bluuebunny/crossref_metadata_2025 huggingface dataset:
Lymph node metastasis of early gastric cancer with submucosal invasion
Authors: Kurihara N , Kubota T , Otani Y , Ohgami M , Kumai K , Sugiura H , Kitajima M
Published: March 2003

Background

A clinicopathological study of early gastric cancer with submucosal invasion was carried out in relation to lymph node metastasis.

Methods

A retrospective study was conducted of 245 patients with submucosal gastric cancer treated by gastrectomy combined with D2 lymph node resection between 1985 and 1994 in a university hospital.

Results

Lymph node metastasis was observed in 34 patients (14 per cent). The mortality rate due to recurrence in patients with lymph node metastasis (three of 34) was significantly higher than in those without lymph node metastasis (five (2 per cent) of 211) (χ2 = 3·95, 1 d.f., P < 0·05). Tumour size, depth of invasion, lymphatic involvement of cancer cells and preoperative diagnosis of advanced cancer correlated significantly with the presence of lymph node metastasis. When the submucosal carcinomas were classified into three categories according to depth of invasion by dividing the submucosal (sm) layer into three equal parts, sm1, sm2 and sm3, the incidence of lymph node metastasis increased from 2 per cent to 12 and 20 per cent respectively.

Conclusion

When the pathological report reveals sm1 invasion after laparoscopic or endoscopic surgery, reoperation should not be necessary because sm1-carcinomas with diameters of less than 2 cm do not usually metastasize to the lymph nodes.
Follow-up of more than 10 years after endoscopic sphincterotomy for choledocholithiasis in young patients
Authors: Sugiyama M , Atomi Y
Published: March 2003

Background

With the advent of laparoscopic cholecystectomy, the indications for endoscopic sphincterotomy (ES) have been extended to young patients with choledocholithiasis. However, the long-term results of ES are largely unknown.

Methods

Between 1977 and 1986, 115 patients aged 60 years or less underwent ES for choledocholithiasis. Stone classification, and early and long-term outcomes of ES were analysed retrospectively.

Results

Early complications occurred in nine patients (7·8 per cent), but there were no deaths. ES and stone clearance were successful in 110 patients. Long-term information was available in 103 of the 110 patients, with a mean overall follow-up duration of 14·2 (range 10·4–19·3) years. Ten patients (9·7 per cent) developed late complications, including stone recurrence and/or cholangitis (nine patients) and acute cholecystitis (one of 23 patients with the gallbladder in situ). The choledochal complication rate was somewhat higher in patients with calcium bilirubinate stones at ES (seven of 65 patients) than in those with cholesterol stones (two of 38 patients). Choledochal complications were manageable endoscopically.

Conclusion

Approximately 10 per cent of patients develop late complications. However, endoscopic retreatment is safe and effective. ES is a reasonable method for treating choledocholithiasis, even in young patients.
Long-term results of femorotibial bypass with vein or polytetrafluoroethylene
Authors: Sayers R D , Raptis S , Berce M , Miller J H
Published: March 2003

Background

This was a retrospective review of the long-term results of femorotibial bypass using autologous vein and polytetrafluoroethylene (PTFE) over 24 years.

Methods

Some 518 patients who underwent 635 femorotibial bypass grafts were studied. Outcome measures analysed included primary and secondary graft patency, limb salvage rates and death.

Results

Overall primary and secondary graft patencies were 62 and 67 per cent respectively at 12 months, and 44 and 48 per cent at 24 months. For vein grafts, the primary and secondary patencies were 63 and 66 per cent at 12 months, and 54 and 56 per cent at 24 months. For PTFE grafts, the primary and secondary patencies were 48 and 54 per cent at 12 months, and 31 and 37 per cent at 24 months. Limb salvage and patient survival rates were 81 and 84 per cent at 12 months, and 73 and 74 per cent at 24 months. Primary and secondary graft patencies for vein were significantly better than for PTFE (P = 0·0001). There was no difference in patency between reversed and in situ grafts.

Conclusion

Femorotibial bypass can produce excellent long-term results. Vein remains the conduit of choice but in the absence of vein acceptable results can be achieved with PTFE.
Malone antegrade continence enema for faecal incontinence and constipation in adults
Authors: Krogh K , Laurberg S
Published: March 2003

Background

In the Malone antegrade continence enema (ACE) technique the appendix or a ‘neoappendix’ created from the caecum is brought to the abdominal wall creating a small stoma. Thereby, antegrade enemas can be administered to empty the colorectum and prevent faecal incontinence or constipation in children with congenital malformations. The aim of this study was to describe the results of the ACE in adults suffering from faecal incontinence or constipation.

Methods

In 16 adult patients (ten women and six men) suffering from severe faecal incontinence (ten patients) or constipation (six patients) the ACE procedure was performed; the appendix was used in 12 and a ‘neoappendix’ was created in four. Patient records were used for the description of surgical procedures and complications. Results were evaluated by a structured telephone interview.

Results

After a follow-up of 1–39 (mean 17) months, four patients had stopped using the stoma because of abdominal pain or lack of effect. Among the other 12 patients overall satisfaction with the stoma was high or very high. In constipated patients mean time for defaecation was reduced from 170 to 45 min. Faecal incontinence was much reduced in eight patients; the impact on social activities and quality of life caused by bowel dysfunction was reduced in all 12 patients.

