bluuebunny/crossref_metadata_2025 huggingface dataset:
Triple therapy and incidence of de novo cancer in renal transplant recipients
Authors: Kehinde E O , Petermann A , Morgan J D , Butt Z A , Donnelly P K , Veitch P S , Bell P R F
Published: March 2007

Some 27 (5·5 per cent) of 492 renal transplant recipients developed de novo cancer between January 1975 and December 1991. Patients administered triple therapy of prednisolone, cyclosporin A and azathioprine had a significantly higher incidence of cancer (seven of 40 patients; 17·5 per cent) than those given prednisolone with cyclosporin (14 of 319; 4·4 per cent) and azathioprine with prednisolone (six of 133; 4·5 per cent) (P= 0·005). In a prospective study between January 1989 and December 1992, 110 renal transplant patients were randomized into three immunosuppressive regimens at the time of transplantation. The incidence of cancer in patients receiving low-dose cyclosporin, azathioprine and prednisolone was three of 45, in those given high-dose cyclosporin and prednisolone none of 23 and in those administered high-dose cyclosporin, nifedipine and prednisolone one of 29. The addition of azathioprine to ongoing maintenance cyclosporin and prednisolone therapy is useful in a subgroup of patients with graft dysfunction, but there are possibly higher risks in the development of de novo carcinoma.
Administration of heparin and antibiotic prophylaxis
Authors: Avery C M , Jamieson N V , Calne R Y
Published: March 2007

An audit was performed to examine the time of administration of heparin and antibiotic prophylaxis to patients at risk of deep vein thrombosis, pulmonary embolism and postoperative wound infection. The records of 648 consecutive patients undergoing major surgery within a 12-month period were reviewed retrospectively. Heparin prophylaxis was given before surgery to only 30·9 per cent of patients undergoing elective procedures and in only 22·7 per cent of emergencies. Antibiotic prophylaxis was given before operation or at induction of anaesthesia to 82·1 per cent of patients undergoing elective procedures and in only 72·1 per cent of emergencies. It is concluded that administration of heparin and antibiotic prophylaxis is inadequate despite the provision of a written protocol.
Prognostic variables in patients with gastrointestinal carcinoid tumours
Authors: McDermott E W M , Guduric B , Brennan M F
Published: March 2007

Prognostic variables in patients with gastrointestinal carcinoid tumour were studied with a view to identifying those most likely to benefit from aggressive therapy. A total of 188 patients were studied; the median follow-up of those surviving was 72 months. On univariate analysis variables of prognostic significance were sex (P <0·01), site of the primary tumour (P <0·01), depth of invasion (P <0·001), tumour size (P <0·005), presence of lymph node (P <0·001) or liver (P <0·001) metastases, mode of discovery (P <0·001) and operative intent (P <0·001). On multivariate analysis the variables independently predictive of death from disease were sex (women have a better prognosis) and presence of metastases at the time of diagnosis.
Reversal of jejunoileal bypass in patients with morbid obesity
Authors: Anderson P E , Pilkington T R E , Gazet J-C
Published: March 2007

Jejunoileal bypass for morbid obesity was performed on 182 patients between 1971 and 1982. At 19 years' follow-up 60 (33 per cent) have had to undergo reversal. The compelling reasons for reversal were life-threatening malnutrition, immune complex disease, renal oxalate stones, osteomalacia and severe electrolyte disturbance. All patients gained weight after reversal of the jejunoileal bypass; most gained all the weight they had lost. Thirty-one patients returned to grade III obesity and 14 to grade II. Twelve patients had an associated vertical gastroplasty: ten regained their previous weight and only two stayed within normal weight. Patients were generally free from bypass-associated symptoms and complications apart from arthralgia and arthritis. This report concludes a series of articles published by the authors on jejunoileal bypass over the past 20 years describing the rise and fall of this surgical procedure.
Resection for extrahepatic recurrence of hepatocellular carcinoma
Authors: Lo C M , Lai E C S , Fan S T , Choi T K , Wong J
Published: March 2007

A total of 277 patients with hepatocellular carcinoma (HCC) underwent hepatic resection over a 20-year period. Twelve of 36 patients with recurrence confined to extrahepatic organs underwent surgical resection. There were no complications but one patient died in hospital from secondary intrahepatic recurrence. The 1-, 2- and 5-year survival rates for these 12 patients after hepatic resection were 92, 52 and 26 per cent respectively and were better than those of 24 patients who did not undergo resection for recurrence. The mean survival following resection for recurrent disease was 19·7 months and the longest survival time was nearly 8 years. Secondary recurrence after resection of metastases developed more commonly in the liver than in extrahepatic organs. Among the eight patients who survived for more than 4 months after the second operation, secondary recurrence developed in the liver and extrahepatic organs in eight and four patients respectively. In selected patients with isolated extrahepatic recurrence of HCC, surgery is effective in controlling extrahepatic disease and offers the only chance of long-term survival.
Civilian and war injuries of the perineum and anal sphincters
Authors: Engel A F , Kamm M A , Hawley P R
Published: March 2007

