Showing papers in "Annals of The Royal College of Surgeons of England in 1991"

Proposed definitions for the audit of postoperative infection: a discussion paper. Surgical Infection Study Group.

Abstract: Infection is an important arbiter of success or failure of surgical practice and the incidence of infection is incorporated into all surgical audit systems. If audit is to be of value the outcome end points of clinical practice must be defined. We have attempted to derive clinical definitions suitable for bedside diagnosis of infection and believe that these should bs supported by, but not be dependent upon, the results of laboratory or imaging techniques. The proposed definitions are intended to form the basis for clinical audit and to allow meaningful comparisons to be made on clear clinical criteria.

Field surgery on a future conventional battlefield: strategy and wound management.

Abstract: Most papers appearing in the surgical literature dealing with wound ballistics concern themselves with wound management in the civilian setting. The pathophysiology of modern war wounds is contrasted with ballistic wounds commonly encountered in peacetime, but it should be noted that even in peacetime the modern terrorist may have access to sophisticated military weaponry, and that patients injured by them may fall within the catchment area of any civilian hospital. Management problems associated with both wound types are highlighted; areas of controversy are discussed. The orthodox military surgical approach to ballistic wounds is expounded and defended.

A multicentre controlled clinical trial of high-volume fresh frozen plasma therapy in prognostically severe acute pancreatitis.

Abstract: Fresh frozen plasma (FFP) has been proposed as a specific therapy for acute pancreatitis. It may replenish important circulating proteins, particularly the naturally occurring anti-protease system. To investigate this potential therapy, 72 patients with predicted severe disease were selected from 301 admissions with acute pancreatitis using the modified Glasgow prognostic scoring system. They were randomised within 6 h of diagnosis to receive FFP (8 units daily for 3 days) or a similar volume of colloid control as part of their intravenous fluid therapy. Clinical progress was monitored and specific blood proteins were measured on days 1, 3 and 7. FFP therapy significantly increased the day 3 concentrations of some of the acute phase proteins (C1-reactive protein P less than 0.02, D-dimer P less than 0.05 and fibrinogen P less than 0.05) as well as some proteins which showed a fall in circulating concentration during the early stages of the disease (alpha 2 macroglobulin P less than 0.001, antithrombin III P less than 0.01 and fibronectin P less than 0.001). However, there was no significant difference between the two groups in terms of clinical outcome. Mortality was 20% in patients who received FFP and 18% in the colloid control group. Despite the ability of FFP therapy to supplement circulating concentrations of several potentially useful proteins during acute pancreatitis, it does not appear to improve clinical outcome.

The management of popliteal aneurysm: the importance of early surgical repair.

Abstract: A total of 58 popliteal aneurysms were found in 40 patients presenting between June 1982 and May 1989 Of these, 51 were caused by atherosclerosis, and there were five post-stenotic aneurysms associated with entrapment, one mycotic and one post-traumatic aneurysm There were 18 patients with bilateral aneurysms, and two others had the first side repaired elsewhere before referral to this hospital Aneurysms were found at other sites in 16 patients Urgent treatment was needed for 32 patients (80%) Two required streptokinase treatment to clear arteries distally Three needed fasciotomy for compartment syndrome Two patients had above-knee amputation Of 36 urgent operations, 13 had postoperative complications (36%) Four grafts were later revised successfully At mean follow-up of 23 months (range 3-96 months), three patients had claudication secondary to preoperative distal arterial occlusion, and one patient had residual mild foot drop These operative results contrast sharply with the low complication rate after elective operation for popliteal aneurysm In these patients, 14 asymptomatic aneurysms were repaired uneventfully Four patients who did not undergo elective operation later developed acute thrombosis (3) and rupture (1) This experience supports our policy that early elective treatment for popliteal artery aneurysm is the most appropriate choice

Postoperative collection and reinfusion of autologous blood in total knee arthroplasty.

