Cent Of Group Research Articles

Dihydroergotamine and the thromboprophylactic effect of dextran 70 in emergency hip surgery

In a prospective randomized controlled trial treatment with a combination of dextran 70 and dihydroergotamine (DHE) was compared with the administration of dextran 70 alone as prophylaxis against postoperative thrombo-embolic complications in emergency hip surgery. Forty-five consecutive patients with a fractured hip entered the study. Twenty-one were randomized to prophylactic treatment with dextran 70 (group 1) and twenty-four patients received dextran 70 and DHE (group 2). Both regimens were initiated pre-operatively and the surgical and postoperative procedures were the same in the two groups. On the first and fourth postoperative day, Tc-plasmin scintigraphy of the lower extremities and pulmonary ventilation/perfusion scintigraphy were performed to detect any deep vein thrombosis (DVT) and/or pulmonary emboli. A total of 19 per cent of group 1 patients developed DVT and so did 25 per cent in group 2; this difference was not statistically significant. Of the detected DVT, 60 per cent were subclinical, and 7 per cent of the patients had minor pulmonary emboli, all of which were symptomless. No therapeutic difference could be demonstrated between the two regimens. A recent report claiming that adding DHE to the prophylactic administration of dextran 70 considerably reduces the incidence of postoperative DVT in emergency hip surgery is questioned.

Malignant left-sided large bowel obstruction managed by subtotal/total colectomy

Of 60 patients presenting with acute obstructing carcinoma of the left colon, 49 underwent immediate resection either by radical subtotal/total colectomy (31 patients, group I) or by radical segmental resection (18 patients, group II) of whom three had immediate anastomosis after on-table bowel irrigation and 15 had a planned staged procedure. The operative mortality rate was 3 per cent in group I and 11 per cent in group II (not a statistically significant difference). However, substantial differences were found for major morbidity (6 versus 44 per cent in groups I and II respectively; P less than 0.01) and mean length of hospital stay (17 days in group I versus 35 days in group II; P less than 0.05). All three patients who had on-table lavage developed anastomotic leaks which necessitated a second operation to form a stoma. Six patients (19 per cent) in group I required antidiarrhoeal medication in the immediate postoperative period. However, subsequent improvement in stool frequency was noted in all patients. It is concluded that subtotal/total colectomy is an acceptable means of managing patients with obstructing carcinoma of the left colon in that it is associated with a low morbidity and mortality rate and good functional results.

Effect of mechanical bowel preparation on anastomotic integrity following low anterior resection in dogs.

To assess the effect of mechanical bowel preparation on anastomotic integrity after low anterior resection, 36 mongrel dogs were randomized to have low anterior resection with or without mechanical bowel preparation. All dogs received prophylactic antibiotics and anastomotic integrity was assessed on the ninth postoperative day by barium enema, inspection of anastomoses for defects after careful excision at laparotomy, and anastomotic bursting pressures. Bursting pressures were significantly higher (P less than 0.005) in the group with bowel preparation. Anastomotic defects were present in 13 per cent of animals with bowel preparation and 47 per cent without bowel preparation (P = 0.057). Pelvic abscess and death from peritonitis occurred in 6 per cent of the group with bowel preparation and 29 per cent of the unprepared group. Mechanical bowel preparation significantly enhanced anastomotic integrity and reduced complications in this model.

Definitive one-stage emergency large bowel surgery.

During a 30-month period, 126 operations for emergency large bowel conditions were performed: 57 were for colonic carcinoma, 26 for acute diverticulitis, 14 for colonic ischaemia, 13 for complications of inflammatory bowel disease, and 16 for other conditions. Sixty-eight patients had peritonitis. One hundred and ten patients (87.3 per cent) underwent immediate resection. Of these, 83 (65.9 per cent of the overall group) had colonic resection with primary anastomosis but without a colostomy, 56 of which were left-sided colonic resections. Excluding 9 of the 68 patients with peritonitis, who had a total colectomy, 66 per cent also underwent resection, anastomosis and no colostomy. Total group mortality was 14.3 per cent: 12.7 per cent in the immediate resection group, 9.6 per cent in those with primary anastomosis and no colostomy, 5.2 per cent in the group with peritonitis undergoing resection and anastomosis, and 25 per cent in those having non-resectional surgery. Complications included an overall wound infection rate of 10.3 per cent and a clinical anastomotic leak rate of 7.2 per cent in those who had anastomosis without colostomy. Our results suggest that resection and primary anastomosis can be performed with acceptable morbidity and mortality in a high proportion of cases of emergency large bowel conditions, irrespective of underlying pathology, site of disease or the presence of peritonitis.

