Fetal heart rate mirrors maternal temperature during posterior fossa craniotomy: a case report

While it is well known that maternal temperature affects fetal heart rate, the exact relationship is not well described. The circumstances accompanying most cases of maternal hypothermia and rewarming (e.g. a drowning event) have precluded a precise quantitative description of this relationship. We describe hypothermia and controlled rewarming during resection of a maternal brain stem tumor in the early third trimester. Continuous electronic fetal heart rate and core temperature monitoring demonstrated a near linear relationship during the development of hypothermia and rewarming. Recognition of the close relationship between maternal temperature and fetal heart rate can help safeguard maternal and fetal health, and prevent unnecessary delivery during non-obstetric surgery in pregnancy.

The "two-week wait" referral pathway allows prompt treatment but does not improve outcome for patients with oesophago-gastric cancer

INTRODUCTION

The Two Week Wait Referral Service (2WW) has been implemented as a means of fast-tracking patients with suspected upper gastrointestinal cancers for endoscopy. Whether or not it impacts on the outcome of these patients is unclear. The aim of this study was to compare the outcome of patients referred through 2WW with that of patients with oesophago-gastric cancer identified through alternate referral pathways (routine, emergency).

METHODS

The study population was 340 patients with oesophago-gastric carcinoma (gastric 154) diagnosed during the time period 01/2006-12/2007 at University Hospitals of Leicester NHS Trust. Data were collected prospectively by the MDT co-ordinator and analysed retrospectively.

RESULTS

135 of the 340 patients with oesophago-gastric cancer were diagnosed through the 2WW, 115 patients through routine referral pathways, and 90 patients were admitted on an emergency basis. Patients referred through 2WW had a median referral to 1st treatment time of 47 days (routine 79, emergency 28, p < 0.001 all group comparisons). The number of patients treated with potentially curative intent was 37 of 135 for the 2WW, 42 of 115 for the routine referrals and 10 of 90 for patients admitted as emergencies. The corresponding median survivals for the groups were 239 days (2WW), 405 days (routine) and 121 days (emergency), p < 0.001 (log rank).

CONCLUSIONS

Referral by 2WW resulted in more rapid treatment than routine referral but this did not translate into an improvement in survival. This suggests that the targeting of endoscopy to patients with alarm symptoms is flawed and a less selective approach should be promoted if curable cancers are to be detected.

Terminal Ileum Perforation as a Consequence of a Migrated and Fractured Oesophageal Stent

Covered self-expanding metallic stents are commonly employed to relieve malignant oesophageal obstruction. We report a case of a patient with oesophageal cancer treated by stent insertion and curative chemoradiotherapy with subsequent stent migration to the stomach. The stent fractured with the distal fragment migrating as far as the terminal ileum where it caused perforation of the bowel.

The inguinal release procedure for groin pain: initial experience in 73 sportsmen/women

OBJECTIVE

To assess the impact of the laparoscopic inguinal release procedure with mesh reinforcement on athletes with groin pain.

DESIGN

Prospective cohort study.

SETTING

Private sector.

PATIENTS

Professional and amateur sportsmen/women undergoing the inguinal release for groin pain.

MAIN OUTCOME MEASUREMENTS

Change in patient's symptoms, functional limitation and time to resuming sporting activity following surgery.

RESULTS

73 sportsmen/women underwent laparoscopic inguinal release in the study period, 37 (51%) of whom were professionals. 95% were male with a median age of 30 years. Following operation, patients returned to light training at a median of 1 week, full training at 3 weeks (professionals-2 weeks) and playing competitively at 4 weeks (professionals-3 weeks). 74% considered themselves match-fit by 4 weeks (84% of professionals). Following surgery, there was a highly significant improvement in frequency of pain, severity of pain and functional limitation in both the whole cohort and professional group. 88% reported a return to full fitness at follow-up, with 73% reporting complete absence of symptoms. 97% of the cohort thought the operation had improved their symptoms.

CONCLUSIONS

This study shows that the laparoscopic inguinal release procedure may be effective in the treatment of a subgroup of athletes with groin pain.

Factors that influence the adequacy of total mesorectal excision for rectal cancer

OBJECTIVE

In 1997 with the start of CRO7 trial it was agreed that adequacy of surgical resection of rectal cancer would be determined by a pathologically determined grading of the mesorectum the so called total mesorectal excision score (TME score). Scores ranged from 1-3 with 3 being a perfect specimen. The aim of this study was to investigate factors which may influence TME scores and establish if local recurrence is related to them.

METHOD

Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Pathology reports of those patients who underwent total mesorectal excision were examined and the TME scores added to the database. Categorical variables were analysed using the chi2 test, continuous variables using ANOVA. Statistical significance was taken as P < 0.05.

