Application of Variable Life Adjusted Display (VLAD) to risk-adjusted mortality of esophagogastric cancer surgery.

PURPOSE: In the new era of revalidation, there is an increasing need to measure surgical outcome objectively. We apply a graphical method, the Variable Life Adjusted Display (VLAD), to esophagogastric resection for malignancy. This technique charts the cumulative difference between expected and actual risk-adjusted mortality over time, allowing observation of performance trends irrespective of case-mix. METHODS: P-POSSUM was applied retrospectively to 182 consecutive patients who underwent resection for esophageal or gastric malignancy in a district general hospital. The primary outcome measured was 30-day mortality. RESULTS: A total of 168 patients were eligible for inclusion, with a median age of 68 years. The overall 30-day mortality rate was 4.2% compared with 7.1% as predicted by P-POSSUM. The resulting VLAD plot demonstrates an upward trend of better than predicted surgical performance. CONCLUSIONS: VLAD has been hereby applied to esophagogastric surgery and has graphically demonstrated risk-adjusted trends in a single general surgeon's performance. For qualitative comparative purposes, including recertification, VLAD is judged to be a simple, directly interpretable, and useful technique for monitoring surgical performance.

Pancreatic mediastinal pseudocyst: report of two cases simulating intrathoracic disease.

Mediastinal pseudocysts of the pancreas are extremely rare. Intra-thoracic symptoms such as dysphagia or dyspnoea due to compression or associated pleural effusions are common and urgent decompression by percutaneous or internal drainage is often necessary.

Impact of open-access endoscopy on detection of early oesophageal and gastric cancer 1994 - 2003: population-based study.

BACKGROUND AND STUDY AIMS: There is conflicting evidence regarding the ability of open-access endoscopy to detect oesophageal and gastric cancers at an earlier stage. The aim of the study was to assess the impact, with regard to earlier diagnosis of oesophageal and gastric cancer, of the first 10 years of a regional open-access endoscopy service in the Dumfries and Galloway region of Scotland. PATIENTS AND METHODS: Data were retrieved from prospectively compiled endoscopy and cancer registry databases. Route of referral (open-access vs. outpatient vs. inpatient), presenting symptoms (alarm vs. benign) and UICC disease stage in consecutive 5-year periods (1994 - 1998 and 1999 - 2003) were compared. RESULTS: 386 oesophagogastric cancers were identified (179 during 1994 - 1998 and 207 in 1999 - 2003). The number of patients undergoing endoscopy increased from 500 per annum prior to the open-access service to 7359 during 1994 - 1998 and 9701 in 1999 - 2003. Patient age, route of referral and presenting symptoms were unchanged. There was no improvement in disease stage at diagnosis (stage I, 7 % vs. 7 %; stage II, 16 % vs. 17 %; stage III, 31 % vs. 28 %). CONCLUSIONS: Despite a 32 % increase in endoscopy workload, the provision, over 10 years, of a regional open-access endoscopy service was not associated with earlier detection of oesophageal or gastric cancer.

The control of male stress incontinence by implantable prostheses.

Twenty-six patients were treated by implantable prostheses in a 10-year period, 22 by primary Kaufman III and four by primary Rosen. Sixteen of 22 patients having the Kaufman III procedure were cured or markedly improved over a follow-up period of 6 months to 10 years. The Rosen prosthesis, whilst simple to install and making the patient continent, eventually produced urethral fistulae in all cases. The Kaufman III prosthesis appears to be the procedure of choice in uncomplicated male stress incontinence.

Splenic abscess: is conservation applicable?

A rare occurrence of salmonella abscess in a congenital cyst of the spleen is presented. Although splenectomy was curative, the role of splenic salvage is discussed. Percutaneous drainage is curative in about 70% of cases and may be the treatment of choice in solitary thick-walled abscesses. It should be remembered, however, that residual or regenerated splenic tissue is no absolute guarantee against sepsis. The treatment of splenic abscess should be individualised.

