Speciality
Spotlight

   




   


Surgery


   

 





General
Surgery

  

  • Velmahos
    GC, Arroyo H, Ramicone E, et al (Univ of Southern
    California, Los Angeles; Los Angeles County,USC Med
    Ctr)


    Timing
    of Fracture Fixation in Blunt Trauma Patients with
    Severe Head Injuries.

    Am J Surg 176: 324-330, 1998.

      

    Early fracture fixation is thought to reduce
    postoperative morbidity by permitting early
    mobilisation and decreasing the release of harmful
    inflammatory mediators. This
    approach is disputed in severe head trauma.

      

    A retrospective study of 47 consecutive patients of
    severe head injury with long bone fracture were
    reviewed. 22
    had undergone fixation within 24 hours and 25 at a
    mean of 143 hours after trauma.

        

    The timing of the fracture fixation did not affect
    morbidity, mortality or neurologic outcome.
    The treatment of patients with severe head
    injuries should be based on sound individual
    clinical assessment rather than mandatory policies
    on long bone fracture fixation.

        

  • Nikolajsen
    L, Ilkjaer S, Jensen TS (Univ Hosp of Aarhus,
    Denmark)


    Effect
    of Preoperative Extradural Bupivacaine and Morphine
    on Stump Sensation in Lower Limb Amputees.

    Br. J Anaesth 81: 348-354, 1998.

         

    This is a randomized double blind study to
    determine if postoperative pain can be prevented by
    the use of preoperative use of extradural
    bupivacaine and morphine.

         

    The pressure pain threshold, touch and pain
    detection thresholds, thermal sensibility, allodynia
    and windup like pain were evaluated before
    amputation and 1 week and 6 months after amputation.

         

    The results indicate that preoperative extradural
    anaesthesia did not prevent postoperative
    hyperexcitability in the stump and had no effect on
    long term hyperalgesia, allodynia or wind-up like
    pain in amputees.

          

  • Larsson
    J, Agardh C-D, Apelqvist 
    J, et al (Univ Hosp, Lund, Sweden)


    Long
    Term Prognosis After Healed Amputation in Patients
    with Diabetes.

    Clin Orthop 350: 149-158, 1998.

        

    This is a prospective study of 220 patients with
    diabetes with foot ulcers subjected to amputation
    after primary treatment. 136
    had a below knee (BK) and 84 patients had an above
    knee (AK) amputation. 
    Of these 29 patients died before healing, 5
    patients with BK amputation underwent after knee
    amputation. 2
    patients did not heal and were excluded.
    The remaining 189 patients were followed up
    for 6.3 years (range, 1-10.8 years).

        

    The time for healing was an average of 29 weeks for
    BK amputations and 8 weeks for AK amputations.

        

    The mortality at 1, 3 and 5 years was 15%, 38% and
    68% respectively. The
    rate of new amputations were required at 1, 3 and 5
    years was 14%, 30% and 49% respectively.

         

    It is concluded that diabetics who underwent an AK
    amputation had a higher mortality rate of new above
    knee amputation and a lower rehabilitation potential
    than those undergoing BK amputations.

          

  • Legro
    MW, Reiber GD, Smith DG, et al (VA Puget Sound
    Health Care System, Seattle; Univ of Washington,
    Seattle; Prosthetics Research Study, Seattle).


    Prosthesis
    Evaluation Questionnaire for Persons with Lower Limb
    Amputations:  Assessing
    Prosthesis-related Quality of Life.

    Arch Phys Med Rehabil 79: 931-938, 1998.

         

    A self administered questionnaire was developed
    for the evaluation of prosthetic care by quantifying
    the evaluation of individuals with amputations with
    regard to their prosthesis and their quality of life
    (PEQ- Prosthesis evaluation questionnaire).
    It consisted of 10 scales regarding
    prosthesis function mobility, psychosocial
    experience and wellbeing.

         

    92 patients completed the questionnaire.
    The internal consistency was high for all
    scales except “transfers”.
    Scores were stable over time.

         

    The scales showed good psychometric properties.
    It is a good tool for evaluation of
    prosthetic care.

          

  • BP
    Boden, DT Kirkendall, Jr Garrett WE (Duke Univ,
    Durham,NC)


    Concussion
    Incidence in Elite College Soccer Players

    Am J Sports Med 26: 238-241, 1998.

         

    The potential for head injuries among soccer
    players and its relation to neuropsychological
    deficits have long been debated. 
    The incidence of concussion in elite college
    soccer players has been assessed.

          

    Methods:
    Seven men’s and 8 women’s soccer teams were studied
    for 2 seasons, and results documented.

         

    Findings:
    29 concussions were diagnosed in 26 athletes (17men
    and 12 women). Concussions
    occurred from contact with :

             

    2)                
    an elbow in 14%

    3)                
    a knee in 3%

    4)                
    a foot in 3%

    5)                
    a ball in 24%

    6)                
    ground in 10%

    7)                
    concrete side lines 3%

    8)                
    goal post in 3%

    9)                
    combination in 10%

      

    69% occurred during games.
    None of them occurred during intentional
    heading of the ball 72% of concussions were grade 1
    and 28% were grade 2.

         


    Conclusions:
    Concussion occurs more commonly in soccer than has
    been believed. Such injuries may result in long term neuropsychological
    changes.

          

  • JT
    Matser, AGH Kessels, BD Jordan, et al (St Anna Hosp
    Geldrop, The Netherlands; Univ of Maastricht, The
    Netherlands; Charles R Drew 
    Univ of Medicine & Science, Los Angeles;
    et al)

    Chronic
    Traumatic Brain Injury in Professional Soccer
    Players.


    Neurology 51: 791-796, 1998.

        

    Repeated concussive and subconcussive blows to
    the head may result in chronic brain injury. Such injuries are common in soccer.

          


    Methods:
    53 active professional soccer players were studied
    along with 27 elite atheletes from non contact
    sports and they were examined neuropsychologically.

         

    Findings: 
    Compared with the controls, the soccer
    players had impaired performances in memory,
    planning, performances were correlated inversely
    with the number of concussions and with the
    frequency of “heading”.
    This also depended on field position with
    higher incidence amongst the forwards and defenders.

          

  • BC
    Barnes, L Cooper, DT Kirkendall, et al (Duke Univ,
    Durham, NC; Univ of Los Angeles)


    Concussion
    History in Elite Male and Female Soccer Players

    Am J Sports Med 26: 433-438, 1998.

         

    Neurophysiologic
    and neuropsychologic changes have been reported in
    active and retired soccer players and
    “heading” has often been cited as the
    cause. There
    is concern about the cumulative effects of
    “heading”.
    The information available in the context is
    conflicting.

           

    Methods:
    All male and female soccer players who completed in
    the 1993 olympic
    Sports Festival were interviewed.
    There were 137 players with a mean age of
    20.5 years. The mechanisms of injuries, frequency of injuries and the outcomes
    were determined.

         

    Results:
    In males there were 74 concussions in 39 players (50
    injuries were Grade I by the Colorado Medical
    Society guidelines). In females, there were 28 concussions in 23
    players (19 injuries were Grade I).
    In males 48 of 74 concussions and in females
    20 of 28 concussions occurred as a result of
    collision with another player.
    The most common symptoms were headache, a
    dazed feeling and dizziness.
    On the basis of the study, the odds that a
    soccer player would sustain a concussion within a 10
    year period were 50% for males and 22% for females.

         

  • JE
    Sturmi, C Smith, JA Lombardo (Ohio State Univ,
    Columbus)


    Mild
    Brain Trauma in Sports: Diagnosis and Treatment
    Guidelines.

    Sports Med 25:351-358, 1998.

          

    Mechanism
    of head injury

    : In any given year 20% of American high school
    football players experience a sports related
    concussion. Other
    sports causing concussion are boxing, ice hockey,
    rugby, motor racing, equestrian sports, martial
    arts, wrestling, gymnastics, cycling, alpine skiing
    and diving. Given
    the brain’s protective anatomy, direct blows are
    tolerated with little injury; the exception being
    the association of a fracture or haematoma.
    The acceleration or deceleration injuries are
    more serious.  Additionally,
    a sharp blow to the athlete’s torso or pelvis can
    cause a concussion. Protective gear and strong muscles can
    dissipate the forces and lessen the severity of the
    injury. Fortunately,
    most injuries are mild.
    Nonetheless, all athletes who sustain a head
    injury, should be properly evaluated irrespective of
    their state of consciousness.

         

    Management:
    The athlete should be rested at once.
    If warranted he should be hospitalised and
    properly evaluated. All
    symptoms must have completely resolved before the
    athlete is allowed to return to play.

        

  • Noble
    David University Hospitals, Aberdeen and Hehlet
    Henrik University Hospitals, DK-2650, Hvidovre,
    Denmark]


    Risks of interrupting drug treatment before surgery The consequences may be as serious as those from drug errors 


    BMJ [VOL-7263], 23 September, 2000 , Pg. No 719

        


    Some surgeons are ignorant of consequences of
    interrupting drug treatment before surgery. This is
    a specially true of abdominal surgeons who have
    patients taking drugs by mouth before surgery.
    Cardiac drugs, antihypertensive and antidiabetic
    drugs are the commonest and most important
    chronically prescribed treatment. It is important
    that these drugs are not discontinued before
    surgery. If they can not be given by mouth they must
    be given by injection. If an injection is not
    available, an alternative drug of similar class can
    be given by injection. As soon as possible, oral
    drugs must be restarted.

         


    Surgeon should be educated in the importance drugs
    being continued to be given to patients and to
    recognize important drugs whose discontinuation may
    harm the patients.

          

  • GB
    Thompson, CS Grant, JA van Heerden et al 
    (Mayo Found, Rochester, Minn):
    Laparoscopic
    versus open posterior adrenalectomy: A case control
    study of 100 patients
    .    

    Surgery 122:  1132-1136, 1997.


         

    Few large
    studies have compared laparoscopic adrenalectomy
    (LA) with conventional open anterior or posterior
    adrenalectomy (PA).

         

    Laparoscopic 
    adrenalectomy is a safe and effective
    procedure that is superior to PA with respect to
    patient satisfaction, length of hospital stay,
    return to normal activities, analgesic requirements
    and late complications. Compared with PA, LA operating times and
    hospital stays are slightly longer. LA is more
    expensive and technically more demanding.

           

  • Navez
    B, Tassett V, Scohy JJ, et al


    Laparoscopic
    Management of Acute PERITONITIS


    Br. J Surg 85: 32-36, 1998

        

    Laparoscopy
    can be safely carried out in patients with
    peritonitis

          

    Advantages:

         

    1.                
    Confirm preoperative diagnosis

    2.                
    Clarify treatment planning

    3.                
    May avoid need for Laparotomy

    4.                
    Particularly useful in patients with
    appendicular or gastroduodenal perforation.

        

    Patients with colonic perforation are more likely to
    require laparotomy, but even they may be managed
    laparoscopically with better surgical expertise.

         

    Caution:

    a)                
    With intense inflammation, it may be
    difficult to explore all parts of the abdomen
    without injuring the intestine.

    b)               
    There may be a danger of missing abscesses
    between loops of intestine, below the diaphragm or
    in the pelvis.

           

  • Lemieur
    TP, Rodriguez JL, Jacobs DM, et al [ Univ of
    Minnesota, Minneapolis]


    Wound Management in Perforated
    Appendicitis


    Am
    Surg 65: 439-443, 1999

        

  • Snyderman
    CH, Kachman K, Molseed L, et al [ Univ of
    Pittsburgh, Pa; Duquesne Univ, Pittsburgh, Pa; Univ
    of Louisville, Ky]


    Reduced Postoperative Infections with an
    Immune-Enhancing Nutritional Supplement


         

  • Heyland
    DK, for the Canadian Critical Care Trials Group
    [Queen’s Univ, Kingston, Ont, Canada; et al]

    The Clinical Utility of Invasive Diagnostic
    Techniques in the Setting of Ventilator – Associated
    Pneumonia


    Chest
    115: 1076-1084, 1999

         

    Ventricular-associated
    pneumonia [VAP] is often diagnosed on clinical
    grounds alone and contributes to the morbidity,
    mortality and costs of caring for critically ill
    patients. Overdiagnosis may be disastrous with the
    use of needless antibiotics and the delay in
    recognition of the ‘true’ diagnosis.

         

    The
    utility of invasive investigations like bronchoscopy,
    with protected brush catheter [PBC] bronchoalveolar
    lavage [BAL] was evaluated in 92 patients receiving
    ventilatory support with
    a clinical suspicion of VAP.

          

    The
    results showed that VAP was often overdiagnosed
    after BAL or PBC after these procedures. Patients
    received fewer antibiotics. Both groups had similar
    duration of mechanical ventilation and ICU stay.
    Those who underwent PBC/BAL had a lower mortality.

         

    Invasive
    diagnostic testing may boost physicians confidence
    in the diagnosis and management of VAP.

           

  • Alter
    MJ, Kruszon-Moran D, Nainan OV, et al [Ctrs for
    Disease Control and Prevention, Atlanta, Ga and
    Hyattsville, Md; Natl Inst of Allergy and Infectious
    Diseases, Bethasda, Md]

    The Prevalence of Hepatitis C Virus Infection in
    the United States, 1988 Through 1994


    N
    Engl J Med 341: 556-562, 1999

         

    Chronic
    infection with Hepatitis C virus [HCV] is a major
    cause of chronic liver disease, but is often
    asymptomatic. Sera was collected from a nationwide
    population survey to assess its prevalence.

