Biomedical subjects
I G Martin
Publications and source records attributed to I G Martin.
Bile leakage following laparoscopic cholecystectomy.
Laparoscopic cholecystectomy (LC) is now the treatment of choice for gallstones, but there has been concern that bile leakage with LC is more frequent than after open cholecystectomy (OC). We have analyzed our experience of this complication with regard to both its incidence and management. From a consecutive series of 500 LC, in which both operative cholangiography and drainage of the gallbladder bed were routine, bile leakage was identified in ten patients (2%). There was no bile duct injury. Nine of the ten patients presented with bile in the drain within 24 h of operation and one patient presented 1 week after operation with a subphrenic collection. Of the ten patients, five settled spontaneously. Of the five remaining patients, two needed laparotomy--one for a subphrenic collection not responding to percutaneous drainage and one for biliary peritonitis. One patient was treated by relaparoscopy and suture of a duct of Luschka and one patient had successful percutaneous drainage of an infected collection; the fifth patient who presented with a late subphrenic collection of bile was shown at endoscopic retrograde cholangiopancreatography (ERCP) to have a cystic duct stump leak and was treated with an endoscopic stent. Bile leakage is seen more frequently after LC than OC for reasons that are currently unclear. We believe that the use of routine gallbladder bed drainage is justified for this reason alone. The majority of bile leaks settle either spontaneously or with minimally invasive intervention.
Fundus-first laparoscopic cholecystectomy.
Removal of the gallbladder with commencement of dissection at the fundus is well recognized as a safe technique during difficult "open" cholecystectomy because it minimizes the risks of damage to the structures in or around Calot's triangle. We report here the routine employment of liver retractors and fundus-first dissection during laparoscopic cholecystectomy (LC) as an alternative to techniques previously described. Retraction of the liver and "fundus-first" dissection was used in 53 patients who underwent laparoscopic cholecytectomy. There were 16 male and 37 female patients. Seven were operations performed during an acute admission and 20 had moderate or severe adhesions involving the gallbladder. Thirteen patients had a preexisting abdominal incision. The procedure was successful in 52 patients (98%), but in one patient it was converted to open operation because of dense adhesions. Median duration of operation was 90 min (range 35-240 min). There was no mortality and two complications (persistent right upper quadrant pain for 2 weeks after operation and bile leakage from the gallbladder bed). The facility to retract the liver and carry out a fundus-first dissection extends techniques developed for "open" surgery into the laparoscopic arena. It offers the surgeon the safety and versatility during laparoscopic cholecystectomy that it confers during conventional open surgery.
Why do some patients experience poor functional results after anterior resection of the rectum for carcinoma?
PURPOSE: The aim of this study was to examine the dynamic inter-relationship of the anal sphincter, residual rectum, and neorectum after low anterior resection for rectal carcinoma. METHODS: Seventy-three patients underwent laboratory tests of anorectal function a median of ten (range 1-100) months after operation. All patients completed quality of life questionnaires and had the level of their anastomoses determined by rigid sigmoidoscopy. Forty-four patients (60 percent) had some form of disturbance of bowel function, which was classified as "poor" function if bowel frequency was four or more in 24 hours and if there was also either fecal leakage or urgency of defecation. Manometric data were analyzed using stepwise logistic regression analysis. RESULTS: Only two factors were found to be significantly and independently associated with poor bowel function, namely, the pressure recorded in the upper part of the anal sphincter in response to distention of the neorectum (15 (7-24) cm of water in patients with poor function vs. 29 (15-58) cm in patients with good function; P < 0.005) and the level of the anastomosis above the anal sphincteric high pressure zone (2.5 (2-3.5) cm in patients with poor function vs. 6 (4-12) cm in patients with good function; P < 0.005). CONCLUSION: Continence after anterior resection is related to an appropriate "sampling" response in the anal sphincter to activity within the neorectum. This in turn, is directly related to length of the residual rectum, which is, therefore, of crucial importance to function.
