bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors leading to local recurrence or death after surgical resection of phyllodes tumours of the breast
Authors: de Roos W K , Kaye P , Dent D M
Published: March 2003

Background

Local recurrence and death from metastases are occasional, but consistent, themes in reports of patients with phyllodes tumours. Factors that might contribute to these outcomes were sought.

Methods

Data from 38 patients with a phyllodes breast tumour were reviewed retrospectively, reclassifying the pathological material using the Pietruszka and Barnes criteria.

Results

At a median of 12 months, nine patients had developed a local recurrence and four had died from metastases. Following local excision in 24 patients (for diagnosis in 13, for ‘fibroadenoma’ in nine and for phyllodes tumour in two patients), 13 had no further surgery and five had local recurrence (three of eight benign tumours, two of two malignant tumours). Wide local excision or mastectomy in 18 patients was followed by four recurrences (one of eight borderline tumours, three of ten malignant tumours). All patients with recurrence had margin involvement on histological examination, but not all patients with margin involvement developed recurrence. Lack of statistical correlation between local recurrence and age, delay, size, grade or type of surgery was confounded by selection bias for more extensive surgery for malignant tumours. Death correlated with size (P = 0·05) and grade (P= 0·03) of tumour.

Conclusion

Inadequate preoperative diagnosis (‘fibroadenoma’ or failure of triple assessment) frequently led to local excision with positive margins. Without revision this often resulted in local recurrence. Local recurrence of any grade was usually followed by further recurrence. Death was related to tumour size and histological grade, confirming these as prognostic factors.
Necrotizing pancreatitis
Authors: Bradley E L
Published: March 2003

There is no single diagnostic test available to confirm the need to operate on a patient with sterile pancreatic necrosis. How should the surgeon decide whether a patient needs surgery? After debridement should the abdomen be closed, drained, lavaged or left open? Professor Bradley of Buffalo General Hospital replies.
Colonic motility before surgery for rectal prolapse
Authors: Brown A J , Horgan A F , Anderson J H , McKee R F , Finlay I G
Published: March 2003

Background

Abdominal rectopexy remains the operation of choice for patients with rectal prolapse. Recurrence rates are low but the functional results are poor. Hindgut motility was measured before abdominal rectopexy to determine whether an underlying neuropathy might explain these poor results.

Methods

Seven women of mean(s.d.) age 56(10) years had a multilumen catheter inserted in the colon before abdominal rectopexy. Colonic intraluminal pressure was recorded for a mean(s.d.) of 19(3) h; the number of peaks over 5 and 50 mmHg, motility and high-amplitude propagated contractions (HAPCs) were measured before and after a meal and compared with the findings in five controls.

Results

Patients had high numbers of contractions greater than 5 mmHg and high motility before meals. Controls responded to meals by increasing motility, unlike patients. HAPCs were seen in one patient but in all controls.

Conclusion

These data show that patients with rectal prolapse have a hindgut motility abnormality before abdominal rectopexy, similar to that observed in spinal cord injury. This may explain the poor functional results after surgery, offering a rationale for colonic resection.
Changing strategy for rectal cancer is associated with improved outcome
Authors: Dahlberg M , Glimelius B , Påhlman L
Published: March 2003

Background

In 1980, surgery for rectal cancer at the Department of Surgery, Uppsala University Hospital was concentrated to a colorectal unit and a more systematic use of adjuvant radiotherapy began. In 1985, total mesorectal excision was introduced. The aim of this study was to determine whether these changes had an impact on the overall treatment outcome.

Methods

Some 423 consecutive patients with rectal cancer had surgery between 1974 and 1995 and were followed up until 1 January 1998. Outcome analysis was made according to the following predefined intervals of diagnosis: 1974–1979, 1980–1984 and 1985–1995.

Results

The overall local recurrence rate was 47 per cent in the first interval, and 13 and 11 per cent during the second and third respectively (P < 0·001). In the third interval, of 119 patients who received preoperative irradiation and underwent radical resection, only three (3 per cent) had locally recurrent rectal cancer. There was improved cancer-specific survival between the first and the last intervals of the study (P = 0·03).

Conclusion

These data are consistent with the interpretation that the results of treatment can be improved by concentration of surgery to a colorectal team.
Correlation between spiral computed tomography, endoscopic ultrasonography and findings at operation in pancreatic and ampullary tumours
Authors: Midwinter M J , Beveridge C J , Wilsdon J B , Bennett M K , Baudouin C J , Charnley R M
Published: March 2003

Background

Spiral computed tomography (CT) allows high-resolution examination of the pancreas, surrounding vascular structures, lymph nodes and liver. Endoscopic ultrasonography (EUS) also allows high-resolution imaging of the pancreas and adjacent structures but is an invasive procedure. With the availability of spiral CT, the role of EUS in the investigation of patients with suspected pancreatic or ampullary tumours is unclear.

Methods

Forty-eight patients with clinical suspicion of a pancreatic or ampullary tumour underwent both spiral CT and EUS. Thirty-four patients had surgical exploration, of whom 17 underwent pancreatic resection and 17 had biliary and gastric bypass. The results of spiral CT and EUS were compared with the operative findings.

