Sir Peter Freyer Memorial Lecture and Surgical Symposium 15th and 16th September, 1995

SIR PETER FREYER MEMORIAL LECTURE AND SURGICAL SYMPOSIUM 15th and 16th September, 1995

SKIN MALIGNANCIES IN A RURAL WEST OF IRELAND POPULATION

J. Calleary, C. Tansey, J. McCormack, S. Kapur, J. Doyle, J. Flynn.

Portiuncula Hospital, Ballinasloe, Co. Galway.

Given the current interest in skin malignancies we reviewed all skin lesions excised at our unit over a one year period, January-December 1994. Our intent was to elucidate their relative frequency in the local catchment area served by the Hospital and institute a public education programme if the results suggested that this would lead to an earlier stage presenting.

Total lesions excised were 474 (374 patients) with a male:female ratio of 4:5, a mean age of 49yrs (range 1-93).

Of the lesions excised 20% were malignant, 91 of the 93 being primary skin malignancies. In addition the pre-malignant condition of solar keratosis was present in 6% of all lesions. Non-malignant lesions were: Naevi (intradermal mainly) (31%); seborrhoeic keratosis (14.45%); papi l lomas (5.5%); haemangiomas (4%) and dermatofibromas (3%). The rest were made up of various lesions from lupus to infective lesions.

New squamous lesions were diagosed in 48 patients. Of these 50% were CIS. The vast majority were over 60 and the male:female was 6:4.

Melanocarcinoma was the diagnosis in 10 lesions (7 patients, 2.1% total patients). Six patients were over 50 yr and in only two was the diagnosis Clark II or less. In conclusion:

I. 20% of lesions were malignant. II. Presentation varied with pathological diagnosis, those

with melanomas tended to present with Clark levels IV or V.

III. A public education programme must be undertaken.

REDUCING THE RISK OF IMPLANTATION OF MALIGNANT CELLS INTRAOPERATIVELY

A, J. Curran, D. Smyth, B. Kane, M. Toner, C. V. I. Timon. Professorial Department of Otolaryngology, Head and Neck

Surgery and Pathology, St. James's Hospital, Dublin 8.

Carcinoma of the upper aero-digestive tract is a common disease of Western society and local recurrence after conceivably curative resection a major pi'oblem. Cells exfoliated from malignant tumours have been demonstrated in washings from operations on patients with cancer of the head and neck. These cells have been considered capable of implanting and giving rise to local recurrence or metastatic deposits. Recent literature has suggested that this can be reduced by specific measures taken intraoperatively. One potential source of contamination would be from gloves and instruments used during the surgery.

The aims of this prospective study were to examine washings taken from surgeon's gloves and from instruments used during neck dissections to determine if exfoliated cancer ceils were indeed present. Identification of tumour cells would have implications for routine practice such as glove changing and instrument cleansing.

Washings were taken from 15 patients undergoing major head & neck procedures. Following removal of the main neck

specimen all surgeons thoroughly washed their hands in a solution of Cytospin r (a cell fixative). All instruments used during the procedure were soaked in the solution. Samples from both glove washings and instruments were spun in a centrifuge for 5 min and supernatant fluid then aspirated. Deposits were re-centrifuged in a Cytospin 3 solution and preparations stained using the PAP technique.

All specimens were carefully studied by an experienced cytologist and 9 of the 15 specimens contained nuclear fragments consistent with turnout cells in both the glove and the instrument washings. From this study it is clearly important to change gloves and instruments prior to irrigation of the operative field with a tumoricidal agent.

A FIVE YEAR CLINICOPATHOLOGICAL EVALUATION OF 91 PATIENTS WITH MENALOCYTIC TUMOURS IN

THE WEST OF IRELAND

K. J. Cronin, J. O'Donoghue, T. Sullivan, F. X. Darmanin, J. McCann.

Department of Plastic, Reconstructive & Hand Surgery, University College Hospital, Galway.

The West of Ireland has one of the highest rates of non- melanoma skin cancer in the world with an incidence as high as 364 per 100,000 population in certain areas. However relatively little is known about the pattern of melanocytic skin tumours in the region. We reviewed 92 cases of melanocytic skin tumours in 91 patents who presented to our service over a five and a half year period. All patients were clinically followed for a period ranging from 1 to 63 months (mean follow up = 41 months) and this information was correlated to pathological parameters. The breakdown of data was as follows:

LENTIGO 52 (56.5%) MALIGNA

MALIGNANT 40 (43.5%) MELANOMA

Superfic. 14 (35%) spreading Nodular 10 (25%) Lentigo Maligna 9 (23%) Melanoma Acralentigenous 4 (10%) Melanoma Undefined 3 (7.5%) metastatic

TOTAL 92 (100%)

There is a higher incidenceof Lentigo Maligna and Lentigo Maligna Melanoma than is reported in other series of melanomas. 25% of the patients with Lentigo Maligna had either synchronous or metachronous non-melanoma skin cancers as compared to 10% of those with malignant melanoma (half of those occurred in the lentigo malignant melanoma subgroup). The majority of patients were treated by excision and direct closure (70%) under local anaesthetic (66%) in the day ward (56%). Complications were seen in 14% and the mortality was 5.4% (5/92; 3 from melanoma). We conclude therefore that there

revisions); two received aorto-coeliac-SMA grafts. One had an aorto-coeliac graft only due to severe distal disease in her SMA and one had an IMA endarterectomy only. There were two deaths within 30 'days of surgery unrelated to bowel ischaemia. Five patients are currently "alive and we'll (follow-up 4 months - 4 years). Four patients died of causes unrelated to mesenteric ischaemia; one died of sepsis 2 years later following prolonged TPN. All patients with successfull grafts ate full diet without pain and gained weight.

Despite a significant morbidity and mortality, reconstructive vascular surgery offers the only hope of survival in these cr i t ica l ly ill pat ients . This small series suggests that an aggressive approach to the management of mesenteric ischaemia maximises the chance of a reasonable quality of life.

THE HAEMODYNAMIC EFFECTS AND CATECHOLAMINE RELEASE IN RESPONSE TO BYPASS

WITH HEPARIN COATING

A. O'Donnell , K. Carson, E. McGovern, D. Phelan, S. McBrinn, D. McCarthy, H. Javadpour, J. McCarthy,

M. Neligan. Departments of Cardiac Surgery & Anaesthesia, Mater

Misericordiae Hospital, Eccles Street, Dublin.

Cardiopulmonary bypass (CPB) is associated with bleeding and thrombotic complications, massive fluid shifts, and cellular and hormonal defense reactions that are collectively termed "the whole body in f lammatory response". This inf lammatory response contributes to the mortality and morbidity following CPB. The exposure of blood to large areas of non-physiological surfaces during CPB is one of the factors contributing to the inflammatory reaction. Heparin coated circuits have been developed to improve the biocompatablity of extracorporeal circuits, with decreased complement activation and neutrophil degranulation being demonstrated. The aim of this investigation was to study the effect of CPB, with and without heparin coated c i rcui ts , on c a t e c h o l a m i n e re lease dur ing CPB and on haemodynamic performance following CPB.

Nineteen patients presenting for elective coronary artery bypass grafting, with normal cardiac function, were randomised to heparin coated (HC, n=9) or non-coated (NC, n=10) CPB groups. A standard anaesthetic technique was used and all patients had an oximetric pulmonary artery flotation catheter inserted. Blood was taken for catecholamine assay at six time points: (1) Following heparin prior to CPB, (2) prior to aortic cross clamping, (3) 15 min after CPB started, (4) 2 min after cross clamp removed, during proximal anastomoses, (5) 2 min after ventilation recommenced, (6) 5 min following protamine sulphate. Plasma catecholamine levels were determined by high pressure liquid chromatography. The haemodynamic parameters (cardiac index and systemic vascular resistance) were measured pre & post CPB, at sternal wiring, then at 1 hour intervals for 6 hr, then at 12 & 18 hr. The groups were similar for age, sex, number of distal anastomoses, CPB times and aortic cross clamp times. There was no significant difference between the groups when examined for adrenaline or noradrenaline levels. Similarly, there was no difference in the haemodynamic performance of the two groups in terms of cardiac index or lowered systemic vascular resistance. We conclude that heparin coated CPB circuits may be more biocompatable but this does not translate into decreased ca techo lamine product ion on CPB or an improvement in haemodynamic performance.

OESOPHAGEAL BILE REFLUX FOLLOWING CHOLECYSTECTOMY: A PROSPECTIVE STUDY

M. T. P. Caldwell, J. P. McGrath, P. J. Byrne, T. N. Walsh, T. P. J. Hennessy.

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

There is an increased incidence of duodenogastric reflux of bile in post-cholecystectomy patients. It has previously been shown that cholecystectomy results in gastro-oesophageal acid ref lux but bile reflux into. the oesophagus has not been investigated in this group of patients. Fiber optic techniques for bile reflux assessment have recently become available and permit ambulatory monitoring. Eighteen patients have been entered into an ongoing prospective study to date. Patients were studied before (n=l 8) and 3 months (n=8) after cholecystectomy by upper /gast rointes t inal endoscopy, s imultaneous 24 hr oesophageal pH and bile and oesophageal manometry.

Results Pre-op Post-up 6.3 (1-11) 16.4 (0.3-30)* Bile Reflux - median (range)

(% time absorbence >0.14) Mean (sem)

DeMeester Acid Reflux Score 15.9(2.5) 35.0 (5.8)* LOSP (mmHg) 14.8(0.9) 12.2 (1.2)

* p<0.05 Wilcoxon Rank Sum Test.

Oesophagea l b i le r e f lux occur red p r e - o p e r a t i v e l y . Cholecys tec tomy results in increased bile reflux. Lower oesophagea l sphincter pressure (LOSP) did not change significantly but acid reflux was significantly increased after surgery. The combination of bile and acid reflux is particularly noxious to the oesophageal squamous epithel ium and has implications for treatment of patients with cholelithiasis and gastro-oesophageal reflux disease.

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PHARYNGEAL CLEARANCE FAILURE AND THE EXTRAOESOPHAGEAL MANIFESTATIONS OF REFLUX

J. P. McGrath, P. Lawlor, P. J. Byrne, C. Timon*, R. C. Stuart, T. N. Walsh, T. P. J. Hennessy.

University Departments of Surgery and Otolaryngology*, St. James's Hospital, Dublin.

Oesophago-pharyngeal reflux has been implicated in the pathogenesis of otolaryngological manifestations of gastro- oesophageal reflux but the mechanism is unclear. This study evaluated pharyngeal and oesophageal clearance in patients with oesophageal or pharyngeal reflux. Fourteen patients with suspected reflux associated otolaryngological disease were studied. 24 hour ambulatory manometry and pHmetry of the pharynx and oesophagus were performed. Seven patients had abnormal pharyngeal acid exposure (Group 1) and 9 had abnormal oesophageal acid exposure only (Group 2).

RESULTS Mean (sem)

Pharyngeal reflux episodes Oesophageal reflux episodes Duration of oesophageal reflux episodes (min) DeMeester acid reflux score Pharyngeal clearance (%) Secondary oesophageal peristalsis (%) Non-transmitted swallows (%)

Wilcoxon Rank Sum Test *p<0.01

Group 1 Group 2

11 (2) 0 77 (5) 68 (4) 7 (1) 3 (1)* 31 (3) 24 (3) 56 (4) 73 (6)* 21 (2) l l (I)* 24 (2) 17 (2)*

The dura t ion of o e s o p h a g e a l ref lux ep i sodes were significantly greater in group 1 but all other reflux parameters were similar between groups. For ty-four per cent of reflux episodes in group 1 were associated with defective pharyngeal swallowing. Pharyngeal swallowing was shown to be the primary means of clearance in both groups. Failure of this mechanism resulted in pharyngeal reflux.

overlapping technique. In 10 (50%) a synchronous anterior levatorplasty and rectocoele repair was performed with fistula excision in 2. 17 patients have been followed up > 3 months. Of these 15 (88%) reported symptomatic improvement with dramatic improvement in quality of life. We conclude that occult anal sphincter injury is a common cause of faecal incontinence which can be successfully repaired.

A 10 YEAR PROSPECTIVE ASSESSMENT OF INGUINAL HERNIORRHAPHY USING A MODIFIED BASSINI

TECHNIQUE

K. Murray, C. J. O'Boyle, A. Carney, J. G. Johnston. Department of Surgery, Mayo General Hospital, Castlebar.

Surgical repair of inguinal hernias is most commonly performed using the well-established Shouldice or Bassini techniques. Disadvantages of the Shouldice operation include prolonged operating time in an elderly population and a tendency for increased post-operative pain due to tightness of the repair. The Bassini method while quicker has higher recurrence rates. We have carried out a 10 year prospective evaluation of an alternative method of inguinal herniorrhaphy using a modified Bassini technique, which incorporates the cremasteric muscle into the posterior wall repair.

Between January 1985-December 1994 three hundred and thirty two patients had inguinal herniorrhaphies under one consultant surgeon. The male : female ratio was 20:1. Median age of the group was 58yr (range 18-85). Forty-two percen{ (1.39) of patients had left-sided hernias, 54%(179) were right-sided and 4% (13) were bilateral. Seventeen patients (5%) had signs of obstruction at presentation. Mean operating time was 30min with a range of 20-55min. Median post-operative hospital stay was 5 days with a range of 1-10 days. Complications of the procedure were few and included haematoma formation (4.2%), wound infection (2%), urinary tract infection (0.9%) and orchitis (0.3%). Morbidity was not operator dependent. All patients were reviewed post-operatively. Our median 6 year recurrence rate is 1.8% (6) which compares favourably with published series. We recommend this repair as a technically straightforward method of inguinal herniorrhaphy with reduced operative time and acceptable morbidity and recurrence rates.

ANAL SPHINCTER REPAIR IN TREATMENT OF FAECAL INCONTINENCE

B. Egan, P. R. O'Connell. Department of Surgery, Mater Misericordiae Hospital,

Dublin.

Obstetrical trauma is the most frequent cause of faecal incontinence in women. Recently using vector manometry and endoanal ultrasound, occult anal sphincter disruption has been shown to be an important component of the pelvic floor injury which may occur during vaginal delivery. The aim of this study was to review our experience of delayed anal sphincter repair in 20 women with occult anal sphincter injury. The mean patient age was 42 yr (range 26 - 65) and the mean duration of symptoms was 30 months (range 4 months - 16 yr). 16 (80%) had had a perineal laceration or recognized third degree tear repaired and 9 (45%) had had a forceps assisted delivery. Two (10%) had associated rectovaginal fistulas. Anal sphincter repair was performed through a transverse perineal incision using Parks'

ACUTE APPENDICITIS AND HELICOBACTER PYLOR! - IS THERE AN ASSOCIATION?

N. F. Fanning, J. Donoghue, P. G. Horgan, A. Pollock, D. Hyde, D. Hourihan, W. A.Tanner, F. B. V. Keane. Department of Surgery, Meath Hospital, Dublin 8.

Appendicitis remains the commonest surgical emergency in developed countries. The infective organisms found most frequently with acute appendicitis are Bacteroides fragilis and Streptococcus faecalis. The role of H. pylori in acute appendicitis has not been investigated to date. H. pylori has been shown to be involved in the pathogenesis of many upper gastrointestinal diseases. There is evidence that H. pylori is viable outside the gastroduodenum. Our study sought to investigate the association between H. pylori and acute appendicitis.

10 successive patients with a histological diagnosis of acute appendicitis were investigated for H. pylori status. The mean age of the population was 21 yr (range 14-42) with an equal male to female ratio. Detection ofH. pylori was initially carried out by three methods: serology, culture, and histology. Serum samples from each patient were taken on admission and follow- up. Each sample was analysed by ELISA technique for IgG antibodies specific for H. pylori. Titres more dilute than 1:400 were deemed positive. Three mucosal samples from each inflamed appendix were cultured on non-selective (chocolate agar) and selective (Wilkin-Chalgeen) media in a CO 2 enriched environment at 37~ for 5 days. Colonies were gram-stained and examined by light microscopy. Formalin-fixed appendices were stained with Steiner, haematoxylin-eosin, alcian blue triple stain to detect H. pylori presence.

All patients had negative serology for H. pylori on admission and at follow-up. After 5 days of culture, numerous colonies of gram- negative and gram-positive bacilli were grown. No H. pylori colonies were grown. Histology in 6 cases did reveal the presence off-/, pylori- like organisms. To determine if these H. pylori-like organisms were indeed H. pylori, polymerase chain reaction (PCR) techniques were employed. Following PCR amplification of the H. pylori gene encoding 16S rRNA, specific and sensitive primers (Hpl-Hp2) were utilised to identify the presence of any H. pylori organisms. In all cases studied no H. pylori was identified.

Thus we have defini t ively shown that H. pylori is not associated with acute appendicitis.

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LAPAROSCOPIC NISSEN FUNDOPLICATION FOR GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

J. Donohue, N. Fanning, P. Horgan, E B. V. Keane, W. A. Tanner.

Department of Surgery, Meath/Adelaide Hospitals, Dublin 8.

The introduction of laparoscopic procedures has dominated the surgical l i t e ra ture in recent years . L a p a r o s c o p i c cholecystectomy is firmly established but the situation with

may be a higher incidence of Lentigo Maligna and Lentigo Malignant Melanoma in the West of Ireland and that patients with these lesions also frequently suffer from non-melanoma skin cancers.

INDUCTION OF A HEAT SHOCK RESPONSE PROTECTS TUMOUR CELLS FROM MONOCYTE MEDIATED LYSIS

E Campbell, H. P. Redmond, C. Condron, D. Bouchier-Hayes.

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

Tumour cells proliferate despite the presence of tumouricidal mediators. We hypothesise that this could be due to the induction of a heat shock response in the tumour cell. The heat shock response appears to represent a universal cellular defense mechanism in native host cells. Tumour cells may also utilise this mechanism to protect themselves from host defense mechanisms by increasing either intracellular levels or surface expression of heat shock proteins (HSP). The aim of this study was to assess the effect of heat shock induction on tumour cell protection against host effector cells. The heat shock response was induced by either sodium arsenite (SA. 0-320txM for 6hr) or by hyperthermia (42~ for 20 min). For the cytotoxicity assays the colorectal tumour cell line, SW707 cells were heat shocked, labelled with 51Cr and incubated with human monocytes (Me) isolated by density centrifugation and plastic adherance from healthy volunteers. Cytotoxieity was assessed by 5~Cr release. Flow cytometric studies on heat shocked SW707 cells to assess surface expression of HSP60 and HSP70 were by an indirect method using a fluocescein isothiocyanate (FITC)-conjugated second antibody.

