bluuebunny/crossref_metadata_2025 huggingface dataset:
Rescue of liver grafts from hepatic artery occlusion in living-related liver transplantation
Authors: Sakamoto Y , Harihara Y , Nakatsuka T , Kawarasaki H , Takayama T , Kubota K , Kimura W , Kita Y , Tanaka H , Ito M , Hashizume K , Makuuchi M
Published: March 2003

Background

Hepatic artery thrombosis after liver transplantation remains a significant cause of graft loss and death. Retransplantation is a difficult option after living-related liver transplantation in Japan.

Methods

Twenty-seven patients underwent living-related liver transplantation with left-sided liver grafts donated from their relatives. The hepatic artery was anastomosed end to end under a surgical microscope. Anticoagulant therapy was maintained for 2 weeks after operation. Routine post-transplant Doppler ultrasonography together with serum blood tests were performed twice a day during the first 2 weeks.

Results

Three patients developed hepatic artery occlusion, which was identified by routine Doppler ultrasonography before the serum transaminase values increased on days 7, 7 and 3 after surgery respectively. In two of the three patients, no apparent arterial thrombosis was recognized and vasospasm was therefore considered to be the cause of the occlusion. Arterial patency was restored by urgent revascularization with reanastomosis in all patients, but one patient with a functional graft died from a cerebral haemorrhage on day 47.

Conclusion

Early diagnosis of hepatic artery occlusion by routine Doppler ultrasonography and revascularization of the graft is an indispensable strategy for preventing graft loss after living-related liver transplantation.
Live kidney donor assessment in the UK and Ireland
Authors: Lumsdaine J A , Wigmore S J , Forsythe J L R
Published: March 2003

Background

The criteria and methods for assessing live kidney donors are not clear. This study was undertaken to establish whether there is a consensus regarding the organization and methods of assessment of living kidney donors by renal transplant centres in the UK and the Republic of Ireland.

Methods

All transplant centres in the UK and Ireland involved in living donor kidney transplantation were contacted by telephone survey followed by postal questionnaire.

Results

Considerable variation was observed in the organization of living kidney donor evaluation and the methods of assessment used. The upper and lower age limits considered acceptable for kidney donation were variable, with six of 29 centres setting no lower age limit and 11 setting no upper age limit. Four centres do not currently offer living donor kidney transplantation. Of the 29 centres involved with living donor transplantation ten had no protocol for donor assessment. A dedicated transplant coordinator/nurse practitioner was employed by 20 centres and ten routinely used an independent medical assessor to evaluate living related donors. The frequency and duration of donor follow-up after kidney donation also varied widely, with 18 centres providing life-time, seven limited and three no follow-up after initial postoperative assessment.

Conclusion

The wide variation in organizational structure and method of assessment of living kidney donors in the UK and Ireland supports the need for establishment of guidelines for this practice.
Value of splenic preservation during distal pancreatectomy for chronic pancreatitis
Authors: Govil S , Imrie C W
Published: March 2003

Background

Pain relief after distal pancreatectomy for chronic pancreatitis is reportedly satisfactory in 50–80 per cent of patients. This study attempted to determine clinical and radiological features that might select patients likely to benefit from distal pancreatectomy, and whether splenic preservation influenced the outcome.

Methods

Thirty-eight patients with chronic pancreatitis, who underwent distal pancreatectomy between 1982 and 1998, were reviewed retrospectively. The outcome of surgery was correlated with the aetiology of pancreatitis and radiological appearance on endoscopic retrograde cholangiopancreatography and computed tomography.

Results

Good results were achieved in 23 of 36 patients for whom follow-up (median 48 months) was available, including all 11 with obstructive pancreatitis. The spleen was preserved in 22 patients. Twelve patients became diabetic after surgery: three of 20 in whom the spleen was preserved and nine of 16 who underwent splenectomy.

Conclusion

Non-alcoholic patients with a normal pancreas proximal to a dominant ductal stricture had a consistently good outcome from surgery. Spleen-preserving distal pancreatectomy, although technically demanding, can be performed safely with results equivalent to those of distal pancreatectomy with splenectomy or autotransplantation. Splenic preservation, apart from preventing postsplenectomy sepsis, might also delay the onset of diabetes.
Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication
Authors: Franzén T , Boström J , Tibbling Grahn L , Johansson K-E
Published: March 2003

Background

This was a prospective study of symptoms, and short-term and long-term reflux competence after partial fundoplication.

Methods

Some 101 patients were operated consecutively with posterior partial (270°) fundoplication. Indications for surgery were reflux disease without erosive oesophagitis in 25 patients, moderate oesophagitis in 43, severe oesophagitis in 25 and paraoesophageal hernia in eight. Symptom score, manometry and pH tests were performed before operation, 6 months after operation and after 6–14 years.

Results

All patients (n = 101) were free from heartburn and regurgitation at early follow-up. There was evidence of clinical recurrence at late follow-up (n = 87) in two of 22 patients without oesophagitis before operation, two of 39 with moderate oesophagitis before operation and three of 19 patients with severe oesophagitis before operation; 92 per cent had good reflux control at late follow-up.

