bluuebunny/crossref_metadata_2025 huggingface dataset:
Carcinoma of the oesophagus and stomach in Wales: a 1-year survey
Authors: Pye J K , Crumplin M K H , Foster M E , Biffin A , Charles J
Published: March 2003

Background

The management and outcome of patients presenting with oesophagogastric carcinoma over a 12-month period in Wales were reviewed.

Methods

Data were collected from September 1995 to September 1996 on 916 consecutive patients and submitted to confidential data analysis. The data originated from 20 hospitals and 70 surgeons treating these patients.

Results

The number of cases managed by each hospital varied between two and 124, and by each surgeon from one to 44. Three tumour sites were identified: carcinoma of the oesophagus (n = 339), carcinoma of the cardia (gastro-oesophageal junction; n = 193) and gastric carcinoma (n = 384). The 30-day mortality rate was 13 per cent for oesophageal carcinoma, 12 per cent for cardia carcinoma and 11 per cent for gastric carcinoma. Resection rates for the three tumour sites were 28, 44 and 56 per cent. There were 16 anastomotic leaks overall. For patients undergoing surgery, there was an inverse relationship between case load and mortality rate. This difference narrowed when ten or more patients were operated on per annum. For surgeons consulting with more than ten patients per annum and who operated on more than 70 per cent of these, the mortality rate was 18 per cent, compared with 5 per cent for those who operated on less than 70 per cent.

Conclusion

Numerically there is a broad range of experience amongst the surgeons who treat carcinoma of the oesophagus and stomach in Wales. There may be an optimum minimal case load and, with careful selection of␣patients for surgery, morbidity and mortality rates should be minimized.
Prospective audit following the introduction of short-course preoperative radiotherapy for rectal cancer
Authors: Lele S , Radstone D , Eremin J , Kendal R , Hosie K B
Published: March 2003

Background

The value of introducing a short course of preoperative radiotherapy before operation for rectal cancer is still subject to debate.

Methods

One hundred consecutive patients, of mean age 68 (range 29–87) years undergoing preoperative radiotherapy for rectal cancer between January 1997 and December 1998 at two radiotherapy centres were audited prospectively.

Results

The time from referral to radiotherapy was 33 (11–74) days and from radiotherapy to operation 5 (1–42) days. There was a higher than expected anastomotic leak rate (15 per cent) and perineal wound infection rate (18 per cent). Patients waiting more than 7 days were more likely to suffer perineal wound breakdown: 15 per cent (n = 39) versus 30 per cent (n = 10).

Conclusion

The high anastomotic leak and perineal wound infection rates suggest that the introduction of preoperative radiotherapy combined with total mesorectal excision should be audited carefully or performed as part of the CRO7 trial.
Prospective study of safety, patient satisfaction and leg ulcer healing following saphenous and subfascial endoscopic perforator surgery
Authors: Nelzén O
Published: March 2003

Background

Subfascial endoscopic perforator surgery (SEPS) is a minimally invasive alternative to conventional techniques for incompetent calf perforators. Although SEPS has been performed for more than a decade, limited and insufficient data have been published regarding its safety, patient satisfaction and results.

Methods

A prospective follow-up was undertaken of consecutive SEPS operations on 149 legs, performed in 138 patients: 67 legs with ulceration, 34 with skin changes and 48 with varicose veins. Conventional saphenous vein surgery was performed, when indicated, together with the SEPS procedure. Follow-up was performed after 1 week and later by postal questionnaire to assess long-term morbidity, late complications and patient satisfaction. Patients with ulcers were followed continuously.

Results

Most operations (n = 107) were performed as day-case surgery. Combined saphenous vein surgery was performed in 89 per cent. No serious complications occurred: wound infection in 7 per cent; severe postoperative pain in 9 per cent; delayed wound healing in 15 per cent. After a median follow-up of 7 (1–31) months, 91 per cent of patients were satisfied. After a median of 32 (14–57) months, ulcer healing had occurred in 30 of 36 patients with open ulceration at the time of operation.

Conclusions

SEPS is a safe procedure, suitable for day-case surgery. Patients are generally satisfied with the outcome and the results of leg ulcer healing are promising.
Retrospective analysis of type of hepatic resection for hepatocellular carcinoma
Authors: Takano S , Oishi H , Kono S , Kawakami S , Nakamura M , Kubota N , Iwai S
Published: March 2003

Background

Hepatic resection for hepatocellular carcinoma is now considered a relatively safe procedure, owing to refined surgical techniques and management.

Methods

Three hundred different types of hepatic resection performed in one hospital were reviewed retrospectively. The operative morbidity and mortality rates and long-term survival were assessed.

Results

Tumours were extirpated by lobectomy or extended lobectomy in 48 patients, by segmentectomy in 53, by subsegmentectomy in 94 and by partial resection in 105. The overall hospital mortality rate was 4 per cent (13 of 300). No operative death occurred after lobectomy or extended lobectomy. Segmentectomy and subsegmentectomy were associated with high postoperative complication and hospital mortality rates. There was a significant difference in survival rate between patients with and without a cancer-free surgical margin of more than 1·0 cm. The overall 5- and 9-year survival rates were 51 and 9 per cent respectively. Rates were 56 and 24 per cent for lobectomy or extended lobectomy.