RESULTS

Between January 2000 and June 2005, 518 patients underwent surgery for adenocarcinoma of the rectum, of these, 287 patients had a total mesorectal excision for mid or lower third tumours under the care of seven colorectal surgeons. All resected specimens were scored by a Consultant GI pathologist. Two hundred and fourteen patients underwent anterior resection and 73 underwent abdomino-perineal resection. The median age of the patients was 73 years (range 38-95 years). One hundred and ninety-four patients were male. Seventy-eight patients were treated with preoperative radiotherapy, 59 short course and 19 long course. TME scores were TME1 n = 30, TME2 n = 99, TME3 n = 158. Fifteen patients developed local pelvic recurrence at 2 years. Total mesorectal excision scores were not statistically influenced by Dukes' stage, width of tumour, preoperative radiotherapy or grade of surgeon. Male patients were statistically more likely to have a TME score of 2 or 3 compared with female P = 0.04. Patients undergoing an anterior resection were statistically more likely to have a TME score of 2 or 3 compared with abdomino-perineal resection P = 0.0001. Tumours with a circumferential resection margin (CRM) of more than 1 mm were more likely to have a TME score of 2 or 3 score (P = 0.0001). There was no relationship between TME and local recurrence (P = 0.966).

CONCLUSION

There is no relationship between the TME score in patients undergoing resectional surgery for adenocarcinoma of the rectum and the development of local recurrence at 2 years. Other factors such as CRM involvement are more likely to have an impact on local recurrence. The factors that influence the quality of TME are the operative procedure of anterior resection, male gender and CRM positivity. There appear to be no deleterious effects on the TME score by Specialist Registrars performing the operation under Consultant supervision. While TME scores may be an index of a technical performance, they appear to have little role in predicting future outcomes.

Glycogen synthase kinase-3 beta; a new target in pancreatic cancer?

Glycogen synthase kinase (GSK) was initially described as a key enzyme involved in glycogen metabolism. However, since that time it has been found to regulate a diverse range of cell functions. In addition to having a major role in the regulation of the important onco-protein beta-catenin, GSK is also a critical regulator of NF-kappaB. NF-kappaB comprises a family of transcription factors which activate the expression of a wide array of genes involved in inflammation, tumourigenesis, metastasis, differentiation, embryonic development, apoptosis. Inflammation mediated by the NF-kappaB family has been implicated in the initiation of pancreatic cancer, resistance to chemotherapy and the development of the debilitating cancer cachexia seen with advanced disease. Hence, GSK has potential as an important new target both in the treatment of resectable pancreatic cancer as an adjuvant to surgery, and in the palliation of inoperable tumours.

Laparoscopic repair of direct inguinal hernia: a new technique that reduces the development of postoperative seroma

BACKGROUND

Seroma are common early postoperative complications encountered in laparoscopic inguinal hernia repair. Previous anecdotal evidence from our surgical practice suggested a lower incidence of postoperative seroma formation with direct hernia repairs when the lax transversalis fascia (TF) is inverted by tacking to the pubic ramus. We undertook a study to investigate whether TF inversion in this way reduces the incidence of postoperative seroma.

METHOD

A total of 216 patients undergoing transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs from August 2003 to December 2005 were included in this prospective non-randomised controlled study. Surgeon 1 would routinely invert the TF whereas surgeon 2 would not. At follow-up the presence of postoperative seroma and pain was recorded.

RESULTS

Mann-Whitney U test demonstrated no significant difference in terms of age, sex and time to follow-up between the surgeons' patient groups (P > 0.05), and Chi-square test demonstrated significantly that inversion of the TF is associated with a lower incidence of postoperative seroma (P < 0.05). There was no significant difference in terms of postoperative pain at follow-up.

CONCLUSION

Inversion of the TF is associated with a statistically lower incidence of postoperative seroma, without increasing postoperative pain despite the use of one or two additional tacks.

Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas

AIMS

We have maintained a highly conservative policy in selecting patients with carcinoma of the head of pancreas for resection. This has been based on tumour size, evidence of lymph node involvement or local invasion outside of the gland at laparotomy, laparoscopy or CT imaging. This study investigated our survival rates following pancreatic resection and examined clinicopathological predictors of survival.

METHODS

Sixty-two consecutive patients undergoing pancreatic resections for malignancy were identified from 1999 onwards. Thirty-three underwent resection for pancreatic ductal adenocarcinoma and were included in our analysis, the remainder included resections for ampullary adenocarcinoma (n=20) or other malignancies (n=9). Patient, tumour and operative characteristics were analysed to assess predictors of survival following resection (Kaplan-Meier survival curves).

RESULTS

Median survival following resection for ductal pancreatic adenocarcinoma was 54 months (ampullary adenocarcinomas achieved a median survival of 62 months) and thirty-day mortality was 2.7% (n=1). Survival was not associated with any demographic or intraoperative factors, such as blood loss, operative duration or anaesthetic technique. Survival curves were significantly worse when perineural or vascular invasion was evident histologically (p=0.023 and 0.0023 respectively). Patients with positive lymph nodes had a significantly shorter survival (p=0.0030) especially when lymph node status was expressed as a percentage of total lymph node yield. If more than 20% of retrieved lymph nodes were positive for tumour, this was a clear predictor of survival (p<0.0001). A positive resection margin was also associated with shortened survival (p=0.0291).

