Spontaneous omental haematoma--clinical image.

A case report of spontaneous omental bleeding attributed to a combination of vigorous abdominal exercise and antiplatelet agents. This case serves to high-light the bleeding risks associated with antiplatelet therapy.

Microbiological assessment of bile during cholecystectomy: is all bile infected?

AIMS: To determine the prevalence of bactibilia in patients undergoing cholecystectomy and to relate the presence or absence of organisms to the preoperative and postoperative course. PATIENTS AND METHODS: Patients undergoing cholecystectomy under the care of a single consultant surgeon during a continuous 5-year period were identified from a prospectively maintained departmental database. Symptoms, clinical signs, findings of investigations, details of treatment and postoperative care were noted. Risk factors for bactibilia (acute cholecystitis, common duct stones, emergency surgery, intraoperative findings and age > 70 years) were documented. Patients were divided according to the presence (B + ) or absence (B-) of bacteria on culture of their bile. RESULTS: In all, 128/180 (70%) of cholecystectomies had full data available for analysis. Bacteria were identified in the bile of 20 (15.6%) patients (B+ group). The B+ group was significantly older at 63.78+/-9.7 versus 61.62+/-13.9 (p<0.05) and contained significantly fewer females than the B- group (p<0.05). All 20 patients (100%) in the B+ group had > or = 1 risk factor, while these factors were present in only 29/108 (30.3%) of patients in the B- group (p<0.05). The overall incidence of infective complications was 20% in the B+ group compared with 0.9% in the B- group (p<0.05) and the bile-related infections were higher in the B+ group (p<0.05). CONCLUSIONS: The study demonstrated that while patients with complicated gallstone disease frequently exhibit bactibilia, patients with uncomplicated cholelithiasis have aseptic bile. The findings would suggest that prophylactic antibiotics should be limited to patients with risk factors for bactibilia.

Giant mature cyst formation following mesh repair of hernias: an underreported complication?

BACKGROUND: Numerous complications have been described following the implantation of synthetic meshes during hernia repair; one of the rarest, with only three reported cases, is giant mature fibrous cyst formation. Our clinical experience with this complication has led us to believe that it may be more common than previously thought. METHODS: Surgical operation notes and pathology archives were reviewed for the period January 1998-January 2002 to determine the prevalence of mature cyst formation following mesh repair of hernias. RESULTS: Out of 1100 hernia repair operations involving the use of synthetic meshes in our institution during the period of study, five developed histologically confirmed mature fibrous cysts giving a prevalence of 0.45% for this complication. CONCLUSION: The formation of a giant mature cyst following mesh repair of hernias is an underreported complication.

Benign scrotal pathology: should all patients undergo surgery?

OBJECTIVE: To evaluate the justification for operative intervention in patients undergoing surgery for benign scrotal pathology, and to assess the associated morbidity. PATIENTS AND METHODS: Consecutive patients in two surgical firms who underwent surgery for benign intrascrotal pathology over a 5-year period were studied retrospectively. RESULTS: In all, 102 patients were included in the study (mean age 51.6 years, range 16-86). Most patients had either epididymal cysts (59) or hydroceles (31) or a combination of the two (eight). Some patients (37) underwent ultrasonography before surgery. The indications for surgery were deemed to be strong in 25% of patients but weak or absent in the remainder. Complications occurred in 31 patients, being minor in 18, but significant in 13, resulting in four re-admissions to hospital. There was no significant difference in the complication rate between those patients with strong indications for surgery (37%) and those with weak indications (28%). CONCLUSIONS: Surgery for benign intrascrotal pathology is frequently undertaken for weak clinical indications and carries significant associated morbidity. This could be avoided in many cases by simple reassurance. Judicious use of ultrasonography is advised. A policy of selective surgical intervention is strongly advocated.

Port-site metastasis following laparoscopic cholecystectomy: a review of the literature and a case report.

Port-site metastasis following laparoscopic cholecystectomy with unsuspected gallbladder carcinoma is a serious problem. We reviewed 45 such cases reported in the English literature to date, and add another case which occurred in a 72-year-old female 13 months after a laparoscopic cholecystectomy for gallstones, who also had an unapparent gallbladder carcinoma. Pre-operative diagnosis of gallbladder carcinoma is possible in less than 10% of cases, with a high index of suspicion. If detected during laparoscopy early conversion to open procedure is recommended. If diagnosed later, however, to contemplate further radical operation depending on histopathology would be unwise as a universal approach, because of increased associated morbidity and mortality. The prospect of cure is also very unrealistic in this condition.

Exploration of the common bile duct for stones: the influence of the flexible choledochoscope and perioperative antibiotic prophylaxis.