Results

The final histological diagnosis was ductal adenocarcinoma (24 patients), ampullary carcinoma (six), serous cystadenoma (two) and chronic pancreatitis (two). EUS demonstrated 33 and spiral CT 26 of the 34 primary lesions. EUS was particularly useful in the assessment of small resectable tumours missed by spiral CT. The sensitivity and specificity of EUS and spiral CT for detecting involvement by the tumour of the superior mesenteric vein, portal vein and lymph nodes were similar, but EUS was less effective at evaluating the superior mesenteric artery.

Conclusion

EUS is an important additional investigation after spiral CT in patients with a suspected pancreatic or ampullary tumour.
Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies
Authors: Radice E , Nelson H , Mercill S , Farouk R , Petty P , Gunderson L
Published: March 2003

Background

Perineal wounds, created at the time of extended resection for locally advanced malignancy and following chemoradiation, are at risk of serious complications.

Methods

To determine whether immediate myocutaneous flap closure prevents complications, 57 patients treated with multimodality therapy and proctectomy (35 perineal wounds) or sacrectomy (22 posterior wounds) were studied. Patients were categorized according to whether they underwent primary skin and pelvic closure (group 1; n = 20); primary skin and omental pelvic closure (group 2; n = 24); or immediate myocutaneous flap closure (group 3; n = 13).

Results

Groups were similar with respect to age and sex; however, group 1 had more primary tumours and required less radical surgery and chemoirradiation than groups 2 and 3. Groups 1 and 2 experienced more complications overall (eight of 20, nine of 24 and three of 13 patients in groups 1, 2 and 3 respectively), more acute wound complications (seven of 20, nine of 24 and two of 13), delayed wound healing (three of 20, six of 24 and one of 13) and more reoperations for perineal wound problems (five of 20, seven of 24 and zero of 13). Patients in group 2 had a significantly longer hospital stay than those in group 1. Flap closure (group 3) did not increase the length of stay. The routine use of primary flap closure reduced overall wound complications (eight of 31 versus ten of 26 patients) and length of hospitalization (13 versus 17 days).

Conclusion

Complete wound healing was achieved in all patients; however, immediate myocutaneous flap closure reduced the need for readmission and reoperation.
Noradrenaline improves the tumour to normal blood flow ratio and drug delivery in a model of liver metastases
Authors: Shankar A , Loizidou M , Burnstock G , Taylor I
Published: March 2003

Background

Vasopressors administered via the hepatic artery appear to increase drug delivery to colorectal liver metastases, but are limited by a short duration of action. This study measured their effect on blood flow and drug delivery during a prolonged infusion in a model of liver metastases.

Methods

In Hooded Lister rats with liver metastases, blood flow in tumour and adjacent normal liver was measured using laser Doppler flowmetry during a 30-min hepatic arterial infusion of endothelin 1, angiotensin II, vasopressin, N-nitro-l-arginine methyl ester (l-NAME), noradrenaline or saline (n = 6 per group). The same agents were co-administered with radiolabelled 5-fluorouracil (5-FU) (n = 6 per group) and uptake in the tumour and normal liver was measured.

Results

The mean(s.d.) duration of effect and resulting percentage changes in tumour to normal blood flow ratio of the vasopressors during this period were: noradrenaline, 2·9(0·4) min and 34(5) per cent (P < 0·05); angiotensin II, 4·2(0·2) min and 10(2) per cent (P < 0·05); vasopressin, 11·1(0·9) min and 7(2) per cent (P < 0·05); endothelin 1, 21·5(2·3) min and 14(5) per cent (P < 0·05); and l-NAME, 22·6(3·3) min and 2(1) per cent (Pnot significant). The mean(s.d.) uptake of radiolabelled 5-FU by the tumour in the groups studied was: saline, 5·1(3·2) × 105 c.p.m. per g tissue; angiotensin II, 5·1(1·4) × 105 c.p.m. per g; endothelin 1, 15·8(14·2) × 105 c.p.m. per g; l-NAME, 3·5(1·3) × 105 c.p.m. per g; and vasopressin, 6·8(3·5) × 105 c.p.m. per g. Significant improvements in 5-FU uptake only resulted from noradrenaline infusion (22·0(9·8) × 105 c.p.m. per g; P < 0·05).

Conclusion

These findings suggest that hepatic arterially infused noradrenaline might be used to improve drug delivery to liver metastases.
Identification of patients likely to benefit from biofeedback for outlet obstruction constipation
Authors: McKee R F , McEnroe L , Anderson J H , Finlay I G
Published: March 2003

Background

Biofeedback for outlet obstruction constipation has a varying success rate. The aim of this study was to identify which patients are likely to respond to biofeedback.

Methods

Thirty patients with severe outlet obstruction constipation were treated by a specialist nurse using three or four sessions of visual and auditory feedback of anal sphincter pressures. All patients were assessed by evacuating proctography, whole-gut transit studies and anorectal physiology before treatment.

Results

Two patients did not complete the course of biofeedback. Nine patients improved. Before treatment these patients had predominantly normal anorectal physiology and were all able to open the anorectal angle at evacuating proctography. Nineteen patients did not improve, of whom only three had no measured abnormality other than inability to empty the rectum. Ten of these patients had abnormal anorectal physiology which may have been due to previous vaginal delivery.

