T. F. Gorey

Laparoscopic versus open appendicectomy: A prospective evaluation

A prospective evaluation of laparoscopic surgery for acute appendicitis over a 6-month period is reported. Sixty-five patients with signs and symptoms of appendicitis necessitating surgery were assigned to open (n = 36) or laparoscopic (n = 29) appendicectomy. Thirty-seven patients were female (22 open) and 28 were male (14 open). The median age was 24 (range 14-64) years for open appendicectomy and 18 (range 14-60) years for the laparoscopic procedure. The mean postoperative stay for open operation was 4.8 (range 1-21) days and for the laparoscopic route 2.2 (range 1-11) days (P < 0.05). Inflammation was confirmed histologically in 72 per cent of the open cases and in 74 per cent of the laparoscopic cases (P not significant). The wound infection rate was 11 per cent (n = 4) for open and 4 per cent (n = 1) for laparoscopic appendicectomy (P < 0.05). The median anaesthesia time was 52 (range 15-90) min for open appendicectomy and 48 (range 20-120) min for laparoscopic surgery (P not significant). After open appendicectomy patients had a median of 5 (range 2-12) intramuscular injections of analgesia compared with a median of 1 (range 0-5) in the laparoscopic group (P < 0.05). Two laparoscopic operations were converted to an open procedure. The results suggest that emergency laparoscopic appendicectomy should be explored further as an alternative to open surgery for acute appendicitis.

Operative Assessment of Intestinal Viability

Acute intestinal ischemia and infarction remain serious clinical problems despite early operative intervention. Accurate intraoperative assessment of intestinal viability is essential in determining the limits of resection in patients with intestinal infarction. Clinical features of bowel viability such as color and peristalsis do not correlate uniformly with bowel survival, and as a result, several techniques have been developed to assess intestinal blood flow at the time of operation. The requirements of an ideal viability test are: 1. The technique must have ready availability, preferably in every operating theater dealing with abdominal emergencies. 2. The necessary equipment must not be cumbersome or require specialized personnel. 3. The method must be accurate with a minimum of false-negative results and, more importantly, few false positives. A false-negative results leaves in situ nonviable bowel, which may lead to early perforation and late stricturing. This situation may be recoverable with further surgical intervention, however. On the other hand, a false-positive assessment of bowel viability results in the resection of potentially recoverable intestine, which is lost forever and may represent a vital difference for morbidity-mortality and long-term nutrition. 4. The technique must be objective and be reproducible. 5. The method must be cost effective. To date, only two tests have found widespread acceptance and clinical applicability: fluorescein assessment and Doppler studies either with ultrasound or as refined in laser velocimetry. Although other techniques may be of some value today or in the future, the most practical approach would appear to be to use fluorescein assessment under a modified Woods lamp as the initial method of evaluating intestinal viability and either Doppler ultrasound or perfusion fluorometry for any areas of particularly doubtful viability.

Widespread chromosomal abnormalities in high-grade ductal carcinoma in situ of the breast. Comparative genomic hybridization study of pure high-grade DCIS.

For a variety of technical reasons it is rarely possible to study cytogenetic abnormalities in ductal carcinoma in situ (DCIS) using traditional techniques. However, by combining molecular biology and computerized image analysis it is possible to carry out cytogenetic analyses on formalin‐fixed, paraffin‐embedded tissue, using comparative genomic hybridization (CGH). The purpose of this study was to identify the prevalence of chromosomal amplifications and deletions in high‐grade DCIS and to look specifically for unique or consistent abnormalities in this pre‐invasive cancer. Twenty‐three cases of asymptomatic, non‐palpable, screen‐detected, high‐grade DCIS were examined using CGH on tumour cells obtained from histology slides. All cases showed chromosomal abnormalities. A wide variety of amplifications and deletions were spread across the genome. The most frequent changes were gains of chromosomes 17 (13 of 23), 16p (13 of 23), and 20q (9 of 23) and amplifications of 11q13 (22 of 23), 12q 24.1–24.2 (12 of 23), 6p21.3 (11 of 23), and 1q31‐qter (6 of 23). The most frequent deletions were on 13q 21.3–q33 (7 of 23), 9p21 (4 of 23), and 6q16.1 (4 of 23). These findings indicate that high‐grade DCIS is, from a cytogenetic viewpoint, an advanced lesion. There was no absolutely consistent finding in every case, but amplification of 11q13 was found in 22 of the 23 cases. The precise significance of this is unknown at present. This region of chromosome 11q harbours a number of known oncogenes, including cyclinD1 and INT2. It is likely that many of these findings are the result of accumulated chromosomal abnormalities, reflecting an unstable genome in established malignancy. Copyright

Electronic learning can facilitate student performance in undergraduate surgical education: a prospective observational study

