The European journal of surgery = Acta chirurgica最新文献

Objective: To find out whether failure of primary wound healing after excision and primary suture for chronic pilonidal sinus predicts recurrence.

Design: Follow-up of one prospective study and one subsequent randomised, multicentre study.

Setting: Three teaching hospitals in WesternNorway.

Subjects: A total of 197 consecutive patients operated on for chronic pilonidal sinus.

Interventions: Fifty two patients in the prospective group were given cloxacillin perioperatively. In the randomised study, 145 patients were randomised to have either a single preoperative dose of cefoxitin 2 g intravenously (n = 73) or no prophylaxis (n = 72). Patients were followed up for a median of 7 years.

Main outcome measures: Recurrence of pilonidal sinus.

Results: In the prospective group there were 10 recurrences (19%). In the randomised study 6 patients (8%) who had been given antibiotic prophylaxis had a recurrence compared with 14 patients (19%) who had not been given prophylaxis (p = 0.09). In both groups, failure of primary normal healing was significantly associated with early recurrence (p = 0.0002). Neither the use of antibiotics nor sex had any significant influence on the incidence of recurrences. Most recurrences occurred within the first year.

Conclusion: Wound complications significantly influenced the recurrence rate whereas antibiotics did not. Most recurrences were seen early.

Objective: To compare stapled haemorrhoidectomy with Milligan-Morgan haemorrhoidectomy.

Design: Prospective open study.

Setting: Teaching hospital, Greece.

Patients: 85 patients with prolapsing haemorrhoids were invited to choose between stapled and Milligan-Morgan haemorrhoidectomy. 48 chose the former and 37 the latter.

Interventions: Operation. Postoperatively, the patients were given analgesics on demand, and were discharged as soon as their condition and particularly their pain had improved.

Main outcome measures: Patients' symptoms and their opinion about the procedures, which were recorded during their follow-up which lasted for 6 months.

Results: Stapling resulted in a significantly shorter operating time, and less postoperative pain and other symptoms, than Milligan-Morgan excision (p < 0.001). Postoperative complications, and mean time in hospital did not differ significantly between the two groups. During the follow-up period there was no significant difference in the incidence of recurrences between the two groups. Six months after the operation, significantly more patients in the stapled group had residual skin tags-external haemorrhoids than in the Milligan-Morgan group, and all these patients had fourth degree haemorrhoids.

Conclusions: Stapled haemorrhoidectomy is a promising method of treatment for prolapsing third degree haemorrhoids. Its effectiveness is questionable for fourth degree ones. Initially, the results are as good as after Milligan-Morgan haemorrhoidectomy, especially for third degree haemorrhoids. However, more patients and longer follow-up periods are required for its long-term efficacy to be confirmed.

Objective: To investigate the relationship between five-year control of reflux and early postoperative oesophageal function after total fundoplication done either laparoscopically or through a laparotomy in severe and mild reflux disease.

Design: Prospective open study.

Setting: University hospital, Sweden.

Patients: In the group with severe disease 9 patients had a laparotomy and 7 laparoscopy. The corresponding figures for the group with mild disease were 21 and 34 respectively.

Results: The increase in lower oesophageal sphincter pressure 6 months after operation in patients with recurrent disease was significantly less than that for patients with good reflux control (p < 0.01). In patients who had laparotomy, including 30% (9/30) with severe reflux disease, good long-term reflux control was found in 93% (27/29). In patients operated on laparoscopically including 17% (7/41) with severe reflux disease good long-term reflux control was found in 90% (35/39).

Conclusion: The mechanism of recurrence differed between patients with severe disease who had a laparotomy and patients with mild disease operated on laparoscopically. Early postoperative manometry was prognostic for recurrence. Long-term reflux control seems to be similar after laparotomy and laparoscopy. Further randomised studies are needed.

Objective: Development of a prognostic tool for patients with unresectable pancreatic cancer to distinguish between with low or high probabilities of survival 3 to 9 months after diagnosis.

Design: Data about individual patients from five studies were pooled. A multivariate proportional hazards model with time-dependent covariates was developed, including age, sex, and metastases. An extended model was developed on a subset of patients, including weight loss, pain, and jaundice at diagnosis.

