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Surgery


   

 






Surgery

  

  • Singh
    GK, Greenberg SB, Yap YS, et al [ St. Louis Univ., St. Christopher
    Hosp. for Children, Philadelphia, Southampton Gen. Hosp. England ]

    Right Ventricular Function and Exercise Performance Late After Primary Repair of Tetralogy of Fallot with Trasannular Patch

    Am J Cardiol 81: 1378-1382, 1998

       

    Current surgical repair of tetralogy of Fallot [TOF] involving
    reconstruction of the right ventricle [RV] usually results in
    chronic pulmonary insufficiency. Exercise performance and RV
    systolic and diastolic functions in a group of patients with
    pulmonary regurgitation, late after primary repair of TOF in
    infancy, was assessed with cine magnetic resonance imaging and
    compared with results in normal individuals.

        

    The study consisted of 10 New York Heart Association [NYHA] class 1
    [n= 7] or II [n=3] patients with chronic pulmonary regurgitation for
    an average of 13.6 years after surgery for TOF with reconstruction
    of the right ventricular outflow tract with a transannular patch, at
    an average age of 6.9 months.

       

    Cine magnetic resonance imaging was performed and ventricular volume
    and function indices were calculated and compared with those of 7
    age and sex matched healthy controls.

        

    All the patients had pulmonary regurgitation and right and left
    ventricular enlargement and lower ejection fractions with diminished
    exercise tolerance correlated with the degree of pulmonary
    regurgitation.

  • R.D. James

    Radiotherapy and Rectal Cancer – The Present Position

    Recent Advances in Surgery, Number 22, Year -1999, Pg.109

       

    The differential effect of XRT is largely due to the ability of normal tissues to repair more nuclear damage than malignant tissues. XRT is used for cancers of the bladder, prostate and uterus as well as the rectum.

     

    Permanent sterility is inevitable. Acute XRT induced enteritis appears approximately 2 weeks after the start of
    XRT. Late XRT-enterities may require extensive surgery for obstruction, bleeding, and fistula formation.

     

    The need of XRT is probably better determined by lateral resection margin
    [LRM] positivity and the need for adjuvant chemotherapy by lymph node
    positivity.

     

    A cure rate of at least 80% has been reported by most series for so-called contact XRT alone for tumours of less than 5 cm in diameter. Contact XRT differs from conventional XRT by delivering an extremely high [100-120
    Gy] tumour surface dose in 3 or 4 treatments of 5 minutes over at least 2 months.

      

    Conservative surgery for larger tumours is safer following pre-operative
    XRT.

     

    Largest [80%] group of patients with rectal cancer are suitable for radical surgery with a view to cure both pre-operative and postoperative XRT reduce local recurrence by 30-50%.

      

    Toxicity was worse for post-operative than for pre-operative
    XRT.

          

  • Preito
    LR, Hordof AJ, Secic M, et al [Columbia Univ, New York; Cleveland
    Clinic Found, Ohio]

    Progressive Tricuspid Valve Disease in Patients with Congenitally Corrected Transposition of Great Arteries

    Circulation 98: 997-1005, 1998

        

    Patients with corrected congenital transposition of the great
    arteries [CTGA] are commonly found to have morphological
    abnormalities of the tricuspid valve, with 20% to 50% having
    clinically significant tricuspid insufficiency [TI]. The progression
    of tricuspid valve disease in such patients is unclear. A long-term
    follow-up study of patients with CTGA, with and without open heart
    surgery, was reported, with special attention to the significance of
    TI or intrinsic right ventricular dysfunction.

        

    The study included 40 patients with CTGA seen at one medical center
    since 1958. Twenty-seven patients were male and 13 female. The mean
    follow-up was 20 years. Potential risk factors for poor outcome were
    evaluated, including age, open heart surgery, TI, cardiac rhythm,
    pulmonary overcirculation, and right ventricular dysfunction.

       

    Twenty-one patients underwent intracardiac repair and 19 had no
    surgery or had closed heart procedures. The only independent
    prognostic factor for death was severe or moderately severe T1 as
    demonstrated by echocardiography and/or angiography. Furthermore,
    the only factor that predicted the presence of T1, was morphological
    abnormalities of the tricuspid valve. The 20-year survival rate was
    93% for patients without T1 vs 49% for those with T1. For patients
    undergoing surgery, survival rate was 34% for patients with T1 vs
    90% for those without T1. Among patients who did not have surgery,
    the 20-year survival rate was 60% with T1 vs 100% without.

         

    Thus presence of T1 in patients with CTGA worsens the prognosis,
    irrespective of whether they are operated or not.

         

  • Niezen
    RA, Helbing WA, van der Wall EE, et al [Leiden Univ. The
    Netherlands]

    Biventricular Systolic Function and Mass Studied with MR Imaging in Children with Pulmonary Regurgitation After Repair of Tetralogy of Fallot

    Radiology 201: 135-140, 1996

       

    Pulmonary Regurgitation [PR] may occur after surgical correction of
    tetralogy of Fallot. With the trend toward earlier correction of
    this congenital condition, there is a longer follow-up period for
    measurement of PR and biventricular function to evaluate the results
    of surgery; this study examined such functions.

         

    The study included 19 children who had been operated at mean age of
    1.5 years. Doppler echocardiography revealed PR in each patient. A
    group of healthy controls was studied for comparison. The mean age
    was 12 years in both groups. The subjects underwent transverse
    gradient-echo MRI of both ventricles, including creation of MR
    velocity maps of pulmonary artery. Measurements of biventricular
    volumes, ejection fraction, myocardial mass, and pulmonary flow
    volumes were made. In addition, 17 patients underwent exercise
    testing.

          

    The patients with corrected tetralogy of Fallot had lower right
    ventricular ejection fractions [ 54% vs 66%] and higher right
    ventricular mass than controls. Left ventricular ejection factor was
    also lower in operated cases than controls [ 52% vs 68%] and was
    significantly correlated with PR. Exercise performance also was seen
    to be reduced in inverse proportion to PR in the operated cases.

         

    Patients operated for correction of tetralogy of Fallot do develop
    pulmonary regurgitation which results in larger biventricular mass
    and reduced ejection fractions; and these effects can be accurately
    measured by MRI.

          

  • Reddy
    VM, McElhinney DB, Phoon CK, et al [Univ of California, San
    Fransisco]

    Geomatric Mismatch of Pulmonary and Aortic Anuli in Children Undergoing the Ross Procedure : Implications for Surgical Management and Autograft Valve Function

    J Thorac Cardiovasc Surg 115: 1255-1263, 1998

        

    Many children treated with the Ross procedure for congenital heart
    lesions have a significant discrepancy between pulmonary and aortic
    anuli. No systematic study was examined whether such mismatch
    presents a contraindication to the procedure. A review of 41
    children who underwent the procedure focuses on the surgical
    management of geomatric mismatch and its effects on autograft valve
    function.

        

    Patients had a mean age of 7.8 years. The diameter of the pulmonary
    valve was greater by 3 mm than that of the aortic valve in 20 cases,
    equal in 12 cases, and less by 3 mm in 9 cases; the differences
    ranged between + 10 to -12 mm. Aortoventriculoplasty was used to
    correct the mismatch in children with a larger pulmonary anulus;
    whereas in those with a larger aortic anulus, the correction was
    made by a gradual adjustment along the circumference of the
    autograft. Patients were followed up [ mean period 31 months] for
    autograft valvular regurgitation.

         

    Two patients required reoperation for moderate regurgitation. In the
    remaining 38 survivors, regurgitation was absent or trivial in 30,
    mild in 7, and moderate in 1. Regurgitation showed no relation with
    the age of the child, mismatch, or previous or concurrent
    procedures. No patient had significant autograft root dilatation.

         

    Thus geomatric mismatch is no contraindication to the Ross procedure
    in children.

         

  • M. Manu, J. Buckels and S. Bramhall [ Department of Surgery and Liver Unit, Queen Elizabeth Hospital, Birmingham BJ5 2TH, UK]

    Molecular Technology and Pancreatic Cancer

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 840-853

         


    This is a review of the molecular changes peculiar to pancreatic cancer and how the use of molecular technology might affect detection, screening, diagnosis, and treatment of the disease.

          

    Over the past 20 years great strides have been made in our understanding of the molecular basis of pancreatic cancer. Advances in molecular biology are now reshaping how diseases are screened for, diagnosed, investigated and treated. In recent years collaboration between clinicians and basic scientists has revealed a unique pattern of genetic and molecular events in pancreatic cancer. This review discusses how these advances may impact on patients with this disease which may improve the outlook for patients with this disease. The ‘molecular age’ promises to deliver better results.

         

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

    Mesh Compared with Non-Mesh Methods of Open Groin Hernia Repair : Systematic Review of Randomized Controlled Trials 

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 854-859

        


    Information was gathered from all randomized and quasi-randomized trials comparing open mesh with open non-mesh methods to assess benefits and safety. Electronic databases were searched and members of the EU Hernia Triallist Collaboration consulted to identify trials. Prespecified data items were extracted from reports and quantitative or if not possible qualitative meta-analysis was performed.

        

    15 eligible trials which included 4005 patients were identified. There were similar number of complications in each group, with few data to address short-term pain and length of hospital stays. Return to activity was earlier in the mesh group in seven out of ten trials. [ P not significant]. There were fewer recurrences in the mesh group- Overall 21 [1.4%] of 1513 versus 72[4.4%] of 1634 [odds ratio 0.39 [95% confidence interval 0.25-0.59]; P<0.001].

        

    Within the data available mesh repair was associated with fewer recurrences.

         

  • M.C. Misra and R. Parshad [ Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India]

    Randomized Clinical Trial of Micronized Flavonoids in the Early Control Bleeding from Acute Internal Haemorrhoids

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 868-872

       

    Effective and non invasive control of acute bleeding could be of practical use in scheduling surgery to a convenient time both for patient and surgeon.

       

    In a 90-day randomized double blind study, treatment with a micronized purified flavonoid fraction [ MPFF] was compared to placebo in 100 outpatients who presented for treatment of acute internal haemorrhoids of less than 3 days duration. The primary endpoint was the cessation of bleeding on the third day of treatment.

       

    Of 50 patients randomized to each group, bleeding ceased within 3 days in 40 patients [ 80% of MPFF group] compared with 19 patients [38% of placebo group]. Continued treatment in patients with no bleeding prevented a relapse in 30 of 47 patients [ MPFF groups] compared with 12 of 30 [placebo group].

       

    They conclude that patients with acute internal haemorrhoids treated with MPFF had rapid cessation of bleeding and a reduced rate of relapse. This could be of value in the more convenient timing of treatment with invasive outpatient procedures.

        

  • G. Nilsson, S. Larson and F. Johnson [ Department of Nursing and Surgery, Lund University, Lund, Sweden]

    Randomized Clinical Trial of Laparoscopic Versus Open Fundoplication : Blind Evaluation of Recovery and Discharge Period

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 873-878

       


    There is a widespread belief that laparoscopic surgery in antireflux procedures has led to easier post operative recovery. A prospective randomized clinical trial was undertaken to verify this belief.

      

    60 Patients with G-E reflux disease were randomized to open or randomized 3600 fundoplication. The type of operation was unknown to the patient and the evaluating nurses.

       

    The Laparoscopic procedure took a longer time [ mean 148 min versus 109 min for open surgery]. The need for analgesics was less in the laparoscopic procedure [ 33.9 years versus 67.5 mg morphine per total hospital stay]. There was no significant difference in postoperative nausea and vomiting. The postoperative respiratory function was better and hospital stay was shorter in the laparoscopic group. No difference was found in the duration of sick leaves.

        

    They conclude that laparoscopic fundoplication takes a longer operating time has better post operative respiratory function has less need for analgesia and a shorter hospital stay. There was no difference in the duration of sick leave.

        

  • H. Tanaka, K. Hirohashi, S. Kubo, T. Shuto, I. Higaki and H. Kinoshita

    Preoperative Portal Vein Embolization Improves Prognosis of Right Hepatectomy for Hepatocellular Carcinoma in Patients with Impaired Hepatic Function

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 879-882

       


    Percutaneous transhepatic portal vein embolization [PTPE] increases the safety of subsequent major hepatectomy. This study aims to determine the effect of PTPE on long term prognosis after hepatectomy in patients with hepatocellular carcinoma
    [HCC].

       

    71 patients underwent hepatectomy for HCC. 33 patients [group 1] underwent preoperative PTPE and 38 patients [group 2] did not have this procedure. The patient were further divided according to the median tumour diameter [cut off 6 cm] and indocyanine green retention rate at 15 min [ICGR15] [cut-off 13%]. 

       

    The cumulative survival rate was significantly higher in group 1 then in group 2 in patients with an ICGR15 of at least 13%. Tumour-free survival rates were similar in both groups. Of patients with tumour recurrence after right hepatectomy, those in group 1 were more frequently subjected to further treatment. 

       

    Preoperative PTPE improves the prognosis after right hepatectomy for HCC in patients with impaired hepatic function although it does not prevent tumour recurrence.

       

  • M.W.
    Buchler, H. Friess, M. Wagner, C. Kulli, V. Wagener and K. Z’graggen [ Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, 3010 Bern, Switzerland]

    Pancreatic Fistula After Pancreatic Head Resection

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 883-889

       

    Pancreatic resections have a low mortality but the morbidity rate is 40% – 60% with a high prevalence of complications. This study analyses the complications after pancreatic head resection with particular attention to pancreatic fistula.

       

    Prospective data on 3311 pancreatic head resections were recorded. The data was grouped according to the procedure performed [ classical Whipple, duodenum-preserving pancreatic head resection [DPPHR] or pylorus-preserving pancreatoduodenectomy [ PPPD].

       

    The mortality rate was 2.1% with no difference between the three procedures. Total and local morbidity rates were 30.4 and 28% respectively. DPPHR had a lower morbidity, both local and systemic than Whipple’s. Pancreatic fistula was seen in 2.1% of 331 patients and was not dependent on the procedure or the aetiology. Re-operations were performed in 3.9% of patients, predominantly for bleeding andnon-pancreatic fistula. None of the patients with pancreatic fistula required re-operation or died in the post-operative period.

        

    A standardized technique and improved perioperative care are responsible for low mortality and low surgical morbidity rates after pancreatic head resection. Pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely requires surgical treatment.

      

  • S.R. Shah, D.F. Mirza, R. Afonso, A.D. Mayer, P. McMaster and J.A.C.Buckels [ Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospitals of Birmingham NHS Trust, Edgbaston, Birmingham B15, 2TH, UK]

    Changing Referral Pattern of Biliary Injuries Sustained During laparoscopic Cholecystectomy

    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 890-891

        


    Laparoscopic cholecystectomy has become the procedure of choice for cholelithiasis but it is reported to have a higher incidence of bile duct injuries than conventional open cholecystectomy [0.6% versus 0.3%]. 

        

    Referral of a patient with a bile duct injury to a tertiary centre is often delayed and after prior surgical attempts are made by the referring surgeon.

       

    This study evaluates changes in the referral patterns since the advent of laparoscopic
    cholecystectomy.

       

    48 patients [mean age 49 years, 17 men] with bile duct injury after laparoscopic cholecystectomy [Jan 1991 to Dec 1998 ] were divided into 2 groups – before and after Jan 1996.

       

    The interval between primary surgery and referral; surgical radiological and/or endoscopic interventions; and sevirity of bile duct injury were noted [Strasberg classification] .

       

    More patients in the less severe : type biliary injury are being referred earlier to a specialist hepatobiliary unit. Most patients still have ineffective corrective surgery before transfer.

        

  • David
    W.Hart, MD, Steven E. Wolf MD, David L. Chinkes, PhD Dennis C. Gore, MD, Ronald P, MIcak, RRT, et al [ From the Department of Surgery, The University of Texas Medical Branch and the Shriners Hospitals for Children, Galveston, Texas

    Determinants of Skeletal Muscle Catabolism After Severe Burn

    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 455-465

       

    This study attempts to determine which patient factor affects the degree of catabolism after severe burn.

       

    151 stable-isotope protein kinetic studies were performed in 102 pediatric and 21 adult patients burned over 20-99.5% of total body surface area [TBSA]. 

       

    Patients demographics, burn characteristics and hospital course variables were correlated with the net balance of skeletal muscle protein synthesis and breakdown across the leg. The data was analyzed sequentially and cumulatively through univariate and cross-sectional multiple regression.

       

    Increasing age, weight and delay in definitive surgical treatment predict increased catabolism. Burns upto 40% TBSA increased catabolism. Thereafter the catabolism did not increase consistently. Resting energy expenditure and sepsis also increase catabolism. On the other hand, burn type, pneumonia, wound contamination, and time after burn did not significantly alter catabolism. From these results the authors conclude that gross muscle mass correlates independently with protein wasting after burn.

       

  • John
    Alverdy, MD, Christopher Holbrook, BS, Flavio Rocha, BS, Louis Seiden, PhD, Richard Licheng Wu, MD, PhD, Mrk Musch, PhD, Eugene Change, MD, Dennis Ohman, PhD, and Sanj Suh, PhD [ From the Departments of Surgery, Internal Medicine, and Pharmacology/Physiological Sciences, University of Chicago, Chicago, Llinois, and the Department of Microbiology and Immunology, Medical College of Virginia, Richmond, Virginia]

    Gut-Derived Sepsis Occurs When the Right Pathogen With the Right Virulence Genes Meets the Right Host
    Evidence for In Vivo Virulence Expression in Pseudomonas Aeruginosa

    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 480-489

       


    The objective of this study is to define the gut-active role of the PA-1 lectin/adhesin, a binding protein of pseudomonas aeruginosa, on lethal gut-derived sepsis after surgical stress, and to determine if this protein is expressed in vivo in response to physical and
    chemical changes in the local microenvironment of the intestinal tract after surgical stress.

       

    Previous work has shown that lethal gut-induced sepsis can be induced after the introduction of P. aeruginosa into the cecum of mice after a 30% hepatectomy but it does not occur in sham operated mice [controls]. The mechanism of this effect is due to the presence of PA-1 lectin / adhesin of P. aeruginosa which induces a permeability defect to a lethal cytotoxin of p. aeruginosa, [exotoxin A] 

       

    3 strains of P aeruginosa [ one lacking functional PA-1] were tested in two complementary systems to assess virulence.

       

    Strains were tested for 1] their ability to adhere to and after the permeability of cultured human colon epithelial cells and [2] Their ability to induce mortality when injected into the caecum of mice after 30% hepatectomy. 24 and 48 hours later these strains were retrieved from the caecum and their PA-1 expression was assessed.

       

    Results indicate that PA-1 plays a putative role in lethal gut derived sepsis in mice because strains lacking functional PA-1 had an attenuated effect and were non lethal. Furthermore surgical stress 

    [hepatectomy] significantly altered the intestinal micro environment resulting in an increase in the luminar norepinephrine associated with an increase in PA-1 expression in retrieved strains of P. aeruginosa. Coincubation of P. aeruginosa with nor-epinephrine increeased [PA-1 expression in vitro suggesting that norepinephrine plays a role in the observed role in vivo.

        

  • Philip R. Schauer, MD,Sayeed Ikramuddin, MD, William Gourash, CRNP, Ramesh Ramanathan, MD, and James Luketich, MD [ From the Department of Surgery, University of Pittsburgh, and the Mark Ravich/ Leon Hirsch Center for Minimally Invasive Surgery, Pittsburgh, Pennsylvania

    Outcomes After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 515-529

         

    This study evaluates the short term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with morbid obesity with a follow up of 1-31 months.

        

    275 consecutive patients who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass [July 1997 to March 2000] A 15 mL gastric pouch and a 75 cm Roux limb. [ 150 cm for superobese] was created using 5 or 6 trocar incisions.

       

    The conversion to open surgery was 1%. Oral feeding began a mean of 1.58 days after surgery with a median hospital stay of 2 days and return to work after 21 days.

       

    One death occurred [0.4%] due to pulmonary embolism. The incidence of early major and minor complications was 3.3% and 27% respectively. The hernia rate was 0.7% , and wound infection rate was 5%. Excess weight loss at 24 and 30 months was 83% and 77% respectively. In patients with more than 1 year follow up most of the comorbidities were improved or resolved. 95% reported significant improvement in quality of life.

       

    Laparoscopic Roux-en-Y gastric bypass is an effective procedure for morbid obasity with minimal morbidity and mortality.

       

  • Harvey J. Sugerman, MD, Elizabeth L, Sugeman, BSN, Jill G, Meador,BSN, Heber H, Newsome , Jr., MD, John M, Kellum, Jr., MD, and Eric J. DeMaria, MD [ From the General /Trauma Surgery Division, Department of Surgery, Medical College of Virgina of Virginia Commonwealth University, Richmond, Virginia]

    Ileal Pouch Anal Anastomosis Without Ileal Diversion

    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos.
    530-541

         

    This study evaluates the results of a one stage stapled ileoanal pouch procedure without temporary ileostomy diversion.

        

    201 such procedures [IPAA] were carried out for ulcerative colitis and familial adenomatous polyposis, and one with concurrent Whipple procedure – of which only 2 were with an ileostomy as a one stage procedure.

        

    These patients were reviewed retrospectively for at least 1 year after surgery.

       

    Of those operated, 178 had ulcerative colitis [38 fulminant], 5 had Crohn’s disease, 1 had intermediate colitis, and 8 had familial adenomatous polyposis. The mean age was 38+ 7 years [7-70 years] with 98 males and 94 females. The average amount of disease tissue between the dentate line and the anastomoses line was 0.9 1cm with 35% anastomosis at the dentate line. The follow up was 89% at 1 year or more [mean 5.1 + 2.4 years] after surgery. The average 24 hour stool frequency was 7.1 + 3.3 of which 0.9 + 1.4 were at night. Control of stool was 95% during daytime and 90% at night. Only 2.3% required to wear a perineal pad. The average length of hospital stay was 10 + 0.3 days with 1.5+ 0.5 readmission for complications. Abscesses or enteric leaks occurred in 23 patients. 

        

    IPAA function was excellent in 19 [ 2 had permanent ileostomies] . In patients taking steroids there was no significant difference in leak rates.

       

    This date proves that the triple stapled IPAA without temporary ileostomy has a low complication rate, low rate of small bowel obstruction, excellent feacal control and permits an early return to functional life.

       

  • R. Phillip Burns, J. Preston Brown, S. Michael Roe, L. Richard Sprouse II, Andrea E, Yancey, and Laura E, Witherspoon, [From the Department of Surgery, University of Tennessee college of Medicine, Chattanooga Unit, chattanooga, Tennessee]

    Stereotactic Core-Needle Breast Biopsy by Surgeons

    Minimum 2-Year Follow-up of Benign Lesions

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 542-548

        

    This study evaluates the reliability of stereotactic core needle biopsy of the breast [SCNB] performed by surgeons to detect histologically benign tissue.

       

    A retrospective study was performed on 694 lesions detected in 619 patients. The breast lesions were classified by mammograms. Benign biopsy specimens were classified as proliferative or non-proliferative. Malignant lesions and those with atypical histopathology were excluded. All benign lesions were followed up for at least two years for any suspicious change requiring repeat biopsy.

       

    Of all biopsies 16% were malignant. The initial diagnosis in the others was benign. 400 lesions were available for follow-up. Of these 373 [93%] were classified as [mammographically]. BI-RADS 3 [probably benign] or 4 [suspicious]. 343 were non proliferative and 157 as proliferative [ 94 had combined proliferative and non proliferative] . The follow up ranged from 24-48 months [mean 33 months]. During the follow-up period 87 lesions underwent either image guided or open biopsy. At the time of follow-up rebiopsy, ductal carcinoma in situ was found on 4 occasions and infiltrating duct carcinoma in one, [ overall false negative of 4.3% i.e. 5 out of 117 cases] and a negative predictive value of 98.8%. No correlation was found between the type of initial pathology and development of malignancy.

       

    The authors conclude that SCNB is an alternative to open biopsy in benign lesions. However given the possibility of sampling error, close mammographic and clinical follow up as required.

       

  • Mark W. Onaitis, Paul M. Kirshbom, Thomas Z. Hayward, Frank J. Quayle, Jerome M. Feldman, Hilliard F. Seigler, and Douglas S. Tyler [ From the Departments of Surgery and Medicine, Duke University Medical Center, Dursham, North Carolina]

    Gastrointestinal Carcinoids : Characterization by Site of Origin and Hormone Production

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 549-556

       

    This study describes a large series of patients with carcinoid tumors in terms of their clinical features, hormonal diagnosis and survival.

       

    A prospective database of carcinoid tumour patients seen at Duke University Medical Center was kept from 1970 onwards.

       

    A retrospective review of medical records was done on this database to record clinical features, hormonal data, pathologic features and survival.

      

    Carcinoids at different sites had different clinical features. Rectal tumours presented with bleeding and midgut carcinoids with flushing diarrhea, and the carcinoid syndrome. 

       

    They had significantly higher levels of serotonin and its breakdown products, corresponding to higher metastatic tumor burdens. Although age, stage, region of origin and urinary levels of 5-HIAA predicted survival by univariate analysis; with a multivariate analysis only the latter there were independent predictors of survival. In patients with metastatic disease midgut tumours had better prognosis than foregut or hindgut tumours.

       

  • Yuman Fong, William Jamagin, and Leslie H, Blumgart [ From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York]

    Gallbladder Cancer : Comparison of Patients Presenting Initially for Definitive Operation With Those Presenting After Prior Noncurative Intervention

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 557-569

       

    This study compares patients with gall bladder cancer presenting for therapy with and without prior operation elsewhere to determine if an initial noncurative procedure alters outcome.

       

    Clinical presentation, operative data, complications and survival were examined for 410 patients [ 240 presented after prior operation elsewhere and the remaining who had no prior operation. 

       

    Overall, 51 patients were inoperable, 92 were subjected to biopsy only 135 to non curative cholecystectomy, 30 to surgical bypass and 102 to potentially curative resections [ portal lymph node dissection and liver parenchymal resection].

       

    The operative mortality was 3.9% . T-stage predicted likelihood of distant metastases and resectability, median survival for resected cases was 26 months and 5 year survival was 38% when resection was not done mortality was 5.4% and 5 year survival was 4%.

       

    The mortality, complications, and long term survival did not alter if prior exploration had been done.

      

    By multivariate analysis, resectability and stage were independent predictors of long term survival but prior surgical exploration was not.

       

  • Eugene S. Flamm, Arthur A. Grigorian, and Alvin Marcovici [ From the Department of Neurosurgery, Albert Einstein College of Medicine, Beth Israel Medical Center, New York, New York]

    Multi factorial Analysis of Surgical Outcomes in Patients with Unruptured Middle Cerebral Artery Aneurysms

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 570-575

       

    The study aims to build a predictive tool for assessing favorable outcome and morbidity in unruptured aneurysms.

    93 patients [ with 101 unruptrured aneurysms] were studied after surgery. Intra operative data was reviewed and seven factors that might affect the outcome were analysed. 

       

    1] Aneurysm size > 10 mm.

    2] Presence of broad neck

    3] Presence of intraaneurysmal plaque

    4] Clipping of more than one aneurysm during the same surgery.

    5] Temporary occlusion of the middle cerebral artery

    6] Multiple clip applications and repositionings 

    7] Use of multiple clips.

       

    The entire group was divided into two subgroups on the basis of the outcome. Each patient was subsequently analysed for the Factor Accumulation Index [FAI]. The sum of the different factors observed.

       

    Group 1: [ Expected outcome] – 86 patients with a total of 92 aneurysms. The results were as follows . 

       

    FAI 1- 6 patients. FAI 2 – 23 patients, FAI 3 – 12 patients, FAI 4
    – 11 patients, FAI 5 – 8 patients FAI 6 – 1 patient, FAI 7 – 1 patient

       

    Group 2 – 7 patients – total morbidity of 7.5% There were no deaths in this group. FAI 1
    – 0,1,2 or 5 [ no patients] FAI 3- 2 patients, FAI 4 – 2 patients, FAI 6
    – 1 patient and FAI 7 – 2 patients.

      

    The authors conclude that it is possible to predict the outcome in aneurysms by calculating FAI. The post operative morbidity increases with an FAI within a range of 3 to 4.

       

  • Ambrosio Hernandez, Farin Smith, BS, QingDing Wang, Xiaofu Wang, BS, and B. Mark Evers [ From the department of Surgery, The University of Texas Medical Branch, Galveston, Texas]

    Assessment of Differential Gene Expression Patterns in Human Colon Cancers

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 530-541

       

    This study uses a novel genomic approach to determine differential gene expression patterns in colon cancers of different metastatic potential.

       

    Human colon cancer cells KM12C [derived from a Dukes B colon cancer] KML 4A [ a metastatic variant derived from KM12C] and KM20 [ derived from Dukes D Colon Cancer] were extracted for RNA. In addition RNA was extracted from normal colon primary cancer and hepatic metastasis in a patient with metastatic colon cancer. Gene expression patterns for approximately 1200 human genes were analyzed and compared by cDNA array techniques.

       

    Of the 1200 genes assessed in the KM cell lines,9 genes were noted to have more than threefold change in expression [either increased or decreased] in the more metastatic KML4A and KM20 cells compared with KM12C. There was more than threefold change in expression of 16 genes in metastatic colon cancer compared with normals.

       

    The authors have identified genes with expression levels that are altered with metastasis.

          

  • Stephen J. Mathes, Paul M. Steinwald, Robert D. Foster, William Y. Hoffman, and James P. Anthony [ From the Division of Plastic and Reconstructive Surgery, University of California at san Francisco, California]

    Complex Abdominal Wall Reconstruction : A Comparison of Flap and Mesh Closure

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 586-596



    This study analyses a series of patients treated for recurrent or chronic abdominal wall hernias and determines a treatment protocol for defect construction.



    104 patients [106 hernias] undergoing abdominal reconstruction for recurrent or chronic complex defects were retrospectively analysed. For each patient, the aetiology, size, location average duration and technique of reconstruction and postoperative results including complications and recurrences was studied.



    Patients were divided into two groups based on the defect. Type 1 had intact skin over the hernia and type II had absent or unstable skin covers. The defects were also assigned to zones based on 

    the primary defect location. Zone 1A, upper midline, Zone 1B lower midline, zone 2 upper quadrant, and zone 3 lower quadrant.



    68% cases were incisional hernias. Of 50 type 1 defects, 10[20%] were repaired directly, 28[56%] were repaired with a mesh and 12[24%] required flap repair . For 56 type II defects 48 [80%] required flap repair. The overall complication and recurrence rates were 29% and 80% respectively.



    They conclude that for Type 1 defect a mesh repair gives the best results with the least complications. For type II defects a flap repair is advisable with tensor fascia lata being the flap of choice particularly in the lower abdomen. Rectus advancement may be used for midline defects. Overall failure is caused by repair under tension, extraperitoneal mesh placement or technical error.

       

  • C. Wright Pinson, Irene D. Feurer, Jerita L. Payne, RN, MSN, Paul E. Wise, Shannon Shockley, and Theodore Speroff [ From the Vanderbilt University Transplant Center, Nashville, Tennessee]

    Health-Related Quality of Life After Different Types of Solid Organ Transplantation 

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 597-607

        

    This study describes the functional health and health related quality of life [QOL] before and after transplantation to compare and contrast outcomes among liver, heart, lung and kidney transplants, and compare these outcomes with selected norms and to explore whether physiologic performance demographics and other clinical variables are predictors of post transplantation overall subjective QOL.

       

    The Karnofsky performance status was assessed objectively for patients before transplantation and upto 4 years after transplantation and scores were compared by repeated measures analysis of variance. Subjective evaluation of QOL overtime was obtained using the short form –36 [ SF-36] and the psychosocial adjustment to illness Scale [PAIS].

       

    Results : Tools were administered to 100 liver, 94 heart, 112 kidney and 65 lung transplant patients. The mean age at transplantation was 48 years, 36% were female. The KPS before transplantation was 37 + 1 for lung 38 + 2 for heart 53 + 3 for liver and 75 + 1 for kidney recipients.

       

    After transplantation the scores improved to 67 + 1 at 3 months. 77 +1 at 6 months 82 + 1 at 12 months, 86 + 1 at 24 months and 84 + 2 at 36 months and 83 + 3 at 48 months.

       

    When patients were stratified by initial performance score as disabled or able, both groups merged in terms of performance by 6 months after liver and heart transplantation. Kidney transplant cases 

    maintained their stratification 2 years after transplantation. The PAIS score improved globally. Path analysis demonstrated a direct effect on the post transplant Karnofsky score by time after transplantation and diabetes, with trends evident for education and preoperative serum cretinine level. Although neither time after transplantation nor diabetes was directly predictive of a composite QAL score that incorporated all 15 subjective domains, recent Karnofsky score and education level were directly predictive of the QOL composite score.

       

    This data provides clearly defined and widely useful QOL outcome benchmarks for different types of solid organ transplants.

        

  • James D. Luketich, Siva Raja , BS, Hiran C. Fernando, William Campbell, Neil A. Christie, Percival O. Buenaventura, Tracey L. Weigel, Robert J. Keenan, and Phillip R. Schauer [ From the Department of Surgery and Radiology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania]

    Laparoscopic Repair of Giant paraesophageal Hernia : 100 Consecutive Cases

    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 608-618

       

    From July 1995 to February 2000, 100 patients [median age 68 years] underwent laparoscopic repair of a giant PEH. Follow up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores.

       

    There were 8 type II hernias, 85 type III, and 7 type IV hernias. Sac removal, Crural repair, and antireflux procedures were performed [ 72 Hissen, 27 Collis-Nissen]. There was no early mortality, but one surgery related death at 5 months from a perioperative stroke. Intra operative complications included pneumothorax, esophageal perforation and gastric perforation. There were 3 conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome and repeat operations [ two for abscess and one each for haematoma, repair leak and recurrent hernia]. Median length of stay was 2 days. Median follow up at 12 months revealed resumption of proton pump inhibitors in10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 [ 0 best, 45, worst]; the 

    satisfaction score was 91%, physical and mental component summary scores were 49 and 54 respectively [normal 50].

       

    Laparoscopic repair of giant PEH was successful in 97% of patients with a minimal complication rate, a 2-day hospital stay and good intermediate results. 

       

  • T.M.D. Hughes, R.P. A’Hern and J.M. Thomas [ Melanoma and Sarcoma Unit, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK]

    Prognosis and Surgical Management of Patients with Palpable Inguinal Lymph Node Metastases from Melanoma

    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 892-901

        

    The aim of this study was to identify factors that influence the outcome of patients undergoing therapeutic groin dissection for clinically detectable melanoma lymph node metastases. 

       

    A retrospective study of 132 cases who underwent lymph node dissection [ inguinal] therapeutically.

       

    60 Patients had superficial inguinal lymph node [SLND] dissection and 72 had combined superficial inguinal and pelvic lymph node dissection [CLND]. 

         

    There was no difference in postoperative morbidity or major lymphoedema. The overall survival rate was 34% at 5 years. On univariate analysis age, the number of superficial inguinal nodes and presence of extra capsular spread had a significant impact on survival. The presence of or absence of pelvic lymph node metastases was a significant prognostic factor [ 19% vs. 47%].

        

    The prognosis of patients with clinically detectable melanoma metastases to the groin is variable and related to the biologic characteristics of each case. CLND provided additional prognostic information and optional regional control but no change in morbidity compared to SLND.

         

  • A.O’Bichere, P. Sibbons, C. Dore, C. Green and R.K.S. Phillips [ St. Marks Hospital and Northwick Park Institute for Medical Research, Harrow, UK]

    Experimental Study of Faecal Continence and Colostomy Irrigation

    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 902-908

        

    This study investigates the effect of modifying colostomy irrigation technique [route, infusion regimen and pharmacological manipulation] on colonic emptying time in a porcine model.

        

    An end colostomy and caecostomy were fashioned for six pigs. Twenty markers were introduced into the caecum immediately before colonic irrigation. Irrigation route [antegrade or retrograde], infusion regimen [ tap water, polyethylene glycol [PEG], 1.5 per cent glycine] and pharmacological agent [glyceryl trinitrate [GTN] 0.25 mg/kg, diltiazem 3.9 mg/kg, bisacodyl 0.25 mg/kg] were assigned to each animal at random. Colonic transit time was assessed by quantifying cumulative expelled markers [CEM] and stool every hour for 12 hours.

