bluuebunny/crossref_metadata_2025 huggingface dataset:
Haemorrhage in pancreatic disease
Authors: Shankar S , Russell R C G
Published: March 2007

Haemorrhage is a life-threatening complication in pancreatic disease. Twenty-five patients with this complication are described; 15 had major bleeding, nine had minor bleeding and one patient had a pseudoaneurysm identified at operation. Of the 15 patients with major bleeding, six presented with this complication and in nine cases it followed pancreatic resection. Of the six patients who presented with major bleeding, five underwent resection with one death while the patient managed conservatively died. The nine patients who had major bleeding after pancreatic resection were managed by ligation of the bleeding artery in six cases with one death, and one patient who rebled after ligation of the bleeding artery was successfully managed by further resection. Three patients with postresection major bleeding were managed conservatively with one death. All minor haemorrhages were managed conservatively without mortality. Deaths after major bleeding were a result of sepsis in three cases and respiratory failure in one. The severity of the underlying pancreatitis was an important factor in two patients. Pseudocysts and pancreatic fistulae were important underlying factors leading to the complication. It is recommended that patients with sepsis, a pancreatic fistula or severe underlying pancreatitis should have their haemorrhage treated by pancreatic resection, while those patients with bleeding following pancreatic resection without such complications can be managed by ligation.
Typhoid perforation
Authors: Gibney E J
Published: March 2007

Typhoid perforation of the bowel carries a high risk of mortality and is a common surgical problem in many developing countries. This review examines the pathogenesis, and discusses diagnosis and management.
Factors influencing local recurrence after excision and radiotherapy for primary breast cancer
Authors: Locker A P , Ellis I O , Morgan D A L , Elston C W , Mitchell A , Blamey R W
Published: March 2007

Between November 1979 and December 1986, 263 patients were treated for primary breast cancer by local excision and radiotherapy at the City Hospital, Nottingham. Local recurrence within the treated breast occurred in 56 patients (21 per cent), in 18 (6·8 per cent) of whom it was gross and uncontrollable. An analysis of clinicopathological features shows patient age, nodal status, tumour size, presence of definitive vascular invasion, adjacent ductal carcinoma in situ and grade to be predictive of local recurrence. A Cox's multivariate analysis of these factors shows the first four to be independently significant. The factors can be combined as a prognostic index which allows identification of patients at high risk of local recurrence. On the basis of these findings we have altered our selection policy for patients suitable for breast conservation.
Non-cyclical mastalgia: An improved classification and treatment
Authors: Maddox P R , Harrison B J , Mansel R E , Hughes L E
Published: March 2007

A prospective study of 72 patients with non-cyclical breast pain was carried out. Non-cyclical breast pain was subdivided into true non-cyclical mastalgia (35 patients) and musculoskeletal pain (37 patients), the latter including Tietze's syndrome and other causes of chest wall pain. Mean age at presentation was significantly greater in the musculoskeletal group (39·3 versus 33·9 years) with a shorter mean duration of pain (14·7 versus 35·4 months) compared with the non-cyclical mastalgia group. True non-cyclical mastalgia was commonly bilateral and located within the upper outer quadrant of the breast, whereas musculoskeletal pain was almost always along the lateral chest wall or costochondral junctions and unilateral in 92 per cent of cases. Breast nodularity was present in 54 per cent of patients with non-cyclical mastalgia, but in only four cases (11 per cent) in the musculoskeletal group. Nine of 14 patients (64 per cent) with non-cyclical mastalgia obtained a good clinical response to drug therapy (over half responding to danazol alone); 19 underwent spontaneous remission, but there was a prolonged mean time to pain resolution of 27 months. In the musculoskeletal group 33 of 34 patients (97 per cent) had a good response to steroid and local anaesthetic injection; three resolved spontaneously without treatment, with a mean time to pain resolution of 17 months. This study indicates that differentiation of musculoskeletal pain from non-cyclical mastalgia may lead to more effective treatment with some prediction of the overall prognosis.
Computer analysis in making preoperative decisions: A rational approach to lymph node dissection in gastric cancer patients
Authors: Kampschöer G H M , Maruyama K , van de Velde C J H , Sasako M , Kinoshita T , Okabayashi K
Published: March 2007

In Japan, R2 lymph node dissection is standard practice for all curatively resected gastric cancer patients. From 1969 to 1984, data were collected prospectively to evaluate this procedure and to provide information for a more rational approach to node dissection for each individual case. A total of 3843 cases was included in this study and an evaluation was made of the prognostic variables and lymph node involvement at various locations. Using a computer program, it is possible to compile a group of treated patients, with prognostic variables exactly matching those of an individual patient. Analysis of this group can then give an indication of the extent of lymph node dissection required for an individual patient. This paper gives a demonstration of the structure of such a system by means of an example.
Total gastrectomy and oesophagojejunostomy with linear stapling devices
Authors: Walther B S , Zilling T , Johnsson F , Staël von Holstein C , Joelsson B
Published: March 2007

