HER2 expression in oesophageal carcinoma and Barrett's oesophagus associated adenocarcinoma: An Australian study

BACKGROUND

Several studies have evaluated the prognostic value of HER2 in oesophageal cancer, but the prognostic influence of HER2 overexpression in oesophageal cancer remains uncertain. The aim of this study was to assess the incidence of HER2 positivity and relationship with clinicopathological features in patients with oesophageal cancer.

DESIGN

The study cohort consisted of 269 patients diagnosed with oesophageal carcinoma in a single institution. HER2 expression was analysed by immunohistochemistry (IHC) and silver in situ hybridization (SISH) in 152 archival oesophageal cancer specimens. Survival analysis was assessed using Hazard models.

RESULTS

HER2 expression was IHC3+ in 14 (9.2%), IHC2+ in 14 (9.2%), IHC1+ in 57 (37.5%), and IHC0 in 67 (44.1%) cases. SISH results confirmed that 15 specimens (9.9%) were HER2 gene amplified. Among 27 squamous cell carcinomas (SCCs) only 3.7% were HER2 positive whereas 11.2% of 125 adenocarcinomas were HER2 positive. The HER2 positive tumours were more likely to occur in men (OR: 5.00, 95% CI: 1.69-14.29), smokers (OR: 10.00, 95% CI: 4.17-25) and in patients with Barrett's oesophagus (OR: 8.33, 95% CI: 3.71-20.00). There was no significant difference in survival between the (HER2 +ve, 14.3 months vs HER2 -ve, 24.6 months, p = 0.42) CONCLUSION: A HER2 prevalence rate of 9.9% was found among patients with oesophageal cancer and no correlation with survival was detected overall.

Meta-analysis: Barrett's oesophagus and the risk of colonic tumours

BACKGROUND

Barrett's oesophagus (BO) is a premalignant condition associated with oesophageal adenocarcinoma. Although speculation exists, it is currently unclear if BO is associated with an increased risk of colonic tumours.

AIM

To conduct a meta-analysis of studies reporting the prevalence of colonic tumours in patients with BO vs. controls and thus quantify the risk of colonic tumours associated with BO.

METHODS

A search was conducted through Medline, PubMed, Embase, and Current Contents Connect to 7 October 2012. We calculated pooled odds ratios (OR) and 95% confidence intervals (CI) using a random-effects model for the risk of all colonic tumours associated with BO, as well as for the subgroups of colorectal cancer (CRC) and benign adenomatous tumours.

RESULTS

In total, 11 studies, with 2580 BO cases, met our inclusion criteria. BO was associated with an increased risk of any colonic tumours (OR: 1.96; 95% CI: 1.56-2.46). BO was associated with an increased risk of benign adenomatous tumours (OR: 1.69; 95% CI: 1.20-2.39), as well as an increased risk of CRC (OR: 1.90; 95% CI: 1.35-2.67). No statistically significant heterogeneity was observed. Publication bias was not present.

CONCLUSIONS

Barrett's oesophagus was associated with an increased risk of both benign adenomatous colonic tumours and colorectal cancer. Barrett's oesophagus had a stronger association with colorectal cancer than with benign colonic tumours. Further prospective cohort studies are needed to confirm the relationship.

Meta-analysis: coeliac disease and the risk of all-cause mortality, any malignancy and lymphoid malignancy

BACKGROUND

Coeliac disease has been associated with an increased risk of mortality and malignancy. However, the strength of this association is conflicting among different studies.

AIM

To perform a systematic review and quantitative meta-analysis to determine the risk of all-cause mortality, any malignancy and lymphoid malignancy in coeliac disease patients.

METHODS

Four electronic databases (Medline, PubMed, Embase and Current Contents Connect) were searched to 4 January 2012, with no language restrictions. From 8698 citations identified, a total of 17 studies met our inclusion criteria.

RESULTS

The all-cause mortality meta-analysis showed an increased risk for all-cause mortality in coeliac patients [odds ratio (OR) 1.24; 95% confidence interval (CI) 1.19-1.30]. A subgroup analysis showed that patients identified by positive serology alone were also at an increased risk of all-cause mortality (OR 1.16; 95% CI 1.02-1.31). The non-Hodgkin lymphoma (NHL) meta-analysis showed an increased risk for NHL in coeliac patients (OR 2.61; 95% CI 2.04-3.33). A subgroup analysis showed that patients identified by positive serology alone were also at an increased risk of NHL (OR 2.55; 95% CI 1.02-6.36). The T-cell non-Hodgkin lymphoma (TNHL) meta-analysis showed an increased risk of TNHL (OR 15.84; 95% CI 7.85-31.94). The any malignancy meta-analysis showed no increased risk (OR 1.07; 95% CI 0.89-1.29).

CONCLUSIONS

Patients with coeliac disease are at an increased risk of mortality and non-Hodgkin lymphoma, particularly T-cell non-Hodgkin lymphoma; they do not have an increased risk of any malignancy overall. Serologically defined patients with coeliac disease have an elevated risk of mortality and non-Hodgkin lymphoma.

Grasper trauma during laparoscopic cholecystectomy

BACKGROUND

The present study characterized the histopathological nature of laparoscopic grasper trauma during laparoscopic cholecystectomy in a prospective, blinded trial in order to establish a model for laparoscopic grasper trauma. The null hypothesis that graspers cause no histologically distinct tissue injury was tested.

METHODS

The gall bladders of 19 patients undergoing laparoscopic cholecystectomy were examined. The area of gall bladder that had been grasped by Debakey laparoscopic forceps was excised (sample), along with an area of gall bladder that had not been grasped (control). Paired specimens were examined by a pathologist (blinded) to identify which was 'sample' and which was 'control' and to assess for histological markers of crushed tissue injury. The data were analysed by chi-squared or Fisher's exact tests.

RESULTS

The pathologist was able to identify the sample (gripped) specimen in 13 of the 19 cases. In the remaining six cases the pathologist was unable to determine the specimen that had been gripped due to either absence of damage (four cases), or severe inflammation precluding assessment (two cases). The ability of the pathologist to distinguish the sample from the control specimen was significant (chi-squared test, P = 0.003). Of the histological markers of crushed tissue injury, focal thinning of the gall bladder wall and epithelial loss were present in significantly more sample (gripped) specimens than control specimens (chi-squared test, P = 0.0002 and P < 0.0001, respectively).