       

    Mean CEM at 6 hours for bisacodyl, GTN and diltiazem were 18.17, 12.17 and zero respectively; all pairwise differences in means were significant. The difference at 12 hours between the two routes and three fluids was significant, but not for PEG versus glycine and bisacodyl versus GTN. Cumulative output was significantly more with antegrade than retrograde route using PEG, but the difference in mean cumulative output for bisacodyl and GTN at [ 12 hours was not significant].

       

    The conclusion drawn is that colonic emptying is more efficient with antegrade than retrograde irrigation. PEG and glycine enhance emptying similar to bisacodyl and GTN solution. This promises improved faecal continence by colostomy irrigation and may justify construction fo a Malone conduit at the time of colostomy in selected patients. 

        

  • E.
    Rullier, F. Zerbib, C. Laurent, M. Caudry and J. Saric [ Departments of Digestive Surgery, Gastroenterology and Radiation Oncology, Saint-Andre Hospital, 33075 Bordeaux Cedex, France]

    Morbidity and Functional Outcome After Double Dynamic Graciloplasty for Anorectal Reconstruction

    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 909-913

        

    The aim of this study was to evaluate the morbidity and functional results in a homogeneous series of patients undergoing double dynamic graciloplasty following APR for rectal cancer.

        

    15 patients[ 10 men and 5 women, mean age of 54 years range [ 39 to 77] underwent anorectal reconstruction with double dynamic graciloplasty after APR for low rectal cancer. 

        

    All patients had preoperative radiotherapy [ 15 Gy] and ten received adjuvant, chemotherapy, 8 had intraoperative radiotherapy [15 Gy] and ten received 

    adjuvant chemotherapy for six months. Surgery was performed in three stages : APR with coloperineal anastomosis and double graciloplasty; implantation of the stimulation 2 months later; and ileostomy closure after a training period.

        

    There was no operative death. At a mean of 28 months [3-48] of follow-up there was no local recurrence; 2 patients had lung metastases. Early and late morbidity occurred in 11 patients [mainly related to neosphinctor], mainly stenosis. Of 12 patients followed up for functional outcome. 7 were continent, 2 were incontinent and 3 had an abdominal colostomy [ 2 for incontinence and one for sepsis]. The restenosis required major surgery and had a poor outcome.

       

    The conclusion is that the double dynamic graciloplasty is associated with a high risk of neosphincter stenosis which may entail morbidity, reintervention and poor functional results. It is suggested that single dynamic graciloplasty should be used for anorectal reconstruction after APR.

        

  • D.C. Jenner , A. Middleton, W.M. Webb, R. Oommen and T. Bates [ The Breast Unit, William Harvey Hospital, Ashfold TN24 OLZ, UK]

    In-Hospital Delay in the Diagnosis of Breast Cancer

    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 914-919

        

    Delay in the diagnosis of breast cancer may prejudice survival. The aim of this study was to determine the incidence, time trends and causes of delay in a dedicated breast clinic. 

        

    The interval between the first visit to the clinic and a definitive diagnosis, was recorded in 1004 patients with invasive breast cancer.

        

    There was a delay of 3 months or more in 42 cases [4.2%]. The median delay was 6 months and the median age at diagnosis was 53 years [range 27-89 years]. Triple assessment was undertaken in 30 patients. Ten did not have a needle biopsy and three patients did not have a mammography. The principal cause of delay was false negative or inadequate needle aspiration cytology [FNAC] in 19 patients, a failure of follow-up in 8 cases, failure of needle localization in two cases, FNAC not carried out in 4 cases, no clinical signs in five patients and one case who did not follow clinical advice. The annual incidence of delay in diagnosis did not change significantly over a 10 year interval.

       

    Triple assessment is not sufficiently sensitive to detect breast cancer and a small delay in diagnosis is inevitable with current techniques.

        

  • L. Jansen, M. H.E. Doting E.J.Th. Rutgers, J. de Vries, R.A. Valdes Olmos and O.E.Nieweg [ Departments of Surgery and Nuclear Medicine, The Netherlands Cancer Institute /Antoni van Leeuwenhock Hospital, Amsterdam and Department of Surgical Oncology, Groningen University Hospital, Groningen, The Netherlands]

    Clinical Relevance of Sentinel Lymph Nodes Outside the Axilla in Patients with Breast Cancer 

    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 920-925

       

    Lymphatic mapping in patients with breast cancer can reveal sentinel lymph nodes that are not located at level I-II of the axilla. The clinical relevance of this is not fully understood.

       

    113 consecutive patients [T1-3 No Mo] with breast cancer were studied. Based on preoperative scintigraphy. Sentinel node biopsy was performed guided by a g probe and patent blue dye. All sentinel nodes that were visible were biopsied and examination of those nodes included step sections and staining with CAM5.2. Axillary node dissection was performed regardless of sentinal lymph node status.

       

    19% [ 21 cases] had sentinel lymph nodes outside level I-II of the axilla, mostly in the internal mammary chain. 22 of the 30 sentinel nodes at these sites were harvested. 3 patients had sentinel nodes only outside the axilla. 4 other patients had metastases outside the axilla. This changed postoperative treatment in 3 patients. No postoperative complication occurred.

       

    Biopsy of sentinel lymph nodes [19% of cases in this series] is technically demanding but the clinical impact was limited – treatment changed in only 3%.

        

  • S. Kitano, D. Baatar, T. Bandoh, T. Yoshida, S. Tsuboi and Matsumoto [ Department of Surgery, I, Qita, Medical University, Oita 879-5593, Japan]

    Transvenous Sclerotherapy for Huge Oesophagogastric Varices Using Open Injection Sclerotherapy 

    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 926-930

        

    This report describes a new procedure for treating huge oesophagogastric varices by open injection
    sclerotherapy.

       

    23 patients with huge oesophagogastric varices underwent laparotomy and devascularization of the upper stomach with splenectomy. The left gastric vein was catheterized for repeated injection of 5% ethanolamine oleate during the postoperative period.

       

    In all patients the varices were eradicated after a mean of 3 sessions of sclerotherapy. There were no deaths or major complications during mean follow up of 41 months. Small recurrent varices in 2 patients were treated successfully by endoscopic sclerotherapy and interventional radiology.

        

    Open injection sclerotherapy is an effective and safe procedure for the treatment of huge oesophagogastric varices.

         

  • David
    W.Hart, MD, Steven E. Wolf MD, David L. Chinkes, PhD Dennis C. Gore, MD, Ronald P, MIcak, RRT, et al [ From the Department of Surgery, The University of Texas Medical Branch and the Shriners Hospitals for Children, Galveston, Texas

    Determinants of Skeletal Muscle Catabolism After Severe Burn

    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 455-465

       


    This study attempts to determine which patient factor affects the degree of catabolism after severe burn.

       

    151 stable-isotope protein kinetic studies were performed in 102 pediatric and 21 adult patients burned over 20-99.5% of total body surface area [TBSA]. 

       

    Patients demographics, burn characteristics and hospital course variables were correlated with the net balance of skeletal muscle protein synthesis and breakdown across the leg. The data was analyzed sequentially and cumulatively through univariate and cross-sectional multiple regression.

        

    Increasing age, weight and delay in definitive surgical treatment predict increased catabolism. Burns upto 40% TBSA increased catabolism. Thereafter the catabolism did not increase consistently. Resting energy expenditure and sepsis also increase catabolism. On the other hand, burn type, pneumonia, wound contamination, and time after burn did not significantly alter catabolism. From these results the authors conclude that gross muscle mass correlates independently with protein wasting after burn.

       

  • John
    Alverdy, MD, Christopher Holbrook, BS, Flavio Rocha, BS, Louis Seiden, PhD, Richard Licheng Wu, MD, PhD, Mrk Musch, PhD, Eugene Change, MD, Dennis Ohman, PhD, and Sanj Suh, PhD [ From the Departments of Surgery, Internal Medicine, and Pharmacology/Physiological Sciences, University of Chicago, Chicago, Llinois, and the Department of Microbiology and Immunology, Medical College of Virginia, Richmond, Virginia]

    Gut-Derived Sepsis Occurs When the Right Pathogen With the Right Virulence Genes Meets the Right Host

    Evidence for In Vivo Virulence Expression in Pseudomonas Aeruginosa

    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 480-489

        


    The objective of this study is to define the gut-active role of the PA-1 lectin/adhesin, a binding protein of pseudomonas aeruginosa, on lethal gut-derived sepsis after surgical stress, and to determine if this protein is expressed in vivo in response to physical and chemical changes in the local microenvironment of the intestinal tract after surgical stress.

       

    Previous work has shown that lethal gut-induced sepsis can be induced after the introduction of P. aeruginosa into the cecum of mice after a 30% hepatectomy but it does not occur in sham operated mice [controls]. The mechanism of this effect is due to the presence of PA-1 lectin / adhesin of P. aeruginosa which induces a permeability defect to a lethal cytotoxin of p. aeruginosa, [exotoxin A] 

      

    3 strains of P aeruginosa [ one lacking functional PA-1] were tested in two complementary systems to assess virulence.

      

    Strains were tested for 1] their ability to adhere to and after the permeability of cultured human colon epithelial cells and [2] Their ability to induce mortality when injected into the caecum of mice after 30% hepatectomy. 24 and 48 hours later these strains were retrieved from the caecum and their PA-1 expression was assessed.

      

    Results indicate that PA-1 plays a putative role in lethal gut derived sepsis in mice because strains lacking functional PA-1 had an attenuated effect and were non lethal. Furthermore surgical stress 

    [hepatectomy] significantly altered the intestinal micro environment resulting in an increase in the luminar norepinephrine associated with an increase in PA-1 expression in retrieved strains of P. aeruginosa. Coincubation of P. aeruginosa with nor-epinephrine increeased [PA-1 expression in vitro suggesting that norepinephrine plays a role in the observed role in vivo.

       

  • Watson A. [ Department of Surgery, Royal Free and University College Medical School, Royal Free Hospital, London NW3 2QG, UK]

    Barrett’s Oesophagus – 50 Years on

    BRJ, Volume –87, Number 5, May, 2000, Pg.Nos 529-531

       


    Norman Barrett first described the columnar-lined oesophagus associated with a congenital short oesophagus.

       

    The incidence of oesophageal adenocarcinoma, as a consequence of gastro-oesophageal reflux disease [GORD] and Barrett’s oesophagus, is increasing more rapidly than that of any other malignancy in the Western world.

       

    There is now very strong evidence that Barrett’s oesophagus is an acuired condition consequent on long-standing GORD. Intestinal metaplasia is a necessary prerequisite to the development of adenocarcinoma.

       

    Malignant transformation occurs in a stepwise process from metaplasia through dysplasia to carcinoma, involving a series of molecular changes that include p53 and p16 mutations, aneuploidy and microsatellite instability.

       

    Management of Barrett’s oesophagus is controversial.

       

    Successful antireflux surgery offers complete and continuous reflux control, which is of particular relevance because intermittent pulse acid exposure causes greater cellular proliferation and de-differentiation of Barrett’s oesophagus cells in culture than either no acid or continuous acid.

       

    The development of adenocarcinoma is inevitable once the cascade of genomic instability has commenced, but effective reflux control before this may have a protective role.

       

    Traditionally, Barrett’s oesophagus has only been deemed to exist if the circumferential columnarized segment exceeds 3 cm in length.

       

    The finding of microscopic intestinal metaplasia of the cardia is more likely to be associated with Helicobacter pylori infection than GORD and has not been demonstrated to progress to cancer.

       

  • E.M.
    Targarona, C. Balague, M.M. Knook and M. Trias [ Departments of General and Digestive Surgery, Hospital de Sant Pau and Hospital Clinic, Barcelona, Spain ]

    Laparoscopic Surgery and Surgical Infection

    BRJ, Volume –87, Number 5, May, 2000, Pg.Nos 536-544

        

    It is now broadly accepted that the immune system is better preserved following laparoscopic than open surgery; this is demonstrated by the diminished release of various markers including interleukin [IL] 6 and C-reactive protein [ CRP]. This decreased immune response results from a significantly smaller tissue injury.

        

    It is also important to analyze the peritoneal response to infection because surgical infection initially develops in he peritoneal cavity.

       

    Pneumoperitoneum causes morphological changes in the peritoneal microstructure, proportional to its duration of use.

       

    Loss of contact and fissures between mesothelial cells, as well as infiltration of macrophages and erythrocytes, have been demonstrated by electron microscopy, features that occur at a faster rate in a contaminated environment.

      

    Carbon dioxide affects intracellular conditions, creating an acidic milieu. 

      

    Carbon dioxide attained a significantly lower intra-abdominal pH than those insufflated with ambient air or helium.

      

    Therefore, carbon dioxide may impair the cellular physiology of macrophages.

      

    The viability of T cells depends on pH level. Both the mechanical factor and the direct influence of carbon dioxide affect peritoneal cell physiology.

      

    The advantages of using gases other than carbon dioxide are still under investigation.

      

    Operative laparoscopy requires pneumoperitoneum at high pressure for a prolonged period.

    Hyperpressure of such duration may increase intraperitoneal infection by peritoneal dissemination. 

      

    However, the incidence of postoperative infectious complications is generally assumed to be low.

      

    The risk of bacteraemia or sepsis is potentially increased by the laparoscopic environment.

       

    The systemic inflammatory response and the number of intra-abdominal abscesses were lower after laparoscopic surgery than after open operation [laparotomy].

       

    It has been demonstrated that the smoke produced by electrocauterization is able to spread viable cells and viruses.

      

    A possible danger of infecting surgical personnel has been attributed to the use of pneumoperitoneum. Suspended particles from the internal cavity may travel from the body through trocar orifices into the ambient air.

      

    There is a consensus, however, that a small risk of infection through aerosolization during interventions with pneumoperitoneum may exist when dealing with patients who are infected with human immunodeficiency virus [HIV] or hepatitis C virus. This risk is smaller than that associated with a cutaneous puncture, yet it is recommended that the situation be avoided by aspirating the intra-abdominal gas at the end of the procedure.

      

    It is important to stress the need to aspirate the pneumoperitoneum at the end of the procedure and to discard or sterilize used instruments.

      

    For open surgery, instruments are easily sterilized by conventional methods [ gas or autoclave]. However, for laparoscopic work the kit is mechanically more complex and so its complete sterilization is difficult; disposable instruments are preferred.

      

    Solid residue exists in higher quantity following sterilization of instruments used for laparoscopic work. It is recommended that surgeons follow manufacturers instructions. Reusable instruments, on the other hand, are able to be dismantled to allow complete cleaning and sterilization.

      

  • L.J. Fon and R.A. J. Spence [ General Surgical Unit, Belfast City Hospital, Belfast, UK]

    Sportsman’s Hernia

    BRJ, Volume – 87, Number 5, May, 2000, Pg. Nos 545-552

       


    Sportsman’s hernia is a debilitating condition, which presents as chronic groin pain. A tear occurs at the external obliqe which may result in an occult hernia.

      

    The diagnosis of sportsman’s hernia is difficult. The condition must be distinguished from the more common osteitis pubis and musculotendinous injuries.

       

    Chronic groin pain is a major diagnostic and therapeutic dilemma.

       

    Groin injury leading to chronic pain is often referred to as the sportsman’s hernia or groin disruption and, sometimes, as pubalgia. 

      

    Gilmore popularized the syndrome of groin disruption as ‘Gilmore’s groin’ in the early 1990s and has reported good results from surgical management. 

      

    Chronic groin pain may originate from muscles, tendons, bones, bursas, fascial structures, nerves and joints.

      

    A deficiency of the posterior inguinal wall is the commonest operative finding in patients with groin pain.

      

    An accurate clinical history and extensive examination of the spine, pelvis, hips, and abdominal and leg musculature plays an important part in determining its cause. 

      

    Pain is notably worse over the pubic tubercle of the affected side, and the area around the external ring is tender.

      

    Coughing, sneezing and kicking a ball exacerbate the symptoms.

      

    Clinical findings typically include a lack of visible external signs in the affected groin, dilatation of the superficial ring [demonstrable by scrotal inversion with the tip of the little finger], a cough impulse and marked tenderness in the opposite groin.

      

    Apart from hernia, two other major causes of groin pain are muscle and tendon injury, and osteitis pubis.

      

    Other less common causes include nerve entrapment and urological pathology. Rarer reported causes include bone and joint dosease, such as stress fractures, snapping hip syndrome, spondylolisthesis, early osteoarthritis and slipped upper femoral epiphysis.

       

    Herniography is performed by injecting contrast medium into the peritoneal cavity. The patient is then moved to an upright position and asked to strain. Anteroposterior and oblique views are taken.

       

    Herniography has been reported to have an accuracy [95-99.5 per cent] and low false negative rate [ 0.5-4.0 per cent] in the detection of abdominal wall hernia.

       

    Negative herniography does not exclude on occult hernia.

       

    MRI can clearly identify structures [ inferior epigastric vessels, inguinal ligament, deep and superficial rings, inguinal canal, spermatic cord, round ligament and vascular structures] that are crucial in the assessment and differentiation of inguinofemoral hernias.

       

    It is superior to CT as an imaging modality for muscle strain injury. 

       

    MRI is of limited value in the diagnosis of calcified tendinitis and bony abnormality at tendon insertion points; these are better visualized using CT.

       

    The main advantage of ultrasonography, CT and MRI is their ability to identify conditions other than hernias that may be responsible for the symptoms.

       

    Initially, conservative management with rest, anti-inflammatory agents, stretching and strengthening exercise should be advised.

       

    Surgical intervention is contemplated when conservative management has failed. There is no consensus to support any particular surgical procedure.

       

    Despite ‘negative’ investigation, in severe and/or persistent cases surgical exploration is justified.

       

    Appropriate repair of the posterior wall of the inguinal canal has proven to be of therapeutic benefit, offering cure to over 60 per cent of the patients and improvement to a further 20 per cent.

       

  • A.J. Smith, J.J. Lewis, N.B. Merchant, D.H.Y. Leung, J.M. Wodruff and M.F. Brennan [ Department of Surgery, Biostatistics and Pathology, Memorial sloan-Kettering Cancer Center, New York, USA]

    Surgical Management of Intra-Abdominal Desmoid Tumours

    BRJ, Volume – 87, Number 5, May, 2000, Pg. Nos 608-613

       

    Intra-abdominal desmoids are uncommon neoplasms. The aggressive nature of these tumours and the potential for major morbidity secondary to resection can present a difficult surgical dilemma.

       

    Intra-abdominal desmoid tumours occur sporadically or in association with familial adenomatous polyposis [FAP] and often present a clinical dilemma.

      

    These tumours exhibit benign histological features and do not metastasize, yet their local behaviour is aggressive as they invade contiguous structures and have a marked propensity to recur after resection.

      

    Intra-abdominal desmoid are frequently associated with the intestinal mesentery, a feature that predisposes to complications of bowel obstruction and fistula formation, and also impedes efforts at resection.

      

    Small series have documented regression following therapy with antioestrogens [tamoxifen, toremifene], non-steroidal agents, cytotoxic chemotherapy and radiotherapy. However, there are also reports of spontaneous regression, making the role of medical therapy unclear.

       

    Of note, there was no difference in the overall survival rate between the completely resected and unresected groups of patients. 

       

    Although most patients undergoing complete resection had positive histological margins, the majority had no recurrence at follow
    – up. 

       

    Significant morbidity and mortality occurred in some patients in whom complete resection was undertaken, usually because of intestinal resection.

       

    Therapeutic decision-making a challenging because surgical resection of these lesions is technically difficult and accompanied by a significant risk of complication, while medical therapy is of unclear benefit.

       

    Biology of intra-abdominal desmoids may be characterized by initial rapid growth followed by stability or regression.

       

    Desmoids are noted for their proclivity to recur following resection in up to one-third of cases.

       

    Heroic resection that endanger the viability of the small intestine and the patient should be avoided. 

       

    Given that these tumours may be associated with minimal symptomatology, a trial of watchful waiting and minimally toxic medical therapy [e.g. antioestrogens, sulindac] may be preferable to resection, especially in patients with lesions intimately involved with the mesenteric vessels.

       

  • a.

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

    Results
    of Surgical Treatment for Faecal Incontinence


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


       

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

     

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

     

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

       

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

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

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


      

    The frequency of postoperative infectious
    complication is significantly increased in patients
    with colorectal cancer receiving 
    perioperative blood transfusion. However, it
    is still debated, if it alters the incidence of
    local recurrence or of the prognosis.

       

    Patients risk variables, operation technique, blood
    transfusion and the development of infectious
    complications was recorded prospectively in 740
    cases undergoing resectional surgery for colorectal
    cancer. Endpoints were overall survival and time to
    diagnosis of recurrent disease in the – curative 
    group [n:532]. The patients were divided into 4
    groups divided with respect of whether blood
    transfusion was given or not as also the development
    or the absence of infectious complications.

        

    19% of
    288 non-transfused cases and 31% of 452 transfused
    patients developed infectious complications. In a
    multivariate analysis, the risk of death was
    significantly increased in patients developing
    infections after transfusion [n=142] compared with
    patients not receiving transfusion or developing
    infection [n=234]: hazard ratio 1.38. Overall survival of transfused group not
    developing infection [n=310]: and patients
    developing infection without preceding transfusion
    [n=54] was not significantly decreased. In an
    analysis of disease recurrence the combination of
    transfusion and subsequent infection [hazard ration
    1.79]. Localisation of cancer in the rectum and
    Dukes classification were independent factors.

       

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

       

  • G.H. Sakorafas and A.G. Tsiotou [ Department of Surgery, 251 Hellenic Air Force Hospital, Messogion and
    Katehaki, Athens 115 25, Greece

    Genetic Predisposition to Breast Cancer : A Surgical Perspective

    Br. J. of Sur., Volume 87, Number 2, February, 2000, Pg. 149

        

    Molecular alterations in proto-oncogenes, tumour suppressor genes, and genes that function in DNA damage recognition and repair are considered to be the hallmarks of a carcinogenic process, including breast
    carcinogenesis.

       

    After a thorough review of literature the authors postulate that hereditary breast cancer accounts for 5-10 per cent of all breast cancer cases. About 90% of hereditary breast cancer involve mutation of BRCA1 and/or BRCA2 genes. Other cancer related genes
    [myc, c-erbB2, Tsg101 and Mdgi] are involved in breast
    carcinogenesis, but they do not give rise to familial breast cancer syndromes. Risk estimation is the most important clinical implication. Management options for the high-risk mutation carriers include cancer surveillance and preventive strategies [prophylactic surgery or
    chemoprevention].

       

    They conclude that despite inadequate knowledge about the genetic predisposition to breast cancer and its clinical implications, the demand for genetic testing is likely to increase. In addition to risk estimation, cancer surveillance and preventive strategies, gene therapy offers a new and theoretically attractive approach to breast cancer management.

       

  • U
    Chetty, W. Jack, R.J. Prescott, C. Tyler and A. Rodger, on behalf of the Edinburgh Breast Unit [ Correspondence to : Mr. U. Chetty, Edinburgh Breast Unit, Western General Hospital, Edinburgh EH4 2XU, UK]

    Management of the Axilla in Operable Breast Cancer Treated by Breast Conservation : a Randomized Clinical Trial

    Br. J. of Sur. Volume 87, Number 2, February, 2000, Pg. 163

       

    In the treatment of operable breast cancer by breast conservation, the extent of axillary dissection, the need for radiotherapy to the axilla and the morbidity associated with these procedures have not been assessed adequately.

      

    Patients with operable breast cancer were randomized to have level III axillary node clearance. Radiotherapy [RT] to the axilla was given selectively. RT was not given to those who had an axillary clearance. The first 54 patients were subjected to node sampling and RT. Subsequently only node positive patients were given RT. The morbidity,
    upper limb volume, and circumference, and glenohumeral and scapular movements were assessed.

      

    No difference was found in local axillary or distant recurrence. There was no statistical difference in the 5-year survival ratio. The morbidity was least in those who had node sampling but no RT, to axilla. RT to axilla who had a node sample resulted in a significant reduction in range of movement of the shoulder. Surgical axillary clearance was associated with significant lymphoedema of the upper extremity.

          

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


    Reduced Postoperative Infections with an
    Immune-Enhancing Nutritional Supplement


    Laryngoscope
    109: 915-921, 1999

      

    This
    is a randomized double blind trial on 136 patients
    who were undergoing radical excisional 
    surgery for squamous cell carcinoma of the 
    aerodigestive 
    tract and who required postoperative
    nutritional supplement.

       

    The patients were divided into four groups. [1] with
    pre and post operative supplementation with Impact
    [2] only post operative supplementation [3] pre and
    post operative standard formula [4] only
    postoperative standard formula.

      

    Group
    1 and Group 2 had significantly reduced rates of
    postoperative sepsis. Group 3 and Group 4 showed no
    effect on rate of wound sepsis healing or hospital
    stay. Postoperative albumin levels were higher in
    Group 1 and Group 2. Impact can reduce postoperative
    sepsis, hospital stay and costs.

        

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

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


    Chest
    115: 1076-1084, 1999

     

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

     

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

     

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

     

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

       

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


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


    N
    Engl J Med 341: 556-562, 1999

        

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

        

    21,
    241 sera samples were tested. An enzyme immunoassay
    and a supplemental test were used to test for
    antibody to HCV [anti-HCV]. Reverse
    transcriptase-polymerase chain reaction for HCV RNA
    and gene sequencing studies were also performed.

        

    The
    result show 1.8% incidence of anti-HCV i.e. 3.9
    million persons in the US had HCV infection [95% 
    confidence level]. Nearly two thirds were
    between 30-49 years of age.

        

    Of
    those with anti-HCV, 74% tested positive for HCV
    i.e. 2.7 million Americans had chronic HCV
    infection. 74% of those had genotype 1 [ 57% – 1a 
    and 17% -1b]. Illegal drug use and high risk
    sexual behavior, poverty, poor education, divorced
    couples were significant risk factors and
    independently.

        

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


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

    Arch
    Intern Med 159: 851-856, 1999


       

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

       

    The
    Wagner classification system was used for this
    study. Variables examined included patient
    demographics, infection and diabetes.

       

    Of
    120 patients, 74% had contiguous osteomyelitis, deep
    tissue involvement or gangrene. 13% underwent
    immediate amputation. 
    Of the remaining, conservative treatment was
    successful in 63% of cases. 21 of 26 [81%] with skin
    ulcers. 35 of 50 [70%] with deep tissue infection or
    suspected osteomyelitis and 1 of 15 [7%] with
    gangrene.

       

    Independent
    factors predictive of failure were fever, elevated
    creatinine, prior hospitalization for diabetic foot
    lesion, duration of diabetes.

       

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

        

  • Penning,
    H.A.J. Gielkens, M. Hemelaar, J.B.V.M. Delemarre,
    W.A. Bemelman, C.B.H.W. Lamers and A.A.M. Masclee [
    Departments of Gastroenterology- Hepatology and
    Surgery, Leiden University Medical Centre, Leiden,
    The Netherlands]

    Prolonged
    Ambulatory Recording of Antroduodenal Motility in
    Slow-Transit Constipation


    Br.
    J. of  Sur., 
    Volume 87, Number 2, February, 2000, Pg.
    211-217

       

    Slow
    transit constipation may be a part of a pan-enteric
    motor disorder. To test this hypothesis 24 hour
    ambulatory antroduodenal manometry was performed and
    orocaecal transit time determined in patients with
    slow transit constipation and in healthy controls.

       

    The antroduodenal motility was recorded with a
    5-channel solid-state catheter. Postprandial
    motility was recorded after consumption of 2
    standardized test meals and interdigestive motility
    was recorded nocturnally. Quantitative and
    qualitative analysis were done. The orocaecal
    transit time was determined by means of lactulose
    hydrogen breath test.

      

    There
    was no difference in the motility between patients
    and controls. However, some minor changes of
    interdigestive motility were observed.
    The proportion of phase II activity of the
    nocturnal cycles of the interdigestive migrating
    motor complex was increased in the patients while
    phase I activity was decreased. The total number of
    phase III fronts with antral onset was decreased.
    Specific motor abnormalities such as retrograde
    propagation of phase III fronts wee more frequent in
    patients.

       

    They
    conclude that in patients with slow transit
    constipation, orocaecal transit time is delayed but
    antroduodenal motility is generally well preserved
    with only minor alterations.

        

  • D.S.
    Walsh, P. Siritongtaworn, K. Pattanapanyasat. P.
    Thavichaigarn, P. Kongcharoen, N. Jiarakul, P.
    Tongtawe, K. Yongvanitchit, C. Komoltri, C.
    Dheeradhada, F.C. Pearce, W.P. Wiesmann and H.K
    Webster [**]

    [**
    Department of Immunology and Medicine, US Army
    Medical Component, Armed Forces Research Institute
    of Medical Sciences, Departments of Surgery,
    Hematology and Clinical epidemiology, Siriraj
    Hospital, Department of Surgery, Pharmongkutklao
    [Royal Thai Army] Hospital, and Department of
    Surgery, Police Hospital, Bangkok, Thailand and
    Division of Surgery, Walter Reed Army Institute of
    Research, Washington, DC, USA ]

    Lymphocyte Activation After Non-Thermal Trauma

    Br.
    J. of  Sur.,  Volume 87, Number 2, February, 2000, Pg. 223-230

       

    Service
    injury causes immunologial changes that may
    contribute to a poor outcome. Longitudinal
    characterization of lymphocyte response patterns may
    provide further insight into the basis of these
    immunological alterations.

      

    Venous
    blood obtained seven times over 2 weeks from 61
    patients with injury severity scores over 20 was
    assessed for lymphocyte and activation markers
    together 
    with serum 
    levels of interleukin [IL]2, IL-4, soluble
    IL-2 receptor [sIL-2R], soluble CD4 [sCD4], soluble
    CD8 [sCD8] and interferon g.

       

    Severe
    injury was associated with profound changes in the
    phenotypic and activation profile in the phenotypic
    and activation profile of circulating lymphocytes.
    Activation was indicated by increased number of T
    cells expressing CD25, sIL-2R and sCD4 and sCD8 were
    found in-patients with sepsis syndrome.

       

    Polytrauma
    is associated with dramatic alterations in the
    phenotypic and activation profile of circulating
    lymphocytes which are generally independent of
    clinical course. In contrast several lymphocyte
    soluble factors including sCD4 and SIL-2R,
    paralleled the clinical course. These data provide
    new insight into lymphocyte responses after injury
    and suggest the further assessment of soluble
    factors as clinical correlates. 

       

  • C.H.
    Yoo, S.H. Noh, D.W. Shin, S.H. Choi and J.S. Min [Department of Surgery, Yonsei University College of Medicine, 134 Shinchon-ku, 120-752, Seoul, Korea ]

    Recurrence Following Curative Resection for Gastric Carcinoma

    Br. J. of Sur., Volume 87, Number 2, February, 2000, Pg. 236-242



    The diagnosis and treatment of recurrent gastric carcinoma is difficult. This study was aimed at determining the risk factors for recurrence of gastric carcinoma and prognosis for these patients.

    508 cases of recurrent gastric carcinoma out of 2328 patients who underwent curative resection for gastric carcinoma were studied retrospectively by univariate and multivariate analysis.

       

    The mean time to recurrence was 21.8 months and peritoneal recurrence was the most common [45.9%]. Logistic regression analysis showed that serosal invasion and lymph node metastasis were risk factors for all recurrence and early recurrence [at 24 months or less]. In addition, independent risk factors involved in each recurrence pattern included younger age, infiltrative or diffuse type, undifferentiated tumour and total gastrectomy for peritoneal recurrence, older age and larger tumour size for disseminated haematogenous recurrence; and older age, larger tumour size, infiltrative or diffuse type, proximally located tumour and subtotal gastrectomy for locoregional recurrence. Other risk factors for early recurrence were infiltrative or diffuse type and total gastrectomy. 

       

    Re-operation for cure was possible in only 19 patients and the mean survival time after conservative treatment or palliative resection was less than 12 months.

       

    The risk factors can be predicted by the clinicopathological features of the primary tumour.

        

  • William H Hindle, Raquel D Arias, et al (Univ of Southern California School of Medicine, Los Angeles)

    Lack of utility in clinical practice of cytologic examination of nonbloody cyst fluid from palpable breast cysts.


    Am J Obstet Gynecol, 182(6),pg.1300 -5


       


    Objective : This study was undertaken to answer the following question: Does cytologic evaluation of nonbloody fluid aspirated from breast cysts contribute to appropriate clinical management?

       


    Study Design: A retrospective review of palpable breast cyst fluid cytologic reports and associated medical records was undertaken to determine whether the cytologic findings affected patient management. Breast cyst size, fluid volume, fluid color, and patient age were abstracted from 689 medical records (1988-1999) of women whose palpable cysts had been aspirated at the Breast Diagnostic Center, Women’s and Children’s Hospital, Los Angeles. These observations were correlated with the fluid cytologic reports.

       


    Results : Except for frankly bloody fluid, all breast fluid cytologic reports listed the results as a cellular, inadequate for cytologic diagnosis, or no malignant cells identified.

      


    Conclusion: In clinical practice only frankly bloody fluid should be submitted for cytologic analysis. All other cyst fluid should be discarded.

       

  • J
    Mourad, J P Elliot and L Lisboa (Phoenix, Arizona)

    Appendicitis in pregnancy: New information that
    contradicts long-held clinical beliefs.



    Am J Obstet Gynecol 2000; 182: 1027-9


       


    Objective: Our purpose was to elicit a better understanding of the presentation of acute appendicitis in pregnancy and to clarify diagnostic dilemmas reported in the literature.

      


    Study Design: The authors retrospectively reviewed 66,993 consecutive deliveries from 1986 to 1995 by a computer program. Selected records were reviewed for gestational age; signs and symptoms at presentation; complications including preterm contractions, preterm labor, and appendiceal rupture; and histologic diagnosis of appendicitis.

       


    Results: Of 66,993 deliveries, 67 (0.1%) were complicated by a preoperative diagnosis of probable appendicitis. Acute appendicitis was confirmed histologically in 45 (67%) of the 67 cases, for an incidence of 1 in 1493 pregnancies in this population. Distribution of suspected appendicitis in pregnancy was as follows; first trimester, 17 cases (25 cases); second trimester, 27 (40%); and third trimester, 23 (34%). Right-lower-quadrant pain was the most common presenting symptom regardless of gestational age (first trimester, 12 (86%) of 14 cases; second trimester, 15 (83%) of 18 cases; and third trimester, 10 (78%) of 13 cases). The mean maximal temperature for proven appendicitis was 37.6°C (35.5°C-39.4°c), in comparison with 37.8°C (36.7°C-38.9°C; not significant) for those with normal histologic findings. The mean leukocyte count in patients with proven appendicitis was 16.4 x 109/L (8.2-27.0 x 109/L), in comparison with 14.0 x109/L (5.9-25.0 x109/L) for patients with normal histologic findings. At the time of surgery, perforation had occurred in 8 cases. Of 23 patients at ³24 weeks’ gestational age, 19(83%) had contractions and an additional 3 patients (13%) had preterm labor with documented cervical change. One patient was delivered in the immediate postoperative period because of abruptio placentae.

      


    Comment: The authors also attempted to validate the original study (1932) by Baer et al regarding change in pain location with advancing gestational age. They were unable to find any reliable sign or symptom that could aid in the diagnosis of acute appendicitis in pregnancy.

       


    They were unable to corroborate the hypothesis of Baer et al that would suggest a right-upper-quadrant location for the pain of appendicitis in the third trimester.

       


    As the appendix becomes obstructed by a coprolith, it distends and visceral afferent nerves are stimulated, causing constant poorly localized pain starting near the umbilicus and eventually migrating to McBurney’s point, which overlies the location of the appendix in most non-pregnant patients. As the full thickness of the appendiceal wall become necrotic and the serosa is damaged, the somatic neurons are stimulated, which localizes the pain to the right lower quadrant. This process appears to remain similar in pregnancy, contrary to the Baer theory and classical obstetric teaching. A high clinical suspicion is necessary to make the diagnosis, and because of overlap with normal pregnancy symptoms, a higher false-positive rate (30%) is not only acceptable but necessary to avoid unacceptable delay, with the possibility of increased morbidity and mortality rates.

       


    Conclusion: Pain in the right lower quadrant of the abdomen is the most common presenting symptom of appendicitis in pregnancy regardless of gestational age. Fever and leukocytosis are not clear indicators of appendicitis in pregnancy and preterm labour is a problem after appendectomy, but preterm delivery is rare.

