bluuebunny/crossref_metadata_2025 huggingface dataset:
Laparoscopic bile duct injuries: a single-institution experience spanning 8 years
Authors: Mudan S S , Reddy K M , Knight M J
Published: March 2003

Background

This audit represents the authors' experience in the management of 42 bile duct injuries following laparoscopic cholecystectomy and is the largest series reported so far in the UK.

Methods

Between November 1990 and May 1998, 42 patients were referred for management of bile duct injury following laparoscopic cholecystectomy. The case notes of all patients were reviewed and follow-up information was obtained to provide a 100 per cent follow-up rate. Aspects of the cholecystectomy, presentation, investigation, definitive treatment and follow-up are discussed.

Results

The referral source was 25 surgeons from 17 different hospitals. The incidence peaked in 1992 (ten cases) and has been stable at four referrals per year over the past 4 years. The median age was 56 years and the M: F ratio 10: 32. Thirty-five laparoscopic operations were performed by consultants and seven by trainees. Intraoperative cholangiography was performed in three. Seventeen operations were converted to an open procedure because of intraoperative difficulty. Injury was noted at operation in nine and an immediate restorative procedure was attempted. Twelve patients had had a reconstructive procedure before referral to this unit and the remainder were referred with a fresh injury. Patients in whom the bile duct was transected (n = 34) presented mostly with jaundice; those with minor injuries not involving the common duct (n = 8) presented with peritonitis. Thirty patients required operation; 25 underwent hepaticojejunostomy reconstruction, two needed revision of a previous biliary–enteric anastomosis, two had primary bile duct repair over a T tube and one required relaparoscopy to clip a leaking cystic duct. At a median of 12 months four patients who had had a reconstruction were symptomatic for cholangitis. Percutaneous transhepatic dilatation was successful in two and a further two required revision of the anastomosis. Another four patients had asymptomatic stenosis and were treated successfully by a single episode of dilatation. Follow-up showed all patients to be asymptomatic at a median follow-up of 42 months; however, six had a raised level of alkaline phosphatase. The remaining patients were managed successfully by therapeutic endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. The overall median hospital stay was 18 days. Perioperative complications were seen in nine patients with no procedure-related deaths.

Conclusion

Although the initial learning curve seems to have been overcome, a steady state of problems now exists and seems likely to continue. Best results were obtained by hepaticojejunostomy. Most postrepair strictures were dealt with without operation.
Diagnosis and staging of pancreatic carcinoma: comparison of manganofodipir trisodium-enhanced magnetic resonance imaging and dynamic contrast-enhanced spiral computed tomography
Authors: King L J , Bell J R G , Healy J C , Amin Z , Predolac D , Wotherspoon A , Thompson J
Published: March 2003

Background

The efficacy of manganofodipir trisodium (MnDPDP)-enhanced magnetic resonance imaging (MRI) and dual-phase dynamic contrast-enhanced spiral computed tomography (CT) in the diagnosis and staging of pancreatic carcinoma was compared.

Methods

Nineteen patients (eight men) aged 50–84 (mean 64) years with known or suspected pancreatic carcinoma were prospectively evaluated with MRI and CT. Precontrast T1 and T2 MRI sequences were supplemented by axial and coronal T1 images at 1·0 T, 20 min and 24 h following intravenous infusion of MnDPDP 0·5 ml/kg. Spiral CT was performed before contrast and dynamically after contrast during the pancreatic and portal venous phases of enhancement. The MRI and CT images were assessed independently by two observers blinded to the results of the other modality. The presence, site and size of any focal pancreatic mass were recorded and potential resectability was assessed by evaluating extraglandular extension, vascular involvement, lymphadenopathy, peritoneal spread and presence of hepatic metastases. Findings on MRI and CT were compared with the findings at surgery.

Results

Pancreatic adenocarcinomas were diagnosed histologically in 15 of 19 patients. MRI and CT each identified all of the proven malignancies. Clear evidence of irresectability with liver metastases or vascular invasion was identified in six of 15 patients at MRI, who did not therefore go on to surgery. In one of these six patients the CT findings were equivocal. Nine of the 15 patients went on to laparoscopy (n = 2) or laparotomy (n = 7). Of␣these nine patients seven were correctly assessed as resectable or␣irresectable on MRI and six by CT. The overall accuracy for assessing resectability was therefore 87 per cent for MRI and 73 per cent for CT. Liver metastases were confidently identified in three of 15 patients on both MRI and CT. Two patients with indeterminate liver lesions on CT were shown to have only benign liver lesions (cysts or haemangiomas) on MRI.

Conclusion

MnDPDP-enhanced MRI performed slightly better than dual-phase dynamic contrast-enhanced CT in the preoperative assessment of pancreatic tumour resectability. MRI also appears to offer an advantage in the evaluation of associated focal liver lesions.
Transmural endoscopic drainage of pancreatic pseudocysts
Authors: Beckingham I J , Krige J E J , Bornman P C , Terblanche J
Published: March 2003

Background

Pancreatic pseudocysts requiring treatment for pain or obstructive symptoms may be drained by percutaneous or open surgical techniques. Endoscopic drainage has been reported in a few small series with short-term follow-up. The aim of this study was to determine the indications and success rates of transmural endoscopic drainage procedures.

