bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of volume of work on the outcome of treatment for patients with colorectal cancer
Authors: Parry J M , Collins S , Mathers J , Scott N A , Woodman C B J
Published: March 2003

Background

Recent recommendations for the reorganization of cancer services emphasize the importance of a ‘minimal acceptable volume of work’. The influence of both hospital and surgical workload has been examined using a population-based series of patients with colorectal cancer.

Methods

Nine hundred and twenty-seven patients with primary colorectal cancer diagnosed during the period 1 January to 30 June 1993 were identified from the North Western Regional Cancer Registry. Case notes were reviewed for information on patient age and sex, histological diagnosis, disease stage, degree of tumour differentiation, mode of admission, identity of operating surgeon, timing of operative procedure, and use of radiotherapy and/or chemotherapy. A multivariate Cox proportional hazards model was then constructed to examine, simultaneously, the effects of patient-, disease- and health service-related variables on survival.

Results

Age, tumour stage and differentiation, and mode of admission were revealed as significant independent prognostic variables. After adjusting for these variables, neither operator grade (consultant versus junior), consultant workload nor hospital throughput were identified as independently influencing patient survival.

Conclusion

The results of this study do not support an association between volume of work and patient outcome.
Chronic groin sepsis following tension-free inguinal hernioplasty
Authors: Taylor S G , O'Dwyer P J
Published: March 2003

Background

Chronic groin sepsis requiring mesh removal is said to be a rare complication of tension-free inguinal hernioplasty. The aim of this study was to determine the number of surgeons performing tension-free inguinal hernioplasty in the West of Scotland and assess the frequency with which chronic groin sepsis was encountered.

Methods

A questionnaire was sent to all consultant surgeons performing inguinal hernia repair in the region and follow-up of patients with chronic groin sepsis following tension-free inguinal hernioplasty was undertaken.

Results

Of 80 consultants who replied to the questionnaire, 79 were performing tension-free hernioplasty. Of these, 76 were performing only open repairs while three were also undertaking laparoscopic repairs. Sixteen consultants reported 20 patients with groin sepsis after mesh repair. Twelve patients were traced; eight had chronic sinuses and four had groin abscesses. The median interval between repair and presentation was 4 months (range from 2 weeks to 39 months). All have required complete (11 patients) or partial (one) removal of mesh to resolve the symptoms.

Conclusion

Tension-free inguinal hernioplasty has become the operation of choice for surgeons in the region. Chronic groin sepsis may be more frequent than reported previously. Complete removal of mesh is required to treat this condition.
Comparison of radioguided excision with wire localization of occult breast lesions
Authors: Luini A , Zurrida S , Paganelli G , Galimberti V , Sacchini V , Monti S , Veronesi P , Viale G , Veronesi U
Published: March 2003

Background

Clinically occult breast lesions are found with increasing frequency as a result of the widespread use of mammographic screening.

Methods

This study reports a new localization technique in which a small quantity of 99mTc-labelled colloidal albumin is inoculated directly into the lesion under stereotactic–radiographic or ultrasonographic guidance. Correct positioning of the inoculum is checked by scintigraphy. A γ ray detection probe is then used to locate the lesion and guide its surgical removal. The results of this method in 30 patients were compared with those obtained using the established hook wire method in another 30 patients.

Results

In the wire localization group, the mean(s.d.) distance from the lesion centre to the specimen margin was 24·5(0·4) (range 15–45) mm. For the radioguided group the figures were 13·8(0·3) (range 5–25) mm. The mean(s.d.) lesion concentricity (difference between the maximum and minimum distance from the lesion border to specimen margin) was 6·2(0·4) (range 2–15) mm in the wire localization group and 3·8(0·2) (range 1–10) mm in the radioguided group.

Conclusion

Use of a γ probe allowed rapid, easy and accurate removal of occult breast lesions. In comparison to the hook wire method, radioguided removal allows reduced excision volume and better lesion centring within the specimen.
Treatment of gallbladder cancer by radical resection
Authors: Todoroki T , Kawamoto T , Takahashi H , Takada Y , Koike N , Otsuka M , Fukao K
Published: March 2003

Background

The use of radical resection for gallbladder cancer is controversial. This study evaluated results of resection for gallbladder cancer and analysed prognostic factors.

Methods

A retrospective review of 135 patients who underwent surgical resection for gallbladder cancer between 1976 and 1998 was performed. Of these, 123 patients underwent radical resection and the remaining 12 had palliative resection. The resections included 32 hepatopancreatoduodenectomies and 57 with adjuvant radiotherapy. Twelve prognostic factors were analysed. A subset of 96 patients with stage IV disease was analysed separately with respect to residual tumour level and adjuvant radiotherapy.

Results

Surgical resection was associated with a 5-year survival rate of 36 per cent, with a mean follow-up time of 870 days. Twenty-two patients have survived more than 5 years including three with stage IV disease. Overall operative morbidity and mortality rates were 13 and 4 per cent respectively. The 5-year survival rate decreased with disease stage: 100, 78, 69 and 11 per cent for stages I (n = 13), II (n = 19), III (n = 7) and IV (n = 96) respectively. Performance status, jaundice, histopathological type and grade, primary tumour, lymph node, distant metastasis, stage grouping, residual tumour level and adjuvant radiotherapy were significant prognostic factors.