Conclusion

For tumours of 2·1 cm or more in size lobectomy appears to carry the least risk of postoperative complications and death in hospital and best achieves a cancer-free surgical margin.
Experimental study of the influence of endoleak size on pressure in the aneurysm sac and the consequences of thrombosis
Authors: Schurink G W H , Aarts N J M , van Baalen J M , Kool L J Schultze , van Bockel J H
Published: March 2003

Background

This was an experimental study of endovascular aortic surgery, looking at the relationship between the size of an endoleak, pressure in the aneurysm sac and the effect of thrombosis produced by coagulation.

Methods

In three pigs, 16 saccular aneurysms were connected to the aorta by various side branches with different diameters and lengths (‘endoleaks’). Mean and pulse pressures were measured in the systemic circulation as well as in the aneurysm sac during the experiment. Duplex ultrasonography was used to determine whether the endoleak and the aneurysm were patent or thrombosed. Thrombosis was influenced by systemic tranexamic acid, fibrinogen in the aneurysm sac, Gelfoam in both endoleak and aneurysm sac, and by Histoacryl glue in the endoleak.

Results

With an open endoleak, the mean pressure in the aneurysm and the aorta was identical. Mean aneurysm pressure was lower with a thrombosed endoleak and was related to the diameter of the endoleak. Pulse pressure was recorded in the aneurysm sac when there was an open endoleak and a non-thrombosed aneurysm, and was related to the diameter of the open endoleak. Thrombosed endoleaks never produced pulse pressure in the aneurysm. If Histoacryl and Gelfoam induced thrombosis of the endoleak, the decrease in mean aneurysm pressure was identical to that resulting from the spontaneous thrombosis of endoleaks.

Conclusion

An open endoleak results in systemic arterial pressure in the aneurysm sac. Pulse pressure is detected if the aneurysm is patent, but absent if there is complete or partial thrombosis of the aneurysm. Endoleak thrombosis, either spontaneous or by embolization, is accompanied by a decrease in mean pressure and the absence of pulse pressure in the aneurysm sac. The extent to which these experimental findings are comparable to the clinical situation represents a field of further research.
Acquiring surgical skills
Authors: Hamdorf J M , Hall J C
Published: March 2003

Background

Technical competence is the bedrock of surgery, yet it has only recently been viewed as a valid area for either critical evaluation or formal teaching.

Methods

This review examines the teaching of surgical skills. The core is derived from a literature search of the Medline computer database.

Results and conclusion

The impetus for surgical change has generally related to the introduction of new technology. Advances initially allowed for open operation within the main body cavities; more recently minimal access surgery has appeared. The latter was introduced in an inappropriate manner, which has led to the evolution of teaching of technical skills away from an apprenticeship-based activity towards more formal skill-based training programmes. There is now a need for a solid theoretical base for the teaching of manual skills that accommodates concepts of surgical competence.
Imaging of anorectal disease
Authors: Stoker J , Rociu E , Wiersma T G , Laméris J S
Published: March 2003

Background

Over the past two decades developments in imaging have changed the assessment of patients with anorectal disease.

Methods

The literature on imaging techniques for anorectal diseases was reviewed over the period 1980–1999.

Results

For the staging of primary rectal tumours, phased array magnetic resonance imaging (MRI) may be regarded as the most appropriate single technique. The combination of endosonography or endoluminal MRI with ultrasonography or spiral computed tomography yields similar results. All techniques have limitations both for local staging and in the assessment of distant metastases. MRI or positron emission tomography is preferable for tumour recurrence. For perianal fistula, high-resolution MRI (phased array or endoluminal) is the technique of choice. For constipation, defaecography is the preferred technique, nowadays with emphasis on functional information. The role of magnetic resonance defaecography is currently being evaluated. For faecal incontinence, endosonography and endoluminal MRI give similar results in detecting sphincter defects; endoluminal MRI has the advantage of detecting external sphincter atrophy.

Conclusion

High-resolution MRI, endosonography and defaecography are currently the optimal imaging techniques for anorectal disease.
Prolonged ambulatory recording of antroduodenal motility in slow-transit constipation
Authors: Penning C , Gielkens H A J , Hemelaar M , Delemarre J B V M , Bemelman W A , Lamers C B H W , Masclee A A M
Published: March 2003

Background

Slow-transit constipation may be part of a pan-enteric motor disorder. To test this hypothesis 24-h ambulatory antroduodenal manometry was performed and orocaecal transit time determined in patients with slow-transit constipation and in healthy controls.

Methods

Antroduodenal motility was recorded with a five-channel solid-state catheter. Postprandial motility was recorded after consumption of two standardized test meals and interdigestive motility was recorded nocturnally. Manometry tracings were analysed for quantitative and qualitative abnormalities. Orocaecal transit time was determined by means of the lactulose hydrogen breath test.

Results

Postprandial motility was no different between patients and controls. However, some minor changes of interdigestive motility were observed. The proportion of phase II activity of the nocturnal cycles of the interdigestive migrating motor complex was increased in patients while phase I activity was decreased. The total number of observed phase III fronts was no different in patients and controls, although the number of phase III fronts with antral onset was decreased. Furthermore, the amplitude of phase III activity of duodenal onset was also decreased. Specific motor abnormalities such as retrograde propagation of phase III fronts were more frequent in patients. Orocaecal transit time was delayed in patients.

