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Martin JL, Rhodes F, Upponi S, Udeaja Y, Swift L, Fear C, Webster R, Webb GJ, Allison M, Paterson A, Gaurav R, Butler AJ, Watson CJE. Localized Liver Injury During Normothermic Ex Situ Liver Perfusion Has No Impact on Short-term Liver Transplant Outcomes. Transplantation 2024:00007890-990000000-00677. [PMID: 38419153 DOI: 10.1097/tp.0000000000004970] [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: 03/02/2024]
Abstract
BACKGROUND Normothermic ex situ liver perfusion (NESLiP) has the potential to increase organ utilization. Radiological evidence of localized liver injury due to compression at the time of NESLiP, termed cradle compression, is a recognized phenomenon but is poorly characterized. METHODS A retrospective analysis of a prospectively collected database was performed of transplanted livers that underwent NESLiP and subsequently had a computed tomography performed within the first 14 d posttransplant. The primary study outcome was 1-y graft survival. RESULTS Seventy livers (63%) were included in the analysis. Radiological evidence of cradle compression was observed in 21 of 70 (30%). There was no difference in rate of cradle compression between donor after circulatory death and donated after brain death donors (P = 0.37) or with duration of NESLiP. Univariate analysis demonstrated younger (area under the receiver operating characteristic, 0.68; P = 0.008; 95% confidence interval [CI], 0.55-0.82) and heavier (area under the receiver operating characteristic, 0.80; P < 0.001; 95% CI, 0.69-0.91) livers to be at risk of cradle compression. Only liver weight was associated with cradle compression on multivariate analysis (odds ratio, 1.003; P = 0.005; 95% CI, 1.001-1.005). There was no difference in 1-y graft survival (16/17 [94.1%] versus 44/48 [91.6%]; odds ratio, 0.69; P = 0.75; 95% CI, 0.07-6.62). CONCLUSIONS This is the first study assessing the impact of cradle compression on outcome. We have identified increased donor liver weight and younger age as risk factors for the development of this phenomenon. Increasing utilization of NESLiP will result in the increased incidence of cradle compression but the apparent absence of long-term sequelae is reassuring. Routine postoperative axial imaging may be warranted.
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Affiliation(s)
- Jack L Martin
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | | | - Sara Upponi
- Department of Radiology, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Yagazie Udeaja
- Department of Radiology, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Lisa Swift
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Corina Fear
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Rachel Webster
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Gwilym James Webb
- Department of Hepatology, Cambridge NIHR Biomedical Research Centre, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Michael Allison
- Department of Hepatology, Cambridge NIHR Biomedical Research Centre, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Anna Paterson
- Histopathology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rohit Gaurav
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Andrew J Butler
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Christopher J E Watson
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
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Canovai E, Butler A, Clark S, Latchford A, Sinha A, Sharkey L, Rutter C, Russell N, Upponi S, Amin I. Treatment of Complex Desmoid Tumors in Familial Adenomatous Polyposis Syndrome by Intestinal Transplantation. Transplant Direct 2024; 10:e1571. [PMID: 38264298 PMCID: PMC10803031 DOI: 10.1097/txd.0000000000001571] [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: 10/02/2023] [Accepted: 10/25/2023] [Indexed: 01/25/2024] Open
Abstract
Background Desmoid tumors are fibroblastic lesions which often have an unpredictable and variable clinical course. In the context of familial adenomatous polyposis (FAP), these frequently occur intra-abdominally, especially in the small-bowel mesentery resulting in sepsis, fistulation, and invasion of the abdominal wall and retroperitoneum. In selected cases where other modalities have failed, the most radical option is to perform a total enterectomy and intestinal transplantation (ITx). In this study, we present our center's experience of ITx for desmoid in patients with FAP. Methods We performed a retrospective review of our prospectively collected database between 2007 and 2022. All patients undergoing ITx for FAP-related desmoid were included. Results Between October 2007 and September 2023, 144 ITx were performed on 130 patients at our center. Of these, 15 patients (9%) were for desmoid associated with FAP (7 modified multivisceral transplants, 6 isolated ITx, and 2 liver-containing grafts). The median follow-up was 57 mo (8-119); 5-y patient survival was 82%, all with functioning grafts without local desmoid recurrence. These patients presented us with several complex surgical issues, such as loss of abdominal domain, retroperitoneal/abdominal wall involvement, ileoanal pouch-related issues, and the need for foregut resection because of adenomatous disease. Conclusions ITx is a viable treatment in selected patients with FAP and extensive desmoid disease. The decision to refer for ITx can be challenging, particularly the timing and sequence of treatment (simultaneous versus sequential exenteration). Delays can result in additional disease burden, such as secondary liver disease or invasion of adjacent structures.
