bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of the method of biopsy on the prognosis of and reliability of receptor assays in patients with operable breast cancer
Authors: Fentiman I S , Millis R R , Chaudary M A , King R J B , Miller K J , Hayward J L
Published: March 2007

A comparison has been made of the survival of contemporary patients treated by mastectomy in whom the original diagnosis was made by either Tru-cut biopsy or by excision biopsy. After a minimum of 5 years of follow-up there was no difference in survival between those biopsied by either method. When subdivided by tumour size again no differences emerged. Among those patients in whom the original Tru-cut biopsy was false negative there was no difference in survival compared with those treated by excision biopsy. This suggests that Tru-cut biopsy is a safe method for obtaining a histological diagnosis in operable breast cancer. Furthermore, when the receptor status of the tumours from the two groups was determined, there was no difference in the percentage of oestrogen receptor positive tumours, nor in the mean receptor value. However, there were more progesterone receptor positive tumours among the Tru-cut group, suggesting that a better tumour sample could have been submitted for analysis. This may be yet another advantage for the use of Tru-cut biopsy for the diagnosis of breast cancer.
Breast scintigraphy with 99mTc-diethylene triamine penta-acetic acid for the detection of malignant disease
Authors: den Outer A J , Pauwels E K J , Zwaveling A , Puylaert J B , Hermans J , de Lange E E
Published: March 2007

A single-blind prospective study of 99mTc-diethylene triamine penta-acetic acid (DTPA) breast scintigraphy was performed on 160 women who presented at the outpatient clinic with suspected breast tumour. The sensitivity of scintigraphy in establishing the diagnosis of breast cancer was 75 per cent. The specificity of scintigraphy in excluding the presence of breast cancer was 91 per cent. The diagnostic value of DTPA breast scintigraphy is at present too low in comparison with mammography to be clinically useful.
Effect of surgical experience on the results of resection for oesophageal carcinoma
Authors: Matthews H R , Powell D J , McConkey C C
Published: March 2007

From 1957 to 1976 oesophageal resection for carcinoma was performed in 1119 patients reported to the West Midlands Cancer Registry. The operations were performed on 581 patients by 127 surgeons who averaged three or less resections per annum the ‘occasional' group’. These were compared with 538 patients (the ‘frequent’ group) whose resections were performed by four surgeons who averaged six or more resections per annum. Operative mortality was 39·4 per cent in the ‘occasional’ group and 21·6 per cent in the ‘frequent’ group (P < 0·001). The age adjusted 5-year survival was 11·1 and 15·2 per cent respectively (P < 0·05) but when the operative deaths were excluded there was no significant difference. We suggest that oesophageal resection for carcinoma should be performed only where there is an acceptably low operative mortality rate.
Adenolymphoma of the parotid: Aetiology, diagnosis and treatment
Authors: Ebbs S R , Webb A J
Published: March 2007

In order to study the changing clinical pattern, diagnosis and surgical treatment of adenolymphoma, the records of all 57 patients with a confirmed histological diagnosis, made at Bristol Royal Infirmary between 1951 and 1984, were reviewed; in 3 patients (5 per cent) bilateral lesions had been found. No characteristics emerged in a review of the history and clinical examination which would have enabled a correct pre-operative diagnosis to be made. During the period of study the incidence of adenolymphoma increased 24-fold. (Parotid pleomorphic salivary adenomas increased in incidence by only 42 per cent over the same period). Before 1965 all patients were men; between 1965 and 1975 the male to female ratio was 3:1; between 1975 and 1985, 1·6:1. Of the 48 patients who had a relevant history taken 45 were smokers (93·8 per cent). It is postulated that tobacco consumption is important in the development of adenolymphoma, and has produced the changes in incidence and sex ratio. Fine needle aspiration biopsy cytology (FNAB) afforded the only method of achieving a pre-operative diagnosis. This was successful in 64·7 per cent. Superficial parotidectomy induced a 43 per cent incidence of facial nerve neurapraxia. Controlled enucleation reduced this to 8 per cent. Enucleation is the procedure of choice for adenolymphoma but can only be employed with confidence if an exact pre-operative diagnosis is made.
Failure to improve survival by improved diagnostic techniques in patients with malignant jaundice
Authors: Gillen P , Peel A L G
Published: March 2007

In a consecutive series of 118 patients with malignant obstructive jaundice at North Tees General Hospital only 70 patients were adjudged fit to undergo surgery. Tumour resection was possible in only four patients. Palliative bypass was performed in 45 patients while 21 patients had no procedure other than an exploratory laparotomy. In contrast to the accuracy of investigation the results of surgery have been poor with considerable mortality (42·8 per cent) and lack of long-term survivors. The results emphasize the role of non-surgical methods for relieving jaundice of malignant aetiology, especially in frail elderly patients and those who have metastases at the time of presentation.
Bile peritonitis after removal of T-tubes from the common bile duct
Authors: Corbett C R R , Fyfe N C M , Nicholls R J , Jackson B T
Published: March 2007

