European Journal of Surgery最新文献

Objective: To estimate the value of estrogen receptor (ER) in benign breast diseases and to find out if the response of benign breast diseases to danazol depends on the ER status of the tissue.

Design: Prospective study.

Setting: University hospital, India.

Material: Samples of tissue from benign breast lesions, 40 fibrocystic disease and 10 fibroadenomas.

Interventions: Enzyme immunoassay for the presence of cytosolic ER.

Main outcome measures: ER concentrations, and correlation with effect of treatment with danazol.

Results: Fibrocystic disease and fibroadenomas showed 30% and 40% ER positivity, respectively. The mean (SD) ER concentration was significantly higher in premenopausal than postmenopausal patients 14.75 (3.79) fmol/mgm compared with 6.2 (1.59) fmol/mg (p < 0.05). All ten patients with mastalgia who had ER-positive lesions (n = 26) responded to danazol, compared with 6 of 16 patients who had ER-negative lesions (p < 0.05). Lesions with diffuse fibrosis (n = 14) and five with lymphocytic infiltration on histology were all ER-negative.

Conclusion: The patients with ER positive breast disease responded better to danazol than patients with ER negative breast disease.

Objective: To compare two modern mesh-based “tension free” hernioplasties, laparoscopic repair and mesh plug technique.

Design: Prospective, non-randomised study.

Setting: Two major medical centres, Greece.

Subjects: 471 patients with 543 inguinal hernias.

Intervention: Patients entering the study were treated in two major medical centres either by laparoscopic repair under general anaesthesia (n = 237) in hospital A, or by insertion of a mesh plug under monitored local, epidural, or spinal anaesthesia (n = 234) in hospital B. Patients with known bilateral inguinal hernias, femoral hernias, and those with both inguinal hernias and cholelithiasis were encouraged to undergo laparoscopic repair.

Main outcome measures: Operative time, hospital mortality, morbidity and length of stay, costs, time to return to work, and recurrence rate.

Results: The median operative time for laparoscopic repair was significantly longer (57 compared with 33 minutes, p < 0.001). Laparoscopic repair was more costly (US$1200 compared with 500), and technically more demanding than insertion of a mesh plug. The median postoperative hospital stay, consumption of narcotic analgesics, and return to full work and heavy activities were similar in the two groups, whereas light activities were started earlier after plug repair [5.4 (2.4) compared with 3.4 (1.5) hours, p < 0.0001]. There were 6 recurrences in the laparoscopic group and 1 in the plug group.

Conclusions: Mesh plug insertion is faster, cheaper, technically easier, does not require general anaesthesia, and is suitable to be done by surgeons as part of their general practice without special instruments and by junior surgeons. Plug repair resulted in fewer short or long term complications and reduced the recurrence rate.

The five years survival rate for patients with gastric cancer is 15–25%. With the aim of improving survival, chemotherapy has been used in different adjuvant settings. Similarly, but with the aim of improving quality of life and prolonging life, chemotherapy has been used extensively in metastatic disease. In this review we have included studies of systemic and intraperitoneal chemotherapy given before, during or after operation and for advanced disease. A meta-analysis has been made on the 21 randomised studies that used adjuvant systemic chemotherapy postoperatively.

A significant survival benefit for the patients treated postoperatively compared with controls was identified (odds ratio (OR) 0.84, 95% confidence interval (CI) 0.74 to 0.96). When western and Asian studies were analysed separately we found no survival benefit for the treated patients in the western groups (OR 0.96 (95CI 0.83 to 1.12)). Flaws in the conduct of several trials made it difficult to draw firm conclusions, including the exclusion of a small but clinically meaningful survival benefit. Preoperative or neoadjuvant chemotherapy has shown effects in some patients, but no significant benefit was found in the few randomised studies. The few studies that reported intraperitoneal therapy showed no detectable survival benefit either. In patients with advanced disease, four small randomised studies found significantly longer survival in the treated patients. The survival benefit is in the range of 3–9 months, and there were also improvements of the quality of life. Several drug combinations have been tested, however, with no confirmed superiority for a particular regimen.

Conclusions: Adjuvant chemotherapy cannot be recommended as a routine because of the lack of confirmed beneficial effects. Some patients with advanced disease will have a clinically important benefit from palliative chemotherapy, so this can be recommended for patients who are otherwise in good health.

Objectives: To audit the management of vascular trauma in Kuwait, 1992–2000.

Design: Retrospective open study.

Setting: Vascular surgery unit, teaching hospital, Kuwait.

Subjects: 155 patients with vascular injuries, most of which (n = 118) involved the extremities, 21 had neck injuries, 10 abdominal, and 6 chest.

Intervention: Revascularisation usually using the long saphenous vein in addition to direct repair or end-to-end anastomosis.

Main outcome: Morbidity (amputation) and mortality.

Results: Four lower limb grafts failed, two of which (2/69, 3%) required amputation. Overall, four patients died (3%), one of pulmonary embolism and 3 of severe injuries to major abdominal vessels. 3/10 patients with abdominal vascular trauma died. Mean (SD) follow up period was 4.4 (2) years.

Conclusions: Civilian violence has increased in Kuwait. Vascular trauma to abdominal vessels is associated with high mortality. Autogenous saphenous vein forms an excellent conduit for revascularisation.

Aberrant cutaneous scar formation is a substantial cause of postoperative morbidity. There is at present no clear consensus on the best way to prevent or treat such scarring, although recently there has been considerable progress in developing an understanding of the mechanisms of tissue repair and scarring. We carried out a literature review using Medline to establish the current understanding of the key events occurring during tissue repair and to identify potential causes of scarring. We now review the key events during tissue repair and the pathogenesis of fibroproliferative disease. Tissue repair is achieved through a multistranded, elegantly coordinated process within which the balance between synthesis and breakdown of matrix is upset during fibrotic disease. Scars form because the signals directing tissue repair are not correctly terminated, and while the initiation and propagation of repair is well understood the signals that direct its cessation have yet to be elucidated.

Objective: To record the current standards of management and education in trauma surgery in 12 geographically and socioeconomically diverse countries in Europe.

Design: Questionnaire study.

Setting: Teaching hospital, Austria.

Intervention: Questionnaire sent to experts on trauma in Austria, France, Germany, Italy, The Netherlands, Norway, Portugal, Romania, Spain, Sweden, Turkey, and the United Kingdom.

Main outcome measure: Comparison of management of patients before, during, and after admission to hospital, and opportunities for initial and in-service training.

Results: Management of patients and opportunities for training varied considerably from country to country, ranging from an organised trauma service throughout with specialised training to a haphazard and variable service that depended more on individual hospitals, doctors and patients.

Conclusions: Standardisation of management and training would be desirable, and should be possible at least in countries that are members of the European Union.