bluuebunny/crossref_metadata_2025 huggingface dataset:
Results of surgical treatment for faecal incontinence
Authors: Österberg A , Eeg-Olofsson K Edebol , Graf W
Published: March 2003

Background

This prospective study was designed to evaluate the results of anterior levatorplasty and sphincteroplasty for faecal incontinence with respect to symptomatic and physiological outcome.

Methods

Thirty-one patients with idiopathic (neurogenic) faecal incontinence underwent anterior levatorplasty and 20 patients with traumatic anal sphincter injury underwent anal sphincteroplasty. The outcome of repair was evaluated at 3 and 12 months using a validated questionnaire and anorectal manometry/manovolumetry.

Results

Eighteen of 31 patients in the levatorplasty group reported continence to solid and liquid stools 1 year after operation compared with two patients before surgery (P < 0·01). The corresponding figures in the sphincteroplasty group were ten and two of 20 respectively (P < 0·05). The incontinence score was improved in both groups after 1 year, from a median score of 14 to 3 in the levatorplasty group (P < 0·001) and from 8·5 to 3·5 in the sphincteroplasty group (P < 0·01). Improvements in the degree of social and physical handicap were also observed in both groups. No changes were seen in anal canal pressures or rectal sensation in either group.

Conclusion

Despite different aetiologies and surgical approaches, anterior levatorplasty and sphincteroplasty yielded similarly successful results in patients with faecal incontinence. Although a marked symptomatic improvement was seen in both groups, no associated physiological alterations could be detected. The reason for the improvement is thus unclear, but it may result from a stenosing effect in the anal canal.
Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer
Authors:   Danish Ranx05 Colorectal Cancer Study Group, Mynster T , Christensen I J , Moesgaard F , Nielsen H J
Published: March 2003

Background

The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis.

Methods

Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications.

Results

Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P < 0·001). The median observation period was 6·8 (range 5·4–7·9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1·38 (95 per cent confidence interval (c.i.) 1·05–1·81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1·79 (95 per cent c.i. 1·13–2·82)), localization of cancer in the rectum and Dukes classification were independent risk factors.

Conclusion

Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.
Results of treatment of 33 patients with peritoneal mesothelioma
Authors: Sebbag G , Yan H , Shmookler B M , Chang D , Sugarbaker P H
Published: March 2003

Background

Peritoneal mesothelioma is a rare peritoneal malignancy, representing approximately one-third of all mesotheliomas. It is regarded as a universally fatal cancer with few treatment options.

Methods

Records of 33 patients with peritoneal mesothelioma were reviewed retrospectively. Demographic, clinical and quantitative prognostic indicators were evaluated and analysed statistically using survival as endpoint. Patients were treated by a uniform strategy involving cytoreductive surgery with peritonectomy procedures and perioperative intraperitoneal chemotherapy (cisplatin, doxorubicin).

Results

There were ten women and 23 men; mean age was 53·0 years. Asbestos exposure was recorded in five patients and a family history of cancer in 13. Presentation was mainly abdominal distension and pain. Median survival was 31·0 months; overall projected survival at 3 years was 56 per cent. The most significant positive predictive factors of survival were: female sex (P = 0·003), low prior surgical score (P = 0·002), completeness of cytoreduction (P = 0·0002) and second-look surgery (P = 0·019). The morbidity rate for this combined treatment was 33 per cent and the perioperative mortality rate was 3 per cent.

Conclusion

Although peritoneal mesothelioma is rare, progress in its management has occurred. Survival has been extended and selection factors by which patients may be allocated to aggressive management strategies have been defined.
Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas
Authors: Ortíz H , Marzo J
Published: March 2003

Background

Low-lying trans-sphincteric anal fistulas respond well to simple fistulectomy or fistulotomy. However, management of high fistulas has long been a serious problem because of the necessity of preserving at least some of the sphincter mechanism. The clinical results of endorectal flap advancement and fistulectomy for complex anal fistulas were assessed.

Methods

A total of 103 consecutive patients with high trans-sphincteric (n = 91) and suprasphincteric (n = 12) fistulas undergoing endorectal advancement flap repair together with core fistulectomy were included in a prospective study. Clinical outcome was assessed in terms of continence and recurrence by an independent observer for a period of 1 year after operation.

Results

Successful healing was achieved in 96 patients (93 per cent). Recurrent fistula occurred in six (7 per cent) of the 91 patients in the trans-sphincteric group and in one of the 12 patients in the suprasphincteric group. Continence disturbance was noted in eight patients (8 per cent). Previous repair and the level of the fistula did not adversely affect the results obtained.

Conclusion

Core fistulectomy associated with endorectal advancement flap repair is a safe and effective technique for any high trans-sphincteric and suprasphincteric fistula, with good results in terms of recurrence and anal continence.
Hyaluronic acid as prognostic marker in resectable colorectal cancer
Authors: Llaneza A , Vizoso F , Rodríguez J C , Raigoso P , García-Muñiz J L , Allende M T , García-Morán M
Published: March 2003

Background

Hyaluronic acid (HA), an extracellular high molecular mass polysaccharide, is thought to be involved in the growth and progression of malignant tumours. The objective of this work was to evaluate the cytosolic HA content in resectable colorectal cancer, its possible relationship with clinicopathological parameters of tumours and its prognostic significance.

