Biomedical subjects
Publications and source records attributed to M R Cox.
Duodenal injury following blunt abdominal trauma is uncommon. The severity of injury can vary from an intramural haematoma to a duodenal rupture with associated transection of the pancreatic duct. A case of duodenal rupture with avulsion of the ampulla of Vater is presented and discussed.
OBJECTIVE: The aim of this study was to prospectively assess the results of laparoscopic cholecystectomy in patients with acute inflammation of the gallbladder. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder disease. Its role in the surgical treatment of acute cholecystitis has not been defined, although a number of recent reports suggest that there should be few contraindications to an initial laparoscopic approach. METHODS: All patients presenting with symptomatic cholelithiasis from October 1990 until June 1992 were evaluated at laparoscopy with intention of proceeding to a laparoscopic cholecystectomy. The gross appearance of the gallbladder was categorized as acute inflammation, chronic inflammation, or no inflammation. Ninety-eight (23.4%) of 418 patients had acute inflammation of the gallbladder: 55 were edematous, 10 were gangrenous, 15 had a mucocele, and 18 had an empyema. RESULTS: The authors assessed outcome in these patients. The frequency of conversion to an open operation was 33.7% for acute inflammation, 21.7% for chronic inflammation (p < 0.05), and 4% for no inflammation (p < 0.001). The conversion rate was highest for empyema (83.3%) and gangrenous cholecystitis (50%), while the conversion rate for edematous cholecystitis was 21.8% and for acute inflammation with a mucocele it was 7%. The median operation time for successful laparoscopic cholecystectomy for acute inflammation was 105 minutes, which was longer than that with no inflammation (90 minutes). However, the incidence of complications was not different from that for chronic or no inflammation. The median postoperative stay for patients with acute gallbladder inflammation was 2 days for successful laparoscopic cholecystectomy and 7 days for patients converted to an open operation. CONCLUSIONS: Laparoscopic cholecystectomy for acute inflammation of the gallbladder is safe and is associated with a significantly shorter postoperative stay compared to open surgery. A greater number of patients required conversion to open operation compared to those with no obvious inflammation. Conversion to open operation was most frequent for empyema and gangrenous cholecystitis, suggesting that once this diagnosis is made, excessive time should not be spent in laparoscopic trial dissection before converting to an open operation.
The potential advantages of laparoscopic surgery for a number of abdominal operations including appendicectomy have been heralded. In this study the aims were to assess prospectively the role of routine diagnostic laparoscopy in the diagnosis of acute appendicitis and determine the efficacy of laparoscopic appendicectomy. Patients with suspected acute appendicitis had diagnostic laparoscopy. When the diagnosis was confirmed laparoscopic appendicectomy was performed. Where an alternative diagnosis was made the appropriate treatment was instituted. If no diagnosis could be made the macroscopically normal appendix was removed by laparoscopic appendicectomy. Eighty-one patients (50 female, 31 male) had an initial diagnostic laparoscopy; 53 had appendicitis and proceeded to laparoscopic appendicectomy. A diagnosis could not be established at diagnostic laparoscopy in six patients and they also proceeded to laparoscopic appendicectomy. An alternative diagnosis was made in the remaining 22 patients (19 female and 3 male), with five proceeding to laparotomy and one patient with mesenteric adenitis having laparoscopic appendicectomy. Seven patients having laparoscopic appendicectomy required conversion to an open operation due to a retrocaecal or perforated appendix. The median operating time for successful laparoscopic appendicectomy was 55 min (range 30-95). Morbidity occurred in five of 53 patients having a successful laparoscopic appendicectomy. The median postoperative hospital stay was 2 days. The median time before return to normal activities was 8 days. Diagnostic laparoscopy is a useful diagnostic technique in women with suspected acute appendicitis, as it improves diagnostic accuracy, reduces the negative appendicectomy rate and avoids unnecessary laparotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
Postoperative adhesions account for 64-79% of admissions with small bowel obstruction (SBO). The aim of this study was to identify the operative procedures and the types of adhesions that cause SBO. A retrospective analysis of all patients with an admission diagnosis of acute adhesive SBO between January 1982 and December 1990 was performed. One hundred and nineteen patients had 144 admissions with an initial diagnosis of acute SBO due to adhesions. The previous operations were: appendicectomy 23.3%; colorectal resection 20.8%; gynaecological surgery 11.7%; upper gastrointestinal (gastric, biliary or splenic) surgery 9.2%; small bowel surgery 8.3%; and more than one previous abdominal operation 23.6%. Sixty-one admissions required surgery to relieve the SBO. Eighteen patients had strangulated small bowel. All but two of these patients had a single band adhesion causing the SBO and associated strangulation. Band adhesions were commonly found following appendicectomy, colorectal resections or gynaecological operations. Seventeen of the 21 patients with previous surgery for a colorectal malignancy had benign adhesions causing the SBO, while four of the six patients with either previous ovarian or previous gastric carcinoma had recurrent malignancy causing the SBO. Five patients had previously undiagnosed carcinomas (three ovarian and two caecal) as the cause of the SBO.
