bluuebunny/crossref_metadata_2025 huggingface dataset:
Uptake of tetracycline in aortic aneurysms: influence on inflammation and proteolysis
Authors: Franklin I J , Harley S L , Greenhalgh R M , Powell J T
Published: March 2003

Background

Derivatives of tetracycline (TC), through their inhibition of matrix metalloproteinases (MMPs), have been suggested as potential medical therapy to limit growth of abdominal aortic aneurysms (AAAs), but penetration of the aortic wall in vivo has not been demonstrated. The uptake and concentration of TC in aneurysm wall, and its effect on MMP and cytokine production, were investigated.

Methods

Patients undergoing elective AAA repair (n = 5) were given a single bolus of intravenous TC 500 mg on induction of anaesthesia. The TC concentrations achieved in serum, aneurysm wall and mural thrombus were determined using a microbiological assay. In separate patients, not given TC, AAA biopsy explants were established and the effect of TC (0, 10 and 100 µg ml–1) on hydroxyproline, MMP-9 and cytokine (MCP-1 and interleukin (IL) 6) secretion were investigated using colorimetric assays and immunoassays.

Results

At the time of aortic cross-clamping median TC concentration was 9 (range 5–12) µg ml–1 in serum, 2·7 (1·3–9·6) µg g–1 in AAA wall and nil in mural thrombus (see Table).

Conclusion

TC rapidly penetrates AAA wall in vivo and inhibits MMP-9 and MCP-1 release by AAA explants. This suggests that TCs have the potential to limit aneurysm growth.
Angioplasty reverses the systemic effects of exercise in intermittent claudication
Authors: Lewis D R , Day A , Baird R N , Smith F C T , Lamont P M
Published: March 2003

Background

The choice between exercise training and percutaneous transluminal angioplasty (PTA) in the treatment of intermittent claudication (IC) remains controversial. Exercise is known to induce systemic effects in claudicants. This study aimed to determine whether such systemic effects are reversed by PTA.

Methods

Ten patients with IC were recruited before PTA. Having emptied the bladder and rested for 1 h, pre-exercise blood and urine samples were collected. Patients underwent treadmill exercise to their maximum walking time and further blood samples were collected at 10, 20 and 30 min. A second urine sample was collected at 60 min. Total antioxidant capacity (TAC) and von Willebrand factor (vWF) were measured in blood, and albumin: creatinine ratio (ACR) and retinol binding protein: creatinine ratio (RBP: Cr) in urine. Patients were recalled 2 weeks after successful angioplasty and the protocol was repeated. Statistical analysis was by Wilcoxon signed rank test.

Results

Following PTA, all patients walked for 5 min on the treadmill. All patients had a significant exercise-induced fall in ankle pressure that was reversed by PTA. Changes in TAC are shown in the Table. There was no significant change in vWF. Exercise in claudicants induced a significant increase in median ACR (pre/post exercise (pre-exercise value divided by post-exercise value) 0·8; P = 0·03) and in median RBP: Cr (pre/post exercise 1·8; P = 0·04). These changes were no longer evident after successful PTA.

Conclusion

Exercise-induced changes in renal glomerular (ACR) and tubular function (RBP: Cr) in claudicants were reversed by successful angioplasty. PTA reduced the systemic TAC before and after exercise suggesting a reduced free radical challenge.
Early and long-term results after necrosectomy for necrotizing pancreatitis
Authors: Tzovaras G , Parks R W , Diamond T , Rowlands B J
Published: March 2003

Background

Necrotizing pancreatitis is a difficult clinical problem associated with significant mortality and morbidity rates. Indications for surgical intervention, and the timing and type of intervention, remain controversial issues. A 10-year experience in the management of this condition in a tertiary referral centre is reviewed; treatment policies and early and long-term results are reported.

Methods

Between 1987 and 1997, 39 consecutive patients (32 men, seven women), with a mean age of 47 (range 13–74) years, underwent necrosectomy for severe necrotizing pancreatitis. Diagnosis was confirmed by contrast-enhanced computed tomography. Twenty-nine patients were referred from other hospitals in Northern Ireland. The aetiology included gallstones (15), alcohol (ten), idiopathic (seven), surgery (two), endoscopic retrograde cholangiopancreatography (two), blunt trauma (one), hyperlipidaemia (one) and pancreas divisum (one). Mean Acute Physiology And Chronic Health Evaluation (APACHE) II score on admission or arrival was 2 (range 5–21). Indications for surgical intervention were clinical deterioration with development of multiple organ failure, despite maximal medical support in the intensive care unit (ICU), or positive fine-needle aspiration for micro-organisms or radiographic evidence of infected necrosis (i.e. presence of gas within peripancreatic collection). The mean interval from onset to intervention was 23 (range 9–47) days. In 13 patients a conventional approach (necrosectomy with primary closure over drains) was used, 14 patients underwent planned staged necrosectomy with delayed closure over drains and in 12 patients necrosectomy with open laparostomy was undertaken.

