Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis

BACKGROUND

No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS).

AIM

To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates.

METHODS

Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014-April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR.

RESULTS

Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001).

CONCLUSION

This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.

Shaped-bolus protocol reduces contrast medium volume in abdominal CT while maintaining image quality

AIM

To prospectively assess whether bolus shaping to exponentially decrease the contrast medium injection rate leads to alteration in image validity or renal function.

MATERIALS AND METHODS

In this prospective study, patients alternatively received 100 ml contrast medium versus 75 ml via bolus shaping. Image quality was assessed via measurement of attenuation values in the aorta, liver, and spleen and also blinded subjective assessment of image sharpness, low contrast detectability, image noise, and overall quality. Renal function was assessed by change in creatinine levels up to 72 hours post-contrast medium administration.

RESULTS

Of 190 abdominal computed tomography (CT) studies performed in the 3-month period, 98 received the 75 ml dose. There was no significant difference in renal function or objective image quality with a significant improvement in image sharpness in the 100 ml group.

CONCLUSIONS

By using bolus-shaping software, it is possible to maintain objective image quality while reducing the contrast medium load to the patient. This has significant implications regarding clinical practice in decreasing cost and risks associated with iodinated contrast media.

Sedation for gastroscopy: Is it an adequately understood and informed choice?

INTRODUCTION

Sedation uptake rates for oesophagogastroduodenoscopy (OGD) vary greatly. Issues concerning adequate information and consent have been raised. Additionally, patient comprehension of sedation options is inconsistent.

METHODS

A closed ended questionnaire was created and delivered to assess patient understanding regarding sedation prior to OGD. The questionnaire was based on British Society of Gastroenterology guidelines.

RESULTS

One hundred and eleven patients were recruited. 90 % of the sedated and 73 % of the unsedated patients were satisfied with their respective decisions (OR 0.283, *p = 0.01). 65 % were unaware of basic differences between conscious sedation and general anesthesia, and 37 % were unaware that driving is permitted after having throat spray alone. The most informed of the age groups had the lowest uptake of sedation and the least informed had the highest uptake.

CONCLUSION

The decision to undergo gastroscopy with or without sedation is not a sufficiently informed one. This study highlights the need for the widespread dissemination of good quality information to inform patients better regarding sedation prior to OGD.

The impact of changes in work practice and service delivery on surgical infection rates in a general surgical unit

Ring-fencing of elective orthopaedic beds has been shown to significantly reduce surgical site infection (SSI) rates. There are fewer studies in general surgical practice. Comparison of overall surgical workload in 2007 and 2011 was performed. Data pertaining to SSI were collected and analysis of this prospectively maintained database was performed on all SSI diagnosed in 2007 and 2011. There was a significant reduction in the crude SSI rate from 117 cases in 2007 (8%) to 42 cases in 2011 (3.5%). A statistically significant reduction in SSI rate for elective surgery was observed, 7.6% vs. 2.5% (p<0.001 Chi-square test). Apart from the introduction of ring fencing, all other contributory variables remained unchanged. Ring-fencing of inpatient general surgical beds has been associated with a significant reduction in SSI rates. These data provide timely supportive evidence that ring-fencing of inpatient beds is an appropriate patient-orientated strategy.

Operative surgical yield from general surgical outpatient clinics; time to change the way we practice?

The aim of this study was to compare the number of patients attending surgical outpatient clinics in a general hospital to the number of resulting elective procedures scheduled in a single year. Patients initially assessed at private consulting rooms are not included in this study. The number of surgical outpatient appointments issued in 2011 totalled 6503 with non-attendances running at 1489 (22.9%). The number of elective surgical theatre cases performed in 2011 (i.e. the surgical yield from that period) came to 1078 with an additional 1470 patients referred for endoscopy and 475 patients referred for minor operations. Operative surgical yield from the currently structured outpatient clinic model is low, with the number of theatre cases coming to only 16.58% of the original number of outpatient appointments issued. Recommendations for the improvement of outpatient services are made. These findings are relevant in the context of streamlining access to surgical services.

Higher surgical training opportunities in the general hospital setting; getting the balance right

BACKGROUND

The general hospital can play an important role in training of higher surgical trainees (HSTs) in Ireland and abroad. Training opportunities in such a setting have not been closely analysed to date.