Methods

Cytosolic HA levels were examined by radiometric assay in 120 patients with resectable colorectal cancer. The mean follow-up period was 33·4 months.

Results

Cytosolic HA levels of tumours ranged widely, from 30 to 29 412 ng per mg protein. Intratumour HA levels were significantly correlated with Dukes stage (P < 0·005), and were higher in patients with advanced tumours (mean(s.e.m.) 2695(446), 2858(293) and 5274(967) ng per mg protein for stages A, B and C respectively). In addition, Cox multivariate analysis demonstrated that tumour HA levels higher than 2000 ng per mg protein predicted shorter relapse-free survival and overall survival periods (both P < 0·05).

Conclusion

There is a wide variability in cytosolic HA levels in colorectal carcinomas, which seems to be related to the biological heterogeneity of these tumours. In addition, high tumour cytosolic HA levels were associated with an unfavourable outcome in patients with resectable colorectal cancer. HA may provide additional information to that given by other biochemical markers currently used in colorectal cancer.
Clinicopathological study of multiple superficial oesophageal carcinoma
Authors: Kanamoto A , Yamaguchi H , Nakanishi Y , Tachimori Y , Kato H , Watanabe H
Published: March 2003

Background

Recently, the diagnosis of superficial oesophageal carcinoma has increased markedly in Japan as a result of advances in endoscopy. A number of these carcinomas have proved to be multiple.

Methods

Some 359 patients with superficial squamous cell carcinoma of the oesophagus who underwent oesophagectomy (n = 276) or endoscopic mucosal resection (EMR) (n = 83) were reviewed retrospectively. The clinicopathological features of patients with multiple superficial oesophageal carcinoma were compared with those of patients with a single superficial oesophageal carcinoma.

Results

Of the 359 patients, 99 (28 per cent) had multiple superficial oesophageal carcinoma. The male: female ratio in patients with multiple carcinoma was 98: 1, compared with 5·3: 1 for those with a single carcinoma (n = 260) (P = 0·0001). The incidence of tobacco and alcohol use was significantly higher in the patients with multiple carcinoma than in those with a single carcinoma (P = 0·04 and P = 0·03 respectively). The incidence of pharyngeal malignancy was also significantly higher in patients with multiple carcinoma (P = 0·02).

Conclusion

The high incidence of multiple superficial oesophageal carcinoma indicates a need for careful evaluation of the oesophagus at the time of initial diagnosis, treatment and follow-up for superficial oesophageal carcinoma. Male sex, smoking, alcohol use and the presence of pharnygeal malignancy are high-risk factors for multiple superficial oesophageal carcinoma.
Postoperative ileus: a preventable event
Authors: Holte K , Kehlet H
Published: March 2003

Background

Postoperative ileus has traditionally been accepted as a normal response to tissue injury. No data support any beneficial effect of ileus and indeed it may contribute to delayed recovery and prolonged hospital stay. Efforts should, therefore, be made to reduce such ileus.

Methods

Material was identified from a Medline search of the literature, previous review articles and references cited in original papers. This paper updates knowledge on the pathophysiology and treatment of postoperative ileus.

Results and conclusion

Pathogenesis mainly involves inhibitory neural reflexes and inflammatory mediators released from the site of injury. The most effective method of reducing ileus is thoracic epidural blockade with local anaesthetic. Opioid-sparing analgesic techniques and non-steroidal anti-inflammatory agents also reduce ileus, as does laparoscopic surgery. Of the prokinetic agents only cisapride is proven beneficial; the effect of early enteral feeding remains unclear. However, postoperative ileus may be greatly reduced when all of the above are combined in a multimodal rehabilitation strategy.
Groin hernia repair in Scotland
Authors: Hair A , Duffy K , McLean J , Taylor S , Smith H , Walker A , Macintyre I M C , O'Dwyer P J
Published: March 2003

Background

The use of mesh for groin hernia repair has dramatically changed the way this common operation is performed. The aim of this study was to survey the methods of groin hernia repair in Scotland and to assess patient satisfaction with the operation.

Methods

Between 1 April 1998 and 31 March 1999 all patients who underwent groin hernia repair in the National Health Service in Scotland were identified. As well as looking at the type of hernia repair performed and postoperative morbidity, patients were sent a Short Form-36 about 3 months after the operation to assess satisfaction and return to normal activity.

Results

Information was obtained on 5506 (97 per cent) of patients who underwent groin hernia repair during the study period. Eighty-five per cent of patients had an open mesh repair and 4 per cent had a laparoscopic repair. Most operations (85 per cent) were performed using general anaesthesia on an inpatient basis (78 per cent), and 8 per cent were for repair of a recurrent hernia. Potentially serious intraoperative complications were rare (seven patients), although they were significantly (P < 0·001) more likely to be associated with a laparoscopic approach or repair of a femoral hernia: relative risk compared with open inguinal hernia repair 33 (95 per cent confidence interval (c.i.) 6–197) and 22 (95 per cent c.i. 3–152) respectively. Wound complications were common and 10 per cent of patients required a district nurse to attend the wound. Patients expressed a high degree of satisfaction; 94 per cent would recommend the same operation to someone else if required.