Results

In patients with slow-transit constipation, orocaecal transit time is delayed but antroduodenal motility is generally well preserved with only minor alterations.
Long-term results of arteriovenous fistulas using transposed autologous basilic vein
Authors: Murphy G J , White S A , Knight A J , Doughman T , Nicholson M L
Published: March 2003

Background

The transposed autologous basilic vein to brachial artery arteriovenous fistula provides vascular access in the absence of adequate superficial vein. The long-term patency and complication rates of this conduit are largely unreported.

Patients and methods

Seventy-four brachiobasilic fistulas were performed in 65 patients. This was a secondary or tertiary access procedure in 84 per cent of patients.

Results

Of the 74 fistulas performed, 50 were successfully used for dialysis (68 per cent) and 24 (32 per cent) were never used, including 13 fistulas that failed without being used for dialysis. Of the 74 fistulas, 46 per cent failed (n = 34), 10 patients died with a functioning fistula (n = 10) and five were transplanted. The 30-day secondary patency was 73 per cent at 1 year, 53 per cent at 2 years and 43 per cent at 3 years rate was 96 per cent. Cumulative secondary patency was 73 per cent at 1 year, 53 per cent at 2 years and 43 per cent at 3 years. Nineteen (26 per cent) fistulas underwent a further 19 operative procedures. Fifty-one (69 per cent) fistulas developed complications. The most common complications were arm oedema (24 per cent), thrombosis (22 per cent) and bleeding (18 per cent).

Conclusion

In high-risk patients the autologous transposed brachiobasilic fistula has equivalent patency and lower complication rates than those reported for polytetrafluoroethylene interposition grafts.
Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy
Authors: Sarli L , Costi R , Sansebastiano G , Trivelli M , Roncoroni L
Published: March 2003

Background

Postoperative shoulder-tip pain occurs frequently following laparoscopic cholecystectomy. The aim of this randomized clinical trial was to evaluate the efficacy of a low-pressure carbon dioxide pneumoperitoneum during laparoscopic surgery in reducing the incidence of postoperative shoulder-tip pain.

Methods

Ninety consecutive patients undergoing laparoscopic cholecystectomy were randomized prospectively into low-pressure (group A) and normal-pressure (group B) laparoscopic cholecystectomy groups. Patients in group A (n = 46) underwent laparoscopic cholecystectomy with 9 mmHg carbon dioxide pneumoperitoneum during most of the operation, and those in group B (n = 44) had laparoscopic cholecystectomy with 13 mmHg pneumoperitoneum. Shoulder-tip pain was recorded on a visual analogue pain scale 1, 3, 6, 12, 24 and 48 h after operation.

Results

The low-pressure pneumoperitoneum did not increase the duration of surgery. There were no significant intraoperative or postoperative complications in either group. Fourteen patients (32 per cent) in group B and five (11 per cent) in group A complained of shoulder pain (P < 0·05). Mean shoulder-tip pain scores at 12 and 24 h and postoperative analgesia requirements were also significantly lower in the low-pressure laparoscopic cholecystectomy group (P < 0·001).

Conclusion

A carbon dioxide pneumoperitoneum pressure lower than that usually utilized to perform laparoscopic surgery reduces both the frequency and intensity of shoulder-tip pain following laparoscopic cholecystectomy.
E-cadherin—catenin cell—cell adhesion complex and human cancer
Authors: Wijnhoven B P L , Dinjens W N M , Pignatelli M
Published: March 2003

Background

The E-cadherin–catenin complex plays a crucial role in epithelial cell–cell adhesion and in the maintenance of tissue architecture. Perturbation in the expression or function of this complex results in loss of intercellular adhesion, with possible consequent cell transformation and tumour progression. Recently, much progress has been made in understanding the interaction between the different components of this protein complex and how this cell–cell adhesion complex is modulated in cancer cells.

Methods

This is an update of the role of the E-cadherin–catenin complex in human cancers. It emphasizes new features and the possible role of the complex in clinical practice, discussed in the light of 165 references obtained from the Medline database from 1995 to 1999.

Results

More evidence is now appearing to suggest that disturbance in protein–protein interaction in the E-cadherin–catenin adhesion complex is one of the main events in the early and late steps of cancer development. An inverse correlation is found between expression of the E-cadherin–catenin complex and the invasive behaviour of tumour cells. Therefore, E-cadherin–catenin may become a significant prognostic marker for tumour behaviour. Besides its role in establishing tight cell–cell adhesion, β- catenin plays a major role in cell signalling and promotion of neoplastic growth. This suggests its dual role as a tumour suppressor and as an oncogene in human cancers.

Conclusion

Recent developments show that the E-cadherin–catenin complex is more than a ‘sticky molecular complex’. Further studies may yield greater insight into the early molecular interactions critical to the initiation and progression of tumours. This should aid the development of novel strategies for both prevention and treatment of cancer.
Fungal prophylaxis in biliopancreatic surgery in immunocompromised patients
Authors: Emparan C , Iturburu I , Diaz-Aguirregoitia J , Beyga Z , Perdigo L F
Published: March 2003

Background

Fungal infection is a devastating complication with an increased incidence in the past decade. Immune-depressed patients undergoing high-risk procedures have an increased incidence of surgical infection, particularly due to fungal colonization.

