Journal Of The Royal College Of Surgeons Of Edinburgh[JOURNAL]
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200 papers
Predictors of excessive blood loss during operative treatment of hip fractures.
Odumala AO, Ayekoloye CI, Packer G
J R Coll Surg Edinb · 2002 Jun · PMID 12109609
OBJECTIVES: To determine the total blood loss and transfusion needs during operative treatments of hip fracture, and identify predictors of excessive blood loss. METHOD: A prospective study of 242 consecutive patients op...
OBJECTIVES: To determine the total blood loss and transfusion needs during operative treatments of hip fracture, and identify predictors of excessive blood loss. METHOD: A prospective study of 242 consecutive patients operated for hip fractures over a 6 month period. The main outcome measure of blood loss was assessed by blood volume in the drainage system and swab weight. A loss of more than 480 mls was considered as excessive blood loss. RESULTS: The study consisted of 190 women and 52 men, mean age was 81.6 years (range 44-99). More than one-third of patients (34%) lost more than 480 mls of blood, and mean units transfused per patient was 2.3. Univariate predictors of increased blood loss were patients of American Society of Anaesthesiology (ASA) grade III and IV, patients at risk of cerebral or cardiac ischemia from volume depletion as defined by the American College of Physicians, patients with two or more pre-existing medical conditions and patients who had a hemiarthroplasty carried out. However, with subsequent multivariate analysis, patients who had undergone a hemiarthroplasty and those at risk predicted increased blood loss. CONCLUSION: Pre-operative characteristics can help determine which patients should have either blood requested on the day of surgery (group and cross-match) or the customary group and save policy.
Short and long-term outcome of pancreatic surgery in a district general hospital.
Hutchins RR, Kojodjojo P, Ho R … +2 more , Bani-Hani A, Snooks SJ
J R Coll Surg Edinb · 2002 Jun · PMID 12109608
Pancreatic surgery is a formidable undertaking with historically high mortality and poor prognosis for periampullary lesions. This has led to recommendations that all pancreatic surgery should be performed in specialist...
Pancreatic surgery is a formidable undertaking with historically high mortality and poor prognosis for periampullary lesions. This has led to recommendations that all pancreatic surgery should be performed in specialist centres. There is no doubt from large series that a low mortality can be achieved in these centres, but there has been no direct comparison between results from these specialist centres and district general hospitals with an interest in pancreatic disease. We present a retrospective, seven-year experience with a 3% 30 day mortality, 39% morbidity and 14 month median survival for malignant disease. Comparison with the UK survey of specialist pancreatic units shows that pancreatic surgery can be safely performed in the setting of a district general hospital with low morbidity and mortality, and good long-term outcome.
Internal fixation of intracapsular fractures.
Parker MJ, Tagg CE
J R Coll Surg Edinb · 2002 Jun · PMID 12109607
The main indications for internal fixation of intracapsular fractures are undisplaced and minimally displaced fractures and displaced intracapsular fractures in those aged less than about 70 years. For displaced fracture...
The main indications for internal fixation of intracapsular fractures are undisplaced and minimally displaced fractures and displaced intracapsular fractures in those aged less than about 70 years. For displaced fractures, closed reduction is to be preferred to open reduction. Numerous different implants may have to be used; with current practice favouring two or three parallel cannulated cancellous screws. These may be inserted either percutaneously or with minimal surgical exposure. Attention to surgical details of fracture reduction and implant positioning will minimise the risk of fracture healing complications. Post-operative care should generally be unrestricted mobilization with weight bearing as tolerated.
Whipple's resection-proximal pancreaticoduodenectomy (PD).
Tait IS
J R Coll Surg Edinb · 2002 Jun · PMID 12109606
Pancreatic resection offers the potential for long-term cure in 15% of patients with pancreatic cancer. This article describes the author's technique of pancreaticoduodenectomy (PD), together with guidelines for disease...
Pancreatic resection offers the potential for long-term cure in 15% of patients with pancreatic cancer. This article describes the author's technique of pancreaticoduodenectomy (PD), together with guidelines for disease staging, pre-operative work-up and patient selection. The role of neo-adjuvant and adjuvant chemotherapy is currently under evaluation and all patients who have a curative resection should be considered for entry into the ESPAC 3 trial that aims to establish the definitive role of adjuvant chemotherapy in pancreatic cancer.
