bluuebunny/crossref_metadata_2025 huggingface dataset:
Role of surgery in mild primary hyperparathyroidism in the elderly
Authors: Roche N A , Young A E
Published: March 2003

Background

The appropriate management of elderly patients with mild hyperparathyroidism is the subject of much debate.

Methods

A Medline literature search was conducted using the keywords ‘hyperparathyroidism’, ‘asymptomatic’ and ‘elderly’. The references of the primary sources were examined for further citations. Personally collected cullings from journals and abstracts from journals were used as an additional source of data.

Results and Conclusion

No prospective randomized controlled trial comparing parathyroidectomy with conservative management for patients with mild or asymptomatic hyperparathyroidism has been published. There are a number of longitudinal studies that attempt to characterize the natural history of hyperparathyroidism, but most do not stratify patients according to age when assessing outcome. None the less, it is clear that elderly patients present with a different spectrum of problems, particularly indistinct neuropsychiatric and musculoskeletal symptoms, and these are likely to be improved by surgery. The evidence allows the conclusion that the truly asymptomatic elderly patient can be successfully managed conservatively; there is a good prospect of benefit from surgery for those with symptomatic disease, and such patients should not be denied an operative option.
Insulin-like growth factor I and truncated keratinocyte growth factor accelerate healing of left-sided colonic anastomoses
Authors: Egger B , Inglin R , Zeeh J , Dirsch O , Huang Y , Büchler M W
Published: March 2003

Background

Human full-length keratinocyte growth factor (KGF) promotes healing of colon anastomoses in rats through mechanisms other than enhancement of collagen synthesis. Since insulin-like growth factor (IGF) I increases matrix synthesis, the aim of this study was to evaluate the effect of systemic truncated KGF (tKGF), IGF-I and combined tKGF–IGF-I administration on the healing of colonic anastomoses in rats.

Methods

Rats underwent laparotomy, division of the left colon, and sigmoidosigmoidostomy. tKGF (1 mg/kg), IGF-I (1 mg/kg), tKGF–IGF-I (both 1 mg/kg) or vehicle was administered intraperitoneally in four groups (n = 18 per group) 12 h before surgical intervention, and then once daily until killing (six animals per group; 2, 4 and 6 days after surgery). Bursting pressure measurements, histological evaluation, morphometric analysis, mucin and collagen staining, and 5-bromo-2′-deoxyuridine (BrdU) immunohistochemistry of the anastomotic site were undertaken.

Results

Administration of tKGF, IGF-I and the combination of both growth factors significantly increased anastomotic bursting pressure at postoperative day 2 (63, 71 and 113 per cent respectively), day 4 (68, 83 and 80 per cent) and day 6 (48, 43 and 43 per cent) compared with the control group. No intergroup differences were found. Histological examination, mucin and BrdU staining, and measurement of colonic crypt depth indicated less inflammation, increased acidic mucin content, a higher crypt cell proliferation rate and thickened mucosal layer in the growth factor-treated animals than in controls. Enhanced collagen staining was observed only in IGF-treated animals.

Conclusion

tKGF and IGF-I markedly accelerate the healing of colonic anastomoses in rats. However, combined administration of the two growth factors does not show additional benefit. Both growth factors may be acting to accelerate host reparative processes as well as to enhance protection of the anastomotic wound bed.
Experimental study of a type 3 phosphodiesterase inhibitor on liver graft function
Authors: Ikegami T , Nishizaki T , Hiroshige S , Ohta R , Yanaga K , Sugimachi K
Published: March 2003

Background

The number of liver transplant recipients is increasing but donor organ shortages have become more severe. The effect of milrinone, a type 3 phosphodiesterase inhibitor (PDEI), on non-heart-beating donor grafts was evaluated using an orthotopic liver transplantation model in rats.

Methods

Type 3 PDEI or normal saline (control group) was given intravenously to the donor animals for 60 min continuously (50 µg kg−1 min−1) before 60 min of warm ischaemia followed by cold preservation and subsequent transplantation. Survival, serum chemistry, bile output, histopathological findings and tissue cyclic 3′,5′-adenosine monophosphate (cAMP) concentrations were then compared.

Results

Five of seven animals in the PDEI group were alive at 7 days, compared with only one of seven rats in the control group (P < 0·01). Serum levels of alanine aminotransferase 2 and 6 h after reperfusion, and hyaluronic acid levels 6 h after reperfusion, were significantly lower in the PDEI group than in the control group. Bile output from the transplanted graft was significantly greater in the PDEI group than in controls 2 h after reperfusion (P < 0·01). The mean necrotic area 6 h after reperfusion was also reduced in the PDEI-treated grafts (P < 0·01). cAMP levels in liver tissue at the end of both warm and cold ischaemia, and 2 and 6 h after reperfusion, were significantly higher in the PDEI group compared with those in the control group.

Conclusion

Type 3 PDEI attenuated the graft injury caused by warm and cold ischaemia and subsequent reperfusion injury via an increase in intracellular cAMP levels. This treatment may be a novel pharmacological intervention for safe and efficient usage of liver grafts from non-heart-beating donors.
Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy
Authors: Kearns S R , Connolly E M , McNally S , McNamara D A , Deasy J
Published: March 2003

Background

Electrocautery is used increasingly for tissue dissection, although fears of excessive scarring and poor wound healing have curtailed its widespread use for skin incision. This study compared electrosurgical incision with traditional scalpel incision.