When performing total gastrectomy and oesophagojejunostomy with a circular stapling device two disadvantages are obvious; firstly, a purse-string suture is needed, and secondly the instrument can be extremely difficult to introduce if the oesophagus is narrow, so that the risk of rupture is substantial. We therefore developed the following technique. When the specimen is attached only to the oesophagus and the Roux-en-Y loop has already been divided with a linear stapling device, a small incision is made on the back wall of the oesophagus and antimesenterically 6 cm distal to the cut end of the Roux-en-Y loop. The two forks of the GIA® or the PLC 50® instrument are introduced into the oesophagus and jejunum, and the two organs are brought together at the hiatus. The instrument is closed and fired. The residual opening is closed with a linear stapler which also includes the front wall of the oesophagus. With a knife, the oesophagus and excessive amounts of tissue are trimmed away, and the oesophagojejunostomy is completed. Fifteen patients (median age 67 years) had a postoperative hospital stay of 10 days (range 8–45 days) after this operation. Leakage occurred in one patient and one patient died. The anastomosis took 12 min to perform (range 8–20 min). Three reoperations were needed: intestinal obstruction, leakage and a negative exploration. The median width of the oesophagojejunal anastomosis 6 months after operation was 32 mm (range 27–40 mm). Oesophagojejunostomy performed with two linear staplers allows a quick and reliable anastomosis independent of oesophageal lumen size and a time-consuming purse-string suture.
Changing patterns in gastric adenocarcinoma
Authors: Kampschöer G H M , Nakajima T , van de Velde C J H
Published: March 2007

A retrospective study was performed on gastric cancer patients admitted to the Cancer Institute Hospital, Tokyo, during the periods 1961–65 (n = 1181) and 1980–84 (n = 1473). The aim of the study was to see whether changes had occurred in gastric cancer patients over the years with respect to histology and tumour localization and, if so, how they compared with reports from the West. The proportion of proximally localized primary tumour increased from 17 to 27 per cent (P = 0·008), and signet-ring cell carcinoma increased from 2 to 22 per cent (P <0·001). These changes were not relative with regard to the declining incidence of intestinal tumours, but absolute. Patients with proximally localized tumours were generally in a more advanced stage of disease than those with distally localized tumours, and thus had poorer survival rates. However, after stratifying into stages, the difference in survival disappeared. The survival rate of patients with signet-ring cell carcinoma was not significantly different from that of patients with other gastric tumours (P >0·05). The discrepancy between the survival rates of Japanese and western gastric cancer patients is attributed by some authors to tumour-related factors. However, we believe that the similar trends found with regard to tumour localization and histology point towards comparable tumour behaviour in the two different geographical areas.
Emergency subtotal oesophagectomy
Authors: Matthews H R , Mitchell I M , McGuigan J A
Published: March 2007

From 1981 to 1987 nine patients have undergone resection and reconstruction of the oesophagus as an emergency, using a two-part left-sided approach with oesophagogastric anastomosis in the neck. Five patients had oesophageal perforation with a carcinoma; one had spontancous perforation of an intrathoracic stomach: two had severe haemorrhage; and one had acute sterile mediastinitis. Following operation there was one postoperative death (11 per cent) and no major complications. Long-term survival was marred only by the development of further malignancy in four patients. Subtotal oesophagectomy has both theoretical and practical advantages over conventional oesophagogastrectomy in oesophageal emergencies and we suggest that it should be considered as the method of choice in the management of these difficult cases.
Laser angioplasty with a pulsed NdYAG laser: Early clinical experience
Authors: Michaels J A , Cross F W , Shaw P , Raphael M , Bowker T J , Bown S G , Adiseshiah M , Marston A
Published: March 2007

Since December 1986, 40 laser angioplasty procedures have been performed using the energy from a pulsed NdYAG laser, delivering near infrared light (1064 nm) in 100-μs pulses of approximately 300 mJ per pulse, directly through a transparent sapphire tipped device. All patients had total occlusion of the superficial femoral artery and symptoms severe enough to warrant surgery, with ulceration or gangrene in eight, rest pain in 14 and severe claudication interfering with life-style in the others. The device was introduced through an antegrade puncture of the superficial or common femoral artery and laser recanalization was followed by attempted balloon angioplasty in all cases. Occlusions were a median length of 15 cm (range 2–35 cm); ten patients had previously undergone failed attempts at conventional balloon angioplasty and four had occluded femoropopliteal grafts. Thirty-seven legs of 34 patients were treated with an average of 60 J (range 10–235 J) with successful recanalization in 27 and immediate reocclusion in seven. The 20 successful recanalizations have been followed up for up to 24 months (median 7 months) with only one late occlusion at 5 months. Failed recanalization was due to poor transmission by the delivery device in the early part of the series (five cases), repeated passage of the device down a collateral branch (four cases), dissection at the site of previous surgery (two cases) or no apparent reason (two cases). Immediate reocclusion was due to very poor run off in patients with severely ischaemic limbs (three cases) or technical difficulties with balloon dilatation (two cases). Complete symptomatic relief was obtained in all the cases of radiologically successful laser angioplasty. Early surgery was required in one case following reocclusion of the artery when an angioplasty balloon failed to deflate, and one patient suffered a skin reaction thought to be due to inadequate removal of the sterilizing solution. A different sterilizing procedure is now followed. Laser angioplasty can reduce the number of patients requiring bypass surgery and improvements in the device and access methods may reduce the number of untreatable cases.
Operative assessment of femorodistal bypass grafts using a new Doppler flowmeter
Authors: Beard J D , Scott D J A , Skidmore R , Baird R N , Horrocks M
Published: March 2007