Results

There were five deaths and 14 patients experienced significant hospital morbidity (fistula, ten; pseudocyst, two; renal failure, two). Variables which correlated with mortality rate were higher APACHE II score, acute renal failure requiring dialysis and early intervention. There was no difference in either mortality or morbidity rate between infected and sterile necrosis, or between the three surgical techniques. Long-term morbidity occurred in 20 surviving patients (incisional hernia, ten; endocrine pancreatic insufficiency, nine; exocrine pancreatic insufficiency, two; pseudocyst, two; chronic renal failure, two; recurrent pancreatitis, one; and chronic pain, one).

Conclusion

A low mortality rate can be achieved in patients with severe necrotizing pancreatitis with aggressive surgical intervention. Early maximal medical treatment and ICU support is essential before intervention, which should preferably be avoided early in the course of the disease and should be based on well defined criteria. The long-term morbidity rate remains high, although not always severe. This emphasizes the need for close follow-up.
Prevalence of R117H mutation in the cationic trypsinogen gene in patients with hereditary pancreatitis
Authors: Creighton J E , Lyall R , Wilson D I , Curtis A , Charnley R M
Published: March 2003

Background

The R117H mutation of the cationic trypsinogen (CT) gene (G to A mutation in exon 3), located on chromosome 7q35, is one of the known mutations that is linked to hereditary pancreatitis (HP) and is thought to alter a trypsin recognition site responsible for the breakdown of inappropriately activated trypsinogen so resulting in pancreatitis. The aim of this study was to determine the prevalence of this mutation in patients with HP and to correlate presence of the mutation with disease characteristics.

Methods

Polymerase chain reaction amplification of the third exon of the CT gene was performed on blood DNA. This was digested by the restriction endonuclease Afl III and fragments were sized by agarose gel electrophoresis. Haplotype analysis was carried out using three short tandem repeat markers in the region of the CT gene.

Results

Seven discrete families with HP (three to seven generations) were identified (22 affected individuals). The mutation was present in individuals from three of the seven families. It was absent in all affected individuals from the other four families. A higher proportion of patients requiring pancreatic surgery was seen in families expressing this mutation (eight of 14 versus one of eight, P = 0·016). Mean(s.d.) age of onset was similar in both groups (7·9(5·8) versus 6·3(10·1) years, P = 0·13). In the affected families, the same high-risk haplotype was present in two families, suggesting a common ancestor. The third family carried a unique haplotype.

Conclusion

A single G to A mutation in the third exon of the CT gene was found in three families with HP originating from this region and appears to be associated with more severe disease. Further work is being undertaken to analyse the CT gene more fully in families in which this common first mutation was not identified.
Prediction of need for multiple dilatations after cervical oesophagogastrostomy
Authors: Hollowood A D , Kavadas V , Vickery C W , Hardwick R H , Barham C P , Alderson D
Published: March 2003

Background

The aim of this study was to investigate the frequency of anastomotic stricture formation after subtotal oesophagectomy with cervical oesophagogastrostomy.

Methods

Patients undergoing surgery over a 3-year period using an identical handsewn single-layer anastomotic technique were studied. Details of the operations, complications and need for anastomotic dilatation were recorded.

Results

Sixty-two patients (41 men) with a mean age of 64 (range 36–90) years were included. Fifty-eight underwent surgery for carcinoma, two for stromal tumours, one for achalasia and one for Crohn's disease. Thirty-two (2 per cent) developed a benign anastomotic stricture requiring a median of 4 (range 1–22) dilatations. The median time from operation to first dilatation was 50 days. There was a significant correlation between the time to first dilatation and the total number of dilatations (P = 0·006). Patients who developed symptomatic strictures within 30 days of operation required a median of 9·5 dilatations compared with 3·5 in those who presented beyond this time (P = 0·01). The development of a clinical leak significantly increased the number of dilatations required, from a mean of 5·2 to 10·4 (P = 0·04).

Conclusion

The incidence of benign anastomotic stricture formation requiring dilatation after cervical oesophagogastrostomy is about 50 per cent. Patients who require dilatation within 30 days of surgery to restore swallowing to normal are likely to require the procedure on multiple occasions and should be counselled accordingly.
Oesophagectomy and total gastrectomy in a specialized district general hospital unit
Authors: Wayman J , Linsley A , Raimes S A
Published: March 2003

Background

The aim was to demonstrate that a low operative mortality rate (less than 5 per cent) is achievable for both oesophagectomy and total gastrectomy (TG) in a medium-sized district general hospital (DGH).

Methods

This was a prospective audit of all oesophagectomies and TGs performed in the first 5 years after establishment of a specialized upper gastrointestinal surgical–anaesthetic team.

Results

Some 82 procedures were undertaken, all by the same surgical team. Forty patients (median age 66 (range 41–76) years) underwent subtotal oesophagectomy (STO) using the two-stage approach. Forty-two patients (median age 68 (range 35–80) years) underwent TG using a left thoracoabdominal approach in four and an abdominal approach in 38. There were no deaths in hospital or within 30 days for either procedure. Two patients in each group died within 90 days: one from myocardial infarction and one from paraneoplastic syndrome after STO; one from pulmonary embolism and one from malignant adhesive obstruction after TG. There was one anastomotic leak in each group. Four patients required a second procedure: for a postoperative bleed, a thoracic duct leak and a feeding jejunostomy (one patient each) after STO; and for drainage of a left subphrenic abscess after TG.

