Speciality
Spotlight

   




   

Surgery


   

 






Surgery

  

  • J. MacFie [ Scarborough Hospital, Wooldlands Drive, Scarborough YO12 6QL, UK]

    Enternal Versus Parenteral Nutrition

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1121-1122

      

    Artificial feeding is necessary in patients with malnutrition or for those whose oral intake is likely to be inadequate for more than seven days.

       

    Enternal feeding is preferred to the parenteral route. It is both cheaper and safer, more physiological, it preserves gut barrier. Parenteral feeding on the other hand may result in mucosal atrophy, bacterial translocation and increased ratio of sepsis. 

        

    Enternal nutrition may often fail to achieve targeted calorie requirements, as a consequence of poor tolerance [bloating, diarrhoea or high gastric aspirates]. The benefits are its effects on gastrointestinal flora, splanchnic blood flow and modulation of immune responses. These benefits may be offset by the invasive methods of enteral feeding
    [percutaneous gastrostomy and jejunostomy]. 

        

    TPN may lead to mucosal atrophy , bacterial translocation and increased sepsis. But though this has been shown in rodents, it has not been proved in humans.

        

    The results of a comparative study between enteral and parenteral nutrition need to be interpreted with caution. They should be considered in the context of overall morbidity.

        

    The increased septic morbidity with TPN, has been attributed to the increased energy intake and consequent hyperglycaemia rather than because of its route of administration; further this may be offset by the higher nutritional value. A recent review of 31 studies concluded that there is no consistent evidence that enternal feeding is associated with improved clinical outcome compared with TPN. 

         

  • L.
    Sarli, R. Costi, G. Sansebastiano*, M. Trivelli and L. Roncoroni [ Institute of General Surgery and Surgical Therapy and * Institute of Hygiene, Parma University School of Medicine, Parma Italy]

    Prospective Randomized Trial of Low-Pressure Pneumoperitoneum for Reduction of Shoulder-tip Pain Following Laparoscopy

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1161-1165

         

    The aim of this study was to evaluate the efficacy of low pressure carbon dioxide pneumoperitoneum during laparoscopy in reducing postoperative shoulder pain.

        

    90 patients were divided into 2 groups group A [n=46] had a 9 mmHg carbon dioxide pneumoperitoneum and group B [ n=44] had a 13 mmHg carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy. The shoulder tip pain was recorded on a visual analogue pain scale 1,3,6,12,24 and 48 hours after operation.

       

    11% of Group A patients had shoulder pain as opposed to 32% in Group B. Mean shoulder tip pain scores and analgesia requirements were also lower in group A. There were no differences in the duration or ease of surgery or complications in the two groups.

        

  • D.
    Ravichandran*, B.G. Kalambe and J.A. Pain [ Department of General Surgery, Poole Hospital, Poole and * Norfolk and Norwich Hospital, Norwich, UK]

    Pilot Randomized Controlled Study of Preservation of Division of Ilioinguinal Nerve in Open Mesh Repair of Inguinal Hernia

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1166-1167

     

    This study included 20 men with primary bilateral inguinal hernias undergoing open tension-free mesh repair. They were randomized for preservation or division of the ilioinguinal nerve. Patients were reviewed on day 1, 4 weeks and 6 months after operation. Any pain, numbness or anesthesia in the area supplied by the nerve were recorded.

     

    As significant difference was noted between the two groups. Sensory loss detected by clinical examination was more common following division of the nerve compared with preservation.

       

  • M.
    Kume, Y. Yamamoto, K. Yamagami, Ishikawa, H. Uchinami and Y. Yamaoka [ Department of Gastroenterological Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo, Kyoto 606-8507]

    Pharmacological Hepatic Preconditioning: Involvement of 70-kDa Heat Shock Proteins [HSP72 and HSP73] in Ischaemic Tolerance After Intravenous Administration of Doxorubicin

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1168-1175

      

    The aim of this study was to determine in an animal model, whether intravenous administration of doxorubicin induces heat shock proteins [HSPs] in liver tissue and subsequent warm ischaemia-reperfusion injury [IRI].

      

    Male Wistar rats were used. Production of HSPs was determined in liver tissue sequentially after injection of doxorubicin. [1mg/kg body weight]. Acquisition of tolerance for 30 min. warm ischaemia and reperfusion of the liver was determined in animals pretreated with doxorubicin. [48 hours beforehand] and in controls. Biochemical liver function and adenine nucleotide concentration 40 min after reperfusion and survival rate at 7 days after ischaemic insult were recorded.

      

    Expression of HSP72 and HSP73 in the liver was confirmed 48 hours after doxorubicin. Biochemical parameters and survival rate, were significantly better in pretreated animals than in controls.

         

  • N.
    Menezes, L.P.Marson, A.C. deBeaux, I.M. Muir and C.D. Auld[ Department of Surgery, Dumfries and Galloway Royal Infirmary, Dumfries, UK]

    Prospective Analysis of a Scoring System to Predict Choledocholithiasis

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1176-1181

     

    The aim of this study was to evaluate prospectively, a scoring system designed to improve the accuracy of common bile duct [CBD] stone prediction before laparoscopic cholecystectomy.

     

    Known risk factors [clinical, biochemical and radiological] for CBD stones were analysed retrospectively in 233 patients. The presence [n=77] or absence [n=156] of CBD stones was determined. Preoperative ERCP or laparoscopic cholangiography. Using multivariate analysis, of the risk factors a new pre-operative scoring system was developed. A score of 3 or more was taken as the
    cut off point to suggest CBD stones. The scoring system was then tested prospectively on 211 patients with gall stone disease.

     

    55 patients scored more than 3 points [predicted ERCP rate of 29%] of whom 23 [42%] had proven CBD stones. Intra-operative cholangiography was successful in 87%. 4% who scored less than 3 points had small [ less than 5 mm] stones demonstrated at operative cholangiography. The overall sensitivity and specificity of this scoring system were 82% and 80% respectively.

        

  • A.Weimann, H. Varnholt, H.J. Schlitt, H. Lang, P. Flemming*, C. Hustedt*, G. Tusch and R. Raab [ Klinik for Abdominal – und Transplantationschirurgie and * Pathologisches Institut, Medizinische Hochschule Hannover, Hannover, Germany]

    Retrospective Analysis of Prognostic Factors After Liver Resection and Transplantation for Cholangiocellular Carcinoma

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1182-1187

        

    This is a retrospective study of 162 patients [1978-1996] of cholangiocellular carcinoma who underwent liver resection and liver transplantation and exploratory laparoctomy with or without drainage. Univariate and multivariate analysis of prognostic factors were performed.

        

    Overall survival rate was 47% at 1 year, 28% at two years and 13% at 5 years.

       

    Resectable tumors had better survival rates [ 64%, 43% and 21% respectively ] and for those who underwent transplantation it was 21%, 8% and zero respectively. The following variables had an effect on survival age, jaundice, liver resection, TNM staging, tumour free margins, vascular infiltration, tumour number, size and serum levels of CEA. Jaundice, N and M category and UICC staging independent prognostic factors.

         

  • S. J. Pain and A.D. Purushotham [Cambridge Breast Unit, Addenbrooke’s Hospital, Cambridge , UK]

    Lymphoedema Following Surgery for Breast Cancer

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1128-1141

     

    Lymphoedema is a common complication of breast cancer treatment, affecting almost 25% of cases. It can cause discomfort, cosmetic and functional problems. It is prone to episodic superficial infections.

     

    A systematic review of all published literature on this problem using the Medline and Cinahl databases with cross -referencing of major articles upto 1999 was undertaken.

     

    The aetiology and pathology of this condition is multifactorial and still not fully understood. Although conservative treatment can be very successful in palliation, it does not afford a cure. The place of surgery and pharmacotherapy remains unclear. Improved understanding of pathophysiology may assist in reducing the incidence of this condition or help to identify high risk cases in whom early conservative treatment may prove effective.

         

  • M.S. Rodgers and J.L. McCall [ Department of Surgery, University of Auckland, Auckland, New Zealand]

    Surgery for Colorectal Liver Metastases with Hepatic Lymph Node Involvement: a Systematic Review

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1142-1155

     

    Liver resection for colorectal metastases is the only known treatment associated with long term survival. Extra hepatic disease is usually considered a contraindication to such treatment. Some surgeons feel that if these nodes can be adequately excised, this should not be considered a contraindication.

     

    A systematic review of literature was undertaken to address these problems [from 1964- 1999].

     

    15 studies were identified that gave data on 145 node positive patients. 5 patients survived 5 years after liver resection [ 1 was disease free, 2 had recurrent disease and in 2 the disease status was not mentioned]. 5 studies containing 83 patients specified a formal lymph node dissection as a part of the operation and four of the five node-positive 5-year survivors were from these group. The authors conclude that these are few 5 year survivors after liver resection with a without lymph node dissection for colorectal hepatic metastases.

        

  • C. Dervenis and C. Bassi [ First Department of Surgery, Konstantopoulion, Agia Olga Hospital, Athens, Greece and Department of Surgery, Pancreatic Unit, University of Verona, Verona, Italy

    Evidence-based Assessment of Severity and Management of Acute Pancreatitis

    BRJ Volume 87, No.3, March 2000, Pg.Nos. 257-258

      

    Acute pancreatitis is a potentially fatal disease, with reported mortality rates ranging from zero to almost 25 per cent, depending on severity.

       

    Severity itself depends greatly on whether or not pancreatic necrosis is present.

       

    Imaging is mandatory, preferably by a magnetic resonance method and, if a definitive diagnosis cannot be reached, all collections should be considered as localized necrosis until proven otherwise. 

       

    Obesity, indicated by a body mass index greater than 30, is a reasonably reliable predictor of severe outcome. 

       

    Assay of C-reactive protein is the only easily available blood test in clinical practice that is a proven discriminator of severe and mild disease, at a cut-off level of 150 mg/ml at 48h after the onset of symptoms.

       

    There is evidence that pleural effusion on an early chest radiograph, which is freely available as a routine test on admission, is probably useful in predicting complications and/or a fatal outcome.

      

    More sophisticated imaging, such as enhanced computed tomography [CT], is a proven indicator of pancreatic necrosis with almost 100 percent sensitivity between days 4 and 10.

      

    Thee is a consensus that the early restoration of circulatory volume and arterial oxygen tension reduces the risk of complications is this disease, but randomized studies have failed to show any benefit from antiproteases and antisecretory drugs on mortality rates. 

      

    There is probably a role for antibiotics in the prevention of complications related sepsis.

     

    Attention should be given to the increasingly encountered fungal infection of pancreatic necrosis secondary to the use of broad-spectrum antibiotics; fungal infection is associated with higher mortality rates.

      

    The role of early enteral nutrition should be considered, as recent randomized studies, although small, have shown a reduction in complications and probably in mortality rate. 

      

    There is strong evidence that urgent endoscopic sphincterotomy is to be recommended in patients with severe biliary pancreatitis with abnormal liver function; this includes patients with cholangitis.

      

    Surgical intervention has a peoven role when there are clinical signs of sepsis due to infected pancreatic necrosis. This may be diagnosed by the only reliable test, namely CT-guided fine-needle aspiration followed by Gram staining and culture of the necrotic material.

      

    There is no evidence in favour of surgery for patients with sterile necrosis.

          

  • T.M.D Hughes and A.J. Spillane [ Sarcoma Unit, Royal Marsden Hospital NHS Trust, Fulham Road, London SW3 6JJ, UK]

    Imaging of Soft Tissue Tumours

    BRJ Volume 87, No.3, March 2000, Pg.Nos. 259-260

       

    Magnetic resonance imaging [MRI] has become the standard for preoperative assessment of soft tissue masses but a review of the recent literature on the imaging of soft tissue tumours has shown that the best available evidence does not support the current paradigm of MRI superiority over contrast-enhanced computed tomography [CT].

      

    The claim that the introduction of MRI has made limb conserving surgery possible is also false. Limb salvage has, in reality, been made possible through a better understanding of the anatomical relationship amd oncological behaviour of these tumours with respect to neurovascular and proximal limb structures, the expanded role of 

    reconstructive procedures and the expert use of preoperative or postoperative radiotherapy.

      

    Errors in judgement arise particularly when peritumoral oedema is mistaken for tumour infiltration, resulting in overestimation of tumour extent.

      

    The claim that MI is superior for the evaluation of anatomical compartment and individual muscle involvement has bot been substantiated.

      

    The best available evidence is contrary to the commonly accepted wisdom that MRI is superior to CT in the assessment of soft tissue tumours.

      

    Imaging determines the site and extent of the lesion, along with the proximity of nearby structures. Clinical assessment by experienced specialists, appropriate biopsy and multidisciplinary review are together of at least equal importance in the management of these tumours.

          

  • T. Yamamoto and M.R.B. Keighley [Second Department of Surgery, Mie University School of Medicine, Tsu, Japan and University Department of Surgery, Queen Elizabeth Hospital Birmingham, UK]

    Smoking and Disease Recurrence After Operation for Crohn’s Disease

    BRJ Volume 87, No.4, April, 2000, Pg.Nos. 398-404

      

    There is increasing speculation about the role of smoking in the pathogenesis of inflammatory bowel disease.

       

    Approximately half of the patients were smokers at the time of operation. In most studies smoking significantly increased the risk of postoperative disease recurrence. Smokers had an approximately twofold increased risk of recurrence compared with non-smokers and the effect of smoking was dose dependent. The increased risk of recurrence among smokers was more prominent in women than in men, and a longer duration of smoking increased the risk of recurrence. Ex-smokers had a similar recurrence rate to non-smokers and giving up smoking soon after operation was associated with a lower probability of recurrence.

      

    Smoking significantly increases the risk of recurrence of disease after operation for Crohn’s disease, especially in women and heavy smokers. Encouraging patients to stop smoking is an important part of the management of Crohn’s disease.

         

  • J.R. Hardy [ Department of Palliative Medicine, Royal, Marsden Hospital, Downs Road, Sutton SM2 5PT, UK

    Medical Management of Bowel Obstruction

    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1281-1283

      

    Bowel obstruction is a relatively common complication of advanced malignancy, particularly in gynaecological and gastrointestinal cancers. The symptoms [ abdominal pain, constipation and vomiting] are most distressing for both patients and their carers.

     

    Surgery can provide valuable palliation in cancer -related bowl obstruction and no patient should be denied a surgical review.

     

    The alternative is symptom control with a range of drugs and medications, and the removal of many of the lines and tubes. 

       

    Considerable controversy surrounds the use of intravenous fluids in dying patients. One school claims that a patient’s fluid requirements reduce dramatically during the terminal phase, and that fluid administration does not prolong life and will only exacerbate problems of fluid retention, toileting, pulmonary secretions and the need for suctioning. Others claim that dehydration contributes significantly to drug toxicity, and to the confusion and agitation so often seen in dying patients.

       

    Diligent mouth care, mouth sponges, sucking ice and sips of fluid relieve thirst and provide comfort.

       

    The widespread application of the subcutaneous route for the delivery of most essential drugs has revolutionized palliative care practices.

      

    Eating is one of life’s great pleasures and to deprive a dying patient of this enjoyment seems harsh. Patients should be allowed to eat small amounts of low-fibre food and to drink as tolerated, if they wish, even if this results in the occasional vomit.

      

    Repeated observations, fluid balance monitoring, radiographs and other investigations are pointless when they are not likely to change management.

      

    The antiemetics most commonly used are levomepromazine, cyclizine or haloperidol. All may be given subcutaneously although none is licensed for delivery by this route.

        

    Pain associated with bowel obstruction is related both to abdominal distension and obstructed peristalsis causing ‘colic’. Diamorphine is the opioid of choice for delivery by the subcutaneous route.

     

    Antimuscarinucs [ e.g. hyoscine butylbromide] may be added for control of colicky pain either ‘as required’ by bolus dose or by a constant subcutaneous infusion.

     

    Dexamethasone is used commonly as an antiemetic and coanalgesic in palliative care.

      

    A short pulse of moderate dose dexamethasone [8 mg/day for 5 days] is generally well tolerated and worth a trial.

     

    Octreotide is a somatostatin analogue that reduces endocrine and exocrine secretion of the pancreas, stomach, and intestine; by decreasing gut mortility and secretions, it facilitates the absorption of water and electrolytes in the bowel.

       

    The development of long-acting somatostatin analogues given monthly by intramuscular injection may facilitate hospital discharge but the high cost of such drugs may be prohibitive.

          

  • I.
    I.Lindsey, R.J. Guy. B.F. Warren and N.J. McC. Mortensen [ Departments of Colorectal Surgery and Cellular Pathology, John Radcliffe Hospital, Oxford UK ]

    II. Anatomy of Denonvilliers’ Fascia and Pelvic Nerves, Impotence and Implications for the Colorectal Surgeon

    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1288-1299

       

    Denonvilliers’ fascia has no macroscopically discernible layers. The so-called posterior layer refers to the fascia propria of the rectum. The incidence of erectile and ejaculatory dysfunction after rectal excision is high in older patients, and when performed for rectal cancer.

      

    Colorectal surgeons should focus on the important anatomy between the rectum and the prostate to improve functional outcomes after rectal excision.

      

    In 1836 Denonvilliers reported his discovery of a ‘prostatoperitoneal’ membranous layer between the rectum and seminal vesicles. 

      

    In 1993, Richardson elegantly demonstrated a dense double layer of elastin in the rectogenital septum on electron micrography, adding further weight to the concept of peritoneal fusion.

      

    Although Denonvilliers’ original description gave no account of the presence of such a membrane in a female, there is a little doubt that the rectovaginal septum is the female counterpart, and is a normal, constant structure.

      

    Surgical appearance of the fascia at operation varies considerably, from a fragile translucent layer to a tough leathery membrane.

      

    Histologically, Denonvilliers’ fascia is composed of dense collagen, smooth muscle fibres and coarse elastic fibres. It is related to the prostate and seminal vesicles anteriorly, and to the rectal wall, the thin anterior mesorectum and the fascia propria posteriorly.

      

    Goligher described the fascia as being more closely adherent to the rectum than to the prostate.

      

    A recent histological study suggests that Denonvilliers’ fascia is more closely adherent to the prostate.

      

    Nervi Erigentes

      

    The pelvic parasympathetic [splanchnic] nerves [nervi erigentes] arise from the sacral roots of S2, S3 and S4. They pierce the endopelvic fascia from behind to enter the plane of the pelvic plexus. The pelvic parasympathetics join the sympathetic hypogastric nerve in a Y-shaped connection to form the pelvic plexus.

      

    Radical prostatectomy has, until recently, rendered most patients impotent.

      

    Impotence resulted from damage to the cavernous nerves, either at the lateral pedicles or when dividing the urethra.

      

    These authors drew three main anatomical conclusions. 

      

    First, a prominent neurovascular bundle is located at the posterolateral border of the apex and base of the prostate. The visible nerves in this bundle branch to give rise to the microscopic cavernous nerves.

      

    Second, the neurovascular bundles are consistently found in the leaves of the lateral pelvic fascia outside the prostatic capsule, at the lateral edge of denonvilliers’ fascia. The bundles and prostatic capsule are separated by only 1.5-3 mm at the base and apex of the prostate respectively.

      

    Third, the nerves in the neurovascular bundles are intimately associated with vessels. These vessels provide a visible landmark to identify the bundles and are generally oriented lateral to the nerves.

       

    The technique of ‘nerve-sparing’ radical prostatectomy evolved as a modification of the original procedure in the light of the above findings.

      

    The risk to potency occurs during rectal dissection, as the pelvic autonomic nerves are intimately related to the rectum.

      

    Sexual dysfunction after pelvic surgery is characterized by erectile dysfunction or impotence, and ejaculatory dysfunction. Impotence may be partial or complete, temporary or permanent. Ejaculatory dysfunction consists of absent ejaculation, retrograde ejaculation and painful ejaculation.

       

    Age is important factor. It is known that the incidence of impotence increases with age;

       

    Permanent impotence in men occurs in 17-100 per cent of cases after abdominoperineal excision of rectum [APER] and in 0-49 per cent after anterior resection of rectum [AR] for rectal cancer.

      

    The rate of impotence after radical excision for inflammatory bowel disease is lower than that after excision for rectal cancer.

      

    There is poorer understanding of postoperative sexual dysfunction in women.

      

    A few studies have addressed neurological damage as a cause of problems such as inability to attain orgasm, and reduced vaginal sensitivity and lubrication, but the dysfunctional outcomes of pelvic nerve damage in women corresponding to those in men that produce erectile and ejaculatory dysfunction are poorly understood. 

