Nine-year single-center experience with nonparastic liver cysts: diagnosis and management

This study presents the experience with laparoscopic deroofing of nonparasitic liver cysts at a single center over a 9-year period. A total of 25 patients, undergoing 32 operations, were identified. Median cyst diameter was 10 cm for de novo cysts and 9.5 cm for recurrent cysts. Six patients had multiple cysts consistent with polycystic liver disease. In total, there were 26 laparoscopic procedures and 2 open conversions. Four procedures were commenced as open, three of which were for recurrent cysts. Minor complications were bleeding from a port site (n=1), pneumothorax (n=2), and intra-abdominal collection (n=1). One major complication of bile leak and relaparotomy occurred following an open deroofing. No major complications were recorded for laparoscopic procedures. Symptomatic recurrence of cysts occurred in four patients with simple cysts (5%) and one patient with polycystic liver disease. We conclude that laparoscopic liver cyst deroofing is an effective method of dealing with symptomatic nonparasitic liver cysts.

Prospective comparison of POSSUM and P-POSSUM with clinical assessment of mortality following emergency surgery

BACKGROUND

Tools to accurately estimate the risk of death following emergency surgery are useful adjuncts to informed consent and clinical decisions. This prospective study compared the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) scoring systems with clinical judgement in predicting mortality from emergency surgery.

METHODS

Data were collected prospectively from 163 patients. Details of the physiological and operative severity scores were recorded for POSSUM and P-POSSUM. The estimates of both the surgeon and anaesthetist for 30-day and in-hospital mortality were also recorded pre-operatively. The accuracies of the four predictions were then compared with actual mortalities using linear and exponential analysis and receiver operator characteristics (ROC).

RESULTS

P-POSSUM gave the most accurate prediction of 30-day mortality using linear analysis [observed to expected ratio (O : E) = 1.0]. POSSUM gave the most accurate prediction using exponential analysis (O : E = 1.15). Clinical judgement of mortality from both operating surgeons and anaesthetists compared favourably with the scoring systems for 30-day mortality (O : E = 0.83 and O : E = 0.93, respectively). ROC analyses showed both clinical judgement and the POSSUM scores to be good predictors of 30-day mortality with area under the curve values (AUC) of 0.903, 0.907, 0.946 and 0.940 for surgeons, anaesthetists, POSSUM and P-POSSUM respectively.

CONCLUSIONS

POSSUM and P-POSSUM appear to be useful indicators for the prediction of mortality. Clinical judgement compares strongly with scoring systems in predicting post-operative mortality, but may underestimate mortality in very high-risk patients with more than 90% mortality.

Molecular prognostic markers in resectable colorectal liver metastases: A systematic review

BACKGROUND

Determination of prognosis in patients with resectable colorectal liver metastases (CLM) is desirable in order to improve case selection for surgery and tailor adjuvant treatment according to individual recurrence risk. Conventional clinicopathological factors lack the sensitivity to accurately achieve this goal. Consideration of tumour biology and the identification of molecular prognostic markers may allow more accurate risk stratification.

METHOD

This systematic review examines evidence from published manuscripts looking at molecular markers in resectable colorectal liver metastases and their correlation with disease recurrence and survival following hepatectomy.

RESULTS

Studies have yielded promising results in the search for prognostic molecular markers of CLM. Molecular biomarkers from varied aspects of tumour biology have been examined and a number of these, including proliferation indices, telomerase, thymidylate synthase, microvessel density and thrombospondin-1 appear to have prognostic utility in this context. Validation of other markers, notably p53, has been limited by a failure of methodologies to account for their biological complexity.

CONCLUSIONS

A biomarker-based approach may yield significant benefits through informed treatment of resectable metastatic colorectal malignancy. Standardised retrospective analyses are necessary to confirm preliminary findings and identify existing and novel markers for inclusion into prospective studies. Assessment and verification of multiple molecular markers in this manner may allow molecular profiling of metastases and tailoring of therapy according to the biological aggressiveness of individual tumours. The advent of genomic- and proteomic-based technologies will allow the simultaneous analysis of multiple molecular markers and the derivation of disease profiles associated with disease recurrence and poor survival.