CONCLUSIONS

Laparoscopic graspers cause tissue trauma that can be assessed histologically. The current study presents a relevant, reproducible, ethically acceptable human model for assessing the interaction between laparoscopic graspers and soft tissues.

Selective vascular occlusion with staged hemihepatectomy for blunt liver trauma

BACKGROUND

A 23-year-old man with extensive blunt trauma to the right lobe of the liver in whom adequate haemostasis could not be achieved by selective suturing and packing was encountered. Contributing factors to poor haemostasis included massive transfusion, hypothermia and acidosis.

METHODS

Hepatic haemostasis was achieved by selective intrahepatic ligation of the right hepatic pedicle and packing.

RESULTS

After resuscitation and stabilization in the intensive care unit, a right hemihepatectomy was performed 14 h later.

CONCLUSIONS

The present case describes a modification of the Pringle manoeuvre, termed 'selective Pringle manoeuvre'. This technique is a useful additional strategy for the management of uncontrollable bleeding in massive hepatic trauma.

The effect of fundoplication on the motility of the canine lower oesophageal sphincter

BACKGROUND

A canine model was used to define whether Nissen fundoplication inhibits gastro-oesophageal reflux by inhibiting transient lower oesophageal sphincter relaxations (TLOSR) or by creating a pressure barrier at the gastro-oesophageal junction.

METHODS

Four surgical models were studied pre-operatively and postoperatively. These were: (i) the surgical mobilization required for fundoplication (sham fundoplication, n = 5); (ii) a standard fundoplication (n = 4); (iii) anterior and posterior myotomy of the lower oesophageal sphincter (LOS; cardiomyotomy, n = 4); and (iv) combined cardiomyotomy and fundoplication (n = 4). Each operative procedure was assessed for its effect on the incidence of TLOSR and gas reflux events, the mean LOS pressure and the LOS pressure profile during swallow events.

RESULTS

Sham fundoplication reduced the rate of evoked TLOSR in response to gaseous gastric insufflation from 9.8+/-1.6/h (mean +/- SEM) to 5.4 +/-1.5/h. The mean LOS pressure was reduced from 25.1+/-2.6 to 18.5+/-2.1 mm Hg but nadir LOS pressure during swallowing was not altered. Nissen fundoplication virtually abolished evoked TLOSR from 10.4+/-1.2/h to 0.4+/-0.4/h, increased mean basal LOS pressure from 19.8+/-2.1 to 27.0+/-1.1 mm Hg and increased the nadir pressure on swallowing from 3.4+/-1.0 mm Hg to 14.4+/-1.0 mm Hg. Cardiomyotomy was associated with a near continuous leakage of gas across a chronically hypotensive LOS. Cardiomyotomy reduced the resting LOS pressure from 14.7+/-1.2 mm Hg to 2.3+/-1.0 mm Hg. Cardiomyotomy with fundoplication was associated with no loss of LOS competence. No gas venting episodes occurred either by passive leakage or by TLOSR. Cardiomyotomy with fundoplication was associated with a fall in mean LOS pressure from 14.3+/-1.5 mm Hg to 7.1+/-1.8 mm Hg but no LOS relaxation occurred during swallowing.

CONCLUSION

Nissen fundoplication is highly effective in preventing reflux across a normal or chronically hypotensive LOS. Fundoplication results in a constant, measurable pressure barrier at the lower end of the oesophagus that is not due to a change in intrinsic LOS tone. Following fundoplication TLOSR are prevented by the constant low-pressure barrier.

Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference?

INTRODUCTION

Curative oesophageal resection for carcinoma may be carried out by either the transhiatal or the Ivor-Lewis transthoracic technique. The aims of this study were to compare the morbidity, 30-day mortality and long-term survival of the two techniques in the treatment of oesophageal carcinoma and to provide data to calculate the sample sizes for a prospective randomized trial.

METHODS

Results from 44 series published between January 1986 and December 1996 were reviewed. Thirty-three papers reported results on 2675 patients having transhiatal (THO) and 29 papers reported results on 2808 patients having Ivor-Lewis oesophagectomy (ILO).

RESULTS

The two groups were comparable in terms of age, sex and stage of the disease. There was no apparent difference in postoperative morbidity between the two groups with respect to respiratory complications (24% for THO, 25% for ILO), cardiovascular complications (12.4% for THO, 10.5% for ILO), wound infection (8.8% for THO, 6.2% for ILO) and chylothorax (2.1% for THO, 3.4% for ILO). The transhiatal group appeared to have a higher incidence of anastomotic leaks (16% for THO, 10% for ILO), anastomotic strictures (28% for THO, 16% for ILO) and recurrent laryngeal nerve injuries (11.2% for THO, 4.8% for ILO). The 30-day mortality was 6.3% for transhiatal and 9.5% for Ivor-Lewis oesophagectomy. Overall long-term survival at 5 years was similar (24% for THO, 26% for ILO).

CONCLUSIONS

The surgical approach to oesophagectomy was not an important determinant of morbidity and long-term survival in patients with oesophageal carcinoma. Transhiatal oesophagectomy was associated with a higher incidence of anastomotic complications and recurrent laryngeal nerve injury. Ivor-Lewis oesophagectomy had a higher mortality. In order to demonstrate a significant difference in morbidity or long-term survival between the two techniques 3100 patients would be required in each arm of a prospective randomized trial.

Somatostatin stimulates the brush-tailed possum sphincter of Oddi in vitro and in vivo

BACKGROUND & AIMS

Somatostatin, a neuropeptide and hormone, is found in the biliary tract of several species. The aim of this study was to map the distribution of somatostatin-like immunoreactive nerve fibers in the extrahepatic biliary tract of the Australian possum and to determine the pharmacological effects of somatostatin 1-14 on sphincter of Oddi activity in vitro and in vivo.

METHODS

Tissue was harvested for immunohistochemistry and sphincter of Oddi for circular or longitudinal muscle contractility. In anesthetized possums, sphincter of Oddi motility was measured by manometry, and transsphincteric flow was measured gravimetrically.