AIMS

The aim of this study was to quantify operative exposure for HSTs over a 5-year period in a single institution.

METHODS

Analysis of electronic training logbooks (over a 5-year period, 2007-2012) was performed for general surgery trainees on the higher surgical training programme in Ireland. The most commonly performed adult and paediatric procedures per trainee, per year were analysed.

RESULTS

Standard general surgery operations such as herniae (average 58, range 32-86) and cholecystectomy (average 60, range 49-72) ranked highly in each logbook. The most frequently performed emergency operations were appendicectomy (average 45, range 33-53) and laparotomy for acute abdomen (average 48, range 10-79). Paediatric surgical experience included appendicectomy, circumcision, orchidopexy and hernia/hydrocoele repair. Overall, the procedure most commonly performed in the adult setting was endoscopy, with each trainee recording an average of 116 (range 98-132) oesophagogastroduodenoscopies and 284 (range 227-354) colonoscopies.

CONCLUSIONS

General hospitals continue to play a major role in the training of higher surgical trainees. Analysis of the electronic logbooks over a 5-year period reveals the high volume of procedures available to trainees in a non-specialist centre. Such training opportunities are invaluable in the context of changing work practices and limited resources.

Beware the ischiorectal abscess

INTRODUCTION

Ischiorectal abscesses have been shown to form sinuses with various deep structures but continuity with the spinal canal is extremely rare.

PRESENTATION OF CASE

A previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches. He had systemic sepsis and resultant coagulapathy (INR 3.4) which precluded investigation of neurological symptoms by lumbar puncture. MRI rectum demonstrated a well circumscribed fluid collection with direct connection to the spinal canal and containing meningeal tissue. It extended inferiorly to the right ischiorectal fossa and abutted the natal cleft. A radiological diagnosis of ischiorectal abscess which had become continuous with a previously existing anterior sacral myelomeningocoele (ASM) was made. He was treated with broad spectrum antibiotics and a neurosurgical opinion was sought. He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically.

DISCUSSION

Few general surgeons would be faced with acute management of complicated ASM. Paucity of literature made application of evidence based medicine difficult. In fit healthy patients surgery is the mainstay of treatment as myelomengingoceles do not regress spontaneously. Conservative management is associated with up to 30% mortality (largely due to bacterial meningitis). The patient in this case was adamant that he did not consent to definitive surgical intervention.

CONCLUSION

This case highlights challenges encountered in the management of complicated ASM in a general hospital.

Life after the cancer strategy: analysis of surgical workload in the general hospital setting

BACKGROUND

The National Cancer Strategy heralded a major reorganisation of the delivery of cancer services in Ireland. As a result of this policy, cancer care was centralised to eight centres. The impact of this strategy on hospitals no longer providing cancer services has not been analysed to date.

AIM

The aim of this study was to examine the impact of centralisation of cancer services on surgical workload at Mayo General Hospital.

METHODS

Data pertaining to all surgical procedures performed in 2007 (prior to the introduction of the National Cancer Strategy) and 2011 were obtained using the Hospital Inpatient Enquiry system. Histopathology reports and theatre registers were also analysed to ensure accuracy of the data.

RESULTS

The numbers of elective and emergency surgical admissions during 2007 and 2011 were broadly similar (2,581 vs. 2,662). One hundred and thirty-five oncological procedures (colorectal and breast) were carried out in 2007 compared with 50 (colorectal) in 2011. This represents a 63% reduction in cancer surgery workload following the implementation of the National Cancer Strategy. There was a concomitant increase in surgery performed for benign conditions (laparoscopic cholecystectomy and hernia repair), which coincided with the innovative introduction of 43 ring-fenced surgical in-patient beds in June 2010.

CONCLUSION

This study demonstrates the impact of the centralisation of cancer services on surgical workload in a non-cancer centre. Our results show that there continues to be a role for general hospitals in the provision of elective surgical services. Hospital network arrangements have the potential to facilitate such developments.

