bluuebunny/crossref_metadata_2025 huggingface dataset:
The Japanese cord blood bank network experience with cord blood transplantation from unrelated donors for haematological malignancies: an evaluation of graft‐versus‐host disease prophylaxis
Authors: Nishihira Hirokazu , Kato Koji , Isoyama Keiichi , Takahashi Tsuneo A. , Kai Shunro , Kato Shunichi , Takanashi Minoko , Sato Norihiro , Sato Hiroyuki , Kitajima Kohichi , Naoe Tomoki , Saito Hidehiko
Published: March 2003

Summary. Cryopreserved umbilical cord blood (CB) from unrelated donors can restore haematopoiesis after myeloablative therapy in patients with haematological malignancy. We investigated the clinical outcomes of CB transplantation (CBT) with special emphasis on graft‐versus‐host disease (GVHD) prophylaxis. Patients with haematological malignancies (n = 216) received intensive chemotherapy or immunosuppressive therapy, followed by transplantation of cryopreserved CB cells from unrelated donors. The clinical outcomes, i.e. haematological reconstitution, the incidence of acute or chronic GVHD, relapse and event‐free survival (EFS), were evaluated. The estimated probability of neutrophil recovery was 88·2%. The median follow‐up for the survivors was 557 d (range 21–1492 d). The overall and EFS rates were 32·6% and 25·5%, respectively, 3·5 years after transplantation. Multivariate analysis using Cox's proportional hazards model showed that high‐risk disease status at CBT and single‐drug GVHD prophylaxis were associated with worse 2‐year EFS rates [P = 0·0013, relative risk (RR) 1·90, 95% confidence interval (CI) 1·28–2·81 and P = 0·0007, RR 1·91, 95% CI 1·31–2·79 respectively). Age at CBT had no significant influence on EFS. Cryopreserved CB from unrelated donors can restore haematopoiesis in patients with haematological malignancy. Although the incidence is low, the prophylaxis for acute GVHD is an important factor for survival of CBT from unrelated donors. A high rate of suitable donors was found, with a probability of 1 to every 18 CB units, when compared with human leucocyte antigen matching at other haematopoietic stem cell banks.
Leucocyte‐specific protein (LSP1) in malignant lymphoma and Hodgkin's disease
Authors: Marafioti Teresa , Jabri Lamia , Pulford Karen , Brousset Pierre , Mason David Y. , Delsol Georges
Published: March 2003

Summary. Biopsies from 319 haematopoietic neoplasms were immunostained for intracellular leucocyte‐specific protein 1 (LSP1) to assess its distribution and to compare its diagnostic value with that of CD45 (leucocyte common antigen: LCA). Most small B‐cell neoplasms expressed LSP1, but one third of diffuse large B‐cell lymphomas (DLBCL) were LSP1 negative. Among the cases with DLBCL (76 samples) tested for both LSP1 and CD45, one fifth expressed only CD45, but five samples were LSP1‐positive and negative for CD45. The latter pattern was also seen in four of nine myelomas. Five out of 14 T‐lymphoblastic lymphomas co‐expressed LSP1 and CD45, and three cases were LSP1 negative and CD45‐positive. Most peripheral T‐cell lymphomas co‐expressed LSP1 and CD45. All anaplastic lymphoma kinase (ALK)‐negative lymphomas of anaplastic large cell morphology (T and null phenotype) expressed LSP1 although the percentage of LSP1‐positive tumour cells was variable, however, only seven out of 30 cases with ALK‐positive lymphoma were LSP1 positive. LSP1 was expressed on Reed–Sternberg cells in 60 out of 66 cases with classic Hodgkin's disease but neoplastic cells were usually negative in lymphocyte predominant Hodgkin's. This study confirms the wide expression of LSP1 within haematopoietic neoplasms and its diagnostic value for a minority of lymphoid tumours that have lost CD45 expression. Furthermore, the strong expression of LSP1 in classic Hodgkin's disease, contrasting with its heterogeneous expression in ALK‐negative anaplastic lymphomas, may help to distinguish the latter lymphomas from patients with tumour cell‐rich Hodgkin's disease.
Factor VII/VIIa: a new antigen in the anti‐phospholipid antibody syndrome
Authors: Bidot Carlos J. , Jy Wenche , Horstman Lawrence L. , Huisheng Huang , Jimenez Joaquin J. , Yaniz Miriam , Ahn Yeon S.
Published: March 2003

