bluuebunny/crossref_metadata_2025 huggingface dataset:
Direct and indirect time spent on care of dental trauma: a 2‐year prospective study of children and adolescents
Authors: Glendor U. , Halling A. , Bodin L. , Andersson L. , Nygren Å. , Karlsson G. , Koucheki B.
Published: March 2003

Abstract – The aim was to account for the total time spent by professional care‐givers (direct time) and by patients and companions engaged as support and help (indirect time) to treat and otherwise attend to children and adolescents with dental trauma to primary and permanent teeth. The study was based on a random sample of 192 children and adolescents with dental traumas reported to an insurance company and prospectively followed up by telephone interviews over a period of 2 years after the trauma episode. On average, direct time represented 16% of total time for all visits for dental trauma to permanent teeth and 11% for trauma to primary teeth. The most extensive type of indirect time was transport time, which took up 30% of the total time spent on injuries to permanent teeth and 36% for injuries to primary teeth. Multiple regression analysis of the impact of dental and demographic injury variables on the time variables showed that complicated trauma was associated with extended time, direct as well as indirect, for permanent and primary teeth injuries. Our estimate of the average relative increase in total time spent by patients and companions in cases of complicated injury to permanent teeth was 117% (95% confidence interval [CI], 52–211) for patients and 112% (95% CI, 42–217) for companions. For transport time a strong predictor was access to a dental clinic near the place of residence. Lack of access could extend the average transport time by 180% (95% CI, 80–335) for patients and 163% (95% CI, 67–317) for their companions in cases of injuries to primary teeth.
Extraradicular infection: a methodological study
Authors: Sunde P. T. , Olsen I. , Lind P. O. , Tronstad L.
Published: March 2003

Abstract – Whether bacteria live or die in periapical lesions of endodontic origin is debated. Sampling of periapical bacteria is difficult due to possible contamination from the indigenous microflora. The aim of this study was to examine whether bacteria were present in periapical lesions of asymptomatic teeth before sampling or were transferred there during sampling. Thirty patients with root‐filled teeth and periapical radiolucencies were divided into two groups, each containing 15 patients. In Group 1, a marginal incision was made to explore the periapical lesion. In Group 2, a submarginal incision was made. Before incision, the gingiva and mucosa were washed with 0.2% chlorhexidine gluconate. Bacterial samples were taken from the mucosa before reflecting the flap, and from the alveolar bone and the periapical lesion immediately after. All samples were cultured anaerobically on all‐purpose and selective media. In Group 1, 12 of the 15 patients (80%) yielded bacteria from their mucosal samples despite the chlorhexidine wash. Bacterial growth was observed in all samples (100%) from the alveolar bone while the periapical lesions gave bacterial growth in 11 of 15 cases (73%). In Group 2, bacteria were cultured from the mucosa in 11 of 15 (73%) patients. Three samples (20%) from the alveolar bone and 10 from the periapical lesions (67%) gave positive growth. The predominant cultivable bacteria were anaerobic. Phenotypic profiling, performed with the data‐based API bioMérieux system, indicated that the sampling technique used prevented mucosal bacteria from reaching the exposed bone and the periapical lesions. Profiling also indicated that following marginal incision, bacteria from the periodontal pocket might have reached the underlying tissues by surgeon‐released bacteremia or direct translocation. Most organisms detected in the periapical lesions were clearly different from the bacteria present at neighboring sites and appeared to have been there before sampling.
Factors associated with root canal ledging during instrumentation
Authors: Kapalas A. , Lambrianidis T.
Published: March 2003

Abstract – The purpose of this study was to identify the presence of a ledge in 141 cases treated in an undergraduate clinic and in 103 cases treated by endodontists, and to identify the clinical factors associated with ledging. A total of 626 root canals were examined and the factors analyzed were canal location, tooth number and canal curvature. The results indicated that 51.5% of the canals treated by students had been ledged, whereas the percentage was 33.2% for intact pulp cavities treated by endodontists and 40.6% in cases of endodontic retreatment. Canal location was found to have an effect on the incidence of ledging as the mesiobuccal, mesiolingual and distal buccal root canals exhibited a significantly higher ledge incidence rate than the distal and palatal root canals. Canal curvature was the most significant variable affecting the incidence of ledging.
Extraction as a treatment alternative follows repeated trauma in a severely handicapped patient
Authors: Tsai Tzong‐Ping
Published: March 2003

Abstract – Handicapped patients with protruding maxillary incisors are prone to repeated dental trauma. A 13‐year‐old girl with cerebral palsy, severe mental retardation and seizure disorder was referred to our department for restoring the traumatized anterior teeth. Despite drug combination, the frequency of seizure attack was around 10 times a month. The oral examination showed multiple caries, gingival hyperplasia, class II malocclusion with 14 mm overjet and deep overbite. During the first 3 years of a 7‐year follow‐up period, six episodes of anterior tooth trauma due to seizure attack occurred. The trauma‐related treatment performed included endodontic therapy, multiple composite restorations, apical repositional flap, and finally extraction of all four upper incisors with fabrication of a semi‐fixed band‐retained denture. The denture restored normal overbite and overjet with improved esthetics. For 4 years following the fabrication of denture, no trauma occurred to the anterior teeth in later seizure attacks. Considering inadequate control of seizure disorder, little ability of the patient to receive comprehensive orthodontic treatment, poor prognosis of restorations, and possible future injuries, the removal of non‐functional, non‐esthetic, trauma‐susceptible incisor teeth can be justified as an alternative to tooth preservation.
Effect of a consensus statement on initial treatment for traumatic dental injuries
Authors: Kahabuka F. K. , Ntabaye M. K. , Van‘t Hof M. A. , Plasschaert A.
Published: March 2003

