An understanding of the normal functioning of the heart and how it fails is important since it allows rational treatment. Pre-existing cardiac disease and myocardial dysfunction is common in the surgical patient. Moreove...An understanding of the normal functioning of the heart and how it fails is important since it allows rational treatment. Pre-existing cardiac disease and myocardial dysfunction is common in the surgical patient. Moreover, the stress response of surgery and the alterations in body physiology seen in the post-operative period may further aggrivate any cardiac compromise. The end result may be a patient who has cold peripheries due to vasoconstriction and hypoperfusion with dyspnoea due to congested lungs and a heart that cannot function adequately. The postoperative patient is at risk of these changes because of the stress response, analgesic therapy, inappropriate fluid management, hypoxia and previous cardiac compromise. The patient with sepsis is at further risk because of alterations in both systolic and diastolic function, which may be the result of inadequate fluid resuscitation and also release of a variety of inflammatory mediators. Until treatments, which are aimed at correcting the effects of these mediators, are proven to be beneficial then the septic patient will continue to be managed according to the physiological principles as outlined by Starling.
The development and refinement of pelvic pouch surgery now allows the excision of a diseased colon while maintaining transanal faecal continence. The success of restorative proctocolectomy is largely dependent on careful...The development and refinement of pelvic pouch surgery now allows the excision of a diseased colon while maintaining transanal faecal continence. The success of restorative proctocolectomy is largely dependent on careful patient selection combined with meticulous surgical technique. The authors discuss the main indications for restorative proctocolectomy and describe the surgical procedure.
The enormous progress that has been made in liver transplantation over the past two decades has culminated in survival approaching 90% at 12 months. The success of the procedure combined with the widening spectrum of dis...The enormous progress that has been made in liver transplantation over the past two decades has culminated in survival approaching 90% at 12 months. The success of the procedure combined with the widening spectrum of disease processes deemed amenable to liver transplantation has meant that there are too few donors for those awaiting transplantation. This has extrapolated to many patients having such advanced disease by the time a suitable donor liver is available, that they are almost non-transplantable. The immediate options facing the transplant community are to decrease the number of patients listed or to increase the number of living donor transplants. Alternatives to liver transplantation such as hepatocyte transplantation, gene therapy, xenotransplantation and the bioartificial liver are being sought but, at best, are some way from clinical application. It is anticipated that a number of liver diseases that are indications for liver transplantation at this time will have progression arrested or will be cured by medical therapy in the future.
Solitary rectal ulcer syndrome (SRUS) is rare in children. Few reported cases have undergone detailed investigations, treatments have been extremely varied and outcome poorly documented. We report two cases of SRUS in ch...Solitary rectal ulcer syndrome (SRUS) is rare in children. Few reported cases have undergone detailed investigations, treatments have been extremely varied and outcome poorly documented. We report two cases of SRUS in children, each with a different macroscopic pathology. The diagnosis was delayed in both cases. The importance of appropriate investigation and the need to tailor treatment to the type of lesion are emphasised. One case of SRUS was associated with a complete, full thickness rectal prolapse and symptoms improved after an abdominal sutured rectopexy. The other patient responded well to endoanal excision of polypoid lesions. The diagnosis and management of this condition in children deserves wider recognition.
Acute dissection of the aorta is a vascular surgical emergency. The majority of dissections originate in the thoracic aorta. Dissection originating in the infrarenal abdominal aorta is very rare and, given the vagueness...Acute dissection of the aorta is a vascular surgical emergency. The majority of dissections originate in the thoracic aorta. Dissection originating in the infrarenal abdominal aorta is very rare and, given the vagueness of presenting symptoms of uncomplicated dissection, diagnosis is very difficult in the early stages. In the absence of a pulsatile abdominal mass, acute uncomplicated aortic dissection should be considered in the differential diagnosis of sudden onset of abdominal and back pain. We report a case of spontaneous infrarenal abdominal aortic dissection occurring in an ostensibly normal aorta, and discuss the diagnostic dilemma and subsequent management of the patient.
Mohammed A, Teo NB, Pickford IR
… +1 more, Moss JG
J R Coll Surg Edinb
· 2000 Dec · PMID 11153434
We report the case of a 72-year-old gentleman with mesenteric angina who was successfully treated with stenting of a coeliac artery stenosis using a Palmaz stent, and review the therapeutic options in the management of m...We report the case of a 72-year-old gentleman with mesenteric angina who was successfully treated with stenting of a coeliac artery stenosis using a Palmaz stent, and review the therapeutic options in the management of mesenteric angina.
Morgagni's hernia is a rare cause of a diaphragmatic hernia. The defect tends to be small and asymptomatic. When symptomatic, a trans-thoracic or trans-abdominal repair has been carried out. We report asymptomatic case,...Morgagni's hernia is a rare cause of a diaphragmatic hernia. The defect tends to be small and asymptomatic. When symptomatic, a trans-thoracic or trans-abdominal repair has been carried out. We report asymptomatic case, presenting in an elderly patient, repaired successfully using a laparoscopic approach and discuss various aspects of technique.