Summary. We investigated antibodies to factor VII/VIIa (FVII/VIIa) and five other common target antigens in 33 patients with a history of anti‐phospholipid syndrome (APS) and 50 healthy controls using an enzyme‐linked immunosorbent assay (ELISA) technique. We found that antibody to FVII/VIIa, a previously unrecognized and common antigen in APS, was present in 67% of patients. Frequencies of antibodies to other target antigens were: anti‐beta‐2 glycoprotein 1 (anti‐β2GP1), 88%; anti‐cardiolipin (anti‐CL), 76%; anti‐phosphatidylethanolamine (anti‐PE), 67%; anti‐phosphatidylserine (anti‐PS), 64%; and anti‐phosphatidylcholine (anti‐PC), 59%. Most patients had antibodies against multiple antigens, but a few were positive for only anti‐β2GP1 (12%) or anti‐CL (3%). Positivity for anti‐FVII/VIIa was significantly associated with positivity for anti‐PE, anti‐PS and/or anti‐PC (P < 0·05) but not anti‐β2GP1. When frequencies of immunoglobulin G (IgG) versus immunoglobulin M (IgM) antibodies were compared, anti‐β2GP1 IgG correlated with the lupus anticoagulant (P < 0·05) and was significantly more prevalent than IgM, but the reverse was seen for all other antigens. In arterial thrombosis, IgM was more prevalent for all antigens, and was significantly associated with FVII/VIIa, PE and PS, whereas in venous thrombosis, IgG was frequently prevalent, especially in association with FVII/VIIa, β2GP1 and CL. In summary, FVII/VIIa is a new and common antigen in APS. Anti‐FVII/VIIa is often associated with anti‐PE, anti‐PS and anti‐PC. The IgM class is more frequently associated with arterial thrombosis and the IgG class with venous thrombosis.
A new mutation, S1285F, within the A1 loop of von Willebrand factor induces a conformational change in A1 loop with abnormal binding to platelet GPIb and botrocetin causing type 2M von Willebrand disease
Authors: Stepanian Alain , Ribba Anne‐Sophie , Lavergne Jean‐Maurice , Fressinaud Edith , Juhan‐Vague Irene , Mazurier Claudine , Girma Jean‐Pierre , Meyer Dominique
Published: March 2003

Summary. We report the identification of a new mutation in exon 28 of the von Willebrand factor (VWF) gene in two related patients with type 2M von Willebrand disease (VWD). The molecular abnormality changes the Ser 1285 to Phe within the A1 loop of VWF. The S1285F mutation was reproduced by site‐directed mutagenesis on the full‐length VWF cDNA. The mutated recombinant VWF (rVWF), F1285rVWF, and the hybrid, S/F1285rVWF, were expressed in COS‐7 cells. F1285rVWF exhibited a slight decrease of high‐molecular‐weight multimers and markedly reduced ristocetin‐ or botrocetin‐induced binding of VWF to platelets in association with a decreased binding to botrocetin. The hybrid S/F1285rVWF showed a normal multimeric profile and bound to platelets in a similar way to the patients' plasma VWF, in the presence of ristocetin or botrocetin. Thus, the new S1285F mutation within the A1 loop was responsible for the type 2M VWD observed in these patients, and was involved in the binding of VWF to botrocetin and to platelet glycoprotein Ib (GPIb). Three anti‐VWF monoclonal antibodies, with conformational epitopes within the A1 loop but distinct GPIb binding inhibitory properties, showed a different interaction with F1285‐rVWF. These results indicate that the S1285F substitution alters the folding of the A1 loop and prevents the correct exposure of the VWF binding sites to botrocetin and GPIb.
De novo deletion within the telomeric region flanking the human α globin locus as a cause of α thalassaemia
Authors: Viprakasit Vip , Kidd Alexa M. J. , Ayyub Helena , Horsley Sharon , Hughes Jim , Higgs Douglas R.
Published: March 2003

Summary. We have identified and characterized a Scottish individual with α thalassaemia, resulting from a de novo 48 kilobase (kb) deletion from the telomeric flanking region of the α globin cluster which occurred as a result of recombination between two misaligned repetitive elements that normally lie ∼83 kb and 131 kb from the 16p telomere. The deletion removes two previously described putative regulatory elements (HS‐40 and HS‐33) but leaves two other elements (HS‐10 and HS‐8) intact. Analysis of this deletion, together with eight other published deletions of the telomeric region, showed that they all severely downregulated α globin expression. Together they defined a 20·4‐kb region of the human α cluster, which contains all of the positive cis‐acting elements required to regulate α globin expression. Comparative analysis of this region with the corresponding segment of the mouse α globin cluster demonstrated conserved non‐coding sequences corresponding to the putative regulatory elements HS‐40 and HS‐33. Although the role of HS‐40 as an enhancer of α globin expression is fully established, these observations suggest that the role of HS‐33 and other sequences in this region should be more fully investigated in the context of the natural human and mouse α globin loci.
Development and functional characterization of human bone marrow mesenchymal cells immortalized by enforced expression of telomerase
Authors: Mihara Keichiro , Imai Chihaya , Coustan‐Smith Elaine , Dome Jeffrey S. , Dominici Massimo , Vanin Elio , Campana Dario
Published: March 2003

Summary. To create immortal mesenchymal cell lines, we transduced primary human bone marrow mesenchymal cells with telomerase reverse transcriptase (TERT). TERT+ mesenchymal cells continued to grow for > 2 years; parallel TERT– cultures underwent senescence after 15 weeks. TERT+ mesenchymal cells did not form foci in soft agar, had a normal karyotype and could differentiate into osteoblasts and chondrocytes. Their capacity to support leukaemic lymphoblasts and normal CD34+ haematopoietic cells was equal to or greater than that of primary cells; 42 TERT+ mesenchymal cell clones varied in their supporting capacity. Immortalized mesenchymal cells offer a promising tool for identifying molecules that regulate human haematopoiesis.
Continued change in the distribution of colorectal carcinoma
Authors: Obrand D I , Gordon P H
Published: March 2003

Background

The aim of this study was to determine whether the previously reported shift in carcinoma from the left colon to the right colon has progressed.