Paediatric surgery--a general hospital experience

Plans to centralise paediatric surgery in Ireland have potentially significant implications for service provision and surgical training. study assesses the workload of paediatric surgery in a district hospital over a five-year period. Paediatric surgical admissions and procedures at Mayo General Hospital from January 2006 - December 2010 were reviewed. Data was obtained from the Hospital inpatient enquiry (HIPE) systems and theatre logbooks. 4,255 surgical procedures were performed in 3981 paediatric patients, accounting for 7.4% of the total surgical workload. 2,578 (65%) of cases were elective and 1403 (35%) of paediatric surgery was performed in the emergency setting; paediatric appendicectomy was the most commonly performed procedure (n = 554) with a complication rate of 2.5%. There were no paediatric surgery related mortalities. Paediatric surgery represents a significant part of the surgical workload. There is a continued need for general paediatric surgical provision in this regional setting, supported by access to specialist centres for complicated paediatric surgery.

Management of the acute appendix mass: a survey of surgical practice

Management of the appendix mass is controversial with no consensus in the literature. Traditionally, the approach has been conservative followed by interval appendicectomy. A survey was distributed to 117 surgeons (100 consultants and 17 final year specialist registrars) to determine how the appendix mass is currently treated in Ireland. In total, 70 surgeons responded. 51 (73%) adopt a conservative approach initially. 48 (68%) favoured interval appendicectomy at six weeks after a period of successful conservative management. 34 (49%) gave risk of recurrence as the reason for performing interval appendicectomy and 16 (22%) would perform interval appendicectomy in order to obtain histological analysis to outrule caecal or appendiceal neoplasm. 44 (63%) opted for a laparoscopic rather than an open approach for interval appendicectomy. No consensus exists in Ireland for management of the appendix mass presenting acutely. The present series demonstrates a trend towards conservative approach initially followed by interval appendicectomy.

Day of surgery admission for the elective surgical in-patient: successful implementation of the Elective Surgery Programme

BACKGROUND AND AIMS

The aim of this prospective cross-sectional study was to determine the impact of (1) ring fencing in-patient general surgical beds and (2) introducing a pre-operative assessment clinic (PAC) on the day of surgery admission (DOSA) rate in a single Irish institution. The secondary aim was to analyse the impact of an increased rate of DOSA on cost efficiency and patient satisfaction.

METHODS

An 18-month period was examined following ring-fencing of elective and emergency surgical beds. A PAC was established during the study period. Prospectively collected data pertaining to all surgical admissions were retrieved using patient administration system software (Powerterm Pro, Eircom Software) and a database of performance information from Irish Public Health Services (HealthStat).

RESULTS

Ring-fencing and PAC establishment was associated with a significant increase in the overall DOSA rate from 56 to 85%, surpassing the national target rate of DOSA (75%). Data relating specifically to general surgery admissions mirrored this increase in DOSA rate from a median of 5 patients per month, before the advent of ring-fencing and PAC, to 42 patients per month (p < 0.0387). 100 patient surveys demonstrated high levels of satisfaction with DOSA, with a preference compared to admission one night pre-operatively. Cost analysis demonstrated overall savings of 340,370 Euro from this change in practice.

CONCLUSION

The present study supports the practice of DOSA through the introduction of ring-fenced surgical beds and PAC. This has been shown to improve hospital resource utilisation and streamline surgical service provision in these economically challenging times.

Successful introduction of ring-fenced inpatient surgical beds in a general hospital setting

This study aimed to assess the impact of ring-fenced inpatient general surgical beds on day of surgery (DOS) admission, duration of elective inpatient stay (DEIS), and cancellation rates over a 6 month period. In June 2010 17 of 60 surgical inpatient beds were decommissioned. The remainder (43) were ring-fenced for general surgery patients only. Comparative analysis examining admission rates, cancellation rates, and theatre activity was performed between a reference period (January-June 2010) and the study period (July-December 2010). Complexity of all operations was graded according to an index schedule of procedures. There was no difference between the reference and study periods in volumes of elective admissions (472 [53.03%] vs. 418 [4797%]) and emergency admissions (928 [50.03%] vs. 927 [49.97%]). DOS admissions increased 5-fold during the study period (38 [8.1%] vs. 190 [45.5%], P < 0.001). Average duration of elective inpatient stay reduced from 4.3 days to 3.06 days in the study period (P < 0.001). No difference was observed in volume of operations performed at all levels of complexity. There were 78 (58.2%) cancellations during the reference period and 56 (41.8%) during the study period with patient non-attendance the most common cause for cancellation in both periods. Ring-fenced surgical beds facilitated higher DOS admission rates and shorter duration of elective inpatient stay, leading to more efficient use of hospital resources.