Conclusion

It is reasonable to aim for an operative mortality rate of under 5 per cent for both STO and TG even in a DGH treating relatively small numbers of patients. Preoperative assessment and peroperative management by a single surgical–anaesthetic team, use of epidural analgesia and treatment in dedicated ward areas are all contributory factors. Clinical, audit and research links to the Northern Oesophago-Gastric Cancer Unit in Newcastle have ensured a uniformity of care across the region.
Pattern of lymph node dissemination from adenocarcinoma of the oesophagogastric junction
Authors: Dresner S M , Wayman J , Bennett M K , Hayes N , Griffin S M
Published: March 2003

Background

Adenocarcinoma of the oesophagogastric junction (OGJ) is rapidly increasing in incidence and the role of radical lymphadenectomy for such tumours remains controversial. The aim of this study was to identify the pattern of metastatic nodal spread by histopathological assessment of all lymph node groups retrieved from resected specimens.

Methods

Data were collected prospectively from patients undergoing potentially curative (R0) resection with lymphadenectomy for adenocarcinoma of the OGJ between January 1996 and May 1998. Patients with type 1 tumours (lower third of the oesophagus) underwent two-stage subtotal oesophagogastrectomy with two-tier lymphadenectomy. Patients with type 2 (gastric cardia) tumours underwent D2 total gastrectomy. At the time of surgery all lymph node groups were dissected out from the specimens, labelled and assessed by a single consultant histopathologist.

Results

A total of 103 patients were studied. Eleven patients were understaged before operation and were inoperable or had palliative resections. Of the remaining 92 patients, 68 had type 1 tumours and 24 had type 2 tumours. Some 2301 nodes were analysed representing a median of 27 nodes per patient (26 from the oesophagectomy group and 30 from the gastrectomy group). Over 70 per cent of all patients had lymph node metastases at the time of surgery. Some 6 per cent of type 1 tumours with lymph node metastases had dissemination in both the abdominal and mediastinal nodal tiers. The common abdominal sites were the paracardial (right, 23 of 41; left, 23 of 41) and left gastric nodes (29 of 41) whereas within the mediastinum paraoesophageal (25 of 41) and bronchial (right, seven of 41; left, six of 41) metastases were more often encountered. Type 2 tumours had positive lymph nodes most frequently in the left paracardial (nine of 16), lesser curve (11 of 16) (N1 group) and left gastric (eight of 16) (N2 group) territories. The extent of lymph node positivity correlated with the T stage and differentiation of the primary tumour, as well as the presence of perineural, lymphatic and vascular invasion (P < 0·05).

Conclusion

The high incidence and widespread dissemination of nodal metastases at the time of surgery seen with these tumours may justify the approach of systematic lymphadenectomy in the hope of performing a curative resection. The current definition of the lymph node sites in the abdominal and mediastinal tiers for type 1 tumours is based on experience with lower-third squamous carcinomas. These results demonstrate a different pattern of dissemination for junctional␣oesophageal adenocarcinomas requiring redefinition of the nodal stations to be resected in radical lymphadenectomies for such tumours.
Validation of the gastrointestinal quality of life index for patients with potentially operable periampullary carcinoma
Authors: Nieveen van Dijkum E J M , Terwee C B , Oosterveld P , van der Meulen J H P , Gouma D J , de Haes J C J M
Published: March 2003

Background

A disease-specific quality of life questionnaire is not available for patients with periampullary carcinoma, although cancer-specific questionnaires and the Gastrointestinal Quality of Life Index (GIQLI) have been used. The aim of this study was to validate the GIQLI for patients with periampullary tumours and to evaluate if subscales of the GIQLI could be identified to allow a more detailed assessment of the patients' quality of life.

Methods

Patients with periampullary carcinoma, included in a study concerning diagnostic laparoscopy, were asked about symptoms and completed a questionnaire comprising the Medical Outcomes Study (MOS) 24 questionnaire, the GIQLI and one question of the Rotterdam Symptom Check List (RSCL). Clinical interpretation and statistical factor analysis were used to identify subscales of the GIQLI.

Results

The GIQLI could be divided into four subscales, measuring physical well-being, mental well-being, digestion and defaecation. All four subscales had a good internal reliability and the construct validity was supported by the pattern of correlations with the MOS and RSCL as well as differences in subscale scores for patients with or without certain symptoms.

Conclusion

In patients with periampullary tumours the GIQLI can be divided into four subscales, measuring different aspects of quality of life. These subscales provide insight into the different problems affecting the patient.
Specialized intestinal metaplasia in patients with gastro-oesophageal reflux disease
Authors: Carton E , Caldwell M T P , McDonald G , Rama D , Tanner W A , Reynolds J V
Published: March 2003

Background

There is an increasing awareness that short (less than 3 cm) segments of Barrett's epithelium and macroscopically normal cardia epithelium may harbour specialized intestinal metaplasia (SIM), a premalignant phenotype. The prevalence of SIM was studied prospectively in an unselected population of patients attending for endoscopy, and the association of SIM with symptoms, lifestyle, medication, endoscopic oesophagitis and carditis was investigated.

Methods

Two hundred consecutive patients underwent endoscopy. Biopsies taken from just below the squamocolumnar junction were stained for SIM, and were analysed for carditis and Helicobacter pylori infection. A detailed questionnaire of symptoms, tobacco consumption and the use of proton pump inhibitors was completed.