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Affiliation(s)
- Emilio Canovai
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andrew Butler
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Susan Clark
- Family Cancer & Lynch Syndrome Clinic, St Mark’s Centre for Familial Intestinal Cancer, St Mark’s Hospital, London North West University Healthcare NHS Trust, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Andrew Latchford
- Family Cancer & Lynch Syndrome Clinic, St Mark’s Centre for Familial Intestinal Cancer, St Mark’s Hospital, London North West University Healthcare NHS Trust, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Ashish Sinha
- Family Cancer & Lynch Syndrome Clinic, St Mark’s Centre for Familial Intestinal Cancer, St Mark’s Hospital, London North West University Healthcare NHS Trust, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Lisa Sharkey
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Charlotte Rutter
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Neil Russell
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Sara Upponi
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Irum Amin
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
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Ghazaly M, Sethi P, Kathirvel M, Tiwari NA, Thillai M, Gaurav R, Surendrakumar V, Ayorinde JOO, Allison M, Upponi S, Watson CJ, Praseedom RK, Gibbs P, Saeb-Parsy K. OUP accepted manuscript. BJS Open 2022; 6:6526445. [PMID: 35143624 PMCID: PMC8830758 DOI: 10.1093/bjsopen/zrab146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mohamed Ghazaly
- Transplant Unit, Addenbrooke’s Hospital, Cambridge, UK
- Department of Surgery, Tanta University, Tanta, Gharbia, Egypt
| | - Pulkit Sethi
- Transplant Unit, Addenbrooke’s Hospital, Cambridge, UK
| | | | | | - Manoj Thillai
- Transplant Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Rohit Gaurav
- Transplant Unit, Addenbrooke’s Hospital, Cambridge, UK
| | | | | | - Michael Allison
- Department of Hepatology, Cambridge Biomedical Research Centre, Addenbrooke’s Hospital, Cambridge, UK
| | - Sara Upponi
- Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK
| | - Christopher J. Watson
- Transplant Unit, Addenbrooke’s Hospital, Cambridge, UK
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Centre, Cambridge, UK
| | | | - Paul Gibbs
- Transplant Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Kourosh Saeb-Parsy
- Transplant Unit, Addenbrooke’s Hospital, Cambridge, UK
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Centre, Cambridge, UK
- Correspondence to: Kourosh Saeb-Parsy, Department of Surgery, Addenbrooke’s Hospital, Hills Road, Box 202, Cambridge CB2 0QQ, UK (e-mail: )
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Hawken J, Upponi S, Corbett G, See TC, Leithead JA. See here! Locating the source of upper GI bleeding. Frontline Gastroenterol 2020; 12:539-540. [PMID: 34712474 PMCID: PMC8515279 DOI: 10.1136/flgastro-2020-101463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/13/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- James Hawken
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Sara Upponi
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - Gareth Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Teik Choon See
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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Gaurav R, Atulugama N, Swift L, Butler AJ, Upponi S, Brais R, Allison M, Watson CJE. Bile Biochemistry Following Liver Reperfusion in the Recipient and Its Association With Cholangiopathy. Liver Transpl 2020; 26:1000-1009. [PMID: 32108995 PMCID: PMC7497270 DOI: 10.1002/lt.25738] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/20/2020] [Accepted: 02/10/2020] [Indexed: 12/24/2022]
Abstract
Cholangiocytes secrete bicarbonate and absorb glucose, producing bile with alkaline pH and low glucose content. These functions of cholangiocytes have been suggested as a marker of bile duct viability during normothermic ex situ liver perfusion, and they are now monitored routinely after reperfusion in our center. In this study, we reviewed the composition of bile immediately after reperfusion in liver transplant recipients to determine normal posttransplant parameters and the predictive value of bile biochemistry for the later development of cholangiopathy. After reperfusion of the liver graft, a cannula was placed in the bile duct to collect bile over a median 44-minute time period. The bile produced was analyzed using a point-of-care blood gas analyzer (Cobas b221, Roche Diagnostics, Indianapolis, IN). A total of 100 liver transplants (35 from donation after circulatory death and 65 from donation after brain death) were studied. Median bile pH was 7.82 (interquartile range [IQR], 7.67-7.98); median bile glucose was 2.1 (1.4-3.7) mmol/L; median blood-bile-blood pH difference was 0.50 (0.37-0.62); and median blood-bile glucose difference was 7.1 (5.6-9.1) mmol/L. There were 12 recipients who developed cholangiopathy over a median follow-up of 15 months (IQR, 11-20 months). Bile sodium (142 versus 147 mmol/L; P = 0.02) and blood-bile glucose concentration differences (5.2 versus 7.6 mmol/L; P = 0.001) were significantly lower and were associated with ischemic cholangiopathy. In conclusion, bile biochemistry may provide useful insights into cholangiocyte function and, hence, bile duct viability. Our results suggest bile glucose is the most sensitive predictor of cholangiopathy.
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Affiliation(s)
- Rohit Gaurav
- Cambridge Transplant UnitAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom
| | - Niroshan Atulugama
- Cambridge Transplant UnitAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom
| | - Lisa Swift
- Cambridge Transplant UnitAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom
| | - Andrew J. Butler
- Cambridge Transplant UnitAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom,Department of RadiologyAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom,Department of PathologyAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom
| | - Sara Upponi
- Department of PathologyAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom,Department of MedicineAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom
| | - Rebecca Brais
- Department of PathologyAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom,Department of SurgeryAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom
| | - Michael Allison
- Department of PathologyAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom,National Institute for Health Research Cambridge Biomedical Research Centre and the National Institute for Health Research Blood and Transplant Research in Organ Donation and TransplantationNational Health Service Blood and Transplant at University of Cambridge and Newcastle UniversityCambridgeUnited Kingdom
| | - Christopher J. E. Watson
- Cambridge Transplant UnitAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom,Department of RadiologyAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom,Department of PathologyAddenbrooke’s HospitalCambridge University Hospitals National Health Service TrustCambridgeUnited Kingdom
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6
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Connell CM, Brais R, Whitaker H, Upponi S, Beh I, Risdall J, Corrie P, Janowitz T, Jodrell DI. Early relapse on adjuvant gemcitabine associated with an exceptional response to 2nd line capecitabine chemotherapy in a patient with pancreatic adenosquamous carcinoma with strong intra-tumoural expression of cytidine deaminase: a case report. BMC Cancer 2020; 20:38. [PMID: 31941506 PMCID: PMC6964020 DOI: 10.1186/s12885-020-6516-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 01/06/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pancreatic adenosquamous carcinoma has a poor prognosis, with limited prospective trial data to guide optimal treatment. The potential impact of drug metabolism on the treatment response of patients with pancreatic adenosquamous carcinoma is largely unknown. CASE PRESENTATION We describe the case of a 51 year old woman with pancreatic adenosquamous carcinoma who, following surgical resection, experienced early disease relapse during adjuvant gemcitabine therapy. Paradoxically, this was followed by an exceptional response to capecitabine therapy lasting 34.6 months. Strong expression of cytidine deaminase was detected within the tumour. CONCLUSIONS This case study demonstrates that early relapse during adjuvant chemotherapy for pancreatic adenosquamous carcinoma may be compatible with a subsequent exceptional response to second line chemotherapy, an important observation given the poor overall prognosis of patients with adenosquamous carcinoma. Cytidine deaminase is predicted to inactivate gemcitabine and, conversely, catalyze capecitabine activation. We discuss strong intra-tumoural expression of cytidine deaminase as a potential mechanism to explain this patient's disparate responses to gemcitabine and capecitabine therapy, and highlight the benefit that may be gained from considering similar determinants of response to chemotherapy in clinical practice.
