The use of intraoperative parathyroid hormone monitoring in minimally invasive parathyroid surgery.

Introduction Surgery is the first-line management option for patients with primary hyperparathyroidism (pHPT). Minimally invasive parathyroidectomy (MIP) is now preferable but few centres offer this service, mainly because of lack of intraoperative parathyroid hormone (IOPTH) testing. The aim of this study was to identify whether the measurement of IOPTH in patients having minimally invasive parathyroidectomy for pHPT alters their management. Methods A retrospective review was carried out of 78 consecutive patients who underwent parathyroid surgery by a single surgeon with a special interest in parathyroid surgery. The clinical impact of IOPTH monitoring was recorded postoperatively in a timely manner. Serum adjusted calcium levels were checked preoperatively (on admission) and one month postoperatively; normalisation was considered a cure. Results In the setting of curative MIP, IOPTH measurement did not influence the management in any of the patients but it could have led to bilateral parathyroid exploration (BPE) in three instances. Similarly, in cases that required lengthening of the MIP incision, IOPTH results did not influence patient management although it could have led to BPE in one case. Conclusion MIP offers an effective cure for patients with hyperparathyroidism. The addition of IOPTH testing adds increased expense, operating time and risk to patients otherwise suitable for MIP.

Two week rule referral for patients with colorectal cancer below the age of 50; are we being ageist?

OBJECTIVES: The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment. METHODS: The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years. RESULTS: There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician's referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria. CONCLUSION: Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor.

Undertaking procedure-based assessment is feasible in clinical practice.

INTRODUCTION: With the development of a new curriculum, workplace based assessments such as procedure-based assessment (PBA) are becoming increasingly common within surgical training. However, there have been concerns about the impact of these assessments on clinical practice. This study assessed the time taken to complete PBA forms to determine whether it is feasible in clinical practice. MATERIALS AND METHODS: PBAs for three colorectal procedures (anterior resection, right hemicolectomy and anal fistula) were undertaken by various trainers and trainees. A pilot study was performed to identify potential reasons for incomplete forms and procedural modifications subsequently applied in the main study. Times taken to complete the consenting and operative components of the forms were recorded. RESULTS: Incomplete forms in the pilot were mainly attributable to time constraints. In the main study, all assessments were completed within 30 min. Assessment times increased with complexity of the procedure. Median times for completing the consenting and operative components in anterior resection were 13 min (range, 8-15 min) and 15 min (range, 10-18 min), respectively. CONCLUSIONS: PBAs are feasible in clinical practice and are valued by trainees as a means of enabling focused feedback and targeted training. Commitment from trainers and trainees will be required but, with adequate planning, the assessment tool is effective with minimal impact on clinical practice.

Bowel function following insertion of self-expanding metallic stents for palliation of colorectal cancer.

OBJECTIVE: Self-expanding metallic stents (SEMS) are an important addition to the treatment of large bowel obstruction. The aim of this study was firstly to assess bowel function following SEMS placement and secondly to identify any potential factors which might aid in the prediction of technical failure of stent insertion. METHODS: A review of all patients undergoing attempted SEMS placement for palliation of malignant left-sided colorectal obstruction over a four-year period (1st May 2000-30th April 2004) was performed. RESULTS: Twenty-one patients (12 male) with a median age of 76 years (range 48-92 years) were included, 11 with metastatic disease and 10 severe comorbidity. SEMS insertion was technically successful in 16 (76%) of 21 cases. Contrast successfully passed through the obstructing lesion in all 16 cases where SEMS placement was technically successful. It only passed through 1 of 5 cases where stenting was not possible (P = 0.0008, Fisher's Exact test). Complications included colonic perforation (1 case), stent migration (1 case) and tumour ingrowth requiring a second stent (1 case). Median survival after SEMS was 12 months (range 1-30 months), and 9 patients died during follow-up. Median bowel frequency following SEMS was 3.5 times per day (range 1-7). Eight patients always passed a liquid stool, 3 others regularly required laxatives and one further patient with poor function after stenting requested a defunctioning stoma. CONCLUSION: Failure of contrast to pass through the obstructing lesion may predict those cases where stenting will not be technically possible. Median survival following SEMS insertion is encouraging in this series, but bowel function is often poor. Expected bowel function should be discussed fully when consenting patients for a SEMS, particularly those with metastatic disease who are otherwise fit for resectional surgery.

Quality of life after low anterior resection with total mesorectal excision and temporary loop ileostomy for rectal carcinoma.