Endovascular repair of abdominal aortic aneurysm: current status.
Hinchliffe RJ, Hopkinson BR
J R Coll Surg Edinb · 2002 Jun · PMID 12109605
INTRODUCTION: Endovascular aneurysm surgery (EVAR) was introduced a decade ago. Early results are promising, however, there remain concerns regarding the longer-term durability of this technique. Consequently, the nation...
INTRODUCTION: Endovascular aneurysm surgery (EVAR) was introduced a decade ago. Early results are promising, however, there remain concerns regarding the longer-term durability of this technique. Consequently, the national multi-centre EVAR trial has been commenced to define the role of endovascular surgery in the management of abdominal aortic aneurysm. DISCUSSION: Successful EVAR requires accurate pre-operative assessment of aneurysm morphology. Current stent-grafts allow 60% of all infra-renal AAA to be treated. Reduced physiological stress and low peri-operative morbidity and mortality rates have been demonstrated with this technique when compared to open repair. Endoleak is an Achilles heel of EVAR, although in itself does not accurately predict outcome. First and second generation devices are estimated to have a 1% per year risk of rupture. CONCLUSIONS: Increased understanding of the issues surrounding aneurysm morphology and successful stent-grafting have allowed a major reduction of early type I endoleak. Late endoleak and graft migration remain problematic. Type I and III endoleaks are risk factors for subsequent rupture although the significance of type II endoleak remains uncertain. More robust indicators of outcome success/failure are required so that follow-up may be rationalised.
Barrett's oesophagus--are British gastroenterologists denying their patients prevention of malignant change?
Rosin RD
J R Coll Surg Edinb · 2002 Jun · PMID 12109604
Adenocarcinoma of the lower oesophagus is rapidly increasing in industrialised countries. The importance of Barrett's oesophagus is because of the potential for it to progress to oesophageal adenocarcinoma. It has a stro...
Adenocarcinoma of the lower oesophagus is rapidly increasing in industrialised countries. The importance of Barrett's oesophagus is because of the potential for it to progress to oesophageal adenocarcinoma. It has a strong correlation to chronic GORD. Symptomatic patients or those with a long segment, if dysplasia is present or the patient is under 50 years of age, should be offered anti-reflux surgery. Patients may be denied the procedure by some gastroenterologists
Pancreatic trauma in Scottish children.
Vitale G, MacLeod S
J R Coll Surg Edinb · 2002 Apr · PMID 12018700
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An alternative approach to fishbone extraction.
Viney R, Reid A
J R Coll Surg Edinb · 2002 Apr · PMID 12018699
We present a novel approach for a common ENT emergency. Under nasendoscopic guidance, a fishbone lodged in the pharynx can be removed with a suction catheter passed nasally.
We present a novel approach for a common ENT emergency. Under nasendoscopic guidance, a fishbone lodged in the pharynx can be removed with a suction catheter passed nasally.
Wandering spleen: case report and literature review.
Satyadas T, Nasir N, Bradpiece HA
J R Coll Surg Edinb · 2002 Apr · PMID 12018698
We report a case of a 17-year-old patient who presented with a 'wandering spleen.' Management options were influenced by her being a Jehovah's Witness.
We report a case of a 17-year-old patient who presented with a 'wandering spleen.' Management options were influenced by her being a Jehovah's Witness.
Spontaneous iliac vein rupture: case report and literature review.
Pedley D, Nagy J, Nichol N
J R Coll Surg Edinb · 2002 Apr · PMID 12018697
Spontaneous rupture of the iliac vein is a rare cause of exsanguinating haemorrhage. A case is described of a 66 year old woman who required immediate resuscitation in Accident and Emergency following a 24 hour history o...
Spontaneous rupture of the iliac vein is a rare cause of exsanguinating haemorrhage. A case is described of a 66 year old woman who required immediate resuscitation in Accident and Emergency following a 24 hour history of left leg and lower quadrant abdominal pain. Emergency laparotomy revealed a 2 cm tear in the left iliac vein. The previously reported cases are reviewed, together with discussion of the patterns of presentation and possible underlying causes.