HSP60 HSP70 % cytotoxicity expression expression SW707 heat shocked (MCF) (MCF)

control 40.15+0.812 10.17+0.150 17.13+0.664 401.tM SA 0.405:0.403* 10.29-!"0.086 13.81+1.769 801.tM SA 2.60+1.756" 10.53+0.196 13.77+2.103 160~tM SA 3.18+1.719" 9.85+0.239 13.72+2.236 320/.tM SA 0.77+0.765* 10.28+0.230 12.45+2.112 42~ 11.50-20.799* 11.05+0.346 14.72-t-2.687

n=mean+SE *p<0.00003 Vs control ANOVA (Scheffe post hoc)

The data indicate that heat shocking tumour cells significantly protects them from M0 mediated tumour cell lysis. Since the flow cytometric data indicate that there is no significant increase in surface expression of HSP60 and HSP70 on the tumour cell when the cells are heat shocked, it is reasonable to infer that the induction of intracellular HSP levels are responsible for the protective effect on the turnout cells. MCF: median channel fluorescence

POOR PULMONARY FUNCTION TESTS DO NOT PRECLUDE PULMONARY RESECTION

K. Aizaz, S, W. MacGowan, A. E O'Donnell, D..A. Luke, E. McGovern.

Department of Cardiothoracic Surgery, St. James's Hospital, James's Street, Dublin 1.

As the only real possibility for cure in lung cancer is surgical resection, it is important that patients with adequate residual

lung function are not refused surgery on the basis of poor pulmonary function tests. Patients with a forced expiratory volume in one second (FEV 1) of 1-1.8 l/s are usually considered high risk for pulmonary resection. The aim of this study was to determine if these patients did indeed have a higher risk than patients with an FEV 1 > 1.8 Us.

Over a six month period (October, 1993 - March, 1994) 35 patients with poor pulmonary function tests, defined as an FEV1 1-1.8 l/s and FVC 1.5-2.4 l/rain were admitted 4 to 5 days prior to surgery for i n t ens ive phys io the r a py c o m b i n e d wfth bronchodilators to optimise pulmonary function.

Pulmonary function improved in 23 patients (Group A) but worsened in 12 patients ' (Group B). All subsequently had pulmonary resection (segmental resection n=3, lobectomy n=l 9, pneumonectomy n=16). There was one peri-operative death in Group B. Compl ica t ions (arrhythmias , wound infect ion, respiratory tract infection, respiratory failure, myocardial infarction, prolonged air leak) were similar in both groups. These data show that patients should not be excluded from surgery on the basis of poor conventional pulmonary function tests alone. A more complete assessment of pulmonary function including

determining post-operative FEVI will allow more patients to avail of the only potential cure for lung cancer.

4

MICROSATELLITE INSTABILITY IN COLORECTAL CANCER PATIENTS WITH FAMILIAL CANCER

SYNDROME

M. Morrin, E Khan, P. V. Delaney. Colorectal Research Unit, Limerick Regional Hospital and

University of Limerick

Recent advances in the study of colorectal cancer genetics have highlighted the role of DNA "mismatch repair" genes in the etiology of HNPCC (Lynch Syndrome II). In their normal roles, these genes are responsible for mismatch recognition and can orchestrate the enzymes that effect repairs. If they do not function, errors accumulate in the course of many generations of cell divisions and eventually tumourigenesis occurs. Such defects in mismatch repair are most easily observed as changes in the length of microsatellite sequences in tumour DNA as compared with normal DNA from the same individual. Tumours with these abnormalities, termed RER+, are characteristic of colorectal cancers in families with HNPCC, bu t can also be observed in approximately 14% of apparently sporadic cases.

We havebeen investigating the incidence of hereditary cancer syndromes in this region. Four families have been identified, each of which have two or more first degree relatives with colorectal cancer, thus categorising them as having familial cancer syndrome. Other families have a high frequency of cancer but with diverse primary locations. Using a combination of PCR- SSCP and direct sequencing to analyse DNA from blood and tumours of'the family members, germline mutations of the p53 tumour suppressor gene have been excluded as a possible reason for the high cancer incidence in these families. However, when microsatellite repeat sequences in normal and tumour DNA of family members were compared, specimens from two members of one family each demonstrated changes in sequence length at two loci. This implies that a defect in mismatch repair could be responsible for tumour development in this family.

INVENTORY OF CLINICAL DECISIONS: A PROFORMA APPROACH TO RECORDING AND ANALYSIS UNDER

WORKING CONDITIONS

S. M. Lavelle, B. Kanagaratnam, V. Cuervas-Mons, A. Gauthier, C. Gips, R. Marques dos Santos, G. P. Molino,

A. Theodossi, D. D. Tsiftsis & project participants. Clinical Science Institute, University College Hospital,

Galway and Madrid, Marseille, Groningen, Coimbra, Torino, London, Crete.

There is an unabsorbable overload of clinical knowledge, much of it contradictory, and considerable variation of beliefs between doctors even in the same specialty. It is likely that there is an optimum knowledge set which is derivable from majority practice.

The objective of the four EU projects, EURICTERUS, IDMR, ICTEC and PECOTEC is to make an indepth inventory in one disease presentation, jaundice, of the decisional evidence in use and its efficacy in hospital practice in Eurol~e using standardised data and a format structured by the clinical decisions.

The method is summative across the projects. EURICTERUS gathered a database of 10,004 cases in 26 countries using neural net, Bayesian and expert system diagnostic systems to provide reproducible quantitated diagnostic accuracy. Neural net attained a diagnostic accuracy on new cases of 67%.

The IDMR project used the same set of clinical data, and in addition structured the decisions that classify, investigate, and treat jaundice patients in 17 hospitals in the EU. Some 6000 decisions were recorded with their sequence, grounds, results outcomes and inter-relationships.

The ICTEC project currently gathers in EU-COST countries the same clinical data set and the decisions on technology usages in jaundice, with about 600 patients and 4000 usages to date, and PECOTEC does the san~e in the east bringing the total countries involved to about 40. The target is 5000 cases. The data are gathered prospectively and anonymously, forwarded to Galway on floppy disk and entered into the database. Quality control is maintained by deta i led protocol, test ing of all instruments in the field, feedback of discrepancies to the observing doctor, and observer agreement studies in regional workshops. The contribution of each technology in each disease is obtained quantitatively by the computed increment the test gives, above the evidence provided by the clinical data.

The projects provide data on 17 common and many rare or combined diseases. Some 44% of patients are surgical, excluding transplantations. Prognostic factors have been obtained for chronic diseases, and the differing clinical pictures of young and old patients from the large database built from many different kinds of hospital, country, climate and degree of technical development. The clinical data provide 66% of the diagnostic evidence and indicate which technologies to employ. Technologies vary considerably, but are about 25% effective in diagnosing the cases to which they are applied~ Illustrative examples will be presented on risk factors, sub-diseases and diagnostic performances.

PRIMARY MALIGNANT TUMOURS OF THE SMALL BOWEL: A DIAGNOSTIC DILEMMA

C. J. O Boyle, N. Hegarty, T. J. Boyle, M. J. Kerin, D. M. Courtney, D. S. Quill, H. F. Given.

Department of Surgery, University College Hospital, Galway.

Primary malignant tumours of the small intestine are rare

5

and insidious. Vague symptomatology and delayed investigation often result in advanced disease at diagnosis. We have reviewed the clinical records of twenty-five patients presenting with primary small bowel malignancies over an eleven-year period (January 1984 December 1994). There were 16 males and 9 females. The median age at presentation was 64 yr (range 34- 80 yr). Eighteen patients had lymphomas (72%), four had primary small bowel adermcafcinomas (16%), two had carcinoid tumours (8%) and there was one leiomyosarcoma (4%).

Abdomina l pain, weight loss and vomi t ing were the commonest presenting symptoms. Thirteen patients (52%) had symptoms for more than five months prior to diagnosis. Five patients presented as surgical emergencies with acute small bowel obst ruct ion or perfora t ion (20%). Barium studies identified pathology in 10 patients (40%). Two tumours were diagnosed on CT scan, 2 on ultrasound scan, 1 on IVP and 1 on mesenteric angiogram. Accurate pre-operative diagnosis was obtained in just 8 patients (32%). In 7 patients a diagnosis of malignancy was made only at laparotomy.

Curative resection was performed in 19 (76%) of our patients, palliative resection in 3 (12%) and 3 patients had unresectable disease. Despite adjuvant chemotherapy, there was a 55% mortality in the patients with lymphoma at a median of 9 months following surgery. One of the 4 patients with adenocarcinomas died six months post-operatively and a further patient is alive with recurrence at 9 years. The patients with carcinoid turnouts and leiomyosarcoma remain well on follow-up.

Primary malignant tumours of the small intest ine are associated with a high mortality. A high index of suspicion and prompt thorough investigation of non-specific gastrointestinal sympt0matology will result in improved survival for patients with these rare but often fatal malignancies.

LAPAROSCOPIC CHOLECYSTECTOMY: A RETROSPECTIVE REVIEW OF 300 CASES

D. F. O'Brien, E. J. Kelly. J. Kelly, D. Richardson. South Infirmary / Victoria Hospital, Cork.

A retrospective review was performed of the first 300 laparoscopic cholecystectomies attempted in the South Infirmary Hospital. All were elective and no acute cases were deliberately attempted. 275 were completed laparoscopical ly (91.6%). Cholangiography was attempted in 265 cases with a success rate of 79%. The mortality rate was zero. Morbidity included one common bile duct injury, recognised and repaired. There were no bile leaks, post op. collections or haemorrhages. There were no bowel injuries. Two incisional hernias to date have been recognised. Two carcinomas of gall bladder were in the series.

Despite recent adverse publicity, our figures indicated that this is a safe operation.

EVOLVING MANAGEMENT OF COMMON BILE DUCT STONES OVER A FIVE YEAR PERIOD

N. F. Fanning, R. Brennan, P. G. Horgan, F. B. V. Keane. Department of Surgery, Meath/Adelaide Hospitals, Dublin 8.

The introduction of laparoscopic techniques has resulted in expanded therapeutic options for the treatment of common bile duct (CBD) stones. The role of laparoscopic duct exploration in the management of CBD stones is unclear and must be compared to established open surgical and endoscopic techniques. With

this in mind, the aim of the study is to audit the current management of choledocholiathisis in this unit.

Over a five year period 173 patients presented with CBD stones. The.mean age was 60.5 + 18 yr (range 20-90), with 52 males and 121 females. The presenting symptoms included bi l iary col ic (53%), jaundice (51%), cholangi t is (13%), pancreatitis (4%) and chest pain (1.7%). 42 (24%) patients had a previous cholecystectomy.

There were 105 (61%) patients treated by ERCP. Of these, 85 (81%) were successful and required no further intervention. Of the 20 (19%) patients with retained stones following ERCP, 18 underwent subsequent surgical exploration, and 2 patients were treated conservatively.

68 (39%) patients underwent primary surgical therapy. Of these, 54 had open exploration of the CBD and 47 (87%) were successful. 18 patients underwent primary laparoscopic CBD explorat ion. 4 cases were converted to open surgery for ana tomical and technica l reasons. Of the 14 completed laparoscopic duct explorations 12 (86%) were successful. Thus a total of 9 (13%) patients had failed primary surgery therapy and these retained CBD stones were treated as follows: ERCP (n=7), dissolution therapy (n= 1), conservative treatment (n=l). There was no mortality in the entire series. The complication rate with ERCP was 12.4% and included pancreatitis (7.6%), cholangitis (1.9%), haemorrhage (1.9%), and obstruction (1%). With open surgery the complication rate was 13.1% and included wound infection (7.4%), DVT (1.9%), pneumonia (1.9%), and bile leak (1.9%). Of the 14 patients undergoing primary laparoscopic CBD exploration there were no complications. There was no significant difference in hospital stay between the three groups. All patients were well on follow up apart from one pa t i en t dy ing at 130 days due to metas ta t i c cholangiocarcinoma. We conclude that the management of choledocholiathisis is in evolution, and laparoscopic CBD exploration is an important additional treatment option.

SURGICAL TREATMENT OF GASTRIC VOLVULUS

S. Reid, C. Walsh, R. Patock, J. Hall. Peterborough District Hospital, Peterborough,

Cambridgeshire, England.

We report a single surgeon's experience using gastropexy to treat 10 gastric volvuli. Over a 10 year period in a district hospital 2 patients presented as emergencies while 8..were repaired electively. There were 7 women and 3 men with a mean age of 65 yr (29-79). The elective procedures were all performed for symptoms, often varied and longstanding, arising from an intrathoracic stomach, associated with a hiatus hernia. Both emergency cases were also associated with hiatus hernia, one of which was related to a previously undiagnosed diaphragmatic rupture. One was repaired as per the elective cases by laparotomy and anterior gastropexy, the other was repaired through a thoracotomy.

There were 2 short term complications and no deaths. There was one long term complication of an internal hernia. Two patients had long term, unexplained, mild epigastric discomfort and one developed a duodenal ulcer 2 years post-op. Long term symptomatic results have been excellent (mean follow up was 21 months with a range of 2 to 72 months).

Elective repair of gastric volvulus is associated with low morb id i ty and offers exce l l en t long term symptomat i c

improvemen t as wel l as avo id ing c a t a s t r o p h i c acute complications associated with acute volvulus.

HELICOBACTER PYLORIS; HISTOLOGICAL CORRELATION WITH UREASE POSITIVITY

D. Evoy, M. Magd-Eldin, D. Curran, P. Keeling. Department of Clinical Surgery & Pathology, James

Connolly Memorial Hospital, Blanchardstown, Dublin 15.

The d i scovery of He l i cobac t e r Pylorus in 1983 has r evo lu t ion i sed the unders tand ing , p a t h o p h y s i o l o g y and subsequent management of peptic ulcer disease. The prevalence of H. pylori infection varies widely between and within populations. All H. pylori infected patients have chronic gastr i t is . Most remain asymptomat ic . Some progress to ulceration or to gastric atrophy with intestinal metaplasia which is associated with gastric cancer. The aim of the study was to correlate urease positivity with the presence of H. pylori and chronic inflammation on histological examination.

103 upper endoscopies were perfo~'med routinely on 103 consecutive patients (58 female, 45 male). All had a urease test and antral biopsy. There were 47 positive urease tests, 44%. 27 (57%) of the urease positive patients had a positive endoscopic finding. 18 (32%) of the urease negative patients had a positive endoscopic finding. 45% of urease positive patients had received previous medical therapy for peptic ulcer disease compared to 61% of urease negative patients. Helicobacter like organisms were seen in 33 of 47 urease positive patients. 46 of 47 urease pos i t i ve pat ients had chronic i n f l a m m a t i o n c o n f i r m e d histologically. Helicobacter like organisms were seen in 33 of 47 urease positive patients. 19 of these 56 urease negative patients had chronic inflammation confirmed histologically. H. pylori was identified histologically in 5 of these 19 patients.

In summary, 44% of our patients were urease positive. Chronic inflammation is strongly associated with being urease positive, but significantly, 19 of 56 urease negative patients had chronic inflammation. Chronic atrophic gastr i t is may be regarded as a premalignant condition and successful eradication of H. pylori confirmed by follow-up other than formal histology may not recognise the continuing presence of chronic gastritis.

6

INFLAMMATION AND ANIONIC SITES IN NECROTIZING ENTEROCOLITIS

N. Ade-Ajayi, L. Spitz, E. Kiely, D. Drake, N. Klein. Department of Surgery, Great Ormond Street Hospital for

Children, London,England.

The ex t r ace l lu l a r mat r ix (ECM) is impor t an t in gastrointestinal development. Glycosaminoglycans (GAGs), major ECM constituents, are attenuated in inflammatory bowel disease.

The aim was to determine the distribution of GAGs in necrotizing enterocolitis and investigate the relationship between GAG modulation and disease severity.

The distribution of GAGs was determined in well preserved and severely diseased bowel from 8 neonates affected by NEC. The technique of cationic gold (pH 1.5) with silver enhancement was employed . Spec i f ic GAGs were iden t i f i ed us ing a combination of cationic gold staining and glycanase digestion.

The relationship between anionic sites and the presence of inflammatory infiltrates was evaluated.

In well preserved intestine, .staining occurred in all layers. The epithelial basement membrane and baso la tera l surfaces, lamina propria and submucosa were particularly prominent. In moderate disease, patchy loss of anionic sites was frequently observed with GAG deficient areas adjacent to intact sites. In severe NEC, there was extensive loss of GAGs in most of the sections examined. Glycanase analysis revealed GAG sensitivity to chondroit inase ABC in epi thel ial and submucosal sites excluding vascular GAGs. Heparanase III affected only vascular anionic sites.

Conclusions: Modulation of gastro-intestinal GAGs could be important in the pathophysiology of NEC and may underlie some of its clinical manifestations, particularly, intraluminal protein and fluid loss.

INTUBATION FOR CARCINOMA OF THE OESOPHAGUS USING THE WILSON-COOK ENDOPROSTHESIS

D. M. O'Hanlon, D. Karat, K. Callanan, W. Crisp, S. M..Griffin. Department of Surgical Gastroenterology, Newcastle

General Hospital, Newcastle-upon-Tyne, England.

Carcinoma of the oesophagus is an uncommon tumour which frequently presents when advanced. Patients often complain of progressive and debilitating dysphagia. It is important that the palliation offered to patients is effective with a low morbidity. The main object of treatment is restoration of the ability to swallow and intubation offers a method of achieving this. In this prospective study a consecutive series of 70 patients undergoing intubation for oesophageal carcinoma was examined. Intubation was performed for advanced disease, in patients in poor condition with stenosing lesions of the oesophageal lumen on endoscopy. The aim of the study was to evaluate the cost, safety, complications and survival following this procedure. The patients had a mean (SEM) age of 70.7 (1.5) yr and 44 (63%) were male. Fifteen patients had carcinoma involving the upper oesophagus , 38 the mid oesophagus and 17 the lower oesophagus. Thirty-five patients had squamous cell carcinoma and 35 had adenocarcinoma. Seven patients had tracheo- oesophageal fistulae. A Wilson-Cook endoprosthesis was inserted endoscopically using intravenous sedation and a pulsion technique. The size used was dependent on the length of tumour and cuffed tubes were used in patients with fistulae. Two patients died in hospital and two died after discharge giving a procedure related mortality of 2.8% and'a 30 day mortality of 5.7%. Nine other patients experienced complications giving a morbidity rate of 12.8%. These included chest infections in 5, hypoxia in 1, haematemesis in 2 and perforation in 1 patient. The median survival following insertion of a Wilson-Cook endoprosthesis was 16 weeks. Twenty patients required a second or further procedure. The indications were tube migration in 22 cases, obstruction in 10 and fistula formation in two patients. Thirty day mortality in this group was significantly greater than after a first procedure (7 patients, 20.1%; P<0.05).

