Pyomyositis mimicking right iliac fossa mass: review of the literature

Pyomyositis is a pyogenic infection of skeletal muscle. Its incidence in temperate countries though low is rising. Most cases from the temperate region involve immuno-compromised patients. The onset is usually insidious with progression to large purulent collections. Because of its low incidence in temperate countries, it is often initially misdiagnosed. A high index of suspicion with appropriate imaging techniques, aggressive surgical intervention and adjunctive antibiotic therapy are the keys to prompt resolution. A case of pyomyositis mimicking right iliac fossa (RIF) mass is described with a review of the literature.

Small bowel volvulus: a review

Small bowel volvulus is a rare but life-threatening surgical emergency. The aetiology may be primary, as is often seen in Africa and Asia, while in Western countries other predisposing conditions usually initiate the volvulus. Early preoperative investigation and expedient surgical treatment is required if bowel infarction is to be prevented. Central abdominal pain resistant to narcotic analgesia should heighten the suspicion of the diagnosis. The diagnostic value of computerised tomography (CT) scanning in such situations has been emphasised. If the bowel is infarcted resection is required, but the optimum treatment for cases with viable small bowel is uncertain, the alternatives either being resection, fixation, or simple derotation.

A measurement of the ability to drive after different types of inguinal hernia repair

Recovery following different types of inguinal hernia repair has been objectively assessed by measuring reaction times when the subject performs an emergency stop in a driving simulator. A control group of patients who underwent varicose vein surgery to the groin under general anaesthetic without any muscle dissection demonstrated no alteration in response times. Eighty-two percent of those who underwent laparoscopic repair and 64% of those who underwent Lichtenstein repair returned to their preoperative times by 7 days after surgery. There was no difference in recovery of response times after Lichtenstein repair performed under local or general anaesthetic, in comparison with 33% of patients after Bassini repair. These results may influence the advice given by surgeons to patients after inguinal hernia surgery.

Controlled trial of preperitoneal local anaesthetic for reducing pain following laparoscopic hernia repair

BACKGROUND

A prospective randomized trial was performed to determine whether local anaesthetic solutions injected into the preperitoneal space may provide additional pain relief following transabdominal preperitoneal laparoscopic hernia repair.

METHODS

One hundred patients undergoing transabdominal preperitoneal laparoscopic hernia repair were allocated randomly to receive (1) bupivacaine 1.5 mg/kg, (2) bupivacaine 1.5 mg/kg with 1 in 200000 adrenaline, (3) bupivacaine 3 mg/kg or (4) saline instilled into the preperitoneal space at the end of the operation. An independent clinical assessor determined the level of pain using a visual analogue pain score and noted the parenteral and oral analgesia requirements at 4, 8, 12 and 24 h after operation.

RESULTS

At each of the time intervals, there was no significant difference between the groups for pain scores (at 24 h, P = 0.71) or the number of doses of either morphine (at 24 h, P = 0.73) or oral analgesia (at 24 h, P = 0.89). There was also no significant difference in the time to return to normal activity or work between the groups.

CONCLUSION

This study suggests that instilling local anaesthetic into the preperitoneal space has no significant effect on postoperative pain relief requirement following laparoscopic hernia repair. Other methods of reducing postoperative pain should be sought that may facilitate day-case laparoscopic hernia surgery.

Are complications of endoscopic sphincterotomy age related?

BACKGROUND

Endoscopic retrograde cholangiopancreatography sphincterotomy is increasingly performed in younger patients undergoing laparoscopic cholecystectomy. However, the safety of endoscopic sphincterotomy in this age group, relative to that in older patients, is unknown.

AIM

To determine whether the development of short term complications following endoscopic sphincterotomy is age related.

PATIENTS AND METHODS

A prospective multicentre audit of 958 patients (mean age 73, range 14-97, years) undergoing a total of 1000 endoscopic sphincterotomies.

RESULTS

Two deaths occurred, both from postsphincterotomy acute pancreatitis. Postprocedural complications developed in 24 patients: pancreatitis in 10, ascending cholangitis in seven, bleeding in four, and retroperitoneal perforation in three. There were six complications (five cases of pancreatitis and one bleed; 2.2%) and no deaths in the 281 (29.3%) patients aged under 65 years. In comparison, 18 (2.6%) of the 677 patients aged over 65 years developed a complication (cholangitis in seven, pancreatitis in five, bleeding in three, and perforation in three). Patients under 35, 45, 55, and 65 years were not at significantly increased risk of complication than those over these ages (relative risk for those under compared with those over 65 years 0.83, 95% confidence intervals 0.41-1.67, p = 0.74).

