bluuebunny/crossref_metadata_2025 huggingface dataset:
Pulsion intubation v. retrosternal gastric bypass for palliation of unresectable carcinoma of the upper thoracic oesophagus
Authors: Angorn I B , Haffejee A A
Published: March 2007

The optimum method of restoring the ability to swallow in patients with oesophageal carcinoma remains controversial. This prospective randomized study evaluates the palliative potential of pulsion intubation v. retrosternal gastric bypass of the excluded oesophagus in 106 patients with unresectable carcinoma; 55 patients were intubated and 51 patients treated by gastric bypass. The operative mortality and morbidity, palliation of dysphagia and postoperative nutritional status were compared in the 2 groups. Intubation resulted in 3 deaths (5·5 per cent) and gastric bypass in 4 deaths (7·8 per cent). Intubation was complicated by chest infection in 13 patients (24 per cent) but complications related to the procedure occurred in only 5 patients and included tube migration (2), respiratory obstruction (1), bleeding (2) and oesophageal perforation (1). Gastric bypass was complicated by chest infection in 14 patients (27 per cent), but procedure-related complications were common and included pneumothorax (3), wound infection (6), subphrenic abscess (2), anastomotic leak (5) and purulent neck discharge (3). Palliation of dysphagia was achieved in 93 per cent of patients following intubation and 92 per cent of patients following bypass. Nutritional status improved more rapidly following intubation. Pulsion intubation is the preferred palliative procedure because of fewer complications and a lesser degree of postoperative catabolism.
A prospective randomized trial of vagotomy in chronic duodenal ulceration: 4-year follow-up
Authors: Koffman C G , Hay D J , Ganguli P C , Elder J B , Gillespie I E , Mantoudis S M , Tweedle D E F , Schofield P F , Palmer M
Published: March 2007

A total of 153 patients (124 male and 29 female) with uncomplicated chronic duodenal ulceration were studied in a prospective, randomized trial of proximal gastric vagotomy (PGV) and truncal vagotomy and pyloroplasty (TVP), conducted in four Manchester hospitals. Of these, 137 patients have now been followed up for 2·5 to 5·5 (mean 4·1) yr. There have been 15 (21 per cent) recurrent ulcers following PGV compared with 5 (7·5 per cent) after TVP (P < 0·05). A satisfactory functional result was obtained in 82 per cent of patients after TVP compared with 73 per cent following PGV and there was little difference between the groups with regard to the incidence of dumping, heartburn and vomiting. There was significantly more diarrhoea following TVP (13 per cent) compared to PGV (1·4 per cent) but this represented only a minor clinical problem.
Symptoms and signs of operable breast cancer 1976–1981
Authors:   The Yorkshire breast cancer group, Benson E A
Published: March 2007

The symptoms and signs of operable breast cancer in 1205 women are reviewed, and in a considerable proportion classic signs are absent. Of the patients 73 per cent were postmenopausal and 76 per cent of cancers presented as discrete lumps. Pain as a presenting symptom was rare (5 per cent), but when questioned 33 per cent of women admitted that the lump was painful. Some 42 per cent of patients had skin tethering or fixation, only 22 per cent had nipple retraction or displacement, and 42 per cent had lesions which appeared to have well-defined edges. Only 32 per cent of lesions were clinically T0 or T1, the majority (56 per cent) being T2, and 12 per cent were T3.
Gastric ulceration after Nissen fundoplication
Authors: Campbell R , Kennedy T , Johnston G W
Published: March 2007

Thirteen patients developed gastric ulcers between 6 months and 8·5 years after Nissen fundoplication. Eight patients presented with epigastric pain alone, 3 with bleeding alone and 2 with both pain and bleeding. Nine ulcers (69 per cent) were high on the lesser curve, close to the fundoplication and 7 of these patients had recurrent hernias. Anatomical distortion produced by fundoplication is probably the most important aetiological factor, though gastric distension, bile reflux gastritis and ischaemia may be contributory.
Transabdominal oesophageal transection for oesophageal varices: Experience in 101 patients
Authors: Umeyama K , Yoshikawa K , Yamashita T , Todo T , Satake K
Published: March 2007

The results of transabdominal oesophageal transection in 101 patients with oesophageal varices are reported. The primary diagnosis was liver cirrhosis in 65 patients, idiopathic portal hypertension in 29 and extrahepatic portal obstruction in 7. Twelve patients died postoperatively. The mortality rate for emergency operations was higher than that for elective and prophylactic procedures. The majority of patients died from hepatic failure. Improvement, judged by radiographic and endoscopic examination, was 100 per cent and 96 per cent, respectively. Post-transection rebleeding was observed in 14 of 89 patients during the follow-up period of 1–13 years. There were 25 late deaths, caused mainly by hepatic failure. The 5-year survival rate, including postoperative deaths, was 72 per cent in idiopathic portal hypertension and 55 per cent in liver cirrhosis. We suggest that transabdominal oesophageal transection is an acceptable operative procedure for oesophageal varices.
Preoperative urography in large bowel cancer: A useless investigation?
Authors: Phillips R , Hittinger Rosemary , Saunders Valerie , Blesovsky Lynda , Stewart-Brown Sarah , Fielding P
Published: March 2007

