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Background and Study Aims: Recurrences after Doppler-guided haemorrhoidal artery ligation (DG-HAL) tend to occur in patients with concurrent mucosal prolapse. We retrospectively compared the results of DG-HAL and rubber band ligation (RBL) for the treatment of haemorrhoidal disease., Patients and Methods: From 2005 to 2009, all patients who underwent either a DG-HAL procedure or RBL were selected. Follow-up was done by telephone using a standardised questionnaire survey to assess patient satisfaction and complaints. When recurrent disease was suspected, patients revisited the clinic for further examination and treatment., Results: A total of 239 DG-HAL patients and 47 RBL patients were analysed. Sixty-seven percent in the DG-HAL group and 79% in the RBL group had an improvement in symptoms after one treatment (p=0.22). Forty-six DG-HAL patients (19%) needed a second procedure versus three patients (6%) in the RBL group (p<0.05). Cox regression analysis showed a significant difference in disease recurrence in favour of RBL (hazard ratio (HR) 3.71, 95% confidence interval (CI) 1.13-12.2). Patients in the DG-HAL group with recurrent haemorrhoids had a higher incidence of mucosal prolapse., Conclusion: DG-HAL seems very effective in treating lower-grade haemorrhoids. In more advanced disease, recurrence occurs due to persisting mucosal prolapse. RBL seems much more effective in reducing the prolapse and the chance of recurrence., (Copyright © 2011 Arab Journal of Gastroenterology. Published by Elsevier Ltd. All rights reserved.)

Background: Mirizzi's syndrome is a rare cause of jaundice. The syndrome refers to common hepatic duct obstruction or choledoch duct obstruction caused by extrinsic compression of an impacted stone in the gallbladder neck or cystic duct., Case Description: A 42-year-old woman was referred to the emergency department with symptoms indicative of obstructive icterus. Endoscopic retrograde cholangiopancreatography (ERCP) and a CT scan revealed signs of Mirizzi's syndrome but no indications of malignancy. Laparoscopic cholecystectomy was decided upon. This procedure revealed that the obstruction was caused by a gallbladder carcinoma., Conclusion: Of those patients suspected of having Mirizzi's syndrome, retrospectively 5-28% prove to have carcinoma of the gallbladder. Therefore in Mirizzi's syndrome before carrying out laparoscopic cholecystectomy a careful diagnostic approach is essential. This includes ERCP or MRI cholangiopancreaticography (MRCP) and a CT scan. Even after these investigations the surgeon should only perform laparoscopic surgery with caution, as it is often converted to an open procedure and because of the risk of presence of a malignancy.

With 16,000 operations every year, acute appendicitis is one of the most common surgical diagnoses in Dutch emergency rooms. Diagnosis is based on clinical features: history, physical examination and laboratory testing. When the diagnosis is made, surgeons tend to operate quickly to prevent complications. In some cases this means that a healthy appendix is removed. The Dutch College of Surgeons wanted to reduce the number of removed healthy appendixes. This topic is discussed worldwide and the introduction of imaging is widely suggested. Ultrasonography and CT are said to be highly reliable in diagnosing appendicitis. While this may be the case in a research setting, it has been shown that in general hospitals they are not so reliable. Furthermore, the rise in the use of preoperative imaging has not brought down the negative appendectomy rate. We believe that imaging should be reserved for certain groups of patients. In the clear-cut cases it only increases the cost, patient burden and risk of complications; preoperative imaging should not be performed routinely.

Background: With an incidence of less than 5%, type II paraesophageal hernias are one of the less common types of hiatal hernias. We report a case of a perforated prepyloric gastric ulcer which, due to a type II hiatus hernia, drained into the mediastinum., Case Presentation: A 61-year old Caucasian man presented with acute abdominal pain. On a conventional x-ray of the chest a large mediastinal air-fluid collection and free intra-abdominal air was seen. Additional computed tomography revealed a large intra-thoracic air-fluid collection with a type II paraesophageal hernia. An emergency upper midline laparotomy was performed and a perforated pre-pyloric gastric ulcer was treated with an omental patch repair. The patient fully recovered after 10 days and continues to do well., Conclusion: Type II paraesophageal hernia is an uncommon diagnosis. The main risk is gastric volvulus and possible gastric torsion. Intrathoracic perforation of gastric ulcers due to a type II hiatus hernia is extremely rare and can be a diagnostic and treatment challenge.