Methods

All patients who presented over a 2-year period to a tertiary referral centre with pancreatic pseudocysts were included in the study. Endoscopic drainage was attempted using a side-viewing endoscope in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complication and recurrence rates.

Results

Sixty-six patients presented with pseudocysts of which 34 were thought to be suitable for endoscopic drainage. Twenty-four were successfully drained. Failures were associated with thick-walled pseudocysts (greater than 1 cm), location in the tail of the pancreas and pseudocysts associated with acute necrotizing pancreatitis. There were no deaths and only one patient required emergency surgery for bleeding from the pseudocyst wall. There were three recurrences with a median of 41 (interquartile range 3–51) months of follow-up, two of which were successfully redrained endoscopically. The long-term success rate of the initial procedure was 62 per cent.

Conclusion

Transmural endoscopic drainage is a safe procedure with minimal complications, although surgical facilities must be available. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of less than 1 cm and a visible bulge into the gastrointestinal lumen. Applying these criteria to the 66 consecutive patients with pancreatic pseudocysts presenting over this initial 2-year study period, 26 (39 per cent) were suitable for the procedure. Technical success was achieved in 24 of the 26 patients and long-term success in 22.
Role of biliary scintiscan in predicting the need for cholangiography
Authors: Mathur S K , Soonawalla Z F , Shah S R , Goel M , Shikare S
Published: March 2003

Background

Currently used predictors for bile duct calculi in patients undergoing cholecystectomy have low specificity resulting in unnecessary cholangiograms being performed. The role of biliary scintiscan in predicting the presence of bile duct calculi was assessed.

Methods

Seventy-five patients with symptomatic gallstone disease were studied prospectively regarding the value of a history of jaundice or acute pancreatitis, raised serum bilirubin and serum alkaline phosphatase levels, and visualization of stones or presence of dilated bile ducts on ultrasonography (standard criteria) in detecting bile duct calculi. Results of biliary scintiscan were evaluated against a combination of standard criteria. The ‘gold standard’ for evaluation was endoscopic or peroperative cholangiography.

Results

Biliary scintiscan had a higher sensitivity and specificity (93 and 94 per cent) than a combination of the above standard and modified predictors for biliary calculi (89 and 71 per cent). A combination of ultrasonography and selective use of scintiscan, in the absence of bile duct dilatation only, had higher values (96 and 98 per cent).

Conclusion

A combination of ultrasonography and biliary scintiscan can accurately predict bile duct calculi and could be used as a guide for selective cholangiography.
Abdominal content containment: practicalities and outcome
Authors: Ghimenton F , Thomson S R , Muckart D J J , Burrows R
Published: March 2003

Background

Alternatives to fascial closure of the abdominal wall are increasingly used in critically ill patients. They pose practical and logistical problems in management which are described in this single-institution study.

Methods

Between January 1994 and December 1997, 157 predominantly young male patients (100 trauma and 57 non-trauma) underwent temporary abdominal content containment (t-ACC) using plastic bags or polyglactin mesh. Indications for t-ACC were severe sepsis requiring reoperation, abdominal compartment syndrome, abdominal wall tissue loss or a combination of these. A total of 385 laparotomies were performed.

Results

Two t-ACC procedures failed owing to technical error and two were complicated by enteric fistulas. Six patients underwent early definitive abdominal closure within 15 days. The remaining survivors had a protracted hospital stay (mean(s.d.) 44·6(26·6) days) and all developed incisional hernias which were challenging to repair. The overall mortality rate was 44 per cent.

Conclusion

Plastic bags were cheaper and as effective as polyglactin mesh for t-ACC. Survivors require a multidisciplinary approach in management, undergo a protracted hospital stay and later need complex incisional hernia repairs.
Evaluation of Delorme's procedure as a treatment for full-thickness rectal prolapse
Authors: Watts A M I , Thompson M R
Published: March 2003

Background

Delorme's procedure is a well tolerated perineal operation for full-thickness rectal prolapse. However, prolapse recurrence is common and reported recurrence rates vary widely. This study attempted to standardize outcome assessment for recurrence following primary and subsequent Delorme's operations. Patient and operative factors were analysed to identify any that might improve patient selection.

Methods

Some 101 primary and 17 secondary Delorme's procedures were carried out on 113 consecutive patients presenting with rectal prolapse, who were followed for a minimum of 12 months, unless death or recurrent prolapse intervened. The rate of prolapse recurrence was calculated using the Kaplan–Meier method of analysis. Patient age, sex, grade of incontinence, presence of diverticular disease, length of mucosal resection and position in the operative series were analysed to identify factors affecting recurrence.

Results

The predicted recurrence-free period for 50 per cent of patients undergoing primary and secondary Delorme's procedures was 91 (95 per cent confidence interval 77–105) and 27 (15–39) months respectively. None of the patient or operative factors analysed was related to recurrent prolapse.

Conclusion

Delorme's procedure is a simple operation with satisfactory functional results which can be considered in all patients of all ages. However, high recurrence rates for primary and repeat operations should be explained to patients when planning their surgical management.
Spontaneous carotid artery aneurysms
Authors: Nair R , Robbs J V , Naidoo N G
Published: March 2003

Background

Spontaneous carotid artery aneurysms are infrequently reported, and are almost always non-atherosclerotic.