Conclusion

Posterior partial fundoplication shows excellent reflux control at early follow-up. Ten years later fewer than 10 per cent of patients have recurrence, which is more common in patients who had severe oesophagitis before operation.
Staging of rectosigmoid neoplasia with colonoscopic endoluminal ultrasonography
Authors: Norton S A , Thomas M G
Published: March 2003

Background

The accurate staging of colorectal neoplasia may aid the stratification of patients for adjuvant treatment. At present the mural extent of neoplasia proximal to the mid rectum is difficult to determine. Prediction of mural invasion could help identify patients suitable for radical resection, minimal access surgery or endoscopic treatment. Colonoscopic endoluminal ultrasonography (EUS) was used in a prospective study to determine the stage of rectosigmoid neoplasia in 121 patients.

Methods

Mural tumour (T) stage was designated by EUS as uT0/1–uT4 in 121 patients. Nodal (N) staging was performed in 39 cases. EUS staging was compared with histological stage (pT and pN) in 93 patients who underwent resection.

Results

Mural staging of disease using colonoscopic EUS showed good correlation with histo-pathological stage (κ = 0·85 (95 per cent confidence interval 0·76–0·95)). Overall pT and pN stage accuracy of EUS was 92 and 65 per cent respectively.

Conclusion

EUS accurately assessed tumour stage although node staging remained suboptimal. Colonoscopic EUS may aid the selection of treatment in patients with rectosigmoid neoplasia.
Role of laparoscopic ultrasonography in the management of patients with oesophagogastric cancer
Authors: Smith A , Finch M D , John T G , Garden O J , Paterson Brown S
Published: March 2003

Background

Laparoscopy and laparoscopic ultrasonography (lapUS) have been shown to improve the staging of patients with oesophagogastric cancer but there remains doubt as to whether most benefit follows laparoscopy alone and how much is contributed by the addition of lapUS.

Methods

The role of lapUS in surgical decision making was evaluated prospectively in a consecutive series of patients with oesophagogastric cancer following conventional radiological assessment. The results of the lapUS findings over and above the laparoscopic findings were documented in order to identify the additional benefit of lapUS.

Results

After initial conventional assessment 41 patients were considered unsuitable for surgery and treated by palliation, with a further 25 patients proceeding to surgery without laparoscopy. Of the 93 patients who underwent laparoscopy, 18 were shown to have irresectable disease and avoided further surgery; a further seven avoided inappropriate surgery by the addition of lapUS. The open–close laparotomy rate was reduced from five of 25 in patients who did not undergo laparoscopy to nine (12 per cent) of 75 by the introduction of laparoscopy and to two (3 per cent) of 68 with the addition of lapUS.

Conclusion

Laparoscopy alone prevented unnecessary surgery in 18 (19 per cent) of 93 patients with oesophagogastric cancer and the addition of lapUS identified a further seven patients (8 per cent) in whom unnecessary surgery was avoided.
Adjuvant medical therapy in peripheral bypass surgery
Authors: Watson H R , Belcher G , Horrocks M
Published: March 2003

Background

A review was conducted of published clinical trials of adjuvant medical therapy in infrainguinal bypass procedures to evaluate the strength of the evidence for the use of various agents.

Methods

Trials were identified by literature search. The methods used were reviewed and the results with each agent tested were assessed taking into account the soundness of the study design.

Results

Thirty-three studies were identified; fewer than half had a randomized and double-blind design. Most were single-centre studies including a mixture of different surgical procedures and patients with varying degrees of lower limb ischaemia. Clinical outcomes were seldom reported. The median sample size was 61. The median follow-up duration was 12 months, but was often not standardized for all patients in a trial. Only aspirin in prosthetic grafts and ticlopidine in vein grafts have been shown in well designed, double-blind, randomized, controlled trials to reduce the likelihood of occlusion in infrainguinal bypass grafts.

Conclusion

The majority of the trials reviewed had significant deficiencies in their design, reducing the reliance that can be placed on their results. Further studies are required to investigate adequately the effectiveness of existing medical therapies for the maintenance of infrainguinal bypass grafts.
Accuracy of intraoperative frozen-section analysis of axillary nodes
Authors: Hingston G R , Cooke T G , Going J J , Simon R , Flett M M
Published: March 2003

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Letters should be no more than 250 words in length and should be typed on A4-sized paper in double spacing.
Intragraft expression of transforming growth factor β1 gene in isolated glomeruli from human renal transplants
Authors: Nicholson M L , Bicknell G R , Barker G , Doughman T M , Williams S T , Furness P N
Published: March 2003

Background

Experimental evidence suggests that transforming growth factor (TGF) β1 is a fibrogenic cytokine. The histopathological changes of chronic renal allograft nephropathy are dominated by fibrotic changes and TGF-β may have an important aetiological role. This study investigated the relationship between intragraft TGF-β gene expression and extracellular matrix protein deposition in human renal allografts.

Methods

Sixteen cadaveric renal transplant recipients immunosuppressed with cyclosporin and steroids were studied. Individual glomeruli were isolated from protocol needle-core biopsies and, following messenger RNA extraction, intragraft gene expression was studied by reverse transcriptase–polymerase chain reaction. Collagen III deposition in these renal transplant biopsies was examined by immunohistochemistry and quantified by computerized histomorphometry.

Results

There was a positive correlation between renal cortical collagen III immunostaining and the levels of glomerular complementary DNA for TGF-β1.

