A case-control study of visual acuity in onychocryptosis

BACKGROUND

There are many theories surrounding the etiology of ingrown toenails (IGTN). Few factors have been formally assessed, but it is widely accepted that a poor nail cutting technique has a causative role.

AIM

To investigate the hypothesis that decreased visual acuity may lead to inadequate nail cutting and the formation of IGTN.

METHODS

A prospective case-control study was performed. Near and distance visual acuity were tested on a population with IGTN (n = 19) and compared with that of an age- and sex-matched control cohort (n = 24) who underwent epidermal cyst excision in the same tertiary referral center. Comparisons of visual acuity were made between groups by Mann-Whitney U-test. Differences were taken to be significant if P < 0.05. Institutional Review Board approval was sought and granted.

RESULTS

No significant difference in visual acuity (near or distance) was demonstrated between patients with IGTN and the control group (P = 0.33).

CONCLUSION

Visual acuity does not appear to play a significant role in the development of IGTN.

Congenital cystic adenomatoid malformation of the lung: hazards of delayed diagnosis

Congenital cystic adenomatoid malformation is a rare pulmonary developmental anomaly, which typically manifests in neonates and infants. Presentation in adulthood is uncommon, with <60 cases reported in the literature. The majority of cases involve one lobe only. We report a case of type 1 congenital cystic adenomatoid malformation in an adult presenting with a respiratory tract infection and haemoptysis. At thoracotomy, complex cystic masses were noted in the right upper and lower lobes. Lung-sparing surgery, in the form of two segmentectomies and a non-anatomical resection, was performed in order to avoid pneumonectomy. Such presentations may be problematic as potentially incomplete resections may increase the risk of complications and malignant transformation. This suggests the importance of appropriate clinical and radiological follow up.

Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis

OBJECTIVE

Despite the high prevalence of hospitalization for left iliac fossa tenderness, there is a striking lack of randomized data available to guide therapy. The authors hypothesize that an oral antibiotic and fluids are not inferior to intravenous (IV) antibiotics and 'bowel rest' in clinically diagnosed acute uncomplicated diverticulitis.

METHOD

A randomized controlled trial was constructed in two District General Hospitals. All clinically diagnosed patients presenting with acute uncomplicated diverticulitis were eligible for the study. Oral and IV regimens utilizing ciprofloxacin and metronidazole were compared. The primary outcomes studied were surrogates for resolution of symptoms (including tenderness on day 3 and length of stay) and failure of oral therapy. Secondary endpoints studied were serial constitutional and biomarker trends.

RESULTS

There were 41 patients in the oral arm and 38 in the IV arm (n = 79). No patient had to be converted to IV antibiotics from the oral group. There was a complete resolution of symptoms in both groups. Tenderness was equivalent in both groups on day 3. Among secondary endpoints, a serial decrease in C reactive protein was the best serological predictor of resolution for both groups.

CONCLUSION

Oral antibiotics are not inferior to intravenous antibiotics in achieving resolution of clinically diagnosed diverticulitis.

Detected peritoneal fluid in small bowel obstruction is associated with the need for surgical intervention

BACKGROUND

Predicting the clinical course in adhesional small bowel obstruction is difficult. There are no validated clinical or radiologic features that allow early identification of patients likely to require surgical intervention.

METHODS

We conducted a retrospective review of 100 patients consecutively admitted to a tertiary level teaching hospital over a 3-year period (2002-2004) who had acute adhesional small bowel obstruction and underwent computed tomography (CT). The primary outcomes that we assessed were conservative management or the need for surgical intervention. We investigated time to physiologic gastrointestinal function recovery as a secondary outcome. We examined independent predictors of surgical intervention in a bivariate analysis using a stepwise logistic regression analysis.

RESULTS

Of the 100 patients investigated, we excluded 12. Of the 88 remaining patients, 58 (66%) were managed conservatively and 30 (34%) underwent surgery. Peritoneal fluid detected on a CT scan (n = 37) was associated more frequently with surgery than conservative management (46% v. 29%, p = 0.046, chi(2)). Logistical regression identified peritoneal fluid detected on a CT scan as an independent predictor of surgical intervention (odds ratio 3.0, 95% confidence interval 1.15-7.84).

CONCLUSION

The presence of peritoneal fluid on a CT scan in patients with adhesional small bowel obstruction is an independent predictor of surgical intervention and should alert the clinician that the patient is 3 times more likely to require surgery.

Radical pancreaticoduodenectomy for benign disease

Whipple's procedure is the treatment of choice for pancreatic and periampullary malignancies. Preoperative histological confirmation of malignancy is frequently unavailable and some patients will subsequently be found to have benign disease. Here, we review our experience with Whipple's procedure for patients ultimately proven to have benign disease. The medical records of all patients who underwent Whipple's procedure during a 15-year period (1987–2002) were reviewed; 112 patients underwent the procedure for suspected malignancy. In eight cases, the final histology was benign (7.1%). One additional patient was known to have benign disease at resection. The mean age was 50 years (range: 30–75). The major presenting features included jaundice (five), pain (two), gastric outlet obstruction (one), and recurrent gastrointestinal haemorrhage (one). Investigations included ultrasound (eight), computerised tomography (eight), endoscopic retrograde cholangiopancreatography (seven; of these, four patients had a stent inserted and three patients had sampling for cytology), and endoscopic ultrasound (two). The pathological diagnosis included benign biliary stricture (two), chronic pancreatitis (two), choledochal cyst (one), inflammatory pseudotumour (one), cystic duodenal wall dysplasia (one), duodenal angiodysplasia (one), and granular cell neoplasm (one). There was no operative mortality. Morbidity included intra-abdominal collection (one), anastomotic leak (one), liver abscess (one), and myocardial infarction (one). All patients remain alive and well at mean follow-up of 41 months. Despite recent advances in diagnostic imaging, 8% of the patients undergoing Whipple's procedure had benign disease. A range of unusual pathological entities can mimic malignancy. Accurate preoperative histological diagnosis may have allowed a less radical operation to be performed. Endoscopic ultrasound–guided fine needle aspirate (EUS-FNA) may reduce the need for Whipple's operation in benign pancreaticobiliary disease in the future.

