Correction: Character angle effects on dissociated dislocation core energy in aluminum

Correction for 'Character angle effects on dissociated dislocation core energy in aluminum' by X. W. Zhou et al., Phys. Chem. Chem. Phys., 2021, 23, 3290-3299, DOI: https://doi.org/10.1039/D0CP05333C.

Character angle effects on dissociated dislocation core energy in aluminum

Dislocation core energy is an important property in materials mechanics but can only be obtained from atomistic simulations. Periodic boundary conditions are ideally suited for atomistic calculations of dislocation energies but have faced two major challenges. First, viable methods to extract core energies from atomistic data of total energies have been developed only for non-dissociated dislocations whereas realistic dislocations are often dissociated into partials. Second, core energy is a function of dislocation character angle. This functional dependence can only be revealed through calculations at a variety of character angles. This requires both additional computational resources and a robust method to implement arbitrary character angles. Here a new procedure has been developed to overcome both challenges. By applying this approach, we have calculated 22 core energies of dissociated dislocations in aluminium over the entire character angle range between 0° and 90°. In addition to the discrete core energy data for dissociated dislocations, we found that core energy can be approximated by a continuous function of character angle. Specifically, our dissociated dislocation core energies have been well fitted to a polynomial Sinoidal function of character angle. We have also discovered that there exists a critical system dimension below which dislocation core energies cannot be calculated due to dislocation transformation.

Molecular dynamics discovery of an extraordinary ionic migration mechanism in dislocation-containing TlBr crystals

MD simulation of dislocation migration under an electrical field.

Early Postoperative Feeding - A Continuing Controversy in Pyloric Stenosis

Two regimens of postoperative fluid management are currently used following pyloromyotomy. Both early or delayed feeding have their advocates. The present study reviews 127 infants managed by the early feeding regimen. Although vomiting was common (79%) early discharge (75% within 72 h) was followed by no adverse effects. Weight gain at 7 days was unaffected by postoperative vomiting. Early feeding and early discharge can be achieved without increase in morbidity and may be the preferred method of postoperative management.

Anal Cancer: The Case for Earlier Diagnosis

The results of treatment in 22 patients with anal carcinoma are reviewed. The overall results are disappointing with only five (28%) surviving more than 5 years. The commonest form of treatment during the study period was an abdomino-perineal excision of rectum (APER). For patients with tumours less than 2 cm in diameter local excision is an acceptable alternative.

The majority (76%) of tumours were diagnosed as common benign conditions by the referring practitioners leading to a delay in initiating definitive treatment. Most tumours (81%) were greater than 2 cm in diameter and therefore unsuitable for local excision.

There was a high recurrence rate (76%) amongst the group treated by APER. This along with the poor overall survival is probably due to late presentation.

A bond-order potential for the Al–Cu–H ternary system

The new potential enables simulations of H₂ interactions with Al alloy surfaces.

Complications and mortality following stoma formation

INTRODUCTION

As stoma formation is thought to be declining, we performed a study to evaluate the rate of stoma formation and the impact on stoma complication rates, together with risk factors for complications.

PATIENTS AND METHODS

Stoma incidence, individual complications and mortality rates were retrieved from a stoma nurse database of 345 stomas created over an 8-year period.

RESULTS

Stoma formation increased over the study period, although the incidence of complications declined. Stoma complications were more frequently seen in emergency surgery. A significant association between stoma complications and mortality was identified.

CONCLUSIONS

Age of patient, urgency of surgery and diagnosis were associated with high levels of morbidity and mortality. Stomas are often formed in frail patients unsuitable for anastomosis formation, which may explain the high mortality in ostomy patients.

Registrar operating experience over a 15-year period: more, less or more or less the same?

BACKGROUND

Concerns have been raised on the effects that recent changes in junior doctor work patterns may have on the breadth and depth of operative exposure achieved during specialist registrar training. This study aimed to determine whether there was any justification for these concerns by assessing whether there have been significant changes in either the number of cases or the case mix operated upon by registrars over the course of the past fifteen years.