Conclusion

TGF-β1 is a profibrotic influence in human renal transplants. The methods described should prove of benefit in investigating the mechanisms of chronic renal allograft damage.
Results of pneumatic dilatation in patients with dysphagia after antireflux surgery
Authors: Gaudric M , Sabate J M , Artru P , Chaussade S , Couturier D
Published: March 2003

Background

The mechanisms and treatment of persistent dysphagia after antireflux surgery are not well established. The results of pneumatic dilatation were evaluated in a retrospective study.

Methods

Sixteen patients were reviewed. All had severe and persistent postoperative dysphagia evaluated by oesophageal manometry before pneumatic dilatation.

Results

Seven patients had one dilatation and nine had two dilatations. There was no complication and no relapse of reflux symptoms. Results were satisfactory in nine patients (mean(s.e.m.) follow-up 19·2(6·9) months) and poor in seven, who required revisional surgery. Age, time since operation and weight loss were not related to the outcome. Thirteen patients had abnormal manometry with an ‘achalasia-like’ motor pattern in four. Lower oesophageal sphincter (LOS) pressure, LOS relaxation and oesophageal contraction amplitude were similar in the two groups. The only difference was in the percentage of normal peristaltic contractions (mean(s.e.m.) 82·2(11) versus 39·1(13·8) per cent for satisfactory and poor results respectively; P < 0·05).

Conclusion

In this retrospective study pneumatic dilatation was effective and safe in nine of 16 patients with dysphagia following antireflux surgery. Peristalsis was normal in eight patients, in seven of whom it was associated with satisfactory results.
Major hepatectomy for hepatocellular carcinoma in patients with an unsatisfactory indocyanine green clearance test
Authors: Lam C M , Fan S T , Lo C M , Wong J
Published: March 2003

Background

Liver failure is the commonest cause of postoperative death in patients with hepatocellular carcinoma (HCC). With the improvement in operative technique and perioperative care, the limit of hepatic functional reserve may be lowered. The aim of this study was to evaluate the postoperative morbidity, mortality and survival rates in patients with an indocyanine green (ICG) retention value higher than 14 per cent, after major hepatectomy for HCC.

Methods

From January 1994 to December 1997, 117 patients underwent major hepatectomy for HCC; 92 patients had preoperative ICG retention at 15 min lower than 14 per cent (median 8·3 (range 1·6–13·8) per cent), while 25 patients had ICG retention greater than 14 per cent (17·4 (range 14·3–35·3) per cent). Data were collected prospectively and analysed retrospectively.

Results

The two groups of patients were similar in terms of age, sex ratio, preoperative platelet count, liver biochemistry, Child–Pugh status and operative procedures performed, but the prothrombin time was significantly longer in the high ICG group. The operative blood loss (1·5 litres), the amount of blood transfused and the number of patients requiring blood transfusion were similar. The postoperative complication rate (41 versus 40 per cent), duration of hospital stay (12 versus 13 days), hospital mortality rate (1 versus 4 per cent) and median survival time (47 versus 45 months) were not significantly different.

Conclusion

With meticulous surgical technique to decrease intraoperative blood loss and good perioperative care, selected patients with limited hepatic functional reserve can achieve a good immediate postoperative result and a survival rate similar to that of patients with good hepatic functional reserve.
Management of liver trauma
Authors: Parks R W , Chrysos E , Diamond T
Published: March 2003

Background and methods

Management of blunt or penetrating injuries to the liver remains a significant challenge. This review discusses the mechanisms of liver injury, grading system for severity, available diagnostic modalities and current management options. It is based on a Medline literature search and the authors' clinical experience.

Results

Unstable patients require immediate laparotomy, but selected patients who are haemo- dynamically stable may be managed without operation. The preferred operative techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing; anatomical resection, hepatic artery ligation and various bypass techniques have a limited, more defined role for selected injuries. Major complications include haemorrhage, sepsis and bile leak.

Conclusion

Enhanced resuscitation, anaesthesia and intensive care have contributed to a significant reduction in mortality rates from liver trauma. Optimum results are obtained with a specialist team that includes an experienced liver surgeon, anaesthetist, endoscopist and interventional hepatobiliary radiologist with expertise in managing postoperative complications.
Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias
Authors: Toms A P , Dixon A K , Murphy J M P , Jamieson N V
Published: March 2003

Background

The assessment of abdominal wall hernias has long been a clinical skill that only occasionally required the supplementary radiological assistance of herniography. However, with the advent of cross-sectional imaging, a new range of diagnostic tools is now available to help the clinician in difficult cases.

Methods

This review explores the ability of computed tomography and magnetic resonance imaging to demonstrate many of the hernias encountered in the anterior abdominal wall. Also discussed is the role of imaging techniques in the management of a variety of hernias.

Results and conclusion

Cross-sectional imaging techniques are being employed with increasing frequency for the assessment of hernias. Although the anatomical detail can usually be delineated clearly, the accuracy of the various methods and their place in the clinical management of hernias has yet to be fully determined.
Touch imprint cytological analysis of sentinel lymph nodes for detecting axillary metastases in patients with breast cancer
Authors: Ratanawichitrasin A , Biscotti C V , Levy L , Crowe J P
Published: March 2003

Background

Sentinel lymph node biopsy is a procedure that examines the first tumour-draining lymph node. Touch imprint cytology may provide a quick method for intraoperative screening of sentinel lymph nodes for the presence of metastases.

