Fine-needle aspiration versus drill-needle biopsy of thyroid nodules: a controlled clinical trial

Percutaneous needle biopsy by two different methods was evaluated in a prospective controlled study of 167 consecutive patients with dominant thyroid nodules. Fine-needle aspiration was superior to high-speed drill-needle biopsy because of its higher diagnostic yield (93.9%). When a sample sufficient for diagnosis was obtained, the accuracy rate for both methods was comparable. Diagnostic errors were due to inadequate samples, difficulties in interpreting hypercellular adenomas, and geographic sampling problems. In the detection of thyroid cancer, neither technique alone appears completely adequate because of occasional false negative errors. The selection of patients for operation should depend on clinical parameters as well as the findings on fine-needle aspiration of thyroid nodules.

Serotypes of Escherichia coli isolated from patients with recurrent pyogenic cholangitis

Strains of Escherichia coli were isolated from laparotomy specimens from Chinese patients with recurrent pyogenic cholangitis in Hong Kong. A large variety of serotypes were found. Several sites were sampled in each patient. While only one serotype was normally isolated from one site, different sites often yielded different serotypes in the same patient. Generally the 'O' types found did not correspond to those found in the faeces of the Hong Kong Chinese population.

Selective coating of gastric ulcer by tripotassium dicitrato bismuthate in the rat

Controlled clinical trials have shown that tripotassium dicitrato bismuthate healed duodenal and gastric ulcers significantly better than placebo. One mechanism suggested is that it forms a protective coat at the ulcer base. We studied this coating action in rats with chronic gastric ulcers produced by a standardized technique for mucosal wounding at the fundoantral junction. Bismuth was identified by histochemical staining using Castel's reagent, the specificity of which was verified in vitro against 13 other metallic compounds and chemicals. Our results showed that tripotassium dicitrato bismuthate had a coating affinity for the ulcer base, but not for the adjacent normal mucosa. All rats treated with tripotassium dicitrato bismuthate 1, 2, 4, and 6 h previously, but not the control rats treated with water or those treated with four other bismuth compounds, manifested a layer of bismuth that coated the ulcer base. Light and electron microscopy of the tripotassium dicitrato bismuthate-treated ulcers--but not their controls-revealed an abundance of macrophages, which had ingested the bismuth. This unique bismuth coat may insulate the ulcer base from acid-pepsin digestion, while the influx of macrophages may expedite reparative processes.

Bacteria and septic complications in patients with perforated duodenal ulcers

To evaluate the clinical significance of bacterial contamination in perforated duodenal ulcers, we prospectively studied septic complications in 184 consecutive patients. All patients received parenteral antibiotics (over 90 percent preoperatively) for at least 7 days. Thirteen infections developed in eight patients (4.3 percent). Peritoneal cultures, performed in 143 unselected patients, were positive in 33.6 percent of cases. Bacterial growth occurred more often and in heavier amounts in patients who underwent exploration late (after 48 hours) and those who had gross peritoneal soilage. Candida and gram-negative organisms predominated, but there was no correlation with pathogens that produced abscesses or wound infections. Old age and late exploration significantly increased the risk of infection. Neither peritoneal soiling nor a positive culture was likely to be clinically important when explorations was performed within 2 days of perforation. We treated perforated ulcers as clean-contaminated cases, and recommend that three doses of prophylactic antibiotics be begun preoperatively in all patients.

Pelvic exenteration for locally advanced colorectal carcinoma

Pelvic exenteration provided worthwhile palliation and achieved a cumulative five-year survival rate of 38.8% in 49 patients who had carcinoma of the lower colon or rectum infiltrating adjoining pelvic viscera. Survival and the disease-free period were not significantly different after total or posterior exenteration. The stage of disease was the major determinant of outcome: five-year survival rates averaged 51.8% and 28.8% for Stages II and III, respectively. Hospital mortality (26.9%) after total exenteration was chiefly due to technical mishaps, and the inclusion of many high-risk but symptomatic elderly patients. Complete clearance of locally advanced colorectal cancer by pelvic exenteration is indicated in fit patients, especially those with Stage II disease.