Methods

Twenty patients undergoing pancreas transplantation, 20 kidney transplant patients undergoing biliary tract surgery, 20 patients with human immunodeficiency virus (HIV) undergoing biliary tract surgery and 20 patients undergoing pancreatic resection for neoplasms were enrolled in a prospective study concerning perioperative surgical infection. All patients underwent surgical procedures by the same surgeon. All had preoperative blood counts, assay of CD lymphocyte populations, complete nutritional evaluation and similar antibiotic prophylaxis. Perioperative care was done to a similar standard and only patients undergoing pancreas transplantation received fungal prophylaxis (nystatin wash and swallow). In patients with clinical signs of infection, cultures were sent with special consideration to fungal infection.

Results

Two of the patients undergoing pancreas transplantation (one of whom died from disseminated candidiasis), three of the kidney transplant patients (two on the wound, one in the catheter), three patients with HIV (two on bile culture, one in the bloodstream) and one of the patients undergoing pancreatic resection (pancreatic fistula and bloodstream) had fungal infection. All patients had concomitant bacterial infections at the time of fungal infection (60 per cent Staphylococcus epidermidis). Patients with fungal infection had increased levels of immunosuppression with decreased CD4 recounts (pancreas transplants and patients with HIV), increased perioperative levels of blood glucose requiring insulin treatment, prolonged antibiotic therapy with broad-spectrum antibiotics (piperacillin–tazobactam), previous positive cultures from the bile of the biliary tract or the duodenum of the transplanted pancreas, and concomitant bacterial infections (especially opportunistic).

Conclusion

Surgical patients with positive cultures from surgical specimens, prolonged broad-spectrum antibiotic therapy and severely decreased lymphocyte immune function had an increased incidence of fungal infection with significant morbidity and mortality rates. Fungal prophylaxis is strongly recommended in these high-risk patients undergoing biliopancreatic tract surgery.
pH-dependent activity of amphotericin B
Authors: Verweij P , Mouton J , Rijs A , Meis J
Published: March 2003

Background

Abscesses caused by Aspergillus spp. are a rare presentation of invasive disease but commonly occur in patients with chronic granulomatous disease (CGD). Although amphotericin B (AmB) is considered standard treatment for these patients, up to 85 per cent of patients fail to respond. Several patients have been reported to respond after treatment was changed to antifungal azoles including itraconazole (ITZ) and voriconazole (VCZ). Although the underlying defect in the host defence is the most important cause of failure, the activity of AmB might be reduced in the local environment inside the abscess. Since pH has been shown to be low in abscesses, the effect of pH on the in vitro activity of AmB and ITZ was investigated.

Methods

Two A. fumigatus isolates and one A. nidulans isolate were cultured from patients with CGD. Two of these patients had failed to respond to treatment with AmB and had responded to treatment with VCZ. Serial twofold dilutions of AmB and ITZ were made in RPMI-1640 and buffered with MOPS at a pH of 4·0, 5·0, 6·0 and 7·0. The minimum inhibitory concentration (MIC) for each isolate was determined after 24 and 48 h of incubation by visual reading.

Results

For all isolates, the MIC of AmB and ITZ at pH 7·0 was 0·25 and 0·06 mg l−1 respectively. The MIC of AmB increased significantly with decreasing pH resulting in a MIC of 16 mg 1−1 at pH 4·0. However, the MIC of ITZ was not affected by the pH of the medium. Although breakpoints have not been established for AmB, MIC values above 0·5 mg 1−1 correspond to clinical failure in patients with yeast infection.

Conclusion

The reduced activity of AmB at low pH might contribute to the failure of patients with fungal abscesses to respond to treatment with AmB. Primary therapy with azoles may be warranted.
Immunomodulation with granulocyte–macrophage colony-stimulating factor and interleukin 2 in an experimental model of sepsis
Authors: Corso V , Fattori L , Torselli L , Assisi A , Papotti R , Nespoli A
Published: March 2003

Background

Previous studies have demonstrated that immunomodulation with granulocyte–macrophage colony-stimulating factor (GM-CSF) reduces the mortality rate in an experimental model of sepsis, decreases levels of tumour necrosis factor in the serum and in the liver, and enhances neutrophil activity. It was also demonstrated recently that immunoprophylaxis with interleukin (IL) 2 can reduce the mortality rate in rats that have undergone caecal ligature and puncture (CLP). In fact, IL-2 is the major activator of the specific immune response (B and T lymphocytes). The aim of this study was to investigate whether IL-2 and GM-CSF together might further decrease the mortality rate in an experimental model of peritonitis in rats, which resembles the clinical situation of bowel perforation and mixed bacterial peritonitis.

Methods

Peritonitis was induced by CLP in four groups of Sprague–Dawley male rats (250 g). Each group included 30 rats. Group 1 underwent CLP and postoperative antibiotic therapy with tobramycin and clindamycin (12·5 μg g−1 day−1 and 4 mg g−1 day−1 respectively for 72 h after operation). Group 2 underwent preoperative intraperitoneal IL-2 injection (1.000.000 units), then CLP and postoperative antibiotic therapy with the same regimen. Group 3 underwent CLP and intraperitoneal GM-CSF injection (l ng g−1 day−1 for 48 h after operation). Group 4 received IL-2, CLP and GM-CSF with the same regimen and antibiotic therapy. Deaths were recorded within 72 h after CLP.