Methods

Touch imprint cytological analysis of sentinel lymph nodes was compared prospectively with the findings obtained on routine paraffin sections. Touch imprint slides from 55 patients with breast cancer were prepared during operation from multiple sections of sentinel lymph nodes, stained with haematoxylin and eosin. A cytopathologist blinded to the histological results interpreted the smears.

Results

The concordance between touch imprint and paraffin sections of sentinel lymph nodes was 98 per cent (54 of 55). When touch imprint analysis of sentinel lymph nodes was compared with paraffin sectioning of all lymph nodes from the axillary node dissection, the concordance was 95 per cent (52 of 55). The sensitivity and specificity of sentinel lymph node touch imprints in detecting metastases were 82 and 100 per cent respectively. The positive and negative predictive values were 100 and 93 per cent respectively.

Conclusion

Touch imprint cytology is potentially useful for the intraoperative evaluation of sentinel lymph nodes in patients with breast cancer.
Outcome of biofeedback for faecal incontinence
Authors: Norton C , Kamm M A
Published: March 2003

Background

Biofeedback has been reported to improve or eliminate symptoms in approximately 70 per cent of patients with faecal incontinence. However, it is unknown which patients respond in relation to the different symptomatic types of faecal incontinence and the different structural sphincter aetiologies.

Methods

One hundred consecutive patients (84 women; median age 49 years) who completed biofeedback treatment were prospectively characterized by symptoms and by structural integrity of the internal and external anal sphincters as assessed endosonographically (87 patients). Patients underwent a median of 4 biofeedback sessions.

Results

Overall, 43 of the 100 patients regarded themselves as symptomatically cured and 24 improved after treatment. Cure or improvement was experienced by 24 of 30 patients with a structurally normal anal sphincter, by 27 of 46 patients with an external anal sphincter structural defect, and by seven of 11 with an isolated internal anal sphincter defect or atrophy. Thirty-three of 60 patients with urge incontinence alone were symptomatically cured, compared with five of 22 of those with only passive incontinence.

Conclusion

Biofeedback retraining is effective in the short term in treating a majority of patients with faecal incontinence. It is most successful in treating urge incontinence, but also helps some patients with passive leakage. Even in patients with structural anal sphincter damage, some symptom improvement or cure is achieved.
Desmoid tumours complicating familial adenomatous polyposis
Authors: Clark S K , Neale K F , Landgrebe J C , Phillips R K S
Published: March 2003

Background

Desmoid tumours are one of the most important and intriguing extracolonic manifestations of familial adenomatous polyposis (FAP). They have been studied only in small numbers of patients.

Methods

Patients with FAP who also had desmoid tumour were identified from a polyposis registry database and their hospital notes were reviewed.

Results

There were 166 desmoids in 88 patients (median age 32 (interquartile range 22–38) years; 51 (58 per cent) female); 83 tumours (50 per cent) were within the abdomen and 80 (48 per cent) were in the abdominal wall. All but 16 individuals (18 per cent) had already undergone abdominal surgery, which was significantly more recent in women (P = 0·01, Mann–Whitney U test). Intra-abdominal desmoids caused small bowel and ureteric obstruction and resulted in ten deaths; survival was significantly poorer than in patients with abdominal wall desmoid alone (χ2 = 3·93, 1 d.f., P = 0·047, log rank test), and eight of 22 patients who underwent resection of intra-abdominal desmoid died in the perioperative period.

Conclusion

Abdominal wall desmoids caused no deaths or significant morbidity; although recurrence was common after excision, the treatment was safe. Intra-abdominal desmoids can cause serious complications and treatment is often unsuccessful; in particular, surgery for desmoids at this site is hazardous.
Long-term functional results of colonic J pouch versus straight coloanal anastomosis
Authors: Barrier A , Martel P , Gallot D , Dugue L , Sezeur A , Malafosse M
Published: March 2003

Background

There are very few studies evaluating the long-term functional outcome of coloanal anastomoses. This retrospective study aimed to compare long-term functional results of straight and colonic J pouch anastomoses.

Methods

Thirty-seven patients, 25 with a straight anastomosis and 12 with a J pouch anastomosis, responded to a standardized telephone questionnaire. The mean time since surgery was 10 (range 4–18) years.

Results

The mean daily stool frequency was similar in both groups of patients (1·1 in patients with a reservoir, 1·5 in patients with a straight anastomosis). In both groups, two-thirds of patients had perfect continence or limited gas incontinence. Faecal incontinence was reported by two patients with a straight anastomosis and one patient with a pouch. Nocturnal stools and fragmentation were slightly more frequent in patients with a straight anastomosis. Half of the patients regularly used medication. Thirty-five of the 37 patients reported satisfaction with functional results.

Conclusion

Long-term functional results of coloanal anastomoses are satisfactory and, unlike early results, similar for both types of anastomosis. The functional benefit of a reservoir, seen in the first year after operation, is less evident with increasing time.
Endoscopic totally extraperitoneal repair of bilateral inguinal hernias
Authors: Knook M T T , Weidema W F , Stassen L P S , Boelhouwer R U , van Steensel C J
Published: March 2003

Background

Recurrence rates associated with bilateral inguinal hernia repair with a giant prosthesis (Stoppa procedure) are low. Endoscopic totally extraperitoneal bilateral inguinal hernia repair with a giant prosthesis combines the low recurrence rate of the Stoppa repair and the advantages of minimally invasive surgery. The aim of this retrospective study was to investigate whether extraperitoneal bilateral inguinal hernia repair could be performed by the minimally invasive, totally extraperitoneal approach.