          

  • Pittet
    D, Wyssa B, Herter-Clavel C, et al [Univ Hosp of
    Geneva, Switzerland]


    Outcome of Diabetic Foot Infections
    Treated Conservatively : A Retrospective Cohort
    Study with Long-term Follow-up


    Arch
    Intern Med 159: 851-856, 1999

        

    Diabetic
    foot lesions are the cause of more hospitalizations
    than any other complications of diabetes. Effective
    guidance needs to be enunciated to minimize human
    and financial cost of diabetic foot lesions. A
    5-year retrospective cohort study with prospective
    long-term follow up was undertaken to identify
    criteria predictive of failure of conservative
    treatment of such lesions.

        

    Conservative
    measures including prolonged culture guided
    parenteral or oral antibiotics was successful
    without amputation in 63% of diabetic foot lesion.

        

  • Kiviluoto T, Siren J, Luukkonen P, et al [Helsinki Univ Central Hosp]


    Randomised Trail of Laparoscopic versus Open Cholecystectomy for Acute and Gangrenous Cholecystitis 


    Lancer 351-325, 1998

          


    Laproscopic cholecystectomy [ LC] is the surgical approach of choice for elective
    cholecystectomy. Use of LC in acute cholecystitis is controversial. Postoperative complications were higher in open cholycystectomy than laperoscopic
    cholecystectomy. Laparoscopic cholecystactomy in patients with acute gangrenous cholecystitis is technically demanding and in experienced hands and in experienced hands, LC can be safe and effective procedure without increase in mortality and morbidity.

        

  • McHale A. Buechter KJ, Cohn I
    Jr, et al [ Louisiana State Univ, New Orieans]


    Surgical Management of Chronic Pain From Chronic Pancreatitis


    Am Surg 63: 1119-1123, 1197

           

    Intractable pain is the major clinical problem in patients with chronic
    pancreatitis.

    Surgery including Puestow’s procedure, pseudocyst drainage, or sphincteroplasty was performed to correct anatomy causing dilation of ducts. For patients with no 

    ductal dilation, or those with recurrent postoperative pain, denervation procedures [i.e.
    thoracoscopic, sympathectomy or resection ] were performed. Surgery provided pain relief in 68% of the patient. No single procedure proved more effective. Results of thoracoscopic sympathectomy are promising.

          

  • Levitt MA, Softer
    SZ, Peria A [Long Island Jewish Med Ctr, New Hyde Park, NY ; Albert Einstein College of Medicine, Bronx, NY
    Continent Appendicostomy in the Bowel Management of Fecally Incontinent Children 


    J Pediatr Surg 32 : 1630-1633, 1997

          


    Fecal incontinence is a common problem in children, affecting many patients with anorectal malformations, spina
    bifida, or Hirschsprung’s disease. Previously appendix was used as a conduct by which to give an antegrade enema. The modified technique was made simpler by plicating the cecum around appendix. This created a one way valve mechanism while leaving appendix in its original place. Cecal wall tissue was used to created new appendix if appendix had been removed earlier. Continent appendicostomy offers the new option for the management of children with fecal incontinence. It provides a safer, effective route for enema administration. The procedure allows patients to remain clean with an inconsoicuous stoma and allow children to catheterize themselves. 

         


    Advantages of antegrade enemas are tremendous. Postoperative complications are low. Significant patient’s satisfaction and compliance can be achieved.

          

  • Rosen HR. Novi G, Zoech G, et al [ Danube Hosp, Vienna]


    Restoration of Anal Sphincter Function by Single-Stage Dynamic Graciloplasty With a Modified [Split Sling] Technique


    Am J Surg 175:187-193, 1998

         


    “Dynamic Graciloplasty” refers to the use of electrostimulation to transform Fast-twitching type II muscle fibers into slow-twitching type I fibers, thus providing skeletal muscles with capacity for tetanic contraction. The operation has given promising results in patients with fecal incontinence or those who have undergone excision of anal sphincter. In one stage procedure, the muscle was transposed and stimulation electrodes and pulse generator implanted. The neosphincter was wrapped with a modified split sling technique. This was followed by controlled neuromuscular stimulation to transform the muscle. With one-stage technique inner continence was achieved within 7 weeks. Muscle wrapped must be placed with correct tension to avoid direct injury
    tuberectum. Functional results are outstanding considering the patients who underwent
    operation for congenital atresia achieved satisfactory continence in 90% of cases. Trials of implanting an artificial bowel sphincter are going on which may become a valuable alternative to graciloplasty in the near future.

         

  • Maria G, Cassetta E, Gui D et al
    [Universita Cattolica del Sarco Cuore, Rome; Centro S Giovanni di
    Dio, Fatebenefratelli, Brescia, Italy]


    A Comparison of Botulinum Toxin and Saline for the Treatment of Chronic Anal Fissure


    N Engl J Med 338: 217-220, 1998

          

    Patients with chronic anal fissure have tearing of the lower half of the anal canal, possibly related to severe constipation or straining at stool. Internal anal sphincter contraction serves to maintain the fissure. Surgical
    sphincterotomy, the most common treatment, is done to relieve symptoms and promote healing. However, it also weakens the the internal sphincter, possibly leading to complications, such as anal deformity and incontinence. Patients received two injections of botulinum toxin A, for a total of 20 units in a volume of 0.4ml. Patients from the original treatment who had persistent fissures were retreated with botulinum toxin, 25 units. No relapses occurred through 16 months of follow-up.

          


    As an alternative to sphincterotomy, patients with chronic anal fissure may be effectively treated with local infiltration of botulinum toxin. This treatment is simple, inexpensive, and does not require anesthesia.

           


    The main alternative to this treatment is application of nitroglycerine ointment. Application of an ointment may be more acceptable to patients.

          

  • Yim JH,Wick
    MR, Philpott GW, et al [Washington Univ, St Louis]


    Underlying Pathology in Mammary Paget’s Disease


    Ann Surg Oncol 4: 287-292, 1997

          


    Mastectomy has been the standard treatment, but recent studies have recommended radiotherapy with no resection. All patients had histologically confirmed Paget’s disease; 92% of patients had underlying carcinoma, either ductal carcinoma in
    situ, invasive ductal cancer, or both. Mammography failed to detect the multifocal lesions in 64% of patients with no palpable mass. Patients with a palpable mass were significantly more likely to have invasive cancer, multifocal lesions, and positive lymph nodes. 

           


    Most patients with mammary Paget’s disease have underlying multifocal carcinoma, including invasive lesions. Therefore, mastectomy remains the standard treatment.

         

  • Kuzbari R, Worseg AP, Tairych G, et al [Univ of Vienna, Austria]

    Sliding Door Technique for the Repair of Midline incisional Hernias 

    Plast Reconstr Surg 101: 135-1242, 1998

         

    Sliding door technique that makes it possible to effect a tensionless and autologous repair of large hernias after midline laparotomy.

        

    In this technique the medical border of the rectus sheath is identified on both sides of the hernia. Rectus sheaths are dissected away from the muscles; Rectus sheaths, after being incised at the aponeuroses of the external oblique muscles, slide towards the midline. The posterior rectus sheaths are sutured. The rectus muscles are secured with overlapping sutures, and the released anterior layers of the rectus sheaths are sutured. Releasing the rectus sheaths from the pull of the external oblique muscles eliminates the most unyielding pull.

         

  • Gonze MD, Manord JD, Leone-BayA, et al [Ochsner Med Institutions, New Orleans, La; Emisphere Technologies Inc, Tarrytown, NY]

    Orally Administered Heparin for Preventing Deep Venous Thrombosis

    Am J Surg 176: 176-178, 1998 

        

    Heparin has a large molecular size that compromises absorption after oral administration. The synthetic acetylated amino acid molecule sodium N-8 amino caprylate [SNAC] facilitates gastrointestinal absorption on heparin. A rat model was used to evaluate an oral combination of SNAC and heparin for the prevention of venous thrombosis.

         

    Venous thrombosis developed in 89% of the control group vs. 25% of the SNAC -with heparin group and 11% of the IV heparin group. If adequate anticoagulation can be achieved using oral heparin, treatment of deep venous thrombosis will likely be simpler and possibly safer.

         

  • Zubair M, Besner GE [Ohio State Univ]

    Pediatric Electrical Burns : Management Strategies

    Burns 23: 413-420, 1997

        

    Most electrical injuries occurring in the home involve children. Low voltage electrical injuries – those involving sources less than 1,000 V – occur more frequently in younger children. 

          

    If these children remain asymptomatic after 4 hours of observation, they may safely be treated on an outpatient basis. Most low-voltage electrical injuries to young children are easily preventable.

          

    Respiratory arrest, cardiac arrhythmia’s and myoglobin induced renal failure are uncommon after a low voltage injury. A child [or adult ] with a low voltage electrical injury who does not have an arrhythmia at the scene or upon arrival to the hospital, and does not have a arrhythmia develop within few is not likely to develop one. Therefore, admission for cardiac monitoring is not indicated, and child should be allowed to go home.

           

  • Arrowsmith J, Usganocar RP, Dickson WA [Morrston Hosp. Swansea UK]

    Electrical Injury and Frequency of Cardiac Complications 

    Burns 23 : 576-578, 1997

           

    Cardiac abnormalities caused by electrical injury are most often apparent at the time of injury. They can also develop later, and 24 hour cardiac monitoring has recommended for patients with electrical injuries. Patients who became unconscious after injury and those with high voltage injuries were more prove to cardiac complications.

          

    Analysis finds a 3% rate of cardiac abnormalities among patients with electrical injuries. For patients who did not lose consciousness at the time of injury and who have normal admission ECG, cardiac complications are unlikely to develop later.

         

  • Mshoup, JM Weisenberger, JL Wang, et al [ Loyola Univ, Maywood, III] 

    Mechanisms of Neutropenia involving myeloid maturation arrest in Burn Sepsis.

    Ann Surg 228 : 112-122, 1998

         

    Burns patients with sepsis have impairments of bone marrow granulopoiesis leading to neutropenia, even though their circulating levels of granulocyte colony stimulating factor -[G-CFS] are normal. 

         

    Mice with burn sepsis had a reduced absolute neutrophil counts but elevated levels of G-CSF in plasma. The neutrophil differentiation pattern showed a shift toward immature mitotic myeloid cells. Neutrophil infiltration into tissues was insignificant on histologic examination. 

         

    This study helps explain this phenomenon of infection-induced neutropenia by showing that there is a maturation arrest of granulocytes in the bone marrow.

        

  • Shin C Kinsky MP, Thomas JA et al [ Yousea Univ Seoul Korea]

    Effect of Cutaneous Burn Injury and Resuscitation on Cerebral Circulation in an ovine model

    Burns 24 : 39-45, 1998

        

    Altered consciousness, delirium, hallucinations, or seizures can occur in adults or children with major or minor burns. 

        

    A 70% to the body surface scald injury was induced in 8 anesthetized sleep. Animals received 30 minutes of resuscitation with Ringer’s Lactate, titrated to restore and maintain baseline oxygen delivery practices. 

         

    During resuscitation, Intracranial pressure increased gradually and cerebral perfusion pressure fell. 

         

    This ovine model showed reduced cerebral perfusion pressure immediately after major cutaneous burn, and again after 6 hours of resuscitation. Blood flow to brain is maintained by cerebral autoregulation in the early phase after injury,, blood flow fails after development of brain edema and elevated intracranial pressure.

          

    A number of burn patients develop encephalopathy even though they have no evidence of head injury. Decreased cerebral blood flow may be contributing to the postburn CNS syndromes.

          

  • Nakamura
    Dy, Gibran NS, Mann R et al [ Univ of Washington ] 

    Unna “sleeve” an effective postoperative dressing for pediatric arm burns 

    J. Burn Care Rehabil 19: 349-351, 1998

         

    A plan was developed that would protect the grafts after surgery while eliminating the need for daily would care. Unna “sleeves” for the postoperative care of children with skin grafts of the arms were used. 

         

    The graft take rate was 100%.

          

    Unna sleeve technique provides an effective postoperative dressing for pediatric arm burns. It provides gentle, uniform pressure while protecting the grafts against mechanical shearing.

         

  • Angele MK, Ayala A, Monfils SA et al [Brown Univ. Rhodc Island -]

    Testosterone and or Low Estradiol : Normally required but harmful for immunologically for males after trauma hemorrhage

    J. Trauma : injury infect —- care 44 : 78-85, 1998

         

    There is clinical and epidemiologic evidence to suggest sex differences in susceptibility to and morbidity from sepsis. Severe hemorrhage leads to marked depression of immune function in males but not in females.

         

    The immune depression in response to trauma hemorrhage in male mice appears to result from high levels to testosterone, low levels of estradiol or both. The finding suggest the possibility and hormonal treatment [ i.e. testosterone receptor blocking agents eg. Flutamide or estradiol] to prevent immune depression in male trauma patients.

          

  • Peters
    JH, De Meester TR, Crooksl et al [ Univ. of S. California]

    The treatment of Gastoesophageal Reflux Disease with Laparoscopic Nissen Fundoplication : Prospective evaluation of 100 patients with “Typical” symptoms 

    Ann Surg 228: 40-50, 1998

         

    Laparoscopic Nissen fundoplication, offering success rates exceeding 90% is becoming the new standard of surgical treatment for Gastroesophageal Reflux Disease [GERD].

          

    This procedure achieved relief of the patients’ primary symptoms in 96% of cases. 

           

    Laparoscopic Nissen fundoplication is safe and highly effective in relieving typical symptoms of GERD. Routine crural closure avoids problems of migration of the fundoplication into the chest.

          

  • Robin
    K.S. Phillips

    Progress in the Management of Anal Disorders

    Recent Advances in Surgery, Number 22, Year-1999, Pg.123

        

    Anal probe MRI supplies superb anatomical definition.

         

    Nitric oxide donors such as glyceryl trinitrate [GTN] and isosorbide dinitrate have been used in order to induce chemical sphincterotomy.

