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Background The management of simultaneously occurring abdominal aortic aneurysm and intra-abdominal malignancy is controversial. It is unclear whether to treat the aneurysm first or the malignancy, or both simultaneously. If the malignancy is resected first there is a risk of postoperative rupture of the aneurysm. If simultaneous surgery is performed there is a risk of prosthetic graft infection from contamination by gastrointestinal or urinary tract contents. Methods Relevant papers from 1960 to 1996, identified from Medline and manual searching, were reviewed. Results and conclusion The literature supports the conclusion that the lesion of greater priority is that posing the greater threat to the patient; this is usually the aneurysm, especially if it is over 6 cm in diameter. For renal malignancies simultaneous surgery is the treatment of choice, but for bladder cancer the best management is unclear. Large aneurysms should usually be resected in preference to colorectal cancer unless the cancer is locally advanced, perforated or likely to result in early intestinal obstruction. If both lesions are complicated there may be a case for simultaneous treatment. [ABSTRACT FROM AUTHOR]

Background The studies on patient-reported symptoms and quality of life following the treatment of rectal cancer were evaluated; guidelines for future quality of life studies in this field are proposed. Methods Relevant papers in the English language were identified via Medline from January 1970 to November 1997, supplemented by a manual search for similar articles. Results Patients suffer various short- and long-term complications after treatment of rectal cancer, although the reported prevalence of such problems varies from study to study. Recent prospective studies have shown that, despite these problems, global quality of life scores as measured by generic questionnaires improve after surgery. Conclusion The methodological shortcomings of previous work must be rectified if quality of life studies are to have relevance in patient management. [ABSTRACT FROM AUTHOR]

Background This paper describes local anaesthetic saphenous disconnection in elderly patients for the treatment of venous ulceration in legs with either saphenous venous reflux alone or in combination with deep venous reflux. Methods Ambulatory venous pressure was measured in 16 legs with saphenous vein reflux alone and in nine legs with combined deep and saphenous venous reflux before, immediately after and 3 months after saphenofemoral or popliteal disconnection. Ulcer area was measured by computerized planimetry before surgery and at 1 and 3 months after operation. No compression bandages or hose were applied after surgery unless the ulcers had not begun to heal after 1 month. Results In legs with saphenous reflux alone all ulcers healed without compression bandages at a median of 81 (range 14–253) days and the pressure relief index (PRI) improved significantly both after surgery and at follow-up. None of the ulcers in the nine limbs with saphenous and deep venous reflux healed without compression bandaging and the PRI was unchanged immediately following surgery and at follow-up. Conclusion Saphenous vein disconnection improves venous function and heals venous ulcers without compression bandaging if the deep veins are normal. This procedure under local anaesthetic may be particularly suitable for elderly patients, but long saphenous vein stripping should be added in young patients. [ABSTRACT FROM AUTHOR]

Background Total mesorectal excision (TME) has been reported to reduce local recurrence and improve survival rates in patients with rectal carcinoma. This paper reports the problems that have arisen with the introduction of this new surgical technique. Methods This was a prospective study of two consecutive groups of patients: one who underwent TME (n=76) and one who did not (non-TME, n=76). Results Postoperative mortality rate in the non-TME and TME group was 5 and 7 per cent respectively, and the rate of anastomotic failure was 8 and 16 per cent respectively. Anastomotic leaks in TME patients were located in the mid and lower rectum. TME patients with anastomotic failure had lower anastomoses and a longer duration of operation than non-TME patients. Intraoperative problems were encountered in 71 per cent of the failures. All TME patients who had a leak required reoperation compared with 25 per cent of non-TME patients. TME patients without postoperative complications stayed significantly longer in hospital than non-TME patients. Conclusion Anastomotic dehiscence increased after introduction of the TME technique but this improved with experience. [ABSTRACT FROM AUTHOR]

The following abstracts are from the papers presented at the 31st Annual Conference of the Vascular Surgical Society of Great Britain and Ireland, held in London, UK, on 26–28 November 1997. President of the Society, Professor Averil O. Mansfield, was in the Chair. [ABSTRACT FROM AUTHOR]