In this study we describe the potential role of autologous platelet gel and fibrin sealant in unilateral total knee arthroplasty to improve the postoperative range of motion and to reduce the incidence of arthrofibrosis. Total knee arthroplasty is often associated with a considerable amount of post-operative blood loss. Persistent limited motion directly after surgery may ultimately result in arthrofibrosis. To counteract these effects we investigated whether the use of autologous derived platelet gel and fibrin sealant would reduce postoperative blood loss, decrease the impaired range of motion and the incidence of arthrofibrosis. All patients were consecutively operated and assigned to the study or control groups. Study group patients (n = 85) were treated with the application of autologous platelet gel and fibrin sealant at the end of surgery. Eighty patients were operated without the use of platelet gel and fibrin sealant, and served as the control group. The postoperative hemoglobin decrease, range of motion and length of hospitalization were recorded. During a 5-month postoperative period patients were followed to observe the incidence of arthrofibrosis. In patients in the treatment group the hemoglobin concentration in blood decreased significantly less when compared to the control group. They also showed a superior postoperative range of motion when compared to those of the control group (P < 0.001). The incidence of arthrofibrosis and subsequent forced manipulation was significantly less (P < 0.001) in patients managed with platelet gel and fibrin sealant. We conclude that peri-operatively applied platelet gel and fibrin sealant may improve the range of motion after total knee arthroplasty, decreases the length of stay and may reduce the incidence of arthrofibrosis.

Prothrombin Complex Concentrate (PCC) is indicated for the acute reversal of oral anticoagulation therapy. To compare the efficacy of a "standard" dosage of 20 ml PCC equivalent to about 500 IU factor IX (group A), and an "individualized" dosage based on a target-INR of 2.1 or 1.5, the initial-INR and the patient's body weight (group B), we performed an open, prospective, randomized, controlled trial. The in vivo response and in vivo recovery of factor II, VII, IX and X in these patients on oral anticoagulation was determined. Ninety three patients (group A: 47; group B: 46) with major bleedings or admitted for urgent (surgical) interventions were enrolled. PCC and Vitamin K (10 mg) were administered intravenously. We evaluated the effect of treatment by the decrease of INR and the clinical outcome. The number of patients reaching the target-INR 15 min after the dosage of PCC was significantly higher in the group treated with an "individualized" dosage, compared to the group treated with a standard dose, (89% versus 43%; p<0.001). So, we conclude that for the acute reversal of oral anticoagulant therapy, an "individualized" dosage regimen of PCC based on the target-INR, the initial-INR, and body weight of the patient, is significantly more effective in reaching the target-INR than a "standard" dosage. The in vivo response and in vivo recovery found in this study was higher then in patients with isolated factor deficiencies. This suggests that the pharmacokinetics in patients on oral anticoagulants may be different.

Perforation of the oesophagus was retrospectively analysed in 59 patients. Cause and extent of perforation, localization, quality of the oesophageal wall and therapeutic modes were subjected to univariate analysis. The perforations of the intrathoracic oesophagus (39) were also subjected to multivariate analysis. Perforation of the cervical oesophagus is seldom lethal and can be adequately treated conservatively in the majority of cases. Perforations of the intrathoracic oesophagus can be divided into two groups, with or without simultaneous perforation of the parietal pleura. The optimal treatment for the group with pleural perforation seems to be resection of the oesophagus and secondary reconstruction, although primary closure is indicated in selected early cases. Perforations of the intrathoracic oesophagus confined to the mediastinum can be adequately treated conservatively in most patients. Perforation of the intra-abdominal oesophagus should be treated like any other intra-abdominal visceral perforation, by closure or diversion, even if this results in resection of the oesophagus.

