Management of synchronous tumours of the oesophagus and pancreatic head: a novel approach.

Synchronous tumours of the oesophagus and pancreatic head are very rare. This report describes a unique case of an adenocarcinoma of the distal oesophagus and a neuroendocrine tumour of the pancreatic head diagnosed synchronously but successfully managed metachronously. Initially, the patient underwent an oesophagectomy, with a colonic reconstruction following some months later by pylorus-preserving pancreaticoduodenectomy. A staged resection was performed after a review of the literature suggested increased morbidity with synchronous major abdominal operations.

Feeding jejunostomy: is its routine use in major upper gastrointestinal surgery justified?

An audit of jejunostomy feeding following major oesophagogastric surgery was carried out. The aim was to measure caloric and nitrogen intake, weight change, and to record complications. Twenty consecutive patients undergoing elective upper gastrointestinal surgery resulting in either an oesophagogastric or oesophagojejunal anastomosis were studied prospectively. In the eighteen cases whose catheters functioned, average calorie and nitrogen intake per day over the first 10 postoperative days was 1360 Kcal and 7.2 g respectively and average weight loss at 10 days was 1.3 kg. There was one major complication due to catheter dislodgement, resulting in an extraperitoneal abscess and subsequent small bowel fistula. In one other case the catheter was blocked from the immediate postoperative period and this could not be remedied. In the eighteen patients who were fed via the jejunostomy for 10 days, mild diarrhoea occurred in eight cases, but was easily managed. As experience with the technique increased, there was a significant increase in the amount of calories and nitrogen administered. This audit has demonstrated that provided care is taken with the technique of insertion of the jejunostomy catheter, satisfactory nutritional support can be provided in patients following oesophageal anastomoses with a low morbidity rate.

Traumatic diaphragmatic rupture.

Twenty-three cases of traumatic diaphragmatic rupture due to blunt and penetrating trauma are reviewed. The need for early diagnosis is stressed. Chest radiography was the most sensitive diagnostic method (66% for blunt trauma), although other techniques are discussed. The high incidence of associated intra-abdominal injury (83%) mandates primary abdominal approach to repair. An overall mortality of 31% reflects the severity of the trauma.

Laser photocoagulation in the treatment of malignant dysphagia.

BACKGROUND: Dysphagia secondary to carcinoma of the oesophagus and gastric cardia is the principal symptom requiring palliation in those patients who present with late-stage disease or who are unfit for surgery. The primary aim of the present study was to determine the safety and efficacy of laser photocoagulation in the palliation of malignant dysphagia. Secondary aims were to look at reasons for failure and predictors of outcome; to determine the most appropriate second line therapy for treatment failures; and to look at the results of treatment for early stage disease. METHODS: Sixty-seven patients treated over a 6-year period with endoscopic Nd:YAG laser photocoagulation were evaluated and the quality of swallowing assessed before and at intervals after treatment. RESULTS: Ninety per cent of patients achieved successful initial palliation. This was sustained in 76% after 3 months of treatment. Within a month before death 71% of patients were palliated but 29% required the addition of second-line treatment to achieve this. Complications were infrequent. There were no deaths attributable to laser treatment. Five of 10 patients treated with radiotherapy developed fibrous stricturing that required endoscopic dilatation. No variables were independently predictive for treatment failure. Six patients with early stage disease experienced prolonged survival. CONCLUSIONS: We conclude that laser photocoagulation offers safe and effective palliation of malignant dysphagia in this group of patients and is appropriate as first-line therapy.

Hepatocolonic vagrancy: wandering liver with colonic abnormalities.

Abnormalities of hepatic fixation resulting in excessive mobility in a transverse plane are uncommonly encountered. The unusual incidental finding of a freely mobile liver and spleen in a patient presenting with sigmoid volvulus is reported. At laparotomy, the inferior aspect of the right hemidiaphragm was smoothly peritonealized, without evidence of coronary or triangular ligaments. It is postulated that this abnormal hepatic mobility reflects persistence of the primitive ventral mesogastrium. To the authors' knowledge, this unusual condition has not previously been recognized. The literature relating to wandering liver is reviewed and four other cases are presented. An invariable association of persisting ventral mesogastrium with abnormalities in colonic anatomy (hepatocolonic vagrancy) is described.

