bluuebunny/crossref_metadata_2025 huggingface dataset:
Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer
Authors: Asao T , Hosouchi Y , Nakabayashi T , Haga N , Mochiki E , Kuwano H
Published: March 2003

Background

A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported.

Methods

Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision.

Results

The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated.

Conclusion

A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.
Prospective evaluation of the morbidity of axillary clearance for breast cancer
Authors: Duff M , Hill A D K , McGreal G , Walsh S , McDermott E W , O'Higgins N J
Published: March 2003

Background

Axillary clearance, despite its morbidity, retains an essential role in the management of patients with breast cancer. The aim of this prospective study was to document the development of arm swelling and limitation of shoulder movement following complete axillary clearance.

Methods

One hundred patients who had axillary clearance to level III, for treatment of breast cancer, were followed prospectively for over 1 year. Arm volumes were measured using an optoelectronic volometer and shoulder movements with a goniometer.

Results

Ten patients had significant arm swelling at 1 year. The swelling was mild in eight and moderate in two. No patient developed severe swelling. Reduced arm movements were noted in the first week after operation but had returned to normal at 6 months.

Conclusion

This study provided accurate documentation of the morbidity associated with axillary clearance, together with a reproducible method of arm volume measurement.
Postoperative liver function after elective right hepatectomy in elderly patients
Authors: Ettorre G M , Sommacale D , Farges O , Sauvanet A , Guevara O , Belghiti J
Published: March 2003

Background

Because the influence of age on the risk of liver resection is controversial, the outcome of major liver resection in patients older than 65 years was evaluated.

Methods

Between 1990 and 1997, 24 patients aged 65 years or more underwent elective right hepatectomy (segments V–VIII) for a malignant liver tumour arising in a normal liver. They were evaluated retrospectively in terms of operative deaths, morbidity and postoperative liver function, and compared with 22 patients aged 40 years or less who had undergone a similar resection during the same interval.

Results

Elective right hepatectomy in patients aged 65 years or more resulted in a similar number of deaths (one versus none) and a similar severe complication rate (12 versus 5 per cent) to that observed in patients aged 40 years or less. Evaluation of liver function on days 2, 5 and 8 after operation, in patients aged 65 years or more and 40 years or less, showed that mean prothrombin time was 52 versus 56 per cent, 58 versus 62 per cent and 76 versus 72 per cent respectively (P not significant) and that the mean total serum bilirubin level was 35 versus 38 µmol/l, 32 versus 36 µmol/l and 25 versus 28 µmol/l (P not significant). Postoperative levels of aminotransferases, γ-glutamyl transpeptidase and alkaline phosphatase were similar in the two groups. Mean(s.d.) duration of hospital stay was 15(7) days in patients aged 65 years or more and 13(4) days in the younger patients.

Conclusion

Postoperative liver function after elective right hepatectomy in selected patients older than 65 years was similar to that in younger patients.
Response of visceral peritoneum to abdominal surgery
Authors: Ivarsson M-L , Falk P , Holmdahl L
Published: March 2003

Background

Postoperative adhesion formation has been associated with a reduced capacity to degrade fibrin within the peritoneal cavity. Peritoneal fibrinolytic capacity has been shown to decrease during the course of a surgical operation. The aim of this study was to investigate whether tissue-type plasminogen activator (tPA), a key fibrinolytic enzyme, is released into the peritoneal cavity during operation.

Methods

Fluid released from the serosal surface of the small bowel was collected in a plastic bag from 16 patients undergoing surgery. Intraoperative blood samples were also taken from seven patients. Concentrations of the fibrinolytic components tPA and urokinase plasminogen activator (uPA), tPA activity and plasminogen activator inhibitor type 1 (PAI-1) concentration were measured by enzyme-linked immunoabsorbent assay.

Results

Intraoperative tPA concentrations were significantly raised in the peritoneal fluid collected compared with peripheral blood levels (P = 0·008). This resulted in a significantly higher tPA activity in the fluid compared with blood (P = 0·001). However, neither uPA (P = 0·29) nor PAI-1 (P = 0·84) concentrations differed significantly in fluid compared with blood.

Conclusion

These data suggest that tPA is rapidly released by the visceral peritoneum during abdominal surgery. The different concentrations in peripheral blood and peritoneum suggest that tPA is released from the peritoneum by an active process, and does not solely derive from leakage of plasma.

Presented in part to the International Congress on Peritoneal Repair and Adhesions (PAX, 5th meeting), Grantham, UK, October 1999, and to the XXXVth European Society for Surgical Research in Malmö, Sweden, June 2000
Value and cost of follow-up after adjuvant treatment of patients with Dukes' C colonic cancer
Authors: Bleeker W A , Mulder N H , Hermans J , Otter R , Plukker J T M
Published: March 2003

Background

The clinical value and costs of different diagnostic tools used to identify potentially curable recurrent disease in patients treated adjuvantly for curatively resected Dukes' C colonic cancer were examined.

Methods

The study group comprised 496 patients treated with chemotherapy over a 1-year interval. Follow-up consisted of interim history, physical examination, liver ultrasonography or computed tomography (CT), measurement of carcinoembryonic antigen (CEA) levels, chest radiography and colonoscopy.

