bluuebunny/crossref_metadata_2025 huggingface dataset:
Long-term prognosis of children with papillary thyroid cancer presenting with pulmonary metastases
Authors: Brink J , van Heerden J , Farley D , McIver B , Thompson G B , Grant C S , Zimmerman D
Published: March 2003

Background

Papillary thyroid cancer (PTC) has a generally favourable prognosis, but elderly patients with distant metastases or extracapsular invasion fair poorly. In small studies with short follow-up, young patients presenting with such extracapsular invasion and pulmonary metastases have faired well. This retrospective study was undertaken to clarify the long-term prognosis of such patients with advanced PTC.

Methods

Twenty-one children and young adults (median age 14 (range 6–20) years) presenting with PTC and pulmonary metastases were treated at a single institution between 1947 and 1998. Mean maximal tumour diameter was 4·65 cm. Initial surgical treatment consisted of total thyroidectomy (n = 16), subtotal thyroidectomy (n = 4) and isthmectomy (n = 1), coupled with a variety of lymph node dissections (n = 20). After operation, 19 patients were treated with ablative and incremental doses of iodine-131 until disease free. All patients were placed on suppressive thyroid hormone after operation. Mean length of follow-up was 21 years (range 3 months to 47 years). Follow-up was less than 3 years in four patients. All patients have undergone post-treatment radionucleotide and radiological evaluation.

Results

Nine of the 21 patients developed recurrent disease. The risk of recurrence at 5 years was 39 (95 per cent confidence interval 14–57) per cent. Eight had cervical lymph node recurrence and no patient developed recurrent pulmonary disease. All patients with identifiable recurrent disease underwent selective lymph node resection, which involved multiple resections in four. At follow-up, 18 patients remain completely free of disease, one patient has recurrent cervical node disease and two patients have died. The disease-free survival at 5 years was 95 (95 per cent confidence interval 86–100) per cent. Cause-specific death occurred in a single patient who died from extensive local disease at age 29 years after 12 years of multiple cervical lymph node recurrences.

Conclusion

A stepwise treatment approach including total thyroidectomy, high-dose iodine-131 treatment and early surgical reintervention for suspected local recurrent disease allows long-term survival and frequent ‘cure’ for young patients with PTC and concomitant pulmonary metastases.
The national liver transplantation audit: an overview of patients presenting for liver transplantation from 1994 to 1998
Authors: Hartley P , Petruckevitch A , Reeves B , Rolles K
Published: March 2003

Background

The aim of this study was to describe current clinical practice in liver transplantation in the UK and Ireland, to provide overall 1-year graft and patient survival rates, and to study some preoperative risk factors.

Methods

All patients receiving a liver transplant in the UK or Ireland between 1 March 1994 and 30 September 1998 were included. Data were collected on patients at the time of transplantation, 3 months after grafting and annually thereafter until the patient's death. The main outcome measures were graft and patient survival at 1 year.

Results

A total of 3102 liver transplants were carried out, of which 87 per cent were first transplants. The mean age at first transplantation was 42 (range 0–76) years. The most common indications for transplantation were primary biliary cirrhosis, alcoholic cirrhosis and posthepatitis C cirrhosis, but variations existed between sexes and centres. Risk factors associated with lower graft and patient survival were the presence of acute disease, being transplanted from hospital, and the need for renal and/or ventilatory support before operation.

Conclusion

Donor and recipient demographics are consistent with data held by the European Liver Transplant Registry, as are 1-year graft and patient survival rates. Variation across centres in factors such as the primary indication for liver transplantation, population demographics, the clinical status of each patient, incidence of retransplantation and other risk factors contributes to the problem of adjusting for case mix.
Experimental models of Gram-negative sepsis
Authors: Parker S J , Watkins P E
Published: March 2003

Background

The mortality rate from sepsis has improved little over the past two decades. One reason for this has been the use of flawed or inappropriate experimental models in preclinical sepsis studies.

Methods

A literature review of animal models of sepsis was performed following a Medline search based on the following medical subject headings: disease models, endotoxin, inflammation, peritonitis and sepsis. Additional references were identified from the papers identified in the search.

Results and conclusion

Many animal models of sepsis have been described but none has proved to be superior. Extrapolation of results from endotoxicosis or bacterial infusion models should be regarded with caution. Peritonitis models should be accepted as the ‘gold standard’ but the use of appropriate virulent bacterial species needs to be ensured. A standardized panel of animal models for the preclinical assessment of immunomodulatory agents should be established, including at least one immuno- suppressed model to simulate the immunocompromised patient with sepsis. A uniform and valid definition of sepsis applicable to both small and large animal species is required.
Randomized trial of needlescopic versus laparoscopic cholecystectomy
Authors: Cheah W K , Lenzi J E , So J B Y , Kum C K , Goh P M Y
Published: March 2003

Background

Several studies have reported the feasibility of using ‘needlescopic’ instruments with a diameter less than 3 mm in minimally invasive surgery. This study reports a comparison of needlescopic cholecystectomy and laparoscopic cholecystectomy.

Methods

Seventy-five patients with symptomatic chronic cholelithiasis were randomized to needlescopic (n = 37) or laparoscopic (n = 38) cholecystectomy.

