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Are abdominal radiographs still over utilised in the assessment of acute abdominal pain? A district general hospital audit.  Anyanwu A C, Moalypour S M.  J Roy Coll Surg Ed 1998; 43: 267-270. 

Several studies have shown that plain abdominal X-rays are unnecessary in most patients with abdominal pain. Except in cases of intestinal obstruction, perforation, severe colitis, renal colic and trauma a plain radiograph rarely provides useful information. As a mode of investigation it lacks both sensitivity and specificity. This study retrospectively reviewed the records of 224 patients presenting to an Accident and Emergency department with acute abdominal pain. Patients with trauma or with symptoms of over one weeks duration were excluded. Overall, 56% patients had a plain abdominal X-ray, but, in only 10% of cases was it regarded as diagnostic. Plain abdominal radiography should not be used as a 'routine' investigation. It has no place in the investigation of gastrointestinal haemorrhage, uncomplicated peptic ulcer disease, appendicitis, urinary tract infection and pelvic pain. It should not be used as a 'screening' investigation. A normal X-ray does not excluded serious pathology. Other investigations, for example, abdominal ultrasound may provide more useful information.

Water-soluble contrast study predicts the need for early surgery in adhesive small bowel obstruction. Chen S-C, Lin F-Y, Lee P-H et al. Br J Surg 1998; 85: 1692-1694. 

Post-operative adhesive obstruction is the commonest cause of small bowel obstruction in adults. The optimal period of conservative management is controversial with recommendations ranging from 12 hours to 5 days. The purpose of this study was to determine whether a 24-hour abdominal radiograph taken after oral Urografin contrast was a reliable indicator for operation in patients with adhesive small bowel obstruction. In this study, 161 patients with adhesive small bowel obstruction and with no evidence of strangulation or gangrene were given oral or nasogastric contrast (40 ml Urografin + 40 ml water) and abdominal X-rays were taken at 4, 8 , 16 and 24 hours. If an earlier plain radiograph showed that contrast had reached the colon within 24 hours no further radiographs were taken. In 112 (70%) patients had contrast within the colon within 24 hours. All of these patients were managed conservatively without complication. In 49 (30%) patients contrast failed to reach the ascending colon. 47 of these patients required surgery for peritonitis (16), intractable pain (12), leukocytosis (11) and persistent pyrexia (8). All required division of adhesions and six required a small bowel resection. The sensitivity, specificity and PPV of contrast reaching the colon as an indicator for successful non-operative treatment was 98, 100 and 100% respectively.

Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis. Merad F, Yahchouchi E, Hay J-M et al. Arch Surg 1998; 133: 309-314.

The use of prophylactic abdominal drainage after colonic resection was proposed by Billroth (1881) and Simm (1884). By those who support its use, it has been claimed to reduce anastomotic leakage, reduce the severity of leaks and facilitate the early diagnosis of intra-abdominal haemorrhage. Opponents claim that they stimulate serous fluid formation, encourage infection and increase leak rates. There have been four randomised trials of the use of abdominal drains following colonic resection but the number of patients enrolled has been small. The aim of this study was to assess complication rates following the use of drains following suprapromontory colonic anastomosis during elective surgery. In total, 317 patients undergoing either ileo-colic or colo-colic anastomosis were randomised to receive either a drain or not. Those receiving a drain were further randomised to suction or non-suction drainage. The main outcome measures were complications that could be either diagnosed early because of the use of a drain (peritonitis, haemorrhage), were enhanced by the use of a drain (wound abscess, hernia) or were directly due to the drain (fistulae, drain tract infection, drains retention). Drains were shortened starting at day 2 and removed by day 5 at the latest. Overall, 8% patients developed complications that could be influenced by the use of a drain. There was no difference between the two groups. There was no difference between suction and non-suction drains. It was concluded that the routine use of abdominal drainage following elective colonic resection and anastomosis does not reduce the rate or severity of anastomotic leak.

Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal surgery. Senkal M, Zumtobel V, Bauer K-H et al. Arch Surg 1999; 134: 1309-1316.

Trauma and surgery induce an immuno-inflammatory response that can result in an increased risk of postoperative septic complications. Several studies have investigated the role of enteral nutrition in modulating this response and immunomodulatory enteral formulations containing arginine, RNA and omega-3 fatty acids have been shown to attenuate many of the cytokine responses. Previous studies have investigated the role of such enteral feeds given in the post-operative period following elective gastrointestinal surgery. The hypothesis of this study was that perioperatively administered enteral immunomodulatory feeds would improve early post-operative morbidity. In this study 154 patients with upper GI malignancy were entered into a prospective randomised double-blind, multicentre clinical trial. Preoperatively patients received for five days either oral immunonutrition or an isoenergetic control diet. Early post-operative enteral feeding was continued using a feeding jejunostomy tube for 10 days. Post-operative infectious complications and the cost-effectiveness were analysed. Fewer infectious complications occurred in the immunonutrition group and the number of complications was significantly reduced after post-operative day 3 (7 vs. 16. p=0.04). The immunomodulatory feed group proved to be cost effective. It was concluded that the perioperative administration of an enteral immunonutrition decreased early post-operative infections and reduced substantially treatment costs.

Accuracy of ultrasonography in the diagnosis of peritonitis compared with the clinical impression of the surgeon. Chen S-C, Lin F-Y, Hsieh Y-S, Chen W-J. Arch Surg 2000; 135; 170-173.

The preoperative diagnostic accuracy of patients with peritonitis has traditionally been poor and as a result early laparotomy has often recommended. This can be both diagnostic and therapeutic. The aim of this study was to assess whether abdominal ultrasonography was superior to the clinical impression of the surgeon in detecting the cause of peritonitis. The study was a prospective case series in which 102 patients (68 men, 34 women, mean age = 47 years) were recruited. The diagnosis of peritonitis was based the presence of generalised abdominal pain and tenderness and a raised white cell count. All 102 patients underwent abdominal ultrasound examination by a staff surgeon without knowledge of the clinical diagnosis. The ultrasound result was classified as either positive or normal. The accuracy of both the clinical impression and ultrasound examination in detecting the cause of peritonitis was compared. Ultrasound and clinical impression accurately diagnosed the cause of peritonitis in 85 (83%) and 52 (51%) of patients respectively. Amongst the 45 patients without a preoperative clinical diagnosis, a diagnosis was made by ultrasound in 32 (71%) of them. There were a total of 98 patients with a positive ultrasound all of whom proceeded to surgery and had abnormal pathological characteristics. The four patients with normal ultrasound received conservative management and made a full recovery. It was concluded that ultrasonography is more sensitive than clinical judgment in the diagnosis of peritonitis and it appears to be useful diagnostic aid in patients in whom the cause of peritonitis is unclear.

Single-layer continuous versus two-layer interrupted intestinal anastomosis. Burch J M,  Franciose R J, Moore E E, Biffl W L,  Offner P J.  Ann Surg 2000;  231:  832-837.

Intestinal anastomoses have been performed for over 150 years using various techniques and materials.  One of the most reliable methods has been the two-layer anastomosis using interrupted silk sutures for an outer inverted seromuscular layer and a continuous absorbable suture for a full-thickness inner layer.  More recently, several reports have advocated a single-layer continuous anastomosis using an absorbable monofilament suture.  The perceived advantages of this technique is that it quicker to perform, costs less and may be associated with a reduced leak rate. The aim of this study was to directly compare a two-layer interrupted with a single-layer continuous anastomosis.  The study was performed in one US medical centre over a three year period.  All patients requiring an intestinal anastomosis were considered eligible for entry into the study.  Patients requiring anastomosis to the stomach, duodenum or rectum were excluded.  Patients were randomly assigned to either a single-layer anastomosis performed with 3-0 polypropylene suture or a two-layered anastomosis with an outer layer of interrupted silk and an inner layer of continuous 3-0 polyglycolic acid.  The time for the construction of the anastomosis was recorded.  Anastomotic leak was defined as radiographic demonstration of a fistula, non-absorbable material draining from the wound after oral administration or visible disruption of the suture line during re-exploration. In total, 65 single-layer and 67 two-layer anastomoses were fashioned.  The groups were evenly matched regarding age, sex, diagnosis and location of anastomosis.  Two (3.1%) and one (1.5%) leaks occurred in the single and two-layer groups respectively.  the mean time to construct the anastomosis was 20.8 min in the single-layer and 30.7 min in the two-layer groups.  The single-layer technique was considerably cheaper.  It was concluded that the single-layer technique is quicker to perform, costs less and is associated with a similar complication rate to the two-layer technique.   

Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score.  Douglas C D, Macpherson N E,  Davidson P M,  Gani J S.  Br Med J 2000;  321:  1-7.

Acute appendicitis is the commonest general surgical emergency seen in most hospitals.  Simple appendicitis may progress to perforation and be associated with significant morbidity and mortality.  As a result, surgeons often ere on the side of caution leading to the removal of a normal appendix in between 15% and 30% of cases.  The proportion of normal appendices removed may be reduced by observing equivocal cases for a period of time.  Also, diagnostic aids including scoring systems, laparoscopy, computer programs, ultrasonography and CT scanning may further reduce the number of appendicectomies performed, but, no single investigation has proved to be superior.  Graded compression ultrasonography is inexpensive and non-invasive but doubts have be expressed regarding its ability to influence the outcome in patients with appendicitis.  The aim of this study was to determine whether the diagnosis of appendicitis by graded compression ultrasonography can improve the clinical outcome.  In a single tertiary referral centre a randomised controlled trial was performed comparing clinical diagnosis (control group) with a diagnostic protocol incorporating both ultrasonography and the Alvarado score (intervention group).  Overall, 302 patients with suspected acute appendicitis were randomised.  The intervention group consisted of 160 patients, 129 of whom underwent ultrasonography.  The investigation was omitted in patients with an Alvarado score less than three or greater than nine.  The main outcome measures were time to operation, duration of hospital stay and adverse outcome - non-therapeutic operation or delayed treatment associated with perforation.  The sensitivity and specificity of ultrasonography was 95% and 89% respectively.  Patients in the intervention groups who underwent therapeutic operation had a shorter mean time to operation (7.0 vs. 10.2 hours. p=0.016).  There was no difference between the groups with regard to mean duration of hospital stay, proportion of patients undergoing a non-therapeutic operation (9% vs. 11%. p=0.59) or delayed treatment in association with perforation (3% vs. 1%. p=0.45).  It was concluded that graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment in acute appendicitis but that it dose not prevent adverse outcome or reduce the length of hospital stay.

Testicular torsion: time is the enemy.  Dunne P J, O'Loughlin B S.  Aust NZ J Surg 2000;  70:  441-442. 

The acute scrotum remains a diagnostic challenge with testicular torsion of utmost concern because of the risks to future fertility and the medico-legal implications to the surgeon of a delayed diagnosis.  The aim of the present study was to retrospectively audit certain clinical variables and the results of investigations of patients with suspected torsion and to correlate these with the diagnosis and outcome of surgery.  Between 1990 and 1995 a total of 99 patients underwent scrotal exploration for suspected torsion at the Royal Brisbane Hospital.  Colour doppler ultrasound, white blood count and urine microscopy results were documented along with the patients age and duration of testicular pain.  In total, 56 patients were found to have a testicular torsion and the testicular loss rate was 23% (n=13).  Patients who had testicular pain of more than 12 hours (n=15) had a testicular loss rate of 67% (n=10).  A negative urine microscopy was suggestive of a testicular torsion, but was not diagnostic.  The white blood count did not help in the diagnosis.  Colour doppler ultrasound was used in only nine patients, with three false-negative results and a sensitivity of only 57%.  It was concluded that time is the enemy in the management of the acute scrotum and that no investigation improves on the clinical diagnosis enough to warrant delay in definitive surgical intervention. 

Analysis of local recurrence and optimizing excision margins for cutaneous melanoma. Ng A K T, Jones W O, Shaw J H F.  Br J Surg 2001; 88: 137-142.

The surgical treatment of primary cutaneous melanoma has under gone considerable changes over the past 15 years as resection margins have become more conservative. There is general agreement that for lesions less than 1 mm thick a 1 cm margin is sufficient. For lesion 2 - 4 mm thick a 2 cm margin is required. The optimal margin for tumours 1 - 2 mm and those greater than 4 mm thick is unclear. Local recurrence can be used as a measure of treatment adequacy. The aim of this study was determine optimum excision margins for different tumour depths in order to obtain useful prognostic information. A retrospective analysis of the Auckland Melanoma Unit database was performed. Patients with local recurrence were identified and stratified by lesion thickness. Optimum excision margins were derived by regression analysis and evaluated against the database. Overall, 84 (7%) of 1155 patients developed local recurrence with a median follow-up of 51 months. Margins predicted to give a local recurrence of zero were: 1 cm for lesions less than 1mm thick, 1.5 cm for lesion 1 -1.5 mm thick and 2 cm for lesions greater than 2 mm thick. Applied to the 1155 patients, there was a significant difference in both local recurrence and mortality rates between optimally and suboptimally excised lesions, except for those with tumours more than 4 mm thick. Overall, 33 (39%) patients with local recurrence died. Both thickness and local recurrence were of prognostic significance. It was concluded that local recurrence in melanomas less than 4 mm thick was due to inadequate treatment. Care must be taken to ensure that all such lesions are optimally excised.

Determinants of death following burn injury. Muller M J, Pegg S P, Rule M R. Br J Surg 2001; 88: 583-587.

Burns are very common affecting approximately 1% of the population each year. The vast majority of these are painful but minor injuries. In contrast, a small number of individuals receive large deep burns associated with the risk of major complications and death. Over the past thirty years burn care has changed considerably. Oliguric renal failure subsequent to burn shock, uncontrolled burn wound infection and post-burn contractural deformities are now uncommon. Improved resuscitation, early surgery, novel skin replacement techniques and nutritional support are well established and may have contributed to an improved outcome. The aim of this study was to establish whether changes in management have improved survival following burn injury and to determine the factors that still contribute to death. A retrospective analysis of data collected from a series of 4094 patients with burns admitted to the Royal Brisbane Hospital, a tertiary referral teaching hospital, between 1972 and 1996 was performed. The overall mortality was 3.6%. This decreased from 5.3% (1972-1980) to 3.4% (1993-1996). The risk of death increased with burn size (BSA > 35%), increasing age (> 48 years), with inhalational injury and female sex. Operative intervention and upper limb burns decreased the risk. It was concluded that modern burn care has decreased to the mortality associated with these injuries. Increasing burn size, increasing age, inhalation injury increased, whilst operative intervention and upper limb burn decreased the risk of death.

Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis.  Lee S L,  Walsh A J,  Ho H S.  Arch Surg 2001;  36:  556-562.

Although the treatment of acute appendicitis is simple and straightforward, its diagnosis remains a challenge.  The negative appendicectomy rate in large series varies from 15% to 35% and is highest in young women.  During the past decade studies of the use of ultrasonography and computed tomography have suggested that these imaging modalities may improve the diagnostic accuracy for acute appendicitis.  The aim of this study was to perform a retrospective review of the value of these imaging modalities in a large cohort of patients assessed and treated at university tertiary care centre.  Between January 1995 and December 1999, 766 patients underwent appendicectomy for suspected acute appendicitis. The epidemiology of acute appendicitis and the roles of clinical assessment, CT, US and laparoscopy were assessed.  The negative appendicectomy rate was 16%.  The incidence of perforated appendicitis was 15%.  A history of migratory pain, a leucocytosis greater than 12 and ultrasonographic appearances had the highest positive predictive value.  The false-negative rates were 60% for CT and 76% for US.  Emergency department evaluation was prolonged by the use of CT or US. The duration of emergency department evaluation did not affect the perforation rate but patients with postoperative complications had longer evaluations.  Morbidity was 6% for non-perforated and 20% for perforated cases. It was concluded that migratory pain, physical examination and initial leukocytosis remain reliable and accurate in diagnosing acute appendicitis.  Neither CT or US improves the diagnostic accuracy or the negative appendicectomy rate and may in fact delay treatment.

Fine-needle aspiration cytology of parotid tumours: is it useful?  Que Hee C, G,  Perry S F.  Aust NZ J Surg 2001;  71:  345-348.