Results

After CLP group 1 (antibiotics) had a mortality rate of 70 per cent; group 4 (IL-2, GM-CSF, antibiotics) had a mortality rate of only 3 per cent which was significantly lower than in that in group 2 (IL-2 and antibiotics) and group 3 (GM-CSF and antibiotics), 33 and 25 per cent respectively (P < 0·0001).

Conclusion

Only one of 30 rats that had CLP and were treated with IL-2, GM-CSF and antibiotics died. Immunomodulation offers a new option in the treatment of sepsis related to peritonitis; in this experimental model treatment with IL-2 and GM-CSF enhanced host resistance to sepsis and decreased the mortality rate.
Prospective randomized trial demonstrates that postoperative administration of glycyl-glutamine alleviates the reduction in human leucocyte antigen DR expression on human monocytes induced by surgery
Authors: Sautner T , Bergmann M , Gornikiewicz A , Manhart N , Spittler A , Götzinger P , Függer R , Roth E
Published: March 2003

Background

The surface expression of major histocompatibility complex class II antigens (human leucocyte antigen (HLA) DR) on monocytes is a major indicator of the immunocompetence of these cells. Surgery, trauma and inflammation lead to a reduction in HLA-DR expression on monocytes, which is associated with an increased susceptibility to infection and sepsis. The authors have shown surface expression of HLA-DR on human monocytes in vitro. Following trauma or surgery, glutamine synthesis and secretion from skeletal muscle is increased; intracellular concentrations of glutamine, however, are significantly decreased. It was therefore hypothesized that postoperative infusion of glutamine dipeptides might prevent the decrease in HLA-DR expression on monocytes.

Methods

Thirty patients undergoing major abdominal surgery were allocated randomly to receive either 1500 ml Vamin (an amino acid solution containing no glutamine) (controls) or an isonitrogenic formulation containing Vamin and glycyl-glutamine (35 g glutamine) (GLY-GLN) or Vamin and alanyl-glutamine (35 g glutamine) (ALA-GLN) as a continuous infusion over 48 h after operation. The operations performed included oesophagectomy (three), gastrectomy (four), partial pancreatoduodenectomy (ten), hemihepatectomy (one) and drainage surgery of the biliary/pancreatic duct (ten). Immediately after the operation and 48 h later blood samples were collected for determination of HLA-DR expression of monocytes in vitro by flow cytometry.

Results

The groups were comparable with respect to age, sex distribution and operating time. In the GLY-GLN group mean HLA-DR expression of monocytes at 48 h was significantly better preserved than in controls.

Conclusion

Postoperative infusion of GLY-GLN alleviates the immunosuppression induced by surgery. GLY-GLN may be superior to ALA-GLN because of the distinct immunological effect of glycine and alanine. The observed GLY-GLN-specific preservation of HLA-DR on monocytes following surgery may contribute to the prevention of infectious complications in patients undergoing major abdominal surgery.
Influence of antibiotic prophylaxis on perioperative risk in traumatology with the new concept of clinic modelling randomized trials in animals
Authors: Celik I , Junge A , Krüger A , Seitz S , Brück E , Gotzen L , Lorenz W
Published: March 2003

Background

Surgical outcome depends not only on different therapies, but also on different additionally applied measures like prophylaxis (antibiotics, heparin, etc.) and their complex interaction. The aim of this study was to establish a new concept of clinic modelling randomized trials (CMRTs) in rats (haemorrhagic shock model) to investigate the harmful or beneficial effects of antibiotic prophylaxis in trauma patients (evidence-based medicine). Elements of the clinical scenario and methodology of randomized trials were modelled as accurately as possible in this CMRT.

Methods

Conditions of the rat model (CMRT) were adapted to the methodology of clinical trials and the clinical scenario with respect to sample size calculation, blinding and randomized allocation in a two-block design (n = 20 animals per group), anaesthesia with fentanyl–droperidol, standardized operation (soft tissue damage, tibia fracture and nailing), antibiotic prophylaxis 1 h before operation (intravenous cefuroxime 20 mg kg−1  versus placebo (sodium chloride)), volume substitution (Ringer) and postoperative analgesia. The clinical situation of healthy (American Society of Anesthesiologists (ASA) grade I and II) and severely injured (ASA III and IV) patients was simulated in the CMRT by sham operation and preoperative blood-letting, respectively, to initiate a relevant shock (1·5 h of mean arterial pressure 50 mmHg, blood pressure measured in the femoral artery). The shock period was followed by resuscitation (volume loading) with Ringer solution 40 ml kg−1. The endpoint was the 21-day mortality rate. Fracture healing was documented by radiography.

Results

The animal model was established successfully. The required blood-letting for relevant shock was 20 ml kg−1. The mortality rate in animals without blood-letting simulating healthy patients (ASA I and II) was zero in the cefuroxime and in placebo groups (n = 20 per group). In the experiment with preoperative blood-letting (ASA III and IV, n = 20 per group) a clear but not significant trend in the mortality rate for the cefuroxime group (20 per cent) versus placebo (40 per cent) could be observed (1 d.f., P > 0·05, χ2 test). Disturbances of fracture healing did not occur.

