bluuebunny/crossref_metadata_2025 huggingface dataset:
Preliminary study of D-dimer as a possible marker of acute bowel ischaemia
Authors: Acosta S , Nilsson T K , Björck M
Published: March 2003

Background

Occlusion of the superior mesenteric artery (SMA) demands prompt recognition and diagnosis. No accurate diagnostic method is available. The aim of this study was to determine whether the fibrinolytic marker D-dimer is a useful early marker of acute bowel ischaemia.

Methods

Fourteen patients suspected of having acute bowel ischaemia were analysed for an increase in plasma D-dimer level.

Results

Six patients had embolic or thrombotic occlusion of the SMA and all had significantly higher D-dimer levels than those without thromboembolic occlusion (P < 0·05). Four patients with strangulation of the small bowel due to adhesions and one with a ruptured aortic aneurysm also had raised D-dimer values.

Conclusion

In patients with suspected thromboembolic occlusive disease of the SMA, a raised level of D-dimer indicated the presence of acute bowel ischaemia, whatever the cause. A more extensive prospective study is needed to evaluate a potential survival benefit using the test as a marker of the need for urgent laparotomy.
Randomized clinical trial of local bupivacaine perfusion versus parenteral morphine infusion for pain relief after laparotomy
Authors: Cheong W K , Seow-Choen F , Eu K W , Tang C L , Heah S M
Published: March 2003

Background

Opioids are often used to decrease pain following laparotomy but are associated with unwanted side-effects. The effectiveness of local perfusion of bupivacaine 0·5 per cent following laparotomy was studied.

Methods

A prospective randomized study involving patients undergoing laparotomy for major colorectal surgery using a left iliac fossa skin crease incision was undertaken. Patients were randomized to receive either intermittent intravenous morphine infusion on demand with patient-controlled analgesia (PCA group) or continuous wound perfusion of local bupivacaine 0·5 per cent for 60 h (LA group).

Results

Seventy patients were recruited, 35 in each group. Patient demographics, surgical and recovery variables and complications were comparable in the two groups. The wound lengths were similar (median 14 cm in both groups). There was no statistically significant difference in postoperative pain scores at rest and with movement between the two groups, except for pain scores at rest on the first postoperative day (P = 0·03). The median total amount of morphine used was significantly greater in the PCA group (median 38 versus 0 mg in the LA group; P < 0·001).

Conclusion

Direct continuous local wound perfusion of bupivacaine 0·5 per cent is as effective as PCA for postoperative pain relief after laparotomy. It is a safe and feasible alternative to parenteral opioids.
Management of aortic aneurysm in the presence of a horseshoe kidney
Authors: Stroosma O B , Kootstra G , Schurink G W H
Published: March 2003

Background

The coexistence of an aortic aneurysm and a horseshoe kidney poses a technical challenge to the vascular surgeon at the time of aneurysm repair. The aim of this review is to develop a guideline for the treatment of patients with this dual pathology.

Method

A literature review combined with local experience provided a total of 176 cases. These were divided into two groups: asymptomatic aneurysms (134) and ruptured aneurysms (42), both in combination with a horseshoe kidney.

Results

Six types of operative approach were described: transperitoneal approach with or without separation of the renal isthmus, retroperitoneal approach, placement of a stent-graft, aneurysmal wrap and exploration without exclusion of the aneurysm. Diagnosis of the horseshoe kidney was made before operation in 81 per cent of patients in the asymptomatic group, and in 55 per cent (23 of 42) in the ruptured group. Computed tomography proved to be the most reliable diagnostic procedure. Occlusion of renal arteries originating from the aneurysm was reported in 51 per cent in the asymptomatic group, and in 74 per cent (23 of 31) in the ruptured group.

Conclusion

The preferred surgical options for asymptomatic patients with an aortic aneurysm and a horseshoe kidney are the placement of a stent-graft or a retroperitoneal approach; both avoid many of the technical difficulties related to the presence of the horseshoe kidney. The approach of choice for a ruptured aneurysm is transperitoneal. Separation of the renal isthmus should be avoided.
Neoadjuvant chemoradiotherapy for operable oesophageal carcinoma: preliminary results from Sheffield
Authors: Welch I McL , Fisher P M , Stoddard C J , Wyman A
Published: March 2003

Background

Surgical resection is the mainstay of treatment for potentially curable oesophageal carcinoma but the long-term survival rate remains 10–20 per cent. Neoadjuvant administration of chemoradiotherapy (NCR) may improve these values. In this study the authors reviewed their preliminary experience with NCR in Sheffield.

Methods

Twenty-five patients with potentially resectable oesophageal carcinoma embarked on a regimen of NCR, with resection planned 4–6 weeks later. Chemotherapy incorporated two cycles of intravenous cis-platinum and 5-fluorouracil with external-beam radiotherapy administered synchronously (30–45 Gy).

Results

Twenty-two of the 25 patients suffered side-effects from NCR, including one death, and seven patients failed to complete NCR as planned. The median interval from diagnosis to surgery was 121 days. Twelve out of 24 patients had significant postoperative complications, including two deaths. Seven patients had a complete histological response to NCR (three out of 15 for adenocarcinoma, four out of nine for squamous carcinoma).

