bluuebunny/crossref_metadata_2025 huggingface dataset:
Recovery of the internal anal sphincter and continence after restorative proctocolectomy
Authors: Farouk R , Duthie G S , Bartolo D C C
Published: March 2007

The internal anal sphincter (IAS) was assessed prospectively using electromyography and manometry in 66 patients (48 men) undergoing restorative proctocolectomy to determine its role in the gradual return of continence. Twenty-nine patients received a J pouch and 37 a W reservoir. Some 38 pouches (J, ten; W, 28) were hand-sewn (mucosal proctectomy with endoanal anastomosis) and 28 (J, 19; W, nine) stapled (end-to-end pouch-anal anastomosis 1 cm above the dentate line). Twelve patients underwent a one-stage procedure (all J pouches), while the remainder had a covering loop ileostomy. Each patient was reassessed immediately after restorative proctocolectomy and again at 7 days, 1 month, 4 months, 9 months and 18 months after pouch formation. Internal sphincter electromyographic activity was greatly reduced after pouch-anal anastomosis (median preoperative frequency 0·51 Hz versus immediate postoperative frequency 0·21 Hz, P < 0·003) and gradually recovered from 4 months after surgery. At 18 months, measurements of IAS function had not fully recovered to preoperative values (median frequency 0·31 Hz; P < 0·03). Resting anal pressures (median preoperative value 99 cmH2O) decreased by over 50 per cent after surgery (median immediate postoperative resting pressure 44 cmH2O) and recovered gradually but incompletely (median pressure at 18 months 63 cmH2O). Eleven patients reported leakage in the follow-up period. The median (range) resting pressure in these patients (54 (40–71) cmH2O) was not significantly different at 9 months from that of those who were continent either before or after operation (59 (46–68) cmH2O). Prolonged recordings in patients with faecal leakage revealed evidence of high-pressure pouch waves that overwhelmed anal sphincter pressures and coincided with leakage. These episodes were most common during sleep, when anal sphincter activity was reduced.
Investigation and management of subclavian steal syndrome
Authors: Delaney C P , Couse N F , Mehigan D , Keaveny T V
Published: March 2007

Patients with subclavian steal syndrome present with symptoms of vertebrobasilar ischaemia. Although angiography has traditionally been used to confirm the diagnosis of subclavian steal and plan reconstructive surgery in symptomatic patients, duplex ultrasonography now offers rapid diagnosis and also permits examination of the other extracranial vessels. The treatment of subclavian steal syndrome is surgical. Extra-anatomic bypass procedures are used to increase inflow to the subclavian artery, abolishing the steal phenomenon. Carotid–subclavian bypass or transposition and subclavian–subclavian or axilloaxillary bypass are the procedures of choice; selection is governed by the presence of coexistent carotid artery disease. Percutaneous transluminal balloon angioplasty of the subclavian artery is an alternative treatment, although the long-term patency rate is inferior to that of extraanatomic bypass.
Experimental models of acute pancreatitis
Authors: Banerjee A K , Galloway S W , Kingsnorth A N
Published: March 2007

Various models of experimental acute pancreatitis are described. An ideal model would be reproducible, have a similar natural history to that of the human disease and a similar response to treatment. Furthermore, it should be relatively cheap and simple. Few, if any, of the available experimental models completely satisfy these criteria. The appropriate choice of model is discussed, as are possible future developments in this field.
Abdominal aortic aneurysm in Scotland
Authors: Samy A K , Whyte B , MacBain G
Published: March 2007

In the 12-year period to December 1991, 5338 new cases of abdominal aortic aneurysm (AAA) were recorded in the Scottish Morbidity Record (SMR) 1. Data from this source were analysed for accuracy; information from 489 of 500 randomly examined case records matched the SMR 1 data, giving an accuracy of 97·8 per cent. There was a steady yearly increase in the number of reported cases, from 283 in 1980 to 612 in 1991; the male to female ratio was 2·5:1. The mean age was 73·1 years, higher in women (73·4 years for intact and 77·2 years for ruptured aneurysm) than in men (69·8 and 71·8 years respectively). The proportion of patients aged over 75 years increased from 29·0 per cent in 1980 to 38·2 per cent in 1991. Rupture occurred in 36·4 per cent of the aneurysms, and 75·0 per cent of these were in men. The increase in numbers occurred in both intact and ruptured cases, particularly the former. The hospital mortality rate for Scotland was 10·5 per cent for intact AAA (including urgent non-ruptured cases) and 54·7 per cent for ruptured aneurysm (including those not operated on), but these figures varied markedly between health boards.
Compartment syndrome following prolonged pelvic surgery
Authors: Peters P , Baker S R , Leopold P W , Taub N A , Burnand K G
Published: March 2007

Compartment syndrome is a rare but serious complication of prolonged pelvic surgery. Prompted by two recent cases the authors studied the effect of limb angulation and elevation on Doppler ankle artery pressure and compartment pressure in ten normal subjects. Mean ankle pressure when supine was 130·5 (95 per cent confidence interval (c.i.) 124·5–136·5) mmHg and fell to 77·2 (95 per cent c.i. 64·6–89·8) mmHg in the Lloyd-Davies position with 10° of head-down tilt. Reversing table tilt to bring the ankle elevation to 0° in Lloyd-Davies supports restored mean ankle pressure to 114·3 (95 per cent c.i. 105·5–122·9) mmHg (P < 0.001). Placing the lower limb in calf supports was found to increase the mean intracompartmental pressure from 3·0 (95 per cent c.i. 1·2–4·8) mmHg to 11·6 (95 per cent c.i. 9·1–14·1) mmHg. Reversing table tilt significantly restores limb perfusion in patients undergoing prolonged pelvic surgery with the legs elevated and may protect against subsequent compartment syndrome.
Somatostatin and primary hyperparathyroidism
Authors: Lucarotti M E , Hamilton J A , Farndon J R
Published: March 2007