Because the submandibular salivary glands of male mice are rich in growth factors such as epidermal growth factor and nerve growth factor, and because there are sporadic reports of sialadenectomized mice showing growth retardation and endocrine abnormalities, we studied oxidative metabolism and fertility after submandibular sialadenectomy. Despite similar intake of food, male mice (n = 60) deprived of submandibular saliva, either by duct ligation or gland excision, initially weighed 12-13% less than the sham controls and had a slower rate of growth (P less than 0.001). After 5 mo, mice with duct ligation caught up with the sham-operated mice, but the differences compared with submandibular-sialadenectomized mice were still apparent at 32 wk (P less than 0.001). The mean respiratory quotient of submandibular-sialadenectomized and duct-ligated mice was 0.71 instead of 0.88 as in the shams at 10, 20, and 30 wk after operation (P less than 0.01). No effect on fecundity was observed in either male or female mice following submandibular sialadenectomy.

Early postlaparotomy needle jejunostomy feeding with an elemental diet resulted in a typical clinical entity in six of 160 patients (4 per cent). In all, an acute condition of the abdomen developed with a grossly distended intestine, filled with fluid and gas, and an empty stomach as confirmed roentgenographically or at a second laparotomy. This complication is presumably caused by carbohydrate hyperosmolarity of the elemental diet and carbon dioxide production by fermentation. The complication was seen predominantly in patients with a Roux-en-Y reconstructed pancreatectomy. In two patients, a negative second laparotomy was performed. In two others, a pancreaticojejunostomy suture line blowout followed, resulting in death. One patient died after aspiration of the gastric contents.

The submandibular salivary gland of the male mouse and its secretions contain growth-promoting factors that accelerate cell proliferation in vitro and also have effects on the gastrointestinal tract in vivo. We therefore stimulated salivary secretion with isoproterenol for studies of the effects of submandibular saliva on intestinal cell proliferation; only submandibular glands respond to isoproterenol by releasing epidermal growth factors and other growth factors into the saliva. Submandibular sialadenectomized and sham sialadenectomized male mice on pair-feeding schedules were given isoproterenol intraperitoneally for 1 wk. A 44% increase in ribonucleic acid and a 13% increase in deoxyribonucleic acid were observed in the jejunum of animals with intact submandibular glands (p less than 0.001). In the ileum, there was a 26% increase in ribonucleic acid, a 47% increase in deoxyribonucleic acid, and a 28% increase in deoxyribonucleic acid specific activity (p less than 0.001). Morphometric measurements showed a 28% increase in villous height (p less than 0.001). No differences were found in colonic mucosa. Submandibular saliva increases the nucleic-acid content of mucosal cells and the villous height in the small intestine of male mice, presumably in part because of the growth factors it contains; a systemic metabolic change could also be present.

Circular, full-thickness dermal burn- and freeze-produced wounds were produced in rats to compare the difference in healing between the two types of thermal injuries. Contraction did not occur in wounds (n = 30) caused by freezing, while burn wounds (n = 30) contracted to less than one-third of original size by 21 days after injury. If the centers of the freeze-produced wounds (n = 12) were excised, contraction would then occur and proceed at the same rate as an open wound. Histologically, the degree of initial tissue destruction by the two types of injuries was similar. The burn wound contained only half the amount of collagen found in the freeze-produced wound. There was a greater and more rapid replacement of collagen in the burn wounds. With both injuries, the highest concentration of collagen was found on the fifteenth day and returned to normal by the twenty-eighth day. The burn wound contained three times the amount of collagen in normal skin, while the freeze-produced wound contained only 1 3/4 times the amount in normal skin. Contraction does not seem to occur in the healing of the freeze-injured skin because the slow removal and replacement of the residual matrix prevents contraction.

