A reduction in serum cytokine levels parallels healing of venous ulcers in patients undergoing compression therapy.

INTRODUCTION: vascular endothelial growth factor (VEGF) and tumour necrosis factor alpha (TNF(alpha)) have been specifically implicated in the tissue damage associated with chronic venous disease (CVD). Furthermore, production of both factors is known to be upregulated in vessel wall cells subject to hypertension. The aim of this study was to determine the local venous levels of VEGF and TNF(alpha) in limbs with venous ulcers before and after treatment with graduated compression. PATIENTS AND METHODS: eight patients with venous ulcers and 8 patients with varicose veins only were included in the study. For ulcer patients, serum samples were taken from the superficial veins in lower limbs and repeated after 4 weeks of treatment with 4-layered graduated compression. Serum from the arms of the same patients served as controls. Determination of the concentrations of VEGF and TNF(alpha) proteins were performed with sandwich enzyme-linked immunosorbent assays. RESULTS: both groups of patients had elevated levels of VEGF and TNF(alpha). In patients with venous ulcers there was a reduction in the levels of both cytokines to below control values with treatment. These changes correlated with healing of the ulcers as determined by reduction in ulcer size. CONCLUSION: these data, for the first time, suggest a central role for both TNF(alpha) and VEGF in the pathogenesis of venous ulceration which may constitute a causative link between venous hypertension and tissue pathology.

Information for surgical patients: implications of the World Wide Web.

OBJECTIVE: To sample the amount and scope of information available on the internet about three common surgical conditions, identify the sources, and to examine the relevance of the web to the surgical community. DESIGN: Internet search. SETTING: General hospital, Republic of Ireland. MATERIAL: Three arbitrarily chosen conditions were sought--varicose veins, inguinal hernia, and gallstones. Four commonly used search engines--Yahoo, Altavista, Excite and Lycos, were used to search worldwide, and then sites restricted to the UK and Republic of Ireland. MAIN OUTCOME MEASURES: Quality and quantity of information available. RESULTS: All four search engines retrieved patient-orientated information on the three conditions. The sites accessed from the web page matches generally presented a comprehensive summary of the condition including aetiology, risk factors and clinical features, but gave variable amounts of information on treatment options, surgical complications, comparisons between treatments, and expected outcomes. Online health magazines provided most of the information sites. CONCLUSION: The internet offers easily-accessible patient-orientated information. Surgeons should make more use of it to satisfy patients' increasing need for information.

Feasibility of day case varicose vein surgery in a district general hospital.

BACKGROUND: Day case surgery may reduce inpatient bed requirements, and varicose surgery may be an ideal operation to test the functioning of a day surgery service. AIMS: To evaluate retrospectively the feasibility of day case varicose vein surgery in all-comers, and to identify the risk factors for admission. METHODS: Over a three-year period from July 1995 to July 1998, all patients requiring varicose vein surgery had their procedure performed as a day case. A standard technique of sapheno-femoral ligation with below-knee stripping of the long saphenous vein and multiple stab avulsions of varicosities was performed. All limbs were dressed with wool in crepe bandage and were reviewed post-operatively at six weeks. RESULTS: Five hundred and forty two patients underwent varicose vein surgery, of whom 26% had bilateral varicose veins, 88% had primary varicose veins and 22% had recurrent disease. The procedure was performed under general anaesthesia in 86% of cases and under spinal anaesthesia in the rest. There was no peri-operative mortality. Ten patients (1.9%) developed post-operative complications. Seventy two per cent of patients were discharged on the day of surgery, a further 25% required admission for one night due to minor anaesthetic complications and patient preference. Four per cent required admission for more than 24 hours. The need for overnight admission was associated with the age of the patients (p < 0.0001), bilateral varicose vein surgery (p < 0.005) and the use of spinal anaesthesia (p < 0.01). CONCLUSION: Although varicose vein surgery is safe, acceptable and cost-effective as a day case procedure, if attempted in all-comers, overnight admission will be required in a significant proportion. Pre-operative selection is advised.

Advanced trauma and life support principles: an audit of their application in a rural trauma centre.

