bluuebunny/crossref_metadata_2025 huggingface dataset:
Long-term survival following repair of ruptured abdominal aortic aneurysm in patients over 75 years of age
Authors: Evans S M , Adam D J , Brittenden J , Bain M , Bradbury A W
Published: March 2003

Background

Previous studies have indicated that patients over the age of 75 years have an increased in-hospital mortality rate following repair of ruptured abdominal aortic aneurysm (AAA). The long-term survival of this patient group has not been reported previously, even though this information may have a strong influence on the decision to operate.

Methods

Interrogation of a prospective database identified 272 patients aged 75 years or over (median age 78 (range 75–93) years) admitted between 1983 and 1995. Long-term patient survival data and survival curves for an age- and sex-matched population were obtained from the General Register Office through the Information and Statistics Division.

Results

Sixty-nine (25 per cent) of the 272 patients did not undergo operation. Eighty-eight (43 per cent) of the 203 patients who had surgery died within the same hospital admission. The 1-, 5- and 10-year survival rates for the remaining 115 patients (median age 77 (range 75–85) years) were 88, 59 and 26 per cent respectively, at a median follow-up of 54 (range 1–157) months. The median life expectancy for this patient group was 69 months. These data are comparable to those of an age- and sex-matched population.

Conclusion

Many patients over the age of 75 years who present with ruptured AAA are considered unfit for surgery. These data demonstrate that, even in this elderly population, survivors of ruptured AAA repair enjoy a near-normal life expectancy.
Perioperative renal function following endovascular repair of abdominal aortic aneurysm with suprarenal and infrarenal stents
Authors: Macierewicz J , Walker S R , Vincent R , Wastie M , Elmarasy N , Hopkinson B R
Published: March 2003

Background

Endovascular repair (EVR) of abdominal aortic aneurysm (AAA) is feasible for selected patients. Placing an uncovered stent across the origins of the renal arteries may improve fixation and seal of the proximal end of the stent-graft. However, this has potential for problems (e.g. renal artery stenosis or microembolization). This study aimed to evaluate the short-term effect of a suprarenal stent on the function of the individual kidney.

Methods

In 30 patients undergoing EVR for AAA, renal function was assessed before and after operation by 99mTc-radiolabelled diethylenetriamine penta-acetate radionuclide renography and daily measurement of serum creatinine levels. Eleven patients had infrarenal stent-grafts using an aorta uni-iliac system (group 1); 19 patients had the device with an uncovered suprarenal stent (modified Gianturco Z stent), ten of which were aorta uni-iliac and nine bifurcated systems (group 2). Individual kidney function was expressed as the whole kidney transit time (WKTT). In addition, glomerular filtration rate (GFR) was measured from serial blood samples following renography.

Conclusion

No result reached statistical significance. Placing an uncovered stent over the origins of the renal arteries does not appear to impair kidney function in the short term.
Immunoglobulin A antibodies against Chlamydia pneumoniae are associated with expansion of small abdominal aortic aneurysms and declining ankle blood pressure
Authors: Lindholt J S , Vammen S , Henneberg E W , Fasting H
Published: March 2003

Background

The potential correlation between chronic infection with Chlamydia pneumoniae and the progression of small abdominal aortic aneurysms (AAAs) and lower limb atherosclerosis was studied.

Methods

Mass screening for AAA was carried out in outdoor clinics at all hospitals in the county. Some 139 men (aged 65–73 years) with a 3·0–4·9-cm AAA were followed prospectively for 1–3 (mean 2·7) years. Initially, an interview and examination was performed, and blood samples were taken.

Results

Some 62 per cent (53–71 per cent) had an immunoglobulin (Ig) A level of 40 or more, or an IgG level of 64 or above. Some 83 per cent (74–93 per cent) had an IgA level of 20 or more, or an IgG level of 32 or more. Men with an IgA level of 20 or more had 51 per cent greater AAA expansion and men with an IgA level of 40 or above had 24 per cent more expansion. An IgA level of 20 or more, or IgA of 40 or greater, were significant independent predictors of AAA expansion adjusted for age, smoking, initial AAA size, steroid treatment, diastolic blood pressure, pulmonary function and other plasma factors. The ankle blood pressure index (ABI) of the IgA-seropositive men decreased 11 per cent, while the ABI decreased by 5 per cent among IgA-seronegative men (P < 0·05). The significant difference persisted after adjusting for age, smoking, initial systolic ankle blood pressure, initial brachial systolic or diastolic blood pressure, but disappeared after adjusting for low-density lipoprotein (LDL) levels.

Conclusion

A high proportion of men with a small AAA have signs of chronic C. pneumoniae infection. The progression of AAAs and lower limb atherosclerosis seems to be correlated to chronic infection with C. pneumoniae.
Randomized double-blind study of dopexamine versus placebo in aortic surgery
Authors: Baguneid M S , Welch M , Bukkari M , Fulford P E , Howe M , Bigley G , McMahon R F T , Eddleston J , Walker M G
Published: March 2003

Background

Mechanisms involved in the development of colonic ischaemia are not fully understood and there are conflicting reports regarding predisposing factors. The aim of this study was to evaluate the effect of dopexamine hydrochloride on the incidence of colonic ischaemia following aortic surgery and to correlate immunohistochemical markers of inflammatory activation in its pathogenesis.