Helicobacter pylori and recurrent ulceration after highly selective vagotomy.
OBJECTIVE: To examine the relationship between Helicobacter pylori and recurrent ulceration after highly selective vagotomy (HSV). SETTING: Academic Department of Surgery at a teaching hospital. PATIENTS: Thirty-eight patients (26 men and 12 women) were studied 2-21 years after HSV. Seven patients had recurrent ulceration. Each patient underwent tests of acid secretion before and 1 week after HSV together with later endoscopic examination of the stomach and duodenum. Four biopsies were taken from the duodenum and gastric antrum. RESULTS: There was no statistical difference in acid output between patients with and those without recurrent ulceration (peak acid output 46.9 versus 55.8 mmol/h, respectively; not significant) before operation. After operation, insulin stimulated acid secretion was significantly higher in patients who later developed recurrent ulceration (0.26 versus 4.1 mmol/h, respectively; P < 0.02). The endoscopic biopsies were tested for H. pylori infection (90 versus 86% for patients without and those with recurrent ulceration, respectively; not significant), gastric metaplasia within the duodenum (23 versus 14% for patients without and those with recurrent ulceration, respectively; not significant), antral gastritis (86 versus 71% for patients without and those with recurrent ulceration, respectively; not significant) and antral intestinal metaplasia (52 versus 43% for those without and those with recurrent ulceration, respectively; not significant). CONCLUSION: H. pylori infection is not influenced by HSV and ulcer recurrence is determined by the completeness of vagotomy rather than by H. pylori status.
Role of circumferential margin involvement in the local recurrence of rectal cancer.
Local recurrence after resection for rectal cancer remains common despite growing acceptance that inadequate local excision may be implicated. In a prospective study of 190 patients with rectal cancer, we examined the circumferential margin of excision of resected specimens for tumour presence, to examine its frequency and its relation to subsequent local recurrence. Tumour involvement of the circumferential margin was seen in 25% (35/141) of specimens for which the surgeon thought the resection was potentially curative, and in 36% (69/190) of all cases. After a median 5 years' follow-up (range 3.0-7.7 years), the frequency of local recurrence after potentially curative resection was 25% (95% CI 18-33%). The frequency of local recurrence was significantly higher for patients who had had tumour involvement of the circumferential margin than for those without such involvement (78 [95% CI 62-94] vs 10 [4-16]%). By Cox's regression analysis tumour involvement of the circumferential margin independently influenced both local recurrence (hazard ratio = 12.2 [4.4-34.6]) and survival (3.2 [1.6-6.53]). These results show the importance of wide local excision during resection for rectal cancer, and the need for routine assessment of the circumferential margin to assess prognosis.
Immunoproliferative small intestinal disease: Mediterranean lymphoma and alpha heavy chain disease.
Gastrointestinal lymphoma, uncommon in the West, is far more prevalent in developing countries where it falls into two groups: 'Western'-type lymphomas, similar to those seen in developed countries, and the so-called Mediterranean-type lymphoma. It is now accepted that Mediterranean lymphoma represents, in the majority if not in all cases, the late stage of alpha heavy chain disease (alpha-HCD). This disease is characterized by abnormal secretion of an immunoglobulin fragment; alpha-HCD and Mediterranean lymphoma constitute two ends of a spectrum of pathology now classified as immunoproliferative small intestinal disease (IPSID). IPSID is associated predominantly with poor socioeconomic conditions; patients present with progressive malabsorption in the second and third decades of life. Diagnosis is established by small bowel biopsy, with or without high serum levels of the alpha heavy chain protein. Treatment consists of an initial staging laparotomy, with debulking of lymphomatous deposits if appropriate, followed by chemotherapy or radiotherapy. Overall prognosis is poor but the recent use of doxorubicin-based chemotherapy offers some hope for the future.
