Speciality
Spotlight

 




 


Gastroenterologist


     

 




  • Byers
    RJ, Eddleston JM, Pearson RC, et al [Univ of
    Manchester, Manchester Royal Infirmary, England]

    Dopexamine Reduces the Incidence of Acute
    Inflammation in the Gut Mucosa After Abdominal
    Surgery in High-risk Patients.


    Crit Care Med 27: 1787-1793, 1999

         

    About 20% of critically ill patients have acute
    inflammation in the stomach/duodenum.
    Dopexamine has dopaminergic receptor agonist
    properties but no alpha or beta [1] effects.
    It may exhibit anti-inflammatory effects. Thus, a study was devised to examine endoscopically and
    histologically the effect of Dopexamine on gut
    mucosa. The study represented the side arm of a
    large,
    prospective, randomized, controlled,
    multicenter European Study [Effect of Dopexamine on
    Outcome after Major Abdominal Surgery].

       

    38 patients with at least one high risk criterion,
    who were undergoing major abdominal surgery of at
    least 1.5 hours’ duration, were submitted to
    endoscopy and biopsy of the upper gastrointestinal
    tract immediately after anesthesia. 
    After being stabilized, patients received
    placebo [Group A, n=12], 0.5 micro-g/Kg per minute
    of dopexamine [Group B, n=13], and 
    2.0 micro-g/kg  
    per minute of
    dopexamine 
    [ Group C, n=13]. At 72 hours, endoscopy and
    biopsy were repeated in 27 patients.
    Upper gut blood flow was estimated using
    tonometry. pH
    was calculated at baseline, after surgery, and
    2,6,12,24,30 and 36 hours after surgery.

       

    Gastric pH decreased significantly and similarly in
    all the three groups, with the greatest increase
    being recorded at the end of surgery. 
    Erythema or hemorrhagic changes were found in
    33.3% of Group A, 38.5% of Group B, and 15.4% of
    Group C. Erosive disease was seen in 25%, 7.7% and
    38.5% respectively. At
    72 hours, endoscopy revealed that the number of
    patients with no detectable abnormality had
    decreased to 25%, 20%, and 33.3% respectively.
    Polymorphonuclear neutrophil proliferation
    was seen in 86%, 37.5% and 37.5% respectively.
    There was no correlation between endoscopy
    and histologic findings.

       

    Dopexamine does protect against the ill effects of
    decreased pH during surgery though it does not
    prevent such a decrease.

         

  • Daneman
    A, Lobo E, Alton DJ, et al [Univ of Toronto]

    The
    Value of Sonography, CT and Air Enema for Detection
    of Complicated Meckel Diverticulum in Children with
    Nonspecific Clinical Presentation

    Opediatr
    Radiol 28: 928-932, 1998


       

    Complicated
    Meckel  diverticulum
    [MD] in children does not always manifest as
    painless rectal bleeding 
    which can create a diagnostic problem.

       

    The inflamed hemorrhagic and inverted intussuscepted
    MDs have a 9 spectrum of recognizable features on
    US, CT, and air enema. Some of these features are specific.

       

    Recognizing the features will facilitate the
    detection of complicated MD in more children who
    have symptoms in addition to those with painless
    rectal bleeding.

        

    The presence of sonographic “gut signature”
    certainly helps in assessing the character of what
    may be a nonspecific mass of mixed echoes.




         

  • Colin
    D. Johnson

    Medical Management of Acute Pancreatitis

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


       

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

       

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

       

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

      

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

       

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

      

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

      

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

      

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

      

    Antibiotic prophylaxis should be given for 7 days.

      

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

      

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

      

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

       

    Lexipafant could reduce organ failure scores and
    local complications.

        
      

  • Robert
    H Fletcher, Harvard Medical school, Boston


    The
    End of Barium Enemas ?

    The
    New Eng J Med., June 15, 2000; Vol.342(24), p.
    1823-1824.

        

    For
    many years, barium enema was the only way to obtain
    a complete structural examination of the colon,
    short of surgery.

        

    With the advent of fiberoptic technology and the
    widespread use of colonoscopy in the 1970’s, the
    role of barium enema came into question.

        

    Whether or not colonoscopy is a better way to
    examine the colon, it has been replacing barium
    enemas in recent years.

         

    For
    surveillance and diagnosis, barium enema should be
    used only when colonoscopy is not available or is
    contraindicated.

        

  • NJ
    Talley, for the Optimal Regimen Cures Helicobacter
    Induced Dyspepsia (ORCHID) Study Group 

    (Univ of
    Syndey, Australia; et al)


    Eradication
    of Helicobacter pylori in functional Dyspepsia:
    Randomized Double Blind Placebo Controlled Trial
    with 12 Months’ Follow Up.

    BMJ
    318: 833-837, 1999.

         

    About
    half the patients with functional dyspepsia have
    H.pylori gastritis. Specific
    treatment of H.pylori infection cured 85% patients
    of their H.pylori infection.

        

    However,
    there was no improvement in their functional
    dyspepsia.

        

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


    Laparoscopic Management of Acute PERITONITIS



    Br. J Surg 85: 32-36, 1998


          


    Laparoscopy can be safely carried out in patients with peritonitis

         


    Advantages:

    1. Confirm preoperative diagnosis

    2. Clarify treatment planning

    3. May avoid need for Laparotomy

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

        


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

        


    Caution:

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

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

           

  • Levitt MA, Softer SZ, Peria A [Long Island Jewish Med Ctr, New Hyde Park, NY; Albert Einstein College of Medicine, Bronx, NY]


    Continent Appendicostomy in the Bowel Management of Fecally Incontinent Children



    J Pediatr Surg 32 : 1630-1633, 1997


         

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

           


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

        

  • Colin D. Johnson


    Medical Management of Acute Pancreatitis



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


         


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

          


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

          


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

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

        


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

         


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

         


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

         


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

         


    Antibiotic prophylaxis should be given for 7 days.

        


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

        


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

          


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

         


    Lexipafant could reduce organ failure scores and local complications.

          

  • Intolerance
    of Cow’s milk and Chronic Constipation in Children


    Iacono G, Cavataio F, Montalto G, et al (Ospedale G
    di Cristina, Palermo, Italy: Universita di palmero,
    Italy)


    N
    Engl J Med 339: 1100- 1104, 1998

         

    It
    is known that ingestion of cow’s milk causes
    constipation in children. To confirm this a double
    blind cross- over trial was conducted to compare the
    effects of cow’s milk and soymilk. This study
    enrolled 65 children with chronic constipation (one
    bowel movement every 3 to 15 days that was
    refractory to laxatives) All the children were on
    cow’s milk before inclusion in the trial. Of the
    65 children 49 (75 %) had anal fissure and perianal
    edema and erythema. The children stopped taking
    cow’s milk and changed over to soymilk. With this
    change their discomfort on defecation, anal edema
    and erythema resolved completely. When rechallenged
    after one month with cow’s milk, their
    constipation with perianal edema reappeared and
    again disappeared with soymilk.

          

    The
    study confirms that intolerance to cow’s milk is a
    very common cause of chronic constipation in
    children.

        

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


    Wound Management in Perforated
    Appendicitis

    Am
    Surg 65: 439-443, 1999


         

    Even
    with prophylactic antibiotics, surgical wound
    infection [SWI] remains the most frequent
    complication of emergency appendectomy [4%-5%]. In
    the past, open wound management was practised in
    cases of perforated appendicitis. The tendency now
    is to go back to primary closure which has proved
    fruitful in children.
    The results of this approach in adults has
    been retrospectively studied.

         

    In
    acute appendicitis with perforation it would be wise
    to treat the wound by the open method.