Conclusion

An open mesh repair using general anaesthesia has become the repair of choice for a groin hernia in Scotland. Despite a high incidence of wound complications, patients are satisfied with this operation.
Randomized controlled trial of standardized meal stimulation for the detection of enteropancreatic endocrine tumours in patients with multiple endocrine neoplasia type 1
Authors: Langer P , Bartsch D K , Schilling T , Kopp I , Celik I , Wild A , Rothmund M
Published: March 2003

Background

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterized by the occurrence of hyperparathyroidism (approximately 100 per cent), and pituitary (approximately 40 per cent) and enteropancreatic endocrine (approximately 70 per cent) tumours. It has been suggested previously that serum pancreatic polypeptide and serum gastrin after standardized meal test stimulation are useful indicators for early identification of enteropancreatic tumours in MEN1. Therefore the usefulness of the meal test was evaluated in a screening programme of MEN1 mutation carriers.

Methods

In a prospective, controlled trial between September 1997 and December 1995, 55 standardized meal stimulation tests (563 kcal) were performed in 13 MEN1 mutation carriers with no evidence of enteropancreatic tumours (group 1); ten patients with MEN1 with histologically, biochemically and radiologically evident enteropancreatic tumours (group 2); and in 28 healthy adults for control (group 3). Genetic analysis was done by single-strand conformation analysis and direct sequencing. Serum pancreatic polypeptide and serum gastrin levels were measured by radioimmunoassay (Ideon, Sweden). Data were analysed using analysis of variance (Kruskal–Wallis test, 2 d.f.) and Mann–Whitney test.

Results

Median (range) basal serum pancreatic polypeptide levels were 214 (38–897) pg ml−1 in group 1, 126 (13–263) pg ml−1 in group 2 and 73 (13–357) pg ml−1 in group 3. Median (range) serum gastrin levels were 103 (37–391), 551 (25–4080) and 65 (17–198) pg ml−1 respectively, but gastrin levels in group 2 were strongly influenced by patients with known gastrinoma. Levels of both variables increased after meal stimulation in all groups. However, there was no significant difference between the groups after stimulation (P > 0·05).

Conclusion

Standardized meal stimulation test does not reliably indicate the presence of enteropancreatic endocrine tumours in patients with MEN1. It is not therefore used in the authors' routine screening programme for patients with MEN1.
Phaeochromocytoma: inherited associations, bilaterality and cortex preservation
Authors: Inabnet W B , Caragliano P , Pertsemlidis D
Published: March 2003

Background

Hereditary phaeochromocytoma (HP) is characterized by early onset, bilateral adrenal involvement, low malignancy rate and genetic linkage with certain familial syndromes. This retrospective review was intended to show the high yield of surveillance, predictable bilaterality and the challenge of cortex-sparing adrenalectomy.

Methods

From 1964 to 1999, 32 patients with HP (mean age 29 years) were treated at a single institution and followed for a mean of 7 (range 0·5–24) years. There were 15 patients with multiple endocrine neoplasia type 2A (MEN2A), 12 with von Hippel–Lindau disease (VHLD), three with von Recklinghausen's disease (VRD) and two patients with familial phaeochromocytoma (FP). Twenty-six of 32 patients underwent bilateral adrenalectomy (12 metachronous). Subtotal resection with orthotopic cortex preservation was performed in four patients and heterotopic autografting in 14 patients. Subcapsular segments were harvested and implanted into the rectus muscle after histological confirmation of the absence of medullary tissue. The following variables were assessed: presenting signs, interval of metachronous disease, recurrence, outcome of cortex preservation and survival.

Results

Phaeochromocytoma was the first manifestation in six of 12 patients with VHLD and four of 15 with MEN2A. Surveillance uncovered medullary thyroid cancer in five of 15 patients with MEN2A, and haemangioblastomas, renal cell carcinoma and islet cell tumours in seven of 15 patients with VHLD and VRD. HP was bilateral in 26 of 32 cases (14 of 15 MEN2A, eight of 12 VHLD, two of three VRD and both FP). In 12 cases of metachronous HP, the mean interval between adrenalectomy was 67 (range 9–156) months. Three of four patients who underwent orthotopic preservation of the adrenal cortex developed recurrence compared with none of 14 patients with heterotopic autotransplantation of cortical tissue. Four patients in this latter group had normal serum cortisol levels and required no exogenous replacement therapy. There was one case of malignant HP and there was no surgical death.

Conclusion

Inherited bilateral phaeochromocytoma is derived from medullary hyperplasia. The long interval of metachronous phaeochromocytoma argues against prophylactic removal of the contralateral ‘normal’ adrenal gland. Phaeochromocytoma frequently heralds coexisting silent VHLD or MEN-2, mandating surveillance for inherited associations. Total adrenalectomy and heterotopic autotransplantation of medulla-free cortex may diminish the need for lifelong steroid substitution and eliminates recurrence.
Cardiac dysfunction during exercise in patients with primary hyperparathyroidism
Authors: Nilsson I-L , Aberg J , Rastad J , Lind L
Published: March 2003

Background

‘Non-traditional’ manifestations of primary hyperparathyroidism (HPT) are controversial, and include morbidity, mortality and risk factors for cardiovascular diseases with some prospects of normalization by parathyroidectomy (PTX). This study evaluated previously unexplored data on cardiac function during exercise in HPT.

