparotomy occurred in 8 per cent of the patients who did not have a defunctioning stoma compared with less than 1 per cent of those patients who had a defunctioning stoma (P < 0·01). There was no mortality related to closure of the stoma but seven patients developed a faecal fistula and ten developed an incisional hernia. Despite current trends to avoid the defunctioning stoma, these results suggest that after total mesorectal excision the faecal stream should be temporarily diverted away from the anastomosis that is 6 cm or less from the anal verge to protect against potentially life-threatening anastomotic leakage.
Comparison of restorative proctocolectomy with and without covering ileostomy in ulcerative colitis
Authors: Järvinen H J , Luukkonen P
Published: March 2007

The experience of restorative proctocolectomy for ulcerative colitis is reported in 16 consective patients with no covering ileostomy (group 2) in comparison with 15 patients with a covering stoma (group 1); in each group a J pouch was constructed. All patients had pre- and postoperative clinical and manometric evaluations of the functional result up to 12 months. There were no deaths or permanent failures. The number of early complications was four in each group. Re-ileostomy was needed in one patient of group 1, and an ileostomy was constructed in three patients of group 2. At 1 year after operation the functional results did not differ between groups 1 and 2 in terms of daily frequency of defaecation (mean 5·6 and 5·4 in 24 h respectively), or in terms of anal basal or maximal squeeze pressures. There was a significant (P<0·01) saving in total hospital stay (median 11 days) and in operating theatre time (mean 41 min) in patients with no covering ileostomy. It is concluded that a covering ileostomy may be unnecessary in restorative proctocolectomy, at least in suitable cases with no technical difficulty at the time of operation.
Principal causes of mechanical bowel obstruction in surgically treated adults in Western Turkey
Authors: Füzün M , Kaymak E , Harmancioǧlu Ö , Astarcioǧiu K
Published: March 2007

A retrospective study of the principal causes of mechanical bowel obstruction occurring in Western Turkey between 1979 and 1989 was undertaken. The records of 14 777 operations performed in the general surgery departments of two hospitals were reviewed. Mechanical bowel obstruction occurred in 582 patients. Among the causes of mechanical bowel obstruction, adhesions were most common (44·0 per cent), followed by strangulated hernia (23·9 per cent), volvuli (12·7 per cent) and colonic carcinomas (10·1 per cent). A previous appendicectomy appeared to be the most important cause of adhesions causing mechanical bowel obstruction.
Light reflection rheography: An effective non-invasive technique for screening patients with suspected deep venous thrombosis
Authors: Thomas P R S , Butler C M , Bowman J , Grieve N W T , Bennett C E , Taylor R S , Thomas M H
Published: March 2007

Light reflection rheography is a simple non-invasive technique for assessing venous function in the leg. One hundred and twenty-four patients referred for venography with a clinically suspected deep venous thrombosis were investigated by light reflection rheography to determine the accuracy of the technique in diagnosing acute thrombosis. In half of the patients venography confirmed a deep venous thrombosis. Light reflection rheography had a sensitivity of 92 per cent and a specificity of 84 per cent in detecting acute thrombosis. The technique had a negative predictive value of 92 per cent in selecting those patients with no thrombosis. Light reflection rheography can be performed at the bedside or in the radiography department which makes it a suitable technique for screening patients with suspected deep venous thrombosis.
Histological study of white blood cells and their association with lipodermatosclerosis and venous ulceration
Authors: Scott H J , Coleridge Smith P D , Scurr J H
Published: March 2007

The number of white blood cells per mm2 has been determined in serial histological slides taken from punch biopsies of skin from the gaiter region in patients with varicose veins. In eight patients the varicose veins were complicated by lipodermatosclerosis of the skin, and in a further six there was a history of ulceration. In uncomplicated varicose veins there was a median of 6 white blood cells per nm2, in patients with lipodermatosclerosis there were 45 white blood cells per mm2, and where there was a history of ulceration, 217 white blood cells per mm2. No change in white blood cell content was observed after the venous pressure was raised for 30 min by sitting the patient with the lower limb dependent. White blood cell infiltration of the skin is associated with lipodermatosclerotic changes caused by venous insufficiency.
Mammography in the management of patients with small breast cancers
Authors: Dixon J M , Chetty U
Published: March 2007

