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Matchett KP, Wilson-Kanamori JR, Portman JR, Kapourani CA, Fercoq F, May S, Zajdel E, Beltran M, Sutherland EF, Mackey JBG, Brice M, Wilson GC, Wallace SJ, Kitto L, Younger NT, Dobie R, Mole DJ, Oniscu GC, Wigmore SJ, Ramachandran P, Vallejos CA, Carragher NO, Saeidinejad MM, Quaglia A, Jalan R, Simpson KJ, Kendall TJ, Rule JA, Lee WM, Hoare M, Weston CJ, Marioni JC, Teichmann SA, Bird TG, Carlin LM, Henderson NC. Multimodal decoding of human liver regeneration. Nature 2024:10.1038/s41586-024-07376-2. [PMID: 38693268 DOI: 10.1038/s41586-024-07376-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/02/2024] [Indexed: 05/03/2024]
Abstract
The liver has a unique ability to regenerate1,2; however, in the setting of acute liver failure (ALF), this regenerative capacity is often overwhelmed, leaving emergency liver transplantation as the only curative option3-5. Here, to advance understanding of human liver regeneration, we use paired single-nucleus RNA sequencing combined with spatial profiling of healthy and ALF explant human livers to generate a single-cell, pan-lineage atlas of human liver regeneration. We uncover a novel ANXA2+ migratory hepatocyte subpopulation, which emerges during human liver regeneration, and a corollary subpopulation in a mouse model of acetaminophen (APAP)-induced liver regeneration. Interrogation of necrotic wound closure and hepatocyte proliferation across multiple timepoints following APAP-induced liver injury in mice demonstrates that wound closure precedes hepatocyte proliferation. Four-dimensional intravital imaging of APAP-induced mouse liver injury identifies motile hepatocytes at the edge of the necrotic area, enabling collective migration of the hepatocyte sheet to effect wound closure. Depletion of hepatocyte ANXA2 reduces hepatocyte growth factor-induced human and mouse hepatocyte migration in vitro, and abrogates necrotic wound closure following APAP-induced mouse liver injury. Together, our work dissects unanticipated aspects of liver regeneration, demonstrating an uncoupling of wound closure and hepatocyte proliferation and uncovering a novel migratory hepatocyte subpopulation that mediates wound closure following liver injury. Therapies designed to promote rapid reconstitution of normal hepatic microarchitecture and reparation of the gut-liver barrier may advance new areas of therapeutic discovery in regenerative medicine.
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Affiliation(s)
- K P Matchett
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - J R Wilson-Kanamori
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - J R Portman
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - C A Kapourani
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- School of Informatics, University of Edinburgh, Edinburgh, UK
| | - F Fercoq
- Cancer Research UK Beatson Institute, Glasgow, UK
| | - S May
- Cancer Research UK Beatson Institute, Glasgow, UK
| | - E Zajdel
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - M Beltran
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - E F Sutherland
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - J B G Mackey
- Cancer Research UK Beatson Institute, Glasgow, UK
| | - M Brice
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - G C Wilson
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - S J Wallace
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - L Kitto
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - N T Younger
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - R Dobie
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - D J Mole
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- University Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - G C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
- Division of Transplant Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - S J Wigmore
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- University Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - P Ramachandran
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - C A Vallejos
- MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- The Alan Turing Institute, London, UK
| | - N O Carragher
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - M M Saeidinejad
- Institute for Liver and Digestive Health, University College London, London, UK
| | - A Quaglia
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
- UCL Cancer Institute, University College London, London, UK
| | - R Jalan
- Institute for Liver and Digestive Health, University College London, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - K J Simpson
- Department of Hepatology, University of Edinburgh and Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - T J Kendall
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
| | - J A Rule
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - W M Lee
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - M Hoare
- Early Cancer Institute, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - C J Weston
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - J C Marioni
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- European Molecular Biology Laboratory, European Bioinformatics Institute, Cambridge, UK
- Wellcome Genome Campus, Wellcome Sanger Institute, Cambridge, UK
| | - S A Teichmann
- European Molecular Biology Laboratory, European Bioinformatics Institute, Cambridge, UK
- Wellcome Genome Campus, Wellcome Sanger Institute, Cambridge, UK
- Department of Physics, Cavendish Laboratory, Cambridge, UK
| | - T G Bird
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Cancer Research UK Beatson Institute, Glasgow, UK
| | - L M Carlin
- Cancer Research UK Beatson Institute, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - N C Henderson
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK.
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK.
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2
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Nielsen MF, de Beaux A, Stutchfield B, Kung J, Wigmore SJ, Tulloh B. Peritoneal flap hernioplasty for repair of incisional hernias after orthotopic liver transplantation. Hernia 2021; 26:481-487. [PMID: 33884521 PMCID: PMC9012720 DOI: 10.1007/s10029-021-02409-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/07/2021] [Indexed: 12/07/2022]
Abstract
Background Repair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in the context of lifelong immunosuppression. The peritoneal flap hernioplasty addresses this problem by using flaps of the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space, exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. We report our short and long-term results of 26 consecutive liver transplant cases with incisional hernias undergoing repair with the peritoneal flap technique. Methods Post-OLT patients undergoing elective peritoneal flap hernioplasty for incisional hernias from Jan 1, 2010–Nov 1, 2017 were identified from the Lothian Surgical Audit system (LSA), a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in Feb 2020. Results A total of 517 liver transplantations were performed during the inclusion period. Twenty-six of these (18 males, 69%) developed an incisional hernia and underwent a peritoneal flap repair. Median mesh size (Optilene Elastic, 48 g/m2, BBraun) was 900 cm2 (range 225–1500 cm2). The median time to repair following OLT was 33 months (range 12–70 months). Median follow-up was 54 months (range 24–115 months) and median postoperative stay was 5 days (range 3–11 days). Altogether, three patients (12%) presented with postoperative complications: 1 with hematoma (4%) and two with chronic pain (8%). No episodes of infection or symptomatic seroma were recorded. No recurrence was recorded within the follow-up period. Conclusion Repair of incisional hernias in patients following liver transplantation with the Peritoneal Flap Hernioplasty is a safe procedure associated with few complications and a very low recurrence rate. We propose this technique for the reconstruction of incisional hernias following liver transplantation.
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Affiliation(s)
- M F Nielsen
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, Scotland, UK.
- Department of Surgery, Hospital of Southern Denmark, Aabenraa, Danmark.
| | - A de Beaux
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, Scotland, UK
| | - B Stutchfield
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, Scotland, UK
| | - J Kung
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, Scotland, UK
| | - S J Wigmore
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, Scotland, UK
| | - B Tulloh
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, Scotland, UK
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Wlodek E, Kirkpatrick RB, Andrews S, Noble R, Schroyer R, Scott J, Watson CJE, Clatworthy M, Harrison EM, Wigmore SJ, Stevenson K, Kingsmore D, Sheerin NS, Bestard O, Stirnadel-Farrant HA, Abberley L, Busz M, DeWall S, Birchler M, Krull D, Thorneloe KS, Weber A, Devey L. A pilot study evaluating GSK1070806 inhibition of interleukin-18 in renal transplant delayed graft function. PLoS One 2021; 16:e0247972. [PMID: 33684160 PMCID: PMC7939287 DOI: 10.1371/journal.pone.0247972] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/11/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Delayed graft function (DGF) following renal transplantation is a manifestation of acute kidney injury (AKI) leading to poor long-term outcome. Current treatments have limited effectiveness in preventing DGF. Interleukin-18 (IL18), a biomarker of AKI, induces interferon-γ expression and immune activation. GSK1070806, an anti-IL18 monoclonal antibody, neutralizes activated (mature) IL18 released from damaged cells following inflammasome activation. This phase IIa, single-arm trial assessed the effect of a single dose of GSK1070806 on DGF occurrence post donation after circulatory death (DCD) kidney transplantation. METHODS The 3 mg/kg intravenous dose was selected based on prior studies and physiologically based pharmacokinetic (PBPK) modeling, indicating the high likelihood of a rapid and high level of IL18 target engagement when administered prior to kidney allograft reperfusion. Utilization of a Bayesian sequential design with a background standard-of-care DGF rate of 50% based on literature, and confirmed via extensive registry data analyses, enabled a statistical efficacy assessment with a minimal sample size. The primary endpoint was DGF frequency, defined as dialysis requirement ≤7 days post transplantation (except for hyperkalemia). Secondary endpoints included safety, pharmacokinetics and pharmacodynamic biomarkers. RESULTS GSK1070806 administration was associated with IL18-GSK1070806 complex detection and increased total serum IL18 levels due to IL18 half-life prolongation induced by GSK1070806 binding. Interferon-γ-induced chemokine levels declined or remained unchanged in most patients. Although the study was concluded prior to the Bayesian-defined stopping point, 4/7 enrolled patients (57%) had DGF, exceeding the 50% standard-of-care rate, and an additional two patients, although not reaching the protocol-defined DGF definition, demonstrated poor graft function. Six of seven patients experienced serious adverse events (SAEs), including two treatment-related SAEs. CONCLUSION Overall, using a Bayesian design and extensive PBPK dose modeling with only a small sample size, it was deemed unlikely that GSK1070806 would be efficacious in preventing DGF in the enrolled DCD transplant population. TRIAL REGISTRATION NCT02723786.
