bluuebunny/crossref_metadata_2025 huggingface dataset:
E2A–PBX1 fusion in adult acute lymphoblastic leukaemia: biological and clinical features
Authors: Foa Robin , Vitale Antonella , Mancini Marco , Cuneo Antonio , Mecucci Cristina , Elia Loredana , Lombardo Romina , Saglio Giuseppe , Torelli Giuseppe , Annino Luciana , Specchia Giorgina , Damasio Eugenio , Recchia Anna , Di Raimondo Francesco , Morra Enrica , Volpe Ettore , Tafuri Agostino , Fazi Paola , Hunger Stephen P. , Mandelli Franco
Published: March 2003

Summary. Molecular and cytogenetic studies performed in 305 adult acute lymphoblastic leukaemia (ALL) patients enrolled in the gimema (Gruppo Italiano Malattie EMatologiche dell'Adulto) multicentric protocols identified an E2A–PBX1 fusion and/or t(1;19) in 10 patients (3·3%). All had common ALL, were mostly CyIg+ and were CD34/CD13/CD33–. Nine patients achieved a complete remission (CR); five patients showed a haematological relapse after 7 months (median). Four patients are alive in first CR with a median follow‐up of 29 months; three patients are molecularly negative. This abnormality is frequently associated with early treatment failure. E2A–PBX1+ adult ALL should be considered for intensified treatment strategies and monitoring of minimal residual disease.
Function of the proximal stomach after Nissen fundoplication
Authors: Wijnhoven B P L , Salet G A M , Roelofs J M M , Smout A J P M , Akkermans L M A , Gooszen H G
Published: March 2003

Background

After Nissen fundoplication patients frequently report upper abdominal (dyspeptic) symptoms. Theoretically, these symptoms may be the result of changes in function of the proximal stomach as induced by fundoplication.

Methods

In this case–control study the response of the proximal stomach to both distension by an air-filled bag and a liquid meal were evaluated with the use of a barostat. In 12 patients after fundoplication and 12 healthy volunteers (age- and sex-matched) perception of symptoms was evaluated during both bag distension and liquid meal stimulus.

Results

The minimal distending pressure required to overcome the intra-abdominal pressure was significantly different between patients and controls (mean(s.e.m.) 9·34(0·26) versus 6·73(0·43) mmHg; P < 0·001). There was no difference between groups in either the fasted state, volume–pressure curve (compliance) or total symptom score. After ingestion of the liquid meal the adaptive relaxation in the fundoplication group was significantly less than that in controls (mean(s.e.m.) 150(29·2) versus 244(34·8) ml; P = 0·04).

Conclusion

This study showed that after Nissen fundoplication compliance of the proximal stomach is no different from that in healthy volunteers. Postprandial relaxation of the proximal stomach is decreased and this abnormality may be involved in the pathogenesis of reported dyspeptic symptoms.
Blood supply of the right and left hepatic ducts
Authors: Stapleton G N , Hickman R , Terblanche J
Published: March 2003

Background

Increasing precision of liver resection and use of reduced liver grafts stimulated this study of the blood supply of the intrahepatic bile ducts.

Method

Corrosion casts of human liver were dissected to study the blood supply of the right and left hepatic ducts.

Results

The dissected casts showed that the ducts are surrounded by a vascular plexus supplied from the main right and left hepatic arteries, segmental arteries, gastroduodenal artery and accessory hepatic arteries. This plexus is closely associated with the arteries supplying the caudate lobe. They arise from both right and left in two general patterns. This plexus links the arterial supplies of the right and left livers. Segment IV and the central portion of the left hepatic duct are often supplied by the right arterial system.

Conclusion

This study provides further insights into bile duct blood supply. The caudate lobe and biliary plexus provide collateral connections between the right and left livers.
Timing of surgery for fulminating pseudomembranous colitis
Authors: Synnott K , Mealy K , Merry C , Kyne L , Keane C , Quill R
Published: March 2003

Background

With increasing antibiotic usage Clostridium difficile colitis is becoming more common. Surgery for fulminating C. difficile colitis, however, is rare because of the effectiveness of specific anticlostridial chemotherapy. Surgical outcome in five patients with fulminating C. difficile colitis involved in a recent outbreak of this disease is reported.

Methods

Five of 138 patients developed fulminating C. difficile colitis unresponsive to medical therapy. All patients had antibiotics in the preceding period. Indications for operation in those who underwent surgery were systemic toxicity with a pyrexia, marked leukocytosis and abdominal signs leading to progressive organ failure, despite appropriate anticlostridial antibiotic therapy.

Results

At operation all patients had a markedly oedematous colon with normal serosa but with acute mucosal colitis. All underwent subtotal abdominal colectomy and ileostomy. Progressive organ failure persisted in four, leading to death, giving a mortality rate of four in five in the operated group in comparison with 3·8 per cent (five of 133 patients) in those treated medically.