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Affiliation(s)
- Claire M. Connell
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
- Department of Oncology, CRUK Cambridge Institute, Li Ka Shing Centre, University of Cambridge, Cambridge, CB2 0RE UK
| | - Rebecca Brais
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
| | - Hayley Whitaker
- Research Department for Tissue & Energy, Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TS UK
| | - Sara Upponi
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
| | - Ian Beh
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
| | - Jane Risdall
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
| | - Pippa Corrie
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
| | - Tobias Janowitz
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
- Department of Oncology, CRUK Cambridge Institute, Li Ka Shing Centre, University of Cambridge, Cambridge, CB2 0RE UK
| | - Duncan I. Jodrell
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
- Department of Oncology, CRUK Cambridge Institute, Li Ka Shing Centre, University of Cambridge, Cambridge, CB2 0RE UK
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7
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Smith J, Godfrey E, Bowden D, Hickman K, Sharkey L, Butler A, Upponi S. Imaging of intestinal transplantation. Clin Radiol 2019; 74:613-622. [DOI: 10.1016/j.crad.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/11/2018] [Indexed: 12/30/2022]
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8
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Watson CJE, Hunt F, Messer S, Currie I, Large S, Sutherland A, Crick K, Wigmore SJ, Fear C, Cornateanu S, Randle LV, Terrace JD, Upponi S, Taylor R, Allen E, Butler AJ, Oniscu GC. In situ normothermic perfusion of livers in controlled circulatory death donation may prevent ischemic cholangiopathy and improve graft survival. Am J Transplant 2019; 19:1745-1758. [PMID: 30589499 DOI: 10.1111/ajt.15241] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/09/2018] [Accepted: 12/16/2018] [Indexed: 01/25/2023]
Abstract
Livers from controlled donation after circulatory death (DCD) donors suffer a higher incidence of nonfunction, poor function, and ischemic cholangiopathy. In situ normothermic regional perfusion (NRP) restores a blood supply to the abdominal organs after death using an extracorporeal circulation for a limited period before organ recovery. We undertook a retrospective analysis to evaluate whether NRP was associated with improved outcomes of livers from DCD donors. NRP was performed on 70 DCD donors from whom 43 livers were transplanted. These were compared with 187 non-NRP DCD donor livers transplanted at the same two UK centers in the same period. The use of NRP was associated with a reduction in early allograft dysfunction (12% for NRP vs. 32% for non-NRP livers, P = .0076), 30-day graft loss (2% NRP livers vs. 12% non-NRP livers, P = .0559), freedom from ischemic cholangiopathy (0% vs. 27% for non-NRP livers, P < .0001), and fewer anastomotic strictures (7% vs. 27% non-NRP, P = .0041). After adjusting for other factors in a multivariable analysis, NRP remained significantly associated with freedom from ischemic cholangiopathy (P < .0001). These data suggest that NRP during organ recovery from DCD donors leads to superior liver outcomes compared to conventional organ recovery.
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Affiliation(s)
- Christopher J E Watson
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Fiona Hunt
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Simon Messer
- Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - Ian Currie
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Stephen Large
- Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - Andrew Sutherland
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Keziah Crick
- Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Stephen J Wigmore
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Corrina Fear
- Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Sorina Cornateanu
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | | | - John D Terrace
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Sara Upponi
- Department of Radiology, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Rhiannon Taylor
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Elisa Allen
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Andrew J Butler
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Gabriel C Oniscu
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
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9
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Smith J, Godfrey E, Bowden D, Hickman K, Sharkey L, Butler A, Upponi S. Imaging of adult intestinal failure. Clin Radiol 2019; 74:603-612. [PMID: 30654907 DOI: 10.1016/j.crad.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/11/2018] [Indexed: 01/30/2023]
Abstract
Intestinal failure is the inability to maintain adequate nutrition or hydration through the gut. It is caused by a diverse range of benign and malignant aetiologies. Imaging takes a central role in the multidisciplinary assessment of patients with intestinal failure.
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Affiliation(s)
- J Smith
- Department of Radiology, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK
| | - E Godfrey
- Department of Radiology, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK
| | - D Bowden
- Department of Radiology, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK
| | - K Hickman
- Department of Radiology, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK
| | - L Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK
| | - A Butler
- Department of Surgery, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK
| | - S Upponi
- Department of Radiology, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 2QQ, UK.
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10
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Parkes M, Noor NM, Dowling F, Leung H, Bond S, Whitehead L, Upponi S, Kinnon P, Sandham AP, Lyons PA, McKinney EF, Smith KGC, Lee JC. PRedicting Outcomes For Crohn's dIsease using a moLecular biomarkEr (PROFILE): protocol for a multicentre, randomised, biomarker-stratified trial. BMJ Open 2018; 8:e026767. [PMID: 30523133 PMCID: PMC6286485 DOI: 10.1136/bmjopen-2018-026767] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The course of Crohn's disease (CD) varies substantially between individuals, but reliable prognostic markers do not exist. This hinders disease management because patients with aggressive disease are undertreated by conventional 'step-up' therapy (in which treatment is gradually escalated in response to refractory or relapsing disease) while those with more indolent disease would be exposed to unnecessary treatment-related toxicity if a more aggressive 'top-down' approach was indiscriminately used. The Predicting outcomes for Crohn's disease using a molecular biomarker trial will assess whether a prognostic transcriptional biomarker, that we have developed and validated, can improve clinical outcomes by facilitating personalised therapy in CD. This represents the first the biomarker-stratified trial in inflammatory bowel disease. METHODS AND ANALYSIS This biomarker-stratified trial will compare the relative efficacy of 'top-down' and 'accelerated step-up' therapy between biomarker-defined subgroups of patients with newly diagnosed CD. 400 participants from ~50 UK centres will be recruited. Subjects within each biomarker subgroup (IBDhi or IBDlo) will be randomised (1:1) to receive one of the treatment strategies until trial completion (48 weeks). The primary outcome is the incidence of sustained surgery and steroid-free remission from the completion of induction treatment through to week 48. Secondary outcomes include mucosal healing, quality-of-life assessments and surrogate measures of disease burden including number of flares, cumulative steroid exposure, number of hospital admissions and number of Crohn's-related surgeries (assessed hierarchically). Analyses will compare the relative benefit of the treatment strategies in each biomarker-defined subgroup, powered as an interaction analysis, to determine whether the biomarker can accurately match patients to the most appropriate therapy. ETHICS AND DISSEMINATION Ethical approval has been obtained and recruitment is under way at sites around the UK. Following trial completion and data analysis, the results of the trial will be submitted for publication in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER ISRCTN11808228; Pre-results.