Surgical treatment of perforated duodenal ulcer: A prospective trial between simple closure and definitive surgery

Seventy-eight patients with perforated duodenal ulcer were prospectively studied between 1977 and 1982. Patients were alternately allocated to receive simple closure (Group I, 33 patients) and definitive surgery (Group II, 32 patients). High-risk patients and those whose conditions dictated a definitive operation were excluded. All patients in Group II had a truncal vagotomy and drainage except one who had a proximal gastric vagotomy. There was no death in Group I or Group II; the complication rate and postoperative course were similar. Twenty-seven patients in Group I and 26 patients in Group II were available for follow-up 12 to 80 months after operation, mean 39 months. Good/excellent results were achieved in 30 per cent of Group I compared with 81 per cent of Group II (P less than 0.01). Eighty-five per cent of Group I patients developed recurrent ulcer symptoms and 33 per cent had already had a second definitive operation. Two patients (8 per cent) in Group II were reoperated upon for recurrent ulcer due to an incomplete vagotomy. In a population of patients where long-term follow-up and medical treatment for duodenal ulcer is unsatisfactory, truncal vagotomy with drainage should be the treatment of choice for perforation. Simple closure should be reserved for high-risk patients or when the surgeon is inexperienced.

The role of surgical local excision in the treatment of rectal cancer.

Selection of patients with ulcerating rectal cancer for treatment by local excision has been governed by a policy based on clinical and histological criteria; if these criteria are not fulfilled, major resection is recommended. This policy was re-examined in three groups of patients treated by local excision: Group 1 for cure (27 patients), Group 2 due to unfitness for major surgery (13 patients), Group 3 for local tumour control in the presence of metastatic disease (6 patients). When the policy was fulfilled, there was a cancer-specific death rate of 8.3 per cent in Group 1 (two patients with poorly differentiated tumours) and 0 per cent in Group 2. Unavoidable policy breaches occurred when patients refused major surgery or were too unfit: in the latter elderly group, this did not have the adverse effect expected. It is concluded that pre-operative clinical digital assessment and histological grading are a satisfactory means of identifying a small group of tumours appropriate for local treatment and that the results justify local excision where the policy is observed.

Early results of surgery in patients considered cimetidine failures.

Fifty-two consecutive unselected duodenal ulcer patients (Group I), who had failed to respond to cimetidine and who subsequently underwent elective vagotomy and drainage, were studied. All patients were symptomatic on cimetidine in full recommended dosage. This group has been compared with another group of 634 duodenal ulcer patients (Group 2) undergoing elective vagotomy and drainage in the 'pre-cimetidine era'. The groups were similar pre-operatively with regard to age, sex, length of history and maximal acid output. Completeness of vagotomy and amount of acid reduction were similar in the two groups. The incidence of recurrent ulceration was 5 per cent in Group I and 5.7 per cent in Group 2. Although, of necessity, follow-up is shorter in the cimetidine failures (mean 2.3 years), there is nothing to suggest that failure to respond to cimetidine precludes a satisfactory surgical result.

