bluuebunny/crossref_metadata_2025_split huggingface dataset:
Clinicopathological features and treatment of intraductal papillary mucinous tumour of the pancreas
Authors: Falconi M , Salvia R , Bassi C , Zamboni G , Talamini G , Pederzoli P 
Published: March 2003

Abstract

Background
The surgical strategy in patients with a pancreatic intraductal papillary mucinous tumour (IPMT) is still controversial. In this study the pathological findings in a series of patients were used to rationalize surgical choice.

Methods
Fifty-one patients with IPMT were observed between 1988 and 1998 and treated by pancreatic resection. Factors evaluated included symptoms, tumour site, type of operation, histological findings and resection margins, tumour stage, follow-up and survival.

Results
Pancreaticoduodenectomy was the most frequent surgical treatment (33 patients; 65 per cent), followed by left pancreatectomy (ten), total pancreatectomy (five) and middle pancreatectomy (three). Histological assessment revealed the tumour to be an adenoma in 13 patients (25 per cent), a borderline tumour in ten (20 per cent) and a carcinoma in 28 (55 per cent), 19 of which were invasive. Mild to moderate dysplasia was present at the resection margin in 20 specimens (41 per cent), and carcinoma in one. Local recurrence was observed in four patients (8 per cent), all of whom underwent a second resection. The 3-year actuarial survival rate for benign and malignant disease was 94 and 69 per cent respectively (P = 0·03).

Conclusion
These results suggest that resection should be the treatment for IPMT. Management of the resection margin could be crucial in avoiding tumour recurrence.
Value of intraoperative duplex imaging during supervised carotid endarterectomy
Authors: Padayachee T S , Brooks M D , McGuinness C L , Modaresi K B , Arnold J A C , Taylor P R 
Published: March 2003

Abstract

Background
For overall benefit, carotid endarterectomy requires low perioperative morbidity and mortality rates. Carotid thrombosis is usually secondary to technical error, which may be related to the experience of the operator. In this retrospective study the clinical and technical outcome of carotid endarterectomies performed by one consultant and five trainees were compared.

Methods
Some 149 patients underwent carotid endarterectomy; 89 were operated on by the consultant and 60 by trainees. Intraoperative duplex imaging of the carotid repair was performed before wound closure, and re-exploration was carried out when there was a residual severe stenosis associated with an intimal flap.

Results
There was no significant difference in clinical outcome between operations done by consultant or trainees. There was a significant increase in the number of stenoses, kinks and flaps in carotid endarterectomies performed by trainees compared with those of the consultant both before (χ2 = 12·0, 1 d.f., P &lt; 0·001) and after (χ2 = 10·1, 1 d.f., P &lt; 0·001) correction.

Conclusion
Intraoperative duplex imaging may facilitate training by providing an objective assessment of the quality of the operation.
Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer
Authors: Gotoda T , Sasako M , Ono H , Katai H , Sano T , Shimoda T 
Published: March 2003

Abstract

Background
When cancer cells are found in the submucosal layer of an endoscopically resected specimen, patients are recommended to undergo gastrectomy with lymph node dissection. If it were possible to identify those patients in whom the risk of lymph node metastasis was negligible, it might be possible to avoid surgery.

Methods
Among those who underwent gastrectomy for gastric cancer from 1980 to 1999, 1091 patients with a cancer invading the submucosa were studied. Clinicopathological factors (sex, age, tumour location, macroscopic type, size, ulceration, histological type, lymphatic–vascular involvement and degree of submucosal penetration) were investigated for their possible association with lymph node metastasis.

Results
Lymph node metastases were found in 222 patients (20·3 per cent). Univariate analysis showed that larger tumour size (more than 30 mm), undifferentiated histological type, lymphatic–vascular involvement and massive submucosal penetration had a significant association with lymph node metastasis. Tumour size, histological type and lymphatic–vascular involvement were independent risk factors for lymph node metastasis. By combining these three factors with submucosal penetration of less than 500 μm, 117 patients could be selected as having a minimal risk of lymph node metastasis (95 per cent confidence interval 0–3·1 per cent).