Goseki grading in gastric cancer: comparison with existing systems of grading and its reproducibility.
A novel grading method which utilises intra-cellular mucin content and tubular differentiation (the Goseki grade) has been applied to 181 gastric cancers removed in potentially curative resections, and compared to conventional tumour grading (well, moderate, poor differentiation) and the Lauren, Ming and WHO classifications. The Goseki grade is significantly related to patient survival and, unlike the existing approaches, remains so after allowing for tumour stage in multivariate analyses. Potential relationships between the Goseki grade, direct tumour spread, lymph node involvement and survival have been investigated. Prognosis is particularly related to mucin content; 55% of patients with mucin-rich tumours dying within 5 years compared to 29% of those with mucin-poor cancers. A smaller proportion of mucin-poor cancers show lymph node involvement (N1 and N2) than mucin-rich tumours (52% v. 73%) and a smaller proportion of cancers showing good tubular differentiation exhibit widespread lymph node involvement (N2) than tubule-poor cancers (11% v. 28%). However, these differences did not achieve statistical significance. When compared to the existing classification or grading methods, the Goseki grade was found to be highly significantly correlated with the WHO and Lauren classifications and to conventional grading, but not to the Ming classification. These inter-relations are largely dependent upon tubular differentiation. There was no relationship between Goseki grade and the lymphocytic response around the tumour margin. Inter-observer agreement on the WHO type and the Lauren, Ming and Goseki grading methods was tested on 70 randomly selected cases.(ABSTRACT TRUNCATED AT 250 WORDS)
Goseki histological grading of gastric cancer is an important predictor of outcome.
TNM (tumour, node, metastases) staging has thus far been the most important guide to prognosis in patients with gastric cancer. Histological grading, in contrast, has not provided any additional information. Recently a novel grading system based on tubular differentiation and mucus production has been proposed, which was correlated with patterns of tumour spread found at necropsy. This study set out to assess its value as a determinant of survival after gastric resection. In a consecutive series of 211 patients who had potentially curative resection for gastric cancer, five histological grading systems were assessed: the Lauren type, the WHO type, degree of differentiation, the type of tumour border, and the lymphocytic response to the tumour and compared with the Goseki grading (I-IV). When T and N stage were taken into account, using Cox's proportional hazards model, only the Goseki grading added further to the ability to predict survival. The proportional hazards ratios were: node negative v node positive 6.5 T1 v T3 2.45; Goseki I v Goseki IV 3.1. Five year survival of patients with mucus rich (Goseki II and IV) T3 tumours was significantly worse than that of patients with mucus poor (Goseki I and III) T3 tumours (18% v 53%, p < 0.003). Goseki grading identifies subgroups of patients with a poorer prognosis than is predicted by TNM staging alone. It could prove useful in the selection of patients for adjuvant therapy after potentially curative resection for gastric cancer.
Gastric cancer: a curable disease in Britain.
OBJECTIVE: To determine whether more vigorous efforts aimed at earlier diagnosis allied to radical surgical resection lead to improved survival of patients with gastric cancer. DESIGN: Prospective audit of all cases of gastric cancer treated during 1970-89. SETTING: Department of surgery, general hospital. SUBJECTS: 493 consecutive patients with gastric adenocarcinoma. MAIN OUTCOME MEASURES: Operative mortality, postoperative morbidity, and five year survival after radical potentially curative resection. RESULTS: 207 (42%) patients underwent potentially curative resection. The proportion of all patients in whom this was possible increased significantly (p < 0.01) from 31% in the first five year period to 53% in the last five year period. The proportion of patients who had early gastric cancer rose from 1% to 15% (p < 0.01) and stage I disease rose from 4% to 26% (p < 0.001). After potentially curative resection, mortality 30 days after operation was 6%. Operative mortality decreased from 9% in the 1970s to 5% in the 1980s. Likewise, the incidence of serious postoperative complications decreased from 33% in the 1970s to 17% in the 1980s (p < 0.01). Five year survival was 60% in patients who underwent curative resection, 98% in patients with early gastric cancer, and 93%, 69%, and 28% in stage I, II, and III disease respectively. By the late 1980s five year survival after operation was about 70%. CONCLUSIONS: These findings suggest that an increasing proportion of patients with gastric cancer could be diagnosed at a relatively early pathological stage when about two thirds are curable by means of radical surgery.
