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]

Randomized clinical trial of a brief psychological intervention to increase walking in patients with intermittent claudication (Br J Surg 2012; 99: 49-56).

Br J Surg. 2012 Jan;99(1):57

Authors: Beard JD

PMID: 22135172 [PubMed - indexed for MEDLINE]

Extended surgery for advanced pancreatic endocrine tumours.

Br J Surg. 2012 Jan;99(1):88-94

Authors: Kleine M, Schrem H, Vondran FW, Krech T, Klempnauer J, Bektas H

Abstract

BACKGROUND: Pancreatic endocrine tumours are often diagnosed at an advanced stage with hepatic metastasis. This study investigated whether extended resections for advanced malignant pancreatic endocrine tumours influenced disease-free and disease-specific survival.

METHODS: Patients who had curative resection of pancreatic endocrine tumours were analysed retrospectively for disease-free and disease-specific survival, with a focus on the role of extended surgical resection.

RESULTS: Forty-one patients were included in the analysis, 13 of whom underwent extended surgical resection in addition to pancreatic resection. This included partial liver resection in nine patients, portal vein resection in three, partial gastric resection in five and liver transplantation in three patients. There were no deaths in hospital or within 30 days. Median follow-up was 40 (range 2-239) months. Thirty-five, 24 and 13 patients survived more than 1, 3 and 5 years respectively. Patients who underwent extended resection had similar disease-specific survival to those who had pancreatic resection alone (hazard ratio (HR) 1·50, 95 per cent confidence interval (c.i.) 0·35 to 6·35; P = 0·581) but with a higher frequency of complications (odds ratio (OR) 4·28, 95 per cent c.i. 1·04 to 17·62; P = 0·044). Among patients with liver metastases, the mortality rate was higher in those in whom liver resection was not possible than in patients who had liver resection (HR 9·24, 1·00 to 85·18; P = 0·049). Patients who had liver resection had similar disease-specific survival to those without liver metastases (HR 0·84, 0·09 to 7·57; P = 0·877).

CONCLUSION: Extended surgical resection for locally advanced and metastatic pancreatic endocrine tumours is feasible with encouraging disease-specific survival.

PMID: 22135173 [PubMed - indexed for MEDLINE]

Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications (Br J Surg 2012; 99: 112-118).

Br J Surg. 2012 Jan;99(1):119

Authors: Gold DM

PMID: 22135174 [PubMed - indexed for MEDLINE]

Systematic review and meta-analysis of intraoperative versus preoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones (Br J Surg 2011; 98: 908-916).

Br J Surg. 2012 Jan;99(1):144; author reply 144

Authors: Siddiqui MN, Siddiqui ZA

PMID: 22135176 [PubMed - indexed for MEDLINE]

Polymorphisms in the toll-like receptor 9 gene associated with sepsis and multiple organ dysfunction after major blunt trauma (Br J Surg 2011; 98: 1252-1259).

Br J Surg. 2012 Jan;99(1):145; author reply 145

Authors: Zhao P, Lu G, Cai L

PMID: 22135177 [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 Jan;99(1):146; author reply 146

Authors: Barreto SG, Paxton T, Whitlaw M

PMID: 22135179 [PubMed - indexed for MEDLINE]

Scientific surgery.

Br J Surg. 2012 Jan;99(1):147

Authors:

PMID: 22135181 [PubMed - indexed for MEDLINE]

Systematic review and meta-analysis of follow-up after hepatectomy for colorectal liver metastases.

Br J Surg. 2012 Jan 19;

Authors: Jones RP, Jackson R, Dunne DF, Malik HZ, Fenwick SW, Poston GJ, Ghaneh P

Abstract

BACKGROUND: The evidence surrounding optimal follow-up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time. METHODS: A systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow-up protocol and long-term survival data were included. For meta-analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow-up. RESULTS: Thirty-five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow-up. Patients undergoing intensive early follow-up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5-year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow-up had a median survival of 40·2 (33·4 to 47·0) months, with a 5-year overall survival rate of 38·4 (32·6 to 44·3) months. CONCLUSION: Evidence regarding follow-up after liver resection is poor. Meta-analysis failed to identify a survival advantage for intensive early follow-up. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22261895 [PubMed - as supplied by publisher]

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction.

Br J Surg. 2012 Jan 19;

Authors: Tan CJ, Dasari BV, Gardiner K

Abstract

BACKGROUND: Use of self-expanding metallic stents (SEMS) as a bridge to surgery has been suggested as an alternative management for acute malignant left-sided colonic obstruction, as emergency surgery has a high risk of morbidity and mortality. This meta-analysis evaluated high-quality evidence comparing preoperative SEMS with emergency surgery. METHODS: Relevant randomized clinical trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990-2011). Primary outcomes were primary anastomosis, stoma and in-hospital mortality rates. Secondary outcomes included anastomotic leak, 30-day reoperation and surgical-site infection rates. RESULTS: Four RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in-hospital mortality, anastomotic leak, 30-day reoperation and surgical-site infection rates. Three trials were stopped prematurely, one because the emergency surgery group had a significantly increased anastomotic leak rate, and two others because of stent-related complications and increased 30-day morbidity following SEMS management. CONCLUSION: Technical and clinical success rates for stenting were lower than expected. SEMS is associated with a high incidence of clinical and silent perforation. However, as a bridge to surgery, SEMS has higher successful primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22261931 [PubMed - as supplied by publisher]

Postoperative adhesion prevention using a statin-containing cellulose film in an experimental model.

Br J Surg. 2012 Jan 13;

Authors: Lalountas M, Ballas KD, Michalakis A, Psarras K, Asteriou C, Giakoustidis DE, Nikolaidou C, Venizelos I, Pavlidis TE, Sakantamis AK

Abstract

BACKGROUND: Intraperitoneal adhesions are a common problem in abdominal surgery. The aim of this study was to compare the effectiveness of Statofilm, a novel antiadhesive film based on cross-linked carboxymethylcellulose and atorvastatin, with that of sodium hyaluronate-carboxymethylcellulose (Seprafilm(®) ) in the prevention of postoperative intraperitoneal adhesions in rats. METHODS: One hundred male Wistar rats underwent a laparotomy and adhesions were induced by caecal abrasion. The animals were allocated to five groups: a control group with no adhesion barrier, Seprafilm(®) group, placebo group with a film containing carboxymethylcellulose without atorvastatin, and low- and high-dose groups with films containing carboxymethylcellulose and atorvastatin 0·125 and 1 mg per kg bodyweight respectively. Adhesions were classified by two independent surgeons 2 weeks after surgery. Caecal biopsies were obtained for histological evaluation of fibrosis, inflammation and vascular proliferation. RESULTS: All antiadhesive film groups (Seprafilm(®) , placebo, low-dose and high-dose) had statistically significant adhesion reduction compared with the control group (P < 0·001, P = 0·015, P < 0·001 and P < 0·001 respectively). The low-dose Statofilm was superior to Seprafilm(®) in terms of adhesion prevention (P = 0·001). Adhesions were present in three-quarters of rats in the Seprafilm(®) group, but only one-quarter in the low-dose Statofilm group. CONCLUSION: The data suggest that the newly developed adhesion barrier Statofilm has better results than Seprafilm(®) in preventing postoperative adhesions in rats. A low-dose atorvastatin-containing film, such as Statofilm, could be evaluated for future clinical application. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22246725 [PubMed - as supplied by publisher]

Body composition and outcome in patients undergoing resection of colorectal liver metastases.

Br J Surg. 2012 Jan 13;

Authors: van Vledder MG, Levolger S, Ayez N, Verhoef C, Tran TC, Ijzermans JN

Abstract

BACKGROUND: Recent evidence suggests that depletion of skeletal muscle mass (sarcopenia) and an increased amount of intra-abdominal fat (central obesity) influence cancer statistics. This study investigated the impact of sarcopenia and central obesity on survival in patients undergoing liver resection for colorectal liver metastases (CLM). METHODS: Diagnostic imaging from patients who had hepatic resection for CLM in one centre between 2001 and 2009, and who had assessable perioperative computed tomograms, was analysed retrospectively. Total cross-sectional areas of skeletal muscle and intra-abdominal fat, and their influence on outcome, were analysed. RESULTS: Of the 196 patients included in the study, 38 (19·4 per cent) were classified as having sarcopenia. Five-year disease-free (15 per cent versus 28·5 per cent in patients without sarcopenia; P = 0·002) and overall (20 per cent versus 49·9 per cent respectively; P < 0·001) survival rates were lower for patients with sarcopenia at a median follow-up of 29 (range 1-97) months. Sarcopenia was an independent predictor of worse recurrence-free (hazard ratio (HR) 1·88, 95 per cent confidence interval 1·25 to 2·82; P = 0·002) and overall (HR 2·53, 1·60 to 4·01; P < 0·001) survival. Central obesity was associated with an increased risk of recurrence in men (P = 0·032), but not in women (P = 0·712). CONCLUSION: Sarcopenia has a negative impact on cancer outcomes following resection of CLM. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22246799 [PubMed - as supplied by publisher]

Systematic review of outcomes after intersphincteric resection for low rectal cancer.

Br J Surg. 2012 Jan 13;

Authors: Martin ST, Heneghan HM, Winter DC

Abstract

BACKGROUND: For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer. METHODS: A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011. RESULTS: Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59·5 years, 67·0 per cent men). R0 resection was achieved by ISR in 97·0 per cent. The operative mortality rate was 0·8 per cent and the cumulative morbidity rate 25·8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6·7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86·3 and 78·6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2·7. CONCLUSION: Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22246846 [PubMed - as supplied by publisher]

Preoperative short-course radiotherapy with delayed surgery in primary rectal cancer.

Br J Surg. 2012 Jan 12;

Authors: Pettersson D, Holm T, Iversen H, Blomqvist L, Glimelius B, Martling A

Abstract

BACKGROUND: Short-course radiotherapy (SRT) with immediate surgery and long-course chemoradiotherapy (CRT) are currently the standard preoperative treatment options for rectal cancer. SRT with surgery delayed for 4-8 weeks (SRT-delay) is an option described for patients with locally advanced tumours who are not fit for CRT. This study examined early toxicity, response to radiotherapy (RT) and short-term outcomes of SRT-delay. METHODS: Patients in the Stockholm region diagnosed with rectal cancer between January 2002 and December 2008, who received SRT (25 Gy over 5-7 days) and had surgery with resection of the primary tumour more than 4 weeks after the start of RT, were identified from a prospective register. Additional data were obtained by retrospective review of clinical records. RESULTS: A total of 112 patients had SRT and delayed surgery. The reasons given for SRT included primary unresectable disease and co-morbidities. Severe RT-induced toxicity was noted in six patients (5·4 per cent). Signs of tumour regression were seen on magnetic resonance imaging in 74 per cent of patients reassessed after RT. Pathological stage (44·9 versus 60·7 per cent stage 0-II; P < 0·001), tumour category (11·9 versus 29·4 per cent T0-T2; P < 0·001) and node category (45·8 versus 63·6 per cent N0; P = 0·014) were significantly lower than those at initial assessment. Nine patients (8·0 per cent) had a complete pathological response. CONCLUSION: The SRT-delay schedule was a feasible alternative with low toxicity. The study indicated a downstaging effect of SRT if surgery was delayed. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22241246 [PubMed - as supplied by publisher]

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 Jan 12;

Authors: Jamal MH, Doi SA, Rousseau M, Edwards M, Rao C, Barendregt JJ, Snell L, Meterissian S

Abstract

BACKGROUND: Short duty hours, imposed by the Accreditation Council of Graduate Medical Education (ACGME) regulations, have been claimed to be associated with loss of continuity of care among surgical patients, leading to a potentially increased risk of adverse surgical outcomes. This systematic review and meta-analysis assessed the strength of associations between duty hour restrictions and morbidity and mortality of various surgical procedures. METHODS: MEDLINE, Embase, BIOSIS Previews(®) , the Education Resources Information Center and the Cochrane Central Register of Controlled Trials (January 2000 to September 2009) were searched, and reports screened to identify comparative studies of mortality and morbidity before and after the introduction of ACGME regulation periods. Random-effects (RE) and quality-effects (QE) meta-analyses were performed to determine the risk of morbidity or death associated with long duty hours compared with shorter duty hours. Results are presented as odds ratio (OR) with 95 per cent confidence interval. RESULTS: A total of 19 data sets (10 articles), including 730 648 subjects in the mortality studies and 64 346 in the morbidity studies, were analysed. Long duty hours were associated with a non-significantly increased risk of death compared with shorter duty hours (OR 1·28, 0·94 to 1·73). There was no difference in morbidity between the two groups (OR 1·03, 0·67 to 1·57). Mortality associations were generally stronger for general surgery, more recent studies and higher-quality studies. Heterogeneity was evident among the studies included. CONCLUSION: The reduction in working hours has not affected patient care negatively in terms of demonstrable differences in morbidity and mortality. However, it cannot be distinguished whether this effect is actually due to a non-detrimental effect of the reduction in working hours or whether any such detriment is offset by continually improving patient care and increased surgical supervision. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22241280 [PubMed - as supplied by publisher]

Role of the insulin-like growth factor 1 axis and visceral adiposity in oesophageal adenocarcinoma.