Results

The duration of surgery in the two groups was similar. Patients in the needlescopic group had less pain (mean visual analogue score 2·2 versus 3·6; P < 0·003) and had smaller scars (median length 17·0 versus 25·0 mm; P < 0·001). In addition, patients in the needlescopic group tended to require fewer intramuscular pethidine injections (P = 0·05). However, oral analgesic requirements in the two groups were similar. There were no complications in either group.

Conclusion

Needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy in patients with chronic cholecystitis.
Impact of mammographic interval on stage and survival after the diagnosis of contralateral breast cancer
Authors: Kaas R , Hart A A M , Besnard A P E , Peterse J L , Rutgers E J T
Published: March 2003

Background

Following treatment for primary breast cancer, annual mammography and regular clinical breast examination is advised. The aim of this study was to investigate whether annual mammography resulted in an improvement in stage of contralateral breast cancers compared with mammography performed at a longer interval.

Methods

This was a retrospective analysis of patients treated for breast cancer, who developed a contralateral breast cancer between 1977 and 1998. Patients were stratified into two groups according to mammographic interval.

Results

Data were available for 275 patients who developed contralateral breast cancer during follow-up. Annual mammography was performed in 51 per cent; these patients were a mean of 5 years younger at diagnosis. Patients who had annual or biennial mammography had comparable rates of impalpable contralateral breast cancer, 30 and 27 per cent respectively. The tumours were of favourable stages in 60 and 58 per cent respectively. Five-year disease-free survival following diagnosis of contralateral breast cancer was 75 per cent in both groups. When the contralateral lesion was detected by mammography, disease-free survival was better, irrespective of the stage of the ipsilateral breast cancer.

Conclusion

No difference was found between the two groups in stage distribution and disease-free survival after the diagnosis of contralateral breast cancer. Survival was better in patients in whom the contralateral breast cancer was first detected by mammography.
High-risk colorectal adenomas and serum insulin-like growth factors
Authors: Renehan A G , Painter J E , Atkin W S , Potten C S , Shalet S M , O'Dwyer S T
Published: March 2003

Background

This study investigated the hypothesis that circulating levels of insulin-like growth factor (IGF) I and its main binding protein (IGFBP-3) predict for the presence of colorectal adenomas, surrogate markers of colorectal cancer risk.

Methods

Within the Flexi-Scope Trial (healthy volunteers aged 55–64 years), at one study centre, IGF-I and IGFBP-3 levels in serum samples collected prospectively from 442 attendants were measured. Of these, 100 individuals underwent a complete screening colonoscopy. There were 47 normal examinations, while in 11 examinations low-risk adenomas and in 42 examinations high-risk adenomas were identified. Estimates of relative risk (RR) for the adenomatous stages were calculated by means of unconditional logistic regression, adjusting for known risk factors.

Results

Mean serum IGF-I and IGFBP-3 levels were similar in individuals with a normal colonoscopy finding and in those with low-risk adenomas. By contrast, the mean(s.d.) serum IGF-I level was increased (190(53) versus 169(54) µg/l; P = 0·06) and the serum IGFBP-3 concentration was significantly decreased (3·22(0·60) versus 3·47(0·62) mg/l; P = 0·05) in individuals with high-risk adenomas compared with levels in those with normal colonoscopy and low-risk adenomas combined. Levels were unaffected by removal of the adenomas. With high-risk adenoma as the dependent factor, regression models demonstrated a significant positive association with IGF-I after controlling for IGFBP-3 (RR per one standard deviation (1s.d.) change 4·39 (95 per cent confidence interval (c.i.) 1·31–14·7); P = 0·02) and, independently, an inverse association with IGFBP-3 after adjustment for IGF-I (RR per 1s.d. change 0·41 (95 per cent c.i. 0·20–0·82); P = 0·01).

Conclusion

These findings suggest that circulating IGF-I and IGFBP-3 levels are related to future colorectal cancer risk and, specifically, may predict adenoma progression.
Inhibition of matrix metalloproteinases enhances breaking strength of colonic anastomoses in an experimental model
Authors: Syk I , Ågren M S , Adawi D , Jeppsson B
Published: March 2003

Background

The breaking strength of colonic anastomoses declines after operation to a minimum at days 3–4, with a subsequent risk of anastomotic dehiscence. The mechanism is thought to be collagen degradation by matrix metalloproteinases (MMPs). This study examined the pathogenic role of MMPs on the mechanical strength of colonic anastomoses by giving the synthetic broad-spectrum MMP inhibitor BB-1101 systemically.

Methods

Forty-eight male Sprague–Dawley rats were treated daily for 7 days with BB-1101 30 mg/kg or vehicle alone (control) starting 2 days before operation. The breaking strength of standardized left-sided colonic anastomoses was measured on postoperative days 1, 3 and 7.

Results

Serum BB-1101 levels were increased at 100 nmol/l in BB-1101-treated rats. The anastomotic breaking strength was 48 per cent higher (P = 0·02) in BB-1101-treated animals compared with controls on postoperative day 3. Neither collagen accumulation nor infiltration of neutrophils in the anastomotic area was influenced by BB-1101 treatment. Net deposition of new collagen in subcutaneous sponges was unaffected by the BB-1101.

Conclusion

The enhanced breaking strength of colonic anastomoses during the critical early postoperative phase found after administration of a broad-spectrum MMP inhibitor implies that MMPs might increase the risk of anastomotic dehiscence.