Colonoscopy.
Leslie A, Steele RJ
J R Coll Surg Edinb · 2002 Apr · PMID 12018696
Colonoscopy is now the gold standard method for investigating most colonic symptoms. However, it is a demanding procedure that can be associated with low completion rates and significant complications, and it requires co...
Colonoscopy is now the gold standard method for investigating most colonic symptoms. However, it is a demanding procedure that can be associated with low completion rates and significant complications, and it requires considerable skill to perform colonoscopy consistently well and safely. In this article, the key steps in performing colonoscopy are described with a view to providing the trainee with a logical sequence of manoeuvres on which to base a sound technique.
Cup removal in revision hip arthroplasty.
Farrington WJ, Dunlop DG, Timperley AJ
J R Coll Surg Edinb · 2002 Apr · PMID 12018695
When revision hip surgery is undertaken to remove a cemented cup from the pelvis the preservation of bone stock and structural integrity of the acetabulum is a major concern. We describe a safe technique for cup removal,...
When revision hip surgery is undertaken to remove a cemented cup from the pelvis the preservation of bone stock and structural integrity of the acetabulum is a major concern. We describe a safe technique for cup removal, which helps avoid a rim fracture occurring during this procedure. This should ensure the defect remains a cavitatory defect and does not become a segmental one with a more uncertain prognosis.
Treatment of hepatic metastases of neuroendocrine malignancies: a 10-year experience.
Dejong CH, Parks RW, Currie E … +3 more , Piris J, Redhead DN, Garden OJ
J R Coll Surg Edinb · 2002 Apr · PMID 12018694
BACKGROUND: Liver metastases from neuroendocrine tumours may give rise to symptoms due to hormone production or mass effect. Accepted management options include administration of somatostatin-analogues, selective chemoem...
BACKGROUND: Liver metastases from neuroendocrine tumours may give rise to symptoms due to hormone production or mass effect. Accepted management options include administration of somatostatin-analogues, selective chemoembolisation or hepatic resection. The aim of this study was to review the management of hepatic neuroendocrine metastases in our unit. METHODS: Patients with neuroendocrine tumours presenting between 1989 and 1999 were identified from pathology, radiology and surgical databases. Case notes were retrospectively reviewed for demographic data, treatment modality and outcome. Response to treatment was based on biochemistry, radiology or symptoms, and response rates were defined accordingly. RESULTS: Thirty patients with a mean age of 55 years presented with, or later developed liver metastases. The most frequent presenting symptoms were abdominal pain (63%), diarrhoea (40%), weight loss (33%) and flushing (13%). Five patients underwent liver resection with complete symptomatic response, nine underwent chemoembolisation with a 75% response rate (either biochemically, radiologically or symptomatic) and fifteen were treated with a somatostatin-analogue, with a response rate of 86%. Median survival from detection of metastases was 45 months. CONCLUSIONS: Liver resection provides good symptomatic relief, but it is only indicated in a small proportion of patients with metastatic neuroendocrine tumours. Both chemoembolisation and somatostatin-analogues offer useful symptomatic control for these patients with good survival prospects.
Assessment of faecal occult blood loss by qualitative and quantitative methods.
Barber MD, Abraham A, Brydon WG … +2 more , Waldron BM, Williams AJ
J R Coll Surg Edinb · 2002 Apr · PMID 12018693
BACKGROUND: Various methods exist for the assessment of faecal occult blood loss in a patient with suspected gastrointestinal blood loss. METHODS: The present study examined the effectiveness and financial implications o...
