Duct-to-mucosa pancreaticogastrostomy is a safe anastomosis following pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula following pancreaticoduodenectomy is relatively common, and remains a major cause of morbidity and mortality. The aim of this study was to evaluate the results of two-layered duct-to-mucosa pancreaticogastrostomy as a method for restoring pancreaticoenteric continuity.

METHODS

Prospectively collected data from 100 consecutive patients who underwent Whipple's pancreaticoduodenectomy for tumour were evaluated. All operations were performed by the same surgeon.

RESULTS

The perioperative 60-day mortality rate was 1.0 per cent. There were no pancreatic fistulas or anastomotic leaks. Sixteen patients had significant complications that delayed discharge from hospital. Twenty-one patients subsequently required empirical pancreatic exocrine supplements.

CONCLUSION

Two-layered duct-to-mucosa pancreaticogastrostomy for restoration of pancreaticoenteric continuity after pancreaticoduodenectomy is associated with a low incidence of complications.

A Prospective Study of the Use of Fine-Needle Aspiration Cytology and Core Biopsy in the Diagnosis of Breast Cancer

A prospective study was carried out on 143 consecutive patients with palpable lumps larger than 2 cm in size which were clinically suspicious of carcinoma. One hundred and five lumps proved to be malignant and 38 were benign. Of the 105 patients with malignancy, confirmation was made in 95 by fine-needle aspiration cytology (FNAC) with a sensitivity of 90.4% and 100 by core biopsy with a sensitivity of 95.2%. The sensitivity of core biopsies increased with the number of cores taken (one core, 76.2%; two cores, 80.9%, three cores, 89.2%; four cores, 95.2%). The combined sensitivity of FNAC and core biopsies was 100%, and so are complementary in the accurate diagnosis of breast cancer. Patients presenting to the breast clinic with a solid suspicious breast lump larger than 2 cm can benefit from FNAC and a minimum of four core biopsies to improve diagnosis.

A prospective randomised trial of two treatments for wound seroma after breast surgery

AIMS

Seroma formation is a recognised complication of breast surgery causing wound pain and discomfort. It was hypothesised that daily aspiration of symptomatic seromas that formed after breast surgery would encourage flap adherence to the chest wall, thereby allowing swifter resolution of seroma.

METHODS

Thirty-six patients undergoing mastectomy and/or axillary clearance who formed seroma post operatively, were randomised into two groups either having daily aspiration of seroma or aspiration as required by patient symptoms.

RESULTS

The daily aspiration required significantly more attendances for aspiration (P<0.005) and the time from surgery to final aspiration was not reduced.

CONCLUSION

Daily aspiration of symptomatic seroma did not result in swifter resolution.

Pilot randomized controlled study of preservation or division of ilioinguinal nerve in open mesh repair of inguinal hernia

BACKGROUND

There is uncertainty as to whether preservation or elective division of the ilioinguinal nerve influences pain and sensory loss following inguinal hernia repair.

METHODS

In 20 men with primary bilateral inguinal hernias undergoing open tension-free mesh repair, the sides (right or left) were randomized for preservation or division of the ilioinguinal nerve. Patients were reviewed on day 1, 4 weeks and 6 months after operation. Any pain or numbness, as well as any loss of sensation in the area supplied by the nerve, was recorded.

RESULTS

No significant difference was seen in pain or numbness between the divided and preserved sides. Sensory loss detected by clinical examination was more common following the division of the nerve compared with preservation.

CONCLUSION

Within the limitations of a small sample size, elective division of the ilioinguinal nerve during inguinal hernia repair does not appear to be associated with a significant increase in postoperative symptoms.

Assessment of breast cancer size: a comparison of methods

Two hundred women presenting with primary breast carcinoma were studied to find the most accurate single or combination of methods to assess breast tumour size. Correlations of the maximum clinical, mammographic and ultrasound tumour diameter were made with maximum histological diameter. Tumour size could be assessed clinically in all 200 patients, and overestimated the size of small tumours and underestimated large tumours (P less than 0.001). Mammographic measurement, which was possible in 145 (72.5%), underestimated the size of large tumours (P less than 0.01). Only 100 women underwent ultrasound examination (size assessed in 86%) and this modality tended to underestimate the size of all tumours (P less than 0.05). All methods of measurement showed similar correlations with histological size. Stepwise linear regression showed that the most accurate and practical estimation could be made using the formula: Histological size = 0.5 x mammographic size + 0.5 x clinical size. We conclude that clinical measurement of breast cancer size is as accurate as that from mammography or ultrasound. Accuracy can be improved by the use of a simple formula of both clinical and mammographic measurements.