RESULTS

Somatostatin immunoreactivity was evident in gallbladder ganglia nerve cell bodies and in nerve fibers of the common bile duct and sphincter of Oddi. Somatostatin 1-14 increased circular and longitudinal muscle contraction amplitude 3-4-fold (P < 0.05), but only the longitudinal muscle contraction amplitude was tetrodotoxin sensitive. Somatostatin 1-14 stimulated spontaneous sphincter of Oddi motility in a tetrodotoxin-insensitive manner, increasing basal pressure, contraction frequency, and amplitude 2-4-fold (P < 0.05) and reducing transsphincteric flow to 25% of control (P < 0.0001).

CONCLUSIONS

Somatostatin-like immunoreactivity is present in the extrahepatic biliary tree, and somatostatin 1-14 stimulates sphincter of Oddi smooth muscle and nerves. The major action is direct stimulation of sphincter of Oddi circular muscle, which reduces transsphincteric flow.

Gastrin-releasing peptide stimulates gallbladder motility but not sphincter of Oddi motility in Australian brush-tailed possum

The neural distribution and action of gastrin-releasing peptide in the extrahepatic biliary tree of the Australian brush-tailed possum was investigated. Immunohistochemical staining of fixed specimens demonstrated gastrin-releasing peptide-containing nerves throughout the neural plexuses of the gallbladder, sphincter of Oddi, and mucosa of the common bile duct. Gastrin-releasing peptide (5-2000 ng/kg) increased gallbladder tone to a level equivalent to that produced by cholecystokinin octapeptide (160 ng/kg). This action was tetrodotoxin-insensitive. Sphincter of Oddi motility and transsphincteric flow were not altered. Possible mediation of the gallbladder response by gastrin was examined. Gastrin (50-2500 ng/kg) stimulated gastric acid secretion, elevated gallbladder motility to 64% of that produced by gastrin-releasing peptide, and did not alter sphincter of Oddi motility. In conclusion, gastrin-releasing peptide-containing nerves are found in the neural plexus of the possum extrahepatic biliary tree. Gastrin-releasing peptide induces gallbladder contraction in part by a direct action on gallbladder smooth muscle and also via release of gastrin.

Substance P stimulates sphincter of Oddi motility and inhibits trans-sphincteric flow in the Australian brush-tailed possum

Substance P containing nerves are widely distributed throughout the gastrointestinal tract. The aims of this study were to determine the distribution of substance P containing nerves in the extrahepatic biliary tree of the Australian brush-tailed possum and to characterize the effect of exogenous substance P on the sphincter of Oddi (SO) motility and transphincteric flow in vivo. Immunohistochemical staining of fixed specimens (n = 8) found moderate numbers of substance P containing nerve cell bodies and fibres throughout the neural plexuses of the SO, in particular in the serosal and intraluminal nerve trunks of the SO and gallbladder. Synthetic porcine substance P (1-2000 ng kg-1), administered by close intra-arterial injection (i.a.; n = 7), produced a dose-dependent elevation in basal pressure [P < 0.01] and an associated dose-dependent reduction in trans-sphincteric flow [P < 0.0001]. Substance P had no significant dose-dependent effect on SO phasic contraction amplitude or frequency. Tetrodotoxin (9 micrograms kg-1, i.a.) did not inhibit the effect of substance P on SO motility and trans-sphincteric flow (n = 5). In conclusion, substance P containing nerves are found throughout the possum extrahepatic biliary tree. Exogenous substance P stimulates SO motility and reduces trans-sphincteric flow in vivo by acting directly on the sphincter smooth muscle.

An intervention on discharge polypharmacy

OBJECTIVE

To determine if providing a way to cancel pre-admission prescriptions would reduce the number of active drug prescriptions (RXs) at discharge.

DESIGN

A randomized non-blinded clinical trial.

SETTING

Inpatient acute medical service of a university affiliated Veterans Administration medical center.

PARTICIPANTS

Twelve medicine ward teams were randomized to control and intervention groups. Patients controlled had been discharged from these teams during 12 weeks and were receiving outpatient medications from this facility at hospital admission; control = 180, intervention = 168.

INTERVENTION

At discharge, intervention teams used a computer-generated drug list to cancel or renew previous outpatient RXs or to prescribe new medications. Control teams could not cancel outpatient drugs and wrote all medications on individual prescriptions.

MEASUREMENTS

The difference between admission and discharge RXs.

RESULTS

There were no significant differences in patients' age, sex, race, Charlson Index (CI), or LOS between patient groups at discharge. The intervention group had fewer RXs on admission (5.4 vs 6.2, P < .05) and at discharge was not significantly different (2.9 vs 2.9, P = .87) from the control group.

CONCLUSIONS

Providing a method for canceling pre-admission medications did not reduce the number of RXs at discharge. Further research is needed to evaluate the appropriateness of the large increase in RXs from admission to discharge for patients in acute hospital settings.

Percutaneous cystogastrostomy with a new catheter for drainage of pancreatic pseudocysts and fluid collections

We describe a new catheter for the initial percutaneous drainage of large symptomatic pancreatic fluid collections and abscesses using a transgastric approach to allow fluid drainage into the gastric lumen. A double-mushroom stent is placed secondarily for long-term internal drainage to the stomach, avoiding the need for an extended period of external catheter drainage. This technique, termed percutaneous cystogastrostomy (PCG), has been used in 19 consecutive patients with one recurrent symptomatic pseudocyst in the follow-up period fo 9-43 months. There was one death within 30 days of PCG and 1 patient proceeded to surgical necrosectomy. After evidence of resolution of the pseudocysts, the internal stent was retrieved in 17 patients by endoscopic snare.

