Doppler-guided haemorrhoidal artery ligation: long-term outcome and patient satisfaction.

OBJECTIVE: Conventional Milligan-Morgan haemorrhoidectomy is associated with significant pain and potentially hazardous complications. Doppler-Guided Haemorrhoidal Artery Ligation (DGHAL) may offer a lower risk, pain-free alternative. We present our early and long-term outcome experience with DGHAL, combined with patient views and satisfaction with the procedure. METHOD: One hundred and thirteen DGHALs were performed over a 13 month period by two surgeons in a single centre. Patients graded the severity of postoperative pain on visual-analogue scales. Clinical follow-up was at 6 weeks (n = 103), with long-term follow-up (n = 90) by postal questionnaire at median of 30 months. RESULTS: Seven out of one hundred and three (6%) patients reported postoperative discomfort requiring analgesia. Ninety-three out of one hundred and three (90%) patients reported complete relief or significant improvement in their symptoms at 6 weeks, dropping to 77/90 (86%) at 30 months. Anal fissures developed in 2/103 (2%) patients, both treated with Diltiazem ointment. Further surgery was required in 8/90 (9%) patients. Eighty-two out of ninety (91%) patients said they would undergo DGHAL again. CONCLUSION: DGHAL is a relatively painless, safe, and effective procedure for symptomatic stage I-III haemorrhoids, for which we have demonstrated long-term durability and acceptability. Its role lies between office based procedures and more invasive operative interventions.

A prospective audit of cholecystectomy in a single health district.

Laparoscopic cholecystectomy is becoming the treatment of choice for patients presenting with gallstones. A prospective audit of all patients undergoing cholecystectomy in a single health district over a six-month period was carried out. The aim was to define those patients not having laparoscopic cholecystectomy and determine the morbidity and mortality associated with open and laparoscopic procedures. Cholecystectomy was performed on 173 patients; 149 operations were attempted laparoscopically, of which 134 were successful, giving a conversion rate of 10%. Elective open cholecystectomy was performed on 24 patients. Twenty of these patients were under the care of a consultant who only performs open cholecystectomy and the others were not offered a laparoscopic procedure because of previous abdominal operations. The median time taken for open cholecystectomy was significantly shorter (P < 0.05) than for laparoscopic cholecystectomy or for converted procedures. Laparoscopic cholecystectomy resulted in bile duct injury in one patient (0.7%). This study shows that the majority of patients with gallstones are being offered laparoscopic cholecystectomy, although some patients will undergo open cholecystectomy. The latter include patients under the care of surgeons not performing laparoscopic cholecystectomy, those presenting as an emergency where laparotomy is performed and those where laparoscopy is contra-indicated. The findings of this study are probably representative of other health districts where a similar mix of surgical practice exists.

Survival after peranal and abdominoperineal resection for rectal carcinoma.

The outcome of a consecutive series of 47 patients with rectal cancer treated by endoscopic transanal resection or peranal local excision was contrasted with that of 42 patients undergoing abdominoperineal resection. Surgery was considered curative for 35 and nine patients treated by abdominoperineal and peranal resection respectively (P < 0.001). Patients undergoing peranal excision were older than those treated by abdominoperineal resection (median 77 versus 69 years, P < 0.01). The 5-year survival rate of patients undergoing peranal resection was 24 per cent compared with 33 per cent for those treated by the abdominoperineal procedure (P < 0.005). When surgery was palliative the survival rate after both procedures was the same. Survival after peranal excision was significantly poorer than that after abdominoperineal resection but this may be acceptable when the stage of disease and age of the patients are taken into account.

Impact of a waiting list initiative on a general surgical waiting list.