Operative measurements using a newly developed Doppler flowmeter were made on 47 in situ femorodistal bypass grafts performed for critical ischaemia. Graft blood flow, peripheral resistance and impedance were measured before and after the injection of 15 mg papaverine down the graft. The proportion of retrograde blood flow at the distal anastomosis was also measured. The success of a graft at 1 month was defined by patency on duplex ultrasound scanning, a rise in the Doppler ankle pressures and an improvement in the clinical state of the limb. By these criteria the 1-month primary success rate was 35 out of 47 (74 per cent). Graft blood flow was of little value in predicting graft outcome but, combined with segmental pressures, accurately located six of eight technical problems which were successfully corrected. After papaverine, the peripheral resistance of all the successful grafts fell below one peripheral resistance unit (PRU). No single measurement was able to completely distinguish between success and failure, although discriminant analysis of all measurements was able to predict success with a sensitivity of 100 per cent and specificity of 97 per cent. A simpler combination of a peripheral resistance after papaverine <1 PRU and a retrograde blood flow <33 per cent predicted success, with a sensitivity of 97 per cent and specificity 83 per cent. These criteria have been validated on a further 26 grafts, achieving a sensitivity of 88 per cent and a specificity of 75 per cent. Simple operative measurements, using a newly developed Doppler flowmeter, enable the detection of technical problems and the accurate prediction of the early outcome of femorodistal grafting.
Evaluation of non-invasive and invasive methods in the assessment of short saphenous vein termination
Authors: Vasdekis S N , Clarke G H , Hobbs J T , Nicolaides A N
Published: March 2007

Surgery of the short saphenous vein is associated with a high recurrence rate because of variations in the anatomy or inadequate clinical examination. To prevent this, accurate definition of the pattern and level of termination of the saphenopopliteal junction and flush ligation is necessary. Clinical examination, Doppler ultrasound, duplex scanning and peroperative venography have been compared to assess the level of termination of the short saphenous vein. In all, 64 limbs of 46 patients were examined. In 39 limbs there was primary short saphenous incompetence, in 13 limbs there was recurrent short saphenous incompetence; in ten of these there was incompetence of the gastrocnemius vein. In 12 limbs a duplex scan did not demonstrate incompetence of the short saphenous vein or gastrocnemius vein. The accuracy of these methods when locating incompetence of the short saphenous vein to within 2 cm of the saphenopopliteal junction was 56 per cent for clinical examination, 64 per cent for Doppler ultrasound and 96 per cent for duplex scanning. When there was no saphenopopliteal junction (9 per cent). duplex scanning correctly detected the pattern of the incompetent vein. The apparent success of clinical examination was because the vein was not felt above the femoral intercondylar groove and 52 per cent of the veins terminated at this level. Duplex scanning is a non-invasive technique which is almost as accurate as venography and provides additional haemodynamic information about the incompetent veins by demonstrating the presence and extent of reflux.
Role for prazosin in reducing the development of rabbit intimal hyperplasia after endothelial denudation
Authors: O'Malley M K , McDermott E W M , Mehigan D , O'Higgins N J
Published: March 2007

Intimal hyperplasia is the universal response to endothelial denudation and occurs after a variety of vascular procedures. In a proportion of cases the smooth muscle cell proliferation may lead to stenosis of the blood vessels. These vessels exhibit increased sensitivity to noradrenaline that can be reduced by the α1-adrenergic antagonist prazosin. Because the α1-adrenergic receptor and platelet-derived growth factor (which promotes vascular smooth muscle cell proliferation) act through the same metabolic pathway, it was postulated that α1-adrenergic blockade might reduce the development of intimal hyperplasia. Twenty-eight New Zealand White rabbits underwent endothelial denudation of the aorta using a Fogarty balloon catheter. Test rabbits were treated with prazosin from the day of operation until they were killed. All rabbits were killed either 1 or 4 weeks after endothelial denudation. Intimal hyperplasia in cross-sections of the aorta was measured using an X — Y digitizer and was standardized in terms of percentage luminal reduction. Prazosintreated rabbits had significantly less luminal reduction at 1 week (0·75(1·8) versus 9·7(3·1) per cent, mean (s.d.), P <0·001) and at 4 weeks (14·7(4·4) versus 25·3(12·8) per cent, P <0·05) than control rabbits. It is concluded that prazosin caused a major reduction in the development of intimal hyperplasia.
Totally stapled abdominal restorative proctocolectomy
Authors: Kmiot W A , Keighley M R B
Published: March 2007

A technique of totally stapled abdominal restorative proctocolectomy is reported in 20 consecutive patients using a 20 × 20 cm J pouch and a stapled ileoanal anastomosis. The stapled ileoanal anastomosis had to be abandoned in three patients because of attempted mucosectomy in one and megarectum in two. One patient receiving steroids had a covering ileostomy. The remaining 16 patients had a totally stapled procedure without a covering ileostomy. Three patients developed serious postoperative morbidity but they were the only patients receiving steroids at the time of the operation. Of the remaining 13 patients none developed serious complications, the median hospital stay was 14 days and the median operating time was 150 min. The operation may be a technical advance particularly in allowing pouch construction without ileostomy in fit patients who are not receiving steroids at the time of operation.
Obstructing carcinomas of the colon
Authors: Serpell J W , McDermott F T , Katrivessis H , Hughes E S R
Published: March 2007

