Pylephlebitis due to perforated diverticulitis.

Pylephlebitis or septic thrombophlebitis of the portal vein is an uncommon and frequently fatal complication of diverticulitis. We describe a case report of a patient with pylephlebitis due to a perforation of the sigmoid. The patient was successfully treated with broad spectrum antibiotics and a Hartmann procedure.

GIST (gastro-intestinal stromal tumour) of the gallbladder: a case report.

The authors report a case of a gastrointestinal stromal tumour (GIST) of the gallbladder. GISTs are rare mesenchymal tumours of the gastrointestinal tract, mesentery and omentum. GISTs are characterized by the expression of the KIT protein, a transmembrane tyrosine kinase receptor for stem-cell factor. Only a few GISTs of the gallbladder have been described in the literature. The behaviour of these tumours is not fully understood but long-term survival is rare. Initial treatment consists of aggressive surgery. Radiotherapy and conventional chemotherapy have been mostly unsuccessful. More recently promising studies have been performed with Imatinib, an orally administered tyrosine kinase inhibitor, in patients with advanced disease.

Patient satisfaction and symptom relief after anal dilatation.

Anal dilatation is used as a simple method of treatment and has been used for both anal fissure and haemorrhoids. This study examined longer-term results among a cohort of 162 patients, 132 of whom responded to a detailed questionnaire, an 82% response (66 patients were male; age range 17-75 years, median 42 years). Follow-up ranged from 16 months to 36 months (median 27 months) after anal dilatation (68 patients for fissure, 32 for haemorrhoids, and 32 for both). In the early months after dilatation, 83% had symptomatic improvement and 76% remained improved. Five (7%) patients with fissure and 11 with haemorrhoids (17%) required further hospital treatment, while 10% and 17%, respectively, had received further treatment from their general practitioners (GPs). Seventy-one percent said they would have a further anal dilation if symptoms recurred. There was no difference in results obtained by surgeons of different seniority. Complications--bleeding (29%) and difficulty controlling flatus (15%) or faeces (8%)--resolved in all cases. The results of anal dilatation for fissure are generally satisfactory in the longer term, with a trend toward better symptom relief in patients with fissure compared with those with haemorrhoids. We do not recommend anal dilatation as the sole treatment of patients with haemorrhoids, but it may be a useful adjunct to other treatments such as banding or sclerotherapy. Morbidity was generally acceptable and the majority of our patients would be prepared to have this procedure again if their symptoms were to return.

Five-year audit of the acute complications of diverticular disease.

BACKGROUND: The objective of this study was to audit the presentation and outcome for patients admitted with an acute complication of diverticular disease. METHODS: This study was a retrospective review of 418 admissions with an acute complication of diverticular disease over a 5-year interval. RESULTS: Of the 418 admissions, 15 patients were eventually found to have an alternative diagnosis. Some 403 patients were studied further. The overall mortality rate in this group was 5.7 per cent. A total of 113 patients (28.0 per cent) required an operation and in this group the mortality rate was 17.7 per cent. All deaths occurred in patients who had surgery for septic complications or bowel obstruction. Of the patients who had surgery, 90.2 per cent had a resection of the involved colon. One-third of these had a primary anastomosis; the remainder underwent Hartmann's procedure. Some 83 patients had a stoma fashioned and of these 72 went on to have the stoma closed. The median age of those who died after operation was 80 years. An American Society of Anesthesiologists (ASA) score of 3 or more, concurrent medical disease and shock on admission were all associated with a high mortality rate (P < 0.001). Some 30 per cent of patients were readmitted during this study with a further complication of diverticular disease. CONCLUSION: The mortality rate after surgery for acute diverticular disease remains excessive and a high-risk group can be identified before operation. A policy of resection and anastomosis appears justified for selected patients. Adopting a practice of interval elective sigmoid colectomy after admission with acute diverticulitis might prevent readmission with further complications.

The acute surgical admission: is mortality predictable in the elderly?

Most scoring systems used to predict mortality are complex. A simple preoperative assessment, the Sickness Assessment (SA), was evaluated as a predictor of mortality in elderly patients admitted as surgical emergencies. The three parameters comprising the SA are: hypotension on admission, the presence of severe chronic disease, whether the patient was independent and self-caring. Prospectively, 487 consecutive patients of over 65 years of age admitted as surgical emergencies were studied. On admission, the SA and the APACHE II score were calculated. Hospital mortality was used as the endpoint. Of 309 patients with zero SA, 21 (7%) died. In 178 with a positive SA, 64 died (36%) (chi 2 = 64.6, P < 0.001). After laparotomy, mortality was 57% (36/67) with a positive SA, but 15% (15/103) with a zero assessment (chi 2 = 33.6, P < 0.001). When the single parameter of hypotension on admission was present, mortality was 77% (23/30). The predictive ability of the APACHE II score was not superior to SA. The SA is a simple preoperative assessment which identifies a high-risk group. It should be used in emergency surgical practice to improve outcome and avoid inappropriate surgery.