METHODS

A retrospective review of theatre records was undertaken, looking at the caseload of the registrars working for the same two consultant surgeons at one district general hospital in four one-year periods (1986-7; 1991-2; 1998-9; 2001-2). The number, subspecialty, and time of each operation were recorded.

RESULTS

Whilst operating experience for the first three periods of the study was static, the most recent assessment point has demonstrated a significant reduction in trainee routine operative experience and also a small reduction in the emergency workload performed by both firms. There was also a significant change in the elective case mixes corresponding to consultant sub-specialisation during this period. In addition, there were notable changes in the nature of the emergency workload and a reduction in the number of cases performed after midnight.

CONCLUSION

SpRs trained during the Calman era appear to be gaining less operative experience than their predecessors in both the elective and emergency settings. With further changes in working patterns currently being implemented, major changes to SpR programmes are required if surgeons are to be adequately trained.

Laparoscopic colorectal surgery in Great Britain and Ireland--where are we now?

OBJECTIVE

We aimed to gather information from the members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to assess trends in the current practice of laparoscopic colorectal surgery.

METHODS

A postal questionnaire survey of the members of ACPGBI.

RESULTS

The response rate was 37% (200/540). Only 45 surgeons currently perform laparoscopic colorectal work in Great Britain and Ireland mainly right hemicolectomy and laparoscopic stoma formation, of these about one third practiced laparoscopy for benign colorectal conditions only. The majority (68%) of surgeons had enough resources at their place of work, but further training seemed to be a major issue. Nearly 22% of surgeons had not had any formal training. Only 50% of surgeons trained their specialist registrars. The incidence of conversion rate was not different for benign or malignant conditions and also did not appear to be related to the duration of experience. Only four surgeons had noted port a site recurrence during the past 10 years. Seventy-five percent (150/200) felt that laparoscopic colorectal work could be carried out safely in a District General Hospital.

CONCLUSION

Laparoscopic colorectal surgery was being performed by a small minority of members of the ACPGBI although more surgeons had started to work in this field in recent years. The main areas of concern appeared to be a wide variation in the range of experience as indicated by the number of operations performed and limited formal training for consultants.

Assessment of basic surgical trainees: can we do more?

INTRODUCTION

Changes to surgical training and reduction of junior doctors' working hours has resulted in trainees spending less time in surgical specialties before becoming eligible to apply for specialist registrar posts. A high quality basic surgical training programme is needed to improve the competence of trainees during their shortened period, an essential part of which is to conduct a formal assessment at the end of each training post and regular appraisals during their period of training.

AIMS

To analyse the existing practice with regard to conducting assessment and appraisals for basic surgical trainees in the South East Wales region.

METHODS

A questionnaire was sent to all the basic surgical trainees in the South East Wales region.

RESULTS

A total of 52 questionnaires were sent out and 44 (84%) were returned. Four candidates were in the first post of their rotation, and were therefore excluded from the study. Nine of the 40 trainees (23%) did not have an assessment in one or more of their posts. There are 17 senior house officer posts available in general surgery in the rotation. Of the 31 "six month" episodes spent in these 17 posts, 27 (87%) underwent an assessment, 12 of the 17 (70%) episodes in trauma and orthopaedics (12 available posts) were assessed, and 31 of the 35 (88%) episodes in accident and emergency (eight available posts) underwent an assessment. Twenty eight of the 40 trainees (70%) did not undergo regular appraisals during the majority of their posts. Only 30%-50% of episodes spent in general surgery, orthopaedics, and accident and emergency underwent appraisals. The majority of the episodes spent in the other surgical specialties (12 posts available in total) had formal assessment and regular appraisals except for urology in which two of seven episodes underwent assessment and one underwent an appraisal. Twelve candidates (30%) expressed the view that operative experience and technical skills must form part of their assessment. Eight trainees (20%) felt that they needed more help from tutors with regard to career advice, preparation of curriculum vitae, and interview techniques for specialist registrar posts. Eight trainees mentioned that they had discussed unsatisfactory posts with their tutors but were not aware of any changes made to these posts.