      

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


    Duodenal Injuries


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


       

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

     

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

      

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

     

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

     

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

     

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

     

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

     

    The
    authors have graded duodenal and pancreatic
    injuries.

     

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

     

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

        

  • K. Holte and H. Kehlet [ Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark]

    Postoperative Ileus : A Preventable Event

    Br.Jour.of Surg. Volume 87, Number 11, Nov. 2000 Pg.Nos. 1480-1493

       

    Postoperative ileus is generally defined as a transient impairment of bowel motility after abdominal surgery or other injury.

        

    Ileus has traditionally been accepted as an obligatory physiological response to abdominal surgery, but the purpose of this response is the elective surgical setting has not been established.

        

    The average paralytic state lasts between 0 and 24 h in the small intestine 24 and 48 h in the stomach and between 48 and 72 h in the colon after major abdominal surgery.

      

    A correlation between some of the widely used clinical endpoints, such as bowel sounds, passage of flatus and stool, is also controversial.

      

    Bowel sounds are non-specific because they may originate in the small bowel as well as in the large bowel, and also require frequent auscultation for assessment. Passage of flatus is highly dependent on reporting by patients. 

      

    Passage of stool, although manifest as a clinical sign, is not specific, as it may indicate only distal bowel emptying and not necessarily the function of entire gastrointestinal tract.

     

    Clinical resolution of ileus to be relatively independent of these technical variables.

      

    As no single objective Variable has yet been found accurately to predict resolution of ileus, he most adequate definition of resolution probably depends on a combined functional outcome of normalization of food intake and bowel function.

       

    Pathogenesis of Postoperative Ileus

    Inhibitory Neural Reflexes

      

    Three anatomically distinguishable reflexes seem to be involved: ultrashort reflexes confined to the wall of the gut, short reflexes involving the prevertebral ganglia, and long reflexes involving the spinal cord.

         

    Long reflexes are probably of most importance, since several experimental studies have shown spinal anesthesia, abdominal sympathectomy and other nerve-cutting techniques to prevent or reduce the development of ileus.

      

    In summary, inhibitory sympathetic reflexes are of major importance in the pathogenesis of ileus. This has substantial clinical implications as these reflexes are subject to modification by epidural blockade.

      

    Numerous transmitters and peptides are involved in regulating gastrointestinal motility and so may be involved in ileus.

      

    Opioids are well established as modulators of transmission in the central and peripheral nervous systems, leading to inhibition of gastric emptying and non-propulsive smooth muscle contraction.

       

    Local inflammatory response is related to the extent of surgical trauma and degree of ileus.

         

    Furthermore, the paralytic gut response to surgery seems to be biphasic, consisting of a short temporary initial paralysis, followed by a longer-lasting impairment of muscle activity paralleling the local tissue concentration of inflammatory cells.

        

    A single dose of neural blockade with spinal or epidural anaesthetic alone or as a supplement to general anesthesia does not influence the duration of ileus.

        

    Analgesic treatment that includes opioids may prolong ileus, and the use of opioid-sparing analgesia with non-steroidal anti-inflammatory drugs [NSAIDs] or other analgesics [balanced analgesia] may reduce ileus.

      

    Epidural bupivacaine significantly reduced ileus.

     

    Based on knowledge of the inhibitory effects of opioids on gut motility, various opioid-sparing analgesic techniques have been developed to avoid the undesirable sequelae of opioid administration in the postoperative period.

      

    The advantageous effect on NSAIDs, apart from the sparing of opioid, may also be related to a direct anti-inflammatory effect mediated by the inhibition of prostaglandin synthesis.

      

    The insertion of a nasogastric tube has been the traditional supportive treatment for postoperative ileus, but it does not shorten time to first bowel movement or time to effective oral food intake.

       

    Nasogastric tube should not be used routinely, and that unnecessary use may contribute to postoperative morbidity such as atelectasis, pneumonia and fever.

      

    Contrary to popular belief, physical exercise does not improve colonic motility in healthy volunteers. 

      

    The presence of food stimulates the secretion of various intestinal hormones, with an overall stimulating effect on gastrointestinal motility.

       

    Early enteral nutrition may improve immune function and reduce postoperative and posttraumatic infectious complications.

       

    The early fed group tolerated a regular diet 3 days before the later fed group.

       

    The proven beneficial effects of continuous epidural local anaesthetics, opioid-sparing analgesics and cisapride have unfortunately not been incorporated in previous controlled clinical studies of early enteral nutrition.

       

    Ileus is clinically non-existent after laparoscopic cholecystectomy.

      

    The mechanisms involved may include reduced activation of inhibitory reflexes and local inflammation due to a reduction in surgical trauma.

      

    Cisapride enchances acetylcholine release from the intrinsic plexus and acts as a serotonin receptor agonist; it may stimulate all aspects of gastrointestinal motility.

      

    Beneficial effect of cisapride on ileus depends on the route of its administration, favoring intravenous or, possibly, oral administration in the postoperative period.

      

    Adverse cardiac effects may occur with cisapride, which may therefore be contraindicated in high risk patients.

      

    Ceruletide is a synthetic peptide whose cholecystokinin antagonis activity may stimulate gastrointestinal motility. 

      

    However, side effects such nausea and vomiting, which may require additional antiemetic treatment, limit the potential use of ceruletide.

       

    Metoclopramide may potentially influence gastrointestinal motility by acting as a dopamine antagonist, as well as by direct and indirect effects on cholinergic and serotonergic receptors throughout the gastrointestinal tract.

       

    None of these studies has demonstrated a significant effect of metoclopramide on the resolution of postoperative ileus.

       

  • Y.
    Morii, T. Arita, K. Shimoda, K. Yasuda, Y. Matsui, M. Inomata and S. Kitano [ Surgery Division, Arita Gastrointestinal Hospital and Department of Surgery I, Oita Medical University, Oita, Japan]

    Jejunal Interposition to Prevent Postgastrectomy Syndromes.

    Br.Jr.of Surg. Volume 87, Number 11, Nov. 2000 Pg. 1576-1579

      

    Postgastrectomy syndromes include reflux gastritis and oesophagitis, dumping syndrome, intractable diarrhoea and afferent loop syndrome. To prevent such syndromes, since January 1994 jejunal interposition has been used following distal gastrectomy.

      

    Recent progress in the diagnosis and surgical treatment of early gastric cancer has markedly reduced the mortality rate.

      

    More attention should be focused on symptom relief to improve the quality of life for ling-term survivors.

      

    Postoperative clinical issues include alkaline reflux gastritis, early and late dumping syndrome, intractable diarrhoea and afferent loop syndrome following gastrectomy: the postgastrectomy syndromes. 

      

    The authors often encountered patients treated by Billroth I repair in whom daily life was disturbed by postgastrectomy syndromes. Therefore, since January 1994, isoperistaltic jejunal interposition has been used following distal gastrectomy.

      

    Curative surgery for patients with early gastric cancer results in a favourable prognosis for long-term survival. More attention could focus on symptom relief to improve the quality of life in survivors. 

      

    Jejunal interposition between the gastric remnant and the duodenum [ gastrojejunoduodenostomy] was first described by Henley. 

      

    The dumping syndrome can be relieved by jejunal interposition.

      

    It is possible that jejunal interposition should be the standard reconstruction following distal
    gastrectomy.

           

  • S.
    Biondo, E. Jaurrieta, J. Marti Rague, E. Ramos, M. Deiros, P. Moreno and L. Farran [ Department of Surgery, Ciudad Sanitaria y Universitaria de Bellvitge, University of Barcelona, Barcelona, Spain]

    Role of Resection and Primary Anastomosis of the left Colon in the Presence of Peritonitis

    Br.Jr.of Surg. Volume 87, Number 11, Nov. 2000 Pg. 1580-1584

       

    Large bowel perforation is an abdominal emergency associated with high morbidity and mortality rates.

       

    Peritoneal contamination by bacteria may lead to septic shock, and surgical intervention must aim to prevent or treat this by removal of the septic focus.

     

    Intraoperative colonic lavage with resection and primary anastomosis [RPA] has been proposed as a safe and expedient method for single-stage resection and anastomosis. It is widely accepted as a safe procedure for treatment of left-sided large bowel obstruction.

       

    Th hypothesis was that peritoneal contamination by itself would not increase the anastomotic dehiscence rate, making the one-stage procedure a safe treatment for both localized and diffuse peritonitis in selected Patients.

       

    Renal function and central venous pressure were always monitored. Parenteral antibiotic therapy included prophylaxis against both aerobic and anaerobic bacteria. Antibiotic treatment was continued after operation.

       

    Renal failure was defined as a creatinine level above 1.4 mg/dl, circulatory failure as systolic arterial pressure less than 90 mmHg requiring inotropic support, and respiratory failure as arterial blood oxygenation lower than 60mmHg.

        

    Immunocompromised status was defined by a concurrent history of exogenous glucocorticoid treatment, extracolonic active malignant neoplasm, cytotoxic chemotherapy, malnutrition, or congenital or acquired immunodeficiency syndrome.

        

    Malnutrition was defined as weight loss of more than 10% of normal corporal weight within the preceding 2 months.

       

    A clinical study by Irvin and Goligher showed that poor mechanical bowel preparation was associated with a significantly higher incidence of anastomatic dehiscence and suggested that peritoneal sepsis itself did not play a major part in anastomotic dehiscence.

       

    Generalized peritonitis, age and coexisting medical illness by themselves are not a formal contraindication to resection, perioperative lavage and primary anastomosis.

       

    The presence of septic shock, faecal peritonitis, immunocompromised status or ASA grade IV at admission are considered to be contraindications for the one-stage procedure. In these patients Hartmann’s intervention is still considered a valid alternative.

          
            

  • Robert
    Udelsman, Patricia I Donovan, RN, BSN, and Lori J. Sokoll, [ From the Department of Surgery and Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland]

    One Hundred Consecutive Minimally Invasive Parathyroid Explorations

    Annals of Surgery, Volume, 232, No.3, Sept. 2000, Pg. Nos. 331-339

       

    Minimally invasive parathyroiddectomy [ MIP] has challenged the traditional approach of bilateral neck exploration for patients with primary hyperparathyroidism.

           

    Most patients with primary hyperparathyroidism have a single adenoma that when resected results in cure.

      

    MIP involves high-quality sestamibi images obtained with single photon emission computed tomography to localize enlarged parathyroid glands in three dimensions, limited exploration after surgeon-administered cervical block anesthesia, rapid intraoperative parathyroid hormone assay to confirm the adequacy of resection, and discharge within 1 to 3 hours of surgery. 

      

    The cure rate was 100%, and there were no long-term complications.

       

    Conclusions – Outpatient MIP appears to be the procedure of choice for most patients with primary hyperparathyroidism.

      

    A group of surgeons has questioned the need for bilateral neck explorations for all patients with primary hyperparathyroidism. This is based on the fact that 85% to 90% of patients with primary hyperparathyroidism have a single parathyroid adenoma that when excised results in cure.

       

    Therefore, if one could determine before surgery where the abnormal parathyroid gland was, a directed operation would appear to be logical.

       

    The exquisitely accurate preoperative diagnosis of primary hyperparathyroidism that can be achieved by measuring intact serum parathyroid hormone [PTH] levels; high quality sestamibi scans, especially when combined with single photon emission computed tomography [SPECT]: the availability and practical use of the intraoperative PTH assay, which can demonstrate resolution of PTH hypersecretion at the time of surgery; a resurgence of interest in local or regional anesthetic techniques; and referring physician and patient interest in minimally invasive techniques.

     

    In all of the patients with double adenomas and multigland hyperplasia, the intraoperative PTH assay did not demonstrate an adequate decrement until all abnormal parathyroid tissue was resected.

      

    Ninety-nine percent of the patients demonstrated a decrease of PTH levels of greater than 50% after tumor excision. This reduction occurred within 5 minutes of parathyroid adenoma resection.

      

    Frozen-section analysis of resected specimens was rarely performed.

       

    There were no deaths. Complications were limited to one unilateral transient recurrent laryngeal nerve injury, which resolved spontaneously 4 months after surgery, and one intraoperative seizure resulting from retrograde intraarterial injection of lidocaine. This was treated with supplemental oxygen and conversion to general anesthesia without sequelae.

      

    Minimally invasive parathyroidectomy is a safe, cost effective technique that permits successful treatment of primary hyperparathyroidism on an ambulatory basis. The procedure is well tolerated and is associated with cure rates that are at least as good as those attained through traditional bilateral exploration.

      

    The technique requires sophisticated technical adjuncts, including high-quality sestamibi scans with three-dimensional reconstruction. 

        

    In addition, we believe that the intraoperative PTH assay is essential.

       

    The sestamibi scan directs the surgeon where to start the exploration, and an adequate decrement in intraopertive PTH confirms the adequacy of resection.

        

    If the case is difficult, the surgeon should not hesitate to extend the incision or convert to general anesthesia.

           

  • Daniel H. Teitelbaum, Robert E Cilley, Neil J. Sherman, et al [ From the Department of Surgery, the University of Michigan Medical Center and the C.S. Mott Children’s Hospital, Ann Arbor, Michigan; the M.S. Hershey Medical Center, Hershay, Pennsylvania; Queen of the Valley Hospital, West Covina, California and the Spectrum Health Center, Grand Rapids, Michigen]


    A Decade of Experience with The Primary Pull-Through for Hirschsprung Disease in the Newborn Period 

    A Multicenter Analysis of Outcomes


    Annals of Surgery, Volume, 232, No.3, Sept. 2000, Pg. Nos. 372-380

       

    The Soave or endorectal pull-through was introduced by Franco Soave at the Institute G. Gaslini in 1955. Use of this procedure has been conventionally approached with the placement of a decompressing colostomy once the diagnosis is made.

        

    This is followed by a definitive pull-through procedure once the child’s intestine is decompressed and he or she reaches approximately 10 kg body weight.

         

    The use of a primary endorectal pull-through [ERPT] in the management of patients with Hirschsprung disease represents a significant change from the classic approach to the treatment of this disease.

        

    One major objection to performing a primary ERPT in a neonate is the concern that delicate structures such as the muscular sphincters may be injured.

       

    Surgeons have performed these one-stage procedures, ranging from the first week of life to several years of age.

        

    Surgical Technique –

    The newborn undergoes serial rectal washouts, and digital dilatations of the rectum are performed the day before surgery. The last of the rectal irrigations has 1% neomycin added to it.

        

    Broad spectrum intravenous antibiotics are given before the beginning of surgery. 

      

    Endorectal dissection was carried out from inside the abdominal cavity.

         

    Ganglionic bowel is mobilized proximally and transected at the transition level. The endorectal dissection is then started approximately 2 cm below the peritoneal reflection. The dissection is continued distally down to 0.5 cm above the dentate line in the newborn.

         

    Submucosal / mucosal cuff is everted out of the rectum and opened anteriorly. The ganglionic bowel is brought down through the muscular cuff, and the anastomosis is performed outside the anal cavity.

         

    At 3 weeks after surgery, gentle rectal dilations are performed with either a #6 or #7 Hegar dilator.

             

  • Mark G. Coleman, Brendam J. Moran

    Small Bowel Obstruction

    Recent Advances in Surgery, Number 22, Year – 1999

        

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

          

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

      

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

      

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

      

    Most settle with conservative management.

       

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

       

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

      

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

        

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

          

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

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

         

  • Cleft Lip and Palate

    Kirschner RE, Wang P, Jawad AF, et al [ Univ of Pennsylvania, Philadelphia; Children’s Hosp, Philadelphia; Children’s Seashore House, Philadelphia]

    Cleft-Palate Repair by Modified Furlow Double-Opposing Z-plasty: The Children’s Hospital of Philadelphia Experience

    Plast Reconstr Surg 104: 1998-2010, 1999

        


    390 patients underwent Furlow palatoplasty. 65 were under the age of 5 years at the time of last speech evaluation. Speech scores were not available in 86 patients, but it was available in 181 nonsyndromic patients at 5 years or older. [ Pittsburgh Weighted scales for speech symtpoms associated with Velopharyngeal incompetence].

        


    88.4% showed no or inaudible nasal escape and 97.2% showed no errors in articulation related to velopharyngeal incompetence. Secondary pharyngeal flap surgery was needed in 7.2% of cases. There was a trend towards better results in patients undergoing surgery before the age of 6 months and towards poorer outcome in Veau class I and II clefts.

        


    Furlow palatoplasty provides outstanding speech results.

        

  • Millard DR, Latham R, Huifen X, et al [Univ of Miami, Fla]

    Cleft Lip and Palate Treated by Presurgical Orthopedics, Gingivoperi-osteoplasty, and Lip Adhesion [POPLA] Compared With Previous Lip Adhesion Method: A Preliminary Study of Serial Dental Casts

    Plast Reconstr Surg 103: 1630-1644, 1999

        


    This study compares the result of POPLA [1978 onwards] through an examination of dental casts.

        


    124 patients with complete unilateral or bilateral cleft lip and complete or incomplete clefts of the primary and secondary palate were evaluated.

        


    63 patients treated by POPLA method were evaluated as group I [41 with UCLP and 22 with BCLP]. 15 from UCLP and 4 from BCLP group later received orthodontic treatment. Group 2 [ 61 patients] were treated with surgical closure of soft palate and lip adhesion [ 36 UCLP and 25 BCLP] 25 of UCLP and 17 of BCLP later received orthodontic treatment.

        


    Serial dental casts were made at birth and at 3, 6 and 9 years of age. The alveolar gap, arch width, anteroposterior distance, incisor crossbite and buccal crossbite were compared. Radiographs were used to assess bony bridge. Average at follow up was 8 years 11 months in group I and 22 years 3 months in group II.

         


    Results- Bone grafting to close the alveolar gap was required in 59% of cases in group II but in only 3% of cases in group I. Similarly a velopharyngeal flap procedure was required in 35% of group II cases but
    in only 16% in group I cases. Multiple tooth anterior crossbite was more frequent in Group I. However multiple tooth buccal crossbite was less common in Group I. Anteroposterior distances were similar in both groups at 6 years of age, but by 9 years of age the maxillary dental arch length had increased in all, but group 2 patients with BCLP. Radiographs revealed bony bridge formation in 63% of UCLP and 83% of BCLP who underwent POPLA procedures.

        


    POPLA method gives very good results.

        

  • Mackay D, Mazahari M, Graham WP, et al [ Milton S Hershey Med Ctr, Hershey, Pa; Lancaster Cleft Palate Clinic, Hershey, Pa]

    Incidence of Operative Procedures on Cleft Lip and Palate Patients 

    Ann Plast Surg 42: 445-448, 1999

        


    Charts of 374 cleft lip and palate patients were reviewed for the number of primary and secondary procedures performed. The follow up period was 15 years.

         


    Each patient underwent an average of 3.3 procedures and 1.2 otolaryngologic procedures. Of 51 patients with UCLP [incomplete] 29 had secondary procedures and 10% had rhinoplasties. Of 19 patients with complete UCLP 37% had secondary procedures. 47% had rhinoplasties. Of 110 patients with complete UCLP 36% had secondary procedures, 45% had rhinoplasties and 72% had a 2-stage palate repair – of 51 patients with BCLP, 84% had secondary lip repair, 73% had rhinoplasties and 84% had a 2-stage palate repair.

         


    The authors feel that the true incidence of operative procedures is underestimated. It is clear however that secondary procedures make up a major component of surgical repair.

        

  • Gosain AK, Conley SF, Santoro TD, et al [ Med College of Wisconsin, Milwaukee]

    A Prospective Evaluation of the Prevalence of Submucous Cleft Palate in Patients with Isolated Cleft Lip Versus Controls

    Plast Reconstr Surg 103: 1857-1863, 1999

        


    This study evaluates the relationship between isolated cleft lip and submucous cleft palate.

        


    25 patients with isolated cleft lip without an overt clefting of the secondary palate were compared with 25 controls [ age 3-6 months compared with controls of 8 months to 13 years].

        


    Physical examination and nasoendoscopy were performed to look for submucous cleft palate —- bifid uvula, midline diastasis of the palatal muscles and notching of the posterior border of the hard palate.

         


    Results – 12% had classic and 6% had occult submucous cleft palate as against none in the control group. 36% had nasoendoscopic evidence of flattening or a midline depression of the posterior palate and musculus uvula, and palpable evidence of palatal muscle diastasis. However only 3 patients met all 3 physical criteria, 4 met only one criterion and 2 did not meet any of the criteria. All 9 patients with submucous cleft palate and 8 other patients had an alveolar cleft i.e. 53% of those with an alveolar cleft also had submucous cleft palate.

         


    Conclusion – About 1/3rd of the isolated cleft lip patients had submucous cleft palate. Nasoendoscopy was a more effective procedure as compared to physical examination. It is recommended that all cleft lip patients be subjected to
    nasoendoscopy.

          

  • Witt P, Cohen D, Grames LM, et al [ washington Univ, St Louis]

    Sphincter Pharyngoplasty for the Surgical Management of Speech Dysfunction Associated with Velocardiofacial Syndrome

    Br J Plast Surg 52: 613-618, 1999

         

    This is a retrospective review of sphincter pharyngoplasty in the management of velocardiofacial syndrome. 

        


    The patients were identified by a computerized craniofacial anomalies registry. 19 patients who underwent velopharyngeal surgical management based on perceptual speech evaluations and instrumental assessments of inadequate velopharyngeal closure were studied.

         


    All patients received a molecular analysis of velocardiofacial syndrome based on fluorescent in situ hybridization analysis of peripheral blood lymphocytes and independent examination by a geneticist.

         


    The surgical outcome was considered successful if perceptual speech evaluation showed elimination of hypernasality , nasal emission turbulence and instrumental assessment revealed 100% velopharyngeal closure.

        


    Results – 18 of 19 patients were managed successfully by sphincter pharyngoplasty. The one failure had mild persistent hypernasality and mild turbulence. This patient was not compliant with continued speech therapy and the parents did not consent to a post-tightening revision surgery. In 5 patients persistent snoring developed postoperatively. One patient had sleep apnea which resolved after use of nasally administered continuous positive airway pressure.

        


    Conclusion – Sphincter pharyngoplasty is a reasonable alternative to pharyngeal flap surgery for velopharyngeal dysfunction.

        

  • David LR, Blalock D, Argenta LC [Wake Forest Univ, Winston-Salem, NC]

    Uvular Transposition: A New Method of Cleft Palate Repair

    Plast Reconstr Surg 104:897-904, 1999

        


    This is a description of a new method of repair that allows simultaneous lengthening of the palate with a mean increase of greater than 1.0 cm; a reduction in the circumference of the nasopharyngeal aperture; and anatomical reconstruction of the muscles of the palate.

        


    62 patients underwent uvular transposition for repair of isolated cleft palate unilateral cleft lip and palate, and other craniofacial syndromes in 32, 13, 14 and 3 children respectively. The age at surgery was between 4 and 10 months [ mean 7 months]. Their mean age at initial speech assessment was 46 months and the mean age at the most recent speech assessment was 66 months.

         


    Technique – The palate was lengthened by using tissue from the uvula by means of a double opposing A plasty. An intravelar veloplasty was done and two thirds of the mass of the uvula was transposed to the nasal surface of the soft palate. This approach of facilitated velopharyngeal closure by significantly lengthening the palate, anatomically reconstructing the palatal excursion
    was needed to achieve closure.

         


    Results – Perceptual nasal emission was normal in 95% patients 3% children required pharyngeal flap for velopharyngeal insufficiency. 

         

  • Lee TJ [Univ of Ulsan, Seoul, Korea]

    Upper Lip Measurements at the Time of Surgery and Follow-up After Modified Rotation -Advancement Flap Repair in Unilateral Cleft Lip Patients 

    Plast Reconstr Surg 104: 911-915, 1999

        


    Caliper measurements of vertical horizontal and nostril still dimensions were compared immediately after surgery and at follow up to determine whether rotation advancement flap repair of a unilateral cleft lip will grow short on the repaired sides.

       


    45 patients [ 30 boys 15 girls] with nonsyndromic unilateral cleft lip underwent a rotation advancement flap repair in 18 who had incomplete defects. The lip was corrected to the same vertical length as the noncleft side. In 27 who had complete defects because of the difficulties of flap rotation the repaired lip was shorter vertically than on the noncleft side. 

        


    Results – There was no change in the growth ratios of the two sides [follow up range 8-84 months]. However the nostril sill became significantly wider on the repaired side.

        

  • Lekkas C, Latief BS, ter Rahe SPN, et al [ Univ of Leiden, The Netherlands; Universitas Indonesia, Jakarta; Catholic Univ of Nijmegen, The Netherlands]

    The Adult Unoperated Cleft Patient: Absence of Maxillary teeth Outside the Cleft Area

    Cleft Palate Craniofac J37: 17-20, 2000

        


    In patients with cleft that is operated on in childhood, absence of one or more teeth is frequently seen. The prevalence of missing permanent teeth outside the cleft region is thought to be more than 24% when the secondary palate is also cleft in bilateral cleft lip and palate the missing teeth may be as high 68.4%. In non cleft population the incidence of missing teeth is estimated as less than 6%.

        


    This study investigates the possible absence of teeth in the postcanine region of the upper jaw in patients who have not undergone surgery to repair cleft.

        


    Dental casts were obtained from 266 adult patients who had not undergone surgery for correction of cleft. The patients were grouped based on the type of cleft, whether unilateral cleft lip and alveolus, unilateral cleft lip and palate, bilateral cleft lip and palate. The majority of patients were younger than 30 year. Casts from 100 controls were studied for comparison.

        


    Results – None of the casts [in all 4 groups] revealed any missing permanent teeth. Numeric tooth anomalies were found only in the area of the cleft.

        

  • H.Nishio, J. Kamiya, M. Nagino, K. Uesaka, T. Sano and Y. Nimura [ First Department of Surgery, Nagoya University School of Medicine, 65 Tsurumaicho, Showaku, Nagoya 466-8550, Japan

    Biliobiliary Fistula Associated with Gallbladder Carcinoma

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1656-1657

        


    Biliobiliary fistula is a troublesome complication,difficult to diagnose and treat. Without a preoperative diagnosis, surgery may result in critical biliary injury. The clinical features of this condition are described. 

        


    Seven of 146 cases operated for gall bladder carcinoma who developed a biliobiliary fistula [3M and 4F] of mean age of 62 years [37-38 years] have been reviewed. All patients underwent preoperative percutaneous transhepatic biliary drainage [PTBD] to relieve obstructive jaundice and prevent cholangitis or evaluate the biliary system. A pre-operative diagnosis of a biliobiliary fistula [BBF] was made in 5 patients. PTBD catheter cholangiography revealed the BBF in only one patient whereas percutaneous transhepatic cholangioscopy showed the BBF in four cases with Mirizzi syndrome. 

        


    Cholangioscopic biopsy revealed no cancer invading the BBF where the gallstone was impacted. In the resected specimen the tumour grew intra as well as extraluminally, filling the gallbladder and pressed a gallstone against the hepatic hilum. 

        


    Gallbladder carcinoma with BBF can be classified as [a] with Mirizzi syndrome [pressure necrosis of the septum between the gall bladder and hepatic ducts] [b] Without Mirizzi syndrome due to necrosis of the tumour. PTCS proved more fruitful than PTBD cholangiography. The demonstration of BBF helped in the design of a rational resection. In two patients the BBF was detected after the resection. The presence or absence of a BBF did not effect surgical decision making.

        

  • The late L.O. Poulsen, A.M. Thulstrup. H.T. Sorensen and H. Vilstrup [ Department of Clinical Epidemiology, Aalborg Hospital and Aarhus University Hospital, Department of Epidemiology and Social Medicine, Denmark]

    Appendicectomy and Perioperative Mortality in Patients with Liver Cirrhosis

    Br. Jr. of Sur. Volume 87, No.12, December 2000, Pgs-1664-4665

        


    Case studies have indicated that patients with liver cirrhosis are at an increased perioperative risk mainly as a result of bleeding and infection.

       


    This study examines the perioperative 30 day mortality after appendicetomy in patients with liver cirrhosis.

        


    Diagnosis and surgical procedures were classified according to the International Classification of Disease [ICD-8]. Patients were included if they had been diagnosed as alcoholic cirrhosis, primary biliary cirrhosis, non-specified cirrhosis, chronic hepatitis and other types of cirrhosis, alcoholism not indicated. Patients who had undergone appendicectomy following a diagnosis of cirrhosis of liver were identified. The control group consisted all others who had undergone appendicetomy in the same period.

        


    Of 22,840 patients with cirrhosis, 69 underwent appendicectomy. The 30 day mortality rate was 9 [ 95% confidence interval [3-18] percent in cirrhotics compared with 0.7 [ 95 percent c.i. 0.6-0.8] percent among 58,982 controls. 

         


    Causes of death were :-

    [1] Bleeding from gastro-oesophageal varices [2] peritonitis, pneumonia, ‘cirrhosis hepatitis’ and ischaemic heart disease [ 1 each]. The risk of 30 day mortality adjusted for age, sex and co-morbidity and estimated as odds ratio was 8 [ 95% c.i. 3-20].

         


    The increased mortality rate in cirrhotics who undergo minor abdominal surgery should be examined in other data sets before survey as basis for recommendation to surgeons. 

        

  • A.Hair, K. Duffy, J. McLean, S. Taylor, H. Smith, A. Walker, I.M.C. Macintyre and P.J. O’Dwyer [ University Department of Surgery, Western Infirmary, Glasgow, Western General Hospital, Edinburgh and Health Economics Unit, Greater Glasgow Health Board, Glasgow, UK]

    Groin Hernia Repair in Scotland

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1722-1726

        


    This study surveys the methods of groin hernia repair in Scotland and assesses patient satisfaction with the operation.

        


    A retrospective study of 5506 patients who underwent groin hernia repair was conducted looking at the type of repair, postoperative morbidity and patient satisfaction.

         


    85% had an open mesh repair 4% had a laparoscopic repair, 8% of cases were operated for recurrent hernia. Potentially serious intra-operative complications were rare [7%] , although they were significantly more likely in laparoscopic repair or in femoral hernia- relative risk compared with open repair 33 [95% confidence interval (c.i.) 6-197] and 22 [95% c.i. 3-152] respectively. Wound complications were common and 10% of cases required a district nurse to attend the wound. Patients expressed a high degree of satisfaction [94% would recommend the same operation].

        


    Open mesh repair under general anaesthesia has become the repair of choice for groin hernia in Scotland.

        

  • D.K. Beattie, R.J.E. Foley and M.J. Callam [ Department of Surgery, Bedford Hospital, Bedford, UK]

    Future of Laparoscopic Inguinal Hernia Surgery

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1727-1728

       


    Despite low recurrence rates [< 1%] with open mesh repair, laparoscopic repair has been promoted as having significant advantages. It has been noted that it is less painful and has a quicker recovery. A randomized comparison reported more recurrences and complications after laparoscopic repair. A postal survey was conducted to determine current operative practice.

        


    374 surgeons responded to the questionnaire. Tension free open mesh repair are preferentially used by 261 surgeons [76.8%] for primary hernia repair. 5.6% [19 surgeons] prefer Shouldice repair and 5% [17 surgeons] advocate laparoscopic repair. The remainder use combinations of mesh, Shouldice, Bassini, plug, darn and laparoscopic repair.

        


    25% currently perform laparoscopic repair [1/3rd for primary repair, 2/3rds for recurrent or bilateral repair]. Roughly half of this favour a transabdominal approach and the others an extraperitoneal approach, some were undecided. An equal number have ceased performing laparoscopic hernia repair in view of its cost, complications, increase in operating time and recurrence rate. Some have never undertaken laparoscopic repair.

        


    65.6% feel that it is unlikely that laparoscopic repair will become the standard technique. Laparoscopic hernia repair has a tenuous foothold in current practice, this survey suggests that this is unlikely to change.

        

  • M.L. Lachat, U. Moehrlen, H.P. Bruetsch and P.R. Vogt [ Department of Cardiovascular Surgery and Urology, University Hospital, Zurich, Switzerland]

    The Seldinger Technique for Difficult Transurethral Cathetarization : A Gentle Alternative to Suprapubic Puncture

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1729-1730

        


    Difficult or unsuccessful transurethral catheterization may lead to iatrogenic urethral lesions which can compromise an otherwise excellent surgical result, cause long term morbidity.

        


    An endoluminal catheter technique, a less invasive alternative to suprapublic bladder drainage has been developed for such cases.

         


    This modified Seldinger technique was used in 21 cases undergoing cardiovascular surgery in whom the transurethral catheter could not be passed. The urethra was lubricated and anaesthetized. An atraumatic 0.035 inch J guidewire, length 30 cm, was inserted through the external urethral meatus and moved gently forward into the urinary bladder. A central venous catheter or 6F balloon catheter [ paediatric Folysil 6F] with tip cut off was then advanced over the guidewire . The guidewire was then removed, urine was aspirated, and the catheter connected to the urimeter and fixed with drapes. No complications followed.

        

  • A.B. Williams
    M.J. Cheetham, C.I. Bartram, S. Halligan, M.A. Kamm, R.J.
    Nicholls, and W.A. Kmiot [Department of Intestinal Imaging, Physiology Unit and Department of Surgery, St. Thomas Hospital, London, UK]

    Gender Difference in the Longitudinal Pressure Profile of the Anal Canal Related to Anatomical Structure as Demonstrated on three-Dimensional Anal Endosonography

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1674-1679

         


    The anal canal squeeze pressure is assumed to be due to the external sphincter contraction. The role of other muscles is explored.

        


    Ten male and ten nulliparous female asymptomatic subjects were subjected to three dimensional anal endosonography and
    manometry. The incremental squeeze pressure at 0.5 cm intervals expressed as a percentage of the maximum pressure recorded anywhere in the anal canal were related to the following anatomical levels:-

        


    Puborectalis overlap between external anal sphincter
    [EAS] and puborectalis, external and internal sphincters, and external sphincter only. Levels were determined by coronal and sagittal endosonographic reconstructions.

        


    The puborectalis had the same length in both sexes [median 23.9 versus 27.1 mm] but represented a greater proportion of the anal canal in women [45% versus 61%]. At the level of the puborectalis alone the pressure generated as a proportion of maximum anal canal pressure was 71% [32-100] per cent in men and 82 [ 41-100] percent in females. At the level of EAS alone the pressure was 60% [4-98] in men and 82% [41-100] in women , and where the EAS was overlapped by the puborectalis the pressure was 98% [60-100] in men and 75% [47-100] in women.

        


    The maximal anal canal squeeze pressure is found where the puborectalis overlaps
    EAS. This segment represents a significant proportion of anal canal length in women.

            

  • H. Ortiz and J. Marzo [ Department of Surgery, Hospital Virgen del Camino, Universidad Publica de
    Navarra, Pamplona, Spain]

    Endorectal Flap Advancement Repair and Fistulectomy for High Trans-Sphincteric and Suprasphincteric Fistulas

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1680-1683

        


    Endorectal flap advancement repair and for fistulectomy for high
    trans-sphincteric and suprasphincteric fistulas.

        


    The management of high fistulas has for long been considered a serious problem because of the necessity of preserving at least some of the sphincter mechanism. The results of endorectal flap advancement and fistulectomy for complex anal fistulas have been assessed.

        


    A prospective study of 103 high trans-sphincteric [n=91] and supra sphincteric [n=12] undergoing this procedure was conducted.

       


    Successful healing was achieved in 96 patients [93%]. Recurrent fistulas were noted in six patients
    [trans-sphincteric] i.e. 7% and in one patient [suprasphincteric]. Continence disturbance was noted in 8 patients [8%]. Previous repair did not adversely affect the results.

        


    The procedure is safe and effective in high fistulas.

          

  • D.C. Winter, C. Taylor,
    G.C. O’Sullivan and B.J. Harvey [ Cork Cancer Research Centre and Department of Surgery, Mercy Hospital and Cellular Physiology Research Unit, University College Cork, Cork Ireland]

    Mitogenic Effects of Oestrogen Mediated by a Non-Genomic Receptor in Human Colon

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1684-1689

        


    Oestrogens are important in mitogens in epithelial cancers particularly where tumours express complementary receptors. Traditionally oestrogen action involves gene-directed [genomic] protein synthesis. It has also been established that more rapid, non-genomic steroid hormone action exists. 