Fine-needle aspiration cytology (FNAC) has been accepted as useful investigative technique in the diagnosis of several tumours, however, its value in parotid tumours continues to be a controversial subject.  The proponents of FNAC in parotid disease feel that it can distinguish benign from malignant neoplasms and can prevent surgery in those with infectious conditions, lymphoma and certain metastatic lesions.  Several studies have reported a poor sensitivity, a high false negative rate thus reducing its usefulness in the eyes of opponents.  Furthermore, it has been claimed that knowing a tissue diagnosis of a parotid tumour rarely affects the type of surgery performed.  The aim of this study was to assess the accuracy and utility of FNAC of parotid tumours.  Between 1995 and 1999, 169 patients underwent both FNAC and subsequent surgery to the parotid.  The results of the FNAC were compared with the histopathological diagnosis obtained form the surgical specimen.  FNAC had an overall diagnostic accuracy of only 56%.  Approximately 10% of FNAC specimens were non-diagnostic.  The sensitivity and specificity for the following diagnoses were respectively, benign 86% and 61%, malignant 57% and 100%, pleomorphic adenoma 78% and 95%, squamous cell carcinoma 52% and 99%, mucoepidermoid carcinoma 14% and 99% and adenocarcinoma 20% and 100%.  Six non-neoplastic conditions were misdiagnosed and all 6 patients underwent surgery.  It was concluded that FNAC was highly specific for malignancy but that its sensitivity was poor.  It can not be relied upon to provide an accurate tissue diagnosis, may fail to identify malignancy and does not prevent patients undergoing surgery for non-neoplastic conditions.

Early enteral feeding versus 'nil by mouth' after gastrointestinal surgery:  systematic review and meta-analysis of controlled trails.  Lewis S J,  Egger M,  Sylvester P A,  Thomas S.  Br Med J 2001;  325:  1-5.

A period of starvation is common practice after gastrointestinal surgery during which an intestinal anastomosis has been fashioned.  The stomach is decompressed with a nasogastric tube and intravenous fluids are administered.  Oral feeding is then re-introduced as gastric motility returns.  The rational for this approach has been to prevent postoperative nausea and vomiting and to 'protect' the anastomosis.  It is, however, unclear whether deferral of enteral feeding is beneficial.  Both clinical and animal studies have suggested that early enteral feeding is advantageous.  Enteral feeding has been shown to prevent mucosal atrophy, increase anastomotic collagen deposition and to reduce post-operative morbidity.  The aim of this study was to determine whether a period of post-operative starvation after gastrointestinal surgery is beneficial in terms of specific outcomes.  A systematic review and meta-analysis was performed of randomised controlled trails comparing any type of enteral feeding started within 24 hours of surgery with nil by mouth management in elective gastrointestinal surgery.  Studies were identified form three electronic databases, reference lists and unpublished trials from pharmaceutical companies.  The outcome measures assessed were anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscesses, length of hospital stay and mortality. Eleven studies with 837 patients met the inclusion criteria.  In six studies patients were fed directly into the small bowel and in five studies the patients were fed orally.  Early feeding reduced the risk of any type of specific infection (RR=0.72, 95% CI 0.54-0.98) and the mean length of hospital stay. Risk reductions were also seen for anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscesses and mortality but these failed to reach statistical significance.  The risk of vomiting was increased amongst those patients fed early.  It was concluded that there was no clear advantage to keeping patients 'nil by mouth' and elective gastrointestinal surgery and that early enteral nutrition may be of benefit.

Predictive clinical and laboratory factors in the diagnosis of temporal arteritis.  Mohamed M A,  Bates T.  Ann R Coll Surg Eng 2001;  84:  7-9.

Temporal arteritis is a common disease, which if unrecognised or not treated early with high dose steroids, can result in unilateral or total blindness. In order to achieve a diagnosis, surgeons are often called upon to perform a temporal artery biopsy in patients suspected of having temporal arteritis. The erythrocyte sedimentation rate (ESR) and a temporal artery biopsy are believed to be the most important investigations in the diagnosis of the disease. Recent publications have suggested that other clinical features and laboratory investigations may predict the result of the temporal artery biopsy, rendering an unnecessary investigation. The aim of this study was to identify any relationship between the results of the biopsy and the presenting features and also to potentially identify any combination of clinical and laboratory parameters that might predict the result of the temporal artery biopsy. The medical records of all patients undergoing a temporal artery biopsy over a 10-year period in a small district general hospital were reviewed. Details of presenting features were recorded and comparisons made between biopsy-positive and biopsy-negative patients. Of 59 patients who underwent a temporal artery biopsy the records of 51 patients were located. Of these, 17 had positive biopsy specimens and 33 negative specimens. In one patient no temporal artery was found in the biopsy specimen. In the biopsy-positive patients, 69% had an ESR greater than 50 mm/hr compared to 31% of the biopsy-negative patients (p=0.03). With regard to the other clinical and laboratory parameters that were evaluated, no statistically significant differences were found between biopsy-positive and biopsy-negative patients. 

Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial.  Moller A M,  Villebro N,  Pedersen T,  Tonnesen H.  Lancet 2002;  359:  114-117. 

Approximately one-third of all patients undergoing surgery are smokers.  Smoking has been repeatedly been shown to be an important risk factor for both intraoperative and postoperative complications.  These included pulmonary, circulatory and infectious complications and impaired wound healing.  The mechanisms leading to these increased risks include chronic pulmonary changes, impaired cardiovascular function, immune function and decreased collagen production.  Many of these effects are reversible and a reduction in the postoperative complication rate has been demonstrated by stopping smoking for 6-8 weeks prior to surgery.  The aim of this study was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee surgery.  A randomised trial was performed in 120 patients assigned 6-8 weeks prior to surgery to either a control (n=60) or a smoking intervention group (n=60).  Smoking intervention consisted of counseling and nicotine replacement therapy and either smoking cessation or at least a 50% smoking reduction.  An assessor, who was masked to the intervention, registered the occurrence of cardiopulmonary, renal, neurological or surgical complications and duration of hospital admission. The main analysis was by intention to treat.  Overall, 8 control and 4 patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled.  The overall complication rate was 18% in the smoking intervention group and was 52% in the control group (p=0.0003).  The most significant effects of intervention were seen for wound-related complications (5% vs. 31%.  p=0.001), cardiovascular complications (0% vs. 10%. p=0.08) and secondary surgery (4% vs. 15%. p=0.07).  The median length of hospital stay was 11 days (range 7-55) in the intervention group and 13 days (range 8-65) in the control group.  It was concluded that an effective smoking intervention programme, 6-8 weeks prior to surgery, reduces postoperative morbidity.

Nutritional approach in malnourished surgical patients.  Braga M, Gianotti L, Nespoli L, Radaelli G,  Di Carlo V.  Ann Surg 2002; 137: 174-180.

Protein energy malnutrition is recognised as an important risk factor for the occurrence of postoperative complications. Thus, artificial nutritional support has been proposed as an essential part of perioperative care for malnourished patients. Feeding enterally rather than parenterally may improve outcome, particularly in malnourished patients who are due to undergo major abdominal surgery. Moreover, administration of standard enteral diets supplemented with arginine, omega-3 fatty acids, glutamine or other key nutritional supplements (immunonutrition) modulates immune and inflammatory responses and gut function. The aim of this study was to evaluate whether administration of perioperative immunonutrition could reduce the rate of postoperative complications and length of hospital stay compared with standard enteral feeds in a homogenous group of patients defined a priori as malnourished. Malnourished patients (<10% weight loss) undergoing major elective surgery for a gastrointestinal malignancy were randomised in to three groups. One group received postoperative enteral nutrition with a standard formula starting within 12 hours of surgery (control group; n=50). Another group preoperatively received one litre per day for 7 consecutive days of a liquid diet enriched with arginine, omega-3 fatty acids and RNA (preoperative group; n=50). Following surgery they received the same standard enteral formula as the control group. A third group received preoperatively one litre per day for 7 consecutive days the enriched liquid diet. Enteral nutrition was continued postoperatively with the same enriched formula (n=50). The primary outcome measures were postoperative complications and length of hospital stay. The 3 groups were comparable for baseline demographics, biochemical markers, co-morbidity factors and surgical variables. An intention-to-treat analysis showed that the total number of complications were 24 in the control group, 14 in the preoperative group and 9 in the perioperative group (p=0.02). Post operative stay was significantly shorter in the preoperative and perioperative groups. It was concluded that perioperative immunonutrition seems to be the best approach to support malnourished patients with cancer.

A combined medical and surgical approach to hydatid disease:  12 years experience at the Hospital for Tropical Diseases, London.  Ayles H M,  Corbett E L,  Taylor I et al.  Ann R Coll Surg Eng 2002;  84:  100-105.