         

    Rubber band ligation is an effective treatment for haemorrhoids at least insofar as the relatively short follow-up of around 2-3 years. Surgical haemorrhoidectomy is a very effective way of treating haemorrhoids.

         

    Patients randomly allocated to receive metronidazole had significantly less pain.

         

    It is probably easiest to consider recto-vaginal septum as an extension of Denonvillier’s fascia that acts to prevent herniation of the rectum into the vagina during defaecation.

         

    The recto-vaginal septum can be damaged either through chronic straining at stool or, more often, as part of a childbirth injury. 

         

    The recto-vaginal septum is often repaired by colorectal surgeons transanally by anterior mucosal excision and rectal wall plication on the premise that there is too much rectum. 

         

    On the other hand, gynecologists, consider the vagina to be excessive, excising a diamond of posterior vaginal wall and placing some sutures in the region of the recto-vaginal septum.

         

  • Mark G. Coleman, Brendam J. Moran

    Small Bowel Obstruction 

    Recent Advances in Surgery, Number 22, Year – 1999





    Mechanical small bowel obstruction [SBO] in adults is a common clinical problem with a significant morbidity and mortality. 



    Adhesions are the cause of half the cases that present with SBO, with fewer being due to malignancy or obstructed heniae. 



    Interestingly, in a significant proportion of those who present with SBO following colorectal cancer surgery, the aetiology is adhesions rather than malignant disease, in contrast to SBO following surgery for gastric or ovarian cancer, in which the commonest cause in malignancy.



    Adhesions are the consequence of injury which may be traumatic, thermal, ischaemic, inflammatory or due to foreign body. 



    Most settle with conservative management.



    Raised temperature, tachycardia, abdominal tenderness, the absence of bowel sounds, faeculent vomiting and a white blood cell count above 18 x 109/1 are positively correlated with strangulation.



    Plain abdominal radiographs are the universally used method for evaluation of SBO to determine its cause and level. 



    Per-oral and intubated contrast studies are similarly effective in terms of their sensitivity [ 92% versus 94%] and specificity [94% versus 89%]. 



    The correct treatment for SBO remains the prompt recognition of those cases requiring immediate surgery and the institution of the regimen that includes intravenous fluids, nasogastric intubation and aspiration. The general philosophy of ‘never let the sun set twice on a bowel obstruction’ remains true today.



    Evidence implicates glove starch and gauze swabs as a cause of adhesions.

    The use of peritoneal lavage with normal saline has not been shown to reduce the rate of adhesion formation.



  • Colin D. Johnson

    Medical Management of Acute Pancreatitis

    Recent Advances in Surgery, Number 22, Year-1999, Pg. 147

         

    Medical management of acute pancreatitis requires early diagnosis. 75-80% of patients will have mild, self limiting disease which can be managed effectively by fasting, intravenous fluids and analgesia.

          

    The cut-off value for diagnosing acute pancreatitis is 3 times the upper limit of the laboratory normal range for amylase or twice normal for lipase. Clinical picture is usually abdominal pain, almost always in the epigastrium. Majority of patients with pancreatitis will have vomited at least once. The most effective investigation in that circumstance is abdominal computed tomography [CT].

           

    Obesity, pleural effusion and are associated with an increased risk of complications and death.

         


    The use of nasogastric aspiration has been shown in a randomized comparison to have no effect on outcome.

          

    Patients with severe pancreatitis often have lung injury leading to hypoxaemia, and systemic hypotension. This results in loss of mucosal barrier function with absorption of endotoxin, and translocation of bacteria. Bacteria which migrate fro the gut may colonize necrotic pancreatic and peripancreatic tissue, converting sterile necrosis to infected necrosis. This has a serious adverse effect of outcome.

          

    Pethidine by continuous intravenous or infusion epidural analgesia is extremely satisfactory.

           

    Systemic inflammatory response syndrome is activated as a result of the pancreatic injury and it is this, which leads to most of the harmful systemic efforts of acute pancreatitis.

           

    Therapy aimed at inhibiting pancreatic secretion with anticholinergic or inhibitory hormones such glucagon, somatostatin, or somatostatin analogues, have all yielded negative findings.

          

    Antibiotic prophylaxis should be given for 7 days.

          

    For many years it was believed necessary to ‘rest the pancreas,’ in order to prevent worsening of pancreatic tissue damage. This now appears to be false, and indeed it seems that depriving the gut lumen of nutrients is likely to impair gut mucosol barrier function and exacerbate the problem of translocation of bacteria.

        

    Platelet activating factor [PAF] appears to be involved in the causation of local damage as a result of pancreatic injury.

         

    Clinical trials using a synthetic PAF antagonist, lexipafant given within 72 h of onset of symptoms have shown very encouraging results. 

         

    Lexipafant could reduce organ failure scores and local complications.

           

  • Marcia Hall Gordon J.S. Rustin

    Testicular Tumour Management

    Recent Advances in Surgery, Number 22, Year-1999, Pg. 173

         

    Many risk factors promoting the development of Germ Cell Tumours [ GCT] have been identified, the best known and most consistent being a history of cryptorchidism.

        

    Most patients present with symptoms relating to the affected testicle [e.g. swelling, pain or aching] and occasionally symptoms and signs referable to metastatic disease [e.g. back pain from retroperitoneal nodes, dyspnoea from pulmonary/mediastinal disease] or, less commonly, hormone-related gynaecomastia.

         

    In the low risk stage 1 GCT, with no treatment other than initial orchidectomy, the mainstay of management is close follow-up with fortnightly markers and regular imaging for metastatic disease. Adjuvant therapy of two cycles of bleomycin, etoposide and cisplatin [BEP] is an acceptable and justifiable way of virtually eliminating the risk of relapse.

        

    Seminoma is exquisitely radiosensitive and characteristically spreads via the lymphatic system, treatment aimed at the retroperitoneal /para-aortic nodes significantly reduces the risk of relapse.

        

    BEP currently remains the standard treatment.

         

    In pure seminoma, residual masses can be safely observed on serial scans and most will shrink and calcify over time; a growing mass, however, would indicate recurrent disease requiring further treatment.

         

    Mature teratoma must be surgically removed before it enlarges locally and becomes inoperable.

         

    Chemotherapy – induced acute toxicities in the treatment of testicular GCT are mostly transient. Fertility is adversely affected by chemotherapy, it usually returns to normal. Concern has been raised about the possible carcinogenic effects of chemotherapy in the long-term. Etoposide is known to be leukaemogenic and secondary tumours have been reported following etoposide containing therapy for
    GCT.

          

    The treatment of GCT overall has not changed a great deal in the last 5 years, although there is a trend toward more frequent use of chemotherapy in the earlier stages.

           

    Surgical conundrum is the benefits o orchidopexy to prevent the development of GCT only orchidopexy done at a very young age can reduce
    risk.

          

  • Markus
    W. Buchler, MD, Beat Gloor, MD, Christophe A,
    Muller, MD, Helmut Friess, MD, Christian A, Seiler,
    MD, and Waldemar Uhl, MD [ From the Department of
    Visceral and Transplantation Surgery, University of
    Bern, Inselspital, Switzerland]

    Acute
    Necrotizing Pancreatitis : Treatment Strategy
    According to the Status of Infection

    Annals
    of Surgery, November 2000, Vol. 232, No.5, Pgs.
    619-626

     

    Infection
    of pancreatic necrosis is the most important risk
    factor contributing to death in severe acute
    pancreatitis. It
    is generally accepted that infected pancreatic
    necrosis should be managed surgically.
    Recent clinical experience has provided
    evidence that conservative management of sterile
    pancratic necrosis including early antibiotic
    administration seems promising
    .

     

    Pancreatic
    infection, if confirmed by fine-needle aspiration,
    was considered an indication for surgery, whereas
    patients without signs of pancreatic infection were
    treated without surgery.

      

    When
    early antibiotic treatment was used in all patients
    with necrotizing pancreatitis [imipenem/cilastatin],
    the characteristics of pancreatic infection changed
    to predominantly gram-positive and fungal
    infections.

      

    Fine-needle
    aspiration showed a sensitivity of 96% for detecting
    pancreatic infection.

     

    These
    results support nonsurgical management, including
    early antibiotic treatment, in patients with sterile
    pancreatic necrosis. Patients with infected necrosis
    still represent a high risk group in severe acute
    pancreatitis, and for them surgical treatment seems
    preferable.

         

  • Andrew
    L, Warshaw, MD [Surgeon-in-Chief, Massachusetts
    General Hospital, and W. Gerald Austen Professor of
    Surgery, Harvard Medical School, Boston,
    Massachusetts

    Pancreatic
    Necrosis – To Debride or Not to Debride – That is
    The Question


    Annals
    of Surgery, November 2000, Vol. 232, No.5, Pgs.
    627-629

       

    There
    has been very considerable progress in our
    understanding of the pathogenesis, diagnosis, and
    management of necrotizing pancreatitis, especially
    the use of contrast-enhanced computed tomography
    [CT] scanning to identify and quantify pancreatic
    necrosis, and fine-needle aspiration [FNA] to detect
    secondary infection of the damaged tissues.

        

    There
    is continuing effort to define and anticipate what
    characteristics predict increased risk of multiple
    organ failure [MOF] and death, in the hopes of
    preventing them.

      

    Infection
    increases the risk of MOF, but sterile necrosis can
    also cause a lethal systemic inflammatory response
    syndrome [SIRS] with mortality from MOF reported as
    high as 38%.

       

    The
    first strategy used by Buchler and colleagues was
    the use of imipenem/cilastatin, which some studies
    have shown to reduce the incidence of infection in
    pancreatic necrosis. Quinolones have also found
    favor because these two classes of antibiotics have
    both broad spectrum and high penetration into the
    pancreas.

       

    It
    must be remembered that antibacterial therapy
    carries the risk of promoting fungal [ candida albicans] infection.

      

    Will
    it be possible also to reduce the incidence of C. albicans
    infection, perhaps with a shorter period of
    antibiotic treatment than the 14-day period used in
    this study, or with prophylaxis using an antifungal
    agent such as ketoconazole?

      

    If
    infection is the most important determinant of
    impending death, then FNA is crucial to therapeutic
    decisions.

      

    The
    allegation that the debridement will increase
    mortality by converting sterile necrosis to infected
    necrosis is without basis: the debrided cavity does
    become contaminated, but this is only surface
    colonization, which does not produce sepsis unless
    the debridement has been inadequate.

      

    A
    critically important observation is that infection
    may develop late, after observation is that
    infection may develop late, after weeks of apparent
    sterility and even after repeatedly sterile FNAs,
    and that designation as sterile must therefore be
    considered mutable.

       

    The
    guidelines proposed by Buchler and associates for
    nonoperative management of sterile necrotizing
    pancreatitis must be applied with caution and
    flexibility – but not as rules.

      

  • L.
    Bardram, P. Funch-Jensen and H. Kehlet [ Department
    of Surgical Gastroenterology, 435, Hvidovre
    University Hospital, DK-2650, Hvidovre, Denmark

    Rapid Rehabilitation
    in Elderly Patients after Laparoscopic Colonic
    Resection

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1540-1545

      

    This
    study combines the laparoscopic approach with a
    perioperative multimodel rehabilitation protocol.

      

    After
    laparoscopy assisted colonic resection, patients
    were treated with epidural anaesthesia for 2 days,
    early mobilization and enteral feeding. Routine use
    of drains, traditional tubes; 
    bladder catheterization and morphine was
    avoided.

      

    50
    consecutive resections [mean age 81 years] were
    performed. The conversion rate was 22%. In those
    where laparotomy was not done the median hospital
    stay was 2.5 days and defaecation occurred in 92% of
    patients in 3 days. Patients were mobilized for more
    than 8 hours after day 2.

      

    Recovery
    after such an approach was good.

        

  • A.
    Osterberg. K. Edebol Eeg-Olofsson* and W.
    Graf [ Department of Surgery and * Clinical
    Neurophysiology, University Hospital, SE-75185
    Uppsala, Sweden

    Results of Surgical
    Treatment for Faecal Incontinence

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1546-1552

     

    This
    study evaluates the results of anterior
    levatorplasty and sphincteroplasty for faecal
    incontinence with respect to symptomatic and
    physiological incontinence.

     

    31 patients with idiopathic [neurogenic] faecal
    incontinence underwent anterior levatorplasty and 20
    patients with traumatic and sphincteric injury
    underwent  sphincteroplasty.
    The results were evaluated at 3 and 12 months.

     

    18
    out of 31 patients undergoing levatorplasty reported
    continence to solid and liquid stools 1 year
    postoperatively compared with 2 patients before
    surgery. The corresponding figures in the
    sphincteroplasty were 10 patients and 2 patients
    [out of 20]. The incontinence score was improved in
    both groups after one year from a median score of 14
    to 3 in the levatorplasty group and from 8.5 to 3.5
    in sphincteroplasty group.
    Improvements in the degree of social and
    physical handicap were also observed in both groups.
    No changes were seen in the anal canal pressures or
    rectal sensation in either group.

        

  • T.
    Mynster, I.J. Christensen*, F. Moesgaard and H.J.
    Nielsen for the Danish RANXO5 Colorectal Cancer
    Study Group [Department of Surgical Gastroenterology
    435, H:S Hvidovre Hospital, University of
    Copenhagen, Hvidovre and * Finsen Laboratory]

    Effects of the
    Combination of Blood Transfusion and Postoperative
    Infectious Complications on Prognosis After Surgery
    for Colorectal Cancer

     Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1553-1562

        

    The
    combination of perioperative blood
    transfusion and subsequent infectious complications
    may be associated with poor prognosis.