OBJECTIVES: To determine the effects of cuts in surgical beds and operating lists upon the waiting list. To evaluate the effects of the Waiting List Initiative upon the total number of patients on the waiting list, the number of patients waiting for more than one year, and the ratio of patients with low priority, non-life-threatening diagnoses to those with a higher priority, potentially more serious, diagnosis. DESIGN: The study of facilities available and waiting list figures between 1979-1991; a prospective study of a Waiting List Initiative. SETTING: The surgical departments of the Royal Berkshire and Battle Hospitals, Reading and Newbury District Hospital. PATIENTS: Those patients on general surgical waiting lists between 1979 and 1993; those patients who had operations under the Waiting List Initiative. RESULT: Between 1979 and 1989 the number of surgical beds fell from 225 to 153, a reduction of 38 per cent. The number of weekly operating lists fell from 40 to 30, a reduction of 25 per cent. The waiting list remained fairly constant, between 1979-1987, with a median of 420 patients (range 295-688) before 1987, against 983 (range 688-1,253) after 1987. After the Waiting List Initiative the total number of patients on the waiting list fell from 1,114 to 904, a fall of 19 per cent. Patients waiting for more than one year fell from 381 to 176 (54 per cent), whilst those waiting less than one year remained constant at 730. The proportion of patients with low priority varicose veins fell from 65 per cent to 40 per cent, whilst the proportion of patients with potentially more serious inguinal hernias rose from 10 per cent to 15 per cent. CONCLUSION: These results demonstrate the relationship between the increase in the size of the waiting list and the decrease in the facilities available in beds and operating sessions. While the Waiting List Initiative has resulted in a reduction in the number of patients waiting more than one year, there has been no reduction in numbers waiting less than one year. The reduction has been achieved at the expense of those patients with potentially more serious clinical conditions.

Breast disease and the general surgeon. I. Referral of patients with breast problems.

OBJECTIVES: To determine the proportion of all new and follow-up patients referred to general surgical outpatient clinics with breast problems. To ascertain how long these patients wait for an appointment and how many require investigation or admission for operation. To review our management of patients with breast problems in the clinic and to determine the ratio of benign breast disease to malignancy. DESIGN: A 3-month prospective outpatient survey with patient details recorded on questionnaires completed by the medical staff. SETTING: The general surgical outpatient clinics of this firm at Battle Hospital, Reading, and Newbury District Hospital, Berkshire. PATIENTS: Those patients attending the above clinics during the 3-month period 1 October to 31 December 1989. RESULTS: In all, 693 new patients and 554 follow-up patients were seen. Of the new patients, 119, and of the follow-up patients 140 were seen for a breast complaint. At Battle Hospital 16% of all new patients presented with a breast problem, while at Newbury Hospital the figure was 24%. Of the follow-up patients at Battle Hospital, 23% were seen for a breast problem, and 41% at Newbury. The overall median waiting time for a new outpatient appointment was 21 days. No investigations were needed in 22% of the patients. The remaining 93 patients had investigations and a total of 70 mammograms and 53 fine needle aspirations for cytology were performed. The mean cost of investigations per patient investigated was estimated at 27 pounds. Of new patients, 58% were discharged from the clinic after a single consultation, and investigations as necessary. In 79% of the patients admitted for an operation, the decision to admit was made on the basis of the initial history and examination alone. Of new patients, 84% did not need admission and were managed in the clinic. In all, 14 breast carcinomas were diagnosed--12% of new patients with breast problems. CONCLUSIONS: The figures suggest that 24% of new patients and 41% of follow-up patients attending a general surgical clinic are seen for a breast problem. The waiting time for new appointments is unacceptably long. Most new patients do not require admission for an operation. Only 12% of new patients referred with a breast problem were found to have a carcinoma.

Case-control study of patient satisfaction with day-case and inpatient inguinal hernia repair.

A case-control study has been carried out to assess patient satisfaction with day-case or inpatient inguinal hernia repair using matched pairs of patients undergoing the same technique of inguinal hernia repair under general anaesthesia. Patients completed a single-page questionnaire 3-6 months after surgery. Although there was no objective difference in recovery, nearly half of the patients felt that they were discharged too early and the majority would prefer inpatient treatment. Day-case patients required significantly more medical attention after discharge and most of the reported wound complications were not known to the hospital. It is concluded that the introduction of day-case surgery in a district general hospital is not without problems and requires changes in working practices and resource availability with careful monitoring of outcome during its implementation.

The effects of cuts in services on the work of a surgical unit in a district general hospital.

A reduction of the total scheduled operating time from 12 to 6.5 sessions/week available to a general surgical firm in a district general hospital resulted in 31% fewer admissions and 33% fewer operations on scheduled lists. Our data has confirmed that the brunt of these cuts were borne by patients awaiting routine surgery (the only category of admission which the surgical team can control). Routine operations performed were 54% fewer after the cuts compared with normal working. We estimate that this resulted in an increase of 89 patients awaiting routine surgery in 1 month. The number of emergency operations which we were able to perform on scheduled lists was reduced from 15/month before the cuts to 7/month after the cuts. Our results also illustrate the value of having a separate community hospital where routine surgery can be performed.

The workload of a surgical unit in a district general hospital.

