BACKGROUND: One of the most promising but unexplored methods for treating patients with irresectable liver tumours is electrolysis. This study examined the effect of increasing 'current dose' on the volume of the lesion induced in normal rat liver. METHODS: A direct current generator, connected to platinum electrodes implanted in the rat liver, was used to examine the effect of (1) varying current doses from 1 to 5 coulombs and (2) electrode separation (2 or 20 mm), on the volume of liver necrosis. RESULTS: There was a significant correlation (P < 0.001) between the current dose and the volume of necrosis produced for each electrode separation. Placing the electrodes 2 mm apart resulted in smaller total volumes of necrosis than placing them 20 mm apart when anode lesions were significantly larger than cathode lesions (P< 0.05). Liver enzymes (aspartate aminotransferase, alanine aminotransferase) were significantly raised 1 day after treatment (P < 0.001) and predicted the total volume of hepatic necrosis (P < 0.001). CONCLUSION: Predictable and reproducible areas of liver necrosis are produced with electrolysis. If these results extrapolate to larger animal models, this technique has potential for patients with irresectable primary and secondary liver tumours.

Animals↗

PubMed1998

Electrochemically induced hepatic necrosis: the next step forward in patients with unresectable liver tumours?

BACKGROUND: The treatment of patients with unresectable liver tumours remains an unsolved clinical problem. Several methods of locoregional treatment have been developed. These methods rely mainly on direct thermal or chemical insults and consequently have their own inherent limitations in clinical usage. The 'ideal' treatment would combine the direct cytotoxic effects of chemical treatments with the relative predictability of thermal insults, without the associated complications. This study aims to investigate whether the direct chemical effect of electrolytic hepatic necrosis is associated with any heating effect, and if so, whether the temperature change is dose-dependent. METHODS: An electrolytic 'dose' sufficient to induce a localized zone of hepatic necrosis was delivered to the livers of rats and pigs via implanted platinum electrodes. RESULTS: The results showed that there was no significant temperature increase at low current levels (2-4 mA) in the rat liver. In the pig, there was a significant (P < 0.01) increase in temperature of 4.2 degrees C during electrolysis, when delivered at between 20 and 50 mA. However, such a small increase in temperature would have been insufficient to cause appreciable thermal necrosis. CONCLUSIONS: This study demonstrates that electrolysis-induced hepatic necrosis is produced without an increase in temperature; clearly cell death results from the direct effects of cytotoxic electrode products and an alteration of intracellular pH. Consequently, it is likely that as a method for ablating liver tumours, electrolysis should be associated with fewer complications than other forms of locoregional treatment.

Animals↗

PubMed1996

Palliation of oesophageal carcinoma using the argon beam coagulator.

Oesophageal intubation occasionally fails to palliate inoperable carcinoma: some tumours are unsuitable for this procedure and others overgrow the tube. This study reports a series of nine patients (median age 79 (range 55-87) years) in whom the argon beam monopolar coagulator via a flexible endoscopic probe was used to ablate such tumours. Fourteen ablation procedures were performed. The endoscope was passed to the stomach at the end of each procedure. There were no complications; the median hospital stay was 2 (range 1-13) days. Thirteen procedures rendered the patients completely asymptomatic for a median of 6 (range 4-12) weeks. Six patients died a median of 14 (range 4-38) weeks after the first ablation, reflecting their limited life expectancy. The argon beam coagulator provides an effective alternative to laser ablation, being considerably cheaper and safer, while maintaining the minimally invasive nature of the palliation.

Aged↗

PubMed1996

A prospective audit of simple mastectomy under local anaesthesia.