Pre-operative radiological and clinical assessment of hepatic tumours--is biopsy necessary?

The pre-operative investigations of 72 consecutive patients who underwent liver resection for hepatic tumours have been reviewed. A combination of clinical, biochemical and radiological findings correctly predicted histology in 93% of cases (the benign or malignant nature in 97%). Biopsy was performed in only 20 patients. Five of the biopsy reports were incorrect (75% accuracy, benign or malignant nature accuracy 90%). Although guided biopsy can be performed during radiological assessment of focal hepatic lesions we argue that it is rarely indicated and can be misleading in patients proceeding to hepatic resection.

Nasogastric suction after elective abdominal surgery: a randomised study

The value of nasogastric tube decompression after elective abdominal operations was assessed in a randomised trial in which 97 patients were and 100 were not allocated postoperative nasogastric decompression. Only two patients in the latter group subsequently required decompression. There was no statistically significant difference in the incidence of mortality, complications (including vomiting) or time to return of intestinal motility between the two groups. There was a significantly higher incidence of sore throat (P less than 0.0001) and nausea (P less than 0.05) in patients who received nasogastric decompression. A postal questionnaire to 259 UK general surgeons (96% replied) revealed that postoperative nasogastric decompression was usually used by 92% of surgeons after a Polya gastrectomy, 72% after a small bowel anastomosis, 49% after a large bowel anastomosis and 20% after cholecystectomy. We conclude that such a routine is not justified and should be reserved for those patients developing specific complications.

Selective arterial embolisation for hepatic trauma

The technique of selective arterial embolisation for patients presenting with major hepatic trauma is described. We have used this technique successfully in four patients, three of whom had continued bleeding after emergency laparotomy. It can abolish localised intrahepatic arterial haemorrhage and arteriovenous shunting. Selective embolisation may prove to be a useful technique in reducing the mortality of major hepatic trauma.

Focal nodular hyperplasia of the liver: results of treatment and options in management

Twenty two patients (19 females) with focal nodular hyperplasia were seen between 1973 and 1989. Five were children, and all the adults were aged under 42 years (median 33 years). Fourteen patients (64%) were symptomatic on presentation. Twelve of the 14 adult women had taken the oral contraceptive pill. Twelve patients, nine of whom were symptomatic, underwent hepatic resection shortly after presentation. There were no deaths or major complications, and all remain well on follow up. Four patients underwent either hepatic artery embolisation or ligation. After an interval of six to 10 years they were asymptomatic and only one has histological evidence of residual focal nodular hyperplasia. Of five patients initially treated conservatively, two were asymptomatic and have remained so for three and 13 years. One of the three symptomatic patients became symptom free after stopping the contraceptive pill. The management of focal nodular hyperplasia requires a flexible approach. Lesions which are asymptomatic can be observed with regular ultrasound and treated if they enlarge or become symptomatic. Symptomatic patients who present while taking the contraceptive pill can also have a trial of conservative treatment. Other symptomatic patients, including those who previously took the pill, are best treated by surgical resection, and, where this is not possible, by embolisation.

Prevention of postoperative renal dysfunction in patients with obstructive jaundice: a multicentre study of bile salts and lactulose

The role of preoperative lactulose and bile salts in the prevention of postoperative renal failure in patients with obstructive jaundice has been evaluated in a prospective randomized trial. One hundred and two patients undergoing surgery for obstructive jaundice (bilirubin greater than 100 mumols/l) were randomized into three groups: those receiving preoperative oral lactulose (n = 35), those receiving oral sodium deoxycholate (n = 32) and a control group of patients receiving no specific treatment (n = 35). All patients received intravenous fluids commencing the night before surgery. One patient in the control group and none in the treatment groups developed postoperative renal failure. Postoperative deterioration of renal function in patients with normal preoperative function was significantly more common in the control group than in the treatment groups (chi 2 = 8.1, d.f. = 2, P less than 0.02). The incidence of renal failure and impairment was lower in this control group than that reported in previous studies. This may be due to the introduction of adequate preoperative hydration. Additional protection occurs by the preoperative administration of either lactulose or sodium deoxycholate.