        


    This study investigates the hypothesis that oestrogen rapidly alters cell membrane activity, intracellular pH and nuclear kinetics in a mitogenic fashion.

        


    Crypts isolated from human distal colon and colorectal cancer cell lines were used as robust model. DNA replication and intracellular pH were measured by radiolabelled thymidine incorporation [12h] and spectrofluorescence respectively. Genomic protein synthesis, sodium-hydrogen exchanger
    [NHE] and protein kinase C [PKC] activity were inhibited with
    cycloheximide, ethylisopropylamiloride and chelerythrine chloride respectively.

        


    Oestrogen induced a rapid [< 5 min] cellular alkalinization of crypts and cancer cells that was sensitive to NHE blockade or PKC inhibition. It increased thymidine incorporation by 44% in crypts and by 38% in cancer cells and this was similarly reduced by inhibiting the NHE or
    PKC.

        


    They conclude that oestrogen rapidly activates cell membrane and nuclear kinetics by a nongenomic mechanisms mediated by
    PKC.

         

  • S.A. Norton and D. Alderson [ University of Surgery, Bristol Royal Infirmary, Bristol Uk]

    Endoscopic Ultrasonography in the Evaluation of Idiopathic Acute Pancreatitis

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1650-1655

         


    The aim of this study was to determine if endoscopic ultrasonography [EUS] is able to detect small gallstones missed at transabdominal ultrasonography in cass of ‘idiopathic’
    pancreatitis.

        


    Forty four patients with ‘idiopathic’ pancreatitis were assessed using EUS for the presence of gall stones or other potential causes of the attack. A control group was also imaged. Ten patients had earlier attacks of pancreatitis. EUS revealed proven pathology in 18 patients. Unconfirmed pathology was evident in 14. No 7

        


    abnormality was seen in only 9 patients. EUS failed in one patient and there were two possible false positive results.

    EUS is able to identify significant pathology in patients with ‘idiopathic ‘
    pancreatitis.

        

  • T.M. Kennedy and
    R.H. Jones [ Department of General Practice and Primary Care, Guy’s King’s and St. Thomas’ School of Medicine, 5 Lambeth Walk, London SE11 6SP, UK]

    Epidemiology of Cholecystectomy and Irritable Bowel Syndrome in a UK Population

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1658-1663

        


    This paper describes the prevalence of cholecystectomy and IBS in a sample of British adults. The association between the two conditions and their relation to consultation behavior and socioeconomic status are analyzed.

        


    A postal questionnaire was sent to 4432 adults between 20-69 years with six general practices. The standard occupational classification was used as a proxy for socioeconomic status.

    Cholecystectomy was reported by 4.1% of women and 1.3% of men. 22.9% of women had IBS [ odds ratio 1.9 (95% confidence interval 1.2-3.2); P<0.01]. The prevalence of cholecystectomy of IBS and of consultation for symptoms of IBS was not influenced by socioeconomic status.

        


    They conclude that symptoms of IBS may cause diagnostic confusion and unproductive surgery. Cholecystectomy may cause IBS like symptoms, a single underlying disorder may produce symptoms in both gastrointestinal and biliary tracts or the associations might be a due to a combination of these factors. 

        

  • M. R. Kell, D. C.Winter, G.C. O’Sullivan, F. Shanahan and H.P. Redmond 

    [Departments of Academic Surgery and Medicine, National University of Ireland, Cork University Hospital and ‘Mercy Hospital, Cork, Ireland]

    Biological Behaviour and Clinical Implications of Micrometastases

    Br. Jr. of Sur. Volume 87, No.12, December 2000, Pgs-1629-1639

         


    The most important prognostic determinant in cancer is the identification of designated tumor burden [metastases]. Micrometastases are microscopic (<2mm) deposits of malignant cells that are segregated spatially from the primary tumour and depend on neovascular formation (angiogenesis) to propogate.

    The literature on micrometastases and their implications in malignant melanoma and epithelial cancers is reviewed.

    Immunohistochemical and serial sectioning methods were used. Molecular techniques were reserved for blood samples and bone marrow aspirates.

         

    Detection of micrometastases in regional lymph nodes and/or bone marrow confers a poor prognosis in epithelial cancers. The concept of sentinel node biopsy combined with serial sectioning and dedicated screening for micrometastases may improve staging procedures. Strategies against angiogenesis may provide novel therapies to induce and maintain micrometastatic dormancy.

         

  • A Llaneza, F. Vizoso, J.C. Rodriguez, P. Raigoso, J.L. Garcia-Muniz, M.T. Allende and M. Garcia-Moran [ Department of Surgery and Nuclear Medicine, Hospital Central de Asturias, Oviedo and Department of Surgery, Hospital de Jove, Gijon, Spain]

    Hyaluronic Acid as Prognostic Marker in Resectable Colorectal Cancer

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs 1690-1696

       


    Hyaluronic Acid [HA] an extracellular high molecular mass polysaccharide, is thought to be involved in the growth and progression of malignant tumours. This study evaluates the cytosolic HA content in resectable colonic cancer, and its possible relationship with clinicopathological parameters of tumours and its prognostic significance.

        


    Cytosolic HA levels were examined by radiometric assay in 120 patients with resectable colorectal cancer. The mean follow up period was 33.4 months. The levels of cytosolic HA levels of tumours ranged widely from 3o to 29412 ng/mg protein. Intratumour HA levels were significantly correlated with Dukes Stage [P<0.005] and were higher in patients with advanced tumours [ mean (s.e.m.) 2695(446), 2858(293) and 5274(967) ng/mg protein for stages A-B and C respectively]. In addition, Cox multivariate analysis demonstrated that tumour HA levels >2000 ng/mg protein predicted shorter relapse free survival and overall survival period [both P<0.05].

        


    They conclude that there is a wide variability in cytosolic HA levels in colorectal cancers, which seems to be related to the biological heterogeneity of the tumours. High tumour cytosolic HA levels were associated with an unfavourable prognosis

         

  • O.Bernell, A. Lapidus and G. Hellers [ Departments of Surgery and Gastroenterology, Karolinska Institute, University Hospitals, S-141 86 Huddinge, Sweden]

    Risk Factors for Surgery and Recurrence in 907 Patients with Primary Ileocaecal Crohn’s Disease

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1697-1701

        


    This study aims to assess the risk for resection and postoperative recurrence, in the treatment of ileocaecal Crohn’s disease and to define factors affecting the course of the disease.

        


    907 patients with primary ileocaecal Crohn’s disease were reviewed retrospectively.

        


    Resection rates were 61, 77 and 83% at 1,5 and 10 years respectively after the diagnosis.

        


    Relapse rates were 28 and 36 per cent 5 and 10 years after the first resection. A younger age at diagnosis resulted in a low resection rate. Presence of perianal Crohn’s disease and long resection segments increased the risk of recurrence, and resection for a palpable mass and /or abscess decreased the recurrence rate. A decrease in the recurrence rate during the study period was observed.

        


    For ileocaecal Crohn’s disease the probability of resection is high and the risk of recurrence moderate. Perianal disease and extensive ileal resection increases the risk of recurrence. Diagnosis in childhood carries a lower risk of primary resection.

        

  • J.B.Y. So, A. Yam, W.K. Cheah, C.K. Kum and P.M.Y. Goh [ Department of Surgery, National University Hospital, Lower Kent Ridge Road, Singapore 119072, Republic of Singapore]

    Risk Factors Related to Operative Mortality and Morbidity in Patients Undergoing Emergency Gastrectomy

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1702-1707

         


    This study aimed to evaluate the results of emergency gastrectomy and to examine the factors that predict the operative outcome.

        


    82 patients who underwent emergency gastrectomy were studied. The following variables were assessed – pathology, mortality rate, morbidity, reasons for reoperation and factors related to the outcome.

        


    There were 64 men and 18 women with a median age of 62 years [30-90]. The indications were bleeding or perforated ulcers in 45 and 20 cases respectively, and bleeding and perforated gastric tumours in 7 and 10 patients respectively.

    The overall mortality was 17% [n=14]. The complication rate was 63%. 13% required
    reoperation.

        


    By multivariate analysis, age greater than 65 years and a hemoglobin level less than 10 g/dl on admission were predictive of complications after emergency gastrectomy. Post-operative pulmonary and cardiac complications and hypotension on admission were independent risk factors associated with operative death. The mortality was not affected by the underlying pathology.

        

  • E. Trondsen, O. Mjaland, J. Raeder and T. Buanes [ Department of Gastroenterological Surgery and Anaesthesiology, Ullevel Hospital and University of Oslo, Oslo, Norway]

    Day-case Iaparoscopic Fundoplication for Gastro-oesophageal Reflux Disease

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs1708-1711

         


    The initial results of outpatient laparoscopic fundoplication for gastro-oesophageal reflux disease are presented.

        


    The inclusion criteria were American Society of Anaesthesiologists grade I-II, living within 30 minutes travel from the hospital and adult company at home.

    The operation [Nissen-Rosetti fundoplication ] was done under general intravenous anaesthesia . 

        


    45 patients were operated. 4 needed admission and 41 were discharged as planned 3-8 hours after the operation, but 5 of these were readmitted. One had to be reexplored for necrosis of the gastric fundus. A further 5 patients visited the OPD but did not need admission.

         


    31 patients were satisfied with the procedure, 5 were indifferent, and 5 were dis-satisfied with the result because of pain.

    The authors conclude that day case laparoscopic fundoplication is safe and well tolerated.

        

  • A.Kanamoto, H. Yamaguchi, Y. Nakanishi, Y. Tachimori, H. Kato and H. Watanabe [ Department of Internal Medicine and Surgery, National Cancer Center Hospital and Pathology Division, National Cancer Center Research Institute, Tokyo, Japan]

    Clinicopathological Study of Multiple Superficial Oesophageal Carcinoma

    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1712-1715

         


    The incidence of superficial oesophageal carcinoma has increased markedly in Japan in recent years as a result of advances in endoscopy.

        


    359 patients with superficial oesophageal carcinoma [squamous cell] who underwent oesophagectomy [n=276] or endoscopic mucosal resection [EMR n=83] were reviewed. The clinico-pathological features were compared with those of a single superficial oesophageal carcinoma.

         


    Of 359 patients 99[28%] had multiple superficial oesophageal carcinoma [M:F = 98:1 compared with 5:3:1 for those with a single carcinoma [n=260]. The incidence of tobacco and alcohol use was significantly higher in patients with multiple carcinomas. The incidence of pharyngeal malignancy was also higher in patients with multiple carcinomas.

        


    They conclude that the high incidence of multiple superficial oesophageal carcinomas indicates a need for careful evaluation of the oesophagus at the time of initial diagnosis, treatment and follow up. Male sex, smoking, alcohol and the presence of pharyngeal malignancy are high risk factors
       

        

  • C
    Wyser, P Stulz, M Soler, et al (Univ Hosp, Basel,
    Switzerland)

    Prospective Evaluation of an Algorithm for the
    Functional Assessment of Lung Resection Candidates.

    Am J Respir Crit Care Med 159: 1450-1456, 1999.

        

    The risk of postoperative complications is increased
    in patients with impaired pulmonary function and
    exercise testing and predicted postoperative
    function have been gaining importance in the
    assessment of candidates for lung resection surgery.
    The authors have worked out an algorithm for
    preoperative functional evaluation and they studied
    this algorithm prospectively.

        

    One hundred thirty-seven patients with clinically
    resectable lesions were studied. The algorithm
    incorporated cardiac history, including an
    electrocardiogram, and the 3 parameters of forced
    expiratory volume in 1 second, diffusing capacity of
    the lungs for carbon monoxide, and maximal oxygen
    uptake, and their respective predicted postoperative
    values were calculated on the basis of radionuclide
    perfusion scans.

       

    These patients were subjected to surgeries, 85 being
    lobectomies, 38 pneumonectomies, and 9 segmental or
    wedge resection surgeries. Five patients were
    considered functionally inoperable. Extubation
    within 24 hours was possible for all patients. 

       

    This algorithm resulted in a low complication rate,
    including mortality and morbidity and it seems to be
    very practical approach to the patient who is being
    considered for lung resection. The split function
    which they have used refers to a lung perfusion
    study that measures the amount of isotope perfusion
    to each lung. It does not require any intubation or
    split lung pulmonary function testing so it is
    relatively easy and practical. With only 2
    postoperative deaths of a result of cardiopulmonary
    failure and both of these individuals were marginal
    at best as they had a maximum oxygen uptake of only
    10mg/kg.ml.


       

  •  B. P. L. Wijnhoven, W. N. M. Dinjens and M. Pignatelli (Departments of Surgery and Pathology, Erasmus University Medical Centre, Rotterdam, The Netherlands and Division of Histopathology, Department of Pathology and Microbiology, Bristol Royal Infirmary, Bristol, UK)

    E-Cadherin-Catenin Cell-Cell Adhesion Complex and Human Cancer

    Br J. Surg August 2000 Vol. 87 (8) Pg. 992-1005 

         


    The E-cadherin-catenin complex plays a crucial role in epithelial cell-cell adhesion and in the maintenance of tissue architecture. Perturbation in the expression or function of this complex results in loss of intercellular adhesion, with possible consequent cell transformation and tumour progression. 

         


    Disturbance in protein-protein interaction in the E-cadherin-catenin adhesion complex is one of the main events in the early and late steps of cancer development.

         


    It has long been known that cell-cell adhesion is generally reduced in human cancers. Reduced cell-cell adhesiveness is associated with loss of contact inhibition of proliferation, thereby allowing escape from growth control signals. Invasion and metastases, the most life-threatening properties of malignant tumours, are considered to be later, but critically important, carcinogenic steps.

          


    In recent years, there has been increasing interest in a large family of transmembrane glycoproteins, called cadherins, which are the prime mediators of calcium-dependant cell-cell adhesion in normal cells. 

         


    There is increasing evidence that modulation of this complex by different mechanisms is an important step in the initiation and progression of human cancers.

        


    E-cadherin is bound via series of undercoat proteins, the catenins, to the actin cytoskeleton. This linkage between transmembranous cadherins and actin filaments of the cytoskeleton is necessary to form strong cell-cell adhesion. 

         


    In general, E-cadherin and catenin staining is strong in well differentiated cancers that maintain their cell adhesiveness and are less invasive, but is reduced in poorly differentiated tumours which have lost their cell-cell adhesion and show strong invasive behaviour. 

        


    Direct evidence implicating E-cadherin in the development of metastases is based on the association between highly metastasizing carcinomas and low E-cadherin immunoreactivity. 

         


    To predict tumour invasion and metastasis in carcinomas, it is useful to investigate not just the expression of E-cadherin but also the expression of the catenins. 

         


    Since the function and expression of the E-cadherin-catenin complex is often reduced in cancer cells, it is suggested that restoration of the E-cadherin-catenin will lead to differentiation and anti-invasive properties. Several drugs have been described to alter the expression of E-cadherin, some of which are already used in the treatment of cancer. 

         


    At least in vitro, insulin-like growth factor 1, tamoxifen, taxol, retinoic acid and progestagens have been shown to upregulate the functions of the E-cadherin-catenin complex, including inhibition of invasion.

         


    Aspirin is probably the most intriguing. Non-steroidal ant-inflammatory drugs are potent preventive agents against colon cancer. Aspirin decreased the rate of tumour formation.

         


    Aspirin produces a decrease in intracellular b-catenin levels, suggesting that modulation of this protein is associated with tumour prevention.

        


    Inactivation of the E-cadherin-catenin cell-cell adhesion complex is mediated by genetic and epigenetic events that occur in both the early and late stages of carcinogenesis.

        


    Elucidation of the mechanisms underlying the changes in E-cadherin and catenin function may lead to the development of novel therapeutic approaches based on biochemical and genetic manipulation.

         

  • W. P. Ceelen, U. Hesse, B. de Hemptinne and P. Pattyn (Department of Abdominal Surgery 2P4, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium)

    Hyperthermic Intraperitoneal Chemoperfusion in the Treatment of Locally Advanced Intra-Abdominal Cancer

    Br J. Surg August 2000 Vol. 87 (8) Pg. 1006-1015 

         


    Surgical treatment of intra-abdominal cancer is often followed by local recurrence. In a subgroup of patients, local recurrence is the sole site of disease, reflecting biologically low-grade malignancy. These patients might, therefore, benefit from local treatment.

         


    A growing body of experimental evidence supports the use of hyperthermia combined with chemotherapy as an adjunct to cytoreductive surgery.

          


    Traditionally, locoregional cancer recurrence with widespread peritoneal implantation has been difficult to treat, most patients undergoing palliative procedures or no surgery at all.

         


    Although intraperitoneal chemotherapy has been used alone or after surgery, taking advantage of the presence of a peritoneal-plasma barrier, its clinical efficacy is moderate. 

        


    Recently, cytoreductive surgery followed by hyperthermic intraperitoneal chemoperfusion (HIPEC) has been described for both treatment and prevention of locoregional cancer spread from various origins, a management plan based on the experimentally noted synergism between hyperthermia and several antineoplastic drugs.

         


    Hyperthermia Alone

         


    The tumoricidal properties of hyperthermia have been recognized since ancient times. The observation of spontaneous tumour regression in patients with hyperpyrexia led to the first clinical application of hyperthermia, which consisted of injection of pyrogenic substances in patients suffering from sarcoma. 

        


    Tumour cell inactivation is time and temperature dependent, and starts at 40-410 C. At temperatures above 430 C exponential inactivation of tumour cells occurs for most rodent cell lines, resembling the effect of ionizing radiation. Human tumour cell lines may be more sensitive to mild hyperthermia (41-420 C) than rodent cell lines.

         


    Hyperthermia with Chemotherapy

         


    Both experimentally and clinically, the antitumoral effect of various chemotherapeutic drugs is enhanced by hyperthermia. A possible disadvantage of the addition of hyperthermia is the induction of multidrug resistance gene (MDR1) expression. 

         


    Most clinical experience with hyperthermic chemoperfusion has involved mitomycin C (MMC) or platinum compounds. MMC is commonly used in the treatment of gastrointestinal cancer, usually in combination with other drugs. Platinum compounds are widely used in the treatment of epithelial ovarian cancer.

         


    Hyperthermia with Radiotherapy 

         


    Several randomized clinical studies have clearly demonstrated that hyperthermia and radiotherapy act synergistically on tumour tissue. 

          


    This synergism is explained by two phenomena observed in animal experiments. First, hyperthermia is cytotoxic to cells in an environment with low partial pressure of oxygen and pH44. Second, hyperthermic treatment at mild temperatures induces reoxygenation of tumour cells, rendering them more sensitive to the effects of radiation therapy. At higher temperatures (over 430 C) the opposite happens.

         


    The delivery of hyperthermia to the peritoneal surfaces by closed perfusion of a heated solution was first described in a clinical situation in 1980.

         


    Extensive cytoreduction followed by HIPEC is associated with considerable rates of morbidity and mortality, and the potential risks of the procedure must be weighed carefully against any potential benefit.

          


    Postoperative morbidity and death may, therefore, relate mainly to the extent and duration of surgery, and not to the hyperthermic perfusion itself.

         


    Peritoneal carcinomatosis is generally considered to be an incurable condition. However, a growing body of both experimental and clinical evidence supports the therapeutic and prophylactic use of HIPEC in patients without systemic disease.

          


    Many surgeons may not be familiar with the use of hyperthermia as an adjunct to surgery; the authors hope that this article will stimulate their interest.

          

  • Professor Denis Castaing, Editor of Annales de Chirurgie, chooses the best from issues published in 1999. 


    Br J. Surg August 2000 Vol. 87 (8) Pg. 1016-1018 

         


    Endocrine Surgery 

    A new approach to endoscopic parathyroidectomy. Using a 15-mm transverse incision on the anterior border of the sternomastoid muscle, the fascia connecting the lateral portion of the strap muscles and the thyroid lobe to the carotid sheath is divided at the level of the prevertebral fascia.

          


    Three trocars are inserted: one 12-mm trocar through the incision and two 2.5-mm trocars above and below the first trocar. Carbon dioxide is insufflated at a pressure of 8 mmHg.

         


    This study demonstrated that endoscopic parathyroid exploration can be performed via a lateral incision.

         


    Colon

    Loop ileostomy ensures faecal diversion to protect an anastomosis or prevent colorectal or anoperineal damage. 

           


    Low morbidity and defunctioning efficiency confirmed the indications for loop ileostomy in planned or emergency colorectal surgery.

       

  • Chen Y-G, Brushart TM (Union Mem Hosp, Baltimore, Md; Johns Hopkins School of Medicine, Baltimore, Md)

    The Effect of Denervated Muscle and Schwann Cells on Axon Collateral Sprouting 

    J Hand Surg [Am] 23A: 1025-1033, 1998



    Regenerative axon sprouting is usually necessary to restore functional recovery of a peripheral nerve. 



    To reinnervate the distal stump, it is also possible that collateral sprouts may be drawn from nearby intact nerves. Intramuscular axon collateral sprouting can be induced by denervated muscle.



    Motor and sensory nerve collateral sprouting is promoted through a perineurial window with the transplantation of denervated muscle and Schwann cells.



    Clinical experience suggests that, in the situation of loss of a sensory nerve, intact adjacent sensory nerves will undergo collateral sprouting to partially reinnervate the area of sensory loss.



    The controversy with the end-to-side nerve repair is whether or not motor axons will collaterally sprout de novo from an uninjured nerve into an end-to-side repair.



    Minimal motor collateral sprouting can be increased when the trophic lure of denervated muscle and Schwann cells is included at the end-to-side repair site.



    The authors also demonstrate that the proximal divided nerve is a source of contamination of motor fibers, even when care is taken to double ligate and cap the proximal stump. 



    This motor contamination from the proximal nerve stump likely accounts for some of the conflicting reports of motor sprouting from the intact donor nerve.

       

  • Mathoulin C, Brunelli F (Clinique Jouvenet, Paris)

    Further Experience With the Index Metacarpal Vascularized Bone Graft

    J Hand Surg [Br] 23B: 311-317, 1998



    When surgical treatment of scaphoid nonunion fails, a corticocancellous vascularized bone graft harvested from the distal part of the index metacarpal can be used to effect repair and to correct any palmar flexion by restoring the scaphoid to its correct position and supplying vascularity to the area.



    Use of a corticocancellous vascularized bone graft resulted in successful scaphoid union.



    This article has an excellent description of the pertinent vascular anatomy. While this vascularized bone graft has not been widely applied for scaphoid nonunion, it has some appeal, especially in the multiply operated-on wrist.

       

  • Frederick A. Moore (General Surgery and Trauma & Critical Care, University of Texas Health Science Center, Houston, Texas)

    Common Mucosal Immunity: A Novel Hypothesis 

    Annals of Surgery January 2000 Vol. 231(1) Pg. 9-10



    Over the past 15 years, considerable research effort has been directed at elucidating the role of the gut in the pathogenesis of nosocomial infections.



    Briefly, trauma patients are resuscitated into the systemic inflammatory response system (SIRS) and when severe, it causes early Multiple Organ Failure (MOF). As time goes on, certain aspects of SIRS are down-regulated to prevent ongoing “auto-destructive” inflammation, which results in delayed immunosuppression and when severe, contributes to the nosocomial infections that cause late MOF. 



    With regard to the gut’s potential involvement, shock (via ischemia/reperfusion injury and inhibitory neuroendocrine reflexes) and emergency laparotomy (via anesthesia and bowel manipulation) cause an early ileus. 



    Disuse (parenteral instead of enteral nutrition) and intensive care unit therapies (e.g., H2-antagonists, narcotics, broad-spectrum antibiotics) promote further gut dysfunction, characterized by progressive ileus, colonization of the upper gut, increased permeability, and decreased gut-associated lymphoid tissue (GALT) function. 



    Consequently, the upper gut becomes a reservoir for pathogens, and local and systemic defense mechanisms that prevent the spread of these organisms become impaired. 



    Primary route of dissemination (i.e., aspiration vs. translocation) is not clear. Prospective randomized controlled trials of gut-specific therapies (e.g., selective gut decontamination, early enteral nutrition, and most recently immuneenhancing enteral formulas) that have consistently demonstrated a reduction in postinjury nosocomial infections (principally pneumonia) are the most convincing evidence.



    In the 1980’s, early nutrition was provided to prevent the acute protein malnutrition induced by SIRS. This presumably maintained vital organ function and blunted immunosuppression. Early enteral nutrition, compared to total parenteral nutrition (TPN), reduced postinjury infections. 



    First, lack of enteral nutrition or lack of specific nutrients (e.g., glutamine, SCFA, fiber) may promote bacterial translocation.



    Second, excessive administration of glucose or lipids with TPN may worsen immunosuppression.



    Third, specific nutrients (e.g., glutamine, arginine, omega-3 fatty acids, and nucleotides) enhance immune effector cell function independent of preventing SIRS-induced acute protein malnutrition. 



    In summary, it emphasizes that the gut is an important immunologic organ that can be modulated to favorably affect systemic immunity. 



    The common mucosal immune system hypothesis is an exciting area of research, and their observations provide an alternative plausible explanation of how early enteral nutrition decreases postinjury infections, and provide new insight into the role of the gut in postinjury MOF and other critical illnesses.

       

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

    Lymphoedema Following Surgery for Breast Cancer

    BJS September 2000 Vol. 87 (9) Pg. 1128-1141

        


    Lymphoedema is a common complication of breast cancer treatment, affecting approximately a quarter of patients. Those affected can have an uncomfortable, unsightly and sometimes functionally impaired limb prone to episodes of superficial infection. The aetiology, pathophysiology and management of these patients is poorly understood. 

        


    Lymphoedema has been described as ‘a progressive pathologic state or condition characterized by chronic inflammatory
    fibromatosis and hypertrophy of the hypodermal and dermal connective tissues.

         


    There exists the extremely rare but potentially fatal possibility of secondary lymphangiosarcoma (Stewart-Treves syndrome).

         


    Axillary clearance, as commonly advocated, provides a guide to prognosis, assists in planning adjuvant systemic therapy and minimizes axillary recurrence; there is emerging evidence to suggest an impact on survival.

         


    Arm swelling in the early postoperative period is commonly observed and tends to settle spontaneously within a matter of weeks. Lymphoedema may, however, develop months or years after this (an interval of over 20 years has been reported), with around 75 per cent of cases occurring in the first year after operation.

         


    Onset may be gradual, or rapid. Patients occasionally identify a precipitating factor, such as a minor infection following a cut or graze, or a greater than usual degree of exercise involving the arm. 

         


    There remain, however, a number of questions regarding arm oedema following breast cancer surgery.

         


    1. Why do some women develop this complication while others do not?

    2. What explains the latent period preceding the onset of oedema?

    3. Why is it that certain sections of the arm are ‘spared’?

    4. Why is it so difficult to create artificial models of lymphoedema in animals, employing far greater surgical trauma than that involved in breast cancer treatment?

         


    Oedema is defined as the accumulation of interstitial fluid in abnormally large amounts. This can occur as a result of one of a number of physiological changes: (a) an increase in filtration pressure caused either locally by arteriolar dilation or venular constriction, or more globally by increased arterial inflow or elevated venous pressure; 

    (b) a reduction in the osmotic pressure gradient resulting from either a decrease in plasma proteins or an increase in osmotically active material in the interstitium; 

    (c) an increase in capillary permeability mediated by ‘lymphagogues’ such as substance P, histamines and kinins; and

    (d) a reduction in the flow of lymph

         


    Kissin et al found the prevalence of swelling following axillary sampling and irradiation to be equivalent to that following clearance of the axilla, and there is general agreement that the combination of surgery and radiotherapy to the axilla is best avoided, with quoted prevalence rates more than double those for surgery alone.

         


    There are other factors contributing to the aetiology of lymphoedema, with alterations noted in arterial inflow, venous return and plasma osmolality, as well as the intriguing possibility of the presence of lymphaticovenous communications. 

        


    Treatment strategies for lymphoedema fall into three main groups: conservative measures, drug treatment and surgery. At present, conservative measures form the mainstay of management, with surgery reserved for resistant cases (if at all). The place of pharmacological therapy is still unclear. 

         


    The principles of conservative treatment of lymphoedema remain unchanged from the middle of the nineteenth century, with attention to the areas of hygiene, massage, compression, and remedial exercises.

        


    There is no place for the use of diuretics in the treatment of lymphoedema; these drugs may even exacerbate the problem by increasing the protein concentration in the interstitium, thus enhancing the stimulus to inflammation and fibrosis. 

        


    Surgery for lymphoedema is usually reserved for cases resistant to conservative measures. Operations may be divided into two groups, namely debulking procedures and attempts to influence lymphatic drainage. 

        


    In 1962, Cockett and Goodwin described the anastomosis of a dilated lumbar lymphatic to the spermatic vein to treat a case of chyluria. Subsequent development of microsurgical techniques has enabled lymphaticovenous anastomosis to emerge as a potential treatment of arm lymphoedema. 

        


    At present lymphoedema following surgery for breast cancer remains a poorly understood and incurable problem. With cure an unrealistic possibility at present, emphasis should be placed on prevention. It may also be that postoperative changes, demonstrated in the latent phase before the development of swelling, might identify those in whom lymphoedema is most likely to occur. Early prophylactic initiation of conservative treatment measures may then prove more efficient than their institution when swelling has become established.

          

  • In studies that reported visceral gangrene, patients did not receive preoperative thrombus prophylaxis. Possibly, this played a role in preventing visceral gangrene. 

        


    The incidence of asymptomatic portal vein thrombosis seems to be significantly higher than that of symptomatic thrombosis. 

        


    Prompt initiation of therapy for portal vein thrombosis seems to be an important determinant for success. 

         


    The role of prophylactic heparin remains uncertain. It is possible that increasing the dosage of prophylactic heparin might be beneficial. 

         


    In conclusion, portal vein thrombosis should be suspected in patients with either fever or abdominal pain after splenectomy. Early treatment is more likely to restore normal flow in the portal vein and to prevent portal hypertension. Routine Doppler ultrasonography after splenectomy might enable early diagnosis and effective treatment. 

         

  • 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

    BJS September 2000 Vol. 87 (9) Pg. 1161-1165

         


    Shoulder-tip pain frequently occurs after laparoscopic cholecystectomy, making postoperative recovery less comfortable.

        


    To test the hypothesis that shoulder-tip pain is secondary to peritoneal stretching and diaphragmatic irritation caused by carbon dioxide, the influence of low-pressure pneumoperitoneum on the frequency and intensity of shoulder-tip pain was examined in patients undergoing laparoscopic cholecystectomy, in a prospective randomized study. 

         


    Laparoscopic cholecystectomy in this study was performed according to the European ‘for-puncture’ technique described by Dubois et al.

         


    Patients in group A underwent laparoscopic cholecystectomy with a short duration of high-pressure (13 mmHg) carbon dioxide pneumoperitoneum followed by a low-pressure (9 mmHg) carbon dioxide pneumoperitoneum, and those in group B had high-pressure (13 mmHg) carbon dioxide pneumoperitoneum all the time. 

         


    In all cases residual carbon dioxide pneumoperitoneum was evacuated at the end of the procedure by compressing the abdomen, taking care to keep the trocar valves open. A drain was left for 24 h in the gallbladder fossa.

         


    There was no correlation between duration of surgery and postoperative shoulder-tip pain. The aetiology and pathogenesis of this type of pain are still not clearly understood.

         


    Carbon dioxide may be transformed, by combining with fluid in the peritoneal cavity, to an irritative carbonic acid. This opinion is supported by the observation that, after laparoscopic cholecystectomy, patients experience less pain if nitrous oxide is used instead of carbon dioxide as pneumoperitoneum gas.

         


    Shoulder pain after laparoscopy could be caused by overstretching of the diaphragmatic muscle fibres owing to the high rate of insufflation. In this case, it would be the volume of the gas utilized for the pneumoperitoneum that caused the diaphragmatic irritation. It has been shown that a low insufflation rate significantly reduces shoulder pain. 

         


    Good results in reducing this kind of pain have been obtained by intraperitoneal normal saline infusion subdiaphragmatically at the end of the operation and, after postdeflation suction, by bupivacaine infusion in the same area. Heating of carbon dioxide gas to 370C during laparoscopy reduces shoulder-tip pain, although specific equipment is required for this purpose.

         


    The results of this study demonstrate the effectiveness in reducing postoperative shoulder-tip pain of an extremely simple intraoperative expedient: the reduction of carbon dioxide pressure, after the introduction of the trocars, from the initial 12-13 mmHg to 9 mmHg.

         


    It is hypothesized that the reduced stretching of diaphragmatic peritoneum also helps to minimize shoulder-tip pain. Operating at a low insufflation pressure means that the insertion of cannulas is more difficult and thus extra care is necessary to avoid injury to intra-abdominal structures. In order to reduce the operative risks, it seemed opportune to perform the initial surgical phase, the introduction of the trocars, at a higher pressure (13 mmHg), reducing pressure immediately afterwards.

         


    On the basis of these results, the widespread use of low-pressure pneumoperitoneum throughout most of a laparoscopic cholecystectomy procedure is recommended.

        

  • 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 Magarectum 

    BJS September 2000 Vol. 87 (9) Pg. 1203-1208

         

    Severe non-obstructive constipation associated with rectal dilatation greater than 6.5 cm on a lateral-view contrast enema is known as megarectum. The condition may commence at birth, childhood or in adult life.



    With the inevitable failure of conservative therapy, many patients are forced to contemplate surgery. Surgical options are limited and results variable. They include subtotal colectomy with ileorectal anastomosis, rectal excision with coloanal anastomosis, anterior resection, the Duhamel procedure and restorative proctocolectomy.



    The new vertical reduction rectoplasty (VRR) operation has been devised based on the hypothesis that reducing rectal capacity in megarectum would restore perception of rectal fullness and improve sensory and bowel function.

         



    Surgical Technique


         


    The sigmoid colon and most of the descending colon are resected, the splenic flexure having first been mobilized, the rectum is then mobilized. 

        


    Identification and preservation of the pelvic autonomic nerves is done as risk of damage to these nerves is greatly reduced by keeping the superior rectal vessels intact throughout the procedure. 

         


    The rectum is bisected into anterior and posterior halves. The anterior portion of the rectum is then excised. A coloneorectal anastomosis is then constructed between the proximal stapled end of the narrowed rectum and the proximal descending colon. The integrity of the suture lines is tested by inflating the narrowed rectum with air introduced via a large. Foley catheter per anum.

        


    A defunctioning loop ileostomy is next constructed in the right iliac fossa and the abdomen is closed. A water-soluble contrast enema is performed approximately 6 weeks after the procedure. If no leaks are apparent, the loop ileostomy is closed.

         


    Preoperative bowel frequency was a median of 2.5 (1-30) per month. Rectal perception of urge to defaecate was either attenuated or absent in all patients. All patients experienced a feeling of incomplete emptying, abdominal pain, bloating and regularly required assistance in the form of laxatives, enemas or manual evacuation.

        


    VRR to reduce rectal volume is a new concept in the treatment of megarectum. Colectomy and ileorectal anastomosis, the most common procedure performed, does not address the rectal abnormality and often results in persistent faecal stasis, frequency or incontinence. 

         


    The operation of VRR is based on the concept that most cases of megarectum are associated with a lack of normal rectal sensation. Reduction in rectal volume is designed to reduce the amount of distension necessary to trigger those sensory receptors important for normal defaecation and which remain within and without the rectal wall following this procedure.

         


    Sigmoid resection removes colon that is often dysmotile in these patients and as a consequence is designed to reduce transit time. Objective assessment indicated that the physiological aims of the procedure were mostly achieved.

        

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Surgery
  

  • Singh GK, Greenberg SB, Yap YS, et al [ St. Louis Univ., St. Christopher Hosp. for Children, Philadelphia, Southampton Gen. Hosp. England ]
    Right Ventricular Function and Exercise Performance Late After Primary Repair of Tetralogy of Fallot with Trasannular Patch
    Am J Cardiol 81: 1378-1382, 1998
       
    Current surgical repair of tetralogy of Fallot [TOF] involving reconstruction of the right ventricle [RV] usually results in chronic pulmonary insufficiency. Exercise performance and RV systolic and diastolic functions in a group of patients with pulmonary regurgitation, late after primary repair of TOF in infancy, was assessed with cine magnetic resonance imaging and compared with results in normal individuals.
        
