The impact of psychiatric comorbidities on emergency general surgical patients' outcomes

BACKGROUND

Psychiatric disorders are increasingly prevalent. Studies have demonstrated that the presence of comorbid psychiatric conditions (CPC) is associated with a number of worsening outcomes in hospitalised patients in general. The relationship between a wide range of psychiatric comorbidities and acute surgical presentations has not been studied to date.

STUDY DESIGN

The Hospital In-Patient Enquiry (HIPE) system and prospectively maintained eHandover were used to identify all surgical emergency admissions to Mayo University Hospital, Ireland. Patient demographics, comorbidities, primary diagnoses, length of stay (LoS), and procedures undergone were recorded over a 12-months period. Subgroup analyses examining LoS variation in surgical presentation types were performed.

RESULTS

1028 admissions occurred over this one year period, amongst 995 patients, the presence of psychiatric comorbidities increased the mean LoS by 1.9 days (p = 0.002). Comorbid depression, dementia, and intellectual disability conferred a significant increase in LoS by 2.4 days, 2.8 days and 6.7 days respectively. Subgroup analysis revealed greater LoS in patients with CPC diagnosed with non-specific abdominal pain (1.4 days, p = 0.019), skin and soft tissue infections (2.5 days, p = 0.040), bowel obstruction (4.3 days, p = 0.047), and medical disorders (18.6 days, p = 0.010). No significant difference was observed in mortality and readmission rates.

CONCLUSION

Psychiatric comorbidities significantly impact length of hospital stay and discharge planning in surgical inpatients. Greater awareness of this can facilitate better care delivery for this population to reduce the LoS and subsequent economic burden on the healthcare system.

Evaluating the Necessity for Routine Sentinel Lymph Node Biopsy in Postmenopausal Patients Being Treated for Clinically Node Negative Breast Cancer the Era of RxPONDER

INTRODUCTION

Traditionally, sentinel lymph node biopsy (SLNB) was performed to inform adjuvant chemotherapy prescription and prognosis in breast cancer. Following RxPONDER, the OncotypeDX Recurrence Score (RS) guides adjuvant chemotherapy prescription for all postmenopausal patients with estrogen receptor positive, human epidermal growth factor receptor-2 negative (ER+/HER2-) breast cancer with 0 to 3 positive lymph nodes (0-3 + LN).

AIMS

To establish the oncological safety of omitting SLNB in postmenopausal patients with ER+/HER2- breast cancer indicated to undergo SLNB and to evaluate the primary determinants of chemotherapy prescription for these patients.

PATIENTS AND METHODS

A retrospective cohort study was undertaken. Cox regression and Kaplan-Meier analyses were performed. Data analytics was performed using SPSS v26.0.

RESULTS

Five hundred and seventy five consecutive patients were included (mean age: 66.5 years, range: 45-96). The median follow-up was 97.2 months (range: 3.0-181.6). Of the 575 patients, just 12 patients had positive SLNB (SLNB+) (2.1%). Using Kaplan-Meier analyses, SLNB+ failed to impact recurrence (P = .766) or mortality (P = .310). However, using Cox regression analyses, SLNB+ independently predicted poorer disease-free survival (hazard ratio: 1.001, 95% confidence interval (95% CI): 1.000-1.001, P = .029). Logistic regression analysis identified RS as the sole predictor of chemotherapy prescription (odds ratio: 1.171, 95% CI: 1.097-1.250, P < .001).

CONCLUSION

Omitting SLNB may be safe and justifiable in postmenopausal patients with ER+/HER2- breast cancer with clinically negative axillae. Following RxPONDER, RS is the most important guide of chemotherapy use in these patients and SLNB may be less important than previously perceived. Prospective, randomized clinical trials are required to fully establish the oncological safety of omitting SLNB in this setting.

Comparison of the Nottingham Prognostic Index and OncotypeDX© recurrence score in predicting outcome in estrogen receptor positive breast cancer

INTRODUCTION

Traditionally, Nottingham prognostic index (NPI) informed prognosis in patients with estrogen receptor positive, human epidermal growth factor receptor-2 negative, node negative (ER+/HER2-/LN-) breast cancer. At present, OncotypeDX© Recurrence Score (RS) predicts prognosis and response to adjuvant chemotherapy (AC).

AIMS

To compare NPI and RS for estimating prognosis in ER + breast cancer.

METHODS

Consecutive patients with ER+/HER2-/LN- disease were included. Disease-free (DFS) and overall survival (OS) were determined using Kaplan-Meier and Cox regression analyses.

RESULTS

1471 patients met inclusion criteria. The mean follow-up was 110.7months. NPI was calculable for 1382 patients: 19.8% had NPI≤2.4 (291/1471), 33.0% had NPI 2.41-3.4 (486/1471), 30.0% had NPI 3.41-4.4 (441/1471), 10.9% had NPI 4.41-5.4 (160/1471), and 0.3% had NPI>5.4 (4/1471). In total, 329 patients underwent RS (mean RS: 18.7) and 82.1% had RS < 25 (270/329) and 17.9% had RS ≥ 25 (59/329). Using multivariable Cox regression analyses (n = 1382), NPI independently predicted DFS (Hazard ratio (HR): 1.357, 95% confidence interval (CI): 1.140-1.616, P < 0.001) and OS (HR: 1.003, 95% CI: 1.001-1.006, P = 0.024). When performing a focused analysis of those who underwent both NPI and RS (n = 329), neither biomarker predicted DFS or OS. Using Kaplan Meier analyses, NPI category predicted DFS (P = 0.008) and (P = 0.026) OS. Conversely, 21-gene RS group failed to predict DFS (P = 0.187) and OS (P = 0.296).