Results

Two hundred and thirteen patients had recurrent disease (median follow-up 43 months). Forty-two patients with recurrence (20 per cent) were treated with curative intent (median survival 38 months; 5-year survival rate 40 per cent). Recurrence was identified by liver ultrasonography or CT (n = 14), evaluation of symptoms (n = 12), colonoscopy (n = 8), CEA measurement (n = 3), chest radiography (n = 2), physical examination (n = 1) and other modalities in two patients. The mean cost of diagnostic procedures per curative resected recurrence for patients amenable to salvage surgery was US$9011. Of all treatable recurrences, 12 of 42 were identified by evaluation of symptoms only. Ultrasonography and colonoscopy identified 22 recurrences at a cost of US$11 790 per patient, while routine follow-up by CEA measurement, chest radiography and physical examination identified a further six at a cost of US$19 850 per patient.

Conclusion

Potentially curable recurrences were detected primarily by liver imaging and colonoscopy. The yield of CEA measurement, chest radiography and physical examination was relatively low; such methods were expensive and should not be recommended in the routine follow-up of these patients.
Selection of patients for laparoscopic repair of perforated peptic ulcer
Authors: Lee F Y J , Leung K L , Lai P B S , Lau J W Y
Published: March 2003

Background

Although randomized and non-randomized studies have evaluated the safety of laparoscopic repair for perforated peptic ulcer, no definite guidelines have been published on selection of patients for laparoscopic repair. This cohort study aimed to define patients who may not benefit from laparoscopic techniques.

Methods

The data from 374 consecutive patients with perforated peptic ulcer treated by simple repair were collected prospectively and analysed.

Results

From January 1992 to December 1998, 219 patients were treated by open suture repair, 109 by laparoscopic sutureless (fibrin glue) repair and 46 by laparoscopic suture repair. The overall leak rate after laparoscopic suture and sutureless repair was 6 and 16 per cent respectively. Leakage was noted to be associated with a significantly higher rate of wound infection, intra-abdominal abscess formation, prolonged ileus (P < 0·001) and longer hospital stay (11 versus 5 days; P < 0·001). Multivariate analysis demonstrated that Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission predicted the likelihood of a leak after laparoscopic fibrin glue repair (P = 0·006).

Conclusion

APACHE II score may be a useful index for selecting patients for laparoscopic fibrin glue repair.
Reduction of experimental adhesion formation by inhibition of plasminogen activator inhibitor type 1
Authors: Falk K , Björquist P , Strömqvist M , Holmdahl L
Published: March 2003

Background

Adhesion formation is a common cause of complications following surgery. A reduction in peritoneal fibrinolytic capacity during operation is a key mechanism in the early formation of adhesions. An increase in the main inhibitor of fibrinolysis, plasminogen activator inhibitor type 1 (PAI-1), is a major factor in the loss of fibrinolytic activity. The aim of this study was to investigate if inhibition of PAI-1 could reduce the formation of adhesions after surgery.

Methods

Mice (n = 53) were subjected to a standard surgical procedure in order to induce adhesion formation to the abdominal side wall. At the conclusion of the operation, fragments for antigen binding of polyclonal rabbit antibody against PAI-1 (PRAP-1) were injected intraperitoneally, at two different concentrations. Control animals received an equal volume of the vehicle (saline). One week after operation adhesion formation was quantified.

Results

Both doses of PRAP-1 significantly reduced adhesion formation compared with the saline control (P = 0·003 and P = 0·002). There were no signs of bleeding in the postoperative period or at reoperation.

Conclusion

The present observations lend further support to the hypothesis of a pivotal role of fibrinolysis in the early formation of adhesions, and open up new possibilities for adhesion reduction by inhibiting PAI-1.
Randomized clinical trial of laparoscopic versus open appendicectomy
Authors: Pedersen A G , Petersen O B , Wara P , Rønning H , Qvist N , Laurberg S
Published: March 2003

Background

Laparoscopy in patients with a clinical suspicion of acute appendicitis has not gained wide acceptance, and its use remains controversial.

Methods

In a randomized controlled trial of laparoscopic versus open appendicectomy, 583 of 828 consecutive patients consented to participate. Three hundred and one patients were allocated to open appendicectomy and 282 patients to laparoscopy, 65 of whom required conversion to open appendicectomy. Length of stay in hospital was the primary endpoint, while operating time, postoperative morbidity, duration of convalescence and cosmesis were secondary endpoints.

Results

Intention-to-treat analysis revealed an equally short hospital stay in the two groups (median 2 days). The median time to return to normal activity (7 versus 10 days) and work (10 versus 16 days) was significantly shorter following laparoscopy. Laparoscopy was associated with fewer wound infections (P < 0·03) and improved cosmesis (P < 0·001), but the operating time was longer (60 versus 40 min). Laparoscopy was associated with more intraperitoneal abscesses (5 versus 1 per cent) but, adjusted for a greater number of gangrenous or perforated appendices in this group, the difference failed to reach statistical significance.

Conclusion

Hospital stay was equally short, whereas laparoscopic appendicectomy was associated with fewer wound infections, faster recovery, earlier return to work and improved cosmesis.
Dysphagia after antireflux surgery
Authors: Wills V L , Hunt D R
Published: March 2003

Background

Dysphagia is experienced by many patients after antireflux surgery. This literature review examines factors associated with the development, prediction and management of postoperative dysphagia.

