Prospective study of omental transposition in patients with chronic spinal injury.

OBJECTIVES: This prospective study was designed to assess the effects of omental transposition in patients with a chronic spinal injury. METHODS: Neurological status was established to be stable and multiple baseline across patient studies were done preoperatively and repeated postoperatively. Assessments included activities of daily living (ADL), functional ability, degree of spasticity, motor power, sensation, pain perception, urodynamic studies, electromyography, sensory evoked potentials (SEPs), and infrared thermography to measure peripheral and general skin vascular responses. Each patient had MRI. Assessments were done at 3, 6, and 12 months after omental transposition in 17 patients. RESULTS: The detailed assessments failed to show significant improvement, although some patients showed minor objective and subjective change in some categories. Neurological deterioration occurred in one patient. There were 20 surgical complications including urinary tract infection, deep vein thrombosis, wound infection, and incisional hernia. CONCLUSIONS: Omental transposition has not been shown to improve neurological function in 17 patients with chronic spinal cord injury, and continued use of this operation in this situation is not supported by this study. Further advances in spinal cord repair may utilise the pedicled omental graft to provide an alternative vascular supply, but its current use should be limited to experimental models.

Randomized trial of laparoscopic cholecystectomy and mini-cholecystectomy.

Three hundred and ten patients having elective cholecystectomy were randomized to either laparoscopic cholecystectomy or mini-cholecystectomy. There were 155 patients in each group. Conversion to open cholecystectomy was significantly more common with laparoscopic cholecystectomy (13 versus 4 per cent) and complications were significantly more frequent with laparoscopic cholecystectomy (9 versus 3 per cent). If laparoscopic cholecystectomy was successful, hospital stay was significantly shorter than for mini-cholecystectomy (2 versus 3 days respectively), but overall the hospital stay was not significantly different. Postoperative analgesia requirements were reduced and return to normal activities and to work were faster after laparoscopic cholecystectomy. There was no significant cost difference between the two procedures.

Intestinal prolapse through the vagina.

We describe the case of a 68-year-old woman who presented with an acute onset spontaneous vaginal vault rupture and intestinal prolapse through the vagina. Results of a literature survey are presented and the causes of vaginal vault rupture are discussed.

Does selective peroperative cholangiography result in missed common bile duct stones?

A prospective randomized trial was undertaken to determine if selective peroperative cholangiography resulted in greater morbidity and mortality from missed common bile duct (CBD) stones. Five hundred and thirty-nine consecutive cholecystectomies were performed over a 3-year period. Two hundred and fifty-four had indications for mandatory peroperative cholangiography and were excluded from the trial. The remaining 285 patients, without a history of jaundice, pancreatitis or abnormal liver function tests, were randomized blindly into two groups. Group 1 underwent peroperative cholangiography (PC) and group 2 did not. If the surgeon found a dilated CBD at surgery then these patients were also excluded from the trial. Selective peroperative cholangiography revealed an unsuspected CBD calculus in 16 of the 132 patients (12%). Up to the time of review no patient from group 2 presented with symptoms or complications from retained CBD stones. One patient in group 1 had endoscopic removal of a retained CBD calculus 16 months after cholecystectomy. All patients were sent a questionnaire at least three years after surgery and 210 responded (74%). One hundred and thirty (62%) of the respondents had peroperative cholangiography. There were 11 deaths from unrelated causes. No difference between the two groups was found for postoperative dietary habit, dyspepsia, pain, flatulence, diarrhoea or signs of biliary obstruction. It seems from these results that a policy of selective cholangiography in our hands may miss a 12% incidence of unsuspected stones but, importantly, this does not appear to influence postoperative morbidity or mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for parathyroid adenoma and hyperplasia: relationship of histology to outcome.