CONCLUSION

In our focused analysis, neither NPI nor RS predicted survival outcomes. However, in the entire series, NPI independently predicted both DFS and OS. On the 40th anniversary since its derivation, NPI continues to provide accurate prognostication in breast cancer, outperforming RS in the current study.

Breast cancer recurrence: factors impacting occurrence and survival

BACKGROUND

Breast cancer mortality has decreased due to improved screening and treatment options. Nevertheless, 25-30% of patients develop disease recurrence and die from the disease dissemination. Patients who develop metastatic disease represent a heterogeneous group and management plans are dependent on molecular subtype, disease burden and metastatic site.

AIM

To determine predictive clinicopathological factors of disease recurrence and their impact on survival in the molecular era.

METHODS

Consecutive patients who breast cancer developed recurrence at our tertiary referral centre between 2000 and 2015 were included. Clinicopathological and treatment data were assessed using descriptive statistics. Oncological outcome was assessed using Cox regression and Kaplan Meier analyses.

RESULTS

Two hundred sixty-five consecutive patients who developed breast cancer recurrence were included; median age at metastasis was 59.3 years (range 27-87 years), and median time to recurrence (TTR) was 47.7 ± 38.5 months (range 3.0-194.3 months). Survival was 24.2% (64/265) 53.2% were luminal A (LABC) (141/265), 18.5% were luminal B (LBBC) (49/265), 18.5% were triple negative (TNBC) (49/265), and 9.8% were human epidermal growth factor receptor-2 overexpressing (HER2 +) (26/265). TTR for patients with LABC was 56.0 ± 41.3 months, LBBC was 48.4 ± 41.1 months, TNBC was 26.9 ± 28.5 months and HER2 + was 34.3 ± 21.8 months. Increased grade (P < 0.001), Nottingham Prognostic Indices (P < 0.001), TNBC (P < 0.001), HER2 + subtype (P < 0.001) and receiving targeted therapy (P = 0.006) predicted shorted TTR. Estrogen receptor positivity (P < 0.001), progesterone receptor positivity (P = 0.010), invasive lobular carcinoma (P = 0.009) and receiving endocrine therapy (P = 0.001) predicted longer TTR.

CONCLUSION

Readily available clinicopathological factors predict risk of metastatic dissemination. Developing a tailored program to identify patients at risk of recurrence is crucial in controlling metastatic dissemination of breast cancer.

Clinicopathological response to neoadjuvant therapies and pathological complete response as a biomarker of survival in human epidermal growth factor receptor-2 enriched breast cancer - A retrospective cohort study

BACKGROUND

Human epidermal growth factor receptor-2 (HER2) is overexpressed in 20-25% of breast cancers. Complete eradication of disease following neoadjuvant therapies and chemotherapy has been referred to as pathological complete response (pCR).

AIMS

To determine clinicopathological predictors of pCR to neoadjuvant therapies and to evaluate pCR as a surrogate to enhanced survival.

METHODS

Consecutive female patients with HER2 positive (HER+) breast cancer managed surgically in a single institution between 2005 and 2015 were included. Descriptive statistics and binary logistic regression were used to determine predictors of pCR. Appraisal of pCR as a predictor of survival was performed using Kaplan-Meier curves and Cox regression analysis.

RESULTS

451 patients were included with a mean age of 56.6 ± 13.4 years (range 23-95). Disease-free (DFS) and overall survival (OS) was 82.3% (371/451) and 82.6% (376/451) respectively with a median follow-up of 108.0 months (range 3-184.0). 118 were treated in the neoadjuvant setting (26.2%): tumour size <50 mm (Odds Ratio (OR): 12.156, P = 0.023) and progesterone receptor negativity (OR: 2.762, P = 0.008) independently predicted breast pCR, while ductal carcinoma (OR: 3.203, P = 0.030) and grade 3 disease (OR: 2.788, P = 0.018) predicted axillary pCR. Both breast and axillary pCR predicted enhanced DFS (Hazard Ratio (HR): 0.470 & HR: 0.449) and OS (HR: 0.383 & HR: 0.307). Axillary pCR independently predicted improved OS (HR: 0.326).

CONCLUSION

pCR is sensitive biomarker and surrogate to survival outcomes in HER2+ breast cancer. Patients likely to achieve pCR may be predicted from traditional clinicopathological characteristics and molecular parameters.

The impact of progesterone receptor negativity on oncological outcomes in oestrogen-receptor-positive breast cancer

Background

Oestrogen receptor (ER) status provides invaluable prognostic and therapeutic information in breast cancer (BC). When clinical decision making is driven by ER status, the value of progesterone receptor (PgR) status is less certain. The aim of this study was to describe clinicopathological features of ER-positive (ER+)/PgR-negative (PgR-) BC and to determine the effect of PgR negativity in ER+ disease.

Methods

Consecutive female patients with ER+ BC from a single institution were included. Factors associated with PgR- disease were assessed using binary logistic regression. Oncological outcome was assessed using Kaplan–Meier and Cox regression analysis.

Results

In total, 2660 patients were included with a mean(s.d.) age of 59.6(13.3) years (range 21–99 years). Median follow-up was 97.2 months (range 3.0–181.2). Some 2208 cases were PgR+ (83.0 per cent) and 452 were PgR- (17.0 per cent). Being postmenopausal (odds ratio (OR) 1.66, 95 per cent c.i. 1.25 to 2.20, P < 0.001), presenting with symptoms (OR 1.71, 95 per cent c.i. 1.30 to 2.25, P < 0.001), ductal subtype (OR 1.51, 95 per cent c.i. 1.17 to 1.97, P = 0.002) and grade 3 tumours (OR 2.20, 95 per cent c.i. 1.68 to 2.87, P < 0.001) were all associated with PgR negativity. In those receiving neoadjuvant chemotherapy (308 patients), pathological complete response rates were 10.1 per cent (25 of 247 patients) in patients with PgR+ disease versus 18.0 per cent in PgR- disease (11 of 61) (P = 0.050). PgR negativity independently predicted worse disease-free (hazard ratio (HR) 1.632, 95 per cent c.i. 1.209 to 2.204, P = 0.001) and overall survival (HR 1.774, 95 per cent c.i. 1.324 to 2.375, P < 0.001), as well as worse overall survival in ER+/HER2- disease (P = 0.004).