Conclusion

Biofeedback for outlet obstruction constipation is more likely to be successful in patients without evidence of severe pelvic floor damage.
Surgical implications of underestimation of adrenal tumour size by computed tomography
Authors: Lau H , Lo C Y , Lam K Y
Published: March 2003

Background

Size of adrenal mass is an important consideration during adrenal surgery, with regard to the choice of surgical approach and management of adrenaloma. The aim of the present study was to evaluate the precision of preoperative computed tomography (CT) on the size estimation of adrenal lesions and to review its potential implications on surgical decision making.

Methods

Records of 110 patients who underwent adrenalectomy for various adrenal pathologies from 1981 to 1997 were reviewed retrospectively. Patients (n = 92) who had documented dimensions of adrenal mass by both preoperative CT and pathological examination were selected for analysis.

Results

CT overall underestimated the actual size of adrenal lesions by 16 per cent compared with measurement of resected specimens (mean 3·1 versus 3·6 cm; P< 0·001). There was a significant underestimation of the actual size of adrenal lesions measuring less than 6 cm by CT but not for lesions larger than 6·0 cm. Phaeochromocytoma (n = 17) was the only pathological condition consistently underestimated by CT.

Conclusion

Conventional CT overall underestimates the real size of adrenal lesions, in particular phaeochromocytoma and adrenal tumours of less than 6·0 cm in size. Surgical decision making based on size should take this limitation into account.
Red blood cells inhibit tumour cell adhesion to the peritoneum
Authors: van Rossen M E E , Stoop M P O , Hofland L J , van Koetsveld P M , Bonthuis F , Jeekel J , Marquet R L , van Eijck C H J
Published: March 2003

Background

Perioperative blood transfusion has been associated with increased tumour recurrence and poor prognosis in colorectal cancer. Blood loss in the peritoneal cavity might be a tumour-promoting factor for local recurrence. The aim of this study was to investigate whether blood in the peritoneal cavity affects local tumour recurrence.

Methods

In an established in vivo rat model the effect of 1·5 ml syngeneic whole blood on tumour cell adhesion and tumour growth was investigated. In the same model the effect of 1·5 ml pure red blood cell (RBC) concentrate and 1·5 ml RBC-derived substances on tumour cell adhesion was studied. In an established in vitro model the effect of increasing numbers of RBCs (0–250 × 106) on tumour cell adhesion and tumour growth was assessed.

Results

Both the presence of blood and RBC concentrate in the peritoneal cavity prevented tumour cell adhesion in vivo (overall P ≤ 0·001 and P ≤ 0·05 respectively), rather than promoting adherence. RBC concentrate and RBC-derived substances had a comparable inhibitory effect on tumour cell adhesion. In in vitro studies RBCs inhibited tumour cell adhesion but not tumour growth.

Conclusion

RBC-derived factors prevent tumour cell adhesion to the peritoneum, and consequently tumour recurrence.
Intraoperative lymphatic mapping and the sentinel node concept in colorectal carcinoma
Authors: Joosten J J A , Strobbe L J A , Wauters C A P , Pruszczynski M , Wobbes Th , Ruers T J M
Published: March 2003

Background

Orderly progression of nodal metastases has been described for melanoma and breast cancer. The first draining lymph node, the sentinel node, is also the first to contain metastases and accurately predicts nodal status. The aim of this study was to assess the feasibility of lymphatic mapping and sentinel node biopsy in colorectal cancer.

Methods

In 50 patients with colorectal cancer patent blue dye was injected around the tumour. After resection of the tumour the specimen was examined to identify blue-stained lymph nodes. Routine histopathological examination was performed on all nodes and the blue, haematoxylin and eosin-stained tumour-negative nodes were tested immunohistochemically.

Results

Lymphatic mapping was possible in 35 of 50 patients (70 per cent). Pathological examination with haematoxylin and eosin staining showed lymph node metastases in 20 of 35 patients. In eight of these 20 patients the blue nodes showed tumour, while in 12 the blue nodes were not involved. This represents a false-negative rate of 60 per cent.

Conclusion

Lymphatic mapping using patent blue dye is feasible in colorectal cancer. The blue-stained nodes do not predict nodal status of the remaining lymph nodes in the resected specimen. The concept of lymphatic mapping and sentinel node identification is not valid for colorectal cancer.
Interstitial laser coagulation for hepatic tumours
Authors: Heisterkamp J , van Hillegersberg R , IJzermans J N M
Published: March 2003

Background

The potential role of interstitial laser coagulation (ILC) for patients with irresectable hepatic tumours is currently being investigated. Since its introduction in 1983 it has evolved into an innovative minimally invasive technique.

Methods

On the basis of a Medline literature search and the authors' experience, the principles, current state and prospects of ILC for hepatic tumours are reviewed.

Results

Animal studies and early clinical studies have shown the safety and feasibility of ILC. The site of interest can be approached at laparoscopy or percutaneously and treatment is easily repeatable. Recent advances include the use of fibres with a cylindrical diffusing light-emitting tip, the length of which is adaptable to tumour diameter, water-cooled fibre systems, simultaneous multiple fibre application, and hepatic inflow occlusion during laser treatment. ILC allows complete destruction of tumours up to 5 cm in diameter. Currently a limitation is the lack of reliable real-time monitoring of laser-induced effects but progress in magnetic resonance imaging techniques should allow accurate temperature measurements to be obtained rapidly during treatment. However, the actual benefit of ILC in terms of patient survival remains to be investigated.