Conclusion

The complete histological response rate to NCR in these patients compares favourably with previous studies, as does the postoperative mortality, but this was at the expense of substantial morbidity and was associated with long delays from diagnosis to operation. At present it is not possible to predict which patients will respond favourably to NCR and whether they will benefit with improved survival.
Oesophageal diverticula
Authors: Thomas M L , Anthony A A , Fosh B G , Finch J G , Maddern G J
Published: March 2003

Background

Oesophageal pulsion diverticula, excluding pharyngeal types, are uncommon sequelae of oesophageal dysmotility. Current opinion favours myotomy as effective therapy, but the role of diverticulectomy, myotomy selection and placement, and the need for fundoplication remain unresolved.

Methods

A Medline search and review of references identified relevant English language articles. Data on epidemiology, aetiology, oesophageal motility, pathology, symptomatology, investigations, surgical management and outcome were examined.

Results

Data were largely retrospective. Significant morbidity and mortality were associated with pulmonary aspiration and diverticulectomy site leaks. Surgical outcome was similar whether or not a diverticulectomy was added to a myotomy, but a myotomy clearly reduced the risk of leaks. Fundoplication reduced the incidence of postcardiomyotomy reflux symptoms. Results from minimally invasive techniques were similar to those of open surgery.

Conclusion

Surgery should be reserved for symptomatic patients; asymptomatic patients may benefit from surveillance. Pulmonary aspiration mandates surgical intervention. Myotomy remains the mainstay of treatment and an adequate subdiverticular extension is crucial in relieving obstruction. A partial fundoplication is preferred in selected patients. Minimally invasive techniques should become the routine approach for oesophageal pulsion diverticula.
Prospective analysis of the diagnostic yield of extended en bloc resection for adenocarcinoma of the oesophagus or gastric cardia
Authors: Hulscher J B F , Van Sandick J W , Offerhaus G J A , Tilanus H W , Obertop H , Van Lanschot J J B
Published: March 2003

Background

The extent of lymph node dissection can affect tumour node metastasis staging. The resulting ‘stage migration’ might hamper stage-by-stage comparison between different forms of oesophageal resection. The aim of this study was to assess the diagnostic impact of extended en bloc lymphadenectomy in staging (adeno)carcinoma of the mid/distal oesophagus or gastric cardia.

Methods

This was a prospective study of 74 patients (67 men and seven women; median age 63 (range 40–78) years) who underwent extended oesophagectomy between 1994 and 2000.

Results

A median of 31 (range 15–78) lymph nodes was resected (and identified), with a median of 5 (range 0–31) positive nodes. Twenty-seven patients (36 per cent) had tumour-positive nodes in extended fields: 15 patients (20 per cent) in the abdomen and 15 patients (20 per cent) in the mediastinum. Subcarinal nodes were most affected (19 per cent). Extended resection led to tumour upstaging in 17 patients (23 per cent); two patients had isolated positive subcarinal nodes and 15 other tumours became M1a owing to positive nodes near the coeliac axis, hepatic artery or splenic artery. Tumour positivity in paratracheal or aortopulmonary nodes occurred in 8 per cent of patients, without influencing staging.

Conclusion

Extended en bloc lymphadenectomy altered staging in 17 of 74 patients (23 per cent) with adenocarcinoma of the oesophagus or cardia, mainly into M1a owing to positive coeliac nodes (20 per cent).
Endovascular intervention compared with carotid endarterectomy
Authors: Beard J D , Cleveland T , Gaines P A , Lonsdale R
Published: March 2003

Background

Endovascular intervention has only recently been used for the treatment of carotid disease. The 30-day outcome of 226 endovascular carotid interventions for atherosclerosis performed since August 1993 is presented.

Methods

All patients were symptomatic apart from four (2 per cent) who underwent intervention before coronary artery bypass. The last presenting symptom was transient ischaemic attack (TIA) (40 per cent), amaurosis fugax (31 per cent), retinal artery occlusion (3 per cent) and stroke (24 per cent). A moderate stenosis (50–69 per cent; North American Symptomatic Carotid Endarterectomy Trial technique) was present in 24 patients (11 per cent), a severe stenosis (70–95 per cent) in 144 (64 per cent), and a preocclusive stenosis (more than 95 per cent) in 58 (26 per cent). The contralateral internal carotid artery was significantly diseased (greater than 70 per cent) or occluded in 65 patients (29 per cent). All patients were pretreated with aspirin; 5000 units heparin and 1·2 mg atropine were given during the procedure. Initially, stents were reserved for treating residual stenosis after angioplasty (16 of 108 procedures). Later, a change was made to primary stenting (116 procedures). A femoral approach was used for all patients.

Results

At 30 days there were four deaths (2 per cent) and eight disabling strokes (4 per cent) (death and disabling stroke rate 5 per cent; death and all-strokes rate 8 per cent). For angioplasty and selective stenting the death and disabling stroke rate and the death and all-strokes rate were 6 and 9 per cent respectively, compared with 5 and 8 per cent for primary stenting (P not significant). However, there was a significant difference between the incidence of all adverse events (31 versus 11 per cent) as a result of fewer TIAs associated with primary stenting. During the same interval, 300 carotid endarterectomies (similar indications and severity of disease) were performed. There were six deaths (2 per cent) and eight disabling strokes (3 per cent) (death and disabling stroke rate 5 per cent; death and all-strokes rate 6 per cent). The complications of both endovascular intervention and conventional endarterectomy seem to be improving with time.

