Quality of life after indefinite diversion/pouch excision in ileal pouch failure patients

OBJECTIVE

Pouch failure occurs in up to 10% of patients over a 10-year period for a variety of reasons. One surgical option is pouch excision (PE) and form a permanent ileostomy. This is a major procedure with potential serious complications. An alternative is indefinite diversion (ID) of the pouch without excision. The aim of this study was to examine the quality of life and functional outcome in these two groups of patients.

METHOD

Ninety-seven patients were identified from the database to have either PE or ID. Fifty-three patients (17 men) responded; comprising 31 patients after PE and 22 patients with ID in a case-control study and completed the SF-36 general health survey and the Cleveland Clinic Foundation (CCF) functional outcomes questionnaire.

RESULTS

There was no significant difference in the domains of SF-36 between the two groups (P > 0.18). All patients with PE had an end ileostomy whereas most patients with ID had a loop ileostomy (18 loop vs 4 end). There was no difference in stoma related complications except for stoma retraction in ID (7%vs 47%; P = 0.003). There was no significant difference in urinary symptoms between PE and ID groups (weak stream 26%vs 14%; P = 0.49, nocturia 22%vs 4%; P = 0.12, urgency 22%vs 9%; P = 0.28, urinary incontinence 22%vs 14%; P = 0.72 respectively). There was no difference in sexually active patients (73%vs 94%; P = 0.11). Of the seven male PE patients, five (71%) could achieve an erection and four (57%) could maintain an erection, compared with all 10 male patients in the ID group (P = 0.151 and 0.05 respectively). Thirty-three per cent of patients with PE and 62% of patients with ID reported that they would have pouch surgery again if indicated (P = 0.052) and 58% of patients with PE and 81% of patients with ID reported that they would recommend pouch surgery to others (P = 0.129). No case of dysplasia was seen in 18 of 22 ID patients in whom histology was available.

CONCLUSION

Quality of life after PE or ID was no different and male sexual function was significantly better after ID. Retraction of the stoma was more common in this group.

Proteomics of the peroxisome

Genomes provide us with a blue print for the potential of a cell. However, the activity of a cell is expressed in its proteome. Full understanding of the complexity of cells demands a comprehensive view of the proteome; its interactions, activity states and organization. Comprehensive proteomic approaches applied to peroxisomes have yielded new insights into the organelle and its dynamic interplay with other cellular structures. As technologies and methodologies improve, proteomics hold the promise for new discoveries of peroxisome function and a full description of this dynamic organelle.

Social deprivation and outcomes in colorectal cancer

Background

The aim of this study was to examine the influence of social deprivation on postoperative mortality and length of stay in patients having surgery for colorectal cancer.

Methods

Data were extracted from the Association of Coloproctology of Great Britain and Ireland database of patients presenting between April 2001 and March 2002. The effect of social deprivation, measured by the Townsend score, on 30-day postoperative mortality and length of stay was evaluated by two-level hierarchical regression analysis.

Results

A total of 7290 (86·8 per cent) patients underwent surgery. Operative mortality was 6·7 per cent and median length of stay 11 days. Deprivation indices were significantly higher in patients with Dukes' ‘D’ cancers, undergoing emergency surgery and with higher American Society of Anesthesiologists (ASA) grades (P < 0·005). Worsening deprivation was associated with higher operative mortality and longer stay (P = 0·014). For each unit increase in deprivation, there was 2·9 (95 per cent confidence interval 0·5 to 5·2) per cent increase in 30-day mortality. On multifactorial analysis, social deprivation was an independent predictor of length of stay, but its effect on operative mortality was explained by differences in ASA grade, operative urgency and Dukes' classification.

Conclusion

Social deprivation was an independent risk factor of postoperative length of stay and associated with higher postoperative mortality. These results have important implications for risk modelling of postoperative outcomes.

Histological examination of circular stapled ‘doughnuts’: Questionable routine practice?

BACKGROUND

Left-sided colonic resections are often anastomosed by the use of the circular stapling gun. Most surgeons routinely submit the resulting set of 'doughnuts' for histological examination.