Methods

The records of 29 patients with a spontaneous carotid aneurysm treated in an academic vascular unit between 1990 and 1998 were reviewed.

Results

All 29 patients were black South Africans; three had bilateral aneurysms. There were 24 men and five women, of mean age 35 (range 13–62) years. Some 25 aneurysms involved the common carotid artery, 12 of which affected the bifurcation, and seven were located in the internal carotid artery. Twenty-five aneurysms were managed surgically, four of which were ligated owing to sepsis. Histological evaluation showed human immunodeficiency virus-related arteritis in four, tuberculous aneurysms in ten, Takayasu's arteritis in two, atherosclerosis in three and non-specific chronic inflammation in four patients. Microbiological examination was negative in all but one patient who had Salmonella sp. cultured. Outcome was generally favourable, but one patient died from massive hemispheric infarction. There were no other new neurological deficits.

Conclusion

Carotid aneurysms pose a considerable surgical challenge but are amenable to operative intervention with good result. Ligation appears to be well tolerated in this group of predominantly non-atherosclerotic aneurysms.
Gunshot injuries of the popliteal artery
Authors: Nair R , Abdool-Carrim A T O , Robbs J V
Published: March 2003

Background

Guidelines for the management of popliteal artery trauma emanate mainly from military experience. This study was undertaken to describe the management of popliteal injuries in a civilian vascular surgical unit with a large trauma workload.

Methods

A retrospective review of records of patients treated between 1983 and 1997 was undertaken.

Results

Some 117 popliteal artery gunshot injuries were treated (83 low velocity, 16 high velocity, 18 shotgun). Associated fractures occurred in 44 patients and 40 had popliteal vein injuries. Treatment of the arterial injury included vein graft interposition in 71, primary reanastomosis in 19, prosthetic graft interposition in four, lateral suture in one, vein patch in one and ligation in one patient; 84 fasciotomies were performed. No perioperative deaths occurred. There were 20 primary and 14 secondary amputations. Factors associated with amputation were high-velocity injuries, delay in revascularization in excess of 7 h, arterial transection, associated fracture, and compartment syndrome or muscle infarction.

Conclusion

Civilian popliteal gunshot injuries are attended by a high amputation rate. Prompt resuscitation and revascularization appear to be the only correctable factors that may improve limb salvage rates.
Prognosis and surgical management of patients with palpable inguinal lymph node metastases from melanoma
Authors: Hughes T M D , A'Hern R P , Thomas J M
Published: March 2003

Background

The appropriate management of melanoma metastatic to inguinal lymph nodes remains controversial. The aim of this study was to identify disease- and treatment-related factors that influence the outcome of patients undergoing therapeutic groin dissection for clinically detectable melanoma lymph node metastases.

Methods

A retrospective analysis was performed on data collected from the case records of patients who had a therapeutic inguinal lymph node dissection performed between 1984 and 1998.

Results

Some 132 patients were suitable for inclusion. Sixty patients had superficial inguinal lymph node dissection (SLND) and 72 had combined superficial inguinal and pelvic lymph node dissection (CLND). There was no difference in postoperative morbidity or major lymphoedema between SLND and CLND. The overall survival rate was 34 per cent at 5 years. On univariate analysis, age (P = 0·003), the number of involved superficial lymph nodes (P = 0·001) and the presence of extracapsular spread (P = 0·003) were found to have a significant impact on survival. The presence or absence of pelvic lymph node metastases in patients who had CLND was a significant prognostic factor for survival (5-year survival 19 versus 47 per cent; P = 0·015).

Conclusion

The prognosis of patients with clinically detectable melanoma metastases to the groin is variable and related to the biological characteristics of each case. CLND provided additional prognostic information and optimal regional control with no increased morbidity compared with SLND.
Changing referral pattern of biliary injuries sustained during laparoscopic cholecystectomy
Authors: Shah S R , Mirza D F , Afonso R , Mayer A D , McMaster P , Buckels J A C
Published: March 2003

More patients with less severe type biliary injury are being referred earlier to a specialist hepatobiliary unit. Most patients still have ineffective corrective surgery before transfer.
Analysis of risk factors for nosocomial sepsis in surgical patients
Authors: Fariñas-Álvarez C , Fariñas M C , Fernández-Mazarrasa C , Llorca J , Casanova D , Delgado-Rodríguez M
Published: March 2003

Background

This study aimed to identify patients at high risk for developing sepsis following surgery according to criteria determined by the American College of Chest Physicians and the Society of Critical Care Medicine Consensus Conference on sepsis.

Methods

A prospective case–control study was performed in surgical patients in a tertiary care centre over 1 year. Patients were identified by a daily prospective surveillance. Controls were selected randomly from the daily list of surgical inpatients. Data were collected prospectively. Crude and adjusted odds ratios (ORs) and their 95 per cent confidence intervals were computed using logistic regression analysis.