Presented in part to the third joint meeting of the European Tissue Repair Society and the Wound Healing Society in Bordeaux, France, 24–28 August 1999, and published in abstract form in Wound Repair Regen 1999; 7: A321
Positron emission tomography and colorectal cancer
Authors: Arulampalam T H A , Costa D C , Loizidou M , Visvikis D , Ell P J , Taylor I
Published: March 2003

Background

The oncological applications of positron emission tomography (PET) have gained widespread acceptance. This rapidly evolving technology has been applied successfully to colorectal cancer, but has not yet become part of routine clinical practice. This review considers (1) the biological basis for the use of PET in colorectal cancer, (2) the technical aspects of PET relevant to the referring clinician and (3) the application of PET to the management of primary and recurrent disease.

Methods

A Medline database search was performed for the period 1980–2000. Experience was also drawn from the first 40 patients with colorectal cancer investigated at this institution.

Results and conclusion

PET has a proven role, and is cost effective in the management of recurrent cancer and the monitoring of therapy. However, further evaluation is still required to justify its routine use for other indications in colorectal cancer. Development of new positron-labelled radio- pharmaceuticals, in parallel with advances in detector technology and innovative models for tracer production and distribution, means that the availability of PET and its applications in the management of colorectal cancer will expand over the coming years.
Treatment strategy for patients with middle and lower third bile duct cancer
Authors: Todoroki T , Kawamoto T , Koike N , Fukao K , Shoda J , Takahashi H
Published: March 2003

Background

The prognosis for patients with middle and lower third bile duct carcinoma remains poor. This study was conducted to identify independent predictors for survival, as well as the patterns of recurrence after curative resection.

Methods

Sixty-seven patients with pathologically verified middle and/or lower third bile duct carcinoma were analysed retrospectively by Cox regression analysis for predictors of survival.

Results

The overall 5-year survival rate after resection was 39 per cent, and 0 per cent for patients who did not undergo resection. The 5-year survival rate was 63 per cent in 26 patients without microscopic residual disease (R0), 16 per cent in 25 patients with microscopic residual tumour (R1) and 0 per cent in six patients with macroscopic residual tumour (R2); ten patients did not undergo resection. Radiotherapy improved the 5-year survival rate in eight patients who had R1 resection compared with the rate in 17 patients who underwent resection alone (8 versus 0), but not significantly so (P = 0·137); however, median survival was significantly longer (P = 0·004) in six patients who had R2 resection compared with that in ten inoperable patients (11·4 versus 3·5 months). Multivariate analysis revealed that the primary tumour and tumour node metastasis (TNM) stage were independent predictors of survival; 13 clinicopathological factors were not independent prognostic factors. Of 26 patients having R0 resection, one had a locoregional relapse only, six had distant metastases only, and five had both types of recurrence. The liver was the most frequent site for metastasis, and microscopic venous invasion (MVI) in the primary tumour was a significant predictor of liver metastasis.

Conclusion

Curative (R0) resection is only one step in curing cancer, and radiotherapy may play a beneficial role in controlling locoregional residual tumour. MVI could be a useful indicator of when systemic adjuvant therapy should be implemented to prevent liver metastasis after R0 resection, although no effective systemic treatment has yet been developed.
Lymph node micrometastasis and prognosis in patients with oesophageal squamous cell carcinoma
Authors: Sato F , Shimada Y , Li Z , Watanabe G , Maeda M , Imamura M
Published: March 2003

Background

The purpose of this study was to investigate whether the presence of lymph node micrometastasis in pathological lymph node-negative (pN0) oesophageal squamous cell carcinoma had prognostic value.

Methods

Some 1840 lymph nodes were obtained from 50 patients with pN0 oesophageal squamous cell carcinoma who underwent curative resection of the primary tumour with systematic lymphadenectomy. These lymph nodes were examined immunohistochemically with anticytokeratin antibody (AE1/AE3). Lymph node micrometastases newly detected by immunohistochemistry were classified as micrometastasis. Additionally, lymph node micrometastases were classified into three stages: stage 1, one individual AE1/AE3-positive cell; stage 2, multiple individual positive cells; stage 3, one or multiple positive clusters.

Results

Micrometastases were detected in 20 patients (40 per cent). A higher stage of micrometastasis was associated with greater pathological tumour (pT) size (P = 0·023). Recurrent tumours developed in nine patients. However, the frequency of recurrence was similar in patients with, or without, micrometastasis (five of 20 and four of 30 patients respectively; P = 0·25). Twenty-three of 30 patients without micrometastasis survived, whereas 15 of 20 patients with micrometastasis were still alive (5-year overall survival 75 and 78 percent respectively, P = 0·91). Twenty-six of 30 patients without micrometastasis had no recurrence, whereas 15 of 20 patients with micrometastasis had no recurrence (5-year relapse-free survival 86 and 73 per cent respectively, P = 0·37). There was no significant difference in prognosis with respect to the stages of micrometastasis. Multivariate analysis also showed that micrometastasis was not an independent prognostic factor (P = 0·73).