    The study consisted of 10 New York Heart Association [NYHA] class 1 [n= 7] or II [n=3] patients with chronic pulmonary regurgitation for an average of 13.6 years after surgery for TOF with reconstruction of the right ventricular outflow tract with a transannular patch, at an average age of 6.9 months.
       
    Cine magnetic resonance imaging was performed and ventricular volume and function indices were calculated and compared with those of 7 age and sex matched healthy controls.
        
    All the patients had pulmonary regurgitation and right and left ventricular enlargement and lower ejection fractions with diminished exercise tolerance correlated with the degree of pulmonary regurgitation.

  • R.D. James
    Radiotherapy and Rectal Cancer – The Present Position
    Recent Advances in Surgery, Number 22, Year -1999, Pg.109
       
    The differential effect of XRT is largely due to the ability of normal tissues to repair more nuclear damage than malignant tissues. XRT is used for cancers of the bladder, prostate and uterus as well as the rectum.
     
    Permanent sterility is inevitable. Acute XRT induced enteritis appears approximately 2 weeks after the start of XRT. Late XRT-enterities may require extensive surgery for obstruction, bleeding, and fistula formation.
     
    The need of XRT is probably better determined by lateral resection margin [LRM] positivity and the need for adjuvant chemotherapy by lymph node positivity.
     
    A cure rate of at least 80% has been reported by most series for so-called contact XRT alone for tumours of less than 5 cm in diameter. Contact XRT differs from conventional XRT by delivering an extremely high [100-120 Gy] tumour surface dose in 3 or 4 treatments of 5 minutes over at least 2 months.
      
    Conservative surgery for larger tumours is safer following pre-operative XRT.
     
    Largest [80%] group of patients with rectal cancer are suitable for radical surgery with a view to cure both pre-operative and postoperative XRT reduce local recurrence by 30-50%.
      
    Toxicity was worse for post-operative than for pre-operative XRT.
          

  • Preito LR, Hordof AJ, Secic M, et al [Columbia Univ, New York; Cleveland Clinic Found, Ohio]
    Progressive Tricuspid Valve Disease in Patients with Congenitally Corrected Transposition of Great Arteries
    Circulation 98: 997-1005, 1998
        
    Patients with corrected congenital transposition of the great arteries [CTGA] are commonly found to have morphological abnormalities of the tricuspid valve, with 20% to 50% having clinically significant tricuspid insufficiency [TI]. The progression of tricuspid valve disease in such patients is unclear. A long-term follow-up study of patients with CTGA, with and without open heart surgery, was reported, with special attention to the significance of TI or intrinsic right ventricular dysfunction.
        
    The study included 40 patients with CTGA seen at one medical center since 1958. Twenty-seven patients were male and 13 female. The mean follow-up was 20 years. Potential risk factors for poor outcome were evaluated, including age, open heart surgery, TI, cardiac rhythm, pulmonary overcirculation, and right ventricular dysfunction.
       
    Twenty-one patients underwent intracardiac repair and 19 had no surgery or had closed heart procedures. The only independent prognostic factor for death was severe or moderately severe T1 as demonstrated by echocardiography and/or angiography. Furthermore, the only factor that predicted the presence of T1, was morphological abnormalities of the tricuspid valve. The 20-year survival rate was 93% for patients without T1 vs 49% for those with T1. For patients undergoing surgery, survival rate was 34% for patients with T1 vs 90% for those without T1. Among patients who did not have surgery, the 20-year survival rate was 60% with T1 vs 100% without.
         
    Thus presence of T1 in patients with CTGA worsens the prognosis, irrespective of whether they are operated or not.
         

  • Niezen RA, Helbing WA, van der Wall EE, et al [Leiden Univ. The Netherlands]
    Biventricular Systolic Function and Mass Studied with MR Imaging in Children with Pulmonary Regurgitation After Repair of Tetralogy of Fallot
    Radiology 201: 135-140, 1996
       
    Pulmonary Regurgitation [PR] may occur after surgical correction of tetralogy of Fallot. With the trend toward earlier correction of this congenital condition, there is a longer follow-up period for measurement of PR and biventricular function to evaluate the results of surgery; this study examined such functions.
         
    The study included 19 children who had been operated at mean age of 1.5 years. Doppler echocardiography revealed PR in each patient. A group of healthy controls was studied for comparison. The mean age was 12 years in both groups. The subjects underwent transverse gradient-echo MRI of both ventricles, including creation of MR velocity maps of pulmonary artery. Measurements of biventricular volumes, ejection fraction, myocardial mass, and pulmonary flow volumes were made. In addition, 17 patients underwent exercise testing.
          
    The patients with corrected tetralogy of Fallot had lower right ventricular ejection fractions [ 54% vs 66%] and higher right ventricular mass than controls. Left ventricular ejection factor was also lower in operated cases than controls [ 52% vs 68%] and was significantly correlated with PR. Exercise performance also was seen to be reduced in inverse proportion to PR in the operated cases.
         
    Patients operated for correction of tetralogy of Fallot do develop pulmonary regurgitation which results in larger biventricular mass and reduced ejection fractions; and these effects can be accurately measured by MRI.
          

  • Reddy VM, McElhinney DB, Phoon CK, et al [Univ of California, San Fransisco]
    Geomatric Mismatch of Pulmonary and Aortic Anuli in Children Undergoing the Ross Procedure : Implications for Surgical Management and Autograft Valve Function
    J Thorac Cardiovasc Surg 115: 1255-1263, 1998
        
    Many children treated with the Ross procedure for congenital heart lesions have a significant discrepancy between pulmonary and aortic anuli. No systematic study was examined whether such mismatch presents a contraindication to the procedure. A review of 41 children who underwent the procedure focuses on the surgical management of geomatric mismatch and its effects on autograft valve function.
        
    Patients had a mean age of 7.8 years. The diameter of the pulmonary valve was greater by 3 mm than that of the aortic valve in 20 cases, equal in 12 cases, and less by 3 mm in 9 cases; the differences ranged between + 10 to -12 mm. Aortoventriculoplasty was used to correct the mismatch in children with a larger pulmonary anulus; whereas in those with a larger aortic anulus, the correction was made by a gradual adjustment along the circumference of the autograft. Patients were followed up [ mean period 31 months] for autograft valvular regurgitation.
         
    Two patients required reoperation for moderate regurgitation. In the remaining 38 survivors, regurgitation was absent or trivial in 30, mild in 7, and moderate in 1. Regurgitation showed no relation with the age of the child, mismatch, or previous or concurrent procedures. No patient had significant autograft root dilatation.
         
    Thus geomatric mismatch is no contraindication to the Ross procedure in children.
         

  • M. Manu, J. Buckels and S. Bramhall [ Department of Surgery and Liver Unit, Queen Elizabeth Hospital, Birmingham BJ5 2TH, UK]
    Molecular Technology and Pancreatic Cancer
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 840-853
         

    This is a review of the molecular changes peculiar to pancreatic cancer and how the use of molecular technology might affect detection, screening, diagnosis, and treatment of the disease.
          
    Over the past 20 years great strides have been made in our understanding of the molecular basis of pancreatic cancer. Advances in molecular biology are now reshaping how diseases are screened for, diagnosed, investigated and treated. In recent years collaboration between clinicians and basic scientists has revealed a unique pattern of genetic and molecular events in pancreatic cancer. This review discusses how these advances may impact on patients with this disease which may improve the outlook for patients with this disease. The ‘molecular age’ promises to deliver better results.
         

  • EU Hernia Trialists Collaboration [ Prof. A. Grant, EU Hernia Triallists Collaboration Secretariat, Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK]
    Mesh Compared with Non-Mesh Methods of Open Groin Hernia Repair : Systematic Review of Randomized Controlled Trials 
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 854-859
        

    Information was gathered from all randomized and quasi-randomized trials comparing open mesh with open non-mesh methods to assess benefits and safety. Electronic databases were searched and members of the EU Hernia Triallist Collaboration consulted to identify trials. Prespecified data items were extracted from reports and quantitative or if not possible qualitative meta-analysis was performed.
        
    15 eligible trials which included 4005 patients were identified. There were similar number of complications in each group, with few data to address short-term pain and length of hospital stays. Return to activity was earlier in the mesh group in seven out of ten trials. [ P not significant]. There were fewer recurrences in the mesh group- Overall 21 [1.4%] of 1513 versus 72[4.4%] of 1634 [odds ratio 0.39 [95% confidence interval 0.25-0.59]; P<0.001].
        
    Within the data available mesh repair was associated with fewer recurrences.
         

  • M.C. Misra and R. Parshad [ Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India]
    Randomized Clinical Trial of Micronized Flavonoids in the Early Control Bleeding from Acute Internal Haemorrhoids
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 868-872
       
    Effective and non invasive control of acute bleeding could be of practical use in scheduling surgery to a convenient time both for patient and surgeon.
       
    In a 90-day randomized double blind study, treatment with a micronized purified flavonoid fraction [ MPFF] was compared to placebo in 100 outpatients who presented for treatment of acute internal haemorrhoids of less than 3 days duration. The primary endpoint was the cessation of bleeding on the third day of treatment.
       
    Of 50 patients randomized to each group, bleeding ceased within 3 days in 40 patients [ 80% of MPFF group] compared with 19 patients [38% of placebo group]. Continued treatment in patients with no bleeding prevented a relapse in 30 of 47 patients [ MPFF groups] compared with 12 of 30 [placebo group].
       
    They conclude that patients with acute internal haemorrhoids treated with MPFF had rapid cessation of bleeding and a reduced rate of relapse. This could be of value in the more convenient timing of treatment with invasive outpatient procedures.
        

  • G. Nilsson, S. Larson and F. Johnson [ Department of Nursing and Surgery, Lund University, Lund, Sweden]
    Randomized Clinical Trial of Laparoscopic Versus Open Fundoplication : Blind Evaluation of Recovery and Discharge Period
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 873-878
       

    There is a widespread belief that laparoscopic surgery in antireflux procedures has led to easier post operative recovery. A prospective randomized clinical trial was undertaken to verify this belief.
      
    60 Patients with G-E reflux disease were randomized to open or randomized 3600 fundoplication. The type of operation was unknown to the patient and the evaluating nurses.
       
    The Laparoscopic procedure took a longer time [ mean 148 min versus 109 min for open surgery]. The need for analgesics was less in the laparoscopic procedure [ 33.9 years versus 67.5 mg morphine per total hospital stay]. There was no significant difference in postoperative nausea and vomiting. The postoperative respiratory function was better and hospital stay was shorter in the laparoscopic group. No difference was found in the duration of sick leaves.
        
    They conclude that laparoscopic fundoplication takes a longer operating time has better post operative respiratory function has less need for analgesia and a shorter hospital stay. There was no difference in the duration of sick leave.
        

  • H. Tanaka, K. Hirohashi, S. Kubo, T. Shuto, I. Higaki and H. Kinoshita
    Preoperative Portal Vein Embolization Improves Prognosis of Right Hepatectomy for Hepatocellular Carcinoma in Patients with Impaired Hepatic Function
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 879-882
       

    Percutaneous transhepatic portal vein embolization [PTPE] increases the safety of subsequent major hepatectomy. This study aims to determine the effect of PTPE on long term prognosis after hepatectomy in patients with hepatocellular carcinoma [HCC].
       
    71 patients underwent hepatectomy for HCC. 33 patients [group 1] underwent preoperative PTPE and 38 patients [group 2] did not have this procedure. The patient were further divided according to the median tumour diameter [cut off 6 cm] and indocyanine green retention rate at 15 min [ICGR15] [cut-off 13%]. 
       
    The cumulative survival rate was significantly higher in group 1 then in group 2 in patients with an ICGR15 of at least 13%. Tumour-free survival rates were similar in both groups. Of patients with tumour recurrence after right hepatectomy, those in group 1 were more frequently subjected to further treatment. 
       
    Preoperative PTPE improves the prognosis after right hepatectomy for HCC in patients with impaired hepatic function although it does not prevent tumour recurrence.
       

  • M.W. Buchler, H. Friess, M. Wagner, C. Kulli, V. Wagener and K. Z’graggen [ Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, 3010 Bern, Switzerland]
    Pancreatic Fistula After Pancreatic Head Resection
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 883-889
       
    Pancreatic resections have a low mortality but the morbidity rate is 40% – 60% with a high prevalence of complications. This study analyses the complications after pancreatic head resection with particular attention to pancreatic fistula.
       
    Prospective data on 3311 pancreatic head resections were recorded. The data was grouped according to the procedure performed [ classical Whipple, duodenum-preserving pancreatic head resection [DPPHR] or pylorus-preserving pancreatoduodenectomy [ PPPD].
       
    The mortality rate was 2.1% with no difference between the three procedures. Total and local morbidity rates were 30.4 and 28% respectively. DPPHR had a lower morbidity, both local and systemic than Whipple’s. Pancreatic fistula was seen in 2.1% of 331 patients and was not dependent on the procedure or the aetiology. Re-operations were performed in 3.9% of patients, predominantly for bleeding andnon-pancreatic fistula. None of the patients with pancreatic fistula required re-operation or died in the post-operative period.
        
    A standardized technique and improved perioperative care are responsible for low mortality and low surgical morbidity rates after pancreatic head resection. Pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely requires surgical treatment.
      

  • S.R. Shah, D.F. Mirza, R. Afonso, A.D. Mayer, P. McMaster and J.A.C.Buckels [ Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospitals of Birmingham NHS Trust, Edgbaston, Birmingham B15, 2TH, UK]
    Changing Referral Pattern of Biliary Injuries Sustained During laparoscopic Cholecystectomy
    Br.Jour. of Surg. Volume 87, No.7, July 2000, Pgs. 890-891
        

    Laparoscopic cholecystectomy has become the procedure of choice for cholelithiasis but it is reported to have a higher incidence of bile duct injuries than conventional open cholecystectomy [0.6% versus 0.3%]. 
        
    Referral of a patient with a bile duct injury to a tertiary centre is often delayed and after prior surgical attempts are made by the referring surgeon.
       
    This study evaluates changes in the referral patterns since the advent of laparoscopic cholecystectomy.
       
    48 patients [mean age 49 years, 17 men] with bile duct injury after laparoscopic cholecystectomy [Jan 1991 to Dec 1998 ] were divided into 2 groups – before and after Jan 1996.
       
    The interval between primary surgery and referral; surgical radiological and/or endoscopic interventions; and sevirity of bile duct injury were noted [Strasberg classification] .
       
    More patients in the less severe : type biliary injury are being referred earlier to a specialist hepatobiliary unit. Most patients still have ineffective corrective surgery before transfer.
        

  • David W.Hart, MD, Steven E. Wolf MD, David L. Chinkes, PhD Dennis C. Gore, MD, Ronald P, MIcak, RRT, et al [ From the Department of Surgery, The University of Texas Medical Branch and the Shriners Hospitals for Children, Galveston, Texas
    Determinants of Skeletal Muscle Catabolism After Severe Burn
    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 455-465
       
    This study attempts to determine which patient factor affects the degree of catabolism after severe burn.
       
    151 stable-isotope protein kinetic studies were performed in 102 pediatric and 21 adult patients burned over 20-99.5% of total body surface area [TBSA]. 
       
    Patients demographics, burn characteristics and hospital course variables were correlated with the net balance of skeletal muscle protein synthesis and breakdown across the leg. The data was analyzed sequentially and cumulatively through univariate and cross-sectional multiple regression.
       
    Increasing age, weight and delay in definitive surgical treatment predict increased catabolism. Burns upto 40% TBSA increased catabolism. Thereafter the catabolism did not increase consistently. Resting energy expenditure and sepsis also increase catabolism. On the other hand, burn type, pneumonia, wound contamination, and time after burn did not significantly alter catabolism. From these results the authors conclude that gross muscle mass correlates independently with protein wasting after burn.
       

  • John Alverdy, MD, Christopher Holbrook, BS, Flavio Rocha, BS, Louis Seiden, PhD, Richard Licheng Wu, MD, PhD, Mrk Musch, PhD, Eugene Change, MD, Dennis Ohman, PhD, and Sanj Suh, PhD [ From the Departments of Surgery, Internal Medicine, and Pharmacology/Physiological Sciences, University of Chicago, Chicago, Llinois, and the Department of Microbiology and Immunology, Medical College of Virginia, Richmond, Virginia]
    Gut-Derived Sepsis Occurs When the Right Pathogen With the Right Virulence Genes Meets the Right Host Evidence for In Vivo Virulence Expression in Pseudomonas Aeruginosa
    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 480-489
       

    The objective of this study is to define the gut-active role of the PA-1 lectin/adhesin, a binding protein of pseudomonas aeruginosa, on lethal gut-derived sepsis after surgical stress, and to determine if this protein is expressed in vivo in response to physical and chemical changes in the local microenvironment of the intestinal tract after surgical stress.
       
    Previous work has shown that lethal gut-induced sepsis can be induced after the introduction of P. aeruginosa into the cecum of mice after a 30% hepatectomy but it does not occur in sham operated mice [controls]. The mechanism of this effect is due to the presence of PA-1 lectin / adhesin of P. aeruginosa which induces a permeability defect to a lethal cytotoxin of p. aeruginosa, [exotoxin A] 
       
    3 strains of P aeruginosa [ one lacking functional PA-1] were tested in two complementary systems to assess virulence.
       
    Strains were tested for 1] their ability to adhere to and after the permeability of cultured human colon epithelial cells and [2] Their ability to induce mortality when injected into the caecum of mice after 30% hepatectomy. 24 and 48 hours later these strains were retrieved from the caecum and their PA-1 expression was assessed.
       
    Results indicate that PA-1 plays a putative role in lethal gut derived sepsis in mice because strains lacking functional PA-1 had an attenuated effect and were non lethal. Furthermore surgical stress 
    [hepatectomy] significantly altered the intestinal micro environment resulting in an increase in the luminar norepinephrine associated with an increase in PA-1 expression in retrieved strains of P. aeruginosa. Coincubation of P. aeruginosa with nor-epinephrine increeased [PA-1 expression in vitro suggesting that norepinephrine plays a role in the observed role in vivo.
        

  • Philip R. Schauer, MD,Sayeed Ikramuddin, MD, William Gourash, CRNP, Ramesh Ramanathan, MD, and James Luketich, MD [ From the Department of Surgery, University of Pittsburgh, and the Mark Ravich/ Leon Hirsch Center for Minimally Invasive Surgery, Pittsburgh, Pennsylvania
    Outcomes After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity
    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 515-529
         
    This study evaluates the short term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with morbid obesity with a follow up of 1-31 months.
        
    275 consecutive patients who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass [July 1997 to March 2000] A 15 mL gastric pouch and a 75 cm Roux limb. [ 150 cm for superobese] was created using 5 or 6 trocar incisions.
       
    The conversion to open surgery was 1%. Oral feeding began a mean of 1.58 days after surgery with a median hospital stay of 2 days and return to work after 21 days.
       
    One death occurred [0.4%] due to pulmonary embolism. The incidence of early major and minor complications was 3.3% and 27% respectively. The hernia rate was 0.7% , and wound infection rate was 5%. Excess weight loss at 24 and 30 months was 83% and 77% respectively. In patients with more than 1 year follow up most of the comorbidities were improved or resolved. 95% reported significant improvement in quality of life.
       
    Laparoscopic Roux-en-Y gastric bypass is an effective procedure for morbid obasity with minimal morbidity and mortality.
       

  • Harvey J. Sugerman, MD, Elizabeth L, Sugeman, BSN, Jill G, Meador,BSN, Heber H, Newsome , Jr., MD, John M, Kellum, Jr., MD, and Eric J. DeMaria, MD [ From the General /Trauma Surgery Division, Department of Surgery, Medical College of Virgina of Virginia Commonwealth University, Richmond, Virginia]
    Ileal Pouch Anal Anastomosis Without Ileal Diversion
    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 530-541
         
    This study evaluates the results of a one stage stapled ileoanal pouch procedure without temporary ileostomy diversion.
        
    201 such procedures [IPAA] were carried out for ulcerative colitis and familial adenomatous polyposis, and one with concurrent Whipple procedure – of which only 2 were with an ileostomy as a one stage procedure.
        
    These patients were reviewed retrospectively for at least 1 year after surgery.
       
    Of those operated, 178 had ulcerative colitis [38 fulminant], 5 had Crohn’s disease, 1 had intermediate colitis, and 8 had familial adenomatous polyposis. The mean age was 38+ 7 years [7-70 years] with 98 males and 94 females. The average amount of disease tissue between the dentate line and the anastomoses line was 0.9 1cm with 35% anastomosis at the dentate line. The follow up was 89% at 1 year or more [mean 5.1 + 2.4 years] after surgery. The average 24 hour stool frequency was 7.1 + 3.3 of which 0.9 + 1.4 were at night. Control of stool was 95% during daytime and 90% at night. Only 2.3% required to wear a perineal pad. The average length of hospital stay was 10 + 0.3 days with 1.5+ 0.5 readmission for complications. Abscesses or enteric leaks occurred in 23 patients. 
        
    IPAA function was excellent in 19 [ 2 had permanent ileostomies] . In patients taking steroids there was no significant difference in leak rates.
       
    This date proves that the triple stapled IPAA without temporary ileostomy has a low complication rate, low rate of small bowel obstruction, excellent feacal control and permits an early return to functional life.
       

  • R. Phillip Burns, J. Preston Brown, S. Michael Roe, L. Richard Sprouse II, Andrea E, Yancey, and Laura E, Witherspoon, [From the Department of Surgery, University of Tennessee college of Medicine, Chattanooga Unit, chattanooga, Tennessee]
    Stereotactic Core-Needle Breast Biopsy by Surgeons
    Minimum 2-Year Follow-up of Benign Lesions
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 542-548
        
    This study evaluates the reliability of stereotactic core needle biopsy of the breast [SCNB] performed by surgeons to detect histologically benign tissue.
       
    A retrospective study was performed on 694 lesions detected in 619 patients. The breast lesions were classified by mammograms. Benign biopsy specimens were classified as proliferative or non-proliferative. Malignant lesions and those with atypical histopathology were excluded. All benign lesions were followed up for at least two years for any suspicious change requiring repeat biopsy.
       
    Of all biopsies 16% were malignant. The initial diagnosis in the others was benign. 400 lesions were available for follow-up. Of these 373 [93%] were classified as [mammographically]. BI-RADS 3 [probably benign] or 4 [suspicious]. 343 were non proliferative and 157 as proliferative [ 94 had combined proliferative and non proliferative] . The follow up ranged from 24-48 months [mean 33 months]. During the follow-up period 87 lesions underwent either image guided or open biopsy. At the time of follow-up rebiopsy, ductal carcinoma in situ was found on 4 occasions and infiltrating duct carcinoma in one, [ overall false negative of 4.3% i.e. 5 out of 117 cases] and a negative predictive value of 98.8%. No correlation was found between the type of initial pathology and development of malignancy.
       
    The authors conclude that SCNB is an alternative to open biopsy in benign lesions. However given the possibility of sampling error, close mammographic and clinical follow up as required.
       

  • Mark W. Onaitis, Paul M. Kirshbom, Thomas Z. Hayward, Frank J. Quayle, Jerome M. Feldman, Hilliard F. Seigler, and Douglas S. Tyler [ From the Departments of Surgery and Medicine, Duke University Medical Center, Dursham, North Carolina]
    Gastrointestinal Carcinoids : Characterization by Site of Origin and Hormone Production
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 549-556
       
    This study describes a large series of patients with carcinoid tumors in terms of their clinical features, hormonal diagnosis and survival.
       
    A prospective database of carcinoid tumour patients seen at Duke University Medical Center was kept from 1970 onwards.
       
    A retrospective review of medical records was done on this database to record clinical features, hormonal data, pathologic features and survival.
      
    Carcinoids at different sites had different clinical features. Rectal tumours presented with bleeding and midgut carcinoids with flushing diarrhea, and the carcinoid syndrome. 
       
    They had significantly higher levels of serotonin and its breakdown products, corresponding to higher metastatic tumor burdens. Although age, stage, region of origin and urinary levels of 5-HIAA predicted survival by univariate analysis; with a multivariate analysis only the latter there were independent predictors of survival. In patients with metastatic disease midgut tumours had better prognosis than foregut or hindgut tumours.
       

  • Yuman Fong, William Jamagin, and Leslie H, Blumgart [ From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York]
    Gallbladder Cancer : Comparison of Patients Presenting Initially for Definitive Operation With Those Presenting After Prior Noncurative Intervention
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 557-569
       
    This study compares patients with gall bladder cancer presenting for therapy with and without prior operation elsewhere to determine if an initial noncurative procedure alters outcome.
       
    Clinical presentation, operative data, complications and survival were examined for 410 patients [ 240 presented after prior operation elsewhere and the remaining who had no prior operation. 
       
    Overall, 51 patients were inoperable, 92 were subjected to biopsy only 135 to non curative cholecystectomy, 30 to surgical bypass and 102 to potentially curative resections [ portal lymph node dissection and liver parenchymal resection].
       
    The operative mortality was 3.9% . T-stage predicted likelihood of distant metastases and resectability, median survival for resected cases was 26 months and 5 year survival was 38% when resection was not done mortality was 5.4% and 5 year survival was 4%.
       
    The mortality, complications, and long term survival did not alter if prior exploration had been done.
      
    By multivariate analysis, resectability and stage were independent predictors of long term survival but prior surgical exploration was not.
       

  • Eugene S. Flamm, Arthur A. Grigorian, and Alvin Marcovici [ From the Department of Neurosurgery, Albert Einstein College of Medicine, Beth Israel Medical Center, New York, New York]
    Multi factorial Analysis of Surgical Outcomes in Patients with Unruptured Middle Cerebral Artery Aneurysms
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 570-575
       
    The study aims to build a predictive tool for assessing favorable outcome and morbidity in unruptured aneurysms.
    93 patients [ with 101 unruptrured aneurysms] were studied after surgery. Intra operative data was reviewed and seven factors that might affect the outcome were analysed. 
       
    1] Aneurysm size > 10 mm.
    2] Presence of broad neck
    3] Presence of intraaneurysmal plaque
    4] Clipping of more than one aneurysm during the same surgery.
    5] Temporary occlusion of the middle cerebral artery
    6] Multiple clip applications and repositionings 
    7] Use of multiple clips.
       
    The entire group was divided into two subgroups on the basis of the outcome. Each patient was subsequently analysed for the Factor Accumulation Index [FAI]. The sum of the different factors observed.
       
    Group 1: [ Expected outcome] – 86 patients with a total of 92 aneurysms. The results were as follows . 
       
    FAI 1- 6 patients. FAI 2 – 23 patients, FAI 3 – 12 patients, FAI 4 – 11 patients, FAI 5 – 8 patients FAI 6 – 1 patient, FAI 7 – 1 patient
       
    Group 2 – 7 patients – total morbidity of 7.5% There were no deaths in this group. FAI 1 – 0,1,2 or 5 [ no patients] FAI 3- 2 patients, FAI 4 – 2 patients, FAI 6 – 1 patient and FAI 7 – 2 patients.
      
    The authors conclude that it is possible to predict the outcome in aneurysms by calculating FAI. The post operative morbidity increases with an FAI within a range of 3 to 4.
       

  • Ambrosio Hernandez, Farin Smith, BS, QingDing Wang, Xiaofu Wang, BS, and B. Mark Evers [ From the department of Surgery, The University of Texas Medical Branch, Galveston, Texas]
    Assessment of Differential Gene Expression Patterns in Human Colon Cancers
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 530-541
       
    This study uses a novel genomic approach to determine differential gene expression patterns in colon cancers of different metastatic potential.
       
    Human colon cancer cells KM12C [derived from a Dukes B colon cancer] KML 4A [ a metastatic variant derived from KM12C] and KM20 [ derived from Dukes D Colon Cancer] were extracted for RNA. In addition RNA was extracted from normal colon primary cancer and hepatic metastasis in a patient with metastatic colon cancer. Gene expression patterns for approximately 1200 human genes were analyzed and compared by cDNA array techniques.
       
    Of the 1200 genes assessed in the KM cell lines,9 genes were noted to have more than threefold change in expression [either increased or decreased] in the more metastatic KML4A and KM20 cells compared with KM12C. There was more than threefold change in expression of 16 genes in metastatic colon cancer compared with normals.
       
    The authors have identified genes with expression levels that are altered with metastasis.
          

  • Stephen J. Mathes, Paul M. Steinwald, Robert D. Foster, William Y. Hoffman, and James P. Anthony [ From the Division of Plastic and Reconstructive Surgery, University of California at san Francisco, California]
    Complex Abdominal Wall Reconstruction : A Comparison of Flap and Mesh Closure
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 586-596

    This study analyses a series of patients treated for recurrent or chronic abdominal wall hernias and determines a treatment protocol for defect construction.

    104 patients [106 hernias] undergoing abdominal reconstruction for recurrent or chronic complex defects were retrospectively analysed. For each patient, the aetiology, size, location average duration and technique of reconstruction and postoperative results including complications and recurrences was studied.

    Patients were divided into two groups based on the defect. Type 1 had intact skin over the hernia and type II had absent or unstable skin covers. The defects were also assigned to zones based on 
    the primary defect location. Zone 1A, upper midline, Zone 1B lower midline, zone 2 upper quadrant, and zone 3 lower quadrant.

    68% cases were incisional hernias. Of 50 type 1 defects, 10[20%] were repaired directly, 28[56%] were repaired with a mesh and 12[24%] required flap repair . For 56 type II defects 48 [80%] required flap repair. The overall complication and recurrence rates were 29% and 80% respectively.

    They conclude that for Type 1 defect a mesh repair gives the best results with the least complications. For type II defects a flap repair is advisable with tensor fascia lata being the flap of choice particularly in the lower abdomen. Rectus advancement may be used for midline defects. Overall failure is caused by repair under tension, extraperitoneal mesh placement or technical error.
       

  • C. Wright Pinson, Irene D. Feurer, Jerita L. Payne, RN, MSN, Paul E. Wise, Shannon Shockley, and Theodore Speroff [ From the Vanderbilt University Transplant Center, Nashville, Tennessee]
    Health-Related Quality of Life After Different Types of Solid Organ Transplantation 
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 597-607
        
    This study describes the functional health and health related quality of life [QOL] before and after transplantation to compare and contrast outcomes among liver, heart, lung and kidney transplants, and compare these outcomes with selected norms and to explore whether physiologic performance demographics and other clinical variables are predictors of post transplantation overall subjective QOL.
       
    The Karnofsky performance status was assessed objectively for patients before transplantation and upto 4 years after transplantation and scores were compared by repeated measures analysis of variance. Subjective evaluation of QOL overtime was obtained using the short form –36 [ SF-36] and the psychosocial adjustment to illness Scale [PAIS].
       
    Results : Tools were administered to 100 liver, 94 heart, 112 kidney and 65 lung transplant patients. The mean age at transplantation was 48 years, 36% were female. The KPS before transplantation was 37 + 1 for lung 38 + 2 for heart 53 + 3 for liver and 75 + 1 for kidney recipients.
       
    After transplantation the scores improved to 67 + 1 at 3 months. 77 +1 at 6 months 82 + 1 at 12 months, 86 + 1 at 24 months and 84 + 2 at 36 months and 83 + 3 at 48 months.
       
    When patients were stratified by initial performance score as disabled or able, both groups merged in terms of performance by 6 months after liver and heart transplantation. Kidney transplant cases 
    maintained their stratification 2 years after transplantation. The PAIS score improved globally. Path analysis demonstrated a direct effect on the post transplant Karnofsky score by time after transplantation and diabetes, with trends evident for education and preoperative serum cretinine level. Although neither time after transplantation nor diabetes was directly predictive of a composite QAL score that incorporated all 15 subjective domains, recent Karnofsky score and education level were directly predictive of the QOL composite score.
       
    This data provides clearly defined and widely useful QOL outcome benchmarks for different types of solid organ transplants.
        

  • James D. Luketich, Siva Raja , BS, Hiran C. Fernando, William Campbell, Neil A. Christie, Percival O. Buenaventura, Tracey L. Weigel, Robert J. Keenan, and Phillip R. Schauer [ From the Department of Surgery and Radiology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania]
    Laparoscopic Repair of Giant paraesophageal Hernia : 100 Consecutive Cases
    Annals of Surgery, Volume 232, Number 4, Pg. Nos. 608-618
       
    From July 1995 to February 2000, 100 patients [median age 68 years] underwent laparoscopic repair of a giant PEH. Follow up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores.
       
    There were 8 type II hernias, 85 type III, and 7 type IV hernias. Sac removal, Crural repair, and antireflux procedures were performed [ 72 Hissen, 27 Collis-Nissen]. There was no early mortality, but one surgery related death at 5 months from a perioperative stroke. Intra operative complications included pneumothorax, esophageal perforation and gastric perforation. There were 3 conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome and repeat operations [ two for abscess and one each for haematoma, repair leak and recurrent hernia]. Median length of stay was 2 days. Median follow up at 12 months revealed resumption of proton pump inhibitors in10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 [ 0 best, 45, worst]; the 
    satisfaction score was 91%, physical and mental component summary scores were 49 and 54 respectively [normal 50].
       
    Laparoscopic repair of giant PEH was successful in 97% of patients with a minimal complication rate, a 2-day hospital stay and good intermediate results. 
       

  • T.M.D. Hughes, R.P. A’Hern and J.M. Thomas [ Melanoma and Sarcoma Unit, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK]
    Prognosis and Surgical Management of Patients with Palpable Inguinal Lymph Node Metastases from Melanoma
    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 892-901
        
    The aim of this study was to identify factors that influence the outcome of patients undergoing therapeutic groin dissection for clinically detectable melanoma lymph node metastases. 
       
    A retrospective study of 132 cases who underwent lymph node dissection [ inguinal] therapeutically.
       
    60 Patients had superficial inguinal lymph node [SLND] dissection and 72 had combined superficial inguinal and pelvic lymph node dissection [CLND]. 
         
    There was no difference in postoperative morbidity or major lymphoedema. The overall survival rate was 34% at 5 years. On univariate analysis age, the number of superficial inguinal nodes and presence of extra capsular spread had a significant impact on survival. The presence of or absence of pelvic lymph node metastases was a significant prognostic factor [ 19% vs. 47%].
        
    The prognosis of patients with clinically detectable melanoma metastases to the groin is variable and related to the biologic characteristics of each case. CLND provided additional prognostic information and optional regional control but no change in morbidity compared to SLND.
         

  • A.O’Bichere, P. Sibbons, C. Dore, C. Green and R.K.S. Phillips [ St. Marks Hospital and Northwick Park Institute for Medical Research, Harrow, UK]
    Experimental Study of Faecal Continence and Colostomy Irrigation
    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 902-908
        
    This study investigates the effect of modifying colostomy irrigation technique [route, infusion regimen and pharmacological manipulation] on colonic emptying time in a porcine model.
        
    An end colostomy and caecostomy were fashioned for six pigs. Twenty markers were introduced into the caecum immediately before colonic irrigation. Irrigation route [antegrade or retrograde], infusion regimen [ tap water, polyethylene glycol [PEG], 1.5 per cent glycine] and pharmacological agent [glyceryl trinitrate [GTN] 0.25 mg/kg, diltiazem 3.9 mg/kg, bisacodyl 0.25 mg/kg] were assigned to each animal at random. Colonic transit time was assessed by quantifying cumulative expelled markers [CEM] and stool every hour for 12 hours.
       
    Mean CEM at 6 hours for bisacodyl, GTN and diltiazem were 18.17, 12.17 and zero respectively; all pairwise differences in means were significant. The difference at 12 hours between the two routes and three fluids was significant, but not for PEG versus glycine and bisacodyl versus GTN. Cumulative output was significantly more with antegrade than retrograde route using PEG, but the difference in mean cumulative output for bisacodyl and GTN at [ 12 hours was not significant].
       
    The conclusion drawn is that colonic emptying is more efficient with antegrade than retrograde irrigation. PEG and glycine enhance emptying similar to bisacodyl and GTN solution. This promises improved faecal continence by colostomy irrigation and may justify construction fo a Malone conduit at the time of colostomy in selected patients. 
        

  • E. Rullier, F. Zerbib, C. Laurent, M. Caudry and J. Saric [ Departments of Digestive Surgery, Gastroenterology and Radiation Oncology, Saint-Andre Hospital, 33075 Bordeaux Cedex, France]
    Morbidity and Functional Outcome After Double Dynamic Graciloplasty for Anorectal Reconstruction
    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 909-913
        
    The aim of this study was to evaluate the morbidity and functional results in a homogeneous series of patients undergoing double dynamic graciloplasty following APR for rectal cancer.
        
