Randomized clinical trial comparing the effect of computed tomography in the trauma room versus the radiology department on injury outcomes.

Br J Surg. 2012 Jan;99 Suppl 1:105-13

Authors: Saltzherr TP, Bakker FC, Beenen LF, Dijkgraaf MG, Reitsma JB, Goslings JC, , Bossuyt PM, Jin PH, Luitse JS, Ponsen KJ, Henny CP, Giannakopoulos GF

Abstract

BACKGROUND: Computed tomography (CT) of injured patients in the radiology department requires potentially dangerous and time-consuming patient transports and transfers. It was hypothesized that CT in the trauma room would improve patient outcome and workflow.

METHODS: A randomized trial compared the effect of locating a CT scanner in the trauma room versus the radiology department in two Dutch trauma hospitals. Injured patients aged at least 16 years were assigned randomly to one of these hospitals at the time of transport. The primary outcome measure was the number of non-institutionalized days within the first year after randomization. Subgroup analyses were performed in patients with multiple trauma or severe traumatic brain injury (TBI).

RESULTS: Some 1124 patients were included, of whom 1045 were available for analysis. The median number of non-institutionalized days was 360 days in the intervention group versus 362 days for the control group (P = 0.068). The time from arrival to the first CT imaging was 13 min shorter in the intervention group (36 versus 49 min; P < 0.001). Patient transfers and transports were reduced by more than half in the intervention group. For both multiple trauma (265 patients) and TBI (121) subgroups, differences in mortality and out-of-hospital days favoured the intervention group, but were not statistically significant.

CONCLUSION: A CT scanner located in the trauma room reduces the time to acquire CT images and improves workflow, but does not lead to substantial improvements in clinical outcomes in a general trauma population. Observed beneficial effects on outcomes in patients with multiple trauma or severe TBI were not statistically significant. Registration number: ISRCTN55332315 (http://www.controlled-trials.com).

PMID: 22441863 [PubMed - indexed for MEDLINE]

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients.

Br J Surg. 2012 Jan;99 Suppl 1:52-8

Authors: Sierink JC, Saltzherr TP, Reitsma JB, Van Delden OM, Luitse JS, Goslings JC

Abstract

BACKGROUND: The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

METHODS: A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER).

RESULTS: Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively.

CONCLUSION: This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.

PMID: 22441856 [PubMed - indexed for MEDLINE]

Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap.

Br J Surg. 2012 May 9;

Authors: Lambe G, Russell C, West C, Kalaiselvan R, Slade DA, Anderson ID, Watson JS, Carlson GL

Abstract

BACKGROUND: Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap. METHODS: The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3-23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204-792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10-174) weeks. RESULTS: Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy. CONCLUSION: Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22569906 [PubMed - as supplied by publisher]

‘Artery-first’ approaches to pancreatoduodenectomy.

Br J Surg. 2012 May 9;

Authors: Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA

Abstract

BACKGROUND: The technique of pancreatoduodenectomy (PD) has evolved. Previously, non-resectability was determined by involvement of the portal vein-superior mesenteric vein. Because venous resection can be achieved safely and with greater awareness of the prognostic significance of the status of the posteromedial resection margin, non-resectability is now determined by involvement of the superior mesenteric artery (SMA). This change, with a need for early determination of resectability before an irreversible step, has promoted the development of an ‘artery-first’ approach. The aim of this study was to review, and illustrate, this approach. METHODS: An electronic search was performed on MEDLINE, Embase and PubMed databases from 1960 to 2011 using both medical subject headings and truncated word searches to identify all published articles that related to this topic. RESULTS: The search revealed six different surgical approaches that can be considered as ‘artery first’. These involved approaching the SMA from the retroperitoneum (posterior approach), the uncinate process (medial uncinate approach), the infracolic region medial to the duodenojejunal flexure (inferior infracolic or mesenteric approach), the infracolic retroperitoneum lateral to the duodenojenunal flexure (left posterior approach), the supracolic region (inferior supracolic approach) and through the lesser sac (superior approach). CONCLUSION: The six approaches described provide a range of options for the early determination of arterial involvement, depending on the location and size of the tumour, and before the ‘point of no return’. Whether these approaches will achieve an increase in the proportion of patients with negative margins, improve locoregional control and increase long-term survival has yet to be determined. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22569924 [PubMed - as supplied by publisher]

Influence of hospital type on outcomes after oesophageal and gastric cancer surgery.

Br J Surg. 2012 May 9;

Authors: Dikken JL, Wouters MW, Lemmens VE, Putter H, van der Geest LG, Verheij M, Cats A, van Sandick JW, van de Velde CJ

Abstract

BACKGROUND: Outcomes after oesophagectomy and gastrectomy vary considerably between hospitals. Possible explanations include differences in case mix, hospital volume and hospital type. The present study examined the distribution of oesophagectomies and gastrectomies between hospital types in the Netherlands, and the relationship between hospital type and outcome. METHODS: Data were obtained from the nationwide Netherlands Cancer Registry. Hospitals were categorized as university hospitals (UH), non-university teaching hospitals (NUTH) and non-university non-teaching hospitals (NUNTH). Hospital type-outcome relationships were analysed by Cox regression, adjusting for case mix, hospital volume, year of diagnosis and use of multimodal therapies. RESULTS: Between 1989 and 2009, 10 025 oesophagectomies and 14 221 gastrectomies for cancer were performed in the Netherlands. The percentage of oesophagectomies and gastrectomies performed in UH increased from 17·6 and 6·4 per cent respectively in 1989 to 44·1 and 12·9 per cent in 2009. After oesophagectomy, the 3-month mortality rate was 2·5 per cent in UH, 4·4 per cent in NUTH and 4·1 per cent in NUNTH (P = 0·006 for UH versus NUTH). After gastrectomy, the 3-month mortality rate was 4·9 per cent in UH, 8·9 per cent in NUTH and 8·7 per cent in NUNTH (P < 0·001 for UH versus NUTH). Three-year survival was also higher in UH than in NUTH and NUNTH. CONCLUSION: Oesophagogastric resections performed in UH were associated with better outcomes but, owing to variation in outcomes within hospital types, centres of excellence cannot be designated solely on hospital type. Detailed information on case mix and outcomes is needed to identify centres of excellence. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22569956 [PubMed - as supplied by publisher]

Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries (Br J Surg 2012; 99: 506-513).

Br J Surg. 2012 Apr;99(4):513-4

Authors: Brundage SI

PMID: 22396050 [PubMed - indexed for MEDLINE]

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves’ disease with a 5-year follow-up (Br J Surg 2012; 99: 515-522).

Br J Surg. 2012 Apr;99(4):522-3

Authors: Niederle B

PMID: 22396051 [PubMed - indexed for MEDLINE]

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis (Br J Surg 2012; 99: 532-539).

Br J Surg. 2012 Apr;99(4):540

Authors: Eglinton TW

PMID: 22396052 [PubMed - indexed for MEDLINE]

Resuscitative emergency thoracotomy in a Swiss trauma centre (Br J Surg 2012; 99: 541-548).

Br J Surg. 2012 Apr;99(4):548-9

Authors: Civil I

PMID: 22396053 [PubMed - indexed for MEDLINE]

Unresectable colorectal cancer liver metastases treated by intraoperative radiofrequency ablation with or without resection.

Br J Surg. 2012 Apr;99(4):558-65

Authors: Kazemier G

PMID: 22396054 [PubMed - indexed for MEDLINE]

Effects of tirapazamine on experimental colorectal liver metastases after radiofrequency ablation (Br J Surg 2012; 99: 567-575).

Br J Surg. 2012 Apr;99(4):576

Authors: Sund M

PMID: 22396055 [PubMed - indexed for MEDLINE]

Liver resection for colorectal cancer metastases involving the caudate lobe (Br J Surg 2011; 98: 1476-1482).

Br J Surg. 2012 Apr;99(4):596; author reply 596

Authors: McLean AL, Russell CD

PMID: 22396056 [PubMed - indexed for MEDLINE]

High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage (Br J Surg 2012; 99: 127-132).

Br J Surg. 2012 Apr;99(4):597; author reply 597

Authors: Arbman G

PMID: 22396059 [PubMed - indexed for MEDLINE]

Clinical significance of liver ischaemia after pancreatic resection (Br J Surg 2011; 98: 1760-1765).

Br J Surg. 2012 Apr;99(4):597-8; author reply 598

Authors: Takaori K, Raut V, Uemoto S

PMID: 22396060 [PubMed - indexed for MEDLINE]

Electrochemotherapy for disseminated superficial metastases from malignant melanoma.

Br J Surg. 2012 Jun;99(6):821-30

Authors: Campana LG, Valpione S, Mocellin S, Sundararajan R, Granziera E, Sartore L, Chiarion-Sileni V, Rossi CR

Abstract

BACKGROUND: The aim of the study was to determine predictive factors for effectiveness, toxicity and local disease control in patients with malignant melanoma treated with bleomycin-based electrochemotherapy (ECT).

METHODS: Electrochemotherapy was offered to patients with superficially disseminated melanoma metastases unsuitable for resection and unresponsive to chemotherapy.

RESULTS: Eighty-five patients were treated with up to six ECT cycles with minimal, mainly dermatological, toxicity. One month after the first ECT, an objective response was observed in 80 patients (94 per cent). After retreatment because of a partial response in 39 patients, a complete response was achieved in 19 patients. Among the 41 (48 per cent) complete responders at first ECT, 19 patients received a second cycle because of new lesions after a median of 6 (range 2-14) months. After a median follow-up of 26 months, six patients experienced local recurrence with a 2-year local progression-free survival rate of 87 per cent. In multivariable analysis, significant predictive factors for response were tumour size (odds ratio (OR) 0·23, 95 per cent confidence interval (c.i.) 0·19 to 0·86; P = 0·003) and number of lesions (OR 0·38, 0·28 to 0·88; P = 0·002). An increasing number of electrode applications (hazard ratio (HR) 2·18, 95 per cent c.i. 1·22 to 3·44; P = 0·041) and ECT cycles (HR 0·46, 0·22 to 0·95; P = 0·005) were predictors of local control. There were no predictors of toxicity. Melanoma thickness and lower limb location of metastases were prognostic for survival.

CONCLUSION: The most suitable candidates for ECT were patients with few and small metastases on the lower limb treated with multiple electrode applications and ECT cycles. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22508342 [PubMed - in process]

Hepatic venous pressure gradient in the assessment of portal hypertension before liver resection in patients with cirrhosis.

Br J Surg. 2012 Jun;99(6):855-63

Authors: Boleslawski E, Petrovai G, Truant S, Dharancy S, Duhamel A, Salleron J, Deltenre P, Lebuffe G, Mathurin P, Pruvot FR

Abstract

BACKGROUND: Preoperative measurement of hepatic venous pressure gradient (HVPG) is not performed routinely before hepatectomy in patients with cirrhosis, although it has been suggested to be useful. This study investigated whether preoperative HVPG values and indirect criteria of portal hypertension (PHT) predict the postoperative course in these patients.

METHODS: Between January 2007 and December 2009, consecutive patients with resectable hepatocellular carcinoma (HCC) in a cirrhotic liver were included in this prospective study. PHT was assessed by transjugular HVPG measurement and by classical indirect criteria (oesophageal varices, splenomegaly and thrombocytopenia). The main endpoints were postoperative liver dysfunction and 90-day mortality.

RESULTS: Forty patients were enrolled. A raised HVPG was associated with postoperative liver dysfunction (median 11 and 7 mmHg in those with and without dysfunction respectively; P = 0·017) and 90-day mortality (12 and 8 mmHg in those who died and survivors respectively; P = 0·026). Oesophageal varices, splenomegaly and thrombocytopenia were not associated with any of the endpoints. In multivariable analysis, body mass index, remnant liver volume ratio and preoperative HVPG were the only independent predictors of postoperative liver dysfunction.

CONCLUSION: An increased HVPG was associated with postoperative liver dysfunction and mortality after liver resection in patients with HCC and liver cirrhosis, whereas indirect criteria of PHT were not. This study suggests that preoperative HVPG measurement should be measured routinely in these patients. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22508371 [PubMed - in process]

International collaboration in the use of registries for new devices and procedures.

Br J Surg. 2012 Jun;99(6):744-745

Authors: Campbell B, Patrick H,

PMID: 22508386 [PubMed - as supplied by publisher]

Simulation-based training and learning curves in laparoscopic Roux-en-Y gastric bypass.

Br J Surg. 2012 Apr 18;

Authors: Zevin B, Aggarwal R, Grantcharov TP

Abstract

BACKGROUND: Ex vivo simulation-based technical skills training has been shown to improve operating room performance and shorten learning curves for basic laparoscopic procedures. The application of such training for laparoscopic Roux-en-$\font\ss=cmss10 scaled 1000 \hbox{Y}$ gastric bypass (LRYGBP) has not been reviewed. METHODS: Relevant studies were identified by one author from a search of MEDLINE and Embase databases from 1 January 1994 to 30 November 2010. Studies examining the learning curves and ex vivo training methods for LRYGBP were included; all other types of bariatric operations were excluded. A manual search of the references was also performed to identify additional potentially relevant papers. RESULTS: Twelve studies (5 prospective and 7 retrospective case series) were selected for review. The learning curve for LRYGBP was reported to be 50-100 procedures. Bench-top laparoscopic jejunojejunostomy, anaesthetized animals and Thiel human cadavers made up the bulk of the reported models for ex vivo training. Most studies were of relatively poor quality. An evidence-based ex vivo training curriculum for LRYGBP is currently lacking. CONCLUSION: Better quality studies are needed to define the learning curve for LRYGBP. Future studies should focus on the design and validation of training models, and a comprehensive curriculum for training and assessment of cognitive, technical and non-technical components of competency for laparoscopic bariatric surgery. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22511220 [PubMed - as supplied by publisher]

Comparison of liver transplantation outcomes from adult split liver and circulatory death donors.