CONCLUSION

Despite the advances made in the management of pancreatic cancer, tumour biology still dictates long-term survival. A highly selective surgical approach to the management of these patients results in good long-term survival.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of pancreatic malignancy with laparoscopy and intraoperative ultrasound

BACKGROUND

Staging laparoscopy for pancreatic malignancy is controversial. This study aimed to assess the efficacy of laparoscopy with intraoperative ultrasound in the management of patients with pancreatic carcinoma.

METHODS

The study involved patients undergoing laparoscopy and intraoperative ultrasound over a period of 42 months. The entry criteria specified radiologic (computed tomography) diagnosis of pancreatic carcinoma and no evidence of metastases.

RESULTS

The study enrolled 100 patients (52 men and 48 women) ages 21 to 83 years (mean, 63 years). On the basis of imaging, 75 patients had lesions judged to be operable, and 25 patients had a pancreatic head lesion larger than 4 cm radiologically, considered to be unresectable, but with no evidence of metastatic disease. At laparoscopy, three patients had a normal examination, with no evidence of a pancreatic mass, and an additional seven patients had other pathology including one lymphoma, one ampullary tumor, two cases of chronic pancreatitis, and three sarcomas. Of the patients with radiologically inoperable disease, 16% had previously undetected metastases, but 24% were judged to be suitable for curative resection. Half of these patients underwent successful resection. Of the patients with radiologically operable disease, undetected liver or peritoneal metastases were found in 20% of the body or tail lesions and in 26% of the pancreatic head lesions. Of the pancreatic head tumors, 12% were found to be larger than 4 cm and therefore unsuitable for curative resection. Consequently, only 53% were confirmed to be suitable for resection. Of the patients explored with a view to curative resection, 42% actually underwent resection, with clearance of resection margins achieved in 77.8%.

CONCLUSION

Of the patients thought to have a resectable tumor on the basis of good quality preoperative imaging, 44% had their management approach altered after laparoscopy and avoided an open procedure. Laparoscopy should therefore be used in the preoperative staging of pancreatic tumors.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Colo-rectal anastomotic leakage often masquerades as a cardiac complication

OBJECTIVE

The aim of this study was to identify the mode of presentation of patients with clinical anastomotic leaks following restorative colorectal resection for carcinoma.

PATIENTS AND METHODS

Prospective information was collected on all patients having restorative resection of colorectal cancer. These data were reviewed for a five-year period (1994-1998) to identify all patients who had suffered a clinical anastomotic leak and their notes were retrieved and reviewed.

RESULTS

Three hundred and seventy-nine patients underwent restorative resection for colorectal cancer during the study period (178 female, 201 male), mean age 70 years (range 36-94). There were 22 (6%) clinical anastomotic leaks. Seven (32%) patients presented with obvious abdominal peritonitis. The remaining 15 (68%) were initially misdiagnosed. Thirteen (59%) patients were treated for cardiac symptoms, 1 (5%) patient for obstruction and 1 (5%) for ascites. The delay in diagnosis ranged from 0 to 11 days (mean 4 days). For the whole series of 379 there were 30 patients who suffered cardiac symptoms (8%) 13(43%) of whom had an anastomotic leak.

CONCLUSION

Patients who develop cardiac symptoms following restorative colorectal resection for carcinoma should have a water soluble enema as there is a 40% chance that they will have an anastomotic leak.

Management of benign rectal strictures: a review of present therapeutic procedures

PURPOSE

A significant benign stricture of the rectum is uncommon but can be a recalcitrant condition to treat. Case reports detailing a particular treatment option abound in the surgical literature. An overall précis of the different techniques available is presented, with a comparison of their relative strengths and weaknesses.

METHODS

A literature search was undertaken from 1963 to the present day, using MEDLINE. Keywords were benign, strictures, and rectum.

RESULTS

Balloon dilation is the most frequent intervention described in the literature. Repeated dilation with time often is required to achieve normal bowel function. Electrocautery resection or incision combined with dilation increases the success rate without increasing the complication rate. Transanal strictureplasty with mechanical staplers is reported as achieving the best success with the smallest complication rate; however, only a minority of strictures are suitable to be managed in this way, and therefore, the numbers treated are small.

CONCLUSIONS

All of the techniques reviewed compared favorably with formal stricture resection in terms of success rate and complications.

A snapshot of MDT working and patient mapping in the UK colorectal cancer centres in 2002

OBJECTIVES

To ascertain the position nationally of Colorectal Multi-Disciplinary Team (MDT) implementation as part of the NHS cancer plan. Also to define nationally patterns of 'bottlenecks' in the patient journey from referral to treatment.

METHODS

A simple questionnaire was sent to the lead clinician at all 183 cancer networks asking about their current MDT organization, and whether they had undertaken a mapping exercise of the patient journey.

RESULTS

Ninety-one percent (n = 166) of the questionnaires were returned, and of these 90% (n = 150) stated that their MDT meeting was up and running. Sixty-two percent (n = 102) stated they were having problems running their MDT meeting and of these 32% (n = 33) did not have a dedicated MDT clerk. Several of the Calman-Hine identified 'core personnel' are attending infrequently. Sixty-four percent (n = 107) of respondents have carried out a patient mapping process with 65% (n = 70) claiming it was a success, leaving 27% (n = 32) with no immediate plans to undertake the process.