Hydatid disease is a common zoonosis caused by the larval cysts of Echinococcus granulosa. The disease is endemic in parts of the world where there is close contact between man and the definitive and intermediate hosts, namely sheep and dogs.  Hydatid cysts most commonly form in the liver, but may occur in any organ.  The cysts are often asymptomatic until they reach a large size, causing pressure on neighbouring structures, leak or rupture.  Until recently the mainstay of treatment has been surgical but over the last 15 years two chemotherapeutic agents (albendazole and praziquantel) have become available.  There are currently no evidence-based guidelines for their use and the indications for operative management of the disease are unclear.  The aim of this study was to retrospectively analyse the management and operative complications of 70 cases presenting to a London teaching hospital over a 12 year period, to assess the impact of new therapeutic strategies and to attempt to define a coherent management policy.  Data regarding presentation, diagnosis, treatment and outcome was collected.  Overall, 37 patients had been previously treated. 35 had hepatic cysts and 26 multiple cysts.  Four patients were treated by surgery alone, 44 by chemotherapy and surgery and 14 by chemotherapy alone.  The combined use of albendazole and praziquantel preoperatively significantly reduced the number of cysts that contained viable protoscolices compared with the use of albendazole alone (1/25 vs. 5/8 p<0.001).  During the 12-year period it became policy to aim for 3months drug treatment (albendazole throughout with praziquantel for 2 weeks), reassess and proceed either to surgery or continue with chemotherapy. 

Male circumcision, penile human papillomavirus infection and cervical cancer in female partners.  Castellague X, Bosch F X, Munoz N et al. N Eng J Med 2002;  346:  1105-1112.

Human papillomavirus (HPV) causes genital warts in both men and women and has been linked to cancers of the cervix, vulva, anus and penis.  Cervical cancer is the second most common cancer in women worldwide and up to 99% of all cases may be attributed to infection by oncogenic HPV genotypes.  Any factor that reduces the probability of acquiring or transmitting HPV may reduce the risk of diseases associated with these infections.  Whether male circumcision reduces the risk of transmitting HPV infection remains unclear.  In this study pooled data on 1913 couples enrolled in a case-control study of cervical carcinoma in-situ and invasive cancer was analysed.  Circumcision status was self reported and in a subgroup confirmed by medical examination.  The presence or absence of penile HPV DNA was assess by polymerase-chain reaction assay in 1520 men and yielded a valid result in the case of 1139 (75%) men.  Penile HPV was detected in 166 of the 847 uncircumcised men (20%) and 16 of 292 circumcised men (6%).  After adjustment for age at first intercourse, lifetime number of sexual partners and other potential confounding variables, circumcised men were less likely than uncircumcised men to have HPV infection (OR=0.37; 95%CI 0.16-0.85).  Monogamous women whose male partners had six or more sexual partners and were circumcised had a lower risk of cervical cancer than those women whose partners were uncircumcised (OR=0.42; 95% CI 0.23-0.79).  It was concluded that male circumcision is associated with a reduced risk of penile HPV infection and in the case of men with a history of multiple sexual partners, a reduced risk of cervical cancer in their current female partners.

Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial.  Rigg J R A,  Jamrozik K, Myles P S et al. Lancet 2002;  359:  1276-1282.

Whether epidural anaesthesia and analgesia improves the outcome of major abdominal surgery is controversial.  Proponents of the technique cite beneficial effects resulting form the attenuation of the surgical stress response.  The reduction, by an effective epidural block, of intraoperative sympathetic stimulation resulting from surgical trauma has putative advantages for coagulation haemostasis and cardiovascular, respiratory, gastrointestinal, metabolic and immune function.  These advantages are widely believed to outweigh the rare but important morbidity risks associated with the insertion of an epidural catheter.  The aim of this study was to compare adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia in a multicentre randomised trial.  In total, 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to define high-risk status were randomly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 hours with general anaesthesia or control.  The primary endpoint was death at 30 days or major postoperative morbidity.  Intention-to-treat analysis involved 447 patients assigned epidural anaesthesia / analgesia and 441 controls.  255 patients (57%) in the epidural group and 268 (61%) in the control group had at least one morbidity endpoint or died (p=0.29).  Mortality at 30 days was low in both groups. Only one of eight categories of morbid endpoints (respiratory failure) occurred less frequently in the patients managed with epidural analgesia (23% vs. 30% p=0.02).  Postoperative epidural analgesia was associated with lower pain scores during the first three postoperative days.  There were no major adverse consequences of epidural-catheter insertion. It was concluded that most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by a combination of epidural anaesthesia and postoperative epidural analgesia.  However, the improvement in analgesia, reduction in respiratory failure and the low risk of serious adverse consequences suggests that many high-risk patients undergoing major abdominal surgery will receive considerable benefit from this technique.

Lymph node dissection for clinically evident lymph node metastases of malignant melanoma.  Meyer T, Merkel S, Gohl J, Hohenberger W.  Eur J Surg Oncol 2002; 28:  424-430.

The introduction of sentinel node biopsy for the staging of malignant melanoma undoubtedly can be regarded as outstanding progress in the early recognition of metastatic involvement of the regional lymph nodes.  Today, it is the preferred screening method to detect patients with clinically negative regional lymph nodes for regional lymph node dissection.  However, there is a considerable number of patients with clinically evident regional lymph node metastases for whom therapeutic node dissection is indicated.  Radical lymph node dissection offers the possibility of local tumour control and even the chance of cure for those with locoregional disease.  The aim of the present study was to assess the pattern of recurrence and factors influencing prognosis after therapeutic node dissection.  Between 1978 and 1997, 140 patients (68 women, 72 men, median age 53 years) with established regional lymph node metastases but without clinically evident distant disease, received cervical, axillary or ileoinguinal nodal dissection.  Univariate and multivariate analysis was performed of factors influencing prognosis.  Median survival of all 140 patients was 25 months and the observed overall 5-year survival rate was 30%.  On univariate analysis, age greater than 50 years, primary tumour site on the trunk, more than three lymph node metastases and extracapsular spread were associated with a significantly worse prognosis.  These four factors remained independent prognostic factors on multivariate analysis.  It was concluded that therapeutic lymph node dissection is worthwhile and offers a potential chance of cure in approximately 30% of melanoma patients with established regional lymph node metastases.  There are however subgroups of patients with a particularly poor prognosis in whom the benefit of radical surgery alone is limited.

Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of uncertain cause:  prospective randomised study.  Ng C S,  Watson C J E,  Palmer C R et al.  Br Med J 2002;  325:  1387-1391. 

Acute abdominal pain is a common surgical emergency requiring admission to hospital.  Initial assessment may yield a diagnosis, but more usually the cause is unclear and a period of observation, together with further radiological and laboratory investigations is required.  A correct diagnosis may emerge over time, but delays may result in inappropriate management affecting both morbidity and mortality.  Inaccurate diagnosis may lengthen hospital stay.  Computed tomography (CT) can diagnose a wide range of acute abdominal conditions such as acute appendicitis, diverticulitis, renal tract calculi, pancreatitis and small bowel obstruction.  Few studies have investigated the role of CT in the diagnosis of acute abdominal pain.  The aim of this study was to determine whether early CT in patients with acute abdominal pain improved the accuracy of diagnosis and reduced hospital stay.  Overall, 120 patients with acute abdominal pain for which no immediate surgical intervention of CT was indicated were randomly assigned to either early CT (with 24 hours of admission; n = 55) or standard practice (radiological investigations as indicated ; n = 65).  The primary outcome measures were accuracy of diagnosis and length of hospital stay.  Early CT reduced hospital stay by 1.1 days (mean = 5.3 vs. 6.4 days) but the difference was not significant.  Early CT missed significantly fewer serious diagnoses. Seven patients in the standard practice arm died.   It was concluded that early abdominopelvic CT for acute abdominal pain may reduce the length of hospital and possibly mortality.  It can also identify unforeseen conditions and potentially serious complications.

Randomized clinical study of Gastrografin® administration in patients with adhesive small bowel obstruction.  Biondo S,  Pares D,  Mora L et al.  Br J Surg 2003;  90:  542-546. 