Conclusions

In ER+ disease, PgR- tumours have more aggressive clinicopathological features and worse oncological outcomes. Neoadjuvant and adjuvant therapeutic strategies should be tailored according to PgR status.

Clinical utility of the 21-gene assay in predicting response to neoadjuvant endocrine therapy in breast cancer: A systematic review and meta-analysis

INTRODUCTION

OncotypeDX© Recurrence Score (RS) is a multigene panel used to aid therapeutic decision making in early-stage, estrogen receptor positive (ER+)/human epidermal growth factor receptor-2 negative (HER2-) breast cancer.

AIM

To compare responses to neoadjuvant endocrine therapy (NET) in patients with ER+/HER2-breast cancer following substratification by RS testing.

METHODS

This systematic review was performed in accordance to the PRISMA guidelines. Studies evaluating pathological complete response (pCR), partial response (PR), and successful conversion to breast conservation surgery (BCS) rates following NET guided by RS were retrieved. Dichotomous outcomes were reported as odds ratios (ORs) with 95% confidence intervals (CIs) following estimation by Mantel-Haenszel method.

RESULTS

Eight prospective studies involving 691 patients were included. The mean age was 62.6 years (range 25-85) and the mean RS was 14.5 (range 0-68). Patients with RS < 25 (OR: 4.60, 95% CI: 2.53-8.37, P < 0.001) and RS < 30 (OR: 3.40, 95% CI: 1.96-5.91, P < 0.001) were more likely to achieve PR than their counterparts. NET prescription failed to increase BCS conversion rates for patients with RS < 18 (OR: 0.23, 95% CI: 0.04-1.47, P = 0.120) and RS > 30 (OR: 1.27, 95% CI: 0.64-2.49, P = 0.490) respectively. Only 22 patients achieved pCR (2.8%) and RS group failed to predict pCR following NET (P = 0.850).

CONCLUSION

Estimations from this analysis indicate that those with low-intermediate RS on core biopsy are four times more likely to respond to NET than those with high-risk RS. Performing RS testing on diagnostic biopsy may be useful in guiding NET prescription.

Clinicopathological correlates, oncological impact, and validation of Oncotype DX™ in a European Tertiary Referral Centre

Oncotype DX™ (ODX) score estimates prognosis and predicts breast cancer recurrence. It also individualizes patient adjuvant chemotherapy prescription in breast cancer. This assay relies on genetic and molecular markers; the clinicopathological phenotype of which are tested routinely. The aim of this study was determine whether clinicopathological and immunohistochemical information predicts ODX recurrence score (RS). Secondly, to assess the impact on adjuvant chemotherapy (AC) and oncological outcome of ODX testing in patients in a European tertiary referral center. Estrogen receptor positive (ER+), human epidermal growth factor receptor-2 negative (HER2-), lymph node negative (LN-), and female breast cancer patients with ODX testing performed between 2007 and 2015 were categorized into low- (<11), intermediate- (11-25), and high-risk (>25) groups. Clinicopathological and immunohistochemical correlates of RS were determined. Predictors of RS were assessed using binary logistic regression. Oncological outcome was assessed using Kaplan-Meier and Cox regression analyses. ODX was performed in 400 consecutive ER+LN- patients. Median follow-up was 74.1 months (3.0-144.4). Low grade (odds ratio [OR]:2.39; 95% confidence interval [CI]:1.04-5.51, p = 0.041) independently predicted low ODX, while high grade (OR:2.04; 95% CI: 1.19-3.49, p = 0.009) and reduced progesterone receptor (PgR) expression (OR: 2.57, 95% CI: 1.42-4.65, p = 0.002) independently predicted high ODX. Omission of AC in intermediate- (p = 0.159) and high-risk (p = 0.702) groups did not negatively impact survival. In conclusion, tumor grade independently predicts low and high RS, while PgR negativity predicts high RS. ODX reduced AC prescription without compromising oncological outcome.

Disease recurrence and oncological outcome of patients treated surgically with curative intent for estrogen receptor positive, lymph node negative breast cancer

BACKGROUND

The molecular era has identified four breast cancer subtypes. Luminal A breast cancer (LABC) is defined by estrogen-receptor positive (ER+), progesterone-receptor positive (PgR+) and human epidermal growth factor receptor-2 negative (HER2-) tumours; these cancers are the most common and carry favourable prognoses.

AIMS

To describe clinicopathologic features, oncological outcome and relapse patterns in LABC.

METHODS

Consecutive female patients diagnosed with ER/PgR+/HER2-, lymph node negative (LN-) breast cancer between 2005 and 2015 were included. Clinicopathological and recurrence data was recorded using descriptive statistics. Oncological outcome was determined using Kaplan-Meier and Cox-regression analyses.

RESULTS

Analysis was performed for 849 patients with median follow-up of 102.1 months. Mean disease-free (DFS) and overall survival (OS) were 85.8% and 91.8%. Seventy patients died during this study (8.2%), while 58 patients had recurrence; 7 had local recurrence (0.8%) and 51 had distant recurrence (DDR) (6.0%). Patients developing DDR were likely to be postmenopausal (P = 0.028), present symptomatically (P < 0.001) and have larger tumours (P < 0.001). The mean time to DDR was 65.7 months, with fatal recurrence occurring in 66.6% of patients with DDR (34/51). Systemic chemotherapy prescription did not influence DDR (P = 0.053). Age >65 (hazards ratio (HR):1.66, 95% Confidence Interval (CI):1.07-2.55, P = 0.022), presenting symptomatically (HR:2.28, 95%CI:1.21-4.29, P = 0.011) and tumour size >20 mm (HR:1.81, 95%CI:1.25-2.62, P = 0.002) predicted DFS, while age>65 (HR:2.60, 95%CI:1.49-4.53, P = 0.001) and being postmenopausal at diagnosis (HR:3.13, 95%CI:1.19-8.22, P = 0.020) predicted OS.