Recurrent sigmoid volvulus - early resection may obviate later emergency surgery and reduce morbidity and mortality

INTRODUCTION

Acute sigmoid volvulus is a well recognised cause of acute large bowel obstruction.

PATIENTS AND METHODS

We reviewed our unit's experience with non-operative and operative management of this condition. A total of 27 patients were treated for acute sigmoid volvulus between 1996 and 2006. In total, there were 62 separate hospital admissions.

RESULTS

Eleven patients were managed with colonoscopic decompression alone. The overall mortality rate for non-operative management was 36.4% (4 of 11 patients). Fifteen patients had operative management (five semi-elective following decompression, 10 emergency). There was no mortality in the semi-elective cohort and one in the emergency surgery group. The overall mortality for surgery was 6% (1 of 15). Five of the seven patients managed with colonoscopic decompression alone who survived were subsequently re-admitted with sigmoid volvulus (a 71.4% recurrence rate). The six deaths in our overall series each occurred in patients with established gangrene of the bowel. With early surgical intervention before the onset of gangrene, however, good outcomes may be achieved, even in patients apparently unsuitable for elective surgery. Eight of the 15 operatively managed patients were considered to be ASA (American Society of Anesthesiologists) grade 4. There was no postoperative mortality in this group.

CONCLUSIONS

Given the high rate of recurrence of sigmoid volvulus after initial successful non-operative management and the attendant risks of mortality from gangrenous bowel developing with a subsequent volvulus, it is our contention that all patients should be considered for definitive surgery after initial colonoscopic decompression, irrespective of the ASA score.

Isolated pancreatic metastases from a bronchogenic small cell carcinoma

We describe the case of a 60 year old female smoker who presented with a three month history of weight loss (14 Kg), generalized abdominal discomfort and malaise. Chest radiography demonstrated a mass projected inferior to the hilum of the right lung. Computed Tomography of thorax confirmed a lobulated lesion in the right infrahilar region and subsequent staging abdominal CT demonstrated a low density lesion in the neck of the pancreas. Percutaneous Ultrasound guided pancreatic biopsy was performed, histology of which demonstrated pancreatic tissue containing a highly necrotic small cell undifferentiated carcinoma consistent with metastatic small cell carcinoma of the bronchus.

Concurrent diagnosis of Crohn's disease and colorectal carcinoma in a young man with abdominal pain

The lead time between diagnosis of Crohn's disease and presentation with a Crohn's related malignancy is generally twenty years from diagnosis. This case outlines that of a young man who presented to the emergency department with abdominal pain and was subsequently discovered to have a malignant stricture complicating underlying Crohn's disease that was previously quiescent and undiagnosed. It demonstrates that a new diagnosis of Crohn's disease does not rule out previously quiescent underlying disease and therefore risk of colrectal carcinoma.

Acute dyspnoea due to an incarcerated right-sided Bochdalek's hernia

We present the case of a 76-year-old man with a right-sided Bochdalek hernia, admitted acutely with dyspnoea, abdominal distension and constipation. A chest radiograph and computed tomogram of the abdomen revealed marked elevation of the right hemidiaphragm caused by herniation of the colon. At laparotomy, strangulation of a portion of transverse colon was identified at the site of the foramen of Bochdalek. The contents of the hernia were reduced and a primary repair of the hernial orifice was performed. The segment of necrosed colon was resected and an end-to-end handsewn anastomosis was constructed. A symptomatic Bochdalek hernia typically presents as a cardiorespiratory emergency in the neonatal period. It can remain silent and present in adulthood with chronic gastro-intestinal or respiratory symptoms. Occasionally it presents with acute dyspnoea or abdominal pain. Early detection and intervention is of the utmost importance to decrease related morbidity and mortality in adults.

Poor awareness of colorectal cancer symptoms; a preventable cause of emergency and late stage presentation

AIMS

To assess knowledge of colorectal cancer (CRC) symptoms among outpatient attendees, and to review disease stage, presentation and duration of symptoms in patients diagnosed with CRC.