No satisfactory medical therapy exists for the treatment of primary hyperparathyroidism. Calcitonin and diphosphonates do not give good long-term control. This work examines the efficacy of the somatostatin analogue octreotide in the management of hyperparathyroidism. Twenty-one patients were admitted before parathyroid surgery and were treated for 6 days with subcutaneous octreotide 100 μg twice daily. Fasting blood samples were taken for determination of serum levels of calcium and parathyroid hormone, and 24-h urinary calcium excretion was measured before and after treatment. A significant decrease in urinary calcium was demonstrated, but the reduction in serum calcium level was not statistically significant and there was no change in serum parathyroid hormone concentration. Octreotide may provide therapy for patients with hyperparathyroidism and for those who have undergone unsuccessful neck exploration or who are unfit for operation. It may ameliorate hypercalciuria and reduce stone formation. The octapeptide may also have a potential role as a diagnostic test in primary hyperparathyroidism by determining the symptomatic effect of reducing raised levels of serum and urinary calcium.
Clinical efficacy of octreotide scintigraphy in patients with midgut carcinoid tumours and evaluation of intraoperative scintillation detection
Authors: Ahlman H , Wängberg B , Tisell L E , Nilsson O , Fjälling M , Forssell-Aronsson E
Published: March 2007

111In-diethylenetriamine penta-acetate-d-Phe1-octreotide scintigraphy was evaluated in a group of 27 patients with disseminated midgut carcinoid tumour. Additional information gained by the intraoperative use of a scintillation detector was studied in five patients with midgut carcinoid tumours and in two with endocrine pancreatic tumours. In 19 patients tumours not recognized by non-invasive radiological methods were visualized in 27 locations, most commonly in liver and para-aortic lymph nodes. Three false-negative tumour locations were noted (ovarian and peritoneal). With guidance from scintigraphic findings, nine patients underwent surgical tumour reduction, leading to complete remission in three. Clinically suspect tumour lesions were measured by the detector in situ, and ex vivo after excision. After excision the tissue: blood activity concentration ratios were calculated. In situ measurements were helpful in the localization of tumours and in the control of adequate clearance of tumour tissue. High tissue:blood activity concentration ratios at 1, 2 and 5 days in the five patients with midgut carcinoid tumour indicate a potential role for radiation therapy with radiolabelled octreotide in patients with somatostatin receptor-positive tumours.
Reoperation after failed antireflux surgery
Authors: Rieger N A , Jamieson G G , Britten-Jones R , Tew S
Published: March 2007

Between 1978 and 1992, 61 patients were operated on for new or recurrent problems after antireflux surgery. Indications for reoperation were recurrent reflux in 50 patients (associated with dysphagia in 14), dysphagia alone in six and postprandial pain in five. At reoperation the cause of the problem was apparent as anatomical breakdown of the repair in 19 patients, gastric pull-through (slipped Nissen procedure) in 14 and paraoesophageal hernia in six. In 18 patients the cause of the symptoms was not readily apparent. Reoperation consisted of fundo-plication alone in 27 patients, fundoplication with pyloroplasty in eight, fundoplication with proximal gastric vagotomy in four, a Collis–Nissen procedure in 11 (four also had pyloroplasty), a Roux-en-Y procedure in four, total gastrectomy in one and reduction of a paraoesophageal hernia in six. Of the 20 patients with some form of destruction of the gastric outlet six experienced troublesome dumping symptoms and in two this was severe. Two patients died from cardiac causes after surgery. Of the remaining 59 patients, 51 rated the procedure as successful. Repeat antireflux procedures can give results almost as good as those of primary antireflux surgery. However, pyloroplasty and gastric resection should be avoided if at all possible.
Risk of cancer following partial gastrectomy for benign ulcer disease
Authors: Lundegårdh G , Adami H-O , Helmick Ch , Zack M
Published: March 2007

The relative risk of developing cancer after partial gastrectomy for benign ulcer disease, expressed as the standardized incidence ratio, was examined in a population-based cohort comprising 6459 patients operated on between 1950 and 1958. Follow-up to 1983 revealed 1112 patients with cancer versus 1128 expected cases (relative risk 1·0 (95 per cent confidence interval (c.i.) 0·9–1·1)). The overall risk increased over time; it was higher in younger than in older patients but was not related to sex, surgical procedure (Billroth I or II gastrectomy) or diagnosis at operation (duodenal or stomach ulcer). There was an increased risk for lung cancer (relative risk 1·5 (95 per cent c.i. 1·2–1·7)), for oesophageal cancer in patients operated on for stomach ulcer (relative risk 2·2 (95 per cent c.i. 1·0–4·2)) and for cancer of the biliary tract in men (relative risk 1·9 (95 per cent c.i. 1·2–2·9)) and in those operated on for duodenal ulcer (relative risk 1·7 (95 per cent c.i. 1·0–2·8)). The overall risk for genital cancer in women was unchanged but decreased with increasing duration of follow-up and age. Cancers of the nervous system occurred less frequently than expected (relative risk 0·5 (95 per cent c.i. 0·3–0·8)), while the risk for cancer of the buccal cavity, lymphatic and haematopoietic systems, pancreas, breast, prostate, kidney and bladder was unchanged.
Experimental pancreatic cancer in the rat treated by photodynamic therapy
Authors: Evrard S , Keller P , Hajri A , Balboni G , Mendoza-Burgos L , Damgé C , Marescaux J , Aprahamian M
Published: March 2007