Background Varices can develop in and around the bile duct in the presence of portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis. The term ‘portal biliopathy’ is used to describe changes in the bile duct due to these varices, which may cause bile duct obstruction. This paper reviews experience of the surgical management of patients with symptomatic portal biliopathy. Methods Nine patients with extrahepatic portal vein obstruction with symptomatic portal biliopathy were reviewed retrospectively. Results Eight patients presented with jaundice, two had abdominal pain and one had recurrent cholangitis. Endoscopic retrograde cholangiography revealed abnormality of the bile duct wall, with stricture in eight patients and bile duct calculi in two. Portasystemic shunting relieved jaundice in five of seven patients, and in two a second-stage hepaticojejunostomy was required. Conclusion Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary. [ABSTRACT FROM AUTHOR]

Background Advances in molecular pathology have enabled a number of colorectal cancer antigens to be identified and characterized. The commonest investigated include 17-1A, 791Tgp72 and carcinoembryonic antigen. Vaccines have been developed that stimulate the immune system to target these antigens. This paper reviews current areas of research in this field. Methods and Results Relevant articles were obtained on vaccines for colorectal cancer from Medline and the Bath Information Data System. A number of approaches are currently being evaluated in Phase I, II and III trials. These include anti-idiotypic antibody immunization, DNA vaccines, mucin and heat shock protein-based vaccines, oncogenes and viral vectors. Conclusion Evidence is accumulating to suggest that immune responses may be generated against colorectal cancer using these approaches. While the concept of vaccination against this malignancy is essentially experimental, surgeons should be aware of current advances. [ABSTRACT FROM AUTHOR]

I Editor i We write in reply to Arnold-Foster's insightful paper on resilience[1]. On this principle, Hackman and Vidmar analysed the number of people in a team and the number of one-to-one relationships or links they need to maintain[3]. It is not a coincidence that SAS patrol teams have four members and that four patrol teams make up a troop. [Extracted from the article]

I Editor i The necessity of preoperative blockade for patients with pheochromocytoma has been controversial over the past 15 years. Like most other retrospective studies on the question[2], the paper did not describe side-by-side the tumour characteristics of those who received blockade and those who did not, in most centres[1]. Indeed, data from the only centre where tumour details were provided show that patients were relatively young with relatively small tumours[1]. [Extracted from the article]

I Editor i We read with interest the paper of Lehrskov I et al i .[1] analysing the non-inferiority of intraoperative fluorescence cholangiography compared with X-ray cholangiography during elective laparoscopic cholecystectomy for complicated gallstone disease[1]. Acute cholecystitis was an exclusion criterion, but the authors conclude intraoperative fluorescence cholangiography may be beneficial in patients with acute cholecystitis. In addition to 15 per cent of patients in whom X-ray cholangiography was not performed, intraoperative fluorescence cholangiography was not able to identify the "critical junction" in 18 per cent (11 of 60), so neither of these methods can be an alternative to meticulous surgical preparation and conversion, if necessary. [Extracted from the article]

In their recent paper, Spinelli and Pellino talked about emergency surgery during the COVID-19 pandemic[1]. A 65-4 per cent decrease in emergency surgery activity was observed; the mean number of patients who underwent emergency surgery daily in each hospital decreased from 2-6 during the control period to 0-9 during pandemic period ( I P i < 0-001). Considering these results, those regions where the COVID-19 pandemic is now developing should assume that emergency surgery activity will decrease to one-third of normal. [Extracted from the article]

I Editor i We want to thank Lin Du and Hong-Lin Chen for their interest in our paper[1]. References 1 Haisley M, Sørensen JA, Sollie M. Postoperative pressure injuries in adults having surgery under general anaesthesia: systematic review of perioperative risk factors. [Extracted from the article]

I Editor i Thank you to Xue I et al i . for their review of our paper[1], highlighting common concerns regarding perioperative administration of intravenous contrast media. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. [Extracted from the article]

I Editor i We thank Jones and Baraza for their interest in our paper[1] and for highlighting the omission of the work of Hughes I et al i .[2] from the meta-analysis. The purpose of our review was to appraise the methodology and level of evidence of educational impact of studies assessing cadaveric simulation for postgraduate training. There remains a deficiency of objective evidence of skill transfer to the live operating theatre following cadaveric simulation training. [Extracted from the article]