Methods

Published studies examining issues related to dysphagia, gastro-oesophageal reflux and fundoplication were reviewed.

Results

Postoperative dysphagia is usually temporary but proves troublesome for 5–10 per cent of patients. Technical modifications, such as a partial wrap, division of short gastric vessels and method of hiatal closure, have not conclusively reduced its incidence. There is no reliable preoperative test to predict dysphagia.

Conclusion

It is uncertain whether postoperative dysphagia arises from patient predilection or is largely a consequence of mechanical changes created by fundoplication. Anatomical errors account for a significant proportion of patients referred for correction of dysphagia but these are uncommon in large single-institution studies. Abnormal manometry cannot predict dysphagia and, on current evidence, ‘tailoring’ the operation does not prevent its occurrence.
Sodium hyaluronate enhances colorectal tumour cell metastatic potential in vitro and in vivo
Authors: Tan B , Wang J H , Wu Q D , Kirwan W O , Redmond H P
Published: March 2003

Background

Sodium hyaluronate has been used intraperitoneally to prevent postoperative adhesions. However, the effect of sodium hyaluronate on tumour growth and metastasis in vitro and in vivo is still unknown.

Methods

Human colorectal tumour cell lines SW480, SW620 and SW707 were treated with sodium hyaluronate (10–500 μg/ml) and carboxymethylcellulose (0·125–1 per cent), and tumour cell proliferation and motility were determined in vitro. For the in vivo experiments male BD IX rats were randomized to a sodium hyaluronate group (n = 11; intraperitoneal administration of 0·5 × 106 DHD/K12 tumour cells and 5 ml 0·4 per cent sodium hyaluronate) or a phosphate-buffered saline group (n = 11; 0·5 × 106 DHD/K12 tumour cells and 5 ml phosphate-buffered saline intraperitoneally). Four weeks later the intraperitoneal tumour load was visualized directly.

Results

In vitro sodium hyaluronate increased tumour cell proliferation and motility significantly. Sodium hyaluronate-induced tumour cell motility appeared to be CD44 receptor dependent, whereas sodium hyaluronate-induced tumour cell proliferation was CD44 receptor independent. In vivo there was a significantly higher total tumour nodule count in the peritoneal cavity of the sodium hyaluronate-treated group compared with the control (P = 0·016).

Conclusion

Sodium hyaluronate enhances tumour metastatic potential in vitro and in vivo, which suggests that use of sodium hyaluronate to prevent adhesions in colorectal cancer surgery may also potentiate intraperitoneal tumour growth.

Presented to the Patey Prize Session of the Surgical Research Society and the annual scientific meeting of the Association of Surgeons of Great Britain and Ireland, Brighton, UK, 4–7 May 1999
Effect of CD4+ and CD8+ cell depletion on wound healing
Authors: Davis P A , Corless D J , Aspinall R , Wastell C
Published: March 2003

Background

Depression of the immune system can result in poor or delayed wound healing.

Methods

Thymectomized rats were depleted of CD4+ and CD8+ lymphocytes by intraperitoneal injection of Medical Research Council Oxford (MRC OX)38 antibodies and MRC OX8. Significant depletion was demonstrated throughout the wound healing process by immunofluorescence studies of peripheral blood. Following depletion the rats underwent laparotomy incisions which were allowed to heal for 10 weeks. Differences in healing were demonstrated by analysing the wounds biomechanically by tensiometry to obtain values of ultimate strength, resilience, toughness, maximum extension and elastic constant.

Results

Wounds of animals depleted of CD4+ lymphocytes showed a significant decrease in ultimate strength, resilience and toughness. Wounds of animals depleted of CD8+ lymphocytes showed a significant increase in ultimate strength, resilience and toughness.

Conclusion

Wounds healed in the absence of T lymphocytes. However, the subsets have an opposing regulatory role, with CD4+ lymphocytes upregulating and CD8+ lymphocytes downregulating wound healing.
Influence of aspirin on early allograft thrombosis and chronic allograft nephropathy following renal transplantation
Authors: Murphy G J , Taha R , Windmill D C , Metcalfe M , Nicholson M L
Published: March 2003

Background

Primary thrombosis and chronic allograft nephropathy are important causes of early and late graft loss, respectively, following renal transplantation. This study examined the potential for aspirin therapy to reduce these complications.

Methods

A consecutive series of 105 cadaveric renal transplants treated with aspirin 150 mg daily for the first 3 months after transplantation was compared with an untreated historical control group (n = 121). Protocol needle-core biopsies were performed on all transplants in both groups at 1 week and 12 months after transplantation. Needle-core allograft biopsies were performed at 3, 6 and 12 months after transplantation, and serum creatinine was measured at each outpatient attendance for the duration of follow-up.

Results

There was a significantly lower rate of primary allograft thrombosis in patients treated with aspirin (none of 105) compared with that in the control group (six (5 per cent) of 121; P = 0·03). There were no differences in renal function or 2-year allograft survival between the two groups. Aspirin-treated patients had a lower incidence of chronic allograft nephropathy at 1 year than controls although this did not reach statistical significance (16 versus 26 per cent; P = 0·075). There were no major bleeding complications in either group in association with peptic ulcer disease or following renal transplant biopsy.

