The contribution of follow-up programs in the reduction of mortality of rectal cancer recurrences.

AIM: The aim of this study is to investigate whether patients, who have undergone curative surgery for rectal cancer and present with recurrence of the disease, could have a better chance of radical reoperation and increased survival if they were diagnosed earlier due to a screening program, when they were still asymptomatic, than those who were not followed up and their recurrence is discovered by its symptoms. METHODS: 113 patients, 52 men and 61 women (mean age 64.19 years, SD 10.76), who presented recurrence of the disease after radical resection for rectal carcinoma were evaluated in a follow-up period of 5 years. 53 of them (46.9%, group I) were asymptomatic and their recurrence was detected in a routine follow-up examination. The remaining 60 patients (53.1%, group II) were not followed up regularly and the recurrence was diagnosed by the development of symptoms. RESULTS: The two groups were comparable with regard to patients' sex, type of operation, postoperative morbidity, tumor stage, histologic differentiation, size of primary tumors, the distance from the anal ring and distal margin. There was no difference in the disease-free period between the two groups (17.3 +/- (SD) 9.9 months in group I versus 20.3 +/- (SD) 14.4 months in group II, p = 0.1). 24 out of 53 patients in group I (45.2%) and 24 out of 60 patients in group II (40%) underwent surgery for their recurrence, but only in 8 and 9 cases, respectively, could the operation be considered as curative. The mean postrecurrence survival was 13.14 +/- (SD) 23.8 months for group I and 10.97 +/- (SD) 18.03 months for group II (p = 0.113). There was no difference in survival between the two groups after surgical treatment of the recurrence (p = 0.14). CONCLUSIONS: Our data show that if we exclude the palliative treatment of symptoms such as hemorrhage or obstruction, only a small percentage of patients with recurrent colorectal cancer will benefit from the treatment and achieve an increased survival, which is independent of the postoperative follow-up program.

Rubber band ligation of symptomatic internal hemorrhoids: results of 500 cases.

BACKGROUND/AIM: In this prospective study the results of rubber band ligation (RBL) of symptomatic hemorrhoids in 500 consecutive patients with 2nd (255 cases), 3rd (218 cases) and 4th degree (27 cases) hemorrhoids are presented. METHODS: The patients' symptoms were hemorrhage in 142 cases (28.4%), prolapse in 33 cases (6.6%) and both hemorrhage and prolapse in 325 cases (65%). Sixteen patients with hemorrhoids had liver cirrhosis and portal hypertension. RBL was performed using the St Marks' applicator (Seward) on an outpatient basis. Multiple ligations in two (259 cases) or three (190 cases) sessions were undertaken in 449 patients (89.8%), while a single ligation was done in 51 cases (10.2%). RESULTS: Successful results were achieved in 440 cases (88%) in a 24-month follow-up. A total of 94 patients (18.8%) had complications which required no hospitalization. Pain and hemorrhage were the most frequent complications. RBL proved to be safe in 16 patients with coagulation disorders due to liver cirrhosis. Two years after RBL, symptomatic recurrence was 11.9% (53/445) with repeat RBL or surgery in 9.2% (41/445). CONCLUSIONS: RBL is a useful, safe and successful method for treating symptomatic 2nd and 3rd degree hemorrhoids, which can be applied successfully in selected cases with 4th degree hemorrhoids, but with an increased rate of recurrence and additional treatment requirements. Also, RBL seems to be safe in patients with liver cirrhosis and portal hypertension.

Factors that influence the effectiveness of surgical gowns in the operating theatre.