Conclusion

Immunohistochemical detection of lymph node micrometastasis may be an indicator of lymphatic dissemination of tumour cells. However, the presence of micrometastasis had no impact on the prognosis of node-negative patients with oesophageal squamous cell carcinoma.
Other primary cancers occurring after treatment of superficial oesophageal cancer
Authors: Kokawa A , Yamaguchi H , Tachimori Y , Kato H , Watanabe H , Nakanishi Y
Published: March 2003

Background

Recent advances in endoscopic diagnosis and treatment have led to better prognosis for patients with superficial oesophageal cancer. The incidence of subsequent other primary cancer (SOPC) has become a new problem for patients who survive after treatment of superficial oesophageal cancer.

Methods

Between 1966 and 1998, 368 patients with superficial oesophageal cancer, histologically confirmed as squamous cell carcinoma after resection, were reviewed for the presence of SOPC.

Results

Among the 368 patients, 43 developed SOPC. The most frequent sites of SOPC were the stomach (11 patients) and hypopharynx (11). Subsequent cancers of the stomach and hypopharynx developed significantly more frequently in heavy smokers. The 5-year cumulative occurrence rate of subsequent cancers within the fields of endoscopy of the upper gastrointestinal tract (stomach, hypopharynx and residual oesophagus) was 15 per cent.

Conclusion

Gastric and hypopharyngeal cancers were frequently found after resection of superficial oesophageal cancer. A history of heavy smoking at the time of initial resection may be a risk factor. To make an early diagnosis of subsequent cancers, follow-up observation by upper gastrointestinal endoscopy is important after treatment of oesophageal cancer.
Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer
Authors: Nesbakken A , Nygaard K , Lunde O C
Published: March 2003

Background

Few studies have evaluated the long-term functional outcome after anastomotic leakage in the treatment of rectal cancer.

Methods

Between 1993 and 1998, 147 patients were admitted with resectable rectal carcinoma, and 92 underwent low anterior resection (LAR). Seventeen patients (18 per cent) developed clinical anastomotic leakage. The functional outcome of 11 of 12 patients, in whom the stoma was subsequently closed and bowel continuity was restored without stricture, was compared with that of 11 matched patients who had undergone LAR without leakage. Anorectal manovolumetry and symptom scoring on visual analogue scales were done 12–48 months after stoma closure.

Results

Nine patients made an uneventful recovery after the initial treatment of anastomotic leakage. Eight developed serious septic complications, four of whom had a pelvic abscess, but there was no death. Five patients had chronic complications that precluded closure of the stoma. Patients who had experienced leakage showed reduced neorectal capacity (120 versus 180 ml; P = 0·04), more evacuation problems (P = 0·02), and a trend towards more faecal urgency (P = 0·09) and incontinence (P = 0·06) than control patients.

Conclusion

Stoma closure was not possible in five of 17 patients who had experienced anastomotic leakage. Patients who had the stoma closed had impaired long-term anorectal function compared with control patients without leakage.
Immune-stimulating effects of low-dose perioperative recombinant granulocyte–macrophage colony-stimulating factor in patients operated on for primary colorectal carcinoma
Authors: Mels A K , Statius Muller M G , van Leeuwen P A M , von Blomberg B M E , Scheper R J , Cuesta M A , Beelen R H J , Meijer S
Published: March 2003

Background

Surgery induces a postoperative immunosuppression, thereby possibly facilitating the outgrowth of pre-existing occult metastases or the seeding of disseminated tumour cells in patients with primary colorectal carcinoma operated on with curative intent. The hypothesis that adjuvant therapy with perioperative recombinant human granulocyte–macrophage colony-stimulating factor (rhGM-CSF) would minimize postoperative immunosuppression was investigated in this pilot study.

Methods

Patients were allocated randomly to receive daily subcutaneous injections with either saline (n = 8) or rhGM-CSF 2·8 µg per kg body-weight (n = 8) from 3 days before operation until 4 days afterwards. Phytohaemagglutinin (PHA) skin test reactivity, monocyte human leucocyte antigen (HLA) DR expression and the extent of the acute-phase response, by determination of white blood cell count and differentiation, plasma interleukin (IL) 6 levels and body temperature in the perioperative period, were examined.

Results

rhGM-CSF treatment minimized postoperative suppression in PHA skin test reactivity and increased the numbers of neutrophils and monocytes while enhancing the expression of HLA-DR in the postoperative period. Additionally, both postoperative plasma IL-6 levels and the incidence of fever tended to be higher in the rhGM-CSF group.

Conclusion

In this pilot study, perioperative administration of low-dose rhGM-CSF stimulated certain immune functions that are normally depressed after operation. The implications for the antitumour responses directly after operation and the formation of liver metastases are currently under investigation.
Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial
Authors: Edwards D P , Leppington-Clarke A , Sexton R , Heald R J , Moran B J
Published: March 2003

Background

The consequences of leakage from low colorectal or coloanal anastomoses are reduced by the use of a loop stoma to divert the faecal stream. Controversy continues as to whether loop ileostomy (LI) or loop transverse colostomy (LTC) is the optimal method of defunctioning such anastomoses.

Methods

Patients requiring defunctioning following anterior resection and total mesorectal excision were randomized to receive either LI or LTC. Comparison was made between the groups regarding the difficulty of stoma formation and closure, the recovery after stoma closure and stoma-related complications. The minimum follow-up after stoma closure was 6 months (median 36 months).

