bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcome of a conservative surgical policy for differentiated thyroid cancer: a prospective population-based cohort study
Authors: Ravindran R , Krukowski Z H
Published: March 2003

Background

The extent of surgery and the requirement for routine total thyroidectomy in patients with papillary or follicular differentiated thyroid cancer (DTC) is contentious. It is desirable to strike a balance between achieving cure and local disease control and avoidable surgical morbidity. Routine total thyroidectomy increases the rate of permanent hypoparathyroidism and may not improve cure or local recurrence rates in patients categorized at low risk. An ongoing prospective study of the outcome of a conservative surgical policy based on an unselected population from the north east of Scotland is reported.

Methods

With few exceptions, all patients with thyroid cancer in north-east Scotland are treated in a specialist unit. Data are recorded prospectively and all patients are reviewed at a dedicated thyroid clinic or by postal review if they leave the area. The mortality, morbidity (including recurrent laryngeal nerve and parathyroid function), recurrence and reoperation rates, and administration of radioactive iodine are recorded. The population of this region is very stable and follow-up is complete in over 97 per cent of patients. The surgical policy is to remove all macroscopic disease from the neck at the first operation and reserve total thyroidectomy for patients with bilateral disease or who are considered at high risk and likely to require postoperative radioactive iodine therapy.

Results

During the period 1977–1996, 238 patients with thyroid cancer were treated of whom 193 (81 per cent) had DTC. Some 148 (77 per cent) of the DTCs were categorized ‘low risk’. Fifty-five (28 per cent) of the 193 patients underwent total or near-total thyroidectomy. The majority of patients (75 per cent low risk; 59 per cent high risk) underwent lobectomy. Seven patients (five low risk; two high risk) have required subsequent completion total thyroidectomy, usually for a rising thyroglobulin level, only three of whom had evidence of DTC in the resected lobe. The mortality rate from DTC was 13 and 1 per cent in high- and low-risk patients respectively. Four (2 per cent) of the 193 patients developed postoperative hypoparathyroidism.

Conclusion

This prospective study suggests that appropriate selection of patients for total thyroidectomy in an endocrine surgical unit is associated with a low mortality rate and little requirement for completion total thyroidectomy. Routine total thyroidectomy is not necessary.
Liver fracture and bleeding
Authors: Krige J E J
Published: March 2003

At laparotomy for blunt abdominal trauma a surgeon in a district general hospital encounters a fractured bleeding liver. How should the problem be handled? Professor J. E. J. Krige of Cape Town, South Africa, replies.
Analysis of local recurrence and optimizing excision margins for cutaneous melanoma
Authors: Ng A K T , Jones W O , Shaw J H F
Published: March 2003

Background

Current guidelines for the treatment of melanoma favour conservatism; however there is still uncertainty regarding best practice for lesions of intermediate thickness. Local recurrence, a measure of treatment adequacy, can be used to determine optimum excision margins and give prognostic information for survival.

Methods

An analysis of the Auckland Melanoma Unit database was performed. Patients with local recurrence were identified and stratified by lesion thickness. Optimum excision margins were derived by regression analysis and evaluated against the database population. Survival and prognostic factors were studied.

Results

Eighty-four of 1155 patients (7 per cent) developed local recurrence. Median follow-up was 51 months. Margins predicted to give a local recurrence of zero were: 1 cm for lesions ≤ 1 mm thick; 1.5 cm for lesions 1–2 mm thick; and 2 cm for lesions > 2 mm thick. Applied to 1155 patients, there were significant differences in both local recurrence and mortality rates between optimally and suboptimally excised lesions, except for those > 4 mm thick. Thirty-three patients (39 per cent) with local recurrence died. Thickness, local recurrence and ulceration were of prognostic significance.

Conclusion

Development of local recurrence in melanomas ≤ 4 mm thick is due to inadequate treatment. It signifies progressive disease and a poor prognosis. Care must be taken to ensure that all such lesions are optimally excised.
The intestinal flora influences adhesion formation around surgical anastomoses
Authors: Bothin C , Okada M , Midtvedt T , Perbeck L
Published: March 2003

Background

Postsurgical adhesion formation is still a cause of postoperative morbidity because no satisfactory treatment or prophylaxis has yet been developed. The present study was designed to investigate the influence of the gastrointestinal flora on adhesion formation around surgical anastomoses.

Methods

Anastomoses were constructed in germfree, conventional, ex-germfree and mono-contaminated rats (Escherichia coli X7 and Lactobacillus acidophilus La5), and adhesion formation was recorded.

Results

The germfree group had a significantly lower adhesion score than all other groups (P < 0·05) apart from the lactobacillus group, which had a significantly lower score than the conventional group (P < 0·05).

Conclusion

The bacterial flora of the gastrointestinal tract enhances adhesion formation around surgical anastomoses.
Suitability for endovascular aneurysm repair in an unselected population
Authors: Woodburn K R , Chant H , Davies J N , Blanshard K S , Travis S J
Published: March 2003

Background

Tertiary referral centres report that up to 60 per cent of patients may be suitable for endovascular repair of abdominal aortic aneurysm (EVAR). The aim of this study was to determine the percentage of abdominal aortic aneurysms (AAAs) presenting to a county-wide vascular service that were suitable for EVAR, and to examine the outcome of subsequent AAA repair in relation to aneurysm morphology.