CONCLUSION

Short term complications following endoscopic sphincterotomy are not related to age. Younger patients undergoing laparoscopic cholecystectomy need not be denied endoscopic sphincterotomy for fear that the risks are greater than if they undergo surgical exploration of the common bile duct.

Laparoscopic hernia repair (TAPP): a new method to reduce port-site-herniation

This article describes a method of transperitoneal laparoscopic hernia repair to reduce port-site herniation by using one umbilical 12-mm port site and a 5-mm laparoscope.

A prospective study of adult inguinal hernia repairs using absorbable sutures

A prospective study was conducted over a 5-year period to determine whether inguinal hernia repair could be safely performed with absorbable suture material (polydioxanone) with reference to recurrence rates, wound pain, haematoma formation and wound infection. Analysis is available for 111 operations involving 111 patients. Mean follow-up was 36 (range 21-66) months, with 81 procedures monitored for more than 2 years. Two-layered hernia repair was used in all cases with polydioxanone as the chosen suture material. Mean post-operative stay was 2.1 days, with no hospital wound infections and three haematomas. Review identified 1 wound infection. There have been two recurrences. Preliminary results suggest that hernia repair with absorbable suture materials is comparable to traditional non-absorbable repair in terms of recurrence and associated wound complications. The additional benefit is the absence of foreign material in the wound region following degradation of the absorbable material. This does not appear to compromise the integrity of the hernia repair. Mesh repairs are increasingly preferred to Shouldice-style repairs in elective inguinal hernias. However, we believe that polydioxanone should be the suture material of choice in obstructed or strangulated hernia. A larger study is required to verify this, as well as a longer follow-up period. The use of absorbable material warrants further investigation.

An audit of thyroid surgery in a general surgical unit

A total of 143 patients undergoing thyroid surgery in a general surgical unit over an 8-year period were reviewed. In only two patients did thoracic inlet views or thyroid function tests alter clinical management. Fine-needle aspiration failed to detect one well-differentiated follicular carcinoma (false-negative rate 1.1%). The sensitivity for malignancy of fine-needle aspiration, ultrasound and radioisotope scan were 94%, 53% and 24%, respectively. The corresponding specificity was 59%, 72% and 58% and accuracy 65%, 70% and 49%, respectively. The specificity of fine-needle cytology for detecting neoplastic disease (adenoma or carcinoma) was 86% and accuracy 91%. Combinations of fine-needle cytology, ultrasound and radioisotope scanning increased the sensitivity for malignancy, so that fewer tumours were missed, but at the cost of reduced specificity, positive predictive value and accuracy. Hence, ultrasound was only recommended when fine-needle aspiration was inconclusive. Overall perioperative morbidity was 6.3% (one case of postoperative bleeding, two wound infections, four cases of prolonged hypocalcaemia). There were two proven cases of transient, but no permanent, recurrent laryngeal nerve injuries as a result of surgery. Thyroid surgery may be performed satisfactorily by general surgeons with an interest in thyroid disease. Fine-needle cytology is the most informative preoperative investigation. Although aspiration cytology, ultrasound, and scintigraphy all have appropriate indications and limitations, there is no single test or group of tests that can substitute for careful clinical assessment and follow-up.

Laparoscopic 'bikini mesh' repair of bilateral inguinal hernia

Laparoscopic hernia repair using a single piece of mesh was performed in 150 patients with bilateral inguinal hernia. The median operating time was 43 (range 30-90) min with a median hospital stay of 1 (range 1-10) days. In all, 138 patients were discharged within 24 h of operation. The median time for return to normal activity was 7 (range 2-60) days and that for return to work 14 (range 2-60) days. One patient required surgery for a port-site hernia and another for a Veress needle injury to the small bowel. Additional complications included bruising in nine patients, cord seromas in seven and urinary retention in two. There have been no recurrences after a median follow-up of 18 (range 1-38) months. The cost benefits of a short hospital stay and rapid return to work afforded by laparoscopic bilateral hernia repair warrant further evaluation.

Laparoscopic adrenalectomy

This report describes the initial collective experience of a group of British surgeons in performing laparoscopic adrenalectomy.