  • Asha Senapati Neil P.J. Cripps 

    Pilonidal Sinus

    Recent Advances in Surgery-23, Year-2000, Pg. 33

        

    There is a male preponderance of 1.5:1 and it typically occurs in hairy young men.

        

    The term pilonidal sinus originates from the Latin words Nidus for nest, Pilus for hair and Sinus for connections to the skin. 

        

    Its aetiology is unknown; the theory that it is congenital is largely discounted. 

        

    In the natal cleft, it is thought that skin follicles are enlarged due to the shearing action of the buttocks. Hair then enters these follicles and infection ensues.

        

    The pathology of this condition is that of chronic sepsis. 

        

    No longer is it considered necessary to excise these widely during surgical treatment.

         

    Treatment of asymptomatic disease is seldom warranted. 

         

    Symptomatic disease may present in three ways [I] as an acute abscess; [ii] a chronic discharging sinus [sometimes with pain]; or [iii] an unhealed midline wound.

        

    Acute Pilonidal Abscess –

    It has been suggested that wide excision and laying open may be done acutely; thus treating the underlying disease at the same time, but this results in a large painful midline wound that may take many months to heal; in some cases it may never do so.

         

    Minimalist approach is simply to drain the pus with a ‘stab’ wound under local anaesthesia.

          

    Once the acute sepsis has settled and before it can recur, definitive treatment can be offered.

          

    Chronic Pilonidal Sinus-

    Many procedures have been described for the chronic situation, none of which is perfect, judged by the yardsticks of primary healing and recurrence of disease. 

         

    Simple shaving and removal of hair may control symptoms without operation, surgery is often required when chronic infection supervenes. 

           

    The most unpleasant complication [which is also difficult to manage] is a persistently unhealed midline wound, commonly seen after other treatments such as laying open or excision of the primary disease. 

          

    Karydakis technique –

    A technique of asymmetric natal cleft would closure. An eccentric, elliptical excision is made with mobilization of a flap from the medical side of the wound. All sinus tracts are excised completely down to the sacral periosteum. The mobilized flap is sutured to the sacrococcygeal fascia and the wound is closed.

         

    The wounds healed well with a recurrence rate of less than 1%.

          

    Pilonidal sinus disease is a benign condition and patients apparently outgrow its infective complications. It is, therefore, imperative that the treatment is no worse than the disease itself.

           

  • C.M.
    Malata, S.A. McIntosh and A.D. Purushotham [
    Departments of Reconstructive and – General Surgery,
    Cambridge Breast Unit, Addenbrook’s Hospital,
    Cambridge, UK ]

    ImmediateBreast
    Reconstruction After Mastectomy for Cancer

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1455-1472

           

    2.     
    Autogenous Tissue Reconstruction – 
    Transverse rectus abdominis myocutaneous flap
    [various types].

            
    Free
    deep inferior epigastric perforator flap
    latissimus dorsi musculocutaneous flap.

      

    3.     
    Other autogenous tissue Techniques – Superior
    and inferior gluteal free flap,
    gluteal perforator free flap, lateral
    transverse

             thigh
    flap, Taylor-Rubens peri-iliac free flap.

     

    Careful
    discussion and evaluation remains vital in choosing
    the correct technique for the individual patient.

       

    The
    aesthetic considerations [comparison with opposite
    breast] and psychological consideration must be looked
    into.

      

  • E.
    Degiannis and K. Boffard [ Department of Surgery,
    Medical School, University of the Witwatersrand, 7
    York Road, Parktown, 2193 Johannesburg, Repyblic of
    South Africa

    Duodenal
    Injuries

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1473-1479

     

    The
    worldwide increase in road traffic accidents and the
    use of firearms has increased the incidence of
    duodenal trauma. Duodenal injury can pose a formidable
    diagnostic and therapeutic problem.
    It can cause serious fluid and electrolyte
    imbalance, chemical inflammation in the peritoneum and
    retroperitoneum which may prove life threatening.
    Again, there is no single method of repair that
    ensures success.

      

    Isolated
    duodenal injuries 
    are uncommon because of its close proximity to
    a number of other viscera and major vascular
    structures. The
    need for an exploration is usually made in the
    operating room. Penetrating
    trauma is the most common form of injury.

      

    Blunt
    trauma is less common, usually causes crushing of the
    duodenum between the spine and steering wheel,
    handlebar or some other force applied to the anterior
    abdomen. Such
    injury may be associated with fracture of L1-L2
    vertebrae. Less
    commonly, deceleration injuries may produce a tear of
    the duodenum at the junction of free and fixed parts.
    High index of suspicion based on mechanism of
    injury and physical examination may lead to 
    further diagnostic studies.

      

    If
    there is peritonitis, the diagnosis is not so
    difficult.

      

    Serum
    amylase is not dependable though serial readings may
    prove more valuable. Radiologically gas
    bubbles may be present in the retro-peritoneum
    near the psoas, kidney and lumbar spine. 
    It may show free gas under the diaphagm and
    very rarely pneumobilia Obliteration of the psoas
    shadow and fractures of the transverse process of the
    lumbar vertebrae are indicative of the retro
    peritoneal injury.

      

    An
    upper GI series with water soluble contrast may prove
    fruitful in 50% of cases. It may rarely show the
    ‘coiled spring’ appearance of complete obstruction
    by a haematoma.

      

    CT
    scan is a very sensitive diagnostic 
    tool especially in children.
    Diagnostic laparoscopy, is not very useful.
    Exploratory laparotomy remains the ultimate diagnostic
    test.

           

    The
    authors have graded duodenal and pancreatic injuries.

             

    Injuries
    to the first and second part of the duodenum requires
    distinct manoeuvres to diagnose the injury [cholangiogram,
    direct inspection] and complex techniques to repair
    them and 3rd and 4th part
    injuries may be treated like small bowel injuries.
    Associated pancreatic injuries may require more
    complex procedures.

      

    Various
    approaches have been described for duodenal haematoma,
    perforations. Duodenal diversion,
    pyloric exclusion and gastrojejunostomy 
    predicled mucosal
    graft or a gastric island  
    flap or jejunal
     
    serosal
    patch and primay anastomosis
    in
    cases of complication have been discussed.

          

    The
    majority of duodenal injuries may be managed by a
    simple repair; complicated injuries require more
    sophisticated procedures.

           

  • K.
    Holte amd J. Kehlet [ Department of Surgical
    Gastroenterology, Hvidovre University Hospital,
    DK-2650 Hvidovre, Denmark

    Postoperative Ileus : A Preventable Event

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1480-1493

      

    Postoperative
    ileus has been traditionally 
    accepted as a normal response to tissue injury.
    This  ileus
    has no beneficial effects and it may contribute to
    delayed recovery and prolonged hospital stay.

         

    This
    article reviews the available literature and updates
    the knowledge on pathophysiology and treatment of
    postoperative ileus.

         

    The
    pathogenesis mainly involves inhibitory neural
    reflexes and inflammatory mediators [ like nitric
    oxide, vasoactive intestinal peptide [VIP] and
    substance ‘P’] have been implicated. Calcitonin
    gene-related peptide, corticotrophin releasing factor
    have also been implicated. 
    Finally opioids are well established as
    modulators of neural transmission.

          

    The
    most effective method of reducing ileus is thoracic
    epidermal blockade with local anaesthetic. Opioids
    sparing analgesic techniques and NSAIDs also reduce
    ileus as does laparoscopic surgery.
    Of the prokinetic drugs only cisapride is
    proven beneficial. The
    effect of early enteric feeding remains unclear.
    If all the above methods are combined, the
    results are considerably improved.

      

  • V.
    Usatoff, R. Brancatisano and R.C.N. Williamson [
    Department of Surgery, Hammersmith Hospital, Imperial
    College School of Medicine, Du Cane Road, London W12
    OHS, UK

    Operative
    Treatment of Pseudocysts in Patients with Chronic
    Pancreatitis

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1494-1499

        

    Pseudocysts
    associated with chronic pancreatitis are generally
    intrapancreatic and associated with parenchymal
    disease. They tend to persist and cause complications.
    Minimally invasive methods of treatment challenge the
    traditional technique of operative management. Open
    surgery allows the definitive treatment of the
    pseudocysts with
    the option of dealing appropriately with the diseased
    pancreas and excluding a neoplastic process.

      

    A
    personal series of 112 consecutive patients operated
    for pseudocysts in the setting of chronic pancreatitis
    was reviewed.  Chronic
    pancreatitis was confirmed by imaging studies in
    association with exocrine/endocrine failure.

     

    31
    patients had multiple cysts and presented with
    complications other than pain in 47. 

    Data
    was collected prospectively regarding the clinical
    presentation, the nature of the operation and its
    outcome.

       

    43%
    of cases underwent drainage procedures, 50% had a
    resection, and 7% had a combination. Larger cysts and
    those located in the head and neck tended to be
    drained while smaller and distal cysts were more often
    resected. The operative mortality was 1%, The morbidity 28%. The cyst
    recurrence rate was 3% and pain was relieved in 74% of
    cases.

      

    The
    introduction of the newer minimally invasive technique
    will have to withstand comparison to this traditional
    approach.

       

  • J.L.
    Poggio, D.M. Nagorney, A.G. Nascimento, C. Rowland,
    P.Kay, R.M. Young and J.H. Donohue [ Department of
    Surgery, Section of Anatomic Pathology and Section of
    Biostatistics, Mayo Clinic, 200 First Street, SW,
    Rochester, Minnesota 55905, USA

    Surgical Treatment of Adult Primary Hepatic Sarcoma

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1500-1505

     

    Primary
    sarcomas of the liver are extremely rare in adults.
    Optimal therapeutic approaches remain unclear.

        

    Twenty
    consecutive adults who are operated for hepatic
    sarcomas were reviewed. The ages ranged between 23 to
    80 years. No predisposing causes could be found except
    in one who had a history of thorotrast exposure 23
    years ago.

     

    19
    patients had hepatic resection and one patient had an
    orthotopic liver transplant. No patient was given
    neo-adjuvant chemotherapy but one patient had
    intra-operative radiotherapy.

     

    Leiomyosarcoma
    was the most common histologic carcinoma [ 5 out of
    20] followed by malignant solitary fibrous tumour [4
    cases] and epithelioid haemagioendothelioma [ 3
    cases]. 14 tumours were high grade sarcomas whereas 6
    were low grade malignancies.

         

    Three
    patients developed local recurrences while 10 patients
    developed metastases and intrahepatic recurrence in 6
    patients were the predominant sites of initial
    treatment failure.

          

    Six patients received salvage chemotherapy.
    Histological grading was the only factor
    significantly associated with patient survival [
    p=03].

      

    With
    complete resection, patient with high grade tumours
    had a 5 year survival rate of 18% compared with 80%
    for patients with low grade tumours. Overall survival
    rate was 37%.

         

    Surgical
    resection is the only effective therapy for primary
    hepatic sarcoma. Better adjuvant therapy is necessary
    for high grade malignancy owing to high failure rate
    with only surgery.

       

  • D.
    Boerma, E.A.J. Rauws T.M. van Gulik, K. Huibregtse, H.
    Obertop and D.J. Gouma [ Department of Surgery and
    Gastroenterology, Academic
    Medical
    Centre, Meibergdreef 9, 1105 AZ Amsterdam, The
    Netherlands

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1506-1509

       

    Spontaneous
    closure of an external pancreatic fistula is unlikely
    when a concomitant downstream obstruction of the
    pancreatic duct inhibits downstream flow. ERCP and
    stent insertion may aid fistula closure.

        

    15
    patients of pancreatic fistula developed after
    operative necrosectomy and debridement of the pancreas
    [ seven men and eight women; ages 25-68 years] were
    evaluated after endoscopic stenting.

      

    Results
    – The median drainage dropped
    from 50-800 ml/day [amylase content of 21,000 to
    493000 U/L] to nil. ERCP was done after a median time of 35 days and revealed a leak
    with obstruction in all cases.
    An endoprosthesis was inserted beyond the site
    of obstruction. In one patient drainage failed and a
    pancreaticojejunostomy had to be done. During
    follow-up [2-55 months] 3 patients required resection
    of the pancreatic tail 
    becau
    se of
    psedocyst formation.

     

    Early
    ERP stenting enhances fistula closure, facilitates
    wound care and surgery is postponed or even avoided.

      

  • X.-Y.
    Yin, P.B.S. Lai, J.F.Y. Lee and J.W.Y. Lau [
    Department of Surgery, The Chinese University of
    HongKong, Prince of Wales Hospital, Shatin, Hong Kong
    Special Administrative Region, China

      

    Effects
    of Hepatic Blood Inflow Occlusion on Liver
    Regeneration Following Partial Hepatectomy In an
    Experimental Model of Cirrhosis

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1510-1515

     

    Hepatic
    blood inflow occlusion during hepatectomy may
    influence postoperative liver regeneration. This study
    explores this phenomenon following partial hepatectomy
    in thioacetamide-induced cirrhotic rates.

     

    43
    cirrhotic Wistar-Furth rats were randomly assigned to
    three groups. Group 1 rats underwent 64% hepatectomy
    alone. Group 2 rats were subjected to 15 min hepatic
    blood inflow occlusion followed by 64% hepatectomy.
    Group 3 rats were subjected to 30 min inflow occlusion
    followed by 64%  hepatectomy.
    Liver function 5-bromo-2’-deoxyuridine [BrdU]
    labeling index and  
    percentage of initial liver weight on days 1, 2
    and 7 posthepatectomy were assessed.

      

    Results
    – Rats in groups 1 and 2 had a significantly higher
    serum albumin level and a markedly lower alanine
    aminotransferase level than animals in group 3 on day
    1 posthepatectomy [p<0.05]. There was 
    no significant difference in the serum level of
    total bilirubin of the three groups on days 1,2 and 7.
    The BrdU labelling index was significantly higher in
    groups 1 and 2 than in group 3 animals on day 1
    posthepatectomy [ p<0.01 and p<0.05
    respectively]. Percentages of initial liver weight were similar in groups 1,2 and 3 on days, 1,2 and 7 after
    respectively.