I Editor i We thank Sall I et al i . for their comments on the 'Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society'[1]. Furthermore, a guideline should be evidence-based and there are no papers describing a "gold standard" method for open preperitoneal mesh repair for umbilical and epigastric hernias. [Extracted from the article]

Although the registry paper included 1000 patients, median follow-up was just 274 days and it is uncertain if all patients undergoing MSA were included and reported. The authors concluded that the device was safe, despite 32 per cent of MSA patients reporting dysphagia, and although no devices were explanted, follow-up was just 6 months. We undertook a detailed analysis over time of reporting of study design, clinical indications, technique standardization, governance arrangements and outcome selection, as an evaluation of how the innovative procedure progressed. [Extracted from the article]

Comment on: Performance of a modified three-level classification in stratifying open liver resection procedures in terms of complexity and postoperative morbidity Kawaguchi I et al i . recently described a three-level classification for stratifying complexity of open liver surgery[1] based on their previously published classification of laparoscopic liver operations[2]. But caudate resection and segmentectomy (Sg) 2/3 resection values are present in the utility method and these fall into the posterosuperior and anterolateral segment groups according to Kawaguchi I et al i .'s original paper[2]. [Extracted from the article]

One of the most popular papers on Twitter this month was Stellingwerf I et al i .'s study on appendicectomy for the treatment of therapy-refractory ulcerative colitis,[1] which received over 10 000 impressions. A Twitter poll showed that despite recent studies showing that antibiotics are unnecessary for uncomplicated diverticulitis[[2]] the majority still prescribe antibiotics in this context. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. [Extracted from the article]

Author response to: Comment on: Prospective cohort study of appendicectomy for treatment of therapy-refractory ulcerative colitis We thank Dai and Jiang for their interesting comment regarding our paper analysing the effect of appendicectomy in patients with refractory ulcerative colitis (UC)[1]. Prospective cohort study of appendicectomy for treatment of therapy-refractory ulcerative colitis. [Extracted from the article]

The Global Surgery Journal Club (@GlobalSurgeryJC) held another tweetchat on 10 August, in which they discussed a BJS paper from the special issue on Global Surgery on the use of the WHO Surgical Safety Checklist and mortality after emergency laparotomy[2]. BJS Editor @MalinASund shared slides from the Swedish Surgical Week in Norrköping, including talks by BJS Editor @ksoreide, and this year's BJS lecturer Dion Morton. Validation of a nomogram to predict the risk of cancer in patients with intraductal papillary mucinous neoplasm and main duct dilatation of 10 mm or less. [Extracted from the article]

Presents summaries of medical articles published in 1999 issues of the periodical 'Annales de Chirurgie,'. Paper on endocrine surgery; Treatment of children with severe duuodenopancreatic trauma.

SummaryBackground: Traditionally, left-sided colon obstruction is managed by a multistaged defunctioning colostomy and resection. However, there is growing acceptance of one-stage primary resection and anastomosis with on-table antegrade irrigation. This paper presents a series of patients managed prospectively by primary anastomosis without intraoperative colonic lavage. Methods: Emergency resection of acutely obstructed left-sided colonic carcinomas was performed. This was followed by primary anastomosis without on-table lavage after bowel decompression using a new technique. Results: Fifty-eight consecutive, unselected patients underwent bowel decompression, resection and primary colocolic anastomosis. Only one patient developed a leak at the anastomotic site, requiring pelvic abscess drainage and transverse loop colostomy. One death occurred 12 h following surgery. Autopsy confirmed that this was due to myocardial infarction. Mean hospital stay was 9·8 days. Conclusion: Emergency surgery on the obstructed left colon can be carried out safely after decompression alone, without intraoperative colonic lavage. [ABSTRACT FROM AUTHOR]