Conclusion

The ACE technique can be used to treat selected adult patients suffering from faecal incontinence or constipation.
Identification and progression of a desmoid precursor lesion in patients with familial adenomatous polyposis
Authors: Clark S K , Johnson Smith T G P , Katz D E , Reznek R H , Phillips R K S
Published: March 2003

Background

Desmoid tumours occur in about 10 per cent of patients with familial adenomatous polyposis (FAP), and are an important cause of morbidity and death. The natural history of desmoids was investigated by documenting prospectively the prevalence and progression of possible precursor lesions.

Methods

A group of patients with FAP and controls were examined at laparotomy. Another group, with FAP and no clinical evidence of desmoid, and a group of controls, underwent abdominopelvic computed tomography.

Results

At laparotomy 13 of 42 patients with FAP had fibromatous mesenteric plaques; seven of these had not had surgery. Seven had more extensive mesenteric fibromatosis and had undergone significantly more laparotomies than the rest. Of 103 patients scanned, two had desmoid tumours and 22 (21 per cent) had mesenteric fibromatosis. On follow-up both desmoid tumours grew rapidly; mesenteric fibromatosis was unchanged in eight and resolved in four of the 12 patients rescanned.

Conclusion

A model of desmoid tumour development is suggested, analogous to the adenoma–carcinoma sequence, in which a less benign phenotype emerges as molecular genetic abnormalities accumulate: mesenteric plaque-like desmoid precursor lesions arise in many patients with FAP before surgery as a result of abnormal fibroblast function; some, perhaps stimulated by surgery, progress to mesenteric fibromatosis; these in turn can give rise to desmoid tumours.
Malignant epithelial parotid gland tumours: analysis and results in 65 previously untreated patients
Authors: Leverstein H , van der Wal J E , Tiwari R M , Tobi H , van der Waal I , Mehta D M , Snow G B
Published: March 2003

Background

Optimal management of malignant epithelial parotid tumours requires knowledge of the available therapeutic modalities and the different biological characteristics. The aim of the study was to review the characteristics of patients at presentation, histological classification, disease-free and overall survival rates, and the results of the applied treatment policy regarding the facial nerve and neck.

Methods

Between 1974 and 1995 a total of 65 patients was treated with curative intent for a previously untreated malignant epithelial parotid gland tumour. All patients underwent some type of parotidectomy, 20 of whom had an en bloc radical neck dissection. In selected cases the facial nerve or its branches were peeled off the tumour thus violating the objective of tumour-free margins and relying heavily on the efficacy of postoperative radiotherapy. In total 51 patients received postoperative radiotherapy. None of the patients was lost to follow-up.

Results

There were 12 locoregional failures (18 per cent). In only one of these 12 patients was salvage therapy successful; the remaining 11 patients died from the tumour. All but one of the eight patients with distant metastasis only died from the tumour. The estimated 5- and 10-year disease-free rates were 68 and 59 per cent respectively. The corresponding survival rates were 75 per cent and 67 per cent. A significant relationship could be observed between tumour stage and survival. The presence of lymph node metastases proved to be the strongest single prognostic factor.

Conclusion

In selected cases a conservative approach towards the facial nerve is justified.
Quality of life in patients undergoing treatment for chronic radiation-induced rectal bleeding
Authors: Dent O F , Galt E , Chapuis P H , Yuile P , Sinclair G , Bokey E L
Published: March 2003

Background

Laser and formalin therapy have recently been shown to be safe methods of haemostasis in patients with chronic radiation-induced rectal bleeding (CRRB). The effectiveness of this treatment in terms of improved quality of life remains to be determined. The aim of this study was to develop a questionnaire measure of self-perceived quality of life in patients with CRRB.

Methods

A self-completed Rectal Bleeding Quality of Life Scale (RBQOLS) based on the social and emotional problems experienced by patients with CRRB was developed using standard psychometric methods. Before laser and formalin therapy, 34 consecutive patients completed the questionnaire which was repeated 1 month after treatment and again 5 months later. The validity of the scale was assessed in relation to patient response to treatment.

Results

The RBQOLS had high reliability (alpha = 0·89) and its concurrent validity was confirmed by a significant association with the pretreatment severity of CRRB assessed endoscopically. The mean RBQOLS score increased from 102 (95 per cent confidence interval 90–114) before treatment to 126 (111–141) after treatment (t = 3·1, 33 d.f., P = 0·004) and 136 (122–151) at follow-up attesting to its predictive validity.

Conclusion

The RBQOLS is a reliable and valid device for assessing quality of life of patients with this uncommon, previously intractable and potentially life threatening complication of radiotherapy.
Informed consent in patients with acute abdominal pain
Authors: Vessey W , Siriwardena A
Published: March 2003

Background

This study aimed to establish perceptions of informed consent in patients undergoing surgery for acute abdominal conditions.

Methods

A prospective observational study was carried out using a structured questionnaire-based interview technique in patients undergoing surgery for acute abdominal conditions. Main outcome measures were to establish the effects of pain and preoperative analgesia on informed consent, patient comprehension of planned surgery and the degree of discussion of potential side-effects and complications.