Dormant liver metastases: an experimental study

Experimental work was undertaken to evaluate whether intrahepatic recurrences, observed after resection of colorectal liver metastases in humans, could be due to the activation of dormant cancer cells already present within the liver at liver resection. About 250 cell aggregates (DHDK12 colon carcinoma cell line) were injected into the portal vein of 70 BD IX rats. Eight weeks later, 43 rats with no apparent liver metastases were divided randomly into three groups: group 1 (n = 15) served as control; group 2 (n = 15) were given cyclosporin A (10 mg kg body-weight-1 day-1) for 28 days; and group 3 (n = 13) underwent a 70 per cent hepatectomy. Twelve weeks after the injection of cells, when the animals were killed, 20 per cent of rats in group 1 had liver metastases, 80 per cent in group 2 (P less than 0.01) and 62 per cent in group 3 (P less than 0.05). Undetectable liver micrometastases may have been present at 8 weeks and had not developed until stimulation by cyclosporin A-induced immunosuppression or by liver regeneration after hepatectomy. A similar mechanism may occur clinically and explain some of the recurrences observed after resection of liver metastases.

Carotid artery surgery in patients with minor stroke.

Of 229 carotid artery reconstructions, 67 were performed in patients after a minor stroke. In this group of patients the operative mortality was 5.9 per cent, compared with 1.8 per cent in the group of patients without preoperative minor stroke operated upon during the same period of time. The 5-year survival in the stroke group was 86 per cent and in the non-stroke group it was 65 per cent. Excluding the postoperative mortality, the survival increases to 90 and 68 per cent respectively. The difference, which is significant at 6 years (P less than 0.05), is explained by a higher incidence of coronary artery disease in the non-stroke group. The postoperative annual stroke frequency was 2.3 per cent in the stroke group and 2.4 per cent in the non-stroke group. The stroke frequency on the operated side during follow-up was 1.6 per cent per year for both groups together. It seems that a minor stroke is no contraindication to carotid artery reconstruction provided the timing of the operation is correct and other contraindications are considered.

The importance of adequate nutrition in closure of small intestinal fistulas.

Abstract Ninety-one patients with small intestinal fistula, exclusive of the peforated duodenal stump and fistula in patients with carcinomatosis, were treated over the period 1960–73. Four regimens were used which permit comparison of early surgery, late surgery and nutritional support without surgery (1500–5000 kcal daily by the intravenous route). A lower mortality (8 per cent) resulted when patients were supported nutritionally combined with late definitive surgery if required after the peritonitis had subsided. The other groups in which no special effort at nutritional support was made resulted in a 33 per cent mortality rate. Spontaneous closure of the fistula occurred in 21 per cent of the group without nutrition and in 56 per cent of the nutrition group. Definitive late surgery was required for distal obstruction, Crohn's disease and undrained abscess. Total intravenous feeding is especially important in patients with fistula associated with peritonitis and sepsis.

Aortofemoral bypass and the role of concomitant femorodistal reconstruction.

A consecutive series of 200 patients having aortofemoral bypass grafts were studied in order to determine the effect of femoropopliteal occlusive disease on the results and the role of concomitant femorodistal bypass. Bifurcated aortic grafts were used in 177 patients and unilateral aortofemoral grafts in 23 giving 377 limbs for study. Of the 377 limbs, 184 (49 per cent) had minimal femoropopliteal disease (Group 1), 24 (6.4 per cent) had a femoropopliteal stenosis (Group 2) and 169 (44.6 per cent) had complete femoropopliteal occlusion (Group 3). In Group 3 aortofemoral bypass was carried out alone in 106 cases (Group 3a): in the other 63 cases femorodistal bypass was carried out at the same time as aortoiliac reconstruction (Group 3b). The cumulative patency at 5 years for all aortofemoral grafts together was 91 per cent. However, that for grafts in Group 3a was only 65 per cent compared with 98 per cent for Groups 1 and 3b and 94 per cent for Group 2. The cumulative patency rate for grafts in Group 3a was significantly lower than for all other groups (P less than 0.001). The operative mortality for those patients who had concomitant aortofemoral and femorodistal grafts (Group 3b) did not differ significantly from that of any of the other groups (P greater than 0.1). Of the cases in Group 3a, 21 (26 per cent) required femoropopliteal reconstruction at a later date. The results indicate that in the presence of combined aortoiliac and femoropopliteal occlusive disease concomitant reconstruction of both arterial segments yields significantly better results than aortoiliac bypass alone.

Identification of risk factors for acute pancreatitis from routine radiological investigation of the biliary tract.