Conclusion
Lymphadenectomy may not be necessary for patients with gastric cancer invading the submucosa who fulfil the above conditions
Role of a spiral computed tomographic grading system in increasing the efficacy of laparoscopic staging for potentially resectable pancreatic and periampullary tumours
Authors: Moses A G W , Redhead D N , Madhavan K K , Garden O J 
Published: March 2003

Abstract

Background
In a recent review of patients with potentially resectable pancreatic malignancy in the authors' unit, it was shown that inappropriate laparotomy was avoided in 35 per cent of patients as a direct result of laparoscopy combined with laparoscopic ultrasonographic staging, following previous spiral computed tomography (CT). However, subsequent analysis has suggested that laparoscopy may have added to information already available on the CT scan in as few as 22 per cent of patients. The aim of this study was to seek to define spiral CT scan criteria that might provide a more selective approach to laparoscopic staging.

Methods
Theatre records and the Lothian Surgical Audit Database were used to identify 124 patients between June 1995 and May 2000 whose investigations for suspected pancreatic tumours had included spiral CT followed by laparoscopic assessment (suspected tumour: pancreatic head, 88; periampullary, 25; lower bile duct, nine; duodenum, two). Each CT scan (with endoscopic retrograde cholangiopancreatography films if appropriate) was examined by a specialist pancreaticobiliary radiologist (D.N.R.) and graded ‘blindly’ according to a modified existing system for determining local resectability (0, no mass; A, fat plane between tumour and vessels; B, normal pancreas between tumour and vessels; C, mass convex to vessel; D, mass concave to vessel; E, vessel encircled; F, vessel occlusion) before the results were compared with findings at laparoscopy and laparotomy.

Results
In groups 0, E and F, only four (7 per cent) of 59 patients benefited from laparoscopic assessment, whereas 27 (42 per cent) of 65 patients avoided an inappropriate laparotomy in groups A–D as a result of improved staging. 0ABCDEFn27244829284Resection209319––Irresectable Laparoscopy23––32– Laparoscopy + laparoscopic US1––1422 Laparoscopic US–5–18112No laparotomy (other)11–211–Inappropriate laparotomy3613412–US, ultrasonography

Conclusion
Based on these results, only patients graded A–D should undergo laparoscopic staging. By adopting this more selective policy in the future, the number of laparoscopic evaluations may be reduced by 48 per cent, while maintaining the efficacy of preventing inappropriate laparotomies at 42 per cent.
Role of hepatectomy in the management of bile duct injuries
Authors: Wakefield C H , Whigham J , Madhavan K K , Garden O J 
Published: March 2003

Abstract

Background
Laparoscopic cholecystectomy is associated with bile duct injuries of a more severe nature than open cholecystectomy. This study examined the emerging role of hepatectomy in the management of major iatrogenic bile duct injuries in the laparoscopic era.

Methods
This was a retrospective cohort study of patients referred to a tertiary hepatobiliary unit with bile duct injuries over a 16-year period until April 2000. Data are expressed as median (range).

Results
Eighty-eight patients (34 men, 54 women) were referred during this interval; their median age was 55 (19–83) years. Injuries resulted from 50 laparoscopic cholecystectomies and 35 open cholecystectomies, with three occurring during gastroduodenal procedures. Laparoscopic surgery was associated with injuries of greater severity than open cholecystectomy: Bismuth type I–II, 32 per cent versus 69 per cent for the open operation; type III–IV, 66 per cent versus 31 per cent for the open procedure (P = 0·02, χ2 test). After referral 73 patients underwent definitive surgical interventions: 57 hepaticojejunostomies, 11 revisions of hepaticojejunostomy, two orthotopic liver transplants and three right hepatectomies. Two patients had subsequent hepatectomy following initial hepaticojejunostomy. Four of the five hepatectomies were for the management of injuries perpetrated at laparoscopic cholecystectomy. Criteria necessitating hepatectomy were liver atrophy on computed tomography (80 versus 11 per cent; P = 0·0001, χ2 test) and a greater incidence of angiographically proven vascular injury (40 versus 6 per cent; P = 0·006, χ2 test); in addition, type III–IV injuries were more frequent (60 versus 42 per cent) in the hepatectomy group. There were no procedure-related deaths. The overall postoperative morbidity rate was 13 per cent. Median hospital stay was 10 days.

Conclusion
Major hepatectomy allows the successful and safe repair of cholecystectomy-related bile duct injuries complicated by concomitant vascular injury, unilateral lobar atrophy and destruction of the biliary confluence.
Decreased tyrosine kinase C expression may reflect developmental abnormalities in Hirschsprung's disease and idiopathic slow-transit constipation
Authors: Facer P , Knowles C H , Thomas P K , Tam P K H , Williams N S , Anand P 
Published: March 2003

Abstract

Background
Some patients with Hirschsprung's disease have refractory constipation following excision of aganglionic bowel, as do patients with idiopathic slow-transit constipation (STC). Gut motility depends on enteric neuronal development in response to expression of trophic factors and their receptors. Recent studies indicate the importance of neurotrophin 3 (NT-3) and its high-affinity receptor tyrosine kinase C (trk C) in enteric neuronal development.