Conclusion

These data confirm the feasibility of endovascular carotid intervention and highlight the need for a large randomized trial comparing it with conventional surgery. The benefit of stents and cerebral protection systems also requires further investigation.
Ischaemic preconditioning before lower limb ischaemia–reperfusion protects against acute lung injury
Authors: Harkin D W , Barros D'Sa A A B , McCallion K , Baker R , Hoper M , Campbell F C
Published: March 2003

Background

Ischaemic preconditioning (IPC) of skeletal muscle, by exposing it to repeated brief periods of ischaemia and reperfusion (I-R) before a subsequent longer ischaemic period, protects against local damage on reperfusion. In a large animal model of hindlimb I-R it was hypothesized that hindlimb IPC would attenuate the systemic inflammatory response syndrome and prevent acute lung injury associated with limb reperfusion injury.

Methods

Anaesthetized ventilated swine (six per group) were used throughout. After midline laparotomy, animals were randomized to the following three groups: bilateral external iliac artery occlusion for 120 min, followed by reperfusion for 180 min (I-R group); IPC (three cycles of 5 min ischaemia, then 5 min reperfusion of both external iliac arteries) followed by bilateral external iliac artery occlusion for 120 min and reperfusion for 180 min (I-R + IPC group); or laparotomy alone (control group). Acute lung injury was assessed by invasive pulmonary artery pressure (PAP) measurement, arterial to alveolar (A-a) oxygen gradient, lung tissue wet: dry weight ratio, and lung myeloperoxidase (MPO) concentration.

Results

Conclusion

Lower limb I-R induces systemic inflammation and acutely impairs oxygen transport associated with lung neutrophil sequestration. IPC attenuates acute pulmonary hypertension, impairment of oxygen transport, oedema and leucosequestration in planned lower limb I-R.
Scottish leg ulcer project: a randomized trial evaluating the implementation of national guidelines
Authors: Ruckley C V
Published: March 2003

Background

Innumerable consensus documents and guidelines have been published, but little is known about their implementation or impact. Community nurses provide more than 80 per cent of the care of patients with chronic leg ulcers. Healing rates of 50–74 per cent at 3 months have been reported in published trials. Outcomes in the community are largely unknown. National guidelines on leg ulcer care were published in 1998 by the Scottish Intercollegiate Guideline Network (SIGN), which produces evidence-based guidelines using strict criteria and methodology. The aim was to evaluate the impact of national guidelines, with or without a structured nurse training programme, on leg ulcer healing rates in the community nationwide.

Methods

Community healthcare trusts covering a population of 2·65 million were divided into 50 geographically and administratively distinct localities averaging 53 000 population, which were randomized to either SIGN guidelines (control) or guidelines plus a guideline-based nurse training programme (intervention). Data were collected from 649 caseload managers by 3-monthly censuses throughout the 2·5 years of the project. After a 6-month baseline period, guidelines were distributed and an intensive programme of training was provided throughout Scotland by a multidisciplinary team in the intervention localities for 51 link nurses, who were trained and resourced to cascade their training to approximately 1700 community nurses.

Results

Some 4413 patients with 4984 ulcerated legs were registered. The mean age of 77 years was more than a decade older than that in published trials. Multiple co-morbidities were reported. The response rate from caseload managers was 99·4 per cent, rising to 100 per cent for the rest of the study. Intercensal follow-up was complete for 98·9 per cent of patients. The baseline 3-month ulcer healing rate was 30 per cent; it remained the same throughout the subsequent 2 years, with no difference between intervention and control groups.

Conclusion

Neither national guidelines nor an intensive training programme made any impact on leg ulcer healing rates. The outcomes of leg ulcer care are poor. The delivery of care requires reorganization. The impact and implementation of consensus statements and guidelines should be evaluated.
Reduction of vascular smooth muscle cell proliferation by immunomodulation
Authors: Chan Y C , Shukla N , Okonko D O , Singh M , Stanford J L , Mansfield A O , Stansby G
Published: March 2003

Background

Immunological factors may play an important role in mediating the progression of atherosclerosis and myointimal hyperplasia, with heat shock proteins being implicated as possible autoantigens. The authors have shown previously that immunomodulation can reduce vascular smooth muscle cell (vSMC) proliferation following balloon injury to rat carotid arteries. The aim of the present study was to examine the effects of immunomodulatory agents on the proliferation of rat aortic vSMCs remote from the area of balloon injury. The agents used were SRL172 (heat-killed Mycobacterium vaccae) and heat shock protein 65 kDa (HSP65) in Freund's incomplete adjuvant. Both these agents are known to influence T-cell responses.

Methods

Male Sprague–Dawley rats were used. All immunizations were given subcutaneously. Four groups were studied (ten animals in each group): group 1 animals were immunized with normal saline, group 2 received SRL172, group 3 SRL172 and HSP65–Freund's, and group 4 HSP65–Freund's. Three immunizations were performed as well as carotid balloon injury. Three animals died, leaving 37 for analysis. Some 5 weeks later the animals were killed and the aorta was harvested. Standard explant techniques were applied to grow aortic vSMCs until confluency, passaged three times, quiesced, and fetal calf serum (FCS) of varying concentrations (0·4–10 per cent) was then added, incubated for another 48 h and cell counts carried out.

