The dedicated emergency surgeon: towards consultant-based acute surgical admissions.

INTRODUCTION: The management of an efficient acute surgical service with conflicting pressures of managing elective and emergency work, compounded by waiting list targets and the maximum 4-h wait for patients in accident and emergency poses a significant challenge. We assess the impact of appointing a dedicated emergency surgeon on the delivery of our emergency surgery service. PATIENTS AND METHODS: A comparative retrospective review was undertaken of all surgical admissions (n = 1622) over a 9-month period (between February and November) in the year before and after (2004 and 2005) the appointment of a dedicated emergency surgeon. The impact on service, training and possible financial consequences of this appointment was assessed. RESULTS: A total of 798 surgical admissions in 2004 were compared with 824 admissions in 2005 for the 9-month periods of this study. In 2004, 258 patients were operated on compared with 286 in 2005 (NS). There was a significant increase in day-time operating from 57% in 2004 to 74% in 2005 (P < 0.001) and a significant increase in consultant-supervised operations from 14% to 52% (P < 0.001), with a consequent fall in out-of-hours operating (43% to 26%; P < 0.001). In addition, there was a significant increase in early (within 48 h) discharges from 41% to 53% (P < 0.001). The salary of the new appointment is more than offset by the quantifiable savings of approximately pound90,000 per annum based on the increased proportion of earlier discharges alone as well as the improved quality of care provided. CONCLUSIONS: The appointment of a dedicated emergency surgery consultant has resulted in an increase in day-time consultant-supervised operating, shorter hospital stay for emergency admissions, improved training for surgical trainees, as well as providing potential financial savings for the trust.

Ghrelin does not stimulate food intake in patients with surgical procedures involving vagotomy.

CONTEXT: Patients with gastric or esophageal surgery and transection of the vagus nerve may suffer from appetite and weight loss but without dysphagia or mechanical obstruction to eating. The gastric hormone ghrelin stimulates food intake and GH release in rodents and man. However, rodents with vagotomy are not sensitive to the feeding effects of ghrelin. OBJECTIVE: The objective of the study was to determine whether humans with vagotomy are sensitive to ghrelin. STUDY DESIGN: The design was a double-blind, randomized, placebo-controlled trial. SETTING: This was a hospital-based study. PATIENTS: Six men and one woman who all had a previous complete truncal vagotomy with lower esophageal or gastric surgery entered and completed the study. INTERVENTION: Each patient received 120-min infusions of saline, 1 pmol/kg.min ghrelin, and 5 pmol/kg.min ghrelin on 3 separate days. After 90 min, a buffet meal was served. MAIN OUTCOME MEASURE: Energy intake at the buffet meal was measured. RESULTS: Ghrelin-stimulated GH release in a dose-dependent manner was measured, confirming bioactivity. However, no change in energy intake was observed with either dose of ghrelin [energy intake (kilojoules): saline 2805 +/- 812; ghrelin 1 pmol/kg.min, 2486 +/- 767; ghrelin 5 pmol/kg.min, 2382 +/- 543; P = not significant]. CONCLUSIONS: Ghrelin is unlikely to be an effective appetite-stimulatory treatment for patients with vagotomy and esophageal or gastric surgery. Our results suggest that an intact vagus nerve may be required for exogenous ghrelin to increase appetite and food intake in man.

Pressure flow study data in a group of asymptomatic male control patients 45 years old or older.

PURPOSE: The role of pressure flow studies in the routine evaluation of patients with benign prostatic hyperplasia remains a controversial issue in urological practice. There are little data on age matched asymptomatic control groups. We evaluated pressure flow findings in such a group. MATERIALS AND METHODS: A total of 24 male patients 47 to 80 years old (mean age 62.5) attending a general surgical clinic were recruited for study after ethical committee approval. The volunteers had never sought medical attention for urinary symptoms and did not perceive themselves as having a urological problem. Volunteers were assessed by International Prostate Symptom Score (I-PSS) and Madsen symptom score, clinical examination, free uroflowmetry, post-void residual ultrasound, repeat pressure flow studies and transrectal ultrasonography. Pressure flow tracings were manually analyzed for standard urodynamic values and the degree of bladder outflow obstruction according to recognized International Continence Society, Abrams-Griffith nomogram, linear passive urethral resistance relation and urethral resistance factor classifications. RESULTS: Median I-PSS was 2.0 (interquartile range 1.2 to 5.7). For I-PSS quality of life the median was 1.0 (interquartile range 0.75 to 2.0). On pressure flow studies 3 patients (13%) had unequivocal obstruction, 7 (29%) were in the equivocal area and 14 (58%) had no obstruction, while 15 (63%) had unstable contractions on medium fill cystometry. CONCLUSIONS: The data show that a surprising number of apparently normal men are obstructed by commonly used criteria. This finding confirms asymptomatic obstruction, suggesting that obstruction may be less important in the development of symptoms than previously thought. Also, until the natural history of obstruction is more clearly defined surgery in obstructed asymptomatic patients is probably unwise.