Methods

One hundred patients requiring elective midline laparotomy were randomized prospectively to either scalpel or diathermy incision. Parameters measured included incision time, wound size, wound blood loss, total intraoperative blood loss and postoperative wound pain. All wound complications were recorded.

Results

The two groups did not differ significantly in relation to patient or wound characteristics. Laparotomy incisions using diathermy were significantly quicker than scalpel incisions (mean(s.e.m.) 6·1(0·4) versus 7·5(0·5) s/cm2; P < 0·04). There was significantly less blood loss in the diathermy group compared with the scalpel group (0·8(0·1) versus 1·7(0·3) ml/cm2; P = 0·002). Postoperative pain scores were significantly lower in the diathermy group for the first 48 h after operation (P < 0·05). Morphine requirements were also significantly lower over the first 5 postoperative days in the diathermy incision group (P < 0·04). There was no difference between groups in wound complications before discharge and at the 1-month follow-up.

Conclusion

Electrosurgical midline incision in elective surgery has significant advantages over scalpel use on the basis of incision time, blood loss, early postoperative pain and analgesia requirements.
Detection, treatment and outcome of axillary recurrence after axillary clearance for invasive breast cancer
Authors: de Boer R , Hillen H F P , Roumen R M H , Rutten H J T , van der Sangen M J C , Voogd A C
Published: March 2003

Background

The aim was to gain insight into the diagnosis, treatment and prognosis of axillary recurrence after axillary clearance for invasive breast cancer in a large patient series.

Methods

Between 1984 and 1994, 4669 patients with invasive breast cancer underwent axillary clearance in eight community hospitals in the south-eastern part of the Netherlands. Using follow-up data in a population-based cancer registry, 59 patients with axillary recurrence were identified.

Results

The median interval between treatment of the primary tumour and the diagnosis of axillary recurrence was 2·6 (range 0·3–10·7) years. In 51 patients (86 per cent), axillary recurrence was found by palpation during routine follow-up. Surgery was part of the treatment of recurrence for 41 of 59 patients. Regional control (complete eradication of axillary recurrence) was achieved in 34 patients (58 per cent). The 5-year actuarial survival rate was 39 (95 per cent confidence interval 25–53) per cent. Patients with negative axillary lymph nodes at the time of diagnosis of the primary tumour and complete eradication of axillary recurrence had the best prognosis.

Conclusion

Patients with axillary recurrence had a poor prognosis, except when complete eradication was achieved and axillary lymph nodes were negative at the time of diagnosis of the primary tumour.
Review of current practice to establish success after vasectomy
Authors: Bradshaw H D , Rosario D J , James M J , Boucher N R
Published: March 2003

Background

This study aimed to examine the criteria used by surgeons in a district general hospital to confirm success following vasectomy, to establish the proportion of men undergoing vasectomy in whom the procedure was unsuccessful according to those criteria, and to evaluate their subsequent management.

Methods

All 15 surgeons performing vasectomy indicated that they required two consecutive azoospermic postvasectomy semen specimens before they advised couples that the vasectomy was successful. Results of postvasectomy semen analysis (PVSA) for all 240 primary vasectomies performed over a 12-month interval were analysed. Minimum follow-up was 30 (range 30–42; median 37) months.

Results

At follow-up 72 men (30 per cent) had not returned postvasectomy samples that fulfilled the criteria, including 18 who were azoospermic on the first PVSA 3 months after vasectomy but who failed to produce a second specimen. In 24 men (10 per cent) who failed to comply with the PVSA protocol, there was no documentation of any further action being taken. No pregnancies were reported in the partners of the study group during this interval and only one patient underwent repeat vasectomy.

Conclusion

The results suggest that the strict requirement of two consecutive azoospermic postvasectomy semen specimens may be unjustified, leads to a high level of non-compliance and causes unnecessary delay in confirming success of the procedure.
Somatostatin receptor imaging, therapy and new strategies in patients with neuroendocrine tumours
Authors: Slooter G D , Mearadji A , Breeman W A P , Marquet R L , de Jong M , Krenning E P , van Eijck C H J
Published: March 2003

Background

Somatostatin receptors have been found on a variety of neuroendocrine tumours, such as carcinoids and paragangliomas, as well as on most pancreatic endocrine and breast tumours. Somatostatin receptor scintigraphy with a radionuclide-labelled somatostatin analogue, [111Indium-diethylenetriaminopenta-acetic acid]octreotide, is a sensitive and specific technique for visualizing in vivo the presence of somatostatin receptors on various tumours.

Methods

Material was identified from previous review articles, references cited in original papers and a Medline search of the literature. Additional material was obtained from recently published abstracts of meetings.