Abstract: A series of 40 patients undergoing primary unilateral total knee arthroplasty were entered into a randomised controlled trial to assess the safety and efficacy of postoperative autologous blood salvage and reinfusion. The mean volume of autologous blood reinfused was 520 ml per patient (51% of the mean total drainage). Homologous blood transfusion was required in only 35% of patients in the study group compared with 95% of patients in the control group (P less than 0.001). The mean volume of homologous blood transfused was 0.9 units per patient in the study group compared with 2.5 units in the control group (P less than 0.001), a saving of 64%.

Nasogastric suction after elective abdominal surgery: a randomised study.

Abstract: The value of nasogastric tube decompression after elective abdominal operations was assessed in a randomised trial in which 97 patients were and 100 were not allocated postoperative nasogastric decompression Only two patients in the latter group subsequently required decompression There was no statistically significant difference in the incidence of mortality, complications (including vomiting) or time to return of intestinal motility between the two groups There was a significantly higher incidence of sore throat (P less than 00001) and nausea (P less than 005) in patients who received nasogastric decompression A postal questionnaire to 259 UK general surgeons (96% replied) revealed that postoperative nasogastric decompression was usually used by 92% of surgeons after a Polya gastrectomy, 72% after a small bowel anastomosis, 49% after a large bowel anastomosis and 20% after cholecystectomy We conclude that such a routine is not justified and should be reserved for those patients developing specific complications

Assessment of burn injury in the accident and emergency department: a review of 100 referrals to a regional burns unit.

Abstract: Accurate assessment of the extent of thermal injury in the accident and emergency (A&E) department is essential if appropriate resuscitation and referral to a specialist unit is to occur. However, review of 100 referrals to a regional burns unit confirms that assessment is often inaccurate, and usually undertaken by no one more senior than a casualty officer, leading to suboptimal treatment and referral. Severe thermal injury should be assessed by a team of senior doctors, according to the major trauma protocol, and casualty officers should receive better training in the assessment of less extensive burns.

The role of reconstructive surgery in the management of war wounds.

Abstract: Reconstructive surgery can be used within a framework of management of war wounds by basic principles. It falls into three groups: i. Primary (emergency) reconstruction; performed as part of initial surgery and as a life-saving procedure. ii. Delayed primary (essential) reconstruction; performed at the time of delayed closure. iii. Elective or non-essential reconstruction. All surgeons involved with the early management of war wounds should be prepared to perform primary and delayed primary reconstruction.

Risk factors and operative mortality in surgery for colorectal cancer.

Abstract: The operative mortality rate after surgery for colorectal carcinoma remains significant. A series of 578 patients has been studied prospectively. The features which most significantly affect operative mortality are the age of the patient, a history of loss of weight, limited preoperative patient mobility and the presence of intestinal obstruction with perforation of the bowel. By identifying high-risk groups of patients, attention may be focused on particular patients at risk, in order to reduce operative mortality.

An MRC prospective randomised trial of radiotherapy versus surgery for operable squamous cell carcinoma of the oesophagus.

Abstract: The objective of the trial was to determine whether there was any difference in survival rates after operable cases of squamous cell carcinoma of the oesophagus were treated by radiotherapy or surgery. It was designed as a prospective, randomised, multicentre trial in the United Kingdom, after staging as potentially operable, and it was planned to enter 100 patients per annum for 4 years, with a minimum follow-up of 5 years, after pre-entry staging of patients under 75 years of age by barium swallow, chest radiographs, oesophagoscopy, biopsy, bronchoscopy and CT scanning. The protocol was published in July 1986; the trial started in January 1987 and was stopped in June 1988 when only 31 patients from 16 centres were entered, although 30 centres had ethical committees' approval and were willing to start the trial. Interventions were to be as follows: 1. Surgery. According to the practice of that particular surgeon and classified as (a) curative resection if the surgeon considered that no macroscopic tumour was left behind, and (b) palliative if incompletely resected. 2. Radiotherapy. (a) Prescribed minimum corrected tumour dose of 5000 cGy with daily dose of 250 cGy in 20 fractions over 4 weeks. (b) Prescribed minimum corrected tumour dose of 6000 cGy with daily dose of 200 cGy in 30 fractions over 6 weeks. The endpoint was to be survival at 1, 2 and 5 years. The trial was discontinued after 18 months because of lack of recruitment and thus the question whether operable squamous cell cancer of the oesophagus, staged before treatment with CT scanning, is to be treated by radiotherapy or surgical resection remains unanswered. It is unlikely that a phase III trial will ever have sufficient support from surgeons to find the answer.