Methods

Thirty patients, of mean age 65 (range 46–84) years, undergoing elective infrarenal aortic surgery were randomized to receive a perioperative infusion of either dopexamine 2 µg kg–1 min–1 (n = 12) or 0·9 per cent saline placebo (n = 18). All patients underwent colonoscopy and biopsy following induction of anaesthesia and at 1 week after operation. Sections were stained with haematoxylin and eosin, and for mast cell tryptase (MCT), myeloperoxidase (MPO) and both the inducible (iNOS) and endothelial (eNOS) isoforms of nitric oxide synthase. Sections were analysed blindly and independently by two histopathologists. Patient and operative data were collected and stored separately.

Results

Colonic ischaemia was noted in nine patients based on microscopic findings. Endoscopy alone had a sensitivity of 56 per cent. There was a significantly lower incidence of colonic ischaemia in patients receiving dopexamine compared with placebo (P < 0·05). One death resulted from colonic infarction in the placebo group 11 days after operation. There was increased MPO and MCT expression in patients with histological evidence of ischaemia (P < 0·05); iNOS staining within the vascular (P = 0·001) and lamina propria (P < 0·05) components of the mucosa was also significantly greater. No association was found with eNOS.

Conclusion

Perioperative dopexamine infusion confers a degree of protection to colonic mucosa following aortic surgery, possibly through an anti-inflammatory effect.
Management of coexisting intra-abdominal disease in aortic surgery
Authors: Oshodi T O , Abraham J S , Brigg I K , Kelly J F
Published: March 2003

Background

The management of coexisting intra-abdominal disease in aortic surgery is controversial. A staged repair is preferred by many and, in general, the symptomatic lesion is treated first. Twenty-one years ago this vascular unit elected a policy of treating such lesions synchronously. This was on the theoretical premises that the benefits of a single operation in these patients would outweigh the potential risks of graft infection and increased complication rates from a prolonged procedure.

Methods

The case records of 676 patients undergoing aortic grafting for aneurysmal or occlusive disease between 1978 and 1998 were analysed retrospectively.

Results

Fifty-five patients (8 per cent) had coexisting intra-abdominal diseases treated at the time of aortic graft surgery. These included biliary disease (26), and gastric (12), intestinal (13), urological (two), hepatic (one) and splenic (one) pathology. The median age at presentation was 72 (range 46–90) years. There were three hospital deaths and five patients required early reoperation, three for lower limb ischaemia and two for intra-abdominal bleeding. One patient developed a subphrenic abscess and there were three superficial wound infections. There were no graft infections in this group of 55 patients.

Conclusion

This large single-centre experience with synchronous intra-abdominal surgery and aortic grafting demonstrates that it is safe and does not predispose to an increased risk of graft infection or perioperative haemorrhage.
Symptoms of varicose veins
Authors: Bradbury A W , Evans C J , Allan P L , Lee A J , Ruckley C V , Fowkes F G R
Published: March 2003

Background

The relationships between varicose veins (VVs) and leg symptoms have not been studied. The aim of this study was to define the relationships between age, sex, leg symptoms and VVs.

Methods

An age-stratified sample of 699 men and 867 women aged 18–64 years, selected randomly from 12 general practices distributed socioeconomically throughout the city, completed a questionnaire regarding leg symptoms (heaviness/tension, swelling, aching, restless legs, cramps, itching, tingling) and underwent a clinical examination.

Results

In men, swelling and cramps (both P ≤ 0·001), and in women swelling (P= 0·02), restless legs (P= 0·001) and itching (P= 0·045), were significantly more common in older subjects. Data have therefore been age adjusted. Women were significantly (P < 0·01) more likely to respond positively when asked about all leg symptoms, except tingling. The commonest symptoms were aching in women (53·8 per cent) and cramps in men (34·0 per cent). There was no difference between right and left legs. In men, only itching was significantly related to trunk VVs (P= 0·011). In women, there was a relationship between trunk VVs and heaviness/tension, aching and itching (P ≤ 0·005). Hyphen-web varices were not related to symptoms in men but were related to heaviness/tension and swelling in women. There was no association between reticular varices and symptoms in either sex.

Conclusion

Even in the presence of VVs, most lower limb ‘venous’ symptoms are non-venous in aetiology. Surgery is unlikely to ameliorate symptoms in the majority of patients.
Contribution of malnutrition to postoperative morbidity in vascular surgical patients
Authors: Durkin M T , Mercer K G , McNulty M F , Phipps L , Upperton J , Giles M , Scott D J A
Published: March 2003

Background

In an elderly population of surgical patients, poor mobility, poor diet and chronic disease contribute to a significant risk of malnutrition. Malnutrition is associated with muscle weakness, fatigue, poor wound healing and immunological dysfunction. The aim of the study was to establish the prevalence of malnutrition in vascular surgical patients and to compare postoperative infection rates in well nourished and malnourished patients.

Methods

A nutritional assessment was performed on 71 patients (49 men; median age 65 (range 26–85) years) attending preassessment for vascular surgical procedures. Nutritional status was measured using validated indicators of malnutrition: estimated weight changes over 3 months; body mass index; mid-arm muscle circumference (MAMC) calculated using triceps skin fold thickness (TSF) and mid-arm circumference (MAC) (MAMC = MAC – (3·14 × TSF)); and serum albumin concentration. Fifty-nine patients were followed after vascular surgery. The incidence of postoperative infections was related to preoperative nutritional status.

