Pseudomembranous colitis presenting as an isolated colonic stricture.
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Aged↗
Biomedical subjects
C Elton
Publications and source records attributed to C Elton.
Accuracy of computed tomography in the detection of blunt bowel and mesenteric injuries.
BACKGROUND: There are conflicting views on the accuracy of computed tomography (CT) findings in patients with bowel and mesenteric injuries (BMIs) following blunt abdominal trauma. The aim of the present study was to assess the accuracy of the CT report during a trauma call. METHODS: Ninety-eight patients underwent preoperative abdominal spiral CT and subsequent laparotomy following blunt trauma between January 1996 and March 2001 at a level I trauma centre. The immediate results of the scans were reported by the on-call radiology registrar and written in the medical notes by the trauma team leader. Seventy of the 98 preoperative abdominal CT scans were retrieved from the radiology department and reported by two consultant radiologists with a special interest in trauma radiology. RESULTS: The sensitivity and specificity of the 70 expert CT reports were 80 (95 per cent confidence interval (c.i.) 66 to 94) and 78 (95 per cent c.i. 65 to 90) per cent respectively for diagnosing a BMI. The sensitivity and specificity of the immediate CT reports were 93 (95 per cent c.i. 84 to 100) and 71 (95 per cent c.i. 60 to 83) per cent respectively. CONCLUSION: Spiral CT is highly sensitive for detecting a BMI following blunt abdominal trauma. This sensitivity is maintained when the scan is reported by a radiology registrar.
Abdominal Injuries↗
Spontaneous rupture of utero-ovarian vessels in labour--a rare case of obstetric haemoperitoneum.
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Adult↗
Mortality, morbidity and functional outcome after ileorectal anastomosis.
BACKGROUND: Total colectomy with an ileorectal anastomosis (IRA) is a commonly performed operation. Postoperative mortality and morbidity are reported to be low and functional outcome is generally rated as good to excellent. The aim of this study was to review postoperative mortality, morbidity and functional results in an effort to identify risk factors predictive of a poor outcome. METHODS: Some 215 patients (118 women and 97 men) with a median age of 33 (interquartile range (i.q.r.) 25-47) years underwent an IRA between November 1990 and December 1999. Median follow-up was 2 years 9 months (i.q.r. 1-5 years). The clinical notes of these patients were reviewed retrospectively to analyse the postoperative course, bowel function and long-term clinical outcome. RESULTS: The indications for surgery included familial adenomatous polyposis (52.1 per cent), Crohn's disease (14.4 per cent), functional bowel disorder (14.4 per cent), ulcerative colitis (8.4 per cent) and colonic carcinoma (4.7 per cent). The overall 30-day mortality and morbidity rates were 0.9 and 26.0 per cent respectively. This included anastomotic leak (6.5 per cent), small bowel obstruction (14.4 per cent), fistula (2.8 per cent) and anastomotic stricture (1.4 per cent). The incidence of fistula and anastomotic stricture was significantly higher in Crohn's disease (P < 0.001 and P = 0.005 respectively). Only 16 of 31 patients with Crohn's disease had a functioning IRA at long-term follow-up. Median stool frequency was 3 (i.q.r. 3-5) per day one year following surgery and did not change with longer follow-up. CONCLUSION: Mortality and morbidity rates following IRA are low. Postoperative fistula and anastomotic stricture are more common in patients with Crohn's disease, approximately half of whom will eventually need a permanent ileostomy. Long-term bowel function for all groups is satisfactory.
Adult↗
The pathophysiology and management of bowel and mesenteric injuries due to blunt trauma.
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Humans↗
Intra-abdominal gastrointestinal tract injuries following blunt trauma: the experience of an Australian trauma centre.