Conclusion

With careful patient selection, radical resection for gallbladder cancer improves the prognosis with acceptable operative mortality and morbidity rates, even for stage IV disease, provided that complete gross tumour resection is combined with radiotherapy.
Contribution of diet, tumour volume and patient-related factors to weight loss in patients with colorectal liver metastases
Authors: Fordy C , Glover C , Henderson D C , Summerbell C , Wharton R , Allen-Mersh T G
Published: March 2003

Background

One of the difficulties in assessing the contribution of tumour-related factors to cancer cachexia is measurement of the extent of disease where dissemination to multiple organ sites has occurred.

Methods

In this study the extent of tumour (both tumour volume and increase in marker levels), diet and patient-related factors (appetite, metabolic hormones, immune activation, liver function and quality of life) were compared in patients with colorectal liver metastases who had lost at least 1 kg in body-weight (weight loss) and patients who had not lost 1 kg in body weight (stable weight) during the preceding month.

Results

Forty patients (22 men; 14 with weight loss) were studied. Liver metastasis volume was significantly greater in patients who lost weight than in those whose weight was stable (median (interquartile range) 1179 (245–1517) versus 119 (23–523) ml; P = 0·003). The prevalence of patients with raised levels of serum immune products was significantly greater in the weight loss group for soluble interleukin (IL) 2 receptor α (sIL2rα) (P = 0·03) and IL-6 (P = 0·05), but not for soluble tumour necrosis factor receptor 1 (sTNFr1) or neopterin. There were significant correlations between serum C-reactive protein and sIL2rα (rs = 0·68, P < 0·0001) and IL-6 (rs = 0·46, P = 0·008) but not sTNFr1 or neopterin levels. Significant differences in appetite, nausea, diet, energy intake, liver function tests and serum levels of metabolic hormones were not detected.

Conclusion

Weight loss in patients with colorectal liver metastases was not explained by changes in diet, quality of life, or hormones, but activation of the innate and incomplete activation of the acquired immune systems may be involved. Agents that attenuate either the acute-phase inflammatory response or T lymphocyte IL-2 receptor upregulation might reduce weight loss in patients with metastatic disease.
Experimental study of the effect of intraportal prostaglandin E1 on hepatic blood flow during reperfusion after ischaemia and hepatectomy
Authors: Hossain M A , Hamamoto I , Wakabayashi H , Goda F , Kobayashi S , Maeba T , Maeta H
Published: March 2003

Background

Prostaglandin E1 (PGE1) has protective effects experimentally and clinically in individual models of hepatic ischaemia–reperfusion injury and of partial hepatectomy. The present study investigated the effects of intraportal administration of PGE1 on hepatic blood flow, systemic arterial pressure and long-term animal survival after 60 min of total liver ischaemia followed by 70 per cent partial hepatectomy in rats.

Methods

Total liver ischaemia was induced by occluding the hepatoduodenal ligament for 60 min. PGE1 0·5 µg per kg per min was infused intraportally for 15 min before inducing ischaemia and for 120 min after ischaemia in the treatment group. Normal saline was infused in the control group. During ischaemia 70 per cent partial hepatectomy was performed. Portal venous flow (PVF), peripheral tissue blood flow (PTBF) and hepatic artery flow were measured before and after ischaemia. Serum biochemical analysis was carried out at 1, 3 and 24 h, and 7 and 14 days; and liver histology at 1 and 24 h, and 7 days after reperfusion. Survival was followed for 1 year.

Results

Intraportal infusion of PGE1 significantly improved PVF and PTBF without affecting the systemic arterial pressure. Long-term survival was significantly higher in the PGE1 group. Serum aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase levels decreased significantly, and 2-h bile flow was significantly improved, in the PGE1 group. Histological examination revealed significant portal venous congestion, sinusoidal congestion, fatty degeneration and tissue necrosis 24 h and 7 days after reperfusion in the control group.

Conclusion

PGE1 has a protective effect against liver damage when the liver is injured by warm ischaemia and reperfusion followed by partial resection.
Endoleak after stent-graft treatment of abdominal aortic aneurysm: a meta-analysis of clinical studies
Authors: Schurink G W H , Aarts N J M , van Bockel J H
Published: March 2003

Background

Endoleak is the major complication after endovascular treatment of abdominal aortic aneurysm (AAA) and its incidence seems to remain significant. Little is known about the association of device type and configuration with respect to the incidence, location, time of onset and fate of endoleakage.

Methods

A meta-analysis was performed via a Medline search of clinical studies after 1995 dealing with the endovascular treatment of AAA. Details of number of patients treated, configuration and type of endovascular device were collected. Data concerning site of origin, time of occurrence and fate of the endoleak were retrieved, along with information on change in diameter of the aneurysm with time.