Chemoprevention of pancreatic cancer: a review of the molecular pathways involved, and evidence for the potential for chemoprevention

BACKGROUND

Pancreatic cancer has a poor prognosis. The use of drugs or natural agents which inhibit or slow down tumour growth therefore has important potential in the development of future therapies.

METHODS

A literature search of the PubMed and ISI Web of Science databases was undertaken to review the current data available on the alterations in signalling pathways found in pancreatic carcinogenesis, in order to identify sites that could be targeted by chemopreventive agents. Several agents of particular relevance to pancreatic cancer were identified, and their possible mechanisms of action reviewed.

RESULTS

Chemopreventive agents such as non-steroidal anti-inflammatory drugs, green tea constituents, and antioxidants have been shown to target various steps in intracellular signalling pathways, particularly those controlling cell proliferation and survival. Work on cell lines and animal models has shown that some of these agents may be able to modulate the growth of pancreatic tumours. Initial clinical trials of some chemopreventives in pancreatic cancer have been undertaken, and have yielded mixed results, prompting the need for further studies.

CONCLUSION

As the molecular pathology of pancreatic cancer becomes better understood, sites of action of chemopreventive substances have been uncovered. Several agents have shown promising results by their ability to inhibit pancreatic carcinogenesis in laboratory studies. If these effects can be successfully translated into human studies then these agents may prove to be valuable adjuvant therapies in the future.

Early warning scores predict outcome in acute pancreatitis

The Early Warning Score (EWS) is a widely used general scoring system to monitor patient progress with a varying score of 0-20 in critically unwell patients. This study evaluated the EWS system compared with other established scoring systems in patients with acute pancreatitis. EWS scores were compared with APACHE scores, Imrie scores, computed tomography grading scores, and Ranson criteria for 110 admissions with acute pancreatitis. A favorable outcome was considered to be survival without intensive therapy unit admission or surgery. Nonsurvivors, necrosectomy, and critical care admission were considered adverse outcomes. EWS was the best predictor of adverse outcome in the first 24 hours of admission (receiver operating curve, 0.768). The most accurate predictor of mortality overall was EWS on day 3 of admission (receiver operating curve, 0.920). EWS correlated with duration of intensive therapy unit stay and number of ventilated days (P < 0.05) and selected those who went on to develop pancreas-specific complications such as pseudocyst or ascites. EWS of 3 or above is an indicator of adverse outcome in patients with acute pancreatitis. EWS can accurately and reliably select both patients with severe acute pancreatitis and those at risk of local complications.

Migration of endoscopic biliary stent and small bowel perforation within an incisional hernia

Long-term complications from biliary stents, such as migration and perforation, are unusual but may occur. Distal perforations most commonly involve the colon or distal ileum. This report describes the case of a perforated small bowel, secondary to a stent trapped within an incisional hernia. Patients with comorbid abdominal pathologies, including colonic diverticulae or abdominal herniae, may be at increased risk of perforation from migrated stents.

Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases

INTRODUCTION

Colovesical fistulae are well-recognized but relatively uncommon presentation to colorectal surgery. As a result, few centres have sufficient experience in the investigation and surgical treatment of colovesical fistulae to develop clear protocols in its management.

METHODS

This study examines the diagnostic and treatment pathways of 90 consecutive patients with colovesical fistulae presenting to a single surgeon, over a six-year period. Using the findings from this study and previously published data, the authors suggest tentative guidelines for the diagnosis and management of such patients.

RESULTS

Pneumaturia and faecaluria were present in 90.1% of all cases. The diagnosis of colovesical fistula is predominately a clinical one, however, cystoscopy was the most accurate test to detect fistulae (46.2%) followed by barium enema (20.1%). Barium enema was the most sensitive test to detect stricture formation (70.6%). Colonic endoscopy was the most reliable means of excluding a colonic malignancy. The most common pathology was diverticular disease (72.2%), colonic carcinoma (15.3%) and Crohn's disease (9.7%). Left sided colonic resections were undertaken in 73.6% of patients, right hemicolectomy in 4.2% and defunctioning loop colostomies in 18.5%. Of the left sided resections, primary anastomosis was achieved in 92% of cases (n = 48) with one postoperative leak and no mortality.