Br J Surg. 2012 Jan 12;

Authors: Donohoe CL, Doyle SL, McGarrigle S, Cathcart MC, Daly E, O’Grady A, Lysaght J, Pidgeon GP, Reynolds JV

Abstract

BACKGROUND: Epidemiological studies have linked obesity with many cancers. The insulin-like growth factor (IGF) 1 axis may be an important mediator in obesity-associated cancer. This study examined the relationship between IGF-1 and its receptor (IGF-1R) in oesophageal adenocarcinoma, a cancer strongly linked to obesity. METHODS: Patients with oesophageal adenocarcinoma considered suitable for attempted curative treatment were studied. Visceral adiposity was defined by waist circumference or visceral fat area. Free and total IGF-1 in serum were measured by enzyme-linked immunosorbent assay. Quantitative polymerase chain resection was used to determine mRNA expression of IGF-1 and IGF-1R in resected tumour samples. IGF-1R expression in tissue microarrays (TMAs) was quantified by immunohistochemistry. RESULTS: A total of 220 patients were studied. Total and free IGF-1 levels were significantly increased in the serum of viscerally obese patients. Gene expression analysis revealed a significant association between obesity status and both IGF-1R (P = 0·021) and IGF-1 (P = 0·031) in tumours. TMA analysis demonstrated that IGF-1R expression in resected tumours was significantly higher in viscerally obese patients than in those of normal weight (P = 0·023). Disease-specific survival was longer in patients with negative IGF-1R expression than in those with IGF-1R-positive tumours (median 60·0 versus 23·4 months; P = 0·027). CONCLUSION: This study highlighted the association of the IGF axis with visceral obesity, and a potential impact on the biology of oesophageal adenocarcinoma through its receptor. Targeting the IGF axis may have a rationale in future studies. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22241325 [PubMed - as supplied by publisher]

Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality.

Br J Surg. 2012 Jan 11;

Authors: de Wilde RF, Besselink MG, van der Tweel I, de Hingh IH, van Eijck CH, Dejong CH, Porte RJ, Gouma DJ, Busch OR, Molenaar IQ,

Abstract

BACKGROUND: The impact of nationwide centralization of pancreaticoduodenectomy (PD) on mortality is largely unknown. The aim of this study was to analyse changes in hospital volumes and in-hospital mortality after PD in the Netherlands between 2004 and 2009. METHODS: Nationwide data on International Classification of Diseases, ninth revision (ICD-9) code 5-526 (PD, including Whipple), patient age, sex and mortality were retrieved from the independent nationwide KiwaPrismant registry. Based on established cut-off points of annually performed PDs, hospitals were categorized as very low (fewer than 5), low (5-10), medium (11-19) or high (at least 20) volume. A subgroup analysis based on a cut-off age of 70 years was also performed. RESULTS: Some 2155 PDs were included. The number of hospitals performing PD decreased from 48 in 2004 to 30 in 2009 (P = 0·011). In these specific years, the proportion of patients undergoing PD in a medium- or high-volume centre increased from 52·9 to 91·2 per cent (P < 0·001). Nationwide mortality rates after PD decreased from 9·8 to 5·1 per cent (P = 0·044). The mortality rate during the 6-year period was 14·7, 9·8, 6·3 and 3·3 per cent in very low-, low-, medium- and high-volume hospitals respectively (P < 0·001). The difference in mortality between medium- and high-volume centres was statistically significant (P = 0·004). The volume-outcome relationship was not influenced by age (P = 0·467). The mortality rate after PD in patients aged at least 70 years was 10·4 per cent compared with 4·4 per cent in younger patients (P < 0·001). CONCLUSION: With nationwide centralization of PD, the in-hospital mortality rate after this procedure decreased. Further centralization of PD is likely to decrease mortality further, especially in the elderly. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22237731 [PubMed - as supplied by publisher]

Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps.

Br J Surg. 2012 Jan 9;

Authors: Hainsworth A, Al Akash M, Roblin P, Mohanna P, Ross D, George ML

Abstract

BACKGROUND: Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors’ previous experience and published literature on myocutaneous flaps. METHODS: A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay. RESULTS: Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery. CONCLUSION: Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22231559 [PubMed - as supplied by publisher]

Risk factors for postoperative bleeding after thyroid surgery.

Br J Surg. 2012 Jan 9;

Authors: Promberger R, Ott J, Kober F, Koppitsch C, Seemann R, Freissmuth M, Hermann M

Abstract

BACKGROUND: Postoperative bleeding after thyroid surgery is a feared and life-threatening complication. The aim of the study was to identify risk factors for postoperative bleeding, with special emphasis on the impact of the individual surgeon and the time to diagnosis of the complication. METHODS: Data on consecutive thyroid operations were collected prospectively in a database over 30 years and analysed retrospectively for potential risk factors for postoperative bleeding. RESULTS: There were 30 142 operations and postoperative bleeding occurred in 519 patients (1·7 per cent). Risk factors identified were older age (odds ratio (OR) 1·03 per year), male sex (OR 1·64), extent of resection (OR up to 1·41), bilateral procedure (OR 1·99) and operation for recurrent disease (OR 1·54). The risk of complications among individual surgeons differed by up to sevenfold. Postoperative bleeding occurred in 336 (80·6 per cent) of 417 patients within the first 6 h after surgery. Postoperative bleeding was diagnosed after 24 h in ten patients (2·4 per cent), all of whom had bilateral procedures. Nine patients required urgent tracheostomy. Three patients died, giving a mortality rate of 0·01 per cent overall and 0·6 per cent among patients who had surgery for postoperative bleeding. CONCLUSION: Observation for up to 24 h is recommended for the majority of patients undergoing bilateral thyroid surgery in an endemic goitre area. Same-day discharge is feasible in selected patients, especially after a unilateral procedure. Quality improvement by continuous outcome monitoring and retraining of individual surgeons is suggested. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22231603 [PubMed - as supplied by publisher]

Scoring system to predict the risk of surgical-site infection after colorectal resection.

Br J Surg. 2012 Jan 9;

Authors: Gervaz P, Bandiera-Clerc C, Buchs NC, Eisenring MC, Troillet N, Perneger T, Harbarth S

Abstract

BACKGROUND: There is no dedicated scoring system for predicting the risk of surgical-site infection (SSI) after resection of the colon or rectum. Generic scores, such as the National Nosocomial Infections Surveillance index, are not used by colorectal surgeons. METHODS: Multivariable analysis of risk factors for SSI was performed in patients who underwent resection of the colon or rectum, and were followed during the first month after operation. A logistic regression model was used to identify determinant variables and construct a predictive score. RESULTS: There were 534 patients of whom 114 (21·3 per cent) developed SSI. In multivariable analysis, four parameters correlated with an increased risk of SSI: obesity (odds ratio (OR) 2·93, 95 per cent confidence interval 1·71 to 5·03), contamination class 3-4 (OR 3·33, 2·08 to 5·32), American Society of Anesthesiologists grade III-IV (OR 1·82, 1·14 to 2·90) and open surgery (OR 2·22, 1·01 to 4·88). Each of these contributed 1 point to the risk score. The observed risk of SSI was 5 per cent for a score of 0, 12·0 per cent for a score of 1 point, 18·7 per cent for 2 points, 44 per cent for 3 points and 68 per cent for 4 points. The area under the receiver operating characteristic curve for the score was 0·729. CONCLUSION: A simple clinical score based on four preoperative variables was clinically useful in predicting the risk of SSI in patients undergoing colorectal surgery. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22231649 [PubMed - as supplied by publisher]

Impact of participation in randomized trials on outcome following surgery for gastro-oesophageal reflux.

Br J Surg. 2012 Jan 9;

Authors: Engström C, Jamieson GG, Devitt PG, Irvine T, Watson DI

Abstract

BACKGROUND: Patients may be unwilling to participate in clinical trials if they perceive risks. Outcomes were evaluated following surgery for gastro-oesophageal reflux in patients recruited to randomized trials compared with patients not in trials. METHODS: This study compared outcomes of patients who had surgery for reflux within or outside randomized trials between 1994 and 2009. The choice of procedure outside each trial was according to surgeon or patient preference. Clinical outcomes were determined 1 and 5 years after surgery using a standardized questionnaire, with analogue scales to assess heartburn, dysphagia and overall satisfaction. Subgroup analysis was undertaken for those aged less than 75 years undergoing laparoscopic Nissen fundoplication. RESULTS: Some 417 patients entered six randomized trials evaluating surgery for reflux and 981 underwent surgery outside the trials. The trial group contained a higher proportion of men and younger patients, and patients in trials were more likely to have undergone Nissen fundoplication. At 1 year, patients in the trials had slightly lower heartburn scores and less abdominal bloating, but otherwise similar outcomes to those not in the trials. At 5 years there were no differences, except for a slightly higher dysphagia score for liquids in the trial group. For the subgroup analysis, demographic data were similar for both groups. There were no differences at 1 year, but at 5 years patients enrolled in the trials had higher scores for dysphagia for liquids and heartburn. All of the statistically significant differences were thought unlikely to be clinically relevant. CONCLUSION: Participation in a randomized trial assessing surgery for reflux did not influence outcomes. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22231692 [PubMed - as supplied by publisher]

Mass casualty incident training in a resource-limited environment.

Br J Surg. 2011 Dec 21;

Authors: Leow JJ, Brundage SI, Kushner AL, Kamara TB, Hanciles E, Muana A, Kamara MM, Daoh KS, Kingham TP

Abstract

BACKGROUND: A mass casualty incident (MCI) occurs when a disaster involves a large number of injured people, overwhelming the capacity of local emergency medical services. This article describes the planning and execution of a MCI workshop created for use in Sierra Leone, a low-income country. METHODS: Surgeons OverSeas (SOS), an international non-governmental organization, partnered with the Sierra Leone Office of National Security and Connaught Hospital to develop a 2-day MCI workshop designed to meet needs specific to their resource-limited environment. Pre- and post-course questionnaires were completed. Day 1 consisted of didactic teaching focused on triage principles, resource deployment, communication/operations and tabletop drills. On day 2 a mock MCI with performance assessments by independent observers was staged, followed by post-event debriefing. RESULTS: Pre-course questionnaires identified the following deficits: lack of triage training (29 per cent), and transportation (19 per cent) and communication (17 per cent) shortfalls. Only 11 per cent could define MCI. During the drill, on-scene and hospital triage was accurate in 28 (93 per cent) and 23 (77 per cent) of 30 casualties respectively. Systematic deficiencies identified included: transport issues, no accurate system for tracking victims, and undersized triage areas. Participants identified interagency coordination (63 of 136 responses; 46·3 per cent) and triage (32 of 136; 23·5 per cent) as the most valuable lessons learned. CONCLUSION: Pre-existing MCI programmes based on first-world logistics do not account for challenges encountered when caring for casualties in resource-constrained settings. Logistical training, rather than medical skills or knowledge, was identified as the educational priority. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22190046 [PubMed - as supplied by publisher]

Imaging vascular trauma.

Br J Surg. 2011 Dec 22;

Authors: Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM,

Abstract

BACKGROUND: Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions. METHODS: A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000-2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included. RESULTS: Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury. CONCLUSION: Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22190106 [PubMed - as supplied by publisher]

Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices.

Br J Surg. 2011 Dec 21;

Authors: Morrison JJ, Hunt N, Midwinter M, Jansen J

Abstract

BACKGROUND: Improvised explosive devices (IEDs) pose a significant threat to military personnel, often resulting in lower extremity amputation and pelvic injury. Immediate management is haemorrhage control and debridement, which can involve lengthy surgery. Computed tomography is necessary to delineate the extent of the injury, but it is unclear whether to perform this during or after surgery. METHODS: The UK Joint Theatre Trauma Registry was searched to identify all UK service personnel who had a traumatic lower extremity amputation following IED injury between January 2007 and December 2010. Data were collected on injury pattern and survival. RESULTS: There were 169 patients who sustained 278 traumatic lower extremity amputations: 69 were killed in action, 16 died from their wounds and 84 were wounded in action, but survived. The median (interquartile range) Injury Severity Score was 75 (21) for those killed in action, 46 (23) for those who died from wounds and 29 (12) for survivors. There were significantly more severe head, chest and abdominal injuries (defined as a body region Abbreviated Injury Scale score of 3 or more) in patients who were killed in action than in those reaching hospital (P < 0·001). Hindquarter amputations were the most lethal, with a mortality rate of 95 per cent. Of the 100 casualties who reached hospital alive, there were nine thoracotomies, one craniotomy and 34 laparotomies. All head or torso injuries that required immediate operation were clinically apparent on admission. CONCLUSION: Higher levels of amputation were associated with greater injury burden and mortality. Intraoperative computed tomography had little value in identifying clinically significant covert injuries. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22190142 [PubMed - as supplied by publisher]

Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre.