Results

The proliferation rate of aortic vSMCs in the control group was significantly greater than that in the other study groups (Fig.). While all the treatment groups had significantly less proliferation compared with the control group (*P < 0·05, †P < 0·01, Mann–Whitney U test), no statistically significant differences existed between any of the study groups.

Conclusion

Immunomodulation may result in a reduction of vSMC proliferation. Although the precise mechanisms involved are unclear, these results are in concordance with previous findings that T-cell immunomodulation decreases the development of myointimal hyperplasia after injury, and suggest that a fundamental phenotypic shift has been produced by these immunizations.
Prospective audit of major amputations for peripheral vascular disease
Authors: Vallabhaneni S R , Hughes D M , Reilly D T , Blair S D , Greaney M G
Published: March 2003

Background

Primary amputation followed by prosthetic fitting has been proposed as an alternative worth considering if lower limb bypass has poor prospects of patency. This is an outcome audit of major amputations at a single centre where amputations were performed only if limb salvage was not possible.

Methods

Consecutive major amputations (n = 162) for peripheral vascular disease from January 1996 to December 1998 were studied prospectively. Duration of hospital stay, causes of morbidity and mortality, and reasons for being unsuitable for prosthesis were recorded. Mobility at admission and after rehabilitation was documented using a standard grading system (grades 1–6).

Results

There were 114 above-knee, 45 below-knee and three through-knee amputations. The 30-day mortality rate was 14 per cent (22 patients), increasing to 29 per cent (47) at 9 months. Some 57 patients (35 per cent) were rehabilitated with a prosthetic limb (30 above knee, 27 below knee). Mobility with prosthesis was better or maintained in 24 patients, worse by one grade in 17, and by two or more grades in the remaining 16. Fifty-eight patients (36 per cent) were unsuitable for an artificial limb; in four this was because of stump-related problems, and the rest because of co-morbidity. Cardiorespiratory events were the most frequent cause of morbidity and mortality. The mean hospital stay after amputation was 37 days in survivors.

Conclusion

Perioperative and late mortality rates following amputation are high. A large proportion of amputees were not suitable for prosthesis, mainly because of co-morbidity. Of the patients receiving a prosthesis, only 42 per cent (15 per cent of the total) maintained or improved their mobility. The results are unlikely to be different if a policy of selective primary amputation were to be adopted. The outcome of amputation is worse than widely perceived despite the improvements in prostheses and a well executed rehabilitation process.
Use of minilaparotomy in the treatment of colonic cancer
Authors: Nakagoe T , Sawai T , Tsuji T , Ayabe H
Published: March 2003

Background

The feasibility and safety of a minilaparotomy approach for curative resection of colonic cancer have not been fully elucidated. The purpose of this study was to compare outcomes utilizing this alternative technique with those of conventional laparotomy.

Methods

Eighty-four patients scheduled to undergo resection for colonic cancer via minilaparotomy between 1997 and 1999 were studied prospectively. The minilaparotomy involved complete resection performed through a skin incision less than 7 cm in length. Sixty-nine patients who underwent a similar resection via a conventional laparotomy between 1994 and 1996 served as the control group.

Results

The minilaparotomy approach was successful in 72 of 84 patients. Colectomy type, operating time and histopathological features of tumours were similar between cases and controls, whereas operative blood loss in the control group was significantly greater (P = 0·002). Postoperative times to standing, walking, passage of flatus and urinary catheter removal were significantly shorter in the minilaparotomy group (P = 0·007, P = 0·003, P = 0·03 and P = 0·006 respectively), and analgesic requirements were significantly lower (P = 0·001). At a median follow-up of 24·8 months there have been no tumour recurrences at the minilaparotomy incision sites.

Conclusion

A minilaparotomy approach to the curative resection of colonic cancer is an attractive alternative to conventional laparotomy in selected patients.
Randomized clinical trial of the effect of open versus laparoscopically assisted colectomy on systemic immunity in patients with colorectal cancer
Authors: Tang C-L , Eu K-W , Tai B-C , Soh J G S , Machin D , Seow-Choen F
Published: March 2003

Background

Laparoscopic surgery is believed to produce an attenuated metabolic stress response and to have a less dampening effect on the immune response than open surgery. To date, the effect has not been studied in a randomized clinical trial of colorectal cancer.

Methods

The study was a two-armed randomized prospective trial conducted in parallel with the UK Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial comparing laparoscopically assisted colorectal surgery for left-sided tumours with conventional open surgery. Systemic immunity was assessed by determining the T- and B-cell counts, the CD4: CD8 ratio, the natural killer cell counts, the immunoglobulin (Ig) G, IgM and IgA levels, and C3 and C4 levels. The white cell phagocytic activity (nitroblue tetrazolium test) was studied before operation and on the third postoperative day.

Results

A total of 236 patients were randomized in the immune study between 11 March 1997 and 14 August 1999; 161 had complete preoperative and postoperative assays for the analysis of results. There was no difference in mean response between the two surgical groups for each of the immune parameters studied. The unadjusted difference for the primary endpoint, T-cell count, 3 days after operation was −1·6 per cent (95 per cent confidence interval −5·0 to 1·8 per cent).

