Sixteenth sir peter freyer memorial lecture and surgical symposium September 13th & 14th, 1991...

SIXTEENTH SIR PETER FREYER MEMORIAL LECTURE and SURGICAL SYMPOSIUM SEPTEMBER 13th & 14th, 1991

SESSION I

1 MANOMETRIC EVALUATION OF THE MECHANISM OF

ANAL SPHINCTERIC INJURY FOLLOWING LOW ANTERIOR RESECTION.

J. Coulter, R. G~ Molloy. K. T. Moran, R. Waldron, W. O. Kirwan. Univefisty Department of Surgery, Cork Regional Hospital.

Imperfections of continence do occur following low anterior resection (LAR), and may present with increased stool frequency or varying degrees of incontinence. This impaired continence has been related to a fall in resting anal sphincteric pressure and may be secondary to a direct injury to the sphincter during transana] passage of the stapling device, or damage to its nerve supply at rectal mobilisation. We have studied the relative contribution of each mechanism to this anal sphineteric impairment, by comparing handsewn anastomoses (n = 7) to transanal stapled anastomoses (n = 7), in 14 dogs undergoing LAR. Anorectal manometry was performed preoperatively, and again on the 10th postoperative day.

Resting anal pressure was significantly reduced after both stapled anastomoses (prcop 49 (+3) mmHg; postop 20 (+4) mmHg p<O.O01), and handsewn anastomoses (prcop 46 (i4) mmHg; postop 35 (+4) mmHg p<0.0I). This reduction in postoperative resting anal pressure was more marked in the stapled group who sustained a 60% reduction relative to a 24% reduction in the handsewn group (p < 0.05). A reduction in resting anal canal pressure would appear to be an inevitable consequence of a rectal sphincter saving resection, whether tramanal manipulation is necessary or not. Damage to its parasym- pathetic innervationis responsible for theintemal sphincter dysfunc- tion which follows a handsewn LAR. The additional pressure drop after a stapled anastomosis is most likely due to peranal manipulation trauma to the internal sphincter. Preoperative manometry may identify patients at high risk of developing a postoperative continence problem in whom avoidance of transanal instrumentation may be desirable.

2 MARLEX MESH ANTERIOR RECTOPEXY FOR RECTAL

PROLAPSE

C. O'Suilleabhain, R. Waldron, A. Horgan, W. O. Kirwan. University Department of Surgery, Cork Regional Hospital, Cork.

Rectal prolapse is a distressing condition, not only because of the uncontrollable prolapse, but also because approximately one-half of these patients are incontinent. We report a7-year experience with 25 Anterior Rectopexies (Ripstein Procedure) for complete rectal prolapse in 24 female and one male. followed up for 6-84 months (median 34 months). A marlex mesh sling was utilized to suspend the rectum from the sacrum.

There was no perioperative mortality or prolapse recurrence. Pre-operatively 5 patients had normal bowel function, 12 were constipated and 12 were incontinent. While only four patients were incominent following surgery, 14 were constipated. Postoperative bowel function was assessed using a modified Visick grading

system (Table 1).

Table I Bowel Function following Anterior Rectopexy (N = 25)

Grade Bowel Function Patient No. I Perfect 5 11 Occasional enema or inability to hold gas 4 111 Daily enema or occasional minor enema 13 1V Frequent soiling 1 V Stoma 2

The Ripstein Anterior Rectapexy is a procedure that cures the rectal prolapse with minimal perioperative morbidity. Faecal incontinence is usually corrected by Rectopexy, but bowel regulation problems are not corrected by this operation. Careful physiologic studies are necessary to increase our understanding of the functional disturbances associated with rectal prolapse.

3 IS ANTERIOR RESECTION WITHOUT A DEFUNCTIONING

COLOSTOMY SAFE?

K. Mealy. P. Burke, J. Hyland. Department of Surgery, St. Vincent's Hospital, Dublin 4.

The need to dcfunction the anastomosis at anterior resection remains controversial. As our policy has been not to perform a defunc tioning colnstomy during anterior resection we examined the outcome of our last one hendred consecutive anterior resections all without a covering colostomy. During this period 20 abdomino perineal resections ( 15% ), five Har tmanfi's procedures (4%) and two resections with ooloanal anastomosis (2%) were also performed. Sixty two patients were male and the mean age was 62.5 (range 36 - 93). Thirty eight of the resections were high and 62 low, defined as completely above or below the peritoneal reflection. Clinical anastomotic dehiscence occurred in six patiants; all in the low anterior resection group (6% of total group or 9.8% of the low anterior resection group). All of these patients l~ad a further laparotomy and end colostomies fashioned. Within the last 52 patients three radiological leaks have also occurred; none of which required any further surgical management. Peri-operative mortality was 4% within the anterior resection group; one death was attributable to anastomotic dehiscence and sepsis whereas the other three deaths were due to unassociated medical conditions. Our results demonstrate similar leakage and nrurtality rates to published studies where anterior resection is frequendy performed with a defunctioning colostemy. These results indicate that the routine use of a defunetiening colostomy at anterior resection is not warranted.

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Vol. 161 No. 8

4 NERVE REGENERATIONACROSS COLOP~ECTAL ANAS- TOMOSES AFTER LOW ANTERIOR RESECTION IN A CA-

NINE MODEI,.

A. F. Horgan, R. G. Mulloy, J. Coulter, M. Sheehan, W. O. Kirwan.

Univeristy Department of Surgery, Regional Hospital. Cork, Ireland.

The recto3anal inhibitory reflex, mediated by enteric intramural autonomigaerves is thought to be an important factor in the preservation of normal anal continence. Following low anterior resection we have previously shown this reflex to be lost but it later returns to normal levels in the majority of cases. It has been postulated, but has never been demonstrated, that the return of the recto-anal inhibitory reflex may be due to a regrowth of these intramural nerves across the colorectal anastomosis.

To investigate this concept and to outline any differences between stapled and hand sewn anastomoses in this regard, ten female greyhound dogs were~ randomised into two groups, all underwent low anterior resection. Five had stapled EEA and five had handsewn anastomoses of the rectum. The recto-anal inhibitory reflex was measured before and after surgery using a microtransducer tipped catheter. Six months post operatively the recto-anal inhibitory response was again measured and the animals sacrificed. The colorec- tat anastomosis was excised, fixed and examined histologically using light microscopy to determine the pattern of innervation at the enastomotic site.

Manometric studies showed the recto-anal inhibitory reflex to be present hi all eases pre-operatively and was recordable in only one case (10%) on the tenth pest-operative day but had returned hi eight cases (80%) after six months.

Longitudinal sections acress file anastomosis were examined histologically and showed clear evidence of regenerating nL~ve minks at the anastomofic site in both stapled and handsewn groups. Com- plete functional iunervatien was also shown in the segment of bowel immediately distal to the anastomosis.

We therefore conclude that the return of the recto-analinhibitory reflex following low anterior resection of the rectum is due to the regeneration of intramural autonomic nerves across the colorectal anastomosis.

5, CROSS-STAPLED END-TO-END ANASTOMOSIS IN LOW

ANTERIOR RESECTION FOR RECTAL CARCINOMA: A SUPERIOR

TECHNIQUE

R. M. Browne, O. Austin, A. P. Clery, J. M. Deasy. Department of Colo-Rectal Surgery, Beanment Hospital,

Dublin 9. Clinical anastumotic leakage in low anterior resection for rectal

carcinoma occurs hi 5-10% of patlants despite standard stapled EEA anastomotic technique. A modification of this technique has obviated the need for a distal pursestring. A flexible transverse stapling instrument (Autosuture Roticulator 55) is applied across the rectum below the tttmour and a double staggered row of staples is inserted as a substitute for a distal pursestring. End-to-end stapled anastomosis is then performed with peranal insertion of the Autosuture Premium CEEA stapling instrument. Ninety eight patients were

16th Sir Peter Freyer Memorial Lecture 521

operated on. The indications for which were rectal carcinoma (n = 85), diver ticulosis (n ~ 9), megarectum (n = 3), ulcerative colitis (n = 1). Rectal tumours were located a mean distanen of 9.8 cms. from the anal verge. Eighty two per cent oftumours were advanced lesions (Dukes B 48%, C 28%, D 6%). The mean height of the anastomosis above the anal verge was 5.5 cms. Sixteen of the first 20 patients had a covering culostomy but only 16 of the last 78 patients have had a temporary stoma (20%). Two patients had clinical evidence of anastomotic leakag e and both survived. Radiological leakage on gastro- grafin enema 10-14 days post-operatively Was 11%. Technical com- plicatinns occurred in 6% of cases (rectal tears 2, loose staples 1, failure to disengage anvil 3). Operating time was less than 3 hours in 40 of the first 50 patients. Perioperative mortality was 2% due to cardiovasacular causes only. Local recurrence of tumour occurred in 6% of patients after a follow-up of 4 yeers.

In conclusion cross-stapled end-to-end anastomosis has made low anterior resection fur rectal carcinoma a safe procedure with low mortality, an acceptable local recma~nce rate and minimal clinical anastomoticleakage. Morco:cer the cumulative anastomotic leak rate of 12% (clinical & radiologieal) is the lowest yet recorded.

6. SIGMO/D VOLVULUS; INCIDENCE/PATHOGENESIS

Sulaimen - Shoaib S. Post-Graduate Institute, Peshawar, Pakistan.

Variant local anatomy, social customs, dietary fibre are impfi- cared in interesting variation in incidence. Development of Gangrene is affected by changes in the mesa-colon.

North-Western part of Pakistan is one of the regions of the world with the highest incidence. 30 consecutive patients received hi a single surgical unit over 18 month period are reviewed. Average age was 53.5 years. Average timepresentation to onset of symptoms was 4.10 days. Incidence was highest in summer months. Incidence of gangrene (8 patients 29.6%) did not correlate with time since presentation or age of patient.

Most patients had a thickened mesocolon. This prevented early vascular occlusion. 4 patients had previous surgery for sigmoid volvuhis. One actually had a colonic resection. Adhesions were implicated in recurring volvulus. An 'adequ ate' sigmoidectomy is the proper procedure for sigmoid volvulus.

7, NEUROENDOCRINE CELL ABNORMALITIES IN THE

COLON OF PATIENTS WITH HIRSCHSPRUNG'S DISEASE

J. Soeda, D. S. O'Briain and P. Purl. Children's Research Centre, Our Lady's Hospital for Sick

Children, Crumlin, Dublin 12.

The gastrointestinal tract and its glandular derivatives contain a variety ofnettroendocrine (NE) cell types that are dispersed along the mucosa. Each NE cell type synthesizes, stores and secretes a specific neuropeptide and/or bioganic amine that acts as a chemical messen- ger in orchestrating the various secretory, motor and absorptive

522

functions of the gut. Changes in the nanlber of endocrine cells in several gastrointestinal tract diseases have been reported. We studied NE cell population in the bowel from 13 patients with Hirschsprung's disease as well as colon from six controls.

Immunohistochemical studies were carried out using monoclonal and polyclonal antibodies against chrornogr anin A and synaptophysin (general markers of NE cells), S-Hydroxytryptamino (S-FIT) (a marker of amine) and Peptide YY (PYY) and somatostatln (markers of neuropeptides). Chromogranin A immunoreactive cells were significantly increased in the aganglionic bowel compared, to ganglionic bowel and controls (p<0.05). There was increase in the number of~synaptophysin immunoreactive cells in the aganglionic bewal ctmpared to ganglionic bowel and controls but the results were not statistically significant. 5-HT immunoreactive cells were also significantly increased in the aganglionic bowel compared to ganglionic bowel and controls (p <0.05). The immunostaining for PYY and somatostatin demonstrated abundance of both these NE cell types in the aganglionlc bowel and this was highly significant compared to ganglionic bowel and controls (p <0.001 ). These results demonstrating the increased levels of infiltrating NE cells in the mucosa of aganglionic colon suggest that the NE cells may have a role in regulating the sustained contraction of the aganglinnlc intes- tino in Hirschspruog's disease.

8~

BACTERIAL TRANSLOCATION AND ANASTOMOTIC INTEGRITY

E. C. Covenoy, V. MclAllistar, E. W. M. McDermott, N. J. O'Higgins.

Department of Surgery, University College Dublin and St. Vincertt's Hospital, Dublin 4.

The aim of this study was to determine the effect of colonic obstruction on bacterial translocation and anastomotlc healing.

Forty Sprague-Dawley rats were randemisedinto two groups. On day I a laparotomy was perfomlad on all animals. In the Control Group, a ligature was placed asound the large bowel, tied and immediate[y-rtfilOv~xl In tile Study Group the ligature was left in place catlsing large bowel obstruction. On day 3, all animals had a rel~gat lsparotomy. Peritoneal culture swabs were taken. In the

-Control Group, the segment of bowel where the ligature had bean placed was reseated with primary anastomosis. In the Study Group, the obstructed segment of bowel with the ligature in situ was resected and a similar primary anastomosis performed.

The animals were killed on day 7 and the bursting pressure of the anastomeses mensured. The anastomosis was considered defective if the bursting pressure was less than 100 mmHg. Six rats died prior to completion and were excluded from analysis.

Results Group Number Defective Bacterial

Anastomisis Transloeation Control 16 1 1 Study 18 9 10 Fishar's exact test p=0.04 p=0.02

Anastomotic breakdown occurs more commonly following primary anastomosis for large bowel obstruction. There is associated bacterial translocadon into the peritoneal'cavity.

9.

I.J.M.S. August, 1992

RESECTION AND PRIMARY ANASTOMOSIS FOR LEFT COLON OBSTRUCTION

M. Mailer, R. Waldron, M. T. P. Caldwell, P. Murchan, W. Beesley, T. M. Feeley,

W. A. Tanner, F. B. V. Keane Deparmaont of Surgery, Adelaide Hospital, Dublin.

The management of obstructing left-sided, colonic and rectal lesions has traditionally been by a staged procedure. The intreduc- don of "on-table lavage", has made primary resection and anastomosis of the large bowel feasible for patients presenting as emergen- cies.

We have studied the perioparative course of 28 patients who pre- santed with left colonic obstruction to determine whether primary re- anastomosis conferred additional morbidity. The patients ranged in age from 29 to 89 years (median: 66 years) at presentation. Fourteen patiems underwent resection, on-table lavage, and anastomosis (OTL) and 14 a Hertmaml'S procedure (H). Four patients in the OTL group were graded as ASA, 4 relative to one patiant in the H group. There was no clinical anastomofic leak in patients undergoing primary asmstomosis. The mean operative time for the OTL procedure was 3.3 hours. There was no significant difference in the postoperative complication rate or mean hospital stay rate for the primary procedures between the two groups. However secondary surgery for patients undergoing colorectal recolmection conferred added morbidity and expense for patients who had a Hurtmann's procedure.

We conclude that resection, on-table lavage, and primary anastomosis is safe in the management of left-sided colonic obstruction and in selected cases is the treatment of choice.

10 THE MODERN MANAGEMENT OF ACUTE COMPLICA-

TIONS OF PEPTIC ULCER DISEASE

F. Abbasakoor, S, E, A, Attwood, L P. McGrath, R. B. Stephens St. James's Hospital, Dublin 8. .

A retrospective study is presented of 100 consecutive patients with a perforated peptic ulcar at our Institution over a six year period. The mean age was 49.1 cvanly dis~buted across the range 16-89 with 24 being over 70 years. All patients underwent emergency surgery and the 30 day mortality was 6% (1% in the 76 patients < 70 years and 20% (5/24) in the > 70 years group). 76 were smokers and the male to female ratio was 3:1. H2 Receptor Antagonists were being consumed by 16% at the time o f their perforation and 20% were taking non-steroidal anti- inflammatory drugs. 94 patients underwent simple closure followed by H2 Receptor Antagonist therapy after surgery and 6 had definitive surgery as their first procedure. Follow up symptoms were assessed using recent out patient attendance and postal questionnaire. Subsequent surgery was required in 5 (2 for gastric outlet obstruction and 3 for persistent symptomatic duodenal ulcer), with a range of 6-69 months follow up. The majority of patients were symptom free requiring no medication. Despite the widespread use of H2 Receptor Antagonists in the community, perforated peptic ulcer is still a common complication. This study demonstrates that perforation can be safely and effectively nranaged by simple emergency surgery.

Vol. 16I No. 8

11. HOW GOOD IS TRADITIONAL CHOLECYSTECTOMY7

E. O'Broin, M. O. Davies, J. McGirdey, C. Maunion, S. Gupta, M. F. Shine, F. Leunon.

International Missionary Training Hospital, Ota" Lady of Lousdes, Drogheda, Co. Louth.

With the recent advances in therapy for cholelithiasis, it is timely to audit the present status of open surgery performed in a typical Irish district hospital in order to provide a backdrop against which to ctiticallyjudge new developments. This is aretrospective study of all non-malignant-l~iliary surgery carried out over a 6 year period between Jantiary 1985 anti December 1990. 721 patients underwent surgery: 555 (77%) were female and 166 (23%) were male. The average age of the patients was 49_+16 years (mean + SD). 67.4% patients were admitted via the surgical outpatient department, 30.6% via the accident unit, 2% via other sources. 673 (93%) had the diagnosis confirmed on ultrasunography. 542 had an elcctlve procedure and 179 patients had an urgent or emexgency operation. The majority of the operations (70%) were performed by a consuItant surgeon: 616 had a simple cholecystectomy (85%), 91 had in addition a common bile duct exploration (13%) and 14 had an additional unrelated proccdure(2%).Tha average hospital stay was 12.3 + 6.3days(meen :i: SD, range 2-34 days). There were no perio- per ative deaths. The general morbidity rate was 24.4% and the procedure-related morbidity rate was 6.5%. For simple eholecystec- temy, the general morbidity rate was 15.1% and the procedure- related morbidity rate was 2.7%. This study camfmns that open cholecystectomy is a safe operation which can be performed with no associated mortality and a low but acceptable morbidity rate.

12. DELAYED PRIMARY ANASTOMOSIS FOR OESOPHAGEAL

ATRESIA: EIGHTEEN MONTHS TO ELEVEN YEARS FOLLOW-UP

G. Ninan, P. Puff, R. J. Fitzgerald, E. J. Guiney end B: O'Don- nell.

Children's Research Centre, Our Lady's Hospital for Sick Children, Cmmlin, Dublin 12.

In 1977 we started treating babies with isolated ocsophageal atresia by delayed primary anastontosis and in 1981 reporlzd our early experience in five eases treated between 1977 and 1979. Since 1979, eleven further consecutive cases have been managed by initial gastrostomy followed by delayed primary oesophageal anastomosis. Their mean gestation was 35 weeks (range 20 to 40 weeks) and mean birth weight was 2040g (range 1140 to 2720g). The oesophagealgap between the two ends when assessed initially at fluoroscopy ranged from 2.2 to 4.5cms (range 3.2 ores). Age at delayed primary anastomosis ranged from 6 to 20 weeks. Anastomotic leak occurred in 3 babies in the immediate postoperative period and all were successfully managed conservatively. Eight of the eleven patients developed anastemotic st:rietares; seven cases required I to 5 oesophageal dilatations. One patient who did not respond to multiple oesophageal dilatations, required resections of oesophageal stricture.