The utility of intravenous urography (IVU) in the preoperative assessment of patients with adenocarcinoma of the large bowel has been investigated in 4226 patients derived from a prospective multicentre study entitled the Large Bowel Cancer Project. An IVU was carried out in 956 of these patients (22·6 per cent), subsequent surgery revealing unsuspected direct urinary tract involvement in 75. However, 42 (56 per cent) had shown no IVU abnormality. Twenty patients having a clinical colovesical fistula had had a preoperative IVU. Only half showed an abnormality. In the entire study group, 10 nephrectomies and 40 other concomitant urinary tract resections were performed. Four of these nephrectomies were associated with right-sided tumours. A significantly higher number of patients with a rectal primary had a preoperative IVU. The value of routine preoperative urography before large bowel cancer surgery is questioned, and other methods of determining function in the other kidney before nephrectomy should be sought.
A physiological appraisal of polyethylene glycol and a balanced electrolyte solution as bowel preparation
Authors: Ambrose N S , Johnson Margaret , Burdon D W , Keighley M R B
Published: March 2007

Seventy-seven patients undergoing bowel preparation with either sennosides and rectal washout (S + RWO; n = 26) or polyethylene glycol and a balanced electrolyte solution (PEG + E) given orally (n = 25) or by nasogastric infusion (n = 26) have been studied. PEG + E was not associated with significant physiological change in electrolytes or blood gases. Patients tolerated PEG + E well and it provided a moderate to good bowel preparation in over 80 per cent of cases. PEG + E was not associated with a change in colonic microflora and was not associated with explosive mixtures of colonic gas due to hydrogen. It is therefore a safe, quick and efficient bowel preparation and provides a safer alternative to mannitol. The solution (PEG + E) may be used orally or by nasogastric infusion and does not require an accompanying intravenous infusion.
Influences of splanchnic nerve blockade on endocrine-metabolic responses to upper abdominal surgery
Authors: Tsuji H , Shirasaka C , Asoh T , Takeuchi Y
Published: March 2007

Twelve patients undergoing gastrectomy received combined epidural and splanchnic nerve blockade (Group E&S), and changes in plasma ACTH, cortisol, glucose and FFA were compared with those undergoing gastrectomy under general anaesthesia (Group G) or epidural analgesia alone (Group E). Plasma ACTH increased in all groups on the day of operation and was significantly higher in Group G than the other groups. Levels of ACTH in Group E&S were lower than Group E, but the differences were not significant. Cortisol response in Group G was most pronounced and prolonged. This cortisol response was significantly attenuated in Group E and was further inhibited in Group E&S. Blood glucose and FFA increased in Groups G and E during the operation but the increase was significantly less in Group E. In Group E&S, glucose and FFA concentrations showed practically no change throughout the study, being significantly lower than in Group E. The results indicated that the splanchnic nerve is responsible for producing endocrine-metabolic responses to gastric surgery even under epidural blockade.
The quality of life after rectal excision for low rectal cancer
Authors: Williams N S , Johnston D
Published: March 2007

The quality of life for patients with carcinoma of the lower two-thirds of the rectum (5–12 cm from the anal verge) treated by abdominoperineal resection (APER, n = 38) was compared with that of a similar group of patients treated by low sphincter saving resection (SSR, n = 40). Assessment was by questionnaire conducted a minimum of one year after operation. Thirty patients (75 percent) after SSR were entirely continent and ten patients (25 percent) had occasional episodes of incontinence. Each patient with a colostomy was incontinent and 25 (66 per cent) had leaks from their appliance (12 frequent; 13 occasional). Patients after APER avoided more items in the diet and took more medication to control their bowel habit than patients after SSR. Fifteen of the 18 patients (83 percent) who were employed before SSR returned to work after operation; only 6 of 15 patients (40 percent) returned to work after APER (P < 0.05). Sexual function was impaired in 6 of 20 men (30 percent) after SSR and in 12 of 18 men (67 percent) after APER (P < 0.06). Depression was significantly more prevalent after APER than after SSR. Patients with low rectal cancer who are treated by modern sphincter saving resection have a quality of life superior to those who are treated by APER.
Limitations of immune complex measurements in colorectal disease
Authors: Hobbiss J , Cooper K M , Moore M , Gowland E , Schofield P F
Published: March 2007

Three techniques (Clq, Raji and L1210 binding assays) alleged to measure circulating immune complexes (ICs) were applied to the sera of 101 patients with colorectal disease (54 carcinoma; 23 inflammatory; 13 benign tumour and 11 miscellaneous) at the time of diagnostic or definitive surgery, and 58 healthy adult controls. Elevated levels in the pathological sera were observed by all 3 methods in order of sensitivity: Raji > Clq > L1210. However, none of them differentiated between benign, inflammatory and neoplastic conditions nor, in the case of colorectal carcinoma, was there any correlation with stage of disease. With the exception of Raji v. L1210 (r = 0·43, P < 0·001), correlations between the various assays were poor and levels of serum carcinoembryonic antigen (CEA) did not correlate with ICs measured by any of the techniques. Indeed, the IC assays were even less discriminatory than CEA, which was elevated mainly in the serum of carcinoma patients and which was positively correlated with serum γ-glutamyl transpeptidase (γ GT) (r = 0·42, P < 0·005). The data suggest that the lack of concordance between the IC assays is a reflection of heterogeneity among ICs, interfering factors present in pathological sera, or both. Thus the IC assays deployed here have neither diagnostic nor prognostic utility in colorectal disease at this time, and immunochemical characterization of the serum reactive material detected by the different assays is required.
The role of percutaneous transhepatic cholangiography and grey-scale ultrasound in the investigation and treatment of bile duct obstruction
Authors: Gibbons C P , Griffiths G J , Cormack Anne
Published: March 2007