Br J Surg. 2012 Jun;99(6):839-47

Authors: Mallik M, Callaghan CJ, Hope M, Gibbs P, Davies S, Gimson AE, Griffiths WJ, Pettigrew GJ

Abstract

BACKGROUND: Adult whole-organ donation after circulatory death (DCD) and ‘split’ extended right lobe donation after brain death (ERL-DBD) liver transplants are considered marginal, but direct comparison of outcomes has rarely been performed. Such a comparison may rationalize the use of DCD livers, which varies widely between UK centres.

METHODS: Outcomes for adult ERL-DBD livers and ‘controlled’ DCD liver transplantations performed at the Cambridge Transplant Centre between January 2004 and December 2010 were compared retrospectively.

RESULTS: None of the 32 patients in the DCD cohort suffered early graft failure, compared with five of 17 in the ERL-DBD cohort. Reasons for graft failure were hepatic artery thrombosis (3), progressive cholestasis (1) and small-for-size syndrome (1). Early allograft dysfunction occurred in a further five patients in each group. In the DCD group, ischaemic cholangiopathy developed in six patients, resulting in graft failure within the first year in two; the others remained stable. The incidence of biliary anastomotic complications was similar in both groups. Kaplan-Meier survival analysis confirmed superior graft survival in the DCD liver group (93 per cent at 3 years versus 71 per cent in the ERL-DBD cohort; P = 0·047), comparable to that of contemporaneous whole DBD liver transplants (93 per cent at 3 years). Patient survival was similar in all groups.

CONCLUSION: Graft outcomes of DCD liver transplants were better than those of ERL-DBD liver transplants. Redefining DCD liver criteria and refining donor-recipient selection for ERL-DBD transplants should be further explored. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22511247 [PubMed - in process]

Abstracts of the Annual Meeting of the Society of Academic and Research Surgery. January 4-5, 2012. Nottingham, United Kingdom.

Br J Surg. 2012 Apr;99 Suppl 4:1-65

Authors:

PMID: 22512010 [PubMed - indexed for MEDLINE]

Randomized clinical trial of glutamine-supplemented versus standard parenteral nutrition in infants with surgical gastrointestinal disease.

Br J Surg. 2012 Apr 19;

Authors: Ong EG, Eaton S, Wade AM, Horn V, Losty PD, Curry JI, Sugarman ID, Klein NJ, Pierro A,

Abstract

BACKGROUND: Addition of glutamine to parenteral nutrition in surgical infants remains controversial. The aim of this trial was to determine whether glutamine supplementation of parenteral nutrition in infants requiring surgery would reduce the time to full enteral feeding and/or decrease the incidence of sepsis and septicaemia. METHODS: A prospective double-blind multicentre randomized clinical trial was performed in surgical infants less than 3 months old who required parenteral nutrition. Patients were allocated to treatment or control groups by means of minimization. Infants received either 0·6 g per kg per day alanyl-glutamine (treatment group) or isonitrogenous isocaloric parenteral nutrition (control group) until full enteral feeding was achieved. Primary outcomes were time to full enteral feeding and incidence of sepsis. Cox regression analysis was used to compare time to full enteral feeding, and to calculate risk of sepsis/septicaemia. RESULTS: A total of 174 patients were randomized, of whom 164 completed the trial and were analysed (82 in each group). There was no difference in time to full enteral feeding or time to first enteral feeding between groups, and supplementation with glutamine had no effect on the overall incidence of sepsis or septicaemia. However, during total parenteral nutrition (before the first enteral feed), glutamine administration was associated with a significantly decreased risk of developing sepsis (hazard ratio 0·33, 95 per cent confidence interval 0·15 to 0·72; P = 0·005). CONCLUSION: Glutamine supplementation during parenteral nutrition did not reduce the incidence of sepsis in surgical infants with gastrointestinal disease. Registration number: ISRCTN83168963 (http://www.controlled-trials.com). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22513659 [PubMed - as supplied by publisher]

Resection margin involvement and tumour origin in pancreatic head cancer.

Br J Surg. 2012 Apr 20;

Authors: Verbeke CS, Gladhaug IP

Abstract

BACKGROUND: Assessment of the origin of adenocarcinoma in pancreatoduodenectomy specimens (pancreatic, ampullary or biliary) and resection margin status is not performed in a consistent manner in different centres. The aim of this review was to identify the impact of such variations on patient outcome. METHODS: A systematic literature search for articles on pancreatic, ampullary, distal bile duct and periampullary cancer was performed, with special attention to data on resection margin status, pathological examination and outcome. RESULTS: The frequent reclassification of tumour origin following slide review, and the wide variation in published incidence of pancreatic (33-89 per cent), ampullary (5-42 per cent) and distal bile duct (5-38 per cent) cancers indicate that the histopathological distinction between the three cancer groups is less accurate than generally believed. Recent studies have shown that the wide range of rates of microscopic margin involvement (R1) in pancreatoduodenectomy specimens (18-85, 0-27 and 0-72 per cent respectively for pancreatic, ampullary and distal bile duct cancers) is mainly caused by differences in pathological assessment rather than surgical practice and patient selection. As a consequence of the existing inconsistency in reporting of these data items, the clinical significance of microscopic margin involvement in each of the three cancer groups remains unclear. CONCLUSION: Inaccurate and inconsistent distinction between pancreatic, ampullary and distal bile duct cancer, combined with inaccuracies in resection margin assessment, results in obfuscation of key clinicopathological data. Specimen dissection technique plays a key role in the quality of the assessment of both tumour origin and margin status. Unless the pathological examination is meticulous and standardized, comparison of results between centres and observations in multicentre trials will remain of limited value. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22517199 [PubMed - as supplied by publisher]

Classification of and cytoreductive surgery for low-grade appendiceal mucinous neoplasms.

Br J Surg. 2012 Apr 20;

Authors: McDonald JR, O’Dwyer ST, Rout S, Chakrabarty B, Sikand K, Fulford PE, Wilson MS, Renehan AG

Abstract

BACKGROUND: Low-grade appendiceal mucinous neoplasm (LAMN) is a precursor lesion for pseudomyxoma peritonei (PMP), which, if treated suboptimally, may later disseminate throughout the abdominal cavity. The role of cytoreductive surgery for these relatively early lesions is unclear. METHODS: Clinicopathological details and treatment outcomes of patients with a LAMN and disease limited to the appendix or immediate periappendiceal tissues, referred to a national treatment centre between 2002 and 2009, were evaluated prospectively. RESULTS: Of 379 patients with a diagnosis of PMP, 43 (median age 49 years) had LAMNs localized to the appendix and periappendiceal tissue. Thirty-two patients initially presented with symptoms of acute appendicitis or right iliac fossa pain. Two distinct lesions were identified: type I (disease confined to the appendiceal lumen) and type II (mucin and/or neoplastic epithelium in the appendiceal submucosa, wall and/or periappendiceal tissue, with or without perforation). Type I lesions were managed by a watch-and-wait surveillance policy with serial measurement of tumour markers and computed tomography in 14 of 16 patients. Seventeen of 27 patients with type II lesions underwent risk-reducing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with low morbidity. After a median follow-up of 40 months, there was no disease progression in either treatment pathway. CONCLUSION: This study identified two LAMN subtypes. Type II lesions have pathological features of increased risk for dissemination and should be considered for risk-reducing cytoreductive surgery. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22517234 [PubMed - as supplied by publisher]

Critical appraisal of the ‘wait and see’ approach in rectal cancer for clinical complete responders after chemoradiation.

Br J Surg. 2012 Apr 27;

Authors: Glynne-Jones R, Hughes R

Abstract

BACKGROUND: Some 10-20 per cent of patients with locally advanced rectal cancer achieve a pathological complete response (pCR) at surgery following preoperative chemoradiation (CRT). Some demonstrate a sustained clinical complete response (cCR), defined as absence of clinically detectable residual tumour after CRT, and do not undergo resection. The aim of this review was to evaluate non-operative treatment of rectal cancer after CRT, and the outcome of patients observed without radical surgery. METHODS: A systematic computerized search identified 30 publications (9 series, 650 patients) evaluating a non-operative approach after CRT. Original data were extracted and tabulated, and study quality evaluated. The primary outcome measure was cCR. Secondary outcome measures included locoregional failure rate, disease-free survival and overall survival. RESULTS: The most recent Habr-Gama series reported a low locoregional failure rate of 4·6 per cent, with 5-year overall and disease-free survival rates of 96 and 72 per cent respectively. These findings were supported by a small prospective Dutch study. However, other retrospective series have described higher recurrence rates. All studies were heterogeneous in staging, inclusion criteria, study design and rigour of follow-up after CRT, which might explain the different outcomes. The definition of cCR was inconsistent, with only partial concordance with pCR. The results suggested that patients who are observed, but subsequently fail to sustain a cCR, may fare worse than those who undergo immediate tumour resection. CONCLUSION: The rationale of a ‘wait and see’ policy relies mainly on retrospective observations from a single series. Proof of principle in small low rectal cancers, where clinical assessment is easy, should not be extrapolated uncritically to more advanced cancers where nodal involvement is common. Long-term prospective observational studies with more uniform inclusion criteria are required to evaluate the risk versus benefit. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22539154 [PubMed - as supplied by publisher]

Selective hepatic vascular exclusion versus Pringle manoeuvre in liver resection for tumours encroaching on major hepatic veins.

Br J Surg. 2012 Apr 27;

Authors: Zhang J, Lai EC, Zhou WP, Fu S, Pan Z, Yang Y, Lau WY, Wu MC

Abstract

BACKGROUND: Control of bleeding is crucial during liver resection, and several techniques have been developed to achieve this. This study compared the safety and efficacy of selective hepatic vascular exclusion (SHVE) and Pringle manoeuvre in partial hepatectomy for liver tumours compressing or involving major hepatic veins. METHODS: All patients undergoing liver resection between January 2003 and December 2010 for liver tumours compressing or involving one or more major hepatic veins were identified retrospectively from a prospective institutional database. Either SHVE or Pringle manoeuvre was used to minimize blood loss during hepatectomy. Data on demographics and the intraoperative and postoperative course were analysed. RESULTS: From the database of 3900 patients, 1420 were identified who underwent liver resection for tumours encroaching on major hepatic veins using either SHVE (550) or the Pringle manoeuvre (870). Intraoperative blood loss (mean(s.d.) 480(210) versus 830(340) ml; P = 0·007) and transfusion requirements (mean(s.d.) 1·3(0·6) versus 2·9(1·4) units; P = 0·008) were significantly less in the SHVE group. In the Pringle group, hepatic vein injury resulted in major intraoperative bleeding of over 1000 ml in 65 patients (7·5 per cent) and air embolism in 14 (1·6 per cent), and three patients (0·3 per cent) died during surgery, whereas there was no major bleeding, air embolism or intraoperative death in the SHVE group. Postoperative liver failure, multiple organ failure and in-hospital death were significantly more common in the Pringle group (P = 0·019, P = 0·032 and P = 0·004 respectively). CONCLUSION: SHVE was more efficacious than the Pringle manoeuvre in minimizing intraoperative bleeding and air embolism during partial hepatectomy for tumours encroaching on major hepatic veins, and decreased the postoperative liver failure rate. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22539200 [PubMed - as supplied by publisher]

Diagnosis of postoperative pancreatic fistula.

Br J Surg. 2012 Apr 27;

Authors: Facy O, Chalumeau C, Poussier M, Binquet C, Rat P, Ortega-Deballon P

Abstract

BACKGROUND: Pancreatic fistula (PF) is a major source of morbidity after pancreatectomy. The International Study Group on Pancreatic Fistula (ISGPF) defines postoperative fistula by an amylase concentration in the abdominal drain of more than three times the serum value on day 3 or more after surgery. However, this definition fails to identify some clinical fistulas. This study examined the association between lipase measured in abdominal drainage fluid and PF. METHODS: Amylase and lipase levels in the abdominal drain were measured 3 days after pancreatic resection. Grade B and C fistulas were classified as clinical fistulas, regardless of whether the measured amylase concentration was considered positive or negative. The PF group included patients with a clinical fistula and/or those with positive amylase according to the ISGPF definition. RESULTS: Sixty-five patients were included. The median level of lipase was higher in patients with positive amylase than in those with negative amylase: 12 176 versus 64 units/l (P < 0·001). The lipase level was 16 500 units/l in patients with a clinical fistula and 224 units/l in those without a clinical fistula (P = 0·001). Patients with a PF had a higher lipase concentration than those without: 7852 versus 64 units/l (P < 0·001). A lipase level higher than 500 units/l yielded a sensitivity of 88 per cent and a specificity of 75 per cent for PF. For clinical fistulas the sensitivity was 93 per cent and specificity 77 per cent when the threshold for lipase was 1000 units/l. CONCLUSION: Lipase concentration in the abdominal drain correlated with PF. A threshold of 1000 units/l yielded a high sensitivity and specificity for the diagnosis of clinical PF. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22539219 [PubMed - as supplied by publisher]

Endovascular suitability and outcome after open surgery for ruptured abdominal aortic aneurysm.