      

    The incidence of permanent bladder denervation after rectal excisional surgery ranges from 0 to 19 per cent.

       

    It appears that bladder dysfunction is more likely after APER than after AR.

      

    Primary radiotherapy for localized prostate cancer causes impotence in 5-40 per cent of patients.]

      

    Sites of Risk of Nerve Damange

    Four key zones exist, one in the abdomen and three in the pelvis.

      

    Inferior Mesenteric Artery Origin

    The risk in the abdomen occurs during ligation of the pedicle of the inferior mesenteric artery, particularly if this is done flush at the aorta. The purely sympathetic hypogastric nerves are vulnerable here.

      

    Posterior Dissection

    Anatomical dissection of the rectum is carried out in the loose areolar connective tissue immediately outside the fascia propria, and the nerves lie just outside this plane.

       

    The damage is purely sympathetic at this level as the nervi erigentes have not yet joined the bundle.

      

    Lateral Dissection

    Straying laterally out of the mesorectal plane may injure the pelvic plexus, particularly if excess traction is placed on the rectum, tenting the plexus superiorly and medially. 

      

    The pattern of nerve damage here and beyond the pelvic plexus tends to be mixed sympathetic and parasympathetic.

      

    Anterior Dissection

    The third pelvic zone of risk is during anterior rectal dissection. There is a very narrow space between the rectum and the prostate and seminal vesicles.

      

    This is probably where most parasympathetic nerve damage occurs, and may explain why impotence is more common the deeper the pelvic dissection goes [high AR versus low AR versus APER].

       

    The anterior plane of dissection may not necessarily be the same plane in which the posterior and lateral dissection is conducted.

     

    There is evidence now that close rectal dissection does not protect the pelvic nerves any more than mesorectal dissection.

      

    The mesorectal plane is the appropriate anterior plane for most rectal cancers.

      

    Conclusion

    Denonvilliers’ fascia arises from the fusion of the two walls of the embryological peritoneal cul-de-sac and extends from the deepest point of the rectovesical pouch to the pelvic floor.

      

    There is no so-called ‘posterior layer’of Denonvilliers’ fascia. 

      

    The ‘posterior layer’ is, in fact, the fascia propria of the rectum.

      

    Dissection between the ‘two layers’ of Denonvilliers’ fascia is really a dissection between the fascia propria of the rectum, containing the mesorectum, and the true Denonvilliers’ fascia covering the prostate and seminal vesicles.

          

  • M.K. Baig and S.D. Wexner [ Department of Colorectal Surgery, Clevaland Clinic Florida, 3000 West Cypress Creek Road, Fort Lauderdale, Florida 33309, USA ]

    Factors Predictive of Outcome After Surgery for Faecal Incontinence

    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1316-1330

      

    Surgical treatment of feacal incontinence may be categorized into procedures that either repair or augment the native sphincter mechanism or, alternatively, require construction of a neosphincter using either autologous tissue or an artificial device.

      

    Procedures such as postanal repair, direct sphincter repair and reefing are seldom used.

      

    Overlapping repair has become the operation of choice in incontinent patients with isolated anterior defects in the external anal sphincter muscle, particularly in postobstetric trauma.

      

    Total pelvic floor repair has been offered as a recent alternative. Neosphincter procedures include a gluteoplasty, non-stimulated and stimulated unilateral or bilateral graciloplasty and artificial bowel sphincter.

      

    The newest alternative, sacral nerve stimulation, seems promising. In the final analysis, case selection and surgical judgement are probably the most important factors influencing the success of surgery for feacal incontinence.

         

  • G.Zeitoun, A. Laurent, F. Rouffet, J-M. Hay, A. Fingerhut, J.-C. Paquet, C. Peillon and the French Associations for Surgical Research

    Multicentre, randomized Clinical Trial of Primany Versus Secondary Sigmoid Resection in Generalized Peritonitis Complicating Sigmoid Diverticulitis

    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1366-1374

       

    The best way to manage generalized peritonitis complicating sigmoid diverticulitis is controversial.

      

    Postoperative peritonitis occurred less often after primary than secondary resection. 

      

    The mortality rate did not differ significantly with regard to operative policy. 

       

    No patient died following a second or third procedure. 

      

    Primary resection is superior to secondary resection in the treatment of generalized peritonitis complicating sigmoid diverticulitis because of significantly less postoperative peritonitis, fewer reoperations and shorter hospital stay.

      

    Operative Protocol

    A midline incision was used. Peritoneal fluids were routinely cultured. Treatment of peritonitis included clearance of pus, faeces, exudate and as much debris and pseudomembraneous material as possible, followed by lavage of the abdominal cavity with 6 litres of warm saline whenever possible [but never less than 2 litres]. Antiseptic solution such as povidone-iodine was added or not according to the surgeon’s preference.

      

    Operative Procedures

    For patients allocated to primary resection, the surgeon was free to choose one of the two following options once sigmoid resection was completed. [1] end colostomy or [2] primary colorectal anastomosis protected or not by a diverting colostomy. A second procedure was necessary either to perform colorectal anastomosis or Hartmann reversal, protected or not by a diverting colostomy, or to close the initial colostomy.

        

    For patients allocated to secondary resection, the perforation of the sigmoid was closed by sutures whenever visible and feasible, and a diverting colostomy was constructed. A second procedure was necessary to resect the sigmoid colon and perform the colorectal anastomosis, protected or not by a diverting colostomy.

       

    Both surgical approaches included : [a] pelvic drainage during the first procedure; [b] clearing the rectum of faecal matter at the end of the first procedure whenever possible; [c] removal of the distal limb of the sigmoid colon and proximal rectum when resection was performed. And [d] mobilization of the splenic flexure as required for tension-free anastomosis.

         

  • J.P. Daniels, M.J. Lamparelli, H. Chave and J.N.L. Simon [ Department of Surgery, St. Richard’s Hospital, Royal West Sussex NHS Trust, Chichester PO19 4SE, UK]

    Recurrent Sigmoid Volvulus Treated by Percutaneous Endoscopic Colostomy

    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1419

       

    Sigmoid volvulus is a life-threatening condition which often occurs in elderly patients with physical and mental illness.

      

    If the sigmoid colon is ischaemic, emergency resection is the only treatment option and is associated with a mortality rate of up to 33 per cent.

      

    Elective open or laparoscopic fixation or resection may be inappropriate or unsafe in frail and elderly patients.

       

    Percutaneous endoscopic colostomy may provide a safe and effective treatment option in recurrent sigmoid volvulus in selected patients.

      

    Following standard bowel preparation and intravenous administration of cefuroxime 750 mg, metronidazole 500 mg and midazolam.

      

    A colonoscope is passed into the proximal sigmoid colon. With good transillumination a 14-Ch gastrostomy tube [Freka, Frenius, Warrington, UK] is placed under local anaesthesia using a standard percutaneous gastrostomy technique.

      

    The procedure is repeated in the distal sigmoid colon, bringing the second tube through the abdominal wall as far from the first as possible to anchor the sigmoid colon to the anterior abdominal wall in two places.

      

    Patients may eat and drink immediately and are discharged as soon as domestic circumstances allow, with an information leaflet on care of the tubes for the patient or carer.

      

    There were no deaths associated with the procedure or from sigmoid volvulus.

      

    There were no septic or other complications.

      

    Percutaneous endoscopic colostomy, under intravenous sedation and local anesthesia, is a safe and effective treatment for recurrent sigmoid volvulus, particularly in patients in whom conventional surgery is considered unsafe.

       

    No recurrence has occurred in patients in whom tubes have been left in situ. The Mic-Key tubes, with a flat external flange, have caused no problems, have proven acceptable to patients and carers, and have been easily changed when necessary.

         

  • A.J.
    Malouf, A.W. Murray and A.B. MacGregor [ Department of Surgery, The Royal Infirmary, Edinburgh, UK]

    Major Intra-Abdominal Pathology Missed at Laparoscopic Cholecystectomy

    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1434-1435

      

    Laparoscopic cholecystectomy has been shown to be an effective and safe treatment for symptomatic cholelithiasis.

        

    There have, however, been reports of serious intraabdominal disease present, but not identified, at the time of operation. Resultant delay in diagnosis often necessitates further surgical intervention, and in cases of malignancy may affect potential curability.

      

    Missed malignant primary lesions have included the colon, pancreas, stomach and lower esophagus.

      

    The commonest reported missed benign disorder has been that of Crohn’s disease.

      

    All patients had preoperative intermittent upper abdominal pain, some being colicky in nature, with persisting unaltered symptoms after operation. All had cholelithiasis documented before operation on ultrasonography and confirmed at operation, and histological evidence of chronic cholecystitis in surgical specimens.

       

    Although accepted as the treatment of choice for symptomatic cholelithiasis, a potential disadvantage of laparoscopic cholecystectomy is the lost ability to palpate the abdominal organs which the formal laparotomy of open cholecystectomy previously allowed. This may result in failure to identify concurrent intra-abdominal pathology producing symptoms attributed to cholelithiasis which led to operation in the first place.

      

    Symptoms frequently attributed to gallstones are not specific to biliary pathology, and sonographic evidence of cholelithiasis on investigation does not necessarily confirm a causal relationship.

      

    Patients should be selected carefully for laparoscopic cholecystectomy on the basis of a typical biliary history in the presence of documented cholelithiasis, and supportive clinical and biochemical findings.

      

    Persistence of symptoms after operation suggests that gallstones identified before operation were incidental, and that preoperative symptoms were related to the underlying tumors.

      

    It also highlights that, if symptoms for which laparoscopic cholecystectomy was performed, do not resolve, patients should be reviewed carefully and reinvestigated to exclude a missed diagnosis.

      

    Diagnostic laparoscopy yields positive findings in up to 76 per cent of patients when evaluating chronic abdominal pain and is effective in the diagnosis, staging and exclusion of intra-abdominal malignancy. If applied routinely during laparoscopic cholecystectomy it may help overcome potential limitations caused by loss of visceral palpation. 

      

    Although the expected pick-up of concurrent major intra-abdominal pathology would be low, it would be a useful intraperative routine at the time of laparoscopic cholecystectomy.

         

  • Professor
    J.E.J. Krige of Cape Town, South Africa

    Liver Fracture and Bleeding

    BRJ, Volume -87, Number 12, December, 2000, Pg.Nos. 1615

      

    At laparotomy for blunt abdominal trauma a surgeon in a district general hospital encounters a fractured bleeding liver. How should the problem be handled?

      

    The surgeon who unexpectedly encounters a major liver injury during a laparotomy for trauma will need to make several rapid critical decisions. The objectives are self evident and clear: stop the bleeding by the simplest means possible, remove devitalized liver tissue, and suture damaged blood vessels and bile ducts.

      

    The surgeon has a variety of options to control liver bleeding.

      

    The choices include diathermy or argon beam coagulation, the use of topical agents such as fibrin glue or Surgical [Ethicon, Livingstone, UK] [ for superficial injuries], inflow occlusion of the portal triad [Pringle manoeuvre], liver packing, hepatorrhaphy, hepatotomy and direct vascular suture, resectional debridement, partial or anatomic resection, and total hepatic vascular isolation with venovenous pypass.

      

    The level of intervention will ultimately be influenced by the surgeon’s experience, local resources and the facilities available. The key is to use the most effective yet simplest option for a specific situation.

      

    The greatest immediate threat is exsanguination. The absolute priority is rapid control of bleeding.

      

    The fracture is closed by manual compression and tamponade maintained by packs and pressure. This may be supplemented by inflow occlusion [Pringle manoeuvre] using an atraumatic vascular clamp across the portal triad.

      

    Pack pressure is maintained until the anesthetist has fully restored intravascular volume. Premature attempts to evaluate the extent of the injury and mobilize the liver before adequate resuscitation may lead to catastrophic blood loss with ensuing hypotension, coagulopathy, acidosis, hypothermia and unnecessary death.

      

    These potential effects should be anticipated and countered by providing warm intravenous solutions, the freshest possible blood, fresh frozen plasma, platelets, cryoprecipitate, a raised ambient theatre temperature and correction of metabolic abnormalities.

      

    If bleeding has stopped after careful pack removal and release of inflow controls, the surgeons should do no more. If bleeding persists, adequate exposure and a clear view of the injury become essential.

      

    Intermittent inflow release and effective suction allow identification of deeper bleeding sites which are controlled by direct suture, ligation, parenchymal suture or a mattress liver suture.

      

    If bleeding is not controlled by portal triad occlusion, major vena cava injury or atypical vascular anatomy is likely.

      

    Resectional debridement implies removal of non-viable liver bordering an injury. Anatomic resection performed through conventional anatomic planes unrelated to the lines of fracture is seldom necessary,

      

    For the surgeon encountering a major liver injury in a district hospital, perihepatic packing should be the first option when lesser procedures do not control bleeding. 

      

    If packing controls the bleeding, no further intervention is necessary. The packs are left in place, the abdomen is closed and definitive treatment deferred until a surgeon who can perform the required surgery is available or the patient can be transferred to a major trauma or hepatobiliary centre.

      

    Even for experienced surgeon, if bleeding is controlled, discretion and packing may be the better part of valour. 

      

    Other factors also influence the decision to pack. If the patient is acidotic [pH below 7.2], hypothermic [body temperature below 320C], coagulopathic or has had a massive transfusion [more than 10 units of blood], the liver should be packed, the abdomen closed and the patient returned to the intensive care unit. Blood volume is restored, the patient warmed, and the acidosis and coagulation defects corrected. 

      

    The technique of perihepatic packing is important. Sufficient packs should be used to provide effective uniform pressure. In this hospital a ‘six pack’ is generally used.

      

    Intra-abdominal pressure should not exceed the critical limit of 25mmHg. An important practical point is to avoid intrahepatic packing because packs forced into deep liver fractures aggravate the injury by increasing the size of the rent and holding it open, as well as tearing small hepatic veins.



    Further intervention may be formidable, requiring sophisticated equipment, and expert anesthesia, surgery and intensive care.

          

  • D.A. Niriella and K.I. Deen [ Academic Department of Surgery, North Colombo General Hospital and University of Kelaniya, Sri Lanka]

    Neosphincters in the Management of Faecal Incontinence

    BRJ, Volume -87, Number 12, December, 2000, Pg.Nos. 1617-1628

       

    The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence.

      

    Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres.

      

    The social and personal stigmas associated with the condition cause silent suffering and deterioration in quality of life.

      

    Surgical intervention is one of many therapeutic options.

      

    Patient selection is important to avoid disappointment. Only some forms of faecal incontinence are amenable to neosphincter reconstruction undertaken in those who have failed to improve on conservative treatment or previously failed to benefit from sphincter or pelvic floor repair.

      

    Surgical methods for treating faecal incontinence include either direct or overlapping sphincter repair for traumatic lesions, obstetric damage or iatrogenic sphincter injury in which pudendal nerve function is intact.

      

    Postanal repair or pelvic floor repair may be undertaken for anatomically intact but poorly functioning sphincters due to pudendal neuropathy.

      

    The principle of anal sphincter substitution involves the use of biological material or artificial mechanical devices to fashion a neosphincter around the non-functioning anal canal.

      

    The later discovery of the possibility of improving fatigue resistance in a muscle such as gracilis by electrical stimulation led to revival of muscle wrap techniques and the development of dynamic graciloplasty.

      

    Dynamic graciloplasty involves the release of the gracilis muscle from its distal attachment to the tibia and the creation of a muscle wrap around the native or artificially constructed anal canal in an a,g or S configuration, with attachment of the gracilis tendon to one of the ischial tuberosities.

      

    Occasionally both gracilis muscles may be transposed around the anal canal in this fashion [double -wrap graciloplasty].

      

    The transposed muscle is then subjected to electrical stimulation to bring about the desired muscle fibre transformation from predominantly type II [fatiguable] to type I [fatigue resistant] muscle.

      

    The purpose of neoanal sphincter construction is to achieve anal canal closure, usually a function of the internal anal sphincter, and to maintain voluntary closure of the anal canal, a function of the striated muscle component. Low frequency electrical stimulation converts type II muscle fibres, found in the gracilis, to type I muscle fibres which are fatigue resistant and thus stimulate internal anal sphincter function.

      

    The advantage of using gracilis as a neosphincter is that its loss does not result in a functional deficit in the lower limb after transposition. The use of two gracilis muscles may be an advantage. 

      

    Artificial sphincters are useful in managing faecal incontinence of neuromuscular origin, such as myasthenia gravis or diabetic neuropathy. Infection is a problem that requires removal of the prosthesis .

      

    However, both types of neosphincter operation are associated with morbidity; postoperative infection and impaired evacuation are predominant.

         

  • N.A. Roche and A.E. Young [ Department of Surgery, S. Thomas’ Hospital, London SE1 7EH, UK

    Role of Surgery in Mild Primary Hyperparathyroidism In the Elderly

    BRJ, Volume -87, Number 12, December, 2000, Pg.Nos. 1640-1649

      

    It is clear that elderly patients present with a different spectrum of problems, particularly indistinct neuropsychiatric and musculoskeletal symptoms, and these are likely to be improved by surgery. The evidence allows the conclusion that the truly asymptomatic elderly patient can be successfully managed conservatively.

      

    Management of primary hyperparathyroidism [HPT] in the elderly, particularly in relation to the role of surgery in the asymptomatic or minimally symptomatic patient.

      

    A diagnosis of primary HPT in an asymptomatic patient did not in all cases mandate referral for operation.

      

    Indication for surgery in asymptomatic patients with hyperparathyroidism-

      

    Serum calcium concentration greater than 0.25-0.4mmol/l above the normal range.

      

    Creatinine clearance reduced by 30 per cent compared with age matched controls, in the absence of other causes.

     

    24-h urinary calcium concentration greater than 400 mg/dl.

      

    Bone mass more than two standard deviations below that of age, sex, and race-matched controls.

      

    Age less than 5o years.

      

    Patients who request surgery or for whom long-term surveillance is unsuitable.

      

    The peak incidence of primary HPT lies between the ages of 55 and 70 years.

      

    The clinical problem is the sheer volume of such elderly patients with mildly raised calcium levels but who have symptoms. Such symptoms are often vague and may or may not be related to HPT, for example bone pain, lethargy, mental disturbance and constipation, all of which are common in the elderly.

         

    The obvious cause of the increased risk of death was cardiovascular disease.

     

    Both parathyroid adenoma weight and preoperative serum calcium levels were shown to be related to the risk of death.

      

    Current opinion is that the fit, young patient should be operated on, even if asymptomatic.

      

    In severe HPT, bone resorption and formation are greatly increased. Focal subcortical erosions and cystic lesions develop as a result of increased osteoclast activity and often act as sites for fracture.

      

    Fatigue, anxiety, lassitude, failing memory and concentration difficulties have all been reported in HPT.

      

    They are also symptoms that are common in the elderly and may be misinterpreted as part of the ageing process, making it difficult to determine whether elderly patients with hypercalcaemia are indeed symptomatic.

      

    Cervical exploration for primary HPT is successful in over 90 per cent of cases, with very low morbidity and mortality rates. HPT occurs more frequently in elderly patients, their symptoms may be difficult to distinguish from those of the general ageing process. 

      

    The most frequently improved symptoms in the older group were fatigue [50.0 per cent], muscular weakness [48.6 per cent] and joint pain [40.9 per cent].

      

    It is clear, as a result of routine serum biochemistry, that primary HPT is nowadays a different clinical entity from that which was originally described. The classical symptoms of renal and bone disease are rarely present, and many of the patients diagnosed are classed as asymptomatic.

       

    Elderly patients with primary HPT present more often with indistinct psychiatric and musculoskeletal symptoms and these are the symptoms most likely to be improved by operation.

      

    Surgery therefore has a definite and constructive role to play in the management of the elderly patient with symptomatic or even mildly symptomatic HPT, but such patients should be warned that, although the operation is safe, the benefit is unpredictable.

          

  • Wang
    PTH, Bonavita JA, DeLone FX Jr, et al [Crozer-Chester Med Ctr, Upland,Pa]

    Ultrasonic Assistance in the Diagnosis of Hand Flexor Tendon Injuries

    Ann Plast Surg 42: 403-407, 1999

       

    This study examines the contribution of ultrasonography to the diagnosis of flexor tendon injuries.

       

    Eight patients were studied, clinically there was inability to flex the finger. Evaluation was performed using an ATL-HDI-3000 US unit with a high -resolution 5- to -9 MHz hockey stick linear probe. Real-time flexor tendon manipulation was performed to stimulate the patient’s symptoms. These findings were compared with the operative findings.

