Journal of the Royal College of Surgeons of Edinburgh最新文献

We followed up 25 patients (average age 47.9 years, range 22 to 77) after open repair of their Achilles tendon rupture. All had been operated on by a single general surgeon using an end-to-end reabsorbable suture, and immobilised in a plaster of Paris cast for six weeks. All patients had been discharged from follow up by 18 weeks from the operation. At an average of 3.4 years (range six months to 9.25 years), 18 had "excellent", six (24%) "good" and one (4%) "satisfactory" results. All but one patient were able to walk on tiptoes, and 20 of the 22 patients examined directly walked without a limp. Ultrasonography showed the injured tendons to be on average 2.3 times thicker in the antero-posterior diameter and 1.7 times thicker in the transverse diameter. In the hands of a single non-specialist but fully trained general surgeon, this management regimen produced full return to pre-operative activities in the majority of patients, and a low rate of local complications. The macroscopic and ultrasonographic appearance of the operated tendon remained abnormal, but this was not associated with any overt clinical disturbance

The prognosis of patients with gastric and oesophageal cancers remains poor but increased knowledge of the factors involved in carcinogenesis and a better understanding of the disease process has led to strategies to improve outcomes. These are discussed under the following headings: (1) Prevention of the disease, (2) early detection of tumours, (3) treatment selection and (4) treatment. The likely impact of developments in each of these areas is considered in relation to population-based data from the Scottish Audit of Gastro-Oesophageal Cancer (SAGOC). Although there are a number of novel developments in the management of gastric and oesophageal cancer it is only by the conduct of controlled trials that the value of these will be determined. More immediate improvements in patient care may be derived from rationalisation of existing resources to ensure that all patients benefit from early diagnosis, the appropriate selection and delivery of treatment. One model of care, which may ensure this is the development of managed clinical networks, would maintain the involvement of all units in the management and treatment of upper GI cancers to a level that is possible with the facilities available. At the same time the patients requiring more specialised treatment would benefit from established referral networks

Background: Iatrogenic injury to the spleen is a recognised complication of abdominal surgery but the extent of the problem is often under-estimated. This may be due to failure to report splenic injury on the operation note or inaccurate recording of the indication for splenectomy. In this review article we have tried to estimate the incidence of iatrogenic splenic injury during abdominal surgery, the morbidity and mortality associated with splenic injury and the risk factors for injury to the spleen. We have also identified the common types and mechanisms of injury to the spleen and have made suggestions as to how splenic injury can be avoided and, when it occurs, how it should be managed.

Methods: A Medline literature search was performed to identify articles relating to "incidental splenectomy", "iatrogenic splenic injury", "iatrogenic splenectomy" and "splenectomy as a complication of common abdominal procedures". The relevant articles from the reference lists were also obtained.

Results: Up to 40% of all splenectomies are performed for iatrogenic injury. The risk of splenic injury is highest during left hemicolectomy (1-8%), open anti-reflux procedures (3-20%), left nephrectomy (4-13%) and during exposure and reconstruction of the proximal abdominal aorta and its branches (21-60%). Splenic injury results in prolonged operating time, increased blood loss and longer hospital stay. It is also associated with a two to ten-fold increase in infection rate and up to a doubling of morbidity rates. Mortality is also reported to be higher in patients undergoing splenectomy for iatrogenic injury. The risk of injury to the spleen is higher in patients who have previously undergone abdominal surgery, in the elderly and in obese patients. A transperitoneal approach significantly increases the risk of splenic injury during left nephrectomy compared with an extraperitoneal approach and the risk is even higher if the indication for surgery is malignancy. Excessive traction, injudicious use of retractors and direct trauma are the commonest mechanisms of injury.

Conclusions: The incidence of iatrogenic splenic injury is underestimated because of poor documentation. Splenic injury during abdominal surgery can be reduced by achieving good exposure and adequate visualisation, avoiding undue traction and by early careful division of splenic ligaments and adhesions. When the spleen is injured splenic preservation is desirable and often feasible, but this should not be at the expense of excessive blood loss

We report here an interesting presentation of a primary colonic carcinoma in a urological setting. A previously unknown case of colonic carcinoma presented with a lesion in the glans penis which was later diagnosed as a secondary deposit from colonic cancer. Penile involvement has been implicated as a metastatic site in several tumours. Although uncommon, this presentation is not unknown. A literature review of this unusual presentation has been performed and is summarised in the article

Recent introduction of new treatment options has significantly altered the approach towards gallstone management. There is now general agreement that cholecystectomy is the treatment of choice for symptomatic gallstones. Controversy, however, exists as to the management of asymptomatic gallstones. The ready availability of abdominal ultrasonography for the investigation of a wide range of abdominal symptoms has resulted in the increased diagnosis of asymptomatic gallstones. Management of such accidentally discovered gallstones poses a dilemma as conclusive evidence of the benefits of cholecystectomy is lacking. This is further complicated by the fact that the majority of asymptomatic gallstones remain so and patients rarely experience symptoms or complications. Furthermore, cholecystectomy is associated with a low but recognised morbidity. Recent introduction of laparoscopic cholecystectomy as the treatment of choice of symptomatic gallstones has further complicated the issue of asymptomatic gallstone management. This article reviews the current management of asymptomatic gallstones in the era of laparoscopic cholecystectomy

End-stage heart failure results from the irreversible destruction of cardiomyocytes, which do not have the capacity to regenerate. Transplantation of myogenic cells into the damaged myocardium is an emerging therapeutic alternative in the management of this major public health problem. Experimental and clinical data suggest that cellular transplantation could improve ventricular function in ischaemic or dilated cardiomyopathies. Implantation of allogeneic and autologous cell types has been applied to induce cardiac myogenesis and, recently, other cell types have been tested for the induction of myocardial angiogenesis. The results of cellular transplantation are encouraging although the role of therapeutic angiogenesis remains to be clarified and the full potential of cellular transplantation to be determined