bluuebunny/crossref_metadata_2025 huggingface dataset:
Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer
Authors: Bartels H , Stein H J , Siewert J R
Published: March 2003

Background

Postoperative mortality after oesophagectomy for oesophageal cancer depends largely on the preoperative physiological status of the patient.

Methods

A composite scoring system to predict the risk of oesophagectomy based on objective preoperative parameters was developed based on a retrospective review of patients operated on and evaluated prospectively in two subsequent patient groups.

Results

An initial retrospective multivariate analysis of 432 patients who had oesophagectomy identified a compromised general status (P<0·001) and poor cardiac (P<0·001), hepatic (P<0·05) and respiratory (P<0·05) function as independent predictors of a fatal postoperative course. Based on the relative risk associated with the individual impaired organ functions, a composite risk score was established. A prospective study in 121 patients confirmed that this composite scoring system provides a better identification of high-risk patients than any of the individual parameters. Inclusion of the composite score into the process of patient selection and choice of the procedure resulted in a decrease of postoperative mortality rate from 9·4 per cent (52 of 553) to 1·6 per cent (four of 252) (P<0·001).

Conclusion

The risk of death after oesophagectomy for oesophageal cancer can be assessed objectively before surgery and quantified by a composite risk score. This score provides a useful tool for refining the criteria of patient selection for resection or the choice of procedure.
Early colorectal cancer: recognition, classification and treatment
Authors: Mainprize K S , Mortensen N J McC , Warren B F
Published: March 2003

Background

With the introduction of colorectal cancer screening and improvements in endoscopic technology, the recognition and management of early colorectal cancer assumes increasing importance.

Methods

A literature review was undertaken using Medline (National Library of Medicine, Washington DC, USA) searches of the headings early colonic, colorectal and rectal cancer, carcinoma and adenocarcinoma up to and including 1997. All relevant references were examined.

Results and conclusion

The diagnosis, classification and treatment options are described. Accurate diagnosis, preoperative and histopathological staging is crucial in the management of early colorectal cancer.
Adjuvant therapy for resectable rectal and colonic cancer
Authors: Heriot A G , Kumar D
Published: March 2003

Background

Recurrence of rectal and colonic carcinoma remains substantial despite apparently curative surgery. Adjuvant therapy has been applied to improve prognosis.

Methods

This review evaluates the use of adjuvant therapy in the management of resectable rectal and colonic carcinoma. It assesses critically the evidence supporting the addition of radiotherapy, chemotherapy, chemoradiotherapy and other treatment modalities to optimal surgery.

Results

In the case of rectal tumours, preoperative is more effective than postoperative radiotherapy; it can significantly reduce the incidence of local tumour recurrence. A number of trials have tended towards showing a survival advantage and a recent large randomized trial has shown a significant improvement in survival in patients with Dukes C tumours. Postoperative chemoradiotherapy is associated with a survival benefit and is standard therapy in the USA, although it is associated with increased toxicity. The effectiveness of preoperative chemoradiotherapy is currently being investigated. Postoperative fluorouracil-containing chemotherapy has resulted in a survival advantage in patients with Dukes C colonic tumours; such therapy may be administered either systemically or intraportally. The evidence of benefit with rectal tumours is more limited. Immunotherapy has been studied to a limited extent and the use of a tumour-directed monoclonal antibody has produced a survival advantage in a single trial.

Conclusion

Preoperative radiotherapy and postoperative chemoradiotherapy can produce a survival advantage in patients with Dukes C rectal carcinoma and reduce local recurrence. Postoperative fluorouracil-containing chemotherapy can produce a survival advantage in those with Dukes C colonic cancer. The optimal use and combination of adjuvant therapy remains uncertain.
Abdominal and dyspeptic symptoms in patients with peptic ulcer treated medically or surgically
Authors: Lindsetmo R-O , Johnsen R , Revhaug A
Published: March 2003

Background

Abdominal and dyspeptic complaints, which are prominent symptoms in patients with peptic ulceration, are commonly reported in the general population. There are few reports of follow-up study of peptic ulcer therapies in which clinical outcome has been compared with symptom reporting in community controls.

Methods

Three populations of patients with peptic ulcer disease (patients who had elective proximal gastric vagotomy (PGV), those having PGV for emergency indications and those receiving medical treatment with H2-receptor antagonists) were included in a questionnaire survey and compared with a group of randomly selected community controls.

Results

The vagotomized patients reported fewer abdominal complaints (P = 0·0003) and fewer dyspeptic complaints lasting for more than 1 week (P = 0·05) than those treated medically. There was no significant difference between vagotomized patients and community controls in the reporting of abdominal (P = 0·2) or dyspeptic (P = 0·9) complaints.

Conclusion

Taking abdominal complaints as the endpoint for former peptic ulcer treatment, surgical treatment with PGV seemed to be superior to therapy with H2-receptor antagonists and produced an almost identical level of complaints to that seen in the community population.
Efficacy of anterior, posterior and total fundoplication in an experimental model
Authors: Watson D I , Mathew G , Pike G K , Baigrie R J , Jamieson G G
Published: March 2003

Background

This study examined the effect of different types of laparoscopic fundoplication on an incompetent lower oesophageal sphincter to test their effectiveness at preventing gastro-oesophageal reflux in the early postoperative period.