Results

Nineteen patients (27 per cent) had normal values for all nutritional indicators examined. The remaining 52 patients (73 per cent) had one (37), two (12), three (two) or four (one) nutritional indicators within the range for malnutrition. Among the 59 patients who underwent surgery there were five chest infections, seven wound infections, one urinary tract infection and one infected central line in 13 patients following six femorodistal bypasses, four abdominal aortic aneurysm repairs and three miscellaneous arterial procedures. The incidence of septic complications was zero in 14 patients with normal nutritional indicators and 41 per cent (13 of 32) in patients with indicators of malnutrition (P < 0·05, Fisher's exact test).

Conclusion

Malnutrition is prevalent among vascular patients and may contribute to postoperative morbidity. Malnourished patients should be identified and referred to the dietician at the earliest opportunity to minimize the morbid effects of undernutrition.
Integrated care pathways for vascular surgery
Authors: Abu-Own A , Sachs R , Louden C , Linnard D , Buckland J , Murphy S , Barker S G
Published: March 2003

Background

Integrated care pathways (ICPs) represent a multidisciplinary approach to clinical patient care.

Methods

A 1-year prospective trial of the use of ICPs for elective vascular surgical procedures was undertaken. A multidisciplinary group constructed ICPs for patients admitted for open repair of abdominal aortic aneurysm, carotid endarterectomy or femoropopliteal bypass grafting. Patient management followed ICPs on a daily basis with signatures required to confirm that each action had been taken. Variances from the ICPs were carefully recorded. Audit of variance data allowed subsequent revision of the ICPs and hence provision of the best possible nursing and clinical practice.

Methods

A total of 33 patients were entered into the study; 16 had a femoropopliteal bypass graft, eight carotid endarterectomy and nine open repair of an abdominal aortic aneurysm. ICPs were well received by patients and staff. They improved communication, promoted an appreciation of each health group's role in patient care, increased nursing autonomy, reduced calls to junior medical staff, improved patient education and confidence, and caused a marked reduction in length of hospital stay. Overall, patients were discharged 13 per cent earlier after open abdominal aortic aneurysm repair, 22 per cent earlier after carotid endarterectomy and 38 per cent earlier after femoropopliteal bypass grafting.

Conclusion

ICPs have clear benefits. They improve overall clinical efficiency and enhance clinical governance. Successful use of ICPs depends upon ‘clinical champions’ and effective project management. Sufficient resources and training are essential.
Percutaneous transluminal angioplasty for lower limb ischaemia
Authors: Brittenden J , Beattie G C , Gillespie I , McBride K , McInnes G , Bradbury A W
Published: March 2003

Background

Percutaneous transluminal angioplasty (PTA) is increasingly performed for lower limb ischaemia of all severities, despite the absence of controlled data demonstrating its efficacy. The aim of this study was to examine the indications and outcome for lower limb ischaemia over a 16-year period.

Methods

A prospectively gathered database of 1287 consecutive PTAs performed between 1982 and 1997 was analysed. Two time intervals were compared: 1982–1991 and 1992–1997.

Results

Since 1992 there has been a fourfold increase in the number of PTAs performed. There has been a significant increase in the number of PTAs performed for critical ischaemia, occlusive lesions and at infrainguinal sites. Although there has been a significant reduction in morbidity, the number of immediate technical and clinical failures has increased (see Table).

Conclusion

Despite a lack of controlled data supporting a more liberal use of PTA in the treatment of lower limb ischaemia, there has been, in this regional vascular unit, a significant increase in the perceived clinical and anatomical indications for the procedure. Randomized controlled trials are urgently required to define the role of PTA in this condition.
Duplex surveillance does not enhance infrainguinal prosthetic bypass graft patency
Authors: Adam D J , Gillies T E , Kelman J , Allan P L , Chalmers R T A
Published: March 2003

Background

All patients discharged from this unit with a patent infrainguinal polytetrafluoroethylene (PTFE) bypass are entered into a graft surveillance programme. Previous internal audit had suggested that duplex surveillance was not worthwhile in this patient group. The aim of this study was to compare the fate of infrainguinal PTFE grafts before and after stopping duplex surveillance.

Methods

Between January 1986 and December 1994, 220 grafts (141 above-knee popliteal, 69 below-knee popliteal, ten tibial) were entered into the duplex surveillance programme. Between January 1995 and June 1996, 56 further grafts (29 above-knee popliteal, 21 below-knee popliteal, six tibial) were followed prospectively without duplex scans.

Results

During the first study interval, an ‘abnormal’ scan was reported in 66 of 220 grafts. For clinical reasons (no further reconstruction feasible), no intervention was undertaken in 56 patients. Of these, 34 grafts occluded and 17 amputations were performed. An intervention to maintain patency was performed in ten patients. In 154 patients with ‘normal’ scans, 53 grafts occluded and 21 amputations were performed. During the second study interval, 20 grafts occluded and 12 amputations were performed. In six patients, an attempt was made to re-establish patency and this was successful in two. Kaplan–Meier 36-month primary and secondary patency rates were 48 and 51 per cent respectively for the group that underwent duplex surveillance, and 58 and 60 per cent for the group that was followed without duplex imaging.