A total of 123 patients undergoing fine needle percutaneous transhepatic cholangiography (PTC) in Newport between 1977 and 1981 are reviewed. PTC was well tolerated with a 9 per cent complication rate, a 5 per cent failure rate and no mortality. Of 111 patients in whom a diagnosis of biliary obstruction was subsequently confirmed, PTC showed the presence of obstruction in 94 per cent, its site in 92 per cent and the correct cause in 87 per cent. Eighteen jaundiced patients were spared laparotomy on the basis of the PTC findings. Grey-scale ultrasound scanning was performed in 99 of these patients. Of 93 with subsequently verified biliary obstruction, ultrasound confirmed the presence of obstruction in 66 per cent, its site in 33 per cent and its cause in 29 per cent. It is concluded that PTC is the more useful investigation in the management of biliary obstruction and that its use may avoid unnecessary surgery.
Sequential bone scans and chest radiographs in the postoperative management of early breast cancer
Authors: Chaudary M A , Maisey M N , Shaw P J , Rubens R D , Hayward J L
Published: March 2007

A total of 241 patients with early breast cancer had serial bone scans and chest radiographs during the first two years of follow-up after primary treatment. Each patient had had a modified radical mastectomy and been found to have involved axillary nodes. They were part of a prospective randomized trial testing the use of l-phenylalanine mustard l-PAM as adjuvant chemotherapy. During the two years, these patients had a total of 832 serial bone scans and 1091 serial chest radiographs. Twenty-five patients (10·4 per cent) had bone metastases detected on sequential scanning, only 13 of whom, however, were asymptomatic at the time of the positive scan. Twelve (5 per cent) patients were found to have pulmonary metastases on routine sequential chest radiography of whom only 8 were asymptomatic at the time of the positive chest radiograph. It is concluded from this study that, apart from their usefulness in the monitoring of clinical trials, serial bone scans and chest radiographs cannot be recommended routinely in the follow-up of asymptomatic patients because of the low yield and high cost involved.
The mechanical properties of glutaraldehyde stabilized human umbilical vein measured in vivo
Authors: Chapman B L W , Charlesworth D
Published: March 2007

Vascular prostheses, when used to bypass the femoral and popliteal arteries, and particularly if the bypass is made to the distal part of the tibial arteries, seldom remain patent, or if they do then for only a limited period of time. Femorotibial bypass with modified human umbilical vein is relatively successful in selected patients and one explanation may be that it resembles human arteries more than other prostheses. We have developed a method of calculating the asymptotic phase speed, from the propagation constant and from this the characteristic impedance of a bypass (all of which characterize viscoelastic behaviour). Calculations were made on measurements of pressure made in vivo. Twenty patients who had a femorotibial bypass, using glutaraldehyde stabilized umbilical vein, were studied and, from measurements of pressure made at operation, we calculated the asymptotic phase speed and the characteristic impedance of the prostheses. Results show that the viscoelastic properties of newly implanted umbilical vein are comparable to those of autogenous saphenous vein.
Antibiotic concentration in the exudate of venous ulcers: The prediction of ulcer healing rate
Authors: Hopkins N F Gowland , Jamieson C W
Published: March 2007

We have designed a test to measure the local circulatory insufficiency in the base of chronic venous ulcers by measuring the concentration of Cefuroxime in the ulcer exudate following a single intravenous injection of the antibiotic at a dose of 500 mg/m2. We have studied 28 patients with 42 ulcers and shown that the concentration achieved increased with in-patient conservative treatment (P < 0·01), decreased again on discharge from hospital if the ulcers had not healed (P < 0·01) and correlated with observed healing rates (r = 0·72). This test may assist in the clinical management of these cases by predicting healing rates and the likely outcome of conservative treatment.
Bile acid receptors in colorectal cancer
Authors: Summerton J , Flynn M , Cooke T , Taylor I
Published: March 2007

Bile acids are thought to be involved in both the aetiology and development of colorectal cancer. In this study the existence of specific bile acid receptor proteins has been postulated. A receptor assay which involved labelling with 14C-deoxycholic acid was performed as well as autoradiography using 3H-deoxycholic acid. In an initial study resected colorectal cancer and adjacent histologically normal colorectal mucosa from 39 patients were studied, as were samples of normal gastric mucosa, cancers and benign colorectal tumours. Specific receptors to deoxycholic acid were detected in 12 (30·8 per cent) of the colorectal cancers, but in only 1 (2·6 per cent) of the samples from normal colorectal mucosa (χ2 = 11·16, P < 0·005). No deoxycholic acid receptors were detected in any other tissue studied. Autoradiographs of colorectal cancers showed binding of 3H-deoxycholic acid in receptor-positive tumour tissue. These findings might provide some explanation for the evidence linking bile acids with the disease.
Oesophageal intubation for advanced oesophageal cancer: The Baragwanath experience 1977–1981
Authors: Diamantes T , Mannell Aylwyn
Published: March 2007

