bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcome of surgery for Graves' disease re-examined
Authors: Cusick Eleri L , Krukowski Z H , Matheson N A
Published: March 2007

The outcome of surgery for Graves' disease in terms of early and late morbidity was studied in 161 patients undergoing subtotal thyroidectomy in the 10-year period 1976–1985. Eighty of these patients had a minimum follow-up of 5 years. There was a low operative morbidity and a zero mortality. The weight of thyroid tissue preserved (in the range 5–10 g) influenced the prevalence of hypothyroidism at one year and at five years. There was a cumulative incidence of hypothyroidism which could not be reliably predicted from biochemical results during the first year. Over 60 per cent of patients with subclinical hypothyroidism at 4 months (63 per cent) or 1 year (70 per cent) did not subsequently need thyroxine replacement within 5 years. Patients remained at risk of developing recurrent toxicity indefinitely and the risk was significantly greater in patients with small goitres (< 50 g). Our results may be improved by leaving larger remnants (9–10 g) in most patients and smaller remnants (2–4 g) in those with small glands in whom alternative treatment, which is to be preferred, is not acceptable. After subtotal thyroidectomy for Graves' disease lifelong follow-up is necessary.
Conservative management of bleeding duodenal ulcer without a visible vessel: Prospective randomized trial
Authors: Saperas E , Piqué J M , Ayuso R Pérez , Bordas J M , Terés J , Pera C
Published: March 2007

Between January 1983 and December 1985, 305 patients were admitted to our hospital because of bleeding duodenal ulcer. A subgroup of 69 patients aged 50 or above in whom emergency endoscopy showed non-arterial bleeding or signs of recent haemorrhage without a visible vessel entered a prospective therapeutic trial. The patients were randomized to receive either (1) early surgery, implying immediate operation, or (2) expectant management, with surgery reserved only for patients with further haemorrhage. The two groups were homogeneous with respect to age, sex, prior ingestion of ulcerogenic drugs, mode of bleeding, admission haematocrit, number with hypovolaemic shock and number with active bleeding on initial endoscopy. Overall mortality was 8·6 per cent. Mortality in patients submitted to early surgery was five times higher than that in those allocated to expectant therapy (14·7 per cent versus 2·9 per cent; risk ratio 5·07). The results suggest that expectant management is advisable in patients with bleeding duodenal ulcer not bleeding massively and in whom endoscopy does not disclose spurting arterial bleeding or a visible vessel.
Surgical treatment of pancreatic pseudocysts
Authors: Köhler H , Schafmayer A , Lüdtke F E , Lepsien G , Peiper H-J
Published: March 2007

Between 1966 and 1980, 54 patients (40 men and 14 women) with a mean age of 38 years were operated on for a pancreatic pseudocyst at the Department of General Surgery, University of Göttingen. The aetiology of the cysts was alcohol abuse in 35 patients, biliary diseases in 8, blunt abdominal trauma in 4, virus-induced in 2 and unknown in 5. With the exception of those who had had trauma, all patients were suffering from chronic pancreatitis. Surgical therapy included in all cases a cystojejunostomy (52 with a Roux-Y-limb and 2 with an omega loop). The mean follow-up period was 13 years (range 6 to 20 years). The late mortality was 15 per cent (8 of 52 patients). Recurrent cysts occurred in two patients (5 per cent) and relapse of pancreatitis in one third of the patients. Deterioration of carbohydrate metabolism was observed in 20 per cent of the patients. After drainage operation stool fat content became normal in 20 per cent and deteriorated in 13 per cent. Persistence or cessation of alcohol intake influenced the long-term results. From these data we conclude that both alcohol withdrawal and sufficient drainage of the pseudocyst are important factors in the prognosis of pseudocyst.
Polydioxanone or polypropylene for closure of midline abdominal incisions: A prospective comparative clinical trial
Authors: Krukowski Z H , Cusick Eleri L , Engeset J , Matheson N A
Published: March 2007

Seven hundred and fifty-seven consecutive patients undergoing a midline abdominal incision were stratified according to age, sex, type of operation and degree of operative contamination and were randomly allocated to mass closure of the abdominal wall with continuous 4 metric polydioxanone (PDX; 374 patients) or continuous 4 metric polypropylene (PPL; 383 patients). Wound infection was less common with PDX (PDX 3·5 per cent; PPL 7·0 per cent; P < 0·05) and there was one dehiscence in each group. The incidence of defective wounds in patients surviving 1 year was similar (7·7 per cent PDX; 9·7 per cent PPL) but the PPL suture had to be removed because of persisting wound pain or sinus formation in five patients. PDX is the preferred suture material for closure of midline abdominal incisions.
Prospective assessment of carotid endarterectomy by clinical and ultrasonic methods
Authors: Aldoori M I , Baird R N
Published: March 2007