CONCLUSIONS

This study has shown that the formal assessment of basic surgical trainees at the end of each training post has to improve further. The existing practice of conducting regular appraisals for the trainees is grossly inadequate. There appears to be a need for formulating guidelines for conducting such appraisals, which would help to improve practice in the future.

Carcinoma of the oesophagus and stomach in Wales: a 1-year survey

Background

The management and outcome of patients presenting with oesophagogastric carcinoma over a 12-month period in Wales were reviewed.

Methods

Data were collected from September 1995 to September 1996 on 916 consecutive patients and submitted to confidential data analysis. The data originated from 20 hospitals and 70 surgeons treating these patients.

Results

The number of cases managed by each hospital varied between two and 124, and by each surgeon from one to 44. Three tumour sites were identified: carcinoma of the oesophagus (n = 339), carcinoma of the cardia (gastro-oesophageal junction; n = 193) and gastric carcinoma (n = 384). The 30-day mortality rate was 13 per cent for oesophageal carcinoma, 12 per cent for cardia carcinoma and 11 per cent for gastric carcinoma. Resection rates for the three tumour sites were 28, 44 and 56 per cent. There were 16 anastomotic leaks overall. For patients undergoing surgery, there was an inverse relationship between case load and mortality rate. This difference narrowed when ten or more patients were operated on per annum. For surgeons consulting with more than ten patients per annum and who operated on more than 70 per cent of these, the mortality rate was 18 per cent, compared with 5 per cent for those who operated on less than 70 per cent.

Conclusion

Numerically there is a broad range of experience amongst the surgeons who treat carcinoma of the oesophagus and stomach in Wales. There may be an optimum minimal case load and, with careful selection of␣patients for surgery, morbidity and mortality rates should be minimized.

Costs of waiting for gall bladder surgery

Laparoscopic cholecystectomy is one of the most commonly awaited general surgical procedures in the UK. However, many patients awaiting a cholecystectomy are admitted with recurrent gallstone related symptoms while on the waiting list, resulting in significant morbidity. The aim of this study was to quantify this problem, and also to analyse the cost implications of these admissions for the NHS. A retrospective study was performed of all patients who underwent an elective cholecystectomy by three consultants in a district general hospital between January 1999 and January 2000. The demographic details, indications for surgery, details of the emergency admissions while on the waiting list, and the treatment given during these episodes were recorded. One hundred and fifty six patients were included in the study, of which 122 (78%) were females. The mean (SD) age of the patients was 54 (5) years. The mean waiting time for surgery in these patients was 12 (3) months. Thirty seven patients (23.7%) were admitted as an emergency due to gallstone related symptoms and complications while awaiting surgery. There were 47 episodes of admissions in total, of which 32 were for biliary colic, 13 were for acute cholecystitis, and two were for acute pancreatitis. In addition to routine blood tests, 20 abdominal radiographs, 10 chest radiographs, three endoscopic retrograde cholangiopancreatography tests, five ultrasonograms, and one computed tomogram were carried out in these patients. The mean duration of each episode of admission was three days. The cost of treatment per episode was pound 946 and the total cost of treating the 37 patients was calculated to be pound 44 462. Performing early laparoscopic cholecystectomy for acute cholecystitis may help to reduce costs by preventing recurrent emergency admissions in these patients. Further studies to identify risk factors associated with recurrent symptoms and complications in patients with gallstone disease may help to prioritize them for early surgery.

The implications of subspecialisation on the management and outcome of surgery for rectal carcinoma

BACKGROUND

The management of rectal carcinoma has changed significantly over the last decade. We studied the changing trends in the management of rectal carcinoma over a 7-year period in a district general hospital.