Conclusion

Prospective duplex surveillance of infrainguinal PTFE bypass grafts does not enhance graft patency and cannot be justified.
Isolated femoral profundoplasty with endarterectomized superficial femoral artery for limb salvage in the elderly
Authors: Witz M , Shnaker A , Lehmann J M
Published: March 2003

Background

This longitudinal observational study was designed to show that isolated profundoplasty to relieve a significant stenosis is a valid procedure for limb salvage in the elderly.

Methods

Twenty-seven patients with critical limb ischaemia underwent isolated profundoplasty using endarterectomized superficial femoral artery as an arterial patch. Nineteen patients were men. The mean age was 72 (range 65–79) years. All patients had rest pain with or without an ischaemic foot ulcer or pedal gangrene.

Results

There was no operative death or immediate operative failure. All 27 limbs were improved, with relief of rest pain, healing of ulcers and healing after minor foot amputations. The 27 patients underwent a mean of 30 (range 12–45) months of periodic observation in an outpatient clinic, either to the present time or until death. Two patients required late amputations and one a femorodistal bypass.

Conclusion

Isolated profundoplasty has a place in leg revascularization in the high-risk elderly patient. Endarterectomized superficial femoral artery as a patch has the advantages of almost universal availability and anatomical convenience.
Laparoscopic ultrasonography is accurate for staging large pancreatic tumours
Authors: Finch M D , Formela L , Jones L , Sutton R , Hartley M N , Slavin J , Neoptolemos J P
Published: March 2003

Background

The accuracy of laparoscopic ultrasonography in staging pancreatic and periampullary tumours in a referral unit was determined and its use for the subgroup of tumours of stage T3 or greater was assessed.

Methods

From a larger series of staging laparoscopies 22 patients with pancreatic lesions and five with periampullary tumours who were being considered for resection were staged with laparoscopy and laparoscopic ultrasonography. Only patients with computed tomography (CT) or magnetic resonance imaging (MRI) scans indicating potentially or equivocally resectable disease were included. The laparoscopist was blinded to the results of CT and MRI. Laparoscopy and laparoscopic ultrasonography were undertaken according to a standard protocol using a B & K Medical Diagnostic Ultrasound System 3535 with a colour flow Doppler module. Ascitic fluid was sent for cytology and metastatic disease was biopsied. Results were recorded on a pro forma which included an assessment of resectability. In the case of large tumours this included an assessment of the potential for a positive resection margin or the need for portal vein resection to obtain tumour clearance. The decision to pursue resection was made by the consultant surgeon, based on all the information available including that from laparoscopic ultrasonography. No patient was denied a surgical exploration on the basis of local irresectability determined only by laparoscopic ultrasonography. The predictions regarding resectability were compared with findings at open surgery and with histology.

Results

Assessment of irresectability by laparoscopic ultrasonography resulted in nine true positives, 16 true negatives, no false positives and one false negative. For pancreatic adenocarcinoma there were eight true positives, 13 true negatives and one false negative. Among the pancreatic group ten of 13 tumours correctly predicted as resectable were stage T3 or greater (Union Internacional Contra la Cancrum, 1997). Of those predicted to be irresectable, all eight were T3 or greater. Among this latter group three were predicted to be irresectable on the basis of local factors alone, two on the basis of metastatic disease alone and three on the basis of both local factors and metastases. Overall, for detection of irresectable disease laparoscopic ultrasonography had a positive predictive value of 100 per cent, a negative predictive value of 94 per cent and an accuracy of 96 per cent. Accuracy was 95 per cent for both the pancreatic tumour subgroup and the T3 pancreatic subgroup.

Conclusion

Laparoscopic ultrasonography was accurate for predicting irresectability in this group of referred patients. The technique was also accurate for the subgroup with T3 or greater pancreatic tumours.
Single-centre audit of endoscopic common bile duct stone retrieval
Authors: Welsh F K S , Mudan S S , Knight M J
Published: March 2003

Background

Endoscopic extraction of stones in the bile duct is not without risk, with complications occurring in up to 10 per cent of patients. The aim of this study was to determine the success and complications of stone retrieval by endoscopic retrograde cholangiopancreatography (ERCP) in this institution.

Methods

This was a retrospective analysis of a prospective database for all ERCPs (single operator, single institution) between 1990 and 1995. Some 271 consecutive patients with a strong suspicion of bile duct stones, from history or investigations, were studied. All patients underwent ERCP and attempted retrieval of bile duct stones if detected. Treatment success was strictly defined as a stone-free postprocedure radiograph. All patients were followed to identify complications occurring within 30 days of the procedure.

Results

The median age of the 271 patients was 73 (range 17–96) years; 62 per cent were women. Some 139 patients had 162 significant other medical conditions (61 per cent cardiopulmonary) that required specialist treatment. The presenting symptoms included painful jaundice (34 per cent), acute pancreatitis (25 per cent), cholangitis (17 per cent), painless jaundice (14 per cent) and abdominal pain alone (9 per cent). Stones were seen at ERCP in 192 patients (71 per cent); the median number of stones was 1 (range 0–20). Successful endoscopic stone retrieval was achieved in 136 patients (71 per cent) at the first attempt, with an overall success rate of 90 per cent. The median number of ERCPs per patient was 1 (range 1–4). There were five false-negative ERCPs (2 per cent) and 19 retrieval failures (10 per cent), which included requirement for percutaneous cholangiography or endoscopic stenting for successful treatment. Complications occurred in eight␣patients (3 per cent), and included cholangitis (1␣per cent), pancreatitis (less than 1 per cent) and haemorrhage (less than 1 per cent). There were two procedure-related deaths (1 per cent), from myocardial infarction and cholangitis.

