The impact of injuries below the knee joint on the long-term functional outcome following polytrauma

Previous studies have suggested that the lower-extremities are among the most frequently injured body regions in polytrauma patients and have a major impact on the functional recovery following polytrauma. In particular, injuries to the distal part of the lower-extremity appear to be associated with a poor functional outcome. Therefore, the goal of this study was to evaluate the impact of injuries below the knee joint on the long-term functional outcome following polytrauma. Three hundred eighty-nine polytrauma patients with associated lower-extremity fractures and a minimum follow-up of 10 years were included in this study. All patients were examined by a doctor, using a patient questionnaire and a standardised physical examination. Significantly, inferior outcomes were seen in patients with fractures below the knee joint as measured by the modified Karlström-Olerud score, Lysholm score, range of motion, weight bearing status, Hannover score for polytrauma outcome (HASPOC), SF-12, Tegner activity score, and inability to work (P < 0.05). Fractures below the knee joint have a significant impact on the functional recovery following polytrauma. We suggest that delayed treatment, thin soft tissue envelope below the knee joint, high-energy trauma, unfavorable blood supply, and complex fracture patterns contribute to these unfavorable outcomes.

A randomised controlled trial of transverse skin crease vs. vertical midline incision for right hemicolectomy

BACKGROUND

A transverse skin crease incision for right hemicolectomy may result in more rapid recovery than traditional vertical midline incision. This hypothesis was tested with a prospective randomised trial.

METHODS

Patients from 2 centres undergoing right hemicolectomy were randomised to received a midline or transverse incision. Incision lengths were sufficient to enable unrestricted resection of the right colon. Patients and carers were blinded to the incisions using strategically placed dressings. Analgesia and oral intake were controlled by the patient. Operative details and recovery parameters were compared.

RESULTS

A total of 28 patients were randomised. Demographic data and tumour characteristics of the two treatment groups were similar. The transverse incision group had a slightly shorter median wound (10 cm vs. 11 cm, p<0.05). Operative time, analgesia requirements, recovery parameters (time to discharge, 6.5 vs. 6.5 days) and frequency of complications were otherwise comparable.

CONCLUSIONS

A transverse skin crease incision for right hemicolectomy results in a slightly smaller wound but no other advantages were demonstrated compared with a traditional vertical midline incision.

The correlation between ion beam/material interactions and practical FIB specimen preparation

The focused ion beam (FIB) tool has been successfully used as both a stand alone analytical instrument and a means to prepare specimens for subsequent analysis by SEM, TEM, SIMS, XPS, and AUGER. In this work, special emphasis is given to TEM specimen preparation by the FIB lift-out technique. The fundamental ion/solid interactions that govern the FIB milling process are examined and discussed with respect to the preparation of electron transparent membranes. TRIM, a Monte Carlo simulation code, is used to physically model variables that influence FIB sputtering behavior. The results of such computer generated models are compared with empirical observations in a number of materials processed with an FEI 611 FIB workstation. The roles of incident ion attack angle, beam current, trench geometry, raster pattern, and target-material-dependent removal rates are considered. These interrelationships are used to explain observed phenomena and predict expected milling behaviors, thus increasing the potential for the FIB to be used more efficiently with reproducible results.

Comparison between midline incision and limited right skin crease incision for right-sided colonic cancers

We compared the postoperative recovery parameters between patients undergoing curative surgery for right-sided colonic carcinoma using a limited skin crease incision and a traditional midline incision. A retrospective study was carried out analyzing clinical records and histopathological reports for all patients operated in one colorectal surgical unit for cancer of the right colon over a 2-year period. Palliative procedures were excluded. We analyzed demographic details, operative data (length of incision and time of operation), recovery parameters (time to parenteral analgesia, time to first oral fluid intake, time to first solid meal, time to discharge) and oncological parameters (lymph node harvest and resection margins). A total of 123 patients were analyzed, 61 with a midline incision and 62 with a skin crease incision. Demographic and tumour data (number of lymph nodes resected and resection margins) as well as postoperative complications were similar between the two groups. Wound length was significantly longer in the midline incision group (median, 20 cm vs. 10 cm; p<0.0005), as was the duration of surgery (median, 60 min vs. 45 min; p0.0005). With regard to postoperative recovery, the skin crease incision group had a significantly quicker return of bowel function ( p<0.0005), shorter time to oral fluid ( p<0.001) and solid food ( p<0.0005) intake, and shorter hospital stay ( p<0.0005) than the midline incision group. There was no statistically significant difference between the two groups concerning postoperative narcotic requirements. In conclusion, the limited skin crease approach for right colon cancer resection is technically feasible and safe. It can achieve the same standards of tumour resection and clearance as the vertical midline approach while reducing postoperative recovery.