Methods
Blinded quantitative immunohistochemical analysis of colon from patients with Hirschsprung's disease (aganglionic, hypoganglionic and normoganglionic) (n = 5), STC (n = 6) and appropriate age-matched control tissues (n = 5) was performed for NT-3 and trk C. Sural nerve morphometry and immunostaining were undertaken in three patients with STC who had abnormalities on limb autonomic and sensory testing.

Results
A significantly higher proportion of submucous plexus neurones was trk C immunoreactive in control infant than adult colon (mean(s.e.m.) 73(9) versus 16(3) per cent of the total; P &lt; 0·001), in accord with a role in development. The proportion of submucous plexus trk C-immunoreactive neurones was reduced in colon from patients with Hirschsprung's disease (28(7) per cent of total in normoganglionic Hirschsprung's disease; P &lt; 0·007 versus infant controls) and STC (10(1) per cent of total; P = 0·053 versus adult controls). No abnormalities of STC sural nerves were detected by morphometry or immunostaining.

Conclusion
Decreased trk C expression may reflect developmental abnormalities in Hirschsprung's disease and idiopathic STC. Trk C activation by NT-3 or drugs may provide novel treatments.
Variation in clinical decision making is a partial explanation for geographical variation in lower extremity amputation rates
Authors: Connelly J , Airey M , Chell S 
Published: March 2003

Abstract

Background
Rates of lower extremity amputation vary significantly both between and within countries. The variation does not appear to support differences in need as an explanation. This study set out to see if variations in clinical decision making might contribute to the explanation.

Methods
Based on an extensive audit database of lower extremity amputations and revascularization operations, a decision model was produced. Drawing on items in this model allowed the selection of six clinical cases that differed in their probability of having amputation as the outcome. Two cases had 80 per cent or more, two cases had 45–55 per cent and two cases had 20 per cent or less probability of amputation. Each of ten consultant vascular surgeons looked at these cases without knowledge of their probability of outcome and decided on amputation or revascularization.

Results
Overall the chance-adjusted level of agreement (kappa coefficient) between the decisions made by ten surgeons on the six clinical cases and the actual outcome was 0·46, indicating a moderate level of agreement. The kappa coefficient for individual surgeons showed complete agreement (κ = 1) for four, substantial agreement (κ = 0·66) for four, fair agreement (κ = 0·32) for one and no agreement other than at a chance level (κ = 0) for one surgeon.

Conclusion
Variations in the clinical decisions made by vascular surgeons given the same patient are likely to explain at least a part of the observed geographical variation in rates of lower extremity amputation. Consensus guidelines may enable more consistent decision making for this problem.
Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia
Authors: Ballantyne A , Jawaheer G , Munro F D 
Published: March 2003

Abstract

Background
In children undergoing a unilateral inguinal herniotomy, the contralateral groin is often explored on the basis of a high incidence of patency of the processus vaginalis. The patency rate is highest in infants but there are no data on the subsequent risk of contralateral hernia development purely in this population. This was a study of the incidence of contralateral inguinal hernia following unilateral inguinal herniotomy in infancy (aged less than 1 year).

Methods
All infants who underwent a unilateral inguinal herniotomy between January 1986 and December 1991 were studied retrospectively.

Results
One hundred and eighty-one infants (165 boys and 16 girls) were studied. Median gestational age was 37 (range 25–42) weeks and median age at operation was 87 (range 1–365) days. The herniotomy was right sided in 82·9 per cent of infants. Follow-up ranged from 5 to 10 years. A contralateral hernia/hydrocele developed in 14 infants (7·7 per cent). None of the hernias was incarcerated. Median time from operation to occurrence of the contralateral hernia was 18 (2–67) months. Gestational age, sex and the side of the hernia did not influence the incidence of contralateral hernia development.

Conclusion
The low incidence of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.
Cyclo-oxygenase 1 and 2 expression is augmented in symptomatic carotid plaques
Authors: Wijeyaratne S M , Abbott C R , Homer Vanniasinkam S , Mavor A I D , Gough M J 
Published: March 2003

Abstract

Background
Macrophage accumulation and increased metalloproteinase levels within carotid plaques are associated with plaque instability. Production of the latter by macrophages and vascular smooth muscle cells (VSMCs) is promoted by prostaglandins synthesized following the action of cyclo-oxygenase (COX) on arachidonic acid.