The trephine colostomy: a permanent left iliac fossa end colostomy without recourse to laparotomy.

Abstract: An operative technique for performing a permanent end sigmoid colostomy without recourse to laparotomy is presented. The results from 16 patients have shown a very low morbidity. The technique was unsuccessful in three patients, each needing a formal laparotomy.

Urological complications of renal transplantation: the impact of double J ureteric stents.

Abstract: In a 10 year series of 350 consecutive renal transplant operations, the overall urological complication rate was 7.7%. During this period double J stents were introduced and were used either in the treatment of actual urological complications or as a prophylactic measure to protect ureters which had been damaged at retrieval. A total of 34 double J stents were used in 33 patients. The indications were: ureteric obstruction (n = 13), urinary leak (n = 5), short transplant ureter anastomosed using an extravesical ureteroneocystostomy (n = 10) and ureteric injury at the time of organ retrieval (n = 6). Thirty-two double J stents were inserted at open operation and two were inserted by an antegrade method after percutaneous nephrostomy. Improvement in renal function occurred in 16 out of the 18 cases of urological complications. No kidneys were lost and there were no deaths as a direct result of these complications. In a number of cases the insertion of a double J stent was the only treatment, thus eliminating the need for more complex surgery. All 16 patients who had a ureteric stent inserted as a prophylactic measure at the time of transplantation made uncomplicated postoperative recoveries. Urinary tract infection was relatively common (27%) after double J stent insertion, but other complications were rare. In conclusion, double J stents have proved to be a useful adjunct in the management of renal transplant related urological complications.

Antibiotic prophylaxis in penetrating injuries of the chest.

Abstract: Most prospective studies recommend antibiotic prophylaxis whilst a thoracostomy tube is in place or even longer. We conducted a randomised study of 188 patients with penetrating chest injuries requiring a chest drain. Of these patients, 95 received a single dose of ampicillin before insertion of the chest tube, the remaining 93 patients received additional antibiotic prophylaxis for as long as the drain was in place. The incidence of intrathoracic sepsis (pneumonia or empyema) was 3.1% and 3.2%, respectively. It is concluded that single-dose prophylaxis in penetrating chest trauma is as effective as prolonged prophylaxis. The importance of chest physiotherapy immediately after the drain insertion and of early removal of the drain is stressed. The role of various possible risk factors in the development of sepsis is discussed.

Non-steroidal anti-inflammatory drugs and stercoral perforation of the colon.

Abstract: Within 6 months, three constipated patients have been seen with stercoral perforation of the colon associated with the ingestion of non-steroidal anti-inflammatory drug medications (NSAIDs) These drugs were taken regularly for painful musculoskeletal disorders 6, 8 and 12 months before admission Constipation is thought to be the most significant contributory factor in the development of colonic stercoral perforation; however, it is unclear why it develops in so few of the many patients with severe constipation NSAID medications have been associated with the perforation of colonic diverticula, but there are no reports of an association with stercoral perforations If our finding of the association is substantiated by other reports there may be a need for greater awareness of lower gastrointestinal problems when prescribing such drugs to constipated patients

A controlled trial of short-term versus standard axillary drainage after axillary clearance and iridium implant treatment of early breast cancer.