BACKGROUND: Low anterior resection (LAR) with total mesorectal excision (TME) may be the optimal operation for carcinoma of the mid or lower rectum. Routine formation of a temporary defunctioning stoma has been recommended with TME. The impact of this strategy on health-related quality of life (HRQOL) has not been addressed. METHODS: A prospective longitudinal study was conducted among 24 patients undergoing LAR with TME and loop ileostomy for rectal cancer. Clinical outcomes were documented. HRQOL was assessed using Short Form 36 (SF-36). Twenty-three patients undergoing high anterior resection (HAR) for rectosigmoid cancer were studied concurrently to determine the effects of major colorectal resection without a stoma. RESULTS: Time to resume normal diet, length of stay in hospital and time to return to non-work activities were similar after HAR or LAR with TME and loop ileostomy. Twelve weeks after HAR SF-36 scores were stable or improved compared with preoperative levels. In contrast, 12 weeks after LAR + TME patients had a reduction in physical functioning scores on SF-36. SF-36 scores improved after ileostomy closure. Ileostomy closure increased total hospital stay and time off non-work activities. CONCLUSION: LAR with TME and temporary loop ileostomy for rectal cancer results in a long total hospital stay and impairs aspects of HRQOL. Prompt stoma closure should be a priority in these patients.

Controlled digital anal dilatation under total neuromuscular blockade for chronic anal fissure: a justifiable procedure.

BACKGROUND: There is widespread antipathy to digital dilatation of the anus (DDA) for medically resistant anal fissure. A retrospective study was therefore undertaken to test the validity of the criticism of this technique. METHODS: Some 273 patients who underwent DDA for fissure between November 1982 and July 1997 were sent a questionnaire and/or telephoned. Those with impaired control were offered investigation. In addition, routine clinic follow-up data were scrutinized in the 302 available notes of the 307 patients who had undergone DDA for fissure to determine its efficacy. RESULTS: Some 241 patients (88.3 per cent) were contacted successfully a median of 7.8 years after operation. Follow-up records showed the fissure to have healed in 89.1 per cent of 302 patients. No patient was rendered incontinent. Fifteen patients indicated persistently impaired control in the questionnaire, nine (3.8 per cent) as a result of the DDA and six preceding it. All 23 patients who had experienced either temporary or permanent impairment, whether or not pre-existing, were invited to attend for ultrasonography and manometric measurements, of whom 18 accepted. No sphincteric fragmentation was seen, and resting and squeeze pressures did not differ from normal. CONCLUSION: A single DDA appears to heal 89 per cent of chronic anal fissures. Consequent impairment of control is infrequent and minor if the procedure is performed carefully and with the patient paralysed.

Surgical care and outcome for patients in their nineties.

BACKGROUND: Surgical care of the elderly poses special problems. Very little has been published on the management of patients aged 90 years and over. METHODS: This study reviewed a consecutive series of patients aged 90 years and over, admitted to hospital over 2 years under five general surgeons and two urologists. There were 129 patients (68 per cent women) aged 90-104 (median 92) years and a total of 141 admissions, 45 elective and 96 emergency. Gastrointestinal conditions were commonest (40 per cent of admissions), followed by undiagnosed abdominal pain (16 per cent), hernia (16 per cent), arterial disease (13 per cent) and urological problems (7 per cent). RESULTS: Operation was required after 66 per cent of admissions (37 of 45 elective admissions and 56 (58 per cent) of 96 emergencies). In contrast to other studies of the very elderly, some patients were American Society of Anesthesiologists (ASA) grade 1, none of whom died after operation; no patient with ASA grade 5 was submitted to operation. Fifteen patients (12 per cent) died in hospital, three of 31 and seven of 50 respectively after elective and emergency surgery. CONCLUSION: Very elderly patients can be managed with a reasonable expectation of good outcome after admission for surgical care.

Psychological morbidity associated with abdominal aortic aneurysm screening.

OBJECTIVES: To identify whether abdominal aortic aneurysm screening causes anxiety in those screened and whether the diagnosis of an aneurysm produces sustained anxiety in subjects in comparison with those in whom no abnormality is detected. DESIGN: Prospective case controlled study. MATERIALS AND METHODS: The 28-item General Health Questionnaire (GHQ) was used to assess psychological morbidity in 161 men attending for routine aneurysm screening in the Gloucestershire Aneurysm Screening Programme. One hundred men had a normal aorta and 61 were identified as having aneurysms. The GHQ was administered just before screening and 1 month later. An anxiety linear analogue scale was also used. RESULTS: There was no difference in anxiety levels between those men with normal aortas and those with aneurysms either before or after screening. There was a statistically significant reduction in both these groups 1 month after screening. CONCLUSION: This study shows that although the invitation to aneurysm screening may cause some mild anxiety, this is not prolonged even when an asymptomatic aneurysm is diagnosed.