Abstract – The aim of this study was to investigate the influence of a consensus statement on dental practitioners’ choice of initial treatment for traumatic dental injuries. Dental practitioners working at government dental clinics in eight cluster sample regions of mainland Tanzania were requested to participate in the study; that is, to record the treatment they provided to children aged 1–17 years seeking dental consultation after injury for a period of 12 months. Six months after the beginning of data collection, a consensus statement was introduced. After the dental practitioners received the consensus statement, the correct treatment they provided increased from 51% to 57%. The unnecessary treatments increased from 54% to 59%, while wrong treatments decreased from 55% to 42%. Only a small improvement was observed in the percentage of correct treatments, but there was a slightly significant improvement in the percentage of wrong treatments provided before and after introduction of the consensus statement. We conclude that the consensus statement had a slight influence on the dental practitioners’ choice of initial treatment for dental trauma in the desired direction.
Splinting of traumatized teeth with a new device: TTS (Titanium Trauma Splint)
Authors: Von Arx Thomas , Filippi Andreas , Buser Daniel
Published: March 2003

Abstract – Displacement injuries of permanent teeth are an increasing emergency in the dental office. Children and adolescents are particularly prone to dental trauma due to participation in risky activitiess. Repositioning or replantation with subsequent stabilization by a dental splint is the standard of care for most displaced or avulsed permanent teeth. Non‐rigid fixation allowing physiologic tooth mobility has been shown to be desirable for periodontal healing. A flexible splint of short duration appears to reduce the risk of dentoalveolar ankylosis or external replacement resorption. Different splinting techniques are currently recommended for stabilization of repositioned or replanted teeth, including a wire‐composite splint, an orthodontic bracket splint or a resin splint. Each splinting option has its specific advantages and shortcomings. This paper describes a new splinting technique which offers improved comfort and handling to the patient and dentist alike.
Treatment of combined endodontic–periodontic lesions by intentional replantation and application of hydroxyapatites
Authors: Yu Liying , Xu Beiyun , Wu Bin
Published: March 2003

Abstract  – A case of combined endodontic–periodontic lesions on a mandibular first molar was treated by intentional replantation and application of hydroxyapatites. Four months after the surgery, a porcelain‐mental full crown restoration was completed. The 15‐month follow‐up examination showed that the tooth was clinically and radiographically healthy and functioned well.
Study of a combined percutaneous local anaesthetic  and nitric oxide‐generating system for venepuncture
Authors: Tucker A. T. , Makings E. , Benjamin N.
Published: March 2003

Summary Nitric oxide (NO) may be generated and delivered into the skin via a novel system of sodium nitrite and ascorbic acid. This placebo‐controlled, double‐blind trial compared the analgesic properties of this system alone and when supplemented with lidocaine. The pain of dorsal hand vein cannulation was assessed in 100 volunteers. The NO‐generating system was prepared by mixing two gels, the first KY jelly™ and sodium nitrite (10% w/v), the second KY jelly™ and ascorbic acid (10% w/v). NO‐generating gel was the placebo treatment, and when combined with lidocaine (final concentration 5%), formed the active treatment. The gels were applied to the dorsum of the hands bilaterally and simultaneously for 10 min. Following cannulation, pain perception was measured with a verbal rating score (VRS) and a visual analogue score (VAS). The active formulation significantly decreased the VRS (p < 0.0001) and also reduced the mean VAS by > 40% compared with placebo (p < 0.001). This investigation suggests a 10‐min topical application of anaesthetic combined with the NO‐generation system may provide effective analgesia for venous cannulation in adults.
Morton's design of the early ether vaporisers
Authors: Desbarax P.
Published: March 2003

Summary The exact design of the ether vaporiser used by William Morton on 16 October 1846 has remained uncertain with many contradictory reports. This article explores the known facts and speculates on the design used on that and subsequent occasions.
Malignant mixed mullerian tumour of the ovary: Prognostic factor and response of adjuvant platinum‐based chemotherapy
Authors: Inthasorn Perapong , Beale Philip , Dalrymple Christopher , Carter Jonathan
Published: March 2003

Objectives: The purpose of the present study was to analyse retrospectively the data of a series of patients presenting to our unit with malignant mixed mullerian tumour (MMMT) of the ovary to identify the prognostic factors and relate them to survival. The role of platinum‐based chemotherapy in the adjuvant treatment of this tumour was also evaluated.

Methods: All patients diagnosed with MMMT of the ovary from 1987 to 2000 were identified from the gynaecological tumour registry of King George V Hospital, Australia. The effect of clinical and histopathological variables on survival was analysed. The response of platinum‐based adjuvant chemotherapy after surgery was also evaluated.