BackgroundOur institution recently introduced a novel internet accessible computer aided learning (iCAL) programme to complement existing surgical undergraduate teaching methods. On graduation of the first full cycle of undergraduate students to whom this resource was available we assessed the utility of this new teaching facility.MethodThe computer programme prospectively records usage of the system on an individual user basis. We evaluated the utilisation of the web-based programme and its impact on class ranking changes from an entry-test evaluation to an exit examination in surgery.Results74.4% of students were able to access iCAL from off-campus internet access. The majority of iCAL usage (64.6%) took place during working hours (08:00–18:00) with little usage on the weekend (21.1%). Working hours usage was positively associated with improvement in class rank (P = 0.025, n = 148) but out-of hours usage was not (P = 0.306). Usage during weekdays was associated with improved rank (P = 0.04), whereas weekend usage was not (P = 0.504). There were no significant differences in usage between genders (P = 0.3). Usage of the iCAL system was positively correlated with improvement in class rank from the entry to the exit examination (P = 0.046). Students with lower ranks on entry examination, were found to use the computer system more frequently (P = 0.01).ConclusionElectronic learning complements traditional teaching methods in undergraduate surgical teaching. Its is more frequently used by students achieving lower class ranking with traditional teaching methods, and this usage is associated with improvements in class ranking.

Superoxide radical and xanthine oxidoreductase activity in the human heart during cardiac operations

BACKGROUND The results of clinical trials of xanthine oxidoreductase inhibition in cardiac surgery are encouraging, although studies have failed to localize the enzyme to the human heart and to localize free radical activity to fresh human heart. METHODS We adapted a histochemical staining technique based on the reduction of nitro blue tetrazolium to formazan by superoxide radical. In six samples of right atrium graded blindly on a scale of 0 through 4, strong staining (median grade, 3) of the microvasculature was seen. This was blocked by allopurinol in paired sections (median grade, 1; p < 0.01). Chemiluminescence can be used as an index of superoxide radical activity. Atrial samples were taken from 13 patients at five time points during coronary bypass grafting and placed in buffered luminol. Then chemiluminescence was measured. RESULTS A 15-fold rise in chemiluminescence (295.93 +/- 39.47 mV) was demonstrated during reperfusion compared with the control value (19.06 +/- 0.47 mV). Chemiluminescence at 1 minute after release of the cross-clamp was significantly higher (p < 0.05) by analysis of variance versus values obtained before bypass and 1 minute before and 30 minutes after reperfusion. CONCLUSIONS In this study we have identified superoxide radical activity and a possible generating system (xanthine oxidoreductase) in the human heart.

Nipple discharge and the efficacy of duct cytology in evaluating breast cancer risk

BACKGROUND Nipple discharge accounts for up to 5% of referrals to breast surgical services. With the vast majority of breast carcinomas originating in the ductal system, symptomatic dysfunction of this system often raises disproportionate clinical concern. The aim of this study is firstly, to evaluate the clinical importance of nipple discharge as an indicator of underlying malignancy and secondly, to assess the diagnostic application of duct cytology in patients presenting with nipple discharge. STUDY DESIGN We performed a retrospective analysis of all patients presenting with nipple discharge as their primary symptom to the symptomatic breast unit at a tertiary referral center over a 30-month period (n = 313). The Hospital Inpatient Enquiry (HIPE) System and BreastHealth database were used to identify our study cohort. Parameters evaluated included patient demographics, clinical presentation, clinical evaluation, radiological assessment and histological/cytological analysis. RESULTS Three-hundred and thirteen patients presented with nipple discharge as their primary complaint. Invasive breast carcinoma was diagnosed by Triple Assessment in 5% of patients. 24% of patients presenting with nipple discharge underwent nipple aspiration and cytological analysis. Duct cytology was diagnostic of the underlying breast carcinoma in 50% of triple assessment diagnosed carcinoma. Four risk factors were identified as having a significant association with breast carcinoma, these included (a) age >50 years (p < 0.0001), (b) bloody nipple discharge (p < 0.008), (c) presence of a breast lump (p < 0.0001) and (d) single duct discharge (p < 0.006). CONCLUSIONS Nipple discharge is a poor indicator of an underlying malignancy. Use of nipple aspiration and duct cytology for the assessment of nipple discharge is of limited diagnostic benefit. However, by utilizing the systematic, gold standard approach of Triple Assessment (clinical, radiological and cytological evaluation), the risk of underlying carcinoma can be accurately defined.

Tc-99m tetrofosmin scintigraphy as an adjunct to plain-film mammography in palpable breast lesions.