Br J Surg. 2012 Apr 30;

Authors: Dick F, Diehm N, Opfermann P, von Allmen R, Tevaearai H, Schmidli J

Abstract

BACKGROUND: Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) has rapidly gained popularity, but superior results may be biased by patient selection. The aim was to investigate whether suitability for endovascular repair predicted survival, irrespective of technique of repair. METHODS: Two blinded investigators independently evaluated preoperative computed tomography angiograms of a consecutive cohort of patients with rAAA. Patients were categorized either ‘suitable’ or ‘unsuitable’ for endovascular repair, if assessments agreed. If assessments disagreed, they were classified ‘borderline suitable’. Correlations between endovascular suitability and clinical outcome were adjusted for suspected confounding factors and tested for robustness using sensitivity analyses. RESULTS: A total of 248 patients with rAAA from January 2001 to December 2010 were included, of whom 237 (95·6 per cent) underwent open repair. Seventy patients (28·2 per cent) were classified as ‘suitable’ and 100 (40·3 per cent) as ‘unsuitable’ for endovascular repair; 63 (25·4 per cent) were considered ‘borderline suitable’. Fifteen (6·0 per cent) could not be assessed and were included in the sensitivity analyses. The postoperative 30-day mortality rate was 15·3 per cent (38 deaths). Multiple logistic regression demonstrated that the odds of perioperative death increased 9·21 (95 per cent confidence interval 2·16 to 39·23) fold for ‘unsuitable’ rAAA (P = 0·003) and 6·80 (1·47 to 31·49) fold for ‘borderline’ rAAA (P = 0·014), compared with ‘suitable’ rAAA. This selection effect was robust across sensitivity analyses and sustained for at least 5 years of follow-up. CONCLUSION: Endovascular suitability was an independent and strongly positive predictor of survival after open repair of rAAA. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22547400 [PubMed - as supplied by publisher]

Pancolonic motor response to subsensory and suprasensory sacral nerve stimulation in patients with slow-transit constipation.

Br J Surg. 2012 May 3;

Authors: Dinning PG, Hunt LM, Arkwright JW, Patton V, Szczesniak MM, Wiklendt L, Davidson JB, Lubowski DZ, Cook IJ

Abstract

BACKGROUND: Sacral nerve stimulation (SNS) is emerging as a potential treatment for patients with constipation. Although SNS can elicit an increase in colonic propagating sequences (PSs), the optimal stimulus parameters for this response remain unknown. This study evaluated the colonic motor response to subsensory and suprasensory SNS in patients with slow-transit constipation. METHODS: Patients with confirmed slow-transit constipation were studied. Either a water-perfused manometry catheter or a high-resolution fibre-optic manometry catheter was positioned colonoscopically to the caecum. A temporary electrode was implanted transcutaneously in the S3 sacral nerve foramen. In the fasted state, three conditions were evaluated in a double-blind randomized fashion: sham, subsensory and suprasensory stimulation. Each 2-h treatment period was preceded by a 2-h basal period. The delta (Δ) value was calculated as the frequency of the event during stimulation minus that during the basal period. RESULTS: Nine patients had readings taken with a water-perfused catheter and six with a fibre-optic catheter. Compared with sham stimulation, suprasensory stimulation caused a significant increase in the frequency of PSs (mean(s.d.) Δ value – 1·1(7·2) versus 6·1(4·0) PSs per 2 h; P = 0·004). No motor response was recorded in response to subsensory stimulation compared with sham stimulation. Compared with subsensory stimulation, stimulation at suprasensory levels caused a significant increase in the frequency of PSs (P = 0·006). CONCLUSION: In patients with slow-transit constipation, suprasensory SNS increased the frequency of colonic PSs, whereas subsensory SNS stimulation did not. This has implications for the design of therapeutic trials and the clinical application of the device. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22556131 [PubMed - as supplied by publisher]

Accuracy of imaging for predicting operative approach in Crohn’s disease.

Br J Surg. 2012 May 3;

Authors: Malgras B, Soyer P, Boudiaf M, Pocard M, Lavergne-Slove A, Marteau P, Valleur P, Pautrat K

Abstract

BACKGROUND: The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn’s disease. METHODS: Patients with Crohn’s disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn’s disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings. RESULTS: Fifty-two patients with Crohn’s disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn’s disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE. CONCLUSION: Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn’s disease lesions before operation, allowing correct prediction of the operative approach. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22556137 [PubMed - as supplied by publisher]

Family history and risk of hospital treatment for varicose veins in Sweden.

Br J Surg. 2012 May 4;

Authors: Zöller B, Ji J, Sundquist J, Sundquist K

Abstract

BACKGROUND: Family history has been suggested as a risk factor for varicose veins, but recall bias may inflate the familial risks. The aim of this nationwide study was to determine familial risks for hospital treatment for varicose veins. METHODS: Data from the Swedish Multi-Generation Register of people aged 0-76 years were linked to Hospital Discharge Register data for 1964-2008. Standardized incidence ratios (SIRs) were calculated for individuals whose relatives were treated in hospital for varicose veins and compared with those whose relatives were not. Only main diagnoses of varicose veins were considered. RESULTS: A total of 39 396 people had hospital treatment for varicose veins. The familial SIR among offspring with one affected parent was 2·39 (95 per cent confidence interval 2·32 to 2·46). The SIR for those with one affected sibling was 2·86 (2·76 to 2·97). SIRs were increased in both men and women. The SIR for individuals with two or more affected siblings or with two affected parents was 5·88 (5·28 to 6·53) and 5·52 (4·77 to 6·36) respectively. The SIR for the wives of men treated for varicose veins was 1·69 (1·59 to 1·80); that for the husbands of women treated for varicose veins was 1·68 (1·58 to 1·79). CONCLUSION: Using the Swedish Hospital Discharge Register, and thereby eliminating recall bias, family history of hospital treatment for varicose veins was associated with an increased risk of similar treatment among relatives. The increased spousal risk suggests a contribution from non-genetic factors. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22556151 [PubMed - as supplied by publisher]

A common language to describe perihilar cholangiocarcinoma.

Br J Surg. 2012 May 3;

Authors: Deoliveira ML, Clavien PA

PMID: 22556154 [PubMed - as supplied by publisher]

Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy.

Br J Surg. 2012 May 4;

Authors: Ansorge C, Strömmer L, Andrén-Sandberg A, Lundell L, Herrington MK, Segersvärd R

Abstract

BACKGROUND: The morbidity rate after pancreaticoduodenectomy remains high (20-50 per cent) and postoperative pancreatic fistula (POPF) is a major underlying factor. POPF has been reported to be associated with pancreatic consistency (PC) and pancreatic duct diameter (PDD). The aim was to quantify the risk of pancreaticojejunostomy-associated morbidity (PJAM) by means of a structured intraoperative assessment of both characteristics. METHODS: This single-centre prospective observational study included pancreaticoduodenectomies performed between 2008 and 2010 with a standardized duct-to-mucosa end-to-side pancreaticojejunostomy. PC and PDD were assessed during surgery and classified into four grades each (from very hard to very soft, and from larger than 4 mm to smaller than 2 mm, respectively). PJAM was defined as POPF (grade B or C in International Study Group on Pancreatic Fistula classification) or symptomatic peripancreatic collection of either abscess or fluid. PJAM of at least Clavien grade IIIb was considered severe. RESULTS: PJAM and POPF were observed in 24 (21·8 per cent) and 17 (15·5 per cent) of 110 patients respectively. Softer PC and smaller PDD were risk factors for POPF (both P < 0·001), symptomatic peripancreatic collections (P = 0·071 and P = 0·015) and PJAM (both P < 0·001). Combining consistency and duct characteristics in a composite classification the PJAM risk was stratified as ‘high’ (both risk factors, PJAM incidence 51 per cent), ‘intermediate’ (softer PC or smaller PDD, PJAM 26 per cent) or ‘low’ (no risk factors, PJAM 2 per cent). Severe PJAM was observed only in patients with smaller PDD. CONCLUSION: A high-risk pancreatic gland had a 25-fold higher risk of PJAM after pancreaticoduoden- ectomy than a low-risk gland. This simple classification can contribute to more individualized patient management and allow stratification of study cohorts with homogeneous POPF risk. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22556164 [PubMed - as supplied by publisher]

In vivo study of the surgical anatomy of the axilla.

Br J Surg. 2012 Apr 16;

Authors: Khan A, Chakravorty A, Gui GP

Abstract

BACKGROUND: Classical anatomical descriptions fail to describe variants often observed in the axilla as they are based on studies that looked at individual structures in isolation or textbooks of cadaveric dissections. The presence of variant anatomy heightens the risk of iatrogenic injury. The aim of this study was to document the nature and frequency of these anatomical variations based on in vivo peroperative surgical observations. METHODS: Detailed anatomical relationships were documented prospectively during consecutive axillary dissections. Relationships between the thoracodorsal pedicle, course of the lateral thoracic vein, presence of latissimus dorsi muscle slips, variations in axillary and angular vein anatomy, and origins and branching of the intercostobrachial nerve were recorded. RESULTS: Among a total of 73 axillary dissections, 43 (59 per cent) revealed at least one anatomical variant. Most notable variants included aberrant courses of the thoracodorsal nerve in ten patients (14 per cent)-three variants; lateral thoracic vein in 12 patients (16 per cent)-four variants; bifid axillary veins in ten patients (14 per cent); latissimus dorsi muscle slips in four patients (5 per cent); and variants in intercostobrachial nerve origins and branching in 26 patients (36 per cent). The angular vein, a subscapular vein tributary, was found to be a constant axillary structure. CONCLUSION: Variations in axillary anatomical structures are common. Poor understanding of these variants can affect the adequacy of oncological clearance, lead to vascular injury, compromise planned microvascular procedures and result in chronic pain or numbness from nerve injury. Surgeons should be aware of the common anatomical variants to facilitate efficient and safe axillary surgery. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22505319 [PubMed - as supplied by publisher]

Applicability and safety of autologous fat for reconstruction of the breast.

Br J Surg. 2012 Apr 4;

Authors: Claro F, Figueiredo JC, Zampar AG, Pinto-Neto AM

Abstract

BACKGROUND: Autologous fat grafting to the breast for cosmetic and reconstructive purposes is still controversial with respect to its safety and efficacy. The objective of this study was to conduct a systematic review of the clinical applicability and safety of the technique. METHODS: An online search of the Cochrane Library, MEDLINE, Embase and SciELO was conducted from July 1986 to June 2011. Studies included in the review were original articles of autologous liposuctioned fat grafting to the female breast, with description of clinical complications and/or radiographic changes and/or local breast cancer recurrence. RESULTS: This review included 60 articles with 4601 patients. Thirty studies used fat grafting for augmentation and 41 for reconstructive procedures. The incidence of clinical complications, identified in 21 studies, was 3·9 per cent (117 of 3015); the majority were induration and/or palpable nodularity. Radiographic abnormalities occurred in 332 (13·0 per cent) of 2560 women (17 studies); more than half were consistent with cysts. Local recurrence of breast cancer (14 of 616, 2·3 per cent) was evaluated in three studies, of which only one was prospective. CONCLUSION: There is broad clinical applicability of autologous fat grafting for breast reconstruction. Complications were few and there was no evidence of interference with follow-up after treatment for breast cancer. Oncological safety remains unclear. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22488516 [PubMed - as supplied by publisher]

Adherence to treatment guidelines and survival in patients with early-stage breast cancer by age at diagnosis.

Br J Surg. 2012 Apr 11;

Authors: van de Water W, Bastiaannet E, Dekkers OM, de Craen AJ, Westendorp RG, Voogd AC, van de Velde CJ, Liefers GJ

Abstract

BACKGROUND: Elderly patients with breast cancer are under-represented in clinical studies. It is not known whether treatment guidelines, based on clinical trials, can be extrapolated to this population. The aim of this study was to assess adherence to treatment guidelines by age at diagnosis, and to examine age-specific survival in relation to adherence to guidelines. METHODS: Patients with early-stage breast cancer aged either less than 65 years, or 75 years or more, diagnosed between 2005 and 2008, were identified from the Netherlands Cancer Registry. Adherence to treatment guidelines for breast and axillary surgery, radiotherapy, chemotherapy and endocrine therapy was determined. Non-adherence to the guidelines was defined as overtreatment or undertreatment. The primary endpoint was overall survival, assessed by means of an instrumental variable, the comprehensive cancer centre region. RESULTS: Some 24 959 patients younger than 65 years and 6561 patients aged 75 years or more were included in the analysis. Median follow-up was 2·8 years. Compared with patients younger than 65 years, those aged at least 75 years were less frequently treated in concordance with guidelines: 62·0 per cent (15 487 patients) versus 55·6 per cent (3647 patients) (P < 0·001). In both age groups, most patients received at least three of five treatment modalities in concordance with guidelines: 98·8 per cent (24 652 patients) and 93·8 per cent (6152 patients) respectively. Analysis of survival using the instrumental variable showed that adherence to guidelines was not associated with overall survival in patients younger than 65 years (P = 0·601) or those aged at least 75 years (P = 0·190). CONCLUSION: Adherence to treatment guidelines was affected by age at diagnosis. However, adherence to the guidelines was not associated with overall survival in either age group. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22492310 [PubMed - as supplied by publisher]

Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy.

Br J Surg. 2012 Apr;99(4):524-31

Authors: Motoi F, Egawa S, Rikiyama T, Katayose Y, Unno M

Abstract

BACKGROUND: Postoperative pancreatic fistula (POPF) remains one of the most common causes of morbidity following pancreaticoduodenectomy (PD). This randomized trial examined whether external stent drainage of the pancreatic duct decreases the rate of POPF after PD and subsequent pancreaticojejunostomy (PJ).

METHODS: Consecutive patients who underwent PD with subsequent construction of a duct-to-mucosa PJ were randomized into a stented and a non-stented group. The primary outcome was the incidence of clinically relevant POPF. Secondary outcomes were morbidity and mortality rates, and hospital stay.