Results: Twenty patients with MMMT of the ovary were identified. Of the six patients with measurable disease, two (33%) had complete response after adjuvant platinum‐based chemotherapy. The median survival of all patients was 8 months, while that of the patients receiving adjuvant platinum‐based chemotherapy was 23 months. Women who were older (>65 years) had a significantly worse survival rate than those who were younger (P = 0.02). The patients with optimal debulking had a better median survival than those with suboptimal debulking, but this difference was not statistically significant (P = 0.21). Sarcomatous component (homologous vs heterologous) was not found to be a significant prognostic factor for predicting survival.

Conclusions: Malignant mixed mullerian tumour of the ovary is a rare and aggressive gynaecological tumour. The current study indicates that patient age was a significant prognostic factor for survival and surgical cytoreduction combined with platinum‐based chemotherapy is the most effective management regimen identified to date to treat MMMT of the ovary.
Incidence of fetal macrosomia and birth complications in Chinese immigrant women
Authors: Westerway Susan Campbell , Keogh John , Heard Rob , Morris Jonathan
Published: March 2003

Objective: To compare rates of fetal macrosomia (birthweight >4000 g) and birth complications in both Chinese women immigrants and Caucasian women for two time periods: 1992 and 1999–2000.

Population: Chinese women immigrants and Caucasian women attending the Royal North Shore Hospital and Hornsby Ku‐Ring‐Gai Hospital in Sydney's northern health region.

Methods: Data used were extracted from the Northern Suburbs Area Health Service OBSTET database. Significance of trends were assessed using χ2 test.

Results: The results show a rise in macrosomic babies born to Chinese immigrants from 4% of total Chinese births in 1992 to 9.8% in 1999–2000 (P = 0.02).There was no significant difference in the rate of macrosomia among Caucasian women with respective rates of 11 and 14% for the same periods. The incidence of post‐partum haemorrhage increased significantly in both Chinese immigrants and Caucasian women (P < 0.001).

Conclusion: Australia has a multicultural population and yet the normal ranges defined for many obstetric investigations do not adjust for ethnicity. The application of values derived from a Caucasian population to other ethnic populations may be inappropriate and conceal important pathologies.
Management of 155 patients with benign liver tumours
Authors: Charny C K , Jarnagin W R , Schwartz L H , Frommeyer H S , DeMatteo R P , Fong Y , Blumgart L H
Published: March 2003

Background

Benign hepatic tumours continue to represent a diagnostic and therapeutic challenge. This study evaluates the indications and results of resection compared with observation in patients with benign hepatic tumours.

Methods

Patients with a primary diagnosis of benign liver tumour were identified from a prospective database and evaluated retrospectively.

Results

From January 1992 to June 1999, 155 patients with benign hepatic tumours were evaluated. The diagnoses included haemangioma (n = 97), focal nodular hyperplasia (FNH) (n = 42), hepatic adenoma (n = 12) and cystadenoma (n = 4). Sixty-eight patients (44 per cent) underwent resection because of symptoms (n = 36), inability to exclude a malignancy (n = 31) or enlargement on serial imaging (n = 11). The operative morbidity and mortality rates were 21 per cent and zero respectively. Thirty patients had a preoperative percutaneous needle biopsy, 19 of which were either incorrect or indeterminate. Overall, 39 of 42 patients with symptoms attributed to the tumour were asymptomatic after resection and 18 of 21 patients with symptoms considered unrelated to the tumour were asymptomatic after a period of observation and/or treatment of unrelated conditions (median follow-up 16 months).

Conclusion

When indicated, resection of benign liver tumours can be performed safely. Symptomatic patients with a small FNH or haemangioma can be observed because their symptoms are unlikely to be related to the liver tumour. Percutaneous needle biopsy rarely changes management.
Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunts
Authors: Taylor A L , Carroll T A , Jakubowski J , O'Reilly G
Published: March 2003

Background

Percutaneous endoscopic gastrostomy (PEG) may be required in neurosurgical patients with a persistently depressed neurological status or severe lower cranial nerve palsies. Such patients may have a coexisting hydrocephalus requiring cerebrospinal fluid (CSF) diversion. Despite the risk of infection resulting from exposure to oropharyngeal flora by the pull-through PEG technique and the secondary pneumoperitoneum seen in one-third of patients, simultaneous peritoneal placement of CSF shunt catheters with PEG is the current practice. The aim of the study was to determine the frequency of CSF diversionary procedures in neurosurgical patients undergoing PEG insertion and the occurrence of infective complications in patients with simultaneous placement of a PEG and a ventriculoperitoneal (VP) shunt.

Methods

This was a retrospective review of all neurosurgical patients undergoing PEG. The presence of hydrocephalus, mode of CSF diversion and the development of subsequent infection in those having coexistent distal peritoneal catheter placement and PEG were determined.

Results

PEGs were placed in 42 neurosurgical patients (9·3 per cent of all PEGs inserted), of whom 21 had a coexisting hydrocephalus. Eight of 16 shunts with distal catheter placement in the peritoneal cavity developed infection requiring revision. Infections occurred with greater frequency in patients with a tracheostomy. There were no shunt infections requiring revision in a second group of 21 patients who had a coexisting shunt and tracheostomy without PEG.