AIMS: The aim of the study was to use the extensive experience of an Australian Level I trauma centre to develop guidelines for diagnosis and management of significant gastrointestinal tract injuries (GITIs). METHODS: This was a retrospective study of 74 patients admitted to Westmead Hospital between 1985 and 1996 who had sustained major gastrointestinal tract (GIT) injuries following blunt trauma. The patients were identified from the trauma unit database. Clinical information was retrieved from the database and augmented by a review of the medical records. RESULTS: Motor vehicle accidents were responsible for 55 (92%) admissions. Laparotomy was performed as a result of a positive diagnostic peritoneal lavage in 26 (35.1%) patients, abdominal signs in 20 (27%), diagnostic findings on computed tomography in 19 (25.7%), haemodynamic instability in eight (10.8%) and a positive contrast study in one (1.4%) patient. There was a total of 95 injuries: one gastric (1.1%), eight duodenal (8.4%), 64 small bowel (67.3%), two appendiceal (2.1%), 19 colonic (20%) and one rectal (1.1%). Thirty day mortality was 23% (17 patients). Seven (9.5%) patients died within 24h of injury, three (4.1%) of which were directly related to the GIT. Ten (13.5%) patients died within 2 weeks of admission, three (4.1%) of which were attributable to the GIT. Thirty day GIT morbidity was 29.7% (22 patients). The development of GIT morbidity was significantly related to a delay to laparotomy of more than 24h (P=0.036) and tachycardia on presentation (P=0.023). Associated injuries, injury severity scores (ISS) and age did not significantly impact on GITI related morbidity and mortality. DISCUSSION: Major GITIs are associated with a high mortality due to the severity and complexity of associated injuries. Morbidity from GITIs correlates to delays in diagnosis and management.
Accidents, Traffic↗
Repair of concomitant inguinal and femoral hernias under local anaesthesia.
We describe the case of a 91-year-old patient with small bowel obstruction due to an obstructed groin hernia. It was decided to repair the hernia under local anaesthesia and sedation because of the patient's age and medical condition. At surgery, concomitant inguinal and femoral hernias were found and repaired. We discuss the technique of repairing groin hernias under local anaesthesia, especially in the elderly, and the previously reported incidence of concomitant hernias.
Aged↗
Initial study to assess the effects of topical glyceryl trinitrate for pain after haemorrhoidectomy.
BACKGROUND: Postoperative pain remains the most dreaded part of haemorrhoidectomy in the minds of both patients and doctors. It may delay patient discharge, recovery, and return to work. Glyceryl trinitrate has been used successfully in the treatment of anal fissures. We investigated its topical use in the management of pain after haemorrhoidectomy. METHOD: Twenty patients were entered into a double-blind trial and randomised into two groups. Group A (n = 10) applied glyceryl trinitrate ointment (0.2% twice daily) to the perianal area following surgery, and Group B applied a placebo ointment. They applied the ointment for up to 42 days after surgery, or until they felt it necessary to stop the treatment. Patients scored their daily anal pain using a visual analogue scale. Six weeks after surgery, patients were reviewed by an independent observer. RESULTS: The total pain score was calculated for each patient. The median score for Group A was 50.65; the median score for Group B was 73.50. There was no significant difference in pain scores between both groups, even when aberrant results were ignored. 20% of patients in each group complained that the ointment caused headache. CONCLUSION: The results suggest that topical glyceryl trinitrate ointment may not significantly reduce postoperative pain following haemorrhoidectomy. Meta-analysis would provide a more definitive answer.
Administration, Topical↗
Unusual site of hydatid disease.
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Adult↗
Pharyngogastric colonic interposition for total oesophageal occlusion in epidermolysis bullosa.
Epidermolysis bullosa comprises a group of rare heritable disorders, characterized by blistering of skin and other epithelial lined structures following minor trauma. In the oesophagus, trauma from food boluses leads to bullae, ulceration and scarring, with formation of strictures. Oesophageal strictures are usually managed with balloon dilatation. We describe a case of a 19-year-old woman whose oesophageal stricture did not respond to balloon dilatation. She underwent a substernal colon interposition between the pharynx and stomach. The surgery included cervical, thoracic and abdominal approaches, with involvement of three specialist surgeons. Three months after surgery, the patient reported to be swallowing with little difficulty. Because of the high risk of morbidity and mortality associated with this surgery, we recommended that the patient should be managed in a specialist centre, with availability of intensive care facilities and the possibility of providing a multidisciplinary approach during surgery.
Adult↗
Initial experience of intramammary prostheses in breast conservation surgery.