In December of 1995 a system of trauma care based on Advanced Trauma Life Support (ATLS) principles was instituted to assess the impact of such principles on trauma care in a rural general hospital setting. This audit reviews the results over a 2 yr period to December 1997. All patients admitted with major trauma (i.e. with life threatening or potentially life threatening injuries) to Cavan General Hospital (CGH) were eligible for inclusion. This numbered 70 patients admitted (for at least 3 days), or who were transferred after resuscitation and stabilization as well as inpatient deaths. Twenty-seven patients who died prior to admission are also reviewed. The endpoints assessed were death, disability and survival 3 months post-accident. Based on injury severity scores 7 per cent of cases suffered fatal non-survivable injury, 20-30 per cent had very serious injury with an overall mortality rate of 17 per cent. The predicted mortality rate was 30 per cent. One-third had their full treatment at CGH with a 76 per cent survival rate. The other two-thirds were transferred for specialist intervention with an overall survival of 80 per cent, a disability rate of 16 per cent and a mortality rate of 4 per cent. No patient died during transportation.

Pathological evidence in support of total mesorectal excision in the management of rectal cancer.

Some 50 total mesorectal excision specimens were examined following rectal excision for cancer. Circumferential margin involvement was rare, but mesorectal tumour deposits were present in 17 of 44 patients with pT3 tumours, and 23 of 44 had mesorectal nodal involvement. No patient with a pT2 tumour had mesorectal involvement. Failure to excise the mesorectum completely has the potential to leave gross or microscopic residual disease that may in theory predispose to local failure. Total mesorectal excision is necessary to avoid incomplete pathological evaluation of the mesorectum and understaging of rectal cancer.

Gastrointestinal haemorrhage from a jejunal gangliocytic paraganglioma.

A case of jejunal gangliocytic paraganglioma is reported in a 54 year old woman who presented with brisk melaena. The tumour was not encapsulated, involved the mucosa and submucosa, and was composed of epithelial nests, spindle cells, and ganglion cells. These cells were mixed, giving carcinoid-like, paraganglioma-like, and ganglioneuroma-like patterns in different areas of the tumour. The lesion was excised locally and recovery was uneventful. Only four previous cases have been reported at this site.

Pulse oximetry in the diagnosis of non-critical peripheral vascular insufficiency.

Pulse oximetry was used to detect return of pulsatile flow in 27 subjects during reactive hyperaemia following 3 min of total limb ischaemia induced by above knee tourniquet occlusion. Fourteen patients with exercise induced leg pain had 18 symptomatic limbs tested. Thirteen controls had 25 limbs tested. Return of pulsatile flow during reactive hyperaemia occurred within 20 s of tourniquet release in the 25 control limbs which was then regarded as normal. The mean time for return of pulsatile flow in 18 symptomatic limbs was 53 +/- 37 s (P < 0.05 versus controls). Three limbs had a normal value, two of which did not have peripheral vascular disease. Pulse oximetry correctly identified all 25 asymptomatic limbs and 15 of 16 patients with claudication secondary to peripheral vascular disease (PVD). This modification of the reactive hyperaemia test using the pulse oximeter is simple and quick to perform. It has potential as a non-invasive screening test for PVD, suitable for outpatient assessment.

Magnetic resonance imaging of rectal carcinoma: a prospective study.

Accurate preoperative staging of rectal cancer is necessary to identify patients who might benefit from adjuvant therapy. Magnetic resonance imaging (MRI) was evaluated in 20 consecutive patients with rectal cancer undergoing 'curative' surgery. Detailed histopathological examination of the resected lesion was correlated with findings of MRI. MRI staging concurred with histological staging in 18 of 20 patients using the Dukes or tumour node metastasis classification but in only 14 using the modified Astler-Coller system. MRI diagnosed transmural invasion in all but one patient with microscopic mural invasion (positive predictive value, 100 per cent; negative predictive value, 80 per cent; overall accuracy, 95 per cent). MRI correctly diagnosed tumour deposits or involved lymph nodes in 12 patients. MRI overstaged one patient, in whom nodes that were enlarged on imaging studies were negative at histological examination (positive predictive value, 92 per cent; negative predictive value, 100 per cent; overall accuracy, 95 per cent). MRI has a role in selected cases for the preoperative assessment of rectal carcinoma.