Conclusion

Aspirin reduced the rate of early graft thrombosis of renal transplants in this series but did not improve renal function or graft survival. A trend towards a lower rate of chronic allograft nephropathy was noted with aspirin treatment. These findings require confirmation in a prospective randomized trial.
Activation peptide of carboxypeptidase B and anionic trypsinogen as early predictors of the severity of acute pancreatitis
Authors: Appelros S , Petersson U , Toh S , Johnson C , Borgström A
Published: March 2003

Background

Early prediction of severity is important in the management of patients with acute pancreatitis. The presence of activation peptides and certain pancreatic proenzymes in plasma and urine has been shown to correlate with severity. This study was designed to assess the value of measuring levels of the activation peptide of carboxypeptidase B (CAPAP) and of anionic trypsinogen.

Methods

Concentrations of CAPAP and anionic trypsinogen were measured in the urine and serum in 60 patients with acute pancreatitis. Preset cut-off levels were used to analyse the accuracy of the tests. Severity was classified retrospectively according to the Atlanta classification.

Results

Concentrations of CAPAP in urine and serum and of anionic trypsinogen in urine correlated with the severity of the pancreatitis. CAPAP in urine showed the highest accuracy. The overall accuracy was 90 per cent, with a positive predictive value of 69 per cent and a negative predictive value of 98 per cent.

Conclusion

In this study, measurement of CAPAP in urine was an accurate way to predict the severity of acute pancreatitis, and was superior to assay of anionic trypsinogen in urine and serum. Measurement of CAPAP in urine may be of value in the management of individual patients with pancreatitis and in the selection of patients for therapeutic trials.
Procalcitonin strip test in the early detection of severe acute pancreatitis
Authors: Kylänpää-Bäck M-L , Takala A , Kemppainen E , Puolakkainen P , Haapiainen R , Repo H
Published: March 2003

Background

Early identification of patients who subsequently develop severe acute pancreatitis would enable the selection of patients who may benefit from early intensive management. Because severe acute pancreatitis is characterized by the development of systemic inflammation the authors studied whether procalcitonin, a marker of systemic inflammation, differentiated between patients with mild and severe acute pancreatitis.

Methods

On admission and 24 h thereafter, serum procalcitonin level was measured by a rapid, semiquantitative PCT®-Q test and serum C-reactive protein (CRP) by an immunoturbidimetric method in a consecutive series of 162 patients with acute pancreatitis. There were 38 severe and 124 mild cases. The accuracy of procalcitonin and CRP in predicting severe acute pancreatitis was compared with that of Ranson and Acute Physiology and Chronic Health Evaluation (APACHE) II scores.

Results

The PCT®-Q test was more accurate in predicting severe acute pancreatitis (sensitivity 92 per cent and specificity 84 per cent at 24 h) than CRP, APACHE II score and Ranson score. Its negative predictive value was high (97 per cent at 24 h), and it detected each patient who developed subsequent organ failure (n = 22).

Conclusion

The PCT®-Q test was a useful screening method for detecting severe acute pancreatitis. It is simple and quick to perform and, unlike currently available multiple factor scoring systems, can easily be adopted into routine clinical practice.
Sentinel nodes outside lymph node basins in patients with melanoma
Authors: Roozendaal G K , de Vries J D H , van Poll D , Jansen L , Schraffordt Koops H , Nieweg O E , Kroon B B R
Published: March 2003

Background

Lymphoscintigraphy occasionally reveals hot spots outside lymph node basins in patients with melanoma. The aim of this study was to evaluate such abnormally located hot spots.

Methods

Sentinel node biopsy was studied prospectively in 379 patients with clinically localized cutaneous melanoma. One day after lymphoscintigraphy, sentinel node biopsy was performed guided by vital blue dye and a γ ray detection probe.

Results

Persisting hot spots outside the regional node basins were seen in 25 patients (6·6 per cent). Several specific drainage patterns were discerned. In five patients, aberrant sentinel nodes were not explored. The hot spot represented a lymphangioma in two patients. Radioactive lymph nodes were identified in the remaining 18 patients (4·7 per cent). Four patients had metastasis in one of these aberrant lymph nodes.

Conclusion

Sentinel nodes were found outside a lymph node basin in 5 per cent of patients. Particular drainage patterns exist. It is recommended to incorporate such sites in the late scintigraphy images and to pursue aberrant sentinel nodes, as they may be the only sites of metastasis.
Local heat-shock priming-induced improvement in microvascular perfusion in osteomyocutaneous flaps is mediated by heat-shock protein 32
Authors: Rücker M , Schäfer T , Roesken F , Spitzer W J , Bauer M , Menger M D
Published: March 2003

Background

Stress conditioning is thought to improve microvascular free flap survival but the mechanisms of protection are not clear. The aim of this study was to determine whether local induction of heat-shock protein (HSP) 32 improves microvascular perfusion in transferred osteomyocutaneous flaps.

Methods

The hindlimb harvest region of osteomyocutaneous flaps in Wistar rats was subjected to stress conditioning by local heating (30 min, 42·5°C) 24 h before microvascular flap transfer. In a second group of animals, after heat-shock priming, the action of HSP-32 was inhibited by tin protoporphyrin IX. Animals with unconditioned flaps served as controls. After transfer, the microcirculation of the muscle, cutaneous, subcutaneous and periosteal tissue of the flap was analysed quantitatively for 6 h using intravital fluorescence microscopy.