Laparoscopic common bile duct exploration: evolution of a new technique

Laparoscopic exploration of the common bile duct (CBD) with a choledochoscope or a stone basket during laparoscopic cholecystectomy was attempted in 60 patients and was successful in 56. The cystic duct was used for entry to the CBD in 46 patients and in 14 a choledochotomy was performed. Of 51 patients with confirmed common duct stones, 38 had complete laparoscopic clearance (75 per cent). In 13 patients the duct was not cleared or was only partially cleared, of whom four went on to have clearance by postoperative percutaneous choledochoscopy down a cystic duct or T-tube track. Two patients with cystic duct tubes passed their remaining stones spontaneously. One patient had open exploration and six required endoscopic retrograde cholangiopancreatography. Of nine patients without stones, choledochoscopy was impossible in three patients whose cholangiogram was later considered to be normal. In five patients stones were excluded by choledochoscopy and in one patient laparoscopic choledochoscopy was undertaken to better define abnormal biliary anatomy; this helped to avoid major bile duct injury. Choledochoscopy was easier with the smaller 3.6-mm ureteroscope but stone removal was more difficult when the basket was too small for the stones, the cystic duct too small relative to stone size or the number of stones was too great. Successful stone clearance was proportional to the level of effort expended, and was limited by operating time and equipment.

Prospective randomized comparison of open versus laparoscopic appendectomy in men

A prospective, randomized trial was performed to compare open appendectomy with laparoscopic appendectomy in men with a clinical diagnosis of acute appendicitis. Sixty-four patients with a median age of 25 years (range 18-84 years) were randomized to open appendectomy (n = 31) or laparoscopic (n = 33) appendectomy. Of the 64 men, 56 (87.5%) had appendicitis (27 open, 29 laparoscopic procedures). The mean operating times were 50.6 +/- 3.7 minutes (+/- SEM) for open and 58.9 +/- 4.0 minutes for laparoscopic appendectomy (p = 0.13). Five (15%) patients randomized to laparoscopic appendectomy had an open operation. The mean postoperative hospital stay was significantly longer for open appendectomy (3.8 +/- 0.4 days) than for laparoscopic appendectomy (2.9 +/- 0.3 days) (t = 2. 05,df = 62,p = 0.045). The complication rate after open appendectomy (25.8%) was not significantly different from that after laparoscopic appendectomy (12.1%). There was a single postoperative death due to a pulmonary embolus in the laparoscopic group and a single death due to cardiac and renal failure in the open group. The mean time to return to normal activities was significantly longer following open appendectomy (19.7 +/- 2.4 days) than after laparoscopic appendectomy (10.4 +/- 0.9 days), (t = 3.75,df = 49,p = 0.001). In conclusion, laparoscopic appendectomy in men has significant advantages in terms of a more rapid recovery compared to open appendectomy. There were no significant disadvantages to laparoscopic appendectomy compared to open appendectomy.

Minimal access surgery of the gastrointestinal tract

In the last 5 years, surgery of the gastrointestinal tract has been revolutionized by the application of minimal access techniques. Following initial enthusiasm, which suggested that most abdominal surgery would ultimately be done via this approach, there is now need for appraisal and evaluation of the role of a number of these minimal access techniques when compared with open surgery. Undoubtedly, the most convincing and total application of minimal access techniques has been in the treatment of gallstone disease. Laparoscopic cholecystectomy is now standard therapy for cholelithiasis and endoscopic sphincterotomy with stone extraction is standard therapy for choledocholithiasis. Where the two conditions co-exist, operative cholangiography allows for the recognition of stones in the bile duct at the time of laparoscopic cholecystectomy and provides the potential avenue for treatment. Most major centres also would recommend routine operative cholangiography during laparoscopic cholecystectomy for the detection of unsuspected stones and as an extra safety procedure in the early identification of potential bile duct injuries. The efficacy of laparoscopic appendicectomy and laparoscopic or thoracoscopic treatment of achalasia of the oesophagus also is supported by data from well conducted prospective studies. Doubt remains regarding the advantage of laparoscopic surgery over other approaches in the treatment of gastro-oesophageal reflux, inguinal hernias and jaundice due to non-resectable cancer. For all three of these conditions, prospective trials are underway and the results of these trials should be assessed prior to widespread adoption of the laparoscopic techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic surgery in women with a clinical diagnosis of acute appendicitis

OBJECTIVES

To assess the routine use of diagnostic laparoscopy and laparoscopic appendicectomy in women with a clinical diagnosis of acute appendicitis.

METHODS

Women who presented with a clinical diagnosis of acute appendicitis between 1 January 1992 and 31 August 1993 were prospectively assessed and 107 underwent diagnostic laparoscopy.

RESULTS

Appendicitis was confirmed in 63 women (59%) and no diagnosis could be made in seven (6%). An alternative diagnosis, most commonly a gynaecological disorder, was made in 37 women (35%). Twenty-eight women with an alternative diagnosis (76%) did not require a laparotomy. Seventy-three patients had a laparoscopic appendicectomy, with an 8% conversion rate to an open operation. The morbidity rate for laparoscopic procedures was 3%, the median inpatient stay was two days and the median time to return to normal activities was eight days.

CONCLUSIONS

Diagnostic laparoscopy should be performed in women who present with a clinical diagnosis of acute appendicitis to confirm the diagnosis, reduce the rate of unnecessary appendicectomy and avoid an unnecessary laparotomy. When acute appendicitis is confirmed, appendicectomy may be performed laparoscopically.

Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis

The development of laparoscopic cholecystectomy has created a dilemma in the management of choledocholithiasis. A number of options exist, including endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy in patients with suspected common bile duct (CBD) calculi, laparoscopic bile duct exploration, open CBD exploration and postoperative ES. None of these options has emerged as ideal or universally acceptable. An alternative technique, peroperative ES, has been developed. A prospective assessment of the use of peroperative ES in 13 patients in whom choledocholithiasis was demonstrated with operative cholangiography is presented. Eleven patients had successful ES and clearance of stones. The CBD could not be cannulated in one patient, and an adequate ES for stone extraction could not be performed in the remaining patient. Both procedures were converted to open CBD exploration. Complications were mild postoperative pancreatitis (two patients) and pulmonary atelectasis (one). The median total operating time was 165 min and the median postoperative hospital stay was 3 days. Peroperative ES at the time of laparoscopic cholecystectomy provides a safe technique for clearance of the CBD.