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Affiliation(s)
- Miles Parkes
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
| | - Nurulamin M Noor
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
| | - Francis Dowling
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Harvey Leung
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Lynne Whitehead
- Clinical Trials Pharmacy, Addenbrooke’s Hospital, Cambridge, UK
| | - Sara Upponi
- Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK
| | - Paul Kinnon
- PredictImmune Ltd, Babraham Research Campus, Cambridge, UK
| | | | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
- PredictImmune Ltd, Babraham Research Campus, Cambridge, UK
| | - Eoin F McKinney
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
- PredictImmune Ltd, Babraham Research Campus, Cambridge, UK
| | - Kenneth G C Smith
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
- PredictImmune Ltd, Babraham Research Campus, Cambridge, UK
| | - James C Lee
- Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
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11
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Watson CJE, Kosmoliaptsis V, Pley C, Randle L, Fear C, Crick K, Gimson AE, Allison M, Upponi S, Brais R, Jochmans I, Butler AJ. Observations on the ex situ perfusion of livers for transplantation. Am J Transplant 2018; 18:2005-2020. [PMID: 29419931 PMCID: PMC6099221 DOI: 10.1111/ajt.14687] [Citation(s) in RCA: 233] [Impact Index Per Article: 38.8] [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: 09/01/2017] [Revised: 01/26/2018] [Accepted: 01/31/2018] [Indexed: 01/25/2023]
Abstract
Normothermic ex situ liver perfusion might allow viability assessment of livers before transplantation. Perfusion characteristics were studied in 47 liver perfusions, of which 22 resulted in transplants. Hepatocellular damage was reflected in the perfusate transaminase concentrations, which correlated with posttransplant peak transaminase levels. Lactate clearance occurred within 3 hours in 46 of 47 perfusions, and glucose rose initially during perfusion in 44. Three livers required higher levels of bicarbonate support to maintain physiological pH, including one developing primary nonfunction. Bile production did not correlate with viability or cholangiopathy, but bile pH, measured in 16 of the 22 transplanted livers, identified three livers that developed cholangiopathy (peak pH < 7.4) from those that did not (pH > 7.5). In the 11 research livers where it could be studied, bile pH > 7.5 discriminated between the 6 livers exhibiting >50% circumferential stromal necrosis of septal bile ducts and 4 without necrosis; one liver with 25-50% necrosis had a maximum pH 7.46. Liver viability during normothermic perfusion can be assessed using a combination of transaminase release, glucose metabolism, lactate clearance, and maintenance of acid-base balance. Evaluation of bile pH may offer a valuable insight into bile duct integrity and risk of posttransplant ischemic cholangiopathy.
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Affiliation(s)
- Christopher J. E. Watson
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of CambridgeCambridgeUK,NIHR Cambridge Biomedical Research CentreCambridgeUK
| | - Vasilis Kosmoliaptsis
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of CambridgeCambridgeUK,NIHR Cambridge Biomedical Research CentreCambridgeUK
| | - Caitlin Pley
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of CambridgeCambridgeUK,NIHR Cambridge Biomedical Research CentreCambridgeUK
| | - Lucy Randle
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of CambridgeCambridgeUK,NIHR Cambridge Biomedical Research CentreCambridgeUK
| | - Corinna Fear
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of CambridgeCambridgeUK,NIHR Cambridge Biomedical Research CentreCambridgeUK
| | - Keziah Crick
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of CambridgeCambridgeUK,NIHR Cambridge Biomedical Research CentreCambridgeUK
| | - Alexander E. Gimson
- NIHR Cambridge Biomedical Research CentreCambridgeUK,Department of MedicineCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Michael Allison
- NIHR Cambridge Biomedical Research CentreCambridgeUK,Department of MedicineCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Sara Upponi
- NIHR Cambridge Biomedical Research CentreCambridgeUK,Department of RadiologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Rebecca Brais
- NIHR Cambridge Biomedical Research CentreCambridgeUK,Department of PathologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Ina Jochmans
- Department of Microbiology and ImmunologyLaboratory of Abdominal TransplantationKatholieke Universiteit LeuvenLeuvenBelgium,Department of Abdominal Transplant SurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | - Andrew J. Butler
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of CambridgeCambridgeUK,NIHR Cambridge Biomedical Research CentreCambridgeUK
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12
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Louis-Auguste JR, Micallef C, Ambrose T, Upponi S, Butler AJ, Massey D, Middleton SJ, Russell N, Rutter CS, Sharkey LM, Woodward J, Gkrania-Klotsas E, Enoch DA. Fatal breakthrough mucormycosis in a multivisceral transplant patient receiving micafungin: Case report and literature review. IDCases 2018; 12:76-79. [PMID: 29942755 PMCID: PMC6010962 DOI: 10.1016/j.idcr.2018.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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] [Indexed: 11/26/2022] Open
Abstract
Introduction Antifungal agents are routinely used in the post-transplant setting for both prophylaxis and treatment of presumed and proven fungal infections. Micafungin is an echinocandin-class antifungal with broad antifungal cover and favorable side effect profile but, notably, it has no activity against molds of the order Mucorales. Presentation of case A 47-year-old woman underwent multivisceral transplantation for intestinal failure-associated liver disease. She had a prolonged post-operative recovery complicated by invasive candidiasis and developed an intolerance to liposomal amphotericin B. In view of her immunosuppression, she was commenced on micafungin as prophylaxis to prevent invasive fungal infection. However, she developed acute graft versus host disease with bone marrow failure complicated by disseminated mucormycosis which was only diagnosed post mortem. Discussion Non-Aspergillus breakthrough mold infections with micafungin therapy are rare with only eight other cases having been described in the literature. Breakthrough infections have occurred within one week of starting micafungin. Diagnosis is problematic and requires a high degree of clinical suspicion and microscopic/histological examination of an involved site. The management of these aggressive infections involves extensive debridement and appropriate antifungal cover. Conclusion A high level of suspicion of invasive fungal infection is required at all times in immunosuppressed patients, even those receiving antifungal prophylaxis. Early biopsy is required. Even with early recognition and aggressive treatment of these infections, prognosis is poor.