A series of 908 cases of colonic carcinoma has been analysed to elucidate reasons for the poor prognosis in obstructing colonic cancer. Complete obstruction was present in 148 cases (16·3 per cent), 280 cases (30·8 per cent) had partial obstruction and 480 (52·8 per cent) presented without obstruction. There were fewer Dukes' A tumours in those with complete obstruction (P <0·005) and greater numbers of advanced tumours (P <0·0005) compared with those without obstruction. This is reflected in a lower curative resection rate of 50·7 per cent in those with obstruction compared with 70·6 per cent in those without obstruction (P <0·001). However, after curative resection there was no significant difference in the distribution of tumour stage. Patients with complete obstruction showed a higher incidence of recurrence (P <0·01) after curative resection, consequent to an increased incidence of local recurrence (P <0·02). Five-year cancer-specific survival for the total series was decreased from 59·1 per cent in patients without obstruction to 31·8 per cent in those with complete obstruction (P <0·001). After curative resection there was also a significant reduction in survival (P <0·001). It is concluded that completely obstructing colonic cancers are more aggressive than other colonic cancers.
Anal canal mucosa in restorative proctocolectomy for ulcerative colitis
Authors: King D W , Lubowski D Z , Cook T A
Published: March 2007

In an attempt to improve continence after restorative proctocolectomy, ileal reservoir-anal anastomosis at the level of the anorectal junction has been advocated. This procedure preserves the entire mucosa of the anal canal. The histological appearances of the anal mucosa have been examined in 16 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis. In 14 patients there was chronic inflammation characteristic of ulcerative colitis. Four patients had moderate dysplasia and in one of these patients an unsuspected adenocarcinoma of the anal canal extending down to the level of the dentate line was present. We believe that the anal mucosa should always be removed down to the level of the dentate line in restorative proctocolectomy for ulcerative colitis.
Role of dietary restriction in Haemoccult® screening for colorectal cancer
Authors: Thomas W M , Pye G , Hardcastle J D , Chamberlain J , Charnley R M
Published: March 2007

The aim of this study was to investigate the effect of dietary restrictions on the positivity rate and yield of neoplasia during a study based on Haemoccult® screening for colorectal neoplasia. Of 18925 participants who completed Haemoccult tests on a normal diet, 647 (3·4 per cent) were positive. All repeated the test with dietary restrictions: 251 remained positive and underwent further investigations which revealed 35 carcinomas and 169 adenomas in 129 subjects. The remaining 396 were sent a further Haemoccult test at 3 months. Of these, 317 (80·1 per cent) completed the test: 31 (9·8 per cent) were positive. Further investigation of the 31 positive subjects revealed four carcinomas and 20 adenomas. Retesting with dietary restriction will reduce the false positive rate of Haemoccult when used for colonic cancer screening. However, if the retest is negative a further test should be performed. To minimize the adverse effect this may have on compliance, we have allowed an interval of 3 months to elapse before this retest is requested.
Acute primary hyperparathyroidism: Experience of 59 cases
Authors: Sarfati E , Desportes L , Gossot D , Dubost C
Published: March 2007

Acute primary hyperparathyroidism is a rare disease with a high mortality rate in some series. Between 1960 and 1986, 1000 patients were treated for primary hyperparathyroidism, among them 59 patients with acute hyperparathyroidism. All these patients were successfully operated on; none of them died before surgery. This study reveals the importance of resuscitation and urgent surgery. It is necessary to rehydrate, to correct electrolyte disorders and to lower serum calcium levels, but it is not necessary to obtain normal serum calcium levels before surgery.
Reducing renal injury during transplantation
Authors: Forsythe J L R , Dunnigan P M , Proud G , Lennard T W J , Taylor R M R
Published: March 2007

Damage sustained by an ischaemic kidney is reduced by cooling the organ. For this reason kidneys are rapidly cooled during the retrieval operation and preserved at low temperature before implantation. When the kidney is removed from cold storage for implantation into the recipient it gradually rewarms (second warm ischaemic time) and a prolonged second warm ischaemic time has been shown to be a cause of acute tubular necrosis following transplantation. The temperature rise in a kidney during implantation has been poorly investigated and little work to minimize that rise has been carried out. This study investigates, in an animal model, the changes that occur in the core temperature of kidneys during the second warm ischaemic time. A jacket has been designed which greatly reduces the rate of kidney rewarming during simulated operative conditions. Kidneys unprotected by the test system showed a rapid rise in temperature from a mean of 1°C to a mean of 20° C after 45 min, compared with those kidneys placed in the protective jacket in which the temperature rose to a mean of only 8° C in the same time. The jacket is not bulky and is simple to use. Maintaining a low kidney core temperature during the second warm ischaemic time will reduce injury to the kidney and should be part of routine clinical practice.
Skin cancer in renal transplant recipients
Authors: Liddington M , Richardson A J , Higgins R M , Endre Z H , Venning V A , Murie J A , Morris P J
Published: March 2007