Abstract: A controlled trial has been conducted to determine the safety of early drain removal after axillary clearance as part of conservation treatment in early breast cancer. A total of 84 patients was entered into the study of whom 41 had the drain removed after 5 days, irrespective of the volume of fluid draining, and 43 had drains removed when fluid was less than 20 ml per day. Of the standard drainage group, 28% required percutaneous aspiration of lymph because of subsequent accumulation, compared with 49% of the short-term drainage group. Early drain removal was not associated with any increase in wound complications nor in cosmetic outcome, but did enable earlier discharge of patients from hospital.

Which general surgical operations must be done at night

Abstract: During the 1980s there has been increasing concern about hospital medical staffing. Achieving a Balance will lead to a reduction in the number of registrars and a possible increase in the work done out-of-hours by consultants. The deleterious effects of long hours of work have also attracted attention and, in particular, there is concern about the safety of operations performed at night by unsupervised junior doctors. There is an urgent need to examine how out-of-hours work can be reduced. This study was conducted in two phases. The out-of-hours surgical workload in four hospitals was examined. Appropriateness of the procedures and activities being carried out was then considered by a consensus panel, aided by a literature review. Most out-of-hours operations were performed by junior staff. The principal reasons suggested for operating at night are lack of day-time theatre space and the need to gain experience. There was considerable variation in the frequency with which different types of operation were performed among hospitals. The views of the panel suggest that up to one-third of operations currently performed at night could be postponed. It may be possible to postpone a higher proportion of operations performed after midnight. The appropriateness of the remaining operations has major implications for the work of consultants following the implementation of Achieving a Balance.

Experience with early anastomosis after the Hartmann procedure.

Abstract: From January 1980 to December 1989, 108 Hartmann procedures were performed and 55 of these patients subsequently had colorectal continuity re-established. Thirty-eight patients had colorectal anastomosis after an average interval of 6.5 months and 17 had early anastomosis performed within 1 month of the primary procedure. On the basis of the experience reported here, it would seem that early colorectal anastomosis does not increase the risk to the patient and may be an easier procedure to perform than the delayed operation. For selected patients, we recommend early colorectal anastomosis after a Hartmann procedure, thus sparing them the problems of life with a temporary colostomy.

Are current techniques of inguinal hernia repair optimal? A survey in the United Kingdom.

Abstract: Data was collected on the techniques currently employed in adult inguinal hernia repair by means of a postal questionnaire to consultants in four Regional Health Authorities in England. Questionnaires were returned by 240 consultants (85%). This identified a considerable range in methods of repair, with a Moloney nylon darn being the sole method used by 35% of consultants, and the Shouldice technique, either alone or in combination with other methods, being used by 20%. Overall, 51% employ a subcuticular suture for skin closure, and traditional skin sutures are used by 31%. There was no association between consultant's date of qualification or subspecialty and type of repair. Consultants qualifying after 1969 are most likely to use a subcuticular suture. Some 14% of all consultants and 19% of those qualifying since 1969 employ a Shouldice procedure and a subcuticular suture.

The use of computed tomography in the evaluation of large multinodular goitres.

Abstract: This study reports one unit's experience of the value of computed tomography (CT) in the evaluation of 24 patients with large cervical and retrosternal goitres. Of these patients, 17 were thought clinically to have symptoms of tracheal compression, but the CT demonstrated significant narrowing in only 12 cases. In the other five patients, surgery was deferred and other causes for their symptoms sought and treated. Seven patients were asymptomatic and CT failed to reveal any evidence of tracheal compression in six. In the remaining patient, however, CT revealed gross narrowing and urgent surgery was performed. When compared with CT, chest/thoracic inlet radiographs were misleading in 48% of patients, with tracheal narrowing being overestimated and underestimated. We conclude that CT gives useful information about tracheal compression in patients with large multinodular goitres, and is more accurate than chest/thoracic inlet radiographs.

Evaluation of current surgical management of acute inflammatory diverticular disease.