      

    Hepatic
    blood inflow occlusion upto 30 min suppressed DNA
    synthesis and hepatocyte proliferation at an early
    posthepatectomy stage and consequently delayed
    recovery of liver function in cirrhotic rats. However
    it did not affect restoration of liver mass or
    survival  after
    64% hepatectomy.


        

  • EU Hernia Trialists Collaboration [ Prof. A. Grant, EU Hernia Triallists Collaboration Secretariat, Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK]

    Laparoscopic Cpmpared with Open Methods of Groin Hernia Repair: Systematic
    Review of Randomized Controlled Trials

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 860-867

         

    This is a systematic review of all published data from all relevant randomized or quasi-randomized trials. Prespecified data items were extracted from reports and where possible a quantitative meta-analysis was performed. Electronic databases were searched and members of the EU Hernia Triallist Collaboration consulted to identify trials. 

        

    34 published reports of eligible trials involving 6804 patients were reviewed. Sample sizes ranged 20 to 1051 with follow up from 6 weeks to 36 months.

        

    The duration of surgery was longer in the laparoscopic group. Operative complications were rare in both groups, but visceral and vascular injuries were common in the laparoscopic group.

        

    The length of hospital stay did not differ significantly in the two groups. The post-operative pain was less in the laparoscopic group and return to usual activity earlier in the laparoscopic group. 

        

    Overall recurrence rates did not differ greatly. Chronic pain and numbness were very rarely reported.

        

    They conclude that laparoscopic repair was associated with less post-operative pain and more rapid return to normal activities but it takes longer to perform and may increase the risk of rare but serious complications.

      



 

   

Speciality Spotlight

   

   
Surgery
   

 

General Surgery
  

  • Velmahos GC, Arroyo H, Ramicone E, et al (Univ of Southern California, Los Angeles; Los Angeles County,USC Med Ctr)
    Timing of Fracture Fixation in Blunt Trauma Patients with Severe Head Injuries.
    Am J Surg 176: 324-330, 1998.
      
    Early fracture fixation is thought to reduce postoperative morbidity by permitting early mobilisation and decreasing the release of harmful inflammatory mediators. This approach is disputed in severe head trauma.
      
    A retrospective study of 47 consecutive patients of severe head injury with long bone fracture were reviewed. 22 had undergone fixation within 24 hours and 25 at a mean of 143 hours after trauma.
        
    The timing of the fracture fixation did not affect morbidity, mortality or neurologic outcome. The treatment of patients with severe head injuries should be based on sound individual clinical assessment rather than mandatory policies on long bone fracture fixation.
        

  • Nikolajsen L, Ilkjaer S, Jensen TS (Univ Hosp of Aarhus, Denmark)
    Effect of Preoperative Extradural Bupivacaine and Morphine on Stump Sensation in Lower Limb Amputees.
    Br. J Anaesth 81: 348-354, 1998.
         
    This is a randomized double blind study to determine if postoperative pain can be prevented by the use of preoperative use of extradural bupivacaine and morphine.
         
    The pressure pain threshold, touch and pain detection thresholds, thermal sensibility, allodynia and windup like pain were evaluated before amputation and 1 week and 6 months after amputation.
         
    The results indicate that preoperative extradural anaesthesia did not prevent postoperative hyperexcitability in the stump and had no effect on long term hyperalgesia, allodynia or wind-up like pain in amputees.
          

  • Larsson J, Agardh C-D, Apelqvist  J, et al (Univ Hosp, Lund, Sweden)
    Long Term Prognosis After Healed Amputation in Patients with Diabetes.
    Clin Orthop 350: 149-158, 1998.
        
    This is a prospective study of 220 patients with diabetes with foot ulcers subjected to amputation after primary treatment. 136 had a below knee (BK) and 84 patients had an above knee (AK) amputation.  Of these 29 patients died before healing, 5 patients with BK amputation underwent after knee amputation. 2 patients did not heal and were excluded. The remaining 189 patients were followed up for 6.3 years (range, 1-10.8 years).
        
    The time for healing was an average of 29 weeks for BK amputations and 8 weeks for AK amputations.
        
    The mortality at 1, 3 and 5 years was 15%, 38% and 68% respectively. The rate of new amputations were required at 1, 3 and 5 years was 14%, 30% and 49% respectively.
         
    It is concluded that diabetics who underwent an AK amputation had a higher mortality rate of new above knee amputation and a lower rehabilitation potential than those undergoing BK amputations.
          

  • Legro MW, Reiber GD, Smith DG, et al (VA Puget Sound Health Care System, Seattle; Univ of Washington, Seattle; Prosthetics Research Study, Seattle).
    Prosthesis Evaluation Questionnaire for Persons with Lower Limb Amputations:  Assessing Prosthesis-related Quality of Life.
    Arch Phys Med Rehabil 79: 931-938, 1998.
         
    A self administered questionnaire was developed for the evaluation of prosthetic care by quantifying the evaluation of individuals with amputations with regard to their prosthesis and their quality of life (PEQ- Prosthesis evaluation questionnaire). It consisted of 10 scales regarding prosthesis function mobility, psychosocial experience and wellbeing.
         
    92 patients completed the questionnaire. The internal consistency was high for all scales except “transfers”. Scores were stable over time.
         
    The scales showed good psychometric properties. It is a good tool for evaluation of prosthetic care.
          

  • BP Boden, DT Kirkendall, Jr Garrett WE (Duke Univ, Durham,NC)
    Concussion Incidence in Elite College Soccer Players
    Am J Sports Med 26: 238-241, 1998.
         
    The potential for head injuries among soccer players and its relation to neuropsychological deficits have long been debated.  The incidence of concussion in elite college soccer players has been assessed.
          
    Methods: Seven men’s and 8 women’s soccer teams were studied for 2 seasons, and results documented.
         
    Findings: 29 concussions were diagnosed in 26 athletes (17men and 12 women). Concussions occurred from contact with :
             
    2)                 an elbow in 14%

    3)                 a knee in 3%

    4)                 a foot in 3%

    5)                 a ball in 24%

    6)                 ground in 10%

    7)                 concrete side lines 3%

    8)                 goal post in 3%

    9)                 combination in 10%
      
    69% occurred during games. None of them occurred during intentional heading of the ball 72% of concussions were grade 1 and 28% were grade 2.
         
    Conclusions: Concussion occurs more commonly in soccer than has been believed. Such injuries may result in long term neuropsychological changes.
          

  • JT Matser, AGH Kessels, BD Jordan, et al (St Anna Hosp Geldrop, The Netherlands; Univ of Maastricht, The Netherlands; Charles R Drew  Univ of Medicine & Science, Los Angeles; et al)
    Chronic Traumatic Brain Injury in Professional Soccer Players.
    Neurology 51: 791-796, 1998.
        
    Repeated concussive and subconcussive blows to the head may result in chronic brain injury. Such injuries are common in soccer.
          
    Methods: 53 active professional soccer players were studied along with 27 elite atheletes from non contact sports and they were examined neuropsychologically.
         
    Findings:  Compared with the controls, the soccer players had impaired performances in memory, planning, performances were correlated inversely with the number of concussions and with the frequency of “heading”. This also depended on field position with higher incidence amongst the forwards and defenders.
          

  • BC Barnes, L Cooper, DT Kirkendall, et al (Duke Univ, Durham, NC; Univ of Los Angeles)
    Concussion History in Elite Male and Female Soccer Players
    Am J Sports Med 26: 433-438, 1998.
         
    Neurophysiologic and neuropsychologic changes have been reported in active and retired soccer players and “heading” has often been cited as the cause. There is concern about the cumulative effects of “heading”. The information available in the context is conflicting.
           
    Methods: All male and female soccer players who completed in the 1993 olympic Sports Festival were interviewed. There were 137 players with a mean age of 20.5 years. The mechanisms of injuries, frequency of injuries and the outcomes were determined.
         
    Results: In males there were 74 concussions in 39 players (50 injuries were Grade I by the Colorado Medical Society guidelines). In females, there were 28 concussions in 23 players (19 injuries were Grade I). In males 48 of 74 concussions and in females 20 of 28 concussions occurred as a result of collision with another player. The most common symptoms were headache, a dazed feeling and dizziness. On the basis of the study, the odds that a soccer player would sustain a concussion within a 10 year period were 50% for males and 22% for females.
         

  • JE Sturmi, C Smith, JA Lombardo (Ohio State Univ, Columbus)
    Mild Brain Trauma in Sports: Diagnosis and Treatment Guidelines.
    Sports Med 25:351-358, 1998.
          
    Mechanism of head injury : In any given year 20% of American high school football players experience a sports related concussion. Other sports causing concussion are boxing, ice hockey, rugby, motor racing, equestrian sports, martial arts, wrestling, gymnastics, cycling, alpine skiing and diving. Given the brain’s protective anatomy, direct blows are tolerated with little injury; the exception being the association of a fracture or haematoma. The acceleration or deceleration injuries are more serious.  Additionally, a sharp blow to the athlete’s torso or pelvis can cause a concussion. Protective gear and strong muscles can dissipate the forces and lessen the severity of the injury. Fortunately, most injuries are mild. Nonetheless, all athletes who sustain a head injury, should be properly evaluated irrespective of their state of consciousness.
         
    Management: The athlete should be rested at once. If warranted he should be hospitalised and properly evaluated. All symptoms must have completely resolved before the athlete is allowed to return to play.
        

  • Noble David University Hospitals, Aberdeen and Hehlet Henrik University Hospitals, DK-2650, Hvidovre, Denmark]
    Risks of interrupting drug treatment before surgery The consequences may be as serious as those from drug errors 
    BMJ [VOL-7263], 23 September, 2000 , Pg. No 719
        
    Some surgeons are ignorant of consequences of interrupting drug treatment before surgery. This is a specially true of abdominal surgeons who have patients taking drugs by mouth before surgery. Cardiac drugs, antihypertensive and antidiabetic drugs are the commonest and most important chronically prescribed treatment. It is important that these drugs are not discontinued before surgery. If they can not be given by mouth they must be given by injection. If an injection is not available, an alternative drug of similar class can be given by injection. As soon as possible, oral drugs must be restarted.
         
    Surgeon should be educated in the importance drugs being continued to be given to patients and to recognize important drugs whose discontinuation may harm the patients.
          

  • GB Thompson, CS Grant, JA van Heerden et al  (Mayo Found, Rochester, Minn): Laparoscopic versus open posterior adrenalectomy: A case control study of 100 patients.    
    Surgery 122:  1132-1136, 1997.

         
    Few large studies have compared laparoscopic adrenalectomy (LA) with conventional open anterior or posterior adrenalectomy (PA).
         
    Laparoscopic  adrenalectomy is a safe and effective procedure that is superior to PA with respect to patient satisfaction, length of hospital stay, return to normal activities, analgesic requirements and late complications. Compared with PA, LA operating times and hospital stays are slightly longer. LA is more expensive and technically more demanding.
           

  • Navez B, Tassett V, Scohy JJ, et al
    Laparoscopic Management of Acute PERITONITIS
    Br. J Surg 85: 32-36, 1998
        
    Laparoscopy can be safely carried out in patients with peritonitis
          
    Advantages:
         
    1.                 Confirm preoperative diagnosis

    2.                 Clarify treatment planning

    3.                 May avoid need for Laparotomy

    4.                 Particularly useful in patients with appendicular or gastroduodenal perforation.
        
    Patients with colonic perforation are more likely to require laparotomy, but even they may be managed laparoscopically with better surgical expertise.
         
    Caution:

    a)                 With intense inflammation, it may be difficult to explore all parts of the abdomen without injuring the intestine.

    b)                There may be a danger of missing abscesses between loops of intestine, below the diaphragm or in the pelvis.
           

  • Lemieur TP, Rodriguez JL, Jacobs DM, et al [ Univ of Minnesota, Minneapolis]
    Wound Management in Perforated Appendicitis
    Am Surg 65: 439-443, 1999
        

  • Snyderman CH, Kachman K, Molseed L, et al [ Univ of Pittsburgh, Pa; Duquesne Univ, Pittsburgh, Pa; Univ of Louisville, Ky]
    Reduced Postoperative Infections with an Immune-Enhancing Nutritional Supplement
         

  • Heyland DK, for the Canadian Critical Care Trials Group [Queen’s Univ, Kingston, Ont, Canada; et al]
    The Clinical Utility of Invasive Diagnostic Techniques in the Setting of Ventilator – Associated Pneumonia
    Chest 115: 1076-1084, 1999
         
    Ventricular-associated pneumonia [VAP] is often diagnosed on clinical grounds alone and contributes to the morbidity, mortality and costs of caring for critically ill patients. Overdiagnosis may be disastrous with the use of needless antibiotics and the delay in recognition of the ‘true’ diagnosis.
         
    The utility of invasive investigations like bronchoscopy, with protected brush catheter [PBC] bronchoalveolar lavage [BAL] was evaluated in 92 patients receiving ventilatory support with a clinical suspicion of VAP.
          
    The results showed that VAP was often overdiagnosed after BAL or PBC after these procedures. Patients received fewer antibiotics. Both groups had similar duration of mechanical ventilation and ICU stay. Those who underwent PBC/BAL had a lower mortality.
         
    Invasive diagnostic testing may boost physicians confidence in the diagnosis and management of VAP.
           

