Transperitoneal ureter following ureteric reimplantation: a rare cause of small bowel obstruction and infarction.
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Adult↗
Biomedical subjects
R G Faber
Publications and source records attributed to R G Faber.
A prospective audit of cholecystectomy in a single health district.
Laparoscopic cholecystectomy is becoming the treatment of choice for patients presenting with gallstones. A prospective audit of all patients undergoing cholecystectomy in a single health district over a six-month period was carried out. The aim was to define those patients not having laparoscopic cholecystectomy and determine the morbidity and mortality associated with open and laparoscopic procedures. Cholecystectomy was performed on 173 patients; 149 operations were attempted laparoscopically, of which 134 were successful, giving a conversion rate of 10%. Elective open cholecystectomy was performed on 24 patients. Twenty of these patients were under the care of a consultant who only performs open cholecystectomy and the others were not offered a laparoscopic procedure because of previous abdominal operations. The median time taken for open cholecystectomy was significantly shorter (P < 0.05) than for laparoscopic cholecystectomy or for converted procedures. Laparoscopic cholecystectomy resulted in bile duct injury in one patient (0.7%). This study shows that the majority of patients with gallstones are being offered laparoscopic cholecystectomy, although some patients will undergo open cholecystectomy. The latter include patients under the care of surgeons not performing laparoscopic cholecystectomy, those presenting as an emergency where laparotomy is performed and those where laparoscopy is contra-indicated. The findings of this study are probably representative of other health districts where a similar mix of surgical practice exists.
Adult↗
Hip ganglion: case report and review of the literature.
We present an unusual case of a ganglion of the hip. The patient presented with a groin mass initially thought to be inguinal lymphadenopathy, related to a scrotal malignant melanoma excised 2 years earlier. Five similar cases have been previously reported. In all cases the pre-operative diagnosis was wrong (femoral hernia, inguinal lymphadenopathy, inguinal abscess). Only at operative exploration was the correct diagnosis made. The diagnosis of hip ganglion should be borne in mind when a patient presents with an inguinal swelling.
Aged↗
Survival after peranal and abdominoperineal resection for rectal carcinoma.
The outcome of a consecutive series of 47 patients with rectal cancer treated by endoscopic transanal resection or peranal local excision was contrasted with that of 42 patients undergoing abdominoperineal resection. Surgery was considered curative for 35 and nine patients treated by abdominoperineal and peranal resection respectively (P < 0.001). Patients undergoing peranal excision were older than those treated by abdominoperineal resection (median 77 versus 69 years, P < 0.01). The 5-year survival rate of patients undergoing peranal resection was 24 per cent compared with 33 per cent for those treated by the abdominoperineal procedure (P < 0.005). When surgery was palliative the survival rate after both procedures was the same. Survival after peranal excision was significantly poorer than that after abdominoperineal resection but this may be acceptable when the stage of disease and age of the patients are taken into account.
Abdomen↗
Impact of a waiting list initiative on a general surgical waiting list.
OBJECTIVES: To determine the effects of cuts in surgical beds and operating lists upon the waiting list. To evaluate the effects of the Waiting List Initiative upon the total number of patients on the waiting list, the number of patients waiting for more than one year, and the ratio of patients with low priority, non-life-threatening diagnoses to those with a higher priority, potentially more serious, diagnosis. DESIGN: The study of facilities available and waiting list figures between 1979-1991; a prospective study of a Waiting List Initiative. SETTING: The surgical departments of the Royal Berkshire and Battle Hospitals, Reading and Newbury District Hospital. PATIENTS: Those patients on general surgical waiting lists between 1979 and 1993; those patients who had operations under the Waiting List Initiative. RESULT: Between 1979 and 1989 the number of surgical beds fell from 225 to 153, a reduction of 38 per cent. The number of weekly operating lists fell from 40 to 30, a reduction of 25 per cent. The waiting list remained fairly constant, between 1979-1987, with a median of 420 patients (range 295-688) before 1987, against 983 (range 688-1,253) after 1987. After the Waiting List Initiative the total number of patients on the waiting list fell from 1,114 to 904, a fall of 19 per cent. Patients waiting for more than one year fell from 381 to 176 (54 per cent), whilst those waiting less than one year remained constant at 730. The proportion of patients with low priority varicose veins fell from 65 per cent to 40 per cent, whilst the proportion of patients with potentially more serious inguinal hernias rose from 10 per cent to 15 per cent. CONCLUSION: These results demonstrate the relationship between the increase in the size of the waiting list and the decrease in the facilities available in beds and operating sessions. While the Waiting List Initiative has resulted in a reduction in the number of patients waiting more than one year, there has been no reduction in numbers waiting less than one year. The reduction has been achieved at the expense of those patients with potentially more serious clinical conditions.
Beds↗
Information overload.
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Information Storage and Retrieval↗
Breast disease and the general surgeon. I. Referral of patients with breast problems.