DISCUSSION

Resection and primary anastomosis should be the treatment of choice for colovesical fistulae, with an acceptable risk of anastomotic leak and mortality. Barium enema, colonic endoscopy and CT should be routine in the investigation of colovesical fistulae.

Pilot study of oral silibinin, a putative chemopreventive agent, in colorectal cancer patients: silibinin levels in plasma, colorectum, and liver and their pharmacodynamic consequences

Silibinin, a flavonolignan from milk thistle, has intestinal cancer chemopreventive efficacy in rodents. It is a strong antioxidant and modulates the insulin-like growth factor (IGF) system by increasing circulating levels of IGF-binding protein 3 (IGFBP-3) and decreasing levels of IGF-I. Here, the hypothesis was tested that administration of oral silibinin generates agent levels in human blood and colorectal and hepatic tissues consistent with pharmacologic activity. Patients with confirmed colorectal adenocarcinoma received silibinin formulated with phosphatidylcholine (silipide) at dosages of 360, 720, or 1,440 mg silibinin daily for 7 days. Blood and biopsy samples of normal and malignant colorectum or liver were obtained before dosing, and blood and colorectal or hepatic tissues were collected at resection surgery after the final silipide dose. Levels of silibinin were quantified by high-pressure liquid chromatography-UV, and plasma metabolites were identified by liquid chromatography-mass spectrometry. Blood levels of IGFBP-3, IGF-I, and the oxidative DNA damage pyrimidopurinone adduct of deoxyguanosine (M1dG) were determined. Repeated administration of silipide was safe and achieved levels of silibinin of 0.3 to 4 micromol/L in the plasma, 0.3 to 2.5 nmol/g tissue in the liver, and 20 to 141 nmol/g tissue in colorectal tissue. Silibinin monoglucuronide, silibinin diglucuronide, silibinin monosulfate, and silibinin glucuronide sulfate were identified in the plasma. Intervention with silipide did not affect circulating levels of IGFBP-3, IGF-I, or M1dG. The high silibinin levels achieved in the human colorectal mucosa after consumption of safe silibinin doses support its further exploration as a potential human colorectal cancer chemopreventive agent.

Oxidative stress in humans following the Pringle manoeuvre

BACKGROUND

Oxidative stress is induced in the liver by application of the Pringle manoeuvre. Malondialdehyde is a carbonyl compound formed during lipid peroxidation and prostaglandin biosynthesis, which combines with DNA to form a number of adducts. Among them is the DNA adduct; 3-(2-deoxybeta-dierythropentafuranosyl) pyr [1, 2-alpha]-purin-10 (3H) one or M1G. This study was undertaken to determine the suitability of M1G as a novel marker of ischemia-reperfusion injury in the liver and its correlation with both the length of Pringle clamp application and the overall length of the operation.

METHODS

Normal and colorectal liver metastatic tissues were obtained in 12 patients before and after application of the Pringle manoeuvre. All samples were snap-frozen in liquid nitrogen at -80 degree centigrade. DNA was extracted and M1G quantification was performed by immunoslotblot analysis.

RESULTS

M1G levels in normal liver tissue were 4.0+/-1.0 per 10(7) nucleotides before the Pringle manoeuvre and 7.4 +/-1.0 per 10(7) nucleotides after the Pringle manoeuvre (mean+/-standard deviation) (P<0.05 by ANOVA). M1G levels in malignant liver tissue were 2.5+/-1.4 per 10(7) nucleotides before the Pringle manoeuvre and 6.5+/-1.9 adducts per 10(7) nucleotides after the Pringle manoeuvre (P<0.05). Adduct levels in normal liver tissue showed a significant correlation with cumulative period of Pringle application.