METHODS

A questionnaire survey was used to evaluate knowledge of symptoms of CRC and other malignancies. A review of patients diagnosed with CRC during a two-year period was performed.

RESULTS

Of 350 survey participants 26.6% could name a CRC symptom, compared to 53.4% for lung cancer and 71.5% for breast cancer. Of 102 patients diagnosed with CRC 3.9% had Dukes A disease, 32.4% had Dukes B, 39.2% had Dukes C and 24.5% had distant metastases. Forty per cent of patients presented acutely. The mean duration of symptoms was 24 weeks.

CONCLUSIONS

Knowledge of CRC symptoms is poor and is reflected in the percentage of late stage and emergency presentations. Increasing public awareness of CRC may lead to earlier presentation and improved survival.

Bouveret's syndrome--a rare presentation of gallstone ileus

We present the case of an elderly Irish male with Bouveret's syndrome--a very unusual cause of gallstone ileus, where a large gallstone occludes the gastric outlet or duodenum causing obstruction. Management of this condition is often controversial. We discuss the various medical, radiological and surgical therapies available for treatment of this rare entity. Bouveret's Syndrome--A Rare Presentation of Gallstone Ileus

Complex regulation and nuclear localization of JRK protein

The mouse jerky gene and its human orthologue, JRK/JH8, encode a putative DNA-binding protein with homology to the CENP-B (centromere-binding protein B). Disruption of the mouse jerky gene by transgene insertion causes generalized recurrent seizures reminiscent of human idiopathic generalized epilepsy. In addition (and similar to a cenp-b null mouse) jerky null mice exhibit postnatal weight loss and reduced fertility. Using fluorescence confocal microscopy, the cellular localization of a JRK-GFP fusion (where GFP stands for green fluorescent protein) was investigated in HeLa cells. JRK-GFP has a dynamic expression pattern in the interphase nucleus, localizing in a small number of punctate nuclear foci and in the nucleolus. The JRK-GFP foci number changes during the cell cycle, but a distinct pattern of three JRK-GFP foci is observed at G(2). The endogenous protein behaves in a similar manner to the GFP-fusion protein. JRK-GFP was found to co-localize with CREST antigens (which recognize the centromere-binding proteins, CENP-A, -B and -C) through S and G(2) phases of interphase and co-localized completely with a subset of PML nuclear bodies at G(2). We speculate that JRK protein associates with a specific chromosomal centromeric locus in G(2), where it associates fully with PML bodies. Research is underway to identify this locus.

Use of cervical ultrasonography in prediction of spontaneous preterm birth in twin gestations

OBJECTIVE

This study was undertaken to compare various ultrasonographic cervical parameters with respect to ability to predict spontaneous preterm birth in twin gestations.

STUDY DESIGN

This prospective study involved 131 women carrying twins who were longitudinally evaluated on 524 occasions between 15 and 28 weeks' gestation with transvaginal cervical ultrasonography and transfundal pressure. The following cervical parameters were obtained: funnel width and length, cervical length, percentage of funneling, and cervical index. Receiver operating characteristic curve analysis was used to determine the ultrasonographic cervical parameter evaluated at 15 to 20 weeks' gestation, 21 to 24 weeks' gestation, and 25 to 28 weeks' gestation that were best for prediction of spontaneous preterm birth at <28 weeks' gestation, <30 weeks' gestation, <32 weeks' gestation, and <34 weeks' gestation.

RESULTS

The median gestational age at delivery was 36 weeks' gestation (range, 21-41 weeks' gestation). Receiver operating characteristic curve analysis indicted that a cervical length of < or =2.0 cm, regardless of gestational age category at cervical measurement, was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. Between 15 and 20 weeks' gestation a cervical length cutoff value of < or =2.0 cm had specificities of 97%, 98%, 99%, and 100% and negative predictive values of 99%, 98%, 95%, and 89% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. The positive predictive values for delivery at <32 and <34 weeks' gestation were 80% and 100%, respectively. Between 21 and 24 weeks' gestation a cervical length of < or =2.0 cm had specificities of 84%, 84%, 85%, and 86% and negative predictive values of 99%, 99%, 94%, and 87% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. Between 25 and 28 weeks' gestation cervical length had excellent negative predictive values of 99%, 98%, 95%, and 93% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively.