Results and conclusion

Somatostatin receptor imaging of neuroendocrine tumours is essential in the diagnostic evaluation of most of these tumours. The expression of somatostatin receptors in vivo not only predicts the outcome of somatostatin analogue treatment but also opens the possibility of new therapeutic strategies. Because better information about spread of the disease can be obtained, more justifiable options for therapy can be proposed.
Tumour necrosis factor inhibitors reduce the acute-phase response in hapten-induced colitis
Authors: Armstrong A M , Foulkes R , Jennings G , Gannon C , Kirk S J , Gardiner K R
Published: March 2003

Background

Tumour necrosis factor (TNF) α has been implicated in the pathogenesis of inflammatory bowel disease. The aim of this study was to assess the contribution of TNF to the pathogenesis of hapten-induced colitis.

Methods

Colitis was induced in Wistar rats using intracolonic instillation of the hapten trinitrobenzenesulphonic acid (TNBS) in ethanol. Animals were treated with monoclonal anti-TNF antibody (cTN3), an idiotype control antibody (CB0006) or pentoxifylline. Colonic and systemic inflammation was assessed quantitatively.

Results

The use of either TNF inhibitor attenuated the acute-phase response in the early stages of colitis. Median (interquartile range (i.q.r.)) α2-macroglobulin levels were reduced in animals pretreated with cTN3 (421 (279–915) μmol/ml) or pentoxifylline (567 (253–1454) μmol/ml) compared with levels in untreated colitic animals (1552 (1406–1998) μmol/ml) (P < 0·001 and P = 0·006, respectively). In established colitis, administration of anti-TNF antibodies resulted in an increase in median (i.q.r.) weight gain (percentage change in body-weight): colitic animals −2·3 (− 5·5 to 9·2) per cent versus cTN3-treated rats 15 (7·5–16·7) per cent; P < 0·05.

Conclusion

The systemic response to TNBS-induced colitis appears to be at least partially dependent on TNF. This study did not provide evidence to support a role for TNF in the pathogenesis of colonic inflammation in this model.
Improving operative safety for cirrhotic liver resection
Authors: Wu C-C , Yeh D-C , Lin M-C , Liu T-J , P'Eng F-K
Published: March 2003

Background

Liver resection in a patient with cirrhosis carries increased risk. The purposes of this study were to review the results of cirrhotic liver resection in the past decade and to propose safe strategies for cirrhotic liver resection.

Methods

Based on the date of operation, 359 cirrhotic liver resections in 329 patients were divided into two intervals: period 1, from September 1989 to December 1994, and period 2, from January 1995 to December 1999. The patient backgrounds, operative procedures and early postoperative results were compared between the two periods. The factors that influenced surgical morbidity were analysed.

Results

In period 2, patient age was higher and the amounts of blood loss and blood transfused were lower. Although postoperative morbidity rates were similar, blood transfusion requirement, postoperative hospital stay and mortality rate were significantly reduced in period 2. No death occurred in 154 consecutive cirrhotic liver resections in the last 38 months of the study. Prothrombin activity and operative time were independent factors that influenced postoperative morbidity.

Conclusion

With improving perioperative assessment and operative techniques, most complications after cirrhotic liver resection can be treated with a low mortality rate. However, more care should be taken if prothrombin activity is low or there is a long operating time.
One-year survey of carcinoma of the oesophagus and stomach in Wales
Authors: Pye J K , Crumplin M K H , Charles J , Kerwat R , Foster M E , Biffin A
Published: March 2003

Background

The aim of the study was to identify all patients who presented with oesophagogastric malignancy within a single National Health Service region (Wales) over 1 year, and to follow the cohort for 5 years. Management and outcome were analysed to identify current practice and draft guidelines for Wales.

Methods

Patients were identified from hospital records. Details were recorded in structured format for analysis.

Results

Analysable data were obtained for 910 of 916 patients. The overall incidence was 31·4 per 100 000 population. Treatment was by resection 298 (33 per cent), palliation 397 (44 per cent) or no treatment 215 (24 per cent). The 30-day mortality rate was 12 per cent and the in-hospital mortality rate was 13 per cent. Some 226 patients (25 per cent) were alive at 2 years. Resection conferred a significant survival advantage over palliation (P < 0·001) and no treatment. Anastomotic leakage occurred in 16 patients (5 per cent), of whom eight died in hospital. ‘Open and close’ operations were common (23 per cent), laparoscopy was infrequent (16 per cent), and many surgeons undertook small caseloads. Operating on fewer than six patients per year increased the mortality rate after partial gastrectomy (P < 0·05) and was associated with a trend to a higher mortality rate after mediastinal and cardia surgery. Operating on more than 70 per cent of patients seen resulted in a significantly higher mortality rate (P < 0·01) irrespective of case volume.

Conclusion

Tumour resection conferred a survival advantage. Wider use of laparoscopy is advocated. Improved selection for surgery should result in a lower mortality rate.
Somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized controlled trials
Authors: Li-Ling J , Irving M
Published: March 2003

Background

The aim of this study was to evaluate, through systematic review, the effectiveness of somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of established enterocutaneous pancreatic fistulas.

Methods

Electronic databases, including Medline and EMBASE, were searched systematically by using keywords including ‘somatostatin’, ‘octreotide’, ‘fistula’ and ‘randomiz(s)ed controlled trial’. In addition, citations of relevant primary and review articles were examined. Particular authors were contacted when necessary. Data on patient recruitment, intervention and outcome were extracted from the included trials and analysed.