Results

Between October 1995 and August 1999, 70 patients were randomized (LTC 36, LI 34) of whom 63 underwent stoma closure (LTC 31, LI 32). There were no significant differences in the difficulty of formation or closure, or in the postoperative recovery between the groups. However, there were ten complications related directly to the stoma in the LTC group: faecal fistula (one patient), prolapse (two), parastomal hernia (two) and incisional hernia during follow-up (five). None of these complications occurred in the LI group.

Conclusion

In this randomized study, the frequency of herniation before or after colostomy closure supports the choice of LI as a method of defunctioning a low anastomosis. Both methods appear to provide satisfactory protection for the low anastomosis.
European Study Group for Pancreatic Cancer-1 interim results: a European randomized study to assess the roles of adjuvant chemotherapy and chemoradiation in resectable pancreatic cancer
Authors: Neoptolemos J P , Dunn J A , Moffitt D D , Almond J , Link K , Beger H , Bassi C , Pederzoli P , Dervenis C , Fernandez-Cruz L , Lacaine F , Spooner D , Kerr D J , Friess H , Büchler M
Published: March 2003

Background

Pancreatic cancer affects 8–12 per 100 000 population per year in Europe. Following resection, the long-term survival rate is only 10–15 per cent and the role of adjuvant treatment is uncertain. The aims of the study were to answer two questions: (1) whether there is a role for chemoradiation (40 Gy and 5-fluorouracil (5-FU), and (2) whether there is a role for chemotherapy (5-FU–folinic acid (FA)) weekly).

Methods

A multicentre European prospective randomized controlled trial was organized by the European Study Group for Pancreatic Cancer (ESPAC). A 2 × 2 factorial design was used, asking both questions of the same patient, and a pragmatic design asking only one of the two questions of each patient. The data were reviewed at regular intervals by the Independent Data and Safety Monitoring Committee (IDSMC).

Results

Some 531 patients with pancreatic ductal adenocarcinoma were randomized from 80 clinicians in 11 countries. Randomization was stratified by resection margin involvement; 82 per cent of patients were negative. Some 239 patients (45 per cent) are alive to date, at a median follow-up of 9 (interquartile range 1–24) months. Preliminary results show no evidence of a benefit for chemoradiation treatment (median survival 14 months with chemoradiation versus 15·7 months without; P = 0·24). There is some evidence of a survival benefit for patients having chemotherapy (median survival 19·5 months versus 13·5 months with no chemotherapy; P = 0·003). The effect is reduced when taking into account whether patients received radiotherapy (P = 0·01), indicating that radiotherapy may reduce the overall benefit of the chemotherapy. The IDSMC recommended closing recruitment to the chemoradiotherapy arm.

Conclusion

There is no role for adjuvant chemoradiotherapy in pancreatic cancer, but there may be a role for chemotherapy. ESPAC-3 is now randomizing between (1) surgery alone, (2) 5FU–FA and (3) gemcitabine.
Initial results with a minimally invasive technique of pancreatic necrosectomy
Authors: Slavin J , Ghaneh P , Sutton R , Hartley M R , Hughes M , Garvey C , Rowlands P , Neoptolemos J P
Published: March 2003

Background

The aim of the study was to evaluate the initial results with a new technique of minimally invasive pancreatic necrosectomy (MIPN).

Methods

A retrospective audit was carried out of pancreatic necrosectomies performed on one unit from October 1996. Patients were divided into two groups: those admitted before November 1998 who underwent a conventional open necrosectomy and those admitted after this date who were considered for treatment with MIPN.

Results

Thirty-one patients underwent pancreatic necrosectomy, of which 20 cases were tertiary referrals. Thirteen patients (median age 51 (range 33–77) years; ten men, three women) admitted before November 1998 underwent a conventional open technique; seven of these patients died. Since then, 18 patients (median age 59 (range 33–74) years; ten women, eight men) have undergone necrosectomy, 12 by MIPN (median of 3 (range 1–6) procedures) and six by an open technique. Reasons for using an open technique included a left renal adenocarcinoma (one patient), poor access route (three patients) and failure to insert a guidewire under computed tomographic control (two patients). There were two deaths during this later period (P < 0·05, Fisher's exact test in comparison with the earlier time period). In patients who were discharged there was no difference in length of stay in the intensive treatment unit (median 5 (range 0–24) versus 5 (range 0–84) days) or in-hospital stay (median 66 (range 29–159) versus 75 (range 31–202) days) between the two time periods.

Conclusion

A minimally invasive approach provides a promising alternative to open pancreatic necrosectomy.
Laparoscopic antireflux surgery in the treatment of the acid-sensitive oesophagus
Authors: Booth M I , Stratford J , Thompson E , Dehn T C B
Published: March 2003

Background

Approximately 10 per cent of patients referred for 24-h oesophageal pH tests with symptoms suggestive of gastro-oesophageal reflux disease will have a normal endoscopic examination and normal distal oesophageal acid exposure times, but a clear temporal correlation between their symptoms and episodes of acid reflux. These patients have an ‘acid-sensitive oesophagus’, which forms part of the spectrum of reflux-related conditions. Their response to antireflux surgery has not been reported previously. This study represents a prospective cohort analysis of a clearly defined group of patients with acid-sensitive oesophagus who have undergone laparoscopic antireflux surgery.