Bile peritonitis can occur when a T-tube is electively removed from the common bile duct, but this is regarded as a rare complication. Plastic T-tubes are known to increase the risk and should not be used. Latex rubber T-tubes are preferred but the complication can still occur. We present three patients with this complication despite the use of a latex T-tube. A questionnaire was sent to 107 surgeons in the South East Thames Region. The replies showed that the complication is far more common than generally realized. Based on these replies the risk of bile peritonitis each time a latex T-tube is electively removed from the common bile duct is calculated to be 0·84 per cent or 1 in every 119 explorations.
Effects of hepatic metastases on resting energy expenditure in patients with colorectal cancer
Authors: Hansell D T , Davies J W L , Burns H J G
Published: March 2007

There are frequent reports that cancer causes an increase in resting energy expenditure (REE), and the presence of hepatic metastases is said to increase REE further. The effect of tumour burden on REE has been measured in 24 patients before and following surgery for colorectal cancer. Fifteen patients had a ‘curative’ resection whereas nine patients were found to have hepatic metastases at the time of surgery. No significant differences in REE were found between the groups either before surgery or at follow-up, by which time all 15 curative resection patients were tumour free and the remaining nine had progression of their hepatic disease. It is concluded that neither surgical removal of the primary tumour nor progression of metastatic hepatic disease significantly alters REE in patients with colorectal cancer.
Influence of tumour site on presentation, management and subsequent outcome in large bowel cancer
Authors: Aldridge M C , Phillips R K S , Hittinger Rosemary , Fry J S , Fielding L P
Published: March 2007

To demonstrate any difference in outcome between patients with carcinoma at various sites within the large bowel, analysis of a large number of patients is necessary. From the Large Bowel Cancer Project, 4292 patients have been evaluated to compare mode of presentation, surgical management, pathological findings and outcome. Carcinoma at the splenic flexure was associated with the highest risk of obstruction (49 per cent); postoperative cardiopulmonary complications (36 per cent); in-hospital mortality (18 per cent); and the lowest age-adjusted 5-year survival (28 per cent), even after curative resection (38 per cent). This survival disadvantage was seen even in those without obstruction. Further, it was not accounted for by differences in age, sex, Dukes' stage or tumour differentiation between the various sites as stratification by these variables failed to alter significance (log rank χ2 = 11·1; d.f. = 4; P < 0·05). Compared with carcinoma of the left colon and rectum, tumours in the right colon were more likely to be poorly differentiated and locally advanced (in terms of fixation and penetration of the bowel wall) but were not associated with a higher risk of either distant spread at presentation or local recurrence. Age-adjusted 5-year survival following curative surgery was higher for the right colon (65 per cent) than the left (59 per cent).
Influence of anticoagulant treatment in preventing graft occlusion following saphenous vein bypass for femoropopliteal occlusive disease
Authors: Kretschmer G , Wenzl E , Wagner O , Polterauer P , Ehringer H , Minar E , Schemper M
Published: March 2007

Seventy-one patients underwent a classical reversed saphenous vein graft for femoropopliteal occlusive disease and were enrolled in a controlled clinical trial. During the second postoperative week the patients were allocated randomly into one of two groups; group 1 consisted of 34 patients who received coumarine, group 2 (37 patients) served as a control group without any anticoagulant treatment. The mean follow-up was 18 months. After 12 months the cumulative patency rate was 81 per cent and after 18 months 75 per cent; for patients receiving coumarine treatment, the respective figures were 90 and 82 per cent and for those with no anticoagulant treatment 72 and 67 per cent, the decrease being significant. When the bypass operation was performed for limb salvage (clinical stages III and IV) the overall results were worse (12 months, 72 per cent; 18 months, 68 per cent) than in stage II and stage II–III (12 months, 90 per cent; 18 months, 85 per cent). In limb salvage surgery the positive effects of anticoagulant treatment were significant (with treatment: 12 months, 87 per cent; 18 months, 87 per cent; without treatment: 12 months, 60 per cent; 18 months, 53 per cent). The site of the distal anastomosis (above knee: 12 months, 81 per cent; 18 months, 73 per cent versus below knee: 12 months, 80 per cent; 18 months, 75 per cent) did not have any demonstrable influence on the patency rate.
Early postoperative course following elective splenectomy in haematological diseases: A high complication rate in patients with myeloproliferative disorders
Authors: Malmaeus J , Akre T , Adami H-O , Hagberg H
Published: March 2007