BACKGROUND: Various methods exist for the assessment of faecal occult blood loss in a patient with suspected gastrointestinal blood loss. METHODS: The present study examined the effectiveness and financial implications of a qualitative guaiac-based method (Haemoccult) of faecal occult blood detection and a quantitative measure of haeme-derived porphyrins (Hemoquant) in 184 patients who underwent assessment of faecal blood loss by both methods over a three year period during assessment of iron deficiency anaemia. MAIN FINDINGS: At least one Haemoccult test was positive in 72.2% of patients while Hemoquant was suggestive of significant blood loss (> 2mg haemoglobin/g faeces) in 29.9%. Patients underwent a total of 324 further endoscopic or radiological investigations of which 76.5% demonstrated no abnormality. A diagnosis was reached in 60 patients (32.6%). A significant potential source of gastrointestinal bleeding was found in 48 patients (26.1%). Hemoquant achieved a sensitivity of 62.5% and a specificity of 81.6% while with Haemoccult it was 85.4% and 32.4%, respectively. Hemoquant was normal in 18 patients with significant gastrointestinal conditions including peptic ulcers and colonic polyps. While Haemoccult only missed 7 lesions, two of these were colonic cancers. The quantitative nature of the Hemoquant test gave little clue as to diagnosis. CONCLUSION: Neither of the tests examined was ideal but Hemoquant had an overall better performance and further investigation of patients with evidence of blood loss from this test should be mandatory.
Sclerosing encapsulating peritonitis secondary to CAPD: the effect of fibrotic debridement on further dialysis.
Klimopoulos S, Katsoulis IE, Margellos V … +1 more , Nikolopoulou N
J R Coll Surg Edinb · 2002 Apr · PMID 12018692
BACKGROUND: Sclerosing peritonitis (SCP) is a complication of continuous ambulatory peritoneal dialysis (CAPD) and is characterized by progressive fibrosis of the peritoneum. Entrapment of the intestine in a fibrous sac...
BACKGROUND: Sclerosing peritonitis (SCP) is a complication of continuous ambulatory peritoneal dialysis (CAPD) and is characterized by progressive fibrosis of the peritoneum. Entrapment of the intestine in a fibrous sac resulting in complete intestinal obstruction is called sclerosing-encapsulating peritonitis (SEP) and represents the most severe form of the disease. Various reports have been pessimistic regarding the surgical outcome when SEP has caused complete intestinal obstruction. Continuation of CAPD after laparotomy is generally considered not feasible. The aim of this article is to present our experience in the surgical management of SEP and, in particular, in the postoperative continuation of CAPD. MATERIAL AND METHODS: Seventeen consecutive patients with SCP among 175 patients undergoing CAPD during a period of 14 years in a single Unit were retrospectively reviewed. Two groups of patients were recognized. The SCP group included 9 patients with incomplete intestinal obstruction that were treated with single peritoneal catheter removal and switching to haemodialysis. The SEP group included 8 patients with complete obstruction that necessitated laparotomy for surgical debridement of the fibrotic tissue and release of the intestinal loops. RESULTS: Switching to haemodialysis improved the majority of the group of patients. In 2 of the SEP group of patients (early in the series), where enterectomy was inevitable, performance of an intestinal anastomosis resulted in leakage with subsequent fatal outcome. Two of the SEP group of patients were transferred to haemodialysis after the laparotomy. In the remaining 4 SEP patients (50%), exposure of a significant portion of active peritoneal surface was achieved - called "neoperitonization"-and allowed effective continuation of peritoneal dialysis for an average duration of 16 months (range 1-32). CONCLUSIONS: In patients with SEP, careful release of the intestinal loops avoiding enterectomies and even inadvertent intestinal wounds is mandatory. Continuation of peritoneal dialysis after meticulous debridement and removal of the fibrotic tissue is possible and may be effective. To the best of our knowledge, there have not been previously reported cases of continuations of CAPD after laparotomy for SEP.
The natural history diverticular disease: is there a role for elective colectomy?
Somasekar K, Foster ME, Haray PN
J R Coll Surg Edinb · 2002 Apr · PMID 12018691
BACKGROUND: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. AIM: To assess whether the complications of di...
BACKGROUND: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. AIM: To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications. MATERIALS AND METHODS: A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients. RESULTS: A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications. CONCLUSIONS: Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.
James IV Lecture: congenital deformities of the spine.
McMaster MJ
J R Coll Surg Edinb · 2002 Apr · PMID 12018690
Congenital anomalies of the vertebrae producing a scoliosis, kyphoscoliosis or kyphosis are potentially serious conditions, which can, on occasion, result in an extremely severe rigid spinal deformity with possible spina...