Methods

The charts of 2169 patients admitted to one institution between 1979 and 1994 with a diagnosis of colorectal carcinoma were reviewed retrospectively. The study was divided into four equal intervals. The large bowel was divided into five regions: right, transverse, left, sigmoid and rectum.

Results

Right-sided lesions increased from 20·6 to 29·9 per cent (P = 0·001) and rectal lesions decreased from 22·0 to 11·3 per cent (P = 0·0002) from the first to the fourth study interval. The frequency of transverse, left and sigmoid colon lesions remained relatively constant.

Conclusion

The continuing trend of increased incidence of right-sided lesions and decreased incidence of rectal lesions was documented. Any screening examination for carcinoma requires total examination of the colon.
International differences in survival from colon cancer: more effective care versus less complete cancer registration
Authors: Prior P , Woodman C B J , Collins S
Published: March 2003

Background

Reporting of a recent international comparison of cancer survival rates has left an impression of inadequate treatment of patients in the UK but failed to address adequately the extent to which differences in survival may reflect variation in the completeness and accuracy of cancer registration. The aim of this study was to quantify the extent to which differences in registration practice may confound comparisons of survival from cancer of the colon.

Methods

A cohort of incident cases of colon cancer identified from records held by the North Western Regional Cancer Registry was used to simulate the effects on survival of changes in clinical and registration factors. The survival curve produced after each simulation was compared with that for aggregated data from 21 European registries.

Results

The observed survival differences were not explained by more effective primary treatment or by misclassification of in situ cases as malignant disease, whereas the exclusion of cases with only a clinical diagnosis produced estimates close to those of the European cohort.

Conclusion

The observed survival differentials may not be due to differences in the quality of care but may reflect the failure of some European registries to register all patients with advanced disease.
Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy
Authors: Gooszen A W , Geelkerken R H , Hermans J , Lagaay M B , Gooszen H G
Published: March 2003

Background

Loop ileostomy or loop transverse colostomy for temporary decompression of a left colonic anastomosis represents an important issue in abdominal surgery.

Methods

A randomized study, comparing loop ileostomy (n = 37; group 1) or loop transverse colostomy (n = 39; group 2), was conducted. Patients were followed from construction to closure of the stoma.

Results

Age, weight, sex and indication for surgery were similar in both groups. After stoma construction complications were reported in nine of 37 patients in group 1 and in one of 39 in group 2 (P < 0·01), leading to postoperative death in five of 37 in group 1 and one of 39 in group 2. In the period between stoma construction and closure significant differences were observed only in prolapse rate (one of 32 group 1, 16 of 38 group 2; P < 0·01), need for temporary adaptation of clothing (eight of 32 group 1, 22 of 38 group 2; P < 0·01) and dietary guidelines (23 of 32 group 1, four of 38 group 2; P < 0·01). One patient died in group 1 and four in group 2; the deaths were not stoma related. After stoma closure eight of 29 patients in group 1 had complications and there were two deaths compared with three of 32 and no deaths in group 2.

Conclusion

Both types of stoma carry a high complication rate with a considerable associated mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status. Based on all three phases studied, routine use of transverse colostomy is advised if decompression of the left colon is indicated.
Marsupialization of fistulotomy wounds improves healing: a randomized controlled trial
Authors: Ho Y-H , Tan M , Leong A F P K , Seow-Choen F
Published: March 2003

Background

Marsupialization of anal fistulotomy wounds leaves less raw unepithelialized tissue to granulate and may improve wound healing.

Methods

Some 103 consecutive patients with uncomplicated intersphincteric or trans-sphincteric fistula in ano were recruited into a randomized controlled trial. Fistula tracts were identified and laid open under general anaesthesia. The patients were randomized to have either the wounds left open (LO group) or wound edges marsupialized to the fistula tract with interrupted absorbable sutures (MS group). Anal manometry was performed before operation, and 6 weeks and 3 months after surgery.

Results

Some 52 patients were randomized to the LO group and 51 to the MS group. There were no differences in the age, sex, fistula type and fistula length distribution between the groups. Mean follow-up times were 9 and 10·2 months respectively. Wounds in the MS group healed faster (mean(s.e.m.) 6·0 (0·4) weeks) than those in the LO group (10·0(0·5) weeks) (P<0·001). Only one patient (2 per cent) in the MS group was incontinent of liquids after operation compared with six (12 per cent) in the LO group. There was less impairment in maximum anal squeeze pressure at 3 months after marsupialization compared with leaving fistulotomy wounds open (P<0·05). Apart from a slightly longer operative time required for marsupialization, the hospitalization and complication rates were the same.

Conclusion

Anal fistulotomy wounds healed faster after marsupialization. Anal squeeze pressures were better preserved and this may improve anal continence.
Intra-abdominal and pelvic abscess in Crohn's disease: results of non-invasive and surgical management
Authors: Jawhari A , Kamm M A , Ong C , Forbes A , Bartram C I , Hawley P R
Published: March 2003

Background

Intra-abdominal and pelvic abscesses occur in 10–30 per cent of patients with Crohn's disease. The aim of this study was to establish the clinical characteristics and outcome of patients admitted over a 4-year period with an abdominal or pelvic abscess secondary to Crohn's disease.

Methods

Patients with Crohn's disease-related intra-abdominal or pelvic abscess were identified from a prospectively collected database, comprising all admissions between 1991 and 1994. Medical records were reviewed retrospectively and data gathered regarding management and outcome.