Methods

An experimental porcine model was used. Initial oesophageal myotomy ensured an incompetent lower oesophageal sphincter with free reflux of ‘intragastric fluid’. Anterior, posterior or total fundoplication was then performed laparoscopically in 15 laboratory pigs (five in each group). Fundoplication competence and efficacy were determined 2 weeks after laparoscopic antireflux surgery by inflating the stomach with liquid through a gastrostomy cannula. Some animals were also studied at 4 and 6 weeks. Lower oesophageal sphincter pressure was determined using a water-perfused oesophageal manometry catheter incorporating a Dent sleeve.

Results

All three types of fundoplication produced similar increases in postoperative resting lower oesophageal sphincter pressure and restored adequate competence to the gastro-oesophageal junction.

Conclusion

All three variants of laparoscopic fundoplication restore gastro-oesophageal competence in the early postoperative period.
Metabolic substrate utilization differs in ileal faecal and urinary reservoirs
Authors: Duffy M M , Regan M C , Harrington M G , Fitzpatrick J M , O'Connell P R
Published: March 2003

Background

Construction of an ileal faecal or urinary reservoir profoundly alters ileal luminal ecology and availability of mucosal metabolic substrates. The aims of this study were to measure mucosal metabolic flux of butyrate and glutamine in histologically normal (control) ileum and to determine the effect of reservoir construction on metabolic fluxes in patients with ileal pouch–anal anastomosis and ileocystoplasty.

Methods

Endoscopic biopsy samples were obtained from normal ileum (n = 10), ileum of patients with ulcerative colitis (n = 10), ileal pouch–anal anastomosis (n = 7), ileocystoplasty (n = 7) and ileal conduit (n = 7). Using a closed microculture technique, biopsy utilization of 14C-labelled butyrate and glutamine was measured as [14C]carbon dioxide production. Biopsy DNA content was measured and [14C]carbon dioxide evolution expressed as picomoles [14C]carbon dioxide per microgram DNA per hour.

Results

The metabolic flux of both butyrate and glutamine was reduced in ileal pouch mucosa compared with that of ileal mucosa in patients with ulcerative colitis. In contrast, the metabolic flux of buyrate alone was reduced in ileal mucosa from ileocystoplasty and ileal conduit compared with that in normal ileal mucosa, while the metabolic flux of glutamine remained unchanged.

Conclusion

Ileal mucosal metabolic fluxes measured in vitro are altered by changing luminal ecology in vivo. These changes may affect the health and mucosal integrity of ileum used to construct these reservoirs.
Ward versus intensive care management of high-risk surgical patients
Authors: Curran J E , Grounds R M
Published: March 2003

Background

Selection of high-risk surgical patients for preoperative and perioperative admission to an intensive therapy unit (ITU) for enhancement of oxygen delivery may reduce postoperative morbidity and mortality rates. Limited resources may prevent admission of all suitable patients. This audit study examined whether it is possible to select patients most at risk and thus reduce surgical morbidity and mortality rates when ITU services are limited.

Methods

This was a retrospective audit comparing the actual outcomes of complications and death with predicted outcomes using the POSSUM socre (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) for 101 general surgical and vascular patients who would have fulfilled previously suggested criteria for preoperative admission to the ITU. Main outcome measures were the number of preoperative ITU admission criteria, American Society of Anesthesiologists (ASA) and POSSUM scores, preoperative oxygen delivery values, intravenous fluid therapy, length of ITU stay, length of hospital stay, postoperative complications and 28-day mortality.

Results

Medical staff allocated patients appropriately. There was a lower mortality rate than predicted from individual POSSUM scores. Patients who were admitted to the ITU before operation had the highest ASA scores, admission criteria and POSSUM scores; they also had significantly lower mortality and morbidity rates than predicted by the POSSUM scoring system.

Conclusion

Patients with the greatest reduction in mortality and morbidity rates were admitted to the ITU before operation and had cardiovascular physiology ‘optimized’ before surgery.
Recent advances in the surgical treatment of faecal incontinence
Authors: Vaizey C J , Kamm M A , Nicholls R J
Published: March 2003

Background

Improved imaging and refined technology have led to a number of recent advances in the surgical treatment of faecal incontinence.

Methods

Original articles, identified using a computer database (Medline), and recently published abstracts of meetings were selected on the basis of greatest clinical relevance; these were reviewed.

Results

Ultrasonographic characterization has led to improved therapeutic strategies. Simple structural damage is readily identified and external sphincter repair results in a good outcome for a majority of patients. For more complex structural damage, or for the newly recognized primary internal sphincter degeneration, alternative treatment strategies are emerging. The electrically stimulated gracilis neosphincter and the artificial bowel sphincter offer good results. The latter may be a more simple operation. For structurally intact but weak sphincters, sacral nerve stimulation is a promising therapy. Other therapies, such as antegrade irrigation, may be helpful for patients with neurological disorders.