One hundred and sixty-seven patients subjected to splenectomy on haematological indications were studied. They were grouped into five diagnostic categories: auto-immune disorders (52 patients), Hodgkin's disease (32) lymphoproliferative malignancies (60), myeloproliferative malignancies (18) and miscellaneous (5). The total number of complications and deaths were 42 (25 per cent) and nine (5 per cent), respectively. Infections were the most common complication, occurring in 30 cases and accounting for 59 per cent of all sequelae. Patients with auto-immune disorders had a high frequency of subphrenic left-sided abscesses (5/52). Splenectomy for Hodgkin's disease was associated with a very low frequency of complications. In the 60 patients with lymphoproliferative malignancies left-sided pneumonia was common (9/60). Complications occurred in 56 per cent of the patients with myeloproliferative disorders, the associated mortality rate being 28 per cent. It is concluded that elective splenectomy in haematological diseases seems to be a safe procedure in most patients with the exception of individuals with myeloproliferative malignancies. The high operative risk in this group makes the benefit questionable. In patients with auto-immune disorders the high frequency of subphrenic abscesses indicates that prophylactic antibiotic treatment should be considered.
Frequency of infections in cirrhotic patients presenting with acute gastrointestinal haemorrhage
Authors: Bleichner G , Boulanger R , Squara P , Sollet J P , Parent A
Published: March 2007

The frequency of infection at the time of admission with upper gastrointestinal haemorrhage has been determined in 149 successive cirrhotic patients admitted to an intensive care unit. Infection status was investigated by clinical examination, chest X-ray, and blood, urine and ascitic fluid culture. At initial examination infection was present in 32 patients (22 per cent) and was often in the form of septicaemia or spontaneous peritonitis; the bacteria responsible were frequently digestive in origin. At endoscopy, acute lesions of gastroduodenal mucosa were more frequent among infected patients, whereas gastro-oesophageal varices and chronic gastroduodenal ulcers were more frequent among the non-infected patients. Acute mucosal lesions were observed in 70 per cent of infected patients and in 19 per cent of non-infected patients. The mortality rate was higher in infected patients. Infection and the frequency of acute mucosal lesions were related to the severity of the cirrhosis. It is suggested that these lesions could be due to stress secondary to infection.
Occult hepatic metastases in colorectal carcinoma
Authors: Finlay I G , McArdle C S
Published: March 2007

Occult hepatic metastases (OHMs) were detected by ultrasound and/or CT scanning in 17 of 71 (24 per cent) patients undergoing apparently curative resection for colorectal carcinoma. One of the patients with OHMs survived 5 years; in contrast, only 5 of 54 patients without evidence of OHMs at surgery died of disseminated disease. The presence or absence of OHMs at the time of surgery predicts the majority of deaths from disseminated disease following apparently curative resection for colorectal carcinoma.
Value of Tru-cut biopsy in the diagnosis of soft tissue tumours
Authors: Kissin M W , Fisher C , Carter R L , Horton L W L , Westbury G
Published: March 2007

The light microscopic appearances of Tru-cut needle biopsies from 50 consecutive soft tissue tumours were assessed by three pathologists and compared with the definitive histological diagnosis. Forty-four patients had soft tissue sarcomas and six had benign soft tissue lesions. A correct predictive diagnosis of sarcoma was made on 87–98 per cent of adequate Tru-cut specimens, the accuracy varying between pathologists. Three sources of diagnostic error were recognized: false positive cores (8 per cent), false negative cores (8 per cent), and cores inadequate for diagnosis (16 per cent). The major source of confusion related to difficulties in differentiating infiltrating fibromatosis from malignant fibrous histiocytoma. The high sensitivity of Tru-cut needle biopsy suggests that it could be a valuable aid in the diagnosis of clinically suspected soft tissue sarcomas.
Natural history of patients with recurrent parotitis and punctate sialectasis
Authors: Watkin G T , Hobsley M
Published: March 2007

The clinical features of 68 patients (26 children and 42 adults) who suffered recurrent attacks of parotitis and in whom sialography had revealed punctate sialectasis of the affected gland is described. The sex incidence was equal in those patients in whom symptoms commenced during childhood (younger than 15). When symptoms commenced later in life, however, there was a marked preponderance of females (female:male = 7.5:1). Bilateral sialography in 16 patients with unilateral symptoms revealed punctate sialectasis in the asymptomatic gland in 11 (69 per cent) of patients. Neither the presence of the sicca syndrome nor auto-antibodies had a significant predictive value as to the outcome of the disease. Five-year follow-up of 52 patients revealed that 56 per cent of adults and 64 per cent of children had shown spontaneous improvement of symptoms with symptomatic treatment alone. In 40 per cent of adults and 4 per cent of children, however, the persistence or worsening of symptoms necessitated parotidectomy. We believe that these results of conservative management indicate that, at least in the first instance and particularly in children, conservative management is justified and that the use of radiotherapy or steroids (with their attendant morbidity) is unnecessary.
Influence of endoscopic papillotomy on the management of bile duct stones
Authors: Thompson M H
Published: March 2007

In a 4 year period two hundred and seventy-nine patients were treated for gallstones in a single surgical unit. One hundred and thirteen were treated for stones in the bile duct, of them 49 patients were treated surgically and 64 endoscopically. Twenty-three patients had papillotomy without previous cholecystectomy. There were two deaths, both after surgery following failure of endoscopic treatment. Morbidity was greater in the surgically treated group. It is concluded that a large proportion of patients with bile duct stones can be treated by endoscopic papillotomy.
The 15-minute dumping provocation test
Authors: Linehan I P , Weiman J , Hobsley M
Published: March 2007

