Br J Surg

Magnetic resonance imaging in evaluation of the common bile duct.

Musella M. Barbalace G. Capparelli G. Carrano A. Castaldo P. Tamburrini O. Musella S.
Experimental and Clinical Medicine Department, University of Reggio Calabria-Catanzaro Medical School, Italy.
BACKGROUND: The ideal method for evaluation of the common bile duct (CBD) before or during cholecystectomy remains controversial. Magnetic resonance cholangiography (MRC) is a new, promising technique. A prospective evaluation is reported. METHOD: Sixty-one patients (45 women) were studied by MRC. There were 29 patients with symptomatic gallstone disease and without clinical, biochemical or ultrasonographic evidence of CBD stones (group 1); 28 of them also underwent intraoperative cholangiography (IOC). In addition, there were 21 patients with symptomatic gallstone disease, with mild biochemical and ultrasonographic signs of CBD involvement (group 2), of whom 19 underwent IOC, and 11 patients with symptomatic CBD stones (group 3), nine of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP) following MRC. RESULTS: MRC showed that no patient in group 1 and three patients in group 2 had CBD stones. Three patients (one in group 1, two in group 2) did not undergo IOC because of technical or clinical problems. In group 3, ERCP confirmed the results of MRC in nine patients. Two patients underwent open surgery because of ultrasonographic, MRC and radiographic signs of pancreatic malignancy. CONCLUSION: MRC could replace IOC and ERCP for identification of asymptomatic CBD stones. In symptomatic patients MRC combined with other non-invasive imaging techniques can direct the surgeon to appropriate management.

Surgical strategies for carcinoma of the hepatic duct confluence.

Ogura Y. Kawarada Y.
First Department of Surgery, Mie University School of Medicine, Tsu., Japan.
BACKGROUND: This study was conducted to clarify the clinicopathological factors influencing appropriate surgical strategy and survival in patients with carcinoma of the hepatic duct confluence. METHODS: A total of 66 patients who underwent local resection of the bile duct with (n = 44) and without (n = 22) hepatectomy were reviewed retrospectively. RESULTS: Fifteen of the 44 patients who had hepatectomy and two of the 22 who did not suffered major postoperative complications (P < 0.05). As the pT category rose, the incidence of microscopic tumour extension increased significantly. Invasion at the surgical margins was more frequent in the patients who did not have hepatectomy than in those who did. Extramural tumour extension was found in 23 of 28 patients, and its prevalence was higher in the hepatic direction than the duodenal direction. Cancer invasion to the caudate lobe was found in nine of 21 patients. Thirty of 44 patients who underwent hepatectomy had a curative resection compared with six of 22 who did not have hepatectomy (P < 0.01). The cumulative survival rates after curative resection were significantly higher than after non-curative resection (P < 0.01). CONCLUSION: Hepatectomy with caudate lobectomy improves the curability and prognosis because these tumours frequently invade the surgical margins. However, operative morbidity is higher with this procedure.

Laparoscopic treatment of symptomatic cysts of the liver.

Diez J. Decoud J. Gutierrez L. Suhl A. Merello J.
Department of Surgery, University Hospital, Buenos Aires, Argentina.
BACKGROUND: Reports of successful treatment of liver cysts by the laparoscopic approach prompted the use of this technique in a series of patients. METHODS: Ten patients with symptomatic liver cysts were treated by the laparoscopic deroofing technique. Eight patients had one solitary cyst, one had two cysts and the remaining patient had polycystic disease with a giant cyst. Hydatid disease was excluded serologically and radiologically but albendazole was used before operation in six cases because hydatid disease is endemic in Argentina. RESULTS: There was no surgical morbidity or death. For between 6 months and 3 years all patients were asymptomatic. Computed tomography showed recurrence of a cyst in one patient, who was successfully reoperated on laparoscopically. CONCLUSION: Laparoscopic fenestration of either solitary or multiple liver cysts is the treatment of choice. It produces minimal surgical trauma, shorter hospital stay and avoids the morbidity of laparotomy. Reduced postoperative adhesions allows repeated procedures if the condition recurs.

Increased plasma levels of atrial natriuretic peptide and endocrine markers of volume depletion in patients with obstructive jaundice.

Gallardo JM. Padillo J. Martin-Malo A. Mino G. Pera C. Sitges-Serra A.
Department of Surgery, Hospital Reina Sofia, Universidad de Cordoba, Barcelona, Spain.
BACKGROUND: Hypovolaemia may cause renal dysfunction in obstructive jaundice. This study investigated whether, in patients with obstructive jaundice: (1) atrial natriuretic peptide (ANP) is increased; (2) fluid-regulating hormones are altered; and (3) biliary drainage improves fluid homoeostasis. METHODS: Forty-three patients with obstructive jaundice were investigated. A renal profile was obtained and levels of ANP, renin, aldosterone and vasopressin were determined. In a subset of 18 patients, studies were repeated 3 days after endoscopic biliary drainage and changes in extracellular volume were measured. RESULTS: Creatinine clearance was impaired in ten of 30 patients. Patients with obstructive jaundice had higher mean levels of ANP (118 versus 40 pg/ml, P = 0.0001) and aldosterone (156 versus 43 pg/ml, P = 0.0001) than matched controls. Increased renin levels were observed in ten of the 43 patients and were associated with impaired creatinine clearance. After biliary drainage ANP concentration decreased (110 versus 67 pg/ml, P = 0.004) as well as aldosterone level (182 versus 85 pg/ml, P = 0.0002) and the mean extracellular volume increased (20.5 versus 23.1 per cent of body-weight, P = 0.001). CONCLUSION: Plasma ANP concentration is increased in obstructive jaundice. Endocrine markers of hypovolaemia are activated in obstructive jaundice. After biliary drainage there is an improvement of endocrine and fluid derangements.

Laparoscopic management of acute peritonitis.

Navez B. Tassetti V. Scohy JJ. Mutter D. Guiot P. Evrard S. Marescaux J.
Service de Chirurgie Generale, Digestive et Urologique, Hopital Saint-Joseph, Gilly, Charleroi, Belgium.
BACKGROUND: The presence of peritonitis has previously been considered to be a contraindication for the laparoscopic approach because of the theoretical risk of malignant hypercapnia and toxic shock syndrome. The aim of this retrospective study was to demonstrate that laparoscopy is feasible, safe and efficient in cases of peritonitis. METHODS: From January 1990 to July 1995, 231 patients had a laparoscopy for acute peritonitis in two centres (91 appendicular peritonitis, 69 gastroduodenal perforated ulcers, 35 perforations of the colon, 36 miscellaneous). RESULTS: The diagnostic accuracy of laparoscopic exploration was 84.8 per cent. The clinical preoperative diagnosis was changed by laparoscopic exploration in 25.1 per cent of patients. An unnecessary laparotomy was avoided in 6.5 per cent of patients and the site of traditional incision was modified in 8.7 per cent. Conversion rates were 25 per cent for appendicular peritonitis, 16 per cent for gastroduodenal perforation and 83 per cent (29 of 35 patients) for colonic perforation. The overall mortality rate was 3.9 per cent. No malignant hypercapnia occurred. Two patients (0.9 per cent) had postoperative septic shock but survived. CONCLUSION: Laparoscopy is feasible and safe in cases of peritonitis. Laparoscopic treatment is particularly effective in the case of appendicular and gastroduodenal perforation. In the case of colonic perforation, the conversion rate remains high but with growing experience and surgical skill, more of these cases will be treated laparoscopically in the future.

Evaluation of ultrasonography and clinical diagnostic scoring in suspected appendicitis.

Galindo Gallego M. Fadrique B. Nieto MA. Calleja S. Fernandez-Acenero MJ. Ais G. Gonzalez J. Manzanares JJ.
Department of Surgery, Hospital General de Segovia, Spain.
BACKGROUND: Several diagnostic aids have been developed to improve diagnosis in suspected appendicitis including ultrasonography and clinical diagnostic scoring. The aim of this study was to elaborate a new scoring system and to measure its accuracy in the preoperative diagnosis of appendicitis, comparing it with the available scoring systems. METHODS: The clinical, radiological and ultrasonographic data of 192 patients with suspected appendicitis were collected prospectively. RESULTS: Only six of the 12 variables analysed were shown to have prognostic significance. Using Bayesian methodology, a weight was given to each criterion and two overall scores were calculated (ultrasonographic and classical scores). A cut-off point was identified to separate patients who needed surgery and those for observation. The ultrasonographic score showed an 81 per cent sensitivity and a 96 per cent specificity, compared with 60 and 73 per cent respectively for the classical score. CONCLUSION: Ultrasonography increases the diagnostic accuracy in patients with suspected acute appendicitis.

Randomized multicentre trial of the influence of recombinant human erythropoietin on intraoperative and postoperative transfusion need in anaemic patients undergoing right hemicolectomy for carcinoma.

Kettelhack C. Hones C. Messinger D. Schlag PM.
Department of Surgery and Surgical Oncology, Robert Rossle Hospital, Berlin, Germany.
BACKGROUND: The possible immunosuppressive effect of blood transfusion and its influence on survival after surgery for cancer makes it worthwhile to seek methods to avoid transfusion wherever possible. Patients with right-sided colonic cancer are frequently anaemic. Such patients were entered into a study that employed erythropoietin to avoid homologous transfusion. METHODS: In a prospectively randomized double-blind placebo-controlled multicentre trial, patients with moderate anaemia (haemoglobin concentration greater than 8.5 g/dl and less than or equal to 13.5 g/dl) presenting with right-sided colonic cancer and scheduled for hemicolectomy were treated with recombinant human erythropoietin (epoetin beta) 20,000 units/day subcutaneously or placebo for at least 10 days over the operative period. RESULTS: Perioperative treatment with epoetin beta was well tolerated and there were no significant differences in morbidity and mortality. Following hemicolectomy, median cumulative blood loss in the two groups was similar (epoetin beta 440 ml versus placebo 345 ml). Sixteen (33 per cent) of 48 patients treated with epoetin beta and 15 (28 per cent) of 54 in the placebo group received perioperative blood transfusions (P not significant). The increase in reticulocyte count between baseline and the last preoperative value was more pronounced in the epoetin beta group than in those receiving placebo (P = 0.036). CONCLUSION: Despite the perioperative administration of 20,000 units erythropoietin per day for at least 10 days, it was not possible to reduce the intraoperative and postoperative transfusion need. None the less, a positive change in the haematological variables of treated patients was clearly discernible. The negative result may be due to the short treatment interval and to iron deficiency, which was present in the majority of patients. The general change of attitude towards allogeneic blood transfusion is demonstrated by the overall low frequency of blood transfusion in this study.

Matrix metalloproteinase 9 level predicts optimal collagen deposition during early wound repair in humans.

Agren MS. Jorgensen LN. Andersen M. Viljanto J. Gottrup F.
Department of Surgery, Sundby Hospital, Copenhagen, Denmark.
BACKGROUND: This study examined two matrix metalloproteinases (MMPs) and their association with deposition of collagen during wound repair. METHODS: In 15 hernia wounds, wound fluid was collected using two Cellstick devices, which were implanted adjacent to two expanded polytetrafluoroethylene (ePTFE) tubes. MMP-2 and MMP-9 levels were analysed 24 and 48 h after operation using specific enzyme-linked immunosorbent assays, and collagen deposition in the ePTFE tubes was measured 10 days after operation as hydroxyproline. RESULTS: The levels of both MMPs in wound fluid were increased compared with those of control serum, although MMP-9 decreased (P < 0.01) in the wounds 24-48 h after operation. The MMP-9 level at 24 h correlated inversely and specifically to deposited collagen measured as hydroxyproline (rs = -0.80, P < 0.01). CONCLUSION: These results indicate that the level of MMP-9 in the early inflammatory phase can predict the amount of collagen deposited later in the wound healing process.

Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy.

Gooszen AW. Geelkerken RH. Hermans J. Lagaay MB. Gooszen HG.
Department of Surgery, University Hospital of Utrecht, The Netherlands.
BACKGROUND: Loop ileostomy or loop transverse colostomy for temporary decompression of a left colonic anastomosis represents an important issue in abdominal surgery. METHODS: A randomized study, comparing loop ileostomy (n = 37; group 1) or loop transverse colostomy (n = 39; group 2), was conducted. Patients were followed from construction to closure of the stoma. RESULTS: Age, weight, sex and indication for surgery were similar in both groups. After stoma construction complications were reported in nine of 37 patients in group 1 and in one of 39 in group 2 (P < 0.01), leading to postoperative death in five of 37 in group 1 and one of 39 in group 2. In the period between stoma construction and closure significant differences were observed only in prolapse rate (one of 32 group 1, 16 of 38 group 2; P < 0.01), need for temporary adaptation of clothing (eight of 32 group 1, 22 of 38 group 2; P < 0.01) and dietary guidelines (23 of 32 group 1, four of 38 group 2; P < 0.01). One patient died in group 1 and four in group 2; the deaths were not stoma related. After stoma closure eight of 29 patients in group 1 had complications and there were two deaths compared with three of 32 and no deaths in group 2. CONCLUSION: Both types of stoma carry a high complication rate with a considerable associated mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status. Based on all three phases studied, routine use of transverse colostomy is advised if decompression of the left colon is indicated.

Avoidable deaths still occur after large bowel surgery. Scottish Audit of Surgical Mortality, Royal College of Surgeons of Edinburgh.

Macarthur DC. Nixon SJ. Aitken RJ.
Department of Surgery, Eastern General Hospital, Edinburgh, UK.
BACKGROUND: Postoperative death following large bowel surgery is relatively infrequent and no large study has analysed the cause of all deaths comprehensively and critically. METHODS: In-hospital deaths following large bowel surgery in South-East Scotland were reviewed by independent assessors. The audit was confidential but not anonymous. Independent assessors' reports were returned to consultants. RESULTS: The audit documented 187 deaths. The independent assessors noted an adverse event in 78 patients (42 per cent). Twenty-six deaths (14 per cent) occurred following an anastomotic leak. A further 43 deaths (23 per cent) occurred because surgery was delayed (17) or there was undue delay in making the initial diagnosis (12) or recognizing a developing complication (14). Consultants operated on only half the patients classed as American Society of Anesthesiologists grade IV or V, or undergoing a second or subsequent operation. CONCLUSION: Half the patients dying in this study had identifiable deficiencies in their management. There is a clear need for greater consultant input with critically ill patients.

