Showing papers in "British Journal of Surgery in 2005"

Transection of the oesophagus for bleeding oesophageal varices

Abstract: Emergency ligation of bleeding oesophageal varices using the Milnes Walker technique was performed in 38 patients. Haemorrhage continued or recurred in hospital in 11 patients, all of whom subsequently died. A further 10 patients died in hospital following operation from hepatic failure and a variety of other causes. Five patients were finally considered suitable for elective shunt surgery, but of 12 patients who were discharged without a further operation, only 2 have re-bled. Although the overall 6-month survival was 32 per cent, in patients with good preoperative liver function this rose to 71 per cent, and the simple scoring system for grading the severity of disturbance of liver function was found to be of value in predicting the outcome of surgery. Since the results of emergency ligation of bleeding oesophageal varices in our hands have been so disappointing we are currently using it less and are trying the mesenteric caval jump graft as an emergency operation for the control of bleeding varices.

The mesorectum in rectal cancer surgery--the clue to pelvic recurrence?

Abstract: Five cases are described where minute foci of adenocarcinoma have been demonstrated in the mesorectum several centimetres distal to the apparent lower edge of a rectal cancer. In 2 of these there was no other evidence of lymphatic spread of the tumour. In orthodox anterior resection much of this tissue remains in the pelvis, and its is suggested that these foci might lead to suture-line or pelvic recurrence. Total excision of the mesorectum has, therefore, been carried out as a part of over 100 consecutive anterior resections. Fifty of these, which were classified as 'curative' or 'conceivably curative' operations, have now been followed for over 2 years with no pelvic or staple-line recurrence.

POSSUM: A scoring system for surgical audit

Abstract: POSSUM, a Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, is described. This system has been devised from both a retrospective and prospective analysis and the present paper attempts to validate it prospectively. Logistic regression analysis yielded statistically significant equations for both mortality and morbidity (P less than 0.001). When displayed graphically zones of increasing morbidity and mortality rates could be defined which could be of value in surgical audit. The scoring system produced assessments for morbidity and mortality rates which did not significantly differ from observed rates.

A classification of fistula‐in‐ano

Abstract: This report contains an analysis of 163 cases of fistula seen and personally treated at St. Mark’s Hospital between the years 1959 and 1968. Details of the anatomy of the tracks of each fistula were carefully recorded. An attempt is made to establish a logical anatomical classification of fistula with special reference to the relationship of the tracks to the sphincter muscles.

Gastrointestinal Quality of Life Index: Development, validation and application of a new instrument

Abstract: At present, an instrument for measuring the quality of life, specifically for patients with gastrointestinal disease, is not available. A new instrument for gastrointestinal disorders that is system-specific has been developed in three phases. In the first phase, questions were collated and then tested on 70 patients with gastrointestinal diseases and those that worked well were retained. In the second phase, the questions were modified and tested on 204 patients and the results verified by international experts. The instrument was also validated against other generic measures of quality of life. During the third phase, the instrument was validated with 168 normal individuals. Reproducibility was tested on 25 patients with stable gastrointestinal disease and responsiveness was tested on 194 patients undergoing laparoscopic cholecystectomy. The result is a bilingual (German and English) questionnaire containing 36 questions each with five response categories. The responses to questions are summed to give a numerical score. It is concluded that the Gastrointestinal Quality of Life Index (GIQLI) is ready to be used in clinical practice and research.

A sarcoma involving the jaws in African children.

Abstract: Thirty-eight cases of a sarcoma involving the jaws of African children are described. This is a syndrome which has not previously been fully recognized. It is by far the commonest malignant tumour of childhood seen at Mulago Hospital.

Incisional hernia: A 10 year prospective study of incidence and attitudes

Abstract: Five hundred and sixty-four patients reviewed 1 year after major abdominal surgery have been studied prospectively by a single observer for 10 years to determine the incidence and significance of incisional hernia. Of 337 (60 per cent) patients completing the 10 year follow-up 37 (11 per cent) developed an incisional hernia and 13 (35 per cent) of these first appeared at 5 years or later. One in three hernias caused symptoms. The late appearing hernias were smaller than the early ones, and caused little trouble. Of the 18 patients who consulted their general practitioner, 11 had symptoms and of these six (55 per cent) were referred for surgical opinion. Many hernias were diagnosed at routine outpatient follow-up and were likely to receive treatment from the surgeon. Most symptomatic patients were offered surgery with the remainder usually being offered a corset. In about half our patients (mainly those without symptoms) surgery was refused or advised against although the patients would have accepted it. Recurrence is common after surgical repair (40 per cent) but seems to be related to surgical technique. The possibility of complications occurring from an incisional hernia does not appear to be discussed with patients although obstruction occurred in 14 per cent of our patients with troublesome hernia.