Intraperitoneal adhesions are the commonest cause of small bowel obstruction.  Considerable controversy exists regarding the therapeutic strategy.  To prevent the risk of strangulation, some authors recommended early surgery for patients with complete intestinal obstruction and reserve conservative management for those with partial obstruction.  A delay in surgical treatment of more than 24 hours increases the complication rate and prolongs postoperative hospital stay.  Some have suggested that, in the absence of signs of strangulation, patients with both partial and complete intestinal obstruction can be safely managed conservatively for 5 days.  The diagnosis of small bowel obstruction is usually not difficult to make but differentiating be partial and complete obstruction can be problematic.  Oral Gastrografin®, a water soluble contrast medium, has been used to differentiate partial and complete obstruction.  It has also been shown to have a therapeutic effect and to predict the need for early surgical intervention.  The aim of this prospective randomised trial was to study the ability of Gastrografin® to resolve small bowel obstruction.  Overall. 83 patients admitted with 90 episodes of symptoms and signs suggestive of postoperative adhesional obstruction were randomised into two groups.  Patients in a control group were treated conservatively.  If obstruction did not resolve by 4-5 days a laparotomy was performed.  Patients in the intervention group received 100 ml of oral Gastrografin®.  Those in whom the contrast reached the colon by 24 hours were considered to have partial obstruction and were fed early.  If Gastrografin® failed to reach the colon and the patient did not improve in the following 24 hours a laparotomy was performed.  Conservative treatment was successful in 77(86%) of episodes.  Thirteen (14%) episodes required operation.  Amongst patients treated conservatively, hospital stay was shorter in the Gastrografin® group.  All patients in whom contrast reached the colon tolerated an early oral diet.  The use of Gastrografin® did not reduce the need for operation.  It was concluded that oral Gastrografin® helps in the management of patients with adhesive small bowel obstruction and allows a shorter hospital stay.

A randomised trial of knife versus diathermy in pilonidal disease.  Duxbury M S,  Blake S M,  Dashfield A,  Lambert A W.  Ann R Coll Surg Engl 2003;  85:  405-407. 

Pilonidal disease is a common, potentially debilitating condition frequently affecting the sacro-coccygeal region of young adults.  Presentation may be with chronic sinuses or following abscess formation.  Treatment options are numerous, but no evidence overwhelmingly supports one specific technique, each having inherent advantages and disadvantages,  Excision of pilonidal disease followed by wound healing by secondary intention is one accepted treatment option.  A prospective randomised trial comparing knife and diathermy excision of pilonidal disease was performed.  The outcome measures assessed were operating time, postoperative pain, functional recovery and wound healing.  Overall, 32 patients undergoing surgery for pilonidal disease were randomised to either scalpel excision (Group 1) or diathermy (Group 2).  Patients received regular peri-operative oral analgesia and a standardised anaesthetic technique. Duration of operation was recorded.  Following surgery, pain, analgesic requirements, sedation, nausea and vomiting scores and time to mobilise and time to complete healing were compared.  Statistical differences between the two groups were noted in five of the outcome measure.  The duration of surgery in Group 2 was significantly less, postoperative pain scores and morphine requirements were lower and mobility was regained sooner.  It was concluded that use of a diathermy needle was superior to a scalpel blade when undertaking excision of pilonidal disease in both acute and chronic patients.

Risk factors predicting the development of complications after foreign body ingestion.  Lai A T Y,  Chow  T L,  Lee D T Y et al.  Br J Surg 2003;  90:  1531-1535.  

The ingestion of foreign bodies is a common clinical problem associated with significant morbidity and mortality.  Some studies have shown that 80 - 90% of foreign bodies that reach the gastrointestinal tract will pass spontaneously.  Some 10-20% will require non-operative intervention and 1% will need surgery.  Foreign body ingestion is commonly seen in children and in adults with intellectual impairment, psychiatric illness and in edentate patients.  An understanding of the risk factors leading to complications after foreign body ingestion might help reduce the morbidity rate by promoting a high index of clinical suspicion and timely treatment.  A consecutive series of 1338 patients with suspected foreign body ingestion over a 4 year period were retrospectively reviewed.  The potential risk factors for complications were analysed by multivariate logistic regression.  The factors recorded were medical illness, age, duration and type of symptoms, types of foreign body ingested, positive cervical radiographic findings and level of foreign body impaction.  Fish bones (63%) were the commonest type of foreign body ingested.  Most of the objects were impacted at or above the cricopharyngeus, the commonest site being the valleculae (31%).  Multivariate analysis showed that presentation delayed for more than 2 days (p < 0.001), positive cervical radiographic signs (p < 0.001) and foreign body impacted at the cricopharyngeus (p = 0.009) or upper oesophagus (p = 0.005) were significant independent risk factors associated with development of complications after foreign body ingestion.  It was concluded that in patients with foreign body ingestion seen on plain cervical radiography, presentation delayed for more than 2 days and foreign body impacted at the level of the cricopharyngeus or upper oesophagus there is high degree of correlation with occurrence of complications.

Efficacy and pitfalls of fine needle aspiration in the diagnosis of neck masses.  Sheahan P,  Fitzgibbon J,  O'Leary G et al.  Surg J R Coll Surg Edinb Irel 2004;  2;  152-156.  

The differential diagnosis of a neck lump covers a broad spectrum of diseases with differing implications for management.  Common causes of a neck lump include reactive lymphadenopathy, inflammatory salivary gland enlargement, thyroid gland masses, branchial cysts and benign neoplasms.  However, over one half of asymmetrical neck masses in adults are reported to be malignant, either primary (usually lymphoma) or secondary (usually carcinoma).  Therefore, the accurate diagnosis of the nature of a swelling is of paramount importance.  Fine needle aspiration biopsy (FNAB) is now well established in the assessment of cervical masses.  The aim of this study was to review the efficacy of FNAB in this assessment, as well as to identify any pitfalls that may limit its usefulness.  Overall, 190 aspirations performed over a five year period were reviewed.  The definitive diagnosis of the mass was determined by review of the patient's case notes.  In this series 37% of all neck lumps were malignant.  The most common cause of a false-negative result, in the case of carcinomatous masses when an adequate sample was obtained, was a cystic neoplasm.  One quarter of all cystic lateral cervical masses not considered suspicious for malignancy by FNAB turned out to be malignant.  It was concluded that repeating FNAB in cases where the original result is negative for carcinoma may increase the sensitivity of FNAB in the detection of cystic carcinomas.

Early oral feeding after colorectal resection: A randomized controlled study.  Feo C V,  Romanini B,  Sortini D et al.  ANZ J Surg 2004;  74:  298-301.

Nasogastric (NG) intubation is widely used following elective abdominal operations although it is associated with morbidity and discomfort.  This study was a randomised controlled trial on the effect of early oral feeding without NG decompression following elective colorectal resection for cancer.  Overall, 100 patients were randomised to either NG catheter and fasting until passage of flatus, followed by liquid diet advanced to solid food (Group A. n=50) or no NG tube, clear fluids the day after surgery, followed by soft-solid food (Group B. n=50).  The endpoints were morbidity, resumption of intestinal function, length of hospital stay and patient well-being evaluated by short-form health survey (SF-36).  Twelve complications occurred in Group A and 13 in Group B.  Seven patients developed vomiting in Group A as compared to 16 patient in Group B (p<0.05).  20% of patients in Group B required NG decompression.  Resumption of intestinal function occurred after 4 days and length of hospital stay was 7 days in both groups.  No significant difference was detected between groups in the SF-36 score before or after the operation.  It was concluded that patients undergoing elective colorectal resection can be managed without postoperative NG catheters with oral feeding started on the first postoperative day.  Abolition of postoperative NG intubation with early oral feeing was a safe approach with only 20% of patients requiring NG decompression because of repeated vomiting.

Randomised clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care.  Smedley F,  Bowling T,  James M et al.  Br J Surg 2004;  91:  983-990.

Gastrointestinal surgery is associated with postoperative morbidity such as wound infection, anastomotic dehiscence, intra-abdominal sepsis and other extraintestinal complications.  Pre-existing malnutrition increases postoperative morbidity and mortality, and duration and cost of hospital stay, prompting the question of whether perioperative nutritional support might improve clinical outcome.  The aim of this study was to examine the clinical effects and cost of administration of oral supplements both before and after surgery.  This was a randomised clinical trial conducted in three centres.  Patients undergoing lower gastrointestinal tract surgery were randomised to one of four groups:  group CC received no nutritional supplements,  group SS took supplements both before and after surgery, group CS received supplements after surgery and group SC were given supplements only before surgery.  Preoperative supplements were give from the time that it was decided to operate up until one day prior to surgery.  Postoperative supplements were started when the patient was able to take free fluids and were continued for four weeks after discharge from hospital.  Data collected included weight change, complications, length of stay, nutritional intake, anthropometrics, quality of life and detailed costings covering all aspects of care.  Some 179 patients were randomised of whom 27 were withdrawn and 152 analysed (CC 44, SS 32, CS 35, SC 41).  Dietary intake was similar in all four groups throughout the study.  Mean energy intake from preoperative supplements was 536 and 542 kcal/day in the SS and SC groups and 2 weeks after discharge from hospital was 274 and 361 kcal/day in the SS and CS groups respectively.  There was significantly less postoperative weight loss in the SS group than in the CC and CS groups (p<0.05) and significantly fewer minor complications in the SS and CS groups than the CC group (p<0.05).  There was no difference in the rate of major complications, anthropometrics and quality of life.  Mean overall costs were great in the CC group, although differences between the groups were not significant.  It was concluded that oral nutritional supplementation started before hospital admission for lower gastrointestinal surgery significantly diminished the degree of weight loss and incidence of minor complications and was cost effective.