Results

The 23 publications included reported on 1189 patients. The 1118 patients with successfully inserted transfemoral endovascular grafts experienced 270 endoleaks (24 per cent). The majority arose from the distal stent attachment site (36 per cent), were present immediately after stent-graft placement (66 per cent) and were persistent in time (37 per cent). Tube grafts were more frequently affected by endoleakage (35 per cent; P < 0·0001), especially at the distal stent attachment site (51 per cent), than bifurcated grafts (18 per cent; P = 0·004) and aortounilateral devices (20 per cent; P = 0·70). Self- expandable stent-grafts were more frequently associated with endoleaks (25 per cent) than balloon-expandable stent-grafts (17 per cent) (P = 0·037).

Conclusion

Endovascular treatment of AAA is an evolving field. Even after the initial learning curve and attention to device-related problems, it is still accompanied by a significant number of endoleaks. Uniform presentation of results of treatment is necessary for analysing the effect of differences between patients, aneurysm morphology and device type.
Periampullary diverticula and pancreaticobiliary disease
Authors: Lobo D N , Balfour T W , Iftikhar S Y , Rowlands B J
Published: March 2003

Background

Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2–3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients.

Methods

The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed.

Results

The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with β-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres.

Conclusion

With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.
Endogenous renal nitric oxide metabolism following experimental infrarenal aortic cross-clamp-induced ischaemia–reperfusion injury
Authors: Pararajasingam R , Weight S C , Bell P R F , Nicholson M L , Sayers R D
Published: March 2003

Background

Abdominal aortic surgery is associated with marked changes in renal haemodynamics. The aim of this study was to investigate the influence of infrarenal cross-clamping on glomerular filtration rate and endogenous renal nitric oxide metabolism.

Methods

Groups of male Wistar rats were subjected to infrarenal aortic cross-clamping followed by reperfusion. Animals were allowed to recover after a left nephrectomy. The glomerular filtration rate of the remaining kidney was measured on the second and seventh day after the procedure before the animal was killed and the remaining kidney harvested. Total nitric oxide synthase (NOS) activity and expression of inducible NOS (iNOS) was determined in renal tissue following 1 h and 7 days of reperfusion.

Results

Glomerular filtration rate was impaired on the second and seventh day after operation in all animals subjected to lower torso ischaemia compared with controls (P < 0·05). Renal NOS activity was increased at 1 h and 7 days in animals subjected to infrarenal cross-clamping compared to controls (P < 0·01). iNOS was detected in renal tissue of animals subjected to infrarenal aortic cross-clamping on the seventh day after operation.

Conclusion

Infrarenal aortic cross-clamping is associated with impairment of renal function in the early postoperative period. There is an increase in endogenous renal nitric oxide metabolism with iNOS expression.
Human pancreatic carcinoma cells are sensitive to photodynamic therapy in vitro and in vivo
Authors: Hajri A , Coffy S , Vallat F , Evrard S , Marescaux J , Aprahamian M
Published: March 2003

Background

The aim of this study was to assess the efficiency of photodynamic therapy (PDT) on human pancreatic cancer cells in vitro and in an animal model.

Methods

Human pancreatic tumour cell lines were submitted to PDT with pheophorbide a (Ph a) a chlorophyll derivative, in culture and after grafting into athymic mice. Ph a was tested in culture (10−10−10–5 mol/l) with a 5-J/cm2 energy treatment and on tumour-bearing Nude mice (30 mg/kg intraperitoneally) with a 100-J/cm2 PDT session. The effect of PDT was assessed in vitro using proliferative, apoptotic and clonogenic tests and in vivo on tumour growth and on the induction of tumour necrosis.

Results

PDT inhibited tumour cell growth in culture by affecting DNA integrity. This tumour cell photodamage started at low concentration (10−7 mol/l) as corroborated by clonogenic and tumour growth tests. A strong necrosis was achieved in vivo with a single PDT session.

Conclusion

PDT destroyed human pancreatic carcinoma after low photosensitizer supply and weak energy application. It exerted this tumoricidal effect via apoptosis induction with a gentle protocol, and apoptosis and/or necrosis with a stronger protocol.
Role of tissue factor expression on tumour cell invasion and growth of experimental pancreatic adenocarcinoma
Authors: Kakkar A K , Chinswangwatanakul V , Lemoine N R , Tebbutt S , Williamson R C N
Published: March 2003

Background

Tissue factor (TF), the physiological procoagulant, is expressed in pancreatic tissue as a result of malignant transformation. The aim of this investigation was to assess its role in pancreatic tumour cell invasion and primary tumour growth.

Methods

The full-length TF gene (1360 base pairs) was cloned into the plasmid DNA vector pcDNA3 in sense and antisense orientations, and these vectors were used to transfect the MIA PaCa-2 human pancreatic adenocarcinoma cell line. TF gene expression was characterized by Northern blot analysis, total cellular antigenic content by enzyme-linked immunosorbent assay and cell surface procoagulant activity by enzymatic assay. Invasion of tumour cells in vitro was determined by a standard Matrigel assay, and primary tumour growth was measured in immunodeficient mice.

Results

Overexpression of the TF gene, confirmed by an increased signal on Northern blotting, was associated with increases in both total antigenic content for TF (P = 0·001) and cell surface procoagulant activity (P = 0·008) in sense cells compared with wild-type cells. Likewise, both in vitro tumour cell invasion (P = 0·001) and primary tumour growth (P = 0·007) were increased in sense transfectants.