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Affiliation(s)
- E. Wlodek
- GlaxoSmithKline, Clinical Unit Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - R. B. Kirkpatrick
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - S. Andrews
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - R. Noble
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - R. Schroyer
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - J. Scott
- JMS Statistics Ltd, Pinner, United Kingdom
| | - C. J. E. Watson
- University of Cambridge and the NIHR Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at the University of Cambridge, Cambridge, United Kingdom
| | - M. Clatworthy
- University of Cambridge and the NIHR Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at the University of Cambridge, Cambridge, United Kingdom
| | | | - S. J. Wigmore
- Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - K. Stevenson
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - D. Kingsmore
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - N. S. Sheerin
- Newcastle Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle, United Kingdom
| | - O. Bestard
- L’Hospitalet de Llobregat, Bellvitge University Hospital, Kidney Transplant Unit, Barcelona, Spain
| | | | - L. Abberley
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - M. Busz
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - S. DeWall
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - M. Birchler
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - D. Krull
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - K. S. Thorneloe
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - A. Weber
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
| | - L. Devey
- GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America
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4
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Affiliation(s)
- S J Wigmore
- Medical Research Council Centre for Inflammation Research, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
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5
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Brudvik KW, Yaqub S, Kemsley E, Coolsen MME, Dejong CHC, Wigmore SJ, Lassen K. Survey of the attitudes of hepatopancreatobiliary surgeons in northern Europe to resection of choledochal cysts in asymptomatic Western adults. BJS Open 2019; 3:785-792. [PMID: 31832585 PMCID: PMC6887667 DOI: 10.1002/bjs5.50208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/29/2019] [Indexed: 12/03/2022] Open
Abstract
Background Todani type 1 and 4 choledochal cysts are associated with a risk of developing cholangiocarcinoma. Resection is usually recommended, but data for asymptomatic Western adults are sparse. The aim of this study was to investigate diagnostic interpretation and attitudes towards resection of bile ducts for choledochal cysts in this subgroup of patients across northern European centres. Methods Thirty hepatopancreatobiliary centres were provided with magnetic resonance cholangiopancreatograms and asked to discuss the management of six cases: asymptomatic non‐Asian women, aged 30 or 60 years, with variable common bile duct (CBD) dilatations and different risk factors in the setting of a multidisciplinary team (MDT). The Fleiss κ value was calculated to estimate overall inter‐rater agreement. Results For all case scenarios combined, 83·3 and 86·7 per cent recommended resection for a CBD of 20 and 26 mm respectively, compared with 19·4 per cent for a CBD of 13 mm (P < 0·001). For patients aged 30 and 60 years, resection was recommended in 68·5 and 57·8 per cent respectively (P = 0·010). There was a trend towards recommending resection in the presence of a common channel, most pronounced in the 60‐year‐old patient. High amylase levels in the CBD aspirate led to recommendations to resect, but only for the 13‐mm CBD dilatation. There were no differences related to centre size or region. MDT discussion was associated with recommendations to resect. Inter‐rater agreement was 73·3 per cent (κ = 0·43, 95 per cent c.i. 0·38 to 0·48). Conclusion The inter‐rater agreement to resect was intermediate, and the recommendation was dependent mainly on the diameter of the CBD dilatation.
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Affiliation(s)
- K W Brudvik
- Department of Hepato-Pancreato-Biliary Surgery Oslo University Hospital Oslo Norway
| | - S Yaqub
- Department of Hepato-Pancreato-Biliary Surgery Oslo University Hospital Oslo Norway
| | - E Kemsley
- Department of Clinical Surgery University of Edinburgh Royal Infirmary, Edinburgh UK
| | - M M E Coolsen
- Department of Surgery Maastricht University Centre Maastricht the Netherlands.,Department of Surgery Rheinisch-Westfälische Technische Hochschule Universitätsklinikum Aachen Aachen Germany
| | - C H C Dejong
- Department of Surgery Maastricht University Centre Maastricht the Netherlands.,Department of Surgery Rheinisch-Westfälische Technische Hochschule Universitätsklinikum Aachen Aachen Germany
| | - S J Wigmore
- Department of Clinical Surgery University of Edinburgh Royal Infirmary, Edinburgh UK
| | - K Lassen
- Department of Hepato-Pancreato-Biliary Surgery Oslo University Hospital Oslo Norway
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6
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Ramachandran P, Dobie R, Wilson-Kanamori JR, Dora EF, Henderson BEP, Luu NT, Portman JR, Matchett KP, Brice M, Marwick JA, Taylor RS, Efremova M, Vento-Tormo R, Carragher NO, Kendall TJ, Fallowfield JA, Harrison EM, Mole DJ, Wigmore SJ, Newsome PN, Weston CJ, Iredale JP, Tacke F, Pollard JW, Ponting CP, Marioni JC, Teichmann SA, Henderson NC. Resolving the fibrotic niche of human liver cirrhosis at single-cell level. Nature 2019; 575:512-518. [PMID: 31597160 PMCID: PMC6876711 DOI: 10.1038/s41586-019-1631-3] [Citation(s) in RCA: 786] [Impact Index Per Article: 157.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 09/04/2019] [Indexed: 12/13/2022]
Abstract
Liver cirrhosis is a major cause of death worldwide and is characterized by extensive fibrosis. There are currently no effective antifibrotic therapies available. To obtain a better understanding of the cellular and molecular mechanisms involved in disease pathogenesis and enable the discovery of therapeutic targets, here we profile the transcriptomes of more than 100,000 single human cells, yielding molecular definitions for non-parenchymal cell types that are found in healthy and cirrhotic human liver. We identify a scar-associated TREM2+CD9+ subpopulation of macrophages, which expands in liver fibrosis, differentiates from circulating monocytes and is pro-fibrogenic. We also define ACKR1+ and PLVAP+ endothelial cells that expand in cirrhosis, are topographically restricted to the fibrotic niche and enhance the transmigration of leucocytes. Multi-lineage modelling of ligand and receptor interactions between the scar-associated macrophages, endothelial cells and PDGFRα+ collagen-producing mesenchymal cells reveals intra-scar activity of several pro-fibrogenic pathways including TNFRSF12A, PDGFR and NOTCH signalling. Our work dissects unanticipated aspects of the cellular and molecular basis of human organ fibrosis at a single-cell level, and provides a conceptual framework for the discovery of rational therapeutic targets in liver cirrhosis.
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Affiliation(s)
- P Ramachandran
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK.
| | - R Dobie
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - J R Wilson-Kanamori
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - E F Dora
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - B E P Henderson
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - N T Luu
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - J R Portman
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - K P Matchett
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - M Brice
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - J A Marwick
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine at the University of Edinburgh, Edinburgh, UK
| | - R S Taylor
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - M Efremova
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - R Vento-Tormo
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - N O Carragher
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine at the University of Edinburgh, Edinburgh, UK
| | - T J Kendall
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
- Division of Pathology, University of Edinburgh, Edinburgh, UK
| | - J A Fallowfield
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
| | - E M Harrison
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - D J Mole
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S J Wigmore
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - P N Newsome
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - C J Weston
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - J P Iredale
- Office of the Vice Chancellor, Beacon House and National Institute for Health Research, Biomedical Research Centre, Bristol, UK
| | - F Tacke
- Department of Hepatology and Gastroenterology, Charité University Medical Center, Berlin, Germany
| | - J W Pollard
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, New York, NY, USA
| | - C P Ponting
- MRC Human Genetics Unit, MRC Institute of Genetics and Molecular Medicine at the University of Edinburgh, Edinburgh, UK
| | - J C Marioni
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
- European Molecular Biology Laboratory, European Bioinformatics Institute (EMBL-EBI), Hinxton, Cambridge, UK
- Cancer Research UK Cambridge Institute, Li Ka Shing Centre, University of Cambridge, Cambridge, UK
| | - S A Teichmann
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
- European Molecular Biology Laboratory, European Bioinformatics Institute (EMBL-EBI), Hinxton, Cambridge, UK
- Theory of Condensed Matter Group, The Cavendish Laboratory, University of Cambridge, Cambridge, UK
| | - N C Henderson
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK.
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7
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Søreide K, Guest RV, Harrison EM, Kendall TJ, Garden OJ, Wigmore SJ. Systematic review of management of incidental gallbladder cancer after cholecystectomy. Br J Surg 2019; 106:32-45. [PMID: 30582640 DOI: 10.1002/bjs.11035] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/16/2018] [Accepted: 10/01/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer. METHODS A systematic PubMed search of the English literature to May 2018 was conducted. RESULTS The search identified 12 systematic reviews and meta-analyses, in addition to several consensus reports, multi-institutional series and national audits. Some 0·25-0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one-third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5-year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross-sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET-avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port-site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused. CONCLUSION Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection.
