Anomalous biliary and vascular anatomy-Potential pitfalls during cholecystectomy.

Laparoscopic cholecystectomy is usually a low-risk procedure associated with a short stay and a low rate of conversion to open surgery. Complications are sometimes associated with anomalous vascular or biliary anatomy. Outlined below are the variations in vascular and biliary anatomy which may result in complications either due to involvement in the inflammatory process or inadvertent division during dissection. Clin. Anat. 30:1103-1106, 2017. © 2017 Wiley Periodicals, Inc.

Role of carcinoembryonic antigen as a marker for colorectal liver metastases.

Carcinoembryonic antigen (CEA), a marker for colorectal adenocarcinoma, can monitor disease progression and treatment response. This study aims to determine the accuracy of CEA in the detection and resectability of colorectal liver metastases. Patients with primary colorectal cancer were divided into three groups: resectable hepatic metastases (group 1), unresectable metastases (group 2), and disease-free cases (group 3). The CEA concentration was recorded pre- and post-hepatectomy in group 1 and on radiological confirmation of disease state in the other groups. It was expressed as median (95% confidence interval [CI]), with predictors of concentration determined. Group 1 (n=141) had pre-operative CEA of 8.9 (4.6-13.1), with 38.1% of patients being normal. Maximum tumour diameter correlated with CEA level (r=0.41, P<0.0001). Post-hepatectomy CEA was 2.3 (1.9-2.7; P<0.0001), with 81.1% of patients being normal. Group 2 (n=158) had CEA of 20.6 (9.4-31.9). Group 3 (n=361) had CEA of 2.0 (1.8-2.2). Sensitivity of CEA pre- and post-hepatectomy was 61.2% and 69.3%, respectively, while specificity was 79.8% for both groups. Concentration was elevated in hepatic colorectal metastases but is not a marker of resectability. A CEA reduction post-resection indicates that it may be used as an indicator of treatment response, while CEA is increased by tumour burden and lesion size.

CT or not CT--that is the question. Whether 'tis better to evaluate clinically and x ray than to undertake a CT head scan!

OBJECTIVE: To evaluate the usage of computed tomography (CT) head scanning in children at the Royal Aberdeen Children's Hospital after the publication of the National Institute of Clinical Excellence (NICE) guidelines on the management of head injury. METHODS: The Accident and Emergency case records of all children presenting with a head injury over a three month period were reviewed and the number of attendances, radiographs, and CT head scans undertaken were noted. Also noted was the number of additional CT head scans that would have been performed if the NICE guidelines had been rigidly followed. RESULTS: Five hundred and thirty seven children were included in the study: 67% were boys. Two hundred and ten (39%) had skull radiographs: six demonstrated skull fractures and eight (1.5%) underwent CT head scan, with one positive report of a skull fracture. There were no reports of intracranial abnormalities. Ninety nine (18.4%) were admitted. Strictly applying all the NICE criteria for CT scanning would have resulted in an additional 54 patients being scanned. CONCLUSION: Rigid adherence to the NICE guidelines in all children with head injuries would have resulted in an almost eightfold increase in CT head scans performed. None of these children had clinical signs of intracranial injury and would have been exposed to a large amount of ionising radiation. The use of guidelines in practice must always be considered in conjunction with clinical judgement.

Esophageal mucosal blood flow: a central role for calcitonin gene-related peptide.

BACKGROUND: Esophageal mucosal blood flow is a dynamic phenomenon dependent on luminal content. Reactive hyperemia, likely a factor in mucosal protection, follows luminal exposure to noxious substances, including bile. The mediators of this response are unknown, although the likelihood is that visceral afferent nerves play a major role. The purpose of this study was to determine whether substance P, calcitonin gene-related peptide (CGRP), or adenosine could mediate this reactive blood flow response. METHODS: Esophageal mucosal blood flow was studied in a rabbit model with the radiolabeled microsphere technique. The effect of intraarterial infusion of CGRP and substance P and intravenous adenosine was studied. Subsequently, the hyperemic response to luminal deoxycholate was measured in the presence of antagonists to CGRP, substance P, and adenosine. Immunohistochemical studies were performed to determine the distribution of CGRP and substance P in the esophagus. RESULTS: CGRP proved to be a potent stimulus to mucosal blood flow. The presence of a CGRP antagonist reduced mucosal blood flow at baseline and after exposure to deoxycholate. Antagonists to substance P and adenosine had no effect on baseline and deoxycholate-stimulated blood flow. CONCLUSIONS: CGRP is likely a major mediator involved in the regulation of esophageal mucosal blood flow.