Conclusion

The clinical impact (evidence based) of antibiotic prophylaxis in traumatology was demonstrated in these experiments. The influence of other currently used antibiotics in trauma patients could be investigated in such animal models (CMRTs) instead of expensive and time-consuming clinical trials. The results of this study suggest the advantage of prophylaxis with cefuroxime in severely injured patients. Other antibiotics and the pathophysiological mechanisms will be investigated in further studies.
Sterile pancreatic necrosis is not a clinical entity
Authors: Kriwanek S , Beckerhinn P , Armbruster C , Roka R
Published: March 2003

Background

The question of whether to operate or not in patients with sterile pancreatic necrosis (SPN) is controversial. The basis for this discussion has been the assumption that SPN represents a clinical entity. The aim of the present study was to question this hypothesis.

Methods

All patients with SPN diagnosed by contrast-enhanced computed tomography and negative bacterial cultures were included in the study. A retrospective analysis of prospectively collected data, including organ function, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, duration of intensive care therapy and hospitalization, and death, was performed.

Results

From 1990 to 1999, 43 patients were treated for SPN. All patients had to undergo intensive care therapy. There were two clearly different types of patient: (1) a group of 20 patients with less severe disease treated successfully without operation and (2) 23 patients with progressive organ dysfunction despite intensive care, who had to undergo surgery. The rates of organ dysfunction (18 versus 100 per cent), median APACHE II scores (7 versus 17), mortality rate (zero versus 26 per cent), duration of intensive care (9 versus 23 days) and hospital stay (26 versus 45 days) were significantly different between the two groups.

Conclusion

According to this study SPN is not a clinical entity. Future discussions on therapeutic strategies should take this finding into consideration.
Isolation of lysogenic staphylophage and its potential use as a treatment of methicillin-resistant Staphylococcus aureus surgical infections
Authors: Rapson M E , Salovska L P , Mann N H
Published: March 2003

Background

The aim was to develop a new cost-effective, accessible method for treating multidrug-resistant bacterial infections in which the possibility for emergence of resistant strains is greatly reduced. Methicillin-resistant Staphylococcus aureus (MRSA) surgical wound infection was used as a model for these studies.

Methods

A collection of lysogenic bacteriophage was made by isolating Staphylococcus-specific bacteriophage (staphylophage) from clinical MRSA samples from England, Bulgaria and Poland. The phage was selected and characterized according to host range, source, morphology and stability. Resistance profiles of the S. aureus isolates (SAIs) for 16 antibiotics, including methicillin, were determined.

Results

Some 86 per cent of the SAIs were multidrug resistant. When the 152 SAIs were incubated with eight different S. aureus cultivating strains 79 per cent produced at least one phage able to infect at least one of the cultivating strains. 72·4 per cent were able to infect two or more.

Conclusion

Lysogenic MRSA isolates are a characterizable, widely available source of staphylophage that can be used as an alternative to the traditional environmental sources. A specific pattern for geographical distribution of lysogenic staphylophage has been demonstrated which further facilitates the isolation process. The narrow host range of bacteriophage compared with chemotherapeutic agents ensures a minimal effect on non-pathogenic bacteria within the patient. This is an ongoing study and these are preliminary results. At the end of the study a method for isolation and development of therapeutic phage will be available for use in the industrial and hospital setting.
Surgical and laboratory findings in children with neutropenic enteropathy
Authors: Tireli G A , Özbey H , Eryilmaz E , Salman T , Anak S
Published: March 2003

Background

The term neutropenic enteropathy (NE) is used to describe inflammatory conditions of the gastrointestinal system in patients who receive chemotherapy for haematological malignancy. Although the initial treatment of choice in NE is non-operative, with bowel rest, decompression, nutritional support and broad-spectrum antibiotics, operative intervention is needed in patients with the advent of the disease. The surgical and laboratory findings of seven patients with NE who required surgical treatment are presented.

Methods

Patients' medical records were reviewed to obtain age, sex, diagnosis, laboratory findings with neutrophil counts, blood cultures and the surgical findings. The onset of neutropenia and the diagnosis of NE were recorded for each patient.

Results

There were four girls and three boys, with a mean age of 6 years (range 9 months to 16 years). The primary diseases were acute myelocytic leukaemia in two, acute lymphocytic leukaemia in one and lymphoma in four patients. In all but two patients, the neutrophil counts were less than 1000 mm−3, with positive blood cultures at diagnosis. The onset of the NE was determined as mean(s.d.) 3(2) days after the onset of neutropenia. Haemorrhage, marked oedema, patchy inflammation and multiple adhesions of the bowel, perforation and localized abscess were the main operative findings. The lesions were mostly localized in the terminal ileum and the ascending colon. After resection of the affected segment of bowel, stomas (three) and end-to-end anastomoses (three) were performed. Primary repair of the perforation site was performed in one patient with gastric perforation. Four patients recovered with rapid resolution of neutropenia, while three patients with persistent neutropenia died.

Conclusion

A favourable outcome for patients with NE is related to early recognition of the intra-abdominal infection, appropriately timed surgical intervention and a prompt postoperative return of normal circulating levels of neutrophils.
Microbiology of postoperative peritonitis
Authors: Röhrborn A , Potreck O , Ebener C , Wolf A , Goretzki P
Published: March 2003

Background

The microbiology of secondary peritonitis is well known and standards of antibiotic therapy are established. In contrast, little is known about the bacteriology of postoperative peritonitis. Resistant strains could be involved and patients may have had previous antibiotic treatment.