Following gastric surgery, the diagnosis of the dumping syndrome (DS) has never been precise. The importance of diagnosis is not only in deciding management, but also in comparing series of incidences. The mainstay of diagnosis has been the gastric emptying and dumping provocation test (DPT); however it requires expensive equipment and the interpretation of the results is subjective and therefore variable. In 38 DPTs the percentage plasma volume and pulse rate changes, 15 min after the ingestion of 150 ml of hypertonic glucose, were expressed as percentages of the maximum values encountered and summed to form a score. The tests were independently interpreted by the authors and where they disagreed the result was defined as equivocal. The score was used with the symptoms provoked to follow a simple algorithm to divide the patients into those with and those without DS. There were six suffering from DS on our current interpretation; the new method identified all of these. Three tests were positive on the scoring scheme only and on review the interpreters agreed that all of these patients were suffering from the dumping syndrome. An accurate test using only the baseline and 15 min samples is simple, cheap and has definite rules of interpretation; the only laboratory measurement needed is the haematocrit estimation of three blood samples.
Post-Mastectomy breast reconstruction using the inflatable tissue expander
Authors: Chisholm E M , Marr Sheelagh , Macfie J , Broughton A C , Brennan T G
Published: March 2007

Breast reconstruction following mastectomy has previously relied on the insertion of a silicone gel implant or the use of a myocutaneous flap. We report the use of an innovation, the inflatable tissue expander, for both immediate and delayed breast reconstruction in 26 patients where soft tissue cover was inadequate to permit the use of the silicone implant. By serial inflation of the tissue expander with saline, sufficient tissue cover was achieved for a second operative placement of a silicone prosthesis of appropriate volume to match the normal breast. To date, 10 patients undergoing delayed reconstruction and 5 of 16 patients with immediate reconstruction have had their final prosthesis inserted, while 3 women are satisfied with the result of the expandable implant and desire no further surgery. Only two technical complications have arisen with loss of the expander in one patient who had had recent radiotherapy and in another the tissue expander was placed much too high on the chest wall. Mechanical failure occurred in three cases where disruption of the seam led to sudden deflation in two and a slow leak from the injection port developed in one. One patient also attempted self-inflation leading to deflation of the tissue expander. The cosmetic results were subjectively and objectively very good with capsular distortion present in only one case. We feel that the inflatable tissue expander is simple and safe to use, may be used for immediate reconstruction without compromising the ablative surgery and should be a choice available to general surgeons for providing safe and cosmetically acceptable reconstructive surgery.
Pattern of spread of bloodborne tumour
Authors: Murphy P , Alexander P , Kirkham N , Fleming J , Taylor I
Published: March 2007

The pattern of bloodborne tumour spread has been studied experimentally in syngeneic rats. A variety of tumour types has been injected intravenously, intraportally and also intra-arterially via the left ventricle. Tumour cell arrest as a factor in the localization of metastases in the lung following intravenous injection of cells, and in the liver following intraportal injection, is emphasized. Once tumour cells have entered the arterial circulation they disseminate to almost all organs in similar proportions to the distribution of cardiac output. The dissemination and arrest of cells is not found to correlate with the later distribution of metastases. For example, certain organs (especially the adrenals) which receive only low fractions of injected cells, are always preferred sites for bloodborne metastasis. A strikingly similar pattern of ‘arterial metastasis’ is also seen for all the tumours used despite their very different histological and biological natures.
Impaired spermatogenesis in testes at risk of torsion
Authors: Anderson J B , Cooper M J , Thomas W E G , Williamson R C N
Published: March 2007

The oligospermia observed after unilateral torsion of the spermatic cord could reflect immunological damage to the opposite testis. An alternative explanation, that there may be a pre-existing defect in spermatogenesis, was tested in 20 post-pubertal males with acute torsion. In a prospective study the contralateral testis was biopsied at operation and the histological appearances were related to subsequent testicular function as assessed by seminal analysis 3 months later. Thirteen patients had biopsy evidence of partial maturation arrest in spermatogenesis which was either mild (6), moderate (4) or severe (3), and ten of these were oligospermic (< 20 × 106/ml). By contrast all seven patients with normal histology had a sperm concentration gt; 25 × 106/ml. Histological grading of spermatogenesis by the Johnsen technique gave a higher score in patients with a normal biopsy (median 9·01, semi-quartile range 8·96–9·21) than in those with abnormal histology (median 8·28, semi-quartile range 7·98–8·45, P < 0·001) and correlated with the log of the sperm concentration 3 months later (r = 0·79, P < 0·001). There was minimal anti-sperm and no anti-testis antibody formation following torsion. Serum FSH levels were raised in 6 of 10 oligospermic patients, while all those with a normal sperm count had FSH concentrations within the normal range. Thus many patients who develop testicular torsion have an underlying defect in spermatogenesis, which correlates closely with poor postoperative exocrine function.
Successful autotransplantation of isolated islets of Langerhans in the cynomolgus monkey
Authors: Gray D W R , Warnock G L , Sutton R , Peters M , McShane P , Morris P J
Published: March 2007