Earlier studies have shown that removal of the submandibular glands of mice retards the rate of contraction of experimentally induced wounds and that communal licking of wounds accelerates contraction in intact animals [Hutson, J. M., Niall, M., Evans, D. & Fowler, R. (1979) Nature (London) 279, 793-795]. In the light of the observation that nerve growth factor (NGF) is secreted in high concentrations in mouse saliva, we have studied the effect of topically applied high molecular weight nerve growth factor (HMW-NGF) upon the rate of wound contraction in sialoadenectomized animals. Results show that HMW-NGF significantly accelerates the rate of wound contraction and that this phenomenon is probably dependent upon the enzymic activity of the protein. Neither diisopropyl fluorophosphate-inactivated NGF nor 2.5S NGF [isolated according to Bocchini, V. & Angeletti, P. U. (1969) Proc. Natl. Acad. Sci. USA 64, 787-794] displays this biological activity. Thus, it may be that one of the physiological roles of NGF in saliva is to promote wound healing by the licking process.

Thirty-eight patients with aneurysms of the splenic artery were identified in the records of 11 years, but only one aneurysm was ruptured. Portal hypertension was found in nine patients (24%); in two of these the reaction surrounding the aneurysm prevented the construction of a patent splenorenal shunt or caused compartmented portal hypertension. One aneurysm encountered during the survey period and another encountered just after its conclusion ruptured into the stomach. There was a twofold overrepresentation of multiparous women. Intraperitoneal rupture is rare, except in pregnancy. If elective therapy is considered, angiography should be performed. Exclusion or resection of the aneurysm is advocated only for patients with symptomatic or ruptured aneurysms or (very rare) large aneurysms and for women of childbearing age. The spleen should be preserved, when possible. In high-risk patients occlusion of the aneurysm via an intra-arterial catheter should be considered. If the splenic artery aneurysm causes compartmented portal hypertension, splenectomy is indicated; if portal hypertension is general, the form of portasystemic decompression chosen should avoid the region of the aneurysm.

Four techniques to close the fascia after midline laparotomy were compared in a prospective randomized multicentre trial. The four techniques were: interrupted closure with polyglactin; continuous closure with polyglactin; continuous closure with polydioxanone-s, and continuous closure with nylon. The early postoperative results in 1491 patients revealed an incidence of wound infection of 8.6 per cent and of wound dehiscence of 2.3 per cent with no statistically significant differences between the four techniques. We reviewed 1156 patients after 1 year. Wound pain was present in 9.7 per cent of the patients, statistically significantly more in the group closed with nylon (16.7 per cent). Suture sinuses developed in 3.5 per cent of the patients, statistically significantly more frequently in the nylon group (7.7 per cent). The total number of incisional hernias detected 1 year postoperatively was high (15.2 per cent) (interrupted polyglactin 16.9 per cent, continuous polyglactin 20.6 per cent, continuous polydioxanone 13.2 per cent and continuous nylon 10.3 per cent). The difference between nylon and continuous polyglactin is statistically significant. The results of this trial indicate that although nylon has the lowest incidence of incisional hernia it also is associated with more wound pain and suture sinuses.

During the period 1978-1984, 525 patients referred with cancer of the oesophagus or gastro-oesophageal junction were assessed for operation and cure. After investigation, 276 patients were selected and operated upon, as a rule, 4 weeks after radiotherapy (40 Gy/4 weeks). In 224 patients (81 per cent) the oesophagus and cardia were resected and reconstructed with stomach (69 per cent), colon (21 per cent), free ileal graft (7 per cent) or Roux-en-Y-oesophagojejunostomy (3 per cent). The postresectional hospital mortality was 14 per cent in all patients and decreased to 5 per cent in 1983. Mortality was higher when the colon was used for reconstruction than when the stomach was used. By postresection staging, 82 patients were found to have stages I and II tumours and 142 patients stage III tumours. Estimated 3-year survival after resection for all male patients was 28 per cent and for all female patients was 42 per cent. Estimated 3-year survival for all patients treated for adenocarcinoma was 31 per cent. Survival was better for stages I and II patients with adenocarcinoma (52 per cent) than for stage III patients (18 per cent) (P less than 0.01). Estimated 3-year survival for all patients treated for squamous cell carcinoma was 33 per cent. Estimated 3-year survival was better for stages I and II patients with squamous cell carcinoma (48 per cent) than for stage III patients (25 per cent) (P less than 0.001). It can be concluded from this study that resection of oesophagus and cardia after radiotherapy offers hope for cure in a subgroup of patients with non-advanced oesophageal cancer. The operation can be performed with acceptable mortality by experienced surgeons, especially when the stomach is used for reconstruction.