    15 patients[ 10 men and 5 women, mean age of 54 years range [ 39 to 77] underwent anorectal reconstruction with double dynamic graciloplasty after APR for low rectal cancer. 
        
    All patients had preoperative radiotherapy [ 15 Gy] and ten received adjuvant, chemotherapy, 8 had intraoperative radiotherapy [15 Gy] and ten received 
    adjuvant chemotherapy for six months. Surgery was performed in three stages : APR with coloperineal anastomosis and double graciloplasty; implantation of the stimulation 2 months later; and ileostomy closure after a training period.
        
    There was no operative death. At a mean of 28 months [3-48] of follow-up there was no local recurrence; 2 patients had lung metastases. Early and late morbidity occurred in 11 patients [mainly related to neosphinctor], mainly stenosis. Of 12 patients followed up for functional outcome. 7 were continent, 2 were incontinent and 3 had an abdominal colostomy [ 2 for incontinence and one for sepsis]. The restenosis required major surgery and had a poor outcome.
       
    The conclusion is that the double dynamic graciloplasty is associated with a high risk of neosphincter stenosis which may entail morbidity, reintervention and poor functional results. It is suggested that single dynamic graciloplasty should be used for anorectal reconstruction after APR.
        

  • D.C. Jenner , A. Middleton, W.M. Webb, R. Oommen and T. Bates [ The Breast Unit, William Harvey Hospital, Ashfold TN24 OLZ, UK]
    In-Hospital Delay in the Diagnosis of Breast Cancer
    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 914-919
        
    Delay in the diagnosis of breast cancer may prejudice survival. The aim of this study was to determine the incidence, time trends and causes of delay in a dedicated breast clinic. 
        
    The interval between the first visit to the clinic and a definitive diagnosis, was recorded in 1004 patients with invasive breast cancer.
        
    There was a delay of 3 months or more in 42 cases [4.2%]. The median delay was 6 months and the median age at diagnosis was 53 years [range 27-89 years]. Triple assessment was undertaken in 30 patients. Ten did not have a needle biopsy and three patients did not have a mammography. The principal cause of delay was false negative or inadequate needle aspiration cytology [FNAC] in 19 patients, a failure of follow-up in 8 cases, failure of needle localization in two cases, FNAC not carried out in 4 cases, no clinical signs in five patients and one case who did not follow clinical advice. The annual incidence of delay in diagnosis did not change significantly over a 10 year interval.
       
    Triple assessment is not sufficiently sensitive to detect breast cancer and a small delay in diagnosis is inevitable with current techniques.
        

  • L. Jansen, M. H.E. Doting E.J.Th. Rutgers, J. de Vries, R.A. Valdes Olmos and O.E.Nieweg [ Departments of Surgery and Nuclear Medicine, The Netherlands Cancer Institute /Antoni van Leeuwenhock Hospital, Amsterdam and Department of Surgical Oncology, Groningen University Hospital, Groningen, The Netherlands]
    Clinical Relevance of Sentinel Lymph Nodes Outside the Axilla in Patients with Breast Cancer 
    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 920-925
       
    Lymphatic mapping in patients with breast cancer can reveal sentinel lymph nodes that are not located at level I-II of the axilla. The clinical relevance of this is not fully understood.
       
    113 consecutive patients [T1-3 No Mo] with breast cancer were studied. Based on preoperative scintigraphy. Sentinel node biopsy was performed guided by a g probe and patent blue dye. All sentinel nodes that were visible were biopsied and examination of those nodes included step sections and staining with CAM5.2. Axillary node dissection was performed regardless of sentinal lymph node status.
       
    19% [ 21 cases] had sentinel lymph nodes outside level I-II of the axilla, mostly in the internal mammary chain. 22 of the 30 sentinel nodes at these sites were harvested. 3 patients had sentinel nodes only outside the axilla. 4 other patients had metastases outside the axilla. This changed postoperative treatment in 3 patients. No postoperative complication occurred.
       
    Biopsy of sentinel lymph nodes [19% of cases in this series] is technically demanding but the clinical impact was limited – treatment changed in only 3%.
        

  • S. Kitano, D. Baatar, T. Bandoh, T. Yoshida, S. Tsuboi and Matsumoto [ Department of Surgery, I, Qita, Medical University, Oita 879-5593, Japan]
    Transvenous Sclerotherapy for Huge Oesophagogastric Varices Using Open Injection Sclerotherapy 
    BJS, Volume 87, Number 7, July 2000, Pg. Nos. 926-930
        
    This report describes a new procedure for treating huge oesophagogastric varices by open injection sclerotherapy.
       
    23 patients with huge oesophagogastric varices underwent laparotomy and devascularization of the upper stomach with splenectomy. The left gastric vein was catheterized for repeated injection of 5% ethanolamine oleate during the postoperative period.
       
    In all patients the varices were eradicated after a mean of 3 sessions of sclerotherapy. There were no deaths or major complications during mean follow up of 41 months. Small recurrent varices in 2 patients were treated successfully by endoscopic sclerotherapy and interventional radiology.
        
    Open injection sclerotherapy is an effective and safe procedure for the treatment of huge oesophagogastric varices.
         

  • David W.Hart, MD, Steven E. Wolf MD, David L. Chinkes, PhD Dennis C. Gore, MD, Ronald P, MIcak, RRT, et al [ From the Department of Surgery, The University of Texas Medical Branch and the Shriners Hospitals for Children, Galveston, Texas
    Determinants of Skeletal Muscle Catabolism After Severe Burn
    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 455-465
       

    This study attempts to determine which patient factor affects the degree of catabolism after severe burn.
       
    151 stable-isotope protein kinetic studies were performed in 102 pediatric and 21 adult patients burned over 20-99.5% of total body surface area [TBSA]. 
       
    Patients demographics, burn characteristics and hospital course variables were correlated with the net balance of skeletal muscle protein synthesis and breakdown across the leg. The data was analyzed sequentially and cumulatively through univariate and cross-sectional multiple regression.
        
    Increasing age, weight and delay in definitive surgical treatment predict increased catabolism. Burns upto 40% TBSA increased catabolism. Thereafter the catabolism did not increase consistently. Resting energy expenditure and sepsis also increase catabolism. On the other hand, burn type, pneumonia, wound contamination, and time after burn did not significantly alter catabolism. From these results the authors conclude that gross muscle mass correlates independently with protein wasting after burn.
       

  • John Alverdy, MD, Christopher Holbrook, BS, Flavio Rocha, BS, Louis Seiden, PhD, Richard Licheng Wu, MD, PhD, Mrk Musch, PhD, Eugene Change, MD, Dennis Ohman, PhD, and Sanj Suh, PhD [ From the Departments of Surgery, Internal Medicine, and Pharmacology/Physiological Sciences, University of Chicago, Chicago, Llinois, and the Department of Microbiology and Immunology, Medical College of Virginia, Richmond, Virginia]
    Gut-Derived Sepsis Occurs When the Right Pathogen With the Right Virulence Genes Meets the Right Host
    Evidence for In Vivo Virulence Expression in Pseudomonas Aeruginosa
    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 480-489
        

    The objective of this study is to define the gut-active role of the PA-1 lectin/adhesin, a binding protein of pseudomonas aeruginosa, on lethal gut-derived sepsis after surgical stress, and to determine if this protein is expressed in vivo in response to physical and chemical changes in the local microenvironment of the intestinal tract after surgical stress.
       
    Previous work has shown that lethal gut-induced sepsis can be induced after the introduction of P. aeruginosa into the cecum of mice after a 30% hepatectomy but it does not occur in sham operated mice [controls]. The mechanism of this effect is due to the presence of PA-1 lectin / adhesin of P. aeruginosa which induces a permeability defect to a lethal cytotoxin of p. aeruginosa, [exotoxin A] 
      
    3 strains of P aeruginosa [ one lacking functional PA-1] were tested in two complementary systems to assess virulence.
      
    Strains were tested for 1] their ability to adhere to and after the permeability of cultured human colon epithelial cells and [2] Their ability to induce mortality when injected into the caecum of mice after 30% hepatectomy. 24 and 48 hours later these strains were retrieved from the caecum and their PA-1 expression was assessed.
      
    Results indicate that PA-1 plays a putative role in lethal gut derived sepsis in mice because strains lacking functional PA-1 had an attenuated effect and were non lethal. Furthermore surgical stress 
    [hepatectomy] significantly altered the intestinal micro environment resulting in an increase in the luminar norepinephrine associated with an increase in PA-1 expression in retrieved strains of P. aeruginosa. Coincubation of P. aeruginosa with nor-epinephrine increeased [PA-1 expression in vitro suggesting that norepinephrine plays a role in the observed role in vivo.
       

  • Watson A. [ Department of Surgery, Royal Free and University College Medical School, Royal Free Hospital, London NW3 2QG, UK]
    Barrett’s Oesophagus – 50 Years on
    BRJ, Volume –87, Number 5, May, 2000, Pg.Nos 529-531
       

    Norman Barrett first described the columnar-lined oesophagus associated with a congenital short oesophagus.
       
    The incidence of oesophageal adenocarcinoma, as a consequence of gastro-oesophageal reflux disease [GORD] and Barrett’s oesophagus, is increasing more rapidly than that of any other malignancy in the Western world.
       
    There is now very strong evidence that Barrett’s oesophagus is an acuired condition consequent on long-standing GORD. Intestinal metaplasia is a necessary prerequisite to the development of adenocarcinoma.
       
    Malignant transformation occurs in a stepwise process from metaplasia through dysplasia to carcinoma, involving a series of molecular changes that include p53 and p16 mutations, aneuploidy and microsatellite instability.
       
    Management of Barrett’s oesophagus is controversial.
       
    Successful antireflux surgery offers complete and continuous reflux control, which is of particular relevance because intermittent pulse acid exposure causes greater cellular proliferation and de-differentiation of Barrett’s oesophagus cells in culture than either no acid or continuous acid.
       
    The development of adenocarcinoma is inevitable once the cascade of genomic instability has commenced, but effective reflux control before this may have a protective role.
       
    Traditionally, Barrett’s oesophagus has only been deemed to exist if the circumferential columnarized segment exceeds 3 cm in length.
       
    The finding of microscopic intestinal metaplasia of the cardia is more likely to be associated with Helicobacter pylori infection than GORD and has not been demonstrated to progress to cancer.
       

  • E.M. Targarona, C. Balague, M.M. Knook and M. Trias [ Departments of General and Digestive Surgery, Hospital de Sant Pau and Hospital Clinic, Barcelona, Spain ]
    Laparoscopic Surgery and Surgical Infection
    BRJ, Volume –87, Number 5, May, 2000, Pg.Nos 536-544
        
    It is now broadly accepted that the immune system is better preserved following laparoscopic than open surgery; this is demonstrated by the diminished release of various markers including interleukin [IL] 6 and C-reactive protein [ CRP]. This decreased immune response results from a significantly smaller tissue injury.
        
    It is also important to analyze the peritoneal response to infection because surgical infection initially develops in he peritoneal cavity.
       
    Pneumoperitoneum causes morphological changes in the peritoneal microstructure, proportional to its duration of use.
       
    Loss of contact and fissures between mesothelial cells, as well as infiltration of macrophages and erythrocytes, have been demonstrated by electron microscopy, features that occur at a faster rate in a contaminated environment.
      
    Carbon dioxide affects intracellular conditions, creating an acidic milieu. 
      
    Carbon dioxide attained a significantly lower intra-abdominal pH than those insufflated with ambient air or helium.
      
    Therefore, carbon dioxide may impair the cellular physiology of macrophages.
      
    The viability of T cells depends on pH level. Both the mechanical factor and the direct influence of carbon dioxide affect peritoneal cell physiology.
      
    The advantages of using gases other than carbon dioxide are still under investigation.
      
    Operative laparoscopy requires pneumoperitoneum at high pressure for a prolonged period.
    Hyperpressure of such duration may increase intraperitoneal infection by peritoneal dissemination. 
      
    However, the incidence of postoperative infectious complications is generally assumed to be low.
      
    The risk of bacteraemia or sepsis is potentially increased by the laparoscopic environment.
       
    The systemic inflammatory response and the number of intra-abdominal abscesses were lower after laparoscopic surgery than after open operation [laparotomy].
       
    It has been demonstrated that the smoke produced by electrocauterization is able to spread viable cells and viruses.
      
    A possible danger of infecting surgical personnel has been attributed to the use of pneumoperitoneum. Suspended particles from the internal cavity may travel from the body through trocar orifices into the ambient air.
      
    There is a consensus, however, that a small risk of infection through aerosolization during interventions with pneumoperitoneum may exist when dealing with patients who are infected with human immunodeficiency virus [HIV] or hepatitis C virus. This risk is smaller than that associated with a cutaneous puncture, yet it is recommended that the situation be avoided by aspirating the intra-abdominal gas at the end of the procedure.
      
    It is important to stress the need to aspirate the pneumoperitoneum at the end of the procedure and to discard or sterilize used instruments.
      
    For open surgery, instruments are easily sterilized by conventional methods [ gas or autoclave]. However, for laparoscopic work the kit is mechanically more complex and so its complete sterilization is difficult; disposable instruments are preferred.
      
    Solid residue exists in higher quantity following sterilization of instruments used for laparoscopic work. It is recommended that surgeons follow manufacturers instructions. Reusable instruments, on the other hand, are able to be dismantled to allow complete cleaning and sterilization.
      

  • L.J. Fon and R.A. J. Spence [ General Surgical Unit, Belfast City Hospital, Belfast, UK]
    Sportsman’s Hernia
    BRJ, Volume – 87, Number 5, May, 2000, Pg. Nos 545-552
       

    Sportsman’s hernia is a debilitating condition, which presents as chronic groin pain. A tear occurs at the external obliqe which may result in an occult hernia.
      
    The diagnosis of sportsman’s hernia is difficult. The condition must be distinguished from the more common osteitis pubis and musculotendinous injuries.
       
    Chronic groin pain is a major diagnostic and therapeutic dilemma.
       
    Groin injury leading to chronic pain is often referred to as the sportsman’s hernia or groin disruption and, sometimes, as pubalgia. 
      
    Gilmore popularized the syndrome of groin disruption as ‘Gilmore’s groin’ in the early 1990s and has reported good results from surgical management. 
      
    Chronic groin pain may originate from muscles, tendons, bones, bursas, fascial structures, nerves and joints.
      
    A deficiency of the posterior inguinal wall is the commonest operative finding in patients with groin pain.
      
    An accurate clinical history and extensive examination of the spine, pelvis, hips, and abdominal and leg musculature plays an important part in determining its cause. 
      
    Pain is notably worse over the pubic tubercle of the affected side, and the area around the external ring is tender.
      
    Coughing, sneezing and kicking a ball exacerbate the symptoms.
      
    Clinical findings typically include a lack of visible external signs in the affected groin, dilatation of the superficial ring [demonstrable by scrotal inversion with the tip of the little finger], a cough impulse and marked tenderness in the opposite groin.
      
    Apart from hernia, two other major causes of groin pain are muscle and tendon injury, and osteitis pubis.
      
    Other less common causes include nerve entrapment and urological pathology. Rarer reported causes include bone and joint dosease, such as stress fractures, snapping hip syndrome, spondylolisthesis, early osteoarthritis and slipped upper femoral epiphysis.
       
    Herniography is performed by injecting contrast medium into the peritoneal cavity. The patient is then moved to an upright position and asked to strain. Anteroposterior and oblique views are taken.
       
    Herniography has been reported to have an accuracy [95-99.5 per cent] and low false negative rate [ 0.5-4.0 per cent] in the detection of abdominal wall hernia.
       
    Negative herniography does not exclude on occult hernia.
       
    MRI can clearly identify structures [ inferior epigastric vessels, inguinal ligament, deep and superficial rings, inguinal canal, spermatic cord, round ligament and vascular structures] that are crucial in the assessment and differentiation of inguinofemoral hernias.
       
    It is superior to CT as an imaging modality for muscle strain injury. 
       
    MRI is of limited value in the diagnosis of calcified tendinitis and bony abnormality at tendon insertion points; these are better visualized using CT.
       
    The main advantage of ultrasonography, CT and MRI is their ability to identify conditions other than hernias that may be responsible for the symptoms.
       
    Initially, conservative management with rest, anti-inflammatory agents, stretching and strengthening exercise should be advised.
       
    Surgical intervention is contemplated when conservative management has failed. There is no consensus to support any particular surgical procedure.
       
    Despite ‘negative’ investigation, in severe and/or persistent cases surgical exploration is justified.
       
    Appropriate repair of the posterior wall of the inguinal canal has proven to be of therapeutic benefit, offering cure to over 60 per cent of the patients and improvement to a further 20 per cent.
       

  • A.J. Smith, J.J. Lewis, N.B. Merchant, D.H.Y. Leung, J.M. Wodruff and M.F. Brennan [ Department of Surgery, Biostatistics and Pathology, Memorial sloan-Kettering Cancer Center, New York, USA]
    Surgical Management of Intra-Abdominal Desmoid Tumours
    BRJ, Volume – 87, Number 5, May, 2000, Pg. Nos 608-613
       
    Intra-abdominal desmoids are uncommon neoplasms. The aggressive nature of these tumours and the potential for major morbidity secondary to resection can present a difficult surgical dilemma.
       
    Intra-abdominal desmoid tumours occur sporadically or in association with familial adenomatous polyposis [FAP] and often present a clinical dilemma.
      
    These tumours exhibit benign histological features and do not metastasize, yet their local behaviour is aggressive as they invade contiguous structures and have a marked propensity to recur after resection.
      
    Intra-abdominal desmoid are frequently associated with the intestinal mesentery, a feature that predisposes to complications of bowel obstruction and fistula formation, and also impedes efforts at resection.
      
    Small series have documented regression following therapy with antioestrogens [tamoxifen, toremifene], non-steroidal agents, cytotoxic chemotherapy and radiotherapy. However, there are also reports of spontaneous regression, making the role of medical therapy unclear.
       
    Of note, there was no difference in the overall survival rate between the completely resected and unresected groups of patients. 
       
    Although most patients undergoing complete resection had positive histological margins, the majority had no recurrence at follow – up. 
       
    Significant morbidity and mortality occurred in some patients in whom complete resection was undertaken, usually because of intestinal resection.
       
    Therapeutic decision-making a challenging because surgical resection of these lesions is technically difficult and accompanied by a significant risk of complication, while medical therapy is of unclear benefit.
       
    Biology of intra-abdominal desmoids may be characterized by initial rapid growth followed by stability or regression.
       
    Desmoids are noted for their proclivity to recur following resection in up to one-third of cases.
       
    Heroic resection that endanger the viability of the small intestine and the patient should be avoided. 
       
    Given that these tumours may be associated with minimal symptomatology, a trial of watchful waiting and minimally toxic medical therapy [e.g. antioestrogens, sulindac] may be preferable to resection, especially in patients with lesions intimately involved with the mesenteric vessels.
       

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

  • T. Mynster, I.J. Christensen*, F. Moesgaard and H.J. Nielsen for the Danish RANXO5 Colorectal Cancer Study Group [Department of Surgical Gastroenterology 435, H:S Hvidovre Hospital, University of Copenhagen, Hvidovre and * Finsen Laboratory]
    Effects of the Combination of Blood Transfusion and Postoperative Infectious Complications on Prognosis After Surgery for Colorectal Cancer
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1553-1562
      
    The frequency of postoperative infectious complication is significantly increased in patients with colorectal cancer receiving  perioperative blood transfusion. However, it is still debated, if it alters the incidence of local recurrence or of the prognosis.
       
    Patients risk variables, operation technique, blood transfusion and the development of infectious complications was recorded prospectively in 740 cases undergoing resectional surgery for colorectal cancer. Endpoints were overall survival and time to diagnosis of recurrent disease in the – curative  group [n:532]. The patients were divided into 4 groups divided with respect of whether blood transfusion was given or not as also the development or the absence of infectious complications.
        
    19% of 288 non-transfused cases and 31% of 452 transfused patients developed infectious complications. In a multivariate analysis, the risk of death was significantly increased in patients developing infections after transfusion [n=142] compared with patients not receiving transfusion or developing infection [n=234]: hazard ratio 1.38. Overall survival of transfused group not developing infection [n=310]: and patients developing infection without preceding transfusion [n=54] was not significantly decreased. In an analysis of disease recurrence the combination of transfusion and subsequent infection [hazard ration 1.79]. Localisation of cancer in the rectum and Dukes classification were independent factors.
       
    The combination of perioperative blood transfusion and subsequent infectious complications may be associated with poor prognosis.
       

  • G.H. Sakorafas and A.G. Tsiotou [ Department of Surgery, 251 Hellenic Air Force Hospital, Messogion and Katehaki, Athens 115 25, Greece
    Genetic Predisposition to Breast Cancer : A Surgical Perspective
    Br. J. of Sur., Volume 87, Number 2, February, 2000, Pg. 149
        
    Molecular alterations in proto-oncogenes, tumour suppressor genes, and genes that function in DNA damage recognition and repair are considered to be the hallmarks of a carcinogenic process, including breast carcinogenesis.
       
    After a thorough review of literature the authors postulate that hereditary breast cancer accounts for 5-10 per cent of all breast cancer cases. About 90% of hereditary breast cancer involve mutation of BRCA1 and/or BRCA2 genes. Other cancer related genes [myc, c-erbB2, Tsg101 and Mdgi] are involved in breast carcinogenesis, but they do not give rise to familial breast cancer syndromes. Risk estimation is the most important clinical implication. Management options for the high-risk mutation carriers include cancer surveillance and preventive strategies [prophylactic surgery or chemoprevention].
       
    They conclude that despite inadequate knowledge about the genetic predisposition to breast cancer and its clinical implications, the demand for genetic testing is likely to increase. In addition to risk estimation, cancer surveillance and preventive strategies, gene therapy offers a new and theoretically attractive approach to breast cancer management.
       

  • U Chetty, W. Jack, R.J. Prescott, C. Tyler and A. Rodger, on behalf of the Edinburgh Breast Unit [ Correspondence to : Mr. U. Chetty, Edinburgh Breast Unit, Western General Hospital, Edinburgh EH4 2XU, UK]
    Management of the Axilla in Operable Breast Cancer Treated by Breast Conservation : a Randomized Clinical Trial
    Br. J. of Sur. Volume 87, Number 2, February, 2000, Pg. 163
       
    In the treatment of operable breast cancer by breast conservation, the extent of axillary dissection, the need for radiotherapy to the axilla and the morbidity associated with these procedures have not been assessed adequately.
      
    Patients with operable breast cancer were randomized to have level III axillary node clearance. Radiotherapy [RT] to the axilla was given selectively. RT was not given to those who had an axillary clearance. The first 54 patients were subjected to node sampling and RT. Subsequently only node positive patients were given RT. The morbidity, upper limb volume, and circumference, and glenohumeral and scapular movements were assessed.
      
    No difference was found in local axillary or distant recurrence. There was no statistical difference in the 5-year survival ratio. The morbidity was least in those who had node sampling but no RT, to axilla. RT to axilla who had a node sample resulted in a significant reduction in range of movement of the shoulder. Surgical axillary clearance was associated with significant lymphoedema of the upper extremity.
          

  • Snyderman CH, Kachman K, Molseed L, et al [ Univ of Pittsburgh, Pa; Duquesne Univ, Pittsburgh, Pa; Univ of Louisville, Ky]
    Reduced Postoperative Infections with an Immune-Enhancing Nutritional Supplement
    Laryngoscope 109: 915-921, 1999
      
    This is a randomized double blind trial on 136 patients who were undergoing radical excisional  surgery for squamous cell carcinoma of the  aerodigestive  tract and who required postoperative nutritional supplement.
       
    The patients were divided into four groups. [1] with pre and post operative supplementation with Impact [2] only post operative supplementation [3] pre and post operative standard formula [4] only postoperative standard formula.
      
    Group 1 and Group 2 had significantly reduced rates of postoperative sepsis. Group 3 and Group 4 showed no effect on rate of wound sepsis healing or hospital stay. Postoperative albumin levels were higher in Group 1 and Group 2. Impact can reduce postoperative sepsis, hospital stay and costs.
        

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

  • Alter MJ, Kruszon-Moran D, Nainan OV, et al [ Ctrs for Disease Control and Prevention, Atlanta, Ga and Hyattsville, Md; Natl Inst of Allergy and Infectious Diseases, Bethasda, Md]
    The Prevalence of Hepatitis C Virus Infection in the United States, 1988 Through 1994
    N Engl J Med 341: 556-562, 1999
        
    Chronic infection with Hepatitis C virus [HCV] is a major cause of chronic liver disease, but is often asymptomatic. Sera was collected from a nationwide population survey to assess its prevalence.
        
    21, 241 sera samples were tested. An enzyme immunoassay and a supplemental test were used to test for antibody to HCV [anti-HCV]. Reverse transcriptase-polymerase chain reaction for HCV RNA and gene sequencing studies were also performed.
        
    The result show 1.8% incidence of anti-HCV i.e. 3.9 million persons in the US had HCV infection [95%  confidence level]. Nearly two thirds were between 30-49 years of age.
        
    Of those with anti-HCV, 74% tested positive for HCV i.e. 2.7 million Americans had chronic HCV infection. 74% of those had genotype 1 [ 57% – 1a  and 17% -1b]. Illegal drug use and high risk sexual behavior, poverty, poor education, divorced couples were significant risk factors and independently.
        

  • Pittet D, Wyssa B, Herter-Clavel C, et al [Univ Hosp of Geneva, Switzerland]
    Outcome of Diabetic Foot Infections Treated Conservatively : A Retrospective Cohort Study with Long-term Follow-up
    Arch Intern Med 159: 851-856, 1999
       
    Diabetic foot lesions are the cause of more hospitalizations than any other complications of diabetes. Effective guidance needs to be enunciated to minimize human and financial cost of diabetic foot lesions. A 5-year retrospective cohort study with prospective long-term follow up was undertaken to identify criteria predictive of failure of conservative treatment of such lesions.
       
    The Wagner classification system was used for this study. Variables examined included patient demographics, infection and diabetes.
       
    Of 120 patients, 74% had contiguous osteomyelitis, deep tissue involvement or gangrene. 13% underwent immediate amputation.  Of the remaining, conservative treatment was successful in 63% of cases. 21 of 26 [81%] with skin ulcers. 35 of 50 [70%] with deep tissue infection or suspected osteomyelitis and 1 of 15 [7%] with gangrene.
       
    Independent factors predictive of failure were fever, elevated creatinine, prior hospitalization for diabetic foot lesion, duration of diabetes.
       
    Conservative measures including prolonged culture guided parenteral or oral antibiotics was successful without amputation in 63% of diabetic foot lesion.
        

  • Penning, H.A.J. Gielkens, M. Hemelaar, J.B.V.M. Delemarre, W.A. Bemelman, C.B.H.W. Lamers and A.A.M. Masclee [ Departments of Gastroenterology- Hepatology and Surgery, Leiden University Medical Centre, Leiden, The Netherlands]
    Prolonged Ambulatory Recording of Antroduodenal Motility in Slow-Transit Constipation

    Br. J. of  Sur.,  Volume 87, Number 2, February, 2000, Pg. 211-217
       
    Slow transit constipation may be a part of a pan-enteric motor disorder. To test this hypothesis 24 hour ambulatory antroduodenal manometry was performed and orocaecal transit time determined in patients with slow transit constipation and in healthy controls.
       
    The antroduodenal motility was recorded with a 5-channel solid-state catheter. Postprandial motility was recorded after consumption of 2 standardized test meals and interdigestive motility was recorded nocturnally. Quantitative and qualitative analysis were done. The orocaecal transit time was determined by means of lactulose hydrogen breath test.
      
    There was no difference in the motility between patients and controls. However, some minor changes of interdigestive motility were observed. The proportion of phase II activity of the nocturnal cycles of the interdigestive migrating motor complex was increased in the patients while phase I activity was decreased. The total number of phase III fronts with antral onset was decreased. Specific motor abnormalities such as retrograde propagation of phase III fronts wee more frequent in patients.
       
    They conclude that in patients with slow transit constipation, orocaecal transit time is delayed but antroduodenal motility is generally well preserved with only minor alterations.
        

  • D.S. Walsh, P. Siritongtaworn, K. Pattanapanyasat. P. Thavichaigarn, P. Kongcharoen, N. Jiarakul, P. Tongtawe, K. Yongvanitchit, C. Komoltri, C. Dheeradhada, F.C. Pearce, W.P. Wiesmann and H.K Webster [**]
    [** Department of Immunology and Medicine, US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Departments of Surgery, Hematology and Clinical epidemiology, Siriraj Hospital, Department of Surgery, Pharmongkutklao [Royal Thai Army] Hospital, and Department of Surgery, Police Hospital, Bangkok, Thailand and Division of Surgery, Walter Reed Army Institute of Research, Washington, DC, USA ]
    Lymphocyte Activation After Non-Thermal Trauma
    Br. J. of  Sur.,  Volume 87, Number 2, February, 2000, Pg. 223-230
       
    Service injury causes immunologial changes that may contribute to a poor outcome. Longitudinal characterization of lymphocyte response patterns may provide further insight into the basis of these immunological alterations.
      
    Venous blood obtained seven times over 2 weeks from 61 patients with injury severity scores over 20 was assessed for lymphocyte and activation markers together  with serum  levels of interleukin [IL]2, IL-4, soluble IL-2 receptor [sIL-2R], soluble CD4 [sCD4], soluble CD8 [sCD8] and interferon g.
       
    Severe injury was associated with profound changes in the phenotypic and activation profile in the phenotypic and activation profile of circulating lymphocytes. Activation was indicated by increased number of T cells expressing CD25, sIL-2R and sCD4 and sCD8 were found in-patients with sepsis syndrome.
       
    Polytrauma is associated with dramatic alterations in the phenotypic and activation profile of circulating lymphocytes which are generally independent of clinical course. In contrast several lymphocyte soluble factors including sCD4 and SIL-2R, paralleled the clinical course. These data provide new insight into lymphocyte responses after injury and suggest the further assessment of soluble factors as clinical correlates. 
       

  • C.H. Yoo, S.H. Noh, D.W. Shin, S.H. Choi and J.S. Min [Department of Surgery, Yonsei University College of Medicine, 134 Shinchon-ku, 120-752, Seoul, Korea ]
    Recurrence Following Curative Resection for Gastric Carcinoma
    Br. J. of Sur., Volume 87, Number 2, February, 2000, Pg. 236-242

    The diagnosis and treatment of recurrent gastric carcinoma is difficult. This study was aimed at determining the risk factors for recurrence of gastric carcinoma and prognosis for these patients.
    508 cases of recurrent gastric carcinoma out of 2328 patients who underwent curative resection for gastric carcinoma were studied retrospectively by univariate and multivariate analysis.
       
    The mean time to recurrence was 21.8 months and peritoneal recurrence was the most common [45.9%]. Logistic regression analysis showed that serosal invasion and lymph node metastasis were risk factors for all recurrence and early recurrence [at 24 months or less]. In addition, independent risk factors involved in each recurrence pattern included younger age, infiltrative or diffuse type, undifferentiated tumour and total gastrectomy for peritoneal recurrence, older age and larger tumour size for disseminated haematogenous recurrence; and older age, larger tumour size, infiltrative or diffuse type, proximally located tumour and subtotal gastrectomy for locoregional recurrence. Other risk factors for early recurrence were infiltrative or diffuse type and total gastrectomy. 
       
    Re-operation for cure was possible in only 19 patients and the mean survival time after conservative treatment or palliative resection was less than 12 months.
       
    The risk factors can be predicted by the clinicopathological features of the primary tumour.
        

  • William H Hindle, Raquel D Arias, et al (Univ of Southern California School of Medicine, Los Angeles)
    Lack of utility in clinical practice of cytologic examination of nonbloody cyst fluid from palpable breast cysts.
    Am J Obstet Gynecol, 182(6),pg.1300 -5
       
    Objective : This study was undertaken to answer the following question: Does cytologic evaluation of nonbloody fluid aspirated from breast cysts contribute to appropriate clinical management?
       
    Study Design: A retrospective review of palpable breast cyst fluid cytologic reports and associated medical records was undertaken to determine whether the cytologic findings affected patient management. Breast cyst size, fluid volume, fluid color, and patient age were abstracted from 689 medical records (1988-1999) of women whose palpable cysts had been aspirated at the Breast Diagnostic Center, Women’s and Children’s Hospital, Los Angeles. These observations were correlated with the fluid cytologic reports.
       
    Results : Except for frankly bloody fluid, all breast fluid cytologic reports listed the results as a cellular, inadequate for cytologic diagnosis, or no malignant cells identified.
      
    Conclusion: In clinical practice only frankly bloody fluid should be submitted for cytologic analysis. All other cyst fluid should be discarded.
       

  • J Mourad, J P Elliot and L Lisboa (Phoenix, Arizona)
    Appendicitis in pregnancy: New information that contradicts long-held clinical beliefs.
    Am J Obstet Gynecol 2000; 182: 1027-9
       
    Objective: Our purpose was to elicit a better understanding of the presentation of acute appendicitis in pregnancy and to clarify diagnostic dilemmas reported in the literature.
      
    Study Design: The authors retrospectively reviewed 66,993 consecutive deliveries from 1986 to 1995 by a computer program. Selected records were reviewed for gestational age; signs and symptoms at presentation; complications including preterm contractions, preterm labor, and appendiceal rupture; and histologic diagnosis of appendicitis.
       
    Results: Of 66,993 deliveries, 67 (0.1%) were complicated by a preoperative diagnosis of probable appendicitis. Acute appendicitis was confirmed histologically in 45 (67%) of the 67 cases, for an incidence of 1 in 1493 pregnancies in this population. Distribution of suspected appendicitis in pregnancy was as follows; first trimester, 17 cases (25 cases); second trimester, 27 (40%); and third trimester, 23 (34%). Right-lower-quadrant pain was the most common presenting symptom regardless of gestational age (first trimester, 12 (86%) of 14 cases; second trimester, 15 (83%) of 18 cases; and third trimester, 10 (78%) of 13 cases). The mean maximal temperature for proven appendicitis was 37.6°C (35.5°C-39.4°c), in comparison with 37.8°C (36.7°C-38.9°C; not significant) for those with normal histologic findings. The mean leukocyte count in patients with proven appendicitis was 16.4 x 109/L (8.2-27.0 x 109/L), in comparison with 14.0 x109/L (5.9-25.0 x109/L) for patients with normal histologic findings. At the time of surgery, perforation had occurred in 8 cases. Of 23 patients at ³24 weeks’ gestational age, 19(83%) had contractions and an additional 3 patients (13%) had preterm labor with documented cervical change. One patient was delivered in the immediate postoperative period because of abruptio placentae.
      
    Comment: The authors also attempted to validate the original study (1932) by Baer et al regarding change in pain location with advancing gestational age. They were unable to find any reliable sign or symptom that could aid in the diagnosis of acute appendicitis in pregnancy.
       
    They were unable to corroborate the hypothesis of Baer et al that would suggest a right-upper-quadrant location for the pain of appendicitis in the third trimester.
       
    As the appendix becomes obstructed by a coprolith, it distends and visceral afferent nerves are stimulated, causing constant poorly localized pain starting near the umbilicus and eventually migrating to McBurney’s point, which overlies the location of the appendix in most non-pregnant patients. As the full thickness of the appendiceal wall become necrotic and the serosa is damaged, the somatic neurons are stimulated, which localizes the pain to the right lower quadrant. This process appears to remain similar in pregnancy, contrary to the Baer theory and classical obstetric teaching. A high clinical suspicion is necessary to make the diagnosis, and because of overlap with normal pregnancy symptoms, a higher false-positive rate (30%) is not only acceptable but necessary to avoid unacceptable delay, with the possibility of increased morbidity and mortality rates.
       
    Conclusion: Pain in the right lower quadrant of the abdomen is the most common presenting symptom of appendicitis in pregnancy regardless of gestational age. Fever and leukocytosis are not clear indicators of appendicitis in pregnancy and preterm labour is a problem after appendectomy, but preterm delivery is rare.
      