Familial osteochondritis dissecans and carpal tunnel syndrome.

A short-statured family -- mother, son and daughter -- each with osteochondritis dissecans (O. D.) of the elbow and two with O.D. of the knee is described. The mother and her siblings had, in addition, carpal tunnel syndrome.

Histopathological review of transitional cell carcinoma of the upper urinary tract.

A histopathological review of 30 patients with transitional cell carcinoma (TCC) of the upper urinary tract showed that 21 patients had dysplastic epithelium adjacent to the tumour, irrespective of the degree of invasion; 20 patients had multifocal disease with some degree of dysplasia or carcinoma elsewhere. It is concluded that radical surgery should be performed whenever possible, even in the superficial low grade tumour.

Missed diagnoses in patients with upper gastrointestinal cancers.

BACKGROUND AND STUDY AIMS: A few studies have been published on cancers missed at previous endoscopy, but detailed analyses of the causes for failure were lacking. The aims of our study were to determine the incidence of and causes for failure to detect oesophageal and gastric cancers after referral of patients to a surgical endoscopy unit. PATIENTS AND METHODS: Out of a consecutive series of 305 patients diagnosed with oesophageal and gastric cancers, we retrospectively identified patients who had undergone an endoscopy within 3 years before the diagnosis. The timing of previous endoscopies, indications for endoscopy, endoscopic findings and the number of biopsy specimens taken were recorded. Missed diagnoses were categorized as either definitely or possibly missed and the reasons for failure were documented. RESULTS: Of the 305 patients, 30 (9.8 %) had undergone a minimum of one endoscopy within the previous 3 years, 20 (67 %) of these within the previous 1 year. Sinister symptoms were present at the time of previous endoscopies in 75 % of patients with oesophageal cancer (n = 16) and in 57.2 % of patients with gastric cancer (n = 14). In 56 % of the patients with oesophageal cancers the initial diagnosis was oesophagitis or benign stricture; in 71.4 % of the patients with gastric cancers the initial diagnosis was gastritis, ulcer or "suspicious lesion". Among those patients with a definitely missed diagnosis (7.2 %), endoscopist errors accounted for the majority of failures (73 %) and the remainder were due to pathologist errors (27 %). CONCLUSIONS: Missed cancers were a frequent finding in patients with oesophageal and gastric cancer who had undergone previous endoscopy, and errors by the endoscopists accounted for the majority of missed lesions. This study emphasizes the importance of identifying signs of early cancers and of having a low threshold for performing multiple biopsies of any suspicious-looking lesion.

Cooling responses in shivering and non-shivering dogs during induced hypothermia.

1. Hypothermia to a temperature of 30 degrees C was induced in both shivering and non-shivering groups of dogs. 2. There was a sustained increase in oxygen consumption in the dogs allowed to shiver and this was up to 300% greater than the oxygen consumption in the relaxed dogs. 3. The increased tissue requirement for oxygen was met both by increased cardiac output and increased oxygen extraction from haemoglobin. 4. Oxygen utilization remained adequate in hypothermia, as shown by the absence of hypoxic acidosis. 5. Heart rate fell during cooling and stroke volume increased to meet the increased oxygen demands associated with shivering during the induction of hypothermia.

Accidental hypothermia and rewarming in dogs.

1. Twenty lightly anaesthetized dogs were cooled to 29 degrees C by cold-water immersion. Ventilation was spontaneous and the animals were allowed to shiver freely. Metabolic heat production and respiratory heat exchange were measured during rewarming. 2. The animals were divided into four groups each of five dogs and each group was rewarmed by a different technique. The control group was allowed to rewarm spontaneously; a second group was given warm (45-50 degrees C) fully humidified air to breathe in addition; a third group was rewarmed in a hot-water bath (42-44 degrees C) and the remaining group was given in muscle relaxant to abolish shivering and rewarmed by warm inspired air only. 3. The group rewarmed in hot water achieved normal core temperature most rapidly but there was no difference in the rewarming rates of the group rewarmed spontaneously and of the group given warm air to breathe in addition. 4. The group given a muscle relaxant and rewarmed with warm inspired air required 12 h to achieve the same core temperature as the shivering groups achieved in 2 h. Compared with the heat produced by shivering the amount of heat which it was possible to transfer across the respiratory tract was so small that it did not materially influence the rate of rewarming.