One patient died at 15 months o f age o f unrelated causes. The ten surviving patients have been followed up from 18 months to eleven years; At follow-up, 7 patients were eating normally. Three patients had swallowing difficulties end all three were found te have ousoph-


ageal strictures on barium swallow, two of them also had gross oesophageal reflux and hiatus hohlia. The height and weight in the ten patients varied from 3rd eentile to 75th eentile. Delayed primary anastomosis is feasible in cases of isolated oesophageal atresia and the patient's own oesophagus is the best. A more aggressive approach should be applied to gastro-oesophageal reflux in these patients.

13. THE MANAGEMENT OF OESOPHAGEAL PERFORATION

A. F. O'Dounell, D. Luke, A. E. Wood. Department of Cardio-thoracic Surgery, Mater Misericordiae Hos-

pital, Dublin.

Perforation of the oesophagus carries a serious prognosis and is associated with a high morbidity and a mortality rate approaching 60%: recommendations regarding l/eatment remain controversial. Between 1984-1991 ten patients with oesophageal per foratious were treated. Patients with anastomotie leaks and malignant perforations were excluded. There were 5 male end 5 female patients; mean age 58 years (23-76 years). There were 8 spontaneous perforations, 2 instrumental and I foreign body perforations. One patient had a second spontaneous perforation after an interval o f four years. Eight perforations were confirmed radiographicaUy and fltree on clinical grounds.

The commonest symptoms were chest pain (10) and dyspnoea (4) and clinical signs included pleural effusion (8), pneumothorax (4) and pneumomediastinum (4). All 10 patients underwent surgical treatment involving: thoracotomy & drainage, gastrostomy and jejeunostumy (8), thoracotemy and muscle flap closure (2), and thoracotomy & drainage (1). Surgery was combined with total parenteral nutrition (mean 19 days) and intensive antimicrobial therapy. Five patients had surgery within 24 hours of perforation and a further 4 patients had surgery within 48 hours. One patient had a delay in diagnosis of 20 days following the first perforation and a 10 day period of conservative management prior to surgery on the second presentation. Two patients were referred for management after normal laparotomius. Oral intake was recommenced alter an average of 22 days and the mean hospital stay was 35 days. Ten of eleven patients were discharged from hospkal with an overall mortality of 0%.

We conclude that the diagnosis of oesophageal perforation is sometimes delayed and that the combination ofthorungh medias tinal drainage, mrtimicrobial therapy and early post-operative nutritional support are essential elements in the successful management of these patients.

14. VENTILATION FOLLOWING ELECTIVE OESOPHAGEC-

TOMY THE EFFECT OF EARLY EXTUBAT1ON.

P. G. Murphy, T. N. Walsh, A. D. K. Hill, H. Li. T. P. J. Hen- nessy.

St. James's Hospital, Dublin 8.

Surgical resection of oesophageal carcinoma provides the best hope of cure and arguably the best palliation. However, post operative morbidity, particularly respiratory complications, may mar the outcome. As a significant nur~b#r of patients required prolonged post operative ventilation, with subsequent difficulty in weaning./n

524

January 1990 we changed our policy from marldatory overnight ventilation to one of emly post operative extubation. The post operative morbidity and mortality was compared for the year before and the year following this change in management. Post cricoid resections were excluded because o f their different respiratory physiology.

1989 1990 Number of patients 36 45 Mean age (years) 66.1 66.8 Ventilated overnight 28 7 Ventilated >24 hours 10 2 Number r ecAuiring reventilation 10 O Mean ICU stay (days) 9.9 5.7" 90 Day in hospital mortality 16.2% 4;4%**

*p <0.01 **p <0.05

This data wonM appear to suggest that, following elective oesophagectomy, early extuballon (on the evening of surgery) is associated with a shorter ICU stay and a reduced in-hospital mortality.

15. A RANDOMISED PROSPECTIVE TRIAL ASSESSING AD-

JUVANT THERAPY IN OESOPHAGEAL CANCER--PRELIMINARY REPORT

A. D. K. Hill, T. N. Walsh, N. Noonan, B. Breslin, P. W. N. Keeling, T. P. J. Hennessy

St. James's Hospital, Dublin 8.

While surgery provides the best hope of cure in onsophageal cancer, the majority of tumours are advanced at presentation. The only hope for improved sm'vival lies with improved adjuvant therapy. The most effective regimens have been associated with a high morbidity mad mortality. We carried out a preliminary examination on the effect of a modified regimen on treatment morbidity and mortality.

All patients less than 76 years with no evidence of metastatic disease, were randomised to either preoperative radiotherapy and chemotherapy followed by surgery or surgery alone. In the l-trst week 267 Rads were administered each day for 5 days with 5 -finorouracil as a radioseusitisar.This was followed by hydration on day 6 and cis- platinum on day 7. Weeks 2 and 3 consisted of radiotherapy alone at a daily dose of 267 Rads. The total dose of radiotherapv was 4000 Rads. The same course of chemotherapy was repeated in week 5 followed by two weeks rest. Surgery was carried out in week 8.

Sx ONLY SX + ADJUVANT (n=17) (n=12)

Average follow up (months) 3.5 4 Adenocarcinoma (%) 11 (64%) 6 (50%) Squamous carcinoma (%) 6 (35%) 6 (50%) Nodal involvement (%) 11 (64%) 2 (16%) Penetration throngh wall (%) 17 (100%) 7(58%) 9 day in hospital mortality (%) NIL 1 (8%) Deaths on follow up (%) 2 (11%) 4 (33%)

Preliminary results suggest that there is no inereasod morbidity using this regimen. Significant bone marro~r depression occurred in

I.J.M.S. August, t992

three patients only. Surgery was no more difficult in the group receiving adjuvant therapy. It is too early to determine whether this regimen of adjuvant therapy will have an impact on survival.

16. TRANSHIATAL OESOPHACECTOMY IN THE MANAGE-

MENT OF EXTENSIVE OESOPHAGFAL CARCINOMA

A. J. Curran, D. B. Gough, I. R. Davidson, P. Keeling. Department of Thoracic & General Surgery, University College

Hospital, Galway.

The purpose of this review is to present our three year experience with transtdatal oesophagectomy in the management of advanced oesophageal carcinoma.

Thirty-fly e patients hay e undergone this procedure for tumours in the upper (3), middle (10) and lower thirds of the oesophagus (22). Four arose in Barrett's oesophagus. 95% presented with dysphagia. Orringer's technique was used and all cervical anastomoses were hand sewn.

The median duration of surgery was 2.9 hm~s (range 1 . 5 ~ . 0 hrs) and the 30 day Hospital mortality 16% (6 patients). Respiratory complications (44%) accounted for four deaths. Median pest-operative stay was 21 days (range 13--53) while median ICU stay was 9 days. 97% ofpatients h~v.l stage 111 disease and 14 (38%) had lymph node involvement.

19 patients have died, leaving 18 alive. The actuarial survival is 56% at one year and 31% at two years. Of the operative survivors 90% resumed normal swallowing although 17 (46%) required outpatient dilatation

Transhiatal oesophagectomy provides safe mad efficient palliation while mortality and one year survival compare with the trans- thoracic approach.

17.

CONTINUOUS MONITORING OF DUODENOGASTRIC RE- FLUX USING AN ION-SPECIFIC SODIUM ELECTRODE

D. P, O'Leary, A. Smythe, N. C, Bird, A. G. Johnson. University Dept. of Surgery, Royal Hallamshire Hospital,

Sheffield.

Duodenog astric reflux (DGR) has bean proposed as an aetiologi- ca] factor in the developmant of gastric ulcers and gastritis, however, clarification of its role is difficult because DGR is frequendy epi- sodic and techniques available for assessing it are unsuitable for prolonged monitoring. We have observed that above 50 mmol/l the (Na + ) of gastric juice correlates closely with DGR. The purpose of this study was to compare levels of DGR in selected clinical settings using prolonged monitoring with a sodium ion selective electrode.

DGR was studied in controls, in patients with persistent pain following gastric surgery, and in gastric ulcer patients, using intra- g as tric Na +/pH electrodes and a data log get. Res ul ts: The procedure was well tolerated for up to 5 hours. Results are presented as the percentage of time (median and range), during which DGR occurred, as deemed by (Na + ) > 50 mmol/l. Data were analysed using the Mann-Whitney U test.

Vol. 161 No. $

Group n DGR % time (range) P.

Controls 15 4.2 (0-37) Gastric Surgery 9 91.0 (3.5-96) 0.0004 Gastric Ulcer 5 67.2 (41.4-96) 0.001

DGR occurred in both controls and patient groups, as has been reported previously, and there was ennsider able overlap in the range of results between groups. Nonetheless, patients with gastric ulcers or postgastrectomy pain had significantly more DGR, as a group, then controls. We anticipate that the prolonged monitoring possible with the sodiimt electrode shouldpermit more precise assessment of DGR and its relationship to symptoms and to pathology.

18. PANCREATIC HEAD AND PERIAMPULLARY

CARCINOMA--TREATMENT OPTIONS

P. Nicholson, K. Mealy, J. Hyland, O. Traynor. Dept. of Surgery, St. Vincent's Hospital, Dublin 4.

Late presentation of patients with Pancreatic Head (PH) and Periam- puL!.ary (PA) carcinoma is frequently thought to preclude the option of curative surgery. However, pre-operative assessment of resecta- bility can be difficult. To examine the role of surgery in these conditions we reviewed 83 patients who presented with PH end PA c arcinom a to our unit over the last eight years. There were 47 men end 36 women with a mean age of 65 (range 33-94). Presenting symptoms were weight loss (66%), jaundice (61%), pain (33%) and nausea end vomiting (28%) The mean duration of symptoms was six weeks. Pre-operative work-up included ultrasound (100%), ERCP (66%), CT scanning (49%) and PTC (33%). Eighteen patients were deemed inoperable and had endoscopic stenting; which was unsuc- cessful in one case. Sixty four patients (78%) mlderwent surgery. Within this surgical group 19 patients (33%) had a Whipples procedure (three Pylorus-preserving) while the remaining 46 patients (67%) had a surgical by-pass. Pre-opor ative invesfig'atlon could not determine reseetability in all patients undergoing surgery. Histologi- cal diagnosis was confirmed in 100% of the curative resection patients, 66% of patients with surgical bypass end 33% of patients undergoing endoscopic stenting. In-hosp'ffhl mortality and significant morbidity was 11% and 15% respectively for the curative resection group, 11% end 16% respectively for the surgical bypass group and 0% and 32% for the endoscopic stenting group. The two and half year post-operative survival rate for curative resection was 60%.

These figures indicate that curative resection in patients with PH and PA carcinoma has a low mortality and good initial survival. Attempt at curative surgery therefore should be seriously considered in a high proportion of these patients.


Session II

19. DISTRIBUTION OF AROMATASE CYTOCHROME p430

ACTIVITY LEVELS IN BREAST ADIPOSE AND TUMOUR TISSUE TAKEN FROM MASTECTOMY SPECIMENS.

K. Dawson, L Aitken, B. A. Cooke, S. P. Parbhco. Royal Free Hospital and Medical School, London, United

Kingdom. Peripheral conversion of androgens to oestrogens may be of im-

portance in post-menopausal breast cancer, as 1/3 of human breast eeneers are hormone dependent. The aromatase enzyme complex is responsible for the conversion of Ci9-androgens to C 18-oestrogens in all oestrogen manufacturing tissues e.g. ovary and placenta. In postmenopansal patients the main site of activity is in peripheral adipose tissue. The recent imxoduction and clinical use of new aromatase inhibitor s has stimulated much interest in the importance of local oestrogen production in the breast by this enzyme and its relevance to breast cancer development and treatment.

The most widely used and convenient method of quentitating P- 450AROM activity is to measure the release of trifiated water, a byproduct of the aromatase reaction, which is produced in equimolar aanounts f~om a radio-labelled substrate. We have validated this assay using specific P~450ARoM inhibition studies and oestrogen end product isolation, and are using it to assay breast cancer sample- . Tissue trom 1 l0 patients with malignant breast disease (40 total mastectumy, 40 segmental masteatomy, 30 malignant htmpectomy) has been collected and stored. Tumour, adipose and nodal samples f rum these patients are currently being processed. To dote, in 40 sanlples from total mastectomy specimens, the following statements can be made: 1. P-450AaOM activity ranged from 0-160 pM oestrogen/mg pro-

tein/hr 1. This is consistent with previous reports. 2. Adipose tissue from the 4 breast quadrants has yielded detect-

able P-450AaOM levels in 25% of samples. 3. Tunlour sanlples showed 40% with detectable P-450 ~ROM actlv -

ity. 4. Contrary to previous reports, in adipose tissde taken from the 4

quadrants of the breast, no clear relationship has been demonstrated between tumour site and levels of P~50^ROM activity in the surrounding adipose tissue. Maximum activity seems to be randomly allocated between quadrants.

These results support the use of this assay in attempting to select a defined subgroup of patients with appreciable aromatase activity, in whom specific aromatase inhibitors may be clinically beneficial.

20. MONOCLONAL ANTIBODY MEDIATED GROWTH INHIBI-

TION OF BREAST CARCINOMA CELLS: INTERACTION WITH THE EPIDERMAL GROWTH FACI'OR RECEPTOR

N. N.Williams, J. M. Daly, M. Herlyn, D. Bouchler-Hayes. The Wistar Institute, Philadelphia, and the Departments of Bin-

chemistry and Surgery, Royal College of Surgeons, Dublin.

In recent years monoclonal antibodies (MAbs) reacting with tumor-associated antigens have attracted considerable interest as potential immunotllerapeutic agents. Transforming growth factor-

526

alpha (TGF-~t) acting via the epidermal growth factor receptor (EGF-R) has been suggested to function as an autocrine growth factor in the progression of many different cancers to the metastatic stage. In this study, we characterized non-immunological anti- mmour effects of MAb 425, a monoclonal antibody which binds to the EGF-R in the breast cancer cell line BT-20. Direct radioimmu- noassays (12SI) were performed using human EGF and MAb 425 to determine the number of Et3F-R present on the line. Anchorage- independent growth assays for the detection of TGF-ct-like activity in spent media of the BT-20 cell line was carried out using the NRK soft agar assayvStiinulation growth assays were performed on the cell line by ~ding TGFqx to cells seeded in 24-well culture plates. Similarly~growth inhibition assays were carried out by adding MAb 425 at different concentrations end determining cell counts at days one and 14 after seeding, using a Coulter cell counter.

Cell Line EGF molecules TGF-ct (ng/ml) % inhibition bound per cell secretion with MAb 425

BT-20 1.2 x !0 ~ 4.6 41

MAb 425 was found to significantly inhibit growth of the breast cancer cell line BT-20. This correlated with the fact that this cell line secreted detectable levels of TGF-~, expressed a high number of EGFR and also responded to exogenously added TGF-~ in standard growth stimulatory assays (not shown). This study demonstrates that in addition to intmunological anti-tumor effects MAb 425 may have a dual, possibly synergistic effect on EGF-R-expressing tumor cells in patients with breast cancer.

21. HISTOLOGICAL CLEARANCE OF IMPALPABLE BREAST

CANCER USING FINE WIRE LOCALISATION BIOPSY

R. C. Stuart, M. J. Allen, W. D. Thompson, A. L. G. Peel. Department oF Surgery, Noah Tees General Hospital, Stockton-

on-Teea, England.

Fine wire hiealisation (FWL) biopsy is traditionally used to diagnose impalpable breast cancer prior to a more definitive surgical resection. The aim of this study is to detertuine whether FWL biopsy can achieve complete histological clearance (defined as a minimum clearance of _> 2mm.) thereby reducing the need for further breast surgery. Seventy two of 129 consecutive FWL biopsies performed were malignant (benign: malignant = 1:1.26). Forty were detected at screening and 32 were clinical referrals. Wire placement to within 5mm. of the lesion was achier ed in 95 % of cases and all lesions were snecessfuly excised. In 87.5% of cases a single piece of tissue was excised. Histological clearance was achieved in 52.8% (n=38). Mammographic features associated with complete clearance were (a) mass lesions, 30 of 47, compared to either microcalcificatlons or parenchymal deformity, 8 of 23, P<0.0%, and (b) small size, 13.8 + 6.5mm. (mean + S.D.), compared to 23.1 + 21.6nml. for lesions incompletely excised, P < 0.01.

Complete excision was more often achieved in screening detected lesions (26/40) compared to clinical referrals (13/32). Patients with multi focal disease had a high incidence of incomplete excision, 23/32, compared with only 11/40 with unifocal disease, P<0.05. Clinically referred patients had a higher incidence of positive lymph nodes (60%) compared to the screening patients: (4.8%), P<0.0I. Only 31 patients required further surgery to the breast. Residual cancer was found at" the FWL biopsy site ih 19. All had previous

I.J.M.S. August. 1992

incomplete FWL biopsies. No patient (n=5) had residual malignancy detected following a histologically complete excision.

Impalpable breast cancers differ in screening and clinically referred patients. Complete histological clearance of impalpable breast cancers can be achieved by the initial diagnostic FWL biopsy.

22. NUCLEOLAR ORGANIZER REGIONS IN FEMALE:

BREAST CARCINOMA

D. T. Hehir, K. Cronin, A. McCann, P. A. Dervan, S. J. Heifer- nan, W. P. Haderman.

Departments of Surgery & Pathology, Mater Hospital, Dublin 7.

Argyrophfl Nucleol~ Organizer Regions (AgNOR's) are acidic proteins which can be highlighted in archival histological tissue by a silver staining technique. We have previously demonstrated the role of AgNOR's in the progonsis o f patients with breast carcinoma I .

The aims of this study were (Fig. 1) to assess the value of AgNOR's in predicting tumour recurrence and (b) correlating AgNOR's with turnout grade.

Fifty-one female patients had segmental mastectomy and radiotherapy for primary breast carcinoma; all patient's were followed prospective to determine tumour recurrence and survival. Represen- tative archival histological specimens were examined for tumour grade, silver stained and counted for AgNORs.

(A) Disease Recurrence (B) Disea_~e Free <36 month.s >60 months

AgNoRS 6.4 + 2.0 2.7 + 1.3 (mean)

There was a a significant correlation between mmour grade and AgNOR's using linear regression analysis.

This study demonstrates that AgNOR's may be useful hi the management of female breast carcinoma and correlates well with tumour grade.

1. Hehir D J, C~onin K, McCaon et al. Nuclcelar organizer regions in breast carcinoma. Br. J. Cancer, 1990; 62:538 (a).

23 IMAGE ANALYSIS AND FLOW CYTOMETRY IN THE

AUTOMATED ANALYSIS OF HISTOLOGICAL GRADE IN BREAST CANCER

M. H. Galea, B. Dilks, A. Gilmour, L. O. Ellis, C. W. Elston,' R. W. Blarney.

City Hospital, Nottingham, England.