      
         

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

    Postoperative Ileus : A Preventable Event

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


         

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

          

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

          

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

          

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

          

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

    Operative Treatment of Pseudocysts in Patients
    with Chronic Pancreatitis


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


         

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

         

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

         

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

         

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

    Surgical Treatment of Adult Primary Hepatic
    Sarcoma


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


         

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

        

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

          

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

           

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

          

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

          

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

         

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

          

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

         

  • D.
    Boerma, E.A.J. Rauws T.M. van Gulik, K. Huibregtse,
    H. Obertop and D.J. Gouma [

     Department of Surgery
    and Gastroenterology, Academic Medical Centre,
    Meibergdreef 9, 1105 AZ Amsterdam, The
    Netherlands

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


          

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

         

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

         

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

         

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

          

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

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

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


        

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

         

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

        

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

        

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

           

  • 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.

             

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

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

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

          

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

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

      

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

     

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

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

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

    Ann Surg 228: 40-50, 1998

         

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

          

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

           

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

            

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

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

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

      

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

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

     

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

          

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

    Vertical Reduction Rectoplasty: A new Treatment for Idiopathic Megarectum

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

     

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

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

        

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

    VRR can improve sensory feedback and defaecation in idiopathic
    megarectum.

       

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

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

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

      

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

     

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

     

    17 women had significant EAS disruption identified by ultrasonography.

     

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

        

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

    Matrix Metalloproteinases, Their Tissue Inhibitors and Colorectal Cancer Staging

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


     

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

     

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

      

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

         

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

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

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

        

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

     

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

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

     

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

     

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

         

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

    Diagnosis and Treatment of Portal Vein Thrombosis Following Splenectomy

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

     

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

       

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

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

       

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

              

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

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

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

      

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

      

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

      

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

           

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

    Natural History of Patients with Adhesive Small Bowel Obstruction

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

      

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

      

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

      

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

      

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

       

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

            

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

    Enternal Versus Parenteral Nutrition

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

       

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

      

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

      

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

       

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

       

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

       

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

          

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

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

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

      

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

      

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

     

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

          

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

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

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

      

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

      

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

      

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

         

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

    Prospective Analysis of a Scoring System to Predict Choledocholithiasis

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

      

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

     

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

      

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

           

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

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

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

      

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

      

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

     

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

       

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

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

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

     

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

     

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

     

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

          

  • 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. 

       

  • 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.

       

  • 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.

        

  • 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.

      

  • 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. 

        

  • 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.

     

  • 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.

       


  • Hawkey
    CJ, for the Omeprazole Versus Misoprostol for NSAID-Induced
    Ulcer Management [OMNIUM] Study Group [Univ Hosp,
    Nottingham, England ; Peninsula Specialist Centre,
    Kippa Ring, Ausralia; Univ Med School, Lublin,
    Poland; et al]

    Omeprazole Compared with Miso prostol for Ulcers
    Associated with Nonsteroidal Anti-inflammatory Drugs

    N Engl J Med 338: 727-734, 1998

        

    Patients needing NSAIDs on a long term basis tend to
    develop gastric or duodenal erosions or ulcers. To
    treat these complications misoprostol in a dose of
    200 mG twice daily was compared with 20 mgm of
    omeprazole on a maintenance basis. 

        

    732 patients were thus studied. Higher doses of both
    drugs were required to control symptoms initially.
    Reason for the comparing these drugs arose because
    misoprostol tended to lead to diarrhea and abdominal
    pain. The study is well controlled. It points out
    that initial stages of active therapy misoprostol
    administration produced more side effects, but
    greater healing. In maintenance both were well
    tolerated.

        

  • Macdonald
    CE, Wicks AC, Playford RJ [Leicester Gen Hosp,
    England]

    Ten Years’ Experience of Screening Patients with
    Barrett’s Oesophagus in a University Teaching
    Hospital

    Gut 41: 303-307, 1997

       

    Medical records from 1984 to 1994 revealed 29,374
    upper gastrointestinal endoscopies. Barrett’s
    oesophageal metaplasia was noted in 409 subjects
    above 50 years of without sex bias. 379 patients
    were investigated thus every year; one subject of
    progressive dysphagia had cancer. 

       

    The authors suggest this to be a wasteful procedure
    if used as a routine.

       

  • Schenk
    BE, Kuipers EJ, Klinkenberg-Knol EC, et al [ Free
    Univ Hosp, Amsterdam; ‘t Lange Land Hosp, Zoetermeer,
    The Netherlands; Bronovo Hosp Den Haag, The
    Netherlands]

    Omeprazole as a Diagnostic Tool in
    Gastroesophageal Reflux Disease

    AM J Gastroenterol 92: 1997-2000, 1997

        

    Gastroesophageal reflux disease [ GERD] can be
    confused with other disorders associated with
    retrosternal discomfort eg. Heart burn. If 40 mgm of
    omeprazole given for 2 weeks relieves symptoms a
    diagnosis of GERD can be made without recourse to
    endoscopy.

        

  • Lower
    Gastrointestinal Problems


    Ko CY, Tong J, Lehman RE, et al [ Univ of
    California, Los Angeles; Univ of California, San
    Francisco]

    Biofeedback is Effective Therapy for Fecal
    Incontinence and Constipation

    Arch Surg 132: 829-834, 1997

       

    Fecal incontinence results from neurogenic causes,
    sphincter injuries or failure of surgical repair. 25
    such patients [21 women and 4 men, median age, 63
    years] were taken for study. 17 patients of
    constipation [ 12 women and 5 men, median age, 50
    years] had pelvic floor dysfunction or expulsion
    weakness.

       

    Retraining the pelvic floor comprised contracting
    the anal sphincter for five seconds. Of the 25
    patients with incontinence 23 improved. The two with
    pudendal nerve disease did not improve. Of the 17
    with constipation 13 showed improvement. The 4 that
    did not improve exhibited colonic delay or were
    unable to follow the biofeedback instructions. 

        

    Biofeedback thus constitutes an important step in
    managing rectal dysfunction.

       

  • Karlbom
    U, Hallden M, Eeg-Olofsson KE, et al [ Univ Hosp,
    Uppsala, Sweden]

    Results of Biofeedback in Constipated Patients :
    A Prospective study

    Dis Colon Rectum 40: 1149-1155, 1997

       

    Paradoxical contraction of the levator any muscle
    can be a cause of constipation usually psychological
    and rarely due to neurologic disorders. Exercising
    this muscle helped 19 of the 28 participants. This
    treatment was carried out for 3 months.

        

  • 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.

        

  • 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.
    aerugin osa. 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.

        

  • J.E.
    Creighton, R. Lyall, D.I. Wilson, A. Curtis and R.M.
    Charnley [Hepatopancreaticobiliary 
    Surgery Unit, Freeman Hospital, Department of
    Human Genetics, Northern Region Genetics Service,
    Royal Victoria Infirmary, and Department of Human
    Genetics and Medicine, University of
    Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK]

    Mutations of the Cationic Trypsinogen Gene in
    Patients with Hereditary Pancreatitis


    Br.J.
    of  Sur.  Volume 87, Number 2, `February 2000, Pg. 170

       

    Hereditary
    pancreatitis has been known to be caused by one of
    two mutations [ R117H and N211]
    of the cationic trypsinogen gene [ PRSS1].
    Families with hereditary pancreatitis were
    investigated for these mutations.

        

    The
    R117H mutation
    was identified in three families and the N21I in
    further five The R117H mutation was associated with
    a more severe phenotype than N211 in terms of mean [s.d.] 
    age of onset of symptoms [8.4[7.2] versus
    16.5[7.1] years; p=0.007] and requirement for
    surgical intervention [8 of 12 versus 4 of 17
    respectively p= 0.029]. Haplotype analysis suggested
    that each mutation had arisen more than once.