Conclusion

Expression of TF enhances in vitro invasion and primary tumour growth of MIA PaCa-2 cells, suggesting that this procoagulant molecule might have a role in pancreatic tumour biology.
During liver regeneration following right portal embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma
Authors: Elias D , de Baere T , Roche A , Ducreux M , Leclere J , Lasser P
Published: March 2003

Background

The relative growth rates of human liver metastases are not known. The aim of this study was to determine in humans the growth rate of liver parenchyma during regeneration and the growth rate of liver metastases during the same process.

Methods

Among 556 patients hepatectomized for a malignant lesion, 48 underwent preoperative selective right portal vein embolization to induce hypertrophy of the left lobe. Five cases were selected because a liver metastasis was present inside the regenerating left lobe. The volumes of the liver metastasis and left lobe were measured with a three-dimensional technique on pre-embolization and postembolization computed tomography (CT) or CT arterial portography. The median interval between the two measurements was 34 (range 28–40) days.

Results

An increase occurred in the volume of the liver metastasis and the left lobe in the four patients with functionally intact liver parenchyma, but not in the patient with an impaired parenchyma. The volumetric increase of the normal liver varied from 59 to 127 per cent, compared with 60 to 970 per cent for the liver metastases. The ratio between the growth rate of the left lobe and the liver metastasis varied from 1·0 to 15·6. The growth rates of two metastases in the left lobe of a single patient were different.

Conclusion

In functionally intact liver parenchyma, during hepatic regeneration or hypertrophy, the growth rate of metastases is more rapid that that of the liver parenchyma. However, a wide variation in growth rate is observed between patients and between metastases.
Modern management of pulmonary embolism
Authors: Tai N R M , Atwal A S , Hamilton G
Published: March 2003

Background

Pulmonary embolism is a significant cause of morbidity and death after operation. The introduction of new technologies in the diagnosis, and thrombolysis in the treatment, of pulmonary embolism has led to a need to reappraise the management of this condition.

Methods

This review encompasses a comprehensive discussion of diagnostic modalities and therapeutic strategies used in the current management of pulmonary embolism. Relevant papers on the diagnosis and treatment of pulmonary embolism were identified from a Medline search for the period 1967–1998. Additional papers were derived from the reference lists of retrieved articles. Articles presenting prospectively gathered data have been referenced preferentially.

Results and conclusion

Algorithms for the diagnosis and treatment of pulmonary embolism are presented.
Adjuvant regional chemotherapy after hepatic resection for colorectal metastases
Authors: Ambiru S , Miyazaki M , Ito H , Nakagawa K , Shimizu H , Nakajima N
Published: March 2003

Background

This study explored the possibility of achieving a better survival rate and reduced recurrence in the remaining liver in patients with colorectal hepatic metastases undergoing hepatic resection. Adjuvant postoperative regional chemotherapy was administered via the hepatic artery or the portal vein.

Methods

A retrospective study was performed on 174 patients after hepatic resection for colorectal metastases. These comprised 78 patients who had hepatic artery infusion (HAI) chemotherapy (HAI group), 30 who had portal vein infusion (PVI) chemotherapy (PVI group) and 66 who had no regional chemotherapy (resection alone group). The three groups were compared with one another in terms of complications, survival rate and patterns of recurrence.

Results

Severe complications did not occur at any point during adjuvant HAI or PVI chemotherapy. The 5-year disease-free survival rate of patients in the HAI, PVI and resection alone groups were 35, 13 and 9 per cent respectively, including six hospital deaths. Patients in the HAI group showed significantly improved recurrence rates in the remaining liver compared with the resection alone group (P = 0·03), and more prolonged disease-free and overall survival than those in the PVI (P = 0·01 and P = 0·02 respectively) and resection alone (P = 0·0001 and P = 0·0006 respectively) groups.

Conclusion

This study suggests that adjuvant HAI chemotherapy after hepatic resection may have therapeutic potential for improved management of patients with colorectal metastases.
Mortality from ruptured abdominal aortic aneurysm in Wales
Authors: Basnyat P S , Biffin A H B , Moseley L G , Hedges A R , Lewis M H
Published: March 2003

Background

The aim of this study was to identify the incidence of, and mortality in, patients with a ruptured abdominal aortic aneurysm (AAA) reaching hospital alive in Wales.

Methods

Patients who presented with a ruptured AAA between September 1996 and August 1997 were analysed. Data were collected prospectively by an independent body, observing strict confidentiality.

Results

Some 233 patients with a confirmed ruptured AAA were identified, giving an incidence of eight per 100 000 total population. Some 133 patients (57 per cent) underwent attempted operative repair; 85 (64 per cent) of these died within 30 days. Of the 233 patients, 92 were admitted under the care of a vascular surgeon and 141 under a non-vascular surgeon. Vascular surgeons operated on 82 patients (89 per cent), of whom 50 (61 per cent) died, whereas non-vascular surgeons operated on 51 patients (36 per cent), of whom 35 (69 per cent) died.