Eliciting the smoker's agenda: implications for policy and practice.

Existing health promotion messages and advice on smoking cessation focus upon the negative aspects of continuing to smoke and contrast these to the benefits of giving up. Benefits of cessation are invariably linked to reduced risks of illness and disease with the process of cessation framed as a largely positive and certainly a health enhancing one. In this paper we present an analysis of data from a cross-sectional, exploratory study in the city of Aberdeen, Scotland, undertaken with 54 people, aged 18-44, who are or have been smokers. The multiple and often contradictory agendas of everyday life, smoking and health are explored. Participants spoke of the dangers of smoking and the potential benefits of giving up as these are considered by health promotion and medical research. However, many smokers experienced a number of benefits from smoking (such as socialising with others and breaks from boredom), and health and social problems with the process of cessation (for example, weight gain, stress, colds, flu). Participants appeared to query the validity of the risks of continuing to smoke and yet indicate a range of health and social difficulties in giving up. The authors assert that an acknowledgement of the attractive, pleasurable aspects of smoking may be seen as unacceptable and irresponsible but this could well provide an opportunity to relate to the everyday and multiple practices of smoking and smokers themselves as illuminated by this research.

The food consumption patterns and perceptions of dietary advice of older people.

BACKGROUND: Prevention policies do not have an upper age limit, and as the overwhelming majority of older people continue to reside in the community there is a growing role for community dietetics and primary care team members in the promotion of healthy eating. METHOD: The multi-method project ascertained the dietary beliefs and practices of older people residing in high-income, low-income and rural localities of Scotland. One hundred and fifty-two people aged 75 years and over were interviewed using a semistructured interview schedule and 24-h food recall questionnaire. RESULTS: An analysis of the food recall questionnaire demonstrated that the diets of the elderly appear to differ little from the Scottish population as a whole. In all groups there was an under consumption of fruits and vegetables reported. Findings from the interviews demonstrated that dietary beliefs were found to be firmly rooted in childhood and lifetime experiences. Participants defined healthy eating as 'proper meals', 'proper foods', and a variety of foods eaten in moderation. These definitions were based upon the consumption of fresh foods which would be considered healthy. Changing and conflicting advice on health and nutrition was contrasted with personal experiences. Few knew of the role of the dietitian or community dietitian. CONCLUSIONS: This study demonstrates a contrast between stated beliefs and actual consumption patterns. Access to food, and the cost and quality of foods impacted upon food practices. The role of the community dietitian should be promoted. Advice on healthy eating must work with contemporary practices and beliefs building upon positive aspects of diet and eating and involving the food industry, retail sector and health services.

Transduodenal excision of ampullary tumours.

The commonly recommended treatment for ampullary tumours--pancreaticoduodenectomy results in significant morbidity and mortality. This study is a retrospective evaluation of the procedure of transduodenal local excision of ampullary tumours. Demographics, symptoms, histological findings and outcomes were retrospectively analysed in 15 patients. Survival analysis was done by the method of Kaplan-Meier and log-rank test. The median age was 68 years (range 54-78). Endoscopic biopsy was accurate in only 41% of cases. CT scan demonstrated a mass in 50% cases. Definitive histology reported 4 adenomas, 2 carcinomas-in-situ and 9 adenocarcinomas. Median hospital stay was 13 days. There was no operative mortality. Mean duration of follow-up was 31 months (range 7-70 months). The procedure appears curative for adenomas and in-situ carcinoma. Overall 3 year actuarial survival for ampullary tumours is 65% while that for moderately differentiated carcinomas is 50%. Pre-operative investigations provide inadequate histological information. Wide local excision is a safe operation with low morbidity and good survival in carefully selected cases. However, the role of local excision for carcinoma appears to be palliative rather than curative.

Biliary complications associated with laparoscopic cholecystectomy--an analysis of common misconceptions.

BACKGROUND: Several views are expressed by surgeons on biliary complications following laparoscopic cholecystectomy as follow: most are caused by trainees; complications occur in the presence of difficult anatomy/pathology; injuries occur more proximally than at open cholecystectomy; most injuries are recognised immediately and most can be managed non-operatively. The aim of our study was to determine if these views are substantiated in clinical practice. METHODS: The mode of presentation, management and outcome of thirty-two patients referred to a hepatobiliary unit over a seven year period were analysed. RESULTS: In 72% of cases the initial operator was a consultant. Five of the 32 complications (16%) occurred in the presence of difficult anatomy/pathology. Two patients had proximal biliary tree injuries, the only mortalities (two) occurring in this group. Only 41% of injuries were detected immediately; 87% required surgical intervention, hepaticojejunostomy being the most common procedure performed (75%). CONCLUSION: Our study shows that the majority of bile duct injuries are not caused by trainees, do not occur because of unusual anatomy/pathology, do not occur in the proximal biliary tree and are not recognised at the time of operation. Most injuries ultimately require major reconstructive surgery for definitive management.