       

  • V.L. Wills, J.O. Jorgensen and D. R. Hunt

    St George Upper Gastrointestinal Surgical Unit, Sydney, New South Wales, Australia

    Role of Relaparoscopy in the Management of Minor Bile Leakage After Laparoscopic Cholecystectomy

    Br.J. of Sur. Volume 87, Number 2, February 2000, Pg. 176

        

    Bile leakage in the absence of major ductal injury may occur from the liver bed or from the cystic duct remnant after cholecystectomy. The early limitations of minimally invasive surgery led to reliance on endoscopic methods to manage this complication. However, repeat laparoscopy permits drainage of the bile collection and direct control of the site of leakage in selected situations.

        

    15 cases of bile leakage [ of 1779 laparoscopic cholecystectomies i.e. 0.8% ] were studied. Two patients had spontaneous resolution. Ten patients with a subvesical duct leak had repeat laparoscopy. The leak was successfully controlled in 8 out of 10 patients by suturing and by a drain. One patient required a subsequent laparotomy for a localized pelvic collection. Three patients had cystic duct stump leakage. This was successfully managed by laparoscopy in one case but required endoscopic management in two.

        

    They conclude that laparoscopy is useful in the management of minor bile leaks after laparoscopic cholecystectomy . Selection of appropriate patients relies on a characteristic clinical presentation after an otherwise uncomplicated
    cholecystectomy.

        

  • 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.

       

  • 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.

          

  • Dorudi
    S, Kinrade E, Marshall NC, et al [ Royal London
    Hosp]

    Genetic Detection of Lymph Node Micrometastases
    in Patients with Colorectal Cancer


    Br J Surg 85: 98-100, 1998

          

    Undetected micro metastases are the most important
    cause of treatment failure in patients with
    putatively curative colorectal cancer surgery. The
    detection in the regional lymph node of mRNA
    expressed from cytokeratin [CK] 20 gene upstaged 4
    of 15 patients. Following a resection for colorectal
    cancer. The CK 20 gene product being a cytokeratin
    is restricted to intestinal epithelium and is not
    likely to be expressed in the lymph node. The editor
    comments that these so called negative nodes by
    hematoxylin eosin may be placed into trials for
    adjuvant therapy once these molecular biology
    techniques are standardized and gained experience in
    clinical practice.

       

  • Delbeke
    D, Martin WH, Sandler MP, et al [ Vanderbilt Unit,
    Nashville, Tenn]

    Evaluation of Benign vs Malignant Hepatic Lesions
    with Positron Emission Tomography


    Arch Surg 133: 510-516, 1998

        

    The relatively low levels of glucose-6-phosphatase
    is most malignant cells results in accumulation and
    trapping of [18F] flurodeoxyglucose [FDG]
    intracellularly, & then visualizing the
    increased uptake. This technique of FDG PET has been
    used in 110 consecutive patients with hepatic tumors
    of 1 cm or greater to differentiate between benign
    vs. Malignant lesions. All liver metastasis from
    adenocarcinoma or sarcoma and all
    cholangiocarcinomas showed increased uptake. Whereas
    hepatocellular carcinoma [HCC] had an increased FDG
    uptake in 16 of 23 patients and poor uptake in 7 of
    23 with the exception of one abscess which had
    increased uptake. Rest all benign lesions revealed a
    poor uptake. The limitation of this technique is
    false positive in a minority of abscess and false
    negative in minority of HCC. FDG PET would also be
    useful in future for staging, detecting recurrences
    and monitoring response.

       

  • Chan TA, Morin
    PJ, Vogelstein B, et al [ Johns Hopkins Univ, Baltimore,
    Md]

    Mechanisms Underlying Nonsteroidal Anti-inflammatory Drug-Mediated Apoptosis

    Proc Natl Acad Sci : U.S.A. 95: 681-686, 1998

      

    Nonsteroidal anti-inflammatory drug [NSAIDs] have been reported to have limited efficacy as chemopreventative agent. The NSAIDs resulted in increase in prostaglandin precursor arachidonic acid [ AA] which in turn stimulated the conversion of sphingomyelin to
    ceramide, a substance known to mediate apoptosis. The editor comments that by manipulation of lipids ceramide and AA by dietary or pharmaceutical agent, may be the key to prevention of colorectal tumors.

        

  • James
    Y.W.Lau, Joseph J.Y. Sung et al (Dept. of 
    Surgery, China)

    Effect of
    Intravenous Omeprazole on Recurrent Bleeding After
    Endoscopic Treatment of Bleeding Peptic Ulcers.

    New
    Eng J Med. August 3, 2000, Vol.343(5), pg.310-316.


         

    After endoscopic treatment of bleeding peptic
    ulcers, bleeding recurs in 15-20% of patients. 
    Authors assessed whether the use of a
    high-dose of a proton pump inhibitor would reduce
    the frequency of recurrent bleeding after endoscopic
    treatment of bleeding peptic ulcers.
    Patients with actively bleeding ulcers or
    ulcers with nonbleeding visible vessels were treated
    with an epinephrine injection followed by
    thermocoagulation. After
    haemostasis was achieved, the 240 patients, were
    randomly assigned in a double-blind fashion to
    receive omeprazole (given as a bolus IV injection of
    80mg followed by an infusion of 8mg/hr for 72 hrs)
    or placebo. After infusion, all patients were given 20mg of omeprazole orally
    daily for 8 weeks. The
    primary end-point
    was recurrent bleeding within 30 days after
    endoscopy.

        

    The conclusion of the study was, after endoscopic
    treatment of bleeding peptic ulcers, a high-dose
    infusion of omeprazole substantially reduces the
    risk of recurrent bleeding.

      

    Editorial – Eric D. Libby

     

    Why
    does omeprazole prevent recurrent bleeding when H2
    receptor antagonists do not ? Perhaps its beneficial
    effect results from protecting the clot rather than
    healing the ulcer.

          

  • 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. Jour. 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. Jr. of Surg. 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.

         

  • 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. 

        

  • 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
       

          

  • P C Hayes, A Lee

    Commentary – What Progress with Artificial Livers?

    The Lancet October 20, 2001, Vol.358 (9290) Pg. 1286-1287

        


    Various procedures have been devised to treat acute liver failure. The results are not very impressive. Results with acute-on-chronic liver failure are somewhat better.

        


    Although many procedures have been tried no system has been shown to be better than others.

       

  • D. N. Lobo, M. A. Memon, S. P. Allison and B. J. Rowlands (Section of Surgery and Clinical Nutrition Unit, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK)

    Evolution of Nutritional Support in Acute Pancreatitis 

    BJS June 2000 Vol. 87 (6), Pg. 695-707



    Acute pancreatitis, a disease of varying severity, has been defined as an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems. Mild disease is associated with minimal organ dysfunction and an uneventful recovery, while severe disease is associated with organ failure and local complications such as necrosis, abscess and pseudocyst formation. 



    Parenteral nutrition has no statistically significant benefit in mild disease, but it may be associated with an increased incidence of catheter-related sepsis if its duration is prolonged. On the other hand, it does not have a negative effect on outcome in severe disease and provides essential nutrients. 



    At the same time, the results of the studies claiming superiority of enteral over parenteral nutrition must be interpreted with caution, as the theoretical benefits of enteral feeding have not yet translated into improved outcome in patients with severe acute pancreatitis.



    Two of the studies that included patients with mild pancreatitis show only a trend towards better outcome in patients fed enterally, while the study that included only patients with severe disease demonstrates a statistically significant reduction in total and septic complications in the enterally fed group.



    What is clearly demonstrated by these trials is that enteral feeding is feasible and practical in these patients, apart from being much cheaper than parenteral feeding. 



    Parenteral nutrition, including fat, is well tolerated, does not stimulate pancreatic secretion and can minimize malnutrition when gastrointestinal dysfunction is prolonged. Similarly, nasojejunal or jejunostomy feeds are well tolerated and, unlike nasogastric or nasoduodenal feeding, do not stimulate the pancreas. 



    A diagnosis of acute pancreatitis is not, therefore, itself an indication for instituting artificial nutrition. Nevertheless, in severely affected patients who are hypercatabolic and/or unable to eat normally for more than 7-10 days, it is prudent to begin artificial nutrition either parenterally or via the jejunum, or both, in order to prevent the clinical consequences of malnutrition.