Abstract: During the period 1980 to 1987, 127 patients were admitted with acute complications of diverticular disease; clinically diagnosed as acute diverticulitis in 86, peritonitis in 33 and colonic obstruction in eight. In those patients diagnosed as acute diverticulitis, conservative treatment was effective in 73 (85%), the other 13 requiring surgery. Of 31 patients, with a clinical diagnosis of peritonitis who underwent operation, 19 (61%) had free purulent or faecal fluid at laparotomy and the remainder had a localised phlegmonous mass. Sigmoid resection was performed in 34 patients and nonexcisional surgery in 18. In the earlier period of the study, there was a preference for the former procedure in patients with peritonitis rather than those with phlegmonous diverticulitis (63% vs 28%), and in the later period of the study, resection was the preferred treatment in both groups (91% vs 93%). The increase in resectional surgery significantly reduced mortality, at completion of treatment, in patients with peritonitis (P less than 0.05) but not in those with phlegmonous diverticulitis. There was an additional benefit of resection in the lower number of procedures per patient (1.5 vs 2.1), a lower median total hospital stay (32 days vs 50.5, P less than 0.01) and a lower wound infection rate (16% vs 32%, P less than 0.01) at the end of treatment. The optimum surgical approach at laparotomy for acutely complicated diverticular disease would therefore appear to be a resectional procedure. Of the patients operated on for 'peritonitis', 39% were found to have a localised diverticular mass/phlegmon.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of the use of disposable skin staplers in bowel anastomoses to reduce laparotomy time in penetrating ballistic injury to the abdomen.

Abstract: Laparotomy and anastomosis of the small bowel after penetrating injury to the abdomen is a lengthy procedure. This paper describes the use of skin staplers for bowel anastomosis and presents the results of a short series of experiments upon dead pigs to compare the staple technique with conventional handsewn anastomosis. The time taken to perform each small bowel anastomosis, the integrity of the anastomosis and the skill required were assessed. The staple technique was considerably faster (mean construction time: 5.4 min, range 4-6 min) than the handsewn technique (mean construction time: 12 min, range 10-14 min), at least halving the anastomosis time (Kolmogorov two-sample test P = 0.05). In addition, the stapled anastomosis had a higher intraluminal failure pressure (mean failure pressure: 65 cmH2O, 6.37 kPa, range 30-70 cmH2O) than the handsewn anastomosis (mean failure pressure: 38.6 cmH2O, 3.78 kPa, range 10-70 cmH2O).

Surgical options for left-sided large bowel emergencies.

Abstract: Current choices of operation for left-sided large bowel emergencies have been established by a questionnaire sent to 218 consultant surgeons asking which operation they would perform under varying circumstances for obstructing sigmoid carcinoma and diverticular disease A 92% response rate was obtained Hartmann's procedure (with or without a mucus fistula) is the most popular operation for all conditions Sigmoid colectomy with primary anastomosis is performed by 40% of surgeons for obstructing carcinomas, but less commonly in other situations On-table lavage is rarely used, and the majority of anastomoses are not protected by a proximal stoma Subtotal colectomy is very seldom employed, except when caecal perforation results from an obstructing carcinoma Some surgeons perform a defunctioning colostomy alone even in the presence of a perforation

Malignant neck lumps: a measured approach.

Abstract: The options currently available for establishing the histological diagnosis of a neck mass are open biopsy or a measured approach involving head and neck examination, fine-needle aspiration biopsy (FNAB) and panendoscopy. We present the results of 10 patients initially managed by open biopsy and 22 who were subject to the alternative approach. All had a histological diagnosis of squamous carcinoma. Seven of the open biopsy patients developed problems related to the biopsy that later adversely affected their management. There were no such problems in the other group. Patients undergoing open biopsy required a mean of one further general anaesthetic and a mean inpatient stay of 7 days longer than the patients in the second group. FNAB in our hospital was shown to be reliable (91% accurate, 93% sensitive, 97% specific), especially for squamous malignancy (100% specific). The relative merits of the two methods are discussed. It is our belief that open biopsy should not be used as a first-line investigation of a neck mass.