Skin cancer was found in 31 of 598 patients transplanted in Oxford. No cases occurred during the first 3 years after transplantation but the prevalence rose after 12 years to 18.2 per cent. The main risk factors predisposing to skin cancer were the time after transplantation and male sex. Comparison with data from other centres suggests that exposure to ultraviolet light is a major aetiological factor in the speed of development of skin cancer. As the incidence of new cases rose progressively with time in our patients, it would seem that skin cancer is likely to become a major clinical problem as more patients enjoy prolonged survival after renal transplantation. Preventative and screening measures should be taken by transplant units both in the UK and in other countries with similar temperate climates.
Clinical decision making and laparoscopy versus computer prediction in the management of the acute abdomen
Authors: Paterson-Brown S , Vipond M N , Simms K , Gatzen C , Thompson J N , Dudley H A F
Published: March 2007

A prospective study has been undertaken of 321 patients with acute abdominal pain admitted to hospital under one surgical firm over a period of 21 months. During the first 10 months patients were classified on admission according to the perceived need for operation, with laparoscopy being performed on all those in whom the need for operation was uncertain. In addition, all women with suspected appendicitis underwent laparoscopy because previous studies by us and others have demonstrated a high error rate in this group. During the second 11 months of the study a similar system of classification and procedure was used but the patient's initial assessment was entered on a structured data sheet. After the patient had been discharged home this information was entered into a computer-aided diagnosis program. Hypothetical retrospective computer-aided decisions were then made about patient management. The final management error rate (correct decision to operate or not) was compared with the actual error rate using the clinical system. The final overall error rate in the first 10 months was 11 out of 163 patients and this was improved to 3 out of 158 in the second 11 months of the study by the addition of the structured data sheet to selective laparoscopy. A management policy based entirely on diagnostic probabilities taken from the computer-aided diagnosis program would have produced an error rate of 26 out of 158. We conclude that in the management of the acute abdomen a policy based on clinical decision combined with selective laparoscopy may be superior to one based on diagnostic probabilities alone. Further improvement in results follows the introduction of a structured data sheet for initial data collection.
Cryotherapy for liver metastases: A new approach
Authors: Charnley R M , Doran J , Morris D L
Published: March 2007

A new system designed for cryosurgery of liver metastases is described. The cryoprobe, which utilizes circulating liquid nitrogen and produces a spherical iceball around each metastasis, is controlled by operative ultrasound. There was nor mortality and all patients left hospital within 10 days. Cryotherapy produced an area of destruction within the liver substance which decreased in size by 6 weeks as shown on serial computed tomographic scanning.
Podophyllin versus scissor excision in the treatment of perianal condylomata acuminata: A prospective study
Authors: Khawaja H T
Published: March 2007

Thirty-seven patients with previously untreated perianal condylomata acuminata were randomly treated by application of 25 per cent podophyllin or scissor excision. The result of treatment was assessed by an independent observer. At 6 weeks, scissor excision completely cleared the warts from 16 of 18 patients (89 per cent) compared with 15 of 19 patients (79 per cent) treated with podophyllin. Following complete clearance by surgery, two patients had recurrent warts at 18 weeks and a further single patient at 42 weeks, giving a cumulative recurrence rate of 19 per cent. In contrast, five of 15 patients whose warts were cleared by podophyllin had recurrent warts at 18 weeks and a further four at 42 weeks representing a cumulative recurrence rate of 60 per cent (χ2 = 3.95, d.f. = 1, P = 0.05). At 42 weeks six patients (32 per cent) were free of disease in the podophyllin group compared with 13 (72 per cent) in the scissor excision group (χ2 = 4.6, d.f.=1, P = 0.03). Scissor excision is therefore preferable to podophyllin application in the treatment of perianal condylomata acuminata.
Lipids in breast carcinogenesis
Authors: Pritchard G A , Jones D L , Mansel R E
Published: March 2007

Excess dietary fat has been identified as a risk factor in the development of human breast carcinoma. However, the quality of fat may be more important than the overall quantity. We have studied the growth of human MCF7 breast carcinoma xenografts in athymic mice treated with dietary supplements of N-6 and N-3 series essential fatty acids given as natural preparations of evening primrose oil and fish oil. Olive oil and normal laboratory diet lacking the essential fatty acids served as controls. Animals treated with essential fatty acids developed tumours which were significantly smaller than both control groups (Mann-Whitney U test, P<0.001). Median tumour weights according to diet were: evening primrose oil, 133 mg; fish oil, 70 mg; olive oil, 212 mg; and control, 270 mg. Nutritional intervention to increase the proportion of essential fatty acids in the diet may have a role in the management of breast carcinoma.
Postsplenectomy sepsis
Authors: Shaw J H F , Print C G
Published: March 2007

This review examines the infectious consequences of elective and emergency splenectomy, highlighting the importance of infection with Streptococcus pneumoniae. The influence of splenectomy on the immune system is discussed and the efficacy of vaccines in preventing postsplenectomy sepsis is reviewed. The value of alternative methods of preventing postsplenectomy sepsis is considered.
Acute pancreatitis and pancreatic fistula formation
Authors: Fielding G A , McLatchie G R , Wilson C , Imrie C W , Carter D C
Published: March 2007