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Affiliation(s)
- K Søreide
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - R V Guest
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - E M Harrison
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - T J Kendall
- Division of Pathology, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - O J Garden
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - S J Wigmore
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
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8
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Kirkegård J, Aahlin EK, Al-Saiddi M, Bratlie SO, Coolsen M, de Haas RJ, den Dulk M, Fristrup C, Harrison EM, Mortensen MB, Nijkamp MW, Persson J, Søreide JA, Wigmore SJ, Wik T, Mortensen FV. Multicentre study of multidisciplinary team assessment of pancreatic cancer resectability and treatment allocation. Br J Surg 2019; 106:756-764. [PMID: 30830974 DOI: 10.1002/bjs.11093] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/09/2018] [Accepted: 11/26/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Multidisciplinary team (MDT) meetings have been adopted widely to ensure optimal treatment for patients with cancer. Agreements in tumour staging, resectability assessments and treatment allocation between different MDTs were assessed. METHODS Of all patients referred to one hospital, 19 patients considered to have non-metastatic pancreatic cancer for evaluation were selected randomly for a multicentre study of MDT decisions in seven units across Northern Europe. Anonymized clinical information and radiological images were disseminated to the MDTs. All patients were reviewed by the MDTs for radiological T, N and M category, resectability assessment and treatment allocation. Each MDT was blinded to the decisions of other teams. Agreements were expressed as raw percentages and Krippendorff's α values, both with 95 per cent confidence intervals. RESULTS A total of 132 evaluations in 19 patients were carried out by the seven MDTs (1 evaluation was excluded owing to technical problems). The level of agreement for T, N and M categories ranged from moderate to near perfect (46·8, 61·1 and 82·8 per cent respectively), but there was substantial variation in assessment of resectability; seven patients were considered to be resectable by one MDT but unresectable by another. The MDTs all agreed on either a curative or palliative strategy in less than half of the patients (9 of 19). Only fair agreement in treatment allocation was observed (Krippendorff's α 0·31, 95 per cent c.i. 0·16 to 0·45). There was a high level of agreement in treatment allocation where resectability assessments were concordant. CONCLUSION Considerable disparities in MDT evaluations of patients with pancreatic cancer exist, including substantial variation in resectability assessments.
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Affiliation(s)
- J Kirkegård
- Department of Surgery, Hepatopancreatobiliary (HPB) Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - E K Aahlin
- Department of Gastrointestinal and HPB Surgery, University Hospital of Northern Norway, Breivika, Norway
| | - M Al-Saiddi
- Department of Radiology, Stavanger University Hospital, Stavanger, Norway
| | - S O Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Coolsen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - R J de Haas
- Department of Radiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - M den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, RWTH University Hospital, Aachen, Germany
| | - C Fristrup
- Odense Pancreas Centre, Department of Surgical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - E M Harrison
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M B Mortensen
- Odense Pancreas Centre, Department of Surgical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - M W Nijkamp
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - J Persson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J A Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - S J Wigmore
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - T Wik
- Department of Radiology, University Hospital of Northern Norway, Breivika, Norway
| | - F V Mortensen
- Department of Surgery, Hepatopancreatobiliary (HPB) Research Unit, Aarhus University Hospital, Aarhus, Denmark
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9
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Jones CH, O'Neill S, McLean KA, Wigmore SJ, Harrison EM. Patient experience and overall satisfaction after emergency abdominal surgery. BMC Surg 2017; 17:76. [PMID: 28668089 PMCID: PMC5494126 DOI: 10.1186/s12893-017-0271-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 06/22/2017] [Indexed: 12/28/2022] Open
Abstract
Background There is a growing recognition of the importance of patient experience in healthcare, however little is known in the context of emergency abdominal surgery. This study sought to quantify the association between patient experience and overall satisfaction. Methods Patient demographics, operation details and 30-day clinical outcome data of consecutive patients undergoing emergency abdominal surgery were collected. Data was collected using validated Patient Reported Experience Measures (PREMs) questionnaires. Categorical data were tested using Mann Whitney U test. Multivariable regression was used to determine independent factors associated with satisfaction. Results In a well-fitting multivariable analysis (R2 = 0.71), variables significantly associated with a higher global satisfaction score were “sufficient information given about treatment” (β = 0.86, 95% CI 0.01–1.70, p = 0.047), "sufficient explanation of risks and benefits of surgery" (β = 1.26, 95% CI 0.18–2.34, p = 0.020), “absence of night-time noise” (β = 1.35, 95% CI 0.56–2.14, p = 0.001) and “confidence and trust in nurses” (β = 1.51, 95% CI 0.54–2.49, p = 0.003). Conclusions Overall patient satisfaction was strongly associated with perceptions of good communication and transfer of information. Confidence and trust in the clinical team is an important determinant of patient experience. Improving the ward environment by reducing noise at night may also improve the overall experience and satisfaction in emergency surgery.
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Affiliation(s)
- C H Jones
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - S O'Neill
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - K A McLean
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - S J Wigmore
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - E M Harrison
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
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10
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Affiliation(s)
- S J Wigmore
- Transplantation Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
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11
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Hughes MJ, Harrison EM, Peel NJ, Stutchfield B, McNally S, Beattie C, Wigmore SJ. Randomized clinical trial of perioperative nerve block and continuous local anaesthetic infiltration via wound catheter versus epidural analgesia in open liver resection (LIVER 2 trial). Br J Surg 2015; 102:1619-28. [PMID: 26447461 DOI: 10.1002/bjs.9949] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 08/04/2015] [Accepted: 08/25/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Analgesia after liver surgery remains controversial. A previous randomized trial of continuous wound infiltration (CWI) versus thoracic epidural analgesia (TEA) after liver surgery (LIVER trial) showed a faster recovery time in the wound infiltration group but better early postoperative pain scores in the TEA group. High-level evidence is, however, limited and opinion remains divided. The aim was to determine whether there is a difference in functional recovery time between patients having CWI plus abdominal nerve blocks versus TEA after liver resection. METHODS A randomized unblinded clinical trial of patients undergoing open liver resection was commenced in December 2012, with follow-up to August 2014. Patients were randomized to receive either wound catheter and nerve block (CWI group) or TEA for 48 h after surgery. The primary outcome measure was functional recovery time. Secondary outcomes were pain scores, complication rates, inflammatory response and central venous pressure (CVP) during transection. RESULTS Of 50 patients randomized initially to each group, 44 received TEA and 49 CWI. Median (i.q.r.) recovery time was 6·5 (5-9·75) and 5·75 (4-7) days in the TEA and CWI groups respectively (P = 0·036). Pain scores were not significantly different between the two groups, and there were no differences in morbidity, inflammatory response or CVP during transection. CONCLUSION Wound infiltration is associated with a reduced time to recovery after open liver resection compared with epidural analgesia. TEA does not offer an advantage over CWI in terms of attenuation of the inflammatory response or pain scores. REGISTRATION NUMBER NCT01747122 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- M J Hughes
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - E M Harrison
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - N J Peel
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - B Stutchfield
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S McNally
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - C Beattie
- Departments of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S J Wigmore
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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12
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Wigmore SJ. Donor age as a risk factor in donation after circulatory death liver transplantation in a controlled withdrawal protocol programme (Br J Surg 2014; 101: 784-792). Br J Surg 2014; 101:793. [PMID: 24817651 DOI: 10.1002/bjs.9531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 03/11/2014] [Indexed: 11/09/2022]
Affiliation(s)
- S J Wigmore
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
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13
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O'Neill S, Leuschner S, McNally SJ, Garden OJ, Wigmore SJ, Harrison EM. Meta-analysis of ischaemic preconditioning for liver resections. Br J Surg 2014; 100:1689-700. [PMID: 24227353 DOI: 10.1002/bjs.9277] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Vascular clamping reduces blood loss during liver resection but leads to ischaemia-reperfusion injury. Ischaemic preconditioning (IP) may reduce this. This study aimed to evaluate IP in liver resection under clamping. METHODS This was a systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating IP in adults undergoing liver resection under either continuous clamping (CC) or intermittent clamping (IC). Primary outcomes were mortality, liver failure and morbidity. Secondary outcomes included duration of operation, blood loss, length of hospital stay, length of intensive therapy unit stay, transfusion requirements, prothrombin time, and bilirubin and aminotransferase levels. Weighted mean differences were calculated for continuous data, and pooled odds ratios (ORs) for dichotomous data. Results were produced with a random-effects model with 95 per cent confidence intervals (c.i.). RESULTS A total of 2960 records were identified and 11 RCTs included 669 patients (IP 331, control 338). No significant difference in mortality (6 RCTs; IP 186, control 190; OR 1·36, 95 per cent c.i. 0·13 to 13·68; P = 0·80) or morbidity (6 RCTs; IP 186, control 190; OR 0·58, 0·31 to 1·07; P = 0·08) was found for IP plus CC versus CC. Nor was there a significant difference in mortality (4 RCTs; IP 122, control 121; OR 1·33, 0·24 to 7·32; P = 0·74) or morbidity (4 RCTs; IP 122, control 121; OR 0·87, 0·52 to 1·47; P = 0·61) for IP plus (CC or IC) versus IC. No significant differences were found for secondary outcome measures. CONCLUSION This meta-analysis failed to find a significant benefit of IP in liver resection.