Conclusions

These results indicate that this increasingly common disease frequently leads to a fatal outcome in patients requiring surgery and implies that earlier surgical consultation may be necessary to improve survival in patients with fulminating C. difficile colitis unresponsive to antibiotic therapy.
Reduced total antioxidant capacity predicts ischaemia–reperfusion injury after femorodistal bypass
Authors: Spark J I , Chetter I C , Gallavin I , Kester R C , Guillou P J , Scott D J A
Published: March 2003

Background

Antioxidant defence systems are essential to protect the body from harmful free radicals released following ischaemia–reperfusion. The aim of this study was to examine the total antioxidant capacity (TAC) of patients with chronic critical leg ischaemia undergoing femorodistal bypass and to correlate this with lipid peroxidation, changes in capillary permeability and clinical outcome.

Methods

Twenty-five patients, 15 men and ten women of median age 71 (range 62–79) years, and 15 matched controls were studied. Blood was taken before operation and after reperfusion, with assays performed for malondialdehyde (a product of lipid peroxidation) and total antioxidant capacity. Changes in capillary permeability were measured by changes in the urinary albumin:creatinine ratio (ACR) following reperfusion of the ischaemic leg and expressed as a percentage increase from the preoperative value. Clinical outcome in terms of the systemic inflammatory response syndrome (SIRS) was recorded.

Results

Vascular patients who developed clinical evidence of a systemic inflammatory reaction following revascularization had a significantly reduced TAC compared with the controls (490 versus 860 µmol/l; P < 0·01, Mann–Whitney U test). These patients also demonstrated an increase in lipid peroxidation (0·5 versus 0·25 µmol/l, P < 0·05) and vascular permeability, as measured by the percentage increase in ACR (365 versus 130 per cent, P < 0·01).

Conclusion

Vascular patients with a lower TAC developed increased capillary permeability as a result of ischaemia–reperfusion, which progressed to SIRS. TAC may provide a test to identify ‘at risk’ patients. It may be possible to augment their defence with exogenous antioxidants.
Matrix metalloproteinase 9 level predicts optimal collagen deposition during early wound repair in humans
Authors: Ågren M S , Jorgensen I N , Andersen M , Viljanto J , Gottrup P
Published: March 2003

Background

This study examined two matrix metalloproteinases (MMPs) and their association with deposition of collagen during wound repair.

Methods

In 15 hernia wounds, wound fluid was collected using two Cellstick devices, which were implanted adjacent to two expanded polytetrafluoroethylene (ePTFE) tubes. MMP-2 and MMP-9 levels were analysed 24 and 48 h after operation using specific enzyme-linked immunosorbent assays, and collagen deposition in the ePTFE tubes was measured 10 days after operation as hydroxyproline.

Results

The levels of both MMPs in wound fluid were increased compared with those of control serum, although MMP-9 decreased (P < 0·01) in the wounds 24–48 h after operation. The MMP-9 level at 24 h correlated inversely and specifically to deposited collagen measured as hydroxyproline (rS = −0·80, P < 0·01).

Conclusion

These results indicate that the level of MMP-9 in the early inflammatory phase can predict the amount of collagen deposited later in the wound healing process.
Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer
Authors: Polati E , Finco G , Gottin L , Bassi C , Pederzoli P , Ischia I
Published: March 2003

Background

In a randomized double-blind study the efficacy of neurolytic coeliac plexus block (NCPB) was compared with pharmacological therapy in the treatment of pain from pancreatic cancer.

Methods

Twenty-four patients were divided into two groups: 12 patients underwent NCPB (group 1) and 12 were treated with pharmacological therapy (group 2). Immediate and long-term efficacy, mean analgesic consumption, mortality and morbidity were evaluated at follow-up. Statistical analysis was performed with the unpaired t test, Mann–Whitney U test and Fisher's exact test.

Results

Immediately after the block, patients in group 1 reported significant pain relief compared with those in group 2 (P < 0·05), but long-term results did not differ between the groups. Mean analgesic consumption was lower in group 1. There were no deaths. Complications related to NCPB were transient diarrhoea and hypotension (P not significant between groups). Drug-related adverse effects were constipation (five of 12 patients in group 1 versus12 of 12 in group 2), nausea and/or vomiting (four of 12 patients in group 1 versus 12 of 12 in group 2) (P < 0·05), one gastric ulcer and one gluteal abscess in group 2.

Conclusion

NCPB was associated with a reduction in analgesic drug administration and drug-related adverse effects, representing an effective tool in the treatment of pancreatic cancer pain.
Correlation between blood loss and inferior vena caval pressure during liver resection
Authors: Johnson M , Mannar R , Wu A V O
Published: March 2003

Background

Blood loss and transfusion requirement are major determinants of mortality and morbidity following liver resection. This study was prompted by the observation that blood loss was excessive when the inferior vena cava (IVC) was distended, and determined whether a correlation exists between blood loss and pressure within the IVC during liver resection.

Methods

A 6-month prospective study was conducted on 20 consecutive patients undergoing liver resection in which two variables were measured, the pressure within the retrohepatic part of the IVC and blood loss during resection.

Results

It was observed that when the caval pressure was less than 6 mmHg the operating field was almost bloodless (mean blood loss 363 (range 305–465) ml). When the caval pressure was between 6 and 12 mmHg the liver became congested and bleeding from the liver surface became significantly greater (1259 (range 415–1789) ml). When caval pressure was greater than 13 mmHg bleeding became excessive (2703 (range 2360–3450) ml). Correlation between blood loss and caval pressure was strong (Pearson correlation coefficient 0·93, P < 0·001).