Laparoscopic management of acute small bowel obstruction.

Bailey IS. Rhodes M. O'Rourke N. Nathanson L. Fielding G.
Royal Brisbane Hospital, Australia.
BACKGROUND: Laparoscopic management of acute small bowel obstruction is hypothetically attractive but little is known of its clinical potential. METHODS: A retrospective study was undertaken of patients with acute small bowel obstruction requiring surgery, managed by a laparoscopic unit (LU; n = 69) and a general unit (GU; n = 70). RESULTS: Laparoscopy was performed in 55 patients (80 per cent) in the LU compared with ten (14 per cent) in the GU. Laparoscopic surgery completed treatment in 31 patients (45 per cent) in the LU and assisted in a further 15 (22 per cent). Patients treated laparoscopically were discharged earlier than those treated by laparotomy (median 3 (range 1-15) versus median 8 (range 1-46) days). Patients treated laparoscopically had a higher chance of early unplanned reoperation than those treated by laparotomy (five of 35 versus four of 88) (P < 0.05). CONCLUSION: Laparoscopy can be performed in a high percentage of patients requiring surgery for acute small bowel obstruction. Hospital stay was reduced but the risk of early unplanned reoperation was increased in patients managed laparoscopically.

Dynamic graciloplasty for severe anal incontinence.

Christiansen J. Rasmussen OO. Lindorff-Larsen K.
Department of Gastrointestinal Surgery D, Herlev Hospital, University of Copenhagen, Denmark.
BACKGROUND: The surgical options for the treatment of anal incontinence where standard procedures have failed include transposition of striated muscles, primarily gracilis and gluteus maximus, and implantation of artificial sphincters. Due to a high proportion of fatigue-prone fibres in striated muscles, the results of transposition without stimulation have been disappointing. This study presents the results of stimulated graciloplasty in 13 patients with severe anal incontinence in whom other surgical procedures had failed. METHODS: The gracilis muscle was transposed around the anal canal according to a previously described technique. Eight weeks later the intramuscular electrodes were implanted into the gracilis at the site of the nerve entry and a neurostimulator was placed in a subcutaneous pocket in the abdominal wall. The patients were followed from 7 to 27 months. RESULTS: Six patients obtained satisfactory continence and five showed marked improvement. Two patients were considered failures. Rectal evacuation problems occurred in three patients, in one so severe that the patient, in spite of satisfactory continence, considered the treatment a failure. CONCLUSION: Dynamic graciloplasty is a viable option in carefully selected patients with severe anal incontinence where other methods have failed.

Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome.

Maas CP. Moriya Y. Steup WH. Kiebert GM. Kranenbarg WM. van de Velde CJ.
Department of Surgery, University Hospital Leiden, The Netherlands.
BACKGROUND: Operative procedures for primary rectal cancer from Japan combine pelvic nerve-preserving techniques with radical tumour resection to ensure optimal local tumour control with minimal bladder and sexual dysfunction. A prospective study was undertaken to evaluate morbidity and functional outcome of such a technique in Dutch patients. METHODS: Forty-seven patients were operated on by a Japanese surgeon. Postoperative course was monitored. Voiding and sexual function were analysed using questionnaires completed by patients. RESULTS: After operation, only prolonged paralytic ileus (five of 47 patients) and perineal wound dehiscence (five of 18) occurred more frequently than reported in literature. There were no deaths. No patient developed urinary incontinence. Three of 11 women and 19 of 30 men were sexually active. Two men were impotent after operation. Impotence was related to sacrifice of the inferior hypogastric plexus (P = 0.037). Preservation of the superior hypogastric plexus was crucial for ejaculation (P = 0.003). CONCLUSION: A relationship between sacrifice of specific nerve structures and accompanying dysfunction was established. The nerve-preserving technique yields good results in terms of morbidity and functional outcome, and should be considered for adoption as a standard surgical procedure for primary rectal cancer.

Genetic detection of lymph node micrometastases in patients with colorectal cancer.

Dorudi S. Kinrade E. Marshall NC. Feakins R. Williams NS. Bustin SA.
Academic Department of Surgery, Royal London Hospital, UK.
BACKGROUND: Undetected micrometastases represent the single most important cause of treatment failure in patients undergoing putatively curative resection for colorectal cancer because current staging techniques are unable to identify patients with minimal residual disease. METHODS: A highly sensitive reverse transcription-polymerase chain reaction technique has been used to amplify tissue-specific messenger RNA from lymph nodes classified as tumour-free using both conventional histopathology and immunohistochemistry. RESULTS: Four of 15 patients were restaged after genetic diagnosis of lymph node micrometastases, while in a further two additional positive nodes were detected. CONCLUSION: Sensitive genetic techniques that detect minimal residual disease merit further study, particularly as there is evidence that patients may benefit from adjuvant chemotherapy.

International differences in survival from colon cancer: more effective care versus less complete cancer registration.

Prior P. Woodman CB. Collins S.
Centre for Cancer Epidemiology, University of Manchester, Withington, UK.
BACKGROUND: Reporting of a recent international comparison of cancer survival rates has left an impression of inadequate treatment of patients in the UK but failed to address adequately the extent to which differences in survival may reflect variation in the completeness and accuracy of cancer registration. The aim of this study was to quantify the extent to which differences in registration practice may confound comparisons of survival from cancer of the colon. METHODS: A cohort of incident cases of colon cancer identified from records held by the North Western Regional Cancer Registry was used to simulate the effects on survival of changes in clinical and registration factors. The survival curve produced after each simulation was compared with that for aggregated data from 21 European registries. RESULTS: The observed survival differences were not explained by more effective primary treatment or by misclassification of in situ cases as malignant disease, whereas the exclusion of cases with only a clinical diagnosis produced estimates close to those of the European cohort. CONCLUSION: The observed survival differentials may not be due to differences in the quality of care but may reflect the failure of some European registries to register all patients with advanced disease.

Marsupialization of fistulotomy wounds improves healing: a randomized controlled trial.

Ho YH. Tan M. Leong AF. Seow-Choen F.
Department of Colorectal Surgery, Singapore General Hospital, Singapore.
BACKGROUND: Marsupialization of anal fistulotomy wounds leaves less raw unepithelialized tissue to granulate and may improve wound healing. METHODS: Some 103 consecutive patients with uncomplicated intersphincteric or trans-sphincteric fistula in ano were recruited into a randomized controlled trial. Fistula tracts were identified and laid open under general anaesthesia. The patients were randomized to have either the wounds left open (LO group) or wound edges marsupialized to the fistula tract with interrupted absorbable sutures (MS group). Anal manometry was performed before operation, and 6 weeks and 3 months after surgery. RESULTS: Some 52 patients were randomized to the LO group and 51 to the MS group. There were no differences in the age, sex, fistula type and fistula length distribution between the groups. Mean follow-up times were 9 and 10.2 months respectively. Wounds in the MS group healed faster (mean(s.e.m.) 6.0 (0.4) weeks) than those in the LO group (10.0(0.5) weeks) (P < 0.001). Only one patient (2 per cent) in the MS group was incontinent of liquids after operation compared with six (12 per cent) in the LO group. There was less impairment in maximum anal squeeze pressure at 3 months after marsupialization compared with leaving fistulotomy wounds open (P < 0.05). Apart from a slightly longer operative time required for marsupialization, the hospitalization and complication rates were the same. CONCLUSION: Anal fistulotomy wounds healed faster after marsupialization. Anal squeeze pressures were better preserved and this may improve anal continence.

Flap advancement and core fistulectomy for complex rectal fistula.

Miller GV. Finan PJ.
Department of Surgery, General Infirmary at Leeds, UK.
BACKGROUND: The treatment of low fistula in ano is well accepted but controversy surrounds the management of high trans-sphincteric fistulas and more complex fistulas. This study assesses the clinical results of advancement flap techniques in association with core fistulectomy for complex fistula in ano. METHODS: A retrospective analysis of the use of advancement flap techniques together with core fistulectomy in 25 patients (26 fistulas) was performed. Clinical outcome was assessed in terms of fistula healing, continence, failure and technical problems. RESULTS: Successful healing of 20 of the 26 complex fistulas was achieved using this technique with no disturbance of continence and minimal (technical) complications. CONCLUSION: Flap advancement and core fistulectomy is a safe, effective procedure for complex rectal fistulas with good functional results and minimal or no disturbance of continence, and should be considered for the treatment of complex perianal fistulas.

Risk factors for rebleeding and death from peptic ulcer in the very elderly.

Chow LW. Gertsch P. Poon RT. Branicki FJ.
Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong.
BACKGROUND: Ageing populations are increasing in many countries and bleeding peptic ulcers in patients older than 60 years carry a greater risk of rebleeding and death. This study aimed to identify the risk factors for rebleeding and death in very elderly patients with peptic ulcer bleeding. The efficacy of treatment in preventing recurrent bleeding and death in this group of patients was also studied by means of prospective data collection and analysis. METHODS: Data relating to 1744 patients treated between September 1985 and January 1994 for peptic ulcer bleeding were collected prospectively and analysed. Patients were stratified by age to one of three groups: group 1 (less than 60 years, n = 833), group 2 (60-79 years, n = 706) and group 3 (80 or more years, n = 205). RESULTS: Univariate and multivariate analyses of 21 factors possibly affecting either rebleeding or death identified age greater than 80 years as one of the factors significantly affecting rebleeding and death. In a comparison of groups 1, 2 and 3, the likelihood of rebleeding and death was significantly greater in group 3. Univariate and multivariate analyses for rebleeding and death were performed for each group. The severity of initial bleeding had a marked bearing on subsequent rebleeding rates for all three groups. In group 3, however, large ulcer size and impaired liver function were additional factors which correlated significantly with final outcome. No rebleeding or morbidity occurred when endoscopic treatment was performed early for patients in group 3 but there was a significantly greater risk of further recurrent haemorrhage and treatment-related morbidity when treatment was performed after the onset of rebleeding. CONCLUSION: Patients aged 80 years or greater had the highest risk of rebleeding and death. For patients below 80 years of age, significant factors related to a fatal outcome included co-morbid illness, complications and the need for mechanical ventilation. For patients aged 80 years or older, the significant factors were ulcer size greater than 2 cm and admission with serum bilirubin level above 20 mmol/l. Endoscopic treatment for the very elderly was effective if carried out early.

Assessment of combined bile acid and pH profiles using an automated sampling device in gastro-oesophageal reflux disease.

Nehra D. Howell P. Pye JK. Beynon J.
Department of General Surgery, Wrexham Maelor Hospital, UK.
BACKGROUND: Bile acid reflux is an important component of duodenogastro-oesophageal reflux but there is no effective method of quantifying it. The contribution of bile acids to oesophageal pH is unknown. METHODS: Oesophageal aspirates were collected over 15 h using a new automated suction device and pH was monitored in ten asymptomatic volunteers (group 1) and 30 patients with reflux oesophagitis (group 2, minimal mucosal injury; group 3, erosive oesophagitis; group 4, stricture or Barrett's oesophagus). Bile acid assay was performed by high-performance liquid chromatography. RESULTS: The concentration of bile acids was significantly higher in group 3 (median (interquartile range) 124 (50-301) mumol/l) and group 4 (181 (85-591) mumol/l) compared with group 1 (0 mumol/l) and group 2 (14 (0-100) mumol/l). Patients in groups 3 and 4 also had significantly greater DeMeester acid scores. Combined bile acid and oesophageal acid reflux was observed in eight of ten patients with stricture or Barrett's oesophagus. There was no correlation between total bile acid concentration and oesophageal acid or alkaline exposure. CONCLUSION: This study supports the theory of toxic synergism between acid and bile acids in reflux oesophagitis. Bile acids may contribute to the pathogenesis of Barrett's metaplasia.

Colorectal cancer vaccines.

Year 1998
Maxwell-Armstrong CA. Durrant LG. Scholefield JH.
Department of Surgery, University of Nottingham, UK.
BACKGROUND: Advances in molecular pathology have enabled a number of colorectal cancer antigens to be identified and characterized. The commonest investigated include 17-1A, 791Tgp72 and carcinoembryonic antigen. Vaccines have been developed that stimulate the immune system to target these antigens. This paper reviews current areas of research in this field. METHODS AND RESULTS: Relevant articles were obtained on vaccines for colorectal cancer from Medline and the Bath Information Data System. A number of approaches are currently being evaluated in Phase I, II and III trials. These include anti-idiotypic antibody immunization, DNA vaccines, mucin and heat shock protein-based vaccines, oncogenes and viral vectors. CONCLUSION: Evidence is accumulating to suggest that immune responses may be generated against colorectal cancer using these approaches. While the concept of vaccination against this malignancy is essentially experimental, surgeons should be aware of current advances.

Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis.