A recently described method for isolation of islets of Langerhans from the human pancreas has been adapted to the cynomolgus monkey pancreas. The mean yield of islets obtained from 13 monkey pancreata was 1319 islets per gram of pancreatic tissue (range 533–1800) and the usual purity of the preparation varied from 5 to 15 per cent islet tissue. Twelve cynomolgus monkeys underwent total pancreatectomy, preparation of islets from the excised pancreas and autotransplantation to either the spleen or the liver. Three animals received no transplant and became immediately diabetic, surviving 4–8 days. Four animals became normoglycaemic after intrasplenic islet transplantation, and survived 6 weeks, at which time splenectomy was performed with immediate onset of diabetes. Splenic vein insulin sampling confirmed the spleen as the source of insulin, and histological examination showed implanted islet tissue in all cases. Five animals became normoglycaemic after intrahepatic islet implantation. Three animals subsequently became diabetic at 4 and 5 months and two animals still have functioning grafts, the longest function being 9 months. These results suggest that in the cynomolgus monkey sufficient islets can be extracted from a single donor pancreas to reverse diabetes.
Oxygen inhalation induced changes in the skin as measured by transcutaneous oxymetry
Authors: McCollum P T , Spence V A , Walker W F
Published: March 2007

Transcutaneous oxygen (P  tcO2) measurements were made on 46 patients with severe ischaemia of the lower limbs and on 17 age-matched controls. Values breathing air, 100 per cent oxygen and the rate of change of P  tcO2 breathing oxygen were recorded. Of 29 below knee amputations there were 4 failures; 16 had P  tcO2 values < 35 mmHg, but 12 of the 16 healed. When the rate of change of P  tcO2 during oxygen inhalation was greater than 9 mmHg/min all below knee amputations healed; all 4 failures were found to have values < 9 mmHg/min while only one patient with a value of < 9 mmHg/min healed a below knee amputation. This study shows that low P  tcO2 values are a poor indication of healing potential. A more reliable index of skin viability is provided by the dynamic measurement PtcO2 changes during oxygen inhalation. The addition of an oxygen inhalation test, when making P  tcO2 measurements, greatly enhances the applicability of the technique in the assessment of the oxygen supply to the skin.
Venous muscle pump function in patients with primary lymphoedema: Assessment by ambulatory strain gauge plethysmography
Authors: Struckmann J , Strange-Vognsen H H , Andersen J , Hauch O
Published: March 2007

The musculovenous pump function was assessed by ambulatory strain gauge plethysmography in 11 patients with primary lymphoedema. The venous function was within the normal range regarding both venous reflux and expelled volume. The values were compared with ten patients with chronic venous insufficiency and oedema. The values for venous function were clearly abnormal for the patients with venous insufficiency and different from those with primary lymphoedema. Ambulatory strain gauge plethysmography may be a useful non-invasive method in distinguishing between oedema of lymphatic or venous origin.
Admission guidelines for head injuries: Variance with clinical practice in accident and emergency units in the UK
Authors: Fowkes F G R , Ennis W P , Evans R C , Roberts C J , Williams L A
Published: March 2007

Guidelines for the initial management of head injuries were formulated by neurosurgeons and a multidisciplinary group of clinicians and administrators attending a seminar convened by the UK Department of Health and Social Security (DHSS). Analysis of data collected previously by the Royal College of Radiologists in nine accident and emergency units in the UK shows that admitting practice varied between centres and was very different from that recommended subsequently in the guidelines. Only 49 per cent (range 22 to 71 per cent) of patients who had skull X-rays and possessed symptoms and signs warranting admission were admitted to hospital and 14 per cent (range 1 to 20 per cent) of those without appropriate symptoms and signs were admitted. Rates of admission for patients with a history of unconsciousness, which according to the guidelines is not a criterion for admission, were up to ten-fold higher than for comparable patients with no such history. Implementation of the guidelines could have a substantial effect on clinical practice and could reduce admissions of patients who had skull X-rays by up to 46 per cent.
Refashioning of phallus stumps and phalloplasty in the treatment of carcinoma of the penis
Authors: Parkash S , Ananthakrishnan N , Roy P
Published: March 2007

The surgical management of 41 patients with carcinoma of the penis is presented. Conservative surgery in the form of a circumcision or a glansplasty was done in eight patients with one recurrence. Circumcision as an adequate procedure is advocated for lesions near the apex of the preputial sac permitting a 2 cm clearance; glansplasty after local excision requires further evaluation. The details of technique of lengthening and refashioning of the residual phallic stump after partial amputation in a further 20 patients is described using a technique which leaves a satisfactory penile stump in patients who would normally be candidates for a total amputation. In a third group of patients requiring a total amputation of penis, reconstruction was done in two stages using scrotal flaps in four with satisfactory results. The reconstructed phallus was adequate as a urinary conduit but was unsuitable for sexual function. A one stage procedure involving covering of the urethra with scrotal flaps appears an attractive alternative to the staged procedure. Conventional multistage reconstructions are not recommended.
Morbidity, mortality and local recurrence following regional node dissection for melanoma
Authors: Bowsher W G , Taylor B A , Hughes L E
Published: March 2007