Laparoscopic colonic resection in inflammatory bowel disease: minimal surgery, minimal access and minimal hospital stay

OBJECTIVE

Laparoscopic surgery for inflammatory bowel disease (IBD) is technically demanding but can offer improved short-term outcomes. The introduction of minimally invasive surgery (MIS) as the default operative approach for IBD, however, may have inherent learning curve-associated disadvantages. We hypothesise that the establishment of MIS as the standard operative approach does not increase patient morbidity as assessed in the initial period of its introduction into a specialised unit, and that it confers earlier postoperative gastrointestinal recovery and reduced hospitalisation compared with conventional open resection.

METHOD

A case-control study was undertaken on laparoscopic resection (LR) vs open colon resection (OR) for IBD. The LR group was collated prospectively and compared with a pathologically matched historical control set. Outcomes measured included: postoperative length of stay, time to normal bowel function and postoperative morbidity. Statistical analysis was performed using spss.

RESULTS

Twenty-eight patients were investigated (14 LR, 14 OR). The two groups were matched for type of operation, type of disease and age. There were no conversions in the LR group. Morbidity and readmissions did not differ significantly between the groups. Those undergoing laparoscopic resection had a quicker return to diet (median 2 vs 4 days; P = 0.000002), time to first bowel motion (2 vs 4 days; P = 0.019) and shorter postoperative length of stay (5.5 vs 12.5; P = 0.0067).

CONCLUSION

These findings support the routine use of MIS for the elective surgical management of IBD in our department. Patients undergoing laparoscopic colectomies for IBD can expect faster return of gastrointestinal function and shorter hospitalisation.

Low molecular weight heparin prophylaxis in day case surgery

BACKGROUND

The role of Low molecular weight heparins (LMWH) in day case/short-stay surgery is unknown.

AIM

To characterise the current national use of LMWH prophylaxis in specific day and short stay surgeries.

METHODS

A standardised anonymous postal questionnaire was sent to all consultant general surgeons in Ireland. The operations selected were herniorraphy, anorectal, varicose vein and laparoscopic cholecystectomy.

RESULTS

Questionnaires were sent to 82 surgeons in 2003. There was a response rate of 68.3% (56). Fifty-four per cent of respondents said there was a protocol in place for administration of LMWH in day case surgery. Of these 41% were not confident that their protocols were being adhered. Fifty-nine per cent of all respondents said they stratified patients according to individual risk. Thirteen per cent reported occurrence of VTE post day case surgery

CONCLUSION

This study demonstrates a heterogeneous pattern of administration of LMWH. In the absence of published validated protocols, the authors suggest a consensus day case protocol.

Laparoscopic colectomy is cheaper than conventional open resection

OBJECTIVE

International randomized trials have endorsed the routine use of laparoscopic techniques in colorectal surgery. The authors hypothesize that the overall care pathway in minimal access resection was cheaper than conventional open resection.

METHOD

This was a case-matched study of consecutive patients undergoing laparoscopic resection between July 2005 and February 2006. Intraoperative (costs, duration, incision length) and postoperative [morbidity, length of stay (LOS), readmission] parameters were examined. Institutional retrospective open controls and national validated figures were used for costings.

RESULTS

Thirty-five laparoscopic and 53 open resections were evaluated. Median LOS was 5 days in the laparoscopic group vs 12 in the open group (P = 0.001). There were two conversions (5.7%) and two readmissions. Mean operative cost of laparoscopic resection was 1557.08 euros, therefore 2.4 bed days need to be saved to recoup the increased cost compared with open resection. The actual median save is 7 days (P = 0.031). A mean of 4591.38 euros and 7 bed days per case is saved by performing the resection laparoscopically. Subgroup analysis of laparoscopic resections clearly demonstrates similar trends.

CONCLUSION

The institutional saving is over 150,000 euros and 245 bed days during the study period. Despite higher operative spending, laparoscopic colorectal resections are significantly cheaper than conventional open resections.

The Accuracy of Combined Versus Largest Diameter in Staging Multifocal Breast Cancer

BACKGROUND

Evaluating the size of multifocal breast cancer for staging purposes is problematic. Historically, the largest tumor focus in isolation has been used to stage multifocal disease and determine optimum adjuvant therapy. This study compared multifocal and unifocal breast cancer to determine if multifocal breast cancer presents at a higher stage.

STUDY DESIGN

We performed a retrospective review of a prospectively collected database of 328 patients who underwent sentinel lymph node biopsy over a 7-year period. Clinical presentation and histopathologic features of multifocal breast cancer were compared with those of unifocal disease.

RESULTS

Fifty-three (16%) patients presented with multifocal disease. Higher tumor grade was observed in the multifocal tumors compared with unifocal tumors (34% versus 20% grade III tumor, multifocal versus unifocal disease; p=0.03). Use of combined tumor focus diameter upstaged (pT status) 18 (34%) patients with multifocal tumors. There was no difference in nodal positivity based on pT status between largest and combined diameter multifocal disease.

CONCLUSIONS

Combined tumor diameter in multifocal breast cancer does not correspond with an increase in sentinel node positivity and should not be used for staging purposes.

Surgical e-learning: validation of multimedia web-based lectures

BACKGROUND

Distance learning has been advocated increasingly as a modern efficient method of teaching surgery. Efficiency of knowledge transfer and validity of web-based courses have not been subjected to rigorous study to date.