AIM

The aim of this study is to question the need for this practice by providing our own experience of the impact of 'doughnut' submission on patient management.

PATIENTS AND METHODS

Patients who had undergone a stapled anastomosis for colorectal cancer resection (1998-2004) were identified from the department cancer database and clinical records and histopathological reports were reviewed for all cases.

RESULTS

From a consecutive series of 100 sets of doughnuts only two showed histological abnormality (inflammatory change and a metaplastic polyp). Three patients had local recurrence over the follow-up period: 12, 14 and 36 months after surgery. Histological review of the 'doughnuts' in these patients did not show any abnormality. None of the above findings had any influence on subsequent management.

CONCLUSION

Histological examination of the 'doughnuts' has a considerable impact in terms of time and resource use. This study has shown no benefit in performing routine histological examination of the 'doughnuts'.

Long-term results of abdominal salvage surgery following restorative proctocolectomy

BACKGROUND

This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy.

METHODS

Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine.

RESULTS

One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32).

CONCLUSION

Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up.

Anabolic effects of acellular bone marrow, platelet rich plasma, and serum on equine suspensory ligament fibroblasts in vitro

The purpose of this study was to investigate the response of suspensory ligament fibroblasts (SLF) to in vitro stimulation using acellular bone marrow (ABM), platelet rich plasma (in vitro PRP), and serum as potential treatment modalities for suspensory desmitis. Blood, bone marrow, and suspensory ligaments were collected from five horses. SLF were harvested, grown until confluent, and stimulated with various concentrations of ABM, PRP, equine serum, foetal bovine serum, and medium (control). The responses to the treatments were assessed using a combination of radio-labeling for total protein synthesis and an ELISA for quantification of Cartilage Oligomeric Matrix Protein (COMP) production. Addition of all of the samples resulted in significant increases in COMP and total protein synthesis over controls (P<0.001). ABM caused the greatest increase in both COMP and total protein synthesis by the SLF. Equine ABM, PRP, and serum contain anabolic factors that promote matrix synthesis by SLF in vitro, with ABM having the greatest effect. Application of bone marrow to injured ligaments may enhance healing by providing anabolic factors, other than or in addition to mesenchymal stem cells, which stimulate matrix production.

A comparison of serial halving and the rule of nines as a pre-hospital assessment tool in burns

Following endorsement of serial halving by the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh this study aimed to determine whether the technique was comparable to the rule of nines in making initial assessments of body surface area burned. Ten 'casualties' were made up to represent burn victims (range 6-61%). An external panel of six consultants and one specialist registrar in plastic surgery were invited to assess the simulated casualties. They gave individual and a consensus estimate of the burned areas. One hundred and twenty-five members of local emergency services and military paramedical staff were given a brief video and slide presentation describing either the rule of nines or serial halving method of burn area assessment. These techniques were then used to assess the 10 simulated casualties, giving 1250 estimates of burn surface area. The understanding of both techniques appeared adequate in both test groups. Estimates from serial halving and rule of nines groups differed from the assessments of the external panel. No statistical difference was demonstrated between serial halving and the rule of nines as an initial assessment tool when determining disposal. Serial halving has an inherent weakness when assessing certain sizes of burn. The rule of nines requires that the assessor knows and understands the proportionate areas of the body. The mathematics of percentages and fractions appeared to confuse some assessors.

A comprehensive expressed sequence tag linkage map for tiger salamander and Mexican axolotl: enabling gene mapping and comparative genomics in Ambystoma

Expressed sequence tag (EST) markers were developed for Ambystoma tigrinum tigrinum (Eastern tiger salamander) and for A. mexicanum (Mexican axolotl) to generate the first comprehensive linkage map for these model amphibians. We identified 14 large linkage groups (125.5-836.7 cM) that presumably correspond to the 14 haploid chromosomes in the Ambystoma genome. The extent of genome coverage for these linkage groups is apparently high because the total map size (5251 cM) falls within the range of theoretical estimates and is consistent with independent empirical estimates. Unlike most vertebrate species, linkage map size in Ambystoma is not strongly correlated with chromosome arm number. Presumably, the large physical genome size ( approximately 30 Gbp) is a major determinant of map size in Ambystoma. To demonstrate the utility of this resource, we mapped the position of two historically significant A. mexicanum mutants, white and melanoid, and also met, a quantitative trait locus (QTL) that contributes to variation in metamorphic timing. This new collection of EST-based PCR markers will better enable the Ambystoma system by facilitating development of new molecular probes, and the linkage map will allow comparative studies of this important vertebrate group.

