Informed consent in surgical research.
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General Surgery↗
Biomedical subjects
C D Johnson
Publications and source records attributed to C D Johnson.
Place of routine operative cholangiography at cholecystectomy.
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Bile Ducts↗
Plasma amylase estimation in recurrent abdominal pain in children.
In a prospective study of 50 children who were admitted on more than one occasion with undiagnosed abdominal pain, the serum amylase was found to be normal in every case. One case of acute pancreatitis was diagnosed in over 8000 admissions. Serum amylase estimation did not contribute to the management of children with recurrent abdominal pain, and acute pancreatitis is so rare that routine amylase estimations cannot be recommended in paediatric surgical practice.
Abdominal Pain↗
Invasive aspergillosis of the sphenoethmoidal sinuses in an immunocompetent host.
Fungal infections of the nose and paranasal sinuses are uncommon; Aspergillus is the most frequently isolated fungal pathogen. Invasive aspergillosis is commonly seen as an opportunistic infection in the immunocomprised, debilitated host. Whereas fulminant infection in the otherwise healthy patient is rare, in the immunocompetent host with persistent signs and symptoms of sinusitis despite appropriate medical management, aspergillosis should be considered. Treatment of paranasal sinus aspergillosis requires correction of immunologic deficits, if possible; aggressive surgical debridement to provide adequate drainage and aeration of the sinuses; and adjunctive antifungal chemotherapy. The authors present an unusual case of invasive aspergillosis of the paranasal sinuses in an immunocompetent host.
Adult↗
Intra-arterial thrombolysis should be the initial treatment of the acutely ischaemic lower limb.
We review and discuss the initial management of acute arterial occlusion. Thrombolytic therapy has been available for over 25 years but has failed to gain universal acceptance in the initial management of this condition. Support for the use of initial thrombolytic therapy in all patients is based on the following arguments. It may be difficult to distinguish clinically between an embolic or a thrombotic occlusion, and inappropriate surgery in the latter may have disastrous consequences. Therefore, arteriography should be performed in all patients. It is then easy to place a catheter for thrombolytic therapy. This therapy allows treatment of associated medical problems before definitive surgery, and it may enable a more accurate assessment of the obstruction and better planning of surgery after dissolution of some of the occluding thrombus. Recanalisation may make reconstructive surgery easier and, finally, the results with initial thrombolysis are better than with surgery alone. The case against the motion is that expeditious surgery is in the patient's best interest, particularly in embolus, and when there is ischaemic damage to the limb. Furthermore, the reports of thrombolysis currently available are uncontrolled and do not demonstrate convincingly that the results of thrombolytic therapy are superior to surgery alone.
Acute Disease↗
Surgical excision alone is adequate treatment for primary colorectal cancer.
This debate examines the arguments for and against the proposal that surgical excision alone is adequate treatment for primary colorectal cancer. The arguments in favour are that the results from curative surgery are excellent and that despite many trials of adjuvant chemotherapy, radiotherapy and immunotherapy, the proposed benefits remain unproven. Recent improvements in surgical technique, particularly for dissection of rectal tumours, have shown the way towards further improvement using surgery alone, and it is clear from a national survey that technical factors related to individual surgeons play a large part in determining recurrence rates. With optimum primary treatment, surgical excision alone is indeed adequate therapy. The arguments against this motion are that although a considerable number of patients do survive with surgery, the 5-year survival rate is poor when there is extensive local invasion or lymphatic metastases. Surgery starts therapy by reducing the tumour load, but other modalities are required to destroy the cells which might subsequently develop into metastases. Trial results with adjuvant therapy are encouraging, although many contain too few patients. We cannot be content with the results of treatment of Dukes' Stage B and C tumours; more trials are needed to determine the best treatment for these patients.
Antineoplastic Combined Chemotherapy Protocols↗
GABA-immunoreactive neurons in the nematode Ascaris.
gamma-Aminobutyric acid (GABA) immunoreactive neurons in the cephalic, somatic, and caudal regions of the Ascaris nervous system were visualized with serial section and whole-mount GABA immunocytochemistry. In the ventral and dorsal nerve cords, GABA-like immunoreactivity (GLIR) is localized to the neurites and cell bodies of identified inhibitory motor neurons and to two fibers, one in each cord, that arise from neurons in the nerve ring. GLIR is absent from identified excitatory motor neurons and from ventral cord interneurons. In neurons containing GLIR, immunoreactivity was present throughout the cell, which argues against an exclusive localization of GABA at conventional synapses. In whole mounts, ten GABA-immunoreactive neurons were present in the cephalic region. These include four nerve ring-associated cells (the RME-like cells), two bilaterally symmetrical pairs of lateral ganglia neurons (the amphid-GABA and deirid-GABA cells) and one bilaterally symmetrical pair of ventral ganglion cells (the VG-GABA cells). In sections, the RME-like cells and the VG-GABA cells were consistently stained through the cephalic region. However, anti-GABA staining of the lateral ganglia cells in sections was light, thus suggesting that they contain less GLIR than the other more intensely stained GABA-immunoreactive neurons. In the caudal region, a single GABA-immunoreactive neuron was present in the dorsal rectal ganglion. Our data suggest that these ten cephalic neurons, and a single dorsal rectal ganglion neuron, use GABA as a neurotransmitter.