Conclusion

Better imaging, refined classification and new operations are leading to improved surgical techniques for faecal incontinence.
Heat shock protein 72 production in liver tissue after experimental total hepatic inflow occlusion
Authors: Dai C-L , Kume M , Yamamoto Y , Yamagami K , Yamamoto H , Nakayama H , Ozaki N , Shapiro A M J , Yamamoto M , Yamaoka Y
Published: March 2003

Background

The pathogenesis of hepatic ischaemia–reperfusion injury is incompletely understood. This study examined the effects of reperfusion with congested portal blood on ischaemia–reperfusion injury of the liver following Pringle's manoeuvre, as monitored by heat shock protein (HSP) 72 production in rat liver tissue.

Methods

Rats were randomized to three groups. In group 1 hepatic ischaemia with portal congestion was induced by Pringle's manoeuvre for 15 min; in group 2 Pringle's manoeuvre was applied for 15 min with an extracorporeal portasystemic shunt; and in group 3 the superior mesenteric vein was occluded for 15 min. The production of HSP72 in liver tissue was measured by Western blotting at 48 h after each intervention. Conventional parameters for hepatic function were examined at 1, 3 and 48 h after reperfusion.

Results

There was marked HSP72 expression in group 1, but not in group 2 or 3, showing that a combination of liver ischaemia and reperfusion of congested portal blood is required to induce strong expression of HSP72 in the tissue. On the other hand, biochemical parameters were raised equally in both groups 1 and 2, reflecting a similar degree of ischaemic hepatocyte injury.

Conclusion

The additional stress impact of temporary portal occlusion upon ischaemia–reperfusion injury of the liver was clearly detected by in situ hepatic HSP72 production in this study.
Outcome after ‘curative’ surgery for carcinoma of the lower third of the rectum
Authors: Topal B , Penninckx F , Kaufman L , Filez L , Aerts R , Ectors N , Kerremans R
Published: March 2003

Background

Controversy exists about the optimal surgical resection for lower third rectal carcinoma. The aim of this retrospective study was to analyse whether the type of surgery is a significant predictor of outcome after curative surgery alone.

Methods

Eighty-two consecutive patients underwent abdominoperineal rectum excision (APRE, 41 patients) or sphincter-saving operation (SSO, 41 patients) for adenocarcinoma at 3·5–7·5 cm from the anal margin. Cox proportional hazards technique with univariate and corrected (multivariate) analyses and the Kaplan–Meier life-table method were used to evaluate the data.

Results

Tumour wall penetration and lymph node involvement, but not the tumour level or the type of surgery, were found to be significant predictors of outcome. The local recurrence rate at 1, 2 and 5 years was 10, 22 and 26 per cent respectively after APRE, and 5, 13 and 21 per cent after SSO. The disease-free survival rate at 1, 2 and 5 years was 85, 67 and 58 per cent respectively after APRE, and 88, 78 and 62 per cent after SSO.

Conclusion

Tumour-related factors are significant predictors of outcome. The type of surgery (APRE or SSO) did not seem to be a significant variable in this non-randomized study.
Polymers that reduce intraperitoneal adhesion formation
Authors: Falk K , Holmdahl L , Halvarsson M , Larsson K , Lindman B , Bengmark S
Published: March 2003

Background

Viscous macromolecules and phospholipids have been shown to reduce postoperative adhesion formation. The ideal agent, or combination of agents, still remains to be identified.

Methods

The effect of hydrophobically modified ethyl (hydroxyethyl) cellulose (HM-EHEC) and polyquarternium-24 (LM-200), two cellulose-derived polymers, and of sphingomyelin, was examined in an animal model. Adhesions were induced in the parietal peritoneum in a standardized manner and quantity, and the morphology of adhesion formation was evaluated after 7 days.

Results

A significant reduction in adhesion formation was seen in animals receiving LM-200 (P = 0·013) and HM-EHEC (P = 0·012) as a short-term treatment compared with controls given saline, but not in animals receiving sphingomyelin (P = 0·733). Additional effects were seen in the animals receiving LM-200 as a prolonged treatment (P < 0·001) compared with controls. There was no difference in the magnitude of the inflammatory response between the groups.

Conclusion

These results suggest that hydrophobically modified polymers are efficient in reducing adhesions, without affecting the inflammatory response.
Bioflavonoid quercetin scavenges superoxide and increases nitric oxide concentration in ischaemia–reperfusion injury: an experimental study
Authors: Huk I , Brovkovych V , Nanobash Vili J , Weigel G , Neumayer Ch , Partyka L , Patton S , Malinski T
Published: March 2003

Background

l-Arginine-depleted environments accompanying ischaemia–reperfusion enhance superoxide production, leading to the formation of reactive oxygen species and a concomitant reduction in basal nitric oxide levels. The bioflavonoid quercetin may prevent these undesirable effects by scavenging superoxide.

Methods

Untreated rabbits were compared with those infused with quercetin (5 mg/kg for 2 min) during hindlimb ischaemia (2·5 h) and reperfusion (2 h). In both groups, nitric oxide concentration was measured (porphyrinic microsensor) in the femoral artery wall. Microvasculature changes (morphometry) and superoxide concentration (chemiluminescence) were measured intermittently in biopsies.