Results

During follow-up, 99 cases and 99 controls were identified. The main risk factors for sepsis found in the multivariate analysis were coma within 48 h before sepsis (OR 13·5, 95 per cent confidence interval 3·6–50·8), low serum albumin level at admission (OR 15·8, 5·4–46·4), two or more intrinsic co-morbidities (OR 11·8, 2·8–49·4) and parenteral nutrition (OR 5·1, 1·5–17·1). Emergency surgery (OR 3·0, 1·4–6·4), abdominal surgery (OR 2·6, 1·0–6·8) and number of surgical interventions (OR 2·5, 1·1–6·1) were the variables related to surgery that significantly increased the risk of sepsis. Both the study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance indices showed a statistically significant trend with sepsis.

Conclusion

Patient-related factors appear to represent the greatest risk for developing postoperative nosocomial sepsis, rather than factors associated with the surgery.
Use of superficial femoropopliteal vein for suprainguinal arterial reconstruction in the presence of infection
Authors: Gibbons C P , Ferguson C J , Edwards K , Roberts D E , Osman H
Published: March 2003

Background

Conventional treatment of mycotic aneurysms or graft infections of the aortoiliac segment by in situ or extra-anatomic prosthetic reconstruction has a high mortality and morbidity rate, with a substantial risk of persistent graft infection. The use of autologous vein may reduce this.

Methods

Eleven patients with suprainguinal arterial infections including two with mycotic aortic aneurysms, four with aortic graft infections, four infected femorofemoral grafts and an infected axillofemoral graft were treated by debridement and in situ reconstruction with autologous superficial femoropopliteal vein. All patients received appropriate antibiotic therapy and were followed by regular postoperative duplex imaging. Preoperative femoral vein duplex imaging was performed in eight of the 11 patients.

Results

Ten of the 11 patients survived with a functioning graft and without limb loss or evidence of infection at 4–33 months. One patient died from myocardial infarction after operation. Three patients had minor swelling of one leg. Four patients required subsequent angioplasty of anastomotic stenoses detected by duplex surveillance.

Conclusion

Superficial femoropopliteal vein is an excellent conduit for suprainguinal reconstruction in the presence of infection. Duplex imaging is useful for confirming the suitability of deep veins for use as a graft and for postoperative surveillance.
Randomized clinical trial of laparoscopic versus open fundoplication: blind evaluation of recovery and discharge period
Authors: Nilsson G , Larsson S , Johnsson F
Published: March 2003

Background

There is a widespread belief that introduction of the laparoscopic technique in antireflux surgery has led to easier postoperative recovery. To test this hypothesis a prospective randomized clinical trial with blind evaluation was conducted between laparoscopic and open fundoplication.

Methods

Sixty patients with gastro-oesophageal reflux disease were randomized to open or laparoscopic 360° fundoplication. The type of operation was unknown to the patient and the evaluating nurses after operation.

Results

The operating time was longer in the laparoscopy group, median 148 versus 109 min (P < 0·0001). The need for analgesics was less in the laparoscopically operated patients, 33·9 versus 67·5 mg morphine per total hospital stay (P < 0·001). There was no significant difference in postoperative nausea and vomiting. On the first day after operation patients in the laparoscopy group had better respiratory function: forced vital capacity 3·2 versus 2·2 litres (P = 0·004) and forced expiratory volume 2·6 versus 2·0 litres (P = 0·008). Postoperative hospital stay was shorter in the laparoscopic group, median (range) 3 (2–6) versus 3 (2–10) days (P = 0·021). No difference was found in the duration of sick leave.

Conclusion

Laparoscopic fundoplication was associated with a longer operating time, better respiratory function, less need for analgesics and a shorter hospital stay, while no reduction in the duration of postoperative sick leave was found compared with open surgery.
Randomized, multicentre, double-blind, placebo-controlled trial of the use of aprotinin in the repair of ruptured abdominal aortic aneurysm
Authors: Robinson J , Nawaz S , Beard J D
Published: March 2003

Background

The use of aprotinin in cardiac surgery reduces blood transfusion requirements. The aim of this trial was to see whether the same benefit applies in the repair of ruptured abdominal aortic aneurysm (AAA).

Methods

In this prospective, randomized trial, nine centres with local ethics committee approval recruited 77 patients with a ruptured AAA. A bolus of aprotinin 2 × 106 units, followed by an infusion of 0·5 × 106 units every 30 min, was administered to 38 patients, and 39 received a placebo infusion. The quantity of blood products transfused during surgery and in the first 12 h after operation was noted, along with the incidence of complications, mortality rates and length of hospital stay.

Results

Seventeen of the 38 patients who received aprotinin and 17 of the 39 given placebo died within 30 days (overall mortality rate 44 per cent). The median amount of blood given to the aprotinin group after operation was 1 (range 0–14) unit, while for the placebo group it was 3 (range 0–13) units (P = 0·02). However, the difference in the total number of units of blood transfused did not reach significance (10 (range 2–29) versus 14 (range 4–38) units respectively).

Conclusion

The use of high-dose aprotinin during the repair of a ruptured AAA reduced blood transfusion requirements in the first 12 h after operation, but had no significant effect on the overall blood transfusion requirement.
Fournier's gangrene: a review of 1726 cases
Authors: Eke N
Published: March 2003

Background

Although there is much consensus, certain controversies exist regarding the management of Fournier's gangrene.