CONCLUSIONS

In twin gestations a cervical length of < or =2.0 cm measured between 15 and 28 weeks' gestation was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. The high specificities indicate that cervical length was better at predicting the absence than the presence of various degrees of spontaneous prematurity.

'Acute abdomen' with a rash

A previously fit and healthy 17-year-old male presented with the clinical symptoms and signs of an acute abdomen and with the secondary complaint of a rash. In view of the primary presenting complaint he was admitted to the surgical ward. The patient was initially booked for an emergency exploratory laparotomy, but after reassessment on the ward a clinical diagnosis of meningococcal septicaemia was made. The patient was treated medically with intravenous antibiotics and supportive therapy, and made a complete recovery. Medical causes of abdominal pain, as exemplified here, can be more life threatening than surgical causes and should be considered in all patients.

False-negative abdominal CT scan in a cocaine body stuffer

Computed tomography (CT) imaging has been touted as one of the best techniques to detect body packets in body packers and stuffers. The majority of experience has been with body packers. We describe a case of a body stuffer who presented with abdominal pain after ingesting a large packet containing multiple small packets, with a falsely negative abdominal CT scan without contrast. This case raises questions regarding the best method of detection of body packets in body stuffers.

Effects of therapeutic amniocentesis on uterine and umbilical artery velocimetry in cases of severe symptomatic polyhydramnios

The objective of this study was to determine the effects of removal of amniotic fluid in cases of symptomatic severe polyhydramnios on Doppler waveform indices of the uterine and umbilical arteries and flow velocities of the uterine arteries. Nine women underwent therapeutic amniocentesis during ten pregnancies for symptomatic polyhydramnios due to Beckwith-Wiedemann Syndrome (n = 1), esophageal atresia (n = 2), chorioangioma (n = 1), twin-twin transfusion syndrome (n = 3), a presumed autosomal recessive syndrome (n = 2), and an unbalanced double translocation (n = 1; partial dup 3q and partial del 9p syndrome). An average of 2.78 +/- 0.9 (range 1-4) 1 of fluid were removed at each procedure between the gestational ages of 18 and 34 weeks (mean of 28 weeks). The systolic/diastolic (S/D) ratio, pulsitility index (PI), and resistance index (RI) of the uterine and umbilical arteries were obtained before and after the procedure using color and pulsed Doppler. After angle correction, the peak systolic velocity (PSV) and mean velocity (MV) in centimeters/second (cm/s) of the uterine arteries were also determined. The presence or absence of a uterine artery waveform notch was determined. Dominant uterine arteries were defined as those with lower impedance indices or higher flow velocities. Statistical analysis was performed with the Wilcoxon signed-rank test. Significance was set at P < 0.05. There was a significant increase in the median value of the uterine artery MV (43.8 vs. 81.1 cm/s, P = 0.005) and PSV (74.2 vs. 125.5 cm/s, P = 0.007) after amniocentesis. The uterine S/D (3.0 vs. 1.84, P = 0.007), PI (1.12 vs. 0.68, P = 0.008), and RI (0.60 vs. 0.45, P = 0.005) impedance indices significantly decreased following amniocentesis. When uterine arteries were categorized as dominant vs. nondominant, there were greater improvements in impedance indices and flow velocities in the nondominant uterine arteries. There were three cases of unilateral and one case of bilateral early diastolic notches of the uterine artery waveforms which either resolved (n = 4) or improved (n = 1). There was no effect on the umbilical artery impedance indices. Therapeutic amniocentesis significantly improved uterine artery impedance indices and resulted in improved flow velocities, while there was no effect on umbilical artery waveform indices. The procedure resulted in the disappearance or improvement of the uterine waveform notch. Our findings suggest that in cases of severe polyhydramnios abnormal uterine artery velocimetry may not be due to lack of trophoblastic invasion of the spiral arteries but to increased intrauterine pressure secondary to polyhydramnios.