Patients and methods

All patients being assessed for AAA repair between January 1998 and December 1999 underwent spiral computed tomography angiography to determine aneurysm morphology and suitability for EVAR. Subsequent outcome for all patients in the study was recorded in a prospective vascular database.

Results

A total of 115 patients was assessed. Sixty-three aneurysms (55 per cent) had one or more absolute contraindications to EVAR, a further 13 (11 per cent) had at least one relative contraindication, and 39 (34 per cent) had no contraindication. Of patients with no absolute contraindication to EVAR, ten underwent successful EVAR, five did not meet recognized criteria for surgery, one awaits EVAR, four remain under observation, one awaits open repair, and 31 underwent open repair without death.

Conclusion

Only 30 per cent of unselected AAAs presenting to a vascular service are entirely suitable for EVAR; most of these patients can safely undergo open AAA repair. These data suggest that increased use of EVAR is only possible by deploying devices in suboptimal morphology, and in treating patients who would not normally be considered for open AAA repair.
Clinical significance of mutator phenotype and chromosome 17p and 18q allelic loss in gastric cancer
Authors: de Manzoni G , Tomezzoli A , Di Leo A , Moore P S , Talamini G , Scarpa A
Published: March 2003

Background

Tumour stage is the only reliable prognostic factor for gastric cancer. The molecular anomalies involved in this process have the potential to serve as additional prognostic markers.

Methods

Forty-four gastric cancers, treated by surgery alone, have been analysed for chromosome 17p and 18q allelic loss and for the presence of microsatellite instability (MSI), using microsatellite markers and DNA from paraffin-embedded tumours.

Results

Eight cancers showed a MSI-positive (MSI+) phenotype. Among the 36 MSI-negative cancers, chromosome 17p and 18q allelic losses were found in 22 of 34 and 19 of 33 informative cases respectively. Multivariate survival analysis indicated MSI status to be an independent prognostic factor along with the tumour stage. MSI+ cancers were associated with longer patient survival, whereas MSI-negative cancers had a significantly poorer prognosis (P = 0·007), with a median actuarial survival of 24 months.

Conclusion

MSI status is an independent prognostic factor among gastric cancers at the same stage. Chromosome 17p and 18q status added no additional prognostic information to that of tumour stage. The combined use of tumour stage and MSI status may help in deciding whether patients with advanced gastric cancer require additional therapy other than surgery alone.
A normal appendix found during diagnostic laparoscopy should not be removed
Authors: van den Broek W T , Bijnen A B , de Ruiter P , Gouma D J
Published: March 2003

Background

Diagnostic laparoscopy has been introduced as a new diagnostic tool for suspected appendicitis. While the normal appendix used to be removed routinely, laparoscopy allows us to leave a normal looking appendix in place. This latter strategy is, however, not generally accepted. The long-term results of not removing a normal looking appendix were evaluated.

Methods

This was a prospective evaluation of 109 diagnostic laparoscopies for suspected appendicitis in which a normal looking appendix was left in place. After a median follow-up of 4·4 years a telephone questionnaire was performed.

Results

There were no false-negative laparoscopies. In 65 patients (60 per cent) another diagnosis was obtained (group 1). In 44 patients (40 per cent) no diagnosis was obtained (group 2). After a median interval of 8 months, 15 patients presented to the emergency department for symptoms possibly involving the appendix, during the median follow-up of 4·4 years. This resulted in readmission of nine patients, of whom eight were reoperated. In only one patient (1 per cent) was a histologically proven appendicitis found and the appendix removed. Some 105 patients were eligible for follow-up. Of the 100 patients interviewed (95 per cent), nine patients (9 per cent) (six in group 1 and three in group 2) still had recurrent pain in the right lower abdominal quadrant. There were no differences between patients with or without another diagnosis obtained during preceding laparoscopy.

Conclusion

It is safe to leave a normal looking appendix in place when a diagnostic laparoscopy for suspected appendicitis is performed, even if another diagnosis cannot be found at laparoscopy.
Blockade of growth factor receptors in ductal carcinoma in situ inhibits epithelial proliferation
Authors: Chan K C , Knox W F , Gandhi A , Slamon D J , Potten C S , Bundred N J
Published: March 2003

Background

Ductal carcinoma in situ (DCIS) expresses c-erbB-2 receptor and epidermal growth factor receptor (EGFR). The aim of this study was to determine whether blocking of c-erbB-2 receptor with a humanized monoclonal antibody, 4D5 (HerceptinTM), or of EGFR with an epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), ZD1839 (IressaTM), would decrease epithelial proliferation in DCIS.

Methods

DCIS tissue from 18 women undergoing surgery was implanted into 16 to 20 athymic nude mice per experiment (eight xenografts per mouse). Treatment commenced 2 weeks after implantation and consisted either of twice-weekly intraperitoneal injections of 4D5 10 mg/kg or of daily gavage with ZD1839 at 100–200 mg/kg for 14 days; appropriate controls were included. Xenografts were removed on days 14, 21 and 28. Proliferation was assessed by counting 1000 epithelial cells after Ki67 immuno- staining.

Results

ZD1839 inhibited proliferation compared with that in controls after 14 days (P < 0·01), whereas 4D5 did not.