CONCLUSION

Our series demonstrated excellent survival outcomes for patients diagnosed with LN- LABC after almost a decade of follow-up. However, following DDR, fatal progression is often imminent.

The relationship between tooth size discrepancy and archform classification in orthodontic patients

Background

Material and Methods

Results

Conclusions

Mesenteric venous thrombosis secondary to an unsuspected JAK2 V617F-positive myeloproliferative disorder

BACKGROUND

Mesenteric venous thrombosis (MVT) is a rare but potentially fatal cause of mesenteric ischaemia. It presents insidiously and often diagnosis is made at emergency surgery. In half of the cases MVT develops without a causative factor, while in cases in which a pro-thrombotic state is found to exist MVT may be the first clinically detected consequence of that state. The myeloproliferative disorders (MPD) are known to contribute to the development of pro-thrombotic states. Recently, the JAK2 V617F mutation has been associated with the MPDs.

CONCLUSION

We describe a case of MVT occurring secondary to an unsuspected MPD, in which the patient was subsequently found to carry this mutation. We highlight the necessity to screen for this mutation in cases of intra-abdominal thromboses so that appropriate systemic anticoagulation may be instituted, and the patient may be followed so as to detect the development of an overt MPD.

Pancreas regeneration after resection: does it occur in humans?

Although pancreatic regeneration after partial resection or pancreatic injury (restitutio ad integrum) has been demonstrated in animal models, whether regeneration occurs in the human pancreas is unknown. Our aim was to determine whether the human pancreas regenerates after subtotal resection. We reviewed pre- and postoperative computerized tomograms (CTs) of 21 patients after proximal pancreatectomy (50-60% resection) for malignancy with no recurrent disease during follow-up of pancreatic parenchymal abnormalities. Three fixed anatomic measurements (pancreatic body width, tail width, and length) were compared with the same region 10 and 21 months after surgery. Data are expressed as mean +/- SEM. Pancreatic measurements before and 10 months after resection did not differ for body width (2.0+/-0.1 cm vs. 1.8+/-0.1 cm), tail width (2.2+/-0.2 cm vs. 1.8+/-0.2 cm) or length (8.2+/-0.3 vs. 7.4+/-0.4 cm) (p> or =0.1 each). At 21 months after resection, measurements were less for body width and tail width (2.2+/-0.2 cm vs. 1.5+/-0.2 cm and 2.2+/-0.1 cm vs. 1.5+/-0.2 cm, respectively; p = 0.01) and unchanged for length (8.1+/-0.4 cm vs. 8.1+/-0.4 cm; p = 0.9). We conclude that the human pancreas does not regenerate after partial anatomic (50%) resection.

A peritrophin-like protein expressed in the embryonic tracheae of Drosophila melanogaster

We have cloned and sequenced a cDNA from Drosophila melanogaster that encodes a protein homologous to the peritrophins, a family of chitin-binding proteins from the peritrophic matrix of insects. Unexpectedly, the gene, Gasp, is expressed in the embryonic tracheae. We suggest that this family of proteins may be present in other tissues than the peritrophic matrix, particularly where nutrient or gas exchange are important, and/or where invasion by parasites or viruses is possible. We have also mapped two similar genes that had been sequenced by the Berkeley Drosophila Genome Project, and find that these three very similar genes are not clustered, but are located on three different chromosomes.

Defunctioning loop ileostomy: a prospective audit

BACKGROUND

Defunctioning loop ileostomies are uncommonly used forms of fecal diversion. The aim of this study was to determine the morbidity associated with both construction and reversal of loop ileostomies.

STUDY DESIGN

An analysis was performed of all patients who underwent loop ileostomy construction or reversal between 1990 and 1997, with data being collected prospectively.

RESULTS

One-hundred-two patients, (43 male, 59 female) with a mean age of 38 years (range 13 to 81 years) had loop ileostomies constructed. Indications for ileostomy construction included inflammatory bowel disease (76 patients), ultralow anterior resection for carcinoma (16 patients), or miscellaneous reasons (10 patients). Nine patients (9%) had complications arising from ileostomy construction including 4 parastomal infections, 3 high output ileostomies, 1 small-bowel obstruction, and 1 ileostomy stenosis in the early postoperative period. Only the stricture required surgical intervention. All other complications improved with conservative management. Mean time to ileostomy reversal was 120 days. Three patients (4%) had complications associated with reversal. All of these complications required surgical intervention, 2 for small bowel obstruction, and 1 for small bowel perforation. Currently 84 patients have had their ileostomy reversed, and 12 patients have had their loop ileostomy converted to a permanent stoma for reasons not related to the loop ileostomy itself.

CONCLUSIONS

Defunctioning loop ileostomy is associated with low morbidity. We recommend a defunctioning ileostomy as the procedure of choice for temporary fecal diversion.

Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy: assessment of initial experience

OBJECTIVE

To evaluate our initial experience with laparoscopic inguinal herniorrhaphy.

DESIGN

We retrospectively studied a consecutive series of patients selectively chosen for laparoscopic repair of inguinal hernia.

MATERIAL AND METHODS

The study cohort consisted of 173 patients treated by a single surgeon between 1992 and 1995. For all operations, a transabdominal approach was used. Follow-up was obtained by telephone contact or letter.