Analysis of local recurrence rates after surgery alone for rectal cancer

Local recurrence (LR) continues to be a major problem following surgical treatment for rectal cancer, and proposed ways of reducing this remain controversial. The aim of this study was to review results from published surgical series in which adjuvant therapies were not used. A Medline search identified series published between January 1982 and December 1992 with follow-up on at least 50 patients with rectal cancer treated surgically for cure, without adjuvant therapy. Fifty one papers reported follow-up on 10,465 patients with a median LR rate of 18.5%. LR was 8.5%, 16.3% and 28.6% in Dukes' A, B and C patients respectively, 16.2% following anterior resection and 19.3% following abdominoperineal resection. Nine papers (1,176 patients) reported LR rates of 10% or less. LR was 7.1% in 1,033 patients having total mesorectal excision and 12.4% in 476 patients having extended pelvic lymphadenectomy. Routine cytocidal stump washout in 1,364 patients was associated with 12.2% LR, however a higher proportion (41%) also underwent total mesorectal excision. In 52% of cases, LR was reported to have occurred with no evidence of disseminated disease. Surgical technique is an important determinant of LR risk. LR rates of 10% or less can be achieved with surgery alone in expert hands.

Endoscopic retrograde cholangiopancreatography following laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the preferred method of treatment for symptomatic choledocholithiasis. Since its introduction there has been an increase in postoperative diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to assess the indications and results of ERCP following laparoscopic cholecystectomy. Sixty-one patients had an ERCP following laparoscopic cholecystectomy. Two broad groups were identified: Group 1 (35 patients) had filling defects (consistent with stones) noted on operative cholangiography, which were not successfully flushed or extracted at the time of laparoscopic cholecystectomy; Group 2 consisted of patients who developed problems following laparoscopic cholecystectomy. Nine patients had post-laparoscopic cholecystectomy pain with abnormal liver function tests (LFT), four of whom had common bile duct (CBD) injuries and three had CBD stones. Eleven patients had post-laparoscopic cholecystectomy pain with a normal diameter common bile duct on ultrasound and normal LFT; only one had a CBD stone. Five patients with a persisting bile leak following laparoscopic cholecystectomy had an ERCP and endoscopic sphincterotomy. In three the leak ceased, while two required subsequent open surgery to drain bile collections and ligate the cystic duct. One patient presented with an episode of transient jaundice but had a normal ERCP. There were six post-ERCP complications; three patients had mild pancreatitis, two had a minor haemorrhage and one an asymptomatic duodenal perforation. Endoscopic retrograde cholangiopancreatography post-laparoscopic cholecystectomy was most valuable for the management of retained stones and the diagnosis and management of post-laparoscopic cholecystectomy pain in association with abnormal LFT. The diagnostic yield was low (9%) when the LFT were normal.

Minimizing the risk of bile duct injury at laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy (LC) has been associated with an increase in the incidence of operative bile duct injuries. An operative technique that involves commencing the laparoscopic dissection on the body of the gallbladder and dissecting toward the cystic duct has been developed that minimizes the risk of major duct injury. The aim of this study was to assess prospectively the safety of this dissection technique. A group of 410 patients underwent LC for symptomatic cholelithiasis from January 1991 to December 1992. There was a single common hepatic duct injury: a small (1 mm) side hole in a patient with acute cholecystitis and choledocholithiasis. It was managed at open operation with exploration of the common bile duct and insertion of a T-tube. There were no partial or complete common bile duct transections in this series. We concluded that the technique of commencing the dissection on the gallbladder is safe and minimizes the risk of serious common bile duct injury at LC.

Sterilization of dental instruments and devices: an update

Dental sterilization techniques have become a focus of attention as a result of disclosure of occupational HIV transmission from an infected dentist to a cluster of patients. Although there has never been a confirmed report of a patient acquiring an infectious blood-borne disease from a dental instrument or device, recommendations for universal sterilization of dental handpieces and other devices have recently been implemented. Because of the higher rate of hepatitis B virus transmissability in the dental health care environment, an upgrade in sterilization protocols may be warranted. Stringent sterilization standards are especially necessary in higher-risk institutional dental care settings. However, a high rate of dental sterilization errors has been reported and traced to operator error. Recent institutional dental sterilization policy changes have been developed to reduce the chance of sterilization error, further diminishing the risk of cross contamination.

Traumatic duodenal rupture and avulsion of the ampulla of Vater

Duodenal injury following blunt abdominal trauma is uncommon. The severity of injury can vary from an intramural haematoma to a duodenal rupture with associated transection of the pancreatic duct. A case of duodenal rupture with avulsion of the ampulla of Vater is presented and discussed.

Laparoscopic appendicectomy: a prospective analysis

The potential advantages of laparoscopic surgery for a number of abdominal operations including appendicectomy have been heralded. In this study the aims were to assess prospectively the role of routine diagnostic laparoscopy in the diagnosis of acute appendicitis and determine the efficacy of laparoscopic appendicectomy. Patients with suspected acute appendicitis had diagnostic laparoscopy. When the diagnosis was confirmed laparoscopic appendicectomy was performed. Where an alternative diagnosis was made the appropriate treatment was instituted. If no diagnosis could be made the macroscopically normal appendix was removed by laparoscopic appendicectomy. Eighty-one patients (50 female, 31 male) had an initial diagnostic laparoscopy; 53 had appendicitis and proceeded to laparoscopic appendicectomy. A diagnosis could not be established at diagnostic laparoscopy in six patients and they also proceeded to laparoscopic appendicectomy. An alternative diagnosis was made in the remaining 22 patients (19 female and 3 male), with five proceeding to laparotomy and one patient with mesenteric adenitis having laparoscopic appendicectomy. Seven patients having laparoscopic appendicectomy required conversion to an open operation due to a retrocaecal or perforated appendix. The median operating time for successful laparoscopic appendicectomy was 55 min (range 30-95). Morbidity occurred in five of 53 patients having a successful laparoscopic appendicectomy. The median postoperative hospital stay was 2 days. The median time before return to normal activities was 8 days. Diagnostic laparoscopy is a useful diagnostic technique in women with suspected acute appendicitis, as it improves diagnostic accuracy, reduces the negative appendicectomy rate and avoids unnecessary laparotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