CONCLUSIONS

Although MDT activity is near-universal, the survey has highlighted a wide variation in MDT meeting implementation across England, with the same problems being experienced by most centres. Organizational problems are common, and we feel that a dedicated MDT clerk is essential for smooth running. Further areas that require development have been identified by most respondents as radiological, oncological and endoscopic services. It is anticipated that true collaboration nationally will develop, and contact with the nine pilot sites is encouraged to explore solutions to difficulties.

Idiopathic chronic ulcerative enteritis--the role of radical surgical resection

Idiopathic chronic ulcerative enteritis is uncommon. It is a term that describes ulceration of the small bowel in the absence of a recognisable cause. Patients mainly present with a surgical abdomen and their management often proves to be a therapeutic challenge. Our series describes three such cases: the first patient presented with a tender left iliac fossa mass and rectal bleeding, the second with peritonitis and pneumoperitoneum, the third with severe acute colitis. All three patients needed urgent surgical intervention with further laparotomies due to recurrent ulceration, perforation and fistula formation in addition to intensive supportive measures such as inotropes and total parenteral nutrition. The importance and challenges of idiopathic chronic ulcerative enteritis are therefore discussed.

Transanal endoscopic microsurgery--lessons from a single UK centre series

OBJECTIVES

Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and selected malignant rectal tumours since 1983. We present a single surgeon's series of 102 procedures.

PATIENTS AND METHODS

A retrospective case note review of 102 procedures performed over a 6-year period between 1996 and 2001.

RESULTS

One hundred and two TEM procedures were performed on 100 patients. 68 for adenomas, 19 potentially curative excisions for carcinoma, 13 palliative procedures for advanced carcinoma and 2 for solitary rectal ulcer syndrome (SRUS). Four adenomas recurred and were successfully treated by various procedures. None went on to develop malignancy, or a further recurrence. Of the cancers, six T1 and 10 T2 were excised with curative intent. Three T3 cancers were excised before endorectal ultrasound was available in the unit and went on to have definitive procedures. One T1 and two T2 carcinomas were not completely histologically excised. These patients were offered definitive procedure and there have been no recurrences. 11 patients underwent palliative TEM procedures, 2 went on to have a recurrence of symptoms. Both underwent a successful second TEM procedure.

CONCLUSIONS

Although longer term follow up is still required, TEM appears to be an effective method of excising benign tumours and T1 carcinomas of the rectum. The role of TEM in the treatment of T2 carcinomas is, as yet, unclear and needs further evaluation although the results of our series and others are encouraging.

Endoscopic-assisted intrathoracic oesophagogastrostomy without thoracotomy for tumours of the lower oesophagus and cardia

AIMS

This study aimed to evaluate the efficacy of a novel technique enabling a trans-hiatal oesophagectomy with intrathoracic anastomosis under direct vision, without thoracotomy.

METHODS

Trans-hiatal dissection of the oesophagus was performed using direct and laparoscopic visualization. The oesophagus was transected above the tumour with a linear endo-GIA-2 60 mum stapler. The stomach was transected and a gastric tube fashioned. The anvil of an appropriately sized CEEA circular stapler was modified enabling it to flatten. It was attached to a novel delivery system introduced under direct vision along a guidewire into the stapled oesophagus. The anvil was realigned to its original position in the distal oesophagus, docked with the body of the stapler and an intrathoracic anastomosis performed.

RESULTS

Ten patients (female n=3, male n=7) aged from 39--77 years (mean age 65 years), ASA 2--3 with distal third tumours were treated. Duration of procedure ranged from 2--5 hours (mean 4 hours). One patient suffered a post-operative chest infection and an anastomotic leak treated successfully with a self-expanding metal stent. Hospital stay ranged from 6--28 days (mean 17 days). There was no mortality.

CONCLUSION

This technique allows a safe intrathoracic anastomosis to be performed trans-hiatally under direct vision, avoiding the need for thoracotomy in patients with high comorbidity.

Pancreas resection and islet autotransplantation for end-stage chronic pancreatitis

OBJECTIVE

To assess the safety and efficacy of islet autotransplantation (IAT) combined with total pancreatectomy (TP) to prevent diabetes.

SUMMARY BACKGROUND DATA

There have been recent concerns regarding the safety of TP and IAT. This is thought to be related to the infusion of large volumes of unpurified pancreatic digest into the portal vein. Minimizing the volume of islet tissue by purifying the pancreatic digest has not been previously evaluated in terms of the postoperative rate of death and complications, pain relief, and insulin independence.

METHOD

During a 54-month period, 24 patients underwent pancreas resection with IAT. Islets were isolated using collagenase and a semiautomated method of pancreas digestion. Where possible, islets were purified on a density gradient and COBE processor. Islets were embolized into the portal vein, within the spleen and portal vein, or within the spleen alone. The total median volume of digest was 9.9 mL.