CONCLUSIONS

This is the first time that the tissue levels of M1G before and after application of the Pringle manoeuvre have been studied. The results show that the Pringle manoeuvre exerts significant oxidative stress in human hepatocytes, which is Pringle-time dependent. The results highlight the potential for oxidative DNA adducts levels as a tool for measuring the severity of ischemia-reperfusion injury.

Clinical aspects of natural anti-angiogenic drugs

Natural products represent a rich resource for drug delivery and are currently being exploited to target tumour angiogenesis. A vast array of products of natural origin have been shown to have anti-angiogenic potential in preclinical models, including purified endogenous inhibitors, and exogenous compounds derived from varied species of plant, animal and micro-organism. Over a dozen of these agents have now entered clinical trial. This review discusses evidence for the efficacy of this drug class and key issues in the translation of pre-clinical results into the development of efficacious drugs for clinical use.

Women presenting with lower abdominal pain: A missed opportunity for chlamydia screening?

INTRODUCTION

Many young women presenting with lower abdominal pain are referred to general surgeons with possible appendicitis. For some of these patients there will be a gynaecological cause for their pain. There has been a steady increase in the incidence of Chlamydia infections and pelvic inflammatory disease (PID) among the general population. Therefore, are general surgeons considering this as a diagnosis for lower abdominal pain in women?

METHODS

One hundred and ninety three women who had been admitted with lower abdominal pain to a single hospital between 1999 and 2001 were identified using computerised records and the notes were examined. One hundred and eighty six women were included in the audit. Investigations and treatments instigated for these patients were then carefully recorded.

RESULTS

Seventy-four patients underwent appendicectomy, of which 59 were histologically confirmed. Eighty-nine patients (47.8%) of admissions had no final diagnosis and were not screened for Chlamydia trachomatis. Sexual history was recorded in only 51% of admissions. Vaginal swabs were sent in only 7.3% of admissions.

CONCLUSION

Current guidelines for Chlamydia trachomatis screening produced by the Chief Medical Officer (CMO) include screening in women presenting with lower abdominal pain as well as those with post-coital or intermenstrual bleeding. Most women who present with classical symptoms of PID will present to gynaecological specialities for further management. However, a significant number of women presenting atypically will be referred to surgeons to exclude gastrointestinal causes for their lower abdominal pain. These women could and probably should be screened for Chlamydia trachomatis.

Dietary polyphenolic phytochemicals—promising cancer chemopreventive agents in humans? A review of their clinical properties

Epidemiological and preclinical evidence suggests that polyphenolic phytochemicals exemplified by epigallocatechin gallate from tea, curcumin from curry and soya isoflavones possess cancer chemopreventive properties. Whilst such naturally occurring polyphenols have been the subject of numerous mechanistic studies in cells, information on their clinical properties, which might help assess their promise as human cancer chemopreventive agents, is scarce. Therefore, we present a review of pilot studies and trials with a cancer chemoprevention-related rationale, in which either healthy individuals or patients with premalignant conditions or cancer received polyphenolic phytochemicals. The review identifies trial design elements specifically applicable to polyphenolic phytochemicals. The available evidence for tea polyphenols tentatively supports their advancement into phase III clinical intervention trials aimed at the prevention of progression of prostate intraepithelial neoplasia, leukoplakia or premalignant cervical disease. In the case of curcumin and soya isoflavones more studies in premalignacies seem appropriate to optimise the nature and design of suitable phase III trials. The abundance of flavonoids and related polyphenols in the plant kingdom makes it possible that several hitherto uncharacterised agents with chemopreventive efficacy are still to be identified, which may constitute attractive alternatives to currently used chemopreventive drugs.

Percutaneous splanchnic nerve radiofrequency ablation for chronic abdominal pain

BACKGROUND

Splanchnic nerve block is a useful alternative to coeliac plexus block in the management of patients with chronic upper abdominal pain. The predictable relationship of the splanchnic nerves to other structures allows for accurate needle placement and hence a low risk of iatrogenic damage. Radiofrequency ablation (RFA) uses a high frequency alternating current to heat tissues leading to thermal coagulation. It produces predictable and accurate lesions and hence is useful alternative to more conventional phenol and alcohol neurolytic methods.