  • Alter MJ, Kruszon-Moran D, Nainan OV, et al [Ctrs for Disease Control and Prevention, Atlanta, Ga and Hyattsville, Md; Natl Inst of Allergy and Infectious Diseases, Bethasda, Md]
    The Prevalence of Hepatitis C Virus Infection in the United States, 1988 Through 1994
    N Engl J Med 341: 556-562, 1999
         
    Chronic infection with Hepatitis C virus [HCV] is a major cause of chronic liver disease, but is often asymptomatic. Sera was collected from a nationwide population survey to assess its prevalence.
          

  • Pittet D, Wyssa B, Herter-Clavel C, et al [Univ Hosp of Geneva, Switzerland]
    Outcome of Diabetic Foot Infections Treated Conservatively : A Retrospective Cohort Study with Long-term Follow-up
    Arch Intern Med 159: 851-856, 1999
        
    Diabetic foot lesions are the cause of more hospitalizations than any other complications of diabetes. Effective guidance needs to be enunciated to minimize human and financial cost of diabetic foot lesions. A 5-year retrospective cohort study with prospective long-term follow up was undertaken to identify criteria predictive of failure of conservative treatment of such lesions.
        
    Conservative measures including prolonged culture guided parenteral or oral antibiotics was successful without amputation in 63% of diabetic foot lesion.
        

  • Kiviluoto T, Siren J, Luukkonen P, et al [Helsinki Univ Central Hosp]
    Randomised Trail of Laparoscopic versus Open Cholecystectomy for Acute and Gangrenous Cholecystitis 
    Lancer 351-325, 1998
          
    Laproscopic cholecystectomy [ LC] is the surgical approach of choice for elective cholecystectomy. Use of LC in acute cholecystitis is controversial. Postoperative complications were higher in open cholycystectomy than laperoscopic cholecystectomy. Laparoscopic cholecystactomy in patients with acute gangrenous cholecystitis is technically demanding and in experienced hands and in experienced hands, LC can be safe and effective procedure without increase in mortality and morbidity.
        

  • McHale A. Buechter KJ, Cohn I Jr, et al [ Louisiana State Univ, New Orieans]
    Surgical Management of Chronic Pain From Chronic Pancreatitis
    Am Surg 63: 1119-1123, 1197
           
    Intractable pain is the major clinical problem in patients with chronic pancreatitis.
    Surgery including Puestow’s procedure, pseudocyst drainage, or sphincteroplasty was performed to correct anatomy causing dilation of ducts. For patients with no 
    ductal dilation, or those with recurrent postoperative pain, denervation procedures [i.e. thoracoscopic, sympathectomy or resection ] were performed. Surgery provided pain relief in 68% of the patient. No single procedure proved more effective. Results of thoracoscopic sympathectomy are promising.
          

  • Levitt MA, Softer SZ, Peria A [Long Island Jewish Med Ctr, New Hyde Park, NY ; Albert Einstein College of Medicine, Bronx, NY Continent Appendicostomy in the Bowel Management of Fecally Incontinent Children 
    J Pediatr Surg 32 : 1630-1633, 1997
          
    Fecal incontinence is a common problem in children, affecting many patients with anorectal malformations, spina bifida, or Hirschsprung’s disease. Previously appendix was used as a conduct by which to give an antegrade enema. The modified technique was made simpler by plicating the cecum around appendix. This created a one way valve mechanism while leaving appendix in its original place. Cecal wall tissue was used to created new appendix if appendix had been removed earlier. Continent appendicostomy offers the new option for the management of children with fecal incontinence. It provides a safer, effective route for enema administration. The procedure allows patients to remain clean with an inconsoicuous stoma and allow children to catheterize themselves. 
         
    Advantages of antegrade enemas are tremendous. Postoperative complications are low. Significant patient’s satisfaction and compliance can be achieved.
          

  • Rosen HR. Novi G, Zoech G, et al [ Danube Hosp, Vienna]
    Restoration of Anal Sphincter Function by Single-Stage Dynamic Graciloplasty With a Modified [Split Sling] Technique
    Am J Surg 175:187-193, 1998
         
    “Dynamic Graciloplasty” refers to the use of electrostimulation to transform Fast-twitching type II muscle fibers into slow-twitching type I fibers, thus providing skeletal muscles with capacity for tetanic contraction. The operation has given promising results in patients with fecal incontinence or those who have undergone excision of anal sphincter. In one stage procedure, the muscle was transposed and stimulation electrodes and pulse generator implanted. The neosphincter was wrapped with a modified split sling technique. This was followed by controlled neuromuscular stimulation to transform the muscle. With one-stage technique inner continence was achieved within 7 weeks. Muscle wrapped must be placed with correct tension to avoid direct injury tuberectum. Functional results are outstanding considering the patients who underwent operation for congenital atresia achieved satisfactory continence in 90% of cases. Trials of implanting an artificial bowel sphincter are going on which may become a valuable alternative to graciloplasty in the near future.
         

  • Maria G, Cassetta E, Gui D et al [Universita Cattolica del Sarco Cuore, Rome; Centro S Giovanni di Dio, Fatebenefratelli, Brescia, Italy]
    A Comparison of Botulinum Toxin and Saline for the Treatment of Chronic Anal Fissure
    N Engl J Med 338: 217-220, 1998
          
    Patients with chronic anal fissure have tearing of the lower half of the anal canal, possibly related to severe constipation or straining at stool. Internal anal sphincter contraction serves to maintain the fissure. Surgical sphincterotomy, the most common treatment, is done to relieve symptoms and promote healing. However, it also weakens the the internal sphincter, possibly leading to complications, such as anal deformity and incontinence. Patients received two injections of botulinum toxin A, for a total of 20 units in a volume of 0.4ml. Patients from the original treatment who had persistent fissures were retreated with botulinum toxin, 25 units. No relapses occurred through 16 months of follow-up.
          
    As an alternative to sphincterotomy, patients with chronic anal fissure may be effectively treated with local infiltration of botulinum toxin. This treatment is simple, inexpensive, and does not require anesthesia.
           
    The main alternative to this treatment is application of nitroglycerine ointment. Application of an ointment may be more acceptable to patients.
          

  • Yim JH,Wick MR, Philpott GW, et al [Washington Univ, St Louis]
    Underlying Pathology in Mammary Paget’s Disease
    Ann Surg Oncol 4: 287-292, 1997
          
    Mastectomy has been the standard treatment, but recent studies have recommended radiotherapy with no resection. All patients had histologically confirmed Paget’s disease; 92% of patients had underlying carcinoma, either ductal carcinoma in situ, invasive ductal cancer, or both. Mammography failed to detect the multifocal lesions in 64% of patients with no palpable mass. Patients with a palpable mass were significantly more likely to have invasive cancer, multifocal lesions, and positive lymph nodes. 
           
    Most patients with mammary Paget’s disease have underlying multifocal carcinoma, including invasive lesions. Therefore, mastectomy remains the standard treatment.
         

  • Kuzbari R, Worseg AP, Tairych G, et al [Univ of Vienna, Austria]
    Sliding Door Technique for the Repair of Midline incisional Hernias 
    Plast Reconstr Surg 101: 135-1242, 1998
         
    Sliding door technique that makes it possible to effect a tensionless and autologous repair of large hernias after midline laparotomy.
        
    In this technique the medical border of the rectus sheath is identified on both sides of the hernia. Rectus sheaths are dissected away from the muscles; Rectus sheaths, after being incised at the aponeuroses of the external oblique muscles, slide towards the midline. The posterior rectus sheaths are sutured. The rectus muscles are secured with overlapping sutures, and the released anterior layers of the rectus sheaths are sutured. Releasing the rectus sheaths from the pull of the external oblique muscles eliminates the most unyielding pull.
         

  • Gonze MD, Manord JD, Leone-BayA, et al [Ochsner Med Institutions, New Orleans, La; Emisphere Technologies Inc, Tarrytown, NY]
    Orally Administered Heparin for Preventing Deep Venous Thrombosis
    Am J Surg 176: 176-178, 1998 
        
    Heparin has a large molecular size that compromises absorption after oral administration. The synthetic acetylated amino acid molecule sodium N-8 amino caprylate [SNAC] facilitates gastrointestinal absorption on heparin. A rat model was used to evaluate an oral combination of SNAC and heparin for the prevention of venous thrombosis.
         
    Venous thrombosis developed in 89% of the control group vs. 25% of the SNAC -with heparin group and 11% of the IV heparin group. If adequate anticoagulation can be achieved using oral heparin, treatment of deep venous thrombosis will likely be simpler and possibly safer.
         

  • Zubair M, Besner GE [Ohio State Univ]
    Pediatric Electrical Burns : Management Strategies
    Burns 23: 413-420, 1997
        
    Most electrical injuries occurring in the home involve children. Low voltage electrical injuries – those involving sources less than 1,000 V – occur more frequently in younger children. 
          
    If these children remain asymptomatic after 4 hours of observation, they may safely be treated on an outpatient basis. Most low-voltage electrical injuries to young children are easily preventable.
          
    Respiratory arrest, cardiac arrhythmia’s and myoglobin induced renal failure are uncommon after a low voltage injury. A child [or adult ] with a low voltage electrical injury who does not have an arrhythmia at the scene or upon arrival to the hospital, and does not have a arrhythmia develop within few is not likely to develop one. Therefore, admission for cardiac monitoring is not indicated, and child should be allowed to go home.
           

  • Arrowsmith J, Usganocar RP, Dickson WA [Morrston Hosp. Swansea UK]
    Electrical Injury and Frequency of Cardiac Complications 
    Burns 23 : 576-578, 1997
           
    Cardiac abnormalities caused by electrical injury are most often apparent at the time of injury. They can also develop later, and 24 hour cardiac monitoring has recommended for patients with electrical injuries. Patients who became unconscious after injury and those with high voltage injuries were more prove to cardiac complications.
          
    Analysis finds a 3% rate of cardiac abnormalities among patients with electrical injuries. For patients who did not lose consciousness at the time of injury and who have normal admission ECG, cardiac complications are unlikely to develop later.
         

  • Mshoup, JM Weisenberger, JL Wang, et al [ Loyola Univ, Maywood, III] 
    Mechanisms of Neutropenia involving myeloid maturation arrest in Burn Sepsis.
    Ann Surg 228 : 112-122, 1998
         
    Burns patients with sepsis have impairments of bone marrow granulopoiesis leading to neutropenia, even though their circulating levels of granulocyte colony stimulating factor -[G-CFS] are normal. 
         
    Mice with burn sepsis had a reduced absolute neutrophil counts but elevated levels of G-CSF in plasma. The neutrophil differentiation pattern showed a shift toward immature mitotic myeloid cells. Neutrophil infiltration into tissues was insignificant on histologic examination. 
         
    This study helps explain this phenomenon of infection-induced neutropenia by showing that there is a maturation arrest of granulocytes in the bone marrow.
        

  • Shin C Kinsky MP, Thomas JA et al [ Yousea Univ Seoul Korea]
    Effect of Cutaneous Burn Injury and Resuscitation on Cerebral Circulation in an ovine model
    Burns 24 : 39-45, 1998
        
    Altered consciousness, delirium, hallucinations, or seizures can occur in adults or children with major or minor burns. 
        
    A 70% to the body surface scald injury was induced in 8 anesthetized sleep. Animals received 30 minutes of resuscitation with Ringer’s Lactate, titrated to restore and maintain baseline oxygen delivery practices. 
         
    During resuscitation, Intracranial pressure increased gradually and cerebral perfusion pressure fell. 
         
    This ovine model showed reduced cerebral perfusion pressure immediately after major cutaneous burn, and again after 6 hours of resuscitation. Blood flow to brain is maintained by cerebral autoregulation in the early phase after injury,, blood flow fails after development of brain edema and elevated intracranial pressure.
          
    A number of burn patients develop encephalopathy even though they have no evidence of head injury. Decreased cerebral blood flow may be contributing to the postburn CNS syndromes.
          

  • Nakamura Dy, Gibran NS, Mann R et al [ Univ of Washington ] 
    Unna “sleeve” an effective postoperative dressing for pediatric arm burns 
    J. Burn Care Rehabil 19: 349-351, 1998
         
    A plan was developed that would protect the grafts after surgery while eliminating the need for daily would care. Unna “sleeves” for the postoperative care of children with skin grafts of the arms were used. 
         
    The graft take rate was 100%.
          
    Unna sleeve technique provides an effective postoperative dressing for pediatric arm burns. It provides gentle, uniform pressure while protecting the grafts against mechanical shearing.
         

  • Angele MK, Ayala A, Monfils SA et al [Brown Univ. Rhodc Island -]
    Testosterone and or Low Estradiol : Normally required but harmful for immunologically for males after trauma hemorrhage
    J. Trauma : injury infect —- care 44 : 78-85, 1998
         
    There is clinical and epidemiologic evidence to suggest sex differences in susceptibility to and morbidity from sepsis. Severe hemorrhage leads to marked depression of immune function in males but not in females.
         
    The immune depression in response to trauma hemorrhage in male mice appears to result from high levels to testosterone, low levels of estradiol or both. The finding suggest the possibility and hormonal treatment [ i.e. testosterone receptor blocking agents eg. Flutamide or estradiol] to prevent immune depression in male trauma patients.
          

  • Peters JH, De Meester TR, Crooksl et al [ Univ. of S. California]
    The treatment of Gastoesophageal Reflux Disease with Laparoscopic Nissen Fundoplication : Prospective evaluation of 100 patients with “Typical” symptoms 
    Ann Surg 228: 40-50, 1998
         
    Laparoscopic Nissen fundoplication, offering success rates exceeding 90% is becoming the new standard of surgical treatment for Gastroesophageal Reflux Disease [GERD].
          
    This procedure achieved relief of the patients’ primary symptoms in 96% of cases. 
           
    Laparoscopic Nissen fundoplication is safe and highly effective in relieving typical symptoms of GERD. Routine crural closure avoids problems of migration of the fundoplication into the chest.
          