    In those with acute on chronic pancreatitis and who are for this or other reasons malnourished on admission, nutritional support should be introduced as early as possible. Jejunal feeding may be preferred where practical and tolerated. 



    A combination of enteral and parenteral nutrition is therefore a reasonable way to meet metabolic demands in these patients; the amount of nutrients delivered parenterally can be progressively reduced as larger volumes are tolerated
    enterally.

  • Hiroyuki
    Komoriyama, Ichiro Tanaka, et al

    Continuous Intraarterial Infusion of Protease Inhibitors in Acute Pancreatitis.

    Drugs of Today, 2001, 37(3): 151-158



    Low-molecular-weight protease inhibitors were synthesized and developed in Japan and are in clinical use there for the treatment of acute
    pancreatitis. However, protease inhibitors are not acknowledged as drugs for the treatment of pancreatitis in other countries. In a recent study in 30 patients with necrotizing
    pancreatitis, survival rate was improved (mortality rate 13.3%) by continuous intraarterial administration of low-molecular-weight protease inhibitors as compared to conventional treatment. In Italy it was reported that pancreatic disorder decreased after the administration of low-molecular-weight protease inhibitors before the start of endoscopic retrograde
    cholangiopancreatography. Low-molecular-weight protease inhibitors may be potential alternative drugs for the treatment and/or prevention of acute pancreatitis and, therefore, warrant further evaluation.



    Development of Pancreatic Enzyme Inhibitors

    Acute pancreatitis is considered to be due to autodigestion of the pancreas. If the defense mechanism of the pancreas is broken down by physical or chemical invasion, successive activation of pancreatic enzymes occurs, which causes acute
    pancreatitis. It was suggested that the activation of pancreatic enzymes is started by
    trypsin. Therefore, a trypsin inhibitor-PI in a narrow sense – which suppresses the activity of trypsin would be an important drug for the radical treatment of
    pancreatitis. The first pancreatic PI was aprotinin, a protein with a molecular weight of 6512, extracted from bovine lungs Based on the effects of aprotinin in experimental models, clinical use was expected. Double-blind clinical trials were performed in 1960s and 1970s. Trapnell et al reported that the mortality rate was reduced by the administration of large doses of aprotinin in the early stage of acute
    pancreatitis, but many studies demonstrated that the mortality rate and incidence of complications caused by acute pancreatitis were not improved by intravenous administration of
    aprotinin. Furthermore, since there were side effects because it is a heterologous protein, aprotinin was not accepted as a drug for the treatment of
    pancreatitis. This led to studies on low-molecular-weight PIs, which can enter cells.



    In 1972, gabexate mesilate (FOY), was developed in Japan as the first low-molecular-weight Pl. Fuji et al developed nafamostat mesilate
    (FUT). FUT inhibits the activities of trypsin, thrombin,
    plasmin, kallikrein, complements, activated coagulation factors and a2MG-trypsin complex. These drugs suppress platelet aggregation and are effective in disseminated intravascular coagulation, which is often caused by acute
    pancreatitis. There have been a number of studies showing that pretreatment with and simultaneous administration of these guanidino compounds are effective in suppressing
    pancreatitis, and these drugs are widely used as first-line treatment for pancreatitis in Japan. Because acute pancreatitis is caused by activation of the pancreatic enzymes, PIs should theoretically suppress inflammation in the pancreas. However, the clinical effects of PIs are often not so good as expected.



    Protease lnhibitors(PIs) for the Prevention of Pancreatitis:

    Recently, PIs have drawn attention as drugs for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography
    (ERCP). In the early stage of acute pancreatitis, trypsinogen is activated. Because PIs inhibit the activity of the key enzyme,
    trypsin, they could theoretically suppress pancreatitis and/or inhibit its development before
    ERCP. It was reported in Japan that administration of PIs before ERCP was effective because subjective symptoms and hyperamylasemia were suppressed.



    Conclusions

    PIs as drugs for the treatment of acute pancreatitis are not used in countries other than Japan. However, improvements due to the continuous injection of PIs directly into the artery circulating in the pancreas, and the usefulness of PIs as a prophylactic for pancreatitis after ERCP have been reported. Therefore, PIs should be considered as acceptable drugs for the treatment and/or prevention of
    pancreatitis.

        

  • Naomi
    Uemura, Shiro Okamoto, et al

    Helicobacter pylori Infection and the Development of Gastric Cancer

    New Eng J Med. Vol.345, Sept. 13, 2001, pg.784-9

      

    Although many studies have found an association between Helicobacter pylori infection and the development of gastric cancer, many aspects of this relation remain uncertain.

      

    Authors prospectively studied 1526 Japanese patients who had duodenal ulcers, gastric ulcers, gastric hyperplasia, or nonulcer dyspepsia at the time of enrollment; 1246 had H. pylori infection and 280 did not. The mean follow-up was 7.8 years.

      

    Conclusion of the study was gastric cancer develops in persons infected with H. pylori but not in uninfected persons. Those with histologic findings of severe gastric atrophy, corpus-predominant gastritis, or intestinal metaplasia are at increased risk. Persons with H. pylori infection and nonulcer dyspepsia, gastric ulcers, or gastric hyperplastic polyps are also at risk, but those with duodenal ulcers are not.

      

  • Jay H Hoofnagle

    Therapy for Acute Hepatitis C

    New Eng J Med. Vol.345, Nov. 15, 2001, pg.1495-97

      

    Jaeckel and coworkers report their experience in Germany with the use of a standardized 24-week course of interferon alfa to treat acute hepatitis C. Of the 44 patients treated, 43 (98 percent) had a sustained biochemical and virologic response, defined by the presence of normal serum alanine aminotransferase levels and the absence of detectable HCV RNA in serum 24 weeks after the end of treatment.

     

    This rate of response is far higher than would be expected by chance. Studies of the natural history of HCV infection suggest that only 15 to 30 percent of people with acute infection recover spontaneously. Furthermore, all but one patient completed therapy, and none had an exacerbation of liver disease.

      

    A 98 percent rate of recovery from acute HCV infection is not only higher than the rate of spontaneous recovery but also higher than the rate of response to even the best therapy for chronic hepatitis C.

      

    Unlike the case with hepatitis A or B, there is no single, reliable diagnostic test for acute hepatitis C. The diagnosis requires a combination of features: biochemical changes suggestive of the disease, along with the detection of HCV RNA in serum and either a recent, known exposure to the virus or documented seroconversion to positivity for antibodies to HCV. It is often difficult to separate acute from chronic disease and hepatitis C from other forms of liver injury.

      

    Jaeckel et al. used a higher dose: 5 million U daily for 4 weeks, followed by a dose of 5 million U thrice weekly for 20 weeks. Are the higher doses necessary? Perhaps more critical is whether pegylated rather than standard interferon should be used to treat acute HCV infection.

       

  • David L Diuguid

    Choosing A Parenteral Anticoagulant Agent

    New Eng J Med. Vol.345, Nov. 1, 2001, pg.1340-41

      

    Unfractionated heparin has a long track record of effectiveness in both the treatment of and prophylaxis against arterial and venous thromboembolic disease. However, because of differences among batches of heparin and problems related to the bioavailability of the drug, monitoring of the anticoagulant effect of heparin has been not only necessary but also problematic. Heparin-induced bleeding and thrombocytopenia can threaten life and limb.

      

    Since 1987, when the first low-molecular-weight heparin was approved for use in the United States, there has been an explosion in the number of available parenteral anticoagulant drugs. There are currently four low-molecular-weight heparins, one heparinoid, two hirudin derivatives, and one direct thrombin inhibitor approved for use, all of which have defined roles in patients requiring anticoagulation. To this plethora of agents is now added fondaparinux, a synthetic sulfated pentasaccharide that was derived from the activated factor X (factor Xa) – binding moiety of unfractionated heparin.