Discussion

This study is unique as it is an independent prospective study of mortality in patients with a ruptured AAA who reached hospital alive. Mortality was independent of the operating surgeon, but vascular surgeons turned down significantly fewer patients than non-vascular surgeons (11 versus 64 per cent, P < 0·001).
Use of colour duplex imaging to diagnose and guide angioplasty of lower limb arterial lesions
Authors: London N J M , Nydahl S , Hartshorne T , Fishwick G
Published: March 2003

Background

The purpose of this study was to investigate whether colour duplex imaging alone could safely and effectively be used to diagnose lower limb arterial lesions and guide subsequent percutaneous transluminal angioplasty (PTA).

Methods

Patients with discrete lower limb arterial lesions, preferably stenoses, which could be visualized clearly by colour duplex imaging were selected for duplex-guided PTA. Duplex-guided PTA was performed in an operating theatre using conventional balloon catheters.

Results

Duplex imaging was used to diagnose and guide PTA of 55 arterial lesions in 50 legs of 45 patients. There were 53 stenoses and two occlusions. The median (range) ankle: brachial pressure index was 0·86 (0·52–1·10) before dilatation and 1·00 (0·83–1·40) immediately after dilatation (P = 0·0001). There were no complications during or after any of the procedures and 46 of the 47 symptomatic legs were markedly improved at a median follow-up of 23 days. Radiographic imaging was not required for any of the procedures.

Conclusion

It is possible to diagnose and angioplasty lower limb arterial lesions using colour duplex imaging alone.
Prognostic significance of anatomical resection and des-γ-carboxy prothrombin in patients with hepatocellular carcinoma
Authors: Imamura H , Matsuyama Y , Miyagawa Y , Ishida K , Shimada R , Miyagawa S , Makuuchi M , Kawasaki S
Published: March 2003

Background

Portal venous tumour extension and intrahepatic metastasis result in a poor prognosis following hepatectomy for hepatocellular carcinoma (HCC). Anatomical resection is, in theory, preferable for eradicating these types of invasion. Des-γ-carboxy prothrombin (DCP) has been reported to be associated with adverse pathological variables. This study investigated the significance of anatomical resection and DCP as predictive factors for postoperative recurrence of HCC.

Methods

A retrospective cohort study was carried out in 138 consecutive patients who underwent hepatectomy for HCC smaller than 5 cm using the Cox proportional hazards model.

Results

Eight factors were univariately related to poor prognosis (in decreasing order of hazard ratio): intrahepatic metastasis, multiple tumours, α-fetoprotein 32 ng/ml or more; DCP greater than 0·1 arbitrary units (AU), tumour-exposed surgical margin, vascular invasion, non-anatomical resection and tumour 2·5 cm or more. Three variables (DCP, vascular invasion and tumour-exposed surgical margin) were excluded by a stepwise procedure in multivariate analysis. Although DCP was not an independent prognostic factor, a model replacing intrahepatic metastasis with DCP showed similar predictive accuracy in a receiver-operating characteristic curve.

Conclusion

Anatomical resection appeared to have a beneficial effect on recurrence-free survival after hepatectomy for HCC. DCP measurement was effective in predicting HCC recurrence and had the advantage that it can be assessed before operation.
Experimental study of liver dysfunction evaluated by direct indocyanine green clearance using near infrared spectroscopy
Authors: El-Desoky A , Seifalian A M , Cope M , Delpy D T , Davidson B R
Published: March 2003

Background

Blood clearance of indocyanine green (ICG) is an objective test of liver function. Hepatic ICG clearance can now be measured directly using near infrared spectroscopy (NIRS). The aim of this study was to evaluate measurement of hepatic ICG clearance by NIRS in an animal model of acute hepatic dysfunction.

Methods

New Zealand white rabbits (n = 36) underwent laparotomy for liver exposure. Hepatic blood flow and microcirculation were measured along with hepatic ICG concentration by NIRS. Hepatic ICG clearance was measured in groups of six animals after reduction of the hepatic blood flow by hepatic artery occlusion and portal vein partial occlusion, lobar ischaemia and reperfusion (I/R), colchicine administration and bile duct ligation. Hepatic ICG uptake and excretion rates were calculated by a non-linear least square curve fitting method from the ICG concentration–time curve.

Results

There was a significant positive correlation between hepatic ICG rate of uptake and both hepatic blood flow and microcirculation (r = 0·79, P = 0·0001; r = 0·59, P = 0·005 respectively). I/R resulted in a significant reduction of both the rates of ICG uptake (mean(s.d.) 0·85(0·59) min−1; P = 0·0002 versus control) and ICG excretion (0·020(0·006) min−1; P = 0·02 versus control). Colchicine decreased the rate of hepatic ICG excretion (0·030(0·010) min−1; P = 0·02 versus control) as did bile duct ligation (0·002(0·001) min−1; P = 0·01 versus control).

Conclusion

Measurement of hepatic ICG clearance by NIRS is a promising technique for assessing hepatic parenchymal dysfunction and may have application in liver surgery and transplantation.
Factors affecting late survival after elective abdominal aortic aneurysm repair
Authors: Yasuhara H , Ishiguro T , Muto T
Published: March 2003

Background

The late prognosis after repair of an abdominal aortic aneurysm (AAA) may be affected by atherosclerosis, which involves various organs including the aorta.