Conclusion

In terms of tools and experience, ILC has now been developed sufficiently to study its effect on survival of patients with irresectable hepatic tumours.
Interleukin 6 in bile as an indicator of liver function after hepatectomy in patients with biliary tract carcinoma
Authors: Maeda A , Nagino M , Takeuchi E , Sano T , Kurumiya Y , Nimura Y
Published: March 2003

Background

Interleukin (IL) 6 is one of the important components of the early signalling pathways leading to liver regeneration, and has been detected in the bile after liver transplantation. IL-6 concentrations in the bile were studied in an attempt to predict liver function after major hepatectomy for biliary tract carcinoma.

Methods

This study involved 24 patients without cirrhosis who underwent major hepatectomy for biliary tract carcinoma. The bile was sampled regularly through external biliary drainage tubes. IL-6 concentrations in bile and serum were measured using an enzyme-linked immunosorbent assay.

Results

Bile IL-6 concentrations increased 37-fold (from mean(s.e.) 56(13) pg/ml before hepatectomy to 2071(398) pg/ml on day 1 after operation) in patients without liver failure after hepatectomy (n = 18) and increased sevenfold (from 71(24) to 530(76) pg/ml) in patients with liver failure after hepatectomy (n = 6). The values were significantly lower in patients with liver failure than in those without liver failure (P < 0·05). The bile IL-6 concentration on day 1 after operation exhibited a significant negative correlation with the maximum serum total bilirubin concentration after hepatectomy. Although serum IL-6 concentrations were also increased in both groups after hepatectomy, there was no significant correlation with postoperative liver function.

Conclusion

Increased bile IL-6 concentrations after hepatectomy may reflect liver regenerative capacity. Measurement of bile IL-6 concentrations may be clinically useful for the early identification of liver failure after hepatectomy.
Unique distribution patterns of metastatic lymph nodes in patients with superficial carcinoma of the thoracic oesophagus
Authors: Matsubara T , Ueda M , Abe T , Akimori T , Kokudo N , Takahashi T
Published: March 2003

Background

Lymph node metastasis is commonly found in carcinoma of the thoracic oesophagus, even when the tumour invades only the submucosa. Although lymph node status greatly influences the outcome, the pattern of early lymphatic spread has not been investigated, and the role of lymph node dissection is still a matter of controversy.

Methods

A series of 110 patients with superficial carcinoma who underwent systematic extended lymph node dissection was investigated retrospectively.

Results

Lymph node involvement was found in 0 per cent (none of nine), 23 per cent (five of 22) and 49 per cent (38 of 78) of tumours that invaded the lamina propria, muscularis mucosa and submucosa respectively. Anatomically distant lymph nodes (recurrent nerve nodes and perigastric nodes) were involved more frequently than other intrathoracic nodes adjacent to the main tumour. Only three patients had involvement limited to the intrathoracic group, and in carcinoma that invaded only the muscularis mucosae, all metastatic nodes were located at the thoracocervical junction or in the abdomen. The 5-year survival rate was 89 per cent in the node-negative group and 54 per cent in the node-positive group (P < 0·0003).

Conclusion

The recurrent nerve nodes and perigastric nodes are the principal proximal regional lymph nodes involved in superficial carcinoma of the thoracic oesophagus. Systematic lymph node dissection, which included these nodes, yielded an acceptable and favourable outcome in patients with node-positive superficial carcinoma.
Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy
Authors: Lin P-W , Lin Y-J
Published: March 2003

Background

Pancreaticoduodenectomy, with either gastrectomy (Whipple procedure) or pylorus-preserving pancreaticoduodenectomy (PPPD), is a complex procedure. Technical diversity, variation and sampling bias exist among surgeons. Previous reports comparing these two procedures are retrospective and not randomized. These factors should be considered seriously and eliminated in comparisons between the two procedures.

Methods

From August 1994 to August 1997, a prospective randomized comparison was conducted between the Whipple procedure and PPPD performed by the same surgeon with the same approach and same anastomotic fashion for periampullary cancer. After exclusion of seven patients, 31 patients were eligible for the study, 16 receiving PPPD and 15 a Whipple procedure. No significant difference in the age, sex distribution, tumour localization or staging was noted between the two groups.

Results

One operative death after PPPD and no operative death after the Whipple procedure resulted in a 3 per cent mortality rate in the 31 patients. Median duration of the Whipple operation was 235 (range 195–305) min, with a median blood loss of 500 (range 230–3100) ml and a median blood transfusion of 0 (range 0–10) units. In the patients who had PPPD, median operating time was 230 (range 170–275) min, median blood loss was 350 (range 100–1200) ml and median blood transfusion was 0 (range 0–4) units. There were two minor leaks from the pancreaticojejunostomy after the Whipple procedure and no leakage after PPPD, resulting in 6 per cent minor leakage in 31 patients. These outcomes were not significantly different. Delayed gastric emptying was observed more frequently after PPPD (six of 16 patients) than after the Whipple procedure (one of 15 patients), with marginal significance (P = 0·08, two-sided Fisher's exact test).