Br J Surg. 2011 Dec 20;

Authors: Rehn M, Lossius HM, Tjosevik KE, Vetrhus M, Ostebø O, Eken T,

Abstract

BACKGROUND: A registry-based analysis revealed imprecise informal one-tiered trauma team activation (TTA) in a primary trauma centre. A two-tiered TTA protocol was introduced and analysed to examine its impact on triage precision and resource utilization. METHODS: Interhospital transfers and patients admitted by non-healthcare personnel were excluded. Undertriage was defined as the fraction of major trauma victims (New Injury Severity Score over 15) admitted without TTA. Overtriage was the fraction of TTA without major trauma. RESULTS: Of 1812 patients, 768 had major trauma. Overall undertriage was reduced from 28·4 to 19·1 per cent (P < 0·001) after system revision. Overall overtriage increased from 61·5 to 71·6 per cent, whereas the mean number of skilled hours spent per overtriaged patient was reduced from 6·5 to 3·5 (P < 0·001) and the number of skilled hours spent per major trauma victim was reduced from 7·4 to 7·1 (P < 0·001). Increasing age increased risk for undertriage and decreased risk for overtriage. Falls increased risk for undertriage and decreased risk for overtriage, whereas motor vehicle-related accidents showed the opposite effects. Patients triaged to a prehospital response involving an anaesthetist had less chance of both undertriage and overtriage. CONCLUSION: A two-tiered TTA protocol was associated with reduced undertriage and increased overtriage, while trauma team resource consumption was reduced. Registration number: NCT00876564 (http://www.clinicaltrials.gov). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22190166 [PubMed - as supplied by publisher]

Risk factors for central bile duct injury complicating partial liver resection.

Br J Surg. 2011 Dec 20;

Authors: Boonstra EA, de Boer MT, Sieders E, Peeters PM, de Jong KP, Slooff MJ, Porte RJ

Abstract

BACKGROUND: Bile duct injury is a serious complication following liver resection. Few studies have differentiated between leakage from small peripheral bile ducts and central bile duct injury (CBDI), defined as an injury leading to leakage or stenosis of the common bile duct, common hepatic duct, right or left hepatic duct. This study analysed the incidence, risk factors and consequences of CBDI in liver resection. METHODS: Patients undergoing liver resection between 1990 and 2007 were included in this study. Those having resection for bile duct-related pathology or trauma, or after liver transplantation were excluded. Characteristics and outcome variables were collected prospectively and analysed retrospectively. RESULTS: There were 19 instances of CBDI in 462 liver resections (4·1 per cent). One-third of patients with CBDI required surgical reintervention and construction of a hepaticojejunostomy. Resection type (P < 0·001), previous liver resection (P = 0·039) and intraoperative blood loss (P = 0·002) were associated with an increased risk of CBDI. Of all resection types, extended left hemihepatectomy was associated with the highest incidence of CBDI (2 of 9 procedures). CONCLUSION: Patients undergoing extended left hemihepatectomy or repeat hepatectomy were at increased risk of CBDI. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22190220 [PubMed - as supplied by publisher]

Current practice of carotid endarterectomy in the UK.

Br J Surg. 2011 Dec 21;

Authors: Rudarakanchana N, Halliday AW, Kamugasha D, Grant R, Waton S, Horrocks M, Naylor AR, Rudd AG, Cloud GC, Mitchell D,

Abstract

BACKGROUND: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid stenosis of 50-99 per cent. This study assessed national surgical practice through audit of CEA procedures and outcomes. METHODS: This was a prospective cohort study of UK surgeons performing CEA, using clinical audit data collected continuously and reported in two rounds, covering operations from December 2005 to December 2007, and January 2008 to September 2009. RESULTS: Some 352 (92·6 per cent) of 380 eligible surgeons contributed data. Of 19 935 CEAs recorded by Hospital Episode Statistics, 12 496 (62·7 per cent) were submitted to the audit. A total of 10 452 operations (83·6 per cent) were performed for symptomatic carotid stenosis; among these patients, the presenting symptoms were transient ischaemic attack in 4507 (43·1 per cent), stroke in 3572 (34·2 per cent) and amaurosis fugax in 1965 (18·8 per cent). The 30-day mortality rate was 1·0 per cent (48 of 4944) in round 1 and 0·8 per cent (50 of 6151) in round 2; the most common cause of death was stroke, followed by myocardial infarction. The rate of death or stroke within 30 days of surgery was 2·5 per cent (124 of 4918) in round 1 and 1·8 per cent (112 of 6135) in round 2. CONCLUSION: CEA is performed less commonly in the UK than in other European countries and probably remains underutilized in the prevention of stroke. Increasing the number of CEAs done in the UK, together with reducing surgical waiting times, could prevent more strokes. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22190246 [PubMed - as supplied by publisher]

Case-matched analysis of outcome after open retropubic radical prostatectomy in patients with previous preperitoneal inguinal hernia repair.

Br J Surg. 2011 Dec 20;

Authors: Peeters E, Joniau S, Van Poppel H, Miserez M

Abstract

BACKGROUND: The impact of preperitoneal mesh repair for inguinal hernia on future pelvic surgery is debatable. This retrospective study investigated the impact of previous preperitoneal inguinal hernia repair (PIHR) on outcome after open retropubic radical prostatectomy (RRP) for prostatic cancer. METHODS: Patients who had open RRP and who had previously undergone PIHR were identified. They were compared with a control group of patients matched for age, body mass index and tumour risk profile who had no history of inguinal hernia repair. Outcome measures included intraoperative data, histopathology and results at follow-up. RESULTS: Sixty patients who had undergone open RRP after a previous PIHR were compared with 60 control patients. Operations lasted longer in the PIHR group (median (interquartile range, i.q.r.) 100 (90-120) versus 90 (85-100) min respectively; P < 0·001) and the operation was assessed as more difficult by the surgeon (P = 0·022). Hospital stay was longer for patients who had undergone PIHR (median (i.q.r.) 7 (6-9) versus 6 (5-7) days; P = 0·012) and urinary catheterization was prolonged (13 (11-14) versus 11 (11-12) days; P = 0·006). Among patients with intermediate- and high-risk disease, fewer lymph nodes were excised in the PIHR group than in the control group (median (i.q.r.) 2 (0-7) versus 8 (5-12) nodes; P < 0·001). CONCLUSION: Open RRP for prostatic cancer was more difficult to perform after previous PIHR, and was associated with a longer hospital stay and less adequate lymphadenectomy for intermediate- and high-risk prostatic cancer. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22190285 [PubMed - as supplied by publisher]

Accuracy of an expanded early warning score for patients in general and trauma surgery wards.

Br J Surg. 2011 Dec 20;

Authors: Smith T, Den Hartog D, Moerman T, Patka P, Van Lieshout EM, Schep NW

Abstract

BACKGROUND: Early warning scores (EWS) may aid the prediction of major adverse events in hospitalized patients. Recently, an expanded EWS was introduced in the Netherlands. The aim of this study was to assess the relationship between this EWS and the occurrence of major adverse clinical events during hospitalization of patients admitted to a general and trauma surgery ward. METHODS: This was a prospective cohort study of consecutive patients admitted to the general and trauma surgery ward of a university medical centre (March-September 2009). Follow-up was limited to the time the patient was hospitalized. Logistic regression analysis was used to assess the relationship between the EWS and the occurrence of the composite endpoint consisting of death, reanimation, unexpected intensive care unit admission, emergency surgery and severe complications. Performance of the EWS was analysed using sensitivity, specificity, predictive values and receiver operating characteristic (ROC) curves. RESULTS: A total of 572 patients were included. During a median follow-up of 4 days, 46 patients (8.0 per cent) reached the composite endpoint (two deaths, two reanimations, 17 intensive care unit admissions, 44 severe complications, one emergency operation). An EWS of at least 3, adjusted for baseline American Society of Anesthesiology classification, was associated with a significantly higher risk of reaching the composite endpoint (odds ratio 11·3, 95 per cent confidence interval (c.i.) 5·5 to 22·9). The area under the ROC curve was 0·87 (95 per cent c.i. 0·81 to 0·93). When considering an EWS of at least 3 to be a positive test result, sensitivity was 74 per cent and specificity was 82 per cent. CONCLUSION: An EWS of 3 or more is an independent predictor of major adverse events in patients admitted to a general and trauma surgery ward. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22183685 [PubMed - as supplied by publisher]

Fenestrated endovascular aneurysm repair.

Br J Surg. 2011 Dec 19;

Authors: Cross J, Gurusamy K, Gadhvi V, Simring D, Harris P, Ivancev K, Richards T

Abstract

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) is a technically challenging operation. The duration, blood loss, and risk of limb ischaemia, contrast-induced nephropathy and reperfusion injury are likely to be higher than after standard endovascular aneurysm repair (EVAR). Benefits of FEVAR over open repair may be less than those seen with standard infrarenal EVAR. This paper is a meta-analysis of observational studies of all published data for FEVAR, with the aim to highlight current issues around the evidence for the potential benefit of FEVAR. METHODS: A search was performed for studies describing FEVAR for juxtarenal abdominal aortic aneurysms. Small series of fewer than ten procedures and studies describing predominantly branched endografts or FEVAR for aortic dissection were excluded. Authors of included papers were contacted to eliminate patient duplication. RESULTS: Eleven studies were identified describing a total of 660 procedures. Definitions of aneurysm morphology were variable, and clear inclusion and exclusion criteria were not always documented. Double fenestrations were more common than triple or quadruple fenestrations. Target vessel perfusion rates ranged from 90·5 to 100 per cent. Eleven deaths occurred within 30 days, giving a 30-day proportional mortality rate of 2·0 per cent. Morbidity was poorly reported. CONCLUSION: FEVAR for repair of suprarenal and juxtarenal aneurysms is a viable alternative to open repair. However, there is no level 1 evidence for FEVAR, and current evidence is weak with many unanswered questions. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22183704 [PubMed - as supplied by publisher]

Systematic review of intraoperative cholangiography in cholecystectomy.

Br J Surg. 2011 Dec 19;

Authors: Ford JA, Soop M, Du J, Loveday BP, Rodgers M

Abstract

BACKGROUND: Intraoperative cholangiography (IOC) is used to detect choledocholithiasis and identify or prevent bile duct injury. The aim of this study was systematically to review the randomized clinical trials of IOC for these two indications. METHODS: MEDLINE, Embase, the Cochrane Library, clinicaltrials.gov and the World Health Organization database of clinical trials were searched systematically (January 1980 to February 2011) to identify trials. Two authors performed the literature search and extracted data independently. Primary endpoints were bile duct injury and retained common bile duct (CBD) stones diagnosed at any stage after surgery. Preliminary meta-analysis was undertaken, but the trials were too methodologically heterogeneous and the outcome events too infrequent to allow meaningful meta-analysis. RESULTS: Eight randomized trials were identified including 1715 patients. Six trials assessed the value of routine IOC in patients at low risk of choledocholithiasis. Two trials randomized all patients (including those at high risk) to routine or selective IOC. Two cases of major bile duct injury were reported, and 13 of retained CBD stones. No trial demonstrated a benefit in detecting CBD stones. IOC added a mean of 16 min to the total operating time. CONCLUSION: There is no robust evidence to support or abandon the use of IOC to prevent retained CBD stones or bile duct injury. Level 1 evidence for IOC is of poor to moderate quality. None of the trials, alone or in combination, was sufficiently powered to demonstrate a benefit of IOC. Further small trials cannot be recommended. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22183717 [PubMed - as supplied by publisher]

The never-ending story of dilatation versus surgery for oesophageal achalasia.

Br J Surg. 2011 Dec 19;

Authors: Zaninotto G, Patti MG

PMID: 22180042 [PubMed - as supplied by publisher]

Axillary recurrence rate 5 years after negative sentinel node biopsy for breast cancer.

Br J Surg. 2011 Dec 19;

Authors: Andersson Y, de Boniface J, Jönsson PE, Ingvar C, Liljegren G, Bergkvist L, Frisell J,

Abstract

BACKGROUND: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the standard axillary staging procedure in breast cancer. Follow-up studies in SLN-negative women treated without ALND report low rates of axillary recurrence, but most studies have short follow-up, and few are multicentre studies. METHODS: Between September 2000 and January 2004, patients who were SLN-negative and did not have ALND were included in a prospective cohort. Kaplan-Meier estimates were used to analyse the rates of axillary recurrence and survival. The risk of axillary recurrence was also compared in centres with high and low experience with the SLN biopsy (SLNB) technique. RESULTS: A total of 2195 patients with 2216 breast tumours were followed for a median of 65 months. Isolated axillary recurrence was diagnosed in 1·0 per cent of patients. The event-free 5-year survival rate was 88·8 per cent and the overall 5-year survival rate 93·1 per cent. There was no difference in recurrence rates between centres contributing fewer than 150 SLNB procedures to the cohort and centres contributing 150 or more procedures. CONCLUSION: This study confirmed the low risk of axillary recurrence 5 years after SLNB for breast cancer without ALND. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22180063 [PubMed - as supplied by publisher]

Prospective surveillance study of the management of intussusception in UK and Irish infants.

