M. P. Brady

Infantile hypertrophic pyloric stenosis: Long-term audit from a general surgical unit

This article describes a 22 year experience of a general surgical unit in the treatment of infantile hypertrophic pyloric stenosis (I HPS). The hospital course of 229 IHPS patients is reviewed. The male:female ratio was 3.6:1, median age 6 weeks (range 2-26 weeks) with a positive family history in 8.3%. The diagnosis of IHPS was established clinically by palpation of a “pyloric tumour” during a pre operative test meal/clinical examination in 92.6%; in the remainder, the diagnosis was made radiologically.Ramstedt’s pyloromyotomy was performed within 5 days of admission in 74% of patients and within 10 days of admission in 89%. The median post-operative hospital stay was 10 days (range 3-60 days). Wound morbidity occurred in 10.0% — wound infection (7.3%) and wound dehiscence (2.6%). However, wound morbidity was reduced in the second half of the series, partly by greater utililisation of non-absorbable suture in place of chromic catgut for wound closure. Mucosal penetration was suspected in 14.8% of cases. Repeat pyloromyotomy was necessary in 1.3%. One baby died (0.4%) — this was in the early part of the series and was directly attributable to fluid and electrolyte disorder.We conclude that Ramstedt’s pyloromyotomy for infantile hypertrophic pyloric stenosis can be performed with acceptable morbidity and minimal mortality in a general surgical unit.

Surgical audit: The value of a morbidity and mortality conference

SummaryA Regular morbidity and mortality conference has been conducted over a period of 18. months. The conference has been a useful forum for postgraduate surgical education and continuous assessment of surgical trainees. The data from each conference have been combined to provide a comprehensive audit of general surgery at a busy teaching hospital.

How Safe is Splenectomy

The increased risk of sepsis in patients following splenectomy has been well documented. Fear of over-whelming post-splenectomy sepsis (OPSI) has resulted in a generalised trend towards splenic salvage among surgeons. However, splenorrhaphy and attempts at splenic salvage may of themselves predispose to significant morbidity, sometimes more serious than increased susceptibility to infection associated with splenectomy. This study aims to assess the risk of splenectomy and subsequent asplenia.We reviewed 246 patients who underwent splenectomy over a 16 year period. Indications for splenectomy were considered under the following headings: haematological (N = 116), trauma (N = 69), visceral carcinoma (N = 28), incidental (N = 13) and miscellaneous (N = 20).There were 28 deaths in the series, primarily among those in the intra-abdominal carcinoma (13) and multiple trauma (13) groups. Two deaths were recorded among patients undergoing elective splenectomy for benign disease. Thrombo-embolic complications were recorded in nine patients; respiratory tract infection in 36 patients and intra-abdominal abscess in two patients. Two cases of post-splenectomy pneumococcal septicaemia were documented, neither of which was fatal.While not an entirely benign procedure, splenectomy can be performed relatively safely, especially when performed for benign disease in an adult population.

Biliary surgery for benign disease a study of 500 consecutive operations.

SummaryAn analysis of 500 consecutive operations on the biliary tract for benign disease, performed over a 5 year period is presented. Twenty-two per cent of patients had common duct exploration, and the incidence of choledochotomy increased with advancing age. The overall incidence of choledocholithiasis was 15.2% and calculi in the common duct were found more frequently in the elderly. The use of operative cholangiography increased over the 5 year study period, but was not associated with any change in the incidence of common bile duct exploration or choledocholithiasis. Four patients had re-exploration for retained calculus (0.8%). The overall operative mortality was 0.6%.

Alveolar Soft Part Sarcoma Presenting as a Pulsating Tumour of the Arm in a Young Woman

SummaryWe present the case of an alveolar soft part sarcoma presenting as a pulsating tumour of the arm in a young woman.

Abdominal aortic aneurysms: The importance of elective repair

Repair of abdominal aortic aneurysms (A A A) is being performed with a progressively lower mortality and morbidity. We reviewed 111 patients who underwent repair of their AAA. Sixty-two were electively repaired and 49 had emergency surgery. Eight patients had cocomitant non-vascular procedures carried out. Operative mortality was 3.2 % and 49 % for elective and emergency cases respectively. Postoperative complications occurred in 40% of elective cases and 72% of emergency cases, respiratory complications being the most common, occurring in 25% and 40% of elective and emergency cases respectively. Subsequent graft complications occurred in six patients, five following emergency surgery.

The interaction of Vitamin A and corticosteroids on wound healing

SummaryIN the steroid treated rat no beneficial effect of topical or parenteral Vitamin A could be demonstrated. In this animal study, there was a significant beneficial effect from an alternate day steroid versus a daily steroid regime.If confirmed in a clinical study, alternate day steroids might be beneficial in a steroid dependent patient undergoing surgery.It is well known that corticosteroids inhibit collagen synthesis and retard wound healing when given prior to, or soon after, injury (Ehrlich and Haut, 1969). Parameters of collagen synthesis and fibre orientation such as wound tensile strength and healing of open wounds are all significantly reduced in the steroid treated wound (Ehrlichet al, 1974). Also, inflammatory markers such as leukocyte infiltration, neo-capillary budding, collagen fibre and hydroxyprolene content are all reduced in corticosteroid treated rat wounds (Ehrlichet al, 1974; Salmela and Ahonen, 1981).Vitamin A may reverse this potentially serious side effect of corticosteroids whilst preserving their beneficial action. Recent work has suggested that this may be only when Vitamin A is given in toxic doses and only for a short period (Salmela, 1981). It has also been suggested that Vitamin A increases the collagen content of polyvinyl alcohol sponge implants (Seifter, 1075). However, this effect has not been substantiated and its only effect may be on the reversal of corticosteroid treated inhibition of wound healing.This experimental study has arisen out of a clinical need to know what effect topical and parenteral Vitamin A has on wound tensile strength and wound healing in a steroid treated rat animal model.

Duration of anaesthesia and post-operative hypoxaemia.

SummaryA PROSPECTIVE study was designed to investigate the relationship between post-operative hypoxaemia and duration of anaesthesia. The Po2 was monitored pre-operatively, 4 hours postoperatively, and daily thereafter for 2 days in 33 female patients undergoing elective biliary tract surgery. A significantly greater fall in Po2 occurred in these patients who had prolonged anaesthetics suggesting that this group of patients should be carefully monitored during the post-operative period and oxygen administered if necessary.

Left colon reconstruction of the pharynx after pharyngolaryngectomy

SummaryUsing pedicled left colon for reconstruction of the pharynx following resection for carcinoma, we were able to restore normal swallowing within three weeks in five of 11 patients with extensive disease. Since only one of these has been a long term survivor this represents very useful palliation as it is of paramount importance in these patients with short survival times to restore normal swallowing as early as possible.

Regional lymph nodes in cancer.

SummaryA controlled experiment on palpation of axillary nodes is described and used to highlight the defects of staging carcinoma of the breast by this method. A plea is made for a more rational method to be employed in this condition.