Methods

Thirty patients with HPT (mean(s.d.) serum calcium 2·96(0·24) mmol l−1) and 30 normocalcaemic controls (selected randomly from the background population, and matched for age and sex) underwent exercise testing, echocardiography and 24-h ambulatory blood pressure recordings before and a mean of 13 months after PTX.

Results

HPT was associated with higher systolic blood pressure during exercise (mean(s.d.) 223(28) versus 203(33) mmHg; P = 0·02), which correlated to the left ventricular (LV) mass and serum PTH (P = 0·014, P = 0·004); higher LV mass in men (mean(s.d.) 142(20) versus 113(28) g m−2), which might relate to the hypertrophic effect of PTH; and increased LV isovolumic relaxation times (mean(s.d.) 102(19) versus 91(15) ms; P = 0·018), indicating LV diastolic dysfunction. ST depression during exercise decreased significantly (mean(s.d.) − 1·0(0·9) versus 0·7(0·5) mm; P = 0·028) and LV mass declined in proportion with the time after PTX (P = 0·04 in men). PTX also affected systolic functions, as fractional shortening, atrioventricular plane displacement and systolic index decreased in men (P = 0·05, P = 0·04, P = 0·04). Twenty-four-hour blood pressures were higher in HPT (P = 0·008), when subjects on β-blockers (seven patients, five controls) were excluded, and were unaltered by PTX.

Conclusion

LV systolic and diastolic dysfunction occurs in HPT. The diastolic dysfunction seems to diminish with time after PTX, while the positive inotropic effect of calcium in itself may alleviate the systolic dysfunction.
Limitations of size as a criterion in evaluating adrenal tumours
Authors: Barnett C C , Dackiw A P B , Pearson A S , Varma D G , El-Naggar A K , Gagel R F , Evans D B , Lee J E
Published: March 2003

Background

Size is considered the single best predictor of malignancy in evaluating adrenal neoplasms identified incidentally during abdominal imaging, yet small adrenal cortical cancers have been reported previously from several centres.

Methods

This was a retrospective evaluation of the value of tumour size and other preoperative clinical parameters in predicting the presence or absence of malignancy in adult patients who underwent adrenalectomy for an adrenal tumour at this institution.

Results

One hundred and sixteen patients underwent adrenalectomy. Diagnoses were adrenal cortical carcinoma (n = 38), phaeochromocytoma (n = 27), metastasis to the adrenal gland (n = 11) and benign tumours (n = 40) (cortical adenoma, 23; cyst, two; cortical hyperplasia, five; ganglioneuroma, four; myelolipoma, six). The median size of the adrenal cortical carcinomas was 9·2 (range 1·7–30) cm; five tumours were smaller than 5·0 cm. The median overall size of the benign tumours (excluding phaeochromocytomas) was 4·0 cm; the median size of the adrenal cortical adenomas was 3·0 cm. Eleven benign tumours were larger than 5·0 cm, including two cortical adenomas. The radiographic features of three of five small adrenal cancers correctly predicted malignancy; the remaining two patients with small cancers had symptoms related to functioning tumours. Conversely, the radiographic features of seven of 11 large benign adrenal tumours correctly predicted benign histology, including five of five myelolipomas.

Conclusion

While size remains a good predictor of histology and clinical behaviour of functioning and non-functioning adrenal neoplasms, both small adrenal cortical cancers and large benign tumours occur with measurable frequency. High-quality imaging studies (computed tomography and magnetic resonance imaging) may be helpful in identifying relatively small yet radiographically atypical adrenal tumours more likely to be cancers, as well as radiographically characteristic benign myelolipomas which may be followed selectively.
Total parathyroidectomy in patients with chronic renal failure
Authors: Saunders R N , Karoo R , Tiong H Y , Murphy G J , Metcalfe M , Nicholson M L
Published: March 2003

Background

Total parathyroidectomy without reimplantation has been advocated as a treatment for hyperparathyroidism in patients with end-stage chronic renal failure. However, there are concerns that a lack of endogenous parathyroid hormone (PTH) can result in hypocalcaemia and adynamic bone disease. The aim of this study was to identify whether this is a significant clinical problem.

Methods

A review of 56 (51 four-gland and five three-gland) histologically confirmed parathyroidectomies performed by the same surgeon between 1994 and 1999 was performed. Mean(s.d.) follow-up was 30(22) months.

Results

Patients could be divided into three groups on the basis of a postoperative serum PTH concentration that was either undetectable (less than 0·1 pmol l−1), less than the upper limit of normal (7·6 pmol l−1 or less) or raised (more than 7·6 pmol l−1). Demographics, mean number of glands excised and histology were similar in each group. Patients with a raised serum level of PTH had a mean(s.d.) value of 54·1(73·3) pmol l−1. Three-gland parathyroidectomy occurred in three patients, raising the possibility of ectopic glands. Two patients had neck re-exploration after four-gland parathyroidectomy; an adenoma and an ectopic gland were identified. One patient had a parathyroid adenocarcinoma.