Results

Thirty-one of 49 patients perceived that pain did not interfere with their ability to give informed consent. Forty of 48 stated that preoperative analgesia did not impair their ability to give informed consent. Forty-two understood why an operation was being planned but 28 patients stated that there had been no preoperative discussion of any potential side-effects or complications of surgery.

Conclusion

In this study the majority of patients perceived that they retained the ability to give informed consent despite the effects of pain and analgesia. Although the majority of patients understood why an operation was being planned there is a clear need for improved discussion of potential side-effects and complications.
Oesophageal dysmotility is not associated with poor outcome after laparoscopic Nissen fundoplication
Authors: Beckingham I J , Cariem A K , Bornman P C , Callanan M D , Louw J A
Published: March 2003

Background

Nissen fundoplication has become the standard operation in the surgical management of gastro-oesophageal reflux disease. Postoperative dysphagia is thought to occur more commonly in patients with oesophageal dysmotility and it has been recommended that fundoplication be modified or avoided in these patients. The aim of this study was to determine the outcome of patients with normal motility and dysmotility undergoing laparoscopic Nissen fundoplication.

Methods

This was a single-centre prospective cohort study with 1-year follow-up, using dysphagia as the main outcome variable. Of 81 patients who underwent laparoscopic surgery, 48 had normal motility and 33 had oesophageal dysmotility (defined as percentage peristalsis, using ten wet swallows, of 50 per cent or less and/or a mean distal pressure of less than 40 mmHg).

Results

Dysphagia was present before operation in 14 of 48 patients with normal motility and 15 of 33 in the dysmotility group (P = 0·2). At 3-month follow-up, new or worse dysphagia was present in 13 of 48 patients in the normal group and four of 33 in the dysmotility group (P = 0·17). At 1 year the incidence of dysphagia was six of 48 in the normal group and five of 33 in the dysmotility group (P = 0·9).

Conclusion

Preoperative manometric assessment of oesophageal motility does not correlate with postoperative outcome, and oesophageal dysmotility should not be regarded as a contraindication to laparoscopic Nissen fundoplication.
Gastric carcinoid expresses the gastrin autocrine pathway
Authors: Smith A M , Watson S A , Caplin M , Clarke P , Griffin N , Varro A , Hardcastle J D
Published: March 2003

Background

In gastric adenocarcinoma the gastrin autocrine–paracrine pathway is activated. As enterochromaffin-like (ECL) cells originate from the same stem as epithelial cells, the aim of this study was to determine if the gastrin autocrine pathway is present in gastric carcinoid.

Methods

Samples from ten patients with gastric carcinoid were assessed by immunocytochemistry using primary antibodies directed against gastrin precursors and the gastrin/cholecystokinin B receptor and detected using the avidin–biotin immunoperoxidase system.

Results

A high level of expression of precursor and mature gastrin peptides, together with the gastrin receptor, was seen in all carcinoids screened.

Conclusion

In common with the glandular epithelium of the stomach the gastrin gene is activated during the neoplastic process in ECL cells. This finding may explain why some carcinoids do not regress after surgical procedures that lower serum gastrin. Antigastrin agents may be a useful treatment for carcinoid either in their own right or as an adjunct to surgery.
Long-term clinical outcome of surgery for solitary rectal ulcer syndrome
Authors: Sitzler P J , Kamm M A , Nicholls R J , Mckee R F
Published: March 2003

Background

When severe symptoms of solitary rectal ulcer syndrome persist despite medical management, surgery may be necessary.

Methods

A retrospective review was carried out of 81 patients undergoing surgery for solitary rectal ulcer syndrome in the 10-year period from 1984 to 1993 to determine the long-term outcome at a minimum follow-up of 12 months. Of the 81 patients, 15 were excluded from further analysis (11 were followed up for less than 12 months, two died and two were lost to follow-up). Sixty-six patients were studied (median age 38 (range 15–77) years; 53 female). Of these, 49 underwent rectopexy, nine Delorme's operation, two anterior resection and four creation of a stoma as the initial operation.

Results

At a median follow-up of 90 (range 12–177) months, the rectopexy had failed in 22 of 49 patients; 19 of these patients underwent further surgery, including rectal resection with coloanal anastomosis (four with three failures), colostomy (11) and other procedures (four). Ultimately, 14 required a stoma. Constipation was the indication for a stoma in nine of the 11 patients who had colostomy as the first procedure after failure of rectopexy. Nine patients had Delorme's operation as the first procedure. At median follow-up of 38 (range 19–107) months, there were four failures. Two of these ultimately required a stoma. Of the seven patients who underwent anterior resection as the initial or subsequent procedure, a stoma was finally necessary in four. Anterior resection used as a salvage procedure was not successful. The overall stoma rate was 30 per cent (20 patients). Of 11 symptoms assessed before operation only incontinence and incomplete evacuation were related to a poor outcome following surgery.

Conclusion

Antiprolapse operations result in a satisfactory long-term outcome in about 55–60 per cent of patients having surgery for solitary rectal ulcer syndrome. Results of anterior resection are disappointing.
Improved outcome after emergency surgery for cancer of the large intestine
Authors: Runkel N S , Hinz U , Lehnert T , Buhr H J , Herfarth Ch
Published: March 2003

Background

Emergency surgery for colorectal cancer has become more aggressive and radical over the past decade. This retrospective review analyses the impact on outcome.