This study describes a safe, effective method for insertion of an endoprosthesis, with a low morbidity and mortality. The average cost for endoscopic insert ion of a Wilson-Cook endoprosthesis in this unit is s and in view of the short median survival in this group of patients the introduction of more costly self-exanding stents is not warranted.

GUT TRANSLOCATION OF BACTERIA IN PANCREATIC CARCINOMA: EFFECTS OF JAUNDICE

P. M. Murchan, B. Mancey-Jones, P. Sedman, C. J. Mitchell, J. Macfie.

Combined Gastroenterology Unit, Scarborough General Hospital, England.

Septic events are a frequent complication in patients with extrahepatic biliary obstruction and pancreatic disease. Animal studies have shown that the absence of enteric bile salts predisposes to gut translocation of bacteria which may result from an altered permeability of the bowel wall and suggested that this phenomenon may be implicated in the aetiology of systemic sepsis in jaundiced patients.

This prospective study investigates the incidence of bacterial translocation in patients with and without extrahepatic biliary obstruction and pancreatic carcinoma. Translocat ion was assessed by culture of mesenteric lymph nodes and enteric serosal b iopsies harvested at t ime of surgery. Intest inal permeability was measured by a dual sugar probe technique employing rhamnose and lactulose.

Bacterial translocation was identified in 2 (10%) jaundiced patients with pancreatic carcinoma (n=20; mean age 67) which was not significantly different (p>0.3) from the prevalence of 33 (13%) recorded in non-jaundiced patients (n=247; mean age 66). There was no difference between the 2 groups in the mean values of intestinal permeability recorded.

This study shows that in man, jaundice does not predispose to bacterial translocation or alter intestinal permeability. We conclude that neither mechanism is relevant to the development of sepsis in jaundiced patients with pancreatic carcinoma.

OPEN ACCESS ENDOSCOPY FACILITATES EARLY DIAGNOSIS OF MALIGNANT AND PREMALIGNANT

LESIONS OF THE UPPER GASTROINTESTINAL TRACT

D. M. O'Hanlon, D. Karat, D. Scott,* S. Raimes, S. M. Griffin. Department of Surgical Gastroenterology and Pathology*,

Newcastle General Hospital, Newcastle-upon-Tyne, England.

Open access endoscopy (OAE) is increasingly being viewed as an efficient and effective method for diagnosing upper GI pathology, obviating the need for clinic review. The greatest potential benefit of OAE is early diagnosis of malignant and in particular of pre-malignant lesions, and rapid institution of appropriate therapy and entry into controlled surveillance programmes when appropriate . This study prospect ive ly evaluated our experience with OAE on 2000 consecutive referrals. All patients had proformas filled by their GPs giving patient details and complaints. These were reviewed by the surgeon and completed after endoscopy. Results see table.

Diagnosis Number (%) mean (SEM) age Age v benign m : f

Carcinoma 85 (4.5) 66.6 (1.2) P<0.0001 1.8 : 1 Oesophageal 23 (1.2) 68.7 (2.2) 1.9 : l Gastric 54 (2.8) 65.2 (1.5) 1.8 : l

Barrett's 54 (2.8) 60.6 (2.0) P=0.0001 1.8 : 1 CAG + in. metapl 179 (9.4) 56.4 (0.9) 1.3 : 1 Benign 1401 (73.6) 53.2 (0.4) 1.3 : 1 Normal 362 (19) 48.6 (0.8) P<0.0001 0.6 : l

Statistics: Mann Whitney U, Significance assumed at P<0.05 level. CAG=Chronic atrophic gastritis plus intestinal metaplasia.

Endoscopy was performed on 1902 patients and had a diagnostic yield of 81%. Carcinoma was diagnosed in 85 and included 54 gastric cancers of which 10 (18%) were early i.e. 1 in 190 endoscopies demonstrated early gastric cancer; 187 patients with potentially pre-malignant lesions were entered into surveillance programmes.

In conclusion this study supports the wider introduction of OAE for the diagnosis of pre-malignant lesions and for the early diagnosis of malignant lesions.

BREAST CANCER - AN AUDIT OF 13 YEARS EXPERIENCE IN A REGIONAL CENTRE

C. J. O'Boyle, M. J. Kerin, T. J. Boyle, D. M. O'Hanlon, D. Maher, H. F. Given.

NBCRI and Department of Surgery University College Hospital Galway.

Despite recent therapeutic advances in breast cancer the most important prognostic indicator is stage of disease at presentation. Since the establishment of the breast unit in 1982, 1103 patients have been treated for breast cancer. All patients were staged according to UICC criteria and have been vigorously followed- up. A metastatic screen including chest X-ray, liver function tests and bone scan was performed at time of diagnosis and whenever there was c l in ical or b iochemica l suspicion of metastases. The aim of this study was to assess the changes in pattern of disease over this period.

1982.85 1986-88 1989-91 1992-94 p value

Number of patients (%) 261(24) 236(21) 260(24) 346(31)

Mean Age (SEM) 56(0.91) 57(0.91) 58(0.95) 58(0.84) p*=0.57

Stage I 57(22) 71(30) 75(29) 86(25) p=0.12 Stage II 149(57) 118(50) 128(49) 173(50) Stage III 39(15) 21(9 ) 31(12) 52(15) Stage IV 16(6) 26(11) 26(10) 35(10)

Node Negative 97(37) 85(36) 107(41) 148(43) p---0.30

ER Negative 94(36) 71(30) 93(36) 97(28) p=0.07 Positive 91(35) 82(35) - 99(38) 152(44) Unknown 76(29) 83(35) 68(26) 97(28)

(p; ANOVA*, Chi-square)

The annual number of cases has increased from 64 (1982) to 126 (1994). There has been no significant change in !;he mean age at presentation, nodal status or estrogen receptor status and, surprisingly, the incidence of early (Stage I) or metastatic breast cancer.

Considering the increased diagnosis of early and pre-invasive breas t cance r from sc reen ing p rog rammes an urgent mammographic screening programme is required for this region.

INVESTIGATION OF "MINIMUM" THERAPY IN ELDERLY PATIENTS (> 70 YEARS) WITH OPERABLE

BREAST CANCER

P. C. Willsher, J. E R. Robertson, M. Hilaly, R. W. Blamey. Nottingham City Hospital, England

We have investigated management approaches aimed at

minimising the impact of therapy on elderly patients with operable breast cancer (BC). Primary tamoxifen therapy was first assessed in a randomised trial comparing tamoxifen alone with mastectomy. 62% (41/66) patients eventual ly failed tamoxifen therapy at a median of 25 months. However21% (14/ 66) patients had greater than 60 months local control, of which seven had greater than 100 months response to tamoxifen. To identify a group who may have long term control with tamoxifen, a second trial randomised patients with high tumour ER content (H score greater than 100) to tamoxifen (N=94) or mastectomy + tamoxifen (N=53). Only 3 patients failed to respond to tamoxifen. At median follow-up of 3 yr 30 (32%) patients have loco-regional failure; 15 had mastectomy, 15 alternative therapy, and none has uncontrolled local recurrence. Patients with static disease after 6 months Tamoxifen were more likely to progress (P=0.04) and had shorter duration of response (median=20 months) than complete or partial responders (median=75 months, p<0.001).

In a separate study the efficacy of wide local excision without radiotherapy for low oestrogen receptor content tumours (<3 cms) was examined in 27 patients. Histological margins were at least 0.5 cms (one patient had re-excision). At median follow- up of 38 months 3 have local recurrence.

Selected patients can have long-term control of their breast cancer with tamoxifen alone. In those patients with small tumours unsuitable for tamoxifen therapy, wide local excision can offer effective control.

8

THE MANAGEMENT OF MAMMOGRAPHICALLY DETECTED BREAST LESIONS

S. G. Shering, S. Mitrovic, A. Rahim, E. W. McDermott, N. J. O'Higgins

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

The management of 73 non-papable breast lesions detected mammographically over a three-year period was reviewed. Thir ty-nine (53%) of pat ients presented with symptoms suggestive of breast disease but without a discrete lump; the remainder of the lesions were detected in asymptomatic patients. Mammographic needle-localised excision biopsy was planned for all patients but the mammographic abnormal i ty had recovered by the time of hospital admission in 8 patients. Twenty-four (36% of the 65 lesions biospsied) were neoplastic (in situ or invasive breast neoplasms). This result compares favourably with those of an audit of needle localised in this unit over the preceding four-year period when 32% of 139 lesions biopsied were neoplastic and with other published results. The lesions were more likely to be neoplastic in symptomatic patients than asymptomatic patients (44% compared to 21%, p=0.05). Compared to the 430 palpable breast neoplasms treated in this centre during the same time period the mammographical ly detected neoplasms were significantly less likely to be invasive (58% compared to 95%, p<0.001) and more likely to be node- nega t ive if invas ive (89% compared to 52%, p=0.05). Complications were observed in 4 (6%) of patients and were all mild and self-limiting. Needle localisation safely and effectively detects breast neoplasms at an early stage and may improve breast cancer mortality.

SMALL BREAST CANCER: AN INTEGRATED INDEX IS STILL IMPORTANT

C. A. Murphy, D. Morgan, C. W. Elston, I. O. Ellis, J. F. R. Robertson, R. W. Blarney.

Nottingham City Hospital, England

It has been reported by Tabar et al that size is the most important factor in determining prognosis in small breast cancer. We routinely perform lymph node sampling in all patients with invasive breast cancer. The results are shown in Table I.

Table I Tumour size Lymph node +re(%) -<5 mm 6/49 (12) 6-10 mm 57/293 (19)

The Nottingham prognostic index (NPI) has then been calculated for these small tumours. This has as its basis not only tumour size but grade and lymph node status. These results are shown in Table II.

Tumour size < 10 mm Table II

NPI n Actuarial 10yr survival good 246 90% moderate 90 73% poor 7 42%

This shows that the index is a more powerful predictor of survival than size alone, even for small tumours. These findings show that biological factors are important in patients with small breast cancer and contradict the findings of Tabar.

PROSPECTIVE EVALUATION OF MRI MAMMOGRAPHY IN PATIENTS WITH SUSPECTED BREAST CARCINOMA

M. P. O'Sullivan, M. G. O'Riordain, J. P. Stack, M. K. Barry, J. T. Ennis, J. M. Fitzpatrick, T. F. Gorey.

Mater Misericordiae Hospital, Dublin.

Conventional mammography is limited in the evaluation of breast lumps because of its relatively low specificity and its inaccuracy in patients with previous breast surgery or with dense breasts. Neo-vascularisation occurs in breast carcinoma due to tumour angiogenesis and this phenomenon may be detected by contrast-enhanced magnetic resonance imaging (MRI).

We prospectively evaluated the use of MRI mammography in patients (n=28) with suspected breast carcinoma. Four of these 28 had a recurrent mass after previous breast cancer surgery. Neo-vascu la r i ty was detected by measur ing the MRI enhancement profile after an intra-venous gadiodamide DTPA injection. An early steep signal increase and a signal maximum >100% within the first 3 rain followed by a plateau phase were considered to represent carcinoma. The breast lesion was later excised for histology and the accuracy of the MRI determined.

Ten patients had histologically-confirmed carcinomas and all were correctly diagnosed by MRI. Seventeen patients had benign disease on histological examination and in these, MRI diagnosed benign disease in 16 and malignant disease in one. Thus the sensitivity of MRI scanning was 100% and the specificity 94%. MRI correctly identified carcinoma in all 4 patients presenting with recurrence after previous surgery. One patient was excluded from the analysis because although a benign lesion was excised, we have been unable to localise and biopsy a second impalpable lesion which was identified as malignant on MRI. MRI mammography is a new technique which accurately differentiates between benign and malignant

breast lumps. Unlike conventional mammography it may be of particular benefit in patients with previous breast surgery. Methods to localise and biopsy impalpable MRI-detected lesions need to be developed.

INVASIVE BREAST CANCER IN WOMEN AGED <35 YEARS - THE NOTTINGHAM EXPERIENCE

J. Kollis, C. W. Elston, I. O. Ellis, J. E R. Robertson, R. W. Blarney.

Nottingham City Hospital, England.

Young age at diagnosis has been claimed to be a prognostic factor in the natural history of breast cancer. Of 3018 patients with primary operable invasive breast cancer treated at the Nottingham Breast Unit 111 patients were less than 35 years of age at diagnosis.

The local recurrence rate and actuarial survival of these women was compared to that of women with invasive breast cancer aged 35 - 50 and 51 - 70. No differences were seen. (Table I).

Table I: Local recurrence / actuarial survival at 220 months versus age

AGE (yr)

<35 35 - 50 51 - 70 18.1% 16.4% 16.1% LOCAL

RECURRENCE ACTUARIAL SURVIVAL

60% 61% 59%

Patients <35 yr presented more frequently with turnouts >2cm (p<0.05), grade III tumours (p<0.0005) and tumours with vascular invasion (p<0.0005). No difference was seen for lymph node positivity.

The Nottingham prognostic index (NPI) was then used to compare the percentage of patients selected for each prognostic group (Table II). A significantly greater percentage of patients <35 yr were in the poor prognosis group compared to patients > 35 yr (p<0.0005).

Table II Percentage o f patients within NPI prognostic groups according to age.

AGE (yr) <35 (n=lll) 35-50 (n=941) 51-70 (n=1624)

EXCELLENT 3% 12% 14% NPI GOOD 11% 20% 21%

GROUPS MODERATE 55% 53% 51% POOR 31% 15% 14%

Conclusion 1) Patients <35 years of age had similar overall survival and

local recurrence rates to patients >35 yr. 2) However, there are >15% more patients <35 yr in the poor

prognosis group due to poorer histological differentiation and larger turnout size.

3) Their survival may be explained by a more aggressive treatment strategy.

THYROID DYSFUNCTION AND BREAST DISEASES

S. G. Shering, H. Mullet, D. F. Smith, A. Zbar, M. J. Murray, E. W. M. McDermott, P. P. A. Smyth, N. J. O'Higgins.

Endocrine Laboratory, Departments of Medicine and Surgery, University College Dublin and St, Vincent's Hospital, Dublin.

The hypothesis that diseases of the thyroid and the breast,

9

particularly breast cancer, could be causally related has long been debated. One of the proposed associations was between breast cancer and Hashimoto's thytoiditis, although this is also disputed. In the present study, antithyroid peroxidase antibodies (TPO.Ab) were measured using a highly sensitive direct radio- immuno-assay in 150 consecutive patients with breast cancer and 40 with benign breast disease (BBD). Thyroid volume was measured by ultrasound using a 7.5 mHz linear transducer. Of those with breast cancer 2 were hyperthyroid, 5 hypothyroid and 16 had non-toxic palpable goitres. Patients with BBD included 3 hyperthyroids, 1 hypothyroid and 4 with non-toxic goitre.

TPO.Ab were present at titres of 0.04-25.1 U/ml' MRC Standard 65/93 (normal reference < 0.3 U/ml) in 541150 (36.0%) of patients with breast cancer and were also present in 1040 (25.0%) of those with BBD (range 0.4-147.0 U/ml) compared to 14.8% of a control female population. Thyroid volume measured by ultrasound was enlarged (>18.0 ml) in 56/150 (37.3%) of patients with breast cancer and in 840 (20.0%) of patients with BBD. This compares to thyroid enlargement of between 6.3 and 8.6% in age-matched female control populations. The presence of TPO antibodies was positively correlated with thyroid enlargement in both groups.

The demons t r a t i on of a high preva lence of thyroid enlargement as well as an apparent underlying auto-immune thyroid disturbance in breast disorders provides strong evidence for an association between the two diseases in the study group which may have pathogenetic significance in the natural history of breast cancer. P. C.

P-GLYCOPROTEIN EXPRESSION IS INDUCED BY CHEMOTHERAPY FOR STAGE III BREAST CANCER

P. C. Willsher, N. Kapucouglu, I. O. Ellis, R. W. Blamey, J. E R. Robertson.

Nottingham City Hospital, England.

P-glycoprotein or P-170 is a 170 KDa membrane protein. It acts as a membrane transport pump which extrudes a number of pharmacologically unrelated chemotherapeutic agents. P- glycoprotein has been implicated in the in vitro development of drug cross resistance - termed multi-drug resistance. To assess the clinical relevance of P-glycoprotein we have examined membrane expression in 34 patients with stage III breast cancer, who received neo-adjuvant chemotherapy (MMM regimen). The objective response rate was 57%. Tissue staining on pre- treatment corecut biopsies was compared with specimens ob t a ined from mastec tomy performed subsequent to chemotherapy. A standard Avidin-Riotin complex method was used with C494 (Signet) as the primary antibody.

The percentage of cells staining positive for P-glycoprotein was significantly increased comparing pre-treatment biopsies (median=5%) with mastectomy specimens (median=48%). (Wilcoxon matched pairs sign rank sum test Z=-3.53, p=0.0004). The percentage of cells with positive staining did not predict for response to chemotherapy for the pre-treatment biopsy. However in mastectomy specimens patients with tumours which failed to respond to chemotherapy tended to have a higher percentage of cells staining positive (median = 73%) than in responders (median = 24%) (p = 0.26).

For the MMM regimen P-glycoprotein expression does not appear to be predictive of primary, chemo resistance. The induction however of P-glycoprotein is likely to be related to

the administration of chemotherapy in breast cancer. This study could not examine whether this induction is associated with secondary chemo-resistance.

THE COST EFFECTIVENESS OF BREAST CANCER FOLLOW UP

C. A. Murphy, S. Holmes, P. Holland, R. W. Blarney. Nottingham City Hospital, England.

A prospective study was performed to analyse the cost and effectiveness of the follow up of primary breast cancer.

Seven hundred and seventeen patients who had undergone mastectomy or treatment with breast conservation when aged <70 with a primary breast cancer (<5 cm) were studied for a total of 779 visits. Clinical examination is carried out at each visit, the only routine investigation performed at intervals is mammography (MGM).

Twenty-five patients were found to have recurrent breast cancer. The mode of presentation and site of recurrence is tabled below of the 25 patients from a group of 63 who underwent further investigation from the cohort of 717.

Mode of presentation of Contralateral Local Regional Distant recurrence primary recurrence recurrence metastases Interval appointment 2 3 4 made by GP or patient

Routine examination 6 7 1 Routine 1 2 investigation (MGM)

n 1 I0 10 5

NB I patient presented with both regional recurrence and distant metastases. The cost to the hospital of funding the 13 weeks of the clinic

plus the investigation of the 63 patients was s 16,197 which gives a total cost per recurrence detected of s

We conclude that breast cancer follow up is cost effective.

