Randomized trial of blunt-tipped versus cutting needles to reduce glove puncture during mass closure of the abdomen.

Eighty-five consecutive patients were randomized to undergo mass closure of the abdomen with no. 1 polydioxanone mounted on either a blunt-tipped (n = 46) or cutting (n = 39) needle. Gloves were changed before closure and tested for perforation afterwards using standard air or water techniques. Fourteen pairs of gloves were punctured when using a cutting needle, and three pairs when a blunt-tipped needle was used. The majority of punctures were to the non-dominant glove. The surgeon was aware of the puncture in eight of the 14 instances involving a sharp needle and in one of the three involving a blunt-tipped needle. Blunt-tipped needles, while not eliminating the risk, significantly reduced the incidence of surgical glove puncture (P < 0.001, Fisher's exact test). The use of cutting needles for abdominal closure should be abandoned.

Palliation of malignant oesophageal perforation and proximal oesophageal malignant dysphagia with covered metal stents.

Twelve patients underwent placement of nine polyethylene-covered self-expanding metal stents (Cook), and three polyurethane-covered Wallstents (Schneider). All obstructing lesions were crossed fluoroscopically and stents placed under fluoroscopic control. Eleven of the 12 patients had recently undergone failed endoscopic stent insertion, which had resulted in oesophageal perforation. Technical success was achieved in 100% of patients, with no immediate complications. The stents were well tolerated and allowed the patients to eat within 12 h of their insertion. Covered stents are technically safe to insert, are best inserted fluoroscopically, and are particularly cost-effective in proximal oesophageal lesions and perforations, where Atkinson tubes are often not tolerated.

The Angelchik prosthesis: results and complications.

Fifty-four patients who had the Angelchik antireflux prosthesis inserted during the period March 1981 to May 1985 were sent a questionnaire and their medical records were reviewed. Forty-four patients replied: 68% said that they were cured, 25% said they were improved and two patients (4.5%) said they were worse after the operation. Of those who replied, 93% would recommend the procedure to others with a similar condition, 89% have had no further heartburn, and 72% have had no further regurgitation. However, it would appear from the responses that eight patients (18% of those who replied) have significant dysphagia not present before operation, at times varying from 8 months to 4 years and 10 months from operation (mean 38.5 months). Six additional patients (14%) had temporary dysphagia, now resolved and five patients (11%) have persisting minor dysphagia not present pre-operatively. Five respondents are known to have postoperative heartburn, two of whom are known to have persisting oesophagitis with ulceration. Nine patients (20%) continue to experience regurgitation, related to dysphagia in eight. Three prostheses have been removed without replacement; one after an oesophageal leak (believed to be related to a simultaneous parietal cell vagotomy), one for severe dysphagia and one which was unsuccessfully used to hold reduced a very large hiatus hernia. Two prostheses have been replaced after they slipped down the stomach wall, one with the tapes detached. (This latter prosthesis was one of the original ones with the tapes attached to the ends of the prosthesis only--a problem which has since been rectified by the manufacturer.) General surgical complications are listed for completeness.