The size and shape of gallstones, the diameter of the common bile duct and the presence of reflux into the pancreatic duct were studied by examining routine contrast investigations of the biliary tract in 174 patients with gallstones. Patients were divided into two groups: 69 who had been admitted to hospital with an attack of acute pancreatitis (group 1) and 105 patients with gallstones who had not had a known attack of pancreatitis (group 2). Four or more gallstones were present in 38 (78 per cent) of 49 visualized gallbladders in group 1 compared with 45 (52 per cent) of 87 in group 2 (P less than 0.005). The smallest gallbladder stone was less than 4 mm in diameter in 69 per cent of group 1 and 44 per cent of group 2 gallbladders (P less than 0.005). Twenty-nine per cent of gallbladder stones in group 1 were clearly faceted compared with 20 per cent in group 2. There were no significant differences in the diameter of the common bile duct or the presence of stones in the common bile duct, although the latter were more common in group 1. Reflux of contrast into the pancreatic duct (on operative or T tube cholangiogram) was more common in group 1 (50 per cent) than group 2 (25 per cent) (P less than 0.025). This study supports the role of numerous small stones and a 'common channel' at the ampulla as aetiological factors in patients who develop acute pancreatitis as a complication of gallstones.

Surgery for left-sided pancreatic cancer.

A total of 590 exocrine pancreatic cancers of the body or tail of the pancreas, operated on between January 1982 and December 1988, were analysed. There were 128 pancreatic resections (group 1), 164 palliative bypasses (group 2) and 293 exploratory laparotomies which included 74 splanchnicectomies (group 3). The mortality rate was lower in group 1 (9 per cent) than in group 2 (19 per cent) (P = 0.012). The mortality rate exceeded 40 per cent in groups 1 and 2 for patients aged more than 70 years with pre-existing organ failure. The morbidity rate was 32 per cent in group 1 and 29 per cent in group 2. Patients with metastases had a median survival of 3.4 months, whatever the operative treatment. In the presence of lymph node involvement there was no significant difference in survival between groups 1 and 2. Patients with no metastases and no lymph node involvement had 1- and 3-year survival rates of 38 and 12 per cent respectively after pancreatic resection. Only patients with a small tumour (< or = 4 cm), no lymph node involvement and no metastases achieved a significantly better survival after resection (P = 0.049). Curative resection should be reserved for a small tumour confined to the pancreas. Fewer than 10 per cent of patients will be suitable for surgery. For the other cases, resection must be considered as a palliative procedure without a significant improvement in survival. It seems justified to limit palliative surgery to candidates for digestive bypass and to use non-surgical palliation for the remainder.

Accuracy of endosonography in the staging of rectal cancer treated by radiotherapy

Endosonography is the best available method for the pretherapeutic staging of rectal cancer. The present prospective study was to determine the influence of previous radiotherapy, widely used in the management of this tumour, on the accuracy of endosonography. A complete endosonographic examination was performed just before surgery in 40 patients with rectal cancer. Endosonographic and pathological staging were compared in group A, 21 patients without previous radiotherapy, and group B, 19 patients with preoperative radiotherapy. While the endosonographic accuracy for lymph node involvement was similar in the two groups (85 per cent compared with 84 per cent), wall invasion was correctly ascertained in 86 per cent in group A but in only 47 per cent in group B (P less than 0.05). After irradiation, the thickening of the rectal wall and the poor visualization of the hyperechoic layers hampered interpretation. Post-radiotherapy inflammation and/or fibrosis probably explained the echographic changes. Radiotherapy therefore altered endosonographic staging of rectal cancer. New interpretation criteria are needed for evaluation and follow-up of rectal cancer treated by radiotherapy.

External and internal anal sphincter responses to rectal distension in normal subjects and in patients with idiopathic faecal incontinence.