RESULTS

The study group consisted of 167 male and 6 female patients with a mean age at operation of 55 years (range, 15 to 81). During the study period, 206 laparoscopic inguinal hernia repairs were performed in the 173 patients. Only one patient (0.6%) required conversion to laparotomy. Bilateral hernia repair was done in 31 patients (18%). Of the 206 procedures, 63 repairs (31%) were performed for recurrent hernias. In 69% of the patients, the procedure was completed on an outpatient basis. Early postoperative complications necessitating surgical intervention occurred in four patients. The median time to return to work or normal physical activity was 7 days for unilateral and 12 days for bilateral hernia repair (P = 0.18). A mean follow-up of 29 months was obtained for 171 patients (99%). In six patients (3%), a recurrent hernia developed. Four of these six patients had previously undergone an open surgical procedure on the side of the recurrence.

CONCLUSION

Laparoscopic inguinal herniorrhaphy is a feasible alternative to open hernia repair. This operation, however, should be reserved for selected patients. Longer follow-up and controlled trials comparing laparoscopic and tension-free open herniorrhaphy are necessary for assessment of the relative benefits of this procedure.

Surgical management of intrahepatic cholangiocarcinoma: a 31-year experience

Intrahepatic cholangiocarcinoma (ICC) is the second most common malignant primary tumor of the liver. It is, though, a rare tumor and little is known regarding its natural history, clinicopathologic characteristics, or the outcomes of surgical therapy. We reviewed the experience of 61 patients with ICC seen by the surgical service at the Mayo Clinic over a 31-year period. Patient demographic and clinical data were recorded, as were survival statistics. Pathologic data were also obtained and patients stratified according to the TNM classification. Twenty-eight patients were resected for cure. Overall, 45 patients died of ICC. Of the patients resected for cure, survival at 3 years was 60%. No pathologic condition was found to be associated with the development of ICC. Overall survival correlated with stage of the tumor. Among patients resected for cure, stage did not correlate with survival. Prognosis for patients with ICC remains poor; resection, though, appears to prolong survival.

Can adrenal incidentalomas be safely observed?

We currently recommend excision of adrenal incidentalomas > or = 4 cm in size and all hormonally active tumors. The optimal management and follow-up of smaller nonfunctioning tumors are controversial. The aim of this study was to determine the clinical outcome of a well defined population of patients with incidentalomas followed without operative intervention. The study group comprised 231 patients, identified from the records of abdominal or thoracic computed tomographic (CT) scans performed between 1985 and 1989. The primary outcome variable analyzed was survival. Follow-up was obtained by office records, telephone contact, or letter. There were 101 male and 130 female patients with a mean age at diagnosis of 64 years (range 5-86 years). Most adrenal tumors were unilateral (right 113; left 98); 20 were bilateral. Mean tumor size was 2 cm (range 1-6 cm). In nine (4%) patients the tumor was > or = 4 cm. Follow-up [mean 7 years; range 1 month (patient died) to 11.7 years] was complete in 224 (97%) patients. Ninety-one (39%) patients had one or more additional CT scans performed during the follow-up period, with only four patients demonstrating a > 1 cm increase in the size of the adrenal mass. Surgical excision of these four lesions identified benign pathology. Eighty-one (35%) patients died of conditions unrelated to adrenal pathology. No patient developed subsequent adrenal hyperfunction or adrenal malignancy. Within the context of our guidelines, conservative management of adrenal incidentalomas considered benign or nonfunctioning at diagnosis is appropriate. Additional information provided by repeat CT scanning appears to confer limited benefit. This study does not support laparoscopic removal of small, nonfunctional adrenal tumors, as has been suggested.

Is familial hyperparathyroidism a unique disease?

BACKGROUND

Familial hyperparathyroidism is a rare condition reported to behave more aggressively than sporadic hyperparathyroidism.

METHODS

A retrospective (1975 to 1995) analysis was performed on 30 such patients. All patients had at least one first-degree relative with surgically treated hyperparathyroidism and no personal or family history of multiple endocrine neoplasia.

RESULTS

There were 19 women and 11 men with a mean age of 39 years (range, 13 to 78 years). Fourteen patients (47%) had nephrolithiasis. The mean serum calcium level was 11.6 mg/dl (range, 10.5 to 15.3 mg/dl). Twenty-three primary and 15 repeat explorations (eight recurrent and seven persistent disease) were performed during the study period. Follow-up was obtained on all patients and ranged from 1 to 21 years (mean, 12 years). At the conclusion of the study, hypercalcemia (five recurrent and one persistent) was present in six patients (20%).

CONCLUSIONS

Familial hyperparathyroidism is a distinct and unique entity. Patients are diagnosed at a young age and have a high incidence of nephrolithiasis. Long-term follow-up is mandatory because of the high incidence of both recurrent and persistent hyperparathyroidism. Surgical treatment should include subtotal parathyroidectomy and routine transcervical thymectomy performed in centers with experience in the management of multiple-gland parathyroid disease.

Audit of colorectal cancer surgery by non-specialist surgeons

BACKGROUND

Some authorities recommend that colorectal cancer should be treated in specialist units but evidence that non-specialist units demonstrate comparatively poor results may be lacking.

METHODS

Between 1987 and 1991, 267 patients were operated on by four general surgeons, none of whom was a specialist in colorectal surgery. Procedure-related complications, postoperative mortality and disease-related survival rates were analysed.

RESULTS

There were four cases of intraperitoneal sepsis (1 per cent) and five of 189 patients (3 per cent) had clinical anastomotic dehiscence; there was no case of wound dehiscence. The postoperative mortality rate after elective and emergency surgery was 2 and 13 per cent respectively. The 5-year disease-related survival rate for curative and palliative surgery was 67 and 9 per cent respectively. There were no significant differences between the surgeons.