Conclusion

Simultaneous placement of a PEG and a VP shunt should be avoided in the acute phase of a patient's hospital admission.
In-hospital mortality from abdominal aortic surgery in Great Britain and Ireland: Vascular Anaesthesia Society audit
Authors: Bayly P J M , Matthews J N S , Dobson P M , Price M L , Thomas D G
Published: March 2003

Background

The mortality rate associated with elective aortic aneurysm repair is widely assumed to be in the region of 5 per cent. This figure does not take into consideration the effect of pre-existing risk factors. The Vascular Anaesthesia Society of Great Britain and Ireland conducted a large audit to estimate the in-hospital mortality rate associated with non-emergency infrarenal aortic surgery throughout the British Isles, and to determine the influence of risk factors on mortality rate.

Methods

This was a multicentre, prospective audit of 177 hospitals throughout the UK and Ireland. Data were collected by questionnaire to include all patients undergoing elective or urgent surgery for infrarenal abdominal aortic aneurysm or aortoiliac occlusive disease over 4 months.

Results

Nine hundred and thirty-three patients were recruited into the audit. The overall mortality rate was 7·3 per cent. Factors increasing the risk of death by up to fivefold included age over 74 years, urgent surgery, operation for occlusive disease, limited exercise capacity, a history of severe angina or cardiac failure, the presence of ventricular ectopics and abnormalities suggesting ischaemic heart disease on electrocardiography.

Conclusion

Although the in-hospital mortality rate was similar to previously published figures, the rate increased considerably when commonly encountered risk factors were present.
Provocation of experimental aortic inflammation and dilatation by inflammatory mediators and Chlamydia pneumoniae
Authors: Tambiah J , Franklin I J , Trendell-Smith N , Peston D , Powell J T
Published: March 2003

Background

The macrophage appears to have a key role in the inflammation and proteolysis associated with the growth and development of abdominal aortic aneurysms. The role of inflammatory mediators and Chlamydia pneumoniae in stimulating the influx of macrophages and dilatation of the abdominal aorta was investigated in an experimental model.

Methods

Periaortic application of calcium chloride solution (and monocyte chemoattractant protein (MCP) 1, a cocktail of cytokines or C. pneumoniae) to the abdominal aorta of New Zealand White rabbits was performed at laparotomy. Some animals were fed a cholesterol-rich diet. The diameter of the aorta was measured by ultrasonography and after perfusion fixation, 3 weeks after laparotomy. Aortic sections were stained with RAM-11 to identify macrophages for counting. The presence of C. pneumoniae DNA was confirmed using the polymerase chain reaction.

Results

Aortic macrophage influx in response to MCP-1, thioglycollate or C. pneumoniae was more than doubled in the cholesterol-fed animals. In response to human recombinant MCP-1 (1 µg) the mean(s.d.) macrophage count increased from 79(19) to 340(215) per unit area (P < 0·02). Even in cholesterol-fed animals, application of MCP-1 (recombinant human or rabbit form) was not associated with aortic dilatation. Application of thioglycollate 0·1 mol/l, or live or formalin-inactivated C. pneumoniae (0·5 × 108 organisms), was associated with a similar increase in macrophages to that caused by MCP-1 and a significant (approximately twofold) increase in aortic diameter after 3 weeks.

Conclusion

Macrophage influx into rabbit abdominal aorta, without macrophage activation, is insufficient to cause experimental aortic dilatation. C. pneumoniae antigens appeared to stimulate aortic dilatation, probably by specific activation of macrophages.
Non-operative management of haemobilia
Authors: Moodley J , Singh B , Lalloo S , Pershad S , Robbs J V
Published: March 2003

Background

The aim was to evaluate a non-operative approach to the management of haemobilia.

Methods

This was a retrospective analysis of patients presenting over 10 years with haemobilia. All patients had upper gastrointestinal endoscopy, abdominal ultrasonography and digital subtraction angiography. Superselective coil and/or Gelfoam embolization was done as close as possible to the bleeding site. Completion angiography was performed routinely to confirm adequate embolization.

Results

There were 23 patients with liver trauma and six with inflammatory conditions. All patients required resuscitation with fluids and blood transfusion, and had the haemobilia controlled successfully by angiographic embolization. There was one death from fulminant hepatic sepsis.

Conclusion

This series attests to the efficacy of a non-operative approach to haemobilia using radiological diagnosis and intervention.
Experience with laparoscopic ultrasonography for defining tumour resectability in carcinoma of the pancreatic head and periampullary region
Authors: Taylor A M , Roberts S A , Manson J McK
Published: March 2003

Background

Computed tomography (CT) is currently the most widely available staging investigation for pancreatic tumours. However, the accuracy of CT for determining tumour resectability is variable and can be poor. Laparoscopic ultrasonography (LUS) is potentially a more accurate method for disease staging. The authors' experience of LUS for staging carcinoma of the pancreatic head and periampullary region is described.