Year 1998
Rau B. Pralle U. Mayer JM. Beger HG.
Department of General Surgery, University of Ulm, Germany.
BACKGROUND: Early detection of infected pancreatic necrosis has a major impact on further management and outcome in acute pancreatitis. The aim of this study was to evaluate the clinical value of ultrasonographically guided fine-needle aspiration cytology (FNAC) in patients with necrotizing pancreatitis over an 8-year period. METHODS: From January 1988 to September 1996 193 (mean 2.0 (range 1-9) aspirations per patient) prospectively assessed FNACs guided ultrasonographically were performed in 98 patients with necrotizing pancreatitis proven by contrast-enhanced computed tomography. Aspirates were considered infected if either Gram stain and/or culture revealed micro-organisms. RESULTS: Ultrasonographically guided FNAC correctly diagnosed infection in 29 of 33 patients with infected necrosis a median of 13 days after onset of symptoms. Of 61 patients with sterile necrosis 55 were identified correctly as sterile by FNAC. There were six false-positive and four false-negative aspirates of which nine occurred during the first week of the disease. In four patients who did not undergo operation FNAC revealed Gram-negative organisms; however, in the absence of repeated aspirations, the positive results remained unconfirmed. An overall sensitivity of 88 per cent and a specificity of 90 per cent was obtained. No difference was found in biochemical and clinical parameters indicating systemic inflammatory response syndrome before each FNAC between patients with proven sterile or infected necrosis. All patients tolerated the procedure well and no major complications were observed. CONCLUSION: Ultrasonographically guided FNAC is a fast and reliable technique for the diagnosis of infected necrosis. As complication rates are very low, the procedure can be repeated at short intervals to improve the diagnostic accuracy. Ultrasonographically guided FNAC is recommended for all patients with necrotizing pancreatitis in whom systemic inflammatory response syndrome persists beyond the first week after onset of symptoms.

Hepatic resection with cryotherapy to involved or inadequate resection margin (edge freeze) for metastases from colorectal cancer.

Year 1998
Dwerryhouse SJ. Seifert JK. McCall JL. Iqbal J. Ross WB. Morris DL.
Department of Surgery, St George Hospital, University of New South Wales, Sydney, Australia.
BACKGROUND: In patients undergoing liver resection for colorectal liver metastases, a resection edge either involved by tumour or with the tumour extending to within 1 cm is associated with a high risk of liver recurrence and survival is reduced markedly. METHODS: Twenty-six patients underwent cryotherapy of the resection edge following liver resection for metastases from colorectal carcinoma with an involved or inadequate (less than 1 cm) resection margin. RESULTS: At a median follow-up of 23 (range 1-47) months four patients were alive and disease free, and 21 had developed recurrence, of whom 13 had died. One patient died following surgery. Sixteen patients developed recurrences involving the liver, only five of which were at the resection margin. CONCLUSION: Cryotherapy to involved or inadequate resection margins improves local disease control considerably. The use of resection edge cryotherapy might allow a greater proportion of patients with liver metastases to be usefully treated and help to avoid high-risk resections.

Bile duct injury during laparoscopic cholecystectomy without operative cholangiography.

Year 1998
Wright KD. Wellwood JM.
Department of Surgery, Whipps Cross Hospital, London, UK.
BACKGROUND: The role of operative cholangiography in the prevention of bile duct injuries is controversial. A prospective audit of biliary injury is presented. METHODS: Laparoscopic cholecystectomy without operative cholangiography was undertaken in a consecutive series of 1200 patients. All biliary injuries were recorded. RESULTS: Meticulous dissection proved to be a reliable safeguard against injury to the right hepatic, common hepatic and common bile ducts. However, four accessory ducts were sacrificed and localized injury to the common hepatic or common bile duct occurred in three patients. These injuries would not have been prevented by operative cholangiography. CONCLUSION: Operative cholangiography is not a prerequisite for the safe performance of laparoscopic cholecystectomy and cannot be relied upon to prevent all biliary injuries.

Risk factors linked to postoperative morbidity in patients with hepatocellular carcinoma.

Year 1998
Shimada M. Takenaka K. Fujiwara Y. Gion T. Shirabe K. Yanaga K. Sugimachi K.
Department of Surgery II, Faculty of Medicine, Kyushu University, Fukuoka, Japan.
BACKGROUND: The aim of this study was to clarify the risk factors for morbidity as well as to establish an optimum surgical strategy for hepatocellular carcinoma (HCC). METHODS: The risk factors linked to postoperative complications were analysed in 388 patients over a 10-year period, according to the kind of operative procedure. RESULTS: Stepwise regression analysis revealed that the most important factors related to postoperative morbidity were: age, creatinine level and the histological grade of fibrosis for the bisegmentectomy; the presence of diabetes mellitus, blood urea nitrogen level, the indocyanine green dye retention rate at 15 min and blood loss for the segmentectomy; the presence of diabetes mellitus and blood loss for subsegmentectomy; the presence of diabetes mellitus, the aspartate aminotransferase level, and the total operating time for resection less than subsegmentectomy. CONCLUSION: The most important risk factors were not always related to liver function tests, but instead to other coexisting conditions such as diabetes mellitus and operation stress including operating time and blood loss. Therefore, any future treatment strategy of hepatic resection for HCC should make every effort both to evaluate coexisting conditions carefully and to reduce operative stress as far as possible.

Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer.

Year 1998
Polati E. Finco G. Gottin L. Bassi C. Pederzoli P. Ischia S.
Institute of Anaesthesiology and Intensive Care, University of Verona, Italy.
BACKGROUND: In a randomized double-blind study the efficacy of neurolytic coeliac plexus block (NCPB) was compared with pharmacological therapy in the treatment of pain from pancreatic cancer. METHODS: Twenty-four patients were divided into two groups: 12 patients underwent NCPB (group 1) and 12 were treated with pharmacological therapy (group 2). Immediate and long-term efficacy, mean analgesic consumption, mortality and morbidity were evaluated at follow-up. Statistical analysis was performed with the unpaired t test, Mann-Whitney U test and Fisher's exact test. RESULTS: Immediately after the block, patients in group 1 reported significant pain relief compared with those in group 2 (P < 0.05), but long-term results did not differ between the groups. Mean analgesic consumption was lower in group 1. There were no deaths. Complications related to NCPB were transient diarrhoea and hypotension (P not significant between groups). Drug-related adverse effects were constipation (five of 12 patients in group 1 versus 12 of 12 in group 2), nausea and/or vomiting (four of 12 patients in group 1 versus 12 of 12 in group 2) (P < 0.05), one gastric ulcer and one gluteal abscess in group 2. CONCLUSION: NCPB was associated with a reduction in analgesic drug administration and drug-related adverse effects, representing an effective tool in the treatment of pancreatic cancer pain.

Laparoscopic stoma formation for faecal diversion.

Year 1998
Hollyoak MA. Lumley J. Stitz RW.
Colorectal Unit, Royal Brisbane Hospital, Queensland, Australia.
BACKGROUND: Laparoscopic creation of an intestinal stoma may be preferable to open operation when intervention is required solely for faecal diversion. METHODS: Experience with laparoscopic intestinal stoma formation for faecal diversion from a single institution is presented. RESULTS: A total of 55 stomas were studied, 40 laparoscopic and 15 open. The conversion rate from laparoscopic to open operation was 5 per cent. Mean(s.e.m.) operating time was significantly reduced for laparoscopic stomas (54(4.7) versus 72(8.7) min). Time to return of bowel function was significantly reduced (1.6(0.3) versus 2.2(0.2) days). Mean(s.e.m.) hospital stay was significantly reduced in the laparoscopic group (7.4(0.5) versus 12.6(2.5) days). CONCLUSION: Morbidity and mortality appeared to be reduced in patients undergoing laparoscopic stoma formation. The technique was found to be safe, suitable for the majority of patients and to give results superior to those of open surgery.

Timing of surgery for fulminating pseudomembranous colitis.

Year 1998
Synnott K. Mealy K. Merry C. Kyne L. Keane C. Quill R.
Department of Surgery, Trinity College, Dublin, Ireland.
BACKGROUND: With increasing antibiotic usage Clostridium difficile colitis is becoming more common. Surgery for fulminating C. difficile colitis, however, is rare because of the effectiveness of specific anticlostridial chemotherapy. Surgical outcome in five patients with fulminating C. difficile colitis involved in a recent outbreak of this disease is reported. METHODS: Five of 138 patients developed fulminating C. difficile colitis unresponsive to medical therapy. All patients had antibiotics in the preceding period. Indications for operation in those who underwent surgery were systemic toxicity with a pyrexia, marked leukocytosis and abdominal signs leading to progressive organ failure, despite appropriate anticlostridial antibiotic therapy. RESULTS: At operation all patients had a markedly oedematous colon with normal serosa but with acute mucosal colitis. All underwent subtotal abdominal colectomy and ileostomy. Progressive organ failure persisted in four, leading to death, giving a mortality rate of four in five in the operated group in comparison with 3.8 per cent (five of 133 patients) in those treated medically. CONCLUSIONS: These results indicate that this increasingly common disease frequently leads to a fatal outcome in patients requiring surgery and implies that earlier surgical consultation may be necessary to improve survival in patients with fulminating C. difficile colitis unresponsive to antibiotic therapy.

Functional results after transanal rectal advancement flap repair of trans-sphincteric fistula.

Year 1998
Kreis ME. Jehle EC. Ohlemann M. Becker HD. Starlinger MJ.
Chirurgische Universitatsklinik Tubingen, Abteilung Allgemeine Chirurgie, Germany.
BACKGROUND: Transanal rectal advancement flap repair is an operation to treat trans-sphincteric fistula which leaves the external sphincter muscle essentially untouched. Anal sphincter function was evaluated prospectively before and after this procedure. METHODS: Anorectal manometry was performed in 24 patients before operation and 3 months after surgery. A detailed standardized questionnaire on faecal continence was answered before surgery, then at 3 and 48 months after surgery. RESULTS: No significant differences were seen between mean(s.e.m.) preoperative and postoperative values for maximum squeeze pressure (100.0(9.7) versus 118.0(12.7) mmHg), maximum resting pressure (56.6(4.3) versus 52.8(4.1) mmHg), rectal compliance (4.4(0.6) versus 3.5(0.5) ml/mmHg) or any other parameter of anorectal manometry. The questionnaire revealed the occurrence of minor incontinence in two patients following surgery, which remained unchanged for 4 years. Three other patients had continence disturbances 4 years after surgery which were probably unrelated to the procedure. CONCLUSION: In addition to high success rates, transanal rectal advancement flap repair also yields excellent functional results. This procedure should be performed for trans-sphincteric fistula in place of alternative treatments whenever feasible.

Cutting seton versus two-stage seton fistulotomy in the surgical management of high anal fistula.

Year 1998
Garcia-Aguilar J. Belmonte C. Wong DW. Goldberg SM. Madoff RD.
Department of Surgery, University of Minnesota Medical School, USA.
BACKGROUND: The aim of this study was to compare the clinical results obtained with the cutting seton and the two-stage seton fistulotomy (TSSF) in the surgical management of high anal fistula. METHODS: The case records of 59 patients with high anal fistula of cryptoglandular origin treated with cutting seton (n = 12) or TSSF (n = 47) over a 5-year period were retrospectively reviewed. There was no difference between the groups in age, sex distribution, or estimated percentage of anal sphincter involved by the fistula. Follow-up was by a mailed questionnaire inquiring about fistula recurrence, incontinence, and degree of satisfaction. Mean follow-up was similar in both groups (27 months for cutting seton versus 33 months for TSSF). Comparisons were made by Student t and chi 2 tests, as required. RESULTS: There were no differences in the rate of fistula recurrence between the groups treated with cutting seton or TSSF (one of 12 versus four of 47), difficulty holding gas (six of 12 versus 25 of 47), underwear staining (six of 12 versus 18 of 47), stool incontinence (three of 12 versus 12 of 27), overall incontinence (eight of 12 versus 31 of 47) and mean incontinence score (4.9 versus 4.2). The fistula healing time and degree of satisfaction with the operation were not significantly different between the groups. One-half of the patients treated by TSSF had the seton removed under general or epidural anaesthesia. CONCLUSION: Both techniques are equally effective in eradicating the fistula, and both are associated with a similar rate of incontinence.

Continued change in the distribution of colorectal carcinoma.

Year 1998
Obrand DI. Gordon PH.
Department of Surgery, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
BACKGROUND: The aim of this study was to determine whether the previously reported shift in carcinoma from the left colon to the right colon has progressed. METHODS: The charts of 2169 patients admitted to one institution between 1979 and 1994 with a diagnosis of colorectal carcinoma were reviewed retrospectively. The study was divided into four equal intervals. The large bowel was divided into five regions: right, transverse, left, sigmoid and rectum. RESULTS: Right-sided lesions increased from 20.6 to 29.9 per cent (P = 0.001) and rectal lesions decreased from 22.0 to 11.3 per cent (P = 0.0002) from the first to the fourth study interval. The frequency of transverse, left and sigmoid colon lesions remained relatively constant. CONCLUSION: The continuing trend of increased incidence of right-sided lesions and decreased incidence of rectal lesions was documented. Any screening examination for carcinoma requires total examination of the colon.

Quality of life after pouch excision.

Year 1998
Tan HT. Morton D. Connolly AB. Pringle W. White M. Keighley MR.
University Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
BACKGROUND: Pouch excision is a devastating experience for patients having restorative proctocolectomy for ulcerative colitis. METHODS: The quality of life among patients having pouch excision for ulcerative colitis was compared with that in those having proctocolectomy and ileostomy for ulcerative colitis using a validated standardized self-administered questionnaire. RESULTS: After pouch excision patients (n = 9) had more troublesome bowel symptoms (mainly from liquid stoma output) than those in the proctocolectomy group (n = 14) (mean(s.d.) score 5.64(0.92) versus 6.13(0.37), P = 0.03). However, the mean scores for the other parameters (systemic symptoms, functional, social and emotional impairment) did not differ significantly. CONCLUSION: Patients having pouch excision for ulcerative colitis have more liquid ileostomy loss but a comparable quality of life to those treated by standard proctocolectomy and ileostomy.

Prognostic factors in a series of 297 patients with gastric adenocarcinoma undergoing surgical resection.