Methods

The intraoperative and postoperative bacteriology (10 days after operation) of all 88 cases of postoperative peritonitis occurring between September 1994 and May 1999 were documented. Resistances were used to determine effective antibiotic therapy.

Results

Compared with secondary peritonitis, enterococci outnumbered Escherichia coli in postoperative peritonitis. While E. coli showed no advanced resistance, the different pattern of bacterial findings (e.g. enterococci, Enterobacter, Gram-positive bacteria) leads to failures of standard therapy for secondary peritonitis. Imipenem–cilastatin failed in 20 per cent, piperacillin–tazobactam in 31, aminoglycosides in 31, ciprofloxacin in 37 and third-generation cephalosporins in 47 per cent (the latter three combined with metronidazole).

Conclusion

Cephalosporins, the ‘gold standard’ in secondary peritonitis, fail in postoperative cases. Carbapenems are the drugs of choice. Aminoglycosides should be avoided in these patients.
Inflammatory response regulation by tacrolimus in an experimental model of multiorgan failure induced by bacterial translocation
Authors: Garcia-Criado F J , Lozano F S , Lorenzo M F , Parreño F C , Valdunciel J J , Gómez-Alonso A
Published: March 2003

Background

Bacterial translocation may induce multiorgan failure (MF), an infrequent but very serious clinical situation. This study used the immunosuppressant tacrolimus to control the inflammatory response in order to avoid MF, and also aimed to elucidate its mode of action.

Methods

Male Wistar rats were divided into three groups: sham group, control MF group (zymosan intraperitoneal injection and studies at 2, 12 and 24 h) and tacrolimus group (different times of administration and studies at 2, 12 and 24 h). Survival, renal and hepatic function, microbiological cultures, neutrophil infiltration, oxygen free radicals, cytokines, cellular adhesion molecules and intracellular transcriptional mechanisms were studied in both renal and hepatic tissue.

Results

Use of tacrolimus before the systemic inflammatory response regulated this response (less production of free radicals, P < 0·01; of cytokines, P < 0·01; of neutrophil infiltration, P < 0·05) by control of nuclear factor κB activation which induces minor expression of cellular adhesion molecules and minor production of the inflammatory mediators controlled by κB.

Conclusion

The use of prophylactic antiflammatory therapy in MF may be useful and tacrolimus has been demonstrated to be a powerful regulator of this situation.
Effects of systemic and intraperitoneal chemotherapy on bacterial translocation and peritoneal defence mechanisms
Authors: Çerci C , Agalar C , Ergin Ç , Eroglu E , Bulbul M , Agalar F
Published: March 2003

Background

The aim of this study was to evaluate the effects of intraperitoneal and systemic chemotherapy on peritoneal defence mechanisms and bacterial translocation.

Methods

Four groups of adult male Wistar Albino rats (n = 10) were used in the study. The groups consisted of intraperitoneal chemotherapy (5-fluorouracil 20 mg kg−1 day−1 for 3 days), systemic chemotherapy (5-fluorouracil 20 mg kg−1 day−1 for 3 days) and their controls (systemic and intraperitoneal isotonic saline solution). Eight hours after the last dose of chemotherapy 10 ml sodium caseinate was applied intraperitoneally and 16 h later laparotomy was done under sterile conditions. During laparotomy 10 ml phosphate-buffered saline was applied and approximately 8 ml of this solution was collected. Phagocytic activity, bactericidal activity, peritoneal total cell numbers and morphology, peripheral blood leucocyte count and bacterial translocation were studied in this peritoneal solution. Tissue samples of mesenteric lymph node, liver, spleen and caecum were taken and homogenized for culturing. Statistical analyses were done with Student's t test for independent samples.

Results

In the systemic chemotherapy group phagocytic activity (36 versus 52 per cent in control) and bactericidal activity (decreased in seven versus two in control) were significantly decreased. Peripheral and peritoneal leucocyte numbers were also decreased in the systemic chemotherapy group. Peritoneal cell morphology was not affected. Bacterial translocation occurred in mesenteric lymph nodes of five rats in this group. Intraperitoneal chemotherapy significantly decreased the phagocytic activity (33 versus 56 per cent in control). Peripheral and peritoneal leucocyte numbers were also decreased but the bactericidal activity and peritoneal cell morphology were not affected. In contrast to the systemic chemotherapy group, bacterial translocation was not detected.

Conclusion

Systemic chemotherapy caused bacterial translocation. Both systemic and intraperitoneal chemotherapy have detrimental effects on peritoneal defence mechanisms under experimental conditions.
Macrophage migration inhibitory factor as a counter-regulatory mediator of cortisol during septic shock
Authors: Beishuizen A , Vermes I , Haanen C , Thijs L G
Published: March 2003

Background

Migration inhibitory factor (MIF) is a widely expressed protein that is secreted in response to inflammatory or hormonal stimuli. MIF is both an endocrine hormone and immunological mediator that counter-regulates glucocorticoid (GC) action. The anti-inflammatory and immunosuppressive properties of GC are often beneficial but host homeostasis requires counter-regulatory systems for which MIF has been proposed.

Methods

Using a time-resolved fluorometric immunoasssay to detect serum MIF levels in patients with septic shock or multitrauma, the relation of MIF to cortisol and adrenocorticotrophic hormone (ACTH) was studied. Serum MIF, cortisol and ACTH were measured serially over 14 days in patients with septic shock (n = 28) and multitrauma (n = 5), and in healthy controls (n = 41). Haemodynamics, Acute Physiology and Chronic Health Evaluation II scores and intensive care unit deaths were also recorded.