Methods

From February 1993 to January 1998, 98 patients with bilateral inguinal hernias underwent surgery. A polypropylene 30 × 10 cm rectangular mesh or a 30 × 10/15 cm ‘slipmesh’ was used. Follow-up, including a physical examination, of 96 per cent of patients was performed.

Results

Median operative time was 60 min. Mostly minor intraoperative complications occurred. Conversion was required for two patients. Apart from one patient with a necrotic fasciitis who died from respiratory failure, only minor postoperative complications (10 per cent) occurred. Median hospital stay was 1 (range 1–21) days. Median recuperation time was 5 (range 1–22) days. Median follow-up (96 per cent) was 32 (range 7–57) months; there were six recurrences among 34 hernias in the group of 17 patients treated with 10 × 30 cm mesh and two (1 per cent) in the group that received 30 × 10/15 cm mesh (162 hernias in 81 patients).

Conclusion

The endoscopic approach for the Stoppa procedure for bilateral inguinal hernia repair is a reliable method with minor complications. It ensures a short recuperation time and the recurrence rate is low owing to adequate overlap of the hernial defect when a ‘slipmesh’ is used.
Role of nitric oxide in intestinal ischaemia-reperfusion injury studied using electron paramagnetic resonance
Authors: Chan K L , Zhang X H , Fung P C W , Guo W H , Tam P K H
Published: March 2003

Background

The role of nitric oxide in intestinal ischaemia–reperfusion (I/R) remains poorly defined, partly because of difficulty in detecting the nitric oxide free radical. In this study nitric oxide production was assessed during intestinal I/R by direct measurement using electron paramagnetic resonance (EPR), and the production of nitric oxide in jejunum and ileum was correlated with their different abilities to resist I/R injury.

Methods

Rats were given an electron spin trapper (diethyldithiocarbamate/ferrous citrate) by intraperitoneal injection. Thirty-six segments each of jejunum and ileum were subjected to 15–90 min of ischaemia and 25 min of reperfusion. Tissue samples were analysed for EPR signals using a spectrometer.

Results

Mean(s.d.) basal nitric oxide level was significantly higher in ileum (3·39(1·42) units) than jejunum (0·65(0·05) units) (P = 0·0005). Increasing ischaemic times in the ileum resulted in decreasing nitric oxide levels (85, 32 and 13 per cent of basal level at 30, 60 and 90 min respectively); reperfusion resulted in further nitric oxide reduction (mean decrease 26 per cent). Severe (grade 3) histological damage was observed in low nitric oxide states (after 15 min of I/R in jejunum, 60 min of I/R in ileum).

Conclusion

Nitric oxide can be measured in intestinal tissues directly by EPR. The findings support a protective role for nitric oxide in I/R, and offer an explanation for the greater resistance to I/R of ileum.
Multicentre study of ultrasonographically guided axillary node biopsy in patients with breast cancer
Authors: de Kanter A Y , van Eijck C H J , van Geel A N , Kruijt R H , Henzen S C , Paul M A , Eggermont A M M , Wiggers T
Published: March 2003

Background

Axillary lymph node dissection is still performed as a staging procedure since lymph node status is the most important prognostic factor in patients with breast cancer. Sentinel node biopsy may replace routine axillary lymphadenectomy, especially in patients with small breast cancers. This study investigated whether ultrasonographically guided fine-needle aspiration cytology (FNAC) of the axillary lymph nodes in clinically node-negative patients was an accurate staging procedure to select patients for sentinel node biopsy.

Methods

One hundred and eighty-five consecutive patients were included. All had axillary ultrasonography and detected nodes were categorized according to their dimensions and echo patterns. Ultrasonographically guided FNAC was carried out if technically possible. These results were compared with the results of the sentinel node biopsy and subsequent axillary dissection.

Results

In 116 patients no lymph nodes were detected by ultrasonographic imaging. Of 69 patients with visible nodes, 31 had malignant cells on FNAC. There were no false-positive results. Some 87 of 185 patients had axillary metastases on definitive histological examination. Ultrasonography was sensitive in patients with extensive nodal involvement. Failure of the examination was caused by problems learning the method, difficulty in puncturing small lymph nodes and sampling error.

Conclusion

In patients without palpable axillary nodes, a sentinel node biopsy could be avoided in 17 per cent since ultrasonography combined with FNAC had already diagnosed axillary metastases. The method is particularly valuable in larger breast cancers.
Prognosis after breast recurrence following conservative surgery and radiotherapy in patients with node-negative breast cancer
Authors: Francis M , Cakir B , Ung O , Gebski V , Boyages J
Published: March 2003

Background

Breast conservation surgery with radiotherapy is a safe and effective alternative to mastectomy for early-stage breast cancer. This retrospective study examined the outcome of patients with isolated local recurrence following conservative surgery and radiotherapy in node-negative breast cancer.

Methods

Between November 1979 and December 1994, 503 women with node-negative breast cancer were treated by conservation surgery and radiotherapy without adjuvant systemic therapy.