Methods

The results of emergency surgery within 24 h of admission were compared between 1982 and 1987 (77 patients) and 1988 and 1993 (75 patients). Patient and tumour characteristics were similar in both groups.

Results

Right colonic obstruction or perforation was treated by primary resection and anastomosis in 11 of 12 patients before 1988 and in all 19 patients thereafter. Primary resection was also the treatment of choice for perforated cancer of the left colon and rectum before 18 of 20) and after (20 of 21) 1988. The rate of primary resection for obstructing cancer of the left colon and rectum increased from 17 of 45 to 30 of 35. One-stage resections for obstructing cancer were performed in ten of 45 and 22 of 35 patients before and after 1988 respectively. The overall mortality rate declined from 14 of 77 to three of 75 after 1988 (P < 0·01). The rate of radical lymphadenectomy rose from six of 46 patients to 42 of 69 after 1988. The 3-year survival rate increased from 50 to 74 per cent (P < 0·05).

Conclusion

The data support further efforts towards improving the immediate and late outcome of emergency surgery in complicated colorectal cancer.
Pain after groin hernia repair
Authors: Callesen T , Bech K , Nielsen R , Andersen J , Hesselfeldt P , Roikjær O , Kehlet H
Published: March 2003

Background

The purpose of the study was to provide a detailed description of postoperative pain after elective day-case open inguinal hernia repair under local anaesthesia.

Methods

This was a prospective consecutive case series study. After 500 hernia operations in 466 unselected patients aged 18–90 years, pain was scored (none, light, moderate or severe) at rest, while coughing and during mobilization, daily for the first postoperative week and after 4 weeks. Pain scores were added together over the first postoperative week.

Results

On days 1, 6 and 28, 66, 33 and 11 per cent respectively had moderate or severe pain while coughing or mobilizing. Total pain scores were higher while coughing or mobilizing than at rest (P<0·001). Younger patients had higher total pain scores than older patients while coughing or mobilizing (P<0·01), but not at rest. No significant differences were found between types of surgery or hernia.

Conclusion

Pain remained a problem despite the pre-emptive use of opioids, non-steroidal anti-inflammatory drugs and local anaesthesia, irrespective of surgical technique.
Resympathectomy for palmar and axillary hyperhidrosis
Authors: Hsu C-P , Chen C-Y , Hsia J-Y , Shai S-E
Published: March 2003

Background

The aim was to analyse patterns of failure or symptom recurrence after primary sympathectomy for palmar or axillary hyperhidrosis, and to carry out tactical problem-solving for resympathectomy and review the operative findings.

Methods

Over a 2-year period, 20 patients (six men and 14 women) underwent resympathectomy for palmar hyperhidrosis (13 patients, 20 sides) or axillary hyperhidrosis (seven patients, ten sides). T2–3 sympathectomy for palmar hyperhidrosis or T4–5 sympathectomy for axillary hyperhidrosis was performed during the repeat procedure. Criteria for evaluation by means of patient questionnaire included good (more than 80 per cent), fair (50–80 per cent) and poor (less than 50 per cent) improvement.

Results

Operative findings included inadequate sympathectomy on 19 sides, nerve regeneration on eight sides and no evidence of previous sympathectomy on three sides. One patient had Kuntz fibre in addition to inadequate sympathectomy. In the palmar hyperhidrosis group, good results were obtained in all 13 patients on all 20 sides after resympathectomy. In the axillary hyperhidrosis group, six of seven patients, or eight of ten sides, showed good results after resympathectomy.

Conclusion

The main cause of primary sympathectomy failure was inadequate surgery, and recurrence of palmar or axillary hyperhidrosis was seldom caused by nerve regeneration. The key factor for preventing failed sympathectomy or recurrent palmar or axillary hyperhidrosis is a first-time sympathectomy that is both accurate and adequate. Most patients with recurrent symptoms can be cured by resympathectomy.
Lymphatic mapping and sentinel node biopsy in breast cancer
Authors: Mcintosh S A , Purushotham A D
Published: March 2003

Background

Sentinel lymph node biopsy is a recently developed, minimally invasive technique for staging the axilla in patients with breast cancer. It has been suggested that this technique will avoid the morbidity associated with more extensive axillary dissection. A wide range of different methods and materials has been employed for lymphatic mapping, but there has been little consensus on the most reliable and reproducible technique.

Methods

This is a comprehensive review of all published literature on sentinel node biopsy in breast cancer, using the Medline and Embase databases and cross-referencing of major articles on the subject.

Results and conclusion

Sentinel node biopsy is a valid technique in breast cancer management, providing valuable axillary staging information. The optimal technique of lymphatic mapping utilizes a combination of vital blue dye and radiolabelled colloid. However, there remain controversial issues which require to be resolved before sentinel node biopsy becomes a widely accepted part of breast cancer care.
Splenic complications in chronic pancreatitis: prevalence and risk factors in a medical–surgical series of 500 patients
Authors: Malka D , Hammel P , Lévy P , Sauvanet A , Ruszniewski P , Belghiti J , Bernades P
Published: March 2003

Background

The prevalence, course, treatment, outcome and risk factors of splenic complications in chronic pancreatitis are poorly documented.

