Survey of general paediatric surgery provision in England, Wales and Northern Ireland.

INTRODUCTION: A survey was carried out to ascertain the current provision of general paediatric surgery (GPS) in all hospitals in England, Wales and Northern Ireland with 100% return rate. The provision of GPS is at a crossroads with a drift of these cases to the overstretched, tertiary referral hospitals. METHODS: The regional representatives on the council of the Association of Surgeons of Great Britain and Ireland (ASGBI) obtained data from their regions. Any gaps in the data were completed by the author telephoning the remaining hospitals to ascertain their current provision. RESULTS: A total of 325 acute hospitals are potentially available to admit elective and/or emergency paediatric patients, of which 25 hospitals provide a tertiary paediatric surgical service. Of the remaining 'non-tertiary' hospitals, 138 provide elective GPS and 147 provide emergency GPS. The ages at which GPS is carried out varies considerably, but 76% of non-tertiary hospitals provide elective GPS to those over the age of 2 years. The ages of emergency cases are 24% over the age of 2 years and 51.5% over the age of 5 years. The age at which surgery is carried out is dependent on the anaesthetic provision. Subspecialisation within each hospital has taken place with a limited number of surgeons providing the elective surgery. 'Hub-and-spoke' provision of GPS to a district general hospital (DGH) from a tertiary centre is embryonic with only 11 surgeons currently in post. An estimate of the annual elective case load of GPS based on the average number of cases done on an operation list works out at 23,000 cases done out with the tertiary centres. DISCUSSION: Almost 10 years ago, a change in the training of young surgeons took place. An increase in training posts in Tertiary centres was made available following advice from the British Association of Paediatric Surgeons (BAPS) but these posts were often not taken up. Many DGH surgeons became uncertain whether they should continue GPS training. A subtle change in the wording of the general guidance by the Royal College of Anaesthetists altered the emphasis on the age at which it was appropriate to anaesthetise children. Change in clinical practice, reducing need, and a drift towards tertiary centres has reduced DGH operations by 30% over a decade. Young surgeons are now seldom exposed to this surgery, and are not being trained in it. The large volume of these low-risk operations in well children cannot be absorbed into the current tertiary centres due to pressure on beds. The future provision of this surgery is at risk unless action is taken now. This survey was carried out to inform the debate, and to make recommendations for the future. The principal recommendations are that: (i) GPS should continue to be provided as at present in those DGHs equipped to do so; (ii) GPS training should be carried out in the DGHs where a high volume of cases is carried out; (iii) management of these cases should use a network approach in each region; (iv) hospital trusts should actively advertise for an interest in GPS as a second subspecialty; and (v) the SAC in general surgery develop a strategy to make GPS relevant to trainee surgeons.

Spontaneous rupture of a normal spleen.

A 45-year-old woman was admitted with a gangrenous toe. She had a pancreatico-renal transplant for end-stage renal disease due to type I insulin dependent diabetes three years previously and had been taking immunosuppressive agents. An epidural catheter was placed to relieve the rest pain. Next day she was found to be hypotensive and tachycardic along with other features of shock. She did not have any clinical symptoms and signs initially. Urgent blood investigations were normal except for Hb of 5.0 g/dl; an ultrasound scan showed free fluid in the peritoneal cavity. Emergency laparotomy after resuscitation confirmed a massive haemoperitoneum secondary to a ruptured spleen. Histology showed loss of areas of the capsule and other areas showing subcapsular haemorrhage with no underlying pathology in the spleen.

One-year survey of carcinoma of the oesophagus and stomach in Wales.