Results

After a median follow-up of 73 months the 5-year rate of freedom from local recurrence was 94 per cent. Thirty-five patients developed an isolated local recurrence within the breast as a first event. Thirty-three patients were treated with salvage mastectomy and two patients were treated with systemic therapy alone. The 5-year rate of freedom from second relapse was 46 per cent and the overall 5-year survival rate was 59 per cent for patients who had salvage mastectomy. Patients who developed breast recurrence as a first event had a 3·25 greater risk of developing distant metastasis (P < 0·001) than those who did not have breast recurrence as a first event.

Conclusion

Salvage mastectomy after local recurrence was an appropriate treatment if there was no evidence of distant metastasis. Breast recurrence after conservative surgery and radiotherapy in node-negative breast cancer predicted an increased risk of distant relapse.
Kupffer cell blockade, tumour necrosis factor secretion and survival following endotoxin challenge in experimental biliary obstruction
Authors: Kennedy J A , Lewis H , Clements W D B , Kirk S J , Campbell G , Halliday M I , Rowlands B J
Published: March 2003

Background

Gram-negative sepsis and its sequelae frequently complicate invasive procedures in patients with obstructive jaundice. In response to endotoxin, Kupffer cells secrete tumour necrosis factor (TNF), a pivotal early mediator of sepsis. An investigation was carried out into the specific role of Kupffer cell TNF secretion following endotoxin challenge in obstructive jaundice.

Methods

Survival following intraperitoneal administration of endotoxin (2·0, 0·02 and 0·0002 mg per 100 g) was determined in rats following bile duct ligation (BDL) or sham operation. Plasma TNF concentration was quantified following endotoxin administration (0·0002 mg per 100 g) at 1, 2 and 6 h. Subsequently, the effect of Kupffer cell blockade by gadolinium chloride on survival and plasma TNF concentration was assessed.

Results

Jaundiced animals showed a significantly increased mortality rate following intraperitoneal injection of endotoxin 2·0 mg per 100 g (BDL 100 per cent versus sham 0 per cent) and 0·02 mg per 100 g (BDL 70 per cent versus sham 0 per cent; P = 0·002, Fisher's exact test). Median plasma TNF concentration was significantly greater in jaundiced animals 1 h after endotoxin administration (BDL 943 (interquartile range (i.q.r.) 211–3900) pg/ml versus sham 64 (i.q.r. 47–127) pg/ml; P = 0·002, Mann–Whitney U test). Kupffer cell blockade with gadolinium chloride increased the survival rate following endotoxin administration in BDL animals (BDL-GdCl3 100 per cent versus BDL-saline 40 per cent; P = 0·0003, Fisher's exact test) and decreased median plasma levels of TNF (BDL-GdCl3 88 (i.q.r. 0–1065) pg/ml versus BDL-saline 16 550 (1255–29 360) pg/ml; P = 0·002, Mann–Whitney U test).

Conclusion

Kupffer cell blockade improved survival and suppressed systemic TNF activity after endotoxin challenge. In obstructive jaundice, hypersecretion of TNF by Kupffer cells may supplement systemic cytokine production and be responsible for significant complications.
Patients' perception of surgical services in a district general hospital
Authors: Johnson R C , Pye J K , Scriven M W , Billings P J , Wood C , Crumplin M K H
Published: March 2003

Background

In addition to studying the outcomes of surgery in terms of mortality and morbidity rates and performance, it is also important to consider how patients perceive the delivery of the service given to them.

Methods

A patient satisfaction survey was carried out by the Surgical Epidemiology and Audit Unit of the Royal College of Surgeons of England, on patients undergoing surgical procedures by the Department of Surgery at Wrexham Maelor Hospital. No day cases were included in the study. Two hospitals in southern England (undergoing the same survey) designated X and Y were used for comparison.

Results

Some 2000 questionnaires were sent out twice; 1666 subjects (83 per cent) responded to the first questionnaire and 1445 (87 per cent) of these responded to a second questionnaire 6 weeks later (overall response 72 per cent). A total of 35 per cent of patients were older than 65 years of age. Some 76 per cent of patients with a malignant condition were seen within 4 weeks of referral compared with 38 per cent of those with a benign condition (P < 0·0001). A total of 78 per cent of patients with cancer were admitted within 4 weeks compared with 84 and 88 per cent in hospitals X and Y. Some 23 per cent of patients were admitted as an emergency. Eighteen per cent of patients did not know who presented a consent form to them before surgery compared with 13 and 17 per cent in hospitals X and Y (P < 0·0001). Some 26 per cent of patients perceived that they had complications after surgery compared with 27 and 25 per cent for hospitals X and Y. A total of 35 per cent of patients did not receive a follow-up appointment and 20 per cent of these patients were unhappy about this. Two areas of major concern revealed by the responses were the lack of written information and the overall poor scores generally attained by the emergency admission ward. However, 94 per cent of patients said that they would return to the same consultant.

Conclusion

Patients were generally happy with their surgical care and there was little difference between the three hospitals studied. Lower scores were given when patients were admitted to emergency admission wards. Higher scores were given when patients received printed information.
Fatal and life-threatening complications in antireflux surgery: analysis of 5502 operations
Authors: Rantanen T K , Salo J A , Sipponen J T
Published: March 2003

Background

There have been few comprehensive studies relating to the life-threatening or fatal complications of antireflux surgery.

Methods

Some 5502 antireflux operations were performed in Finland between January 1987 and January 1996 (population approximately 5 million); 3993 procedures (72·6 per cent) were open fundo-plications, 1162 (21·1 per cent) laparoscopic fundoplications and 347 (6·3 per cent) other antireflux procedures.