Conclusion

Proliferation in DCIS was decreased by EGFR tyrosine kinase inhibition but not by c-erbB-2 receptor blockade. ZD1839, an orally active and selective EGFR-TKI, has potential as adjuvant therapy in DCIS.
Gastrointestinal complications in lung transplant survivors that require surgical intervention
Authors: Hoekstra H J , Hawkins K , de Boer W J , Rottier K , van der Bij W
Published: March 2003

Background

Lung transplantation is widely accepted as a treatment for end-stage lung disease. At present, information regarding the incidence and outcome of acute gastrointestinal complications in lung transplant survivors is limited.

Methods

Since 1990, 127 lung transplantations have been performed in 125 patients: 73 males (58 per cent) and 52 females (42 per cent) of median age 43 (range 9–64) years. Patients received a standard induction and maintenance regimen of immunosuppression.

Results

At a median follow-up of 2·6 (range 0–8·6) years the overall survival rate was 68 per cent. An acute abdomen requiring surgical intervention was diagnosed in 12 patients (10 per cent). The median time following lung transplantation was 19 (range 3–68) months. Eight cases of bowel perforation, two of appendicitis, one of colitis, one of cholecystitis, and one pneumoperitoneum were encountered. Four Hartmann procedures, two sigmoid resections, one small bowel resection, two appendicectomies, a subtotal colectomy, a cholecystectomy and an exploratory laparotomy were performed with minimal morbidity and no postoperative death.

Conclusion

Lung transplant survivors are at increased risk of developing an acute abdomen because of the use of high-dose immunosuppressive agents. Physicians who evaluate lung transplant patients for an acute abdomen should have a low threshold for surgical intervention.
Scintigraphic assessment of colonic transit in women with slow-transit constipation arising de novo and following pelvic surgery or childbirth
Authors: Scott S M , Knowles C H , Newell M , Garvie N , Williams N S , Lunniss P J
Published: March 2003

Background

Colonic transit has not been compared between patients with slow-transit constipation (STC) arising de novo (idiopathic) and those whose symptoms followed pelvic surgery or childbirth (acquired).

Methods

In 48 women, with either idiopathic (n = 36) or acquired (n = 12) STC, 111In-radiolabelled diethylene-triamine penta-acetic acid colonic scintigraphy was performed to determine patterns of delay (generalized or left sided), the ‘severity’ of transit disturbance between subgroups, and the association with age or duration of symptoms. Results were compared with those in healthy women. Patterns of colonic transit disturbance were assessed using previously defined criteria. In those with a generalized delay, variables reflecting the overall rate of isotope progression throughout the colon were calculated: gradient of geometric centre of isotope progression and estimated evacuation time of the isotope.

Results

The pattern of transit delay was similar between the subgroups, but the ‘severity’ of the transit abnormality was significantly worse in those with chronic idiopathic symptoms. In the chronic idiopathic STC subgroup only, there was a significant correlation between both age and duration of symptoms and severity of transit disturbance.

Conclusion

This study demonstrates that differences in colonic transit exist between subgroups of patients with STC. These might be explained by differences in duration of symptoms or differences in aetiology.
Clinicopathological features and treatment of intraductal papillary mucinous tumour of the pancreas
Authors: Falconi M , Salvia R , Bassi C , Zamboni G , Talamini G , Pederzoli P
Published: March 2003

Background

The surgical strategy in patients with a pancreatic intraductal papillary mucinous tumour (IPMT) is still controversial. In this study the pathological findings in a series of patients were used to rationalize surgical choice.

Methods

Fifty-one patients with IPMT were observed between 1988 and 1998 and treated by pancreatic resection. Factors evaluated included symptoms, tumour site, type of operation, histological findings and resection margins, tumour stage, follow-up and survival.

Results

Pancreaticoduodenectomy was the most frequent surgical treatment (33 patients; 65 per cent), followed by left pancreatectomy (ten), total pancreatectomy (five) and middle pancreatectomy (three). Histological assessment revealed the tumour to be an adenoma in 13 patients (25 per cent), a borderline tumour in ten (20 per cent) and a carcinoma in 28 (55 per cent), 19 of which were invasive. Mild to moderate dysplasia was present at the resection margin in 20 specimens (41 per cent), and carcinoma in one. Local recurrence was observed in four patients (8 per cent), all of whom underwent a second resection. The 3-year actuarial survival rate for benign and malignant disease was 94 and 69 per cent respectively (P = 0·03).

Conclusion

These results suggest that resection should be the treatment for IPMT. Management of the resection margin could be crucial in avoiding tumour recurrence.
Value of intraoperative duplex imaging during supervised carotid endarterectomy
Authors: Padayachee T S , Brooks M D , McGuinness C L , Modaresi K B , Arnold J A C , Taylor P R
Published: March 2003

Background

For overall benefit, carotid endarterectomy requires low perioperative morbidity and mortality rates. Carotid thrombosis is usually secondary to technical error, which may be related to the experience of the operator. In this retrospective study the clinical and technical outcome of carotid endarterectomies performed by one consultant and five trainees were compared.

Methods

Some 149 patients underwent carotid endarterectomy; 89 were operated on by the consultant and 60 by trainees. Intraoperative duplex imaging of the carotid repair was performed before wound closure, and re-exploration was carried out when there was a residual severe stenosis associated with an intimal flap.

Results

There was no significant difference in clinical outcome between operations done by consultant or trainees. There was a significant increase in the number of stenoses, kinks and flaps in carotid endarterectomies performed by trainees compared with those of the consultant both before (χ2 = 12·0, 1 d.f., P < 0·001) and after (χ2 = 10·1, 1 d.f., P < 0·001) correction.