10

CAROTID ENDARTERECTOMY IN THE ELDERLY PATIENT

P. T. McCollum, A. da Silva, L. de Cossart, for the VSS Audit Committee.

Vascular Unit, Ninewells Hospital, Dundee, DDI 9SY & VSS office, Countess of Chester Hospital, Chester.

A prospective study of 112 patients aged 76 ys or greater, undergoing carotid surgery in the UK and Ireland, was performed to evaluate the risk of vascular surgery in this age group within the society.

Fifty nine surgeons (range 2 - 39 cases each) were sampled and all patients, aged 76 or more, undergoing surgery over a 6 month period (1/3/1994 - 3 I/8/1994) were included in the study. All incomplete and inconsisistent data were checked. Indications for surgery were TIA (37.5%), AF (25.9%), CVA (18.8%) and "others" (17.8%). Pre-op arteriograms were performed in 50.9%. Mean ipsilateral stenosis was 82% (50% - 99%). Twenty-six percent of patients had pre-op neurological consults. Shunts were used in 66.1%, tacking sutures in 39.3%, drains in 74.1% and patches in 57.1% of cases.

At thirty days, there was I (0.9%) death and 1 post-op CVA (0.9%). Sixteen percent of pat ients had one or more complication, usually minor. Statistical analysis showed no significant differences in outcome or risk factors when compared

with a younger group of 589 patients having carotid surgery during the same period.

A combined stroke/death rate of 1.8% at 30 days for the elderly group was lower than that for the younger group but this was not significant. This large study suggests that members of the Vascular Society of GB and Ireland currently perform carotid surgery with a highly acceptable risk of stroke in the elderly population. As life expectancy in these patients is generally approximately five years, such surgery is cost effective and offers the probability of a much reduced stroke risk in selected ,patients.

KETOCONAZOLE, A THROMBOXANE SYNTHETASE INHIBITOR, DECREASES PANCREATITIS-INDUCED

LUNG INJURY

D. Hamilton. C. J. Kelly, K. Stokes, H. P. Redmond, P. Broe, D. Bouchier-Hayes.

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

We have previously demonstrated in an experimental model of acute pancreatitis that the acute lung injury is secondary to neutrophil infiltration. The factors inducing this infiltration remain unclear. Thromboxane A2, a macrophage product, initiates inflammatory cascades that can lead to neutrophil infi l trat ion. I(etokonazole, an imidazole derivative, is a thromboxane synthetase inhibitor. We evaluated the effect of ketoconazole on lung injury associated with pancreatitis. Pancreatitis was induced in Sprague-Dawley rats, by infusion of caerulein (0.06mg/Kg). Animals were randomized into controls (n=13) and a group treated with oral ketoconazole (10mg/Kg) (n=l 1). MPO and BAL PMN were used to measure neutrophil infiltration in the lung. Wet:dry lung weights and BAL prot. were used to measure pu lmonary microvascular permeability.

Control (N=13) Ketoconazole (N=ll)

MPO (u/gm) 0.54_+0.160 0.40+-0.147 * BAL PMN (106/ml) 13.27+4.466 8.17_+4.554 * Wet:dry 4.77+_0.378 4.25+_0.430 @ BAL prot.(mcg) 1 3 1 . 5 - + 4 2 . 9 4 98.5+_30.79 *

Mean+_S.D., * p<0.05, @ p<0.005 vs Control using student t-tests.

These data demonstrate that ketoconazole, a thromboxane synthetase inhibitor, significantly reduces pancreatitis-induced pulmonary neutrophil influx and pulmonary microvascular protein and fluid leakage. These data support the hypothesis that release of thromboxcane, A2 may in part be responsible for the neutrophil mediated lung injury in pancreatitis and suggest a possible therapeutic role for ketoconazole.

MPO=Myeloperoxidase. BAL PMN=Bronchoalveolar lavage neuerophil count. BAL prot.=Bronchoalveolar lavage protein.

LEG ULCERS: A SEAMLESS SERVICE

J. Crinnion, N. Morton*, P. A. Grace. Department of Surgery, Ealing Hospital NHS Trust and

*Community Nursing Service, West London Health Care Trust, London, England.

Leg ulcers are a major health problem with 1-2% of the.adult population requiring treatment for ulcers at least once in their

11

lifetime at an annual cost in the UK of s million. Over a 12 month period 137 patients with 175 affected legs were referred to a new community-based leg ulcer service in Ealing. Patients were referred by district or practice nurse (n=102), hospital consultants (n=41), general practitioners (n=30) and other (n=2). Prior to treatment, the duration of the ulcer, ulcer size, ankle brachial indices, evidence of venous disease and diabetes mellitus were documented by a district nurse specifically trained in the management of leg ulcers. All patients were reviewed by a nurse coordinator either in the community clinics or with a vascular surgeon in tl~e hospital clinic. Ulcers in young people, those slow to heal or with a possible arterial or malignant aetiology were reviewed jointly. 165 ulcers in 127 patients were treated with compression bandaging. There was a linear relationship between the size of the ulcer and the time to healing with healing rates at 24 weeks of 78% for small (<10 cm), 46% for medium (10-20 cm) and 21% for larger (>20 cm) ulcers. Other results were:

Duration of Age Females ulcer (mths) n L+SEM %

A0.1-3.0 55 72+_13 51 B3.1-12.0 42 72+11 71 C >12.0 78 76_+9 62 Total 175 74+11 60

*p<0.001 vs B and C

Arterial Venous Diabetes % healed @ % % % 12wks 24wks

9 87 16 71" 90* 5 93 14 41 47 0 100 14 27 50 4 95 15 42 61

A retrospective analysis revealed that prior to the initiation of the new service crude ulcer healing results in Ealing were about 21%. These data indicate that: (1) ulcer healing is related to ulcer duration and size prior to treatment, (2) significant improvement in ulcer healing occurs with the introduction of a dedicated leg ulcer service, (3) leg ulcers are effectively managed in nurse-led community clinids. We conclude that a "seamless service" embracing both community and hospital practice is the ideal method for the management of leg ulcer disease.

REVASCULARISATION FOR MESENTERIC ISCHAEMIA

N. Ross, S. Naidu, P. Gervaz, R. J. Holdsworth, E A. Stonebridge, E T. McCollum.

Vascular Unit, Ninewells Hospital, Dundee DDI 9SY.

Mesenter ic arterial insuf f i c iency is general ly an underdiagnosed and uniformly fatal disease entity without intervention. Over a four year period, ten patients have had mesenteric revascularisation in the vascular unit. All data have been prospectively entered into a database and long term follow- up instituted.

All patients had acute or chronic mesenteric ischaemia; none had emboli. Seven were female and mean age at first operation was 64 (range 51-76). All were smokers with coexistant peripheral vascular disease. All patients had a history of abdominal pain which was initially intermittent - duration 15 days-9 years prior to their presentation of acute abdominal pain. All had significant weight loss.

All patients had extensive severe ischaemia at operation. Two patients with a short history (4 days & 13 days) of constant pain had pre-gangrenous bowel at operation. One patient with pain for a month and sudden deterioration had severely ischaemic bowel at operation and developed gangrenous bowel when his graft failed 13 days after operation. Six patients received aortoSMA bypa-ss grafts (one requir ing two subsequent

appendicectomy, herniorrhaphy and colectomy is far from clear. Laparoscopic ant i - ref lux surgery has only been recently described. We audit our experience with laparoscopic Nissen fundoplication (LNF).

Since 1993, 41 patients have undergone LNF in this unit. There were 23 males and 18 females of average age 43 yr (range 16-70 yr). The mean duration of symptoms was 4 months and all had biopsy proven oesophagitis secondary to reflux, and unresponsive to treatment with Losec. Symptomatology included retrosternal pain, epigastric pain, reflux, nausea, vomiting and belching. All patients had pre-operative pH and pressure studies with a mean total time pH < 4 of 16.0% (range 6.8 - 38.3).

Thirty-seven patients had successful completion of LNF, four patients were converted to open operations because of technical problems at the beginning of the series. Mean hospital stay for those successfully undergoing LNF was 4.0 days and there were no complications in this group. All patients are well on follow up, but all patients had some degree of dysphagia to solids which resolves at various time intervals fol lowing LNF without intervention.

FAECAL PANCREATIC ELASTASE 1 (PEI) ASSAY AS A DIAGNOSTIC TEST FOR CHRONIC PANCREATITIS

P. M. Murchan, A. Mahmood, K. Dave, J. Macfie, C. J. Mitchell.

Combined Gastroenterology Unit Scarborough General Hospital, England.

Human PE 1 is not degraded by intestinal transit and its faecal concentration is claimed to reflect pancreatic exocrine function. An ELISA test is now commercially available (ScheBo Tech) to measure PE1 excretion from a faecal sample. Initial studies suggest that this test is sensitive and differentiates between moderate and severe chronic pancreatitis (CP). However, its specificity is less certain part icularly for realist ic disease controls with diarrhoea, steatorrhoea or jaundice.

We measured faecal PEI concentration in 37 patients. Fifteen had moderate (5) or severe (10) CP at pancreatography. Eight patients had non-pancreatic jaundice and 15 had diarrhoea due to intestinal disease of whom 4 had steatorrhoea.

Faecal PE1 was abnormal in all 'q5 patients with CP and correctly distinguished between severe (PEl<100ug/g) and moderate disease (PE1 100-200ug/g). However in patients with non-pancreat ic diarrhoea markedly abnormal results also occurred in 7 patients (47%). Patients with non-pancreatic jaundice had less abnormal results but still overlapped with those obtained in moderate CP.

We conclude that faecal PE1 is useful to assess exocrine insufficiency in established CP. However it appears unreliable as a diagnostic test for CP.

A COMPUTERISED-EXPERT SYSTEM IMPROVES POST- OPERATIVE CARE IN SURGICAL PATIENTS. A

REQUIEM FOR THE JUNIOR DOCTOR?

P. M. Murchan, J. Stewart, A. Cole, R. Hartley, T. G. Brennan. Department of Surgery, St James 's Univers i ty Hospital , Computer-Based Learning Unit, University of Leeds, England.

Avoidable morbidity in patients following surgery often results from inadequate evaluation of problems by junior doctors. A computer system designed to direct inexperienced doctors to obtain further clinical information, s0ggest possible diagnoses

or recommend lines of appropriate investigation would improve patient care. Over the past four years, we have been developing a post-operative expert medical system (POEMS), a knowledge- based computer system that assists junior doctors with these tasks. The design of POEMS is such that it only off6rs advice when a minimum quorum of patient information is available. If important clinical data is not entered, the computer rejects any attempt at diagnosis and requests that further information "be provided.

In a six month period, 89 consecut ive pos t -opera t ive problems from one surgical unit were assessed. Case histories and the post-operative medical events from which junior doctors formulated particular complication diagnoses or recommended specific actions were examined by senior surgeons. In only 11 cases was there sufficient information collected by the juniors to either support a safe diagnosis or propose a correct line of investigation. All cases were then presented to POEMS, which corroborated these findings of inadequate clinical assessment in 80 cases. Junior doctors were then asked to provide further information for 31 of these cases. When analysed by the system, there was concurrence for 26 of these 31 patient problems.

Problems occurring in post-operative patients are frequently assessed incompletely. POEMS can ident i fy the miss ing information that is necessary for proper evaluation of post- operative complications and may assist junior doctors in their management of surgical patients.

14

CALCIUM ALGINATE DRESSINGS PROMOTE SPLIT SKIN GRAFT DONOR SITE HEALING

J. M. O'Donoghue, S. T. O'Sullivan, E. Beausang, J. Panchal, M. O'Shaughnessy, T. P. E O'Connor.

Department of Plastic Surgery, Cork University Hospital.

The most widely used dressing for split skin graft donor sites is paraffin gauze. Problems related to donor site morbidity include healing, infection and dressing slippage. The aim of this study was to examine these parameters using two different dressings. 51 patients were randomised into a prospective study. 30 patients were dressed with calcium alginate dressings, while 21 were dressed with paraffin gauze. All grafts were harvested from the thigh with an electric dermatome at a setting of 0.01 in. There were no significant differences in the age ranges or gender distribution of the two groups. Each donor site was first inspected ten days post skin harvesting. In the calcium alginate group 10/30 patients were unhealed at day ten, while in the paraffin gauze group I0/21 were unhealed (p<0.01 on chi- analysis). There were two infections in the study, both occurring in the alginate group, while there was no significant difference in dressing slippage between the two groups. Calcium alginate dressings on split skin graft donor sites appear to be a significant improvement on healing when compared to a traditional dressing of tulle gras.

TO INVESTIGATE THE ROLE OF INTERFERON-G AND ITS B L O C K I N G M O N O C L O N A L A N T I B O D Y IN THE TREATMENT OF SURGICAL SEPSIS FOLLOWING INJURY

P. O'Grady, R. W. G. Watson, H. P. Redmond, D. Bouchier-Hayes.

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

Interferon-), (IFN-y) is a potent immunostimulant which has been shown to be detrimental when administered during septic

LPS: Treatment

IFN-y IgG Anti-IFN-~/

HLA/LPS: IFN-y IgG Anti-IFN-y

shock. Blockade of this cytokine however is beneficial during the acute septic response. The aim of this study was to evaluate the cellular effects of this cytokine and its blocking monoclonal antibody (MoAb) in lethal sepsis following injury. 100 female CD-I mice were randomized into two groups: Septic=LPS vs injury=hind limb amputation (HLA). After 24 hr mice were challenged with LPS (1.1 mg/200ul/mouse) and after a further 2 hr treatment with either IFN-% anti-IFN-y or IgG-I (MoAb Isotype control) was administered. End point survival was determined after one week. Peritoneal and systemic cellular activation was assessed by release of the reactive oxygen intermediate O 2- and CDIlb receptor expression.

PMO PMO PMN Mr Survival O~-(nmol) CDIIb CDIIb CDIIb

0 0.14-+0.02 ~ 30-+3 60-+4 ~ 178-+7 ~ 20 0.08_+0.01 38-+5 50_+5 70_+5 30* 0.06_+0.04 - - 45_+3 150-+4

81 0.23+0.04 21+2 80+4 100-+11 65 0.15+0.05 100-&_10 40+2 175+9 63* 0.11_+0.03# 28+61" 200-+7t

*Stats=Chi square test=p<0.05 vs IFN-y. ~ vs IgG. tStats= ANOVA=p<0.05 vs IgG

IFN-y was detrimental when given to control septic animals. Howeve r i ts b lock ing MoAb was p ro tec t ive (p<0.05) . Conversely IFN-~/was protective in injured septic animals compared with antilFN-y (p<0.05). These findings demonstrate that the immune stimulant IFN-y has therapeutic potential in the immunosuppressed injured host predisposed to sepsis, While blockade of this cytokine is required for protection in the septic host with a normal immune response.

BACTERIAL COLONISATION OF UPPER GASTROINTESTINAL TRACT IS ASSOCIATED WITH

SEPTIC MORBIDITY IN SURGICAL PATIENTS

P. M. Murchan, B. Mancey-Jones, D. Johnstone, C. J. Mitchell, J. Macfie.

Combined Gastroenterology Unit, Scarborough General Hospital, North Yorkshire, England.

Pathologic colonisa t ion of the normally steri le upper g a s t r o i n t e s t i n a l t rac t may be an impor tan t p re lude to development of septic complicat ions in postoperative and critically ill patients. We correlated the proximal gut flora, the results from a 'severity of illness' physiological assessment as used in POSSUM scorirrg, with the incidence of septic complications in patients presenting to a surgical unit.

Oiae hundred and twenty patients (80 laparotomy, 40 no operation but abdominal pathology) underwent nasogastric intubation as part of standard clinical treatment. Gastric aspirate (10ml) was obtained under sterile conditions and sent for microbiological culture. Physiological POSSUM-type scoring was performed on all patients by the same clinician. All septic events were recorded and the microbiology assessed.

Our results showed patients with multi-organism colonisation had a significantly greater incidence of septic complications compared to those with mono- or no organisms isolated from the aspirate. (p = 05, X2). Furthermore, patients with low POSSUM-type scoring (<20) had a significantly lower incidence of septic events and aspirate culture growth. Lactobacilli. were frequently isolated in non-septic patients (22% mean POSSUM

score 17+2)+but were absent in all but one of the patients with septic complications (mean POSSUM score 28+4,+p= <005, X2). We conclude that colonisation of the upper gastrointestinal tract predisposes to septic complications in surgical patients.

THE USE OF HYPERBARIC OXYGEN FOR THE SURGICAL PATIENT

J. O'Donnell, E. McCarthy, T. O'Dwyer*, N. Flynn. Department of Anaesthesia and Hyperbaric Chamber,

University College Hospital, Gaway. *Department of ENT, Mater Hospital, Dublin

Hyperbaric oxygen (HBO) therapy has traditionally been used in the treatment of decompression sickness and carbon monoxide poisoning. Since the 1960's it has also been used to treat a variety of surgical conditions such as necrotizing soft tissue injuries, refractory osteomyelitis, radiation tissue damage and compromised skin grafts and flaps with much success. The basic mechanisms of action are; (a) mechanical effects, which lead to compression and reduction of the size of closed gas containing spaces in the body and; (b) an elevated partial pressure of oxygen in the tissues causing a number of beneficial effects. In cases of tissue damage, an increase in the partial pressure of oxygen from less than 30mmHg in ischaemic tissue to between 250 - 300mmHg has a direct toxic effect on strict anaerobic orsanisms, an increased phagocytic capability of leucocytes, an increased f ibroblast act ivi ty and collagen formation and f inal ly an increased neovascular izat ion of ischaemic and irradiated areas. In bone osteoclast activity is also enhanced, leading to more rapid breakdown of dead bone in the case of osteomyelitis or osteoradionecrosis. The standard treatment of these condit ions consists of 90-120 rain of hyperbaric therapy, twice daily for 2-3 weeks. We discuss the management and outcome of cases of mandibular osteomyelitis and osteoradionecrosis which were treated in our hyperbaric chamber.

15

RECOMBINANT GAMMA INTERFERON (rIFN-y) INDUCED MAJOR HISTOCOMPATIBILITY (MHC)

ANTIGEN EXPRESSION AUGMENTS NK AND LAK CELL CYTOLYSIS OF ZR75-I CELLS

J. M. O'Donoghue, C. Curran S. Duggan, D. Bouchier-Hayes, H. E Given.

Departments of Surgery, Beaumont Hospital, Dublin, and University College Hospital, Galway.