Results

Forty-two patients (21 per cent) had SIM: 19 (15 per cent) of 126 in an endoscopically normal oesophagus, 15 (24 per cent) of 63 in a short segment of Barrett's epithelium and eight of 11 in classical Barrett's oesophagus. There was a significant association between SIM and carditis (P < 0·0001) and endoscopic oesophagitis (P = 0·03).

Conclusion

SIM is prevalent in patients undergoing endoscopy, does not correlate with symptoms or H. pylori infection, but is significantly associated with endoscopic and pathological markers of gastro-oesophageal reflux.
Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm
Authors: Vardulaki K A , Walker N M , Day N E , Duffy S W , Ashton H A , Scott R A P
Published: March 2003

Background

The prevalence of abdominal aortic aneurysm (AAA) in a community-based sample of men and women aged 65–79 years was correlated with known risk factors. In addition, the effect of high blood pressure and the use of antihypertensive medication on growth of AAAs were studied.

Methods

Aortic diameter was assessed by ultrasonography and data on risk factors were collected by self-administered questionnaire for 5356 men and women as part of a randomized controlled trial.

Results

Current hypertension increased the risk of having an aortic aneurysm by 30–40 per cent while use of antihypertensive medication increased the risk by 70–80 per cent, adjusting for current blood pressure. There was no clear relationship between hypertension and growth rates of existing aneurysms in this study, although these results were largely from data on small aneurysms. Men were nearly six times more likely to develop an AAA than women; the risk increased by 40 per cent every 5 years after the age of 65 years. Smoking was an independent risk factor for AAA, with level of exposure being more significant than duration.

Conclusion

Male sex, smoking and hypertension are strong risk factors for the development of AAA. In this study hypertension did not significantly increase the growth rate of existing aneurysms. Smoking remains the most important avoidable risk factor for AAA. The analyses presented here suggest that selection for screening, other than by age and sex, is not worthwhile.
Diagnostic failures in endoscopy for acute upper gastrointestinal haemorrhage
Authors: Chung Y F A , Wong W K , Soo K C
Published: March 2003

Background

Oesophagogastroduodenoscopy (OGD) is the diagnostic tool of choice in acute upper gastrointestinal haemorrhage. However, the factors causing diagnostic failure are not well documented or discussed.

Methods

OGDs performed by a single surgeon for acute upper gastrointestinal haemorrhage were reviewed retrospectively for ‘missed’ diagnosis.

Results

There were nine cases (1·4 per cent) of ‘missed’ diagnosis in 638 OGDs performed over a 3-year period. Incomplete examination caused by a fundal pool precluded three examinations in which two Dieulafoy's lesions and one chronic gastric ulcer were later found. Other difficult examination sites were the cardia/high lesser curve (three cases), the stomal line of a gastrojejunostomy anastomosis (two) and at the junction of the first and second part of the duodenum (one). Four of the overlooked diagnoses were Dieulafoy's lesions.

Conclusion

OGD was able to diagnose the cause of bleeding in 98·6 per cent of patients with acute upper gastrointestinal haemorrhage. The factors that caused diagnostic failure were a difficult examination site and failure to recognize lesions (Dieulafoy's).
Manometric assessment of an artificial bowel sphincter
Authors: Savoye G , Leroi A M , Denis P , Michot F
Published: March 2003

Background

This study investigated the relationship between functional clinical results after artificial bowel sphincter implantation and manometric assessment in 12 consecutive patients.

Methods

A postoperative manometric study was performed in 12 patients, including measurement of resting and squeeze pressures, opening characteristics and pressure during straining. The relationship between postoperative findings, clinical outcome and preoperative manometric data was investigated. Anal pressure after rectal distension with a closed cuff was studied in seven patients. Results were expressed as mean(s.d.).

Results

Continence for solid stool was achieved in all 12 patients. Five patients remained incontinent for gas. Anal resting pressure was 108(22) cmH2O; there was no difference between continent and incontinent patients. Rectal distension induced anal relaxation in six of seven patients. Total duration of cuff opening was 113(8) s with an amplitude of 60(22) per cent; residual pressure was correlated with the preoperative resting pressure. The total duration of the opening phase in patients with defaecation difficulties (47(24) (range 0–65) s) was shorter than that in patients without defaecation difficulties (178(78) (range 100–320) s) (P = 0·0022).

Conclusion

Postoperative defaecation difficulties after implantation of an artificial bowel sphincter are related to a short duration of opening of the cuff. The anal sphincter played a role in postoperative resting anal pressures and allowed relaxation even if the cuff was closed.
Exercise training and peripheral vascular disease
Authors: Tan K H , de Cossart L , Edwards P R
Published: March 2003

Background

Conservative management is advocated as a treatment of choice for patients with intermittent claudication. This is a review of the mechanisms behind the improvement following an exercise rehabilitation programme.

Methods

All Medline articles from the National Library of Medicine, USA containing the text words ‘claudication’ or ‘peripheral vascular disease’ and ‘exercise’ were reviewed. Cross-referencing from relevant articles was carried out.