The cause, management and outcome of 23 patients with a pancreatic fistula following acute pancreatitis are reviewed. Nineteen patients developed an external fistula following necrosectomy or drainage of a pancreatic abscess or pseudocyst; four of these patients died. In the 15 survivors spontaneous closure occurred in 11 cases with low output fistulae; operative intervention was needed in the four cases with high output fistulae. Four patients with internal fistulae had not undergone previous surgery; two of them had a pancreaticopleural fistula with associated pancreaticogastric fistulae, while two had pancreatic ascites. All four of these patients required surgical intervention and one died.
Surgical audit of patients undergoing common bile duct exploration for stone
Authors: McEntee G P , Mulvin D M , Peel A L G
Published: March 2007

One hundred and sixty-four patients operated on for calculus disease of the common bile duct during the period 1977–85 were followed in a special clinic; the attendance for follow-up at 1, 3, 5 and 7 years was 90, 74, 60 and 54 per cent respectively. Eleven patients died during the study period (6·7 per cent), none of the deaths being attributable to biliary tract disease. The overall incidence of retained calculus was 2·4 per cent (four patients), but no cases of retained calculi were recorded in the last 4 years of the study; in this period, with the advent of choledochoscopy and fluoroscopic cholangiography, the incidence of the supraduodenal compared with the transduodenal approach to the common bile duct increased significantly (P<0·001). Twenty-two of 56 patients (39 per cent) followed up for 5 years remained or became symptomatic after surgery, the majority of whom had underlying conditions unrelated to disease of the biliary or pancreatic tree. This specific follow-up clinic has been of value in the long-term audit of patients undergoing bile duct surgery for choledocholithiasis and it has verified that a change of policy from transduodenal to supraduodenal choledochotomy with preservation of the sphincter, and use of the choledochoscope and fluorocholangiography, produce better results.
Effects of a somatostatin analogue (SMS 201-995) on the growth and development of hepatic tumour derived by intraportal injection of Walker cells in the rat
Authors: Nott D M , Baxter J N , Yates J , Grime J S , Day D W , Cooke T G , Jenkins S A
Published: March 2007

Administration of a long acting analogue of somatostatin, SMS 201-995 (2 μg subcutaneously twice a day) for 3 weeks after intraportal administration of Walker cells significantly inhibited their growth and development in the liver. This was not due to a direct cytotoxic effect of the analogue on Walker cells whose growth was stimulated in vitro. Furthermore, SMS 201-995 had no effect on the growth of Walker cells implanted into the thigh of rats suggesting that the inhibitory action of the analogue could be confined to tumour cells growing in the liver. Further studies suggested that the inhibitory effect of SMS 201-995 on the growth of Walker cells in the liver could be related to a marked stimulation of the hepatic reticuloendothelial system, by a reduction in portal venous flow in the early stages of treatment or by a combination of these effects. Further studies are required to delineate more precisely the mechanism whereby SMS 201-995 inhibits the growth of hepatic tumour derived from intraportal administration of Walker cells.
Prognostic value of nucleolar organizer regions and ploidy values in advanced colorectal cancer
Authors: Moran K , Cooke T , Forster G , Gillen P , Sheehan S , Dervan P , Fitzpatrick J M
Published: March 2007

The prognostic value of nucleolar organizer regions and ploidy status in patients with Dukes' C colorectal cancer was determined. In addition, nucleolar organizer regions and ploidy status were compared with the established prognostic indices age, sex, tumour location and degree of histological differentiation. Fifty-one patients (27 men, 24 women) aged 35–81 years (median 64·8 years) were studied. Five years after presentation, 16 patients were alive and well. Survivors had significantly lower nucleolar organizer region counts (median value and range) in primary tumours 12 (8–15) and lymph node metastases 11 (8–15) than non-survivors 17 (14–25) and 18 (13–25) respectively (P<0·05). Fewer survivors had aneuploid tumours than non-survivors: four survivors compared with 17 non-survivors. In a regression analysis model, nucleolar organizer regions were the most important individual variable for predicting survival (χ2 = 15, P0·01) while ploidy values (χ2 = 6, P0·2) were equivalent to histological differentiation.
Long term results of anorectal myectomy for chronic constipation
Authors: Pinho M , Yoshioka K , Keighley M R B
Published: March 2007

Early evaluation of anorectal myectomy in this unit suggested that it might provide clinical benefit to patients with outlet obstruction. Long term results of anorectal myectomy are now available in 63 patients operated on between February 1984 and February 1988 with a median follow-up of 30 months. Spontaneous rectal evacuation without the need for laxatives was recorded in only 11 patients (17 per cent), while 44 (70 per cent) achieved no functional improvement. Mild incontinence developed in 6 patients (10 per cent). Results were independent of preoperative colonic transit or histological evidence of aganglionosis.
Prognosis after surgery for colonic Crohn's disease
Authors: Andrews H A , Lewis P , Allan R N
Published: March 2007