The operative aetiology and types of adhesions causing small bowel obstruction

Postoperative adhesions account for 64-79% of admissions with small bowel obstruction (SBO). The aim of this study was to identify the operative procedures and the types of adhesions that cause SBO. A retrospective analysis of all patients with an admission diagnosis of acute adhesive SBO between January 1982 and December 1990 was performed. One hundred and nineteen patients had 144 admissions with an initial diagnosis of acute SBO due to adhesions. The previous operations were: appendicectomy 23.3%; colorectal resection 20.8%; gynaecological surgery 11.7%; upper gastrointestinal (gastric, biliary or splenic) surgery 9.2%; small bowel surgery 8.3%; and more than one previous abdominal operation 23.6%. Sixty-one admissions required surgery to relieve the SBO. Eighteen patients had strangulated small bowel. All but two of these patients had a single band adhesion causing the SBO and associated strangulation. Band adhesions were commonly found following appendicectomy, colorectal resections or gynaecological operations. Seventeen of the 21 patients with previous surgery for a colorectal malignancy had benign adhesions causing the SBO, while four of the six patients with either previous ovarian or previous gastric carcinoma had recurrent malignancy causing the SBO. Five patients had previously undiagnosed carcinomas (three ovarian and two caecal) as the cause of the SBO.

Laparoscopic cholecystectomy for acute inflammation of the gallbladder

OBJECTIVE

The aim of this study was to prospectively assess the results of laparoscopic cholecystectomy in patients with acute inflammation of the gallbladder.

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder disease. Its role in the surgical treatment of acute cholecystitis has not been defined, although a number of recent reports suggest that there should be few contraindications to an initial laparoscopic approach.

METHODS

All patients presenting with symptomatic cholelithiasis from October 1990 until June 1992 were evaluated at laparoscopy with intention of proceeding to a laparoscopic cholecystectomy. The gross appearance of the gallbladder was categorized as acute inflammation, chronic inflammation, or no inflammation. Ninety-eight (23.4%) of 418 patients had acute inflammation of the gallbladder: 55 were edematous, 10 were gangrenous, 15 had a mucocele, and 18 had an empyema.

RESULTS

The authors assessed outcome in these patients. The frequency of conversion to an open operation was 33.7% for acute inflammation, 21.7% for chronic inflammation (p < 0.05), and 4% for no inflammation (p < 0.001). The conversion rate was highest for empyema (83.3%) and gangrenous cholecystitis (50%), while the conversion rate for edematous cholecystitis was 21.8% and for acute inflammation with a mucocele it was 7%. The median operation time for successful laparoscopic cholecystectomy for acute inflammation was 105 minutes, which was longer than that with no inflammation (90 minutes). However, the incidence of complications was not different from that for chronic or no inflammation. The median postoperative stay for patients with acute gallbladder inflammation was 2 days for successful laparoscopic cholecystectomy and 7 days for patients converted to an open operation.

CONCLUSIONS

Laparoscopic cholecystectomy for acute inflammation of the gallbladder is safe and is associated with a significantly shorter postoperative stay compared to open surgery. A greater number of patients required conversion to open operation compared to those with no obvious inflammation. Conversion to open operation was most frequent for empyema and gangrenous cholecystitis, suggesting that once this diagnosis is made, excessive time should not be spent in laparoscopic trial dissection before converting to an open operation.

Percutaneous cystogastrostomy for treatment of pancreatic pseudocysts

Cystogastrostomy or cystojejunostomy at open operation has been the usual treatment for symptomatic pancreatic pseudocyst. The aim of this study was to assess prospectively the results of percutaneous cystogastrostomy (PCG) for the treatment of symptomatic pseudocysts. The technique of PCG comprised initially of drainage of the pseudocyst with a 10 Fr percutaneous, transgastric catheter. This initial drainage catheter had two components; the first, between the pseudocyst and the stomach, drained the pseudocyst and the second, between the stomach and exterior, acted as a percutaneous gastrostomy. The initial drain was left in situ for 14 days, at which time it was exchanged percutaneously for the definitive PCG; a double ended Mallecot type catheter that drained between the pseudocyst and the stomach. The latter catheter was left in situ until there was no residual pseudocyst demonstrated on computerized tomography scan and was removed endoscopically. Eleven patients with large (> 6 cm), symptomatic pseudocysts have been treated with PCG. All patients were treated successfully without the need for surgical intervention. The median time to radiological resolution was 24 days. There were four episodes of sepsis, two related to central venous line infections nad two related to catheter blockage. Percutaneous, cystogastrostomy blockage was managed by either replacing the initial drain or inserting a second catheter. The median follow up after successful treatment was 9 months (range 2-17). There were no symptomatic recurrences and one small (2 cm) asymptomatic recurrent pseudocyst. This preliminary experience with PCG demonstrates the efficacy of this procedure for treating symptomatic pancreatic pseudocysts.

Laparoscopic cholecystectomy and management of choledocholithiasis

The advent of laparoscopic cholecystectomy (LC) has led to a reassessment of the approach to the management of choledocholithiasis. In a consecutive series of 418 patients undergoing LC, common bile duct (CBD) stones were suspected pre-operatively in 130 patients. Forty-five of the patients (35%) were found to have CBD stones on either pre-operative endoscopic retrograde cholangiopancreatography (ERCP; 20) or on operative cholangiography (OC; 25). Common bile duct stones were detected on OC in a further 12 of 288 patients (4.2%) without pre-operative suspicion of choledocholithiasis. Of the total of 57 patients with CBD stones, the duct was cleared by pre-operative ERCP and endoscopic sphincterotomy (ES) in 15 patients. In 13 patients, two of whom had had a pre-operative ERCP and ES, duct clearance was achieved by relaxing the sphincter pharmacologically and flushing the CBD via the OC catheter. One patient had an on-table ERCP and ES with successful stone extraction during LC. Eleven patients were converted to open operation with bile duct exploration. Sixteen patients had a postoperative ERCP. In five patients the CBD stones had passed spontaneously in the time between LC and ERCP. Ten patients required ES to clear the duct of stones. One patient had a failed ERCP and is still awaiting a repeat. The remaining patient was scheduled, but did not return for follow-up ERCP. In summary, pre-operative ERCP was indicated in less than 10% of patients in this series.(ABSTRACT TRUNCATED AT 250 WORDS)