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Affiliation(s)
- S O'Neill
- Medical Research Council Centre for Inflammation Research, Tissue Injury and Repair Group, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent,, Edinburgh EH16 4SA, UK
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14
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Ventham NT, Hughes M, O'Neill S, Johns N, Brady RR, Wigmore SJ. Systematic review and meta-analysis of continuous local anaesthetic wound infiltration versus epidural analgesia for postoperative pain following abdominal surgery. Br J Surg 2013; 100:1280-9. [PMID: 24244968 DOI: 10.1002/bjs.9204] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Local anaesthetic wound infiltration techniques reduce opiate requirements and pain scores. Wound catheters have been introduced to increase the duration of action of local anaesthetic by continuous infusion. The aim was to compare these infiltration techniques with the current standard of epidural analgesia. METHODS A meta-analysis of randomized clinical trials (RCTs) evaluating wound infiltration versus epidural analgesia in abdominal surgery was performed. The primary outcome was pain score at rest after 24 h on a numerical rating scale. Secondary outcomes were pain scores at rest at 48 h, and on movement at 24 and 48 h, with subgroup analysis according to incision type and administration regimen(continuous versus bolus), opiate requirements, nausea and vomiting, urinary retention, catheter-related complications and treatment failure. RESULTS Nine RCTs with a total of 505 patients were included. No differences in pain scores at rest 24 h after surgery were detected between epidural and wound infiltration. There were no significant differences in pain score at rest after 48 h, or on movement at 24 or 48 h after surgery. Epidural analgesia demonstrated a non-significant a trend towards reduced pain scores on movement and reduced opiate requirements. There was a reduced incidence of urinary retention in the wound catheter group. CONCLUSION Within a heterogeneous group of RCTs, use of local anaesthetic wound infiltration was associated with pain scores comparable to those obtained with epidural analgesia. Further procedure-specific RCTs including broader measures of recovery are recommended to compare the overall efficacy of epidural and wound infiltration analgesic techniques.
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15
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Abstract
With recent 'working-time'-related changes to surgical training structure, the value of dedicated research during surgical training has been questioned. Online survey examining career and academic outcomes following a period of surgically related dedicated research at a Scottish University between 1972 and 2007. Of 58 individuals identified, contact details were available for 49 and 43 (88%) responded. Ninety-five percent (n = 41) of respondents continue to pursue a career in surgery and 41% (n = 17) are currently in academic positions. Ninety-one percent (n = 39) had published one or more first-author peer-reviewed articles directly related to their research, with 53% (n = 23) publishing three or more. Respondents with a clinical component to their research published significantly more papers than those with purely laboratory-based research (P = 0.04). Eighty-one percent (n = 35) thought that research was necessary for career progression, but only 42% (n = 18) felt research should be integral to training. In conclusion, the majority of surgical trainees completing a dedicated research period, published papers and continued to pursue a surgical career with a research interest. A period of dedicated research was thought necessary for career progression, but few thought dedicated research should be integral to surgical training.
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Affiliation(s)
- B M Stutchfield
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Edinburgh, Scotland, UK.
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16
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McNally SJ, Wigmore SJ. The Scottish Liver Transplant Unit: current and future perspectives. Scott Med J 2011; 56:223-6. [PMID: 22089045 DOI: 10.1258/smj.2011.011162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Scottish Liver Transplant Unit (SLTU) opened in 1992 and has now performed over 900 liver transplants. During this time there have been major changes in both organ donation and transplantation. Currently liver transplantation is restricted by limited organ supply. Scotland has one of the lowest rates of organ donation in Europe and one of the most rapidly increasing rates of cirrhosis. The consequent waiting list mortality has driven innovations including increasing use of marginal grafts, organs donated after cardiac death, split-liver transplants and the development of living-donor liver transplantation. To maintain liver transplantation, there is an urgent need to increase organ donation rates and to find novel treatments which optimize outcomes from marginal grafts. This review addresses the surgical aspects of liver transplantation and how these have evolved over the two past decades. Major changes are currently underway in organ donation organization, and there is continuing refinement of organ treatment and storage. A number of measures to maintain and improve organ preservation and function are currently being evaluated in clinical trials, and cell therapy holds significant potential for the future. Scotland has a rising need for liver transplantation and the SLTU continues to provide high-quality care and to be at the forefront of the latest advances in organ transplantation.
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Affiliation(s)
- S J McNally
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK.
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17
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Affiliation(s)
- S J Wigmore
- Department of Transplantation Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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18
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Stutchfield BM, Simpson K, Wigmore SJ. Systematic review and meta-analysis of survival following extracorporeal liver support. Br J Surg 2011; 98:623-31. [DOI: 10.1002/bjs.7418] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2010] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Extracorporeal liver support (ELS) systems offer the potential to prolong survival in acute and acute-on-chronic liver failure. However, the literature has been unclear on their specific role and influence on mortality. This meta-analysis aimed to test the hypothesis that ELS improves survival in acute and acute-on-chronic liver failure.
Methods
Clinical trials citing MeSH terms ‘liver failure’ and ‘liver, artificial’ were identified by searching MEDLINE, Embase and the Cochrane registry of randomized controlled trials (RCTs) between January 1995 and January 2010. Only RCTs comparing ELS with standard medical therapy in acute or acute-on-chronic liver failure were included. A predefined data collection pro forma was used and study quality assessed according to Consolidated Standards of Reporting Trials (CONSORT) criteria. Risk ratio was used as the effect size measure according to a random-effects model.
Results
The search strategy revealed 74 clinical studies including 17 RCTs, five case–control studies and 52 cohort studies. Eight RCTs were suitable for inclusion, three addressing acute liver failure (198 participants) and five acute-on-chronic liver failure (157 participants). The mean CONSORT score was 14 (range 11–20). Overall ELS therapy significantly improved survival in acute liver failure (risk ratio 0·70; P = 0·05). The number needed to treat to prevent one death in acute liver failure was eight. No significant survival benefit was demonstrated in acute-on-chronic liver failure (risk ratio 0·87; P = 0·37).
Conclusion
ELS systems appear to improve survival in acute liver failure. There is, however, no evidence that they improve survival in acute-on-chronic liver failure.
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Affiliation(s)
- B M Stutchfield
- Department of Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - K Simpson
- Department of Hepatology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - S J Wigmore
- Department of Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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19
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Wigmore SJ. Similar liver transplantation survival with selected cardiac death donors and brain death donors (Br J Surg 2010; 97: 744-753). Br J Surg 2010; 97:753. [PMID: 20393980 DOI: 10.1002/bjs.7080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- S J Wigmore
- Department of Transplantation Surgery, University of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
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20
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Affiliation(s)
- L Devey
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
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21
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Deans DAC, Tan BH, Wigmore SJ, Ross JA, de Beaux AC, Paterson-Brown S, Fearon KCH. The influence of systemic inflammation, dietary intake and stage of disease on rate of weight loss in patients with gastro-oesophageal cancer. Br J Cancer 2009; 100:63-9. [PMID: 19127266 PMCID: PMC2634686 DOI: 10.1038/sj.bjc.6604828] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/05/2008] [Accepted: 11/21/2008] [Indexed: 02/06/2023] Open
Abstract
Although weight loss is often a dominant symptom in patients with upper gastrointestinal malignancy, there is a lack of objective evidence describing changes in nutritional status and potential associations between weight loss, food intake, markers of systemic inflammation and stage of disease in such patients. Two hundred and twenty patients diagnosed with gastric/oesophageal cancer were studied. Patients underwent nutritional assessment consisting of calculation of body mass index, measurement of weight loss, dysphagia scoring and estimation of dietary intake. Serum acute-phase protein concentrations were determined by enzyme-linked immunosorbent assay. In all, 182 (83%) patients had lost weight at diagnosis (median loss, 7% body weight). Weight loss was associated with poor performance status, advanced disease stage, dysphagia, reduced dietary intake and elevated serum C-reactive protein (CRP) concentrations. Multiple regression identified dietary intake (estimate of effect, 38%), serum CRP concentrations (estimate of effect, 34%) and stage of disease (estimate of effect, 28%) as independent variables in determining degree of weight loss. Mechanisms other than reduced dietary intake or mechanical obstruction by the tumour appear to be involved in the nutritional decline in patients with gastro-oesophageal malignancy. Recognition that systemic inflammation plays a role in nutritional depletion may inform the development of appropriate therapeutic strategies to ameliorate weight loss, making patients more tolerant of cancer-modifying treatments such as chemotherapy.
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Affiliation(s)
- D A C Deans
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - B H Tan
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - S J Wigmore
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - J A Ross
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - A C de Beaux
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - S Paterson-Brown
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - K C H Fearon
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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Abstract
In vivo models of hepatic ischaemia/reperfusion injury (IRI) are widely used to study both the mechanisms of hepatic ischaemic injury and to seek means of hepatic protection. Achieving high-quality reproducible data are essential if the results of multiple studies are to be compared and reconciled. This paper presents our findings concerning the effect of intraoperative thermoregulation upon signal to noise ratios of hepatic IRI experiments in mice. Four experiments were conducted, using three different strategies for core temperature maintenance. Animals underwent hepatic IRI and euthanized 24 h postoperatively for measurement of plasma alanine aminotransferase (ALT). Duration of ischaemia was used to adjust the severity of injury. Experiment 1 utilized a constant output heating system and resulted in rising postoperative ALTs following increasing durations of hepatic ischaemia. Experiment 2, using the same constant output heating system confirmed a difference between ischaemic and sham-operated animals. Experiment 3 used a thermostatically controlled heating system and resulted in highly variable results with a small, but statistically significant correlation between ALT levels and rectal temperature readings. Experiment 4 used a homeothermic warming system and demonstrated highly reproducible data from increasing durations of ischaemia. High-quality data from hepatic ischaemia/reperfusion models are dependent upon careful control of intraoperative temperature. The use of homeothermic warming systems is recommended and conversely, the use of thermostatically controlled warming mats is to be avoided in these models.
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Affiliation(s)
- L Devey
- Liver Research Group, Institute of Biomedical Research, University of Birmingham, 5th Floor, Wolfson Drive, Edgbaston, Birmingham B15 2TT, UK.