Methods

Patients with splenic complications in a medical–surgical series of 500 consecutive patients with proven chronic pancreatitis prospectively followed up for a mean of 7·0 years were compared with patients without splenic complications.

Results

Eleven men (2·2 per cent) with alcoholic chronic pancreatitis (median duration 2 (range 0–5) years) had a splenic complication: intrasplenic pseudocyst (n = 5), subcapsular haematoma (n = 2) or splenic rupture (n = 4). All patients except one underwent splenectomy, five of whom also underwent distal pancreatectomy. There were no deaths. Patients with splenic complications had pancreatic tail necrosis (six of 11 versus 17·4 per cent; P = 0·007), distal pseudocyst (six of 11 versus 11·7 per cent; P = 0·0009) or splenic vein occlusion (seven of 11 versus 10·8 per cent; P < 0·0001) more frequently than those without. In the 22 patients with distal pseudocyst and splenic vein occlusion, the prevalence of splenic complications was 18 per cent (odds ratio 15·0 (95 per cent confidence interval 4·0–55·7).

Conclusion

Splenic complications occur early in the course of chronic pancreatitis, are rare and are favoured by splenic vein occlusion and pseudocyst or necrosis of the pancreatic tail. Surgical treatment is usually required.
Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy
Authors: Dwerryhouse S J , Brown E , Vipond M N
Published: March 2003

Background

With the advent of laparoscopic cholecystectomy, endoscopic retrograde cholangiography (ERC) is frequently employed before operation to detect common bile duct stones. However, this is an invasive technique with recognized complications. This study evaluated the accuracy of magnetic resonance cholangiography (MRC) to detect choledocholithiasis in selected patients before laparoscopic cholecystectomy.

Methods

Patients scheduled for elective laparoscopic cholecystectomy, with risk factors for common bile duct stones, underwent MRC followed by ERC or peroperative cholangiography.

Results

Over a 2-year period 40 patients were studied. MRC had a sensitivity of 88 per cent, specificity of 93 per cent, positive predictive value of 78 per cent and negative predictive value of 97 per cent for the detection of common bile duct stones.

Conclusion

MRC is a simple non-invasive method for preoperative screening for common bile duct stones in at-risk patients. In this study it would have reduced the need for ERC by three-quarters.
Nitric oxide generation is increased in experimental renal warm ischaemia–reperfusion injury
Authors: Weight S C , Furness P N , Nicholson M L
Published: March 2003

Background

Nitric oxide has a clearly defined place in normal renal homoeostasis while there is a continuing debate as to its role under pathophysiological conditions. This study investigated the role of nitric oxide in a model of renal warm ischaemia–reperfusion injury.

Methods

Groups of rats underwent bilateral renal warm ischaemia (for 15–60 min) followed by reperfusion (20 or 80 min) before unilateral nephrectomy for measurement of renal nitric oxide (as nitroxides) and oxidative damage. Renal function was measured on days 2 and 7 before killing and nephrectomy. A further group received the nitric oxide synthase inhibitor NG-nitro l-arginine methyl ester (l-NAME; 50 mg per kg body-weight) before induction of warm ischaemia.

Results

In early reperfusion there was a correlation between the duration of warm ischaemia (15–45 min) and renal nitrate (r2 = 0·97) which increased from a mean(s.e.m.) baseline value of 95(5·9) to 208(17·3) nmol per mg protein following 45 min of warm ischaemia. Levels were further raised at 80 min and maintained through to day 7 (241(12·5) nmol per mg protein in 45-min group). This rise was attenuated by l-NAME (P < 0·01) as was the early rise in oxidative damage seen otherwise. By day 7, however, oxidative damage was increased (all P≤0·01).

Conclusion

Renal nitric oxide increased early in recoverable warm ischaemia–reperfusion injury and remained raised to day 7. Nitric oxide synthase inhibition ameliorated early but exacerbated late damage suggesting that the early burst of nitric oxide is cytotoxic but that overall nitric oxide may exert a cytoprotective effect.
No correlation between phaeochromocytoma catecholamine secretion and granule ultrastructure
Authors: Mihai R , Wong N A C S , Luckett M , Sheffield E , Farndon J R
Published: March 2003

Background

It is uncertain whether biochemical markers of catecholamine secretion in patients with phaeochromocytoma correlate with tumour ultrastructure granule morphology.

Methods

Fifteen patients with an adrenal phaeochromocytoma (n=13) or paraganglioma (n = 2) (three men, 12 women; age 17–79 years) were studied. Catecholamine secretion was estimated by measuring urinary levels of free noradrenaline, adrenaline and dopamine. The number and type of secretory granules were evaluated by two independent observers on electron micrographs (area analysed approximately 70 µm2). Large round or elongated medium-density granules were adrenaline-type granules, whereas electron-dense granules lying in a vacuole were of noradrenaline type.

Results

No correlation was found between noradrenaline output and the number or percentage of noradrenaline-type granules, although tumours with normal noradrenaline output had only a minority of this type of granule (less than 25 per cent). Adrenaline-type granules were predominant (77 per cent of 163 granules) in a tumour secreting only adrenaline, but the proportion of adrenaline-type granules in six tumours with normal adrenaline output varied significantly (range 7–89 per cent). It was not possible to evaluate the granule type associated with dopamine secretion because one tumour secreting 14900 nmol dopamine and 1570 nmol adrenaline daily had a predominance of noradrenaline-type granules (63 per cent of 132 granules) and two dopamine-secreting tumours (5500 and 4250 nmol per day respectively) had 93 and 13 per cent noradrenaline-type granules.