Conclusion

This study suggests that one of the keys to decreasing blood loss and transfusion requirement during liver resection is to lower pressure within the IVC.
Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome
Authors: Bartels H E , Stein H J , Siewert J R
Published: March 2003

Background

Lesions of the trachea or main-stem bronchi with air leakage are a grave complication of oesophagectomy.

Methods

Prevalence, predisposing factors and outcome of non-malignant lesions of the trachea or main-stem bronchi were analysed retrospectively in a consecutive series of 785 patients who had oesophagectomy for oesophageal cancer.

Results

Overall 31 of 785 patients developed a tracheobronchial fistula 1–30 days after oesophagectomy. Based on the location of the lesions and clinical circumstances, the tracheobronchial fistulas were thought to be due to surgical injury (four patients), cuff pressure of the tracheostomy tube (two), local peritracheal infection resulting from a cervical anastomotic leak (seven) or ‘ischaemia’ after extensive peritracheal dissection (18). On multivariate analysis, transthoracic en bloc resection (P < 0·01) and preoperative radiochemotherapy for locally advanced tumours located at or above the level of the tracheal bifurcation (P < 0·01) predisposed to this complication.

Conclusion

Non-malignant tracheobronchial lesions are a serious complication of transthoracic oesophagectomy with extensive lymph node dissection, particularly in patients undergoing preoperative radiochemotherapy for locally advanced tumours.
Surgical resection of locally recurrent colorectal adenocarcinoma
Authors: Delpero J R , Pol B , Le Treut Y P , Bardou V J , Moutardier V , Hardwigsen J , Granger F , Houvenaeghel G
Published: March 2003

Background

Recurrence rates after curative resection of colorectal adenocarcinoma remain steady at 50 per cent. Thirty per cent of the deaths are linked to locoregional recurrence. The aim of this study was to evaluate the results of resection for locoregional recurrence.

Methods

This retrospective review analysed a series of 120 patients who underwent resection of colonic (56) or rectal (64) locoregional recurrence. Sixty-nine resections were considered as curative. Sixty-one recurrences required extended resection. There were nine synchronous hepatic resections.

Results

The hospital mortality rate was 7 per cent and the morbidity rate was 40 per cent. The overall 5-year survival rate was 27 per cent. Survival was significantly higher: (1) after curative resection (44 versus 0 per cent after palliative resection, P < 0·0001); (2) in women (44 versus 11 per cent for men, P = 0·0036); and (3) after resection for intramural recurrence (45 versus19 per cent for extramural recurrence, P = 0·0024). Multifactorial analysis showed that curability of the resection was the most important prognostic parameter.

Conclusion

The results in this highly selected group seem to justify an attempt at reresection whenever possible. Long-term results may be improved by using adjuvant treatment.
Prediction of resectability of pancreatic malignancy by computed tomography
Authors: McCarthy M J , Evans J , Sagar G , Neoptolemos J P
Published: March 2003

Background

The accuracy of computed tomography (CT) in predicting resectability of pancreatic malignancy has been questioned recently and alternative methods have been recommended.

Methods

To determine the accuracy of CT for predicting resectability and its influence on survival, a standard protocol for performing CT and reporting the results was developed and then compared retrospectively with the ability of one surgeon to perform a resection during 1989–1994. Postoperative survival was determined.

Results

Of 88 consecutive patients 35 (40 per cent) had CT-resectable disease and 53 (60 per cent) had CT-irresectable disease. Twenty-one patients were excluded because of advanced disease or poor performance status. Of the remaining 67 patients, 47 (70 per cent) had pancreatic ductal adenocarcinoma and 20 (30 per cent) had ampullary adenocarcinoma, of whom 32 had a resection, 32 had a palliative bypass and three had only a staging laparoscopy. The sensitivity and specificity for computed tomographic prediction of resectability were 72 and 80 per cent respectively. The positive predictive value was 77 per cent and the negative predictive value 76 per cent. There were seven false-positive and nine false-negative findings. Survival was more dependent on whether or not resection was performed than on computed tomographic predictability of resection.

Conclusion

CT was reasonably accurate in predicting resectability but cannot be relied on entirely, requiring an improvement in staging methods for pancreatic malignancy.
Effect of the introduction of total mesorectal excision for the treatment of rectal cancer
Authors: Carlsen E , Schlichting E , Guldvog I , Johnson E , Heald R J
Published: March 2003

Background

Total mesorectal excision (TME) has been reported to reduce local recurrence and improve survival rates in patients with rectal carcinoma. This paper reports the problems that have arisen with the introduction of this new surgical technique.

Methods

This was a prospective study of two consecutive groups of patients: one who underwent TME (n = 76) and one who did not (non-TME, n = 76).

Results

Postoperative mortality rate in the non-TME and TME group was 5 and 7 per cent respectively, and the rate of anastomotic failure was 8 and 16 per cent respectively. Anastomotic leaks in TME patients were located in the mid and lower rectum. TME patients with anastomotic failure had lower anastomoses and a longer duration of operation than non-TME patients. Intraoperative problems were encountered in 71 per cent of the failures. All TME patients who had a leak required reoperation compared with 25 per cent of non-TME patients. TME patients without postoperative complications stayed significantly longer in hospital than non-TME patients.