Results and conclusion

The poor physical status of a patient with intermittent claudication is not solely due to a reduction in blood flow to the lower limbs; associated factors, such as metabolic inefficiency, poor cardiorespiratory reserve and exercise-induced inflammation contribute. An exercise programme frequently improves both the physical aspect and quality of life, and the success of such exercise is multifactorial. An increase in the blood flow to the lower extremity is uncommon. Other factors, such as a redistribution of blood flow, changes in oxidative capacity of the skeletal muscles and greater utilization of oxygen, occur and the associated metabolic dysfunction of the skeletal muscles is rectified. Following exercise training, blood rheology improves and exercise-induced inflammation is ameliorated; cardiorespiratory status also benefits and the oxygen cost of exercise decreases.
In vivo evaluation of an implantable portal pump system for augmenting liver perfusion
Authors: Jiao L R , Seifalian A M , Davidson B R , Habib N
Published: March 2003

Background

Increasing portal inflow in cirrhosis using a mechanical pump reduces portal venous pressure and improves liver function. A pump has been developed for portal vein implantation in human cirrhosis. This study describes the initial in vivo evaluation in a porcine model.

Methods

Five Large White pigs underwent laparotomy and exposure of the liver. Flow in the hepatic artery, portal vein and hepatic microcirculation was monitored continuously. Hepatic tissue oxygenation was measured by near-infrared spectroscopy. After baseline measurements the pump was inserted into the portal vein. Pump flow rate was then increased stepwise to 50 per cent over the baseline value for a period of 2 h. The pump was then stopped for 20 min and left in situ while continuing to collect systemic and hepatic haemodynamic data. The animal was killed and biopsies for histological examination were taken from the liver, small intestine and spleen.

Results

The baseline total hepatic blood flow was 626(39) ml/min; the hepatic artery supplied 18·4(2·1) per cent and the portal vein 81·6(2·1) per cent. The pump was inserted successfully in all animals without surgical complications. During surgical insertion of the pump, the temporary portal vein occlusion resulted in a significant rise in hepatic artery blood flow (22(3) per cent; P < 0·01 versus baseline). Portal vein flow was augmented by pumping; there was a significant correlation between the pump motor speed and portal vein flow (P < 0·0001). This inflow correlated directly with flow in the hepatic microcirculation and hepatic tissue oxygenation (P < 0·001). The pump ran satisfactorily throughout the study. Histological examination revealed no evidence of structural damage to the liver or ischaemic changes in the small intestine or spleen.

Conclusion

It is technically possible and safe to insert an implantable pump in the portal vein. Portal venous blood flow can be increased up to 50 per cent with a resultant increase in flow in the hepatic microcirculation and hepatic oxygenation and without adverse effects on either hepatic or systemic haemodynamics.
Sportsman's hernia
Authors: Fon L J , Spence R A J
Published: March 2003

Background

Sportsman's hernia is a debilitating condition which presents as chronic groin pain. A tear occurs at the external oblique which may result in an occult hernia. The definition, investigation and treatment of this condition remain unclear.

Methods

A systematic Medline search was performed and all literature pertaining to chronic groin pain, groin injury, sportsman's hernia and sportsman's groin from 1962 to 1999 was retrieved for analysis.

Results

The costs of computed tomography and magnetic resonance imaging are such that their routine use for assessment of patients with groin pain cannot be justified. They may, however, be employed in difficult cases to help define the anatomical extent of a groin injury. Plain radiography, ultrasonography and scintigraphy should be the usual first-line investigations to supplement clinical assessment. Herniography may help in situations of obscure chronic groin and pelvic pain. There is no consensus view supporting any particular surgical procedure for sportsman's hernia. A number of reports have been published describing different repairs of the posterior inguinal wall deficiency. Appropriate repair of the posterior wall results in therapeutic benefit in selected cases.

Conclusion

The diagnosis of sportsman's hernia is difficult. The condition must be distinguished from the more common osteitis pubis and musculotendinous injuries. Early surgical intervention is usually, although not always, successful when conservative management has failed.
Oesophageal resection for high-grade dysplasia in Barrett's oesophagus
Authors: Zaninotto G , Parenti A R , Ruol A , Costantini M , Merigliano S , Ancona E
Published: March 2003

Background

The aims of this study were to evaluate the prevalence of invasive cancer in patients with high-grade dysplasia in Barrett's oesophagus and to verify whether a second endoscopy with multiple biopsies could improve the accuracy of preoperative diagnosis. In addition, the mortality, morbidity and survival rates in patients with high-grade dysplasia having oesophageal resection were recorded.

Methods

Fifteen patients were observed from 1982 to 1998; the first seven patients were offered primary oesophageal resection after diagnosis. The other eight patients underwent a second endoscopy with a median of 12 biopsies examined. All later underwent oesophageal resection.

Results

Invasive adenocarcinoma was found in five patients, with a minimal difference between the first and second periods (two of seven versus three of eight). There were no perioperative deaths. Early morbidity was observed in eight patients and late morbidity in four. The actuarial survival rate was 79 per cent at 5 years. The Karnofsky status was unchanged from preoperative values in 13 of 15 patients after a median follow-up of 46 months.

Conclusion

These patients with high-grade dysplasia had a 33 per cent probability of harbouring invasive oesophageal carcinoma but even a second endoscopy failed to identify patients with invasive tumour. Oesophagectomy was performed with no deaths and remains a rational treatment in patients fit for surgery.
Analysis of 153 gunshot wounds of the liver
Authors: Marr J D F , Krige J E J , Terblanche J
Published: March 2003

Background

Gunshot wounds of the liver may result in substantial morbidity and death, and optimal management of complex injuries is controversial.