Conclusion

The lack of correlation between hormone output and granularity suggests that other factors determine secretory patterns in these tumours.
Prospective assessment of the hepatic perfusion index in patients with colorectal cancer
Authors: Warren H W , Gallagher H , Hemingway D M , Angerson W J , Bessent R G , Wotherspoon H , Mcardle C S , Cooke T G
Published: March 2003

Background

This prospective study was designed to test the hypothesis that abnormal liver blood flow is related to poor prognosis in patients with colorectal cancer.

Methods

The hepatic perfusion index (HPI), measured by dynamic hepatic scintigraphy, was assessed in 202 patients with colorectal cancer. Assessment for overt hepatic metastasis included liver palpation at laparotomy and perioperative computed tomography (CT). Follow-up at a dedicated clinic included regular abdominal ultrasonography and CT.

Results

The HPI was abnormal (greater than 0·37) in 92 (88 per cent) of 105 patients with overt liver metastases. Of 89 patients with no evidence of overt metastases or residual tumour after primary resection, 52 had an abnormal and 37 a normal HPI. At a median follow-up of 39 (range 13–76) months, 25 of 38 patients with recurrnce had an abnormal HPI. Some 31 of 45 patients who died had an abnormal HPI. The HPI predicted overall recurrence (P = 0·04, log rank test). Multivariate analysis showed the HPI was independent of Dukes stage for predicting disease-free survival (P = 0·04, relative risk 1·94 (95 per cent confidence interval (c.i.) 1·03–3·67)) but this just failed to attain significance for overall survival (P = 0·055, relative hazard 1·88 (95 per cent c.i. 1·00–3·58)).

Conclusion

The HPI predicts a poor outcome in patients with colorectal cancer and may be useful in patient selection for adjuvant chemotherapy.
Dynamic graciloplasty in the treatment of patients with faecal incontinence
Authors: Sielezneff I , Malouf A J , Bartolo D C C , Pryde A , Douglas S
Published: March 2003

Background

Dynamic graciloplasty is a recent innovation in the surgical management of faecal incontinence. This study reports further experience with this procedure in a series of consecutive patients.

Methods

Between July 1994 and February 1998, 21 dynamic graciloplasties were performed in 18 patients with total faecal incontinence. The two most recent patients were excluded because of follow-up less than 6 months. Continence scores and manometric data were collected before operation and 6 months afterwards. Subsequent clinical data were obtained at regular outpatient review. Seven patients had a three-stage procedure (vascular delay and stoma creation; gracilis transposition and implantation of stimulator and leads; stoma closure), four patients had a two-stage procedure (stoma, with transposition and implantation; stoma closure) and five underwent a one-stage procedure without defunctioning stoma.

Results

Mean(s.d.) follow-up was 20(10·2) months, and was complete in all patients. Eight of the 16 patients had postoperative morbidity. Thirty-three subsequent admissions and 23 reoperations were required to treat complications, to correct technical problems or to manage outcome failures. A defunctioning stoma did not protect wounds from infection (P= 0·6) or reduce the postoperative morbidity rate (P= 0·14). Continence scores were improved by the procedure (P< 0·001) and anal canal pressure increased with stimulation (mean increase 35·9 cmH2O, P< 0·001). Two patients required revisional surgery for perielectrode fibrosis. Five patients had revisional surgery for electrical device failure. Thirteen of the 16 patients were either improved or fully continent after operation, and satisfied with the result of the procedure. Ultimate failure (n = 3) occurred in patients with chronic preoperative constipation or diarrhoea, or abnormal rectal sensitivity.

Conclusion

Dynamic graciloplasty is an effective procedure in selected cases of end-stage faecal incontinence. Patient motivation is essential given the necessity for close follow-up.
Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity
Authors: O'Brien P E , Brown W A , Smith A , McMurrick P J , Stephens M
Published: March 2003

Background

Surgical control of morbid obesity should benefit from a minimally invasive approach and the ability to adjust the degree of gastric restriction.

Methods

The Lap-Band adjustable gastric banding system was evaluated prospectively in a consecutive series of 302 patients, and data on perioperative outcome and weight loss pattern at up to 4 years of follow-up are presented. Some 302 patients (89 per cent women; mean age 39 years, mean weight 124 kg) were entered into the study. Laparoscopic placement was used in 277 patients. Previous gastric stapling surgery was the principal reason for an elective open approach.

Results

The incidence of significant early complications was 4 per cent and included two perforations of the stomach after open placement. The mean length of stay after laparoscopic placement was 3·9 days and only one complication (infected reservoir site) occurred in these patients. The principal late complication of prolapse of the stomach through the band occurred in 27 patients (9 per cent). Significant modification of technique and patient care has enabled reduction of this complication in the latter part of the series. Mean(s.d.) excess weight loss was 51·0(17) per cent at 12 months (n = 120), 58·3 (20) per cent at 24 months (n = 43), 61·6(2) per cent at 36 months (n = 25) and 68·2(21) per cent at 48 months (n = 12).

