bluuebunny/crossref_metadata_2025_split huggingface dataset:
Limb salvage in the octogenarian
Authors: Ramamoorthy P , Johnson B J , Wilkinson A R , Galloway J M , McCollum P T 
Published: March 2003

Abstract

Background
Critical limb ischaemia (CLI) presents a unique set of problems in the elderly patient. Foremost among these is the much greater likelihood of loss of independence and reduced quality of life if major amputation is required. For this reason it has been this unit's policy to attempt reconstructive vascular surgery in almost all cases of CLI. The outcome of this policy was examined.

Methods
All patients had surgery performed under one consultant and data were entered prospectively on to a database.

Results
Risk factors included diabetes (17 per cent), smoking (78 per cent) and ischaemic heart disease (31 per cent). Some 127 patients had either femoropopliteal (59), femorodistal (64) or popliteal–distal grafts (four) performed for limb-threatening ischaemia. Follow-up was performed at 3, 6 and 12 months and then at annual intervals until death. Seventeen of these patients required a subsequent major amputation, 12 at the below-knee and five at the above-knee level. Mean follow-up was 2 years. The perioperative mortality rate was 15 per cent, although eight of these patients were admitted with acute or chronic ischaemia. Cumulative graft secondary patency rate was 68 per cent at 4 years for vein grafts. Some 95 per cent of patients with patent grafts were independently mobile.

Conclusion
Excellent results can be achieved for limb salvage with a relatively low morbidity in this group. Elderly patients with CLI do not live long and avoidance of amputation is particularly desirable in order to maximize the quality of their remaining life.
Patients with a failed infrainguinal bypass graft have abnormal lipid metabolism
Authors: Lewis D R , Taberner P V , Lemon M J C , Day A , Shih M F , Brooks S T , Bird R N , Lamont P M , Smith F C T 
Published: March 2003

Abstract

Background
Dyslipidaemias adversely affect vascular tone, endothelial function and platelet activation. Abnormal lipid metabolism has not been established as a risk factor for infrainguinal bypass graft failure. Lipid metabolism was evaluated prospectively in patients with patent and occluded grafts.

Methods
Twenty-eight patients with failed infrainguinal grafts (group 1) were identified from a prospective computerized database. Twenty matched controls with functioning grafts (group 2) were recruited from a graft surveillance programme. Fasting blood samples were analysed for triglyceride (TG), high-density lipoprotein (HDL) and cholesterol. A newly devised rapid TG tolerance test was conducted with analysis of TG at 1, 2 and 2·5 h. Endothelial lipoprotein lipase (LPL) was measured 30 min after intravenous administration of heparin 50 units kg–1.

Results
The cholesterol: HDL ratio was significantly higher in group 1 than group 2 (median 6·0 (range 3·1–10·0) versus 4·7 (2·3–9·4); P= 0·0008, Mann–Whitney test) as was fasting TG (2·6 (1·0–6·3) versus 1·7 (0·6–4·7) mmol l–1; P= 0·03). The area under the curve of the TG tolerance test was not significantly different (P= 0·08); however, the 2·5-h levels of TG were significantly different between the groups (group 1, 2·0 (0·5–6·6) mmol l–1; group 2, 1·2 (0·3–6·8) mmol l–1; P= 0·01). LPL was significantly lower in group 1 (52·4 (2·2–235·9) versus 86·8 (28·6–281·5) mmol/l; P= 0·04).

Conclusion
These data suggest that abnormal lipid metabolism is a significant risk factor for infrainguinal graft occlusion. This study provides a rationale for randomized trials of lipid-modifying therapies in patients undergoing arterial reconstruction for peripheral vascular disease.
Endovascular aneurysm repair: the need for randomized controlled trials
Authors: Brennan J , Harris P L , Gilling-Smith G L , Bakran A 
Published: March 2003

Abstract

Background
An audit of endovascular aneurysm repair (EVAR) was undertaken in order to assess the efficacy of this new approach in the treatment of abdominal aortic aneurysm.