Conclusion

Intraoperative duplex imaging may facilitate training by providing an objective assessment of the quality of the operation.
Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer
Authors: Gotoda T , Sasako M , Ono H , Katai H , Sano T , Shimoda T
Published: March 2003

Background

When cancer cells are found in the submucosal layer of an endoscopically resected specimen, patients are recommended to undergo gastrectomy with lymph node dissection. If it were possible to identify those patients in whom the risk of lymph node metastasis was negligible, it might be possible to avoid surgery.

Methods

Among those who underwent gastrectomy for gastric cancer from 1980 to 1999, 1091 patients with a cancer invading the submucosa were studied. Clinicopathological factors (sex, age, tumour location, macroscopic type, size, ulceration, histological type, lymphatic–vascular involvement and degree of submucosal penetration) were investigated for their possible association with lymph node metastasis.

Results

Lymph node metastases were found in 222 patients (20·3 per cent). Univariate analysis showed that larger tumour size (more than 30 mm), undifferentiated histological type, lymphatic–vascular involvement and massive submucosal penetration had a significant association with lymph node metastasis. Tumour size, histological type and lymphatic–vascular involvement were independent risk factors for lymph node metastasis. By combining these three factors with submucosal penetration of less than 500 μm, 117 patients could be selected as having a minimal risk of lymph node metastasis (95 per cent confidence interval 0–3·1 per cent).

Conclusion

Lymphadenectomy may not be necessary for patients with gastric cancer invading the submucosa who fulfil the above conditions
Role of a spiral computed tomographic grading system in increasing the efficacy of laparoscopic staging for potentially resectable pancreatic and periampullary tumours
Authors: Moses A G W , Redhead D N , Madhavan K K , Garden O J
Published: March 2003

Background

In a recent review of patients with potentially resectable pancreatic malignancy in the authors' unit, it was shown that inappropriate laparotomy was avoided in 35 per cent of patients as a direct result of laparoscopy combined with laparoscopic ultrasonographic staging, following previous spiral computed tomography (CT). However, subsequent analysis has suggested that laparoscopy may have added to information already available on the CT scan in as few as 22 per cent of patients. The aim of this study was to seek to define spiral CT scan criteria that might provide a more selective approach to laparoscopic staging.

Methods

Theatre records and the Lothian Surgical Audit Database were used to identify 124 patients between June 1995 and May 2000 whose investigations for suspected pancreatic tumours had included spiral CT followed by laparoscopic assessment (suspected tumour: pancreatic head, 88; periampullary, 25; lower bile duct, nine; duodenum, two). Each CT scan (with endoscopic retrograde cholangiopancreatography films if appropriate) was examined by a specialist pancreaticobiliary radiologist (D.N.R.) and graded ‘blindly’ according to a modified existing system for determining local resectability (0, no mass; A, fat plane between tumour and vessels; B, normal pancreas between tumour and vessels; C, mass convex to vessel; D, mass concave to vessel; E, vessel encircled; F, vessel occlusion) before the results were compared with findings at laparoscopy and laparotomy.

Results

In groups 0, E and F, only four (7 per cent) of 59 patients benefited from laparoscopic assessment, whereas 27 (42 per cent) of 65 patients avoided an inappropriate laparotomy in groups A–D as a result of improved staging. 0ABCDEFn27244829284Resection209319––Irresectable Laparoscopy23––32– Laparoscopy + laparoscopic US1––1422 Laparoscopic US–5–18112No laparotomy (other)11–211–Inappropriate laparotomy3613412–US, ultrasonography

Conclusion

Based on these results, only patients graded A–D should undergo laparoscopic staging. By adopting this more selective policy in the future, the number of laparoscopic evaluations may be reduced by 48 per cent, while maintaining the efficacy of preventing inappropriate laparotomies at 42 per cent.
Role of hepatectomy in the management of bile duct injuries
Authors: Wakefield C H , Whigham J , Madhavan K K , Garden O J
Published: March 2003

Background

Laparoscopic cholecystectomy is associated with bile duct injuries of a more severe nature than open cholecystectomy. This study examined the emerging role of hepatectomy in the management of major iatrogenic bile duct injuries in the laparoscopic era.

Methods

This was a retrospective cohort study of patients referred to a tertiary hepatobiliary unit with bile duct injuries over a 16-year period until April 2000. Data are expressed as median (range).

Results

Eighty-eight patients (34 men, 54 women) were referred during this interval; their median age was 55 (19–83) years. Injuries resulted from 50 laparoscopic cholecystectomies and 35 open cholecystectomies, with three occurring during gastroduodenal procedures. Laparoscopic surgery was associated with injuries of greater severity than open cholecystectomy: Bismuth type I–II, 32 per cent versus 69 per cent for the open operation; type III–IV, 66 per cent versus 31 per cent for the open procedure (P = 0·02, χ2 test). After referral 73 patients underwent definitive surgical interventions: 57 hepaticojejunostomies, 11 revisions of hepaticojejunostomy, two orthotopic liver transplants and three right hepatectomies. Two patients had subsequent hepatectomy following initial hepaticojejunostomy. Four of the five hepatectomies were for the management of injuries perpetrated at laparoscopic cholecystectomy. Criteria necessitating hepatectomy were liver atrophy on computed tomography (80 versus 11 per cent; P = 0·0001, χ2 test) and a greater incidence of angiographically proven vascular injury (40 versus 6 per cent; P = 0·006, χ2 test); in addition, type III–IV injuries were more frequent (60 versus 42 per cent) in the hepatectomy group. There were no procedure-related deaths. The overall postoperative morbidity rate was 13 per cent. Median hospital stay was 10 days.

