A systematic review of stapled hemorrhoidectomy.

HYPOTHESIS: Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. DATA SOURCES: Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966-June 2001), EMBASE (January 1980-June 2001), Current Contents (June 1993-June 2001), Ovid HEALTHSTAR (January 1975-June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid* and (stapl* or convent*) or hemorrhoid* and (stapl* or convent*). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid* or hemorrhoid*. STUDY SELECTION: Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. DATA EXTRACTION: Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. DATA SYNTHESIS: Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, -0.89 days; 95% confidence interval, -1.42 to -0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. CONCLUSIONS: Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital.

OBJECTIVE: To investigate the nature and duration of clinical instability (i.e., abnormalities in simple physical observations or laboratory test results) in hospital patients before a "critical event" (i.e., a cardiac arrest or an unplanned admission to intensive care). DESIGN: Retrospective survey of medical records of all patients having critical events (CEs) over 12 months. Data on hospital and Intensive Care Unit (ICU) patients were obtained for comparison with the study population. SETTING: A 300-bed metropolitan teaching hospital with a seven-bed ICU. PATIENTS: All patients having CEs over a 12-month period (January to December 1997). MAIN OUTCOME MEASURES: Number of patients with clinical instability before a CE; duration of clinical instability before a CE; number of medical reviews of each patient before a CE; mortality rate and length of hospital stay for all patients. RESULTS: There were 122 CEs in 112 patients (median, 1; range, 1-4). Of the CEs, 79 were unplanned ICU admissions (14 subsequent to cardiac arrest calls), and 43 were cardiac arrest calls not resulting in ICU admission. Each CE was preceded by a median of two (range, 0-9) criteria for clinical instability. The median duration of instability before a CE was 6.5 hours (range, 0-432 hours), and in that time a median of two (range, 0-13) medical reviews took place. The incidence of CEs in the total hospital population (122 CEs/19,853 admissions) and in ICU patients (79 unplanned admissions/515 admissions) was 0.6% and 15%, respectively. There were 70 deaths (62%) among the 112 patients, compared with a total of 392 deaths (2% of admissions) in the hospital, of which 107 were in ICU. CONCLUSIONS: Very few patients suffer a CE while in hospital. However, those who do frequently manifest abnormalities in simple physical observations and laboratory test results before the CE. More rapid intervention in response to warning signs might provide a better outcome for these patients.

A critical evaluation of free paper abstracts accepted for the 1996 RACS Annual Scientific Congress.

BACKGROUND: Abstracts form a major part of medical information dissemination and a measure by which papers are accepted for meetings. Concerns have been raised about the quality of abstracts presented to the Annual Scientific Congress (ASC) and second, about the validity of the term 'scientific' to describe this meeting. METHODS: A critical evaluation was made of all free paper abstracts in general surgery from the ASC 1996, using a standard assessment process. They were judged on presentation and content. A direct comparison was made to the content of abstracts from the Surgical Research Society of Australasia 1995(SRSA) meeting. RESULTS: The ASC abstracts scored 87% (6.1/7.0) for presentation but with clear deficiencies. The score of 49% (7.4/15.0) for the content of the ASC abstracts was significantly less than the score of 65% (9.8/15.0) that was attained by the SRSA abstracts when assessed on content. (Wilcoxon rank sum test, P < 0.000002.) CONCLUSIONS: The quality of the presentation of abstracts was adequate but could clearly be improved, especially with regard to the specific instructions to authors. The ASC abstracts were significantly less scientific in content that those of the SRSA abstracts. The criteria used to select abstracts for the ASC should be reviewed and the title of the annual College meeting should be reconsidered.

Transverse disruption of the abdominal wall--a tell-tale sign of seat belt related hollow viscus injury.

A pattern of injuries has been observed in five (5) female front seat passengers wearing seat belts. All were involved in high speed frontal impact motor vehicle accidents on country roads. Varying degrees of abdominal wall disruption involving fat, fascia or muscle, were universally associated with hollow viscus injury and right-sided rib fractures. Most patients had mesenteric or omental tears, flail chests and left clavicular injuries. Intimal tears of the distal aorta, right breast injuries and spinal injuries were also observed. The hollow viscus and mesenteric injuries may result from direct crushing, sudden rises of intraluminal pressure, or shearing forces acting at points of mesenteric attachments. At laparotomy it is recommended that necrotic or contused fascia and muscle be excised with primary abdominal closure and contused fat be excised or curetted and suction drainage applied to the subcutaneous tract. Abdominal wall disruption from seat belt trauma reflects the forces involved on impact and should alert the surgeon to the observed pattern of internal injuries.

Enhancement of neutrophil chemiluminescence after elective gastrointestinal surgery.

Neutrophil count and luminol-dependent chemiluminescence were measured pre-operatively and on the second, sixth and ninth days after operation in nine patients undergoing major, elective gastrointestinal surgery. The aim of the study was to test the hypothesis that elective surgery as a form of injury has no prolonged deleterious effect on neutrophil activity in non-septic patients. A significant increase in neutrophil count was demonstrated in all patients at Day 2 (P less than 0.01) and Day 9 (P less than 0.01). Neutrophil chemiluminescence increased on Day 2 and Day 6, the increase on Day 6 being significant (P less than 0.02). In the first 9 days after elective gastrointestinal surgery, a biphasic neutrophilia occurs and the metabolic response of neutrophils to an opsonized particle is not impaired. These data would support the hypothesis that major elective surgery has no deleterious effects on neutrophil activity, and indeed that neutrophil activity may be enhanced.