CONCLUSION

Disease-related variables such as early-stage disease and fewer patients presenting as emergencies may have a greater favourable influence on ultimate survival than surgeon-related variables.

Laparoscopic oophorectomy: a prospective evaluation in pre-menopausal breast cancer with particular reference to incidence and severity of menopausal symptoms

Laparoscopic oophorectomy offers potential advantages over other methods of ovarian ablation. In this prospective study the technique, complications and side-effects have been assessed in 69 consecutive patients. Menopausal symptoms were assessed using two scoring systems - the Kupperman index and the Women's Health Questionnaire. The serum beta oestradiol levels fell rapidly post-operatively (from 540 pmol/l to 25 pmol/l within 1 month). Menopausal symptoms were mild in 75% of patients and severe in none. Complications occurred in three patients. Laparoscopic oophorectomy has an important role to play in the management of pre-menopausal breast cancer and this study confirms that is well tolerated and gives good short-term results.

Methods of renal blood flow measurement

Variations in regional renal blood flow have been implicated in a variety of disease states. Many techniques have been developed in an attempt to accurately assess these changes. The microsphere technique is the most widely used method at the present time. This technique allows focal measurements to be performed, but there is a conflict between the resolution of the method and the number of microspheres necessary in each sample. New imaging techniques such as tomography and autoradiography enable visual assessment of renal blood flow. Though there is no ideal method, these techniques have opened up new possibilities in the quantification of regional renal blood flow.

Cholinergic agents modulate transport in the isolated, perfused ileum

The mammalian small intestine is extensively innervated by cholinergic nerve fibers, including projections to the muscular and submucosal layers. This study tested the hypothesis that cholinergic agents modulate ileal transport independent of alterations in intestinal vascular resistance and motility. Ten-centimeter segments of rabbit ileum (n = 32) were vascularly perfused ex vivo with a physiologic electrolyte solution containing red cells. The lumen was perfused with an electrolyte solution containing [14C]polyethylene glycol. Net fluxes of water, sodium, and chloride were calculated during three 20-min periods: basal, drug infusion, and recovery. Agents infused at a final arterial concentration of 10(-5) mole/liter included acetylcholine, atropine, and hexamethonium. Measured perfusion pressure reflected changes in vascular resistance. Recovery calculations controlled for motility effects. Acetylcholine caused significant secretion of water, sodium, and chloride (P < 0.05). The infusion of atropine or hexamethonium alone had no effect. Atropine but not hexamethonium prevented the prosecretory effect of acetylcholine. There were no significant changes in perfusion pressure or 14C recovery for any infused agent. Acetylcholine-induced ileal secretion is (1) mediated via atropine-sensitive muscarinic cholinergic receptors, (2) independent of extraintestinal neural pathways, and (3) independent of changes in vascular resistance or motility. These data support the hypothesis that acetylcholine influences ileal transport directly, independent of alterations in vascular resistance and motility.

A prospective study of acid reflux and globus pharyngeus using a modified symptom index

Previous authors have demonstrated an association between gastro-oesophageal reflux and globus pharyngeus. With the advent of 24-h pH monitoring the strength of this association has been questioned. A prospective study was performed using a 'Symptom Index' of acid reflux. A positive result was recorded when one out of two globus sensations occurred with acid reflux. The symptom index was assessed prospectively in 21 patients with a history of globus pharyngeus. In eight patients with significant acid reflux as defined by standard pH criteria the symptom index was positive in all cases. The remaining 13 patients had no objective evidence of significant reflux and the symptom index was negative. The symptom index is a useful additional marker to determine the significance of acid reflux in the pathogenesis of globus pharyngeus.

Luminal dopamine modulates canine ileal water and electrolyte transport

Previous studies have suggested that dopamine stimulates active ileal ion absorption via alpha 2-adrenergic or dopaminergic receptor activation. Identification of a dopamine 1a receptor on rat enterocytes located in intestinal crypts prompted this investigation of the effect of luminally administered dopamine on water and ion transport in the canine ileum. Absorption studies (n = 27) were performed in dogs with 25-cm ileal Thiry-Vella fistulas. Perfusion with [14C] PEG was used to calculate absorption of water and electrolytes from the Thiry-Vella fistula. Experiments consisted of three 1-hr periods: basal, luminal drug infusion at 10(-4) M, and recovery. Agonists used included dopamine (DOP: alpha-adrenergic, D1 and D2 receptor) and SKF 38393 (D1 receptor). Antagonists used included terazosin (TZ: alpha 1) and yohimbine (YOH: alpha 2). DOP caused significant increases in water and electrolyte absorption. TZ and YOH prevented the dopamine-induced proabsorptive response. Luminal DOP may serve as a proabsorptive modulator of ileal transport, acting via alpha 1, alpha 2, and dopaminergic receptors. The development of more potent proabsorptive dopamine analogs, which maintain the ability to broadly activate mucosal receptors, may be useful in such clinical situations as diabetic diarrhea, short gut syndrome, or following small bowel transplantation.

Neural mechanisms in basal and meal-stimulated ileal absorption

The ingestion of a meal stimulates absorption from the jejunal lumen and is dependent on intact neural pathways. Few studies of ileal absorptive responses to a meal have been performed. This study tested two hypotheses: (1) a meal stimulates ileal glucose, water, and ion absorption, and (2) intact intestinal neurotransmission is necessary to maintain the basal and meal-stimulated absorptive states in the ileum. Absorption studies (n = 50) using 14C-labeled PEG were performed on six dogs with 25-cm ileal Thiry-Vella fistulas (TVF). Four groups were randomly studied over 4 hr. Intraluminal oxethazaine (2 mg/dl) was administered to the TVF in Groups 2 and 4 after the 1st hour to produce neural blockade. A control volume of water was administered to the TVF in Groups 1 and 3 after the 1st hour. A 480 kcal meal was ingested at the end of the 2nd hour in groups 3 and 4. Ileal water, ion, and glucose absorption were increased significantly (P < 0.05) by the ingestion of a meal. TVF oxethazaine significantly reduced (P < 0.05) basal water and ion absorption but had no effect on meal-stimulated absorption. Ileal absorption of water, ions, and glucose is significantly increased by the ingestion of a meal. Basal ileal absorption appears to be partly dependent upon intact neurotransmission. Postprandial ileal absorption appears to be independent of neural blockade, implicating circulating hormones, paracrine mediators, or neurotransmission within the myenteric plexus of the enteric nervous system as the primary modulators of meal-stimulated ileal absorption.