Thoracoscopic cardiomyotomy for achalasia.

Twelve patients with achalasia treated by cardiomyotomy via a thoracoscopic approach have been studied prospectively. Seven patient had previously undergone balloon dilatation with an unsatisfactory result. The procedure was completed successfully in all patients without recourse to thoracotomy. Morbidity was minimal and postoperative stay averaged 4 days. The functional result was good/excellent in 11 patients and fair in one.

Superficial (early) gastric cancer.

A review of superficial gastric cancer (SGC) has been carried out. Data on the 20 cases who underwent surgery in the 6 years 1982-87 were obtained. The diagnosis of malignancy was established histologically preoperatively in 95% of cases, although more than one endoscopy was required in 50%. In 75%, the primary was confined to the mucosa and in the remainder it had penetrated the submucosa. Lymph node metastases were present in 20%, but distant metastases were not detected. There were no postoperative deaths, and no patient was diagnosed as having recurrent disease during a median follow-up period of 33 months.

Splenectomy for trauma: morbidity, mortality and associated abdominal injuries.

Management of ruptured spleen still frequently requires splenectomy. A retrospective analysis of patients undergoing splenectomy for trauma at Box Hill Hospital, Melbourne, over a 14-year period was conducted; 141 of 145 cases were due to blunt trauma. The mortality rate was 10% and all deaths occurred as a result of road traffic accidents. The overall complication rate was 43%, varying from 25% in those with an isolated splenic injury to 100% with multiple system injuries. There was zero incidence of associated intra-abdominal injury in the group sustaining a ruptured spleen as a result of a fall, assault or sporting injury, in contrast to a nearly 50% incidence following road traffic and bicycle accidents. Whether these associated injuries would have been neglected had laparotomy for splenic trauma not been performed is uncertain, and so non-operative management of splenic trauma remains contentious, particularly in cases following vehicular accidents.

Collis-Nissen gastroplasty fundoplication for complicated gastro-oesophageal reflux disease.

Collis-Nissen gastroplasty fundoplication is a widely accepted operation for patients with gastro-oesophageal reflux disease complicated by oesophageal shortening. Assessment of this operation by 24 h oesophageal pH monitoring has not previously been reported. Our aim was to correlate clinical and endoscopic results with 24 h pH studies. Twenty-nine patients had a gastroplasty fundoplication, as a result of which twenty-five (86%) had an excellent clinical result, 2 (7%) had a good result and 2 (7%) had a poor result. The two poor results were in patients who had previously undergone anti-reflux surgery. All 29 patients had pre-operative pH monitoring. Twenty-three patients had postoperative pH studies. Oesophageal acidification times were normal postoperatively in 16 of 23 patients however, 7 still had an abnormal study. One of the two patients with a poor clinical result was studied and persistent severe oesophageal acidification was demonstrated. The remaining 6 patients with abnormal studies were asymptomatic. Five of the 6 asymptomatic patients also had a normal oesophagogastroscopy with no macroscopic oesophagitis. We conclude that 24 h pH monitoring after the Collis-Nissen operation should only be performed to assess clinically and endoscopically poor results.

Survival following non-penetrating trauma of the great cardiac vein.

A 62 year old female who survived cardiac tamponade due to an isolated tear to the great cardiac vein in a motor vehicle accident is presented. It is believed that this is the first report of such an isolated blunt cardiac injury.

A prospective trial of open versus laparoscopic appendicectomy.

BACKGROUND: An assessment of the value of laparoscopic appendicectomy was performed. METHODS: During 1993, all patients above the age of 13 years admitted with clinical appendicitis to Box Hill were assigned to an open or laparoscopic procedure depending on whether the surgeon on call was an 'open' or 'laparoscopic' surgeon for the purpose of the study. Ninety-two patients were entered in the study, of whom 57 were in the open group. The rate of histologically proven appendicitis was 73.9%. RESULTS: No significant difference between the groups was found in the use of narcotic analgesia, length of stay or incidence of wound infection. However, operating time was significantly longer in the laparoscopic group. CONCLUSIONS: Laparoscopic appendicectomy on an unselected group of patients does not confer many advantages but laparoscopy may be beneficial in certain subgroups.