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Affiliation(s)
- John R Louis-Auguste
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christianne Micallef
- Clinical Microbiology & Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim Ambrose
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sara Upponi
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J Butler
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dunecan Massey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen J Middleton
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Russell
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charlotte S Rutter
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Lisa M Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeremy Woodward
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David A Enoch
- Clinical Microbiology & Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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13
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Hakeem A, Chen J, Iype S, Clatworthy MR, Watson CJE, Godfrey EM, Upponi S, Saeb‐Parsy K. Pancreatic allograft thrombosis: Suggestion for a CT grading system and management algorithm. Am J Transplant 2018; 18:163-179. [PMID: 28719059 PMCID: PMC5763322 DOI: 10.1111/ajt.14433] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 03/27/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 01/25/2023]
Abstract
Pancreatic allograft thrombosis (PAT) remains the leading cause of nonimmunologic graft failure. Here, we propose a new computed tomography (CT) grading system of PAT to identify risk factors for allograft loss and outline a management algorithm by retrospective review of consecutive pancreatic transplantations between 2009 and 2014. Triple-phase CT scans were graded independently by 2 radiologists as grade 0, no thrombosis; grade 1, peripheral thrombosis; grade 2, intermediate non-occlusive thrombosis; and grade 3, central occlusive thrombosis. Twenty-four (23.3%) of 103 recipients were diagnosed with PAT (including grade 1). Three (2.9%) grafts were lost due to portal vein thrombosis. On multivariate analysis, pancreas after simultaneous pancreas-kidney transplantation/solitary pancreatic transplantation, acute rejection, and CT findings of peripancreatic edema and/or inflammatory change were significant risk factors for PAT. Retrospective review of CT scans revealed more grade 1 and 2 thromboses than were initially reported. There was no significant difference in graft or patient survival, postoperative stay, or morbidity of recipients with grade 1 or 2 thrombosis who were or were not anticoagulated. Our data suggest that therapeutic anticoagulation is not necessary for grade 1 and 2 arterial and grade 1 venous thrombosis. The proposed grading system can assist clinicians in decision-making and provide standardized reporting for future studies.
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Affiliation(s)
- A. Hakeem
- Department of SurgeryUniversity of Cambridge and NIHR Cambridge Biomedical Research Centre, and NIHR Blood and Transplant Research Unit in Organ Donation and TransplantationCambridgeUK
| | - J. Chen
- Department of SurgeryUniversity of Cambridge and NIHR Cambridge Biomedical Research Centre, and NIHR Blood and Transplant Research Unit in Organ Donation and TransplantationCambridgeUK
| | - S. Iype
- Department of SurgeryUniversity of Cambridge and NIHR Cambridge Biomedical Research Centre, and NIHR Blood and Transplant Research Unit in Organ Donation and TransplantationCambridgeUK
| | - M. R. Clatworthy
- Department of MedicineUniversity of Cambridge and NIHR Cambridge Biomedical Research Centre, and NIHR Blood and Transplant Research Unit in Organ Donation and TransplantationCambridgeUK
| | - C. J. E. Watson
- Department of SurgeryUniversity of Cambridge and NIHR Cambridge Biomedical Research Centre, and NIHR Blood and Transplant Research Unit in Organ Donation and TransplantationCambridgeUK
| | - E. M. Godfrey
- Department of RadiologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - S. Upponi
- Department of RadiologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - K. Saeb‐Parsy
- Department of SurgeryUniversity of Cambridge and NIHR Cambridge Biomedical Research Centre, and NIHR Blood and Transplant Research Unit in Organ Donation and TransplantationCambridgeUK
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14
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Ali JM, Rajaratnam SG, Upponi S, Hall NR, Fearnhead NS. Colonic transit in the empty colon after defunctioning ileostomy: do we really know what happens? Tech Coloproctol 2015; 19:165-72. [PMID: 25697292 DOI: 10.1007/s10151-015-1278-5] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 11/17/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is disagreement amongst surgeons about the use of oral mechanical bowel preparation (MBP) prior to low anterior resection with diverting ileostomy. Colonic transit in the early post-operative period is an important factor in determining the role of MBP, as propagation of any stool remaining in the defunctioned colon may exacerbate morbidity in the event of anastomotic leak. We studied colonic transit time in the first 7 days following low anterior resection with diverting ileostomy. METHODS We conducted a prospective observational study of patients with rectal cancer undergoing elective low anterior resection with diverting ileostomy in a tertiary colorectal unit. Twenty radio-opaque markers were inserted into the caecum via the distal limb of the loop ileostomy at surgery. Plain abdominal radiographs were taken on post-operative days 1, 3 and 5. The primary endpoint was passage of the markers to the neorectum. Data were collected on treatment, return of gastrointestinal function and complications. RESULTS Twenty-two patients (mean age 68.5 years; 18 males) participated in the study. In 20 patients, all markers remained in the right colon on day 7. Three markers were present in the left colon in one patient, and eight markers were present in the neorectum in another patient, on the seventh day. CONCLUSIONS Colonic transit may be abolished by the presence of diverting ileostomy. It should now be established whether clearance of the left colon alone, using enemas, is sufficient for patients undergoing low anterior resection, thus avoiding the morbidity associated with oral MBP.