A prospective randomised study of drains in infra-peritoneal rectal anastomoses

Although increasing evidence suggests that prophylactic drainage after intra-peritoneal colorectal anastomoses is unnecessary, drains for infra-peritoneal rectal anastomoses, where the leak rate is higher, are widely employed still. The aim of this study was to assess the effect of prophylactic drainage after anastomosis below the peritoneal reflection. All patients attending one specialist unit over an 8-month period for elective rectal cancer resection with an infra-peritoneal anastomosis were randomised to drainage or no drainage. The incidence of anastomotic leak and complications specific to the drain as well as other complications were compared. Fifty-nine patients were analysed (31 with drain). Twenty-five of the drained and 16 of the no-drain patients had a defunctioning stoma (p=ns). The groups were comparable for demographic data, operation and anastomotic height from the anal verge. There were three leaks (10%) in the drain group and five leaks (18%) in the no-drain group (p=ns). There were 2 (7%) patients in each group with a clinical leak. There were no specific drain complications and the incidence of other complications was similar in both groups. In conclusion, this study supports the contention that there is no difference in morbidity with or without the use of a drain for infra-peritoneal anastomoses.

Stapled mucosectomy for acute thrombosed circumferentially prolapsed piles: a prospective randomized comparison with conventional haemorrhoidectomy

OBJECTIVE

Stapled mucosectomy has been developed as an alternative to conventional haemorrhoidectomy for the elective treatment of haemorrhoids, but has not been assessed in the emergency setting. The aim of this study was to compare this technique with a conventional procedure for acute thrombosed circumferential prolapsed haemorrhoids.

PATIENTS AND METHODS

A prospective randomized comparison of conventional Milligan-Morgan haemorrhoidectomy and stapled mucosectomy was carried out on 35 consecutive patients presenting with acute thrombosed circumferential prolapsed haemorrhoids. Operative data, postoperative stay, pain assessment and persistent symptoms were compared at discharge and at 2 week and 6 week review. Additionally at 6 week review the time to return to work was recorded and an endoanal ultrasound was carried out.

RESULTS

Thirty patients were randomized and followed up for six weeks. Although postoperative stay and in-hospital analgesia were the same, patients from the stapled group reported significantly more pain at discharge. However, by 2 weeks the conventional group reported significantly higher pain scores particularly on passing stool. By this stage over half the stapled group patients reported no pain at all. More patients in the conventional group complained of persistent symptoms of pain, bleeding and discharge at 2 week and 6 week review with 20% requiring readmission compared with none in the stapled group. The median return to work was significantly shorter for the stapled group (14 days vs 28 days, P < 0.05). Although all patients claimed to be continent, two patients from each group had ultrasonic evidence of internal sphincter damage.

CONCLUSION

Stapled mucosectomy for acute thrombosed circumferential piles is feasible and may result in less pain, a more rapid resolution of symptoms and an earlier return to work compared with a conventional procedure.

Biofeedback avoids surgery in patients with slow-transit constipation: report of four cases

Biofeedback is established treatment for intractable constipation in patients with an element of pelvic floor dysfunction. In those with intractable slow-transit constipation and normal pelvic floor function, colectomy is usually recommended. We report four patients with isolated slow-transit constipation who benefited from biofeedback and avoided surgery. All four patients were extensively investigated for pelvic floor dysfunction before undergoing a standard biofeedback course of four outpatient sessions. All improved in terms of bowel frequency, laxative use, bloating, straining, and lifestyle. Improvement has been maintained for a median of nine (range, 5-12) months without the requirement for further treatment. Biofeedback represents a safe and inexpensive treatment for these patients and may avoid surgery in a significant proportion.