Method

Publications in English on Fournier's gangrene from January 1950 to September 1999 were obtained through the Medline database and relevant reference lists in publications. It was possible to identify 1726 cases for study. Data extracted for review included country of reported cases, number of patients in each report and relevant clinical features.

Results

Fournier's gangrene occurs worldwide. However, its definition has generated considerable controversy as efforts are made to refine the original description in the light of increasingly understood aetiological factors. Attempts to classify the disease into primary and secondary forms have not been successful. The basic pathological process, necrotizing fasciitis, has been identified in the perineum of women and children, although the disease afflicts the male more often than the female. Most reported cases have occurred in the USA and Canada. The major sources of sepsis are the local skin, colon, anus and rectum, and the lower urinary tract. Colonic, anal and rectal sources carry the worst prognosis. Diabetes mellitus is important in aetiological terms. Rare causes include vasectomy and circumcision. Investigations are essential to define the cause of an episode but not for the diagnosis of the disease. Early aggressive treatment of Fournier's gangrene and underlying conditions is essential. Hyperbaric oxygen and honey are treatment modalities yet to be universally adopted. Risk of death, 16 per cent overall in this series, is related to the patient's condition at presentation.

Conclusion

Controversies over the definition of Fournier's gangrene persist but these do not affect the treatment options. The diagnosis is made on clinical grounds. The occurrence of the disease in women is under-reported and may go unrecognized by some clinicians. Some treatment options, such as hyperbaric oxygenation and radical excision, remain controversial.
Multicentre study of thyroid nodules in patients with Graves' disease
Authors: Kraimps J L , Bouin-Pineau M H , Mathonnet M , De Calan L , Ronceray J , Visset J , Marechaud R , Barbier J
Published: March 2003

Background

The association of Graves' disease with thyroid nodules and thyroid carcinoma is rarely reported. The incidence seems to be increasing according to recent literature. The aim of this multicentre study was to review patients who had surgery for Graves' disease associated with thyroid nodules, and to evaluate the risk of thyroid carcinoma.

Methods

A retrospective study was made of 557 consecutive patients who underwent operation for Graves' disease between 1991 and 1997 in five endocrine surgery departments. Each patient underwent clinical, biochemical, ultrasonographic and scintigraphic evaluation. None of the patients had had previous radioactive iodine therapy or external irradiation. Surgery consisted of either a subtotal or total thyroidectomy.

Results

Nodules were observed before operation in 140 patients (25·1 per cent). Thyroid carcinoma was diagnosed in 21 patients (15·0 per cent), always inside a nodule. The incidence of thyroid carcinoma associated with Graves' disease was 3·8 per cent (21 of 557 patients): 20 papillary and one follicular carcinoma. The carcinoma was multifocal in two patients. Tumour diameter ranged from 2 to 25 mm. A nodule was palpable in four patients.

Conclusion

This multicentre study of patients having thyroidectomy for Graves' disease showed that 3·8 per cent had a carcinoma; the rate of carcinoma in cold nodules was 15·0 per cent. Surgery should be advised in any patient with Graves' disease and a thyroid nodule; the operation should be total thyroidectomy.
Effect of colectomy on gastric emptying in idiopathic slow-transit constipation
Authors: Hemingway D M , Finlay I G
Published: March 2003

Introduction

Gastric emptying is delayed in patients with idiopathic slow-transit constipation (ISTC). Gastric emptying was measured before and after colectomy and ileorectal anastomosis in patients with ISTC to determine whether the abnormality persists after operation.

Methods

Twelve patients undergoing colectomy for severe ISTC had solid-phase gastric emptying measured after an overnight fast. All 12 had an uncomplicated subtotal colectomy and ileorectal anastomosis; 11 had an excellent functional outcome. In ten of these patients gastric emptying was repeated within 3 months of operation. Seven patients (including the remaining two) had the study performed at 1 year.

Results

All 12 patients had severely delayed gastric emptying before operation. Gastric emptying remained delayed in the ten patients who underwent an early postoperative gastric emptying study. Six of seven patients assessed at 1 year had improved gastric emptying, of whom four had returned to normal. Functional outcome did not relate to gastric emptying.

Conclusion

Patients with ISTC have delayed gastric emptying. In some patients this returns to normal after colectomy, but is persistent in others. This may have implications for our understanding of ISTC.
Portal flow augmentation for liver cirrhosis
Authors: Jiao L R , Seifalian A M , Mathie R T , Habib N , Davidson B R
Published: March 2003

Background

Portal hypertension due to chronic liver disease is a major cause of death worldwide. Orthotopic liver transplantation offers the best therapeutic option but is available to only a minority of patients. In the past few years mechanically pumping portal venous inflow has been reported to reduce portal hypertension and improve liver function.

Methods

A review of the published data on augmented portal perfusion for the treatment of portal hypertension in cirrhosis was carried out by searching Medline and other online databases. From each published study portal pressure and blood flow data before and after augmented portal perfusion were used to calculate the change in mean intrahepatic portal vascular resistance (IHPR). The standardized data were then combined to allow meta-analysis.