Delay in the diagnosis and prognosis of carcinoma of the right colon.

Of 152 consecutive patients with carcinoma of the right colon, 61 (40 per cent) suffered delays in treatment of more than 12 weeks from the onset of symptoms, with a mean delay of 48 weeks. The most common error was failure to initiate or complete the investigation of iron-deficiency anaemia (33 patients). False-negative barium enema investigations occurred in 16 cases. Patients with delays in diagnosis had survival rates not significantly different from those who presented early. Thirty-one patients with anaemia and no abdominal symptoms had a significantly higher survival rate than 30 presenting with abdominal symptoms, despite delays in treatment (P < 0.02). Greater vigilance is required in the investigation of patients presenting with iron-deficiency anaemia.

Abdominal pain: a surgical audit of 1190 emergency admissions.

In an audit of 1190 emergency admissions with abdominal pain (1166 patients) in a general surgical unit, the diagnosis was non-specific abdominal pain (NSAP) in 415 (35 per cent), acute appendicitis in 200 (17 per cent) and intestinal obstruction in 176 (15 per cent). The largest number of admissions occurred in the age groups 10-29 years (31 per cent) and 60-79 years (29 per cent). Surgical operations were performed in 551 patients (47 per cent) and there was a 16 per cent incidence of unnecessary appendicectomy (22 per cent in the age group 20-29 years). Fifty-one deaths resulted in a 30-day hospital mortality rate of 4.4 per cent and a perioperative mortality rate of 8 per cent. The mortality rate increased significantly in patients aged greater than or equal to 60 years, and patients aged 80-89 years had a perioperative mortality rate of 20 per cent. The causes of perioperative death included laparotomy for inoperable disease (28 per cent), ruptured abdominal aortic aneurysm (23 per cent), perforated peptic ulcer (16 per cent) and colonic resections (14 per cent). The perioperative mortality rates for ruptured aneurysm and perforated ulcer were 71 and 23 per cent respectively. The duration of inpatient stay increased significantly with the age of the patients, including those with NSAP. The results of the study indicate a need to review the methods of management of ruptured aortic aneurysm and perforated peptic ulcer, the methods of diagnosis of appendicitis, particularly in young females, and the factors that determine the duration of stay of patients suffering from NSAP.

Mortality and perforated peptic ulcer: a case for risk stratification in elderly patients.

In a consecutive series of 284 patients with a perforated peptic ulcer (229 pyloroduodenal, 55 gastric) there was a 26 per cent hospital mortality rate, and patients aged greater than or equal to 70 years (n = 176) had a significantly higher mortality rate (34 per cent) than patients aged less than 70 years (14 per cent, P less than 0.001). Multiple clinical variables were significantly more common in the elderly group of patients (65 per cent), in those having non-steroidal anti-inflammatory drugs or steroid therapy (56 per cent), in patients where there is an absence of a previous dyspeptic history (69 per cent), and when risk factors such as delayed presentation (33 per cent) and the presence of shock on admission to hospital (27 per cent) are present. Definitive operations (vagotomy or gastrectomy) had an increased mortality rate in the elderly (P = 0.018). Risk scores based upon the presence of shock, delayed presentation or concurrent medical illness could have predicted 87 per cent of postoperative deaths in elderly subjects, and it is suggested that risk stratification and greater caution in the use of definitive operations for perforated ulcer may result in a reduction in the high mortality rate in elderly subjects.

Management of symptomatic gallstones in the elderly.

In a study of 544 patients with symptomatic gallstones 158 subjects were aged greater than 70 years. Elderly patients had a significantly higher incidence of emergency presentation, jaundice, cholangitis, ductal stones, biliary drainage procedures, and acute complications requiring urgent or emergency surgery (P less than 0.001); they had more than twice the incidence of postoperative complications in comparison with patients aged less than 70 years. There was an increased perioperative mortality in the elderly (1.3 per cent after cholecystectomy and 2.9 per cent after bile duct exploration, P = 0.039). Conservative treatment in 11 per cent of elderly patients resulted in no mortality due to gallstones, but 3 of 17 patients had recurrent biliary symptoms. It was estimated that 38 per cent of the bile duct explorations in the elderly might have been avoided by referral for endoscopic sphincterotomy, but surgical treatment of gallstones in the district general hospital is relatively safe and specialist referral should be considered only in the relatively small number of 'high risk' cases.