The responses of the external anal sphincter and the internal anal sphincter to rectal distension were studied in 18 female patients who had idiopathic faecal incontinence with perineal descent and 11 female control subjects, by measuring pressures at six sites within the anal canal and the electrical activity of the external sphincter. The pressure profile in the normal anal canal, at rest, was asymmetric with the highest pressure recorded in the outermost channels. Rectal distension caused a transient increase in the activity of the external sphincter, which was associated with an increase in anal pressure, particularly in the outermost two channels. This was followed by a symmetrical reduction in anal pressure throughout the anal canal, caused by relaxation of the internal sphincter and shortening of the high-pressure zone. Two patterns of response were observed in the patients with idiopathic incontinence. Twelve patients (group 1) showed normal anal relaxation, but the maximum anal pressures recorded during rectal distension or a conscious squeeze were abnormally low, suggesting weakness of the external anal sphincter. The remaining six subjects (group 2), who were older than the group 1 patients, had much lower resting pressures and showed only external sphincter contraction in response to rectal distension, with no obvious internal sphincter relaxation. However, the maximum pressures recorded during a conscious contraction of the external sphincter were lower in this group than in the normal control subjects. These results suggest that group 2 patients have impaired internal anal sphincter tone, as well as external anal sphincter weakness. This may explain why all except one of the group 2 patients, compared with only 17 per cent of group 1 patients, reported incontinence to both solids and liquids.

A comparative evaluation of ear diseases in children of higher versus lower socioeconomic status

This study was conducted with an aim to assess the prevalence and profile of ear diseases in children from the higher and lower socioeconomic strata of society. Two groups of schools within Delhi were selected. Group A comprised of government schools located in slum areas with an average parental income of INR (Indian National Rupees) 1050 per month and group B of elite private schools with an average family income of TNR 35,000 per month. Three thousand children between the ages of 5-12 years were screened with the help of a written proforma and ear examination. Tympanometry and audiometry were done, where required. 19.6 per cent of children of group A were found to be suffering from ear diseases compared to 2.13 per cent of group B children. The two groups were also compared for number of family members, status of hygiene and parental education.

A prospective, randomized clinical study on the effects of an amine fluoride/stannous fluoride toothpaste/mouthrinse on plaque, gingivitis and initial caries lesion development in orthodontic patients

The aim of this study was to examine the effect of combined use of a toothpaste/mouthrinse containing amine fluoride/stannous fluoride (AmF/SnF2; meridol) on the development of white spot lesions, plaque, and gingivitis on maxillary anterior teeth in orthodontic patients. A prospective, randomized, double-blind study with 115 orthodontic patients (42 males and 73 females, average age 14.4 years, drop outs 18) was designed. Group A (50) brushed twice daily with an AmF/SnF2 toothpaste (1400 ppm F) and rinsed every evening with an AmF/SnF2 solution (250 ppm F). Group B (47) brushed twice daily with a sodium fluoride (NaF) toothpaste (1400 ppm F) and rinsed every evening with a NaF solution (250 ppm F). Visible plaque index (VPI), gingival bleeding index (GBI) and white spot lesion index (WSL) were recorded on the six maxillary anterior teeth at bonding and after debonding, and evaluated with t tests. In group A no significant differences between bonding and debonding were recorded for WSL (1.02 +/- 0.08 versus 1.05 +/- 0.13, P = 0.14), VPI (0.10 +/- 0.21 versus 0.12 +/- 0.21, P = 0.66) or GBI (0.13 +/- 0.21 versus 0.16 +/- 0.22, P = 0.47), whereas statistically significant differences were found in group B between bonding and debonding for WSL (1.00 +/- 0.02 versus 1.08 +/- 0.17, P = 0.01), VPI (0.06 +/- 0.13 versus 0.17 +/- 0.25, P = 0.01) and GBI (0.06 +/- 0.12 versus 0.16 +/- 0.21, P = 0.01). The increase in lesions on the upper anterior teeth was 4.3 per cent in group A and 7.2 per cent in group B. It was concluded that the combined use of an AmF/SnF2 toothpaste/mouthrinse had a slightly more inhibitory effect on white spot lesion development, plaque and gingivitis on maxillary anterior teeth during fixed orthodontic treatment compared with NaF.