METHODS

A retrospective analysis of all patients with histologically proven rectal adenocarcinoma who underwent operative treatment between January 1991 and December 1997 was performed. The type of operative procedure, local recurrence rate and completeness of pathology reporting was documented.

RESULTS

There were 200 operative procedures: 102 anterior resections (AR), and 98 abdominoperineal resections (APR). This included 17 palliative resections because of metastatic disease (n = 8) or extensive local invasion (n = 7) or both (n = 2). The APR rate steadily declined from 72% in 1991 to 19% in 1997 (p < 0.005). Subspecialist 'colorectal' surgeons performed only 24% of the operations in 1991 but the figure for 1997 was 85% (p < 0.01). No circumferential resection margin was reported in 1991 but was reported in 85% of the cases in 1997 (p < 0.001). There was a steady increase in stapled anastomoses from 43% in 1991 to 93% in 1997 (p < 0.03). There were 15 local recurrences following 'curative' resection; 7 following APR and 8 following AR (n.s.).

CONCLUSION

There was a significant increase in the rate of restorative resection of rectal cancer with a concomitant reduction in permanent stoma formation; this may be attributed to an increase in subspecialisation. Despite this, a low rate of local recurrence was maintained throughout the study period.

Tuberculous parotitis

Tuberculosis, though rare, should be considered in the differential diagnosis of a diffuse swelling of the parotid with enlarged cervical glands, particularly in young, feverish adults.

Prioritizing treatment in cases of concurrent abdominal aortic aneurysm

Patients with concomitant abdominal aortic aneurysm (AAA) and intra-abdominal malignancy present a clinical dilemma because of the difficulty in deciding which pathology to address first. As this scenario is not commonly encountered, clear guidelines are not available to help in the decision-making process. Surgery for malignancy has been said to increase the risk of postoperative aneurysm rupture, but simultaneous cancer surgery and primary repair of the aneurysm may carry the risk of prosthetic graft infection. This paper describes a further complication that may arise in the setting of concomitant intra-abdominal malignancy carcinoma and AAA, namely peripheral embolism.

The natural history diverticular disease: is there a role for elective colectomy?

BACKGROUND

The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease.

AIM

To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications.

MATERIALS AND METHODS

A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients.

RESULTS

A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications.

CONCLUSIONS

Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.

Prevention of venous thromboembolism in Wales: results of a survey among general surgeons

OBJECTIVE

To examine the current attitudes towards the prevention of venous thromboembolism among a cohort of surgeons.

DESIGN

A postal survey, comprising a questionnaire covering various aspects of venous thromboembolism prophylaxis was sent to all (n=84) consultant general surgeons in Wales.

RESULTS

Replies were received from 57 surgeons (68%), all of whom routinely used prophylaxis, the most frequent modalities used being heparin (100%) and graded compression stockings (79%). A combination of physical and pharmacological methods was used by over 89% of surgeons, with 60% starting prophylaxis more than two hours before operation. All surgeons continued prophylaxis after surgery, 53% until patients were mobile, 45% until they were discharged, and one surgeon continued prophylaxis for seven days after discharge. The thrombosis risk factors considered most important by surgeons when deciding about prophylaxis were (i) a previous history of venous thromboembolism, (ii) hypercoagulability, and (iii) malignancy.

CONCLUSIONS

This study confirms that Welsh surgeons conform to standard methods, but also highlights some uncertainties that are present in current surgical practice. Those who responded all routinely used prophylaxis, the timing of which was variable. The main risk factors identified when considering prophylaxis were previous history of deep vein thrombosis/pulmonary embolism, hypercoagulability, and the presence of malignancy. Suggestions for future practice are made.

Nurse-led direct access endoscopy clinics: the future?

BACKGROUND

Many studies have shown that rectal bleeding is a good indicator of underlying colorectal pathology, and that ost of the lesions in patients presenting with rectal bleeding lie in the left side of the colon [1, 5, 9, 12, 23, 26]. The recent acceptance of the nurse-practitioner by the National Health Service may allow the use of nurse-endoscopists to develop throughout the United Kingdom. This study aimed to audit a unique nurse-led direct-access nurse-endoscopy service with regard to its efficacy and cost effectiveness, and to monitor patient satisfaction and direct referrals from the primary health sector.