Results

Thirty-six patients were identified with Crohn's disease-related abscess, of whom 15 were considered for initial percutaneous drainage. Drainage was technically possible in eight of these patients: it failed in four, gave good long-term results in two, and was followed by recurrence after 3 years in one and by later surgery unrelated to the abscess in one. Twenty-eight patients underwent surgery, with only four requiring a stoma. Complications occurred in 12 patients. At 3 months, 22 of the 36 patients were in remission.

Conclusion

Crohn's intra-abdominal abscesses are associated with a high morbidity rate. Selected cases can be drained percutaneously, without adding to the morbidity, and sometimes resulting in abscess resolution.
Bile duct obstruction due to portal biliopathy in extrahepatic portal hypertension: surgical management
Authors: Chaudhary A , Dhar P , Sarin S K , Sachdev A , Agarwal A K , Vij J C , Broor S L
Published: March 2003

Background

Varices can develop in and around the bile duct in the presence of portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis. The term ‘portal biliopathy’ is used to describe changes in the bile duct due to these varices, which may cause bile duct obstruction. This paper reviews experience of the surgical management of patients with symptomatic portal biliopathy.

Methods

Nine patients with extrahepatic portal vein obstruction with symptomatic portal biliopathy were reviewed retrospectively.

Results

Eight patients presented with jaundice, two had abdominal pain and one had recurrent cholangitis. Endoscopic retrograde cholangiography revealed abnormality of the bile duct wall, with stricture in eight patients and bile duct calculi in two. Portasystemic shunting relieved jaundice in five of seven patients, and in two a second-stage hepaticojejunostomy was required.

Conclusion

Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary.
Significance of local recurrence of rectal cancer as a local or disseminated disease
Authors: Maetani S , Onodera H , Nishikawa T , Morimoto H , Ida K , Kitamura O , Imamura M
Published: March 2003

Background

The nature of ‘local recurrence’ of rectal cancer remains unclear.

Methods

Fifty-nine patients with locally recurrent rectal cancer who underwent extended repeat resections including total pelvic exenteration (39) and sacrectomy (43) were reviewed. Twelve patients had distant metastases before or at the time of repeat resection.

Results

The 5-year survival rate was 25 per cent. A second recurrence occurred in 45 patients including five of the eight 5-year survivors. Thirty-six of these recurrences had locoregional manifestations and 29 had distant metastases. Of 18 prognostic factors examined, the most significant determinant was the postoperative carcinoembryonic antigen doubling time (CEADT), followed by the preoperative CEADT, carcinoembryonic antigen (CEA) level and occurrence of distant metastases, in decreasing order. Late onset of first recurrence was also a favourable indicator. Thus, the growth rate of the tumour had a more profound impact on survival than the current extent of tumour progression. After operation the CEADT was reduced in patients with second recurrence (P = 0·05).

Conclusion

Locally recurrent rectal cancer is a manifestation of disseminated disease spreading locoregionally and often to distant organs with a low probability of long-term cure. However, survival varies widely depending on the tumour growth rate, which is biologically predetermined and is also influenced by surgery.
Encouraging results of split-liver transplantation
Authors: Mirza D F , Achilleos O , Pirenne J , Buckels J A C , Mcmaster P , Mayer A D
Published: March 2003

Background

Liver donor shortage presently accounts for a 10 per cent waiting list mortality rate. Split-liver transplantation (SLT) can improve utilization of this scarce resource.

Methods

Twenty-four SLTs (11 left, 13 right grafts) from 13 livers were performed in 23 patients (nine adults, 14 children), comprising 4·5 per cent of all orthotopic liver transplants (14 urgent or emergency, ten elective). The left graft comprised segments II and III, whereas the right graft comprised segments V–VIII in eight cases, IV–VIII in three, and segments I, IV–VIII, and I, V–VIII in one case each. Additional arterial extension grafts were required in six of 24 cases, and portal venous interposition graft in one.

Results

Twenty-one grafts showed good initial function, with one primary non-function and two initial poor function. The median peak aspartate aminotransferase level was 782 (range 94–2301) and 982 (range 382–2520) units/l for left and right grafts respectively. Five patients died (all urgent recipients), all within the first 30 days after surgery. Two SLT recipients underwent subsequent retransplantation. All ten elective recipients are alive. The 1-year actuarial patient and graft survival rates at a median follow-up of 20 months were 78 and 68 per cent respectively.

Conclusion

These encouraging results compare favourably with those of reduced-size and whole-liver transplantation and justify wider application of this technique, thereby optimizing donor resource use.
TRISS methodology in trauma: the need for alternatives
Authors: Demetriades D , Chan L S , Velmahos G , Berne T V , Cornwell E E , Belzberg H , Asensio J A , Murray J , Berne J , Shoemaker W
Published: March 2003

Background

Trauma and Injury Severity Score (TRISS) methodology has become a standard tool for evaluating the performance of trauma centres and identifying cases for critical review. Recent work has identified several limitations and questioned the validity of the methodology in certain types of trauma.

Methods

The usefulness and limitations of the TRISS methodology were evaluated in an urban trauma centre. Trauma registry data of 5445 patients with major trauma were analysed with respect to 30 demographic, prehospital, injury severity and hospitalization attributes. The performance of TRISS was measured primarily by the percentage of misclassifications, including false positives and false negatives, comparing the survival status predicted by TRISS with the true status. Sensitivity, specificity, and positive and negative predictive values were also measured for subgroups defined by the 30 attributes. Logistic regression analysis was used to identify significant independent factors related to the performance of TRISS.