METHODS

An entirely web-based surgical 5-week lecture course was designed. Fifty per cent of the lectures were prepared as HTML slides with voice-over while the other group was presented in the text-only form. Only written material presented was examined. The lectures were presented via an educational web module. The lecture series was balanced specifically to reduce the pre-existent knowledge bias. Web usage was estimated utilising surrogates, including the number of hits as well as log-on timing. Face validity was assessed by a standardised questionnaire.

RESULTS

Eighty-eight students took part in the lecture series and subsequent examination and questionnaire. Median multiple choice questionnaire (MCQ) marks were significantly higher in the aural lecture-derived stems versus the non-aural (P = 0.012, Mann-Whitney U-test). There was widespread approval of web-based learning as an adjunct to conventional teaching. Usage rates were augmented significantly in the final week when compared to the previous 4 weeks (mean total hits weeks 1-4 +/- SEM: 100.9 +/- 9.7 and mean total hits week 5: 152.1 +/- 13.1; P < 0.001, Kruskal-Wallis). However, total hits did not correlate with overall examination results (r(2) = 0.16). The aural lectures demonstrated higher face validity than the non-aural for content and presentation (P < 0.05, Kruskal-Wallis).

CONCLUSIONS

The addition of aural files to the novel web-based lecture series is face valid and results in significantly increased examination performance.

A surgically induced hypoxic environment causes changes in the metastatic behaviour of tumours in vitro

The use of laparoscopic techniques for curative resections of malignant tumours has been under scrutiny. The potential benefits to the patient in the form of earlier recovery and less immune paresis are countered by the reports of increased tumour recurrence. The biological sequelae of the hypoxic laparoscopic environment on tumour cells is unknown. Components of the metastatic cascade were evaluated under in vitro laparoscopic conditions using a human colonic adenocarcinoma cell line (SW1222). Exposure to the laparoscopic gases carbon dioxide and helium for 4 h, comparable to the duration of a laparoscopic colorectal resection, had no effect on cell viability. A cellular hypoxic insult was demonstrated by the induction of hypoxia inducible factor 1alpha (HIF-1alpha). Exposure also resulted in significant reduction in homotypic adhesion as well as to a variety of extracellular matrix components. These effects were recoverable under re-oxygenation. The changes were reflected at the molecular level by significant down regulation of adhesion molecules known to be involved in tumour progression (E-cadherin, CD44 and beta1 sub-unit). Modulation of adherence has significant implications for laparoscopic oncological surgery, demonstrating that tumours become potentially more friable and easier to disseminate in surgeons who are less experienced or where instrumentation is sub-optimal.

Inguinal hernia repair protects testicular function: a prospective study of open and laparoscopic herniorraphy

BACKGROUND

Despite the frequency of open and laparoscopic herniorraphy the effect of the hernia and subsequent repair on testicular function is unknown. Our objective was to determine if there is an association between inguinal hernia and hernia repair on testicular function.

STUDY DESIGN

Thirty-seven men aged 18 to 70 years were enrolled in a prospective internally controlled cohort study. They underwent Doppler ultrasonography and serum testicular hormone analysis pre- and post- either open Lichtenstein's repair or laparoscopic totally extraperitoneal hernioplasty. These surrogates of testicular function were measured up to 6 months postrepair.

RESULTS

Thirty-seven consecutive patients underwent either Lichtenstein (n = 17) or totally extraperitoneal hernioplasty (n = 20) hernia repair as per surgeon preference. Preoperatively there was a significant elevation in the sonographic resistive index (RI) in the affected (hernia) side compared with the normal side (0.601, 0.569; p < 0.001). This elevation in RI was reversed posthernia repair at a median followup of 6.1 months. Inguinal hernia or repair did not affect testicular volume. The choice of either Lichtenstein or totally extraperitoneal hernioplasty hernia did not significantly alter the testicular function.

CONCLUSIONS

Patients with inguinal hernia have an elevated testicular vascular resistance, which is reversed after repair. The choice of laparoscopic or open herniorraphy did not affect reversal of this surrogate of testicular function.

Splenic preserving distal pancreatectomy of a solid pseudopapillary pancreatic tumour

BACKGROUND

Solid pseudopapillary tumours are rare primary lesions of the pancreas. They occur most commonly in young female patients. They are traditionally regarded as benign tumours with malignant potential.

AIM

We describe the incidental finding of this rare pancreatic lesion in a healthy 37-year-old female which was treated with splenic preserving distal pancreatectomy.

RESULTS

The patient underwent curative resection with an uncomplicated postoperative course. Histology revealed the tumour origin with clear resection margins. The patient did not require adjunct therapy. Follow-up computed tomography (CT) scanning has demonstrated no evidence of local recurrence.

CONCLUSION

The authors conclude that splenic preservation is safe and desirable where no compromise in oncological principles exists. Despite improvements in histological characteristics of solid pseudopapillary tumours, no prognostic features exist and each case must be followed-up on an individual basis.

Construct validation of a novel hybrid surgical simulator

BACKGROUND

Simulated minimal access surgery has improved recently as both a learning and assessment tool. The construct validation of a novel simulator, ProMis, is described for use by residents in training.

METHODS

ProMis is a surgical simulator that can design tasks in both virtual and actual reality. A pilot group of surgical residents ranging from novice to expert completed three standardized tasks: orientation, dissection, and basic suturing. The tasks were tested for construct validity. Two experienced surgeons examined the recorded tasks in a blinded fashion using an objective structured assessment of technical skills format (OSATS: task-specific checklist and global rating score) as well as metrics delivered by the simulator.