Sixty-three carotid endarterectomies in 60 patients were followed by clinical and duplex scanning at 2 weeks postoperatively and at 3-monthly intervals for 3 years (mean 18 months). Four patients died (two of stroke, two of myocardial infarction) and four survivors had recurrent ipsilateral symptoms. Two had an immediate mild hemiparesis which recovered completely within 36 h; in both, the endarterectomized arteries were patent on scanning. The other two experienced amaurosis fugax for 2–3 weeks at 2 and 24 weeks; scanning showed that the sites of both endarterectomies had become occluded. Ultrasound assessment at 2 weeks showed that 43 of 61 (70·5 per cent) endarterectomized arteries were widely patent. There were three occlusions, one stenosis of > 75 per cent, three stenoses of > 50 per cent and eleven stenoses of < 50 per cent. At 6 months a total of five vessels were occluded, with > 75 per cent stenosis in three and > 50 per cent stenosis in eight. At latest follow-up, six of eight arteries with > 50 per cent stenosis shown earlier had scans which had reverted to normal. Tacking down of the distal intima was associated with higher incidence of restenosis and occlusion (P < 0·01). Women were more predisposed to restenosis by neointimal hyperplasia (P < 0·05). All restenosis occurred within the first 6 months postoperatively (26·2 per cent) and fell to 16·4 per cent at the end of the study.
Synchronous and ‘early’ metachronous carcinomas of the colon and rectum
Authors: Finan P J , Ritchie Jean K , Hawley P R
Published: March 2007

In a review of cases of colorectal cancer presenting to St. Mark's Hospital over the 16-year period 1970–85, 59 patients were found to have a synchronous carcinoma (3·4 per cent). Although 82 per cent of these synchronous tumours were distal to the splenic flexure (and hence within reach of a 60 cm flexible sigmoidoscope) only 42 per cent were detected pre-operatively: the remaining tumours were noted at surgery (24 per cent) or found incidentally on pathological examination of the resected specimen (34 per cent). Histological examination of these synchronous lesions revealed a high proportion with favourable stage (Dukes' A — 75 per cent) and grade (well or moderate differentiation - 90 per cent). Over the same 16-year period, 10 patients presented with an ‘early’ metachronous lesion (<3 years from initial surgery). Review of these cases noted negative findings on the initial barium studies in four patients and a failure to conduct full examination of the colon at initial presentation in the remaining six. It is concluded that full examination of the colon in all patients presenting with primary colorectal cancer is mandatory and that, in the light of this experience and recent reports in the literature, this should be by pre- or peroperative colonoscopy.
Submucosal versus ligation excision haemorrhoidectomy: A comparison of anal sensation, anal sphincter manometry and postoperative pain and function
Authors: Roe A M , Bartolo D C C , Vellacott K D , Locke-Edmunds Jill , Mortensen N J Mcc
Published: March 2007

Submucosal (SM) and ligation excision (LE) haemorrhoidectomy were compared to establish whether SM is a less painful procedure and whether anal sensation is better preserved by SM, and, if so, how this relates to postoperative function. There were 18 SM and 22 LE patients. Anal sphincter manometry and anal mucosal electrosensitivity were measured pre-operatively and 6 weeks after surgery. Postoperative pain was assessed by linear analogue scale. Anal sphincter pressures which were high pre-operatively fell to normal after surgery. Neither operation affected functional sphincter length or the recto-anal inhibitory reflex. Forty per cent of patients showed ultraslow waves on sphincter motility studies. These were associated with the highest pressures and in all but three cases disappeared after surgery. There were no differences in postoperative pain scores between the two techniques but there was a wide range from no pain to very severe pain in both groups. Submucosal haemorrhoidectomy preserved anal sensation better than ligation excision but this was not reflected in improved function. There was minor leakage and soiling in 50 per cent of patients from both groups and two SM and LE patients had initial faecal incontinence. All these symptoms had resolved by 6 weeks.
Symptomatic submucosal lipoma of the large bowel
Authors: Creasy T S , Baker A R , Talbot I C , Veitch P S
Published: March 2007

Symptomatic large bowel lipomata may be of considerable size and usually present in middle age with symptoms of obstruction or bleeding. Although they are rare, their recognition is important so that patients may be spared unnecessary colonic resection for a presumptive malignant diagnosis. Colonoscopic removal may often be feasible. Six cases are reported together with a review of the literature emphasizing the characteristic features.
Effect of carotid endarterectomy on cerebral blood flow and its response to hypercapnia
Authors: Bishop C C R , Butler Lorraine , Hunt T , Burnand K G , Browse N L
Published: March 2007

Cerebral blood flow (CBF) was measured in 14 patients before carotid endarterectomy, 3 h after surgery and 2 days postoperatively using the intravenous xenon-133 technique. In 11 of the patients CBF was remeasured at 6 months and in 8 patients CBF and the response to hypercapnia (5 per cent CO2 in air) was measured pre-operatively and 6 months following surgery. All operations were performed using an intraluminal Javid shunt and internal carotid artery (ICA) ‘stump’ pressure was recorded. CBF measured at 3 h after endarterectomy revealed a postoperative cerebral hyperperfusion with significantly increased flows in both hemispheres. There was a significant correlation between carotid cross clamping time and ipsilateral hemispheric CBF increase which implied an ischaemic aetiology for the hyperperfusion and supported the routine use of an intraluminal shunt in carotid endarterectomy. Six months after surgery, CBF had returned to its pre-operative value but reactivity to CO2 was significantly improved, which suggested that the operation had increased cerebral reserve.
Popliteal vein entrapment caused by the third head of the gastrocnemius muscle
Authors: Iwai T , Sato S , Yamada T , Muraoka Y , Sakurazawa K , Kinoshita H , Inoue Y , Endo M , Yoshida T , Suzuki S
Published: March 2007