Small bowel obstruction (SBO) due to adhesions is often initially treated non-operatively but the safety and duration of non-operative treatment is controversial. The aims of this study were to assess the safety of non-operative treatment and determine the optimal duration of non-operative treatment in adhesive SBO. A retrospective analysis of patients admitted with a diagnosis of adhesive SBO following an initial period of non-operative treatment was performed. Patients whose condition resolved with non-operative treatment were compared with patients who required surgical intervention after an initial period of non-operative treatment. There were 123 admissions having an initial period of non-operative treatment. The SBO resolved in 85, the remaining 38 required surgical intervention. Complete resolution occurred within 48 h in 75 (88%) cases, the remaining 10 had resolved by 72 h. Thirty-one of 38 patients required surgical intervention for SBO more than 48 h duration after admission. The difference between cases resolving within 48 h and those requiring surgery after 48 h was significant (chi 2 = 113, P < 0.001). Three (2.4%) patients, initially treated non-operatively, had small bowel strangulation. All three were operated on within 24 h of admission when changes in clinical findings suggested small bowel strangulation may be present. There were no deaths in the group having an initial period of non-operative treatment. In the absence of any signs of strangulation, patients with an adhesive SBO can be managed safely with non-operative treatment. Most cases of adhesive SBO that will resolve, do so within 48 h of admission.(ABSTRACT TRUNCATED AT 250 WORDS)
The advent of laparoscopic cholecystectomy (LC) has led to a reassessment of the approach to the management of choledocholithiasis. In a consecutive series of 418 patients undergoing LC, common bile duct (CBD) stones were suspected pre-operatively in 130 patients. Forty-five of the patients (35%) were found to have CBD stones on either pre-operative endoscopic retrograde cholangiopancreatography (ERCP; 20) or on operative cholangiography (OC; 25). Common bile duct stones were detected on OC in a further 12 of 288 patients (4.2%) without pre-operative suspicion of choledocholithiasis. Of the total of 57 patients with CBD stones, the duct was cleared by pre-operative ERCP and endoscopic sphincterotomy (ES) in 15 patients. In 13 patients, two of whom had had a pre-operative ERCP and ES, duct clearance was achieved by relaxing the sphincter pharmacologically and flushing the CBD via the OC catheter. One patient had an on-table ERCP and ES with successful stone extraction during LC. Eleven patients were converted to open operation with bile duct exploration. Sixteen patients had a postoperative ERCP. In five patients the CBD stones had passed spontaneously in the time between LC and ERCP. Ten patients required ES to clear the duct of stones. One patient had a failed ERCP and is still awaiting a repeat. The remaining patient was scheduled, but did not return for follow-up ERCP. In summary, pre-operative ERCP was indicated in less than 10% of patients in this series.(ABSTRACT TRUNCATED AT 250 WORDS)
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Cystogastrostomy or cystojejunostomy at open operation has been the usual treatment for symptomatic pancreatic pseudocyst. The aim of this study was to assess prospectively the results of percutaneous cystogastrostomy (PCG) for the treatment of symptomatic pseudocysts. The technique of PCG comprised initially of drainage of the pseudocyst with a 10 Fr percutaneous, transgastric catheter. This initial drainage catheter had two components; the first, between the pseudocyst and the stomach, drained the pseudocyst and the second, between the stomach and exterior, acted as a percutaneous gastrostomy. The initial drain was left in situ for 14 days, at which time it was exchanged percutaneously for the definitive PCG; a double ended Mallecot type catheter that drained between the pseudocyst and the stomach. The latter catheter was left in situ until there was no residual pseudocyst demonstrated on computerized tomography scan and was removed endoscopically. Eleven patients with large (> 6 cm), symptomatic pseudocysts have been treated with PCG. All patients were treated successfully without the need for surgical intervention. The median time to radiological resolution was 24 days. There were four episodes of sepsis, two related to central venous line infections nad two related to catheter blockage. Percutaneous, cystogastrostomy blockage was managed by either replacing the initial drain or inserting a second catheter. The median follow up after successful treatment was 9 months (range 2-17). There were no symptomatic recurrences and one small (2 cm) asymptomatic recurrent pseudocyst. This preliminary experience with PCG demonstrates the efficacy of this procedure for treating symptomatic pancreatic pseudocysts.
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Collis-Nissen gastroplasty fundoplication is a widely accepted operation for patients with gastro-oesophageal reflux disease complicated by oesophageal shortening. Assessment of this operation by 24 h oesophageal pH monitoring has not previously been reported. Our aim was to correlate clinical and endoscopic results with 24 h pH studies. Twenty-nine patients had a gastroplasty fundoplication, as a result of which twenty-five (86%) had an excellent clinical result, 2 (7%) had a good result and 2 (7%) had a poor result. The two poor results were in patients who had previously undergone anti-reflux surgery. All 29 patients had pre-operative pH monitoring. Twenty-three patients had postoperative pH studies. Oesophageal acidification times were normal postoperatively in 16 of 23 patients however, 7 still had an abnormal study. One of the two patients with a poor clinical result was studied and persistent severe oesophageal acidification was demonstrated. The remaining 6 patients with abnormal studies were asymptomatic. Five of the 6 asymptomatic patients also had a normal oesophagogastroscopy with no macroscopic oesophagitis. We conclude that 24 h pH monitoring after the Collis-Nissen operation should only be performed to assess clinically and endoscopically poor results.