METHODS

A nurse-led open-access flexible sigmoidoscopy (OAFS) service for patients reporting fresh rectal bleeding was established at our center in February 1996. A prospective audit of sigmoidoscopic findings and a retrospective analysis of referral patterns from local general practitioners were conducted. A questionnaire survey of both patient and general practitioner satisfaction also was conducted at the same time.

RESULTS

Since February 1996, 706 patients have been referred to our service. Rectal bleeding was by far the most common cause for referral, representing the dominant symptom in 92% of the referrals received. Although 99% of the patients underwent a complete sigmoidoscopic examination, 16% of these examinations were limited because of several factors combined. A cause for bleeding was identified in 91% of the patients, with 24% of them experiencing subsequent significant pathology. Of the patients surveyed, 99% were satisfied with the service provided. The results also show nurse-led OAFS to be a more effective use of financial resources, costing $90 less per patient than general practitioner referrals sent to a consultant for further action.

CONCLUSIONS

Rectal bleeding is a good indicator of underlying colorectal disease. Most of the significant lesions presenting with this symptom are found in the left side of the colon. A nurse-led OAFS is safe, effective, and acceptable to patients. It also is more cost effective than a consultant-led service.

Management of the impalpable testis: a six year review together with a national experience

The management of undescended testes remains variable, and the use of laparoscopy for localisation is controversial. This study reviews the need for laparoscopy and also assesses the current practice among a cohort of surgeons.A retrospective review of all patients undergoing orchidopexy was performed, together with a postal survey of all members of the Welsh Surgical Society. Of the 139 orchidopexies performed, the testis was deemed impalpable in 39 (28%) cases. All patients were treated with groin exploration, and only in two (5%) patients was the testis not located. From the survey, replies were received from 90 (81%) surgeons, of whom 65 (72%) were still performing orchidopexy. Forty eight (74%) surgeons performed orchidopexy between the age of 2 and 3, and only 32 (36%) performed preoperative investigations. The follow up period was variable with the majority of patients seen at six weeks. Laparoscopy for the impalpable testis is not initially warranted. An inguinal exploration is regarded as the definitive investigation. This has the advantage of providing the diagnosis and treatment in the majority of cases.

Splenogonadal fusion: report of a rare variety

We report an unusual case of splenogonal fusion in a 10-year-old boy with an undescended left testis. He suffered from congenital limb defects, a known association with splenogonadal fusion, and had originally been admitted for orchidopexy.

One-year survey of carcinoma of the oesophagus and stomach in Wales

BACKGROUND

The aim of the study was to identify all patients who presented with oesophagogastric malignancy within a single National Health Service region (Wales) over 1 year, and to follow the cohort for 5 years. Management and outcome were analysed to identify current practice and draft guidelines for Wales.

METHODS

Patients were identified from hospital records. Details were recorded in structured format for analysis.

RESULTS

Analysable data were obtained for 910 of 916 patients. The overall incidence was 31.4 per 100 000 population. Treatment was by resection 298 (33 per cent), palliation 397 (44 per cent) or no treatment 215 (24 per cent). The 30-day mortality rate was 12 per cent and the in-hospital mortality rate was 13 per cent. Some 226 patients (25 per cent) were alive at 2 years. Resection conferred a significant survival advantage over palliation (P < 0.001) and no treatment. Anastomotic leakage occurred in 16 patients (5 per cent), of whom eight died in hospital. 'Open and close' operations were common (23 per cent), laparoscopy was infrequent (16 per cent), and many surgeons undertook small caseloads. Operating on fewer than six patients per year increased the mortality rate after partial gastrectomy (P < 0.05) and was associated with a trend to a higher mortality rate after mediastinal and cardia surgery. Operating on more than 70 per cent of patients seen resulted in a significantly higher mortality rate (P < 0.01) irrespective of case volume.