Conclusion

Total parathyroidectomy may leave residual functional parathyroid tissue that is not visualized at surgery. However, in patients who had no functional parathyroid tissue after operation there was little clinical or biochemical evidence of an increased incidence of hypocalcaemia or bone disease.
Randomized trial of parathyroidectomy in mild, asymptomatic primary hyperparathyroidism as measured by the SF-36 health survey
Authors: Talpos G B , Rao D S , Bone H G , Parfitt A M , Kleerekoper M , Alam M , Honasoge D , Divine G
Published: March 2003

Background

Management of patients with asymptomatic primary hyperparathyroidism (HPT) remains controversial despite a National Institutes of Health consensus statement on this issue. As part of the above statement, a randomized clinical trial was recommended since none exist to address this issue.

Methods

Informed consent was obtained from 53 asymptomatic patients with confirmed primary HPT who agreed to participate in this randomized clinical trial of parathyroidectomy versus observation. Upon entry to the study and 24 months later the patients completed the SF-36 health survey which is an instrument that measures nine different levels of function. Scores were tabulated and the difference over 24 months between operated and non-operated patients was compared with Student's t test.

Results

Fifty-three patients (42 women and 11 men) with asymptomatic, mild primary HPT (serum calcium 10·1–11·5 mg dl−1) who agreed to participate were randomized into either a surgical group or an observation group. Mean serum calcium for these patients was 10·3 mg dl−1. The only demographic difference between the groups was age; the operated group was older (66·7 versus 62·6 years; P < 0·03). Scores on three of the nine domains (health perception, emotional problems and social functioning) on the SF-36 were significantly different (P < 0·05), all favouring the operated group.

Conclusion

Improved function, as measured by the SF-36 health assessment tool, is seen after parathyroidectomy compared with non-operated patients. This work supports surgical management of mild primary HPT at the time of diagnosis since many patients have reversible non-classical symptoms of the disease.
Hypothyroidism following hemithyroidectomy: incidence, risk factors and management
Authors: McHenry C R , Slusarczyk S J
Published: March 2003

Background

Hypothyroidism is often an unrecognized sequela of hemithyroidectomy. The purpose of this study was to determine the incidence, risk factors and management of hypothyroidism occurring after hemithyroidectomy for nodular thyroid disease.

Methods

All euthyroid patients who underwent hemithyroidectomy from 1992 to 1999 were evaluated for age, sex, preoperative and postoperative serum thyroid-stimulating hormone (TSH) levels, pathology and follow-up. Time of diagnosis and therapeutic doses of thyroid hormone were determined for patients with hypothyroidism. Patients who underwent completion thyroidectomy and those who were on thyroid hormone before operation for TSH suppression or after operation for prevention of recurrent disease were excluded.

Results

During the study period, 70 euthyroid patients underwent hemithyroidectomy. Postoperative hypothyroidism was diagnosed in 25 (36 per cent) with a mean(s.d.) TSH level of 8·51(6·53) (units l−1). Hypothyroidism was subclinical in 16 and overt in nine patients. There were no significant sex or age differences between hypothyroid and euthyroid patients. The mean(s.d.) preoperative serum TSH level was 1·94(1·00) (units l−1) in patients diagnosed with postoperative hypothyroidism compared with 1·08(0·75) (units l−1) in euthy-roid patients (P < 0·05). Associated lymphocytic thyroiditis was present in ten of 25 hypothyroid patients compared with ten of 45 euthyroid patients (P > 0·05). Nineteen patients received thyroid hormone treatment in doses varying from 0·5 to 1·9 (mean 1·3) g kg−1. Follow-up varied from 1 month to 7 years (mean 1 year). All but one hypothyroid patient was diagnosed within 2 months of surgery.

Conclusion

Postoperative hypothyroidism occurs in 36 per cent of patients following hemithyroidectomy. It is usually asymptomatic, and can be diagnosed early after surgery. Hypothyroid patients have higher preoperative TSH levels than euthyroid patients and treatment is accomplished with lower than normal replacement doses of thyroid hormone.
Value of intra-arterial calcium-stimulated venous sampling for regionalization of pancreatic insulinomas
Authors: Lo C-Y , Chan F-I , Tam S C F , Fan S-T , Lam K S L
Published: March 2003

Background

Although the need for routine preoperative localization of insulinoma is challenged, accurate preoperative localization is regarded as the prerequisite for successful laparoscopic resection of insulinoma. Intra-arterial calcium stimulation with hepatic venous sampling for insulin gradients (ASVS) has been reported to be the most sensitive preoperative localization technique. The authors' experience with ASVS to localize and guide management of insulinomas is reviewed.

Methods

Between 1991 and 1999, 20 patients underwent surgical resection for insulinomas. Sixteen patients (11 men, five women; median age 43 years) underwent ASVS for preoperative localization of insulinoma based on equivocal standard imaging studies. Intraoperative ultrasonography was performed routinely. The accuracy of ASVS was compared with that of intraoperative findings and other methods of localization.