Long-term outcomes of restorative proctocolectomy for Crohn's disease and indeterminate colitis

INTRODUCTION

The present study aims to evaluate the short-term and long-term outcomes of patients undergoing restorative proctocolectomy (RPC) for Crohn's disease (CD) and Indeterminate colitis (IC) and to identify factors associated with adverse outcomes.

METHODS

A descriptive study of 52 patients with CD or IC from a total of 1652 patients undergoing primary or salvage RPC in a single tertiary referral centre between 1978 and 2003. Primary outcomes were ileal pouch failure (excision or indefinite diversion), adverse events and functional outcomes (bowel frequency, urgency and continence).

RESULTS

Patients with IC or IC favouring ulcerative colitis (Group 1, n = 26) had a pouch failure rate of 11.5%vs 57.5% for patients with CD or IC favouring CD (Group 2, n = 26). Pouch salvage surgery was undertaken in 15 patients with a 13.3% failure rate. Patients in Group 2 were 2.6 times more likely (95% CI: 0.96-7. No significant differences were evident between CD and IC patients with regards to pelvic sepsis (19.2%vs 15.4%), anastomotic stricture (23.1%vs 21.7%), small bowel obstruction (26.9%vs 26.9%) or pouchitis (15.4%vs 11.5%). The 24-h bowel frequency (7.5 vs 8), faecal urgency, daytime or night time incontinence were similar between patients with CD or IC..17) to develop a pouch-related fistula than patients in Group 1.

DISCUSSION

Crohn's disease and to a great extent indeterminate colitis favouring CD were both associated with high failure rates and postoperative pouch-related fistula rates. Despite these problems, functional outcomes for patients with CD or IC were similar. Patients with IC should remain candidates for RPC but careful pre-operative assessment is advised to exclude clinical signs favouring the diagnosis of CD. The complications associated with failure are extensive and the option of reconstructive surgery in patients with CD should be questioned.

Evolution of salamander life cycles: a major-effect quantitative trait locus contributes to discrete and continuous variation for metamorphic timing

The evolution of alternate modes of development may occur through genetic changes in metamorphic timing. This hypothesis was examined by crossing salamanders that express alternate developmental modes: metamorphosis vs. paedomorphosis. Three strains were used in the crossing design: Ambystoma tigrinum tigrinum (Att; metamorph), wild-caught A. mexicanum (Am; paedomorph), and laboratory Am (paedomorph). Att/Am hybrids were created for each Am strain and then backcrossed to their respective Am line. Previous studies have shown that a dominant allele from Att (met(Att)) and a recessive allele from lab Am (met(lab)) results in metamorphosis in Att/Am hybrids, and met(Att)/met(lab) and met(lab)/met(lab) backcross genotypes are strongly associated with metamorphosis and paedomorphosis, respectively. We typed a molecular marker (contig325) linked to met and found that met(Att)/met(lab) and met(Att)/met(wild) were associated with metamorphosis in 99% of the cases examined. However, the frequency of paedomorphosis was 4.5 times higher for met(lab)/met(lab) than for met(wild)/met(wild). We also found that met(Att)/met(wild) and met(wild)/met(wild) genotypes discriminated distributions of early and late metamorphosing individuals. Two forms of phenotypic variation are contributed by met: continuous variation of metamorphic age and expression of discrete, alternate morphs. We suggest that the evolution of paedomorphosis is associated with genetic changes that delay metamorphic timing in biphasic life cycles.