Initial experience of laparoscopic cholecystectomy in a district hospital.

Fifty-five consecutive unselected patients were submitted for laparoscopic cholecystectomy, and the procedure completed laparoscopically in fifty cases. The outcome is presented with particular reference to the duration of surgery, postoperative pain and nausea, the length of hospital stay and the time taken to recover normal activities. This technique is shown to have major advantages over conventional gallbladder surgery for the majority of patients.

PET-CT accurately predicts the pre-operative characteristics of colorectal hepatic metastases.

BACKGROUND: Since 2002, Positron Emission Tomography (PET-CT) has been considered to be an essential pre-operative investigation in the management of colorectal liver metastases (CRLM) in our institution. This study aimed to compare characteristics of hepatic metastases on PET-CT with post-operative histological findings and pathology of the primary tumour. METHODS: All patients with CRLM, who underwent surgical intervention from 2002 to 2008, were reviewed. PET-CT and pathology reports of hepatic resections and original colorectal resections were retrieved. Patient demographics, colorectal staging, number of metastases and their maximum diameter from both PET-CT and pathology reports were recorded. Values were expressed as mean (±SD). RESULTS: 141 patients were identified. The maximum diameter on PET-CT (4.2 ± 2.6) was similar to pathology (4.8 ± 3.6; p = 0.39), with significant correlation (r = 0.72, p < 0.0001). The number of lesions on PET-CT (1.6 ± 1.0) was similar to pathology (1.7 ± 1.3; p = 0.43) with significant correlation (r = 0.80, p < 0.0001). Mean SUV max was 9.22 (±4.39), with no correlation to lesion diameter (r = 0.25, p = 0.045), but significantly increased with decreasing differentiation (p = 0.01). CONCLUSIONS: PET-CT scanning accurately detected the number of lesions and their maximum diameter, with radiological evidence of poorer differentiation. Further studies of non-surgical patients are required to assess its overall accuracy.

The role of surgery for pancreatic cancer: a 12-year review of patient outcome.

INTRODUCTION: Pancreatic cancer has a poor prognosis with <5% alive at 5 years, despite active surgical treatment. The study aim was to review patients undergoing pancreatic resection and assess the effect of clinical and pathological parameters on survival. PATIENTS AND METHODS: All patients who had undergone radical pancreatic surgery, January 1996 to December 2008, were identified from the unit database. Additional information was retrieved from the patient records. The demographic, clinical, and pathological records were recorded using Microsoft Excel. Survival was assessed using Kaplan-Meier and predictors of survival determined by multinominal logistic regression and log rank test. RESULTS: 126 patients were identified from the database. The majority (106) had a Whipple's procedure, 14 had a distal pancreatectomy and 6 had local periampullary excision. The average age of the Whipple's group of patients was 61.7 years (± 11.7) with most procedures performed for malignancy (n=100). Survival was worse with adenocarcinoma compared to all other pathologies (p=0.013), while periampullary tumours had a better prognosis compared to other locations (p=0.019). Survival decreased with poorer differentiation (p=0.001), increasing pT (p<0.001) and pN stage (p<0.001). Survival was worse with perineural (p=0.04) or lymphovascular invasion (p=0.05). A microscopic postive resection margin (R1) was associated with a worse survival (p=0.007). Tumour differentiation (p=0.001) and positive nodal status (p<0.001) were found to be independent predictors of mortality. CONCLUSION: Tumour differentiation and nodal status are important predictors of outcome. A positive resection margin is associated with a poorer survival.

Women's views of the cervical smear test: implications for nursing practice--women who have not had a smear test.