Conclusion

Major hepatectomy allows the successful and safe repair of cholecystectomy-related bile duct injuries complicated by concomitant vascular injury, unilateral lobar atrophy and destruction of the biliary confluence.
Decreased tyrosine kinase C expression may reflect developmental abnormalities in Hirschsprung's disease and idiopathic slow-transit constipation
Authors: Facer P , Knowles C H , Thomas P K , Tam P K H , Williams N S , Anand P
Published: March 2003

Background

Some patients with Hirschsprung's disease have refractory constipation following excision of aganglionic bowel, as do patients with idiopathic slow-transit constipation (STC). Gut motility depends on enteric neuronal development in response to expression of trophic factors and their receptors. Recent studies indicate the importance of neurotrophin 3 (NT-3) and its high-affinity receptor tyrosine kinase C (trk C) in enteric neuronal development.

Methods

Blinded quantitative immunohistochemical analysis of colon from patients with Hirschsprung's disease (aganglionic, hypoganglionic and normoganglionic) (n = 5), STC (n = 6) and appropriate age-matched control tissues (n = 5) was performed for NT-3 and trk C. Sural nerve morphometry and immunostaining were undertaken in three patients with STC who had abnormalities on limb autonomic and sensory testing.

Results

A significantly higher proportion of submucous plexus neurones was trk C immunoreactive in control infant than adult colon (mean(s.e.m.) 73(9) versus 16(3) per cent of the total; P < 0·001), in accord with a role in development. The proportion of submucous plexus trk C-immunoreactive neurones was reduced in colon from patients with Hirschsprung's disease (28(7) per cent of total in normoganglionic Hirschsprung's disease; P < 0·007 versus infant controls) and STC (10(1) per cent of total; P = 0·053 versus adult controls). No abnormalities of STC sural nerves were detected by morphometry or immunostaining.

Conclusion

Decreased trk C expression may reflect developmental abnormalities in Hirschsprung's disease and idiopathic STC. Trk C activation by NT-3 or drugs may provide novel treatments.
Variation in clinical decision making is a partial explanation for geographical variation in lower extremity amputation rates
Authors: Connelly J , Airey M , Chell S
Published: March 2003

Background

Rates of lower extremity amputation vary significantly both between and within countries. The variation does not appear to support differences in need as an explanation. This study set out to see if variations in clinical decision making might contribute to the explanation.

Methods

Based on an extensive audit database of lower extremity amputations and revascularization operations, a decision model was produced. Drawing on items in this model allowed the selection of six clinical cases that differed in their probability of having amputation as the outcome. Two cases had 80 per cent or more, two cases had 45–55 per cent and two cases had 20 per cent or less probability of amputation. Each of ten consultant vascular surgeons looked at these cases without knowledge of their probability of outcome and decided on amputation or revascularization.

Results

Overall the chance-adjusted level of agreement (kappa coefficient) between the decisions made by ten surgeons on the six clinical cases and the actual outcome was 0·46, indicating a moderate level of agreement. The kappa coefficient for individual surgeons showed complete agreement (κ = 1) for four, substantial agreement (κ = 0·66) for four, fair agreement (κ = 0·32) for one and no agreement other than at a chance level (κ = 0) for one surgeon.

Conclusion

Variations in the clinical decisions made by vascular surgeons given the same patient are likely to explain at least a part of the observed geographical variation in rates of lower extremity amputation. Consensus guidelines may enable more consistent decision making for this problem.
Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia
Authors: Ballantyne A , Jawaheer G , Munro F D
Published: March 2003

Background

In children undergoing a unilateral inguinal herniotomy, the contralateral groin is often explored on the basis of a high incidence of patency of the processus vaginalis. The patency rate is highest in infants but there are no data on the subsequent risk of contralateral hernia development purely in this population. This was a study of the incidence of contralateral inguinal hernia following unilateral inguinal herniotomy in infancy (aged less than 1 year).

Methods

All infants who underwent a unilateral inguinal herniotomy between January 1986 and December 1991 were studied retrospectively.

Results

One hundred and eighty-one infants (165 boys and 16 girls) were studied. Median gestational age was 37 (range 25–42) weeks and median age at operation was 87 (range 1–365) days. The herniotomy was right sided in 82·9 per cent of infants. Follow-up ranged from 5 to 10 years. A contralateral hernia/hydrocele developed in 14 infants (7·7 per cent). None of the hernias was incarcerated. Median time from operation to occurrence of the contralateral hernia was 18 (2–67) months. Gestational age, sex and the side of the hernia did not influence the incidence of contralateral hernia development.

Conclusion

The low incidence of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.
Cyclo-oxygenase 1 and 2 expression is augmented in symptomatic carotid plaques
Authors: Wijeyaratne S M , Abbott C R , Homer Vanniasinkam S , Mavor A I D , Gough M J
Published: March 2003

Background

Macrophage accumulation and increased metalloproteinase levels within carotid plaques are associated with plaque instability. Production of the latter by macrophages and vascular smooth muscle cells (VSMCs) is promoted by prostaglandins synthesized following the action of cyclo-oxygenase (COX) on arachidonic acid.