Patients with pelvic and perineal non-obstetric trauma were studied to determine the clinical outcome in relation to faecal continence. Between 1980 and 1992, 65 patients were referred for post-traumatic assessment of the anal sphincters and continence mechanism. All patients were continent before trauma. Using clinical examination, manometry, concentric-needle electromyography and most recently anal endosonography, external sphincter defects were identified in 56 patients, of whom 52 underwent overlapping sphincter repair. The external sphincter was considered to be intact in nine patients. At a median follow-up of 12 months a good result (continence grades 1 and 2) was achieved in 36 of 52 patients and a poor outcome (continence grades 3 and 4) in ten; six patients were lost to follow-up. A good clinical result was associated with a significant increase in resting pressure (median increase 15 cm H2O; P = 0·017) and squeeze pressure (median increase 35 cmH2O; P = 0·001). At postoperative assessment three patients with a poor outcome were shown to have a second unsuspected contralateral sphincter defect that had not been repaired. Physiological and endosonographic investigation combined with late surgical repair leads to a good outcome in most patients with traumatic sphincter damage.
Wedge resection alone or combined with segmental phenolization for the treatment of ingrowing toenail
Authors: Fulton G J , O'Donohoe M K , Reynolds J V , Keane F B V , Tanner W A
Published: March 2007

A retrospective analysis was undertaken of 387 patients treated surgically for ingrowing toenail between 1987 and 1989. In all, 203 patients were assessed and had 309 procedures performed on the median and/or lateral margins of one or both halluces. The procedures were performed by all grades of surgeon. A total of 126 wedge resections and 183 wedge resection-segmental phenolization combination treatments were performed. There were significantly fewer recurrences in the group receiving combination treatment (eight; 4·4 per cent) than in that having wedge resection alone (22; 17·5 per cent) (P < 0·001). Patients having procedures performed by senior house officers had a significantly greater chance of recurrence if a wedge resection alone was performed. It is concluded that the combination procedure gives better long-term results than wedge resection alone and can be used successfully by all grades of surgeon.
Endovascular repair of abdominal aortic aneurysm: Limitations of the single proximal stent technique
Authors: Sayers R D , Thompson M M , Nasim A , Bell P R F
Published: March 2007

Endovascular repair of abdominal aortic aneurysm (AAA) has been performed using both a single proximal stent technique and a double (proximal and distal) stent method to anchor a graft in the aneurysm lumen. This study examined the effect of the single proximal stent technique on femoral artery blood flow, renal function and the occurrence of back-bleeding into the aneurysm sac in a canine model; eight dogs were used. Femoral artery blood flow and glomerular filtration rate were not affected by graft–stent insertion. Two graft–stent combinations failed to deploy in the correct position and led to graft thrombosis in one case. The six correctly positioned grafts all showed back-bleeding from around the distal end into the aneurysm sac. The single proximal stent technique for endovascular repair of AAA is inadequate and attention should continue to focus on a double (proximal and distal) stent method or a bifurcated system.
Screening for abdominal aortic aneurysm: A single scan is enough
Authors: Emerton M E , Shaw E , Poskitt K , Heather B P
Published: March 2007

A group of 223 men who were found to have a normal abdominal aortic diameter (less than 2·6 cm) at the age of 65 or 66 years when first examined by ultrasonography in 1988 was studied again 5 years later. Twenty-seven patients had died, none from confirmed aneurysm rupture, and repeat scans were obtained in 189 of the 196 survivors. A further patient was reassessed at laparotomy. Mean aortic diameter was unchanged during the intervening 5 years and 166 of 189 repeat scan measurements were within 3 mm of the original value. Only two patients were found to have an aortic diameter of 3 cm or more on rescanning. These results suggest that a single ultrasonographic examination at the age of 65 years can safely be used to exclude over 90 per cent of those examined from future risk of significant aneurysmal dilatation of the aorta, with important cost and organizational benefits for a population screening programme.
Impaired homocysteine metabolism: A risk factor in young adults with atherosclerotic arterial occlusive disease of the leg
Authors: Aronson D C , Onkenhout W , Raben A M T J , Oudenhoven L F I J , Brommer E J P , van Bockel J H
Published: March 2007

To assess the prevalence of impaired homocysteine metabolism in young adults with arterial occlusive disease, 80 consecutive patients under 45 years old were screened. Various laboratory blood investigations and a standardized methionine loading test were performed. In the first 52 patients plasma levels of free homocysteine were determined; thereafter the levels of total homocysteine (a more sensitive measure of impaired homocysteine metabolism) were measured. The methionine loading test was abnormal in 15 patients (19 per cent) who did not differ from the other 65 with respect to prevalence of other risk factors, clinical characteristics, and electrocardio-graphic and angiographic findings. Blood levels of glucose, vitamins B6 and B12, folate, protein C and protein S, fibrinogen and low-density lipoprotein cholesterol did not differ significantly between the two groups. The prevalence of impaired homocysteine metabolism in young patients with arterial occlusive disease is greater than the 1–2 per cent found in the normal population.
Effect of pulsatile shear stress on endothelial attachment to native vascular surfaces
Authors: Thompson M M , Budd J S , Eady S L , James R F L , Bell P R F
Published: March 2007

An in vitro model of vascular damage was used to investigate the ability of seeded endothelial cells to resist shear stresses generated in a perfusion circuit. At perfusion rates of 100 ml/min the maximum shear stress reached 16.5 dyn/cm2. At this level the rate of cell detachment from the damaged vascular surface was 88 per cent per h for the first 20 min of flow but gradually decreased to 5 per cent per h after 90 min. These findings suggest that endothelial cells may be retained on damaged vascular surfaces in conditions that approximate to arterial flow.
Pattern of injury in those dying from traumatic amputation caused by bomb blast
Authors: Hull J B , Bowyer G W , Cooper G J , Crane J
Published: March 2007