Br J Surg. 2011 Dec 19;

Authors: Samad L, Marven S, El Bashir H, Sutcliffe AG, Cameron JC, Lynn R, Taylor B

Abstract

BACKGROUND: Intussusception is the most common cause of acute intestinal obstruction in infants. This study examined the clinical presentation, management and outcomes of intussusception in this age group. METHODS: Prospective surveillance of intussusception in infants was carried out between March 2008 and March 2009 in the UK and Ireland. Monthly cards were sent to paediatric clinicians who were requested to notify cases of intussusception. RESULTS: The study identified 261 confirmed cases. The commonest presenting symptom/sign was non-bilious vomiting, in 210 (80·5 per cent) of the infants. Abdominal ultrasonography was done in 247 infants (94·6 per cent) and was diagnostic in 242 (98·0 per cent), compared with plain abdominal X-ray, which was diagnostic in 33 (23·6 per cent) of 140 infants. Enema reduction was carried out in 240 (92·0 per cent) of the 261 infants; the majority (237, 98·8 per cent) had pneumatic reduction with a success rate of 61·2 per cent (145 of 237). Surgery was required in 111 infants (42·5 per cent); 92 operations were as a result of unsuccessful enema reduction, and the remaining 19 infants (17·1 per cent) had primary surgery. Forty-four infants (39·6 per cent of operations) needed a bowel resection. The majority of children (238, 91·2 per cent) recovered uneventfully; 21 (8·0 per cent) had sequelae, one child died (0·4 per cent), and the outcome was unknown for one infant. CONCLUSION: This study described current treatment patterns for intussusception in infancy; these represent a benchmark for improved standards of care for this condition. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22180094 [PubMed - as supplied by publisher]

Long-term results after laparoscopic reoperation for failed antireflux procedures (Br J Surg 2011; 98: 1581-1587).

Br J Surg. 2011 Nov;98(11):1587-8

Authors: Manson J

PMID: 21964683 [PubMed - indexed for MEDLINE]

Randomized clinical trial of fibrin sealant versus titanium tacks for mesh fixation in laparoscopic umbilical hernia repair (Br J Surg 2011; 98: 1537-1545).

Br J Surg. 2011 Nov;98(11):1545

Authors: Simons MP

PMID: 21964682 [PubMed - indexed for MEDLINE]

Management and outcomes of haemorrhage after pancreatogastrostomy versus pancreatojejunostomy (Br J Surg 2011: 98: 1599-1607).

Br J Surg. 2011 Nov;98(11):1607-8

Authors: Gouma DJ

PMID: 21964685 [PubMed - indexed for MEDLINE]

Long-term functional results and quality of life after transanal endoscopic microsurgery (Br J Surg 2011; 98: 1635-1643).

Br J Surg. 2011 Nov;98(11):1643

Authors: Borley N

PMID: 21964686 [PubMed - indexed for MEDLINE]

Novel bulking agent for faecal incontinence (Br J Surg 2011; 98: 1644-1652).

Br J Surg. 2011 Nov;98(11):1653

Authors: Burke D

PMID: 21964687 [PubMed - indexed for MEDLINE]

Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery (Br J Surg 2011; 98: 1068-1078).

Br J Surg. 2011 Nov;98(11):1673-4; author reply 1674

Authors: Evans C, Qureshi A, Soin B

PMID: 21964688 [PubMed - indexed for MEDLINE]

Role of mammography in the triple assessment of single-quadrant breast symptoms (Br J Surg 2011; 98: 951-955).

Br J Surg. 2011 Nov;98(11):1673; author reply 1673

Authors: Lal A, Evoy D, Geraghty J, McDermott E

PMID: 21964690 [PubMed - indexed for MEDLINE]

Systematic review of outcome of downstaging hepatocellular cancer before liver transplantation in patients outside the Milan criteria (Br J Surg 2011; 98: 1201-1208).

Br J Surg. 2011 Nov;98(11):1674; author reply 1675

Authors: Ravaioli M, Cucchetti A, Cescon M, Piscaglia F, Ercolani G, Trevisani F, Pinna AD

PMID: 21964691 [PubMed - indexed for MEDLINE]

Endoscopic and surgical management of serrated colonic polyps (Br J Surg 2011; 98: 1685-1694).

Br J Surg. 2011 Dec;98(12):1694

Authors: Pullan R

PMID: 22034179 [PubMed - indexed for MEDLINE]

Open repair of ruptured abdominal aortic aneurysm in patients aged 80 years and older.

Br J Surg. 2011 Dec;98(12):1713-8

Authors: Biancari F, Venermo M,

Abstract

BACKGROUND: Open repair of ruptured abdominal aortic aneurysm (RAAA) in patients aged 80 years and older may be questioned owing to the patients’ high operative risk and short life expectancy.

METHODS: Data on patients aged at least 80 years, admitted for RAAA at four Finnish university hospitals, were collected and analysed retrospectively.

RESULTS: Three hundred and ten consecutive patients aged 80 years and older with RAAA reached hospital alive; 200 (64·5 per cent) underwent open repair. The number of open repairs increased during the last 5 years (49·0 per cent of the whole series), with no significant increase in the number of patients treated conservatively. The overall in-hospital mortality rate was 72·9 per cent. The operative mortality rate was 59·0 per cent and decreased from 66 to 52 per cent during the last 5 years (P = 0·050). On multivariable analysis, shock was the only independent predictor of immediate postoperative death (odds ratio 4·97, 95 per cent confidence interval 2·09 to7·94; P < 0·001). Classification and regression tree analysis showed that preoperative haemoglobin level and presence of shock were predictive of immediate postoperative death; 19 (95 per cent) of 20 patients with shock and a haemoglobin level below 68 g/l died immediately after surgery. Among the 82 survivors of surgery, survival rates at 1, 3 and 5 years were 90, 68 and 45 per cent respectively. These values were not significantly different from those of the age-, sex- and year-matched general population (P = 0·885).

CONCLUSION: Survival after open repair of RAAA among patients aged 80 years and older is sufficient to justify the procedure, particularly in patients in a stable haemodynamic condition.

PMID: 22034180 [PubMed - indexed for MEDLINE]

Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant.

Br J Surg. 2011 Dec;98(12):1742-51

Authors: Mise Y, Hasegawa K, Satou S, Aoki T, Beck Y, Sugawara Y, Makuuchi M, Kokudo N

Abstract

BACKGROUND: Hepatic vein (HV) reconstruction may prevent venous congestion following resection of liver tumours that encroach on major HVs. This study aimed to identify criteria for venous reconstruction based on preoperative evaluation of venous congestion.

METHODS: A volumetric analysis using image-processing software was performed in selected patients with liver tumours suspected on preoperative imaging of major HV invasion. The size of the non-congested liver remnant (NCLR) was calculated by subtracting the congested area from the liver remnant. Venous reconstruction was scheduled in patients who met the following criteria: normal liver function (indocyanine green retention rate at 15 min (ICGR(15) ) of less than 10 per cent) with a NCLR smaller than 40 per cent of total liver volume (TLV), or liver dysfunction (ICGR(15) 10-20 per cent) with a NCLR smaller than 50 per cent of TLV. Surgical outcomes and liver regeneration were investigated.

RESULTS: A total of 55 patients with suspected HV invasion were enrolled. Sacrifice of one or more HVs was deemed possible in 37 patients. Venous reconstruction was scheduled in 18 patients. At operation, there was seen to be no venous involvement in 11 patients. The HV was sacrificed in 29 patients, and preserved or reconstructed in 24. Volume restoration ratios at 3 months were similar in the sacrifice (88 per cent) and preserve (87 per cent) groups. Operating time was shorter (465 min) and blood loss was lower (580 ml) in the sacrifice than in the preserve group (523 min and 815 ml respectively).

CONCLUSION: The HV can be sacrificed safely according to the proposed criteria, reducing surgical invasiveness without influencing the postoperative course.

PMID: 22034181 [PubMed - indexed for MEDLINE]

Value of hepatic venous pressure gradient measurement before liver resection for hepatocellular carcinoma (Br J Surg 2011; 98: 1752-1758).

Br J Surg. 2011 Dec;98(12):1758-9

Authors: Ko S

PMID: 22034182 [PubMed - indexed for MEDLINE]

Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection.

Br J Surg. 2011 Dec;98(12):1775-83

Authors: Almoudaris AM, Burns EM, Mamidanna R, Bottle A, Aylin P, Vincent C, Faiz O

Abstract

BACKGROUND: Complication management appears to be of vital importance to differences in survival following surgery between surgical units. Failure-to-rescue (FTR) rates have not yet distinguished surgical from general medical complications. The aim of this study was to assess whether variability exists in FTR rates after reoperation for serious surgical complications following colorectal cancer resections in England.

METHODS: The Hospital Episode Statistics (HES) database was used to identify patients undergoing primary resection for colorectal cancer between 2000 and 2008 in English National Health Service (NHS) trusts. Units were ranked into quintiles according to overall risk-adjusted mortality. Highest and lowest mortality quintiles were compared with respect to reoperation rates and FTR-surgical (FTR-S) rates. FTR-S was defined as the proportion of patients with an unplanned reoperation who died within the same admission.

RESULTS: Some 144 542 patients undergoing resection for colorectal cancer in 150 English NHS trusts were included. On ranking according to risk-adjusted mortality, rates varied significantly between lowest and highest mortality quintiles (5·4 and 9·3 per cent respectively; P = 0·029). Lowest and highest mortality quintiles had equivalent adjusted reoperation rates (both 4·8 per cent; P = 0·211). FTR-S rates were significantly higher at units within the worst mortality quintile (16·8 versus 11·1 per cent; P = 0·002).

CONCLUSION: FTR-S rates differed significantly between English colorectal units, highlighting variability in ability to prevent death in this high-risk group. This variability may represent differences in serious surgical complication management. FTR-S represents a readily collectable marker of surgical complication management that is likely to be applicable to other surgical specialties.

PMID: 22034183 [PubMed - indexed for MEDLINE]

Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection (Br J Surg 2011; 98: 1775-1783).

Br J Surg. 2011 Dec;98(12):1784

Authors: Blazeby JM

PMID: 22034184 [PubMed - indexed for MEDLINE]

Outcomes following surgery for colorectal cancer with synchronous peritoneal metastases.

Br J Surg. 2011 Dec;98(12):1785-91

Authors: Mulsow J, Merkel S, Agaimy A, Hohenberger W

Abstract

BACKGROUND: The optimal treatment of peritoneal carcinomatosis of colorectal origin appears to be a combination of systemic chemotherapy and complete surgical cytoreduction with synchronous intraperitoneal chemotherapy. The aim of this study was to assess the feasibility of, and outcomes following, surgical treatment and systemic chemotherapy alone.

METHODS: Prospectively collated data from the Erlangen Registry for Colorectal Cancer were analysed for patients presenting with peritoneal carcinomatosis of colorectal origin between 1990 and 2006. Operative and adjuvant treatment, along with details of postoperative morbidity, were evaluated and correlated with survival outcomes after 5 years.

RESULTS: Some 125 patients underwent surgical resection for colorectal cancer and synchronous peritoneal carcinomatosis. Two-thirds also had non-peritoneal distant metastases. R0/R1 resection was possible in 24 (59 per cent) of 41 patients with peritoneal metastases alone, and in a further seven patients with both peritoneal and distant metastases (overall R0/R1 resection rate 24·8 per cent). In-hospital morbidity and mortality rates were 32·0 and 12·0 per cent respectively. Twenty-three of the 31 patients who underwent R0/R1 resection developed recurrent disease. Median survival for the entire group was 12 months. Following R0/R1 resection median survival was 25 months and the 5-year survival rate 22 per cent. Six (4·8 per cent) of the 125 patients survived for more than 5 years.

CONCLUSION: Complete resection of all metastatic disease was associated with improved survival and was possible in almost 60 per cent of patients with peritoneal metastases alone.

PMID: 22034185 [PubMed - indexed for MEDLINE]

Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery (Br J Surg 2011; 98: 1068-1078).

Br J Surg. 2011 Dec;98(12):1805; author reply 1805-6

Authors: Stevens MF, de Nes L, Hollmann MW

PMID: 22034187 [PubMed - indexed for MEDLINE]

Randomized clinical trial of tissue glue versus absorbable sutures for mesh fixation in local anaesthetic Lichtenstein hernia repair (Br J Surg 2011; 98: 1245-1251).

Br J Surg. 2011 Dec;98(12):1806; author reply 1806-7

Authors: Sanders DL

PMID: 22034189 [PubMed - indexed for MEDLINE]

Abdominal organ donation after death (Br J Surg 2011; 98: 1185-1187).

Br J Surg. 2011 Dec;98(12):1807; author reply 1807

Authors: Clancy MJ

PMID: 22034190 [PubMed - indexed for MEDLINE]

Abstracts of the XVII Congress of the Spanish Society of Surgical Research. October 27-28, 2011. Oviedo, Spain.

Br J Surg. 2011 Dec;98 Suppl 8:S1-9

Authors:

PMID: 22167900 [PubMed - indexed for MEDLINE]

Case-controlled study of critical care or surgical ward care after elective open colorectal surgery.