Methods
An international register of EVAR was started in 1996, with emphasis on close follow-up.

Results
Data have now been accumulated for 895 cases. The 30-day mortality rate is low at 3 per cent; patients who died generally had major co-morbidity. At discharge 14 per cent were identified as having an endoleak (persistent blood flow outside the lumen of the endoluminal graft but within the aneurysm sac) and another 18 per cent developed new endoleaks during the first year of follow-up. Continued expansion of the aneurysm was observed in 22 per cent. This occurred in 53 per cent of patients with an identified endoleak compared with 11 per cent of those in whom no endoleak was demonstrated (P &lt; 0·01). Aneurysm rupture after EVAR occurred in six patients, three of whom died.

Conclusion
That EVAR is technically feasible is beyond doubt. Close follow-up has identified problems specific to the minimally invasive approach. The significance of endoleaks in particular remains unclear, but the strong association with continued aneurysm expansion is of concern. The primary purpose of EVAR, however, is to prolong life and in this study the cumulative 2-year survival rate (including operative deaths) was 85 per cent. In patients without any complications the benefits of the minimally invasive approach are readily apparent. Thus, while there is no place for unrealistic optimism, there certainly appears to be a role for EVAR. To prevent inappropriate widespread application of this new approach, or indeed unwarranted condemnation, randomized controlled trials comparing EVAR with conventional management are essential.
Prospective study examining differences in quality of life between patients surviving 2 years after oesophagectomy and patients dying within 2 years of surgery
Authors: Blazeby J M , Farndon J R , Alderson D 
Published: March 2003

Abstract

Background
Quality of life (QL) measurement is important for patients with oesophageal cancer but longitudinal studies may contain a bias because assessments only include healthy survivors who are able to complete questionnaires. This study examined QL in patients undergoing oesophagectomy by comparing results from those surviving 2 years after operation with results from patients dying within 2 years.

Methods
Between November 1993 and May 1995, 52 patients (36 men; mean age 67 years) underwent oesophagectomy. Prospective QL assessments were performed with the European Organisation for Research on Treatment of Cancer QLQ-C30 and the dysphagia scale from the oesophageal cancer module before treatment, 6 weeks, 3, 6, 9 and 12 months after operation, and at 6-month intervals thereafter, for a minimum of 3 years after operation. Mortality and morbidity rates and survival data were recorded.

Results
Two years after operation, 17 patients (33 per cent) were alive (group 1) and 35 had died (group 2). Groups were comparable for age, sex, tumour histology and length, dysphagia grade and performance scores. Six weeks after surgery patients in group 1 had worse functional, symptom and global health QL scores than before treatment. These subsequently improved such that by 9 months after operation most QL scores had returned to preoperative levels, except for persisting problems with dyspnoea and diarrhoea. Six weeks after operation patients in group 2 also reported worse QL in all domains, but this never recovered. Six months after treatment patients in group 2 had significantly worse physical, role, emotional and social function than those surviving 2 years and significantly more problems with appetite loss (P &lt; 0·001). The notable exception in both groups was dysphagia, which improved after operation. This improvement was maintained until death or for the duration of the study.

Conclusion
Patients dying within 2 years of operation suffer an irreversible loss of QL, except that dysphagia is relieved. Further work is needed to assess whether additional postoperative support or the use of multimodality adjuvant treatment can improve the outcome for this group of patients.
Tonometric measurement of gastric intramucosal pH following oesophagectomy predicts postoperative complications
Authors: Boyle N H , Owen W J , Pearce A C , Hunter D , Beale R J , Mason R C 
Published: March 2003

Abstract

Background
Gastric mucosal hypoperfusion can be assessed tonometrically by measuring the gastric intramucosal pH (pHi); its ability to predict outcome in the critically ill has been demonstrated previously. This study employed the new technique of recirculating gas tonometry to measure gastric pHi following oesophagectomy; its ability to predict anastomotic complications was tested, since ischaemia at the oesophagogastric anastomosis is thought to be an important factor in their aetiology.