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

  • K. Holte and H. Kehlet [ Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark]
    Postoperative Ileus : A Preventable Event
    Br.Jour.of Surg. Volume 87, Number 11, Nov. 2000 Pg.Nos. 1480-1493
       
    Postoperative ileus is generally defined as a transient impairment of bowel motility after abdominal surgery or other injury.
        
    Ileus has traditionally been accepted as an obligatory physiological response to abdominal surgery, but the purpose of this response is the elective surgical setting has not been established.
        
    The average paralytic state lasts between 0 and 24 h in the small intestine 24 and 48 h in the stomach and between 48 and 72 h in the colon after major abdominal surgery.
      
    A correlation between some of the widely used clinical endpoints, such as bowel sounds, passage of flatus and stool, is also controversial.
      
    Bowel sounds are non-specific because they may originate in the small bowel as well as in the large bowel, and also require frequent auscultation for assessment. Passage of flatus is highly dependent on reporting by patients. 
      
    Passage of stool, although manifest as a clinical sign, is not specific, as it may indicate only distal bowel emptying and not necessarily the function of entire gastrointestinal tract.
     
    Clinical resolution of ileus to be relatively independent of these technical variables.
      
    As no single objective Variable has yet been found accurately to predict resolution of ileus, he most adequate definition of resolution probably depends on a combined functional outcome of normalization of food intake and bowel function.
       
    Pathogenesis of Postoperative Ileus
    Inhibitory Neural Reflexes
      
    Three anatomically distinguishable reflexes seem to be involved: ultrashort reflexes confined to the wall of the gut, short reflexes involving the prevertebral ganglia, and long reflexes involving the spinal cord.
         
    Long reflexes are probably of most importance, since several experimental studies have shown spinal anesthesia, abdominal sympathectomy and other nerve-cutting techniques to prevent or reduce the development of ileus.
      
    In summary, inhibitory sympathetic reflexes are of major importance in the pathogenesis of ileus. This has substantial clinical implications as these reflexes are subject to modification by epidural blockade.
      
    Numerous transmitters and peptides are involved in regulating gastrointestinal motility and so may be involved in ileus.
      
    Opioids are well established as modulators of transmission in the central and peripheral nervous systems, leading to inhibition of gastric emptying and non-propulsive smooth muscle contraction.
       
    Local inflammatory response is related to the extent of surgical trauma and degree of ileus.
         
    Furthermore, the paralytic gut response to surgery seems to be biphasic, consisting of a short temporary initial paralysis, followed by a longer-lasting impairment of muscle activity paralleling the local tissue concentration of inflammatory cells.
        
    A single dose of neural blockade with spinal or epidural anaesthetic alone or as a supplement to general anesthesia does not influence the duration of ileus.
        
    Analgesic treatment that includes opioids may prolong ileus, and the use of opioid-sparing analgesia with non-steroidal anti-inflammatory drugs [NSAIDs] or other analgesics [balanced analgesia] may reduce ileus.
      
    Epidural bupivacaine significantly reduced ileus.
     
    Based on knowledge of the inhibitory effects of opioids on gut motility, various opioid-sparing analgesic techniques have been developed to avoid the undesirable sequelae of opioid administration in the postoperative period.
      
    The advantageous effect on NSAIDs, apart from the sparing of opioid, may also be related to a direct anti-inflammatory effect mediated by the inhibition of prostaglandin synthesis.
      
    The insertion of a nasogastric tube has been the traditional supportive treatment for postoperative ileus, but it does not shorten time to first bowel movement or time to effective oral food intake.
       
    Nasogastric tube should not be used routinely, and that unnecessary use may contribute to postoperative morbidity such as atelectasis, pneumonia and fever.
      
    Contrary to popular belief, physical exercise does not improve colonic motility in healthy volunteers. 
      
    The presence of food stimulates the secretion of various intestinal hormones, with an overall stimulating effect on gastrointestinal motility.
       
    Early enteral nutrition may improve immune function and reduce postoperative and posttraumatic infectious complications.
       
    The early fed group tolerated a regular diet 3 days before the later fed group.
       
    The proven beneficial effects of continuous epidural local anaesthetics, opioid-sparing analgesics and cisapride have unfortunately not been incorporated in previous controlled clinical studies of early enteral nutrition.
       
    Ileus is clinically non-existent after laparoscopic cholecystectomy.
      
    The mechanisms involved may include reduced activation of inhibitory reflexes and local inflammation due to a reduction in surgical trauma.
      
    Cisapride enchances acetylcholine release from the intrinsic plexus and acts as a serotonin receptor agonist; it may stimulate all aspects of gastrointestinal motility.
      
    Beneficial effect of cisapride on ileus depends on the route of its administration, favoring intravenous or, possibly, oral administration in the postoperative period.
      
    Adverse cardiac effects may occur with cisapride, which may therefore be contraindicated in high risk patients.
      
    Ceruletide is a synthetic peptide whose cholecystokinin antagonis activity may stimulate gastrointestinal motility. 
      
    However, side effects such nausea and vomiting, which may require additional antiemetic treatment, limit the potential use of ceruletide.
       
    Metoclopramide may potentially influence gastrointestinal motility by acting as a dopamine antagonist, as well as by direct and indirect effects on cholinergic and serotonergic receptors throughout the gastrointestinal tract.
       
    None of these studies has demonstrated a significant effect of metoclopramide on the resolution of postoperative ileus.
       

  • Y. Morii, T. Arita, K. Shimoda, K. Yasuda, Y. Matsui, M. Inomata and S. Kitano [ Surgery Division, Arita Gastrointestinal Hospital and Department of Surgery I, Oita Medical University, Oita, Japan]
    Jejunal Interposition to Prevent Postgastrectomy Syndromes.
    Br.Jr.of Surg. Volume 87, Number 11, Nov. 2000 Pg. 1576-1579
      
    Postgastrectomy syndromes include reflux gastritis and oesophagitis, dumping syndrome, intractable diarrhoea and afferent loop syndrome. To prevent such syndromes, since January 1994 jejunal interposition has been used following distal gastrectomy.
      
    Recent progress in the diagnosis and surgical treatment of early gastric cancer has markedly reduced the mortality rate.
      
    More attention should be focused on symptom relief to improve the quality of life for ling-term survivors.
      
    Postoperative clinical issues include alkaline reflux gastritis, early and late dumping syndrome, intractable diarrhoea and afferent loop syndrome following gastrectomy: the postgastrectomy syndromes. 
      
    The authors often encountered patients treated by Billroth I repair in whom daily life was disturbed by postgastrectomy syndromes. Therefore, since January 1994, isoperistaltic jejunal interposition has been used following distal gastrectomy.
      
    Curative surgery for patients with early gastric cancer results in a favourable prognosis for long-term survival. More attention could focus on symptom relief to improve the quality of life in survivors. 
      
    Jejunal interposition between the gastric remnant and the duodenum [ gastrojejunoduodenostomy] was first described by Henley. 
      
    The dumping syndrome can be relieved by jejunal interposition.
      
    It is possible that jejunal interposition should be the standard reconstruction following distal gastrectomy.
           

  • S. Biondo, E. Jaurrieta, J. Marti Rague, E. Ramos, M. Deiros, P. Moreno and L. Farran [ Department of Surgery, Ciudad Sanitaria y Universitaria de Bellvitge, University of Barcelona, Barcelona, Spain]
    Role of Resection and Primary Anastomosis of the left Colon in the Presence of Peritonitis
    Br.Jr.of Surg. Volume 87, Number 11, Nov. 2000 Pg. 1580-1584
       
    Large bowel perforation is an abdominal emergency associated with high morbidity and mortality rates.
       
    Peritoneal contamination by bacteria may lead to septic shock, and surgical intervention must aim to prevent or treat this by removal of the septic focus.
     
    Intraoperative colonic lavage with resection and primary anastomosis [RPA] has been proposed as a safe and expedient method for single-stage resection and anastomosis. It is widely accepted as a safe procedure for treatment of left-sided large bowel obstruction.
       
    Th hypothesis was that peritoneal contamination by itself would not increase the anastomotic dehiscence rate, making the one-stage procedure a safe treatment for both localized and diffuse peritonitis in selected Patients.
       
    Renal function and central venous pressure were always monitored. Parenteral antibiotic therapy included prophylaxis against both aerobic and anaerobic bacteria. Antibiotic treatment was continued after operation.
       
    Renal failure was defined as a creatinine level above 1.4 mg/dl, circulatory failure as systolic arterial pressure less than 90 mmHg requiring inotropic support, and respiratory failure as arterial blood oxygenation lower than 60mmHg.
        
    Immunocompromised status was defined by a concurrent history of exogenous glucocorticoid treatment, extracolonic active malignant neoplasm, cytotoxic chemotherapy, malnutrition, or congenital or acquired immunodeficiency syndrome.
        
    Malnutrition was defined as weight loss of more than 10% of normal corporal weight within the preceding 2 months.
       
    A clinical study by Irvin and Goligher showed that poor mechanical bowel preparation was associated with a significantly higher incidence of anastomatic dehiscence and suggested that peritoneal sepsis itself did not play a major part in anastomotic dehiscence.
       
    Generalized peritonitis, age and coexisting medical illness by themselves are not a formal contraindication to resection, perioperative lavage and primary anastomosis.
       
    The presence of septic shock, faecal peritonitis, immunocompromised status or ASA grade IV at admission are considered to be contraindications for the one-stage procedure. In these patients Hartmann’s intervention is still considered a valid alternative.
          
            

  • Robert Udelsman, Patricia I Donovan, RN, BSN, and Lori J. Sokoll, [ From the Department of Surgery and Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland]
    One Hundred Consecutive Minimally Invasive Parathyroid Explorations
    Annals of Surgery, Volume, 232, No.3, Sept. 2000, Pg. Nos. 331-339
       
    Minimally invasive parathyroiddectomy [ MIP] has challenged the traditional approach of bilateral neck exploration for patients with primary hyperparathyroidism.
           
    Most patients with primary hyperparathyroidism have a single adenoma that when resected results in cure.
      
    MIP involves high-quality sestamibi images obtained with single photon emission computed tomography to localize enlarged parathyroid glands in three dimensions, limited exploration after surgeon-administered cervical block anesthesia, rapid intraoperative parathyroid hormone assay to confirm the adequacy of resection, and discharge within 1 to 3 hours of surgery. 
      
    The cure rate was 100%, and there were no long-term complications.
       
    Conclusions – Outpatient MIP appears to be the procedure of choice for most patients with primary hyperparathyroidism.
      
    A group of surgeons has questioned the need for bilateral neck explorations for all patients with primary hyperparathyroidism. This is based on the fact that 85% to 90% of patients with primary hyperparathyroidism have a single parathyroid adenoma that when excised results in cure.
       
    Therefore, if one could determine before surgery where the abnormal parathyroid gland was, a directed operation would appear to be logical.
       
    The exquisitely accurate preoperative diagnosis of primary hyperparathyroidism that can be achieved by measuring intact serum parathyroid hormone [PTH] levels; high quality sestamibi scans, especially when combined with single photon emission computed tomography [SPECT]: the availability and practical use of the intraoperative PTH assay, which can demonstrate resolution of PTH hypersecretion at the time of surgery; a resurgence of interest in local or regional anesthetic techniques; and referring physician and patient interest in minimally invasive techniques.
     
    In all of the patients with double adenomas and multigland hyperplasia, the intraoperative PTH assay did not demonstrate an adequate decrement until all abnormal parathyroid tissue was resected.
      
    Ninety-nine percent of the patients demonstrated a decrease of PTH levels of greater than 50% after tumor excision. This reduction occurred within 5 minutes of parathyroid adenoma resection.
      
    Frozen-section analysis of resected specimens was rarely performed.
       
    There were no deaths. Complications were limited to one unilateral transient recurrent laryngeal nerve injury, which resolved spontaneously 4 months after surgery, and one intraoperative seizure resulting from retrograde intraarterial injection of lidocaine. This was treated with supplemental oxygen and conversion to general anesthesia without sequelae.
      
    Minimally invasive parathyroidectomy is a safe, cost effective technique that permits successful treatment of primary hyperparathyroidism on an ambulatory basis. The procedure is well tolerated and is associated with cure rates that are at least as good as those attained through traditional bilateral exploration.
      
    The technique requires sophisticated technical adjuncts, including high-quality sestamibi scans with three-dimensional reconstruction. 
        
    In addition, we believe that the intraoperative PTH assay is essential.
       
    The sestamibi scan directs the surgeon where to start the exploration, and an adequate decrement in intraopertive PTH confirms the adequacy of resection.
        
    If the case is difficult, the surgeon should not hesitate to extend the incision or convert to general anesthesia.
           

  • Daniel H. Teitelbaum, Robert E Cilley, Neil J. Sherman, et al [ From the Department of Surgery, the University of Michigan Medical Center and the C.S. Mott Children’s Hospital, Ann Arbor, Michigan; the M.S. Hershey Medical Center, Hershay, Pennsylvania; Queen of the Valley Hospital, West Covina, California and the Spectrum Health Center, Grand Rapids, Michigen]
    A Decade of Experience with The Primary Pull-Through for Hirschsprung Disease in the Newborn Period 
    A Multicenter Analysis of Outcomes
    Annals of Surgery, Volume, 232, No.3, Sept. 2000, Pg. Nos. 372-380
       
    The Soave or endorectal pull-through was introduced by Franco Soave at the Institute G. Gaslini in 1955. Use of this procedure has been conventionally approached with the placement of a decompressing colostomy once the diagnosis is made.
        
    This is followed by a definitive pull-through procedure once the child’s intestine is decompressed and he or she reaches approximately 10 kg body weight.
         
    The use of a primary endorectal pull-through [ERPT] in the management of patients with Hirschsprung disease represents a significant change from the classic approach to the treatment of this disease.
        
    One major objection to performing a primary ERPT in a neonate is the concern that delicate structures such as the muscular sphincters may be injured.
       
    Surgeons have performed these one-stage procedures, ranging from the first week of life to several years of age.
        
    Surgical Technique –
    The newborn undergoes serial rectal washouts, and digital dilatations of the rectum are performed the day before surgery. The last of the rectal irrigations has 1% neomycin added to it.
        
    Broad spectrum intravenous antibiotics are given before the beginning of surgery. 
      
    Endorectal dissection was carried out from inside the abdominal cavity.
         
    Ganglionic bowel is mobilized proximally and transected at the transition level. The endorectal dissection is then started approximately 2 cm below the peritoneal reflection. The dissection is continued distally down to 0.5 cm above the dentate line in the newborn.
         
    Submucosal / mucosal cuff is everted out of the rectum and opened anteriorly. The ganglionic bowel is brought down through the muscular cuff, and the anastomosis is performed outside the anal cavity.
         
    At 3 weeks after surgery, gentle rectal dilations are performed with either a #6 or #7 Hegar dilator.
             

  • Mark G. Coleman, Brendam J. Moran
    Small Bowel Obstruction
    Recent Advances in Surgery, Number 22, Year – 1999
        
    Mechanical small bowel obstruction [SBO] in adults is a common clinical problem with a significant morbidity and mortality. 
          
    Adhesions are the cause of half the cases that present with SBO, with fewer being due to malignancy or obstructed heniae. 
      
    Interestingly, in a significant proportion of those who present with SBO following colorectal cancer surgery, the aetiology is adhesions rather than malignant disease, in contrast to SBO following surgery for gastric or ovarian cancer, in which the commonest cause in malignancy.
      
    Adhesions are the consequence of injury which may be traumatic, thermal, ischaemic, inflammatory or due to foreign body. 
      
    Most settle with conservative management.
       
    Raised temperature, tachycardia, abdominal tenderness, the absence of bowel sounds, faeculent vomiting and a white blood cell count above 18 x 109/1 are positively correlated with strangulation.
       
    Plain abdominal radiographs are the universally used method for evaluation of SBO to determine its cause and level. 
      
    Per-oral and intubated contrast studies are similarly effective in terms of their sensitivity [ 92% versus 94%] and specificity [94% versus 89%]. 
        
    The correct treatment for SBO remains the prompt recognition of those cases requiring immediate surgery and the institution of the regimen that includes intravenous fluids, nasogastric intubation and aspiration. The general philosophy of ‘never let the sun set twice on a bowel obstruction’ remains true today.
          
    Evidence implicates glove starch and gauze swabs as a cause of adhesions.
    The use of peritoneal lavage with normal saline has not been shown to reduce the rate of adhesion formation.
         

  • Cleft Lip and Palate
    Kirschner RE, Wang P, Jawad AF, et al [ Univ of Pennsylvania, Philadelphia; Children’s Hosp, Philadelphia; Children’s Seashore House, Philadelphia]
    Cleft-Palate Repair by Modified Furlow Double-Opposing Z-plasty: The Children’s Hospital of Philadelphia Experience
    Plast Reconstr Surg 104: 1998-2010, 1999
        
    390 patients underwent Furlow palatoplasty. 65 were under the age of 5 years at the time of last speech evaluation. Speech scores were not available in 86 patients, but it was available in 181 nonsyndromic patients at 5 years or older. [ Pittsburgh Weighted scales for speech symtpoms associated with Velopharyngeal incompetence].
        
    88.4% showed no or inaudible nasal escape and 97.2% showed no errors in articulation related to velopharyngeal incompetence. Secondary pharyngeal flap surgery was needed in 7.2% of cases. There was a trend towards better results in patients undergoing surgery before the age of 6 months and towards poorer outcome in Veau class I and II clefts.
        
    Furlow palatoplasty provides outstanding speech results.
        

  • Millard DR, Latham R, Huifen X, et al [Univ of Miami, Fla]
    Cleft Lip and Palate Treated by Presurgical Orthopedics, Gingivoperi-osteoplasty, and Lip Adhesion [POPLA] Compared With Previous Lip Adhesion Method: A Preliminary Study of Serial Dental Casts
    Plast Reconstr Surg 103: 1630-1644, 1999
        
    This study compares the result of POPLA [1978 onwards] through an examination of dental casts.
        
    124 patients with complete unilateral or bilateral cleft lip and complete or incomplete clefts of the primary and secondary palate were evaluated.
        
    63 patients treated by POPLA method were evaluated as group I [41 with UCLP and 22 with BCLP]. 15 from UCLP and 4 from BCLP group later received orthodontic treatment. Group 2 [ 61 patients] were treated with surgical closure of soft palate and lip adhesion [ 36 UCLP and 25 BCLP] 25 of UCLP and 17 of BCLP later received orthodontic treatment.
        
    Serial dental casts were made at birth and at 3, 6 and 9 years of age. The alveolar gap, arch width, anteroposterior distance, incisor crossbite and buccal crossbite were compared. Radiographs were used to assess bony bridge. Average at follow up was 8 years 11 months in group I and 22 years 3 months in group II.
         
    Results- Bone grafting to close the alveolar gap was required in 59% of cases in group II but in only 3% of cases in group I. Similarly a velopharyngeal flap procedure was required in 35% of group II cases but in only 16% in group I cases. Multiple tooth anterior crossbite was more frequent in Group I. However multiple tooth buccal crossbite was less common in Group I. Anteroposterior distances were similar in both groups at 6 years of age, but by 9 years of age the maxillary dental arch length had increased in all, but group 2 patients with BCLP. Radiographs revealed bony bridge formation in 63% of UCLP and 83% of BCLP who underwent POPLA procedures.
        
    POPLA method gives very good results.
        

  • Mackay D, Mazahari M, Graham WP, et al [ Milton S Hershey Med Ctr, Hershey, Pa; Lancaster Cleft Palate Clinic, Hershey, Pa]
    Incidence of Operative Procedures on Cleft Lip and Palate Patients 
    Ann Plast Surg 42: 445-448, 1999
        
    Charts of 374 cleft lip and palate patients were reviewed for the number of primary and secondary procedures performed. The follow up period was 15 years.
         
    Each patient underwent an average of 3.3 procedures and 1.2 otolaryngologic procedures. Of 51 patients with UCLP [incomplete] 29 had secondary procedures and 10% had rhinoplasties. Of 19 patients with complete UCLP 37% had secondary procedures. 47% had rhinoplasties. Of 110 patients with complete UCLP 36% had secondary procedures, 45% had rhinoplasties and 72% had a 2-stage palate repair – of 51 patients with BCLP, 84% had secondary lip repair, 73% had rhinoplasties and 84% had a 2-stage palate repair.
         
    The authors feel that the true incidence of operative procedures is underestimated. It is clear however that secondary procedures make up a major component of surgical repair.
        

  • Gosain AK, Conley SF, Santoro TD, et al [ Med College of Wisconsin, Milwaukee]
    A Prospective Evaluation of the Prevalence of Submucous Cleft Palate in Patients with Isolated Cleft Lip Versus Controls
    Plast Reconstr Surg 103: 1857-1863, 1999
        
    This study evaluates the relationship between isolated cleft lip and submucous cleft palate.
        
    25 patients with isolated cleft lip without an overt clefting of the secondary palate were compared with 25 controls [ age 3-6 months compared with controls of 8 months to 13 years].
        
    Physical examination and nasoendoscopy were performed to look for submucous cleft palate —- bifid uvula, midline diastasis of the palatal muscles and notching of the posterior border of the hard palate.
         
    Results – 12% had classic and 6% had occult submucous cleft palate as against none in the control group. 36% had nasoendoscopic evidence of flattening or a midline depression of the posterior palate and musculus uvula, and palpable evidence of palatal muscle diastasis. However only 3 patients met all 3 physical criteria, 4 met only one criterion and 2 did not meet any of the criteria. All 9 patients with submucous cleft palate and 8 other patients had an alveolar cleft i.e. 53% of those with an alveolar cleft also had submucous cleft palate.
         
    Conclusion – About 1/3rd of the isolated cleft lip patients had submucous cleft palate. Nasoendoscopy was a more effective procedure as compared to physical examination. It is recommended that all cleft lip patients be subjected to nasoendoscopy.
          

  • Witt P, Cohen D, Grames LM, et al [ washington Univ, St Louis]
    Sphincter Pharyngoplasty for the Surgical Management of Speech Dysfunction Associated with Velocardiofacial Syndrome
    Br J Plast Surg 52: 613-618, 1999
         
    This is a retrospective review of sphincter pharyngoplasty in the management of velocardiofacial syndrome. 
        
    The patients were identified by a computerized craniofacial anomalies registry. 19 patients who underwent velopharyngeal surgical management based on perceptual speech evaluations and instrumental assessments of inadequate velopharyngeal closure were studied.
         
    All patients received a molecular analysis of velocardiofacial syndrome based on fluorescent in situ hybridization analysis of peripheral blood lymphocytes and independent examination by a geneticist.
         
    The surgical outcome was considered successful if perceptual speech evaluation showed elimination of hypernasality , nasal emission turbulence and instrumental assessment revealed 100% velopharyngeal closure.
        
    Results – 18 of 19 patients were managed successfully by sphincter pharyngoplasty. The one failure had mild persistent hypernasality and mild turbulence. This patient was not compliant with continued speech therapy and the parents did not consent to a post-tightening revision surgery. In 5 patients persistent snoring developed postoperatively. One patient had sleep apnea which resolved after use of nasally administered continuous positive airway pressure.
        
    Conclusion – Sphincter pharyngoplasty is a reasonable alternative to pharyngeal flap surgery for velopharyngeal dysfunction.
        

  • David LR, Blalock D, Argenta LC [Wake Forest Univ, Winston-Salem, NC]
    Uvular Transposition: A New Method of Cleft Palate Repair
    Plast Reconstr Surg 104:897-904, 1999
        
    This is a description of a new method of repair that allows simultaneous lengthening of the palate with a mean increase of greater than 1.0 cm; a reduction in the circumference of the nasopharyngeal aperture; and anatomical reconstruction of the muscles of the palate.
        
    62 patients underwent uvular transposition for repair of isolated cleft palate unilateral cleft lip and palate, and other craniofacial syndromes in 32, 13, 14 and 3 children respectively. The age at surgery was between 4 and 10 months [ mean 7 months]. Their mean age at initial speech assessment was 46 months and the mean age at the most recent speech assessment was 66 months.
         
    Technique – The palate was lengthened by using tissue from the uvula by means of a double opposing A plasty. An intravelar veloplasty was done and two thirds of the mass of the uvula was transposed to the nasal surface of the soft palate. This approach of facilitated velopharyngeal closure by significantly lengthening the palate, anatomically reconstructing the palatal excursion was needed to achieve closure.
         
    Results – Perceptual nasal emission was normal in 95% patients 3% children required pharyngeal flap for velopharyngeal insufficiency. 
         

  • Lee TJ [Univ of Ulsan, Seoul, Korea]
    Upper Lip Measurements at the Time of Surgery and Follow-up After Modified Rotation -Advancement Flap Repair in Unilateral Cleft Lip Patients 
    Plast Reconstr Surg 104: 911-915, 1999
        
    Caliper measurements of vertical horizontal and nostril still dimensions were compared immediately after surgery and at follow up to determine whether rotation advancement flap repair of a unilateral cleft lip will grow short on the repaired sides.
       
    45 patients [ 30 boys 15 girls] with nonsyndromic unilateral cleft lip underwent a rotation advancement flap repair in 18 who had incomplete defects. The lip was corrected to the same vertical length as the noncleft side. In 27 who had complete defects because of the difficulties of flap rotation the repaired lip was shorter vertically than on the noncleft side. 
        
    Results – There was no change in the growth ratios of the two sides [follow up range 8-84 months]. However the nostril sill became significantly wider on the repaired side.
        

  • Lekkas C, Latief BS, ter Rahe SPN, et al [ Univ of Leiden, The Netherlands; Universitas Indonesia, Jakarta; Catholic Univ of Nijmegen, The Netherlands]
    The Adult Unoperated Cleft Patient: Absence of Maxillary teeth Outside the Cleft Area
    Cleft Palate Craniofac J37: 17-20, 2000
        
    In patients with cleft that is operated on in childhood, absence of one or more teeth is frequently seen. The prevalence of missing permanent teeth outside the cleft region is thought to be more than 24% when the secondary palate is also cleft in bilateral cleft lip and palate the missing teeth may be as high 68.4%. In non cleft population the incidence of missing teeth is estimated as less than 6%.
        
    This study investigates the possible absence of teeth in the postcanine region of the upper jaw in patients who have not undergone surgery to repair cleft.
        
    Dental casts were obtained from 266 adult patients who had not undergone surgery for correction of cleft. The patients were grouped based on the type of cleft, whether unilateral cleft lip and alveolus, unilateral cleft lip and palate, bilateral cleft lip and palate. The majority of patients were younger than 30 year. Casts from 100 controls were studied for comparison.
        
    Results – None of the casts [in all 4 groups] revealed any missing permanent teeth. Numeric tooth anomalies were found only in the area of the cleft.
        

  • H.Nishio, J. Kamiya, M. Nagino, K. Uesaka, T. Sano and Y. Nimura [ First Department of Surgery, Nagoya University School of Medicine, 65 Tsurumaicho, Showaku, Nagoya 466-8550, Japan
    Biliobiliary Fistula Associated with Gallbladder Carcinoma
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1656-1657
        
    Biliobiliary fistula is a troublesome complication,difficult to diagnose and treat. Without a preoperative diagnosis, surgery may result in critical biliary injury. The clinical features of this condition are described. 
        
    Seven of 146 cases operated for gall bladder carcinoma who developed a biliobiliary fistula [3M and 4F] of mean age of 62 years [37-38 years] have been reviewed. All patients underwent preoperative percutaneous transhepatic biliary drainage [PTBD] to relieve obstructive jaundice and prevent cholangitis or evaluate the biliary system. A pre-operative diagnosis of a biliobiliary fistula [BBF] was made in 5 patients. PTBD catheter cholangiography revealed the BBF in only one patient whereas percutaneous transhepatic cholangioscopy showed the BBF in four cases with Mirizzi syndrome. 
        
    Cholangioscopic biopsy revealed no cancer invading the BBF where the gallstone was impacted. In the resected specimen the tumour grew intra as well as extraluminally, filling the gallbladder and pressed a gallstone against the hepatic hilum. 
        
    Gallbladder carcinoma with BBF can be classified as [a] with Mirizzi syndrome [pressure necrosis of the septum between the gall bladder and hepatic ducts] [b] Without Mirizzi syndrome due to necrosis of the tumour. PTCS proved more fruitful than PTBD cholangiography. The demonstration of BBF helped in the design of a rational resection. In two patients the BBF was detected after the resection. The presence or absence of a BBF did not effect surgical decision making.
        

  • The late L.O. Poulsen, A.M. Thulstrup. H.T. Sorensen and H. Vilstrup [ Department of Clinical Epidemiology, Aalborg Hospital and Aarhus University Hospital, Department of Epidemiology and Social Medicine, Denmark]
    Appendicectomy and Perioperative Mortality in Patients with Liver Cirrhosis
    Br. Jr. of Sur. Volume 87, No.12, December 2000, Pgs-1664-4665
        
    Case studies have indicated that patients with liver cirrhosis are at an increased perioperative risk mainly as a result of bleeding and infection.
       
    This study examines the perioperative 30 day mortality after appendicetomy in patients with liver cirrhosis.
        
    Diagnosis and surgical procedures were classified according to the International Classification of Disease [ICD-8]. Patients were included if they had been diagnosed as alcoholic cirrhosis, primary biliary cirrhosis, non-specified cirrhosis, chronic hepatitis and other types of cirrhosis, alcoholism not indicated. Patients who had undergone appendicectomy following a diagnosis of cirrhosis of liver were identified. The control group consisted all others who had undergone appendicetomy in the same period.
        
    Of 22,840 patients with cirrhosis, 69 underwent appendicectomy. The 30 day mortality rate was 9 [ 95% confidence interval [3-18] percent in cirrhotics compared with 0.7 [ 95 percent c.i. 0.6-0.8] percent among 58,982 controls. 
         
    Causes of death were :-
    [1] Bleeding from gastro-oesophageal varices [2] peritonitis, pneumonia, ‘cirrhosis hepatitis’ and ischaemic heart disease [ 1 each]. The risk of 30 day mortality adjusted for age, sex and co-morbidity and estimated as odds ratio was 8 [ 95% c.i. 3-20].
         
    The increased mortality rate in cirrhotics who undergo minor abdominal surgery should be examined in other data sets before survey as basis for recommendation to surgeons. 
        

  • A.Hair, K. Duffy, J. McLean, S. Taylor, H. Smith, A. Walker, I.M.C. Macintyre and P.J. O’Dwyer [ University Department of Surgery, Western Infirmary, Glasgow, Western General Hospital, Edinburgh and Health Economics Unit, Greater Glasgow Health Board, Glasgow, UK]
    Groin Hernia Repair in Scotland
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1722-1726
        
    This study surveys the methods of groin hernia repair in Scotland and assesses patient satisfaction with the operation.
        
    A retrospective study of 5506 patients who underwent groin hernia repair was conducted looking at the type of repair, postoperative morbidity and patient satisfaction.
         
    85% had an open mesh repair 4% had a laparoscopic repair, 8% of cases were operated for recurrent hernia. Potentially serious intra-operative complications were rare [7%] , although they were significantly more likely in laparoscopic repair or in femoral hernia- relative risk compared with open repair 33 [95% confidence interval (c.i.) 6-197] and 22 [95% c.i. 3-152] respectively. Wound complications were common and 10% of cases required a district nurse to attend the wound. Patients expressed a high degree of satisfaction [94% would recommend the same operation].
        
    Open mesh repair under general anaesthesia has become the repair of choice for groin hernia in Scotland.
        

  • D.K. Beattie, R.J.E. Foley and M.J. Callam [ Department of Surgery, Bedford Hospital, Bedford, UK]
    Future of Laparoscopic Inguinal Hernia Surgery
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1727-1728
       
    Despite low recurrence rates [< 1%] with open mesh repair, laparoscopic repair has been promoted as having significant advantages. It has been noted that it is less painful and has a quicker recovery. A randomized comparison reported more recurrences and complications after laparoscopic repair. A postal survey was conducted to determine current operative practice.
        
    374 surgeons responded to the questionnaire. Tension free open mesh repair are preferentially used by 261 surgeons [76.8%] for primary hernia repair. 5.6% [19 surgeons] prefer Shouldice repair and 5% [17 surgeons] advocate laparoscopic repair. The remainder use combinations of mesh, Shouldice, Bassini, plug, darn and laparoscopic repair.
        
    25% currently perform laparoscopic repair [1/3rd for primary repair, 2/3rds for recurrent or bilateral repair]. Roughly half of this favour a transabdominal approach and the others an extraperitoneal approach, some were undecided. An equal number have ceased performing laparoscopic hernia repair in view of its cost, complications, increase in operating time and recurrence rate. Some have never undertaken laparoscopic repair.
        
    65.6% feel that it is unlikely that laparoscopic repair will become the standard technique. Laparoscopic hernia repair has a tenuous foothold in current practice, this survey suggests that this is unlikely to change.
        

  • M.L. Lachat, U. Moehrlen, H.P. Bruetsch and P.R. Vogt [ Department of Cardiovascular Surgery and Urology, University Hospital, Zurich, Switzerland]
    The Seldinger Technique for Difficult Transurethral Cathetarization : A Gentle Alternative to Suprapubic Puncture
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1729-1730
        
    Difficult or unsuccessful transurethral catheterization may lead to iatrogenic urethral lesions which can compromise an otherwise excellent surgical result, cause long term morbidity.
        
    An endoluminal catheter technique, a less invasive alternative to suprapublic bladder drainage has been developed for such cases.
         
    This modified Seldinger technique was used in 21 cases undergoing cardiovascular surgery in whom the transurethral catheter could not be passed. The urethra was lubricated and anaesthetized. An atraumatic 0.035 inch J guidewire, length 30 cm, was inserted through the external urethral meatus and moved gently forward into the urinary bladder. A central venous catheter or 6F balloon catheter [ paediatric Folysil 6F] with tip cut off was then advanced over the guidewire . The guidewire was then removed, urine was aspirated, and the catheter connected to the urimeter and fixed with drapes. No complications followed.
        

  • A.B. Williams M.J. Cheetham, C.I. Bartram, S. Halligan, M.A. Kamm, R.J. Nicholls, and W.A. Kmiot [Department of Intestinal Imaging, Physiology Unit and Department of Surgery, St. Thomas Hospital, London, UK]
    Gender Difference in the Longitudinal Pressure Profile of the Anal Canal Related to Anatomical Structure as Demonstrated on three-Dimensional Anal Endosonography
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1674-1679
         
    The anal canal squeeze pressure is assumed to be due to the external sphincter contraction. The role of other muscles is explored.
        
    Ten male and ten nulliparous female asymptomatic subjects were subjected to three dimensional anal endosonography and manometry. The incremental squeeze pressure at 0.5 cm intervals expressed as a percentage of the maximum pressure recorded anywhere in the anal canal were related to the following anatomical levels:-
        
    Puborectalis overlap between external anal sphincter [EAS] and puborectalis, external and internal sphincters, and external sphincter only. Levels were determined by coronal and sagittal endosonographic reconstructions.
        
    The puborectalis had the same length in both sexes [median 23.9 versus 27.1 mm] but represented a greater proportion of the anal canal in women [45% versus 61%]. At the level of the puborectalis alone the pressure generated as a proportion of maximum anal canal pressure was 71% [32-100] per cent in men and 82 [ 41-100] percent in females. At the level of EAS alone the pressure was 60% [4-98] in men and 82% [41-100] in women , and where the EAS was overlapped by the puborectalis the pressure was 98% [60-100] in men and 75% [47-100] in women.
        
    The maximal anal canal squeeze pressure is found where the puborectalis overlaps EAS. This segment represents a significant proportion of anal canal length in women.
            

  • H. Ortiz and J. Marzo [ Department of Surgery, Hospital Virgen del Camino, Universidad Publica de Navarra, Pamplona, Spain]
    Endorectal Flap Advancement Repair and Fistulectomy for High Trans-Sphincteric and Suprasphincteric Fistulas
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1680-1683
        
    Endorectal flap advancement repair and for fistulectomy for high trans-sphincteric and suprasphincteric fistulas.
        
    The management of high fistulas has for long been considered a serious problem because of the necessity of preserving at least some of the sphincter mechanism. The results of endorectal flap advancement and fistulectomy for complex anal fistulas have been assessed.
        
    A prospective study of 103 high trans-sphincteric [n=91] and supra sphincteric [n=12] undergoing this procedure was conducted.
       