Surgical excision vs. Mohs' micrographic surgery for basal-cell carcinoma of the face:  randomised controlled trial.  Smeets N W J,  Krekels G A M,  Ostertag J U et al.  Lancet 2004;  364:  1766-1772.

Basal-cell carcinoma (BCC) is the most common cancer in white people and its incidence continues to increase.  Although such cancers rarely metastasis, some cause substantial morbidity and even mortality.  Tumour removal, preservation of healthy skin, aesthetic outcome and costs are important in the treatment of this predominantly facial skin tumour.  A previous randomised trial showed that surgery was preferable to radiotherapy.  Most BCCs worldwide are treated by surgical excision.  It has been shown that rates of tumour recurrence are lower after Mohs' micrographic surgery (MMS) compared with other surgical treatments.  However, MMS is more time consuming and more expensive.  The aim of this study was to compare outcomes of primary and recurrent facial BCCs treated by either surgical excision or MMS.  Overall, 408 primary and 204 recurrent facial BCCs (374 and 191 patients respectively) were randomised to either surgical excision or MMS and received treatment at two hospitals in the Netherlands.  The primary outcome measure was recurrence and analysis was by intention to treat.  Of the BCCs included in the trial, 397 primary and 201 recurrent tumours were actually treated.  Of the patients with primary carcinomas, 21 had both MMS and surgical excision of different tumours.  Nine with recurrent tumours had both treatments on different skin tumours.  Of the primary carcinomas, 5(3%) recurred after surgical excision and 3(2%) after MMS during 30 months of follow-up.  Of the recurrent carcinomas 3(3%) recurred after surgical excision and none after MMS during 18 months of follow-up.   Although the results favoured MMS, there were not statistically different.  Total operative costs were higher than for surgical excision.  It was concluded that no definitive comment on recurrence rates of either primary or recurrent BCCs is yet possible after treatment with either surgical excision or MMS.  Although the recurrence rates were lower after MMS than surgical excision, the difference was not significant.

Excision margins in high-risk malignant melanoma.  Thomas J M,  Newton-Bishop J,  A'Hern R et al.  N Engl J Med 2004;  350:  757-766. 

The risk of death from cutaneous melanoma is determined mainly by the thickness of the tumour, the presence or absence of tumour ulceration, microdeposits of melanoma in sentinel lymph nodes, the site of the tumour and the patient's sex.  Traditionally, wide margins of excision have been used to prevent lymphatic spread, but over the past decade, margins have become smaller because previous trials have suggested that narrow margins are safe.  The width of excision margins have been investigated in three randomised trials with predominantly thin tumours with a good prognosis.  Wide margins were associated with similar rates of recurrence and survival.  The aim of this study was evaluated the effect of margin of excision on the outcome in patients with high-risk malignant melanoma.  A randomised trial was conducted comparing 1-cm and 3-cm resection margins in patients with cutaneous melanomas more than 2 mm thick.  Of the 900 patients who were enrolled, 453 were randomly assigned to undergo surgery with a 1-cm margin if excision and 447 with 3-cm margin of excision.  The median follow-up was 60 months.  A 1-cm margin of excision was associated with significantly increased risk of locoregional recurrence.  There were 168 locoregional recurrences (as first events) in the group with 1-cm margins of excision, as compared with 142 in the group with 3-cm margins (HR 1.26, 95% CI 1.00-1.59. p=0.05).  There were 128 deaths attributable to melanoma in the group with 1-cm margins as compared with 105 deaths in the group with 3-cm margins (HR 1.24,  95% CI 0.96-1.61. p=0.1).  Overall survival was similar in the two groups.  It was concluded that a 1-cm margin of excision for a melanoma with a poor prognosis (as defined by a tumour thickness of at least 2mm) is associated with a significantly greater risk of recurrence than a 3-cm margin, but with a similar overall survival rate.

Randomised clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery.  Bucher P,  Gervaz P, Soravia C et al.  Br J Surg 2005; 92:  409-414.

The morbidity and mortality rates associated with colorectal surgery have decreased substantially over the past century.  Since the first attempts at bowel surgery, a major aim has been to reduce the rate of postoperative infectious complications, especially of anastomotic dehiscence.  Mechanical bowel preparation (MBP) is considered to be one of the critical factors in preventing complications. Some authors have questioned the role of bowel preparation.  The aim of this randomised clinical trial was to compare the outcome of patients who underwent elective left-sided colorectal surgery with or without MBP.  Patients scheduled for elective left-sided colorectal resection with primary anastomosis were randomised to preoperative MBP (3 litres of polyethylene glycol; group 1) or surgery without MBP (group 2). Postoperative abdominal infectious complications and extra-abdominal morbidity were recorded prospectively.  Overall, 153 patients were included in the study, 78 in group 1 and 75 in group 2.  Demographic, clinical and treatment characteristics did not differ significantly between the two groups.  The overall rate of abdominal infectious complications (anastomotic leak, intra-abdominal abscess, peritonitis and wound infections) were 22% in group 1 and 8% in group 2 (p=0.028).  Anastomotic leak occurred in 5 patients (6%) in group 1 and one patient (1%) in group 2 (p=0.021).  Extra-abdominal morbidity rates were 24% and 11% respectively (p=0.034).  Hospital stay was longer for patients who had MBP.  It was concluded that left-sided elective colorectal surgery without MBP is safe and associated with reduced postoperative morbidity.

Is mechanical bowel preparation mandatory for elective colon surgery?  Ram E,  Sherman Y,  Weil R et al.  Arch Surg 2005;  140:  285-288.

The value of mechanical bowel preparation (MBP) for elective colorectal surgery is debatable.  MBP aims to rid the colon and rectum of solid stool and faecal content, to lower bacterial load and to reduce the incidence of postoperative anastomotic complications and infectious complications.  It may however cause discomfort to the patients, prolong hospitalisation and may induce water and electrolyte imbalance.  The aim of this prospective randomised study was to assess whether there was any difference in the postoperative results in patients undergoing elective colonic surgery with or without MBP.  All patients who underwent elective large bowel resection in one institution between 1999 and 2002 were included.  The patients were randomly assigned to the two study groups.  All patients received antibiotic prophylaxis.  The patients in the MBP group received Sofodex for bowel preparation.  A total of 329 patients participated in the study, 165 without MBP and 164 with MBP.  The two groups were well matched for age, sex and type of surgical procedure.  Overall, 286 patients (82%) underwent surgery for colorectal cancer and 61 patients (18%) for benign disease.  The hospitalisation was longer in the bowel-prepared group however this was not statistically significant.  The time to first bowel movement was similar in the two groups.  Overall, 62 patients (38%) in the non-MBP group and 77 patients (47%) of the MBP group suffered from postoperative complications.  It was concluded that there was no advantage for MBP in elective colorectal surgery.  

Randomized clinical trial or bowel preparation with a single phosphate enema or polyethylene glycol before elective colorectal surgery.  Platell C,  Barwood N,  Makin G.  Br J Surg 2006;  93:  427-433.

In 1998, a review of clinical trials evaluating the efficacy of mechanical bowel preparation in patients undergoing elective colorectal surgery concluded that there was limited evidence to support the use of mechanical bowel preparation and that there was a need for clinical trials to compare the more traditional bowel preparation with either no preparation or simple techniques such as a single phosphate enema.  The aim of this clinical trial was to evaluate whether a single phosphate enema was as effective as oral polyethylene glycol (PEG) solution in preventing anastomotic leakage.  Patients were randomised to receive either a single phosphate enema or three litres of oral PEG solution prior to surgery.  Patients were followed up for a minimum of 6 weeks to detect anastomotic leakage. Overall, there were 147 patients in each group and the groups were well matched for putative risk factors at baseline.  Patients in the enema group had more anastomotic leaks requiring reoperation than those in the PEG group (4% vs. 0%, p=0.013; RR=2.04 (95% CI = 1.82-2.30).  The mortality rate was higher in the PEG group (2.7% vs. 0.7%, p=0.176; OR=1.62 (95% CI = 0.45-37.0).  It was concluded that bowel preparation with a phosphate enema was associated with a higher risk of anastomotic leak requiring reoperation compared with oral PEG.  These results do not support the routine use of a phosphate enema in patients undergoing elective colorectal surgery.