Br J Surg. 2011 Nov 21;

Authors: Swart M, Carlisle JB

Abstract

BACKGROUND: Evidence for the benefit of critical care after surgery is limited. This study assessed the value of immediate admission to the critical care unit (CCU) after open colorectal surgery. METHODS: Patients aged over 45 years were screened with a cardiopulmonary exercise test to determine their anaerobic threshold. Less fit patients defined by an anaerobic threshold below 11 ml oxygen per kg per min were assigned to either critical care or surgical ward care. Those with an anaerobic threshold of 11 ml oxygen per kg per min or above were assigned to ward care. The outcome measure was the number of cardiac events. RESULTS: Of 153 patients who underwent exercise testing, 55 had an anaerobic threshold of at least 11 ml oxygen per kg per min (ward care) and 98 had a threshold of less than 11 ml oxygen per kg per min, of whom 39 were allocated to ward care and 51 to critical care. Median length of CCU stay was 31 (range 5-46) h. More cardiac events occurred in patients allocated to ward care (7 of 39) than in those allocated to critical care (0 of 51): absolute difference 18 (95 per cent confidence interval 10 to 26) per cent (P = 0·002). There were no cardiac events in patients with an anaerobic threshold of 11 ml oxygen per kg per min or higher. CONCLUSION: Patients with an anaerobic threshold of at least 11 ml oxygen per kg per min and those with a threshold below 11 ml oxygen per kg per min managed in the CCU had fewer cardiac events. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22101443 [PubMed - as supplied by publisher]

Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare.

Br J Surg. 2011 Nov 18;

Authors: Nicolay CR, Purkayastha S, Greenhalgh A, Benn J, Chaturvedi S, Phillips N, Darzi A

Abstract

BACKGROUND: The demand for the highest-quality patient care coupled with pressure on funding has led to the increasing use of quality improvement (QI) methodologies from the manufacturing industry. The aim of this systematic review was to identify and evaluate the application and effectiveness of these QI methodologies to the field of surgery. METHODS: MEDLINE, the Cochrane Database, Allied and Complementary Medicine Database, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Embase, Health Business(™) Elite, the Health Management Information Consortium and PsycINFO(®) were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Empirical studies were included that implemented a described QI methodology to surgical care and analysed a named outcome statistically. RESULTS: Some 34 of 1595 articles identified met the inclusion criteria after consensus from two independent investigators. Nine studies described continuous quality improvement (CQI), five Six Sigma, five total quality management (TQM), five plan-do-study-act (PDSA) or plan-do-check-act (PDCA) cycles, five statistical process control (SPC) or statistical quality control (SQC), four Lean and one Lean Six Sigma; 20 of the studies were undertaken in the USA. The most common aims were to reduce complications or improve outcomes (11), to reduce infection (7), and to reduce theatre delays (7). There was one randomized controlled trial. CONCLUSION: QI methodologies from industry can have significant effects on improving surgical care, from reducing infection rates to increasing operating room efficiency. The evidence is generally of suboptimal quality, and rigorous randomized multicentre studies are needed to bring evidence-based management into the same league as evidence-based medicine. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22101509 [PubMed - as supplied by publisher]

Prognostic significance of peritoneal washing cytology in patients with gastric cancer.

Br J Surg. 2011 Nov 18;

Authors: Lee SD, Ryu KW, Eom BW, Lee JH, Kook MC, Kim YW

Abstract

BACKGROUND: Positive peritoneal washing cytology is a poor prognostic factor in patients with gastric cancer. The right therapeutic approach for this condition has not been well documented. METHODS: Patients who underwent surgery for gastric cancer with suspected serosal invasion and peritoneal washing cytology at the Korean National Cancer Centre between May 2001 and December 2009 were included in this retrospective study. Clinicopathological factors and overall survival were analysed with respect to the cytological results and presence of peritoneal metastases. Prognostic factors were analysed in patients with positive cytology but without overt peritoneal metastases. RESULTS: A total of 1072 patients were included in the analysis, of whom 900 had negative cytology (C0 group) and 172 had positive cytology (C1 group). No peritoneal metastases (P0) were found in 830 patients (92·2 per cent) in the C0 group. Peritoneal metastases (P1) were found in 76 patients (44·2 per cent) in the C1 group. Median overall survival times in the P0 C1, P1 C0 and P1 C1 subgroups were 20·0, 14·0 and 10·0 months respectively. Multivariable analysis of the P0 C1 subgroup revealed that clinical N0-2 category and gastric resection were significantly associated with better prognosis (median survival 24·0 versus 13·0 months for N0-2 versus N3, and 21·0 versus 4·0 months for resected versus non-resected). CONCLUSION: Positive washing cytology in patients with gastric cancer is a negative prognostic factor for patients with, as well as those without, overt peritoneal metastases. Resection is an option in patients with clinical stage N0-2 disease without peritoneal metastases but with a positive washing cytology finding. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22101572 [PubMed - as supplied by publisher]

Multicentre observational study of the natural history of left-sided acute diverticulitis.

Br J Surg. 2011 Nov 21;

Authors: Binda GA, Arezzo A, Serventi A, Bonelli L,

Abstract

BACKGROUND: The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. METHODS: The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. RESULTS: Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment. CONCLUSION: Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22105809 [PubMed - as supplied by publisher]

Use of Hospital Episode Statistics to investigate abdominal aortic aneurysm surgery.

Br J Surg. 2012 Jan;99(1):66-72

Authors: Johal A, Mitchell D, Lees T, Cromwell D, van der Meulen J

Abstract

BACKGROUND: A coding framework was evaluated to study patients undergoing open surgical replacement of an abdominal aortic aneurysm (AAA) in the English Hospital Episode Statistics (HES) database. The objective was to create groups of patients who are homogeneous with respect to diagnosis, prognosis and treatment.

METHODS: The frequency and consistency of potentially relevant diagnosis (International Classification of Diseases, 10th revision) and procedure (Office of Population Censuses and Surveys Classification, 4th revision) codes were assessed in patients admitted to English National Health Service hospitals between April 2003 and March 2008. Administrative codes were compared with diagnosis and procedure codes to check that patients who had undergone emergency surgery for a ruptured AAA were admitted as an emergency.

RESULTS: Of 20 290 patients undergoing AAA replacement, 19 250 (94·9 per cent) had a consistent diagnosis (unruptured or ruptured AAA); 79·3 per cent of patients with an emergency replacement were coded as having a ruptured AAA and 95·7 per cent of those with a non-emergency replacement as having an unruptured AAA. Of patients who had undergone emergency replacement of a ruptured AAA, 93·3 per cent were coded as having been admitted as an emergency.

CONCLUSION: Coding consistency was high. The proposed framework could define homogeneous groups by combining diagnosis, procedure and administrative codes. It also allows an assessment of potential miscoding at national and hospital level. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22105834 [PubMed - in process]

P-selectin mediates neutrophil rolling and recruitment in acute pancreatitis.

Br J Surg. 2011 Nov 23;

Authors: Hartman H, Abdulla A, Awla D, Lindkvist B, Jeppsson B, Thorlacius H, Regnér S

Abstract

BACKGROUND: The adhesive mechanisms regulating leucocyte-endothelium interactions in the pancreas remain elusive, but selectins may play a role. This study examined the molecular mechanisms mediating leucocyte rolling along the endothelium in the pancreas and the therapeutic potential of targeting the rolling adhesive interaction in acute pancreatitis (AP). METHODS: Pancreatitis was induced by retrograde infusion of 5 per cent sodium taurocholate into the pancreatic duct, repeated intraperitoneal administration of caerulein (50 µg/kg) or intraperitoneal administration of L-arginine (4 g/kg) in C57BL/6 mice. A control and a monoclonal antibody against P-selectin were administered before and after induction of AP. Serum and tissue were sampled to assess the severity of pancreatitis, and intravital microscopy was used to study leucocyte rolling. RESULTS: Taurocholate infusion into the pancreatic duct increased the serum level of trypsinogen, trypsinogen activation, pancreatic neutrophil infiltration, macrophage inflammatory protein (MIP) 2 formation and tissue damage. Immunoneutralization of P-selectin decreased the taurocholate-induced increase in serum trypsinogen (median (range) 17·35 (12·20-30·00) versus 1·55 (0·60-15·70) µg/l; P = 0·017), neutrophil accumulation (4·00 (0·75-4·00) versus 0·63 (0-3·25); P = 0·002) and tissue damage, but had no effect on MIP-2 production (14·08 (1·68-33·38) versus 3·70 (0·55-51·80) pg/mg; P = 0·195) or serum trypsinogen activating peptide level (1·10 (0·60-1·60) versus 0·45 (0-1·80) µg/l; P = 0·069). Intravital fluorescence microscopy revealed that anti-P-selectin antibody inhibited leucocyte rolling completely in postcapillary venules of the inflamed pancreas. CONCLUSION: Inhibition of P-selectin protected against pancreatic tissue injury in experimental pancreatitis. Targeting P-selectin may be an effective strategy to ameliorate inflammation in AP. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22109627 [PubMed - as supplied by publisher]

Resuscitative emergency thoracotomy in a Swiss trauma centre.

Br J Surg. 2011 Dec 2;

Authors: Lustenberger T, Labler L, Stover JF, Keel MJ

Abstract

BACKGROUND: Resuscitative emergency thoracotomy (ET) is performed as a salvage manoeuvre for selected patients with trauma. However, reports from European trauma centres are scarce. METHODS: A retrospective analysis was undertaken of injured patients who underwent resuscitative ET in the emergency department (ED) or operating room (OR) between January 1996 and September 2008. Survival in the ED and to hospital discharge was analysed using logistic regression. RESULTS: During the study interval 121 patients required a resuscitative thoracotomy, of which 49 (40·5 per cent) were performed in the ED and 72 (59·5 per cent) in the OR. Patients in the OR had higher blood pressure on arrival (median 110 versus 60 mmHg; P < 0·001), were less often in severe haemorrhagic shock (63 versus 94 per cent; P < 0·001), had fewer serious head injuries (Abbreviated Injury Score of 3 or above in 33 versus 53 per cent; P = 0·031) and more often had a penetrating stab wound as the dominating mechanism (25 versus 10 per cent; P = 0·042) compared with those in the ED. Ten patients (20 per cent) survived to hospital discharge after ED thoracotomy, compared with 53 (74 per cent) of those treated in the OR. Penetrating injury and Glasgow Coma Scale score above 8 were independent predictors of hospital survival following ED thoracotomy. No patient with a blunt injury and no detectable signs of life on admission survived. Three of 26 patients with blunt trauma and signs of life on admission survived to hospital discharge. CONCLUSION: Resuscitative ET may be life-saving in selected patients. Location of the procedure is dictated by injury severity and vital parameters. Outcome is best when signs of life are present on admission, even for blunt injuries. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22139553 [PubMed - as supplied by publisher]

Surgical response to the 2008 Mumbai terror attack.

Br J Surg. 2011 Dec 2;

Authors: Bhandarwar AH, Bakhshi GD, Tayade MB, Borisa AD, Thadeshwar NR, Gandhi SS

Abstract

BACKGROUND: Mumbai, the financial capital of India, was attacked by terrorists at various famous, densely populated places on 26 November 2008. The attack lasted for 60 h, resulting in multiple civilian casualties from bullet and blast injuries. The aim was to review the disaster management plan and analyse the injury patterns and surgical response. METHODS: The disaster management plan was activated in the Sir Jamshetjee Jejeebhoy Group of Hospitals as soon as the earliest casualties were reported. The casualty receiving area was converted into a triage zone; patients were accordingly sent to different stations for further management. There was rotation of the duties of the medical personnel every 8 h for increased efficiency. RESULTS: A total of 271 casualties were encountered, of which 108 were dead at admission. Some 163 patients were triaged, 23 of whom received primary care as outpatients. The remaining 140 patients needed admission to hospital; 194 operations were performed in 127 patients. There were six postoperative deaths. CONCLUSION: This was a unique terrorist attack targeted on civilians and continuing for more than 2 days. The casualties consisted of military injuries due to combined firearm and blast trauma. Primary triage, or onsite triage once the site is safe, optimizes management. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22139597 [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. 2011 Dec 2;

Authors: Bosman A, de Jong MB, Debeij J, van den Broek PJ, Schipper IB

Abstract

BACKGROUND: No consensus exists as to whether antibiotic prophylaxis in tube thoracostomy as primary treatment for traumatic chest injuries reduces the incidence of surgical-site and pleural cavity infections. METHODS: A systematic literature search was performed according to PRISMA guidelines to identify randomized clinical trials on antibiotic prophylaxis in tube thoracostomy for traumatic chest injuries. Data were extracted by two reviewers using piloted forms. Mantel-Haenszel pooled odds ratios (ORs) were calculated with 95 per cent confidence intervals (c.i.). RESULTS: Eleven articles were included, encompassing 1241 chest drains in 1234 patients. Most patients (84·7 per cent) were men, and a penetrating injury mechanism was most common (856, 69·4 per cent). A favourable effect of antibiotic prophylaxis on the incidence of pulmonary infection was found, with an OR for the overall infectious complication rate of 0·24 (95 per cent c.i. 0·12 to 0·49). Patients who received antibiotic prophylaxis had an almost three times lower risk of empyema than those who did not receive antibiotic treatment (OR 0·32, 0·17 to 0·61). A subgroup analysis in patients with penetrating chest injuries showed that antibiotic prophylaxis in these patients reduced the risk of infection after tube thoracostomy (OR 0·28, 0·14 to 0·57), whereas in a relatively small blunt trauma subgroup no effect of antibiotic prophylaxis after blunt thoracic injury was found. CONCLUSION: Infectious complications are less likely to develop when antibiotic prophylaxis is administered to patients with thoracic injuries requiring chest drains after penetrating injury. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22139619 [PubMed - as supplied by publisher]

Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis.

