Randomized clinical trial of the influence of local subcutaneous infiltration vs subcutaneous and deep infiltration of local anaesthetic on pain after appendicectomy.

INTRODUCTION: Local anaesthesia is commonly used to provide pain relief after surgery. The aim of this randomized, blinded prospective trial was to evaluate whether local subcutaneous and deep infiltration of local anaesthetic provides better postoperative pain control than subcutaneous infiltration alone. METHOD: Eighty-four patients undergoing open appendicectomy for presumed acute appendicitis were randomly assigned into two groups. Group A received local infiltration of the skin prior to incision with bupivacaine whilst group B received half the bupivacaine infiltrated into the skin and the other half deep-to-external oblique to create a local nerve field blockade. Postoperative pain was assessed, on a scale of 1 to 10, at 1, 4, 8 and 24 h postextubation. RESULTS: At time intervals of 1, 4 and 8 h, there was no significant difference in pain score between group A and group B. At 24 h group B had significantly lower pain scores than group A (2.3 vs 3.4, P = 0.016). CONCLUSION: Both methods of administration of local anaesthetic produced consistently low pain scores in the first 24 h after appendicectomy. There may be additional benefit in a local nerve field blockade in combination with local anaesthetic skin infiltration.

Doppler-guided haemorrhoidal artery ligation: long-term outcome and patient satisfaction.

OBJECTIVE: Conventional Milligan-Morgan haemorrhoidectomy is associated with significant pain and potentially hazardous complications. Doppler-Guided Haemorrhoidal Artery Ligation (DGHAL) may offer a lower risk, pain-free alternative. We present our early and long-term outcome experience with DGHAL, combined with patient views and satisfaction with the procedure. METHOD: One hundred and thirteen DGHALs were performed over a 13 month period by two surgeons in a single centre. Patients graded the severity of postoperative pain on visual-analogue scales. Clinical follow-up was at 6 weeks (n = 103), with long-term follow-up (n = 90) by postal questionnaire at median of 30 months. RESULTS: Seven out of one hundred and three (6%) patients reported postoperative discomfort requiring analgesia. Ninety-three out of one hundred and three (90%) patients reported complete relief or significant improvement in their symptoms at 6 weeks, dropping to 77/90 (86%) at 30 months. Anal fissures developed in 2/103 (2%) patients, both treated with Diltiazem ointment. Further surgery was required in 8/90 (9%) patients. Eighty-two out of ninety (91%) patients said they would undergo DGHAL again. CONCLUSION: DGHAL is a relatively painless, safe, and effective procedure for symptomatic stage I-III haemorrhoids, for which we have demonstrated long-term durability and acceptability. Its role lies between office based procedures and more invasive operative interventions.

Partial excision of the clavicle for nonunion in National Hunt Jockeys.

National Hunt jockeys suffer a disproportionate number of clavicular fractures and their return to riding may be considerably delayed by refracture and symptomatic nonunion, with obvious implications. We report six such cases in which excision of the clavicular fragment distal to the fracture was associated with an early return to work and no recurrent injury to the shoulder.

A comparison of laparoscopic and open inguinal hernia repair in servicemen.

In a prospective comparison of 70 servicemen undergoing inguinal hernia repair by either the Shouldice method or by laparoscopy, it was found that the laparoscopic operation took longer (mean 52.6 minutes compared to 28.4) and required a postoperative hospital stay as long as that following open operation. However the postoperative analgesia requirement was significantly less, and the patients undergoing laparoscopic herniorraphy were able to regain full fitness and to return to work earlier than those having a Shouldice repair. Despite the higher costs of the laparoscopic operation we believe that the earlier return to work makes this technique cost-effective.

Surgery for large intra-abdominal desmoid tumors: report of four cases.