Synchronous proctocolectomy and ileoanal pouch formation and the risk of Crohn's disease.

There is controversy on the advisability of one-stage proctocolectomy and the formation of an ileoanal pouch. Accurate preoperative diagnosis is essential to avoid the error of constructing a pouch in a patient with Crohn's disease. Twenty-four consecutive patients undergoing subtotal colectomy for inflammatory bowel disease were reviewed. All patients had been treated with systemic steroids, 23 were on 5-aminosalicylates and 11 on azathioprine. The preoperative diagnoses, based on a combination of clinical features, colonoscopy, barium enema and biopsy histology, were ulcerative colitis (19), Crohn's disease (four) and inflammatory bowel disease (unclassified) (one). The final diagnosis was made on histological examination of the resected specimen. A discrepancy between initial and final diagnosis occurred in eight patients. In three, the diagnosis was changed from ulcerative colitis to Crohn's disease. Three preoperative diagnoses of Crohn's disease were changed to ulcerative colitis (one), Behçet's disease (one) and diverticulitis (one) on final histology. These data suggest that caution should be exercised in performing synchronous proctocolectomy with the formation of an ileoanal pouch.

Exfoliative cytology in the diagnosis of breast disease.

A total of 393 nipple discharge or scrape smears from 360 women were examined cytologically over a 12-year period. Twenty-nine breast cancers (8 per cent) have been histologically confirmed in this group, of which 16 had malignant smear cytology (sensitivity 55 per cent). Nine patients with breast cancer and positive cytology had impalpable tumours. Two of these cancers were not detected by any other investigation. Thirteen patients with nipple discharge had false-negative cytology, but there were no false-positive results (specificity 100 per cent). All patients with expressible or spontaneous nipple discharges and those with skin changes at the nipple should undergo examination of cytological smears.

Scrape cytology in the diagnosis of Paget's disease of the breast.

Eczema of the nipple is an important symptom presenting to the general surgeon in the out-patient department. The diagnosis of Paget's disease of the nipple has traditionally been made by incision biopsy necessitating at least a local anaesthetic. We present 14 patients with nipple skin change, in whom the technique of scrape cytology was used to identify patients with Paget's disease. In our series eight cases of Paget's disease were successfully identified by scrape cytology with no false negatives or positives. We suggest that this is a quick, easy, non-invasive method of screening eczema of the nipple in the out-patient clinic.

Somatostatin and primary hyperparathyroidism.

No satisfactory medical therapy exists for the treatment of primary hyperparathyroidism. Calcitonin and diphosphonates do not give good long-term control. This work examines the efficacy of the somatostatin analogue octreotide in the management of hyperparathyroidism. Twenty-one patients were admitted before parathyroid surgery and were treated for 6 days with subcutaneous octreotide 100 micrograms twice daily. Fasting blood samples were taken for determination of serum levels of calcium and parathyroid hormone, and 24-h urinary calcium excretion was measured before and after treatment. A significant decrease in urinary calcium was demonstrated, but the reduction in serum calcium level was not statistically significant and there was no change in serum parathyroid hormone concentration. Octreotide may provide therapy for patients with hyperparathyroidism and for those who have undergone unsuccessful neck exploration or who are unfit for operation. It may ameliorate hypercalciuria and reduce stone formation. The octapeptide may also have a potential role as a diagnostic test in primary hyperparathyroidism by determining the symptomatic effect of reducing raised levels of serum and urinary calcium.

Patient selection and timing of dynamic computed tomography in acute pancreatitis.

Dynamic computed tomography (CT) is the most accurate method for determining the extent of necrosis in acute pancreatitis. Debate exists, however, regarding patient selection and the optimal timing of CT. This study examined selection based on biochemical and/or clinical criteria and the influence of delayed dynamic CT performed 5-10 days after the onset of an attack. A total of 120 patients with acute pancreatitis were studied. Dynamic CT was performed if any of the following criteria were identified: a biochemically severe attack (according to Glasgow criteria) in the first 24 h, C-reactive protein (CRP) level above 120 mg/l in the first 3 days or failure of clinical resolution within 7 days. Of 42 patients selected for CT, five died from multisystem organ failure before day 5. There were no deaths or delayed complications in the 78 patients not selected for scanning. Positive Glasgow criteria alone in the scanned group had a sensitivity for predicting necrosis (as recognized by CT) of 22 per cent and a specificity of 20 per cent. Measurement of CRP level alone had a sensitivity of 26 per cent and specificity of 80 per cent. Failure of clinical resolution had a sensitivity of only 7 per cent but a specificity of 100 per cent. The combination of Glasgow criteria and CRP level had a sensitivity of 44 per cent and specificity of 100 per cent. Delayed complications (pseudocyst, five; infection, six) occurred only in patients with necrosis, and there were two deaths. An 'at-risk' group can be identified for CT on the basis of biochemical and clinical observations. Neither routine nor emergency dynamic CT in acute pancreatitis seems justified.