Br J Surg. 2011 Nov 17;

Authors: Hull TL, Joyce MR, Geisler DP, Coffey JC

Abstract

BACKGROUND: Emerging evidence suggests that a laparoscopic approach to colorectal procedures generates fewer adhesions. Even though laparoscopic ileal pouch-anal anastomosis (IPAA) is a lengthy procedure, the prospect of fewer adhesions may justify this approach. The aim of this study was to assess abdominal and adnexal adhesion formation following laparoscopic versus open IPAA in patients with ulcerative colitis. METHODS: A diagnostic laparoscopy was performed at time of ileostomy closure. All abdominal quadrants and the pelvis were video recorded systematically and graded offline. The incisional adhesion score (IAS; range 0-6) and total abdominal adhesion score (TAS; range 0-10) were calculated, based on the grade and extent of adhesions. Adnexal adhesions were classified by the American Fertility Society (AFS) adhesion score. RESULTS: A total of 43 patients consented to participate, of whom 40 could be included in the study (laparoscopic 28, open 12). Median age was 38 (range 20-61) years. There was no difference in age, sex, body mass index, American Society of Anesthesiologists grade and time to ileostomy closure between groups. The IAS was significantly lower after laparoscopic IPAA than following an open procedure: median (range) 0 (0-5) versus 4 (2-6) respectively (P = 0·004). The TAS was also significantly lower in the laparoscopic group: 2 (0-6) versus 8 (2-10) (P = 0·002). Applying the AFS score, women undergoing laparoscopic IPAA had a significantly lower mean(s.d.) prognostic classification score than those in the open group: 5·2(3·7) versus 20·0(5·6) (P = 0·023). CONCLUSION: Laparoscopic IPAA was associated with significantly fewer incisional, abdominal and adnexal adhesions in comparison with open IPAA. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22095139 [PubMed - as supplied by publisher]

Prognostic value of tumour necrosis and host inflammatory responses in colorectal cancer.

Br J Surg. 2011 Nov 16;

Authors: Richards CH, Roxburgh CS, Anderson JH, McKee RF, Foulis AK, Horgan PG, McMillan DC

Abstract

BACKGROUND: Tumour necrosis is a marker of poor prognosis in some tumours but the mechanism is unclear. This study examined the prognostic value of tumour necrosis and host inflammatory responses in colorectal cancer. METHODS: This was a retrospective study of patients undergoing potentially curative resection of colorectal cancer at a single surgical institution over a 10-year period. Patients who underwent preoperative radiotherapy were excluded. The systemic and local inflammatory responses were assessed using the modified Glasgow Prognostic Score and Klintrup-Makinen criteria respectively. Original tumour sections were retrieved and necrosis graded as absent, focal, moderate or extensive. Associations between necrosis and clinicopathological variables were examined, and multivariable survival analyses carried out. RESULTS: A total of 343 patients were included between 1997 and 2007. Tumour necrosis was graded as absent in 32 (9·3 per cent), focal in 166 (48·4 per cent), moderate in 101 (29·4 per cent) and extensive in 44 (12·8 per cent). There were significant associations between tumour necrosis and anaemia (P = 0·022), white cell count (P = 0·006), systemic inflammatory response (P < 0·001), local inflammatory cell infiltrate (P = 0·004), tumour node metastasis (TNM) stage (P = 0·015) and Petersen Index (P = 0·003). On univariable survival analysis, tumour necrosis was associated with cancer-specific survival (P < 0·001). On multivariable survival analysis, age (hazard ratio (HR) 1·29, 95 per cent confidence interval 1·00 to 1·66), systemic inflammatory response (HR 1·74, 1·27 to 2·39), low-grade local inflammatory cell infiltrate (HR 2·65, 1·52 to 4·63), TNM stage (HR 1·55, 1·02 to 2·35) and high-risk Petersen Index (HR 3·50, 2·21 to 5·55) were associated with reduced cancer-specific survival. CONCLUSION: The impact of tumour necrosis on colorectal cancer survival may be due to close associations with the host systemic and local inflammatory responses. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22086662 [PubMed - as supplied by publisher]

Gene therapy in the treatment of peripheral arterial disease.

Br J Surg. 2011 Nov 8;

Authors: Mughal NA, Russell DA, Ponnambalam S, Homer-Vanniasinkam S

Abstract

BACKGROUND: Peripheral arterial disease remains a significant global health burden despite revolutionary improvements in endovascular techniques over the past decade. The durability of intervention for critical limb ischaemia is poor, and the condition is associated with high morbidity and mortality rates. To address this deficiency, alternative therapeutic options are being explored. Advances in the fields of gene therapy and therapeutic angiogenesis have led to these being advocated as potential future treatments. METHODS: Relevant medical literature from PubMed, Embase, the Cochrane Library and Google Scholar from the inception of these databases to June 2011 was reviewed. RESULTS: Encouraging outcomes in preclinical trials using a variety of proangiogenic growth factors have led to numerous efficacy and safety studies. However, no clinical study has shown significant benefit for gene therapy over placebo. CONCLUSION: Identifying the optimal site for gene delivery, choice of vector and duration of treatment is needed if gene therapy is to become a credible therapeutic option for peripheral arterial disease. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22068822 [PubMed - as supplied by publisher]

Endarterectomy versus carotid stenting.

Br J Surg. 2011 Nov 8;

Authors: Naylor AR

PMID: 22068880 [PubMed - as supplied by publisher]

Persisting symptoms after intrathoracic anastomotic leak following oesophagectomy for cancer.

Br J Surg. 2011 Nov 8;

Authors: van der Schaaf M, Lagergren J, Lagergren P

Abstract

BACKGROUND: Intrathoracic anastomotic leak is a major cause of postoperative mortality and morbidity after resection for oesophageal cancer. Little is known about persisting symptoms after this complication. In this Swedish nationwide cohort study, it was hypothesized that intrathoracic anastomotic leak makes patients more susceptible to persisting eating difficulties, odynophagia, dysphagia, trouble swallowing saliva and reflux. METHODS: Patients who underwent oesophagectomy for oesophageal cancer, and had reconstruction with a gastric conduit and an intrathoracic anastomosis, between April 2001 and December 2005 were included. Symptoms were measured using an oesophageal cancer-specific health-related quality-of-life questionnaire (QLQ-OES18), developed by the European Organization for Research and Treatment of Cancer. Multivariable logistic regression models were used to calculate risk estimates for symptoms, expressed as odds ratio (OR) with 95 per cent confidence interval, 6 months after intrathoracic anastomotic leakage. RESULTS: Among the 277 patients included in the study, the 29 patients with an intrathoracic anastomotic leak had a fourfold increased risk (OR 4·05, 1·47 to 11·16) of eating difficulties and a more than twofold greater risk (OR 2·59, 1·15 to 5·82) of odynophagia, 6 months after surgery, compared with patients without a leak. There was a twofold increased risk of trouble swallowing, but this was not statistically significant (OR 1·98, 0·58 to 6·67). CONCLUSION: Patients with an intrathoracic anastomotic leak after oesophageal cancer surgery were at increased risk of eating difficulties and odynophagia 6 months after surgery. Higher risks of reflux and dysphagia were not found among patients with anastomotic leak. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22068914 [PubMed - as supplied by publisher]

Tumour-related factors and prognosis in breast cancer detected by screening.

Br J Surg. 2011 Nov 8;

Authors: Olsson A, Borgquist S, Butt S, Zackrisson S, Landberg G, Manjer J

Abstract

BACKGROUND: Breast cancer detected by screening has an unexplained prognostic advantage beyond stage shift compared with cancers detected clinically. The aim was to investigate biological factors in invasive breast cancer, with reference to mode of detection and rate of death from breast cancer. METHODS: Histology, oestrogen receptor α and β, progesterone receptor, human epidermal growth factor receptor (HER) 2, cyclin D1, p27, Ki-67 and perinodal growth were analysed in 466 tumours from a prospective cohort, the Malmö Diet and Cancer Study. Using logistic regression, odds ratios were calculated to investigate the relationship between tumour characteristics and mode of detection. The same tumour factors were analysed in relation to standard prognostic features. Death from breast cancer was analysed using Cox regression with adjustments for standard tumour factors; differences following adjustment were analysed by means of Freedman statistics. RESULTS: None of the biological tumour characteristics varied with mode of detection of breast cancer. After adjustment for age, tumour size, axillary lymph node involvement (ALNI) and grade, women with cancer detected clinically had an increased risk of death from breast cancer (hazard ratio 2·48, 95 per cent confidence interval 1·34 to 4·59), corresponding to a 37·2 per cent difference compared with the unadjusted model. Additional adjustment for biological tumour factors studied caused only minor changes. CONCLUSION: None of the biological tumour markers investigated explained the improved prognosis in breast cancer detected by screening. None of the factors was related to ALNI, suggesting that other mechanisms may be responsible for tumour spread. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22068957 [PubMed - as supplied by publisher]

Effect of HER2 status on risk of recurrence in women with small, node-negative breast tumours.

Br J Surg. 2011 Nov;98(11):1561-5

Authors: Tanaka K, Kawaguchi H, Nakamura Y, Taguchi K, Nishiyama K, Ohno S

Abstract

BACKGROUND: Adjuvant trastuzumab for small, node-negative, human epidermal growth factor receptor 2 (HER2)-positive breast cancer remains controversial. The purpose of this study was to investigate the risk of recurrence in women with pathological tumour node (pTN) T1 N0 tumours.

METHODS: Patients with pT1 N0 breast cancer diagnosed at the National Kyushu Cancer Centre between 2001 and 2007 were reviewed. Patients were categorized according to HER2 status.

RESULTS: Four hundred and fifty-four patients who had pT1 N0 tumours, and had not received adjuvant trastuzumab, were identified. The HER2-negative and -positive groups comprised 376 and 78 patients (17·2 per cent) respectively. At a median follow-up of 46·3 months, there were 18 recurrences.The 5-year relapse-free survival (RFS) rates were 97·2 and 88 per cent in the HER2-negative and -positive groups respectively (P < 0·001). Multivariable analysis identified HER2-positive tumour as an independent predictor of RFS in patients with pT1 N0 tumours (hazard ratio 6·65, 95 per cent confidence interval 2·53 to 17·49; P < 0·001).

CONCLUSION: Women with pT1 N0 HER2-positive breast cancer have a high risk of recurrence.

PMID: 22059233 [PubMed - in process]

Healthcare resource use and medical costs for the management of oesophageal cancer.

Br J Surg. 2011 Nov;98(11):1589-98

Authors: Gordon LG, Eckermann S, Hirst NG, Watson DI, Mayne GC, Fahey P, Whiteman DC,

Abstract

BACKGROUND: This study examined the interaction between natural history, current practice patterns in diagnosis, monitoring and treatment of oesophageal cancer, and associated health resource utilization and costs.

METHODS: A cost analysis of a prospective population-based cohort of 1100 patients with a primary diagnosis of oesophageal cancer was performed using chart review from the Australian Cancer Study Clinical Follow-Up Study. The analysis enabled estimation of healthcare resources and associated costs in 2009 euros by stage of disease and treatment pathway.

RESULTS: Most patients (88·5 per cent) presented with stage II, III or IV cancer; 61·1 per cent (672 of 1100) were treated surgically. Overall mean costs were €37,195 (median €29,114) for patients undergoing surgery and €17,281 (median €13,066) for those treated without surgery. Surgery contributed 66·4 per cent of the total costs (mean €24,697 per patient) in the surgical group. In the non-surgical group, use of chemotherapy was more prevalent (81·9 per cent of patients) and contributed 61·1 per cent of the total costs. Other important cost determinants were gastro-oesophageal junction tumours, treatment location and tumour stage. Mean costs of those monitored for Barrett’s oesophagus (7·3 per cent of patients) were lower, although about one-third still presented with advanced-stage cancer.

CONCLUSION: Overall costs for managing oesophageal cancer were high and dominated by surgery costs in patients treated surgically and by chemotherapy costs in patients treated without surgery. Radiotherapy, treatment location and cancer subtype were also important. Monitoring for Barrett’s oesophagus and earlier-stage detection were associated with lower management costs, but the potential net benefit from surveillance strategies needs further investigation.

PMID: 22059235 [PubMed - in process]

Quality of life and health status before and after ileal pouch-anal anastomosis for ulcerative colitis.

Br J Surg. 2011 Nov 3;

Authors: Heikens JT, de Vries J, Goos MR, Oostvogel HJ, Gooszen HG, van Laarhoven CJ

Abstract

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is considered the surgical treatment of choice for patients with ulcerative colitis. Quality of life (QoL) and health status are the most important patient-related outcomes. Studies investigating QoL are often cross-sectional and focus on health status. This longitudinal study evaluated QoL and health status after IPAA for ulcerative colitis and compared these with reference data from a healthy population. METHODS: Patients with ulcerative colitis who underwent a pouch operation between 2003 and 2008 completed validated questionnaires for QoL and health status. Questionnaires were completed before pouch surgery, and 6, 12, 24 and 36 months after operation. The effect of IPAA on QoL and health status was analysed, and data were compared with reference values from the healthy Dutch population. RESULTS: Data were obtained for 30 of the 32 patients. Six months after IPAA, QoL was at least comparable with that of the reference population in four of six domains. Twelve months after IPAA, overall QoL had improved, supported by findings in three QoL domains. Six months after IPAA, health status was comparable to that of the reference population in three of eight dimensions, and after 3 years it was at least comparable in five dimensions. CONCLUSION: QoL and health status increased after IPAA and reached levels comparable with those of the healthy reference population in a majority of domains and dimensions. QoL was restored first after IPAA, followed by health status. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22052254 [PubMed - as supplied by publisher]

Early intraperitoneal metabolic changes and protease activation as indicators of pancreatic fistula after pancreaticoduodenectomy.