Three cases of the popliteal vein entrapment syndrome have been encountered during the past 3 years. The third head of the gastrocnemius muscle appeared to be the cause of this rare condition with the vessels in their normal position. Partial resection of the excess muscle was sufficient to relieve symptoms.
Prognostic significance of oestrogen and progestogen receptor activities in breast cancer
Authors: Hawkins R A , White Gillian , Bundred N J , Dixon J M J , Miller W R , Stewart Helen J , Forrest A P M
Published: March 2007

The prognostic significance of the tumour activities of 2 steroid receptors, those for oestrogen (ER) and for progestogen (PgR), has been studied in 372 patients with breast cancer, in whom follow-up was available for 2-6 years (median 41 months). Of 252 patients with operable disease, 75·8 per cent had ER-positive tumours and 46·4 per cent had PgR-positive tumours, though a small additional fraction (6·3 per cent) had an equivocal PgR assay result. For the 236 patients with unequivocal receptor status, the relationships between disease-free interval or overall survival and receptor activity and other factors were evaluated by univariate and multivariate analyses. The latter revealed that only tumour size, node status, menstrual status and ER status related significantly to both disease-free interval and survival, though adjuvant therapy also related to disease-free interval, and tumour grade related to survival. It is concluded that measurements of PgR activity do not add to the prognostic significance of ER status.
Consultations for breast disease in general practice and hospital referral patterns
Authors: Maureen Roberts M , Elton R A , Robinson S E , French K
Published: March 2007

As part of the evaluation of a health education campaign about breast disease, consultations for breast problems were monitored in five general practices over an 18-month period in Edinburgh. No increase was found as a result of the campaign, nor was there any increase in the number of biopsies performed. On average, each GP saw 13 women with breast problems each year, a rate of 1·6 per cent; 29 per cent were referred to hospital, regardless of their age. The most common presenting symptom was pain (47 per cent), with 35 per cent complaining of a lump. The reasons for hospital referral are discussed. It is suggested that GPs may refer too many young women to a specialist clinic, although this may be inevitable.
Prognostic factors related to survival and groin recurrence following therapeutic lymph node dissection for lower limb malignant melanoma
Authors: Kissin M W , Simpson D A , Easton D , White H , Westbury G
Published: March 2007

A retrospective analysis was carried out of 133 patients undergoing therapeutic lymph node dissection for malignant melanoma of the lower limb. A radical ilio-obturator dissection (RID) was performed in 106 patients and a superficial femoral dissection (SFD) in the remaining 27. On univariate analysis five factors were found to be significant indicators of prognosis. These were: Clark level of the primary (P = 0·02); primary melanoma thickness (P = 0·04); total number of positive nodes (P<0·001); number of positive femoral nodes (P < 0·001); and number of positive ilio-obturator nodes (P<0·001). On multiple regression analysis only the number of positive nodes in each compartment remained a significant independent factor (P<0·001). The morbidity associated with RID was not significantly greater than after SFD. RID was, however, associated with a reduction in subsequent groin recurrence. Radical nodal clearance is the operation of choice. This technique provides maximum prognostic information, reduces the likelihood of local untreatable disease and possibly improves overall survival rates—especially when only one iliac node is involved.
Changes in the plasma sodium concentration after minor, moderate and major surgery
Authors: Guy A J , Michaels J A , Flear C T G
Published: March 2007

The plasma sodium concentration, [Na]P, falls following major surgery and this fall is exacerbated by the administration of sodium-free or sodium-low intravenous fluids in the postoperative period. As a prelude to prospective, but controlled, studies we observed the range of [Na]P on admission for surgery in 477 patients. In 309 patients the extent of the change in [Na]P by the first postoperative day (Δ[Na]) was related to the severity of the operation undergone (minor, moderate or major) and the volume of potentially hypo-osmolar intravenous fluid given. The mean admission [Na]P was significantly lower with increasing severity of proposed operation. A highly significant fall occurred in [Na]P following surgery of every grade; such falls in [Na]P were seen even when no potentially hypo-osmolar fluids were administered. A significant inverse relationship between admission [Na]P and Δ[Na] was demonstrated. We conclude that [Na]P falls following surgery of any severity and that such falls occur even when exogenous dilution cannot be implicated as a cause.
Thermogenesis after major elective surgical procedures
Authors: Carli F , Aber V R
Published: March 2007

Sequential changes of body temperature have been measured for 48 h in 147 patients after major elective abdominal, cardiac, orthopaedic and pelvic surgery. Core temperature (aural canal) started to increase immediately after surgery reaching a mean peak value of 37·5°C 14 h (range 8-16) after the end of surgery. Subsequently, a second peak of 37·4°C was shown 18 h (range 16-20) later. The time interval between these two peak temperatures was constant for all types of surgery studied. A close examination of core temperature oscillations during a 72-h postoperative period and a comparison with a pre-operative 24-h cycle in a group of 14 patients who underwent cardiac surgery did not show any circadian rhythm. In the third part of the study, analysis of postoperative body temperature and metabolic rate showed a similar pattern of increase for core and mean skin temperatures, and oxygen consumption.
Kinetic changes in experimental colonic urinary diversion
Authors: Strachan J R , Matthews Joyce , Rees H C , Cooke T
Published: March 2007