Oesophageal intubation was performed for 324 patients with advanced squamous cell carcinoma of the oesophagus. Peroral pulsion and traction techniques were used. There were 88 deaths in hospital (mortality rate, 27 per cent). The mortality rate did not appear to be directly related to the general condition of the patient or to the experience of the operator. Adequate palliation of dysphagia was achieved in 61 per cent of intubated patients, but a high rate of late complications impaired the quality of life following intubation. It is concluded that the insertion of an oesophageal tube was neither a safe nor satisfactory method for palliation of malignant dysphagia.
The value of operative pancreatography
Authors: Cooper M J , Williamson R C N
Published: March 2007

Between 1978 and 1982 operative pancreatography was undertaken in 39 patients (mean age 47 years) using 1 of 4 different techniques. Final diagnoses were chronic pancreatitis (15), isolated dorsal pancreas (10), carcinoma head of pancreas (3), acute pancreatitis (3) and miscellaneous pancreatic conditions (8). Retrograde (transduodenal) pancreatograms were successfully obtained in 10 of 12 patients, including 3 via the minor papilla. Prograde cannulation was achieved after distal pancreatectomy in 15 of 16 patients, 10 of whom had an isolated dorsal pancreas. ‘Ambigrade’ pancreatography was performed after direct puncture of a palpable duct in 6 patients and cystography in another 5 patients with pseudocysts. No complications of pancreatography were seen and the radiological findings modified the operative procedure in 16 patients (41 per cent).
Localization and excision of occult breast lesions
Authors: Chetty U , Kirkpatrick A E , Anderson T L , Lamb J , Roberts M M , Humeniuk V , Forrest A P M
Published: March 2007

Between 1976 and 1982, 190 non-palpable mammographic abnormalities considered to be suspicious of malignancy were excised using a needle localization technique. The indications for biopsy, technique for localization, method for confirmation of excision and histopathological preparation are presented. The histopathological diagnosis of these lesions were 150 benign and 40 malignant. There was no clear correlation between the mammographic appearances and the occurrence of cancer. Compared with 100 consecutive women with palpable breast cancer the impalpable and mammographically detected tumours were smaller, more often non-invasive and associated with negative axillary nodes.
The role of protease in immunoregulation
Authors: Donnelly P K , Shenton B K , Alomran A M , Francis D M A , Proud G , Taylor R M R
Published: March 2007

Whilst immunodepression is widely recognized in patients subject to trauma or chronic disease, the mechanism of this process is poorly understood. We found that most of the lymphocyte suppressive activity of plasma from severely ill patients was attributable to the protein α2-macroglobulin (α2M) and low molecular weight peptide (<10 000). The only major variation in α2M concentration was found in patients subject to trauma, when it was depressed at times of high plasma suppressive activity. In order to explain qualitative immunosuppressive differences in α2M we studied its functional role as the main route for binding and degrading proteolytic enzyme (protease). In normal plasma minor degrees of protease complex formation to α2M caused greatly increased suppressive activity due principally to α2M and the abnormal appearance of low molecular weight peptide (≤10 000). Study of protease inhibitor function in patients suffering from acute or chronic illness suggested that in these patients their plasma becomes immunosuppressive due to inadequate handling of protease, resulting in α2M-protease complexes or inhibitory peptides persisting in the circulation. Opportunities for background immunoregulation by altering protease metabolism are considered.
The effective management of venous ulceration
Authors: Negus D , Friedgood Anne
Published: March 2007

The importance of the direct perforating veins of the lower leg in the aetiology of venous ulceration is supported by the results of a 6-year study of 77 patients with 109 ulcerated legs. Incompetent perforating veins were demonstrated by examination and Doppler ultrasound, and confirmed at operation, in 108 legs. Subfascial ligation of these veins, with stripping of incompetent saphenous veins when necessary, was followed by elastic compression stockings in 44 legs (40 per cent) in which deep vein incompetence was demonstrated by non-invasive methods and phlebography. Some 91 ulcers (84·3 per cent) remain healed (76 per cent > 3-year follow up). Eight patients with rheumatoid arthritis in addition to venous incompetence had a 75 per cent failure rate. If these patients are excluded, 88 (92 per cent) of 96 ulcerated legs remain healed. It is submitted that these results support the argument for the importance of perforating vein incompetence in the aetiology of venous ulceration. They also suggest that a more optimistic attitude towards treatment is justified.
Long term results of 66 femoral-to-femoral by-pass grafts: a 9-year follow-up
Authors: Mosley J G , Marston A
Published: March 2007

Over an 8-year period, 66 femoral-to-femoral grafts were performed for unilateral iliac artery disease. The grafts were inserted retropubically with an operative mortality of 4·5 per cent. The minimum follow-up has been 12 months and cumulative patency 80 per cent at 6 years. Sixteen patients had critical ischaemia (preoperative Doppler ankle pressure < 40 mmHg) and 50 patients had severe ischaemia (preoperative ankle pressure > 40 mmHg). The graft significantly improved initial ankle pressures and this improvement was maintained at late follow-up (average 45 months). There was no evidence of a detrimental effect on the donor limb. Long term patency was adversely affected if there was preoperative critical ischaemia, a woven Dacron prosthesis was used or the patient continued to smoke.
Early results of subcutaneous mastectomy with immediate silicone prosthetic implant for carcinoma of the breast
Authors: Ward D C , Edwards M H
Published: March 2007