Results

Use of somatostatin or octreotide for the prevention of postpancreatectomy complications, including pancreatic fistulas, was identified in 14 randomized controlled trials, including one abstract and one conference proceeding, involving a total of 1686 patients. Use of somatostatin or octreotide for the treatment of established enterocutaneous pancreatic fistulas was identified in ten trials involving a total of 301 patients. Significant heterogeneity was found among the identified trials with regard to the definition of fistula, dosage of octreotide, starting time and duration of the treatment, among other factors.

Conclusion

There was major disagreement between the studies on whether use of the drugs in question is of value in preventing postoperative complications. This analysis suggests that, in units where the postoperative fistula rate following pancreaticoduodenectomy for neoplasia and other pancreatic conditions exceeds 10 per cent, somatostatin or octreotide administered before operation may significantly reduce the rate of major postoperative complications, particularly pancreatic fistulas. The identified evidence also suggests that there may be a limited role for such drugs in the treatment of established postoperative enterocutaneous pancreatic fistulas. A major conclusion is that further clarification of the roles of these drugs is still required through large, high-quality, randomized trials.
Standards of documentation of the surgeon—patient consultation in current surgical practice
Authors: Fernando K J , Siriwardena A K
Published: March 2003

Background

This study was designed to assess the reliability of the system whereby junior doctors document the surgeon–patient consultation in general surgical practice in the UK.

Methods

A prospective observational study was carried out, with an independent observer recording details of the surgeon–patient consultation and assessing the reliability of documentation. An exact record of the information given by consultants was transcribed in shorthand at the time of consultation. Data were recorded in the categories recommended for notation by the General Medical Council: clinical findings, decisions made, information given to patient and treatment prescribed. Case notes were examined within 24 h of the ward round to ascertain reliability of the documentation.

Results

The study population comprised 432 surgeon–patient consultations. There were important deficiencies in the documentation of consultants' clinical findings and management decisions. In addition, information given by consultants to the patients regarding clinical findings and treatment planned (including the need for operation) was recorded in a median of 6 per cent of consultations.

Conclusion

This study provides objective evidence of shortfalls in the documentation of the surgeon–patient consultation process. These deficiencies are such that, under present circumstances, the requirements of the General Medical Council with respect to case note documentation are not fulfilled in this setting.
Acute-phase protein response, survival and tumour recurrence in patients with colorectal cancer
Authors: Wigmore S J , MacMahon A J , Sturgeon C M , Fearon K C H
Published: March 2003

Introduction

An acute-phase protein response (APPR) has been associated with reduced crude survival rates and increased recurrence following apparently curative resection in patients with colorectal cancer. This study investigated the prognostic significance of a preoperative and postoperative APPR in relation to disease-specific mortality rate.

Methods

Some 202 patients with colorectal cancer were followed for at least 5 years. C-reactive protein concentration, measured before and at 3 months after operation, was used as an index of the APPR. Univariate and multivariate analyses were performed on a number of potential prognostic factors.

Results

Thirty-six per cent of patients had an APPR and this was associated with a higher rate of local tumour invasion, fewer curative resections and a higher carcinoembryonic antigen (CEA) concentration. There was no difference in Dukes' stage between patients with or without an APPR. The most important prognostic factor related to both disease-specific and crude survival was Duke's stage (P < 0·0001). Subgroup analysis demonstrated that APPR had prognostic significance only in patients with advanced disease (P = 0·013). An APPR was present in a minority of patients (11 per cent) after operation and was not associated with increased likelihood of tumour recurrence.

Conclusion

The APPR is increased in more than a third of patients presenting with colorectal cancer and is associated with more frequent local tumour invasion, fewer curative resections and a higher CEA level. An APPR at 3 months after operation does not have the prognostic significance reported by earlier studies.
Epidemiology of abdominal aortic aneurysms in the Asian community
Authors: Spark J I , Baker J L , Vowden P , Wilkinson D
Published: March 2003

Background

Studies relating to the ethnic origin of patients with an abdominal aortic aneurysm (AAA) are few and are mainly concerned with the differences between black and white Americans. The purpose of this study was to determine whether the incidence of AAA among the Asian population of Bradford is different from that in the Caucasian population.

Methods

A retrospective study of patients with an AAA was carried out between 1990 and 1997 using data collected by the Patient Administrative Service, personal databases of the vascular consultants and theatre records. Information about the ethnic composition of the population of Bradford was obtained from the 1991 national census. Demographic data, including ethnic origin and clinical details, were obtained from patient notes.

Results

Two hundred and thirty-three patients with an AAA were identified during the study interval. The Asian population comprised 14·0 per cent of the total population of Bradford. Twenty-eight AAAs would be expected per year. All of the aneurysms identified occurred in the Caucasian population and none in the Asian community.

Conclusion

These early results suggest that AAA is rare among the Asian population.
Determinants of death following burn injury
Authors: Muller M J , Pegg S P , Rule M R
Published: March 2003

Background

Burn care has changed considerably. Early surgery, nutritional support, improved resuscitation and novel skin replacement techniques are now well established. The aim of the study was to establish whether changes in management have improved survival following burn injury and to determine the contributory factors leading to non-survival.

Methods

This was a retrospective outcome analysis of data collected from a consecutive series of 4094 patients with burns admitted to a tertiary referral, metropolitan teaching hospital between 1972 and 1996.