Results

The overall misclassification rate was 4·3 per cent. However, in many subgroups of patients with severe trauma the misclassification rate was very high: 34 per cent in patients older than 54 years with Injury Severity Score (ISS) greater than 20; 29 per cent in those with fall injuries and ISS above 20; 29 per cent in patients with injuries involving four or more body areas and ISS greater than 20; 28·6 per cent in patients with injuries needing admission to the intensive care unit (ICU) and ISS greater than 20; 26·4 per cent in patients in severe distress before reaching hospital with ISS greater than 20; and 26·1 per cent in patients whose ISS score was above 20 and who had complications in hospital.

Conclusion

The TRISS methodology has major limitations in many subgroups of patients, especially in severe trauma. In its present form TRISS has no useful role in major urban trauma centres. Its use should be seriously reconsidered, if not abandoned.
Influence of graft material on blood rheology and plasma biochemistry following insertion of an infrainguinal bypass graft
Authors: Woodburn K R , Rumley A , Love J G , Murray G D , Lowe G D O
Published: March 2003

Background

Occlusive arterial disease causes alterations in blood rheology and levels of potential thrombotic and fibrinolytic mediators. The aim of this study was to investigate the effect of graft materials on these parameters in patients undergoing successful infrainguinal revascularization.

Methods

Some 186 consecutive infrainguinal grafts were observed for 12 months. Venous blood was sampled before operation and at 3, 6, and 12 months after surgery. Samples were assayed for thrombotic and rheological parameters. An area under the curve analysis was used to compare the effects of vein and synthetic grafting on these parameters in 99 patients whose grafts remained patent and free from stenosis.

Results

Plasma levels of fibrin degradation products were significantly higher in patients with synthetic grafts (n = 46) than in those with autogenous vein grafts (n = 53) (median 274 versus150 ng/ml; P < 0·001). There were no significant differences in plasma fibrinogen or any other parameters between the two groups.

Conclusion

Patients with a synthetic infrainguinal graft have a higher fibrin turnover than those with a vein graft. Further studies are required to determine whether this increase in fibrin turnover is an essential requirement to maintain patency of a synthetic infrainguinal graft.
Risk factors for anastomotic leakage after resection of rectal cancer
Authors: Rullier E , Laurent C , Garrelon J L , Michel P , Saric J , Parneix M
Published: March 2003

Background

The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage, which is associated with a 6–22 per cent mortality rate. The aim of this retrospective study was to evaluate the risk factors for clinical anastomotic leakage after anterior resection for cancer of the rectum.

Methods

From 1980 to 1995, 272 consecutive anterior resections for rectal cancer were performed by the same surgical team; 131 anastomoses were situated 5 cm or less from the anal verge. The associations between clinical anastomotic leakage and 19 patient-, tumour-, surgical- and treatment-related variables were studied by univariate and multivariate analysis.

Results

The rate of clinical anastomotic leakage was 12 per cent (32 of 272). Multivariate analysis of the overall population showed that only male sex and level of anastomosis were independent factors for development of anastomotic leakage. The risk of leakage was 6·5 times higher for anastomoses situated less than 5 cm from the anal verge than for those situated above 5 cm; it was 2·7 times higher for men than for women. In a second analysis of low anastomoses (5 cm or less from the anal verge; n = 131), obesity was statistically associated with leakage.

Conclusion

A protective stoma is suitable after sphincter-saving resection for rectal cancer for anastomoses situated at or less than 5 cm from the anal verge, particularly for men and obese patients.
Histamine in human breast cancer
Authors: Reynolds J L , Akhter J A , Magarey C J , Schwartz P , Adams W J , Morris D L
Published: March 2003

Background

Histamine inhibits lymphocyte function in vitro at concentrations of greater than 10−6 mol/l. The aim of this study was to determine whether histamine concentrations in breast cancers were sufficient to produce an immunological effect.

Methods

Tumour and adjacent normal breast content of histamine was measured using a radioenzymatic assay in 29 patients having surgery for breast cancer.

Results

The median content of histamine in breast cancer tissue was 5·4 (range 0·9–27·3) µg/g (median concentration 4·5 × 10−5 mol/l), and was significantly greater than that in adjacent breast tissue (P = 0·007).

Conclusion

The concentration of histamine in breast cancer was sufficient to inhibit lymphocyte function and could be locally immunosuppressive.
Survival following pancreaticoduodenectomy with resection of the superior mesenteric–portal vein confluence for adenocarcinoma of the pancreatic head
Authors: Leach S D , Lee J E , Charnsangavej C , Cleary K R , Lowy A M , Fenoglio C J , Pisters P W T , Evans D B
Published: March 2003

Background

The survival of patients who underwent pancreaticoduodenectomy with or without en bloc resection of the superior mesenteric–portal vein (SMPV) confluence for adenocarcinoma of the pancreatic head was compared.