Restorative proctocolectomy for Chagasic megacolon.

Chagas' disease is endemic in South America, affecting several million people. Megacolon, the commonest intestinal manifestation, causes severe constipation and usually requires surgery. We report a case which was treated by restorative proctocolectomy. We believe this to be a useful new technique in the treatment of this condition.

pS2 immunostaining of colorectal carcinoma.

This study was aimed at assessing the significance of pS2 immunostaining in colorectal adenocarcinoma and adjacent tissue. Paraffin sections of 63 surgically resected colorectal adenocarcinomas were stained with a pS2 specific monoclonal antibody using the avidin-biotin complex immunoperoxidase technique. Several tumor sections also included adjacent nonneoplastic mucosa. Six tubular adenomas and five hyperplasic polyps found in the resected bowels were also examined. Focal staining for pS2 was seen in 32 tumors (51%). In all but one case, less than 10% of the tumor cells were stained. pS2 staining was more common in right-sided than in left-sided tumors (p < 0.05), and was more prevalent in Dukes C than combined Dukes A and B tumors (p < 0.05). No significant relationship was found between pS2 positivity and the degree of tumor differentiation, patients' sex, or outcome of the disease as judged by the development of recurrence or metastasis. Strong pS2 positivity was seen in hyperplastic polyps and in nonneoplastic mucosa adjacent to many tumors. Tubular adenomas were either negative or showed focal superficial staining. It is concluded that pS2 immunostaining in colorectal adenocarcinoma does not seem to have prognostic significance, but may reflect developmental differences between the right and left side of the colon. The presence of pS2 staining in adjacent nonneoplastic mucosa and in hyperplastic polyps suggests that the epithelium in these areas is of a regenerative or reactive nature.

HER2 (c-erbB-2) oncoprotein expression in colorectal adenocarcinoma: an immunohistological study using three different antibodies.

Paraffin wax sections of 70 surgically resected colorectal adenocarcinomas were examined for the overexpression of HER2/c-erbB-2 oncoprotein using three different specific antibodies and the avidin-biotin immunoperoxidase technique. The patients included 38 men and 32 women aged between 47 and 80 years. The tumours were derived from various parts of the large intestinal tract, and represented all three stages of Dukes' classification and the three histological grades of differentiation. Many tumour sections also included adjacent normal or transitional mucosa. Eight tubular adenomas found in the colectomy specimens in association with some carcinomas were also examined. No positive membrane staining was seen in any of the 70 carcinomas, four adenomas, two hyperplastic polyps, nor in the adjacent normal or transitional mucosa. It is suggested that the overexpression of c-erbB-2 gene product is unlikely to be as common and as pronounced in colorectal adenocarcinoma as it is in ductal carcinoma of the breast.

Factors influencing variability of localisation of antibodies to carcinoembryonic antigen (CEA) in patients with colorectal carcinoma--implications for radioimmunotherapy.