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Affiliation(s)
- J M Ali
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, BOX 201, Hills Road, Cambridge, CB2 0QQ, UK,
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15
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Metaxa D, Balakrishnan A, Upponi S, Huguet EL, Praseedom RK. Surgical intervention for mediastinal pancreatic pseudocysts. A case series and review of the literature. JOP 2015; 16:74-77. [PMID: 25640789 DOI: 10.6092/1590-8577/2904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
CONTEXT Development of mediastinal pancreatic pseudocysts is a rare complication of pancreatitis. There is currently no consensus on the optimal management of this condition, options for which include conservative management with somatostatin analogues, endoscopic drainage procedures and surgery. CASE REPORT Here we present two patients with mediastinal pancreatic pseudocysts which were initially managed endoscopically. However, in both cases, this led to complications secondary to the endoscopic procedures, recurrence or non-resolution of symptoms, requiring surgical cystogastrostomy and/or cystojejunostomy. CONCLUSION These cases suggest that surgery may be ultimately necessary for mediastinal pancreatic pseudocysts where endoscopic procedures might have a high likelihood of failure.
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Affiliation(s)
- Dafni Metaxa
- Department of Hepatopancreaticobiliary Surgery, Addenbrooke's Hospital. Cambridge, United Kingdom.
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16
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Connolly SS, Raja A, Stunell H, Parashar D, Upponi S, Warren AY, Gnanapragasam VJ, Eisen T. Diagnostic accuracy of preoperative computed tomography used alone to detect lymph-node involvement at radical nephrectomy. Scand J Urol 2015; 49:142-8. [DOI: 10.3109/21681805.2014.969307] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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17
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Upponi S, Butler AJ, Watson CJE, Shaw AS. Encapsulating peritoneal sclerosis--correlation of radiological findings at CT with underlying pathogenesis. Clin Radiol 2013; 69:103-9. [PMID: 24209872 DOI: 10.1016/j.crad.2013.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 08/29/2013] [Accepted: 08/29/2013] [Indexed: 12/11/2022]
Abstract
Encapsulating peritoneal sclerosis (EPS) is a rare entity most commonly associated with peritoneal dialysis (PD). Several imaging features at computed tomography (CT) are common to many diseases; however, appreciation of the features unique to this condition interpreted with the appropriate clinical findings is crucial to diagnosis.
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Affiliation(s)
- S Upponi
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - A J Butler
- Academic Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - C J E Watson
- Academic Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - A S Shaw
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK.
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18
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Barrett T, Upponi S, Benaglia T, Tasker AD. Multidetector CT findings in patients with mesenteric ischaemia following cardiopulmonary bypass surgery. Br J Radiol 2013; 86:20130277. [PMID: 23966376 DOI: 10.1259/bjr.20130277] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To investigate CT findings in patients with pathologically proven mesenteric ischaemia post-cardiopulmonary bypass surgery and compare them with the control group of patients without ischaemia. METHODS 68 patients were identified by a search of local surgical and pathological databases; these patients met the inclusion criteria of a laparotomy within 1 month of a procedure requiring cardiopulmonary bypass and a CT abdomen/pelvis within 1 week of the pathological diagnosis. Two radiologists independently reviewed the studies, evaluating 17 separate findings relating to the bowel, the vasculature or other structures; consensus was subsequently reached. The diagnostic value of CT findings was assessed using logistic regression. RESULTS 52 of 68 patients had pathologically proven ischaemia. Portal venous gas, mesenteric venous gas and small bowel faeces sign all had specificities of >0.94 for ischaemia but low sensitivity (<0.27). Differential mural enhancement had high sensitivity (0.92) but poor specificity (0.50). The combination of pneumatosis, bowel loop dilatation and differential mural enhancement predicted bowel ischaemia with a probability of 98%. The hardest signs to interpret based on poor interreader kappa agreement were bowel wall thinning, mesenteric stranding and differential mural enhancement. CONCLUSION A combination of CT signs was predictive of ischaemic bowel; however, the more specific findings lacked sensitivity. If clinical suspicion is high for bowel ischaemia, prompt surgical intervention is warranted, regardless of CT findings. ADVANCES IN KNOWLEDGE Arterial occlusion was uncommon and venous occlusion was not present, which is supportive of a predominantly non-occlusive aetiology for ischaemia in this patient group.
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Affiliation(s)
- T Barrett
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.
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19
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Abstract
Clinicians working in any acute medical/surgical unit need an understanding of mesenteric ischaemia. Acute mesenteric ischaemia is a life-threatening vascular emergency associated with high morbidity and mortality. However, prompt diagnosis with the use of contrast-enhanced CT, more specifically CT angiography, has replaced catheter angiography as the new standard and is readily available in many emergency departments. Similarly, new hybrid open surgery endovascular treatment can minimise the surgical insult to these often critically ill elderly patients. Together, these changes can change the previously grim prognosis associated with this condition. By contrast, chronic mesenteric ischaemia (CMI) is an insidious disease and often a diagnosis of exclusion. However, it can cause a significant reduction in a patient's quality of life, due to 'mesenteric angina' and food avoidance, yet can potentially be treated simply and effectively. Recognition of the typical clinical history and imaging findings is key to making the diagnosis in a timely fashion. Radiology plays a significant role in the diagnosis and increasingly in the treatment of mesenteric ischaemia. Other clinicians should have a basic understanding of what radiology can and cannot offer. The advantages and limitations of commonly used imaging modalities-plain films, CT, MRI and ultrasound, are examined. The significance of findings, such as pneumatosis coli and portal gas are explained. Finally, the different endovascular management of both acute and CMI is discussed, which have emerged as minimally invasive options to complement open revascularisation surgery.