RESULTS

The findings showed excellent interrater reliability (Cronbach's alpha of 0.88 for the checklist and 0.93 for the global rating). The median scores in the experience groups were statistically different in both the global rating and the task-specific checklists (p < 0.05). The scores for the orientation task alone did not reach significance (p = 0.1), suggesting that modification is required before ProMis could be used in isolation as an assessment tool.

CONCLUSIONS

The three simulated tasks in combination are construct valid for differentiating experience levels among surgeons in training. This hybrid simulator has potential added benefits of marrying the virtual with actual, and of combining simple box traits and advanced virtual reality simulation.

Optimising preoperative diagnosis in phyllodes tumour of the breast

The role of the pathologist in the preoperative diagnosis of phyllodes tumours of the breast is critical to appropriate surgical planning. However, reliable differentiation of phyllodes tumour from cellular fibroadenoma remains difficult. Preoperative diagnostic accuracy allows correct surgical treatment, avoiding the pitfalls of reoperation because of inadequate excision, or surgical overtreatment. Specific clinical indices may arouse diagnostic suspicion but are unreliable for confirmation, as with current imaging modes. Fine needle aspiration cytology has a high false negative rate. Few studies have evaluated the role of core needle biopsy, but it may prove a useful adjunct. Both diagnostic and prognostic information may in future be gained from application of immunohistochemical and other techniques assessing the expression of proliferative markers including p53, Ki-67, and others.

Proton pump inhibition is a feasible primary alternative to surgery and balloon dilatation in adult peptic pyloric stenosis (APS): report of six consecutive cases

INTRODUCTION

Surgery has been the gold standard in the treatment of adult pyloric stenosis (APS). The introduction of proton pump inhibitors (PPIs) in 1989 revolutionised the treatment of peptic ulcer disease and its complications.

PATIENTS AND METHODS

We carried out a prospective study to evaluate the effectiveness of PPIs as an alternative to surgery for treatment of APS. Six consecutive patients admitted with a diagnosis of adult peptic pyloric stenosis between November 1999 and August 2002 were studied. The diagnosis was confirmed with endoscopy. All patients were commenced on a twice-daily dose of intravenous PPI. This was changed to oral treatment after 2 days. Main outcome measures evaluated were resolution of symptoms on PPIs and failure of medical therapy.

RESULTS

There were five females and one male. Median age at diagnosis was 72 years (range, 30-90 years). Median duration of symptoms was 2 weeks (range, 1-5 weeks). Of the patients, five had a history of peptic ulcer disease. Complete resolution was achieved in 5 patients (83%). Median duration for resolution of symptoms was 9 days (range, 5-14 days). All patients were changed to oral PPIs after 2 days. One patient did not respond to oral therapy and required surgical intervention (pyloroplasty). Median follow-up was 26 months (range, 6-48 months). There was no recurrence of symptoms. All patients were discharged on low-dose PPI.

CONCLUSIONS

This study supports the view that proton pump inhibitors are a safe and feasible alternative to surgery in adult pyloric stenosis secondary to peptic ulcer disease.

Laparoscopic environmental changes during surgery enhance the invasive potential of tumours

OBJECTIVE

The use of laparoscopic techniques in resection of malignant tumours has been proposed to offer potential benefit to the patient in the form of earlier recovery and less immune paresis; however, reported tumour seeding, both peritoneal and at port site, has put this approach into question. The biological effects of the introduction of carbon dioxide or helium to form a pneumoperitoneum on tumour invasion and dissemination are unknown.

METHODS

A human colonic adenocarcinoma cell line (SW1222) was exposed to in vitro laparoscopic environment of either carbon dioxide or helium for 4 h, mimicking the duration of a laparoscopic colorectal resection. Alteration in production of matrix metalloproteinase (MMP)-2, MMP-9 and urokinase-type plasminogen activator (uPA) due to exposure to a laparoscopic environment was determined by zymography and correlated to invasive capacity by a standard Matrigel-based invasion assay. Incorporation of specific gelatinase inhibitors or antibodies directed at the uPA receptor was utilized to determine the relative importance of proteases.

RESULTS

Exposure to the laparoscopic environment significantly enhanced production of the proteases MMP-2, MMP-9 and uPA. A concomitant enhancement of invasive capacity was also observed, being blocked by specific protease inhibitors. Changes in both protease production and aggression were observable for at least 24 h following the removal of the operative environment, indicating the possible long-term effects of the initial insult.

CONCLUSION

Exposure to the laparoscopic environment enhances the invasive capacity of colonic adenocarcinomas via a well-defined protease-determined pathway. It therefore appears likely that tumour cells released into the operative field can be made increasingly aggressive by a laparoscopic operative environment and can thus contribute to disease dissemination.

Peritoneal nebulizer: a novel technique for delivering intraperitoneal therapeutics in laparoscopic surgery to prevent locoregional recurrence

BACKGROUND

Peritoneal involvement is a significant issue in the treatment of gastrointestinal malignancies. Current statistics indicate that after surgical intervention, up to 20% of patients will present with locoregional metastasis. The ability to inhibit initial tumor adhesion to the mesothelial lining of the peritoneum may be considered critical in the inhibition of tumor development. This article describes, the use of a novel nebulizer system capable of delivering high-concentration, low-dose therapeutics to the peritoneal cavity.

METHODS

For this study, 30 male WAG rats were inoculated with CC531 colorectal tumor cells. The rats were randomized into three groups: control group (n = 10), heparin-treated group (n = 10), and high-molecular-weight hyaluronan-treated group (n = 10). A peritoneal cancer index was used to determine tumor burden at 15 days. Analysis of variance (ANOVA) was used to compare multiple group means.