Conclusion

There is no difference in the systemic immune response in patients having laparoscopically assisted colectomy compared with those undergoing conventional open surgery for colorectal cancer.
Book reviews
Authors: Bcrgqvist D , Cheslyn-Curtis S
Published: March 2003

Vascular Reconstructions: Anatomy, Exposures, and Techniques

J. J. Hoballah 285 × 219 mm. Pp. 393. Illustrated. 2000. New York: Springer. £65⋅00.

Schein's Common Sense Emergency Abdominal Surgery

M. Schein 235 × 156 mm. Pp. 382. Illustrated. 2000. Berlin: Springer. £30⋅50.
Radio-guided sentinel node detection for gastric cancer
Authors: Kitagawa Y , Fujii H , Mukai M , Kubota T , Otani Y , Kitajima M
Published: March 2003

Background

Radio-guided detection of sentinel nodes (SNs) has been used to predict regional metastases in patients with malignant melanoma and breast cancer. However, the validity of the SN hypothesis is still controversial for gastrointestinal cancers including gastric cancer. The aim of this study was to test the feasibility and accuracy of radio-guided mapping of SNs for gastric cancer.

Methods

Some 145 consecutive patients with gastric cancer diagnosed as T1 or T2 and evaluated clinically as N0 were enrolled. Endoscopic injection of technetium-99m-radiolabelled tin colloid was performed before operation and radioactive SNs were identified with a γ probe. Standard radical gastrectomy with lymphadenectomy was performed in all patients and all resected nodes were evaluated by routine histopathological examination.

Results

Using radio-guided methods, SNs were detected in 138 (95·2 per cent) of 145 patients. The SN was positive in 22 of 24 patients with lymph node metastasis. The incidence of metastasis in the SNs (7·8 per cent) was significantly higher than that in the non-SNs (0·3 per cent) (P < 0·01). The diagnostic accuracy according to SN status was 98·6 per cent (136 of 138).

Conclusion

Radio-guided SN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with early-stage gastric cancer.
Percutaneous radiofrequency thermoablation as an alternative to surgery for treatment of liver tumour recurrence after hepatectomy
Authors: Elias D , De Baere T , Smayra T , Ouellet J F , Roche A , Lasser P
Published: March 2003

Background

Radiofrequency (RF) current, converted into heat through ion agitation and friction, can destroy liver tumours by means of coagulation necrosis. This study assessed whether percutaneous RF ablation is a useful and safe technique for the treatment of liver tumour recurrence after hepatectomy.

Methods

Forty-seven patients presenting with local recurrence after hepatectomy for malignant tumours (29 with colorectal secondaries) were treated with percutaneous RF ablation instead of repeat hepatectomy. RF thermal ablation was performed under image guidance for 12–15 min. This group represented 63 per cent of 75 patients treated with curative intent for liver recurrence in the same time interval. The other 28 patients underwent repeat hepatectomy.

Results

The mean(s.d.) number of liver metastases destroyed was 1·4(0·7) (range 1–3) and their diameter was 21(8) (range 9–35) mm. Twenty-six patients presented with liver recurrence at least once but up to three times after the initial RF application. Incomplete local RF treatment was observed in six of 47 patients. Fifteen patients developed extrahepatic recurrence. The mean(s.d.) interval between RF ablation and the last follow-up visit was 14·4(10·1) (range 5·5–40) months. One death and three major complications occurred. Survival rates at 1 and 2 years were 88 and 55 per cent respectively. A retrospective study of the authors' database over two similar consecutive periods showed that RF ablation increased the percentage of curative local treatments for liver recurrence after hepatectomy from 17 to 26 per cent and decreased the proportion of repeat hepatectomies from 100 to to 39 per cent.

Conclusion

Percutaneous RF treatment increases the number of patients eligible for curative treatment. It should be preferred to repeat hepatectomy when feasible and safe because it is less invasive. Repeat hepatectomy is indicated only when percutaneous RF ablation is contraindicated or fails.
Transoesophageal echocardiography shows high risk of gas embolism during laparoscopic hepatic resection under carbon dioxide pneumoperitoneum
Authors: Schmandra T C , Mierdl S , Bauer H , Gutt C , Hanisch E
Published: March 2003

Background

The ultrasonically activated scalpel (UAS) enables safe and effective laparoscopic tissue dissection, making hepatic resection feasible. This study compared blood loss and risk of gas embolism using the UAS during open hepatic resection and laparoscopic hepatic resection.

Methods

Female pigs were divided into two groups for laparoscopic (n = 7) and open (n = 5) left hepatic lobectomy. The UAS was used for both tissue cutting and coagulation. Laparoscopic liver resection was performed under carbon dioxide pneumoperitoneum (intraperitoneal pressure 12 mmHg). During surgery animals were monitored haemodynamically by an arterial line and Swan-Ganz catheter. Two-dimensional transoesophageal echocardiography (2D-TEE) was used to detect gas emboli with special attention to the right atrium and ventricle. Gas emboli were graded according to size, and correlated with haemodynamic and blood gas data.