      

    Low-molecular-weight heparins are less likely to cause thrombocytopenia than unfractionated heparin, since they bind poorly to platelet surfaces.

      

    Low-molecular-weight heparins replace unfractionated heparin altogether for prophylaxis in patients at moderate risk for venous thromboembolic disease (for example, after a myocardial infarction or abdominal
    surgery).

        


















    Indications
    for and contraindications to parenteral
    anticoagulant agents

    Anticoagulant
    Agent

    CLASS

    APPROVED
    AND APPROPRIATE INDICATIONS

    CONTRAINDICATION

    Unfractionated
    heparin
    Antithrombin
    III inhibitor
    Treatment
    of venous thromboembolism or unstable
    angina; used when rapid reversal is
    important
    Prophylactic
    treatment
    Enoxaparin Low-molecular-weight
    heparin
    Prophylaxis
    in moderate-risk or high-risk patients,
    treatment of venous thromboembolism or
    unstable angina
    Regional
    anesthesia
    Dalteparin Low-molecular-weight
    heparin
    Prophylaxis
    in moderate-risk or high-risk patients,
    treatment of venous thromboembolism or
    unstable angina
    Regional
    anesthesia
    Tinzaparin Low-molecular-weight
    heparin
    Prophylaxis
    in moderate-risk or high-risk patients,
    treatment of venous thromboembolism
    Regional
    anesthesia
    Ardeparin Low-molecular-weight
    heparin
    Approved;
    not being marketed
    Regional
    anesthesia
    Lepirudin Hirudin
    derivative
    Heparin-induced
    thrombocytopenia with thrombosis
    Thrombocytopenia
    other than heparin-induced thrombocytopenia
    Argatroban Direct
    thrombin inhibitor
    Heparin-induced
    thrombocytopenia with thrombosis
    Thrombocytopenia
    other than heparin-induced thrombocytopenia
    Danaparoid Heparinoid Prophylaxis
    against thrombosis in heparin-induced
    thrombocytopenia
    Thrombocytopenia
    other than heparin-induced thrombocytopenia
    Bivalirudin Hirudin
    derivative
    Unstable
    angina or angioplasty
    Unknown
    Fondaparinux Synthetic
    factor Xa inhibitor
    Prophylaxis
    in high-risk patients?
    Unknown
           


            

  •  

 



 

 

Speciality Spotlight

 

 
Gastroenterologist
     

 

  • Byers RJ, Eddleston JM, Pearson RC, et al [Univ of Manchester, Manchester Royal Infirmary, England]
    Dopexamine Reduces the Incidence of Acute Inflammation in the Gut Mucosa After Abdominal Surgery in High-risk Patients.
    Crit Care Med 27: 1787-1793, 1999
         
    About 20% of critically ill patients have acute inflammation in the stomach/duodenum. Dopexamine has dopaminergic receptor agonist properties but no alpha or beta [1] effects. It may exhibit anti-inflammatory effects. Thus, a study was devised to examine endoscopically and histologically the effect of Dopexamine on gut mucosa. The study represented the side arm of a large,
    prospective, randomized, controlled, multicenter European Study [Effect of Dopexamine on Outcome after Major Abdominal Surgery].
       
    38 patients with at least one high risk criterion, who were undergoing major abdominal surgery of at least 1.5 hours’ duration, were submitted to endoscopy and biopsy of the upper gastrointestinal tract immediately after anesthesia.  After being stabilized, patients received placebo [Group A, n=12], 0.5 micro-g/Kg per minute of dopexamine [Group B, n=13], and  2.0 micro-g/kg   per minute of dopexamine  [ Group C, n=13]. At 72 hours, endoscopy and biopsy were repeated in 27 patients. Upper gut blood flow was estimated using tonometry. pH was calculated at baseline, after surgery, and 2,6,12,24,30 and 36 hours after surgery.
       
    Gastric pH decreased significantly and similarly in all the three groups, with the greatest increase being recorded at the end of surgery.  Erythema or hemorrhagic changes were found in 33.3% of Group A, 38.5% of Group B, and 15.4% of Group C. Erosive disease was seen in 25%, 7.7% and 38.5% respectively. At 72 hours, endoscopy revealed that the number of patients with no detectable abnormality had decreased to 25%, 20%, and 33.3% respectively. Polymorphonuclear neutrophil proliferation was seen in 86%, 37.5% and 37.5% respectively. There was no correlation between endoscopy and histologic findings.
       
    Dopexamine does protect against the ill effects of decreased pH during surgery though it does not prevent such a decrease.
         

  • Daneman A, Lobo E, Alton DJ, et al [Univ of Toronto]
    The Value of Sonography, CT and Air Enema for Detection of Complicated Meckel Diverticulum in Children with Nonspecific Clinical Presentation
    Opediatr Radiol 28: 928-932, 1998
       
    Complicated Meckel  diverticulum [MD] in children does not always manifest as painless rectal bleeding  which can create a diagnostic problem.
       
    The inflamed hemorrhagic and inverted intussuscepted MDs have a 9 spectrum of recognizable features on US, CT, and air enema. Some of these features are specific.
       
    Recognizing the features will facilitate the detection of complicated MD in more children who have symptoms in addition to those with painless rectal bleeding.
        
    The presence of sonographic “gut signature” certainly helps in assessing the character of what may be a nonspecific mass of mixed echoes.


         

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

  • Robert H Fletcher, Harvard Medical school, Boston
    The End of Barium Enemas ?
    The New Eng J Med., June 15, 2000; Vol.342(24), p. 1823-1824.
        
    For many years, barium enema was the only way to obtain a complete structural examination of the colon, short of surgery.
        
    With the advent of fiberoptic technology and the widespread use of colonoscopy in the 1970’s, the role of barium enema came into question.
        
    Whether or not colonoscopy is a better way to examine the colon, it has been replacing barium enemas in recent years.
         
    For surveillance and diagnosis, barium enema should be used only when colonoscopy is not available or is contraindicated.
        

  • NJ Talley, for the Optimal Regimen Cures Helicobacter Induced Dyspepsia (ORCHID) Study Group 
    (Univ of Syndey, Australia; et al)
    Eradication of Helicobacter pylori in functional Dyspepsia: Randomized Double Blind Placebo Controlled Trial with 12 Months’ Follow Up.
    BMJ 318: 833-837, 1999.
         
    About half the patients with functional dyspepsia have H.pylori gastritis. Specific treatment of H.pylori infection cured 85% patients of their H.pylori infection.
        
    However, there was no improvement in their functional dyspepsia.
        

  • Navez B, Tassett V, Scohy JJ, et al 
    Laparoscopic Management of Acute PERITONITIS
    Br. J Surg 85: 32-36, 1998
          
    Laparoscopy can be safely carried out in patients with peritonitis
         
    Advantages:
    1. Confirm preoperative diagnosis
    2. Clarify treatment planning
    3. May avoid need for Laparotomy
    4. Particularly useful in patients with appendicular or gastroduodenal perforation.
        
    Patients with colonic perforation are more likely to require laparotomy, but even they may be managed laparoscopically with better surgical expertise.
        
    Caution:
    a) With intense inflammation, it may be difficult to explore all parts of the abdomen without injuring the intestine.
    There may be a danger of missing abscesses between loops of intestine, below the diaphragm or in the pelvis.
           

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

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

  • Intolerance of Cow’s milk and Chronic Constipation in Children
    Iacono G, Cavataio F, Montalto G, et al (Ospedale G di Cristina, Palermo, Italy: Universita di palmero, Italy)
    N Engl J Med 339: 1100- 1104, 1998
         
    It is known that ingestion of cow’s milk causes constipation in children. To confirm this a double blind cross- over trial was conducted to compare the effects of cow’s milk and soymilk. This study enrolled 65 children with chronic constipation (one bowel movement every 3 to 15 days that was refractory to laxatives) All the children were on cow’s milk before inclusion in the trial. Of the 65 children 49 (75 %) had anal fissure and perianal edema and erythema. The children stopped taking cow’s milk and changed over to soymilk. With this change their discomfort on defecation, anal edema and erythema resolved completely. When rechallenged after one month with cow’s milk, their constipation with perianal edema reappeared and again disappeared with soymilk.
          