Methods

One hundred and fifty-three patients with civilian gunshot liver injuries were treated during the 10-year period 1986–1995. Demographic, clinical and operative data were recorded. Factors influencing postoperative complications and death were analysed.

Results

One hundred and forty-two patients (93 per cent) had single missile injuries and 11 (7 per cent) had shotgun injuries. Three patients were treated non-operatively and 150 patients underwent operation. In 105 patients (70 per cent) the injuries to the liver were minor and required either no treatment (93) or simple suture of bleeding vessels (12). Forty-five patients (30 per cent) had major injuries which were either packed only (26) or required more complex surgical intervention (19). This included resectional debridement (ten), major venous repair (eight) and hepatotomy (one); eight of these patients required packing combined with the procedure. Associated intra-abdominal injuries occurred in 115 patients (77 per cent). The overall mortality rate was 17 per cent (26 patients). Death was directly attributable to the liver injury in 13 patients (8 per cent), 12 of whom died from uncontrolled bleeding. Complications occurred in 63 (51 per cent) of 124 survivors, and correlated with the type and severity of the liver injury and the number of associated injuries.

Conclusion

Most gunshot liver injuries can be managed by simple surgical techniques. In complex injuries control of major haemorrhage is vital and perihepatic packing may be life saving before undertaking definitive repair of the injury under controlled conditions.
Influence of a specialized leg ulcer service on management and outcome
Authors: Ghauri A S K , Taylor M C , Deacon J E , Whyman M R , Earnshaw J J , Heather B P , Poskitt K R
Published: March 2003

Background

The organization of leg ulcer care is poorly defined in the community. This study assessed the overall influence of a specialized community service on management and outcome of chronic leg ulcers, irrespective of aetiology.

Methods

Assessment and outcome of ulcers were compared in patient samples (n = 200) from East and West Gloucestershire, before and after the introduction of specialized clinics into East Gloucestershire. In clinics, vascular disease was routinely assessed by duplex scanning and determination of the ankle: brachial pressure index.

Results

There was no coordinated community structure for the care of patients with leg ulcers before the service was introduced, and 74 and 67 per cent of limbs in East and West Gloucestershire respectively had aetiology undiagnosed. After introduction of the clinics, the 12-week healing rate increased from 12 to 22 per cent in East Gloucestershire (P = 0·05) and to 47 per cent in the specialized East Gloucestershire clinics (P < 0·001). The 12-month recurrence rate decreased from 50 to 41 per cent in East Gloucestershire and to 17 per cent in the East clinics (P < 0·001). The West Gloucestershire control showed no significant changes.

Conclusion

A specialized leg ulcer service with defined protocols provides an improved management structure for treating patients with leg ulcers in the community. Accurate diagnosis of chronic leg ulcers and improved outcome may be achieved within this specialized service.
Prospective analysis of a scoring system to predict choledocholithiasis
Authors: Menezes N , Marson L P , deBeaux A C , Muir I M , Auld C D
Published: March 2003

Background

The management of choledocholithiasis in the laparoscopic era remains debatable. A common policy is to perform preoperative endoscopic retrograde cholangiopancreatography (ERCP) on patients suspected of having common bile duct (CBD) stones, using standard risk criteria. The aim of this study was to evaluate prospectively a scoring system designed to improve the accuracy of CBD stone prediction before laparoscopic cholecystectomy.

Methods

Known clinical, biochemical and radiological risk factors for CBD stones were analysed retrospectively in 233 patients. The presence (n = 77) or absence (n = 156) of CBD stones was determined by preoperative ERCP and/or laparoscopic cholangiography. Using multivariate analysis, the significant risk factors for CBD stones were identified and a new preoperative scoring system was developed. A score of 3 or more was taken as the cut-off point to suggest CBD stones and the need for preoperative ERCP. This scoring system was then tested prospectively in 211 consecutive patients with symptomatic gallstones requiring surgery. Patients whose bile ducts could not be demonstrated by ERCP or operative cholangiography were excluded.

Results

Fifty-five patients scored 3 or more (predicted ERCP rate of 29 per cent), of whom 23 (42 per cent) had proven CBD stones. Intraoperative cholangiography was successful in 87 per cent. Five patients (4 per cent) who scored less than 3 had small stones (less than 5 mm) demonstrated at operative cholangiography. The overall sensitivity and specificity of this scoring were 82 and 80 per cent respectively.

Conclusion

Formal risk assessment of the presence of CBD stones using this scoring system is simple and may be used for preoperative selection of patients for biliary tract imaging by magnetic resonance cholangiography or ERCP.
Diagnosis and treatment of portal vein thrombosis following splenectomy
Authors: van 't Riet M , Burger J W A , van Muiswinkel J M , Kazemier G , Schipperus M R , Bonjer H J
Published: March 2003

Background

Portal vein thrombosis is a rare but potentially fatal complication of splenectomy. The aim of this study was to assess the incidence, risk factors, treatment and outcome of portal vein thrombosis after splenectomy in a large series of patients.