Amyloid tumour of the colon

A case of amyloid tumour of the colon and the first in association with a carcinoma is reported. A previously healthy 65 year old man presented with non-specific symptoms of lower abdominal pain and flatulence without rectal bleeding. A clinical diagnosis of diverticular disease was made and colonoscopy performed. Two lesions (one at 15 cm and the other at 30 cm from the anal margin) were found on endoscopy and removed. On histology, the lesion at 15 cm was a moderately differentiated adenocarcinoma and that at 30 cm contained amyloid. Further tests (standard tinctorial methods and immunohistochemistry) revealed the 30 cm lesion to be an amyloid tumour of the colon of AL (lambda) type. When biopsy of an atypical, large, solitary colorectal lesion reveals amyloid deposition, the possibility of an amyloid tumour should be considered and the lesion resected.

An audit of surgery of the parotid gland

The management of patients undergoing 50 surgical procedures to the parotid gland was reviewed. The overall accuracy of fine needle aspiration cytology was 87%, false-positive and false-negative rates for malignant disease both being 4%. The sensitivity, specificity and accuracy of fine needle cytology for malignant parotid tumours was 66%, 95%, and 91%, respectively, that of benign tumours (pleomorphic adenoma or Warthin's tumour) being 88%, 83% and 87%, respectively. Sensitivity, specificity and accuracy for the remaining (principally inflammatory) parotid diseases was 100%, 95% and 96%, respectively. The predictive value of a positive test for malignant tumours, benign tumours and inflammatory conditions was 66%, 94% and 75%, respectively. The negative predictive value for these conditions was 95%, 71% and 100%, respectively. Facial nerve weakness after parotidectomy occurred in three patients (8.8%), being permanent in two cases (both malignant). Although Frey's syndrome was not recorded in any of the notes, careful follow-up revealed two cases (6%). To date there have been no local recurrences after excision of either benign or primary malignant parotid masses. One patient with squamous cell carcinoma metastatic to the parotid gland died, despite block dissection of the neck and radiotherapy. This small series with a limited follow-up suggests that diseases of the parotid gland can be managed by general surgeons with an interest in this field. Although fine needle aspiration and ultrasonic scan may be helpful, the decision to operate should be made on clinical grounds.

Recurrent inguinal hernia after laparoscopic repair: possible cause and prevention

Eleven patients with recurrent inguinal hernia after laparoscopic hernia repair were referred for treatment. A medial recurrence associated with a mature peritoneal sac was identified in each case. The prosthetic mesh medial to the inferior epigastric artery had rolled away from the pubic ramus to expose Hesselbach's triangle. All cases were successfully treated by insertion of a second mesh to cover the defect and overlap the original mesh. To date there have been no further recurrences. Lessons learnt from experience of such laparoscopic transperitoneal hernia repair include that: the prosthetic mesh must be placed so that it reaches or crosses the midline; at least three staples should fix the mesh to the pubic ramus; a large mesh (13 x 9 cm) with a greater surface area should reduce the pressure tending to disrupt the mesh; and bilateral hernia is best managed by inserting a single piece of mesh (28 x 9 cm) fully unfolded as it crosses the midline to ensure coverage of both medial direct defects ('bikini repair'). Application of these principles may reduce the incidence of recurrence after laparoscopic inguinal hernia repair.

The ability of laparoscopic clips to withstand high intraluminal pressure

OBJECTIVE

To determine if commercially available clips for laparoscopic surgery become displaced with high intraluminal pressures.

DESIGN

In vivo model in which the splenic, renal, and mesenteric vessels together with the gallbladder of anesthetized living pigs were individually occluded using titanium and absorbable clips and then subjected to pressures of 300 mm Hg; and in vitro model in which the procedure was repeated on freshly removed human gallbladders with the attached segment of cystic duct.

INTERVENTION

The intraluminal pressure of the occluded segment was increased until (1) the clip was released, (2) the vessel burst, or (3) the predetermined pressure (300 mm Hg) was obtained.

RESULTS

A total of 90 clips were examined. No clip could be displaced from any porcine vessel at intraluminal pressures of up to 300 mm Hg. One vessel burst before the predetermined pressure was obtained, the clips remaining intact. Clips placed on the porcine and human models also could not be displaced by a pressure of 300 mg Hg.

CONCLUSION

Commercially available titanium and absorbable clips do not disrupt when subjected to high intraluminal pressures. Postoperative bile leaks are more likely to result from necrosis of the cystic duct than displacement of the clip by the pressure within the biliary system.