Conclusion

Anastomotic dehiscence increased after introduction of the TME technique but this improved with experience.
Structured data collection improves the diagnosis of acute appendicitis
Authors: Körner H , Söndenaa K , Söreide J A , Andersen E , Nysted A , Lende T H
Published: March 2003

Background

Structured preoperative data collection and computer-assisted methods are claimed to improve diagnostic accuracy in patients with acute abdominal pain. The aim of this study was to evaluate a possible age- and sex-related effect of using structured data collection in the preoperative diagnosis of patients with suspected acute appendicitis.

Methods

Between 1989 and 1994, clinical and demographic data from 1764 consecutive patients were recorded. In 1990 and 1992, various detailed symptom, clinical and laboratory data were collected prospectively on a structured registration form. Age- and sex-specific diagnostic accuracy as well as perforation rate were calculated for each year.

Results

Diagnostic accuracy increased significantly by 5 (95 per cent confidence interval (c.i.) 1–9) per cent when structured data registration was applied. In female patients aged between 13 and 40 years, diagnostic accuracy increased by 16 (95 per cent c.i. 8–24) per cent. Significant changes in diagnostic accuracy were not seen in other subgroups. Perforation rates remained unchanged during the entire study period.

Conclusion

In this population-based study, diagnostic accuracy in patients operated on for suspected acute appendicitis increased for all patients when structured preoperative data collection was used. However, the only subgroup with a significant increase in diagnostic accuracy was female patients aged between 13 and 40 years. Perforation rate was unaffected by structured data collection.
Genetic alterations in chronic pancreatitis: evidence for early occurrence of p53 but not K-ras mutations
Authors: Gansauge S , Schmid R M , Muller J , Adler G , Mattfeldt T , Beger H G
Published: March 2003

Background

In patients suffering from chronic pancreatitis the risk for the development of pancreatic cancer ranges from 4 to 6 per cent. Various mutations are associated with pancreatic cancer, especially of p53 and K-ras. The incidence of these mutations in resected chronic pancreatitic tissue was investigated.

Methods

In the present study DNA from 80 samples of tissue from patients with chronic pancreatitis was isolated and subjected to single-strand conformation polymorphism (SSCP) analysis of p53 exons 5–9 and restriction fragment length polymorphism analysis of K-ras (codon 12).

Results

No mutations in the K-ras gene were detected. On SSCP analysis, eight of 80 cases of chronic pancreatitis showed alterations (two in exon 5, four in exon 6, two in exon 7). DNA sequence analysis revealed one deletion of 21 amino acids (exon 5), four polymorphisms in exon 6 with no change in the amino acid sequence, one point mutation in exon 5, and two point mutations located in the intron between exons 6 and 7.

Conclusion

These data show that in some cases of chronic pancreatitis mutations in the p53 gene occur without morphological evidence of pancreatic cancer.
Prospective randomized controlled trial to compare skin staples and polypropylene for securing the mesh in inguinal hernia repair
Authors: Mills I W , Mcdermott I M , Ratliff D A
Published: March 2003

Background

The Lichtenstein tension-free repair has become the standard method for repairing inguinal hernia in many surgical units. This study compared two methods of mesh fixation.

Methods

Fifty men undergoing unilateral primary Lichtenstein inguinal hernia repair under general anaesthesia were randomized into two groups. In the control group polypropylene mesh was secured with 2/0 polypropylene sutures and the skin closed with subcuticular 3/0 polydioxanone. In the study group polypropylene mesh was secured with skin staples and the skin was closed with staples from the same staple gun. Duration of the operation was recorded. Early follow-up was achieved by patient review at 6 weeks and postal questionnaire at 12 weeks.

Results

The operation was significantly shorter when staples were used (median 20 min 0 s versus 29 min 30 s, P < 0·001). There was no significant difference in the incidence of postoperative complications or pain score. The study group reported earlier return to normal activity (4 weeks 0 days versus 6 weeks 2 days, P < 0·01) although there was no difference in the time taken to return to work or driving.

Conclusion

The use of skin staples to secure mesh in the Lichtenstein inguinal hernia repair significantly reduced the duration of the operation and was as effective as conventional mesh fixation with polypropylene in the short term.
Magnetic resonance imaging in evaluation of the common bile duct
Authors: Musella M , Barbalace G , Capparelli G , Carrano A , Castaldo P , Tamburrini O , Musella S
Published: March 2003

Background

The ideal method for evaluation of the common bile duct (CBD) before or during cholecystectomy remains controversial. Magnetic resonance cholangiography (MRC) is a new, promising technique. A prospective evaluation is reported.

Method

Sixty-one patients (45 women) were studied by MRC. There were 29 patients with symptomatic gallstone disease and without clinical, biochemical or ultrasonographic evidence of CBD stones (group 1); 28 of them also underwent intraoperative cholangiography (IOC). In addition, there were 21 patients with symptomatic gallstone disease, with mild biochemical and ultrasonographic signs of CBD involvement (group 2), of whom 19 underwent IOC, and 11 patients with symptomatic CBD stones (group 3), nine of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP) following MRC.