Methods

Fifty-one patients with potentially resectable pancreatic tumours defined at CT underwent further investigation with LUS. Twenty-seven patients subsequently had an open laparotomy. The evaluations of tumour resectability at CT and LUS were compared with the operative findings.

Results

At LUS, 24 patients were considered to have resectable tumours, 21 non-resectable tumours and six patients were shown to have no pancreatic tumour mass. Twenty-two patients deemed to have a resectable tumour at LUS underwent surgery. Twenty patients were confirmed to have resectable disease and two patients had non-resectable disease. A further five patients underwent surgery. In all five the ultrasonographic diagnosis was confirmed at surgery (four patients with non-resectable disease and no pancreatic tumour in one patient). LUS prevented unnecessary extensive surgery in 53 per cent of patients. For the 22 patients who underwent surgery for potentially resectable disease, the positive predictive value of LUS for defining tumour resectability was 91 per cent.

Conclusion

LUS is an accurate additional investigation for defining tumour resectability and directing management in patients with potentially resectable carcinoma of the pancreatic head or periampullary region.
Randomized clinical trial of stapled versus Milligan—Morgan haemorrhoidectomy
Authors: Shalaby R , Desoky A
Published: March 2003

Background

The introduction of a stapling technique for the treatment of haemorrhoids has the potential for less postoperative pain, a short operating time and an early return to full activity. The outcome of stapled haemorrhoidectomy was compared with that of current standard surgery in a randomized controlled study.

Methods

Two hundred patients were randomized to either stapled haemorrhoidectomy (n = 100) or Milligan–Morgan haemorrhoidectomy (n = 100) between March 1997 and December 1998. Each patient received standardized postoperative analgesic and laxative regimens, and completed a linear analogue pain score every 6 h during the first day after operation, after the first motion and daily until the end of the first week. Operating time, frequency of postoperative analgesic intake, hospital stay, time to return to normal activity and postoperative complications were also recorded.

Results

The mean(s.d.) age of patients in the stapled and surgical groups was 44·1(3·2) and 49·1(12·2) years respectively. The stapled group had a shorter operating time, less frequent postoperative analgesia intake, shorter hospital stay and earlier return to normal activity. Early and late complications, and functional outcome were better in the stapled group.

Conclusion

Use of a circular stapler in the treatment of haemorrhoidal disease was safe, and was associated with fewer complications than conventional haemorrhoidectomy.
Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies
Authors: Kate V , Ananthakrishnan N , Badrinath S
Published: March 2003

Background

The possible advantage of eradication of Helicobacter pylori in patients with perforated duodenal ulcer is unknown. This study was planned to assess the prevalence of H. pylori after simple closure of a perforated duodenal ulcer and to study the effect of H. pylori eradication on ulcer persistence and recurrence.

Methods

Some 202 patients were followed prospectively for 2 years after simple closure of a perforated duodenal ulcer (prospective group). A second group of 60 patients was reviewed 5 years or more after perforation closure (retrospective group). The prevalence of H. pylori in patients with perforated duodenal ulcer was compared with that in controls. Patients in the prospective group were randomized to receive either ranitidine alone or quadruple therapy (ranitidine, colloidal bismuth subcitrate, metronidazole and tetracycline) after operation. The incidence of H. pylori infection after the two treatments and the association with residual or recurrent ulcer were studied. In the retrospective group long-term ulcer recurrence was correlated with H. pylori status.

Results

The prevalence of H. pylori in patients with perforated duodenal ulcer was not significantly different from that in controls. At every interval of follow-up in the prospective group and in the retrospective group the H. pylori infection rate was significantly higher in patients who had recurrent or residual ulcers.

Conclusion

Eradication of H. pylori after simple closure of a perforated duodenal ulcer should reduce the incidence of residual and recurrent ulcers.
Randomized study comparing cardiac response in endovascular and open abdominal aortic aneurysm repair
Authors: Cuypers P W M , Gardien M , Buth J , Peels C H , Charbon J A , Hop W C J
Published: March 2003

Background

The aim was to compare the cardiac response and the incidence of adverse cardiac events during and after endovascular (EVAR) and open (OR) repair of abdominal aortic aneurysms (AAAs).

Methods

Seventy-six patients with an AAA suitable for EVAR, and in a general condition allowing open surgery were randomized to EVAR (57 patients) or OR (19 patients). The analysis was on an intention-to-treat basis. Haemodynamic variables were assessed intraoperatively before, during and after aortic occlusion. During the procedure myocardial ischaemia was identified with use of electrocardiography (ECG) and transoesophageal echocardiography (TEE). After operation, cardiac complications were diagnosed by clinical observation, 12-lead ECG at 1 h, 1 day and 7 days, echocardiography at 1 month and measurement of cardiac enzymes.

Results

After aortic occlusion, a greater decrease in systemic vascular resistance compared with baseline was observed with OR than with EVAR (− 396 and −70 dyne s/cm5 respectively; P = 0·03). The stroke work index, as a direct measure of myocardial performance, demonstrated a decrease during OR and an increase during EVAR during aortic occlusion (− 6·6 and +1·7 g m/m2 respectively; P = 0·03) as well as after aortic occlusion (− 7·6 and +3·4 g m/m2 respectively; P < 0·01), compared with baseline. The incidence of postoperative clinical cardiac complications was comparable in the two study groups; however, myocardial ischaemia, as observed by ECG and TEE, was observed more frequently in the OR group (ten of 19 versus 15 of 57 patients; P = 0·05).