TRANSVAGINAL SLING USING ACELLULAR HUMAN DERMAL ALLOGRAFT: SAFETY AND EFFICACY IN 253 PATIENTS

PURPOSE

We evaluated the safety and efficacy of using human dermal allograft material for transvaginal slings to treat female stress urinary incontinence (SUI).

MATERIALS AND METHODS

We present a prospective series of 253 patients with SUI treated with a transvaginal sling using a Repliform cadaveric human dermal allograft (LifeCell Corp., The Woodlands, Texas) and a bone anchor fixation kit. Clinical history, urogynecologic examination and videourodynamics were performed preoperatively. Results were assessed by a third party through validated quality of life questionnaires (Incontinence Impact Questionnaire and Urogenital Distress Inventory), overall impression and percent of improvement as perceived by the patients, and pad use. Scheduled followup examination were performed to rule out erosion, infection, obstruction, pain or recurrent incontinence.

RESULTS

Complete followup was available on 234 of 253 patients. Average followup was 18 months. Of the patients 78% were cured or improved according to the questionnaires. The average improvement was 80%. At 18 months of followup incontinence average distress and scores decreased 10 and 7 points, respectively. Complications were de novo urgency in 5% of cases, recurrent SUI in 15% with no cases of persistent SUI, retention in 2% and slow vaginal wall healing in 1.7%. Of 156 patients 51 (22%) had persistent urgency. There were no cases of vaginal or urethral erosion, osteitis pubis or osteomyelitis.

CONCLUSIONS

Our data indicate that use of human dermal allograft for transvaginal slings is associated with low complication rates and favorable outcomes at an average of 18 months of followup.

Evaluation of minimally invasive analysis system for cough leak point pressure measurement

PURPOSE

Leak point pressure (LPP) measurement has become standard in the diagnosis of stress urinary incontinence. Leak point pressure is determined by increasing abdominal pressure, which can be done with a Valsalva maneuver or coughing, that is Valsalva LPP and cough LPP (CLPP). It may be influenced by catheter size, bladder volume and interobserver variability. A new, computerized LPP measuring technique for routine use in daily urodynamic practice was tested at a female unit urodynamic practice to evaluate female urinary incontinence.

MATERIALS AND METHODS

A total of 28 female patients with a mean age of 54.07 years (range 23 to 82) and urinary incontinence underwent a new, minimally invasive measurement of the cough leak point. Measurements are made with the patient standing and repeated 3 times per patient. Additionally, parameters of the corresponding leak were recorded simultaneously. All patients underwent new CLPP measurement and a standard, complete urodynamic investigation, including filling cystometry with abdominal LPP and urethral pressure profile at rest. Statistical evaluation was done by linear regression analysis and the correlation coefficients among CLPP, age, standard abdominal LPP and maximum urethral pressure, and among the 3 measurements for each patient.

RESULTS

: The assignment of leakage to the pressure signal presented no problem. All CLPP data were reproducible in the 3 repeated measurements per patient. No correlation was seen between CLPP and abdominal LPP or the urethral pressure profile.

CONCLUSIONS

The study confirm that the CLPP is a practicable, consistent and minimally invasive method in routine use. Clinical use is easy and reproducible, and only 1 catheter is required for measurement.

Computer-identified nuclear localization signal in exon 1A of the transporter DMT1 is essentially ineffective in nuclear targeting

Divalent metal transporter 1 (DMT1; also called DCT1, Nramp2, or SLC11A2) has multiple isoforms that localize differently in many cell types. DMT1 +IRE species (encoded by mRNA with an iron-responsive element) are limited to the plasma membrane and cytosolic vesicles. In neural cells, -IRE isoforms of DMT1 (encoded by mRNA lacking an IRE) localize to the nucleus, plasma membrane, and cytosolic vesicles. In considering nuclear compartmentalization of -IRE isoforms, we hypothesized that the newly identified exon 1A in the N-terminus of this transporter might contain a nuclear localization signal. DNA constructs starting with exon 1A and ending with exons encoding alternative isoforms were made and transiently transfected into HEK293T and PC12 cells as well as rat sympathetic neurons. None of the constructs appeared in the nucleus despite the presence of exon 1A. Antibody specific for exon 1A was also used in both immunostaining and Western blots to investigate localization of exon 1A expressed both endogenously and ectopically in cells. Again, nuclear localization of DMT1 containing exon 1A was not observed. Our data suggest that exon 1A is neither sufficient nor necessary for DMT1 to appear in the nucleus.