40% of breast cancers demonstrate down regulation of MHC gene products. This is associated with a poor prognosig. Unlike MHC dependent cytotoxic T lymphocytes, NK and LAK cells spontaneously lyse cancer cells, and are an important element in the control of metastatic disease. However, the influence of MHC gene product expression by cancer cells on NK and LAK cell mediated cytolysis is not completely understood.

The aim of this study was to determine the effect of MHC class I and II antigen expression by the metastatic breast cancer cell line ZR75-1 on NK and LAK cel l-mediated cytolysis. ZR75-1 was shown by immunohistochemistry not to express MHC antigens. Maximal MHC gene transcription was achieved by incubating the cells with rlFN-y (1000 units per ml for 48 hr). NK and LAK cells were then isolated from a healthy volunteer. The target cancer cells were chromated and added to

serial dilutions of NK and LAK cells to give final effector/target cell ratios of 20:1 ; 10:1 ; 5:1 and 2.5:1. Lysis was determined by measuring -~JCr release in a gamma counter. Results were expressed as percent specific cytolysis + SE%.

MHC gene product induction resulted in a significant increase in NK and LAK cell-mediated cytolysis at all effector/target cell ratios, p < 0.001. Masking the antigens with complete blocking antibodies attenuated this response.

In the clinical situation, up-regulation of MHC antigens with rlFN-~, may help improve prognosis by augmenting the ability of NK and LAK cells to lyse metastatic cells.

ETHANOL INHIBITS BILIARY SPHINCTER OF ODDI MOTILITY

S. Tierney, Z. Qian, P. A. Lipsett, H. A. Pitt, K. D. Lillemoe. Department of Surgery, Johns Hopkins Medical Institutions,

Baltimore, MD, USA.

The direct effects of ethanol on the sphincter of Oddi may contribute to alcoholic pancreatitis. However, patients with alcohol-induced cirrhosis also have an increased incidence of gallstones. In the prairie dog, the common bile and pancreatic ducts enter the duodenum separately facilitating pressure measurement in the sphincter choledochus in isolation. We therefore tested the hypothesis that the effects of ethanol are mediated in part through an alteration in sphincter of Oddi motility. Twenty-six male prairie dogs fed a nonlithogenic diet were studied. Under o~-chloralose anesthesia, a side hole pressure monitored perfusion catheter was positioned in the biliary sphincter of Oddi and perfused with degassed water at 0.15 ml/ min. Femoral arterial and venous catheters were placed. Sphincter of Oddi phasic wave frequency (F), amplitude (A), and motility index (MI=FxA) as well as arterial blood pressure were monitored for l0 min intervals before (baseline), during 20 min intravenous infusions of 15mg (n=9), 150mg/kg (n=10) and 1.5g/kg (n=7) ethanol and for 20 min after ethanol infusion. The 15mg dose of ethanol had no effect whereas the 150mg dose tended to reduce sphincter of Oddi motility. The results at 1.5g were:

Frequency Amplitude Motility Index

Baseline 100-2_0% 100+0% 100-2-_0% 0-10 min infusion 89:!:3%* 79+6%* 70-1:5%* 11-20 " infusion 89+6% 80-Z-_8~ * 71+8%* 0-10 " post-inf 79-+8%* 68+7%* 54_+8%* 11-20 " post-inf 86_+6% 76-t-8%* 65+7~o*

Mean-+SE (% of baseline); *p<0.05 vs baseline (Wilcoxon)

These data demonstrate 1) that ethanol infusion inhibits both sphincter of Oddi frequency and amplitude and 2) that this effect persists for at least 20 min following ethanol infusion. We conclude that ethanol may contribute to gallstone formation by altering biliary sphincter motility.

involvement are assumed to have distant metastatic spread. Between 1973 and 1988, 408 lymph node positive patients

aged <70 yr with primary invasive breast cancer were treated at the Nottingham Breast Unit without adjuvant systemic therapy. The actuarial survival for each histological group was plotted to 216 months. For each grade there was a constant yearly actuarial probability of death - 8% for grade Ill, 5% for grade II and 3% for grade I.

However, at a certain time for each grade, the logarithmic plot of survival suddenly altered to a horizontal line indicating no further deaths from that time. This was at 10 yr (21% survival) for grade III, 14 yr (30% survival) for grade II and 15 yr (65% survival) for grade I.

This suggests that survival for lymph node positive breast cancer patients after a certain time interval, dependent on histological grade, is very good and may equate to a cure.

MEASUREMENT OF THE RENAL BLOOD FLOW ADAPTIVE RESPONSE FOLLOWING NEPHRECTOMY.

I. S. Young, M. K. Barry, M. C. Regan, J. G. Geraghty, J. M. Fitzpatrick.

Department of Surgery, Mater Misericordiae Hospital, Dublin.

More than 90% of blood entering the kidney goes to supply the renal cortex, resulting in a cortical perfusion rate of between 500 and 850 ml/min/100 gram of tissue depending on the technique used. Following nephrectomy alterations in regional renal blood flow occur in the contralateral kidney as part of the homeostat ic response. Establ ished techniques for the measurement of these regional renal blood flow changes have provided very limited information to date. This study was designed to investigate regional differences in renal blood flow following nephrectomy using an autoradiographic technique. Quantitative autoradiography utilising 14C iodoantipyrine was used to measure intrarenal blood flow in anaesthetised Sprague Dawley rats. Four groups were studied (N=6/group): control, 30 min, 2 hr and 24 hr post-nephrectomy (PN). Animals were killed at the same time point to determine statistical spread. Using a scanning camera microscope attachment, magnified images of renal tissue and autoradiographs were transferred to an image analyser. These were used to determine blood flow to the cortex, higher optical density regions (HODR) within the cortex and the medulla.

CONTROL 30MinPN 2HrPN 24HrPN ml/100g/min ml/100g/min ml/100g/min ml/100g/min

Cortex 806.8_+63.3 1041.2+54.6" 1152.6+...54.1" 749.6+32.9

HODR 1079.1_+82.7 1393.9-2-_88.2" 1653.5+143.6" 1049.3+111.4

Medulla 373.8_+38.8 309.5_+32.5 594.7_+37.5* 315.7+8.1 Mean(SEM) * P < 0.05 compared to control (Student t-test)

SURVIVAL IN LYMPH NODE POSITIVE BREAST CANCER PATIENTS ACCORDING TO HISTOLOGICAL

GRADE - POSSIBLE EVIDENCE OF CURE

J. Kollias, D. A. L. Morgan, J. E R. Robertsoo, R. W. Blamey.

Nottingham City Hospital

Breast cancer patients who have evidence of lymph node

These data indicate that quantitative autoradiography may be used to accurately assess changes in regional renal blood flow after nephrectomy. There are discrete regions of higher blood flow within the cortex (HODR), which account for a significant proportion of the increase in blood flow to the contralateral kidney at 2 hr post-nephrectomy. At 24 hr post- nephrectomy, blood flow values have returned to control levels. This adaptive response is currently under further investigation in our laboratory.

16

ALTERED INDUCTION OF INTERLEUKIN-2 PROMOTER-SPECIFIC TRANSCRIPTION FACTORS IN

CD4+T CELLS FOLLOWING BURN INJURY

C. B. O Suilleabhain, M. L. Rodrick, A. F. Horgan, S. T. O'Sullivan, J. A. Mannick, J. A. Lederer.

Department of Surgery, Harvard Medical School/Brigham and Women's Hospital, 75 Francis St., Boston. MA 02115,

U.S.A.

Injury, including burn injury, remains a major cause of death and sepsis is the most frequent cause of mortality in seriously injured patients who survive the early resuscitative period. It has now been established that serious injury paradoxically leads to decreased resistance to infection, both in patients and in animal models of injury.

Decreased T cell production of interleukin-2 (IL-2) plays a fundamental role in the immunosuppression seen after injury. We have previously shown in a murine rdodel of thermal injury reduced IL-2 mRNA expression. This was most significant between days 7-10 following thermal injury. The IL-2 gene enhancer/promoter contains a number of transcription factor binding sites including an Oct binding site called NFIL-2A, proximal and distal NFAT and AP-1 sites, and a single NFrB binding site that act to coord ina te ly regulate IL-2 gene t ranscr ip t ion . In this s tudy, we inves t iga ted molecu la r mechanisms that may be responsible for the reduced T-cell production of IL-2 folkiwing injury by using electrophoretic mobility shift assays (EMSA) to determine whether CD4+ T- cells from burn-injured mice demonstrated any defects in the activation of NFIL-2A, AP-1, and NFrB transcription factors.

Mice were anaesthetized and either burned or sham burned using an established burn injury protocol. At days 3 and 9 after burn injury, spleen cells were prepared for in vitro stimulation overnight with 5 ug/ml of concanavalin A (Con A) after which CD4+ T-cells were purified from whole spleen .cell suspensions by positive selection using a complement-mediated antibody depletion approach. Nuclear extracts were then prepared from these cells to be tested for the presence ofAP-l, NFrB and NFIL- 2A binding factors by EMSA using 32p-labelled oligonucleotide probes that contain these corresponding binding sites in the murine IL-2 gene enhancer/promoter. EMSA analysis of these nuclear extracts demonstrated both upper and lower migrating AP-I, NFKB and NFIL-2A binding complexes that were similar at day 3 in Con A-stimulated CD4+ cells from sham and burned mice. In contrast , different EMSA binding patterns were observed between sham and burned mice in Con A-stimulated CD4+ ce l l s a t day 9 after burn injury. A lower mobility was observed in both upper and lower complexes of NFrB in burn as compared to sham animals. In addition, the upper AP-1 complex was noted to be absent in the burns group. The differences in EMSA binding patterns indicate different sets of AP-1 and NFrB proteins are present in the nucleus of activated CD4+ T cells from sham as compared to burn injured mice. We have begun to examine which AP-I and NFrB subunits are the targets of these defects using antibodies specific for AP-1 and NFKB transcription factor protein subunits. These findings indicate that burn injury induces a profound alteration in the functional activation of T cells that involves at least two sets of transcription factor complexes of the IL-2 promoter region.

PHARYNGEAL REFLUX: UPPER OESOPHAGEAL SPHINCTER OR OESOPHAGEAL BODY DISORDER?

J. P. McGrath, R. C. Stuart, P. Lawlor, P. J. Byrne, T. N. Walsh, 3". P. J. Hennessy.

University Department of Surgery, St. James's Hospital, Dublin.

Pharyngeal reflux is implicated in the extra-oesophageal man i fes ta t ions of GORD. This s tudy examined upper oesophageal sphincter function and oesophageal body function in patients with pharyngeal reflux. Fourteen patients with documented GORD underwent simultaneous pharyngeal and oesophageal pH and motili ty studies. On the basis of the pharyngeal pH profile, patients were categorised as having pharyngeal reflux, (Group 1, n=6) or oesophageal reflux only (Group 2, n=8).

RESULTS Mean (sem) Group 1 Group 2 pH monitoring Pharyngeal reflux episodes (no.) 14 0 Oesophageal reflux episodes (no.) 84 (7) 69 (8) Duration of oesophageal reflux episodes (mins) 5 (2) 3 (1)~* Manometry (mmHg) Proximal wave amplitude 48 (3) 22 (2)* Middle wave amplitude 54 (3) 34 (4)* Distal wave amplitude 52 (4) 30 (3)* Upper sphincter pressure 59 (5) 54 (4) Lower sphincter pressure 8 (1) 9 (1)

Wilcoxon Rank Sum Test *p<0.01

Patients with pharyngeal reflux were distinguished by the duration of oesophageal reflux episodes. Upper sphincter pressures were similar in both groups. Mean peristaltic wave amplitude was significantly greater in group 1 but clearance was not improved suggesting this to be a secondary event. Delayed clearance of oesophageal reflux was the most significant factor in predisposing to pharyngeal reflux.

GORD = Gastro-Oesophageal Reflux Disease Wilcoxon Rank Sum Test *p <0.01

17

EVALUATION OF THE ANTICANCER POTENTIAL OF THE VITAMIN A DERIVATIVE, FENRETINIDE

C. J. O'Boyle, C. Curran, M. Canney, K. Feeley, D. M. O'Hanlon, D. Maher, C. E. Connolly*, H. F. Given.

NBCRI and Departments of Surgery and Pathology*, University College Hospital, Galway

The retinoids, a group of compounds structurally related to vitamin A, play an important rote in cel lular growth and differentiation. We have studied the effects of fenretinide (4- HPR), a synthetic retinoid, on MCF-7 (human) and RBA (rat) mammary adenocarcinoma cell-lines, and on tumours induced in female Sprague-Dawley rats. Growth curves were plotted for different doses of 4-HPR in vitro and the concentrations at which 50% of growth inhibition occurred (EDso) was calculated (see table).

RBA was then injected subcutaneously at a concentration of 5 x 105 cel ls /50uL medium into 3 day-old rats (156 rats) and resulted in 100% tumour take within two weeks. In the case of for ty-s ix of these animals the mothers were fed a diet incorporated with 4-HPR in a concentration of 3mmol/kg in the latter stages of pregnancy and while weaning (as the retinoid is concentrated in breast tissue). Turnout growth was monitored twice-weekly for a period of five weeks. After sacrificing the adult rats, full autopsies were performed and all tumours recovered were archived for histopathological analysis.

% GROWTH AS COMPARED TO CONTROL MCF-7 RBA

Dose omol/l DaY 2 Day4 Day 6 Day 2 Day4 Day 0.1 121 109 104 108 89 86 0.5 76 69 57 96 73 66 1 71 70 45 98 69 56 3 57 32 27 88 29 19 5 44 17 3 65 7 18 10 14 1 0 15 1 0 ED 50 4.07 2.05 0.79 6.5 1.95 1.32

The growth of both cell-lines, in vitro, was progressively inhibited with increasing concentrations of 4-HPR and with prolonged exposure to the drug. In vivo, fenretinide had no effect on tumour take. However, mortality was significantly decreased in the treated animals (13% v 36%, p < 0.01). We attribute this improved survival to prevention of metastatic lung disease, which was present in 97.5% of controls at autopsy. These anticancer effects of fenretinide may have considerable implications for the chemoprevention and adjuvant therapy of breast cancer in humans.

THE ANTI-TUMOUR EFFICACY OF TAURINE AND RECOMBINANT INTERLEUKIN-2 IN VIVO

H. Abdih, N. Finnegan, H. P. Redmond, M. Da Costa, D. Bouchier-Hayes.

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

The administration of recombinant interleukin-2 (rlL-2) is limited by the induction of increased microvascular permeability causing a vascular leak syndrome (VLS). We have previously demonstrated in v i t ro that the amino-acid taurine (Tau) significantly attenuated rlL-2-induced endothelial cell (EC) injury while the tumour cytotoxicity of LAK cells was enhanced. In this study the in v ivo antineoplastic effects of multiple injections of taurine in combination with rlL-2 were investigated in a B 16 melanoma pulmonary metastases model and its impact on the associated vascular leak was examined. Lung metastases of B 16 cells were established in mice by tail vein injection. Ten days after injection mice were randomized into six treatment groups including rlL-2 (50,000 IU/ml), Tau (10%), Tau/IL-2 and IL-2/glycine (6%). All treatments were given as i.p. injections in 0.5 ml every hr for five days. Control animals recevied saline in the same manner as treated animals. On day 18 after tumour injection the mice were sacrificed; lungs were removed, weighed and metastases counted in a blinded fashion with the aid of a dissection microscope.

Thus far in our investigations treatment of tumour-bearing C57BL/6 mice for 5 days with Tau+rlL-2 resulted in a 35.6% reduction in the number of lung nodules as compared to 24.9% for the group that received rlL-2 alone. Mean wet lung weights of the Tau/rlL-2 group (0.14+0.008g) were less than that of the non-tumour-bearing group (0.15+0.017g) while the rlL-2 group (0.16+0.004g) showed an overall increase in wet weight. Thus administration of taurine during rlL-2 immunotherapy may increase the anti-tumour activity of this cytokine, possibly by an immune enhancement mechanism, while attenuating the associated vascular leak of rlL-2. This may allow for the administration of increased doses of rlL-2. Thus taurine may have an important role in modulating both metastatic growth and the associated toxicity of rlL-2 immunotherapy. rlL-2: recombinant Interleukin-2, Tau: tauirne: LAK cell: lymphokine-activated killer cell.

SPORT INJURIES - - NEED FOR FURTHER EDUCATION

M. Shafii, A. J. Martin. Accident and Emergency Department, University College

Hospital, Galway.

Sport injuries account for a large proportion of the workload attending Accident and Emergency Departments. The aim of this study was to determine the number and types of injury seen in this region and furthermore to evaluate peoples' knowledge of first aid measures after injury, so as to establish guidelines for the future prevention of such injuries.

All sport in jur ies a t tending Accident & Emergency Department between 1/7/1993 to 1/1/1994 were prospectively analysed and the following facts were established in each case. Age, sex, type of sport, previous injury, site of injury, first aid measures after injury and ability to continue after injury were recorded.

A total of 448 cases were analysed. Gaelic football, hurling, soccer and basketball accounted for 29, 18, 17 and 11% respectively. The remaining 25% was accounted for by a variety of other sports. The average age for males was 20.3 yr and for females was 19.2 yr, with male to female ratio of 4.2:1. The injuries seen in Gaelic and hurling were mainly to the upper limb. Soccer injuries were mostly lower limb injuries. Majority of injuries were direct trauma related (92.5%). First aid was carried out in only a small minority of cases (5%) and first aid knowledge among the patients was of a generally poor standard. Hand fractures accounted for 66% of all fractures seen and reflects the local preference for high speed contact sports. 90.5% of patients required more than one visit to hospital. The economic burden of sport injures is, therefore, heavy. Poor knowledge of first aid measures requires correct ion at fundamental level.

Hand injuries should be treated vigorously in order to avoid subsequent disability. Future preventative measures in this area will require the design of more user friendly hand protection and its mandatory use.

CERVICAL TRAUMA: ASSESSMENT OF THE ADEQUACY OF LATERAL X-RAY VIEWS

P. Neary, D. Mulcahy, M. Dolan, M. Stephens, F. McManus, M. Walsh.

Department of Orthopaedic Surgery, Mater Misericordiae Hospital, Dublin 7.

The radiographic visualisation of the entire cervical spine is an essential step in the assessment of_patients with suspected cervical injury. We assessed the adequacy of initial lateral cervical X-rays in patients referred to our spinal unit with cervical trauma.