Results

Immunohistochemistry revealed that HSP-32 was detectable only after priming and not in unconditioned flaps. Priming did not alter functional capillary density or capillary red blood cell velocity compared with that in unconditioned flaps. However, heat-shock priming induced significant capillary dilatation (P < 0·05) and thus a substantial increase in capillary blood flow volume (P < 0·05) in all tissues of the transferred flaps. Inhibition of HSP-32 by tin protoporphyrin IX completely abolished the priming-induced improvement in capillary perfusion, as indicated by the lack of increased capillary diameters and volumetric blood flow.

Conclusion

The present study demonstrated that stress conditioning by local heat-shock priming improves nutritive perfusion in osteomyocutaneous flaps by capillary dilatation, probably mediated through the vasoactive action of HSP-32.
Laparoscopy in the staging of pancreatic cancer
Authors: Pisters P W T , Lee J E , Vauthey J N , Charnsangavej C , Evans D B
Published: March 2003

Background

Over the past decade, laparoscopy has emerged as a popular method of detecting extrapancreatic metastatic disease in patients presumed to have localized pancreatic cancer.

Methods and results

The English language literature on laparoscopic staging of pancreatic cancer was reviewed. Interpretation of this literature on staging laparoscopy is difficult because (1) there has been inconsistent use of high-quality computed tomography (CT) in prospective studies, (2) many studies have included patients with locally advanced disease, and (3) the R0/R1/R2 resection rates among patients staged by laparoscopy have not been reported, making it impossible to correlate laparoscopic findings with the R0 resection rate. Laparoscopy may prevent unnecessary laparotomy in a proportion of CT-staged patients presumed to have resectable pancreatic cancer. However, routine laparoscopy is performed on patients judged to have resectable disease by high-quality CT, this fraction of patients is between 4 and 13 per cent.

Conclusion

When state-of-the-art CT is available, the routine use of staging laparoscopy may not be easily justified from the data in the recent literature. Selective use of laparoscopy may be more appropriate and will probably be a more cost-effective staging approach. Criteria are presented for the selective use of laparoscopy in the staging of patients with localized pancreatic cancer.
Impact of laparoscopic surgery on experimental hepatic metastases
Authors: Gutt C N , Riemer V , Kim Z G , Erceg J , Lorenz M
Published: March 2003

Background

Metastatic disease to the liver is one of the major factors determining outcome after colonic resection with curative intention. The influence of laparoscopic surgery on metastatic disease in the liver is still largely unknown.

Methods

An intrasplenic tumour cell inoculation was performed in 30 WAG-Rij rats. After 7 days the rats were randomized into three operative groups: laparotomy (n = 10), laparoscopy with 7 mmHg carbon dioxide pneumoperitoneum (n = 10) and gasless laparoscopy (n = 10). A small bowel segmental resection was carried out in all rats. Some 21 days later the rats were evaluated for number and diameter of tumour nodules and cancer index score at eight different abdominal sites.

Results

Hepatic tumour growth scored with the cancer index was significantly reduced in the gasless laparoscopy group compared with that in the carbon dioxide laparoscopy group (P = 0·04) and the laparotomy group (P = 0·02). Tumour growth at the port site and total tumour load were significantly reduced in the gasless group compared with the laparotomy group (P ≤ 0·04).

Conclusion

Laparoscopy with carbon dioxide insufflation seems to stimulate the growth of dormant tumour cells into overt liver metastases. Gasless laparoscopy on the other hand may have a protective effect against metastatic disease in the liver. The promoting and inhibiting effects of laparoscopic procedures on growth of liver metastases need further evaluation.
Extensive surgical cytoreduction and intraoperative hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei
Authors: Witkamp A J , de Bree E , Kaag M M , van Slooten G W , van Coevorden F , Zoetmulder F A N
Published: March 2003

Background

Pseudomyxoma peritonei remains a fatal disease. However, extensive surgical cytoreduction combined with intraoperative heated intraperitoneal chemotherapy (HIPEC) has recently emerged as a new treatment modality, which might improve survival.

Methods

Patients underwent treatment if the tumour appeared to be technically resectable on preoperative abdominal computed tomography and there were no distant metastases. After aggressive surgical cytoreduction, HIPEC with the administration of mitomycin C was performed for 90 min. Depending on histological grading, patients received adjuvant 5-fluorouracil and leucovorin therapy.

Results

Forty-six patients were treated. Optimal surgical cytoreduction was obtained in 40 patients. Postoperative surgical complications occurred in 18 patients. Four patients died as a direct result of the treatment. Bone marrow suppression due to mitomycin C toxicity occurred in 22 patients. There was no other major toxicity related to the HIPEC procedure. After a median follow-up of 12 months, 40 patients are alive, eight of whom have proven recurrence. The actuarial survival rate (Kaplan–Meier) at 3 years was 81 per cent.

Conclusion

These results confirm that extensive surgery combined with HIPEC is feasible in patients with pseudomyxoma peritonei and that improved long-term survival might be achieved.
Expression of gastrin in developing gastric adenocarcinoma
Authors: Henwood M , Clarke P A , Smith A M , Watson S A
Published: March 2003

Background

A stepwise progression through premalignant stages has been identified for the intestinal type of gastric carcinoma. As gastrin has been identified as a growth factor for the intestinal type of gastric adenocarcinoma, the aim of this study was to investigate whether gastrin is expressed in premalignant gastric conditions.