This is the first of two papers reporting the findings of a study on the views of women with regards to the cervical smear test. In this first paper the views of those who have not had a smear test are analysed. The implications of those views for nursing practice in primary health care are identified and explored. Conducted in 1989-1990, the ESRC-funded study was located in the north-east of England and drew respondents from two age groups living in working-class localities. Focusing upon the views of women who have not had a smear test, a number of conclusions were evident: (a) that the call, recall system did not invite all women in the screening target group for a smear test; (b) that beliefs and attitudes, rather than practical problems, were cited as major factors in non-attendance; and (c) that women hold strong views on aspects of service delivery they would like to see in place. Thus the organization and delivery of the service might be reviewed. However, the barriers posed by beliefs and attitudes must be further explored through community-based work encompassing all community-based health professionals.

Women's views of the cervical smear test: implications for nursing practice--women who have had a smear test.

This is the second of two papers reporting the findings of a study on the views of women with regards to the cervical smear test. In the first paper (vol. 18, no. 6), the views of those who have not had a smear test were analysed. In this paper, the views of women who have had a smear test are identified and analysed. The implications of those views for nursing practice in primary health care are explored. Conducted in 1989-1990, the ESRC-funded study was located in the north-east of England and drew respondents from two age groups living in working-class localities. Focusing upon the views of women who have had a smear test, a number of conclusions are evident: (a) that a high proportion of respondents were screened opportunistically; (b) that negative views of the service concerned fear and embarrassment and the lack of, or inadequacy of, an explanation; (c) that positive aspects of the service were staff attitudes, convenience and familiarity; and (d) an understanding of the cytology process and the aetiology of cervical cancer was not linked to the level of (non) involvement in the screening service. Thus the organization and delivery of the service might be reviewed. However, the negative views pose a number of problems that must be further explored through primary health care work encompassing all community-based health professionals.

Health issues in remote and rural areas.

In March 1996 a conference on the theme health issues in remote and rural areas was held in Inverness. Sponsored by the Scottish Office, Highland Health Board and the Department of General Practice and Primary Care, University of Aberdeen, participants included representatives from the Scottish Office, the seven Health Boards with areas designated as remote and rural, the Health Education Board for Scotland, The Royal College of General Practitioners, voluntary sector organisations and academics. In this paper we introduce the theme and outline the debates detailed in the following three papers.

A critical appraisal of the draw and write technique.

The draw and write technique is increasingly popular in health education research with children. It is generally employed in the setting of the school classroom and is promoted as a 'bottom-up' approach which enhances participation by children. In this paper we critically appraise the use of this method. Against the background of a consideration of carrying out qualitative health promotion research with children we examine the origins and use of children's drawings in a number of disciplines and practice environments. We argue that, although the draw and write technique has made an important contribution to health education research, it fails to reflect the processes involved in the construction and collection of such data. A range of methodological, analytical and ethical issues are raised. We conclude that health education research with children must involve taking children seriously as social actors and query the assumption that drawing enables children to communicate their thought any more than does conversational language. We suggest that the development of research should be premised upon an appreciation of the social context and the world of the child.

Getting the message across: the development and evaluation of a health education video in general practice.

While many practices use, purchase or hire videos for health education purposes, a general practice in the North East of Scotland developed its own video. The practice staff were able to incorporate practice information and health education messages while using a local theme where all scenes in the video were either from within the town itself (where the practice is based) or within the surgery and all those appearing in the video are patients, local residents, and surgery staff. After showing in the waiting room of the surgery for two months, the video was evaluated for its potential to convey health information and its effectiveness in triggering patients to pick up specially designed healthy living leaflets on smoking, exercise, diet or alcohol that accompanied the video or to discuss health topics from the video. The evaluation showed that 84% of the patients interviewed watched the video and many provided positive comments. Whilst the video provided information in a comprehensible format and it was appreciated by many of the patients, few had picked up the leaflets or discussed any of the health issues with their GPs.

The promotion of healthy eating: food availability and choice in Scottish island communities.

Communities in rural areas are in receipt of health education messages on healthy eating aimed at the population. These messages are invariably composed without regard to where people reside, and, in particular, to the availability of, and access to, foodstuffs in rural areas. In this paper the authors present data derived from a participative health needs assessment on the topic of food, diet and health. The research was conducted in a number of islands of the Western Isles of Scotland and comprised seven focus groups, 33 semi-structured interviews, one community and one policy workshop, and a final community feedback session. The needs assessment demonstrated a dichotomy between local experiences of food availability, island food cultures and the contents of healthy eating advice. As a result of the research, local people and health care professionals developed a range of activities on the topic of the traditional island diet. People noted the potentially positive elements of this diet for health but also the possibility of promoting social cohesion through the consideration of food and diet histories. In addition, lobbying at a national level was also identified as necessary to the development of a 'healthy food policy'.