Results

There was no complication arising from the procedure. A median step-up of tenfold (right 3–37-fold; left 3–72-fold) in insulin level 30–60 s after injection to at least one feeding artery was observed in 14 patients. Enucleation and distal resection were performed in six and ten patients respectively. In the era of laparoscopy, open enucleation and laparoscopic resection were adopted for two tumours each located at the pancreatic head and tail respectively. Twelve of the 14 solitary tumours were located correctly; all four at the head, one of three in the body and all seven at the tail. Two patients with multiple endocrine neoplasia type 1 and multiple tumours had the dominant tumours located at the tail. The overall accuracy of this test was 88 per cent compared with 11, 31, 43 and 67 per cent for ultrasonography, computed tomography, magnetic resonance imaging and endoscopic ultrasonography respectively. Intraoperative ultrasonography readily located two tumours missed by ASVS which, in turn, guided the removal of a tumour located at the splenic hilum that eluded detection by intraoperative ultrasonography.

Conclusion

ASVS is the most accurate preoperative localization tool for localizing insulinomas. It guides the adoption of the minimally invasive approach and, in combination with intraoperative ultrasonography, enhances surgical success in the management of insulinoma.
Neutralizing vascular endothelial growth factor activity inhibits thyroid cancer growth in vivo
Authors: Soh E Y , Kim K J , Eigelberger M S , Wong M G , Duh Q-Y , Clark O H
Published: March 2003

Background

Without angiogenesis, tumours cannot grow larger than a few millimetres in size, the limit of diffusion. Vascular endothelial growth factor (VEGF) is an endothelial-specific mitogen and is a major regulator of physiological and pathological angiogenesis. Higher levels of VEGF messenger RNA expression and VEGF production and secretion have been found in FTC-133 cells than normal thyroid cells.

Methods

To investigate the relationship between VEGF and thyroid tumour angiogenesis and growth, human dermal matrix inoculated with FTC-133 cells was xenografted into nude mice or directly injected subcutaneously. To block the function of VEGF, the neutralizing anti-VEGF monoclonal antibody A.4.6.1 (mAb A.4.6.1) was injected intraperitoneally 100 μg per 0·2 ml twice weekly. As control, an antibody of the same isotype (immunoglobulin G1), directed against the gP120 protein (Ab 5B6), or phosphate-buffered saline (PBS) was used. To evaluate the dermal matrix as a model for angiogenesis studies, rhVEGF was inoculated into the dermal matrix pocket and xenografted into mice.

Results

In vivo study using the dermal matrix showed that the number of blood vessel ingrowths paralleled the concentration of rhVEGF and was highest at the concentration of 100 ng ml−1. Mice treated with the mAb A.4.6.1 developed fewer blood vessels (mean 7 per high-power field (HPF)) than control mice (18 per HPF in Ab 5B6 and 22 per HPF in PBS) (P < 0·01). The size of tumours between mAb A.4.6.1- and Ab 5B6- or PBS-treated groups showed a significant difference from the second week after the inoculation of FTC-133 cells. The tumours from mice treated with mAb A.4.6.1 were smaller (mean(s.d.) 0·09(0·02) g at 5 weeks) than tumours from mice treated with Ab 5B6 (5·38(1·15) g) or PBS (4·00(0·72) g) (P < 0·001, two-tailed unpaired t test).

Conclusion

VEGF is produced by thyroid cancer cell line FTC-133 and stimulates angiogenesis and growth of thyroid cancer. More importantly, this stimulation can be blocked by mAb A.4.6.1.
Role of antiapoptotic genes in genetic control of programmed cell death in Hashimoto's thyroiditis
Authors: Hammond L J , Palazzo F F , Murphy B J , Goode A W , Mirakian R
Published: March 2003

Background

In Hashimoto's thyroiditis (HT) thyroid cells die by apoptosis, programmed cell death. In addition to the reported abnormal Fas expression on thyrocytes, a decreased expression of the Bcl-2 antiapoptotic genes has also been demonstrated in thyrocytes. The ratio of the expression of death antagonists (e.g. Bcl-2 and Bcl-Xl) to death agonists (Bax, Bak, Bcl-Xs and Bad) appears to determine the survival or death of thyrocytes under both physiological and pathological conditions.

Methods

The constitutive expression of Bcl-X was investigated in thyroid cells from ten multinodular goitre (MNG), ten Graves disease and four HT samples by immunofluorescence, confocal microscopy and Western blotting. The effect of proinflammatory cytokines (interferon (IFN) γ, tumour necrosis factor (TNF) α and interleukin (IL) 1 on Bcl-X expression on cultured thyrocytes was also studied.

Results

By in situ staining, an overall decreased Bcl-X expression was observed within the thyrocyte compartment in HT samples in comparison to that seen on thyrocytes from ten samples of MNG thyroid. Intrathyroidal lymphocytes were positive for Bcl-X. These findings were quantified using confocal microscopy which demonstrated an intensity of Bcl-X staining in MNG twice that of HT specimens. The ten specimens of Graves disease showed an intermediate and patchy staining on thyrocytes. In vitro studies have confirmed constitutive Bcl-X expression both by flow cytometry and Western blotting analysis with the latter showing a 27-kDa signal in all samples that corresponds to Bcl-Xl. IFN-γ, alone and in combination with TNF-α and IL-I, decreased Bcl-X expression on thyrocytes.