Surgery for carcinoma of the breast is becoming less radical even to the extent of breast conservation. Subcutaneous mastectomy and implant offers itself as an alternative, retaining a breast shape and removing almost all breast tissue. Forty-four consecutive patients who had this procedure for breast carcinoma were studied with a follow-up of 5–44 months (mean 25·3 months). Only 4 patients (9 per cent) had local recurrences, i.e. recurrence in the skin flap or scar. This compares favourably with other series and other forms of treatment. Removal of the prosthesis was necessary in 10 patients due to local factors. The cosmetic result as assessed by the patients was almost universally pleasing. Twenty-six of 27 patients with prostheses in situ who were interviewed in person or by postal questionnaire were pleased with the results of their surgery. The absence of high recurrence rates locally and high patient acceptance makes this a definite surgical alternative.
Central breast carcinoma treated by simultaneous mastectomy and latissimus dorsi flap reconstruction
Authors: Nash A G , Hurst P A E
Published: March 2007

Simultaneous mastectomy with latissimus dorsi flap reconstructions have been performed on 15 women with primary central breast cancer and on 5 women with local recurrence after local excision and deep X-ray treatment. The indications and technique are discussed. There was no mortality and no initial morbidity. No prosthesis has become infected. One prosthesis has slipped laterally, requiring removal and re-insertion at the time of nipple reconstruction. In all patients an acceptable cosmetic result, as assessed by the patient and the surgeon, has been achieved. Follow-up is very brief, 1–18 months, but there is as yet no sign of local recurrence.
The cutaneo-anal reflex: A useful index of neuropathy?
Authors: Bartolo D C C , Jarratt J A , Read N W
Published: March 2007

Recent studies have suggested that the latency of the cutaneo-anal reflex is prolonged in idiopathic faecal incontinence, suggesting neuropathic damage to the external anal sphincter. Electrical responses were recorded from the external anal sphincter following stimulation of the ipsilateral and contralateral perianal skin in normal subjects and patients with idiopathic faecal incontinence. Ipsilateral stimulation gave rise to shorter latencies of the earliest responses to stimulation compared with contralateral stimulation (P < 0·001). When care was taken to compare results obtained by stimulating the skin on corresponding sides of the sphincter, the latency of both the early and late components of the cutaneo-anal reflex in incontinent patients was not significantly different from that in control subjects. The durations of the motor unit potentials, obtained by conventional electromyography, were prolonged in incontinent patients, indicating that they have external sphincter neuropathy. The data support the suggestion that external sphincter neuropathy in idiopathic faecal incontinence is due to a stretch injury to the pudendal nerve, and indicate that measurement of the latency of the cutaneo-anal reflex may be an inadequate means of demonstrating nerve damage in patients with idiopathic faecal incontinence.
Single dose metronidazole with and without cefuroxime in elective colorectal surgery
Authors: Mitchell N J , Evans D S , Pollock D
Published: March 2007

Seventy patients undergoing elective colorectal surgery for malignant and inflammatory bowel disease were allocated randomly to one of two groups. Patients in group 1 were given, after induction of anaesthesia, a single dose of metronidazole 500 mg i.v. Patients in group 2 were given in addition a single dose of cefuroxime 1·5 g i.v. of 34 patients in group 1, 4 (11·8 per cent) developed postoperative infection. of 36 patients in group 2, 5 (13.6 per cent) developed postoperative infection. No significant difference was noted in the incidence of postoperative sepsis between the two treatment groups.
Laparoscopic common bile duct exploration: Evolution of a new technique
Authors: Khoo D E , Walsh C J , Cox M R , Murphy C A , Motson R W
Published: March 2007

Laparoscopic exploration of the common bile duct (CBD) with a choledochoscope or a stone basket during laparoscopic cholecystectomy was attempted in 60 patients and was successful in 56. The cystic duct was used for entry to the CBD in 46 patients and in 14 a choledochotomy was performed. Of 51 patients with confirmed common duct stones, 38 had complete laparoscopic clearance (75 per cent). In 13 patients the duct was not cleared or was only partially cleared, of whom four went on to have clearance by postoperative percutaneous choledochoscopy down a cystic duct or T-tube track. Two patients with cystic duct tubes passed their remaining stones spontaneously. One patient had open exploration and six required endoscopic retrograde cholangiopancreatography. Of nine patients without stones, choledochoscopy was impossible in three patients whose cholangiogram was later considered to be normal. In five patients stones were excluded by choledochoscopy and in one patient laparoscopic choledochoscopy was undertaken to better define abnormal biliary anatomy; this helped to avoid major bile duct injury. Choledochoscopy was easier with the smaller 3·6-mm ureteroscope but stone removal was more difficult when the basket was too small for the stones, the cystic duct too small relative to stone size or the number of stones was too great. Successful stone clearance was proportional to the level of effort expended, and was limited by operating time and equipment.
Results from pouch salvage
Authors: Korsgen S , Nikiteas N , Ogunbiyi O A , Keighley M R B
Published: March 2007