METHODS

The present study examined a series of 10 patients undergoing percutaneous RFA splanchnic nerve blockade for chronic pancreatitis. Pain levels, anxiety, quality of life, daily activity, mood and interpersonal relationships were all assessed pre- and postprocedure, using a visual analogue score. Median follow-up was 18 months (range: 12-24 months). Statistical analysis was undertaken using non-parametric Wilcoxon matched pair analysis, statistical significance was set at the 95% confidence intervals.

RESULTS

Splanchnic nerve RFA not only led to a decrease in pain scores, opiate analgesia use and acute admissions for pain; but it also resulted in improvement of other parameters associated with long-term debilitating chronic pain, such as anxiety levels, daily activity, overall mood and general perception of health. There were no major complications. All changes observed were statistically significant.

CONCLUSION

Although preliminary data regarding RFA ablation of splanchnic nerves are encouraging, further trials are also needed comparing percutaneous splanchnic nerve ablation with opioid analgesia and coeliac plexus blockade.

Expression of thrombospondin-1 in resected colorectal liver metastases predicts poor prognosis

PURPOSE

The aim of this study was to examine the expression and prognostic relevance of thrombospondin-1 (TSP-1) in tumor biopsies taken from a consecutive series of liver resections done at the University Hospitals of Leicester and the Royal Liverpool Hospital.

EXPERIMENTAL DESIGN

Patients having undergone a liver resection for colorectal liver metastases at our institutions between 1993 and 1999 inclusive were eligible. Inclusion criteria were curative intent, sufficient tumor biopsy, and patient follow-up data. One hundred eighty-two patients were considered in this study. Standard immunohistochemical techniques were used to study the expression of TSP-1 in 5-microm tumor sections from paraffin-embedded tissue blocks. TSP-1 was correlated with survival using the Kaplan-Meier method and log-rank test for univariate analysis and the Cox proportional hazard model for multivariate analysis.

RESULTS

One hundred eighty-two patients (male, n = 122 and female, n = 60) ages between 25 and 81 years (mean, 61 years) were included. TSP-1 was expressed around blood vessels (n = 45, 25%) or in the stroma (n = 59, 33%). No expression was detected in the remaining tumors. TSP-1 significantly correlated with poor survival on univariate (P = 0.01 for perivascular expression and P = 0.03 for stromal expression) and multivariate analysis (P = 0.01 for perivascular expression).

CONCLUSION

TSP-1 is a negatively prognostic factor for survival in resected colorectal liver metastases.

Molecular prognostic markers in pancreatic cancer: a systematic review

Pancreatic cancer is one of the most lethal tumours of the gastrointestinal tract. The ability to predict which patients would benefit most from surgical intervention and/or chemotherapy would be a great clinical asset. Considerable research has focused on identifying molecular events in pancreatic carcinogenesis, and their correlation with clinicopathological variables of pancreatic tumours and survival. This systematic review examined evidence from published manuscripts looking at molecular markers in pancreatic cancer and their correlation with tumour stage and grade, response to chemotherapy and long-term survival. A literature search was undertaken using PubMed and MEDLINE search engines, using the keywords p53, p21, p16, p27, SMAD4, K-ras, cyclin D1, Bax, Bcl-2, EGFR, EGF, c-erbB2, HB-EGF, TGFbeta, FGF, MMP, uPA, cathepsin, heparanase, E-cadherin, laminins, integrins, TMSF, CD44, cytokines, angiogenesis, VEGF, IL-8, beta-catenin, DNA microarray, and gene profiling. A bewildering number of biomarkers are currently under evaluation. For the most part, the evidence regarding their application as prognostic indicators is conflicting. The advent of gene microarray and mass spectrometric protein profiling offers the potential to examine many different biomarkers simultaneously. This 'protein/gene signature' could revolutionise work in this field and allow researchers to develop accurate and reproducible predictions of survival based on protein or gene profiles.

