How long should suction drains stay in after breast surgery with axillary dissection?

Daily suction drainage volumes were recorded for 63 patients after wide local excision of a breast carcinoma with axillary dissection (n = 37) or mastectomy with axillary dissection (n = 26). Suction drains were removed at the discretion of the clinical ward staff after a median of 4 days (range 1-7 days). In all, 32 patients (51%) later developed seromas requiring needle aspiration. Minor wound infection rate was not significantly higher in patients who developed seromas than those who did not (5 vs 2). Seroma formation was associated with a larger total suction drain volume (mean 480 ml (range 28-1150 ml) vs 240 ml (range 10-635 ml); P = 0.0001). The median yield of axillary lymph nodes was significantly greater in those who developed seromas (11 (range 4-20) vs 8 (range 1-19); P = 0.002). There was no difference in the volume drained in the 24 h preceding drain removal (mean 60 ml (range 0-150 ml) vs 50 ml (range 0-290 ml); NS). Keeping drains in situ longer did not protect against seroma formation. By 48 h, 74% of the total volume drained by each drain had been collected. Seroma formation after breast surgery with axillary dissection is an inconvenience for a high proportion of patients. This complication does not seem to be reduced by prolonged suction drainage of the wound, which in itself delays patient discharge and causes further inconvenience.

Ultrasound localization of screen detected impalpable breast tumours.

Accurate localization of a tumour is imperative before excision biopsy for impalpable breast lesions seen on screening mammography. Ultrasound localization has the advantages of being simple, quick and noninvasive. In a 3-year period from September 1989, 185 women have required localization of a breast tumour prior to biopsy, 159 were performed using a wire localization technique and 26 (14%) were performed using ultrasound alone. Twenty-two out of the 26 were malignant lesions. The mean maximum diameter of tumour diagnosed by ultrasound compared to histological sample was 10.6 mm (8.5-12.7*) to 11.1 mm (8.9-13.3*) with a correlation of r = 0.87. In the malignant cases the mean maximum diameter of tissue excised was 63.0 mm (57.2-65.9*). Complete excision was obtained in 21 out of the 22 patients with malignant disease by one operation. Ultrasound alone has been used successfully as a means of preoperative localization in selected cases prior to excision biopsy of a breast tumour.

Should endoscopic stenting be the initial treatment of malignant biliary obstruction?

Forty-two patients with biliary obstruction caused by a stricture had a diagnostic ERCP with subsequent insertion of a straight 10G endoprosthesis. These patients represented 70% of a cohort in which stent insertion had been attempted. The majority (63%) had pancreatic carcinoma, but 22% had malignant hilar obstruction. Five patients (12%) died within a few days of stent insertion; ERCP may have contributed to two deaths. Jaundice was relieved in all survivors. Median hospital stay was 6 days (range 2-32 days). After further investigation, nine patients were thought to be potentially curable and underwent laparotomy. Late complications after stent insertion alone included cholangitis (26%) and recurrent jaundice (28%). Only one patient developed gastric outlet obstruction and needed a gastroenterostomy. Median survival in the endoprosthesis group was 11 weeks (range 2-84 weeks). Survival was longer for patients with bile duct (14 weeks) rather than hilar strictures (6 weeks). Median survival after subsequent surgery was 40 weeks (range 4-80 weeks) with two long-term survivors. This study confirms that ERCP and stent insertion is a useful initial treatment for obstructive jaundice due to a biliary stricture, being both diagnostic and therapeutic. Subsequent evaluation for curative surgery is not precluded and in the majority of cases worthwhile palliation may be achieved by stenting alone.

Primary squamous cell carcinoma of the caecum.

A case of primary squamous cell carcinoma of the caecum arising in a tubulo-villous adenoma is described. This rare lesion develops following genomic derangement of the multipotential colonic stem cells. The literature is reviewed and factors contributing towards squamous cell differentiation discussed.

Signet ring cell adenocarcinoma of bladder secondary to long-term catheterization.

A case of signet ring cell adenocarcinoma of the bladder occurring in association with long-term suprapubic catheterization is presented, the tumor appearing to have arisen in dysplastic glands of metaplastic urothelium. The possible implications of this findings are presented.

Single dose cefotaxime plus metronidazole versus three dose cefuroxime plus metronidazole as prophylaxis against wound infection in colorectal surgery: multicentre prospective randomised study.