Fifty patients' radiographs were reviewed. There were thirty six males and fourteen females with a mean age of forty two yr (range 15-84). The commonest mechanism of injury was a road traffic accident (34 patients), and twenty-two patients had a neurological deficit on admission. Despite pulling down the shoulders and taking swimmers views C7 - T1 was not visualised in eighteen patients. Four patients had injuries at this level and one of these was a missed diagnosis. This patient had a double level injury with a coexisting fracture at C2. Twelve patients had injuries at C6 - C7 level. This level was visualised in forty six patients (92%) and there were no missed diagnoses. Four patients (8%) had injury at more than one level in the cervical

18

spine. Two patients had late subluxation at levels that were normal on initial X-ray examination.

Standard lateral radiographs may be inadequate in visualising the entire cervical spine in over one third of patients with suspected cervical injury. It is imperative that the entire cervical spine be visualised in these patients. Computerised tomography should be performed to avoid the possibility of missed injury.

PROBLEMS OF INTER-HOSPITAL TRANSFERS OF PATIENTS WITH SERIOUS HEAD INJURIES

D. P. O'Brien, J. P. Phillips. Department of Neurosurgery, Beaumont Hospital, Dublin.

Trauma is the leading cause of death in persons between 1-40 years of age. In addition, cerebral injuries contribute significantly to 75% of all trauma fatalities. We reviewed our experience with cerebral trauma with particular emphasis on inter-hospital transfer of patients with head injuries, by the way of a number of inter-related clinical and neuropathological studies. Firstly, over a twelve month period, 225 patients with acute head injuries were admitted to the National neurosurgical centre (NNC) at Beaumont Hospital, Dublin. Of these, 11% (25) were admitted directly to the NNC. 25% (56) were transferred from other Dublin hospitals and 64% (I 44) were transferred from other hospitals "Outside the Pale". The mean distance travelled for the latter group was 105 Km (median = 96 Km). Fifty-four per cent of head injuries occurred at weekends and / or on Bank holidays i.e. computerised tomography (CT) scanners not available in peripheral hospitals during these times plus fewer medical staff available to escort these patients over potentially long distances. Of the 200 patients involved in inter-hospital transfers. 53.5% were intubated and ventilated. Nineteen patients (8%) had "normal" scans. Secondly, a recent study of 100 consecutive "fatal" head injuries admitted to the NNC revealed that 7% died from extra-cranial injuries alone i.e. no evidence of cerebral injury. Four of these seven patients died from extra- cranial "haemorrhage" - i.e. potentially avoidable deaths. Thirdly, another clinical study on fifty consecutive inter-hospital transfers of seriously ill patients to the NNC revealed 15 (30%) "unstable" patients on arrival to the neurosurgical unit (hypotensive = 6; not intubated and ventilated = 3; blocked endotracheal tube = 1; hypercapneic = 1 ; status epilepticus = 1; hypoxic = 1; cardiac arrest = 1; clinically "coned" = 1). Twenty- nine patients (58%) were escorted by anaesthetists.

Inter-hospital transfer of critically ill patients in Ireland is a potentially hazardous yet an everyday occurrence. Initial resuscitation and stabilisation of trauma victims is mandatory prior to transfer. Intubation and ventilation is recommended if the Glasgow coma scalg is less than 8 and the patient preferably accompanied by an experienced anaesthetist. Wider availability of"out-of-hours" CT and greater usage of"image-link" systems would probably reduce the number of unnecessary transfers and potentially avoidable deaths.

CT-SCAN IMAGE-TRANSFER FROM PERIPHERAL HOSPITALS TO THE NATIONAL NEUROSURGICAL

UNIT: AUDIT OF THE FIRST SIX MONTHS

T. A. Carroll, D. O'Brien, D. Rawluk. National Neurosurgical Unit, Beaumont Hospital, Dublin.

Two image-transfer systems allow transmission of CT-scan

images from six peripheral hospi ta ls to the National Neurosurgical Centre at Beaumont Hospital, Dublin. We sought to determine the extent of use of the image-transfer systems over the first six months of operation by retrospective review of hospital records. During this period, from the 1st November 1994 to the 30th April 1995, 46 CT-scans were sent by image- transfer with the clinical picture communicated by phone (Galway 9, Crumlin 0, Meath 1, Ardkeen 7, Tullamore 7, Sligo 22). During the same period, 209 patients from peripheral hospitals were referred for CT-scan in Beaumont Hospital of which 24 patients scanned were from one of the six image- transfer hospitals (Galway 2, Crumlin 7, Meath O, Ardkeen 1, Tullamore 8, Sligo 6). The pattern of referral for CT-scan was similar to the previous six months. Forty-seven patients in total from the six peripheral hospitals required transfer for admission to Beaumont of which only four had initial scans sent by image- transfer. A similar pattern of infrequent use of the image-transfer systems was observed with on-call consultations. Conclusion: the Image-transfer service has made little impact on the referral of patients for CT-scan in Beaumont Hospital and subsequent admission. The service is limited by its use only during the standard working day and by the small number of participating hospitals.

19

BIOMECHANICAL ANALYSIS OF TENSILE STRENGTH. IN PARTIALLY DIVIDED FLEXOR TENDONS

K. J. Cronin, M. Shafii, F. X. Darmanin, T. Sullivan, J. McCann.

Department of Plastic, Reconstructive and Hand Surgery, University College Hospital, Galway.

The optimum treatment of partially divided flexor tendons is controversial. Some authors maintain that all partially divided tendons should be repaired I while others suggest that only those injuries in excess of 60% cross-sectional area require formal repair 2. We examined the mean tensile strengths of freshly harvested sheep flexor digitorum tendons which were partially divided to varying degrees (0%, 25%, 50%, 75%, 90% and 100% of cross-sectional area) and then compared the results to tendons which were partially divided and then repaired. Tendons with 50% or less division of cross-sectional area were repaired using a 6/0 running epitendinal suture while those with 75% or greater division were repaired using a 4/0 modified Kessler suture in conjunclion with a running 6/0 epitendinal suture. The results were as follows:

MEAN MAXIMAL MEAN MAXIMAL GROUP TENSILE STRENGT OF TENSILE STRENGTH

TENDON ALONE OF REPAIRED (Newtons) TENDONS (Newtons)

INTACT TENDONS 690.0 (n=20) N/A 25% DIVISION 592.6 (n=10) 570.4 (n=10) 50% DIVISION 460.5 (n=10) 448.5 (n=10) 75% DIVISION 307.4 (n=10) 330.0 (n=10) 90% DIVISION 260.1 (n=10) 273.4 (n=10) 100% DIVISION 0 38.8 (n=20)

This data indicates that flexor tendons which are divided by up to 90% still have a relatively high tensile strength which is very significantly stronger than the conventionally employed Ressler-Mason-Allen suture (p<0.001). Also the addition of a repair to a partially divided tendon did not significantly increase the tensile strength. We conclude therefore that early active mobilisation of partially divided flexor tendons is relatively safe as the tendon retains a reasonably high tensile strength and also

that the addition of a repair to a partially divided flexor tendon does not increase its tensile strength to a significant degree.

References 1. D. D. McGeorge and J. HStilwelL Partial Flexor Tendon Injuries: To Repair Or Not; Journal of Hand Surgery (British Volume, 1992) 17b: 176-177. 2. H. E. Kleinert. Commentary on "Should an incompletely severed tendon be sutured?" Plastic and Reconstructure Surgery 1976; 57: 2: 236.

A NEW TREATMENT TECHNIQUE FOR ZYGOMATIC ARCH FRACTRURES

E. Beausang, K. Herbert, M. O'Shaughnessy, T. P. F. O'Connor.

Department of Plastic Surgery, Cork University Hospital, Cork.

Since the turn of the century, many techniques of reduction of zygomatic fractures have been described in the literature. These include: (1) intra-oral approaches; (2) maxillary antral approaches; (3) lateral brow approach; (4) temporal approach; (5) reduction using a bone hook, a screw eye, and a towel clip.

Despite the large number of techniques available, few give specific mention to isolated fractures of the zygomatic arch, which account for approximately t 0% of all zygomatic fractures. We now describe a new percutaneous technique which is simple to perform, does not require any incision or hair shaving, and which deals specifically with the problem of isolated arch fractures. We have sucessfullly used this technique to treat 8 patients over a 15 month period. The mean follow-up period was 8 months (range 2 - 23 months), and to date there have been no complications.

THE MANAGEMENT OF BURNS PATIENTS

P. Neary, M. Kerins, M. O'Donnell, D. Lawlor, M. McHugh, G. Edwards.

Department of Plastic and Reconstructive Surgery, St. James's Hospital, Dublin 8.

The National Burns Unit is a tertiary referral centre for acute burn trauma. We reviewed the ae t io logy and surgical management of patients admitted to our unit from January 1993 to December 1994.

There were 225 patients admitted with a mean age of 42 yr (range 7 - 93). The male, female ratio was 2:1. Inpatient stay was a mean of 36 days (range 1 - 261). Total body surface area (TBSA) burned ranged from 1-65%. 153 patients (68%) had less than 10% TBSA burned. 22 patients (10%) had greater than 30% TBSA burned. 27% had burns involving the head and neck region. The most common aetiological factor was flame (120 patients ) with scald second commonest (43 patients). 80% of burns occurred in a domestic environment.

Initial fluid resuscitation remains the mainstay of acute burn treatment based on the regime devised by Muir and Barclay in the late 1950's. 130 patients underwent surgical intervention. 117 patients had wound debridement and split skin grafting, many requiring multiple surgical interventions. 84 patients were managed via topical dressings, 6 pat ients necessitated escharotomies and 5 patients had flaps. There were 20 deaths (9%) over this period, 50% of these were elderly patients with TBSA burned over 30%, the remainder had burns over 40%. The mean age in this group was 62 yr (range 16-89 yr).

The effective management of this common form of injury is

dependent upon correct fluid resuscitation and appropriate surgical intervention. The burns patient needs long periods of hospital stay even those treated conservatively. Many of those treated operatively still required multiple procedures.

GUESTS OF THE NATION

J. Rice, J. P. McCabe, F. McManus. Cappagh Orthopaedic Hospital, Finglas, Dublin 11 .

Refugees from the conflict in Bosnia-Herzegovina have been evacuated to Ireland.

A group of thirtyzsix such refugees have had their rehabilitation coordinated at Cappagh Orthopaedic Hospital in the past year. Their injuries required intervention from a number of specialities. They required prolonged periods in hospital. All but one of this group want long term residency in Ireland.

We conclude that the care of a group of war refugees is a major undertaking in terms of logistics, surgical management and subsequent social integration.

ACUTE SPINAL INJURY: ASSESSMENT OF THE BENEFIT OF MRI

J. Sparkes, P. Neary, F. McManus, M. Walsh. Department of Orthopaedic Surgery, Mater Misericordiae

Hospital, Dublin 7.

The Mater Misericordiae Hospital is a tertiary referral unit for acute spinal trauma. Routinely patients with neurological deficit undergo both computerised tomography and magnetic resonance imaging (MRI) of the traumatised spine. We retrospectively reviewed 45 consecutive cases over an eighteen month period to assess the role MRI had in initial patient management.

There was a male female ratio of 3 : 1 with a mean age of 43 yr (range 17-84). The most common aetiological factor was road traffic accidents (50%). All 45 patients had a significant neurological deficit. There were 30 cervical injuries, (5 were multilevel injuries), 4 thoracic injuries, (2 were multilevel injuries), and 11 lumbar injuries. Two cases had management altered on the basis of initial MRI findings. One patient had a hangman's fracture of C2 post attempted suicide. The patient was comatose on admission and MR outruled the necessity of operative intervention. The second patient had a burst fracture of L 1. MR revealed anterior cord compression secondary to disc protrusion and was subsequently surgically decompressed. In the remaining 43 patients MR did not alter initial management.

The MRI has the technical advantage of superior soft tissue definition and is a non irradiating procedure, however in the vast majority of cases (95%) it does not alter initial patient management. A consensus on a stricter selective scanning protocol may need to be addressed for this expens ive investigation.

20

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY - AN ANALYSIS OF INITIAL RESULTS

S. Hayes, N. Hegarty, P. McCarthy, M. Corcoran, H. Bredin. Department of Urology, University College Hospital, Galway.

Within the past thirteen years extracorporeal shock wave lithotripsy has established itself as the optimal treatment modality for most upper renal tract calculi. Developments in lithotriptors have meant that a procedure which originally

required general anaesthesia, can now be performed with simple analgesia (with or without concomitant sedation), often on a day patient basis.

The ESWL service was commenced in University College Hospital Galway, Urology department in April 1994 using the Breakstone 100 lithotriptor. Prior to this, upper renal tract calculi were treated by stenting or extraction at ureteroscopy, PCNL or open lithotomy, or were referred to centres outside the region. We reviewed 34 consecutive cases of renal and upper ureteric stones treated in the first year of service.

Of the 34 patients treated (23 male, 11 female), 22 had a single calculus, and 12 had two or more calculi. 15 patients underwent a single ESWL treatment. A high success rate has been achieved to date, defined as patients being stone free or possessing only small asymptomatic fragments at 3 month follow up. Failure to respond to treatment occurred in only 3 patients. 2 of these required stone extraction at ureteroscopy and 1 required PCNL. No patient proceeded to open lithotorny. We conclude that ESWL has provided an "effective means for the treatment of most renal and upper ureteric stones and has greatly reduced the need for more invasive procedures in patients presenting to our unit.

AN OUT-PATIENT TRANSRECTAL ULTRASOUND - GUIDED PROSTATE BIOPSY SERVICE

P. McCarthy, D. O'Keeffe, J. Candon, M. Corco~an, H. Bredin. Departments of Radiology and Urology, University College

Hospital, Galway.

The objective was to assess the role of an out-patient prostate biopsy service in a large general hospital.

All patients are referred for an ultrasound scan by either of two urological firms. The scans were performed using a 7MHz probe (EC-7, Acuson XP-10 128, California, USA). Biopsies were performed if strict guidelines regarding digital rectal exam (DRE), prostate specific antigen (PSA) levels and ultrasound appearances were met. An 18 gauge Tru-cut needle with a Biopty gun was used in all cases. Sextant quadrant or locally-guided biopsies were performed depending on the indications.

To date 86 patients have been scanned, of whom 41 have had biopsies.

To date, one patient has had significant haenaturia for which admission was not required. No patient has developed a urinary tract infection (antibiotic prophylaxis is administered). Overall there has been a very low level of complications, with pain after more than 6 biopsies being the most commonly noted. An incidence of 56% malignancy is detected in biopsies performed in this manner.

Outpatient transrectal ultrasound-guided prostate biopsy is a safe procedure, as long as meticulous attention to antisepsis is observed and a fallback mechanism is available to allow admission should complications arise.

THE TREATMENT OF.BENIGN PROSTATIC HYPERPLASIA WITH HIGH INTENSITY FOCUSED ULTRASOUND

E. D Mulligan, T. H. Lynch, D. Mulvin, L. Vingers, J. M. Smith, J. M. Fitzpatrick.

Mater Misericordiae Hospital, Dublin.

High intensity focused ultrasound (HIFU) is a new treatment modality for the management of benign prostatic hyperplasia

(BPH). HIFU administered rectally causes contact free coagulative necrosis of the prostate gland. Temperatures between 80 and 100~ within the focal area are obtained and tissues outside this area remain intact.

We present the results of a phase 2 trial to determine the effectiveness of transrectal high intensity focused ultrasound in the management of men with BPH. All men treated had symptomatic BPH who were initially felt suitable for TURP. All had a symptom score as defined by the American urological association of greater than 18, peak urinary flow rates of less than 14ml/sec. Patients were treated under general anaesthesia and followed up at l, 3 and 12 months by means of symptom score, uroflow and post-void residual volume.

To date 13 patients have been treated:

Means Baseline 1 month 3 months 6 months 1 year 2 year

Max flow 9.9 14.2 14.1 14.1 15.8 10.6 ml/sec Post void 86 89 13.3 residual AUA symptom 22.6 10.7 9.4 5.8 4.9 7.2 score

Transient post Operative urinary retention was the only significant post operative morbidity. Two patients had a TURP for persistent significant outflow obstructive symptoms post treatment and one patient underwent urethral dilatation.

This study demonstrates the clinical efficacy of high intensity focused ultrasound in the management of symptomatic BPH but further evaluation is necessary to compare it to the gold standard transurethral resection of the prostate.

TRANSURETHRAL NEEDLE ABLATION FOR THE TREATMENT OF SYMPTOMATIC BENIGN PROSTATIC

HYPERPLASIA

H. Corby, T. H. Lynch, K. Barry, I. Eardley, J. Frick, B. Goldwasser, P. Wiklund, J. M. Fitzpatrick.

Mater Misericordiae Hospital, Dublin.

Transurethral needle ablation TM procedure (TUNA TM

procedure) is a new treatment modality for symptomatic benign prostatic hyperplasia (BPH). It utilises radiofrequency radiation which is applied producing temperatures in the order of 80~ This results in a coagulative necrosis which spares the prostatic urethra.

The results of a phase 2 study to assess the efficacy of TUNA therapy in the treatment of men with symptomatic benign prostatic hyperplasia are presented.

Five European centres (Dublin, Ireland; Leeds, UK; Salzburg, Austria; Tel Aviv, Israel; Stockholrn~ Sweden) have recruited patients into this study. All patients entered had an international prostate symptom score (IPSS) greater than 13 and a peak urinary flow rate less than 12ml/sec. Patients were treated with local urethral anaesthesia and intravenous sedation. Follow up at 1, 3, 6 and 12 months is by means of symptom score, uroflow and estimation of post void residual by abdominal ultrasound. In three centres urodynamic studies were also performed.

To date 68 patients have been treated. The mean IPSS symptom score has fallen from a pre-treatment mean of 21.4 to 8.6 at three months and 5.6 at six months. The pre-treatment flow rate has improved from 8.5 to 13.6 (6 months). The quality of life has improved from 4.3 (pre-treatment) to 1.25 at six months. The most common post-operative side effects to date have been haematuria and dysuria.

21

These early results show a very favourable response to this new treatment modality but further follow-up is required to assess the long term results.

orifice. It provides a high rate of daytime incontinence (85%). Significant bacteruria does not persist in these patients. This technique uses established procedures of urethral preservation and ileal pouch formation.

A SIMPLE ILEAL SUBSTITUTE BLADDER: EXPERIENCE WITH THE STUDER POUCH

E. Rogers, R. Weaver, P. T. Scardino. Scott Department of Urology, Baylor College of Medicine &

the Methodist Hospital, Houston, Texas.