Year 1998
Sanchez-Bueno F. Garcia-Marcilla JA. Perez-Flores D. Perez-Abad JM. Vicente R. Aranda F. Ramirez P. Parrilla P.
Department of General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain.
BACKGROUND: Gastric cancer has a poor prognosis. The aim of this study was to determine the influence of several clinicopathological variables on outcome in a series of 297 Western patients undergoing surgical resection for gastric adenocarcinoma. METHODS: The results were analysed retrospectively and prognostic factors were identified in a univariate and Cox proportional hazards regression model. Mean patient age at the time of operation was 61.9 years; 65.7 per cent were men. Mean follow-up was 7.8 (range 1-15) years. Of the 297 patients undergoing surgery, 70 per cent had subtotal gastrectomy, 26.3 per cent underwent total gastrectomy and 3.7 per cent had proximal gastrectomy. RESULTS: The overall survival rate was 38.9 per cent at 5 years. In th univariate analysis, survival-related factors were weight loss (P < 0.05), abdominal mass (P < 0.01), dysphagia (P < 0.001), type of gastrectomy (subtotal gastrectomy versus total gastrectomy, P < 0.001), intention of resection (curative versus palliative resection, P < 0.001), tumour site (P < 0.001), histopathological grade (low versus high grade, P < 0.05), tumour diameter less than 3 cm (P < 0.001), degree of gastric wall invasion (P < 0.001), degree of lymph node invasion (P < 0.001) and stage of the neoplasia (P < 0.001). Other variables had no significant influence. In the multivariate analysis, degree of gastric wall invasion, lymph node invasion, tumour size and dysphagia at presentation were the only independent prognostic variables. CONCLUSION: From these data it was possible to derive a prognostic index with which patients could be classified as at low, intermediate or high risk.

Restenting malignant oesophageal strictures.

Year 1998
Lagattolla NR. Rowe PH. Anderson H. Dunk AA.
Department of Surgery, Eastbourne District General Hospital, UK.
BACKGROUND: Self-expanding metal stents are used to palliate malignant strictures of the oesophagus. This study was designed to identify the characteristics of patients requiring restenting of malignant oesophageal strictures. METHODS: Fifty-three stents were inserted in 42 patients. Thirty-two patients did not require further stenting (once-stented group). Ten patients received second stents for recurrent oesophageal obstruction (restented group), with one patient requiring restenting a second time. Comparisons were drawn between the once-stented and restented groups with regard to survival, patient, tumour and procedural characteristics. RESULTS: There were no significant differences with regard to tumour grade, tumour type, involvement of the cardia, procedural difficulties or the need for postprocedural oesophageal dilatation between the two groups. Survival from initial stenting was significantly greater in the restented group (median 24 (range 4-43) weeks) than in the once-stented group (median 9.5 (range 1-84) weeks) (P < 0.05). The mean length of stents used in the once-stented group was significantly greater than that of the initial stents used in the restented group (12 versus 10 cm, P = 0.032). CONCLUSION: Inserting a covered stent through a previously inserted uncovered stent is an uncomplicated and well tolerated technique which maintains palliation from obstructing oesophageal carcinoma. The need for restenting cannot be predicted on the basis of tumour characteristics alone.

Management of malignant oesophageal obstruction with self-expanding metallic stents.

Year 1998
Cowling MG. Hale H. Grundy A.
Department of Diagnostic Radiology, St George's Hospital and Medical School, London, UK.
BACKGROUND: The use of self-expanding metal stents for palliation of malignant dysphagia is increasing. Experience in 70 patients was reviewed with respect to the value of stenting and management of the complications encountered. METHODS: Oesophageal stents were inserted in 70 patients (42 men) of mean age 73 years with malignant oesophageal obstruction. Data regarding stent insertion and degree of dysphagia were gathered prospectively. RESULTS: Seventy-six stents were placed in 70 patients. By the end of the study 57 patients had died and 13 were still alive. Three patients died within 3 days of stent insertion and dysphagia was relieved in 64 of the 67 patients remaining. Stent migration, tumour ingrowth and overgrowth, and food impaction were encountered during follow-up in eight patients. CONCLUSION: Insertion of self-expanding metal stents for the palliation of malignant oesophageal obstruction is a successful therapy which can be carried out with relative ease. Palliation of dysphagia with an appropriate stent can be expected in up to 95 per cent of patients.

Function of the proximal stomach after Nissen fundoplication.

Year 1998
Wijnhoven BP. Salet GA. Roelofs JM. Smout AJ. Akkermans LM. Gooszen HG.
Department of Surgery, University Hospital Utrecht, The Netherlands.
BACKGROUND: After Nissen fundoplication patients frequently report upper abdominal (dyspeptic) symptoms. Theoretically, these symptoms may be the result of changes in function of the proximal stomach as induced by fundoplication. METHODS: In this case-control study the response of the proximal stomach to both distension by an air-filled bag and a liquid meal were evaluated with the use of a barostat. In 12 patients after fundoplication and 12 healthy volunteers (age- and sex-matched) perception of symptoms was evaluated during both bag distension and liquid meal stimulus. RESULTS: The minimal distending pressure required to overcome the intra-abdominal pressure was significantly different between patients and controls (mean(s.e.m.) 9.34(0.26) versus 6.73(0.43) mmHg; P < 0.001). There was no difference between groups in either the fasted state, volume-pressure curve (compliance) or total symptom score. After ingestion of the liquid meal the adaptive relaxation in the fundoplication group was significantly less than that in controls (mean(s.e.m.) 150(29.2) versus 244(34.8) ml; P = 0.04). CONCLUSION: This study showed that after Nissen fundoplication compliance of the proximal stomach is no different from that in healthy volunteers. Postprandial relaxation of the proximal stomach is decreased and this abnormality may be involved in the pathogenesis of reported dyspeptic symptoms.

Late results of paraoesophageal hiatus hernia repair with fundoplication.

Year 1998
Luostarinen M. Rantalainen M. Helve O. Reinikainen P. Isolauri J.
Department of Surgery, Tampere University Hospital, Finland.
BACKGROUND: Most published reports on results of surgical treatment for paraoesophageal hiatus hernia have been based on patient questionnaires, and seldom included endoscopy or barium meal examinations. METHODS: Eight pure and 14 mixed-type paraoesophageal hernias were evaluated a median of 37 (range 2-241) months after surgical repair. An antireflux procedure was done in 19 cases. Before operation all had endoscopy or barium meal (20 and 19 patients respectively); after operation 19 had endoscopy and 12 also had barium meal examination. Oesophageal 24 h pH monitoring was done in five cases before surgery, and in 11 afterwards. RESULTS: Preoperative symptoms of reflux were reported by 18, and were often accompanied by dysphagia, postprandial vomiting or epigastric pain. Symptoms improved after operation, and 21 of the 22 patients were satisfied with the result. At follow-up examination, a recurrent hernia was found in eight of the 19 patients examined. Four of these hernias were sliding, two were mixed type and two purely paraoesophageal. DISCUSSION: Recurrence of symptoms was associated with persistence of reflux rather than hernia recurrence. Concomitant antireflux procedure is recommended in all operations for mixed-type hiatus hernia, but it should also be considered for purely paraoesophageal hernia if reflux cannot be excluded before operation, or if retro-oesophageal dissection is needed.

Novel approach to the treatment of intestinal fistula in the inaccessible abdomen: transbursal end-to-side duodenogastrostomy.

Year 1998
Bosscha K. van Vroonhoven TJ.
Department of Surgery, University Hospital Utrecht, The Netherlands.
BACKGROUND: Treatment of enterocutaneous fistula in patients with intra-abdominal sepsis and a surgically inaccessible abdomen is frequently unsuccessful. METHODS: A new approach has been devised: total disconnection of the proximal digestive tract, which can be performed through the bursa omentalis without entering the scarred abdomen. RESULTS: The procedure was carried out in four patients with high-output small bowel fistula and an inaccessible abdomen. Output of fistulas stopped promptly, recovery from intra-abdominal sepsis was achieved, the abdomens became accessible again and continuity of the digestive tract could be restored in all patients after intervals of 2-5.5 months. CONCLUSION: Transbursal end-to-side duodenogastrostomy is a useful procedure when traditional surgical interventions have failed or cannot be applied.

Management of faecal incontinence following obstetric injury.

Year 1998
Cook TA. Mortensen NJ.
Department of Colorectal Surgery, John Radcliffe Hospital, Headington, Oxford, UK.
BACKGROUND: Faecal incontinence is common in women and the major aetiological factor is childbirth. Increasing numbers of women with faecal incontinence are presenting to surgical clinics. METHODS: A literature review was performed on Medline database for English language publications an obstetric injury. The incidence, presentation, assessment and treatment of faecal incontinence following obstetric injury were evaluated. RESULTS AND CONCLUSIONS: Third-degree tear occurs in association with less than 1 per cent of vaginal deliveries, but occult sphincter injury occurs at one-third of deliveries and may be significant in later life. Incontinence may result from sphincter damage or nerve injury, or both. Risk factors for these injuries can be identified. Clinical evaluation, anorectal physiology and endoanal ultrasonography allow accurate planning of subsequent surgery. Overlapping anterior anal sphincter repair provides symptomatic control of continence in 80 per cent of patients. Repair of an acute anal sphincter injury after a third-degree tear is controversial and a defined policy should be agreed between obstetric and colorectal teams.

Adjuvant therapy for resectable rectal and colonic cancer.

Year 1998
Heriot AG. Kumar D.
Department of Colorectal Surgery, St George's Hospital, London, UK.
BACKGROUND: Recurrence of rectal and colonic carcinoma remains substantial despite apparently curative surgery. Adjuvant therapy has been applied to improve prognosis. METHODS: This review evaluates the use of adjuvant therapy in the management of resectable rectal and colonic carcinoma. It assesses critically the evidence supporting the addition of radiotherapy, chemotherapy, chemoradiotherapy and other treatment modalities to optimal surgery. RESULTS: In the case of rectal tumours, preoperative is more effective than postoperative radiotherapy; It can significantly reduce the incidence of local tumour recurrence. A number of trials have tended towards showing a survival advantage and a recent large randomized trial has shown a significant improvement in survival in patients with Dukes C tumours. Postoperative chemoradiotherapy is associated with a survival benefit and is standard therapy in the USA, although it is associated with increased toxicity. The effectiveness of preoperative chemoradiotherapy is currently being investigated. Postoperative fluorouracil-containing chemotherapy has resulted in a survival advantage in patients with Dukes C colonic tumours; such therapy may be administered either systemically or intraportally. The evidence of benefit with rectal tumours is more limited. Immunotherapy has been studied to a limited extent and the use of a tumour-directed monoclonal antibody has produced a survival advantage in a single trial. CONCLUSION: Preoperative radiotherapy and postoperative chemoradiotherapy can produce a survival advantage in patients with Dukes C rectal carcinoma and reduce local recurrence. Postoperative fluorouracil-containing chemotherapy can produce a survival advantage in those with Dukes C colonic cancer. The optimal use and combination of adjuvant therapy remains uncertain.

Endoprostheses for colonic strictures.

Year 1998
Akle CA.
No information.
BACKGROUND: Patients who present with large bowel obstruction often undergo emergency surgical intervention with its attendant risk of morbidity and death. A colostomy may be inevitable and this detracts from the patient's quality of life, especially when palliation is the only option. METHODS: This review examines the possibility of a more conservative approach using metallic stents to relieve colonic obstruction, either as the first stage of a curative surgical procedure or for palliation without surgery. The various stents available are examined. RESULTS: Case reports show that relief of obstruction can be achieved in over 80 per cent of patients, allowing subsequent elective surgery or achieving palliation for several months. Complications are rare but include colonic perforation, particularly when predilatation of the stricture has to be performed. Such complications are generally recognized early and patients can proceed to surgery and colostomy, as would previously have been conventional treatment; on occasion a small leak may be treated conservatively with success. The advent of newer endoprostheses which do not require active dilatation may improve the rate of successful deployment and lessen the risk of perforation. CONCLUSION: The development of new endoprostheses has allowed their adaptation for use in the colon and, perhaps, the distal small bowel. The technology is evolving rapidly and warrants serious consideration in selected patients with large bowel obstruction before embarking on surgery. There is an urgent need for a controlled trial to establish whether such intervention for malignant strictures, potentially curable by surgery, leads to an increased risk of metastatic disease.

An 8-year experience of hepatic resection: indications and outcome.

Year 1998
Finch MD. Crosbie JL. Currie E. Garden OJ.
University Department of Surgery, Royal Infirmary, Edinburgh, UK.
BACKGROUND: Most reports highlighting decreasing operative morbidity and mortality rates following hepatic resection have focused on the management of metastatic disease. Information on the full range of hepatic disease is lacking. METHODS: The indications for hepatic resection in a specialist hepatobiliary unit have been reviewed and the operative morbidity and mortality rates assessed. RESULTS: Among 129 patients undergoing 133 hepatic resections between October 1988 and September 1996, the principal indication for resection was hepatic malignancy (102 resections), metastatic in 66 cases. Other indications included contiguous tumour (n = 20), primary tumour (n = 16) and benign disease (n = 31). Some 116 procedures were classical anatomical resections. Blood transfusion was required in 40 per cent of cases but major morbidity occurred in 20 per cent. There were six deaths following surgery, five of which were due to hepatic failure and followed resection for malignancy or trauma. The 3-year survival rate in patients resected for colorectal metastases was 65 per cent. CONCLUSION: This experience has demonstrated an increasing role for hepatic resection in a wide variety of hepatobiliary pathologies. Despite the low postoperative mortality rate, the significant risk of complications in the postoperative period serves to emphasize the need for careful selection of patients for such surgery, which should be undertaken in specialist centres.

Prediction of resectability of pancreatic malignancy by computed tomography.