RESULTS: Of 114 PD procedures, 93 were suitable for inclusion in the study after informed consent. The rate of clinically relevant POPF was significantly lower in the stented group than in the non-stented group: three of 47 (6 per cent) versus ten of 46 (22 per cent) (P = 0·040). Among patients with a dilated duct, rates of POPF were similar in both groups. Among patients with a non-dilated duct, clinically relevant POPF was significantly less common in the stented group than in the non-stented group: two of 21 (10 per cent) versus eight of 20 (40 per cent) (P = 0·033). No significant differences in morbidity or mortality were observed. Univariable analysis identified body mass index (BMI), pancreatic cancer,pancreatic texture, pancreatic duct size and duct stenting as risk factors related to clinically relevant POPF. Multivariable analysis taking these five factors into account identified high BMI (risk ratio(RR) 11·45; P = 0·008), non-dilated duct (RR 5·33; P = 0·046) and no stent (RR 10·38; P = 0·004) as significant risk factors.

CONCLUSION: External duct stenting reduced the risk of clinically relevant POPF after PD and subsequent duct-to-mucosa PJ.

PMID: 22497024 [PubMed - in process]

Day-case thyroid surgery.

Br J Surg. 2012 Mar 30;

Authors: Doran HE, Palazzo F

PMID: 22467490 [PubMed - as supplied by publisher]

Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer.

Br J Surg. 2012 Mar 30;

Authors: O’Leary DP, O’Brien O, Relihan N, McCarthy J, Ryan M, Barry J, Kelly LM, Redmond HP

Abstract

BACKGROUND: Axillary ultrasonography (AUS) and fine-needle aspiration cytology (FNAC) can establish axillary lymph node status before surgery, although this technique is hampered by poor adequacy rates. To achieve consistently high rates of FNAC adequacy, rapid on-site evaluation (ROSE) of FNAC samples was introduced. METHODS: This single-centre, retrospective observational study of patients with newly diagnosed breast cancer undergoing preoperative AUS and FNAC between February 2008 and November 2010 examined the effect of the introduction of ROSE. RESULTS: A total of 381 patients were included. AUS revealed 152 axillae with suspicious radiological features. FNAC was positive for malignant cells in 75 (49·3 per cent) of 152 samples. Sentinel lymph node mapping was avoided in 75 patients, representing 19·7 per cent of the entire study population. Adequacy rates increased from 78 per cent to 96 per cent following the introduction of ROSE (P = 0·001). The overall sensitivity and specificity of AUS and FNAC was 80·6 and 100 per cent respectively. A lymph node diameter equal to or larger than 10 mm and extranodal extension were significantly associated with positive FNAC (P < 0·001 and P = 0·012 respectively). Maximum lymph node diameter of at least 10 mm was an independent predictor of positive FNAC (odds ratio 11·2, 95 per cent confidence interval 3·32 to 37·76; P < 0·001). CONCLUSION: AUS with FNAC provided accurate preoperative staging of the axilla for metastatic breast disease and avoided unnecessary sentinel lymph node mapping. The introduction of ROSE ensured the efficiency of AUS and FNAC. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22473359 [PubMed - as supplied by publisher]

Systematic review of trocar-site hernia.

Br J Surg. 2012 Mar;99(3):315-23

Authors: Swank HA, Mulder IM, la Chapelle CF, Reitsma JB, Lange JF, Bemelman WA

Abstract

BACKGROUND: Broad implementation of laparoscopic surgery has made trocar-related complications clinically important. Trocar-site hernia (TSH) is an uncommon, but potentially serious, complication that occasionally requires emergency surgery. This systematic review was conducted to establish the prevalence and risk factors for TSH.

METHODS: The review was conducted according to the PRISMA guidelines. MEDLINE, Embase, Web of Science and the Cochrane Library were searched to 7 June 2010 for studies on TSH.

RESULTS: Twenty-two articles were included. One study was a randomized clinical trial, five were prospective cohort studies and 16 were retrospective cohort studies. The prevalence of TSH is low, with a median pooled estimate of 0·5 (range 0-5·2) per cent. No meta-analysis on risk factors could be performed. Pyramidal trocars, 12-mm trocars and a long duration of surgery were identified as the most important technical risk factors for TSH. Older age and a higher body mass index were observed to be patient-related risk factors.

CONCLUSION: TSH is an uncommon complication of laparoscopic surgery. The most important technical risk factors are the design and size of the trocars. The scientific evidence for recommendations to avoid TSH is sparse.

PMID: 22213083 [PubMed - indexed for MEDLINE]

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda.

Br J Surg. 2012 Mar;99(3):436-43

Authors: Petroze RT, Nzayisenga A, Rusanganwa V, Ntakiyiruta G, Calland JF

Abstract

BACKGROUND: Disparities in the global availability of operating theatres, essential surgical equipment and surgically trained providers are profound. Although efforts are ongoing to increase surgical care and training, little is known about the surgical capacity in developing countries. The aim of this study was to create a baseline for surgical development planning at a national level.

METHODS: A locally adapted World Health Organization survey was conducted in November 2010 to assess emergency and essential surgical capacity and volumes, with on-site interviews at 44 district and referral hospitals in Rwanda. Results were compiled for education and capacity development discussions with the Rwandan Ministry of Health and the Rwanda Surgical Society.

RESULTS: Among 10·1 million people, there were 44 hospitals and 124 operating rooms (1·2 operating rooms per 100,000 persons). There was a total of 50 surgeons practising full- or part-time in Rwanda (0·49 total surgeons per 100,000 persons). The majority of consultant surgeons worked in the capital (covering 10 per cent of the population). Anaesthesia was performed primarily by anaesthesia technicians, and six of 44 hospitals had no trained anaesthesia provider. Continuous availability of electricity, running water and generators was lacking in eight hospitals, and 19 reported an absence or shortage in the availability of pulse oximetry. Equipment for life-saving surgical airway procedures, particularly in children, was lacking. A dedicated emergency area was available in only 19 hospitals. In 2009 and 2010 over 80,000 surgical procedures (major and minor) were recorded annually in Rwanda.

CONCLUSION: A comprehensive countrywide assessment of surgical capacity in resource-limited settings found severe shortages in available resources. Immediate local feedback is a useful tool for creating a baseline of surgical capacity to inform country-specific surgical development.

PMID: 22237597 [PubMed - indexed for MEDLINE]

Recruiting patients into randomized clinical trials in surgery.

Br J Surg. 2012 Mar;99(3):307-8

Authors: Blazeby JM

PMID: 22237652 [PubMed - indexed for MEDLINE]

Predictive factors for postoperative constipation and continence after stapled transanal rectal resection.

Br J Surg. 2012 Mar;99(3):416-22

Authors: Boenicke L, Reibetanz J, Kim M, Schlegel N, Germer CT, Isbert C

Abstract

BACKGROUND: Although stapled transanal rectal resection (STARR) has become an important surgical option in the treatment of obstructive defaecation syndrome, objective data about parameters that predict its success or failure are not yet available.

METHODS: Medical history, clinical and radiomorphological data were obtained prospectively from a multi-institutional STARR registry. Predictive factors for postoperative constipation (Cleveland Clinic Constipation Score, CCS) and incontinence (Cleveland Clinic Incontinence Score, CCIS) were identified using univariable and multivariable analysis.

RESULTS: Data were obtained for 181 of 201 patients in the STARR registry, with completed median follow-up of 19·4 (range 12-41) months. Although the CCS decreased significantly overall (from mean(s.d.) 16·3(4·9) to 6·7(4·1); P < 0·001), 31 patients (17·1 per cent) complained about persisting constipation. CCIS levels remained unchanged overall, but 16 patients (8·8 per cent) had new-onset faecal incontinence. Multivariable analysis revealed that rectocele (β = -0·302, P < 0·001) and intussusception (β = -0·392, P < 0·001) were independent predictors of low CCS levels, and intussusception (β = -0·216, P = 0·001) and enterocele (β = -0·171, P = 0·012) were independent predictors of low CCIS levels. In contrast, small rectal diameter (β = -0·293, P < 0·001), low squeeze pressure (β = -0·188, P = 0·005) and increased pelvic floor descent at rest (β = 0·264, P < 0·001) predicted high CCIS levels.

CONCLUSION: Factors for a favourable outcome after STARR included rectocele, intussusception and enterocele, whereas small rectal diameter, low sphincter pressure and increased pelvic floor descent were unfavourable. These findings should be integrated into the therapy algorithm for STARR.

PMID: 22237693 [PubMed - indexed for MEDLINE]

Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients (Br J Surg 2012; 99: 336-344).

Br J Surg. 2012 Mar;99(3):345

Authors: Helling TS

PMID: 22287071 [PubMed - indexed for MEDLINE]

Mass casualty incident training in a resource-limited environment (Br J Surg 2012; 99: 356-361).

Br J Surg. 2012 Mar;99(3):361

Authors: Weiser TG

PMID: 22287072 [PubMed - indexed for MEDLINE]

Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices (Br J Surg 2012; 99: 362-366).

Br J Surg. 2012 Mar;99(3):367

Authors: Holcomb JB

PMID: 22287073 [PubMed - indexed for MEDLINE]

Risk factors for postoperative bleeding after thyroid surgery (Br J Surg 2012; 99: 373-379).

Br J Surg. 2012 Mar;99(3):380

Authors: Brauckhoff M

PMID: 22287074 [PubMed - indexed for MEDLINE]

Postoperative adhesion prevention using a statin-containing cellulose film in an experimental model (Br J Surg 2012; 99: 423-429).

Br J Surg. 2012 Mar;99(3):430

Authors: Schreinemacher MH

PMID: 22287075 [PubMed - indexed for MEDLINE]

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda (Br J Surg 2012: 99: 436-443).

Br J Surg. 2012 Mar;99(3):444

Authors: Gawande A

PMID: 22287076 [PubMed - indexed for MEDLINE]

Importance of specimen length during temporal artery biopsy (Br J Surg 2011; 98: 1556-1560).

Br J Surg. 2012 Mar;99(3):445; author reply 445

Authors: Rohman L, Phillips AW

PMID: 22287077 [PubMed - indexed for MEDLINE]

Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair (Br J Surg 2012; 99: 29-37).

Br J Surg. 2012 Mar;99(3):446; author reply 446

Authors: Ashraf N, Uzzaman M

PMID: 22287080 [PubMed - indexed for MEDLINE]

Population-based study of the need for cholecystectomy after obesity surgery.

Br J Surg. 2012 Mar 7;

Authors: Plecka Östlund M, Wenger U, Mattsson F, Ebrahim F, Botha A, Lagergren J

Abstract

BACKGROUND: Weight loss following obesity surgery is associated with gallstone formation, but there is limited evidence on whether prophylactic cholecystectomy is indicated during obesity surgery. The aim of this study was to clarify the need for cholecystectomy following obesity surgery. METHODS: A Swedish nationwide, population-based cohort study was conducted during the 22-year interval 1987-2008. Need for later cholecystectomy for gallstone disease was assessed in patients who had undergone obesity surgery in comparison with the general population of corresponding age, sex and calendar year. This need was also compared with the need for cholecystectomy in cohorts of patients who had undergone antireflux surgery and appendicectomy. Standardized incidence ratios (SIRs) with 95 per cent confidence intervals (c.i.) were calculated to estimate the relative risk. RESULTS: In the obesity surgery cohort of 13 443 patients, the observed number of cholecystectomies (1149, 8·5 per cent) exceeded the expected number by over fivefold (SIR 5·5, 95 per cent c.i. 5·1 to 5·8). The observed need for imperative cholecystectomy (for cholecystitis, cholangitis, pancreatitis, or jaundice; 427, 3·2 per cent) was also greater than expected (SIR 5·2, 4·7 to 5·7). The SIR peaked 7-24 months after obesity surgery and decreased with longer follow-up. The SIRs for cholecystectomy after antireflux surgery and appendicectomy were 2·4 (2·2 to 2·6) and 1·7 (1·6 to 1·7) respectively. CONCLUSION: An increased need for cholecystectomy after obesity surgery was confirmed, but was probably partly due to an increased detection of gallbladder disease only because of the surgery; the individual’s risk of imperative cholecystectomy was low. Therefore, prophylactic cholecystectomy might not be recommended during obesity surgery. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22407811 [PubMed - as supplied by publisher]

Evaluation of five risk prediction models for elective abdominal aortic aneurysm repair using the UK National Vascular Database.

Br J Surg. 2012 Mar 13;

Authors: Grant SW, Grayson AD, Mitchell DC, McCollum CN

Abstract

BACKGROUND: There is no consensus on the best risk prediction model for mortality following elective abdominal aortic aneurysm (AAA) repair. The objective was to evaluate the performance of five risk prediction models using the UK National Vascular Database (NVD). METHODS: Data on elective AAA repairs from the NVD between January 2008 and December 2010 were analysed. The models assessed were: Glasgow Aneurysm Score (GAS), Vascular Biochemical and Haematological Outcome Model (VBHOM), physiological component of the Vascular Physiological and Operative Severity Score for enUmeration of Mortality (V-POSSUM), Medicare and Vascular Governance North West (VGNW). Overall model discrimination and calibration in equally sized risk-group quintiles were assessed. RESULTS: The study cohort included 10 891 patients undergoing elective AAA repair (median age 74 years, 87·3 per cent men). The in-hospital mortality rates following endovascular and open repair were 1·3 and 4·7 per cent respectively (2·9 per cent overall). The Medicare and VGNW models both showed good discrimination (area under receiver operating characteristic (ROC) curve 0·71), whereas the GAS, VBHOM and V-POSSUM models showed poor discrimination (area under ROC curve 0·60, 0·61 and 0·62 respectively). The VGNW model was the only one to predict the overall mortality rate in the cohort (3·3 per cent predicted versus 2·9 per cent observed; P = 0·066). The VGNW model demonstrated good calibration, predicting risk accurately in four risk-group quintiles. The Medicare, V-POSSUM and VBHOM models accurately predicted risk in three, two and no risk-group quintiles respectively. CONCLUSION: The Medicare and VGNW models contain similar risk factors and showed good discrimination when applied to the NVD. Both models would be suitable for risk prediction after elective AAA repair in the UK. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22415901 [PubMed - as supplied by publisher]

Rectal perforation with life-threatening peritonitis following stapled haemorrhoidopexy.