Findings on mammography resulted in a change of treatment policy in 17 of 200 patients with small breast cancers (T1/T2 <4 cm, N0/N1, M0). Twelve patients were considered unsuitable for conservation therapy because of mammographic evidence of either extensive in situ carcinoma or more than one focus of invasive carcinoma. These patients were treated by mastectomy and histology confirmed widespread in situ carcinoma or multifocal/multicentric invasive carcinoma. Seven patients were found to have unsuspected contralateral lesions on mammography, of which five were subsequently shown to be malignant. Routine preoperative mammography is essential in the management of patients with small breast cancers.
Gunshot wound of the abdomen: Role of selective conservative management
Authors: Demetriades D , Charalambides D , Lakhoo M , Pantanowitz D
Published: March 2007

This prospective study includes 146 patients with gunshot wounds of the abdomen. One hundred and five patients (72 per cent) had an acute abdomen on admission and were operated on immediately. The remaining 41 patients (28 per cent) had minimal or equivocal abdominal signs and were observed with serial clinical examinations. Seven of the observed patients needed subsequent laparotomy, but there was no mortality or serious morbidity. Had a policy of mandatory exploration for abdominal gunshot wound been applied the incidence of unnecessary or negative laparotomies would have been 27 per cent. By using a policy of selective conservatism this figure was only 5 per cent. We suggest that abdominal gunshot wounds should be assessed and managed exactly like knife wounds. Physical examination is reliable in detecting significant intra-abdominal injuries. Many carefully selected patients with abdominal gunshot wounds can safely be managed non-operatively.
Major trauma: A district general hospital experience
Authors: Ingham Clark C L , Tabone-Vassallo M
Published: March 2007

A retrospective review of all patients with major trauma admitted to a busy suburban district hospital was conducted over a 1-year period. Outcome for each patient was assessed using the TRISS system which calculates the probability of survival based on anatomical extent of injury and degree of physiological disturbance at the time of admission. Thirty-nine patients were admitted following major trauma, of whom nine died. Seven of the deaths were in patients with a greater than 50 per cent chance of survival according to the TRISS system. In contrast, four patients survived who had a greater than 50 per cent chance of death. Details of these 11 cases are given. The numbers of patients who were referred to neurosurgeons and cardiothoracic surgeons in regional specialist centres were recorded, as was the relative contribution of general and orthopaedic surgeons in our own hospital. We conclude that, in the absence of specialized trauma centres, a reasonable standard of care for patients who have sustained major trauma can be delivered in a district general hospital.
Regeneration of the spleen and splenic autotransplantation
Authors: Holdsworth R J
Published: March 2007

This paper reviews the subject of regeneration of the spleen and discusses the role of splenic autotransplantation following splenectomy for trauma.
Intra-arterial thrombolytic therapy in the management of acute and chronic limb ischaemia
Authors: Barr H , Lancashire M J R , Torrie E P H , Galland R B
Published: March 2007

A group of 54 patients with acute or chronic limb ischaemia were initially treated with low dose intra-arterial thrombolytic therapy using streptokinase (10000 units h−1) or plasminogen activator (0·5 mg h−1). Complete thrombolysis was obtained in 90 per cent of patients with symptoms of less than 1 week duration, and in 50 per cent with symptoms of greater than 1 week (P<0·05). Successful lysis in 36 patients was followed by successful bypass surgery in seven, percutaneous angioplasty in 13, no further treatment in 13, repeat thrombolysis in two and amputation in one. Failed therapy was associated with major amputation in 40 per cent. One patient died of haemorrhage and another of stroke as a direct result of thrombolytic treatment. The most common complication was haematoma at the site of cannulation of the vessel. Intra-arterial thrombolytic therapy can be very useful for the management of acute and chronic limb ischaemia, but complications do occur and patients should be carefully selected.
Towards an appropriate training for vascular surgeons
Authors: Cawthorn S J , Giddings A E B
Published: March 2007

The increasing demand for fully trained vascular surgeons in the UK has highlighted the need for urgent review of that training. Such a review must examine the number of trainees required and the number and role of teaching centres. Vascular surgical training should only take place where an integrated approach, including experience in interventional radiology and intensive care, is available. The relationship of vascular to general surgery must now be defined with training needs in mind if we are to provide an appropriate service within the next decade.
Bilateral nephrectomy before transplantation: Indications, surgical approach, morbidity and mortality
Authors: Darby C R , Cranston D , Raine A E G , Morris P J
Published: March 2007