A retrospective study of 110 patients, out of a total of 743 open cholecystectomies, who have undergone common bile duct (CBD) exploration for stones between 1985 and 1990. CBD exploration was performed in the presence of abnormal peroperative cholangiogram in 86 (78%) patients. The remaining 24 patients were known to have either an abnormal preoperative ERCP or palpable ductal stones at the time of surgery. Post exploratory choledochoscopy was performed as an additional completion procedure in 58 (53%) patients and it identified further stones in 28 (48.3%) of these patients. There were three patients in whom no stones were identified on exploration of the CBD. Documented evidence of peroperative antibiotic prophylaxis was obtained in 78 (71%) patients. A total of 27 (24.5%) patients developed complications including seven (6.4%) patients with retained stones. In four of these patients with retained stones, flexible choledochoscopy was undertaken as an additional completion procedure to ensure ductal clearance. Cardiorespiratory and septic complications were the next most common problems occurring in 6.5% and 5.4% respectively, of patients reviewed. In conclusion, the retained stone rate has fallen from 14% in 1987 to 6.4% in this study. The choledochoscope has influenced this as it identified further residual stones following conventional exploration. The sepsis rate has also fallen from 19.5% to 4.5% in this study. We believe this is due to the use of antibiotic prophylaxis.

Reversal of vasectomy and the general surgeon.

Reversal of vasectomy is a difficult procedure. Most surgeons still perform a macroscopic vasovasostomy. However, there is a little guidance in the current literature on the results that can be expected from such procedures. Patients may therefore be given unrealistic expectations preoperatively. Our study shows the results of macroscopic reversals of vasectomy performed over a 9-year period. A survey of Welsh surgeons is also presented concerning their preferred techniques and estimated success rates for reversals. The study clearly shows that a macroscopic vasovasostomy is the commonest method employed, with a wide variation in estimated success rates. Patients considering a macroscopic reversal of vasectomy should be warned of a less than 20% success rate.

PIP: 33 patients over a 9 year period had undergone macroscopic vasovasostomies (a single layer anastomosis) at a surgical unit at the University Hospital of Wales in Cardiff. 4 patients were lost to follow-up. The partners of 5 (17%) of the remaining 29 vasectomy reversal patients had become pregnant. The interval between vasectomy and reversal for these 5 men was shorter than that for those who did not have a successful vasectomy reversal (6.2 years vs. 8.9 years). After the reversal, 13 men had a normal sperm count (20,000,000/ml) and 12 had no sperm at all. 77% of the Welsh surgeons responding to a questionnaire had performed vasectomy reversals. All these surgeons had used a one-layer anastomosis. 54% used low power magnification, 43% used no magnification, and 3% used an operating microscope. 64% did not use a stent. The remaining 46% did use a stent. General surgeons and urologists generally used the same techniques. There was a wide variation in the estimates of patients who fathered children after vasectomy reversal among the 31 surgeons. Most surgeons (11) reported a pregnancy rate of 21-30%. 2 surgeons said that 60-70% of their vasectomy reversal patients fathered children. The authors recommend that surgeons tell patients undergoing a macroscopic reversal of vasectomy of a less than 20% success rate.

Determination of a critical level of tissue oxygenation in acute intestinal ischaemia.

Tissue oxygen tension (PtO2) was measured using a miniaturised polarographic oxygen electrode in 134 segments of rat small intestine of varying degrees of ischaemia. Without knowledge of the PtO2 levels, the viability of each segment was scored using clinical parameters and tissue damage scored by independent histological examination. Histologically non-viable bowel had significantly impaired tissue oxygenation when compared with viable bowel (t test, p less than 0.001). Marked degrees of tissue hypoxia were frequently tolerated before major histological damage became apparent, a critical PtO2 level of 1.9 mmHg being identified. The overall accuracy rate of PtO2 measurement in the operative prediction of intestinal viability was 92.5%, which contrasts with a rate of only 57.7% for clinical criteria alone.

Non-specific abdominal pain: the resource implications.

Non-specific abdominal pain (NSAP) is responsible for a significant proportion of emergency surgical admissions with resultant resource implications. The extent of the problem was assessed in a consecutive group of 100 patients, aged between 15 and 35 years, admitted with lower abdominal pain to one general surgical firm. No less than 67 of these patients (67%) were diagnosed as having NSAP (13.29% of all general surgical admissions), most (75%) being female and having a mean hospital stay of 4.1 days. Only 11 patients (11%) had appendicitis and the remaining 22 had miscellaneous gynaecological, urological or gastrointestinal problems. Detailed analysis of the resources used revealed that the mean cost to the NHS of each case of NSAP was 807 pounds, the bulk of which was attributable to the hospital stay. Wider assessment of the problem (by means of postal questionnaire) suggests that the cost to the NHS in Wales is in the region of 6 million pounds per year and may be over 100 million pounds per year in the UK as a whole.

