Effects of four intraoperative ventilatory strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients.

BACKGROUND: Respiratory function is impaired in obese patients undergoing laparoscopic surgery. This study was performed to determine whether repeated lung recruitment combined with PEEP improves respiratory compliance and arterial partial pressure of oxygen (Pa(O2)) in obese patients undergoing laparoscopic gastric banding. METHODS: Sixty patients with BMI >30 kg m(-2) were randomized, after induction of pneumoperitoneum, to receive either PEEP of 10 cm H2O (Group P), inspiratory pressure of 40 cm H2O for 15 s once (Group R), Group R recruitment followed by PEEP 10 cm H2O (Group RP), or Group RP recruitment but with the inspiratory manoeuvre repeated every 10 min (Group RRP). Static respiratory compliance and Pa(O2) were determined after intubation, 10 min after pneumoperitoneum (before lung recruitment), and every 10 min thereafter (after recruitment). Results are presented as mean (SD). RESULTS: Pneumoperitoneum decreased respiratory compliance from 48 (3) to 30 (1) ml cm H2O(-1) and decreased Pa(O2) from 12.4 (0.3) to 8.8 (0.3) kPa in all groups (P<0.01). Immediately after recruitment, compliance was 32 (1), 32 (2), 40 (2), and 40 (1) ml cm H2O(-1) and Pa(O2) was 9.1 (0.3), 9.1 (0.1), 11.9 (0.1), and 11.9 (0.1) kPa in Groups P, R, RP, and RRP, respectively (P<0.01). Ten and 20 min later, Pa(O2) in Group R decreased to 9.2 (0.1) kPa and compliance in Group PR decreased to 33 (2) ml cm H2O(-1), respectively (P<0.01). CONCLUSIONS: Group RRP recruitment strategy was associated with the best intraoperative respiratory compliance and Pa(O2) in obese patients undergoing laparoscopic gastric banding.

Follow up after LLETZ: could schedules be modified according to risk of recurrence?

OBJECTIVES: To document the pattern of recurrence of disease following large loop excision of the transformation zone (LLETZ) to identify a low risk group of women who might benefit from less intensive cytological surveillance. DESIGN: Analysis of prospectively collected information with retrospective review of follow up smears. POPULATION: Three thousand, five hundred and sixty women who underwent LLETZ (median age 31 years; IQR 12 years). SETTING: Colposcopy clinic at Northern Gynaecological Oncology Centre, Gateshead. METHODS: Women treated with LLETZ from 1988 to 1995 were reviewed. Information on the pathology from LLETZ was collected prospectively and information on the subsequent smears was obtained from the family health authorities. RESULTS: Invasive cancer was detected on the original LLETZ in 134 women who were excluded from the study. Of the remaining 3,426 women, histology of LLETZ showed high grade CIN (II and III) in 2,371 (69%). At least one follow up smear was undertaken in 3,385 women (99%). This constituted 9,765 women years of follow up with a mean duration of 35 months. Four hundred and seventeen women (12.2%) had a dyskaryotic follow up smear. Incomplete excision of the lesion and an age of > or = 50 years at the time of the LLETZ were associated with an increased risk of recurrent CIN. Based on these risk factors the study group was divided into three risk groups: 1. women aged < 50 with no disease at the margins (n = 1680); 2. women aged > or = 50 with disease at the margins (n = 93); and 3. women aged < 50 with positive margins, or aged > or = 50 with negative margins (n = 1653). The cumulative survival without recurrent CIN at five years for these groups were 92%, 57% and 86%, respectively. CONCLUSION: Women aged > or = 50 with CIN at the margins of excision constituted a small minority high risk group (3%). Consideration should be given to repeat treatment of these women rather than surveillance. Women aged < 50 with complete excision of low grade CIN comprised 51% of the study group. These women were at low risk of recurrent CIN and might benefit from less intensive cytological surveillance following LLETZ.

Simultaneous bilateral cataract extraction.

PURPOSE: To evaluate the visual outcome and safety of simultaneous bilateral cataract extraction. SETTING: Stobhill Hospital NHS Trust, Glasgow, United Kingdom. METHODS: This retrospective case review comprised 259 consecutive patients (518 eyes) who had simultaneous bilateral cataract surgery. Surgeries included bilateral extracapsular procedures, uniocular extracapsular procedures performed simultaneously with a different type of intraocular lens surgery in the other eye, and 1 bilateral intracapsular procedure. Outcome measures were postoperative best spectacle-corrected visual acuity (BSCVA), intraoperative and postoperative complication rates, and conjunctival swab culture results. RESULTS: Eighty-three percent of patients (75% of eyes) with measured preoperative and postoperative BSCVA achieved an acuity of 6/12 or better. Intraoperative and postoperative complication rates were similar to those in previous reports of unilateral extracapsular surgery and simultaneous bilateral cataract surgery. Endophthalmitis occurred in 1 eye (0.19%). There were no bilateral complications that resulted in visual loss. Cultures were positive from 42% of conjunctival swabs; 81% of positive cultures were coagulase-negative Staphylococcus and 10% were Staphylococcus aureus. CONCLUSIONS: Simultaneous bilateral cataract surgery did not lead to an increased incidence of serious intraoperative or postoperative complications, and visual acuity results were good.

Rupture of the uterus in labour: a review of 14 cases in a general hospital.

This study aimed to identify the risk factors and clinical presentations associated with rupture of the uterus in labour and to determine material and fetal outcomes. Rupture of the uterus is a potentially devastating complication of childbirth and remains one of the major causes of maternal and perinatal mortality and morbidity.

Accuracy of preoperative histology and macroscopic assessment of cervical involvement in endometrial carcinoma.

OBJECTIVE: To compare the diagnostic accuracy between the preoperatively and macroscopically established determination of cervical involvement in endometrial carcinoma. STUDY DESIGN: During the period 1987 to 1991, 154 patients with endometrial cancer were evaluated in a retrospective blind manner with the objective of assessing the diagnostic accuracy of the preoperative (prehysterectomy curettage) and the macroscopic (sectioned surgical specimen) determination of th involvement of the cervix. The results were compared with histological findings of the hysterectomy specimen (gold standard). RESULTS: Preoperative pre-hysterectomy curettage established a sensitivity of 38% and a specificity of 91% whereas the macroscopic findings (gross appearance) confirmed a sensitivity of 50% and a specificity of 95%. A prevalence of 17% for cervical involvement was found. In patients with cervical involvement diagnosed on pre-hysterectomy curettage, a positive predictive value of 45% and negative predictive value of 88% were established. A positive predictive value of 68% and a negative predictive value of 90% resulted from the judgement of the cervical gross appearance. CONCLUSIONS: We conclude that the cervical involvement of endometrial carcinoma diagnosed on pre-hysterectomy tissue is less predictive than the judgement of the intraoperative gross appearance of the cervix.

Role of appendicectomy in the surgical management of ovarian cancer.

There is a paucity of literature on the role of appendicectomy in the staging and cytoreductive procedures for ovarian cancer. In this series of 129 patients with ovarian carcinoma over a period of 9 years. (June 1985-June 1995) at the Northern Regional Department of Gynaecological Oncology, Gateshead, appendicectomy was performed in 31 patients. 11/31 were found to have metastases to the appendix. The concept of appendicectomy of a macroscopically abnormal appendix to achieve optimum debulking is accepted. The need for a prospective evaluation of the histological findings from macroscopically normal appendices removed in the presence of clinically staged early and advanced disease is required to define the role of appendicectomy in this group of patients.