Determination of Cryptosporidium parvum oocyst viability by fluorescence in situ hybridization using a ribosomal RNA-directed probe

AIMS

Fluorescence in situ hybridization (FISH) has been proposed for species-specific detection, and viability determination of Cryptosporidium parvum oocysts. FISH-based viability determination depends on rRNA decay after loss of viability. We examined the effects of RNase(s) and RNase inhibitors on FISH of C. parvum.

METHODS AND RESULTS

FISH was performed using a 5'-Texas red-labelled DNA oligonucleotide probe at 1 pM microl(-1). Intact and heat-permeabilized oocysts were treated with 1-100 microg ml(-1) RNase. FISH of intact oocysts appeared unaffected by exogenous RNase if this was neutralized before permeabilization. FISH fluorescence of heat-killed oocysts stored in phosphate-buffered saline at room temperature decayed by 1/2 after 55 h, but remained detectable after 6 days. Addition of vanadyl ribonucleoside complex (VRC) extended rRNA half-life of heat-permeabilized oocysts to 155 h.

CONCLUSIONS

Extended rRNA half-life may result in viability overestimation using FISH. RNase pretreatment before FISH is recommended to destroy residual rRNA in recently killed oocysts. Incorporation of 1-10 mM l(-1) VRC before FISH permeabilization steps should neutralize RNase activity.

SIGNIFICANCE AND IMPACT OF THE STUDY

Elimination of FISH fluorescence of nonviable C. parvum is desirable. Use of RNase and VRC is suggested to reduce numbers of false-positive 'viable' oocysts.

Metagenomics, gene discovery and the ideal biocatalyst

With the rapid development of powerful protein evolution and enzyme-screening technologies, there is a growing belief that optimum conditions for biotransformation processes can be established without the constraints of the properties of the biocatalyst. These technologies can then be applied to find the ‘ideal biocatalyst’ for the process. In identifying the ideal biocatalyst, the processes of gene discovery and enzyme evolution play major roles. However, in order to expand the pool genes for in vitro evolution, new technologies, which circumvent the limitations of microbial culturability, must be applied. These technologies, which currently include metagenomic library screening, gene-specific amplification methods and even full metagenomic sequencing, provide access to a volume of ‘sequence space’ that is not addressed by traditional screening.

Cold visceral perfusion improves early survival in patients with acute renal failure after thoracoabdominal aortic aneurysm repair

INTRODUCTION

Despite advances in organ protection during thoracoabdominal aortic aneurysm (TAAA) repair, acute renal failure (ARF) remains a significant clinical problem, associated with increased morbidity and mortality. We studied outcome of ARF after TAAA repair in patients who underwent either warm or cold visceral perfusion.

METHOD

Between 1991 and 2001 657 TAAA repairs were performed, of which 359 (55%) had either warm or cold visceral perfusion. Twelve patients with renal failure who had undergone preoperative dialysis were excluded from the study. Of the remaining 347 patients, ARF developed in 81 (23%) after TAAA repair. Forty-four (54%) of the 81 patients with ARF received cold visceral perfusion, and 37 (46%) patients received warm visceral perfusion. ARF was defined as either an increase of 1 mg/dL in serum creatinine (SCr) concentration per day for 2 consecutive days or dialysis requirement. Patient records were reviewed through hospital discharge.