BACKGROUND: The aim of the study was to identify all patients who presented with oesophagogastric malignancy within a single National Health Service region (Wales) over 1 year, and to follow the cohort for 5 years. Management and outcome were analysed to identify current practice and draft guidelines for Wales. METHODS: Patients were identified from hospital records. Details were recorded in structured format for analysis. RESULTS: Analysable data were obtained for 910 of 916 patients. The overall incidence was 31.4 per 100 000 population. Treatment was by resection 298 (33 per cent), palliation 397 (44 per cent) or no treatment 215 (24 per cent). The 30-day mortality rate was 12 per cent and the in-hospital mortality rate was 13 per cent. Some 226 patients (25 per cent) were alive at 2 years. Resection conferred a significant survival advantage over palliation (P < 0.001) and no treatment. Anastomotic leakage occurred in 16 patients (5 per cent), of whom eight died in hospital. 'Open and close' operations were common (23 per cent), laparoscopy was infrequent (16 per cent), and many surgeons undertook small caseloads. Operating on fewer than six patients per year increased the mortality rate after partial gastrectomy (P < 0.05) and was associated with a trend to a higher mortality rate after mediastinal and cardia surgery. Operating on more than 70 per cent of patients seen resulted in a significantly higher mortality rate (P < 0.01) irrespective of case volume. CONCLUSION: Tumour resection conferred a survival advantage. Wider use of laparoscopy is advocated. Improved selection for surgery should result in a lower mortality rate.

Patients' perception of surgical services in a district general hospital.

BACKGROUND: In addition to studying the outcomes of surgery in terms of mortality and morbidity rates and performance, it is also important to consider how patients perceive the delivery of the service given to them. METHODS: A patient satisfaction survey was carried out by the Surgical Epidemiology and Audit Unit of the Royal College of Surgeons of England, on patients undergoing surgical procedures by the Department of Surgery at Wrexham Maelor Hospital. No day cases were included in the study. Two hospitals in southern England (undergoing the same survey) designated X and Y were used for comparison. RESULTS: Some 2000 questionnaires were sent out twice; 1666 subjects (83 per cent) responded to the first questionnaire and 1445 (87 per cent) of these responded to a second questionnaire 6 weeks later (overall response 72 per cent). A total of 35 per cent of patients were older than 65 years of age. Some 76 per cent of patients with a malignant condition were seen within 4 weeks of referral compared with 38 per cent of those with a benign condition (P < 0.0001). A total of 78 per cent of patients with cancer were admitted within 4 weeks compared with 84 and 88 per cent in hospitals X and Y. Some 23 per cent of patients were admitted as an emergency. Eighteen per cent of patients did not know who presented a consent form to them before surgery compared with 13 and 17 per cent in hospitals X and Y (P < 0.0001). Some 26 per cent of patients perceived that they had complications after surgery compared with 27 and 25 per cent for hospitals X and Y. A total of 35 per cent of patients did not receive a follow-up appointment and 20 per cent of these patients were unhappy about this. Two areas of major concern revealed by the responses were the lack of written information and the overall poor scores generally attained by the emergency admission ward. However, 94 per cent of patients said that they would return to the same consultant. CONCLUSION: Patients were generally happy with their surgical care and there was little difference between the three hospitals studied. Lower scores were given when patients were admitted to emergency admission wards. Higher scores were given when patients received printed information.

Oesophageal and gastric cancer pathology reporting: a regional audit.

AIM: To audit the information content of pathology reports of oesophageal and gastric cancer resection specimens in Wales. METHODS: All such reports from the 16 NHS histopathology laboratories in Wales in a one year period were evaluated for their information content. Two standards were used: (1) best practice reporting, and (2) a minimum dataset required for informed patient management that included clear statements on histological tumour type, depth of tumour invasion, lymph node involvement, and completeness of excision. RESULTS: 282 reports were audited. Minimum standards were achieved in 77% of gastric resections (156/203) and 53% of oesophageal resections (42/79). All laboratories achieved minimum standards in some gastric cancer reports (range 50-100%); three laboratories did not achieve minimum standards in any oesophageal cancer reports (range 0-100%). Best practice reporting was achieved in only 20% of gastric and 18% of oesophageal cancer reports. Failure to include an explicit statement on completeness of excision or involvement of the oesophageal circumferential resection margin were the most frequent causes of inadequate reporting. Most other data items were generally well reported, but apparent inadvertent omission of just one item was noted in many of the substandard reports. CONCLUSIONS: This audit shows the need to improve the information content of pathology reports in gastric and oesophageal cancer. The widespread implementation of template proforma reporting is proposed as the most effective way of achieving this. Multidisciplinary meetings of clinicians involved in cancer management should provide a forum for greater communication between pathologists and surgeons, and help to maintain standards of pathological practice.