Acute colonic pseudo-obstruction following major orthopaedic surgery

OBJECTIVE

Acute colonic pseudo-obstruction (ACPO) has been linked with multiple aetiologies including orthopaedic surgery. However, the actual incidence and natural progression are not well described in these patients. We aim to assess the incidence of ACPO in patients undergoing elective orthopaedic procedures, and to examine for potential exacerbating factors.

PATIENTS AND METHODS

All patients from the orthopaedic directorate that had abdominal imaging in the five years from August 1998 to August 2003 were identified from radiology archives. A manual search of the patients' notes was conducted with data recorded on the patients' history, operative details and their postoperative course including their haematological and biochemical results. Details regarding their ACPO were documented with respect to the onset of symptoms, how the diagnosis was achieved, what treatment was instigated and how the condition progressed. A control group of age and sex matched patients was included for comparison.

RESULTS

Thirty-five patients with ACPO were identified. The operations included 21 hip replacements, 10 knee replacements and 4 spinal operations. The incidence of ACPO was 1.3%, 0.65% and 1.19%, respectively. In comparison to control patients, patients with ACPO had a lower postoperative serum sodium (P = 0.001), a higher serum urea (P = 0.021) and remained in hospital longer (P < 0.001).

CONCLUSION

ACPO is uncommon in orthopaedic patients, however, its occurrence results in prolonged hospital stay. Attention to patients' postoperative fluid balance and biochemical status may reduce the incidence.

Role of inflammation in pancreatic carcinogenesis and the implications for future therapy

BACKGROUND

The link between inflammation and pancreatic cancer has been observed for a number of gastrointestinal neoplasms. This review examines the role of inflammation in pancreatic carcinogenesis and how it can be utilised to develop new therapies against pancreatic cancer.

METHODS

A literature review of Pubmed, Medline and Web of Science databases was undertaken using the key words, pancreatic cancer, inflammation, inducible nitric oxide, interleukins, pro-inflammatory cytokines, cyclooxygenase-2, NF-kappa B, reactive oxygen species, DNA adducts, lipoxygenases, chemoprevention.

RESULTS

Epidemiological evidence and molecular studies both in vitro and in vivo all support the hypothesis that inflammation plays an important in the initiation and progression of pancreatic tumours.

CONCLUSION

Sustained damage caused by chronic inflammation may precede the onset of frank malignancy by a significant interval. As such, suppression of inflammatory changes and oxidative damage, may help delay or even prevent the inception of pancreatic neoplasia.

Differences in attitudes between patients with primary colorectal cancer and patients with secondary colorectal cancer: is it reflected in their willingness to participate in drug trials?

Recruitment of patients into drug trials is essential in order to evaluate new treatments. Knowing why patients enter drug trials and their fears regarding them can be used in future research to ensure good recruitment and provide a supportive atmosphere for patients. Forty patients with colorectal cancer and 30 patients with colorectal liver metastases were asked to participate in a drug trial involving the oral consumption of a diet-derived agent of unknown therapeutic action. All patients agreeing or refusing to participate were asked to complete a short questionnaire with a series of options detailing the reasons behind their decision. Patients with colorectal hepatic metastases were motivated by altruism in entering the trial (e.g. helping others, helping the investigator) and displayed a realistic expectation that the drug would give little direct benefit to them. Patients with primary colorectal tumours were motivated by more 'selfish' reasons such as helping themselves and displayed an unrealistic expectation concerning any therapeutic benefit from the trial drug. Over 90% of all patients polled stated that their decision was made after reading the patient information leaflet. Patients with different stages of the same disease have very different fears and anticipations of drug trials, which need to be addressed specifically. The importance of the initial contact is demonstrated. Unrealistic expectations regarding the trial drug are common despite clear information to the contrary.

The introduction of a nutrition clinical nurse specialist results in a reduction in the rate of catheter sepsis

BACKGROUND

Catheter-related sepsis remains the major confounding factor in the long-term delivery of TPN. Previous studies have shown that the introduction of clinical nurse specialists (CNS) can lead to a reduction in sepsis from TPN catheters. This retrospective study aimed to determine the impact of a nutrition CNS on the rate of catheter-related sepsis. Furthermore, the cost of providing such a service was examined to see if it was offset from the savings obtained from reducing venous access infection.