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Affiliation(s)
- Sara Upponi
- Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK
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20
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Hon LQ, Ganeshan A, Nazir S, Upponi S, Bungay H, Uberoi R, Warakaulle D. Computed Tomographic Appearances of Hepatic Vascular Lesions. Curr Probl Diagn Radiol 2009; 38:264-73. [DOI: 10.1067/j.cpradiol.2009.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Upponi S, Ganeshan A, D'Costa H, Betts M, Maynard N, Bungay H, Slater A. Radiological detection of post-oesophagectomy anastomotic leak - a comparison between multidetector CT and fluoroscopy. Br J Radiol 2008; 81:545-8. [PMID: 18559902 DOI: 10.1259/bjr/30515892] [Citation(s) in RCA: 51] [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] [Indexed: 11/05/2022] Open
Abstract
The purpose of this study was to directly compare CT with fluoroscopy for the diagnosis of occult anastomotic leak following oesophagectomy. Patients undergoing oesophagectomy and gastric conduit formation for the treatment of oesophageal cancer were eligible for inclusion. Imaging was performed 6-8 days post-operatively. Patients underwent multislice CT examination of the chest and abdomen with a bolus of oral contrast, followed by fluoroscopic water-soluble contrast swallow (with subsequent use of barium if this was normal). The studies were reviewed by a consultant radiologist, who was blinded to the results of the other modality. Images were reported as showing "no leak", "possible leak" or "definite leak". The presence of mediastinal gas or fluid or extraluminal contrast at CT was recorded. The clinical outcome after reinstituition of oral intake was used as a reference standard. Patient preference for modality was recorded. 52 patients were recruited. Four were found to have leak on CT and fluoroscopy. 11 had possible leak at CT, but normal fluoroscopy: 2 of these had a leak confirmed later, whereas 9 had no leak. 37 had normal CT and fluoroscopy findings, and remained clinically well. The sensitivity, specificity, positive and negative predictive values were 100%, 80%, 40% and 100%, respectively, for CT, and 67%, 100%, 100% and 96%, respectively, for fluoroscopy. The positive predictive value of mediastinal air, air/fluid and extraluminal contrast were 25%, 75% and 50%, respectively. 35 patients found CT more tolerable. In conclusion, CT was better tolerated and more sensitive but less specific than fluoroscopy for detecting occult anastomotic leak.
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Affiliation(s)
- S Upponi
- Department of Clinical Radiology, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DZ, UK
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22
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Ganeshan A, Anderson E, Upponi S, Planner A, Slater A, Moore N, D'Costa H, Bungay H. Imaging of obstructed defecation. Clin Radiol 2008; 63:18-26. [DOI: 10.1016/j.crad.2007.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2006] [Revised: 04/25/2007] [Accepted: 05/01/2007] [Indexed: 10/22/2022]
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23
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Ganeshan A, Upponi S, Hon LQ, Warakaulle D, Uberoi R. Hepatic arterial infusion of chemotherapy: the role of diagnostic and interventional radiology. Ann Oncol 2007; 19:847-51. [PMID: 18029972 DOI: 10.1093/annonc/mdm528] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hepatic arterial infusion of chemotherapy (HAIC) delivers higher local drug concentration to unresectable liver tumors with fewer significant systemic side-effects. It has been shown to produce better response rates than systemic chemotherapy and remains an important treatment option in patients with advanced, inoperable primary or metastatic hepatic tumors. Traditionally, catheters for HAIC were inserted surgically under general anesthesia. The advancement and expansion of interventional radiology have made it possible for catheter-port systems to be inserted percutaneously under local anesthesia with no significant increase in morbidity. A comprehensive review of the literature, techniques and complications of percutaneous placement of catheter-port systems for HAIC is presented in this article.
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Affiliation(s)
- A Ganeshan
- Department of Radiology, John Radcliffe Hospital, Headley Way, Oxford, UK
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24
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Ganeshan A, Upponi S, Hon LQ, Uthappa MC, Warakaulle DR, Uberoi R. Chronic Pelvic Pain due to Pelvic Congestion Syndrome: The Role of Diagnostic and Interventional Radiology. Cardiovasc Intervent Radiol 2007; 30:1105-11. [PMID: 17805925 DOI: 10.1007/s00270-007-9160-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [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: 04/19/2007] [Revised: 07/13/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
Abstract
Chronic pelvic pain (CPP) is a common cause of gynecologic referral. Pelvic congestion syndrome, which is said to occurs due to ovarian vein incompetence, is a recognized cause of CPP. The aim of this paper is to briefly describe the clinical manifestations, and to review the role of diagnostic and interventional radiology in the management of this probably under-diagnosed condition.
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Affiliation(s)
- Arul Ganeshan
- Department of Radiology, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
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25
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Upponi S, Ganeshan A, Slater A, D'Costa H, Low L, Maynard N, Bungay H. Imaging following surgery for oesophageal cancer. Clin Radiol 2007; 62:724-31. [PMID: 17604759 DOI: 10.1016/j.crad.2007.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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: 08/03/2006] [Revised: 01/23/2007] [Accepted: 01/29/2007] [Indexed: 11/16/2022]
Abstract
The incidence of oesophageal malignancy is increasing in the UK. Surgical management with oesophagectomy is determined by tumour location, stage and extent of lymphadenectomy,and is also dependent on patient age and co-morbidity. Surgery is associated with considerable postoperative morbidity and mortalities of up to 7%. The indications for imaging and findings in both the immediate and delayed postoperative periods are discussed.