       

    3 cases of flexor digitorum profundus tendon rupture were diagnosed by USG. These injuries resulted from forceful extension, penetrating injury, delayed rupture 3 weeks after previous repair respectively. In all 3 cases the US findings were confirmed at surgery. In the remaining 5 cases [forceful extension, penetrating trauma, phalangeal fracture and crush injury]. The US showed the tendons to be intact; at operation, in 3 cases these findings were confirmed. 

       

    The authors conclude that US is a useful diagnostic tool for clinically equivocal flexor tendon injuries.

          

  • Drape J-L, Tardif-Chastenet de Gery S, Silbermann-Hoffman O, et al [ Hopital Cochin, Paris; Hopital Bichat, Paris]

    Closed Ruptures of the Flexor Digitorum Tendons: MRI Evaluation

    Skeletal Radiol 27: 617-624, 1998

     

    This study evaluates the role of MRI in the diagnosis and management of closed flexor digitorum tendon ruptures.

      

    10 patients [7 male, 3 female mean age 48.5 years] with suspected closed ruptures of FDT underwent preoperative MRI of the hand with T1 weighted spin-echo sequences, 3-D gradient-echo images, and curved reconstructions to examine the FDT. The level of rupture, the gap between the tendon ends and the position of the proximal end of the tendon were then compared between MRI and operative findings.

      

    MRI indicated 12 FDT ruptures, FDP alone 4 cases, FDP +FDS rupture 3 cases, and FDS alone 2 cases, and FDL alone 2 cases. These findings were confirmed at surgery. The level of rupture, the gap between the tendon ends correlated well with operative findings; further, MRI could detect tendinitis in 3 adjacent tendons. 

      

    The authors conclude that MRI can accurately identify the level of tendon rupture and the gap between the tendon ends and is useful in the diagnosis and management of tendon ruptures.

         

  • Gabl
    VM, Lener M, Pechlanner S, et al [ Universitatsklinik fur Unfallchirurgie, Innsbruck, Germany; Institut fur Magnetresonanztomographie und Spektroskopie, Innsbruck, Germany]

    Closed Traumatic Rupture or Overuse Syndrome of the Flexor Tendon Pulleys? Early Diagnosis by MRI [German]

    Handchir Microchir Plast Chir 28: 317-321, 1996

      

    This study examines the efficacy of MRI for the diagnosis of closed injuries to the flexor tendon pulleys.

      

    18 rock climbers with recent injuries were studied. 8 [overuse injuries] were treated conservatively along with [short pulley ruptures]. 2 patients with long pulley ruptures were operated [tendon grafting]. They were followed up for 36 months.

       

    An MRI was done in all cases for diagnosis. Bowstringing or flexion contracture after treatment was not clinically detectable in any patient. All but 1 patient had nearly normal range of movement. Lasting swelling was the only clinical feature of partial instability. MRI was able to detect minor bowstringing and scars in most patients.

       

    They conclude that MRI was useful in detecting the presence and extent of pulley injury.

        

  • Failla
    JM, Jacobson J, van Holsbeeck M [Henry Ford Hosp, Detroit]

    Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/Dislocations

    J Hand Surg [Am] 24A: 257-266, 1999

     

    This study evaluates the usefulness of ultrasonography in the diagnosis of torn interosseous membrane [10M] in forearm fractures/dislocations.

       

    US was performed transversely on 2 cadaver forearms with intact IOM and again to confirm transection after 10M was transected in 1 forearm. Then US was performed in 2 Galeazzi fracture-dislocations 1 Essex-Lopresti injury were and compared with findings at operation. The authors conclude that US is a useful modality to diagnose and locate a torn IOM allowing primary repair to be performed.

         

  • Wallace AL, Haber M, Sesel K, et al [ Prince of Wales Hosp, Sydney, Australia; IIIawarra Private Hosp, Wollongong, Australia]

    Ultrasonic Diagnosis of Interosseous Ligament Failure In Radioulnar Dissociation

    Injury 30: 59-63, 1999

      

    Complex fractures of the elbow can be difficult to diagnose – thus “radioulnar dissociation is sometimes accompanied by interosseous ligament failure. This study used ultrasonography to make a diagnosis of I0M tear with comminuted radial head fracture. They feel that US imaging to an unexpensive, safe and readily available modality for obtaining images at baseline and throughout the healing process and for detecting occult injury of the interosseous ligament.

         

  • Wolf
    JM, Weiss A-PC [Brown Univ, Providence, RI]

    Portable Mini-fluoroscopy Improves Operative Efficiency In Hand Surgery

    J Hand Surg [Am] 24A: 182-184, 1999

      

    This study compares the use of traditional radiographic confirmation versus mini-fluoroscopy in a paired, retrospective cohort case study.

       

    30 patients underwent closed reduction or internal fixation of phalangeal shaft fractures or metacarpophalangeal or inter-phalangeal joint fusions. Standard intraoperative and lateral radiographs were used in 15 procedures and portable mini-fluoroscopy in the other 15 procedures.

       

    The minifluoscopy reduced operative time by 55% in phalangeal fractures by 39% in wrist fusion and by 48% in the in-situ 4 corner fusion.

       

    They conclude that mini-fluoroscopy is a safe effective and efficient modality in the tested surgical procedures.

            

  • Turgeon
    TR, MacDermid JC, Roth JH [Univ of Western Ontario, London; St Joseph’s Health Centre, London, Ont]

    Reliability of the NK Dexterity Board

    J Hand Ther 12: 7-15, 1999

      

    This study evaluates the reliability of the NK dexterity test as a part of a comprehensive computerized hand evaluation system.

        

    37 volunteers [24 women and 13 men] were tested on the NK dexterity board on 2 separate occasions. On each occasion individuals moved small, medium and large objects in 3 separate tests and separately with each hand.

       

    Most complained of arm or forearm fatigue, and had difficulty with threading the medium and large screw-type objects. Intraoccasion
    intraclass correlation coefficients [ICCs] [n=12; 3 tests x 2 hands x 2 occasions] were fair in half of the comparisons and excellent in the other half. Reliability was better in the dominant hand. ICCs for tests involving small medium objects were fair but for large objects were excellent.

     

    They conclude that although the NK dexterity board has fair-to-excellent reliability, there is a room for improvement. Suggestions made for improving the insrumentation include adding a steel lining to the plastic receptacle of the small steel screw, changing the T-shaped object in the medium sized test from aluminum to steel reducing the length of threading on the large screw object, and establishing a method to lubricate the large screw object.

     

    Nonetheless, this board has several advantages including its ability to test a wide variety of gross and fine movements, a computerized recording system that reduces operative error and normative data in the software for comparison based on age and sex.

         

  • Marx
    RG, Bombardier C, Wright JG [Univ of Toronto]

    What do we Know About the Reliability and Validity of Physical Examination Tests Used to Examine the Upper Extremity?

    J Hand Surg [Am] 24A: 185-193, 1999

      

    For a physical examination to be useful each test must be reliable and valid. A review was made of the reliability and validity of commonly used physical examination tests for disorders of the upper extremity.

       

    Relevant articles from literature, standard tests and fro consulting experts, were reviewed and analyzed separately from the point of the impairment of function and diagnosis.

      

    The tests for range of motion and strength testing were considered reliable. The tests used to diagnose upper extremity disorders like carpal tunnel syndrome and rotator cuff tendinopathy have varying degrees of validity. Overall, there is sparse evidence regarding the reliability and validity of physical examination for the upper extremities both from the point of diagnosis and impairment of function.

      

    It is therefore recommended that these tests not be used in isolation. It is important that the properties of each test be documented, so clinicians may reliably and accurately examine patients.

  • Oxford GE, Jonsson R Olofsson J, et al [Univ of Florida, Gainesville; Univ of Bergen, Norway; Haukeland Univ. Hosp, Bergen, Norway; et al]

    Elevated levels of Human Salivary Epidermal Growth Factor After Oral and Juxtaoral Surgery

    J Oral Maxillofac Surg 57: 154-158, 1999, Pg.133



    Saliva provides a natural reservoir of growth factors. Salivary epidermal growth factor concentrations were increased within 24 hours after surgery. Surgery also stimulates increased synthesis and secretion of growth factors in saliva. Increased concentrations of saliva-derived growth factor may help promote wound healing.



    We have all seen animals cleaning their wounds by licking – and it works. Additionally, we know how quickly oral wounds heal, seemingly after a slow initial period, with a subsequent rapid recovery.

  • Santler G, Karcher H, Ruda C, et al [Univ Clinic for Dentistry, Graz, Austria]

    Fractures of the Condylar Process : Surgical Versus Nonsurgical Treatment

    J Oral Maxillofac Surg 57: 392-397, 1999, Pg.150



    Improved materials for osteosynthesis, including Kirschner wires, wires, miniplates and lag screws has made open surgical treatment more promising. 



    Patients treated nonsurgically were treated by maxillomandibular fixation [MMF] or without MMF. 



    Patients treated surgically or nonsurgically had no significant difference in mobility, joint problems, occlusion,and muscle pain or nerve disorders.



    Minimally invasive therapy for condylar process fractures remains the method of choice. 



    Condylar mandible has a tremendous capability for reparation, self-reconstruction, and remodeling. 

  • Fitzpatrick
    RE (Univ of California, San Diego)

    Treatment of Inflamed Hypertrophic Scars Using
    Intralesional 5-FU

    Dermatol Surg 25: 224-232, 1999


         


    Hypertrophic scars and keloids are causes by a
    variety of injuries to skin.



    Intralesoinal injections of 5-FU in a concentration
    of 50 mg/ml were administered in doses ranging from
    2 to 50 mgm.



    Mixing 0.1ml of kenlog and 0.9 ml of 5-FU in the
    same syringe caused less pain and had greater
    efficacy.



    It was rare for a scar to not respond favorably.
    Scars with greatest response were typically red,
    most inflamed, most

    symptomatic and most firmly indurated.



    The first signs of response were reduced pain and
    itching softening of scar, flattering and decreased
    redness. Hypertrophic scars were more responsive
    than keloids.



  • Tabaqchali MA, Hanson JM, Proud G [Royal Victoria Infirmary, Newcastle upon Tyne, England

    Drains for Thyroidectomy /Parathyroidectomy : Fact or Fiction?

    Ann R Coll Surg Engl 81: 302-305, 1999, Pg.219



    The primary reason that drains are routinely placed after neck wound hematoma and seroma and obstruction. 



    Postoperative bleeding hematoma was significantly higher in patients who received drains than in those who did not. Wound infection was observed only in patients with drains.



    A meticulous haemostatic technique is more important than the use of drains. 



         

  • Sarhadi NS, Shaw-Dunn J[Univ of Glasgow, Scotland]

    Transthecal Digital Nerve Block: An Anatomical Appraisal

    J Hand Surg [Br] 23B: 490-493, 1998

      

    This study investigates the anatomical basis of a transthecal digital nerve block for local anesthesia of digits in 60 digits from 40 cadavers.

      

    Methylene blue and latex were injected into cadaveric digits to determine how anesthesia fluid injected into the flexor tendon sheath may spread around the finger.

       

    In digits when 3cc of solution was injected, irrespective of the puncture site, blotchy dye stains were seen on the dorsum of the proximal part of the finger, and the sides of the interphalangeal joint and the metacarpophalangeal joint and both the neurovascular bundles and the flexor tendon sheath were also stained. Dye stains were seen at the wrist when the injections were given at the thumb base and the little finger. Injections in the other fingers did not stain the proximal palm.

      

    If only 0.5cc were injected into the tendon sheath, staining appeared on the dorsum of the digit at its base and around the p.i.p. joint. It also tracked alongside the vessels. The fatty tissue showed linear staining, but no staining of nerves. Deeper staining was seen at the base of the proximal phalanx or in the region of the middle phalanx.

      

    Transthecal injection of 1 ml, resulted in a pool of dye around the neurovascular bundles, in the tissue space enclosed by Cleland’s ligament and Grayson’s ligament right to the tip of the finger.

      

    The authors conclude that injected dye solution escapes from the flexor tendon sheath around the vincular vessels, through the perivascular loose areolar tissue, and spreads alongside the main digital vessels and nerves and their branches.

          

  • Lundborg G, Rosen B, Lindberg S [Malmo Univ, Sweden]

    Hearing as Substitution for Sensation : A new Principle for Artificial Sensibility

    J Hand Surg [Am] 24A: 219-224, 1999

      

    Sense substitution is commonly used among patients with sensory deficits, such as the use of Braille to read by blind people. This study describes an attempt to use hearing as a substitute for lost sensibility.

      

    This study used vibrotactile stimuli to generate sounds as a substitute for hand sensibility. Miniature condenser microphones were attached to the distal, dorsal side of a glove to magnify the friction sound generated. The signal from the microphone was processed by a stereo amplifier which separated signals from different fingers into different channels. These sounds were then fed through earphones to patients with lost hand sensibility [3 had undergone median nerve repair, 1 had an replantation of an amputated forearm, 1 had a myoelectric prosthesis, and 4 had cosmetic prostheses. The patients participated in studies to assess spatial resolution and differentiation between textures.

      

    The spatial resolution of signals allowed patients to differentiate between the various fingers. Friction sounds enabled the patients to identify textures – such as glass, metal, wood and paper.

      

    The findings suggest that hearing may provide a useful substitute for lost hand sensibility.

         

  • D.M. Hemingway and I.G. Finlay [ Department of Coloproctology, Glasgow, Royal Infirmary, Glasgow, UK]

    Effect of Colectomy on Gastric Emptying in Idiopathic Slow-transit Constipation

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1193-1196

      

    Gastric emptying is delayed in patients with idiopathic slow-transit constipation [ ISTC]. This study evaluates the effect of colectomy and ileorectal anastomosis on this delayed gastric emptying.

      

    Twelve patients suffering from ISTC were subjected to colectomy [subtotal] and ileorectal anastomosis. Out of these 11 had an excellent functional outcome. In 10 of these gastric emptying was assessed after 3 months. 7 of these [including the remaining two] had the same study at the end of one year.

       

    Gastric emptying remained delayed at the end of 3 months at the end of one year gastric emptying had improved [ 4 had returned to normal] functional outcome did not relate to gastric emptying.

       

    Patients with ISTC have delayed gastric emptying time, which may return to normal in some after colectomy but is persistent in others.

          

  • C.M. Wright, O.F. Dent, M. Barker, R.C. Newland, P.H. Chapuis, E.L. Bokey, J.P. Young, B.A. Leggett, J.R. Jass and G.A. Macdonald [ Department of Surgery, Princess Alexandra Hospital, Conjoint Gastroenterology Laboratory, Royal Brisbane Hospital Research Foundation Clinical Research Center, Department of Pathology , University of Queensland and Department of Medicine, University of Queensland and Clinical Sciences Unit, Queensland Institute of Medical Research, Brisbane, Queensland, Department of Sociology, Australian National University]

    Prognostic Significance of Extensive Microsatellite Instability in Sporadic Clinicopathological Stage C Colorectal Cancer

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1197-1202

       

    Colorectal cancers exhibiting microsatellite instability [MSI] appear to have unique biological behaviour. This study analyses the association between extensive MSI [MSI-H], clinicopathological features and survival in an unselected, group of patients with Sporadic Australian Clinico-Pathological Stage [ACPS] C [tumour node metastasis stage III] colorectal cancer.

      

    255 patients who underwent resection for sporadic ACPS C colorectal cancer between 1986-1992 were studied. No chemotherapy was given and a minimum follow up period was 5 years. Archival normal and tumour DNA was extracted and amplified by polymerase chain reaction using a radioactive labeling technique. MSI-4 was defined as instability in 40 percent or more of seven markers.

      

    21 patients showed MSI-H. No association was found between MSI and age or sex. Tumours exhibiting MSI-H were more commonly right sided, larger and more likely to be high grade. After adjustment for age, sex, and other variables, patients with MSI-H had improved survival rates.

        

  • N.S. Williams, O.A. Fajobi, P.J. Lunniss, S.M. Scott, A.J.P. Eccersley and O.A. Ogunbiyi [ Academic Department of Surgery, The Royal London Hospital, London, UK]

    Vertical Reduction Rectoplasty: A new Treatment for Idiopathic Megarectum

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1203-1208

        

    Idiopathic megarectum is of unknown aetiology and the results of surgery are unsatisfactory. The poor evacuatory function has been attributed to rectal hypo-anesthesia and poor perception of rectal filling. It was hypothesized that by reducing the capacity of the rectum, the sensory thresholds to rectal distension and perception of urge to defaecate would be improved. 

    6 patients with idiopathic megarectum were subjected to vertical reduction rectoplasty [VRR] and concomitant sigmoid colectomy. Postoperative rectal compliance was evaluated by means of a programmable electronic barostat. Phyiological data was compared with eight healthy volunteers.

       

    Bowel frequency increased from 2.5 to 16 per month after surgery. 4 patients reported improved rectal perception of the urge to defaecate. Threshold for defaecatory urge and maximum tolerated volume were significantly reduced. The rectal compliance was no different from that in healthy volunteers. Colonic transit time decreased significantly and evacuation on proctography increased from a median of 30% to 50%. At a median of 57 weeks follow up, 5 patients expressed continued satisfaction.

    VRR can improve sensory feedback and defaecation in idiopathic megarectum.

         

  • M.
    M.Fynes, M. Behan, C.O’Herlihy and P.R. O’Connell [ Department of Surgery and Radiology, Mater Misericordiae Hospital and Department of Obstetrics and Gynecology, National Maternity Hospital, University College Dublin, Dublin, Ireland ]

    Anal Vector Volume Analysis Complements Endoanal Ultrasonographic Assessment of Postpartum Anal Sphincter Injury

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1209-1214

     

    This study aims to determine the role of anal vector manometry in the assessment of postpartum anal sphincter injury and to determine the most suitable method of anal vector volume analysis for identifying significant external anal sphincter [EAS] injury in an at-risk parous population.

       

    101 women with a history of instrumental or traumatic vaginal delivery were studied by anal ultrasonography and anal vector
    manometry.

        

    17 women had significant EAS disruption identified by
    ultrasonography.

        

    Anal vector manometry provided complementary functional information. Anal Vector Symmetry index [AVSI] determined by analysis of mean maximum squeeze pressure, yielded 100 per cent sensitivity for significant EAS disruption with a positive predictive value of 61%.

         

  • E.A. Baker, F.G. Bergin and D.J. Leaper [ Professorial Unit of Surgery, North Tees General Hospital, Stockton on Tees TS19 8PE, UK]

    Matrix Metalloproteinases, Their Tissue Inhibitors and Colorectal Cancer Staging

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1215-1221

      

    Matrix metalloproteinases [MMPs] and their tissue inhibitors [TIMPs] are important in tumour invasion and metastases. This study measured the levels of MMPs and TIMPs and total MMP activity in colorectal tumour cases and compared them with normal and correlated with clinical and pathological staging.

      

    Gelatin zymography [MMP-2 and MMP-9] enzyme linked immnunosorbent assays [MMP-1, MIMP-3, TIMP-1 and TIMP-2] and quenched fluorescent substrate hydrolysis [total MMP activity] were employed in resection specimens from 50 patients, four with adenomas and 46 with colorectal cancer.

      

    The levels of active MMP-2 and MMP-9 and total MMP-1, MMP-3 MMP-9 and total MMP1, MMP3, and TIMP-3 were significantly greater in tumour tissue than in normal colon. However, TIMP-2 levels were significantly greater in normal tissue. The total MMP activity was greater in tumours. Correlations were found between MMP and TIMP levels and pathological tumor staging. MMP1 appeared to be most important as its concentration correlated positively with Dukes staging, tumor differentiation and lymphatic invasion.

           

  • M.M.P. J. Reijnen, B.M. de Man, Th. Hendriks, V.A. Postma, J.F. G.M. Meis, and H. van Goor [ Departments of Surgery and Medical Microbiology, University Hospital Nijmegen, The Netherlands]

    Hyaluronic Acid-based Agents do not Affect Anastomotic Strength in the Rat Colon, in Either the Presence or Absence of Bacterial Peritonitis

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1222-1228

        

    This study investigates the influence of two hyaluronic acid agents on the development of strength in colonic anastomosis during the first postoperative week, in normal rats and in rats with bacterial peritonitis.

        

    In 90 male Wistar rats, a 1-cm segment was resected from the descending colon and an end to end anastomosis was constructed. In 180 rats. A bacterial peritonitis was induced by caecal ligation and puncture [CLP]. Some 24 hours later the abdomen was reopened. The caecum was taken out and after resection of 1 cm segment, an anstomosis was made. 