Conclusion

Endoscopic stone retrieval can be achieved successfully with low morbidity and mortality rates, even in patients with significant co-morbidity. These data provide further support for dedicated units offering a regional ERCP service.
Impact of endoscopic ultrasonography on the management of idiopathic pancreatitis
Authors: Norton S A , Alderson D
Published: March 2003

Background

Conventional ultrasonography may fail to detect small stones responsible for acute pancreatitis, leading to a false diagnosis of idiopathic pancreatitis and exposing 33–66 per cent of these patients to the risk of a recurrent attack from untreated gallstone disease. The aim of this study was to assess whether identification of a potential aetiology in patients with ‘idiopathic’ pancreatitis, using endoscopic ultrasonography (EUS), had any effect on outcome.

Methods

EUS was performed following a diagnosis of idiopathic pancreatitis, using the GF UM-20 echoendoscope (Olympus). The presence of gallstones or other pathology was determined and any appropriate treatment was provided. The frequency of attacks of pancreatitis before and after treatment of the presumed cause was calculated.

Results

Of 20 patients with idiopathic pancreatitis, evidence of gallstone disease (e.g. stones, microlithiasis) was seen in 12 patients leading to endoscopic sphincterotomy and/or cholecystectomy in nine. Pancreatic disease was seen in three patients, of whom one underwent pancreatic duct stenting. One patient underwent cholecystectomy for recurrent pain, despite a normal EUS result, with a diagnosis of acalculous cholecystitis. No pathology was seen in a further four patients. The frequency of attacks of pancreatitis was 1·1 per patient-year before treatment versus 0 per patient-year after treatment (P < 0·0001). The overall morbidity rate from investigation and treatment was 0·05 per cent. This resulted from one episode of post-ERCP pancreatitis following endoscopic sphincterotomy, which resolved rapidly with conservative treatment.

Conclusion

EUS is able to detect pancreatic and biliary abnormalities that are not visible with conventional ultrasonography and can guide appropriate treatment. EUS should be performed before a diagnosis of idiopathic pancreatitis is made, to reduce the risk of recurrent pancreatitis from unrecognized gallstones or other pathology.
Cost implications of endoscopic surveillance of patients with Barrett's oesophagus
Authors: Howell G W , Russel K , Bani-Hani K , Martin I G
Published: March 2003

Background

The cost implications of a 13-year endoscopic surveillance programme for patients with Barrett's oesophagus were assessed and it was considered whether this represents a justifiable use of resources.

Methods

From a population of 597 patients with Barrett's oesophagus, 357 patients (207 men; mean age 61 years) entered a yearly endoscopic surveillance programme. Twelve patients (11 men) developed adenocarcinoma a mean of 72 months after entering the programme. The costs of the surveillance programme were calculated using figures for this institution.

Results

The cost of detecting one cancer at the institution's incidence rate of one cancer per 69 patient-years of follow-up was £24 236. The cost for male patients was £15 801 and for female patients £122 973. For male patients with specialized mucosa the cost was £13 969 per cancer detected. Comparing the stage presentation of surveillance cancers with the stage of adenocarcinomas presenting generally in this institution, the cost per life-year saved was estimated at £6097 for male patients.

Conclusion

Yearly endoscopic surveillance of patients with Barrett's oesophagus is expensive compared with other established screening programmes (e.g. £6006 per breast cancer detected) but for male patients with specialized mucosa it is probably justified. However, its role in female patients must be questioned given the high cost and low yield of cancers.
Prospective randomized trial of laparoscopic Nissen fundoplication versus maintenance proton pump inhibition in the treatment of gastro-oesophageal reflux disease in patients aged under 65 years: preliminary results
Authors: Decadt B , Lowndes R , Rhodes M
Published: March 2003

Background

Laparoscopic Nissen fundoplication (LNF) was compared with maintenance proton pump inhibition (PPI) in patients with gastro-oesophageal reflux disease (GORD).

Methods

Some 113 patients (60 men; median age 45 (range 25–64) years) presented between June 1997 and June 1998 with a history of GORD of at least 2 years' duration. After giving informed consent they were investigated by endoscopy, 24-h pH and oesophageal manometry. Of 66 patients who completed the investigations, 57 had significant GORD; these were randomized, 29 to PPI and 28 to LNF.

Results

Endoscopic findings were equivalent in the two groups: 75 per cent of the PPI group had a hiatus hernia compared with 78 per cent of the LNF group; 54 per cent of the PPI group had oesophagitis compared with 71 per cent in the LNF group. Twenty-four-hour pH monitoring revealed De Meester scores of 21 (range 7–92) in the PPI group compared with 20 (range 10–99) in the LNF group. Manometry revealed a median␣lower oesophageal sphincter pressure (LOSP) of 10 (range 0–30) mmHg in the PPI group compared with 7 (range 1–30) mmHg in the LNF group. At 3 months after start of therapy, 24-h pH monitoring revealed a median De Meester score of 11 for both groups (PPI range 7–24, LNF range 9–39). Median LOSP was 15 mmHg in the PPI group compared with 17 mmHg in the LNF group.