Laparoscopic nephrectomy: initial experience and cost implications

OBJECTIVE

To assess the results and cost implications of laparoscopic nephrectomy.

PATIENTS AND METHODS

Ten patients underwent attempted laparoscopic nephrectomy and nephro-ureterectomy. The cost of the laparoscopic procedures was estimated to allow comparison with that of open surgery.

RESULTS

Two patients required conversion to an open procedure, one for a colonic tear, the other for irretrievable loss of pneumoperitoneum. The median operating time for successful cases was 3 h (range 2.5-4). The mean morphine equivalent of analgesia delivered per patient was 18 mg (range 10-28). There was no mortality. Post-operative complications consisted of one case of prolonged ileus and another of chest infection. The median hospital stay of successful cases was 5 days (range 4-17), and the mean time to return to normal activity was 4 weeks (range 3-6). The cost of the procedure using re-usable instruments was approximately 2000 pounds, comprising 100 pounds for equipment. 900 pounds theatre costs and 1000 pounds for hospital stay. Using disposable equipment adds up to 900 pounds to the cost. In comparison an open nephrectomy typically costs around 2300 pounds.

CONCLUSION

Laparoscopic nephrectomy is associated with lower analgesia requirements, shorter hospital stay and quicker return to work than equivalent open procedures. The cost, particularly when performed with re-usable instruments, is not prohibitive being comparable with that of open nephrectomy. With further experience it should become part of the armamentarium of urological surgeons.

Neoplastic lesions of the appendix

Neoplasms occur in 0.5 per cent of appendices. Ultrasonography or computed tomography is beneficial, but preoperative detection is rare. At operation, the diagnosis is considered in under half of cases. Mucocele, localized pseudomyxoma peritonei, benign tumours and most appendiceal carcinoids are cured by appendicectomy alone. Right hemicolectomy is indicated for: (1) invasive adenocarcinoma; (2) tumours close to the caecum; (3) lesions larger than 2 cm; (4) mucin production; (5) invasion of the lymphatics, serosa or mesoappendix; and (6) cellular pleomorphism with a high mitotic rate. Tumours of 1-2 cm, small mucinous carcinoids, adenocarcinoma confined to the mucosa, and tumours in children may be treated by appendicectomy alone at the surgeon's discretion. The 5-year survival rate associated with classical carcinoid is more than 90 per cent. The prognosis of mucinous carcinoid is intermediate between that of classical carcinoid and well differentiated adenocarcinoma. The prognosis of adenocarcinoma is determined by Dukes' stage and is similar, stage for stage, to that of colorectal carcinoma.

Prospective trial comparing Lichtenstein with laparoscopic tension-free mesh repair of inguinal hernia

A prospective study of 242 patients with inguinal hernia who underwent tension-free mesh repair by the laparoscopic transperitoneal (n = 121) or the open Lichtenstein (n = 121) technique was performed. There was no significant difference in operation time between the laparoscopic (median (range) 35 (20-90) min) and Lichtenstein (40 (20-90) min) procedures. Discharge within 24 h of operation was more common after laparoscopic surgery (89.3 per cent versus 48.7 per cent). Consequently, hospital stay was reduced with this approach (median (range) 1 (1-7) days versus 2 (1-10) days for patients who had a Lichtenstein repair). There was no significant difference in parenteral analgesia requirements or visual analogue pain scores between the two groups. Although use of oral analgesia in hospital was greater in patients who underwent Lichtenstein hernioplasty, this may reflect their longer stay. Rehabilitation to normal activity and return to work was shorter in patients receiving laparoscopic repair (median 7 and 10 days, respectively) than Lichtenstein repair (14 and 21 days) (P < 0.001). Initial results suggest that laparoscopic procedures may be associated with more rapid rehabilitation compared with that of open tension-free mesh surgery. Most patients with inguinal hernia undergoing tension-free mesh repair by either technique would be suitable for day-case surgery.

Adenocarcinoma of the distal duodenum: two cases managed by pylorus preserving pancreatico-duodenectomy and adjuvant chemotherapy

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Ruptured silicone breast implant: a misleading chest X-ray

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Herniography for occult hernia and groin pain

In a prospective 3-year study herniography was used to assess patients with unexplained groin pain in whom clinical signs were inconclusive. Fifty-two patients were studied. No serious complications were observed. Twenty-two hernias were identified in 18 patients. The positive herniographic findings were confirmed at operation in 12 patients. Of 34 patients with a negative herniogram, none has developed a hernia. Pain settled spontaneously in 29 patients and five were referred to a pain clinic for further management.