Methods
A gastric tonometer was placed in the gastric tube of 28 consecutive patients undergoing oesophageal resection. They were connected to a Tonacap analyser (Datex-Engstrom Division, Instrumentarium Corporation, Helsinki, Finland) which automatically samples gas from the intragastric tonometer balloon and measures the carbon dioxide concentration within it. In conjunction with simultaneously taken arterial blood samples, gastric pHi was calculated at the end of the operation and then at 12-h intervals for up to 48 h after operation. Patients who survived were followed for 3 months and all postoperative complications were recorded. Statistical comparison was made using the independent samples t test.

Results
Eight patients suffered an anastomotic leak or benign stricture after operation; five others had a life-threatening complication not thought to be related to the anastomosis, of whom two survived. Over the first 24 h after operation median gastric pHi was lower at all three measurement points in the complication group than in the no complication group (P &gt; 0·05 in all cases). However, at 36 and 48 h there were significant differences (in both cases P &lt; 0·01); at these times median (range) pHi in the complication group was 7·19 (7·00–7·24) and 7·20 (7·03–7·49) respectively, and in the no complication group 7·28 (7·12–7·39) and 7·32 (7·25–7·44). A mean pHi at 36 and 48 h after operation of 7·25, with both measurements less than this value as a discriminating coefficient, was employed. This had a sensitivity of 92 per cent and a specificity of 92 per cent for predicting all complications. Applied specifically to anastomotic complications the sensitivity was 100 per cent and specificity 92 per cent.

Conclusion
Gastric pHi is easily measured after operation using recirculating gas tonometry. By taking measurements at 36 and 48 h, it appears possible to predict postoperative complications following oesophagectomy and the technique may provide a useful adjunct to the monitoring of these patients.
Lateral resection margin and prognosis following R0 resection for oesophageal carcinoma
Authors: Dexter S P L , Mapstone N , Martin I G 
Published: March 2003

Abstract

Background
For patients with rectal carcinoma, the finding of tumour within 1 mm of the circumferential resection margin is of independent prognostic importance. For patients undergoing oesophageal resection the significance of finding tumour within 1 mm of the lateral margin has not been described prospectively.

Methods
A series of 68 patients undergoing radical R0 oesophagectomy for carcinoma (46 adenocarcinomas) was studied prospectively. The resection specimens were examined prospectively by one pathologist and staged using the 1987 tumour node metastasis (TNM) classification. In addition, specimens in which tumour cells were seen within 1 mm of the lateral margin were regarded as being circumferential margin (CRM) positive. Survival was calculated using the Kaplan–Meier method and the Cox hazard model was used to identify independent effects on survival.

Results
The overall 3-year survival rate was 30 per cent (56 per cent stage I, 42 per cent stage II and 19 per cent stage III; P &lt; 0·04). Although for patients with the CRM involved (n = 38) the survival rate was 20 per cent compared with 40 per cent in those in whom tumour was more than 1 mm from the lateral margin (P = 0·15), using Cox's proportional hazards model the effect of CRM involvement was not independent of the TNM stage.

Conclusion
The impact of CRM involvement in oesophageal cancer may be less marked than for rectal carcinoma. A larger study is needed to quantify the true importance of CRM involvement, particularly with the increasing use of neoadjuvant therapies.
Management of proximal axillary and subclavian artery injuries
Authors: McKinley A G , Carrim A T O Abdool , Robbs J V 
Published: March 2003

Abstract

Background
The aim of this study was to review the management and outcome of proximal axillary and subclavian artery injuries, and to estimate the prehospital mortality rate for subclavian injury through forensic pathology autopsy data.

Methods
Data were collected prospectively for 260 patients who presented between 1977 and 1996 with trauma to the proximal axillary and subclavian arteries.