Results

Seven papers were identified on normal and cirrhotic animal and human livers with augmented flow (50% to fourfold over baseline) for 30–180 min. Meta-analysis revealed that the increased portal venous inflow was associated with a significant rise in portal venous pressure on the hepatic side (P < 0·001), a significant reduction on the mesenteric side (P < 0·001) and a significant reduction in IHPR (P = 0·013). Limited data were available to support improved liver function.

Conclusion

Detailed in vivo cirrhotic liver studies on augmented portal flow in experimental models assessing haemodynamic and functional changes are required before clinical evaluation.
Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials
Authors:   EU Hernia Trialists Collaboration, Grant A
Published: March 2003

Background

The place of laparoscopic groin hernia repair remains controversial. Individual randomized controlled trials alone have not provided statistically reliable results when considering recurrence, potentially serious complications and chronic pain.

Methods

A rigorous systematic review was performed of published data from all relevant randomized or quasi-randomized trials. Electronic databases were searched and members of the EU Hernia Trialists Collaboration consulted to identify trials. Prespecified data items were extracted from reports and, where possible, quantitative meta-analysis was performed.

Results

Thirty-four published reports of eligible trials were included, involving 6804 participants. Sample sizes ranged from 20 to 1051, with follow-up from 6 weeks to 36 months. Duration of operation was longer in the laparoscopic groups (P < 0·001, Sign test). Operative complications were uncommon for both methods, but visceral and vascular injuries were more frequent in the laparoscopic group (4·7 per 1000 versus 1·1 per 1000). Postoperative pain was less among laparoscopic groups (P = 0·08). Length of hospital stay did not differ significantly between groups (P = 0·50), but return to usual activity was earlier for laparoscopic groups (P < 0·001). Chronic pain and numbness were reported for only a small minority of trials. Overall, recurrences did not differ between groups, but comparison of laparoscopic with open non-mesh repair favoured laparoscopic methods, significantly so for transabdominal preperitoneal repair (Peto odds ratio 0·56 (95 per cent confidence interval 0·33–0·93); P = 0·026).

Conclusion

Although the rigorous search maximized trial identification, variation in trial reporting made formal meta-analysis difficult. Laparoscopic repair was associated with less postoperative pain and more rapid return to normal activities, but it takes longer to perform and may increase the risk of rare, but serious, complications.
Dietary glycine decreases liver injury after haemorrhagic shock in rats
Authors: Mauriz J L , Matilla B , Culebras J M , González P , González-Gallego J
Published: March 2003

Background

Resuscitation from haemorrhagic shock induces profound changes in the physiological processes of the liver and activates inflammatory cascades that include activation of stress transcriptional factors and upregulation of tumour necrosis factor (TNF) synthesis. This process is accompanied by increased levels of free radicals that may contribute to acute organ damage. Intravenous administration of glycine, a simple amino acid, has been reported to decrease release of TNF and to improve the survival rate of rats after haemorrhagic shock or endotoxin administration. The effects of feeding a glycine-containing diet (5 per cent) on liver injury and on the oxidant–antioxidant balance in resuscitated haemorrhagic rats has been investigated.

Methods

Rats were bled to maintain mean arterial pressure at 30–35 mmHg for 1 h and subsequently resuscitated with 60 per cent shed blood and lactate Ringer's solution. Thiobarbituric acid reactive substances (TBARS) and the oxidized: reduced glutathione (GSSG: GSH) ratio were measured as markers of oxidative stresss. The activities of the antioxidant enzymes superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (Cat) were determined in liver cytosol.

Results

Levels of aspartate aminotransferase (ASAT) were increased 22-fold and levels of alanine aminotransferase (ALAT) eightfold 20 h after resuscitation. Leucocyte infiltration and pericentral necrosis were also observed. Serum nitrite concentration increased by 69 per cent. Liver TBARS increased by 32 per cent and the GSSG: GSH ratio by 106 per cent. There was a significant reduction in total liver glutathione concentration (−42 per cent) and in the activities of SOD (−23 per cent), GPx (−26 per cent) and Cat (−46 per cent). Serum nitrite, liver TBARS concentration and the antioxidant enzyme activities remained unchanged in animals receiving dietary glycine. The GSSG: GSH ratio and total glutathione concentration did not significantly differ from control values. The increase in serum ASAT and ALAT levels and in hepatic necrosis were markedly reduced.

Conclusion

Dietary glycine prevents liver injury caused by haemorrhagic shock in the rat. Diminished availability of nitric oxide and maintenance of the oxidant–antioxidant balance may reduce the pathophysiological sequelae of severe haemorrhage.
Procalcitonin plasma level as a marker of systemic infection in surgical patients in the intensive care unit
Authors: Giannopoulou P , Greka P , Voros D , Giamarellou H
Published: March 2003

Background

Increased (more than 0·5 ng ml−1) extrathyroidal production of procalcitonin (PCT; the prodromal molecule of calcitonin) has been proven to characterize cases of systemic bacterial infection. The aim of the present study was to investigate the possible role of PCT as an infection marker in 59 febrile surgical patients in the intensive care unit who were under several antimicrobial regimens.