Malignant obstruction of the left colon

The management of malignant obstruction of the colon distal to the splenic flexure is controversial. The 'traditional' three-stage procedure is marred by frequent failure to complete the planned sequence of operations and a resulting high permanent stoma rate. At each stage the mortality rate (7 per cent) and morbidity rate (30 per cent) are significant. The mortality rate following primary resection with delayed anastomosis (Hartmann's procedure) is 10 per cent. However, many patients experience complications and only 60 per cent have the stoma reversed. Primary anastomosis may be performed after subtotal or segmental colonic resection. The reported mortality rate is about 10 per cent with anastomotic leakage in 4-6 per cent, but cases are often carefully selected. It is difficult to suggest clear guidelines based on existing data. Although there are strong arguments in favour of a single-stage procedure, surgeons must decide whether available resources and local circumstances permit this. The alternative is Hartmann's procedure or referral to a surgeon with an interest in emergency colorectal surgery.

Jass' classification revisited

BACKGROUND

In 1986, Jass and colleagues claimed to have improved on Dukes' classification of prognosis for carcinoma of the colon and rectum. To have clinical relevance, such results should be reproducible and confirmed by other institutions.

STUDY DESIGN

Retrospective clinicopathologic study of 312 carcinomas of the colon and rectum to determine whether or not Jass' classification is superior to that of Dukes' as assessed by their relative reproducibility and prognostic significance.

RESULTS

Dukes' classification had excellent intraobserver and interobserver reproducibility (kappa values of 0.86 and 0.93, respectively). In contrast, the reproducibility of variables assessed by Jass showed only slight to fair agreement (lymphocytic infiltration: intraobserver and interobserver kappa values of 0.08 and 0.05, respectively, growth pattern: intraobserver and interobserver kappa values of 0.37 and 0.41, respectively). Dukes' stage and patient age were the most important prognostic variables on multivariate regression analysis. Tumor differentiation, nuclear polarity, tubule configuration, and lymphocytic infiltration remained significantly related to survival in the presence of Dukes' stage and age. The model which best predicted prognosis was a combination of Dukes' stage, patient age and tumor differentiation. Further addition of the variables assessed by Jass to this model did not significantly improve the prediction of prognosis.

CONCLUSIONS

Dukes' classification is of greater prognostic value and more reproducible than the components of Jass' classification. The continued use of Dukes' classification is, therefore, warranted for prognostic and therapeutic decisions in patients with carcinoma of the colon and rectum.

Malignant anal tumours

Anal tumours represent 5 per cent of anorectal cancers and exist as two clinical entities: tumours of the anal canal and those of the anal margin. Smoking and sexual behaviour, particularly homosexual anal intercourse, are important aetiological factors. This association is related to anal warts and human papillomavirus infection, notably type 16, which is found in around 70 per cent of warts. Symptoms are non-specific and are frequently attributed to benign conditions. Rectal examination reveals a characteristically infiltrating lesion and any suspicious anal area should be biopsied. There are two histological types. Squamous carcinoma comprises approximately 95 per cent of anal tumours and includes the 35 per cent of tumours derived from the anal transition zone (cloacogenic tumours), containing a mixture of squamous and mucinous elements. The remaining 5 per cent of anal tumours are adenocarcinoma. Squamous cell tumours of the anal canal are probably best treated using radiotherapy (with chemotherapy) as complete response rates, 5-year survival rates, and incidences of normal sphincter function and significant toxicity are around 80, 70, 75 and 20 per cent respectively. Treatment failures may be salvaged by surgery. The 5-year survival and local recurrence rates for radical surgery are around 60 and 25 per cent respectively; there are few indications for local excision. In contrast, 60 per cent of anal margin tumours are suitable for local excision, the 5-year survival rate being in excess of 80 per cent. Combining radiotherapy with surgery may give additional benefit. Current randomized controlled trials should further clarify the relative merits and demerits of the treatment options.