Methods

Expression of the isoenzymes COX-1 and COX-2 was assessed in carotid plaques removed from 12 asymptomatic patients and 11 patients who had had a neurological event within 30 days of carotid endarterectomy. Patients were matched for age, sex, risk factors and degree of stenosis. For each plaque, paraffin sections obtained at 3-mm intervals throughout its length were stained with goat antihuman antibodies to COX-1 and COX-2. The percentage of the area that stained positively was determined within the cap, shoulder regions and sclerotic component of the plaques (computerized planimetry).

Results

The median (interquartile range) percentage area staining for COX-1 (symptomatic versus asymptomatic) was: cap 8·37 (4·38–13·65) versus 1·07 (0·31–4·51) per cent, P < 0·0006; shoulder 11·76 (3·02–29·48) versus 1·41 (0·73–2·70) per cent, P < 0·0026; sclerotic component 0·08 (0·02–0·54) versus 0·06 (0·04–0·24) per cent, P < 0·4. Values for COX-2 were: cap 9·62 (4·87–12·50) versus 0·27 (0·02–2·41) per cent, P < 0·0001; shoulder 11·45 (2·34–24·16) versus 0·44 (0·02–2·97) per cent, P < 0·0038; sclerotic component 1·36 (0·24–2·61) versus 0·06 (0·02–0·49) per cent, P < 0·0081. Further, COX-2 expression was greater than COX-1 staining in the sclerotic component of the plaques (P < 0·05, Mann–Whitney U test).

Conclusion

Plaques that had recently become symptomatic exhibited increased COX-1 and COX-2 expression, particularly in the cap and shoulder regions. Such changes would increase macrophage and VSMC metalloproteinase production (collagenolysis) and reduce collagen synthesis by VSMCs. Such events are likely to promote plaque instability or rupture. These findings suggest that COX-1 and COX-2 inhibitors might have a therapeutic role in the prevention of further neurological events.
Autologous or homologous transfusion in aortic surgery: randomized trial
Authors: Torella F , Wong J C L , Haynes S L , McCollum C N
Published: March 2003

Background

Aortic surgery often requires blood transfusion, which may cause complications and postoperative infection. Autologous transfusion was evaluated in a multicentre clinical trial.

Methods

Some 145 patients undergoing elective aortic surgery in eight hospitals were randomized to either ‘homologous’ or ‘autologous’ transfusion, a combination of acute normovolaemic haemodilution (ANH) and intraoperative cell salvage. Homologous blood was administered when the haemoglobin concentration fell below 8 g dl−1.

Results

Median (interquartile range (i.q.r.)) blood loss was 668 (400–862) ml or 17 (10–24) per cent of blood volume in aortobifemoral bypass, and 1120 (765–1700) ml or 24 (17–36) per cent in aneurysm repair (P < 0·001). Autologous transfusion reduced homologous blood requirements from a median (i.q.r.) of 2 (0–4) units to 0 (0–2) units (P = 0·008). Independent predictors of blood transfusion were homologous transfusion strategy (odds ratio (OR) 2·3 (95 per cent confidence interval 1·1–5·0); P = 0·03), low preoperative haemoglobin concentration (OR 3·7 (1·7–8·2); P < 0·001), prolonged surgery (OR 2·1 (1·0–4·8); P = 0·05) and blood loss (OR 3·0 (1·4–6·5); P = 0·007). Patients with a preoperative haemoglobin concentration greater than 13·5 g dl−1 and who lost less than 20 per cent of their blood volume rarely required transfusion. There was no significant difference between the groups in terms of morbidity, mortality and postoperative hospital stay.

Conclusion

Autologous transfusion reduced the need for homologous blood in aortic surgery, but was useful only in patients with low haemoglobin levels or when blood loss exceeded 20 per cent of the blood volume. ANH alone is indicated for patients undergoing aortobifemoral bypass and in those with a higher haemoglobin level and blood volume.
More venous leg ulcers are healed by three-layer than by four-layer paste bandages: a randomized clinical trial
Authors: Meyer F J , Burnand K G , McGuiness C L , Lagattolla N R F , Eastham D
Published: March 2003

Background

The aim of this study was to compare prospectively the number of ulcers healed, time to total healing and bandage tolerability of three- and four-layer paste bandages.

Methods

All patients with clinical evidence of venous ulceration were considered for the study. Ulcers were stratified by size into one of three groups and patients were randomized within each group to receive either three- or four-layer paste bandages. Patients with diabetes, sickle-cell disease, ankle: brachial pressure index less than 0·9, positive autoimmune serology, or ulcers smaller than 0·25 cm2 or larger than 100 cm2 in diameter were excluded. Complete ulcer healing was the only study endpoint. A venous aetiology was confirmed with duplex imaging, foot volumetry and venography. All patients were followed for 1 year and classified according to clinical manifestations, etiological factors, anatomic involvement and pathophysiological features (CEAP) criteria.

Results

A total of 133 patients was entered into the study; 80 per cent of patients (51 of 64) receiving three-layer bandages healed, compared with 65 per cent of those (45 of 69) having four layers (P < 0·05, χ2 test). This difference was apparent only after 16–20 weeks of treatment. The time to total healing increased with increasing ulcer size. Three-layer paste bandages were quicker to apply and better tolerated than four layers. There were more post-thrombotic legs in the four-layer group (46 versus 38 per cent), but half-refilling times did not differ significantly. These results were unaffected when analysis was restricted to confirmed venous ulcers.