An experimental model of colonic urinary diversion was performed on male Wistar rats to see if faeces, urine or a faeces and urine mixture produces tumours. Cell kinetic techniques, including the crypt cell production rate, and cellular DNA measurement were used to examine the effect of urine and of faeces on the colonic mucosa. Urinary diversion into the colon significantly increased colonic crypt activity. Tumours were found at the anastomosis when urine and faeces were mixed at 4 months, and at 6 months with urine alone.
Discrimination is not impaired by excision of the anal transition zone after restorative proctocolectomy
Authors: Keighley M R B , Winslet M C , Yoshioka K , Lightwood R
Published: March 2007

Anal sensation has been assessed using a constant current stimulator in 21 patients after restorative proctocolectomy (15 J pouch, 6 W pouch). The anal transition zone (ATZ) has been excised in 15 patients but preserved in 6. Results were compared with 14 age- and sex-matched patients with ulcerative colitis (UC) and 14 controls. Median threshold values in the lower, mid and upper zones of the anal canal in pouch patients were: 6·8 mA, > 15·0 mA and > 15·0 mA respectively compared with 3·9 mA (P<0·01), 5·7 mA (P<0·01) and 11·4 mA (P<0·01) in UC and 3·5 mA (P<0·01), 4·2 mA (P<0·01) and 11·4 mA (P<0·01) in controls. The mid and upper zone threshold anal sensation was significantly lower when the ATZ had not been removed and except in the lower zone did not differ from UC or controls (median threshold sensations when ATZ was preserved were: lower zone, 5·8 mA; mid zone, 5·5 mA; upper zone, 7·5 mA). Paired studies in eight patients showed that excision of the ATZ was associated with a significant impairment in anal sensation (mid zone: 5·7 versus > 15·0 mA, P<0·05; upper zone: 7·5 versus > 15·0 mA, P<0·05) whereas no change in anal sensation was recorded when the ATZ was preserved. Despite these physiological changes, no clinical benefit could be identified in patients in whom the ATZ was preserved. Discrimination was normal in all except one patient. The incidence of soiling, nocturnal incontinence and failure to defer defaecation for more than 1 h was recorded in 3/15 patients (20 per cent) whose ATZ had been removed, compared with 1/6 patients (17 percent) in whom the ATZ had been preserved. We conclude that excision of the ATZ does not eliminate the ability to discriminate and does not increase the risk of impaired continence after ileo-pouch anal anastomosis.
The solid bolus oesophageal egg transit test: Its manometric interpretation and usefulness as a screening test
Authors: Eriksen C A , Holdsworth R J , Sutton D , Kennedy N , Cuschieri A
Published: March 2007

The standardized 99mTc-labelled solid bolus oesophageal egg transit test (OET) was developed for assessing oesophageal motility. Its value in detecting oesophageal motility disorders was compared with oesophageal manometry in 102 symptomatic patients. Of 32 patients with normal OET, 22 (68·8 per cent) had normal manometry, whereas of 61 patients with abnormal manometry, 51 (84 per cent) had abnormal OET (χ2 = 15·82, P<0·001). The computer-generated condensed image of the OET clearly defined five transit patterns: normal (n=32); oscillatory (n=21); non-clearance (n=16); ‘step’ delay (n=16) and non-specific delay (n=17). The oscillatory pattern occurred in only one patient with normal manometry, but in all six with manometrically defined achalasia and two with diffuse oesophageal spasm. The predictive value of a positive (abnormal) OET test in detecting abnormal motility (both specific and non-specific disorders) was 73 per cent, and for specific motility disorders was 100 per cent. The predictive value of a negative (normal) test in excluding specific motor disorders was 94 per cent. Manometric tertiary contractions and low amplitude waves occurred in 6/32 and 1/32 patients with normal OET but in 31/70 and 21/70 with abnormal OET (χ2 = 5·14, P<0·02; χ2 = 7·85, P<0·001 respectively). Patients showing oscillation demonstrated significantly more tertiary contractions (17/21) and low amplitude waves (12/21) compared with 20/81 and 10/81 patients without oscillation (χ2 = 20·47, P<0·001; χ2 = 17·22, P<0·001 respectively). The solid bolus oesophageal transit test provides an objective screening test of specific oesophageal motility disorders and should be performed before oesophageal manometry.
Recurrence of varices after oesophageal transection: Intra-operative and postoperative assessment by endoscopy
Authors: Koyanagi N , Iso Y , Higashi H , Kitano S , Sugimachi K
Published: March 2007

Intra-operative and postoperative endoscopy were used in 16 patients with portal hypertension to investigate whether intra-operative elimination of oesophageal varices by oesophageal transection with devascularization leads to prevention of variceal recurrence and rebleeding. Intra-operative elimination of the varices was achieved in 12 patients. In ten patients the varices recurred and in two cases rebled, during the follow-up period of 6-43 months (average 25 months). of the ten patients with recurrent varices, eight (including the two who bled acutely in the postoperative period) successfully underwent endoscopic injection sclerotherapy. Postoperative endoscopy was performed at 5-monthly intervals. It is concluded that intra-operative elimination of the varices will not prevent recurrence and that a closer follow-up using endoscopy more than three times a year is a significant aid in the management of these patients.
Surgical management of bleeding gastric ulceration
Authors: Rogers P N , Murray W R , Shaw R , Brar S
Published: March 2007