Traumatic amputation of limbs caused by bomb blast carries a high risk of mortality. This paper describes 73 amputations in 34 deaths from bomb blast in Northern Ireland. The principal aim was to determine the sites of traumatic amputation to provide a biophysical basis for the development of protective measures. Few amputations were through joints; nearly all were through the bone shafts. The most common site in the tibia was the upper third. The distribution of femoral sites resulting from car bombs differed from that characterizing other types of explosion. For car bombs the principal site of amputation was the upper third; for other types of device it was the lower third. It is concluded that flailing is not a notable contributor to limb avulsion. The pattern of amputation is consistent with direct local pressure loads leading to bone fracture; the amputation itself is a secondary event arising from the flow of combustion products.
Management of soft tissue sarcoma
Authors: Pitcher M E , Fish S , Thomas J M
Published: March 2007

A total of 485 patients with a proven or suspected diagnosis of soft tissue sarcoma were referred over a 3-year period. Of these, 61 were referred for opinion only and 424 for definitive treatment. Overall there were 223 patients with primary soft tissue sarcoma and 84 with recurrent sarcoma, 84 with benign soft tissue tumours and 22 with non-soft tissue sarcoma malignancy; 11 patients were referred with known metastatic disease. The commonest benign tumours mimicking soft tissue sarcoma were fibromatosis and benign intermuscular or intramuscular lipoma. The malignant tumours suspected clinically of being soft tissue sarcoma were bone tumours, lymphoma and metastatic carcinoma. Of the 172 patients with primary soft tissue sarcoma referred with a proven diagnosis this had been established by excision biopsy in 94 and open incision biopsy in 48. By contrast, of those undiagnosed at referral, 44 of 51 patients with soft tissue sarcoma had the diagnosis made by Tru-cut core biopsy. Amputation was performed in four of 165 patients with primary extremity soft tissue sarcoma and in five of 54 with recurrent extremity sarcoma, giving an overall amputation rate of 4 per cent. It is proposed that the amputation rate for extremity soft tissue sarcoma can be reduced by the use of reconstructive procedures, particularly myocutaneous flaps to the proximal limbs and limb girdles, and free vascularized flaps to sites distal to the midthigh and midarm.
Paraoesophageal hernia repair with and without concomitant fundoplication
Authors: Rakić S , Peško P , Dunjić M S , Gerzić Z
Published: March 2007

There is currently no consensus as to whether an antireflux procedure should accompany surgical repair of paraoesophageal hernia. Forty consecutive patients with paraoesophageal hernia were studied. Surgery routinely included transabdominal hernia reduction, excision of the sac and crural repair. The addition of fundoplication was based on the presence of preoperative endoscopic evidence of oesophagitis. Twenty-three patients without endoscopic oesophagitis had no antireflux procedure whereas 17 with oesophagitis underwent concomitant antireflux surgery. Thirty-six patients were followed for 1–7 years. Patients without endoscopic oesophagitis had no postoperative reflux problems. All patients with oesophagitis who underwent fundoplication were improved or cured of reflux. The selection of patients for antireflux repair can satisfactorily be based on preoperative endoscopic findings.
Laparoscopic splenectomy for idiopathic thrombocytopenic purpura
Authors: Gigot J F , Healy M L , Ferrant A , Michaux J L , Njinou B , Kestens P J
Published: March 2007

Laparoscopic splenectomy was performed on eight patients with idiopathic thrombocytopenic purpura refractory to medical treatment. Preoperative infusion of immunoglobulin G γ-globulin was used to boost the platelet count. Accessory spleens were sought by preoperative computed tomography and peroperative examination of the usual anatomical locations. Seven patients underwent successful laparoscopic splenectomy, with a mean postoperative stay of 3·6 days. One patient with an accessory spleen detected before operation but not during laparoscopy required conversion to open surgery for control of haemorrhage from the splenic hilum. Another patient had a transient pancreatic fistula. Laparoscopic splenectomy is feasible and safe in patients with idiopathic thrombocytopenic purpura. Long-term results require evaluation as detection of accessory spleens can prove difficult during laparoscopy.
Hepatic resection for metastatic tumours from gastric cancer: Analysis of prognostic factors
Authors: Ochiai T , Sasako M , Mizuno S , Kinoshita T , Takayama T , Kosuge T , Yamazaki S , Maruyama K
Published: March 2007

Determinants of prognosis after hepatic resection for metastasis from gastric cancer were studied in a retrospective series of 21 patients, including four who survived more than 5 years after surgery. All patients underwent apparently curative resection. Synchronous or metachronous resection, age, sex, histological type, depth of invasion, lymphatic and venous invasion, lymph node involvement and number of hepatic metastases were analysed as prognostic factors for survival. Serosal invasion was the only significant determinant at synchronous resection. Both lymphatic and venous invasion were significant prognostic factors available after histological examination. Combined analysis of these two histological variables revealed that patients positive for both were at a significantly higher risk for both overall and disease-free survival. It is suggested that hepatic resection should be attempted in patients with synchronous or metachronous metastases if there is no serosal invasion by the primary gastric tumour, and if the primary tumour has neither venous nor lymphatic invasion in the case of metachronous metastases.
Combined resection of the pancreas and portal vein for pancreatic cancer
Authors: Takahashi S , Ogata Y , Tsuzuki T
Published: March 2007