Toxic bile acids in gastro-oesophageal reflux disease: influence of gastric acidity.

BACKGROUND: Bile acid toxicity has been shown in the gastric, colonic, and hepatic tissues; the effect on oesophageal mucosa is less well known. AIMS: To determine the spectrum of bile acids refluxing in patients with gastro-oesophageal reflux disease and its relation to oesophageal pH using a new technique of combined oesophageal aspiration and pH monitoring. METHODS: Ten asymptomatic subjects and 30 patients with symptoms of gastro-oesophageal reflux disease (minimal mucosal injury, erosive oesophagitis (grade 2 or 3 Savary-Miller), Barrett's oesophagus/stricture; n=10 in each group) underwent 15 hour continuous oesophageal aspiration with simultaneous pH monitoring. Bile acid assay of the oesophageal samples was performed using modified high performance liquid chromatography. RESULTS: The peak bile acid concentration and DeMeester acid scores were significantly higher in the patients with oesophagitis (median bile acid concentration 124 micromol/l; acid score 20.2) and Barrett's oesophagus/stricture (181 micromol/l; 43. 3) than patients with minimal injury (14 micromol/l; 12.5) or controls (0 micromol/l; 11.1). The predominant bile acids detected were cholic, taurocholic, and glycocholic acids but there was a significantly greater proportion of secondary bile acids, deoxycholic and taurodeoxycholic acids, in patients with erosive oesophagitis and Barrett's oesophagus/stricture. Although bile acid reflux episodes occurred at variable pH, a temporal relation existed between reflux of taurine conjugates and oesophageal acid exposure (r=0.58, p=0.009). CONCLUSION: Toxic secondary bile acid fractions have been detected in patients with extensive mucosal damage. Mixed reflux is more harmful than acid reflux alone with possible toxic synergism existing between the taurine conjugates and acid.

Assessment of combined bile acid and pH profiles using an automated sampling device in gastro-oesophageal reflux disease.

BACKGROUND: Bile acid reflux is an important component of duodenogastro-oesophageal reflux but there is no effective method of quantifying it. The contribution of bile acids to oesophageal pH is unknown. METHODS: Oesophageal aspirates were collected over 15 h using a new automated suction device and pH was monitored in ten asymptomatic volunteers (group 1) and 30 patients with reflux oesophagitis (group 2, minimal mucosal injury; group 3, erosive oesophagitis; group 4, stricture or Barrett's oesophagus). Bile acid assay was performed by high-performance liquid chromatography. RESULTS: The concentration of bile acids was significantly higher in group 3 (median (interquartile range) 124 (50-301) mumol/l) and group 4 (181 (85-591) mumol/l) compared with group 1 (0 mumol/l) and group 2 (14 (0-100) mumol/l). Patients in groups 3 and 4 also had significantly greater DeMeester acid scores. Combined bile acid and oesophageal acid reflux was observed in eight of ten patients with stricture or Barrett's oesophagus. There was no correlation between total bile acid concentration and oesophageal acid or alkaline exposure. CONCLUSION: This study supports the theory of toxic synergism between acid and bile acids in reflux oesophagitis. Bile acids may contribute to the pathogenesis of Barrett's metaplasia.

Automated oesophageal reflux sampler--a new device used to monitor bile acid reflux in patients with gastro-oesophageal reflux disease.

A new automated suction device has been developed to aspirate the contents of the distal oesophagus to monitor the constituents of the refluxate in patients with gastro-oesophageal reflux disease. Using antimony and glass electrodes with solid-state pH recorders it has been conclusively shown that gastric acid is responsible for the mucosal damage seen in reflux oesophagitis but new evidence is emerging that other constituents of the gastroduodenal juice, in particular bile acids, are also damaging to the oesophageal mucosa. The main difficulty lies in that there is no reliable method of monitoring this component of the refluxate except by direct aspiration of the contents for assay. This new technique of oesophageal sampling utilizing a software-controlled suction process with simultaneous pH recording has helped to identify patients at risk of refluxing potentially harmful substances and is a valuable addition to the armamentarium of investigative procedures for patients with gastro-oesophageal reflux disease.