Results

The overall mortality rate was 3·6 per cent. This decreased from 5·3 per cent (1972–1980) to 3·4 per cent (1993–1996) (P = 0·076). The risk of death was increased with increasing burn size (relative risk (RR) 95·90 (95 per cent confidence interval 12·60–729·47) if more than 35 per cent of the total body surface area was burned; P < 0·001) increasing age (RR 7·32 (3·08–17·42) if aged more than 48 years; P < 0·001), inhalation injury (RR 3·61 (2·39–5·47); P < 0·001) and female sex (RR 1·82 (1·23–2·69); P = 0·003). Operative intervention (RR 0·11 (0·06–0·21); P < 0·001) and the presence of an upper limb burn (RR 0·53 (0·35–0·79); P = 0·002) decreased the risk.

Conclusion

Modern burn care has decreased the mortality rate. Increasing burn size, increasing age, inhalation injury and female sex increased, while operative intervention and an upper limb burn decreased, the risk of death.
Role of tumour necrosis factor in lung injury caused by intestinal ischaemia–reperfusion
Authors: Köksoy C , Kuzu M A , Kuzu I , Ergün H , Gürhan I
Published: March 2003

Background

Despite the well known inflammatory effects of tumour necrosis factor α (TNF), the mechanism of TNF-mediated lung injury following ischaemia–reperfusion (I/R) is still unclear. In this study, the role of TNF in the development of acute lung injury following intestinal I/R was investigated.

Methods

Male Wistar rats underwent either sham operation (n = 10), 1 h of superior mesenteric artery occlusion and 2 h of reperfusion (I/R, n = 10), or pretreatment with anti-TNF polyclonal antibody 2 mg/kg and I/R (n = 6). Lung injury was evaluated by Evans blue dye concentration, immunohistochemical staining and morphometric analysis. Intestinal injury was assessed by Evans blue dye concentration and histological examination.

Results

Intestinal I/R resulted in lung injury characterized by an increase in Evans blue dye concentration, neutrophil sequestration, and obvious staining for expression of pulmonary CD11b and CD18. Pretreatment of animals with anti-TNF antibody led to a reduction in the sequestration of neutrophils, and a decrease in expression of pulmonary intracellular adhesion molecule 1 and CD18. Anti-TNF antibody pretreatment also reduced the intestinal microvascular injury but not histological grade after intestinal I/R.

Conclusion

Treatment with an anti-TNF antibody resulted in a significant attenuation of lung injury following intestinal I/R. The data indicate that TNF is an important trigger for upregulation of pulmonary endothelial and neutrophil adhesion molecules after intestinal I/R.
Leptin and its relation to weight loss, ob gene expression and the acute-phase response in surgical patients
Authors: Moses A G W , Dowidar N , Holloway B , Waddell I , Fearon K C H , Ross J A
Published: March 2003

Background

Patients with cachexia suffer from anorexia, weight loss and hypermetabolism. This study examined the relationship between plasma leptin concentration, leptin gene expression, weight loss and the acute-phase response in a group of surgical patients.

Methods

Body composition, plasma leptin, interleukin (IL) 6, soluble tumour necrosis factor receptor (sTNF-R) 55, sTNF-R75 and C-reactive protein were analysed in a cohort of 28 patients undergoing elective surgery. Subcutaneous and omental leptin messenger RNA (mRNA) was analysed in a subgroup of 14 patients.

Results

After adjustment for fat mass (FM), a significant partial correlation coefficient was found between plasma leptin and serum IL-6 concentration (P = 0·037). A positive correlation was found only between plasma leptin and omental leptin mRNA (P = 0·009). Patients with an acute-phase response had a significantly higher level of plasma leptin per unit FM (P = 0·049). Stepwise multiple regression showed that FM (P < 0·0005) and serum IL-6 (P = 0·018) were independent predictors of plasma leptin level.

Conclusion

Plasma leptin levels appear to be influenced by proinflammatory cytokines. Omental fat may have more influence on plasma leptin than subcutaneous fat. Accelerated weight loss in patients with cancer with an ongoing inflammatory response could be mediated in part by inappropriately high plasma levels of leptin.
Early gallbladder carcinoma does not warrant radical resection
Authors: Wakai T , Shirai Y , Yokoyama N , Nagakura S , Watanabe H , Hatakeyama K
Published: March 2003

Background

This study was designed to address whether gallbladder cancer invading the muscle layer (stage pT1b) is a local disease and whether radical resection is necessary.

Methods

A retrospective analysis of 25 patients with pT1b gallbladder tumours, 13 of whom underwent simple cholecystectomy and 12 radical resection with regional lymph node dissection, was performed. A total of 147 regional lymph nodes was examined for metastasis. The median follow-up time was 95 months.

Results

No patient had blood vessel or perineural invasion on histology. Lymphatic vessel invasion was seen in one patient. Both overt metastasis and micrometastases were absent in all lymph nodes examined. Overall 10-year survival was 87 per cent. The outcome after simple cholecystectomy was comparable to that after radical resection (P = 0.16). Two patients who underwent radical resection died from tumour relapse in distant sites.