Cimetidine versus surgery for recurrent ulcer after gastric surgery

The efficacy of cimetidine vs. surgery in the treatment of recurrent ulcers after definitive surgery for chronic duodenal ulcer was evaluated in two comparable groups (23 each) of patients. Cimetidine 1 g daily healed 79% and 91.6% of recurrent ulcers, as assessed endoscopically, after 6 and 12 weeks respectively. At the end of one year, maintenance treatment with cimetidine (400 mg nocte) prevented relapse in 89.5% of the healed ulcers, while surgery was successful in 94.4% (p greater than 0.1). The cimetidine group experienced significantly (p less than 0.05) less side effects than the surgical group, with respectively 10% and 50% of patients having Visick grade II and above. After one year of maintenance treatment, cimetidine was withdrawn, and ulcer recurred in 71.4% within six months. The relapse rates between the two groups were significantly different by life-table analysis (p less than 0.01). We conclude that cimetidine was as effective as surgery in preventing relapse of postsurgical recurrent ulcers and had fewer side effects, but indefinitely prolonged therapy appeared necessary.

Double-breasted technique for the repair of urethral fistulas after hypospadias surgery

Urethral fistula formation after urethroplasty for hypospadias is a frequent occurrence. Repeated failures can occur even after multiple attempts at repair. A surgical procedure is described using the double-breasted principle to treat these resistant cases. Twenty-four patients were operated on using this technique and have been followed up from 6 to 27 months. There were 3 failures in the earlier cases but these patients were cured by a repeat of the procedure.

Experimental splenosis: a comparative study in rats

The growth of the splenic remnant after partial splenectomy and autogenous splenic implants was compared in immature rats. Implants placed in the subcutaneous pouch of the anterior abdominal wall and the retroperitoneal space had none or minimal regeneration. Splenulus formed in the omental wrap were small, multiple and the combined weight was less than the original graft tissue, and more ectopic splenulus and intra-abdominal adhesions were formed. Splenic remnants after three-quarter splenectomy with an intact blood supply grew to 30-46% of the weight of the spleen of the control; and increased in size as the animal matured.

A prospective study of operative risk factors in perforated duodenal ulcers

Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients. Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%). Concurrent medical illness, preoperative shock, and longstanding perforations (more than 48 hours) were significant features that increased mortality. Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors. No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period. We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations.

The surgical management of primary intrahepatic stones

Primary intrahepatic stones are commonly found in association with recurrent pyogenic cholangitis. In 115 patients with this condition, the intrahepatic stones were removed by four different methods: common duct exploration (n = 74), transhepatic intubation (n = 10), hepatotomy (n = 5) and hepatic resection (n = 26). The choice of methods was guided by the location of stones and the condition of the bile ducts and the liver. These extraction procedures were combined with drainage procedures, i.e. sphincteroplasty and choledochojejunostomy, whenever the proper indications were present. The operative mortality was 4.3 per cent. Long term follow-up (median 7 years and 8 months) on 91 patients revealed that common duct exploration, transhepatic intubation and hepatotomy were associated with high incidences of recurrent symptoms requiring reoperation (23.6 per cent, 37.5 per cent and 75 per cent respectively). In most instances, failures were due to recurrent stone formation in the stenotic intrahepatic ducts. Hepatic resection had the lowest failure rate (4.2 per cent) and none of the patients had recurrent stones.

Intrathoracic gastric bypass for carcinoma of oesophagus found unresectable at exploration

Assessment of the resectability of carcinoma of the oesophagus or cardia may be inaccurate. At exploration, 8 patients in whom resection was contemplated were found to have unresectable lesions. An intrathoracic oesophagogastric bypass was performed without further change of position. Five patients were discharged from hospital and survived between 3 and 20 months before they finally succumbed to metastases. Each of them was able to take an ordinary diet. The aims of palliation were achieved.

Jejunal loop bypass and fundoplication for malignant esophagobronchial fistula

A new operation was designed to supplement the Kirschner operation for patients with locally advanced carcinoma of the esophagus and who, in addition, had had a gastrectomy for peptic ulcer disease. Bypass of the esophageal obstruction was by jejunal loop, and gastroesophageal reflux was prevented by fundoplication. Eighteen patients underwent this operation with a mortality of 27.8 per cent. Death occurred in one of the three patients with leakage of the esophagojejunal anastomosis. One patient had gangrene of the jejunal loop develop. Severe bronchopneumonia was the cause of death in all five. The functional result in the surviving patients was satisfactory and they lived for a mean period of 3.6 months postoperatively. It is not advocated that this operation replace the Kirschner operation, which we consider the operation of choice for locally advanced carcinoma of the esophagus, but as an alternative procedure in those patients in whom a previous gastric resection precluded a Kirschner operation.