Glucose and insulin levels in duodenal ulcer disease before and after surgery.

Glucose and insulin responses to a standardized test meal in patients with chronic duodenal ulceration were measured pre-operatively and again post-operatively. An abnormal pre-operative glucose tolerance contributes to an even more deranged post-operative glucose tolerance. However, following administration of an alpha-glucosidase inhibitor, Acarbose, these post-operative abnormalities are markedly attenuated.

Comparison of length of stay after hernia repair in two Victorian hospitals. Standards Sub-committee of the Victorian State Committee of the Royal Australasian College of Surgeons.

The objective of this study was to ascertain factors which determine the length of stay in relation to adult patients admitted for hernia surgery in two different hospitals. It was conducted prospectively on a total of 141 patients, 82 in a central hospital and 59 in a district hospital. There were no significant differences with regard to age, sex, type of hernia, pre-existing disease and postoperative complications. There was a significant difference between the average length of stay in the two hospitals (6.7 days in the central hospital and 3.9 days in the district hospital). There was a longer pre-operative stay in the central hospital through administrative problems, availability of operating time and admission for pre-operative investigations. In the postoperative period there was a significant difference between the day of operation and the time the surgeon stated that the patient could be discharged (i.e. the surgically advised discharge (SAD) date). This period was 4 days at the central hospital, as against 2 days at the district hospital. Once the SAD date was determined, there was no difference between the two hospitals with regard to placement. Consideration should be given to improving admission practices, including patient 'work-up' in the preadmission phase and to shortening the postoperative stay after hernia surgery.

Developing clinical indicators for cholecystectomy.

This study sets out to develop a set of clinical indicators for the frequently performed procedure, simple cholecystectomy. Four hundred consecutive cases of cholecystectomy were reviewed retrospectively and data were collected regarding the pre-operative condition of the patient as well as any postoperative complications. From this database a set of clinical indicators for simple cholecystectomy are recommended: wound infection rate 4.5%, re-operation or performance of another therapeutic procedure 3.5%, length of stay 7 days, and mortality < 0.025%. These threshold figures are to serve only as a 'flag' to possible problems.

Colorectal resection in Victoria:a comparison of hospital based and individual audit.

BACKGROUND: The results of personal audit have not been tested against a hospital-based audit previously and the results of two such audits of colorectal resection in the State of Victoria have provided this opportunity. In addition, data reflecting the results of colorectal resection across a range of hospitals and surgeons in the Victorian community have been obtained. METHODS: A total of 535 patients undergoing a colorectal resection, with an anastomosis performed, were studied in two serially conducted prospective audits arranged by the Standards Sub-Committee of the Victorian State Committee. One study was public hospital-based and the second was based on voluntary reporting by individual surgeons. RESULTS: Similar results were obtained in each study, demonstrating the accuracy of individual reporting. The combined results (wound infection rate 12.3%, anastomotic leak rate 3.7% and mortality 4.5%) are compared to previously published data. CONCLUSIONS: In the State of Victoria the results of audit by individual surgeons performing colorectal resection were similar to the hospital-based audit. The results obtained compare favourably with previously published data.

Clinical indicators in colorectal surgery.

Two studies conducted in the state of Victoria have tested potential clinical indicators and the suggested thresholds for resection of colorectal carcinoma where an anastomosis has been performed. These studies involving 535 patients were independent of one another: one hospital based and one surgeon based. Threshold figures for these draft indicators have been compared with the study figures and found to be similar. It is suggested that wound infection (elective operation without formation of a stoma), anastomotic leak (clinically recognized) and mortality (elective operations in patients under the age of 80 years) are the most appropriate clinical indicators of colorectal resection for carcinoma.