Background The ideal method for staging tumours of the oesophagus and gastric cardia is not known. This paper was designed to assess the value of laparoscopy and laparoscopic ultrasonography in the staging of oesophageal and cardial carcinoma. Methods From October 1993 to January 1996, 60 patients in whom no metastases were seen on gastroscopy, ultrasonography of the abdomen and supraclavicular region, helical computed tomography of the chest and abdomen or endosonography were scheduled for laparoscopy and laparoscopic ultrasonography. Results Some 40 patients had carcinoma of the oesophagus, in one of whom liver metastases were found at laparoscopy and proven histologically. On laparoscopic ultrasonography metastases were found in four patients but were impossible to biopsy. These lymph node metastases were confirmed at exploratory laparotomy. Twenty patients had carcinoma of the gastric cardia; distant metastases were found in four at laparoscopy. On laparoscopic ultrasonography metastases were present in four further patients, all proven by biopsy. Conclusion In this study laparoscopy was not an effective staging technique for oesophageal carcinoma. The inclusion of laparoscopic ultrasonography was of little benefit. A problem that was encountered was biopsy under laparoscopic guidance. In carcinoma of the gastric cardia, laparoscopy was more effective; adding laparoscopic ultrasonography doubled the number of patients seen to have metastatic disease. [ABSTRACT FROM AUTHOR]

Background Paraoesophageal hiatal hernia is relatively rare compared with sliding hernia but it is associated with serious complications. Its clinical management presents a major challenge since many patients are elderly and unfit for a formal repair. This paper describes a laparoscopic method aimed at reducing the complications of open repair. Methods Thirteen patients treated for symptomatic paraoesophageal hernia were included in the study. Eleven patients successfully underwent a simple laparoscopic modification of the Boerema anterior gastropexy. Two patients required an open anterior gastropexy through a minilaparotomy because of incomplete reduction of the hernia. A five-puncture technique was used. The stomach and any other contents of the sac were reduced into the abdomen and the stomach was firmly fixed to the fascia of the anterior abdominal wall with Gore-Tex sutures tied extracorporeally. Results There was one postoperative death due to spontaneous intrathoracic perforation of the posterior aspect of the stomach in an elderly woman with severe cardiac disease. There was no postoperative morbidity. Eight of the ten patients who went home following laparoscopic gastropexy have remained asymptomatic on follow-up. In three patients, two in the laparoscopic group and one in the open group, symptoms recurred. Conclusion While anterior gastropexy has a significant incidence of recurrent herniation, the clinical results of this simple procedure in a high-risk population support its use as the initial surgical option. [ABSTRACT FROM AUTHOR]

Reviews of research papers on topics including prophylactic mesh does not prevent hernia during colostomy, operative surgery for diverticulitis, and comparison between laparoscopic and open adhesiolysis for small bowel obstruction is provided.

The article lists several research papers about clinical trials in surgery which were added to the scientific surgery archive of the journal "British Journal of Surgery".

The article presents biographies of several speakers related surgical field of medicine including Sam Alberti, Robert D. Madoff and A. Darzi. It informs about Alberti who is director of Museums and Archives at the Royal College of Surgeons of England and organizes exhibitions on race, museum history and the Hunterian Museum's bicentenary. It mentions about Madoff who is a professor of Surgery at the University of Minnesota and has published academic research papers in medical journals.

A response by O. Fraiz, E Burns and J. Nicholls to a letter to the editor about their paper "Volume Analysis of Outcome Following Restorative Proctocolectomy" in a 2011 issue of the "British Journal of Surgery" is presented.

The article presents information on a paper titled "Pathogenesis and Treatment of Fistula-in-ano," by professor Alan Parks, which was published in the "British Journal of Surgery" in 1961. Parks introduced the concept of the origin of anal fistula as based on the anal glands of the intersphincteric space. The article also explains the inability of sepsis to drain into the anal canal which may be attributed to the obstruction of the ducts.

Comments on an paper entitled 'Probiotics,' released in a 2001 issue of the 'British Journal of Surgery.' Composition and interactions of gut bacteria; Involvement of bacteria in the etiology of inflammatory bowel disease (IBD); Effectiveness of a single probiotic in every case of IBD; Results of treatment with lactobacillus plantarum.

The author discusses a study which explores the short-term benefits of laparoscopic subtotal colectomy in patients with inflammatory bowel disease (IBD). The author believes that the study's findings are important in determining the role of laparoscopic approach in acute and subacute conditions. The author mentions the lack of randomized trials and clear definitions of complications as the paper's major limitation.