Br J Surg. 2012 Mar 15;

Authors: Faucheron JL, Voirin D, Abba J

Abstract

BACKGROUND: Stapled haemorrhoidopexy is a well recognized alternative to haemorrhoidectomy, and is associated with reduced pain and earlier return to normal activity. This paper reports all published cases of life-threatening sepsis following stapled haemorrhoidopexy, identifies causative factors and makes recommendations. METHODS: A systematic review of the literature was performed by searching the major electronic databases. All relevant references were reviewed for possible inclusion. All references of the relevant articles were screened for any further articles that were not identified in the initial search. RESULTS: From 2000 to the present, 29 articles reporting complications in 40 patients were identified. Thirty-five patients underwent laparotomy with faecal diversion and a further patient was treated by low anterior resection. A specific complication was rectal perforation with peritonitis. Factors that led to life-threatening sepsis were identified in 30 patients. Despite surgical treatment and resuscitation, there were four deaths. CONCLUSION: Severe sepsis can complicate stapled haemorrhoidopexy. Rectal perforation and peritonitis are a particular risk of this technique and the associated mortality rate is high. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22418745 [PubMed - as supplied by publisher]

Impact of anastomotic complications on outcome after laparoscopic gastrectomy for early gastric cancer.

Br J Surg. 2012 Mar 14;

Authors: Nagasako Y, Satoh S, Isogaki J, Inaba K, Taniguchi K, Uyama I

Abstract

BACKGROUND: The effects of anastomotic complications after laparoscopically assisted gastrectomy (LAG) have not been studied widely. The aims of this observational study were to identify potential factors that predict anastomotic complications and investigate the impact of anastomotic complications in patients undergoing gastrectomy for early gastric cancer. METHODS: The study included consecutive patients with histologically proven T1 gastric adenocarcinoma treated by LAG with regional lymphadenectomy between August 1997 and March 2008, who had not received neoadjuvant chemotherapy. Anastomotic complications included anastomotic leakage, stricture and remnant gastric stasis of grade II or higher (modified Clavien classification) and were identified by clinical assessment and confirmatory investigation. Predictive factors for the development of anastomotic complications were identified by univariable and multivariable analyses. Long-term survival with or without anastomotic complications was examined. RESULTS: Anastomotic complications occurred in 37 (9·3 per cent) of 400 patients. Multivariable analysis indicated surgeon experience as the only independent predictor of anastomotic complications (hazard ratio 4·40, 95 per cent confidence interval 2·04 to 9·53; P < 0·001). Patients with anastomotic complications had a significantly worse overall 5-year survival rate than those without (81 versus 94·2 per cent; P = 0·009). CONCLUSION: Anastomotic complications after LAG lead to worse long-term survival. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22418853 [PubMed - as supplied by publisher]

Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula.

Br J Surg. 2012 Mar 20;

Authors: Gans SL, van Westreenen HL, Kiewiet JJ, Rauws EA, Gouma DJ, Boermeester MA

Abstract

BACKGROUND: Somatostatin analogues are used for the treatment of pancreatic fistula, with the aim of achieving fistula closure or reduction of output. METHOD: MEDLINE, Embase and Cochrane databases were searched systematically for relevant articles followed by hand-searching of reference lists. Data on patient recruitment, intervention and outcome were extracted and meta-analysis performed where reasonable. RESULTS: Seven randomized clinical trials met the inclusion criteria and included a total of 297 patients with fistulas of the gastrointestinal tract; of these, 102 patients had fistulas of pancreatic origin. Pooling of closure rates showed no significant difference between patients treated with somatostatin analogues compared with controls: odds ratio 1·52 (95 per cent confidence interval 0·88 to 2·61). Owing to inconsistent descriptions, pooling of results was not possible for other endpoints, such as time to fistula closure. CONCLUSION: There is no solid evidence that somatostatin analogues result in a higher closure rate of pancreatic fistula compared with other treatments. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22430616 [PubMed - as supplied by publisher]

Systematic review of total pancreatectomy and islet autotransplantation for chronic pancreatitis.

Br J Surg. 2012 Mar 20;

Authors: Bramis K, Gordon-Weeks AN, Friend PJ, Bastin E, Burls A, Silva MA, Dennison AR

Abstract

BACKGROUND: Total pancreatectomy and islet autotransplantation (TP/IAT) is a treatment option in a subset of patients with chronic pancreatitis. A systematic review of the literature was performed to evaluate the outcome of this procedure, with an attempt to ascertain when it is indicated. METHODS: MEDLINE (1950 to present), Embase (1980 to present) and the Cochrane Library were searched to identify studies of outcomes in patients undergoing TP/IAT. Cohort studies that reported the outcomes following the procedure were included. The MOOSE guidelines were used as a basis for this review. RESULTS: Five studies met the inclusion criteria. The techniques reported for pancreatectomy and islet cell isolation varied between studies. TP/IAT was successful in reducing pain in patients with chronic pancreatitis. Comparing morphine requirements before and after the procedure, two studies recorded significant reductions. Concurrent IAT reduced the insulin requirement after TP; the rate of insulin independence ranged from 46 per cent of patients at 5 years’ mean follow-up to 10 per cent at 8 years. The impact on quality of life was poorly reported. The studies reviewed did not provide evidence for optimal timing of TP/IAT in relation to the evolution of chronic pancreatitis. CONCLUSION: This systematic review showed that TP/IAT had favourable outcomes with regard to pain reduction. Concurrent IAT enabled a significant proportion of patients to remain independent of insulin supplementation. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22434330 [PubMed - as supplied by publisher]

Clinical and biomarker profile of trauma-induced secondary cardiac injury.

Br J Surg. 2012 Mar 21;

Authors: De’ath HD, Rourke C, Davenport R, Manson J, Renfrew I, Uppal R, Davies LC, Brohi K

Abstract

BACKGROUND: Secondary cardiac injury has been demonstrated in critical illness and is associated with worse outcomes. The aim of this study was to establish the existence of trauma-induced secondary cardiac injury, and investigate its impact on outcomes in injured patients. METHODS: Injured adult patients eligible for enrolment in the Activation of Coagulation and Inflammation in Trauma 2 study, and admitted to the intensive care unit between January 2008 and January 2010, were selected retrospectively for the study. Markers of cardiac injury (brain natriuretic peptide (BNP), heart-type fatty acid binding protein (H-FABP) and troponin I) were measured on admission, and after 24 and 72 h in blood samples from injured patients. Individual records were reviewed for adverse cardiac events and death. RESULTS: During the study period, 135 patients were enrolled (106 male, 78·5 per cent) with a median age of 40 (range 16-89) years. Eighteen patients (13·3 per cent) had an adverse cardiac event during admission and these events were not associated with direct thoracic injury. The in-hospital mortality rate was higher among the adverse cardiac event cohort: 44 per cent (8 of 18) versus 17·1 per cent (20 of 117) (P = 0·008). Raised levels of H-FABP and BNP at 0, 24 and 72 h, and troponin I at 24 and 72 h, were associated with increased adverse cardiac events. BNP levels were higher in non-survivors on admission (median 550 versus 403 fmol/ml; P = 0·022), after 24 h (794 versus 567 fmol/ml; P = 0·033) and after 72 h (1043 versus 753 fmol/ml; P = 0·036), as were admission troponin I levels. CONCLUSION: Clinical and cardiac biomarker characteristics support the existence of trauma-induced secondary cardiac injury, which is associated with death, and unrelated to direct thoracic injury. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22437496 [PubMed - as supplied by publisher]

Outcomes of simultaneous pancreas-kidney transplantation from brain-dead and controlled circulatory death donors.

Br J Surg. 2012 Mar 22;

Authors: Qureshi MS, Callaghan CJ, Bradley JA, Watson CJ, Pettigrew GJ

Abstract

BACKGROUND: Organ scarcity has prompted increased use of organs from donation after circulatory death (DCD) donors. An early single-centre experience of simultaneous pancreas-kidney (SPK) transplantation from controlled DCD donors is described here. METHODS: Outcomes of SPK transplants from DCD and donation after brain death (DBD) donors between August 2008 and January 2011 were reviewed retrospectively. RESULTS: SPK transplants from 20 DCD and 40 DBD donors were carried out. Donor and recipient characteristics were similar for both groups, although pancreas cold ischaemia times were shorter in DCD recipients: median (range) 8·2 (5·9-10·5) versus 9·5 (3·8-12·5) h respectively (P = 0·004). Median time from treatment withdrawal to cold perfusion was 24 (range 16-110) min for DCD donors. There were no episodes of delayed pancreatic graft function in either group; the graft thrombosis rates were both 5 per cent. Similarly, there were no differences in haemoglobin A1c level at 12 months: median (range) 5·4 (4·9-7·7) per cent in DCD group versus 5·4 (4·1-6·2) per cent in DBD group (P = 0·910). Pancreas graft survival rates were not significantly different, with Kaplan-Meier 1-year survival estimates of 84 and 95 per cent respectively (P = 0·181). CONCLUSION: DCD SPK grafts had comparable short-term outcomes to DBD grafts, even when procured from selected donors with a prolonged agonal phase. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22437616 [PubMed - as supplied by publisher]

Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery.

Br J Surg. 2012 Mar;99(3):346-55

Authors: Sultan J, Griffin SM, Di Franco F, Kirby JA, Shenton BK, Seal CJ, Davis P, Viswanath YK, Preston SR, Hayes N

Abstract

BACKGROUND: Oesophagogastric cancer surgery is immunosuppressive. This may be modulated by omega-3 fatty acids (O-3FAs). The aim of this study was to assess the effect of perioperative O-3FAs on clinical outcome and immune function after oesophagogastric cancer surgery.

METHODS: Patients undergoing subtotal oesophagectomy and total gastrectomy were recruited and allocated randomly to an O-3FA enteral immunoenhancing diet (IED) or standard enteral nutrition (SEN) for 7 days before and after surgery, or to postoperative supplementation alone (control group). Clinical outcome, fatty acid concentrations, and HLA-DR expression on monocytes and activated T lymphocytes were determined before and after operation.

RESULTS: Of 221 patients recruited, 26 were excluded. Groups (IED, 66; SEN, 63; control, 66) were matched for age, malnutrition and co-morbidity. There were no differences in morbidity (P = 0·646), mortality (P = 1·000) or hospital stay (P = 0·701) between the groups. O-3FA concentrations were higher in the IED group after supplementation (P < 0·001). The ratio of omega-6 fatty acid to O-3FA was 1·9:1, 4·1:1 and 4·8:1 on the day before surgery in the IED, SEN and control groups (P < 0·001). There were no differences between the groups in HLA-DR expression in either monocytes (P = 0·538) or activated T lymphocytes (P = 0·204).

CONCLUSION: Despite a significant increase in plasma concentrations of O-3FA, immunonutrition with O-3FA did not affect overall HLA-DR expression on leucocytes or clinical outcome following oesophagogastric cancer surgery. Registration number: ISRCTN43730758 (http://www.controlled-trials.com).

PMID: 22237467 [PubMed - indexed for MEDLINE]

Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms.

Br J Surg. 2012 Mar 5;

Authors: Sweeting MJ, Thompson SG, Brown LC, Powell JT,

Abstract

BACKGROUND: Surveillance is a common management strategy for small abdominal aortic aneurysm (AAA) (3·0-5·4 cm in diameter). Individual characteristics, other than diameter, may influence aneurysm growth or rupture rates. METHODS: Individual data were collated from 15 475 people under follow-up for a small aneurysm in 18 studies. The influence of co-variables (including demographics, medical and drug history) on aneurysm growth and rupture rates (analysed using longitudinal random-effects modelling and survival analysis with adjustment for aneurysm diameter) were summarized in an individual patient meta-analysis. RESULTS: The mean aneurysm growth rate of 2·21 mm/year was independent of age and sex. Growth rate was increased in smokers (by 0·35 mm/year) and decreased in patients with diabetes (by 0·51 mm/year). Mean arterial pressure had no effect and antihypertensive or other cardioprotective medications had only small, non-significant effects on aneurysm growth, consistent with the observation that calendar year of enrolment was not associated with growth rate. Rupture rates were almost fourfold higher in women than men (P < 0·001), were double in current smokers (P = 0·001) and increased with higher blood pressure (P = 0·001). CONCLUSION: Follow-up schedules for individuals with a small AAA may need to consider diabetes and smoking, in addition to aneurysm diameter. The differing risk factors for growth and rupture suggest that a lower threshold for surgical intervention in women may be justified. No single drug used for cardiovascular risk reduction had a major effect on the growth or rupture of small aneurysms. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22389113 [PubMed - as supplied by publisher]

Randomized clinical trial comparing infrahepatic inferior vena cava clamping with low central venous pressure in complex liver resections involving the Pringle manoeuvre.