Conclusion

In this prospective randomized study, both PPPD and the Whipple procedure were associated with low mortality and operative morbidity rates. There was no significant difference between PPPD and Whipple resection in terms of operative mortality and morbidity, operating time, blood loss and blood transfusion. PPPD was associated with more frequent delayed gastric emptying, although study of more patients is needed to confirm this.
Fertility after ileal pouch–anal anastomosis in women with ulcerative colitis
Authors: Olsen K Ø , Joelsson M , Laurberg S , Öresland T
Published: March 2003

Background

Women with ulcerative colitis are believed to have normal fertility but colectomy and ileal pouch–anal anastomosis (IPAA) may impair fertility. The aim was to compare fertility in patients with ulcerative colitis before and after IPAA with that in the national population.

Methods

Some 258 consecutive women who had undergone IPAA for ulcerative colitis were identified. Data were collected by questionnaire and from medical records. The observed number of births was compared with the number expected by indirect standardization by age and calendar year. Fertility from the age of 15 years to colectomy, from the onset of ulcerative colitis to colectomy, and from the 12 months after stoma closure to the time of data collection was investigated.

Results

A total of 237 women (92 per cent) responded. From the age of 15 years to colectomy there were 251 deliveries compared with an expected number of 286 (P < 0·05). The number of births from the onset of ulcerative colitis to colectomy was 120, compared with an expected 131 (P > 0·3). From the 12 months after ileostomy closure until data collection there were 34 deliveries, compared with an expected 69 (P < 0·001).

Conclusion

There is a considerable reduction in postoperative fertility after restorative surgery for ulcerative colitis.
Lateral ligaments of the rectum: an anatomical study
Authors: Jones O M , Smeulders N , Wiseman O , Miller R
Published: March 2003

Background

The lateral ligaments of the rectum are surrounded by confusion and misconception. Their identification before ‘hooking them on the finger’, clamping and ligating is considered in many surgical texts to be an essential step in mobilization of the rectum. By contrast, it is the experience of many colorectal surgeons that the mesorectum can be dissected out either by diathermy or sharp dissection alone.

Methods

Dissection in the mesorectal plane was performed on 28 cadaveric pelves.

Results

In ten of the pelves, no connective tissue structure crossed from the pelvic side wall to the rectum. The remaining 18 had only very insubstantial connective tissue strands crossing this space. A total of 17 middle rectal arteries were found, all of them unilateral. Fourteen of these vessels crossed the mesorectum independent of any structure, while the remainder were part of a neurovascular bundle with a connective tissue element.

Conclusion

It is proposed that the ‘lateral ligaments’ of the rectum do not exist and that the term should be dropped from surgical texts. When present, the middle rectal artery is a small vessel, close to the pelvic floor. The entire rectum may be mobilized by sharp dissection without the need for clamping or ligation of any significant structure.
Adenocarcinomas of the distal oesophagus and gastric cardia are one clinical entity
Authors: Wijnhoven B P L , Siersema P D , Hop W C J , van Dekken H , Tilanus H W
Published: March 2003

Background

Adenocarcinomas of the distal third of the oesophagus and the gastric cardia have similar characteristics but different staging criteria are being used. In the present study the question is addressed whether these tumours should be regarded and staged as one clinical entity.

Methods

From January 1987 to January 1997, 252 patients with an adenocarcinoma of the oesophagus (n = 111) or gastric cardia (n = 141) underwent transhiatal resection. Pathology, pathological tumour node metastasis (pTNM) stage and survival were analysed retrospectively, and a comparison was made between tumours of the oesophagus and gastric cardia.

Results

Barrett's epithelium was diagnosed in 54 per cent of oesophageal adenocarcinomas compared with 13 per cent of adenocarcinomas of the gastric cardia (P < 0·001). Oesophageal carcinomas had a more favourable pT stage, fewer positive locoregional lymph nodes (pN1–2 56 versus 62 per cent; P = 0·3), but more distant metastases accounted for by positive lymph nodes around the coeliac axis (pM1 19 versus 4 per cent; P < 0·001). Five-year overall survival (26 versus 27 per cent; P = 0·9) and survival according to tumour stage were no different between the groups. Multivariate analysis showed that the location of the primary tumour was not an independent prognostic factor.

Conclusion

Adenocarcinomas of the distal oesophagus and gastric cardia should be regarded as one clinical entity. Uniform staging criteria for both malignancies are recommended.
Physiological comparison of open and endovascular aneurysm repair
Authors: Treharne G D , Thompson M M , Whiteley M S , Bell P R F
Published: March 2003

Background

This prospective study compared morbidity and mortality rates following conventional and endovascular abdominal aortic aneurysm (AAA) repair using a physiological scoring system.

Methods

Between December 1994 and November 1997, 104 elective open aneurysm repairs and 49 endovascular aneurysm repairs were performed. These patient cohorts were compared using the Portsmouth predictor equation (P-POSSUM) scoring system. Data collected prospectively from patient notes were used to obtain physiological and operative severity scores which were analysed to compare expected and observed mortality and morbidity rates.

Results

There were three deaths (6 per cent) in the endovascular AAA repair group and 17 (16 per cent) in the conventional aneurysm repair group, whereas the P-POSSUM formulae predicted mortality rates of 8 and 19 per cent respectively. Although the mean physiological scores were similar for both groups (endovascular 20·8 versus conventional 20·1), the operative severity score was significantly greater in the conventional group (26·3 versus 19·7; P < 0·001).