OBJECTIVE: To compare the barrier function, comfort, and protection afforded by nine types of surgical gowns during use and to identify factors that may influence their effectiveness. DESIGN: Prospective randomised study. SETTING: Teaching hospital, Greece. MATERIAL: 4 Types of disposable single layer gowns, 1 reusable cloth gown, and 4 types of disposable reinforced gowns used during 250 major operations by the surgeon and first assistant (total n = 500). INTERVENTIONS: Direct observation by specially trained nurse and questionnaire to surgeons. MAIN OUTCOME MEASURES: Contamination of the outside of the gown, blood strike through, safety, and comfort. RESULTS: Half of all gowns became contaminated on the outside. The mean total rate of strike through was 90% in reusable gowns (528/586 areas contaminated), 11% in disposable single layer gowns (95/855 areas contaminated), and 3% in disposable reinforced gowns (42/1407 areas contaminated). There were differences in strike through among the disposable gowns depending on the material and design, the reinforced gowns consistently showing less strike through than the single layer ones. The areas most vulnerable to strike through were the cuff, forearm, thigh, chest, and abdomen. From 80% to 99% of surgeons felt comfortable and protected wearing disposable gowns, but only 0 to 4% of surgeons felt comfortable and safe with reusable gowns. CONCLUSIONS: Reusable cloth gowns have a high strike through rate and were rejected by most surgeons. Reinforced disposable gowns provided better protection. The highest strike through was at the cuffs, forearms, and thighs, and this requires new designs for surgical gowns.

Laparoscopic resection of a large right adrenal gland cyst.

A case of a benign cyst of the right adrenal gland resected laparoscopically is presented. The approach was through the right subcostal space mobilizing the right lobe of the liver and the right colonic flexure. The procedure was of 75 min duration and was uneventful. The patient was discharged the 3rd postoperative day free of postoperative pain. The advantages and disadvantages of this new modality for the treatment of adrenal gland cysts are discussed.

Role of early and extensive surgery in the treatment of severe necrotizing soft tissue infection.

Forty-two patients with necrotizing soft tissue infection are reviewed. Bacterial culture revealed between two and seven types of micro-organism in each patient. All patients were treated with radical surgical debridement and a combination of antibiotics. In 30 patients, early diagnosis and treatment resulted in only two deaths. Delayed surgical intervention in 12 patients transferred from outside hospitals was followed by nine deaths. Predisposing factors and site of infection did not affect outcome. Of 26 patients with systemic manifestations of sepsis, 16 survivors responded well to initial surgical debridement.

Surgical common trunk training in Europe.

There are wide variations of surgical common trunk training programmes among European countries. Variations are also found in entry criteria to training programmes, in training evaluation methods and final certification, and also in accreditation of training institutions. Finally manpower control should be applied to secure production of an adequate number of competent surgeons and consequently high quality of health care.

CT characterization of multivesicular hydatid cysts.

One hundred seventy-eight abdominal multivesicular hydatid cysts were classified into three types (A, B, C) based on CT densities and morphology of cysts. The CT density of viable daughter cysts was always appreciably lower than those of mother hydatid cysts. This density differential between mother and daughter hydatid cyst fluid is a useful diagnostic sign.

Radionuclide visualization of acute occlusive and nonocclusive intestinal ischemia.

A noninvasive radionuclide technique to visualize ischemic small intestine was evaluated. Vascular ligation of 20-30 cm ileum was done in rabbits. After induction of ischemia, technetium (99mTc) methylene diphosphonate (TMDP) was injected IV at intervals up to 24 hours. Images were recorded 1 and 3 hours after injection of radioisotope and showed preferential (9:1) uptake by ischemic bowel. Positive scans were present in all animals up to 4 hours and in 75% at 10-12 hours, but in none 24 hours after induction of ischemia. Nonocclusive intestinal ischemia was simulated in 4 dogs by infusing norepinephrine into a jejunal mesenteric arterial branch. After 1 hour, an IV bolus of TMDP was injected and images recorded at intervals up to 3 hours. Selective uptake of isotope by the ischemic segment was observed in all animals. Angiography confirmed that isotope uptake was confined to the infused segment. These studies show that occlusive intestinal ischemia can be detected, by radionuclide imaging up to 12 hours, and nonocclusive (low flow) ischemia for at least 4 hours, after onset.

Acute appendicitis complicating pregnancy.

Seventeen cases of acute appendicitis complicating pregnancy were analysed. The presenting symptoms were abdominal pain, nausea and anorexia. The usual physical findings were direct abdominal tenderness and rectal tenderness. Correct diagnosis was more difficult when gestation was advanced. This was reflected both by the severity of the disease process found at operation and by the increasing foetal mortality rate. Delay in diagnosis and treatment is the main factor causing high maternal and foetal death rates, especially when pregnancy is advanced.