RESULTS

The median number of islets transplanted was 140,419 international islet equivalents per kilogram. The median increase in portal pressure was 8 mmHg. Early complications included duodenal ischemia, a wedge splenic infarct, partial portal vein thrombosis, and splenic vein thrombosis. Intraabdominal adhesions were the main source of long-term problems. Eight patients developed transient insulin independence. Three patients were insulin-independent as of this writing. Patients had significantly decreased insulin requirements and glycosylated hemoglobin levels compared with patients undergoing TP alone. Of the patients alive and well as of this writing, four had failed to gain relief of their abdominal pain and were still opiate-dependent.

CONCLUSION

Combined TP and IAT can be a safe surgical procedure. Unfortunately, almost all patients were still insulin-dependent, but they had decreased daily insulin requirements and glycosylated hemoglobin levels compared with patients undergoing TP alone. A prospective randomized study is therefore needed to assess the long-term benefit of TP and IAT on diabetic complications.

A coculture model of intrahepatic islet transplantation: activation of Kupffer cells by islets and acinar tissue

Clinical and experimental studies of intrahepatic islet transplantation have allowed histological and systemic observations to be made, but the location of the transplanted islets makes it difficult to assess direct effects on the cells of the liver. An in vitro coculture model of Kupffer cells with islets or pancreatic acinar tissue is described, using porcine tissue and measuring the secretion of thromboxane B2, prostaglandin E2, 6-keto-prostaglandin F1alpha, and prostaglandin F2alpha as an indicator of Kupffer cell stimulation. The results have demonstrated activation of Kupffer cells in the presence of acinar or islet tissue, both when the cells were in direct contact and when separated by a membrane. This indicated that the stimulation was due to a soluble factor or factors, and was confirmed by the culture of Kupffer cells with acinar conditioned medium. The degree of stimulation was much greater with acinar tissue than with islets. In subsequent experiments, aprotinin, an enzyme activation inhibitor, was added to the cocultures in an attempt to reduce Kupffer cell activation. This had no effect, possibly due to the fact that the endogenous pancreatic enzymes may already be activated during digestion of the pancreas. Aprotinin alone caused an increase in secretion of eicosanoids from Kupffer cells. The high response to acinar tissue is of particular relevance to islet autotransplantation in which unpurified pancreatic digest is often transplanted. The clinical effectiveness of aprotinin in the light of these results is discussed. In conclusion, although unable to mimic the complex situation following intrahepatic islet transplantation, the coculture model described here allows the opportunity to assess the events relating to specific cell types, and will provide the scope to undertake more detailed studies on the mechanisms involved. The same model could be applied to the coculture of pancreatic tissue with hepatocytes to determine any effects on the normal function of hepatocytes.

Incidental adult nesidioblastosis after distal pancreatectomy for endocrine microadenoma

Persistent hyperinsulinaemic hypoglycaemia (nesidioblastosis) presenting with hypoglycaemia is extremely rare in adults. The features are suggestive of an insulinoma with a vague presentation and delayed diagnosis. We describe a report of adult nesidioblastosis in association with a pancreatic endocrine microadenoma.

Intrahepatic biliary cystadenoma causing luminal common bile duct obstruction

BACKGROUND

Biliary cystadenomas are rare cystic tumours that arise in the liver or less frequently in the extrahepatic biliary system. They are commoner in middle-aged women, their most favoured site is the right hepatic lobe.

METHODS

Case report and review of the literature.

RESULTS

We present only the second case of an intrahepatic cystadenoma causing luminal obstruction of the common bile duct. Clinical presentation is often non-specific and can prove to be a diagnostic challenge.

CONCLUSION

Wide local excision of biliary cystadenomas is recommended, with regular radiological follow-up.

The evolution of a vascular surgeon at a district general hospital: is sub-specialisation inevitable?

We report a 15-year retrospective audit to evaluate the change in arterial surgical commitment on general surgical case mix of a single surgeon with a vascular interest at a district general hospital. There was a 409% increase in the number of arterial procedures performed combined with a fall of 52% in the total number of operations over the study period. We conclude that, with such a rapidly growing arterial caseload, sub-specialisation to vascular surgery is inevitable.

The feasibility of spleen-preserving pancreatectomy for end-stage chronic pancreatitis

BACKGROUND

It is considered difficult to preserve the spleen at the time of distal or total pancreas resection for chronic pancreatitis (CP). The aim of this study was to assess the feasibility of preserving the spleen in patients requiring total or completion pancreatectomy for CP.

METHODS

All patients having total or completion pancreatectomy for CP were evaluated postoperatively in terms of morbidity, mortality, and pain relief. To assess splenic vascularity, all patients underwent abdominal ultrasound and power doppler imaging to assess splenic perfusion and the patency of the remaining splenic vessels.