  • Robin K.S. Phillips
    Progress in the Management of Anal Disorders
    Recent Advances in Surgery, Number 22, Year-1999, Pg.123
        
    Anal probe MRI supplies superb anatomical definition.
         
    Nitric oxide donors such as glyceryl trinitrate [GTN] and isosorbide dinitrate have been used in order to induce chemical sphincterotomy.
         
    Rubber band ligation is an effective treatment for haemorrhoids at least insofar as the relatively short follow-up of around 2-3 years. Surgical haemorrhoidectomy is a very effective way of treating haemorrhoids.
         
    Patients randomly allocated to receive metronidazole had significantly less pain.
         
    It is probably easiest to consider recto-vaginal septum as an extension of Denonvillier’s fascia that acts to prevent herniation of the rectum into the vagina during defaecation.
         
    The recto-vaginal septum can be damaged either through chronic straining at stool or, more often, as part of a childbirth injury. 
         
    The recto-vaginal septum is often repaired by colorectal surgeons transanally by anterior mucosal excision and rectal wall plication on the premise that there is too much rectum. 
         
    On the other hand, gynecologists, consider the vagina to be excessive, excising a diamond of posterior vaginal wall and placing some sutures in the region of the recto-vaginal septum.
         

  • Mark G. Coleman, Brendam J. Moran
    Small Bowel Obstruction 
    Recent Advances in Surgery, Number 22, Year – 1999


    Mechanical small bowel obstruction [SBO] in adults is a common clinical problem with a significant morbidity and mortality. 

    Adhesions are the cause of half the cases that present with SBO, with fewer being due to malignancy or obstructed heniae. 

    Interestingly, in a significant proportion of those who present with SBO following colorectal cancer surgery, the aetiology is adhesions rather than malignant disease, in contrast to SBO following surgery for gastric or ovarian cancer, in which the commonest cause in malignancy.

    Adhesions are the consequence of injury which may be traumatic, thermal, ischaemic, inflammatory or due to foreign body. 

    Most settle with conservative management.

    Raised temperature, tachycardia, abdominal tenderness, the absence of bowel sounds, faeculent vomiting and a white blood cell count above 18 x 109/1 are positively correlated with strangulation.

    Plain abdominal radiographs are the universally used method for evaluation of SBO to determine its cause and level. 

    Per-oral and intubated contrast studies are similarly effective in terms of their sensitivity [ 92% versus 94%] and specificity [94% versus 89%]. 

    The correct treatment for SBO remains the prompt recognition of those cases requiring immediate surgery and the institution of the regimen that includes intravenous fluids, nasogastric intubation and aspiration. The general philosophy of ‘never let the sun set twice on a bowel obstruction’ remains true today.

    Evidence implicates glove starch and gauze swabs as a cause of adhesions.
    The use of peritoneal lavage with normal saline has not been shown to reduce the rate of adhesion formation.


  • Colin D. Johnson
    Medical Management of Acute Pancreatitis
    Recent Advances in Surgery, Number 22, Year-1999, Pg. 147
         
    Medical management of acute pancreatitis requires early diagnosis. 75-80% of patients will have mild, self limiting disease which can be managed effectively by fasting, intravenous fluids and analgesia.
          
    The cut-off value for diagnosing acute pancreatitis is 3 times the upper limit of the laboratory normal range for amylase or twice normal for lipase. Clinical picture is usually abdominal pain, almost always in the epigastrium. Majority of patients with pancreatitis will have vomited at least once. The most effective investigation in that circumstance is abdominal computed tomography [CT].
           
    Obesity, pleural effusion and are associated with an increased risk of complications and death.
         
    The use of nasogastric aspiration has been shown in a randomized comparison to have no effect on outcome.
          
    Patients with severe pancreatitis often have lung injury leading to hypoxaemia, and systemic hypotension. This results in loss of mucosal barrier function with absorption of endotoxin, and translocation of bacteria. Bacteria which migrate fro the gut may colonize necrotic pancreatic and peripancreatic tissue, converting sterile necrosis to infected necrosis. This has a serious adverse effect of outcome.
          
    Pethidine by continuous intravenous or infusion epidural analgesia is extremely satisfactory.
           
    Systemic inflammatory response syndrome is activated as a result of the pancreatic injury and it is this, which leads to most of the harmful systemic efforts of acute pancreatitis.
           
    Therapy aimed at inhibiting pancreatic secretion with anticholinergic or inhibitory hormones such glucagon, somatostatin, or somatostatin analogues, have all yielded negative findings.
          
    Antibiotic prophylaxis should be given for 7 days.
          
    For many years it was believed necessary to ‘rest the pancreas,’ in order to prevent worsening of pancreatic tissue damage. This now appears to be false, and indeed it seems that depriving the gut lumen of nutrients is likely to impair gut mucosol barrier function and exacerbate the problem of translocation of bacteria.
        
    Platelet activating factor [PAF] appears to be involved in the causation of local damage as a result of pancreatic injury.
         
    Clinical trials using a synthetic PAF antagonist, lexipafant given within 72 h of onset of symptoms have shown very encouraging results. 
         
    Lexipafant could reduce organ failure scores and local complications.
           

  • Marcia Hall Gordon J.S. Rustin
    Testicular Tumour Management
    Recent Advances in Surgery, Number 22, Year-1999, Pg. 173
         
    Many risk factors promoting the development of Germ Cell Tumours [ GCT] have been identified, the best known and most consistent being a history of cryptorchidism.
        
    Most patients present with symptoms relating to the affected testicle [e.g. swelling, pain or aching] and occasionally symptoms and signs referable to metastatic disease [e.g. back pain from retroperitoneal nodes, dyspnoea from pulmonary/mediastinal disease] or, less commonly, hormone-related gynaecomastia.
         
    In the low risk stage 1 GCT, with no treatment other than initial orchidectomy, the mainstay of management is close follow-up with fortnightly markers and regular imaging for metastatic disease. Adjuvant therapy of two cycles of bleomycin, etoposide and cisplatin [BEP] is an acceptable and justifiable way of virtually eliminating the risk of relapse.
        
    Seminoma is exquisitely radiosensitive and characteristically spreads via the lymphatic system, treatment aimed at the retroperitoneal /para-aortic nodes significantly reduces the risk of relapse.
        
    BEP currently remains the standard treatment.
         
    In pure seminoma, residual masses can be safely observed on serial scans and most will shrink and calcify over time; a growing mass, however, would indicate recurrent disease requiring further treatment.
         
    Mature teratoma must be surgically removed before it enlarges locally and becomes inoperable.
         
    Chemotherapy – induced acute toxicities in the treatment of testicular GCT are mostly transient. Fertility is adversely affected by chemotherapy, it usually returns to normal. Concern has been raised about the possible carcinogenic effects of chemotherapy in the long-term. Etoposide is known to be leukaemogenic and secondary tumours have been reported following etoposide containing therapy for GCT.
          
    The treatment of GCT overall has not changed a great deal in the last 5 years, although there is a trend toward more frequent use of chemotherapy in the earlier stages.
           
    Surgical conundrum is the benefits o orchidopexy to prevent the development of GCT only orchidopexy done at a very young age can reduce risk.
          

  • Markus W. Buchler, MD, Beat Gloor, MD, Christophe A, Muller, MD, Helmut Friess, MD, Christian A, Seiler, MD, and Waldemar Uhl, MD [ From the Department of Visceral and Transplantation Surgery, University of Bern, Inselspital, Switzerland]
    Acute Necrotizing Pancreatitis : Treatment Strategy According to the Status of Infection
    Annals of Surgery, November 2000, Vol. 232, No.5, Pgs. 619-626
     
    Infection of pancreatic necrosis is the most important risk factor contributing to death in severe acute pancreatitis. It is generally accepted that infected pancreatic necrosis should be managed surgically. Recent clinical experience has provided evidence that conservative management of sterile pancratic necrosis including early antibiotic administration seems promising.
     
    Pancreatic infection, if confirmed by fine-needle aspiration, was considered an indication for surgery, whereas patients without signs of pancreatic infection were treated without surgery.
      
    When early antibiotic treatment was used in all patients with necrotizing pancreatitis [imipenem/cilastatin], the characteristics of pancreatic infection changed to predominantly gram-positive and fungal infections.
      
    Fine-needle aspiration showed a sensitivity of 96% for detecting pancreatic infection.
     
    These results support nonsurgical management, including early antibiotic treatment, in patients with sterile pancreatic necrosis. Patients with infected necrosis still represent a high risk group in severe acute pancreatitis, and for them surgical treatment seems preferable.
         

  • Andrew L, Warshaw, MD [Surgeon-in-Chief, Massachusetts General Hospital, and W. Gerald Austen Professor of Surgery, Harvard Medical School, Boston, Massachusetts
    Pancreatic Necrosis – To Debride or Not to Debride – That is The Question
    Annals of Surgery, November 2000, Vol. 232, No.5, Pgs. 627-629
       
    There has been very considerable progress in our understanding of the pathogenesis, diagnosis, and management of necrotizing pancreatitis, especially the use of contrast-enhanced computed tomography [CT] scanning to identify and quantify pancreatic necrosis, and fine-needle aspiration [FNA] to detect secondary infection of the damaged tissues.
        
    There is continuing effort to define and anticipate what characteristics predict increased risk of multiple organ failure [MOF] and death, in the hopes of preventing them.
      
    Infection increases the risk of MOF, but sterile necrosis can also cause a lethal systemic inflammatory response syndrome [SIRS] with mortality from MOF reported as high as 38%.
       
    The first strategy used by Buchler and colleagues was the use of imipenem/cilastatin, which some studies have shown to reduce the incidence of infection in pancreatic necrosis. Quinolones have also found favor because these two classes of antibiotics have both broad spectrum and high penetration into the pancreas.
       
    It must be remembered that antibacterial therapy carries the risk of promoting fungal [ candida albicans] infection.
      
    Will it be possible also to reduce the incidence of C. albicans infection, perhaps with a shorter period of antibiotic treatment than the 14-day period used in this study, or with prophylaxis using an antifungal agent such as ketoconazole?
      
    If infection is the most important determinant of impending death, then FNA is crucial to therapeutic decisions.
      
    The allegation that the debridement will increase mortality by converting sterile necrosis to infected necrosis is without basis: the debrided cavity does become contaminated, but this is only surface colonization, which does not produce sepsis unless the debridement has been inadequate.
      
    A critically important observation is that infection may develop late, after observation is that infection may develop late, after weeks of apparent sterility and even after repeatedly sterile FNAs, and that designation as sterile must therefore be considered mutable.
       
    The guidelines proposed by Buchler and associates for nonoperative management of sterile necrotizing pancreatitis must be applied with caution and flexibility – but not as rules.
      

  • L. Bardram, P. Funch-Jensen and H. Kehlet [ Department of Surgical Gastroenterology, 435, Hvidovre University Hospital, DK-2650, Hvidovre, Denmark
    Rapid Rehabilitation in Elderly Patients after Laparoscopic Colonic Resection
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1540-1545
      
    This study combines the laparoscopic approach with a perioperative multimodel rehabilitation protocol.
      
    After laparoscopy assisted colonic resection, patients were treated with epidural anaesthesia for 2 days, early mobilization and enteral feeding. Routine use of drains, traditional tubes;  bladder catheterization and morphine was avoided.
      
    50 consecutive resections [mean age 81 years] were performed. The conversion rate was 22%. In those where laparotomy was not done the median hospital stay was 2.5 days and defaecation occurred in 92% of patients in 3 days. Patients were mobilized for more than 8 hours after day 2.
      
    Recovery after such an approach was good.
        

  • A. Osterberg. K. Edebol Eeg-Olofsson* and W. Graf [ Department of Surgery and * Clinical Neurophysiology, University Hospital, SE-75185 Uppsala, Sweden
    Results of Surgical Treatment for Faecal Incontinence
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1546-1552
     
    This study evaluates the results of anterior levatorplasty and sphincteroplasty for faecal incontinence with respect to symptomatic and physiological incontinence.
     
    31 patients with idiopathic [neurogenic] faecal incontinence underwent anterior levatorplasty and 20 patients with traumatic and sphincteric injury underwent  sphincteroplasty. The results were evaluated at 3 and 12 months.
     
    18 out of 31 patients undergoing levatorplasty reported continence to solid and liquid stools 1 year postoperatively compared with 2 patients before surgery. The corresponding figures in the sphincteroplasty were 10 patients and 2 patients [out of 20]. The incontinence score was improved in both groups after one year from a median score of 14 to 3 in the levatorplasty group and from 8.5 to 3.5 in sphincteroplasty group. Improvements in the degree of social and physical handicap were also observed in both groups. No changes were seen in the anal canal pressures or rectal sensation in either group.
        

  • T. Mynster, I.J. Christensen*, F. Moesgaard and H.J. Nielsen for the Danish RANXO5 Colorectal Cancer Study Group [Department of Surgical Gastroenterology 435, H:S Hvidovre Hospital, University of Copenhagen, Hvidovre and * Finsen Laboratory]
    Effects of the Combination of Blood Transfusion and Postoperative Infectious Complications on Prognosis After Surgery for Colorectal Cancer
     Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1553-1562
        
    The combination of perioperative blood transfusion and subsequent infectious complications may be associated with poor prognosis.

  • Asha Senapati Neil P.J. Cripps 
    Pilonidal Sinus
    Recent Advances in Surgery-23, Year-2000, Pg. 33
        
    There is a male preponderance of 1.5:1 and it typically occurs in hairy young men.
        
    The term pilonidal sinus originates from the Latin words Nidus for nest, Pilus for hair and Sinus for connections to the skin. 
        
    Its aetiology is unknown; the theory that it is congenital is largely discounted. 
        