In a nine-year period from 1977 to 1985 sixty-one patients underwent surgery for bleeding gastric ulceration in the Western Infirmary, Glasgow. Nineteen patients were treated by partial gastrectomy, twenty-two had undersewing of the ulcer plus vagotomy and drainage and twenty had undersewing alone. Mortality in the three groups was 26, 45 and 10 per cent respectively. All groups of patients were similar in terms of age, severity of haemorrhage, delay before surgery and grade of surgeon performing the procedure. Out-patient follow-up (mean: 37 months) of patients treated by undersewing alone revealed that 73 per cent were symptom free. Treatment of bleeding gastric ulceration by undersewing alone is effective and should be considered in patients who require surgery.
Assessment of microtransducers in anorectal manometry
Authors: Miller R , Bartolo D C C , Roe A M , McC Mortensen N J
Published: March 2007

It has been reported that microtransducer-tipped catheters (transducer) produce reliable reproducible measurements which correlate well with water-filled balloon systems. Maximum resting pressure (MRP) and maximum voluntary contraction pressures(MVC) were compared using a standard station pull-through technique in 12 patients. There was a poor correlation for both MRP: microballoon, 115 cmH2O (60–160 cm H2O); transducer 60 (20–110), r = 0.62, P < 0.05, and MVC: microballoon, 202 (60–375); transducer, 175 (60–210), r = 0.42, n.s. To determine whether this was due to radial variation in pressures measured by the transducer, we studied a further 39 patients with both systems. At each station, transducer measurements were made at each of four quadrants. We found better correlation for MRP: microballoon, 100 (40–175); transducer, 66 (34–120), r = 0.72, P < 0.001, and MVC: microballoon, 225 (55–650); transducer, 180 (50–470), r = 0.87, P < 0.001, but a significant radial variation for the transducer where rotation reduced MRP pressure measurements by 21 per cent (0–600 per cent), and MVC 17 per cent (0–76 per cent). Moreover there was a significant difference between anterior and posterior MRP in the upper anal canal, anterior 35 (5–80) versus posterior 25 (10–60), P < 0.05. These results account for the poor correlation between random positioning of the microtransducer-tipped catheter and indicate that radial orientation must be taken into account.
Use of myocutaneous flaps for primary cover following lymph node dissection for malignant melanoma
Authors: Morgan R H , Horgan K , Hughes L E
Published: March 2007

We report seven patients undergoing palliative surgery for advanced malignant melanoma, who required wide excision of skin and underlying tissue in association with lymph node dissection. In each case, primary closure of the wound was facilitated by the use of a myocutaneous flap. Four ilio-inguinal lymph node dissections were closed with rectus abdominis flaps, two cervical dissections were closed with a pectoralis major flap, and a limited latissimus dorsi flap was used for one axillary clearance. Primary healing was achieved in all cases; morbidity was low, with one wound infection and two limited lymphatic collections. All donor sites were closed primarily and healed well. We conclude that in selected patients the use of a myocutaneous flap procedure gives excellent coverage of large defects with low morbidity. In particular, there is rapid convalescence and return of good function after palliative resections, while the wide excision minimizes local recurrence where the tumour is in proximity to overlying skin.
Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma
Authors: Dent D M , Madden M V , Price S K
Published: March 2007

The contention that the R2 radical gastrectomy for localized and potentially curable gastric carcinoma may be superior to gastrectomy without lymphadenectomy (R1) was assessed by randomized trial. Five years after commencement 403 patients have been evaluated at surgery and only 43 (11 per cent) found eligible (S0–2, P0, H0, N0–1), 22 of whom underwent R1 and 21 R2 gastrectomy. Seven patients had final histological stages in excess of the protocol. The R2 group had a longer operating time (P<0.005), a greater blood transfusion requirement (P<0.005), a longer hospital stay (0.05>P>0.025) and required reoperation in four cases. There were no postoperative deaths. Four patients have died from the disease in the R1 group and five in the R2 group, there being no difference in the probability of survival at a median follow-up of 3.1 years. The small proportion of patients suitable for radical R2 surgery, the high associated morbidity and the fact that survival advantage has yet to be proven in trial suggest that this procedure should not yet be performed outside of controlled clinical trials.
A rational technique for surgical operation on Borrmann type 4 gastric carcinoma: Left upper abdominal evisceration plus Appleby's method
Authors: Furukawa H , Hiratsuka M , Iwanaga T
Published: March 2007

Borrmann type 4 gastric carcinoma, including linitis plastica, is difficult to detect at an early stage and the results of surgical treatment remain poor. We have used ‘left upper abdominal evisceration plus Appleby's method (LUAE + Apl.)’ as a radical surgical procedure for this disease. During the period 1983–86, 30 cases of Borrmann type 4 gastric carcinoma underwent this procedure (Group A). These cases were compared with 30 patients who underwent total gastrectomy with pancreaticosplenectomy (Group B) during the period 1980–82. Although this is not a randomized study and the extent of resection was greater in Group A, the operation time, amount of blood loss, and number of complications were similar for both methods. When the survival rates were compared, the 3-year survival rate in stage II-III cases was higher for Group A (83.3 per cent) than for Group B (42.2 per cent) (P<0.05). One patient in Group A and 12 patients in Group B died with peritoneal metastasis within 3 years of operation in stage II-III. The LUAE + Apl. method is a rational and useful technique for the surgical treatment of Borrmann type 4 gastric carcinoma.
Non-invasive treatment for retained common bile duct stones in patients with T tube in situ: Saline washout after intravenous ceruletide
Authors: Tritapepe R , Di Padova C , Di Padova F
Published: March 2007