Animals↗
Specialization in general surgery.
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Education, Medical, Graduate↗
Prevention of postoperative renal dysfunction in patients with obstructive jaundice: a multicentre study of bile salts and lactulose.
The role of preoperative lactulose and bile salts in the prevention of postoperative renal failure in patients with obstructive jaundice has been evaluated in a prospective randomized trial. One hundred and two patients undergoing surgery for obstructive jaundice (bilirubin greater than 100 mumols/l) were randomized into three groups: those receiving preoperative oral lactulose (n = 35), those receiving oral sodium deoxycholate (n = 32) and a control group of patients receiving no specific treatment (n = 35). All patients received intravenous fluids commencing the night before surgery. One patient in the control group and none in the treatment groups developed postoperative renal failure. Postoperative deterioration of renal function in patients with normal preoperative function was significantly more common in the control group than in the treatment groups (chi 2 = 8.1, d.f. = 2, P less than 0.02). The incidence of renal failure and impairment was lower in this control group than that reported in previous studies. This may be due to the introduction of adequate preoperative hydration. Additional protection occurs by the preoperative administration of either lactulose or sodium deoxycholate.
Acute Kidney Injury↗
Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains.
We reviewed our recent experience with management of 23 consecutive patients with acute necrotizing pancreatitis. All patients had documented necrotizing pancreatitis with parenchymal or peripancreatic necrosis. Our method of treatment has evolved from our previous approach of controlled open lesser sac drainage (marsupialization) to staged necrosectomy/debridement with delayed primary closure over drains. With this latter approach, hospital mortality was 4 of 23 patients (17 per cent), but significant morbidity still occurred in 12 of 23 patients (52 per cent). However, recurrent intra-abdominal abscess before discharge occurred in only one patient. We believe that this operative approach toward the severely ill patient with acute necrotizing pancreatitis who requires operative intervention will minimize the occurrence of intra-abdominal sepsis.
Acute Disease↗
Animal experimentation.
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Animal Welfare↗
The cephalogastric phase of the pancreatic response to food in the dog.
We studied post-meal pancreatic secretion and gastrin release in conscious dogs with duodenal Thomas cannulas. Normal dogs were tested in physiological conditions and with an i.v. infusion of atropine 20 micrograms/kg/h or secretin 0.5 CU/kg/h. The responses were also studied after antral and truncal vagotomy. In the early phase (0-20 min) of the response, before gastric emptying started, antral vagotomy reduced fluid and protein outputs, and truncal vagotomy reduced them still more. Atropine reduced only the protein response. Gastrin release reached a peak after 20-25 min. After antral and truncal vagotomy, gastrin release was reduced within 10 min after the meal. Late-phase (greater than 20 min) pancreatic secretion depended on the presence of chyme in the duodenum. The effects of atropine and antral vagotomy in the cephalogastric phase could be explained by antropancreatic reflexes stimulating fluid secretion (atropine-resistant pathway) and protein output (atropine-sensitive pathway).
Animals↗
Complicated Crohn's disease in the over 70 age group.
Crohn's disease is rare and is infrequently reported in the over 70 age group. Such patients often present urgently with acute complications of Crohn's disease. Seven patients with Crohn's disease all presented with complications. The diagnosis was initially unsuspected in these patients, and in 3 cases coexisting diverticular disease led to a delay in diagnosis. Three patients with ileocolic disease presented with peritonitis or bowel obstruction. In a further 2 patients a diagnosis of Crohn's disease was not made until after histological examination of resected tissue. It is likely that, as the population ages, more elderly patients will present with complicated Crohn's disease. Surgeons should be aware of this possibility to allow appropriate management of this condition, which generally has a favourable prognosis in this age group.
Aged↗
National statistics for diet, alcohol consumption, and chronic pancreatitis in England and Wales, 1960-88.
This study compared national statistics for consumption of alcohol and dietary intake with the numbers of cases of chronic pancreatitis as recorded in a 10% sample of all hospital discharges (Hospital In-Patient Enquiry) and with the annual number of deaths. Hospital discharges for chronic pancreatitis became more common throughout the study period (7.0-11.1 discharges per million per year in 1960-4; 26.8-32.4 discharges per million per year in 1980-4). The most rapid increase was from 1975-82. The rate increased fourfold in men, but only twofold in women, and the increase began earlier in men (1976) than in women (1980). Annual deaths from chronic pancreatitis also rose progressively (46-70 in 1960-4; 64-91 in 1985-8). The annual per capita consumption of alcohol rose from 4.0-4.9 litres in 1960-4 to a peak of 7.7 litres in 1979; it has been relatively stable (6.9-7.6 litres) in 1980-8. Total dietary energy intake assessed in the National Food Survey fell progressively, with a correspondingly greater fall in carbohydrate intake, so that the energy contributions of fat and protein rose slightly, although total fat and protein consumption fell from 1965-9 to 1980-4. These changes were small in relation to total dietary intake and seemed to be unrelated to the changes in the numbers of chronic pancreatitis discharges. There was a close correlation (r = 0.96) between per capita alcohol consumption and the numbers of discharges with chronic pancreatitis six years later. This suggests that epidemiological trends in chronic pancreatitis in the United Kingdom might be predictable from population based statistics of alcohol consumption.