Conclusion

The Lap-Band is an effective method for achieving good weight loss in the morbidly obese at up to 4 years of follow-up. Laparoscopic placement has been associated with a short length of stay and a low frequency of complications. The ability to adjust the setting of the device to achieve different degrees of gastric restriction has enabled progressive weight loss throughout the period of study.
Indications for early mandatory laparotomy in abdominal stab wounds
Authors: Leppäniemi A K , Voutilainen P E , Haapiainen R K
Published: March 2003

Background

Patients with an abdominal stab wound presenting with shock, peritonitis or evisceration are usually subjected to early laparotomy, although very few studies have been done to validate the criteria.

Methods

In a retrospective study of 209 consecutive patients with stab wounds of the anterior abdomen, flank or lower chest, 23 clinical and radiological criteria were evaluated for their accuracy in predicting the presence of significant abdominal organ injury.

Results

Overall, 89 patients (43 per cent) had a significant abdominal injury. The criteria with the highest positive predictive values for significant injury were: signs of continuing haemorrhage in initially normotensive patients (86 per cent), shock on admission (83 per cent) and generalized peritonitis (81 per cent). No positive direct or indirect signs of peritoneal penetration including omental evisceration, extraluminal air on plain radiography, or free peritoneal fluid on abdominal ultrasonography were independent predictors of significant injury.

Conclusion

Signs of major internal haemorrhage or generalized peritonitis are reliable criteria by themselves for early laparotomy. Peritoneal penetration is a poor indicator of significant organ injury and warrants direct organ-specific evaluation, such as computed tomography or laparoscopy, to identify patients who can safely be treated without operation.
Randomized comparison of prevertebral and retrosternal gastric tube reconstruction after resection of oesophageal carcinoma
Authors: van Lanschot J J B , van Blankenstein M , Oei H Y , Tilanus H W
Published: March 2003

Background

After potentially curative resection of oesophageal cancer and prevertebral gastric tube reconstruction, approximately one-quarter of patients develop secondary dysphagia due to locoregional recurrence. In half of them dysphagia can be prevented by using an extra-anatomical reconstruction route. The present randomized study was conducted to compare the technical and functional results after prevertebral and retrosternal gastric tube reconstruction.

Methods

Sixty patients underwent resection of a carcinoma of the oesophagus or gastro-oesophageal junction with curative intent. Subsequently, these patients were randomly allocated to either prevertebral (n = 30) or retrosternal (n = 30) gastric tube reconstruction. Early and late complications and functional results were carefully monitored.

Results

Creation of the retrosternal tunnel was not accompanied by any perioperative complications. Postoperative recovery, anastomotic leakage and benign stricture formation were not significantly different between the two groups. Functional results, as measured by scintigraphic gastric emptying, quantitative and qualitative oral food intake, and changes in body-weight were similar in the two groups.

Conclusion

After subtotal oesophagectomy retrosternal gastric tube reconstruction can be performed easily and safely, and gives functional results similar to those obtained with prevertebral reconstruction. In patients at high risk for developing secondary malignant dysphagia the extra-anatomical route is the reconstruction of first choice.
Local and systemic effects of intraoperative whole-colon washout with 5 per cent povidone–iodine
Authors: Basha G , Penninckx F , Mebis J , Filez L , Geboes K , Yap P
Published: March 2003

Background

Segmental intraluminal instillation of several tumoricidal agents including povidone–iodine has been advocated to prevent anastomotic recurrence after colonic resection for colorectal cancer. The local and systemic effects of on-table whole-colon washout using 5 per cent povidone–iodine were assessed in patients undergoing elective surgery for colorectal cancer.

Methods

The local effect of 5 per cent povidone–iodine on the colonic mucosa and the effect of colonic mucosal damage by povidone–iodine on tumour take was first investigated in Fischer 344 rats. In 12 euthyroid non-allergic patients, on-table whole-colon lavage via the appendix was performed. Systemic (thyroid function) and local (mucosal damage assessed by repeat biopsies) effects were studied, as well as the in vitro tumoricidal effect of the final anal effluent on tumour cell suspensions.

Results

After 30 min of contact with povidone–iodine the rat colonic mucosa was severely injured, with detachment of the epithelial cell layer. Povidone–iodine-induced ‘colitis’ did not result in tumour development after inoculation of 106 Mtln3 carcinoma cells in ten rats. Epithelial desquamation was also observed, in all but one patient, 1 and 4 h after colonic lavage. However, epithelial restitution started within 1 day and no abnormality was revealed after 3–7 days. Urinary iodine excretion increased markedly and was not within normal values after 1 week. Levels of thyroid hormones decreased significantly but became normal within 1 week. The anal effluent containing povidone–iodine was found to be tumoricidal in vitro on a human colonic carcinoma cell line and on a tumour cell suspension produced from the patient's tumour.

Conclusion

On-table whole-colon washout using 5 per cent povidone–iodine seems clinically feasible. This technique deserves further study as a substitute for preoperative bowel preparation and may help to prevent recurrent cancer due to implantation of viable exfoliated tumour cells.
Preoperative magnetic resonance staging of rectal cancer with an endorectal coil and dynamic gadolinium enhancement
Authors: Drew P J , Farouk R , Turnbull L W , Ward S C , Hartley J E , Monson J R T
Published: March 2003

Background

The aim of the study was to assess the value of endorectal coil magnetic resonance imaging (MRI) with gadolinium enhancement in the preoperative staging of rectal cancer.