Congenital anomalies of the vertebrae producing a scoliosis, kyphoscoliosis or kyphosis are potentially serious conditions, which can, on occasion, result in an extremely severe rigid spinal deformity with possible spinal cord compression. The key to successful management depends on: (1) Early diagnosis while the curve is still small. (2) Anticipation of the likely prognosis based on the type and site of the vertebral anomaly, the degree of growth imbalance it produces and the amount of spinal growth remaining. (3) Preventing progression of the deformity and this may necessitate surgical treatment in the first few years of life. It is much better to carry out a relatively simple operation to balance the growth of the spine at an early stage than to wait and perform potentially hazardous anterior and posterior spinal surgery as a salvage procedure at a later stage.
Current concepts in immunotherapy for the treatment of colorectal cancer.
Indar A, Maxwell-Armstrong CA, Durrant LG … +2 more , Carmichael J, Scholefield JH
J R Coll Surg Edinb · 2002 Apr · PMID 12018689
Immunotherapy could have a role in the therapy of colorectal cancer as there is now convincing evidence that the immune system can specifically recognize and destroy malignant cells. The MAb 17-1A has been used in advanc...
Immunotherapy could have a role in the therapy of colorectal cancer as there is now convincing evidence that the immune system can specifically recognize and destroy malignant cells. The MAb 17-1A has been used in advanced and primary disease, along with newer agents such as anti-epidermal growth factor receptor (EGFR) antibody. Immunotherapy with autologous tumour cell vaccine, genetic modification of immunostimulatory cytokines, suicide genes and TAAs as discussed. The multiplicity of peptide and carbohydrate antigens which can be potential targets for immunotherapy are also discussed. These include MUC1, Thomsen-Friedenreich and Sialosyl-Tn antigens and HER2 / neu. Active specific immunotherapy with the anti-idiotypic antibodies CEAVac and 105AD7, along with DC vaccines, is being currently used in adjuvant clinical trials. 105AD7 has been shown to cause significantly greater apoptosis of tumour cells in colorectal cancer patients, while CEAVac generated T cell proliferative anti-CEA responses. Dendritic cells pulsed with tumour mRNA or TAAs currently are being assessed in clinical trials. The role of HSPs in the anti-tumour immune response is discussed. Non-specific immunotherapeutic agents used in clinical trials with chemotherapeutic regimens have not shown any definitive benefit. Tumour progression may occur as result of escape from the host anti-cancer immune response. Better understanding of mechanisms of tumour evasion could explain why immunotherapy trials in patients have not shown better results. These include down-regulation of immune responses by the tumour, altered expression of MHC and/or TAAs by tumour cells, altered expression of adhesion molecules by tumour and/or DCs and usurpation of the immune response to the advantage of the cancer.
Fluid resuscitation in pre-hospital trauma care: a consensus view.
Greaves I, Porter KM, Revell MP
J R Coll Surg Edinb · 2002 Apr · PMID 12018688
Fluid administration for trauma in the pre-hospital environment is a challenging and controversial area. The available evidence does not clearly support any single approach. Nevertheless, some provisional conclusions may...
Fluid administration for trauma in the pre-hospital environment is a challenging and controversial area. The available evidence does not clearly support any single approach. Nevertheless, some provisional conclusions may be drawn. It was with this intention that the Faculty of Pre-Hospital Care (RCSEd) arranged to meet in August 2000 in an attempt to reach a working consensus. The following guidelines are the result of those discussions. It is intended that they will be modified as future research brings clarity to the area. When treating trauma victims in the pre-hospital arena cannulation should take place en route, where possible. Only two attempts at cannulation should be made. Transfer should not be delayed by attempts to obtain intravenous access. Entrapped patients require cannulation at the scene. Normal saline may be titrated in boluses of 250 ml against the presence or absence of a radial pulse (caveats; penetrating torso injury, head injury, infants).
A novel method of shortening an aortic graft.
Saunders SM, Jenkins SC, Deol HK … +1 more , Ham RJ
J R Coll Surg Edinb · 2002 Feb · PMID 11878303
We describe a simple method of shortening the abdominal aortic graft during an emergency procedure which is easy to perform and does not unduly delay the completion of the operation.
We describe a simple method of shortening the abdominal aortic graft during an emergency procedure which is easy to perform and does not unduly delay the completion of the operation.
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