Between March 1976 and December 1992, 137 (57 per cent) of 239 patients with pancreatic duct cell cancer underwent resection; 79 (58 per cent) of the 137 had combined resection of the pancreas and portal vein. Sixty-three of the 79 patients underwent resection of the portal vein alone; six died (mortality rate 10 per cent). The mortality rate was the same as that in 58 patients with no resection of the portal vein. In the remaining 16 patients adjacent arteries were also resected, with seven deaths. Of patients with resection of the portal vein alone who underwent curative resection, four survived more than 5 years, accounting for nearly half of the nine 5-year survivors. Combined resection of the pancreas and portal vein is associated with both an increased resectability rate and improved long-term survival.
Laparoscopic ultrasonography in the evaluation of the biliary tree during laparoscopic cholecystectomy
Authors: Greig J D , John T G , Mahadaven M , Garden O J
Published: March 2007

A prospective comparative study to evaluate operative cholangiography and laparoscopic ultrasonography in the detection of common bile duct (CBD) stones was undertaken in 54 patients undergoing laparoscopic cholecystectomy. Laparoscopic ultrasonography with a 7·5-MHz linear-array probe was performed before gallbladder mobilization. The incidence of choledocholithiasis at operation was 13 per cent (seven patients). Cholangiograms were not obtained in six patients, one of whom had common duct stones identified by laparoscopic ultrasonography. Operative cholangiography detected five of the remaining six CBD stones with two false-positive examinations. Laparoscopic ultrasonography detected five of the seven stones with two false-positive examinations. The finding of a CBD diameter of 7 mm or greater and gallbladder stones of up to 3 mm in diameter by laparoscopic ultrasonography would have identified all patients with common duct stones and implies that none of these would have undergone false duct exploration. Laparoscopic ultrasonography is useful in the detection of choledocholithiasis.
Lipid peroxidation and prostaglandins in colorectal cancer
Authors: Hendrickse C W , Kelly R W , Radley S , Donovan I A , Keighley M R B , Neoptolemos J P
Published: March 2007

Dietary fat, arachidonic acid metabolism and lipid peroxidation have all been implicated in colorectal carcinogenesis. Fatty acids, prostaglandins (PGE2, PGF2α) and malondialdehyde (MDA), the stable end-product of lipid peroxidation of polyunsaturated fatty acids (PUFAs), were studied in paired tumour and normal mucosa of 20 patients with colorectal cancer. Levels of arachidonic acid and total PUFAs were increased in the phospholipid fraction of tumours (P < 0·05). Levels of PGE2 and MDA were also higher in tumours (P < 0·001) and there was a significant correlation between MDA and PGE2 concentrations (rs = 0·69, P < 0·01). In contrast to previously reported in vitro studies, this work suggests that lipid peroxidation may be enhanced in human colorectal tumours. As PGE2 and MDA have been shown to be involved in carcinogenesis, these may be considered potential therapeutic targets for preventing or treating colorectal carcinoma.
Malignant obstruction of the left colon
Authors: Deans G T , Krukowski Z H , Irwin S T
Published: March 2007

The management of malignant obstruction of the colon distal to the splenic flexure is controversial. The ‘traditional’ three-stage procedure is marred by frequent failure to complete the planned sequence of operations and a resulting high permanent stoma rate. At each stage the mortality rate (7 per cent) and morbidity rate (30 per cent) are significant. The mortality rate following primary resection with delayed anastomosis (Hartmann's procedure) is 10 per cent. However, many patients experience complications and only 60 per cent have the stoma reversed. Primary anastomosis may be performed after subtotal or segmental colonic resection. The reported mortality rate is about 10 per cent with anastomotic leakage in 4–6 per cent, but cases are often carefully selected. It is difficult to suggest clear guidelines based on existing data. Although there are strong arguments in favour of a single-stage procedure, surgeons must decide whether available resources and local circumstances permit this. The alternative is Hartmann's procedure or referral to a surgeon with an interest in emergency colorectal surgery.
Somatostatin receptor-dependent growth inhibition of liver metastases by octreotide
Authors: van Eijck C H J , Slooter G D , Hofland L J , Kort W , Jeekel J , Lamberts S W J , Marquet R L
Published: March 2007

Rats were administered the somatostatin analogue octreotide 15 μg intraperitoneally twice daily for 4 weeks after intraportal injection of somatostatin receptor-positive pancreatic tumour cells (CA-20948) and somatostatin receptor-negative colonic tumour cells (CC531). Octreotide significantly inhibited the growth and development of somatostatin receptor-positive tumour cells in the liver. The median number of liver tumours was 286 (range 146 to greater than 500) in the treated animals and more than 500 (range 250 to in excess of 500) in the controls (P<0·05). This significant difference in tumour load was also represented in the mean(s.e.m.) liver weight (14·5(3·7) g in animals given octreotide versus 17·9(3·0) g in the controls). No effect of octreotide treatment was found on the growth and development of somatostatin receptor-negative tumour cells in the liver. The median (range) number of tumours was 6·5 (0–425) in the treated animals and 11·0 (0–475) in the controls. Mean(s.e.m.) liver weights were 14·0(5·7) g and 11·8(4·5) g respectively. There was no difference in serum levels of growth hormone, prolactin and insulin-like growth factor between control and octreotide-treated rats. The growth inhibition of somatostatin receptor-positive tumour cells was unlikely to be the result of suppressed secretion of one of these tumour growth factors. Octreotide may be useful for the treatment of patients with somatostatin receptor-positive hepatic metastases, which can be demonstrated by somatostatin receptor scintigraphy.
Influence of viral hepatitis status on operative morbidity and mortality in patients with primary hepatocellular carcinoma
Authors: Higashi H , Matsumata T , Adachi E , Taketomi A , Kashiwagi S , Sugimachi K
Published: March 2007