Conclusion

Three-layer paste bandages are significantly more effective at healing venous ulcers than four-layer bandages. They are also cheaper and better tolerated. Some 20–35 per cent of venous ulcers remain unhealed at 1 year despite adequate compression.
Distal arterial reconstruction in Scotland 1989–1998
Authors: Holdsworth R J , Paterson H M
Published: March 2003

Methods

A retrospective analysis of national hospital discharge data (Scottish Morbidity Record 1) from 1989 to 1998 was undertaken.

Results

The population of Scotland has remained constant at 5·1 million. A total of 975 distal arterial grafts were performed in 10 years. The overall rate of distal reconstruction increased from 0·9 per 100 000 population in 1989, peaked at 2·6 per 100 000 in 1994, and has since declined steadily to 1·8 per 100 000 in 1998 (Table). There were huge interregional variations in the rate of reconstruction, with up to a 17-fold variation in annual rates between the 12 mainland health boards. The variations in distal reconstruction between the health boards were not reflected in reduced amputation rates, nor was the decline in distal reconstruction easily explained by increased non-femoral angioplasty.

Conclusion

Rates of distal arterial reconstruction in Scotland fall well below those of comparable European countries. It is likely that insufficient distal operations are undertaken to impact on amputation rates. The authors recommend an increased provision of specialist vascular surgical expertise in Scotland.
Prognosis following venous thromboembolism in women taking combined oral contraceptives
Authors: Egun A , Uzoigwe A , Riding G , McCollum C N
Published: March 2003

Background

It is widely believed that ‘post-thrombotic limb’ always follows deep vein thrombosis (DVT). Prognosis following both DVT and pulmonary embolism (PE) was investigated.

Methods

Some 155 women (mean age 25·5 (range 16–49) years) who developed venous thromboembolism while taking third-generation oral contraceptives were studied. The venous system was assessed by duplex imaging a mean of 4·8 years after DVT.

Results

Fourteen (15 per cent) of 96 women suffering PE died. Of the 82 surviving patients, 12 (15 per cent) had chest pain and/or dyspnoea at rest or on exertion. Of the 103 women with confirmed DVT, 59 (57 per cent) had had only calf thrombosis and 44 (43 per cent) had had iliofemoral vein thrombosis. At follow-up, 13 (22 per cent) and 21 (48 per cent) women with calf and iliofemoral thrombosis respectively had leg symptoms, including swelling, pain and lipodermatosclerosis (P = 0·011). Duplex imaging was normal in 60 patients (58 per cent). There was no significant difference in leg symptoms (31 versus 34 per cent) or incompetence on duplex imaging (41 versus 42 per cent) between those who were anticoagulated for 3 months (n = 39) or 6 months (n = 64) respectively. Leg symptoms were more frequent in the 41 women with DVT discharged without elastic stockings, affecting 19 (46 per cent) compared with only 15 (24 per cent) of 62 discharged with stockings (P = 0·034).

Conclusion

The majority of women regained venous patency and became asymptomatic, despite extensive DVT. Elastic stockings were often omitted despite the evidence of long-term benefit.
Surgery for venous insufficiency: are venous function tests necessary?
Authors: Bhowmick A , Picton A , McCollum C N
Published: March 2003

Background

The role of duplex imaging and measurement of ambulatory venous pressure (AVP) in the preoperative assessment of patients with venous insufficiency (VI) and primary varicose veins (VV) was investigated.

Methods

Venous incompetence was confirmed by duplex imaging in 58 legs: 38 had VI, demonstrated by eczema, oedema or pigmentation, and 20 had VV and normal skin. AVP was measured from a cannulated dorsal foot vein before and after ten tip-toe exercises. This was repeated following occlusion of the superficial veins by narrow tourniquets. Pressure relief index (PRI) was calculated as the fall in AVP in calf exercise × 90 per cent refilling time in seconds. The criterion for superficial vein surgery was doubling of PRI on superficial vein occlusion.

Results

Superficial venous incompetence (SVI) was confirmed in all legs with duplex imaging. Deep vein incompetence (DVI) was found in 17 legs (45 per cent) with VI and in two (10 per cent) of the VV legs (P = 0·012, χ2 test). Venous function was normal (PRI greater than 1000) in six. Median PRI in patients with VI and VV was 177 and 289, rising to 717 and 1026 respectively after superficial vein occlusion. Initial PRI was significantly lower in patients with DVI (P < 0·001). PRI improved by 135 per cent in SVI and by 318 per cent in legs with DVI (P = 0·01). PRI did not double following superficial venous occlusion in 20 legs (35 per cent) with SVI and in three (16 per cent) with deep incompetence (P = 0·01).

Conclusion

Clinical examination and duplex imaging alone cannot predict who will benefit most from superficial venous surgery. AVP measurement rationalizes decision-making and may avoid unnecessary operations.
Association between hyperhomocysteinaemia and abdominal aortic aneurysm
Authors: Caldwell S , Burns P , Haggart P , Bradbury A W , Mosquera D A
Published: March 2003

Background

Hyperhomocysteinaemia is associated with occlusive vascular disease. In vitro evidence has demonstrated the induction of a serine elastase by homocysteine in vascular smooth muscle. Anecdotal evidence from case reports and post-mortem studies has suggested an association with abdominal aortic aneurysm (AAA). The aim was to determine the prevalence of hyperhomocysteinaemia in patients with AAA.