RESULTS

Of 35 patients having total pancreatectomy, the spleen was preserved in 30 patients (19 women, 11 men; median age 40 years). The etiology of CP was mainly idiopathic (n = 14) or alcohol related (n = 12). All patients presented with chronic abdominal pain (median 5 years) requiring opiate-derived analgesia for pain relief. Fifteen patients (50%) had undergone previous therapeutic intervention for pain relief. The spleen was preserved with either an intact splenic artery and vein in 19 patients and or the short gastric vessels (n = 11). The mean duration of the procedure was 7 hours (range 5 to 11) and mean blood loss was 1,090 mL. The 30-day mortality was 3.8% (n = 1). Five patients had splenic complications (17%). These included splenectomy (n = 2), intrasplenic collection (n = 2), and a wedge splenic infarct (n = 1). Two of these complications were related to intrasplenic islet autotransplants. Follow-up with abdominal ultrasound and power doppler scanning showed no other abnormalities; blood flow was demonstrable in all patients with intact splenic arteries and vein (n = 19). The mean hospital stay was 25 days. Of the 24 patients who were beyond 6 months' follow-up, 82% (n = 20) have complete relief of pain, and 4 still require opiate analgesia.

CONCLUSIONS

Spleen-preserving pancreatectomy is a feasible procedure for chronic pancreatitis, providing complete pain relief in 80% of patients. When the splenic artery and vein cannot be preserved, there is a minimal risk of splenic complications that may require further treatment; but for the majority of patients, splenectomy is avoided.

Experience of combined endoscopic percutaneous stenting with ultrasound guidance for drainage of pancreatic pseudocycts

The therapeutic options for treatment of pancreatic pseudocysts are numerous. We report our experience of combined endoscopic and ultrasound guided percutaneous stenting for pancreatic pseudocysts. Data were prospectively collected for 20 consecutive patients. All patients had undergone a standard technique of combined endoscopic and ultrasound guided percutaneous placement of double J stents, between a pancreatic pseudocyst and the stomach. Patients age ranged between 25 and 84 years. Thirteen of the pseudocysts were due to acute pancreatitis and 7 were due to chronic pancreatitis. The duration of the combined procedure was mean 50 min (range 30-95 min). The length of hospital stay was mean 5 days (range 2-77 days. Only two patients suffered postoperative complications; one was re-admitted 2 weeks following stenting with acute cholecystitis, the other suffering a perforated duodenal ulcer 3 weeks after stenting. There were two failures early in the series, both due to stent migration, these stents were of a small size, (4.7 French). Following this the stent size was increased to at least 7 French, no further failures occurred. There was no operative mortality for the series. Follow-up ranged between 6 months and 5 years. We conclude that a combined percutaneous and endoscopic cyst-gastrostomy stent is a safe and effective treatment for patients with suitably placed pseudocysts.

A prospective controlled trial of the efficacy of isopropyl alcohol wipes before venesection in surgical patients

It has previously been suggested that skin preparation before venesection with antiseptic agents is unnecessary. However thousands of doctors and medical students continue to use isopropyl alcohol (IPA) swabs for venesection, at an estimated cost of 10,000 P per annum in a 500 bed hospital. An audit of IPA swab use among junior doctors and medical students at our institution was undertaken; 76% of doctors and 100% of medical students routinely prepared the skin with alcohol before venesection and only one used the swabs correctly. A randomised single-blind controlled trial was conducted of IPA versus no IPA skin preparation before venesection. There were 194 patients in the study, 93 in the IPA group and 101 controls. There was no statistical difference with respect to complications at the venepuncture site between the two groups.

The effect of oral irrigation with a magnetic water treatment device on plaque and calculus

Calculus formation on tooth surfaces is analogous to the formation of lime and scale deposits in plumbing. Magnetic water devices have been shown to significantly reduce scale deposits in industry; therefore an oral irrigator with a magnetic water device may have a similar effect on calculus. To test this hypothesis, a double-blind clinical study was established using 64 irrigators, 30 of which had their magnetic devices removed. 54 patients with heavy supragingival calculus were given irrigators at random after prophylaxis. Instructions were given to irrigate twice a day, particularly the lower 6 anterior teeth. The patients were also told not to floss these 6 teeth which were to be the study teeth. They were examined after 3 months and measurements were taken of the accretions adhering to the study teeth. No attempt was made to determine whether the adhering material was hard or soft so it must be assumed that at least some of the measured material was also plaque. The measurements of the group using an irrigator with a magnetic device showed a 44% greater reduction in calculus volume (p < 0.0005) and a 42% greater reduction in area (p < 0.0001) over the group using an unmagnetized irrigator. There appears to be a statistically significant difference in supragingival accretion volumes between conventional irrigation and using an irrigator with a magnetic water treatment device.

Correlation of broiler breeder male semen production and testes morphology

Broiler breeder males were fed either a 9, 12, or 15% protein diet (2,819 kcal/kg metabolizable energy) from 6 to 50 wk of age. From 48 through 49 wk of age semen volume (VOL) and concentration (CONC) and number of spermatozoa per ejaculate (NSE) were determined, and at 50 wk of age body weight (BWT) and testes weight (TWT) were measured. Spermatogenic activity was evaluated histologically by a) a computer-aided assessment of seminiferous epithelial area (SEA), tubular diameter (TD), and epithelial height (EH); and b) visual appraisal of seminiferous tubular size and maturity of cell types (testes score-TS). Relationships among NSE, TS, SEA, TD, EH, BWT, and TWT were determined. Dietary protein had no significant effect on VOL, CONC, NSE, BWT, TWT, TS, SEA, EH, or TD. Significant positive correlation coefficients were observed among NSE, TS, SEA, TD, and EH, indicating moderate effectiveness of these methods in evaluating reproductive state. Low correlations between NSE and other variables may have resulted from 25% of the males having high TS but failing to ejaculate semen. Body weight and TWT, as well as BWT and NSE, were positively correlated. The SEA and TD had higher correlations with TWT than with BWT.