Penetrating abdominal stab wounds: a plea for a more conservative policy.

This is a retrospective study of 107 penetrating abdominal stab wounds which have been reviewed on the basis of the clinical indications for surgery. Eighty-four patients underwent laparotomy. The unnecessary laparotomy rate was 35 per cent and the mortality 2.4 per cent. Important complications developed in 44 per cent of those undergoing surgery. Evaluation of clinical variables is presented and it is suggested that in the absence of shock, generalized peritonitis or evisceration, careful initial assessment, monitoring and regular re-examination would be a satisfactory method of treatment for many cases. This would result in a decrease in unnecessary laparotomies and associated excess morbidity.

Congenital absence of the gallbladder: ways of avoiding laparotomy.

Two cases of congenital absence (agenesis) of the gallbladder seen at one hospital over a 5-year period are presented. One patient presented with ascending cholangitis due to choledocholithiasis, while the other presented with right upper quadrant abdominal pain and equivocal findings on ultrasound and oral cholecystography. Although diagnosis was made at laparotomy in both cases, it is likely that the arrival of laparoscopic cholecystectomy will avoid laparotomy in the future. The place of laparoscopy in establishing the presence of this anomaly is discussed.

Prospective analysis of a scoring system to predict choledocholithiasis.

BACKGROUND: The management of choledocholithiasis in the laparoscopic era remains debatable. A common policy is to perform preoperative endoscopic retrograde cholangiopancreatography (ERCP) on patients suspected of having common bile duct (CBD) stones, using standard risk criteria. The aim of this study was to evaluate prospectively a scoring system designed to improve the accuracy of CBD stone prediction before laparoscopic cholecystectomy. METHODS: Known clinical, biochemical and radiological risk factors for CBD stones were analysed retrospectively in 233 patients. The presence (n = 77) or absence (n = 156) of CBD stones was determined by preoperative ERCP and/or laparoscopic cholangiography. Using multivariate analysis, the significant risk factors for CBD stones were identified and a new preoperative scoring system was developed. A score of 3 or more was taken as the cut-off point to suggest CBD stones and the need for preoperative ERCP. This scoring system was then tested prospectively in 211 consecutive patients with symptomatic gallstones requiring surgery. Patients whose bile ducts could not be demonstrated by ERCP or operative cholangiography were excluded. RESULTS: Fifty-five patients scored 3 or more (predicted ERCP rate of 29 per cent), of whom 23 (42 per cent) had proven CBD stones. Intraoperative cholangiography was successful in 87 per cent. Five patients (4 per cent) who scored less than 3 had small stones (less than 5 mm) demonstrated at operative cholangiography. The overall sensitivity and specificity of this scoring were 82 and 80 per cent respectively. CONCLUSION: Formal risk assessment of the presence of CBD stones using this scoring system is simple and may be used for preoperative selection of patients for biliary tract imaging by magnetic resonance cholangiography or ERCP.

Laparoscopic cholangiography: a prospective study.