Over an 11-year period, 17 salvage procedures were performed on a failed ileal pouch-anal anastomosis carried out for ulcerative colitis from a series of 157 patients. Ten pouches were saved, four excised and three defunctioned. Salvage procedures included five operations for fistulas (three of five successful), six reoperations on the ileoanal anastomosis (five of six successful), three new pouches after previous pouch excision (all failed), and three miscellaneous: excision of an efferent limb (successful), pouchpexy for a pouch prolapse (successful) and postanal repair for incontinence (failed). Pouch salvage may be successful in the motivated patient who wishes to avoid a permanent ileostomy.
Technique for full-thickness muscle closure of laparoscopic port sites
Authors: Robertson G S M , Lloyd D M , Kelly M J , Veitch P S
Published: March 2007

Since the introduction of laparoscopic surgery there have been several case reports of incisional hernia at sites where laparoscopic trocars have been inserted through the abdominal wall1–5. These occur predominantly through port sites with a diameter of 10 mm or more, either through the linea alba at the umbilicus, or through more lateral defects. Fascial closure reduces the incidence but does not eliminate hernias entirely as they can occur into the subfascial space1,2. As complex laparoscopic surgery involving the use of several large ports becomes increasingly common, the incidence of this complication is likely to increase. The authors believe it is important to perform a full-thickness closure of all muscle defects 10 mm or greater in diameter.
Removal of circulating cytokines by continuous haemofiltration in patients with systemic inflammatory response syndrome or multiple organ dysfunction syndrome
Authors: Wakabayashi Y , Kamijou Y , Soma K , Ohwada T
Published: March 2007

High continuous levels of plasma circulating cytokines have been reported in patients with systemic inflammatory response syndrome (SIRS)1. Such patients either produce excessive amounts of cytokines or cannot clear them from the circulation, and have been suggested to be at an increased risk of developing multiple organ dysfunction syndrome (MODS)2. In this context, cytokine removal may prevent the development of MODS. A study was therefore made of the effects of continuous haemofiltration (CHF) on blood levels of circulating cytokines and on pulmonary, cardiovascular or renal function in patients with SIRS or MODS.
Correlation between acute physiology and chronic health evaluation (APACHE) III score and immunological parameters in critically ill patients with sepsis
Authors: Rogy M A , Oldenburg H S A , Coyle S , Trousdale R , Moldawer L L , Lowry S F
Published: March 2007

A relationship between physiological parameters of severe sepsis and immunological function has not been established. In ten severely ill patients with sepsis physiological risk was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE) III score, while one component of immunological function was evaluated using peripheral blood mononuclear cell (PBMC) cytokine production after stimulation with lipopolysaccharide (LPS) in vitro. Five of the ten patients died. Mean(s.e.m.) APACHE III scores at admission were not significantly different between survivors and non-survivors (82(13) versus 95(13)) but after 72 h they were lower in survivors (51(13) versus 111(15), P < 0·05). Downregulation of cytokine production by PBMC on LPS stimulation was a transient event in survivors. Survivors had a three-fold increase in tumour necrosis factor α bioactivity within 72 h, but there was no increase in non-survivors. A similar pattern was demonstrated for interleukin (IL) 1β (P < 0·05 between survivors and non-survivors) and IL-6 (P = 0·06) immunoactivity. Physiological as well as immunological parameters in critically ill patients with sepsis independently predicted hospital survival (r2 = 0·2). These data demonstrate a relationship between the pattern of cytokine production in vitro and survival.
Antioxidant depletion during aortic aneurysm repair
Authors: Khaira H S , Maxwell S R J , Thomason H , Thorpe G H G , Green M A , Shearman C P
Published: March 2007

Ischaemia–reperfusion injury generates oxygen-derived free radicals leading to local and distant damage. A simple method of following oxidative activity is to measure the consumption of endogenous scavenging antioxidants; an enhanced chemiluminescent assay was used to study this phenomenon in 21 patients undergoing surgery for abdominal aortic aneurysm (AAA). Samples of peripheral venous blood were taken before induction of anaesthesia and then from a central venous line and the inferior mesenteric vein before, during, and after clamping of the aorta. Further specimens were taken from the central line at 2, 6 and 24 h after operation. Antioxidant concentration in the peripheral, central and inferior mesenteric blood were similar, indicating that anaesthesia and surgical dissection had no effect. Levels decreased significantly in central and inferior mesenteric blood during and after clamping, but returned to normal by 24 h. These results confirm ischaemia-reperfusion phenomena in AAA repair.
Radical surgery for advanced gallbladder carcinoma
Authors: Miyazaki M , Itoh H , Ambiru S , Shimizu H , Togawa A , Gohchi E , Nakajima N , Suwa T
Published: March 2007