A satisfactory bladder substitute would be one that allows voluntary control of voiding. We performed a procedure using detubularised ileal bladder substitute formed into a pouch in male pa t ients with an intact urethra undergoing cytoprostatectomy for bladder cancer. This procedure was performed with some modifications in twenty patients wi th transitional cell carcinoma of the bladder, who underwent radical cytoprostatectomy and urethral preservation.

Their ages ranged from 43 to 76 yr with a median of 64 yr. Follow-up ranged from 5 to 52 months, with a median of 15.5 months. At preoperative evaluation, all patients were considered to have localised disease and all were continent of urine. The distal ileum was divided 15cm from the ileocecal junction, and a 40cm segment of proximal ileum was fashioned into a pouch. The pouch was approximated without tension to the urethra and anastomised to it. The proximal division of the ileum was then created in nondetubularised bowel 18cm proximal to the pouch. The ureters were anastomised to this nondetubularised Segment.

The median operative time required to perform the entire prodedure was 6 hr and 55 min. The median postopeative stay for these patients was 11 days with a range of 7-128 days. The median estimated blood loss for the procedure was 1400mls (Range 750-800mls). A median number of 2 units of blood were transfused into each patient (Range 0-4). Three patients did not require transfusion.

No patient suffered an operative mortality. Two patients had myocardial infarctions postoperatively. Overall 11 patients required antibiotic treatment for bacteruria, but only 2 patients had symptomatic urinary tract infections. There were no urinary fistula post-operatively. All patients have been carefully followed for recurrence of malignancy including surveillance of the urethra with wash cytologies. Two patients have died from metastatic disease.

Urinary continence both day and night without the need for pads has been achieved in 8 patients. However, 5 patients selectively empty their bladders at night, requiring alarm clocks to awaken. A further 9 patients are continent during the day, but require pads at night to prevent bedwetting. Two patients have had daytime and nocturnal incontinence. The median time required to achieve total continence was 15 weeks (Range 5- 24). In all patients voiding occurs via the urethra and is initiated by abdominal straining.

Urodynamic studies were performed under fluoroscopic control in patients six months postoperatively. The median capacity of the pouch is 519cc (Range 250-700cc). The average peak pressure at full capacity is 45cm of water with a range of 30-55cm of water. Peak flow rates range from 9-35cc per second. There has been no loss of a renal unit as a consequence of surgery from urinary reflux.

The Studer neobladder has a number of advantages for the patient and the urologist. From the patients' perspective, it enables him to void from a closed urinary tract through a normal

22

ENDOSCOPIC MANAGEMENT OF PRENATALLY DIAGNOSED HIGH GRADE VESICOURETHERAL REFLUX

R. Kumar, P. Puri. Children's Research Centre, Our Lady's Hospital for Sick

Children, Crumlin, Dublin 12.

Antenatally diagnosed hydronephrosis is the most common congenital condition detected by prenatal sonography. The majority of hydronephrosis resolve postnatally. High grade vesicouretheral reflux (VUR) is an important cause of persistent hydronephrosis. The aim of this study was to describe the natural history and endoscopic management of persistent high grade VUR detected antenatally.

Between 1989 and 1994, 31 infants were seen in our hospital with prenatally diagnosed hydronephrosis. 22 infants had bilateral hydronephrosis and 9 had unilateral. VUR was noted in 26 kidneys. According to the international classification of reflux 16 units had grade V reflux, 5 units grade IV, 3 units grade III, 2 units grade II, 20 units were bilateral and 6 units were unilateral. In 6 kidneys it was secondary to PUV. 4 units were associated with duplex system and 3 units with PUJ obstruct ion. All chi ldren were given prophylact ic chemoprophylaxis and followed up.

2 units had n o n - f u n c t i o n i n g kidneys and required nephrourectectomy. 12 of the 26 units required submucosal teflon injection (STING)procedure because of persistent high grade reflux Grade V in 10 and Grade IV in 2 units and infection. VUR was resolved in 10 units following STING.

High grade VUR is an important cause of persistent antenatally diagnosed hydronephrosis. Most of these are bilateral and high grade. Early STING is successful in eliminating VUR in this group of patients.

THE FATE OF THE DEFUNCTIONED BLADDER FOLLOWING SUPRAVESICAL URINARY DIVERSION

A. B. Adeyoju, T. Lynch, J. Corr, T. E. D. McDermott, R. Grainger, J. Thornhill, M. Butler.

Department of Urology, Meath Hospital, Heytesbury Street, Dublin 8.

Supravesical urinary diversion without cystectomy is not uncommon for a variety of disorders affecting the lower urinary tract. Little attention has been given to the fate of the native bladder left in situ.

This retrospective study (over 23 yr) set out to determine the nature and incidence of complications arising from the bladder in 35 patients who had supra-vesical urinary diversion without coricomitant cystectomy. Thirty-three cases had ileal loop diversion, 2 had cutaneous ureterostomies. There were a variety of indications and patients with malignant disease were excluded from this study. There were 15 males (mean age 41, range 13-72 yr) and 20 females (mean age 49 yr, range 15-81 yr). Mean length of follow-up was 5.2 yr (range 1-23 yr).

Bladder complications in 28% of patients (N=10) included; pyocystis (N=3, 1 mild, 2 severe), haemorrhage (N=3, 2 mild, 1

severe), and pain/spasm (N=7, 4 mild, 3 severe). No patient developed carcinoma during follow-up. Patients with interstitial cystitis or those with bladder outflow obstruction and/or vesical fistula appeared at higher risk of developing complications. Four patients required cystectomy to treat severe symptoms while the remaining 6 achieved symptom control without surgery.

Supravesical urinary diversion is successful in managing a variety of lower urinary tract problems but we now recommend consideration of primary cystectomy at the time of diversion in particular for patients with interstitial cystitis, bladder outflow obstruction or vesical fistulae.

ISCHAEMIC PRECONDITIONING PROTECTS AGAINST RENAL ISCHAEMIA REPERFUSION INJURY

D. Keegan, H. Abdih, K. Stokes,. C. J. Kelly, H. P. Redmond, D. Bouchier-Hayes.

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

Renal ischaemia and reperfusion may result in significant renal impairment or acute renal failure. In addition, ischaemia- reperfusion (IR) injury to the kidney has been implicated in increasing both acute and chronic allograft rejection, lschaemic preconditioning .is the process by which transient ischaemia induces tolerance of the stressed ceils to subsequent episodes of oxidative stress eg. IR. The present study investigates the protect ive effect of t rans ient ischaemia ( ischaemic preconditioning) on renal revascularization injury. A left nephrectomy Sprague-Dawley rat model was used after which the rats were randomised into three groups: control; IR; IR +ischaemic preconditioning {PrelR). Preliminary experiments demonstrated that optimal ischaemic preconditioning was achieved by clamping the right renal pedicle for two three minute periods with a three minute reperfusion lapse between them. The renal vessels were then unclamped and the animals allowed to recover for four hr. This was followed by the actual IR insult consisting of 45 min of ischaemia and 2 hr of reperfusion. At the end of the two hour reperfusion period the animals were sacrificed and kidney oedema was assessed using the weight difference between left and right kidneys. Myeloperoxidase activity was used as an indicator of renal neutrophil (PMN) influx. Renal function was evaluated by measuring serum creatinine, urea and potassium levels and urine output.

Control IR PrelR

Myeloperoxidase (units/g) 0.6-t-0.15 1.0"20.07" 0.5_+0.075 % weightchange -1.0• 15.1• -1.1+3.045 Urine output (ml) 0.9• 0 .8+0 .19 1.3+0.20 Urea (mM) 9.3• 11.8+0.79" 9.5•163 Creatinine (JAM) 81.3• 107.3• 88.6•163 Potassium (mM) 4.8+_0.45 7.1• 5.5_+0.13s * and & = IR Vs Control; s and $ = IR Vs PreIR; * and s _< 0.05; & and $: P g 0.005. Mean• Analysis by unpaired Students t-test

lschaemia-reperfusion caused a significant renal functional impairment reflected by an increase in serum levels of urea, creatinine, and potassi/am as well as marked organ oedema and increase in neutrophil infiltration. Ischaemic preconditioning prevented the IR induced impairment in renal function and organ oedema. This was associated with a decrease in neutrophil infiltration. Thus, we have shown for the first time that ischaemic preconditioning protects against renal IR injury possibly by preventing neutrophil mediated tissue injury.

INDICATIONS FOR INVESTIGATION IN BLUNT RENAL TRAUMA

N. Hegarty, J. Calleary, M. Corcoran, H. Bred• *E McCarthy. Department of Urology, *Department of Radiology UCHG,

Galway.

The decision on which patients presenting with blunt renal trauma to investigate continues to be a source of debate. Whereas patients presenting with blunt renal trauma and frank haematuria are generally fully investigated, many suggest that patients presenting with blunt renal trauma, microscopic haematuria and without becoming hypotensive should be treated conservatively without the need for radiological investigation.

In the four year period Jan 1991 - Dec 1994, 44 patients with blunt renal trauma and no other associated injury were admitted under the care of the Urology Service, UCHG. Of these 40 (90.9%) were male and 4 (9.1%) were female, with a mean age of 27 yr (range 6 - 86 yr). The injuries were sports-related in 50% of cases, the remainder being secondary to domestic, industrial or road traffic accidents. The majority presented with haematuria and/or pain and the renal injury when present was identified in all patients. On clinical, laboratory and radiological assessment, the injuries were classified as minor in 86.4% of patients or major in 13.6%. In 12 patients (27.17%) a pre- existing renal abnormality was detected; in 8 (18%) of whom it was considered significant, however there was no relation between the extent of renal injury and the pre-exist ing abnormality.

It would appear that a substantial number of patients admitted with blunt renal trauma will be found to have a pre-existing renal abnormality, and this would justify full radiological investigation of patients even when the trauma history and clinical examination might suggest trivial injury.

23

PERCUTANEOUS KIRSCHNER WIRE FIXATION OF COLLES FRACTURES: PROSPECTIVE STUDY OF A

NEW VARIATION USING 3 K-WIRES

A. H. Mirza, M. O'Sullivan. Merlin Park Regional Hospital, Galway.

35 consecutive patients with a displaced Colles fracture were treated with closed reduction and percutaneous fixation using a technique of fixation with three Kirchner wires.

First K-wire was inserted dorsal to the volar, intrafocally, through the fracture site and angulated 45 ~ to prevent dorsal displacement and angulation. Real• the importance of brachioradialis as a significant deforming force, two K-wires were inserted from radial to ulnar side near the tip of radial styloid process, catching hold of the fragments securely, thus preventing radial as well as rotational malalignment during fracture union, Wires were left superficial to skin to facilitate removal in outpatients after six weeks.

Radiological assessment was carried out by measuring the parameters of dorsal/volar tilt, radial inclination and radial shortening on initial, immediate post-op., and late radiographs at the time of review. Severity of fracture on initial radiograph was assessed using the grading system outlined by Lidstrom and Frykman for classifying results.

72% of fractures had severe deformity (Grade 4) and the remaining 28% had moderate deformity (Grade 3) on admission. 71% of fractures were intra-articular and 29% extra-articular.

At the time of review 70% of radiographs showed no, or

insignificant, deformity (Grade 1), 21% slight deformity (Grade 2) and 9% - moderate deformity (Grade 3).

Clinical end results were evaluated using the Demerit point system desc r ibed by Gar t land and Werley, modif ied by Sarmiento.

88% of patients achieved excellent or good results: (excellent 51%; good 37%) while the remaining 12% achieved fair results. Two patients had superficial skin tract infection, settled by a course of antibiotics.

The study showed that additional fixation improves both rad io log ica l and c l in ica l results in Col les fractures. We recommend this technique for displaced extra-articular, as well as the majority of intra-articular fractures, particularly in the elderly.

SPINAL INJURY IN SPORTS: REVIEW AND RECOMMENDATIONS

J. Sparkes, P. Neary, E McManus, M. Walsh. Department of Orthopaedic Surgery, Mater Misericordiae

Hospital, Dublin 7.

The spinal unit in the Mater Hospital is a specialised tertiary referral unit treating acute spinal injuries. We-reviewed the incidence aetiology and treatment of spinal injuries sustained through sporting activities in the past 2 years.

There were 297 patients admitted to the spinal unit, of these 22 were sports related injuries (7.5%). There were 14 males and 8 females. The mean age was 33 yr, (range 18 - 67). The mean inpatient stay was 15 days (range 2 - 87). The sports involved included equestrian (12), rugby (3),diving (2), parachuting (1), gymnastics (1), flying (1), volleyball ~ ) and gaelic football (1). The majority of equestrian injuries were experienced riders. Sixteen patients had vertebral fractures, four had multiple level fractures and four had concomitant non spinal injuries. Ten patients had significant neurological deficits. Si te of injury included cervical (11), thoracic (5), lumbar (6). Eight patients required surgical stablisation of their fractures, minerva collar applied in four, plaster jacket in five and cervical collar in five patients. There was no mortality in this series.

The high prevalence of equestrian related injuries in this series emphasises the necessity of awareness of the possibility of spinal injury in accidents. Those involved should be informed of the risks and in event of accident implementation of basic precautions to protect the spine should be employed.

IMPROVED RESULTS WITH OPEN WOUND MANAGEMENT FOR HIGH-PRESSURE INJECTION

INJURIES OF THE HAND

S. T. O'Sullivan, E. Beausang, J. M. O'Donoghue, M. O'Shaughnessy, T. P. F. O'Connor.

Department of Plastic Surgery, Cork University Hospital.

High-pressure injection injury to the hand is a serious and potentially limb-threatening condition. Injected agents such as grease, paint and paint thinner, hydraulic oil, diesel oil and gasoline are very toxic to subcutaneous tissues and injection of these substances results in an intense inflammatory reaction. Treatment of these injuries consists of immediate exploration and debridement, with meticulous removal of all the injected agent. Our unit has employed a pol icy of early aggressive debridement with open-wound management and delayed closure

for these injuries. We present the results of such a management policy in 13 cases of high-pressure injection injury.

Between 1988 and 1995, thirteen patients presented following high-pressure injection injuries of the hand or upper limb. Eleven patients were male. Patient age ranged from 16 to 64 yr, with a mean age of 38.5 yr. The dominant hand was involved in five cases and the index finger was most commonly involved (.6 cases). Substances injected included paint or paint thinner (4), oil (3), grease (2), and water, sodium azide solution, butane gas and oil-based vaccine (1 each).

In all cases, management involved early decompression with wide surgical debridement and open-wound management. Pulse- je t lavage was routinely ' employed along with meticulous dissection to remove all the irritant material. Twelve cases required serial surgical debridement. Primary closure was attempted in one case but subsequently required secondary procedures. In three cases delayed primary closure was possible at the second procedure. Salvage of the affected digit was possible in 84.6% of Cases. Terminalisation of index finger was required in one case, and ray amputation of index finger was required in another. One patient lost approximately 50% of pulp substance of thumb following multiple dcbridements. Full finger and hand function was documented in eight cases on follow-up 61.5%. Three patients complained of finger stiffness, including the patient with pulp loss, one of whom required secondary scar release and skin grafting. Both patients who required amputation and the patient with pulp loss complained of mild to moderate severity cold and touch hypersensitivity. All patients in this series were able to resume their normal occupations within 8 months of injury. We recommend early, aggressive management of such injuries employing an open wound management policy which we believe results in improved outcome.

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INFORMED CONSENT - FROM WHOM?

D. Mulcahy, D. McCormack, K. Cunningham, N. Cassidy, M. Walsh.

Department of Orthopaedic Surgery, Mater Hospital, Eccles Street, Dublin 7.

There are two prerequisites to obtaining legally safe informed consent. The first is that the pat ient has a "subs tan t ia l understanding" of the proposed procedure, the second is that the doctor obtaining the informed consent has sufficient knowledge to explain the nature of the procedure to the patient. Junior doctors often lack sufficient technical or specialist training to fully inform their patients and thus meet legal requirements.

A multiple choice type questionnaire was distributed to final year medical students and house officers (some of whom had completed a rotat ion through the or thopaedic unit). The questions were based on the type of questions that a patient might ask prior to signing a consent form, e.g. Will I be in plaster? How long?.What complications might I have? etc.

There was a substantial difference in the scores obtained by each of the three groups. House officers scored higher than medical students witfi the best scores obtained by those who had worked in the orthopaedic unit. There remained however, s igni f icant misunders tand ing of cer ta in p rocedures and conditions. The implications of this are that the onus falls even more on specialists to ensure that their patients receive a more detailed explanation of the proposed intervention.

A NEW TENORRHAPHY USING BUTYL-2- CYANOACRYLATE ADHESIVE IN COMBINATION WITH A

6/0 POLYGLYCONATE CROSSWEAVE SUTURE: AN IN VITRO ANALYSIS OF TENSILE STRENGTH AND GAP

FORMATION

K. J. Cronin, M. Shafii, E X. Darmanin, T. Sullivan, J. McCann. Department of Plastic, Reconstructive & Hand Surgery,

University College Hospital, Galway.

Early mobilisation of repaired zone II flexor tendon injuries h a s led to improved post=operative functional outcome. The mobilisation process must by its very nature place forces on an immature repair which can lead to the complications of gap formation at the repair site and in some cases to frank disruption of the repair. The ideal tenorrhaphy would yield a repair that w a s strong enough to tolerate early mobilisation without gapping or rupture and which would glide easily within the flexor sheath. We tes ted a new t eno r rhaphy compr i sed of Buty l -2 - cyanoacrylate adhesive in combination with a 6/0 polyglyconate epitendinal crossweave suture on freshly harvested Flexor Digitorum Profundus sheep tendons and compared the results to other tendon repairs. The results were as follows:

Mod. Kessler (4/0) Mod. Kessler (4/0) with 6/0 over+over Mod. Kessler (4/0) with 6/0 cross- 28.9 weave Butyl-2- cyanoacrylate 35.8 a l o n e

6/0 cross-weave 26:3 a l o n e

Butyl-2- cyanoacrylate and 44.0 6/0 cross-weave

Mean Load to Mean Load to lmm Gap (N) Repair Failure (N)

3.73 34.7 24.8 38.8

65.0

35.8

54.3

72.5

The new tenorrhaphy was significantly more resistant to gap formation (44.0 N vs. 24:8 N; p<0.01) and had a significantly higher tensile strength (72 N vs. 38.8 N; p<0.01) than the commonly employed Kessler-Mason-Allen technique. While we acknowledge that this is purely an in vitro study we feel that adhesives may have a role in tendon repair in the future.