A letter to the editor is presented in response to the paper "Volume Analysis of Outcome Following Restorative Proctocolectomy" in a 2011 issue of the "British Journal of Surgery."

The author comments on the article "Systematic Review and Meta-Analysis of Steatosis as a Risk Factor in Major Hepatic Resection," by V. E. de Meijer, et al, which appeared in the September 2010 issue. According to the author, the presence of non-alcoholic fatty liver disease and hepatic steatosis in the livers of patients that require resection has a significant impact on postoperative course. The risk of morbidity and mortality in patients, which is addressed in the article, is discussed. Overall, the paper's informative discussion is praised.

The following abstracts are from papers presented at the 43rd annual scientific meeting of the Vascular Society of Great Britain and Ireland, held in Bournemouth 12-14 November 2008. The President of the Society, Mr MJ Gough, was in the Chair. The BJS Prize was won by Mr TY Tang from Cambridge University Hospital, and the Founder's Prize was won by Mr PJE Holt from St George's Regional Vascular Institute, London. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Aims: Intestinal intubation with a Jones tube has been suggested as a way to reduce the incidence of recurrent adhesive small bowel obstruction by allowing the subsequent adhesions to form in a favorable position. This paper aims to assess the success and long term outcome of this technique using a retrospective study. Methods: A case-note review was performed on all the patients who were identified as having the Jones intestinal tube placed over an eleven year period from 1980 to 1991, with a follow up to 2001, yielding a total of 56 patients. The indication for placement and outcome following placement of the tube were documented with particular reference to recurrence of adhesive obstruction. Results: Data on 46 patients were available, with a median follow up of 92 months representing 353 patient years: 34 patients had the tube placed during emergency surgery for division of adhesions; 12 patients had the tube placed on an elective basis of which 7 had the Jones tube placed as prophylaxis against adhesive obstruction during formation of a Parks pouch, the remaining 5 having the tube placed for recurrent small bowel obstruction. Four patients in total had recurrent small bowel obstruction; two of these had intervening surgery not related to adhesive obstruction. Conclusion: Intestinal intubation with a Jones tube is a safe and effective method of preventing recurrent adhesive obstruction. It is also effective prophylactically where the initial surgery is likely to result in multiple adhesions. [ABSTRACT FROM AUTHOR]

Comments on an article by F.F. Palazzo, D.L. Francis, D. Lawes and M. Clifton on the randomized clinical trial comparing loop ileostomy and loop transverse colostomy for fecal diversion following total mesorectal excision, published in the August 2002 issue of the journal 'British Journal of Surgery.' Concerns regarding the methodology given in the paper; Authors' failure to define primary and secondary endpoints.

Aims: The best management of patients with either thrombosed or nonthrombosed popliteal aneurysms has yet to be established. This paper describes our experience managing such aneurysms. Methods: A prospective study was carried out of all patients presenting with popliteal aneurysm (PA) during January 1988–December 2001. Since 1993, asymptomatic PA <3 cm in diameter without distortion were managed conservatively. Ultrasound scans were carried out at 6-monthly intervals. These results were compared with conservative management of popliteal aneurysms of >3 cm in diameter in patients who declined or were unfit for operation and with those patients who underwent elective bypass of PA. Results of patients presenting with thrombosed PA are also described. Results: Fifty-eight patients (two women) presented with 92 PA. Some 39 had thrombosed PA and these patients were significantly more likely to have bilateral aneurysms (P < 0.001). Of the non-thrombosed PA managed conservatively none below 3 cm in diameter thrombosed. Patency of PA 2–3 cm in diameter was no worse than patency following elective bypass (P = 0.37). The risk of postoperative complications was greater with thrombosed compared with non-thrombosed PA (P < 0.005). Pre-operative lysis for thrombosed PA was associated with more complications than operation and on table lysis (P < 0.05). Conclusions: Careful monitoring of asymptomatic PA < 3 cm in diameter is safe. Pre-operative lysis is associated with increased risks compared with operation alone in those patients presenting with thrombosed PA. [ABSTRACT FROM AUTHOR]

Presents a reply on comments about an article on transtibial amputation published on the 2001 issue of 'British Journal of Surgery.' Omission of several papers in the bibliography; Mobilization of patients using a prothesis; Advantage of skew flap over long posterior flap.

