Delayed diagnosis of infarcted small bowel due to right-sided Bochdalek hernia.

We report a case of an adult patient with small bowel infarction, secondary to a strangulated Bochdalek hernia.

Large bowel impaction by the BioEnterics Intragastric Balloon (BIB) necessitating surgical intervention.

A case of large bowel impaction caused by migration of a BioEnterics Intragastric Balloon (BIB) is presented. The literature is reviewed regarding both the use and the complications inherent in such balloon devices. This is the first reported case of an intragastric balloon impacted in the colon 9 months after insertion.

The value of guidelines in a breast screening service.

The use of agreed guidelines in the management of common surgical and medical conditions has received much attention and enjoys varying degrees of support. In May 1992 the UK Breast Screening Programme produced guidelines with the intention of providing criteria for all units to attempt to achieve. We have investigated these guidelines as a means of comparative audit and stimulus for change. Two units were compared, one in a teaching centre and the other in a district general hospital. Although both units performed for the most part within the guidelines, areas where improvement could be made were identified and measures to correct deficiencies taken. This resulted in improved performance in those areas. The study demonstrates that guidelines can have considerable benefit in helping to identify problems in the provision of care and introducing measures to improve the situation.

Use of a eutectic mixture of local anaesthetics in the release of preputial adhesions: is it a worthwhile alternative?

OBJECTIVE: To see if a eutectic mixture of local anaesthetics (EMLA) could be used effectively for the release of preputial adhesions as a day case procedure. PATIENTS AND METHODS: A total of 36 consecutive symptomatic children had their preputial adhesions separated under local anaesthetic with EMLA. RESULTS: The procedure was successful in 27 children. Of these, 16 remained symptom free at 9 to 12 months follow up although five children had slight recurrence of adhesions. The other 11 children were listed for circumcision at 2 weeks following the procedure because of marked recurrence of adhesions. CONCLUSION: EMLA cream is a good alternative to general anaesthetics in the separation of preputial adhesions. The technique is operator-dependent and better results were obtained when one person was using it regularly. Separation of adhesions is a worthwhile procedure in boys with symptomatic non-retractile foreskins.

GORA: a scoring system for the quantification of risk of graft occlusion.

Auditing the outcome from vascular surgery with regard to graft occlusion is made difficult by variations in the type of surgery performed and the case mix. These difficulties are compounded when attempting to compare units. In the present study we have attempted to develop a scoring system to predict the risk of graft occlusion, and thus compensate for these variables. Prospectively collected data from 214 consecutive patients undergoing vascular reconstructive surgery (233 arterial grafts) were analysed. Graft occlusion occurred in 82 patients (35.2%). Using a multivariate linear regression analysis of these data a five-factor, five-grade scoring system has been devised (GORA: Graft Occlusive Risk Assessment). Logistic regression analysis of the observed risk of occlusion with this derived score produced the following relationship between the odds ratio of occlusive risk and GORA score: (logeR/1 - R = (0.229 x score) - 4.165). The score was then validated in a different group of 186 patients (196 arterial grafts). In both groups the score was found to predict accurately the risk of graft occlusion (P < 0.001). There was no significant difference in the receiver operating characteristic curves between the estimation and validation groups.

Attenuating the hypertensive response to laryngoscopy and endotracheal intubation using awake fibreoptic intubation.

Blood pressure and pulse rate measurements were recorded in 35 patients undergoing endotracheal intubation during general anaesthesia (Group A), and 35 patients who had an awake fibreoptic intubation under local anaesthesia (Group B). The mean arterial pressure in Group A rose by a mean of 35 mmHg immediately after intubation, compared with a mean fall of 9 mmHg in Group B. The mean pulse rate in Group A rose by 24 beats per minute (b.p.m.) immediately after intubation, compared with a rise of 3 b.p.m. in Group B. Both these differences were statistically significant (P less than 0.0001 and P less than 0.001 respectively, Mann Whitney U test). Postoperative discomfort was assessed 24 h later by means of linear analogue scales. There was a statistically higher mean score in relation to nose discomfort in Group B (P less than 0.002). Awake fibreoptic intubation successfully reduces the pressor response to endotracheal intubation in normotensive adults. It is suitable for use in those patients who are at risk from the pressor response.

Horner's syndrome caused by an intercostal chest drain.

Horner's syndrome occurred in a young woman as a complication of the treatment of a traumatic pneumothorax with an intercostal drain. The nerve damage probably occurred when the lung had fully re-expanded, pressing the tip of the intercostal drain, lying at the apex of the pleural cavity, on to the sympathetic chain.

Methicillin resistant Staphylococcus aureus; the role of antisepsis in the control of an outbreak.

Between February 1983 and September 1985, an outbreak of methicillin-resistant Staphylococcus aureus involving 151 patients and staff occurred in a district general hospital. At its peak, 43 cases occurred in 3 months. Sixty-two patients suffered morbidity and two died. Conventional isolation techniques and once-daily whole body washing of affected patients with triclosan successfully controlled the outbreak.

Comparison of extraperitoneal and transperitoneal methods of aorto-iliac reconstruction. Twenty years experience.

The operative technique of extraperitoneal approach to the aorta is described. The results of operation on the aorta using this technique are compared with those using the standard transperitoneal approach.

Long term intravenous rifampicin after massive small bowel resection.

A case of jejuno-ileal tuberculosis in a patient thought to be suffering from Crohn's disease is described, with special reference to the use of intravenous rifampicin in the postoperative phase.

Extended deep femoral angioplasty and lumbar sympathectomy as a limb salvage procedure.

Limb salvage in 27 limbs (26 patients) using the combined operations of extended deep femoral angioplasty and lumbar sympathectomy is described. A successful result was obtained in 14 cases (52%) at 6 months falling to 12 (45%) at 16 months. Prediction of outcome and postoperative progress was monitored by the measurement of the leg: arm pressure ratio using the Doppler ultrasound apparatus. No patient with a preoperative ratio of less than 0.3 had a successful result. It is proposed that lumbar sympathectomy is a logical adjunct to surgery in these patients in order to enhance the development of the collateral circulation.