    The study confirms that intolerance to cow’s milk is a very common cause of chronic constipation in
    children.
        

  • Lemieur TP, Rodriguez JL, Jacobs DM, et al [ Univ of Minnesota, Minneapolis]
    Wound Management in Perforated Appendicitis
    Am Surg 65: 439-443, 1999
         
    Even with prophylactic antibiotics, surgical wound infection [SWI] remains the most frequent complication of emergency appendectomy [4%-5%]. In the past, open wound management was practised in cases of perforated appendicitis. The tendency now is to go back to primary closure which has proved fruitful in children. The results of this approach in adults has been retrospectively studied.
         
    In acute appendicitis with perforation it would be wise to treat the wound by the open method.
      
         

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

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

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

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

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

  • 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.
             

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  • 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. 
       

  • 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.
       

  • 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.
        

  • 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.
      

  • 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. 
        

  • 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.
     

  • 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.
       

  • Hawkey CJ, for the Omeprazole Versus Misoprostol for NSAID-Induced Ulcer Management [OMNIUM] Study Group [Univ Hosp, Nottingham, England ; Peninsula Specialist Centre, Kippa Ring, Ausralia; Univ Med School, Lublin, Poland; et al]
    Omeprazole Compared with Miso prostol for Ulcers Associated with Nonsteroidal Anti-inflammatory Drugs
    N Engl J Med 338: 727-734, 1998
        
    Patients needing NSAIDs on a long term basis tend to develop gastric or duodenal erosions or ulcers. To treat these complications misoprostol in a dose of 200 mG twice daily was compared with 20 mgm of omeprazole on a maintenance basis. 
        
    732 patients were thus studied. Higher doses of both drugs were required to control symptoms initially. Reason for the comparing these drugs arose because misoprostol tended to lead to diarrhea and abdominal pain. The study is well controlled. It points out that initial stages of active therapy misoprostol administration produced more side effects, but greater healing. In maintenance both were well tolerated.
        

  • Macdonald CE, Wicks AC, Playford RJ [Leicester Gen Hosp, England]
    Ten Years’ Experience of Screening Patients with Barrett’s Oesophagus in a University Teaching Hospital
    Gut 41: 303-307, 1997
       
    Medical records from 1984 to 1994 revealed 29,374 upper gastrointestinal endoscopies. Barrett’s oesophageal metaplasia was noted in 409 subjects above 50 years of without sex bias. 379 patients were investigated thus every year; one subject of progressive dysphagia had cancer. 
       
    The authors suggest this to be a wasteful procedure if used as a routine.
       

  • Schenk BE, Kuipers EJ, Klinkenberg-Knol EC, et al [ Free Univ Hosp, Amsterdam; ‘t Lange Land Hosp, Zoetermeer, The Netherlands; Bronovo Hosp Den Haag, The Netherlands]
    Omeprazole as a Diagnostic Tool in Gastroesophageal Reflux Disease
    AM J Gastroenterol 92: 1997-2000, 1997
        
    Gastroesophageal reflux disease [ GERD] can be confused with other disorders associated with retrosternal discomfort eg. Heart burn. If 40 mgm of omeprazole given for 2 weeks relieves symptoms a diagnosis of GERD can be made without recourse to endoscopy.
        

  • Lower Gastrointestinal Problems
    Ko CY, Tong J, Lehman RE, et al [ Univ of California, Los Angeles; Univ of California, San Francisco]
    Biofeedback is Effective Therapy for Fecal Incontinence and Constipation
    Arch Surg 132: 829-834, 1997
       
    Fecal incontinence results from neurogenic causes, sphincter injuries or failure of surgical repair. 25 such patients [21 women and 4 men, median age, 63 years] were taken for study. 17 patients of constipation [ 12 women and 5 men, median age, 50 years] had pelvic floor dysfunction or expulsion weakness.
       
    Retraining the pelvic floor comprised contracting the anal sphincter for five seconds. Of the 25 patients with incontinence 23 improved. The two with pudendal nerve disease did not improve. Of the 17 with constipation 13 showed improvement. The 4 that did not improve exhibited colonic delay or were unable to follow the biofeedback instructions. 
        
    Biofeedback thus constitutes an important step in managing rectal dysfunction.
       

  • Karlbom U, Hallden M, Eeg-Olofsson KE, et al [ Univ Hosp, Uppsala, Sweden]
    Results of Biofeedback in Constipated Patients : A Prospective study
    Dis Colon Rectum 40: 1149-1155, 1997
       
    Paradoxical contraction of the levator any muscle can be a cause of constipation usually psychological and rarely due to neurologic disorders. Exercising this muscle helped 19 of the 28 participants. This treatment was carried out for 3 months.
        

  • 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.
        

  • 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. aerugin osa. 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.
        

  • J.E. Creighton, R. Lyall, D.I. Wilson, A. Curtis and R.M. Charnley [Hepatopancreaticobiliary  Surgery Unit, Freeman Hospital, Department of Human Genetics, Northern Region Genetics Service, Royal Victoria Infirmary, and Department of Human Genetics and Medicine, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK]
    Mutations of the Cationic Trypsinogen Gene in Patients with Hereditary Pancreatitis
    Br.J. of  Sur.  Volume 87, Number 2, `February 2000, Pg. 170
       
    Hereditary pancreatitis has been known to be caused by one of two mutations [ R117H and N211] of the cationic trypsinogen gene [ PRSS1]. Families with hereditary pancreatitis were investigated for these mutations.
        
    The R117H mutation was identified in three families and the N21I in further five The R117H mutation was associated with a more severe phenotype than N211 in terms of mean [s.d.]  age of onset of symptoms [8.4[7.2] versus 16.5[7.1] years; p=0.007] and requirement for surgical intervention [8 of 12 versus 4 of 17 respectively p= 0.029]. Haplotype analysis suggested that each mutation had arisen more than once.
       

  • V.L. Wills, J.O. Jorgensen and D. R. Hunt
    St George Upper Gastrointestinal Surgical Unit, Sydney, New South Wales, Australia
    Role of Relaparoscopy in the Management of Minor Bile Leakage After Laparoscopic Cholecystectomy
    Br.J. of Sur. Volume 87, Number 2, February 2000, Pg. 176
        
    Bile leakage in the absence of major ductal injury may occur from the liver bed or from the cystic duct remnant after cholecystectomy. The early limitations of minimally invasive surgery led to reliance on endoscopic methods to manage this complication. However, repeat laparoscopy permits drainage of the bile collection and direct control of the site of leakage in selected situations.
        
    15 cases of bile leakage [ of 1779 laparoscopic cholecystectomies i.e. 0.8% ] were studied. Two patients had spontaneous resolution. Ten patients with a subvesical duct leak had repeat laparoscopy. The leak was successfully controlled in 8 out of 10 patients by suturing and by a drain. One patient required a subsequent laparotomy for a localized pelvic collection. Three patients had cystic duct stump leakage. This was successfully managed by laparoscopy in one case but required endoscopic management in two.
        
    They conclude that laparoscopy is useful in the management of minor bile leaks after laparoscopic cholecystectomy . Selection of appropriate patients relies on a characteristic clinical presentation after an otherwise uncomplicated cholecystectomy.
        

  • 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.
       

  • 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.
          