The influence of associated viral hepatitis status on 119 patients with primary hepatocellular carcinoma (HCC) undergoing hepatic resection was investigated. Operative morbidity and mortality were examined in three patient groups: 31 patients (group B) positive for hepatitis B surface antigen (HBsAg), 14 (group Be) positive for both HBsAg and hepatitis B e antigen, and 74 (group C) positive for hepatitis C virus antibody (HCVAb). Preoperative liver function in groups Be and C was similar and more impaired than that of patients in group B; combined active hepatitis was seen most frequently in group C (68 per cent). The tumour size in group B was significantly greater than that in groups Be and C. Postoperative complications occurred more frequently in group C (39 per cent) and early postoperative deaths, other than those from cancer, were seen in nine patients positive for HCVAb, of whom three developed postoperative liver failure. Patients with HCC and hepatitis B without seroconversion as well as hepatitis C frequently have active hepatitis, which may impair liver function and play an important role in operative morbidity and mortality.
Prevention of hepatitis B infection: A survey of surgeons and interventional cardiologists
Authors: Caruana-Dingli G , Berridge D C , Chamberlain J , Gould K , Harrison J
Published: March 2007

Hepatitis B immunization and the use of protective measures against blood contamination were assessed in a group of clinicians associated with invasive procedures. A self-administered confidential questionnaire was sent to 140 surgeons and interventional cardiologists, of whom 105 (75 per cent) replied. Ninety-five respondents (90 per cent) were immunized against hepatitis B, most (63 per cent) by an occupational health department and the majority within 5 years of this study. Only 80 per cent had had their immunity tested after immunization. Barrier protective techniques were used infrequently, with 30 per cent of respondents wearing impermeable gowns, 14 per cent wearing visors and 9 per cent using double-gloving for all procedures. Department of Health guidelines on protection from hepatitis B were published after this survey and the implementation of these guidelines in an NHS trust hospital is discussed.
Long-term pain: Less common after laparoscopic than open cholecystectomy
Authors: Stiff G , Rhodes M , Kelly A , Telford K , Armstrong C P , Rees B I
Published: March 2007

Persistent symptoms after cholecystectomy are common, occurring in up to 40 per cent of patients. Severe pain persists in 10 per cent of cases. A total of 450 patients were studied, 200 after open cholecystectomy and 250 after the laparoscopic operation. Patient notes were reviewed and a postal questionnaire was circulated. Responses were obtained from 155 patients (77·5 per cent) undergoing opencholecystectomy and 205 (82·0 per cent) having the laparoscopic operation. Mean(s.d.) follow-up was 32(23) months after open cholecystectomy and 15(7) months after the laparoscopic procedure. Right upper quadrant pain was more common after open cholecystectomy (9·7 versus 3·4 per cent, P < 0·05). Indigestion and heartburn were equally prevalent in the two groups. Some 59·4 per cent of patients were free from symptoms after open cholecystectomy compared with 63·4 per cent following the laparoscopic operation; there was symptomatic improvement in 30·3 and 31·7 per cent respectively. Symptoms were the same or worse in 10·3 per cent of patients after open cholecystectomy compared with 4·9 per cent after the laparoscopic operation (P < 0·05). Patients report significantly less right upper quadrant pain after laparoscopic than after open cholecystectomy.
Pouch–vaginal fistula after restorative proctocolectomy: Aetiology and management
Authors: O'Kelly T J , Merrett M , Mortensen N J , Dehn T C B , Kettlewell M
Published: March 2007

Pouch-vaginal fistula is a rare complication following restorative proctocolectomy. Seven patients who developed such a fistula are presented. Six pouch-vaginal fistulas occurred at the level of the pouch-anal anastomosis and one 3 cm above the anastomosis, level with the posterior vaginal fornix. The anastomosis had been hand-sewn in four patients (following mucosectomy) and stapled in three. Five fistulas presented within the perioperative period (median 16 (range 10–30) days) and two at 186 and 273 days. Treatment was successful in the patients who presented early, and these remain continent with functioning pouches. If not already present (two patients), an ileostomy was raised. Repair was by endovaginal flap advancement, combined with fistulotomy and sphincter repair in two patients. Treatment was unsuccessful in the two patients who presented late; in both the diagnosis was revised to Crohn's disease, necessitating pouch excision.
Factors affecting continence after surgery for anal fistula
Authors: Lunniss P J , Kamm M A , Phillips R K S
Published: March 2007