Results
The majority of victims (214, 82 per cent) were admitted following stab injury. Some 154 patients (59 per cent) presented within 24 h of sustaining an injury and, of these, 59 (38 per cent) required immediate surgery. An additional 67 patients (26 per cent) attended 2 days or more after injury. Comparison of these data with those from forensic autopsy reports suggests that the prehospital mortality rate for penetrating subclavian trauma was approximately 75 per cent.

Conclusion
Approximately 25 per cent of subclavian artery injuries caused minimal initial symptoms but delayed complications prompted attendance for medical attention. The majority of patients who survived subclavian artery injury and attended for medical attention were haemodynamically stable on admission; selective arteriography provided valuable information in these patients. Supraclavicular and infraclavicular incisions avoided clavicular division and reduced the postoperative morbidity associated with distal subclavian artery injuries.
Role of relaparoscopy in the management of minor bile leakage after laparoscopic cholecystectomy
Authors: Wills V L , Jorgensen J O , Hunt D R 
Published: March 2003

Abstract

Background
Bile leakage in the absence of major ductal injury may occur from the liver bed or from the cystic duct remnant after cholecystectomy. The early limitations of minimally invasive surgery led to reliance on endoscopic methods to manage this complication. However, repeat laparoscopy permits drainage of the bile collection and direct control of the site of leakage in selected situations.

Methods
Details of 15 patients with bile leakage after laparoscopic cholecystectomy were recorded prospectively and are reviewed.

Results
Postoperative bile leakage occurred after 15 (0·8 per cent) of 1779 laparoscopic chole-cystectomies. Two patients with bile in drainage fluid had spontaneous resolution. Ten patients with a subvesical duct leak had repeat laparoscopy. The leak was successfully controlled by suturing in eight patients, and by a laparoscopically placed drain in two. One patient required a subsequent laparotomy for a loculated pelvic collection. Three patients had cystic duct stump leakage. This was managed successfully by laparoscopy in one case but required endoscopic management in two.

Conclusion
Laparoscopy is useful in the management of minor bile leaks after laparoscopic chole-cystectomy. Selection of appropriate patients relies on a characteristic clinical presentation after an otherwise uncomplicated cholecystectomy.
Behavioural treatment (biofeedback) for constipation following hysterectomy
Authors: Roy A J , Emmanuel A V , Storrie J B , Bowers J , Kamm M A 
Published: March 2003

Abstract

Background
Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment.

Methods
Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance.

Results
Follow-up after completing treatment was a median of 28 (range 12–44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0·73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups.

Conclusion
The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.
Genetic predisposition to breast cancer: a surgical perspective
Authors: Sakorafas G H , Tsiotou A G 
Published: March 2003

Abstract

Background
Molecular alterations in proto-oncogenes, tumour suppressor genes, and genes that function in DNA damage recognition and repair are considered to be hallmarks of a carcinogenic process, including breast carcinogenesis.

Methods
A computer-assisted search of the English literature (Medline database, 1990–1999) was performed, followed by a manual search of the reference list of pertinent articles retrieved.

Results
Hereditary breast cancer accounts for 5–10 per cent of all breast cancer cases. About 90 per cent of hereditary breast cancers involve mutation of the BRCA1 and/or BRCA2 genes. Other cancer-related genes (including myc, c-erbB2, Tsg101 and Mdgi) are involved in breast carcinogenesis, but they do not give rise to familial breast cancer syndromes. Risk estimation is the most important clinical implication. Management options for the high-risk mutation carriers include cancer surveillance and preventive strategies (prophylactic surgery or chemoprevention).

Conclusion
Despite inadequate knowledge about the genetic predisposition to breast cancer and its clinical implications, the demand for genetic testing is likely to expand rapidly. In addition to risk estimation, cancer surveillance and preventive strategies, gene therapy offers a new and theoretically attractive approach to breast cancer management.
Beneficial effects of arterialization of the portal vein on extended hepatectomy
Authors: Shimizu Y , Miyazaki M , Shimizu H , Ito H , Nakagawa K , Ambiru S , Yoshidome H , Nakajima N 
Published: March 2003

Abstract

Background
Extended hepatectomy may result in postoperative liver failure. The aim of this study was to evaluate the effects of arterialization of the portal vein on oxygen supply, hepatic energy metabolism and liver regeneration after extended hepatectomy.