Conclusion

In this study open aortic aneurysm repair had a higher operative severity than endovascular repair, which was reflected in the increased mortality rate.
Endoscopic band ligation of oesophageal varices
Authors: Tait I S , Krige J E J , Terblanche J
Published: March 2003

Background

For 25 years the optimal management of bleeding oesophageal varices has included endoscopic injection sclerotherapy (EIS) both to arrest bleeding and to prevent rebleeding. However, the recent innovation of endoscopic variceal ligation (EVL) may be a more effective treatment; this paper reviews its efficacy.

Methods

All Medline (National Library of Medicine, Washington DC, USA) articles containing the text words ‘oesophageal varices’, ‘sclerotherapy’ or ‘band ligation’ were reviewed. Prospective randomized studies comparing sclerotherapy with band ligation, or combinations thereof, were included.

Results

After an acute variceal bleed EVL is as effective as EIS for control and eradication of oesophageal varices. Initial control of bleeding is similar, but eradication is achieved in fewer sessions with EVL. EVL is associated with lower rebleeding rates and fewer procedure-related complications; it is also more effective for control of active bleeding at initial endoscopy. Combination therapy (EIS plus EVL) confers no advantage over EVL alone.

Conclusion

EVL is similar to EIS for control of bleeding varices, but the former has less associated morbidity, lower rebleeding rates and achieves more rapid variceal eradication. EVL should be considered the endoscopic treatment of choice in the management of variceal haemorrhage.
Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas
Authors: Suzuki Y , Fujino Y , Tanioka Y , Hori Y , Ueda T , Takeyama Y , Tominaga M , Ku Y , Yamamoto Y M , Kuroda Y
Published: March 2003

Background

Resection of the non-fibrotic pancreas is prone to postoperative pancreatic fistula because of well preserved exocrine secretions and easily crushed soft parenchyma. The purpose of this study was to evaluate ultrasonic dissection for division of the non-fibrotic pancreas in distal pancreatectomy.

Methods

All pancreata included in this study were soft on direct palpation and their main ducts had no dilatation, at least proximally from the transection line. Fifty-eight patients with gastric cancer or pancreatic disease were randomly assigned to the two groups. In the ultrasonic dissection (UD) group (n = 27), all pancreatic ducts were identified and ligated securely. The stump was left open without parenchymal suturing. In the conventional (CV) group (n = 31), the pancreas was cut with a knife and the stump was oversewn in mattress fashion. The main pancreatic duct was ligated in all patients in both groups. Pancreatic fistula was defined as a pancreatic fluid discharge for more than 7 days after operation diagnosed according to amylase concentration in the drainage fluid.

Results

In the UD group, approximately 20–30 tubes including a mean(s.d.) 5·2(0·8) (range 4–6) pancreatic ducts were skeletonized and ligated per patient. There were nine pancreatic fistulas (16 per cent); one in the UD group and eight in the CV group (P= 0·020).

Conclusion

In distal pancreatectomy for the non-fibrotic pancreas, ultrasonic dissection without suture closure of the stump reduced the incidence of pancreatic fistula compared with conventional division and suture, in this randomized trial.
Controlled digital anal dilatation under total neuromuscular blockade for chronic anal fissure: a justifiable procedure
Authors: Strugnell N A , Cooke S G , Lucarotti M E , Thomson W H
Published: March 2003

Background

There is widespread antipathy to digital dilatation of the anus (DDA) for medically resistant anal fissure. A retrospective study was therefore undertaken to test the validity of the criticism of this technique.

Methods

Some 273 patients who underwent DDA for fissure between November 1982 and July 1997 were sent a questionnaire and/or telephoned. Those with impaired control were offered investigation. In addition, routine clinic follow-up data were scrutinized in the 302 available notes of the 307 patients who had undergone DDA for fissure to determine its efficacy.

Results

Some 241 patients (88·3 per cent) were contacted successfully a median of 7·8 years after operation. Follow-up records showed the fissure to have healed in 89·1 per cent of 302 patients. No patient was rendered incontinent. Fifteen patients indicated persistently impaired control in the questionnaire, nine (3·8 per cent) as a result of the DDA and six preceding it. All 23 patients who had experienced either temporary or permanent impairment, whether or not pre-existing, were invited to attend for ultrasonography and manometric measurements, of whom 18 accepted. No sphincteric fragmentation was seen, and resting and squeeze pressures did not differ from normal.

Conclusion

A single DDA appears to heal 89 per cent of chronic anal fissures. Consequent impairment of control is infrequent and minor if the procedure is performed carefully and with the patient paralysed.
Peroperative time–motion analysis of diagnostic laparoscopy with laparoscopic ultrasonography
Authors: den Boer K T , de Wit L T , Dankelman J , Gouma D J
Published: March 2003

Background

Advanced technology is being introduced rapidly into laparoscopic procedures, frequently without an accurate evaluation of its functioning. In this study, standardized time–motion analysis was applied to evaluate the peroperative surgical process and the technical equipment used in 18 cases of diagnostic laparoscopy with laparoscopic ultrasonography (DLLU).

Methods

The image through the laparoscope, the ultrasonograph and an overview of the operating theatre were recorded simultaneously. The time for each phase, efficient actions (e.g. identifying lesions by inspection, making an ultrasonogram or taking a biopsy) and limiting factors (e.g. technical problems, time spent waiting) were determined, and a current standard was defined.

Results

Of the actions performed, 52 per cent were qualified as efficient, 17 per cent were classified as time spent waiting for personnel, instruments were positioned in 13 per cent, and unnecessary instrument exchanges were involved in 10 per cent. The evaluation led to a significant reduction in delay times and resulted in design criteria for improved biopsy instruments. The current standard was calculated from the mean time and number of actions determined for each phase.