Conclusion

Haemodynamic changes were less severe and there was a lower incidence of myocardial ischaemia during EVAR than during OR. Studies are needed to demonstrate whether this may reduce the operative mortality rate.
Prospective randomized double-blind placebo-controlled trial of glyceryl trinitrate in endoscopic retrograde cholangiopancreatography-induced pancreatitis
Authors: Sudhindran S , Bromwich E , Edwards P R
Published: March 2003

Background

One possible aetiology of pancreatitis following endoscopic retrograde cholangio pancreatography (ERCP) is cannulation-induced spasm of the sphincter of Oddi and consequent pancreatic duct obstruction. Sublingual glyceryl trinitrate (GTN) has been shown to produce periampullary sphincter relaxation. The aim of this study was to determine whether prophylactic long-acting GTN could reduce the incidence of ERCP-induced pancreatitis.

Methods

In a randomized double-blind study, prophylactic treatment with GTN (2 mg given sublingually 5 min before endoscopy) was compared with placebo in 186 patients who presented for elective ERCP. The primary endpoint was the occurrence of pancreatitis within 24 h, defined as a serum amylase concentration greater than 1000 units/ml in association with a visual analogue pain score of more than 5.

Results

The incidence of pancreatitis was lower in the GTN group compared with placebo (seven of 90 versus 17 of 96; P < 0·05). Mean serum amylase values were similar in the two groups. The protective effect of GTN appears to be highest in the diagnostic ERCP group (one of 54 versus ten of 66; P = 0·012) and in the group in which cholangiography alone was performed (one of 54 versus eight of 57; P = 0·032).

Conclusion

Prophylactic treatment with GTN reduces the incidence of pancreatitis following ERCP but does not seem to reduce the extent of hyperamylasaemia or the severity of pancreatitis.
Preserved endothelial integrity and nitric oxide synthase in saphenous vein grafts harvested by a ‘no-touch’ technique
Authors: Tsui J C S , Souza D S R , Filbey D , Bomfim V , Dashwood M R
Published: March 2003

Background

The saphenous vein is the most commonly used conduit for coronary artery bypass surgery, but 1-year occlusion rates as high as 30 per cent have been reported. In conventional surgery, considerable damage to the vein occurs during harvesting. The aim of this study was to compare endothelial integrity and nitric oxide synthase (NOS) in saphenous veins harvested by a novel ‘no-touch’ technique and veins harvested conventionally.

Methods

Immunohistochemistry was used to study endothelial integrity, and a combination of histochemistry and autoradiography was employed to identify NOS in human saphenous veins harvested by conventional and no-touch techniques.

Results

The endothelial lining of conventional grafts was reduced compared with that of no-touch grafts (52 versus 73 per cent; P = 0·04). This was associated with a concomitant reduction of NOS availability; NOS was also present in the adventitial vasa vasorum of no-touch vessels.

Conclusion

Some of the sites with potential for nitric oxide release in vivo are removed during conventional saphenous vein harvesting. These sites were preserved after no-touch harvesting, suggesting the potential to improve coronary artery bypass graft patency.
Preservation of endothelial integrity and function in experimental vascular anastomosis with non-penetrating clips
Authors: Zeebregts C , van den Dungen J , Buikema H , Tiebosch A , van der Want J , van Schilfgaarde R
Published: March 2003

Background

Vascular repair with sutures is associated with disruption of the endothelial lining and subsequent thrombus formation on the intraluminal lesions. This experimental study was designed to determine whether the use of non-penetrating clips improved endothelial preservation.

Methods

In ten female pigs, 25-mm arteriotomies were made in both carotid arteries. The arteriotomies were repaired with jugular vein patches. On the left side, the repair was done with 1·4-mm titanium clips, and on the right side with two running 6/0 polypropylene sutures. Next, the aorta was divided and subsequently repaired with 2-mm clips in five of these pigs, and with two running 5/0 polypropylene sutures in the remaining five pigs. Endothelial function was studied at the anastomotic site in the carotid arteries by determination of endothelium-dependent and -independent relaxatory responses. Morphometric examination of the carotid arteries and inspection of the aortic endothelium were performed by means of scanning electron microscopy.

Results

Maximal endothelium-dependent relaxation to adenosine 5′-diphosphate was less in sutured than in clipped carotid arteries (P < 0·05), while there was no difference in maximal endothelium-independent relaxation to sodium nitrite. This result in clipped carotid arteries was not accompanied by less intimal hyperplasia. Screening of the aortic anastomotic line showed better preservation of endothelial architecture after clip anastomosis. Mean cross-clamp time for carotid patch repair was significantly less when using clips than with sutures.

Conclusion

The use of non-penetrating clips for vascular anastomoses preserved endothelial function and structural integrity better than running sutures, although the degree of intimal hyperplasia was similar.
Detection and clinical significance of occult tumour cells in colorectal cancer
Authors: Tsavellas G , Patel H , Allen-Mersh T G
Published: March 2003

Background

A variety of techniques have been employed for the detection of occult tumour cells in the blood, bone marrow and lymph nodes of patients with colorectal cancer. This review examines the methods used, results obtained and the clinical significance of studies in this field.