Forty patients with end-stage renal failure, who had undergone simultaneous bilateral native nephrectomy before a subsequent renal transplant operation, were reviewed with particular reference to the indications and surgical approach for bilateral nephrectomy and to the complications of the procedure. The main indications for bilateral nephrectomy are hypertension resistant to medical therapy, persistent symptomatic renal infection, severe renal protein loss and occasionally polycystic kidneys or bilateral renal tumours. In this consecutive series of 40 patients both kidneys were removed because of chronic pyelonephritis with reflux (n = 28), glomerulonephritis with reflux (n = 9) and uncontrolled hypertension (n = 3). Surgical morbidity was less in patients who had bilateral nephrectomy performed through bilateral vertical lumbotomy incisions. There was no surgical mortality.
Anal endosonography in the investigation of faecal incontinence
Authors: Law P J , Kamm M A , Bartram C I
Published: March 2007

Forty-four consecutive patients with incontinence of solid stool of traumatic or idiopathic aetiology were examined by anal endosonography and standard anorectal physiology tests. Anal endosonography showed an external anal sphincter defect in four out of 11 (36 per cent) patients with idiopathic (neurogenic) incontinence. In the remaining seven patients both parts of the sphincter were intact and a linear relationship was found between the resting anal canal pressure and the endosonographic thickness of the internal anal sphincter. Twenty-eight out of 33 (85 per cent) patients with incontinence of traumatic origin had external sphincter defects, confirmed by concentric needle electromyogram mapping in the 19 patients in whom this was performed. Eleven of these 28 (39 per cent) patients also had disruption of the internal spincter. Anal endosonography has revealed significant abnormalities in patients with faecal incontinence and has a complementary role to anorectal physiology in the routine investigation of these patients.
Ultrasonography in the diagnosis of acute appendicitis
Authors: Ooms H W A , Koumans R K J , Ho You P J Kang , Puylaert J B C M
Published: March 2007

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter ≧ 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms (‘abortive appendicitis’). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendicectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.
Primary repair of colon injuries in a developing country
Authors: Naraynsingh V , Ariyanayagam D , Pooran S
Published: March 2007

Because there are several specific disadvantages to a colostomy in a developing country, primary repair for colon injury was electively performed. Sixty-one consecutive patients with colon injury were seen between 1978 and 1989 and 57 of these (93 per cent) underwent primary repair. In four a colostomy was constructed. Emergency repair was carried out regardless of site or mode of injury, presence of hypotension or peritoneal contamination. There was one death unrelated to anastomotic complications and one anastomotic leakage. The faecal fistula closed spontaneously in 4 weeks. The wound infection rate was 10 per cent. These data support the emerging view that primary repair of colon injury is the management of choice.
Oestrogen receptor D5 antibody is an independent negative prognostic factor in gastric cancer
Authors: Harrison J D , Jones J A , Ellis I O , Morris D L
Published: March 2007

Recent studies have demonstrated oestrogen receptors in tissues other than those considered to be sex hormone responsive, for instance in gastric cancer. In vitro experiments have shown oestradiol to be trophic to gastric cancer cell lines. The effect of D5 (an oestrogen receptor-related protein) status on survival was therefore studied in a group of 188 consecutive patients undergoing surgery for gastric cancer. Ninety-two patients (49 per cent) were positive for the D5 antibody. There were no differences between the D5-positive and D5-negative groups for age or adverse prognostic features such as high grade tumours or advanced stage. The D5-negative patients had a significant survival advantage over the D5-positive patients. The 95 per cent confidence interval for survival in the patients with D5-negative tumours was 63-101 weeks compared with 39-66 weeks for the patients with D5-positive tumours (Mantel-Cox statistic = 4·15, P=0·042). Prognostic factor analysis with a Cox proportional hazards model showed tumour stage (P = 0·001) and D5 status (P = 0·003) to be significant independent factors in gastric cancer. Laurén type, grade and gender were not significant independent factors in this small series.
Suturing or stapling in gastrointestinal surgery: A prospective randomized study
Authors: George W D
Published: March 2007