Methods

Nineteen patients (nine male and ten female; median age 32 years) underwent laparoscopic antireflux surgery for acid-sensitive oesophagus. All had had an incomplete response to medical therapy.

Results

Eighteen of 19 patients were graded Visick I or II at 6 months after operation; all 16 patients followed for 1 year were graded Visick I or II. There were significant falls in DeMeester symptom score (4·0 versus 0·5; P < 0·001), symptom events (20 versus none; P < 0·001), number of reflux episodes (17 versus two; P < 0·001) and overall acid exposure times (1·2 versus 0·3 per cent; P < 0·001) after operation.

Conclusion

Laparoscopic antireflux surgery is a valid and effective treatment for patients with an acid-sensitive oesophagus.
Fate of hypertension after repair of coarctation of the aorta in adults
Authors: Bhat M A , Neelakandhan K S , Unnikrishnan M , Rathore R S , Mohan Singh M P , Lone G N
Published: March 2003

Background

Unrepaired aortic coarctation is known to have a detrimental effect on survival. The benefit of coarctation repair on systolic hypertension in adults has been questioned. This retrospective study was conducted to evaluate the impact of repair of aortic coarctation on systolic hypertension in adults.

Methods

Repair of aortic coarctation was performed in 84 patients aged 16–54 (mean 29) years. All patients were hypertensive before surgical intervention (mean systolic blood pressure 162 mmHg; mean diastolic blood pressure 93 mmHg). All patients underwent echocardiography and/or cardiac catheterization. The peak mean systolic gradient across the coarctation was 60 mmHg. The patients were followed after coarctation repair for between 1 and 12 (mean 5·2) years.

Results

There was significant regression of hypertension (P < 0·001) in all patients. Thirty-five patients (42 per cent) did not need any antihypertensive medication 3 months after surgery. The prevalence of hypertension at the last follow-up (after mean 5·2 years) was 31 per cent.

Conclusion

Surgical repair of coarctation of the aorta in adults leads to regression of systolic hypertension and a decreased requirement for antihypertensive medication.
Interleukin 6 and the prognosis of abdominal aortic aneurysms
Authors: Jones K G , Brown L C , Brull D J , Humphries S E , Greenhalgh R M , Powell J T
Published: March 2003

Background

Abdominal aortic aneurysm (AAA) is a familial disorder, inflammation being an important pathophysiological feature. Increased plasma concentrations of the inflammatory cytokine interleukin (IL) 6 have been associated with AAA and early aortic dilatation. This study was designed to test the hypothesis that high concentrations of plasma IL-6 and/or IL-6 genotype predict rapid AAA growth.

Methods

Genomic DNA from 466 patients, kept under ultrasonographic surveillance for small AAAs, was analysed for a G to C polymorphism at position −174 of the IL-6 promoter. Baseline plasma IL-6 concentration was measured by enzyme-linked immunosorbent assay and AAA growth rates were calculated by linear regression.

Results

The median concentration of plasma IL-6 was 4·9 (range 0–604) pg ml−1. IL-6 concentration was not associated with aneurysm growth rate. The frequency of the C allele was 0·40, similar to that in the healthy population. Patients of GG genotype had a lower plasma concentration of IL-6 than patients of either GC or CC genotype (median 1·9, 4·8 and 15·6 pg ml−1 respectively; P = 0·047, Kruskal–Wallis test). The AAA growth rate for patients of GG, GC and CC genotypes was 0·38, 0·36 and 0·36 cm per year respectively (P = 0·37). Mortality was lower for patients of GG genotype than for those with GC or CC genotype: hazard ratio 0·51 (95 per cent confidence interval (c.i.) 0·25–1·00), P = 0·05; and 0·32 (95 per cent c.i. 0·12–0·93), P = 0·036, for all-cause and cardiovascular mortality respectively.

Conclusion

Genetic polymorphism is associated with clinical events in patients with an AAA. The G to C IL-6 polymorphism at position −174 predicts future cardiovascular mortality. Neither plasma IL-6 concentration nor IL-6 genotype predicts AAA growth.
Evaluation of duplex ultrasonography versus other investigations in the diagnosis of ‘venous aetiology’ in patients with leg ulcers
Authors: Drinkwater S , McGuinness C , Lockhart S , Burnand K
Published: March 2003

Background

The aim was to compare duplex imaging, venography, foot volumetry and air plethysmography in patients with healed leg ulcers considered to be caused by venous disease to discover whether duplex scanning alone could confirm a venous aetiology. The importance of isolated reflux in a segment of the deep system below a competent valve was assessed.

Methods

A total of 125 patients with 153 healed leg ulcers was examined. An Acuson (Mountain View, California, USA) scanner was used to detect reflux lasting for more than 0·5 s in the deep, superficial and calf perforating veins; the findings were compared with those obtained with ascending venography, foot volumetry and air plethysmography.

Results

Thirteen legs showed no reflux on duplex imaging, but ten of these had abnormal foot volumetry and 12 had abnormal plethysmography. Venography showed post-thrombotic change in 26 legs, but there was evidence of deep venous scarring in only six on duplex ultrasonography. Eight of 75 legs with a normal venogram had ‘complete’ (thigh-to-calf) deep reflux on duplex imaging. Forty-five legs showed segmental deep reflux on duplex imaging, of which 29 had associated perforating vein incompetence. Mean half-refilling times on foot volumetry were 8·46 s for femoral and 5·84 s for popliteal reflux, compared with 3·84 s in the 33 patients who had thigh-to-calf reflux (P < 0·05).