Setting: Multicentre study, The Netherlands, Norway, USA, UK, and Canada.

Subjects: 1020 patients with unresectable pancreatic cancer.

Main outcome measures: Prediction of prognosis.

Results: Patients with metastases, pain, or weight loss at diagnosis had a significantly poorer prognosis than the others. Older men had a worse prognosis than younger men, while older women had a better prognosis than younger ones. Patients with jaundice had a relatively good prognosis. Differences in survival among the studies were incorporated in a prognostic score chart.

Conclusion: The prognostic score chart can be used to select patients with relatively low expectation of survival for endoscopic palliation, and patients with relatively high expectation for surgical palliation.

Objective: To investigate the effect of various doses of melatonin on reduction in mesenteric blood flow (MBF) and increase in tumour necrosis factor alpha (TNFalpha) concentration caused by injection of lipopolysaccharide (LPS).

Design: University Hospital, Turkey.

Setting: Open experimental study.

Animals: 59 Swiss albino mice.

Interventions: Animals were injected with melatonin solvent or 1, 10, 100, or 500 mg/kg melatonin. Ten minutes later control animals were injected with saline, and the experimental group with LPS.

Main outcome measures: Mesenteric blood flow and serum TNFalpha concentration.

Results: In control animals, 100 and 500 mg/kg melatonin reduced MBF. LPS reduced MBF in solvent, 1, and 10 mg/kg melatonin groups. The concentration of TNFalpha was considerably increased in the mice given LPS. Melatonin reduced this response significantly.

Conclusion: In high doses melatonin directly reduces MBF. It has no protective effect on the LPS-induced decrease in MBF. In lower doses it blocks, but at higher doses reduces, LPS-induced TNFalpha production.

Objective: To find out if two immunomodulatory drugs used in organ transplantation (FK506 (tacrolimus) and OKT3 (Orthoclone) would reduce early inflammatory complications in experimental acute pancreatitis.

Design: Laboratory study.

Setting: University hospital, Germany.

Animals: 36 Balb/c mice.

Interventions: Pancreatitis induced by 7 intraperitoneal injections of cerulein 50 microg/kg at hourly intervals followed by FK506 0.32 mg/kg, OKT3 0.6 mg/kg, or 0.9% sodium chloride (controls) (n = 12 in each group). 12 hours after induction of pancreatitis the animals were killed.

Main outcome measures: Serum amylase activity and interleukin-6 (IL-6) concentrations; histological damage to pancreas and lungs, apoptotic cells in pancreas; and myeloperoxidase activity in lungs.

Results: No animal died during the experiment. At 12h serum amylase activity and IL-6 concentrations were increased in all 3 groups, but highest in the OKT3 group. The pancreatic histological score, apoptosis, and inflammatory infiltration were lower in the two experimental groups than controls, but the degree of vacuolisation of acinar cells was similar. Packed cell volume was higher in the control than the experimental groups, and pulmonary damage and myeloperoxidase activity were less in the experimental groups than the controls.

Conclusion: Single therapeutic doses of FK506 and OKT3 reduced the early severity of pancreatitis, pulmonary damage, and haemoconcentration in mice. Single doses of FK506 or OKT3 may therefore be effective in preventing the early complications of pancreatitis.

Objective: To present our experience of isolated tuberculosis of the breast, 1988-98.

Design: Retrospective study of case notes and radiographs.

Setting: Hamad General Hospital, Qatar.

Subjects: 13 multiparous women with tuberculosis of the breast.

Main outcome measures: Objective confirmation of diagnosis and adequacy of treatment.

Results: We found an overall incidence of histologically confirmed tuberculosis to be 0.4%/year. All patients presented with a lump, 2 had nipple discharge and one had a palpable axillary node on the same side. 7 were treated by excision biopsy, 3 by incision and drainage, and 3 had fine needle aspiration (FNA) as their only procedure. All diagnoses were confirmed histologically. 2 patients developed recurrences during treatment but these were successfully treated.

Conclusion: Although the incidence of the disease is low, the diagnosis should be suspected in young multiparous women with a breast lump in whom malignancy has been excluded. The minimum of surgical intervention (incision or excision biopsy) together with antituberculous drugs seems to be the most successful treatment.