The safety and duration of non-operative treatment for adhesive small bowel obstruction

Small bowel obstruction (SBO) due to adhesions is often initially treated non-operatively but the safety and duration of non-operative treatment is controversial. The aims of this study were to assess the safety of non-operative treatment and determine the optimal duration of non-operative treatment in adhesive SBO. A retrospective analysis of patients admitted with a diagnosis of adhesive SBO following an initial period of non-operative treatment was performed. Patients whose condition resolved with non-operative treatment were compared with patients who required surgical intervention after an initial period of non-operative treatment. There were 123 admissions having an initial period of non-operative treatment. The SBO resolved in 85, the remaining 38 required surgical intervention. Complete resolution occurred within 48 h in 75 (88%) cases, the remaining 10 had resolved by 72 h. Thirty-one of 38 patients required surgical intervention for SBO more than 48 h duration after admission. The difference between cases resolving within 48 h and those requiring surgery after 48 h was significant (chi 2 = 113, P < 0.001). Three (2.4%) patients, initially treated non-operatively, had small bowel strangulation. All three were operated on within 24 h of admission when changes in clinical findings suggested small bowel strangulation may be present. There were no deaths in the group having an initial period of non-operative treatment. In the absence of any signs of strangulation, patients with an adhesive SBO can be managed safely with non-operative treatment. Most cases of adhesive SBO that will resolve, do so within 48 h of admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrent traumatic splenic rupture two years after non-operative treatment of splenic trauma

Non-operative and conservative surgical management are now the preferred methods of treatment for blunt splenic trauma in children and adults. These conservative strategies evolved as the risk of late septic complications following splenectomy for trauma became apparent. Although recurrent splenic trauma following conservative management of the ruptured spleen is rare, its surgical management may pose some difficult problems. We present a case in which a second episode of splenic trauma required surgery, two years after the successful non-operative management of the first splenic injury.

OPEN CHOLECYSTECTOMY: A CONTROL GROUP FOR COMPARISON WITH LAPAROSCOPIC CHOLECYSTECTOMY

Laparoscopic cholecystectomy is rapidly becoming accepted as the best method for the treatment of symptomatic cholelithiasis. Randomized clinical trials comparing laparoscopic cholecystectomy with open cholecystectomy are unlikely to be performed. In order to compare these two operations, surgeons need an historical control group of patients who have undergone a conventional open cholecystectomy. The aim of this study was to document a control group of patients having an open cholecystectomy and compare them with patients having a laparoscopic cholecystectomy. This was achieved by a retrospective study of all patients who had an open cholecystectomy from January 1985 to December 1989. Four hundred and fifty-seven patients, 345 women and 112 men, had a cholecystectomy. Exploration of the common bile duct (ECBD) was performed in 59 (12.5%) cases. The mean operative duration was 73 min for cholecystectomy and 118 min for cholecystectomy and ECBD. The shortest mean postoperative stay was for an elective cholecystectomy (5.3 days) and the longest mean postoperative stay was for urgent admissions requiring ECBD (12.0 days). Operative dissection was difficult in 14.1% of elective cases and 51.8% of urgent cases. Ninety-seven (19.5%) patients had an additional procedure, unrelated to cholelithiasis, at the same operation; 44 did not require laparotomy, 31 had interval appendectomies, and 22 other cases required laparotomy in order to perform the additional procedure. All but one patient required postoperative narcotic analgesia. The mean duration of narcotic analgesia was 2.3 days. The complication rate was 35.2% for cholecystectomy and 62.5% for ECBD. If pulmonary atelectasis is excluded as a complication, these complication rates fell to 6.8% and 20.1%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Linitis plastica carcinoma of the colon mimicking Crohn's colitis

Primary linitis plastica carcinoma of the colon is an uncommon morphological type of colorectal carcinoma. Linitis plastica of the stomach may spread to the colon producing a similar lesion to primary colonic linitis plastica. This case report describes a case of linitis plastica of the colon that had many of the clinical, endoscopic, radiological and operative features of Crohn's colitis. The precise origin of the linitis plastica carcinoma was not clear: it may have been clonic or gastric, although the former is favoured. This case illustrates a number of facets of this unusual colonic carcinoma.

An evaluation of radionuclide bone scanning and liver ultrasonography for staging breast cancer

The use of nuclear bone scanning and liver ultrasonography to stage breast cancer is an established practice in many hospitals. A 3 year prospective study was undertaken to assess the usefulness of these two investigations. Three hundred and fifty-eight patients were analysed: 133 had stage I disease, 188 were stage II and 37 were stage III. Bone scans were performed on 339 (94.7%) patients; 302 had stage I or stage II disease; and 37 were stage III. Bone scans were positive for metastases in only 0.9% of stage I and II patients but were positive in 16.2% of patients with stage III disease. None of the 309 (96.2%) stage I or stage II patients who had an ultrasound scan had any liver metastases detected whereas positive scans were obtained in 5.4% of stage III patients. It can be concluded that the incidence of demonstrable bone or liver metastases in stage I and stage II breast cancer patients is so low that the use of routine scanning can be abandoned.

Collis-Nissen gastroplasty fundoplication for complicated gastro-oesophageal reflux disease

Collis-Nissen gastroplasty fundoplication is a widely accepted operation for patients with gastro-oesophageal reflux disease complicated by oesophageal shortening. Assessment of this operation by 24 h oesophageal pH monitoring has not previously been reported. Our aim was to correlate clinical and endoscopic results with 24 h pH studies. Twenty-nine patients had a gastroplasty fundoplication, as a result of which twenty-five (86%) had an excellent clinical result, 2 (7%) had a good result and 2 (7%) had a poor result. The two poor results were in patients who had previously undergone anti-reflux surgery. All 29 patients had pre-operative pH monitoring. Twenty-three patients had postoperative pH studies. Oesophageal acidification times were normal postoperatively in 16 of 23 patients however, 7 still had an abnormal study. One of the two patients with a poor clinical result was studied and persistent severe oesophageal acidification was demonstrated. The remaining 6 patients with abnormal studies were asymptomatic. Five of the 6 asymptomatic patients also had a normal oesophagogastroscopy with no macroscopic oesophagitis. We conclude that 24 h pH monitoring after the Collis-Nissen operation should only be performed to assess clinically and endoscopically poor results.