Consecutive series of laparoscopic-assisted vs. minilaparotomy restorative proctocolectomies

PURPOSE

Compared with open restorative proctocolectomy, laparoscopic procedures may reduce postoperative recovery times and give a more cosmetically acceptable scar, but operative time may be prolonged. We describe a minilaparotomy technique for restorative proctocolectomy and compare recovery parameters with a laparoscopic procedure.

METHODS

A consecutive series of patients undergoing laparoscopic-assisted restorative proctocolectomy were compared with a subsequent consecutive series of patients undergoing a minilaparotomy procedure. This method incorporates a suprapubic incision. Mobilization of the colon is performed in the usual manner with visualization of less accessible areas made possible by using an illuminated St. Mark's retractor. Operative and recovery parameters were analyzed for each group retrospectively.

RESULTS

Twenty-five patients were compared (12 in the laparoscopic group). Wound length was significantly longer in the open group (median, 14 vs. 8.5 cm; P < 0.01), but operative times were shorter (median, 120 vs. 150 minutes; P < 0.01). There were no differences in any of the recovery parameters analyzed, including analgesic requirements, time to ileostomy function, first fluid intake, time to solid diet, length of hospital stay, and complications.

CONCLUSION

The only advantage of a laparoscopic-assisted procedure over a minilaparotomy technique was the size of the wound. The minilaparotomy restorative proctocolectomy achieves the same postoperative recovery parameters and has a shorter operative time. This technique is recommended for surgeons less experienced in laparoscopy.

Efficacy of moxidectin 2 per cent gel against naturally acquired strongyle infections in horses, with particular reference to larval cyathostomes

The efficacy of moxidectin 2 per cent equine gel against naturally acquired strongyle infections was assessed in 18 ponies which had grazed on contaminated pasture before being housed for eight weeks. Twenty-four hours before the treatment, two randomly selected ponies were euthanased and their worm burdens were determined. Eight of the remaining 16 ponies were treated with moxidectin 2 per cent gel while the other eight were given a placebo gel. Eight weeks later the 16 animals were necropsied and their worm burdens established. A 100 per cent efficacy was recorded against adult and lumenal L4 cyathostomes and adult Strongylus and Triodontophorus species. Digest recoveries of larval cyathostomes indicated a 90.8 per cent (P<0.002) reduction in early L3 and a 99.9 per cent (P<0.001) reduction in developing stages. There was a reduction in faecal egg output of between 96 and 100 per cent in the treated animals compared with the controls.

Tip-of-the-tongue phenomena: an introductory phenomenological analysis

The issue of meaningful yet unexpressed background-to language and to our experiences of the body-is one whose exploration is still in its infancy. There are various aspects of "invisible," implicit, or background experiences which have been investigated from the viewpoints of phenomenology, cognitive psychology, and linguistics. I will argue that James's concept of the phenomenon of fringes, as explicated by Gurwitsch, provides a structural framework from which to investigate and better understand ideas and concepts that are indeterminate, particularly those experienced in the sense of being sought-after. Johnson's conception of the image-schematic gestalt (ISG) provides an approach to bridging the descriptive gap between phenomenology and cognitive psychology. Starting from an analysis of the fringes, I will turn to a consideration of the tip-of-tongue (TOT) state, as a kind of feeling-of-knowing (FOK) state, from a variety of approaches, focusing mainly on cognitive psychology and phenomenology. I will then integrate a phenomenological analysis of these experiences, from the James/Gurwitsch structural viewpoint, with a cognitive/phenomenological analysis in terms of ISGs, and further integrate that with a cognitive/functional analysis of the relation between consciousness and retrieval, employing Anderson et al's theory of inhibitory mechanisms in cognition. This synthesis of these viewpoints will be employed to explore the thesis that the TOT state and similar experiences may relate to the gestalt nature of schemas, and that figure/ground and other contrast-enhancing structures may be both explanatory and descriptive characterizations of the field of consciousness.