AUDIT OF PATIENT TRANSPORTATION TIMES TO A REGIONAL ORTHOPAEDIC UNIT

K. Mulhall, M. Murphy, M. O'Sullivan. Department of Orthopaedics, Merlin Park Hospital, Galway.

We present an audit of the transportation times of 102 consecutive acute referrals from associated peripheral hospitals to the regional orthopaedic unit at Merlin Park Hospital.

Merlin Park Hospital is the orthopaedic referral centre for Counties Galway, Mayo and Roscommon (Total Pop.: 342,000). The hospitals serving this area and their respective distances from Merlin Park Hospital are: UCHG (3 miles), Castlebar General Hospital (50 miles), Portiuncula General Hospital, Ballinasloe (40 miles) and Roscommon General Hospital (50 miles).

Merl in Park Hospi ta l received a total of 2,041 acute orthopaedic admissions in 1994. The various means of transport available to patients are ambulance, own car and boat/helicopter from the west coast islands.

Three separate aspects of transportation time were analysed,

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i.e. primary transportation time (from site of injury to local hospital), time spent in first hospital and secondary transport to M.P.H. The mean overall transportation time (i.e. time from injury to admission at M.P.H.) for those cases within two standard deviat ions from the mean for the various hospitals were: Castlebar 14 hr 42 min, UCHG 7 hr 29 min, Roscommon 17 hr 21 rain and Ballinasloe 9 hr 19 min.

A great variety in the range of transportation times w a s

discovered which did not always correlate well with severity of injury or need for prompt definitive orthopaedic treatment.

Recognition and subsequent rapid safe transportation of patients suffering from serious orthopaedic injuries is necessary if preventable complications are to be consistently avoided.

CLOSED INTRA-MEDULLARY NAILINGS FOR (IMPENDING) FRACTURES OF METASTATIC DISEASE

OF LONG BONES

A. Purl, K. Mulhall, M. O'Sullivan. Department of Orthopaedics, Merlin Park Hospital, Galway.

We present a retrospective study of closed intramedullary nailings for pathologic (Impending) fractures of long bones at Merlin Park Hospital from July '92 - December '94. A total of 88 intramedullary nailings were performed in this period, femoral - 36, tibial - 34, humeral - 17 and ulna - 1. Trauma, expectedly, accounted for the majority of these cases.

We reviewed 19 nailings in 13 patients (female - 11 and male - 2) with metastatic long bone disease (approximately 20.9% of all I.M. nails). Eight lesions were located in the femur, tibia - 5, humerus - 5 and ulna - I. Ten na i l ings were performed prophylactically (femoral - 4, tibial - 5 and ulna - 1) while the remaining nine were for pathological fractures (femoral - 4, humeral - 5). There was no mortality related to the surgical procedure.

All patients, except one (male, carcinoma prostate), had confirmed primary with some form of treatment (surgical, r ad io the rapy , chemothe rapy) i n s t i t u t ed by the t ime o f presentation.

Carcinoma breast was the predominant primary - 7 out o f 11 female patients. The two male patients had - carcinoma prostate and multiple myeloma.

Majority of patients (11 out of 13) had widespread metastasis confirmed in 5 by whole body bone scan and by plain films in the remaining. Only four patients are alive at present, Mean survival time for these patients was 28 weeks. (Range 4 weeks to 60 weeks).

Pain relief and satisfactory mobilisation was achieved in the majority of patients post nai l ing. No mechanical failure was observed. One patient developed D.V.T. post-operatively, which was successfully managed. Closed intramedullary nailing is a safe technique and ideal method for stabilizing the whole bone, especially with multiple metastasis in a single bone. Prophylactic nailing avoids the trauma of fracture in an already compromised patient with bony metastasis and has much to justify it as an early intervention.

TIBIAL PLATEAU FRACTURES: THE MATER EXPERIENCE

P. Neary, B. Dhaif, E McManus, M. Walsh. Department of Orthopaedic Surgery, Mater Misericordiae

Hospital, Dublin 7.

We retrospectively analysed all t ibial plateau fractures

admitted to the department of orthopaedic surgery at the Mater Misericordiae Hospital since 1992, highlighting the distribution of pattern type.

We analysed thirty-one fractures using the classification of Schatzker. There were 19 male and 12 female patients. The average age was 65 yr with a range of 20 to 93 yr. Type 1, 3 and 4 were the commonest types encountered. There was a significant difference in the pattern distribution compared to the Toronto experience (1968-1975) and the Swedish experience (1986). Unexpectedly the average age in type 1 which is a lateral condyle wedge fracture was over 60 yr. This is usually a fracture of a younger age group (in the thirties). The mechanism of injury was accidental fall in the majority of type 1. However, overall almost 50% of cases were due to road traffic accidents.

In conclusion, the patterns of tibial plateau fractures encounterd in this Irish series is markedly different from other previous series. We suspect that the mechanism of injury is a determining factor.

THE GROSSLY OBESE AND MINIMALLY INVASIVE SURGERY (MIS)

P. D. Carey, R. J. Delicata. University Hospital of Wales, University of Wales College

of Medicine, Cardiff, South Glamorgan.

A recent training manual from the Royal College of Surgeons (laparoscopic surgery basics skills) lists morbid obesity as a contraindication to MIS. However, morbidity associated with surgery, in the obese, such as wound infection and atelectasis is likely to be reduced with use of the minimal approach.

From April '94 to March '95 we prospectively performed laparoscopic cholecystectomy in a consecutive series of 17 (14 female: 3 male) patients with a body mass index (BMI*) greater than 35kg/mL All had symptomatic gallstones and one patient (female, aged 35, BMI = 39.5kg/m 2) required conversion owing to inability to establish a pneumoperitoneum.

N = 16 mean age (yr) mean (SD) BMI mean operative mean hospital (kg/m 2) time (rain) stay (day)

13F; 3M 50 38.2 + 2.7 97.6 (33) 2.7 (2.6) range (30-70) range (35.1-42.6) range (60-180) range (1-9)

Postoperative pulmonary complications occurred in 2/16 patients (13%). However, there were no thromboembolic events or wound infections.

Technical problems included inability to introduce the Veress needle subumbilically due to a pendulous abdomen: a problem circumvented by the use of a subcostal stab incision in 4/16 patients. We found the Hassan technique impossible when a thick layer of subcutaneous fat is present. Difficulty was also encountered in reaching the gal l -bladder with standard instruments (eg, scissors or dubois hook) introduced via roUtine port sites. Use of a different port, or in some instances an additional 5mm port conveniently located usually sufficed.

In conclusion, laparoscopic cholecystectomy is safe and has negligible complication and low conversion rate in the grossly obese patient. Technical problems which arise relate to the creation of the pneumoperitoneum and instrument placement and can be overcome by modification of standard techniques

* BMI = Weight (kg) Height 2 (m 2)

PREDICTING CONVERSION FROM LAPAROSCOPIC TO OPEN CHOLECYSTECTOMY E Abbasakoor, R. B. Stephens. St. James's Hospital, Dublin 8.

Laparoscopic cholecystectomy (L.C.) has replaced open cholecystectomy (O.C.) for most patients, but a significant minority require conversion to O.C. Predicting conversiotr would allow accurate counselling of patients and an early decision to move to, or select, open surgery thus enhancing patient care.

Three hundred and twenty-seven cholecystectomies were performed by one surgical firm overa 52 month period. The patients were evaluated to see if conversion could have been predicted. An initial open approach was adopted in 16 (4.9%). Of the 311 laparoscopic approaches 25 (8%) were opened. Those pre3enting with biliary colic alone had a 4.8% conversion rate (12/251). This compared with 21% (6/28) for those with acute cholecystitis and 15% (4/26) for those with acute pancreatitis. Half of six with obstructive jaundice from gallstones who had had successful ERCP for stone removal were also opened. Overall, males and patients over sixty years were twice as likely to be opened. Patients having a pre-operative ERCP and those admitted as emergencies had a four fold increase in conversion. The main reason being uncertain anatomy in the face of adhesion/inflammation 68% (17/25). Of the remainder; in 16% the gallbladder could not be removed despite good views (4/25) or because of complications (4/25). The morbidity was 5% of those undergoing laparoscopic surgery with one class 1 bile duct injury. One patient who required a laparotomy for a complication following laparoscopic surgery died from a stroke three months post-op.

Acute cholecystitis, acute pancreatitis, age, pre-operative ERCP, and sex are likely predictors of those who may need conversion to O.C.

LAPAROSCOPICALLY-ASSISTED COLECTOMY: IS THERE AN INDICATION?

A. J. Hussey, T. J. Boyle, B. Garrihy, D. J. Nolan, O. J. McAnena.

Department of Surgery, University College Hospital, Galway.

Laparoscopic surgery has appeal for the performance of intra- abdominal procedures with minimal invasion, however the range of its applicability requires further definition. The utilisation of laparoscopy in colorectal surgery has been limited by concern regarding the adequacy of 'clearance' of malignant disease with this technique. A series of patients in whom laparoscopic mobilisation of the colon was performed to assist colectomy, facilitating a'less invasive abdominal incision, is reported.

From July 1994, 17 pat ients have undergone a laparoscopically-assisted colectomy (LAC). (11 males, 6 females; mean age: 57.5 yr, range: 20-81 yr). The indication for surgery and the procedure performed are listed in the table. LAC was only undertaken for benign disease, or for low colorectal malignancies, with the 'cancer operation' being performed at open surgery. Operative technique was as follows:

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INDICATION

Ulcerative Colitis 3

Crohn's Disease 1 Polyposis Coli 1

RIF/Caecal mass (hislology benign) 1 Diverticular Disease/

Fistula 1 Diverticular Disease/

Occult rectal carcinoma 1 Rectosigmoid carcinoma 4 Rectal carcinoma 5

With the pat ient in

PROCEDURE

Proctocolectomy + Pouch 1 Proctocolectomy + Ileostomy 1 Panproctocolectomy 1 Subtotal Colectomy + Ileostomy 1 Subtotal Colectomy + Ileorectal Anastomosis 1

Right Hemicolectomy 1

Sigmoid Colectomy 1

Rectosigmoid Colectomy 1 Anterior Resection 9

+ End Colostomy 4 + Loop Colostomy 1 + Small bowel resection 1

the Lloyd-Davis posi t ion, pneumoperi toneum was induced in the standard fashion. Laparoscopic access was via 4 ports (10mm x 3; 5mm x 1). Depending on the procedure, the splenic flexure alone, or with the transverse colon and hepatic flexure, was mobilised laparoscopically. Thereafter, access was via a transverse lower abdominal incision for completion of the procedure.

In all patients, colonic mobi l i sa t ionwas successfully achieved at laparoscopy. There were no complications related to this procedure. In 1 patient, a major pelvic bleed occurred during the open dissection. Mean operating time (total) was 222.5 min (range: 180-380). Colonic mobi l i sa t ion was completed in less than 1 hr in all cases. 3 patients developed specific post-operative complications (anastomotic dehiscence: 1, Pouch sepsis / excision: 1, pelvic abscess: 1). Initial results indicate reduced post-operative respiratory complications, analgesia requirements and hospital stay in patients undergoing laparoscopically assisted colectomy.

LAPAROSCOPY IN CHILDREN WITH AMBIGUOUS GENITALIA

R. Kumar, R. Fitzgerald. Our Lady's Hospital for Sick Children, Crumlin, Dublin 12.

Laparoscopy in children has now become a well established and safe procedure. Ambiguous genitalia in children constitutes a rare but important group of disorders, where, precise cause must be established as quickly, as possible. This paper reviews our experience with laparoscopy in the management of children with complex ambiguous genitalia.

Between June 94 and April 95, four children presented with complex ambiguous genitalia. Laparoscopy, was done in all cases and biopsy of the gonads were done where indicated.

1. A case Of persistent mullerian duct syndrome. 2. A case of androgen insensitivity syndrome. 3. A case of mixed gonadal dysgenesis. 4. A case of true hermaphrodite. The role of laparoscopy in the management of these cases is

discussed. We propose a simple flow sheet for the progressive

investigation and management of these children. We conclude that laparoscopy is a simple and efficient alternative to open surgery in the management of ambiguous genitalia.

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LAPAROSCOPIC SPLENECTOMY USING THE LATERAL APPROACH - AN IMPROVED TECHNIQUE

J. Kollias, D. Watson, B. J. Coventry, P. Malycha. Royal Adelaide Hospital, Adelaide, South Australia.

Laparoscopic splenectomy is gaining popularity in the surgical treatment of ITP and other splenic disorders requiring splenectomy. Early reports described the procedure with the laparoscope placed through the an umbilical port and the patient in the supine or lithotomy position. We report an alternative approach to Iaparoscopic splenectomy using a lateral position and port placement.

Between May 1994 and January 1995, 8 patients underwent laparoscopic splenectomy for steroid dependent ITP in the lateral position. The median time taken to free the spleen of its attachments was 60 min and the median anaesthetic time was 100 rain. No patients required perioperative blood or platelet transfusion. One patient developed moderate subcutaneous bruising of the left flank which settled spontaneously. The median postoperative inpatient stay was 2 days.

The lateral position for laparoscopic splenectomy offers advantages over the conventional supine approach providing direct access to the splenic hilum as well as utilising gravity to assist retraction of adjacent organs.

PREDICTING LAPAROSCOPIC RESECTABILITY OF THE MALIGNANT COLON USING CT AND REAL TIME

ULTRASOUND (US) SCANNING

P. D. Carey, S. C. Ward, S. P. Y. Kwok, W.Y. Lau, J. W. Bergman, G. E. B. Hacking, C. Metreweli, A. K. C. Li.

Prince of Wales HospitaI, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.

An analysis of the initial 30 cases of laparoscopic assisted resection (LAC) for colorectal cancer (CRC) demonstrated a 33% conversion rate. Reasons stated included bulk of tumour, fixity to adjacent structures and adhesion of small bowel loops. Pre-operative workup did not include imaging of the primary lesion. Thus in attempting to improve case selection and reduce the operative conversion rate we prospectively studied 22 consecutive patients undergoing surgery for CRC.

There were 11 male and 11 female patients, aged 32-87 yr(4<60). Following colonoscopy and biopsy confirming malignancy, each patient underwent an US and CT (different radiologists) examination of abdomen and pelvis to assess tumour fixity, invasion of adjacent structures and mesentery, evidence of adhesions and presence of interposed small bowel loops. Each radiologist was blinded from the results of the alternative procedure. Twelve patients went on to have successful LAC, 6 were converted, 3 had laparoscopy only and 1 had a planned open procedure. Fo l lowing surgery a retrospective analysis of operative findings and stated reasons for conversion in relation to the radiological findings was performed.

When the lesion was Visualised, ultrasound (61%) proved a more reliable indicator of resectability. All lesions not visuaiised on USS (6) were resectable laparoscopically. CT provided useful information about the tumours when US was suboptimal. However, CT falsely identified tumour fixity in 5% and incorrectly identified resectability in 14%. Neither modality was reliable in assessing mesenteric invasion of vessel involvement.

It is tempting to assume that the lesions not seen on US are small and thus laparoscopically resectable. However, the results

of the study suggests that USS should be a routine part of the assessment of primary CRCs before LAC and that CT may be of use when US fails to visualise the lesion.

LAPAROSCOPIC INGUINAU HERNIA REPAIR

P. Madhavan, J. Donohoe, M. O'Donohue,W. A. Tanner, E B. V. Keane.

Meath/Adelaide Hospital, Dublin.

Laparoscopic inguinal hernioraphy is a recent addition to the minimal access surgery armamentarium. There is much debate about the advantages of a laparoscopic inguinal hernioraphy. The perceived advantages of a laparoscopic procedure include 1) less post operative pain, 2) earlier return to full activity, 3) easier repair of bilateral and recurrent hernias and 4) improved cosmesis.

In the period Jan. 1992 - December 1994 85 laparoscopic repairs were performed. Two could not be followed up and were excluded from the results. Thiry-one were done transperitoneally (TAPP) and 52 properitoneally (PP). Currently only properitoneal hernia repairs are being done. All patients were followed up by means of a postal questionnaire and if necessary by telephone.

Thir ty-one TAPP and 52 PP repairs were successfully performed. There were 5 conversions in total. The mean age was 49 (range 16-81). The average stay in hospital 3 days (range 1-6) There were 67 indirect and 15 direct hernias. Six of the hernias were recurrent. The mean operating time was 84 min. There were 10 complications and 6 hernias recurred. The mean time to get back to work was 2 weeks (TAPP) and 1 week (PP). 19% of the patients needed home analgesia. 71% of the TAPP repairs and 80.7% of the PP repairs were satisfied with the operation.

The technique of laparoscopic hernia repair will be performed with increasing frequency in the years to come. It is a technique that will evolve and be standardised. Properitoneal hernia repair in our opinion is the technique of choice for the laparoscopic approach and has comparable recurrence rates - 1.92%, in the short term, to the gold standard open repair. Long term follow up and a controlled trial will be needed to fu l ly evaluate this technique.

COMPARISON OF SYMPTOMS IN PATIENTS FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY VERSUS

CONTROLS

D. A. McNamara, M. K. O'Don0hoe, W. A. Tanner, F. B. V. Keane.

Department of Surgery, Meath/Adelaide Hospitals, Dublin 8.

The resolut ion o f symptoms fo l lowing laparoscopic cholecystectomy is frequently used as a measure of the success of the procedure. Similar abdominal symptoms often occur in the absence of biliary tract disease.

The abdominal symptoms of 212 patients fol lowing iaparoscopic cholecystectomy were compared with a control popula t ion of 62. All patients had had laparoscopic cholecystectomy between April 1989 and 1994. The control population presented to out-patients with non-gastrointestinal problems and were proven not to have gallstones by ultrasound examination.

A self-assessment form was posted to the patients. Post- operative patients were additionally requested to rate the success of their operation on a scale of 0 (failure) to 10 (complete success).

The mean age of the cases was 44.9 yr and of the controls 48.5 yr. There was no significant difference in the incidence of abdominal pain, bloating or nausea between the two groups. 19.3% of patients complained of frequent heartburn following laparoscopic cholecystectomy as compared to 3.2% of control patients (p=0.05). Furthermore 11.3% of post-operative patients complained of dysphagia versus 6.4% of the control group (p< 0.05).

120 (57.1%) patients judged their operation to be a complete success, while 9 (4.3%) were entirely dissatisfied. The mean success rating given was 8.5%.

Conclusions. Abdominal pain, bloating and nausea occur as frequently in the general population as in patients following laparoscopic cholecystectomy. Patients are more likely to suffer from heartburn and dysphagia following laparoscopic cholecystectomy than a normal population suggesting a l ink between cholecys tec tomy and lower oesophageal dysfunction.

28