  • Dorudi S, Kinrade E, Marshall NC, et al [ Royal London Hosp]
    Genetic Detection of Lymph Node Micrometastases in Patients with Colorectal Cancer
    Br J Surg 85: 98-100, 1998
          
    Undetected micro metastases are the most important cause of treatment failure in patients with putatively curative colorectal cancer surgery. The detection in the regional lymph node of mRNA expressed from cytokeratin [CK] 20 gene upstaged 4 of 15 patients. Following a resection for colorectal cancer. The CK 20 gene product being a cytokeratin is restricted to intestinal epithelium and is not likely to be expressed in the lymph node. The editor comments that these so called negative nodes by hematoxylin eosin may be placed into trials for adjuvant therapy once these molecular biology techniques are standardized and gained experience in clinical practice.
       

  • Delbeke D, Martin WH, Sandler MP, et al [ Vanderbilt Unit, Nashville, Tenn]
    Evaluation of Benign vs Malignant Hepatic Lesions with Positron Emission Tomography
    Arch Surg 133: 510-516, 1998
        
    The relatively low levels of glucose-6-phosphatase is most malignant cells results in accumulation and trapping of [18F] flurodeoxyglucose [FDG] intracellularly, & then visualizing the increased uptake. This technique of FDG PET has been used in 110 consecutive patients with hepatic tumors of 1 cm or greater to differentiate between benign vs. Malignant lesions. All liver metastasis from adenocarcinoma or sarcoma and all cholangiocarcinomas showed increased uptake. Whereas hepatocellular carcinoma [HCC] had an increased FDG uptake in 16 of 23 patients and poor uptake in 7 of 23 with the exception of one abscess which had increased uptake. Rest all benign lesions revealed a poor uptake. The limitation of this technique is false positive in a minority of abscess and false negative in minority of HCC. FDG PET would also be useful in future for staging, detecting recurrences and monitoring response.
       

  • Chan TA, Morin PJ, Vogelstein B, et al [ Johns Hopkins Univ, Baltimore, Md]
    Mechanisms Underlying Nonsteroidal Anti-inflammatory Drug-Mediated Apoptosis
    Proc Natl Acad Sci : U.S.A. 95: 681-686, 1998
      
    Nonsteroidal anti-inflammatory drug [NSAIDs] have been reported to have limited efficacy as chemopreventative agent. The NSAIDs resulted in increase in prostaglandin precursor arachidonic acid [ AA] which in turn stimulated the conversion of sphingomyelin to ceramide, a substance known to mediate apoptosis. The editor comments that by manipulation of lipids ceramide and AA by dietary or pharmaceutical agent, may be the key to prevention of colorectal tumors.
        

  • James Y.W.Lau, Joseph J.Y. Sung et al (Dept. of  Surgery, China)
    Effect of Intravenous Omeprazole on Recurrent Bleeding After Endoscopic Treatment of Bleeding Peptic Ulcers.
    New Eng J Med. August 3, 2000, Vol.343(5), pg.310-316.
         
    After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15-20% of patients.  Authors assessed whether the use of a high-dose of a proton pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After haemostasis was achieved, the 240 patients, were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus IV injection of 80mg followed by an infusion of 8mg/hr for 72 hrs) or placebo. After infusion, all patients were given 20mg of omeprazole orally daily for 8 weeks. The primary end-point was recurrent bleeding within 30 days after endoscopy.
        
    The conclusion of the study was, after endoscopic treatment of bleeding peptic ulcers, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding.
      
    Editorial – Eric D. Libby
     
    Why does omeprazole prevent recurrent bleeding when H2 receptor antagonists do not ? Perhaps its beneficial effect results from protecting the clot rather than healing the ulcer.
          

  • 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. Jour. 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. Jr. of Surg. 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.
         

  • 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. 
        

  • 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
       
          

  • P C Hayes, A Lee
    Commentary – What Progress with Artificial Livers?
    The Lancet October 20, 2001, Vol.358 (9290) Pg. 1286-1287
        
    Various procedures have been devised to treat acute liver failure. The results are not very impressive. Results with acute-on-chronic liver failure are somewhat better.
        
    Although many procedures have been tried no system has been shown to be better than others.
       

  • D. N. Lobo, M. A. Memon, S. P. Allison and B. J. Rowlands (Section of Surgery and Clinical Nutrition Unit, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK)
    Evolution of Nutritional Support in Acute Pancreatitis 
    BJS June 2000 Vol. 87 (6), Pg. 695-707

    Acute pancreatitis, a disease of varying severity, has been defined as an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems. Mild disease is associated with minimal organ dysfunction and an uneventful recovery, while severe disease is associated with organ failure and local complications such as necrosis, abscess and pseudocyst formation. 

    Parenteral nutrition has no statistically significant benefit in mild disease, but it may be associated with an increased incidence of catheter-related sepsis if its duration is prolonged. On the other hand, it does not have a negative effect on outcome in severe disease and provides essential nutrients. 

    At the same time, the results of the studies claiming superiority of enteral over parenteral nutrition must be interpreted with caution, as the theoretical benefits of enteral feeding have not yet translated into improved outcome in patients with severe acute pancreatitis.

    Two of the studies that included patients with mild pancreatitis show only a trend towards better outcome in patients fed enterally, while the study that included only patients with severe disease demonstrates a statistically significant reduction in total and septic complications in the enterally fed group.

    What is clearly demonstrated by these trials is that enteral feeding is feasible and practical in these patients, apart from being much cheaper than parenteral feeding. 

    Parenteral nutrition, including fat, is well tolerated, does not stimulate pancreatic secretion and can minimize malnutrition when gastrointestinal dysfunction is prolonged. Similarly, nasojejunal or jejunostomy feeds are well tolerated and, unlike nasogastric or nasoduodenal feeding, do not stimulate the pancreas. 

    A diagnosis of acute pancreatitis is not, therefore, itself an indication for instituting artificial nutrition. Nevertheless, in severely affected patients who are hypercatabolic and/or unable to eat normally for more than 7-10 days, it is prudent to begin artificial nutrition either parenterally or via the jejunum, or both, in order to prevent the clinical consequences of malnutrition.

    In those with acute on chronic pancreatitis and who are for this or other reasons malnourished on admission, nutritional support should be introduced as early as possible. Jejunal feeding may be preferred where practical and tolerated. 

    A combination of enteral and parenteral nutrition is therefore a reasonable way to meet metabolic demands in these patients; the amount of nutrients delivered parenterally can be progressively reduced as larger volumes are tolerated enterally.

  • Hiroyuki Komoriyama, Ichiro Tanaka, et al
    Continuous Intraarterial Infusion of Protease Inhibitors in Acute Pancreatitis.
    Drugs of Today, 2001, 37(3): 151-158

    Low-molecular-weight protease inhibitors were synthesized and developed in Japan and are in clinical use there for the treatment of acute pancreatitis. However, protease inhibitors are not acknowledged as drugs for the treatment of pancreatitis in other countries. In a recent study in 30 patients with necrotizing pancreatitis, survival rate was improved (mortality rate 13.3%) by continuous intraarterial administration of low-molecular-weight protease inhibitors as compared to conventional treatment. In Italy it was reported that pancreatic disorder decreased after the administration of low-molecular-weight protease inhibitors before the start of endoscopic retrograde cholangiopancreatography. Low-molecular-weight protease inhibitors may be potential alternative drugs for the treatment and/or prevention of acute pancreatitis and, therefore, warrant further evaluation.

    Development of Pancreatic Enzyme Inhibitors
    Acute pancreatitis is considered to be due to autodigestion of the pancreas. If the defense mechanism of the pancreas is broken down by physical or chemical invasion, successive activation of pancreatic enzymes occurs, which causes acute pancreatitis. It was suggested that the activation of pancreatic enzymes is started by trypsin. Therefore, a trypsin inhibitor-PI in a narrow sense – which suppresses the activity of trypsin would be an important drug for the radical treatment of pancreatitis. The first pancreatic PI was aprotinin, a protein with a molecular weight of 6512, extracted from bovine lungs Based on the effects of aprotinin in experimental models, clinical use was expected. Double-blind clinical trials were performed in 1960s and 1970s. Trapnell et al reported that the mortality rate was reduced by the administration of large doses of aprotinin in the early stage of acute pancreatitis, but many studies demonstrated that the mortality rate and incidence of complications caused by acute pancreatitis were not improved by intravenous administration of aprotinin. Furthermore, since there were side effects because it is a heterologous protein, aprotinin was not accepted as a drug for the treatment of pancreatitis. This led to studies on low-molecular-weight PIs, which can enter cells.