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23
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Mehta NN, Ravikumar R, Coldham CA, Buckels JAC, Hubscher SG, Bramhall SR, Wigmore SJ, Mayer AD, Mirza DF. Effect of preoperative chemotherapy on liver resection for colorectal liver metastases. Eur J Surg Oncol 2007; 34:782-6. [PMID: 18160247 DOI: 10.1016/j.ejso.2007.09.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Accepted: 09/04/2007] [Indexed: 12/18/2022] Open
Abstract
AIM To compare the effects of preoperative chemotherapy on liver parenchyma morphology, as well as morbidity and mortality after liver resection for colorectal liver metastases. METHODS Prospectively collected data on 173 patients undergoing liver resection for CLM between 1/2003 and 9/2005 was analysed in three groups: A: preoperative oxaliplatin (Ox, n=70); B: other chemotherapeutic agents (OC, n=60); and C: surgery alone without chemotherapy (SA, n=43). Blood transfusion, hospital stay, operative procedure, peak postoperative bilirubin levels, complications and histopathology of the resected liver were compared. RESULTS Intra-operative blood transfusion requirement (34%) and biliary complications (16%) was higher in patients receiving oxaliplatin-based chemotherapy (p=0.01 and p=0.06, respectively). Oxaliplatin-based chemotherapy was also associated with sinusoidal dilatation of mild grade in 52.8% vs. 26.6% and 23.3% patients (p=0.007 and p=0.004) in other groups, respectively. Steatosis was similarly distributed across the study group. Postoperative mortality was 2, 1 and 4 patients, respectively (p=ns). CONCLUSION Oxaliplatin-based preoperative chemotherapy is associated with vascular alterations in the liver parenchyma without significantly increasing the risk of steatosis, or postoperative morbidity and mortality.
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Affiliation(s)
- N N Mehta
- Hepato-biliary-pancreatic Surgery and Liver Transplant Unit, Nuffield House, Queen Elizabeth Hospital, Edgbaston, Birmingham B152TH, UK
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Deans DAC, Wigmore SJ, Gilmour H, Tisdale MJ, Fearon KCH, Ross JA. Reply: Expression of the proteolysis-inducing factor core-peptide mRNA is upregulated in both tumour and adjacent normal tissue in gastrooesophageal malignancy. Br J Cancer 2007; 98:243. [PMID: 18087288 PMCID: PMC2359703 DOI: 10.1038/sj.bjc.6604117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- D A C Deans
- 1Tissue Injury and Repair Group, Clinical and Surgical Sciences, University of Edinburgh, The Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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25
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Deans DAC, Wigmore SJ, de Beaux AC, Paterson-Brown S, Garden OJ, Fearon KCH. Clinical prognostic scoring system to aid decision-making in gastro-oesophageal cancer. Br J Surg 2007; 94:1501-8. [PMID: 17703501 DOI: 10.1002/bjs.5849] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Accurate prediction of prognosis in gastro-oesophageal cancer remains challenging. The aim of this study was to develop a robust model for outcome prediction.
Methods
The study included 220 patients with gastric or oesophageal cancer newly diagnosed over a 2-year period. Patients were staged and underwent treatment following discussion at a multidisciplinary team (MDT) meeting. Clinical and investigative variables were collected, including performance and nutritional status, and serum C-reactive protein (CRP) level. Primary endpoints were death within 12 and 24 months.
Results
Overall median survival was 13 months. Advanced clinical stage (P < 0·001), reduced performance score (P < 0·001), weight loss exceeding 2·75 per cent per month (P = 0·026) and serum CRP concentration above 5 mg/l (P = 0·031) were identified as independent prognostic indicators in multivariable analysis. A prognostic score was constructed using these four variables to estimate a probability of death. Applying the model gave an area under the receiver–operator characteristic curve of 0·84 and 0·85 for prediction of death at 12 and 24 months respectively (both P < 0·001).
Conclusion
This model accurately estimated the probability of death within 12 and 24 months. This may aid the MDT decision-making process.
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Affiliation(s)
- D A C Deans
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK.
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Affiliation(s)
- C S Bhati
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Richards DA, Silva MA, Murphy N, Wigmore SJ, Mirza DF. Extracellular amino acid levels in the human liver during transplantation: a microdialysis study from donor to recipient. Amino Acids 2007; 33:429-37. [PMID: 17235452 DOI: 10.1007/s00726-006-0480-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Accepted: 11/20/2006] [Indexed: 11/28/2022]
Abstract
Using microdialysis, we have monitored extracellular levels of amino acids and related amines in the human liver at three stages of the transplantation procedure: donor retrieval, back table preparation and during 48 h post-implantation. By comparing the ratio of mean levels at the donor and back table stages, with the ratio between early (2-6 h) and late (43-48 h) post-reperfusion, these amines were classified into one of three groups. In one group, back table levels were markedly higher than during the donor stage, with levels declining over time post-reperfusion. A second group had much lower levels in the back table than during the donor phase, and post-reperfusion levels were either stable or increased over time. Concentrations of amino acids in the final group remained relatively constant at all stages. This study illustrates the value of microdialysis in providing organ-specific metabolic data that may indicate specific mechanisms of poor graft function.
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Affiliation(s)
- D A Richards
- Department of Pharmacology, Medical School, University of Birmingham, Edgbaston, Birmingham, UK.
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Deans DAC, Wigmore SJ, Gilmour H, Paterson-Brown S, Ross JA, Fearon KCH. Elevated tumour interleukin-1beta is associated with systemic inflammation: A marker of reduced survival in gastro-oesophageal cancer. Br J Cancer 2006; 95:1568-75. [PMID: 17088911 PMCID: PMC2360731 DOI: 10.1038/sj.bjc.6603446] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Systemic inflammation is associated with adverse prognosis cancer but its aetiology remains unclear. We investigated the expression of proinflammatory cytokines within normal mucosa from healthy controls and tumour tissue in cancer patients and related these levels with markers of systemic inflammation and with the presence of a tumour inflammatory infiltrate. Tissue was collected from 56 patients with gastro-oesophageal cancer and from 12 healthy controls. Tissue cytokine mRNA concentrations were measured by real-time PCR and tissue protein concentrations by cytometric bead array. The degree of chronic inflammatory cell infiltrate was recorded. Serum cytokine and acute phase protein concentrations (including C-reactive protein (CRP)) were measured by enzyme-linked immunosorbent assay. Proinflammatory cytokines were significantly overexpressed (interleukin (IL)-1β, IL-6, IL-8 and tumour necrosis factor-α) both at mRNA and protein levels in the cancer specimens compared with mucosa from controls. Interleukin-1β was expressed in greatest (10–100-fold) concentration and protein levels correlated significantly with systemic inflammation (CRP) (P=0.05, r=0.31). A chronic inflammatory infiltrate was observed in 75% of the cancer specimens and was associated with systemic inflammation (CRP: P=0.01). However, the presence of chronic inflammation per se was not associated with altered cytokine expression within the tumour. Both a chronic inflammatory infiltrate and systemic inflammation (CRP) were associated with reduced survival (P=0.05 and P=0.03, respectively). Tumour chronic inflammatory infiltrate and tumour tissue IL-1β overexpression are potential independent factors influencing systemic inflammation in oesophagogastric cancer patients.
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Affiliation(s)
- D A C Deans
- Tissue Injury and Repair Group, Department of Clinical and Surgical Sciences, MRC Centre for Inflammation Research, The Chancellor's Building, Edinburgh University, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - S J Wigmore
- Tissue Injury and Repair Group, Department of Clinical and Surgical Sciences, MRC Centre for Inflammation Research, The Chancellor's Building, Edinburgh University, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - H Gilmour
- Tissue Injury and Repair Group, Department of Clinical and Surgical Sciences, MRC Centre for Inflammation Research, The Chancellor's Building, Edinburgh University, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - S Paterson-Brown
- Tissue Injury and Repair Group, Department of Clinical and Surgical Sciences, MRC Centre for Inflammation Research, The Chancellor's Building, Edinburgh University, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - J A Ross
- Tissue Injury and Repair Group, Department of Clinical and Surgical Sciences, MRC Centre for Inflammation Research, The Chancellor's Building, Edinburgh University, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - K C H Fearon
- Tissue Injury and Repair Group, Department of Clinical and Surgical Sciences, MRC Centre for Inflammation Research, The Chancellor's Building, Edinburgh University, 49 Little France Crescent, Edinburgh EH16 4SB, UK
- University Department of Surgery, Royal Infirmary, 51 Little France Crescent, Edinburgh EH16 4SA UK. E-mail:
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Lowrie AG, Wigmore SJ, Wright DJ, Waddell ID, Ross JA. Dermcidin expression in hepatic cells improves survival without N-glycosylation, but requires asparagine residues. Br J Cancer 2006; 94:1663-71. [PMID: 16685272 PMCID: PMC2361319 DOI: 10.1038/sj.bjc.6603148] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Proteolysis-inducing factor, a cachexia-inducing tumour product, is an N-glycosylated peptide with homology to the unglycosylated neuronal survival peptide Y-P30 and a predicted product of the dermcidin gene, a pro-survival oncogene in breast cancer. We aimed to investigate whether dermcidin is pro-survival in liver cells, in which proteolysis-inducing factor induces catabolism, and to determine the role of potentially glycosylated asparagine residues in this function. Reverse cloning of proteolysis-inducing factor demonstrated ∼100% homology with the dermcidin cDNA. This cDNA was cloned into pcDNA3.1+ and both asparagine residues removed using site-directed mutagenesis. In vitro translation demonstrated signal peptide production, but no difference in molecular weight between the products of native and mutant vectors. Immunocytochemistry of HuH7 cells transiently transfected with V5-His-tagged dermcidin confirmed targeting to the secretory pathway. Stable transfection conferred protection against oxidative stress. This was abrogated by mutation of both asparagines in combination, but not by mutation of either asparagine alone. These findings suggest that dermcidin may function as an oncogene in hepatic as well as breast cells. Glycosylation does not appear to be required, but the importance of asparagine residues suggests a role for the proteolysis-inducing factor core peptide domain.