Prognosis of colorectal cancer in the elderly.

The prognosis of colorectal cancer in the elderly was examined in a study of 306 consecutive patients. The patients were divided into two groups: Group 1 included 171 patients of average age 77 years (range 70-97); Group 2 comprised 135 patients of average age 59 years (range 22-69). There was no significant difference between the two groups with regard to the mode of presentation, the location and Duke's classification of the tumours, the incidence of palliative operations, and the perioperative mortality. The surgical mortality rates in Group 1 were 6 per cent overall, 4 per cent after elective operations, and 16 per cent after emergency surgery; the corresponding mortality rates for Group 2 were 3 per cent, 1 per cent, and 20 per cent. Emergency surgery was associated with a significantly higher incidence of perioperative death at any age (P less than 0.001) and most deaths resulted from complications of coexisting medical disorders or thrombo-embolic complications. Crude actuarial 5-year survival curves showed an increased death rate in Group 1 after 18 months and a significantly lower 5-year survival (P less than 0.05) but the age-corrected survival curves for the two groups were not significantly different, and it was concluded that the prognosis for colorectal cancer in the elderly is not significantly different from that of younger patients.

Gastric cancer: an audit of 122 consecutive cases and the results of R1 gastrectomy.

In a consecutive series of 122 patients with gastric carcinoma, 9 per cent had no operation, 27 per cent had incurable disease at laparotomy, and 64 per cent underwent gastric resection. R1 gastrectomy was performed in 73 of the 78 resections. The operative mortality after gastric resection was 4 per cent, but there were no deaths after potentially curative resections. The actuarial 5-year survival was 20 per cent overall, 60 per cent in patients undergoing a 'curative' resection with N0 disease, and 18 per cent in patients with N1 disease. Local or regional recurrence without evidence of distant metastases was identified in 11 per cent of cases after 'curative' resections. The probability of survival was adversely affected by N1 nodal involvement (P less than 0.005) and by the presence of poorly differentiated or anaplastic tumours (P less than 0.001). Only 6 per cent of patients had early gastric cancer, and absolute curative resections by Japanese criteria were possible in only 5 per cent of cases. The results suggest that the unfavourable presenting pathology is the principal determinant of the poor prognosis of gastric cancer. A more radical or extended lymphadenectomy (R2/3 gastrectomy) might have cured more patients with N1 metastases, but only 12 per cent of potentially curable patients had N1 disease in this study, and it appears that more radical surgery may have little effect on the overall survival rates for gastric cancer.

Simple skin closure.

Traditionally, general surgeons in the UK have shown little concern for the results of skin wound closure unless the wounds have undeniable cosmetic importance, as in surgery of the face, neck, or breasts. However, in recent years greater significance has been attached to the scarring and other complications that may result from skin sutures. Various techniques of wound closure, sutures, staples, clips, and other materials are now available to the surgeon. This article reviews these recent developments.

Wound healing.

The majority of wounds encountered in the accident and emergency department are superficial in nature and a consequence of accidental trauma or the elective surgical incision of infected foci. The techniques of management of such cases have undergone few changes in recent years, and any advances of a practical or therapeutic nature have been comparatively modest. On the other hand, many major advances have occurred in our understanding of the factors involved in the basic pathophysiology of wound repair. This paper is a summary of our present concept of the process of repair in soft tissues.

Vitamin C requirements in postoperative patients.

The postoperative ascorbic acid requirements of 63 surgical patients were assessed by measurement of buffy layer leucocyte ascorbic acid and the ascorbic acid content of white blood cells. There was a significant reduction in ascorbic acid levels following surgery. The postoperative changes were unrelated to the extent of surgical trauma or the volume of blood transfused during surgery but there was a significant correlation between postoperative ascorbic acid measurements and white blood cell counts. It appears that postoperative leucocytosis and release by the bone marrow of white blood cells with a low ascorbic acid content may partly account for the postoperative changes in buffy layer and white blood cell ascorbic acid measurements. However, surgical operations were followed by an authentic increase in ascorbic acid requirements, and there was a 42 per cent reduction in circulating white blood cell ascorbic acid levels on the third postoperative day. The findings of this study create an argument for the use of ascorbic acid supplements in surgical patients although it is unlikely that postoperative changes in leucocyte ascorbic acid have pathologic significance in wound repair.