Year 1998
McCarthy MJ. Evans J. Sagar G. Neoptolemos JP.
Department of Academic Surgery, City Hospital NHS Trust, Birmingham, UK.
BACKGROUND: The accuracy of computed tomography (CT) in predicting resectability of pancreatic malignancy has been questioned recently and alternative methods have been recommended. METHODS: To determine the accuracy of CT for predicting resectability and its influence on survival, a standard protocol for performing CT and reporting the results was developed and then compared retrospectively with the ability of one surgeon to perform a resection during 1989-1994. Postoperative survival was determined. RESULTS: Of 88 consecutive patients 35 (40 per cent) had CT-resectable disease and 53 (60 per cent) had CT-irresectable disease. Twenty-one patients were excluded because of advanced disease or poor performance status. Of the remaining 67 patients, 47 (70 per cent) had pancreatic ductal adenocarcinoma and 20 (30 per cent) had ampullary adenocarcinoma, of whom 32 had a resection, 32 had a palliative bypass and three had only a staging laparoscopy. The sensitivity and specificity for computed tomographic prediction of resectability were 72 and 80 per cent respectively. The positive predictive value was 77 per cent and the negative predictive value 76 per cent. There were seven false-positive and nine false-negative findings. Survival was more dependent on whether or not resection was performed than on computed tomographic predictability of resection. CONCLUSION: CT was reasonably accurate in predicting resectability but cannot be relied on entirely, requiring an improvement in staging methods for pancreatic malignancy.

Bile duct obstruction due to portal biliopathy in extrahepatic portal hypertension: surgical management.

Year 1998
Chaudhary A. Dhar P. Sarin SK. Sachdev A. Agarwal AK. Vij JC. Broor SL.
Department of Gastrointestinal Surgery, Govind Ballabh Pant Hospital, New Delhi, India.
BACKGROUND: Varices can develop in and around the bile duct in the presence of portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis. The term 'portal biliopathy' is used to describe changes in the bile duct due to these varices, which may cause bile duct obstruction. This paper reviews experience of the surgical management of patients with symptomatic portal biliopathy. METHODS: Nine patients with extrahepatic portal vein obstruction with symptomatic portal biliopathy. were reviewed retrospectively. RESULTS: Eight patients presented with jaundice, two had abdominal pain and one had recurrent cholangitis. Endoscopic retrograde cholangiography revealed abnormality of the bile duct wall, with stricture in eight patients and bile duct calculi in two. Portasystemic shunting relieved jaundice in five of seven patients, and in two a second-stage hepaticojejunostomy was required. Conclusion: Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary.

Laparoscopic drainage of liver abscesses.

Year 1998
Tay KH. Ravintharan T. Hoe MN. See AC. Chng HC.
Department of Surgery, New Changi Hospital, Singapore.
BACKGROUND: The mainstay of the management of liver abscesses has been intravenous antibiotics and radiologically guided percutaneous drainage. However, not all abscesses are treated successfully in this way, and some require surgical drainage. Laparoscopic drainage of liver abscesses may be an alternative to open surgical drainage. METHODS: Twenty consecutive patients with liver abscesses treated by laparoscopic drainage in combination with intravenous antibiotics were studied prospectively. Fifteen had had failed percutaneous drainage previously. RESULTS: There were 13 right lobe and seven left lobe abscesses ranging from 6 to 25 cm in diameter. Mean operating time was 38 min. Seventeen patients were drained successfully. Three patients developed recurrent symptoms of which two resolved with conservative measures, but one required a second laparoscopic procedure. There were no intraoperative or other postoperative complications in the 20 patients. Follow-up ranged from 5 to 12 months. CONCLUSIONS: Laparoscopic drainage of liver abscesses, in combination with systemic antibiotics, is a safe and viable alternative in all patients who require surgical drainage following failed medical or percutaneous treatment, and in those with large abscesses.

Effect of endoscopic sphincterotomy and interval cholecystectomy on late outcome after gallstone pancreatitis.

Year 1998
Hammarstrom LE. Stridbeck H. Ihse I.
Department of Surgery, University of Lund, Sweden.
BACKGROUND: Endoscopic sphincterotomy alone, or followed by cholecystectomy, are options in patients with gallstone pancreatitis. METHODS: Ninety-six patients of median age 74 (range 30-93) years with gallstone pancreatitis had endoscopic retrograde cholangiography and were followed for a median of 84 (range 33-168) months. Forty-eight of 49 patients with, and nine of 47 without, common bile duct (CBD) stones had urgent endoscopic sphincterotomy. One patient with, and six without, CBD stones had delayed endoscopic sphincterotomy a median of 35 (range 12-111) days after acute pancreatitis. Thus, 64 patients had endoscopic sphincterotomy (group 1) and 32 did not (group 2). Fifteen and 16 patients in each group respectively had interval cholecystectomy after a median of 3 months and 1 month. RESULTS: Patients in groups 1 and 2 had similar rates of interval cholecystectomy (15 of 64 versus 16 of 32 patients respectively) or required cholecystectomy (15 of 49 versus five of 16 patients), recurrent CBD calculi (three of 64 versus three of 32 patients) or total length of hospitalization after interval cholecystectomy (median 15.5 and 15 days) or required (median 22 and 24 days) cholecystectomy. The overall incidence of recurrent pancreatitis was one of 64 patients in group 1 and five of 32 in group 2 (P = 0.02), but after interval cholecystectomy the recurrence rate of biliopancreatic symptoms was similar (one of 15 patients versus three of 16 patients respectively). CONCLUSION: Endoscopic sphincterotomy, but not interval cholecystectomy, reduced the overall incidence of recurrent pancreatitis, but not of late biliary complications. Some 31 per cent of the patients required cholecystectomy, suggesting that routine cholecystectomy should be considered in fit patients following acute pancreatitis.

Genetic alterations in chronic pancreatitis: evidence for early occurrence of p53 but not K-ras mutations.

Year 1998
Gansauge S. Schmid RM. Muller J. Adler G. Mattfeldt T. Beger HG.
Department of General Surgery, University of Ulm, Germany.
BACKGROUND: In patients suffering from chronic pancreatitis the risk for the development of pancreatic cancer ranges from 4 to 6 per cent. Various mutations are associated with pancreatic cancer, especially of p53 and K-ras. The incidence of these mutations in resected chronic pancreatitic tissue was investigated. METHODS: In the present study DNA from 80 samples of tissue from patients with chronic pancreatitis was isolated and subjected to single-strand conformation polymorphism (SSCP) analysis of p53 exons 5-9 and restriction fragment length polymorphism analysis of K-ras (codon 12). RESULTS: No mutations in the K-ras gene were detected. On SSCP analysis, eight of 80 cases of chronic pancreatitis showed alterations (two in exon 5, four in exon 6, two in exon 7). DNA sequence analysis revealed one deletion of 21 amino acids (exon 5), four polymorphisms in exon 6 with no change in the amino acid sequence, one point mutation in exon 5, and two point mutations located in the intron between exons 6 and 7. CONCLUSION: These data show that in some cases of chronic pancreatitis mutations in the p53 gene occur without morphological evidence of pancreatic cancer.

Structured data collection improves the diagnosis of acute appendicitis.

Year 1998
Korner H. Sondenaa K. Soreide JA. Andersen E. Nysted A. Lende TH.
Department of Surgery, Rogaland Central Hospital, Stavanger, Norway.
BACKGROUND: Structured preoperative data collection and computer-assisted methods are claimed to improve diagnostic accuracy in patients with acute abdominal pain. The aim of this study was to evaluate a possible age- and sex-related effect of using structured data collection in the preoperative diagnosis of patients with suspected acute appendicitis. METHODS: Between 1989 and 1994, clinical and demographic data from 1764 consecutive patients were recorded. In 1990 and 1992, various detailed symptom, clinical and laboratory data were collected prospectively on a structured registration form. Age- and sex-specific diagnostic accuracy as well as perforation rate were calculated for each year. RESULTS: Diagnostic accuracy increased significantly by 5 (95 per cent confidence interval (c.i.) 1-9) per cent when structured data registration was applied. In female patients aged between 13 and 40 years, diagnostic accuracy increased by 16 (95 per cent c.i. 8-24) per cent. Significant changes in diagnostic accuracy were not seen in other subgroups. Perforation rates remained unchanged during the entire study period. CONCLUSION: In this population-based study, diagnostic accuracy in patients operated on for suspected acute appendicitis increased for all patients when structured preoperative data collection was used. However, the only subgroup with a significant increase in diagnostic accuracy was female patients aged between 13 and 40 years. Perforation rate was unaffected by structured data collection.

Risk factors for anastomotic leakage after resection of rectal cancer.

Year 1998
Rullier E. Laurent C. Garrelon JL. Michel P. Saric J. Parneix M.
Department of Digestive Surgery, University of Bordeaux, France.
BACKGROUND: The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage, which is associated with a 6-22 per cent mortality rate. The aim of this retrospective study was to evaluate the risk factors for clinical anastomotic leakage after anterior resection for cancer of the rectum. METHODS: From 1980 to 1995, 272 consecutive anterior resections for rectal cancer were performed by the same surgical team; 131 anastomoses were situated 5 cm or less from the anal verge. The associations between clinical anastomotic leakage and 19 patient-, tumour-, surgical-, and treatment-related variables were studied by univariate and multivariate analysis. RESULTS: The rate of clinical anastomotic leakage was 12 per cent (32 of 272). Multivariate analysis of the overall population showed that only male sex and level of anastomosis were independent factors for development of anastomotic leakage. The risk of leakage was 6.5 times higher for anastomoses situated less than 5 cm from the anal verge than for those situated above 5 cm; it was 2.7 times higher for men than for women. In a second analysis of low anastomoses (5 cm or less from the anal verge; n = 131), obesity was statistically associated with leakage. CONCLUSION: A protective stoma is suitable after sphincter-saving resection for rectal cancer for anastomoses situated at or less than 5 cm from the anal verge, particularly for men and obese patients.

Vaginal endosonography of the anal sphincter complex is important in the assessment of faecal incontinence and perianal sepsis.

Year 1998
Poen AC. Felt-Bersma RJ. Cuesta MA. Meuwissen GM.
Department of Surgery, University Hospital 'Vrije Universiteit', Amsterdam, the Netherlands.
BACKGROUND: Anal endosonography is an established technique in the evaluation of anorectal disease. However, it is sometimes difficult to visualize the anterior part of the sphincter complex and anal endosonography may be impossible when anal pain or stenosis is present. The aim of this study was to evaluate vaginal endosonography in the diagnosis of faecal incontinence and perianal sepsis. METHODS: Anal and vaginal endosonography were performed in 56 women with faecal incontinence (n = 36) or perianal sepsis (n = 20). The technique and pelvic floor anatomy were described, anal sphincter measurements with anal and vaginal endosonography were compared, and the additive value of vaginal over anal endosonography in the diagnosis of faecal incontinence and perianal sepsis was assessed. RESULTS: The pelvic floor was clearly imaged with vaginal endosonography. However, after a relatively short learning curve it was still not possible to image the anal sphincters in three of 28 patients. Except for external anal sphincter thickness, which was significantly lower, all anal canal structure measurements were greater with vaginal than with anal endosonography. Concerning the diagnosis of either faecal incontinence or perianal sepsis, vaginal endosonography added important information in comparison with anal endosonography in 14 (25 per cent) of 56 patients. CONCLUSION: Vaginal endosonography provides reliable images of the anal sphincters in an undistorted fashion, thereby increasing the diagnostic yield of faecal incontinence and perianal sepsis in 25 per cent of patients. Therefore, endosonographists should become acquainted with this technique.

Management of symptomatic locoregional recurrence during regional chemotherapy for colorectal liver metastases.

Year 1998
Davies MM. Fordy C. Burke D. Allen-Mersh TG.
Department of Gastrointestinal Surgery, Imperial College School of Medicine, Chelsea, UK.
BACKGROUND: The incidence of symptomatic locoregional recurrence is doubled in patients receiving regional chemotherapy with hepatic arterial floxuridine infusion (HAI) compared with that in those with colorectal liver metastases treated by symptom control. This study assessed the management of symptomatic locoregional recurrence in HAI-treated patients with colorectal liver metastases. METHODS: A retrospective review of all patients with colorectal liver metastases treated by HAI in one hospital over a 10-year period was carried out and the management of those who developed symptomatic locoregional recurrence was studied. RESULTS: Twenty-three (14 per cent) of 166 HAI-treated patients with colorectal liver metastases developed symptoms of locoregional recurrence. Liver metastases were responding to HAI at the onset of symptoms in 19 (ten abdominal, nine pelvic recurrence) of the 23 patients. Resection of abdominal recurrence was possible in seven of the ten patients, with a median hospital stay of 14 days; there was one perioperative death. Resected patients survived a median of 15 months after resection of the recurrence, with five of seven remaining free of symptoms of locoregional recurrence. In contrast, six of nine HAI-responding patients with pelvic recurrence treated by external beam radiotherapy died from uncontrolled symptomatic pelvic disease. CONCLUSION: Resection of abdominal recurrence achieved worthwhile palliation in patients with HAI-controlled liver metastases, but palliation of pelvic recurrence by irradiation was unsatisfactory.

Intra-abdominal and pelvic abscess in Crohns disease: results of noninvasive and surgical management.

Year 1998
Jawhari A. Kamm MA. Ong C. Forbes A. Bartram CI. Hawley PR.
Department of Surgery, St. Mark's Hospital, Northwick Park, Harrow, UK.
BACKGROUND: Intra-abdominal and pelvic abscesses occur in 10-30 per cent of patients with Crohn's disease. The aim of this study was to establish the clinical characteristics and outcome of patients admitted over a 4-year period with an abdominal or pelvic abscess secondary to Crohn's disease. METHODS: Patients with Crohn's disease-related intra-abdominal or pelvic abscess were identified from a prospectively collected database, comprising all admissions between 1991 and 1994. Medical records were reviewed retrospectively and data gathered regarding management and outcome. RESULTS: Thirty-six patients were identified with Crohn's disease-related abscess, of whom 15 were considered for initial percutaneous drainage. Drainage was technically possible in eight of these patients: it failed in four, gave good long-term results in two, and was followed by recurrence after 3 years in one and by later surgery unrelated to the abscess in one. Twenty-eight patients underwent surgery, with only four requiring a stoma. Complications occurred in 12 patients. At 3 months, 22 of the 36 patients were in remission. CONCLUSION: Crohn's intra-abdominal abscesses are associated with a high morbidity rate. Selected cases can be drained percutaneously, without adding to the morbidity, and sometimes resulting in abscess resolution.