Results

Approximately 6 min into the period of ischaemia a rapid increase in nitric oxide level from a mean(s.e.m.) basal level of 50(20) to 450(30) nmol/l was observed. In untreated animals, nitric oxide concentration dropped to an undetectable level (less than 1 nmol/l) during reperfusion. In quercetin-treated animals, the decrease in nitric oxide concentration was slower, such that substantial amounts (60(20) nmol/l) accumulated during reperfusion. In biopsies after ischaemia–reperfusion maximal calcium ionophore A23187-stimulated nitric oxide concentration increased (25-30 per cent) in the presence of quercetin, while the superoxide concentration decreased.

Conclusion

Quercetin treatment mollified ischaemia–reperfusion injury to skeletal muscle by scavenging destructive superoxide and enhancing the cytoprotective nitric oxide concentration.
In vivo pressure profiles of thigh-length graduated compression stockings
Authors: Wildin C J , Hui A C W , Esler C N A , Gregg P J
Published: March 2003

Background

The aim of the study was to assess whether the appropriate pressure profile is generated by thigh-length graduated compression stockings in human subjects. The effect of leg posture on the pressure profile was assessed in three commonly used brands of graduated compression stockings.

Methods

The study involved 17 human volunteers from the Department of Orthopaedic Surgery. Three different brands of stockings commonly recommended for the prevention of deep vein thrombosis were applied to each individual and the interface pressure profile under the stocking was measured. The effect of posture was assessed by comparing the interface pressure profile with the subject supine and in standing and sitting positions.

Results

Appropriate median pressure profiles were achieved only with the subject standing or supine. In the sitting position with the knee flexed, a high median interface pressure in excess of 28 mmHg was generated at the popliteal fossa. Overall, inconsistent performance was found in all three brands of stockings; fewer than 30 per cent of the pressure readings fell within 20 per cent of the ‘ideal’. Reversed pressure profile was observed in over 70 per cent of subjects.

Conclusion

Thigh-length graduated compression stockings may be most effective in bedridden patients. Knee-length stockings may be more suitable for the prevention of deep vein thrombosis in ambulant patients.
Subparietal hepaticojejunal access loop for the long-term management of intrahepatic stones
Authors: Beckingham I J , Krige J E J , Beningfield S J , Bornman P C , Terblanche J
Published: March 2003

Background

The subparietal hepaticojejunal biliary access loop is a recognized technique for the long-term management of primary intrahepatic stone disease. This paper assesses the results of this approach in a series of South African patients.

Methods

Between 1985 and 1997, 21 patients, of mean age 34 (range 24–66) years, underwent surgical extraction of intrahepatic stones and formation of an hepaticojejunal access loop. The access loop was subsequently used for further stone removal and stricture dilatation. Patients were followed prospectively (median 47 months) and details of the number and type of procedures performed, stone clearance rates, morbidity and subsequent outcome were recorded.

Results

The distribution of intrahepatic stones was left lobe in 13 of 21 patients, right lobe in one and bilateral in seven. Six patients underwent additional left lobectomy at the initial operation because of associated atrophy of the left lobe. Following operation, stone removal and/or stricture dilatation was performed on 97 occasions (median 4 (range 0–24) procedures per patient). Complete stone clearance was achieved in 17 of 21 patients with partial clearance in the remaining four. There were no major complications and no deaths associated with the procedures.

Conclusion

The subparietal access loop permits long-term access to the intrahepatic ducts allowing removal of stones and dilatation of strictures with minimal patient discomfort and low morbidity.
Early results of a randomized trial of rifampicin-bonded Dacron grafts for extra-anatomic vascular reconstruction
Authors: Braithwaite B D , Davies B , Heather B P , Earnshaw J J
Published: March 2003

Background

The aim of this study was to determine whether the routine use of an antibiotic-bonded gelatin-coated Dacron graft could reduce the incidence of prosthetic graft infection. Extra-anatomic grafts were chosen for study as they have the highest risk of graft infection. This paper reports early results up to 1 month after surgery.

Methods

This multicentre study involved 14 vascular units in the UK. A total of 257 patients underwent extra-anatomic bypass. Patients were randomized to rifampicin bonding (1 mg/ml rifampicin soak for 15 min before graft insertion) or a control group. Routine three-dose antibiotic prophylaxis was administered to patients in both groups.

Results

There were 178 men and 79 women of median age 69 (range 43–92) years. Rifampicin-bonded (n=123) and control (n=134) groups were well matched for clinical details, risk factors and operative techniques. No side-effects were noted from rifampicin bonding. Only one patient (in the control group) developed a graft infection and this proved fatal. There were no significant differences between bonded and unbonded grafts in terms of perioperative mortality rate (9 and 5 per cent respectively), median hospital stay (10 days for both groups), total infective complications (15 and 21 per cent respectively) or need for postoperative antibiotics (13 and 18 per cent respectively).

Conclusion

Early results from this study have not identified any significant advantage in the routine use of rifampicin bonding, but the rate of graft infection was very low (0·4 per cent). Gelatin coating alone may provide protection against infection. Definitive recommendations about the role of antibiotic bonding cannot be made until longer follow-up becomes available.
Traumatic and septic shock alias post-trauma critical illness
Authors: Hardaway R M
Published: March 2003

Background

The mortality associated with septic shock, both in percentage of septic shock cases and total number of septic shock cases, has been increasing over the past several decades. This is despite major advances in diagnosis and treatment. The basic cause of traumatic and septic shock has been only partially elucidated.