Eighty-six patients who underwent regional node dissection (RND) for melanoma were reviewed with respect to short and long term postoperative morbidity, mortality and local recurrence rate. Twenty-eight per cent of dissections were prophylactic and seventy-two per cent therapeutic. There were significant wound related complications which tended to delay hospital discharge, in particular following axillary and groin dissections, but symptomatic long term complications were infrequent. The postoperative mortality rate was 1·2 per cent. Local recurrence in RND scars was particularly common in the neck (33 per cent). RND for melanoma is a safe procedure, with significant short term but relatively little long term morbidity. Both recurrence and morbidity should be borne in mind when considering patients for prophylactic RND. Surgeons should be prepared to use axial or myocutaneous flaps where extensive skin resection is necessary. A controlled trial of prophylactic antibiotics would be useful to try to reduce the incidence of wound infection.
Enteric bacteriology, absorption, morphology and emptying after ileal pouch–anal anastomosis
Authors: O'Connell P R , Rankin D R , Weiland L H , Kelly K A
Published: March 2007

The aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch–anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 ± 2 months (mean ± s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch–anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.
Internal sphincterotomy for chronic anal fissure: Long term effects on anal pressure
Authors: Chowcat N L , Araujo J G C , Boulos P B
Published: March 2007

In 28 patients with chronic anal fissure the median anal canal pressure was 98 cmH2O, significantly higher than in control subjects (P < 0·001). After lateral internal sphincterotomy the pressure dropped by 50 per cent to normal levels and the fissures healed with no change in pressure over 12 months. Ten patients also had normal anal pressures and were asymptomatic 4–6 years after internal sphincterotomy. Adequate internal sphincterotomy appears to reduce permanently anal canal pressure, suggesting that abnormal activity in the sphincter contributes to the development of a fissure.
Blind total gastrectomy for massive bleeding from the stomach
Authors: Primrose J N , Gledhill T , Quirke P , Johnston D
Published: March 2007

The source of massive haemorrhage from the stomach cannot always be identified even with the use of fibreoptic endoscopy and angiography. Six patients with massive, continuing, non-variceal haemorrhage from the stomach are described in whom total gastrectomy was eventually required. Three patients were shown to have bled from submucosal arteriovenous malformations, two from erosive gastritis and one from a vessel in an ulcer at the oesophagogastric junction. One patient died as a result of surgery and another died later of disseminated malignant disease. The functional results in the remaining patients were surprisingly good and rebleeding has not occurred. Total gastrectomy is a satisfactory ‘last resort’ treatement for life-threatening gastric haemorrhage for which no cause can be found.
Endoscopic treatment of inoperable colorectal cancers with the Nd YAG laser
Authors: Bown S G , Barr H , Matthewson K , Hawes R , Swain C P , Clark C G , Boulos P B
Published: March 2007

Seventeen patients with cancers of the rectum or distal sigmoid and considered inoperable because of old age, severe concomitant disease or advanced stage of malignancy, were treated endoscopically with the Nd YAG laser. Symptoms included rectal bleeding, obstruction, diarrhoea and incontinence. Significant improvement was achieved in 15 (88 per cent) and there were no complications. The procedure was carried out with simple bowel preparation and minimal sedation and, for otherwise fit individuals, the mean total hospital stay was 6·8 days, with day case therapy sometimes possible. Three patients required further therapy for recurrent symptoms 6–8 weeks after treatment. Fourteen patients died 1–39 weeks after therapy (mean survival 15 weeks). Three are alive and free of bowel symptoms after 39–54 weeks. This technique is the only non-surgical therapy that can be used safely for lesions above the peritoneal reflection and provides palliation at least as good as electrocoagulation, cryotherapy and radiotherapy with minimal upset to these seriously ill patients.
Re-routing procedures for ectopic anus in the adult
Authors: Keighley M R B
Published: March 2007

Four cases of adult ectopic anus are described. All patients presented with incontinence; in two there was a history of constipation. Electromyography correctly identified the site of the anal sphincters pre-operatively. The anorectum was mobilized and re-routed through the sphincter ring with repair of the perineal body. There was improvement in anal canal pressures on voluntary contraction after operation in all three cases studied. Continence was restored in three patients but results were poor in one patient because of persistent constipation. Severe constipation may be a contra-indication to this procedure.
Surgical management of severe intractable postvagotomy diarrhoea
Authors: Cuschieri A
Published: March 2007