Histological grade is a strong independent predictor of prognosis in breast cancer, but has failed to gain widespread acceptance because of poor i-eproducibllity between centres.

A score derived from flow cytometric and semi-automated image analtysis which can be used to replace grade was derived from paraffin embedded archival material of 230 patients with primary operable breast cancer. The standard deviation of nuclear size (OBSZSD), amorphologlcal measure ofnucle~ ple~maorphism, was

Vol. 161 No.

obtained by image analysis (CAS 200) and the proliferative index (Pl), the sum of %S + %G2M fractions of the cell cycle derived from flow cytometric DNA histograrns (FACS). These two variables, together with DNAploidy, ER status, CerbB2 andNCRC-I I staining were assessed in a stepwise multiple regressio n analysis controlling for grade: only OBSZSD and P1 showed independent association. Combining these two variables, the following score was derived: Score = (0.3 x OBSZSD) + (0.3 X PI).

In a Kmskall-Wallis analysis of variance these scores showed significant relationship with grade: Ctfi-square = 68.6 p < 0.0001. By assessing the distribution of histological grade in the 230 study patients, anddividing the score into equivalent r~ages, prognostic informaSion equivalent to grade was obtained.

A semi-objective measurement of histological grade using image analysis and flow cytometry is described. This can be calculated by technical officers�9 Correlation with grade has been confirmed retro- spoctively and is presantly being tested prospectively.

24. DNA FINGERPRINTING OF BREAST LESIONS

S. O'Rourke, M: H. Galea, A. Mookens, A. Gilmour, R. Carter, D. Parkln, R. W. Blarney.

City Hospital, Hucknall Road, Nottinglmm.

Genetic fingerprinting offers a s~msitive method for determining hypervariable DNA fragments specific to an individual such that every normal cell in the body should give the same pattern. The chromosome structure of invasive breast cancers is severely dam- aged.Therefore there must be aphase at which the fingerprint pattern becomes abnormal. We have examined the constitutional and tumour DNA of 59 patients with a variety of breast lesions using DNA fingerprinting analysis. The restriction enzyme Hae IlI and the Jeffrey's minisetellite probes 33.6 and 33.15 were used. Alterations in the DNA fmgesprint pattern were correlated with histological type and grade and nodal stage as well as with the DNA index of the lesions, as determined by flow cytometry. The relative tumour content of each biopsy was determined. 59% (28/47) of invasive cancers of all types exhibited 1 or more DNA fingerprint change when tested with a combination of both probes, and this increased to 72% (18125) when only ductal lesions were analysed.

Results: Histological diagnosis n No. of cases

with F/P changes 1. Benign lesion 9 2. In sito CA 3 3. Grade I invasive CA 13 6 4. Grade 11 invasiveCA t9 13 5. Grade 111 invasiveCA 15 9

Genetic f'mgerprinting may be used to detect minimal changes in the DNA in Order to define the borderline between the normal and the malignant cell.


25. EXPERIENCE WITH NEEDLE LOCALISATION BIOPSY OF

THE BREAST

N. F. Couse, C. P. Delaney, P. G. Horgan, J. M. Fitzpatrick. T. F. Gorey.

Surgical Professorial Unit, Mater Misericordiae Hospital and University College, Dublin

Screening manonography is effective in detecting carcinoma of the breast in the preclinical stage. 82 asymptomatic women attending for screening mammography had abnormal mammograms. Needle localisation and breast biopsy of the abnormal area were performed. All specimens were sent for specimen mammography and histologi- ca] examination.

82 women, mean age 56.3 years (50-~5), had 83 needle guided biopsies performed. Wire displacement prior to or during surgery was suspected by the surgeon in 6 cases (7%); Nonetheless, in 5 of 6 patients the correct area was hiopsied. The histological diagnosis was benign breast disease in 48 biopsies (58%), invasive carcinoma in 32 (38%) and intraduct carcinoma in 3 (4%). Biopsy failed to remove the suspicious lesion in 3 patients (4%), in one of whom the wire was obviously misplaced. In these 3 patients, the submitted histology was benign bnt repeat biopsy was advised. Surgical complications occurred in 3 patient~ (4%), 2 haematomas and one wound infection.

Needle localisation of suspicious non palpable breast lesions yields a high percentage of cancers. The procedure has minimal morbidity. Specimen mamurogr aphy and care ful histological examination are required to confirm accurate biopsy. Repeat patient mammography is indicated if there is doubt about the accuracy of biopsy.

Session III 26.

GLOVE PERFORATION IN ORTHOPAEDIC SURGERY

J. M. O'Byme, J. P. McCabe, M. Stephem, F. McManus. Dept. of Orthopaedic Surgery, Mater Misericordiae Hospital,

Dublin 7. An intact barrier between file surgeons hands and the patient is

important to prevent transmission of disease in either direction. Between 10% to 40% of surgical gloves develop punctures during General Surgery cases. In this study we determine if the incidence of glove perfcrration was higher in orthopaedic surgery and whether factors specific to or thopaedie snsgery~ouble gloving, instrumentation, etc. played a role.

One hundred and eighty two pairs of gloves were tested. The gloves used were Ansell and Regent. Surgeon, first assistant and nurse completed questionnaires that specifically asked the nature of the operation, (instrumentation or not), whether they were aware of a perforation and, if so, how it had happened. Gloves were tested for holes by inflating the glove with water and occluding the cuff. Where double gloves were used, the findings in both gloves were recorded.

The total perforation rate was 40 per cent. Sixteen per cent of the gloves had umecognised perforations. The surgeon was most at risk of perforation. The perforations were usually associated with metal implantation. Double gloving appears to offer protection in that when external glove was perforated, the intem',d glove was usually undamaged.

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27. CLINICAL APplICATION OF VIBRATION ARTHIROM-

ETRY IN ANTERIOR KNEE PAIN.

J. L.Mangan. D. A. Bar'r, G. J. Mulvenna, P. Maginn, W. G. Kemohan and R. A. B. Mullah.

Queens University of Belfast, Department of Orthopaedic Surgery, Musgrave Park HospitaL, Belfast.

Patients with anterior knee pain present a diagnostic challenge. Arthroscopy provides evidence that derangement ofpatellar articular cartilage is related to the clinical situation. Development of a non invasive method of assessing the patellofemoral joint may solve a clinical problem. Vibration artbrometry is a new non-invasive diagnostic medallty, which assesses patellar vibrations. Thesevibratians are thought to be the result of friction and compliance of patellofcm- oral articular cartilage. Accelerometers used to detect these vibra- fious, produce a continuous signal, teffaedphysiologicalpatellofem- oral erepitus (PPC).

Two groupe of volunteers were investigated to determine the features of PPC. To def'me the characteristics of normal PPC, 10 normal subjects, group A, were examined. A second group (B) of 10 subjects with knee pain was investigated to ascertain distinguislu'ng properties of the groups signals. Three dimensional spectral analysis (frequency v,s joint angle vs amplitude) was performed on the PPC signal of eaeli group. The frequency harmonics of the signaI produced by group A varied regularly with time, while that of group B varied in a bizarre fashion. Waveform analysis revealed that group A had a significantly higher beat repetition rate (mean frequency = 32Hz, s.d. = 6Hz) than group B (mean frequency=12Hz, s.d.=7Hz). This is explained by reference to intra-ar tieular friction.. Defining a ccefllcient of asymmetry given by the proper ratio of the time periods from the peak of the beat waveform to each of its zero crossings, it was observed that group B had a strong tendency to asymmetry (m ean=0.31~ s.d. ---O.B ) compared to group A (mean=0.22, s.d .=0.03 ). This may be explained by consideration of articular cartil age compli- mace. These observations support the hypothesis that differences in friction and compliance of articular cartilage occur in normal and symptomatic knees and confirms a role for PPC analysis in non- invasive study of articular cartilage.

28. THE ROLE OF IMAGING MODALITIES IN DETERMINING THE LEVEL OF BONE RESECTION IN THE TREATMENT

OF OSTEOSARCOMA.

S. J. O'Flanagan, J. P. Stack, P. Derven, B. Hurson. Cappagh Hospital & Mater Hospital.

Amputation has been the traditional definitive treatment for osteosarcoma. With recent advances in chemotherapy, imaging techniques and reconstructive limb surgery, limb salvage is now a valid alternative for the majority of patients. The level of proximal and distal bone resection in limb salvage is based on the pre-operative evaluation of the extent of inlramcdullary tumour. We compared the accuracy of Magnntie Resonance Imaging (MRI), Computerised Tomography (CT), and Isotope Bone Searming in predicting pre- operatively, the correct level of intramedullary involvement. The measurements were subsequendy compared to the actual tumour extent as determined by serial histological examinatiorts of the resected specimens following definitive surgery. Thirty four patients


with primary ostensarcuma of a long bone were studied. MRI was 96% accurate in oudinlng the extent of medullary tumour whereas CT scans had an accuracy of 75%. With MRI, the T1 weighted sequence werebestin indicating the tumour-marrow inteafface whereas soft tissue extension was best determined using the T2 weighted sequence. The inaccuracies found with CT were found to be due to a lack of inherent contrast available with CT compounded by the narrow marrow cavity, slice thickness and volume averaging.

The presence o f a flexion con traeture of ajoim close to the tumour was an important cause for inaccurate measurements from both MR[ and CT scanning. The role of Isotope bonn scanning is eonf'med to detecting skeletal metastases and rarely the presence of skip lesions.

29. CALF VENOUS PUMP FUNCTION FOLLOWING ANKLE

FRACTURES

S. Tiemey, P. Fitzgerald, P. Burke, T. O'Sullivan, P. Grace, D. Bouehier-Hayes.

Dept. of Surgery, Beaumont Hospital, Dublin.

Venous thrombotic complications following fractures of the lower limb are assumed to be due to direct trauma and loss of the calf venous pump following immobilisation. We used air plethysmogra- phy to quantify calf pump function in the immobilised limb following ankle fractures in 15 patients. Calf venous volurae (VV), the rate of venous filling (VFI) and venous volume changes produced by calf muscle contraction i.e. ejection volume fraction (EVF) and residual volume fraction (RVF) were measured in the uninjured (control) and fractured limbs immediately prior to and following six weeks of immobilisation. Fractures were treated by internal fixation and the limb was hnmobilised in plaster of paris for six weeks. The results are expressed as mean + S.D. and compared using Students t-test for unpaired observalious.

Immediate Six Weeks Control Fracture Control Fracture

VV(ml) 93_+44.2 [04+31.6 97.5-+30.9 114_+26.5 VFl(ml/.sec) 3-+3.5 2.2:t:1.6 I .S-+I .2 1.2_+0.6 EVF (%) 59+9.4 17.3+7.2" 56.8_+10.8 31+10.8"* RVF(%) 37_+17.7 70-&1S.9" 24_+26 55.8_+12.8#

*p<0.00I **p<0.00S #p<.03

In summary these data indicate that there is significant reduction in EVF% and increase in RVF% immediately following and six weeks 'after internal fixation of ankle fractures. The risk of thiom- hntie complications may thus be prolonged following lower limb fractures and we speculate that antithrombofic measures may be indicated-during the siy~,~eek period of immobilisation in plaster.

30. VARIATION AMONGST TRAINEE SURGEONS IN INTER- PRETING DIAGNOSTIC PERITONEAL LAVAGE FLUID IN

BLUNT ABDOMINAL TRAUMA

J. P. Wyatt, R. J. Evans, S. P. Cusack. Edinburgh Royal Infirmary and Western General Hospital,

Edinburgh.

Objective:--To study the techniques and criteria used by a group of British trainee surgeons when performing diagnostic peritoneal lavage in blunt abdominal trauma.

Vol. 161 No. 8

l)esign:~A short questionnaire followed by assessment of seven bags of simulated peritoneal fluid.

Subjects:~50 trainee surgeons (37 registrars and 13 senior registrars).

Results:--I 2 surgeons (24%) preferred a "closed" technique and 37 (74%) did not perform peritoneal aspiration prior to lavage. 43 surgeons (86%) had never measured lavage cell counts.

11 surgeons (22%) attempted to read newsprint through the bugs of lavage fluid. Visual assessment revealed a wide variation, with thresholds for a positive result ranging from 2460 to 48700 red blood cells per cubic rnm. 42 surgeons (84%) had thresholds outside the "accepted" r affge. Senior registrars had significantly higher thresholds than ragistrars.

Conclusion:--Thexe was a reliance upon visual assessulent of diagnostic peritoneal lavage fluid amongst the trainee surgeons ques- tioned, who had misconceptions about the technique nsed and assessment of the fluid. The higher thresholds seen amongst senior registrars may have resulted from previous experience of "false- positive lavages. In ol"der to avoid these unnecessary laparotomies and to detect injuries which would otherwise be missed, we recommend adoption of routine cell count analysis on diagnostic peritoneal lavage fluid.

31. TRENDS IN FATAL TRAUMA--A FIVE YEAR REVIEW

M. T. P. Caldwell, C. Egleston, S. McGowan, E. McGovem. Department of Cardiothoracic Surgery, St. James's Hospital,

Dublin 8.

The autopsy reports and clinical data of 96 patients presenting to St. James's Hospital with trauma of fatal outcome over a five year period, 1986-1990, were analysed in order to assess the nature and distribution of the trauma and to determine if any of the fatalities were potentially avoidable.

The mean age was 42 years with peaks in the 3rd and 8th decades, and the male: female ratio was 4:1. All cases were the result of blunt trauma r The vast majority were due to road traffic accidents with a small number of industrial and domestic accidents. Filly-three percent had significant chest injuries---one third of these had aortic transection. Forty-four percent had major intra-abdominal injuries and 66~ severe cranio-cerebr al trauma, Fifty-four percent had muhisystem involvement. Twenty-nine of the 96 cases were alive on arrival at the hospital and with retrospective assessment of their elirical records it would appear that 8 of these were potentially salvageable, death resulting from a delay in diagnosis and/or inter- vention.

In summary, it would appear that blunt injury is the predominant mechanism in major trauma in this country, in contrast with large trauma series from North America in which penetrating injury accounts for 25-30% of cases; thoracic, abdominal and cerebral injuries occur with similar frequencies, and a significant number of potentially salvageable patients die following hospital admission due to inappropriate management. These findings have implications for the development of trauma care facilities in th~s country.


32. RAPID EN-LINE BLOOD WARMINO--A NEW MICROWAVE

DEVICE

M. J. Allen, S. D. Schwaitzberg, R. J. Connolly. New England Medical Center, Boston, Massachusetts, U.S.A.

In the setting of massive rapid transfusion requirements, the heating capabilities of conventional blood warming devices are frequently exceeded. The rapid intravenous infusion of large v~l- umes of fluid at less than physiologic temperature can have an adverse effect on patient outcome, making transfusion-associated hypothermia a matter of considerable importance to those involved in rite resuscitation of severely injured hypovolaemic patients. We investigated the possibility of using microwave energy to provide rapid in-line blood warming.

50ml of fresh whole blood was drawn from 10 healthy volunteers, anticoagulated, divided into 4 equal aliquots, and cooled to a mean of 18~ Three aliquots were then exposed to microwave heating by injection through a prototype in-line blood warming device at flow rates ranging from 250-500 ml/minute. An average post-warming blood temper ature of 37.8~ was achieved in a single pass. Control samples were similarly treated but without microwave exposure. Laboratory analysis of free plasma haemoglobin, haptoglobin, PCV, FBC and electrolytes showed no significant differences between microwave heated blood and controls. LDH levels were slightly elevated in the heated group but within normal limits.

These data indicate that microwave energy used in a prototype blood warming device is capable of providing effective in-line heating of large volumes of blood at high flow rates without causing excessive acute haemolysis. Such technology should prove of benefit in the management of hypovolaemin shock and the prevention of transfusion-associated hypothermia. Further workis currentlyunder- way to perfect it's design and assess the effect of acute microwave heating on the invivo survival of cellular dements of blood.

33. EVALUATION OF NUCLEAR PROLIFERATION ANTIGEN

EXPRESSION IN BREAST TUMOURS

R. P, Sullivan. G. Mortimer. Department of Pathology, University College Hospital, Galway.

A prospective series of benign and malignant breast tumours has been evaluated immunohistologically for expression of the nuclear proliferation antigens Ki67 and PCNA in fresh frozen sections and paraffin wax sections respectively. The proliferation index (P1) for Ki67 and PCNA was determined in each instance. The Pl of each antigen was higher in malignant tumours than in benign tumours. Within the malignant group there was variability of the P1 of each antigen between cases with good correlation between the two in individual cases. The Pl was further correlated with standard histological grading criteria for each malignant tumour. Comparison of the 2 antigens revealed a substantially clearer and stronger reaction with Ki67 than with PCNA. This approach should result in more accurate grading and prognostication in breast cancer. Refs:-- 1. Brown D C, Garter KC. Monoclonal antibody

Ki67: its use in histopathology. Histopethology 1990; 17:489-503.

2. Hall PA, Levi~n DA, Woods AL et al. Proliferating Cell Nuclear Antigen (PCNA) Inununolocalization in Paraf- fin Sections. f. Pathol. 1990; 162: 285-294.

530

34. DOES MASTECTOMY FLAP SUTURING AFFECT SEROMA

FORMATION?

E. C. Coveney, J, G. Geraghty, E. W. M. McDermott, P. J. O'Dwyer, N. J. O'Higgins.

Department of Surgery, St. Vincent's Elm Park, Dublin 4.

Wound seromas are a significant cause of morbidity following modified radical mastectomy.

The effect of zlfsing the dead space by suturing the skin flaps to the tmderlying'muscle on seroma formation and its sequelae was evaluated."

Forty consecutive mastectomies with axillary clearance to level 111 were prospectively randomised into 2 Groups. The operative procedure was identical except that in Group I the skin flaps were sutured to the underlying muscle. In both Groups two suction drains were inserted prior to wound closure and were removed 72 hours later. Shoulder mobilisation was commenced on the first postoperative day in both groups. Results are presented below:

Group 1 Group 2 Stats Number 20 20 Total drainage (mls) 272(46) 395(39) p<0.0S* Number of seromas 5 17 1 p<0.0001** Mean seroma volume (mls) 236(41) 429(56) NS* Wound breakdown 0 3 NS* (Values are mean (SE), * Student's t test, ** Chi square with Yates correction)

A similar number of axillarynodes were retrieved in both groups (16.2 v 18.4), NS). A mean overall reduction in long term shoulder mobility was found in the unsutured group and this was significant in elevation and external rotation. Hospital stay was shorter in Group I (7.8 v 9.1,NS).

This study demonstrates that sutming mastectomy skin flaps to the underlying muscle results in reduced seroma incidence and volume with decreased complications.

35. IS ISOTOPE BONE SCINTIGRAPHY NECESSARY IN

BREAST CANCER

B. S. McGlone, D. P. O'Brien, H. A. Yotmis, D. B. Gough & H. F. Given.

Department of Surgery, University College Hospital, Galway.