Selective histological necrosis of experimental pancreatic carcinoma by photodynamic therapy (PDT) has been successful with haematoporphyrin derivatives and phthalocyanine as photosensitizers. This report describes the feasibility of PDT with pheophorbide A as the photosensitizer to treat azaserine-induced pancreatic rat carcinoma and analyses survival of the animals. An organ distribution study 24h after pheophorbide A administration (9 mg/kg intravenously) gave a selectivity ratio of 13·5:1 between tumour and surrounding tissue. Light of 660 nm and 100 J/cm2 induced selective necrosis of the tumour. Six of nine rats were cured in 120 days whereas all 36 control animals died within 35 days (P < 0·01). The pancreas and hepatic pedicle were relatively unaffected by PDT, but the duodenum was injured.
Preoperative endoscopic drainage for malignant obstructive jaundice
Authors: Lai E C S , Mok F P T , Fan S T , Lo C M , Chu K M , Liu C L , Wong J
Published: March 2007

The role of preoperative endoscopic drainage for patients with malignant obstructive jaundice was evaluated in a randomized controlled trial. A total of 87 patients were assigned to either early elective surgery (44 patients) or endoscopic biliary drainage followed by exploration (43). Thirty-seven patients underwent successful stent insertion and 25 had effective biliary drainage. Complications related to endoscopy occurred in 12 patients. After endoscopic drainage significant reductions of hyperbilirubinaemia, indocyanine green retention and serum albumin concentration were observed. Patients with hilar lesions had a significantly higher incidence of cholangitis and failed endoscopic drainage after stent placement. The overall morbidity rate (18 patients versus 16) and mortality rate (six patients in each group) were similar in the two treatment arms irrespective of the level of biliary obstruction. Despite the improvement of liver function, routine application of endoscopic drainage had no demonstrable benefit. Endoscopic drainage is indicated only when early surgery is not feasible, especially for patients with distal obstruction.
Modulation of immune function and weight loss by l-arginine in obstructive jaundice in the rat
Authors: Kennedy J A , Kirk S J , McCrory D C , Halliday M I , Barclay G R , Rowlands B J
Published: March 2007

Jaundiced surgical patients have a high incidence of postoperative complications. Many causative factors have been identified including cachexia and immune suppression. The amino acid L-arginine has anabolic and immunostimulatory properties. It was hypothesized that dietary supplementation with L-arginine would diminish the weight loss and immune suppression of obstructive jaundice. Sixteen male Wistar rats rendered jaundiced by bile duct ligation were allocated to two groups. The test group (n = 8) received drinking water supplemented with 1·8 per cent L-arginine ad libitum and the control group (n = 8) received a solution of isonitrogenous glycine. Both groups had free access to standard chow. Body-weight, and fluid and food intake were recorded. After 21 days, delayed-type hypersensitivity to 2,4-dinitrofluorobenzene was assessed. Animals receiving L-arginine consumed more food than controls (mean(s.e.m.) 414(16) versus 360(13) g, P < 0·05) and lost less weight (mean(s.e.m.) proportion of initial body-weight lost 7·8(1·2) versus-14·8(1·4) per cent P < 0·05). The delayed-type hypersensitivity response was significantly greater in rats receiving L-arginine (mean(s.e.m.) increase in ear thickness 23·9(2·7) versus 9·4(2·1) per cent, P < 0·05). In this animal model of obstructive jaundice dietary supplementation with L-arginine diminished both weight loss and immune suppression.
Early laparoscopic biliary injury: Experience in New Zealand
Authors: Windsor J A , Vokes D E
Published: March 2007

Data on the incidence, nature and management of early laparoscopic biliary injury up to January 1993 were obtained by a postal questionnaire sent to all New Zealand general surgeons (n = 214; response rate 71 per cent) and to all endoscopists who perform endoscopic retrograde cholangiography (n = 16; response rate 100 per cent). A total of 41 injuries (surgeons' survey, 22; endoscopists' survey, 19) occurred in an estimated 4000 laparoscopic cholecystectomies; 16 involved the common bile and hepatic ducts, and 25 the cystic and segment V ducts. Operative cholangiography was performed in one patient. The diagnosis of injury was made after operation in 31 of 41 patients and after discharge in 21. Conservative management was undertaken in only 19 patients. This prospective audit documents an increase in the incidence of early biliary injury after the introduction of laparoscopic cholecystectomy in New Zealand. The results highlight the need for further study to determine the best way to ensure early and accurate diagnosis of biliary injury and to define optimal conservative and operative management.
Irritable bowel syndrome in patients discharged from surgical wards with non-specific abdominal pain
Authors: Doshi M , Heaton K W
Published: March 2007