Oesophageal squamous cell carcinoma: I. A critical review of surgery

Abstract: Authors writing an oesophageal cancer include adenocarcinoma to a variable extent--between 1 and 75 per cent--but the true incidence of this histological type is about 1 per cent. Most adenocarcinomas are gastric in origin, involving the lower oesophagus, have a lower operative mortality than in the middle or upper one-third of the oesophagus and poorer prognosis than squamous cell carcinoma, but there is no alternative treatment to surgery. Squamous cell carcinoma of the oesophagus, separated incompletely but as far as possible, has been analysed by reviewing data on 83 783 patients in 122 paERS. After trying to standardize the data, it appears that of 100 patients with the condition, 58 will be explored and 39 have the tumour resected, of whom 13 will die in hospital. Of the 26 patients leaving hospital with the tumour excised, 18 will survive for 1 year, 9 for 2 years and 4 for 5 years. Oesophageal resection for squamous cell carcinoma has the highest operative mortality of any routinely performed surgical procedure today.

Surgical therapy of oesophageal carcinoma.

Abstract: During the past 10 years, postoperative mortality associated with surgical treatment of oesophageal carcinoma has been reduced by one-half. However, it appears that all efforts to improve long-term survival with extensive excisional procedures and adjuvant chemotherapy and radiotherapy have failed. Fifty-six of 100 patients presenting to the surgeon with an oesophageal carcinoma have resectable disease. Recent studies suggest that seven of them will die from postoperative complications and 49 patients will be discharged from the hospital after an average of 3 weeks. Of these patients, 27 will survive the first, 12 the second, and ten the fifth year. Although it may be possible to further reduce postoperative complications and mortality, the chances of improving the long-term prognosis of patients with oesophageal carcinoma seem small.

Hepatic metastases from colorectal carcinoma: Impact of surgical resection on the natural history

Abstract: From 1960 to 1987, 1209 patients with colorectal liver metastases were recorded, and followed until 1 January 1990. In 242 cases the diagnosis was based on external imaging, whereas 967 patients had operative confirmation and staging of their liver disease. Three groups of patients were analysed: group 1 involved 921 cases, of whom 902 were deemed non-resectable whereas 19 could not be unequivocally classified. Only 21 patients lived for longer than 3 years, seven survived for 4 years, but there were no 5-year survivors. Group 2 comprised 62 highly selected patients who at laparotomy demonstrated resectable metastatic spread confined to the liver, but this was not treated mainly because of a formerly different therapeutic approach. These patients had a significantly longer median survival time (14.2 versus 6.9 months), but also failed to achieve 5-year survival. The 226 patients forming group 3 underwent hepatic resection with intent to cure. Nine of them had minimal macroscopic disease left, and 34 with all gross tumour removed had positive margins. Survival of patients with these 43 eventually non-radical resections followed an identical course as in group 2 (median survival 13.3 months, maximum 42 months). Of the 183 patients with potentially curative resection ten died after surgery (5.5 per cent). Actuarial 5 and 10-year survival rates in the remaining 173 patients were 40 and 27 per cent with 25 and seven patients alive at respective periods of time. Until 1 January 1990, 64 patients remained free from recurrent disease for up to 24 years. In three patients the tumour status at death was unclear. The other 106 patients developed definite cancer relapse. Nevertheless they demonstrated a prolongation of survival time by a median of 1 year when compared with the 43 non-radically resected patients or the 62 untreated patients with resectable liver-only metastases, and accomplished a maximum survival time of 8 years. Radical excision of colorectal secondaries to the liver therefore offers effective palliation, and in a small number the chance of a cure.

Ischaemia-reperfusion injury

Abstract: Ischaemia-reperfusion injury is a complex phenomenon often encountered in surgical practice. The consequences of such injury are local and remote tissue destruction, and sometimes death. Several different processes have been implicated. This review discusses the pathology of such injury, the mechanisms of free radical production, and the role of neutrophils and endothelial factors in ischaemiareperfusion. Finally, several mechanisms that limit ischaemia-reperfusion injury are discussed and a number of novel Therapies presented

Risk of lymphoedema following the treatment of breast cancer.

Abstract: The incidence of lymphoedema was studied in 200 patients following a variety of treatments for operable breast cancer. Lymphoedema was assessed in two ways: subjective (patient plus observer impression) and objective (physical measurement). Arm volume measurement 15 cm above the lateral epicondyle was the most accurate method of assessing differences in size of the operated and normal arm. Arm circumference measurements were inaccurate. Subjective lymphoedema was present in 14 per cent whereas objective lymphoedema (a difference in limb volume greater than 200 ml) was present in 25.5 per cent. Independent risk factors contributing towards the development of subjective late lymphoedema were the extent of axillary surgery (P less than 0.05), axillary radiotherapy (P less than 0.001) and pathological nodal status (P less than 0.10). The risk of developing late lymphoedema was unrelated to age, menopausal status, handedness, early lymphoedema, surgical and radiotherapeutic complications, total dose of radiation, time interval since presentation, drug therapy, surgery to the breast, radiotherapy to the breast and tumour T stage. The incidence of subjective late lymphoedema was similar after axillary radiotherapy alone (8.3 per cent), axillary sampling plus radiotherapy (9.1 per cent) and axillary clearance alone (7.4 per cent). The incidence after axillary clearance plus radiotherapy was significantly greater (38.3 per cent, P less than 0.001). Axillary radiotherapy should be avoided in patients who have had a total axillary clearance.