Two-hundred and three patients who attended our Breast Unit with manunary carcinoma had radioisotope bone scintigraphy performed at presentation. All patients with Stages I (n=82) and 11 (I1=88 ) had "negative" scans at presentation whereas one patient with Stage 111 disease (n=21) and all patients with Stage IV disease (n=12) had "positive" scans at presentation. Locomotor symptoms were present in 6/12 Stage IV patients and in 16/191 non-metastatic patients (p<0.0001). The tumour marker CA15-3 was elevated in 9/ 12 patients with Stage IV disease and 14/191 non metastatic cases (p<0.0001). Serum calcium levels were normal in Stage ] disease, subnormal in one patient from each of Stages 11 and 111, and were

1.J.M_S. August, 1992

above normal in three patients in Stage IV patients (3/12). The alkaline pbo sphatase was elev ated in one patient from e ach of Stage s I and 11, normal in the S tage 111 group and w&g elevated in four Stage IV patients (4/12). During the follow-up period, another sixteen patients progressed to metastatic bone disease of whom seven developed locomotor symptoms, all exhibited elevated CA15 3 levels and four exhibited raised alkaline phosphatase levels. Of tile total twenty-eight patients with bone metastases, eight (29%) developed serious complications of osteolysis and these included; hyper calcaemia (n=2), pathological fractures (n =5) and one patient developed both of these complications simultaneously.

We conclude that baseline bone scans ~e not necessary in patients presenting with Stages I or ] 1 dise&se. However, because of the strong possibility of patients progressing to metastatic bone disease, some surveillance mechanism mus t be employed during the follow-up period to identify those cases. Of the non-radiological parameters routinely available, we advocate CA15-3 as the simplest and most reliable indicator of bone metastases.

36. SYSTEMIC T-CELL FUNCTION AND BREAST CARCI-

NOMA

D. P. O'Brien, D. B. Gough, C. Phelan*, H. F. Given. Depts. Immunology* and Surgery, University College Hospital,

Galway.

It is widely held that carcinogenesis is due to a combination of factors that include alteration of growth phenomena in native cells and a lack of imnmne surveillance and appropriate res'pome in the host. Cell mediated immunity is reputed to play an important role in the host- tumour reaction. We prospectively examined cell mediated immunity (T-Cell function) in sixty-four women presenting to our Breast Unit. From venous blood samples, lymphocytes were isolated using the Ficoll density gradient method. These cells were cultured at a concentration of 10"10 s cells per ml in a medium consisting of a mitogen, RPMI, 10% Fetal Calf Serum and 1% Pencillin and Strep- tomyein for 72 hours at 37.0~ and 5~ C02. At 68 hours, l0 mlcolitres of tritiated Thymidine was added. The amount of isotope incorporated reflects lymphocyte proliferation (blastogenesis) and functional capability. Endogenous IL-2 and (Tmnour Necrosis Fac- tor) TNF levels were performed using enzyme linked immunoabsor- bant assays. A cohort of healthy controls were used to compare and standardise the results. The results of blastogenesis were trans- formed to log 10 and immundinoompe tenee rag arded as less thin1 two Standard Deviations from the log 10 mean. As individual groups, there was no significant difference between Stages 1 IV carcinoma and the controls. There were individuals flora all gro ups who were classlfiable as irmnunoincompetent ( 17/64 Con- A) of whom 5,4,3 and 5 were Stage 1,I 1,111 and IV respectively. Although increase in age can decrease lymphocyte proliferation, immunomcompetence was found in a wide age range (34-83 years; mean (median) 62(60) years. There was no statistical significance between endogeno us IL-2 levels and TNF levels. Thus, cell mediated immunolncompetance does not appear to be related to stage of disease, nor does there appear to be significant IL-2 depletion or cachectin production in mammary carcinonaa.

Vol. 161 No. s

37. CYTOKINE/HORMONE INTERACTIONS ON OESTROGEN DEPENDENT HUMAN BREAST CARCINOMA CELL LINE

J. Byme, K. Barry, D. Gough, L. Hartrahan, F. Given. National Breast Cancer Research Institute, University College

Hospital, Galway.

Advances ha recombinant technology and cell culture technique facilitate the study of the potential for immunotherapy and hormonal manipulationin cancer. The effects of in vivo and ha vitro hormonal agents on human mammary carcinoma are well eharacterised, but the effects of immunomodulators are less well defined. The aim of the following experiments was to examine the growth characteristics of an oestregen dependent human mammary carcinoma cell line (ZR- 75 - 1 ) and how these might be altered by the anti-oestrogen receptor agent tamoxifan and the immunomodulator Interleukin-2 (IL-2).

Oestrogen dependent ZR-75-l cells (4xlOs/ml) were maintained ha Dulbeccos Modified Medium with 10% fetal calf serum and oes~'adiol (10 6M) at 37 ~ and 5 % CO 2 in 24 well plates and exposed to wrious concentrations of tamoxifen and IL-2. Cell number (mean of 6 wells) and viabilily were assessed using acridine orange staining at 2, 4 and 6 days and compared to standard growth curves (without IL-2 or tamoxifen).

Ceils exposed to oestradiol alone (standard growth curve) increased from 4X105/arl to 5.9(+0.6). 7.3(+0.48), 7.8(+0.4) and 8.4(_+0.5) x 10~/ml, over days 2, 4, 6 and 8 respectively. Addition of tamoxifen (200, 400, 600 and 800 ng/ml) significantly reduced viability of ceils after 4 days culture to ].45(-+0.58), 0.7(_+0.2), 0.67(_+0.2) and 0.48(_+0.23) xl0S/ml respectively, p<0.00l for each concentration of tamoxifen compared to standard growth curve. I1- 2 at 10,50 and.100units/ml also inhibited growth ]n a dose dependent manner with maximalinhibition occurring at 6 days for IL-2 concentrations of 10, 50 and 100 units/ml (3.4(_+1.1)xl0S~ 0.67(_+0.37)x105, and 0.1(• respectively, p<0.001 for each compared to standard growth curve.

These data suggest growth inhibition induced by both l L-2 and tamoxifen on an oestrogen dependent breast carcinoma cell line (supplemented with oeslradiol). This may add to our understanding o f hormona/cytukine interactions mad illustrates potential for IL-2 in oestrogen dependent breast tumours.

38. REVIEW OF 40 PATIENTS WITH DUCTAL CARCINOMA IN

S1TU

J. P. Sweeatey, A. M. Korebrits, J. V Reynolds, E. W. M. McDer- mott, N. J. O'Higgins.

Breast Institute, Department of Surgery, U.C.D., St. Vincent's Hospital, Dublin.

Ductal carcinoma in situ (DCIS) of the breast is thought to represent a number of biologically different processes, ranging in clinical presentation from a palpable mass to a maannographically- detected abnormality. The optimal management of this heterog end us eonditionis controversial. Wereviewed 40 consecutive patients with DCIS. The presenting feature was a palpable mass (n =21), needle~ localised mammographic calculi (n = 1,1), nipple discharge (n =4), and Paget's disease (n = 1). Treatment was by total mastectomy (n =21), wide local excision (n = 12), excision biopsy alone (n -~1), and wide local excision lo]lowed by radiotherapy (n-3). At a mean


folio w-up o f 34 months (range 3-120), 39 pailcnts (98%) are disease- free, one patient developing metas rases from a previous eontralateral havasive breast carcinoma. No patient treated by mastectumy has developed local recurrence, but 4 patients (21%) treated by wide local excision have recurred. All recurrences were ha the s~rne area as the original lesion, 2 manifesting the same histological subtype of DCIS and 2 an invasive carcinoma. All 4 recurrences were managed by mastcctumy.

These figures support an excellent predicted outcome for DCIS, irrespective of the mode of presentation. Mastectomy is the appropriate treatmant for extensive DCIS. Breast con~rvation sm'gery should be restricted to those patients with microscopically lee alised disease, and should take the form of wide local excision or quadrantectomy and not merely excision biopsy. The role o fradiother apy is uncertain.

39. EARLY ASSESSMENT OF scREENED NEEDLE

LOCALISED BREAST CANCERS

C. P. Delaney, N. F. Couse, P. G. Horgan, J. M. Fitzpatrick, T. F Gorey.

Department of Surgery, University College Hospital. Galway.

Mammographic needle localisation of breast abnormalities is useful for biopsy of nonpalpable breast lesions. During a screening program 82 manunographic abnormalities were identified, stere- otactieally localised and biopsied of which 39% were malignant.

32 carcinomas were found in 31 patients, mean age 58.3 + 4.6 years. Of these 66% were of th~ left breast. 94% of lesions were accurately needle localised. 28 l~-sions were diagnosed as infiltrating ductal carcinoma with 7 having an associated intraduetal carcinoma. 4 lesions had intraductal carcinoma alone. Resection margins were clear in 50% of cases. 27% of lesions measured 1 cm or less, with 62% between 1 and 2 cm and 11% greater than 2 cm in size. Margins of resection were clear in 50% of biopsies.

�9 25 women (78%) underwent total m~_steetomy and axillary clearance, 4 ( 12.5 %) had wider excision with or without axillary clearance or radiotherapy a~td 3 (9%) had radiotherapy alone. Of the 27 (84%) who ~mderwent further local surgery, there was residual tumour ha 9 (33%) of which 3 were hatraductal carcinoma alone. Of 28 axillary clearances, 23 (82%) were clear of nodal involvement.

Manlmographic needle localisatinn allows accurate biopsy of early nonpalpable carcinomas o f the breast. Although Otis has not yet been shown to increase survival, it does allow the option o f more conservative surgery ha these women.

40. FIVE YEAR AUDIT OF HERNIA SURGERY IN GALWAY

D. M. O'Hanlan, M. A. Stokes and H. F. Given. Department of Surgery., University College Hospital, Galway.

In the five years 1986 to 1990, 1375 operations for abdominal wall hemias have been performed in this hospital. This study has been performed to audit our pe[formanee and to detect any changes ha our practice.

The patients were predominantly male (87%) and had a mean age o f43.4 year s. with two obv ious peaks in childhood (8 % were less thau a year old) and the mid 60s. Patients had their hemias for

532

a mean of two and a half years before presentation. Conversely the mean length of time on the waiting list was only 1.5 months. This was significantly longer in 1990 (>4.5 months, p <0.05 ). Coinciding with this. the number of hernias performed annually has fallen by 25% between the first three years and the last two years.

Inguinal hernias accounted for 86% (94% in males). Femoral hernias accounted for 28% of all female hernias, but less than 2% of all male heroins. Incisienal hernias were also more common in women. More than two-thirds of inguinal bemias were indirect. Right sided herniaswere more common (57%). 9% were recurrent hernias. 87%of cases were performed elcotively. Obstructed and stranguhtedhemias occurred more commonly in females (p <0.0001 ). There was a wound infection rate o f4.5 %, a mean pos t -~a t i ve stay of 5 days and a recurrence rate of 4%. These were all significantly higher in non-elective and recurrent surgery. The status of the surgeon also had an effect:--

Number (%) Wound Infection Rate Recurrence Rate Consultanl 40% 3.5% 2.0% S. Registrar 20% 4.0% 6.] % Registrar 28% 4.8% 6.3% SHO 12% 6.8% 1.7%

41. THE LMMUNOMODULATORY ROLE OF MACROPHAGE

ACtiVATING CYTOKINES IN INTRA-ABDOMINAL SEPSIS

H. P. Redmond, J. McCarthy, P. Grace; J. M. Daiy, D. Bouchier- Hayes.

University of Pennsylvania, USA and Dept. of Surgery, Beaumont Hospital.

The macrophage (MO) plays a pivotal role in immune response to infection. This study examined the effects of the MO activating cytokines (intefferun-g (IFN-g) and interleukin-4 (IL-4) and their monnolonal antibodies (MoABs) in modulating host response to intra-abdominalsepsis. CFW mice (n=198) were given: IFN-g, IL4, IgGI isotype control antibody (TRFKS), anti-lFN:g and anti-lLA. Study 1: mice (n = 16/group) received E. coli (33x106 org Ip), and two hours later received cytokine: 104 traits or MoAB: 500ug; bolus , dose. Study 2: Mice (n=15/group) received cecal ligation and punc- ture Were randomized to the same treatment groups and studied for survival Study 3: Mice (n=15/group) received CLP and received cytokine 104 unils/3 days or MoAB l(N)u/3 days in divided doses.

Percenl Survival IFN-g IL~- IgGI anti-lFN-g anti-lL-4

Study 1 25 - - 0 65*# - Study 2 �9 7 0 0 27@ 0 Study 3 25 27 24 31 63**

Chi square: *<.001 vs IgGI, #p<.OS v5 IFN-g. Log Rank ~ vs IgGl: @p=.Ol vs IFN-g: * *p<.OS vs lgGI and IL-4. IFN-g and IL- 4 were not protective when given 2 hours after E. coli or CLP. Anti- 1FN-g offered significant protection against E. coli and CI.P (single dose), Bolus anti-lL~l was not protective against CLP, but divided administration significantly enhanced survival. Treatment with MoABs against IFN-g and IL-4 was protectNe against intra-abdomi- hal sepsis, presumably by inhibiting excessive MO activation.

LLM.S. August, 1992

42. NEONATAL JAUNDICE---A TEN YEAR REVIEW

P. Losty, E. ]. Guiney. Department of Paediatrie Surgery/Children's Research Centre,

Our Lady's Hospital for Sick Childrort, Crumlin, Dublin 12.

Abnormalities of the bopatobiliary system in infancy are rare and of considerable surgical importance. Over a ten year period (1980- 1990) 113 infants have been treated at O.L.H.S.C. for jaundice related pathology. The aefiology was broad spectrum and included 'Medical' and 'Surgical' categories--'physiologic' (41), sepsis (18), alpha- 1-antitrypsin deficiency (5), neonatal hepatitis (7), TPN related (5), Alagille syndrome (2), biliary atresia (26), and others (9).

Twenty six infants (biliary atresia) were of special surgical interest and their outcome herein discussed. All infants underwent Kasal's por toenterostomy as primary surgical treatment, mean age 54 days (range 28-98 days). Patients that developed features of hepatic decompensation were evaluated for liver transplantation. Following the Kasai procedure 13 of 26 patients (50%) achieved total biliary drainage, 5 of 26 (19%) partial drainage and 8 of 26 (31%) no drainage. Eight of 26 p atienta (31%) have undergone liver transplan tation, 6 of whom were > 2 years (mean age 3.5 yews, range 8 months 6.5 years). Currently 12 of 26 patients are alive (46%) - 8 (31%) have had the Kasal operation only, all of whom are excreting bilu (4 'jaundice free'/4 partial successes). The other four pailunts (4/12) are alive following liver transplantation (survival 50%). We predict two further patients will need transplantation.

We conclude that despite liver l~ansplantation being increasingly offered as primary treaUnent for biliary atresia, Kasai's portoenteros- tomy remains a worthwhile procedure. The benefits derived from delaying transplantation permits improvements in growth and nutritional status and increases the liklihood of donor organ availability which remains a major challenge in offering transplantation to small infants.

43. A COMPARATIVE WOUND HEALING STUDY OF ELEC-

TROSURGERY AND SCALPEL IN FASCIA M. Murphy, P. E. M. Butler, P. G. Grace, D. Bouchier-Hayes.

Departments of Surgery and Anatomy, Royal College of Surgeons �9 and Beaumont Hospital, Dublin.

Electrosurgery has many stated advantages over the more traditional scalpel such as reduction of: foreign material from the wound; blood loss; operating time and post-operative pain. Many previous authors have reported poor initial tensile strength and a delay in reaching maximum tensile strength in electrosurgical wounds. We decided to test this finding and see if size of electrode has any effect on wound healing.

60 mice were divided into 5 groups of 12 mice each. Using halothane anaesthesia and a clean technique, 2 incisions were made on each mouse using either a steel scalpel (SS), standard (SE) or modified (ME) electrosurgical electrode. The two cutting modalities used in each mouse were varied randomly. Mice were killed 3,5,7,9 and 16 days post-operatively and the tensile strength of the healing fascia was measured. Results are expressed as mean 2. standard deviation.

DAYS POST-OPERATION INCISION 3 5 7 9 16 SS 2.1+_2.3 1.5+1.1 17_+12 29+17 33_+13 SE 1.4_+2.6 2.8_+2.1 7+_6 30-+13 32_+9 ME 2.3+_0.9 2.8_+0,9 1 9 + 6 24+_16 41+16 No statistical difference was found between the cutting modalifies. and changing the size of the electrode had no effect on the tensile strength of the healing wound.

Vol. 161 No. 8

This finding is enntrea'y to previous reports of delayed wound healing using electrosurgery and supports its use in modem surgery when a bloodless field has an obvious benefit in reduction of health risks to medical personnel.

44. SELECTIVE RADIOTHERAPY OF PRIMARY LIVER CANCER

J. R. Novell, K. Dawson, S. K. Hobbs. The Royal Free Hospital, London.

131-1 Lipjodol, a radiolabelled oily contrast medium, was administered t618 patients with primary unresectable intrahepatic ma- lignancie~s. Ten patients with hepatocellular carcinoma (HCC), mean age 63 (SD 10) years, received a mean total activity of 1080 (SD 521) MBq via the hepatic artery as one or two treatments. All showed selective localisation of the isotope with tumour:liver ratios of up to 30:1, and no evidence of lung, thyroid or bone marrow toxicity was seen. The mean cumulative radiation dose was 33 (SD 34) Gy to turnout, 3.7 (SD 1.6) Gy to liver and 3.9 (SD 1.9) Gy to lung. Partial tumour response (reduction in tumour size > 50% + reduction in serum AFP levels) was seen in 6 patients. The mean survival to date is 9.0 (SD 6.8) months,

Eight patients with,intrahepaiic or hiler cholangiocercinoma (CCA), mean age 55 (SD 6) years, received a mean total activity of 668 (SD 325) MBq via the hepatic artery. Only one patient showed selective localisation of the isotope In this patient the cumulative radiation dose from two treatments was 9.6 Gy to tumour, 6.4 Gy to Ever and 1.5 Gy to lung. The mean survival in CCAis 9.2 (SD 10.4) months.

131-1 Lipiodol is capable of delivering highly., selective internal irradiation to inoperable foci of HCC with objective response in 60% of cases. Localisation of the isotope was demonstrated in one patient with CCA although the tumour:liver ratio was smaller. Tumour- selective uptake of 131-1 Lipiodol by CCA has not previously been reported.

45. BLOOD TRANSFUSION REQUIREMENTS IN LIVER

TRANSPLANTATION O. Smith, K. Dawson, G. Hazlehurst, B. Brozovic, K. Relies, A.

Burroughs, S. Mallett A. Mehta. Royal Free Hospital and School of Medicine, London NW3 20G.