Conclusion

Absence of reflux in all venous segments on duplex imaging does not exclude a venous aetiology for ulceration. Segmental femoral and popliteal incompetence on duplex imaging is usually associated with other sites of valvular incompetence, but depresses calf function less than thigh-to-calf reflux.
Mortality rates from ruptured abdominal aortic aneurysms in England
Authors: Hafez H , Clayton G , Greenhalgh R M , Davies A H
Published: March 2003

Background

Over the past 10 years significant advances have been made in understanding the natural history and pathophysiology of aortic aneurysm disease. Despite a rapid improvement in alternative repair techniques, surgery for abdominal aortic aneurysm (AAA) remains the standard method of treatment. The aim of this study was to evaluate the efficacy of this treatment at a national level.

Methods

Data for elective and emergency AAA procedures performed in England between 1989 and 1998 were obtained from the Department of Health Hospital Episode Statistics. Data for deaths secondary to ruptured and non-ruptured AAA in England for the same period were obtained from the Office of National Statistics. All figures represent age-adjusted incidence per 100 000 population.

Results

The rise in elective and emergency AAA repair rates affected mainly men rather than women. The rise in death rates from ruptured AAA was 30·3 per cent in women and 2·0 per cent in men.

Conclusion

Despite a considerable increase in elective AAA repair procedures in England, deaths from ruptured AAA continue to rise. These findings highlight the need for an efficient national strategy for improving the outcome of patients with AAA.
Systemic levels of plasmin–antiplasmin complexes are correlated with the expansion rate of small abdominal aortic aneurysms
Authors: Lindholt J S , Jorgensen B , Vammen S , Fastin H , Henneberg E W
Published: March 2003

Background

The cystatine proteolytic system, the serine proteolytic system and the metallodependent proteolytic system have all been reported to be involved in the matrix degradation of the aortic wall, causing abdominal aortic aneurysm (AAA). Plasmin is a common activator of all three systems and could theoretically be involved in the pathogenesis of AAA by activating all three systems. However, plasmin is immediately inactivated by antiplasmin, forming plasmin–antiplasmin (PAP) complexes when it reaches the circulation. This study was designed to assess whether the systemic levels of PAP complex in conservatively treated patients with AAA could be related to the natural history of AAA.

Methods

In 1994, 112 of 141 men with AAA (greater than 3 cm) diagnosed by population screening were interviewed, examined, and had blood samples taken and prepared for serum and ethylenediamine tetra-acetic acid plasma by a standard method. The serum and plasma were frozen at − 21°C until analysis. Of the 112 patients, 99 were followed with annual control scans and blood pressure measurements for 1–5 (mean 2·5) years, and were referred for operation if the AAA exceeded 5 cm in diameter. Of the 99 patients, a random sample of 70 had their level of PAP complexes determined (Dade Behring, Rødovre, Denmark). Furthermore, the level of serum elastin peptides (SEPs) was determined by enzyme-linked immunosorbent assay. Spearman's rank sum correlation test, multivariate linear regression analysis and receiver–operator characteristic (ROC) curve analysis were used for statistical analysis (SPSS 10.0; SPSS, Chicago, Illinois, USA).

Results

The level of PAP complex was positively correlated with annual expansion rate (r = 0·29, P = 0·01), but not with the initial AAA size (r = 0·17, P = 0·16) or SEP (r = 0·04, P = 0·77). The significant association to expansion persisted after adjustment for initial AAA size, SEP and smoking. Furthermore, the level of PAP complex was significantly predictive for AAAs expanding to operation recommendable size (area under ROC curve 65 per cent), with an optimal sensitivity and specificity of 65 and 67 per cent respectively. SEP level was also significantly predictive for AAAs expanding to operation recommendable size (area under ROC curve 56 per cent), with an optimal sensitivity and specificity of 56 and 57 per cent.

Conclusion

The progression of AAA seems to be caused by a general activation of the proteolytic systems involving plasmin and not by genetic or environmental factors causing increased activation of specific proteases or decreased activity of their specific inhibitors. Furthermore, the level of PAP complex in patients with an aneurysm seems to have a better and independently predictive value of the natural history of AAA, compared with the best serological predictor known to date, the serum level of elastin peptides.
Enhanced critical care improves the mortality rate following elective aneurysm repair
Authors: Anderton M , Treharne G , London N , Naylor R , Bell P R , Thompson M M
Published: March 2003

Background

In a previous study performed at this centre (1994–1997) to document the impact of instituting an endovascular programme, the mortality rate for elective infrarenal aneurysm repair was unacceptable (16 per cent). In an attempt to reduce this complication rate, two fundamental changes in practice were instituted. First, patients were selected and counselled for operation on the basis of a physiological scoring system, POSSUM (Physiological and Operative Surgical Score for the enUmeration of Mortality and morbidity). Second, patients were admitted to the critical care unit for at least 3 days after operation, before discharge to the ward. The aim of the study was to audit the result of these changes.

