Operative cholangiography. Review of 7,529 operations on the biliary tree in a community hospital.

Primary operation for cholelithiasis ranks third in frequency among general surgical procedures performed in this country each year [16]. The mortality and morbidity associated with retained common duct stones are apparent to all biliary surgeons. Although operative cholangiography is a standard procedure in many centers, some still use this adjunct to biliary surgery infrequently, as shown by the 51 percent performance rate in the present study. However, the literature is replete with evidence supporting the routine use of cholangiography. In the present report positive findings on common duct exploration almost doubled when operative cholangiography was added to the clinical and operative criteria for common duct exploration. Our experience indicates that common duct exploration is not always required when the patient has jaundice if normal operative cholangiograms support the patient's history and other laboratory findings. Cholangiography was also found to be accurate in the five cases in which a secondary biliary procedure had to be performed.

Short-bowel syndrome: a collective review.

Neonates can now be expected to survive with very short lengths of bowel because of advances in pediatric neonatal care and in parenteral and enteral nutrition. Most pediatric surgeons have only a few patients with this problem under their care, so individual experience is limited. This collective survey, carried out by postal questionnaires to pediatric surgeons in the British Association of Paediatric Surgeons in the United Kingdom with an interest in the gastrointestinal tract, documents current techniques of management, the complications encountered, and reviews the clinical and economic consequences of prolonged total parenteral nutrition. We conclude that within the limitations of resources and our understanding of prognosis, neonates, especially if less than 35 weeks' gestation, with remaining jejunoileal segment of greater than 20 cm with an intact ileocecal valve (ICV) or greater than 30 cm without an ICV, should be considered salvageable.

Surgical management of infantile hypertrophic pyloric stenosis--can it be performed by general surgeons?

INTRODUCTION: Debate exists as to whether IHPS can be treated in district general hospitals as effectively as in specialist paediatric surgical units. AIM: To review the surgical treatment of IHPS in babies admitted to a district general hospital under the care of two consultant general surgeons with a paediatric surgical interest. PATIENTS AND METHODS: The case notes of 66 babies operated on for IHPS over a 42 month period between April 1995 and September 1998 were retrospectively reviewed. Demographics, operative details, hospital stay, and overall complications were all documented. RESULTS: Peri-operative complications occurred in 2 patients, both requiring omental patches for duodenal perforation. Nine patients had 1 or 2 episodes of postoperative vomiting; 4 had either a wound or urinary tract infection; and 1 baby developed an incisional hernia. There was no mortality. DISCUSSION: The complication rate seen in this series is comparable to that of specialist centres, and supports current guidelines suggesting that IHPS can be managed by general surgeons with a paediatric surgical interest in a district general hospital.

Maximum carotid artery wall thickness and risk factors in a young primary prevention population.

Maximum carotid artery wall thickness was utilized in a primary prevention population and compared with baseline risk factors. Carotid wall thickness was measured between the blood-intima and media-adventitia interfaces by B-mode ultrasonography using software calipers at points of protrusion. Long-axis measures were confirmed by short-axis assessment. The maximum carotid wall thickness for each subject was divided by age in years to yield an annual accretion rate (called carotid intima-media thickness accretion rate [CIMTAR]). The entire study population was then divided by median CIMTAR to investigate the association with baseline variables used in standard risk assessments with the bifurcated groups. Traditional risk factors such as age, diabetes, smoking, hyperlipidemia, and obesity were not associated with greater than median CIMTAR. Only male gender (P = 0.02) and systolic blood pressure (P = 0.002) in baseline variables were associated with an elevated CIMTAR for the entire population. Among those not taking lipid-lowering therapy at baseline, only systolic blood pressure remained significant (P = 0.0002). Correlations between low-density lipoprotein (LDL) cholesterol level and maximum carotid wall thickness/CIMTAR were weak for the entire population (r = -0.17/r = -0.12, respectively). Measure of maximum carotid wall thickness may select patients earlier for treatment than traditional risk factors. The addition of CIMTAR to risk algorithms may permit a single-point assignation of subsequent vascular risk that is more efficacious than traditional risk factors.

Ovarian cancer presenting as chest wall subcutaneous nodule: a case report and a literature review.

BACKGROUND: Distant metastasis from primary epithelial ovarian carcinoma is commonly found as nodal and intraperitoneal spread, spread via haematogenous routes or transcoelomic spread. Ovarian cancer presents in different ways, but common presentations include abdominal pain, distention or ascites due to metastatic involvement of peritoneal cavity. Most tumour present at advanced stage and distant metastases to common and uncommon sites are found in patients who have undergone treatment for primary ovarian cancer. Subcutaneous metastatic nodules from primary ovarian cancer are rarely found in advanced disease. We describe a case of asymptomatic ovarian carcinoma presenting as a chest wall nodule. CASE: An unusual case of primary ovarian carcinoma presenting as asymptomatic chest wall subcutaneous nodules that subsequently were diagnosed as metastatic lesions. CONCLUSION: An unusual case of ovarian carcinoma where the patient was totally asymptomatic and referred with two tiny subcutaneous nodules. Therefore, lumps of recent onset, although asymptomatic, should either have fine needle aspiration cytology or excision biopsy.

Delay in diagnosis and treatment of symptomatic colorectal cancer.