     

    The animals in both groups were randomized to receive either an HA-carboxymethylcellulose [CMC] bioresorbable membrane, 0.4%, HA solution or no treatment. One third of each group was killed at day 1, 3 and 7 after operation. Cultures were taken from the abdominal cavity for microbiological analysis in half of the animals. Subsequently, both bursting pressure and breaking strength were determined as parameters for anastomotic strength.

     

    No differences were noted in the different groups in anastomotic bursting pressure or breaking strength and in the number of bacteria cultured from the abdominal cavity.

     

    HA-CMC can safely be used to prevent postoperative adhesions after bowel resections.

         

  • M. van ‘t Riet, J.W.A. Burger, J.M. van Muiswinkel, G. Kazemier, M.R. Schipperus and H.J. Bonjer [ Departments of Surgery, Radiology and Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands]

    Diagnosis and Treatment of Portal Vein Thrombosis Following Splenectomy

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1229-1233

     

    The study assesses the incidence, risk factors treatment and outcome of portal vein thrombosis after splenectomy in a large series of patients.

     

    563 splenectomies were reviewed retrospectively, 2% [9 cases] were complicated by symptomatic portal vein thrombosis.

    All these 9 cases had either fever or abdominal pain. 2 of 16 patients [myeloproliferative disorder] and 4 of 49 [haemolytic anaemias] developed portal vein thrombosis. Early treatment [within 10 days] was successful in all patients while delayed treatment was ineffective.

     

    Portal vein thrombosis should be suspected after splenectomy if there is fever and/or abdominal pain. Patients with myeloproliferative disorders or haemolytic anaemia were at a higher risk. Early detection with Doppler ultrasonography and early treatment could be life saving.

         

  • T.
    Funai, H. Osugi, M. higashino and Kinoshita [ Second Department of Surgery, Osaka City University Medical School, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan]

    Estimation of Lymph Node Metastasis by Size in Patients with Intrathoracic Oesophageal Cancer

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1234-1239

         

    The aim of this study was to establish criteria for the preoperative diagnosis of lymph node metastases based on size and shape of nodes.

       

    123 patients were studied. 6822 nodes were obtained by extended lymphadenectomy. The nodes were classified anatomically and their size was measured by the operating surgeon during or immediately after surgery. All were examined histologically and criteria for diagnosis of metastasis were evaluated.

      

    The size of the nodes varied by anatomical site. They were smallest in the neck and largest at the tracheal bifurcation. The cut off value for the diagnosis of metastases was 5 mm in the neck. 6 mm in the abdomen and 8 mm in the mediastinum, except for tracheal nodes. Lymph node 10 mm or larger tended to become spherical when involved by metastasis.

         

  • G. Miller, J. Boman, I. Shrier and P.H. Gordon [ Division of Colorectal Surgery and Center for Epidemiology and Community Studies, Sir Mortimer B, Davis -Jewish General Hospital and McGill University, Montreal, Canada]

    Natural History of Patients with Adhesive Small Bowel Obstruction

    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1240-1247

       

    The aims of this study was to determine factors predisposing to adhesive small bowel obstruction [SBO], to note the long term prognosis and recurrence rates for operative and non operative treatment,to elicit the complication rate of operations and to highlight factors predictive of recurrence.

      

    410 patients accounting for 675 admissions over a period of 10 years were reviewed retrospectively.

      

    The frequency of previous surgery was 24% colorectal surgery, 22% gynaecological surgery, 15% herniorrhaphy 14% appendicectomy .

      

    A history of colorectal surgery [odds 2.7] vertical incision [2.5%] tended to produce multiple matted adhesion rather than an obstructive band. At initial admission, 36% were treated by means of an operation. As the number of admissions increased, the recurrence rate increased and the time interval between admission decreased. Patients with an adhesive band had 25% readmission, rate compared with 49% for those with matted adhesions.

      

    Patients treated without operation had 34% readmission rate compared in the 32% for those treated with surgery. A shorter time to readmission, no difference in reoperation rate and fewer in patient days over all admissions.

           

  • Wright
    JG, Hawker GA, Bombardier C, et al [Univ of Toronto; Sunnybrook & Women’s College Hosp, North York, Ont; Vanderbilt Univ, Nashville, Tenn; et al]

    Physician Enthusiasm as an Explanation for /area Variation in the Utilization of Knee Replacement Surgery

    Med Care 37: 946-956, 1999

       

    This study examines the variation in the utilization of knee replacement surgery by county in the Canadian province of Ontario. The factors evaluated included the characteristics and opinions of the physicians and specialists, severity of disease, access to the procedure, use of alternative surgery and population factors.

       

    Knee replacement was more frequently used in older patients and in medical school affiliated hospitals. The referring physicians were usually males, trained outside North America. Orthopedic surgeons had a higher propensity for performing knee replacements and better perceptions of the outcomes. 

       

    The authors conclude that the local orthopedic surgeons have a major influence on the rate of knee replacement in a given geographic area. Efforts to reduce variation in surgeon opinion might reduce although not eliminate, geographic variation.

      

  • Coyte PC, Hawker G, Croxford R, et al [Univ o Toronto; Women’s College Hosp, Toronto; Hosp for Sick Children, Toronto]

    Rates of Revision Knee Replacement In Ontario, Canada

    J Bone Joint Surg Am 81-A: 773-782, 1992

       

    This analysis includes 18,520 knee replacements performed in Ontario from 1984 to 1991. One study algorithm was used to identify primary versus revision 

    knee replacements and another was used to link revision to primary knee replacements.

       

    The survival of the primary knee replacements was assessed using the Kaplan Meier method and factors affecting survival were identified using a proportional
    – hazards regression model. 

       

    Overall 7% of the total number of knee replacements were revisions. Osteoarthritis was the commonest indication for primary knee replacement. The time to revision surgery was significantly longer for patients older than 55 years, rural population and in those with rheumatoid arthritis revision.

       

    Revision replacement surgery was done earlier in teaching or speciality hospitals. Long term revision rates were low. The estimated rate of revision within 7 years varied significantly according to the algorithm used from 4.3% to 9%.

       

    They conclude that revision knee replacement is a rare event. Many factors affect thus likelihood like age, sex, area of residence and type of hospital.

      

  • Robertsson O, Borgquist L, Knutspm K, et al [Univ Hosp, Lund, Sweden; Linkoping Univ, Sweden]

    Use of Unicompartmental Instead of Tricompartmental Prostheses for Unicompartmental Arthrosis in the Knee is a Cost-effective Alternative : 15,437 Primary Tricompartmental Prostheses Were Compared With 10,624 Primary Medial or Lateral Unicompartmental Prostheses 

    Acta Orthop Scand 70: 170-175, 1999

       

    This study evaluates the cost of UKA [Unicompartmental] and TKA [Tricompartmental] procedures including implant cost. Length of hospital stay and the difference in the number of expected revisions. 

       

    The analysis included 15,437 primary TKAs and 10,624 primary medial or lateral UKAs over an 11 year period. Registry data was used to compare length of hospital stay in the 2 groups. Survival data was used to calculate the
    cumulative revision rate [CRR] and relative risk of revision. The risk of second revision and infection were calculated as well. 

        

    The proportion of patients undergoing UKA implantation declined during the period of study. ‘The average age at primary operation was 73 years [TKA] and 71 years [UKA]. The postoperative stay averaged 12.3 days [TKA] and 10.7 days [UKA]. The 10 year CRR was 12% [TKA] AND 16% [UKA]. The rate of serious complications was significantly lower in UKA group. The cost of a UKA was 57% that of TKA procedure.

        

    The conclusion is that the cost of UKA implantation is lower than TKA implantation [inclusive of higher revision rate]. It also has a shorter hospital stay. The costs may be further reduced by proper selection of patients.

        

  • Parentis MA, Rumi MN, Deol GS, et al [Pennsylvania State Univ, Hershey] 

    A Comparison of the Vastus Splitting and Median Parapatellar Approaches in Total Knee Arthroplasty

    Clin Orthop 367 : 107-116, 1999

       

    This is a controlled prospective study [randomized] comparing the two approaches.

       

    42 consecutive patients [51 knees] with degenerative disease of the knee were subjected to TKA.

       

    The median parapatellar approach used a standard midline incision. In the vastus medialis splitting approach the same incision was used; however at the level of the supero medial corner of the patella, the vastus medialis fascia was incised along the margin of the quadriceps tendon and elevated medially. The muscle was then split bluntly. 

       

    Electromyography performed pre and postoperatively was used to evaluate the two approaches relative to their effect on the innervation of the quadriceps mechanism. 

        

    The two randomized groups were similar in age, weight and other clinical parameters. Postoperatively, no significant differences were noted during the hospital stay at 2, 6 and 12 weeks in terms of straight leg raise, ROM and hospital for special surgery scores, short arc quadriceps strength or tourniquet time. Blood loss was significantly greater in the standard approach [ 200 vs 129.6 ml]. 9 patients [43%] who had vastus splitting approach had abnormal postoperative electromyograms.

        

    The two approaches are similar when compared clinically. Longer tern studies, however, are needed to determine the clinical significance of denervation of the vastus medialis muscle by the vastus splitting approach.

         

  • Aglietti P, Buzzi R, De Felice R, et al [Univ of Florence, Italy]

    The Insall-Burstein Total Knee Replacement in Osteoarthritis : A 10-Year Minimum Follow-up

    J Arthroplasty 14: 560-565, 1999

       

    The Insall-Burstein posterior stabilized [IBPS] TKA was designed to improve maximal flexion and function. Previous studies have presented midterm results with this prosthesis. This study presents a ten year follow up result using the IBPS in patients with osteoarthritis. 

       

    99 IBPs TKAs in 86 patients [76 women and 10 men average age 69 years] with osteoarthritis were followed up. Follow up evaluation consisted of annual clinic visits, including the knee Society Score and radiographs. 10-15 years follow up data were available on 60 knees.

       

    58% had excellent results [Knee Society Scores ], 25% had good results, 7% had fair results and poor results in 10%. The knees had an average of 1060 of flexion. 9% had moderate patellofemoral crepitation. 8% showed osteolysis around the tibial and femoral components whereas 12% showed polyethylene wear. The 10% failure rate included 4 knees with aseptic loosening, 1 with deep infection and 1 with recurrent patellar dislocation. The 10 year cumulative success rate with revision as the end point was 92%.

       

    The IBPS TKA replacement achieves good results on a long term basis.

       

  • Cloutier J-M, Sabouret P, Deghrar A [Universite de Montreal]

    Total Knee Arthroplasty with Retention of Both Cruciate Ligaments : A Nine to Eleven –year Follow-up Study

    J Bone Joint Surg Am 81-A: 697-702, 1999

       

    Most current knee replacement systems retain the posterior or both the ACL and PCL. Despite arguments that ACL retention complicates the knee replacements procedure, the authors routinely seek to retain both ligaments when possible. A prospective study of 163 TKAs with retention of both cruciate ligaments.

       

    Of 204 TKAs performed from 1986-1988 both cruciate ligaments were retained in 163. Follow-up results were available on 107 knees of 89 patients: 96 women and 34 men with an average age of 67 years at index arthroplasty. [75% had osteoarthritis 25% had rheumatoid arthritis]. Varus deformity was present in 67% valgus in 16%. At operation ACL appeared normal in 96 knees and partially degenerated in 67. 

       

    At 10 year follow up, 97% had good to excellent results. 91% had good pain relief with an average range of flexion of 107. AP stability was normal in 89% with movement of less than 5 mm. The remaining 11% had 5-10 mm of movement. Mediolateral stability was normal in 90% whereas 10% had 5-10 mm of movement. Varus alignment was between 50 to 100 in 88%. The average knee score was 91 points, with an average functional score of 82. 10 year revision free survival was 95%. The revision rate was 4% with no revisions for patellar problems or aseptic loosening of the tibial component.

       

    The ten year follow up shows good results.

       

  • Gill GS, Joshi AB, Mills DM [ Lubbock, Tex]

    Total Condylar Knee Arthroplasty : 16- to 21-Year Results

    Clin Orthop 367: 210-215, 1999

       

    This study reports the long-term results of posterior cruciate retention total condylar knee arthroplasty performed by a single surgeon in private practice.

    159 knee arthroplasties were performed [139 patients] using total condylar knee prostheses between 1976-1982. A 16 year follow-up was available on 72 knees of 63 patients [42 men, 21 women] average age 61 years]. The main indication was osteoarthrosis. Follow up included clinical evaluation based on knee society clinical rating systems and radiographs.

       

    5 knees experienced delayed complications [ 3 had patellar stress fracture; 1 each of delayed supracondylar fracture and patellar tendon rupture]. Revision surgery was performed on 1 knee. 2 more cases were advised revision surgery but declined on medical risk grounds. There were no cases of aseptic loosening. The mean knee score improved from 40.3 points preoperatively to 88.4 points at follow up.

       

    86% had excellent results, 7% had good to fair result and poor in 7%. Among patients undergoing revision surgery, 20 year prosthesis survivorship was 98.6%. 

       

    Total Condylar Knee arthroplasty with posterior cruciate ligament retention gives excellent results in private practice.

        

  • Li
    PLS, Zamora J, Bentley G [King’s College Hosp, London; Southend Gen Hosp, Essex, England; Royal Natl Orthopaedic Hosp, Stanmore, England]

    The Results at Ten Years of the Insall-Burstein II total Knee Replacement: Clinical, Radiological and Survivorship Studies

    J Bone Joint Surg Br 81-B:647-653, 1999

       

    The 10 year results of the use of Insall-Burstein II prosthesis in a general orthopaedic unit are discussed. 

       

    146 total knee replacements [IB-II prosthesis] were performed on 121 patients [ 39 men, 82 women aged 46-86 years]. At ten years, 78 patients [94 knees] were available for follow-up. The hospital for special surgery [HSS] scoring system and the knee society rating system were used to evaluate outcome.

       

    79% had good to excellent result, 14% had a fair result and 9% had a poor result. The average knee society score was 87 [ at 10 years] and the average functional score was 56 [advanced age and infirmity]. The average knee society pain score increased significantly from 4 [pre-operatively] to 45 at 10 years. The mean ROM improved from 88% to 100%, walking distance improved from less than 500 m. to 500-1000 m. There were 9 revisions because of infection [n=5] aseptic loosening [n=4] for a cumulative survival rate at 92.3% at 10 years. Secondary patellar resurfacing was necessary in 8 patients with severe anterior knee pain. 3 had to undergo knee lateral release for patellar maltracking. 1 had a patellar tendon rupture repair, 6 had postoperative infection, one had a nonfatal pulmonary embolus. 4 had deep vein thrombosis. 1 had a stroke and 1 had a fracture of the posterolateral cortex of tibia. 7 patients had to be manipulated under anesthesia. 

       

    Radiographs of 104 knees were available for follow up. 10 tibial components showed radiolucent lines but none required revision. 

       

    The long term results of Insall-Burstein II total knee replacement orthroplasty are good with 90% , 10 year survival.

        

  • ElkinsRC, Knott-Craig CJ, Ward KE, et al [Univ of Oklahoma, Oklahoma City]

    The Ross Operation in Children : 10-Year Experience

    Ann Thorac Surg 65 : 496-502, 1998

       


    The Ross operation for aortic valve replacement in children has been performed for 30 years, but its widespread acceptance was delayed because of the procedure’s technical demands and the need to place 2 valves at risk. With modifications in operative technique, the Ross operation in now the operation of choice for children and young adults who require aortic valve replacement. Researchers reviewed the records of 150 consecutive patients to provide additional long-term follow-up of the Ross operation. There were 112 boys and 38 girls of median age 12 years. Primary diagnosis was aortic stenosis in 40, aortic insufficiency in 29, and a combination of both in 81. Most had undergone other procedures before the Ross operation.

       


    Eight-year survival was 97.3%. Six patients required reoperation with restitution of valve function and two with late dysfunction required a replacement procedure. At 8 years 90% were free of any dysfunction, 94% were free of any obstruction, and 89% were free of any gradient across the valve needing a reoperation. All patients had active lives unencumbered by the need to take any anticoagulants.

        


    The Ross operation in children has an excellent rate of success at a low risk. Valve related complications are not life threatening and long-term satisfactory valve function can be achieved.

        

  • D’Souza
    SJA, Tsai WS, Silver MM, et al [Univ of Toronto]

    Diagnosis and Management of Stenotic Aorto-Arteriopathy in Childhood

    J Pediatr 132: 1016-1022, 1998

       

    Patients with stenotic aorto-arteriopathy [SAA], an uncommon group
    of vascular diseases, have segmental stenoses of the aorta and its
    branches. The new common type is middle aortic syndrome,
    characterized by severe stenosis of the thoracic and abdominal
    aorta. The differential diagnosis includes mainly Takayasu Arteritis
    [TA] and fibromuscular dystrophy or other noninflammatory
    aortic-arterial diseases. An experience with the management of SAA
    in childhood is reviewed, including the results of several different
    management approaches.

        

    The 16-year experience included 14 children and adolescents with
    acquired SAA. There were 7 boys and 7 girls, aged 4 to 18 years.
    Most of the patients were asymptomatic, with hypertension noted at
    routine examination. Clinical findings included abdominal bruits in
    8, mixed absent/diminished and normal pulses in 8, and leg
    claudication in 4. On angiography, 13 showed involvement of the
    abdominal or descending thoracic aorta. A mid thoracoabdominal
    coarctation was detected in most patients. Eleven patients received
    a diagnosis of TA. It was difficult to distinguish TA from
    fibromuscular dysplasia on clinical or angiographic grounds.

         

    Treatment commenced with antihypertensive therapy. In patients with
    TA, prednisolone did not reverse aortic disease but it did worsen
    the hypertension. Six patients underwent percutaneous transluminal
    balloon angioplasty of renal artery stenoses, but the renal arteries
    restenosed. Renal autotransplantation – excision of the stenotic
    segment of the renal artery with reimplantation of the kidney on to
    the disease free renal artery – was performed in 5 patients. This
    provided temporary improvement in blood pressure in most patients;
    one patient had renal artery thrombosis with deteriorating renal
    function. Three patients underwent balloon angioplasty of the
    abdominal aorta with implantation of stents. In one case this was
    followed by open renal autotransplantation. There were 3 deaths.

        

    Thus diagnosis and management of SAA in children is a difficult
    problem, requiring multiple procedures, aimed mainly at preventing
    end-organ damage.

        

  • Knott-Craig
    CJ. Elkins RC, Lane MM, et al [Univ of Oklahoma, Oklahoma City].

    A 26-year Experience with Surgical Management of Tetralogy of Fallot : Risk Analysis for Mortality or Late Reintervention 

    Ann Thorac Surg 66: 506-511, 1989

        

    Since the early 1990s, the trend in correction of tetralogy of
    Fallot [TOF] has been toward primary repair and away from 2-stage
    repair. The results suggest that primary repair offers improved
    outcomes, although the long term effects on survival and recurrent
    right ventricular outflow tract disease remain unclear. A 26-year
    experience with TOF repair was reviewed to analyze effects of the
    trend toward early repair on early outcomes and recurrent right
    ventricle obstruction.

        

    From 1971 to 1997, 291 patients were operated for repair of TOF at
    the author’s institute; 68% had primary repair, 21% had a staged
    repair and the rest had palliative surgery only. The pathology was
    complex in 23% of patients, most often including pulmonary atresia.
    Follow-up information was available on 90% of the patients, with a
    median duration of follow-up nearly 11 years.

       

    The overall in-hospital mortality rates were 11% for primary repair,
    18% for staged repair and 16% for the rest. During the 1990s the
    mortality rates decreased to 2%, 12% and 0% respectively. After 1990
    the patients age at surgery was 0.6 years, compared with the earlier
    2 years. Significant risk factors for in-hospital death on
    multivariate analysis were hypothermic circulatory arrest, pulmonary
    artery patch angioplasty, earlier years of surgery, and closure of
    the foramen ovale.

       

    Among patients who survived to hospital discharge, the 20-year
    survival was 98% for those with TOF with pulmonary stenosis vs 88%
    for those with pulmonary atresia. Fourteen percent of patients
    required reoperation on the right ventricular outflow tract. The 20
    year rate of freedom from such intervention was 86% for patients
    with pulmonary stenosis vs 43% for those with pulmonary atresia.
    Among the latter group, the rate of freedom from reintervention was
    85% after primary repair vs 91% for those with staged repair.
    Patients less than one year were less likely to be free of
    reintervention, though the difference was not significant.