Methods

Data sources include research papers on the subject of traumatic and septic shock from 1875 to the present. These papers numbered over 10 000, few of which are included in the reference list because many are duplicative or negative. Over 1000 articles were reviewed which documented the unsuccessful search for a treatment for septic shock based on the theory that septic shock is due to endotoxin and its secondarily induced host mediators. These references are available from the author.

Results and conclusion

The concept of a shock toxin in trauma and sepsis as promulgated during World War I is correct. This toxin is a thrombogenic aminophospholipid which occurs only on the inner layer of all cell membranes and is liberated by cell destruction. It causes disseminated intravascular coagulation which may obstruct the microcirculation of any or all organs, producing multiple organ failure by microclots. These microclots may be lysed by plasminogen activator and circulation to the organs restored.
Tube caecostomy to protect rectal anastomoses
Authors: Thomson W H F , White S , O'Leary D P
Published: March 2003

Background

Low rectal anastomoses are associated with a substantial risk of anastomotic leakage. Tube caecostomy offers a potentially simple method of anastomotic protection.

Methods

Some 226 patients undergoing restorative rectal resection with on-table colonic lavage and tube caecostomy over an 11-year period were reviewed. Endpoints selected included clinical anastomotic leakage, requirement for a subsequent formal stoma and complications of tube caecostomy.

Results

Overall, clinical anastomotic leakage occurred in 25 patients with a caecostomy (11·1 per cent). All leaks were noted among patients in whom caecostomy protection had been used after low anterior resection, giving a leak rate of 14·9 per cent (25 of 168) for this group of whom 17 (10·1 per cent) required reoperation and a formal stoma, and five (3·0 per cent) died. Complications of caecostomy or prolonged drainage after tube removal occurred in ten (4·4 per cent) and 15 (6·6 per cent) patients respectively. There were two cases of life-threatening invasive infection.

Conclusion

Tube caecostomy provides inadequate protection of rectal anastomoses; complications are common and may be life threatening.
Growth rates and risk of rupture of abdominal aortic aneurysms
Authors: Vardulaki K A , Prevost T C , Walker N M , Day N E , Wilmink A B M , Quick C R G , Ashton H A , Scott R A P
Published: March 2003

Background

Early identification of abdominal aortic aneurysms (AAAs) may reduce the risk of death from rupture by providing the opportunity for elective repair. Before a screening policy for AAA is implemented, the growth rates of AAAs and the accompanying risk of rupture without intervention should be established.

Methods

The growth rates of AAAs were calculated using longitudinal aneurysmal growth data from screening studies in Chichester and Huntingdon. Estimates of the growth rates of AAAs and the risks of rupture over time were made taking measurement error and individual variability into account.

Results

Growth rate estimates were found to vary by initial aortic diameter, with a more rapid growth seen in large aneurysms (50 mm or more). The rate of aneurysm growth did not differ with age or sex. The estimated risk of rupture of an AAA with an initial diameter of 45 mm did not exceed 20·5 per cent over 5 years. An AAA with an initial diameter of 30 mm has a 4·0 per cent or less chance of rupture over 5 years.

Conclusion

The study provides a more accurate assessment of the risk of aneurysm rupture without surgery and helps to define rescreening intervals for those with an enlarged aortic diameter.
Learning curve for oesophageal cancer surgery
Authors: Sutton D N , Wayman J , Griffin S M
Published: March 2003

Background

Surgical training and experience are frequently claimed to influence early and late outcome measures. The aim of this study was to examine any improvement in an individual surgeon's performance in one operation over a period of 7 years from initial appointment to date.

Methods

Patients undergoing Ivor Lewis subtotal oesophagectomy performed by a single surgeon between April 1990 and December 1996 were identified from a prospectively compiled oesophageal cancer database. Operating time (abdominal, thoracic and ‘one-lung time’), blood loss, transfusion requirements (intraoperative and total), extent of lymphadenectomy (number of lymph nodes sampled), intensive treatment unit (ITU) stay, hospital stay, postoperative morbidity and mortality, pathological stage, grade and survival were recorded.

Results

The records of 150 patients were identified for analysis. The cohort was split into five groups, each of 30 patients operated on consecutively. Each of the groups was comparable for age, sex, smoking history, preoperative haemoglobin and creatinine levels, weight loss, American Society of Anesthesiologists' grade, and histological stage and grade of disease. Analysis of the variables pertaining to operation revealed a significant improvement with time including reduced single-lung operating time (P = 0·01), reduced blood loss (P = 0·03), reduced transfusion requirement (P < 0·0001), reduced ITU stay (P < 0·0001), reduced inpatient stay (P < 0·0001) and an increased yield of lymph nodes (P < 0·0001).

Conclusion

This study showed a continuing improvement in a surgeon's performance over a 7-year period. With the current trend to shorter training periods there is a case for continuing supervision of the ‘fully trained’ surgeon within highly specialist units.
Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery
Authors: Salvadori B , Marubini E , Miceli R , Conti A R , Cusumano F , Andreola S , Zucali R , Veronesi U
Published: March 2003

Background

This study aimed to analyse the possibility of surgical rescue of intrabreast tumour recurrence (IBTR) following conservative operation for breast cancer, i.e. quadrantectomy, axillary dissection and radiotherapy.