Preservation of rectal function after low anterior resection with formation of a neorectum

Recent advances in surgery have enabled low rectal cancers to be resected, while at the same time restoring bowel continuity and preserving the anal sphincter. Although a permanent stoma is avoided and the operation is oncologically sound, function may be compromised. Many patients with a straight coloanal anstomosis suffer from urgency, incontinence, and bowel frequency-the so-called anterior resection syndrome. Over the last 15 years, surgical developments have aimed at improving function after restoration of bowel continuity, essentially by creating a neorectum. The best known and most widely practiced operation involves formation of a colonic J-pouch. The physiological and functional outcomes of the colonic J-pouch are discussed, along with controversies surrounding construction. Although a J-pouch improves some aspects of function, the results are not perfect. Alternatives to the colonic J-pouch are appraised, indicating future areas of development.

Encephalomyelitis associated with a Sarcocystis neurona-like organism in a sea otter

An adult female sea otter housed for 5 years in an outdoor habitat in an aquarium developed signs of neurologic disease. Bilateral caudal paresis was evident initially and other neurologic signs consistent with CNS disease developed rapidly. Diagnostic work-up included CBC, serum biochemical analyses, determination of serum antibody titers, radiography of the vertebral column, CSF analysis, muscle biopsy, computed tomography of the brain, and assays for mercury, lead, and thiamine. A tentative diagnosis of encephalitis caused by a Sarcocystis neurona-like organism was made on the basis of detection of CSF antibodies by use of Western blot analysis. Response to treatment was not satisfactory and the sea otter was euthanatized. Immunohistochemical staining revealed S neurona-like organisms within foci of inflammation in the brain and spinal cord. This report provides evidence that, for sea otters, there may be a mode of transmission of an S neurona-like organism that does not involve opossums.

Squamous cell carcinoma of the colon in an asbestos worker

We report a case of squamous cell carcinoma of the colon in an asbestos worker. We speculate whether the asbestos exposure could have been causative and review the literature.

The use of a proforma improves colorectal cancer pathology reporting

The detail and accuracy of pathological reporting for colorectal cancer is becoming increasingly recognised as important in the overall management of the patient. However, there is criticism of the variable standards of reporting. We assessed how the use of a proforma affected the completeness of reporting within one hospital. Data on all colorectal cancer patients attending one teaching hospital has been collected prospectively over a 15 month period from 1997 to 1998. The Royal College of Surgeons/Association of Coloproctology proforma lists all items considered to be essential for a complete pathological report of colorectal cancer. Its introduction in September 1997 allowed us to compare reporting before the proforma to that after. Of 54 patients, 46 (85%) had one or more items missing from their report before introduction of the proforma compared with only 8/44 (18%) patients after the proforma (P < 0.001). Circumferential resection margins and apical node status were the items most often absent, being significantly more frequently reported after the proforma (P < 0.05 and P < 0.001, respectively). There was no difference in the median number of lymph nodes harvested after proforma introduction. The introduction of the proforma has not only resulted in improvements in reporting, but has increased the dialogue between surgical oncologists and pathologists. These features should result in improved overall management of the colorectal cancer patient.

Outcome after surgical resection for high-grade anal intraepithelial neoplasia (Bowen's disease)

BACKGROUND

High-grade anal intraepithelial neoplasia (Bowen's disease) may predispose to anal carcinoma. Treatment options include surgical resection but effectiveness remains uncertain. This paper reports long-term follow-up of patients with high-grade anal intraepithelial neoplasia treated by surgical resection.

METHODS

Between 1989 and 1996, 46 patients were identified with high-grade anal intraepithelial neoplasia. Thirty-four underwent local excision of all macroscopically abnormal disease and the resulting defect was left open, closed primarily or skin grafted. Regular follow-up subsequently included anoscopy and biopsy of any suspicious lesions.

RESULTS

Median follow-up was 41 (range 12-104) months. Total excision was difficult; 19 patients had histological evidence of incomplete excision at the time of initial resection. Some 12 of 19 had histo-logically proven recurrent high-grade intraepithelial neoplasia within 1 year. Even with microscopically complete excision two of 15 patients subsequently developed recurrent high-grade intraepithelial neoplasia at 6 and 32 months after operation. No patient developed carcinoma but five had complica-tions of anal stenosis or faecal incontinence.

CONCLUSION

Although no definite recommendations can be made for the treatment of high-grade anal intraepithelial neoplasia, these results illustrate some potential drawbacks of surgical excision with a high potential for incomplete excision and persistent disease, even after complete excision in some patients, and a high morbidity rate.

