Chronic constipation in the elderly: an unusual presentation of colonic dysmotility in an elderly patient.

Introduction. Chronic constipation is common in the elderly, and often no underlying pathology is found. Primary colonic dysmotility has been described in children but is rare in the elderly. Case report. We present an 82-year-old female with long standing constipation presenting acutely with large bowel obstruction. Laparotomy and Hartman's procedure was performed, and a grossly distended sigmoid colon was resected. Histology revealed a primary myopathic process. Conclusion. Primary colonic myopathy should be considered in elderly patients presenting with large bowel obstruction and a long preceding history of constipation, particularly when previous endoscopic examinations were normal.

Triple-vessel mesenteric ischaemia presenting with gastric ulceration.

We present an unusual presentation of chronic mesenteric ischaemia in a patient with recurrent gastric ulceration that highlights both the importance of recognition of ischaemia as a possible aetiology in those refractory to conventional treatment and the success of percutaneous transluminal mesenteric angioplasty in these cases.

Value of intraoperative abdominal cavity culture in appendicectomy: a retrospective study.

Appendicectomy is one of the most common surgical emergency procedures. Intraperitoneal culture during appendicectomy is routine practice in some hospitals, while some surgeons advocate abandoning this routine. The aim of our study is to determine the value of intraoperative abdominal cavity culture and its impact on the patient management. Retrospective analysis was performed on 498 patients who underwent appendicectomy over 2.5-year period. The median of the postoperative hospital stay was 2 days, while the median time taken to receive culture results was 3 days. A positive culture was found in 42.6%. Approximately 42.7% of the patients were discharged from the hospital before receiving the culture results. The culture and sensitivity results altered the antibiotic regimen in one patient (0.85%). Intraoperative abdominal cavity culture results were seldom used for clinical management in patients with acute appendicitis. The traditional surgical practice of routinely culturing peritoneal fluid in these patients should be abandoned.

The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study.

INTRODUCTION: The Modified Early Warning Score (MEWS) is a simple, physiological score that may allow improvement in the quality and safety of management provided to surgical ward patients. The primary purpose is to prevent delay in intervention or transfer of critically ill patients. PATIENTS AND METHODS: A total of 334 consecutive ward patients were prospectively studied. MEWS were recorded on all patients and the primary end-point was transfer to ITU or HDU. RESULTS: Fifty-seven (17%) ward patients triggered the call-out algorithm by scoring four or more on MEWS. Emergency patients were more likely to trigger the system than elective patients. Sixteen (5% of the total) patients were admitted to the ITU or HDU. MEWS with a threshold of four or more was 75% sensitive and 83% specific for patients who required transfer to ITU or HDU. CONCLUSIONS: The MEWS in association with a call-out algorithm is a useful and appropriate risk-management tool that should be implemented for all surgical in-patients.

Esomeprazole 20 mg vs. pantoprazole 20 mg for maintenance therapy of healed erosive oesophagitis: results from the EXPO study.

BACKGROUND: Following initial healing of erosive oesophagitis, most patients require maintenance therapy to prevent relapse. AIM: To compare endoscopic and symptomatic remission rates over 6 months' maintenance therapy with esomeprazole or pantoprazole (both 20 mg once daily) in patients with healed erosive oesophagitis. METHODS: Patients with symptoms of gastro-oesophageal reflux disease and endoscopically confirmed erosive oesophagitis at baseline were randomized to receive esomeprazole 40 mg or pantoprazole 40 mg for up to 8 weeks. Patients with healed erosive oesophagitis and free of moderate/severe heartburn and acid regurgitation at 4 weeks or, if necessary, 8 weeks entered the 6-month maintenance therapy phase of the study. RESULTS: A total of 2766 patients (63% men; mean age 50 years) received esomeprazole 20 mg (n = 1377) or pantoprazole 20 mg (n = 1389) and comprised the intention-to-treat population. Following 6 months of treatment, the proportion of patients in endoscopic and symptomatic remission was significantly greater for those receiving esomeprazole 20 mg (87.0%) than pantoprazole 20 mg (74.9%, log-rank test P < 0.0001). Esomeprazole 20 mg produced a higher proportion of patients free of moderate to severe gastro-oesophageal reflux disease symptoms and fewer discontinuations because of symptoms than pantoprazole 20 mg (92.2% vs. 88.5%, P < 0.001). CONCLUSIONS: Esomeprazole 20 mg is more effective than pantoprazole 20 mg for maintenance therapy following initial healing of erosive oesophagitis and relief of gastro-oesophageal reflux disease symptoms.

Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer.

BACKGROUND AND OBJECTIVES: Simple methods to identify colorectal cancer patients at risk of recurrence are needed. This study aimed to determine if neutrophil-to-lymphocyte ratio (NLR) predicts survival in colorectal cancer patients. METHODS: Two-hundred thirty patients diagnosed with colorectal cancer over a two-year period were identified from a prospectively maintained colorectal cancer database. NLR was calculated from pre-operative full blood counts. In the case of patients who did not undergo surgery, the full blood count from their out-patient visit was used. Known prognostic factors were recorded. Overall and cancer-specific survival were calculated. RESULTS: Pre-operative NLR greater than 5 correlated with overall and cancer-specific survival in univariate analyses. NLR was not independent of Dukes stage. CONCLUSIONS: Pre-operative NLR may represent a simple method of identifying colorectal cancer patients with a poor prognosis pre-operatively.

A randomized comparative study of esomeprazole 40 mg versus pantoprazole 40 mg for healing erosive oesophagitis: the EXPO study.

AIM: To assess the efficacy of the 8-week therapy with esomeprazole 40 mg vs. pantoprazole 40 mg for healing erosive oesophagitis (EE) as part of a management study. METHODS: Patients had a history of gastro-oesophageal reflux disease symptoms (> or =6 months) and had suffered heartburn on at least 4 of the 7 days preceding enrollment. Endoscopies were performed to grade EE severity using the Los Angeles (LA) classification system at baseline, 4 and 8 weeks (if unhealed at 4 weeks). Heartburn severity was recorded by patients on diary cards. The primary end point was healing of EE by week 8 of treatment. RESULTS: Of 3170 patients randomized, the intent-to-treat population consisted of 3151 patients (63% male, mean age: 50.6 years, 27% Helicobacter pylori-positive). Esomeprazole 40 mg healed a significantly greater proportion of EE patients than pantoprazole 40 mg at both 4 weeks (life table estimates: esomeprazole 81%, pantoprazole 75%, P < 0.001) and 8 weeks (life table estimates: esomeprazole 96%, pantoprazole 92%, P < 0.001). The median time to reach sustained heartburn resolution was 6 days in patients receiving esomeprazole and 8 days with pantoprazole (P < 0.001). CONCLUSION: Esomeprazole 40 mg is more effective than pantoprazole 40 mg for healing EE and providing resolution of associated heartburn.

Margin involvement and outcome in oesophageal carcinoma: a 10-year experience in a specialist unit.

AIMS: Positive microscopic margins after major cancer surgery adversely affect prognosis. We questioned whether the benefit of a multimodal approach in oesophageal carcinoma is due to reduced resection margin involvement and whether multimodal therapy alters the disease course when margins are involved. METHODS: Pathology specimens of 212 patients, treated with either multimodal therapy or surgery alone, were re-reviewed to assess margin involvement by tumour. Margin status was compared with recurrence and survival data. RESULTS: Margin involvement was decreased with multimodal therapy (16 of 103 patients) vs surgery (33 of 109 patients), associated with reduced tumour recurrence and a significant survival advantage. However, even with involved margins, multimodal therapy had lower recurrence vs surgery and a small survival benefit. CONCLUSIONS: Multimodal therapy significantly reduces margin involvement. The benefit of multimodal therapy remains highly significant for patients with clear margins. This study confirms for oesophageal carcinoma the value of an aggressive surgical approach in achieving negative resection margins.

D2 lymphadenectomy in the management of gastric cancer.