CONCLUSION

Tumour resection conferred a survival advantage. Wider use of laparoscopy is advocated. Improved selection for surgery should result in a lower mortality rate.

Beware of groin pain in the elderly athlete

A62-year-old man, who was a keen amateur swimmer, presented to the orthopaedic department in June 1996 with a 4-month history of lower back pain, which had developed after he had been swimming. Mild tenderness was noted over his left sacroiliac joint, straight leg raising was normal, and resisted movements failed to reproduce his pain. He was advised to alter activity and discharged.

His pain persisted, however, and 10 months later had become localized to his right groin. Further review in the orthopaedic clinic revealed a full range of movement of his hips, but extreme abduction was painful. Plain radiographs of the lumbar spine showed degenerative changes. His pain was attributed to lumbar root irritation, and so he was referred for physiotherapy.

By October 1997, 16 months after initial presentation, there was no real improvement. A soft tissue magnetic resonance imaging scan confirmed spondylosis and degenerate discs, but no actual disc prolapse. As he was still troubled with pain, specifically in the right groin, a general surgical opinion was requested.

Localized tenderness was demonstrated at the deep ring, but no herniation noted. ‘Gilmore's groin’ was suspected, but his advancing age aroused suspicion, therefore other causes needed to be excluded. There was nothing else to find on clinical examination of his abdomen, but rectal examination revealed a hard nodular prostate. A prostate-specific antigen (PSA) test was performed, and this was significantly elevated at 168 ng/ml (normal Ã4 ng/ml). Plain pelvic X-rays were obtained, and reported as sclerotic lesions involving left ischium, right superior pubic ramus and adjacent pubic bone (Figure 1). An isotope bone scan later revealed multiple areas of increased activity consistent with metastatic disease (Figure 2). A subsequent tru-cut biopsy confirmed carcinoma of the prostate.

Therapeutic manipulation of the temporomandibular joint

We present a prospective study of manipulation of the temporomandibular joint (TMJ) under a general anaesthetic undertaken to find out the success rate in an effort to reduce the number of patients referred for invasive surgery.

RESULTS

Of the 55 patients invited to participate in this study, 15 improved, 15 did not, 6 showed partial improvement, and 19 were not treated. The median pre-treatment opening was 20mm (range 13-27). Among those who improved after manipulation, the median opening after treatment was 38mm (range 35-56). Some of those who improved experienced a return of TMJ clicking but not of joint or muscle tenderness.

CONCLUSION

Manipulation under general anaesthesia helps some patients with disc displacement without reduction.

The impact of open access flexible sigmoidoscopy: a comparison of two services

BACKGROUND

Open access flexible sigmoidoscopy (OAFS) is an integral part of colorectal cancer services. This study compares the impact of two types of open-access flexible sigmoidoscopy services on the utilisation of barium enema and tumour-stage migration.

METHODS

This was a non-randomised comparison (over two one-year periods, four years apart) of two unselected groups of patients, with different inclusion criteria, in adjacent similarly populated health districts. One offered a nurse practitioner endoscopy service while the other had a doctor-led colorectal clinic.

RESULTS

The doctor-led service with its broad inclusion criteria detected more colorectal cancers [13.2% versus 0.7%; OR = 16.05; 2.16-119.2]. Neither nurse practitioner (130 cases) nor doctor-led (262 cases) flexible sigmoidoscopy reduced the total number of barium enemas [Odds Ratio (OR) = 1.16 (95% CI 1.03-1.3)]. However, the doctor-led service did reduce the number of barium enemas requested by general practitioners (from 249 to 152). The total number of colorectal cancers (detected by all available methods) were similar [OR = 0.82 (0.53-1.25)] and both services resulted in a similar tumour-stage migration [OR = 1.39 (0.31-6.23)].