A questionnaire was used to discover the prevalence of seven recognized symptoms of irritable bowel syndrome (IBS) in 96 patients who had been discharged from hospital 1–2 years previously with the diagnosis of non-specific abdominal pain. Compared with 1897 controls from a population survey in the same city, the patients were more likely to have these symptoms; the differences were statistically significant in most cases. The frequency of recurrent abdominal pain with features suggesting an intestinal origin was increased fivefold in male and fourfold in female patients (P < 0·001). Criteria for the diagnosis of IBS were present in 37 per cent of women and 19 per cent of men, versus 5 and 2 per cent respectively in controls (P < 0·001). Approximately half the patients remembered having symptoms of IBS at the time of admission and 70 per cent had had other attacks of abdominal pain. At the time of admission, the hospital notes mentioned the possibility of IBS in only 6 per cent of cases. Most patients would have welcomed an explanation for the pain at the time of their hospital admission.
Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum
Authors: Karanjia N D , Corder A P , Bearn P , Heald R J
Published: March 2007

Over 14 years 276 patients with rectal cancer underwent surgery; 219 who underwent low anterior resection of the rectum with total mesorectal excision were studied. There were 24 (11·0 per cent) major anastomotic leaks associated with peritonitis or a pelvic collection and 14 (6·4 per cent) minor leaks that were asymptomatic and detected by contrast enema. All major leaks occurred at an anastomotic height of less than 6cm (P = 0·08). The abdominoperineal excision rate was 9·1 per cent. Major leaks were associated with failure to defunction in 11 of 62 patients and with a defunctioning colostomy in 13 of 157 (P = 0·03). Of the 24 patients with major leaks seven developed peritonitis, one with a defunctioned anastomosis (P = 0·002), and three died (P = 0·02). Use of the sigmoid colon led to major leakage in seven of 32 patients compared with 17 of 187 when the splenic flexure was employed (P = 0·05). There was no increase in the local recurrence rate but only nine patients with major leakage and a temporary stoma have had these closed. Key technical factors incude: a clean dry pelvie cavity, pulsatile colonic blood supply, suction drainage started during closure and mobilization of ample tissue to fill the pelvic space.
Anterior anal sphincter repair in patients with obstetric trauma
Authors: Engel A F , Kamm M A , Sultan A H , Bartram C I , Nicholls R J
Published: March 2007

Anterior sphincter repair for faecal incontinence related to obstetric trauma was performed in 55 patients: 32 with incontinence after delivery and 23 with late onset. Anal endosonography and physiological tests were performed before and after surgery. After a median of 15 (range 6–36) months, 42 patients had improved, 11 had not improved and two were awaiting colostomy closure. The postoperative squeeze pressure was increased (by 20 versus 5 cmH2O, P = 0·05) and the external sphincter was more frequently intact (32 of 35 versus five of 11, P = 0·003) in those with a good outcome. Patients with an intact external sphincter had higher postoperative squeeze pressures (50 versus 20 cmH2O, P = 0·004). Patients with late-onset incontinence were older than those who developed incontinence soon after delivery (median 59 versus 32 years, P < 0·001) and had longer pudendal nerve terminal motor latencies (2·3 versus 2·2 ms, P = 0·03). Failure of repair is related to persistent external sphincter defects. Late-onset incontinence, even with a prolonged pudendal nerve terminal motor latency, does not preclude a good outcome.
Pathobiology of intimal hyperplasia
Authors: Davies M G , Hagen P-O
Published: March 2007

In the current vascular interventional environment, high restenosis rates have increased awareness of the significance of intimal hyperplasia, a chronic structural lesion that develops after vessel wall injury, and which can lead to luminal stenosis and occlusion. Intimal hyperplasia may be defined as the abnormal migration and proliferation of vascular smooth muscle cells with associated deposition of extracellular connective tissue matrix. The pathology of intimal hyperplasia is reviewed with particular attention to its physiology, pharmacology, cell biology and molecular biology.
Radiotherapy and the management of the axilla in early breast cancer
Authors: Falk S J
Published: March 2007

The role of radiotherapy in the management of the axilla in early breast cancer is examined. A few, carefully selected, clinically node-negative postmenopausal women may require no intervention to the axilla. Otherwise, surgical clearance is the preferred sole management of the axilla, resulting in an excellent level of local control and providing optimal information for the use of systemic adjuvant therapy. Axillary radiotherapy can also provide equivalent levels of long-term control in the clinically node-negative axilla, but the chronic disabling syndrome of brachial plexopathy is documented at all radiation doses that can sterilize microscopic disease, irrespective of the radiotherapy technique. A combination of radiotherapy and axillary surgery results in an increased morbidity rate compared with either alone. Women who receive radiotherapy to the breast alone are not at risk of brachial plexopathy.
Percutaneous transluminal angioplasty of the tibial arteries
Authors: Sivananthan U M , Browne T F , Thorley P J , Rees M R
Published: March 2007

To evaluate the results of percutaneous transluminal angioplasty (PTA) of the tibial vessels, results of 50 procedures performed in 38 patients since 1988 were analysed retrospectively. A total of 73 tibial vessels were treated: 32 anterior tibial arteries, 16 posterior tibial arteries, four peroneal arteries, 12 tibioperoneal trunks and nine trifurcation lesions. Forty-four of 50 PTA procedures were performed in conjunction with interventions in the femoropopliteal arteries and six as isolated procedures. One patient required a femorodistal graft following perforation of the popliteal artery during atherectomy. Distal emboli occurred in two patients and acute thrombosis of both the angioplastied tibial vessels occurred in a third. The technical success rate was 96 per cent. Patients were followed for a mean(s.d.) of 21(13) months. At the latest follow-up, 58 per cent had improved clinically. There were significant improvements in 43 per cent of limb isotope blood flow studies and 52 per cent of ankle : brachial Doppler pressure indices in treated limbs at this time. PTA should be the first treatment option in patients with infrapopliteal arterial disease needing intervention, whenever it is technically feasible.
Light-reflective cerebral oximetry and jugular bulb venous oxygen saturation during carotid endarterectomy
Authors: Williams I M , Picton A , Farrell A , Mead G E , Mortimer A J , McCollum C N
Published: March 2007

