An audit of the preoperative investigation of surgical patients.

The pattern of preoperative investigation was audited in 256 patients entering hospital for elective surgery over a 12-week period. During the initial 6 weeks (phase one), no guidance was given to the house surgeons and the investigations were assessed as being 'indicated' or 'not indicated' according to preset criteria. A total of 272 investigations was performed on 117 patients. Minor modifications were made to the criteria. At the beginning of the second 6-week period (phase two), the modified criteria were distributed to the house surgeons as a guide to preoperative investigation. During this time 308 investigations were performed on 136 patients. The number of investigations (excluding ECGs) that were available at the time of surgery rose significantly (P < 0.001) from 66% in phase one to 81% in phase two. The percentage of investigations deemed to have been indicated rose significantly (P < 0.001) from 53% in the first phase to 90% in the second phase. It is calculated that in practice 94% of the maximum possible savings of 7080 pounds could be achieved over the course of 1 year by implementing these criteria for preoperative investigations.

Appendicectomy at cholecystectomy--an appraisal.

The effect of incidental appendicectomy in patients undergoing elective biliary surgery has been studied prospectively in 430 patients. In 236 patients the appendix was removed at the time of biliary surgery; in 194 patients the appendix was not removed or had already been removed at a previous operation. There was no significant difference between the two groups with regard to the incidence of septic complications--especially wound infection--more general complications, or in the mean post-operative stay in hospital. Histological examination of the macroscopically normal appendices revealed a surprising incidence of pathology (greater than 50 per cent). Provided the patient receives routine antibiotic prophylaxis, there appears to be a case for removing the appendix at the time of cholecystectomy if it is readily accessible.

The use of gentamicin-PMMA chains in abdominal surgery: a pilot study of prophylaxis against wound infection.

A prospective study was carried out to examine the effectiveness of gentamicin-impregnated polymethylmethacrylate beads in the prevention of wound sepsis after gastro-intestinal surgery. The beads were laid in the abdominal and perineal incisions (61 wounds) of 55 patients at the end of the operative procedures, and were withdrawn in stages from the fifth post-operative day. This method of administration results in a sustained high antibiotic concentration in the wound with low serum and urine concentrations, thus eliminating the dangers of gentamicin toxicity. Wound infection occurred in only 1 instance, a favourable result when compared to historical controls. It is suggested that further controlled studies of this method of topical prophylactic antibiotic administration are indicated.

Management of obstructing carcinoma of the left colon by extended right hemicolectomy.

In obstructing carcinomas of the left colon, primary resection with immediate colocolonic anastomosis is associated with a high risk of anastomotic dehiscence, and therefore, it has become traditional to manage such patients with staged resection. In obstructing carcinomas of the right colon, immediate resection of the lesion with ileocolonic anastomosis is acceptable. The scope of right hemicolectomy can be extended to encompass obstructing carcinomas of the left colon by performing subtotal or total colectomy with ileosigmoid or ileorectal anastomosis. Herein, we have reported the outcome in 16 patients treated in this manner. The operative mortality was 12.5 percent, which compared favorably the mortality of other methods of surgical management. Extended right hemicolectomy achieves in one operation relief of intestinal obstruction, tumor resection, restoration of gut continuity, elimination of the risks of synchronous or metachronous colonic tumors, and a possible increase in the 5 year survival rate. In our experience, the frequent passage of liquid stools is not a problem. This approach justifies further study.

Treatment of the perineal wound after proctectomy by intermittent irrigation.

Between 1977 and 1983, 43 patients underwent proctectomy (40 patients for carcinoma, three for ulcerative colitis). The subsequent perineal wound received primary closure and the pelvic space was treated with intermittent irrigation and suction drainage using a double-lumen catheter. Primary healing of the perineal wound occurred in 56.4% of cases and in 89.7% of cases the perineal wound had healed completely by the sixth postoperative week. The relationships between perineal wound healing and the age and sex of the patient, the stage of the tumor, and the tumor distance from the anal verge were assessed. The period of hospitalization was significantly reduced when the perineal wound underwent primary healing. The results obtained in terms of wound healing are comparable with the best published results using continuous irrigation. Our method is advantageous in that it does not necessitate immobilization of the patient.

High bile duct strictures.

The diagnosis and surgical treatment of carcinoma of the common hepatic duct present diffucult problems. Accurate preoperative localization of the obstructive lesion is essential and slim needle transhepatic percutaneous cholangiography is the investigation of choice. Worth while palliation may be achieved if biliary-enteric flow can be reestablished by introducing a plastic stenton through the obstructive lesion in the bile duct. Three patients are reviewed who survive 36, 31 and 26 months after this operation. A further patient died of metastases after 5 months.

Relation between transmucosal potential difference, ionic flux, and the intraluminal supply of H+ in the ferret stomach.

To investigate the relation between gastric transmucosal potential difference, ionic flux, and the intraluminal concentration of H+, test solutions containing various concentrations of HCl were instilled into ferret stomachs both before and after exposure to various doses of acetic acid. The changes in ionic composition of the test solution were determined and the transmucosal potential difference was recorded throughout each experiment. The results showed that after exposure to the organic acid (1) ionic flux was proportional to the concentration of acetic acid used and was a direct function of the concentration of H+ within the lumen, and (2) the decrease in transmucosal potential difference was proportional to the concentration of acetic acid used but did not appear to be related to the subsequent magnitude of ionic flux. It is suggested that the decrease in gastric transmucosal potential difference that follows exposure of the gastric mucosa to an organic acid is a measure of the increase in mucosal permeability, whereas the subsequent ionic movements are governed by the concentration of H+ within the gastric lumen.

The selective use of combined supraduodenal and transduodenal exploration of the common bile duct.

The results of combined supraduodenal and transduodenal exploration of the common bile duct in 42 selected cases are presented. The indications for this operation were: the presence of multiple calculi in the common bile duct; stones impacted in the ampullary region; residual stones in the common bile duct following previous surgery on the biliary tract; stricture at the papilla and pancreatitis associated with cholelithiasis. After the procedure no patient had residual stones in the common bile duct. Serious complications were infrequent; there were no postoperative deaths and post-operative pancreatitis occurred in only one patient.

Retrograde jejunogastric intussusception: report of 2 cases.

Two clinical variants of jejunogastric intussusception are described. In one, self-reduction is the rule, whilst in the other strangulation occurs and emergency surgery is mandatory. A case illustrating each variant is presented and its diagnosis and treatment are discussed.

Effect of vagal innervation on the secretory responses of canine gastric pouches exposed to bile.

The changes in the secretory response to a meat meal, after preliminary exposure of vagally innervated and vagally denervated fundic pouches to ox bile at pH 7 and pH 2, have been defined. In the innervated pouches, exposure to bile at both pH levels caused transient inhibition of gastric acid secretion. In both types of pouch, the output of Na+ in the gastric juice was presistently increased due to enhanced exchange diffusion. The changes were more pronounced after exposure to bile at pH 2 than after exposure to bile at pH 7. After exposure to bile, exchange diffusion was more increased in the innervated pouches than in the denervated. The results suggested that the innervated mucosa was more susceptible than was the denervated mucosa to the injurious effects of bile.