Technological advances in radiography in the form of image intensification has not only made internal fixation of femoral neck fracture much easier but these high resolution films can be saved as hard copies and can also...Technological advances in radiography in the form of image intensification has not only made internal fixation of femoral neck fracture much easier but these high resolution films can be saved as hard copies and can also be reversed into 'positives' at a later date. However, requesting routine post-operative check radiographs for these fractures are still a common practice. A retrospective study was carried out to compare the quality of image intensifier films with conventional post-operative radiographs. 79 sets of films were reviewed with particular reference to adequacy of fixation and possible joint penetration by the screws. No significant difference was noted between the two sets of films. We suggest that routine post-operative radiographs after femoral neck fracture fixation are unnecessary unless there is some clinical indication. This has significant implications in relation to patient discomfort, radiation exposure and cost-effectiveness.
In 1791, the year in which Mozart died, there was born in Edinburgh a man who had some of the attributes of genius and whose name, but for a trivial mischance, might today occupy a distinguished place in the illustrious...In 1791, the year in which Mozart died, there was born in Edinburgh a man who had some of the attributes of genius and whose name, but for a trivial mischance, might today occupy a distinguished place in the illustrious history of the Edinburgh Medical School. Instead of this, his career was shattered and his reputation blighted forever by fortuitous association with a gruesome and macabre scandal the story of which is as shocking today as it was to our forebears 172 years ago. To the world at large the memory of this man, Robert Knox, is almost as infamous as Bluebeard or Jack the Ripper, while his outstanding abilities and substantial achievements are largely forgotten, and yet he was never formally accused, far less convicted of any crime.
The role of the sentinel node in the management of malignant melanoma is currently being investigated in specialist centres the world over. The methods employed in identifying the sentinel node(s) depend on the locally a...The role of the sentinel node in the management of malignant melanoma is currently being investigated in specialist centres the world over. The methods employed in identifying the sentinel node(s) depend on the locally available human and technical resources. We describe a three-part technique commonly used by most established centres i.e. lymphoscintigraphy, vital blue dye injection and the use of intra-operative gamma probe.
Critically ill patients are hypermetabolic and have increased nutrient requirements. Although it is assumed that nutritional support is beneficial in this group of patients there are no well designed clinical trials to t...Critically ill patients are hypermetabolic and have increased nutrient requirements. Although it is assumed that nutritional support is beneficial in this group of patients there are no well designed clinical trials to test this hypothesis. The rationale for nutritional support, therefore, is based upon clinical judgement. Although it is not known how long a critically ill patient can tolerate what is effectively starvation, the loss of lean tissue which occurs in catabolic patients (20-40 g nitrogen/day) suggests that depletion to a critical level may occur after 14 days. Total parenteral nutrition given to malnourished patients with gastrointestinal cancer for 7 to 10 days before surgery has been shown to decrease complications by about 10%. Wound healing and normal immune responses are dependent upon adequate nutrient intake, and it seems reasonable, therefore, to commence feeding as soon as possible. Earlier feeding may decrease length of stay and complication rates in both critically ill patients and following surgery. It has been shown in randomised controlled trials of both enteral and parenteral feeding in the critically ill, that current regimens are sub-optimal. Calorie intake was shown to be often considerably in excess of metabolic requirements alone, and variable study design has made comparisons impossible. Despite the lack of knowledge regarding even the most simple of nutritional requirements in these patients, the administration of specific micronutrients and specialised supplements has attracted attention. Again, many of these more recent studies are limited because of poor study design.
Morgan-Jones R, Cutler L, Kaul S
… +1 more, Smith K
J R Coll Surg Edinb
· 2000 Dec · PMID 11153427
We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trauma Unit at the North Staffordshire Royal Infirmary following acute injury. We assessed the patient's level of pain and perc...We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trauma Unit at the North Staffordshire Royal Infirmary following acute injury. We assessed the patient's level of pain and perception of pain relief in the period from their admission to hospital and surgery, or the first 24 hours as an inpatient using a questionnaire. We found that 54% of patients described their pain as 'severe' or 'the worst possible pain'. Significantly, 36% of patients would have liked more analgesia. We conclude that patients are not receiving the analgesia they require following acute injury.
BACKGROUND: Day case haemorrhoidectomy has been shown to be safe and acceptable to patients. The best way to introduce such evidence into clinical practice remains unclear: The aim is to assess the effectiveness of guide...BACKGROUND: Day case haemorrhoidectomy has been shown to be safe and acceptable to patients. The best way to introduce such evidence into clinical practice remains unclear: The aim is to assess the effectiveness of guidelines on the introduction of day-case haemorrhoidectomy in a general surgical unit. METHODS: Prospective audit of day-case haemorrhoidectomy and retrospective review of in-patient procedures. The effectiveness of guidelines in encouraging day-case haemorrhoidectomy is assessed by analysis of avoidable admissions. RESULTS: In the year prior to introduction of the guidelines 75 patients had elective haemorrhoidectomy, none as day-cases. In the year following the introduction of the guidelines 80 patients had elective haemorrhoidectomy, 35 (44%) as day cases. There were no complications or re-admissions. Of the 45 in-patients 31 (69%) were eligible for day surgery. CONCLUSIONS: The establishment of clear guidelines and their dissemination results in significant changes in practice. However, audit has demonstrated that alternative strategies are needed to encourage changes in clinical practice.