The value of water-soluble contrast radiology in the management of acute small bowel obstruction.

A series of 127 consecutive patients with symptoms and signs and radiological features suggestive of acute small bowel obstruction underwent water-soluble contrast small bowel follow-through examination. A dose of 100 ml of Gastrograffin in adults, or 20-50 ml in children, was injected via a nasogastric tube and supine plain abdominal radiographs were taken at 30 min and 4 h after administration. If contrast passed to the colon a non-operative course was followed. If there was a clear cut-off in contrast level in the small bowel or if contrast failed to pass into the large bowel by 4 h, patients underwent laparotomy. Based on these radiological findings 15 patients (11.8%) underwent surgery and all had established small bowel obstruction at laparotomy. The remaining 112 patients were successfully managed conservatively. Water-soluble contrast radiology is safe, easy to use and to interpret, and is a major benefit in differentiating mechanical from other causes of small bowel obstruction. Our experience indicates that this underused technique is of significant value in identifying those patients who require urgent surgery.

The prognostic value of nucleolar organiser regions in colorectal cancer: a 5-year follow-up study.

Nucleolar organiser regions (AgNORs) are loops of ribosomal DNA which reflect the cellular activity or malignant potential of the cell and are identified by a specific staining technique. The purpose of this study was to assess the prognostic value of AgNORs in colorectal cancer and to compare it with other accepted prognostic methods. We studied 164 patients who were surgically staged for colorectal cancer and who had complete follow-up data available for 5 years. Using a highly specific silver staining and counting technique each patient was given an AgNOR score. There were 5 Dukes' C tumours, 108 were Dukes' B and 5 were Dukes' A. No cancer deaths occurred in patients with Dukes' A tumours. The incidence of well-differentiated, moderately-differentiated and poorly-differentiated tumours was 37.2%, 53.7% and 9.1%, respectively. Non-survivors had significantly higher AgNOR scores compared with survivors (mean value +/- SD, 14.2 +/- 0.9 vs 8.2 +/- 0.6, P less than 0.0001). In a regression analysis model AgNOR score was the most significant individual variable for predicting survival (chi 2 = 15, P less than 0.01) when compared with Dukes' classification, histological grade, tumour depth or vascular invasion.

Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy.

To identify patients with common bile duct stones, all patients considered for laparoscopic cholecystectomy in this unit undergo intravenous cholangiography (IVC) with tomography and, more recently, operative cholangiography. To date 100 consecutive patients with symptomatic gallstones have undergone laparoscopic cholecystectomy with no specific exclusion criteria. Eight patients of 100 were found to have duct stones on IVC with one false-positive. These IVC data were compared with data from 52 patients who also had operative cholangiograms performed. One stone was detected on operative cholangiography that was not identified on IVC. No additional information was gained from operative cholangiography. These data suggest that preoperative IVC is adequate for the detection of duct stones in patients considered for laparoscopic cholecystectomy.

Gastrointestinal complications in 4473 patients who underwent cardiopulmonary bypass surgery.

Thirty-nine gastrointestinal complications occurred in 35 of 4473 patients (0.78 per cent) who underwent surgery involving cardiopulmonary bypass during an 8-year period. The mortality rate when one of these complications occurred was 22 (63 per cent) representing 11.5 per cent of the 191 deaths from all causes in the series. The relative risk of developing a gastrointestinal complication was 1:249 when the heart was not opened, 1:66 when it was and 1:5 after cardiac transplantation. Gastrointestinal bleeding (n = 20) was the most common complication of whom nine (45 per cent) died, followed by intestinal infarction (n = 12) with eight (67 per cent) deaths and acute pancreatitis (n = 6) all of whom died. There was one death after surgery for gastrointestinal bleeding (n = 7). No patient survived bowel infarction without operation but resection was possible in five of the eight who underwent surgery, four of whom survived. The results demonstrate that surgical intervention is not associated with undue mortality but inappropriate conservative therapy is poorly tolerated in this high-risk group.