Tumour localisation of anti-tumour antibodies varies greatly between patients. Factors which may be responsible for this have been investigated in 56 patients with colorectal carcinoma with a view to improving radioimmunotherapy. Thirty-seven to seventy-four MBq of 125-I labelled mouse monoclonal antibody to CEA, was given intravenously and tumour resected 70-480 h later. Percentage injected activity kg-1 (% inj.act kg-1) in tumour, was inversely correlated with the time interval between injection and operation (P = 0.004). To assess the influence of other parameters on localisation, patients were divided into two time groups according to time interval between injection and operation, 70-120 h (n = 33) and 144-480 h (n = 23). In neither group was there a significant correlation of % inj.act kg-1 with time. The % inj.act kg-1 in tumour showed a significant correlation with that in the blood for both groups (P = 0.005 and P = 0.01). There was no significant correlation for either time group between % inj.act kg-1 in tumour and serum CEA values, the per cent of tumour cells positive for CEA and vascularity. Tumour to blood ratios varied considerably (range 0.3-28.5:1) suggesting that factors other than time and persistence of activity in the blood contribute to efficient targeting. Tumour to blood ratios were inversely correlated with % inj.act kg-1 in blood for the 70-120 h group (P = 0.007), and were positively correlated with % inj.act kg-1 in tumour (P = 0.012). Autoradiography showed that antibody localised predominantly on tumour cells but was distributed heterogeneously, was not solely related to the expression of antigen and in some cases accumulated in necrotic more than viable areas of tumour. Penetration of antibody into malignant acinar structures was poor and CEA-positive cells closer to the blood supply were targeted to a greater extent than distant cells. Preoperative administration of radiolabelled antibody to CEA may be helpful in selecting patients with favourable localisation for radioimmunotherapy.

Reversible plane xanthoma, vasculitis, and peliosis hepatis in giant lymph node hyperplasia (Castleman's disease): a case report and review of the cutaneous manifestations of giant lymph node hyperplasia.

A patient is described who had generalized plane xanthomas, cutaneous vasculitis, peliosis hepatis, and intraabdominal giant lymph node hyperplasia of the plasma cell type. After excision of the abdominal mass, the xanthomas resolved and the liver returned to its normal size, but the patient continued to develop skin lesions. A review is presented of the cutaneous manifestations of giant lymph node hyperplasia.

The value of radioimmunoguided surgery in first and second look laparotomy for colorectal cancer.

Radioimmunoguided surgery (RIGS) using an anti-CEA (A5B7) monoclonal antibody has been assessed in 52 patients (43 primary excisions and nine second look procedures) undergoing surgery for colorectal carcinoma. The antibody localized in 97.8 percent of primary tumours and in 88.8 percent of the principal tumor in second look procedures. Additional information concerning the extent of primary tumor was obtained in 11 of 43 patients (25.5 percent) undergoing excision of primary carcinoma and five of nine patients (55 percent) in the second look series. Incorrect information was obtained about the extent of the primary tumour in six patients (11.3 percent), whereas no incorrect information was obtained during second look procedures. RIGS correctly predicted the subsequent Dukes' staging in 77 percent of first look cases (sensitivity 65 percent, specificity 90 percent), although accurate identification of individual nodes was impossible. The technique influenced the surgical procedure performed in 2 of 43 cases (4.6 percent) in primary surgery and in three of nine patients undergoing second look laparotomy (33 percent). RIGS in primary colorectal carcinoma may provide additional information concerning extent of locally advanced tumors in particular and the principle that the subsequent surgery may be influenced has been established. The technique appears to have a greater role in second look procedures where it may help determine the extent of recurrent tumour. Larger follow-up series are required to define how the additional information provided by this technique may best be exploited.

Cytoreductive surgery in disseminated non-seminomatous germ cell tumours of testis.

Between 1977 and 1988, 67 patients underwent surgical removal of residual metastatic deposits following an aggressive chemotherapy regimen (cisplatin, vincristine, methotrexate and bleomycin alternating with etoposide, actinomycin D and cyclophosphamide) for disseminated germ cell tumours of the testis (stage IIB or above). Ninety-one surgical procedures were performed. There were 63 (69 per cent) retroperitoneal lymph node dissections, 16 (18 per cent) thoracotomies, three (3 per cent) hepatic resections, three (3 per cent) craniotomies, five (5 per cent) delayed orchidectomies and one anterolateral decompression of the vertebral column. Nine (13 per cent) patients required a repeat retroperitoneal node dissection and one patient needed a repeat thoracotomy to remove recurrent metastatic deposits during the period of follow-up. Multivisceral resections and vascular reconstruction procedures were required in 20 (30 per cent) patients undergoing retroperitoneal node dissection. Fifty-five (82 per cent) patients remain in complete remission with a mean follow-up period of 49.6 months (range 2-121 months). Nine (13 per cent) patients died with metastatic disease between 2 months to 4 years after operation. There were three deaths in the perioperative period (4 per cent). The histology of the resected metastases revealed undifferentiated active tumour in 20 (30 per cent) patients, differentiated mature teratoma in 29 (43 per cent) patients and fibrosis/necrosis in 18 (27 per cent) patients. Twelve (60 per cent) patients with undifferentiated elements and 15 patients (60 per cent) with raised preoperative tumour markers (poor prognostic categories) are in complete remission. Cytoreductive surgery in patients with metastatic germ cell tumours offers the best chance of remission following chemotherapy even in poor prognostic group categories.