RESULTS

Nebulization therapy was performed without any complication in the cohort. Heparin inhibited macroscopic intraperitoneal tumor growth completely (p = 0.0001) without affecting tumor cell viability. The introduction of hyaluronan attenuated both tumor size and distribution, was compared with the control group (p = 0.002).

CONCLUSION

Nebulized heparin and hyaluronic acid using a novel nebulization technique attenuates peritoneal tumor growth after laparoscopic surgery. The technique itself is easy to use and safe.

Hypoxia augments gelatinase activity in a variety of adenocarcinomas in vitro

BACKGROUND

Hypoxia within solid adenocarcinomas and protease up-regulation has been independently implicated as poor prognostic indicators in a variety of tumor types. The authors hypothesize that Matrix Metalloproteases (MMP) are up-regulated in direct response to a hypoxic environment.

MATERIALS AND METHODS

Colonic (SW1222), breast (MDA-MB231), and pancreatic (PSN-1) tumor cell lines were exposed to hypoxia (1% oxygen/94% nitrogen/5% carbon dioxide) for periods of up to 24 h. Reaction to a hypoxic environment was determined via invasion across a Matrigel-coated 8-microm Transwell filter. Activity of MMP 2 and 9 was assessed using gelatin zymography. Expression of tissue inhibitor of metalloproteases 1 (TIMP-1) was quantified using ELISA (Biotrak). Correlation between protease expression and invasive capacity was determined using a specific gelatinase inhibitor (MMPI; Calbiochem).

RESULTS

All tumor lines demonstrated augmented invasion over 72 h (P < 0.01 all groups). Concomitant significant increase in MMP 2 and 9 activity was observed in the SW1222 and PSN-1 lines. MDA-MB231s showed increase in MMP 9 expression and in a unidentified 103-kDa gelatinase (P < 0.001). The hypoxia-augmented invasion was attenuated by the addition of a specific gelatinase inhibitor confirming interdependence.

CONCLUSIONS

Hypoxia induces an increased invasive capacity via gelatinase up-regulation without loss of cell viability. This suggests a mechanism explaining the poorer prognosis seen in patients with protease-secreting solid adenocarcinomas.

Hypoxia increases reepithelialization via an alphavbeta6-dependent pathway

Reepithelialization is an essential step in successful cutaneous wound healing. Human keratinocytes, integral in this process, have been shown to have increased motility in the hypoxic healing edge of wounds correlating with the clinical success of semiocclusive hypoxic dressings, although the underlying mechanisms remain poorly understood. Subconfluent human keratinocyte cell monolayers were exposed to 1% hypoxia for up to 24 hours or control conditions. Re-oxygenation studies were performed up to 72 hours. Cellular alphav subunit and alphavbeta6 integrin expression was measured by flow cytometry. Migration scratch assays on fibronectin following hypoxic exposure were performed over 24 hours. Relative matrix metallo-proteinase (MMP)-2, 9 activity was determined by gelatin zymography with TIMP-1 levels assayed by enzyme-linked immunoassay. Sustained increases in alphav and alphavbeta6 expression were shown up to 48 hours in re-oxygenation studies (P < 0.001). Standardized scratch assays confirmed increased migration in the hypoxic group (P < 0.05). This effect was attenuated by the addition of a specific inhibitor of the alphavbeta6 integrin. MMP-2 and -9 activity was up-regulated following hypoxic exposure (P < 0.001; P < 0.05, respectively), whereas increased MMP expression was significantly retarded by addition of an alphavbeta6 inhibitor (P < 0.05). Migration on fibronectin was attenuated by a specific gelatinase inhibitor. We conclude that integrin alphavbeta6-dependent MMP-2 and -9 up-regulation is an important feature of increased migration in hypoxic human keratinocytes.

Tumour-expressed CD43 (sialophorin) mediates tumourmesothelial cell adhesion

Mesothelial cell intercellular adhesion molecule-1 (ICAM-1) has recently been shown to play a role in tumour cell adherence to the peritoneum. However, solid tumours poorly express its most ubiquitous ligand, beta2 integrin. The aim of this study was to investigate the role of the beta2 integrin subunit and CD43, a known ligand for ICAM-1, in the development of peritoneal metastases. beta2 Integrin subunit and CD43 expression was assessed on a number of tumour cell lines. Adhesion of SW1222 and PSN-1 cells to human peritoneal mesothelial cells was investigated using a fluorometric assay incorporating an inhibitory antibody to beta2 integrin and CD43. beta2 Integrin expression was not inducible on these tumour cell lines, but Western blotting demonstrated CD43 expression in all the cancer cell lines examined and cell surface expression was confirmed by flow cytometry. The anti-CD43 antibody significantly reduced adhesion of PSN-1 and SW1222 cells to HPMC, however beta2 integrin inhibition did not reduce tumour cell adhesion. CD43 is expressed by a variety of carcinoma cell lines, and plays a role in tumour cell-peritoneal adhesion probably via interactions with its putative ligand ICAM-1.

Attitudes towards skills examinations for basic surgical trainees

Objective measures of surgical skill and cognition are becoming available. A questionnaire study examining surgeons' beliefs towards a skills-based examination, current standards and possible benefits was devised. Three hundred pairs of standardised anonymous questionnaires were sent to consultants and their basic surgical trainees (BSTs) irrespective of surgical specialty. Responses were requested using a Likert scale (1-5, 3=neutral response). Two-hundred and two replies were received (including 54 pairs). BST experience ranged from 6 to 60 months (mean 24 months). When questioned regarding current training in basic surgical skills, only 34% believed that they were given adequate training at present. Sixty-four per cent of respondents believed the introduction of a skills examination would raise standards and 66% believed it necessary. Eighty-three per cent of respondents believed that they or their BST would practice these skills, if an examination were introduced and 85% wanted or would provide dedicated teaching time for this. However, 68% had no access to a dedicated skills facility, and uptake of these, where available, was variable. When questioned about their ability to perform the six appropriate tasks, there was a poor correlation of scoring between the groups. Consultants and their BSTs do not believe that they are given adequate training in basic skills. The introduction of an examination would lead to practice of these skills and is seen as a positive move.