Conclusion

HT thyrocytes underexpress Bcl-X whereas intrathyroidal lymphocytes have been found to be positive. It is proposed that the decreased Bcl-X expression on thyrocytes of HT glands occurs as a result of proinflammatory cytokine release by infiltrating activated lymphocytes. The overall impairment of antiapoptotic gene protection may contribute to the susceptibility of HT thyrocytes to apoptosis.
Heat-stable plasma constituent responsible for caspase activation in Hashimoto's thyroiditis
Authors: Palazzo F F , Hammond L J , Murphy B J , Goode A W , Mirakian R
Published: March 2003

Background

Autoimmune thyroid disease is characterized by a spectrum of thyroid activity, with Graves disease (GD) and Hashimoto's thyroiditis (HT) at the extremes of over and under activity respectively. Hypothyroidism in HT is caused by apoptotic thyrocyte death, which is achieved via a cascade of cysteine protease (caspase) activity. It is still unclear whether thyrocyte death is the result of caspase activation secondary to extrinsic Fas/FasL interaction with the activation of procaspase 8 and/or of cytochrome C release from thyrocyte mitochondria consequent to impaired expression of the Bcl2/Bcl-X thyrocyte survival genes. This study was designed to clarify whether plasma constituents have a role in thyrocyte apoptosis and whether differential apoptotic kinetics can be observed in thyroid diseases.

Methods

Cultured thyrocytes from fresh surgical specimens were incubated with 5 and 20 per cent plasma from patients with multinodular goitre (MNG), GD and HT for between 5 and 180 min. Procaspase 8, caspase 3 and cytochrome C activities were monitored using Western blotting on thyroid lysates. Procaspase 8 was also studied microscopically using light microscopy and immunofluoroscopy. To ascertain the role of complement activity in the induction of apoptosis, thyrocytes from MNG, GD and HT thyroids were also exposed to heat-treated plasma (56°C for 45 min) for varying time intervals before caspase 8 estimation.

Results

Western blot and immunofluoroscopy confirmed that human plasma induces procaspase 8 in thyrocytes; Western blots also showed activation of cytochrome C and caspase 3 in these cells. At 30 min and up to 90 min thyrocyte procaspase 8 expression and the expression of breakdown products of this protein appeared to be more marked in the thyrocytes treated with HT plasma than MNG and GD plasma. Procaspase 8 expression was not altered by the heat of plasma. Thyrocytes exposed to plasma of patients with autoimmune and non-autoimmune conditions showed similar bands for caspase 3 and cytochrome C. The cytochrome C signal was stronger in the cells exposed to HT plasma at 30 min.

Conclusion

A heat-stable constituent of human plasma induces programmed cell death in thyrocytes. Plasma from patients with HT appears to induce a greater death stimulus than that from patients with other thyroid conditions. Fas/FasL interaction appears to be involved in apoptotic thyrocyte death. The role of mitochondrial cytochrome C in the induction of cell death is unclear.
Thyroid transcription factor 2 gene expression in thyroid malignancy
Authors: Sequeira M J , Fuehrer D , Ludgate M , Wheeler M H
Published: March 2003

Background

Expression of thyroid-specific proteins such as thyroglobulin is controlled by several transcription factors. Thyroid transcription factor (TTF) 2 is the most recently characterized and has a temporal expression during thyroid embryogenesis suggesting a role in initiating differentiation. Studies on other thyroid-specific genes have shown a gradual loss in differentiation as a tumour progresses, although a good marker to distinguish follicular adenoma from follicular carcinoma is still needed. There is no information on TTF-2 expression in varying thyroid pathologies. Given its central role in thyroid differentiation, reverse transcriptase–polymerase chain reaction (PCR) was used to investigate this in both archival and fresh thyroid tissues and fine-needle aspirates.

Methods

Thyroid tissue was obtained with informed consent, snap frozen, and total RNA and messenger RNA (mRNA) was extracted. Since TTF-2 has no introns in the coding region, it was necessary to use mRNA. The RNA was reverse transcribed using oligo(dT) and MMV reverse transcriptase. The quality of the complementary DNA (cDNA) was verified by PCR using intron–exon boundary spanning primers for the phosphoglucokinase (PGK) housekeeping gene; a 250-base pair (bp) product is derived from cDNA but a 650-bp product from amplification of contaminant genomic DNA. PCR amplification of TTF-2 used two sets of primers; A + D spans the DNA-binding region and gives a product of 460 bp while primers P + E generate a product of 370 bp in the carboxyl end of the coding region. Products were analysed by agarose gel electrophoresis and compared with a 100-bp ladder.

Results

A single band of 250 bp was obtained in all 33 thyroid tissue samples but in only three of eight fine-needle aspirates, after 40 cycles, using the PGK primers. Appropriate size products were obtained, after 30 cycles, invariably with both sets of TTF-2 primers, in all 18 benign thyroid nodules of varying pathology, including all five follicular adenomas, and in five of 15 malignant thyroid nodules. Four of five papillary carcinomas and one of seven follicular carcinomas expressed TTF-2; neither of two anaplastic carcinomas and one other carcinoma did not. One of six benign and one of two malignant thyroid nodules expressed TTF-2 on fine-needle aspiration cytology.

Conclusion

The results suggest loss of TTF-2 expression in poorly differentiated thyroid tumours and that TTF-2 may be helpful in distinguishing follicular adenoma from follicular carcinoma.
Neosphincters in the management of faecal incontinence
Authors: Niriella D A , Deen K I
Published: March 2003

Background

Surgical treatment of end-stage faecal incontinence has its origin in the early 1950s. Interest has been revived as a result of technical advances achieved in the recent past. The purpose of this article is to review the principles that underlie the use of skeletal muscle transposition around the anal canal and of electrical stimulation in the treatment of incontinence, and to explore new methods of treatment of this condition.