AIMS: We assessed the cosmetic and psychological effects of prosthetic intramammary breast reconstruction on women undergoing complete local excision for breast cancer. METHODS: Twenty-two women (mean age 54) underwent insertion of a Nagor silicone prosthesis into the breast cavity immediately following complete local excision. Following surgery, patients were assessed (range: 6 weeks to 1 year) by a postal questionnaire and independent photographs. RESULTS: Eighteen out of twenty-two (81.8%) women completed and returned the questionnaire, and 14 out of 22 (63.6%) women were photographed. Thirteen out of eighteen (72.2%) women were either satisfied or very satisfied with the prosthesis, and 10 had experienced no problems since surgery. From the group of patients who were either satisfied or very satisfied, the total photograph assessment score was 135 out of a possible maximum score of 165. Five patients (27.8%) were very dissatisfied and requested removal of the prosthesis. CONCLUSIONS: When performing a complete local excision for carcinoma of the breast, insertion of an intracavity prosthesis should be considered when this would significantly improve the cosmetic outcome.
Breast Implantation↗
Partial cardiomyectomy--an animal model of gastro-oesophageal reflux.
Various procedures have been adopted to provide experimental models of gastro-oesophageal reflux. Although some procedures have produced better results than others, previous literature does not assert that experimental gastro-oesophageal reflux can be produced reliably in all animals. This study attempts to compare two procedures to produce a working model of gastro-oesophageal reflux in the rabbit: (i) cardiomyotomy and (ii) cardiomyectomy. The animals underwent intraoesophageal pH monitoring one week before and one week following surgery. The mean changes in % reflux time from preoperative to one week postoperative were compared. The cardiomyotomy group did not demonstrate significant gastro-oesophageal reflux (p > 0.2, p < 0.5), the mean change in % reflux time was 10.5 +/- 14.11%, whereas the cardiomyectomy group did demonstrate significant reflux (p < 0.001) with a mean change in % reflux time of 22.35 +/- 3.05%. A further study investigated the cardiomyectomy procedure in ten rabbits. Animals underwent preoperative, one-week and four-week postoperative intraoesophageal manometry and pH studies. The mean change in values from preoperative to four weeks postoperative were compared. There was a significant increase in mean % reflux time from a preoperative value of 3.05 +/- 2.29% to 42.08 +/- 12.05% at four weeks after surgery (p < 0.001). There was also a significant decrease in mean basal LOS pressure from a preoperative value of 15.00 +/- 5.49 mmHg to 4.45 +/- 1.90 mmHg four weeks following surgery (p < 0.001). This study showed that cardiomyectomy alone produces effective gastro-oesophageal reflux in the rabbit, and thus provides an experimental model to test the effectiveness of antireflux procedures.
Animals↗
Intercostal muscles in the rabbit: surgical anatomy and flap construction.
Demos and colleagues (1967) obtained good antireflux results from transposing an intercostal myoneurovascular pedicle around the gastro-oesophageal junction in dogs. An intact neurovascular supply is essential for the viability of a muscle flap. The aim of this study was to delineate the nerve and arterial supply to the left 11th intercostal muscle in the rabbit and to assess whether this muscle could be mobilized as a viable flap. The innervation of the muscle was studied using the methods of gross dissection in cadaveric specimens, and histological staining techniques. The arterial supply was studied using gross dissection, and aortography. In three non-recovery experiments, intercostal muscle was transposed around the gastro-oesophageal junction. The distal motor latency was recorded after electrical stimulation of the intercostal wraps. Gross dissection, histological staining techniques, and aortography showed that the left 11th intercostal muscle group in the rabbit is supplied by segmental vein, artery and nerve, running between external and internal intercostal muscles. Aortography and electrical stimulation demonstrated that the muscle group could be mobilized with an intact neurovascular supply. The left 11th intercostal muscle group has potential as a viable muscle flap for use in surgical procedures within the upper abdomen.
Animals↗
Evaluation of an intercostal myoneurovascular transposition as a lower esophageal neosphincter.