Results

MRC showed that no patient in group 1 and three patients in group 2 had CBD stones. Three patients (one in group 1, two in group 2) did not undergo IOC because of technical or clinical problems. In group 3, ERCP confirmed the results of MRC in nine patients. Two patients underwent open surgery because of ultrasonographic, MRC and radiographic signs of pancreatic malignancy.

Conclusion

MRC could replace IOC and ERCP for identification of asymptomatic CBD stones. In symptomatic patients MRC combined with other non-invasive imaging techniques can direct the surgeon to appropriate management.
Ignoring small lymph nodes can be a major cause of staging error in gastric cancer
Authors: Noda N , Sasako M , Yamaguchi N , Nakanishi Y
Published: March 2003

Background

Stage migration in gastric cancer confounds establishment of standard treatment according to stage.

Methods

To determine how closely lymph nodes should be examined to report correct staging, 402 node-positive patients were evaluated retrospectively. A total of 23 233 lymph nodes were reviewed histologically and their maximum dimension was measured. Another 254 nodes from 12 patients were used to evaluate shrinkage after fixation and preparation of the histological slide.

Results

Metastasis was detected in 3142 nodes, 1163 with well differentiated tumours (WDTs) and 1979 with poorly differentiated tumours (PDTs). Mean(s.d.) size of metastatic nodes was 7·80(5·08) mm in all, 8·44(5·74) mm in WDTs and 7·42(4·62) mm in PDTs. Both positive and negative nodes shrank between 10 and 20 per cent during histological processing. If all nodes 5 mm or less in size when fixed are ignored 37·8 per cent of all metastatic nodes will be missed. Downstaging will occur in 14·9 per cent and 4·2 per cent of the cases if all nodes less than 6 and 4 mm respectively are ignored.

Conclusion

To keep the rate of stage migration caused by this factor below 5 per cent, all lymph nodes 4 mm or more in size (5 mm when fresh) should be retrieved and examined.
Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis
Authors: Rau B , Pralle U , Mayer J M , Beger H G
Published: March 2003

Background

Early detection of infected pancreatic necrosis has a major impact on further management and outcome in acute pancreatitis. The aim of this study was to evaluate the clinical value of ultrasonographically guided fine-needle aspiration cytology (FNAC) in patients with necrotizing pancreatitis over an 8-year period.

Methods

From January 1988 to September 1996 193 (mean 2·0 (range 1–9) aspirations per patient) prospectively assessed FNACs guided ultrasonographically were performed in 98 patients with necrotizing pancreatitis proven by contrast-enhanced computed tomography. Aspirates were considered infected if either Gram stain and/or culture revealed micro-organisms.

Results

Ultrasonographically guided FNAC correctly diagnosed infection in 29 of 33 patients with infected necrosis a median of 13 days after onset of symptoms. Of 61 patients with sterile necrosis 55 were identified correctly as sterile by FNAC. There were six false-positive and four false-negative aspirates of which nine occurred during the first week of the disease. In four patients who did not undergo operation FNAC revealed Gram-negative organisms; however, in the absence of repeated aspirations, the positive results remained unconfirmed. An overall sensitivity of 88 per cent and a specificity of 90 per cent was obtained. No difference was found in biochemical and clinical parameters indicating systemic inflammatory response syndrome before each FNAC between patients with proven sterile or infected necrosis. All patients tolerated the procedure well and no major complications were observed.

Conclusion

Ultrasonographically guided FNAC is a fast and reliable technique for the diagnosis of infected necrosis. As complication rates are very low, the procedure can be repeated at short intervals to improve the diagnostic accuracy. Ultrasonographically guided FNAC is recommended for all patients with necrotizing pancreatitis in whom systemic inflammatory response syndrome persists beyond the first week after onset of symptoms.
Epidemiology and potential for prevention of abdominal aortic aneurysm
Authors: Wilmink A B M , Quick C R G
Published: March 2003

Background

Ruptured abdominal aortic aneurysm (AAA) is a common cause of death which is preventable by elective repair of an asymptomatic AAA.

Methods

The literature was reviewed with emphasis on epidemiological studies and population-based screening surveys.

Results and Conclusion

The prevalence of small AAA ranges between 3 and 8 per cent. The incidence of asymptomatic AAA seems to be increasing, although exact incidence estimates vary. The most important risk factors for AAA are male sex, age, family history and smoking. Hypertension is associated with a mildly increased risk, but diabetes is not associated with any increase. Primary prevention of AAA is not a realistic option. There is no evidence of an effective medical treatment to prevent growth of small AAAs, although trials with propranolol are under way. The only intervention to prevent death from aneurysm is elective repair of the asymptomatic lesion. Screening for asymptomatic AAA can reduce the incidence of rupture. However, further studies are needed to determine the cost effectiveness of screening compared with that of other health programmes.
Anomalous pancreaticobiliary junction without congenital choledochal cyst
Authors: Sugiyama M , Atomi Y
Published: March 2003

Background

Anomalous pancreaticobiliary junction (APBJ) without congenital choledochal cyst (CCC) carries a high risk of gallbladder carcinoma development. The aim of this study was to obtain information allowing early diagnosis and appropriate management.

Methods

The clinical features, imaging findings and surgical outcome of 18 patients with APBJ without CCC were analysed retrospectively.