Forty-four patients with advanced gallbladder carcinoma (18 with stage pT3 and 26 with stage pT4 of the Union Internacional Contra la Cancrum classification) were aggressively managed by extended heptatic resection in 33 patients, bile duct resection in 28, pancreaticoduodenectomy in seven, gastrointestinal resection in eleven and portal vein resection and reconstruction in seven. Adjacent organ involvement was classified as follows: type I, hepatic involvement with or without gastrointestinal invasion (Ia, Ib); type II, bile duct involvement with or without gastrointestinal invasion (IIa, IIb); type III, hepatic and bile duct involvement with or without gastrointestinal invasion (IIIa, IIIb); type IV, gastrointestinal involvement without hepatic or bile duct invasion. Fourteen of 15 patients with type I tumours had a curative resection compared with seven of 26 with type III lesions (P < 0·0001). The surgical mortality rate was two of 15 patients with type I tumours, seven of 26 with type III tumours and nine of 44 for the whole group. The long-term survival rate after curative resection was four and two of 23 at 3 and 5 years respectively, significantly better than two and none of 21 at 1 and 2 years after non-curative resection (P < 0·01). The survival rate after curative resection for patients with type I tumours was four and two of 14 at 3 and 5 years respectively, significantly better than for other types (P < 0·05). This classification of advanced gallbladder carcinoma according to involvement of adjacent organs might be helpful in planning surgery for this condition; in particular, type I tumours should be treated by a radical surgical procedure to achieve a favourable outcome.
Nitric oxide and the rectoanal inhibitory reflex: Retrograde neuronal tracing reveals a descending nitrergic rectoanal pathway in a guineapig model
Authors: Stebbing J F , Brading A F , McC Mortensen N J
Published: March 2007

Nitric oxide has been implicated as the neurotransmitter mediating internal anal sphincter (IAS) relaxation during the rectoanal inhibitory reflex. However, there has been no direct demonstration of a nitrergic rectoanal neuronal pathway appropriate to mediating the reflex. This study combined retrograde neuronal tracing techniques with enzyme histochemistry in a guinea-pig model. Wheatgerm agglutinin conjugated to horseradish peroxidase was injected into the IAS. Transported tracer was demonstrated in neurones of the myenteric ganglia of the distal rectum and all labelled neurones showed co-localization with nitric oxide synthase as revealed by reduced nicotinamide adenine dinucleotide phosphate diaphorase histochemistry. In vivo anal canal manometry showed that the mean maximal resting pressure was 16 (8–20) cmH2O and confirmed the presence of the rectoanal inhibitory reflex. In vitro organ bath studies showed that strips of IAS developed spontaneous myogenic tone and relaxed in response to intrinsic nerve stimulation. Addition of Nω-nitro-l-arginine (l-NOArg) reduced the relaxant response in a dose-dependent fashion; the relaxant response was maximally reduced by a mean(s.e.m.) 35·2(3·8) per cent (P <0·001) at a concentration of 3 × 10−5 mol/l l-NOArg. This study provides direct anatomical evidence of a descending nitrergic rectoanal neuronal pathway in a guinea-pig model. In vivo anal manometry and in vitro organ bath studies provide additional evidence that this pathway is responsible for the inhibitory motor innervation of the rectoanal inhibitory reflex.
Physiological and clinical outcome of anterior sphincteroplasty
Authors: Oliveira L , Pfeifer J , Wexner S D
Published: March 2007

A total of 55 women underwent sphincteroplasty for the treatment of faecal incontinence related to anterior defects. Patients were followed prospectively for a mean of 29 months to evaluate the outcome overall and according to age. All patients were evaluated clinically by means of a questionnaire and graded using an incontinence scoring system ranging from 0 (perfect continence) to 20 (complete incontinence). Some 52 patients (95 per cent) had had a previous vaginal delivery and 30 (55 per cent) had a history of previous anal sphincter repair. Physiological and functional parameters in patients with a successful outcome (n = 39) were compared with those in patients with a poor outcome (n = 16). The results were also compared in patients under (n = 39) and over (n = 16) 60 years of age. Overall, patients with a successful outcome had a significant change in mean and maximal resting and squeeze pressures. These changes correlated well with the increase in the high-pressure zone (HPZ) length from 1·0–2·2 cm (P = 0·0002) and with functional outcome (change in incontinence score from 15·3 to 5·8; P < 0·0001). In patients over 60 years of age, a significant change in mean squeeze pressure (P = 0·03) and HPZ length (P = 0·01) was noted and correlated with functional outcome (change in incontinence score from 14·3 to 6·4; P < 0·0001). A successful outcome after anterior sphincteroplasty is related to improvement in sphincter function even in an older population. These results demonstrate that age itself does not seem to be a predictor of poor outcome. Patients should not be denied a repair exclusively on grounds of age.
Transient rise in intact parathyroid hormone concentration after surgery for primary hyperparathyroidism
Authors: Tisell L-E , Jansson S , Nilsson B , Lundberg P A , Lindstedt G
Published: March 2007

Two-site immunometric assays for determination of the level of intact parathyroid hormone (PTH) in serum have enabled detailed clinical studies of PTH secretion. Fifty- one patients with primary hyperparathyroidism were studied before surgery and 2 years after operation. PTH levels dropped to low values after operation. A rebound increase in PTH concentration occurred from 10 days to 3 months after surgery. Abnormally raised postoperative PTH concentrations were noted in 31 per cent of the patients, who had lower serum concentrations of ionized calcium (Ca2+) than the rest (P < 0·003). Before operation these patients had a more pronounced hyperparathyroidism than the others. At 2 years after surgery there was still a positive correlation between PTH concentrations before and after surgery (P < 0·001). The rebound increase in the level of PTH was a general phenomenon probably caused by low Ca2+ concentrations at the time of remineralization of bone. This phenomenon was transient. The positive correlation between preoperative and postoperative PTH concentrations shows that effects of hyperparathyroidism can remain for a long time after surgical cure.
Colorectal cell kinetics
Authors: Gilliland R , Williamson K E , Wilson R H , Anderson N H , Hamilton P W
Published: March 2007