Factors affecting broiler breeder performance. 7. Effect of varying levels of dietary protein on the development and reproductive performance of the dwarf broiler breeder

Vedette dwarf broiler breeder female chicks were raised in floor pens and fed a standard starter ration. At 3 wk of age, 1,032 pullets were divided into four dietary treatment groups (258 bird/treatment). Birds were transferred into individual cages at 18 wk of age and at 21 wk of age assigned to one of four laying rations. Dietary treatments consisted of a 4 X 4 factorial design with four developer diets (12, 14, 16, and 18% protein) and four layer diets (12, 14, 16, and 18% protein). Body weight was determined at 6, 12, and 17 wk of age and thereafter at 4 wk intervals. Hen-day egg production was determined weekly from 21 to 58 wk of age. Specific gravity and egg weights were measured at 4-wk intervals on eggs collected over 4-day periods. Fertility and hatchability were measured at 32, 34, and 44 wk of age on the one-half of the birds in each treatment that had been artificially inseminated weekly with .05 mL of semen from Ross males. Embryonic mortality and chick weights of offspring were recorded when the breeder flock was 32 and 44 wk of age. Dietary treatment had a significant effect on body weight (P greater than .05) at Week 12, (12% and 14% vs. 16% and 18%) but by Week 17 differences were no longer significant. Significant differences in body and egg weights during the laying cycle were detected (P less than .05), with hens receiving the higher protein (16% and 18%) laying diets exhibiting heavier body and egg weights.(ABSTRACT TRUNCATED AT 250 WORDS)

Semen and carcass evaluation of broiler breeder males fed low protein diets

At 43 days of age, 246 broiler breeder males were randomly assigned to either a 9, 12, or 15% protein diet (isocaloric) fed on a restricted basis until birds were 50 wk of age. Birds fed the 15% protein diet served as the control group for maintaining body weight. All groups received equal quantities of feed. Semen production was monitored weekly from 17 through 49 wk of age. Semen was evaluated for volume, concentration, and number of spermatozoa per ejaculate during four periods: 25 through 30, 36 through 37, 42 through 43, and 48 through 49 wk of age. Carcass composition and testes weight were sampled at 22 and 28 wk; at 50 wk of age all remaining males were analyzed. The dietary protein effect on body weight was linear (P less than .05). Birds fed the 9% protein diet had the lowest weights, while birds fed 12 and 15% protein became similar in body weight with increasing age. Semen volume, concentration, number of spermatozoa per ejaculate, and testes weight were unaffected by dietary protein level. The percentage of males that produced semen when fed the 9% protein diet was greater (P less than or equal to .09) with males fed 12 and 15% dietary protein. Dietary protein had a significant negative linear effect (P less than or equal to .001) on percent carcass fat at 50 wk of age but no effect on percentage carcass protein. Reducing dietary protein to 9% decreased male body weight slightly, increased carcass fat, and had no adverse effects on semen production through 50 wk of age.

The effect of dietary cholesterol, energy intake, and oxygen consumption on cholesterol metabolism in the chick

This experiment, involving 320 chicks, was conducted to determine the effects of dietary cholesterol, restricted caloric intake, and genetic lines on cholesterol metabolism in the bird. The two lines of chicks studied had been divergently selected for oxygen consumption and had been shown to differ significantly (P less than .01) in weight gain and carcass lipid deposition. The dietary treatments, administered for a 2-week period, consisted of two levels of dietary cholesterol (none and supplemented) for each of two levels of energy (ad libitum and restricted). At the end of this 2-week period, the birds were injected intravenously with 1-14C-acetate and their livers removed 4 hr later. Hepatic cholesterol and lipid synthesis were measured by the uptake of acetate. Added dietary cholesterol significantly (P less than .01) decreased hepatic cholesterol synthesis, lipid synthesis, and specific activity of hepatic cholesterol but increased plasma and liver cholesterol. However, the elevation in plasma and liver cholesterol represented only .9 and 1.8% respectively, of the increase in total intake of dietary cholesterol. Metabolizable energy of diets fed ad libitum was also significantly (P less than .01) reduced with supplemented dietary cholesterol. A significant (P less than .01) difference in body weight was present between the two lines, with low oxygen consuming (LOC) birds exhibiting heavier body weights than high oxygen consuming (HOC) birds. A significant interaction between line and energy intake (P less than .05) was present for hepatic cholesterol levels; LOC birds exhibited higher levels of hepatic cholesterol than HOC birds when both groups were fed at restricted levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholesterol metabolism in the laying hen as influenced by dietary cholesterol, caloric intake, and genotype

