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Objective: Conventional Milligan-Morgan haemorrhoidectomy is associated with significant pain and potentially hazardous complications. Doppler-Guided Haemorrhoidal Artery Ligation (DGHAL) may offer a lower risk, pain-free alternative. We present our early and long-term outcome experience with DGHAL, combined with patient views and satisfaction with the procedure., Method: One hundred and thirteen DGHALs were performed over a 13 month period by two surgeons in a single centre. Patients graded the severity of postoperative pain on visual-analogue scales. Clinical follow-up was at 6 weeks (n = 103), with long-term follow-up (n = 90) by postal questionnaire at median of 30 months., Results: Seven out of one hundred and three (6%) patients reported postoperative discomfort requiring analgesia. Ninety-three out of one hundred and three (90%) patients reported complete relief or significant improvement in their symptoms at 6 weeks, dropping to 77/90 (86%) at 30 months. Anal fissures developed in 2/103 (2%) patients, both treated with Diltiazem ointment. Further surgery was required in 8/90 (9%) patients. Eighty-two out of ninety (91%) patients said they would undergo DGHAL again., Conclusion: DGHAL is a relatively painless, safe, and effective procedure for symptomatic stage I-III haemorrhoids, for which we have demonstrated long-term durability and acceptability. Its role lies between office based procedures and more invasive operative interventions.

Context: Intussusception in adults is rare, accounting for 0.1% of adult hospital admissions. In contrast to this, it is the leading cause of obstruction in children. In up to 90% of adults a cause can usually be found, but in children this is rarely the case., Case Report: We report the case of a 27-year-old lady with a subacute bowel obstruction caused by a jejunal heterotopic pancreas and describe its successful surgical management., Conclusion: The causes of intussusception in adults are discussed in the literature review.

Laparoscopic cholecystectomy is becoming the treatment of choice for patients presenting with gallstones. A prospective audit of all patients undergoing cholecystectomy in a single health district over a six-month period was carried out. The aim was to define those patients not having laparoscopic cholecystectomy and determine the morbidity and mortality associated with open and laparoscopic procedures. Cholecystectomy was performed on 173 patients; 149 operations were attempted laparoscopically, of which 134 were successful, giving a conversion rate of 10%. Elective open cholecystectomy was performed on 24 patients. Twenty of these patients were under the care of a consultant who only performs open cholecystectomy and the others were not offered a laparoscopic procedure because of previous abdominal operations. The median time taken for open cholecystectomy was significantly shorter (P < 0.05) than for laparoscopic cholecystectomy or for converted procedures. Laparoscopic cholecystectomy resulted in bile duct injury in one patient (0.7%). This study shows that the majority of patients with gallstones are being offered laparoscopic cholecystectomy, although some patients will undergo open cholecystectomy. The latter include patients under the care of surgeons not performing laparoscopic cholecystectomy, those presenting as an emergency where laparotomy is performed and those where laparoscopy is contra-indicated. The findings of this study are probably representative of other health districts where a similar mix of surgical practice exists.

Objectives: To determine the effects of cuts in surgical beds and operating lists upon the waiting list. To evaluate the effects of the Waiting List Initiative upon the total number of patients on the waiting list, the number of patients waiting for more than one year, and the ratio of patients with low priority, non-life-threatening diagnoses to those with a higher priority, potentially more serious, diagnosis., Design: The study of facilities available and waiting list figures between 1979-1991; a prospective study of a Waiting List Initiative., Setting: The surgical departments of the Royal Berkshire and Battle Hospitals, Reading and Newbury District Hospital., Patients: Those patients on general surgical waiting lists between 1979 and 1993; those patients who had operations under the Waiting List Initiative., Result: Between 1979 and 1989 the number of surgical beds fell from 225 to 153, a reduction of 38 per cent. The number of weekly operating lists fell from 40 to 30, a reduction of 25 per cent. The waiting list remained fairly constant, between 1979-1987, with a median of 420 patients (range 295-688) before 1987, against 983 (range 688-1,253) after 1987. After the Waiting List Initiative the total number of patients on the waiting list fell from 1,114 to 904, a fall of 19 per cent. Patients waiting for more than one year fell from 381 to 176 (54 per cent), whilst those waiting less than one year remained constant at 730. The proportion of patients with low priority varicose veins fell from 65 per cent to 40 per cent, whilst the proportion of patients with potentially more serious inguinal hernias rose from 10 per cent to 15 per cent., Conclusion: These results demonstrate the relationship between the increase in the size of the waiting list and the decrease in the facilities available in beds and operating sessions. While the Waiting List Initiative has resulted in a reduction in the number of patients waiting more than one year, there has been no reduction in numbers waiting less than one year. The reduction has been achieved at the expense of those patients with potentially more serious clinical conditions.