Methods
Portal haemodynamics were evaluated 0 or 10 days after arterialization of the portal vein in three experimental groups: 85 per cent partial hepatectomy, 85 per cent partial hepatectomy 10 days after arterialization of the portal vein and 85 per cent partial hepatectomy 10 days after ligation of the hepatic artery. Survival rates, weight of the regenerating liver, levels of adenine nucleotides and hepatic energy charge were assessed.

Results
Arterialization of the portal vein caused a significant increase in partial pressure of oxygen and oxygen saturation. Portal blood flow 10 days after arterialization was significantly increased. Survival rate and weight of the regenerating liver in the group with arterialization of the portal vein were significantly higher than those in the other two groups. The group with arterialization of the portal vein showed the highest levels of adenosine 5′-triphosphate.

Conclusion
The increase in portal blood flow and oxygen supply produced by arterialization of the portal vein has beneficial effects on hepatic energy metabolism and liver regeneration, and leads to improved survival after experimental extended hepatectomy.
Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy
Authors: Horgan A F , Finlay I G 
Published: March 2003

Abstract

Background
Variability in rates of local recurrence following resection of rectal cancer has led to the suggestion that all patients should undergo preoperative radiotherapy. This centre employs a selective policy of radiotherapy only in patients with evidence of advanced local disease determined by preoperative staging.

Methods
A retrospective review was carried out of 114 consecutive patients with rectal cancer. Patients were divided before operation into palliative and curative groups based on preoperative staging. Only patients in the palliative group were offered preoperative radiotherapy. Total mesorectal excision (TME) was performed for all tumours of the middle or lower rectum.

Results
The perioperative mortality rate was 0·9 per cent and anastomotic dehiscence occurred in 2·8 per cent. Local recurrence developed in 4 per cent of patients in the ‘curative’ group and in seven of 15 of those assigned to the palliative group before operation (P &lt; 0·01). Positive lateral resection margins were significantly associated with a risk of subsequent recurrence (ten of 13 versus three (3 per cent) of 93; P &lt; 0·001).

Conclusion
Preoperative adjuvant radiotherapy can be omitted reasonably in patients in whom there is no evidence of locally advanced disease, provided that adequate surgery, incorporating TME for low tumours, is performed.
Duplex-guided thrombin injection for iatrogenic femoral artery pseudoaneurysm is effective even in anticoagulated patients
Authors: Lennox A F , Delis K T , Szendro G , Griffin M B , Nicolaides A N , Cheshire N J 
Published: March 2003

Abstract

Background
The aim was to evaluate the efficacy and safety of percutaneous thrombin injection as an alternative non-operative method for treating postcatheterization femoral artery pseudoaneurysm in both anticoagulated and non-anticoagulated patients.

Methods
Thirty consecutive patients with a femoral artery pseudoaneurysm secondary to radiological catheterization confirmed by duplex imaging were included. Thrombin 200–2000 units (1000 units/ml) in a titrating dose was injected into the centre of the cavity under duplex ultrasonographic guidance. Thrombosis was assessed in real time using B mode and colour flow. No sedation or anaesthesia was required during the procedure. The distal pulses and ankle pressures were evaluated before and immediately after the injection, to exclude propagation of thrombus into the femoral artery.

Results
Successful rapid thrombosis of the false cavity was induced in all 30 patients. There were no immediate or mid-term procedure-related complications, or recurrences at 6 weeks. Eighteen patients were anticoagulated therapeutically at the time and following the procedure with either heparin or warfarin.

Conclusion
Percutaneous thrombin injection is a simple, quick, painless, safe and effective technique, particularly in patients taking anticoagulants.