Surgical management of infantile hypertrophic pyloric stenosis--can it be performed by general surgeons?

INTRODUCTION

Debate exists as to whether IHPS can be treated in district general hospitals as effectively as in specialist paediatric surgical units.

AIM

To review the surgical treatment of IHPS in babies admitted to a district general hospital under the care of two consultant general surgeons with a paediatric surgical interest.

PATIENTS AND METHODS

The case notes of 66 babies operated on for IHPS over a 42 month period between April 1995 and September 1998 were retrospectively reviewed. Demographics, operative details, hospital stay, and overall complications were all documented.

RESULTS

Peri-operative complications occurred in 2 patients, both requiring omental patches for duodenal perforation. Nine patients had 1 or 2 episodes of postoperative vomiting; 4 had either a wound or urinary tract infection; and 1 baby developed an incisional hernia. There was no mortality.

DISCUSSION

The complication rate seen in this series is comparable to that of specialist centres, and supports current guidelines suggesting that IHPS can be managed by general surgeons with a paediatric surgical interest in a district general hospital.

Microdochectomy for single-duct discharge from the nipple

Microdochectomy has been the accepted treatment for single-duct nipple discharge. Review of 97 consecutive patients undergoing microdochectomy between 1980 and 1987 revealed a total of eight patients with ductal carcinoma in situ. All of these had pre-operative mammography, results of which were highly suspicious of malignancy in six patients. Tiny foci of ductal carcinoma in situ were found in the two patients with normal mammograms. We suggest an expectant policy in cases where the mammogram is normal, omitting routine microdochectomy.

Subcutaneous mastectomy for primary operable breast cancer

Subcutaneous mastectomy has been performed on 98 patients with primary breast cancer. Eighty-four have undergone breast reconstruction using a silicone prosthesis. The overall complication rate has been low. The rates of local recurrence and survival are similar to those in patients undergoing simple mastectomy.

Salivary cortisol and dehydroepiandrosterone sulphate levels in postmenopausal women with primary breast cancer

Cortisol and dehydroepiandrosterone sulphate (DHAS) were measured in saliva from postmenopausal women with primary breast cancer and a control group of comparable age. Specimens were collected at 2-hr intervals during wake-span for two consecutive days, and circadian rhythmicity was demonstrated for each of the hormones in both populations. The marginally elevated levels of cortisol and lower levels of DHAS associated with the cancer group, and the larger inter-subject variation, make it unlikely that these hormone measurements would be of value in identifying women at risk of developing breast cancer.

Initial results from a programme of breast self-examination

As part of a national study of early detection of breast cancer, 28663 women aged between 45 and 64 have been invited to attend a teaching programme on the method of self-examination with the advice to practise it regularly. This paper reports the early results of the Nottingham study on 14905 who have attended. To date there have been 717 self-referrals. One hundred and thirty-nine of these had a significant abnormality on either clinical examination or mammography and eight biopsies have been performed. Cancer was detected in 43 women. This is a detection rate of 2.9 cancers per 1000 educated. Mean tumour size was 2.3 cm (0.5-6.0 cm) and 56% were lymph node negative.

Prolactin and breast skin temperature rhythms in postmenopausal women with primary breast cancer

Plasma prolactin and cortisol were determined and breast skin temperatures measured in 8 postmenopausal diurnally active-nocturnally resting women, 7 with primary breast cancer and 1 with benign breast disease. In all subjects, prolactin peaked during the early morning hours. Cortisol and oral temperature served as internal physiological markers of anticipated rhythmicity in adrenocortical function and metabolism. In all patients studied, the tumour site had an increased mesor (midline-estimating statistic of rhythm) and reduced amplitude of the circadian breast skin temperature rhythm when compared to a similar site on the contralateral breast. Thermal asymmetry was also observed between left and right breasts. A cancer, if in the left breast, may reinforce lower amplitude and perhaps a higher mesor (associated with the healthy left breast in these particular patients), whereas if it is located in the right breast, it tends to nullify inter-mammary differences in mesor and amplitude. Screening for breast cancer appears to require subjects being monitored on at least two occasions before thermal abnormalities due to tumour or preneoplasia become discernible.

Delay in diagnosis and treatment of symptomatic colorectal cancer

Mean delay between the onset of symptoms and treatment was 30.5 weeks in a hundred patients with colonic carcinoma and 38 weeks in a hundred patients with rectal carcinoma. Most of this delay occurred outside hospital and delays attributable to the patient and family doctor were almost equal in duration. Patient delay is largely the result of not knowing the importance of bowel symptoms, while delay with the family doctor was the result of not examining patients with possible rectal carcinomas and not recognising symptoms suggestive of colonic carcinoma. 42% of patients with colonic carcinoma were admitted for emergency treatment, 76% having already consulted their doctor about symptoms on one or more occasions. Hospital delay consisted mainly in waiting for investigations, poor quality barium enemas, and inadequate sigmoidoscopy. There was no relation between the duration of symptoms and the Dukes stage of the tumour.