Staged resection or primary anastomosis for obstructing lesions to the left colon

The management of obstructing left-sided colonic and rectal lesions has traditionally been by a staged procedure. The introduction of 'on-table lavage', has made primary resection and anastomosis of the large bowel feasible for patients presenting as emergencies. We have studied the perioperative course of 28 patients who presented with left colonic obstruction to determine whether primary anastomosis conferred additional morbidity. The patients ranged in age from 29 to 89 years (mean 66 years) at presentation. The ASA status of patients was comparable in both groups (Table 1). Fourteen patients underwent resection, on-table lavage, and primary anastomosis (PA) and 14 a Hartmann's procedure (HP). The mean operative time for the PA procedure was 200 minutes compared to 110 minutes for the HP group. There was no significant difference in the postoperative complication rate nor mean hospital stay rate for the primary procedures between the two groups. There was no clinical anastomotic leak in patients undergoing primary anastomosis. However secondary surgery for patients undergoing colorectal reconnection conferred added morbidity for patients who had a HP. We conclude that resection, on-table lavage, and primary anastomosis is safe in the management of left-sided colonic obstruction and in most cases is the treatment of choice.

A new method using vaginal ultrasound and transfundal pressure to evaluate the asymptomatic incompetent cervix

OBJECTIVE

To evaluate the ability of ultrasound with transfundal pressure to detect the incompetent cervix in pregnant women at risk for this condition.

METHODS

One hundred fifty pregnant women with no prior pregnancy losses were scanned transabdominally, and 31 asymptomatic pregnant women with a prior history of cervical incompetency or risk for this condition were scanned transvaginally. The control patients were scanned once between 16-24 weeks, and the patients at risk were studied 73 times between 8-25 weeks. After evaluating the cervix and its internal os, transfundal pressure was applied. Cervical cerclages were placed for cervical funneling and shortening in response to transfundal pressure or for a grossly incompetent cervix on ultrasound evaluation.

RESULTS

Transfundal pressure elicited no changes in the internal cervical os of the 150 control patients, of whom 141 delivered at term, two miscarried at 22 and 23 weeks, and seven delivered prematurely (4.7%). Fourteen of the 31 pregnancies at risk for cervical incompetency revealed opening of the internal os or descent of the fetal membranes with transfundal pressure. Thirteen of these 14 pregnancies were treated with cerclage, with nine (64%) proceeding to term, three (21%) delivering prematurely, and two (14%) aborting. The one patient who did not receive a cerclage also aborted. In six cases, the cervix and its internal os appeared normal but the membranes protruded into the endocervical canal in response to transfundal pressure.

CONCLUSION

Application of transfundal pressure during transvaginal ultrasound evaluation of the cervix and its internal os may assist in detecting the asymptomatic incompetent cervix.

An analysis of the diagnostic accuracy of endoscopic biopsy and cytology in the detection of oesophageal malignancy

The role of combined cytohistological examination in the differentiation of benign from malignant oesophageal mucosal lesions was studied in 331 patients. Malignancy was confirmed by specimen histopathology in 58 patients. Both endoscopic biopsy and cytology were positive in 41 (71%) patients. Endoscopic biopsy alone suggested malignancy in 10 cases (17%) while cytology was positive after negative biopsy in seven (12%). Cytology yielded four false positive and 10 false negative results giving a sensitivity level of 81%, a specificity of 98% and a positive predictive value for oesophageal malignancy of 92%. Histology on the other hand yielded one false positive and seven false negative results providing a sensitivity of 87%, a specificity of 99% and a positive predictive value of 96%. No patients were left undiagnosed using both diagnostic modalities; cytology increased the diagnostic yield from 87% to 100%. Exfoliative cytology was most valuable in the diagnosis of tumours of the lower one-third of the oesophagus where seven of 31 malignancies (23%) were identified by this method alone (P less than 0.05). Neither the histological type of the tumour nor the morphological appearance was found significantly to affect the diagnostic yield (P greater than 0.05). We conclude that cytological examination should be standard practice in the investigation of oesophageal lesions.