Results

There were 43 fatal or life-threatening complications (prevalence 0·8 per cent). Twenty-two followed primary open fundoplication (prevalence 0·6 per cent), 15 laparoscopic fundoplication (prevalence 1·3 per cent) (P < 0·05), one refundoplication and five other antireflux procedures. The overall mortality rate was 0·3 per cent. Nine patients (0·2 per cent) died after open fundoplication, one (0·1 per cent) following laparoscopic fundoplication (P = 0·43), one following refundoplication and four after other antireflux procedures. Laparoscopic fundoplication was followed by 14 non-fatal life-threatening complications (prevalence 1·2 per cent), open fundoplication by 13 (prevalence 0·3 per cent) (P < 0·01) and other antireflux procedures by one life-threatening complication (0·3 per cent).

Conclusion

Laparoscopic fundoplication was associated with more life-threatening complications than open fundoplication. This may compromise the advantages of the laparoscopic technique.
Combined inguinal and pelvic lymph node dissection for stage III melanoma
Authors: Hughes T M D , Thomas J M
Published: March 2003

Background

The incidence of melanoma is increasing in the UK and a significant number of patients are still presenting with primary lesions of poor prognosis. As a consequence there is likely to be an increasing number of patients with lymph node metastases for whom the appropriate extent of groin dissection remains controversial. This review summarizes the evidence to enable surgeons to make an informed decision about the management of patients with melanoma metastases to the groin lymph nodes.

Methods

A Medline search was performed to identify all English language articles about melanoma containing the words lymphadenectomy, lymph nodes, inguinal or lymphoedema. Eighty-seven relevant articles were selected from 3904 abstracts retrieved; 34 were related directly to the aim of this review.

Results

There are no randomized controlled trials comparing the outcome of combined inguinal and pelvic lymph node dissection (CLND) and superficial inguinal lymph node dissection (SLND). Excision of pelvic lymph node metastases is reported to yield a 5-year survival rate of 0–35 per cent. Recurrence within the pelvis occurs in 9–18 per cent of patients after SLND and in less than 5 per cent after CLND. Morbidity following either CLND or SLND is poorly reported. Major long-term lymphoedema limiting patient activity affects 6–20 per cent of patients after groin dissection. Cloquet's node was demonstrated in one study to be a useful predictor of pelvic lymph node involvement. Patients may be selected for pelvic node dissection on the basis of clinical findings, the results of pelvic computed tomography and the status of Cloquet's node.

Conclusion

The controversy surrounding the appropriate management of cytologically positive inguinal nodes in melanoma can be resolved only by a prospective randomized trial comparing CLND with SLND. Morbidity and local disease control must be measured as outcomes in addition to disease-free and overall survival.
Value of a surgical high-dependency unit
Authors: Jones H J S , Coggins R , Lafuente J , de Cossart L
Published: March 2003

Background

A minority of hospitals in the UK have a high-dependency unit (HDU). One reason for this is a lack of evidence supporting its benefit. This study sought to compare the outcomes of patients undergoing major abdominal surgery with regard to HDU utilization.

Methods

Data were collected prospectively from two groups of patients over 10 months. Patients in the no-HDU group underwent major abdominal surgery in a hospital without an HDU and returned to a general surgical ward. The other group was managed initially in an HDU. Data collected included Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) scores, complications, deaths and length of stay.

Results

Physiological and operative scores as calculated on the RAJIS POSSUM software were similar in both groups. The HDU group comprised 121 patients. Sixty-four developed a complication whereas 58·81 were expected to, giving an observed: expected (O: E) ratio of 1·09. Sixteen deaths occurred and 14·54 were expected (O: E ratio 1·10). Some 50 per cent stayed in hospital longer than was predicted. The no-HDU group comprised 71 patients. Fifty-nine developed a complication compared with 33·82 expected (O: E ratio 1·74). Ten deaths occurred, whereas 8·88 were expected, giving an O: E ratio of 1·13. Some 63 per cent stayed longer than predicted. The O: E ratios for morbidity were significantly different (P < 0·0005). The complications that occurred more frequently in the absence of an HDU were chest infection, arrhythmias and hypotension.

Conclusion

Postoperative management on an HDU was associated with fewer cardiorespiratory complications. There was no difference in mortality rate but there was a trend towards shorter hospital stay.
Vocal cord paralysis after subtotal oesophagectomy
Authors: Hulscher J B F , van Sandick J W , Devriese P P , van Lanschot J J B , Obertop H
Published: March 2003

Background

Although vocal cord paralysis is a well known complication of subtotal oesophagectomy, precise data concerning origin, incidence and associated morbidity are lacking.

Methods

A retrospective study was performed of 241 patients who underwent transhiatal oesophagectomy for carcinoma of the mid/distal oesophagus between 1994 and 1998. Preoperative and postoperative laryngoscopy results were available for 140 patients.

Results

There were 109 men and 31 women, of mean age 63 years. Thirty-one patients (22 per cent) with recurrent laryngeal nerve paralysis were identified, three with bilateral and 28 with unilateral dysfunction. Paralysis occurred ipsilateral to the side of the cervical incision in 22 of 28 patients. It was permanent in six patients. The associated morbidity was substantial: pulmonary complications were more common in patients with vocal cord paralysis (12 of 31 versus 26 (24 per cent) of 109), leading to significantly more reintubations, and a significantly prolonged ventilation time and stay in the intensive care unit.