Anorectal physiology and continence were assessed prospectively before and after surgery in 50 patients with chronic perianal sepsis. Functional and physiological parameters were unchanged after surgery in 13 control patients who had sepsis but who did not undergo division of the anal sphincter. Group 1 comprised 22 patients with internal sphincter division alone (15 intersphincteric, seven trans-sphincteric treated by a loose seton technique) and group 2 consisted of 15 patients with a trans-sphincteric fistula laid completely open. In group 1 the median (interquartile range (i.q.r.)) resting pressure in the distal 1 cm of the anal canal was reduced from 68 (60–90) cmH2O before surgery to 44(35–60) cmH2O after operation (P<0·001); squeeze pressure was less affected, but function deteriorated in 11 of the 22 patients. The median (i.q.r.) resting pressure in group 2 patients also fell, from 68(34–84) cmH2O before operation to 28 (20–54) cmH2O afterwards (P = 0·003); median (i.q.r.) maximum squeeze pressure decreased more, from 124(76–170) cmH2O to 72 (48–112) cmH2O (P=0·002). Functional deficit occurred in eight of the 15 patients. Incontinence was related to low resting pressure, reflecting internal sphincter integrity, and to local epithelial electrosensitivity (reflecting scarring), but not to squeeze pressure, fistula type or surgical treatment.
Effect of an endovascular stent on healing of an end-to-end polytetrafluoroethylene–artery anastomosis in a canine model
Authors: Chalmers R T A , Hoballah J J , Sharp W J , Kresowik T F , Corson J D
Published: March 2007

A canine model of end-to-end anastomosis between the iliac arteries and polytetrafluoroethylene grafts was developed; a self-expanding Wallstent was placed across one anastomosis. The opposite limb acted as a control. Animals were killed at 4 or 12 weeks. Sections were taken and the intimal thickness and luminal area calculated. At 12 weeks intimal thickness was significantly greater at anastomoses in control sections (P = 0·007), and at the interface between the proximal stent and graft in stented graft limbs (P = 0·01). Control graft limbs had significantly enhanced intimal thickness at the anastomotic level at 12 weeks compared with that at 4 weeks (P = 0·0002), while there was no such increase for the stented side. There was no significant difference in luminal area between control and stented graft limbs. Anastomotic neointimal hyperplasia in a canine graft-artery bypass model is modified by endovascular stenting.
Bradykinin, coronary artery disease and gastro-oesophageal reflux
Authors: Caldwell M T P , Byrne P J , Marks P , Walsh T N , Hennessy T P J
Published: March 2007

Gastro-oesophageal reflux and coronary artery disease frequently coexist. Stimulation of myocardial vagal receptors impairs lower oesophageal sphincter (LOS) function and may explain this link. This study examined the role of bradykinin, produced in increased quantities by the ischaemic myocardium, in activating this reflex. Thirteen dogs had patches soaked in bradykinin 100 μg/ml and saline applied sequentially to the left ventricular epicardium. Eleven of these animals were further divided into two subgroups: group 1 animals (six dogs) had the above sequence repeated after obliteration of sympathetic afferent fibres with phenol and those in group 2 (five animals) underwent sequential intravenous and intra-atrial injection of bradykinin 0·2 μg/kg. Epicardial bradykinin produced a fall in mean(s.e.m.) LOS tone from 13·3(1·3) to 6·0(0·5) sphinctometer units (P< 0·002), accompanied by a reduction in mean(s.e.m.) arterial pressure from 95(4) to 83(5) mmHg (P< 0·002). Destruction of sympathetic afferent fibres did not alter the LOS effect. Intra-atrial, but not intravenous, bradykinin reproduced the LOS effect. this suggests a cardiac origin. Myocardial release of bradykinin may play a role in producing transient LOS relaxation, predisposing to gastro-oesophageal reflux.
Survival after peranal and abdominoperineal resection for rectal carcinoma
Authors: Savage A P , Reece-Smith H , Faber R G
Published: March 2007

The outcome of a consecutive series of 47 patients with rectal cancer treated by endoscopic transanal resection or peranal local excision was contrasted with that of 42 patients undergoing abdominoperineal resection. Surgery was considered curative for 35 and nine patients treated by abdominoperineal and peranal resection respectively (P < 0·001). Patients undergoing peranal excision were older than those treated by abdominoperineal resection (median 77 versus 69 years, P < 0·01). The 5-year survival rate of patients undergoing peranal resection was 24 per cent compared with 33 per cent for those treated by the abdommoperineal procedure (P < 0·005). When surgery was palliative the survival rate after both procedures was the same. Survival after peranal excision was significantly poorer than that after abdominoperineal resection but this may be acceptable when the stage of disease and age of the patients are taken into account.
Antegrade enemas for the treatment of severe idiopathic constipation
Authors: Hill J , Stott S , MacLennan I
Published: March 2007

The technique of appendicocaecostomy produces a continent catheterizable channel through which colonic washouts are given. This procedure was performed on six women of mean age 33·5 years with severe idiopathic constipation (mean stool frequency less than 1 per week) resistant to medical therapy. All patients had prolonged colonic transit times, three had evidence of obstructed defaecation and all had reduced or absent voluntary anal squeeze pressure. Patients found the appendicocaecostomy and catheterization acceptable, and symptoms of abdominal distension and pain resolved. All patients were able to initiate defaecation and evacuate the colon within 1h of irrigation, and no patient had appreciable incontinence. Irrigation was necessary every 48–72h. Adults with intractable constipation and pelvic floor weakness would be at risk of faecal incontinence after ileorectal anastomosis; it is in these patients that appendicocaecostomy has potential for the greatest benefit.
Comparative audit of colorectal resection with the POSSUM scoring system
Authors: Sagar P M , Hartley M N , Mancey-Jones B , Sedman P C , May J , Macfie J
Published: March 2007