Methods

Data were collected prospectively for all patients admitted for elective aneurysm repair between November 1998 and January 2000. POSSUM score, postoperative mortality and morbidity, and intensive care unit (ITU) or high dependency unit stay were compared between historical controls (1994–1997) and operations performed after the change in practice.

Results

The results are tabulated below as median values.

Comparison between the two groups demonstrated that after changes in referral practice, the perioperative mortality rate improved significantly from 16 to 4 per cent. Comparison of the patient cohorts demonstrated no significant differences in preoperative physiological status.

Conclusion

These data demonstrate that defined changes in the perioperative management of patients undergoing elective aneurysm surgery may favourably affect mortality. As there was no difference in POSSUM scores between the two groups, it is likely that the improved outcome reflects more intensive postoperative care.
Impact of subintimal angioplasty on treatment of critical leg ischaemia
Authors: Tisi P V , Mirnezami A , Baker S , Tawn J , Parvin S D , Darke S G
Published: March 2003

Background

Distal bypass for critical leg ischaemia (CLI) is technically demanding and a physiological challenge to the patient. Angioplasty offers an attractive alternative, the application of which may be extended by subintimal techniques. This study reports on the immediate success of subintimal angioplasty and its impact on workload in this unit since the introduction of the technique in 1997.

Methods

This was a retrospective review of a consecutive series of 166 legs (156 patients) with CLI treated by subintimal angioplasty from 1997 to 1999. Society for Vascular Surgery and International Society for Cardiovascular Surgery criteria were used to determine clinical status and patency.

Results

From 1997 to 1998 the rate of subintimal angioplasty increased, with a corresponding reduction in major amputation and surgery rates (P < 0·001, χ2 test). The increase in surgical reconstruction in 1999 could reflect delayed treatment of patients with late occlusion of a previously dilated segment.

The technical success rate of subintimal angioplasty was 84·9 per cent (25 primary failures). Twelve proceeded to bypass surgery, with one occluded graft subsequently requiring amputation. Amputation was needed in three other patients with technical failure, while a further patient had a successful repeat subintimal angioplasty.

Conclusion

Subintimal angioplasty has an increasing role in limb salvage, particularly in patients unfit for operation.
Outcome of subintimal angioplasty in a district general hospital
Authors: Shaw M B K , Braithwaite B D , DeNunzio M , Hinwood D , Nash R , Callum K G
Published: March 2003

Background

The results from major institutions of subintimal angioplasty are good. The aim was to determine the early and intermediate outcome of the technique of subintimal angioplasty in a district general hospital.

Methods

After formal training, two consultant radiologists performed subintimal angioplasty on 50 consecutive patients for the treatment of intermittent claudication (23 patients) and ulceration or gangrene (27). Patients were classified as Rutherford grade III–VI. The patient group contained 35 men and 15 women with a median age of 72 (range 45–93) years. The median treated length was 17·5 cm in the superficial femoral artery, 12·5 cm in the popliteal artery and 7·5 cm in the peroneal artery. Those with a technically successful procedure were followed with clinical assessment at 6 weeks and colour duplex ultrasonography at 6 months.

Results

Thirty-nine (78 per cent) of the 50 procedures were technically successful. Sixty per cent of these were patent at 6 months on colour duplex ultrasonography. The primary technical success rate in the first 25 consecutive patients to undergo angioplasty was 64 per cent (16 patients), compared with 92 per cent (23 patients) in the second group of 25; this difference was significant (P = 0·004, χ2 test). The overall patency rate at 6 months in the first 25 consecutive patients was 43 per cent, compared with 69 per cent in the second 25; this difference was statistically significant (P = 0·02, χ2 test).

Conclusion

After a short learning interval, subintimal angioplasty can be used effectively in a district general hospital, with good medium-term patency rates.
Pharmacotherapy and outcome in intermittent claudication
Authors: Chong P F S , Seaman H , Golledge J , Gibbs R , Lawrenson R , Greenhalgh R M , Davies A H
Published: March 2003

Background

Intermittent claudication (IC) carries an increased risk of vascular death compared with that in age-matched controls. The role of antiplatelets and statins in the reduction of this risk in new claudicants was evaluated in an observational study of a prospectively gathered database, the General Practice Research Database (GPRD), with 430 practices contributing 8 million patients in the UK.

Methods

All patients aged 40–79 years with newly diagnosed IC and no history of previous peripheral vascular disease were identified using recognized GPRD OXMIS codes. Prescription of antiplatelet therapy (APT) up to 12 months before or after diagnosis, and the use of statin therapy (ST) at the time of diagnosis, of IC was noted. Odds ratios (ORs) adjusted for APT, ST, sex, age, smoking, diabetes, and coexisting cardiac and cerebrovascular disease were calculated. Patients with critical limb ischaemia were excluded. Outcome measures were all-cause death, fatal stroke and fatal myocardial infarction (MI) up to 5 years after diagnosis of IC.

Results

Between 1988 and 1993, 20 474 patients with newly diagnosed IC were identified. The Table summarizes the results.

Conclusion

Prescription rates of statins and antiplatelets in new claudicants in the UK are low and could be improved. These results suggest that ST is associated with a significant reduction in all-cause mortality rate in new claudicants. Patients receiving APT demonstrated a significant reduction in death from MI.