BACKGROUND: Gastric carcinoma is a significant cause of death in Ireland. Surgery offers the best option of cure, but the five-year survival following resection remains dismal at 10-15%. Experience from Japan and from some Western units suggest that an extended (D2) lymphadenectomy in association with gastrectomy increases the prospect of cure, but concern about the morbidity and mortality of this operation and lack of evidence from randomised studies has limited its acceptance. AIMS: This study reports the experience of a specialist upper gastrointestinal unit with D2 gastrectomy in a four-year audit. METHODS: Sixty-two resections were performed for gastric cancer. RESULTS: Nineteen patients were deemed unsuitable for the D2 procedure and underwent a more limited lymphadenectomy (D0 or D1). Forty-three patients underwent D2 resection, 12 with an oesophagogastrectomy, 22 with total gastrectomy and nine with a sub-total distal resection. Eight patients undergoing D2 resection had extended resections, five with splenectomy and three with a distal pancreatectomy. Post-operative complications occurred in 31% of patients. Thirty-day and 90-day mortality were zero. Median survival was 822 days in the D2 group (range 120-1,320). CONCLUSIONS: These results show that a D2 gastrectomy can be performed with a low morbidity and mortality and a median survival of greater than two years.

Laparoscopic exploration of the common bile duct: beyond the learning curve.

BACKGROUND: Bile duct clearance at open cholecystectomy had become normal surgical practice before the introduction of laparoscopic cholecystectomy. However, perceived technical difficulties have deterred many surgeons from treating common bile duct stones at the time of laparoscopic cholecystectomy. This has led to a reliance on preoperative clearance of ducts known to have stones and postoperative clearance of ducts found to have stones at operation or those that subsequently develop complications of retained stones. METHODS: The authors describe a series of 120 consecutive bile duct explorations carried out between April 1991 and February 1997 in a series of 1,237 laparoscopic cholecystectomies. RESULTS: Laparoscopic exploration and clearance of the bile ducts was achieved in 89% of cases in the whole series, and 97% success was attained in the last 60 cases, which also were associated with a decrease in operating time. CONCLUSIONS: We believe that for surgeons familiar with open common bile duct exploration and laparoscopic cholecystectomy, the next logical step is laparoscopic exploration of the common bile duct at the time of cholecystectomy, which is safe and readily mastered.

A comparison of multimodal therapy and surgery for esophageal adenocarcinoma.

BACKGROUND: Uncontrolled studies suggest that a combination of chemotherapy and radiotherapy improves the survival of patients with esophageal adenocarcinoma. We conducted a prospective, randomized trial comparing surgery alone with combined chemotherapy, radiotherapy, and surgery. METHODS: Patients assigned to multimodal therapy received two courses of chemotherapy in weeks 1 and 6 (fluorouracil, 15 mg per kilogram of body weight daily for five days, and cisplatin, 75 mg per square meter of body-surface area on day 7) and a course of radiotherapy (40 Gy, administered in 15 fractions over a three-week period, beginning concurrently with the first course of chemotherapy), followed by surgery. The patients assigned to surgery had no preoperative therapy. RESULTS: Of the 58 patients assigned to multimodal therapy and the 55 assigned to surgery, 10 and 1, respectively, were withdrawn for protocol violations. At the time of surgery, 23 of 55 patients (42 percent) treated with preoperative multimodal therapy who could be evaluated had positive nodes or metastases, as compared with 45 of the 55 patients (82 percent) who underwent surgery alone (P<0.001). Thirteen of the 52 patients (25 percent) who underwent surgery after multimodal therapy had complete responses as determined pathologically. The median survival of patients assigned to multimodal therapy was 16 months, as compared with 11 months for those assigned to surgery alone (P=0.01). At one, two, and three years, 52, 37, and 32 percent, respectively, of patients assigned to multimodal therapy were alive, as compared with 44, 26, and 6 percent of those assigned to surgery, with the survival advantage favoring multimodal therapy reaching significance at three years (P=0.01). CONCLUSIONS: Multimodal treatment is superior to surgery alone for patients with resectable adenocarcinoma of the esophagus.

Surgery and human immunodeficiency virus-1 infection.

BACKGROUND: HIV and AIDS continues to be a significant health problem with many patients requiring the attention of a general surgeon. METHOD: A retrospective case note review over a two-year period was undertaken. RESULTS: 237 patients underwent invasive procedures. The majority 100 patients (145 procedures) were for venous access. Anorectal problems in 69 patients presents a particular problem in this group and major surgery in 26 patients (30 procedures) has a definite role in selected patients. CONCLUSION: The surgical management of patients with AIDS is discussed with reference to safety. Recognition of specific disease patterns in this group is important and best managed by a dedicated team.