METHODS

Prior to the employment of a nutrition CNS, the total number of septic catheter complications were retrospectively collected over a 12-month period. Following appointment of the CNS, all patients requiring TPN were prospectively studied for signs of catheter-related sepsis and the data collected over a 4-year period.

RESULTS

The overall sepsis rate (cumulative percentage) fell significantly in the 4-year period after the nutrition CNS was appointed, from 52% to 2.3%. The reduction in venous catheter access was accompanied by a decrease in cost related to wastage of TPN and insertion of new Hickman lines.

CONCLUSION

The role of the CNS is primarily to improve the quality of care provided, but also to provide cost effectiveness. We have demonstrated that in addition to reducing infection rate of central venous catheters; the cost of employing a nutrition CNS is almost completely covered by the savings resulting from the reduction in wasted central venous catheters, TPN and operating time.

Changes in the Wnt signalling pathway in gastrointestinal cancers and their prognostic significance

Many steps in the Wnt signalling pathway may be altered during the process of carcinogenesis. This Review focuses on the changes observed in gastrointestinal cancers. A literature search was undertaken and the currently available data summarised. Understanding the alterations to this signalling pathway may help to reveal future targets for therapeutic agents. In addition, since in some tumours, levels of components of the Wnt pathway have been found to correlate with clinical stage, their potential use as prognostic indicators is highlighted.

Consumption of the putative chemopreventive agent curcumin by cancer patients: assessment of curcumin levels in the colorectum and their pharmacodynamic consequences

Curcumin, a constituent of the spice turmeric, has been shown to reduce the adenoma burden in rodent models of colorectal cancer accompanied by a reduction of levels of the oxidative DNA adduct 3-(2-deoxy-beta-di-erythro-pentafuranosyl)-pyr[1,2-alpha]-purin-10(3H)one (M(1)G) and of expression of the enzyme cyclooxygenase-2 (COX-2). We tested the hypothesis that pharmacologically active levels of curcumin can be achieved in the colorectum of humans as measured by effects on levels of M(1)G and COX-2 protein. Patients with colorectal cancer ingested curcumin capsules (3,600, 1,800, or 450 mg daily) for 7 days. Biopsy samples of normal and malignant colorectal tissue, respectively, were obtained at diagnosis and at 6 to 7 hours after the last dose of curcumin. Blood was taken 1 hour after the last dose of curcumin. Curcumin and its metabolites were detected and quantitated by high-performance liquid chromatography with detection by UV spectrophotometry or mass spectrometry. M(1)G levels and COX-2 protein expression were measured by immunoslot blot and Western blotting, respectively. The concentrations of curcumin in normal and malignant colorectal tissue of patients receiving 3,600 mg of curcumin were 12.7 +/- 5.7 and 7.7 +/- 1.8 nmol/g, respectively. Curcumin sulfate and curcumin glucuronide were identified in the tissue of these patients. Trace levels of curcumin were found in the peripheral circulation. M(1)G levels were 2.5-fold higher in malignant tissue as compared with normal tissue (P < 0.05 by ANOVA). Administration of curcumin (3,600 mg) decreased M(1)G levels from 4.8 +/- 2.9 adducts per 107 nucleotides in malignant colorectal tissue to 2.0 +/- 1.8 adducts per 107 nucleotides (P < 0.05 by ANOVA). COX-2 protein levels in malignant colorectal tissue were not affected by curcumin. The results suggest that a daily dose of 3.6 g curcumin achieves pharmacologically efficacious levels in the colorectum with negligible distribution of curcumin outside the gut.