Methods

The influence of organ dysfunction and atherosclerosis on the long-term survival of 338 consecutive patients undergoing successful elective AAA repair between 1980 and 1997 was analysed using Cox hazards model. Survival rate was compared with that of 349 patients undergoing successful revascularization for aortoiliac occlusive disease (AIOD) during the same interval.

Results

Renal dysfunction and a previous history of cerebrovascular events were important variables predicting late death (risk ratio 1·980 and 1·903 respectively), while a history of cardiac disease predicted only cardiac-related death. The survival rate in patients with normal renal function was significantly better than that in those with renal dysfunction (P = 0·0371). Similarly, the survival rate was significantly better in patients without a history of previous cerebrovascular events (P = 0·0414). The survival rate after AAA repair was nearly identical to that of age- and sex-matched patients with grade II or III symptoms who had surgery for AIOD.

Conclusion

Advanced atherosclerosis with underlying organ dysfunction is a true determinant of long-term survival following elective repair of AAA.
Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children
Authors: Shankar K R , Lloyd D A , Kitteringham L , Carty H M L
Published: March 2003

Background

The use of oral contrast in evaluating children by computed tomography (CT) following blunt trauma is controversial. The aim of this study was to evaluate retrospectively the use of oral contrast with abdominal CT in children with suspected abdominal injury.

Methods

The medical records of 101 children who underwent CT for abdominal trauma between 1993 and 1997 were reviewed for data pertaining to the mechanism of injury, clinical findings and management. Scans were reviewed by a paediatric radiologist and criteria of intestinal injury on CT described by Cox and Kuhn were used: (1) extraluminal air or contrast material, (2) focal area of thickening of bowel wall and mesentery, and (3) free intraperitoneal fluid in the absence of solid organ injury.

Results

CT was performed within a median time of 2·4 (range 1–48) h after the injury. On 37 (62 per cent) of 60 scans in children who had oral contrast, the duodenum was not opacified after a mean delay of 30 min. Intestinal injury was suspected on CT in four children. In two children with CT evidence of intestinal injury (with/without oral contrast) rupture of the duodenojejunal flexure (n = 1) or ileal perforation (n = 1) was found at laparotomy. Two children had a false-positive scan, leading to negative laparotomy; one scan with oral contrast incorrectly suggested a duodenal leak and in another child CT without oral contrast showed thickening of bowel wall with free intraperitoneal fluid but no specific intestinal injury was identified at laparotomy. One patient had two negative CT scans (with and without oral contrast) and underwent laparotomy for clinical suspicion of bowel injury; rupture of the splenic flexure of the colon was found at laparotomy.

Conclusion

CT is not reliable for diagnosing intestinal injuries and this is not improved by use of oral contrast. Omission of oral contrast was not associated with delay in the diagnosis of intestinal injury. Since intestinal injuries are uncommon in children, a prospective multicentre study would determine more precisely the role of the routine use of oral contrast.
Abnormal neurophysiology in patients with oesophageal motility disorders
Authors: Rate A J , Hobson A R , Barlow J , Bancewicz J
Published: March 2003

Background

The pathology of oesophageal motility disorders is poorly understood. Oesophageal manometry provides only a descriptive assessment of luminal pressure changes. This study applied the investigative methods of the neurophysiologist to gain insight into the pathophysiology of these disorders.

Methods

Twelve healthy volunteers and 28 patients with oesophageal motility disorders underwent oesophageal manometry and balloon stimulation studies. Cortical evoked potentials (CEPs) in response to electrical stimulation of the oesophagus and oesophageal motor evoked potentials (MEPs) to transcranial magnetic stimulation of the cerebral cortex were recorded.

Results

Only two patients had abnormalities with a primary defect in muscle function. Fifteen had abnormal responses to balloon stimulation with normal CEPs and MEPs, suggesting a defect in the intrinsic nerves of the oesophagus. Five with achalasia did not respond to balloon stimulation and had abnormal CEPs and MEPs, suggesting widespread neural defects. The remainder had a variety of abnormal responses suggesting possible defects in receptor sensitivity, central processing or sensory neuropathy. There was no correlation between the manometric diagnosis and abnormal neuro-physiology, except in patients with achalasia.

Conclusion

Neurophysiological testing suggests that oesophageal motility disorders are most com-monly due to a variety of neural defects.
Assessment of lower extremity venous function using foot venous pressure measurement
Authors: Fukuoka M , Okada M , Sugimoto T
Published: March 2003

Background

Measurement of foot venous pressure (FVP) is useful for evaluating chronic venous insufficiency (CVI) functionally, because CVI always causes venous hypertension. In the present study, the various FVP parameters were analysed according to the new classification of venous disorders based on clinical, aetiological, anatomical and pathophysiological data (the CEAP classification).

Methods

During the past 7 years, a total of 257 legs in 196 consecutive patients with CVI have been studied. The following FVP parameters were assessed: the percentage decrease in pressure from rest with manual calf compression, the rate of increase of pressure during 4 s after compression (4SR) and the time to 50 per cent recovery of pressure (RT50) after release of compression.