The combination of ceruletide-induced relaxation of the sphincter of Oddi plus flushing with saline has recently been proposed as a novel procedure for the treatment of residual common bile duct (CBD) stones. In this study we have administered intravenous ceruletide (2 ng kg−1 body weight min−1 for 1 h) plus intraductal saline (800–3000 ml, infused at a rate that kept biliary pressure below 30 cmH2O) to a group of 14 patients. The treatment induced the passage of residual stones in 11 subjects (79 per cent) with complete clearance in 7 (50 per cent). The majority of the cleared concretions (11/15) had a diameter < 10 mm. No severe side-effects were recorded during the treatment. Four of the seven subjects who exhibited incomplete CBD clearance underwent a short cycle of mono-octanoin administration in order to reduce the size of residual radiolucent stones. This course of treatment was followed by another attempt with intravenous ceruletide and saline washout which gave a successful response in an additional three cases. These data indicate that the combination of ceruletide and flushing is a safe and inexpensive method for treatment of residual stones. The procedure is feasible for both radiolucent and radio-opaque stones and is mainly eligible for small concretions of diameter <10 mm. Larger (>10 mm) radiolucent stones may be partially dissolved with mono-octanoin and then eliminated by the washout technique.
Pancreatitis and hyperparathyroidism
Authors: Sitges-Serra A , Alonso M , De Lecea C , Gores P F , Sutherland D E R
Published: March 2007

Hypercalcaemia is considered to be a rare cause of pancreatitis but the true cause-and-effect relationship between hyperparathyroidism and pancreatic inflammatory disease remains controversial. Over 100 patients have been reported in whom both processes have occurred concurrently, but doubts have been expressed as to whether or not this association is due to chance. We report 10 new cases of hypercalcaemic hyperparathyroidism associated with different types of pancreatitis. Seven patients had primary hyperparathyroidism and three had hyperparathyroidism after renal transplantation. Two experienced acute pancreatitis after parathyroidectomy. of the remaining eight patients, five had hypercalcaemia equal to or above 120 mg/l. The prevalence of pancreatitis in our series of 86 cases of primary hyperparathyroidism is 8 per cent. Acute and chronic calcifying types of pancreatitis were observed. Three patients died of the disease, two of them after renal transplantation. It is suggested that pancreatitis may complicate the clinical course of hyperparathyroidism, particularly when hypercalcaemia is moderate to severe and/or there are other risk factors such as treatment with steroids and azathioprine after renal transplantation.
Approach to ingrowing toenails: The wedge resection/segmental phenolization combination treatment
Authors: Issa M M , Tanner W A
Published: March 2007

One hundred and seventy procedures were performed on one hundred and forty patients with ingrowing toenails. Each patient was randomly allocated to one of three treatment groups. There were 55 wedge resections (WR), 53 segmental phenolizations (SP) and 62 wedge resection/segmental phenolization combination treatments (WR/SP). All patients were followed up for 6 months. The duration and intensity of postoperative pain was assessed and the recurrence rate monitored. Postoperative pain was less in the WR/SP group (9.4 ± 13.5 h) than in the WR group (30.0 ± 37.6 h, P<0.001). There were seven recurrences in the WR group, four in the SP group, and none in the WR/SP group. The results in the WR/SP group were statistically significant when compared with the WR group (P<0.01) and with the SP group (P<0.05). We conclude that the WR/SP combination procedure is a superior form of treatment for ingrowing toenails.
Smooth muscle tumours of the digestive tract: Report of 160 cases
Authors: He L-J , Wang B-S , Chen C-C
Published: March 2007

Of 160 patients seen in the period 1951–84 with smooth muscle tumours of the digestive tract, 71 proved to have leiomyomas, 87 had leiomyosarcomas and 2 had leiomyoblastomas. Tumour diameter was frequently greater in patients with leiomyosarcoma. The surgical mortality was 2.8 per cent after treatment of leiomyoma and 10.3 per cent after treatment of leiomyosarcoma. After resection of leiomyosarcoma the 2-year survival rate was 86 per cent and the 5-year survival rate was 43 per cent. The only hope of cure of these malignant lesions lies in surgical resection but, even when the lesion is incurable, resection may allow worthwhile palliation.
Surgical approaches to vertebral artery injuries
Authors: Hatzitheofilou C , Demetriades D , Melissas J , Stewart M , Franklin J
Published: March 2007

Twenty patients with penetrating injuries of the vertebral artery who were treated as emergencies were subjected to the following operative approaches: five cases, Henry's approach (posterior) and modified Henry's approach (anterior); five cases, limited exposure and application of metal clips; four cases, plugging of the arterial defect with Oxycell or crushed muscle; three cases, control with ligatures and non-conventional exposure of the artery; one case, inflation of a balloon catheter within the vertebral canal; one case, repair of the lacerated first extraosseous part of the vertebral artery. One patient died from exsanguination on the operating table, before any repair was possible. The overall mortality was 20 per cent and the mean hospital stay 6·1 days. Thirty-five per cent of the patients presented with neurological complications, and 55 per cent left the hospital well. No advantage of Henry's classical approach over limited exposure and control with metal clips was shown, when mortality, hospital stay and long-term problems were compared. Because of its relative simplicity we suggest that the metal clipping of the vertebral artery, above and below the site of injury, is an effective technique that can be used to stop the bleeding. One case presented as a false aneurysm of the vertebral artery, following a stab wound. This was successfully treated with excision of the aneurysm and vertebrovertebral artery bypass, using a saphenous vein graft.
Angiodysplasia of the colon: Endoscopic diagnosis and treatment
Authors: Santos J C M , Aprilli F , Guimarães A S , Rocha J J R
Published: March 2007