Recent histopathologic evidence challenges the teaching that enlargement of a solitary parathyroid gland is invariably caused by an adenoma, whereas multiple gland enlargement results from hyperplasia. We have re-examined the parathyroid tissue obtained from 152 consecutive patients undergoing surgery for primary hyperparathyroidism and compared it with their clinical outcome. Our approach was to excise enlarged glands and biopsy the remainder. In 124 patients (82%) at least three glands were biopsied or removed. The ratio of adenoma to hyperplasia was reversed by our histologic re-examination; adenomas were found in only 27 patients (25 single, two double), whereas hyperplasia was found in 117 patients (one gland, 87 patients; two glands, 16 patients; three glands, five patients; four glands, nine patients). Normal tissue only was reported in eight patients. During a 2-year follow-up, five patients (3%) developed hypocalcemia and none developed recurrent hypercalcemia. Our results indicate that a full neck exploration with removal of all enlarged glands is more important than the histologic diagnosis in planning a successful surgical strategy for primary hyperparathyroidism.

Familial and idiopathic colonic varices: an unusual cause of lower gastrointestinal haemorrhage.

A patient is described presenting with an acute lower gastrointestinal haemorrhage as a result of extensive colonic varices. Further investigation revealed that there were no oesophageal varices or splenomegaly. Liver biopsy showed grade II fatty change only, with no other specific or significant pathological features. Transhepatic portography showed a raised portal pressure (20 mm/Hg) but the portal system was patent throughout. There was an abnormal leash of vessels in the caecum thought to represent a variceal plexus. This patient was diagnosed as having idiopathic colonic varices. This case is discussed together with nine other reports of idiopathic colonic varices from the published literature. Four of these reports describe idiopathic colonic varices in more than one member of the same family. Possible modes of inheritance, aetiology of variceal change, natural history, and prognosis are discussed.

Postoperative analgesia for haemorrhoidectomy. A comparison between caudal and local infiltration.

This study compared the analgesic effectiveness of local infiltration of bupivacaine with caudal extradural bupivacaine in the first 48 hours after haemorrhoidectomy. Surgical and anaesthetic protocol was rigidly standardised. The caudal group had significantly less pain in the first 6 hours after haemorrhoidectomy, and on first bowel opening, when compared to those who received local infiltration of bupivacaine. There was no significant difference between the two groups with respect to further analgesic requirements, complications, time to first bowel action, and duration of hospital stay. The definite advantage of caudal extradural bupivacaine for haemorrhoidectomy must be balanced against the rare but potentially serious complications associated with its use.

Staples or sutures for low colorectal anastomoses: a prospective randomized trial.

One hundred and eighteen patients undergoing low colorectal anastomoses were randomly allocated to reconstitution by either single layer interrupted extramucosal sutures or circular staple gun. In the 60 patients undergoing sutured anastomosis there were 2 (3 per cent) clinical leaks and 4 (7 per cent) radiological leaks, and no failures. Of the 58 patients who underwent stapled anastomosis there were 4 failures, 7 (12 per cent) clinical leaks, 14 (24 per cent) radiological leaks and 1 death. Stapled anastomoses were more than ten times as expensive as sutured anastomoses and there were no savings in time or numbers of associated colostomies. An interrupted extramucosal suture technique remains the ultimate standard for low colorectal anastomosis.

Out-patient treatment of haemorrhoids: a randomized clinical trial to compare rubber band ligation with phenol injection.

A prospective randomized clinical trial comparing rubber band ligation (RBL) with phenol injection in 269 patients with symptomatic haemorrhoids presenting to one surgical clinic over a 6 year period, has been carried out. Questionnaires were completed by 215 patients (106 RBL and 109 injection) with an average follow up of 2.75 years. A successful outcome was achieved in 89 per cent of those receiving RBL compared with 70 per cent for injection (P less than 0.001). All symptoms tended to respond more favourably to RBL, the results achieving statistical significance in patients complaining of bleeding and prolapse (P less than 0.01 and P less than 0.05 respectively). Complications from either technique were minimal. It is concluded that RBL is superior to phenol injection in the out-patient treatment of haemorrhoids.