Retrocolic pelvic omentoplasty in abdominoperineal excision of the rectum.

Abstract: A series of 53 patients underwent abdominoperineal excision of the rectum, 25 by the conventional method and 28 using retrocolic pelvic omentoplasty without drains. There were no differences in age, sex ratios, indications for surgery, stage of cancer and preoperative haemoglobin. There were no differences in the incidence of postoperative abdominal complications (wound dehiscence, obstruction and bleeding) between the two groups. However, patients undergoing omentoplasty without drainage stayed in hospital for a significantly shorter period (median of 16 days compared to 24 days) and benefited from far faster primary healing of the perineum (median of 20 days vs 133 days). It is concluded that retrocolic pelvic omentoplasty without drainage results in shortened postoperative hospital stay and promotes primary perineal healing after abdominoperineal excision of the rectum.

Use of operating theatres: the effects of case-mix and training in general surgery.

Abstract: Details of theatre occupancy times for a surgical unit in a district general hospital and associated cottage hospital were recorded over a 4-month period. The average time of the procedures individually and reclassified within the BUPA schedule showed that both the severity of the procedure and the grade of surgeon influenced future theatre needs. For almost every type of procedure, as expected, consultants were quicker than registrars, who in turn were faster than SHOs. The hidden cost of training surgeons in general surgical operative procedures can be estimated as a result. It is concluded that current measures of resource use which rely only on the bed use and ignore operating theatre needs and training requirements for non-consultant grades will be misleading, particularly in relation to the large element of minor or intermediate surgery which constitutes the bulk of most district health authorities' workload.

The varicose vein waiting list: results of a validation exercise.

Abstract: A lengthening waiting list for treatment of varicose veins in a busy teaching hospital prompted a careful review Patients were sent a detailed questionnaire which addressed current symptoms, progression of the complaint and the desire for surgical treatment Of 519 patients on the waiting list, replies were received from 471 (91%) Forty-eight patients could not be traced after two questionnaires had been sent and enquiries made with their last known local GP A further 87 (17%) patients were removed from the waiting list because they no longer desired treatment or had had treatment in the private sector The remaining 384 patients were sent appointments for specially organised Saturday morning assessment clinics attended by consultants and senior registrars Eighty patients failed to attend without giving a reason and were removed from the waiting list Of 304 patients reviewed, surgical treatment was considered necessary for 219, of whom 182 were suitable for day-case surgery, leaving only 37 patients of the original 519 who required inpatient surgical care This study has shown how careful assessment and the increased provision of day-case facilities can relieve pressure on inpatient care

Deaths following trauma: an audit of performance.

Abstract: The TRISS methodology was applied to identify preventable trauma deaths in a retrospective audit of 267 (M = 0.908) patients admitted to a teaching hospital through the resuscitation room of its accident and emergency department during a 1-year period. No unexpected survivors were identified; of the 44 deaths (Z = 5.35), 25 (56.8%) were judged preventable by the TRISS method. Those deaths deemed preventable were subjected to peer review by a panel of six consultants. The findings are discussed in respect of recommendations made for UK trauma centre provision by the Working Party Report of the Royal College of Surgeons of England on the management of patients with major injuries.

Application of the laryngeal mask airway to thyroid surgery and the preservation of the recurrent laryngeal nerve.

Abstract: We report our experience of using the laryngeal mask airway (LMA) in 13 consecutive patients undergoing thyroid surgery and discuss the advantages and limitations of the technique We also describe a method, based on the use of the LMA, for identifying and preserving the recurrent laryngeal nerve during thyroid surgery

Control of presacral bleeding in rectal surgery.

Abstract: A technique for controlling life-threatening presacral bleeding is described. This consists of a sterilised metallic drawing pin pushed through the synthetic coagulant Surgicel (Johnson and Johnson) directly into the bleeding point in the sacrum. Two patients are described in which this technique was used with a successful outcome.