The long-term prognosis including operation rates, the incidences of recurrent disease, morbidity and mortality and current status has been analysed in a group of 360 patients with Crohn's colitis grouped according to the primary site of macroscopic disease at diagnosis. The group has been followed from diagnosis for a mean period of 14·9 years. The overall operation rate was 76 per cent. Prolonged spontaneous or drug induced remission occurred at all sites: right-sided disease (11 per cent), extensive colonic disease (21 per cent) and left-sided disease (38 per cent). The cumulative reoperation rates at 5 and 10 years after right hemicolectomy were 26 and 46 per cent, after colectomy and ileorectal anastomosis 46 and 60 per cent, and after panproctocolectomy 10 and 21 per cent, respectively. There was a twofold excess mortality rate from related Crohn's disease deaths during the period of review, but the mortality rate has fallen with time. There have only been 11 related deaths in the last decade, of which eight were probably unavoidable. The current status of most patients is good, although treatment has included a permanent stoma in less than half (41 per cent) the patients still under review. Currently all but 14 patients are well and symptom-free and only 16 are receiving specific medical treatment. Until the aetiology of Crohn's colitis is understood, if medical treatment has failed to resolve symptoms, appropriate surgical treatment in experienced hands is an effective way of restoring patients with chronic persistent symptoms to good health.
Functional closure of the femoral canal revealed by computed tomographic scanning
Authors: Hahn-Pedersen J , Bojsen-Møller F , Rosenklint A
Published: March 2007

The lacuna vasorum contains, as well as the external iliac vessels, a space called the femoral canal which allows pulsation and other changes in the diameter of the two vessels. The canal is closed by a connective tissue septum which is too weak to prevent a herniation alongside the vessels. The functional closure of the canal was investigated by artificial augmentation of the intraluminal pressure of the vein in five specimens and by computed tomographic (CT) scanning during a Valsalva manoeuvre in ten normal persons. In the abdomen the intraluminal and extraluminal pressures are raised in parallel, with no consequence for the diameter of the vessels. In the area of the lacuna vasorum the intravenous pressure is conveyed down to the first competent valve which is located 0·5 cm distal to the inguinal ligament, while the extraluminal pressure is reduced to normal. At each rise of the intra-abdominal pressure the vein will therefore bulge and exactly fill the empty space of the femoral canal thus preventing herniations by an on-demand mechanism. By CT scanning it was found that the vein in the femoral canal increased its diameter 2·5–3·0 times during the Valsalva manoeuvre.
The role of contrast radiography in presumed bowel obstruction
Authors: Riveron Fernando A , Obeid Farouck N , Horst H Mathilda , Sorensen Victor J , Bivins Brack A
Published: March 2007

A retrospective review of 229 patients with a final diagnosis of small-bowel obstruction was undertaken to evaluate the role of contrast radiography in the management of their conditions. In 84 patients (37%) the clinical findings and plain abdominal roentgenograms were sufficient for diagnosis and subsequent management. Of the remaining 145 patients with equivocal findings, 27% had an upper gastrointestinal series, 29% a barium enema, and 44% had both. Useful information (complete obstruction, unobstructed passage of contrast, or diagnosis other than adhesional obstruction) was obtained from 86% of the radiographic studies. Three patients had negative contrast studies yet eventually underwent adhesiolysis (enterolysis) and were classified as false-negative. Two patients had evidence of high-grade obstruction yet had nonoperative resolution and were classified as false-positive. The mortality in the contrast group (7%) was not statistically different than that in the no-contrast group (7%). Contrast radiography is a safe and effective means of increasing diagnostic accuracy in patients with presumed small-bowel obstruction. (SURGERY 1989; 106: 496-501.).

From The Division of Trauma and Critical Care Surgery, Henry Ford Hospital, Detroit, Mich.
Local low dose intra-arterial thrombolytic therapy: The risk of stroke or major haemorrhage
Authors: Berridge D C , Makin G S , Hopkinson B R
Published: March 2007

The use of local low dose thrombolysis is gradually increasing. Most experience is with streptokinase, although newer agents such as recombinant tissue plasminogen activator (rTPA) may offer more effective lysis with reduced complications. We have reviewed the experience documented in 19 prospective series published between 1974 and 1988 in an attempt to define the incidence of stroke, major haemorrhage and minor haemorrhage. The overall risk of stroke was 1·0 per cent. of patients (14 cases). Major haemorrhage occurred in 5·1 per cent of patients (71 cases) and minor haemorrhage occurred in 14·8 per cent (92 out of 620 cases). There was little difference between the two thrombolytic agents, although the experience with lower doses of rTPA suggests it may offer a reduced risk of haemorrhagic complications. It is essential that all studies concerning thrombolysis should give their exclusion and inclusion criteria in full to allow an accurate appraisal of haemorrhagic complications, with the hope of improved patient selection and reduced morbidity in the future.
Intravenous digital subtraction angiography for extracranial carotid artery disease
Authors: Turner W H , Murie J A
Published: March 2007

Intravenous digital subtraction angiography is relatively hazardous and inaccurate. It appears from the literature to have little place in either the screening of patients with putative carotid artery disease or in the assessment of those about to undergo carotid endarterectomy.
Long term outcome after resection of the first rib for thoracic outlet syndrome
Authors: Lepäntalo M , Lindgren K-A , Leino E , Lindfors O , von Smitten K , Nuutinen E , Tötterman S
Published: March 2007