Methods

Ninety archival samples of atrophic gastritis, intestinal metaplasia, mild gastric epithelial dysplasia, moderate gastric epithelial dysplasia, severe gastric epithelial dysplasia and intestinal-type gastric adenocarcinoma were obtained. Immunocytochemistry was performed using antibodies directed against gastrin and its post-translational precursors, and the gastrin/cholecystokinin B receptor. Positive staining was identified using the avidin–biotin immunoperoxidase method and quantified using an image analysis system.

Results

Gastrin and its receptor were shown to be expressed in specimens of atrophic gastritis, intestinal metaplasia, epithelial dysplasia and the intestinal type of gastric carcinoma.

Conclusion

Gastrin seems to be an important growth factor in gastric carcinogenesis.
Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children
Authors: Lintula H , Kokki H , Vanamo K
Published: March 2003

Background

Appendicectomy is the most common emergency surgical operation in children. The aim of this study was to compare recovery after appendicectomy using either a laparoscopic or an open technique in children.

Methods

Sixty-one children aged 4–15 years undergoing appendicectomy for suspected uncomplicated appendicitis were studied. The study was prospective, randomized and single-blinded, with parallel groups. Standardized anaesthetic technique and pain management were used. The study endpoints were postoperative pain, need for rescue analgesia, and length of hospital stay.

Results

Children had significantly less pain after laparoscopic compared with open appendicectomy 8 h after operation and on the first and second postoperative mornings (P < 0·05). Laparoscopic appendicectomy resulted in a reduced requirement for rescue analgesia with oxycodone in hospital: mean(s.d.) 3·6(2·5) versus 5·8(3·3) doses (mean difference 2·2 doses, 95 per cent confidence interval (c.i.) 0·6–3·8 doses); P = 0·01. The mean(s.d.) length of hospital stay was significantly shorter in the laparoscopic group: 1·9(0·7) versus 2·6(0·9) days (mean difference 0·7 days, 95 per cent c.i. 0·3–1·1 days); P = 0·001. Three children who had open appendicectomy developed a wound infection.

Conclusion

Laparoscopic appendicectomy is associated with less postoperative pain and a shorter hospital stay than open appendicectomy in children undergoing surgery for uncomplicated appendicitis.
Analysis and surgical treatment of persistent dysphagia after Nissen fundoplication
Authors: Bais J E , Wijnhoven B P L , Masclee A A M , Smout A J P M , Gooszen H G
Published: March 2003

Background

After Nissen fundoplication, troublesome dysphagia develops in 5–10 per cent of patients. The mechanism of dysphagia has not been fully resolved, in spite of a number of studies focusing on oesophageal motility and lower oesophageal sphincter (LOS) dynamics. Tightness and length of the wrap have had considerable attention, without giving a fully satisfactory explanation of the pathophysiological mechanism.

Methods

Eighteen patients with persistent dysphagia after Nissen fundoplication needing reoperation were studied. Eighteen patients, matched for age and sex, without dysphagia after Nissen fundoplication were used as controls. Reoperation consisted of conversion of a 360° into a 270° wrap. Barium swallow, endoscopy, oesophageal manometry and 24-h pH monitoring were performed before and after (re)operation.

Results

Peristaltic amplitude, velocity and duration of contraction were not significantly influenced by operation. In 16 of 18 patients with dysphagia, LOS relaxation was incomplete and the residual relaxation pressure was significantly higher than that in the group without dysphagia (P < 0·01). No correlation was found between LOS pressure and peristaltic amplitude, nor between LOS pressure and ramp pressure in the distal oesophagus. After reoperation, basal LOS pressure decreased significantly (P < 0·01) and LOS relaxation was complete in all but three patients; residual relaxation pressure decreased (P < 0·01) and was significantly lower than that after uncomplicated Nissen fundoplication. In the latter group, LOS pressure, residual relaxation pressure and ramp pressure increased significantly after operation (P < 0·01).

Conclusion

A return to complete LOS relaxation and a decrease in residual relaxation pressure play an important role in resolving dysphagia.
Laparoscopic Nissen versus anterior fundoplication in patients with oesophageal dysmotility: a randomized controlled trial
Authors: Ackroyd R , Watson D I , Devitt P G , Game P A , Jamieson G G
Published: March 2003

Background

It has been postulated that in patients with oesophageal dysmotility a partial fundoplication may be associated with a better outcome than a Nissen fundoplication. This study aimed to compare laparoscopic anterior fundoplication with laparoscopic Nissen fundoplication in patients with disordered peristalsis.

Methods

One hundred and seven patients with documented gastro-oesophageal reflux disease were randomized to undergo either a Nissen fundoplication (n = 53) or an anterior 180° hemifundoplication (n = 54), and were seen at follow-up at least once a year by a blinded investigator who used standardized clinical grading systems to assess postoperative dysphagia, heartburn and patient satisfaction. Patients were divided into two groups depending on preoperative oesophageal manometric findings: normal peristalsis (81 patients) or disordered peristalsis (26 patients – propagated less than 50 per cent of swallows and/or distal peristaltic amplitude less than 40 mmHg).