Methods

A literature search was performed using Pubmed and Medline, employing keywords related to treatment of faecal incontinence by neosphincter reconstruction. Basic science and clinical aspects of neosphincter reconstruction were gathered from relevant texts, original articles and recently published abstracts.

Results

The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence. However, electrostimulator failure may result in explantation in a proportion of patients. Impairment of evacuation is a functional setback in approximately one-third of patients with the gracilis neosphincter. Overall, improvement of continence may be expected in up to 90 per cent of patients according to some reports. By contrast, experience with the artificial neosphincter, which is less expensive, has been limited to a few tertiary centres across the world. Reported continence of stool is 100 per cent, and that of gas and stool 50 per cent, following implantation of the artificial sphincter. Both of the above operations have been associated with implant-related infection and impaired evacuation.

Conclusion

Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres. Patients are likely to benefit from a plan that incorporates preoperative counselling and a selective approach.
Biological behaviour and clinical implications of micrometastases
Authors: Kell M R , Winter D C , O'Sullivan G C , Shanahan F , Redmond H P
Published: March 2003

Background

The most important prognostic determinant in cancer is the identification of disseminated tumour burden (metastases). Micrometastases are microscopic (smaller than 2 mm) deposits of malignant cells that are segregated spatially from the primary tumour and depend on neovascular formation (angiogenesis) to propagate.

Methods

The electronic literature (1966 to present) on micrometastases and their implications in malignant melanoma and epithelial cancers was reviewed.

Results

Immunohistochemical techniques combined with serial sectioning offer the best accuracy for detection of nodal micrometastases. Molecular techniques should be reserved for blood samples or bone marrow aspirates. Detection of micrometastases in regional lymph nodes and/or bone marrow confers a poor prognosis in epithelial cancers. The concept of sentinel node biopsy combined with serial sectioning and dedicated screening for micrometastases may improve staging procedures. Strategies against angiogenesis may provide novel therapies to induce and maintain micrometastatic dormancy.

Conclusion

The concept of micrometastases has resulted in a paradigm shift in the staging of epithelial tumours and our overall understanding of malignant processes.
Need for secondary interventions after endovascular repair of abdominal aortic aneurysms. Intermediate-term follow-up results of a European collaborative registry (EUROSTAR)
Authors: Laheij R J F , Buth J , Harris P L , Moll F L , Stelter W J , Verhoeven E L G
Published: March 2003

Background

The frequency of secondary interventions after endovascular repair of abdominal aortic aneurysms (AAAs) was assessed and correlated with findings at clinical and imaging examination during follow-up.

Methods

Data were studied from 1023 patients with a follow-up of 12 months or longer, collected by 56 institutions in a multicentre data registry (EUROSTAR). Surveillance data were provided by the centres between September 1996 and November 1999.

Results

Overall, 186 patients (18 per cent) had a secondary intervention occurring a mean of 14 months after the initial endograft procedure. Twelve per cent of the interventions were transabdominal, 11 per cent consisted of an extra-anatomic bypass and 76 per cent involved a transfemoral procedure. The rates of freedom from intervention at 1, 3 and 4 years were 89, 67 and 62 per cent respectively. Migration (relative risk (RR) 8·9) and rupture (RR 22·6) were the most frequent causes of secondary transabdominal interventions. Graft limb thrombosis was the principal indication for extra-anatomic bypass (RR 37·5 for clinical evidence of graft limb thrombosis). Endoleak, graft kinking, stenosis or thrombosis and device migration were significant causes for secondary transfemoral interventions (RR 2·5–6·9).

Conclusion

The high incidence of late secondary interventions is a cause for concern with regard to broad application of endovascular AAA repair, and emphasizes the need for lifelong surveillance.
Experimental sodium phosphate and polyethylene glycol induce colonic tissue damage and oxidative stress
Authors: Coskun A , Uzunkoy A , Duzgun S A , Bozer M , Ozardali I , Vural H
Published: March 2003

Background

Bowel washout solutions may damage colonic mucosa and cause shallow ulceration, which may result in diagnostic errors and complications. The effects of polyethylene glycol (PEG) and sodium phosphate on rat colon were investigated histologically and by measurement of indicators of oxidative stress.

Methods

Thirty Wistar albino rats were divided into three groups and received PEG, sodium phosphate or tap water alone (control). After 8 h, histological changes in colonic mucosa were evaluated. The tissue concentration of malonyldialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) in colon homogenates was also measured.

Results

Animals in the sodium phosphate and PEG groups had significantly more colonic mucosal damage than controls, the damage induced by sodium phosphate being worse than that caused by PEG. MDA levels were significantly higher in the sodium phosphate and PEG groups than in controls and were higher in the sodium phosphate group than in the PEG group, whereas differences in SOD and GSH-Px activities were significant only between control and both sodium phosphate and PEG groups.

Conclusion

Sodium phosphate and PEG cause histological damage and trigger oxidative stress on colonic mucosa. The tissue damage and oxidative stress induced by sodium phosphate is more profound than that produced by PEG.