Learning curves in surgical practice.

Learning curves are often referred to in the context of medical education and training, though their trajectories and natures are a matter of debate. The origins of this concept derive from industry and its relevance to contemporary medicine and surgery remains controversial. We describe the history, derivation, character and possible mechanisms to deal with the implications of learning curves in the current climate of clinical governance and modernizing medical careers.

Endometriosis: presentation to general surgeons.

We present nine cases of endometriosis presenting to general surgeons over a period of 4.5 years at Gwynedd Hospital, Bangor. A total of 83 cases of endometriosis was found on analysis of pathology records. Of these, 73 presented to gynaecologists, one to a dermatologist and nine to general surgeons. The presentation to general surgeons includes swelling related to Pfannanstiel scar (two), swelling in inguinal canal (two), umbilical nodule (one), rectal bleeding (one), recurrent abdominal pain (one), mimicking ovarian tumour (one) and presenting as pelvic peritonitis (one). Six were elective admissions and three were admitted as an emergency. All were premenopausal (range 19-49 years) women. None had any previous history of endometriosis or subfertility. Two patients with cyclical symptoms were correctly diagnosed clinically, and the others were postoperative diagnosis. Six patients required gynaecological referral and four of these required further medical treatment. None of them has required further surgical intervention in follow-up (range 4 weeks to 3 years). Endometriosis usually presents to general surgeons with deposits at extragonadal sites. Some patients may present as an emergency with abdominal pain. Endometriosis should be included in the differential diagnosis of women presenting with swellings related to umbilicus, surgical scars, inguinal canal and pelvis, especially if symptoms are cyclical. Usually, surgical excision is adequate. Selected cases require gynaecological referral and further medical therapy.

Severe haemorrhage from a lumbar artery as a complication of percutaneous renal biopsy.

A patient is described with severe haemorrhage from a lumbar artery following percutaneous renal biopsy. The exact source of haemorrhage in this previously unreported complication proved difficult to locate even at surgical exploration.

The influence of pancreatic juice on 64Cu absorption in the rat.

The absorption of 64Cu from closed duodeno-jejunal loops in anaesthetized rats was significantly less in the presence of pancreatic juice compared with that in the presence of saline (9 g sodium chloride/l). The inhibition of 64Cu absorption caused by pancreatic juice was similar to that achieved with bile. Studies using solutions of electrolytes and of pancreatic extracts showed that the inhibitory effect of pancreatic secretions was due to its protein-enzyme content and not to its bicarbonate content. Pancreatic secretion and bile influence Cu absorption and thereby affect Cu homeostasis.

Superior mesenteric venous thrombosis.

Superior mesenteric venous occlusion may be difficult to recognize, but is important as it carries a better prognosis than superior mesenteric arterial occlusion, an may be amenable to surgical treatment. Three cases of primary superior mesenteric venous occlusion are described. The diagnosis was unsuspected until discovered at laparotomy. Non-viable bowel was present in all cases and in two cases thrombosed veins were apparent in the mesentery. The lesion was localized in distribution, and generous bowel resection with primary anastomosis was performed. Recovery was uncomplicated in all cases. When the thrombosis appears well localized, generous resection with primary anastomosis seems a suitable alternative to resection and exteriorization or conservative treatment with a second-look procedure.