Mechanism of sphincter impairment following low anterior resection

It has been postulated that reduction in anal resting pressure following low anterior resection is due to intraoperative injury to the internal anal sphincter during transanal passage of the stapling device or damage to its nerve supply in the course of rectal mobilization. The aim of this study was to assess the relative importance of either mechanism. Fourteen dogs had a standard segment of colon and distal rectum excised. Colorectal reconstruction was performed using either a low stapled EEA (U.S. Surgical Corporation, Norwalk, CT) colorectal anastomosis (n = 7) or a handsewn anastomosis (n = 7). Anorectal manometry was performed preoperatively and again on the 10th postoperative day. Resting anal pressure was significantly reduced after EEA anastomosis (mean +/- SEM: before, 49 +/- 3 mm Hg; after, 20 +/- 4 mm Hg; P less than 0.001) and handsewn anastomosis (mean +/- SEM: before, 46 +/- 4 mm Hg; after, 35 +/- 4 mm Hg; P less than 0.01). Postoperative resting pressures were also significantly reduced (P less than 0.05) following EEA anastomosis when compared with the handsewn group. This study suggests that damage to the innervation of the internal anal sphincter during rectal mobilization and further direct injury to the sphincter during transanal instrumentation both contribute to the fall in anal resting pressure observed following low anterior resection.

An audit of surgery for seventy-one primary parotid tumours

Seventy-one consecutive patients who presented with lumps in the parotid gland over an eight year period (1981-1989) were analysed. Two-thirds of the patients presented with a history of swelling for over one year, while a quarter (24%) had a parotid mass for over five years at initial referral. The pathology of these masses was diverse, with pleomorphic adenoma being the commonest (64%). Superficial parotidectomy was the commonest procedure employed (50/71) with local excision being performed only in the initial part of our series (15/71). There were five cases of permanent facial palsy, four following radical resection for malignancy. Tumour recurrence rate was 2/15 (13%) in cases treated by local excision while none of the 50 patients treated by superficial parotidectomy had tumour recurrence at a mean follow-up of five years. Only three patients developed Frey's Syndrome. It is recommended that increased community awareness of early referral of a parotid mass is necessary, as surgical treatment in the form of superficial parotidectomy, which is the ideal procedure for such lumps, carries minimal morbidity when performed by a surgeon with a special interest in parotid surgery.

Familial infantile oesophageal achalasia

Oesophageal achalasia is uncommon in children and in its familial form it is a rarity. The presentation and management of two male siblings who presented with oesophageal achalasia as infants are reported. A high degree of consanguinity in the parents of the children existed, suggesting autosomal recessive transmission.

Starting laparoscopic cholecystectomy--the pig as a training model

Laparoscopic cholecystectomy is a reality and units must convert from open to endoscopic technique. To this end we have used the pig, whose biliary anatomy resembles the human, as a laboratory in vivo training model. Laparoscopic cholecystectomy has been performed in 35 animals. Techniques of pneumoperitoneum, vision, manipulation, clipping, ligation, cutting, diathermy and gall bladder removal were quickly mastered. All surviving animals underwent postmortem examination after 4 weeks. Following this laboratory programme, laparoscopic cholecystectomy in the human was introduced and has been completed successfully in 70 cases.

Primary gastric lymphoma: incidence and role of surgery

The histological subgroups of primary gastric tumours presenting to one surgical unit over two successive six year periods were analysed and the therapeutic value of gastric resection assessed. An increased incidence of gastric lymphoma (13% relative to 5%) occurred in the second six year period. This increase could not be attributed to improved morphological or histochemical techniques. The diagnosis of lymphoma was confirmed preoperatively in 13 (94%) of the 14 patients by a combination of multiple endoscopic biopsies and brush cytology. Five of the six patients who underwent a potentially curative resection are tumour free at a mean follow-up of four years. Histological grading, whether high or low, had no bearing on survival. Gastric lymphoma is increasing in incidence and should be considered in the evaluation of gastric tumours as surgical resection at present offers the best prospect of long term survival.

Declining indications for abdominoperineal resection

In 126 consecutive patients operated on for carcinoma of the lower two-thirds of the rectum, a consistent policy of sphincter preservation resulted in 100 (79 per cent) having anterior resection and 22 (17 per cent) abdominoperineal resection. Perioperative complications in the anterior resection group were: death (two patients), clinical leakage (three patients), pulmonary embolism (five patients), pelvic haematoma (one patient), small bowel obstruction (one patient) and wound sepsis (six patients). Of 55 patients who had a potentially curative anterior resection with follow-up of at least 2 years, one developed local recurrence. Five per cent of patients had significant continence problems. Low anterior resection for carcinoma is associated with low perioperative morbidity, satisfactory functional results and acceptable local recurrence rates.