Methods

Some 120 subjects (60 controls and 60 patients with AAA) were studied prospectively. Epidemiological, clinical and haematological data were collected. Patients were defined as having AAA if ultrasonographic measurement of the aorta was greater than 4·5 cm. Those with evidence of occlusive peripheral vascular disease or an ankle: brachial pressure index lower than 0·8 were excluded. Homocysteine was measured with a commercial high-pressure liquid chromatography analyser. The reference range from age-matched controls was 8·9–14·3 µmol l−1.

Results

The median(s.d.) value of homocysteine for patients was significantly higher than that for the control group: 13·1(7·88) versus 10·9(5·07) µmol l−1 (P = 0·03, Mann–Whitney U test). Hyperhomocysteinaemia (homocysteine concentration greater than 14·3 µu;mol l−1) was present in 48 per cent of patients with AAA, compared with 24 per cent of the control population (P < 0·01, χ2 test). There were no significant differences between groups with regard to age, folate levels, vitamin B12 concentration or renal function.

Conclusion

These results strongly suggest an association between hyperhomocysteinaemia and AAA. If studies currently ongoing demonstrate a causal relationship between hyperhomocysteinaemia and vascular disease progression, it raises the possibility of treating small aneurysms with vitamin supplementation to slow their growth.
P-selectin deficiency is protective against remote organ injury in a model of ruptured abdominal aortic aneurysm
Authors: Stewart J B , Norman K E , John A E , Chan P , Hellewell P G
Published: March 2003

Background

Multisystem organ failure (MSOF) accounts for 50–60 per cent of postoperative deaths following repair of ruptured abdominal aortic aneurysm (AAA). A murine model is described in which the combined insults of hypotension and aortic clamping reproduce the physiological changes during repair of ruptured AAA. The resulting remote organ injury (the hallmark of MSOF) is prevented in the absence of the adhesion molecule P-selectin, which mediates neutrophil–endothelial interaction.

Methods

C57BL6 wild-type mice (n = 4) and mice constitutively unable to express P-selectin (P–/–) (n = 4) were subjected to 60 min of controlled hypotension followed by cross-clamping of the infrarenal aorta for 60 min, reinfusion of shed blood and then 60 min of reperfusion. Controls (n = 16) were sham-operated, had hypotension only or clamp/reperfusion only. Lungs and kidneys were harvested and assayed for the neutrophil-specific marker myeloperoxidase (MPO), which indicates inflammatory infiltrate in the tissue.

Results

MPO levels in the organs of C57BL6 mice subjected to hypotension and aortic clamping were 50 times greater than those in sham-operated mice. MPO levels in sham-operated P–/– animals were similar to those in sham-operated C57BL6 mice. MPO levels in the lungs and kidneys of P–/– mice subjected to hypotension and aortic clamping were unchanged from those in sham-operated P–/– mice.

Conclusion

The combined effects of hypotension and infrarenal aortic clamping, followed by reperfusion, are synergistic. This gives rise to a profound early inflammatory reaction in tissues remote from the site of ischaemia–reperfusion, which is likely to contribute towards clinical MSOF after ruptured AAA repair. Absence of the adhesion molecule P-selectin protects against this remote organ injury.
Renal disease, age and outcome after aortic aneursym repair
Authors: Refson J , Wilmink T , Kerle M , Pillay W , Mansfield A , Cheshire N J W , Wolfe J H N
Published: March 2003

Background

The safety of conventional aneurysm repair is undergoing increased scrutiny as less invasive methods are developed, certain high-risk groups identified and the evidence for the risk of rupture is refined. An understanding of the relationship between preoperative risk factors and outcome is particularly important in elderly patients requiring a prophylactic operation.

Methods

Risk factors (extent of aneurysm, ischaemic heart disease, renal function, hypertension, diabetes, serum cholesterol concentration, age and sex) were studied in 393 consecutive patients undergoing elective juxtarenal and infrarenal aneurysm repair between 1993 and 1999 (inclusive), and were related to hospital mortality.

Results

The overall mortality rate was 5·1 per cent (20 of 393). Multivariate logistic regression analysis revealed that age and creatinine concentration were independent risk factors for in-hospital mortality. Extent of aneurysm was not an independent risk factor, nor was a history of myocardial ischaemia, sex, hypertension, diabetes or serum cholesterol level. The comparative risk related to age and serum creatinine concentration is shown in the Table.

Creatinine level had no influence on outcome in patients aged under 70 years. However, in those over 70 years of age, an increase in creatinine concentration of 10 μmol l−1 increased the relative risk by 0·1 (95 per cent c.i. 0·01–0·18). Increasing age by 10 years increased the relative risk by 1·5 (95 per cent c.i. 0·6–2·4).

Conclusion

Advances in preoperative and perioperative care appear to have reduced the significance of ischaemic heart disease and juxtarenal repair so that age and renal disease are currently major determinants of survival. In aneurysms of less than 7 cm in diameter, where the risk of rupture is less than 10 per cent per year, the natural history of the disease in elderly patients with renal failure appears to be more benign than the treatment.