Administration of analgesia for acute abdominal pain sufferers in the accident and emergency setting

BACKGROUND

Recent trials suggest that the early administration of analgesia in patients with acute abdominal pain facilitates examination and does not delay diagnosis. We investigated current practice regarding analgesia for these patients.

METHODS

All patients admitted via the accident and emergency department with abdominal pain were included. The main outcome measures evaluated were waiting time for analgesia and its relationship to subjective visual analogue pain scores and clinical diagnoses.

RESULTS

Data from 107 consecutive patients were investigated; seven patients were excluded. Forty-two per cent were male. The mean age was 40.1 years (6-85). The mean overall waiting time for analgesia was 1.4 h (2 min to 14 h). Sixty-seven per cent received analgesia within one hour, although 22% waited 2-14 h after presentation. Those with mild pain waited significantly longer for analgesia (mean 247 min) than those with severe pain (mean 82 min; P=0.01). Those with moderate pain had intermediate waiting times (mean 111 min), although they were not statistically different from the severe group (P=0.43). Female patients had to wait longer (mean 129 min) than male patients (mean 69 min; P=0.09 analysis of variance). Of 64% who were general practitioner referrals, only 11% (all severe group, P=0.02) received analgesia in the community. Neither clinical diagnosis nor age influenced the timing of analgesia. Seventy-three per cent received analgesia in the casualty department (mean 0.5 h; range 0.02-3.2), whereas those admitted in the ward without receiving analgesia in casualty had to wait significantly longer for their pain relief (mean 5 h; 1.2-14).

CONCLUSION

This study shows the need for standardized protocols for analgesia usage in patients presenting with acute abdominal pain.

Perioperative diagnosis of cystosarcoma phyllodes of the breast may be enhanced by MIB-1 index

BACKGROUND

The recurring theme in cystosarcoma phyllodes (CSP) is one of underdiagnosis by pathologists and undertreatment by surgeons. Major areas of investigation relating to the diagnosis of CSP center on accurate preoperative diagnosis, elucidating the relevance of histological classification with respect to outcome, and identifying novel markers to reliably differentiate CSP from fibroadenoma (FA).

MATERIALS AND METHODS

Fifteen CSP and 7 cellular FA controls (where the preoperative diagnosis was unclear) were retrospectively investigated. Preoperative histological and radiological investigations were reviewed for efficacy. The ability of MIB-1 antibody to differentiate the two fibroepithelial lesions was investigated using immunohistochemical estimation of the MIB-1 index.

RESULTS AND DISCUSSION

Preoperative core biopsy had a sensitivity of 75% but was carried out in only 23% of cases. Fine needle aspiration cytology and radiological assessment were not efficacious in preoperative diagnosis. Proliferative activity (MIB-1 indices) was significantly higher in CSP than in a selected population of FA where there was preoperative diagnostic uncertainty (P < 0.0001). Indices were also able to determine CSP subclassification. This suggests MIB-1 as a constructive adjunctive investigation when evaluating histological features to differentiate CSP from FA in difficult cases.

CONCLUSIONS

The use of MIB-1 may increase the sensitivity of preoperative core biopsy diagnosis, offering more effective surgical planning and decreasing immediate reoperation rates.

Dislocation of the mandible

We report the first case of bilateral temporomandibular joint (TMJ) dislocation in a woman after endoscopy. We go on to discuss the case reports published in the literature, with particular focus on potential factors that may predispose to this complication, and we offer some suggestions on dealing with this significant complication.

Laparoscopic-type environment enhances mesothelial cell fibrinolytic activity in vitro via a down-regulation of plasminogen activator inhibitor-1 activity

BACKGROUND

Fewer intraperitoneal adhesions have been observed after laparoscopic surgery compared with conventional techniques. The aim of this study is to assess the effect of the pneumoperitoneum on mesothelial cell fibrinolytic activity by use of an in vitro model.

METHODS

Human peritoneal mesothelial cells were seeded onto 24-well plates and incubated in carbon dioxide or helium at 5 mm Hg for 4 hours or standard culture conditions. Supernatant was removed for analysis at 0, 24, 48, and 72 hours after gas incubation and analyzed for plasminogen activator activity, total tissue plasminogen activator (tPA), and total plasminogen activator inhibitor-1 (PAI-1) concentrations by use of an enzyme-linked immunosorbent assay. The effect of different insufflation pressures (0, 7, and 14 mm Hg) was also examined.

RESULTS

Enhanced plasminogen activator activity was observed at 48 hours and 72 hours from cells exposed to CO(2) (P<.04 each) and helium (P<.05 each) compared with control. This was associated with a decrease in PAI-1 concentrations at 48 and 72 hours in both the CO(2) and helium groups compared with control (P<.03 each, CO(2) vs control; and P<.04 each, helium vs control). No changes in tPA levels were observed. Changes in insufflation pressures did not affect plasminogen activator activity.

CONCLUSIONS

These results suggest that incubation of human mesothelial cells with both CO(2) and helium in the absence of oxygen enhances mesothelial cell fibrinolytic activity because of a reduction in PAI-1 concentrations. These changes may participate in the observed reduction in adhesions after laparoscopic surgery relative to open surgery.