Effect of alpha 1-adrenergic blockade on canine ileal water, electrolyte, and glucose absorption

Meal ingestion stimulates an increase in small intestinal water and electrolyte absorption. Endogenous norepinephrine may at least partially mediate this meal-stimulated proabsorptive response. Luminally administered alpha 1-adrenergic agonists such as norepinephrine and phenylephrine cause significant small bowel absorption, which can be prevented by the selective alpha 1-adrenergic antagonist terazosin. This study tested two hypotheses: (1) a meal stimulates ileal water, electrolyte, and glucose absorption; and (2) meal-stimulated ileal absorption is mediated via alpha 1-adrenergic receptor activation. Absorption studies (N = 27) were performed on dogs with 25-cm ileal Thirty-Vella fistulas (TVF). Perfusion with [14C]PEG was used to calculate absorption of water, electrolytes, and glucose from the TVF. Three groups were randomly studied over 4 hr: (1) terazosin alone, (2) meal alone, and (3) terazosin plus meal. Terazosin (10(-4) M) was administered to the TVF in groups 1 and 3 following the first hour. A 480-kcal mixed canine meal was ingested at the end of the second hour in groups 2 and 3. Ileal water, electrolyte, and glucose absorption increased significantly in response to meal ingestion (P < 0.05). Luminal terazosin did not significantly alter basal or meal-stimulated ileal absorption. In conclusion, meal ingestion stimulates ileal absorption of water, electrolytes, and glucose. Neither basal nor meal-stimulated ileal absorption is altered by alpha 1-adrenergic receptor blockade. These data suggest that nonadrenergic neural pathways or humoral factors are the likely mediators of meal-induced intestinal absorption.

Nitric oxide modulates water and electrolyte transport in the ileum

OBJECTIVE

To test the hypothesis that nitric oxide is a modulator of ileal water and ion transport.

SUMMARY BACKGROUND DATA

Nitric oxide is produced in the vascular endothelium and enteric neural plexuses of the intestine and is involved in gastrointestinal motility and smooth muscle contractility. Little is known about the role of nitric oxide in intestinal epithelial transport.

METHODS

Ten-centimeter rabbit ileal segments (n = 50) were vascularly perfused with an electrolyte solution containing red cells. The lumen was perfused with a solution containing 14C-PEG. Net fluxes of water and ions were calculated during three 20-minute periods: basal, drug infusion, and recovery. Perfusion pressure was recorded to document changes in vascular resistance. Agents infused included the nitric oxide synthase substrate L-arginine, the nitric oxide source sodium nitroprusside, the substrate control D-arginine, and the nitric oxide synthase inhibitor NG-nitro-L-arginine methyl ester.

RESULTS

L-arginine and sodium nitroprusside caused absorption of water and ions. NG-nitro-L-arginine methyl ester caused secretion of water and ions, which was prevented by synchronous infusion of L-arginine. Infusion of D-arginine had no effect. Both L-arginine and sodium nitroprusside caused mild vasodilation.

CONCLUSIONS

Inhibition of endogenous nitric oxide synthesis by NG-nitro-L-arginine methyl ester causes secretion of water and ions. This secretion is reversed by administration of the nitric oxide synthase substrate L-arginine. These findings are consistent with the hypothesis that endogenous nitric oxide has a proabsorptive influence over the ileum in the basal state.

Luminal adrenergic agents modulate ileal transport: discrimination between alpha 1 and alpha 2 receptors

Luminal alpha-adrenergic agonists alter ileal water, ion, and glucose transport by a local mechanism. This study tested the hypothesis that luminal adrenergic agents modulate ileal transport selectively, via specific alpha 1 and alpha 2 receptors. Absorption studies (n = 72) were performed on dogs with 25-cm ileal Thiry-Vella fistulas (TVF). Perfusion with (14C) polyethylene glycol was used to calculate absorption of water, ions, and glucose from the TVF. Experiments included four 1-hour periods. Agonists used were phenylephrine (alpha 1), clonidine (alpha 2), and norepinephrine (alpha 1 > alpha 2 and beta). Antagonists used were terazosin (alpha 1) and yohimbine (alpha 2). Phenylephrine and norepinephrine caused significant increases in water and ion absorption (p < 0.05). Clonidine caused significant decreases in water, ion, and glucose absorption (p < 0.05). Terazosin and yohimbine had no effect alone. Terazosin prevented the proabsorptive effect of phenylephrine and norepinephrine, and yohimbine blocked the prosecretory effect of clonidine. Yohimbine significantly increased the norepinephrine-induced proabsorptive effect. Luminal alpha-adrenergic agents selectively modulate ileal transport. Alpha 1-receptor activation causes a proabsorptive response, whereas alpha 2-receptor activation causes a prosecretory response. The combination of a luminally administered mixed alpha- and beta-adrenergic agonist (norepinephrine) with alpha 2 receptor blockade (yohimbine) may prove useful in pathologic secretory states such as intestinal transplants, diabetic diarrhea, or diarrhea-associated endocrinopathies.