Of 34 patients with massive lower intestinal bleeding, 17 (11 men and 6 women, age range 33–85 years; mean 64·8 years) were diagnosed as having angiodysplasia of the colon. The diagnosis was made by colonoscopy and the lesions were treated successfully by fulguration in 13 (86·6 per cent) of 15 patients. Two of the 17 patients underwent surgical resection of the involved intestinal segment. One patient still has sporadic intestinal haemorrhage, and another patient died from bleeding of the left colon after blind right colectomy. The remaining 13 patients have had no further bleeding in the 1–7 years following colonoscopic fulguration. Colonoscopy is a useful method of diagnosing angiodysplasia of the colon and affords the possibility of treatment.
Recurrent inguinal hernia: A personal study
Authors: Marsden A J
Published: March 2007

A personal series of 287 recurrent inguinal hernias repaired by a single consultant surgeon is presented. Four techniques of repair were employed in the series: Bassini operation; a posterior ‘lace repair’; complete closure of the canal after division of the spermatic cord and local repair of isolated defects. The overall recurrence rate, 27 failures in 287 operations (9 per cent) is disappointing. The best technique is excision of the cord and canal closure, two failures in 43 operations (5 per cent). Cord excision does carry a risk of testicular complications.
Gastric outlet loss and enterogastric reflux after gastrectomy
Authors: Iici T , Whitfield P F , Boulos P B , Hobsley M
Published: March 2007

The relationship of gastric secretion in response to a single injection of insulin and in response to a histamine infusion, before and after partial gastrectomy, was analysed in 58 patients. The aspirated gastric juice was corrected for gastric outlet loss and enterogastric reflux. Gastrectomy drastically reduced the stimulated gastric secretion by a similar proportion for the two secretagogues, thereby implying that antral gastrin plays no greater part in one than in the other. Gastric outlet losses were also reduced after gastrectomy, but as a fraction of gastric contents, both gastric outlet loss and enterogastric reflux more than doubled; the possible relationship of these findings to the aetiology of gastric ulcer is discussed.
Treatment policy for the management of carcinoma of the oesophagus
Authors: Desa L , Raghunath A S , Chawla S L , Peel A L G , Dellipiani A W
Published: March 2007

The management of 120 consecutive patients with carcinoma of the oesophagus, treated in a district general hospital over a 10-year period is reviewed. The treatment options were by endoscopic methods, radiotherapy, surgery or a combination of these. Adenocarcinoma was the most frequent histological type (51 per cent) and 41 per cent of patients had squamous carcinoma. In addition to survival the quality of swallowing and the incidence of late complications following the treatment options was assessed. Primary surgery was carried out in 21 cases (operability rate 17·5 per cent) and 81 per cent of these cases were resectable. The overall operative mortality rate was 14·3 per cent (6 per cent in resected cases) and the 5-year survival rate was 9·5 per cent. After primary radiotherapy only 5 per cent of patients survived 2 years. The majority of patients were treated by endoscopic intubation with an overall mortality of 16·6 per cent and a mean survival of 5·5 months. Patients treated surgically experienced the best symptomatic relief and had the lowest incidence of late complications, when compared with those treated differently. However the overall results of surgery were poor and there remains the need to compare the results of surgery and radiotherapy in similar groups of patients.
Comparison of colonic reservoir and straight colo-anal reconstruction after rectal excision
Authors: Nicholls R J , Lubowski D Z , Donaldson D R
Published: March 2007

The clinical and physiological results in 13 patients having a colonic J reservoir-anal anastomosis (CR) and 15 consecutive patients having a straight colo-anal reconstruction (SC) have been compared. The groups were matched for age, sex, level of tumour and proximal and distal resection margins. The incidence of postoperative complications was similar in each group. The mean follow-up in CR patients was 7 ± 4 months and 47 ± 23 months in SC patients. Stool frequency per 24 h was ⩽ 2 in all CR patients while it was > 2 in 40 per cent of the SC patients (P < 0·05). Three CR patients and six SC patients had minor incontinence, all but one of the rest were fully continent. One patient had a major leak. There was no significant difference in mean resting anal voluntary contraction pressure in the two groups, with mean values within the normal range. The mean rectal sensitivity threshold volume in CR patients (83 ± 30 ml) and SC patients (52 ± 22 ml) was significantly different (P < 0·05) as was the mean maximum tolerable volume (317 ± 122 ml and 174 ± 83 ml respectively, P<0·01). There was no significant difference in balloon expulsion testing, defaecating proctography or methyl cellulose evacuation in the two groups. The addition of a colonic reservoir appears to avoid the high stool frequency occurring in some patients after straight colo-anal anastomosis.
Clinical and functional results after restorative proctocolectomy
Authors: Pescatori M , Mattana C , Castagneto M
Published: March 2007