Results

At all follow-up intervals beyond 6 months, patients who underwent an anterior fundoplication experienced less dysphagia and were more likely to be satisfied with the clinical outcome. The magnitude of outcome differences was independent of peristaltic status, and there was no trend towards a poorer outcome in patients with poor peristalsis who underwent Nissen fundoplication.

Conclusion

The concept of tailoring the specific antireflux procedure according to preoperative peristaltic status was not supported by this trial. However, laparoscopic anterior fundoplication was associated with less dysphagia overall and an improved clinical outcome at 3 years.
Photodynamic therapy for dysplastic Barrett's oesophagus: long-term follow-up
Authors: Kelty C J , Ackroyd R , Brown N J , Stephenson T J , Stoddard C J , Reed M W R
Published: March 2003

Background

Photodynamic therapy (PDT) is a novel treatment in which tissue damage is caused by the action of light on a previously administered photosensitizing agent. The results of long-term follow-up of the use of PDT in patients with dysplastic Barrett's oesophagus are presented.

Methods

Thirty-seven patients with low-grade dysplastic Barrett's oesophagus were treated with oral 5-aminolaevulinic acid (ALA) 30 mg kg1, followed by laser endoscopy 4 h later. Patients were treated between December 1995 and December 1998, and all were followed regularly with endoscopy and biopsies in the authors' surveillance programme.

Results

All patients initially showed eradication of dysplasia, and 32 of 37 had a macroscopic reduction in the length of columnar epithelium. The effect was maintained for a median of 43 (range 18–54) months, although one patient developed a late carcinoma.

Conclusion

ALA-induced PDT can provide safe and effective ablation of low-grade dysplastic Barrett's oesophagus, and the effects appear to be maintained for a protracted period of time.
High risk of surgical intervention in hereditary pancreatitis
Authors:   UK and Ireland consortium of the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer, Howes N , Lerch M M , Mössner J , Endres S , Deviere J , Verreman G , Lucidi V , Charnley R , Imrie C , Hall R , Olah A , Ihse I , Steenbergan W , O'Donnell M , Greenhalf W , Ellis I , Rutherford S , Mountford R , Whitcombe D C , Neoptolemos J P
Published: March 2003

Background

The aim of the study was to quantify the risk of surgical intervention in families with hereditary pancreatitis referred to the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC).

Methods

Recruitment to EUROPAC started in 1997; families were considered if two or more members had chronic pancreatitis of unknown aetiology. Families were tested for protease serine 1 (PRSS1) mutations using polymerase chain reaction restriction digestion, sequencing the PRSS1 gene-screened negative families. Clinical information about surgical intervention was obtained from family members and referring clinicians, and the cumulative incidence of surgical intervention in the N291 and R122H mutation groups was determined with the Kaplan–Meier method.

Results

Forty-four families had the R122H mutation, 21 the N291 mutation, and 31 were negative for both. Some 14 (35 per cent) of 40 patients (median age 26·5 (95 per cent confidence interval (c.i.) 21·5–36·3) years) with the N291 mutation had an operative procedure for complications of pancreatitis, compared with 21 (25 per cent) of 83 patients (median age 24 (95 per cent c.i. 13·8–35·8) years) with the R122H variant. This resulted in a cumulative lifetime risk for surgical intervention of 0·6 (95 per cent c.i. 0·5–0·8) for the R122H mutation and 0·6 (0·5–0·8) for the N291 mutation (P = 0·11, log rank test).

Conclusion

Hereditary pancreatitis carries a significantly increased risk of surgical intervention in this cohort of patients, which equates to an estimated lifetime risk of around 60 per cent. The risk of surgery appears to be independent of PRSS1 mutation type.
New classification of oesophageal and gastric carcinomas
Authors: Dolan K , Walker S J , Sutton R , Williams E M I
Published: March 2003

Background

The current International Classification of Diseases (ICD)-O classification of carcinomas of the oesophagus and stomach causes epidemiological and clinical confusion, particularly the use of the term cardia and the overlapping subsites described in the stomach. This study compared the epidemiological and clinical features of each subtype and subsite of carcinoma of the oesophagus and stomach to assess requirements for a new classification of these carcinomas.

Methods

Data were extracted with appropriate validity checks on all cases of oesophageal and gastric carcinoma identified throughout the period 1974–1993 by the Merseyside and Cheshire Cancer Registry, which covers a population of 2·5 million. Comparison of all identifiable epidemiological and clinical features of adenocarcinomas at four different subsites, namely the upper two-thirds of the oesophagus, the lower third of the oesophagus, cardia and subcardia of the stomach, was performed.

Results

There were 5322 primary carcinomas of the oesophagus and 10 535 carcinomas of the stomach registered between 1974 and 1993. The incidence of adenocarcinoma of the lower oesophagus and cardia trebled in males and doubled in females, whereas adenocarcinoma of the subcardia region of the stomach declined in both sexes. The incidence of adenocarcinoma of the lower oesophagus and of the cardia was similar for median age at diagnosis, male: female ratio, percentage of patients who smoked, and survival; both were significantly different from values for carcinoma of the subcardia in these respects.