Mean delay between the onset of symptoms and treatment was 30.5 weeks in a hundred patients with colonic carcinoma and 38 weeks in a hundred patients with rectal carcinoma. Most of this delay occurred outside hospital and delays attributable to the patient and family doctor were almost equal in duration. Patient delay is largely the result of not knowing the importance of bowel symptoms, while delay with the family doctor was the result of not examining patients with possible rectal carcinomas and not recognising symptoms suggestive of colonic carcinoma. 42% of patients with colonic carcinoma were admitted for emergency treatment, 76% having already consulted their doctor about symptoms on one or more occasions. Hospital delay consisted mainly in waiting for investigations, poor quality barium enemas, and inadequate sigmoidoscopy. There was no relation between the duration of symptoms and the Dukes stage of the tumour.

Cholecystectomy with closed suction drainage.

In this prospective, consecutive, and nonrandomized study, 200 patients had cholecystectomy in a seven-month period. Half of them had drainage with Penrose drains and the other half with a closed suction system. The average hospitalization was one day shorter in the latter. No complications related to its use were found. Retrospective evaluation appears to indicate some conservation of medical care expenditures.

Subcutaneous mastectomy for primary operable breast cancer.

Subcutaneous mastectomy has been performed on 98 patients with primary breast cancer. Eighty-four have undergone breast reconstruction using a silicone prosthesis. The overall complication rate has been low. The rates of local recurrence and survival are similar to those in patients undergoing simple mastectomy.

Microdochectomy for single-duct discharge from the nipple.

Microdochectomy has been the accepted treatment for single-duct nipple discharge. Review of 97 consecutive patients undergoing microdochectomy between 1980 and 1987 revealed a total of eight patients with ductal carcinoma in situ. All of these had pre-operative mammography, results of which were highly suspicious of malignancy in six patients. Tiny foci of ductal carcinoma in situ were found in the two patients with normal mammograms. We suggest an expectant policy in cases where the mammogram is normal, omitting routine microdochectomy.

Salivary cortisol and dehydroepiandrosterone sulphate levels in postmenopausal women with primary breast cancer.

Cortisol and dehydroepiandrosterone sulphate (DHAS) were measured in saliva from postmenopausal women with primary breast cancer and a control group of comparable age. Specimens were collected at 2-hr intervals during wake-span for two consecutive days, and circadian rhythmicity was demonstrated for each of the hormones in both populations. The marginally elevated levels of cortisol and lower levels of DHAS associated with the cancer group, and the larger inter-subject variation, make it unlikely that these hormone measurements would be of value in identifying women at risk of developing breast cancer.

Preliminary results of the Nottingham breast self-examination education programme.

Between June 1979 and December 1984, 49,573 women (study population) between the ages of 45 and 64 years and living in one health district were invited to attend breast self-examination sessions as part of the DHSS 'UK Trial of Early Detection of Breast Cancer'. Of the women invited 50.2 per cent attended for education. A total of 319 breast cancers were diagnosed in the study population during this period. The tumour characteristics, patient prognostic groups and survival have been compared with a control population consisting of the 319 consecutive breast cancers diagnosed immediately before the start of the DHSS trial, in women of the same age group and living in the same health district. There has been a significant reduction in the size at presentation of operable tumours (P less than 0.01) and there has been a small (3.4 per cent) reduction in lymph node involvement, but this is not significant. The rates of presentation of both in situ and advanced carcinoma have not significantly changed following the introduction of a breast self-examination education programme. At this stage no overall survival difference has been identified between the two groups but the median follow up of the study population is limited (25 months).

Initial results from a programme of breast self-examination.

As part of a national study of early detection of breast cancer, 28663 women aged between 45 and 64 have been invited to attend a teaching programme on the method of self-examination with the advice to practise it regularly. This paper reports the early results of the Nottingham study on 14905 who have attended. To date there have been 717 self-referrals. One hundred and thirty-nine of these had a significant abnormality on either clinical examination or mammography and eight biopsies have been performed. Cancer was detected in 43 women. This is a detection rate of 2.9 cancers per 1000 educated. Mean tumour size was 2.3 cm (0.5-6.0 cm) and 56% were lymph node negative.

Prolactin and breast skin temperature rhythms in postmenopausal women with primary breast cancer.

Plasma prolactin and cortisol were determined and breast skin temperatures measured in 8 postmenopausal diurnally active-nocturnally resting women, 7 with primary breast cancer and 1 with benign breast disease. In all subjects, prolactin peaked during the early morning hours. Cortisol and oral temperature served as internal physiological markers of anticipated rhythmicity in adrenocortical function and metabolism. In all patients studied, the tumour site had an increased mesor (midline-estimating statistic of rhythm) and reduced amplitude of the circadian breast skin temperature rhythm when compared to a similar site on the contralateral breast. Thermal asymmetry was also observed between left and right breasts. A cancer, if in the left breast, may reinforce lower amplitude and perhaps a higher mesor (associated with the healthy left breast in these particular patients), whereas if it is located in the right breast, it tends to nullify inter-mammary differences in mesor and amplitude. Screening for breast cancer appears to require subjects being monitored on at least two occasions before thermal abnormalities due to tumour or preneoplasia become discernible.