A prospective randomized study of 1004 patients is reported, comparing surgical stapling and manual suturing techniques in the construction of gastrointestinal anastomoses. The incidence of clinical leaks was similar between the two groups (sutured 3·2 per cent, stapled 4·7 per cent; P = 0·22), while for radiological leaks the incidence was significantly higher in the sutured group (12·2 per cent versus 4·1 per cent, P<0·05). Stapling instruments afforded significantly quicker anastomoses, mean(s.e.m.) 28·1(0·7) versus 14·3(0·5) min (P<0·001), and quicker operations, 115·5(2·4) versus 103·8(2·2) min (P < 0·001). The two groups were found to be comparable in other respects such as operative mortality, requirements for blood transfusion, incidence of infective complications, recovery of gastrointestinal function and postoperative hospital stay.
Results of fundoplication in a UK paediatric centre
Authors: Parikh D , Tam P K H
Published: March 2007

Of 55 children (age 3 months to 16 years) who had fundoplication, major complications occurred in nine (16 per cent): paraoesophageal hernia (five cases), prolonged ileus (two cases), recurrent gastro-oesophageal reflux (one case), and accidental perforation (one case). The single most important factor resulting in complications was the omission of crural repair; of seven patients without crural repair, five developed paraoesophageal hernia/recurrence. Four patients required repeat fundoplication for severe recurrent symptoms and one of these developed the unusual complication of pericardiogastric fistula. Thirteen patients had strictures before operation from reflux oesophagitis, six (46 per cent) resolved after fundoplication alone, six responded to dilatation (mean five sessions), and one required colon interposition. Our preliminary experience with balloon dilatation was encouraging: three of three patients responded after one dilatation only. These results confirmed the efficacy of surgery in controlling reflux: 100 per cent in the short-term and 89 per cent on a 1–6 year follow-up. Major complications might well be reduced by routine crural repair.
Improving results in the treatment of gastric cancer: An 11-year audit
Authors: Akoh J A , Sedgwick D M , Macintyre I M C
Published: March 2007

Of 280 patients presenting to one hospital with gastric cancer between 1975 and 1985, 97 (35 per cent) did not undergo surgery and 29 per cent (54 out of 183) of those who did had no resection performed. The 30-day operative mortality rate in the study period was 15 per cent (28 out of 183) but in the subsequent 4-year period this fell to 7 per cent (5 out of 69). The survival rate correlated significantly with depth of invasion but not with tumour site or degree of differentiation. The incidence of early gastric cancer in this series was 5 per cent but the 5-year survival rate in this group was 52 per cent suggesting that the true incidence might be even lower. The overall 5-year survival rate in our area 20 years ago was only 5·2 per cent but in this series it was 11 per cent overall and 24 per cent after resection, and with actuarial correction 15 per cent overall and 28 per cent after resection. The continuing improvement in operative mortality rates and in 5-year survival rates gives grounds for optimism, but the disease must be diagnosed earlier if this improvement in outlook is to continue.
Non-ominous micrometastases of gastric cancer
Authors: Gunvén P , Maruyama K , Okabayashi K , Sasako M , Kinoshita T
Published: March 2007

So-called R2 or wider meticulous node dissection was performed in 1368 patients with resected gastric cancer invading beyond the submucosa but without distant metastases. Survival rates were similar in subsets of patients with or without microscopic node metastases and macroscopically normal lymph nodes. The extent of node metastases has previously been shown to be one of the two most important prognostic factors in gastric cancer without distant metastases, and its lack of impact in these patient groups was not explained by the imbalance of other prognostic factors. The findings indicate that micrometastases of gastric cancer are curable by a wide node dissection made in the absence of palpable abnormality. They also offer the possibility that an extensive node dissection may yield good stage-specific survival rates, in part because of upstaging of patients. The findings should influence the recording of node metastases for evaluation of stage-specific treatment results and for research purposes.
Predictors of death from aortic aneurysm among middle-aged men: The Whitehall study
Authors: Strachan D P
Published: March 2007

Among 18403 male civil servants examined at age 40–64 years there were 99 deaths attributed to aortic aneurysm during 18 years of follow-up. Each case was matched by age to ten controls who survived longer than the case. The risk of all types of fatal aneurysm was substantially increased for current smokers of manufactured cigarettes (rate ratio compared with lifelong non-smokers—6·5; 95 per cent confidence interval 2·3–18·7), pipe or cigars (6·7; 1·7–26·5) and hand-rolled cigarettes (25·0; 7·5–83·3). Diastolic blood pressure was strongly associated with dissecting aneurysm (rate ratio per 10 mmHg increase = 2·4; 95 per cent confidence interval 1·7–3·2) and abdominal aneurysm (1·5; 1·2–1·9) but not other aneurysms (1·0; 0·7–1·5). The independent effects of height, adiposity, plasma cholesterol, glucose intolerance, reported angina and intermittent claudication were not significant. Hypertension and smoking, particularly of hand-rolled cigarettes, are confirmed as major and potentially remediable risk factors for fatal aortic aneurysm.
Near-infrared spectroscopy in peripheral vascular disease
Authors: Cheatle T R , Potter L A , Cope M , Delpy D T , Smith P D Coleridge , Scurr J H
Published: March 2007