The treatment options for breast cancer in elderly or unfit patients can be complicated by their coexistent medical problems. This study assesses the feasibility of simple mastectomy under local anaesthesia by means of a prospective audit on 36 patients with breast carcinoma and an ASA grade of 3 or worse. In 27 patients the tumour had escaped from tamoxifen control, no patients having had previous radiotherapy. Operation time ranged from 40 to 70 min, average blood loss was 200 ml and an average inpatient stay of 5 days. Only two patients had a resection margin less than 1 cm and in none was there significant morbidity or mortality despite the patients' poor pre-operative medical condition. This confirms the potential of using local anaesthetic for simple mastectomy. Eliminating the morbidity/mortality due to general anaesthesia widens the range of treatment available (especially to medically unfit patients) giving them the option of a rapid resolution to what could be a distressing protracted condition.

Adult↗

PubMed1996

The role of the radiologist in surgical management: an audit of clinico-radiological conferences.

A prospective analysis of the radiological findings and final diagnoses of 342 patients discussed at joint surgical/radiological conferences over a seven-month period was undertaken in an attempt to define the role of the radiologist in the clinical management of surgical patients. Although the diagnosis had already been correctly made on clinical or radiological grounds in 38% (130/342) of patients presented at the X-ray conferences, careful review of the films resulted in an immediate firm diagnosis in a further 9% (31/342), or promoted further radiological investigations which were responsible for an eventual definitive diagnosis in 20% of the remainder (32/169). The input of the radiologist in selecting the most appropriate additional investigation was particularly valuable in the management of more complex clinical problems.

Critical Pathways↗

PubMed1996

Randomized comparison of oral and intravenous fluid regimens after gallbladder surgery.

Numerous studies of post-operative fluid status have utilized sophisticated measurements of electrolyte distribution and fluid shift without relating results to clinical practice. The aim of this prospective randomized study was to investigate the response of patients undergoing abdominal surgery of moderate severity to conservative post-operative fluid administration. Forty-five patients undergoing open cholecystectomy were randomized to receive 2.51 of fluid (1 l normal saline and 1.51 5% dextrose), 1 l of normal saline, or free oral fluids (groups 1, 2, 3, respectively). Serum and urine osmolality and electrolytes were measured pre-operatively and at 24 and 48 h post-operatively. Patients remained in the study irrespective of the urine output. Plasma electrolytes and osmolality remained within normal limits in all three groups despite significant changes in urine electrolyte and osmolality in groups 2 and 3. This confirms that a conservative approach to fluid administration has no detrimental effect on hydration in fit patients with uncomplicated surgery.

Adult↗

PubMed1996

Case report: bladder opacification following enteral iopamidol as a sign of occult intestinal infarction.

A case of intestinal infarction due to superior mesenteric artery embolism is described in a 30-year-old female with Crohn's disease. This was accompanied by bladder opacification following enteral iopamidol administered at endoscopic retrograde cholangiopancreatography. The likely mechanism of this finding is transmural and transperitoneal absorption of enteral contrast medium and its significance as a sign of mesenteric ischaemia is discussed.

Adult↗

PubMed1996

New thoughts on the aetiology of haemorrhoids and the development of non-operative methods for their management.

Haemorrhoids constitute a frequent clinical problem. A variety of conservative treatment options have been proposed, the majority of which can be safely performed on an outpatient basis. Haemorrhoidectomy, however, remains the ultimate treatment for large, third degree haemorrhoids.

Constipation↗

PubMed1995

What should I do about my patient's gall stones?

The problem of benign biliary disease is one that causes significant morbidity and social economic strain in the western world. The classical treatment, cholecystectomy, has been challenged by various medical and surgical techniques in a seemingly random nature. The development of the treatment of gall stone disease is reviewed by analysis of published studies over the last 20 years. The advantages and disadvantages are discussed as an overview and summary of the current management of gall stone disease in the light of our knowledge of its malignant potential.

Chenodeoxycholic Acid↗

PubMed1994

The effect of communication between the right and left liver on the outcome of surgical drainage for jaundice due to malignant obstruction at the hilus of the liver.