OBJECTIVES: To determine the proportion of all new and follow-up patients referred to general surgical outpatient clinics with breast problems. To ascertain how long these patients wait for an appointment and how many require investigation or admission for operation. To review our management of patients with breast problems in the clinic and to determine the ratio of benign breast disease to malignancy. DESIGN: A 3-month prospective outpatient survey with patient details recorded on questionnaires completed by the medical staff. SETTING: The general surgical outpatient clinics of this firm at Battle Hospital, Reading, and Newbury District Hospital, Berkshire. PATIENTS: Those patients attending the above clinics during the 3-month period 1 October to 31 December 1989. RESULTS: In all, 693 new patients and 554 follow-up patients were seen. Of the new patients, 119, and of the follow-up patients 140 were seen for a breast complaint. At Battle Hospital 16% of all new patients presented with a breast problem, while at Newbury Hospital the figure was 24%. Of the follow-up patients at Battle Hospital, 23% were seen for a breast problem, and 41% at Newbury. The overall median waiting time for a new outpatient appointment was 21 days. No investigations were needed in 22% of the patients. The remaining 93 patients had investigations and a total of 70 mammograms and 53 fine needle aspirations for cytology were performed. The mean cost of investigations per patient investigated was estimated at 27 pounds. Of new patients, 58% were discharged from the clinic after a single consultation, and investigations as necessary. In 79% of the patients admitted for an operation, the decision to admit was made on the basis of the initial history and examination alone. Of new patients, 84% did not need admission and were managed in the clinic. In all, 14 breast carcinomas were diagnosed--12% of new patients with breast problems. CONCLUSIONS: The figures suggest that 24% of new patients and 41% of follow-up patients attending a general surgical clinic are seen for a breast problem. The waiting time for new appointments is unacceptably long. Most new patients do not require admission for an operation. Only 12% of new patients referred with a breast problem were found to have a carcinoma.
Appointments and Schedules↗
Breast disease and the general surgeon. II. Effect of audit on the referral of patients with breast problems.
OBJECTIVES: To determine the number of patients with breast problems referred to general surgical clinics in a district general hospital and to assess the effect of changes implemented following the previous study on waiting time, investigations performed, and management of the patients. DESIGN: Two prospective outpatient audits with patient details recorded on questionnaires by the medical staff. SETTING: The general surgical outpatient clinics of a single general surgical firm at Newbury District Hospital, Berkshire. PATIENTS: Those patients attending the above clinics during two 3-month periods, 1 October to 31 December 1989 (Study 1), and 16 April to 19 July 1990 (Study 2). RESULTS: Of new referrals, 25% were for a breast problem. The waiting time fell from a median of 22 days in Study 1 to 10 days in Study 2. There was no significant difference between the studies for the proportion of each type of investigation performed. Between 80% and 85% of new patients did not need admission for an operation; however, of those operations performed, 65% were for carcinoma. The number of patients diagnosed as having carcinoma was the same in the two studies. CONCLUSIONS: That 25% of new, and up to 40% of follow-up patients seen in a general surgical clinic have breast problems. Many patients do not regard their symptoms as worrying and will not attend early clinic appointments even if these are offered. Writing to patients and general practitioners with the results of investigations ensures quicker receipt of the diagnosis and treatment plan, and reduces follow-up attendance. Only 15-20% of new patients need admission for an operation, and carcinoma is found in only 13-17%. Open access to the clinics does not result in general practitioners referring patients unnecessarily with breast problems.
Appointments and Schedules↗
Case-control study of patient satisfaction with day-case and inpatient inguinal hernia repair.
A case-control study has been carried out to assess patient satisfaction with day-case or inpatient inguinal hernia repair using matched pairs of patients undergoing the same technique of inguinal hernia repair under general anaesthesia. Patients completed a single-page questionnaire 3-6 months after surgery. Although there was no objective difference in recovery, nearly half of the patients felt that they were discharged too early and the majority would prefer inpatient treatment. Day-case patients required significantly more medical attention after discharge and most of the reported wound complications were not known to the hospital. It is concluded that the introduction of day-case surgery in a district general hospital is not without problems and requires changes in working practices and resource availability with careful monitoring of outcome during its implementation.
Adult↗
The workload of a surgical unit in a district general hospital.
A 3-month prospective study of the workload of a surgical unit in a district general hospital was performed to identify the relationship between outpatient work, admissions to hospital, and scheduled operating lists. We have shown that under 60% of all new cases seen in the outpatient clinic had admissions arranged after initial consultation. Over two-thirds of inpatient admissions were for emergencies or urgent cases, and thus not able to be controlled by the surgical team. One-third of emergency admissions had an operation within 24 h of admission. One third of the total number of cases on scheduled lists were emergency or urgent cases (taking up approximately 50% of the operating time). Of all admissions, 32% were as day cases. Of all routine operations, 35% were performed at a community hospital taking only 18% of all our admissions.
Ambulatory Surgical Procedures↗
The effects of cuts in services on the work of a surgical unit in a district general hospital.