Interval appendectomy after conservative treatment of appendiceal mass.  Lai H-W,  Loong C-C,  Chiu J-H et al. World J Surg 2006;  30:  351-357. 

The treatment of appendiceal masses has been debated for more than 100 years.  Low complication rates have been shown after conservative treatment.  However the role of interval appendicectomy after conservative treatment of an appendicular mass remains controversial.  The rate of recurrent appendicitis after conservative management is approximately 10% and the complication rate after interval appendicectomy is significant.  The aim of this study was to clarify the role of interval appendicectomy following conservative treatment of an appendicular mass.  Between 1998 and 2003 patients with an appendiceal mass who were treated conservatively were studied retrospectively.  Data on demographics, rates of appendicitis recurrence, duration of hospital stay and complication rates were collected and analysed.  A total of 165 patients were studied (89 males, 76 females).  The mean age was 53 years (range 7-89 years).  The rate of appendicitis recurrence was 25%; most recurred within 6 months after discharge (83%).  The benefit of preventing recurrence is less than 16% if interval appendicectomy is performed 6 weeks after discharge and less than 10% if performed 12 weeks after discharge.  The complication rate of appendicectomy before or after recurrence was 10% in both groups.  The duration of the second hospital stay for patients who underwent interval appendicectomy before or after recurrence was 4.4 (SD 3.3) vs. 6.8 (SD 5.7; p=0.023).  Of the 165 patients, 17 (10%) had there diagnosis changed after further investigation of surgery and 5 patients were found to have colonic cancer.  It was concluded that patients who have recovered from conservative treatment of an appendicular mass should undergo further investigation to rule out a colon cancer.  Interval appendicectomy benefits less than 20% of patients.

Randomised clinical trial of single-dose antibiotic prophylaxis for non-reconstructive breast surgery.  Hall J C,  Willsher P C,  Hall J L.  Br J Surg 2006:  93:  1342-1346. 

The reported incidence of wound infection after breast surgery is variable due to the lack of standard criteria for measuring wound infection rates, diverse periods of follow up and the inclusion of different types of operations and patients.  Four clinical trials have evaluated the efficacy of prophylactic antibiotics for patients undergoing primary breast surgery.  All described a lower incidence of wound infection in patients receiving antibiotic prophylaxis, however none reported a statistically significant difference.  The aim of this study was to determine whether a single dose of flucloxacillin could prevent wound infection after primary non-reconstructive breast surgery.  The study included 618 patients undergoing local excision (n=490), mastectomy (n=107) or microdochectomy (n=21).  Patients were randomised to receive either a single dose of flucloxacillin (2g) immediately after the induction of anaesthesia or no intervention.  Wound morbidity was monitored by an independent research nurse for 42 days after surgery. The incidence of wound infection was similar in the two groups: 10 of 311 (3.2%) in the flucloxacillin group and 14 of 307 (4.6%) in the control group (Chi-squared = 0.75, p=0.387.  RR = 0.71; 95% CI 0.32-1.53).  The groups had similar wound scores and rates of cellulitis.  Wound infection resented at a median of 16 days after surgery.  It was concluded that the administration of a single dose of flucloxacillin failed to reduce the rate of wound infection after non-reconstructive breast surgery

Randomised clinical trial of surgical technique and local antibiotics for ingrowing toenail.  Bos A M C,  van Tilburg M W A,  van Sorge A A et al.  Br J Surg 2007;  94:  292-296.

Ingrowing toe nails (IGTN) are a common surgical problem often leading to considerable discomfort and pain.  Various aetiologies have been described including paring nails too closely, ill fitting shoes, direct trauma and genetic predisposition.  A wide range of conservative and surgical methods are available but all are associated with high recurrence rates.  The literature suggests that the use of phenol may be beneficial for most patients but at the cost of an increased risk of postoperative infection.  The aim of this study was to evaluate two different surgical treatments.  Partial avulsion of the nail and excision of the matrix was compared with partial avulsion and the application of phenol.  The effect of local application of antibiotic on both treatments was also examined.  Overall, 123 patients with IGTN were randomly assigned to one of four groups.  All patients had partial nail avulsion.  This was combined with excision of the matrix or application of phenol with or without local application of gentamicin.  The primary outcome measure was symptomatic recurrence of IGTN. In total, 117 patients were available for follow up.  Phenol gave significantly better results than matrix excision with respect to recurrence at one year (p<0.001).  There was no difference in terms of signs of infection at one week between the two groups.  Antibiotics had no effect in reducing the risk of infection or in reducing the rate of recurrence.  It was concluded that partial nail avulsion with phenolization gave better results than partial nail avulsion with matrix excision.  Local antibiotics did not reduce signs of infection or recurrence.  Use of phenol did not produce more signs of infection than matrix excision.

Hydrocortisone therapy for patients with septic shock.  Sprung C L,  Annane D,  Keh D et al.  N Engl J Med 2008;  358:  111-124. 

Hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotrophin.  This was a multicentre, randomised, double-blind, placebo-controlled trial.  Patients were assigned to receive 50m intravenous hydrocortisone (n=251) or placebo (n=248) every 6 hours for 5 days.  The dose of hydrocortisone was then tapered over a six day period.  At 28 days, the primary outcome measure was death amongst those patients who did not have a response to a corticotrophin test.  Of the 499 patients in the study, 233 (47%) did not have a response to the corticotrophin test (125 in the hydrocortisone group and 108 in the placebo group).  At 28 days, there was no difference in mortality between patients in the two study groups who did not have a response to corticotrophin (29% in the hydrocortisone group and 36% in the placebo group. p=0.69) or between those who had a response to corticotrophin (29% in the hydrocortisone group and 29% in the placebo group. p=1.00).  At 28 days, 86 of the 251 patients in the hydrocortisone group (34%) and 78 of 248 patients in the placebo group (31%) had died (p=0.51).  In the hydrocortisone group, shock was reversed more quickly than in the placebo group.  However, there were more episodes of superinfection, including new sepsis and septic shock.  It was concluded that hydrocortisone did not improve survival or reverse shock in patients with septic shock, either overall or in patients who did not have a response to corticotrophin, although hydrocortisone did hasten shock reversal in patients in whom shock was reversed.

Randomised clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis.  Hansson J,  Korner U,  Khorram-Manesh A et al.  Br J Surg 2009;  96:  473-481. 

Appendicectomy is a classical surgical procedure which as first described in the 1880s.  Non-operative management had been used earlier for many patients, but morbidity and mortality were high for both conservatively treated and appendicectomized patients. In recent years there has been increased interest in antibiotic therapy as primary treatment and several studies have indicated that perforated appendicitis in children can be treated with antibiotics.  In addition, retrospective studies in adults with perforated appendicitis treated conservatively have indicated that late recurrences exhibit a mild clinical course.  On randomized trial that compared appendicectomy with antibiotic therapy found 88% improved without surgery.  The aim of this study was to investigate whether antibiotic therapy is a feasible first-line therapy in unselected men and women older than 18 years.  Consecutive patients were allocated to study (antibiotics) ore control (surgery) groups according to date of birth.  Study patients received intravenous antibiotics for 24 hours and continued at home with oral antibiotics for 10 days.  Control patients had a standard appendicectomy.  Follow-up at one and 12 months was carried out according to intention-to-treat and per protocol.  Study and control patients were comparable at inclusion.  Overall, 106 (53%) of 202 patients allocated to antibiotics completed the treatment and 154 (92%) of 167 patients allocated to appendicectomy had surgery.  Treatment efficacy was 91% for antibiotics and 89% for surgery.  Recurrent appendicitis occurred in 15 patients (14%) after a median follow up of one year.  A third of recurrences appeared within 10 days and two-thirds between 3 and 16 months after hospital discharge.  Minor complications were similar between the groups.  Major complications were three times higher in patients who had an appendicectomy (p<0.05).  It was concluded that antibiotic treatment appears to be safe first-line therapy in unselected patients with acute appendicitis.