    Successful healing was achieved in 96 patients [93%]. Recurrent fistulas were noted in six patients [trans-sphincteric] i.e. 7% and in one patient [suprasphincteric]. Continence disturbance was noted in 8 patients [8%]. Previous repair did not adversely affect the results.
        
    The procedure is safe and effective in high fistulas.
          

  • D.C. Winter, C. Taylor, G.C. O’Sullivan and B.J. Harvey [ Cork Cancer Research Centre and Department of Surgery, Mercy Hospital and Cellular Physiology Research Unit, University College Cork, Cork Ireland]
    Mitogenic Effects of Oestrogen Mediated by a Non-Genomic Receptor in Human Colon
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1684-1689
        
    Oestrogens are important in mitogens in epithelial cancers particularly where tumours express complementary receptors. Traditionally oestrogen action involves gene-directed [genomic] protein synthesis. It has also been established that more rapid, non-genomic steroid hormone action exists. 
        
    This study investigates the hypothesis that oestrogen rapidly alters cell membrane activity, intracellular pH and nuclear kinetics in a mitogenic fashion.
        
    Crypts isolated from human distal colon and colorectal cancer cell lines were used as robust model. DNA replication and intracellular pH were measured by radiolabelled thymidine incorporation [12h] and spectrofluorescence respectively. Genomic protein synthesis, sodium-hydrogen exchanger [NHE] and protein kinase C [PKC] activity were inhibited with cycloheximide, ethylisopropylamiloride and chelerythrine chloride respectively.
        
    Oestrogen induced a rapid [< 5 min] cellular alkalinization of crypts and cancer cells that was sensitive to NHE blockade or PKC inhibition. It increased thymidine incorporation by 44% in crypts and by 38% in cancer cells and this was similarly reduced by inhibiting the NHE or PKC.
        
    They conclude that oestrogen rapidly activates cell membrane and nuclear kinetics by a nongenomic mechanisms mediated by PKC.
         

  • S.A. Norton and D. Alderson [ University of Surgery, Bristol Royal Infirmary, Bristol Uk]
    Endoscopic Ultrasonography in the Evaluation of Idiopathic Acute Pancreatitis
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1650-1655
         
    The aim of this study was to determine if endoscopic ultrasonography [EUS] is able to detect small gallstones missed at transabdominal ultrasonography in cass of ‘idiopathic’ pancreatitis.
        
    Forty four patients with ‘idiopathic’ pancreatitis were assessed using EUS for the presence of gall stones or other potential causes of the attack. A control group was also imaged. Ten patients had earlier attacks of pancreatitis. EUS revealed proven pathology in 18 patients. Unconfirmed pathology was evident in 14. No 7
        
    abnormality was seen in only 9 patients. EUS failed in one patient and there were two possible false positive results.
    EUS is able to identify significant pathology in patients with ‘idiopathic ‘ pancreatitis.
        

  • T.M. Kennedy and R.H. Jones [ Department of General Practice and Primary Care, Guy’s King’s and St. Thomas’ School of Medicine, 5 Lambeth Walk, London SE11 6SP, UK]
    Epidemiology of Cholecystectomy and Irritable Bowel Syndrome in a UK Population
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1658-1663
        
    This paper describes the prevalence of cholecystectomy and IBS in a sample of British adults. The association between the two conditions and their relation to consultation behavior and socioeconomic status are analyzed.
        
    A postal questionnaire was sent to 4432 adults between 20-69 years with six general practices. The standard occupational classification was used as a proxy for socioeconomic status.
    Cholecystectomy was reported by 4.1% of women and 1.3% of men. 22.9% of women had IBS [ odds ratio 1.9 (95% confidence interval 1.2-3.2); P<0.01]. The prevalence of cholecystectomy of IBS and of consultation for symptoms of IBS was not influenced by socioeconomic status.
        
    They conclude that symptoms of IBS may cause diagnostic confusion and unproductive surgery. Cholecystectomy may cause IBS like symptoms, a single underlying disorder may produce symptoms in both gastrointestinal and biliary tracts or the associations might be a due to a combination of these factors. 
        

  • M. R. Kell, D. C.Winter, G.C. O’Sullivan, F. Shanahan and H.P. Redmond 
    [Departments of Academic Surgery and Medicine, National University of Ireland, Cork University Hospital and ‘Mercy Hospital, Cork, Ireland]
    Biological Behaviour and Clinical Implications of Micrometastases
    Br. Jr. of Sur. Volume 87, No.12, December 2000, Pgs-1629-1639
         
    The most important prognostic determinant in cancer is the identification of designated tumor burden [metastases]. Micrometastases are microscopic (<2mm) deposits of malignant cells that are segregated spatially from the primary tumour and depend on neovascular formation (angiogenesis) to propogate.
    The literature on micrometastases and their implications in malignant melanoma and epithelial cancers is reviewed.
    Immunohistochemical and serial sectioning methods were used. Molecular techniques were reserved for blood samples and bone marrow aspirates.
         
    Detection of micrometastases in regional lymph nodes and/or bone marrow confers a poor prognosis in epithelial cancers. The concept of sentinel node biopsy combined with serial sectioning and dedicated screening for micrometastases may improve staging procedures. Strategies against angiogenesis may provide novel therapies to induce and maintain micrometastatic dormancy.
         

  • A Llaneza, F. Vizoso, J.C. Rodriguez, P. Raigoso, J.L. Garcia-Muniz, M.T. Allende and M. Garcia-Moran [ Department of Surgery and Nuclear Medicine, Hospital Central de Asturias, Oviedo and Department of Surgery, Hospital de Jove, Gijon, Spain]
    Hyaluronic Acid as Prognostic Marker in Resectable Colorectal Cancer
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs 1690-1696
       
    Hyaluronic Acid [HA] an extracellular high molecular mass polysaccharide, is thought to be involved in the growth and progression of malignant tumours. This study evaluates the cytosolic HA content in resectable colonic cancer, and its possible relationship with clinicopathological parameters of tumours and its prognostic significance.
        
    Cytosolic HA levels were examined by radiometric assay in 120 patients with resectable colorectal cancer. The mean follow up period was 33.4 months. The levels of cytosolic HA levels of tumours ranged widely from 3o to 29412 ng/mg protein. Intratumour HA levels were significantly correlated with Dukes Stage [P<0.005] and were higher in patients with advanced tumours [ mean (s.e.m.) 2695(446), 2858(293) and 5274(967) ng/mg protein for stages A-B and C respectively]. In addition, Cox multivariate analysis demonstrated that tumour HA levels >2000 ng/mg protein predicted shorter relapse free survival and overall survival period [both P<0.05].
        
    They conclude that there is a wide variability in cytosolic HA levels in colorectal cancers, which seems to be related to the biological heterogeneity of the tumours. High tumour cytosolic HA levels were associated with an unfavourable prognosis
         

  • O.Bernell, A. Lapidus and G. Hellers [ Departments of Surgery and Gastroenterology, Karolinska Institute, University Hospitals, S-141 86 Huddinge, Sweden]
    Risk Factors for Surgery and Recurrence in 907 Patients with Primary Ileocaecal Crohn’s Disease
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1697-1701
        
    This study aims to assess the risk for resection and postoperative recurrence, in the treatment of ileocaecal Crohn’s disease and to define factors affecting the course of the disease.
        
    907 patients with primary ileocaecal Crohn’s disease were reviewed retrospectively.
        
    Resection rates were 61, 77 and 83% at 1,5 and 10 years respectively after the diagnosis.
        
    Relapse rates were 28 and 36 per cent 5 and 10 years after the first resection. A younger age at diagnosis resulted in a low resection rate. Presence of perianal Crohn’s disease and long resection segments increased the risk of recurrence, and resection for a palpable mass and /or abscess decreased the recurrence rate. A decrease in the recurrence rate during the study period was observed.
        
    For ileocaecal Crohn’s disease the probability of resection is high and the risk of recurrence moderate. Perianal disease and extensive ileal resection increases the risk of recurrence. Diagnosis in childhood carries a lower risk of primary resection.
        

  • J.B.Y. So, A. Yam, W.K. Cheah, C.K. Kum and P.M.Y. Goh [ Department of Surgery, National University Hospital, Lower Kent Ridge Road, Singapore 119072, Republic of Singapore]
    Risk Factors Related to Operative Mortality and Morbidity in Patients Undergoing Emergency Gastrectomy
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1702-1707
         
    This study aimed to evaluate the results of emergency gastrectomy and to examine the factors that predict the operative outcome.
        
    82 patients who underwent emergency gastrectomy were studied. The following variables were assessed – pathology, mortality rate, morbidity, reasons for reoperation and factors related to the outcome.
        
    There were 64 men and 18 women with a median age of 62 years [30-90]. The indications were bleeding or perforated ulcers in 45 and 20 cases respectively, and bleeding and perforated gastric tumours in 7 and 10 patients respectively.
    The overall mortality was 17% [n=14]. The complication rate was 63%. 13% required reoperation.
        
    By multivariate analysis, age greater than 65 years and a hemoglobin level less than 10 g/dl on admission were predictive of complications after emergency gastrectomy. Post-operative pulmonary and cardiac complications and hypotension on admission were independent risk factors associated with operative death. The mortality was not affected by the underlying pathology.
        

  • E. Trondsen, O. Mjaland, J. Raeder and T. Buanes [ Department of Gastroenterological Surgery and Anaesthesiology, Ullevel Hospital and University of Oslo, Oslo, Norway]
    Day-case Iaparoscopic Fundoplication for Gastro-oesophageal Reflux Disease
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs1708-1711
         
    The initial results of outpatient laparoscopic fundoplication for gastro-oesophageal reflux disease are presented.
        
    The inclusion criteria were American Society of Anaesthesiologists grade I-II, living within 30 minutes travel from the hospital and adult company at home.
    The operation [Nissen-Rosetti fundoplication ] was done under general intravenous anaesthesia . 
        
    45 patients were operated. 4 needed admission and 41 were discharged as planned 3-8 hours after the operation, but 5 of these were readmitted. One had to be reexplored for necrosis of the gastric fundus. A further 5 patients visited the OPD but did not need admission.
         
    31 patients were satisfied with the procedure, 5 were indifferent, and 5 were dis-satisfied with the result because of pain.
    The authors conclude that day case laparoscopic fundoplication is safe and well tolerated.
        

  • A.Kanamoto, H. Yamaguchi, Y. Nakanishi, Y. Tachimori, H. Kato and H. Watanabe [ Department of Internal Medicine and Surgery, National Cancer Center Hospital and Pathology Division, National Cancer Center Research Institute, Tokyo, Japan]
    Clinicopathological Study of Multiple Superficial Oesophageal Carcinoma
    Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1712-1715
         
    The incidence of superficial oesophageal carcinoma has increased markedly in Japan in recent years as a result of advances in endoscopy.
        
    359 patients with superficial oesophageal carcinoma [squamous cell] who underwent oesophagectomy [n=276] or endoscopic mucosal resection [EMR n=83] were reviewed. The clinico-pathological features were compared with those of a single superficial oesophageal carcinoma.
         
    Of 359 patients 99[28%] had multiple superficial oesophageal carcinoma [M:F = 98:1 compared with 5:3:1 for those with a single carcinoma [n=260]. The incidence of tobacco and alcohol use was significantly higher in patients with multiple carcinomas. The incidence of pharyngeal malignancy was also higher in patients with multiple carcinomas.
        
    They conclude that the high incidence of multiple superficial oesophageal carcinomas indicates a need for careful evaluation of the oesophagus at the time of initial diagnosis, treatment and follow up. Male sex, smoking, alcohol and the presence of pharyngeal malignancy are high risk factors
       
        

  • C Wyser, P Stulz, M Soler, et al (Univ Hosp, Basel, Switzerland)
    Prospective Evaluation of an Algorithm for the Functional Assessment of Lung Resection Candidates.
    Am J Respir Crit Care Med 159: 1450-1456, 1999.
        
    The risk of postoperative complications is increased in patients with impaired pulmonary function and exercise testing and predicted postoperative function have been gaining importance in the assessment of candidates for lung resection surgery. The authors have worked out an algorithm for preoperative functional evaluation and they studied this algorithm prospectively.
        
    One hundred thirty-seven patients with clinically resectable lesions were studied. The algorithm incorporated cardiac history, including an electrocardiogram, and the 3 parameters of forced expiratory volume in 1 second, diffusing capacity of the lungs for carbon monoxide, and maximal oxygen uptake, and their respective predicted postoperative values were calculated on the basis of radionuclide perfusion scans.
       
    These patients were subjected to surgeries, 85 being lobectomies, 38 pneumonectomies, and 9 segmental or wedge resection surgeries. Five patients were considered functionally inoperable. Extubation within 24 hours was possible for all patients. 
       
    This algorithm resulted in a low complication rate, including mortality and morbidity and it seems to be very practical approach to the patient who is being considered for lung resection. The split function which they have used refers to a lung perfusion study that measures the amount of isotope perfusion to each lung. It does not require any intubation or split lung pulmonary function testing so it is relatively easy and practical. With only 2 postoperative deaths of a result of cardiopulmonary failure and both of these individuals were marginal at best as they had a maximum oxygen uptake of only 10mg/kg.ml.
       

  •  B. P. L. Wijnhoven, W. N. M. Dinjens and M. Pignatelli (Departments of Surgery and Pathology, Erasmus University Medical Centre, Rotterdam, The Netherlands and Division of Histopathology, Department of Pathology and Microbiology, Bristol Royal Infirmary, Bristol, UK)
    E-Cadherin-Catenin Cell-Cell Adhesion Complex and Human Cancer
    Br J. Surg August 2000 Vol. 87 (8) Pg. 992-1005 
         
    The E-cadherin-catenin complex plays a crucial role in epithelial cell-cell adhesion and in the maintenance of tissue architecture. Perturbation in the expression or function of this complex results in loss of intercellular adhesion, with possible consequent cell transformation and tumour progression. 
         
    Disturbance in protein-protein interaction in the E-cadherin-catenin adhesion complex is one of the main events in the early and late steps of cancer development.
         
    It has long been known that cell-cell adhesion is generally reduced in human cancers. Reduced cell-cell adhesiveness is associated with loss of contact inhibition of proliferation, thereby allowing escape from growth control signals. Invasion and metastases, the most life-threatening properties of malignant tumours, are considered to be later, but critically important, carcinogenic steps.
          
    In recent years, there has been increasing interest in a large family of transmembrane glycoproteins, called cadherins, which are the prime mediators of calcium-dependant cell-cell adhesion in normal cells. 
         
    There is increasing evidence that modulation of this complex by different mechanisms is an important step in the initiation and progression of human cancers.
        
    E-cadherin is bound via series of undercoat proteins, the catenins, to the actin cytoskeleton. This linkage between transmembranous cadherins and actin filaments of the cytoskeleton is necessary to form strong cell-cell adhesion. 
         
    In general, E-cadherin and catenin staining is strong in well differentiated cancers that maintain their cell adhesiveness and are less invasive, but is reduced in poorly differentiated tumours which have lost their cell-cell adhesion and show strong invasive behaviour. 
        
    Direct evidence implicating E-cadherin in the development of metastases is based on the association between highly metastasizing carcinomas and low E-cadherin immunoreactivity. 
         
    To predict tumour invasion and metastasis in carcinomas, it is useful to investigate not just the expression of E-cadherin but also the expression of the catenins. 
         
    Since the function and expression of the E-cadherin-catenin complex is often reduced in cancer cells, it is suggested that restoration of the E-cadherin-catenin will lead to differentiation and anti-invasive properties. Several drugs have been described to alter the expression of E-cadherin, some of which are already used in the treatment of cancer. 
         
    At least in vitro, insulin-like growth factor 1, tamoxifen, taxol, retinoic acid and progestagens have been shown to upregulate the functions of the E-cadherin-catenin complex, including inhibition of invasion.
         
    Aspirin is probably the most intriguing. Non-steroidal ant-inflammatory drugs are potent preventive agents against colon cancer. Aspirin decreased the rate of tumour formation.
         
    Aspirin produces a decrease in intracellular b-catenin levels, suggesting that modulation of this protein is associated with tumour prevention.
        
    Inactivation of the E-cadherin-catenin cell-cell adhesion complex is mediated by genetic and epigenetic events that occur in both the early and late stages of carcinogenesis.
        
    Elucidation of the mechanisms underlying the changes in E-cadherin and catenin function may lead to the development of novel therapeutic approaches based on biochemical and genetic manipulation.
         

  • W. P. Ceelen, U. Hesse, B. de Hemptinne and P. Pattyn (Department of Abdominal Surgery 2P4, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium)
    Hyperthermic Intraperitoneal Chemoperfusion in the Treatment of Locally Advanced Intra-Abdominal Cancer
    Br J. Surg August 2000 Vol. 87 (8) Pg. 1006-1015 
         
    Surgical treatment of intra-abdominal cancer is often followed by local recurrence. In a subgroup of patients, local recurrence is the sole site of disease, reflecting biologically low-grade malignancy. These patients might, therefore, benefit from local treatment.
         
    A growing body of experimental evidence supports the use of hyperthermia combined with chemotherapy as an adjunct to cytoreductive surgery.
          
    Traditionally, locoregional cancer recurrence with widespread peritoneal implantation has been difficult to treat, most patients undergoing palliative procedures or no surgery at all.
         
    Although intraperitoneal chemotherapy has been used alone or after surgery, taking advantage of the presence of a peritoneal-plasma barrier, its clinical efficacy is moderate. 
        
    Recently, cytoreductive surgery followed by hyperthermic intraperitoneal chemoperfusion (HIPEC) has been described for both treatment and prevention of locoregional cancer spread from various origins, a management plan based on the experimentally noted synergism between hyperthermia and several antineoplastic drugs.
         
    Hyperthermia Alone
         

    The tumoricidal properties of hyperthermia have been recognized since ancient times. The observation of spontaneous tumour regression in patients with hyperpyrexia led to the first clinical application of hyperthermia, which consisted of injection of pyrogenic substances in patients suffering from sarcoma. 
        
    Tumour cell inactivation is time and temperature dependent, and starts at 40-410 C. At temperatures above 430 C exponential inactivation of tumour cells occurs for most rodent cell lines, resembling the effect of ionizing radiation. Human tumour cell lines may be more sensitive to mild hyperthermia (41-420 C) than rodent cell lines.
         
    Hyperthermia with Chemotherapy
         
    Both experimentally and clinically, the antitumoral effect of various chemotherapeutic drugs is enhanced by hyperthermia. A possible disadvantage of the addition of hyperthermia is the induction of multidrug resistance gene (MDR1) expression. 
         
    Most clinical experience with hyperthermic chemoperfusion has involved mitomycin C (MMC) or platinum compounds. MMC is commonly used in the treatment of gastrointestinal cancer, usually in combination with other drugs. Platinum compounds are widely used in the treatment of epithelial ovarian cancer.
         
    Hyperthermia with Radiotherapy 
         

    Several randomized clinical studies have clearly demonstrated that hyperthermia and radiotherapy act synergistically on tumour tissue. 
          
    This synergism is explained by two phenomena observed in animal experiments. First, hyperthermia is cytotoxic to cells in an environment with low partial pressure of oxygen and pH44. Second, hyperthermic treatment at mild temperatures induces reoxygenation of tumour cells, rendering them more sensitive to the effects of radiation therapy. At higher temperatures (over 430 C) the opposite happens.
         
    The delivery of hyperthermia to the peritoneal surfaces by closed perfusion of a heated solution was first described in a clinical situation in 1980.
         
    Extensive cytoreduction followed by HIPEC is associated with considerable rates of morbidity and mortality, and the potential risks of the procedure must be weighed carefully against any potential benefit.
          
    Postoperative morbidity and death may, therefore, relate mainly to the extent and duration of surgery, and not to the hyperthermic perfusion itself.
         
    Peritoneal carcinomatosis is generally considered to be an incurable condition. However, a growing body of both experimental and clinical evidence supports the therapeutic and prophylactic use of HIPEC in patients without systemic disease.
          
    Many surgeons may not be familiar with the use of hyperthermia as an adjunct to surgery; the authors hope that this article will stimulate their interest.
          

  • Professor Denis Castaing, Editor of Annales de Chirurgie, chooses the best from issues published in 1999. 
    Br J. Surg August 2000 Vol. 87 (8) Pg. 1016-1018 
         
    Endocrine Surgery 
    A new approach to endoscopic parathyroidectomy. Using a 15-mm transverse incision on the anterior border of the sternomastoid muscle, the fascia connecting the lateral portion of the strap muscles and the thyroid lobe to the carotid sheath is divided at the level of the prevertebral fascia.
          
    Three trocars are inserted: one 12-mm trocar through the incision and two 2.5-mm trocars above and below the first trocar. Carbon dioxide is insufflated at a pressure of 8 mmHg.
         
    This study demonstrated that endoscopic parathyroid exploration can be performed via a lateral incision.
         
    Colon
    Loop ileostomy ensures faecal diversion to protect an anastomosis or prevent colorectal or anoperineal damage. 
           
    Low morbidity and defunctioning efficiency confirmed the indications for loop ileostomy in planned or emergency colorectal surgery.
       

  • Chen Y-G, Brushart TM (Union Mem Hosp, Baltimore, Md; Johns Hopkins School of Medicine, Baltimore, Md)
    The Effect of Denervated Muscle and Schwann Cells on Axon Collateral Sprouting 
    J Hand Surg [Am] 23A: 1025-1033, 1998

    Regenerative axon sprouting is usually necessary to restore functional recovery of a peripheral nerve. 

    To reinnervate the distal stump, it is also possible that collateral sprouts may be drawn from nearby intact nerves. Intramuscular axon collateral sprouting can be induced by denervated muscle.

    Motor and sensory nerve collateral sprouting is promoted through a perineurial window with the transplantation of denervated muscle and Schwann cells.

    Clinical experience suggests that, in the situation of loss of a sensory nerve, intact adjacent sensory nerves will undergo collateral sprouting to partially reinnervate the area of sensory loss.

    The controversy with the end-to-side nerve repair is whether or not motor axons will collaterally sprout de novo from an uninjured nerve into an end-to-side repair.

    Minimal motor collateral sprouting can be increased when the trophic lure of denervated muscle and Schwann cells is included at the end-to-side repair site.

    The authors also demonstrate that the proximal divided nerve is a source of contamination of motor fibers, even when care is taken to double ligate and cap the proximal stump. 

    This motor contamination from the proximal nerve stump likely accounts for some of the conflicting reports of motor sprouting from the intact donor nerve.
       

  • Mathoulin C, Brunelli F (Clinique Jouvenet, Paris)
    Further Experience With the Index Metacarpal Vascularized Bone Graft
    J Hand Surg [Br] 23B: 311-317, 1998

    When surgical treatment of scaphoid nonunion fails, a corticocancellous vascularized bone graft harvested from the distal part of the index metacarpal can be used to effect repair and to correct any palmar flexion by restoring the scaphoid to its correct position and supplying vascularity to the area.

    Use of a corticocancellous vascularized bone graft resulted in successful scaphoid union.

    This article has an excellent description of the pertinent vascular anatomy. While this vascularized bone graft has not been widely applied for scaphoid nonunion, it has some appeal, especially in the multiply operated-on wrist.
       

  • Frederick A. Moore (General Surgery and Trauma & Critical Care, University of Texas Health Science Center, Houston, Texas)
    Common Mucosal Immunity: A Novel Hypothesis 
    Annals of Surgery January 2000 Vol. 231(1) Pg. 9-10

    Over the past 15 years, considerable research effort has been directed at elucidating the role of the gut in the pathogenesis of nosocomial infections.

    Briefly, trauma patients are resuscitated into the systemic inflammatory response system (SIRS) and when severe, it causes early Multiple Organ Failure (MOF). As time goes on, certain aspects of SIRS are down-regulated to prevent ongoing “auto-destructive” inflammation, which results in delayed immunosuppression and when severe, contributes to the nosocomial infections that cause late MOF. 

    With regard to the gut’s potential involvement, shock (via ischemia/reperfusion injury and inhibitory neuroendocrine reflexes) and emergency laparotomy (via anesthesia and bowel manipulation) cause an early ileus. 

    Disuse (parenteral instead of enteral nutrition) and intensive care unit therapies (e.g., H2-antagonists, narcotics, broad-spectrum antibiotics) promote further gut dysfunction, characterized by progressive ileus, colonization of the upper gut, increased permeability, and decreased gut-associated lymphoid tissue (GALT) function. 

    Consequently, the upper gut becomes a reservoir for pathogens, and local and systemic defense mechanisms that prevent the spread of these organisms become impaired. 

    Primary route of dissemination (i.e., aspiration vs. translocation) is not clear. Prospective randomized controlled trials of gut-specific therapies (e.g., selective gut decontamination, early enteral nutrition, and most recently immuneenhancing enteral formulas) that have consistently demonstrated a reduction in postinjury nosocomial infections (principally pneumonia) are the most convincing evidence.

    In the 1980’s, early nutrition was provided to prevent the acute protein malnutrition induced by SIRS. This presumably maintained vital organ function and blunted immunosuppression. Early enteral nutrition, compared to total parenteral nutrition (TPN), reduced postinjury infections. 

    First, lack of enteral nutrition or lack of specific nutrients (e.g., glutamine, SCFA, fiber) may promote bacterial translocation.

    Second, excessive administration of glucose or lipids with TPN may worsen immunosuppression.

    Third, specific nutrients (e.g., glutamine, arginine, omega-3 fatty acids, and nucleotides) enhance immune effector cell function independent of preventing SIRS-induced acute protein malnutrition. 

    In summary, it emphasizes that the gut is an important immunologic organ that can be modulated to favorably affect systemic immunity. 

    The common mucosal immune system hypothesis is an exciting area of research, and their observations provide an alternative plausible explanation of how early enteral nutrition decreases postinjury infections, and provide new insight into the role of the gut in postinjury MOF and other critical illnesses.
       

  • S. J. Pain and A. D. Purushotham (Cambridge Breast Unit, Addenbrooke’s Hospital, Cambridge, UK)
    Lymphoedema Following Surgery for Breast Cancer
    BJS September 2000 Vol. 87 (9) Pg. 1128-1141
        
    Lymphoedema is a common complication of breast cancer treatment, affecting approximately a quarter of patients. Those affected can have an uncomfortable, unsightly and sometimes functionally impaired limb prone to episodes of superficial infection. The aetiology, pathophysiology and management of these patients is poorly understood. 
        
    Lymphoedema has been described as ‘a progressive pathologic state or condition characterized by chronic inflammatory fibromatosis and hypertrophy of the hypodermal and dermal connective tissues.
         
    There exists the extremely rare but potentially fatal possibility of secondary lymphangiosarcoma (Stewart-Treves syndrome).
         
    Axillary clearance, as commonly advocated, provides a guide to prognosis, assists in planning adjuvant systemic therapy and minimizes axillary recurrence; there is emerging evidence to suggest an impact on survival.
         
    Arm swelling in the early postoperative period is commonly observed and tends to settle spontaneously within a matter of weeks. Lymphoedema may, however, develop months or years after this (an interval of over 20 years has been reported), with around 75 per cent of cases occurring in the first year after operation.
         
    Onset may be gradual, or rapid. Patients occasionally identify a precipitating factor, such as a minor infection following a cut or graze, or a greater than usual degree of exercise involving the arm. 
         
    There remain, however, a number of questions regarding arm oedema following breast cancer surgery.
         
    1. Why do some women develop this complication while others do not?
    2. What explains the latent period preceding the onset of oedema?
    3. Why is it that certain sections of the arm are ‘spared’?
    4. Why is it so difficult to create artificial models of lymphoedema in animals, employing far greater surgical trauma than that involved in breast cancer treatment?
         
    Oedema is defined as the accumulation of interstitial fluid in abnormally large amounts. This can occur as a result of one of a number of physiological changes: (a) an increase in filtration pressure caused either locally by arteriolar dilation or venular constriction, or more globally by increased arterial inflow or elevated venous pressure; 
    (b) a reduction in the osmotic pressure gradient resulting from either a decrease in plasma proteins or an increase in osmotically active material in the interstitium; 
    (c) an increase in capillary permeability mediated by ‘lymphagogues’ such as substance P, histamines and kinins; and
    (d) a reduction in the flow of lymph
         
    Kissin et al found the prevalence of swelling following axillary sampling and irradiation to be equivalent to that following clearance of the axilla, and there is general agreement that the combination of surgery and radiotherapy to the axilla is best avoided, with quoted prevalence rates more than double those for surgery alone.
         
    There are other factors contributing to the aetiology of lymphoedema, with alterations noted in arterial inflow, venous return and plasma osmolality, as well as the intriguing possibility of the presence of lymphaticovenous communications. 
        
    Treatment strategies for lymphoedema fall into three main groups: conservative measures, drug treatment and surgery. At present, conservative measures form the mainstay of management, with surgery reserved for resistant cases (if at all). The place of pharmacological therapy is still unclear. 
         
    The principles of conservative treatment of lymphoedema remain unchanged from the middle of the nineteenth century, with attention to the areas of hygiene, massage, compression, and remedial exercises.
        
    There is no place for the use of diuretics in the treatment of lymphoedema; these drugs may even exacerbate the problem by increasing the protein concentration in the interstitium, thus enhancing the stimulus to inflammation and fibrosis. 
        
    Surgery for lymphoedema is usually reserved for cases resistant to conservative measures. Operations may be divided into two groups, namely debulking procedures and attempts to influence lymphatic drainage. 
        
    In 1962, Cockett and Goodwin described the anastomosis of a dilated lumbar lymphatic to the spermatic vein to treat a case of chyluria. Subsequent development of microsurgical techniques has enabled lymphaticovenous anastomosis to emerge as a potential treatment of arm lymphoedema. 
        
    At present lymphoedema following surgery for breast cancer remains a poorly understood and incurable problem. With cure an unrealistic possibility at present, emphasis should be placed on prevention. It may also be that postoperative changes, demonstrated in the latent phase before the development of swelling, might identify those in whom lymphoedema is most likely to occur. Early prophylactic initiation of conservative treatment measures may then prove more efficient than their institution when swelling has become established.
          

  • In studies that reported visceral gangrene, patients did not receive preoperative thrombus prophylaxis. Possibly, this played a role in preventing visceral gangrene. 
        
    The incidence of asymptomatic portal vein thrombosis seems to be significantly higher than that of symptomatic thrombosis. 
        
    Prompt initiation of therapy for portal vein thrombosis seems to be an important determinant for success. 
         
    The role of prophylactic heparin remains uncertain. It is possible that increasing the dosage of prophylactic heparin might be beneficial. 
         
    In conclusion, portal vein thrombosis should be suspected in patients with either fever or abdominal pain after splenectomy. Early treatment is more likely to restore normal flow in the portal vein and to prevent portal hypertension. Routine Doppler ultrasonography after splenectomy might enable early diagnosis and effective treatment. 
         

  • 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
    BJS September 2000 Vol. 87 (9) Pg. 1161-1165
         
    Shoulder-tip pain frequently occurs after laparoscopic cholecystectomy, making postoperative recovery less comfortable.
        
    To test the hypothesis that shoulder-tip pain is secondary to peritoneal stretching and diaphragmatic irritation caused by carbon dioxide, the influence of low-pressure pneumoperitoneum on the frequency and intensity of shoulder-tip pain was examined in patients undergoing laparoscopic cholecystectomy, in a prospective randomized study. 
         
    Laparoscopic cholecystectomy in this study was performed according to the European ‘for-puncture’ technique described by Dubois et al.
         
    Patients in group A underwent laparoscopic cholecystectomy with a short duration of high-pressure (13 mmHg) carbon dioxide pneumoperitoneum followed by a low-pressure (9 mmHg) carbon dioxide pneumoperitoneum, and those in group B had high-pressure (13 mmHg) carbon dioxide pneumoperitoneum all the time. 
         
    In all cases residual carbon dioxide pneumoperitoneum was evacuated at the end of the procedure by compressing the abdomen, taking care to keep the trocar valves open. A drain was left for 24 h in the gallbladder fossa.
         
    There was no correlation between duration of surgery and postoperative shoulder-tip pain. The aetiology and pathogenesis of this type of pain are still not clearly understood.
         
    Carbon dioxide may be transformed, by combining with fluid in the peritoneal cavity, to an irritative carbonic acid. This opinion is supported by the observation that, after laparoscopic cholecystectomy, patients experience less pain if nitrous oxide is used instead of carbon dioxide as pneumoperitoneum gas.
         
    Shoulder pain after laparoscopy could be caused by overstretching of the diaphragmatic muscle fibres owing to the high rate of insufflation. In this case, it would be the volume of the gas utilized for the pneumoperitoneum that caused the diaphragmatic irritation. It has been shown that a low insufflation rate significantly reduces shoulder pain. 
         
    Good results in reducing this kind of pain have been obtained by intraperitoneal normal saline infusion subdiaphragmatically at the end of the operation and, after postdeflation suction, by bupivacaine infusion in the same area. Heating of carbon dioxide gas to 370C during laparoscopy reduces shoulder-tip pain, although specific equipment is required for this purpose.
         
    The results of this study demonstrate the effectiveness in reducing postoperative shoulder-tip pain of an extremely simple intraoperative expedient: the reduction of carbon dioxide pressure, after the introduction of the trocars, from the initial 12-13 mmHg to 9 mmHg.
         
    It is hypothesized that the reduced stretching of diaphragmatic peritoneum also helps to minimize shoulder-tip pain. Operating at a low insufflation pressure means that the insertion of cannulas is more difficult and thus extra care is necessary to avoid injury to intra-abdominal structures. In order to reduce the operative risks, it seemed opportune to perform the initial surgical phase, the introduction of the trocars, at a higher pressure (13 mmHg), reducing pressure immediately afterwards.
         
    On the basis of these results, the widespread use of low-pressure pneumoperitoneum throughout most of a laparoscopic cholecystectomy procedure is recommended.
        

  • 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 Magarectum 
    BJS September 2000 Vol. 87 (9) Pg. 1203-1208
         
    Severe non-obstructive constipation associated with rectal dilatation greater than 6.5 cm on a lateral-view contrast enema is known as megarectum. The condition may commence at birth, childhood or in adult life.

    With the inevitable failure of conservative therapy, many patients are forced to contemplate surgery. Surgical options are limited and results variable. They include subtotal colectomy with ileorectal anastomosis, rectal excision with coloanal anastomosis, anterior resection, the Duhamel procedure and restorative proctocolectomy.

    The new vertical reduction rectoplasty (VRR) operation has been devised based on the hypothesis that reducing rectal capacity in megarectum would restore perception of rectal fullness and improve sensory and bowel function.
         
    Surgical Technique
         
    The sigmoid colon and most of the descending colon are resected, the splenic flexure having first been mobilized, the rectum is then mobilized. 
        
    Identification and preservation of the pelvic autonomic nerves is done as risk of damage to these nerves is greatly reduced by keeping the superior rectal vessels intact throughout the procedure. 
         
    The rectum is bisected into anterior and posterior halves. The anterior portion of the rectum is then excised. A coloneorectal anastomosis is then constructed between the proximal stapled end of the narrowed rectum and the proximal descending colon. The integrity of the suture lines is tested by inflating the narrowed rectum with air introduced via a large. Foley catheter per anum.
        
    A defunctioning loop ileostomy is next constructed in the right iliac fossa and the abdomen is closed. A water-soluble contrast enema is performed approximately 6 weeks after the procedure. If no leaks are apparent, the loop ileostomy is closed.
         
    Preoperative bowel frequency was a median of 2.5 (1-30) per month. Rectal perception of urge to defaecate was either attenuated or absent in all patients. All patients experienced a feeling of incomplete emptying, abdominal pain, bloating and regularly required assistance in the form of laxatives, enemas or manual evacuation.
        
    VRR to reduce rectal volume is a new concept in the treatment of megarectum. Colectomy and ileorectal anastomosis, the most common procedure performed, does not address the rectal abnormality and often results in persistent faecal stasis, frequency or incontinence. 
         
    The operation of VRR is based on the concept that most cases of megarectum are associated with a lack of normal rectal sensation. Reduction in rectal volume is designed to reduce the amount of distension necessary to trigger those sensory receptors important for normal defaecation and which remain within and without the rectal wall following this procedure.
         
    Sigmoid resection removes colon that is often dysmotile in these patients and as a consequence is designed to reduce transit time. Objective assessment indicated that the physiological aims of the procedure were mostly achieved.
        

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