BACKGROUND: Open access flexible sigmoidoscopy (OAFS) is an integral part of colorectal cancer services. This study compares the impact of two types of open-access flexible sigmoidoscopy services on the utilisation of ba...BACKGROUND: Open access flexible sigmoidoscopy (OAFS) is an integral part of colorectal cancer services. This study compares the impact of two types of open-access flexible sigmoidoscopy services on the utilisation of barium enema and tumour-stage migration. METHODS: This was a non-randomised comparison (over two one-year periods, four years apart) of two unselected groups of patients, with different inclusion criteria, in adjacent similarly populated health districts. One offered a nurse practitioner endoscopy service while the other had a doctor-led colorectal clinic. RESULTS: The doctor-led service with its broad inclusion criteria detected more colorectal cancers [13.2% versus 0.7%; OR = 16.05; 2.16-119.2]. Neither nurse practitioner (130 cases) nor doctor-led (262 cases) flexible sigmoidoscopy reduced the total number of barium enemas [Odds Ratio (OR) = 1.16 (95% CI 1.03-1.3)]. However, the doctor-led service did reduce the number of barium enemas requested by general practitioners (from 249 to 152). The total number of colorectal cancers (detected by all available methods) were similar [OR = 0.82 (0.53-1.25)] and both services resulted in a similar tumour-stage migration [OR = 1.39 (0.31-6.23)]. CONCLUSION: Open access flexible sigmoidoscopy services have minimal impact on the utilisation of radiology services. Broader inclusion criteria of doctor-led services produce a higher cancer-yield. Tumour-stage migration may be related to greater awareness of colorectal cancer symptoms rather than to the type of OAFS.
Ross S, Jabbar A, Ramsay CR
… +3 more, Watson AJ, Grant AM, Krukowski ZH
J R Coll Surg Edinb
· 2000 Dec · PMID 11153424
This article reports patient perceived symptomatic outcome at a median of 23 months after surgery for a consecutive series of 200 patients who underwent a laparoscopic anterior partial fundoplication for gastro-oesophage...This article reports patient perceived symptomatic outcome at a median of 23 months after surgery for a consecutive series of 200 patients who underwent a laparoscopic anterior partial fundoplication for gastro-oesophageal reflux disease (GORD). Responses to postal questionnaires indicated that for the majority of patients the outcome was good, with 62% reporting minimal GORD symptoms. However, for a significant minority, the outcome was less favourable, and for 10% the outcome was poor. Continuing evaluation of the procedure is needed to establish its place in the management of GORD.
The upper midface area comprises mainly the naso-orbito-ethmoidal (NOE) region which plays a paramount role in facial expression. Fractures of this area often result in neglected bony defects in the fragile periorbital r...The upper midface area comprises mainly the naso-orbito-ethmoidal (NOE) region which plays a paramount role in facial expression. Fractures of this area often result in neglected bony defects in the fragile periorbital region with major secondary impairments such as traumatic telecanthus, orbital dystopia, and/or enophthalmos. Permanent cranial nerve deficits also can occur as the result of post-traumatic/post-operative sequelae. Seventy-one patients (age range 7-78 years) with severe high midface trauma, treated from January 1989 to December 1996, were reviewed with a minimum follow-up of 2 years. The patient population has been distributed according to the fracture type in three groups: Group 1 (n = 35): Isolated NOE with/without associated central midface injury; Group 2 (n = 22): NOE associated with craniofacial injury and Group 3 (n = 14): NOE associated with orbital displacement. The estimated post-surgical parameters included qualitative and quantitative data from the long-term clinical evaluation. Persistent headache and/or concentration difficulties were mainly noted in Group 1. Smell reduction or anosmia was reported mainly in Group 2. Deficits of the trigeminal and/or the facial nerve were found in Group 3. Enophthalmos and/or telecanthus were predominantly seen with injuries associated with orbital displacement.
Kerrigan JJ, Mansell JP, Sengupta A
… +2 more, Brown N, Sandy JR
J R Coll Surg Edinb
· 2000 Dec · PMID 11153422
This review concentrates on mechanisms of palatogenesis. This includes theories of shelf elevation, the role of matrix and identification of molecules and growth factors, which have key roles. The areas where failure to...This review concentrates on mechanisms of palatogenesis. This includes theories of shelf elevation, the role of matrix and identification of molecules and growth factors, which have key roles. The areas where failure to develop could potentially lead to clefting are highlighted. A key part of shelf fusion is the breakdown of the medial edge epithelium, a process that is probably dependent on enzymes involved in matrix turnover. There is good evidence that the matrix metalloproteinases may provide a common link to the multiple genetic and environmental factors that are known to cause clefting.