Results

Fourteen patients had symptoms, including those of acute pancreatitis (five patients). In 16 patients the gallbladder showed abnormalities, including carcinoma (eight) and mucosal hyperplasia (11). Ultrasonography detected gallbladder carcinoma with 100 per cent sensitivity and mucosal hyperplasia with 91 per cent sensitivity. A long common channel was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) in all patients, endoscopic ultrasonography in nine of ten, and magnetic resonance cholangiopancreatography (MRCP) in five of five. Five of eight patients with gallbladder carcinoma underwent extended cholecystectomy with bile duct excision. Three patients with cancer and eight with no cancer had cholecystectomy alone. None developed bile duct carcinoma or acute pancreatitis after operation. All patients without malignancy remained asymptomatic for a mean follow-up period of 4·7 years.

Conclusion

Prophylactic cholecystectomy is recommended for patients with APBJ without CCC. For early diagnosis of APBJ, gallbladder abnormalities on ultrasonography or acute pancreatitis of unknown aetiology should prompt further investigation with ERCP or less invasive imaging modalities such as endoscopic ultrasonography and MRCP.
Controlled trial of preperitoneal local anaesthetic for reducing pain following laparoscopic hernia repair
Authors: Deans G T , Wilson M S , Brough W A
Published: March 2003

Background

A prospective randomized trial was performed to determine whether local anaesthetic solutions injected into the preperitoneal space may provide additional pain relief following transabdominal preperitoneal laparoscopic hernia repair.

Methods

One hundred patients undergoing transabdominal preperitoneal laparoscopic hernia repair were allocated randomly to receive (1) bupivacaine 1·5 mg/kg, (2) bupivacaine 1·5 mg/kg with 1 in 200 000 adrenaline, (3) bupivacaine 3 mg/kg or (4) saline instilled into the preperitoneal space at the end of the operation. An independent clinical assessor determined the level of pain using a visual analogue pain score and noted the parenteral and oral analgesia requirements at 4, 8, 12 and 24 h after operation.

Results

At each of the time intervals, there was no significant difference between the groups for pain scores (at 24 h, P = 0·71) or the number of doses of either morphine (at 24 h, P = 0·73) or oral analgesia (at 24 h, P = 0·89). There was also no significant difference in the time to return to normal activity or work between the groups.

Conclusion

This study suggests that instilling local anaesthetic into the preperitoneal space has no significant effect on postoperative pain relief requirement following laparoscopic hernia repair. Other methods of reducing postoperative pain should be sought that may facilitate day-case laparoscopic hernia surgery.
Surgical endoscopic techniques in the diagnosis and follow-up of patients with lymphoma
Authors: Gossot D , de Kerviler E , Brice P , Mariette X , Meignin V , Cazals-Hatem D , Frija J , Célérier M
Published: March 2003

Background

In patients with lymphoma, tissue for histology can be obtained through image-guided techniques or by surgery. The aim of this study was to assess the efficacy of surgical endoscopic techniques in obtaining adequate tissue specimens.

Methods

Ninety-two patients with suspected or confirmed lymphoma were referred for a surgical biopsy of a deeply located intrathoracic or intra-abdominal mass or lymph node. The 86 patients who had surgery using a surgical endoscopic technique were included in this study. There were 54 men and 32 women, of mean age 34 (range 15–78) years. Most were selected directly for surgery while five previously had a failed computed tomography-guided biopsy. A total of 89 procedures were performed in 86 patients: laparoscopy (15 patients), thoracoscopy (61) and mediastinoscopy (13).

Results

No patient died. One intraoperative complication occurred during thoracoscopy (1 per cent). Two postoperative complications were noted (2 per cent). Three patients required conversion to open surgery (3 per cent). Adequate tissue for histology was obtained by surgical endoscopic procedures in 87 per cent. Twelve of 13 mediastinoscopies were successful. After thoracoscopy, the success rate was 92 per cent but only nine of 15 laparoscopies were considered successful.

Conclusion

In patients with lymphoma, surgical endoscopic techniques have a high diagnostic yield and a low morbidity rate. Barring exceptional circumstances these should be favoured rather than conventional open surgery.
Contribution of computed tomography to decision making in the management of adhesive small bowel obstruction
Authors: Donckier V , Closset J , Van Gansbeke D , Zalcman M , Sy M , Houben J J , Lambilliotte J P
Published: March 2003

Background

In adhesive small bowel obstruction, the early recognition of complications such as strangulation or volvulus is essential to choose between surgical or conservative initial treatment. The objective of this study was to determine prospectively the contribution of computed tomography (CT) to decision making in the management of these patients.

Methods

Patients with suspected adhesive small bowel obstruction had CT at admission. Patients with CT signs of volvulus or strangulation and/or clinical signs of peritoneal irritation underwent urgent surgery; other patients had conservative initial treatment.

Results

Fifty-four patients were evaluated. CT demonstrated signs of strangulation or volvulus in 19 patients, including three with signs of peritoneal irritation. Within this group, urgent laparotomy was performed in 17 patients and confirmed the CT diagnosis in 16. Thirty-seven patients without clinical or CT signs of complications had initial conservative treatment; among them, seven of 12 with a distal obstruction determined by CT required a delayed operation for persisting obstruction, compared with two of 25 patients with a proximal obstruction (P<0·01).