Br J Surg. 2012 Mar 2;

Authors: Zhu P, Lau WY, Chen YF, Zhang BX, Huang ZY, Zhang ZW, Zhang W, Dou L, Chen XP

Abstract

BACKGROUND: Control of bleeding remains key to successful hepatic resection. The present randomized clinical trial compared infrahepatic inferior vena cava (IVC) clamping with low central venous pressure (CVP) during complex hepatectomy using portal triad clamping (PTC). METHODS: Consecutive patients undergoing complex hepatectomy were allocated randomly to PTC combined with infrahepatic IVC clamping or to PTC with low CVP. Primary outcome was blood loss during parenchymal transection. Secondary outcomes were intraoperative surgical and haemodynamic parameters, postoperative recovery of liver and renal function, postoperative morbidity and mortality, and duration of hospital stay. RESULTS: Between January 2008 and September 2010, 192 patients were randomized. Compared with low CVP, infrahepatic IVC clamping significantly decreased blood loss during parenchymal transection (mean(s.e.m.) 243(158) versus 372(197) ml; P < 0·001), was associated with faster recovery of liver function, and caused less impairment in renal function and fewer haemodynamic changes. The degree of cirrhosis correlated positively with CVP (R(2) = 0·963, P = 0·019) and with infrahepatic IVC pressure (R(2) = 0·950, P = 0·025). For patients with moderate or severe cirrhosis, infrahepatic IVC clamping was more efficacious in controlling blood loss during parenchymal transection (mean(s.e.m.) 2·9(1·8) versus 6·1(2·4) ml/cm(2) ; P < 0·001). CONCLUSION: PTC combined with infrahepatic IVC clamping is more efficacious in controlling bleeding during complex hepatectomy than PTC with low CVP, especially in patients with moderate to severe cirrhosis. Registration number: NCT01355887 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22389136 [PubMed - as supplied by publisher]

Abstracts of the 46th Annual Scientific Meeting of the Vascular Society of Great Britain and Ireland. November 24-26, 2011. Edinburgh, Scotland.

Br J Surg. 2012 Mar;99 Suppl 3:1-16

Authors:

PMID: 22393575 [PubMed - in process]

Accuracy of an expanded early warning score for patients in general and trauma surgery wards (Br J Surg 2012; 99: 192-197).

Br J Surg. 2012 Feb;99(2):197-8

Authors: Sarani B

PMID: 22222801 [PubMed - indexed for MEDLINE]

Indications for fenestrated endovascular aneurysm repair (Br J Surg 2012; 99: 217-224).

Br J Surg. 2012 Feb;99(2):225

Authors: Wyatt MG

PMID: 22222803 [PubMed - indexed for MEDLINE]

Selective decontamination of the oral and digestive tract in surgical versus non-surgical patients in intensive care in a cluster-randomized trial (Br J Surg 2012; 99: 232-237).

Br J Surg. 2012 Feb;99(2):238

Authors: Ytrebø LM

PMID: 22222804 [PubMed - indexed for MEDLINE]

Quality of life and health status before and after ileal pouch-anal anastomosis for ulcerative colitis (Br J Surg 2012; 99: 263-269).

Br J Surg. 2012 Feb;99(2):269

Authors: Blazeby JM

PMID: 22222805 [PubMed - indexed for MEDLINE]

Multicentre observational study of the natural history of left-sided acute diverticulitis (Br J Surg 2012; 99: 276-285).

Br J Surg. 2012 Feb;99(2):285-6

Authors: Flum DR

PMID: 22222806 [PubMed - indexed for MEDLINE]

Letter 1: Routine colonoscopy following acute uncomplicated diverticulitis (Br J Surg 2011; 98: 1630-1634).

Br J Surg. 2012 Feb;99(2):300; author reply 300-1

Authors: Page AA, Khan A, Davies RJ

PMID: 22222807 [PubMed - indexed for MEDLINE]

Letter 2: Routine colonoscopy following acute uncomplicated diverticulitis (Br J Surg 2011; 98: 1630-1634).

Br J Surg. 2012 Feb;99(2):300; author reply 300-1

Authors: Colvin HS, Velineni R, Robertson AG, Yalamarthi S, Driscoll PJ

PMID: 22222809 [PubMed - indexed for MEDLINE]

Self-expanding metallic stents for large bowel obstruction (Br J Surg 2011; 98: 1625-1629).

Br J Surg. 2012 Feb;99(2):301-2; author reply 302

Authors: Thorlacius H

PMID: 22222810 [PubMed - indexed for MEDLINE]

Effect of type of alcoholic beverage in causing acute pancreatitis (Br J Surg 2011; 98: 1609-1616).

Br J Surg. 2012 Feb;99(2):302; author reply 302

Authors: Vohra R, Miller G

PMID: 22222813 [PubMed - indexed for MEDLINE]

Abstracts of the 3rd Annual Scientific Meeting of the British Obesity & Metabolic Surgery Society (BOMSS). January 19-20, 2012. Bristol, United Kingdom.

Br J Surg. 2012 Mar;99 Suppl 2:1-19

Authors:

PMID: 22355819 [PubMed - indexed for MEDLINE]

Systematic review and meta-analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer.

Br J Surg. 2012 Feb 23;

Authors: Martin ST, Heneghan HM, Winter DC

Abstract

BACKGROUND: Following neoadjuvant chemoradiotherapy (CRT) and interval proctectomy, 15-20 per cent of patients are found to have a pathological complete response (pCR) to combined multimodal therapy, but controversy persists about whether this yields a survival benefit. This systematic review evaluated current evidence regarding long-term oncological outcomes in patients found to have a pCR to neoadjuvant CRT. METHODS: Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The systematic review included all original articles reporting long-term outcomes in patients with rectal cancer who had a pCR to neoadjuvant CRT, published in English, from January 1950 to March 2011. RESULTS: A total of 724 studies were identified for screening. After applying inclusion and exclusion criteria, 16 studies involving 3363 patients (1263 with pCR and 2100 without) were included (mean age 60 years, 65·0 per cent men). Some 73·4 per cent had a sphincter-saving procedure. Mean follow-up was 55·5 (range 40-87) months. For patients with a pCR, the weighted mean local recurrence rate was 0·7 (range 0-2·6) per cent. Distant failure was observed in 8·7 per cent. Five-year overall and disease-free survival rates were 90·2 and 87·0 per cent respectively. Compared with non-responders, a pCR was associated with fewer local recurrences (odds ratio (OR) 0·25; P = 0·002) and less frequent distant failure (OR 0·23; P < 0·001), with a greater likelihood of being alive (OR 3·28; P = 0·001) and disease-free (OR 4·33, P < 0·001) at 5 years. CONCLUSION: A pCR following neoadjuvant CRT is associated with excellent long-term survival, with low rates of local recurrence and distant failure. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22362002 [PubMed - as supplied by publisher]

Randomized comparison of self-fixating and sutured mesh in open inguinal hernia repair.

Br J Surg. 2012 Feb 23;

Authors: Pierides G, Scheinin T, Remes V, Hermunen K, Vironen J

Abstract

BACKGROUND: Chronic groin pain after mesh repair of inguinal hernia has been attributed to the presence of sutures. METHODS: This randomized clinical trial compared inguinal hernia repair using a self-fixating composite mesh or a sutured lightweight mesh, with pain at 1 year as primary outcome. Patients completed a self-evaluation questionnaire at 2 weeks and were examined after 1 year. RESULTS: Some 198 patients received self-fixating mesh and 196 sutured mesh. There were no differences between the groups in mean pain scores measured on a visual analogue scale during 2 weeks of immediate convalescence or at 1 year. Chronic pain and discomfort was experienced by 36·3 per cent of patients in the self-fixating and 34·1 per cent in the sutured mesh group (P = 0·658), affecting the everyday life of 1·1 and 2·8 per cent respectively (P = 0·448). CONCLUSION: Open inguinal hernia repair with a composite self-fixating mesh resulted in similar pain in the early postoperative convalescence period and at 1 year as repair with a sutured lightweight mesh. Registration number: NCT01026935 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22362035 [PubMed - as supplied by publisher]

Nutritional screening for risk prediction in patients scheduled for abdominal operations.

Br J Surg. 2012 Feb 24;

Authors: Kuppinger D, Hartl WH, Bertok M, Hoffmann JM, Cederbaum J, Küchenhoff H, Jauch KW, Rittler P

Abstract

BACKGROUND: Increased risks related to surgery might reflect the nutritional status of some patients. Such a group might benefit from perioperative nutritional support. The purpose of this study was to identify the relative importance of nutritional risk screening along with established medical, anaesthetic and surgical predictors of postoperative morbidity and mortality. METHODS: This prospective observational study enrolled consecutive eligible patients scheduled for elective abdominal operations. Data were collected on nutritional variables (body mass index, weight loss, food intake), age, sex, type and extent of operation, underlying disease, American Society of Anesthesiologists grade and co-morbidities. A modified composite nutritional screening tool (Nutritional Risk Screening, NRS 2002) currently recommended by European guidelines was used. Relative complication rates were calculated with multiple logistic regression and cumulative proportional odds models. RESULTS: Some 653 patients were enrolled of whom 132 (20·2 per cent) sustained one or more postoperative complications. The frequency of this event increased significantly with a lower food intake before hospital admission. No other individual or composite nutritional variable provided comparable or better risk prediction (including NRS 2002). Other factors significantly associated with severe postoperative complications were ASA grade, male sex, underlying disease, extent of surgical procedure and volume of transfused red cell concentrates. CONCLUSION: In abdominal surgery, preoperative investigation of feeding habits may be sufficient to identify patients at increased risk of complications. Nutritional risk alone, however, is not sufficient to predict individual risk of complications reliably. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22362084 [PubMed - as supplied by publisher]

Ten-year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction.

Br J Surg. 2012 Feb 24;

Authors: Romics L, Chew BK, Weiler-Mithoff E, Doughty JC, Brown IM, Stallard S, Wilson CR, Mallon EA, George WD

Abstract

BACKGROUND: The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients. METHODS: A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage. RESULTS: Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence). CONCLUSION: Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22367773 [PubMed - as supplied by publisher]

Prospective randomized trial of preoperative enteral immunonutrition followed by elective total gastrectomy for gastric cancer.

Br J Surg. 2012 Feb 24;

Authors: Fujitani K, Tsujinaka T, Fujita J, Miyashiro I, Imamura H, Kimura Y, Kobayashi K, Kurokawa Y, Shimokawa T, Furukawa H,

Abstract

BACKGROUND: Perioperative enteral immunonutrition is thought to reduce postoperative morbidity in patients undergoing major gastrointestinal surgery. This study assessed the clinical effects of preoperative enteral immunonutrition in well nourished patients with gastric cancer undergoing total gastrectomy. METHODS: Well nourished patients with primary gastric cancer, fit for total gastrectomy, were randomized to either a control group with regular diet, or an immunonutrition group that received regular diet supplemented with 1000 ml/day of immunonutrients for 5 consecutive days before surgery. The primary endpoint was the incidence of surgical-site infection (SSI). Secondary endpoints were rates of infectious complications, overall postoperative morbidity and C-reactive protein (CRP) levels on 3-4 days after surgery. RESULTS: Of 244 randomized patients, 117 were allocated to the control group and 127 received immunonutrition. SSIs occurred in 27 patients in the immunonutrition group and 23 patients in the control group (risk ratio (RR) 1·09, 95 per cent confidence interval 0·66 to 1·78). Infectious complications were observed in 30 patients in the immunonutrition group and 27 in the control group (RR 1·11, 0·59 to 2·08). The overall postoperative morbidity rate was 30·8 and 26·1 per cent respectively (RR 1·18, 0·78 to 1·78). The median CRP value was 11·8 mg/dl in the immunonutrition group and 9·2 mg/dl in the control group (P = 0·113). CONCLUSION: Five-day preoperative enteral immunonutrition failed to demonstrate any clear advantage in terms of early clinical outcomes or modification of the systemic acute-phase response in well nourished patients with gastric cancer undergoing elective total gastrectomy. Registration number: ID 000000648 (University Hospital Medical Information Network (UMIN) database). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22367794 [PubMed - as supplied by publisher]

Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision.

Br J Surg. 2012 Feb 24;

Authors: Ly J, Mittal A, Windsor J

Abstract

BACKGROUND: Skin incisions have traditionally been made using a scalpel. Cutting diathermy, a more recent alternative, is thought to increase the risk of infection, impair healing and decrease cosmesis. Recent studies suggest otherwise, claiming that diathermy may offer potential advantages with respect to blood loss, incision time and postoperative pain. The aim of this meta-analysis was to compare skin incisions made by either scalpel or cutting diathermy. METHODS: A systematic literature search and review was performed for studies published from January 1980 until June 2011. Randomized clinical trials comparing scalpel and cutting diathermy for skin incisions of any operation were included. Primary outcomes included wound complication rate, blood loss, incision times and pain scores. RESULTS: Fourteen randomized trials met the criteria for inclusion in the meta-analysis, providing outcome data for a total of 2541 patients (1267 undergoing skin incision by cutting diathermy and 1274 by scalpel). The median length of follow-up across all studies was 6 weeks (range 4 days to 19 months). Compared with a scalpel incision, cutting diathermy resulted in significantly less blood loss (mean difference 0·72 ml/cm(2) ; P < 0·001) and shorter incision times (mean difference 36 s; P < 0·001), with no differences in the wound complication rate (odds ratio 0·87; P = 0·29) or pain score at 24 h (mean difference 0·89; P = 0·05). CONCLUSION: Skin incisions made by cutting diathermy are quicker and associated with less blood loss than those made by scalpel, and there are no differences in the rate of wound complications or postoperative pain. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22367850 [PubMed - as supplied by publisher]

Indications for fenestrated endovascular aneurysm repair.

Br J Surg. 2012 Feb;99(2):217-24

Authors: Cross J, Raine R, Harris P, Richards T,

Abstract

BACKGROUND: Endovascular technology has advanced rapidly in the development of fenestrated endovascular aneurysm repair (FEVAR). Current evidence for endovascular aneurysm repair is limited to infra-renal aortic aneurysms. With increased costs and complexity of FEVAR, its current role is unclear. A national multicentre, cross-disciplinary consensus model was developed to propose indications for FEVAR.