Methods

A Medline literature search was performed using the terms colorectal cancer, minimal residual disease, micrometastasis, polymerase chain reaction, reverse transcriptase polymerase chain reaction and immunocytochemistry; further references were obtained from key articles.

Results

Immunocytochemical examination of bone marrow is the benchmark for detecting clinically significant occult disease. Larger standardized studies are required to confirm the prognostic significance of molecular assays for the detection of tumour cells in blood and bone marrow. The prognostic significance of lymph node tumour cells detected by either immunohistochemical or molecular methods awaits further affirmation.

Conclusion

Standardization of terminology and techniques used, combined with large prospective clinical studies, is required if detection of occult residual disease is to become a prognostic marker for recurrence in colorectal cancer.
Diagnosis and prognosis of breast cancer by magnetic resonance spectroscopy of fine-needle aspirates analysed using a statistical classification strategy
Authors: Mountford C E , Somorjai R L , Malycha P , Gluch L , Lean C , Russell P , Barraclough B , Gillett D , Himmelreich U , Dolenko B , Nikulin A E , Smith I C P
Published: March 2003

Background

The aim was to develop robust classifiers to analyse magnetic resonance spectroscopy (MRS) data of fine-needle aspirates taken from breast tumours. The resulting data could provide computerized, classification-based diagnosis and prognostic indicators.

Methods

Fine-needle aspirate biopsies obtained at the time of surgery for both benign and malignant breast diseases were analysed by one-dimensional proton MRS at 8·5 Tesla. Diagnostic correlation was performed between the spectra and standard pathology reports, including the presence of vascular invasion by the primary cancer and involvement of the excised axillary lymph nodes.

Results

Malignant tissue was distinguished from benign lesions with an overall accuracy of 93 per cent. From the same spectra, lymph node involvement was predicted with an overall accuracy of 95 per cent, and tumour vascular invasion with an overall accuracy of 94 per cent.

Conclusion

The pathology, nodal involvement and tumour vascular invasion were predicted by computerized statistical classification of the proton MRS spectrum from a fine-needle aspirate biopsy taken from the primary breast lesion.
Molecular mechanisms of renal allograft fibrosis
Authors: Waller J R , Nicholson M L
Published: March 2003

Background

Chronic graft nephropathy (CGN) remains the leading cause of renal allograft loss after the first year following transplantation. Histologically it is characterized by glomerulosclerosis, intimal hyperplasia and interstitial fibrosis. The pathogenesis is unclear, but is likely to involve both immunological and non-immunological factors. Despite improvements in short-term graft survival rates, new immunosuppressive regimens have made no impact on CGN.

Methods

A review of the current literature on renal transplantation, novel immunosuppression regimens and advances in the molecular pathogenesis of renal allograft fibrosis was performed.

Results and conclusion

Recent advances in understanding of the underlying molecular mechanisms involved suggest autocrine secretion of cytokines and growth factors, especially transforming growth factor β, are associated with a change in fibroblast phenotype leading to the deposition of extracellular matrix. Repeated insults trigger upregulation of the tissue inhibitors of matrix metalloproteinases, favouring accumulation of extracellular matrix. To date, no drug has proved effective in inhibiting or reducing allograft fibrosis. The deleterious consequences of chronic immunosuppression on the development of such fibrosis are now recognized; newer immunosuppressive drugs, including rapamycin and mycophenolate mofetil, reduce profibrotic gene expression in both experimental and clinical settings, and offer potential strategies for prolonging allograft survival.
Postoperative futility: a clinical algorithm for setting limits
Authors: McCullough L B , Jones J W
Published: March 2003

This is the sixth in a series of articles on ethics, professional governance and the law that BJS will run through the remainder of 2001.
Prospective study of the effect of laparoscopic Nissen fundoplication on reflux mechanisms
Authors: Straathof J W A , Ringers J , Masclee A A M
Published: March 2003

Background

Laparoscopic Nissen fundoplication effectively reduces acid reflux and reflux symptoms. Little is known about the effect on reflux mechanisms, especially on transient lower oesophageal sphincter relaxations (TLOSRs).

Methods

Twenty-seven patients were studied prospectively before and after laparoscopic Nissen fundoplication, by simultaneous recording of pH and lower oesophageal sphincter (LOS) characteristics using sleeve manometry. In all of the 27 patients the operation was judged successful, based on major improvement or resolution of reflux symptoms and acid reflux. Vagus nerve integrity was studied indirectly by the secretion of pancreatic polypeptide (PP) in response to insulin-induced hypoglycaemia.

Results

After fundoplication basal LOS pressure increased significantly from mean(s.e.m.) 13(1) to 22(1) mmHg (P < 0·001). Laparoscopic Nissen fundoplication significantly decreased the frequency of TLOSR in the fasting period from mean(s.e.m.) 2·5(0·5) to 0·6(0·2) per h, and in the postprandial period from 4·0(0·4) to 1·3(0·3) per h (P < 0·01). The percentage of TLOSRs associated with reflux also decreased significantly from 24(10) to 0(0) per cent in the fasting period and from 42(6) to 12(6) per cent in the postprandial period, before and after fundoplication respectively (P < 0·01). After operation the PP response was abnormal in three patients, pointing to vagus nerve dysfunction. Postoperative TLOSR frequency and LOS pressure were no different between patients with and without vagus nerve dysfunction.