RESULTS

Twenty six (32%) of the 81 patients in whom ARF developed died, 17 of 37 (46%) patients in the warm perfusion group versus 9 of 44 (21%) patients in the cold perfusion group (P <.02). Median onset of ARF was on postoperative day 1 in both groups. Twenty-six of 81 (32%) patients recovered renal function, 10 of 37 (27%) patients in the warm perfusion group versus 16 of 44 (36%) patients in the cold perfusion group. Preoperative SCr concentration was predictive of recovery of renal function (odds ratio, 4.5 per mg/dL increase; P <.03) in patients who received either warm or cold visceral perfusion.

CONCLUSIONS

ARF after TAAA repair remains a significant clinical problem. Recovery of renal function occurred in approximately one third of patients. Preoperative SCr concentration was the only significant determinant of recovered renal function. While cold visceral perfusion did not alter renal recovery, it significantly reduced hospital mortality.

Review and re-analysis of domain-specific 16S primers

The Polymerase Chain Reaction (PCR) has facilitated the detection of unculturable microorganisms in virtually any environmental source and has thus been used extensively in the assessment of environmental microbial diversity. This technique relies on the assumption that the gene sequences present in the environment are complementary to the "universal" primers used in their amplification. The recent discovery of new taxa with 16S rDNA sequences not complementary to standard universal primers suggests that current 16S rDNA libraries are not representative of true prokaryotic biodiversity. Here we re-assess the specificity of commonly used 16S rRNA gene primers and present these data in tabular form designed as a tool to aid simple analysis, selection and implementation. In addition, we present two new primer pairs specifically designed for effective "universal" Archaeal 16S rDNA sequence amplification. These primers are found to amplify sequences from Crenarchaeote and Euryarchaeote type strains and environmental DNA.

Characterization of the metabolic burden onEscherichia coli DH1 cells imposed by the presence of a plasmid containing a gene therapy sequence

The presence of a plasmid, containing gene sequences for DNA immunotherapy that are not expressed in microbial culture, imposed a degradation in bioreactor performance in cultures of the host E. coli strain. Significant decreases in growth rate (24%) and biomass yield (7%) and a corresponding increase in overflow metabolism were observed in a strain containing a therapeutic sequence (a hepatitis B antigen under the control of a CMV promotor). The observed increase in overflow metabolism was incorporated into a Metabolic Flux Analysis (MFA) model (as acetate secretion). Metabolic flux analysis revealed an increase in TCA cycle flux, consistent with an increased respiration rate observed in plasmid-containing cells. These effects are thought to result from increased ATP synthesis requirements (24%) arising from the expression of the Kanr plasmid marker gene whose product accounted for 18% of the cell protein of the plasmid-containing strain. These factors will necessitate significantly higher aeration and agitation rates or lower nutrient feed rates in high-density cultures than would be expected for plasmid-free cultures.

Comparison of CT and MRI in the pre-operative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI

OBJECTIVE

It has been suggested that MRI may be used as the sole modality of choice in pre-operative staging in rectal cancers. Knowledge of tumour stage and a threatened Circumferential Resection Margin (CRM) pre-operatively are essential for planning neo-adjuvant therapy and as predictors of local recurrence. At present most units utilize CT scanning to assess these parameters. The aim of our study was two fold: firstly to examine the accuracy of preop CT and MRI staging of rectal cancers compared with final histology and secondly to assess the accuracy of MRI in predicting penetration of the mesorectal envelope (ME).

PATIENTS AND METHODS

All patients with biopsy proven rectal adenocarcinoma underwent thin slice MRI and CT scan pre-operatively. Forty-seven patients have been prospectively entered into the study: 24 male (median age 68 years; range 38-91 years). Eleven patients were unsuitable for surgery leaving 36 patients available for study.

RESULTS

CT correctly staged patients with T1/T2 rectal cancers more often than MRI (77% vs. 43%, P = 0.226). Patients with T1/T2 tumours were overstaged more often by MRI compared with CT (54% vs. 23%, P = 0.226). A greater proportion of patients with T3 tumours were correctly staged by MRI than CT (76% vs. 41%, P = 0.08); and more T3 disease was understaged by CT than MRI (54 vs. 18%, P = 0.032). CT and MRI staged T4 disease equally. In the assessment of mesorectal envelope integrity, MRI had a sensitivity of 80% and a specificity of 84%. The positive predictive value was 44% and the negative predictive value 96%.