Three trials, each with 24 hens, were conducted to determine the effects of dietary cholesterol, caloric intake, and genotype on the synthesis, storage, and excretion of cholesterol in the laying hen. The two genotypes of birds used in this experiment had been divergently selected for high and low oxygen consumption and had been shown to differ significantly (P less than .01) in body weight gain and carcass lipid deposition from 0 to 4 weeks of age. The dietary treatment, administered for a 2-week period to birds in each genotype, consisted of two levels of dietary cholesterol (0 and 1% added) and two energy intakes (ad libitum and 75% ad libitum). The experimental design was a 2 X 2 X 2 factorial. One percent added cholesterol versus none supplemented produced a significant (P less than .01) decrease in available metabolizable energy and uptake of acetate into liver cholesterol while causing significant (P less than .01) increases in egg and liver cholesterol but not in plasma cholesterol. Restricting caloric intake, as compared to ad libitum feeding, resulted in significantly (P less than .01) decreased egg production and total amount of cholesterol excreted via the egg with significantly (P less than .05) increased plasma and liver cholesterol levels but no change in egg cholesterol concentration. Differences were significant (P less than .05) between the two genotypes in feed intake and hepatic cholesterol and lipid synthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Biological availability of selenodicysteine in chicks

The biological availability of selenium (Se) in selenodicysteine (SDC) for chicks was evaluated using plasma glutathione peroxidase (SeGSHpx) activity and tissue Se levels as criteria. In each of two trials day-old Single Comb White Leghorn chicks were fed a basal diet low in Se but supplemented with vitamin E during Days 1 to 14. On Day 15 three replicate groups of eight chicks were assigned to each dietary treatment. Dietary treatments consisted of feeding the basal diet alone or supplemented with approximately 50, 100, or 150 ppb Se as either sodium selenite or SDC from Days 15 to 27. Pooled samples of blood, liver, and breast muscle were obtained from four chicks per replicate group on Day 27. Activity of SeGSHpx and the concentration of Se in plasma, whole blood, muscle, and liver were highly correlated (P less than .0001) with supplemental dietary Se. In Trial 1 no differences were observed between the slopes for each compound upon determining linear regression equations for SeGSHpx, plasma Se, whole blood Se, muscle Se, or liver Se versus supplemental dietary Se. In Trial 2 there were no differences between the slopes for each compound in equations for SeGSHpx, plasma Se, or whole blood Se versus supplemental dietary Se. The ratio of slopes (SDC/sodium selenite) was .82 for both muscle Se and liver Se versus dietary Se. Thus, data indicate that Se in SDC is highly available for chicks.

Effect of dietary cholesterol and genotype on cholesterol metabolism in roosters

An experiment, involving 32 roosters, was designed to study the interaction of dietary cholesterol and genotype on cholesterol metabolism in roosters. The two lines of birds used in this study had been divergently selected for high and low oxygen consumption and had been shown to differ significantly (P less than .01) in body weight gain and carcass lipid deposition from hatch to 4 weeks of age. The dietary treatments, administered for a 2-week period, were 0 and 1% dietary cholesterol added to a basal mash diet. Two separate trials were run, each with 16 roosters, resulting in four replicates of each treatment per line for each trial (block). After the trial period, the birds were injected with 1-(14)C-acetate and livers were removed; hepatic cholesterol synthesis was measured by the uptake of labeled acetate into liver digitonin precipitable sterols. Plasma and liver cholesterol levels were also measured. The data were analyzed as a randomized complete block design. Added dietary cholesterol significantly (P less than .01) increased both plasma and liver cholesterol levels over the control while significantly (P less than .01) decreasing the uptake of acetate into hepatic cholesterol in both lines by about 7-fold. Plasma cholesterol was significantly (P less than .05) greater in the high than low oxygen-consuming birds, and liver cholesterol was higher (P less than .10) in the low than high oxygen-consuming line.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of fiber on cholesterol metabolism in the Coturnix quail

This experiment involving 288 Coturnix quail was conducted to determine the effects of various fiber sources (alfalfa, wheat bran, dried brewer's grain, cellulose, and pectin) on serum, liver and egg yolk cholesterol, and egg production. The fiber sources were added at a rate to provide 6.25% fiber to a corn-soybean meal diet and fed for a 28-day experimental period. Serum, liver, and egg cholesterol levels were measured as pen composite samples at the end of the experimental period. No difference was exhibited in egg yolk cholesterol among any of the groups (P greater than .10). Liver and serum cholesterol levels were elevated in the birds fed the pectin and wheat brain diets as compared with that in birds fed the other fiber source; also, metabolizable energy intakes and eggs per hen day (EHD) were decreased for both groups. When data were adjusted for EHD by covariance analysis, the treatment differences no longer appeared (P greater than .05). These results indicate that 1) there is a basal quantity of cholesterol deposited in the egg on which fiber intake, energy consumed, or egg production have very little effect and that 2) there is an inverse relationship between serum and tissue cholesterol levels and the total quantity of cholesterol excreted via the egg.