Results

During open and laparoscopic hepatic resection the UAS resulted in minimal blood loss and effective tissue dissection. No air embolism was seen during open surgery. With laparoscopic hepatic resection 2D-TEE revealed gas embolism in all animals. Gas embolism was accompanied by cardiac arrhythmia in four of seven animals. No direct correlation was observed between embolism episodes and blood gas variables. There were no deaths after episodes of embolization. A significant decrease in arterial partial pressure of oxygen was seen at the end of the laparoscopic procedure in all animals.

Conclusion

The UAS causes minimal blood loss during both open and laparoscopic hepatic resection. Laparoscopic liver dissection under carbon dioxide pneumoperitoneum carries a high risk of gas embolism.
Systematic review and meta-analysis of interventions for postoperative fatigue
Authors: Rubin G J , Hotopf M
Published: March 2003

Background

Postoperative fatigue is common, even after uncomplicated operations. Various theories have been presented regarding its aetiology, each suggesting different possible interventions. The purpose of this review was to identify all studies that have assessed interventions for postoperative fatigue and to evaluate these interventions using meta-analytical techniques.

Methods

Randomized controlled trials of interventions, identified from a systematic search of relevant databases, were evaluated according to standardized criteria and categorized according to intervention modality. Data relating to the efficacy of each intervention at four different postoperative time-points were collated and data synthesis by meta-analysis was performed.

Results

Analgesia is effective in reducing fatigue immediately after operation. Perioperative administration of human growth hormone reduces fatigue between 8 and 30 days after abdominal surgery. Weaker evidence was found to suggest an influence of glucocorticoid administration and of surgical technique on fatigue in the first week after operation. No evidence was found to support the theory that psychosocial or nutritional interventions affect the symptom.

Conclusion

While the results demonstrate that improved analgesia can attenuate immediate postoperative fatigue in most patient groups, further research is needed to determine whether the efficacy of human growth hormone and glucocorticoids extends beyond abdominal surgery. The paucity of research into cognitive–behavioural, sleep and activity-based interventions also needs to be addressed.
Complications of radiofrequency coagulation of liver tumours
Authors: Mulier S , Mulier P , Ni Y , Miao Y , Dupas B , Marchal G , De Wever I , Michel L
Published: March 2003

Background

Radiofrequency coagulation (RFC) is being promoted as a novel technique with a low morbidity rate in the treatment of liver tumours. The purpose of this study was to assess critically the complication rates of RFC in centres with both large and limited initial experience, and to establish causes and possible means of prevention and treatment.

Methods

This is an exhaustive review of the world literature (articles and abstracts) up to 31 December 2001; 82 independent reports of RFC of liver tumours were analysed.

Results

In total, 3670 patients were treated with percutaneous, laparoscopic or open RFC. The mortality rate was 0·5 per cent. Complications occurred in 8·9 per cent: abdominal bleeding in 1·6 per cent, abdominal infection in 1·1 per cent, biliary tract damage in 1·0 per cent, liver failure in 0·8 per cent, pulmonary complications in 0·8 per cent, dispersive pad skin burn in 0·6 per cent, hepatic vascular damage in 0·6 per cent, visceral damage in 0·5 per cent, cardiac complications in 0·4 per cent, myoglobinaemia or myoglobinuria in 0·2 per cent, renal failure in 0·1 per cent, tumour seeding in 0·2 per cent, coagulopathy in 0·2 per cent, and hormonal complications in 0·1 per cent. The complication rate was 7·2, 9·5, 9·9 and 31·8 per cent after a percutaneous, laparoscopic, simple open and combined open approach respectively. The mortality rate was 0·5, 0, 0 and 4·5 per cent respectively.

Conclusion

The morbidity and mortality of RFC, while low, is higher than previously assumed. With adequate knowledge, many complications are preventable.
Randomized clinical trial comparing quality of life after straight and pouch coloanal reconstruction
Authors: Sailer M , Fuchs K-H , Fein M , Thiede A
Published: March 2003

Background

Functional results after rectal resection with straight coloanal anastomosis are poor. While most functional aspects are improved with coloanal J pouch anastomosis, it is still unclear whether this translates into better quality of life. The aim of this trial was to investigate health-related quality of life as a primary endpoint in patients undergoing sphincter-saving rectal resection.

Methods

Sixty-four patients were randomized to either straight (n = 32) or coloanal J pouch (n = 32) anastomosis. Patients were studied before operation, at the time of stoma reversal and at 3-month intervals for 1 year thereafter. Quality of life was measured using two generic (Gastrointestinal Quality of Life Index and European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30) and one disease-specific (EORTC QLQ-CR38) instruments. Functional results using a standardized score as well as manometric variables were recorded.

Results

Thirty-nine patients (19 with a pouch and 20 with a straight anastomosis) completed the trial. There was a marked difference between the two groups with regard to quality of life profile. Patients with a pouch reconstruction had a significantly better quality of life, particularly in the early postoperative period.

Conclusion

Patients undergoing low anterior rectal resection and coloanal J pouch reconstruction may expect not only better functional results but also an improved quality of life in the early months after surgery compared with patients who receive a straight coloanal anastomosis.
Laparoscopic ultrasonography is a complement to cholangiography for the detection of choledocholithiasis at laparoscopic cholecystectomy
Authors: Catheline J M , Turner R , Paries J
Published: March 2003

Background

Intraoperative cholangiography and laparoscopic ultrasonography are both used in the detection of common bile duct stones at laparoscopic cholecystectomy. The aim of this prospective study was to determine whether laparoscopic ultrasonography has an alternative or a complementary role with respect to cholangiography in achieving this end.