Conclusion

Preliminary results suggest that LNF provides the same reduction in acid reflux as maintenance PPI in the short term. Further study of this group of patients will assess not only the physiological benefits of surgery versus maintenance PPI but also its impact on well being and relative costs of the two treatments.
Reliable screening for acute pancreatitis with rapid urine trypsinogen-2 test strip
Authors: Kylänpää-Bäck M-L , Kemppainen E , Puolakkainen P , Hedström J , Haapiainen R , Perhoniemi V , Kivilaakso E , Korvuo A , Stenman U-H
Published: March 2003

Background

This study was designed to evaluate the validity of a new rapid urinary trypsinogen-2 test strip (Actim Pancreatitis) for detection of acute pancreatitis in patients with acute abdominal pain.

Methods

A total of 525 consecutive patients presenting with abdominal pain at two emergency units was included prospectively and tested with the Actim Pancreatitis test strip. Urine trypsinogen-2 concentrations were also determined by a quantitative method. The diagnosis and assessment of severity of acute pancreatitis was based on raised serum and urinary amylase levels, clinical features and findings on dynamic contrast-enhanced computed tomography.

Results

In 45 patients the diagnosis of acute pancreatitis could be established. The Actim Pancreatitis test strip result was positive in 43 of them resulting in a sensitivity of 96 per cent. Thirty-seven false-positive Actim Pancreatitis test strips were obtained in patients with non-pancreatic abdominal pain resulting in a specificity of 92 per cent. Nine patients with severe acute pancreatitis were all detected by the dipstick.

Conclusion

A negative Actim Pancreatitis strip result excludes acute pancreatitis with high probability. Positive results indicate the need for further evaluation, i.e. other enzyme measurements and/or radiological examinations. The test is easy and rapid to perform, unequivocal in its interpretation and can be used in healthcare units lacking laboratory facilities.
Surgical treatment for recurrent gastro-oesophageal reflux disease after failed antireflux surgery
Authors: Bais J E , Horbach J M L M , Masclee A A M , Smout A J P M , Terpstra J L , Gooszen H G
Published: March 2003

Background

Recurrent or persistent symptoms occur in 10–15 per cent of patients after antireflux surgery. Failure of surgery is not uniform in its presentation. The cause of failure is not easily detected and even harder to treat. Different approaches have been proposed and few reports are available on the objective and subjective outcome of reoperation.

Methods

This study focuses on 30 patients (16 men and 14 women; age range 20–69 years) with recurrent symptomatic gastro-oesophageal reflux disease (GORD) resistant to medical treatment. In all patients reoperation was by the Belsey Mark IV antireflux operation. A clinical history, endoscopy and oesophageal manometry were obtained in all patients, and 24-h pH monitoring was performed in 27 of 30 before and in most patients after the Belsey procedure.

Results

Symptomatic improvement was reported in 24 of 30 patients. Oesophagitis (present before operation in 19 patients) was cured or remained absent in 24 of 30 patients, stabilized in one, improved in four and deteriorated in one. Relief of symptoms combined with absence of oesophagitis was obtained in 21 of 30 patients, with concomitant normalization of the 24-h pH profile in 11 of 22 patients. The median basal lower oesophageal sphincter (LOS) pressure increased significantly from 6·9 to 9·0 mmHg (P < 0·01). Redo surgery had no effect on oesophageal body motility.

Conclusion

Reoperation performed for documented recurrent GORD had a good and lasting effect on symptoms, on oesophagitis (both in 24 of 30 patients) and on the combination of both (21 of 30). In these patients reoperation increased basal LOS pressure and decreased reflux time. Overall, the results approximate to those of primary operation.
Characteristics of patients with pancreatic cancer expressing a novel cancer cachectic factor
Authors: Wigmore S J , Todorov P T , Barber M D , Ross J A , Tisdale M J , Fearon K C H
Published: March 2003

Background

Recently a novel tumour-derived cachectic factor was identified in the murine MAC16 colonic adenocarcinoma model of cachexia. This factor, provisionally named proteolysis-inducing factor (PIF), was subsequently identified in the urine of weight-losing patients with cancer but not in the urine of weight-stable patients with cancer or weight-losing controls with benign disease. This study determined the nutritional characteristics of patients with pancreatic cancer who excrete PIF in the urine and investigated the relationship between PIF and the acute-phase protein response.

Methods

PIF was isolated from urine by precipitation and ultrafiltration and was then identified by Western blotting of nitrocellulose membranes using a previously developed monoclonal antibody. Full nutritional assessment of patients was undertaken at the same time as urine collection.

Results

PIF was detected in the urine of 80 per cent of patients (n = 55). These patients had a significantly greater total weight loss and rate of weight loss than patients whose urine did not contain PIF (median 12·5 (range 4–43) kg versus 4·5 (0–14) kg; P < 0·0002). No association was evident between the presence of PIF in patients' urine and serum C-reactive protein (CRP) concentration. Furthermore, the accelerated weight loss associated with PIF expression also appeared to be independent of the acute-phase response. Overall the presence of PIF was not associated with reduced survival, although the previously reported association between raised CRP concentration and poor prognosis was confirmed.