Conclusion

Most pT1b gallbladder carcinomas spread only locally. Additional radical resection is not necessary when the depth of invasion of gallbladder carcinoma is limited to the muscle layer after simple cholecystectomy.
Myocardial infarction following aortic surgery: a comparison of cardiac troponin I and creatine kinase ratio
Authors: Haggart P C , Adam D J , Ludman P F , Bradbury A W
Published: March 2003

Background

Perioperative myocardial infarction may be underdiagnosed and/or misdiagnosed because World Health Organization criteria are often not met and creatinine kinase/creatinine kinase-muscle band (CK/CK-MB) ratios can be difficult to interpret. Cardiac troponin (cTn) I is the most sensitive and specific marker of myocardial cell necrosis but is not yet widely available. The aim was to compare cTnI and CK/CK-MB ratios in the diagnosis of myocardial infarction following aortic surgery.

Methods

This prospective study included 58 patients undergoing elective (27 aneurysm, seven occlusive) or emergency (24 ruptured aneurysms) aortic surgery. cTnI concentration was measured before operation and 6, 24, 48, 72 and 96 h after surgery. CK and CK-MB levels were measured where cTnI was detectable. Clinical and electrocardiographically detected cardiac events were documented prospectively.

Results

Conclusion

More than half of patients undergoing emergency, and more than a quarter of those undergoing elective, aortic surgery suffer myocardial necrosis as determined by cTnI concentration. This is accompanied by an increased CK/CK-MB ratio in less than one-fifth of cases.
Mortality following aortic surgery as a possible indicator of clinical performance
Authors: Rigby K , Palfreyman S , Michaels J
Published: March 2003

Background

The mortality rate following aortic surgery has been suggested as a possible indicator of clinical performance.

Methods

Routine hospital data on mortality following aortic surgery were collected for a 2-year interval in the Trent region. Procedural and diagnostic codes, mode of admission, district of residence, treatment and specialty data were analysed and compared with audit data and the Operating Theatre Information System.

Results

Inaccuracies in coding using the HRG (Health Resource Group) codes meant that 21·4 per cent of elective aortic cases (HRG Q01) were probably emergencies and 26 per cent of probable emergency ruptures were not coded as vascular emergencies. The HRG system does not identify complex procedures carried out in specialist centres, thereby distorting the overall mortality figures. Case mix and patient selection introduced a bias, apparent between tertiary and district general hospitals, with higher-risk elective and lower-risk emergency cases at tertiary referral centres. For patients aged over 80 years, two districts undertook no elective aortic surgery, and the rates for emergency surgery varied between 16 and 25 per cent in the districts and 77 per cent in the tertiary centre. After correction for these factors, there remains significant variation in mortality rates between tertiary referral centres and the district hospitals (Table).

Conclusion

Some of the difficulties in using crude mortality rates as an indicator of performance have been highlighted. They are subject to bias and distortions owing to the collection of incorrect information, patient selection differences between hospitals, case-mix differences and tertiary transfer of complicated cases. Other case-mix factors can be accounted for only with more detailed collection of clinical data such as POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) scores. However, there remains considerable and worrying variation in selection and outcomes of patients undergoing aortic surgery.
Randomized trial of vein versus dacron patching during carotid endarterectomy
Authors: Hayes P D , Alroggen H , Steel S , London N J M , Thompson M M , Bell P R F , Naylor A R
Published: March 2003

Background

A recent overview has indicated that, while routine patching is safer than primary closure following carotid endarterectomy (CEA), there is no systematic evidence that patch type influences outcome. Most surgeons perceive that prosthetic patches are more thrombogenic than vein patches. This study tested the hypothesis that it is the patient who is prothrombotic rather than the nature of the patch.

Methods

Some 274 patients undergoing 276 CEAs were randomized to either dacron (Du Pont, Stevenage, UK) patch closure (n = 137) or vein patch closure (n = 139). All patients with an accessible cranial window were monitored for 3 h after operation using transcranial Doppler (TCD) ultrasonography. The number and rate of embolizations were quantified, together with the requirement for selective dextran therapy to control high rates of postoperative embolization. All patients were assessed after operation and again at 30 days by a neurologist, and all underwent duplex imaging at 30 days.

Results

The 30-day death or any stroke rate was 2·2 per cent for dacron-patched patients and 3·6 per cent for vein-patched patients (P = 0·72). Dacron-patched patients had a higher incidence of postoperative emboli (median 5 (interquartile range 0–10·5)), compared with a median of 3 (interquartile range 1–17) for vein (P = 0·028). However, the incidence of detecting more than 50 emboli was virtually identical and patch type had no effect on the incidence of sustained high-rate embolization requiring dextran therapy (5·3 per cent for dacron versus 3·7 per cent for vein). No patient had a carotid thrombosis at 30 days.

Conclusion

Sustained high-rate embolization, previously shown to be highly predictive of progression to carotid thrombosis, appears to be patient dependent rather than related to patch type.
Role of Chlamydia pneumoniae in an experimental animal model of aneurysm formation
Authors: Tambiah J R S , Franklin I J , Powell J T
Published: March 2003

Background

Chlamydia pneumoniae has been implicated in the pathogenesis of vascular disease. C. pneumoniae DNA is present in 40–50 per cent of abdominal aortic aneurysm biopsies. This study investigated whether C. pneumoniae has a causal role in experimental aortic dilatation.