    In 1972, gabexate mesilate (FOY), was developed in Japan as the first low-molecular-weight Pl. Fuji et al developed nafamostat mesilate (FUT). FUT inhibits the activities of trypsin, thrombin, plasmin, kallikrein, complements, activated coagulation factors and a2MG-trypsin complex. These drugs suppress platelet aggregation and are effective in disseminated intravascular coagulation, which is often caused by acute pancreatitis. There have been a number of studies showing that pretreatment with and simultaneous administration of these guanidino compounds are effective in suppressing pancreatitis, and these drugs are widely used as first-line treatment for pancreatitis in Japan. Because acute pancreatitis is caused by activation of the pancreatic enzymes, PIs should theoretically suppress inflammation in the pancreas. However, the clinical effects of PIs are often not so good as expected.

    Protease lnhibitors(PIs) for the Prevention of Pancreatitis:
    Recently, PIs have drawn attention as drugs for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). In the early stage of acute pancreatitis, trypsinogen is activated. Because PIs inhibit the activity of the key enzyme, trypsin, they could theoretically suppress pancreatitis and/or inhibit its development before ERCP. It was reported in Japan that administration of PIs before ERCP was effective because subjective symptoms and hyperamylasemia were suppressed.

    Conclusions
    PIs as drugs for the treatment of acute pancreatitis are not used in countries other than Japan. However, improvements due to the continuous injection of PIs directly into the artery circulating in the pancreas, and the usefulness of PIs as a prophylactic for pancreatitis after ERCP have been reported. Therefore, PIs should be considered as acceptable drugs for the treatment and/or prevention of pancreatitis.
        

  • Naomi Uemura, Shiro Okamoto, et al
    Helicobacter pylori Infection and the Development of Gastric Cancer
    New Eng J Med. Vol.345, Sept. 13, 2001, pg.784-9
      
    Although many studies have found an association between Helicobacter pylori infection and the development of gastric cancer, many aspects of this relation remain uncertain.
      
    Authors prospectively studied 1526 Japanese patients who had duodenal ulcers, gastric ulcers, gastric hyperplasia, or nonulcer dyspepsia at the time of enrollment; 1246 had H. pylori infection and 280 did not. The mean follow-up was 7.8 years.
      
    Conclusion of the study was gastric cancer develops in persons infected with H. pylori but not in uninfected persons. Those with histologic findings of severe gastric atrophy, corpus-predominant gastritis, or intestinal metaplasia are at increased risk. Persons with H. pylori infection and nonulcer dyspepsia, gastric ulcers, or gastric hyperplastic polyps are also at risk, but those with duodenal ulcers are not.
      

  • Jay H Hoofnagle
    Therapy for Acute Hepatitis C
    New Eng J Med. Vol.345, Nov. 15, 2001, pg.1495-97
      
    Jaeckel and coworkers report their experience in Germany with the use of a standardized 24-week course of interferon alfa to treat acute hepatitis C. Of the 44 patients treated, 43 (98 percent) had a sustained biochemical and virologic response, defined by the presence of normal serum alanine aminotransferase levels and the absence of detectable HCV RNA in serum 24 weeks after the end of treatment.
     
    This rate of response is far higher than would be expected by chance. Studies of the natural history of HCV infection suggest that only 15 to 30 percent of people with acute infection recover spontaneously. Furthermore, all but one patient completed therapy, and none had an exacerbation of liver disease.
      
    A 98 percent rate of recovery from acute HCV infection is not only higher than the rate of spontaneous recovery but also higher than the rate of response to even the best therapy for chronic hepatitis C.
      
    Unlike the case with hepatitis A or B, there is no single, reliable diagnostic test for acute hepatitis C. The diagnosis requires a combination of features: biochemical changes suggestive of the disease, along with the detection of HCV RNA in serum and either a recent, known exposure to the virus or documented seroconversion to positivity for antibodies to HCV. It is often difficult to separate acute from chronic disease and hepatitis C from other forms of liver injury.
      
    Jaeckel et al. used a higher dose: 5 million U daily for 4 weeks, followed by a dose of 5 million U thrice weekly for 20 weeks. Are the higher doses necessary? Perhaps more critical is whether pegylated rather than standard interferon should be used to treat acute HCV infection.
       

  • David L Diuguid
    Choosing A Parenteral Anticoagulant Agent
    New Eng J Med. Vol.345, Nov. 1, 2001, pg.1340-41
      
    Unfractionated heparin has a long track record of effectiveness in both the treatment of and prophylaxis against arterial and venous thromboembolic disease. However, because of differences among batches of heparin and problems related to the bioavailability of the drug, monitoring of the anticoagulant effect of heparin has been not only necessary but also problematic. Heparin-induced bleeding and thrombocytopenia can threaten life and limb.
      
    Since 1987, when the first low-molecular-weight heparin was approved for use in the United States, there has been an explosion in the number of available parenteral anticoagulant drugs. There are currently four low-molecular-weight heparins, one heparinoid, two hirudin derivatives, and one direct thrombin inhibitor approved for use, all of which have defined roles in patients requiring anticoagulation. To this plethora of agents is now added fondaparinux, a synthetic sulfated pentasaccharide that was derived from the activated factor X (factor Xa) – binding moiety of unfractionated heparin.
      
    Low-molecular-weight heparins are less likely to cause thrombocytopenia than unfractionated heparin, since they bind poorly to platelet surfaces.
      
    Low-molecular-weight heparins replace unfractionated heparin altogether for prophylaxis in patients at moderate risk for venous thromboembolic disease (for example, after a myocardial infarction or abdominal surgery).
        

    Indications for and contraindications to parenteral anticoagulant agents

    Anticoagulant Agent

    CLASS

    APPROVED AND APPROPRIATE INDICATIONS

    CONTRAINDICATION

    Unfractionated heparin

    Antithrombin III inhibitor

    Treatment of venous thromboembolism or unstable angina; used when rapid reversal is important

    Prophylactic treatment

    Enoxaparin

    Low-molecular-weight heparin

    Prophylaxis in moderate-risk or high-risk patients, treatment of venous thromboembolism or unstable angina

    Regional anesthesia

    Dalteparin

    Low-molecular-weight heparin

    Prophylaxis in moderate-risk or high-risk patients, treatment of venous thromboembolism or unstable angina

    Regional anesthesia

    Tinzaparin

    Low-molecular-weight heparin

    Prophylaxis in moderate-risk or high-risk patients, treatment of venous thromboembolism

    Regional anesthesia

    Ardeparin

    Low-molecular-weight heparin

    Approved; not being marketed

    Regional anesthesia

    Lepirudin

    Hirudin derivative

    Heparin-induced thrombocytopenia with thrombosis

    Thrombocytopenia other than heparin-induced thrombocytopenia

    Argatroban

    Direct thrombin inhibitor

    Heparin-induced thrombocytopenia with thrombosis

    Thrombocytopenia other than heparin-induced thrombocytopenia

    Danaparoid

    Heparinoid

    Prophylaxis against thrombosis in heparin-induced thrombocytopenia

    Thrombocytopenia other than heparin-induced thrombocytopenia

    Bivalirudin

    Hirudin derivative

    Unstable angina or angioplasty

    Unknown

    Fondaparinux

    Synthetic factor Xa inhibitor

    Prophylaxis in high-risk patients?

    Unknown

     

     

     

     

            

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