METHODS: All UK FEVAR centres and a wide selection of high-volume aneurysm treatment centres were invited to participate. The RAND appropriateness methodology was used. Five key steps were undertaken: meta-analysis of current literature; survey of current UK practice; nominal group establishment and definition of key clinical attributes; round 1–online survey of case vignettes; and round 2–nominal group consensus meeting.

RESULTS: More than 90 per cent of UK FEVAR centres participated. Literature review showed heterogeneous case series with no clear indications for use of FEVAR. Survey of current practice showed wide variations in aneurysm management. Consensus agreement on the role of FEVAR was achieved in 68·8 per cent of cases. Consensus for FEVAR was agreed in areas of moderate risk from open repair and need for suprarenal clamping, but it was less likely to be indicated in patients aged 85 years or more with 5·5-6-cm aneurysms, or short-necked infrarenal aortic aneurysms.

CONCLUSION: These data record areas of agreement and define the grey area of equipoise. Consequently, guidelines and recommendations can be developed on the indications for FEVAR to inform clinicians, commissioners and health economists.

PMID: 22222802 [PubMed - indexed for MEDLINE]

Surgical resection for non-familial adenomatous polyposis-related intra-abdominal fibromatosis.

Br J Surg. 2012 Feb 22;

Authors: Wilkinson MJ, Fitzgerald JE, Thomas JM, Hayes AJ, Strauss DC

Abstract

BACKGROUND: Intra-abdominal fibromatosis (IAF) in the context of familial adenomatosis polyposis (FAP) is associated with significant morbidity and high recurrence rates after surgical resection. Non-surgical treatments are therefore advocated. This study explored outcomes in patients with IAF not associated with FAP who underwent surgical resection. METHODS: Data were analysed from a prospectively collected database at a sarcoma tertiary referral centre. RESULTS: From 2001 to 2011, 15 patients without FAP underwent primary curative surgical resection of IAF. Their median (range) age was 42 (19-64) years. Median tumour size was 18 (8·5-25) cm and weight 1306 (236-2228) g. Complete macroscopic clearance was obtained in all patients. There were no deaths in hospital or within 30 days and only one patient developed a major complication. Median follow-up was 40 (6-119) months. During follow-up two patients developed a recurrence after a disease-free interval of 12 and 16 months. CONCLUSION: In contrast to FAP-associated IAF, non-FAP-associated IAF has a very low recurrence rate after surgical resection. Surgical resection is therefore advocated as first-line treatment in patients with non-FAP-associated IAF when resection can be performed with low morbidity. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22359346 [PubMed - as supplied by publisher]

Provider volume and long-term outcome after elective abdominal aortic aneurysm repair.

Br J Surg. 2012 Feb 17;

Authors: Holt PJ, Karthikesalingam A, Hofman D, Poloniecki JD, Hinchliffe RJ, Loftus IM, Thompson MM

Abstract

BACKGROUND: Robust risk-adjusted analyses have demonstrated that a reduction in perioperative mortality is associated with the repair of an abdominal aortic aneurysm (AAA) in centres with a high operative caseload (volume). However, the long-term impact of this volume-related effect on mortality remains unknown. METHODS: Demographic and clinical data were extracted from UK Hospital Episodes Statistics for patients undergoing elective repair of an infrarenal AAA from 1 April 2000 to 31 March 2005. The long-term mortality of this cohort was investigated through linkage to the UK Office for National Statistics (ONS) registry. Risk-adjusted survival was analysed using Cox proportional hazards modelling to identify the effect of hospital volume on long-term mortality. RESULTS: A total of 14 396 patients with mean age of 72 years, of whom 85·7 per cent were men, underwent elective repair of an infrarenal AAA in England. They were linked to follow-up using ONS data. Risk-adjusted analysis of all-cause mortality by Cox proportional hazards modelling demonstrated a significant effect of hospital volume across all quintiles up to 2 years (P = 0·013). Remodelling the data after excluding in-hospital mortality still demonstrated the significant effect of hospital volume on late outcome. CONCLUSION: There is a long-term benefit to patients who undergo elective AAA repair in a high-volume hospital. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22344599 [PubMed - as supplied by publisher]

Regional variation in the incidence of abdominal aortic aneurysm in Sweden.

Br J Surg. 2012 Feb 20;

Authors: Hultgren R, Forsberg J, Alfredsson L, Swedenborg J, Leander K

Abstract

BACKGROUND: The risk factor profile is similar between patients with abdominal aortic aneurysm (AAA) and coronary heart disease (CHD). CHD is more common in the north of Sweden. It is unknown whether similar regional differences in the incidence of AAA exist. The aims of this study were to investigate whether there is a regional gradient of AAA incidence, and to compare time trends and the frequency of interventions between regions. METHODS: Swedish citizens have a 12-digit personal identification number. The Swedish Hospital Discharge Register covers inpatient care (diagnosis, admission, procedure codes, sex, date of birth, county). Population size was obtained from the central statistical bureau. Regions were south, mid and north. RESULTS: All records for 1990-2005 were extracted and 35 418 individuals with AAA were identified (74·8 per cent men). The highest age-standardized incidence (102·7 per 100 000) was found in men in the north region. The age-adjusted incidence ratio for men in the north region compared with the south was 1·38 (95 per cent confidence interval 1·34 to 1·42). Similar differences were found in women: incidence ratio for north compared with south region 1·39 (1·07 to 1·81). The proportion treated was larger in men and varied by region: 46·9 per cent of men in the mid region compared with 43·7 per cent in the south received treatment (P < 0·001), whereas 29·8 per cent of women in the north region versus 25·4 per cent in the south had an intervention (P = 0·001). The incidence did not increase over time. CONCLUSION: The higher incidence of AAA in the north of Sweden corresponds well with reported CHD patterns. The incidence of AAA in the population did not increase significantly over time, in contrast to the increasing intervention rates. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22351570 [PubMed - as supplied by publisher]

The surgical significance of residual mucosal abnormalities in rectal cancer following neoadjuvant chemoradiotherapy.

Br J Surg. 2012 Feb 20;

Authors: Smith FM, Chang KH, Sheahan K, Hyland J, O’Connell PR, Winter DC

Abstract

BACKGROUND: Local excision of rectal cancer after neoadjuvant chemoradiotherapy (CRT) has been proposed as an alternative to radical surgery in selected patients. However, little is known about the significance of the morphological and histological features of residual tumour. METHODS: Patients who had undergone CRT at the authors’ institution between 1997 and 2010 were identified. Multiple features were assessed as putative markers of pathological response. These included: gross residual disease, diameter of residual mucosal abnormalities, tumour differentiation, presence of lymphovascular/perineural invasion and lymph node ratio. RESULTS: Data from 220 of 276 patients were suitable for analysis. Diameter of residual mucosal abnormalities correlated strongly with pathological tumour category after CRT (ypT) (P < 0·001). Forty of 42 tumours downstaged to ypT0/1 had residual mucosal abnormalities of 2·99 cm or less after CRT. Importantly, 19 of 31 patients with a complete pathological response had evidence of a residual mucosal abnormality consistent with an incomplete clinical response. The ypT category was associated with both pathological node status after CRT (P < 0·001) and lymph node ratio (P < 0·001). Positive nodes were found in only one of 42 patients downstaged to ypT0/1. The risk of nodal metastases was associated with poor differentiation (P = 0·027) and lymphovascular invasion (P < 0·001). CONCLUSION: In this series, the majority of patients with a complete pathological response did not have a complete clinical response. In tumours downstaged to ypT0/1 after CRT, residual mucosal abnormalities were predominantly small and had a 2 per cent risk of positive nodes, thus potentially facilitating transanal excision. The presence of adverse histological characteristics risk stratified tumours for nodal metastases. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22351592 [PubMed - as supplied by publisher]

Encapsulating peritoneal sclerosis.

Br J Surg. 2012 Feb 20;

Authors: van Dellen D, Augustine T

PMID: 22351602 [PubMed - as supplied by publisher]

Effects of tirapazamine on experimental colorectal liver metastases after radiofrequency ablation.

Br J Surg. 2012 Feb 13;

Authors: Govaert KM, Nijkamp MW, Emmink BL, Steller EJ, Minchinton AI, Kranenburg O, Borel Rinkes IH

Abstract

BACKGROUND: Radiofrequency ablation (RFA) is a common procedure for the management of colorectal liver metastases. RFA-generated lesions are surrounded by a rim of hypoxia that is associated with aggressive outgrowth of intrahepatic micrometastases. Hypoxia-activated prodrugs such as tirapazamine are designed selectively to induce apoptosis in tumour cells under hypoxic conditions. Therefore, it was hypothesized that tirapazamine may have therapeutic value in limiting hypoxia-associated tumour outgrowth following RFA. METHODS: Murine C26 and MC38 colorectal cancer cells were grown under hypoxia and normal oxygenation in vitro, and treated with different concentrations of tirapazamine. Apoptosis and cell cycle distribution were assessed by western blot and fluorescence-activated cell sorting analysis. Proliferative capacity was tested by means of colony-formation assays. Mice harbouring microscopic colorectal liver metastases were treated with RFA, followed by a single injection of tirapazamine (60 mg/kg) or saline. Tumour load was assessed morphometrically 7 days later. RESULTS: Tirapazamine induced apoptosis of colorectal tumour cells under hypoxia in vitro. Under normal oxygenation, tirapazamine caused a G2 cell cycle arrest from which cells recovered partly. This reduced, but did not abolish, colony-forming capacity. A single dose of tirapazamine largely prevented accelerated outgrowth of hypoxic micrometastases following RFA. Tirapazamine administration was associated with minimal toxicity. CONCLUSION: Tirapazamine induced apoptosis in colorectal cancer cells in a hypoxia-dependent manner and potently suppressed hypoxia-associated outgrowth of liver metastases with limited toxicity. This warrants further study to assess the potential value of tirapazamine, or other hypoxia-activated prodrugs, as adjuvant therapeutics following RFA treatment of colorectal liver metastases. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22331808 [PubMed - as supplied by publisher]

Sex-specific time trends in first admission to hospital for peripheral artery disease in Scotland 1991-2007.

Br J Surg. 2012 Feb 9;

Authors: Inglis SC, Lewsey JD, Chandler D, Byrne DS, Lowe GD, Macintyre K,

Abstract

BACKGROUND: This study examined trends for all first hospital admissions for peripheral artery disease (PAD) in Scotland from 1991 to 2007 using the Scottish Morbidity Record. METHODS: First admissions to hospital for PAD were defined as an admission to hospital (inpatient and day-case) with a principal diagnosis of PAD, with no previous admission to hospital (principal or secondary diagnosis) for PAD in the previous 10 years. RESULTS: From 1991 to 2007, 41 593 individuals were admitted to hospital in Scotland for the first time for PAD. Some 23 016 (55·3 per cent) were men (mean(s.d.) age 65·7(11·7) years) and 18 577 were women (aged 70·4(12·8) years). For both sexes the population rate of first admissions to hospital for PAD declined over the study interval: from 66·7 per 100 000 in 1991-1993 to 39·7 per 100 000 in 2006-2007 among men, and from 43·5 to 29·1 per 100 000 respectively among women. After adjustment, the decline was estimated to be 42 per cent in men and 27 per cent in women (rate ratio for 2007 versus 1991: 0·58 (95 per cent confidence interval 0·55 to 0·62) in men and 0·73 (0·68 to 0·78) in women). The intervention rate fell from 80·8 to 74·4 per cent in men and from 77·9 to 64·9 per cent in women. The proportion of hospital admissions as an emergency or transfer increased, from 23·9 to 40·7 per cent among men and from 30·0 to 49·5 per cent among women. CONCLUSION: First hospital admission for PAD in Scotland declined steadily and substantially between 1991 and 2007, with an increase in the proportion that was unplanned. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22318673 [PubMed - as supplied by publisher]

Risk of anastomotic leakage with non-steroidal anti-inflammatory drugs in colorectal surgery.

Br J Surg. 2012 Feb 9;

Authors: Gorissen KJ, Benning D, Berghmans T, Snoeijs MG, Sosef MN, Hulsewe KW, Luyer MD

Abstract

BACKGROUND: With the implementation of multimodal analgesia regimens in fast-track surgery programmes, non-steroidal anti-inflammatory drugs (NSAIDs) are being prescribed routinely. However, doubts have been raised concerning the safety of NSAIDs in terms of anastomotic healing. METHODS: Data on patients who had undergone primary colorectal anastomosis at two teaching hospitals between January 2008 and December 2010 were analysed retrospectively. Exact use of NSAIDs was recorded. Rates of anastomotic leakage were compared between groups and corrected for known risk factors in both univariable and multivariable analyses. RESULTS: A total of 795 patients were divided into four groups according to NSAID use: no NSAIDs (471 patients), use of non-selective NSAIDs (201), use of selective cyclo-oxygenase (COX) 2 inhibitors (79), and use of both selective and non-selective NSAIDs (44). The overall leak rate was 9·9 per cent (10·0 per cent for right colonic, 8·7 per cent for left colonic and 12·4 per cent for rectal anastomoses). Known risk factors such as smoking and use of steroids were not significantly associated with anastomotic leakage. Stapled anastomosis was identified as an independent predictor of leakage in multivariable analysis (odds ratio (OR) 2·22, 95 per cent confidence interval 1·30 to 3·80; P = 0·003). Patients on NSAIDs had higher anastomotic leakage rates than those not on NSAIDs (13·2 versus 7·6 per cent; OR 1·84, 1·13 to 2·98; P = 0·010). This effect was mainly due to non-selective NSAIDs (14·5 per cent; OR 2·13, 1·24 to 3·65; P = 0·006), not selective COX-2 inhibitors (9 per cent; OR 1·16, 0·49 to 2·75; P = 0·741). The overall mortality rate was 4·2 per cent, with no significant difference between groups (P = 0·438). CONCLUSION: Non-selective NSAIDs may be associated with anastomotic leakage. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22318712 [PubMed - as supplied by publisher]

Counting the cost of cancer surgery for advanced and metastatic disease.