    In the natal cleft, it is thought that skin follicles are enlarged due to the shearing action of the buttocks. Hair then enters these follicles and infection ensues.
        
    The pathology of this condition is that of chronic sepsis. 
        
    No longer is it considered necessary to excise these widely during surgical treatment.
         
    Treatment of asymptomatic disease is seldom warranted. 
         
    Symptomatic disease may present in three ways [I] as an acute abscess; [ii] a chronic discharging sinus [sometimes with pain]; or [iii] an unhealed midline wound.
        
    Acute Pilonidal Abscess –
    It has been suggested that wide excision and laying open may be done acutely; thus treating the underlying disease at the same time, but this results in a large painful midline wound that may take many months to heal; in some cases it may never do so.
         
    Minimalist approach is simply to drain the pus with a ‘stab’ wound under local anaesthesia.
          
    Once the acute sepsis has settled and before it can recur, definitive treatment can be offered.
          
    Chronic Pilonidal Sinus-
    Many procedures have been described for the chronic situation, none of which is perfect, judged by the yardsticks of primary healing and recurrence of disease. 
         
    Simple shaving and removal of hair may control symptoms without operation, surgery is often required when chronic infection supervenes. 
           
    The most unpleasant complication [which is also difficult to manage] is a persistently unhealed midline wound, commonly seen after other treatments such as laying open or excision of the primary disease. 
          
    Karydakis technique –
    A technique of asymmetric natal cleft would closure. An eccentric, elliptical excision is made with mobilization of a flap from the medical side of the wound. All sinus tracts are excised completely down to the sacral periosteum. The mobilized flap is sutured to the sacrococcygeal fascia and the wound is closed.
         
    The wounds healed well with a recurrence rate of less than 1%.
          
    Pilonidal sinus disease is a benign condition and patients apparently outgrow its infective complications. It is, therefore, imperative that the treatment is no worse than the disease itself.
           

  • C.M. Malata, S.A. McIntosh and A.D. Purushotham [ Departments of Reconstructive and – General Surgery, Cambridge Breast Unit, Addenbrook’s Hospital, Cambridge, UK ]
    ImmediateBreast Reconstruction After Mastectomy for Cancer
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1455-1472
           

    2.      Autogenous Tissue Reconstruction –  Transverse rectus abdominis myocutaneous flap [various types].
            
    Free deep inferior epigastric perforator flap latissimus dorsi musculocutaneous flap.
      
    3.      Other autogenous tissue Techniques – Superior and inferior gluteal free flap, gluteal perforator free flap, lateral transverse
             thigh flap, Taylor-Rubens peri-iliac free flap.
     
    Careful discussion and evaluation remains vital in choosing the correct technique for the individual patient.
       
    The aesthetic considerations [comparison with opposite breast] and psychological consideration must be looked into.
      

  • E. Degiannis and K. Boffard [ Department of Surgery, Medical School, University of the Witwatersrand, 7 York Road, Parktown, 2193 Johannesburg, Repyblic of South Africa
    Duodenal Injuries
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1473-1479
     
    The worldwide increase in road traffic accidents and the use of firearms has increased the incidence of duodenal trauma. Duodenal injury can pose a formidable diagnostic and therapeutic problem. It can cause serious fluid and electrolyte imbalance, chemical inflammation in the peritoneum and retroperitoneum which may prove life threatening. Again, there is no single method of repair that ensures success.
      
    Isolated duodenal injuries  are uncommon because of its close proximity to a number of other viscera and major vascular structures. The need for an exploration is usually made in the operating room. Penetrating trauma is the most common form of injury.
      
    Blunt trauma is less common, usually causes crushing of the duodenum between the spine and steering wheel, handlebar or some other force applied to the anterior abdomen. Such injury may be associated with fracture of L1-L2 vertebrae. Less commonly, deceleration injuries may produce a tear of the duodenum at the junction of free and fixed parts. High index of suspicion based on mechanism of injury and physical examination may lead to  further diagnostic studies.
      
    If there is peritonitis, the diagnosis is not so difficult.
      
    Serum amylase is not dependable though serial readings may prove more valuable. Radiologically gas bubbles may be present in the retro-peritoneum near the psoas, kidney and lumbar spine.  It may show free gas under the diaphagm and very rarely pneumobilia Obliteration of the psoas shadow and fractures of the transverse process of the lumbar vertebrae are indicative of the retro peritoneal injury.
      
    An upper GI series with water soluble contrast may prove fruitful in 50% of cases. It may rarely show the ‘coiled spring’ appearance of complete obstruction by a haematoma.
      
    CT scan is a very sensitive diagnostic  tool especially in children. Diagnostic laparoscopy, is not very useful. Exploratory laparotomy remains the ultimate diagnostic test.
           
    The authors have graded duodenal and pancreatic injuries.
             
    Injuries to the first and second part of the duodenum requires distinct manoeuvres to diagnose the injury [cholangiogram, direct inspection] and complex techniques to repair them and 3rd and 4th part injuries may be treated like small bowel injuries. Associated pancreatic injuries may require more complex procedures.
      
    Various approaches have been described for duodenal haematoma, perforations. Duodenal diversion, pyloric exclusion and gastrojejunostomy  predicled mucosal graft or a gastric island   flap or jejunal
      serosal patch and primay anastomosis in cases of complication have been discussed.
          
    The majority of duodenal injuries may be managed by a simple repair; complicated injuries require more sophisticated procedures.
           

  • K. Holte amd J. Kehlet [ Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark
    Postoperative Ileus : A Preventable Event
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1480-1493
      
    Postoperative ileus has been traditionally  accepted as a normal response to tissue injury. This  ileus has no beneficial effects and it may contribute to delayed recovery and prolonged hospital stay.
         
    This article reviews the available literature and updates the knowledge on pathophysiology and treatment of postoperative ileus.
         
    The pathogenesis mainly involves inhibitory neural reflexes and inflammatory mediators [ like nitric oxide, vasoactive intestinal peptide [VIP] and substance ‘P’] have been implicated. Calcitonin gene-related peptide, corticotrophin releasing factor have also been implicated.  Finally opioids are well established as modulators of neural transmission.
          
    The most effective method of reducing ileus is thoracic epidermal blockade with local anaesthetic. Opioids sparing analgesic techniques and NSAIDs also reduce ileus as does laparoscopic surgery. Of the prokinetic drugs only cisapride is proven beneficial. The effect of early enteric feeding remains unclear. If all the above methods are combined, the results are considerably improved.
      

  • V. Usatoff, R. Brancatisano and R.C.N. Williamson [ Department of Surgery, Hammersmith Hospital, Imperial College School of Medicine, Du Cane Road, London W12 OHS, UK
    Operative Treatment of Pseudocysts in Patients with Chronic Pancreatitis
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1494-1499
        
    Pseudocysts associated with chronic pancreatitis are generally intrapancreatic and associated with parenchymal disease. They tend to persist and cause complications. Minimally invasive methods of treatment challenge the traditional technique of operative management. Open surgery allows the definitive treatment of the pseudocysts with the option of dealing appropriately with the diseased pancreas and excluding a neoplastic process.
      
    A personal series of 112 consecutive patients operated for pseudocysts in the setting of chronic pancreatitis was reviewed.  Chronic pancreatitis was confirmed by imaging studies in association with exocrine/endocrine failure.
     
    31 patients had multiple cysts and presented with complications other than pain in 47. 

    Data was collected prospectively regarding the clinical presentation, the nature of the operation and its outcome.
       
    43% of cases underwent drainage procedures, 50% had a resection, and 7% had a combination. Larger cysts and those located in the head and neck tended to be drained while smaller and distal cysts were more often resected. The operative mortality was 1%, The morbidity 28%. The cyst recurrence rate was 3% and pain was relieved in 74% of cases.
      
    The introduction of the newer minimally invasive technique will have to withstand comparison to this traditional approach.
       

  • J.L. Poggio, D.M. Nagorney, A.G. Nascimento, C. Rowland, P.Kay, R.M. Young and J.H. Donohue [ Department of Surgery, Section of Anatomic Pathology and Section of Biostatistics, Mayo Clinic, 200 First Street, SW, Rochester, Minnesota 55905, USA
    Surgical Treatment of Adult Primary Hepatic Sarcoma
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1500-1505
     
    Primary sarcomas of the liver are extremely rare in adults. Optimal therapeutic approaches remain unclear.
        
    Twenty consecutive adults who are operated for hepatic sarcomas were reviewed. The ages ranged between 23 to 80 years. No predisposing causes could be found except in one who had a history of thorotrast exposure 23 years ago.
     
    19 patients had hepatic resection and one patient had an orthotopic liver transplant. No patient was given neo-adjuvant chemotherapy but one patient had intra-operative radiotherapy.
     
    Leiomyosarcoma was the most common histologic carcinoma [ 5 out of 20] followed by malignant solitary fibrous tumour [4 cases] and epithelioid haemagioendothelioma [ 3 cases]. 14 tumours were high grade sarcomas whereas 6 were low grade malignancies.
         
    Three patients developed local recurrences while 10 patients developed metastases and intrahepatic recurrence in 6 patients were the predominant sites of initial treatment failure.
          
    Six patients received salvage chemotherapy. Histological grading was the only factor significantly associated with patient survival [ p=03].
      
    With complete resection, patient with high grade tumours had a 5 year survival rate of 18% compared with 80% for patients with low grade tumours. Overall survival rate was 37%.
         
    Surgical resection is the only effective therapy for primary hepatic sarcoma. Better adjuvant therapy is necessary for high grade malignancy owing to high failure rate with only surgery.
       

  • D. Boerma, E.A.J. Rauws T.M. van Gulik, K. Huibregtse, H. Obertop and D.J. Gouma [ Department of Surgery and Gastroenterology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1506-1509
       
    Spontaneous closure of an external pancreatic fistula is unlikely when a concomitant downstream obstruction of the pancreatic duct inhibits downstream flow. ERCP and stent insertion may aid fistula closure.
        
    15 patients of pancreatic fistula developed after operative necrosectomy and debridement of the pancreas [ seven men and eight women; ages 25-68 years] were evaluated after endoscopic stenting.
      
    Results – The median drainage dropped from 50-800 ml/day [amylase content of 21,000 to 493000 U/L] to nil. ERCP was done after a median time of 35 days and revealed a leak with obstruction in all cases. An endoprosthesis was inserted beyond the site of obstruction. In one patient drainage failed and a pancreaticojejunostomy had to be done. During follow-up [2-55 months] 3 patients required resection of the pancreatic tail  because of psedocyst formation.
     
    Early ERP stenting enhances fistula closure, facilitates wound care and surgery is postponed or even avoided.
      

  • X.-Y. Yin, P.B.S. Lai, J.F.Y. Lee and J.W.Y. Lau [ Department of Surgery, The Chinese University of HongKong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
      
    Effects of Hepatic Blood Inflow Occlusion on Liver Regeneration Following Partial Hepatectomy In an Experimental Model of Cirrhosis
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1510-1515
     
    Hepatic blood inflow occlusion during hepatectomy may influence postoperative liver regeneration. This study explores this phenomenon following partial hepatectomy in thioacetamide-induced cirrhotic rates.
     
    43 cirrhotic Wistar-Furth rats were randomly assigned to three groups. Group 1 rats underwent 64% hepatectomy alone. Group 2 rats were subjected to 15 min hepatic blood inflow occlusion followed by 64% hepatectomy. Group 3 rats were subjected to 30 min inflow occlusion followed by 64%  hepatectomy. Liver function 5-bromo-2’-deoxyuridine [BrdU] labeling index and   percentage of initial liver weight on days 1, 2 and 7 posthepatectomy were assessed.
      
    Results – Rats in groups 1 and 2 had a significantly higher serum albumin level and a markedly lower alanine aminotransferase level than animals in group 3 on day 1 posthepatectomy [p<0.05]. There was  no significant difference in the serum level of total bilirubin of the three groups on days 1,2 and 7. The BrdU labelling index was significantly higher in groups 1 and 2 than in group 3 animals on day 1 posthepatectomy [ p<0.01 and p<0.05 respectively]. Percentages of initial liver weight were similar in groups 1,2 and 3 on days, 1,2 and 7 after respectively.
      
    Hepatic blood inflow occlusion upto 30 min suppressed DNA synthesis and hepatocyte proliferation at an early posthepatectomy stage and consequently delayed recovery of liver function in cirrhotic rats. However it did not affect restoration of liver mass or survival  after 64% hepatectomy.

        

  • EU Hernia Trialists Collaboration [ Prof. A. Grant, EU Hernia Triallists Collaboration Secretariat, Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK]
    Laparoscopic Cpmpared with Open Methods of Groin Hernia Repair: Systematic Review of Randomized Controlled Trials
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 860-867
         
    This is a systematic review of all published data from all relevant randomized or quasi-randomized trials. Prespecified data items were extracted from reports and where possible a quantitative meta-analysis was performed. Electronic databases were searched and members of the EU Hernia Triallist Collaboration consulted to identify trials. 
        
    34 published reports of eligible trials involving 6804 patients were reviewed. Sample sizes ranged 20 to 1051 with follow up from 6 weeks to 36 months.
        
    The duration of surgery was longer in the laparoscopic group. Operative complications were rare in both groups, but visceral and vascular injuries were common in the laparoscopic group.
        
    The length of hospital stay did not differ significantly in the two groups. The post-operative pain was less in the laparoscopic group and return to usual activity earlier in the laparoscopic group. 
        
    Overall recurrence rates did not differ greatly. Chronic pain and numbness were very rarely reported.
        
    They conclude that laparoscopic repair was associated with less post-operative pain and more rapid return to normal activities but it takes longer to perform and may increase the risk of rare but serious complications.
      

 

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