Conclusion

CT is useful for the evaluation of adhesive small bowel obstruction, to detect accurately patients with complications who require urgent operation and to determine the location of the adhesion, which represents a significant prognostic factor for success of conservative treatment.
Antireflux surgery in the laparoscopic era
Authors: Watson D I , Jamieson G G
Published: March 2003

Background

The recent development of laparoscopic techniques for fundoplication has created renewed interest in surgery for gastro-oesophageal reflux disease, leading to reports of large clinical series from many centres. However, controversy remains about technical aspects of laparoscopic antireflux surgery, with no consensus yet reached about a standard operative technique. It is important, therefore, to reassess critically the results of laparoscopic surgery for reflux disease, so that its current status can be determined.

Methods

Published outcome studies for laparoscopic antireflux surgery, as well as selected studies from the era of open antireflux surgery, were reviewed to assess outcomes.

Results

The results of case series for laparoscopic antireflux surgery with short- and medium-term follow-up, as well as the early results of randomized trials, confirm that this approach reduces the early overall morbidity of surgery for reflux disease. However, certain complications may be more common, for instance paraoesophageal hiatus herniation, pneumothorax and oesophageal perforation, requiring surgeons to use specific strategies which can help to avoid these problems. Published studies and trials do not support the routine or selective application of a posterior partial fundoplication technique or routine division of the short gastric vessels during Nissen fundoplication.

Conclusion

At present, a short loose Nissen fundoplication performed laparoscopically, with or without division of the short gastric vessels, is an appropriate surgical approach for gastro-oesophageal reflux disease. However, long-term outcomes following laparoscopic antireflux surgery will not be available for some years, and must be awaited before the final status of the various laparoscopic techniques can be confirmed.
d-lactate as an early marker of intestinal ischaemia after ruptured abdominal aortic aneurysm repair
Authors: Poeze M , Froon A H M , Greve J W M , Ramsay G
Published: March 2003

Background

Patients with a ruptured abdominal aortic aneurysm (AAA) are at risk of developing colonic ischaemia after surgery. It is difficult to diagnose this ischaemia at an early stage. d-lactate is produced by intestinal bacteria after ischaemia. L-lactate is released in increased amounts during hypoxia by anaerobic metabolism. This study investigated both variables as a marker for intestinal ischaemia in patients with a ruptured AAA.

Methods

Twenty-four patients with ruptured AAA were divided retrospectively into two groups with and without ischaemic complications, as verified by colonoscopy. Blood had been taken on admission to the intensive care unit (ICU). Median time to colonoscopy was 9 days after surgery. As controls, four patients with pneumonia, six healthy subjects, five patients with an elective AAA repair, and six patients with sepsis and acute tubular necrosis were included.

Results

d-lactate level on admission was significantly increased in patients with colonic ischaemia after ruptured AAA compared with the level in patients without ischaemia (P < 0·05), patients with sepsis (P < 0·001), those with pneumonia and healthy subjects (P < 0·01). L-lactate concentration was similar in the group with intestinal complications and in patients without colonic ischaemia; however, L-lactate levels were higher in patients with pneumonia and sepsis than in healthy subjects (P < 0·05).

Conclusion

On admission to the ICU, d-lactate, but not L-lactate, levels may predict later colonic ischaemia following repair of a ruptured AAA.
Repair of ventral hernias with expanded polytetrafluoroethylene patch
Authors: Balén E M , Díez-Caballero A , Hernández-Lizoáin J L , Pardo F , Torramadé J R , Regueira F M , Cienfuegos J A
Published: March 2003

Background

Operations for large and recurrent abdominal hernias have a high associated recurrence rate, although it is lower when prosthetic material is used. Expanded polytetrafluoroethylene (ePTFE) seems to be the best tolerated prosthetic material in surgery.

Methods

A series of 45 ventral hernias repaired using ePTFE for closure or reinforcement of the herniorrhaphy has been evaluated prospectively. Thirty-six were midline incisional hernias and nine were transverse or pararectal ventral hernias. There were 13 recurrent ventral hernias and three defects were operated as an emergency procedure. The patch was sutured to the anterior aponeurosis with a running non-absorbable suture. Some other kind of intra-abdominal procedure was undertaken in 12 cases.

Results

ePTFE was well tolerated. Complications occurred in five patients. Major complications were found in three patients: cutaneous necrosis requiring a myocutaneous flap; and infection of the prosthesis (primary, and secondary to enterocutaneous fistula due to diverticulitis, both requiring removal of the patch). Mean follow-up was 39 months and hernia recurrence occurred in only one patient.

Conclusion

This clinical experience shows that ePTFE is a very reliable prosthetic material for the repair of abdominal wall hernias.
Co-existing abdominal aortic aneurysm and intra-abdominal malignancy: reflections on the order of treatment
Authors: Morris H L , da Silva A F
Published: March 2003

Background

The management of simultaneously occurring abdominal aortic aneurysm and intra-abdominal malignancy is controversial. It is unclear whether to treat the aneurysm first or the malignancy, or both simultaneously. If the malignancy is resected first there is a risk of postoperative rupture of the aneurysm. If simultaneous surgery is performed there is a risk of prosthetic graft infection from contamination by gastrointestinal or urinary tract contents.