Methods

To be considered for surgery, patients were required to fulfil the following computed tomography criteria for resectability: (1) absence of extrapancreatic disease, (2) no evidence of tumour extension to the superior mesenteric artery (SMA) or coeliac axis, and (3) a patent SMPV confluence. Tumour adherence to the superior mesenteric vein (SMV) or SMPV confluence was assessed at operation and en bloc venous resection was performed when necessary to achieve complete tumour extirpation.

Results

Seventy-five consecutive patients underwent pancreaticoduodenectomy, 44 without venous resection and 31 with en bloc resection of the SMPV confluence. There were no perioperative deaths in either group; late (more than 6 months) occlusion of the reconstructed SMPV confluence contributed to the death of two patients. Median survival in the 31 patients who required venous resection at the time of pancreaticoduodenectomy was 22 months, and that for the 44 control patients was 20 months (P = 0·25).

Conclusion

Patients with adenocarcinoma of the pancreatic head who require venous resection during pancreaticoduodenectomy for isolated tumour extension to the SMV or SMPV confluence (in the absence of tumour extension to the SMA or coeliac axis) have a duration of survival no different from that of patients who undergo standard pancreaticoduodenectomy. These data suggest that venous involvement is a function of tumour location rather than an indicator of aggressive tumour biology.
Arteriovenous fistula using transposed basilic vein
Authors: Butterworth P C , Doughman T M , Wheatley T J , Nicholson M L
Published: March 2003

Background

Patients who need long-term haemodialysis often require multiple operations to maintain their vascular access. The options for secondary or tertiary access procedures may become increasingly limited. Prosthetic conduits are commonly used in difficult cases but are associated with a high incidence of complications.

Methods

The brachial artery–transposed basilic vein arteriovenous fistula has been used in preference to a prosthetic graft on 31 occasions.

Results

There were no technical failures and 28 of these fistulas matured. No major infective complications occurred.

Conclusion

This procedure should be considered before resorting to a prosthetic graft for vascular access.
Trials and tribulations of vascular surgical benchmarking
Authors: Berridge D C , Scott D J A , Beard J D , Hands L
Published: March 2003

Background

Benchmarking is a new tool to assess the efficiency of different hospitals. Classification of operations using healthcare resource groups (HRGs) is related to parameters including number of cases, length of stay (LOS) and age profile.

Methods

A National Comparative Database was used to compare three hospitals. Analysis was confined to the major HRGs involved with vascular/venous surgery.

Results

For high-volume low-complexity varicose vein surgery, all three hospitals had similar numbers of patients and LOS. In contrast, the LOS for routine vascular operations in hospital A was double that in hospital B (16·3 versus 7·4 days). Hospital A had three times as many patients classified as ‘other – peripheral vascular disease’ as hospital C and six times as many as hospital B (329, 49 and 111 for hospitals A, B and C respectively). LOS following major amputation in hospitals A and C was nearly double that in hospital B (32·4, 18·3 and 33·6 days for hospitals A, B and C respectively).

Conclusion

There were a number of significant variations between the three hospitals during the 9-month interval. Explanations included the methods of coding, local facilities including availability of rehabilitation beds and difference in the patients' age profiles. Benchmarking in its present format reveals a number of variations which may not necessarily reflect real differences in clinical performance.
Spinal cord complications of thoracoabdominal aneurysm surgery
Authors: Lintott P , Hafez H M , Stansby G
Published: March 2003

Background

Although rare, paralysis secondary to spinal cord ischaemia after aortic aneurysm surgery is a devastating complication. Many papers have been published on this topic but without a clear consensus on the best way of minimizing the problem. Recent articles have included advanced pharmacological approaches and the literature has been reviewed in light of these.

Methods

Relevant papers were identified by an extensive text word search of the Medline database and a review of quoted articles.

Results

Spinal cord complications are commoner after the repair of Crawford type II aneurysms than less extensive aneurysms. The presence of dissection, rupture and prolonged clamp times are associated with an increased incidence. About a quarter of all cord problems develop over 24 h after surgery and this may be due to a reperfusion type injury, although the exact mechanisms are by no means clear.

Conclusion

A combination of rapid surgery, left heart bypass for the repair of more extensive aneurysms, free spinal drainage and the avoidance of postoperative hypoxia and hypotension help to minimize spinal cord ischaemia. No pharmacological agent has yet been shown conclusively to improve outcome in the clinical setting.
Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy
Authors: Doctor N , Dooley J S , Dick R , Watkinson A , Rolles K , Davidson B R
Published: March 2003

Background

Bile leaks and bile duct strictures are major complications of cholecystectomy which increased in incidence after the introduction of laparoscopic surgery. The management and outcome of these complications following the introduction of laparoscopic cholecystectomy was reviewed.

Methods

Eighteen patients of median age 45 (range 22–70) years were treated between January 1992 and December 1995. Six patients had a common hepatic duct (CHD) stricture, four following a failed previous repair. Nine patients had bile leaks from bile duct transection (four), cystic stump (four) or segment V duct (one). Two patients had partial bile duct damage with primary sutured repair at time of cholecystectomy. One patient had recurrent haemobilia from a hepatic artery pseudoaneurysm.

Results

Cystic stump or segment V leaks were treated successfully by endoscopic stenting (median follow-up 42 months). Roux loop biliary reconstruction was carried out in nine patients: two CHD strictures, three of the four failed primary CHD repairs and four bile duct transections. All had normal liver function test results at median follow-up of 30 months. The two patients with partial duct injuries repaired at initial surgery required no further intervention. The right hepatic artery aneurysm was successfully embolized. There have been no deaths or major complications of endoscopic, radiological or surgical intervention.