Management of cyclical mastalgia

In order to establish the current treatment of cyclical mastalgia, a postal questionnaire was sent to 276 consultant general surgeons (over 25% of the UK total), randomly selected from the 12 UK regional health authorities. Surgeons were questioned about their choices of treatment for cyclical mastalgia, after initial resassurance, and for persistent pain. Two hundred and forty-five (89%) responded, out of whom 219 saw patients with breast disease. Twenty-three (11%) of these surgeons were identified as having a major interest in breast disease. Danazol, used by 75% of surgeons, was the drug most commonly prescribed. Initial treatments by non-specialist surgeons included danazol (31%), analgesia (19%) and diuretics (17%), and by breast surgeons evening primrose oil (30%), tamoxifen (13%) and vitamin B6 (13%). For persistent pain 46% of non-specialist surgeons prescribed danazol and 18% surgery, whereas 65% of breast surgeons prescribed danazol and 30% bromocriptine. A wide variety of therapies are used, but danazol is the most common. For persistent unresponsive pain, local excision biopsy surgery is frequently considered by non-specialist surgeons. Breast specialist tend initially to use other methods that are associated with fewer side-effects and reserve other treatments such as danazol and bromocriptine for persistent cases.

Combined tamoxifen and anabolic steroid as primary treatment for breast carcinoma in the elderly

Fifty-one consecutive patients aged over 70 years with localized breast carcinoma received primary treatment with tamoxifen and nandrolone decanoate. Results were compared to a control group of 51 age, tumour volume and nodal status-matched patients selected from a cohort who had primary treatment with tamoxifen alone. One year after commencement of treatment 31 (60%) patients treated with tamoxifen and nandrolone showed regression of their tumour, compared to 24 (47%) in the control group. Twenty-two (44%) patients had side effects attributable to nandrolone. Only four (8%) patients continued nandrolone for more than 12 months, and at 3 years after commencement of treatment 21 (40%) patients from each group had tumour regression. We argue that nandrolone should not be used as primary treatment in breast carcinoma, but may have a role to play in patients who fail to respond to tamoxifen.

Current practice in biliary surgery

A questionnaire enquiring about current practices in biliary surgery was sent to over 25 per cent of consultant general surgeons in the UK; 90 per cent replied. Only 56 per cent use antibiotic prophylaxis for elective cholecystectomy, and 84 per cent for emergency cholecystectomy. Duration of use, choice of agent and absence of prophylaxis for high-risk cases were inappropriate in up to 20 per cent of cases. Of the respondents 84 per cent routinely perform operative cholangiography and use T tubes, and 75 per cent routinely place a peritoneal drain after cholecystectomy. Despite controversies in the literature, most UK surgeons still follow traditional practices in biliary surgery.

Pancreaticogastrostomy: the preferred operation for pain relief in chronic pancreatitis

We present the results of surgery in 53 patients with intractable pain due to chronic pancreatitis associated with pancreatic duct dilatation. Using a limited mucosal to mucosal anastomosis over a silastic T tube the main pancreatic duct was drained in 33 patients into a Roux-en-Y jejunal loop (pancreaticojejunostomy, PJ) and in 20 patients into the stomach (pancreaticogastrostomy, PG). There was one postoperative death in the PJ group and none in the PG group. All patients were followed up for a minimum of four years. There was significantly greater pain relief in the PG group both at 1 (P less than 0.01) and 4 years (P less than 0.05) after surgery. We argue that PG is the operation of choice to relieve intractable pain in most patients with chronic pancreatitis associated with duct dilatation.

Prevention of endotoxaemia in obstructive jaundice--a comparative study of bile salts

Systemic endotoxaemia is associated with postoperative renal dysfunction in obstructive jaundice, and can be prevented by the pre-operative administration of certain bile salts. In order to find the most effective bile salt for use in this condition, a comparison of the anti-endotoxic activities of different bile salts was performed. Bile salts were incubated in vitro with endotoxin and the resultant endotoxin level was measured with a quantitative limulus assay. The in vivo effects of different oral bile salts on the intestinal absorption of radiolabelled endotoxin from rats with obstructive jaundice were compared. The in vitro and in vivo anti-endotoxic activities of bile salts related to their known detergent activities. Deoxycholic acid and its conjugates were the most effective and should be the bile salts of choice for further clinical evaluation in obstructive jaundice in man.