A total of 112 first ribs in 103 patients were resected over 11 years for thoracic outlet syndrome. Seventy-seven patients (84 operations) were followed up for 2·5 years or more to assess the long term results of this procedure and the factors affecting them. One month after surgery 52 per cent of limbs were asymptomatic and 77 per cent were at least improved. A follow-up examination was performed, on average 6·1 years after the operation, by two independent examiners. This evaluation showed a permanent success rate of 37 per cent among 84 limbs examined. These long term results compare unfavourably with previously published data. The reason for the poor final outcome seemed to be difficulty in selecting patients for the operation. This was not aided by any of the preoperative tests. Patients in this study were evaluated by independent examiners, and only a total absence of preceding symptoms was accepted as the criterion for success. We emphasize the importance of unbiased evaluation and long term follow-up.
Attachment of indium-111 labelled endothelial cells to pretreated polytetrafluoroethylene vascular grafts
Authors: Budd J S , Bell P R L , James R F L
Published: March 2007

This study investigated the effect of different surface coatings on endothelial cell attachment to polytetrafluoroethylene (PTFE) vascular grafts. Small segments of PTFE vascular grafts were precoated with one of a number of substances: gelatin, poly-l-lysin, fibronectin, or collagen type I, III or IV. Indium-III labelled endothelial cells were then seeded on to the grafts and left for either 10, 30, 60 or 120 min. The unattached cells were removed and the degree of cell attachment was calculated. All coatings were significantly better at enhancing endothelial cell attachment at all times compared with controls, and fibronectin was significantly better as a coating material than any other material used. By pretreating with a substance such as fibronectin, the number of endothelial cells attaching to PTFE vascular grafts can be greatly increased, thereby enhancing the cell seeding process.
Comparison of intracavitary bleomycin and talc for control of pleural effusions secondary to carcinoma of the breast
Authors: Hamed H , Fentiman I S , Chaudary M A , Rubens R D
Published: March 2007

In a prospective randomized study, patients with pleural effusions secondary to breast carcinoma were randomly allocated to be treated by pleurodesis using either intracavitary talc or bleomycin. For 25 assessable treatments in 22 patients, recurrence of effusion was observed in 5 of 15 (33 per cent) of the bleomycin group compared with none in the talc group. It is concluded that talc is superior to bleomycin in controlling pleural effusions secondary to breast carcinoma, but bleomycin may have a role in patients unfit for general anaesthesia or with extensive disease elsewhere.
Management of high grade parotid carcinomas
Authors: Wyatt M G , Coleman N , Eveson J W , Webb A J
Published: March 2007

Thirty-four patients admitted to the Bristol Royal Infirmary during the 20-year period 1966–85 and diagnosed as suffering from high grade parotid carcinoma were studied. The male:female ratio was 2·4:1, with a mean age at presentation of 68 years. Facial swelling was present in all patients with a mean duration of 9·9 months before treatment. Pain, deep fixation, facial nerve involvement, ulceration and distal metastases were all associated with a poor prognosis. Diagnosis was made either at operation or by fine needle biopsy. All 34 patients received radiotherapy. Fourteen patients (41 per cent) underwent a definitive surgical procedure. The local recurrence rates for the non-surgical and surgically treated groups were 30 per cent (six patients) and 36 per cent (five patients) respectively; twelve patients (60 per cent) in the non-surgical group developed distant metastases as opposed to six patients (43 per cent) in the surgical group. Both local and distant recurrent, disease are indicators of poor prognosis, with only one patient alive at 104 months. Seven patients (21 per cent) remain recurrence free. Definitive surgery, combined with radiotherapy, improved survival in those with amenable localized disease.
Long acting somatostatin analogue in dumping syndrome
Authors: Tulassay Z , Tulassay T , Gupta R , Cierny G
Published: March 2007

The effect of long acting somatostatin analogue, SMS 201-995, on postprandial dumping syndrome was studied in eight patients with Billroth II gastric resection. Each patient was subjected to two oral glucose challenges with 75 g glucose. One challenge was premedicated with 50 μg SMS 201–995 subcutaneously 15 min before the oral intake of glucose, the other with placebo. With placebo all patients experienced the subjective symptoms of the early dumping syndrome with significant (P<0·001) increases (mean (s.d.)) in pulse rate (from 66 (8) to 102 (10) beats/min), in packed cell volume (from 0·36 (0·05) to 0·43 (0·1) l/l) and in the plasma levels of vasoactive intestinal polypeptide (from 3·0 (0·5) to 10·2 (1·8) pmol/l). During the somatostatin study the subjective symptoms and the changes in the various parameters were not detected. In the control study seven patients showed postprandial hypoglycemia. In these patients significant elevations (P<0·001) in the insulin level (from 10 (0·9) to 40 (9·1) μE/ml) and gastric inhibitory peptide (GIP) concentration (from 100 (13) to 220 (41) ng/l) were seen, compared with the initial values. During the application of SMS 201-995 hypoglycaemia did not develop and plasma insulin and GIP concentrations remained unchanged. These results indicate that the long acting somatostatin analogue alleviates the symptoms of early and late postprandial dumping syndromes.
Hepatic resection for colorectal secondaries
Authors: Karanjia N D , Rees M , Schache D , Heald R J
Published: March 2007

A postal survey of consultant surgeons in England and Wales was carried out to assess current attitudes towards screening for and treatment of hepatic metastases from primary colorectal carcinoma. The results showed that pre-, intra- and postoperative screening were inadequate. There was no consensus as to which patients would benefit from major hepatic resection for colorectal liver secondaries. Fewer than one-third of potentially operable patients underwent liver surgery.