CONCLUSION

Open access flexible sigmoidoscopy services have minimal impact on the utilisation of radiology services. Broader inclusion criteria of doctor-led services produce a higher cancer-yield. Tumour-stage migration may be related to greater awareness of colorectal cancer symptoms rather than to the type of OAFS.

The nurse practitioner endoscopist

Most upper and lower gastrointestinal endoscopies in Great Britain and Ireland are performed by surgeons, physicians or radiologists. Since the introduction of the 'nurse endoscopist' by the British Society of Gastroenterology Working Party, few centres in the UK have adopted this policy. We have reviewed the anxiety about nurse practitioner endoscopists among patients and physicians. Finally, the role and future of the nurse practitioner endoscopist in the UK is discussed.

External oblique aponeurosis nerve entrapment as a cause of groin pain in the athlete

BACKGROUND

Groin pain in sportsmen is a common management problem. The results of surgical exploration in 25 male athletes presenting with groin pain are described.

METHODS

All patients had had failed non-operative management. All groins were explored via an inguinal incision and the patients were reviewed for the presence of pain, function and their own subjective opinion.

RESULTS

Nineteen injuries were unilateral and six bilateral. One patient had an occult inguinal hernia and another had a patent processus vaginalis. In the others, defects were found in the external oblique aponeurosis through which neurovascular bundles containing terminal branches of the iliohypogastric nerve passed. These tears were repaired after division of the bundles. The mean time to referral was 29.3 weeks (range 4-79 weeks). After operation no pain or only mild pain was experienced in 28 groins. All had improved function. Twenty of 23 patients described the operation as good or excellent. The mean time to resumption of sporting activities after operation was 11.6 (range 4-20) weeks.

CONCLUSION

Athletes' groin pain may be due to nerve entrapment in the external oblique aponeurosis. An awareness of this injury may reduce delays in operating leading to an earlier return to sport.

Coarctation of the aorta: a trap for the unwary during laparoscopic cholecystectomy

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Antegrade continent enema management of chronic fecal incontinence in children

BACKGROUND/PURPOSE

Fecal incontinence impedes social and psychological development in children. Conventional bowel management with rectal enemas, medication, and biofeedback frequently will provide intervals free of fecal soiling sufficient for children to be socially continent.

METHODS

This report details the improvement achieved by antegrade irrigation of the colon when conventional bowel management programs have failed to provide satisfactory intervals free of fecal soiling. Twenty-three children had conduits performed to administer antegrade continent enemas in the colon from December 1993 to May 1997.

RESULTS

Twenty of the children were available for evaluation. One child was lost to follow-up, and two were noncompliant with the irrigation program. Fourteen of the 20 children are out of diapers. Four of the six wearing diapers, do so for urinary, not fecal incontinence. Two patients (10%) still require diapers for fecal incontinence. Parents were pleased with the efficacy of antegrade irrigation and the decrease in family stress with the elimination of fecal soiling.

CONCLUSIONS

Ninety percent of the children available for follow-up benefited from antegrade irrigations of the colon. The antegrade irrigations were an improvement over conventional bowel management programs because a predictable interval free of soiling could be established. This allowed families to plan activities and improved the self-esteem of their children.

Long-term results of surgery for childhood achalasia

Childhood achalasia is an uncommon condition characterised by the absence of oesophageal peristalsis together with increased resting pressure and failure of relaxation of the lower oesophageal sphincter. The currently accepted management is a modified Heller's cardiomyotomy with Nissen fundoplication; however, the long-term results are uncertain. A retrospective review of the notes of 10 children undergoing surgical treatment of achalasia at our institution over a 23-year period were reviewed. There were six boys and four girls. The median age at onset of symptoms was 123 months and at diagnosis was 133 months. Five children were below average weight at the time of presentation. All underwent a modified Heller's operation and Nissen fundoplication. The follow-up ranged from 12 to 277 months with a mean of nearly 10 years. The results were excellent in terms of symptomatic improvement in eight of ten with one good and one moderate outcome. All children below average weight have shown improvement postoperatively. We would conclude that the management of achalasia in childhood should consist of an extended Heller's cardiomyotomy performed by the abdominal approach with the addition of an antireflux procedure such as Nissen fundoplication.