Objectives: To determine the proportion of all new and follow-up patients referred to general surgical outpatient clinics with breast problems. To ascertain how long these patients wait for an appointment and how many require investigation or admission for operation. To review our management of patients with breast problems in the clinic and to determine the ratio of benign breast disease to malignancy., Design: A 3-month prospective outpatient survey with patient details recorded on questionnaires completed by the medical staff., Setting: The general surgical outpatient clinics of this firm at Battle Hospital, Reading, and Newbury District Hospital, Berkshire., Patients: Those patients attending the above clinics during the 3-month period 1 October to 31 December 1989., Results: In all, 693 new patients and 554 follow-up patients were seen. Of the new patients, 119, and of the follow-up patients 140 were seen for a breast complaint. At Battle Hospital 16% of all new patients presented with a breast problem, while at Newbury Hospital the figure was 24%. Of the follow-up patients at Battle Hospital, 23% were seen for a breast problem, and 41% at Newbury. The overall median waiting time for a new outpatient appointment was 21 days. No investigations were needed in 22% of the patients. The remaining 93 patients had investigations and a total of 70 mammograms and 53 fine needle aspirations for cytology were performed. The mean cost of investigations per patient investigated was estimated at 27 pounds. Of new patients, 58% were discharged from the clinic after a single consultation, and investigations as necessary. In 79% of the patients admitted for an operation, the decision to admit was made on the basis of the initial history and examination alone. Of new patients, 84% did not need admission and were managed in the clinic. In all, 14 breast carcinomas were diagnosed--12% of new patients with breast problems., Conclusions: The figures suggest that 24% of new patients and 41% of follow-up patients attending a general surgical clinic are seen for a breast problem. The waiting time for new appointments is unacceptably long. Most new patients do not require admission for an operation. Only 12% of new patients referred with a breast problem were found to have a carcinoma.

A case-control study has been carried out to assess patient satisfaction with day-case or inpatient inguinal hernia repair using matched pairs of patients undergoing the same technique of inguinal hernia repair under general anaesthesia. Patients completed a single-page questionnaire 3-6 months after surgery. Although there was no objective difference in recovery, nearly half of the patients felt that they were discharged too early and the majority would prefer inpatient treatment. Day-case patients required significantly more medical attention after discharge and most of the reported wound complications were not known to the hospital. It is concluded that the introduction of day-case surgery in a district general hospital is not without problems and requires changes in working practices and resource availability with careful monitoring of outcome during its implementation.

We report a prospective controlled trial looking at the outcome of major abdominal surgery judged on the ability of patients to return to their preoperative activity level. Eighty patients were included in the study. Forty of these were over 80 years old and the remainder in the age group 40-65 years. Fifty-four per cent of the over 80s demonstrated an increased level of dependance six months after surgery compared to 18% of the 40-65 year olds. The mortality rate at six months was 42% for the over 80 group. The poor prognosis of elderly surgical patients not only in their increased mortality rate but also in their dependency should be considered before they are subjected to major abdominal surgery.

A 3-month prospective study of the workload of a surgical unit in a district general hospital was performed to identify the relationship between outpatient work, admissions to hospital, and scheduled operating lists. We have shown that under 60% of all new cases seen in the outpatient clinic had admissions arranged after initial consultation. Over two-thirds of inpatient admissions were for emergencies or urgent cases, and thus not able to be controlled by the surgical team. One-third of emergency admissions had an operation within 24 h of admission. One third of the total number of cases on scheduled lists were emergency or urgent cases (taking up approximately 50% of the operating time). Of all admissions, 32% were as day cases. Of all routine operations, 35% were performed at a community hospital taking only 18% of all our admissions.

Of 292 patients, excision of the tumour with replacement by stomach or jejunum was carried out in 216 in whom the lesion was considered operable on both technical and general grounds, intubation was performed in 45 and the remaining 31 were managed without operation. Of the 216 in whom resection was performed, only 20 per cent were free from local spread, lymph node involvement or secondary deposits at the time of operation. Hospital mortality was 18 per cent and did not significantly differ between one 5-year period and another. Survival at 1 year was 54 per cent, at 2 years 25 per cent and at 5 years 14 per cent. The average length of survival following intubation was 2.6 months and following non-operative management 2.8 months. The poor average survival of between 3.5 and 5 months obtained in those patients with secondary deposits at the time of resection suggests that resection is of questionable value in this group. There was a marked difference in survival following Roux loop procedures compared with upper partial gastrectomy for tumours of the lower third and cardia in patients without lymph node involvement or secondary deposits, strongly suggesting that upper partial gastrectomy, although a rather simpler and quicker operation, is not the operation of choice in these patients. On 31 December 1976, after a minimum follow-up of 1 year, there were only 22 patients still alive of the original 292 (7.5 per cent).