Replies to a comment on the author's paper about gender differences in the longitudinal pressure profile of the anal canal related to anatomical structure as demonstrated on a three-dimensional anal endosonography. Method used to demonstrate the anatomy of the striated components of the sphincter; Relationship between the anal musculature and manometric profile of both sexes.

Aims: Intestinal obstruction in patients with advanced malignancy is a common condition resulting in significant morbidity; and historically, surgical intervention is associated with an unacceptable mortality with only marginal clinical benefits. This paper examines current surgical practice and its results for this difficult oncological emergency. Methods: A retrospective cohort study of patients who underwent emergency surgery for intestinal obstruction in the presence of advanced metastatic malignancy. Patients were identified from prospectively collected databases over a 5-year period. Principal outcome measures were operative mortality, overall survival and symptom control. Results: A total of 76 patients were identified with a median age of 66 (23–90) years. The commonest disease primary was colorectal (54 per cent), followed by gynaecological malignancy (15 per cent). Forty-seven (62 per cent) of patients had undergone surgical treatment of their primary, 23 (30 per cent) had chemotherapy and eleven (15 per cent) radiotherapy at a median interval from treatment to obstruction of 17, 7 and 19 months, respectively. At laparotomy a benign cause for obstruction was identified in seven (9 per cent) patients, multiple obstructing metastases in 51 (67 per cent) and an obstructing primary with advanced peritoneal disease in 16 (21 per cent). In only five (6 per cent) of cases was the laparotomy nontherapeutic, the remaining patients undergoing intestinal resection (51 per cent), bypass (18 per cent), defunctioning stoma (18 per cent) and adhesionolysis (5 per cent). Median postoperative stay was 14 (8–39) days, 30 day mortality 16 per cent (n = 12) with an in hospital mortality of 28 per cent (n = 21). Median survival following laparotomy for obstruction was 6 months 95 per centCI (3–9), Cox's proportional hazard model identified previous radiotherapy and nontherapeutic laparotomy to be independently associated with poor postoperative outcome (median survival; 75 v 260 days, P = 0.02 and 32 v 212 days, P = 0.002, respectively). Seven patients (10 per cent) developed further obstructive symptoms following their therapeutic laparotomy. Conclusions: With current perioperative care, operative intervention for intestinal obstruction in the presence of advanced malignancy is no longer associated with prohibitive mortality. If some form of palliative procedure is feasible, substantial obstruction-free survival is attainable. [ABSTRACT FROM AUTHOR]

Presents a guideline on good publication practice. Need for a balance intellectual contributions to the conception, design, analysis and writing of the study against data collection and work routine; Avoidance of disputes over attribution of academic credit; Responsibility of authors for the content of the paper.

SummaryBackground: Despite advances in diagnosis, surgery, antimicrobial therapy and intensive care support, the mortality rate associated with severe secondary peritonitis remains unacceptably high. This article presents various surgical treatment strategies for severe secondary peritonitis, emphasizing the role of open management of the abdomen and planned relaparotomies. Methods: Material was identified from previous review articles, references cited in original papers and a Medline search of the literature. Results and conclusion: Surgical treatment of severe secondary peritonitis is highly demanding and very complex. The combination of improved surgical techniques, antimicrobial therapy and intensive care support has improved the outcome of such peritonitis following perforation or anastomotic disruption of the digestive tract, or infected necrotizing pancreatitis. However, aggressive surgical treatment strategies, such as open management of the abdomen and planned relaparotomies, may have reached their limits. [ABSTRACT FROM AUTHOR]

Background: A large number of scoring systems for assessing a patient’s risk of complications or death has been developed over recent years. This is a review of those that are of relevance to general surgeons. Methods: A Medline literature search was performed to identify all articles concerning ‘severity of illness’, ‘morbidity’, ‘mortality’ and ‘postoperative complications’ in the field of surgery from 1966 to 1997. Further searches were performed to find papers about specific identified scoring systems, and relevant articles from the reference lists of these were also sought. Results and conclusion: The advantages of an accurate assessment of a patient’s risk include, on an individual level, the opportunity to give a more accurate prognosis and choose the most appropriate treatment. If the risk of an adverse outcome is known for a group of patients, the actual outcome can be compared with the predicted outcome, and comparison can be made between groups in different surgical units for the purposes of audit or research. The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) is the most appropriate of the currently available scores for general surgical practice. [ABSTRACT FROM AUTHOR]