Conclusion

Endoscopic stenting successfully treats cystic stump and segment V duct leaks. Duct strictures, including failed initial repairs and transections, have a good outcome with Roux-en-Y loop reconstruction.
Oesophageal cancer staging using endoscopic ultrasonography
Authors: Vickers J , Alderson D
Published: March 2003

Background

Despite encouraging results from Europe and the USA, endoscopic ultrasonography has yet to become established in the UK for imaging gastrointestinal lesions. The aim of this prospective study was to investigate the accuracy of endoscopic ultrasonography for local tumour (T) and lymph node (N) staging of oesophageal cancer.

Methods

Endoscopic ultrasonography was performed in 50 consecutive patients with operable oesophageal cancer. Its accuracy for locoregional tumour staging was assessed and a detailed analysis of the distribution of ultrasonographically detected lymph nodes performed.

Results

Endoscopic ultrasonography was highly accurate for both local tumour (92 per cent correct T stage prediction) and lymph node (86 per cent correct N stage prediction) staging compared with final histology. The procedure was also superior to open surgical staging performed by the surgeon; it had a tendency to overestimate malignant involvement of individual lymph nodes and had only limited ability to identify small benign lymph nodes, particularly in the abdomen.

Conclusion

Endoscopic ultrasonography was reliable for both local tumour and lymph node staging of oesophageal cancer.
A 21-year experience of abdominal aortic aneurysm operations in Edinburgh
Authors: Bradbury A W , Adam D J , Makhdoomi K R , Stuart W P , Murie J A , Mcl. Jenkins A , Ruckley C V
Published: March 2003

Background

This study reviews the results of infrarenal abdominal aortic aneurysm (AAA) surgery over 21 years (1 January 1976 to 31 December 1996).

Methods

A prospectively gathered database was analysed.

Results

Infrarenal AAA repair was performed in 1515 patients: 492 (32·5 per cent) had elective repair of an asymptomatic AAA; 194 (12·8 per cent) had elective repair of a symptomatic AAA; 156 (10·3 per cent) had emergency repair of a symptomatic non-ruptured AAA; and 673 (44·4 per cent) had surgery for a ruptured AAA. The 30-day and/or same admission mortality rates were 6·1, 5·8, 14·1 and 37 per cent respectively. Operative mortality increased in all four groups over the study interval, although this only attained statistical significance in patients having elective repair of a symptomatic, non-ruptured AAA. There was a significant increase in the age of patients undergoing elective repair of an asymptomatic AAA, but not in the other three groups. There was also a significant increase in the proportion of straight ‘tube’ grafts inserted in all four groups.

Conclusions

It remains the minority of patients who have elective operation before the onset of symptoms and/or rupture. Despite anaesthetic and surgical specialization, the results of AAA repair have not improved over the past two decades. Operative mortality may be increasing, possibly because of the increasing age and associated comorbidity of the patients presenting to this unit.
Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies
Authors: McAlister F A , Clark H D , Wells P S , Laupacis A
Published: March 2003

Background

There is controversy over whether perioperative allogeneic red blood cell transfusions are associated with an increased risk of cancer recurrence, postoperative infection or death in patients with cancer undergoing surgery.

Methods

A systematic meta-analysis was performed to answer this question. Studies were identified from electronic databases (Medline 1966–1997, Cancerlit 1983–1997, Current Contents, Cinahl 1982–1996, Healthstar 1990–1997, Bioabstracts 1990–1996 and Embase), by hand search of the bibliographies of identified studies and relevant journals, and by contact with experts in the field. All randomized controlled trials or prospective cohort studies with active comparator controls (autologous or leucocyte-depleted allogeneic blood) were eligible for inclusion if they reported on mortality, infection or recurrence rate in patients with cancer undergoing potentially curative surgical resection. The validity of the identified studies was assessed by means of a standardized scale, and data abstraction was carried out by two investigators independently. A random effects model was used for data synthesis.

Results

Of the 2172 references identified, only 17 studies fulfilled the inclusion criteria. After exclusion of duplicate publications, six randomized controlled trials and two prospective cohort studies with appropriate concurrent controls were included in the analysis. The summary risk ratios were 0·95 (95 per cent confidence interval (c.i.) 0·79–1·15) for all-cause mortality and 1·06 (95 per cent c.i. 0·88–1·28) for cancer recurrence, the two endpoints that were appropriate to combine statistically. There was significant heterogeneity (explainable by differences in study design and patient characteristics) in the postoperative infection data and the summary risk ratio was 1·00 (95 per cent c.i. 0·76–1·32) for the four studies that were appropriate to subject to meta-analysis. Given the sample sizes of these eight studies, this meta-analysis had insufficient power to detect a relative difference of less than 20 per cent in the frequency of death, cancer recurrence or infection between the allogeneic and control transfusion arms.