Comparison of outcome after colorectal resection between different surgical units is difficult. Crude rates of morbidity and mortality may give a distorted picture as such rates fail to account for variations in case mix and physiological status of patients. The simple and validated scoring system POSSUM (Physiological and Operative Severity Score for en Umeration of Mortality and morbidity) was used to compare outcome after colorectal resection in two units. Consecutive series of patients who underwent colorectal resection in unit 1 (a university teaching hospital) or unit 2 (a district general hospital) were scored with the POSSUM system. Postoperative complications and 30-day mortality were recorded. In unit 1, 66 patients underwent colorectal resection with a mortality rate of 6 per cent and a morbidity rate of 9 per cent. In unit 2 the rates of mortality and morbidity were 9 and 26 per cent respectively for 182 patients undergoing colorectal resection. However, application of POSSUM predicted a mortality rate of 5·2 per cent for patients in unit 1 and 9·8 per cent for those in unit 2 with predicted morbidity rates of 11·2 and 23·9 per cent respectively. Direct comparison of outcome between these two units would be misleading. Application of POSSUM allows more realistic comparative audit of colorectal resection.
Role of lipid mediators in the pathogenesis of skeletal muscle infarction and oedema during reperfusion after ischaemia
Authors: Homer-Vanniasinkam S , Gough M J
Published: March 2007

During revascularization of skeletal muscle lipid mediators are released that may have a role in the pathogenesis of reperfusion injury. This study investigated the efficacy of the lipid mediator antagonists U74500A (a lipid peroxidation inhibitor), GR32191 (a thromboxane A2 receptor antagonist) and SC41930 (a leukotriene B4 (LTB4) receptor antagonist) in altering muscle viability and oedema, in a rat hindlimb model of 6-h ischaemia and 4-h reperfusion. Study groups comprised normal, ischaemic (6-h ischaemia) and control rats, and animals receiving the lipid mediator antagonists. Ischaemia itself did not result in muscle oedema or necrosis but both occurred following reperfusion (P<0·01). Muscle viability was preserved by all lipid mediator antagonists (P<0·01 versus controls, P not significant versus normal and ischaemia), with the LTB4 receptor antagonist ameliorating limb oedema (P<0·01 versus controls). These results demonstrate a role for lipid mediators in reperfusion injury and suggest that their antagonists might aid the management of acute limb ischaemia.
Experience with brain biopsy in acquired immune deficiency syndrome-related focal lesions of the central nervous system
Authors: Iacoangeli M , Roselli R , Antinori A , Ammassari A , Murri R , Pompucci A , Scerrati M
Published: March 2007

Involvement of the central nervous system (CNS) in patients with acquired immune deficiency syndrome (AIDS) is an increasing clinical problem. The most common brain complications are toxoplasmosis (50–70 per cent), primary CNS lymphoma (20–30 per cent) and progressive multifocal leucoencephalopathy (10–20 per cent). Almost two-thirds of these conditions can be treated, early diagnosis and therapy leading to survival with a good quality of life. Although clinical and neuroradiological criteria alone may have high predictive value, they are not sufficient to distinguish the broad spectrum of diseases reliably. Consequently, biopsy appears necessary for definite diagnosis in some cases. The potential role and timing of brain biopsy have been assessed. Twenty-four of 50 human immunodeficiency virus-seropositive patients with focal cerebral lesions were considered for biopsy between October 1991 and December 1992. Twelve underwent brain biopsy, seven stereotactic and five ultrasonographically guided. A diagnosis was achieved in 11 patients: six primary lymphoma, three progressive multifocal leucoencephalopathy, and one mycotic and one tuberculous abscess. Both techniques proved to be safe and reliable, with a 92 per cent diagnostic rate. These data confirm the usefulness of biopsy in patients with AIDS with its wide range of associated cerebral lesions that require different aggressive treatments. On the basis of this preliminary experience and reports in the literature, it is considered that brain biopsy is indicated for patients with focal enhancing cerebral mass lesions seen on computed tomography and magnetic resonance imaging who do not respond to an appropriate trial of empirical antitoxoplasmosis therapy and for those showing rapid clinical deterioration in whom imaging and serology do not suggest toxoplasmosis.
Hypotension induced by haemorrhage impairs lower oesophageal sphincter function
Authors: Caldwell M T P , Marks P , Byrne P J , Walsh T N , Hennessy T P J
Published: March 2007