Pain relief after inguinal hernia repair: a randomized double-blind study.

A randomized double-blind study was undertaken using 0.5 per cent bupivacaine ilioinguinal field block and oral papaveretum-aspirin tablets to assess pain relief after hernia surgery. A consecutive series of 200 men undergoing repair of a unilateral inguinal hernia underwent random allocation into one of the four groups to receive: bupivacaine and papaveretum-aspirin (group 1), bupivacaine and oral placebo (group 2), saline and papaveretum-aspirin (group 3), or saline and oral placebo (group 4). Patients were prescribed postoperative opiates to be given on demand. Pain levels and mobility were assessed at 6 and 24 h after operation. Patients in group 1 reported significantly less pain, required less additional opiates and had better mobility than those in group 4 (pain score P < 0.001 at 6 h and P = 0.002 at 24 h) and group 3 (P = 0.002 for pain and mobility scores at 6 h). Bupivacaine alone provided good immediate postoperative pain relief (P = 0.002 group 2 versus group 4 at 6 h). The combination of bupivacaine and papaveretum-aspirin provided the best results and is suitable for day-case postoperative analgesia.

The use and impact of a daily general surgical emergency operating list in a district general hospital: a prospective study.

Daytime emergency operating lists (EOL) have been shown to reduce out-of-hours operating but problems with their introduction have been reported. A six-month prospective study of EOL and unscheduled operations (USO) was undertaken. Two firms use their EOL differently--one including mostly emergencies, the other including a number of urgent elective cases. After the introduction of EOL only 9 per cent of emergency operations were performed after midnight. Including urgent elective cases on the EOL allowed full use of available theatre time but meant that proportionately more emergency operations were unscheduled. A senior surgeon was involved with 75 per cent of EOL and 36 per cent of USO operations, and a senior anaesthetist with 52 per cent of EOL and 14 per cent of USO. Senior anaesthetic involvement would have been greater if there were more senior staff. There had been a marked increase in the number of USO over the four years previous to this study. EOL do reduce out-of-hours operating and allow excellent supervision and therefore training opportunities. Care must be taken with the case mix to balance full use of theatre time with reduction in out-of-hours operating.

Expression and processing of parathyroid hormone-related protein in a pancreatic endocrine cell tumour associated with hypercalcaemia.

We describe a patient with a neuroendocrine tumour of the pancreas associated with hypercalcaemia which was attributed to production of parathyroid hormone-related protein (PTHrP) by the tumour. Plasma PTHrP 1-86 was significantly raised, and fell following surgical resection of the tumour. PTHrP mRNA and peptide were identified in tumour tissue by in-situ hybridization and immunohistochemistry respectively. PTHrP was quantitated in an extract of tumour tissue by three region-specific immunoassays (PTHrP 1-34 45.2 pmol/g, PTHrP 37-67 81.7 pmol/g, PTHrP 1-86 27.3 pmol/g) and suggested the presence of excess of amino-terminal and mid-region immunoreactivity. On chromatography of the tumour extract the first peak eluted as 22 kDa and comprised approximately equimolar 1-34, 37-67 and 1-86 activities. The second and major peak of 16 kDa contained only 37-67 activity, while the third peak of 6 kDa contained only 1-34 activity. This suggested that the tumour contained a native or intact form of PTHrP together with two major subfragments containing 37-67 and 1-34 activity respectively. Thus chromatographic separation and quantitation of PTHrP by region-specific immunoassays have provided new information on in-vivo proteolytic processing by tumour tissue by indicating that a site of cleavage is located between residues 17 and 61. Our findings are compatible with cleavage at residue 37, a site previously indicated from in-vitro studies.

Spontaneous rupture of the oesophagus (Boerhaave's syndrome).

Five cases of spontaneous rupture of the oesophagus are reported. All cases had surgery within 12 hours, and all survived, illustrating the value of early diagnosis in this rare condition. None had their diagnosis made before admission to the hospital. Myocardial infarction is the commonest misdiagnosis and frequently results in delayed treatment. We believe that a simple direct question to enquire of the patient whether or not vomiting preceded the onset of the severe pain would significantly reduce the rate of misdiagnosis.