Minimally invasive treatment for common bile duct stones.
The impact of endoscopic surgery on the management of stones in the common bile duct (CBD) was studied. All patients with proven common duct stones managed by a single consultant during a 21-month period were included. Of a total of 60 patients, 48 were referred because of symptoms or signs of calculi in the CBD and 12 were found to have common duct stones although symptoms were related primarily to the gallbladder. Of the 48 patients referred with common duct stones, 41 (85 per cent) were successfully treated by endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy (ES) (complications were cholangitis (one patient), mild acute pancreatitis (one), impacted retrieval basket (one)). Of the remaining seven patients, two underwent open exploration (one after failed laparoscopic exploration) and five had successful laparoscopic duct exploration. One patient underwent laparoscopic exploration of the CBD but subsequently died. Of the patients with primary gallbladder symptoms, eight underwent preoperative ES, one was treated by laparoscopic duct exploration, one by conversion to open operation and in two patients duct stones were removed at postoperative ERC. The overall mortality rate was 2 per cent and the incidence of complications 12 per cent. Open exploration of the CBD was performed in three patients (5 per cent). This experience suggests that open duct exploration will become increasingly infrequent and may be replaced by endoscopic surgery in the majority of patients.
High gastric juice ascorbic acid concentrations in members of a gastric cancer family.
Gastric juice ascorbic acid, total vitamin C, nitrite and N-nitroso-compound concentrations were determined in fasting gastric juice from four second generation members of a gastric cancer family, all of whom had Helicobacter pylori-associated chronic gastritis and intestinal metaplasia. Juice pH, nitrite and N-nitroso-compound concentrations were low. Juice ascorbate levels were comparable to those found in subjects with normal histology. The findings are contrary to our previous experience with juice ascorbate in H. pylori gastritis.
Laparoscopic cholecystectomy as a routine procedure for gallstones: results of an 'all-comers' policy.
A total of 165 consecutive patients with gallstones were considered for laparoscopic cholecystectomy. Three were excluded. The median age was 52 years and 76 per cent were women. Eighteen patients underwent urgent operation. Laparoscopic cholecystectomy was successful in 160 of the 162 patients (99 per cent). The two failures were the result of dense adhesions and stones in the bile duct. There were no deaths but major complications occurred in three patients: fenestration of the colon sutured laparoscopically; bleeding from a cannulation site and subsequent laparotomy for a strangulated hernia; and subphrenic abscess. There were 13 minor complications, but no bile duct injuries or peritonitis. The median postoperative hospital stay was 1 day. Bile duct stones were present in 14 patients (9 per cent) and were removed by endoscopic sphincterotomy (11 patients), by laparoscopic exploration of the common duct (two) and by conversion to laparotomy (one). These results suggest that laparoscopic cholecystectomy is applicable to the large majority of patients who require elective or urgent cholecystectomy, if appropriate radiological and endoscopic support is available.
A requiem for vagotomy.
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After-hours treatment of anterior dental trauma in Newcastle and western Sydney: a four-year study.