Orthotopic liver transplantation (OLT) has become an established therapeutic option in the treatment of end-stage liver disease resulting from a wide variety of congenita/and acquired disorders�9 However, it does impose substantial logistical and financial burdens on the transfusion service. Clinical features predicting greater blood product requirements include: (i) cirrhosis; (ii) ascitos; (iii) coagula- tion abnornaalities; (iv) smlsitisation to red cell or HLA antigens; and (v) when the donor organ is ABOincompatible, Over a 2 year period 60 consecutive patients tmderwent OLT, performed by the same surgeon using a standard anaesthetic procedure.

The purpose of this study was to ev',duate the haematological support needed to support a liver transplant programme and to determine if intraoperative aprotinin (an inhibitor of fibrinolysis) administration had a significant impact on blood product usage in liver transplantation,

BLOOD PRODUCT REQUIREMENTS~00LT PATIENTS RBC FFP PLATELETS

Aprotonin (n=24) 7.4 10.5 8.5 No Aprotenin (n=26) 15 15 12

Our data suggests that the use of aprotinin significantly reduces blood component usage for OLT (p<O.OS). In addition both ITU stay (p<O.OS) and operative haemostasis (p<O.OS) were significantly reduced.


Session IV 46.

PURSE STRING SUTURE FOR STAPLED OESOPHAGEAL ANASTOMOSIS: HAND SEWN OR AUTOMATIC?

R. Waldron, D. S. O'Riordain, D. Buckley, D. Waldron, W. O. Kil-wan.

University Department of Surgery, Cork Regional Hospital.

For insertion of the purse string suture in the performance of stapled gastroinlestinal anastomoses an autogmtic purse string (APS) device (US Surgical Corporation) has been advocated as an alternative to the traditional handsewn method (1).

Fifteen greyhound dogs had a distal oesophagectomy and gastro- oesophageal anastomosis using a25 mm EEA stapling instrument. The dogs were randomised into two groups: In group A, (n=8), the APS was used and in group B, (n=7), the oesophageal purse string was handsewn. The animals were immediately sacrified and the anastomofic integrity assessed by both gross and histological examination, arid measurement of anastomotic bursting pressures and breaking strengths.

There were 5 defuctiv e anastomoses in group A compared to none in group B, p=O.037, and 6 defective o esophageal doughnuts in group A compared to none in group B, p=0.011. The defects were due to failure to incorporate oesophageal mucosa and submucosa into the anastomosis. Two specific faults with the APS were identified. Mean anastomotic bursting pressures were significantly reduced in group A, (54,8 + 9.7 imnHg) compared to group B, (79.6 -+ 2.9 mmHg), p=0.032. Mean breaking strengths where anastomoses were defective (1547 + 150 gndcm) were lower than where anastomoses were intact (2008 + 41 gt~cm), p=0,009.

In comparison to the handsewn method, use o f the APS in stapled oesophageal anastomoses results in an increased incidence of anastomotic defects, which result in demonstrably weaker anastomoses.

I. Holscher AH, Siewert IR. New technique for temporary purse string suture in stapler anastomosis, Br. J. Surg. 1990;77:526.

47. HUMAN MONOCYTE TNF PRODUCTION AND UPTAKE OF ENDOTOXIN MAY BE REGULATED BY INTERLEUKLIN-2

D. Gough, D. O'Brien, C. Curran, F. Given. Department of Surgery, University College Hospital, Galway.

Immunosuppressed patients are at an increased risk of sepsis related complications mediated in part by monocyte derived mmour necrosis factor (TNF) secreted in response to endetoxin. The aim of the study was to assess whether T-lymphocytas or their products e.g. IL2, might regulate TNF production in response to endotoxin or monocytc uptake of cmdotoxin. Blood from a healthy human vohm- teer was separated over ficoll, and both the resulting periperal blood mononuclear ceils (PB MC) (1 ml ofIxlO6 cells/ml) and the adherent monocyte fraction were cultured with endotoxin (LPS) (0,0.05, 0.1,0.5 and lmg/nfl), IL 2 (10,50 and 100 units/ml) or beth m RPMI 1640 (37 ~ C for 24 hours) to yield supematants for determination of TNF production (ELISA method). Adherent cells were also cultured with tritiated endotoxin (0.001-0.25 mg/ml) for 5 minutes following 5 minutes pre-hacubation with IL-2 (0,I0,50,100 units/ml) and cell

�9 uptake of ~itium determined on a beta counter. TNF production by adherent cells (748pg/ml) gradually in-

creased with increasing concentrations of LPS (0.05-1mg/ml). In

534

PBMC, TNF production was significantly greater than in adllerent cells (p<0.01) but decreased (225-115 pg/ml) in response to increasing concentrations of endotuxin (0.05-lmg/ml). TNF production by PBMC in response to 0.1 mg LPS was inhibited by IL-2 in a dose dependent manner (218,206,168,] 15 pg/ml TNF) in response to (0,10,50,1DO units Ik2). A similar inhibition of TNF production by IL-2 was observed in adherent cells. In adherent cells, IL-2 (10 and 1 DO units/ml) significantly reduced uptake of tritiated LPS (0.1 mg/ ml) by 39_+9%, and 51 5: 11% respectively.

TNF production, by PBMC, in contrast to monocytes alone, decreased in response to increasing endntoxin concentrations suggesting a down regulation of TNF production by the PBMC con population. Thls may be related to PBMC IL-2 production as this cytokine decreased expected TNF production in response to endotoxin, and limited uptake of labelk~d endotoxin on monoeytes. These results may explain the association between impaired immunity and increased sensitivity to complications of sepsis.

48 , IMPROVED FREQUENCY OF DEFAECATION FOLLOWING

LOW ANTERIOR RESECTION: COLONIC POUCH OR SEROMYOTOMY?

D. Waldron, A. Horgan, L. G~'ey, R. Waldron, W. O. Kirwan. University Department of Surgery, Regional Hospital, Cork.

Low anterior resection with coloanal anastomosis is now a more frequent option in the surgical Ixeatment of rectal cancer. Frequency of defaecation, with occasional effects on anorectal continence, remains a significant post operative problem. Colonic resections with low colo-rectal anastomosis were performed on 24 minipigs to assess the influence of the addition of seromyotomy and/or a colonic pouch to ~e traditional anterior resection. Six animals were subjected to anterior resection alone (AR), anterior resection and seromyotomy (ARS), anterior resection and colonic pouch (ARP), anterior resection and colonic pouch with seromyotomy (ARPS), respectively. Anal pressures and distal large bowel compliance and capacity were measured pre-operatlvely and 1 months postoperatively. Large bowel transit time, as a measure of bowel frequency, was estimated pre-oporatively and at 1 week and 1 month post-operatively by counting the number o fresidual inert markers on a plain ab - dominal x-ray taken at 24 hours.

Resting and squeeze anal canal pressures were not significantly altered at 1 month by the operative procedure in any group. AR did not result in a significant change in compliance, 3.7 + 2 vs 3.7 + I (P >0.9), or capacity, 38.3 + 11 vs 42.5 _+ 12 ml. (P >0.5), of the neorectum. This was reflected in a significantly worse retention of markers at 1 month as compared with ARS, 1.7 5:0.7 vs 6 + 1.8 (P>O.OS), ARP 1.7 + 0.7 vs. 8.7 _+ 1.4 (0.01), and ARPS, 1.7 _+ 0.7 vs. 13.5 + 0.8 (P < 0.001 ). ARS did not result in improved nc~orectal compliance, 3.4 5:1.6 vs. 3.4 + 0.7 (P > 0.8), but did significantly improve capacity, 40 5:7.1 vs. 54.2 +_ 13.9 ml. (P< 0.05 ). ARP and ARPS had a more marked effect on compliance and capacity of the neorectum as compared with preoperative values. Colonic transit of inert markers at 1 week was equally rapid in all groups. At one month ARS, ARP and ARPS were all significandy slower than AR.

These results suggest that significantly improved frequency of defaecation following low anterior resection can be achieved by the fashioning of a colonic pouch but that this effect can also follow a colonic wall seromyotomy alone and can be inereased by seromyotomy of the pouch.

I.LM.S. August, 1992

49. BENEFICIAL EFFECT OF VERAPAMIL IN ACUTE PAN-

CREAT1T1S

A. Leally, A. Darzi, P. Grace, D. Leader, D. Bouclfier-Hayes, P. Broe.

Departments of Surgery and Pathology, R.C.S.I., Beaumont Hos- pital, Dublin 9.

Calcium blockade with verapamil has been shown to ameliorate ischaemic injury in heart, kidney and small intestine. This study evaluated the effect ofverapamil in an experimental model of acute haemorrhagic pancreatitis. Thirty eight male Sprague-Dawley rats (300gm) were anaesthetized with Haloflame in room air. Pancreatitis was induced by injection of 0.2ml of 4% sodium tattrocholate over 60 seconds into the pancreatic duct. Serum amylase was estimated prior to induction o f pancreatitis and at 24 hours. Animals were ran domized into four groups by intramuscular administration of 1 ml saline or verapamil (lgm/kg body weight) either before induction of pancreatitis or two hours later. All pancreatic specimen were examined histologically following postmortem examination. Differences between groups were analysed by Student's T test for serum amylase, and Fischer's exact test for survival.

Amylase + SEM n 0 hours 24 hours Survival

Group 1 saline pretreatment 12 4100 (872) 12,700 (3555) 25% Group 2 vet. pretreatment 10 3905 (900) 7,305 (1236) 90% Group 3 saline at 2 hours 8 4231(649) 12,143(1662) 38% Group4ver. at2hours 8 3581(679) 12,400(1881) 50%

Statistical significance NS N~ *P<0.05 (Ivs2)

Pancreatitls was confirmed histologically in all animals. Calcium blockade with vcrapamil successfully ameliorated acute pancreatitis, but delayed treatmant wes not effective.

50. INTRACEREBROVENTRICULAR NPY INCREASES GAS-

TRIC AND PANCREATIC SECRETION 1N DOGS

J. G. Geoghegan, C. A. Cheng, D. C. Lawson, T. N. Pappas. Duke University Medical Center, Durhan'~ NC, USA.

Neuropeptide Y (NPY) is the most potent central stimulant of feeding known. Current evidence suggests that it is important in the iniation of feeding behaviour. Its dual localisatinn in the gut and in brain centres known to modulate gut function, suggests that NPY may play a role in the central regulation of other gut functions. In this study, the effect of intracerebroventricu!ar (ICV) administration of NPY on gastric and pancreatic secretion was investigated in dogs�9

METHODS: Six dogs were prepared with gastric and pancreatic fistulas, and cerebroventricular guides. NPY (125, 250, 500 pmol/ kg) or control was injected into the lateral cerebral ventricle. Gastric and pancreatic (Panc) secretions, and blood for pancreatic polypep- tide (PP) and insulin radioimmuno assay were collected for two hours after ICV injection.

VoI. 161 No. 8

RESULTS: (expressed as integrated outputsd2 hr + SEM)

DOSE of NPY (pmol/kg) control 250 500

Gash'it acid (retool/2 h) 0.2+0.1 14.6• 11.1• PancHC03(mmol/2h) 159• 667_+181" 363__.124" PP (pg.mirdml) 159• 16 317• 372:t:93" Insulin (pg.min/ml) 12.8 + 7.6 13.9 + 3.4 20.7 • 2.9*

(*p<0.05, ANOVA)

CONCLUSIONS: lntracureboventricular NPY increases gastric acid, pan~:reatic bicarbonate, PP and insulin secretion in dogs. This mimics the cephalic phase secretory response to feeding. Given NPY's known effects on feeding, it would be logical for NPY to also play a role in triggering release of cephalic phase secretion.

51. DOES RADIOTHI~RAPY CHANGE THE DEOXYRIBONU- CLEIC ACID CONTENT OF PROSTATIC CARCINOMA?

D. O'Sullivan, M. M. Lieber, T. V Colby, D. M. Barrett. Mayo Clinic, Rochester. Minnesota, U.S.A.

External beam radiotherapy is widely used in the treatment of prostatic carcinoma. Post-treatment biopsies are positive in 30 to 90% of patients and these ~re usually of higher grade and have a worse progtiosis. This has created concern as to the effect of radiotherapy on tumour ceils as initial DNA content is related to prognosis.

DNA content was measured in pre and pest-irradiation prostatic tissue from fifty patients using static image cyt~photometly. 6urn thick Feulgen stained archival tissue sections were studied using file Kontron IBAS 2000 image analysis system. 100 tumour nuclei were measured and 30 lymphocytes from a lymph node were used as an internal reference stand ard on each slide. The DNA Index is the ratio of tumour to lymphocyte DNA. Mayo grading and Gleason scoring was also carried out on adjacent tissue sections.

DNA increased in 28 patients, decreased in 18 and was un- changed in 3. The degree of change was not related to the initial DNA content or the dose of radiation. Mean (S.D.) Before Mean (S.D.) After p Value

1.3 (0.4) DNA Index 1.45 (0.4) 0.027 6.7 (I.0) Gleason Score 7.8 (1.5) 0.001 2.5 (0.6) Mayo Grade. 3 (0.7) 0.01

75% of patients with an initial DNA index of> 1.5 had early symptomatic progression ax opposed to 25% when < 1.5 (p=0.04). In- crease in DNA index wsx not related to survival but deterioration in Gleason score and Mayo grade both indicated worsened survival, p=0.03 and 0.04 respectively.

DNA content increases after radiotherapy which may be due to radiation damage creating abnormal nuclear forms. More imper- tarttly it may be due to selection of tad•177 cells which ~e also more malignant.


52 GENETIC FINGERPRINT EXPRESSION IN SUPERFICIAL

BLADDER CANCER

E. Rogers, J. Greally, L. Hanrahan, H. C. Bred• M. 0. Corenran. University Departments of Urology and Pathology, University

College Hospital, Galway. Introduction:

The application of molecular cloning technology to cancer research has shown that invasive cancers display deletions of the short ann of Chromosome 17. This region contains the P53 Oneogene, which is linked to a number of non-coding tandem repeat regions (VNTR's). DNA probes bind to these VNTR regions yielding char- acteristie genetic fingerprints. The demonstration of altered fingerprints in superficial bladder cancers, may indicate that tumour invasion is imminent. Patients/Materials and Methods:

In a prospective study, tumour tissue was obtained from 15 patients with S uperficial Transitional Cell Carcinoma of the Bladder (10 Grade I; 5 Grade I/). The tumour DNA was extracted and purified, underwent restriction enzyme digestion, and the presence or absence of abnormal fingerprints detected by probe hybrid•177 on Southern blots. Results:

Tile genetic fingerprint was fully expressed in all patients studied, and there has been no evidence of turnout invasion to date. Discussion:

It appears that abnonnal genetic fingerprints do not occur in the earliest stages of a superficial bladder cancer's evolution. However, it remains possible that such abnormalities occur in the later invasive stages, where they would be of llttie predictive value.

53. DESCRIPTION OF A NEW TUMOUR SPECIFIC RFLP

IN BREAST CARCINOMA

J. Byrne, M. Kelmy, P. Horgan, F. Given, D. Headon. NBCRI & Dept. of Biochemistry, University College, Galway,

Ireland.

Survival in breast carch~oma remains suboptimal and identifica- tio n of at risk patients remains an unrealised goal.

Our isolation ul the cDNA (tuPR-I) for the human Progesterone Receptor (PR) provided a molecular probe for detection of alterations in the PR gene. A 1.85kt~ fragment encoding the DNA-binding and hormone binding domain of the l~auman PR was used to analyze RFLPs in human blood and breast tissue. Genomic DNA was prepared from breast turnouts and blood, digested by restriction enzyme Taq I, and subjected to Southern blotting, In 8/42 blood samples and 11/47 breast nunours a distinct 1.90kb RFLP was detected. Blood from none of the 40 controls displayed this fragment suggesting that this is a germ line ahbmaly in these patients and not a mutation in tumour DNA. Amplification of the Her-2(neu onco- g erie was found in only one of the RFLP group. Clinical follo wup w as carried out in all cases and histological correlates reviewed.

This data suggests that PR DNA analysis offers a potential means of identifying patients at risk of developing breast carcinoma.

536

Session V

54. INTRA-ARTERIAL 6-HYDROXY DOPAMINE INDUCES A

REGIONAL CHEMICAL SYMPATHECTOMY

A. Grace, P. A. Grace, D. Bouchier-Hayes. Dept. of Surgery, Royal College of Surgeons in Ireland,

Beaumont Hospital, Dublin 9.

A r~uniber of substances have been used parenterally to induce regio~ al chemical sympathectomy. Previous studies have shown that 6~)H dopamine (643HD) produces long lasting depletion of nonad- renaIine in peripheral sympathetic nerves. We tested the hypothesis that intra-arterial 6-0HD would induce a regional sympathectomy in a rabbit hind limb.

Following induction of anaesthesia the right femoral artery was exposed in 17 male White New Zealand rabbits. Ten animals received an i.a. injoction of 6-0H dopamine (20mg/kg) while seven animals were given an i.a. injection of ascorbic acid (the vehicle for 6-0HD) only. Using a Laser Doppler Flowmeter (DIODOPP) skin blood flow was measured in beth hind limbs pre-injection, one hour, one week and one month pest injection. The difference in skin blood flow between the limbs was calculated for each time point. Results (median and range) were:

Pre- post Injection N Injection 1 hour 1 week 1 month

6-0HD 10 0(--3/+2) 6(+2/+14)* 18(+9/+26)20(+13/+22)* Contro 1 7 1( -2 /+2) 1 ( -2 /+3) 1( -2 /+4) 0(-1/+2) *p<0.02 vs. contralateral limb (Wilcoxon signed Rank Test)

These data indicate that a single i.a. injection of 6-0HD results in a significant increase in skin blcod flow localised to the territory of the artery injected. This increase is seen at one hour and is maintained for at least one month post-injection. We speculate that 6-0HD may be useful for inducing sympatheetomy in the clinical setting.

55. VEIN GRAFT HARVEST DOES NOT ALTER

ENDOTHELIUM DEPENDENT RELAXATION

S. Cross, D. Hehir, S. O'Briain*, P. Hartigan**, M. P. Colgar~ D. Moore, G. Shanik.

Departments of Vascular Surger/and P',~hology*, St. James's Hospital and

Department of Physiology**, Trinity College, Dublin.

The vascular endothelium is believed to be an important modu- lator of v asomotor tone by its production of the endothelinm derived relaxing factor (EDRF). When a vein is grafted into the arterial circulation, endothelial damage occurs. Although a neoendothelium develops we have previously demonstrated a persistent loss of endothelitun-dependent relaxation to acetylcholine (ACh) t.