Conclusion

Although mostly transient, vocal cord paralysis is a frequent complication with significant associated morbidity. In an extended transthoracic resection (including a lymphadenectomy in the aortopulmonary window where the left recurrent laryngeal nerve is at risk) the cervical anastomosis should be made on the left side, to minimize the risk of bilateral vocal cord paralysis.
Twenty-three years of experience of carotid endarterectomy
Authors: Hussain T , Senaratine J W B , Green F R , Collin J , Hands L , Morris P J
Published: March 2003

Background

Carotid endarterectomy (CEA) has been an evidence-based treatment for symptomatic severe carotid stenosis since 1991. Surgical techniques and patient selection have changed over the years. The results of CEA in a single centre over a 23-year period were reviewed.

Methods

Prospectively gathered preoperative, operative, postoperative and long-term follow-up data were analysed. Routine intraoperative shunting and patch closure has been used since 1988. Data were analysed using the χ2 test or by logistic regression, adjusting for age at operation and date of operation.

Results

Five hundred and seventy-three CEAs (37 bilateral and three repeat procedures) were carried out on 533 patients. Trainees performed an increasing proportion of CEAs from 1996 to 1998 (15, 50 and 56 per cent respectively). The perioperative death rate was 0·8 per cent and the rate of any perioperative neurological deficit was 6·9 per cent. Other causes of morbidity included nerve injury (5·1 per cent) of which the commonest was to the hypoglossal nerve (2·7 per cent). During follow-up (median 4 (range 0–22) years) there were 81 neurological events (15·9 per cent) which included 35 ipsilateral (6·6 per cent) and 18 contralateral (3·4 per cent) strokes. There was no significant difference in outcome for grade of surgeon, intraoperative shunting or patch closure. Major causes of death were cardiac death (74; 14·6 per cent) followed by stroke (23; 4·5 per cent) and cancer (20; 3·9 per cent).

Conclusion

The introduction of routine intraoperative shunting and patch closure, as well as allowing surgical trainees to perform supervised CEAs, has not affected perioperative morbidity and mortality rates or long-term outcome.
Deaths from ruptured abdominal aortic aneurysm in Wales
Authors: Basnyat P S , Biffin A , Moseley L , Hedges R , Lewis M H
Published: March 2003

Background

The aim was to determine the true incidence and operative mortality rate of patients with ruptured abdominal aortic aneurysm (AAA) who reach hospital alive in Wales.

Methods

Patients presenting with a ruptured AAA between September 1996 and August 1997 were analysed. The data were collected prospectively by an independent body, observing strict confidentiality.

Results

Two hundred and thirty-three patients with confirmed ruptured AAA were identified. One hundred and thirty-three patients (57 per cent) underwent attempted operative repair. Eighty-five (64 per cent) died within 30 days. All 100 patients who received no operation died. Of the 233 patients, 92 were admitted under vascular surgeons (VSs) and 141 under non-vascular surgeons (NVSs). VSs operated on 82 patients (89 per cent) of whom 50 (61 per cent) died; NVSs operated on 51 (36 per cent) of whom 35 (69 per cent) died.

Conclusion

This study is the only independent prospective study of death among patients with ruptured AAA who reached hospital alive. Some 57 per cent of the patients with a ruptured AAA were operated on. The operative mortality rate was 64 per cent and the overall mortality rate was 79 per cent. VSs were significantly more aggressive (89 per cent) in the management of ruptured AAA (i.e. more likely to operate) than NVSs (36 per cent) (P < 0·0001). Despite this, the operative mortality rate for VSs was 61 per cent, whereas for NVSs it was 69 per cent (P = 0·372). The overall mortality rate (including operated and non-operated patients) for NVSs (89 per cent) was significantly higher than that for VSs (65 per cent) (P < 0·0001). In Conclusion, ruptured AAA is common in Wales and associated with a high mortality rate even when managed by VSs.
Superficial femoral angioplasty
Authors: Seedawy E El , Black D , Shaw J , Belch J , McCollum P
Published: March 2003

Background

Superficial femoral angioplasty (percutaneous transluminal angioplasty, PTA) is a widely performed therapeutic modality used throughout the UK in the treatment of intermittent claudication. However, there is still concern over its efficacy in the management of atherosclerotic occlusive disease. Long-term outcome was examined in patients undergoing PTA for short (less than 10 cm) occlusions or stenoses.

Methods

Data were collected prospectively for 413 patients undergoing femoral angioplasty and entered into a database for long-term outcome analysis. Patients were seen at 3, 6 and 12 months and at yearly intervals. Doppler ultrasonography and clinical assessment were performed in all patients and duplex imaging was carried out in those in whom there was doubt about patency. Finally, surviving patients were simply questioned as to whether they felt the original PTA to have been worthwhile.

Results

Mean follow-up time was 7 (range 2–11) years. Excluding an initial technical failure rate of 8 per cent, cumulative primary patency at 1, 2, 3, 4 and 5 years was 64, 55, 36, 21 and 14 per cent respectively. Moreover, clinical assessment revealed improvement of the presenting complaint in only 40, 29, 17, 9 and 7 per cent respectively.

Conclusion

Superficial femoral PTA does not appear to be effective in the management of intermittent claudication in most patients.