AIM To investigate the use of Tc-99m tetrofosmin as a breast imaging agent and to compare results of Tc-99m tetrofosmin scintimammography with plain-film mammography and pathological outcome. PATIENTS AND METHODS Forty-four patients (mean age, 51 years; range 26-79 years) with a palpable breast mass requiring fine needle aspiration biopsy (FNAB) were prospectively studied. All patients had Tc-99m tetrofosmin scintimammography. Patients over 35 years of age had two view mammography performed on the same day. FNAB was performed within 2 weeks of imaging, and patients referred for surgery as appropriate. Results of scintigraphy and plain-film mammography were correlated with pathological outcome. RESULTS Of the 44 patients, 21 had biopsy proven malignancy while 23 had benign lesions. Of the 21 patients with carcinoma, 20 (95.2%) had positive Tc-99m tetrofosmin scintimammography while 21 (91.3%) of the 23 patients with benign histology had negative scintigraphy. The sensitivity of scintimammography was 95.24%, the specificity was 91.3%, with a positive predictive value of 90.9% and a negative predictive value of 95.45%. Thirty-eight patients had two view mammography performed (six patients were <35 years of age). Of these 38 patients, 21 had biopsy proven malignancy while 17 had benign histology (all patients <35 years of age had benign histology). Of the 21 patients with malignancy, plain-film mammography was suspicious for malignancy in 17 (81%) while four were reported as benign. Of the 17 with benign disease, 14 patients (82.4%) had benign appearances on plain-film mammography while three (18%) had one or more findings suspicious for malignancy. The sensitivity of plain-film mammography in our group was 81%, with a specificity of 82.4%, a positive predictive value of 85% and a negative predictive value of 77.8%. Tc-99m tetrofosmin scintimammography correctly characterized all seven lesions where mammographic evaluation was limited because of dense breast parenchyma or previous surgery and/or radiotherapy. CONCLUSION Tc-99m tetrofosmin scintimammography is an accurate, well tolerated and non-invasive method of differentiating benign from malignant palpable breast lesions. Negative Tc-99m tetrofosmin scintimammography excludes malignancy with a high degree of confidence while false-positive scintigraphy can occur in cases of proliferative dysplasia and hypercellular fibroadenoma. Tc-99m tetrofosmin scintimammography is particularly useful when plain-film mammography is indeterminate or limited in patients with dense breasts or a history of previous surgery and/or radiotherapy.

Endoscopic management of common duct stones with laparoscopic cholecystectomy.

In the first year from October 1990 since starting the procedure 65 laparoscopic cholecystectomies were carried out on one surgical service. There were 4 planned open cholecystectomies and 8 laparoscopic procedures converted during the same period: 7 of these were in the first 3 months with only 1 of the last 53 being opened. Surgery was carried out during the same admission in 22 patients presenting as emergencies: acute cholecystitis (9), colic (6), pancreatitis (3), jaundice (4). Two patients had later laparotomies for complications; one patient bled from the umbilical stab and with ongoing peritonism had a pelvic haematoma drained on day 5 and a second was opened following a bile leak caused by a displaced cystic ductclip-both recovered uneventfully. Peroperative cholangiography was performed in 13 patients; 2 were positive (15%) and had ERCP papillotomy 3 days post op without complication. One patient who presented with pancreatitis had ERCP performed post-op without incident. Seven patients had laparoscopic cholecystectomy following papillotomy for common duct stones. The gallbladder was extracted per umbilicus in 45 (3 wound infections) and per right subcostal stab in 20 (no infections). Mean hospital stay was 48 hours (1–4 days) in uncomplicated cases.In conclusion, the learning curve is associated with higher conversion rates. Extraction through pliable hypochondrial muscles is easier and may be safer and less traumatic. Perioperative endoscopic papillotomy is safe and effective for choledochal stones.

Minimally invasive parathyroidectomy with operative ultrasound localization of the adenoma

BackgroundMinimally invasive parathyroidectomy is the procedure of choice for primary hyperparathyroidism due to parathyroid adenoma. Adequate perioperative adenoma localization is essential for this operation. We describe a technique using ultrasound to perform minimally invasive parathyroidectomy.Methods99mTc sestamibi scanning was performed on patients with primary hyperparathyroidism to localize parathyroid adenomas; no intraoperative gamma probe was used. We also performed pre- and intraoperative ultrasound scanning to localize these adenomas.ResultsAll patients underwent successful localization and removal of their parathyroid adenomas. At follow-up, all patients were well, with calcium within normal limits.ConclusionThe use of intraoperative ultrasound facilitates minimally invasive parathyroidectomy and may obviate the need for intraoperative 99mTc sestamibi scanning.

Comparison of cytomorphological and architectural heterogeneity in mammographically-detected ductal carcinoma in situ.

Many classification schemes have been proposed for ductal carcinoma in situ. Architectural heterogeneity is widely recognized. Cytonuclear grade appears to have greater prognostic significance than architectural pattern. This study assesses heterogeneity using a classification based on cytological grade and compares this to architectural heterogeneity in mammographically detected ductal carcinoma in situ. One hundred and twelve cases were classified according to architectural subtypes and the carcinoma nuclei were graded. Necrosis and micro‐ calcification were assessed. Eighty‐four percent of ductal carcinomas in situ had a single nuclear grade, whereas only 39% showed a single architectural pattern. High grade nuclei were present in 87% of cases. Necrosis was associated with high nuclear grade. In contrast to architectural heterogeneity, this study shows little ductal carcinoma in situ heterogeneity when classification is based on nuclear grade. Thus, a cytomorphological classification should have the advantage of consistency and reproducibility in comparison to architecture‐based classification systems.