Methods

The biliary trees of 900 patients undergoing laparoscopic cholecystectomy were examined routinely by the two methods. The diagnostic power of each investigation and of the two techniques in combination was evaluated. The statistical non-random concordance between the two methods was also determined.

Results

Laparoscopic ultrasonography was performed in all 900 patients. Cholangiography was performed in 762 (85 per cent). The mean (range) duration was 9·8 (4–21) min for laparoscopic ultrasonography and 17·6 (7–42) min for cholangiography. For the detection of common bile duct stones, with a kappa coefficient of 0·57 (95 per cent confidence interval (c.i.) 0·43 to 0·71), the non-random concordance between the two methods was considered to be fair to good. The sensitivity of laparoscopic ultrasonography was 0·80 (95 per cent c.i. 0·65 to 0·91) and its specificity was 0·99 (95 per cent c.i. 0·98 to 1·00). The respective values for cholangiography were 0·75 (95 per cent c.i. 0·59 to 0·87) and 0·99 (95 per cent c.i. 0·98 to 1·00). The examinations combined had a sensitivity of 0·95 (95 per cent c.i. 0·86 to 0·99) and a specificity of 0·98 (95 per cent c.i. 0·96 to 1·00).

Conclusion

Laparoscopic ultrasonography and intraoperative cholangiography are complementary, as the combination of both methods maximizes the intraoperative detection of choledocholithiasis.
In situ ablation of experimental liver metastases delays and reduces residual intrahepatic tumour growth and peritoneal tumour spread compared with hepatic resection
Authors: Isbert C , Boerner A , Ritz J-P , Schuppan D , Buhr H J , Germer C-T
Published: March 2003

Background

The aim of this study was to evaluate the influence of in situ ablation and hepatic resection of experimental liver metastases on residual intrahepatic tumour growth and macroscopic peritoneal tumour spread.

Methods

Two colonic carcinomas (CC 531) were implanted into 90 WAG rat livers, one in the right liver lobe (untreated tumour) and one in the left liver lobe (treated tumour) of each rat. The animals were randomized into two test groups and a sham-operated control group. Animals in group 1 received in situ ablation (laser-induced thermotherapy) of the treated tumour. Rats in group 2 were submitted to partial hepatectomy. Untreated tumour volumes were calculated and the incidence of macroscopic peritoneal spread was determined at different times.

Results

After 21 days median (95 per cent confidence interval) volumes of untreated tumours were 507 (282) mm3 in group 1, 2096 (994) mm3 in group 2 and 1896 (755) mm3 in group 3. Compared with values obtained before treatment, growth of the untreated tumours had increased significantly after 4 days in group 2, after 7 days in group 3 and after 10 days in group 1. Macroscopic peritoneal tumour spread was detected in six of 30 animals in group 1 (laser), in 20 of 30 in group 2, and in 24 of 30 in group 3.

Conclusion

Compared with hepatic resection, in situ ablation of experimental liver metastases delays and reduces residual intrahepatic tumour growth and macroscopic peritoneal tumour spread.
Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques
Authors: Fagevik Olsén M , Wennberg E , Johnsson E , Josefson K , Lönroth H , Lundell L
Published: March 2003

Background

Pulmonary complications are frequently seen after thoracoabdominal resection of the oesophagus. The aim of this study was to compare the effects of two different breathing exercise regimens applied in the immediate postoperative period on the risk of pulmonary insufficiency after thoracoabdominal resection.

Methods

Seventy patients undergoing thoracoabdominal resection for cancer of the oesophagus and cardia were randomized after operation to breathing exercises by inspiratory resistance–positive expiratory pressure (IR-PEP) (n = 36) or continuous positive airway pressure (CPAP) (n = 34). The study groups were well matched for all relevant clinical and demographic data.

Results

Respiratory function deteriorated significantly immediately after operation; the lowest values of forced vital capacity and peak expiratory flow were measured during the first postoperative day and oxygen saturation was lowest on days 4–6. Significantly fewer patients in the CPAP group required reintubation and prolonged artificial ventilation (P < 0·05). There were minor non-significant differences between the study groups with respect to respiratory and other postoperative variables, usually in favour of CPAP.

Conclusion

Provision of CPAP in the immediate postoperative period decreased the risk of respiratory distress requiring reintubation and the need for artificial ventilation compared with breathing exercises by IR-PEP.
Rectal washout with cytotoxic solution can be extended to the whole colon
Authors: Mariani P P , van Pelt J F , Ectors N , Topal B , D'Hoore A , Penninckx F
Published: March 2003

Background

Rectal irrigation with a cytotoxic agent does not kill viable intraluminal cancer cells proximal to the primary tumour. To prevent implantation of these cells at the time of restorative proctectomy, the feasibility of retrograde whole-colon irrigation just before surgery was explored.

Methods

The cytotoxic efficacy of different combinations of povidone–iodine (PVPI) and Gastrografin was tested with the trypan blue exclusion test on a human colon carcinoma cell line (SW620) in vitro. Subsequently, a retrograde whole-colon lavage with PVPI 5 per cent and Gastrografin 12 per cent was performed in 14 euthyroid, non-allergic patients with colorectal cancer using a colostomy irrigation set. Thyroid function and mucosal damage were assessed.