Previous work has shown promising results for an intercostal myoneurovascular transposition in the prevention of gastroesophageal reflux following esophagectomy. A first study evaluated the intercostal transposition procedure and compared it with the Nissen fundoplication using a rabbit model of gastroesophageal reflux. Group A underwent partial cardiomyectomy to produce gastroesophageal reflux. Group B underwent cardiomyectomy, and intercostal transposition around the gastric cardia. Group C underwent Nissen fundoplication and cardiomyectomy. All animals had preoperative and 1-week and 4-week postoperative intraesophageal manometry and pH studies. At the 4-week interval, macroscopic and microscopic esophageal histopathology was assessed. The mean change in values from preoperative to 4 weeks postoperative were compared. Group B showed significantly lower reflux time (P < 0.001) and grade of esophagitis (P < 0.005), and significantly greater average lower esophageal sphincter basal pressure (P < 0.001) and abdominal length of sphincter (P < 0.01) when compared with Group A. There was no statistical significance between the results of Group B and Group C. A second study assessed whether reflux was prevented by an anatomical structure, or a muscle flap acting in a physiological manner. At autopsy, the ten rabbits from Group B underwent removal of the intercostal wrap, and the right 11th intercostal muscle as a control. There was a significant difference in the quantity of viable muscle tissue between muscle flaps and controls (P < 0.001), the muscle flaps having generally little viable muscle left 4 weeks after surgery. A further experiment to evaluate this result found that loss of muscle tissue was due to excessive stretch and not due to damage of the intercostal neurovascular bundle during mobilization. Two groups of animals underwent electromyographic studies. The first group underwent recordings of all intercostal muscles. The second group underwent intercostal transposition around the gastric cardia, and insertion of recording electrodes into the muscle flap. The electromyographic activity of the muscle flap was recorded at 0, 2, and 4 weeks after surgery. The second group demonstrated activity in the muscle flaps simultaneous with diaphragmatic contractions. This activity, although much reduced, was still present 4 weeks after surgery. These studies showed that the intercostal transposition and Nissen fundoplication procedures are equally effective in preventing experimental gastroesophageal reflux. The antireflux properties of the intercostal transposition were possibly the result of anatomical buttressing of the gastroesophageal junction, and not due to a fully viable contracting muscle flap.
Animals↗
Laparoscopic appendicectomy: a trainee's perspective.
Minimally invasive surgery is rapidly becoming an integral part of general surgery. Many general surgeons have been trained to undertake laparoscopic cholecystectomy. It has been recommended that laparoscopic appendicectomy should be the training operation for junior surgeons. The aim of our study was to assess whether laparoscopic appendicectomy training can safely be introduced to junior surgeons in a district general hospital. During the 11 month study period, 27 laparoscopic and 38 open appendicectomies were performed. The median anaesthetic time was 80 min for laparoscopic and 52.5 min for open appendicectomies. Laparoscopic appendicectomies cost, on average, 618 pounds and open appendicectomies 770 pounds per case. The complication rate between the two procedures was equal. We therefore showed that laparoscopic appendicectomy by junior surgeons is both safe and cost-effective. Although the registrar did most of the laparoscopic appendicectomies, with resultant less operating for the SHO, laparoscopic appendicectomy provided the SHO with training in diagnostic laparoscopy and laparoscopic dissection. We conclude that basic laparoscopic training should be introduced early in surgical training, after which laparoscopic appendicectomy is a safe procedure for surgical trainees.
Adolescent↗
Ethanol-induced growth inhibition in embryonic chick brain is associated with changes in cytoplasmic cyclic AMP-dependent protein kinase regulatory subunit.
Several lines of research have suggested that ethanol-induced changes in the adenylate cyclase/protein kinase cascade may contribute to the growth retardation observed in infants exposed to ethanol in utero. Based on studies with an embryonic chick model, the data presented here suggest that chronic ethanol treatment significantly lowered the binding of cyclic AMP by protein kinase regulatory subunit (RII) and reduced the level of phosphorylation of RII by the endogenous cytoplasmic protein kinase catalytic subunit. Furthermore, ethanol treatment altered the phosphorylation of at least one other brain cytosolic protein (molecular weight = 62-65 kD).
Animals↗