Methods
Expression of the isoenzymes COX-1 and COX-2 was assessed in carotid plaques removed from 12 asymptomatic patients and 11 patients who had had a neurological event within 30 days of carotid endarterectomy. Patients were matched for age, sex, risk factors and degree of stenosis. For each plaque, paraffin sections obtained at 3-mm intervals throughout its length were stained with goat antihuman antibodies to COX-1 and COX-2. The percentage of the area that stained positively was determined within the cap, shoulder regions and sclerotic component of the plaques (computerized planimetry).

Results
The median (interquartile range) percentage area staining for COX-1 (symptomatic versus asymptomatic) was: cap 8·37 (4·38–13·65) versus 1·07 (0·31–4·51) per cent, P &lt; 0·0006; shoulder 11·76 (3·02–29·48) versus 1·41 (0·73–2·70) per cent, P &lt; 0·0026; sclerotic component 0·08 (0·02–0·54) versus 0·06 (0·04–0·24) per cent, P &lt; 0·4. Values for COX-2 were: cap 9·62 (4·87–12·50) versus 0·27 (0·02–2·41) per cent, P &lt; 0·0001; shoulder 11·45 (2·34–24·16) versus 0·44 (0·02–2·97) per cent, P &lt; 0·0038; sclerotic component 1·36 (0·24–2·61) versus 0·06 (0·02–0·49) per cent, P &lt; 0·0081. Further, COX-2 expression was greater than COX-1 staining in the sclerotic component of the plaques (P &lt; 0·05, Mann–Whitney U test).

Conclusion
Plaques that had recently become symptomatic exhibited increased COX-1 and COX-2 expression, particularly in the cap and shoulder regions. Such changes would increase macrophage and VSMC metalloproteinase production (collagenolysis) and reduce collagen synthesis by VSMCs. Such events are likely to promote plaque instability or rupture. These findings suggest that COX-1 and COX-2 inhibitors might have a therapeutic role in the prevention of further neurological events.
Autologous or homologous transfusion in aortic surgery: randomized trial
Authors: Torella F , Wong J C L , Haynes S L , McCollum C N 
Published: March 2003

Abstract

Background
Aortic surgery often requires blood transfusion, which may cause complications and postoperative infection. Autologous transfusion was evaluated in a multicentre clinical trial.

Methods
Some 145 patients undergoing elective aortic surgery in eight hospitals were randomized to either ‘homologous’ or ‘autologous’ transfusion, a combination of acute normovolaemic haemodilution (ANH) and intraoperative cell salvage. Homologous blood was administered when the haemoglobin concentration fell below 8 g dl−1.

Results
Median (interquartile range (i.q.r.)) blood loss was 668 (400–862) ml or 17 (10–24) per cent of blood volume in aortobifemoral bypass, and 1120 (765–1700) ml or 24 (17–36) per cent in aneurysm repair (P &lt; 0·001). Autologous transfusion reduced homologous blood requirements from a median (i.q.r.) of 2 (0–4) units to 0 (0–2) units (P = 0·008). Independent predictors of blood transfusion were homologous transfusion strategy (odds ratio (OR) 2·3 (95 per cent confidence interval 1·1–5·0); P = 0·03), low preoperative haemoglobin concentration (OR 3·7 (1·7–8·2); P &lt; 0·001), prolonged surgery (OR 2·1 (1·0–4·8); P = 0·05) and blood loss (OR 3·0 (1·4–6·5); P = 0·007). Patients with a preoperative haemoglobin concentration greater than 13·5 g dl−1 and who lost less than 20 per cent of their blood volume rarely required transfusion. There was no significant difference between the groups in terms of morbidity, mortality and postoperative hospital stay.

Conclusion
Autologous transfusion reduced the need for homologous blood in aortic surgery, but was useful only in patients with low haemoglobin levels or when blood loss exceeded 20 per cent of the blood volume. ANH alone is indicated for patients undergoing aortobifemoral bypass and in those with a higher haemoglobin level and blood volume.
More venous leg ulcers are healed by three-layer than by four-layer paste bandages: a randomized clinical trial
Authors: Meyer F J , Burnand K G , McGuiness C L , Lagattolla N R F , Eastham D 
Published: March 2003

Abstract

Background
The aim of this study was to compare prospectively the number of ulcers healed, time to total healing and bandage tolerability of three- and four-layer paste bandages.