Epidemiology of varicose veins

Abstract: Assessment and treatment of varicose veins comprises a significant part of the surgical workload. In the UK, National Health Service waiting lists suggest that there is still considerable unmet need. This review analyses all published data on the epidemiology of varicose veins, paying particular regard to the differing epidemiological terminology, populations sampled, assessment methods and varicose vein definitions, which account for much of the variation in literature reports. Half of the adult population have minor stigmata of venous disease (women 50-55 per cent; men 40-50 per cent) but fewer than half of these will have visible varicose veins (women 20-25 per cent; men 10-15 per cent). The data suggest that female sex, increased age, pregnancy, geographical site and race are risk factors for varicose veins; there is no hard evidence that family history or occupation are factors. Obesity does not appear to carry any excess risk. Accurate prevalence data allow provision of appropriate resources or at least aid rational debate if demand is greater than the resources available.

Risk factors for anastomotic failure after total mesorectal excision of rectal cancer

Abstract: Background: Anastomotic leakage is a major complication of rectal cancer surgery. The aim of this study was to investigate risk factors associated with symptomatic anastomotic leakage after total mesorectal excision (TME). Methods: Between 1996 and 1999, patients with operable rectal cancer were randomized to receive short-term radiotherapy followed by TME or to undergo TME alone. Eligible Dutch patients who underwent an anterior resection (924 patients) were studied retrospectively. Results: Symptomatic anastomotic leakage occurred in 107 patients (11.6 per cent). Pelvic drainage and the use of a defunctioning stoma were significantly associated with a lower anastomotic failure rate. A significant correlation between the absence of a stoma and anastomotic dehiscence was observed in both men and women, for both distal and proximal rectal tumours. In patients with anastomotic failure, the presence of pelvic drains and a covering stoma were both related to a lower requirement for surgical reintervention. Conclusion: Placement of one or more pelvic drains after TME may limit the consequences of anastomotic failure. The clinical decision to construct a defunctioning stoma is supported by this study.

Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic and anatomical changes.

Abstract: Background: The aim of this study was to evaluate the anatomical and haemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration. Methods: Legs with open or recently healed ulceration and saphenous reflux were treated with multilayer compression bandaging or superficial venous surgery plus compression as part of a clinical trial. Venous duplex imaging was performed before treatment and at 1 year. Legs were stratified before surgery as having no deep reflux, segmental deep reflux or total deep reflux. Venous refill times (VRTs) were calculated before treatment and at 1 year using photoplethysmography, with and without a narrow below-knee cuff inflated to 80 mmHg. Results: Of 214 legs investigated, 112 were treated with compression and 102 with compression plus surgery. Saphenous surgery abolished deep reflux in ten of 22 legs with segmental deep reflux and three of 17 with total deep reflux. Overall median (range) VRT increased from 10 (3–48) to 15 (4–48) s 1 year after surgery (P < 0·001). Preoperative change in VRT on application of a below-knee tourniquet correlated with actual change in VRT following surgery. Conclusion: Superficial venous surgery resulted in a significant haemodynamic benefit for legs with venous ulceration despite co-existent deep reflux; residual saphenous reflux was common. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Effect of vaginal delivery on the pelvic floor: A 5‐year follow‐up

Abstract: We have studied the pelvic floor musculature and its innervation in 14 of 24 (58 per cent) multiparous women who had been recruited into a study of the effect of childbirth on the pelvic floor as part of a prospective investigation that began in 1983. These 24 women had all delivered by the vaginal route without forceps assistance. Five of the 14 had developed clinical symptoms of stress incontinence 5 years later; two of them had had a further uncomplicated vaginal delivery during this time. There was manometric and neurophysiological evidence of weakness because of partial denervation of the pelvic floor striated sphincter musculature, with pudendal neuropathy, which was more marked in those women with incontinence. These findings provide direct evidence for the hypothesis that pudendal neuropathy due to vaginal delivery persists and may worsen with time.