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Affiliation(s)
- S Upponi
- Department of Radiology, John Radcliffe Hospital, Oxford, UK
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26
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Ganeshan A, Upponi S, Uberoi R, D'Costa H, Picking C, Bungay H. Minimal-preparation CT colon in detection of colonic cancer, the Oxford experience. Age Ageing 2007; 36:48-52. [PMID: 17114203 DOI: 10.1093/ageing/afl116] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [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: 11/14/2022] Open
Abstract
BACKGROUND the main colonic imaging modalities, including barium enema, colonoscopy and computed tomography colonography, require bowel preparation. Performing these imaging procedures in the elderly can difficult due to immobility, incontinence and poor tolerance of bowel cleansing. Minimal preparation CT (MPCT) colon was introduced in the early 1990s in the UK. Much of the published literature on MPCT colon is limited by small patient numbers and short duration of follow-up. OBJECTIVE the aim of this study is to review our experience with the MPCT technique involving a large consecutive cohort of patients with long follow-up. METHODS all studies of MPCT performed in a 1-year period between July 2000 and July 2001 at our institution were reviewed retrospectively. MPCT reports were cross-referenced with the cancer registry to allow for an average period of 30 months follow-up. A definite diagnosis of cancer was only given following the appearance on the cancer registry. Those patients who had negative MPCT colon were assumed to be true negatives if no corresponding name was identified on the cancer registry. In the event of data mismatch, patient notes were reviewed to ascertain a diagnosis. RESULTS 391 MPCT examinations were performed during the period of the study (209 males, median age 82: age range 56-91 years). Thirty-four patients who had MPCT colon during the study period appeared on the cancer registry. A further three patients with disseminated colorectal malignancy identified on MPCT colon died without histological confirmation (tumour prevalence = 9.5%). Thirty-two of the registry confirmed 34 cases were detected on MPCT colon, giving a sensitivity of 0.94 (95% confidence interval 0.86-1.00). Including the three cases without histological confirmation gives a slightly higher sensitivity of 0.95. There were seven patients with definitely abnormal MPCT colons, who did not appear on the registry, resulting in specificity for definite abnormality of 0.98 (confidence interval 0.97-1.0). However, three of these seven are those who died of disseminated colorectal malignancy as above, raising the specificity to 0.99. Fourteen cases (3.5%) of extra-colonic malignancies were observed in this study. CONCLUSION even with the longer follow-up of this large cohort of patients the sensitivity and specificity in our study for the diagnosis of colorectal cancer with MPCT remains comparable with that of other studies and this technique competes well with other common colonic imaging modalities.
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Affiliation(s)
- Arul Ganeshan
- John Radcliffe Hospital, Radiology Department, Headley Way, Headington, Oxford OX3 9DU, UK.
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Planner AC, Phillips A, Bungay HK, Anderson EM, Ferrett CG, Lindsey I, Upponi S. Picture quiz. Imaging 2006. [DOI: 10.1259/imaging/21163827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Purushotham AD, Upponi S, Klevesath MB, Bobrow L, Millar K, Myles JP, Duffy SW. Morbidity After Sentinel Lymph Node Biopsy in Primary Breast Cancer: Results From a Randomized Controlled Trial. J Clin Oncol 2005; 23:4312-21. [PMID: 15994144 DOI: 10.1200/jco.2005.03.228] [Citation(s) in RCA: 397] [Impact Index Per Article: 20.9] [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: 11/20/2022] Open
Abstract
Purpose Axillary lymph node dissection (ALND) as part of surgical treatment for patients with breast cancer is associated with significant morbidity. Sentinel lymph node biopsy (SLNB) is a newly developed method of staging the axilla and has the potential to avoid an ALND in lymph node–negative patients, thereby minimizing morbidity. The aim of this study was to investigate physical and psychological morbidity after SLNB in the treatment of early breast cancer in a randomized controlled trial. Patients and Methods Between November 1999 and February 2003, 298 patients with early breast cancer (tumors 3 cm or less on ultrasound examination) who were clinically node negative were randomly allocated to undergo ALND (control group) or SLNB followed by ALND if subsequently found to be lymph node positive (study group). A detailed assessment of physical and psychological morbidity was performed during a 1-year period postoperatively. Results A significant reduction in postoperative arm swelling, rate of seroma formation, numbness, loss of sensitivity to light touch and pinprick was observed in the study group. Although shoulder mobility was less impaired on average in the study group, this was significant only for abduction at 1 month and flexion at 3 months. Scores reflecting quality of life and psychological morbidity were significantly better in the study group in the immediate postoperative period, with fewer long-term differences. Conclusion SLNB in patients undergoing surgery for breast cancer results in a significant reduction in physical and psychological morbidity.
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Affiliation(s)
- Anand David Purushotham
- Cambridge Breast Unit Box 97, Addenbrooke's Hospital, Cambridge University Hospitals, NHS Foundation Trust, Hills Rd, Cambridge CB2 2QQ, United Kingdom.
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Abstract
The use of sentinel node biopsy in primary breast cancer raises many new controversies with regard to extra-axillary nodes. Three cases with intramammary nodes are discussed in relation to sentinel node biopsy.
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Affiliation(s)
- S Upponi
- Cambridge Breast Unit, Addenbrookes Hospital, Cambridge, UK
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Abstract
Recent reports have described attempts at preserving the intercostobrachial nerve in patients undergoing axillary clearance for breast cancer. However, the anatomy of the nerve encountered by the surgeon operating in the axilla has not been previously described in any detail. In this study, we were able to document the anatomy of this nerve in 45 out of 50 consecutive patients undergoing axillary clearance. We found the anatomy variable, but have illustrated six main variants. In addition, we were able to preserve the nerve in 40 out of 50 cases.
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Affiliation(s)
- G H Cunnick
- Department of General Surgery, Princess Royal Hospital, Haywards Health, West Sussex, UK
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Abstract
To date, there has been a lack of published data concerning the training of breast and axillary examination, yet this remains an essential part of the triple assessment of breast lumps. In this study, we aimed to determine the competence of junior doctors in examining the breast and axilla, and whether this skill improved with time. We compared the findings of a specialist registrar and senior house officer with those of a consultant in 15 consecutive one-stop breast clinics in a district general hospital. The results suggested that although specialist registrars become proficient after this period, senior house officers do not progress at the same rate. This may have important implications for training and the organization of breast clinics.
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Affiliation(s)
- G H Cunnick
- Department of General Surgery, Princess Royal Hospital, Haywards Heath, West Sussex, UK
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