Conclusion

PIF is associated with an accelerated rate of weight loss in patients with a tumour of the pancreatic head. This observation appears to be independent of the effect of an increased hepatic acute-phase protein response.
Autonomic nerve plexus involvement and prognosis in patients with rectal cancer
Authors: Ueno H , Mochizuki H , Fujimoto H , Hase K , Ichikura T
Published: March 2003

Background

A detailed knowledge of the fundamental basis for cancer involvement of the autonomic nerve plexus and the outcome of patients with such cancer foci is important when considering nerve-preserving surgery for rectal cancer.

Methods

Extrarectal autonomic nerve plexuses were obtained from 61 patients with advanced rectal cancer who were undergoing extended resection of the rectum with the associated nervous system. The specimens were sectioned totally so that any indirect cancer involvement of the extrarectal autonomic nerves and/or the surrounding tissue could be detected.

Results

Autonomic nerve plexus involvement was observed in nine patients: none of 25 with Dukes A/B, six of 28 with Dukes C and three of eight with Dukes ‘D’ lesions. Five of 26 patients with nodal involvement in the pararectal area had such foci, and four of eight patients with nodal involvement further from the primary tumour. Furthermore, of the nine patients with nerve plexus involvement, seven had extranodal cancer deposits in the mesorectum. The 3-year survival rate of patients with nerve plexus involvement was 33 per cent, while it was 83 per cent in those without such disease.

Conclusion

Nerve plexus involvement was observed in direct proportion to the extent of cancer spread to the mesorectum, and the prognosis of patients with such disease was unfavourable. Further investigation is needed to better identify those patients who would clearly benefit from an en bloc resection of the autonomic nerves.
Bladder and sexual dysfunction after mesorectal excision for rectal cancer
Authors: Nesbakken A , Nygaard K , Bull-Njaa T , Carlsen E , Eri L M
Published: March 2003

Background

Urinary and sexual dysfunction are recognized complications of rectal excision for cancer. The aim of this study was to examine the frequency of such complications after mesorectal excision, shortly after this method was introduced.

Methods

Spontaneous flowmetry, residual volume of urine measurement and urodynamic examination, including cystometry and simultaneous detrusor pressure and urinary flow recording, was carried out before and 3 months after curative rectal excision. Urinary symptoms and sexual function were evaluated by means of questionnaires before and after operation. Each patient served as his or her own control.

Results

Forty-nine consecutive patients, 39 of whom had a total mesorectal excision (TME) and ten a partial mesorectal excision, were examined before surgery and 35 again after operation. In two patients, a weak detrusor was detected before operation. Two patients developed signs of bladder denervation after operation. Transitory moderate urinary incontinence appeared in four other women. Six of 24 men reported some reduction in erectile function and one became impotent. Two men reported retrograde ejaculation. All the complications were seen in the TME group.

Conclusion

Mesorectal excision for rectal cancer resulted in a low frequency of serious bladder and sexual dysfunction.
Recurrence following curative resection for gastric carcinoma
Authors: Yoo C H , Noh S H , Shin D W , Choi S H , Min J S
Published: March 2003

Background

The diagnosis and treatment of recurrent gastric cancer remains difficult. The aim of this study was to determine the risk factors for recurrence of gastric cancer and the prognosis for these patients.

Methods

Of 2328 patients who underwent curative resection for gastric cancer from 1987 to 1995, 508 whose recurrence was confirmed by clinical examination or reoperation were studied retrospectively. The risk factors that determined the recurrence patterns and timing were investigated by univariate and multivariate analysis.

Results

The mean time to recurrence was 21·8 months and peritoneal recurrence was the most frequent (45·9 per cent). Logistic regression analysis showed that serosal invasion and lymph node metastasis were risk factors for all recurrence patterns and early recurrence (at 24 months or less). In addition, independent risk factors involved in each recurrence pattern included younger age, infiltrative or diffuse type, undifferentiated tumour and total gastrectomy for peritoneal recurrence; older age and larger tumour size for disseminated, haematogenous recurrence; and older age, larger tumour size, infiltrative or diffuse type, proximally located tumour and subtotal gastrectomy for locoregional recurrence. Other risk factors for early recurrence were infiltrative or diffuse type and total gastrec-tomy. Reoperation for cure was possible in only 19 patients and the mean survival time after conservative treatment or palliative operation was less than 12 months.

Conclusion

The risk factors for each recurrence pattern and timing of gastric cancer can be predicted by the clinicopathological features of the primary tumour. Since the results of treatment remain dismal, studies of perioperative adjuvant therapy in an attempt to reduce recurrence are warranted.
Effect of liver blood flow and function on hepatic indocyanine green clearance measured directly in a cirrhotic animal model
Authors: Jiao L R , El-Desoky A A , Seifalian A M , Habib N , Davidson B R
Published: March 2003

Background

Peripheral blood clearance of indocyanine green (ICG) has been used as a test of liver function but gives little information on biliary excretion. Hepatic ICG uptake and clearance can be measured directly by near-infrared spectroscopy (NIRS). Direct ICG measurement has not previously been correlated with liver blood flow and function in cirrhosis.

Methods

Two groups of New Zealand white rabbits (n = 12) underwent laparotomy for liver exposure. Cirrhosis was induced by feeding animals (n = 6) with a high-cholesterol (2 per cent) diet for 16 weeks. Hepatic blood flow and microcirculation were measured. Hepatic ICG concentration was measured directly using NIRS probes on the liver surface. From the ICG concentration–time curve, hepatic ICG uptake and excretion rates were calculated by a non-linear least square curve fitting method.