A surgical safety checklist to reduce morbidity and mortality in a global population.  Haynes A B,  Weiser T G,  Berry  W R et al.  N Engl J Med 2009;  360:  491-496.

Surgery has become an integral part of global health care, with an estimated 234 million operations performed annually.  Surgical complications are common and often preventable.  It was hypothesised that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.  Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, New Delhi, Amman, Auckland, Manila, Ifakara, London and Seattle) representing a variety of economic circumstances and diverse populations of patients participated in the WHO Safe Surgery Saves Lives program.  Prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing non-cardiac surgery was collected.  Data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist was then collected.  The primary endpoints was the rate of complications, including death, during hospitalization within the first 30 days of the operation.  The rate of death was 1.5% before the checklist was introduced and decreased to 0.8% after (p=0.003).  Inpatient complications occurred in 11% of patients at baseline and in 7% after the introduction of the checklist (p<0.001).  It was concluded that implementation of the checklist was associated with concomitant reductions in the rate of death and complications among patients at least 16 years of age who were undergoing non-cardiac surgery in a diverse group of hospitals

Smoking is a major risk factor for wound dehiscence after midline abdominal incision; case–control study.  Abbas S M,  Hill A G.  ANZ J Surg 2009; 79:  247-250.

The incidence of acute fascial wound dehiscence (AFWD) after major abdominal operations is as high as 3%. AFWD is associated with mortality rates of 15–20%. Male gender, advanced age and numerous systemic factors including malignancy, hypoproteinaemia and steroid use have been associated with increased risk. The aim of the present study was to investigate the association between smoking prevalence and AFWD. The records from one hospital were retrieved from the 1997–2006 period for patients who had undergone midline abdominal surgery and developed AFWD. A return to the operating theatre for closure of the fascial dehiscence was required for study group inclusion. Each patient in the study group was matched to two control patients who had been admitted in the same year for surgery and who had a similar initial surgical intervention. Conditional logistic regression was used to calculate odds ratios with 95% confidence intervals, representing the risk of developing fascial wound dehiscence in smokers compared with the non-smoking group. There were 52 patients (32 male, 20 female) and 104 controls (64 male, 40 female). Median age for both groups was 63 years. A history of heavy tobacco use (≥20 pack-years) was more prevalent in those who had AFWD (46%) compared with the control group (16%; P = 0.0002; odds ratio 3.7). It was concluded that smoking is associated with an increased incidence of acute fascial wound dehiscence following laparotomy. It is not known whether smoking is a causal or a surrogate factor.

Pus swabs in incision and drainage of perianal abscesses.  What is the point?  Leung E,  McArdle K,  Yazbek-Hanna M.  World J Surg 2009;  33:  2448-2451.

The clinical effectiveness of pus swabs for microbiological analysis during incision and drainage of perianal abscess is controversial. Its cost implication is often overlooked. The present study aimed to determine if submission of pus swabs can be avoided without a negative effect on outcome. All consecutive cases of incision and drainage of perianal abscess between January 2004 and 2008 were retrospectively reviewed. Patient demographics, microbiological results, and clinical outcome with a follow-up of 6 months were assessed. A review of patient records revealed 235 cases (59 F:176 M; age range: 6–99 years; median: 37 years). In 38 cases no swabs were taken; in 28 cases (12%), 106 cases (45%), and 16 cases (7%) swabs contained skin flora organisms, coliform / Bacteroides, and sterile, respectively. Within 6 months follow-up, 185 of the abscesses had healed, leaving 39 cases of fistula (25 cases had setons remained in situ for their fistulas at 6 months follow-up) and 11 patients were lost from follow-up. Fistulas were not associated with coliform / Bacteroides found on microbiological analysis (p > 0.05). In only 4 cases (1.7%) were the swab results mentioned in follow-up reports. It was concluded that surgeons tend not to review microbiological results at patient follow-up. Furthermore, the preliminary findings suggest that microbiological results have no correlation with presence of fistulas or prognosis. Randomized controlled trials are warranted to assess whether abandoning submission of pus swabs will affect clinical effectiveness of treatment in patients with perianal abscess.

Chlorhexidine-alcohol vs povidone-iodine for surgical site asepsis.  Darouchie R O,  Wall M J,  Itami K M F et al.  New Engl J Med 2010;  362: 18-26. 

Since the patient's skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. It was hypothesized that preoperative skin cleansing with chlorhexidine–alcohol is more protective against infection than is povidone–iodine. Adults undergoing clean-contaminated surgery in six hospitals were randomly assigned to preoperative skin preparation with either chlorhexidine–alcohol scrub or povidone–iodine scrub and paint. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections. A total of 849 subjects (409 in the chlorhexidine–alcohol group and 440 in the povidone–iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine–alcohol group than in the povidone–iodine group (9.5% vs. 16.1%; P=0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine–alcohol was significantly more protective than povidone–iodine against both superficial incisional infections (4.2% vs. 8.6%, P=0.008) and deep incisional infections (1% vs. 3%, P=0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups. It was concluded that preoperative cleansing of the patient's skin with chlorhexidine–alcohol is superior to cleansing with povidone–iodine for preventing surgical-site infection after clean-contaminated surgery.

Preventing surgical site infections in nasal carriers of Staphylococcus aureus. Bode L G M,  Kluytmens J A J W,  Wertheim H F L et al.  New Engl J Med 2010;  362: 9-17. 

Nasal carriers of Staphylococcus aureus are at increased risk for health care–associated infections with this organism. Decolonization of nasal and extra-nasal sites on hospital admission may reduce this risk. A randomized, double-blind, placebo-controlled, multicentre trial was used to assess whether rapid identification of S. aureus nasal carriers by means of a real-time polymerase-chain-reaction (PCR) assay, followed by treatment with mupirocin nasal ointment and chlorhexidine soap, reduces the risk of hospital-associated S. aureus infection. From October 2005 through to June 2007, a total of 6771 patients were screened on admission. A total of 1270 nasal swabs from 1251 patients were positive for S. aureus. Overall, 917 of these patients were enrolled in the intention-to-treat analysis, of whom 808 (88.1%) underwent a surgical procedure. All the S. aureus strains identified on PCR assay were susceptible to methicillin and mupirocin. The rate of S. aureus infection was 3.4% (17 of 504 patients) in the mupirocin–chlorhexidine group, as compared with 7.7% (32 of 413 patients) in the placebo group (relative risk of infection, 0.42; 95% confidence interval [CI], 0.23 to 0.75). The effect of mupirocin–chlorhexidine treatment was most pronounced for deep surgical-site infections (relative risk, 0.21; 95% CI, 0.07 to 0.62). There was no significant difference in all-cause in-hospital mortality between the two groups. The time to the onset of nosocomial infection was shorter in the placebo group than in the mupirocin–chlorhexidine group (P=0.005). It was concluded that the number of surgical-site S. aureus infections acquired in the hospital can be reduced by rapid screening and decolonizing of nasal carriers of S. aureus on admission.

2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: a randomised, multicentre trial.  Gillgren P,  Drzewiecki K,  Niin M et al.  Lancet 2011;  378:  1635-1642. 

Optimum surgical resection margins for patients with clinical stage IIA—C cutaneous melanoma thicker than 2 mm are controversial. The aim of the study was to test whether survival was different for a wide local excision margin of 2 cm compared with a 4-cm excision margin. A randomised controlled trial in nine European centres was undertaken. Patients with cutaneous melanoma thicker than 2 mm, at clinical stage IIA—C, were allocated to have either a 2-cm or a 4-cm surgical resection margin. Patients were randomised in a 1:1 allocation to one of the two groups and stratified by geographic region. Randomisation was done by sealed envelope or by computer generated lists with permuted blocks. The primary endpoint was overall survival. The trial was not masked at any stage. Analyses were by intention to treat. Adverse events were not systematically recorded. Overall, 936 patients were enrolled from Jan 22, 1992, to May 19, 2004; 465 were randomly allocated to treatment with a 2-cm resection margin, and 471 to receive treatment with a 4-cm resection margin. One patient in each group was lost to follow-up but included in the analysis. After a median follow-up of 6·7 years (IQR 4·3—9·5) 181 patients in the 2-cm margin group and 177 in the 4-cm group had died (hazard ratio 1·05, 95% CI 0·85—1·29; p=0.64). 5-year overall survival was 65% (95% CI 60—69) in the 2-cm group and 65% (40—70) in the 4-cm group (p=0·69). This study suggests that a 2-cm resection margin is sufficient and safe for patients with cutaneous melanoma thicker than 2 mm.

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