The assessment of cell proliferation in colorectal tissue may provide information with both prognostic and therapeutic implications. A variety of methods are available, including flow cytometric estimations of S phase fraction, immunohistochemical and autoradiographic visualization of exogenous and endogenous proliferation proteins, and morphological and stathmokinetic techniques. There is some correlation between Dukes stage and proliferation state features, and there is increased proliferative activity throughout the adenoma–carcinoma sequence. Data on cell proliferation rates are difficult to obtain. When correctly applied, the metaphase arrest technique remains the ‘gold standard’ of measuring proliferation, but its usefulness in clinical practice is limited. Recent studies have employed dual measurement flow cytometry and double labelling techniques to produce rate data.
Severe complications of perianal sepsis in patients with human immunodeficiency virus
Authors: Consten E C J , Slors J F M , Danner S A , Sars P R A , Obertop H , van Lanschot J J B
Published: March 2007

Fifty human immunodeficiency virus (HIV)-infected patients with perianal sepsis were studied. Seven (14 per cent) had serious septic complications, four patients with severe necrotizing gangrene, and three with abscesses in the mediastinum, liver and brain respectively. CD4 + lymphocyte counts were significantly lower in patients with severe septic complications as compared with those with uncomplicated perianal sepsis (P<0·05). In patients with HIV presenting with rare (metastatic) abscesses, perianal sepsis must always be kept in mind as a possible focus. Although HIV-infected patients have a limited life expectancy perianal fistulas and abscesses should be aggressively treated, because of the high risk of severe complications.
Blood flow in the lower limb after balloon angioplasty of the superficial femoral artery
Authors: Hussain S T , Smith R E , Clark A L , Wood R F M
Published: March 2007

Using duplex ultrasonography lower-limb blood flow measurements were obtained in 20 patients with intermittent claudication. Assessments of flow were made in the common femoral artery, profunda femoris artery (PFA) and superficial femoral artery (SFA) before and after angioplasty for stenoses of short segments of the SFA. Blood flow was measured at rest and after exercise on a cycle ergometer. Collateral flow was calculated using an established mathematical model. Results were compared with the ankle: brachial systolic pressure index (ABPI) after exercise. Although there was no overall increase in resting limb blood flow, an increase in mean(s.d.) SFA flow from 148(79) to 312(94) ml min−1, with a concomitant decrease in PFA flow from 224(84) to 98(43) ml min−1 was noted 1 week after angioplasty (P<0·05). At rest there was an increase in mean(s.d.) ABPI from 0·62(0·12) to 0·89(0·23) (P<0·05). Collateral flow was estimated to have decreased from 186(34) to 18(8) ml min−1; the pattern of change in flow was similar after exercise. Angioplasty of the SFA remains controversial because of the risk of restenosis. The above methodology allows assessment of whether patients can re-establish collateral flow or whether limb blood flow will be significantly compromised if restenosis occurs.
An evaluation of the POSSUM surgical scoring system
Authors: Whiteley M S , Prytherch D R , Higgins B , Weaver P C , Prout W G
Published: March 2007

POSSUM (Physiological and Operative Severity Score for the enumeration of Morbidity and mortality) has been studied as a possible surgical audit system for a 9-month interval using a sample of 28 per cent of the general surgical workload. Mortality or survival was analysed as an endpoint. In this sample the published POSSUM predictor equation for mortality overpredicted deaths by a factor of more than two. The bulk of the overprediction occurred in the group at lowest risk (predicted mortality 10 per cent or less), in which death was overpredicted by a factor of six. This is the most important group for audit purposes since it contains the majority of surgical patients and is composed of fit patients undergoing minor surgery. The published predictor equation for mortality returns a minimum predicted mortality of 1·08 per cent, clearly far higher than that expected for a fit patient having minor surgery. Logistic regression was done on a set of 1485 surgical episodes to generate a local predictor equation for mortality. This process gave a predictor equation that fitted well with the observed mortality rate and gave a minimum predicted risk of mortality of 0·20 per cent. The previously published POSSUM predictor equation for mortality performed badly when tested using a standard test of goodness of fit for logistic regression and must be modified.
Parathyroidectomy in the West Midlands
Authors: Ready A R , Sabharawal T , Barnes A D
Published: March 2007

A retrospective audit was made of 101 patients undergoing parathyroidectomy, performed by 20 general surgeons in the West Midlands region during 1992. The mean number of cases per surgeon was five; nine surgeons performed fewer than three parathyroidectomies. Some 57 patients had primary hyperparathyroidism. Only seven were diagnosed by general practitioners and referral was invariably to a non-endocrine physician. Delay between diagnosis and surgical referral exceeded 2 years in 12 patients. Four patients (7 per cent) with primary hyperparathyroidism remained hypercalcaemic after first exploration; all were operated on by surgeons who performed fewer than four parathyroidectomies per year. Minor complications occurred in 32 per cent of patients. All 44 patients with renal hyperparathyroidism were treated in specialist units where diagnosis and treatment were expeditious; parathyroidectomy was successful in 41. Hyperparathyroidism should be managed in specialized units and by surgeons who perform parathyroidectomy frequently. A heightened awareness of primary hyperparathyroidism is required at primary care level.