A retrospective study was made of 75 consecutive patients treated for a tumour of the head of the pancreas and the peri-ampullary region from January 1978 to August 1981. These patients underwent either pancreatic resection--pancreatoduodenectomy (n = 24) and total pancreatectomy (n = 10)--palliative procedures (n = 29) or exploratory laparotomy (n = 12). Clinical signs and diagnostic procedures, such as ultrasonography and coeliac arteriography, were studied for their value in preoperative assessment of operability. Vaso-invasion, as revealed by arteriography and, to a lesser extent, ultrasonographic signs of a tumour and the absence of jaundice were poor prognostic signs. The operative mortality was 8 per cent for the group as a whole, but somewhat higher (13 per cent) for the group that underwent pancreatoduodenectomy. No patient died after total pancreatectomy. The operative mortality was 27 per cent in all patients aged 70 years or older, but only 3 per cent in patients under 70 years. One-year patient survival was 94 per cent after pancreatoduodenectomy for peri-ampullary cancer and 57 per cent after resection for cancer of the head of the pancreas. The results of this study point to pancreatic resection as the treatment of choice for resectable tumours of the peri-ampullary region and the head of the pancreas in patients under 70 years of age. Coeliac arteriography and ultrasonography have been found to be useful for preoperative classification of tumour stage.

A case of massive retrogastric bleeding from a neurofibroma arising from the gastric wall is described. The tumour was removed without opening the gastric mucosa. The possibility of neurofibroma should be borne in mind when there is unexplained bleeding from the digestive tract or the intraperitoneal or retroperitoneal space, particularly in patients with von Recklinghausen's disease.

Increased salivary flow stimulated by intravenous isoproterenol (IPR) (6 mg/kg) doubled the incidence of gastric stress ulceration in normal male mice, but not after submandibular sialadenectomy. The submandibular salivary glands in these mice secrete large amounts of several growth factors, including epidermal growth factor (EGF) and nerve growth factor (NGF). Intragastric instillation of a quantity of high molecular weight NGF equimolar to that in IPR-stimulated saliva doubled the incidence of stress ulcers after submandibular sialadenectomy. This action of NGF in vivo is not mediated by its nerve growth promoting properties nor its plasminogen activating property.

Details are given of the postoperative course of 56 patients after pancreatoduodenectomy, and 11 after total pancreatectomy. The main indication was adenocarcinoma (56 cases). The most serious complication was leakage from the pancreatojejunostomy, which occurred in nine patients and was fatal in seven of these (10%). This was the only cause of death in the group. The observed mortality was appreciably higher (38%) in the 13 patients aged over 70 years. Contrary to recent reports, jaundice was not found to influence postoperative mortality adversely, nor was preoperative biliary drainage found to reduce mortality.

In a prospective, randomized study 145 patients with duodenal ulcer have been followed 5-7 years after proximal gastric vagotomy (PGV) or truncal vagotomy with antrectomy (TVA). Postoperative complications were significantly higher after TVA (P less than 0.0005). There was one death due to anastomotic leakage after TVA. The recurrence rate was significantly higher after PGV (9.9 per cent). Postoperative symptoms were less after PGV (P less than 0.01). Due to the recurrence rate after PGV there was no overall significant difference in the Visick grading, although perfect results (Visick I) were seen significantly more often (P less than 0.01). It is concluded that better results follow PGV.

In 35 patients with lunatomalacia, radial shortening (20 cases) was compared with ulnar lengthening (15 cases) 5 (1-14) years postoperatively. There was no radiographic evidence of recovery of the architecture of the lunate bone. The time of consolidation of the osteotomy with screw and plate fixation averaged 3 months after radial shortening and 4 months after ulnar lengthening. Pseudoarthrosis developed in 1 case of radial shortening and in 3 cases after ulnar lengthening. The two groups were equal with satisfactory results in two thirds of the patients.