Laparoscopic enhancement of tumour cell binding to the peritoneum is inhibited by anti-intercellular adhesion molecule-1 monoclonal antibody

BACKGROUND

There still remain some concerns over the phenomenon of port-site metastases (PSM) after laparoscopic surgery. The aim of this study was to investigate the effect of the pneumoperitoneum on tumor-mesothelial cell interactions.

METHODS

The adhesion of a colon carcinoma cell line to a mesothelial cell monolayer exposed to carbon dioxide, helium, or air was assessed using an in vitro adhesion assay. Changes in adherence were correlated with alterations in cell surface molecule expression by the mesothelial cells using flow cytometry after exposure to the different environments.

RESULTS

Exposure of the mesothelial cells to an in vitro pneumoperitoneum significantly enhanced tumor cell binding to the mesothelial cell monolayer. No differences in cell viability were observed between the groups. This was associated with increased expression of mesothelial intercellular adhesion molecule-1 (ICAM-1) mediated by nuclear factor kappa-B. The enhanced adhesion was abolished by ICAM-1 inhibition.

CONCLUSIONS

This study demonstrated that the laparoscopic environment increases the susceptibility of the mesothelium to tumor cell adherence, and this may be explained by changes in ICAM-1 expression.

The role of total mesorectal excision in the management of rectal cancer

BACKGROUND

Total mesorectal excision (TME) was described 20 years ago and is now being established as the therapeutic gold standard for middle and lower third rectal cancers in a number of countries worldwide.

METHODS

The authors reviewed published data regarding TME since its first description in 1982. Emphasis was placed on basic principles, achievable recurrence rates, evidence for use of adjunctive strategies, and the potential of TME.

RESULTS

Local recurrence rates following TME approximate 6.6% from published series, accounting for more than 5,000 patients. The available evidence for TME is largely composed of retrospective series, although benefits of TME compare favorably to established conventional controls. Recent studies have clarified the benefit of adjunctive radiotherapy with TME. There is considerable scope for development of TME within the minimal access setting, providing first principles are observed.

CONCLUSIONS

Despite initial controversy, TME is now a feasible, reproducible, adjunctive surgical therapy in the management of rectal cancer.

ICAM-1 mediated tumor-mesothelial cell adhesion is modulated by IL-6 and TNF-alpha: a potential mechanism by which surgical trauma increases peritoneal metastases

Peritoneal metastases frequently occur in different gastrointestinal cancers and have a poor prognosis. It is known that surgical injury promotes tumor growth and local recurrence rates and also the degree of surgical trauma correlated with the amount of tumor implantation into the peritoneum. The mechanism that mediates tumor cell adhesion to the mesothelium is not fully understood. This study investigates the role of ICAM-1, an important mediator of trans-mesothelial leucocyte migration, in tumor-mesothelial interactions as the initial step in the development of peritoneal recurrence using an in vitro model incorporating mesothelial cell monolayer derived from omental samples. We also investigate how the cytokines interleukins 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) modulate this process. We demonstrate that ICAM-1 blockade reduces the ability of both pancreatic and colonic cancer cell lines to adhere to the mesothelium. Preincubation of the mesothelial cell monolayer with either IL-6 or TNF-alpha enhances tumor cell adhesion, and this is associated with an increased expression of ICAM-1. Mesothelial CD44 expression, which has previously been implicated in this process, was unaffected by these cytokines. The use of an inhibitory monoclonal antibody against ICAM-1 attenuated the enhanced adhesion mediated by IL-6 or TNF-alpha. This study suggests that mesothelial ICAM-1 plays a role in the adhesion of tumor cells to the peritoneum in the development of peritoneal metastases.

Objective measurement of breast cancer oestrogen receptor status through digital image analysis

AIMS

The authors have previously described quantitative, computer-assisted analysis of oestrogen receptor status in immuno-histochemically stained sections in patients with primary breast cancer. The aim of this study was to validate the aforementioned system against the commonly used methods of assessing oestrogen receptor status.

METHODS

Paraffin embedded sections from 156 patients with primary breast carcinoma were stained with anti-alpha-oestrogen receptor monoclonal antibody (1D5) using a standard immunohistochemical protocol. Images from 10 high-powered fields were captured from each section using a digital camera mounted on a microscope and analyzed using Adobe Photoshop image analysis software. A nuclear mask was obtained by digitally selecting the nuclear area. Staining intensity in the nuclear mask was then analyzed using red-scale absorption characteristics. Manual assessment of oestrogen receptor status was performed through counting the percentages of cells that are positive from 200 randomly sampled nuclei from ten high powered fields HPF. Cut off value for positivity was taken as 10%. Cytosolic oestrogen receptor concentration was measured through enzyme immunisation. Cut off value for ER positivity was taken as 200 fmol/g (wet tissue).

RESULTS

One hundred and fifty-six sections were studied of which 41 were ER negative. Median percentage positivity in the remainder was 90% (17-100) by manual assessment. The median red scale value was 108 (58-156). A close correlation was observed between median optical density of the nuclear mask and percentage positivity assessed manually (P<0.0001). There was a significant correlation between the optical density of the nuclear mask and cytosolic oestrogen receptor concentration (P<0.001).

CONCLUSION

Oestrogen receptor positivity can be accurately assessed through digital image analysis. This process offers objective data regarding the amount of oestrogen receptors within the nuclei as well as the percentage of nuclei, which express oestrogen receptors.

Laparoscopic staging of pancreatic tumors induces increased invasive capacity in vitro

INTRODUCTION

Laparoscopy and laparoscopic ultrasound have a well-defined role in staging patients with pancreatic malignancy. The effect of the hypoxic pneumoperitoneum induction on tumor biology is unknown. The authors investigated whether an in vitro pneumoperitoneum augments the invasive capacity of pancreatic tumors and elucidate a mechanism by which this may occur.