A 3-month prospective study of the workload of a surgical unit in a district general hospital was performed to identify the relationship between outpatient work, admissions to hospital, and scheduled operating lists. We have shown that under 60% of all new cases seen in the outpatient clinic had admissions arranged after initial consultation. Over two-thirds of inpatient admissions were for emergencies or urgent cases, and thus not able to be controlled by the surgical team. One-third of emergency admissions had an operation within 24 h of admission. One third of the total number of cases on scheduled lists were emergency or urgent cases (taking up approximately 50% of the operating time). Of all admissions, 32% were as day cases. Of all routine operations, 35% were performed at a community hospital taking only 18% of all our admissions.

Major abdominal surgery in the over-eighties.

We report a prospective controlled trial looking at the outcome of major abdominal surgery judged on the ability of patients to return to their preoperative activity level. Eighty patients were included in the study. Forty of these were over 80 years old and the remainder in the age group 40-65 years. Fifty-four per cent of the over 80s demonstrated an increased level of dependance six months after surgery compared to 18% of the 40-65 year olds. The mortality rate at six months was 42% for the over 80 group. The poor prognosis of elderly surgical patients not only in their increased mortality rate but also in their dependency should be considered before they are subjected to major abdominal surgery.

The value of permixon in benign prostatic hypertrophy.

A double-blind trial comparing the effect of Permixon (160 mg bd) against placebo in the treatment of benign prostatic hypertrophy is described. In both groups a significant improvement in flow rate and subjective assessment of symptoms was seen. There was no significant difference between the results of treatment in either group.

Observations on rat collagenase-separated islets and long-term composite islet allografts.

Collagenase digest preparations of isolated rat islets and long-surviving allogeneic rat islets implanted beneath the kidney capsule of a composite kidney and islet allograft have been studied immunocytochemically and by electron microscopy. The four main endocrine cell types were identified in the collagenase preparations with minimal evidence of cell damage. In contrast, there were only granulated B cells in the composite grafts and amongst the granules of these cells there was pleomorphism. The granule appearances may support previous suggestions that paracrine control of insulin secretion is lacking in these composite grafts.

Isolated pancreatic islet allografts in rats rendered immunologically unresponsive to renal allografts. The effect of the site of transplantation.

Long-surviving Lewis (RT-1(1)) renal allografts (LS-LEW) were induced in 20 DA (RT-1a) rats by 14-day treatment with cyclosporine . All were made diabetic 100 days after transplantation using streptozotocin; 7 LS-LEW were untreated and all remained diabetic; 5 LS-LEW were given Lewis islets beneath the kidney capsule without further immunosuppression. Prolonged graft survival (greater than 100 days) was seen in 4 rats. Lewis islets were given into the portal vein in 5 LS-LEW. Prolonged graft survival was seen in 4 rats. Third-party BN islets were given beneath the kidney capsule in 3 LS-LEW; these islets were rejected in less than 9 days. In contrast Lewis islets transplanted into untreated diabetic DA rats beneath the renal capsule or into the portal vein survived for a mean of 8.3 days and 4 days, respectively. In a separate experiment long-surviving Lewis renal allografts were induced in 7 PVG rats (LS-PVG) by cyclosporine treatment. These animals were made diabetic 100 days after transplantation and then were given Lewis islets under the renal capsule of the transplant kidney. Prolonged islet graft survival was seen in 6 rats, and 5 diabetic PVG rats given Lewis islets beneath the renal capsule rejected the islets within 8 days. Thus, once a recipient rat has accepted a renal allograft under the influence of cyclosporine treatment, it will accept permanently an islet allograft of the same strain as the kidney. This effect applies to both strain combinations tested, is not influenced by the site of islet implantation, and is specific for islets of the same strain as the renal allograft.

Major histocompatibility complex antigens in the rat pancreas, isolated pancreatic islets, thyroid, and adrenal.

Monoclonal antibodies to rat class I and class II MHC antigens have been used with the peroxidase-antiperoxidase technique to localize these antigens in the DA rat pancreas, isolated pancreatic islets, adrenal, and thyroid tissue. The class I (RT1A) antigens were found to be expressed by pancreatic islet cells, adrenal cortical cells, thyroid follicular cells, and--in low concentration--on cells of the adrenal medulla. These same cells did not express class II (Ia or RT1B) antigens. However, interstitial dendritic cells, staining intensely for class II antigens were present in thyroid, adrenal and pancreatic tissue, and within isolated pancreatic islets. These cells probably represent the immunogenic passenger leukocyte.