Conclusion

This time–motion study provided detailed insight into the peroperative process of DLLU, leading to improvements in the surgical process and instruments used. The defined current standard will enable evaluation of the learning curve and new technologies.
Phase II trial of radical surgery for locally advanced pelvic neoplasia
Authors: Bramhall S R , Harrison J D , Burton A , Wallace D M A , Chan K K , Harrison G , White A , Fielding J W L
Published: March 2003

Background

Reported operative mortality and survival rates following total pelvic exenteration (TPE) for recurrent pelvic neoplasia are now as good as those for many primary treatments. The currently accepted primary treatments for these tumours are, however, still either radiotherapy alone or radiotherapy and chemotherapy. The primary aim of this study was to evaluate the safety and tolerability of TPE and secondarily to ascertain survival after TPE.

Methods

This was a phase II study of 50 patients with locally advanced pelvic tumours who underwent TPE.

Results

Thirty-two patients (64 per cent) underwent TPE for recurrent carcinoma of the cervix, seven (14 per cent) for rectal cancer, three (6 per cent) for vulval carcinoma, three (6 per cent) for vaginal carcinoma, two (4 per cent) for prostate cancer and three (6 per cent) for other tumours. The 30-day mortality rate was 8 per cent with an in-hospital mortality rate of 16 per cent. The crude morbidity rate was 62 per cent, with 23 patients (46 per cent) having grade III or IV toxicity. A complete response was achieved in 63 per cent and a partial response in 37 per cent of patients. The overall median survival time was 86 weeks; it was 111 weeks in patients in whom a complete response was achieved.

Conclusion

The survival and operative mortality rates that are now attainable with TPE are comparable to those achieved with chemoradiotherapy in advanced pelvic neoplasia. TPE should no longer be reserved for salvage therapy and should perhaps be compared with chemoradiotherapy as first-line treatment in a phase III randomized trial in patients with these tumours.
Selective impairment of glucose storage in human sepsis
Authors: Saeed M , Carlson G L , Little R A , Irving M H
Published: March 2003

Background

Glucose utilization in sepsis is impaired but the mechanisms are unclear. This study examined the effect of sepsis on total glucose utilization, oxidation and storage, and the energetic costs of these metabolic processes.

Methods

Glucose infusion rate (GIR), glucose oxidation rate (GOR), non-oxidative disposal rate and the energetic cost of glucose storage were studied in 24 patients with abdominal sepsis and in 26 healthy controls, using indirect calorimetry and the euglycaemic hyperinsulinaemic clamp with insulin infusion rates of 40 and 240 mU m−2 min−1.

Results

Basal GOR was significantly lower in septic patients than in controls (1·5 versus 2·3 mg per kg fat-free mass (FFM) per min, P < 0·001). Septic patients had a significantly lower GIR at 40 mU m−2 min−1 (4·2 versus 9·1 mg per kg FFM per min) and at 240 mU m−2 min−1 (7·5 versus 11·8 mg per kg FFM per min), relative to controls (P < 0·001). GOR was similar in septic and control subjects at both rates of insulin infusion whereas non-oxidative disposal was significantly lower in septic patients (P < 0·001) and accounted entirely for the reduction in GIR. The energetic cost of glucose disposal was unaffected by sepsis.

Conclusion

Sepsis is associated with selective impairment of glucose storage but the energetic cost of non-oxidative disposal is unaffected.
Multimodal therapy for squamous carcinoma of the oesophagus
Authors: Lehnert T
Published: March 2003

Background

The results of surgical treatment for oesophageal squamous cell cancer have improved over recent decades, but the long-term prognosis for patients with tumours of stage II or higher is still unsatisfactory. While uncontrolled series of adjuvant or neoadjuvant treatment have reported favourable survival rates, the true benefit of multimodal treatment can be determined only by randomized controlled trials.

Methods

The literature was searched for prospective randomized controlled trials (PRCTs) examining the effect of neoadjuvant or adjuvant treatment on the long-term survival of patients with squamous cell cancer of the oesophagus.

Results

More than 30 PRCTs studying multimodal treatment concepts aimed at improving the prognosis of squamous cell carcinoma of the oesophagus were identified. These trials have not documented improved survival by adjuvant radiotherapy or chemotherapy. Following neoadjuvant radiotherapy or chemotherapy (or a combination of both), resectability of squamous cell carcinoma is not increased, the postoperative mortality rate appears to be higher and survival is not prolonged.

Conclusion

Past multimodality protocols have not improved the prognosis of squamous carcinoma of the oesophagus. Careful design and reporting, together with strict control of surgical procedures, should allow more meaningful analysis of future multimodal treatment studies. At present, neoadjuvant or adjuvant treatment cannot be recommended outside such clinical protocols.
Saphenoperitoneal shunts for patients with intractable ascites associated with chronic liver disease
Authors: Vadeyar H J , Doran J D , Charnley R , Ryder S D
Published: March 2003

Background

Ascites is a common complication in patients with chronic liver disease. Some patients are resistant to diuretics and need therapeutic paracentesis on a regular basis. This is inconvenient in the long term and also has resource implications. Alternatively, these patients may be treated by peritoneovenous shunts, which require insertion of a foreign body into a central vein and are prone to occlusion. A new technique for peritoneovenous shunting without the use of foreign material is described.