Patient information following emergency laparoscopy for right iliac fossa pain

Laparoscopy is increasingly used as a diagnostic and therapeutic tool in the management of emergency surgical admissions. Laparoscopic scars give little clue to the operation performed. Hence, the future assessment of patients re-admitted with abdominal pain, often needs to rely on the patient's own account of the operation performed. This study attempted to evaluate the quality of communication between surgeons and patients regarding the results of their laparoscopy and how much information was retained by the patients on discharge. Seventy-seven patients were identified from computerised medical records. A detailed case note review was undertaken looking at operative findings, procedure performed, and documentation of surgeon-to-patient communication. A questionnaire was posted to patients asking their opinion regarding the quality of communication from surgeons. The questionnaire asked specific questions regarding the patient's understanding of the operation performed and its findings. Overall communication between surgeons and patients was good. However, a small proportion of patients were unsure of their diagnosis and what therapeutic procedure had been performed following laparoscopy. This included one patient (out of 28 who had undergone laparoscopic appendectomy) who was unsure if their appendix had been removed. Two from 12 patients diagnosed with pelvic pathology at laparoscopy who were unclear of their diagnosis and two patients with histologically normal appendices who thought their appendices had been inflamed at removal. Greater effort must be made to inform patients of their laparoscopic findings and any therapeutic procedure performed. We recommend the use of written information leaflets to be sent to the patient's home address to ensure that all patients are fully aware of their laparoscopic findings. For any future emergency admission, the patient's knowledge of any previous surgery and whether their appendix is in situ is of considerable diagnostic value to the assessing clinician. More effort must be made to enable patients to retain such necessary information.

Impact of a critical care outreach team on critical care readmissions and mortality

AIMS

The aim of a critical care outreach team is to facilitate discharges from critical care beds, educate ward staff in the management of deteriorating patients, facilitate transfer to critical care and reduce readmission rates to critical care. Although intuitively a good idea, there are few data to support outreach in terms of reducing the readmission rate to critical care and subsequent patient mortality. This retrospective observational study attempted to determine the change in the critical care readmission rate, an indicator of the quality of critical care, critical care mortality and in-hospital mortality following the introduction of a critical care outreach team in a major teaching hospital.

METHODS

A retrospective review of 1380 discharges from critical care was undertaken and the readmissions identified (n = 176). Readmission rate, mortality and other demographic data were compared between the pre and post-outreach periods.

RESULTS

Critical care mortality, in-hospital mortality and 30-day mortality were all reduced in the post-outreach period amongst readmissions to critical care. There was also a decease in the overall mortality of all patients admitted to critical care. There were no apparent causative factors for this reduction in mortality before and following outreach.

CONCLUSIONS

There are many confounding factors in assessing the impact of outreach teams in hospitals. This study tentatively concludes that outreach teams may have a favourable impact on mortality rate amongst readmissions to critical care, but more data is needed from multicentre trials.

Two-stage liver resection and chemotherapy for bilobar colorectal liver metastases

BACKGROUND

A significant number of patients with colorectal metastatic disease confined to the liver are inoperable at assessment. For these patients, the outlook is poor. Chemotherapy can 'down-stage' some tumours and render them operable. The authors present a series of patients with inoperable disease despite down-staging with chemotherapy, who underwent a two-stage resection to clear their metastatic disease.

METHODS

The case-notes of 11 patients who were found to have inoperable hepatic metastatic disease were identified using computerised medical records and mean hospital stay, survival and long-term follow-up data was noted.

RESULTS

The mean follow-up from initial resection was 13.5 months (range of 5-20 months). Three deaths were recorded in the follow-up interval. Causes of death included recurrence of hepatic disease following completion of two-stage resection, progression of original hepatic disease leading to inoperability at second stage operation and recurrence of original primary colorectal tumour. The mean survival in the patients who died was 17 months (range of 15-19 months). The remaining patients are alive to date with six patients showing no evidence of hepatic recurrence, follow-up period of 13 months (range of 8-20 months). One patient developed de novo prostate cancer and is awaiting his second liver resection, and one patient has stable hepatic disease with no evidence of progression.

CONCLUSION

Two-stage liver resection can prolong survival when compared to chemotherapy alone, with a recurrence rate equivalent to ablation techniques. Longer-term studies are needed for further evaluation.