Br J Surg. 2011 Nov 3;

Authors: Ansorge C, Regner S, Segersvärd R, Strömmer L

Abstract

BACKGROUND: Ischaemia and local protease activation close to the pancreaticojejunal anastomosis (PJA) are potential mechanisms of postoperative pancreatic fistula (POPF) formation. To provide information on the pathophysiology of POPF, intraperitoneal microdialysis was used to monitor metabolic changes and protease activation close to the PJA after pancreaticoduodenectomy (PD). METHODS: In patients who underwent PD, intraperitoneal metabolites (glycerol, lactate, pyruvate and glucose) were measured by microdialysis, and lactate and glucose in blood were monitored, every 4 h for 5 days, starting at 12.00 hours on the day after surgery. Trypsinogen activation peptide (TAP) was measured in microdialysates as a marker of protease activation. RESULTS: Intraperitoneal glycerol levels and the ratio of lactate to pyruvate were higher after PD and glucose levels were lower in seven patients who later developed symptomatic POPF than in eight patients with other surgical complications (OSC) and 33 with no surgical complications (NSC) (all P < 0·050). TAP was detected at a concentration greater than 0·1 µg/l in six of seven patients with POPF, two of eight with OSC and two of 33 with NSC. Intraperitoneal lactate concentrations were higher than systemic levels in all patients on days 1 to 5 after surgery (P < 0·001). In patients with POPF, high intraperitoneal lactate concentrations were observed without systemic hyperlactataemia. CONCLUSION: Early in the postoperative phase, patients who later developed clinically significant POPF had higher intraperitoneal glycerol concentrations and lactate/pyruvate ratios, and lower glucose concentrations in combination with a TAP level exceeding 0·1 µg/l close to the PJA, than patients who did not develop POPF. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22052299 [PubMed - as supplied by publisher]

Outcomes following surgery without radiotherapy for rectal cancer.

Br J Surg. 2011 Nov 3;

Authors: Mathis KL, Larson DW, Dozois EJ, Cima RR, Huebner M, Haddock MG, Wolff BG, Nelson H, Pemberton JH

Abstract

BACKGROUND: This study determined survival and recurrence rates following curative resection of rectal cancer without radiotherapy. METHODS: This was a retrospective review of the Mayo Clinic database of patients with rectal cancer treated with curative intent using surgery alone from 1990 to 2006. Patients who received neoadjuvant chemotherapy or radiation therapy and those who had any postoperative radiotherapy were excluded. Details were collected from the database and patient records using a protocol approved by the institutional review board. RESULTS: Some 655 consecutive patients with rectal cancer treated with curative intent using surgery alone were identified; 397 had stage I disease, 125 stage II and 133 stage III. Four hundred and nine patients underwent anterior resection (AR) and 246 abdominoperineal resection (APR). Median follow-up was 62 months. The 5-year rate of local recurrence was 4·3 per cent, disease-free survival 90·0 per cent and cancer-specific survival 91·5 per cent. Stage-specific and all-stage disease-free survival did not differ significantly between AR and APR. The 5-year cumulative local recurrence rate was lower following AR than APR (3·6 versus 5·5 per cent; P = 0·321). There were only two patients with positive margins and type of operation was not significant on multivariable analysis. CONCLUSION: Well-performed, standardized APRs have similar local recurrence to AR. Radiation therapy may not confer much additional benefit. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22052336 [PubMed - as supplied by publisher]

High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage.

Br J Surg. 2011 Oct 28;

Authors: Rutegård M, Hemmingsson O, Matthiessen P, Rutegård J

Abstract

BACKGROUND: It is controversial whether division of the inferior mesenteric artery close to the aorta influences the risk of anastomotic leakage, especially in the elderly and unfit. This population-based study was carried out to evaluate the independent association between a high arterial ligation and anastomotic leakage in anterior resection for rectal cancer. METHODS: All patients who had anterior resection for rectal cancer from 2007 to 2009 inclusive were identified in the Swedish Colorectal Cancer Registry. The association between high tie and anastomotic leakage was evaluated in a logistic regression model, with adjustment for confounders. Stratification was performed for co-morbidity as judged by the American Society of Anesthesiologists (ASA) classification. RESULTS: Symptomatic anastomotic leakage occurred in 81 (9·9 per cent) of 818 patients with a high tie and 108 (9·8 per cent) of 1101 without. Overall, the use of a high tie was not associated with a higher risk of anastomotic leakage (odds ratio (OR) 1·00, 95 per cent confidence interval 0·72 to 1·39). There was no increased risk in patients classifed as ASA grade I or II (OR 0·97, 0·69 to 1·35), or in those graded ASA III or IV (OR 1·26, 0·58 to 2·75). CONCLUSION: In the present population-based setting, use of a high tie was not associated with an increased rate of symptomatic anastomotic leakage. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22038493 [PubMed - as supplied by publisher]

Randomized clinical trial of a brief psychological intervention to increase walking in patients with intermittent claudication.

Br J Surg. 2011 Oct 28;

Authors: Cunningham MA, Swanson V, O’Caroll RE, Holdsworth RJ

Abstract

BACKGROUND: Increased walking is often recommended for patients with intermittent claudication (IC). Current methods to increase walking in these patients increase capability but not daily behaviour. This trial assessed whether a brief psychological intervention could increase daily walking at 4 months. METHODS: This randomized, single-centre, parallel-group trial was conducted between April 2008 and July 2010. Patients newly diagnosed with IC were randomly assigned into two groups. All clinical staff involved in patient management were blinded to allocation. The control group received usual care plus researcher contact, and the treatment group received usual care and a brief psychological intervention to modify illness and walking beliefs and to develop a personalized walking action plan. The psychological intervention was delivered in two 1-h sessions in participants’ homes. The primary outcome was daily steps measured by pedometer 4 months later. Analyses were by intention to treat. RESULTS: Of 109 patients screened, 72 were eligible for inclusion; 58 patients consented to participate and were randomly allocated to usual care (30) or brief psychological intervention (28). All 58 participants were included in the analysis of the primary outcome. Compared with controls at 4-month follow-up, participants who received the psychological intervention walked a mean of 1575·63 (95 per cent confidence interval 731·97 to 2419·29) more steps per day. There were no adverse events. CONCLUSION: A brief psychological intervention significantly increased daily walking in patients with IC at 4 months. This study provided support for a potentially new direction in the treatment of IC. Registration number: ISRCTN28051878 (http://www.controlled-trials.com). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22038532 [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. 2011 Oct 31;

Authors: Sajid MS, Leaver C, Baig MK, Sains P

Abstract

BACKGROUND: The objective of this study was systematically to analyse published randomized trials comparing lightweight mesh (LWM) with heavyweight mesh (HWM) in open inguinal hernia repair. METHODS: Randomized trials on LWM versus HWM were selected from the standard electronic databases. Reported outcomes were analysed systematically using RevMan. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. RESULTS: Nine randomized trials containing 2310 patients were included. There was significant heterogeneity among trials. There was no difference in duration of operation, postoperative pain, recurrence rate, testicular atrophy and time to return to work between LWM and HWM groups. The two mesh types had a similar risk of perioperative complications, but LWM was associated with a reduced risk of developing chronic groin pain (risk ratio (RR) 0·61, 95 per cent confidence interval 0·50 to 0·74) and a reduced risk of developing other groin symptoms, such as stiffness and foreign body sensations (RR 0·64, 0·50 to 0·81). CONCLUSION: The use of LWM for open inguinal hernia repair was not associated with an increased risk of hernia recurrence. LWM reduced the incidence of chronic groin pain as well as the risk of developing other groin symptoms. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22038579 [PubMed - as supplied by publisher]

Transanal specimen extraction in robotic rectal cancer surgery.

Br J Surg. 2011 Oct 31;

Authors: Kang J, Min BS, Hur H, Kim NK, Lee KY

Abstract

BACKGROUND: The aim of this study was to identify the benefits of robotic transanal specimen extraction (RTSE) compared with minilaparotomy specimen extraction (MSE). METHODS: Patients who underwent totally robotic surgery with curative intent for treatment of adenocarcinoma of the rectum below 12 cm from the anal verge were selected from the authors’ database. Patients were divided into RTSE and MSE groups according to the method of specimen delivery. Clinicopathological features and perioperative surgical outcomes were compared between the two groups. RESULTS: There were 53 patients in the RTSE group and 66 in the MSE group. No differences were observed in overall complications. Postoperative recovery was faster in the RTSE group in terms of resumption of a soft diet (mean(s.d.) 3·5(1·5) versus 4·6(1·7) days; P < 0·001) and length of hospital stay (9·0(4·8) versus 11·3(5·3) days; P = 0·016). Pain scores on a visual analogue scale were significantly lower in the RTSE group than in the MSE group from day 2 to day 5 after surgery (P = 0·021 to P < 0·001). CONCLUSION: RTSE in robotic rectal cancer surgery was associated with less pain and a faster recovery than MSE. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22038650 [PubMed - as supplied by publisher]

Management of late postoperative complications of bariatric surgery.

Br J Surg. 2011 Oct;98(10):1345-55

Authors: Hamdan K, Somers S, Chand M

Abstract

BACKGROUND: The prevalence of obesity is increasing worldwide and the past decade has witnessed an exponential rise in the number of bariatric operations performed. As a consequence, an increasing number of patients are presenting to non-specialist units with complications following bariatric procedures. This article outlines the management of the most common late postoperative complications that are likely to present to the general surgeon.

METHODS: A search was conducted for late postoperative complications after bariatric surgery using PubMed, Embase, OVID and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding or sleeve gastrectomy, and late or delayed complications. Only studies with follow-up longer than 6 months were included.

RESULTS: The most common long-term complications after gastric banding include band slippage and erosion. Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. Hepatobiliary complications pose a particular challenge because of the altered anatomy. Functional disorders such as reflux and dumping, and nutritional deficiencies are common and should be differentiated from conditions that require urgent investigations and timely surgical intervention.

CONCLUSION: The immediate management of bariatric patients presenting with complications outside the immediate postoperative period requires adherence to basic surgical principles. Accurate diagnosis often relies on high-quality contrast and cross-sectional imaging, and effective surgical intervention necessitates a broad understanding of the altered anatomy, advanced surgical skills and liaison with specialists in the field when necessary.

PMID: 21887775 [PubMed - indexed for MEDLINE]

Sentinel lymph node biopsy and survival in elderly patients with cutaneous melanoma (Br J Surg 2011; 98: 1400-1407).

Br J Surg. 2011 Oct;98(10):1407

Authors: de Bree E

PMID: 21887776 [PubMed - indexed for MEDLINE]

Cost-utility of bariatric surgery for morbid obesity in Finland.

Br J Surg. 2011 Oct;98(10):1422-9

Authors: Mäklin S, Malmivaara A, Linna M, Victorzon M, Koivukangas V, Sintonen H

Abstract

BACKGROUND: The aim of this study was to evaluate the cost-utility of bariatric surgery (gastric bypass, sleeve gastrectomy and gastric banding) compared with ordinary treatment in the Finnish healthcare system.

METHODS: Analysis was done from a healthcare provider’s perspective using a combination of a decision tree and a Markov model, with a time horizon of 10 years. Health-related quality of life was estimated from a representative population survey, and other parameter values were based on registers, systematic reviews, controlled studies and expert opinion.

RESULTS: In the base-case analysis, bariatric surgery was both more effective and less costly than the ordinary treatment. The mean costs were €33,870 and €50,495, and the mean number of quality-adjusted life-years 7·63 and 7·05, for bariatric surgery and ordinary treatment respectively. Uncertainty around the parameter values was tested comprehensively in sensitivity analyses, and the results were robust.

CONCLUSION: Surgery for morbid obesity increases health-related quality of life, and reduces the need for further treatments and total healthcare costs. According to this analysis, non-operative care would be more costly for the Finnish healthcare system on average after 5 years following surgery.

PMID: 21887777 [PubMed - indexed for MEDLINE]

Management of late postoperative complications of bariatric surgery (Br J Surg 2011; 98: 1345-1355) and Cost-utility of bariatric surgery for morbid obesity in Finland (Br J Surg 2011; 98: 1422-1429).

Br J Surg. 2011 Oct;98(10):1430

Authors: Adamina M

PMID: 21887778 [PubMed - indexed for MEDLINE]

Operative notes do not reflect reality in laparoscopic cholecystectomy (Br J Surg 2011; 98: 1431-1436).

Br J Surg. 2011 Oct;98(10):1436

Authors: Soybel DI

PMID: 21887779 [PubMed - indexed for MEDLINE]

The significant rectal neoplasm and mucosectomy by transanal endoscopic microsurgery (Br J Surg 2011; 98: 1342-1344).

Br J Surg. 2011 Oct;98(10):1495; author reply 1495-6

Authors: Barendse RM, Fockens P, Bemelman WA, de Graaf EJ, Dekker E

PMID: 21887781 [PubMed - indexed for MEDLINE]

Surgeon volumes in oesophagogastric and hepatopancreatobiliary resectional surgery (Br J Surg 2011; 98: 891-893).