Surgical resection of locally recurrent colorectal adenocarcinoma.

Year 1998
Delpero JR. Pol B. Le Treut P. Bardou VJ. Moutardier V. Hardwigsen J. Granger F. Houvenaeghel G.
Institute J. Paoli-I. Calmettes, France.
BACKGROUND: Recurrence rates after curative resection of colorectal adenocarcinoma remain steady at 50 per cent. Thirty per cent of the deaths are linked to locoregional recurrence. The aim of this study was to evaluate the results of resection for locoregional recurrence. METHODS: This retrospective review analyzed a series of 120 patients who underwent resection of colonic (56) or rectal (64) locoregional recurrence. Sixty-nine resections were considered as curative. Sixty-one recurrences required extended resection. There were nine synchronous hepatic resections. RESULTS: The hospital mortality rate was 7 per cent and the morbidity rate was 40 per cent. The overall 5-year survival rate was 27 per cent. Survival was significantly higher: (1) after curative resection (44 versus 0 per cent after palliative resection, P < 0.0001); (2) in women (44 versus 11 per cent for men, P = 0.0036); and (3) after resection for intramural recurrence (45 versus 19 per cent for extramural recurrence, P = 0.0024). Multifactorial analysis showed that curability of the resection was the most important prognostic parameter. CONCLUSION: The results in this highly selected group seem to justify an attempt at reresection whenever possible. Long-term results may be improved by using adjuvant treatment.

Abdominal lymphangioma in adults and children.

Year 1998
de Perrot M. Rostan O. Morel P. Le Coultre C.
Department of Surgery, University Hospital of Geneva, Switzerland.
BACKGROUND: Abdominal lymphangioma is a rare tumour usually classified with mesenteric and retroperitoneal cysts. This experience of abdominal lymphangiomas contrasts the differences between tumours in children and adults. METHODS: Between 1970 and 1996, six patients had surgical resection of an abdominal lymphangioma. RESULTS: There were three children aged 4 years or less and three adults aged 36-76 years. Two children presented with an acute abdomen and one with a rapidly enlarging abdominal girth. Lymphangiomas were located in the mesentery and gastrointestinal tract. In adults, symptoms lasted from months to years and lymphangiomas were found in the pancreas, spleen and retroperitoneum. CONCLUSION: In this series, abdominal lymphangioma presented more acutely in children and usually involved the mesentery, whereas in adults the history was longer and the tumour was found in the retroperitoneum.

Reconstruction after total gastrectomy by the interposition of a double jejunal pouch using a double stapling technique.

Year 1998
Ikeda M. Ueda T. Shiba T.
Second Department of Surgery, Toho University School of Medicine, Tokyo, Japan.
BACKGROUND: After total gastrectomy, sustaining good nutrition is extremely important for maintaining quality of life. A technique of neogastric pouch formation based on current physiological reconstructive principles is presented. METHODS: The use of a modified interpositioned double jejunal pouch following total gastrectomy in 18 patients with cancer was reviewed. This technique results in a complete pouch and uses a double stapling technique with site-specific anastomosis between the oesophagus and pouch, in which a Hisoid angle is created. RESULTS: There were no anastomotic leaks and pouch blood flow was within normal expected limits. Mean oesophageal pH above 7.0 for one 24-h period was 7.7 per cent. Emptying half-time was 67.8 min. After 2 years mean body-weight was 98.3 per cent of expected, mean food volume was 94.0 per cent of expected and mean meal frequency was 3.0 per day. CONCLUSION: This form of gastric reconstruction is an acceptable procedure which improves the quality of life in patients undergoing total gastrectomy.

Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome.

Year 1998
Bartels HE. Stein HJ. Siewert JR.
Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technischen Universitat Munchen, Germany.
BACKGROUND: Lesions of the trachea or main-stem bronchi with air leakage are a grave complication of oesophagectomy. METHODS: Prevalence, predisposing factors and outcome of non-malignant lesions of the trachea or main-stem bronchi were analysed retrospectively in a consecutive series of 785 patients who had oesophagectomy for oesophageal cancer. RESULTS: Overall 31 of 785 patients developed a tracheobronchial fistula 1-30 days after oesophagectomy. Based on the location of the lesions and clinical circumstances, the tracheobronchial fistulas were thought to be due to surgical injury (four patients), cuff pressure of the tracheostomy tube (two), local peritracheal infection resulting from a cervical anastomotic leak (seven) or 'ischaemia' after extensive peritracheal dissection (18). On multivariate analysis, transthoracic en bloc resection (P < 0.01) and preoperative radiochemotherapy for locally advanced tumours located at or above the level of the tracheal bifurcation (P < 0.01) predisposed to this complication. CONCLUSION: Non-malignant tracheobronchial lesions are a serious complication of transthoracic oesophagectomy with extensive lymph node dissection, particularly in patients undergoing preoperative radiochemotherapy for locally advanced tumours.

Screening for gastric cancer by Helicobacter pylori serology: a retrospective study.

Year 1998
Whiting JL. Hallissey MT. Fielding JW. Dunn J.
Department of Surgery, University of Birmingham, UK.
BACKGROUND: Screening by serology for Helicobacter pylori in young dyspeptic patients has been shown to be effective in reducing demand for endoscopy. H. pylori has been implicated in the causation of gastric cancer and the reported seropositivity rate in patients with gastric cancer ranges from 69 to 94 per cent. The aim of this study was to assess the potential value of Helicobacter antibodies as a method of selecting dyspeptic patients over the age of 45 years for endoscopy. METHODS: A retrospective comparison of the antibody status to H. pylori was made between 154 patients with gastric cancer and a sex- and date of birth-matched dyspeptic control group. Results from the former group were correlated with demographic data and tumour characteristics. RESULTS: Significantly more patients with gastric cancer were seropositive than controls (77 versus 66 per cent). H. pylori was not related to the Lauren classification of the tumour. Tumour site was significant: body and antrum tumours were associated with Helicobacter whereas cardial tumours appeared to be unrelated. CONCLUSION: Screening by antibody assays to H. pylori would miss more than 30 per cent of current gastric cancers. The increasing incidence of cardial cancer would cause this percentage to rise in the future.

Early colorectal cancer: recognition, classification and treatment.

Year 1998
Mainprize KS. Mortensen NJ. Warren BF.
Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK.
BACKGROUND: With the introduction of colorectal cancer screening and improvements in endoscopic technology, the recognition and management of early colorectal cancer assumes increasing importance. METHODS: A literature review was undertaken using Medline (National Library of Medicine, Washington DC, USA) searches of the headings early colonic, colorectal and rectal cancer, carcinoma and adenocarcinoma up to and including 1997. All relevant references were examined. RESULTS AND CONCLUSION: The diagnosis, classification and treatment options are described. Accurate diagnosis, preoperative and histopathological staging is crucial in the management of early colorectal cancer.

Total vascular exclusion of the liver for the resection of lesions in contact with the vena cava or the hepatic veins.

Year 1998
Berney T. Mentha G. Morel P.
Clinic of Digestive Surgery, Geneva University Hospital, Switzerland.
BACKGROUND: This study reviews experience with total vascular exclusion of the liver (TVE), for the resection of tumours in contact with the hepatic veins or the vena cava. METHODS: A retrospective study was carried out of 366 hepatic resections performed over 13 years. Forty-one patients (11 per cent) were operated under TVE. RESULTS: Twenty-four patients were operated for malignancy and 17 for benign disease. Major hepatectomy was performed in 26 patients and minor hepatectomy in 15. The technique allowed vascular repair in eight patients. Median intraoperative blood transfusion was 2 (range 0-26) units; 14 patients required none. Median duration of TVE was 29 (range 5-58) min. No deaths occurred. Significant complications occurred in ten patients. Morbidity was related to the malignant nature of the lesion, duration of surgery and volume of blood transfusion, but not to duration of TVE. CONCLUSION: TVE facilitates resection of critically located hepatic lesions with safety and minimal blood loss. Within the limits of 1 h, prolonged TVE does not increase morbidity.

Prospective randomized trial of systemic antibiotics in patients undergoing liver resection.

Year 1998
Wu CC. Yeh DC. Lin MC. Liu TJ. P'eng FK.
Department of Surgery, Taichung Veterans General Hospital, Taiwan.
BACKGROUND: Systemic antibiotics are administered frequently after hepatectomy to prevent infective complications, but their effectiveness is uncertain. METHODS: A total of 127 patients with liver tumours were prospectively randomized into two groups after hepatectomy: in group 1 (62 patients) no antibiotics were given until the appearance of infective complications; in group 2 (65 patients) intravenous cephazolin 1 g every 6 h and gentamicin 80 mg every 8 h were given for 7 days. On the day before surgery all patients received bowel preparation by clear liquid diet and oral antibiotics (neomycin 1 g and erythromycin 1 g, given together in three doses). RESULTS: The infective complication rate was 23 per cent in both groups (P = 0.95). The hospital costs were higher in group 2 (P < 0.001). Of the group 1 patients, 51 (82 per cent) did not require antibiotic treatment. No patient in either group died after hepatectomy. CONCLUSION: Postoperative systemic antibiotics cannot prevent infective complications, and their routine use after hepatectomy is unnecessary and costly. The use of antibiotics should be delayed until infective complications and persistent septic symptoms occur.

Encouraging results of split-liver transplantation.

Year 1998
Mirza DF. Achilleos O. Pirenne J. Buckels JA. McMaster P. Mayer AD.
Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
BACKGROUND: Liver donor shortage presently accounts for a 10 per cent waiting list mortality rate. Split-liver transplantation (SLT) can improve utilization of this scarce resource. METHODS: Twenty-four SLTs (11 left, 13 right grafts) from 13 livers were performed in 23 patients (nine adults, 14 children), comprising 4.5 per cent of all orthotopic liver transplants (14 urgent or emergency, ten elective). The left graft comprised segments II and III, whereas the right graft comprised segments V-VIII in eight cases, IV-VIII in three, and segments I, IV-VIII, and I, V-VIII in one case each. Additional arterial extension grafts were required in six of 24 cases, and portal venous interposition graft in one. RESULTS: Twenty-one grafts showed good initial function, with one primary non-function and two initial poor function. The median peak aspartate aminotransferase level was 782 (range 94-2301) and 982 (range 382-2520) units/l for left and right grafts respectively. Five patients died (all urgent recipients), all within the first 30 days after surgery. Two SLT recipients underwent subsequent retransplantation. All ten elective recipients are alive. The 1-year actuarial patient and graft survival rates at a median follow-up of 20 months were 78 and 68 per cent respectively. CONCLUSION: These encouraging results compare favourably with those of reduced-size and whole-liver transplantation and justify wider application of this technique, thereby optimizing donor resource use.

Carcinoma of the head of the pancreas arising from the uncinate process.

Year 1998
Birk D. Schoenberg MH. Gansauge F. Formentini A. Fortnagel G. Beger HG.
Department of General Surgery, University of Ulm, Germany.
BACKGROUND: Carcinoma located in the uncinate process (CUP) of the pancreatic head is considered to be rare. Exact epidemiological data, however, are not available because the series published so far consist of fewer than ten patients. The purpose of this prospective study was to evaluate the clinical appearance of CUP and to compare findings with those of patients with carcinoma in the ventral aspect of the pancreatic head (VPC), which represents the most frequent localization. RESULTS: Some 39 (8 per cent) of 506 evaluated patients suffered from CUP. Mean age was 63.3 years. The most frequent complaints were upper abdominal pain (n = 32) and weight loss (n = 35). Jaundice was seen in only five patients and was never an early symptom. The level of CA19-9 was raised in 33 patients. The best diagnostic procedure to detect CUP was computed tomography (CT) (sensitivity 93 per cent), whereas endoscopic retrograde cholangiopancreatography was not useful (sensitivity 21 per cent). Vascular involvement was significantly (P < 0.01) more common in CUP (n = 19) than in VPC (48 versus 19 per cent). This finding and the fact that most patients with CUP were diagnosed at a late stage with distant metastasis or severe vascular involvement present (n = 21) are responsible for the significantly lower rate of operation (n = 25) (64 versus 92 per cent, P < 0.05) and the significantly shorter median survival time (5 versus 11 months, P < 0.05). CONCLUSION: Patients with CUP have a poor prognosis as a result of the lack of early symptoms (jaundice) and early vascular involvement due to the proximity of the uncinate process to the mesenteric root. A raised level of CA19-9, together with weight loss and/or upper abdominal pain, should prompt CT.

Raised endothelin 1 levels in patients with colorectal liver metastases.

Year 1998
Shankar A. Loizidou M. Aliev G. Fredericks S. Holt D. Boulos PB. Burnstock G. Taylor I.
Department of Surgery, University College Medical School, London, UK.
BACKGROUND: Endothelin 1 (ET-1), a vasoconstrictor peptide, has been implicated as a tumour growth stimulator and an angiogenesis factor. METHODS: To assess the involvement of ET-1 in colorectal cancer, immunoelectron microscopy for ET-1 was performed in colorectal liver metastases and normal liver (n = 6). ET-1 plasma levels were measured by radioimmunoassay in patients with colorectal cancer, with (n = 18) and without (n = 12) liver metastases, and in controls (n = 22). RESULTS: In normal liver, ET-1 was present in endothelial cells; in tumour, it was observed in endothelial cells, tumour cells and myofibroblasts. Mean(s.d.) plasma ET-1 levels were 2.75 (1.37) pg/ml in controls, 4.53(1.61) pg/ml in patients with colorectal liver metastases (P = 0.001) and 3.92(1.32) pg/ml in patients without metastases (P = 0.02). CONCLUSION: ET-1 was present in various cell types within colorectal liver metastases and raised levels were found in the plasma of patients with colorectal cancer. ET-1 may not only modulate tumour vascular tone but also act on tumour growth and angiogenesis, both locally and systemically.