Cyclosporin A (Cy A) was evaluated in dogs to assess its effectiveness of prolonging survival of allogeneic pancreatic islet tissue transplanted to the spleens of totally pancreatectomized mongrel dogs. Thirty-seven dogs were made diabetic by total pancreatectomy. Ten untreated pancreatectomized animals survived a mean (+/-SE) of 6.3 +/- 0.9 days and died with mean (+/-SE) plasma glucose levels of 23.2 +/- 2.7 mmol/liter. Dispersed pancreatic fragments, prepared by collagenase digestion without separation of exocrine and endocrine components, were directly implanted into the splenic pulp of 27 pancreatectomized dogs. Twelve dogs given autotransplants became normoglycemic after 4.3 +/- 0.5 days and remained so until killed at 60 days post-transplant, although normal glucose tolerance tests were not achieved. Eight nonimmunosuppressed dogs given allogeneic pancreatic fragments did not become normoglycemic but survived for 13.0 +/- 2.1 days, the dogs dying with a terminal plasma glucose of 22.7 mmol/liter. An additional seven dogs given allogeneic transplants were given Cy A (oral solution), 25 mg/kg/day, for 14 days, and, although failing to become normoglycemic, survived for 28.1 +/- 5.4 days and died with terminal plasma glucose levels of 25.1 +/- 0.6 mmol/liter. Intrasplenic complications included subcapsular hematomas, intrasplenic necrosis and cavitation, capsular perforations, and arteriolar thrombosis. The failure to achieve normoglycemia with allogeneic dispersed pancreatic tissue in dogs treated with Cy A and the complications associated with the implantation of the tissue in the spleen do not suggest that this approach is worthy of clinical trial.

This study showed that a heterotopic autotransplant of the tail of the pancreas was capable of maintaining adequate glucoregulatory function in pancreatectomized dogs, glucose tolerance test curves, and K values not differing from normal dogs 4 months after transplantation. Hyperinsulinemia in the fasting state was observed in the absence of hypoglycemia in autograft and allograft recipients. Intraductal Ethibloc injection produced total replacement of the exocrine gland at 4 months by fibrosis but with the preservation of islets. Cyclosporin A (Cy A, oral drinking solution) in a dose of 25 mg/kg/day given to recipients of heterotopic segmental allografts produced a slight but significant prolongation of graft survival, but a dose of 40 mg/kg/day resulted in indefinite graft survival (greater than 100 days) in five of eight allograft recipients. During intravenous glucose tolerance tests (IVGTTs), fasting hyperinsulinemia and significantly impaired glucose degradation (K values) was observed in long-term surviving allograft recipients 4 months after transplantation. In four long-term surviving pancreatic allograft recipients initially given 40 mg/kg/day, the dose of Cy A was gradually reduced after 4 months to a maintenance dose of 5 mg/kg/day by 6 months. On a dose of 5 mg/kg/day, three dogs rejected their grafts between 18 and 28 days after this schedule had commenced. Successful reversal of the hyperglycemia in two of three dogs that rejected their grafts was achieved by i.v. methylprednisolone and increased doses of Cy A. These results indicate that Cy A alone could significantly prolong the survival of canine pancreatic segmental allografts, but initially higher doses were required than that found to be effective in prolonging renal allograft survival in the dog.

The effect on glucose metabolism of altering the site of the venous drainage of an isograft of isolated adult islets implanted beneath the renal capsule, from the systemic circulation to the portal circulation was determined in streptozotocin-induced diabetic rats. Reversal of diabetes was accomplished by the transplantation of 1000-1200 isolated islets beneath the left kidney capsule. The rate of fall of the glucose concentration (as expressed by the K value) was found to be significantly decreased in transplanted animals (1.7 +/- 0.5%/min; mean +/- SD) compared with normal animals (2.4 +/- 0.5%/min). Draining the left renal vein into the portal circulation restored the K value to that of normal animals (2.5 +/- 0.4%). However the fasting glucose concentration was significantly higher and the basal insulin levels lower in both normal and transplanted rats with a renoportal shunt.