Br J Surg. 2011 Oct;98(10):1496; author reply 1496-7

Authors: Davies N

PMID: 21887782 [PubMed - indexed for MEDLINE]

Clinical significance of liver ischaemia after pancreatic resection.

Br J Surg. 2011 Dec;98(12):1760-5

Authors: Hackert T, Stampfl U, Schulz H, Strobel O, Büchler MW, Werner J

Abstract

BACKGROUND: Liver ischaemia after pancreatic resection is a rare but potentially serious complication. The aim of this study was to determine the impact of postoperative liver ischaemia after pancreatic resection.

METHODS: All consecutive patients undergoing pancreatic resection between January 2007 and August 2008 in the Department of Surgery in Heidelberg were identified retrospectively from a prospectively collected database and analysed with a focus on postoperative hepatic perfusion failure. Laboratory data, computed tomography (CT) findings, symptoms, therapy and outcome were recorded.

RESULTS: A total of 762 patients underwent pancreatic resection in the study period. Seventeen patients (2·2 per cent) with a postoperative increase in liver enzymes underwent contrast-enhanced CT for suspected liver perfusion failure. The types of perfusion failure were hypoperfusion without occlusion of major hepatic vessels (6 patients) and ischaemia with arterial (5) and/or portal vein (6) involvement. The overall mortality rate was 29 per cent (5 of 17 patients). Therapy included conservative treatment (7), radiological or surgical revascularization and necrosectomy or resection of necrotic liver tissue (10). Outcome varied from full recovery (4 patients) to moderate systemic complications (6) and severe complications (7) including death. Simultaneous involvement of the portal vein and hepatic artery was always fatal.

CONCLUSION: Postoperative liver perfusion failure is a rare but potentially severe complication following pancreatic surgery requiring immediate recognition and, if necessary, radiological or surgical intervention. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22021030 [PubMed - in process]

Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications.

Br J Surg. 2011 Oct 21;

Authors: Ratto C, Parello A, Donisi L, Litta F, Zaccone G, Doglietto GB

Abstract

BACKGROUND: Dearterialization should reduce arterial overflow to haemorrhoids. The purpose of this study was to assess the topography of haemorrhoidal arteries. METHODS: Fifty patients with haemorrhoidal disease were studied. Using endorectal ultrasonography, six sectors were identified within the lower rectal circumference. Starting from the highest level (6 cm above the anorectal junction), the same procedure was repeated every 1 cm until the lowest level was reached (1 cm above the anorectal junction). Colour duplex imaging examinations identified haemorrhoidal arteries related to the rectal wall layers, and the arterial depth was calculated. RESULTS: Haemorrhoidal arteries were detected in 64·3, 66·0, 66·0, 98·3, 99·3 and 99·7 per cent of the sectors 6, 5, 4, 3, 2 and 1 cm above the anorectal junction respectively (P < 0·001). Most of the haemorrhoidal arteries were external to the rectal wall at 6 and 5 cm (97·9 and 90·9 per cent), intramuscular at 4 cm (55·0 per cent), and within the submucosa at 3, 2 and 1 cm above the anorectal junction (67·1, 96·6 and 100 per cent) (P < 0·001). The mean arterial depth decreased significantly from 8·3 mm at 6 cm to 1·9 mm at 1 cm above the anorectal junction (P < 0·001). CONCLUSION: This study demonstrated that the vast majority of haemorrhoidal arteries lie within the rectal submucosa at the lowest 2 cm above the anorectal junction. This should therefore be the best site for performing haemorrhoidal dearterialization. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22021046 [PubMed - as supplied by publisher]

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. 2011 Oct 24;

Authors: Melsen WG, de Smet AM, Kluytmans JA, Bonten MJ,

Abstract

BACKGROUND: Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) are effective in improving survival in patients under intensive care. In this study possible differential effects in surgical and non-surgical patients were investigated. METHODS: This was a post hoc subgroup analysis of data from a cluster-randomized multicentre trial comparing three groups (SDD, SOD or standard care) to quantify effects among surgical and non-surgical patients. The primary study outcome was 28-day mortality rate. Duration of mechanical ventilation, duration of intensive care unit (ICU) and hospital length of stay, and bacteraemia rates were secondary outcomes. RESULTS: The subgroup analyses included a total of 2762 surgical and 3165 non-surgical patients. Compared with standard care, adjusted odds ratios (ORs) for mortality were comparable in SDD-treated surgical and non-surgical patients: 0·86 (95 per cent confidence interval 0·69 to 1·09; P = 0·220) and 0·85 (0·70 to 1·03; P = 0·095) respectively. However, duration of mechanical ventilation, ICU stay and hospital stay were significantly reduced in surgical patients who had SDD. SOD did not reduce mortality compared with standard treatment in surgical patients (adjusted OR 0·97, 0·77 to 1·22; P = 0·801); in non-surgical patients it reduced mortality (adjusted OR 0·77, 0·63 to 0·94; P = 0·009) by 16·6 per cent, representing an absolute mortality reduction of 5·5 per cent with number needed to treat of 18. CONCLUSION: Subgroup analysis found similar effects of SDD in reducing mortality in surgical and non-surgical ICU patients, whereas SOD reduced mortality only in non-surgical patients. The hypothesis-generating findings mandate investigation into mechanisms between different ICU populations. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22021072 [PubMed - as supplied by publisher]

Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders.

Br J Surg. 2011 Oct 21;

Authors: Pournaras DJ, Aasheim ET, Søvik TT, Andrews R, Mahon D, Welbourn R, Olbers T, le Roux CW

Abstract

BACKGROUND: The American Diabetes Association recently defined remission of type II diabetes as a return to normal measures of glucose metabolism (haemoglobin (Hb) A1c below 6 per cent, fasting glucose less than 5·6 mmol/l) at least 1 year after bariatric surgery without hypoglycaemic medication. A previously used common definition was: being off diabetes medication with normal fasting blood glucose level or HbA1c below 6 per cent. This study evaluated the proportion of patients achieving complete remission of type II diabetes following bariatric surgery according to these definitions. METHODS: This was a retrospective review of data collected prospectively in three bariatric centres on patients undergoing gastric bypass, sleeve gastrectomy and gastric banding. RESULTS: Some 1006 patients underwent surgery, of whom 209 had type II diabetes. Median follow-up was 23 (range 12-75) months. HbA1c was reduced after operation in all three surgical groups (P < 0·001). A total of 72 (34·4 per cent) of 209 patients had complete remission of diabetes, according to the new definition; the remission rates were 40·6 per cent (65 of 160) after gastric bypass, 26 per cent (5 of 19) after sleeve gastrectomy and 7 per cent (2 of 30) after gastric banding (P < 0·001 between groups). The remission rate for gastric bypass was significantly lower with the new definition than with the previously used definition (40·6 versus 57·5 per cent; P = 0·003). CONCLUSION: Expectations of patients and clinicians may have to be adjusted as regards remission of type II diabetes after bariatric surgery. Focusing on improved glycaemic control rather than remission may better reflect the benefit of this type of surgery and facilitate improved glycaemic control after surgery. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22021090 [PubMed - as supplied by publisher]

Randomized clinical trial of percutaneous transluminal angioplasty, supervised exercise and combined treatment for intermittent claudication due to femoropopliteal arterial disease.

Br J Surg. 2011 Oct 21;

Authors: Mazari FA, Khan JA, Carradice D, Samuel N, Abdul Rahman MN, Gulati S, Lee HL, Mehta TA, McCollum PT, Chetter IC

Abstract

BACKGROUND: The aim was to compare percutaneous transluminal angioplasty (PTA), a supervised exercise programme (SEP) and combined treatment (PTA plus SEP) for intermittent claudication due to femoropopliteal arterial disease. METHODS: Consenting patients with femoropopliteal arterial lesions were randomized to one of three treatment arms: PTA, SEP, or PTA plus SEP. All patients received optimal medical treatment. Patients were assessed at baseline and 1, 3, 6 and 12 months after intervention. Clinical (ankle pressures, walking distances, symptoms) and quality-of-life (QoL) outcomes (Short Form 36, VascuQol) were analysed. RESULTS: A total of 178 patients (108 men, median age 70 years) were included. All three treatment groups demonstrated significant clinical and QoL improvements. One year after PTA (60 patients, 8 withdrew), 37 patients (71 per cent) had improved (16 mild, 16 moderate, 5 marked), nine (17 per cent) showed no improvement and six (12 per cent) had deteriorated. After SEP (60 patients, 14 withdrew), 32 patients (70 per cent) had improved (19 mild, 10 moderate, 3 marked), six (13 per cent) showed no improvement and eight (17 per cent) had deteriorated. After PTA plus SEP (58 patients, 11 withdrew), 40 patients (85 per cent) had improved (18 mild, 20 moderate, 2 marked), seven (15 per cent) showed no improvement and none had deteriorated. On intergroup analysis, PTA and SEP alone were equally effective in improving clinical outcomes, although the effect was short-lived. PTA plus SEP produced a more sustained clinical improvement, but there was no significant QoL advantage. CONCLUSION: For patients with intermittent claudication due to femoropopliteal disease, PTA, SEP, and PTA plus SEP were all equally effective in improving walking distance and QoL after 12 months. Registration number: NCT00798850 (http://www.clinicaltrials.gov). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22021102 [PubMed - as supplied by publisher]

Abstracts of the Annual Scientific Meeting of the Association of Upper Gastrointestinal Surgeons for Great Britain and Ireland. September 15-16, 2011. Belfast, United Kingdom.

Br J Surg. 2011 Nov;98 Suppl 7:1-55

Authors:

PMID: 22029049 [PubMed - indexed for MEDLINE]

Value of hepatic venous pressure gradient measurement before liver resection for hepatocellular carcinoma.

Br J Surg. 2011 Oct 19;

Authors: Stremitzer S, Tamandl D, Kaczirek K, Maresch J, Abbasov B, Payer BA, Ferlitsch A, Gruenberger T

Abstract

BACKGROUND: Portal hypertension associated with liver cirrhosis increases the risk of postoperative complications after liver resection for hepatocellular carcinoma (HCC). This study assessed the role of preoperative hepatic venous pressure gradient (HVPG) assessment in identifying portal hypertension. METHODS: All patients who underwent liver resection for HCC between January 2000 and December 2009 at the Department of General Surgery, Medical University Vienna, were analysed retrospectively. HVPG was assessed prospectively in a subset of patients before liver resection. The influence of this assessment on postoperative complications was investigated. RESULTS: A total of 132 patients were enrolled, of whom 39 underwent HVPG measurement. Mean(s.d.) HVPG was 6·4(3·0) and 4·3(1·4) mmHg in patients with and without postoperative complications respectively (P = 0·028). Complication rates differed significantly at a cut-off HVPG value of 5 mmHg: 11 of 21 patients with a gradient of 1-5 mmHg developed complications versus 12 of 14 patients with a higher value (P = 0·045). HVPG exceeding 5 mmHg was associated with worse liver fibrosis (P = 0·004), higher rates of postoperative liver dysfunction (5 of 13 versus 1 of 18; P = 0·022) and ascites (7 of 14 versus 3 of 21; P = 0·022), and a longer hospital stay (median (range) 11 (7-26) versus 8 (4-20) days; P = 0·034). Overall postoperative morbidity did not differ between patients who had preoperative HVPG assessment and those who did not (P = 0·142). CONCLUSION: Preoperative HVPG assessment predicted liver fibrosis and postoperative complications. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 22009385 [PubMed - as supplied by publisher]

Multicentre study of the quality of a large administrative data set and implications for comparing death rates.

Br J Surg. 2011 Oct 13;

Authors: Holt PJ, Poloniecki JD, Thompson MM

Abstract

BACKGROUND: The aim was to compare the completeness and accuracy of the English Hospital Episode Statistics (HES) with a ‘gold standard’ data set for a sample of hospitals and to determine the effect of data quality on comparisons of hospital death rates. METHODS: A multicentre audit of data quality was undertaken, based on a sample of all elective abdominal aortic aneurysm (AAA) repairs performed in England. All elective AAA repairs in nine collaborating hospital trusts were included over a 2-year interval. Cases were identified from HES, local databases, hospital administration systems and theatre records. The main outcome measures were the numbers of cases and deaths according to HES compared with case-note review. The recording of co-morbidities and the effect of data accuracy on mortality analyses and risk adjustment were quantified. RESULTS: A total of 1102 elective AAA repairs were identified from HES data. Of 962 procedures with case-note review, 827 (86·0 per cent, 95 per cent confidence interval 84·0 to 88·0 per cent) were confirmed as elective AAA repair. The survival status with HES was 99·8 per cent accurate on comparison with the Office for National Statistics death registry. There was no significant difference in mortality assessment between the HES data and the ‘gold standard’ data set (5·3 versus 5·0 per cent; P = 0·753). Smaller hospitals were more affected by data inaccuracies than larger hospitals. CONCLUSION: This study confirmed that HES data can be used effectively to compare mortality between hospitals. Administrative data will be used increasingly for assessing performance and clinicians should accept responsibility to improve coding. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 21994091 [PubMed - as supplied by publisher]