Are relatives of patients with multiple HNPCC spectrum tumours at increased risk of cancer?

BACKGROUND

Relatives of patients with early onset colorectal cancer, a feature of hereditary non-polyposis colorectal cancer (HNPCC), are at increased risk of colorectal cancer.

AIMS

To investigate risk in relatives of patients with multiple primary cancers, another feature of HNPCC.

METHODS

Details were obtained on patients from one region who had developed colorectal cancer and a separate primary from the HNPCC tumour spectrum (colorectal, stomach, urinary, ovary, endometrial). Overall, 157 patients had second primaries occurring between 1990 and 1995 and 128 completed family histories were obtained by structured interview (study group). A comparison group of 444 patients with a single colorectal cancer were similarly interviewed.

RESULTS

Fifteen families (13%) from the study group were suggestive of HNPCC compared with three (0.7%, p<0.0001) from the comparison group. Overall risk of colorectal cancer in close relatives of the study group was 3.4 times the general population rate compared with 1.8 times for the comparison group. Bowel cancer risk was even higher for relatives of bowel/ovary and bowel/endometrial subgroups, but was similar to the comparison group for the bowel/bowel subgroup. Finally, extracolonic HNPCC associated cancers were seen twice as frequently as expected in the general population in relatives of the study group.

CONCLUSION

This study highlights the importance of taking a family history in patients with multiple primary cancers and indicates the risk of malignancy in their relatives.

Frequency of replication errors in colorectal cancer and their association with family history

BACKGROUND

Replication errors (RERs) characterise tumours of hereditary non-polyposis colorectal cancer (HNPCC). RER status may therefore improve identification of such families previously diagnosed by family history alone.

AIMS

To assess RER and HNPCC frequency within a population of colorectal cancer patients and a regional population of family history defined (Amsterdam criteria) HNPCC families.

METHODS

Family history was assessed by personal interview in a population of 479 patients with colorectal cancer attending one follow up clinic. Seven fluorescently labelled microsatellites were used to investigate RER frequency in colorectal cancers from 89 patients of this population with varying degrees of family history and 20 Amsterdam criteria positive families (four with a known germline mutation, 16 with unknown mutation status) from the regional population.

RESULTS

Only four of the follow up population (0.8%) came from families meeting the Amsterdam criteria with only one showing RERs. The frequency of RERs was similar in the early onset cancer group (less than 50 years of age), those with a family history, and those with no family history of colorectal cancer. From the regional population, RERs were identified in 4/4 families with a mutation but only 8/16 families with unknown mutation status.

CONCLUSIONS

No correlation was seen between RER status and strength of family history except in HNPCC families. Results also indicate that half of the Amsterdam criteria defined families do not exhibit RERs, perhaps suggesting a different mechanism of tumorigenesis.

Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence?

PURPOSE

This study examines the prognostic significance of circumferential margin involvement by tumor in resected specimens after potentially curative rectal cancer surgery.

METHODS

During an eight-year period, all patients with rectal cancer were prospectively audited. For tumors of the middle and lower thirds of the rectum, a total mesorectal excision was performed; for tumor of the upper third, mesorectal excision proceeded at least 5 cm distal to the primary tumor. Resected specimens were subjected to careful histologic assessment, and patients undergoing curative procedures were entered into a surveillance program to detect both local and distant recurrence.

RESULTS

Of 218 patients in the cohort, 9 had no resection, 14 underwent local excision, 1 had pre-operative radiotherapy, and 42 patients (20 percent) had palliative resections and were excluded from further analysis. This left 152 patients having a curative resection, of whom 20 (13 percent) had tumor within 1 mm of the circumferential margin. After follow-up until death or a median period of 41 months, recurrent disease was seen in 24 percent of patients with a negative margin and 50 percent with a positive margin. Both disease-free survival and mortality were significantly related to margin involvement (log-rank, P = 0.01 and P = 0.005, respectively). Local recurrence, however, was not significantly different in the two groups (11 and 15 percent, respectively; log-rank, P = 0.38).

CONCLUSIONS

When mesorectal excision is performed, circumferential margin involvement is more an indicator of advance disease than inadequate local surgery. Patients with an involved margin may die from distant disease before local recurrence becomes apparent.