Methods

In addition to standard evaluation, patients with rectal lesions were assessed by MRI obtained with a pelvic phased-array coil in combination with an endorectal coil.

Results

The study group comprised 29 patients with rectal cancer staged with an endorectal coil who had surgery without preoperative adjuvant therapy. In addition to standard T1- and T2-weighted images, dynamic contrast-enhanced images were acquired in all patients. Considerable interobserver variation was noted, particularly for pathological tumour stage pT1 or pT2 (κ = 0·36). Compared with pathological findings, endorectal MRI correctly staged nine patients, overstaged 16 and understaged four. Whilst lymph node metastases were accurately detected in 70 per cent of patients, the positive predictive value was only 58 per cent.

Conclusion

MR staging of rectal cancer with an endorectal coil and gadolinium enhancement is inaccurate for early tumours (stage T1 or T2) and is associated with a considerable degree of interobserver variation for individual scan sequences.
Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme
Authors: Kehlet H , Mogensen T
Published: March 2003

Background

Hospital stay after colonic surgery is usually between 5 and 10 days, limiting factors being pain, ileus, organ dysfunction and fatigue. Single-modality intervention to reduce these factors with laparoscopic surgery usually requires a hospital stay of 5 days. This paper reports the results of a multimodal rehabilitation regimen after open sigmoidectomy.

Methods

Sixteen unselected patients scheduled for elective sigmoid resection (median age 71 years) underwent operation under combined spinal–epidural anaesthesia. After operation, epidural analgesia was continued for 48 h, with immediate oral nutrition and mobilization, and with planned discharge 2 days after surgery.

Results

The median postoperative hospital stay was 2 (range 2–6) days (48 h), patients being mobilized for a median of 5 h on the second postoperative day (24–48 h) and for 10 h on the third day (48–72 h). Within 48 h of operation 14 patients had an oral intake of 2000 ml or more and 15 had resumed defaecation. Fatigue and pain scores were low during the first 8–9 days after operation, with a median of 13 h of mobilization per day after discharge. There were no medical or surgical complications during 30 days of follow-up, except for two patients who suffered postspinal headache.

Conclusion

Postoperative recovery after open colonic surgery may be accelerated by effective pain relief integrated into an accelerated rehabilitation programme.
Carotid endarterectomy before and after publication of randomized controlled trials
Authors: Brittenden J , Murie J A , Jenkins A McL , Ruckley C V , Bradbury A W
Published: March 2003

Background

In 1991, the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated that carotid endarterectomy (CEA), in addition to best medical therapy, significantly reduces ipsilateral stroke in patients with high-grade (70 per cent or more) carotid artery stenosis compared with best medical therapy alone. In 1995, the Asymptomatic Carotid Atherosclerosis Study demonstrated that CEA was of benefit in asymptomatic patients with stenosis greater than 60 per cent. The aim of this paper was to examine how the practice and outcome of CEA have changed since publication of these data.

Methods

A prospectively gathered computerized database comprising 634 consecutive CEAs was studied. Two time intervals were analysed: 1975–1991 inclusive (17 years) and 1 January 1992 to 1 May 1998 (6 years 4 months).

Results

Since 1991, there has been a fourfold increase in the number of CEAs performed annually for symptomatic disease. CEA is now performed almost exclusively for high-grade (more than 70 per cent) stenosis. There has been a significant reduction in the total peri-operative neurological event rate (12·5 versus 5·9 per cent, P < 0·05), and the 30-day combined major stroke (Rankin grade 3–5) and mortality rate has fallen to 2·0 per cent. The number of patients who have CEA for asymptomatic disease remains small with 16 of 30 being randomized within the Asymptomatic Carotid Surgery Trial.

Conclusion

Publication of ECST and NASCET data has been associated with a major increase in the number of CEAs performed for symptomatic disease in this unit. Despite a greater proportion of high-risk patients, the results have improved progressively.
Quantitative study of capillary density in the skin of the foot in peripheral vascular disease
Authors: Lamah M , Mortimer P S , Dormandy J A
Published: March 2003

Background

The aim of this study was to investigate possible differences in capillary density of the skin of the foot between normal subjects and patients with peripheral vascular disease.

Methods

Using in vivo video microscopy, a method was developed to measure the average capillary density (ACD) of the skin of the foot and toes. In a cross-sectional observational study, 21 patients with intermittent claudication and 23 patients with rest pain or ischaemic ulceration were compared with 19 age- and sex-matched controls.

Results

Mean(s.e.m). values of ACD of the foot were 33·7(1·9) and 34·4(1·7) per mm2 in the right and left sides respectively for controls, 31·2(1·8) per mm2 (P not significant) and 31·9(2·6) per mm2 (P not significant) in the symptomatic and contralateral sides respectively for patients with claudication, and 22·0(1·8) per mm2 (P < 0·001) and 24·3(1·7) per mm2 (P < 0·001) in the symptomatic and contralateral sides respectively for patients with rest pain or ulceration.

Conclusion

Capillary density of the skin of the foot is significantly reduced in patients with arterial ulceration compared with that in patients with claudication and healthy subjects.