Methods

Of 2544 patients treated with this approach, 209 presented with an IBTR as the first and only sign of relapse. Some 197 patients were considered suitable for further surgery; 12 were inoperable. Six patients declined operation.

Results

Reoperative surgery was total mastectomy in 134 patients (70 per cent) and further local resection in 57 (30 per cent). Median follow-up after second surgery was 73 (range 1–192) months. The overall survival probability at 60 months was 70 per cent after mastectomy and 85 per cent following further local excision. There was no difference in disease-free survival between the two operative groups. Second IBTR was more common at 5 years in the re-excision group (19 versus 4 per cent).

Conclusion

Since the type of surgery did not seem to affect survival, breast conservation can be considered in selected patients with IBTR.
No survival benefit from combined pancreaticosplenectomy and total gastrectomy for gastric cancer
Authors: Kitamura K , Nishida S , Ichikawa D , Taniguchi H , Hagiwara A , Yamaguchi T , Sawai K
Published: March 2003

Background

It remains unknown whether extended surgery improves the survival rate of patients with gastric cancer. This study was a review of combined pancreaticosplenectomy with total gastrectomy for gastric cancer.

Methods

The clinicopathological details of 190 patients who underwent combined pancreaticosplenectomy with total gastrectomy between 1969 and 1996 were compared retrospectively with those of 206 patients who underwent total gastrectomy with splenectomy alone.

Results

There was no statistical difference in the survival rate when pancreaticosplenectomy was added to total gastrectomy. The mortality rate was similar, but the morbidity rate was higher in patients who had pancreaticosplenectomy. Six patients who had direct pancreatic invasion and two thought to have involved lymph nodes along the splenic artery survived for more than 5 years after operation. In the latter group, the metastatic lymph nodes along the splenic artery could have been resected without pancreatectomy.

Conclusion

Since a combined pancreaticosplenectomy adds no survival advantage to total gastrectomy for gastric cancer, this procedure should no longer be regarded as routine.
Evaluation of a protocol for the non-operative management of perforated peptic ulcer
Authors: Marshall C , Ramaswamy P , Bergin F G , Rosenberg I L , Leaper D J
Published: March 2003

Background

The non-operative management of perforated peptic ulcer has previously been shown to be both safe and effective although it remains controversial. A protocol for non-operative management was set up in this hospital in 1989. Adherence to the guidelines in the protocol has been audited over a 6-year period with a review of outcome.

Methods

The case-notes of patients with a diagnosis of perforated peptic ulcer were reviewed. Twelve guidelines from the protocol were selected for evaluation of compliance to the protocol.

Results

Forty-nine patients underwent non-operative treatment initially. Eight patients failed to respond and underwent operation. Complications included abscess formation (seven patients), renal failure (one), gastric ileus (one), chest infection (two), and cardiac failure and stroke (one). Four deaths occurred in this group. Adherence to certain protocol guidelines was poor, notably those concerning prevention of thromboembolism, use of antibiotics, use of contrast examination to confirm the diagnosis and referral for follow-up endoscopy. Two gastric cancers were detected on subsequent endoscopy.

Conclusion

This experience demonstrates that non-operative treatment can be used successfully in a general hospital. Adherence to protocol guidelines was found to be variable and the protocol has therefore been simplified. This study highlights the need for an accurate diagnosis and the importance of follow-up endoscopy.
Intraoperative abdominal ultrasonography
Authors: Luck A J , Maddern G J
Published: March 2003

Background

Ultrasonography during abdominal surgery has been reported since the 1960s, but its use did not become widespread until the recent availability of high-frequency, high-resolution transducers. This review discusses the application of intraoperative ultrasonography to open and laparoscopic abdominal surgery.

Methods

A literature search (Medline) was undertaken. All papers pertaining to the subject matter that were located were included in the review.

Results

Intraoperative ultrasonography influences surgical strategy in up to 50 per cent of liver resections for malignancy. It is the single most sensitive technique for the detection of occult hepatic metastases at the time of primary colorectal resection. In pancreatic surgery, intraoperative ultrasonography is of value in the localization of islet cell tumours and in the assessment of resectability of adenocarcinoma. The technique may also have a role in staging laparoscopy, and in the operative management of kidney and gastrointestinal diseases.

Conclusion

Ultrasonography is an ideal operative tool as it is safe, reproducible and requires no special patient preparation or positioning. It should be regarded as an essential component of major hepatobiliary and pancreatic procedures. The recent availability of flexible laparoscopic probes is likely to lead to a similar impact on minimal access surgery.
Risk scoring in surgical patients
Authors: Jones H J S , de Cossart L
Published: March 2003

Background

A large number of scoring systems for assessing a patient's risk of complications or death has been developed over recent years. This is a review of those that are of relevance to general surgeons.

Methods

A Medline literature search was performed to identify all articles concerning ‘severity of illness’, ‘morbidity’, ‘mortality’ and ‘postoperative complications’ in the field of surgery from 1966 to 1997. Further searches were performed to find papers about specific identified scoring systems, and relevant articles from the reference lists of these were also sought.