Methods

All patients who had undergone a splenectomy in the University Hospital, Rotterdam, between 1984 and 1997 were reviewed retrospectively. Splenectomy that was followed by symptomatic portal vein thrombosis was selected for analysis. Risk factors for portal vein thrombosis were sought.

Results

Of 563 splenectomies, nine (2 per cent) were complicated by symptomatic portal vein thrombosis. All these patients had either fever or abdominal pain. Two of 16 patients with a myeloproliferative disorder developed portal vein thrombosis after splenectomy (P = 0·03), and four of 49 patients with haemolytic anaemia (P = 0·005). Treatment within 10 days after splenectomy was successful in all patients, while delayed treatment was ineffective.

Conclusion

Portal vein thrombosis should be suspected in a patient with fever or abdominal pain after splenectomy. Patients with a myeloproliferative disorder or haemolytic anaemia are at higher risk; they might benefit from early detection and could have routine Doppler ultrasonography after splenectomy.
Estimation of lymph node metastasis by size in patients with intrathoracic oesophageal cancer
Authors: Funai T , Osugi H , Higashino M , Kinoshita H
Published: March 2003

Background

The preoperative evaluation of lymphatic metastasis in patients with oesophageal cancer is of vital importance in determining a therapeutic strategy. The aim of this study was to establish criteria for the preoperative diagnosis of lymph node metastases based on the size and shape of nodes.

Methods

Some 123 patients with intrathoracic oesophageal cancer were studied and 6822 nodes were obtained by extended lymphadenectomy. The nodes were classified anatomically and their size was measured by the operating surgeon during or immediately after operation. All were examined histologically and criteria for the diagnosis of metastasis were evaluated.

Results

The size of the lymph nodes varied by anatomical site. Nodes were smallest in the neck and largest at the tracheal bifurcation. The cut-off value for the diagnosis of metastasis was 5 mm in the neck, 6 mm in the abdomen and 8 mm in the mediastinum, except for tracheal nodes. Lymph nodes 10 mm or larger tended to become spherical when involved by metastasis.

Conclusion

The incidence of metastasis in each lymph node can be estimated by its size. Discounting nodes less than 10 mm can lead to an underestimation of the stage of oesophageal cancer during preoperative evaluation.
Vertical reduction rectoplasty: a new treatment for idiopathic megarectum
Authors: Williams N S , Fajobi O A , Lunniss P J , Scott S M , Eccersley A J P , Ogunbiyi O A
Published: March 2003

Background

The aetiology of idiopathic megarectum is unknown and the results of surgery are often unsatisfactory. Rectal hyposensation is common and poor perception of rectal filling may contribute to the poor evacuatory function. By reducing the capacity of the rectum, it was hypothesized that sensory thresholds to rectal distension and perception of urge to defaecate would be improved.

Methods

Vertical reduction rectoplasty (VRR) and concomitant sigmoid colectomy was performed on six patients with idiopathic megarectum. Patients were evaluated before and after operation by detailed questionnaire and anorectal physiology. Postoperative rectal compliance was also studied by means of a programmable electronic barostat. Where appropriate, physiological data were compared with those obtained in eight healthy volunteers.

Results

Bowel frequency increased from a preoperative median of 2·5 to 16 per month after operation. Four patients reported improved rectal perception of the urge to defaecate. Thresholds for defaecatory urge and maximum tolerated volume were significantly reduced following VRR (P < 0·05). Post-VRR rectal compliance was no different from that in healthy volunteers. Colonic transit time decreased significantly after VRR (P < 0·05) and evacuation on proctography increased from a median of 30 per cent to 50 per cent. At a median of 57 weeks' follow-up five of the six patients expressed continued satisfaction with the results.

Conclusion

VRR is a new approach to the treatment of idiopathic megarectum. Clinical and physiological studies confirm that it can improve sensory feedback and defaecation. The procedure needs further evaluation as the number of patients undergoing the procedure increases.
Pilot randomized controlled study of preservation or division of ilioinguinal nerve in open mesh repair of inguinal hernia
Authors: Ravichandran D , Kalambe B G , Pain J A
Published: March 2003

Background

There is uncertainty as to whether preservation or elective division of the ilioinguinal nerve influences pain and sensory loss following inguinal hernia repair.

Methods

In 20 men with primary bilateral inguinal hernias undergoing open tension-free mesh repair, the sides (right or left) were randomized for preservation or division of the ilioinguinal nerve. Patients were reviewed on day 1, 4 weeks and 6 months after operation. Any pain or numbness, as well as any loss of sensation in the area supplied by the nerve, was recorded.

Results

No significant difference was seen in pain or numbness between the divided and preserved sides. Sensory loss detected by clinical examination was more common following the division of the nerve compared with preservation.

Conclusion

Within the limitations of a small sample size, elective division of the ilioinguinal nerve during inguinal hernia repair does not appear to be associated with a significant increase in postoperative symptoms.
Matrix metalloproteinases, their tissue inhibitors and colorectal cancer staging
Authors: Baker E A , Bergin F G , Leaper D J
Published: March 2003

Background

Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) are important in tumour invasion and metastasis. The levels of MMPs, TIMPs and total MMP activity were compared in paired colorectal tumour (n = 50) and normal tissue (n = 49) samples and correlated with clinical and pathological staging.