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Affiliation(s)
- A G Lowrie
- Tissue Injury and Repair Group, Chancellor's Building, The University of Edinburgh Medical School, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK.
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Koukoutsis I, Bellagamba R, Morris-Stiff G, Wickremesekera S, Coldham C, Wigmore SJ, Mayer AD, Mirza DF, Buckels JAC, Bramhall SR. Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed. Dig Surg 2006; 23:224-8. [PMID: 16874003 DOI: 10.1159/000094754] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2006] [Accepted: 05/25/2006] [Indexed: 12/22/2022]
Abstract
AIM To document the prevalence and to evaluate the management strategies of haemorrhagic complications following pancreaticoduodenectomy (PD). METHODS All patients who underwent PD from 1/2000 to 10/2005 and experienced at least one episode of haemorrhage during the 30 first days postoperatively were recorded. Etiology of haemorrhage, treatment strategy and mortality rate were recorded and analyzed. RESULTS A total of 362 patients underwent PD during this period and 32 (8.8%) had haemorrhage postoperatively of whom 15 died (47% mortality rate). Primary intraluminal haemorrhage was recorded in 13 patients, primary intra-abdominal haemorrhage in 5 patients and secondary haemorrhage in 14 patients. Successful management of haemorrhage with angioembilization occurred in 2 patients in the study group. Statistical analysis revealed sepsis and sentinel bleed as risk factors for post-PD haemorrhage and pancreatic leak and sentinel bleed as risk factors for secondary haemorrhage (p < 0.05). CONCLUSIONS Haemorrhage after PD is a life-threatening complication. Sepsis, pancreatic leak, and sentinel bleed are statistical significant factors predicting post-PD haemorrhage. Sentinel bleed is not statistically significant associated with postoperative mortality, but with the onset of secondary haemorrhage. The effectiveness of therapeutic angioembolization was not demonstrated in our study.
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Affiliation(s)
- I Koukoutsis
- Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg 2006; 93:738-44. [PMID: 16671062 DOI: 10.1002/bjs.5290] [Citation(s) in RCA: 336] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mortality in patients with acute pancreatitis is associated with the number of failing organs and the severity and reversibility of organ dysfunction. The aim of this study was to assess the significance of early systemic inflammatory response syndrome (SIRS) in the development of multiorgan dysfunction syndrome (MODS) and death from acute pancreatitis. METHODS Data for all patients with a diagnosis of acute pancreatitis between January 2000 and December 2004 were reviewed. Serum C-reactive protein (CRP), Acute Physiology And Chronic Health Evaluation (APACHE) II scores and presence of SIRS were recorded on admission and at 48 h. Marshall organ dysfunction scores were calculated during the first week of presentation. Presence of SIRS and raised serum CRP levels on admission and at 48 h were correlated with the cumulative organ dysfunction scores in the first week. RESULTS A total of 759 patients with acute pancreatitis were identified, of whom 45 (5.9 per cent) died during the index admission. SIRS was identified in 162 patients on admission and was persistent in 138 at 48 h. The median (range) cumulative Marshall score in patients with persistent SIRS was significantly higher than that in patients in whom SIRS resolved and in those with no SIRS (4 (0-12), 3 (0-7) and 0 (0-9) respectively; P < 0.001). Thirty-five patients (25.4 per cent) with persistent SIRS died from acute pancreatitis, compared with six patients (8 per cent) with transient SIRS and four (0.7 per cent) without SIRS (P < 0.001). No correlation was observed between CRP level on admission and Marshall score (P = 0.810); however, there was a close correlation between CRP level at 48 h and Marshall score (P < 0.001). CONCLUSION Persistent SIRS is associated with MODS and death in patients with acute pancreatitis and is an early indicator of the likely severity of acute pancreatitis.
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Affiliation(s)
- R Mofidi
- Department of Clinical and Surgical Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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Deans DAC, Wigmore SJ, Gilmour H, Tisdale MJ, Fearon KCH, Ross JA. Expression of the proteolysis-inducing factor core peptide mRNA is upregulated in both tumour and adjacent normal tissue in gastro-oesophageal malignancy. Br J Cancer 2006; 94:731-6. [PMID: 16495932 PMCID: PMC2361198 DOI: 10.1038/sj.bjc.6602989] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Gastro-oesophageal cancer is associated with a high incidence of cachexia. Proteolysis-inducing factor (PIF) has been identified as a possible cachectic factor and studies suggest that PIF is produced exclusively by tumour cells. We investigated PIF core peptide (PIF-CP) mRNA expression in tumour and benign tissue from patients with gastro-oesophageal cancer and in gastro-oesophageal biopsies for healthy volunteers. Tumour tissue and adjacent benign tissue were collected from patients with gastric and oesophageal cancer (n=46) and from benign tissue only in healthy controls (n=11). Expression of PIF-CP mRNA was quantified by real-time PCR. Clinical and pathological information along with nutritional status was collected prospectively. In the cancer patients, PIF-CP mRNA was detected in 27 (59%) tumour samples and 31 (67%) adjacent benign tissue samples. Four (36%) gastro-oesophageal biopsies from healthy controls also expressed PIF-CP mRNA. Expression was higher in tumour tissue (P=0.031) and benign tissue (P=0.022) from cancer patients compared with healthy controls. In the cancer patients, tumour and adjacent benign tissue PIF-CP mRNA concentrations were correlated with each other (P<0.0001, r=0.73) but did not correlate with weight loss or prognosis. Although PIF-CP mRNA expression is upregulated in both tumour and adjacent normal tissue in gastro-oesophageal malignancy, expression does not relate to prognosis or cachexia. Post-translational modification of PIF may be a key step in determining the biological role of PIF in the patient with advanced cancer and cachexia.
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Affiliation(s)
- D A C Deans
- Department of Clinical and Surgical Sciences, Cell Injury and Apoptosis Section, Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Edinburgh University, The Chancellor's Building, (SU227) 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - S J Wigmore
- Department of Clinical and Surgical Sciences, Cell Injury and Apoptosis Section, Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Edinburgh University, The Chancellor's Building, (SU227) 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - H Gilmour
- Department of Pathology, Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - M J Tisdale
- Department of Pharmaceutical Sciences, Aston University, Birmingham, UK
| | - K C H Fearon
- Department of Clinical and Surgical Sciences, Cell Injury and Apoptosis Section, Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Edinburgh University, The Chancellor's Building, (SU227) 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - J A Ross
- Department of Clinical and Surgical Sciences, Cell Injury and Apoptosis Section, Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Edinburgh University, The Chancellor's Building, (SU227) 49 Little France Crescent, Edinburgh EH16 4SB, UK
- Department of Clinical and Surgical Sciences, Cell Injury and Apoptosis Section, Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Edinburgh University, The Chancellor's Building, (SU227) 49 Little France Crescent, Edinburgh EH16 4SB, UK. E-mail:
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Thomson BNJ, Parks RW, Redhead DN, Welsh FKS, Madhavan KK, Wigmore SJ, Garden OJ. Refining the role of laparoscopy and laparoscopic ultrasound in the staging of presumed pancreatic head and ampullary tumours. Br J Cancer 2006; 94:213-7. [PMID: 16434983 PMCID: PMC2361120 DOI: 10.1038/sj.bjc.6602919] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Laparoscopy and laparoscopic ultrasound have been validated previously as staging tools for pancreatic cancer. The aim of this study was to identify if assessment of vascular involvement with abdominal computed tomography (CT) would allow refinement of the selection criteria for laparoscopy and laparoscopic ultrasound (LUS). The details of patients staged with LUS and abdominal CT were obtained from the unit's pancreatic cancer database. A CT grade (O, A-F) of vascular involvement was recorded by a single radiologist. Of 152 patients, who underwent a LUS, 56 (37%) had unresectable disease. Three of 26 (12%) patients with CT grade O, 27 of 88 (31%) patients with CT grade A to D, 17 of 29 (59%) patients with CT grade E and all nine patients with CT grade F were found to have unresectable disease. In all, 24% of patients with tumours <3 cm were found to have unresectable disease. In those patients with tumours considered unresectable, local vascular involvement was found in 56% of patients and vascular involvement with metastatic disease in 17%, while 20% of patients had liver metastases alone and 5% had isolated peritoneal metastases. The remaining patient was deemed unfit for resection. Selective use of laparoscopic ultrasound is indicated in the staging of periampullary tumours with CT grades A to D.