Results

It took 2 min and approximately 1 litre of infused solution to reach the caecum in all patients. The solution was 100 per cent tumoricidal in vitro and remained so after colonic irrigation. Total serum tri-iodothyronine (T3) levels decreased and those of reverse T3 increased, but normalized after 1 week. Superficial epithelial desquamation was observed shortly after irrigation; however, complete restoration occurred within 7 days.

Conclusion

A rectal washout can easily be extended to a retrograde irrigation of the whole colon in elective colorectal cancer surgery. This may help to prevent anastomotic and local recurrence due to implantation of viable exfoliated tumour cells.
Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct
Authors: Tranter S E , Thompson M H
Published: March 2003

Background

Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence.

Methods

A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used.

Results

Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0–6) per cent, compared with 1 (0–5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1–19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3–16) per cent, which is greater than 8 (2–17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients.

Conclusion

Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy.
Effects of glycosaminoglycans on proliferation of epithelial and fibroblast human malignant mesothelioma cells: a structure–function relationship
Authors: Potten Christopher , Darzynkiewicz Zbigniew , Sasaki Kohsuke , Syrokou A. , Tzanakakis G. , Tsegenidis T. , Hjerpe A. , Karamanos N. K.
Published: March 2003

Abstract. Proteoglycans interact with other effective macromolecules regulating a variety of cellular events via their glycosaminoglycan (GAG) chains. The effects of all known glycosaminoglycans (GAGs) produced by normal cells and tissues on the proliferation of two human malignant mesothelioma cell lines, one with fibroblast‐like morphology and the other with epithelial differentiation – both able to produce hyaluronan (HA), galactosaminoglycans (GalAGs) and heparan sulphate (HS) containing proteoglycans – have been studied. Cell proliferation was assessed by measuring [3H]thymidine incorporation and cell number. GalAGs, i.e. chondroitin sulphates (CSs) and dermatan sulphate (DS), strongly stimulate the proliferation of fibroblast‐like cells in a dose‐dependent manner (170–250% at 100 μg/ml), independently of their sulphation pattern. In epithelial cells, however, only DS stimulates cell proliferation. The effects of CSs on proliferation of epithelial cells are not depended on their sulphation pattern. Thus, CSs either with ‐[GlcA‐GalNAc‐(‐6‐O‐SO3−)]‐ or ‐[GlcA‐GalNAc‐(‐4‐O‐SO3−]‐ as the commonest unit, had no significant effect. l‐Iduronic acid (IdoA)‐rich heparin and fast‐moving HS (fm‐HS), a HS fraction with a heparin‐like structure, had significant antiproliferative effects on mesothelioma cells of both types (30–70% at 1.0 μg/ml and 85–90% at 100 μg/ml, respectively). GlcA‐rich HS, however, had no significant effects. HA inhibits only the proliferation of fibroblast‐like cells by 25% at 50 and 100 μg/ml. Keratan sulphate suppresses cell proliferation (10–30%) in both cell lines. In the view of these findings, a structure–function relationship of GAGs on cell proliferation of the two human malignant mesothelioma cell lines is discussed. Other factors, such as chain conformation and geometry, as well as interactions of growth factors with GAGs, possibly involved in the regulation of cell proliferation, are also discussed.
Dilazep, a nucleoside transporter inhibitor, modulates cell cycle progression and DNA synthesis in rat mesangial cells in vitro
Authors: Sakumura T. , Fujii Z. , Umemoto S. , & T. Murakami ,   Dagger, Kawata Y. , Fujii K. , Minami M. , Sasaki K. , Matsuzaki M.
Published: March 2003

The direct effects of the nucleoside transporter inhibitor dilazep on the cell cycle of mesangial cells have not before been investigated. The purpose of this study was to elucidate whether dilazep can inhibit the proliferation of mesangial cells and how it interferes with the cell cycle of these cells. DNA histograms were used and BrdUrd uptake rate was measured by flow cytometry. There was no significant difference in the cell numbers among the untreated group and the 10−5M, 10−6M or 10−7M dilazep‐treated groups at 24 h of incubation. However, at 48 and 72 h, the cell numbers in the dilazep‐treated groups were significantly lower compared with that of the untreated group (P0.005). The DNA histograms of cultured rat mesangial cells at 12, 24, and 48 h of incubation with 10−5 M dilazep showed that the ratio of the S phase population in the dilazep‐treated group decreased by 2.2% at 12 h, by 9.6% at 24 h, and by 18.9% at 48 h compared with the untreated group. The ratio of the G0/G1 phase population in the dilazep‐treated group significantly increased: 6.8% at 12h (P 0.05), 13.9% at 24 h (P 0.001), and 76.5% at 48 h (P 0.001) compared with the untreated group. A flow cytometric measurement of bivariate DNA/BrdUrd distribution demonstrated that the DNA synthesis rate in the S phase decreased after 6 h (P 0.005) and 12 h (P 0.05) of incubation compared with the untreated group. These results suggest that dilazep inhibits the proliferation of cultured rat mesangial cells by suppressing the G1/S transition by prolonging G2/M and through decreasing the DNA synthesis rate