Near-infrared spectroscopy has been performed on the calf muscles of 38 subjects, 21 normal controls without vascular disease and 17 patients with peripheral vascular disease. Oxygen consumption was measured in the calf by calculating the rate of conversion of oxyhaemoglobin to deoxyhaemoglobin during a period of tourniquet-induced ischaemia. Postischaemic reoxygenation was also measured. Median oxygen consumption in patients with peripheral vascular disease was 0·10 ml 100 g tissue−1 min−1, while in the control group it was 0·20 ml 100 g tissue−1 min−1 (P<0·03, Mann—Whitney U test). The median time taken to reach maximum oxyhaemoglobin levels after ischaemia was 40 s in patients with peripheral vascular disease and 20 s in controls (P<0·02). The results indicate that oxygen consumption is reduced in peripheral vascular disease. Near infrared spectroscopy is a non-invasive method for assessing metabolic improvement resulting from surgical or pharmacological treatment.
Results of a recently instituted programme of thrombolytic therapy in acute lower limb ischaemia
Authors: Dawson K J , Reddy K , Platts A D , Hamilton G
Published: March 2007

Twenty-eight patients with acute lower limb ischaemia received low dose intra-arterial thrombolytic therapy over a 2-year period. Eighteen patients received streptokinase and ten patients received recombinant tissue plasminogen activator (rTPA). Indications included arterial thromboemboli and graft failures. Mean ischaemic times were similar in both groups. Treatment time to achieve lysis was significantly less with rTPA (P<0·01). Subsequent vascular procedures, including angioplasty or reconstruction, were undertaken in 36 per cent of patients. Arterial puncture site bleeding occurred in eight (29 per cent) patients. Three (11 per cent) patients suffered rethrombosis after initial successful lysis. All rethromboses were successfully lysed with rTPA. There were two major amputations. Five (18 per cent) patients died, all lytic failures in the streptokinase treatment group. There were no cerebral haemorrhagic events and no patient died as a result of thrombolytic therapy. Good clinical outcome was obtained in nine of 18 patients treated with streptokinase and in nine of ten patients treated with rTPA. Intra-arterial thrombolysis provides effective therapy with high rates of limb salvage and a low mortality rate. This study suggests that rTPA may be a more effective agent, causing less morbidity, than streptokinase.
Comparison of different vascular prostheses and matrices in relation to endothelial seeding
Authors: Vohra R , Thomson G J L , Carr H M H , Sharma H , Walker M G
Published: March 2007

Thin-walled expanded polytetrafluoroethylene (ePTFE), woven Dacron® and gelatin-impregnated Dacron (Gelseal®) vascular grafts were compared, the grafts being coated with three different matrices: collagen IV, fibronectin and preclot matrix. In addition, untreated ePTFE and Gelseal were examined. The graft segments, coated with these matrices, were incubated with radiolabelled adult human endothelial cells for 30, 60 and 90 min. Endothelial cell adherence was calculated from the ratio of radioactive counts in the grafts to counts in grafts plus supernatants. Endothelial cell attachment to untreated grafts was poor, but a suitable matrix significantly improved adherence. All three matrices tested gave good results, although preclot was best; 30–60 min incubation was sufficient for optimum cell attachment. Cell adherence to both Dacron and ePTFE was significantly better than to Gelseal. The type of prosthetic polymer and the substrate protein coating used to promote endothelial cell adherence are two important factors which may determine the ultimate success of endothelial seeding in the operating room.
Spontaneous abdominal arteriovenous fistulae: Report of eight cases and review of the literature
Authors: Gilling-Smith G L , Mansfield A O
Published: March 2007

The spontaneous rupture of an abdominal aneurysm into an adjacent major vein results in a profound and rapidly worsening haemodynamic disturbance. Survival depends on prompt diagnosis and closure of the fistula at operation. Eight cases are reported and modes of presentation, diagnostic criteria and management principles are reviewed in a detailed analysis of 148 cases in the English literature.