Colorectal carcinoma: importance of clinical and pathological factors in survival

A series of clinicopathological variables was assessed on 312 patients undergoing surgical resection for primary colorectal cancer. Although the presence of venous invasion was related to mortality (P = 0.02), classifying invasion into involvement of thick-walled or thin-walled veins did not produce a variable of prognostic value. Intestinal obstruction (P = 0.04) and the macroscopic appearance of the tumour (P = 0.04) were related to mortality from colorectal cancer, but not from all causes of death. Duke's stage, increasing patient age and poorly differentiated tumours were the variables which were individually most significantly related to poor prognosis (P < 0.001 for each analysis). Cox's regression analysis identified these three variables as independent predictors of outcome in colorectal cancer. This study confirms that Duke's stage, patient age and tumour differentiation are still the most important clinicopathological variables in colorectal cancer.

DNA densitometry of colorectal cancer

DNA analysis was assessed by densitometry for 281 cases of colorectal adenocarcinoma. Detection of aneuploidy in a single case rose from 65% if one, to 92.5% when three or more sections, were analysed. Although aneuploid tumours had significantly larger nuclear areas than near diploid tumours (p = 0.009), densitometric measurements showed no association with clinicopathological variables. DNA content determined by densitometry was compared with that from flow cytometry on 465 tissue sections from 241 cases. Aneuploidy assessed by flow cytometry was significantly associated with that determined by densitometry (p < 0.01 for all comparisons), ploidy state being similar in 381 sections (82%, kappa = 0.63, p < 0.001), and 187 cases (77.6%, kappa = 0.57, p < 0.001). Univariate survival analysis showed that DNA densitometric variables had no significant association with survival in (a) all cases, (b) cases without lymph node metastases, or (c) cases without distant metastases. Multivariate regression analysis of densitometric and clinicopathological variables identified Dukes's stage, patient age, and tumour differentiation as the combination of variables most closely related to survival. Densitometric measurement of DNA content could not significantly improve on the prognostic model containing these three variables. It is concluded that, although the assessment of DNA content by densitometry is comparable with that of flow cytometry, conventional histological variables remain the best predictors of prognosis in colorectal cancer.

The role of flow cytometry in carcinoma of the colon and rectum

Flow cytometry was performed upon 312 patients with adenocarcinoma of the colon and rectum, satisfactory results being obtained with 275 (108 diploid, 130 aneuploid and 37 tetraploid). The proportion of nondiploid instances increased from 28 percent if one, to 80 percent when six specimens were assessed per patient. Reproducibility of the technique showed substantial agreement in the assessment of deoxyribonucleic acid ploidy (Kappa value equals 0.74). Increasing values of cells in the diving (G2/M) phase of the cell cycle were associated with little lymphocytic tumor infiltration (p = 0.0002) and extensive tumor fibrosis (p = 0.003). Univariate survival analysis revealed that, although diploid tumors tended to have a better prognosis than nondiploid tumors (p = 0.06), no flow cytometric variable was significantly related to survival. Flow cytometry similarly was not of prognostic value in instances without lymph node metastases or without distant metastases. Multivariate regression analysis of flow cytometric and clinicopathologic variables identified Dukes' stage, patient age and tumor differentiation as the combination of variables most closely related to survival. No flow cytometric variable could significantly improve on the prognostic model containing these three variables. It is concluded that conventional histologic variables remain the best predictors of prognosis in carcinoma of the colon and rectum.

Morphometric analysis of colorectal cancer

Thirteen nuclear and cellular morphometric variables were measured in 312 cases of colorectal adenocarcinoma. All variables, except nuclear shape factors, differed significantly (P < 0.001) between normal colorectal and tumor tissue. In adenocarcinomas, epithelial nuclei in well-differentiated mucosa tended to be elliptic, while those in poorly differentiated mucosa were more spheric. Increasing values of maximum nuclear and elliptic diameter were associated with progression from none to simple tubule configuration (P < 0.001), none to easily discerned nuclear polarity (P < 0.001), and expanding growth pattern (P < 0.001). Univariate survival analysis revealed that none of the morphometric variables was significantly related to patient survival. Multivariate regression analysis showed that no morphometric variable could add significantly to a model containing the variables of patient age, Dukes stage, and tumor differentiation. Morphometry may be useful in distinguishing malignant from normal tissue and degrees of differentiation, but it is of little prognostic value in colorectal adenocarcinoma.