In an attempt to further characterlse the nature of this functional abnormality, we have developed an experimental sham vein graft model (SVG) to study endothelium dependent relaxation and compare it with standard vein grafts (VG). 10 male New Zealand white rabbits underwent sham vein grafting of the L. External Jugular Vein (LEJV). Following exposure, a 2 cm segment of LEJV was excised,

I.J.M.$. August, 1992

S tored in heparinised saline and reimplanted into the LEJV. The right EJV was prepared in a similar fashion and then grafted into the R. Common Carotid Artery (VG). At 4 weeks the SVG and VG from each animal were harvested and mounted under isometric tension in an organ bath. Acetylcholine (ACh l 0 - 7 M) was added to the SVG and VG preeontracted with norepinephrine (10 - 6 M) to produce relaxation via the production ofEDRF. SVG demonstrated a significant relaxation to ACh of 68 + 18% (Mean.+ SEM). In marked contrast ACh did not relax the precontracted VG. Graft intimal thickness was measured by computer assisted morphometry. The VG demonstrated an almost eight fold increase in intimal thickening as compared with the SVG (289 + 26 vs 36 + 7 microns, p<0.0001). These data indicate that loss of endo thelinm dependent relaxation in vein grafts is not due to vein h~vest but is related to artefialisation of the grafted vein. This would support our belief that the imitu technique does not confer added protection for endothelial function.

1. K. Cross, M. E1 Sanadiki, I Murrray, E. Mikat, R. McCarm, P. O. Hagen. Functional abnormalities of experimental autogenous vein graft neoendothelium. Ann Surg, ]988; 208:631 - 8.

56. SELECTIVE SURGERY FOR RUPTURED ABDOMINAL

AORTIC ANEURYSM?

S. Z. Zaidi, D. J. Hehir, K. S. Cross, M. P. Colgan, D. J. Moore, D. G. Shanik,

Department of Vascular Surgery, St. James's Hospital, Dublin 8.

Ruptured abdominal aortic aneurysm is a common emergency which carries a high mortality despite advances in resnsitation and surgery. Because emerge~acy treatment is expensive, accurate pre- diction of successful outcome could help select patients likely to snrvive surgery.

To determine clinical pre-operative factors which might carry a significant bearing on outcome, we caried out a retrospective study in St. Janles's Hospital during a four year period. Ninety six pafiants were treated with abdominal aortic aneurysms (AAA); 60 elective (AAAE) and 36 ruptured (AAAR). Among AAAR, 23 (64%) survived operation (Group A), and 13 (36%) died (Group B). Age, systolic BP, haemoglobin and blood product requirements were recorded.

Mean Age Mean Systolic Mean Hgb (Range) B.P. (mmHg) (Gin/d2)

Group A 68 (50 - 84) 100 11 Group B 75 (66 - 88) 64 9

CONCLUSION: Patients under 68 years with B.P. 100 mmHg or more on presentation and Hgb 11 grams or more, had a better than 60% chance of survival. Conversely elderly patients (over 75), with shock (BP<60 mmHg and Hgb<9 grams) have a very poor prognosis (<40% survival). We have introduced a prospective study based on a scoring system called Ruptured Aneurysm Survival Index to determine a rational treatment protucol for management of ruptured A A A patients.

Vol. 161 No. S

57. ABDOMINAL AORTIC SURGERY: TRANSVERSE OR

MIDLINE INCISION?

P. Lacy, S. Cross. P. Burke, D. Hehir, D. Moore, G. Shanik. Department of Vascular Surgery, St. Jaraes's Hospital, Dublin 8.

The multipurpose retractor allows equal access to the abdominal aorta irrespective of whether the skin incision is transverse or midline. Howe~er, there is evidence in the literature to suggest that midline abdominal incisions are associated with greater pest-operative m0~'bidity.

The aim o f this ongoing study is to assess the effect of the type of incision on pest-operative morbidity in patients undergoing elective abdominal aortic surgery. Thirty patients (mean age 67_+ 8 yrs) were randomised to have midiine (n = 18) or transverse (n = 12) incisions. All patients had pre-operafive evaluation and were followed for seven days post-operatively.

RESULTS (MEAN + S.D.) MIDLINE TRANSVERSE P VALUE

Decrease in F.V.C. (%) 57_+11 58+12 >0.05 Decrease ha F.E.V. (~ 52 _+ 14 48 _+ 24 >0.05 Resp. complications (~ 26.7 16.7 0.39 Morphine Day 3 0.2_+0.2 0.2-+0.2 0.65 (mg/kg/hr) Day 7 0.004 -+ .004 0.002 -+.002 0.73 Hospital stay (days) 11_+2 12_+3 >0.05 LC.U. stay (hours) 76 -+ 36 74 _+ 28 >0.05 Time to open (mins) 11 + 5 13 • 6 >0.05 Time to close (rains) 25 _4-I 1 21 -+ 6 >0.05 Operation time (mlns) 261 _+ 129 265 • 105 >0.05 -% Patients --Day 3 50 43 >0.05 Pain Free - - Day 7 80 85 >0.05

in addition, we did not find that the transverse incision in any way compromised exposure. These early results show no statistically significant difference between the two groups and this is contrary to the experience of others. /f there truly are differences in postoperative morbidity, then they are small. We are continuing to collect data toincrease thepower of the study. (Statistical analysis: ANOVA)

58. ASSOCIATION BETWEEN COMPLEMENT ACTIVATION

AND PROSTHETIC GRAFT FAILURE

J, E. Coleman. C. S. McEnroe, J.A. Gelfand, R. J. Connolly, T. F. O'Donnell, A. D. Callow.

Departments of Vascular Surgery, New England Medical Centre, Tufts University Boston and St. lames's Hospital, Dublin.

Polymer stlrfaces activate complement pathways resulting in platelet and leucocyte deposition as well as possible release of growth factors. A consequence of these interactions may be early graft failure or intimal hyperplasia leading to late graft failure.

CSa generation in human plasma by vascular sutures, both aone and in combination with synthetic vascular prostheses was measured by radioizmnunoassay to determine file influence of suture ntaterials on CSa activation.

,Prolene and ePTFE suture material caused significant activation of CSa (p <.01 ) while Novafil did not. Both Dacron and ePTFE graft material caused significant acfiviation (p < .01 ) of C5a. The activa-


tlon by the graft materials was significanfly higher than the suture material. The addition of the suture rtmterials to the eFFFE did not increase the CSa levels above the ePTFE material alone. In contrast, the addition of either Prolene or Novafil suture to Dacron material elevated CSalevels significantly over plain Dacronmaterial (p<.Ol). The conabination of Dacron material with ePTFE suture did not increase CSa levels over plain Dacron material.

Since this study demonstrates that vascular prostheses and suture material influence human complement activation, it may be that this interaction contributes to early or late graft failure by enhancing platelet reactivity or neoinfimal proliferation respectively. These observations may also offer a clinical explanation for failure of endothelial cell retention on seeded prostheses.

59. ABOVE-KNEE POLYTETRAFLUOROETHYLENE IN

CRITICAL ISCHAEMIA

D. J. Buckley, D. S. O'Riurdain, J. A. O'Dormell. University Department of Surgery, Regional Hospital, Cork.

Though autogenous saphenons vein (ASV) is the conduit of choice for most infrainguinal bypasses, it has been suggested that polytetr afluoroethylene (PTFE) may be a comparable alternative for above knee reconsUractions (1).

Seventy-one consecutive above-knee fermoro-popliteal PTFE protheses performed between 1981 and 1989 for critical ischaemia were followed to determine graft patency and limb salvage, Follow- up was 3 monthly by clinical, non-invasive and if required, angiogra- phic means. Results were calculated by life table analysis.

Limb salvage was 97%, 84% and 77% and graft patency 80%, 55% and 39% at l, 3 and 5 years respectively. Of 29 occlusions, critical isuhaemia re-emerged in 14 (48%): 9 (64%) had below knee secondary reconstructions (6 with ASV) and 5 (36%) had amputation. Three secondary bypasses occluded with limb loss: i ASV and 2 PTFE. No operative mortality occurred. Operative morbidity was 18.3%; pulmonary 8.5%, wound 5.6% and cardiac 4.2%.

Limb salvage and early Patency with above knee PTFE are comparable with ASV. We favour PTFE, above the knee in the elderly and debilitated where life span is short arid operative morbidity is mininfised, In others a policy of primary above-knee PTFE where feasible, preserving ASV for subsequent more distal use, may optimise limb salvage.

1. F. L Veith, S. K. Gupta, E. Asccr et at. Six year prospective multicantar randomized comparison of autologous saphenous vein mad expanded polytotr aflouroethylene grafts in infr ainguinal arterial reconstructions .L Vasu Surg 1986; 3:104 - 114.

60. A RATIONAL APPROACH TO EMBOLIC ARTERIAL

OCCLUSION

P. Meagher, S. Tierney, K. Boos, P. Gillen, T. Corrigan. Department of Vascular Surgery, Mater Miserlcordiac Ho~ital,

Dublin 7. The management of acute embolic arterial occlusion may vary.

Treatment options include inurtediate embolee tomy, elective embolectomy following angiograpbx interventional thrombolysis and conservative management. We have reviewed our experience with acute embolic arterial occlusions over a 5 year period to evolve a rational management course�9 Immediate embolectomy was reserved

538

for critical limb ischaemia as defined by complete los s of movement and sensation which did not respond to conservative management (I/ V Heperin and vascular position of 45 ~ elevation). Non critical ischaemia was assessed with angiography and a decision taken to infuse Streptokinase or proceed to elective embolactomy. Improve- ment of non-critical iachacmia on conservative management with return of pulses obviated the need for embolcctomy.

46 embolic occlusions were seen in 33 patients over a 5 year period. There were 19 males and 14 females. Mean age was 65.8 years, At presentation 14 limbs were critically ischaemic and had immediate embblectomy. Non critical ischaemic limbs had elective embolector @ in 26 cases (56%). Interventional thrombolysis was used ~ 4 cases (9%). Two patients were managed conservatively (5%). The results of acute embolic arterial occlusions in this study showed an overall in-hospital mortality of 13 % (6 patients all related ~o underlying disease). Limb loss occurred in 21%, of these, the mean duration prior to presentation was 4 days.

Four patients were managed with Streptokinase, 2 successfully mad 2 required electiv e embelectomy. Two elderly patien ks managed conservatively with non-critical iachaeutia avoided surgery.

At follow-up (mean 6 months range--3 months--2 years) recur rent emboli bad occurred in 6 patients, (uncontrolled atrial fibrilla- tion in 3, no source, in 3). Recurrent embeli resulted in one death (16%) and one limb loss (16%). There was no further limb loss on fullow-up of the remaining patients.

(Acute embolic arterial occlusion carries a significant mortality and morbidity, usually related to underlying disease but a planned approach may lead to a satisfactory outcome, both short and long term.

62.


EVALUATION OF THE ATYPICAL CLAUDICANT

M..1. Kerin, D. Wilkinson, A. Parkin, R. C. Kester. St. James' University Hospital, Leeds.

Several diseases other than arterial obstruction can present with the symptoms of claudication and the selection o f the true claudicant (TC) from the non-claudicant (NCi is often difficult. We have used a gamma camera and radioactive isotope to measure the peripheral blood flow in a consecutive series of 88 patients presenting to the unit with a history of atypical claudic ation. All patients had a full clinical history, physical examination, including the presence of peripheral pulses (PP), ankle/brachial doppler pressure ratio (ABDR) and isotope limb blood flow (ILBF) measttrement as part of their initial work-up. Lumbar spine, hip and knee x-ray, myelography and arteriography were performed when indicated.

TC (n=SO) 50 (100%) 36 (72%) 32 (64%) NC (n=38) 0 (0%) 8 (21%) 28 (72%)

ILBF was a more sensitive index of true claudication (TC) than ABDR or positive PP in the 50 true claudicants, All 10 non- claudicants (NC) whose pain remained undiagnosed despite normal ILBF were found to have normal arteriograms.

We recolmnend ILIBF as an accurate, cheap and readily available initial screening test in the diagnosticany difficult vascular patient.

61. SEROTONIN INDUCED CONTRACTILITY IN HUMAN

SAPHENOUS VEIN IS INHIBITED BY NAFF1DROFURYL

R. Vashisht, M. Sian, E. J. Sharp, M. K. O'Malley. Department of Surgery, Chafing Cross Hospital, London.

Vascular endothelial denudation contributes to vasospasm by causing platelet aggregation and the subsequent release of vasocon- strictors such as serotonin. It has recendy been suggested that naftidrofuryl fumurate (NIT) may oppose serotonin-induced va~- constriction. Rings of human saphenous vein were suspended in an organ bath at aresting tension of 1.5 gm for 1 hour. Prior to each dose- re spouse curve contractility was confirmed and standardis ed'with an addition 40 mmol KCL. Cumulative dose-restgmse curves and maximal contraction in response to serotonm were recorded and this was then repeated in the presence of NFF at 10 SM and 10-3M. Sensitivity to serotonin in each of the three curves was measured using the ED5o and statistical significance was assessed with the paired t test.

Serotonin Serotonin Serotonin Max + NFT 10 aM - NFF 10 3M Contractility (gm) 62.07 + 4.09 20,85 + 1.42 6.14 + 0.82

ED5o 2.33 + 0.25 8.73 -+ 1.01 1.65 -+ 0.64 M of (Serotonin) X l 0 7 X I 0 ~ X10 '~ (n=14; X + S.E.M.; P<0,O0000I between al! groups)

We conclude that NFTreduces serotonin-indueed contractility in a dose dependent fashion in rings of human saphenous vein IN VITRO, These results suggest a possible role for NFr in reducing vasospasm and supports its further investigation IN VIVO.

63. LIMITING THE EXTENT OF UPPER THORACIC

SYMPATHECTOMY MIN/MISES COMPENSATORY HYPERHIDROSIS

M M. Maher, D. S. O'Riordaln. R. P. Waldron, D. J. Waldron, M. P. Brady.

University Department of Surgery, Cork Regional Hospital.

Primary palm ar hyperhidrosis is a cormnon and o ften socially and psychologically disabling condition. In a severe case surgical inter- vention may be the only effective treatment.

Ninety-four consecutive patients undergoing bilateral upper thoracic sympathectomy (UT.) for severe, socially disabling primary palmar hyperhidrnsis (PH) were reviewed. The operative approach was supra-clavicular and a limited sympathectomy was performed from below TI to above T3. denerv afing the palm only. Follow up was complete in 86 (91%) at a median period of 31 months. All patients had complete andpermanent relief of PH. Nineteen (22%) developed compensatory hyperhidrosis (CH) end this was the commonest cause of patient dissatisfaction. Although axill~y dcnervation was not performed, axillary sweating was a problem post-operatively in only one patient. Significant morbidity occurred following 6 out of 188 procedures (3.2%): one subclavian artery injury and one brachial plexus injury, neither of which resulted in permanent disability; one permanent Homer's syndrome; and 3 pnanmothoraces requiring chest drainage. Minor problems developed following 22 procedures (11.7%).

UTS by the supraclavicular approach is a ~afe and effective method of trealment for primary PH.

Our low incidence of CH may be explained by the limited extent of sympathectomy. Extensive sympathectomy to include axillary denervation is urmecessary and should be avoided to minintise compensatory sweating.

Vol. 161 ,No. g

64, ENDOTHELIAL CELL SEEDING OF ePTFE GRAFT MATERIAL TREATED WITH A SYNTHETIC RGD-

CONTAINING PEPTIDE

M. Allen New England Medical Center, Boston, Massachusetts, USA.

Autologous endothelial cell seeding was introduced in an attempt to improye the patency of small diameter prostthetic vascular grafts. A prerequisite for the endothelialisation of ePTFE grafts is surface pretreatment'with fibronectin, fibrin or collagen. Recent advances in molecular biology have revealed that the cell attachment site of many extracellular proteins involved in cell adhesion contain the amino acid sequence Arginine-Glycine-Aspar tic Acid (RGD). These studies examined the possibility of using a synthetic RGD-containing peptide (PepTite-2000) as a substrate to support a seeded endothelial cell (EC) monolayer on ePTFE graft material.

Canine ECs were seeded in vitro onto 2 cm 2 disks of ePTFE treated with either PepTide-2000 or human fibronectin (FN), Un- treated ePTFE disks were also seeded. EC attachment and extent of monolayer formation was assessed by light microscopy of formalin fixed grafts after varying periods of incubation in-vitro, No EC attachment to untreated ePTFE was observed. EC attachment to FNcoated ePTFE occurred rapidly and a complete monolayer ( 100% surface coverage) consistently developed within 24 hours of seeding. EC attachment to RGD-pcptide treated ePTFE was much slower, with many seeded celis failing to adhere. However, all EC monolayer did develop and persist on several RGD-treated grafts, although the monolayer formed failed to achieve 100% surface coverage on the majority of these grafts.

These findings demonstrate that ePTFE graft material coated with a synthetic RGD-containing peptide is capable o f supporting an EC monolayer in-vitro. Although the RGD-enntaining peptide used in these studies appears to be a less satisfactory substrate than human fibronectin tur EC attachment, similar synthetic peptides may represent an important advance in the effort to develop a new small diameter bio-prosthetic vascular graft.

65. DIETHYLSTILBOESTROL NO LONGER HAS A ROLE IN THE MANAGEMENT OF PATIENTS WITH ADVANCED

PROSTATE CANCER

T. H, Lyncy, B. Waymont, L, Emtage, G. R. Blackledge, M. A. Hughes, D. M. A. Wallace.

Queen Elizabeth Hospital, Birmingham.

The standard treatment for advanced prostate cancer is hormonal manipulation which is usually achieved by urchidectemy or the use of oestrogens. Znladex has now become a starMard therapy for advanced prostate cancer, avoiding both the side effects ofoestrogen therapy and the need for operation. We present the long term results of a randomised trial of Zoladex, 3.6 mg depot every 28 days, compared with Diethylstilbeestrol (DES), 3 mg per day.

Between 1985 and 1988, 250 patients with advanced prostate cancer were randomised equally to receive either Zoladex or DES. Metastatic disease was present in 76% of patients with the remainder having only locally advanced disease. Patients characteristics were comparable between the two groups with a minimum follow-up o f 30 months (median 46 months),

Subjective responses were seen in 79% of those treated with


Zoladex and 60% of those in the DES group (p 0.03 ). Tbe objective response rate was 71% in the Zoladex arm and 57% in the DES arm (p=0.02). Response was seen significantly earlier with Zoladex (median 3 months) than DES (median 6 months). There was no significant difference in acturial survival between Zoladex (85 deaths) and DES (81 deaths), with 35% of all patients alive at three years. DES therapy was discontinued in 32 patients because of adverse reactions whereas only one patient was withdrawn fi-om Zoladcx.

Zoladex is as effective as DES in terms of smwival and has a higher overall response rate with responses achieved more quickly. DES is associated with increased incidence of severe adverse reac- lions. We feel that there is no longer a role for stilboestrol in the treatment of prostate cancer.

66. INITIAL STUDIES ON REPEATED ADMINISTRATION OF

TOPICAL CHEMOTHERAPY TO THE UPPER RENAL TRACTS

D. O'Sullivan, L. Mynderse, D. M. Barrett. Mayo Clinic, Rochester, Minnesota, USA.

Upper urinary tract transitional cell tumours of low stage can be treated effectively by local excision or endoscopic resection. There unforttmately is no effective method of administering topical prophylactic and therapeutic chemotherapy. Thus the same comprehen- sive management used in the bladder is not possible. We describe simple method of access which allows repeated outpatient admini- st:ration of topical therapy.