Ruptured hepatocellular carcinoma as a complication of transarterial oily chemoembolization.

Year 1998
Liu CL. Ngan H. Lo CM. Fan ST.
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
BACKGROUND: Transarterial oily chemoembolization (TOCE) is frequently employed as a non-operative treatment for hepatocellular carcinoma (HCC). Serious complications of TOCE are well known but ruptured HCC as a fatal complication of TOCE has not been reported previously. METHODS: A retrospective study was performed on all patients who received TOCE for treatment of HCC from January 1989 to October 1996; the complication of ruptured HCC within 2 weeks from the procedure was recorded. RESULTS: During the study period, 391 patients received a total of 1443 sessions of TOCE (mean 3.7 sessions per patient) for the treatment of HCC, with an overall median survival of 10.4 months. Six patients developed ruptured tumour within 2 weeks after TOCE, resulting in an overall incidence of 1.5 per cent per patient or 0.4 per cent per procedure. All except one patient died 1-25 days after tumour rupture. Factors common to these six patients included: (1) male sex; (2) large tumour size (range 8-17 cm in diameter); (3) tumour located in the right lobe of the liver; (4) tumour ruptured after the first session of TOCE; and (5) TOCE performed as primary treatment without previous hepatic resection. CONCLUSION: Ruptured HCC is a serious complication of TOCE although the incidence is low. It occurred predominantly in men after the first session of TOCE for a large irresectable tumour of the right lobe.

Improved survival in patients with rectal cancer: a population-based register study.

Year 1998
Dahlberg M. Pahlman L. Bergstrom R. Glimelius B.
Department of Surgery, Akademiska sjukhuset, University of Uppsala, Sweden.
BACKGROUND: Between 1985 and 1989, only one centre in Sweden combined preoperative radiotherapy with total mesorectal excision (TME) in the primary treatment of rectal cancer. The aim of this study was to investigate whether this change in primary treatment had an impact on the outcome. METHOD: The survival rate of 94,262 patients with colorectal cancer from the total Swedish population between 1960 and 1989 was analysed. RESULTS: A continuous improvement in relative survival rate occurred during the first year of follow-up for both colonic and rectal cancer. Some improvement was also seen during follow-up years 2-5, but this was much more pronounced during the last period (1985-1989) for rectal cancer in the county of Uppsala. The improvement was particularly marked during follow-up years 3-5. CONCLUSION: There are strong indications from this study that altered primary treatment for rectal cancer results in improved long-term survival.

Significance of local recurrence of rectal cancer as a local or disseminated disease.

Year 1998
Maetani S. Onodera H. Nishikawa T. Morimoto H. Ida K. Kitamura O. Imamura M.
Research Centre for Biomedical Engineering and Department of Surgery, Faculty of Medicine, Kyoto University, Japan.
BACKGROUND: The nature of 'local recurrence' of rectal cancer remains unclear. METHODS: Fifty-nine patients with locally recurrent rectal cancer who underwent extended repeat resections including total pelvic exenteration (39) and sacrectomy (43) were reviewed. Twelve patients had distant metastases before or at the time of repeat resection. RESULTS: The 5-year survival rate was 25 per cent. A second recurrence occurred in 45 patients including five of the eight 5-year survivors. Thirty-six of these recurrences had locoregional manifestations and 29 had distant metastases. Of 18 prognostic factors examined, the most significant determinant was the postoperative carcinoembryonic antigen doubling time (CEADT), followed by the preoperative CEADT, carcinoembryonic antigen (CEA) level and occurrence of distant metastases, in decreasing order. Late onset of first recurrence was also a favourable indicator. Thus, the growth rate of the tumour had a more profound impact on survival than the current extent of tumour progression. After operation the CEADT was reduced in patients with second recurrence (P = 0.05). CONCLUSION: Locally recurrent rectal cancer is a manifestation of disseminated disease spreading locoregionally and often to distant organs with a low probability of long-term cure. However, survival varies widely depending on the tumour growth rate, which is biologically predetermined and is also influenced by surgery.

Effect of the introduction of total mesorectal excision for the treatment of rectal cancer.

Year 1998
Carlsen E. Schlichting E. Guldvog I. Johnson E. Heald RJ.
Surgical Department, Ullevaal Hospital, University of Oslo, Norway.
BACKGROUND: Total mesorectal excision (TME) has been reported to reduce local recurrence and improve survival rates in patients with rectal carcinoma. This paper reports the problems that have arisen with the introduction of this new surgical technique. METHODS: This was a prospective study of two consecutive groups of patients: one who underwent TME (n = 76) and one who did not (non-TME, n = 76). RESULTS: Postoperative mortality rate in the non-TME and TME group was 5 and 7 per cent respectively, and the rate of anastomotic failure was 8 and 16 per cent respectively. Anastomotic leaks in TME patients were located in the mid and lower rectum. TME patients with anastomotic failure had lower anastomoses and a longer duration of operation than non-TME patients. Intraoperative problems were encountered in 71 per cent of the failures. All TME patients who had a leak required reoperation compared with 25 per cent of non-TME patients. TME patients without postoperative complications stayed significantly longer in hospital than non-TME patients. CONCLUSION: Anastomotic dehiscence increased after introduction of the TME technique but this improved with experience.

Abdominal ultrasonography in the diagnosis of colonic cancer.

Year 1998
Richardson NG. Heriot AG. Kumar D. Joseph AE.
Department of Colorectal Surgery, St George's Hospital, London, UK.
BACKGROUND: Colonic cancer is normally diagnosed by barium enema or colonoscopy. Neither investigation is ideal, especially in the elderly patient. This study investigates the potential role of abdominal ultrasonography in the diagnosis of colorectal carcinoma. METHODS: Fifty-four patients with known or suspected colonic carcinoma were referred for abdominal ultrasonography. A single radiologist performed scans on these patients and the site of any colonic mass or wall thickening considered to be consistent with a colonic carcinoma was reported. All carcinomas were confirmed by histology on tissue obtained at colonoscopy or surgery against which the ultrasonographic diagnosis was compared. Colonic masses detected in patients undergoing routine abdominal ultrasonography for abdominal symptoms were also reported. RESULTS: Forty-five of the 54 patients referred had colonic carcinoma and abdominal ultrasonography detected 43 of the tumours and correctly identified the site of 41. The sensitivity, specificity and accuracy of abdominal ultrasonography in the detection of colonic tumours considered to be consistent with a colonic carcinoma was 96, 67 and 91 per cent respectively. Seven tumours were identified in patients referred before any other investigation had been carried out. CONCLUSION: Abdominal ultrasonography may detect a colonic mass or wall thickening consistent with a colonic carcinoma with a high degree of accuracy and may be useful when barium enema or colonoscopy is not possible.

Influence of blood components and faeces on the in vitro cancericidal activity of povidone-iodine.

Year 1998
Basha G. Penninckx F. Yap P.
Department of Abdominal Surgery, University Clinic Gasthuisberg, Catholic University of Leuven, Belgium.
BACKGROUND: Tumoricidal agents have been used to kill viable exfoliated tumour cells following colorectal cancer surgery. Recent in vivo experiments have thrown some doubt on the tumoricidal activity of povidone-iodine. METHODS: The cytotoxic effect of distilled water and of povidone-iodine at 0.04, 0.4, 0.8, 2 and 4 per cent final concentrations on human SW620 colonic cancer cells in the presence of red blood cells, purified haemoglobin and red blood cell (RBC) membranes, plasma, albumin, faeces and bacteria was investigated. Cell viability was assessed using the trypan blue assay and MTT test. RESULTS: The presence of albumin and plasma decreased the tumoricidal activity of povidone-iodine except for the highest concentration tested. Bacterial suspension did not influence the efficacy of povidone-iodine. Faecal material was found to have an intrinsic tumoricidal effect. Both intact and lysed RBCs very strongly inhibited the tumoricidal activity of all povidone-iodine concentrations tested. This inhibitory effect was due to haemoglobin, but not to RBC membranes. CONCLUSIONS: Low concentrations of povidone-iodine fail to kill all 'exfoliated' cancer cells in the presence of proteins, intact or lysed RBCs. Therefore, washing out of these organic materials before application of a relatively high povidone-iodine concentration (e.g. 5 per cent or greater) may be more useful in killing viable exfoliated tumour cells during surgery for colorectal cancer.

Long-term beneficial effects of a gastric reservoir on weight control after total gastrectomy: a study of potential mechanisms.

Year 1998
Liedman B. Bosaeus I. Hugosson I. Lundell L.
Department of Surgery, Sahlgren's University Hospital, Gothenburg, Sweden.
BACKGROUND: Weight loss after total gastrectomy is a regular occurrence. Reconstruction with a gastric substitute has been suggested to facilitate recovery, but few randomized studies are available. METHODS: In a randomized study comparing subtotal, total and total gastrectomy with an S-shaped pouch, 36 patients who had total gastrectomy with or without a pouch survived for more than 3 (mean 5.2) years. Body composition (four-chamber model, dual-energy X-ray absorptiometry, anthropometric data) was evaluated before operation, after 12 months and at long-term follow-up. Food intake was registered as a 4-day food record at 12 months and at long-term follow-up. RESULTS: At long-term follow-up those allocated to the gastric substitute arm had lesser degrees of weight loss consisting mainly of the depletion of body fat stores, whereas lean body mass showed no significant decrease when adjusted for the process of ageing. There was no significant difference in food intake. CONCLUSION: Reconstruction with an S-shaped gastric substitute facilitates long-term recovery after total gastrectomy and should be considered when the prognosis is favourable.

Relation between tumour necrosis factor alpha and interleukin 1beta producing capacity of peripheral monocytes and pulmonary complications following oesophagectomy.

Year 1998
Katsuta T. Saito T. Shigemitsu Y. Kinoshita T. Shiraishi N. Kitano S.
Department of Surgery I, Oita Medical University, Japan.
BACKGROUND: Adult respiratory distress syndrome and pneumonia remain a significant cause of morbidity and death following oesophagectomy. The aim of this study was to clarify the association between tumour necrosis factor (TNF) alpha and interleukin (IL) 1beta with these pulmonary complications. METHODS: The in vitro TNF-alpha and IL-1beta producing capacity of peripheral monocytes with or without lipopolysaccaride (LPS) and serum level of IL-6 was measured in 19 patients with oesophageal cancer before and after surgery and in ten age-matched controls. RESULTS: Six patients had raised TNF-alpha and IL-1beta producing capacity of monocytes without LPS both before operation and on the day after surgery. In these patients plasma elastase and serum IL-6 levels subsequently increased while the ratio of arterial partial pressure of oxygen to fraction inspired oxygen decreased, and they developed bilateral lung infiltration on chest radiography on days 3-7. Five of the six developed pneumonia compared with none of the remaining 13 patients (P < 0.05). CONCLUSION: Pulmonary impairment and pneumonia following oesophageal surgery was associated with raised monocyte producing capacity of TNF-alpha and IL-1beta. These markers may be valuable in the preoperative assessment of patients awaiting oesophagectomy.

Antibiotic prophylaxis in the initial management of severe acute pancreatitis.

Year 1998
Powell JJ. Miles R. Siriwardena AK.
University Department of Surgery, Royal Infirmary of Edinburgh, UK.
BACKGROUND: The role of antibiotic prophylaxis in the initial management of patients with acute pancreatitis is an area of major controversy. Contrary to earlier clinical trials, recent experimental and clinical studies have accrued evidence that warrants reappraisal of current clinical practice. This article reviews these recent advances in knowledge. METHODS: All papers derived from a Medline search for the years 1990-1997 inclusive using the text words 'acute', 'pancreatitis', 'antibiotic' and 'antibiotics' were studied. Additional papers were derived from reference lists within papers identified by the Medline search. Only experimental and clinical papers relevant to the issue of prophylactic antibiotic therapy in acute pancreatitis are included in the review. RESULTS AND CONCLUSION: Current experimental evidence favours the use of prophylactic antibiotics in severe acute pancreatitis. The results of contemporary randomized clinical trials restricted to patients with prognostically severe acute pancreatitis have demonstrated improvement in outcome associated with antibiotic treatment.

Diagnosis and treatment of sphincter of Oddi dysfunction.

Year 1998
Tzovaras G. Rowlands BJ.
Department of Surgery, The Queen's University of Belfast, UK.
BACKGROUND Sphincter of Oddi dysfunction is a challenge from both the diagnostic and therapeutic point of view. There is much ongoing debate about the accuracy and usefulness of various diagnostic tests, as there is about the effectiveness of proposed therapeutic alternatives. METHODS: A comprehensive review of the past 15 years' literature was undertaken, using the Medline database and cross-referencing of major articles on the subject. RESULTS AND CONCLUSION: Endoscopic and surgical treatments result in similar outcomes, with considerable failure rates. The latter reflect the difficulties in accurate diagnosis and a lack of sound objective criteria for selecting patients for intervention. In addition, in some patients sphincter of Oddi dysfunction may be only part of a generalized motility disorder of the gastrointestinal tract.

Recent advances in the surgical treatment of faecal incontinence.

Year 1998
Vaizey CJ. Kamm MA. Nicholls RJ.
St Mark's Hospital London, Harrow, UK.
BACKGROUND: Improved imaging and refined technology have led to a number of recent advances in the surgical treatment of faecal incontinence. METHODS: Original articles, identified using a computer database (Medline), and recently published abstracts of meetings were selected on the basis of greatest clinical relevance; these were reviewed. RESULTS: Ultrasonographic characterization has led to improved therapeutic strategies. Simple structural damage is readily identified and external sphincter repair results in a good outcome for a majority of patients. For more complex structural damage, or for the newly recognized primary internal sphincter degeneration, alternative treatment strategies are emerging. The electrically stimulated gracilis neosphincter and the artificial bowel sphincter offer good results. The latter may be a more simple operation. For structurally intact but weak sphincters, sacral nerve stimulation is a promising therapy. Other therapies, such as antegrade irrigation, may be helpful for patients with neurological disorders. CONCLUSION: Better imaging, refined classification and new operations are leading to improved surgical techniques for faecal incontinence.