        

    The long-term retrospective study suggests that survival after
    primary repair of TOF has improved significantly over the years and
    even infants do well. Staged repair has to be reserved for patients
    with complex pathology only. 

                

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Speciality Spotlight

   

   
Surgery
   

 

Surgery
  

  • J. MacFie [ Scarborough Hospital, Wooldlands Drive, Scarborough YO12 6QL, UK]
    Enternal Versus Parenteral Nutrition
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1121-1122
      
    Artificial feeding is necessary in patients with malnutrition or for those whose oral intake is likely to be inadequate for more than seven days.
       
    Enternal feeding is preferred to the parenteral route. It is both cheaper and safer, more physiological, it preserves gut barrier. Parenteral feeding on the other hand may result in mucosal atrophy, bacterial translocation and increased ratio of sepsis. 
        
    Enternal nutrition may often fail to achieve targeted calorie requirements, as a consequence of poor tolerance [bloating, diarrhoea or high gastric aspirates]. The benefits are its effects on gastrointestinal flora, splanchnic blood flow and modulation of immune responses. These benefits may be offset by the invasive methods of enteral feeding [percutaneous gastrostomy and jejunostomy]. 
        
    TPN may lead to mucosal atrophy , bacterial translocation and increased sepsis. But though this has been shown in rodents, it has not been proved in humans.
        
    The results of a comparative study between enteral and parenteral nutrition need to be interpreted with caution. They should be considered in the context of overall morbidity.
        
    The increased septic morbidity with TPN, has been attributed to the increased energy intake and consequent hyperglycaemia rather than because of its route of administration; further this may be offset by the higher nutritional value. A recent review of 31 studies concluded that there is no consistent evidence that enternal feeding is associated with improved clinical outcome compared with TPN. 
         

  • L. Sarli, R. Costi, G. Sansebastiano*, M. Trivelli and L. Roncoroni [ Institute of General Surgery and Surgical Therapy and * Institute of Hygiene, Parma University School of Medicine, Parma Italy]
    Prospective Randomized Trial of Low-Pressure Pneumoperitoneum for Reduction of Shoulder-tip Pain Following Laparoscopy
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1161-1165
         
    The aim of this study was to evaluate the efficacy of low pressure carbon dioxide pneumoperitoneum during laparoscopy in reducing postoperative shoulder pain.
        
    90 patients were divided into 2 groups group A [n=46] had a 9 mmHg carbon dioxide pneumoperitoneum and group B [ n=44] had a 13 mmHg carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy. The shoulder tip pain was recorded on a visual analogue pain scale 1,3,6,12,24 and 48 hours after operation.
       
    11% of Group A patients had shoulder pain as opposed to 32% in Group B. Mean shoulder tip pain scores and analgesia requirements were also lower in group A. There were no differences in the duration or ease of surgery or complications in the two groups.
        

  • D. Ravichandran*, B.G. Kalambe and J.A. Pain [ Department of General Surgery, Poole Hospital, Poole and * Norfolk and Norwich Hospital, Norwich, UK]
    Pilot Randomized Controlled Study of Preservation of Division of Ilioinguinal Nerve in Open Mesh Repair of Inguinal Hernia
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1166-1167
     
    This study included 20 men with primary bilateral inguinal hernias undergoing open tension-free mesh repair. They were randomized for preservation or division of the ilioinguinal nerve. Patients were reviewed on day 1, 4 weeks and 6 months after operation. Any pain, numbness or anesthesia in the area supplied by the nerve were recorded.
     
    As significant difference was noted between the two groups. Sensory loss detected by clinical examination was more common following division of the nerve compared with preservation.
       

  • M. Kume, Y. Yamamoto, K. Yamagami, Ishikawa, H. Uchinami and Y. Yamaoka [ Department of Gastroenterological Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo, Kyoto 606-8507]
    Pharmacological Hepatic Preconditioning: Involvement of 70-kDa Heat Shock Proteins [HSP72 and HSP73] in Ischaemic Tolerance After Intravenous Administration of Doxorubicin
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1168-1175
      
    The aim of this study was to determine in an animal model, whether intravenous administration of doxorubicin induces heat shock proteins [HSPs] in liver tissue and subsequent warm ischaemia-reperfusion injury [IRI].
      
    Male Wistar rats were used. Production of HSPs was determined in liver tissue sequentially after injection of doxorubicin. [1mg/kg body weight]. Acquisition of tolerance for 30 min. warm ischaemia and reperfusion of the liver was determined in animals pretreated with doxorubicin. [48 hours beforehand] and in controls. Biochemical liver function and adenine nucleotide concentration 40 min after reperfusion and survival rate at 7 days after ischaemic insult were recorded.
      
    Expression of HSP72 and HSP73 in the liver was confirmed 48 hours after doxorubicin. Biochemical parameters and survival rate, were significantly better in pretreated animals than in controls.
         

  • N. Menezes, L.P.Marson, A.C. deBeaux, I.M. Muir and C.D. Auld[ Department of Surgery, Dumfries and Galloway Royal Infirmary, Dumfries, UK]
    Prospective Analysis of a Scoring System to Predict Choledocholithiasis
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1176-1181
     
    The aim of this study was to evaluate prospectively, a scoring system designed to improve the accuracy of common bile duct [CBD] stone prediction before laparoscopic cholecystectomy.
     
    Known risk factors [clinical, biochemical and radiological] for CBD stones were analysed retrospectively in 233 patients. The presence [n=77] or absence [n=156] of CBD stones was determined. Preoperative ERCP or laparoscopic cholangiography. Using multivariate analysis, of the risk factors a new pre-operative scoring system was developed. A score of 3 or more was taken as the cut off point to suggest CBD stones. The scoring system was then tested prospectively on 211 patients with gall stone disease.
     
    55 patients scored more than 3 points [predicted ERCP rate of 29%] of whom 23 [42%] had proven CBD stones. Intra-operative cholangiography was successful in 87%. 4% who scored less than 3 points had small [ less than 5 mm] stones demonstrated at operative cholangiography. The overall sensitivity and specificity of this scoring system were 82% and 80% respectively.
        

  • A.Weimann, H. Varnholt, H.J. Schlitt, H. Lang, P. Flemming*, C. Hustedt*, G. Tusch and R. Raab [ Klinik for Abdominal – und Transplantationschirurgie and * Pathologisches Institut, Medizinische Hochschule Hannover, Hannover, Germany]
    Retrospective Analysis of Prognostic Factors After Liver Resection and Transplantation for Cholangiocellular Carcinoma
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1182-1187
        
    This is a retrospective study of 162 patients [1978-1996] of cholangiocellular carcinoma who underwent liver resection and liver transplantation and exploratory laparoctomy with or without drainage. Univariate and multivariate analysis of prognostic factors were performed.
        
    Overall survival rate was 47% at 1 year, 28% at two years and 13% at 5 years.
       
    Resectable tumors had better survival rates [ 64%, 43% and 21% respectively ] and for those who underwent transplantation it was 21%, 8% and zero respectively. The following variables had an effect on survival age, jaundice, liver resection, TNM staging, tumour free margins, vascular infiltration, tumour number, size and serum levels of CEA. Jaundice, N and M category and UICC staging independent prognostic factors.
         

  • S. J. Pain and A.D. Purushotham [Cambridge Breast Unit, Addenbrooke’s Hospital, Cambridge , UK]
    Lymphoedema Following Surgery for Breast Cancer
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1128-1141
     
    Lymphoedema is a common complication of breast cancer treatment, affecting almost 25% of cases. It can cause discomfort, cosmetic and functional problems. It is prone to episodic superficial infections.
     
    A systematic review of all published literature on this problem using the Medline and Cinahl databases with cross -referencing of major articles upto 1999 was undertaken.
     
    The aetiology and pathology of this condition is multifactorial and still not fully understood. Although conservative treatment can be very successful in palliation, it does not afford a cure. The place of surgery and pharmacotherapy remains unclear. Improved understanding of pathophysiology may assist in reducing the incidence of this condition or help to identify high risk cases in whom early conservative treatment may prove effective.
         

  • M.S. Rodgers and J.L. McCall [ Department of Surgery, University of Auckland, Auckland, New Zealand]
    Surgery for Colorectal Liver Metastases with Hepatic Lymph Node Involvement: a Systematic Review
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1142-1155
     
    Liver resection for colorectal metastases is the only known treatment associated with long term survival. Extra hepatic disease is usually considered a contraindication to such treatment. Some surgeons feel that if these nodes can be adequately excised, this should not be considered a contraindication.
     
    A systematic review of literature was undertaken to address these problems [from 1964- 1999].
     
    15 studies were identified that gave data on 145 node positive patients. 5 patients survived 5 years after liver resection [ 1 was disease free, 2 had recurrent disease and in 2 the disease status was not mentioned]. 5 studies containing 83 patients specified a formal lymph node dissection as a part of the operation and four of the five node-positive 5-year survivors were from these group. The authors conclude that these are few 5 year survivors after liver resection with a without lymph node dissection for colorectal hepatic metastases.
        

  • C. Dervenis and C. Bassi [ First Department of Surgery, Konstantopoulion, Agia Olga Hospital, Athens, Greece and Department of Surgery, Pancreatic Unit, University of Verona, Verona, Italy
    Evidence-based Assessment of Severity and Management of Acute Pancreatitis
    BRJ Volume 87, No.3, March 2000, Pg.Nos. 257-258
      
    Acute pancreatitis is a potentially fatal disease, with reported mortality rates ranging from zero to almost 25 per cent, depending on severity.
       
    Severity itself depends greatly on whether or not pancreatic necrosis is present.
       
    Imaging is mandatory, preferably by a magnetic resonance method and, if a definitive diagnosis cannot be reached, all collections should be considered as localized necrosis until proven otherwise. 
       
    Obesity, indicated by a body mass index greater than 30, is a reasonably reliable predictor of severe outcome. 
       
    Assay of C-reactive protein is the only easily available blood test in clinical practice that is a proven discriminator of severe and mild disease, at a cut-off level of 150 mg/ml at 48h after the onset of symptoms.
       
    There is evidence that pleural effusion on an early chest radiograph, which is freely available as a routine test on admission, is probably useful in predicting complications and/or a fatal outcome.
      
    More sophisticated imaging, such as enhanced computed tomography [CT], is a proven indicator of pancreatic necrosis with almost 100 percent sensitivity between days 4 and 10.
      
    Thee is a consensus that the early restoration of circulatory volume and arterial oxygen tension reduces the risk of complications is this disease, but randomized studies have failed to show any benefit from antiproteases and antisecretory drugs on mortality rates. 
      
    There is probably a role for antibiotics in the prevention of complications related sepsis.
     
    Attention should be given to the increasingly encountered fungal infection of pancreatic necrosis secondary to the use of broad-spectrum antibiotics; fungal infection is associated with higher mortality rates.
      
    The role of early enteral nutrition should be considered, as recent randomized studies, although small, have shown a reduction in complications and probably in mortality rate. 
      
    There is strong evidence that urgent endoscopic sphincterotomy is to be recommended in patients with severe biliary pancreatitis with abnormal liver function; this includes patients with cholangitis.
      
    Surgical intervention has a peoven role when there are clinical signs of sepsis due to infected pancreatic necrosis. This may be diagnosed by the only reliable test, namely CT-guided fine-needle aspiration followed by Gram staining and culture of the necrotic material.
      
    There is no evidence in favour of surgery for patients with sterile necrosis.
          

  • T.M.D Hughes and A.J. Spillane [ Sarcoma Unit, Royal Marsden Hospital NHS Trust, Fulham Road, London SW3 6JJ, UK]
    Imaging of Soft Tissue Tumours
    BRJ Volume 87, No.3, March 2000, Pg.Nos. 259-260
       
    Magnetic resonance imaging [MRI] has become the standard for preoperative assessment of soft tissue masses but a review of the recent literature on the imaging of soft tissue tumours has shown that the best available evidence does not support the current paradigm of MRI superiority over contrast-enhanced computed tomography [CT].
      
    The claim that the introduction of MRI has made limb conserving surgery possible is also false. Limb salvage has, in reality, been made possible through a better understanding of the anatomical relationship amd oncological behaviour of these tumours with respect to neurovascular and proximal limb structures, the expanded role of 
    reconstructive procedures and the expert use of preoperative or postoperative radiotherapy.
      
    Errors in judgement arise particularly when peritumoral oedema is mistaken for tumour infiltration, resulting in overestimation of tumour extent.
      
    The claim that MI is superior for the evaluation of anatomical compartment and individual muscle involvement has bot been substantiated.
      
    The best available evidence is contrary to the commonly accepted wisdom that MRI is superior to CT in the assessment of soft tissue tumours.
      
    Imaging determines the site and extent of the lesion, along with the proximity of nearby structures. Clinical assessment by experienced specialists, appropriate biopsy and multidisciplinary review are together of at least equal importance in the management of these tumours.
          

  • T. Yamamoto and M.R.B. Keighley [Second Department of Surgery, Mie University School of Medicine, Tsu, Japan and University Department of Surgery, Queen Elizabeth Hospital Birmingham, UK]
    Smoking and Disease Recurrence After Operation for Crohn’s Disease
    BRJ Volume 87, No.4, April, 2000, Pg.Nos. 398-404
      
    There is increasing speculation about the role of smoking in the pathogenesis of inflammatory bowel disease.
       
    Approximately half of the patients were smokers at the time of operation. In most studies smoking significantly increased the risk of postoperative disease recurrence. Smokers had an approximately twofold increased risk of recurrence compared with non-smokers and the effect of smoking was dose dependent. The increased risk of recurrence among smokers was more prominent in women than in men, and a longer duration of smoking increased the risk of recurrence. Ex-smokers had a similar recurrence rate to non-smokers and giving up smoking soon after operation was associated with a lower probability of recurrence.
      
    Smoking significantly increases the risk of recurrence of disease after operation for Crohn’s disease, especially in women and heavy smokers. Encouraging patients to stop smoking is an important part of the management of Crohn’s disease.
         

  • J.R. Hardy [ Department of Palliative Medicine, Royal, Marsden Hospital, Downs Road, Sutton SM2 5PT, UK
    Medical Management of Bowel Obstruction
    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1281-1283
      
    Bowel obstruction is a relatively common complication of advanced malignancy, particularly in gynaecological and gastrointestinal cancers. The symptoms [ abdominal pain, constipation and vomiting] are most distressing for both patients and their carers.
     
    Surgery can provide valuable palliation in cancer -related bowl obstruction and no patient should be denied a surgical review.
     
    The alternative is symptom control with a range of drugs and medications, and the removal of many of the lines and tubes. 
       
    Considerable controversy surrounds the use of intravenous fluids in dying patients. One school claims that a patient’s fluid requirements reduce dramatically during the terminal phase, and that fluid administration does not prolong life and will only exacerbate problems of fluid retention, toileting, pulmonary secretions and the need for suctioning. Others claim that dehydration contributes significantly to drug toxicity, and to the confusion and agitation so often seen in dying patients.
       
    Diligent mouth care, mouth sponges, sucking ice and sips of fluid relieve thirst and provide comfort.
       
    The widespread application of the subcutaneous route for the delivery of most essential drugs has revolutionized palliative care practices.
      
    Eating is one of life’s great pleasures and to deprive a dying patient of this enjoyment seems harsh. Patients should be allowed to eat small amounts of low-fibre food and to drink as tolerated, if they wish, even if this results in the occasional vomit.
      
    Repeated observations, fluid balance monitoring, radiographs and other investigations are pointless when they are not likely to change management.
      
    The antiemetics most commonly used are levomepromazine, cyclizine or haloperidol. All may be given subcutaneously although none is licensed for delivery by this route.
        
    Pain associated with bowel obstruction is related both to abdominal distension and obstructed peristalsis causing ‘colic’. Diamorphine is the opioid of choice for delivery by the subcutaneous route.
     
    Antimuscarinucs [ e.g. hyoscine butylbromide] may be added for control of colicky pain either ‘as required’ by bolus dose or by a constant subcutaneous infusion.
     
    Dexamethasone is used commonly as an antiemetic and coanalgesic in palliative care.
      
    A short pulse of moderate dose dexamethasone [8 mg/day for 5 days] is generally well tolerated and worth a trial.
     
    Octreotide is a somatostatin analogue that reduces endocrine and exocrine secretion of the pancreas, stomach, and intestine; by decreasing gut mortility and secretions, it facilitates the absorption of water and electrolytes in the bowel.
       
    The development of long-acting somatostatin analogues given monthly by intramuscular injection may facilitate hospital discharge but the high cost of such drugs may be prohibitive.
          

  • I. I.Lindsey, R.J. Guy. B.F. Warren and N.J. McC. Mortensen [ Departments of Colorectal Surgery and Cellular Pathology, John Radcliffe Hospital, Oxford UK ]
    II. Anatomy of Denonvilliers’ Fascia and Pelvic Nerves, Impotence and Implications for the Colorectal Surgeon
    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1288-1299
       
    Denonvilliers’ fascia has no macroscopically discernible layers. The so-called posterior layer refers to the fascia propria of the rectum. The incidence of erectile and ejaculatory dysfunction after rectal excision is high in older patients, and when performed for rectal cancer.
      
    Colorectal surgeons should focus on the important anatomy between the rectum and the prostate to improve functional outcomes after rectal excision.
      
    In 1836 Denonvilliers reported his discovery of a ‘prostatoperitoneal’ membranous layer between the rectum and seminal vesicles. 
      
    In 1993, Richardson elegantly demonstrated a dense double layer of elastin in the rectogenital septum on electron micrography, adding further weight to the concept of peritoneal fusion.
      
    Although Denonvilliers’ original description gave no account of the presence of such a membrane in a female, there is a little doubt that the rectovaginal septum is the female counterpart, and is a normal, constant structure.
      
    Surgical appearance of the fascia at operation varies considerably, from a fragile translucent layer to a tough leathery membrane.
      
    Histologically, Denonvilliers’ fascia is composed of dense collagen, smooth muscle fibres and coarse elastic fibres. It is related to the prostate and seminal vesicles anteriorly, and to the rectal wall, the thin anterior mesorectum and the fascia propria posteriorly.
      
    Goligher described the fascia as being more closely adherent to the rectum than to the prostate.
      
    A recent histological study suggests that Denonvilliers’ fascia is more closely adherent to the prostate.
      
    Nervi Erigentes
      
    The pelvic parasympathetic [splanchnic] nerves [nervi erigentes] arise from the sacral roots of S2, S3 and S4. They pierce the endopelvic fascia from behind to enter the plane of the pelvic plexus. The pelvic parasympathetics join the sympathetic hypogastric nerve in a Y-shaped connection to form the pelvic plexus.
      
    Radical prostatectomy has, until recently, rendered most patients impotent.
      
    Impotence resulted from damage to the cavernous nerves, either at the lateral pedicles or when dividing the urethra.
      
    These authors drew three main anatomical conclusions. 
      
    First, a prominent neurovascular bundle is located at the posterolateral border of the apex and base of the prostate. The visible nerves in this bundle branch to give rise to the microscopic cavernous nerves.
      
    Second, the neurovascular bundles are consistently found in the leaves of the lateral pelvic fascia outside the prostatic capsule, at the lateral edge of denonvilliers’ fascia. The bundles and prostatic capsule are separated by only 1.5-3 mm at the base and apex of the prostate respectively.
      
    Third, the nerves in the neurovascular bundles are intimately associated with vessels. These vessels provide a visible landmark to identify the bundles and are generally oriented lateral to the nerves.
       
    The technique of ‘nerve-sparing’ radical prostatectomy evolved as a modification of the original procedure in the light of the above findings.
      
    The risk to potency occurs during rectal dissection, as the pelvic autonomic nerves are intimately related to the rectum.
      
    Sexual dysfunction after pelvic surgery is characterized by erectile dysfunction or impotence, and ejaculatory dysfunction. Impotence may be partial or complete, temporary or permanent. Ejaculatory dysfunction consists of absent ejaculation, retrograde ejaculation and painful ejaculation.
       
    Age is important factor. It is known that the incidence of impotence increases with age;
       
    Permanent impotence in men occurs in 17-100 per cent of cases after abdominoperineal excision of rectum [APER] and in 0-49 per cent after anterior resection of rectum [AR] for rectal cancer.
      
    The rate of impotence after radical excision for inflammatory bowel disease is lower than that after excision for rectal cancer.
      
    There is poorer understanding of postoperative sexual dysfunction in women.
      