Methods

PCT values were calculated every other day during the whole duration of the febrile period using the immunochemiluminescence method (Brahms Diagnostica, Berlin, Germany). A subgroup of ten patients (three with multiple trauma, seven with an intra-abdominal site of infection) were considered to have sepsis (SS) because of their positive blood cultures (two Gram positive, eight Gram negative). A total of 30 patients presented with the systemic inflammatory response syndrome (SIRS), which was considered to have a septic aetiology in nine (four with peritonitis, one with pancreatitis and four with multiple trauma) (white blood cell count greater than 25 000 μl−1, temperature above 39·5°C). Of the remaining patients, seven had an intra-abdominal abscess (IA) with various causes, six had acute non-complicated pancreatitis (AP) and six had localized burns (LB) (13·5–25 per cent of the total body surface).

Results

PCT values on the first day of fever (asymmetrical underlying distribution) are shown in the Table.

Conclusion

(1) Increased PCT levels are the hallmark of sepsis even from the first day of its appearance as opposed to cases of localized infection. (2) PCT levels are increased in cases of SIRS of infectious origin. (3) Low PCT levels (less than 1 ng ml−1) in patients with pancreatitis are indicative of an uncomplicated evolution. (4) Unexpectedly high PCT levels should be taken into consideration for the choice of optimal antimicrobial regimen.
Nitric oxide synthase-independent pathway(s) of nitric oxide formation after intestinal ischaemia–reperfusion
Authors: Bahrami S , Sobhian B , Kozlov A , Duvigneau C , Nohl H , Jafarmadar M , Redl H
Published: March 2003

Background

Recent evidence suggests that nitric oxide produced in the gastrointestinal tract, in concert with other vasoactive mediators, plays an essential role in the regulation of splanchnic circulation.

Methods

To determine the sites and pathways of nitric oxide formation, electron paramagnetic resonance spectroscopy and the nitric oxide trap diethyldithiocarbamate-Fe were used to detect directly nitric oxide formed in intestine, liver and lungs of rats subjected to local intestinal ischaemia–reperfusion (I/R), in the presence or absence of nitric oxide donors or inhibitors. In addition, the role of nitric oxide in control of the gastrointestinal circulation was determined by means of a coloured microsphere technique employing N-(G)-Monomethyl-L-arginine (L-NMMA) in rats subjected to haemorrhagic shock followed by resuscitation.

Results

In contrast to remote organs lung and liver (no change), intestinal I/R resulted in an increase in nitric oxide formation in intestinal tissues. Administration of the non-specific nitric oxide inhibitor L-NMMA caused a decrease in I/R-independent basal nitric oxide levels in lung and liver but did not influence the I/R-induced increase in nitric oxide formation in intestinal tissues. In support of this, reverse transcriptase–polymerase chain reaction analyses showed inducible nitric oxide synthase (NOS) expression in the lung but not in intestinal tissues. In the microsphere experiment, a moderate and therapeutic dose of L-NMMA administered after the completion of resuscitation, which improved haemodynamic conditions and outcome, did not alter the intestinal circulation.

Conclusion

The data suggest that the early-phase I/R-induced nitric oxide formation in ischaemic intestinal tissue is probably NOS independent, while nitric oxide formation in normoxic remote tissues is partially NOS dependent. In addition, the authors' nitric oxide-related therapeutic approaches reveal that only the regulation of nitric oxide (e.g. nitric oxide supplementation during resuscitation or reperfusion and/or nitric oxide inhibition or modulation after resuscitation) may protect against hypovolaemic insults.
Surveillance of infections acquired in intensive care units in the Netherlands
Authors: Mintjes-de Groot A J , Geubbels E L P E , van den Berg J M J , de Boer A S
Published: March 2003

Background

The aim was to develop and implement standardized surveillance of infections acquired in the intensive care unit (ICU) in the PREZIES network of hospitals in the Netherlands.

Methods

Surveillance was standardized by protocol and uniform software. Patients were included if they stayed in the ICU for 48 h or more. Data were aggregated at the national level and analysed univariately.

Results

Standardized surveillance of infections acquired in the ICU was introduced in 22 (5 per cent) of hospitals in the Netherlands. Data on 990 patients from ten hospitals (July 1997 to September 1998) were available for analysis. Median length of stay was 6 days. The median Acute Physiology and Chronic Health Evaluation score was 18 and the median age 64 years. In total 256 patients became infected. Per 1000 patient days, 16·1 pneumonias, 3·7 cases of central vascular catheter-related sepsis and 11·1 urinary tract infections were found. Per 1000 patient days, patients were ventilated for 708 days, had a urinary catheter for 950 days and a central vascular catheter for 746 days. Selective contamination of the gastrointestinal tract was employed in 6 per cent and systemic antibiotics in 68 per cent of patients.

Conclusion

It is possible to conduct standardized surveillance of ICU-acquired infections. The data provide insight into the incidence of nosocomial infections in ICU patients in the Netherlands and can be used as reference values for participating hospitals.
Dutch reference data on the incidence of surgical site infection
Authors: Geubbels E , Mintjes J , van den Berg J M , de Boer A
Published: March 2003

Background

The PREZIES national surveillance network supports Dutch hospitals in introducing surveillance of surgical site infection (SSI), generates reference data on the incidence of SSI and associated risk factors, and provides an infrastructure for interventional research. Its ultimate goal is to reduce the occurrence of SSI. The aim was to discuss the methods and results of the national SSI surveillance.

