Thoracoscopic sympathectomy.

Surgical sympathectomy has traditionally been achieved by 'open' surgical techniques. The transaxillary, cervical, or dorsal approaches have not been without morbidity and cosmetically have been found to be less than ideal. The main indication for sympathectomy in most units is palmar and axillary hyperhidrosis refractory to medical treatment, although it has been used with some success in troublesome causalgia. Use of sympathectomy in Raynaud's disease remains disappointing. In our unit thoracoscopic sympathectomy has been performed since 1980. A CO2 pneumothorax is initially created in the usual manner. This is followed by electrocoagulation of the sympathetic chain under direct vision using a unipolar diathermy. The lung is then reinflated under direct vision. Chest drains are not inserted. Both sides are performed at the same sitting, and the patient usually leaves hospital the following day. The functional and cosmetic results are excellent on short and long term follow-up with few side effects. Permanent Horner's syndrome has not been reported using this technique. As with all upper limb sympathectomies, patients should be warned of possible compensatory hyperhidrosis. Embracing the tenets of minimally invasive surgery, thoracoscopic sympathectomy should be considered the approach of choice for surgical sympathectomy.

Laparoscopic versus open appendicectomy: a prospective evaluation.

A prospective evaluation of laparoscopic surgery for acute appendicitis over a 6-month period is reported. Sixty-five patients with signs and symptoms of appendicitis necessitating surgery were assigned to open (n = 36) or laparoscopic (n = 29) appendicectomy. Thirty-seven patients were female (22 open) and 28 were male (14 open). The median age was 24 (range 14-64) years for open appendicectomy and 18 (range 14-60) years for the laparoscopic procedure. The mean postoperative stay for open operation was 4.8 (range 1-21) days and for the laparoscopic route 2.2 (range 1-11) days (P < 0.05). Inflammation was confirmed histologically in 72 per cent of the open cases and in 74 per cent of the laparoscopic cases (P not significant). The wound infection rate was 11 per cent (n = 4) for open and 4 per cent (n = 1) for laparoscopic appendicectomy (P < 0.05). The median anaesthesia time was 52 (range 15-90) min for open appendicectomy and 48 (range 20-120) min for laparoscopic surgery (P not significant). After open appendicectomy patients had a median of 5 (range 2-12) intramuscular injections of analgesia compared with a median of 1 (range 0-5) in the laparoscopic group (P < 0.05). Two laparoscopic operations were converted to an open procedure. The results suggest that emergency laparoscopic appendicectomy should be explored further as an alternative to open surgery for acute appendicitis.

Argyrophylic nucleolar organiser regions (AgNOR's) as a prognostic indicator in breast carcinoma.

Silver staining nucleolar organiser regions (AgNOR's) were determined in archival histological specimens of breast carcinoma. Representative samples from forty-eight female patients were counted manually for AgNOR's--median 3.85 (range 1.1-10.2 AgNOR's per cell). Taking the median value of 3.85 as a cutoff, the patients were divided into two groups: A = Those with AgNOR counts > 3.85; B = Patients with AgNOR counts < or = 3.85. The 5 year survival was 21% in group A and 85% in group B (p < 0.001). There was no significant correlation between AgNOR's and tumour size, lymph node status, tumour grade, menopausal status and oestrogen receptors. We conclude that nucleolar organiser regions may be useful as a prognostic indicator in breast carcinoma especially in patients in whom other prognostic information is unavailable.

Colorectal carcinoma over 30 years at one hospital: no evidence for a shift to the right.

Many recent reports in the North American literature have documented an increase in the ratio of proximal to distal colorectal cancers with an increase in right-sided lesions. In order to assess trends in the distribution of large bowel carcinoma at our hospital we reviewed the files of 1553 patients who presented with primary colorectal carcinoma over a 30-year period. Thirty-nine percent of patients were over 70 years old and 51% were in the 50-69 year age group. Seventy five percent of the carcinomas were left-sided, 22% right-sided and caecal carcinomas accounted for 18%. This distribution varied only slightly over the study period. Left-sided lesions were more common in males (55%: p less than 0.005), and right-sided lesions were more common in females (57%: p less than 0.005). Caecal carcinoma was more common in patients over 69 years old than in younger patients (p less than 0.001). In elderly females (greater than 69 years) 30% of colorectal carcinomas occurred in the caecum. These findings may have important implications for the investigation of patients with suspected colorectal disease or for screening programmes.

Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis.

Endoscopic transthoracic electrocautery of the sympathetic chain has been the preferred treatment for palmar or axillary hyperhidrosis in this unit since 1980. A retrospective study was carried out of the first 112 patients with case material derived from a postal questionnaire, chart review and outpatient assessment. Eighty-five patients undergoing bilateral transthoracic electrocautery who replied to the questionnaire (76 per cent response rate) form the basis of this study. There were 65 females and 20 males with a mean age of 24.3 years (range 15-40 years). The hands alone were affected in 20 patients (24 per cent), the axillae alone in 17 (20 per cent) and both areas in 48 (56 per cent). Mean hospital stay was 3.1 days (range 1-7 days). Outcome was assessed by 92 per cent of patients immediately after operation as 'very much improved' or 'moderately improved', and this assessment persisted in 85 per cent after a mean follow-up of 43 months (range 3-95 months). Cosmetic results were rated as satisfactory by 95 per cent. Apart from pain after operation, morbidity was limited to transient Horner's syndrome in three patients, surgical emphysema in three, and pneumothorax requiring a chest drain in one. A repeat procedure was needed in one patient because of an inadequate first operation. Some compensatory hyperhidrosis occurred in 54 (64 per cent) patients. As a minimally invasive procedure, endoscopic transthoracic electrocautery should be considered the treatment of choice for palmar and axillary hyperhidrosis.

Inferior mesenteric artery aneurysm.

This case reports a very large inferior mesenteric artery aneurysm and highlights the importance of proper preoperative arteriography in the patients work-up. In addition the case demonstrates an anomalous arterial supply to the gastrointestinal tract from a dilated inferior mesenteric artery which due to occlusion of the superior mesenteric artery and coeliac axis may have been instrumental in the development of this aneurysm.