Biopsy of resectable colorectal liver metastases causes tumour dissemination and adversely affects survival after liver resection

Liver resection is increasingly being performed for metastatic colorectal cancer. This study assessed the need for preoperative biopsy of suspected metastases and whether biopsy has any effect on long-term survival. Prospectively collected data on patients who underwent liver resection for colorectal metastases between 1986 and 2003 were reviewed retrospectively. The endpoints of morbidity, operative mortality and long-term survival were compared between patients who had biopsy before referral (group 1) and those who did not (group 2). Patient demographics and disease distribution were similar for 90 patients in group 1 and 508 in group 2. Seventeen patients (19 per cent) who had undergone biopsy either at the time of colorectal resection or radiologically had evidence of needle-track deposits. Operative mortality and morbidity rates in the two groups were similar. The 4-year survival rate after liver resection was 32.5 (s.e. 5.5) per cent in group 1, compared with 46.7 (2.8) per cent in group 2 (P = 0.008). Needle-track deposits are common after biopsy of suspected colorectal liver metastases. Biopsy of metastases confers poorer long-term survival on patients after liver resection and cannot be justified in patients with potentially resectable disease.

Extremity Fractures of Patients with Spinal Cord Injuries

Abstract 1. 1. In a group of 1,363 patients with traumatic spinal cord injuries, 156 (11 per cent) sustained fractures of the extremities; no comparable study has been noted in the literature. 2. 2. The case material was divided into four groups; Group I contained twenty-eight patients with thirty-four fractures of the upper extremities incurred in the accident which caused the spinal cord injury; Group II contained fifty-two patients with eighty-one fractures of the lower extremities incurred in the accident which caused the spinal cord injury; Group III contained eight patients with eight fractures of the upper extremities incurred after the spinal cord injury; Group IV contained eighty-one patients with 119 fractures incurred after the spinal cord injury. Within this group the most common fracture in forty patients was an impacted supracondylar fracture of the distal femur which was termed “the paraplegic fracture.” 3. 3. Groups I and II comprise 44 per cent; Group III, 4 per cent and Group IV, 52 per cent of all patients. 4. 4. In Group IV fractures occurred more often with lower than with upper motor neuron lesions and more frequently with complete than incomplete cord or cauda injuries. The significance of these findings is discussed. 5. 5. Fractures of the 156 patients occurred most frequently in the age group of twenty-one to forty years. 6. 6. Open fractures occurred in 41 per cent in Group I, 18 per cent in Group II, 0 per cent in Group III and 1.7 per cent in Group IV; there were sufficient battle injuries in Groups I and II to explain this distribution of open fractures. 7. 7. The magnitude of the trauma was sufficient in Groups I to III to cause the fracture. On the contrary, 44 per cent of the patients in Group IV sustained fractures of the lower extremities with so minimal an amount of trauma, that the fracture was called “pathologic.” 8. 8. Renal calculosis among 156 patients with fractures was twice as high (14.1 per cent) as that in 1,485 patients without fractures (6.8 per cent). Stones formed in patients with lower motor neuron lesions more often than in those with upper motor neuron lesions. 9. 9. The same fundamental principles of fracture management were applicable in patients with functional extremities and cord damage as in those without cord damage. However, another type of fracture therapy should be applied in patients whose cord injury has rendered their extremities useless so that alignment is only of secondary importance. This therapy consists of “pillow-splints,” sandbag splints and placing on Foster bed in preference to casts which carry the danger of pressure sores or operative procedures which may lead to more complications in the paraplegic than in the neurologically normal individual. 10. 10. “Exuberant” callus was most frequently encountered in Group IV, less in Group II and was inversely related to the degree of alignment. 11. 11. Nonunion occurred in 16 per cent of the patients in Group I, in 5.7 per cent in Group II, in 12.5 per cent in Group III and in 3.7 per cent in Group IV. The potential role played by the interruption of the sympathetic outflow has been discussed. 12. 12. Braces of the lower extremities may be an important factor in preventing these fractures since none of our patients was thus protected at the time of fracture.

Investigation of a simplified artificial lighting programme to improve the fertility of sows in commercial piggeries

Two artificial lighting regimens were studied in a commercial unit of 800 sows. The aim was to develop a simplified lighting regimen to overdrive the effects of season on reproduction....