Br J Surg. 2012 Feb 9;

Authors: Russell RC, Treasure T

PMID: 22318744 [PubMed - as supplied by publisher]

Role of positron emission tomography-computed tomography in predicting survival after neoadjuvant chemotherapy and surgery for oesophageal adenocarcinoma.

Br J Surg. 2012 Feb;99(2):239-45

Authors: Gillies RS, Middleton MR, Han C, Marshall RE, Maynard ND, Bradley KM, Gleeson FV

Abstract

BACKGROUND: Positron emission tomography combined with computed tomography (PET-CT) is increasingly being used in the staging of oesophageal cancer. Some recent reports suggest it may be used to predict survival. None of these studies, however, reported on the prognostic value of PET-CT performed before neoadjuvant chemotherapy and surgery. The aim of this study was to determine whether pretreatment PET-CT could predict survival.

METHODS: Consecutive patients with oesophageal adenocarcinoma who underwent PET-CT before neoadjuvant chemotherapy and resection were included. Maximum standardized uptake value (SUV(max)), fluorodeoxyglucose (FDG)-avid tumour length and the presence of FDG-avid local lymph nodes were determined for all patients. Kaplan-Meier survival analysis was performed and multivariable analysis used to identify independent prognostic factors.

RESULTS: A total of 121 patients were included (mean age 63 years, 97 men) of whom 103 underwent surgical resection. On an intention-to-treat basis, overall survival was significantly worse in patients with FDG-avid local lymph nodes (P < 0·001). SUV(max) and FDG-avid tumour length did not predict survival (P = 0·276 and P = 0·713 respectively). The presence of FDG-avid local lymph nodes was an independent predictor of poor overall survival (hazard ratio (HR) 4·75, 95 per cent confidence interval 2·14 to 10·54; P < 0·001) and disease-free survival (HR 2·97, 1·40 to 6·30; P = 0·004).

CONCLUSION: The presence of FDG-avid lymph nodes, but not SUV(max) or FDG-avid tumour length, was an independent adverse prognostic factor.

PMID: 22329010 [PubMed - in process]

Intraoperative, postoperative and reoperative problems with ileoanal pouches.

Br J Surg. 2012 Feb 3;

Authors: Sagar PM, Pemberton JH

Abstract

BACKGROUND: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches. METHODS: The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed. RESULTS: Although the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation. CONCLUSION: A structured management plan will minimize the adverse consequences of the problems associated with pouches. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22307828 [PubMed - as supplied by publisher]

Factors influencing the quality of total mesorectal excision.

Br J Surg. 2012 Feb 6;

Authors: Garlipp B, Ptok H, Schmidt U, Stübs P, Scheidbach H, Meyer F, Gastinger I, Lippert H

Abstract

BACKGROUND: Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence. METHODS: Data from the multicentre observational German Quality Assurance in Rectal Cancer Trial were used. Patients undergoing low anterior resection for rectal cancer between 1 January 2005 and 31 December 2009 were included. Multivariable analysis using a stepwise logistic regression model was performed to identify predictors of suboptimal TME. RESULTS: From a total of 6179 patients, complete data sets for 4606 patients were available for analysis. Pathological tumour category higher than T2 (pT3 versus pT1/2: odds ratio (OR) 1·22, 95 per cent confidence interval 1·01 to 1·47), tumour distance from the anal verge less than 8 cm (OR 1·27, 1·05 to 1·53), advanced age (65-80 years: OR 1·25, 1·03 to 1·52; over 80 years: OR 1·60, 1·15 to 2·22), presence of intraoperative complications (OR 1·63, 1·15 to 2·30), monopolar dissection technique (OR 1·43, 1·14 to 1·79) and low case volume (fewer than 20 procedures per year) of the operating surgeon (OR 1·20, 1·06 to 1·36) were independently associated with moderate or poor TME quality. CONCLUSION: TME quality was influenced by patient- and treatment-related factors. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22311576 [PubMed - as supplied by publisher]

Effect of Roux-en-Y gastric bypass on testosterone and prostate-specific antigen.

Br J Surg. 2012 Feb 2;

Authors: Woodard G, Ahmed S, Podelski V, Hernandez-Boussard T, Presti J, Morton JM

Abstract

BACKGROUND: Obese men have lower serum levels of testosterone, dehydroepiandrosterone (DHEA) and prostate-specific antigen (PSA), but an increased risk of dying from prostate cancer. The aim of this study was to examine the effect of surgically induced weight loss on serum testosterone, DHEA and PSA levels in obese men. METHODS: Consecutive men undergoing Roux-en-$\font\ss=cmss10 scaled 1000 \hbox{Y}$ gastric bypass (RYGB) participated in a prospective, longitudinal study. Main outcomes were changes were body mass index (BMI), percentage excess weight loss, serum levels of testosterone, DHEA and PSA, PSA mass and plasma volume, measured before operation and 3, 6 and 12 months later. RESULTS: In 64 patients, mean BMI fell from 48·2 kg/m(2) before operation to 39·2, 35·6 and 32·4 kg/m(2) at 3, 6 and 12 months after RYGB. Testosterone levels rose significantly from 259 ng/dl to 386, 452 and 520 ng/dl respectively. Serum PSA levels increased significantly from 0·51 ng/ml to 0·67 ng/ml at 12 months. There were no significant changes in DHEA or PSA mass. CONCLUSION: RYGB normalizes the serum testosterone level. PSA levels increase with weight loss and may be inversely correlated with changes in plasma volume, indicating that PSA levels may be artificially low in obese men owing to haemodilution. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22302466 [PubMed - as supplied by publisher]

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.

Br J Surg. 2012 Jan 30;

Authors: Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K,

Abstract

BACKGROUND: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up. METHODS: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics. RESULTS: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881). CONCLUSION: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis. Registration number: NCT01008488 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22290281 [PubMed - as supplied by publisher]

A model for rural trauma care.

Br J Surg. 2012 Mar;99(3):309-14

Authors: McSwain N, Rotondo M, Meade P, Duchesne J

Abstract

BACKGROUND: In the United States and many other countries, there has been limited attempt to develop a trauma system that addresses the unique trauma situations that occur in rural areas. Rather the planners have attempted to simply extend the urban based trauma system into rural communities. This extension does not address the needs of the majority of patients who are injured in rural communities.

METHODS: A review of the types of patients seen in the rural communities, the volume of these patients and the destination protocols used in the rural communities as taught by the ACS/ATLS and the implications of the CDC Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage were reviewed, assessed and compared to the needs in the rural areas for a rural trauma system. In addition, a quality assessment tool was used from a major trauma centre whereby the frequency of patients transported to the centre that were inappropriate for the trauma centre was indicated by the volume that were discharged in 6 h.

RESULTS: Most of the patients injured in the rural communities can be treated in the critical access and rural hospital (> 90 per cent) and can be provided with good care without the need for emergency medical service (EMS) transportation long distances to the trauma centre, inappropriate use of air EMS vehicles thus circumventing families having to travel long distances to see patients, incurring expense and inconvenience, and avoiding loss of revenue to the local hospitals and the overload of urban trauma centres. Rather triage criteria can be taught as per the EMS systems, training given to rural hospital personnel, hospital administrators instructed as to the benefit of such a system, citizens educated as to the advantage of keeping their loved ones closer to home and trauma system registries used to enhance the correct use of the trauma system.

CONCLUSION: Only 5-10 per cent of trauma injuries require the resources of a trauma centre. Proper triage and medical provider education can be used for the benefit of the patient, the EMS system, the rural and urban hospital, and proper quality assurance to assure that the ‘right patient is treated at the right hospital at the right time’, for the benefit of the patient. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287070 [PubMed - in process]

Use of models in identification and prediction of physiology in critically ill surgical patients.

Br J Surg. 2012 Jan 27;

Authors: Cohen MJ

Abstract

BACKGROUND: With higher-throughput data acquisition and processing, increasing computational power, and advancing computer and mathematical techniques, modelling of clinical and biological data is advancing rapidly. Although exciting, the goal of recreating or surpassing in silico the clinical insight of the experienced clinician remains difficult. Advances toward this goal and a brief overview of various modelling and statistical techniques constitute the purpose of this review. METHODS: A review of the literature and experience with models and physiological state representation and prediction after injury was undertaken. RESULTS: A brief overview of models and the thinking behind their use for surgeons new to the field is presented, including an introduction to visualization and modelling work in surgical care, discussion of state identification and prediction, discussion of causal inference statistical approaches, and a brief introduction to new vital signs and waveform analysis. CONCLUSION: Modelling in surgical critical care can provide a useful adjunct to traditional reductionist biological and clinical analysis. Ultimately the goal is to model computationally the clinical acumen of the experienced clinician. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287099 [PubMed - as supplied by publisher]

Tissue engineering and the road to whole organs.

Br J Surg. 2012 Jan 30;

Authors: Vacanti JP

PMID: 22287115 [PubMed - as supplied by publisher]

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves’ disease with a 5-year follow-up.

Br J Surg. 2012 Jan 27;

Authors: Barczyński M, Konturek A, Hubalewska-Dydejczyk A, Gołkowski F, Nowak W

Abstract

BACKGROUND: The extent of thyroid resection in Graves’ disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves’ disease and mild active ophthalmopathy. METHODS: Participants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves’ ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism. RESULTS: Two hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5-year follow-up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves’ ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury. CONCLUSION: TT for Graves’ disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. Registration number: NCT01408368 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287122 [PubMed - as supplied by publisher]

Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer.

Br J Surg. 2012 Jan 27;

Authors: Segelman J, Granath F, Holm T, Machado M, Mahteme H, Martling A

Abstract

BACKGROUND: This was a population-based cohort study to determine the incidence, prevalence and risk factors for peritoneal carcinomatosis (PC) from colorectal cancer. METHODS: Prospectively collected data were obtained from the Regional Quality Registry. The Cox proportional hazards regression model was used for multivariable analysis of clinicopathological factors to determine independent predictors of PC. RESULTS: All 11 124 patients with colorectal cancer in Stockholm County during 1995-2007 were included and followed until 2010. In total, 924 patients (8·3 per cent) had synchronous or metachronous PC. PC was the first and only localization of metastases in 535 patients (4·8 per cent). The prevalence of synchronous PC was 4·3 per cent (477 of 11 124). The cumulative incidence of metachronous PC was 4·2 per cent (447 of 10 646). Independent predictors for metachronous PC were colonic cancer (hazard ratio (HR) 1·77, 95 per cent confidence interval 1·31 to 2·39; P = 0·002 for right-sided colonic cancer), advanced tumour (T) status (HR 9·98, 3·10 to 32·11; P < 0·001 for T4), advanced node (N) status (HR 7·41, 4·78 to 11·51; P < 0·001 for N2 with fewer than 12 lymph nodes examined), emergency surgery (HR 2·11, 1·66 to 2·69; P < 0·001) and non-radical resection of the primary tumour (HR 2·75, 2·10 to 3·61; P < 0·001 for R2 resection). Patients aged > 70 years had a decreased risk of metachronous PC (HR 0·69, 0·55 to 0·87; P = 0·003). CONCLUSION: PC is common in patients with colorectal cancer and is associated with identifiable risk factors. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287157 [PubMed - as supplied by publisher]

Reoperative surgery for bilateral multinodular goitre in the era of total thyroidectomy.

Br J Surg. 2012 Jan 30;

Authors: Vasica G, O’Neill CJ, Sidhu SB, Sywak MS, Reeve TS, Delbridge LW

Abstract

BACKGROUND: Total thyroidectomy, rather than bilateral subtotal thyroidectomy, is now accepted as the preferred management for bilateral benign multinodular goitre (BMNG) in order to reduce the need for reoperative surgery. The aim of this study was to examine whether this approach has had an impact on presentation for bilateral reoperative thyroid surgery. METHODS: This was a retrospective cohort study. The study group comprised patients presenting with recurrent BMNG who underwent bilateral reoperative thyroid surgery following previous bilateral subtotal or partial thyroidectomy. They were compared with patients undergoing unilateral reoperative thyroid surgery following previous lobectomy, and those undergoing primary total thyroidectomy for BMNG. RESULTS: Between 1 January 1987 and 31 December 2009, 12 354 consecutive thyroid procedures were undertaken. Among those with BMNG, primary total thyroidectomy was undertaken in 3298 patients, unilateral reoperative thyroidectomy in 337 and bilateral reoperative thyroidectomy in 191. Presentations of patients with recurrent BMNG declined gradually over the study period following the change in policy from subtotal to total thyroidectomy; only five patients (representing less than 0·5 per cent of all thyroid surgery) underwent bilateral reoperative surgery for BMNG in the last year of the study. Four of these patients had their initial operation before 1987 and in another unit, whereas the remaining patient initially had surgery overseas. CONCLUSION: The introduction of a policy of initial total thyroidectomy for bilateral BMNG has essentially eliminated the need for bilateral reoperative surgery for recurrent goitre. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22287186 [PubMed - as supplied by publisher]

Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair (Br J Surg 2012; 99: 29-37).

Br J Surg. 2012 Jan;99(1):37-8

Authors: Montgomery A

PMID: 22135171 [PubMed - indexed for MEDLINE]