A survey of glove preferences of general and orthopaedic surgeons in North West Thames Regional Health Authority.

The glove preferences of all the consultant surgeons and consultant orthopaedic surgeons in North West Thames were surveyed by questionnaire. Responses were received from 59 of 78 general surgeons and 47 of 55 orthopaedic surgeons. Twenty-two percent of general surgeons never double gloved compared with 4% of orthopaedic surgeons (P < 0.01). Seventy-three percent of general surgeons double gloved for 'high risk' patients compared with 17% of orthopaedic surgeons (P < 0.001). When double gloving the majority of surgeons (67%) used their normal sized glove inside and half a size larger on the outside.

Inpatient and post-discharge wound infections in general surgery.

The wound infection incidence during inpatient stay was compared with the post-discharge infection incidence for 1 month using audit data and a patient questionnaire. The true infection rate was found to be 20% compared with an apparent rate of 2.4% (P < 0.001). The study highlights the problems of postoperative monitoring in the context of shorter inpatient stays and fewer routine outpatient appointments.

Hypoxemia during outpatient gastrointestinal endoscopy: the effects of sedation and supplemental oxygen.

STUDY OBJECTIVES: To compare the effects on oxygen saturation as measured by pulse oximetry (SpO2) and ECG changes of endoscopy alone, sedation followed by endoscopy, and sedation followed by endoscopy with supplemental oxygen (O2) during upper gastrointestinal (GI) endoscopy. STUDY DESIGN: Randomized trial. SETTING: Outpatient gastroenterology clinic at a university medical center. PATIENTS: 58 healthy patients scheduled for outpatient upper GI endoscopy, with no clinical evidence of respiratory disease. INTERVENTIONS: Patients were randomly allocated to three groups: Group 1 received no benzodiazepines before endoscopy and breathed room air throughout (n = 18), Group 2 received midazolam intravenously (i.v.) before endoscopy and breathed room air throughout (n = 20), and Group 3 received i.v. midazolam and 2 L/min O2 through nasal cannulae during endoscopy (Group 3; n = 20). MEASUREMENTS AND MAIN RESULTS: Data collection, which included heart rate, cardiac rhythm, and SpO2 were recorded at seven intervals: baseline, topical anesthesia of the oropharynx, mouth gag insertion, endoscope insertion, biopsy, endoscope removal, and five minutes postendoscopy. In Group 2, mean SpO2 decreased after midazolam was administered and remained depressed during endoscopy (p < 0.05). After midazolam was given, Group 2 patients differed significantly from patients in Groups 1 and 3 (p < 0.05). CONCLUSIONS: The use of hypnotic doses of benzodiazepines is the primary factor responsible for the reduced oxygenation seen during endoscopy. Neither the presence of the endoscope alone nor the use of midazolam with supplemental O2 caused a decreased oxygenation. This study also suggests that the routine use of benzodiazepines is unnecessary when the endoscopy is of short duration, and the endoscopist employs good topicalization of the oropharynx. In patients who require sedation for endoscopy, O2 administration prevents hypoxemia.

The expression of mmp-7 messenger-RNA in primary and metastatic human colorectal adenocarcinoma.

MMP-7 mRNA expression was examined by RT-PCR and Southern blot hybridisation following cDNA synthesis of extracted tissue RNA in a total of 33 colorectal cancer patients. Expression was studied in tumour tissues and compared to adjacent non-neoplastic tissues. MMP-7 mRNA was detected in all tumour samples, with no qualitative difference between primary and metastatic tumours and there was no relation to Dukes' clinical stage. Adjacent nonneoplastic colon and rectum (65%) and liver (100%) also expressed MMP-7, although the signal intensity was weaker. In contrast, only 31% of adjacent non-neoplastic lymph nodes expressed MMP-7. The results suggest that MMP-7 is probably expressed early in the neoplastic transformation in patients with colorectal adenocarcinoma.