Collision tumour of the ampulla of Vater: carcinoid and adenocarcinoma

Obstructive jaundice is most commonly due to luminal stones or lesions of the head of the pancreas and more rarely ampullary and primary common bile duct lesions. Obstruction due to lesions of the ampulla of Vater may be due to adenocarcinoma which has a significantly better long term prognosis than carcinomas located in the head of the pancreas. A case is presented where two tumours were identified at the ampulla of Vater of the resected specimen one an adenocarcinoma and the other a carcinoid tumour representing a collision tumour.

Day-case surgery in children under 2 years of age: experience in a district general hospital and survey of parental satisfaction

One surgeon's experience of day-case paediatric surgery in a population aged less than 2 years at a district general hospital is reported. During a 6-year period from 1989 to 1994, 82 day-case operations were performed in 79 infants and young children. All children were managed by a multidisciplinary team including surgeon, paediatric anaesthetist and paediatric nurses. There was no mortality and minimal morbidity. A telephone survey of parents enquiring into satisfaction with all aspects of pre-, peri-, and post-operative care revealed that the procedures are well-accepted. The survey also showed that there was no increased utilization of primary health care professionals when day-case surgery is performed in this young age group. We conclude that paediatric day-case surgery is safe and well-tolerated by both infants and parents and is suitable for performance in non-specialist centres provided a team approach is adopted.

Dyschromatopsia (number 97) and rectal bleeding

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New option for recurrent rectovaginal fistulas

PURPOSE

To describe an operative technique for repair of recurrent rectovaginal fistulas.

METHODS

A diamond-shaped cutaneous flap advancement into the vagina and a standard endoanal advancement flap are described for use as an alternative option in treatment of recurrent rectovaginal fistulas.

RESULTS

Complete healing of fistula was achieved with no impairment of continence.

CONCLUSION

This technique is suitable in treatment of recurrent rectovaginal fistulas especially in frail and elderly patients.

'Gilmore's groin'--or is it?

Groin injuries are a common and often difficult diagnostic problem. This paper reviews six patients presenting with symptoms highly suggestive of the syndrome 'Gilmore's groin', but in whom the pathophysiology of the groin disruption and its surgical management differed from Gilmore's description.

A comparison of two alginate dressings used in surgical wounds

A report of a study that examined some clinical characteristics of two commonly used wound dressings

Exploration of the common bile duct for stones: the influence of the flexible choledochoscope and perioperative antibiotic prophylaxis

A retrospective study of 110 patients, out of a total of 743 open cholecystectomies, who have undergone common bile duct (CBD) exploration for stones between 1985 and 1990. CBD exploration was performed in the presence of abnormal peroperative cholangiogram in 86 (78%) patients. The remaining 24 patients were known to have either an abnormal preoperative ERCP or palpable ductal stones at the time of surgery. Post exploratory choledochoscopy was performed as an additional completion procedure in 58 (53%) patients and it identified further stones in 28 (48.3%) of these patients. There were three patients in whom no stones were identified on exploration of the CBD. Documented evidence of peroperative antibiotic prophylaxis was obtained in 78 (71%) patients. A total of 27 (24.5%) patients developed complications including seven (6.4%) patients with retained stones. In four of these patients with retained stones, flexible choledochoscopy was undertaken as an additional completion procedure to ensure ductal clearance. Cardiorespiratory and septic complications were the next most common problems occurring in 6.5% and 5.4% respectively, of patients reviewed. In conclusion, the retained stone rate has fallen from 14% in 1987 to 6.4% in this study. The choledochoscope has influenced this as it identified further residual stones following conventional exploration. The sepsis rate has also fallen from 19.5% to 4.5% in this study. We believe this is due to the use of antibiotic prophylaxis.