Methods

Relevant papers from 1960 to 1996, identified from Medline and manual searching, were reviewed.

Results and conclusion

The literature supports the conclusion that the lesion of greater priority is that posing the greater threat to the patient; this is usually the aneurysm, especially if it is over 6 cm in diameter. For renal malignancies simultaneous surgery is the treatment of choice, but for bladder cancer the best management is unclear. Large aneurysms should usually be resected in preference to colorectal cancer unless the cancer is locally advanced, perforated or likely to result in early intestinal obstruction. If both lesions are complicated there may be a case for simultaneous treatment.
Experimental study of the effect of intra-abdominal pressure during laparoscopy on tumour growth and port site metastasis
Authors: Jacobi C A , Wenger F A , Ordemann J , Gutt C , Sabat R , Müller J M
Published: March 2003

Background

The influence of raised intraperitoneal pressure during laparoscopy on tumour growth and port site metastasis is still unknown.

Methods

Tumour growth of colonic adenocarcinoma DHD/K12/TRb was measured after laparoscopy with carbon dioxide at different pressures (0, 5, 10 and 15 mmHg) in a rat model. Cell kinetics were determined after incubation with carbon dioxide (0, 5, 10 and 15 mmHg) in vitro (n = 60). Additionally, tumour growth was measured subcutaneously and intraperitoneally 4 weeks after laparoscopy at different intraperitoneal pressures (5, 10 and 15 mmHg) (n = 100).

Results

In vitro tumour growth decreased significantly after incubation with carbon dioxide at 10 and 15 mmHg compared with a pressure of 0 or 5 mmHg. In vivo, mean(s.d.) intraperitoneal tumour weight was significantly increased after laparoscopy at 5 mmHg (919(1085) mg) and at 10 mmHg (1274(1523) mg) (P < 0·05), but decreased again after laparoscopy with an intraperitoneal pressure of 15 mmHg (731(929) mg) compared with the control group (365(353) mg) (P = 0·3). Mean(s.d.) subcutaneous tumour growth was promoted after laparoscopy at 5 mmHg (172(234) mg), at 10 mmHg (190(253) mg) and at 15 mmHg (178(194) mg) compared with controls (48(33) mg) (P < 0·05).

Conclusion

In vitro, raised intraperitoneal pressure leads to suppression of tumour growth. In vivo, intraperitoneal tumour growth is suppressed only by higher pressure (15 mmHg). Subcutaneous tumour growth is stimulated by carbon dioxide independently of the intraperitoneal pressure.
Hepatocellular carcinoma
Authors: Akriviadis E A , Llovet J M , Efremidis S C , Shouval D , Canelo R , Ringe B , Meyers W C
Published: March 2003

Background

Hepatocellular carcinoma is one of the world's most common malignancies. The aims of the present paper are to review data on (1) epidemiology and screening programmes for the early detection of the tumour and (2) advances in the diagnostic imaging and management.

Methods

Relevant English language articles, published between January 1985 and December 1997, were reviewed. Articles were identified through Medline search, using the key words ‘hepatocellular carcinoma’. Articles cited in the bibliographies of these articles were searched manually.

Results

Hepatocellular carcinoma has a heterogeneous geographical distribution. Although its risk factors have been identified, the efficacy of screening programmes remains uncertain. Imaging has improved substantially with the recent application of dual-phase helical computed tomography and magnetic resonance imaging employing specific contrast agents. The comparative efficacy of conservative therapy and surgical resection is uncertain, since well controlled trials are lacking.

Conclusion

Hepatocellular carcinoma is commonly a problem of two diseases, the malignancy itself and cirrhosis. This renders treatment rarely curative, even when surgical resection can be applied in a technically successful sense. Liver transplantation could be a definitive treatment but this is plagued by limited donor resources.
Diagnosis and conservative management of intrathoracic leakage after oesophagectomy
Authors: Sauvanet A , Baltar J , Le Mee J , Belghiti J
Published: March 2003

Background

Although intrathoracic leakage is a major complication of oesophagectomy, precise data concerning diagnostic features and results of conservative treatment are lacking.

Methods

From 1986 to 1994, 409 oesophagectomies with stapled oesophagogastrostomy were performed, including 358 Lewis–Tanner and 51 Sweet procedures. A water-soluble contrast swallow was routinely performed on day 7 or later, before oral intake was begun. All patients except one received conservative non-surgical treatment, including nutritional support and perianastomotic drainage.

Results

Leaks were diagnosed in 38 patients (9·3 per cent). The leakage rate was 7·8 per cent after the Lewis–Tanner procedure and 20 per cent after the Sweet procedure (P < 0·01). Eleven patients had no symptoms. Seven of the 27 patients with symptoms had a contrast swallow that was normal, and subsequently developed a confirmed fistula after the onset of oral intake. Five patients had to undergo reoperation. All asymptomatic patients and 18 symptomatic patients recovered. Nine patients died, mainly from multiple organ failure, including three who had reoperation for resection of the gastroplasty.

Conclusion

The potential presence of clinically silent fistula and the deleterious role of oral intake still justify routine detection of leakage after oesophageal resection. Conservative treatment results in survival with preservation of the gastroplasty in most patients, unless multiple organ failure occurs.