Methods

The participating institutions developed a surveillance protocol and an agreement on participation and privacy aspects. For each patient under surveillance, infection control practitioners collected data on the type of procedure, the occurrence of a superficial and/or deep SSI, and on several risk factors, i.e. age, American Society of Anesthesiologists score, wound contamination class, duration of surgery, preoperative length of stay, use of antibiotic prophylaxis, multiple surgery and elective/emergency surgery. Hospitals received standardized feedback reports comparing their own SSI rates with the national reference. Validation and use of surveillance data were studied within subsets of hospitals.

Results

Since June 1996, 70 of 114 hospitals of all types and sizes participated. The Table shows the number of operations, the incidence of all SSIs, the use of prophylactic antibiotics and the number of participating hospitals for five commonly recorded procedures.

Of 38 hospitals studied, 19 used surveillance results in education, 22 in policy and decision making, and 16 in initiating interventions. Five reported a reduction in SSI incidence. A prevalence survey of SSI showed high agreement (κ = 0·88) with the validating team.

Conclusion

The PREZIES network provides hospitals with good quality national reference data that are used to support their policy for prevention of SSI.
New approach in flow-cytometric determination of endotoxin during endotoxic shock
Authors: Staubach K-H , Nolde J , Brade H , Woltmann A , Bruch H-P
Published: March 2003

Background

Serum endotoxin was formerly measured with the non-specific Limulus lysate assay. The present approach was to quantitate the amount of endotoxin bound by peripheral mononuclear cells in order to develop a method for the diagnosis of early septic shock.

Methods

Using a murine monoclonal antibody (WN1-222/5), which binds highly specifically to lipopolysaccharide (LPS), a new method for measuring the amount of LPS bound to peripheral mononuclear cells was developed. Ten pigs were studied under sedation and peripheral mononuclear cells were taken every 4 h to determine the concentration of endotoxin by flow cytometry. The results are shown in the Table.

Results

The percentage of marked mononuclear cells increased during shock. Only in the last hours before death did the rate of increase decline.

Conclusion

Preliminary data on marked mononuclear cells showed that the amount of natural incorporated endotoxin, i.e. the quantity of bound endotoxin before infusion, was 32 per cent.
Endothelins and carbon monoxide interact to regulate rat liver microcirculation after haemorrhagic shock
Authors: Rensing H , Bauer I , Pannen B H J , Paxian M , Bauer M
Published: March 2003

Background

Upregulation of stress-induced vascular mediators such as endothelin (ET) 1, nitric oxide synthase (NOS)–nitric oxide or the haem oxygenase (HO)–carbon monoxide pathway may contribute to altered microvascular responsiveness after ischaemia and reperfusion. A profound induction of HO-1 and an increase in portal resistance after blockade of the HO pathway has been shown to occur after haemorrhagic shock and resuscitation (H/R). This study investigated whether the observed increased portal resistance after blockade of the HO pathway was mediated by a concomitant upregulation of ET-l.

Methods

Sprague–Dawley rats (n = 10 per group) were subjected to H/R (mean arterial pressure 40 mmHg for l h, followed by 5 h of resuscitation). Expression of HO-1, inducible NOS (iNOS) and ET-1 was studied by standard Northern blot analysis and reverse transcriptase–polymerase chain reaction. At 6 h either the ET antagonist bosentan 10 mg kg−1 or vehicle was injected. After 10 min the HO pathway was blocked in all animals by tin protoporphyrin (SnPP) IX 50 μmol kg−1. Subsequently portal flow and portal pressure or sinusoidal liver blood flow (assessed by intravital epifluorescence microscopy) were measured for 30 min.

Results

A profound induction in ET-1 paralleled induced HO-1 messenger RNA (mRNA) gene expression after H/R (ET-1, mean(s.d.) 9·0(1·1)-fold; HO-1, 5·9(0·3)-fold induction at 6 h); iNOS mRNA was below the detection limit. Blockade of the HO pathway led to a significant peak increase in the portal vein resistance (ΔPVR; P < 0·05). There was a trend to a lower peak increase after administration of bosentan (P = 0·07) (ΔPVR: sham SnPP-IX, 0·17(0·05) mmHg min mF−1; shock vehicle SnPP-IX, 0·57(0·15) mmHg min mF−1; shock bosentan SnPP-IX, 0·29(0·05) mmHg min mF−1). Regarding liver microcirculation, pretreatment with bosentan significantly attenuated the observed decrease in perfused sinusoids (PS) and in perfusion index (PI) after blockade of the HO pathway (shock vehicle SnPP-IX: PS 23·1(1·1) mm−1, PI 1000(134) μm3 s−1 mm−1; shock bosentan SnPP-IX: PS 28·8(1·8) mm−1, PI 1483(159) μm3 s−1 mm−1; P < 0·05).

Conclusion

These results suggest a functional interaction of the unregulated vasodilator carbon monoxide and the vasoconstrictor ET-1 at the sinusoidal level in rat liver after H/R.