Alcohol Drinking↗
T1-weighted snapshot gradient-echo MR imaging of the abdomen.
Magnetization-prepared ultrashort-repetition-time (snapshot) gradient-echo imaging is a technique of magnetic resonance (MR) imaging with many potential applications. In the application of this technique to abdominal imaging, the effects on contrast of phase-encoding order, resolution, preparation-phase inversion time, and data-acquisition flip angle were predicted and then demonstrated with images obtained in examinations of 22 patients. In the analysis of 36 liver lesions, snapshot images were compared with corresponding T1-weighted spin-echo images on the basis of signal-to-noise ratio (S/N) of liver and contrast-to-noise ratio (C/N) between liver and lesion. Snapshot MR imaging produced abdominal images with 192 (or 256) x 256 resolution, negligible motion artifact, and C/N 1.29 times (+/- 0.48) higher than that in T1-weighted spin-echo imaging. Acquisition times were 13 seconds or less, short enough for imaging during suspended respiration. Also, use of a phased-array multicoil further improves the S/N in snapshot images without acquisition-time penalty.
Abdomen↗
Comparison of the effects of hydrochlorothiazide and furosemide on lithium disposition.
OBJECTIVE: This study examined the interaction between lithium and diuretics, comparing both the pharmacokinetic and the pharmacodynamic variable of hydrochlorothiazide, furosemide, and placebo. METHOD: The study, which took place in an outpatient research clinic of a university hospital, used a double-blind, placebo-controlled crossover design. The subjects were normal, healthy male volunteers who responded to recruitment announcements. Thirteen subjects entered and completed the study. All subjects took lithium, 300 mg b.i.d., for 6 weeks. Hydrochlorothiazide, 25 mg b.i.d.; furosemide, 20 mg b.i.d.; and placebo were given during weeks 2, 4, and 6 in a random order of assignment. Serum lithium levels and indices of diuretic activity were measured during each week. RESULTS: The subjects' serum lithium levels after 5 days of taking hydrochlorothiazide were significantly higher than after 5 days of taking furosemide and placebo. At the doses studied, hydrochlorothiazide was also more potent than furosemide in increasing plasma renin activity, increasing sodium excretion, and decreasing lithium excretion. CONCLUSIONS: The observed differences between diuretics in effects on serum lithium may have been due to differences in the potency of the diuretics at the doses studied as well as in the site of action of the diuretic effect. The results must be interpreted cautiously, however, because the effects were small and of questionable clinical significance, and the study used healthy volunteers and low doses of lithium instead of psychiatric patients and the usual therapeutic levels of lithium.
Adult↗
Recurrent pancreatitis in the presence of a visceral artery aneurysm.
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Acute Disease↗
CT of acute pancreatitis: correlation between lack of contrast enhancement and pancreatic necrosis.
This study was performed to determine if a correlation exists between pancreatic parenchymal enhancement or lack thereof on contrast-enhanced CT and surgical evidence of pancreatic necrosis. Accurate CT assessment of pancreatic vascular perfusion would be helpful in preoperative planning before pancreatic debridement and necrosectomy. The CT scans and medical records were blindly and retrospectively reviewed in 13 patients with the operative diagnosis of pancreatic necrosis. In all cases, CT examinations preceded surgery within 72 hr. Surgical and pathologic findings served as the gold standards for the diagnosis of pancreatic necrosis. Seven (54%) of 13 patients had a region or regions of parenchymal necrosis within the head, body, and/or tail of the pancreas seen during surgery. All seven of these patients had no pancreatic enhancement on CT in at least one region of the pancreas (CT sensitivity = 100%). In four of the seven, two regions were found to be necrotic at surgery, but only one of the two segments did not enhance on CT scans. In three of the seven patients, lack of contrast enhancement on CT (no enhancement of the pancreatic head and body in two patients and throughout the gland in another) correlated with necrosis in the same regions at surgery. The remaining six (46%) patients, who had peripancreatic or small, focal, and/or superficial areas of pancreatic necrosis at surgery, had normal pancreatic enhancement on CT. Our results show that regions of pancreatic necrosis found surgically correlate with lack of enhancement of pancreatic parenchyma on CT. Peripancreatic necrosis and minor areas of focal or superficial parenchymal necrosis were not detected on CT.
Acute Disease↗