Results

The incidence of skin changes due to venous stasis increased as the percentage pressure drop and RT50 fell. In addition, a pressure drop of less than 72 per cent and an RT50 of less than 20 s could detect legs with skin changes with a sensitivity of 76 per cent and a specificity of 62 per cent. In legs with primary varicose veins, pressure drop, 4SR and RT50 values deteriorated in proportion to the severity of the associated deep venous reflux.

Conclusion

FVP parameters correlate well with the severity of clinical manifestations and venous reflux, and could be used quantitatively to evaluate the severity of CVI.
Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection
Authors: Neudecker J , Schwenk W , Junghans T , Pietsch S , Böhm B , Müller J M
Published: March 2003

Background

The aim of the study was to evaluate whether perioperative epidural analgesia had any effect on the duration of postoperative ileus after laparoscopic sigmoid resection.

Methods

Twenty patients were randomized to surgery either with (group 1; n = 10) or without (group 2; n = 10) thoracic epidural analgesia. The major endpoint of the study was the time to the first postoperative bowel movement. Secondary endpoints were the interval until oral feeding was tolerated, incidence of postoperative vomiting, postoperative analgesic consumption use of patient-controlled analgesia (PCA) until the fourth day after operation, subjective pain perception and the incidence of epidural-related side-effects.

Results

Age, sex and American Society of Anesthesiologists classification were similar in the two groups. The first bowel movement was documented after a median of 54 (95 per cent confidence interval 32–127) h in group 1 and 77 (31–99) h in group 2 (P = 0·8). Oral feeding without additional parenteral therapy was tolerated after 48 (40–64) h in group 1 and after 56 (48–64) h in group 2 (P = 0·6). Postoperative vomiting occurred in two patients from each group. During epidural therapy the use of PCA was lower in group 1 (0·30 (0·19–0·96) mg morphine per kg) than in group 2 (0·56 (0·37–0·80) mg/kg) (P < 0·05). Postoperative pain perception during rest and while coughing was similar in both groups. Three patients experienced reversible side-effects of epidural therapy (motor deficit, two patients; bladder dysfunction, one).

Conclusion

Perioperative thoracic epidural analgesia did not have a clinically relevant effect on the duration of postoperative ileus after laparoscopic sigmoid resection.
External anal sphincter atrophy on endoanal magnetic resonance imaging adversely affects continence after sphincteroplasty
Authors: Briel J W , Stoker J , Rociu E , Laméris J S , Hop W C J , Schouten W R
Published: March 2003

Background

There is still considerable debate about the value of preoperative anorectal physiological parameters in predicting the clinical outcome after sphincteroplasty. Recently it has been reported that atrophy of the external anal sphincter can be clearly shown with endoanal magnetic resonance imaging (MRI). The aims of this study were to investigate the prevalence of external anal sphincter atrophy in women with anterior sphincter defects due to obstetric injury and to determine the impact of external anal sphincter atrophy on the outcome of sphincteroplasty.

Methods

In this prospective study, 20 consecutive women (median age 50 (range 28–75) years) with faecal incontinence due to obstetric trauma were assessed before operation with endoanal ultrasonography and endoanal MRI. The external anal sphincter was examined and evaluated for the presence of atrophy. The clinical outcome of sphincteroplasty was interpreted without knowledge of the magnetic resonance and ultrasonographic images.

Results

In all patients anterior sphincter defects could be demonstrated with ultrasonography and MRI. External anal sphincter atrophy could only be demonstrated on MRI. Eight of 20 patients had external anal sphincter atrophy. Continence was restored in 13 patients. Outcome was significantly better in those without external anal sphincter atrophy (11 of 12 patients versus two of eight; P = 0·004).

Conclusion

External anal sphincter atrophy can only be visualized on endoanal MRI and affects continence after sphincteroplasty. Endoanal MRI is valuable in the preoperative assessment of patients with faecal incontinence.
High early mortality rate from acute pancreatitis in Scotland, 1984–1995
Authors: McKay C J , Evans S , Sinclair M , Carter C R , Imrie C W
Published: March 2003

Background

Death from acute pancreatitis within the first week after admission is usually a consequence of multiple organ dysfunction. Reports from specialist centres suggest that, with improvements in resuscitation and supportive care, such deaths are becoming uncommon but it is unclear if this is reflected in a decrease in early mortality rate from acute pancreatitis in the general population.

Methods

Data concerning patients discharged with a diagnosis of acute pancreatitis (International Classification of Disease-9 code 577·0) between 1984 and 1995 were obtained from the Information and Statistics Division, National Health Service in Scotland, and analysed on a computer database.

Results

The incidence of acute pancreatitis in Scotland continues to increase in both sexes. The in-hospital mortality rate (death from all causes) was 7·5 per cent and showed a slight but significant downward trend over the period of study. Death within 7 days of hospital admission accounted for 53·7 per cent of all deaths and the proportion of early deaths did not decline over the study interval.