A novel instrument using reflected near-infra-red light spectroscopy to measure cerebral oxygen saturation non-invasively was evaluated during carotid endarterectomy; cerebral perfusion was compared with jugular bulb venous oxygen saturation and transcranial Doppler ultrasonographic measurements. Initially, oximetry sensors with light source-detector separation distances of 10 and 27 mm were positioned over the frontal area, while a cannula positioned in the jugular bulb permitted sampling for jugular bulb venous oxygen saturation. To increase cerebral oxygen saturation sensitivity, modified sensors with light source-detector separation distances of 30 and 40 mm were relocated over the middle cerebral artery territory. The changes in cerebral and jugular bulb venous oxygen saturation, and in peak blood flow velocity before and 30 s after carotid clamping and declamping were recorded. The modified cerebral perfusion system achieved improved correlations between cerebral and jugular bulb venous oxygen saturation changes during carotid clamping and declamping (r = 0·92, P<0·001). The correlation between change in cerebral oxygen saturation and the percentage change in peak flow velocity on both cross-clamping and declamping was equally strong (r=0·90, P< 0·001). Near-infra-red cerebral spectroscopy reliably detects changes in cerebral oxygen saturation during carotid endarterectomy and may have wide applications in monitoring brain perfusion during neurosurgery and cardiopulmonary bypass surgery, and in closed head injury.
Serum lipofuscin as a prognostic indicator of adult respiratory distress syndrome and multiple organ failure
Authors: Roumen R M H , Hendriks Th , de Man B M , Goris R J A
Published: March 2007

Toxic oxygen free radical damage is thought to play an important role in events such as trauma and sepsis, in which adult respiratory distress syndrome (ARDS) and multiple organ failure (MOF) are the major causes of late death. Serum lipofuscin concentration has been proposed as an indicator of lipid peroxidation caused by toxic oxygen free radicals. Serum lipofuscin level was measured in 75 healthy controls and sequentially in 66 patients in the intensive care unit; the latter included 18 patients who had undergone elective major vascular surgery, 20 after repair of ruptured abdominal aortic aneurysm and 28 with severe blunt trauma. Fifteen of the 66 patients died within 2 days. Ten of the remaining 51 patients developed ARDS and/or MOF and 41 had an uncomplicated postoperative course. Serum lipofuscin concentration in controls showed a positive correlation with age. Compared with controls, all three patient groups had significantly increased lipofuscin concentrations during the first day after major vascular surgery, trauma or shock. In addition, the ten patients who subsequently developed ARDS and/or MOF showed significantly increased lipofuscin levels on day 1, compared with those in the 41 who had an uncomplicated clinical course. The concentration of serum lipofuscin, which may act as a simple and valuable measure of grading oxidative stress, is positively related to the incidence of subsequent ARDS and/or MOF in patients at risk of these syndromes.
Interleukin 6 is a prognostic indicator of outcome in severe intra-abdominal sepsis
Authors: Patel R T , Deen K I , Youngs D , Warwick J , Keighley M R B
Published: March 2007

Levels of plasma cytokines and circulating endotoxin were assessed in 41 patients with severe intra-abdominal sepsis. Comparison was made with the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system. Blood samples were taken within 24 h of onset of the sepsis syndrome and at serial times thereafter. Increased levels of interleukin (IL) 6 (range 50–25 500 pg/ml) were detectable in all patients with sepsis. Eighteen of the 19 deaths were attributable to sepsis and higher levels of IL-6 at the onset of the sepsis syndrome correlated with a poor outcome. The sensitivity of IL-6 concentration in predicting mortality was 86·4 per cent with a specificity of 78·9 per cent and an overall correct classification rate of 82·9 per cent. IL-6 level was a better predictor than APACHE II score (sensitivity 72·7 per cent, specificity 57·9 per cent, correct classification rate 65·9 per cent). Levels of tumour necrosis factor α, IL-1β and endotoxin did not correlate with mortality rate. Plasma IL-6 concentrations may help in planning future strategies to decrease the mortality rate associated with sepsis.
Role of fine-needle aspiration cytology and needle-core biopsy in the diagnosis of lobular carcinoma of the breast
Authors: Sadler G P , McGee S , Dallimore N S , Monypenny I J , Douglas-Jones A G , Lyons K , Horgan K
Published: March 2007

Fine-needle aspiration cytology (FNAC) plays a key role in the preoperative diagnosis of carcinoma of the breast but is less reliable in the diagnosis of infiltrating lobular carcinoma. The method of diagnosis was reviewed in 56 patients with lobular carcinoma who had attended screening and symptomatic clinics. In 29 patients FNAC results demonstrated malignant cells; 15 of these had palpable disease and the mean tumour size was 21 mm. In 27 patients FNAC failed to demonstrate malignant cells; 13 lesions were palpable and the mean tumour size was 23 mm. Ten patients were diagnosed by needle-core biopsy when FNAC was not diagnostic. FNAC may fail to diagnose even large lobular carcinoma and needle-core biopsy is strongly recommended in this situation.
Recurrence pattern of oesophageal carcinoma after limited resection does not support wide local excision with extensive lymph node dissection
Authors: van Lanschot J J B , Tilanus H W , Voormolen M H J , van Deelen R A J
Published: March 2007