Methods

Experimental aneurysms were established in cholesterol-fed rabbits by periaortic application of calcium chloride solution and a combination of thioglycollate (a non-specific macrophage activator) or C. pneumoniae (live, formalin fixed or heat inactivated at 108 organisms per ml). After 3 weeks, aortic diameter was measured and aortas were harvested for analysis of macrophage counts. C. pneumoniae DNA was measured by polymerase chain reaction and C. pneumoniae antigens (both membrane and heat shock protein 60) were determined by immunostaining.

Results

Live or formalin-fixed C. pneumoniae at concentrations of 108 organisms per ml mimicked the effects of thioglycollate to produce aortic dilatation associated with macrophage influx. Lower concentrations of C. pneumoniae had a minimal effect.

Conclusion

In this experimental study, high doses of C. pneumoniae membrane antigens stimulated macrophage influx and aortic dilatation. Lipopolysaccharide had a lesser effect. C. pneumoniae antigens could contribute to an in vivo aggregate pathogen burden by provoking an inflammatory response.
Poor outcome following revascularization predicted by thromboelastography
Authors: Vig S , Chitolie A , Maurice E , Boa F , Bevan D H , Halliday A , Dormandy J
Published: March 2003

Background

Infrainguinal revascularization procedures are associated with a high risk of graft failure, amputation and early death. Hypercoagulability predicts a poor overall outcome but conventional tests are expensive and results are not immediately available. A cheap, rapid method for identifying hypercoagulability would allow screening before revascularization. Thromboelastography (TEG) is a rapid, reliable, bedside method of assessing whole blood clotting. Normally used to assess hypocoagulability, this study determined the role of TEG in identifying patients with a poor prognosis following revascularization.

Methods

Between November 1998 and January 2000, 106 patients with critical leg ischaemia were admitted for radiological or surgical revascularization (mean age 71 (range 33–90) years). All underwent TEG analysis, standard thrombophilia screening (STS), and fasting homocysteine and fibrinogen assays. All patients were followed for 6 months after revascularization by means of clinical examination, ankle: brachial pressure index (ABPI) and duplex imaging.

Results

At the 6-month follow-up of 106 patients, 29 (27 per cent) had arterial or graft occlusion, five (5 per cent) had died and four (4 per cent) had undergone a major amputation. Analysis of risk factors revealed that a hypercoagulable TEG (P = 0·0009), STS and/or raised fibrinogen level (P = 0·01), and rest pain (P = 0·006) were associated with poor outcome. Other factors such as age, sex, diabetes, current or previous smoking, coronary artery or cerebrovascular disease, hypertension, previous intervention, aspirin or lipid-lowering therapy were not significantly different. In addition, hyperlipidaemia, hyperhomocysteinaemia, raised level of C-reactive protein, eyrthrocyte sedimentation rate, lipoprotein a level, haemocrit, STS or fibrinogen alone were not useful as predictors of poor outcome.

Conclusion

TEG, a rapid inexpensive test of hypercoagulability, is associated with poor outcome following infrainguinal revascularization.
Long-term results of treating hepatic colorectal metastases with cryosurgery
Authors: Ruers T J M , Joosten J , Jager G J , Wobbes T
Published: March 2003

Background

The purpose of this study was to determine the long-term efficacy of cryosurgery as an adjunct to hepatic resection in patients with colorectal liver metastases not amenable to resection alone.

Methods

Thirty patients met the following inclusion criteria: metastases confined to the liver and judged irresectable, ten or fewer metastases, cryosurgery alone or in combination with hepatic resection allowed tumour clearance.

Results

Median follow-up was 26 (range 9–73) months. Overall 1- and 2-year survival rates were 76 and 61 per cent respectively. Median survival was 32 months. Disease-free survival at 1 year was 35 per cent, at 2 years 7 per cent. Six patients developed recurrence at the site of cryosurgery; given that the total number of cryosurgery-treated lesions was 69 the local recurrence rate was 9 per cent.

Conclusion

In patients with colorectal liver metastases, local ablative techniques can be used as an effective adjunct to hepatic resection to obtain tumour clearance.
Prediction of the response to chemoradiation and prognosis in oesophageal squamous cancer
Authors: Kishi K , Doki Y , Miyata H , Yano M , Yasuda T , Monden M
Published: March 2003

Background

The sensitivity of cancer cells to chemotherapy and radiation therapy depends on various biological properties. This study investigated the expression of p53, CDC25B and metallothionein (MT), and evaluated their clinical significance in chemoradiation therapy (CRT) for oesophageal squamous cell carcinoma.

Methods

The expression of p53, CDC25B and MT was evaluated by immunohistochemistry using biopsy specimens taken before CRT for 77 patients with oesophageal squamous cell carcinoma, and correlated with the pathological effects of CRT and survival.

Results

p53-positive tumours and MT-positive tumours had a poor response to CRT, whereas tumours with strong CDC25B expression were associated with a good response. When each patient was scored for the presence of the three biological factors, there was a strong correlation between the sensitivity score and the pathological effect of CRT (P < 0·001), and a (non-significant) difference in the 5-year survival rate between patients with a high score and those with a low score (67 versus 34 per cent respectively; P = 0·12).