Methods

Gelatin zymography (MMP-2 and MMP-9), enzyme-linked immunosorbent assays (MMP-1, MMP-3, TIMP-1 and TIMP-2) and quenched fluorescent substrate hydrolysis (total MMP activity) were employed in resection specimens from 50 patients, four with adenomas and 46 with colorectal cancer.

Results

The levels of active MMP-2 and MMP-9 and total MMP-1, MMP-3 and TIMP-1 were significantly greater in tumour tissue than in normal colon (e.g. TIMP-1 tumour median 72 (range 25–351) versus normal 26 (4–107) ng per mg total protein content; P < 0·05); however, TIMP-2 levels were significantly greater in normal tissue (P < 0·05). Total MMP activity was significantly greater in tumour than in normal tissue (15 025 (1750–174 400) versus 7250 (750–354 650) pmol l−1 min−1 mg protein−1; P < 0·05). Correlations were found between both MMP and TIMP levels and pathological tumour staging. MMP-1 appeared to be most important as its concentration correlated positively with Dukes staging, tumour differentiation and lymphatic invasion.

Conclusion

The levels of the studied MMPs and total MMP activity were upregulated in colorectal tumours. MMP-1 is important in colorectal cancer progression.
Timing of endothelin and nitric oxide inhibition is crucial for survival in septic shock
Authors: Iskit A B , Guc M O
Published: March 2003

Background

The effect of endothelin and nitric oxide inhibition on survival from septic shock was investigated in mice, with particular emphasis on the timing of the administration of their blockers after an endotoxin (lipopolysaccharide; LPS) challenge.

Methods

Male Swiss albino mice (20–40 g) received LPS (Escherichia coli 055: B5; 60 mg kg−1 intraperitoneally) followed by intraperitoneal injection of the endothelin receptor antagonist bosentan 30 mg kg−1, either 2 or 12 h after LPS, alone or in addition to intraperitoneal nitric oxide synthase blockers l-canavanine 20 or 100 mg kg−1, L-NAME 3 mg kg−1 or aminoguanidine 15 mg kg−1, which were given twice, at 2 and 6 h after LPS. Control animals received saline and survival rates in each group (n = 10) were recorded over 24 h at 6-h intervals.

Results

At 24 h, the survival rate was 10 per cent in controls, but 30 per cent (P not significant) and 70 per cent (P < 0·05) in animals that received bosentan only at 2 and 12 h respectively, indicating a relatively ‘late’ involvement of endothelin. In contrast, these values were 70 per cent (P < 0·05) and 80 per cent (P < 0·05) at 12 h for L-NAME and l-canavanine, which both decreased to 10 per cent (P not significant) at 24 h implying a relatively ‘early’ involvement of nitric oxide. A higher value (60 per cent; P < 0·05) was obtained when bosentan given at 2 h was combined with L-NAME. The best outcome (90 per cent survival rate; P < 0·05) was observed when bosentan was given at 12 h in combination with L-NAME at 2 and 6 h. Interestingly, the survival rate was 70 per cent (P < 0·05) in the aminoguanidine group, which can be explained by other pharmacological effects of this drug in addition to nitric oxide blockade.

Conclusion

Nitric oxide plays a significantly deleterious role during the early phases of septic shock, in contrast to a relatively late involvement of endothelin peptides. This should be taken into consideration when devising treatment strategies.
Gram-positive bacterial cell wall products upregulate surface expression of intercellular adhesion molecule 1, human leucocyte antigen DR and CD14 on monocytes in human whole blood
Authors: Jørgensen P F , Wang J E , Almløf M , Thiemermann C , Aasen A O
Published: March 2003

Background

The aim was to investigate the influence of Gram-positive cell wall components on monocyte surface inflammatory receptors compared with lipopolysaccharide (LPS) in human whole blood.

Methods

Human whole blood from six healthy donors was incubated with peptidoglycan (PepG) 10 μg ml−1 from Staphylococcus aureus and Bacillus subtilis, lipoteichoic acid (LTA) 100 μg ml−1 from S. aureus and LPS 10 ng ml−1 from Escherichia coli in microcentrifuge tubes at 37°C with slow rotation for 4 h. Subsequent to incubation with fluorescein isothiocyanate (FITC)- and phycoerythrine (PE)-labelled monoclonal antibodies, surface molecule (CD14, CD54, CD58, CD64, CD80 and human leucocyte antigen (HLA) DR) expression was analysed by flow cytometry performed on the FACScan using the CellQuest software.

Results

All surface molecules except CD80 were expressed constitutively on monocytes in whole blood. Stimulation with either type of PepG, LTA and LPS did not induce any changes in expression of CD58 or CD64, nor did they induce expression of CD80. However, significant upregulation of CD54 and HLA-DR was observed in all donors. Contrary to LPS, PepG and LTA also upregulated the expression of monocyte surface CD14.

Conclusion

The Gram-positive cell wall products PepG and LTA strongly upregulated the expression of intercellular adhesion molecule 1 (CD54) and HLA-DR on monocytes in human whole blood, as was seen in LPS-stimulated whole blood. In contrast to Gram-negative endotoxin, the Gram-positive cell wall products also upregulated the expression of the LPS receptor CD14. This suggests possible differences in intracellular signalling between Gram-positive cell wall products and Gram-negative LPS in monocytes.