The effect of haemorrhage-induced hypotension on lower oesophageal sphincter (LOS) tone was studied in 11 adult mongrel dogs. Mean(s.e.m.) blood loss of 760(66) ml, corresponding to 42 per cent of estimated blood volume, was associated with a significant fall in LOS tone (14·2(1·0) versus 7·2(0·6) sphinctometer units, P<0·002). This was associated with a reduction in mean(s.e.m.) arterial blood pressure (99(7) versus 53(3) mmHg, P<0·002) and heart rate (113(6) versus 106(5) beats per min, P=0·06). Group 1 animals (n = 6) received autotransfusion, restoring LOS tone to prehaemorrhage values. Dogs in group 2 (n = 5) were given intravenous erythromycin 4 mg/kg, which also restored LOS tone. This effect was transient, lasting a mean(s.e.m.) of only 67(7) min. Infusion of an equivalent volume of 0·9 per cent saline following cessation of the erythromycin effect restored LOS tone to control values although the animals remained hypotensive. Reduction in LOS tone with haemorrhage may be part of a vagal reflex mediated by myocardial afferent C fibres and may explain the high incidence of pulmonary aspiration in shocked patients.
Long-term effects of postoperative total parenteral nutrition supplemented with glycylglutamine on subjective fatigue and muscle protein synthesis
Authors: Petersson B , von der Decken A , Vinnars E , Wernerman J
Published: March 2007

Seventeen patients undergoing elective open chole-cystectomy were given conventional total parenteral nutrition either with (nine patients) or without (eight) glutamine supplementation of 20 g/day for 3 days after surgery and thereafter ordinary food for the following 27 days. Muscle protein synthesis, as assessed by the total concentration of ribosomes, decreased in control patients on day 3 following surgery and remained low on days 10, 20 and 30 (P < 0·05). In patients who received glutamine the total ribosome concentration was maintained on the third day after operation. Concurrently, the subjective feeling of fatigue increased on days 3 and 10 after surgery and the nitrogen balance was negative after operation in both groups, without any difference related to glutamine supplementation. Intravenous glutamine after surgery counteracts a decline in muscle protein synthesis only for as long as it is provided.
Percutaneous cystogastrostomy for chronic pancreatic pseudocyst
Authors: Henriksen F W , Hancke S
Published: March 2007

During the years 1984–1992, 74 patients of mean age 45 (range 6–71) years with chronic pancreatic pseudocyst were treated by percutaneous cystogastrostomy. They comprised 45 men and 29 women. A diagnosis of chronic pancreatitis was verified in 55 patients (74 per cent); pain was the indication for treatment in all cases. The catheter was successfully placed at the first attempt in 68 patients (92 per cent). Immediate complications occurred in four patients (5 per cent); there have been none since 1986. Abscess formation was seen in eight patients (11 per cent). One patient died 4 days after the procedure from myocardial infarction giving a mortality rate of 1 per cent; no death has occurred since 1986. The mean observation time was 27 (range 0–108) months. Pain disappeared or decreased in almost 90 per cent of patients and weight gain was seen in 80 per cent. The method described is less traumatic than operation, and mortality and complication rates compare favourably with those seen after surgery; the results are at least as good.
Iodized oil in the treatment of hepatocellular carcinoma
Authors: Bhattacharya S , Novell J R , Winslet M C , Hobbs K E F
Published: March 2007

When injected into the hepatic artery the contrast agent Lipiodol (iodized poppy seed oil) is selectively retained by hepatocellular carcinoma (HCC) for a prolonged period of time. Liver computed tomography (CT) performed after Lipiodol angiography is more sensitive than ordinary CT at imaging HCC. Arterial administration of cytotoxic drugs and radioisotopes conjugated to Lipiodol has been shown to be reasonably safe in patients with irresectable HCC. These therapies, often combined with embolization, provide effective palliation, better tumour response and improved survival compared with other available treatments. Their use as a preoperative adjunct to surgical resection of HCC is controversial.
Right atrial electrocardiography: A technique for the placement of central venous catheters for chemotherapy or intravenous nutrition
Authors: Madan M , Shah M V , Alexander D J , Taylor C , McMahon M J
Published: March 2007

Central venous catheters used for chemotherapy are usually sited so that the catheter tip lies in the superior vena cava. This study evaluated right atrial electrocardiography as a method of accurately placing the catheter tip in 34 patients over a period of 22 months. An electrocardiograph adaptor was connected to the catheter and the tip advanced into a central vein until a biphasic P wave was identified. In 31 of 34 patients the characteristic P wave changes were observed and the position of the catheter tip confirmed by screening to be in the superior vena cava. Right atrial electrocardiography is an accurate, reliable and rapid method of positioning the tip of a central venous catheter, and avoids or reduces exposure to radiation.
Closure of midline laparotomy incisions with polydioxanone and nylon: The importance of suture technique
Authors: Israelsson L A , Jonsson T
Published: March 2007

The healing of midline laparotomy incisions closed with a continuous suture of nylon or second-generation polydioxanone was evaluated in a randomized clinical trial. The effect of suture technique, reflected in the suture length to wound length ratio, was also assessed. All patients who underwent abdominal surgery through a midline incision were included except those with incisional hernia after previous midline operation. Wound dehiscence occurred in five (0·6 per cent) of 813 patients and wound infection in 73 (9·0 per cent). These rates were similar for both suture materials, as were those for the development of suture sinus and prolonged postoperative wound pain. Incisional hernia 12 months after surgery was found in 49 (15·1 per cent) of 325 wounds sutured with polydioxanone and in 50 (15·7 per cent) of 318 closed with nylon (P=0·91). There was a significant correlation between the hernia rate and the suture to wound length ratio for both materials (P<0·001). These results indicate that suture of midline laparotomy wounds is as safe with polydioxanone as it is with nylon. Incisional hernia is associated more with suture technique than with the material used.