Methods

Eight patients with chronic liver disease and diuretic-resistant ascites underwent this procedure. During operation, the long saphenous vein was divided at the mid-thigh level and inverted towards the inguinal canal, where it was anastomosed directly to the peritoneum at the internal inguinal ring using non-absorbable suture material.

Results

Seven patients had successful shunt formation; the remaining patient had to have the shunt removed because of ascitic leakage. In those who underwent successful shunt formation, the need for paracentesis and the dose of diuretic was significantly reduced over a median follow-up of 8 months. Hospital stay in the month after discharge was significantly less than that in the month before operation. Three patients died during follow-up from causes unrelated to the operation. One patient underwent successful liver transplantation.

Conclusion

This study suggests that saphenoperitoneal shunting is potentially a safe and effective therapy for patients with diuretic-resistant ascites. It retains the benefits of peritoneovenous shunting without the adverse effects of insertion of foreign material.
Experimental study of the influence of intestinal flora on the healing of intestinal anastomoses
Authors: Okada M , Bothin C , Kanazawa K , Midtvedt T
Published: March 2003

Background

The beneficial effects of the normal intestinal flora on wound healing in the skin have already been confirmed, and this study attempted to elucidate the influence of the intestinal flora on the healing process in intestinal anastomoses.

Methods

Five groups of rats were studied: germ-free, conventional, monocontaminated with Lactobacillus acidophilus La5 or Escherichia coli X7 and ex-germ-free (conventionalized). All animals underwent ileal and colonic resections followed by anastomoses. Seven days later they were killed and the bursting pressure and hydroxyproline concentration of the anastomoses were measured. The microbiological status of the animals was confirmed weekly.

Results

No bacteria were detected in the germ-free rats and no other bacteria were found in the monocontaminated animals. Conventional rats had a significantly higher anastomotic bursting pressure both in the ileum compared with rats monocontaminated with L. acidophilus, and in the colon compared with germ-free rats. The ex-germ-free rats also showed a significantly higher bursting pressure than germ-free animals and rats monocontaminated with either L. acidophilus or E. coli in the ileum and colon.

Conclusion

The presence of the intestinal flora enhanced the healing of intestinal anastomoses. The data suggest that this effect depends on differences in the types of bacteria in the intestine.
Contrast-enhanced colour Doppler ultrasonography in suspected breast cancer recurrence
Authors: Winehouse J , Douek M , Holz K , Madjar H , Gillams A , Lees W , Baum M
Published: March 2003

Background

Postoperative scarring and radiotherapy changes in the conservatively treated breast often mimic breast cancer recurrence, resulting in many unnecessary biopsies. Local breast cancer recurrence may be detected more accurately with contrast-enhanced colour Doppler imaging.

Methods

Fifty-eight women with suspected local breast cancer recurrence were evaluated prospectively by means of conventional and contrast-enhanced colour Doppler imaging before surgical biopsy.

Results

Sensitivity for the detection of breast cancer recurrence using contrast enhancement was 94 per cent (specificity 67 per cent). Contrast enhancement significantly increased overall diagnostic accuracy, from 80 to 90 per cent (P < 0·04).

Conclusion

Contrast-enhanced colour Doppler imaging is a highly accurate method for detecting local breast cancer recurrence. Its adoption may substantially reduce biopsy rates.
Protective effect of preconditioning and adenosine pretreatment in experimental skeletal muscle reperfusion injury
Authors: Papanastasiou S , Estdale S E , Homer-Vanniasinkam S , Mathie R T
Published: March 2003

Background

Prolonged ischaemia followed by reperfusion (I/R) of skeletal muscle results in significant tissue injury. Ischaemic preconditioning (IPC), achieved by repeated brief periods of I/R before prolonged ischaemia or adenosine pretreatment, can prevent I/R injury in cardiac muscle. The aim of this study was to ascertain in a rodent model if damage to skeletal muscle due to global hindlimb tourniquet-induced I/R could be similarly attenuated.

Methods

Anaesthetized rats were randomized (n = 6–10 per group) to five groups: sham-operated controls; I/R (4 h of ischaemia, 2 h of reperfusion); IPC (three cycles of 10 min of ischaemia/10 min of reperfusion) alone; IPC immediately preceding I/R; or adenosine 1000 µg/kg immediately before I/R. At the end of reperfusion, biopsies were taken from the left gastrocnemius muscle for measurement of myeloperoxidase (MPO) and reduced glutathione (GSH). Before ischaemia and at the end of reperfusion, blood samples were taken for measurement of nitric oxide metabolites, tumour necrosis factor (TNF) α and macrophage inflammatory protein (MIP) 2.

Results

IPC before I/R resulted in lower levels of MPO (P < 0·001) and TNF-α (P = 0·004), and higher levels of GSH (P < 0·001) and nitric oxide metabolites (P = 0·002) than I/R alone. Adenosine had effects comparable to IPC pretreatment (P < 0·001 for MPO, P = 0·002 for GSH, P = 0·02 for nitric oxide metabolites and P = 0·001 for TNF-α). There was no difference in the blood pressure or the MIP-2 concentration among the groups.

Conclusion

IPC or pretreatment with adenosine ameliorates the I/R injury of skeletal muscle.