Clinical research may be either epidemiological or experimental. Epidemiological (observational) research includes cross-sectional, case-control, and cohort studies and draws attention to associations, which may or may not denote cause and effect. Experimental research may be explanatory, the purpose of which is to advance our knowledge of physiological or pathological events; or it may be pragmatic, the purpose of which is to influence our treatment of patients. All these types of clinical research have their own rules, but underlying the detailed rules are the universal ones of telling the truth and doing no harm. Copyright © 1998 Taylor and Francis Ltd.
To review our experience of a non-selective policy for the treatment of ruptured abdominal aortic aneurysm to see if the policy was justified, and to identify any preoperative risk factors that adversely influenced outcome.
Retrospective study.
Teaching hospital, Republic of Ireland.
258 patients admitted with abdominal aortic aneurysms between January 1982 and December 1993.
Definitive surgical treatment.
Morbidity, mortality, and risk factors.
In-hospital mortality for all patients was 43% (110/258). Overall, women did worse than men (28/44, 64%, died, compared with 96/214, 45%, p = 0.03). The mortality among patients over the age of 80 (23/45, 51%) was not significantly different from that among younger patients (97/202, 48%). Blood pressure, platelet count, and haemoglobin concentration were all significantly lower preoperatively among those who died (p < 0.05).
Age alone cannot be used to justify witholding definitive surgical treatment. Treatment should be aimed towards reversing haematological and haemodynamic abnormalities preoperatively to try to improve outcome. Copyright © 1998 Taylor and Francis Ltd.
To assess the function of the pylorus after pylorus-preserving pancreaticoduodenectomy (PPPD) done for periampullary or pancreatic cancer.
Prospective, observational controlled clinical study.
Teaching hospital, Italy.
17 patients who had undergone PPPD, and 15 healthy control subjects.
Endoscopy to check for gastritis and marginal ulcers and 24 h-pH monitoring and 99mTc HIDA scintigraphy to detect jejunogastric reflux. Scintigraphy was also used to evaluate gastric and jejunal transit after a solid meal labelled with 99mTc colloid sulphur.
Signs of delayed gastric emptying, jejunogastric reflux and gastric outlet obstruction in the short and long term.
In the early postoperative period only 1 patient had delayed gastric emptying. In the long term, two patients had symptoms of dyspepsia and 8/11 showed alkaline reflux with persistent gastric pH more than 4 for more than 12 hours; 3 had histological signs of gastritis. There was no difference in gastric emptying compared with controls, but three patients had prolonged emptying time (T1/2 more than 85 minutes). Endoscopy findings correlated with pH monitoring results.
After PPPD, most patients have abnormal pyloric function, but it is clinically evident in only a small proportion. Copyright © 1998 Taylor and Francis Ltd.
To compare among surgeons the risk-adjusted rates of wound infection and incisional hernia after midline incisions.
Prospective clinical study.
County hospital, Sweden.
1013 patients who underwent midline laparotomy between August 1989 and June 1993.
Wounds were sutured by a continuous technique and details of patients and operations were recorded. The suture technique was monitored by the suture length:wound length ratio.
Postoperative wound infection, and incidence of incisional hernia at 12 months.
The details of patients and operations varied significantly among surgeons. Senior surgeons sutured with a lower suture length:wound length ratio than juniors (mean (SD) 4·1 (1·4) compared with 5·3 (2·1), p < 0·01). The individual rates of wound infection varied from 0 to 27% (mean 10%) and that of incisional hernia from 5% to 26% (mean 15%). After correction for patient selection three surgeons had significantly higher rates of wound infection and one significantly lower than the others, two surgeons had significantly higher rates of incisional hernia and two significantly lower. Only one surgeon differed significantly in the rate of incisional herniation after also adjusting for the suture technique. The length of surgical experience did not affect the rate of wound complications.
The suture technique, monitored by the SL:WL ratio, is the most important factor for variability in the incidence of incisional hernia among surgeons in continuously sutured midline incisions. The suture technique may also help to explain the variability in rates of wound infection. Copyright © 1998 Taylor and Francis Ltd.
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