Conclusion

Although more studies are required before a definitive statement can be made, at this time there is no evidence that allogeneic blood transfusion increases the risk of clinically important adverse sequelae in patients with cancer undergoing surgery.
Effect of graft reperfusion on intracellular calcium levels in mononuclear leucocytes during human orthotopic liver transplantation
Authors: Enright S M , Srinivasa R , Bellamy M C
Published: March 2003

Background

Orthotopic liver transplantation (OLT) is accompanied by local and systemic manifestations of the ischaemia–reperfusion syndrome. Local effects are mediated in part through changes in intracellular calcium levels in Kupffer cells. Arachidonic acid metabolites mediate increases in intracellular calcium concentration and thus potentiate the effect of free radicals. This study was carried out to characterize white blood cell (WBC) calcium changes as a mediator for white cell activation in human OLT.

Methods

Twenty consecutive patients had OLT using standard surgery and anaesthesia techniques. Blood samples were drawn for estimation of WBC cytosolic calcium content at induction of anaesthesia, 5 min before graft reperfusion and 15 min after reperfusion. The rate of rise in intracellular calcium concentration after the addition of a calcium chloride 1 mmol l−1 solution to the extracellular milieu was used as an estimate of membrane calcium permeability.

Results

Both extracellular (P = 0·0002) and intracellular (P = 0·0008) calcium concentrations rose with time. However, at no time was there a correlation between extracellular and intracellular calcium levels or rate of calcium influx (r2 = 0·002, P = 0·78). There was a significant increase in intracellular calcium concentration (P = 0·0008) and in the rate of rise of intracellular calcium levels (P = 0·0009) after reperfusion.

Conclusion

There was a significant increase in circulating monocyte membrane permeability for calcium and cytosolic calcium concentration following reperfusion in human OLT. This was independent of extracellular calcium concentration. These results are consistent with WBC activation by reperfusion and could be implicated in the systemic reperfusion syndrome seen in OLT in humans.
Comparison of POSSUM and the Portsmouth predictor equation for predicting death following vascular surgery
Authors: Wijesinghe L D , Mahmood T , Scott D J A , Berridge D C , Kent P J , Kester R C
Published: March 2003

Background

The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) scoring system has been proposed as an accurate predictor of death which takes account of case mix. It appears to overpredict death, and may have drawbacks which prevent accurate individual or subgroup analysis. An alternative system, the Portsmouth predictor equation for mortality (P-POSSUM) may have overcome these problems, but its apparent advantage could be related to inappropriate analysis of POSSUM predictions.

Methods

Some 312 patients having arterial procedures were studied. POSSUM and P-POSSUM scores were used to predict death and compared with actual outcomes. The observed:predicted (O:E) mortality ratios were calculated by two methods for each of the scoring systems. First the analysis devised by the inventors of POSSUM was used and second the method devised for P-POSSUM.

Results

The O:E ratio for POSSUM using its recommended ‘exponential’ method of analysis was 1·14, but it was 0·59 if the P-POSSUM ‘linear’ analysis was used. The O:E ratio for P-POSSUM using its correct method of analysis was 0·89, but it was 0·67 if the method of analysis devised for POSSUM was used.

Conclusion

The O:E ratios for POSSUM and P-POSSUM were close to unity when the appropriate analysis was performed. Both POSSUM and P-POSSUM overpredicted death if the incorrect analysis was used.
Different gastric emptying of solid and liquid meals after pylorus-preserving pancreatoduodenectomy
Authors: Kobayashi I , Miyachi M , Kanai M , Nagino M , Kondo S , Kamiya J , Nakao M , Hayakawa N , Nimura Y
Published: March 2003

Background

Transient gastric stasis immediately after pylorus-preserving pancreatoduodenectomy (PPPD) is a common complication, but the cause remains unknown. Changes in gastric emptying were investigated in patients undergoing PPPD for periampullary malignancy.

Methods

In 14 patients undergoing PPPD, liquid- and solid-phase gastric emptying were evaluated before and after operation (mean 38 (range 27–53) days after operation). Two pharmacological gastric-emptying tests were used: the acetaminophen test for liquid-phase emptying and the sulphamethizole capsule food test for solid-phase gastric emptying.

Results

All patients exhibited delayed solid emptying but fairly good liquid emptying.

Conclusion

Gastric function in the early postoperative period after PPPD is characterized by delayed solid-phase but good liquid-phase emptying.
Provision of training in carotid surgery does not compromise patient safety
Authors: Naylor A R , Thompson M M , Varty K , Sayers R D , London N J M , Bell P R F
Published: March 2003

Background

Vascular surgeons perceive that carotid endarterectomy carries a higher risk of stroke if performed by a surgical trainee. Accordingly, some trainees consider that they receive a less than adequate training in carotid surgery before taking up a consultant position. The aim of this study was to establish whether the stroke rate was adversely affected if carotid endarterectomy was performed by a surgical trainee under consultant supervision.

Methods

This was a prospective study of 151 consecutive patients undergoing carotid endarterectomy between 1 January and 31 December 1996 using a standardized technique including intraoperative and postoperative transcranial Doppler monitoring and completion angioscopy.

Results

The overall mortality and/or disabling stroke rate was 0·7 per cent (one of 151 patients), whereas the mortality and/or any stroke rate was 1·3 per cent (two of 151). Surgical trainees performed 82 of 151 carotid endarterectomies, with a mortality rate of 1 per cent and a mortality and/or any stroke rate of 2 per cent. There was no significant difference in the incidence of retained thrombus or intimal flaps between trainees and consultants as detected by angioscopy.

Conclusion

Vascular surgical trainees can receive a comprehensive training in carotid artery surgery without incurring an unacceptable increase in operative risk.