Choledochoscopy: are stones missed? A controlled study.

Although the choledochoscope has been available for several years, its use had not achieved universal acceptance. Enthusiasts claim that the incidence of retained stones in the common bile duct would be reduced by using the instrument, but no controlled study by the same team has been reported. Patients undergoing biliary surgery by one surgical team in Southampton were operated upon in one of three hospitals. The choledochoscope was available for use at only one hospital, but the other two were otherwise fully equipped, and no selection of patients was made for any particular hospital. Over a period of 7 years, 707 patients underwent elective or emergency cholecystectomy. Routine choledochography was performed and stones were found or suspected in the bile ducts in 103 (14.6 per cent). The choledochoscope was used in 54 of the bile duct explorations and in 10 patients residual calculi following routine exploration were identified by the instrument. Postoperative T-tube choledochography was performed in 35 patients following choledochoscopy, 31 with choledocholithiasis at operation, and no unsuspected retained stones were demonstrated. In the 49 patients undergoing duct exploration by the same team without the choledochoscope, 32 were found to have choledocholithiasis. Thirty-six postoperative choledochograms were performed and six patients were found to have retained stones. There were no additional complications attributed to the use of the instrument. We conclude that the use of the choledochoscope should reduce the incidence of retained bile duct stones.

A comparison of polyglycolic acid and catgut sutures in rat colonic anastomoses.

Standard colonic wounds were closed in 44 rats by either polyglycolic acid or catgut sutures. Seven days later portions of the colonic wounds were measured for tensile strength and examined histologically. There was no difference in the mortality, strength of the anastomosis or the amount of inflammation induced by either of the suture materials used.

Effects of haemorrhage upon surgical operations.

The complications of emergency surgery for acute upper gastro-intestinal haemorrhage in 95 patients were compared with those of surgery for non-bleeding benign peptic ulceration in 380 patients. There was a significantly higher number of senior surgeons performing emergency surgery for haemorrhage. There was a significantly higher mortality (10-5 %), wound dehiscence rate (12-6 %) and wound complication rate with re-bleeding (33-7 %) in the post-haemorrhage patients compared with the non-bleeding group (1-3, 1-8 and 11-6 % respectively). There was no significant difference in the incidence of chest infection in the two groups. Mortality and morbidity after haemorrhage were correlated directly with the amount of blood transfused before surgery. Rats were used to study the effect of the removal of 13 % of the blood volume, and its restoration after varying time intervals, upon subsequent wound healing. Abdominal wounds were tested at 7 days for breaking and bursting strength. There was no difference between the wound strength of the control animals and animals which had been bled for 4 minutes before wounding. A significant reduction of wound strength occurred in animals which had been bled for 30-60 minutes before wounding. Prolonged blood loss was associated with deficient wound healing even if blood loss was restored before the wounds were made. Stored blood may be deficient in a factor which is necessary for normal wound healing.

Ascorbic acid levels in stored blood and in patients undergoing surgery after blood transfusion.

Blood was obtained from 11 healthy voluteers, mixed with two standard types of anticoagulant used in blood transfusion centres and stored for 21-28 days at 4 degrees C. Leucocyte ascorbic acid (LAA) fell to deficient levels after 7 days in all cases. There were no corresponding changes in plasma ascorbic acid (PAA) levels. LAA and PAA were measured before, during and after surgery in 5 control patients who underwent definitive operations for benign peptic ulceration and in 4 patients under-going surgery for bleeding peptic ulceration. The average amount of blood administered to the latter group was 10 units. There was a fall in LAA and PAA in both groups of patients after operation. This fall had returned to normal by 7 days in the controls, but the LAA remained at a deficient level at 7 days in the patients who had bled. Deficient ascorbic acid in stored blood may contribute to low leucocyte ascorbic acid levels in patients after blood transfusion and may contribute to the increased complication rate when surgery is undertaken in these patients.