PURPOSE: Desmoids are rare, locally aggressive but nonmetastasizing fibrous masses that occur sporadically and in association with familial adenomatous polyposis. Therapeutic options are limited, and there is reluctance to operate on mesenteric desmoids because of the risk of complications or recurrence. Consequently, there is an increasing reliance on alternative therapeutic modalities. Nonsurgical options are of variable efficacy, however, and surgery is still required for the complications of desmoids. Each of the last four patients with desmoids presenting to this unit has required life-saving surgery as a result of failure of nonsurgical treatments or the development of complications. METHODS: We present case reports of four consecutive patients with large mesenteric desmoid tumors requiring surgical management. RESULTS: All four patients had massive mesenteric desmoids. Three cases associated with familial adenomatous polyposis had developed their desmoids after colectomy while the sporadic desmoid had continued to grow rapidly after diagnosis at laparotomy. Sulindac and toremifene were unsuccessful in all cases and one patient with familial adenomatous polyposis suffered dramatic erosion of her desmoid through the abdominal wall during antisarcoma chemotherapy. Two others required emergency laparotomy for complications, and the sporadic case underwent elective resection for symptomatic relief. Three had complete excision of their desmoid, and all remained well with no recurrence at a median follow-up of 12 (range, 7-14) months. CONCLUSION: Despite the risks, there remains a role for surgery in the management of large mesenteric desmoids.

Telomere length in familial adenomatous polyposis-associated desmoids.

PURPOSE: The aim of this study was to establish the length of telomeres in familial adenomatous polyposis-associated desmoids. METHODS: DNA from 21 desmoids and five desmoid precursor lesions was digested with HinfI and RsaI restriction enzymes. Southern blotting of the resolved fragments was performed, and the membranes were hybridized with a specific probe attached to a chemiluminescent substrate. Terminal restriction fragment lengths were measured. RESULTS: The median terminal restriction fragment length for the desmoids was 8 (range, 6-9.6) vs. 7.7 (range, 6.4-9.9) kb for their controls. Median terminal restriction fragment length for the desmoid precursor lesions was 9 (range, 7.8-10.4) vs. 8.8 (range, 6.8-10.9) kb for their controls. There was no statistically significant difference between samples and their controls. CONCLUSION: Immortality may not be necessary for desmoid development, or there may be other mechanisms maintaining telomere length. Novel treatments involving telomerase inhibition will be inappropriate in the management of desmoids.

Desmoids in familial adenomatous polyposis are monoclonal proliferations.

Desmoids are poorly-understood, locally aggressive, non-metastasizing fibromatoses that occur with disproportionate frequency in patients with familial adenomatous polyposis (FAP). Their nature is controversial with arguments for and against a neoplastic origin. Neoplastic proliferations are by definition monoclonal, whereas reactive processes originate from a polyclonal background. We examined clonality of 25 samples of desmoid tissue from 11 female FAP patients by assessing patterns of X-chromosome inactivation to calculate a clonality ratio. Polymerase chain reaction (PCR) amplification of a polymorphic CAG short tandem repeat (STR) sequence adjacent to a methylation-sensitive restriction enzyme site within the human androgen receptor (HUMARA) gene using fluorescent-labelled primers enabled analysis of PCR products by Applied Biosystems Genescan II software. Twenty-one samples from nine patients were informative for the assay. Samples from all informative cases comprised a median of 66% (range 0-75%) clonal cells but from the six patients with a clonality ratio < or =0.5 comprised a median of 71% (65-75%) clonal cells. FAP-associated desmoid tumours are true neoplasms. This may have implications in the development of improved treatment protocols for patients with these aggressive tumours.

Familial adenomatous polyposis complicated by an intrahepatic desmoid tumor: report of a case.

Desmoids are uncommon proliferations of fibroblasts that occur with disproportionate frequency in patients with familial adenomatous polyposis. They do not metastasize and are histologically benign. Despite this, the unpredictable and often aggressive nature of familial adenomatous polyposis-associated desmoids and their tendency to occur in intra-abdominal sites means that they present a difficult management problem, and they are a leading cause of death in patients with familial adenomatous polyposis who have undergone colectomy. We report a case of a patient with familial adenomatous polyposis who had extensive and aggressive desmoid disease and whose management was further complicated by a large intrahepatic desmoid. There are no previous reports of desmoids occurring in the liver.