The recurrence pattern after ‘limited’ resection for oesophageal carcinoma was analysed to determine whether more extensive local excision of tumour in combination with radical lymphadenectomy improves locoregional disease control and long-term survival. A total of 143 patients who underwent limited surgery with curative intent between 1983 and 1989 were studied: 90 with squamous cell carcinoma (group 1) and 53 with adenocarcinoma (group 2) of the thoracic oesophagus. One patient was lost to follow-up. Tumour recurrence occurred in 40 patients (44 per cent) in group 1 and 35 (66 per cent) in group 2. Locoregional recurrence in isolation occurred in 11 per cent of patients in group 1 and 8 per cent of those in group 2; locoregional recurrence was detected in combination with tumour elsewhere in 19 and 28 per cent respectively. In conclusion, one-third of patients at the most might potentially have benefited from more radical local tumour resection. Theoretical advantages such as a prolonged disease-free interval and definite cure should be weighed against the higher risk of serious complications. More extensive procedures should therefore be performed only in controlled clinical studies.
Emergency transjugular intrahepatic portasystemic stent shunting as salvage treatment for uncontrolled variceal bleeding
Authors: McCormick P A , Dick R , Panagou E B , Chin J K T , Greenslade L , McIntyre N , Burroughs A K
Published: March 2007

Creation of a transjugular intrahepatic portasystemic stent shunt (TIPSS) was used as a rescue treatment for patients with variceal bleeding refractory to standard medical and endoscopic treatment. Over a 2-year period 242 episodes of variceal bleeding were treated and emergency shunting was performed on 20 patients with uncontrolled bleeding (Pugh grade A, one; B, seven; C, 12). The procedure was technically successful and controlled bleeding in all patients. Six patients had early rebleeding within 5 days, and further shunting was required in two. Two had late rebleeding related to shunt occlusion and had a further TIPSS procedure followed by portacaval shunting. Twelve patients died within 40 days from liver failure and sepsis, and there were two late deaths after 2 and 6 months, unrelated to bleeding. TIPSS insertion is an effective therapeutic option in patients with acute variceal bleeding refractory to medical and endoscopic treatment. However, despite control of bleeding in this group, the hospital mortality rate was high, reflecting the severity of the underlying liver disease.
Patterns of portal vein occlusion and their aetiological significance
Authors: Stringer M D , Heaton N D , Karani J , Olliff S , Howard E R
Published: March 2007

Clinical and angiographic findings in 53 patients with portal vein occlusion were reviewed to determine the relationship between the pattern of venous occlusion and its aetiology. Five major patterns were identified. Group 1 comprised three children with idiopathic intrahepatic portal vein occlusion alone (hepatoportal sclerosis). Those in group 2 (25 patients), with occlusion of the main portal vein, accounted for almost half the total number and for most of those with a probable congenital aetiology. The ten patients in group 3 had angiographic occlusion and collateralization of the main portal and superior mesenteric veins. Intra-abdominal sepsis, other than that from pancreatic disease, was associated with this pattern of venous occlusion in which the splenic vein is spared. No patients with isolated portal and splenic vein occlusion (group 4) were recorded. Widespread thrombosis throughout the portal venous system (group 5; 15 patients) had a multifactorial aetiology but was typically observed in hypercoagulable states that were also associated with hepatic vein occlusion or other deep vein thromboses.
Treatment of patients with irresectable liver metastases from colorectal cancer by chemo-occlusion with degradable starch microspheres
Authors: Civalleri D , Pector J-C , Håkansson L , Arnaud J-P , Duez N , Buyse M
Published: March 2007

Chemo-occlusion of the liver increases the tumour concentration of drugs. Thirty-nine patients with colorectal liver metastases received a monthly bolus administration of mitomycin C (10 mg/m2 on day 1) plus a continuous infusion of 5-fluorouracil (500 mg/m2 daily from days 1 to 5). Drugs were given via both portal (one-third of the dose) and arterial (two-thirds) routes to control large and small metastases. Arterially administered mitomycin C was mixed with individualized doses of degradable starch microspheres. In 16 patients treatment was not started or was interrupted early because of arterial or portal catheter problems. In 23 patients who received two or more cycles of treatment the mean (s.d.) microsphere dose was 835(399) mg. Toxicity was mild, consisting mainly of pain. Five complete and five partial responses were seen, and six patients had stable disease. The median time to progression and length of survival were 6 and 16 months respectively. The relatively high rates of complete and overall response in hypovascular tumours (six of 12 lesions) may support the rationale of chemo-occlusion.
Plasma gastrin and cholecystokinin responses after pylorus-preserving pancreatoduodenectomy and defunctioned Roux loop pancreaticojejunostomy
Authors: Kingsnorth A N , Formela L J , Chen D , Rehfeld J F
Published: March 2007