Prognostic factors in colorectal cancer

The prognostic power of the extent of tumour invasion is indisputable; Dukes' classification has repeatedly been proven to be strongly correlated with patient survival. Modifications have led only to confusion, resulting in caution being required in the classification of patients with Dukes' A tumours. In the UK, the American tumour node metastasis and Australian clinicopathological systems are frequently considered too complex for routine clinical use. Meanwhile, Jass's classification may be complicated by observer variation between pathologists, and recent evidence suggests that it offers no advantage over that of Dukes. All the conventional staging systems also fail to take the skill of the surgeon into account when determining outcome. Attempts at quantifying tumour structure have not heralded the expected major advance. For instance, the expense and uncertain prognostic value of tumour DNA content assessed by flow cytometry are likely to restrict widespread use of this technique. It may soon be possible, however, to provide optimum treatment for patients based on individual tumour doubling times. Classification using knowledge of how a small number of cells in the tumour have the ability to invade locally, enter blood vessels and metastasize would also provide important prognostic information on which treatment could be based. Until then, the ease of use and high prognostic power of Dukes' classification ensure that, after 60 years, it is still the 'gold standard' against which all other prognostic classifications in colorectal cancer should be assessed.

Prostatectomy in a district hospital

In order to monitor the safety and efficacy of a new service for transurethral prostatectomy, an audit was performed, prospectively, over a period of 7.25 years. Of 304 prostatectomies performed, 91% were by transurethral prostatectomy. The proportion of patients with retention was 52%, 16% were uraemic and the incidence of carcinoma of the prostate was 21%. The operative mortality rate was 1.0%. An outline of the treatment policy and the data on complications and revision operations are presented. Comparisons are made with the experience of teaching centres and other district hospitals. Transurethral prostatectomy can be performed safely in the district general hospital and is a service which is essential to the smooth running of the surgical department.

A quarter of a century of portasystemic shunting for oesophageal varices

Seventy-three patients who had received portasystemic shunts were reviewed to assess the current role of this procedure in the treatment of portal hypertension. Survival at 1, 5 and 10 years was 85%, 68% and 45% respectively. Survival was significantly greater (P less than 0.001) in Child's grade A patients compared with Child's grade B patients and in non-alcoholics compared with alcoholics. Previously absent encephalopathy developed in 43% of those with non-selective shunts compared with 21% of those with selective shunts. Six of the 12 patients who experienced recurrent variceal haemorrhage had associated shunt thrombosis: five of these required further shunts or oesophageal transection to control their bleeding and the other patient died before further surgery could be instituted. Shunt surgery still has a role in the treatment of a small number of carefully selected patients with portal hypertension.

Percutaneous nephrostomy in an unusual case of ureteric obstruction

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Auditing perioperative mortality

An audit of mortality following operation was performed over ten years classifying deaths into those that were 'expected' and 'unexpected'. 'Unexpected' deaths were defined as those in which, after careful consideration of the prevailing clinical circumstances at the time of operation, the probability of death following operation was felt to be low. This definition is a more helpful assessment of surgical performance than overall perioperative mortality as it highlights cases where improvements in surgical management might be achieved. In audits involving surgical mortality, the classification of deaths into 'expected' and 'unexpected' is recommended.

Neck sprain--a major cause of disability following car accidents

One hundred and thirty-seven patients attending hospital following road traffic accidents were contracted regarding pain in the neck between 1 and 2 years later. Eighty-five (62 per cent) stated that they had suffered pain in the neck at some time following their accident compared with 42 (30.6 per cent) who were noted to have pain in the neck when examined soon after the accident. Thirty-one patients (22.6 per cent) still felt occasional pain 1 year after the accident and 5 had continuous pain at 1 year. Pain in the neck occurred irrespective of the direction of impact but was disproportionately common in rear impact accidents. Patients wearing seat belts experienced pain more frequently than unbelted patients.

Incidence and duration of neck pain among patients injured in car accidents

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Peritoneovenous shunting in intractable ascites

Fourteen patients in whom peritoneovenous shunts were inserted for intractable ascites or malignancy were reviewed.Reduction in ascites was obtained in all patients by the time of discharge with significant diuresis and weight loss. Significant decrease in haemoglobin, packed cell volume, platelet count and prothrombin time also occurred. Coagulation studies were abnormal in 60 per cent of patients in whom they were performed with bruising or detectable bleeding occurring in 28.5 per cent of all patients. Late blockage of the shunt occurred in five patients and was less frequent in Denver than in Le Veen type shunts.Cumulative mortality one month after shunt insertion was 28.5 per cent and at one year was 78.5 per cent reflecting the severity of the underlying disease.Peritoneovenous shunting should be reserved for palliation in patients resistant to full conventional medical therapy.