The Gloucestershire Aneurysm Screening Programme: the first 2 years' experience.

5337 men aged 65 were invited for ultrasound examination of the abdominal aorta between September 1990 and October 1992 as part of a General Practice based aneurysm screening programme covering the County of Gloucestershire. 4232 (79%) attended. 3877 (91.6%) had aortic diameters equal to or less than 2.5 cm. 302 (7.1%) had aortic diameters in the range 2.6-3.9 cm and 53 (1.3%) had a diameter of 4.0 cm or greater. Mean aortic diameter was 2.04 cm (S.D. 0.50 cm). The practicalities, costs and benefits of a community based aneurysm screening programme are discussed.

Distribution of aortic diameter in a screened male population.

Between September 1990 and August 1991, 2291 men aged 65 years were invited for ultrasonographic screening of the aorta in the Gloucestershire aneurysm screening programme; 1748 (76.3 per cent) attended. An aortic diameter less than or equal to 2.5 cm was found in 1547 (88.5 per cent); 174 (10.0 per cent) had diameters in the range 2.6-4.0 cm, and 26 (1.5 per cent) had diameters greater than 4.0 cm. The mean(s.d.) aortic diameter was 2.1(0.55) cm and 97.5 per cent of patients had a diameter less than or equal to 3.3 cm. Any man over the age of 65 years with an aortic diameter greater than 3.3 cm has an aortic aneurysm.

Surgical management of intestinal radiation injury.

The management of 14 cases of radiation injury to the intestinal tract over a 4-year period is evaluated. The longest latent interval between radiation treatment and symptoms was 30 years. Eight patients were treated surgically; six were treated conservatively by laser therapy or application of formalin to the affected mucosa. The indications for surgery were rectovaginal fistula (four), rectal stricture (one), radiation proctitis (eight), and small bowel obstruction (one). Seven patients underwent large bowel resection. These consisted of four anastomoses with coloanal J-reservoirs, two low anterior resections, and one coloanal anastomosis without reservoir. There was no perioperative mortality. Morbidity occurred in one of the eight surgical cases. Radical resection of the radiation-damaged rectum has been shown to be a safe and reliable treatment for rectovaginal fistulas, rectal strictures, and proctitis unresponsive to medical measures. Coloanal J-reservoir is the procedure of choice to avoid urgency and frequency symptoms associated with coloanal sleeve anastomosis. Laser therapy for hemorrhagic proctitis can achieve an important place in the management of this problem without recourse to surgery.

Control of presacral bleeding in rectal surgery.

A technique for controlling life-threatening presacral bleeding is described. This consists of a sterilised metallic drawing pin pushed through the synthetic coagulant Surgicel (Johnson and Johnson) directly into the bleeding point in the sacrum. Two patients are described in which this technique was used with a successful outcome.

Clinical evaluation of combined use of CEA, CA19-9 and CA50 in the serum of patients with pancreatic carcinoma.

CEA, CA19-9 and CA50 are tumour-associated antigens defined by monoclonal antibodies that have been raised against adenocarcinoma cell lines, but no single antibody is specific for the detection of pancreatic malignancy. The aim of this study was to determine whether the combined use of CEA, CA19-9 and CA50 would improve diagnostic accuracy. An immunoradiometric assay was used for the detection of CEA and CA19-9 and the Delfia system for CA50. Serum was collected from 65 normal subjects, 16 with pancreatitis and 28 with pancreatic carcinoma. Of the 28 cancer patients, 24 (85%) had a CA19-9 level above 46 mu/ml, 26 (92%) had a CA50 level above 21 mu/ml and 10 (37%) had a CEA level above 7 ng/ml. Multivariant discriminant analysis on the combined antibodies showed that 96% of the malignant group, 13% of the pancreatitis group and 11% of the normal group were positive, with an overall correct classification of 91% into the three groups (multivariant discriminant analysis P less than 0.05). Thus the combined use of CEA, CA19-9 and CA50 improves diagnostic accuracy in differentiating benign from malignant disease of the pancreas.