Debate continues regarding the optimal management of irresectable malignant proximal biliary obstruction. Controversy exists concerning the ability of unilateral drainage to provide adequate biliary decompression with tumors that have occluded the communication between the right and left hepatic ductal systems. Between October 1986 and October 1989, 18 patients with malignant proximal biliary obstruction were treated by an intrahepatic biliary enteric bypass. Patients were divided into two groups based on the presence or absence of a communication between the right and left biliary systems. In Group I (n = 9), there was free communication; and in Group II (n = 9) there was no communication. There were two perioperative deaths (11%) one due to persistent cholangitis and the other to myocardial insufficiency both with one death in each group. The median survival (excluding perioperative deaths) was 5.6 months. Comparison of pre- and postoperative serum levels of bilirubin and alkaline phosphatase showed a significant decrease in each group, but no difference between the groups in the size of the reduction. Sixteen patients survived at least three months and the palliation was judged as excellent in eight, fair in five, and unchanged in three. These results demonstrate the effectiveness of biliary enteric bypass regardless of communication between the left and right biliary ductal systems.

Adult↗

PubMed1993

Who's afraid of informed consent?

OBJECTIVE: To test the assumption that patients will become unduly anxious if they are given detailed information about the risks of surgery in an attempt to obtain fully informed consent. DESIGN: Preoperative anxiety assessed before and after patients were randomly allocated an information sheet containing either simple or detailed descriptions of possible postoperative complications. SETTING: Four surgical wards at two Sheffield hospitals. SUBJECTS: 96 men undergoing elective inguinal hernia repair under general anaesthesia. MAIN OUTCOME MEASURE: Change in anxiety level observed after receiving information about potential complications. RESULTS: Detailed information did not increase patient anxiety (mean Spielberger score at baseline 33.7 (95% confidence interval 31.3 to 36.2), after information 34.8 (32.1 to 37.5); p = 0.20, paired t test). A simple explanation of the facts provided a statistically significant degree of reassurance (mean score at baseline 34.6 (31.5 to 37.6), after information 32.3 (29.8 to 34.9); p = 0.012), although this small effect is likely to be clinically important only in those whose baseline anxiety was high (r = 0.27, p = 0.05). CONCLUSIONS: In men undergoing elective inguinal hernia repair a very detailed account of what might go wrong does not increase patient anxiety significantly and has the advantage of allowing patients a fully informed choice before they consent to surgery, thus reducing the potential for subsequent litigation.

Anxiety↗

PubMed1993

Extended left hepatectomy: technical aspects of an evolving procedure.

Lessons learned in an operative experience of 14 patients submitted to extended left hepatectomy for the management of liver tumours are presented. There were no deaths within 30 days of operation. Essential preoperative studies, indications and technical details of the operation are described. The importance of the morphology of the tumour and the influence of the tumour on the technique to be adopted are emphasized. Modifications of technique that allow selection of patients for the procedure, control of venous bleeding, accurate identification of the sectorial portal pedicles within the right liver and definition of the plane of parenchymal transection are addressed.

Hepatectomy↗

PubMed1993

Trivial chest injury: a case for vigilance.

Explore the source record for details and available documents.

Accidental Falls↗

PubMed1993

Improvements in survival by aggressive resections of hilar cholangiocarcinoma.

The operative management of hilar cholangiocarcinoma has evolved because of advances in diagnostic imaging that have permitted improved patient selection, and refinements in operative techniques that have lowered operative mortality rates. Over a 4-year period, 48 patients with hilar cholangiocarcinoma were managed. Twenty-seven patients were treated by palliative measures. Preoperative investigation identified 29 patients who were judged fit for operation without proven irresectability by radiologic studies, and 21 of the 29 patients had tumor removal (72%). Twenty-three operative procedures were performed: local excision (n = 12) (two had subsequent hepatic resection), and hepatic resection primarily (n = 9). Eight patients had complications (35%), and one patient died (4.3%). The mean actuarial survival after local excision in 36 months, and after hepatic resection, 32 months. Palliation as assessed by personal interview was excellent for more than 75% of the months of survival. A combination of careful patient selection and complete radiologic assessment will allow an increased proportion of patients to be resected by complex operative procedures with low mortality rate, acceptable morbidity rate, and an increase in survival with an improved quality of life.

Actuarial Analysis↗