The effect of stapler diameter and proximal colostomy on narrowing at experimental circular stapled large bowel anastomoses.

The effect of stapler diameter and proximal colostomy on large bowel anastomotic narrowing was studied in 23 ewes, to test the hypotheses that stapler diameter is inversely proportional to narrowing and that a colostomy increases narrowing. Large bowel anastomoses were performed with ILS Proximate circular staplers of 25, 29 and 33 mm diameter (six in each group), and assessed at 12 weeks for anastomotic narrowing, hydroxyproline content and histology. In five animals a proximal loop colostomy was added after anastomosis with the 29 mm stapler and similarly assessed at 6 weeks. Neither radiological nor clinical anastomotic leaks occurred and there were no deaths. Comparison of narrowing indices showed no statistically significant difference between the three stapler diameters. Colostomy significantly increased narrowing. Hydroxyproline content was greater at all anastomoses compared with controls. Anastomoses with the 25 mm staplers had a significantly reduced hydroxyproline content compared to the 29 and 33 mm staplers, which may be explained by anastomotic dilatation. The tendency for stapled anastomoses to develop narrowing should not necessarily influence the surgeon's choice of stapler diameter when performing large bowel anastomoses. Moreover, dilatation by faeces may be a factor in reducing staple anastomotic narrowing and, when safe, a proximal colostomy is best avoided.

Short stay surgery for inguinal hernia: experience of the Shouldice operation, 1970-1982.

Between mid 1970 and mid 1982, 696 patients underwent 718 operations for primary inguinal hernias by the Shouldice surgical technique. Follow-up to 31 December 1983 revealed 6 recurrences, 40 patients died during the follow-up period and 37 were lost to the study. Five patients required re-operation for complications of the suture material. Polypropylene was the most efficacious of the suture materials used during the study. Duration of hospital stay and age at operation do not influence the probability of recurrence. The operation gave consistently good results when performed by either a consultant surgeon or a surgeon in training. Using the Shouldice surgical technique the probability of recurrence of the inguinal hernia at 10 years is only 1 per cent.

Gastric and intestinal bleeding in multiple neurofibromatosis with cardiomyopathy.

A case of multiple neurofibromatosis is described with histologically divergent lesions in the jejunum, stomach and colon presenting with bleeding and complicated by idiopathic hypertrophic subaortic stenosis. An aggressive surgical approach to gastro-intestinal bleeding in multiple neurofibromatosis is recommended.

Failure of staple closure and large bowel anastomotic leakage.

Between July and November 1985, we have detected radiologically failure of staple closure after large bowel anastomosis with the Ethicon Proximate ILS Stapler in four patients. Three of the patients had clinical evidence of an anastomotic leakage. The problem, which has also occurred in an experimentally stapled anastomosis, appears to be a recent phenomenon and may be caused by an instrumental failure. Because the staplers are disposable, tracing the possible fault has been difficult. Documentation is recommended in patients' notes of the instrument and the batch numbers of all disposable surgical staplers that are used in operations.

Skin bacteria and Op Site chest dressings.

Growth of skin bacteria on the infraclavicular region was studied in two series of male volunteers. In the first, Op Site, a polyurethane adhesive film dressing, was compared with an occlusive polyvinyl chloride (PVC) dressing, on povidone iodine (PVI) prepared skin in 10 volunteers. Bacteria were sampled, using perspex cylinders and buffered Triton X-100 detergent, at 2, 4, 7 and 14 days, cultured aerobically and anaerobically, and colonies counted at 24 and 48 h respectively. Colony counts under Op Site were less than for undressed (control) skin and under PVC, at all days sampled, the difference being statistically significant at 2 and 14 days for controls and 4 days for PVC. In the second, four regimens of skin preparation, with Op Site dressings were compared in 12 volunteers, skin being sampled 4, 7 and 14 days. Chlorhexidine (CHD) and PVI were compared with and without defatting. Defatting significantly reduced colony counts at 4 and 7 days, whereas no differences were demonstrated between CHD and PVI. The combination of defatting and CHD resulted in colony counts consistently less than 10(3) organisms at 4 and 7 days. Op Site does not potentiate the growth of skin bacteria and is preferable to an occlusive PVC adhesive dressing. Op Site may be left intact on the chest for up to 7 days, colony counts remaining within acceptable limits.

Behaviour of synthetic absorbable sutures with and without synergistic enteric infection.

The behaviour of synthetic absorbable sutures, polyglycolic acid (PGA) and polydioxanone (PDS), has been tested in an experimental guinea pig model utilising synergistic enteric bacteria. Braided PDS gave a wound sepsis rate of 42%, monofilament PDS 36%, and PGA 26%, while sepsis rate in the controls was 30%. The dissolution characteristics of PGA and monofilament PDS appeared to be unaffected by the presence of infection, while that of braided PDS was significantly increased. Braided PDS also showed more rapid dissolution characteristics than PGA.