Methods
All patients with clinical evidence of venous ulceration were considered for the study. Ulcers were stratified by size into one of three groups and patients were randomized within each group to receive either three- or four-layer paste bandages. Patients with diabetes, sickle-cell disease, ankle: brachial pressure index less than 0·9, positive autoimmune serology, or ulcers smaller than 0·25 cm2 or larger than 100 cm2 in diameter were excluded. Complete ulcer healing was the only study endpoint. A venous aetiology was confirmed with duplex imaging, foot volumetry and venography. All patients were followed for 1 year and classified according to clinical manifestations, etiological factors, anatomic involvement and pathophysiological features (CEAP) criteria.

Results
A total of 133 patients was entered into the study; 80 per cent of patients (51 of 64) receiving three-layer bandages healed, compared with 65 per cent of those (45 of 69) having four layers (P &lt; 0·05, χ2 test). This difference was apparent only after 16–20 weeks of treatment. The time to total healing increased with increasing ulcer size. Three-layer paste bandages were quicker to apply and better tolerated than four layers. There were more post-thrombotic legs in the four-layer group (46 versus 38 per cent), but half-refilling times did not differ significantly. These results were unaffected when analysis was restricted to confirmed venous ulcers.

Conclusion
Three-layer paste bandages are significantly more effective at healing venous ulcers than four-layer bandages. They are also cheaper and better tolerated. Some 20–35 per cent of venous ulcers remain unhealed at 1 year despite adequate compression.
Distal arterial reconstruction in Scotland 1989–1998
Authors: Holdsworth R J , Paterson H M 
Published: March 2003

Abstract

Methods
A retrospective analysis of national hospital discharge data (Scottish Morbidity Record 1) from 1989 to 1998 was undertaken.

Results
The population of Scotland has remained constant at 5·1 million. A total of 975 distal arterial grafts were performed in 10 years. The overall rate of distal reconstruction increased from 0·9 per 100 000 population in 1989, peaked at 2·6 per 100 000 in 1994, and has since declined steadily to 1·8 per 100 000 in 1998 (Table). There were huge interregional variations in the rate of reconstruction, with up to a 17-fold variation in annual rates between the 12 mainland health boards. The variations in distal reconstruction between the health boards were not reflected in reduced amputation rates, nor was the decline in distal reconstruction easily explained by increased non-femoral angioplasty.

Conclusion
Rates of distal arterial reconstruction in Scotland fall well below those of comparable European countries. It is likely that insufficient distal operations are undertaken to impact on amputation rates. The authors recommend an increased provision of specialist vascular surgical expertise in Scotland.
Prognosis following venous thromboembolism in women taking combined oral contraceptives
Authors: Egun A , Uzoigwe A , Riding G , McCollum C N 
Published: March 2003

Abstract

Background
It is widely believed that ‘post-thrombotic limb’ always follows deep vein thrombosis (DVT). Prognosis following both DVT and pulmonary embolism (PE) was investigated.

Methods
Some 155 women (mean age 25·5 (range 16–49) years) who developed venous thromboembolism while taking third-generation oral contraceptives were studied. The venous system was assessed by duplex imaging a mean of 4·8 years after DVT.

Results
Fourteen (15 per cent) of 96 women suffering PE died. Of the 82 surviving patients, 12 (15 per cent) had chest pain and/or dyspnoea at rest or on exertion. Of the 103 women with confirmed DVT, 59 (57 per cent) had had only calf thrombosis and 44 (43 per cent) had had iliofemoral vein thrombosis. At follow-up, 13 (22 per cent) and 21 (48 per cent) women with calf and iliofemoral thrombosis respectively had leg symptoms, including swelling, pain and lipodermatosclerosis (P = 0·011). Duplex imaging was normal in 60 patients (58 per cent). There was no significant difference in leg symptoms (31 versus 34 per cent) or incompetence on duplex imaging (41 versus 42 per cent) between those who were anticoagulated for 3 months (n = 39) or 6 months (n = 64) respectively. Leg symptoms were more frequent in the 41 women with DVT discharged without elastic stockings, affecting 19 (46 per cent) compared with only 15 (24 per cent) of 62 discharged with stockings (P = 0·034).

Conclusion
The majority of women regained venous patency and became asymptomatic, despite extensive DVT. Elastic stockings were often omitted despite the evidence of long-term benefit.