CONCLUSIONS

These results suggest significant differences between accurate pre-operative "T" staging by CT and MRI for rectal cancer. MRI has the potential however, to accurately assess mesorectal envelope invasion. Further analysis is required to assess whether MRI can be used as the sole modality in pre-operative staging of rectal cancers.

Randomized controlled trial of four-layer bandaging and simple venous surgery for venous ulceration

Background

No randomized controlled trials exist to show whether simple venous surgery benefits healing or maintenance of healing of venous ulcers.

Methods

Some 121 consecutive patients with new episodes of venous ulceration were identified; 45 patients were unfit or unwilling for randomization. The remaining 76 (39 women) were assigned randomly to received a four-layer bandage (n = 39) or simple venous surgery (n = 37). All patients were followed for a minimum of 6 months. Outcome was assessed at a minimum of 6 months as healing and health-related quality of life (HRQL).

Results

The two groups had similar co-morbidity and pattern of venous incompetence. There were no major complications in either group. The healing rate was 64 per cent (25 of 39) in the conservatively treated group and 68 per cent (25 of 37) in the operated group (P = 0·75, Pearson χ2 test). There was no significant difference between time to ulcer healing in the two treatment groups (log rank statistic = 0·69, P = 0·41). Patterns of venous incompetence did not affect the healing rate. There were no major differences in HRQL between the two groups.

Conclusion

This pilot study suggests that simple venous surgery gives no adjuvant benefit to four-layer bandaging in venous ulceration from the point of view of healing rate and quality of life.

Major colorectal cancer resection should not be denied to the elderly

AIMS

Adjuvant therapy after surgery for colorectal cancer is often denied to the elderly for various reasons. This study was to determine morbidity and mortality risk after surgery in the elderly and whether this is affected by adjuvant therapy.

METHODS

Data were collected prospectively and entered on a database for all patients undergoing resection of colorectal cancer between January 1994 and July 2000. A total of 304 patients were included, 65 aged 80 years and over.

RESULTS

There were 84 deaths, 21 (30%) in the over 80s, and 63 (26%) in the under 80s (P=0.51). The 'in-hospital' mortality was 10.1% in the over 80s and 3.8% in the under 80s (P=0.056). In the over 80s the colon was more affected than the rectum (P=0.002). The over 80s were less likely to be offered adjuvant therapy, 7.2% vs 42.1% (P<0.001). The 5 year survival (all-cause mortality) in the over 80s was 58.5% and 47.6% in the under 80s (P=0.25). Cox's regression analysis of all patients identified the following factors to be independently related to overall survival: age>80 years, post-operative leak, increasing Dukes stage and distant recurrence of disease.

CONCLUSION

This study has demonstrated that surgery should not be denied to elderly patients with colorectal cancer as despite a higher post-operative morbidity and mortality rate and with the absence of adjuvant therapy, favourable long-term outcome can be achieved by resectional surgery alone.

Is acute type A aortic dissection a true surgical emergency?

Untreated acute aortic dissection involving the ascending aorta (type A) is associated with a high early mortality owing to rupture. Despite advancements in surgical technique and critical care, early mortality remains high. Operative mortality may be related to the technical challenges associated with intervening on the acutely dissected aorta as well as the multiorgan insult it induces. In this article, we review our approach to acute type A aortic dissection with regard to diagnosis, initial medical management, surgical repair, and timing of repair.

The effect of aortic dissection on outcome in descending thoracic and thoracoabdominal aortic aneurysm repair

It is estimated that 20% to 40% of the patients who survive the acute phase of aortic dissection will develop significant aneurysmal dilatation of the descending thoracic or thoracoabdominal aorta. Aortic dissection has long been considered a risk factor for mortality and neurologic deficit following surgical repair of the descending thoracic and/or thoracoabdominal aorta. In this article we review the surgical approach to patients with aortic dissection and thoracoabdominal aortic aneurysms and discuss the impact of adjuncts on survival and neurologic outcome.