Oxygenation in the stomach and the effect of truncal vagotomy.

A Clark polarographic oxygen electrode allowed detailed mapping of tissue oxygen (PtO2) levels on the anterior surface of the stomach in five patients undergoing cholecystectomy. No significant difference in mean PtO2 was detectable between greater and lesser curvatures. A significant difference in mean PtO2 was detected between the body of the stomach and the pylorus (Mann-Whitney, P less than 0.01). The effect of truncal vagotomy on PtO2 was evaluated in six patients undergoing this procedure for duodenal ulceration. Mean postvagotomy stomach PtO2 levels (46 +/- 12 mmHg) were significantly lower (Wilcoxon test, P less than 0.001) than prevagotomy levels (59 +/- 14 mmHg). Truncal vagotomy did not have any significant effect on small intestinal PtO2. This work provides the first objective evidence of the relatively diminished tissue oxygenation in the gastric antrum and pyloric region, and confirms blood flow studies of the effects of vagotomy.

Percutaneous transluminal angioplasty of the subclavian artery.

A series of 12 consecutive cases of symptomatic subclavian artery stenosis or occlusion treated by percutaneous transluminal angioplasty are described. In seven cases stenoses were successfully dilated, and in four out of five cases occlusions were recanalised using standard angioplasty technique. Complications were trivial and did not prolong hospital stay, all patients being discharged within 48 h of the procedure. Percutaneous transluminal angioplasty of the subclavian artery is a safe, effective procedure and recommended as the treatment of first choice in symptomatic subclavian stenosis or occlusion.

Intraoperative tissue oximetry in the human gastrointestinal tract.

Tissue oxygen tension was measured using a modified Clark oxygen electrode in the gastrointestinal tract of 33 patients undergoing laparatomy. The electrode, which incorporated a thermistor, had a linear response to oxygen tension (r = 0.995, p less than 0.001). The patients were all maintained on an inspired oxygen concentration of 33 +/- 3% and had a mean arterial oxygen tension (PaO2) of 124.9 +/- 31.9 mm Hg. Tissue oxygen tension measurements (mm Hg, mean +/- SD) were recorded from the serosal surfaces of the stomach (46.3 +/- 15.4), mid-ileum (36 +/- 9.7), terminal ileum (33.5 +/- 11.5), cecum (30.3 +/- 7.4), transverse colon (38.5 +/- 10), descending colon (29.3 +/- 11), and sigmoid colon (39.2 +/- 7.7) and tended to increase with increasing PaO2 (r = 0.70, p less than 0.001). Arterial occlusion resulted in a gradual decrease in tissue oxygen tension. It is concluded that intraoperative tissue oxygen tension measurement is feasible, and that the technique may have clinical applications in the assessment of intestinal viability.

A multicenter trial of the use of the proteolytic enzyme inhibitor aprotinin in colorectal surgery.

Animal studies have demonstrated the value of the proteolytic enzyme inhibitor, aprotinin, in reducing collagen breakdown and improving the healing of experimental colonic anastomoses. A double-blind, multicenter, prospective trial has evaluated the use of aprotinin in the prevention of anastomotic leakage in patients. Two hundred sixteen patients undergoing colonic resection and anastomosis were studied. Patients were randomized to receive either aprotinin or placebo intravenously, peroperatively, and for the first three postoperative days. Anastomotic integrity was assessed clinically and by Hypaque enema on the tenth postoperative day. Although the use of aprotinin was not associated with a significant overall decrease in anastomotic leakage rates, in 95 patients undergoing anterior resection, leakage rates in those receiving aprotinin (clinical 10.8 percent; radiologic 32.4 percent) were lower than in those receiving placebo (17.2 percent and 43.1 percent, respectively). An apparent adverse association was noted, however, in patients undergoing left hemicolectomy or sigmoid colectomy who received aprotinin.

Morbidity and mortality of common bile duct exploration.

This retrospective study reviews the complications which occurred in 257 patients who had supraduodenal exploration of the common bile duct in one hospital during a 15-year period. One hundred and eighteen patients (46 per cent) developed complications: septic and cardiorespiratory complications were most common, occurring in 19.5 per cent and 16.7 per cent of patients respectively. Postoperative retained stones were detected in 37 patients (14 per cent), causing complications in 54 per cent. Peroperative postexploratory cholangiography did not significantly reduce the incidence of this problem. None of the 12 patients who had postexploratory choledochoscopy had retained stones. Five patients (1.9 per cent) died, three of whom had duct procedures in addition to supraduodenal exploration and two of whom had retained stones. It is concluded that common bile duct exploration has a high associated morbidity, particularly due to sepsis and retained stones.