Results and conclusion

The advantages of an accurate assessment of a patient's risk include, on an individual level, the opportunity to give a more accurate prognosis and choose the most appropriate treatment. If the risk of an adverse outcome is known for a group of patients, the actual outcome can be compared with the predicted outcome, and comparison can be made between groups in different surgical units for the purposes of audit or research. The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) is the most appropriate of the currently available scores for general surgical practice.
Effect of radioimmunoscintigraphy in management of recurrent colorectal cancer
Authors: Lunniss P J , Skinner S , Britton K E , Granowska M , Morris G , Northover J M A
Published: March 2003

Background

Radioimmunoscintigraphy (RIS) is being used increasingly as a new investigation in the diagnosis of recurrent colorectal cancer. This study assessed the efficacy of 99mTc-radiolabelled PR1A3 scanning in a cohort of patients with possible recurrent colorectal cancer and the effects of scan interpretation on subsequent clinical management.

Methods

The scans and case notes of patients scanned over a 3-year period were reviewed.

Results

Forty-seven scans in 40 patients were available for analysis. In 39 instances in which scan interpretation could be verified accurately, sensitivity for recurrent colorectal cancer was 22 of 23 (96 per cent), specificity for recurrent colorectal cancer was eight of 16 (50 per cent), positive predictive value for recurrence was 22 of 30 (73 per cent) and negative predictive value for recurrence was eight of nine (89 per cent). In 16 of the 40 patients, scan interpretation strengthened a management decision or altered management. This was beneficial to ten patients and possibly detrimental to six.

Conclusion

This study demonstrated that RIS is sensitive in the detection of recurrent colorectal cancer and benefited the patient in one-quarter of cases. For the majority of patients, accurate detection of recurrent disease cannot be followed by curative therapy, but there is an important subgroup of patients in whom RIS alters management beneficially. However, a randomized prospective study is needed to confirm this.
Effect of training on the incidence of nerve damage in thyroid surgery
Authors: Lamadé W , Renz K , Willeke F , Klar E , Herfarth Ch
Published: March 2003

Background

In thyroid surgery early postoperative recurrent laryngeal nerve (RLN) dysfunction offers a sensitive measure of the quality of the operation. The aim of this study was to analyse the effect of training in thyroid surgery on the rate of early functional disturbances of the RLN after thyroid resection.

Methods

In 617 patients (median age 48 years, female to male ratio 2·8: 1) who underwent unilateral or bilateral thyroid resection, 1059 RLNs were subjected to operative risk. Laryngoscopy was performed before and after operation. The 45 surgeons were divided into three groups: group 1, specialist thyroid surgeons; group 2, experienced surgeons; and group 3, residents. Personal gain of experience was defined by the preceding number of thyroid operations. Within each group the complication profile was determined by adding the personal complication profiles of each surgeon.

Results

The complication rates were low during surgical residency (group 3). In group 2 complication rates increased up to the 50th operation. Group 1 showed the expected exponential decrease to under 1 per cent after another 130 operations.

Conclusion

Complication rates are affected considerably by the extent of surgical experience in a non-linear and complex logarithmic manner, starting with low rates in the beginner group, peaking after further experience and then decreasing exponentially.
Outcome of strictureplasty for duodenal Crohn's disease
Authors: Yamamoto T , Bain I M , Connolly A B , Allan R N , Keighley M R B
Published: March 2003

Background

The outcome of strictureplasty for duodenal Crohn's disease has not been critically documented. The aim of this study was to assess the outcome of strictureplasty for duodenal Crohn's disease.

Methods

A retrospective review was undertaken of 13 patients who underwent strictureplasty (including four pyloroplasties) for obstructive duodenal Crohn's disease between 1974 and 1997.

Results

Ten patients underwent strictureplasty as the primary procedure, and in three strictureplasty was used as a revision procedure after previous bypass surgery. Two patients developed anastomotic breakdown and were treated either by Roux-en-Y duodenojejunostomy or partial gastrectomy. Symptoms of obstruction persisted in four patients after strictureplasty; three eventually resolved after prolonged nasogastric aspiration, but the other required gastrojejunostomy. In the long term, six patients developed restricture at the previous strictureplasty site. Five required repeat strictureplasty and the other patient underwent duodenojejunostomy. One patient who had repeat strictureplasty required a further strictureplasty because of restricture at the previous strictureplasty site. Overall nine of 13 patients required further surgery because of early postoperative complications or restricture at the strictureplasty site.

Conclusion

Strictureplasty for duodenal Crohn's disease is associated with a high incidence of postoperative complications and restricture.
Experimental study of the effect of intraperitoneal heparin on tumour implantation following laparoscopy
Authors: Neuhaus S J , Ellis T , Jamieson G G , Watson D I
Published: March 2003

Background

Conclusions drawn from clinical reports of port site metastases following laparoscopic resection of intra-abdominal malignancy are now supported by a burgeoning experimental literature which suggests that laparoscopy promotes tumour metastasis to wounds. This study investigated the effect of intraperitoneal blood and heparin on the incidence of tumour cell implantation and port site metastasis.

Methods

Twenty-four Dark Agouti rats underwent laparoscopy with carbon dioxide insufflation and the instillation of a tumour cell suspension and/or blood into the peritoneal cavity. Rats were allocated randomly to one of the following study groups (six rats per group): (1) controls; (2) intraperitoneal blood (2 ml blood introduced from a syngeneic donor rat); (3) intraperitoneal heparin; (4) intraperitoneal blood and heparin. Rats were killed 7 days after the procedure, and the peritoneal cavity and port sites were examined for the presence of tumour.