Twelve 8Ch and two 6Ch silicone pigtail, cathelers were inserted into the renal pelvis in ten 20 kg pigs. Four were inserted at open surgery and the rest were inserted percutaneously under fluoroscopic guidance. They were bilateral in four animals. The catheters were cormected to injection ports placed subcutaneously in the flank. 15 mg of Thiotepa was given into the port each week tor eight weeks.

Percutmaeons radiographic studies showed effective per fusion of all-calyces in 12 of 14 kidneys if the animal remained supine and w as turned from side to side. The two failures were due to misplacement of the catheter into the ureter. Whitaker studiesthrough the port showed no change in the per fusinn pressure in 9 of the 12 units. The three failures were due to port toss from wound infections. Ten implants were in place, without ill-effect, for the 10 to 14 weeks of the study. Chemotherapy did not have an adverse effect on normal mucosa. All showed mild chronic inflammation with some papilla formation in the area in contact with the catheter. There were no systemic side effects from the chemotherapy.

Longterm access and repeated chemotherapy to the upper ~acts is feasible and will allow improved treamlent of upper tract tumonrs.

67 . PROSTATIC ENZYME LEVELS IN SERUM DURING

TRANSURETHRAL PROSTATECTOMY

E. Rogers, H. Grimes*, F. Chambers*, D. L,owe**, H. C. Bredin, M. O. Corcoran.

Departments of Urology, E iochemistry* and Anaesthetics**, University College Hospital, Galway:

Individual studies on the epithelial molecules, Prostatic Acid Phosphatase (P.A.P.) and Prostatic Specific antigen (P.S.A.) have shown that these vasoactive kinlns are absorbed into the systemic

540

circulation during transurethral resection of the prostate (T.U .R.P.), The serum levels of P.A.P. and P.S .A, are reported to correlate with the degree of irrigant fluid absorption.

Creatine Phnsphokinase (C.P.K.) is an inert prostatic enzyme re- siding in the fibromnsculas st~oma. The systemic absorption of C.P.K. during T.U.R.P. has not been studied. In order to assess if prostatic enzyme absorption is uniform during transurethral surgery, and their relationship to irrigant absorption, we prospectively compared the pre- andpost- operative levels of P.A.P., P.S ,A. and C.P.K. in 20 patients withBenign Prostatic Hyperplasla.

While there was wide inter-individual variation in the baseline levels 0 f-tile enzymes, all three became elevated in the serum peat- operatively. This reached a peak at one hum and subsided to baseline values within 24 hours. All enzyme levels were markedly elevate, d in two patients with dihitional hYlxmatraemia, but clinical symptoms of T.U.R.P. syndrome were not apparent.

68. ACUTE URINARY RETENTION: A COMPARISON OF

SUPRAPUBIC VERSUS URETHRAL CATHETERISATION

A. F. Horgan, D. J, Waldron, B. Prasad, D. C. O'Sullivan. Department of Urology, Regional Hospital, Cork.

Eighty-six consecutive patients presented to the Accident and Emergency Deparwaent with acute urinary retention due to prosta- tomegaly and required catheterisation. Fifty six received suprapubic catheters and thirty were cathetelised urethrally. Both groups were followed up for three years. Of the thirty patients catheterised urethrally, tweNe (40%) developed urinary tract infections compared to ten (18%) urinm'y tract infections in thc 56 patients eatheterised supr apubically (p <0.05). Five ( 17 %) of the urethr al~group developed urethral strictures with no strictures in the suprapubic group (p <0.01 ). Two Patients catheterised urethrally developed epididymo- orchitis and one developed a septicaemia. None of the patierits with suprapubie catheters developed these complications. Furthermore, sixteen (2.5%) patients catheterised suprapubieally underwent successful trial clamping of their catheter, whereas seven (23.2%) patients required recatheterisation following removal of their urethral catheters. Dislodgement of the suprapubic catheter occurred in thirteen patients (23%).

We recommend that suprapubic catheters be used in all eases of acute urinary retention in preference to the urethral route.

69. A PROSPECTIVE RANDOMISED CONTROLLED TRIAL OF

URETHRAL VERSUS SUPRAPUBIC BLADDER CATHETERISATION IN ABDOMINAL SURGERY

M. Barry P. Gillen, M. McNicholas*, O. Traynur. J. Hyland. Departments of Surgery and Radiology*, St. Vincent's Hospital,

Elm P~k, Dublin 4.

Bladder catheterisation is routine during major abdominal surgery. Suprapubic catheters may reduce post-operative urinary infections and facilitate a trial of voiding without recourse to catheter removal.

To test this hypothesis we prospectively studied 67 patients undergoing bladder cathaterisation during elective surgery. All pa- tienta had pie-operative urinary flow rates, post-micturition ultrasound and urine cultures. Pre-operative urinary infectinrts were ex-

I.LM.S. August, 1992

eluded (7 patients). Patients were randomisad to receive either urethral catheter on induction or insertion of suprapubic catheter at laparotomy. All patients had post-operative urine cultures daily until catheter removal and post-operative urinary flow rates and post- micturition ultrasound were performed after catheter removal.

RESULTS: Sixty patients were randemised (24 suprapubic, 36 urethral). The mean age and male:female ratio were similar in both groups. There was no significant difference in urinary flow rates (volume, peak flow, voiding time) 10re or post-operatively in either urethral or suprapubic groups. Tbere were 6 post-operative urinary infections--3 in each group. Catheter duration v,,~ a mean of 5 days in both groups. One patient developed gross haematuria post suprapubic insertion and required bladder irrigation. Two further suprapubic catheters leaked and were replaced with urethral catheters. In addition there were 4 technical failures of insertion of suprapubic catheters.

CONCLUSION: This study failed to demostrate a benefit of suprapubie catheters over urethral and the routine use of suprapubic catheters may be associated with an unacceptably high complication rate.

70. CLINICAL EXPERIENCE WITH URINARY CYTOLOGy

H. Bredin, T. H. O'Dowd, M. Corcoran. Departments of Urology and Cytopathology University College

Hospital, Galway.

During the period 1/4/90 to 31/3/91, 718 urine samples were examined cytologically by the Department of Cytopathology, Uni- versity College Hospital, Galway. 28 of these urines were reported as either suspicious for malignancy or frankly mglignant. The records of 19 of these positive cases have been examined and show that 14 had urinary tract ma~gnancy and 5 had benign disease. In 1 of the patient~ with positive cytology a diagnosis of malignancy was not discovered until alerted by the positive cytology report.

To assess the accuracy of urinasy cytology in patients with bladder neoplasm it was decided to review fire records of all patients with bladder cancer for the period 1/4/90- 31/! 2/90.54 patients with either a current bladder turnour or a previous history of bladder tumour were admitted during this period. The hospital notes of 40 of these patients have been examined to date end in 30 patients urine cytology had been carried out. In 13 of these patients a diagnosis of high grade (Grade 3 - 4) bladder carcinoma wa s made and in 9 of these patients (69%) the urine cytology was either frankly malignant or anspieious for malignsncy. In theremalning 17 patients withlower grade (Grade 1 - 2) tumours the urine was either suspicious or frankly malignant in 7 patients (41%).

We feel that urinary cytology is an important test in urological patients and that it is reasonable to use it as a screening procedure in all adult patients being admitted to a Urology Department because it may alert the urologist to a diagnosis of malignancy not previonsly suspected. In addition it is felt that even in patients with known history of bladder cancer the finding of a positive urinary cytology may antedate the discovery of a tamour recurrence alerting the urologist of this possibility.

Vol. 161 No. 8

71. URINARY CYTOLOGY IN THE DETECTION OF BLADDER

CANCER

J. M. O'Donoghue, P. G. Horgan, M. Comoran,, M. MeGuire, F. Given.

Departments of Surgery and Urology*, U.C.H., Galway.

The diagnosis of bladder cancer is most commonly made on the basis of eystoscopieally aided biopsy. The use of urinary cytology has been mainly confined to that of an adjuvant role in the diagnosis and fo!!ow u p of such patients. We have in this study analysed the accuracy of cytological examination of voided urine in a population of 265 patients presenting to the department of urology with sus- pectod bladder lesions. Bladder carcinoma w as confirmed histologically in 51 patients. Of these, 42 were identified correctly by cytological examination. Over',dl 34 patients were labelled frankly malignant on cytology, of whom 2 were negative on final histology. 13 patients had been designated as suspiciou s, however with 3 benign on final histological diagnosis. These data give a sensitivity for diagnosis of bladder cancer of 82%, a specificity of 97%, a positive predictive value of 94% and a negative l:gedictive value of 96%.

Neither the morphological appearance or the site of turnout slg nificanfly affected the diagnostic yield of cytological examination. However, cytology was found to be most effective in the diagnosis of carcinoma-in-situ (accuracy of 100%). We conclude from these data that voided urine cytology is a useful adjuvant in the diagnosis of bladder cancer, but do not recommend that it take the place of cystoscopy and biopsy.


73. XANTHOGRANULOMATOU S PYELONEPHR1TIS AT THE

MEATH HOSPITAL ' ~"

M. Gleeson, T. Creagh, R. Grainger, T. E. D. McDermott, M. R. Butler.

Department of Urology, Meath Hospital, Dublin 8.

Xanthogranulomatons pyelonephrltis (X.P.) is a rare inflammatory renal condition histologieally characterized by macrophages with lipid filled foamy cytoplasm. Between 1969 and 1989, 46 patients with X.P. were treated at the Meath Hospital. There were 35 females and 18 males with an average age of 47 years (range 22 - 77 years). Their presenting complaints were loin pain (36), pyrexia (17), malaise (10), weight loss (6), dysuria (12), haematuria (4) and cutaneous fistula (2). Intravenous urography demons trated calculi in 36 cases with no contrast excretion by 38 kidneys. Thirty four patients had urinary tract infections (usually Proteus Mirabilis or E. Coli) and perinephric abscess drainge was required pre-operatively in 6 patients prior to undergoing nephrectomy.

Post nephrectomy complicatiops were wound infections (6), wound sinus (4), pyrexia (1), pneumonia (1), D.V.T. (I) and pseudo- membranous colitis (1).

After an average post operative follow up of 4.4 years (range I - 20 years), 41 patients were.asymptomatic, 3 had recurrent U.T.rs, 1 had chronic pyelonephritis and 1 died of renal failure.

This paper highlights the varying presentations of patients with X.P. artd demonstrates that the majority of patients are cured by nephrectemy.

72. HAEMOSPERMIA: TO INVESTIGATE OR NOT?

A. McNamara, T. Creagh, R. Grainger, T. B. D. McDermott, M. R. Buffer.

Department of Urology, Meath Hospital, Dublin.

Haemospermia is an alarming symptom but is it associated with significant pathology? We reviewed 45 patients (age 25 - 72 years) investigated for haemospurmia at the Meath Hospital between 1980 and I990. Twenty three patients had haemospermia only while 22 patients had ~ssociated symptoms: haematuria (6), frequency/dysuria (8), poor flow (2), painful ejaculation (2) and testicular pain (4). All patients were investigated by full blood count, blood urea nitrogen, urine analysis and culture, intravenous pyelogram and cystoscopy. Twenty of the twenty three patients (87%) with heemospemfia alone had normalinvestigations and were discharged with no recurrence. Two patients with recurrent isolated haemosper miahad an area ofincre~ed vascularity in the prostatic urcthrawhich was diathermised with no recurrence. One patient had a Klebsiella infection successfully treated with antibiotics. Of 22 patients with associated symptoms 17 patients (77%) had normal investigations with no recurrence. Four of the remaining five patients had an area of hlcreased vasculasity in the prostatic urethra diathennlsed with no recurrence. One patient had a urinary tract infection. In conclusion, isolated haemospermia is not a significant symptom and urine analysis alone is sufficient investigation unless it recurs when cysto is indicated. Associated symptoms should be investigated as indicated.

SESSION VI

74. ~ REDUCING MORTALITY DUE TO OPPORTUNISTIC INFECTION POST CARDIAC TRANSPLANTATION

J. P. Hurley, R. Hone, P. Dervan, M. Neligan, A. E. Wood. National Cardiac Unit, Mater Hospital, Dublin.

Between 1985 and 1990, 46 adult cardiac transplants were performed in Ireland. This represented a ~adual yearly increase in numbers to twenty in 1990. The one year survival has been 80% form the first four years of the programme. Opportunistic infections have been a leading cause of morbidity and mortality. Fourteen (32%) of patients have developed infection (Cytomegalovirus 6, Pneumocys- tis 4, Herpes Simplex 2, Nocardia 1, Toxoplasmosis 1, accounting for 4 (33%) of deaths.

Since the introduction o f prophylactic anti-CMV Hyper-irmnane Globulin and the adoption of an aggressive early open lung biopsy protocol there have been no deaths in 10 cases of opportunistic infection representing a significant (p<0.05) reduction in mortality. All CMV negative recipients transplanted from CMV positive do- nors receive prophylactic anti CMV hyperimmenc Globulin, and while this has not significanffy reduced sero conversion, the infec- tiuns devdoped have been mimer, easier to treat and there have been no deaths.

Prior to the introduction of early open hmg biopsy positive diagnosis in three of the lout fatalities secondary to infection was a post-naortem diagnosis. Based on symptonaatology and radiograph

542

appearances we have performed 8 open lung biopsies through a "mini" postero-lateral thoracotomy, glving us a positive diagnosis in 7 (88%) cases with only one false negative, subsequently corrected by repeat biopsy. The procedure has been accompanied by minimal morbidity and no mortality.

We conclude that a policy of prophylaxis in patients at high risk of CMV together with an aggressive diagnostic approach can significandy reduce mortality due to infection post transplant.

75. PERIOPERATIVE OXYGEN FLUX IN MAJOR SURGERY

J. Hurley, M. White, P. McDonagh, D. Pbelan, D. Luke, E. McGovcrn.

National Cardiac Surgery Unit, Mater Hospjtial, Dublin.

Augmentation of tissue oxygenation in the critically ill improves survival. The aim of this prospective rendomised study was to determine whether inadequate tissue oxygenation, as reflected by a rise in lactate levels, occurs in patients with normal veturicular function having elective cardiac surgery. Secondly to assess the effect of augmentingliaemndynamic indices to "snpranormal" levels on oxygen delivery (I)02) and oxygen consumption (V02), thereby determining if it is possible to attenuate any peroperative tissue oxygen debt that occurs. Twenty four patients with ejection fractions < 0.5 were randomly assigned to two groups. After induction of anaesthesia, baseline lactate, cardiac index (CI), systemic vascular resistance (S VR), end D02/V02 were measured. The treatment group received a 24 hour infusion o f dopexamine, an ionotrope, at 2ug/kg/ min and the controls received saline. Recordings continued at preset intervals pre and post bypass. Lactate rose significenfly in both groups (P<0.05), demonstrating inadequate tissue oxygenation oc- curing intraol:,'eratively in both groups and persisting in the first twenty four hour peried. However, in the group receiving depexent- ine, CI and DO2/VO2 were significantly greater (P < 0.05) and SVR was significantly lower then in controls (P <0.05). The rise in VO2 in the ionotropieally driven group was accompmaied by an earlier fall in lactates in the postoperative period. The study demoustrates that inadequate tissue oxygenation occurs in low risk patients with normal ventricular function undergoing cardiac surgery. It also shows that by deliberately augmenting the c~diac index and thereby increasing oxygen delivery and consumption it is possible to attenuate the porioper ative oxygen debt which should Jm~cove post operafive organ function and be of significant benefit to the critically ill surgical patient.

76. NEUROBLASTOMA~AN ANALYSIS OF FIFTY

CONSECUTVIE CASES

P. Losty, F. Quiun, F. Breatnach, A. O'Meara, R. J. Fitzgerald. Department of Paediata'ic Surgery/Oncology, The Children's

Research Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12.

The past twenty years has witnessed significant improvaments in the survival rates of childhood cancers. Yet, despite these trends the prognosis of children with neuroblastomaremains poor. During a ten year period (1979 - 1989), 50 ctfildren with neuroblastoma presented

LJ.M.S. August. 1992

to OLHSC for treatment. The series comprised 20 females and 30 males---a palpable abdominal mass was the most common presentation. Primary lumour sites included cervical (3), mediastinum (9), abdominal (34), pelvic ( 1 !, unknown (3). Urinary VMA was elevated in 60% of cases.

Overall survival in the series was 38% (See Table). Among 16 patients in whom the N-myc oncegene was measured all survivors (8) had < 10 copies. Improvements in survival awaits development of more effective chemotherapeutic agents, refinements in marrow transplantation mad improved understanding of tumour biology/host immunology. VMA screening programmes in Japan are producing promising improvements in survival in asymptomatic children and may prove cost effective in the future.

NEUROBLASTOMA DATA SURVIVAL VS. STAGE (2 YEAR DISEASE FREE SURVIVAL)

Evans Stage No. Patients Survival No. %

2 2 100 H 8 7 87 IlI 8 3 38 IV 27 4 15 IVs 5 3 60

TOTAL 50 19 38

77. THE ROLE OF SPLENI~CTOMY IN MODERN SURGICAL

PRACTICE

J. P. McGrath, S. E. A. Attwood, S. R. McCanrt, R. B. Stephens. St. James's Hospital, Dublin 8.

One hundred and six patients underwent primm~y splenectomy over an eight year period at St. James's Hospital (1982 - 1990). The indications, post operative recovery and Iongterm fullow-up were examined retrospectively with particular interest in the role of spleneetomy for both diagnosis and management of haematulogical ctrnditions; benign and malignant. The details of 102 p~ients were traced. Thirty five had a haematological malignency, Non-Hodgkins lymphomas (15), Hodgkins lymphomas (4), Hairy Cell leukaemias (12) mid other leukaerrLias (4). In 24, surgery was therapeutic and 11 diagnostic or as a staging t~rocedure. In Hairy Cell leukaemia the results showed a5 year actuarial survivalof90% end 84% at 10 years. The survival o f the other gronps of malignencies varied depending on the grade, stage end type of malignancy. Thirty five patients had Idiopathic thrombooyctopaenic purpura, refractory to steroids and 22 had ruptured spleens following road traffic accidents. Splenee- tomy also helped correct the haematohigical disorder in Hereditary Spherocytosis (4), Autoimmune haemolytic anaemia (2), Felty's syndrome (3), Duncan's syndrome (1), Myelofibrosis (1) and primary hypersplen~sm (1). Post operative mortality for the whole group of 102 splenectomies was zero with minimal morbidity. Spienectomy in current surgical practice is safe and useful for specific diagnostic and therapeutic indications with excellent longterm results.

Vol. 161 No. 8

78. PROSPECTIVE EVALUATION OF SARCOMAS

E. F. Gaffney, P. A. Derven and Dublin Soft Tissue Tumour Panel.

St. Jumes's, Mater, St. Vinoent's and Beaumont Hospitals, Dublin.