Plasma fatty acid profiles in benign breast disorders.

Breast pain (mastalgia) and macroscopic breast cysts present commonly. Mastalgia may be improved by dietary manipulation to reduce saturated fat or supplement essential fatty acid intake. Fatty acid profiles were measured in women with mastalgia and breast cysts, before and during treatment with evening primrose oil, a rich source of essential fatty acids. The fatty acid profiles of both groups of patients were abnormal, with increased proportions of saturated fatty acids and reduced proportions of essential fatty acids. Treatment with evening primrose oil improved the fatty acid profiles towards normal, but this was not necessarily associated with a clinical response.

A randomized trial of dietary intervention with essential fatty acids in patients with categorized cysts.

Two hundred women with breast cysts proven by aspiration were entered into a randomized double-blind trial of Efamol (evening primrose oil) at a dose of 6 capsules daily or equivalent placebo dose for a year. Cysts were categorized by initial electrolyte composition, and follow-up continued for 1 year posttherapy. Recurrent cyst formation in the first year was slightly (but not significantly) lower in the Efamol group compared with the placebo-treated group. The Efamol treatment was well tolerated as the dropout rate was only 7% and equal in both the active and placebo groups. The initial electrolyte composition did not predict for cyst recurrence.

Long ischaemic stricture of the interposed colon.

A case is reported of a long segment stricture in a colonic oesophageal replacement with radiographic evidence to support the diagnosis of ischaemia. Ischaemia of the substitute organ following oesophageal resection is a well recognised, serious complication that usually results in anastomotic leakage. If the anastomosis heals primarily, late manifestations of ischaemia are rare.

Clinical experience of drug treatments for mastalgia.

Results of randomised trials and open studies in 291 patients with severe persistent breast pain in whom breast cancer had been excluded showed that drug therapy produced a good or useful result in 77% of those with cyclical mastalgia and 44% of those with non-cyclical mastalgia. In patients with cyclical mastalgia good or useful responses were obtained with danazol in 70%, with bromocriptine in 47%, and with evening-primrose oil in 45%. The equivalent response rates in patients with non-cyclical mastalgia were 31%, 20%, and 27% respectively. Progestagens were not effective in either group. Failure to respond to one drug did not preclude response to a different drug. Patients with Tietze's syndrome did not respond to drug therapy, but 7 out of 10 responded to injection of lignocaine and hydrocortisone around the affected costochondral junction.

Developments in contact X-ray microscopy in biomedical research.

Contact X-ray microscopy (microradiography) is a method of studying the microstructure of biological tissue. These techniques have been used to study the historadiological details of human breast tissue and sections of human ear ossicles. X-ray microscopy can also be used to demonstrate variations in structural densities seen in histological specimens including the detection of microcalcification. A modification of existing apparatus is described which has resulted in improved image-contrast and detail. The ability of X-rays to penetrate relatively thick sections of tissue makes it an ideal method for studying the morphology of biological structures, particularly in calcified tissue. The tissues may be further examined by conventional histology, elemental analysis, etc. The technique has a complementary role to alternative methods of tissue microscopy.

Natural history of breast pain.

258 patients with breast pain were restudied 2 to 7 years after initial assessment in a special mastalgia clinic. Pain persisted at follow-up in 65% of patients. Mastalgia was cyclical in two-thirds. Mean duration of pain in patients experiencing complete relief before follow-up examination was 6.8 years, while duration of pain persisting at follow-up ranged from 2 to 30 years. In patients who had relief or substantial improvement in pain, the improvement was spontaneous in 22% and resulted from a hormonally related event--menopause, pregnancy, or use of oral contraceptives--in the remainder. Onset of cyclical pain before the age of 20 years was followed by a prolonged course. A quarter of the patients had non-cyclical pain. There were two populations of patients in this group. One experienced relief after a mean of 3 years, and in the other pain still persisted after 2-22 years. Relief was spontaneous in one half, and rarely followed a hormonally related event. About 70% of the patients, with both cyclical and non-cyclical pain, considered that their pain had warranted active treatment. This study indicates that the type of pain and age at onset may allow some prediction of the course of the disease and may aid the choice of therapy.