Simple laparoscopic gastropexy as the initial treatment of paraoesophageal hiatal hernia.

Year 1998
Agwunobi AO. Bancewicz J. Attwood SE.
Department of Surgery, Royal Albert Edward Infirmary, Wigan, UK.
BACKGROUND: Paraoesophageal hiatal hernia is relatively rare compared with sliding hernia but it is associated with serious complications. Its clinical management presents a major challenge since many patients are elderly and unfit for a formal repair. This paper describes a laparoscopic method aimed at reducing the complications of open repair. METHODS: Thirteen patients treated for symptomatic paraoesophageal hernia were included in the study. Eleven patients successfully underwent a simple laparoscopic modification of the Boerema anterior gastropexy. Two patients required an open anterior gastropexy through a minilaparotomy because of incomplete reduction of the hernia. A five-puncture technique was used. The stomach and any other contents of the sac were reduced into the abdomen and the stomach was firmly fixed to the fascia of the anterior abdominal wall with GORE-TEX sutures tied extracorporeally. RESULTS: There was one postoperative death due to spontaneous intrathoracic perforation of the posterior aspect of the stomach in an elderly woman with severe cardiac disease. There was no postoperative morbidity. Eight of the ten patients who went home following laparoscopic gastropexy have remained asymptomatic on follow-up. In three patients, two in the laparoscopic group and one in the open group, symptoms recurred. CONCLUSION: While anterior gastropexy has a significant incidence of recurrent herniation, the clinical results of this simple procedure in a high-risk population support its use as the initial surgical option.

Pancreatic cancer resection in elderly patients.

Year 1998
DiCarlo V. Balzano G. Zerbi A. Villa E.
Department of Surgery, San Raffaele Hospital, Milan, Italy.
BACKGROUND: Pancreatic cancer resection is considered a high-risk procedure in patients aged 70 years or older. METHODS: Some 398 patients with pancreatic adenocarcinoma, observed between 1990 and 1995, were reviewed. Operative outcome and survival of 33 patients aged 70 years or more were compared with findings in 85 younger patients who underwent resection. RESULTS: Resectability was not significantly different between the elderly and younger patients; neither were mortality or overall morbidity. However, patients aged 70 years or more had more relaparotomies (P < 0.01) and more haemorrhagic complications (P < 0.001). Nutritional recovery after resection was satisfying even for elderly patients (body-weight gain and increase in serum albumin concentrations, P < 0.05). Univariate analysis showed a moderately poorer survival in the elderly (P = 0.09). Multivariate analysis demonstrated that tumour diameter, grading and Union Internacional Contra la Cancrum stage were independent prognostic factors, whereas age was not. CONCLUSION: Patients aged 70 years or more can benefit from pancreatic cancer resection similarly to younger patients.

Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head.

Year 1998
Leach SD. Lee JE. Charnsangavej C. Cleary KR. Lowy AM. Fenoglio CJ. Pisters PW. Evans DB.
Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
BACKGROUND: The survival of patients who underwent pancreaticoduodenectomy with or without en bloc resection of the superior mesenteric-portal vein (SMPV) confluence for adenocarcinoma of the pancreatic head was compared. METHODS: To be considered for surgery, patients were required to fulfil the following computed tomography criteria for resectability: (1) absence of extrapancreatic disease, (2) no evidence of tumour extension to the superior mesenteric artery (SMA) or coeliac axis, and (3) a patent SMPV confluence. Tumour adherence to the superior mesenteric vein (SMV) or SMPV confluence was assessed at operation and en bloc venous resection was performed when necessary to achieve complete tumour extirpation. RESULTS: Seventy-five consecutive patients underwent pancreaticoduodenectomy, 44 without venous resection and 31 with en bloc resection of the SMPV confluence. There were no perioperative deaths in either group; late (more than 6 months) occlusion of the reconstructed SMPV confluence contributed to the death of two patients. Median survival in the 31 patients who required venous resection at the time of pancreaticoduodenectomy was 22 months, and that for the 44 control patients was 20 months (P = 0.25). CONCLUSION: Patients with adenocarcinoma of the pancreatic head who require venous resection during pancreaticoduodenectomy for isolated tumour extension to the SMV or SMPV confluence (in the absence of tumour extension to the SMA or coeliac axis) have a duration of survival no different from that of patients who undergo standard pancreaticoduodenectomy. These data suggest that venous involvement is a function of tumour location rather than an indicator of aggressive tumour biology.

Laparoscopic cholangiography: a prospective study.

Year 1998
Sabharwal AJ. Minford EJ. Marson LP. Muir IM. Hill D. Auld CD.
Department of Surgery, Dumfries and Galloway Royal Infirmary, Dumfries, UK.
BACKGROUND: The place of cholangiography has been controversial in the conventional and now in the laparoscopic setting. The aim of this study was to evaluate laparoscopic cholangiography and compare use of a portable C-arm image intensifier with conventional radiography. METHODS: One hundred and ninety-seven consecutive patients undergoing laparoscopic cholecystectomy were randomized before operation to cholangiography by either C-arm image intensifier or conventional radiography. Data were collected on a pro forma completed immediately after the operation. RESULTS: Cholangiography was successful in 93.0 per cent of patients. Cholangiography with an image intensifier was significantly faster. In 19 patients the ductal system was obscured by a cannula; in 17 of these cases a metal cannula was used. In 31.6 per cent of patients the clip on the cystic duct was within 1 cm or less of the common bile duct (CBD). CONCLUSION: Laparoscopic cholangiography is a safe procedure. Use of an image intensifier should be the preferred method of obtaining images. Metal cannulas are more likely to obscure the ductal system. The proximity of the clip on the cystic duct to the CBD highlights the potential for injury caused by electrocautery or erroneous clip application.

Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy.

Year 1998
Doctor N. Dooley JS. Dick R. Watkinson A. Rolles K. Davidson BR.
Department of Surgery, Royal Free Hospital and Medical School, London, UK.
BACKGROUND: Bile leaks and bile duct strictures are major complications of cholecystectomy which increased in incidence after the introduction of laparoscopic surgery. The management and outcome of these complications following the introduction of laparoscopic cholecystectomy was reviewed. METHODS: Eighteen patients of median age 45 (range 22-70) years were treated between January 1992 and December 1995. Six patients had a common hepatic duct (CHD) stricture, four following a failed previous repair. Nine patients had bile leaks from bile duct transection (four), cystic stump (four) or segment V duct (one). Two patients had partial bile duct damage with primary sutured repair at time of cholecystectomy. One patient had recurrent haemobilia from a hepatic artery pseudoaneurysm. RESULTS: Cystic stump or segment V leaks were treated successfully by endoscopic stenting (median follow-up 42 months). Roux loop biliary reconstruction was carried out in nine patients: two CHD strictures, three of the four failed primary CHD repairs and four bile duct transections. All had normal liver function test results at median follow-up of 30 months. The two patients with partial duct injuries repaired at initial surgery required no further intervention. The right hepatic artery aneurysm was successfully embolized. There have been no deaths or major complications of endoscopic, radiological or surgical intervention. CONCLUSION: Endoscopic stenting successfully treats cystic stump and segment V duct leaks. Duct strictures, including failed initial repairs and transections, have a good outcome with Roux-en-Y loop reconstruction.

Anovestibular fistula to Bartholins gland.

Year 1998
Cripps NP. Northover JM.
St Mark's Hospital, Harrow, UK.
BACKGROUND: Acquired fistulation from the anal canal to Bartholin's gland has not been reported before. This fistula has been identified in 11 women treated between 1991 and 1995. METHODS: All discharge diagnoses during this period were searched. The clinical records of patients managed for this diagnosis were reviewed. RESULTS: Eleven women aged 24-49 years were identified. Seven of 11 fistulas arose in association with inflammatory bowel disease (five Crohn's disease, two ulcerative colitis). Patients typically presented with the vulval passage of flatus and faeces or acute sepsis of Bartholin's gland. Time to diagnosis of the fistula ranged from 1 to 15 (median 8) months after the onset of symptoms. Anatomically, all fistulas were high trans-sphincteric or suprasphincteric. All eight fistulas for which repair was attempted (five in the presence of inflammatory bowel disease) remain healed at short-term follow-up. Proctocolectomy was undertaken in two patients with severe Crohn's colitis. CONCLUSION: Ano-Bartholin's fistulas, although rare in general surgical practice, present with troublesome symptoms and may be repaired successfully. Gynaecologists and surgeons should be aware of this clinical entity to avoid unnecessary delays in treatment.

Outcome following laparoscopic resection for colorectal cancer.

Year 1998
Psaila J. Bulley SH. Ewings P. Sheffield JP. Kennedy RH.
Yeovil District Hospital, Higher Kingston, UK.
BACKGROUND: A prospective comparison of laparoscopic or laparoscopically assisted colorectal resection versus open resection has been undertaken to evaluate early benefits and cost implications. METHODS: Consecutive patients with colorectal cancer underwent either elective laparoscopic (n = 25) or open (n = 29) resection. RESULTS: Mean hospital stay was significantly shorter in the laparoscopic group: 10.7 versus 17.8 days. Mean morphine requirements were less in patients who had laparoscopic resection and their recovery, as measured by the dynamometer hand grip and the SF-36 symptom score, was more rapid. Adequate tumour clearance was achieved in the laparoscopic group. In both groups, the number of lymph nodes harvested was similar. Port-site or wound recurrence has not been observed at a median follow-up of 28 months. CONCLUSION: When laparoscopic colorectal resection is possible, there are significant early benefits for patients.

Surgical treatment of severe duodenal polyposis in familial adenomatous polyposis.

Year 1998
Penna C. Bataille N. Balladur P. Tiret E. Parc R.
Department of Digestive Surgery, Hopital Saint-Antoine, Paris, France.
BACKGROUND: Patients with familial adenomatous polyposis (FAP) are at risk for adenomas and cancers in the duodenum but the ideal management of duodenal polyposis remains uncertain. METHODS: The outcome of surgical resection was analysed in 18 patients with FAP who had severe duodenal polyposis. RESULTS: Duodenotomy and clearance of duodenal adenomas was performed seven times in six patients. There were two duodenal leaks and, after a mean follow-up of 53 (range 36-72) months, duodenal adenomas recurred in all patients and five had severe polyposis. Pancreatoduodenectomy was performed in seven patients with severe duodenal polyposis. Histology of the specimens revealed two unsuspected duodenal carcinomas at an early stage. After a mean follow-up of 42 months all patients were alive and well, and there was no case of jejunal polyposis. Pancreatoduodenectomy was attempted in five patients with duodenal cancer and only one survived more than 4 years. CONCLUSION: Surgical excision of duodenal adenomas should be discussed before carcinoma occurs. Surgical polypectomy fails to guarantee a polyp-free duodenum and carries a risk of postoperative complications whereas pancreatoduodenectomy eliminates the risk of duodenal cancer with an acceptable morbidity rate. Pancreatoduodenectomy could be offered to some patients with large or multiple villous duodenal adenomas repeatedly showing severe dysplasia.

Association between restriction fragment length polymorphism of the L-myc gene and susceptibility to gastric cancer.

Year 1998
Shibuta K. Mori M. Haraguchi M. Yoshikawa K. Ueo H. Akiyoshi T.
Department of Surgery and Pathology, Medical Institute of Bioregulation, Kyushu University, Beppu, Japan.
BACKGROUND: L-myc polymorphism has been documented to be a representative genetic trait which is related an individual's susceptibility to several cancers. However, there have been no reports concerning any significant association between susceptibility to gastric cancer and L-myc polymorphism. METHODS: The distribution of L-myc polymorphism in 61 patients with gastric cancer was determined by polymerase chain reaction-based restriction fragment length polymorphism and compared with that of 107 healthy control subjects. RESULTS: There was a significant difference in the distribution of both genotypes (P = 0.024) and allele frequencies (P = 0.026) between the two groups. The relative risk of gastric cancer for genotypes with the shorter (S) allele was 3.09 compared with the longer (L) allele homozygote. No significant correlation with clinicopathological features of the cancers except for prognosis was found. The patients with SS genotypes had a worse prognosis than those with LL or LS genotypes (P = 0.029). CONCLUSION: L-myc polymorphism may be significant in an individual's susceptibility to gastric cancer in Japan, and may be a useful marker for identifying patients at high risk of developing gastric cancer.

Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the left colon.

Year 1998
Turegano-Fuentes F. Echenagusia-Belda A. Simo-Muerza G. Camunez F. Munoz-Jimenez F. Del Valle Hernandez E. Quintans-Rodriguez A.
Emergency Department (Surgical Section), University General Hospital Gregorio Maranon, Madrid, Spain.
BACKGROUND: Palliative colostomy is still unavoidable in many patients with malignant obstruction of the left colon. This report describes an initial experience and follow-up in a small series of patients with left-sided colon obstruction in whom transanal self-expanding metal stent (SEMS) placement was attempted for palliative purposes. METHODS: Palliative transanal SEMS placement was attempted in 11 patients with malignant obstruction of the rectosigmoid region. The selection criteria included patients with advanced pelvic disease, peritoneal carcinomatosis and/or multiple parenchymatous metastatic disease. Wallstent oesophageal endoprostheses were used, and the technique was carried out by interventional radiologists. RESULTS: The technique succeeded in relieving the obstruction in seven patients, and surgical intervention was prevented in six. Five of these six patients died with an unobstructed colon from 26 days to 7 months after SEMS placement. The technique failed in four patients, three of whom underwent emergency colostomy. CONCLUSION: Transanal SEMS placement is an appealing method for the relief of obstruction in selected patients, obviating the need for palliative colostomy.