Of 84 patients who underwent restorative proctocolectomy with an ileoanal reservoir in 21 Italian departments of surgery, 51 had ulcerative colitis, 32 familial polyposis and 1 intractable constipation. Follow-up information is available for all 58 patients who had their ileostomy closed, the length of follow-up ranging between 2 and 78 months. There were no operative deaths. A failure rate (i.e. excision of the pouch) of 3 per cent was observed. Sepsis was the most common postoperative complication, and was most often related to ileoanal anastomosis dehiscence (15 per cent), followed by small-bowel obstruction requiring laparotomy (10 per cent). Clinical ‘pouchitis’ occurred in 14 per cent of patients after ileostomy closure. The average frequency of defaecation was four motions per 24 h; evacuation was spontaneous in all patients and only 5 per cent complained of troublesome faecal soiling while 34 per cent had occasional incontinence to flatus and mucus. Patients with a short or absent rectal cuff had a lower rate of incontinence (30 versus 48 per cent, difference not statistically significant) without any increase in the frequency of genito-urinary disorders. None of the two most used reservoirs, the J (n = 40) and S pouch (n = 17) showed significant superiority in terms of bowel frequency and continence. Incontinence was more likely in patients whose ileostomy closure had been delayed for more than one year.
Growth-promoting action of gastrin on human colonic and gastric tumour cells cultured in vitro
Authors: Watson S A , Durrant L G , Morris D L
Published: March 2007

The gastrointestinal hormone, gastrin, was examined for its trophic effect on the growth of colorectal and gastric tumour cells. All of the freshly disaggregated colorectal and gastric human adenocarcinomas responded to pentagastrin in 24 hcultures in vitro. Two newly established adenocarcinoma cell lines showed a response to pentagastrin at passage 2 but not at passage 6. Long-established cell lines did not respond to pentagastrin; however, upon synchronization of the human gastric cell line, MKN45, a trophic growth response with gastrin-17 was observed. This response was enchanced when the same cell line was grown as a xenograft in nude mice and then examined in vitro for gastrin dependence; this dependence was gradually reduced on further in vitro passaging. These results indicate that trophic responses to gastrin are lost during in vitro culture and may be underestimated by using long-established tumour cell lines. However, as all of the early cultures of colorectal and gastric tumours respond trophically to gastrin, perhaps gastrin-receptor blockers may be an important therapeutic modality for these patients.
Influence of age on the mortality from acute pancreatitis
Authors: Fan S T , Choi T K , Lai C S , Wong J
Published: March 2007

The influence of age on the mortality rate of 268 patients with acute pancreatitis was studied. The hospital mortality rate for patients aged below 50 years was 5·9 per cent. The figure increased to 21·3 per cent in patients aged over 75; the high mortality was accounted for by a higher incidence of deaths related to concomitant medical or surgical diseases in the same hospital admission rather than to complications resulting directly from the pathological process of acute pancreatitis. When only deaths due to complications of acute pancreatitis were analysed, the mortality rate was not significantly different between the young and elderly groups. Moreover, the complication rate and the proportion of patients having severe disease (judged by the number of prognostic signs) were not higher in the elderly. Thus acute pancreatitis was intrinsically not more serious were it not for the presence of concomitant diseases with advanced age.
Hepatic metastases from colorectal cancer: Resection or not
Authors: Greenway B
Published: March 2007

This review evaluates the available evidence dealing with the natural history of hepatic metastases in patients with colorectal cancer. Methods of detection of such metastases are discussed and the factors influencing survival after surgical resection are reviewed.
Continuous enteral nutrition during the early adaptive stage of the short bowel syndrome
Authors: Levy E , Frileux P , Sandrucci S , Ollivier J M , Masini J P , Cosnes J , Hannoun L , Parc R
Published: March 2007

Sixty-two patients with the short bowel syndrome (30–150 cm) were managed by continuous enteral nutrition (CEN) in the early adaptive phase. In all, 82 per cent were referrals from other units and 85 per cent of referrals had failure of one or more organ systems on admission. There were intra-abdominal abscesses in 41 per cent of patients and 37 per cent had an enterocutaneous fistula. The diet included polysaccharides, medium chain triglycerides and protein hydrolysates, mixed with a high-viscosity tapioca suspension. An elemental diet was used initially in 15 per cent of patients. Thirty-three patients had an interruption of the gastrointestinal tract by a temporary enterostomy. Chyme was re-infused into the distal intestine in 20 cases. ‘Zero-time’ was taken as the time of operation or, for referred patients treated conservatively, the date of admission. CEN was commenced at a mean of 14 days from zero-time. Total parenteral nutrition could be discontinued at a mean of 36 days and exclusive oral alimentation was resumed at a mean of 87 days. Patients with small bowel longer than 80 cm attained enteral autonomy earlier than patients with a shorter length. Mean faecal volume did not increase following institution of CEN, suggesting tolerance to the high-viscosity diet. In cases with re-infusion of enteric content, the distal circuit (length of distal small intestine 46 cm) was able to absorb 70 per cent of the volume re-infused (mean volume 2700 ml). Body weight and nutritional markers increased significantly during the course of CEN. This study suggests that enteral autonomy can be attained early in the short bowel syndrome, even under challenging conditions. Elemental formulae do not appear to offer a benefit over polymeric diets.