Systemic cytokine response after major surgery

Abstract: The systemic cytokine response to major surgical trauma was studied in 20 patients undergoing elective aortic surgery and five patients after inguinal hernia repair. Tumour necrosis factor alpha and interferon gamma were not detected in these patients. An early and short-lived interleukin 1 beta (IL-1 beta) response to major surgery was detected only by intensive sampling in the perioperative period. The IL-1 beta peak preceded a more marked interleukin 6 (IL-6) response that peaked 4-48 h after surgery. IL-6 levels had fallen sharply by 48-72 h in all patients who had an uneventful postoperative course. The IL-6 peaks were significantly lower after hernia surgery than after major aortic operations (P < 0.001); IL-1 beta was not detected in any samples. Three patients undergoing aortic surgery developed unexpected major postoperative complications. IL-6 levels in this group were significantly higher than those of the other patients undergoing aortic surgery within 6-8 h of skin incision, and remained elevated for longer. These rises in plasma IL-6 levels preceded the clinical onset of major complications by 12-48 h. The systemic IL-1 beta and IL-6 response to surgical trauma increased with the severity of the surgical insult. An early, exaggerated IL-6 response was associated with the subsequent clinical development of major complications.

Systemic inflammatory response syndrome

Abstract: Background Localized inflammation is a physiological protective response which is generally tightly controlled by the body at the site of injury. Loss of this local control or an overly activated response results in an exaggerated systemic response which is clinically identified as systemic inflammatory response syndrome (SIRS). Compensatory mechanisms are initiated in concert with SIRS and outcome (resolution, multiple organ dysfunction syndrome or death) is dependent on the balance of SIRS and such compensatory mechanisms. No directed therapies have been successful to date in influencing outcome. Method This review examines the current spectrum and pathophysiology of SIRS. Results and conclusion Further clinical and basic scientific research is required to develop the global picture of SIRS, its associated family of syndromes and their natural histories.

Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum

Abstract: Over 14 years 276 patients with rectal cancer underwent surgery; 219 who underwent low anterior resection of the rectum with total mesorectal excision were studied. There were 24 (11.0 per cent) major anastomotic leaks associated with peritonitis or a pelvic collection and 14 (6.4 per cent) minor leaks that were asymptomatic and detected by contrast enema. All major leaks occurred at an anastomotic height of less than 6 cm (P = 0.08). The abdominoperineal excision rate was 9.1 per cent. Major leaks were associated with failure to defunction in 11 of 62 patients and with a defunctioning colostomy in 13 of 157 (P = 0.03). Of the 24 patients with major leaks seven developed peritonitis, one with a defunctioned anastomosis (P = 0.002), and three died (P = 0.02). Use of the sigmoid colon led to major leakage in seven of 32 patients compared with 17 of 187 when the splenic flexure was employed (P = 0.05). There was no increase in the local recurrence rate but only nine patients with major leakage and a temporary stoma have had these closed. Key technical factors include: a clean dry pelvic cavity, pulsatile colonic blood supply, suction drainage started during closure and mobilization of ample tissue to fill the pelvic space.

The nature of haemorrhoids.

Abstract: An anatomical and clinical study aimed at uncovering factors likely to be helpful in understanding the true nature of haemorrhoids is described. The main finding was of specialized 'cushions' of submucosal tissue lining the anal canal; it is argued that piles are merely the result of their displacement.

Foreign body in the oesophagus: Review of 2394 cases

Abstract: A total of 2394 patients with a foreign body in the oesophagus was treated in our unit between 1965 and 1976, including 343 children in whom fish bones (146) and coins (134) were most commonly responsible; in adults, bones (fish and chicken) were commonest. Most of the foreign bodies were impacted in the cervical oesophagus. Pharyngoscopy and oesophagoscopy were carried out under general anaesthesia in all cases except those in which the foreign body was ejected spontaneously or when the patient refused the examination. Oesophageal perforation due to a foreign body was encountered in only one child. Two patients in the series developed the fearsome complication of oesophagoaortic fistula.

Postoperative infection and natural killer cell function following blood transfusion in patients undergoing elective colorectal surgery.

Abstract: The frequency of infection in 197 patients undergoing elective colorectal surgery and having either no blood transfusion, transfusion with whole blood, or filtered blood free from leucocytes and platelets was investigated in a prospective randomized trial. Natural killer cell function was measured before operation and 3, 7 and 30 days after surgery in 60 consecutive patients. Of the patients 104 required blood transfusion; 48 received filtered blood and 56 underwent whole blood transfusion. Postoperative infections developed in 13 patients transfused with whole blood (23 per cent, 9.5 per cent confidence interval 13–32 per cent), in one patient transfused with blood free from leucocytes and platelets (2 per cent, 9.5 per cent confidence interval 0.05–11 per cent) and in two non-transfusedpatients (2 per cent, 95 per cent conjidence interval 0.3-8per cent) (P < 0.01). Natural killer cell function was significantly (P < 0.001) impaired up to 30 days after surgery in patients transfused with whole blood. These data provide a strong case against the use of whole blood transfusion in patients undergoing elective colorectal surgery.