This study investigated anterior dental trauma presenting after-hours in Newcastle and western Sydney. During the four-year period 1983-1986, all patients presenting with anterior dental injuries to the Royal Newcastle Hospital (n = 382) or Westmead Hospital (n = 362) on week nights, weekends or public holidays were studied. In both areas, upper central incisors were the teeth injured most frequently. The mean numbers of teeth injured per patient were 1.9 at Newcastle and 2.0 at Westmead. The frequencies of injury types found in Newcastle and Westmead were similar. Luxations and avulsions accounted for 39.5 per cent of injuries at Newcastle and 39.6 per cent at Westmead. In Newcastle, the rate of occurrence of trauma was highest and relatively uniform in the 6-11, 12-17 and 18-23 year age groups. At Westmead, it was highest in the 6-11 year age group, followed closely by the 12-17 year age group. In both centres, the four main causes of trauma were falls, assaults and fights, sports and bicycle accidents. These accounted for 69 per cent of all injuries in Newcastle and for 69.4 per cent at Westmead. This study found a great similarity between Newcastle and western Sydney in relation to the predominant age and sex groups affected, causes of trauma, injury types and numbers and locations of injured teeth per patient. It is suggested that anterior dental trauma presenting after-hours may be more severe, involve more teeth per patient and affect predominantly older age groups than is the situation during normal hours.
The palatal radicular groove. Two case reports.
Two cases of the rare anomaly, the palatal radicular groove, affecting maxillary lateral incisors, are reported and discussed. Both were considered to be untreatable. Horizontal sections of one of these cases demonstrated a canal configuration not previously reported.
Perineal scent gland of wild and domestic cavies: bacterial activity and urine as sources of biologically significant odors.
Several studies were conducted to evaluate the source of biologically relevant odorous substances in male wild cavy (Cavia aperea ) perineal gland secretions. In the first study, using a habituation procedure, male wild cavies distinguished between the urine of two individuals after exposure to the perineal secretions of one of the individuals. However, these animals did not distinguish between the perineal secretions of two individuals after exposure to the urine of one of the individuals. These results suggest that urine is a component of cavy perineal gland secretions as normally found in the perineal sac. Other studies were designed to evaluate the possible role of bacteria in producing biologically relevant odors from cavy perineal gland secretions. Microbiological analyses of secretion that had accumulated in the perineal sacs ("dirty") or been squeezed directly from the glands ("clean") of wild and domestic (C. porcellus) cavies indicated large numbers of bacteria inhabited these secretions. In behavioral studies using two-choice preference tests, male wild cavies spent more time investigating conspecific dirty perineal gland secretions than clean secretions. Clean secretions, however, which had been incubated for 48 hr at 37 degrees C were preferred by these cavies over clean secretions which had been frozen at -60 degrees C during the same time period. In a final experiment it was found that wild cavies preferred conspecific clean secretion that had been sterilized and incubated with bacteria over uninoculated sterilized secretion. Together, these results indicate that urine and bacteria are responsible for components of biologically significant odors of cavy perineal scent marks.
Chemoinvestigatory and sexual behavior of male guinea pigs following vomeronasal organ removal.
The vomeronasal organs of male guinea pigs were removed (VNX; n = 10) or males experienced sham surgery (Sham; n = 10). Subsequently a battery of chemosensory tests of investigatory responsiveness to conspecific urine was conducted. Additionally, male subjects were paired with female conspecifics for short and long periods and social and sexual behaviors were monitored. VNX males exhibited a depression in urine investigation and this depression became more profound following repeated testing and/or the passage of time. By 6.3 months following surgery, investigatory responsiveness to urine was practically eliminated. Maintenance of responsiveness to urine odors may require reinforcing input through the accessory olfactory system. In contrast to these effects on responsiveness to odors, VNX and Sham males were indistinguishable in their social and sexual behavior. These data indicate that male guinea pigs without a VNO: (1) Exhibit a depression of investigation of urine odors which is time dependent and which may involve an extinction-like process; (2) continue to discriminate classes of urine (e.g., urine from male vs urine from female conspecifics); and (3) exhibit normal sexual behavior. The vomeronasal organ in the male domestic guinea pig is apparently critical for the maintenance of normal responsiveness to sex odors but, in its absence, other sensory systems are capable of maintaining normal sexual behavior under conditions of laboratory testing.