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Affiliation(s)
- B N J Thomson
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - R W Parks
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK. E-mail:
| | - D N Redhead
- Department of Radiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - F K S Welsh
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - K K Madhavan
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - S J Wigmore
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - O J Garden
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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Abstract
BACKGROUND Considerable debate surrounds the timing of repair of injury to the common bile duct following cholecystectomy. In the absence of sepsis or significant peritoneal soiling, repair within the first week may be optimal. This study compared the outcome of early (within the first 2 weeks) and delayed (between 2 weeks and 6 months) repair. METHODS Data on all patients referred with biliary injuries were recorded prospectively. In the absence of sepsis or significant peritoneal soiling, repair was considered within 2 weeks. RESULTS Between November 1988 and November 2003, 123 patients were referred with injury to the biliary tree. Repair of the injury had been attempted in 55 patients (44.7 per cent) before referral. Of the 68 patients with no previous repair, nine were managed without surgery and 59 required subsequent surgical reconstruction of the ductal injury. Within the first 2 weeks after injury, 22 patients underwent primary biliary repair and three had revision of a failed biliary repair. Between 2 weeks and 6 months, a further 22 injuries were repaired. Successful repair was possible in 22 of 25 early repairs compared with 20 of 22 delayed repairs (P = 0.615). The overall operative mortality rate for patients undergoing repair was 4 per cent (two of 47 patients). CONCLUSION A successful outcome was achieved in a high proportion of patients (42 of 47) when repair of the bile duct injury was undertaken in a unit experienced in the management of biliary injury. In selected patients, early repair within the first 2 weeks resulted in a similar outcome to that of delayed repair.
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Affiliation(s)
- B N J Thomson
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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Gray MR, Joyce WP, Karran SJ, Wigmore SJ, Rainey JB. Restoration of intestinal continuity following Hartmann's procedure: The Lothian experience 1987–1992. Br J Surg 2005. [DOI: 10.1002/bjs.1800820843] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- M R Gray
- Department of Surgery, Lister Hospital, Coreys Mill Lane, Stevenage, Hertfordshire SG1 4AB, UK
| | - W P Joyce
- Department of Surgery, Cavan General Hospital, Cavan, Ireland
| | - S J Karran
- Department of Surgery, Royal South Hants Hospital, Southampton SO14 0YG, UK
| | - S J Wigmore
- Department of Surgery, The Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK
| | - J B Rainey
- Department of Surgery, The Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK
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Wigmore SJ, Plester CE, Ross JA, Fearon KCH. Contribution of anorexia and hypermetabolism to weight loss in anicteric patients with pancreatic cancer. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02525.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The shortage of organs for transplantation has led researchers to look for new techniques to expand the donor pool. Preconditioning strategies have the potential to protect organs from transplant associated injury or may improve the function of substandard organs so that they become suitable for transplantation. Translating this type of technology to the clinical setting raises ethical issues, particularly relating to the deceased donor. It is important that society has the opportunity to discuss the issues raised by implementation of preconditioning strategies before they are implemented rather than as a reaction to them.
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Affiliation(s)
- S J McNally
- Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Medical School (6 floor), University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK.
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Connor S, Alexakis N, Garden OJ, Leandros E, Bramis J, Wigmore SJ. Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery. Br J Surg 2005; 92:1059-67. [PMID: 16044410 DOI: 10.1002/bjs.5107] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The role of somatostatin and its analogues in reducing complications after pancreatic resection is controversial. This is a meta-analysis of the evidence of benefit. METHODS A literature search using Medline and ISI Proceedings with exploration of the references identified 22 studies. Of these, ten met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95 per cent confidence intervals (c.i.) using the Mantel-Haenszel method. Level of significance was set at P < 0.050. RESULTS Outcomes for 1918 patients were compared. Somatostatin and its analogues did not reduce the mortality rate after pancreatic surgery (OR 1.17 (0.70 to 1.94); P = 0.545) but did reduce both the total morbidity (OR 0.62 (0.46 to 0.85); P = 0.003) and pancreas-specific complications (OR 0.56 (0.39 to 0.81); P = 0.002). Somatostatin and its analogues reduced the rate of biochemical fistula (OR 0.45 (0.33 to 0.62); P < 0.001) but not the incidence of clinical anastomotic disruption (OR 0.80 (0.44 to 1.45); P = 0.459). CONCLUSION Somatostatin and its analogues reduce the incidence of complications after surgery.
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Affiliation(s)
- S Connor
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary, Edinburgh, UK
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Clayton RAE, Henderson J, McCracken SE, Wigmore SJ, Paterson-Brown S. Practical experience and confidence in managing emergencies among preregistration house officers. Postgrad Med J 2005; 81:396-400. [PMID: 15937207 PMCID: PMC1743297 DOI: 10.1136/pgmj.2004.024190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess the experience gained by pre-registration house officers (PRHOs) at the end of their first post. To assess confidence in managing common emergencies and experience gained in practical procedures. To compare traditional six month posts with four month posts and to compare the experiences of PRHOs posted in teaching hospitals (THs) with those based in district general hospitals (DGHs). DESIGN Interview questionnaire. PARTICIPANTS 152 graduates from Edinburgh University Medical School in 2000 who had completed their first PRHO post by February 2001. RESULTS There were few significant differences in confidence in managing emergencies and in numbers of practical procedures attempted between respondents from four and six month posts or between those holding TH and DGH posts. PRHOs had gained little experience in practical procedures: fewer than 15% had performed five or more of a number of procedures including lumbar puncture, pleural aspiration, chest drainage, and insertion of nasogastric tube. A high proportion of PRHOs indicated that they felt confident initiating management of conditions in specialties of which they had little or no experience. CONCLUSIONS Rotations of three four month posts do not seem to reduce overall experience in the PRHO year. There is little difference in experience gained between TH and DGH posts. PRHOs perform few practical procedures and some may be overconfident in their own abilities.
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Affiliation(s)
- R A E Clayton
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
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Wheelhouse NM, Lai PBS, Wigmore SJ, Ross JA, Harrison DJ. Mitochondrial D-loop mutations and deletion profiles of cancerous and noncancerous liver tissue in hepatitis B virus-infected liver. Br J Cancer 2005; 92:1268-72. [PMID: 15785740 PMCID: PMC2361973 DOI: 10.1038/sj.bjc.6602496] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The largest single underlying cause of hepatocellular carcinoma (HCC) worldwide is hepatitis B virus (HBV) infection. Hepatitis B virus increases cellular oxidative stress and the development of HCC occurs after a long latency period. The study was carried out to determine whether mitochondrial DNA abnormalities were associated with HCC in individuals with HBV. The frequency of mutation and deletion of specific areas of the mitochondrial genome in tumour and matched normal tissue of patients with HBV infection was investigated in the current study. The percentage of control subjects harbouring D-loop mutations was 11%, which was significantly lower than that observed in both the noncancerous (49%, P=0.033) and tumour tissue (59%, P=0.014) of patients with HCC. In contrast, the number of cases in which the common 4977 bp deletion of the mitochondrial genome was detected was significantly greater in control liver and noncancerous liver tissue of subjects with HCC (100 and 95%, respectively) than in cancerous liver tissue (28%, P<0.001). These observations suggest that the inflammatory process contributes to the rate of mitochondrial mutations. However, the lower frequency of the large deletion in cancerous tissue suggests that there is selection against either mitochondria, which harbour large deletions, or against cells that contain these mitochondria during hepatocarcinogenesis.
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Affiliation(s)
- N M Wheelhouse
- Cell Injury and Apoptosis Group, Edinburgh MRC Centre for Inflammation Research, College of Medicine and Veterinary Medicine, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK
| | - P B S Lai
- Department of Surgery, Division of Hepato-biliary and Pancreatic Surgery, Chinese University of Hong Kong, Hong Kong SAR, China
| | - S J Wigmore
- Cell Injury and Apoptosis Group, Edinburgh MRC Centre for Inflammation Research, College of Medicine and Veterinary Medicine, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK
| | - J A Ross
- Cell Injury and Apoptosis Group, Edinburgh MRC Centre for Inflammation Research, College of Medicine and Veterinary Medicine, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK
- Cell Injury and Apoptosis Group, Edinburgh MRC Centre for Inflammation Research, College of Medicine and Veterinary Medicine, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK. E-mail:
| | - D J Harrison
- Cell Injury and Apoptosis Group, Edinburgh MRC Centre for Inflammation Research, College of Medicine and Veterinary Medicine, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK
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Affiliation(s)
- S J Wigmore
- Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Medical School 6th Floor, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK
- Tissue Injury and Repair Group, MRC Centre for Inflammation Research, Medical School 6th Floor, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK. E-mail:
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42
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Abstract
BACKGROUND AND AIMS Major liver resection incurs a risk of postoperative liver dysfunction and infection and there is a lack of objective evidence relating residual liver volume to these complications. PATIENTS AND METHODS Liver volumetry was performed on computer models derived from computed tomography (CT) angioportograms of 104 patients with normal synthetic liver function scheduled for liver resection. Relative residual liver volume (%RLV) was calculated as the relation of residual to total functional liver volume and related to postoperative hepatic dysfunction and infection. Receiver operator characteristic curve analysis was undertaken to determine the critical %RLV predicting severe hepatic dysfunction and infection. Univariate analysis and multivariate logistic regression analysis were performed to delineate perioperative predictors of severe hepatic dysfunction and infection. RESULTS The incidence of severe hepatic dysfunction and infection following liver resection increased significantly with smaller %RLV. A critical %RLV of 26.6% was identified as associated with severe hepatic dysfunction (p<0.0001). Additionally, body mass index (BMI), operating time, and intraoperative blood loss were significant prognostic indicators for severe hepatic dysfunction. It was not possible to predict the individual risk of postoperative infection precisely by %RLV. However, in patients undergoing major liver resection, infection was significantly more common in those who developed postoperative severe hepatic dysfunction compared with those who did not (p=0.030). CONCLUSIONS The likelihood of severe hepatic dysfunction following liver resection can be predicted by a small %RLV and a high BMI whereas postoperative infection is more related to liver dysfunction than precise residual liver volume. Understanding the relationship between liver volume and synthetic and immune function is the key to improving the safety of major liver resection.
