The sensitivity of diagnostic serum amylase (>1000 iu/l) was assessed in 417 patients with acute pancreatitis as a r'esult of gall stones (258) The serum amylase activity rises sharply within the first 24 hours of an attack of acute pancreatitis and then declines steadily to normal levels over the following 5-7 days.' 2 Although a number of abdominal and extra-abdominal conditions can result in a high amylase activity,3 in patients with an appropriate clinical picture, the specificity and the sensitivity are well over 90%.45 With the generally available Phadebas method (normal range 70-300 iu/l), the level diagnostic of acute pancreatitis is considered to be > 1000-1200,' 56although an MRC study used a level >2000 iu/1.7 However, any value above the upper limit of normal is sometimes used by authors from Europe8 and North America.9 While it is generally stated that the amylase activity has no prognostic importance,' " precise details relating this to both aetiology and the severity of the attack are surprisingly lacking.A number of studies have challenged the primary diagnostic role of serum amylase, and a case has been made for the use of serum lipase instead,3 2 13 as it remains raised for a slightly longer period.'4 In a study in which computed tomography was used8 to assess the pancreas, a normal amylase activity (<160 iu/l) was seen in 19% of 352 attacks of acute pancreatitis;8 implicitly, a diagnostic level in this study was taken as any value above the upper limit of normal. No difference was found between patients with a normal serum amylase value and the subsequent clinical course. Most patients presented at least two days after the onset of the attack, 34% had a gall stone aetiology, and 29% had a clinically severe course.8 If the results in this study were applicable to Britain, these would strengthen the case for the routine use of lipase. The value of amylase determination as a diagnostic tool may be influenced by the prevalence of different aetiological factors, the proportion of severe attacks, and the time that patients are usually admitted to hospital after the onset ofan attack, and the present study was undertaken to assess these relations in two hospitals from the Midlands region of England.

This is the largest study to audit the impact of HIV/AIDS in general surgical practice in the UK retrospectively. Surgery for HIV patients can be safely conducted with a low complication rate for the diagnostic and anorectal procedures that comprise the vast majority of surgery in HIV/AIDS patients. Medical treatment for patients with HIV/AIDS has developed dramatically over the last two decades. In parallel, this has resulted in a heavy, new and varied workload for general surgeons, who have also had to adapt in order to deal with the challenging spectrum of this disease.

Summary The tumour vasculature is vital for the establishment, growth and metastasis of solid tumours. Its physiological properties limit the effectiveness of conventional anti-cancer strategies. Therapeutic approaches directed at the tumour vasculature are reviewed, suggesting the potential of anti-angiogenesis and the targeting of vascular proliferation antigens as cancer treatments.

Tetanus remains an important disease worldwide. In the United Kingdom, the elderly and intravenous drug users are at particular risk of acquiring clinical tetanus. Tetanus is associated with a high morbidity and mortality. Once the diagnosis of tetanus is suspected, intensive management is necessary. In this article we review the history, epidemiology, microbiology, clinical features, mode of transmission, pathogenesis, differential diagnosis, management, complications and prevention of this life threatening disease.

There are no objective data available on the relative strengths of inguinal hernia repairs. The aim of this randomized controlled study was to measure th force required to disrupt laparoscopic and open mesh repairs in a porcine model. Eleven pigs had inguinal hernia repair following randomization to an open mesh group (n = 5) or a transabdominal preperitoneal laparoscopic group (n = 6). Four weeks after operation the pigs were killed and the pelvic girdles were mounted in a test jig on a mechanical testing machine. The applied disruption forces were measured and recorded. Mean(s.d.) force required to disrupt the normal inguinal canal (n = 11) was 68.6(30.1) N with no difference between groups. The open mesh repair required 110.3(41.4) N and the laparoscopic mesh 220.0(95.2) N. Both open and laparoscopic mesh repairs were stronger than the normal side (P < 0.03). The laparoscopic mesh repair was stronger than the open mesh repair (P = 0.04). This model provides a standardized method for mechanically testing inguinal hernia repairs in pigs. It confirms that both open and laparoscopic mesh hernia repairs are stronger than the non-herniated normal side at 4 weeks after operation. Laparoscopic mesh repair is stronger than open mesh repair. The weakest points of the repairs correlate well with those identified in clinical reports.

Transcaecal ileal diversion has been used in association with primary resection and anastomosis to defunction an elective distal colonic anastomosis in 10 patients and to allow on-table colonic lavage with subsequent colonic defunction in 11 patients presenting as an emergency with distal colonic obstruction. Post-operative wound sepsis occurred in four patients (19%) with a clinical anastomotic leak in one patient. The median hospital stay was 14 (10-19) days. Transcaecal ileal diversion is simple to perform. It may facilitate primary resection and anastomosis in both the elective and emergency situation without increasing morbidity, mortality or the hospital stay.

Incidental findings of carcinoid tumours should be treated at initial surgery whilst elective surgery and further management should be undertaken in specialist centres by a multidisciplinary team. Asymptomatic patients have a better prognosis than those with symptoms. In advanced cases surgery combined with chemotherapy and liver resection is appropriate. The outlook for the majority of cases is good.

This review paper studies the reasons behind the delay in presentation of colorectal carcinoma. Such delay can occur at three different levels: delay on the part of the patient, delay by the general practitioner prior to patient referral and delay incurred at the hospital after patient referral. There is some evidence that patient delay has decreased in recent years; general practitioner delay is disputed by some authors, but there is considerable evidence that it exists. Hospital delay can be influenced by the general practitioner; there is evidence that it has increased in recent years and is likely to increase further with the current pressure on in-patient beds.