Conclusion

The combined evaluation of p53, CDC25B and MT may help to identify patients with advanced oesophageal squamous cell carcinoma who will benefit from preoperative CRT.
Comparative anatomical study of division of the ileocolic pedicle or the superior mesenteric pedicle for mesenteric lengthening
Authors: Martel P , Blanc P , Bothereau H , Malafosse M , Gallot D
Published: March 2003

Background

Lengthening of the mesentery by vascular division may be necessary to perform an ileal pouch–anal anastomosis without tension. The aim of this study was to compare, in fresh cadavers, the increase in mesentery length after division of the ileocolic pedicle (ICP) and the superior mesenteric pedicle (SMP).

Methods

Total colectomy was performed in 12 fresh cadavers, which were then randomly divided into two groups. Pouch–anal anastomosis was performed with division of the ICP in one group of six cadavers and with division of the SMP in the other. The ileum was measured and the increase in length was recorded and compared statistically.

Results

The mean(s.d.) increase in length was 3·0(0·8) cm after ICP division and 6·5(1·1) cm after SMP division (P < 0·001). The distance between the end of the ileum and the point giving the greatest length was 25·5(5·0) cm in the ICP group and 46·8(4·2) cm in SMP group (P < 0·001).

Conclusion

In fresh cadavers, the increase in mesenteric length was greater after SMP division than after ICP division, but if pouch–anal anastomosis is performed a short segment of small bowel must be removed.
Adrenal surgery before and after the introduction of laparoscopic adrenalectomy
Authors: Miccoli P , Raffaelli M , Berti P , Materazzi G , Massi M , Bernini G
Published: March 2003

Background

The widespread introduction of laparoscopic adrenalectomy (LA) may have broadened the indications for a surgical approach to adrenal lesions. The aim of this study was to evaluate how the introduction of the laparoscopic technique changed the profile of patients referred for adrenal surgery.

Methods

Some 243 patients, who underwent adrenal surgery between November 1986 and December 1999, were divided in two groups: patients in group 1 underwent surgery before the introduction of LA (November 1986 to May 1993) and those in group 2 were operated on after the introduction of LA (June 1993 to December 1999). The groups were compared with respect to gender, age, preoperative diagnosis and lesion size.

Results

There were 88 patients in group 1 and 155 in group 2. The mean number of adrenal operations per month was 1·1 during the first period and 2·0 during the second. No differences were found in gender and lesion size. The statistical analysis showed a significant difference in indications for surgery (P = 0·005). The patients in group 2 were older but, after excluding those with metastases, the difference between the two groups was not significant.

Conclusion

The introduction of LA resulted in an increase in the number of patients referred. The criteria for patient selection did not change, but more patients with adrenal metastases and incidentaloma were operated on laparoscopically.
Early reoperation for acute dysphagia following laparoscopic fundoplication
Authors: Bessell J R , Adair W D , Smithers B M , Martin I , Menzies B , Gotley D C
Published: March 2003

Background

A small number of patients develop acute severe dysphagia for which reoperation is necessary within 10 days of laparoscopic fundoplication. The aim of this study was to identify clinical variables that might predict the likelihood of this condition occurring, such that it could be avoided in the future.

Methods

This was a prospective cohort study from three tertiary referral centres, using reoperation for acute dysphagia as the main outcome variable. Gastrointestinal symptom rating scale, and psychological well-being index questionnaires were undertaken before laparoscopic fundoplication, and dysphagia scores were determined before operation and 1 year later. Standard preoperative assessment included gastroscopy, oesophageal manometry and pH studies.

Results

Twelve (1·9 per cent) of the 617 patients suffered acute dysphagia, which was predicted by older age and female sex, and resulted in a longer duration of hospital stay. This condition was not predicted by any other demographic, clinical, investigative or operative variables.

Conclusion

The study did not identify useful criteria by which severe acute dysphagia could be anticipated and thereby avoided following laparoscopic fundoplication.
Randomized clinical trial to determine if delay from time of penetrating colonic injury precludes primary repair
Authors: Kamwendo N Y , Modiba M C M , Matlala N S , Becker P J
Published: March 2003

Background

There is often a delay of more than 12 h in transferring patients with penetrating colonic injury from outlying hospitals to a regional referral centre. The aim of this prospective study was to determine whether primary suture of a penetrating colonic injury in the presence of delayed presentation, shock, peritoneal contamination or associated injuries leads to increased morbidity and mortality rates.

Methods

Patients with penetrating colonic injuries were randomized to primary closure or colostomy. Patients were compared with regard to interval from injury to operation, associated injuries, duration of operation, postoperative complications and hospital stay.

Results

Two hundred and forty patients were seen over a 69-month period. The interval from injury to operation ranged from 3 to 56 h, and was similar in the two treatment groups. Postoperative complications were similar in the two groups but there were significant differences in operation time (mean(s.d.) 127·1(45·8) min for primary repair and 142·3(43·0) min for colostomy; P = 0·009) and length of hospital stay (mean (range) 9 (6–56) versus 26 (13–64) days respectively; P < 0·001).

Conclusion

Delay from time of penetrating colonic injury is not a contraindication to primary repair.