    A few studies have addressed neurological damage as a cause of problems such as inability to attain orgasm, and reduced vaginal sensitivity and lubrication, but the dysfunctional outcomes of pelvic nerve damage in women corresponding to those in men that produce erectile and ejaculatory dysfunction are poorly understood. 
      
    The incidence of permanent bladder denervation after rectal excisional surgery ranges from 0 to 19 per cent.
       
    It appears that bladder dysfunction is more likely after APER than after AR.
      
    Primary radiotherapy for localized prostate cancer causes impotence in 5-40 per cent of patients.]
      
    Sites of Risk of Nerve Damange
    Four key zones exist, one in the abdomen and three in the pelvis.
      
    Inferior Mesenteric Artery Origin
    The risk in the abdomen occurs during ligation of the pedicle of the inferior mesenteric artery, particularly if this is done flush at the aorta. The purely sympathetic hypogastric nerves are vulnerable here.
      
    Posterior Dissection
    Anatomical dissection of the rectum is carried out in the loose areolar connective tissue immediately outside the fascia propria, and the nerves lie just outside this plane.
       
    The damage is purely sympathetic at this level as the nervi erigentes have not yet joined the bundle.
      
    Lateral Dissection
    Straying laterally out of the mesorectal plane may injure the pelvic plexus, particularly if excess traction is placed on the rectum, tenting the plexus superiorly and medially. 
      
    The pattern of nerve damage here and beyond the pelvic plexus tends to be mixed sympathetic and parasympathetic.
      
    Anterior Dissection
    The third pelvic zone of risk is during anterior rectal dissection. There is a very narrow space between the rectum and the prostate and seminal vesicles.
      
    This is probably where most parasympathetic nerve damage occurs, and may explain why impotence is more common the deeper the pelvic dissection goes [high AR versus low AR versus APER].
       
    The anterior plane of dissection may not necessarily be the same plane in which the posterior and lateral dissection is conducted.
     
    There is evidence now that close rectal dissection does not protect the pelvic nerves any more than mesorectal dissection.
      
    The mesorectal plane is the appropriate anterior plane for most rectal cancers.
      
    Conclusion
    Denonvilliers’ fascia arises from the fusion of the two walls of the embryological peritoneal cul-de-sac and extends from the deepest point of the rectovesical pouch to the pelvic floor.
      
    There is no so-called ‘posterior layer’of Denonvilliers’ fascia. 
      
    The ‘posterior layer’ is, in fact, the fascia propria of the rectum.
      
    Dissection between the ‘two layers’ of Denonvilliers’ fascia is really a dissection between the fascia propria of the rectum, containing the mesorectum, and the true Denonvilliers’ fascia covering the prostate and seminal vesicles.
          

  • M.K. Baig and S.D. Wexner [ Department of Colorectal Surgery, Clevaland Clinic Florida, 3000 West Cypress Creek Road, Fort Lauderdale, Florida 33309, USA ]
    Factors Predictive of Outcome After Surgery for Faecal Incontinence
    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1316-1330
      
    Surgical treatment of feacal incontinence may be categorized into procedures that either repair or augment the native sphincter mechanism or, alternatively, require construction of a neosphincter using either autologous tissue or an artificial device.
      
    Procedures such as postanal repair, direct sphincter repair and reefing are seldom used.
      
    Overlapping repair has become the operation of choice in incontinent patients with isolated anterior defects in the external anal sphincter muscle, particularly in postobstetric trauma.
      
    Total pelvic floor repair has been offered as a recent alternative. Neosphincter procedures include a gluteoplasty, non-stimulated and stimulated unilateral or bilateral graciloplasty and artificial bowel sphincter.
      
    The newest alternative, sacral nerve stimulation, seems promising. In the final analysis, case selection and surgical judgement are probably the most important factors influencing the success of surgery for feacal incontinence.
         

  • G.Zeitoun, A. Laurent, F. Rouffet, J-M. Hay, A. Fingerhut, J.-C. Paquet, C. Peillon and the French Associations for Surgical Research
    Multicentre, randomized Clinical Trial of Primany Versus Secondary Sigmoid Resection in Generalized Peritonitis Complicating Sigmoid Diverticulitis
    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1366-1374
       
    The best way to manage generalized peritonitis complicating sigmoid diverticulitis is controversial.
      
    Postoperative peritonitis occurred less often after primary than secondary resection. 
      
    The mortality rate did not differ significantly with regard to operative policy. 
       
    No patient died following a second or third procedure. 
      
    Primary resection is superior to secondary resection in the treatment of generalized peritonitis complicating sigmoid diverticulitis because of significantly less postoperative peritonitis, fewer reoperations and shorter hospital stay.
      
    Operative Protocol
    A midline incision was used. Peritoneal fluids were routinely cultured. Treatment of peritonitis included clearance of pus, faeces, exudate and as much debris and pseudomembraneous material as possible, followed by lavage of the abdominal cavity with 6 litres of warm saline whenever possible [but never less than 2 litres]. Antiseptic solution such as povidone-iodine was added or not according to the surgeon’s preference.
      
    Operative Procedures
    For patients allocated to primary resection, the surgeon was free to choose one of the two following options once sigmoid resection was completed. [1] end colostomy or [2] primary colorectal anastomosis protected or not by a diverting colostomy. A second procedure was necessary either to perform colorectal anastomosis or Hartmann reversal, protected or not by a diverting colostomy, or to close the initial colostomy.
        
    For patients allocated to secondary resection, the perforation of the sigmoid was closed by sutures whenever visible and feasible, and a diverting colostomy was constructed. A second procedure was necessary to resect the sigmoid colon and perform the colorectal anastomosis, protected or not by a diverting colostomy.
       
    Both surgical approaches included : [a] pelvic drainage during the first procedure; [b] clearing the rectum of faecal matter at the end of the first procedure whenever possible; [c] removal of the distal limb of the sigmoid colon and proximal rectum when resection was performed. And [d] mobilization of the splenic flexure as required for tension-free anastomosis.
         

  • J.P. Daniels, M.J. Lamparelli, H. Chave and J.N.L. Simon [ Department of Surgery, St. Richard’s Hospital, Royal West Sussex NHS Trust, Chichester PO19 4SE, UK]
    Recurrent Sigmoid Volvulus Treated by Percutaneous Endoscopic Colostomy
    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1419
       
    Sigmoid volvulus is a life-threatening condition which often occurs in elderly patients with physical and mental illness.
      
    If the sigmoid colon is ischaemic, emergency resection is the only treatment option and is associated with a mortality rate of up to 33 per cent.
      
    Elective open or laparoscopic fixation or resection may be inappropriate or unsafe in frail and elderly patients.
       
    Percutaneous endoscopic colostomy may provide a safe and effective treatment option in recurrent sigmoid volvulus in selected patients.
      
    Following standard bowel preparation and intravenous administration of cefuroxime 750 mg, metronidazole 500 mg and midazolam.
      
    A colonoscope is passed into the proximal sigmoid colon. With good transillumination a 14-Ch gastrostomy tube [Freka, Frenius, Warrington, UK] is placed under local anaesthesia using a standard percutaneous gastrostomy technique.
      
    The procedure is repeated in the distal sigmoid colon, bringing the second tube through the abdominal wall as far from the first as possible to anchor the sigmoid colon to the anterior abdominal wall in two places.
      
    Patients may eat and drink immediately and are discharged as soon as domestic circumstances allow, with an information leaflet on care of the tubes for the patient or carer.
      
    There were no deaths associated with the procedure or from sigmoid volvulus.
      
    There were no septic or other complications.
      
    Percutaneous endoscopic colostomy, under intravenous sedation and local anesthesia, is a safe and effective treatment for recurrent sigmoid volvulus, particularly in patients in whom conventional surgery is considered unsafe.
       
    No recurrence has occurred in patients in whom tubes have been left in situ. The Mic-Key tubes, with a flat external flange, have caused no problems, have proven acceptable to patients and carers, and have been easily changed when necessary.
         

  • A.J. Malouf, A.W. Murray and A.B. MacGregor [ Department of Surgery, The Royal Infirmary, Edinburgh, UK]
    Major Intra-Abdominal Pathology Missed at Laparoscopic Cholecystectomy
    BRJ, Volume -87, Number 10, October, 2000, Pg.Nos. 1434-1435
      
    Laparoscopic cholecystectomy has been shown to be an effective and safe treatment for symptomatic cholelithiasis.
        
    There have, however, been reports of serious intraabdominal disease present, but not identified, at the time of operation. Resultant delay in diagnosis often necessitates further surgical intervention, and in cases of malignancy may affect potential curability.
      
    Missed malignant primary lesions have included the colon, pancreas, stomach and lower esophagus.
      
    The commonest reported missed benign disorder has been that of Crohn’s disease.
      
    All patients had preoperative intermittent upper abdominal pain, some being colicky in nature, with persisting unaltered symptoms after operation. All had cholelithiasis documented before operation on ultrasonography and confirmed at operation, and histological evidence of chronic cholecystitis in surgical specimens.
       
    Although accepted as the treatment of choice for symptomatic cholelithiasis, a potential disadvantage of laparoscopic cholecystectomy is the lost ability to palpate the abdominal organs which the formal laparotomy of open cholecystectomy previously allowed. This may result in failure to identify concurrent intra-abdominal pathology producing symptoms attributed to cholelithiasis which led to operation in the first place.
      
    Symptoms frequently attributed to gallstones are not specific to biliary pathology, and sonographic evidence of cholelithiasis on investigation does not necessarily confirm a causal relationship.
      
    Patients should be selected carefully for laparoscopic cholecystectomy on the basis of a typical biliary history in the presence of documented cholelithiasis, and supportive clinical and biochemical findings.
      
    Persistence of symptoms after operation suggests that gallstones identified before operation were incidental, and that preoperative symptoms were related to the underlying tumors.
      
    It also highlights that, if symptoms for which laparoscopic cholecystectomy was performed, do not resolve, patients should be reviewed carefully and reinvestigated to exclude a missed diagnosis.
      
    Diagnostic laparoscopy yields positive findings in up to 76 per cent of patients when evaluating chronic abdominal pain and is effective in the diagnosis, staging and exclusion of intra-abdominal malignancy. If applied routinely during laparoscopic cholecystectomy it may help overcome potential limitations caused by loss of visceral palpation. 
      
    Although the expected pick-up of concurrent major intra-abdominal pathology would be low, it would be a useful intraperative routine at the time of laparoscopic cholecystectomy.
         

  • Professor J.E.J. Krige of Cape Town, South Africa
    Liver Fracture and Bleeding
    BRJ, Volume -87, Number 12, December, 2000, Pg.Nos. 1615
      
    At laparotomy for blunt abdominal trauma a surgeon in a district general hospital encounters a fractured bleeding liver. How should the problem be handled?
      
    The surgeon who unexpectedly encounters a major liver injury during a laparotomy for trauma will need to make several rapid critical decisions. The objectives are self evident and clear: stop the bleeding by the simplest means possible, remove devitalized liver tissue, and suture damaged blood vessels and bile ducts.
      
    The surgeon has a variety of options to control liver bleeding.
      
    The choices include diathermy or argon beam coagulation, the use of topical agents such as fibrin glue or Surgical [Ethicon, Livingstone, UK] [ for superficial injuries], inflow occlusion of the portal triad [Pringle manoeuvre], liver packing, hepatorrhaphy, hepatotomy and direct vascular suture, resectional debridement, partial or anatomic resection, and total hepatic vascular isolation with venovenous pypass.
      
    The level of intervention will ultimately be influenced by the surgeon’s experience, local resources and the facilities available. The key is to use the most effective yet simplest option for a specific situation.
      
    The greatest immediate threat is exsanguination. The absolute priority is rapid control of bleeding.
      
    The fracture is closed by manual compression and tamponade maintained by packs and pressure. This may be supplemented by inflow occlusion [Pringle manoeuvre] using an atraumatic vascular clamp across the portal triad.
      
    Pack pressure is maintained until the anesthetist has fully restored intravascular volume. Premature attempts to evaluate the extent of the injury and mobilize the liver before adequate resuscitation may lead to catastrophic blood loss with ensuing hypotension, coagulopathy, acidosis, hypothermia and unnecessary death.
      
    These potential effects should be anticipated and countered by providing warm intravenous solutions, the freshest possible blood, fresh frozen plasma, platelets, cryoprecipitate, a raised ambient theatre temperature and correction of metabolic abnormalities.
      
    If bleeding has stopped after careful pack removal and release of inflow controls, the surgeons should do no more. If bleeding persists, adequate exposure and a clear view of the injury become essential.
      
    Intermittent inflow release and effective suction allow identification of deeper bleeding sites which are controlled by direct suture, ligation, parenchymal suture or a mattress liver suture.
      
    If bleeding is not controlled by portal triad occlusion, major vena cava injury or atypical vascular anatomy is likely.
      
    Resectional debridement implies removal of non-viable liver bordering an injury. Anatomic resection performed through conventional anatomic planes unrelated to the lines of fracture is seldom necessary,
      
    For the surgeon encountering a major liver injury in a district hospital, perihepatic packing should be the first option when lesser procedures do not control bleeding. 
      
    If packing controls the bleeding, no further intervention is necessary. The packs are left in place, the abdomen is closed and definitive treatment deferred until a surgeon who can perform the required surgery is available or the patient can be transferred to a major trauma or hepatobiliary centre.
      
    Even for experienced surgeon, if bleeding is controlled, discretion and packing may be the better part of valour. 
      
    Other factors also influence the decision to pack. If the patient is acidotic [pH below 7.2], hypothermic [body temperature below 320C], coagulopathic or has had a massive transfusion [more than 10 units of blood], the liver should be packed, the abdomen closed and the patient returned to the intensive care unit. Blood volume is restored, the patient warmed, and the acidosis and coagulation defects corrected. 
      
    The technique of perihepatic packing is important. Sufficient packs should be used to provide effective uniform pressure. In this hospital a ‘six pack’ is generally used.
      
    Intra-abdominal pressure should not exceed the critical limit of 25mmHg. An important practical point is to avoid intrahepatic packing because packs forced into deep liver fractures aggravate the injury by increasing the size of the rent and holding it open, as well as tearing small hepatic veins.

    Further intervention may be formidable, requiring sophisticated equipment, and expert anesthesia, surgery and intensive care.
          

  • D.A. Niriella and K.I. Deen [ Academic Department of Surgery, North Colombo General Hospital and University of Kelaniya, Sri Lanka]
    Neosphincters in the Management of Faecal Incontinence
    BRJ, Volume -87, Number 12, December, 2000, Pg.Nos. 1617-1628
       
    The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence.
      
    Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres.
      
    The social and personal stigmas associated with the condition cause silent suffering and deterioration in quality of life.
      
    Surgical intervention is one of many therapeutic options.
      
    Patient selection is important to avoid disappointment. Only some forms of faecal incontinence are amenable to neosphincter reconstruction undertaken in those who have failed to improve on conservative treatment or previously failed to benefit from sphincter or pelvic floor repair.
      
    Surgical methods for treating faecal incontinence include either direct or overlapping sphincter repair for traumatic lesions, obstetric damage or iatrogenic sphincter injury in which pudendal nerve function is intact.
      
    Postanal repair or pelvic floor repair may be undertaken for anatomically intact but poorly functioning sphincters due to pudendal neuropathy.
      
    The principle of anal sphincter substitution involves the use of biological material or artificial mechanical devices to fashion a neosphincter around the non-functioning anal canal.
      
    The later discovery of the possibility of improving fatigue resistance in a muscle such as gracilis by electrical stimulation led to revival of muscle wrap techniques and the development of dynamic graciloplasty.
      
    Dynamic graciloplasty involves the release of the gracilis muscle from its distal attachment to the tibia and the creation of a muscle wrap around the native or artificially constructed anal canal in an a,g or S configuration, with attachment of the gracilis tendon to one of the ischial tuberosities.
      
    Occasionally both gracilis muscles may be transposed around the anal canal in this fashion [double -wrap graciloplasty].
      
    The transposed muscle is then subjected to electrical stimulation to bring about the desired muscle fibre transformation from predominantly type II [fatiguable] to type I [fatigue resistant] muscle.
      
    The purpose of neoanal sphincter construction is to achieve anal canal closure, usually a function of the internal anal sphincter, and to maintain voluntary closure of the anal canal, a function of the striated muscle component. Low frequency electrical stimulation converts type II muscle fibres, found in the gracilis, to type I muscle fibres which are fatigue resistant and thus stimulate internal anal sphincter function.
      
    The advantage of using gracilis as a neosphincter is that its loss does not result in a functional deficit in the lower limb after transposition. The use of two gracilis muscles may be an advantage. 
      
    Artificial sphincters are useful in managing faecal incontinence of neuromuscular origin, such as myasthenia gravis or diabetic neuropathy. Infection is a problem that requires removal of the prosthesis .
      
    However, both types of neosphincter operation are associated with morbidity; postoperative infection and impaired evacuation are predominant.
         

  • N.A. Roche and A.E. Young [ Department of Surgery, S. Thomas’ Hospital, London SE1 7EH, UK
    Role of Surgery in Mild Primary Hyperparathyroidism In the Elderly
    BRJ, Volume -87, Number 12, December, 2000, Pg.Nos. 1640-1649
      
    It is clear that elderly patients present with a different spectrum of problems, particularly indistinct neuropsychiatric and musculoskeletal symptoms, and these are likely to be improved by surgery. The evidence allows the conclusion that the truly asymptomatic elderly patient can be successfully managed conservatively.
      
    Management of primary hyperparathyroidism [HPT] in the elderly, particularly in relation to the role of surgery in the asymptomatic or minimally symptomatic patient.
      
    A diagnosis of primary HPT in an asymptomatic patient did not in all cases mandate referral for operation.
      
    Indication for surgery in asymptomatic patients with hyperparathyroidism-
      
    Serum calcium concentration greater than 0.25-0.4mmol/l above the normal range.
      
    Creatinine clearance reduced by 30 per cent compared with age matched controls, in the absence of other causes.
     
    24-h urinary calcium concentration greater than 400 mg/dl.
      
    Bone mass more than two standard deviations below that of age, sex, and race-matched controls.
      
    Age less than 5o years.
      
    Patients who request surgery or for whom long-term surveillance is unsuitable.
      
    The peak incidence of primary HPT lies between the ages of 55 and 70 years.
      
    The clinical problem is the sheer volume of such elderly patients with mildly raised calcium levels but who have symptoms. Such symptoms are often vague and may or may not be related to HPT, for example bone pain, lethargy, mental disturbance and constipation, all of which are common in the elderly.
         
    The obvious cause of the increased risk of death was cardiovascular disease.
     
    Both parathyroid adenoma weight and preoperative serum calcium levels were shown to be related to the risk of death.
      
    Current opinion is that the fit, young patient should be operated on, even if asymptomatic.
      
    In severe HPT, bone resorption and formation are greatly increased. Focal subcortical erosions and cystic lesions develop as a result of increased osteoclast activity and often act as sites for fracture.
      
    Fatigue, anxiety, lassitude, failing memory and concentration difficulties have all been reported in HPT.
      
    They are also symptoms that are common in the elderly and may be misinterpreted as part of the ageing process, making it difficult to determine whether elderly patients with hypercalcaemia are indeed symptomatic.
      
    Cervical exploration for primary HPT is successful in over 90 per cent of cases, with very low morbidity and mortality rates. HPT occurs more frequently in elderly patients, their symptoms may be difficult to distinguish from those of the general ageing process. 
      
    The most frequently improved symptoms in the older group were fatigue [50.0 per cent], muscular weakness [48.6 per cent] and joint pain [40.9 per cent].
      
    It is clear, as a result of routine serum biochemistry, that primary HPT is nowadays a different clinical entity from that which was originally described. The classical symptoms of renal and bone disease are rarely present, and many of the patients diagnosed are classed as asymptomatic.
       
    Elderly patients with primary HPT present more often with indistinct psychiatric and musculoskeletal symptoms and these are the symptoms most likely to be improved by operation.
      
    Surgery therefore has a definite and constructive role to play in the management of the elderly patient with symptomatic or even mildly symptomatic HPT, but such patients should be warned that, although the operation is safe, the benefit is unpredictable.
          

  • Wang PTH, Bonavita JA, DeLone FX Jr, et al [Crozer-Chester Med Ctr, Upland,Pa]
    Ultrasonic Assistance in the Diagnosis of Hand Flexor Tendon Injuries
    Ann Plast Surg 42: 403-407, 1999
       
    This study examines the contribution of ultrasonography to the diagnosis of flexor tendon injuries.
       