Erythromycin accelerates gastric emptying after pancreaticoduodenectomy. A prospective, randomized, placebo-controlled trial

OBJECTIVE

This study tested the hypothesis that erythromycin, a motilin agonist, reduces the incidence of early DGE after pancreaticoduodenectomy.

SUMMARY BACKGROUND DATA

Delayed gastric emptying (DGE) is a leading cause of morbidity after pancreaticoduodenectomy, occurring in up to 40% of patients. The pathogenesis of DGE has been speculated to involve factors such as peritonitis from anastomotic leaks, ischemia to the antropyloric muscles, and gastric atony in response to resection of the duodenal pacemaker or reduction in circulating motilin levels.

METHODS

Between November 1990 and January 1993, 118 patients undergoing pancreaticoduodenectomy completed this prospective, randomized, placebo-controlled trial. The patients received either 200 mg of intravenous erythromycin lactobionate every 6 hours (n = 58), or an identical volume of 0.9% saline (n = 60) from the third to tenth postoperative days. On the tenth postoperative day, a dual phase radionuclide gastric emptying study was performed.

RESULTS

The erythromycin and control groups were comparable regarding multiple preoperative, intraoperative, and postoperative factors. The erythromycin group had a 37% reduction in the incidence of DGE (19% vs. 30%), a significantly reduced (p < 0.05) need to reinsert a nasogastric tube for DGE (6 vs. 15 patients), and a significantly reduced (p < 0.01) per cent retention of liquids at 30 minutes and solids at 30, 60, 90, and 120 minutes. No major adverse reactions to erythromycin were observed.

CONCLUSIONS

Erythromycin is a safe, inexpensive drug that significantly accelerates gastric emptying after pancreaticoduodenectomy and reduces the incidence of DGE by 37%. These data support the use of erythromycin to decrease early DGE after pancreaticoduodenectomy.

Luminal adrenergic agonists modulate ileal transport by a local mechanism

Intestinal transport is controlled by neural pathways, hormones, and luminal agents. Luminal adrenergic agents influence water and ion transport in the jejunum. This study tested two hypotheses: (i) luminal adrenergic agents influence ileal water, ion and glucose transport, and (ii) luminal adrenergic agents exert their effects locally and selectively. Absorption studies (n = 46) were performed on dogs with two adjacent 25-cm ileal Thiry-Vella fistulas (TVF). Perfusion with [14C]polyethylene glycol was used to calculate absorption of water, ions, and glucose from the distal TVF. Experiments were composed of three 1-hr periods: basal, luminal adrenergic agonist infusion, and recovery. In group 1 the adrenergic agonists were administered to the distal TVF: norepinephrine (alpha 1 > alpha 2 and beta), phenylephrine (alpha 1), clonidine (alpha 2), and isoproterenol (beta). In group 2 the adrenergic agonists were administered to the proximal TVF, with absorption measured in the distal TVF. In group 1 norepinephrine and phenylephrine caused a significant increase in water absorption (P < 0.05). Clonidine and isoproterenol caused decreased absorption of water and ions, with clonidine causing significantly decreased absorption (P < 0.05) of water, ions, and glucose. In group 2 there were no changes in distal TVF absorption. Luminal adrenergic agents did not alter the heart rate in either group. Luminal adrenergic agonists modulate ileal transport via a local mechanism. A proabsorptive response is observed with alpha 1 agonists, while alpha 2 and beta agonists cause a prosecretory effect. Inhibition of glucose absorption appears to be selectively mediated via the alpha 2-adrenergic receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

Site specificity and meal stimulation of the intestinal absorption of water, electrolytes, and bile acids

Ileal water and electrolyte absorption exceed jejunal absorption in both the basal and meal-stimulated states. The purposes of these experiments were to determine: (1) if luminal bile acids alter basal or meal-stimulated intestinal absorption, and (2) if there is site specificity or meal stimulation of intestinal bile acid absorption. Twenty-five centimeters of canine proximal jejunal and distal ileal Thiry-Vella fistulas were constructed. Simultaneous jejunal and ileal absorption studies (n = 88) were performed with a luminal perfusate containing polyethylene glycol labeled with radioactive carbon-14 to calculate the absorption of water, electrolytes, and the bile acid taurocholate (TC). In group 1, there was no TC in the luminal perfusate, whereas in group 2, 10 mM of TC was present in the luminal perfusate. Half of the observations were performed after a meal stimulus, which consisted of an orally ingested, 480-kcal mixed nutrient meal. Intraluminal TC did not affect basal or meal-stimulated water or electrolyte absorption. In both the basal and meal-stimulated states, ileal absorption of water, electrolytes, and TC significantly exceeded jejunal absorption (p < 0.05). A meal significantly stimulated water and electrolyte absorption in both the jejunum and ileum, but it stimulated absorption of TC in the ileum only (p < 0.05). Intraluminal TC does not alter basal or meal-stimulated intestinal water and electrolyte absorption. A meal stimulates increased water and electrolyte absorption in both the jejunum and the ileum, but it stimulates bile acid absorption in the ileum only. Bile acid absorption is site specific and responsive to a meal stimulus.

Contraction stress test after hyperstimulation patterns during antepartum fetal heart rate monitoring

Hyperstimulation during fetal heart rate (FHR) monitoring occurs when a deceleration in the FHR accompanies a contraction lasting greater than 90 seconds or contractions more frequent than every 2 minutes. A posthyperstimulation contraction stress test (CST) was performed, and if it was reactive negative, the next day's test was evaluated. On the next day, 170/250 (68%) of the tests were reactive negative, 33/200 (13%) of the patients underwent labor induction, 28/250 (11%) of the tests had hyperstimulation patterns again, and 19/250 (8%) of the tests were reactive equivocal; there were no positive tests. In this series of 250 repeat tests there were no adverse outcomes in patients who had a reactive negative CST after a hyperstimulation pattern, suggesting that the second test can be performed in a week rather than in a day.