Several methods can be used to re-establish gastrointestinal continuity after the standard Whipple's Billroth II procedure or Longmire pylorus-preserving pancreatoduodenectomy (PPPD). Standard pancreatoduodenectomy abolishes the postprandial gastrin response whereas the response after Longmire PPPD is similar to that in controls. A novel reconstruction after PPPD has been designed to separate the biliary and pancreatic secretions by restoring continuity in the Billroth I manner, retaining the gastric antrum and with the pancreatic remnant anastomosed to a separate defunctioned Roux loop. Gastrin and cholecystokinin (CCK) responses were measured in the fasting state and after a standard liquid meal of 250 ml containing 15 per cent protein, 30 per cent fat and 55 per cent carbohydrate with an energy value of 525 kJ. Basal gastrin and CCK concentrations were similar in five healthy unoperated controls, and after standard pancreatoduodenectomy (five patients) and isolated Roux loop PPPD (six patients). In controls and after the new PPPD operation, but not after standard pancreatoduodenectomy, mean(s.e.m.) postprandial plasma gastrin values rose from 8·66(0·33) to 13·00(0·33) pmol 1−1 at 10 min (controls) and from 7·66(1·56) to 15·00(1·36) pmol 1−1 at 10 min (defunctioned Roux loop PPPD); the concentration remained raised for 20 min then fell transiently; a second peak was maintained for 40 min (controls) to 60 min (modified PPPD). In controls, mean(s.e.m.) postprandial plasma CCK concentrations rose from 0·43(0·12) basal to 10·50(1·03) pmol 1−1 and returned to basal after 60 min. After standard pancreatoduodenectomy postprandial CCK concentrations rose at a similar rate and remained raised for 80 min. After isolated Roux loop PPPD plasma CCK concentrations remained low (mean(s.e.m.) 0·38(0·29) pmol 1−1)after the test meal.
Significance of aneuploidy
Authors: Rew D A
Published: March 2007

Aneuploidy is a state of abnormal and highly variable DNA and chromosome content found in both hereditary disorders and human malignancy. For two decades flow cytometry has allowed a wide-ranging survey of aneuploidy in clinicopathological series. Although up to 75 per cent of all tumours analysed display aneuploidy, its value as a clinical marker of biological aggressiveness is still uncertain. New technologies promise to reveal more precisely the genetic and subchromosomal changes that constitute aneuploidy and contribute to the malignant phenotype in human tumours.
Clinical relevance of intraoperative embolization detected by transcranial Doppler ultrasonography during carotid endarterectomy: A prospective study of 100 patients
Authors: Gaunt M E , Martin P J , Smith J L , Rimmer T , Cherryman G , Ratliff D A , Bell P R F , Naylor A R
Published: March 2007

A study was performed to investigate the clinical significance of microembolization detected by transcranial Doppler ultrasonography (TCD) by determining the quantity and character of emboli and correlating these with neurological and psychometric outcome, fundoscopy, automated visual field testing and computed tomographic brain scans in 100 consecutive patients undergoing carotid endarterectomy. Embolization was detected in 92 per cent of successfully monitored operations. Most emboli were characteristic of air and not associated with adverse clinical outcome. However, more than ten particulate emboli during initial carotid dissection correlated with a significant deterioration in postoperative cognitive function. A relationship between persistent particulate embolization in the immediate postoperative period, and both incipient carotid artery thrombosis and the development of major neurological deficits was observed. Immediate intervention, based on TCD evidence of embolization, has the potential to avert neurological deficits resulting from particulate embolization.
Long-term results of highly selective vagotomy: A prospective study with implications for future laparoscopic surgery
Authors: Wilkinson J M , Hosie K B , Johnson A G
Published: March 2007

Between 1979 and 1984, 141 patients (110 men, 31 women) underwent highly selective vagotomy (HSV) by a standard open technique for duodenal ulcer. All patients had received preoperative treatment with full-dose H2-receptor antagonists. Some 107 of these patients underwent HSV for persistent relapse on withdrawal of H2-receptor antagonists (relapsing responders) and 30 because of non-response to such drugs. After 4 years of follow-up, non-responders were found to be more likely to have symptoms after operation (P <0·001), but did not have a higher rate of recurrent ulceration. At a median of 11 (range 8–14) years after operation 126 patients were still alive; 115 (91 per cent) of these were followed up. Ten patients (9 per cent) were found to have had endoscopically proven recurrence and eight (7 per cent) still had symptoms without evidence of recurrence. The endoscopic recurrence rate and symptom rate at 11 years were no longer significantly different between relapsing responders and non-responders. The preoperative response to H2-receptor antagonist therapy does not help in predicting the likelihood of ulcer recurrence or long-term symptoms after HSV. Postoperative symptoms do not necessarily predict long-term ulcer recurrence. The long-term endoscopic recurrence rate after HSV is low and, if equally good results can be obtained laparoscopically, this will be an important and cost-effective option in the management of duodenal ulcer.
Genetic susceptibility to colorectal cancer in patients under 45 years of age
Authors: Hall N R , Finan P J , Ward B , Turner G , Bishop D T
Published: March 2007

A study was conducted to assess the genetic contribution to the development of colorectal cancer in young probands. Of 83 patients aged 45 years or under diagnosed with colorectal cancer in one health region over a 2-year period, 65 or their surviving next of kin were available for interview, from whom were obtained 60 detailed and five limited family histories. Five families fulfilled the Amsterdam criteria and a further eight satisfied less strict criteria for hereditary non-polyposis colorectal cancer, a total of 20 per cent of the cohort. Eleven of these families came from the subgroup of 13 probands who had one or more first-degree relatives with colorectal cancer. Overall the relative risk of colorectal cancer in close relatives was 5·2 (P<0·0001). This risk was highest for female relatives at 9·7 (P<0·0001) and relatives of female probands at 6·7 (P<0·0001). This study highlights the importance of taking a family history in this group of patients. Screening by colonoscopy for all close relatives of young patients with colorectal cancer is recommended.
Plasma elastase in venous disease
Authors: Shields D A , Andaz S K , Sarin S , Scurr J H , Smith P D Coleridge
Published: March 2007