Effects of rheumatic mitral valvular disease and mitral valve replacement on growth and development

The effects of rheumatic mitral valvular disease and mitral valve replacement on the growth and development of 37 Southern Chinese children were studied. The stature and body weight were measured before and after operation. All the patients had their skeletal maturity and cortical bone growth assessed after operation, but only 10 patients were similarly assessed before operation. At the time of operation the stature and body weight of all patients were generally retarded. The surgery which corrected the haemodynamic abnormality resulted in increases in the growth rates in stature and body weight but there was no evidence of a catch-up growth with subsequent return to normal dimensions. The patients who are skeletally immature had retarded bone ages and impaired growth of cortical bone. The general trend, though less marked, also showed a reduction in cortical bone in the skeletally mature patients. Surgery appears, at least partially, to alleviate the adverse effects of the disease on the growth and development of patients.

Carcinoma of the colon and rectum with liver involvement

The records of 126 patients with adenocarcinoma of the colon and rectum who presented with liver involvement were reviewed. Prognosis was determined by the amount of metastases to the liver, which was usually extensive of ascites or a raised alkaline phosphatase level was present. The longest survival period was achieved with resection of the primary tumor along with hepatic lesions confined to a single lobe, especially those due to direct tumor infiltration. If liver deposits were found bilaterally, palliative resection of the primary lesion relieved intestinal symptoms. This may also prolong the survival time, because a fixed primary tumor appeared to diminish the outlook among patients with comparable liver disease. Palliative resection in the presence of ascites resulted in a high mortality, and the survival rate was no better than that after diversion procedures. We recommend resection without anastomosis for carcinoma of the rectosigmoid in patients with ascites and unresectable secondary lesions of the liver.

The bacteriology of recurrent pyogenic cholangitis and associated diseases

Ninety-five patients with recurrent pyogenic cholangitis had a range of specimens taken at laparotomy for bacterial culture. Bacteria were isolated from 68% of cases. Escherichia coli was the predominant pathogen. Other aerobic and anaerobic intestinal bacteria were also isolated. Liver biopsy, bile and gallstones were the most rewarding specimens for culture. Infection was usually localized, but systemic infection occurred occasionally. The site of infection is probably in the liver parenchyma; however, the route by which intestinal bacteria invade the liver is not known. Sixty per cent of the cases of recurrent pyogenic cholangitis had gallstones and 20% were infected with Clonorchis sinensis.

The treatment of second degree haemorrhoids by injection, rubber band ligation, maximal anal dilatation, and haemorrhoidectomy: a prospective clinical trial

One hundred and twenty patients with confirmed second degree haemorrhoids were randomly allocated to four treatment groups; injection, rubber band ligation, maximal anal dilatation, and haemorrhoidectomy. Each groups consisted of 30 patients. All patients were regularly followed up for at least one year. Assessment at one year showed that haemorrhoidectomy "cured" the haemorrhoids in 29 out of 30 patients. Rubber band ligation relieved 25 out of 30 and maximal anal dilatation 24 out of 30. Injection was the least effective treatment, and relieved 18 of the 30 patients, with a cure rate of 60% only. Haemorrhoidectomy caused pain in all cases, anal stenosis in two, postoperative haemorrhage in two, and the patients required an average hospital stay of 11.5 days and an average of a further 15.5 days off work. Rubber band ligation was painless in 26 patients out of 30, and maximal anal dilatation was painless in 25 our of 30. There were no postoperative complications in the latter two treatment groups. Haemorrhoidectomy is good in "curing" the disease, but the higher possibility of postoperative pain and complications and longer hospital stay would not justify its use in the treatment of second degree haemorrhoids. Both rubber band ligation and maximal anal dilatation are effective and relatively free from complications. Rubber band ligation has the additional advantage of not requiring hospital stay or anaesthesia and is therefore considered to be the most appropriate method of treatment for second degree haemorrhoids.