BACKGROUND: The place of cholangiography has been controversial in the conventional and now in the laparoscopic setting. The aim of this study was to evaluate laparoscopic cholangiography and compare use of a portable C-arm image intensifier with conventional radiography. METHODS: One hundred and ninety-seven consecutive patients undergoing laparoscopic cholecystectomy were randomized before operation to cholangiography by either C-arm image intensifier or conventional radiography. Data were collected on a pro forma completed immediately after the operation. RESULTS: Cholangiography was successful in 93.0 per cent of patients. Cholangiography with an image intensifier was significantly faster. In 19 patients the ductal system was obscured by a cannula; in 17 of these cases a metal cannula was used. In 31.6 per cent of patients the clip on the cystic duct was within 1 cm or less of the common bile duct (CBD). CONCLUSION: Laparoscopic cholangiography is a safe procedure. Use of an image intensifier should be the preferred method of obtaining images. Metal cannulas are more likely to obscure the ductal system. The proximity of the clip on the cystic duct to the CBD highlights the potential for injury caused by electrocautery or erroneous clip application.

Needle core biopsy of the breast with a spring-loaded device.

Over a 2-year period, 151 outpatients with a palpable breast lump requiring needle core biopsy were randomized to a Tru-Cut 14-G (T14), Bioptycut 14-G (B14) or Bioptycut 18-G (B18) needle. Use of a Biopty gun resulted in less pain than a Tru-Cut needle. An inadequate sample was obtained after two needle passes in 11 of 49 (T14), none of 51 (B14) and two of 51 (B18) patients (chi 2 = 14.6, 2 d.f., P = 0.0007). Tissue samples were assessed by a single pathologist for tissue volume and overall diagnostic value; the B14 group scored better than the B18 and T14 for both of these parameters (P < 0.003). The sensitivities were 68 (T14), 88 (B14) and 96 (B18) per cent (overall chi 2 = 7.3, 2 d.f., P = 0.026). The Biopty gun with a 14-G needle results in a higher sampling success rate, greater diagnostic sensitivity and a better specimen quality than the Tru-Cut, and is much easier to use.

Hepatobiliary complications in chronic pancreatitis.

Thirty nine patients undergoing surgery for chronic pancreatitis were investigated for evidence of hepatobiliary disease. In addition to pre-operative assessment by liver function tests, ultrasound, ERCP (in 33) and percutaneous transhepatic cholangiography (in five), all had peroperative liver biopsy. Common bile duct stenosis was diagnosed in 16 (62%) of the 26 patients with successful cholangiography. Features of extrahepatic biliary obstruction were found on biopsy in 11 patients, three of whom showed features of secondary sclerosing cholangitis. No patients had secondary biliary cirrhosis. Three had parenchymal liver disease (cirrhosis, resolving hepatitis and alcoholic hepatitis respectively) and two others had features suggestive of previous alcohol-induced injury. Five (83%) of the patients with clinical jaundice had biopsy features of extrahepatic biliary obstruction, as did eight (67%) with alkaline phosphatase above twice normal and seven (44%) with radiological common bile duct stenosis. Neither alkaline phosphatase rise, nor common bile duct stenosis alone or in combination, were a reliable indication of the need for biliary enteric bypass surgery. Pre-operative liver biopsy may be a valuable adjunct in the assessment of such patients.

Audit of colorectal cancer surgery by non-specialist surgeons.

BACKGROUND: Some authorities recommend that colorectal cancer should be treated in specialist units but evidence that non-specialist units demonstrate comparatively poor results may be lacking. METHODS: Between 1987 and 1991, 267 patients were operated on by four general surgeons, none of whom was a specialist in colorectal surgery. Procedure-related complications, postoperative mortality and disease-related survival rates were analysed. RESULTS: There were four cases of intraperitoneal sepsis (1 per cent) and five of 189 patients (3 per cent) had clinical anastomotic dehiscence; there was no case of wound dehiscence. The postoperative mortality rate after elective and emergency surgery was 2 and 13 per cent respectively. The 5-year disease-related survival rate for curative and palliative surgery was 67 and 9 per cent respectively. There were no significant differences between the surgeons. CONCLUSION: Disease-related variables such as early-stage disease and fewer patients presenting as emergencies may have a greater favourable influence on ultimate survival than surgeon-related variables.