Experience with the surgical management of 23 patients with postvagotomy diarrhoea is outlined. The most common pre-operative abnormalities are rapid gastric emptying (14/23) and fast small bowel transit (23/23). Three patients were found to have steatorrhoea due to organic disease. Peptic ulcer surgery performed at a young age (x¯ = 29 years, range 21–37) appears to be the only identifiable risk factor. The results of medical treatment with bile salt binding agents were disappointing in the long term. In 10 out of 13 patients treated with antiperistaltic segments, the procedure had to be reversed because of episodes of severe postprandial colic, intestinal obstruction and bacterial overgrowth. A good result with relief of the explosive diarrhoea was obtained by the distal onlay reversed ileal graft in six out of seven patients. This procedure creates a passive non-propulsive segment, and has no undesirable sequelae. It should be considered in those patients in whom the diarrhoea is not controlled by conservative measures.
Incisional herniae following median sternotomy incisions: Their incidence and aetiology
Authors: Davidson B R , Bailey J S
Published: March 2007

A retrospective study was carried out of all patients undergoing cardiothoracic surgery through a median sternotomy incision under the care of a single surgical firm over an 8 year period in order to assess the incidence and aetiology of incisional epigastric herniae. Of the 582 procedures carried out, follow-up information was obtained in 475 (81·6 per cent) of which 20 (4·2 per cent) had developed incisional herniae (70 per cent of these within 3 months). Seven (35 per cent) of the herniae were symptomatic and required repair. The main predisposing factors were the male sex, the nature of surgery carried out (notably aortic valve replacement), obesity and the presence of postoperative complications of wound infection and left ventricular failure. Herniae were not found in those patients having wound closure using non-absorbable sutures.
Objective measurement by ultrasound to distinguish cyclosporin A toxicity from rejection
Authors: Parvin S D , Rees Y , Veitch P S , Bell P R F
Published: March 2007

Measurement of the cross-sectional area of the transplanted kidney with ultrasound has been used to differentiate between cyclosporin A toxicity and rejection both in the immediate post-transplant period and at the time of conversion from cyclosporin A to azathioprine. Of 40 patients studied 21 have been converted from cyclosporin A to azathioprine. There were 12 rejection episodes in 9 patients in the early post-transplant period, and 7 rejection episodes in 7 patients at the time of conversion from cyclosporin A to azathioprine. All of these episodes were correctly diagnosed by ultrasound. Eight episodes of drug induced toxicity in seven patients were, in all but one case, diagnosed correctly. In only 8 of the 19 rejection episodes was the diagnosis suspected clinically at the time ultrasound detected an increase in cross-sectional area.
Flap-Valve theory of anorectal continence
Authors: Bartolo D C C , Roe A M , Locke-Edmunds J C , Virjee J , Mortensen N J McC
Published: March 2007

The most important component of continence is considered to be the puborectalis muscle which is reputed to function by creating a flap-valve mechanism in which the anterior rectal wall occludes the upper anal canal. To elucidate this, anal and rectal pressures were measured simultaneously together with external anal sphincter and puborectalis electromyogram and synchronously superimposed on an image intensifier displaying the rectum outlined by barium. We studied 13 subjects at rest, and during a Valsalva manoeuvre. There was a significant rise in rectal and sphincter pressures (P < 0·005) and external sphincter and puborectalis EMG (P < 0·005). In a further 13 patients Valsalva manoeuvres were performed during proctography alone. In all subjects the anterior rectal wall was always clearly separated from the upper sphincter despite a maximal effort and a rectum filled with sufficient liquid to produce a desire to defaecate. These findings question the flap-valve theory of continence and suggest the puborectalis functions by sphincteric occlusion of the anal canal.
Alteration in colonic epithelial cell DNA associated with intestinal neoplasia: Selection of high risk patients
Authors: Matthews Joyce L , Glynn M , Parkins A , Cooke T
Published: March 2007

The proliferative activity of the colonic crypts of patients who are at high risk of developing colonic tumours has been assessed. Cells from the upper parts of the colonic crypts were collected at colonoscopy, and were stained for DNA by the Feulgen technique. Using a microdensitometer the DNA content of the cells was measured and a proliferative index calculated. Patients with single neoplasms had a proliferative index similar to controls although individual patients with hyperplastic mucosa could be identified. Patients with multiple neoplasms had an elevated proliferative index. These results may form the basis of a screening programme for colonic tumours.
Blood transfusion and recurrence of cancer of the colon and rectum
Authors: Francis D M A , Judson R T
Published: March 2007

Clinical and experimental studies indicate that transfusion of allogeneic blood has immunomodulating properties, and that the behaviour of some tumours may be influenced by the immune system of the host. Eighty-seven patients who had undergone ‘curative’ resection of cancer of the colon or rectum were studied retrospectively to determine whether blood transfusion adversely affected the rate of cancer recurrence. Fifty-three patients (61 per cent) were transfused and 34 were not. The transfused and non-transfused groups were comparable in terms of age, sex, duration of follow-up, mode of presentation, stage of disease and haemoglobin level at discharge from hospital, and differed in admission haemoglobin and distribution of tumour locations (right- or left-sided colonic or rectal tumours). Recurrent malignancy was detected in 36 per cent of transfused patients and 26 per cent of non-transfused patients (P > 0·1). There was no association between the number of transfusions and recurrence for any tumour site or stage. The incidence of recurrence was significantly higher in those patients who received transfusions during surgery than in those who received transfusion either before or after surgery (χ2 = 7·01, d.f. = 1, P>0·01) or no transfusions (χ2 = 4·23, d.f. = 1, P>0·05). The study indicates that factors influencing the need for blood transfusion during operation had a greater bearing on prognosis than receipt of a blood transfusion per se and that future prospective studies investigating the association between transfusion and cancer recurrence need to determine accurately the indications for transfusion.
Duodenum-preserving total pancreatectomy for end stage chronic pancreatitis
Authors: Lambert M A , Linehan I P , Russell R C G
Published: March 2007