Results

Tumour implantation and port site metastases were reduced by the intraperitoneal administration of heparin, but increased by the presence of intraperitoneal blood.

Conclusion

The results of this study suggest that tumour implantation following laparoscopy is promoted by the presence of intraperitoneal blood and that this effect may be reduced by the use of intraperitoneal heparin.
Minimizing recurrence after sigmoid volvulus
Authors: Chung Y F A , Eu K-W , Nyam D C N K , Leong A F P K , Ho Y H , Seow-Choen F
Published: March 2003

Background

This study was a retrospective review of a series of patients with sigmoid volvulus to identify risk factors for recurrence and recommend appropriate treatment.

Methods

Thirty-five patients with sigmoid volvulus were treated over 8 years.

Results

Six patients had emergency surgery for peritonitis. Twenty-eight of the other 29 patients had successful endoscopic decompression; 15 of these patients had elective surgery during the same admission. Twelve of the 14 patients who refused operation after endoscopic decompression developed recurrent volvulus, a median of 2·8 months later. Eight subsequently agreed to surgery and underwent elective operation following repeat decompression. Of 29 patients who had surgery, 27 had sigmoid colectomy (two were initial Hartmann procedures) and two had subtotal colectomy. Six patients who had sigmoid colectomy developed recurrent volvulus. Concomitant megacolon and megarectum at the time of initial surgery were significant predictors of recurrence.

Conclusion

Subtotal colectomy, carried out as the primary procedure if there is concomitant megacolon or megarectum, might reduce the risk of recurrent sigmoid volvulus.
Transhiatal approach to total gastrectomy for adenocarcinoma of the gastric cardia
Authors: Wayman J , Dresner S M , Raimes S A , Griffin S M
Published: March 2003

Background

A thoracoabdominal approach has traditionally been described for the resection of tumours of the gastric cardia. The aim of this study was to evaluate a transhiatal approach for resection of cancers of the gastric cardia.

Methods

Twenty consecutive patients undergoing transhiatal gastro-oesophagectomy for cancer of the gastric cardia were studied. Data were collected prospectively with regard to operating time, operative blood loss, intensive care unit (ICU) stay, analgesia use, duration of hospital stay, and pathological details of resection margin clearance and lymph node yield. Results were compared with those of the 20 preceding patients for whom the same prospective information had been recorded following resection via the standard thoracoabdominal approach.

Results

The transhiatal approach required a shorter operating time (median 190 (range 105–255) versus 280 (225–330) min; P = 0·004). It resulted in less blood loss (median 405 (180–2000) versus 1000 (420–3200) ml; P = 0·03) and fewer days in the ICU (median 0 (0–31) versus 2 (1–8) days; P = 0·005) despite being performed in an older patient population (median 71 (43–78) versus 63 (59–70) years; P = 0·016). There was no difference in either the lymph node harvest or length or involvement of upper resection margins.

Conclusion

The transhiatal approach to the resection of tumours at the gastric cardia is a valid and safe alternative to the standard thoracoabdominal technique. This technique avoids thoracotomy and its associated morbidity and is accompanied by reduced blood loss, decreased operating time and a shorter ICU stay.
Randomized clinical trial of laparoscopic versus open inguinal hernia repair
Authors: Juul P , Christensen K
Published: March 2003

Background

Several studies have suggested that better results are obtained after laparoscopic repair of inguinal hernia than after conventional operation. This is most obvious for bilateral and recurrent hernias but less accepted for primary unilateral hernias.

Methods

This was a randomized clinical trial comparing transabdominal preperitoneal laparoscopic repair with the Shouldice technique in patients with primary unilateral hernia. Some 138 patients were randomized to laparoscopic hernia repair and 130 to open surgical repair.

Results

The complication rates in the two groups were similar. In the laparoscopic group the patients returned to work more rapidly with a median time of 13 versus 18 days (P < 0·005) and had a shorter period of analgesia intake with a median time of 2·1 versus2·7 days (P< 0·02). The follow-up was 97·8 per cent complete. At a median of 12 months, four recurrences (2·9 per cent) were detected in the laparoscopic group and three (2·3 per cent) in the open group.

Conclusion

This study shows that in patients with a primary unilateral hernia laparoscopic repair results in less postoperative pain and a quicker recovery than open repair.
Accuracy of intraoperative frozen-section analysis of axillary nodes
Authors: Dixon J M , Mamman U , Thomas J
Published: March 2003

Background

Intraoperative assessment of axillary lymph node involvement would allow selection of patients who would benefit from axillary lymph node dissection.

Methods

Eighty-eight patients undergoing mastectomy or wide excision had four nodes sampled and sent for frozen-section examination.

Results

Frozen-section analysis of the nodes was correct in 81 of the 88 patients but missed seven of the 26 patients who had involved nodes on paraffin section (sensitivity 73 per cent).

Conclusion

Frozen-section analysis of axillary lymph nodes as currently practised cannot be recommended for routine use although it may have a role in specific groups of patients.