    Eight patients were studied, clinically there was inability to flex the finger. Evaluation was performed using an ATL-HDI-3000 US unit with a high -resolution 5- to -9 MHz hockey stick linear probe. Real-time flexor tendon manipulation was performed to stimulate the patient’s symptoms. These findings were compared with the operative findings.
       
    3 cases of flexor digitorum profundus tendon rupture were diagnosed by USG. These injuries resulted from forceful extension, penetrating injury, delayed rupture 3 weeks after previous repair respectively. In all 3 cases the US findings were confirmed at surgery. In the remaining 5 cases [forceful extension, penetrating trauma, phalangeal fracture and crush injury]. The US showed the tendons to be intact; at operation, in 3 cases these findings were confirmed. 
       
    The authors conclude that US is a useful diagnostic tool for clinically equivocal flexor tendon injuries.
          

  • Drape J-L, Tardif-Chastenet de Gery S, Silbermann-Hoffman O, et al [ Hopital Cochin, Paris; Hopital Bichat, Paris]
    Closed Ruptures of the Flexor Digitorum Tendons: MRI Evaluation
    Skeletal Radiol 27: 617-624, 1998
     
    This study evaluates the role of MRI in the diagnosis and management of closed flexor digitorum tendon ruptures.
      
    10 patients [7 male, 3 female mean age 48.5 years] with suspected closed ruptures of FDT underwent preoperative MRI of the hand with T1 weighted spin-echo sequences, 3-D gradient-echo images, and curved reconstructions to examine the FDT. The level of rupture, the gap between the tendon ends and the position of the proximal end of the tendon were then compared between MRI and operative findings.
      
    MRI indicated 12 FDT ruptures, FDP alone 4 cases, FDP +FDS rupture 3 cases, and FDS alone 2 cases, and FDL alone 2 cases. These findings were confirmed at surgery. The level of rupture, the gap between the tendon ends correlated well with operative findings; further, MRI could detect tendinitis in 3 adjacent tendons. 
      
    The authors conclude that MRI can accurately identify the level of tendon rupture and the gap between the tendon ends and is useful in the diagnosis and management of tendon ruptures.
         

  • Gabl VM, Lener M, Pechlanner S, et al [ Universitatsklinik fur Unfallchirurgie, Innsbruck, Germany; Institut fur Magnetresonanztomographie und Spektroskopie, Innsbruck, Germany]
    Closed Traumatic Rupture or Overuse Syndrome of the Flexor Tendon Pulleys? Early Diagnosis by MRI [German]
    Handchir Microchir Plast Chir 28: 317-321, 1996
      
    This study examines the efficacy of MRI for the diagnosis of closed injuries to the flexor tendon pulleys.
      
    18 rock climbers with recent injuries were studied. 8 [overuse injuries] were treated conservatively along with [short pulley ruptures]. 2 patients with long pulley ruptures were operated [tendon grafting]. They were followed up for 36 months.
       
    An MRI was done in all cases for diagnosis. Bowstringing or flexion contracture after treatment was not clinically detectable in any patient. All but 1 patient had nearly normal range of movement. Lasting swelling was the only clinical feature of partial instability. MRI was able to detect minor bowstringing and scars in most patients.
       
    They conclude that MRI was useful in detecting the presence and extent of pulley injury.
        

  • Failla JM, Jacobson J, van Holsbeeck M [Henry Ford Hosp, Detroit]
    Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/Dislocations
    J Hand Surg [Am] 24A: 257-266, 1999
     
    This study evaluates the usefulness of ultrasonography in the diagnosis of torn interosseous membrane [10M] in forearm fractures/dislocations.
       
    US was performed transversely on 2 cadaver forearms with intact IOM and again to confirm transection after 10M was transected in 1 forearm. Then US was performed in 2 Galeazzi fracture-dislocations 1 Essex-Lopresti injury were and compared with findings at operation. The authors conclude that US is a useful modality to diagnose and locate a torn IOM allowing primary repair to be performed.
         

  • Wallace AL, Haber M, Sesel K, et al [ Prince of Wales Hosp, Sydney, Australia; IIIawarra Private Hosp, Wollongong, Australia]
    Ultrasonic Diagnosis of Interosseous Ligament Failure In Radioulnar Dissociation
    Injury 30: 59-63, 1999
      
    Complex fractures of the elbow can be difficult to diagnose – thus “radioulnar dissociation is sometimes accompanied by interosseous ligament failure. This study used ultrasonography to make a diagnosis of I0M tear with comminuted radial head fracture. They feel that US imaging to an unexpensive, safe and readily available modality for obtaining images at baseline and throughout the healing process and for detecting occult injury of the interosseous ligament.
         

  • Wolf JM, Weiss A-PC [Brown Univ, Providence, RI]
    Portable Mini-fluoroscopy Improves Operative Efficiency In Hand Surgery
    J Hand Surg [Am] 24A: 182-184, 1999
      
    This study compares the use of traditional radiographic confirmation versus mini-fluoroscopy in a paired, retrospective cohort case study.
       
    30 patients underwent closed reduction or internal fixation of phalangeal shaft fractures or metacarpophalangeal or inter-phalangeal joint fusions. Standard intraoperative and lateral radiographs were used in 15 procedures and portable mini-fluoroscopy in the other 15 procedures.
       
    The minifluoscopy reduced operative time by 55% in phalangeal fractures by 39% in wrist fusion and by 48% in the in-situ 4 corner fusion.
       
    They conclude that mini-fluoroscopy is a safe effective and efficient modality in the tested surgical procedures.
            

  • Turgeon TR, MacDermid JC, Roth JH [Univ of Western Ontario, London; St Joseph’s Health Centre, London, Ont]
    Reliability of the NK Dexterity Board
    J Hand Ther 12: 7-15, 1999
      
    This study evaluates the reliability of the NK dexterity test as a part of a comprehensive computerized hand evaluation system.
        
    37 volunteers [24 women and 13 men] were tested on the NK dexterity board on 2 separate occasions. On each occasion individuals moved small, medium and large objects in 3 separate tests and separately with each hand.
       
    Most complained of arm or forearm fatigue, and had difficulty with threading the medium and large screw-type objects. Intraoccasion intraclass correlation coefficients [ICCs] [n=12; 3 tests x 2 hands x 2 occasions] were fair in half of the comparisons and excellent in the other half. Reliability was better in the dominant hand. ICCs for tests involving small medium objects were fair but for large objects were excellent.
     
    They conclude that although the NK dexterity board has fair-to-excellent reliability, there is a room for improvement. Suggestions made for improving the insrumentation include adding a steel lining to the plastic receptacle of the small steel screw, changing the T-shaped object in the medium sized test from aluminum to steel reducing the length of threading on the large screw object, and establishing a method to lubricate the large screw object.
     
    Nonetheless, this board has several advantages including its ability to test a wide variety of gross and fine movements, a computerized recording system that reduces operative error and normative data in the software for comparison based on age and sex.
         

  • Marx RG, Bombardier C, Wright JG [Univ of Toronto]
    What do we Know About the Reliability and Validity of Physical Examination Tests Used to Examine the Upper Extremity?
    J Hand Surg [Am] 24A: 185-193, 1999
      
    For a physical examination to be useful each test must be reliable and valid. A review was made of the reliability and validity of commonly used physical examination tests for disorders of the upper extremity.
       
    Relevant articles from literature, standard tests and fro consulting experts, were reviewed and analyzed separately from the point of the impairment of function and diagnosis.
      
    The tests for range of motion and strength testing were considered reliable. The tests used to diagnose upper extremity disorders like carpal tunnel syndrome and rotator cuff tendinopathy have varying degrees of validity. Overall, there is sparse evidence regarding the reliability and validity of physical examination for the upper extremities both from the point of diagnosis and impairment of function.
      
    It is therefore recommended that these tests not be used in isolation. It is important that the properties of each test be documented, so clinicians may reliably and accurately examine patients.

  • Oxford GE, Jonsson R Olofsson J, et al [Univ of Florida, Gainesville; Univ of Bergen, Norway; Haukeland Univ. Hosp, Bergen, Norway; et al]
    Elevated levels of Human Salivary Epidermal Growth Factor After Oral and Juxtaoral Surgery
    J Oral Maxillofac Surg 57: 154-158, 1999, Pg.133

    Saliva provides a natural reservoir of growth factors. Salivary epidermal growth factor concentrations were increased within 24 hours after surgery. Surgery also stimulates increased synthesis and secretion of growth factors in saliva. Increased concentrations of saliva-derived growth factor may help promote wound healing.

    We have all seen animals cleaning their wounds by licking – and it works. Additionally, we know how quickly oral wounds heal, seemingly after a slow initial period, with a subsequent rapid recovery.

  • Santler G, Karcher H, Ruda C, et al [Univ Clinic for Dentistry, Graz, Austria]
    Fractures of the Condylar Process : Surgical Versus Nonsurgical Treatment
    J Oral Maxillofac Surg 57: 392-397, 1999, Pg.150

    Improved materials for osteosynthesis, including Kirschner wires, wires, miniplates and lag screws has made open surgical treatment more promising. 

    Patients treated nonsurgically were treated by maxillomandibular fixation [MMF] or without MMF. 

    Patients treated surgically or nonsurgically had no significant difference in mobility, joint problems, occlusion,and muscle pain or nerve disorders.

    Minimally invasive therapy for condylar process fractures remains the method of choice. 

    Condylar mandible has a tremendous capability for reparation, self-reconstruction, and remodeling. 

  • Fitzpatrick RE (Univ of California, San Diego)
    Treatment of Inflamed Hypertrophic Scars Using Intralesional 5-FU
    Dermatol Surg 25: 224-232, 1999
         
    Hypertrophic scars and keloids are causes by a variety of injuries to skin.

    Intralesoinal injections of 5-FU in a concentration of 50 mg/ml were administered in doses ranging from 2 to 50 mgm.

    Mixing 0.1ml of kenlog and 0.9 ml of 5-FU in the same syringe caused less pain and had greater efficacy.

    It was rare for a scar to not respond favorably. Scars with greatest response were typically red, most inflamed, most
    symptomatic and most firmly indurated.

    The first signs of response were reduced pain and itching softening of scar, flattering and decreased redness. Hypertrophic scars were more responsive than keloids.

  • Tabaqchali MA, Hanson JM, Proud G [Royal Victoria Infirmary, Newcastle upon Tyne, England
    Drains for Thyroidectomy /Parathyroidectomy : Fact or Fiction?
    Ann R Coll Surg Engl 81: 302-305, 1999, Pg.219

    The primary reason that drains are routinely placed after neck wound hematoma and seroma and obstruction. 

    Postoperative bleeding hematoma was significantly higher in patients who received drains than in those who did not. Wound infection was observed only in patients with drains.

    A meticulous haemostatic technique is more important than the use of drains. 

         

  • Sarhadi NS, Shaw-Dunn J[Univ of Glasgow, Scotland]
    Transthecal Digital Nerve Block: An Anatomical Appraisal
    J Hand Surg [Br] 23B: 490-493, 1998
      
    This study investigates the anatomical basis of a transthecal digital nerve block for local anesthesia of digits in 60 digits from 40 cadavers.
      
    Methylene blue and latex were injected into cadaveric digits to determine how anesthesia fluid injected into the flexor tendon sheath may spread around the finger.
       
    In digits when 3cc of solution was injected, irrespective of the puncture site, blotchy dye stains were seen on the dorsum of the proximal part of the finger, and the sides of the interphalangeal joint and the metacarpophalangeal joint and both the neurovascular bundles and the flexor tendon sheath were also stained. Dye stains were seen at the wrist when the injections were given at the thumb base and the little finger. Injections in the other fingers did not stain the proximal palm.
      
    If only 0.5cc were injected into the tendon sheath, staining appeared on the dorsum of the digit at its base and around the p.i.p. joint. It also tracked alongside the vessels. The fatty tissue showed linear staining, but no staining of nerves. Deeper staining was seen at the base of the proximal phalanx or in the region of the middle phalanx.
      
    Transthecal injection of 1 ml, resulted in a pool of dye around the neurovascular bundles, in the tissue space enclosed by Cleland’s ligament and Grayson’s ligament right to the tip of the finger.
      
    The authors conclude that injected dye solution escapes from the flexor tendon sheath around the vincular vessels, through the perivascular loose areolar tissue, and spreads alongside the main digital vessels and nerves and their branches.
          

  • Lundborg G, Rosen B, Lindberg S [Malmo Univ, Sweden]
    Hearing as Substitution for Sensation : A new Principle for Artificial Sensibility
    J Hand Surg [Am] 24A: 219-224, 1999
      
    Sense substitution is commonly used among patients with sensory deficits, such as the use of Braille to read by blind people. This study describes an attempt to use hearing as a substitute for lost sensibility.
      
    This study used vibrotactile stimuli to generate sounds as a substitute for hand sensibility. Miniature condenser microphones were attached to the distal, dorsal side of a glove to magnify the friction sound generated. The signal from the microphone was processed by a stereo amplifier which separated signals from different fingers into different channels. These sounds were then fed through earphones to patients with lost hand sensibility [3 had undergone median nerve repair, 1 had an replantation of an amputated forearm, 1 had a myoelectric prosthesis, and 4 had cosmetic prostheses. The patients participated in studies to assess spatial resolution and differentiation between textures.
      
    The spatial resolution of signals allowed patients to differentiate between the various fingers. Friction sounds enabled the patients to identify textures – such as glass, metal, wood and paper.
      
    The findings suggest that hearing may provide a useful substitute for lost hand sensibility.
         

  • D.M. Hemingway and I.G. Finlay [ Department of Coloproctology, Glasgow, Royal Infirmary, Glasgow, UK]
    Effect of Colectomy on Gastric Emptying in Idiopathic Slow-transit Constipation
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1193-1196
      
    Gastric emptying is delayed in patients with idiopathic slow-transit constipation [ ISTC]. This study evaluates the effect of colectomy and ileorectal anastomosis on this delayed gastric emptying.
      
    Twelve patients suffering from ISTC were subjected to colectomy [subtotal] and ileorectal anastomosis. Out of these 11 had an excellent functional outcome. In 10 of these gastric emptying was assessed after 3 months. 7 of these [including the remaining two] had the same study at the end of one year.
       
    Gastric emptying remained delayed at the end of 3 months at the end of one year gastric emptying had improved [ 4 had returned to normal] functional outcome did not relate to gastric emptying.
       
    Patients with ISTC have delayed gastric emptying time, which may return to normal in some after colectomy but is persistent in others.
          

  • C.M. Wright, O.F. Dent, M. Barker, R.C. Newland, P.H. Chapuis, E.L. Bokey, J.P. Young, B.A. Leggett, J.R. Jass and G.A. Macdonald [ Department of Surgery, Princess Alexandra Hospital, Conjoint Gastroenterology Laboratory, Royal Brisbane Hospital Research Foundation Clinical Research Center, Department of Pathology , University of Queensland and Department of Medicine, University of Queensland and Clinical Sciences Unit, Queensland Institute of Medical Research, Brisbane, Queensland, Department of Sociology, Australian National University]
    Prognostic Significance of Extensive Microsatellite Instability in Sporadic Clinicopathological Stage C Colorectal Cancer
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1197-1202
       
    Colorectal cancers exhibiting microsatellite instability [MSI] appear to have unique biological behaviour. This study analyses the association between extensive MSI [MSI-H], clinicopathological features and survival in an unselected, group of patients with Sporadic Australian Clinico-Pathological Stage [ACPS] C [tumour node metastasis stage III] colorectal cancer.
      
    255 patients who underwent resection for sporadic ACPS C colorectal cancer between 1986-1992 were studied. No chemotherapy was given and a minimum follow up period was 5 years. Archival normal and tumour DNA was extracted and amplified by polymerase chain reaction using a radioactive labeling technique. MSI-4 was defined as instability in 40 percent or more of seven markers.
      
    21 patients showed MSI-H. No association was found between MSI and age or sex. Tumours exhibiting MSI-H were more commonly right sided, larger and more likely to be high grade. After adjustment for age, sex, and other variables, patients with MSI-H had improved survival rates.
        

  • N.S. Williams, O.A. Fajobi, P.J. Lunniss, S.M. Scott, A.J.P. Eccersley and O.A. Ogunbiyi [ Academic Department of Surgery, The Royal London Hospital, London, UK]
    Vertical Reduction Rectoplasty: A new Treatment for Idiopathic Megarectum
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1203-1208
        
    Idiopathic megarectum is of unknown aetiology and the results of surgery are unsatisfactory. The poor evacuatory function has been attributed to rectal hypo-anesthesia and poor perception of rectal filling. It was hypothesized that by reducing the capacity of the rectum, the sensory thresholds to rectal distension and perception of urge to defaecate would be improved. 
    6 patients with idiopathic megarectum were subjected to vertical reduction rectoplasty [VRR] and concomitant sigmoid colectomy. Postoperative rectal compliance was evaluated by means of a programmable electronic barostat. Phyiological data was compared with eight healthy volunteers.
       
    Bowel frequency increased from 2.5 to 16 per month after surgery. 4 patients reported improved rectal perception of the urge to defaecate. Threshold for defaecatory urge and maximum tolerated volume were significantly reduced. The rectal compliance was no different from that in healthy volunteers. Colonic transit time decreased significantly and evacuation on proctography increased from a median of 30% to 50%. At a median of 57 weeks follow up, 5 patients expressed continued satisfaction.
    VRR can improve sensory feedback and defaecation in idiopathic megarectum.
         

  • M. M.Fynes, M. Behan, C.O’Herlihy and P.R. O’Connell [ Department of Surgery and Radiology, Mater Misericordiae Hospital and Department of Obstetrics and Gynecology, National Maternity Hospital, University College Dublin, Dublin, Ireland ]
    Anal Vector Volume Analysis Complements Endoanal Ultrasonographic Assessment of Postpartum Anal Sphincter Injury
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1209-1214
     
    This study aims to determine the role of anal vector manometry in the assessment of postpartum anal sphincter injury and to determine the most suitable method of anal vector volume analysis for identifying significant external anal sphincter [EAS] injury in an at-risk parous population.
       
    101 women with a history of instrumental or traumatic vaginal delivery were studied by anal ultrasonography and anal vector manometry.
        
    17 women had significant EAS disruption identified by ultrasonography.
        
    Anal vector manometry provided complementary functional information. Anal Vector Symmetry index [AVSI] determined by analysis of mean maximum squeeze pressure, yielded 100 per cent sensitivity for significant EAS disruption with a positive predictive value of 61%.
         

  • E.A. Baker, F.G. Bergin and D.J. Leaper [ Professorial Unit of Surgery, North Tees General Hospital, Stockton on Tees TS19 8PE, UK]
    Matrix Metalloproteinases, Their Tissue Inhibitors and Colorectal Cancer Staging
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1215-1221
      
    Matrix metalloproteinases [MMPs] and their tissue inhibitors [TIMPs] are important in tumour invasion and metastases. This study measured the levels of MMPs and TIMPs and total MMP activity in colorectal tumour cases and compared them with normal and correlated with clinical and pathological staging.
      
    Gelatin zymography [MMP-2 and MMP-9] enzyme linked immnunosorbent assays [MMP-1, MIMP-3, TIMP-1 and TIMP-2] and quenched fluorescent substrate hydrolysis [total MMP activity] were employed in resection specimens from 50 patients, four with adenomas and 46 with colorectal cancer.
      
    The levels of active MMP-2 and MMP-9 and total MMP-1, MMP-3 MMP-9 and total MMP1, MMP3, and TIMP-3 were significantly greater in tumour tissue than in normal colon. However, TIMP-2 levels were significantly greater in normal tissue. The total MMP activity was greater in tumours. Correlations were found between MMP and TIMP levels and pathological tumor staging. MMP1 appeared to be most important as its concentration correlated positively with Dukes staging, tumor differentiation and lymphatic invasion.
           

  • M.M.P. J. Reijnen, B.M. de Man, Th. Hendriks, V.A. Postma, J.F. G.M. Meis, and H. van Goor [ Departments of Surgery and Medical Microbiology, University Hospital Nijmegen, The Netherlands]
    Hyaluronic Acid-based Agents do not Affect Anastomotic Strength in the Rat Colon, in Either the Presence or Absence of Bacterial Peritonitis
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1222-1228
        
    This study investigates the influence of two hyaluronic acid agents on the development of strength in colonic anastomosis during the first postoperative week, in normal rats and in rats with bacterial peritonitis.
        