Leiomyomata of the small intestine are rare benign tumours of the small intestine that usually present with gastrointestinal bleeding, vague abdominal pains or small bowel obstruction. A case is reported of a patient who presented with an acute abdomen due to infarction of a leiomyoma of the proximal jejunum.
Laparoscopic cholecystectomy is rapidly becoming accepted as the best method for the treatment of symptomatic cholelithiasis. Randomized clinical trials comparing laparoscopic cholecystectomy with open cholecystectomy are unlikely to be performed. In order to compare these two operations, surgeons need an historical control group of patients who have undergone a conventional open cholecystectomy. The aim of this study was to document a control group of patients having an open cholecystectomy and compare them with patients having a laparoscopic cholecystectomy. This was achieved by a retrospective study of all patients who had an open cholecystectomy from January 1985 to December 1989. Four hundred and fifty-seven patients, 345 women and 112 men, had a cholecystectomy. Exploration of the common bile duct (ECBD) was performed in 59 (12.5%) cases. The mean operative duration was 73 min for cholecystectomy and 118 min for cholecystectomy and ECBD. The shortest mean postoperative stay was for an elective cholecystectomy (5.3 days) and the longest mean postoperative stay was for urgent admissions requiring ECBD (12.0 days). Operative dissection was difficult in 14.1% of elective cases and 51.8% of urgent cases. Ninety-seven (19.5%) patients had an additional procedure, unrelated to cholelithiasis, at the same operation; 44 did not require laparotomy, 31 had interval appendectomies, and 22 other cases required laparotomy in order to perform the additional procedure. All but one patient required postoperative narcotic analgesia. The mean duration of narcotic analgesia was 2.3 days. The complication rate was 35.2% for cholecystectomy and 62.5% for ECBD. If pulmonary atelectasis is excluded as a complication, these complication rates fell to 6.8% and 20.1%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
The use of nuclear bone scanning and liver ultrasonography to stage breast cancer is an established practice in many hospitals. A 3 year prospective study was undertaken to assess the usefulness of these two investigations. Three hundred and fifty-eight patients were analysed: 133 had stage I disease, 188 were stage II and 37 were stage III. Bone scans were performed on 339 (94.7%) patients; 302 had stage I or stage II disease; and 37 were stage III. Bone scans were positive for metastases in only 0.9% of stage I and II patients but were positive in 16.2% of patients with stage III disease. None of the 309 (96.2%) stage I or stage II patients who had an ultrasound scan had any liver metastases detected whereas positive scans were obtained in 5.4% of stage III patients. It can be concluded that the incidence of demonstrable bone or liver metastases in stage I and stage II breast cancer patients is so low that the use of routine scanning can be abandoned.
Primary linitis plastica carcinoma of the colon is an uncommon morphological type of colorectal carcinoma. Linitis plastica of the stomach may spread to the colon producing a similar lesion to primary colonic linitis plastica. This case report describes a case of linitis plastica of the colon that had many of the clinical, endoscopic, radiological and operative features of Crohn's colitis. The precise origin of the linitis plastica carcinoma was not clear: it may have been clonic or gastric, although the former is favoured. This case illustrates a number of facets of this unusual colonic carcinoma.
The aim of this study was to assess prospectively the value of thyroid nuclear scans and ultrasound examination in the preoperative investigation of patients with a solitary thyroid nodule. Total thyroid lobectomy for a solitary thyroid nodule was performed in 68 cases. Each patient had a thyroid isotope scan (except two women who were pregnant) and thyroid ultrasound examination. There were 10 (15 per cent) malignant nodules, 11 (16 per cent) benign neoplastic nodules and 47 (69 per cent) benign non-neoplastic nodules. All of the patients with malignant nodules who were scanned had a solitary cold nodule on thyroid scan, as did 40 (69 per cent) of those with benign solitary nodules. Ultrasound examination of the thyroid suggested correctly that one of 16 (6 per cent) cystic lesions, four of 16 (25 per cent) complex solid-cystic lesions and three of 18 (17 per cent) of solid lesions were malignant. One lesion reported as multinodular on ultrasonography and one reported as normal also turned out to be malignant. Thyroid isotope scans and ultrasound do not accurately differentiate between benign and malignant conditions and their routine use in the investigation of a solitary thyroid nodule should be abandoned.
A persistent perineal sinus following proctocolectomy or proctectomy is a not infrequent complication associated with considerable morbidity. Two cases are presented where the perineal sinus was closed using a rectus abdominis flap. This method of closure allows safe, complete excision of the sinus and insertion of a muscle flap which completely fills the defect, enabling complete, primary healing of the perineum.