Infarcation of a jejunal leiomyoma presenting as an acute abdomen

Leiomyomata of the small intestine are rare benign tumours of the small intestine that usually present with gastrointestinal bleeding, vague abdominal pains or small bowel obstruction. A case is reported of a patient who presented with an acute abdomen due to infarction of a leiomyoma of the proximal jejunum.

A retrorectal abscess due to Crohn's disease of the terminal ileum

A case of retrorectal abscess due to Crohn's disease is reported. This is a rare complication, of which only one previous report in the literature has been found.

Closure of persistent post-proctectomy perineal sinus using a rectus muscle flap

A persistent perineal sinus following proctocolectomy or proctectomy is a not infrequent complication associated with considerable morbidity. Two cases are presented where the perineal sinus was closed using a rectus abdominis flap. This method of closure allows safe, complete excision of the sinus and insertion of a muscle flap which completely fills the defect, enabling complete, primary healing of the perineum.

Solitary thyroid nodule: a prospective evaluation of nuclear scanning and ultrasonography

The aim of this study was to assess prospectively the value of thyroid nuclear scans and ultrasound examination in the preoperative investigation of patients with a solitary thyroid nodule. Total thyroid lobectomy for a solitary thyroid nodule was performed in 68 cases. Each patient had a thyroid isotope scan (except two women who were pregnant) and thyroid ultrasound examination. There were 10 (15 per cent) malignant nodules, 11 (16 per cent) benign neoplastic nodules and 47 (69 per cent) benign non-neoplastic nodules. All of the patients with malignant nodules who were scanned had a solitary cold nodule on thyroid scan, as did 40 (69 per cent) of those with benign solitary nodules. Ultrasound examination of the thyroid suggested correctly that one of 16 (6 per cent) cystic lesions, four of 16 (25 per cent) complex solid-cystic lesions and three of 18 (17 per cent) of solid lesions were malignant. One lesion reported as multinodular on ultrasonography and one reported as normal also turned out to be malignant. Thyroid isotope scans and ultrasound do not accurately differentiate between benign and malignant conditions and their routine use in the investigation of a solitary thyroid nodule should be abandoned.

Response of canine lower esophageal sphincter to gastric distension

The aim of this study was to localize the region of the stomach responsible for triggering distension-induced transient lower esophageal sphincter relaxation (TLESR). The canine stomach was partitioned into subsegments by a row of buttressed sutures. This separated either the fundus from the lesser curve or the proximal stomach from the antrum. After 1 mo each region was progressively distended while gastroesophageal pressures were monitored. At the time of the first TLESR, gastric wall tension was estimated from the bag pressure and volume. Distension of the intact stomach, lesser curve, or proximal stomach in 12 dogs produced a progressive increase in lower esophageal sphincter (LES) pressure, which was interrupted at low gastric wall tension (29, 35, and 40 mmHg.cm, respectively) by a superimposed TLESR. Background LES pressure fell progressively with distension of the antrum but was unchanged by distension of the fundus alone. Both the fundus and antrum had significantly higher thresholds for triggering TLESR (96 and 105 mmHg.cm). In another two dogs truncal vagotomy performed at the time of gastric partitioning prevented both the change in background LES pressure, and the triggering of TLESR, associated with proximal gastric and antral distension. We conclude that the subcardiac region of the stomach is primarily responsible for triggering TLESR induced by distension and that the effect on background LES pressure depends on the region distended.

Influence of posture on transient lower oesophageal sphincter relaxation and gastro-oesophageal reflux in the dog

The hypothesis that suppression of transient lower oesophageal sphincter relaxation (TLOSR) in recumbent postures in the dog is dependent upon the sensing of a gastric pool of liquid in proximity to the lower oesophageal sphincter was examined. Constant gastric insufflation with air (80 ml/min) was used to evoke TLOSR in unsedated, fasting animals. Oesophageal motility was monitored with a perfused manometric sleeve catheter assembly. Gastrooesophageal flow was recognized manometrically and by oesophageal pH recording. TLOSR occurred significantly less frequently in three recumbent positions (right lateral, left lateral and supine) than when the dog stood on four legs, but was more likely to be associated with acid reflux when they occurred in recumbent positions. Aspiration of the gastric pool was found to have no effect on triggering of TLOSR although it reduced the frequency with which acid reflux was associated with TLOSR. It is concluded that the low rate of occurrence of TLOSR in recumbent positions is unlikely to be explained by the presence of a gastric pool of liquid in proximity to the lower oesophageal sphincter.

Effect of general anaesthesia on transient lower oesophageal sphincter relaxations in the dog

This report investigates the hypothesis that gastro-oesophageal flow is modulated by central nervous activity. The hypothesis was examined using the canine model in which gastro-oesophageal flow was stimulated by gastric insufflation of air at 80 ml/min and central nervous depression was produced with the anaesthetic agents thiopentone, nitrous oxide and halothane. Duplicate paired studies were performed in four dogs, either unsedated or anaesthetized. Gastro-oesophageal flow was assessed manometrically by a sleeve catheter assembly and by pH electrode. Gastric compliance was assessed by inflation of a thin-walled, plastic bag. Transient lower oesophageal sphincter relaxation, the dominant mechanism of retrograde trans-sphincter flow in unsedated animals, was abolished by general anaesthesia. Retrograde flow of gas across the lower oesophageal sphincter in anaesthetized animals eventually occurred, but only after massive gastric distension and elevation of gastric pressure to lower oesophageal sphincter pressure. The effects observed could not be explained by a direct action of anaesthetic on the lower oesophageal sphincter or on the gastric wall. It is proposed that general anaesthesia results in blockade of the neural pathway responsible for transient lower oesophageal sphincter relaxation by withdrawal of facilitative higher centre activity. The findings have implications for the use of sedation in experimental studies on factors which control gastro-oesophageal reflux, and clinical application to the risk of tracheal aspiration during general anaesthesia.