Results

MIF levels were raised significantly on day 1 in septic shock (mean(s.d.) 12·5(3·7) ng ml−1) compared with trauma (3·1(1·7) ng ml−1) and controls (2·5(2·1) ng ml−1). The time course of both MIF and cortisol showed persistently high levels in sepsis, independent of shock reversal or haemodynamics. Non-survivors had higher MIF levels than survivors from septic shock (P < 0·05). Regression analysis showed a significant correlation between MIF and cortisol levels (r = 0·72), but no correlation was found between MIF and other variables.

Conclusion

Increased serum MIF levels occurred in septic shock compared with trauma and controls. In septic shock a clear correlation was found between MIF and cortisol levels, suggesting a parallel increase of MIF with cortisol and indicating a counter-regulatory activity of MIF to dampen the protective effects of GC. Non-survivors had higher MIF levels at most time points, indicating that MIF might be a potential prognostic marker in septic shock.
Impairment of renal blood flow after renal ischaemia–reperfusion is not aggravated by low plasma levels of arginine
Authors: Nijveldt R J , Prins H A , Rauwerda J A , van Lambalgen A A , Teerlink T , van Leeuwen P A M
Published: March 2003

Background

The fundamental role of the l-arginine–nitric oxide pathway has not been established for maintaining renal blood flow. Plasma levels of arginine appear to be rate limiting for nitric oxide synthesis in various cell types. Low plasma levels of arginine are seen after major surgery, trauma and sepsis. The present study was designed to establish the effects of low arginine plasma levels on renal blood flow during the initial phase of renal ischaemia–reperfusion.

Methods

In this unilateral renal ischaemia–reperfusion model, male Wistar rats were used. Arginase infusion (ASE) was used to lower arginine plasma levels to 50 per cent of normal; control rats received saline infusion (SAL). After an ischaemic period of 90 min, the kidney was perfused for 150 min (IR kidney). The contralateral kidney was left in situ and served as a control (CL kidney). Blood flow measurement was performed at the end of the experiment using radiolabelled microspheres. Blood samples were taken for amino acid analysis (high-pressure liquid chromatography).

Results

Infusion of arginase efficiently decreased plasma levels of arginine (ASE mean(s.d.) 45·3(4·8) μmol/dm3 versus SAL 107·5(6·0) μmol/dm3; P < 0·0001). In both SAL and ASE rats, a significantly lower blood flow was found in the IR kidney compared with the (non-ischaemic) CL kidney. Lowering arginine plasma levels by arginase did not influence renal blood flow compared with SAL, in both IR and CL kidneys.

Conclusion

In this acute, unilateral renal ischaemia–reperfusion model, low arginine plasma levels did not further aggravate renal blood flow.
Jejunal interposition to prevent postgastrectomy syndromes
Authors: Morii Y , Arita T , Shimoda K , Yasuda K , Matsui Y , Inomata M , Kitano S
Published: March 2003

Background

Postgastrectomy syndromes include reflux gastritis and oesophagitis, dumping syndrome, intractable diarrhoea and afferent loop syndrome. To prevent such syndromes, since January 1994 jejunal interposition has been used following distal gastrectomy. The aim of this study was to evaluate the benefit of this procedure.

Methods

A consecutive series of 42 patients who underwent distal gastrectomy for gastric cancer was studied. Twenty-two patients had a Billroth I procedure before January 1994, and 20 patients had isoperistaltic jejunal interposition using a 10–12-cm segment after January 1994.

Results

The mean operating time was 260 min for Billroth I and 352 min for jejunal interposition. No serious postoperative complications arose. Reflux gastritis occurred in 19 patients after Billroth I but in none after jejunal interposition. Five patients in the Billroth I group had complaints consistent with dumping syndrome, compared with none after jejunal interposition. The barium gastric emptying time was significantly shorter after Billroth I (mean(s.d.) 269(225) s) than after jejunal interposition (736(479) s) (P < 0·01).

Conclusion

Jejunal interposition prevented reflux gastritis and inhibited rapid gastric emptying. Postgastrectomy syndromes were effectively prevented by this reconstruction procedure.
Lymphoedema following surgery for breast cancer
Authors: Pain S J , Purushotham A D
Published: March 2003

Background

Lymphoedema is a common complication of breast cancer treatment, affecting approximately a quarter of patients. Those affected can have an uncomfortable, unsightly and sometimes functionally impaired limb prone to episodes of superficial infection. The aetiology, pathophysiology and management of these patients is poorly understood.

Methods

This is a systematic review of all published literature on lymphoedema following treatment for breast cancer, using the Medline and Cinahl databases with cross-referencing of major articles on the subject up to the end of 1999.

Results and Conclusion

The aetiology and pathophysiology of lymphoedema in patients with breast cancer appear to be multifactorial and are still not fully understood. Although conservative treatment techniques can be very successful in controlling symptoms, they do not afford a cure. The place of surgical and pharmacological therapy remains unclear. Improved understanding of the pathophysiology may assist in reducing the incidence of this condition, or help to identify those at greatest risk, in whom early initiation of conservative treatment measures may prove effective.