Reticulo-endothelial function in obstructive jaundice

A study of reticulo-endothelial function was performed in 30 patients with obstructive jaundice. Reticulo-endothelial phagocytic function, measured by the clearance of intravenous human micro-aggregated albumin, was significantly depressed in jaundiced patients compared with non-jaundiced controls (P less than 0.001). There was a significant correlation (P less than 0.001) between phagocytic function and plasma bilirubin level but not with transaminase or bile salt level. Phagocytic function was not related to the presence of malignancy, but was markedly reduced in patients with cholangitis. There was no reduction in hepatic sinusoidal blood flow, opsonin levels (fibronectin, IgG, complement) or serum opsonic activity to account for the reticulo-endothelial dysfunction.

Bile salts, endotoxin and renal function in obstructive jaundice

Surgical treatment for the relief of obstructive jaundice is still complicated by postoperative acute renal failure in almost 10 per cent of patients. Renal failure in the patient with jaundice is associated with the presence of bacterial endotoxin in the peripheral blood, and enteric endotoxin absorption is facilitated by the absence of bile salts from the intestine. Oral replacement of bile salts should prevent endotoxemia and renal failure. Forty-six patients with jaundice were studied. Twelve patients received sodium deoxycholate preoperatively, 12 received chenodeoxycholic acid and 22 acted as controls. Endotoxemia was measured by the limulus test and renal function assessed by 24 hour creatinine clearance. No patient given deoxycholate preoperatively had systemic endotoxemia or postoperative impairment of renal function. Endotoxemia was reduced in the chenodeoxycholic acid group, but not significantly, and renal function was not protected. Sodium deoxycholate is undergoing further evaluation in a multicenter randomized prospective study.

Small bowel obstruction: computer-assisted prediction of strangulation at presentation

A multivariate computer analysis has been performed on the presenting data of patients with simple small bowel obstruction that settled with conservative treatment (n = 120) and of patients with viable strangulation small bowel obstruction (n = 38) and non-viable strangulation small bowel obstruction (n = 39) found at operation. Initially only 66 per cent of patients with viable strangulation and 46 per cent of those with non-viable strangulation had been treated by immediate surgery after resuscitation. The remainder had been treated conservatively for a median of 3.8 and 2.2 days respectively before undergoing surgery. The computer predicted on the basis of presenting symptoms and signs that 82 per cent of patients with viable strangulation and 97 per cent of those with non-viable strangulation had or would develop strangulation and should have undergone immediate surgery. We advocate that the computer can assist in the management of patients with small bowel obstruction.

Leiomyosarcoma of the scrotum

A case of leiomyosarcoma arising from the dartos muscle of the scrotum is described. Review of the literature reveals only eight other cases, and aspects of management of these and our case are discussed.

Measurement of operative plasma endotoxin levels in jaundiced and non-jaundiced patients

A study of portal plasma endotoxin levels was performed using a chromogenic limulus amoebocyte lysate (LAL) assay. The assay proved sensitive and reproducible. In only 1 of 25 healthy subjects was the systemic plasma endotoxin level above 100 pg/ml (equivalent Escherichia coli 0111B4). In 30 non-jaundiced patients undergoing surgery the mean (+SEM) portal plasma endotoxin level (60 + 9 pg/ml) was significantly higher (p less than 0.05) than the mean level in the systemic blood (46 + 6 pg/ml), supporting the concept of endotoxin absorption from the intestine into the portal blood. In 20 patients with obstructive jaundice undergoing surgery 42% of portal, 45% of inferior mesenteric and 35% of systemic venous plasma endotoxin levels were above 100 pg/ml. There were significantly higher levels in the portal (p less than 0.05) and inferior mesenteric (p less than 0.05) compared with the systemic blood. Neither the presence of malignancy nor the duration of surgery appeared to influence endotoxin absorption. The significance of raised plasma endotoxin levels in obstructive jaundice is discussed.

Reticuloendothelial system phagocytic function in obstructive jaundice and its modification by a muramyl dipeptide analogue

Measurement of reticulo-endothelial system (RES) phagocytic function by clearance of intravenous micro-aggregated human albumin (HMAA) showed prolonged clearance in both patients (p less than 0.001) and rats (p less than 0.001) with extrahepatic biliary tract obstruction compared with non-jaundiced controls. After the administration of the immune stimulator, N-acetyl-L-alpha-aminobutyryl-D-isoglutamine, the mean HMAA clearance rate in jaundiced animals was similar to that of non-jaundiced controls. The implications of modifying RES phagocytic function to prevent overspill of endotoxins from the portal to systemic circulation in obstructive jaundice are discussed.