OBJECTIVE: To establish whether a single preoperative dose of cefotaxime plus metronidazole was as effective as a standard three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery. DESIGN: Prospective randomised allocation to one of two prophylactic antibiotic regimens in a parallel group trial. Group sequential analyses of each 250 patients were performed. SETTING: 14 District general and teaching hospitals. PATIENTS: 1018 Adults having colorectal operations were randomised, of whom 943 were evaluated. Demographic features, conditions requiring surgery, and operative procedures were similar in the two groups. Most patients had surgery for carcinoma of the colon or rectum. INTERVENTIONS: Group 1 received cefotaxime 1 g intravenously plus metronidazole 500 mg intravenously preoperatively. Group 2 received cefuroxime 1.5 g intravenously plus metronidazole 500 mg intravenously preoperatively, followed by cefuroxime 750 mg intravenously plus metronidazole 500 mg intravenously eight hours and 16 hours postoperatively. MAIN OUTCOME MEASURES: Development of surgical wound infection (as evidenced by the presence of pus), death, or discharge from hospital. RESULTS: Wound condition was scored on a five point scale on alternate days until discharge or for up to 20 days postoperatively. Wound infection rates were: group 1, 32/453 (7.1%; 95% confidence interval 4.7% to 9.4%); group 2, 33/454 (7.3%; 95% confidence interval 4.9% to 9.6%). Death rates (group 1: 26/470 (5.5%); group 2: 31/471 (6.6%], the incidence of postoperative complications, the median duration of hospital stay (12 days), and antibiotic tolerance were all similar in the two groups. Pooled data from groups 1 and 2 showed that wound infections were more frequent when minor faecal contamination had occurred at operation and when the duration of operation exceeded 90 minutes (greater than 90 min 11.2% of cases; less than 90 min 4.8%) and were associated with an extended hospital stay. CONCLUSIONS: A single preoperative dose of cefotaxime plus metronidazole is an efficacious as a three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery and has practical advantages in eliminating the need for postoperative antibiotics.

Pleomorphic rhabdomyosarcoma of the urinary bladder in association with recurrent urinary-tract infection.

An unusual case of pleomorphic rhabdomyosarcoma is presented which arose in the urinary bladder of an adult male in association with recurrent urinary-tract infection and bladder outflow obstruction, secondary to a chronic post-traumatic urethral stricture.

Squamous cell carcinoma of the anus arising within condyloma acuminatum.

Condyloma acuminatum are 'warty' lesions of viral aetiology. Four cases of squamous carcinoma arising within such condyloma are reported and discussed.

Does the addition of disinfectant to urine drainage bags prevent infection in catheterised patients?

The value of adding chlorhexidine to urine drainage bags of male patients treated with indwelling catheters after prostatectomy and other transurethral operations was assessed in a randomised, prospective, controlled was assessed in a randomised, prospective, controlled study. Chlorhexidine kept the contents of all drainage bags sterile, but the frequency of urinary infection in the chlordexidine group (51%) did not differ significantly from that in the control group (45%). Most infections were endogenous, caused by organisms which probably came from the patient's own urethra. It was concluded that the method has no value in urology units where standards of catheter care and closed drainage are properly maintained. Controlled studies in other types of catheterised patients are needed, especially when the risks of cross-infection are high.

Acute necrotizing colitis and obstruction.

Acute necrotizing colitis is a rare complication of colonic obstruction. Six cases occurring during a 20-month period are described. The presenting features were those of colonic obstruction with shock but without perforation. At laparotomy changes ranged from mucosal necrosis to frank gangrene in the colon proximal to the obstructing lesion. Gram stains of resected colon showed Gram-positive bacilli, resembling clostridia, invading the mucosa and submucosa. Two patients treated by defunctioning colostomy alone died but the remaining 4 survived after total colectomy. The cause is not known but raised intraluminal pressure may result in terminal mucosal ischaemia allowing anaerobic organisms to invade the bowel wall.

Arterial embolisation in renal carcinoma: a useful procedure?

Twenty-eight patients underwent embolisation over a 2-year period. III effects followed embolisation in 16 (57%), 2 of whom died. Attention is drawn to the intolerance of many patients to the length of the procedure. Of 24 patients undergoing operation, one case was inoperable and difficulty was encountered in 9. No perirenal plane of oedema was identified. No specimen examined histologically showed complete infarction. The tumour tissue was more resistant to infarction than normal kidney and 8 tumours (35%) appeared to have escaped completely. It is concluded that the role of embolisation is limited and that a combination of methods for achieving adequate arterial occlusion must be used for the optimum effect.

A randomised controlled trial to compare local with general anaesthesia for short-stay inguinal hernia repair.

A series of 117 consecutive unselected patients with clinically reducible unilateral inguinal herniae were admitted for short-stay repair. Seven expressed a strong preference for one form of anaesthesia (6 general (GA)) local (LA) and 7 were unfit for GA; these were excluded from the trial. The remaining 103 patients were allocated at random to receive either LA or GA in order to compare the two methods of anaesthesia. The resulting groups (53 LA, 50 GA) were well matched for age and obesity. Perand postoperative symptoms were assessed with linear analogues self-assessment questionnaires. Statistically significant differences were demonstrated between the groups; those patients having LA were able to walk, eat, and pass urine earlier than those having GA, who experienced more nausea, vomiting, sore throat, and headache. The postoperative course and additional symptoms were otherwise similar. Forty-five LA patients experienced mild pain during the operation, but nevertheless 85% of the total group said they would consent to its use again. Ninety-three patients (90%) were discharged at 24 h. LA was applicable to all types of clinically reducible inguinal hernia and was an acceptable, safe, and satisfactory alternative to GA.

Biochemical aids to the staging of breast cancer.

Up to fifteen plasma proteins were measured before treatment in 249 women presenting with lumps in the breast. Concentrations showed considerable overlap between the various clinical stages, and were often normal even in metastatic disease. A discriminant function is proposed, based on measurement of C-reactive protein, beta 2-microglobulin, carcinoembryonic antigen and ferritin and calculation of a score for each subject. High-risk scores resulted for all 18 patients with Stage 4 (i.e., metastatic) disease, and the number of Stage 1 patients attaining high scores was consistent with the reported incidence of development of metastases in such a group. Follow-up studies are in progress.