Conclusion

Laparoscopic Nissen fundoplication significantly increased fasting and postprandial LOS pressure and significantly decreased the rate of TLOSR. This resulted in a significant reduction in oesophageal acid exposure but postprandial LOS characteristics were preserved.
Readmissions after pancreatoduodenectomy
Authors: van Geenen R C I , van Gulik T M , Busch O R C , de Wit L T , Obertop H , Gouma D J
Published: March 2003

Background

Readmission after pancreatoduodenectomy because of tumour recurrence or surgery-related complications can adversely affect patient outcome.

Methods

From October 1992 to June 1999, 283 consecutive resections were performed (243 for malignant disease and 40 for benign disease). The hospital mortality rate was 1 per cent (three of 283). All readmissions were analysed with regard to indication, treatment and outcome.

Results

One hundred and six patients (38 per cent) were readmitted, 64 (60 per cent) because of tumour recurrence and indications such as gastrointestinal obstruction (n = 19), biliary obstruction (n = 15) and pain (n = 21), of whom 30 patients (47 per cent) were in a preterminal condition. Median hospital stay and hospital-free survival after discharge were 14 and 51 days respectively. Median survival after surgical treatment (n = 14) was 58 days, and ascites was significantly associated with poor survival. Forty-seven (44 per cent) of the patients were readmitted for surgical complications such as abscess (n = 11), fistula (n = 8) and gastrointestinal obstruction (n = 8). Median hospital stay was 15 days and median hospital-free survival after discharge was 1035 days.

Conclusion

Readmission after pancreatoduodenectomy was common (38 per cent), 60 per cent for tumour recurrence and 44 per cent for surgery-related complications. Survival after surgical bypass procedures for tumour recurrence was limited, particularly when ascites was present. Patients readmitted for complications of surgery had a good prognosis.
Cystatin C deficiency is associated with the progression of small abdominal aortic aneurysms
Authors: Lindholt J S , Erlandsen E J , Henneberg E W
Published: March 2003

Background

The cysteine protease inhibitor cystatin C may play a role in the development and progression of abdominal aortic aneurysms (AAAs).

Methods

From a mass screening trial of men aged 65–73 years, 151 small AAAs were followed for a mean of 2·9 years. Of these patients, 142 had serum samples taken to determine the levels of cystatin C, creatinine and C-reactive protein (CRP).

Results

Serum cystatin C concentration correlated negatively with AAA size (r = − 0·22 (95 per cent confidence interval (c.i.) −0·59 to −0·02)) and annual expansion rate (r = − 0·24 (95 per cent c.i. −0·75 to −0·05)), persisting after adjustment for renal function, smoking, diastolic blood pressure, CRP, age and AAA size. Creatinine clearance and CRP did not correlate with size or expansion rate. Thirty-one AAAs had expanded to over 50 mm, when operation was recommended. The serum level of cystatin C was a significant predictor of this occurrence, with a sensitivity and specificity of 61 and 57 per cent respectively. However, initial AAA size had the optimal sensitivity and specificity (both 81 per cent) in this regard.

Conclusion

Deficiency of cystatin C was associated with increased aneurysm size and expansion rate, possibly due to lack of inhibition of cysteine proteases.
Diagnosis and management of a mediastinal leak following radical oesophagectomy
Authors: Griffin S M , Lamb P J , Dresner S M , Richardson D L , Hayes N
Published: March 2003

Background

The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis.

Methods

Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy.

Results

Nineteen patients (6·5 per cent) developed a proven mediastinal leak at a median of 8 (range 3–30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5–8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died.

Conclusion

Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.
Function of a colonic J pouch continues to improve with time
Authors: Harris G J C , Lavery I C , Fazio V W
Published: March 2003

Background

J pouch–anal anastomosis is thought to give superior functional results to straight coloanal anastomosis after rectal resection. Follow-up studies have suggested that this improvement is not maintained and that evacuatory difficulties may increase.

Methods

Some 119 consecutive patients had a coloanal anastomosis after resection for rectal carcinoma over 113 months, 62 with a J pouch and 57 with a straight coloanal anastomosis. Functional results were determined by patient questionnaire. The two groups were compared for the first and second 5-year intervals of study.

Results

Patients who had a J pouch had significantly better median Kirwan continence scores for the duration of the study and 5–9 years after surgery: 1 versus 2 (P = 0·05) and 1 versus 2 (P < 0·01), respectively. Some 5–9 years after surgery the median number of nocturnal bowel movements was significantly lower in patients who had a J pouch than in those with a straight coloanal anastomosis (0 versus 1; P = 0·02). Similarly, significantly better results were seen with regard to evacuation difficulties and urgency of defaecation.

Conclusion

The function of the J pouch was superior to that of the straight coloanal anastomosis and appeared to improve with time.