The Dublin Soft Tissue Turnout Pand is reviewing all soft tissue and visceral sarcomas and sarcoma-like lesions acceasioned by four pathology departraents affiliated with the three Dublin medical schools. In 1989 and 1990,193 eases were evaluated, of which 120 were malign~t~ The most common sarcomas were leiomyosarcoma (27) and malignant fibrous histiocytoma (17).

Partiei]l~ diagnostic problems are (i) the distinction between certain reactive lesions and low grade sarcomas, (ii) small round cell tumours in young adults end (iii) nov_-sarcomas presenting as undif- ferentiated soft tissue taanours. Lesions in category (i) require close clinical correlation and follow-up. Lesions in categories (ii) end (iii) require electron microscopic examination (EM) end immuno-cyto- chemicalstainung (ICM). In 60 - 75% of cases aconsensus diagnosis is based on routine H end E sections. EM and ICM provide comple- mentary ultrastructural and functional data that may establish or support a diagnosis. Also assessed are grade, resection margins and likely biological bohaviour. Trea~nent end follow up data is being obtained to enable a multidisciplinary working group to rationalise future management of this heterogeneous group of tmnours.

79. LOCAL HYPOTHERMIA PROTECTS THE SMALL BOWEL

FROM ISCHAEMIA

A Heunessy, P. Grace, M. Leader, D. Bouchier-Hayes. Departments of Surgery end Pathology, R.C.S.I., Beaumont

Hospital, Dublin 9. Several authors have shown that a reduction in temperature

decreases the metabolic rate of tissues. Hypothermia has been used clinically to prolong ischaemia time and organ preservation. The effects of hypothermia on small bowel ischaentia have not previ- o usly been studied. We tested the hypothesis thathypothennia would protect the small bowel from ischaemie injury in the rat model. In 38 SpragueDawley rats the small bowel was displaced via a midline abdominal incision. In 5 animals no further procedures were performed (group A), while rite bowel was made hypothermlc only in another 5 rats, (group B).

Hypotherrnia was achieved by immersing the bowel in slushed ice at 2~ the remaining 28 rats the superior mesanteric artery was clampe d for 30 and 60 rain. without (groups C & D) end with (group E & F) hypothermia. The entire small bowel was examined histologically and the degree of injury was graded from 0 to 5 by a blinded observer. Results (median end range) were:

Group A B C D F F n 5 5 7 7 7 7 Grade

Median 0 1" 4* 5* 3 *~ 4* + Range (0-1) (1-2) (4 -5) (4-5) (I-4) (2 -4)

*p<0.05 vs. A. ' p<O.05 vs. C + p<0.05 vs. D. (Mann-Whitney Rank Sum Test).

In anmmary these data demonstrate that hypothermia protects the small bowel from ischemic injury at 30 and 60 mins. We conclude that local hypothermia decreases small bowel injury and its use should be considered in patients with potential mesenteric ischaemia, e.g. incarcerated inguinal hernia.

16lh Sir Peter Freyer Memorial Lecture 543

80. THORACOTGM1ES FOI~ LUNG CARCINOMA:

A THREE YEAR AUDIT

F. S. Taleb, D. P. O'Brien, P. Keeling. Department of Surgery, University College Hospital, Galway.

Lung carcinoma is the commonest malignancy today in the adult population. Although surgery plays an important role in the management of patients with this condition, the results are often disappoint- ing. We have reviewed our experience of tboracotumies for lung can morea in a Regional Thoracic Unit over a three year period (1988 - 1990 inclusive). Ninety-nine patients were reviewed (male: female = 3.3:1). Despite non-productive cough being the commonest presenting symptom (68%) followed by haemoptysis (37%), a surpris- ingly significant number of patients were asymptomatic and picked up incidendaUy on chost x-ray. Ten per cent of patients suffered from major pre-existing lung pathologies, and seven per cent had a past history of other malignencies. Only 13% of these patients were non- smoke~. Though 97% of patients had a "positive" chest xray, only 16 % had a "positive" sputum cytological result. Fibreoptic broncho- seopy was successful in the diagnosis of the tumour in 52% of cases whereas per cutaneous t'me needle aspiration biopsies were positive in 76% of all performed. Over 10% of mediastinnscopies were positive-but there was found to be a 21% false negative rate. Of the procedures performed, 36% were pneumonectomies, 42% were lobectomies, 8% were segmentectomies and the remaining 16% were exploratory thoracotomies. The histological findings were as follows: Squamons Cell Carcinoma (63%), Adenocarcinoma (22%), Large Cell (g%), Sarcoma (3%), Mixed Cell (2%) and Carcinuld (2%). Over 55% of patients were Stage 1, 29% were Stage n and 15% were Stage 111. Eleven patients (11%) developedlocalrecurrence of whom eight had lymph node involvement at operation, seven had bronchial margin involvement and four had initial turnouts > 3 cm in diameter. Post~operative complications were found to be more common after pneumonectomy (74%) than after lobectomy (60%) and segmentectomy (2%). Nine patients died post-operatively and another nine during follow-up.

Our experience illustrates the pattern of presentations, empha- sises the fallibility of one-sample sputum cytology analysis and mediastinoscopy.

81. NOW WE ARE ONE~-THE FIRST YEAR OF THE PLASTIC SURGERY UNIT IN UNIVERSITY COLLEGE HOSPITAL,

GALWAY.

M. V. McKiernan, P. J. Leyden, J. J. McCenn. Department of Plastic Surgery, University College Hospital,

Galway.

Rarely these days has one the opportunity to participate in setting up anew department from scratch. In this paper we report on the first year's activity in the department of plastic surgery in Galway.

University College Hospital (UCH) Galway is a 433 bed Re- gional referral centre, with 128 surgical beds. 40,000 patients are referred to the Accident/Emcrgency department each year. The plastic surgery unit occupies 12 beds. In to tal there were 7,318 operations performed (general, vascular, thoracic, urologic, plastic) in the year ended December 1989. Of these, 75% were elective and 25%

544

were emergency procedures. In this departmenfs first year, 770 plastic operations wereporformed, of which 445 (57.8%) were emergency procedures and 325 (42.2%) were elective. Emergency surgery consisted of: 62% hand trauma, 26% facial injuries, with 12% others.

Out-patients were seen at one weekly clinic. A total number of 1,983 patients were seen in 44 clinics, a mean of 45 per week. 371(18.7%) new patients were seen (8.4 / week), along with 1,612 (81.3%) reviews. 245 patients were seen in consultation, both in UCH and Merlin Park hospitals. The waiting list after one year holds 156 (theatre) and 150 (OPD).

Many problems are encountered in setting up a new depar tsnent. We dis r ~hose we have met with, and how we have managed them.

82. LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY~

INTERIM RESULTS OF THE RANDOMISED TRIAL

I.J.M.S. Allgust, 1992

options for the patient presenting with an inguinal hernia. Over a 12 month period we prospectively compared 15 patients undergoing laparoscopic herniotomy with 15 patients in whom a Bassini herninr- raphy was performed. The mean anaesthetic time required for the laparoscopic group was 126 minutes compared with 75 minutes for the Bassini group. A Mean of 1.7 was recorded on the visual analogue pain scale by the laparoscopic group compared with 5.5 by the Bassini group at 24 hours post operatively. There was no immediate complications in the laparoscopic group while one wound infection and two c ases of urinary retention occurred hi the B as shli group. Tlre mean postoperative stay was 1.7 days in the laparoscopic group compared with 3.7 days in the Bassini group. To date one recurrence has occmred in the laparoseopic group most likely due to fracture of a prolene suture which was traumatized during the procedure. No recurrences have occurred in the Bassini group. While the results are initially encouraging, a stringent clinical trial and long term follow up will be necessary before the role of this new surgical procedure was validated.

A. D. K. Hill, S. E. A. Attwood, P. G. Murphy,.R.B. Stephens. St. Jamas's Hospital, Dublin 8.

Laparoscopic removal of the acute appendix is feasible, however, the advantages of laparoscopic removal have not been shown in a randomised controlled trial.. From January 1991, all patients presenting to one constfltant with symptoms and signs suggestive of acute appendicitis were randomised to either laparoscopic or classical appendicectemy after informed consent.34patinnts wererandomised, 17 had a laparosenpy, one was grossly normal and left in sire, and another was converted to open operation because of obvious faecal soiling. The remaining 17 patients had a classical appendicectomy.

Laparoscopic Classical (n=15) (n=18)

Mean age (years)' 20.8 (12 - 29) 22.9 (15 - 52) Length of stay (days) 3.3 (1 - 7) 3.9 (1 - 7) Mean operating time (mins) 65(25-130) 51(15-100) Histology positive 12/15 17/18

Four complications occurred. One patient developed urinary retention and another developed a prolonged ileus after classical ap- pendicectomies. Two patients required readmission for non specific abdominal pain after laparoscopic appendicectomy both of whom settled on conservative management. These results would suggest that laparoscopic removal of the acute appendix is safe and effective. However, from the data it is difficult to identify an advantage of one procedure over the other. Greater numbers will be needed to establish statistically significant differences between the tWO procedures.

83. LAPAROSCOPIC MANAGEMENT OF INGUINAL HERNIAS

J. Coleman, A. Querashi, N. Ajayi, G. McEntee, P. Grace, H. Osborne, D. J. Bouchier-Hayes.

Department of Surgery, R.C.S.I., Beaumont Hospital, Dublin 9.

Laparoscopic surgery has broadened the surgical therapeutic

84. LAPAROSCOPIC CHOLECYSTECTOMY:

THE NEED TO RETRIEVE THE DROPPED STONE

S. Johnston, K. O'Malley, G. McEntee, P. Grace, E. Smyth, D. L Bouchier-Hayas.

Department of Surgery, R.C.S.I., Beaumont Hospital, Dublin 9.

Laparoscopic cholecystectomy is rapidly replacing open surgery as the commonest treatment for symptomatic gallstones. Perforation of the gallbladder may occur during the procedure resulting in leakage of bile and gallstones into the peritoneal cavity. This study evaluated file effect of sterile and infected bile either alone or in combination with gallstones on the peritoneal cavity of the rat. Male Sprague-Dawley rats were divided into five groups of 15 rats each. Groups 1 - 3 received an intraperitoneal (IP) unjection (2ml) of: 1. sterile bile, 2. infected bile (I x l 0 ~ E-Col/ml) and 3.saline. In groups 4 and 5 a small lower midline incision was made dgough which a gallstone 203 mm in diameter, was placed in the right upper peritoneal cavity. The wound was closed with 3/0 PDS suture and 2 ml of sterile (group 4) or infected (group 5) bile was injected intr aperitone- ally. In group 6 a Sham laparotomy was performed and 2 ml of saline injected intraperitoneally. The animals were sacrificed at 1 month and at laparotomy the gallstone was located and the presence of intraperitoneal pathology noted. Results were:

Group 1 2 3 4 5 6

IP Inject SterileInfected Saline Sterile Infected Sham (2ml) Bile Bile Bile Bile Gallstone + + - - Adhesions 0 0. 0- 11 (73%) ]0(67%) 0 IP Abscess 0 0 0 2 (14%) 0 0

All of the 'adhesions observed were dense adhesions. In summary this study suggests that 1. Leakage of bile alone during laparoscopy is harmless. 2. bile and gallstones act synergistically in the peritoneal cavity to produce dense adhesions. We conclude that every effort should be made to retrieve gallstones lost hi the peritoneal cavity during laparoscopic cholecystectomy.

Vol. I61 No. $

85. LASER VAGOTOMY FACT OR FICTION?

A. Daszi, A. Quereshi, G. McEntec, A. Leahy, P. Grace, D. Bouchier-Hayes.

Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9.

The concept of laparoscopic vagotomy is revolutionary, however, carrying outhighly selective vagotomy through an operating la- paroscope is atedinus and time consuming operation. C~bon diox- ide laser (C02) has been described to destroy peripheralnerves selec- tively arid preserve the vessels within the neuro-vascular bundle ( 1 ). In this study we examined the effects of CO2 laser beam on the vagal distribution of the anterior wall of the stomach. Posterior truncal vagolomy and CO'2 liner anterior aeromyotomy (L.V.) was carried out in 10 mongrel dogs. Furthermore, 5 dogs received highly selective vagotomy as controls (H.S.VJ). Basal acid pH (BApH) and maximal acid pH (MApH) in response to pentagastrin (7.5 ug/kg) was measured tree and pest vagotomy

Operation Pre-Vagotomy Post-Vagotomy n BApH MApH BApk MApH

UV.10 4.01 1.55 4.96 4.17 H.S.V.S 4.17 1.07 4.57 3.92

Thepre andpost operative BAptt were the same inbeth treatment groups. Although there was no significant differtmce in the MApH post vagotomy in either group. There was more than 50% reduction in the MApH post vagotomy in L.V. and H.S.V. These results indicate that CO2 laser effectively destxoys vagal nerve fibres as the MApH was similar following both L.V. and H.S.V. The application of CO2 lase~ vagotumy through an operating laparosqope should be investigated.

1. G. Von Schreiber, H. Oswald, M. Danz. C02 laser effekte peripheren markhaltigen herren. Z. Exp. Clair. 1974; 7:2 - 8.

86. PROSPECTIVE EVALUATION OF LAPAROSCOPIC

VERSUS OPEN APPENDICECTOMY

O. Austin, W. P. Hederman, P. R. O'Connell, T. Gore),, J. M. Fitzpatrick, O. J. MeAnena.

Department of Surgery, Mater Misericordiae Hospital, Dublin.

Laparoscopic surgery for gallbladder disease has rapidly been ac- ceptod as theprimary treata-aent for galls tones. To date most surgeons doubt the validity of laparoscopic removal for acute appendicitis as the open procedure is attendant with few life threatening complications. Wound infection, prolonged hospital stay, and delay in return to normal activity remain a problem following open appendicectomy, however.

For six months, starting January 1991, this prospective study was undertaken to assess the feasibility of laparoscopic surgery for acute appendicitis. 65 patients with signs and symptoms of appendicitis necessitating surgery were randomly assigned to open (n = 36 ) versus the laparoscopic (n = 29) route. 37 were female (22 open) 28 male ( 14 open); mean ages were 24 (14 -64) years for open and 18 years (14 - 60) for laparoscopic. Results were as follows:


Open. (n-~36) Laparoscopic (n=27) Pnstop stay (days) 4.8 (1 - 21) 2.2 (1 - 11)* Anaesthesia time (mins) 52 (15 - 90) 48 (20 - 120) Histologically inflamed (%) 72 76 Wound infection (%) 11 4* I.M. Analgesia postop 5 1" (Mean values, ( ) = range; *p<0.05, Mann Whitney analysis)

One patient in the lap. group was converted to open procedure as the appendix was perforated at the base end a Roeder loop tie could not be secured. This was the only patient in the lap groop compileated by wound infection and prolonged (i.e. >4 days) postoperative stay. Another was converted for technical reasons. Two patients had laparoscopy only following identification of ovarian pathology.

Our re.suits suggest that emergency laparoscopic appendicectomy should be further explored as an alternative to open surgery.

87. A PROSPECTIVE STUDY OF THE EFFECTS OF

SUPPLEMENTAL OXYGEN ON ARTERIAL OXYGEN SATURATION DURING ENDOSCOPY

D. P. O'Leary, M .W. Recd. J. L. Duncan, A, G. Johnson, C. S, Reilly.

University Department of Surgery, Royal Hallamshire Hospital, Sheffield.

Upper alimentary endoscopy carries a small but definite risk of mortality from respiratory falinre. Hypoxia during endoscopy is common, but it is unclear whether this is due to the procedure itself, or to use of sedation. The purpose of this study was .to investigate the effects of endoscopy on arterial oxygen saturation in sedated end unsedated patients, and to determine whether supplemental oxygen conferred any benefit.

152 patients underwent elective upper alimentary endoscopy either with sedation (Diazemuls 5 10 mg i.v .), or without it; and were randomized to receive room air or supplemental oxygen (41..~min) by nasal prongs. Arterial oxygen saturation (SAO2%), was measured at 5 second intervals using an Ohmeda Bins 3700 pulsoximeter.

Incidence of significant hypoxia (SAO2<92%) by group (Gp)

% P n 1. No Sedation, No Suppl Oxygen 58 43% 2. Sedation, No Suppl Oxygen 19 63% 3. No Sedation, Suppl Oxygen 56 11% <0.05 vs Gpl 4. Sedation, Suppl Oxygen 19 16% <0.05 vs Gp2

No patients developed signs of respiratory insufficiency. None- theless, significant hypoxia occurred in a high proportion of unsedated as well as sedated patients, Use of supplemental oxygen reduced significantly the incidence of hypoxia in both groups. These data indicate that unrecognized hypoxia is corronon during endoscopy. We now advocate a policy of routine oxygen therapy during endoscopy, or selective use based on routine pulsoximetry.

546

88. PULMONARY ASPIRATION DURING LAPAROSCOPY:

ASSESSING THE RISK WITH TRACHEAL & OESOPHAGEAL pH MONITORING

C. McGibney, P. Lawlor, B. Lawless, E. MeGuirmess, S. Leahy, T. P. J. Hennessy.

Departments of Anaesthesia, Gynaeeology and General Surgery, SL Jm'nes's Hospital, Dublin.

Laparoscopy, rotitine in gynaecology, is now well established as a"minimallyinv~ive" alternative to traditional operative approaches in general su/geiy (appandieectomy, cholecystectomy). Features of this procedure eg. intra-abdominal insufflation and trendelenburg position (plus reversal of same) may lead to pulmonary aspiration (PA). The pH values of bronchial mucosa lie between 5.4 and 6.9. Thus aspiration of pharyngeal contents of local origin or secondary m gastro-oesophageal regurgitation - GR which have a pH<4 or pH>7, may result In pulmonary problems.

To determine the incidence of G R ~ t h acid and alkaline---and its relationship to the tracheal pH profile during routine laparoscopy,

IJ.M.S. August, 1992

oasophageaI and tracheal pH monitoring was carried out simultaneously in an unselected group of patients (n= 15) undergoing elective gynaecological surgery. Results were compared to reported figures for non-laparoscopic ele~ctive surgey (NLES).

RESULTS: % of Patients (I1=15) with pH<4 In Oesophagus In Trachea

Per-op Recovery Per-op Laparoscopy: *46% 31% *23~ Reported values for NLES: 17% 34% 0%

*p < 0.01

Laparoscopy wa~s associated with greater per,-operative acid exposure times in the oesophagus* and trachea*. However, if alkaline episodes w ere also considered the percentage of patients with potentially harmful refluxes rose to 62% and 46% respectively.

Laparoscopy carries a higher risk for pulmonary aspiration than non-laparoscopic elective surgery. This risk is grossly underesti- mated if acid (pH<4) parameters alone a~e used for assessment. Routine and appropriate use of pharyngeal suctioning and pro- kinetic agents may decrease the risk of pulmonary aspiration, particularly in the less-protected recovery period.

Sixteenth sir peter freyer memorial lecture and surgical symposium September 13th & 14th, 1991...

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Transcript of Sixteenth sir peter freyer memorial lecture and surgical symposium September 13th & 14th, 1991...