Conclusion

These results suggest that scope remains for considerable improvement in the early management of acute pancreatitis. There is an urgent need to improve the early recognition of severe pancreatitis coupled to a willingness on behalf of clinicians to transfer these patients at an early stage to a centre with high-dependency and intensive care facilities supervised by a multidisciplinary team with expertise in the endoscopic, radiological and surgical management of these patients.
Nitric oxide synthetase and Helicobacter pylori in patients undergoing appendicectomy
Authors: Kell M R , Winter D C , Ryan D , Lynch M , Brew B , Rajpal P , Kirwan W O , Redmond H P
Published: March 2003

Background

This study was designed to determine whether Helicobacter pylori forms part of the normal microenvironment of the appendix, whether it plays a role in the pathogenesis of acute appendicitis, and whether it is associated with increased expression of inducible nitric oxide synthetase (iNOS) in appendicular macrophages.

Methods

Serology for H. pylori was performed on 51 consecutive patients undergoing emergency appendicectomy. Appendix samples were tested for urease activity, cultured and stained for H. pylori, graded according to the degree of inflammatory infiltrate, and probed immunohistochemically for iNOS expression.

Results

The mean age of the patients was 21 (range 7–51) years. Seventeen patients (33 per cent) were seropositive for H. pylori but no evidence of H. pylori was found in any appendix specimen. However, an enhanced inflammatory cell infiltration was observed in seropositive patients (P < 0·04) and the expression of macrophage iNOS in the mucosa of normal and inflamed appendix specimens was increased (P < 0·01).

Conclusion

H. pylori does not colonize the appendix and is unlikely to be a pathogenic stimulus for appendicitis. Priming effects on mucosal immunology downstream from the foregut may occur after infection with H. pylori.
Xenotransplantation
Authors: White S A , Nicholson M L
Published: March 2003

Background

Over the past 10 years xenotransplantation has generated much interest in the hope that it will enable us to overcome the current lack of human organ donors. This review examines the evolution and current therapeutic strategies that have been developed to overcome the predominant problem of graft rejection.

Methods

A literature review was undertaken using a Medline search from January 1966 to August 1999.

Results and conclusion

Despite the considerable advances that have been made in molecular biological techniques, xenograft rejection cannot be prevented without significant immunosuppression and toxic side-effects. The problem of delayed rejection, in particular, will probably be very difficult to overcome, although some of the difficulties associated with hyperacute rejection have been resolved. The potential risk of porcine endogenous retrovirus transmission has generated much debate recently, but it is likely that some of the important issues relating to xenotransplantation will never be resolved until carefully regulated clinical trials are allowed to begin.
Transcranial Doppler-directed dextran therapy in the prevention of postoperative carotid thrombosis
Authors: Hayes P , Lennard N , Smith J , Abbott R , Evans D , London N , Bell P , Naylor A R
Published: March 2003

Background

Evidence suggests that embolization precedes carotid thrombosis, a previously unpredictable event complicating 2–3 per cent of all carotid endarterectomies. It was hypothesized that dextran 40 therapy might prevent progression to complete thrombosis in high-risk patients.

Methods

Between October 1995 and July 1998, 400 consecutive patients were monitored following carotid endarterectomy using transcranial Doppler ultrasonography. Those with sustained embolization (more than 25 in 10 min) or those with emboli that distorted the middle cerebral artery waveform were commenced on an incremental dextran 40 infusion.

Results

Two hundred and sixteen patients (54 per cent) had one or more emboli detected (96 per cent within 2 h of flow restoration) but only 15 (4 per cent) required dextran therapy. Embolization ceased in each case although the dextran dose had to be adjusted in four. In one of the latter patients, embolization recurred on day 5 but was again controlled with high-dose dextran. Overall, the death and any stroke rate was 2 per cent and no patient suffered a stroke due to carotid thrombosis.

Conclusion

A few patients develop sustained embolization following carotid endarterectomy which, in previous studies, has been shown to be highly predictive of carotid thrombosis. The authors' experience to date suggests that dextran can stop this phase of embolization and prevent progression to complete carotid thrombosis. However, the dose of dextran has to be adjusted in 25 per cent of patients (i.e. blind administration of dextran may not be effective) and, very rarely, embolization may recur later.
Near-infrared spectroscopic monitoring of patients undergoing carotid endarterectomy under locoregional anaesthesia
Authors: Williams D J , Laws P , Imray C , Lambert A W , Horrocks M
Published: March 2003

Background

The level of cerebral desaturation, which is associated with a change in level of consciousness during carotid endarterectomy, was measured by near-infrared spectroscopy.

Methods

Patients were recruited in two centres over 24 months. Surgery was performed under deep and superficial cervical block using 0·5 per cent bupivacaine, with temazepam as a premedication. Cerebral oxygenation was measured by Critikon 2020 near-infrared spectrophotometers (Johnson and Johnson Medical, Newport, UK).

Results

Forty-nine procedures were performed on 45 patients (39 men; age range 52–84 (mean 68) years). Recordings were made from the ipsilateral frontal site in 38 patients, from the ipsilateral temporal site in 23 and bifrontally in eight patients. Monitoring failed in three subjects. Percentage changes in regional cerebral oxygen saturation are detailed below.

Conclusion

Significantly different levels of cerebral desaturation occur in patients with neurological compromise during carotid endarterectomy compared with those who are unaffected.