METHODS

A pancreatic (PSN-1) adenocarcinoma cell line was exposed to an in vitro pneumoperitoneum (carbon dioxide (CO2) or helium) for a maximum of 2 h or left in normal growth conditions (control). Cells were nonenzymatically harvested and placed in invasion assays. These were performed over 72 h using Matrigel coated 8-mm Transwell filters and analyzed using MTS colorimetric assay. Gelatin zymography was employed to assess the level of matrix metalloproteases (MMP) 2 and 9 (gelatinase A and B) secretion. Expression of tissue inhibitor of metalloproteases 1 (TIMP-1) was assessed using ELISA (Biotrak). Inhibition of invasion assays was performed using a specific gelatinase inhibitor (MMPI; Calbiochem).

RESULTS

The invasive capacity of pancreatic tumour cells is augmented versus control in both helium (p <0.05) and CO2 (p <0.001) groups. Concomitant significant upregulation of the gelatinase activity was demonstrated with both insufflants (p <0.05; 0.001, respectively). Enhanced invasion was attenuated by the addition of a specific gelatinase inhibitor (p <0.05).

CONCLUSIONS

These results indicate the invasive capacity of pancreatic tumor cells is augmented by laparoscopic staging in vitro. This is in part mediated by increased gelatinase activity and may be attenuated by the addition of specific inhibitors.

Laboratory-based validation of a novel suture technique for wound closure

Wound closure in open surgery is a fundamental skill acquired early during the surgeon's career. Individual modifications are adopted frequently by the more experienced surgeon in an effort to increase efficiency. To date, there has been no objective measurement regarding whether these modifications significantly impact economy of movement or procedure time. The advent of the Imperial College Surgical Assessment Device (ICSAD) allows standardized, objective evaluation of a novel suture technique for wound closure (study group) developed by one of the senior authors (DBH) and compares the technique to the current method taught by the Royal College of Surgeons of Great Britain and Ireland (control group). Ten surgical registrars underwent both tasks in a standardized manner for five repetitions. Mean total movements and duration of procedure were decreased significantly for the study group (analysis of variance: = 0.018 and = 0.033 respectively) with an economy index (total movements/total time) of 0.79 movements per second for the control group vs. 0.67 for the study group. This study demonstrates ICSAD's usefulness in defining a novel suture technique as a more efficient method of cutaneous closure than the currently advocated technique.

Pneumoperitoneum augmented tumor invasiveness is abolished by matrix metalloproteinase blockade

BACKGROUND

Certain surgical strategies, including Helium (He) and carbon dioxide (CO2) insufflation in laparoscopy, have been shown to induce a hypoxic environment. This may have a significant effect on the invasive capacity of tumor cells and may be a factor in the incidence of port-site metastases seen in patients following laparoscopic resection for malignancy.

METHODS

A colon adenocarcinoma cell line (SW1222) was exposed to an in vitro pneumoperitoneum of CO2 or He at 3 mmHg or left in normal growth conditions (control). After a 4-hour exposure to an in vitro pneumoperitoneum, the ability of the cells to invade through 8.0-microm Transwell filters coated with Matrigel was analyzed by colorimetric MTS assay and by direct staining of the filters. The effect of the addition of a known blocker of matrix metalloproteinases (MMPs), 1,10-phenanthroline (1,10-P), was investigated.

RESULTS

Cells exposed to an in vitro pneumoperitoneum demonstrate significantly increased invasive capacity compared to the control set, without loss of viability (He vs control, p <0.001; CO2 vs control, p <0.001). This augmented capacity is abolished by the addition of 1,10-P (p <0.01).

CONCLUSION

Exposure of a colonic adenocarcinoma cell line to either a CO2 or He pneumoperitoneum causes an increase in tumor cell invasiveness, which is abolished by the presence of a known inhibitor of MMPs. This suggests that MMPs have an important role in the metastatic potential of tumors exposed to a hypoxic operative environment.

Unfractionated heparin, time for a change?

BACKGROUND

In Ireland physician transfer to utilisation of Low Molecular Weight Heparin for Venous Thromboembolism has been slow, despite evidence of efficacy and concern about the level of anticoagulation achieved with Unfractionated Heparin.

OBJECTIVE

To examine the effectiveness of Unfractionated Heparin administration in a teaching hospital in Ireland. Primary outcomes measured were time to therapeutic APTT and length of hospital stay.

METHODS

We identified 50 consecutive eligible patients treated with continuous intravenous unfractionated heparin for Venous Thromboembolism from the period August 1994 to December 1996 at Beaumont Hospital, Dublin, Ireland. Data analysed included length of hospital stay, costing data and anticoagulation parameters (time to therapeutic APTT, percentage of time within therapeutic range, number of diagnostic tests, heparin dosages).

RESULTS

A significant number of patients (22%) never achieved therapeutic APTT levels. Of those who did achieve therapeutic APTT levels at some time during their therapy, therapeutic range APTT was maintained only 28% of the time on heparin. 57% of the time results were below therapeutic while 15% of the time results were above therapeutic. Also 26% of the patients were discharged with INR results outside the therapeutic range despite an average length of stay of 13.3 days (over twice the ideal of 6 days). Ineffective anticoagulation influenced hospital length of stay in 60% of cases in our evaluation. Average cost of treatment with Unfractionated Heparin was 5897.86 Pounds versus the projected cost of Low Molecular Weight Heparin at 2562.78 Pounds for 6 days of in-patient therapy or 60.78 Pounds for outpatient therapy (excluding physician visit costs).

CONCLUSIONS

Unfractionated Heparin therapy as reviewed in our study is sub-optimal with inadequate anti coagulation and prolonged hospitalisation. Low Molecular Weight heparin, with comparable therapeutic effect documented elsewhere, overall may cost less.