The classical Whipple procedure for chronic pancreatitis has been associated with significant long term postoperative morbidity. The pylorus-preserving procedure of Longmire has reduced but not eliminated the long-term morbidity. Preservation of the whole duodenum with total pancreatectomy has been introduced for the treatment of patients with end-stage chronic pancreatitis after favourable experience with this procedure in infants for nesidioblastosis. Fourteen patients with chronic pancreatitis have had a total pancreatectomy with preservation of the duodenum and the bile duct. All patients are still alive (median follow-up 9·5 months) and none suffered major complications in the perioperative period. One patient developed a biliary stricture at 3 months, requiring biliary reconstruction. Six of the patients have returned to full-time work; nine require no analgesia. All patients require pancreatic enzyme replacement, and all patients have gained weight postoperatively. Diabetic control is satisfactory with a twice daily insulin regime. Duodenum-preserving total pancreatectomy is feasible in the adult without mortality or high morbidity; early experience suggests that preserving the duodenum improves gastrointestinal function with easier control of the diabetes.
Primary sclerosing cholangitis: Biliary drainage and duct dilatation
Authors: Krige J E J , Terblanche J , Harries-Jones E P , Bornman P C
Published: March 2007

A further extension of the U-tube technique is described in the treatment of six patients with primary sclerosing cholangitis who developed progressive jaundice and recurrent biliary sepsis. All six patients had operative intrahepatic duct dilatation and U-tube placement. Three patients in addition had a Roux-en-Y hepaticojejunal anastomosis. Five patients are improved and are well after a median follow-up period of 56 months. Two patients have had the U-tube removed electively. Three patients with progressive disease required further percutaneous catheter dilatation of intrahepatic strictures via the U-tube tract. Application of the technique permits evaluation of the biliary system by tube cholangiography and provides access in complex cases for repeated therapeutic intrahepatic stricture dilatation.
Popliteal artery trauma: A high risk injury
Authors: Krige J E J , Spence R A J
Published: March 2007

The clinical presentation and management of 28 popliteal artery injuries following penetrating and blunt trauma during a 6 year period is reviewed. Clinical and Doppler evaluation identified an arterial injury in 24 (85 per cent) patients. In eight (29 per cent) patients with arteriovenous fistulae or false aneurysms, pedal pulses were palpable during initial assessment. Three (10·7 per cent) patients had limb amputation attributable to delayed vascular repair, crush injury and sepsis. End-to-end arterial repair following blunt trauma resulted in early failure with thrombosis in two patients. Autogenous vein grafting was used in 12 patients and is advocated in all blunt popliteal arterial injuries. Routine repair of associated venous injuries and liberal criteria for early fasciotomy were used. Exoskeletal fixation or skeletal traction for compound and comminuted fractures is recommended for simplicity of application and wound management. The significant functional orthopaedic disability following blunt arterial trauma at the knee is emphasized.
One hundred patients ten years after parietal cell vagotomy
Authors: Von Holstein C Staël , Graffner H , Oscarson J
Published: March 2007

One hundred patients with duodenal or pyloric/prepyloric ulcer disease were operated with parietal cell vagotomy (PCV) and followed for a minimum of 10 years. At 6 weeks, 1,5 and 10 years postoperatively gastric secretory tests, haematological work-up and clinical examination or telephone interview were performed. There was no operative mortality and the frequency of postoperative sequelae was minimal. The cumulative ulcer recurrence rate was 18 per cent and another 14 per cent had slight to moderate symptoms of epigastric pain without any signs of ulcer. Upper gastrointestinal endoscopy was used to reveal recurrences but was performed only if the patient had symptoms of recurrence. A rise in basal acid secretion and in pentagastrin-stimulated secretion was observed the first year postoperatively, whereas insulin-stimulated peak acid output increased during the first 5 years. We conclude that PCV has a low rate of per- and postoperative complications and an acceptable recurrence rate. Therefore, it seems that PCV is the method of choice in chronic duodenal ulcer disease.
Effect of cimetidine on prognosis after simple closure of perforated duodenal ulcer
Authors: Simpson C J , Lamont G , Macdonald I , Smith I S
Published: March 2007

A prospective controlled study in 60 patients undergoing simple closure of perforated duodenal ulcer demonstrated a significant (P > 0·05) benefit following postoperative cimetidine treatment, in terms of avoiding subsequent dyspeptic symptoms and complications of peptic ulcer disease. Thus cimetidine is recommended in the follow-up management of perforated duodenal ulcers.