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Affiliation(s)
- M J Schindl
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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43
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Abstract
The majority of patients who present with hilar cholangiocarcinoma will have incurable disease and require only palliation. Efficient relief of disabling symptoms is required with minimal morbidity and mortality and can be achieved by either surgical or non-operative options. A review of the indications, anatomical considerations and surgical techniques is presented. Segment III cholangio-jejunostomy is the most frequently used surgical bypass procedure and in those patients with an expected survival of more than 6 months, surgical palliation offers good quality and long-lasting palliation. There is a need for randomized controlled data to define the optimal role of surgical palliation in this difficult disease.
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Affiliation(s)
- S. Connor
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - S. J. Wigmore
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - K. K. Madhavan
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - R. W. Parks
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - O. J. Garden
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
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44
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Stewart GD, O'Súilleabháin CB, Madhavan KK, Wigmore SJ, Parks RW, Garden OJ. The extent of resection influences outcome following hepatectomy for colorectal liver metastases. Eur J Surg Oncol 2004; 30:370-6. [PMID: 15063889 DOI: 10.1016/j.ejso.2004.01.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2004] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The acceptable indications for liver resection in patients with colorectal metastases have increased significantly in the last decade. It is thus becoming more difficult to ascertain the limitations for selection as the boundaries have been greatly extended. This has resulted in not only more extensive resections, but more atypical and bilobar resections. The aim of this study was to compare the outcome of patients undergoing different extent of liver resection in a specialist unit. METHODS All patients undergoing liver resection for colorectal metastases at the Royal Infirmary of Edinburgh between October 1988 and April 2001 were reviewed. Patients were allocated into one of three groups: standard group, extended group, and segmental group. Patient information was collected from a prospectively completed database. RESULTS One hundred and thirty-seven patients had liver resections for colorectal metastases during the study period. There were 69 standard hepatectomies, 41 extended resections and 27 segmental resections. CEA level was significantly lower in the segmental group(p = 0.012). There was a significant difference between the groups in terms of median operating time (p < 0.0001, Kruskal-Wallis test), operative blood loss (p = 0.006, Kruskal-Wallis test) and post-operative stay ( p = 0.036, Kruskal-Wallis test). Major post-operative complications were similar between standard and extended resections but less following segmental resection (p = 0.050. Predicted median survival was 51 months following standard resection, 23 months following extended resection and 59 months after segmental resection ( p = 0.037, log rank test), however, there was no difference between the three groups for actual 5-year survival (p = 0.662, Pearson chi-square test). CONCLUSION Morbidity and mortality rates were comparable with other previous studies as was overall survival, although survival in patients undergoing extended resections was reduced. There was an acceptable level of morbidity and mortality for all three groups. Patients undergoing segmental resection had fewer complications, shorter length of stay, and the longest median survival suggesting adequate oncological clearance. Segmental resection has a role for favourably placed tumour deposits if oncological clearance can be ensured. Extended liver resections have a role for selected patients with bilobar colorectal metastases or large solitary deposits close to the hepatic vein confluence.
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Affiliation(s)
- G D Stewart
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, University of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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45
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Wigmore SJ, Redhead DN, Thomson BNJ, Parks RW, Garden OJ. Predicting survival in patients with liver cancer considered for transarterial chemoembolization. Eur J Surg Oncol 2004; 30:41-5. [PMID: 14736521 DOI: 10.1016/j.ejso.2003.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Transarterial chemoembolization (TACE) has been used extensively to treat tumours confined to the liver in patients unsuitable for surgical resection. This study attempts to identify patients with liver cancer most likely to benefit from this type of treatment. PATIENTS AND METHODS All patients undergoing TACE for liver cancer between 1989 and 2001 were included in the study. RESULTS In a group of 137 consecutive patients undergoing TACE, univariate analysis identified a number of pre-treatment factors that were associated with poor prognosis. Multivariate analysis of these factors subsequently identified three pre-treatment factors; age greater than 60, serum alkaline phosphatase concentration >120U/l and albumin less than 35 g/l; that were independently and significantly associated with reduced survival duration. A scoring system was devised with one point allocated for each adverse factor which produced median survivals related to points scored as follows, 0 points-20 months, 1 point-12 months, 2 points-7 months and 3 points-4 months. To validate this scoring system the next 40 consecutive patients undergoing TACE were studied prospectively. These patients had median survival durations related to points scored as follows 0 points not calculable, 1 point-10 months, 2 points-7 months, 3 points-4 months. CONCLUSION This simple scoring system can be used to predict prognosis in patients with liver cancer and may assist in clinical decision making in the selection of patients likely to benefit from TACE.
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Affiliation(s)
- S J Wigmore
- Department of Clinical and Surgical Science, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, EH16 4SA Edinburgh, UK.
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46
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Abstract
Traumatic cholecystectomy is a rare condition that has always been described in the context of major trauma and associated liver or biliary injuries. We present a case of isolated traumatic cholecystectomy following a trivial injury which resulted in both a delayed presentation and a difficult diagnosis.
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Affiliation(s)
- P M Brennan
- Department of Clinical and Surgical Sciences (Surgery), The University of Edinburgh, Royal Infirmary, Edinburgh, UK
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47
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Abstract
BACKGROUND Pancreatico-bronchial fistulas are a rare complication of acute or chronic pancreatitis. Both conservative and surgical management have been described previously. CASE OUTLINE The management of a 68-year-old woman with acute pancreatitis complicated by a pancreatico-bronchial fistula was reviewed. CT scanning and magnetic resonance cholangio-pancreatography demonstrated a pancreatic pseudocyst with extension into the posterior mediastinum and right pleura. Despite conservative management as well as ERCP with pancreatic stent insertion, the fistula failed to resolve. Successful management of this difficult problem was achieved with distal pancreatectomy and intercostal drainage. DISCUSSION Pancreatico-bronchial fistulas may be managed conservatively, but there should be a low threshold for surgical intervention if endoscopic measures fail.
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Affiliation(s)
- BNJ Thomson
- Clinical and Surgical Sciences (Surgery), Royal Infirmary of EdinburghEdinburghUK
| | - SJ Wigmore
- Clinical and Surgical Sciences (Surgery), Royal Infirmary of EdinburghEdinburghUK
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48
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Abstract
Transarterial chemoembolisation of liver tumours is typically followed by elevated body temperature and liver transaminase enzymes. This has often been considered to indicate successful embolisation. The present study questions whether this syndrome reflects damage to tumour cells or to the normal hepatic tissue. The responses to 256 embolisations undertaken in 145 patients subdivided into those with hepatocyte-derived (primary hepatocellular carcinoma) and nonhepatocyte-derived tumours (secondary metastases) were analysed to assess the relative effects of tumour necrosis and damage to normal hepatocytes in each group. Cytolysis, measured by elevated alanine aminotransferase, was detected in 85% of patients, and there was no difference in the abnormalities in liver function tests measured between the two groups. Furthermore, cytolysis was associated with a higher rate of postprocedure symptoms and side effects, and elevated temperature was associated with a worse survival on univariate analysis. Multivariate analysis demonstrated that there was no benefit in terms of survival from having elevated temperature or cytolysis following embolisation. Cytolysis after chemoembolisation is probably due to damage to normal hepatocytes. Temperature changes may reflect tumour necrosis or necrosis of the healthy tissue. There is no evidence that either a postchemoembolisation fever or cytolysis is associated with an enhanced tumour response or improved long-term survival in patients with primary or secondary liver cancer.
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Affiliation(s)
- S J Wigmore
- Department of Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary, SI Little France Crescent, Edinburgh EH16 4SA, UK.
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49
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Affiliation(s)
- S J Wigmore
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK
| | - K C H Fearon
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK
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50
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Wigmore SJ, Fearon KCH, Sangster K, Maingay JP, Garden OJ, Ross JA. Cytokine regulation of constitutive production of interleukin-8 and -6 by human pancreatic cancer cell lines and serum cytokine concentrations in patients with pancreatic cancer. Int J Oncol 2002; 21:881-6. [PMID: 12239630 DOI: 10.3892/ijo.21.4.881] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Patients with pancreatic cancer frequently demonstrate symptoms such as weight-loss and muscle wasting and have clinical evidence of a systemic inflammatory response. Such effects may be mediated by pro-inflammatory cytokines derived from tumor cells. The production of interleukin-6 and -8 by pancreatic cancer cell lines and the influence of other cytokines on this production was studied. IL-8 was produced by all cell lines and production was increased following exposure to IL-1 and TNF. Cytokine-stimulated, but not basal IL-8 production was reduced by co-incubation with IL-4 in the MIA PaCa-2 and PANC-1 cell lines. The CFPAC cell line produced IL-6, but this production was not altered by IL-1, TNF or IL-4. In the PANC-1 cell line IL-8 and IL-8 receptors were only detected by PCR in cells which had been stimulated with TNF or IL-1. Serum concentrations of IL-6 and IL-8 were elevated in patients with pancreatic cancer compared with controls. In conclusion, human pancreatic cancer cell lines elaborate pro-inflammatory cytokines which have the potential to mediate elements of the systemic inflammatory response.
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Affiliation(s)
- S J Wigmore
- Department of Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh, EH3 9YW, UK
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