Conclusion

These data suggest that there is considerable overlap between adenocarcinomas of the lower oesophagus and adenocarcinomas currently classified as of the cardia. The authors believe this is due to the group of carcinomas classified as cardia consisting mainly of carcinomas that traverse the gastro-oesophageal junction. These carcinomas were different in all studied parameters from carcinomas of the stomach and should be classified separately from gastric carcinomas. A new subsite classification of oesophageal and gastric carcinomas is proposed that includes the gastro-oesophageal junction as a subsite of the oesophagus and that simplifies the subsite classification of the stomach into proximal, distal and overlapping.
Magenstrasse and Mill vertical gastric stapling for morbid obesity
Authors: Featherstone N , Dachtler J , Johnston D , Sue-Ling H M
Published: March 2003

Background

The aim of the study was to determine the effects of a new vertical gastric stapling procedure used alone or in combination with a Roux-en-Y gastric bypass for patients with morbid obesity.

Methods

A consecutive series of 100 patients with morbid obesity underwent either vertical gastric stapling alone (Magenstrasse and Mill procedure; MM) (n = 80) or combined with a limited Roux-en-Y gastric bypass (MM-GB) (n = 20). Median age (39 versus 40 years), body mass index (45·9 versus 45·8) and M: F ratio (1: 4 versus 1: 3) were similar between the two groups of patients. The median follow-up of patients who underwent the MM procedure was 36 (range 0–72) months, and 15 (0–36) months for patients who had the combined MM-GB procedure.

Results

The operative mortality rate was 0 per cent and there were no major postoperataive complications. Median length of stay was 7 days for patients who had the MM procedure and 10 days for those who underwent combined MM-GB. One year after operation median(s.d.) weight loss was 38·6(15·1) kg in the MM group, compared with 50·4(8·4) kg in the MM-GB group (P = 0·02). Patients who had the MM procedure had lost 30(8·3) per cent of their original weight, compared with 36(3·2) per cent for those who had a combined MM-GB procedure (P = 0·03).

Conclusion

Gastric stapling for morbid obesity is safe in specialized surgical units. Weight loss after the combined MM-GB procedure was greater than that following the MM procedure alone, although this has to be set against the potential long-term complications of a gastric bypass procedure.
Prognostic factors and survival after hepatic resection for hepatocellular carcinoma without cirrhosis
Authors: Nagasue N , Ono T , Yamanoi A , Kohno H , El-Assal O N , Taniura H , Uchida M
Published: March 2003

Background

Detailed follow-up of patients with chronic hepatitis has resulted in increased diagnosis of hepatocellular carcinoma (HCC) in patients without cirrhosis. Despite numerous studies on hepatic resection, the prognostic factors for intrahepatic recurrence and survival are not well known for patients with HCC without cirrhosis.

Methods

Among 349 patients with HCC treated in the past 13 years, cirrhosis was absent in 126 patients (36 per cent). Curative hepatic resection was carried out in 100 (79 per cent) of these patients. Risk factors for intrahepatic recurrence and prognostic factors for survival were evaluated by univariate and multivariate analyses.

Results

Postoperative morbidity and mortality rates were 22 and 3 per cent respectively. The 5- and 10-year disease-free and overall survival rates were 31 and 50 per cent, and 22 and 47 per cent respectively. Blood loss, surgical resection margin, intrahepatic metastasis, portal vein invasion and extent of hepatic resection were independently associated with overall survival. However, the only risk factors for intrahepatic recurrence were portal vein invasion and hepatitis C virus (HCV) infection. The former was related to early recurrence while the latter was related to later recurrence. The 5-year disease-free survival rate was 58 per cent in patients with hepatitis B virus infection while it was 6 per cent in patients with HCV infection (P < 0·001).

Conclusion

In the treatment of HCC without cirrhosis, major hepatectomy is advocated to prevent early recurrence. Liver transplantation may be required for patients with HCV infection.
Expression of the RET proto-oncogene in papillary thyroid carcinoma and its correlation with clinical outcome
Authors: Kjellman P , Learoyd D L , Messina M , Weber G , Höög A , Wallin G , Larsson C , Robinson B G , Zedenius J
Published: March 2003

Background

In papillary thyroid carcinoma (PTC), presence of the oncogenes RET/PTC has been described, but their correlation with prognosis is debated. The aim of this study was to investigate the expression of the RET proto-oncogene (RET) and correlate it with clinical outcome.

Methods

Sixty-one PTCs were analysed for expression of RET and the oncogenes RET/PTC1–4 by polymerase chain reaction of complementary DNA.

Results

Twenty-nine PTCs (48 per cent) expressed the RET tyrosine kinase domain (RET-TK). Twelve expressed wild-type RET (WT-RET). One tumour expressed RET/PTC3, one a variant of RET/PTC3, and one RET/PTC1 and WT-RET simultaneously. The remaining 14 expressed RET-TK only. WT-RET expression was detected more frequently in poorly differentiated PTCs (P < 0·05) and in PTCs from patients with aggressive disease (P < 0·01). WT-RET expression remained an independently significant risk factor for aggressive disease when analysed together with other recognized risk factors using a stepwise multiple logistic regression model.

Conclusion

Almost half of the PTCs showed RET-TK expression; in only three was this explained by expression of a RET/PTC rearrangement. Instead, expression of WT-RET was detected in 45 per cent of the RET-TK-positive tumours and this expression was an independently significant risk factor for aggressive PTC.