Results

There was a significant reduction in ICG uptake rate (mean(s.d.) 0·300(0·130) versus 2·040(0·420) min−1; P = 0·0001) and ICG excretion rate (0·007(0·009) versus 0·227(0·096) min−1; P = 0·002) in cirrhotic animals. The hepatic ICG uptake rate correlated with hepatic blood flow and flow in the microcirculation (r = 0·81, P = 0·002; r = 0·92, P < 0·001, respectively). The hepatic ICG excretion rate was significantly associated with indicators of impaired liver function including bilirubin (r = −0·86, P = 0·0004), aspartate aminotransferase (r = −0·81, P = 0·001) and lactate dehydrogenase (r = −0·83, P = 0·0008).

Conclusion

ICG uptake measured directly by NIRS reflects the reduced liver blood flow and perfusion in cirrhosis and its excretion correlates with the degree of liver parenchymal dysfunction. This technique may allow a more accurate method of liver function assessment than peripheral blood ICG clearance.
Functional outcome after restorative panproctocolectomy for ulcerative colitis decreases an otherwise enhanced quality of life
Authors: O'Bichere A , Wilkinson K , Rumbles S , Norton C , Green C , Phillips R K S
Published: March 2003

Background

Restorative panproctocolectomy is a favoured operation for ulcerative colitis, but altered bowel habit may adversely affect overall quality of life.

Methods

Specific and generic quality of life questionnaires and an instrument to award money for continuing disability based on government guidelines were sent to 103 patients who had curative surgery for ulcerative colitis between 1995 and 1997. Seventy-one patients returned completed questionnaires: 30 with an ileostomy (representing incontinence and abnormal body image), 11 with a Koch pouch (representing continence and abnormal body image) and 30 with a pelvic pouch (representing continence and normal body image).

Results

Patients valued the disability of having an ileostomy similar to that for a Koch pouch or a pelvic pouch: £40 000, £30 000 and £40 000 respectively (P = 0·97). There was no sex difference. Body image measured with a visual analogue scale (least = 1, worst = 10) was worst with the ileostomy and Koch pouch (8 each) and best with a pelvic pouch (5) (P = 0·06). However, pelvic pouches scored significantly worse than an ileostomy with regard to altered bowel emptying (pelvic pouch, 8; Koch pouch, 7; ileostomy, 5) (P = 0·01).

Conclusion

Poor function after pelvic pouch surgery offsets any advantage in body image over an ileostomy. Thus, overall quality of life and perceived monetary damage were the same for the two operations. Improved pelvic pouch function is likely to be reflected in better quality of life after restorative panproctocolectomy.
Immunoglobulin G and albumin levels in whole gut lavage fluid provide an objective measure of pouch ileitis
Authors: Evgenikos N , Bartolo D C C , Hamer-Hodges D W , Ghosh S
Published: March 2003

Background

Gut protein loss is a characteristic of inflammatory bowel disease (IBD), and immunoglobulin (Ig) G, albumin and α1-antitrypsin concentrations in whole gut lavage fluid (WGLF) correlate with clinical disease activity. If inflammation in ileoanal pouches is similar to IBD, then measurement of protein-losing enteropathy by analysis of WGLF may provide an objective assessment of disease activity in pouches.

Methods

Forty-two patients who had restorative proctocolectomy for ulcerative colitis underwent whole gut lavage with a polyethylene glycol–electrolyte solution. The first clear effluent was filtered, processed by the addition of protease inhibitors and stored at −70°C. IgG, albumin and α1-antitrypsin were assayed in WGLF. The Pouchitis Disease Activity Index (PDAI) was calculated after pouchoscopy and biopsy; the Moskowitz criteria for pouchitis were also applied.

Results

There was a significant correlation of the pouchoscopy score and the PDAI with the concentration of WGLF IgG. All patients with ‘pouchitis’ according to the Moskowitz criteria had a WGLF IgG concentration greater than 10 μg/ml. The WGLF albumin level also showed a significant correlation with the PDAI, but α1-antitrypsin concentration did not.

Conclusion

Analysis of WGLF for IgG and albumin may be useful in the assessment of disease activity in pouch inflammation.
Laparoscopic surgery and surgical infection
Authors: Targarona E M , Balagué C , Knook M M , Trías M
Published: March 2003

Introduction

It has been observed that the metabolic response to surgical injury is less after laparoscopic surgery than after open surgery. However, the effect of laparoscopic surgery on surgical infection has not been given much attention in the surgical literature, even though it may decrease the incidence of infectious complications. The objective of this study was to assess the influence that laparoscopic surgery has on surgical infection and to highlight certain controversial aspects.

Methods

A review of the literature was undertaken to examine the relationship between laparoscopic surgery and surgical infection. This was achieved primarily by using PubMed Medline as a source of material.

Results and conclusion

Laparoscopic surgery is associated with better preservation of the immune system than open surgery. This results in a decreased incidence of infectious complications. Although carbon dioxide pneumoperitoneum affects the peritoneal response to injury, it seems to have no harmful effect in terms of intra-abdominal infection. Nevertheless, at laparoscopic operation the virulence of intestinal micro-organisms should be recognized and, while knowing the advantages of minimally invasive surgery, the surgeon should consider the complexity of this technique. Furthermore, maintenance of laparoscopic instruments should be governed by the same norms as those used in open surgery; recommendations offered by the manufacturers should be respected.