Comparison of anti-fetal colonic microvillus and anti-CEA antibodies in peroperative radioimmunolocalisation of colorectal cancer.

Local recurrence of colorectal cancer may result from failure to assess accurately the extent of tumour at operation. It has been suggested that peroperative radioimmunolocalisation may improve this assessment. The degree to which this is possible has been studied using a hand-held gamma detecting probe and comparing two 125I-labelled monoclonal antibodies to colorectal tumours. The antibodies were to fetal colonic microvillus membrane (FM1D10) and to carcinoembryonic antigen (A5B7). Sixty-nine per cent (9/13) of the FM1D10 and 98% (43/44) of A5B7 labelled tumours took up significant amounts of antibody with a tumour to normal colon ratio of more than 1.5:1. The uptake was significantly better for A5B7 with a median tumour to normal colon ratio of 3.3 (1.1-13.8) compared to 1.85 (0.75-7.7) for FM1D10 (P less than 0.001). The tumour: colon ratio of both antibodies was independent of the serum CEA, Dukes' stage or the degree of histological differentiation. There was a linear correlation for tumour to normal colon ratios between the gamma detecting probe and the same tissue examined in a conventional well counter (correlation coefficient r = 0.78, P less than 0.001). Colorectal tumours demonstrate a rapid and reliable uptake of anti-CEA monoclonal antibody A5B7. This antibody can be detected with a peroperative gamma detecting probe and has the potential to improve the surgeon's appreciation of the extent of tumour and therefore may influence the surgery performed. Detailed clinical studies are now being carried out.

Oestrogen receptors in colorectal carcinoma.

The oestrogen receptor content of colorectal adenocarcinoma was investigated using an established ligand binding biochemical assay and two more recently introduced techniques using specific monoclonal antibodies (Abbott ER-EIA and ER-ICA assay kits). Twenty nine tumours were investigated by the ligand binding assay. Only one (3.4%) tumour gave a weakly positive result (11 fmol/mg cytosol protein); the rest were all negative. Where sufficient tissue was available, the receptors were also determined by a quantitative immunoassay in 18 patients and an immunohistochemical method in 13 patients. The results were similarly all negative. It is concluded that most colorectal carcinomas, irrespective of sex, are oestrogen receptor negative, and it is thus unlikely that hormonal manipulation would have an influence on the course of the disease.

Simple closure of perforated duodenal ulcer: a prospective evaluation of a conservative management policy.

One hundred and thirteen consecutive patients admitted with a perforated duodenal ulcer over a 5-year period (1978-82) and treated by simple closure have been followed prospectively over a median period of 43 months. Patients were divided into two categories according to their previous history of dyspepsia; group 1 (66 patients) with a chronic history of more than 3 months and group 2 (47 patients) where there was no history of dyspepsia or a history of less than 3 months duration. The follow-up periods were similar (group 1, 44 months; group 2, 43 months). The overall recurrence rate was 42 per cent and to date only 14 per cent of the total group of 113 patients have required a definitive operation. The incidence of ulcer recurrence was higher in group 1 than in group 2 in terms of total recurrence (group 1, 50 per cent; group 2, 32 per cent) and patients requiring further surgery (group 1, n = 14, 21 per cent; group 2, n = 7, 15 per cent). Five of these 21 patients required an emergency procedure for haemorrhage or reperforation (group 1, n = 2; group 2, n = 3). There were no significant differences between the 5-year predictive recurrence rate or the requirement for definitive surgery between the groups. Five of the 27 patients currently on medical treatment have required maintenance treatment while the remaining patients receive active treatment for a mean of 20 per cent of the time since they developed recurrent ulceration. These results support continuation of our 'wait and see' policy following simple closure of perforated duodenal ulcer, even in patients with a history of chronic dyspepsia.

Cavernous haemangioma of breast in a man with contralateral gynaecomastia and a family history of breast carcinoma.

A 73-year-old man with a cavernous haemangioma of the right breast is presented. The patient had had gynaecomastia of the left breast 8 years earlier. Prior to that he had been on cimetidine for 2 years. The patient's mother and sister had breast carcinomas, while two other sisters and a brother had carcinomas of kidney, uterus and lung respectively.