Background: Hospital stay after colonic surgery is usually between 5 and 10 days, limiting factors being pain, ileus, organ dysfunction and fatigue. Single-modality intervention to reduce these factors with laparoscopic surgery usually requires a hospital stay of 5 days. This paper reports the results of a multimodal rehabilitation regimen after open sigmoidectomy. Methods: Sixteen unselected patients scheduled for elective sigmoid resection (median age 71 years) underwent operation under combined spinal–epidural anaesthesia. After operation, epidural analgesia was continued for 48 h, with immediate oral nutrition and mobilization, and with planned discharge 2 days after surgery. Results: The median postoperative hospital stay was 2 (range 2–6) days (48 h), patients being mobilized for a median of 5 h on the second postoperative day (24–48 h) and for 10 h on the third day (48–72 h). Within 48 h of operation 14 patients had an oral intake of 2000 ml or more and 15 had resumed defaecation. Fatigue and pain scores were low during the first 8–9 days after operation, with a median of 13 h of mobilization per day after discharge. There were no medical or surgical complications during 30 days of follow-up, except for two patients who suffered postspinal headache. Conclusion: Postoperative recovery after open colonic surgery may be accelerated by effective pain relief integrated into an accelerated rehabilitation programme. [ABSTRACT FROM AUTHOR]

Background: In 1991, the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated that carotid endarterectomy (CEA), in addition to best medical therapy, significantly reduces ipsilateral stroke in patients with high-grade (70 per cent or more) carotid artery stenosis compared with best medical therapy alone. In 1995, the Asymptomatic Carotid Atherosclerosis Study demonstrated that CEA was of benefit in asymptomatic patients with stenosis greater than 60 per cent. The aim of this paper was to examine how the practice and outcome of CEA have changed since publication of these data. Methods: A prospectively gathered computerized database comprising 634 consecutive CEAs was studied. Two time intervals were analysed: 1975–1991 inclusive (17 years) and 1 January 1992 to 1 May 1998 (6 years 4 months). Results: Since 1991, there has been a fourfold increase in the number of CEAs performed annually for symptomatic disease. CEA is now performed almost exclusively for high-grade (more than 70 per cent) stenosis. There has been a significant reduction in the total peri-operative neurological event rate (12·5 versus 5·9 per cent, P < 0·05), and the 30-day combined major stroke (Rankin grade 3–5) and mortality rate has fallen to 2·0 per cent. The number of patients who have CEA for asymptomatic disease remains small with 16 of 30 being randomized within the Asymptomatic Carotid Surgery Trial. Conclusion: Publication of ECST and NASCET data has been associated with a major increase in the number of CEAs performed for symptomatic disease in this unit. Despite a greater proportion of high-risk patients, the results have improved progressively. [ABSTRACT FROM AUTHOR]

Background: Ultrasonography during abdominal surgery has been reported since the 1960s, but its use did not become widespread until the recent availability of high-frequency, high-resolution transducers. This review discusses the application of intraoperative ultrasonography to open and laparoscopic abdominal surgery. Methods: A literature search (Medline) was undertaken. All papers pertaining to the subject matter that were located were included in the review. Results: Intraoperative ultrasonography influences surgical strategy in up to 50 per cent of liver resections for malignancy. It is the single most sensitive technique for the detection of occult hepatic metastases at the time of primary colorectal resection. In pancreatic surgery, intraoperative ultrasonography is of value in the localization of islet cell tumours and in the assessment of resectability of adenocarcinoma. The technique may also have a role in staging laparoscopy, and in the operative management of kidney and gastrointestinal diseases. Conclusion: Ultrasonography is an ideal operative tool as it is safe, reproducible and requires no special patient preparation or positioning. It should be regarded as an essential component of major hepatobiliary and pancreatic procedures. The recent availability of flexible laparoscopic probes is likely to lead to a similar impact on minimal access surgery. [ABSTRACT FROM AUTHOR]