The plasma elastase level was measured as a marker of neutrophil degranulation in three groups, each of 15 patients, with uncomplicated varicose veins, lipodermatosclerosis (LDS) and venous ulceration. The values obtained were compared with those in age- and sex-matched control subjects. Significantly higher levels of elastase were found in all patient groups compared with controls: median 25·6 ng/ml for patients with uncomplicated varicose veins, 22·1 ng/ml for those with LDS, 26·0 ng/ml for those with venous ulceration. There was no difference in neutrophil count between the patient and control groups. These results provide evidence of increased neutrophil degranulation in patients with venous disease. The finding of raised elastase levels in all three patient groups shows that this was not due solely to the inflammatory process characterizing LDS and venous ulceration.
Asymptomatic popliteal aneurysm: Elective operation versus conservative follow-up
Authors: Dawson I , Sie R , van Baalen J M , Van Bockel J H
Published: March 2007

In a retrospective study 42 patients with asymptomatic popliteal artery aneurysm were followed without surgery to identify variables predicting the risk of complications. The mean aneurysm size was 3·1 cm. Abnormal ankle pulses were found in 18 of the 42 limbs in which an asymptomatic popliteal aneurysm was present. Follow-up was complete (mean 6·2 years). Twenty-five patients developed complications at a mean observation time of 18 months. As a result three lost the limb, eight had claudication, two needed a fasciotomy and one had a peroneal nerve palsy. The cumulative risk of developing complications during follow-up was 24 per cent at 1 year, rising to 68 per cent at 5 years. Patients with absent ankle pulses and those already operated on for abdominal aortic aneurysm proved to be especially at risk. Patient survival appeared to be normal for the period of observation. It is concluded that asymptomatic aneurysm of the popliteal artery is a potentially dangerous lesion that may justify elective surgery; it is possible to select those at highest risk.
Breast cancer incidence, penetrance and survival in probable carriers of BRCA1 gene mutation in families linked to BRCA1 on chromosome 17q12–21
Authors: Porter D E , Cohen B B , Wallace M R , Smyth E , Chetty U , Dixon J M , Steel C M , Carter D C
Published: March 2007

Eight breast cancer pedigrees with a high probability of containing individuals with the BRCA1 gene mutation (odds 79·2–99·9 per cent) were identified through genetic linkage analysis using probes located within q12–22 on the long arm of chromosome 17. Some 102 female relatives were successfully typed with one or both of adjacent markers D17S588 and D17S579, and 41 were probable non-BRCA1 mutation carriers. Of the remaining 61 women classified as probable BRCA1 carriers, breast cancer was diagnosed in 35. As expected from epidemiological segregation analysis studies, 13 of these had bilateral disease. Approximately two-thirds of women unaffected by malignancy and alive at the time of observation were non-BRCA1 carriers. Lifetime disease penetrance of the BRCA1 gene was 88 per cent and this plateau was reached earlier (by age 65 years) than that estimated in segregation analysis. The survival curve of patients with breast cancer was less steep in BRCA1 gene carriers than that in the general population; 5-, 10- and 20-year survival rates unadjusted for non-cancer deaths were 83, 63 and 41 per cent respectively. The 5-year survival rate was significantly higher in BRCA1 carriers than that in an age-matched Scottish population (P<0·05).
Herniography for occult hernia and groin pain
Authors: Eames N W A , Deans G T , Lawson J T , Irwin S T
Published: March 2007

In a prospective 3-year study herniography was used to assess patients with unexplained groin pain in whom clinical signs were inconclusive. Fifty-two patients were studied. No serious complications were observed. Twenty-two hernias were identified in 18 patients. The positive herniographic findings were confirmed at operation in 12 patients. Of 34 patients with a negative herniogram, none has developed a hernia. Pain settled spontaneously in 29 patients and five were referred to a pain clinic for further management.
Penetrating cardiac injuries: Clinical classification and management strategy
Authors: Saadia R , Levy R D , Degiannis E , Velmahos G C
Published: March 2007

The management of penetrating cardiac injury is controversial. To facilitate decision making, a simple clinical classification of patients with such an injury is proposed. Five categories are considered: (1) lifeless, (2) critically unstable, (3) cardiac tamponade, (4) thoracoabdominal injury and (5) benign presentation. Investigation, if indicated, and the timing and setting of surgical intervention are discussed for each category.
Molecular and cellular basis of cancer invasion and metastasis: Implications for treatment
Authors: Jiang W G , Puntis M C A , Hallett M B
Published: March 2007

In the past decade significant advances in establishing the underlying biological mechanisms of tumour invasion and metastasis have been made. Some of the triggering factors and genes relevant to metastatic spread have been identified. Advances have also been made in understanding the signal transduction pathways involved in invasion and metastasis. This increased comprehension of the malignant metastatic process has enabled new antimetastatic strategies to be devised. This review summarizes progress in these areas and discusses the implications for the treatment of metastasis.