A reduction of the total scheduled operating time from 12 to 6.5 sessions/week available to a general surgical firm in a district general hospital resulted in 31% fewer admissions and 33% fewer operations on scheduled lists. Our data has confirmed that the brunt of these cuts were borne by patients awaiting routine surgery (the only category of admission which the surgical team can control). Routine operations performed were 54% fewer after the cuts compared with normal working. We estimate that this resulted in an increase of 89 patients awaiting routine surgery in 1 month. The number of emergency operations which we were able to perform on scheduled lists was reduced from 15/month before the cuts to 7/month after the cuts. Our results also illustrate the value of having a separate community hospital where routine surgery can be performed.
Emergencies↗
Relationship between insulin- and histamine-stimulated gastric secretion before and after vagotomy.
The relationship of gastric secretion in response to a single injection of insulin and in response to a histamine infusion, in unoperated patients with duodenal ulcer was studied before and after vagotomy. The secretion in response to insulin was significantly less than that in response to histamine. The ratio was about 0.7 before vagotomy, and about 0.4 after vagotomy irrespective of the adequacy of vagotomy. Highly significant correlations were obtained between the responses to the two stimuli, both in the unoperated group and in the whole postoperative group as well as in the inadequate vagotomy group, but not in patients after adequate vagotomy. Thus, the proportional differences between individuals in response to insulin were substantially the same as the proportional differences in response to histamine. The algebraic excess of histamine- over insulin-stimulated secretion before vagotomy did not differ from the value after vagotomy. Histamine-stimulated secretion after adequate vagotomy approximated to, but after inadequate vagotomy was greater than the preoperative algebraic excess of histamine- over insulin-stimulated secretion. These results are consistent with a new model of acetylcholine/histamine-receptor relationships. A certain proportion of the parietal cells are insensitive to the vagus but sensitive to histamine; and those sensitive to the vagus are also sensitive to histamine, but only when their vagal innervation is intact.
Adolescent↗
Value of outpatient follow-up after curative surgery for carcinoma of the large bowel.
The records were reviewed of 406 patients with carcinoma of the large bowel who had been treated at the Middlesex Hospital during 1958-62. Of these patients, 180 were followed up regularly in this hospital after radical surgery, and from six months to 15 years after operation they were seen 2319 times; 71 developed a recurrent carcinoma but, of these, 41 recurrences (58%) were diagnosed at times other than those of the patients' routine outpatient appointments, although they were being regularly reviewed. Only one patient with recurrence appeared to have been cured by further surgery. For the present, adequate education of patients in the symptoms of early recurrence, with instruction to return if any of these develop, is likely to be more effective than the unsatisfactory and time-consuming routine follow-up still used in many hospitals.
Anus Neoplasms↗
Thiocyanate as a marker of saliva in gastric juice?
One source of error in gastric secretion studies is swallowed saliva. The possibility that salivary thiocyanate might be used to measure this contamination has been investigated. Thiocyanate concentration was measured in saliva and gastric juice collected simultaneously in 22 duodenal ulcer patients undergoing routine insulin and histamine secretion studies. On stimulation, despite the increase in the rate of gastric secretion this was not matched by an appropriate fall in the concentration of thiocyanate in gastric juice. Moreover, in one-third of the gastric juice specimens, the thiocyanate concentration was greater than in the simultaneous samples of saliva. Thus, contrary to what has been claimed, thiocyanate is present not only in saliva but also in gastric juice. Therefore it cannot be used as a marker of salivary contamination. An adequate marker of this source of error has not yet been found.
Duodenal Ulcer↗
The quantification in human gastric juice of duodenogastric reflux by sodium output and by bile-labelling using indocyanine green.
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Adult↗
Surgical haemorrhage in patients given prophylactic heparin.
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Hemorrhage↗
Gallstone disease presenting as septicaemic shock.
Three patients are described who were admitted to hospital with septicaemic shock due to gallstones, but in none of whom had the presence of gallstones, been diagnosed previously. All 3 had positive blood cultures, Clostridium welchii being isolated in one patient (in another patient this organism was isolated from the bile). Two patients had renal failure requiring dialysis. All 3 patients survived. The management of this serious presentation of gallstones, hitherto poorly described in British literature, is discussed.
Aged↗
Vascular malformations of the parotid region.
Five adult patients with vascular malformations in the parotid region are described. Three of these patients had lumps in the parotid gland clinically indistinguishable from parotid tumours: one had a diffuse swelling of the check, and the fifth had a pulsatile tumour in the deep lobe of the gland. Two patients had a characteristic sign-the lump in the cheek became more obvious, both visually and on palpation, when the masseter muscle was tensed. In 3 of the patients calcified opacities, resembling phleboliths, were demonstrated on plain X-ray examination. This is only the third report of vascular malformations of the parotid region in the British literature; no other report of a pulsating tumour within the parotid gland has been found in a search of the world literature.
Adolescent↗