    In 90 male Wistar rats, a 1-cm segment was resected from the descending colon and an end to end anastomosis was constructed. In 180 rats. A bacterial peritonitis was induced by caecal ligation and puncture [CLP]. Some 24 hours later the abdomen was reopened. The caecum was taken out and after resection of 1 cm segment, an anstomosis was made. 
     
    The animals in both groups were randomized to receive either an HA-carboxymethylcellulose [CMC] bioresorbable membrane, 0.4%, HA solution or no treatment. One third of each group was killed at day 1, 3 and 7 after operation. Cultures were taken from the abdominal cavity for microbiological analysis in half of the animals. Subsequently, both bursting pressure and breaking strength were determined as parameters for anastomotic strength.
     
    No differences were noted in the different groups in anastomotic bursting pressure or breaking strength and in the number of bacteria cultured from the abdominal cavity.
     
    HA-CMC can safely be used to prevent postoperative adhesions after bowel resections.
         

  • M. van ‘t Riet, J.W.A. Burger, J.M. van Muiswinkel, G. Kazemier, M.R. Schipperus and H.J. Bonjer [ Departments of Surgery, Radiology and Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands]
    Diagnosis and Treatment of Portal Vein Thrombosis Following Splenectomy
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1229-1233
     
    The study assesses the incidence, risk factors treatment and outcome of portal vein thrombosis after splenectomy in a large series of patients.
     
    563 splenectomies were reviewed retrospectively, 2% [9 cases] were complicated by symptomatic portal vein thrombosis.
    All these 9 cases had either fever or abdominal pain. 2 of 16 patients [myeloproliferative disorder] and 4 of 49 [haemolytic anaemias] developed portal vein thrombosis. Early treatment [within 10 days] was successful in all patients while delayed treatment was ineffective.
     
    Portal vein thrombosis should be suspected after splenectomy if there is fever and/or abdominal pain. Patients with myeloproliferative disorders or haemolytic anaemia were at a higher risk. Early detection with Doppler ultrasonography and early treatment could be life saving.
         

  • T. Funai, H. Osugi, M. higashino and Kinoshita [ Second Department of Surgery, Osaka City University Medical School, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan]
    Estimation of Lymph Node Metastasis by Size in Patients with Intrathoracic Oesophageal Cancer
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1234-1239
         
    The aim of this study was to establish criteria for the preoperative diagnosis of lymph node metastases based on size and shape of nodes.
       
    123 patients were studied. 6822 nodes were obtained by extended lymphadenectomy. The nodes were classified anatomically and their size was measured by the operating surgeon during or immediately after surgery. All were examined histologically and criteria for diagnosis of metastasis were evaluated.
      
    The size of the nodes varied by anatomical site. They were smallest in the neck and largest at the tracheal bifurcation. The cut off value for the diagnosis of metastases was 5 mm in the neck. 6 mm in the abdomen and 8 mm in the mediastinum, except for tracheal nodes. Lymph node 10 mm or larger tended to become spherical when involved by metastasis.
         

  • G. Miller, J. Boman, I. Shrier and P.H. Gordon [ Division of Colorectal Surgery and Center for Epidemiology and Community Studies, Sir Mortimer B, Davis -Jewish General Hospital and McGill University, Montreal, Canada]
    Natural History of Patients with Adhesive Small Bowel Obstruction
    Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1240-1247
       
    The aims of this study was to determine factors predisposing to adhesive small bowel obstruction [SBO], to note the long term prognosis and recurrence rates for operative and non operative treatment,to elicit the complication rate of operations and to highlight factors predictive of recurrence.
      
    410 patients accounting for 675 admissions over a period of 10 years were reviewed retrospectively.
      
    The frequency of previous surgery was 24% colorectal surgery, 22% gynaecological surgery, 15% herniorrhaphy 14% appendicectomy .
      
    A history of colorectal surgery [odds 2.7] vertical incision [2.5%] tended to produce multiple matted adhesion rather than an obstructive band. At initial admission, 36% were treated by means of an operation. As the number of admissions increased, the recurrence rate increased and the time interval between admission decreased. Patients with an adhesive band had 25% readmission, rate compared with 49% for those with matted adhesions.
      
    Patients treated without operation had 34% readmission rate compared in the 32% for those treated with surgery. A shorter time to readmission, no difference in reoperation rate and fewer in patient days over all admissions.
           

  • Wright JG, Hawker GA, Bombardier C, et al [Univ of Toronto; Sunnybrook & Women’s College Hosp, North York, Ont; Vanderbilt Univ, Nashville, Tenn; et al]
    Physician Enthusiasm as an Explanation for /area Variation in the Utilization of Knee Replacement Surgery
    Med Care 37: 946-956, 1999
       
    This study examines the variation in the utilization of knee replacement surgery by county in the Canadian province of Ontario. The factors evaluated included the characteristics and opinions of the physicians and specialists, severity of disease, access to the procedure, use of alternative surgery and population factors.
       
    Knee replacement was more frequently used in older patients and in medical school affiliated hospitals. The referring physicians were usually males, trained outside North America. Orthopedic surgeons had a higher propensity for performing knee replacements and better perceptions of the outcomes. 
       
    The authors conclude that the local orthopedic surgeons have a major influence on the rate of knee replacement in a given geographic area. Efforts to reduce variation in surgeon opinion might reduce although not eliminate, geographic variation.
      

  • Coyte PC, Hawker G, Croxford R, et al [Univ o Toronto; Women’s College Hosp, Toronto; Hosp for Sick Children, Toronto]
    Rates of Revision Knee Replacement In Ontario, Canada
    J Bone Joint Surg Am 81-A: 773-782, 1992
       
    This analysis includes 18,520 knee replacements performed in Ontario from 1984 to 1991. One study algorithm was used to identify primary versus revision 
    knee replacements and another was used to link revision to primary knee replacements.
       
    The survival of the primary knee replacements was assessed using the Kaplan Meier method and factors affecting survival were identified using a proportional – hazards regression model. 
       
    Overall 7% of the total number of knee replacements were revisions. Osteoarthritis was the commonest indication for primary knee replacement. The time to revision surgery was significantly longer for patients older than 55 years, rural population and in those with rheumatoid arthritis revision.
       
    Revision replacement surgery was done earlier in teaching or speciality hospitals. Long term revision rates were low. The estimated rate of revision within 7 years varied significantly according to the algorithm used from 4.3% to 9%.
       
    They conclude that revision knee replacement is a rare event. Many factors affect thus likelihood like age, sex, area of residence and type of hospital.
      

  • Robertsson O, Borgquist L, Knutspm K, et al [Univ Hosp, Lund, Sweden; Linkoping Univ, Sweden]
    Use of Unicompartmental Instead of Tricompartmental Prostheses for Unicompartmental Arthrosis in the Knee is a Cost-effective Alternative : 15,437 Primary Tricompartmental Prostheses Were Compared With 10,624 Primary Medial or Lateral Unicompartmental Prostheses 
    Acta Orthop Scand 70: 170-175, 1999
       
    This study evaluates the cost of UKA [Unicompartmental] and TKA [Tricompartmental] procedures including implant cost. Length of hospital stay and the difference in the number of expected revisions. 
       
    The analysis included 15,437 primary TKAs and 10,624 primary medial or lateral UKAs over an 11 year period. Registry data was used to compare length of hospital stay in the 2 groups. Survival data was used to calculate the cumulative revision rate [CRR] and relative risk of revision. The risk of second revision and infection were calculated as well. 
        
    The proportion of patients undergoing UKA implantation declined during the period of study. ‘The average age at primary operation was 73 years [TKA] and 71 years [UKA]. The postoperative stay averaged 12.3 days [TKA] and 10.7 days [UKA]. The 10 year CRR was 12% [TKA] AND 16% [UKA]. The rate of serious complications was significantly lower in UKA group. The cost of a UKA was 57% that of TKA procedure.
        
    The conclusion is that the cost of UKA implantation is lower than TKA implantation [inclusive of higher revision rate]. It also has a shorter hospital stay. The costs may be further reduced by proper selection of patients.
        

  • Parentis MA, Rumi MN, Deol GS, et al [Pennsylvania State Univ, Hershey] 
    A Comparison of the Vastus Splitting and Median Parapatellar Approaches in Total Knee Arthroplasty
    Clin Orthop 367 : 107-116, 1999
       
    This is a controlled prospective study [randomized] comparing the two approaches.
       
    42 consecutive patients [51 knees] with degenerative disease of the knee were subjected to TKA.
       
    The median parapatellar approach used a standard midline incision. In the vastus medialis splitting approach the same incision was used; however at the level of the supero medial corner of the patella, the vastus medialis fascia was incised along the margin of the quadriceps tendon and elevated medially. The muscle was then split bluntly. 
       
    Electromyography performed pre and postoperatively was used to evaluate the two approaches relative to their effect on the innervation of the quadriceps mechanism. 
        
    The two randomized groups were similar in age, weight and other clinical parameters. Postoperatively, no significant differences were noted during the hospital stay at 2, 6 and 12 weeks in terms of straight leg raise, ROM and hospital for special surgery scores, short arc quadriceps strength or tourniquet time. Blood loss was significantly greater in the standard approach [ 200 vs 129.6 ml]. 9 patients [43%] who had vastus splitting approach had abnormal postoperative electromyograms.
        
    The two approaches are similar when compared clinically. Longer tern studies, however, are needed to determine the clinical significance of denervation of the vastus medialis muscle by the vastus splitting approach.
         

  • Aglietti P, Buzzi R, De Felice R, et al [Univ of Florence, Italy]
    The Insall-Burstein Total Knee Replacement in Osteoarthritis : A 10-Year Minimum Follow-up
    J Arthroplasty 14: 560-565, 1999
       
    The Insall-Burstein posterior stabilized [IBPS] TKA was designed to improve maximal flexion and function. Previous studies have presented midterm results with this prosthesis. This study presents a ten year follow up result using the IBPS in patients with osteoarthritis. 
       
    99 IBPs TKAs in 86 patients [76 women and 10 men average age 69 years] with osteoarthritis were followed up. Follow up evaluation consisted of annual clinic visits, including the knee Society Score and radiographs. 10-15 years follow up data were available on 60 knees.
       
    58% had excellent results [Knee Society Scores ], 25% had good results, 7% had fair results and poor results in 10%. The knees had an average of 1060 of flexion. 9% had moderate patellofemoral crepitation. 8% showed osteolysis around the tibial and femoral components whereas 12% showed polyethylene wear. The 10% failure rate included 4 knees with aseptic loosening, 1 with deep infection and 1 with recurrent patellar dislocation. The 10 year cumulative success rate with revision as the end point was 92%.
       
    The IBPS TKA replacement achieves good results on a long term basis.
       

  • Cloutier J-M, Sabouret P, Deghrar A [Universite de Montreal]
    Total Knee Arthroplasty with Retention of Both Cruciate Ligaments : A Nine to Eleven –year Follow-up Study
    J Bone Joint Surg Am 81-A: 697-702, 1999
       
    Most current knee replacement systems retain the posterior or both the ACL and PCL. Despite arguments that ACL retention complicates the knee replacements procedure, the authors routinely seek to retain both ligaments when possible. A prospective study of 163 TKAs with retention of both cruciate ligaments.
       
    Of 204 TKAs performed from 1986-1988 both cruciate ligaments were retained in 163. Follow-up results were available on 107 knees of 89 patients: 96 women and 34 men with an average age of 67 years at index arthroplasty. [75% had osteoarthritis 25% had rheumatoid arthritis]. Varus deformity was present in 67% valgus in 16%. At operation ACL appeared normal in 96 knees and partially degenerated in 67. 
       
    At 10 year follow up, 97% had good to excellent results. 91% had good pain relief with an average range of flexion of 107. AP stability was normal in 89% with movement of less than 5 mm. The remaining 11% had 5-10 mm of movement. Mediolateral stability was normal in 90% whereas 10% had 5-10 mm of movement. Varus alignment was between 50 to 100 in 88%. The average knee score was 91 points, with an average functional score of 82. 10 year revision free survival was 95%. The revision rate was 4% with no revisions for patellar problems or aseptic loosening of the tibial component.
       
    The ten year follow up shows good results.
       

  • Gill GS, Joshi AB, Mills DM [ Lubbock, Tex]
    Total Condylar Knee Arthroplasty : 16- to 21-Year Results
    Clin Orthop 367: 210-215, 1999
       
    This study reports the long-term results of posterior cruciate retention total condylar knee arthroplasty performed by a single surgeon in private practice.
    159 knee arthroplasties were performed [139 patients] using total condylar knee prostheses between 1976-1982. A 16 year follow-up was available on 72 knees of 63 patients [42 men, 21 women] average age 61 years]. The main indication was osteoarthrosis. Follow up included clinical evaluation based on knee society clinical rating systems and radiographs.
       
    5 knees experienced delayed complications [ 3 had patellar stress fracture; 1 each of delayed supracondylar fracture and patellar tendon rupture]. Revision surgery was performed on 1 knee. 2 more cases were advised revision surgery but declined on medical risk grounds. There were no cases of aseptic loosening. The mean knee score improved from 40.3 points preoperatively to 88.4 points at follow up.
       
    86% had excellent results, 7% had good to fair result and poor in 7%. Among patients undergoing revision surgery, 20 year prosthesis survivorship was 98.6%. 
       
    Total Condylar Knee arthroplasty with posterior cruciate ligament retention gives excellent results in private practice.
        

  • Li PLS, Zamora J, Bentley G [King’s College Hosp, London; Southend Gen Hosp, Essex, England; Royal Natl Orthopaedic Hosp, Stanmore, England]
    The Results at Ten Years of the Insall-Burstein II total Knee Replacement: Clinical, Radiological and Survivorship Studies
    J Bone Joint Surg Br 81-B:647-653, 1999
       
    The 10 year results of the use of Insall-Burstein II prosthesis in a general orthopaedic unit are discussed. 
       
    146 total knee replacements [IB-II prosthesis] were performed on 121 patients [ 39 men, 82 women aged 46-86 years]. At ten years, 78 patients [94 knees] were available for follow-up. The hospital for special surgery [HSS] scoring system and the knee society rating system were used to evaluate outcome.
       
    79% had good to excellent result, 14% had a fair result and 9% had a poor result. The average knee society score was 87 [ at 10 years] and the average functional score was 56 [advanced age and infirmity]. The average knee society pain score increased significantly from 4 [pre-operatively] to 45 at 10 years. The mean ROM improved from 88% to 100%, walking distance improved from less than 500 m. to 500-1000 m. There were 9 revisions because of infection [n=5] aseptic loosening [n=4] for a cumulative survival rate at 92.3% at 10 years. Secondary patellar resurfacing was necessary in 8 patients with severe anterior knee pain. 3 had to undergo knee lateral release for patellar maltracking. 1 had a patellar tendon rupture repair, 6 had postoperative infection, one had a nonfatal pulmonary embolus. 4 had deep vein thrombosis. 1 had a stroke and 1 had a fracture of the posterolateral cortex of tibia. 7 patients had to be manipulated under anesthesia. 
       
    Radiographs of 104 knees were available for follow up. 10 tibial components showed radiolucent lines but none required revision. 
       
    The long term results of Insall-Burstein II total knee replacement orthroplasty are good with 90% , 10 year survival.
        

  • ElkinsRC, Knott-Craig CJ, Ward KE, et al [Univ of Oklahoma, Oklahoma City]
    The Ross Operation in Children : 10-Year Experience
    Ann Thorac Surg 65 : 496-502, 1998
       
    The Ross operation for aortic valve replacement in children has been performed for 30 years, but its widespread acceptance was delayed because of the procedure’s technical demands and the need to place 2 valves at risk. With modifications in operative technique, the Ross operation in now the operation of choice for children and young adults who require aortic valve replacement. Researchers reviewed the records of 150 consecutive patients to provide additional long-term follow-up of the Ross operation. There were 112 boys and 38 girls of median age 12 years. Primary diagnosis was aortic stenosis in 40, aortic insufficiency in 29, and a combination of both in 81. Most had undergone other procedures before the Ross operation.
       
    Eight-year survival was 97.3%. Six patients required reoperation with restitution of valve function and two with late dysfunction required a replacement procedure. At 8 years 90% were free of any dysfunction, 94% were free of any obstruction, and 89% were free of any gradient across the valve needing a reoperation. All patients had active lives unencumbered by the need to take any anticoagulants.
        
    The Ross operation in children has an excellent rate of success at a low risk. Valve related complications are not life threatening and long-term satisfactory valve function can be achieved.
        

  • D’Souza SJA, Tsai WS, Silver MM, et al [Univ of Toronto]
    Diagnosis and Management of Stenotic Aorto-Arteriopathy in Childhood
    J Pediatr 132: 1016-1022, 1998
       
    Patients with stenotic aorto-arteriopathy [SAA], an uncommon group of vascular diseases, have segmental stenoses of the aorta and its branches. The new common type is middle aortic syndrome, characterized by severe stenosis of the thoracic and abdominal aorta. The differential diagnosis includes mainly Takayasu Arteritis [TA] and fibromuscular dystrophy or other noninflammatory aortic-arterial diseases. An experience with the management of SAA in childhood is reviewed, including the results of several different management approaches.
        
    The 16-year experience included 14 children and adolescents with acquired SAA. There were 7 boys and 7 girls, aged 4 to 18 years. Most of the patients were asymptomatic, with hypertension noted at routine examination. Clinical findings included abdominal bruits in 8, mixed absent/diminished and normal pulses in 8, and leg claudication in 4. On angiography, 13 showed involvement of the abdominal or descending thoracic aorta. A mid thoracoabdominal coarctation was detected in most patients. Eleven patients received a diagnosis of TA. It was difficult to distinguish TA from fibromuscular dysplasia on clinical or angiographic grounds.
         
    Treatment commenced with antihypertensive therapy. In patients with TA, prednisolone did not reverse aortic disease but it did worsen the hypertension. Six patients underwent percutaneous transluminal balloon angioplasty of renal artery stenoses, but the renal arteries restenosed. Renal autotransplantation – excision of the stenotic segment of the renal artery with reimplantation of the kidney on to the disease free renal artery – was performed in 5 patients. This provided temporary improvement in blood pressure in most patients; one patient had renal artery thrombosis with deteriorating renal function. Three patients underwent balloon angioplasty of the abdominal aorta with implantation of stents. In one case this was followed by open renal autotransplantation. There were 3 deaths.
        
    Thus diagnosis and management of SAA in children is a difficult problem, requiring multiple procedures, aimed mainly at preventing end-organ damage.
        

  • Knott-Craig CJ. Elkins RC, Lane MM, et al [Univ of Oklahoma, Oklahoma City].
    A 26-year Experience with Surgical Management of Tetralogy of Fallot : Risk Analysis for Mortality or Late Reintervention 
    Ann Thorac Surg 66: 506-511, 1989
        
    Since the early 1990s, the trend in correction of tetralogy of Fallot [TOF] has been toward primary repair and away from 2-stage repair. The results suggest that primary repair offers improved outcomes, although the long term effects on survival and recurrent right ventricular outflow tract disease remain unclear. A 26-year experience with TOF repair was reviewed to analyze effects of the trend toward early repair on early outcomes and recurrent right ventricle obstruction.
        
    From 1971 to 1997, 291 patients were operated for repair of TOF at the author’s institute; 68% had primary repair, 21% had a staged repair and the rest had palliative surgery only. The pathology was complex in 23% of patients, most often including pulmonary atresia. Follow-up information was available on 90% of the patients, with a median duration of follow-up nearly 11 years.
       
    The overall in-hospital mortality rates were 11% for primary repair, 18% for staged repair and 16% for the rest. During the 1990s the mortality rates decreased to 2%, 12% and 0% respectively. After 1990 the patients age at surgery was 0.6 years, compared with the earlier 2 years. Significant risk factors for in-hospital death on multivariate analysis were hypothermic circulatory arrest, pulmonary artery patch angioplasty, earlier years of surgery, and closure of the foramen ovale.
       
    Among patients who survived to hospital discharge, the 20-year survival was 98% for those with TOF with pulmonary stenosis vs 88% for those with pulmonary atresia. Fourteen percent of patients required reoperation on the right ventricular outflow tract. The 20 year rate of freedom from such intervention was 86% for patients with pulmonary stenosis vs 43% for those with pulmonary atresia. Among the latter group, the rate of freedom from reintervention was 85% after primary repair vs 91% for those with staged repair. Patients less than one year were less likely to be free of reintervention, though the difference was not significant.
        
    The long-term retrospective study suggests that survival after primary repair of TOF has improved significantly over the years and even infants do well. Staged repair has to be reserved for patients with complex pathology only. 
                

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