The Kupffer cell in experimental extrahepatic cholestasis in the rat--a light microscopy, immunohistochemical and electron microscopy study

Kupffer cell phagocytic function is reduced in the presence of obstructive jaundice. To investigate possible mechanisms we report a study of the rat liver in extrahepatic cholestasis, using light microscopy, immunohistochemistry and electron microscopy, Immunohistochemistry was performed with monoclonal antibodies specific for rat Kupffer cells ED 1, ED 2 and ED 3 and monoclonal antibodies directed against class II antigens of the rat major histocompatibility complex Ox 3 and Ox 6. Extrahepatic cholestasis was produced by bile duct ligation. In bile duct ligated animals light microscopy showed proliferation of bile ductules and an increase in sinusoidal cells. Immunohistochemistry with ED 1, ED 2 and ED 3 demonstrated a marked increase in the number of positive cells, but few of these cells were positive with Ox 3 and Ox 6, whereas the proliferating bile ductules were strongly positive. Electron microscopy revealed two homogeneous granular substances within the sinusoidal lumen and loss of the space of Disse. Despite a reduction in Kupffer cell phagocytic function in obstructive jaundice there is an increase in Kupffer cells, but these cells appear to be in an inactivated state as few express class II antigens on their surface. Furthermore the granular substance within the space of Disse may interfere with function.

Experimental and clinical study of lactulose in obstructive jaundice

The role of lactulose in preventing endotoxaemia in obstructive jaundice has been investigated. A prospective study was performed on 24 consecutive patients with obstructive jaundice undergoing surgery. Twelve patients were given oral lactulose before operation and were compared with twelve controls. Endotoxaemia was reduced in peroperative portal (P less than 0.05) and postoperative systemic (P less than 0.05) blood samples in the lactulose treated group, and a significant fall (P less than 0.05) occurred in the postoperative 24 h creatinine clearances in controls compared with the lactulose treated group. Results from animal experiments in which oral lactulose reduced endotoxin related mortality in obstructive jaundice (P less than 0.05), and the in vitro demonstration of a direct anti-endotoxic action of lactulose suggest that its beneficial action is due in part to an inactivation of endotoxin.

Malignant melanoma of a parotid lymph gland. An unusual case

A case of malignant melanoma in an intra-parotid lymph gland treated by excision is reported. The patient remains disease-free 9 years after surgical treatment, and no primary lesion has been found.

Management of choledochal cysts in adults

The management of 7 adults with choledochal cysts is described. Three patients presented with abdominal pain, 3 with jaundice and one with cholangitis. Three patients underwent total or partial cyst excision and the remaining patients underwent cyst drainage into a Roux-en-Y jejunal loop. There was no operative mortality and all patients have remained well for up to 6 years following surgery. It is argued that total cyst excision is the treatment of choice, but where this is not possible a Roux-en-Y choledochocystojejunostomy is the recommended alternative.

Non-steroidal anti-inflammatory drugs and peptic ulcer perforation

A retrospective study is reported in which the ingestion of non-steroidal anti-inflammatory drugs (NSAID) in 269 patients with perforated peptic ulceration and 269 age/sex matched controls admitted between 1973-1982 was compared. A highly significant statistical difference was found (p less than 0.001) in those aged over 65. There was no statistical difference, however, in those aged under 65. Furthermore we have shown a highly statistically significant correlation (p less than 0.0001) between the annual number of patients aged over 65 with perforated peptic ulcers taking NSAID and the annual number of prescriptions issued for these drugs in the region. No such correlation was found for patients aged under 65 years. We suggest that the elderly especially women are unduly susceptible to NSAID associated peptic ulcer perforation, and discuss factors that may account for this.

Factors influencing recurrence of urethral strictures after endoscopic urethrotomy: the role of infection and peri-operative antibiotics

One hundred patients who had undergone 162 urethrotomies were reviewed. Factors which influenced the outcome of the procedure are discussed. Peri-operative infection occurred in 38% of cases and significantly increased the recurrence rate unless the patients were treated with antibiotics.

Primary leiomyosarcoma of the pulmonary artery

A case is described of a pulmonary artery leiomyosarcoma. This is the first report in which such a tumour did not involve the main pulmonary trunk.